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Care Transformation Collaborative of RI
News & Updates | August 2024
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Stephen Kogut, PhD, MBA RPh, and Professor of Pharmacy Practice, University of Rhode Island College of Pharmacy, Highlights the Impact of Pharmacists in Diabetes Care and Ambulatory Settings
This project highlighted the value pharmacists provide in the ambulatory care setting and exemplifies the URI College of Pharmacy’s ideals for progressive pharmacy practice.
Most notably, Dr. Kelley Sanzen’s leadership and astute vision for this project were instrumental to the success achieved. Her vision was to positively impact patients with diabetes by effectively utilizing ambulatory care pharmacists and implementing reimbursable services in primary care to create a sustainable model for care team expansion.
The participating pharmacists displayed exemplary skill at the practice sites in executing this challenging initiative, which entailed identifying candidate patients, establishing new workflows, and managing data for evaluating clinical outcomes. Pharmacists and care team members used continuous glucose monitoring and their skill sets to educate patients on self-management skills which allowed patients to optimize food choices, increase physical activity, understand results from glucose monitoring, and adhere to medication regimens as cornerstones of diabetes care.
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Patricia Hoffman, PharmD, BCPS, CDOE, CVDOE, and Clinical Pharmacist at the Miriam Hospital Discusses Overcoming Challenges in the Pharmacy-Led Continuous Glucose Monitoring Project for Patients with Diabetes and Behavioral Health Conditions
How does the Pharmacy-Led Continuous Glucose Monitoring Quality Improvement Project address the needs of patients with both diabetes and behavioral health conditions? What challenges did you face, and how did you overcome them?
Patients with behavioral health conditions are at higher risk for uncontrolled blood sugar and diabetes complications due to their medications. They are also more likely to develop mental health issues like anxiety and depression.
To address these needs, we focused on building trust through more frequent and longer visits, often requiring active listening. For example, some patients with schizophrenia initially refused CGM due to fear of the device. We used YouTube videos and discussions to explain the benefits, emphasizing control over their diabetes. Persistence, education, and patient involvement helped us overcome these challenges.
Additionally, we addressed issues like patients removing sensors early by involving them in the process. Younger, tech-savvy patients adapted quickly, though financial and social concerns remain difficult to address without a social worker.
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Final Pro-CGM Collaborative: Success in Diabetes Management and Pharmacist-Led Care
The final Pro-CGM Pharmacy QI Learning Collaborative meeting in July highlighted the successful implementation of Pro CGM for diabetes management, resulting in over 500 patients wearing devices and a net reduction of 0.943 in A1c. The project emphasized the vital role of pharmacists in patient care, supported by UnitedHealthcare funding.
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CTC-RI Annual Conference: Special Session on LGBTQIA+ Health
Join us at the CTC-RI’s annual conference on October 31, at the Crowne Plaza, where we are excited to feature a special session titled "From Data to Equity: Improving LGBTQIA+ Health in RI," featuring experts discussing best practices for using SOGI data in healthcare. The session will cover culturally appropriate care, sexual health, and the Safe Zone Program for LGBTQ+ inclusion.
| | 2024 State Scorecard on Women's Health and Reproductive Care | | |
The 2024 State Scorecard on Women’s Health and Reproductive Care ranks Massachusetts, Vermont, and Rhode Island as top performers based on 32 health measures. Mississippi, Texas, Nevada, and Oklahoma rank lowest. Deaths among women aged 15-44 were highest in the Southeast, with leading causes including pregnancy complications, substance use, and chronic conditions.
Maternal deaths were highest in Tennessee, Mississippi, and Louisiana, while Vermont, California, and Connecticut had the lowest rates. Uninsurance rates were highest in Texas, Georgia, and Oklahoma, particularly in states without Medicaid expansion. The overturning of Roe v. Wade has further impacted reproductive healthcare access in 21 states.
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ECHO® Learning Series: Best Practices in Addressing Sexually Transmitted Infections (STI) in Primary Care
Join us for a free, collaborative ECHO® virtual learning program that uses an “all teach, all learn” approach and provides an opportunity to learn together from subject matter experts and case study examples.
This series will focus on strategies to promote recommended best practices for improving STI screening in primary care. Strategies will help practices and other organizations improve early identification and treatment of STIs. Participants will collaborate and engage in ongoing learning.
