Dr. Kerzer and Dr. David featured in CTC newsletter

Published 09/28/2018

For September's Care Transformation Collaborative News update, Dr. Martin Kerzer and Dr. Kristin David were featured for their presentation at the national PCMH Congress forum regarding integrated behavioral health.

The original article can be found at: http://campaign.r20.constantcontact.com/render?m=1102872219705&ca=ea2040ce-3610-4815-8074-9d264226cf1c



Care Transformation Collaborative News
CTC practices present integrated behavioral health findings at PCMH Congress 
Two Care Transformation Collaborative of RI primary care practices - Associates in Primary Care and Providence Community Health Center - were selected to present their work and outcomes at the national PCMH Congress forum. Martin Kerzer D.O., Kristin David Psy.D, and Susanne Campbell CTC Senior Project Director presented "A Successful Blueprint for Integrating Behavioral Health into Primary Care" on the work that Associates in Primary Care has done to implement universal screening for depression, anxiety and substance use disorder within primary care and take a population health approach to better address the needs of patients with behavioral health needs.  
Leaders from Providence Community Health Center Andrew Saal, MD, MPH Chief Medical Officer and Nelly Burdette Psy.D Director of Integrated Behavioral Health discussed the operational and clinical system changes required when scaling the universal screening pilot up to the whole population in their presentation,"Population Health Meets Integrated Behavioral Health within an FQHC."
2019 CTC pediatric expansion applications due Oct. 31
The Care Transformation Collaborative of Rhode Island is planning to expand its pediatric initiative - PCMH-Kids - and has officially opened its Call for Applications. Pediatric primary care practices are encouraged to apply for the January 2019 expansion opportunity before the October 31, 2018 application deadline. 

Accepted practices will receive supplemental payments for three years from health plans in our multi-payer initiative to transform their practice and be recognized as a patient-centered medical home. The added financial incentives enable practices to:
  • Implement team-based care, support the costs of a Care Coordinator in the practice. CTC will assist with the integration of a Care Coordinator into the practice;
  • Improve satisfaction for your patients and a practices care team;
  • Use EMR and data tools to enhance workflows, inform care coordination and meet reporting requirements;
  • Earn additional incentive payments for achieving quality, customer experience, and utilization thresholds; and more.
Best Practice Sharing Corner: Aquidneck Pediatrics, Coastal Waterman and Providence Community Health Center
Our CTC/PCMH Kids practices are doing great work in using the team approach to improve care. At the September Practice Reporting/Transformation Committee meeting, practices discussed what they are doing to improve their performance on clinical quality measures and addressing patient/family needs.  Becky DeConto RN BSN AE-C shared the pre-visit planning tool that Aquidneck Pediatrics medical assistants use which has helped standardize the work flow and led to improvements in their quality measures.  They have recently added to the tool prompts for obtaining medical related social needs information and formed a referral relationship and process for connecting patients with community resources based on identified needs. Beth Lange MD discussed how Coastal Medical Waterman has established an on-site relationship with Evolution Nutrition Services which is used when patients have an "out of range" BMI.

Providence Community Health Center Team Fisher Prairie Avenue has also made an impact in helping patients with reducing their A1C levels, and Team Abroquena at Randall Square has increased alternative visit types and started offering group visits for patients who have diabetes. 
OHIC has provided CTC with an update on their performance and reporting responsibilities. All CTC and PCMH Kids primary care practices are expected to: 
  1. Submit quality performance measures via web survey by October 15, 2018 per the clinical quality measurement specifications which can be found here ; 
  2. Start to plan for meeting the new Cost Management Requirement that builds upon NCQA quality improvement QI 09 element Resource Stewardship 
OHIC has additionally provided practices with updated Frequently Asked Questions with more information on primary care clinical performance expectations.  

Important to note that all CTC and PCMH Kids practices are expected to provide baseline information on the new clinical measures identified in the clinical quality measurement specifications but new measures will be report-only.

