Primary Care Works! Care Transformation Collaborative of Rhode Island Debra Hurwitz, BSN, MBA, RN-Executive Director CTC-RI November 7, 2017

CTC-RI Overview Vision: Rhode Islanders enjoy excellent health and quality of life. They are engaged in an affordable, integrated healthcare system that promotes active participation, wellness, and delivers high quality comprehensive healthcare. Mission: To lead the transformation of primary care in Rhode Island in the context of an integrated healthcare system; and to improve the quality of life, the patient experience of care, the affordability of care, and the health of populations we serve. Approach: CTC-RI brings together critical payers, providers, purchasers, consumers, educators and other leaders to develop, implement, evaluate, refine and spread models to deliver, pay for, and sustain high quality comprehensive primary care.

CTC Goals Increase Capacity and Access to Patient-Centered Medical Homes (PCMH) Improve Quality and Patient Experience Reduce Cost of Care Improve Population Health Improve Provider Satisfaction (“Fostering joy in work”)

Primary Care Works The Care Transformation Collaborative of Rhode Island has a growing impact across the state, and includes: 106 primary practices, including internal medicine, family medicine, and pediatric practices. Approximately 525,000 Rhode Islanders receive their care from one of our practices. 320 providers across our adult and pediatric practices. Investment from every health insurance plan in Rhode Island, including private and public plans. All Federally Qualified Health Centers in Rhode Island participate in our Collaborative.

New Adult and Pediatric Practices Aquidneck Pediatrics (Newport) Atwood Pediatrics (Johnston) Barrington Family Medicine (Barrington) Barrington Pediatrics (Barrington) Children’s Medical Group (Providence) Coastal Bald Hill Pediatrics (Warwick) Coastal Toll Gate Pediatrics (Warwick) Cranston Pediatrics (Cranston) East Side Pediatrics (Providence) Kingstown Pediatrics (N. Kingstown) Northern RI Pediatrics (Cumberland) Thomas D. Puleo, MD (Cranston) A to Z Primary Care (Warwick) Brookside Medical Associates (Cumberland) CCAP-Primary Care Partners (Warwick) EBCAP-Barrington (Barrington) Lincoln Primary Care (Lincoln) Nardone Medical Associates (Providence) Ocean State of Coventry (Coventry) Ocean State of Westerly (Westerly) PCHC-Randall Square (Providence) Charter Care Physicians (Lincoln) Gilbert Teixeira, MD (E. Providence) Michelle VanNieuwenhuize, MD, LLC (Lincoln) Robert A. Carrellas, MD (Middletown) Richard VanNieuwenhuize, MD (Lincoln) Wayland Medical Associates (Providence) Welcome new practices 3 CPC+ Practices Pediatric Practices: 200 providers serving 100,000 children and families

Primary Care Multi-Payer Investment Works At the Practice Level: Primary care practices use multi-payer investment to improve practice population health At the State Level: State Innovation Model: 20 million CPC+: 35 Million over 5 years

Primary Care Multi-Payer Works at the Patient Level Rhode Island rose from 7th to 4th in stacked rankings nationally on 44 measures of population health!!!! Second lowest in health disparities for whites, blacks and Hispanics  – next to MA!   http://www.commonwealthfund.org/interactives/2 017/mar/state-scorecard/

Primary Care Works: In the Neighborhood Screening, Brief Intervention and Referral to Treatment (SBIRT)

Primary Care Works: Integrated Behavioral Health

Total Cost of Care (PMPM) APCD Claims 1/1/16-12/31/16 |------------ CTC Practice Cohorts -----------------| CTC practices out perform the comparison group Data Source: Rhode Island All Payer Claims Database

Utilization: Inpatient Discharges APCD claims 1/1/16 - 12/31/16 |------------ CTC Practice Cohorts -----------| CTC practices out perform the comparison group Data Source: Rhode Island All Payer Claims Database

Utilization: Specialists Visits APCD claims 1/1/16 - 12/31/16 |------------ CTC Practice Cohorts --------| Data Source: Rhode Island All Payer Claims Database

Primary Care Works: Partnerships Thank you to our Sponsors Rhode Island Department of Health: Chronic Care and Community Equity Patient Engagement: SIM and RIQI Nurse Care Manager/Care Coordinator Training: UnitedHealth Plan Integrated Behavioral Health Initiatives: Rhode Island Foundation/Tufts/SIM

Primary Care Works : Partnerships Thank you for your advocacy! Thank you to our health plans Blue Cross and Blue Shield of RI Neighborhood Health Plan of RI Tufts Health Plan UnitedHealth care

CTC Strategic Priorities 2017-2018 Improve Cost of Care and Efficiency Expand Clinical Strategy Committee to include ACO/AE representatives (Focus on primary care/specialist collaboration) Expand Community Health Teams/ Implement SBIRT Integrated Behavioral Health Work – implement grant Support training, evaluation Patient Engagement Expand Work force development (NCM/CC training) Improve CTC data analytic capability, leverage APCD Increase standardized actionable reports to practices 2015 Strategic Priorities – general feedback from Board Comments – further develop the priorities with the health plans; plans should be creating the play book?; different for different organizations (e.g. FQHC) ACO analytics TCC Priorities too broad for 2015 – and very ambitious – review with the Board