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Care Transformation Collaborative of RI
News & Updates | June 2023
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Spotlight: Supporting the nursing student pipeline to bolster the primary care workforce
As CTC-RI works to bring industry leaders and voices to the table to collaborate and address Rhode Island's primary care workforce crisis, one important avenue to address is our pipeline for nurse care managers. To help primary care practices provide quality care and better outcomes, nursing schools must provide primary care-centered education opportunities and properly trained educators to lead them. We asked University of Rhode Island College of Nursing professor Ginette Ferszt PhD, RN, PMHCNS-BC, FAAN, to share her insight following a recent presentation to CTC-RI.
Rhode Island's primary care industry is currently facing a workforce shortage - in which ways are nurses uniquely impacted by this challenge?
The healthcare workforce shortage is continuing to have a significant impact on practicing nurses. Since insufficient staffing has a negative impact on patient outcomes, nurses are experiencing heightened stress and job dissatisfaction. When nurses are unable to meet patient care needs, their morale is affected. During the pandemic, approximately 100,000 nurses left the workforce and have not been replaced. We cannot afford to lose more nurses in the healthcare sector.
In which ways are you working to address the current workforce challenges?
CTC-RI is continuing to make major strides in addressing issues in the delivery of primary care and is well positioned to be a leader in supporting the education of nurses to move into the positions of nurse care managers. My work as a CTC-RI consultant is focused on having nursing students precepted by experienced nurse care managers who are working in primary care practices and have completed the nurse care manager core curriculum training program. I continue to be a member of the American Nurses Association and the American Association of Critical-Care Nurses and actively support their efforts to advocate for legislation that will increase the workforce.
What opportunities lie ahead for supporting the industry, collaboration, and the future workforce?
Partnerships between healthcare organizations, educational institutions, government and industry associations are essential in developing long-term solutions to address the critical shortage in the healthcare sector. Some important solutions that have been identified are funding for capital projects that will increase laboratories and simulation, increase in salaries for nurses, grants and scholarships to increase diversity, payment for transportation and daycare for associate degree nurses to obtain their baccalaureate degree, and incentives for retired nurses and nursing faculty to return to the workforce. Nurses need to increase their participation in local, state and national initiatives to ensure that our voice is heard.
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Apply now! Free Nurse Care Manager / Care Coordinator G-learn Core Curriculum Program
CTC-RI is excited to invite a new cohort of Nurse Care Managers / Care Coordinators (NCM/CC) to participate in the fall 2023 NCM/CC Standardized Core Curriculum G-learn Program. Now in its sixth year, the program was developed in partnership with Geisinger to meet our primary care community’s requests for more care management training in Rhode Island. The 12-15 week program, running September 2023 through January 2024, supports NCM/CCs to apply key care management concepts in their primary care practices.
Participants will complete up to 23 online interactive modules on topics such as criteria-based level of care determination, care management approaches for targeted high-risk conditions, and transitions of care and time management. Online learning is supplemented by a weekly small-group call with RI-based trained faculty to discuss concepts and real-world application. All learners will complete a case study capstone presentation at the close of the program and will be able to earn up to 18.5 CEUs for their participation.
This program is offered free-of-charge to RI NCM/CCs through generous support from UnitedHealthcare and the RI Department of Health. Applications are due by July 24. Learn more and apply. Questions can be directed to Michelle Mooney, mmooney@ctc-ri.org.
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CTC-RI continues targeted healthcare workforce development efforts
CTC-RI is committed to supporting healthcare workforce development efforts across disciplines. Our new Primary Care Provider Workforce Development Committee, co-chaired by Drs. Jeffrey Borkan and Denise Coppa, is hard at work drafting a strategic plan. As this roadmap is developed, we're continuing efforts to support the workforce, so stay tuned for updates on CTC-RI's progress in these important areas:
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Nurse Care Managers: Our G-learn training series is for nurses in the field and 4th-year nursing students.
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Integrated behavioral health (IBH) clinicians: We are incentivizing new IBH clinicians to complete the UMass Integrated Care Curriculum to deepen their clinical skills, with a new cohort available in fall 2023. Monthly “Meet and Eats” offer IBH clinicians peer support and consultation.
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Community health workers: We're helping community health workers connect to training efforts through the DULCE project and Rhode to Equity monthly training and network meeting.
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Pharmacists: Pharmacists are leading our data-driven quality improvement project to increase team capacity for using professional use continuous glucose monitoring for patients with diabetes.
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Breakfast of Champions focuses on improving care teams to support primary care
In an exciting June Breakfast of Champions meeting, CTC-RI hosted Paul Del Guercio, MD, Southcoast Family Medicine, Steven Moberg, Chief Operating Officer, Team Care Medicine, Allyson Manning, RN, Team Care Medicine, and Arnold Goldberg, MD, Thundermist Health Center Warwick Associate Program Director. Dr. Del Guercio spoke to his practice’s experience leveraging the team care model which engages the use of team care assistants to reduce provider workload and burnout. Steven Moberg and Allyson Manning spoke to implementation, benefits of and training on the Team Care Medicine model. Dr. Goldberg followed up with a presentation on the Brown/Kent Residency at Thundermist West Warwick focusing on the team members and key characteristics of a high-performing team. To view the recording, find additional resources and claim CME credit, check out our page on CME Coursework.
