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Women’s Medicine Collaborative Joins Innovative State Initiative Focused on Transforming Primary Care


All major RI health care stakeholders looking to promote “patient-centered medical homes”

  Iris Tong, MD

The Women’s Medicine Collaborative has been selected to join a groundbreaking statewide initiative focused on promoting the patient-centered medical home model throughout Rhode Island.

Established in 2006, the Rhode Island Chronic Care Sustainability Initiative (CSI-RI) is a community-wide collaborative effort to develop a sustainable model of primary care that will improve the care of chronic diseases and lead to better overall health outcomes for Rhode Islanders.

One of the first multi-payer patient-centered medical home demonstration projects in the United States, CSI-RI promotes the patient-centered medical home (PCMH), a model of primary care that is patient-focused, coordinated, accessible and team-based. By putting an emphasis on prevention, wellness and appropriate treatment, the program aims to improve care, lower costs and better health outcomes – particularly for people with chronic diseases, such as diabetes, heart disease, and depression.

Currently, CSI-RI – which is also supported by the R.I. Medicaid program, along with the state’s major health insurers – serves more than 260,000 Rhode Islanders across 48 sites and practices.

The CSI-RI selection committee followed an extensive and objective selection process, based on the applicants’ service to Medicare and Medicaid patients, ability to use Electronic Health Records, commitment to establishing a patient-centered care team and demonstration of high quality care. The Women’s Medicine Collaborative is the only Lifespan practice selected to participate.

“We have always supported and embraced patient-centered care and strongly believe in focusing on a patient’s entire health needs, not just a single condition or diagnosis,” said Iris Tong, MD, director of primary care at the Women’s Medicine Collaborative. “Having an opportunity to be part of CSI-RI gives us a more systematic approach that will allow us to support patients in a more meaningful way and will help us continuously improve quality and service. We’re proud to be a part of this innovative initiative.”

In a PCMH, clinicians use advanced health information technology to power patient-centered health care teams, which coordinate care for patients throughout the health care system. In these practices, patients have a point person –a nurse care manager – who they can call to help navigate a complex and confusing health care system. The care team also works with the patient to develop an individualized holistic health care plan that meets their needs. The practice then uses advanced health information technology to ensure that the patient gets the right care, at the right place, at the right time.

Tong believes the program will have a positive impact on Women’s Medicine Collaborative patients trying to manage a chronic illness. “This progressive and collaborative approach allows us to bridge the gap between appointments, making sure individuals stay on track with taking certain medications, following diet and lifestyle changes or adhering to other treatment goals.”

CSI-RI quality benchmarks have shown positive ratings from patients on aspects of their experience, including access, communication with their physician, office staff responsiveness, share decision-making, self-management and support. CSI-RI practices are improving their accreditation scores, provider job satisfaction and chronic care quality measures, particularly those related to diabetes. CSI-RI is monitoring additional practice results, including positive trends toward reducing emergency department admission rates.