Delivery of Care

Changing the priorities of the “sick care” industry

The next gen of primary care practices in RI seeks to put emphasis on behavioral health integration, sustainability, and placed-based community investment

Photo by Richard Asinof

Gov. Dan McKee, at a Dec. 15, 2021, State House news conference, announcing new restrictions.

Photo courtesy of Mayor Maria Rivera Twitter feed

Central Falls Mayor Maria Rivera hugging Dr. Beata Nelken on Thursday, Dec. 29, posted by the Mayor in a tweet that said: "The highlight of my day. It's been a day, but Dr. Nelken made it all worth it. She's definitely our community hero."

By Richard Asinof
Posted 1/3/22
The conflict over the future health care model for primary care is being played out on the streets of Rhode Island. As the health care delivery system is reconfigured amidst the continuing COVID pandemic, here is an in-depth interview with the leadership team of the Care Transformation Collaborative, looking to invest in strategies outside of the office.
What are the opportunities for bottom-up innovation to change the way that health care is delivered at the community level? As health care workers become an increasingly important part of the health care continuum of care, how quickly will they become unionized? Will schools be forced to pause in-person classes until the omicron variant is more under control? Are the estimates that as many as 250,000 Rhode Islanders are outside a system of health care accurate? Will the failure of the leadership of the R.I. General Assembly to spend $1.1 billion in American Rescue Plan Act funds during the last nine months reverberate at the ballot box in November? What responsibility does the news media bear in failing to report on the severe problems with low Medicaid rate reimbursements?
Going into the CVS to pick up some aspirin brought me face-to-face with four young men, maskless, rudely and busily consuming their ice cream and cookies, apparently bought at a nearby shop catering to late night revelers, oblivious to the world around them. I stood back, as far away from them at the line for the cash register as I could, wondering what drove them to be so reckless and inconsiderate in their behaviors. Did they have a death wish?
Perhaps it was my mistake for even venturing out to buy aspirin. It was early evening, and I was returning from a medical imaging appointment, where strict procedures and masking were in place. I was glad that I had chosen to be double-masked. For the most part, I avoid all unnecessary public interactions these days, because I am immuno-compromised.
I asked the cashier, after the four had departed: what was the store’s policy around the wearing of masks? The cashier, who was masked, said that the store manager told him not to worry about customers who were not wearing masks. Just up the street from the CVS, the line at the dessert shop was backed up out on the street, and among the dozens waiting on line, no one appeared to be masked.
The mood and the people were far different from the line outside of Jenks Park Pediatrics on Broad Street in Central Falls, where all different kinds of families – young mothers, grandmothers, teenagers, fathers and children, awaited the opportunity to be tested, all masked.
That was my “Rhode map” for the week between Christmas and New Years, witnessing the worst of Rhode Island at the check out at CVS, and the best of Rhode Island at the pediatrics practice in Central Falls. It gave new meaning to the word, “uncovered.”

PROVIDENCE – At a time when the state is reconfiguring its future health care delivery system, including the proposed merger of Care New England, Lifespan and Brown University into a consolidated academic medical enterprise that will control 80 percent of the market share, there is a concerted effort underway to create a sustainable, integrated platform of primary care delivery – an investment not addressed in any of the current strategies for how best to spend the $1.1 billion in American Rescue Plan Act funds, including the Rhode Island Foundation’s “Make It Happen: Investing for Rhode Island’s Future.”

What future model of care emerges is still up for grabs. In his recent Dec. 17, 2021, blog post, Christopher Koller, the president of the Milbank Memorial Fund, asked the prescient question: “Is the provision of care an act of service or a transaction?”

In the post, Koller contrasted the work being done by a community health center in Providence, which had created a playground for kids from a school across the street from its flagship site, with the corporate model being pursued by the retail giant, CVS. “CVS wants to go big on primary care, envisioning hundreds of physician-led primary care centers as part of revised store footprint more focused on medical care than motor oil,” Kohler wrote.

CVS was not alone in discovering primary care, Koller continued. “Drugstore rivals Walmart and Walgreens are similarly investing in the service. Venture capital is chasing the lucrative [and wholly publicly funded] Medicare Advantage market. Primary care is at the center of most of those strategies, which are delivered by practices partnering with or established by companies like Aledale and Iora Health.”

