Call for applications

Implementing Primary Care and Pharmacy Services to Improve Care and Outcomes for Patients with Diabetes, CKD, and Tobacco Use

Care Transformation Collaborative of Rhode Island (CTC-RI)
Funded by UnitedHealthcare and RIDOH | Program Period: October 2026 – June 2028

APPLICATION FORM | Due: September 1, 2026 by 5:00PM EST
The Care Transformation Collaborative of Rhode Island (CTC-RI), in partnership with the University of Rhode Island (URI) College of Pharmacy and the Rhode Island Department of Health (RIDOH) invites up to six (6) primary care practices the opportunity to apply for funding to join a 21-month quality improvement initiative that has been funded by UnitedHealthcare and RIDOH to improve screening rates for patients with diabetes for earlier detection of diabetes-related eye and kidney disease. This initiative builds on CTC-RI’s prior pharmacy-led diabetes quality improvement work and expands to include a new tobacco screening component.

To access the PDF format copy of the Call for Applications, please download from CTC-RI's Basecamp at the link here: https://public.3.basecamp.com/p/zWVrfqgHUULeEzrZUAJBwiQx

To access the PDF format copy of this application, please download from CTC-RI's Basecamp at the link here: https://public.3.basecamp.com/p/dT62aM3H4qj4jLc4Nd5EL9Qe

Please join us for 2 informational sessions on this project via ZOOM by following this link: https://ctc-ri.zoom.us/j/82192427849?pwd=UMgwEMQaTdfRaaG0CoPfZztkwQeTYV.1
- August 11, 2026 7:30- 8:30AM
- August 19, 2026 12:00-1:00PM
For questions, contact: Marije Thomas, mthomas@ctc-ri.org
Section 1: Practice Information
Practice Name
Street Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Name of primary contact for questions about this application

First NameLast Name
Email Address
example@example.com
Phone
Please enter a valid phone number.Format: (000) 000-0000.
Location of the practice site that will be participating in this program (town/city):
If you are applying on behalf of an organization with multiple sites, please complete a separate application for each participating site.
Can your team commit to monthly 1-hour practice facilitation meetings? (Virtual)
Can your team commit to virtual quarterly learning sessions (1.5 hours each)
Are you part of a system of care?
If yes, which system of care?
All practices that are a part of a system of care are required to submit a Systems of Care/ Leadership Letter of Support along with their application. The letter may be found via this link. Please share this link (https://ctc-ri.jotform.com/sign/262104429073047/invite/01kysnxbd7830022cfd06f5e52) with the appropriate person in your organization to complete the letter of support.

If you need additional support in completing this form please reach out to mthomas@ctc-ri.org
Provide name of the Electronic Health Record system your practice currently uses:

Other
Please indicate if your practice is anticipating changing its Electronic Health Record within the next 24 months
Does your practice have an embedded pharmacist on site?
If no, describe pharmacy support available to the practice:
Please provide a list (or upload document) of practice team providers from 2024 to current, and their NPI number. NPIs are collected to support accurate matching of provider level claims data in the All Payer Claims Database (APCD) for program evaluation and quality measurement purposes. Please select "add row" to populate more fields as needed.
Or upload a file with the provider names and NPI numbers:

Cancelof

Approximate Payer Mix (Jan 1, 2025 – Dec 31, 2025) for primary practice site

Rows	# of patients	% of total panel
Commercial
Medicaid
Medicare (Under 65)
Medicare (65 and Older)
Dual (Medicare/Medicaid)
Uninsured / Self-Pay
Other

Patients total (automatically populated from approx. payer mix above)
Panel Demographics (Optional)

The demographic questions below are optional. CTC-RI is working to better understand the populations served across our learning collaboratives. This information will not be used for scoring and will not affect your application. Estimates are welcome — you do not need to run a report. If data are not available, select that option.

Race / Ethnicity - Estimated percentage of your active patient panel (ages 18+) by race/ethnicity. Check the range that bestreflects your panel, or mark Not Available.

Rows	0%	1–10%	11–25%	26–50%	>50%	Not Available
Hispanic or Latino
Black or African American
White (non-Hispanic)
Asian
Other / Multiracial

Estimated percentage of patients with a primary language other than English:

Rows	0%	1–10%	11–25%	26–50%	>50%	Not Available
Estimated % of panel

Top languages spoken (if known):
Section 2: Diabetes, CKD, and Tobacco Use Information
Please provide number and percent of patients over the age of 18 in your practice with a diagnosis of diabetes and/or CKD:
Number of patients with diabetes:    *
Percentage of total patient population:     *
Number of patients with CKD (any stage):   *
Percentage of total patient population:   *
Baseline Practice Assessment