Two participation options:
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Full participation: Participate in at least four of six sessions and be willing to present a case (includes $250 stipend payments for up to 20 individuals or sites)
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Flexible participation: Attend individual sessions with no commitment to sharing a case (no incentive payment).
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*Sessions will occur monthly on the 4th Wednesday (7:30–8:30am) starting in September. (*November and December sessions follow an adjusted schedule due to holidays).
Learn More Here
Questions? Contact Nijah Mangual (nmangual@ctc-ri.org)
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Rhode Island MomsPRN ECHO® Learning Series: Pediatric Sleep
Starts in September! Register by August 22
Building upon the success of past RI MomsPRN professional education efforts, we are expanding offerings to promote recommended screening tools for maternal behavioral health, and screening tool resources and provide a renewed focus on respectful, culturally responsive, and linguistically appropriate care. Participants will collaborate and engage in ongoing learning.
Two participation options:
- Full participation: Participate in at least six out of eight sessions and be willing to present a case study ($250 stipend payment).
- Flexible participation: Attend individual ECHO® sessions with no commitment to sharing a case (no incentive payment).
Click here to learn more or view the planned ECHO® session calendar.
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Improving Behavioral Health Care: A Standardized Approach to Tracking Spending
With nearly half of Americans facing a behavioral health issue in their lifetime, state officials are focusing on improving access to quality care and ensuring appropriate funding for these services. A new report from the Milbank Memorial Fund explores how states can use a standardized methodology to measure behavioral health spending, helping to promote better care and support for patients with conditions like depression, anxiety, and opioid addiction. By defining and tracking spending, states can make informed decisions that improve care access and quality. The report builds on recommendations from a previous Milbank report, offering guidance for implementation.
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July Review and August Focus: Advancing Medicaid and Housing Health Initiatives
In July, the Clinical Strategy Committee reviewed key updates on the MassHealth Primary Care Sub-Capitation Program and the NY Health Equity Reform (NYHER) 1115 Amendment. Experts discussed lessons learned from Massachusetts' primary care Medicaid capitation and New York's efforts to address health-related social needs for Medicaid patients.
Looking ahead, our August meeting will focus on "Housing is Health," exploring the vital connections between housing and health with insights from leaders in the field. To join the discussion, email Michelle Mooney at mmooney@ctc-ri.org.
| | CTC-RI's Linda Cabral, MM, and Michelle Mooney, MPA at the HEZ Learning Community event | |
"Strengthening Health Literacy for Communities of Color: Key Insights from the HEZ Learning Community"
At the July HEZ Learning Community, Linda Cabral, MM, Senior Program Manager at CTC-RI, Michelle Mooney, MPA, Program Coordinator at CTC-RI, and Allegra Scharff, MPH, RIDOH Chief of Healthcare Equity, presented key recommendations to improve health literacy for communities of color through clinical-community partnerships. These recommendations came from a year-long Community of Practice (CoP) that ran from October 2023 to June 2024. The CoP brought together nearly 80 partners from healthcare, community-based organizations, and community health workers to enhance collaboration and support health equity in Rhode Island.
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UMass Center for Integrated Care’s "Primary Care Behavioral Health"
We’re thrilled to share that six applicants have been accepted into the UMass Center for Integrated Care’s "Primary Care Behavioral Health" course this fall. Funded by UnitedHealthcare and Blue Cross & Blue Shield of RI, this program includes 26 e-learning modules and offers 36 Continuing Education Units (CEUs), with one-on-one mentoring from Dr. Liz Cantor and Dr. Kristin David.
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Save the Date: Improving Primary Care and Specialist Collaboration
Join us on September 13 from 7:30 to 9:00 AM to discuss enhancing collaboration between primary care and specialists in Rhode Island. We’ll cover successful e-consult programs and strategies for improving alignment to boost care quality and lower costs.
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CBO Spotlight: Justice Resource Center
Our primary care transformation efforts often include the support and partnership of statewide community-based organizations (CBOs). CTC-RI is spotlighting a different CBO monthly to recognize and appreciate their work in our communities.
This month, we're spotlighting the Justice Resource Center, which partners with individuals, families, communities, and government to pursue the social justice inherent in opening doors to opportunity and independence.
In what ways does your organization uniquely support Rhode Islanders?
Justice Assistance is a nonprofit organization based in Cranston that has been providing services to justice-involved people since 1978. Through our programs and partnerships, we provide people with the opportunity to have a fresh start by offering support to complete court conditions, hosting expungement clinics, and through our CORES program providing support to find new careers and access to mental health counseling.
