Rhode Island – Medical Homes

In July 2011, Rhode Island enacted the Rhode Island All-Payer Patient Centered Medical Home Act (P.L. 2011, ch. 260). The legislation requires the participation of state-regulated health insurers going forward in a PCMH collaborative. In addition, the Medical Home Act elevated the Rhode Island Executive Office of Health and Human Services to the position of co-convener.

Several medical home projects are currently underway in Rhode Island.

Care Transformation Collaborative of Rhode Island (CTC)

The multi-payer CTC, formally the Rhode Island Chronic Care Sustainability Initiative (CSI-RI), was first convened by the Rhode Island Office of the Health Insurance Commissioner in June 2006 and corresponded with a state directive for health plans to invest an additional $100 million in primary care. Payment to participating practices began in October 2008 with five pilot sites. The program has expanded five times since 2008. After the fifth expansion in 2014, more than 400 providers at 73 practice sites and nearly all of Rhode Island’s payers and purchasers participate in the initiative.

Two Community Health Team pilots were established in 2013; one pilot is located at South County Hospital in Wakefield, RI and the second at Blackstone Valley Community Health Care in Pawtucket, RI. These Community Health Teams work with primary care practices in a given region or network to improve care for the highest risk patients with chronic conditions, employing community health workers and behavioral health clinicians as practice extenders. Community Health Teams are also a component of Rhode Island’s State Innovation Model (SIM) plans, but the work in these two locations was already underway when Rhode Island’s SIM grant was announced. For more information on the state’s SIM plans, click here.

Further information is available on the CTC website and the 2014 Orientation Binder.

Connect Care Choice (CCC)

Rhode Island Medicaid implemented the CCC program in September 2007. This program, which operates under the authority of Rhode Island’s Global 1115 wavier, builds on a primary care case management (PCCM) structure to provide access to advanced medical homes for adults with chronic conditions. Practices receive per member per month (PMPM) payments to coordinate care for participating members.

Federal support: Many of Rhode Island’s medical home projects are receiving support through various federal funding streams.

  • CMS has approved three Health Home State Plan Amendments (SPAs) in Rhode Island. The first SPA (approved 11/23/11, effective 10/1/11) focuses on children and youth with special health care needs served by CEDARR Family Centers; the second SPA (approved 11/23/11, effective 10/1/11) focuses on adults with severe mental illness served by Community Mental Health Organizations. The third SPA (approved 11/6/13, effective 7/1/13) created health homes for Medicaid enrollees with opioid substance use disorder undergoing or qualifying for medication assisted treatment. To learn more about Section 2703 Health Homes, visit the CMS Health Homes webpage.
  • Rhode Island was one of the eight states selected to participate in the Medicare Advanced Primary Care Practice (MAPCP) demonstration program, originally scheduled to conclude at the end of 2014. CMS has committed to continuing Medicare’s participation through 2016. The First Annual Report is available here.
  • Rhode Island was awarded a $15.9 million Beacon Community grant in July 2010. Beacon Community funding was used to increase the effective use of health information technology (IT) in medical homes to improve diabetes care, reduce tobacco use, increase screening for depression, and reduce preventable acute care utilization. Although Beacon funding ended in 2013, the Rhode Island Quality Institute continues to support CTC practices in achieving Meaningful Use and connecting to the state’s health information exchange.

Last Updated: June 2015

Forming Partnerships The Care Transformation Collaborative of Rhode Island (CTC): Rhode Island’s Office of the Health Insurance Commissioner convened a multi-stakeholder coalition. In addition to the participating payers and purchasers, partnering stakeholders include primary care provider organizations, the Rhode Island Department of Human Services, and the Rhode Island Department of Health.
Defining & Recognizing a Medical Home Definition:The Care Transformation Collaborative of Rhode Island (CTC): Stakeholders have adopted the Joint Principles of the Patient Centered Medical Home.

Health Homes: Section 2703 of the Affordable Care Act defined a health home as “a designated provider (including a provider that operates in coordination with a team of health care professionals) or a health team selected by an eligible individual with chronic conditions to provide health home services.” Health home services statutorily include: “comprehensive care management; care coordination and health promotion; comprehensive transitional care, including appropriate follow-up, from inpatient to other settings; patient and family support (including authorized representatives; referral to community and social support services, if relevant; and use of health information technology to link services, as feasible and appropriate.”

Recognition:The Care Transformation Collaborative of Rhode Island (CTC): Practices are expected to achieve Level 3 NCQA recognition and meet additional criteria, including establishing compacts with four high volume specialists (including at least one hospitalist). The Contractual Performance Standards can be found here.

Connect Care Choice (CCC): Participating primary care providers are required to meet state-developed standards that include incorporation of the Chronic Care Model, use of team-based care, adoption of e-prescribing, and links to community supports and behavioral health providers. Additional information may be found on page 11 of this report.

ACA Section 2703 Health Homes – CEDARR Family Centers: CEDARR Family Centers are expected to meet state-developed certification standards that are available online. Additional standards specific to serving as a 2703 health home, such as using health information technology (IT) and conducting regular body mass index (BMI) screenings, have also been developed.