Please provide information about the following items:
1. Practice team reviews performance data on a regular basis specific to patients with diabetes and CKD, including glycemic control, kidney health evaluation, and retinopathy screening. If yes, describe how data is used to improve care.
1.1 If Yes, Please Describe
2. Practice is currently collecting screening rates on patients with diabetes:(1) Kidney Health Evaluation(KHE), which requires BOTH the estimated glomerular filtration rate (eGFR) AND urine albumin-creatinine ratio (uACR) to be completed for the same patient, (2) retinal eye exams(diabetic retinopathy screening), (3) HbA1c control (< 8%, >9% and missing/not done).
2.1 If Yes, Please Describe
3. Practice currently screens patients for tobacco and nicotine use using a standardized tool.
3.1 If yes, describe the tool and workflow.
4. Practice refers patients who use tobacco to the RI Nicotine Helpline/QuitNowRI or another cessation resource.
4.1 If yes, describe referral process
5. Practice is working to improve any of the screening rates above.
5.1 If so, please explain.
6. Practice team has demonstrated ability to identify gaps in care based on race, ethnicity, language, insurance status, or other factors.
6.1 If Yes, Please Describe
Practice Questions

Please answer the following questions in 500 words or fewer each.
7.The goal of this pharmacy-driven quality improvement initiative is to improve screening rates for patients with diabetes and CKD, including earlier detection of kidney disease and diabetic retinopathy, improve glycemic control, and to integrate tobacco screening and referral to treatment into chronic disease workflows. How does your practice team and system of care intend to use the funds from CTC-RI to join this initiative?

0/500
8. Please describe your provider champion, pharmacist champion, and organizational leadership (IT/practice management/care management) and their commitment to pharmacist-driven quality improvement. Describe how the practice team plans to work together on this initiative. If a system of care is interested in identifying a lead practice with other sites participating, describe the participation plan.

0/500
9.What barriers do you envision in improving CKD and diabetic retinopathy screening rates and glycemic control, and how do you anticipate addressing them? Please address workflow, EHR capabilities, and staff capacity

0/500
10. What barriers do you envision in integrating tobacco screening and referral to treatment (SBIRT) into your existing chronic disease workflows, and how do you plan toaddress them? Include any current tobacco cessation resources or partnerships your practice uses.

0/500
11. Describe your patient engagement strategies for patients with diabetes and/or CKD, including what matters most to patients in your panel. How will your practice address health equity and engage patients from populations with higher rates of chronic disease?

0/500
12. Describe any challenges you anticipate in obtaining, reporting, and submitting data for the measures used in this project. Describe any current relevant uses of data or patient feedback related to screening rates for CKD, diabetic retinopathy, and tobacco use in your practice or system of care.

0/500
13. Describe opportunities you may have to spread the interventions to a larger number of providers, and how your practice plans to sustain improvements after the program period.

0/500

Appendix A: Practice Cover Letter

Multi-site organizations applying for different quality improvement teams should complete one letter for each site
Date*
TO: CTC-RI Selection Committee
From:   Practice Leadership Representative*
RE: Implementing Primary Care and Pharmacy Services to Improve Care and Outcomes for Patients with Diabetes, CKD, and Tobacco Use - Care Transformation Collaborative of Rhode Island (CTC-RI)

On behalf of   Insert Practice Name* , please accept this practice cover letter for the CTC-RI Implementing Primary Care and Pharmacy Services toImprove Care and Outcomes for Patients with Diabetes, CKD, and Tobacco Use, funded by RIDOH and UnitedHealthcare. As an organizational leader representative, I attest that the following staff members accept the conditions stated in the application and, if awarded, are committed to achieving the objectives of this initiative, including participation in monthly practice facilitation meetings and all learning collaborative sessions.
Practice Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Quality improvement team, including providers, and potentially a nurse care manager, behavioral health clinician, practice manager, social worker, medical assistant, IT support staff member, as applicable to the practice with the understanding that members of the team will be invited to participated in monthly practice facilitation meetings based on planned agenda.

The following person or persons have agreed to participate in the Implementing Primary Care and Pharmacy Services to Improve Care and Outcomes for Patients with Diabetes Initiative; these staff members will complete the data requirements, attend the kickoff meeting, and the practice facilitation meetings.

Quality Improvement Team (please fill in details below):

Rows	Name	Contact (Email/Phone)
Key Contact / QI Team Lead
Provider / Physician Champion (if different)

Additional QI Team Members (please fill out details below):

Rows	Name	Contact (Email/Phone)
Nurse / Care Manager
Pharmacist
Medical Assistant
IT / EHR Support Staff
Practice Manager
Community Health Worker
Other

Letter signed by practice leadership representative, confirming acknowledgement and authorization on behalf of all quality improvement team members.
Practice Leadership Representative Signature* Print Name* Date*
Should be Empty:

Implementing Primary Care and Pharmacy Services to Improve Care and Outcomes for Patients with Diabetes, CKD, and Tobacco Use

Section 1: Practice Information

Panel Demographics (Optional)

Section 2: Diabetes, CKD, and Tobacco Use Information

Baseline Practice Assessment

Practice Questions

Appendix A: Practice Cover Letter