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Join us on June 20! Team-Based Care: Upstream USA
Learn from Upstream USA, a national nonprofit working to expand equitable access to contraceptive care and reduce unplanned pregnancy. The hour-long session (June 20, 8-9am) will explore how this program has been implemented in partner health centers in Rhode Island to assess pregnancy intent and support contraceptive care, a critical component of patient-centered, equitable primary care. In addition, attendees will learn more about this initiative from the perspective of two primary care practices they have worked with in Rhode Island. CEU credits will be available. Details and registration here.
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RI MomsPRN Learning Collaborative: Housing Fundamentals – What Care Teams Need to Know
Last month, the RI Maternal Psychiatry Resource Network (RI MomsPRN) program, funded by the RI Department of Health and in partnership with CTC-RI, hosted a learning collaborative meeting with nine practices focused on housing fundamentals for care teams.
Led by Jeannine Casselman, JD of MLPB, practices learned about policies that impact housing availability and access, legal protections, and problem-solving strategies to barriers impacting housing stability. At the meeting, practices reported on their progress in implementing universal screening of their perinatal patient population given the conclusion of their yearlong continuation efforts (access the session recording here).
As a reminder, providers and health care staff seeing pregnant and postpartum people are welcome to contact the RI MomsPRN teleconsultation line (401-430-2800 or RIMomsPRN@CareNE.org) M-F, 8-4pm for real-time assistance. Behavioral health clinicians from Women & Infants Hospital, including specialized psychiatrists, psychologists, and resource and referral specialists, are available for clinical consultation on diagnosis, treatment planning medication safety, and resource and referral support. Note: RI MomsPRN is not a patient/public-facing line.
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A year ago, seven primary care practices joined our second Health Transitions of Care learning collaborative to improve transitions from pediatric to adult health care. Last month, they presented at our final meeting to share their experience, patient success stories, discuss sustainability, and next steps. CTC-RI presented the practices' results, along with patient feedback.
The practice assessment of activities looked at the six core elements of health transitions and also considered young adult and parent/caregiver feedback and leadership. On patient feedback, 87.5% of the young adults surveyed felt that they had been sufficiently prepared to move to an adult provider. Practices reported a positive experience incorporating workflows to support transition activities and partnering with young adults to transition. Increased provider discussion around this topic has occurred, and a broader system of care approach is being explored to ensure a smooth transition process for more young adults.
This learning collaborative was supported by the RI Department of Health and Tufts Health Plan. (Access the meeting recording here or presentation slides here). Stay tuned as an additional learning collaborative opportunity will be available tentatively for November 2023.
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Clinical Strategy meeting focuses on investing in communities
The May Clinical Strategy Committee focused on investing in communities, featuring a presentation from Nationwide Children's Hospital. Christine Sander, Senior Director of Infant & Child Wellness, leader of the hospital’s Pediatric Vital Signs initiative, and director of the Ohio Better Birth Outcomes Collaborative, spoke about Partners for Kids. This program focuses on improving the health of children through high-value, innovative care and community partnerships. Nick Jones, Vice President for Community Wellness, spoke about the hospital’s Healthy Neighborhoods Healthy Families initiative which focuses on helping families with affordable housing and workforce training. Following their presentation, Zachary Nieder, RI Foundation Senior Strategic Initiative Officer, Larry Warner, DrPH, United Way Chief Impact and Equity Officer, and Garry Bliss, Prospect CharterCARE PHSRI-Medicaid AE Program Director, each spoke to their organization’s work in the community and the need for further RI initiatives.
June’s Clinical Strategy Meeting will focus on Massachusetts Medicaid (MassHealth) primary care health reform and social risk adjustment. We welcome presenters from MassHealth including Martha Farlow, MHA, Policy Director, Sonali Duggal, MBA, Integrated Fiscal Strategy Director, Tadelech Mengesha, MPP, Integrated Fiscal Strategy Deputy Director, and Mohammad Dar, MD, Senior Medical Director, as well as Arlene Ash, PhD, MS, Professor and Chief, Div. Biostatistics & Health Services Research, Dept Quantitative Health Sciences, UMass Chan Medical School.

All are invited to attend our monthly Clinical Strategy meetings. To view the recording, find additional resources and claim CME credit, check out our page on CME Coursework.
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Care Coordination First ECHO Learning Session: Entitlement to Eligibility
In May, CTC-RI kicked off the first of its seven-session Care Coordination ECHO series, funded by the RI Department of Health, on improving care coordination for families with young adults with special healthcare needs transitioning from pediatric to adult care.
