Delivery of Care

Making primary care a primary investment

As the state struggles to deal with the disruptions caused by the COVID pandemic, the Care Transformation Collaborative positions Rhode Island to make better investments in primary care delivery

Image courtesy of CTC 202o Annual Report

One of the innovations in care developed by the Care Transformation Collaborative has been the introduction of an integrated behavior model, to expand universal screening for depression, anxiety and substance use at primary care practices, with an embedded behavioral professional as part of the care team.

By Richard Asinof
Posted 5/10/21
The COVID-19 pandemic has challenged the status quo in health care delivery. Here in Rhode Island, the Care Transformation Collaborative has been an innovative leader in pioneering new approaches, as detailed in an in-depth interview.
Is there a need to devote more resources on the statewide level to support community health centers, which provide primary care to approximately one-quarter of all Rhode Islanders? What can be learned from the way that integrated behavioral health screenings have become part of the practice guidelines for the Care Transformation Collaborative members? Does there need to be a professional organization that supports community health workers and their continuing education? When will the R.I. Department of Health undertake a comprehensive survey of nurses who are practicing in Rhode Island? How will the work of Healthcentric Advisors to assist the Rhode Island Foundation with its long-term health plan in data analysis and research improve the outcomes?
Every organization, it seems, has developed its own online presence to disseminate news and information to its stakeholders, from the Care Transformation Collaborative to the Greater Providence Chamber of Commerce to the Rhode Island Communities for Addiction Recovery Efforts. The more thorough and comprehensive the content, the more siloed the flow of information becomes – with groups talking to themselves, about themselves.
At the same time, there is enormous competition across social media platforms to aggregate news content – and to influence buying decisions and political decisions. The problem, of course, is the phrase captured by Steven Colbert: “truthiness.”
At the heart of the health paradigm is the relationship between the patient and the doctor or nurse, one where privacy is protected and valued – as well as the sense of humanity.
While metrics and algorithms provide a way to improve outcomes, on a transactional basis, health care, like teaching, depends on the rapport and trust between those interacting.

PROVIDENCE – Most of the recent discussions around the future of the health care industry in Rhode Island have focused on the proposed consolidation of the state’s two largest large hospital systems and Brown University into one large academic medical enterprise – as well as troubling questions raised by the sale of the third largest hospital system, CharterCARE, owned by the for-profit, private equity firm, Prospect Medical Holding, in California, and its financial health.

What’s gotten left out of the conversation is a glaring omission: the future of primary care in Rhode Island. Why is that?

Research has found, time and again, that it’s not hospitals but primary care practices that are the major drivers of better population health outcomes [with the caveat that only 10 percent of health outcomes are determined by what happens in a doctor’s or nurse’s office, and that ZIP codes may be a better determinant of health outcomes than one’s genetic code]. The successful launch of a network of Health Equity Zones in Rhode Island continues to gain traction. But that’s a story for another day.

Yet, if you pay heed to Christopher Koller, the president of the Millbank Memorial Fund and the former R.I. Health Insurance Commissioner, high-quality primary care is the key building block in efforts to rebuild the foundation of health care delivery.

“We can’t allow health care to be transactionalized,” Koller warned in a recent thread on Twitter, touting a new 449-page consensus report by the National Academies of Sciences, Engineering, and Medicine, “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care,” which was released on May 4.

The top three recommendations in the report to support primary care were:

• Pay for primary care teams to care for people, not doctors to deliver services.

• Ensure that high-quality primary care is available to every individual and family in every community.

• Train primary care teams where people live and work.

The conclusion of the report’s authors, which included Koller, was blunt: “High-quality primary care is the foundation of a high-functioning health care system and is critical for achieving health care’s quadruple aim [enhancing patient experience, improving population health, reducing costs, and improving the health care team experience].”

Yet there is a growing disparity between demand for services and resources, the NASEM report continued. Primary care delivery in the U.S. “remains weak and under-resourced, accounting for 35 percent of health care visits while receiving only about 5 percent of health care expenditures.”

Further, the NASEM report said: “The foundation is crumbling: visits to primary care clinicians are declining, and the workforce pipeline is shrinking, with clinicians opting to specialize in more lucrative health care fields.”

Unequal access to primary care remains a concern, and the COVID-19 pandemic amplified pervasive economic, mental health, and social health disparities that ubiquitous high-quality primary care might have reduced,” the report continued. “The pandemic also pushed many primary care practices to the brink of insolvency, with most practices uncertain about their financial viability.”

Translated, primary care needs to become front-and-center in any conversation around the future of health care in Rhode Island.