The corporate pursuit of capturing the primary care market, Koller argued, is for the same reason that Willie Sutton once gave about why he robbed banks – because that is where the money is. Koller wrote: “There is gold in them primary care hills… Whether your business model is focused on building consumer loyalty, or reducing excess utilization, at only 5 percent to 7 percent of the health care budget, high-quality primary care builds great trusting relationships and exercises enormous leverage over the remainder of the health care pie.”

Koller then posed the question at the heart of the conflict: “Does primary care, and by extension all of health care, exist to meet the needs of the community or individual?”

Creating the school playground, which Koller discovered on an impromptu tour of the facility led by the health center’s chief medical officer, was “unreimbursed,” done in response to a request from the community. It stood in contrast, Koller said, to the approach “that looks to create and meets needs for untapped markets to generate financial returns for an investment of private capital,” where “patients are consumers with varying needs and resources who shop in a market.”

The conflict Koller wrote about is literally being played out on the streets of Rhode Island.

On the brink
The COVID pandemic has exposed all the inequities and weaknesses of the current health care delivery system, as each new COVID variant emerges. Workforce shortages and surging demand for services [driven in large part by the unvaccinated falling sick and flooding hospitals] have all but crippled the state’s hospital and emergency care departments. The decades-long failure to increase the state Medicaid reimbursement rates has compounded the crises caused by the pandemic, shredding the safety net. In turn, the state’s COVID testing infrastructure has been overwhelmed by the growing demand.

The illusion that things were under control, carefully managed by Gov. Dan McKee at his news conference on Wednesday afternoon, Dec. 15, at the State House, supported by a cast that included the president and CEOs of Lifespan [Dr. Tim Babineau] and Care New England [Dr. James Fanale], the president of the Rhode Island Medical Society [Dr. Elizabeth Lange], and the president of the R.I. Hospitality Association [Dale Venturini], among others, when the Governor announced “increased” measures around masking, appears to be quickly unraveling.

The planned reopening of public schools in Providence on Jan. 3, 2022, to be done on a staggered schedule over three days to permit the COVID testing of students, is being met with resistance. Some Providence community activists, using the hashtag “#sickout2savelives,” have launched a social media campaign on Twitter. “We can do something,” the messaging urged, written in black letters on a bright yellow background. “January 3rd/Just don’t go.”

The rationale being given for the “sickout” was as follows: “Most schools have not addressed the airborne transmission of COVID-19 or the fact that it is a disease that affects children. The virus mutated while policy remains stagnant. We were unprepared for DELTA and we are tragically unprepared for OMICRON.” Stay tuned.

A visit to the front lines
Last week, Central Falls Mayor Maria Rivera took to Twitter, championing the heroic efforts of pediatrician Dr. Beata Nelken and her team in Central Falls, which had been providing hundreds of tests to desperate Rhode Island families beginning more than a week before Christmas. Rhode Islanders [and not just from Central Falls] had been lining up along Broad Street, waiting for hours, often in the cold and rain, escaping the news media’s attention – until Mayor Rivera began to raise her Twitter voice of alarm.

“Central Falls families are waiting in lines for hours on end waiting for a COVID test. Kids in the freezing cold. Parents risking their jobs. Health care workers working endless shifts,” Mayor Rivera tweeted on Tuesday afternoon, Dec. 28, posting photos of the long lines outside Jenks Park Pediatrics and the state-run test site at Blackstone Valley Community Health Care Center.

On Wednesday, Dec. 29, Mayor Rivera invited Gov. Dan McKee and other state officials to bear witness to the testing snafu, as the lines stretched along Broad Street in Central Falls. The visit led to a big change in state testing policies – culminating with the planned opening of an indoor, state-run COVID-19 test site in the former Rite Aid Building at 1114 Broad St., on Monday, Jan. 3, 2022.

While the breakdown of services at hospitals has captured most of the news media’s attention span, until Mayor Rivera used her platform to share what was happening in Central Falls, there were similar scenes reported of long lines in the West End of Providence, where Asthenis Pharmacy was also providing COVID tests on a walk-up basis. [Editor's Note:  For the record, there have been long lines reported at all testing sites around Rhode Island this weekend.]

The health care system is experiencing a meltdown, “the worst in my career,” said one doctor at a local community health care center. “Contingencies upon contingencies,” the doctor said, describing how the staff was trying to cope not only with the surge of increased demand but absent health care workers who had come down with COVID or who were in quarantine because of contact with someone who had tested positive.

