A patient-centered medical home project in the state of Rhode Island has blossomed under UMass Medical School’s management, growing from a pilot project of only 13 practice sites to a program with 73 practice sites that give more than 320,000 Rhode Island residents access to this innovative care model.
CSI-RI aims to improve quality outcomes, improve patient experiences and reduce the costs of unnecessary hospital utilization. In 2014, inpatient admissions were reduced by 7.2 percent, which translated into incentive payments to the practices in the program.
“The number of applications we’ve received from practices to join our initiative tells us that providers are looking for more innovative ways to provide quality care to their patients, and are interested in participating in a program that moves them toward value-based payment,” said Debra Hurwitz, MBA, BSN, RN, an Office of Program Development senior program development associate and co-director of the Rhode Island Chronic Care Sustainability Initiative, or CSI-RI.
“We look forward to supporting our new practices as they transform into high-performing patient-centered medical homes, strengthening our efforts to improve the way primary care is delivered and paid for throughout our state.”
The Office of Program Development within UMass Medical School’s Commonwealth Medicine division has been running the initiative, since 2011 under a recently extended contract with The Rhode Island Foundation. UMass Medical School provides CSI-RI with the management team and infrastructure that enables it to execute projects in a timely manner, including leadership, project management, program development and the management of subcontracts.
Funded primarily by the commercial health plans that participate in the program, CSI-RI was launched as a pilot project with five primary care practices in 2008 under former R.I. Health Insurance Commissioner Christopher F. Koller. CSI-RI will become a permanent nonprofit organization with a new name, Care Transformation Collaborative, in June of next year.
CSI-RI has been providing care to about 220,000 Rhode Island residents and the expansion adds another 107,000 adults, increasing the total of state residents with access to a patient-centered medical home to 30 percent. The goal is to give 500,000 Rhode Island residents—half the population of the state—access to health care through a patient-centered practice over the next five years.
Under CSI-RI, a multi-payer collaboration of insurers and Medicare and Medicaid, the primary care practice integrates team-based, comprehensive and preventive care. The patients work with their health care providers to make treatment decisions and manage their care. In addition to the patient and medical provider, the teams include behavioral health providers, nurse care managers, medical assistants, front desk staff, specialists, hospitals, home care agencies and laboratory facilities.
Practices accepted into the program must meet prerequisites, including having an electronic health record, and established registries for managing population health, meeting a federal requirement for “meaningful use,” completing a National Committee for Quality Assurance self-assessment in preparation for achieving Level 3 recognition, and having the ability to report data from their EHR. Once in CSI, the practices are required to hire a nurse care manager and establish a compact with specialists for patient care.
Part of UMass Medical School’s role in CSI-RI is planning and hosting learning collaboratives for medical professionals involved in the project. The CSI management team partnered with Blue Cross and Blue Shield of Rhode Island, The Rhode Island Foundation and Brown University to deliver a learning collaborative, “The Primary Care Team: The Future is Now,” Oct. 9 in Warwick. More than 275 attended.
The collaborative was the subject of news coverage by theProvidence Business News and online newspaper Convergence RI. Both articles detailed the growth of CSI-RI, as well as its innovative collaborative model.
“Learning opportunities like this help provide our care teams with new ideas and ways to approach primary care issues that are continuously changing and to assist patients with better managing their health,” Hurwitz told the Providence Business News.
“CSI-RI is a unique combination of program and project management specialists working with community-based clinicians and state officials on an innovation initiative," said Louise C. Eichman, MA, PMP, executive director of the Office of Program Development & Enterprise Project Management Office at UMass Medical School.
A team of UMass Medical School Office of Program Development project managers and coordinators have been managing CSI-RI. In addition to Hurwitz, they include Senior Project Manager Susanne Campbell, RN, MS; Project Coordinator Catherine Sampson, BS; and Project Coordinator Michael Mobilio, BS. UMass Medical School has also hired the program’s assistant director, Pano Yeracaris, MD, MPH.
The initiative is conducting two Community Health Team pilot programs that provide outreach to high-risk patients with social and behavioral health needs. The community health teams conduct home visits to assess patients’ needs, and then connect them to community resources to help them stay in their homes.