How can a partnership with primary care providers strengthen your work?
The organization is in the process of opening JA Health & Wellness which will provide primary care services to those in the community. Through the efforts of our Community Health Worker, Monique, we have learned that primary care is something many of our clients do not have access to. Our clients come with a unique set of barriers to care and having primary care available to them greatly improves their ability to find meaningful careers and future opportunities.
What's something you'd like the primary care community to understand about your organization?
Justice Assistance is a support for patients who are seeking primary care. We would like to extend our services to any primary care providers who may have adult patients who have been or are justice-involved. At Justice Assistance we believe in providing support for anyone who comes through our doors, and if there are individuals who need support that we can provide please reach out to us and we will assist the best we can.
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Save the date for the PCP-Specialist Forum this fall!
Plan to join us on September 13 (7:30-9:00 am) for a powerful discussion on improving collaboration and communication between primary care and specialty groups across systems of care in RI, including:
- The successful e-consults and e-referrals program covered by most payers
- Efforts to improve PCP-specialist alignment that increase high-value visits and reduce costs
- Progress on a statewide, EHR-agnostic, e-consult solution
| | Job Opportunity: Work with the Care Transformation Collaborative of RI! | |
Contracts And Grants Analyst II
CTC-RI is seeking a detail-oriented and organized Contracts and Grants Analyst II to manage the lifecycle of contracts and grants and perform general finance-related tasks.
An ideal candidate has a bachelor's degree in business, finance, or accounting and 4-7 years of experience with contracts, budgeting, and finance. They enjoy working with small, dynamic teams that work hard and support each other. The individual is organized, process-oriented, and eager to advocate for systems to improve the efficiency and effectiveness of the current contract and grant management processes. This is a newly created position with the opportunity to build a new approach to contracts and grants management.
| | | Find past CTC-RI learning sessions and CME/CEUs here! | | Practice Resources and Information | | | |
Request a Community Health Network presentation
Want to learn more about the Community Health Network or do a deep dive into specific programs on the CHN menu? CHN can schedule a virtual or in-person session with you and/or your team! Email Erica Hanson at Erica.Hanson@health.ri.gov or call 222-7954 with any questions.
Expand Your Skills: Free Fall TBI ECHO Course with CME Credits Available
Interested in being able to test and treat your patients for “latent” TB infection within primary care? Join us this fall for a six-session virtual and interactive TBI ECHO course! You can receive up to 6 AMA Category 1 CME credits and the course is free. Register here.
Practice Resources: FUEL Program for Lifestyle Modification
The FUEL program is a 12-month lifestyle modification study offered by Brown Medical and Miriam Hospital at no cost. Participants will use an online platform to gradually adjust their eating and exercise habits, with most losing 5-7% of their starting weight if desired. The gold-standard weight loss treatment involves no meal replacements or medications. As part of a research study, everything is free for patients, making it a valuable resource for those seeking additional support for lifestyle changes recommended by their healthcare provider. Learn more here: FUEL Research Study.
National Immunization Awareness Month: Join the Vaccine Small Talk on August 27
August is National Immunization Awareness Month and Healthcentric Advisors are hosting a Vaccine Small Talk "What Makes a Successful Vaccine Campaign: Thoughts from the Field" on August 27, 2024, from 12:00-12:45 PM. Register here.
Free Asthma Support for Children in Providence
Do your children struggle with asthma? If you live in Providence, the Healthy Providence Healthy Homes Program offers free asthma education, home assessments, and interventions to improve asthma control and reduce triggers in your home to families with asthmatic children aged 2-17. Read more.
Webinar on Mobility and Fall Prevention in Older Adults
Dr. Elizabeth Eckstrom from Oregon Health & Science University will discuss mobility in primary care and Age-Friendly health systems. She will cover key topics, including fall prevention in older adults, the new World Falls Guidelines, and the STEADI Toolkit for reducing accidents and injuries.
Register here to attend the event on Thursday, October 17 at 2:30 PM ET.
Save the date: Rhode Island World Diabetes Day on November 12
Join us at the free conference full of helpful, eye-opening, and inspirational presentations, discussions, and Q&A sessions. There will be informative sessions for healthcare professionals (clinicians, nurses, dietitians, pharmacists, social workers, etc.) and CME credits, too! Learn more at www.riwdd.org.