Another doctor, in private practice, lamented the lack of walk-in testing sites. “Walgreens and CVS is the state strategy, it seems,” the doctor told ConvergenceRI.

[Editor’s Note: Cranston Street, like Broad Street in Central Falls, is not in the line of sight for most news reporters in Rhode Island. The barriers to testing – including language barriers – for underserved populations could be used to illustrate a seminar at the Brown School of Public Health looking at systemic health and racial inequities in health care delivery. Indeed, while the testing drama was being playing out on the streets in Central Falls, many in the news media were distracted by a tweet by a state Republican, who told an apocryphal story about allegedly losing a black friend, blaming it on Critical Race Theory.]

Sea change in primary care
There are major sea changes underway in efforts to create the next generation of primary care delivery in Rhode Island, focused on integrating behavioral health into the practices, expanding the reach of community health workers as an important tool in delivering care where people live, in a culturally appropriate manner, targeting what some experts have estimated to be as many as 250,000 Rhode Islanders who are not participating in a system of care delivery.

It is a positive story, occurring well below the radar screen, without much media scrutiny, as Rhode Island, the nation, and the world struggles with the COVID contagion, while partisan misinformation seeks to exploit the fears of many.

The work is being conducted in large part by the all-payer Care Transformation Collaborative, which has grown since its inception in 2008 with five pilot practices, under the direction of Christopher Koller, the first R.I. Health Insurance Commissioner, to now include 128 primary practices, including internal medicine, family medicine, and pediatric practices. Today, more than 700,000 Rhode Islanders receive their care from the patient-centered medical home practices that include PCMH-Kids – even if the patients are unaware of their “membership.”

The efforts by the Care Transformation Collaborative are happening at a time when Rhode Island is at a tipping point when it comes to future health care delivery around primary care – particularly for the future of the R.I. Medicaid office, which provides health care for approximately one-third of all Rhode Islanders, accounting for nearly one-third of the entire state budget, during a time when the failure to increase Medicaid rates for providers – for primary care, for dental work, for behavioral health, for substance use treatment, and for early intervention – has precipitated a crisis that keeps spreading, much like a virus attacking the state’s safety net. The state is involved in a re-procurement process for selecting the managed care organizations for much of the care delivered to Medicaid members in Rhode Island.

[Editor’s Note: And, for the most part, the news media has been AWOL in its reporting duties. On the last day of 2021, The Providence Journal finally published a news story by G. Wayne Miller, “RI’s low Medicaid reimburse rates endanger dental and care and other services for the needy.” Better late than never.

The problems had been documented and detailed by two different Senate legislative commissions, the first one in 2020, and a second one that is ongoing. See links below to the ConvergenceRI stories, “Open wider,” “To have and have not,” “When do low Medicaid rates create a break glass emergency,” and “Will Medicaid remain part of RI EOHHS?”]

Here is the ConvergenceRI interview with three leaders of the Care Transformation Collaborative of Rhode Island: Pano Yeracaris, MD, MPH, Chief Clinical Strategist; Debra Hurwitz, MBA, BSN, RN, Executive Director; and Susanne Campbell, RN, MS, PCMH CEE, Senior Program Director. The interview took place on Dec. 21, 2021.

ConvergenceRI: There seems to be so much confusion around COVID. What is the simplest advice that you can give to patients regarding the best ways to protect themselves from COVID?
YERACARIS: That is not our realm, per se, the clinical realm. I guess I would reflect that following the Department of Health guidance is very important – masks and vaccines and hand washing and distance.

The new omicron variant seems to be much more infectious, and we don’t know what that means. It is going to be a tough holiday season. I would say: hang in there, folks. Use technology when you can; the phone is still very valuable to make [health care] connections, especially for those at risk.

HURWITZ: I think there is a lot of confusion out there, as you said. The omicron is a new variant. It is easily spread. I know that recently, Lifespan put out a call and the Governor seemed to act on that, invoking restrictions again in the state, because the hospital is having difficulty being able to staff and cover the in-patient needs and the ED.

There is a pretty serious workforce issue that is going on in health care across the board, not just in Rhode Island. There is not enough staff.