Rhode Island on the front lines
In his role as the state’s first Health Insurance Commissioner, Koller played a critical role in attempting to change health care delivery. He was the author of the state’s affordability standards, an attempt to redirect how money was invested in the delivery of care. Koller was also the originator of the Chronic Care Sustainability Initiative in Rhode Island, a pilot program begun in 2008 to create an all-payer platform to improve the delivery of primary care in the state through the creation of patient-centered medical homes.

The initial idea was that CSI-RI would reward practices for performance and improvement on chronic care quality measures related to diabetes, high blood pressure and depression. To qualify for payments, practices had to demonstrate either a 50 percent improvement from their initial baseline numbers or meet a specified benchmark level.

During the last 13 years, what had begun as CSI-RI has been transformed into the Care Transformation Collaborative, a constantly evolving platform to support primary care delivery in Rhode Island. It now includes PCMH-Kids, a cohort of pediatric practices, as a full partner in the effort. [See links below to ConvergenceRI stories, “PCMH Kids leaps ahead,” and “The art of coordinated health care when it comes to children.”]

Other recent initiatives include: the Rhode Island Maternal Psychiatry Resource Network [MomsPRN], which supports the behavioral health needs of expecting mothers; integrated behavioral health screenings; and a new telehealth learning collaborative.

Today, the Care Transformation Collaborative includes more than a hundred primary practices, including internal medicine, family medicine and pediatric practices, with some 750 providers participating across the network. Perhaps equally impressive, approximately 650,000 Rhode Islanders are receiving care from one of the practices – roughly two-thirds of the entire state’s population, even if the patients may not be aware that they belong to a patient-centered medical home.

The work of the Care Transformation Collaborative is supported by investments from every health insurance plan, including private and public plans. And, all of the federal qualified community health centers participate in the collaborative.

ConvergenceRI reached out to the leaders of the Care Transformation Collaborative to share how they have responded to the public health crisis that is the coronavirus pandemic – and the ways that it has reshaped the world of primary care delivery.

And, as would befit a working collaborative, the answers to the questions posed by ConvergenceRI were composed in team approach, with Dr. Pano Yeracaris, chief clinical strategist; Debra Hurwitz, MBA, BSN, RN, executive director; Susanne Campbell, RN, MS, PCMH CCE, senior program director; Linda Cabral, MM, SBIRT/CHT, project manager; Dr. Patricia Flanagan, MD. FAAP, Lifespan Physician Group; and Jennifer Capewell, BA, manager, administration, all contributing.

ConvergenceRI: Can you talk about the latest efforts being undertaken by CTC-RI, such as the Pediatric Virtual Care 2.0 strategies? And the “Healthcare Transfer of Care Quality Improvement Initiative?”
CTC: Over the last 6 months, the Care Transformation Collaborative of Rhode Island/ PCMH-Kids, with funding from UnitedHealthcare, has sponsored a primary care telehealth webinar series, with topics selected based on the practice/patient telehealth needs assessment findings [completed by 47 practices with over 900 patient responses].

The Pediatric Virtual Care Strategies webinar will feature Dr. Mick Connors, MD, CEO and co-founder of Anytime Pediatrics, who will speak on pediatrician and patient perspectives on telehealth, what are the obstacles, and how to use telehealth to help children, youth and families better manage chronic conditions.

Our 12-month learning collaborative, “Pediatric/Adult Health Care Transfer of Care Quality Improvement Initiative,” funded by the R.I. Department of Health and Tufts Health Plan, will provide a shared learning opportunity for pediatric and adult practices to work together to create an efficient and sustainable approach to assist youth transfer from pediatric to adult care.

ConvergenceRI: What does the recent acquisition of Coastal Medical by Lifespan mean for primary care practices in Rhode Island?
CTC: Coastal Medical can be expected to continue providing high-quality primary care. There are challenges in becoming part of a larger, hospital-led system, and there are always opportunities to leverage a strong primary care focus with strengthened connections to hospitals and specialists to improve quality of care and lower costs at the same time.

Studies do suggest that this type of “vertical integration” tends to increase total costs. However, work in Rhode Island continues to focus on lowering cost and improving quality through strong “comprehensive primary care,” which can be a source of optimism.

ConvergenceRI: Will CTC-RI be participating in the new Rhode Island Foundation initiative around how to invest $1 billion in discretionary funding under the American Rescue Plan?
CTC: CTC-RI is excited about the work that the Rhode Island Foundation is doing to support the state in deciding how to invest the funding from the American Rescue Plan. We will be submitting our ideas on how Rhode Island can best position itself to increase equity in the delivery of health care.

When clinical and community sectors work synergistically, they can improve care and support patients better than either of these sectors could do alone. We believe supporting a comprehensive infrastructure that can accelerate these linkages would be a worthy investment.