Practices will be asked to identify the NCQA resource stewardship measure they will track and monitor in the selected menu item. The Institute for Healthcare Improvement (IHI) provides a performance improvement framework the practice team can use to plan and implement their resource stewardship plan: PLAN/DO/STUDY/ACT (See IHI PDSA Tool for details on how to complete a PDSA). NCQA additionally provides a NCQA Quality Measurement and Improvement Worksheet for documenting the performance plan and results.
Don't miss out on the November 1st Annual Conference!
Jointly provided by CTC and Brown University Medical School, the November 1st CTC Annual Conference is designed to help identify, develop and utilize comprehensive primary care strategies to improve care and lower costs. Key components of the morning program include sessions on recognizing what patients want, building community partnerships, strengthening team based care, collaborating with specialists, and learning about options for state-wide initiatives to improve population health. The afternoon sessions will focus on obtaining and using information to improve care and population health including Neighborhood risk scores, Consumer Engagement Platform, KIDSNET and Medical Home Portal. Interactive Program on What Patients Want will be repeated to increase options for team participation.

The agenda is designed to accommodate attendee work schedules and interests. Attendees may choose
to register for the morning session (7:30am -12:30pm), or afternoon session (1:30-3:30pm) or the full day
program. All CTC practices, past and present, are welcomed to attend. For registration and more information, click here.
Getting Ready to Meet the Customer Experience CAHPS Survey Requirements 
CTC-RI has selected DataStat as its qualified vendor for conducting the customer experience survey (CAHPS). CTC-RI, with financial support from the health plans, covers the costs associated with administering the CAHPS survey for practices currently participating in the CTC-RI program. All CTC-RI practices that are presently participating in the CTC common contract with the health plans are required to meet the CAHPS survey project milestones within the outlined timeframes.

DataStat has prepared a "Starter Kit" which includes important information including link to access the on line portal and required timelines for meeting the CAHPS survey expectations, and sample patient notice that practices can use to encourage participation. Practices are required to complete the DataStat registration by October 9, 2018 and complete the patient data files by 10/26/18.  

As the certified data vendor for this project, DataStat will administer the survey (English, Spanish and Portuguese) and collect data from the patients seen at the practice site using approved NCQA protocols. Conducting the patient experience survey using a standardized survey tool for both adults and childrenwill enable the practice to obtain credit for the NCQA quality improvement competency.  CTC and DataStat will not be submitting data to NCQA for the NCQA "distinction" option as there are added costs associated with submitting data to NCQA for distinction, and practices do not need "distinction" for NCQA quality improvement credit. 
CTC Advances Workforce Development Through Continued Implementation of the Statewide Nurse Care Manager Core Curriculum Training Program
The May 2017 Healthcare Workforce Transformation Report: Preparing the workforce for a healthy Rhode Island calls out the need to teach core concepts of health system and practice transformation by educating the healthcare workforce about the significance of value-based payments, care management, social determinants of health, health equity, population health and data analytics. Recognizing the critical role nurses play in the delivery and transformation of primary care, the Care Transformation Collaborative of Rhode Island committed to addressing this challenge though implementation of a state-wide standardized learning curriculum coupled with coaching by NCM/CC faculty.   