The first session, with 59 attendees, focused on Entitlement Eligibility. Our RIPIN presenters, Tara Hayes, Family Voices Manager and Stephanie Trafka, Family Voices Health Research Support Specialist, provided a case presentation on challenges that families experience in transitioning from pediatric to adult healthcare services. They led an open discussion about opportunities for transition process improvement, ways partnering with RIPIN can help families and professionals navigate the process together, and how the Medical Home Portal is a resource.
(Access the meeting recording, presentation slides, and meeting evaluation for CME/CEU credit or a certificate of participation).
The next session is on June 29, 7:30-8:30am. Register here. Questions? Reach out to Kim Nguyen-Leite at knguyenleite@ctc-ri.org.
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Announcing our second keynote speaker for the CTC-RI Annual Conference! | |
CTC-RI is excited to announce our Annual Conference second keynote speaker: Scott Conard, MD, DABFP, FAAFM, CEO, Converging Health. Board-certified in family and integrative medicine, Dr. Conard has been seeing patients for over 35 years and was a UTHSCD Associate Clinical Professor for 21 years. He has been the principal investigator in over 60 clinical trials, written many articles, and published five books on health, wellbeing, leadership and empowerment.
Starting as a solo practitioner, Dr. Conard grew his medical practice to over 510 clinicians over the following 20 years. In its final form, the practice was a value-based integrated delivery network (IDN) that reduced the cost of care dramatically through prevention and proactive engagement. When this was acquired by a hospital system, he became the Chief Medical Officer for a brokerage/consulting firm and an innovation lab for effective health risk reducing interventions. Read more.
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Missed CTC-RI meeting or learning session? Catch up here! | | |
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CTC-RI offers CME credits for select meetings, including asynchronous viewing of meeting recordings. Learn more and access evaluation forms here.
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Medicaid Pediatric Healthcare Recovery Program Behavioral Health ECHO® Learning Series | Medication Management in Pediatrics | May 2023 (presentation and recording)
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ECHO® Learning Series - Support for Care Givers | May 25, 2023 (evaluation)
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ECHO® Learning Series - Understanding and Responding to Dementia Related Behaviors | May 11, 2023 (evaluation)
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Practice Resources, News, and Information | | |
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MLPB May Update: Spotlight on Rhode Island!
Access news and resources from MLPB's newsletter here. We're proud to see this month's newsletter spotlight our work in Rhode Island, with our Rhode to Equity conference!
PCPAC Meeting: Hepatitis C Treatment in the Primary Care Setting
The Primary Care Physician Advisory Committee invites you to attend their upcoming meeting (June 21, 7:30-8:30am) on the current epidemiology of hepatitis C, the diagnosis of hepatitis C, and the current treatment and management of hepatitis C in the primary care setting. Details.
Affordable Connectivity Program (ACP) - Discounts on internet for eligible households
Now through June 22, Online for All is running a Week of Action, hosted by U.S. Department of Education and Civic Nation, to create awareness about the Affordable Connectivity Program (ACP), to help ensure that eligible households can afford the broadband they need for work, school, healthcare and more. Stakeholders from industry, education, nonprofits, and other sectors are committing to outreach and events to raise awareness of and encourage enrollment in the ACP. This fact sheet includes a number of resources for participants, including a communications tool kit, and information on training. To sign-up or request more information on the ACP Week of Action please visit onlineforall.org or email onlineforall@civicnation.org.
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Upcoming CTC-RI Committee Meetings and Workgroups
- June 16, 07:30-09:00AM – Clinical Strategy Committee
- June 23, 07:30-08:45AM – Board of Directors
- July 10, 07:30-09:00AM – Prior Authorization Meeting
- July 12, 08:00-09:00AM – Taskforce of Primary Care Provider Workforce
- July 21, 07:30-09:00AM – Clinical Strategy Committee
- July 28, 07:30-08:45AM – Board of Directors
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Upcoming Learning Collaboratives and Professional Development
- June 15, 07:30-08:30AM – Pediatric Weight Management ECHO® Session
- June 16, 12:00-01:00PM – Integrated Behavioral Health Meet and Eat
- June 20, 08:00-09:00AM – Best Practices in Team-Based Care (formerly NCM/CC Best Practice Sharing)
- June 21, 08:00-09:30AM – Care + Community + Equity Best Practice Sharing
- June 22, 07:30-08:30AM – Medicaid Recovery Program BH ECHO Learning Session - Suicide Risk, Prevention & Tools
- June 29, 07:30-09:00AM – Care Coordination ECHO® Session #2
- July 13, 07:30-08:30PM – Improving Child Health in RI (formerly PCMH-Kids Stakeholder Meeting)
- July 18, 08:00-09:00AM – Best Practices in Team Based Care (formerly NCM/CC Best Practice Sharing)
- July 19, 07:30-09:00AM – Asthma QI Learning Collaborative
- July 20, 07:30-08:30AM – Pediatric Weight Management Best Practice Sharing
- July 21, 12:00-01:00PM – Integrated Behavioral Health Meet and Eat
- July 26, 07:30-08:30AM – Care Coordination ECHO Series
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