ConvergenceRI: The focus of your recent “breakfast of champions” session was about sharing the best practices about the wellness of providers, and how that was linked to improving the quality of services that were being offered to patients.

Given all the stresses on the workforce that is being overwhelmed by the demands being placed upon them by COVID, what are the lessons that can be learned about how best to improve the wellness of providers? What steps can they take?
YERACARIS: We are looking at the effects on [staff] having to spend less time on the electronic health records and documentation, through team-based documentation. That is just a small example of why we are stressing the importance of team-based care, because we think that it will make everybody’s jobs better and the care for patients better, when folks are less stressed.

It is a hard time to do that [given COVID]. You also need to take a system approach. Yes, you want to do the things for the individual – do whatever the things that work, [such as] mindfulness, exercise, deep breathing, eating healthy, all the things that probably improve people’s overall quality of life.

But when you are working in a very demanding job, which is what health care is, you need to have a system – that is the value of a system [approach]. It is an ongoing conversation for us, one that we have been trying to conduct over the years.

HURWITZ: The culture of organizations has always been an important aspect of the patient-centered medical home, with joy in work [seen] as the fourth goal of the Triple Aim. Organizational culture and performance and really working together as a team can bring success and satisfaction to people who are in the workforce.

Patient-centered medical homes are team-based; it is a team sport. And so, culture is really important. We now have the ability and the need to look at that, and think about how they can really strengthen the culture.

You saw that in those presentations at Breakfast of Champions session, where there is focus on real engagement with staff, and bringing people together. [ConvergenceRI “attended” the virtual Zoom gathering.]

It doesn’t have to be about money. It can be other things that create an environment of safety and support for staff – [where they feel that] they are being heard. And, if the staff is doing well, they are better able to take care of their patients.

Burnout is always an issue in health care. As Pano [Yeracaris] said, health care is a hard job. It has always been a challenge to deal with burnout. COVID has amped that up. It is a very stressful and difficult environment.

Folks need to figure out ways to intentionally pay attention to the signs of burnout and strategies that organizations can put together to support and reduce burnout.

Nelly Burdette, [health care consultant to CTC] and a senior director of Behavioral Health, just did a really great presentation. She got the most amazing feedback; one of the individuals was an administrator level at the health system, and she was taken aback by the fact that she didn’t realize that she was having the symptoms of burnout. And it was now on her radar as something that was really important to address.

We felt like that was an amazing positive outcome, from an awareness perspective, that it was OK to focus on burnout and to figure out how to address it.

ConvergenceRI: The R.I. Department of Health did this study about adverse childhood experiences, or ACEs, which I always refer to as “toxic stress,” and the practical applications of this knowledge into clinical settings. CTC has been on the front lines in integrating behavioral health care into the primary care practice setting, making sure that you have clinicians on site, so that patients do not have to set up multiple appointments, and to receive medications as necessary.

Mental health and behavioral health conditions have become rampant under COVID, and the increasing unmet demand has demonstrated that there is a lack of resources at the community level. If you could double down on the importance of doing screening – and the fact that from your last comments, about how providers are often unaware themselves about how burnout is affecting them, how does that play out in terms of treating patients?
CAMPBELL: First of all, I want to say thank you. I’ve been reading ConvergenceRI; you’ve been doing such a great job of trying to raise issues. I just want to say thank you to you, because I can really tell you are working so hard to raise issues and bring things forward.

ConvergenceRI: Thank you.
HURWITZ: I want to second that. Richard. You do an amazing job of bringing all of these different pieces together and asking the hard questions. Thank you.

CAMPBELL: Sometimes we work in partnership with the Medical Legal Partnership in Boston. Yes, in fact, people have a lot of stress. And yes, primary care practices are actively trying to understand that are the healthy social needs that can be addressed.

One of the points that the Partnership has made, and I so appreciate it, is that while we are looking at what people might need, it is also important to try and understand what their strengths are. And, to start conversations with people about what is it that they are doing that is working for them, as well as what their needs are.

I know that our primary care practices are doing a lot of work around connecting people with resources; a lot of the primary care practices are trying to sign up with Unite Us [a social service digital referral network in Rhode Island]. But I think it is really important and helpful to start with people by asking: What is working for them? And, what they can do that might increase that strength?

