Care + Community + Equity
Care + Community + Equity
Through Care + Community + Equity (CCE) the Diabetes, Heart Disease and Stroke Program (DHDS) at the Rhode Island Department of Health (RIDOH) seeks to improve population health outcomes and the quality of care for people with or at risk of diabetes and cardiovascular disease. As a quality improvement initiative, CCE consists of three focus areas:
- Diabetes Control and Prevention
- Cardiovascular Disease Management and Prevention
- Self-Measurement of Blood Pressure
Rhode Island’s Federally Qualified Health Centers and free clinics were invited to participate in January 2019. Since then, five Federally Qualified Health Centers and two free clinics have maintained participation in CCE by implementing quality improvement projects, submitting quarterly data for clinical quality measures, and attending quarterly best practice sharing meetings.
Diabetes Control and Prevention (Prediabetes) - Year 4 Scope of Work
Cardiovascular Disease Management and Prevention - Year 4 Scope of Work
Self Measurement of Blood Pressure - Year 4 Scope of Work
Measurement Specifications - Year 4 Scopes of Work
Link To CTC-RI/RIDOH Portal for Data Entry
The links below include information on SMBP/hypertension, Cholesterol, and Hypertension.
- Best Practices for Heart Disease and Stroke: A Guide to Effective Approaches and Strategies
- Heart Disease and Stroke Prevention’s (DHDSP) Best Practices Clearinghouse
- Link to the National Forum for Heart Disease & Stroke Prevention
- Advancing Pharmacy-Related Interventions to Control Hypertension and Manage Cholesterol Learning Collaborative Resources
- Implementing Ambulatory Blood Pressure Monitoring
General Information
- NHCI Event Links - May 2022
- Motivational Interviewing to Promote Behavior Change
- Setting SMART Goals with Your Patients
- Readiness to Change Conversation
- 5-Minute Nutrition Counseling Tool
- 2022 Telehealth CPT Codes Cheat Sheet
- 2022 Telehealth CPT Codes: Cheat Sheet
- Telehealth Resources
- A Content Analysis of Smartphone-Based Applications
- Health Equity Guiding Principles for Inclusive Communication
- A Strengths-Based Approach to Screening
- QI Essentials Toolkit
- QI Essentials Toolkit: PDSA Worksheet
- Behavioral Health Skills for Community Health Workers - Virtual Training Flyer 2022
- Tools for Action - Healthy People 2030
- Community-Clinical Linkages Health Equity Guide
- Getting Started with Telehealth
- Telehealth: What To Know For Your Family
- United States Health Infographics
- Healthy People 2030
- Older Americans 2020: Key Indicators of Well-Being
- Strategies to Increase Physical Activity
- Formalizing a Successful Performance Improvement Process
- NCQA Kidney Health Toolkit
- Patient Care | Smoking and Tobacco Use
- Tobacco Cessation Change Package
- Tobacco Cessation Resource Guide for Health Centers
Team Based Care
- Health Equity Zones
- Cambridge Health Alliance Team-Based Care Toolkit
- Team-Based Care to Improve Blood Pressure Control PowerPoint
- Creating Patient-Centered Team-Based Primary Care white paper
- CDC Coffee Break: Evaluating Team-Based Care
- Cambirdge Health Alliance Team-Based Care Implementation Guide and Toolkit
- Best Practice Guide Team-Based Care
- Core Concepts for Team Based Care
- How Well Does Your Team Communicate?
Our Mission
The mission of CTC-RI is to support the continuing transformation of primary care in Rhode Island as the foundation of an ever-improving integrated, accessible, affordable, and equitable health care system. CTC-RI brings together critical stakeholders to implement, evaluate and spread effective multi-payer models to deliver, pay for and sustain high-quality, comprehensive, accountable primary care.