Thanks to a grant from UnitedHealthcare, 139 nurse care managers have successfully completed the xG Learn NCM core curriculum training program with 51 NCM/CC completing the program in September 2018. A key objective of the training is to assist NCM/CC with developing and immediately applying a working knowledge of care management strategies and using Rhode Island resources to meet patient needs. The final "capstone" experience involves learners sharing how they have applied the care management strategies to assist patients/families with complex needs. The September NCM/CC Best Practice Committee meeting provided an opportunity to discuss the evaluation results to date and for NCM/CC to share patient success stories. 
September 2018 Quarterly Breakfast of Champions
CTC hosted another 'Breakfast of Champions' session on September 14 at the Shriners Imperial Room in Cranston with almost 60 participants. Pano Yeracaris, MD MPH led with a CTC program update on the integrated behavioral health qualitative evaluation and preliminary data from the All-Payer Claims Database (APCD). Matthew Salisbury, MD of CharterCARE Medical Associates, Pontiac Avenue office presented on their work with embedding the scribe function within the care team. Wrapping up the morning presentations, Jeannine Casselman of Medical-Legal Partnership Boston (MLPB) gave a talk on team-based social determinants of health (SDOH) care. We would appreciate your feedback and suggestions for future topics using this event survey.
Community Health Teams Highlighted at Health Equity Summit
Over 700 people attended the Health Equity Summit on September 20, 2018 and CTC had a poster presentation highlighting the work of our Community Health Teams (CHTs). The poster described the CHT model and showcased the projects and partnerships across five of the teams. We also showcased the important work that our CHTs are doing with SBIRT screening, completing over 2500 since September 2017.
Roberta Goldman, PhD and Mardia Coleman, MS presented their findings and recommendations from the Qualitative Evaluation for the CTC-RI Integrated Behavioral Health Pilot Program on August 24, 2018 to the CTC Board of Directors who approved it for dissemination. At the September 14 Breakfast of Champions, Pano Yeracaris MD MPH, CTC Chief Clinical Strategist, followed up with a presentation of a Total Cost of Care Analysis demonstrating that the IBH practices had a significantly lower cost of care than the comparison group.
Building capacity around navigating complex social determinants of health
CTC hosted a training with the Medical Legal Partnership of Boston (MLBP) on September 21. The training, entitled "Social Determinants of Health - Moving from What and Why to How" offered Community Health Team (CHT) staff and other community health workers an overview of some of the social factors affecting people's health and well-being. Jeannine Casselman, Esq. from MLBP offered guidance and resources for staff as they work with low-income patients to meet basic needs for food, housing and utilities, education and employment, health care, and personal and family stability and safety.  CTC will continue to work with MLBP on ways to enhance the skills of CHT staff working with clients on complex social issues.
CTC Keynote at Behavioral Health Summit for RI Chapter of Healthcare Executives
Dr. Nelly Burdette, CTC Senior Integrated Behavioral Health Leader was asked to deliver the keynote address at the Behavioral Summit for the RI Chapter of Healthcare Executives. Held at Butler Ray Conference Center on 9/6/18, the presentation was entitled, "Leading Change: Advancing the Behavioral Health of the Population through Integrated Care." Noteworthy topics included proving access for patients with mild-moderate behavioral health conditions in primary care; the basic need for universal screening of depression, anxiety and substance use, developing social determinants of health screenings, and reimbursement models that move from volume to value. 
In the News: "Provider Payment Reform: Right Course, Wrong Students?"
Former Rhode Island Health Insurance Commissioner Christopher Koller, president of Milbank Memorial Fund, wrote a recent blog highlighting provider payment reform:

Provider Payment Reform: Right Course, Wrong Students?
Sep 24, 2018 | Christopher F. Koller, President
For the last eight years, the US health care system, led by Medicare, has been going to school, learning how to do comprehensive provider payment reform. The most important courses have focused on how to improve performance for entire populations of people. Efforts to promote accountable care organizations (ACOs) in particular have attempted to use payment changes to establish a seismic shift in the function of the health care provider: from an individual who produces successful patient encounters to a team member who improves outcomes for an entire population of people.
Recent evaluations of these efforts seem to indicate that some providers in these payment reform efforts are learning the course lessons better than others. While some poor performers might be making excuses and asking to be graded on a curve or making sure their poor grades don't have significant consequences, others have figured out how to succeed without even taking the class. Policymakers should look for opportunities to act on these findings.
Practice Resources
Avenues of Healing: Healthy Mind, Healthy Body
On Saturday, Oct. 13th, mind-body medicine expert, psychotherapist, executive coach, and yoga instructor Courtnay Meletta, MA, will lead a free, enjoyable and educational morning event on breast cancer and survivorship. Details can be found here
Webinar on October 2: The Truth About E-Cigarettes 
Please join the New England QIN-QIO and guest speaker Brian King, PhD, MPH, national tobacco control expert from the CDC on Tuesday, October 2nd from 12:00-1:00 PM. CEU's and CME's available. Registration is available here.
RIBGH 2018 Healthcare Summit on October 5
This year's Rhode Island Business Group on Health Annual Health Care Summit will focus on "Low-value Care Next Steps." How much of a problem is low-value care to RI and what is being done about it? For registration and details, click here.
NICHQ Learning Community Applications Open for Pediatrics Supporting Parents 
This initiative has the ambitious long-term goal of improving pediatric primary care to foster social and emotional development in the same way that it focuses on physical health and cognitive development. Selected family and pediatric practices will take part in a 17-month learning community launching January 2019. Application deadline is October 31 -- for details and application information click here.
Bradley Conference Fall Series 2018
Bradley Hospital is hosting practical, state-of-the-art education for behavioral health, with programs in October and December. Bradley Conference is designed to provide education for psychologists, social workers, physicians, nurses, certified counselors, speech/language and occupational therapists, teachers, milieu associates, and other professionals who work with children, adolescents or adults.  Topics address different behavioral health populations and treatment modalities and are intended to provide practical, state-of-the-art information. For details, click here
Webinar: Back to School - Helping Children and Parents
Starting a new school year is exciting, but can come with mental health challenges for students, teachers, parents and caregivers alike. The importance of initiating back-to-school routines, a positive mindset and leading by example can help make the transition much easier. Dr. Philip Liu, Child and Adolescent Psychiatrist, will discuss methods for families returning to school, cell phone and social media usage, bullying and why children refuse and have anxiety about school. He offers approaches and solutions to each of the different situations. If you are a mental health professional that works closely with school age children, this webinar is sure to help you prepare your patients and their families on how to face challenges throughout the school year. Webinar will be held on October 17 at 1pm, register here.
Updates and News from the Immunization Community
The 2017-18 flu season was exceedingly difficult, in part because of low vaccine effectiveness. There were 178 pediatric deaths during the 2017-18 flu season compared to 93 in the 2015-16 season
and 110 in the 2016-17 season. The Immunization schedules for the 2018-19 season are now available for review and printing, along with additional news updates and information on immunization, available here
Mental Health First Aid Training: Suicide Screening and Prevention
Mental Health First Aid is an eight-hour course that gives people the skills to help someone who is developing a mental health problem or experiencing a mental health crisis. The evidence behind the program demonstrates that it does build mental health literacy, helping the public identify, understand, and respond to signs of mental illness. Upcoming November and December trainings focused on suicide screening and prevention can be found here.
Finger on the Pulse: Stay Social with Rhode Island Quality Institute
Have you checked out RIQI on Facebook, Twitter or LinkedIn? Follow us to stay up-to-date on what we are doing in the community. We post updates on CMS regulation changes, the latest TCPi news, health awareness tips and information on upcoming events.  
Follow us on FacebookTwitter, and LinkedIn
2018 TCPi National Expert Panel Conference Roundup 
Members of the RIQI TCPi practice transformation team travelled to Columbia, Maryland in August to attend the 2018 National Expert Panel Conference. The conference recognized Exemplar Practices in the TCPi program. RIQI brought representatives from CODAC Behavioral Health, South County Health, University Orthopedics and University Surgical Associates. Our clinicians did an amazing job sharing their successes and stories of how RIQI helps them with their practice transformation. We are so honored that these Rhode Island practices are nationally recognized as outstanding organizations. Check out pictures from the conference!
Questions? Get in touch: Susan Dettling (401.276.9141 x236, sdettling@riqi.org)
Mark your calendar for this upcoming Educational Event
Webinar: Friday, November 2, 2018 ▪ 7:30 AM - 9:00 AM
Hot HIPAA Topics with Linn Freedman

RIQI's annual live Webinar presentation with industry leading privacy and security attorney Linn Foster Freedman of Robinson & Cole LLP will focus on hot topics related to privacy and security and HIPAA compliance. This session will also offer certification to fulfill your annual HIPAA training requirement. 

For more information about participating in TCPI, please contact us at info@riqi.org or 888.858.4815.
Upcoming Meetings (for CTC members)

October 11, 2018, 07:30-08:30AM - Quarterly Adult IBH Program Meeting (RIQI)
October 12, 2018, 10:00-11:30AM - Community Health Team Best Practice Meeting (formerly CHT Implementation meeting) (Warwick Public Library)
October 16, 2018, 08:00-09:30AM - NCM/Care Coordinator Best Practice Sharing (301 Metro Center Blvd)
October 17, 2018, 03:00-04:30PM - SBIRT/CHT Executive Committee Meeting (RIQI)
October 19, 2018, 07:30-09:00AM - Clinical Strategy Committee (Brown Physician Patient Center)
October 24, 2018, 08:00-09:30AM - Practice Reporting and Transformation Committee (RIQI)
October 28, 2018, 07:30-08:45AM - Board of Directors (HCA)
Care Transformation Collaborative of RI | ctc-ri@ctc-ri.org | ctc-ri.org