Part Two

PROVIDENCE – One of the more glaring omissions from the smart growth conversations and agenda at the 2018 Power of Place summit organized by Grow Smart RI was the lack of discussion about the ways that a community’s access to primary health care was linked to future smart growth opportunities.

Yes, Dr. Nicole Alexander-Scott, director of the R.I. Department of Health, received one of five 2018 Smart Growth awards, as an “Outstanding Smart Growth Leader,” for her championing of 10 health equity zones in Rhode Island, community-based groups that seek to develop local solutions to health, economic and social disparities, for which she received a standing ovation.

Right before the award ceremony, Alexander-Scott personally thanked ConvergenceRI for continued reporting on health equity zones, in particular, last week’s story, “The team sport of community building and convergence.” [See link to ConvergenceRI story below.]

But no, Alexander-Scott had not been invited to speak at the summit, nor had health equity zones been featured as one of the topics in the breakout sessions, a lost opportunity for convergence. The folks with whom ConvergenceRI sat with during lunch said that they have never heard anything about health equity zones.

And, surprisingly, one of the board members of Grow Smart RI, when questioned about the absence at the summit of any discussions about access to primary care as a function of building smart, resilient communities, rejected the idea that primary care was an important factor in community building.

Late for the summit
ConvergenceRI had been late for the summit, choosing instead to attend an early morning session at the Marriott on Orms Street about the “State of Primary Care in Rhode Island,” hosted by the Care Transformation Collaborative of Rhode Island, the R.I. Office of the Health Insurance Commissioner, and the R.I. Executive Office of Health and Human Services, which drew more than a hundred participants, talking about the challenges of expanding primary care and integrating behavioral health care within an all-payer patient-centered medical home model.

The Care Transformation Collaborative was founded in 2008 as a pilot program under the leadership of former R.I. Health Insurance Christopher Koller, with five pilot sites, to test the model of an all-payer, patient-centered medical home model for primary care in Rhode Island.

During the last decade, it has expanded to 106 adult and pediatric primary care sites and 665 providers, serving approximately 550,000 Rhode Islanders, including internal medicine, family medicine and pediatric practices, according to 2016-2017 annual report.

Four major health plans in Rhode Island provide direct support for the practices through a common contract, which includes supplemental per member per month payments designed to drive practice transformation and quality improvement.

In addition, under the affordability standards created under the authority of the R.I. Office of the Health Insurance Commissioner, commercial health insurers in Rhode Island were required to increase their investments in primary care [which grew from 5 percent in 2008 to nearly 11 percent in 2014], according to Dr. Thomas Bledsoe, a physician with Brown Medicine, in a letter in the 2016-2017 annual report.

In 2016, according to data from the state’s All-Payer Claims Database, the practices under the Care Transformation Collaborative achieved a $217 million reduction in total cost of care, compared to non-patient centered medical homes in Rhode Island.

In addition, under an Integrated Behavioral Health initiative begun in 2015, patients who are part the Care Transformation Collaborative umbrella have been universally screened for depression, anxiety and substance-use disorders, and then connected to onsite behavioral health clinicians embedded in the primary care practices.

Further, an initial pilot program to test the value of community health teams was launched in 2014, to address high-risk patients with complex care needs. That program was then expanded in 2017, with funding from the federal State Innovation Model grant and the R.I. Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals.

An inflection point
For all the accomplishments of the Care Transformation Collaborative in the last decade, the development of the patient-centered medical home has reached what might be termed an inflection point.

Much of the conversation at the March 29 session involved the challenges moving forward: the difficulty in attracting and retaining primary care physicians, given the relatively low starting salaries in Rhode Island, compared to neighboring states; the increasing burden of electronic health records and the decreasing amount of time spent with patients; the reality that the funds from the State Innovation Model program will run out this year; the expansion of Accountable Care Organizations and Accountable Entities that are part of hospital systems; the need for higher reimbursement rates from health insurers; and the challenges posed when primary care practices expand their screening for depression.

After the session, ConvergenceRI asked Blue Cross & Blue Shield of Rhode Island, which has made major investments in the concept of patient-centered medical homes [totaling nearly $80 million in the last five years, according to Kim Keck, president and CEO of the health insurer, in an 2017 interview], to frame the importance of the investment in primary care and the Care Transformation Collaborative moving forward.