ACA Section 2703 Health Homes – Community Mental Health Organizations (CMHOs): Participating CMHOs are required to meet state licensing requirements for behavioral health organizations, as well as comply with health home standards. CMHOs are also required to establish transitional care agreements with hospitals and other inpatient facilities (e.g., psychoatric treatment centers) and long-term care facilities, and to submit a proposal describing their health home care model and regularly report on practice transformation.

ACA Section 2703 Health Homes – Opioid Treatment Programs (OTPs): Participating OTPs are required to sign a Certification Agreement that outlines provider standards and care coordination responsibilities, including requirements to maintain staffing levels for a multi-disciplinary care team to provide the health home services (4.55 FTE for every 125 patients served).

Aligning Reimbursement & Purchasing The Care Transformation Collaborative of Rhode Island (CTC): Under a new common developmental contract, participating practices receive a base payment of $5.50 per-member-per-month (PMPM) to fund practice transformation and nurse care management. As practices transform, payment can increase or decrease based on meeting specific performance targets related to NCQA recognition, utilization, quality and patient experience (max payment: $8.75 PMPM). Detailed information on the payment methodology can be found on page 10 of this PDF.Connect Care Choice (CCC): Practices receive monthly care coordination fees intended to account for the time needed to care for complex patients. Practices that care for moderate to high-risk CCC members and have a nurse care manager integrated into their practice receive PMPM payments of $35-40 PMPM.

ACA Section 2703 Health Homes – CEDARR Family Centers: CEDARR Family Centers receive federal match for three distinct bundled services: initial family intake and needs assessment ($366); family care plan development ($347); and family care plan review ($397). Centers may also bill for health needs coordination and therapeutic consultation; rates vary based on coordinators’ education level.

ACA Section 2703 Health Homes – Community Mental Health Organizations (CMHOs): Participating CMHOs receive $442.21 PMPM for providing enhanced health home services for members with serious and persistent mental illness.

ACA Section 2703 Health Homes – Opioid Treatment Programs (OTPs): OTPs receive a weekly bundled rate ($87.52 fee-for service; $52.52 RIte Care) for each patient based on staffing costs to provide the health homes services.

Supporting Practices The Care Transformation Collaborative of Rhode Island (CTC): Participating practices receive support through practice coaching and learning collaboratives. They also received health information technology support through the Beacon Community program between 2010 and 2013, as well as ongoing data feedback. The Rhode Island Quality Institute has continued to provide key data analysis and practice functions provided by the Beacon Community after the Beacon funding ended.Two Community Health Team pilots were established in 2013; the community health teams employ community health workers and behavioral health clinicians to work with primary care practices to improve care for the highest risk patients with chronic conditions.Additionally, practices have received financial support to hiring nurse care managers or contract for remote nurse care manager support.
Measuring Results The Care Transformation Collaborative of Rhode Island (CTC): The Commonwealth Fund is paying for researchers at the Harvard School of Public Health to conduct an evaluation of the CTC.The 2014-2015 clinical quality measures are included in Contractual Performance Standards, found here.The Centers for Medicare & Medicaid Services (CMS) is also evaluating the impact of CTC on outcomes for Medicare patients through a contract with RTI International. NASHP and the Urban Institute are subcontractors to RTI. The First Annual Report is available here, and the state has reported promising improvements in process measures.ACA Section 2703 Health Homes – CEDARR Family Centers: Rhode Island will use claims and encounter data, the KIDSNET database, quarterly and annual health home reports to Medicaid, and annual chart reviews to measure success toward the state’s five goals for this state plan amendment:

  1. Improve care coordination;
  2. Improve health outcomes for children and youth with special healthcare needs (CYSHCN);
  3. Decrease the occurrence of secondary conditions;
  4. Decrease emergency department utilization and inpatient treatment for ambulatory sensitive conditions; and
  5. Improve transitions of care between inpatient/residential care and community settings.

The state is also working to develop surveys to measure process outcomes and lessons learned at participating CEDARR Family Centers.

ACA Section 2703 Health Homes – Community Mental Health Organizations (CMHOs): Rhode Island will use claims and encounter data, intake surveys of CMHO clients, chart reviews, and the RHode Island Behavioral Health Online Database to evaluate progress toward the state’s six goals for this state plan amendment:

  1. Improve care coordination;
  2. Reduce preventable emergency department utilization;
  3. Increase preventive services utilization;
  4. Improve management of chronic conditions;
  5. Improve transitions to community mental health organzation services; and
  6. Reduce hospital readmissions.

The state is also collecting data on patient experience of care.

ACA Section 2703 Health Homes – Opioid Treatment Programs (OTPs): Quality improvement and clinical outcomes goals include reduced use of high cost/high use services (pharmacy, lab, residential treatment), reduced rates of drug use and smoking, and increased patient engagement and self-management. The state plan amendment also identifies psychosocial goals, including reduced rates of arrest and incarceration, increased rates of employment, and increased housing stability.