Delivery of Care

Innovations at work in primary care in Rhode Island

The positive story you may have never heard about or read about

Image courtesy of YouTube

The success of the Care Transformation Collaborative in Rhode Island has Massachusetts in awe, according to Marie Ganim, the R.I. Health Insurance Commissioner.

By Richard Asinof
Posted 11/11/19
The story of how the Care Transformation Collaborative has reshaped the delivery of primary care in Rhode Island remains mostly an untold, unheralded tale of how Rhode Island is a national leader in innovation in health care delivery, which had Massachusetts officials saying they are in awe of what has been done.
Who will provide the impetus to change the practice of asking about pain as a vital sign of health? What happens when patients talk back to doctors, challenging the need for unnecessary tests? What is the role of nurses in the future health care delivery system as participants in decision-making at the executive level? What is the average waiting time to secure an appointment at a primary care practice in Rhode Island? How are denials of claims factored into analyses of the All Payer Claims Database when looking at costs? When will the state consider increasing Medicaid rates for behavioral health and mental health services as a way to address the growing unmet needs in Rhode Island? Why does the Providence Journal editorial board continue to flog the failed attempts to merge Lifespan and Care New England health systems, attempting to put the blame on Care New England?
One of the delights of attending the Care Transformation Collaborative annual conference was the opportunity to visit the numerous tables of groups and organizations in the lobby, checking in with those staffing the tables about what they believed to be the most pressing health issues they were confronting in their day-to-day delivery of services. Many of the organizations, it turned out, were subscribers to ConvergenceRI, and though they had not met me personally before, they shared with me how much they appreciated the digital news platform, which was regularly shared with them, and the in-depth coverage I provided.
Collaboration is hard work; sharing is often harder. Having the opportunity to hear directly from readers of ConvergenceRI, to engage with them in conversation, to listen to what matters most about health care to them, was an antidote to the tendency of people to talk at you in conferences.

WARWICK – What we talk about when we talk about health care is a complicated, convoluted topic of public discourse.

All health care is personal, all health care is political, and much of what we know about health care is driven by our personal experiences and ability to access care and to afford to pay the bills for such care.

We all have our own stories to tell, most of which do not find their ways into the news, except when the outrage becomes too great to ignore.

Alas, there is little common ground to be found in the political discussions around health care, particularly when it comes to electoral politics, except that the current status quo is not working, in large part because of the ever-rising costs of medical expenses.

We face demographic challenges of an aging population, living longer, beset by chronic diseases such as diabetes, heart disease, and Alzheimer’s. For the last two years, we have seen a decrease in life expectancy in the U.S. for the first time in two decades, tied to the growing epidemic of deaths from substance use and abuse, a symptom of the health care malaise, what sociologists have called the diseases of despair, linking the rising number of deaths from alcohol, suicide and drugs to economic failings. The escalating costs of treating a rising plague of chronic diseases threatens to bankrupt our current system of care. And, the public health threats from man-made climate change – from drought to floods to fires to the spread of infectious diseases such as Dengue, Zika and malaria – become more pronounced every day.

The hot topic for voters in the 2020 Presidential campaign will be health care, if you ask voters what issue matters most to them. [Here in Rhode Island, the big question is whether political polling by news media outlets will include questions about health care, broken down by gender, income and age.]

The great divide, at least among Democratic presidential candidates, is about how to solve the health care delivery morass. Or, simply put, will a national Medicare For All health plan cost too much to implement, even as health care costs threaten to overwhelm American families.

[The irony, of course, is that many of the commentators and reporters on TV, because they have health care plans paid mostly by their employers, are often immune from the terrible personal choices many Americans face around health care.]

Meanwhile, back in Rhode Island
Here in Rhode Island, the health care industry is one of the cornerstones of the state’s current and future economic prosperity, representing the largest sector of private employment as well as the largest projected job creator.

Rhode Island, with its relatively small, stable population of 1 million residents, has provided a proving ground for many innovations in the delivery of health care.

In the last few years, thanks to the leadership of the R.I. Department of Health, the vernacular around health care has changed, to begin to talk about health equity when we talk about the health of communities, recognizing that 80 percent of health outcomes are tied to what happens in communities, while 10 percent is tied to genetics and another 10 percent is tied to clinical interventions.

