NCM and Care Coordinator Resources

You are here

August 2018

June 2018


March 2018

CTC  Practice Application for Integrated Behavioral Health Practice Facilitation Services

January 2018


December 2017

RI PCMH Cost Management Strategies Self Assessment Tool
Draft Process: Care Transitions to/from Hospital and ED
BCBSRI Advanced Primary Care Program Policies 2018
CTC NCM Measure Definition Document
How to Access High Risk Reports from Health Plans and Communicate with Health Plans
Revised 2017 Measure Specifications Adult and Pedi CTC-OHIC
RI Care Transformation Collaborative (CTC) Nurse Care Manager (NCM) Strategy Checklist for meeting Service Delivery Requirement: Develop High Risk
Registry and Reportable Fields for Care Management (Due 12/31/17)

August 2017

Nurse Care Manager Best Practice Sharing Committee Meeting: High Risk Screening Tool and Care Coordinator Services Discussion:

High Risk Screening Tool

Updates were provided from the following two practices (Hasbro Pedi Primary Care and Pediatric Associates) that have piloted the tool.

High Risk Identification/Care Coordination Group Discussion     

  • Does your practice have defined criteria of what it means to be a high-risk patient? If so, what are those conditions?
  • How are you receiving referrals in your practice?
  • Who do the referrals come from
  • How do you receive them – verbal handoff, handwritten note, message in EHR, etc.
  • Where do you document your intervention / patient engagement?
  • What is your process and timeline for following up with patients / families?
  • All practices receive lists from the health plans on patients considered high-risk. Do you run your own lists out of your EHR, in addition, on patients that your practice deems to be high risk?
  • Are there patients that you think you’re missing – patients who may not fall under practice or health-plan defined criteria that you think should have care management?
  • Are there any risk factors or other items missing on the tool that you think should be included?
  • How much interaction do you have with local schools on co-management for children who are considered high-risk and/or have care management needs?

Incorporating Pediatric-To-Adult Transition into NCQA Patient-Centered Medical Home Recognition

Pediatric Assistant for Pediatric-To-Adult Transition: BCBSRI Workflow

June 2017

Nurse Care Manager Best Practice Sharing Committee Meeting: "De-prescribing: Implementing Less is More" Presentation

Christine Eisenhower, PharmD, BCPS, Clinical Assistant URI Collage of Pharmacy, presented at the June 20 Nurse Care Manager meeting and discussed the challenges in de-prescribing medicines for older adults with complex regimes and resources that are available to assist prescribers, nurse care managers, pharmacists and caregivers.  This presentation was offered as part of the 2017 Geriatric Education Series: Optimal Drug Therapy Program. 

January 2017

Chronic Care and Disease Management Program Presents: 

Rhode Island Department of Health, Women's Cancer Screening Program
Thursday, January 19, 2017 Click here for more information.

December 2016

Supplemental Nurtition Assistance Program (SNAP) Information
Low-income familites, seniors, individuals with disabilities and non-disabled single adults may be eligible for nutrition assistance through SNAP.

SNAP Eligibility Guidelines
SNAP Facts for Seniors
Policy SNAP-shot Medical Expence Deductions


Rhode Island’s First
Weight + Wellness Summit
Tuesday, March 7, 2017
8am to 4pm
Crowne Plaza, Warwick, RI
Exhibitor space available (some with scholarships)
Convening community resources to create a Rhode Island where healthful, affordable choices in food and physical activity are the natural daily default for all. 
Who should attend? Healthcare professionals, policy makers, health advocates, educators, producers and purveyors of wholesome foods, nutritionists, community leaders, urban planners and everyone who has an interest in making regular exercise and sound nutrition convenient and affordable for all Rhode Islanders.
For more information contact: Rhode Island Medical Society at 401-443-2386 or

October 2016

Nurse Care Manager Measure Definitions

Click here to learn more about Lifespan's 10th Annual Oncology Nursing Education Day on 10/29/16.

September 2016

Detecting Delirium
Depression in Assisted Living

August 2016

Nurse Care Manager Workforce Development Through an Academic-Practice Partnership
The Rhode Island School of Nursing Nurse Care Managment Graduate Certificate Program

May 2016

Mazimizing the Role of the Medical Assistant Learning Session

Our Mission

The mission of the Care Transformation Collaborative is to lead the transformation of primary care in Rhode Island in the context of an integrated health care system; and to improve the quality of care, the patient experience of care, the affordability of care, and the health of the populations we serve.