“Blue Cross continues to support the efforts of the Care Transformation Collaborative to grow this initiative, as we strongly believe that transforming primary care practices into ones that can become part of accountable systems of care, which ultimately can result in lower costs, but, more importantly, can improve quality and patient outcomes,” said Dr. Gus Manocchia, the chief medical officer.

“The CTC has played a predominant and vital role to function as an incubator so that a primary care practice can enter the program and emerge as a transformed practice with the necessary infrastructure to operate within an accountable care organization structure,” he continued.

“We continue to see signs of positive momentum in the impact patient-centered medical homes are having on the health care environment, particularly in areas of clinical quality,” he said, adding that it was difficult to accurately quantify the return on investment.

“We can see that costs are going down, but that view doesn’t always include the infrastructure investments needed to help a primary care practice become a patient-centered medical home,” Manocchia explained. “We do know that those practices that have been practicing as a PCMH the longest are the ones showing the most impact on cost reduction.”

In her interview in September of 2017, Keck stressed that clinical outcomes were the priority when looking at the return on investment in primary care. “The returns [on investment] that I look at, first and foremost, are the outcomes, not so much in ROI analytics, but in clinical outcomes,” she told ConvergenceRI.

“The results we talk about are things like reductions in avoidable ER admissions, something like [reductions] of close to 20 percent in avoidable ER emissions. And, increased screening for certain cancers, like a 20 percent increase in breast cancer screening.”

No crossovers
There were few if any crossovers, besides ConvergenceRI, who attended both sessions: the Power of Place summit and the State of Primary Care, which was a shame, given the numerous potential intersections in the conversations around content and a sense of place. [The existing silos appear to be as strong and inflexible as the steel beams in both new construction and older former bank office buildings.]

Investing in primary care with a sense of place
The day after the summit, on Friday, March 30, The Rhode Island Foundation announced new funding focused on primary care interventions with a sense of place:

• Blackstone Valley Community Health Care received $70,000 to add health coaches to its primary care teams, in order to promote health behavior change and bridge linguistic and cultural barriers between its medical staff and its patients. “We provide care to 60 or 70 percent of the population of Central Falls,” said Ray Lavoie, executive director of the community health center, in the news release.

Deploying health coaches within a single clinical enterprise that can instantly produce clinical data on patients, Lavoie continued, “has potential to have a profound impact on the public health of an entire community that has high levels of poverty, unemployment and poor health outcomes.”

Blackstone Valley said it intended to recruit participants in the Community Health Worker Training program at Rhode Island College, using the grant to pay stipends to the participants.

• The city of Central Falls received $35,000 to help develop partnerships between the city’s EMS services and nearby urgent care centers, starting with the urgent care center at the Neighborhood Health Station in Central Falls run by Blackstone Valley.

“These partnerships will help us make sure that EMS is available whenever it is needed, and that Central Falls residents have access to the urgent care and primary care they need,” said Mayor James Diossa in the news release.

The goals, according to Diossa, include improving the delivery of primary health care, reducing instances of non-emergency 911 calls, reducing the number of non-emergent emergency room transports, and reducing the number of Central Falls residents being re-admitted to hospitals due to poor management of chronic disease. [Diossa received a Smart Growth award for his work on the Central Falls Green & Complete Streets initiative.]

• The Scituate Health Alliance, a rural Neighborhood Health Station, received $35,000 to support the cost of providing a town nurse. Working in collaboration with primary care providers at Well One, social service agencies, religious and volunteer groups, the local libraries and other partners, the town nurse helps ensure that the community’s primary health care needs are being met.

According to the Alliance, Scituate is the only town in the U.S. to guarantee residents access to primary medical and dental care.

“Despite the fact that there is a great deal of evidence of the value of primary medical and dental care for prevention, early detection and treatment for health concerns, far too many members of our community need assistance in order to take advantage of these services,” said Lynn Blanchette, PhD, RN, vice president of the Alliance. “Retaining the town nurse will enable this program to grow and ensure that unmet primary care needs at the individual and population level are being met, through community assessment, program planning and evaluation.”