The sustained growth of Health Equity Zones in Rhode Island, working at the community level to create solutions that adhere to the needs identified by community assessments, puts the state at the forefront of health innovation in the nation.

Similarly, the Neighborhood Health Station in Central Falls, developed by the Blackstone Valley Community Health Care Center, offers a different model of delivering integrated primary and urgent health care to an underserved community.

One of the biggest breakthroughs in health equity “consciousness,” if that is the right phrase, occurred with the release of the first edition of the Rhode Island Life Index on Wednesday, Oct. 23, a survey conducted by Blue Cross and Blue Shield of Rhode Island, in conjunction with the School of Public Health at Brown University, which found that zip codes may be more important than genetic code in determining health outcomes, and identified that housing costs were intrinsically tied to health outcomes.

As one long-time housing advocate, in the words of Homer Simpson, responded: “D’oh!”

An ongoing quiet revolution
The next day, on Thursday, Oct. 24, the 2019 Care Transformation Collaborative annual conference, entitled “Advancing Integrated Primary Care: Innovations at Work,” was held at the Crowne Plaza in Warwick, drawing an overflow crowd of providers and practitioners.

What began as a pilot, all-payer initiative with eight primary care practices more than a decade ago has now become the dominant force in delivering integrated primary care in Rhode Island.

As Debra Hurwitz, the executive director of the Care Transformation Collaborative, said in her opening remarks, the Collaborative now includes 128 primary care practices, including both adult and pediatric practices, with more than 800 providers participating in the program, with a total of more 700,000 patients in Rhode Island being treated at practices that are patient-centered medical homes. [Most patients may be unaware that the practice they are being seen by is a member of a PCMH, or that they are participants in the Care Transformation Collaborative.]

The latest results from the Commonwealth Fund found that Rhode Island was ranked seventh in the nation in its scorecard for health system performance, Hurwitz said, and that it was the most improved state over the last five years, a testament to the work being done by the Care Transformation Collaborative.

Hurwitz also shared the results of the latest efforts around care transformation, focused on integrating behavioral health screening into primary care practices and the successful growth of community health teams as an extension of primary care, working in the community, and the reduction in risk scores as a result.

Hurwitz also welcomed the latest cohort of pediatric primary care practices to join with the collaborative.

Believe it or not, Massachusetts has Rhode Island envy
Marie Ganim, the R.I. Health Insurance Commissioner, shared a story about her experiences the day before the conference, attending a gathering in Massachusetts with included many of the leading elected officials, at which she presented, along with Christopher Koller, the first R.I. Health Insurance Commissioner, what was happening with primary care practice transformation in Rhode Island.

Most of the time, Ganim began, when Rhode Island is doing comparisons with Massachusetts, it is about how great Massachusetts is doing with things like its education or its economy. But, when it came to primary care, Ganim said, the shoe was now on the other foot.

“They were in awe,” Ganim said. The Massachusetts Secretary of Health and Human Services interrupted her presentation to say: “This is excellent. We need to be doing this.”

The message Ganim brought back with her for the conference attendees was this: “The work that you all have been doing, and maybe you don’t see it in your day-to-day practices, what we’re doing is transformative and it is leading the nation.”

A day chock full of deep dives

The conference was divided into numerous breakout sessions, with topics relevant to practice transformation, such as: “Innovations in Working with Specialists: High Value Care Coordination,” and “Innovations in Community: Acute Care at Home Model – Partnering with Paramedics.” And “Innovations in Care: CODAC and Pain Solutions” and “Re-Defining Recovery – What Matters Most.” Also “Innovations in Care: Assessing and Treating Anxiety in Pediatric Population.”

Two of the featured participants were Drs. Somava Sava and Paul Woods, who spoke about “Supporting Population Health through Team-Based Practice Redesign and Broad Community Partnerships.”

The overriding theme throughout the event was the focus on creating a culture of collaboration, as evidenced by the support provided to the annual CTC conference by a host of organizations, including: Healthcentric Advisors; Rhode Island commercial health plans, including Blue Cross and Blue Shield of Rhode Island, Neighborhood Health Plan of RI, Tufts Health Plan and UnitedHealthcare; Brown University; the Rhode Island Health Care Association; the R.I. Department of Health; the R.I. Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals; the R.I. Geriatric Center at URI; the Rhode Island Quality Institute; the Rhode Island Foundation; and the Rhode Island Shriners Imperial Room.

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