PROVIDENCE – The orientation for representatives of the 25 new primary care practices that have been selected to join the latest expansion of the R.I. Chronic Care Sustainability Initiative, or CSI-RI, took place on a cold, rainy December evening on Dec. 9, after a day of constant downpours.

To judge from the faces of many of those who filled the medical school lecture hall at Brown University, it had been a long day at work. And, as much as they were there to embark on a new journey to lead them toward the promised land of a more rewarding way to practice medicine, one that is patient-focused, coordinated, accessible and team-based, their enthusiasm seemed tempered by a realistic understanding of the hard work required to get there.

If changing behaviors of patients is difficult, changing the cultures and traditions at a medical practice may be even harder [a topic addressed during the orientation session by both Dr. Tom Bledsoe and Dr. Pano Yeracaris, co-director of CSI-RI].

Hittner as cheerleader
Dr. Kathleen Hittner, the R.I. Health Insurance Commissioner, served in the role of cheerleader for the new primary care practices, welcoming them on their journey.

Hittner began from a perch high up on the mountain of health care policy transformation, talking about the way in which the affordability standards introduced by her predecessor, Christopher F. Koller, were a way “to make health care more affordable and the increase in costs more predictable in the future.”

Hittner briefly explained the standards, what they are, how they worked, and what changes she had planned in the future. The first standard introduced by Koller had increased the spend that insurance carriers made on primary care by 1 percent a year, resulting in a net increase of $62 million more dollars in primary care, according to Hittner. In turn, she continued, the overall “rate of spend” for primary care went from 5.7 percent to 10.7 percent.

Some of that money, Hittner said, went to support the CSI-RI project, and some also went to fund CurrentCare, the state’s health information exchange managed by the R.I. Quality Institute, which she said was considered by state officials to be part of primary care. [Hittner did not give a more detailed breakdown of what was considered “primary care” spending.]

Moving forward, Hittner promised that “we are going to support the CSI-RI project and CurrentCare."

Hittner said there were two things that were needed to transform the way that health care is delivered: the all-payer, patient-centered home model of care – “and you guys are all working on that, and that’s what we want” – and changing the way we pay for services.

“I’m very proud of all of you, and the work you do. I think getting going on this kind of project is just great,” she said. “I think you can rest assured those offices that have done it are quite happy they have done it, and all of them feel better about their practice.”

With CSI-RI, Hittner continued, “that’s where we’re going to see a decrease in costs that should demonstrate we’re saving the system money.”

The nitty-gritty
Much of the content of the orientation involved the nitty-gritty of practice transformation, team-based care, developing workflows, improving quality reporting, and engaged leadership.

The strategic work at the implementation level of patient-centered medical homes is the kind of health care innovation tool that could become a marketable export for Rhode Island, as the concept of PCMH expands nationwide.

Before the session, ConvergenceRI sat down with CSI-RI co-directors Debra Hurwitz and Dr. Pano Yeracaris to talk about the transformation of health care in Rhode Island and the changing landscape.

ConvergenceRI: Can you provide a framework for what is happening in Rhode Island? How do you see the changing landscape?
HURWITZ: There is a lot going on. We’re still waiting to hear about the SIM [State Innovation Model]. Our fingers are crossed.

YERACARIS: It has big potential [for Rhode Island]. In the SIM application, CSI-RI is framed as the kind of model [for care delivery transformation] and a framework that can be used to move forward.

It recognizes the value of high-quality delivery of primary care. That is our mission, using patient-centered medical homes and teamwork to put the focus on patient populations and communities, [achieving] high-quality care and cost-effectiveness.

In our [latest] expansion, we are going from 48 to 73 practices.

ConvergenceRI: Are there other models of care that would be willing to endorse, within your framework? How does an Accountable Care Organization, or a Neighborhood Health Station, fit within your framework? Is there enough room for friendly collaboration?
HURWITZ: It’s something we’re talking about right now. There’s a lot of [health care delivery] transformation work going on in the state, in primary care. We are seeing a market place change, we’re seeing more change toward ACOs. The challenge for us is to figure out how we get primary care practices to go through the contracts we have now and come out on the other side, ready to engage in an Accountable Care Organization and shared savings, in a continuum that moves forward in a more integrated alignment.

YERACARIS: We’re not the end-all-to-get-all; we’re more like the base of a foundation to get something started. It’s my personal view, and not the rest of the organization’s, that we’re focusing on what’s best for the citizens of Rhode Island, in terms of health, and a focus on the impact on the quality of life. It doesn’t matter who does it, as much as that it’s the principle, moving forward.

ConvergenceRI: Have you had any interaction with the R.I. Department of Health and their new program to fund Health Equity Zones through the Centers for Health, Equity and Wellness, to talk about collaboration?
HURWITZ: We just met with Ana Novais [the director of the CHEW program] this morning to talk about that. The R.I. Department of Health is leading the way nationally, we are actively collaborating, and we want to find out ways we can collaborate even more, with individuals combining awareness and health literacy and how that connects to patient-centered medical homes.

ConvergenceRI: What kinds of research are you conducting on the CSI-RI initiative?
HURWITZ: We have three different data streams the R.I. Quality Institute is [helping us to manage]. Some of the data is from practices. It gets analyzed and fed in, checked for accuracy, it gets assembled and put on the website, and practices can look at their quality metrics.

The Institute is also managing patient surveys, retaining a third-party vendor. Once a year we get the data back and analyze it.

A third [data stream] is around claims data and how we get utilization statistics. We are working with Research Triangle Associates, contracted through the R.I. Quality Institute.

ConvergenceRI: Are both community health teams up and running, in Pawtucket and in South County? You’re using the NextGen IT system through Blackstone Valley Community Health Care, correct?
YERACARIS: Yes, both community health teams are up and running now, and they are using the NextGen Electronic Health Record system.

ConvergenceRI: Does it have the potential to provide population health management analytics for CSI-RI?
HURWITZ: I think what we’re going to see next in terms of Big Data is the All Payers Claims Database [APCD] when it goes live.

We’re looking forward to our first set of reports; they’re on track for delivering reports to CSI-RI in April. That’s what we’ve been told. It will be a tremendous vehicle to get in the hands of patients.

ConvergenceRI: Have you heard about the new research consortium being developed by Stephen Buka at Brown University, focused on metrics and outcomes for early childhood education programs on a statewide basis?
HURWITZ: No. We are planning to conduct a program evaluation, comparing our work to other states. Since that time, we’ve gotten more data to look at quality and metrics. We’re planning to work with Ira Wilson and the Quality Institute to do another, more robust program evaluation, looking at what’s working and what isn’t working.

ConvergenceRI: At the Rhode Island Business Group on Health event this fall, you [Dr. Yeracaris] said you disagreed with Stephen Farrell, the head of UnitedHealthcare of New England. Can you elaborate?
YERACARIS: I don’t remember exactly what I said. I believe I was saying that the human component is still very important, that relationships matter. Data is important, technology is important, but relationships are also very important.”