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A focus on getting health care providers more geriatric training | Providence Business News
July 19, 2024
As the Ocean State’s aging population is expected to skyrocket in the coming years, a University of Rhode Island program providing elder care education is set to expand with the help of a federal grant. The Rhode Island Geriatric Education Center at URI recently received $5 million from the federal Health Resources and Services Administration, which has been funding the program since it started in 1996. Read more.
EOHHS: Looking back and looking ahead
July 15, 2024
Health and human services workforce challenges were on the front burner of the Governor's office and General Assembly during the recently completed legislative session. Read about some major accomplishments, many of which reflect the Rhode Ahead priorities established by stakeholders at the end of the 2023 legislative session.
Dr. Michael Fine: What’s crazy about primary care in Rhode Island?
July 12, 2024
Good news for Rhode Island! The General Assembly passed two bills and created a study commission to improve access to primary care. Bill 2024-S 2716A establishes a primary care training sites program, funded with $2.7 million. Bill 2024-S 2717A adds $500,000 to the Wavemaker program to help primary care clinicians with student loan repayment. Additionally, a 21-member commission will study Rhode Island’s healthcare workforce, including the potential for a URI medical school. Kudos to Senators Pam Lauria and Sue Sosnowski for their leadership. Investing in primary care leads to better health outcomes and significant cost savings. Read more.
Milbank Memorial Fund: How payment caps can reduce hospital prices and spending: Lessons from the Oregon State Employee Plan
July 10, 2024
Oregon’s 2017 legislation capping hospital payments in the state employee plan led to over $100 million in savings within 27 months by reducing hospital prices, according to a study led by Roslyn C. Murray and colleagues from the Brown University School of Public Health. In a new issue brief, the authors explain this policy and offer key lessons for other states considering hospital payment caps. Rhode Island's Next Generation Affordability Standards work is cited. Read more.
RI Legislative Press: New law will allow graduating nurses to start practicing sooner
June 26, 2024
STATE HOUSE — A new law sponsored by Senate Majority Whip Valarie Lawson and Rep. Stephen M. Casey will allow graduate registered nurses to begin practicing before taking their national licensing exam. The legislation (2024-S 2083, 2024-H 7826), which was part of the Senate’s HEALTH Initiative of legislative priorities, was signed by the governor Tuesday after passage by the General Assembly. Read more.
Rhode Island Current: A good reason to celebrate PrideFest: Survey ranks R.I. first in nation on LGBTQ+ safety
June 17, 2024
Among the bills passed by both House and Senate included a healthcare provider shield law, expanded coverage for PrEP drugs and legislation to make name changes easier in probate court. Read more.
Dr. Nadine Hewamudalige named "40 Under 40" by Providence Business News
June 10, 2024
Congratulations to CTC-RI Board Member Dr. Nadine Hewamudalige, Medical Director for the Providence Community Health Centers, on the award. Read more here.
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Upcoming CTC-RI Committee Meetings and Workgroups
- August 23, 07:30-08:45AM – Board of Directors
- September 11, 08:00-09:00AM – CTC-RI Primary Care Workforce Taskforce
- September 20, 07:30-09:00AM – Clinical Strategy Committee
- September 27, 07:30-08:45AM – Board of Directors
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Upcoming Learning Collaboratives and Professional Development
- August 22, 07:30-08:30AM – Pediatric Sleep ECHO Series
- August 26, 12:00-01:00PM – Healthy Tomorrows Quarterly Learnng Collaborative
- September 05, 07:30-08:30AM – Virtual Coffee Breaks with Dr. Pat Flanagan & Dr. Beth Lange
- September 10, 07:30-09:00AM – Implementing the 4M Model and Supporting Care Partners of People with Dementia: A Path to Level 1 or Level 2 Recognition from Institute for Healthcare Improvement Learning Collaborative
- September 12, 07:30-09:00AM – DULCE Quarterly Learning Collaborative
- September 13, 07:30-09:00AM – PCP/Specialist Forum
- September 17, 08:00-09:00AM – Best Practices in Team-Based Care
- September 17, 12:00-01:00PM – MomsPRN ECHO Series
- September 18, 07:30-09:00AM – CTC-RI Demographic Data Collection Quality Improvement
- September 20, 12:00-01:00PM – IBH Meet and Eat
- September 25, 07:30-08:30AM – ECHO: Best Practices in Addressing Sexually Transmitted Infections (STIs) in Primary Care
- September 26, 07:30-08:30AM – Pediatric Sleep ECHO series
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