ConvergenceRI: That is so insightful. I have always disliked the way that the pain scale has been used with patients – on a scale of one to 10, what is your pain level today. I always felt that it was the wrong question to ask. And when I questioned providers about it, they would respond by asking me: what question would you ask instead?
I suggested they ask: What is the best thing that happened to you in the last week? It reframes the conversation, just as asking a patient, “Tell me about your strengths,” does.
CAMPBELL: We are working with the R.I. Department of Health to get additional resources for community health workers. One of the things we want to try and do as we build out the curriculum in training community health workers is to encourage the agency to look at strength-based interviewing as a core competency.

As you know, community health workers are really important members on the team. As we start using community health workers more, it is helpful for them to learn these interviewing skills that will really help them focus on the patient.

YERACARIS: Strength-based interviewing is the other side of the work that we are involved with in screening for adverse childhood events. Our family and community focus works on building the strengths of mothers and young families, the work we are doing to connect family home visiting with pediatric practices.

The other part of the work is connecting to the Health Equity Zones and community efforts, and to the schools – that to me is one of the biggest lessons I would take from our efforts. It reinforces how critically important those connections are, and the building and strengthening of resilience in families, which everyone talks about, but those efforts are under-funded continuously, chronically under-funded.

Instead, the money is spent on prisons and on other pieces of the “sick care” industry.

ConvergenceRI: If you had a magic wand and could redirect how resources were invested, where would you like to see the money flowing?
YERACARIS: In pediatrics and early child care. As Dr. Pat Flanagan [a pediatrician who is currently president of the Rhode Island chapter of the American Academy of Pediatrics and co-founder of PCMH-Kids], says: “A one-dollar investment in pediatrics and early child care is equal to six dollars in the return on investment in avoiding costs down the way.” We need greater investments and resources supporting children and families.

CAMPBELL: We have been on the front lines of the community health team experiment, piloting community health teams for a number of years, and seeing some great results both in terms of clinical outcomes as well as dealing with the social determinants and the social needs of patients and families.

Through community health workers, we are able to bring behavioral health services out into the community, to meet with people in their homes, and to help them stabilize, and to refer, if necessary, to do some short-term treatment. The community health team model we feel, is successful.

Now, the really good news is that community health workers are becoming a covered benefit under Medicaid. And so, there will actually be a way to help fund the services provided by community health workers. Hopefully, it is sufficient.

What we are seeing now is that the systems of care have contracts with the insurers and they are supportive of this kind of work. So, individuals who are a part of, or attributed to a system of care, will likely be able to take advantage of the kinds of services that we piloted in community health teams over the last five to seven years.

What we came to a realization at CTC recently is that there are still about 250,000 people in the state who are not part of a system of care. And so, we began to worry about how those individuals would get access to the types of services that address social and behavioral health needs in the community.

These are often complex, high-need patients, and so we did an analysis, and brought that back to our board of directors. Blue Cross [and Blue Shield of RI] has been very supportive about this.

What we are facing now is a kind of a rebuild, if you will, refocusing our efforts relative to community-based services, and saying, there is a group that is not really being addressed by the managed care system of care organizing principals. And how do we, as a state, help fund that.

The great thing is that Blue Cross has stepped up and shown a lot of leadership and support in wanting to help provide services to those individuals who are outside of the system of care. We are hoping that others will come along to do the same.

What we worry about, Richard, is that where the pilot program was grant funded, we could do things as an “all-payer,” we didn’t have to collect money from anybody. We would pay them though a grant, if you understand what I am saying. So, it was all-payer blind. What we worry about now are the individuals who are uninsured, because there is no funding source.

We are thrilled Medicaid is putting the pieces together to be able to pay for this. We are thrilled that Blue Cross is stepping up to the plate for their commercial plans and their Medicare advantage patients.

We are in active discussions with other payers. Tufts [Health Plan] is supportive with their membership in the state.

With UnitedHealthcare, we are having discussions. It is a national organization, but, we are having discussions with them as well.

But it still leaves people out. There are still uninsured individuals that we are not sure how the system works for them.

But we keep looking for ways to fund the services in a way that a primary care practice doesn’t have to figure out who is paying what. If the patient needs the service, they should be able to get the services. And that is where, given the way that the system of care is constructed right now, either fee for service, or by payer, it leaves groups out.

This is a time when there is a lot of focus on equity and on minorities and on individuals who are left behind. We had something that was working really well, but it was grant funded, and so now, we are trying to get it to become sustainable.

