Partners for Age Friendly Care
Rhode Island
Transforming health care for older adults and their care partners.
Three Rhode Island organizations working together to help primary care practices put age-friendly care into every visit.
Join the next cohort ▶ Watch the film
A partnership of CTC-RI, the Rhode Island Department of Health and the Rhode Island Geriatric Education Center at URI
Rhode Island is getting older
21%of Rhode Islanders are 65 or older
25%will be 65 or older by 2030
36,000Rhode Island caregivers provide 50 million unpaid hours a year
Sources: Care Transformation Collaborative of Rhode Island newsletter, August 2026. Caregiver figures: Alzheimer’s Association.
The partnership
More together than apart
In 2023, the Care Transformation Collaborative of Rhode Island, the Rhode Island Department of Health and the Rhode Island Geriatric Education Center at URI pooled their funding and expertise, with support from UnitedHealthcare. The first cohort was planned for three practices. Together, they started with six.
“We’ve done more together than any of us could have done separately.”
Susanne CampbellCare Transformation Collaborative of Rhode Island
The framework
The 4Ms of age-friendly care
A simple framework from the Institute for Healthcare Improvement, built into the everyday work of a primary care visit.
01
What Matters
Know and align care with each older adult’s specific health outcome goals and care preferences.
02
Medication
If medication is necessary, use Age-Friendly medication that does not interfere with What Matters.
03
Mentation
Prevent, identify, treat and manage dementia and depression.
04
Mobility
Ensure that older adults move safely every day to maintain function and do What Matters.
+ Rhode Island adds a fifth focus: the caregivers. See how →
The 4Ms come from Age-Friendly Health Systems, an initiative of The John A. Hartford Foundation and the Institute for Healthcare Improvement, in partnership with the American Hospital Association and the Catholic Health Association of the United States.
Learn about the 4Ms →
The film
See it in practice
Go inside Breakwater Primary Care in Warwick, where the 4Ms are part of every visit.
▶ Watch the film Premieres November 19
For practices
Support for every practice
- A practice facilitator who meets with your team every month
- Learning sessions with other Rhode Island practices
- $6,000 to support the time your team puts in
- A path to Age-Friendly recognition from the Institute for Healthcare Improvement
“Having a practice facilitator is invaluable. They really hold your hand, work elbow to elbow with you.”
Jayne DaylorPractice Facilitator, Rhode Island Department of Health
Caregivers
Seeing the people behind the patient
170caregivers identified in the first cohort alone
Most primary care practices have never asked about caregivers. Through this work, practices now screen for caregiver stress and connect families with help, including direct referrals to the Alzheimer’s Association.
“We were able to connect the patient with the Alzheimer’s Association through a direct referral in our electronic health record.”
Dr. Gregory SteinmetzBreakwater Primary Care
Recognized in Rhode Island
Age-Friendly care across the state
Congratulations to every Rhode Island site recognized by the Institute for Healthcare Improvement.
Primary care
- Breakwater Primary Care*Lincoln
- Breakwater Primary Care*Pawtucket
- Breakwater Primary Care*Warwick
- Brown Medicine Primary Care Geriatrics*East Providence
- Care New England Family Care CenterPawtucket
- Care New England Family Medicine*Coventry
- Care New England Internal Medicine*Pawtucket
- Care New England Internal Medicine*Warwick
- Care New England Primary Care for Older AdultsProvidence
- Clinica Esperanza / Hope ClinicProvidence
- Comprehensive Community Action Family Health Services*Coventry
- Comprehensive Community Action Family Health Services*Cranston
- Comprehensive Community Action Primary Care Partners*Warwick
- Comprehensive Community Action Warwick Health Center*Warwick
- Drs. Brennan, Cronin & Associates*East Greenwich
- Oak Street Health Branch AvenueProvidence
- Oak Street Health South ProvidenceProvidence
- Oak Street Health WarwickWest Warwick
- Oak Street Health WoonsocketWoonsocket
- PACE Rhode Island*East Providence
- PACE Rhode Island*Newport
- PACE Rhode Island*Westerly
- PACE Rhode Island*Woonsocket
- Roger Williams Senior Health Care Associates*Providence
- University Internal Medicine*Pawtucket
- VA Providence Home Based Primary CareProvidence
Hospitals and other care
- Kent HospitalWarwick
- Rhode Island HospitalProvidence
- The Miriam HospitalProvidence
- VA Providence Hospital in HomeProvidence
- Encompass Health Rehabilitation HospitalJohnston
- Enhabit Home HealthWarwick
- John Clarke Senior LivingMiddletown
Recognized as of November 1, 2026. The list grows every year.
* Practice participated in the CTC-RI 4M Age-Friendly Quality Improvement (QI) Collaborative. See the full list at IHI →
* Practice participated in the CTC-RI 4M Age-Friendly Quality Improvement (QI) Collaborative. See the full list at IHI →
Four steps to age-friendly care
01
Join a cohort
Cohort 5 is forming now. Practices of every size are welcome.
02
Learn together
Three learning sessions with practices across the state.
03
Test what works
Six months with your practice facilitator, trying changes in your own workflow.
04
Get recognized
Apply for Age-Friendly recognition from the Institute for Healthcare Improvement.
Ready to bring the 4Ms to your practice?
Join the next cohort →Join us
Bring age-friendly care to your practice
Tell us a little about your practice and we’ll be in touch. Include your name, practice or organization, your role and the best way to reach you.
Contact us about the next cohort →
Or email [EMAIL ADDRESS]
Acknowledgements
With support from UnitedHealthcare.
This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number [grant number], [program name], totaling [award amount]. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, HRSA, HHS or the U.S. Government.
This project is supported by the Centers for Disease Control and Prevention (CDC) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling [award amount] with [percent] funded by CDC/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement by, CDC/HHS or the U.S. Government.
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.