ConvergenceRI: What are the top three lessons to be learned from the coronavirus pandemic in terms of primary care delivery in Rhode Island?
CTC: Going through a pandemic is a surefire way to make long-lasting changes in the delivery of primary care. There are some positive lessons that we can take away from this experience. A big lesson reinforced the value of a strong and ongoing multi-payer/multi-stakeholder primary care learning community.

Primary care organizations and associated practices were able to respond in a patient- and community-focused manner across Rhode Island to support the leadership provided by the RI Department of Health. Ongoing communication and collaboration between practices, payers, and relevant state agencies allowed for sharing of actions and strategies to better meet the needs of patients.

Some specific lessons include:
• Telehealth is here to stay. It is amazing how quickly providers were able to transition to virtual visits. The reimbursement support from payers helped to facilitate this. Both patients and providers benefitted from having a telehealth option available to them.

We conducted a telehealth primary care/patient needs assessment in early fall [with 47 practices participating and more than 900 patient survey responses]. The majority of patients reported that the phone or video visit was able to address what was bothering them, agreed or strongly agreed that they were satisfied with the telehealth visit and that telehealth promoted appropriate access to care.

Patients reported that if a phone or video appointment had not been available to address healthcare concerns, they may have gone to an Emergency Room or not be seen by any clinician. Many patients would like to continue having a telehealth visit as an option, particularly for behavioral health visits.

• Alternative payment methodologies could offer primary care the flexibility they need. Severe declines in patient visits caused drastic revenue reductions and greatly impacted primary care practices.

As a system, we need broad stakeholder input as to the best way to restructure payments to providers in a way that financially incentivizes low-cost, high-value care.

Primary care can benefit from a flexible payment structure that could support services such as interdisciplinary teams, care coordination, self-management support, and ongoing communication. New payment models and changing reimbursement rates can provide the financial stability and flexibility primary care needs in time of crisis.

• Need for enhanced community clinical linkages. As has been highlighted many times over, COVID-19 threw a spotlight on racial and ethnic disparities already well-known by primary care providers.

Primary care is a critical partner in advancing population health goals to address health inequities. As a state, how can we best support primary care to enhance their capabilities to work with community partners to address important health issues?

ConvergenceRI: Is there any renewed interest in screening for toxic stress in pediatric practices?
CTC: It’s not clear what you mean by “renewed” interest nor how you would like us to “screen for toxic stress.” Many pediatric practices in Rhode Island have been screening for unmet social needs and family stress over the past several years. The need for this screening has certainly increased over the past year with the financial and family-stress impact of COVID-19.

Not only do we need to continue to screen for unmet needs but we need to begin screening for and supporting Positive Childhood Experiences [PCE], which can help build resilience and counter the effects of Adverse Childhood Experiences [ACE].

ConvergenceRI: What has been the response to your expanded newsletter efforts to be a source of aggregated news content?
CTC: Our monthly CTC-RI newsletters have been a well-received source of news and content from our organization, with hundreds of practices and health care leaders getting our timely updates, from announcements about new initiatives and learning collaboratives to financial resources and best practice spotlights.

Our readership continues to increase, with our monthly newsletter now seeing more than 500+ active readers and the launch of a timely COVID-19 briefing for our primary care community since the start of the pandemic.

In an industry where many care team members have challenging schedules and limited time, our newsletters are helpful tools to quickly organize and share need-to-know updates.

ConvergenceRI: What is your response to the ongoing work by the Compact regarding increases in health care costs in RI, which were 4.1 percent in 2019, and 4.4 percent in 2018, well above the 3.2 suggested cap?
CTC: CTC-RI supports the work of the RI Cost Trend Committee and recognizes the importance of a statewide, data-driven approach to controlling costs. That focused work has really just begun in earnest. Direct primary care spend is at most 10 percent of total medical expenses. There is extensive evidence that high-quality and accountable primary care lowers total cost.

However, increases in pharmaceutical expenses and other categories can overshadow the impact of primary care on cost trend.

ConvergenceRI: Have you developed new data research about health outcomes in Rhode Island related to behavioral health screening?
CTC: There is currently no new research data regarding behavioral health screening. Importantly, behavioral health and social needs screening is becoming a standard practice in primary care.
Having integrated behavioral health clinicians as part of the primary care team is becoming fairly widespread in Rhode Island. The advances in telemedicine will allow this kind of “virtual integration” and support to smaller practices as well.

ConvergenceRI: What questions haven’t I asked, should I have asked, that you would like to talk about?
CTC: The recently released [May 4, 2021] report from the National Academies of Science, Engineering, Medicine, entitled “Implementing High-Quality Primary Care: Rebuilding the Foundation of Health Care,” is consequential and offers detailed and comprehensive recommendations for federal and state governments concerning building a health care system for the future.

The report’s focus on primary care reinforces the years long efforts made in Rhode Island to build and nurture a strong primary care foundation as a core part of improving equity, quality and the affordability of health care.

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