We have to keep addressing it with our state partners and our other payer partners. The question is: Are the uninsured everyone’s responsibility?

ConvergenceRI: As you know, I have been reporting on the Senate commission hearings about the future of the R.I. Executive Office of Health and Human Services. The major complaint that keeps emerging in all those hearings is the fact that the reimbursement rates for Medicaid are too low. The outgoing Medicaid director saw no value in having the R.I. General Assembly mandate a higher rate of reimbursements, even as Early Intervention services had to be halted because there was no money to pay providers.

There were questions about how managed care organizations were determining – or not determining – network adequacy. There were questions about accountability, of whether the managed care organizations or the Medicaid office, was able to respond to the issues being faced by the community.

The entire system of managed care organizations is in the midst of a new state procurement process. Do we need an audit of where the money is going and how it is being spent? And, how is the flow of dollars related to network adequacy and whether or not people are being left out of the systems of care?
YERACARIS: I don’t know if we can comment on network adequacy. You may be aware of the report, from a year ago, that looked at trying to use a common methodology among the six New England states to measure primary care spend. It has some limitations, because it looks at claims, but no non-claims spending.

But when you dig into it, Rhode Island came out, I think, number four, out of six. On the other hand, when you dig into Medicaid itself, and the comparison of Rhode Island Medicaid with other six New England states, you do start to see [the differences], because most of the expense is in support of primary care that is claims based. There are no large commercial contracts that give the “per member per month” for primary care management.

But that is an area that is worth looking at, because from a primary care standpoint, it reinforces what we are hearing around the low payment rates for Rhode Island Medicaid, particularly around pediatrics.

Our big concern around payments is to make sure that community behavioral health in this kind of scenario is not the same as office-based care. Community health workers spend a lot of time in the community, not doing billable services and fee for service.

We are actually encouraged that it not be fee for service. But even as it applies to Medicaid to get it to be a covered benefit, everyone’s goal is to move this into a different payment model.

HURWITZ: A population-based model. What we are acutely aware of is that our pediatric providers have some of the lowest rates in the country.

During the first couple years of the Affordable Care Act, the rates were bumped up to same rates as Medicare equivalent rates. That really worked well – and it allowed the pediatric offices to have the kind of resources that they need to really work with families, and with the schools, and with all the things that pediatricians do, on the behavioral health side of it.

And then, it went back to the old, lower rates. During COVID, there was a supplemental rate increase, recognizing that pediatric practices were on the verge of going bankrupt. Some of them did, because of the fee for service payment model, a lack of volume, and the low rates.

Our pediatricians are really not paid at an adequate rate. And behavioral health workers, in the children’s behavioral health system, haven’t seen pay raises in a long, long time. Their rates our low, they haven’t seen increases, and it is very difficult to find people to work in that system. So, we’ve got problems there as well.

If we had a magic wand, we could wave it and fix financial problems, certainly some of those underlying inequities and disparities in payments as compared to the rest of the country – and what is needed for people to actually wan to work in health care – need to be addressed.

We have to have more workforce development strategies to start engaging people from the community and the understanding that they bring with them, around culture and the language spoken.

To get more people working in health care that reflect the kind of individuals who live in Rhode Island would be a good thing.

ConvergenceRI: How would we do that? What is the best way to do that?
HURWITZ: We have been asking about that. I hear, more and more, you actually have to start even before high school, giving kids and young people opportunities to learn, working in different capacities in the health care system.

With the community health workers positions opening up, they can serve as an entry level for lots of people to get into a wide range of positions. Community health workers are being utilized more and more across the board as important team members.

CAMPBELL: I think one of the real strengths that we have in Rhode Island is that we the R.I. Office of the Health Insurance Commissioner. OHIC recently put out in draft form, for public comment, the next-gen affordability standards, to look at, again, investments in primary care and in behavioral health, and addressing community health needs.

ConvergenceRI: Are you supportive of what you have seen in those new draft affordability standards?
CAMPBELL: We are in the middle of collecting comments from our primary care practices. But, personally, I think they are terrific step forward.

YERACARIS: I think our comments are mostly going to be supportive, but expand on some of the details within the draft, voicing strong support for behavioral health being connected to pediatric practices.

In terms of community investment, we need to recognize that everyone benefits when services are available across the board to all Rhode Islanders.


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