Issue 24
April, 2017
Welcome to Synergy
We are pleased to present the twenty-fourth issue of Synergy, a monthly newsletter about the progress and processes of the Suffolk Care Collaborative (SCC).

The definition of synergy is the increased effectiveness that results when two or more entities work together. We are confident that the combined efforts of the many dedicated partners within the SCC will help the Collaborative reach its goals, leading to improved health for the residents of Suffolk County.  

About Suffolk Care Collaborative (SCC):  SCC is an alliance of healthcare providers in Suffolk County, Long Island, NY, formed to support New York State's Delivery System Reform Incentive Payment (DSRIP) initiative. Under the guidance and leadership of Stony Brook Medicine, SCC established a Population Health Management Service Organization to improve county-wide health by addressing a wide range of challenges to health in order to improve outcomes by encouraging wellness, making healthcare more accessible and reducing costs by decreasing unnecessary hospital utilization.  For more information, visit our website:

In This Issue
Tobacco Free Campus Initiative Kick-Off
Andrea Spatarella and Patricia Folan from Northwell Health's Center for Tobacco Control discussing various types of training offered to behavioral health sites

As part of the Tobacco Free Campus at Behavioral Health Sites DSRIP initiative, the Suffolk Care Collaborative (SCC) has partnered with the Tobacco Action Coalition of Long Island and Northwell Health's Center for Tobacco Control to carry out the Tobacco Free Campus Initiative. The overall goal of the Tobacco Free Campus at Behavioral Health Site Initiative is to assist behavioral health sites through their transition in becoming tobacco free campuses. Tobacco free properties are cleaner, free of cigarette butts and other tobacco litter. Policies prohibiting tobacco use on worksite grounds are known to be an effective way to change smoking-related behavior patterns. Literature shows that about 50% of people with behavioral health disorders smoke, compared to 23% of the general population. Through this initiative, the SCC and its partners hope to create healthier and safer environments for all clients, staff and visitors and ensure that tobacco dependence is addressed with all clients at behavioral health sites. We also hope to build upon tobacco cessation trainings and resources for behavioral health site staff members and their clients.

On April 25, 2017, the SCC hosted a kick-off breakfast with representatives from each of our contracted behavioral health sites. During this breakfast, representatives met with project leads, PJ Tedeschi, Director of the Tobacco Action Coalition of Long Island; Patricia Folan, Director, and Andrea Spatarella, Nurse Practitioner, from Northwell Health's Center for Tobacco Control. Attendees of the breakfast received Tobacco Free Grounds Implementation Toolkits.  The toolkit acts as a guide for sites as they expand upon their existing smoke free policies or create new tobacco free policies. The toolkit highlights the various forms of technical assistance provided to the behavioral health sites as they transition to tobacco free status. Additionally, the toolkit includes a Tobacco Free Site Readiness Survey for organizations to complete based on their current practices and policies. Beginning in May, the project leads will be using the results of these surveys during site visits where they will be tailoring their assistance to each site's needs. The toolkit also includes local tobacco cessation resources as well as ones that are specific to the behavioral health community.   The toolkit can be found online here .
Announcing 2017 
Primary Care & Behavioral Health Integrated Care Learning Collaboratives
For Primary Care Schedule click here.  F or Behavioral Health Schedule click here .

The Suffolk Care Collaborative is pleased to announce the launch of the 2017 Primary Care and Behavioral Health Learning Collaboratives! The Suffolk Care Collaborative has partnered with Center of Excellence for Integrated Care (COE) to offer our primary care and behavioral health providers the opportunity to participate in this re-vamped informative and interactive learning collaborative series.
The COE will be leading robust bi-monthly learning collaboratives to discuss pertinent topics in integrated care, such as New York State billing and regulations, integrated care program evaluation, sustainability and business models, practice tools, group services, joint treatment planning, staffing competencies, workflow strategies, and data registries . During each one-hour live webinar, the COE will present 25 minute "quickinar" on the specified topic, followed by a question and answer session. Based on the quickinar topic and discussion, recommendations and strategies for participating sites will be presented. All learning collaboratives will take place from 12:00pm -1:00pm. The series will be split between our primary care and behavioral health providers, so please see the Primary Care (Model 1) and Behavioral Health (Model 2) fliers for more information and a complete list of dates and topics for each. This learning collaborative series is open to ALL SCC primary care and behavioral health partners, regardless of their Stony Brook, Northwell, or Catholic Health Services Hub affiliation.
To register, please use this  link.  
Learning Collaborative Spotlight: The New Face of Healthcare
Primary Care, Behavioral Health, and Hospital Providers Joined for a Learning Collaborative on Building an Integrated System of Care in Suffolk County.

As the SCC Project Management Office moves from program design to program implementation, we have convened program committees as Learning Collaboratives. The goal of the collaboratives is to create a community of knowledge that can help participants accelerate program implementation, systematic change and make lasting breakthroughs that meets or exceeds program expectations.

On March 24, 2017, the Suffolk Care Collaborative and Communities of Solutions co-hosted a learning collaborative, at the Coram Fire Department, titled The New Face of Healthcare: Building an Integrated System of Care in Suffolk County. Recognizing that the landscape of our healthcare system is changing from a fee-for-service environment and towards a value based payment environment, we extended this educational and networking opportunity for providers in Suffolk County to prepare for this new environment.

In echoing the population engaged in the Transition of Care program (TOC), Screening Brief Intervention and Referral to Treatment program (SBIRT), and Primary Care and Behavioral Health Integration program, this mini-conference brought together primary care providers, behavioral health providers, hospital providers, and health homes in order to facilitate the creation of a collaborative climate that will serve to improve population health in Suffolk County. This interactive event featured timely and informative presentations, in addition to a guided workshop session during which participants were able to connect with other providers in their region.

In advance of this learning collaborative, geographic cohorts were created; 14 cohorts grouped primary care providers, behavioral health, and hospital providers by region.  These cohorts were mapped,   and participants were seated at the event according to their region.  Click here to view regional cohort maps.   This deliberate seating method allowed for discussion to take place between provider types located proximally, allowing for providers to learn of services available in their local region, fostering space for potential partnerships to initiate.

The three primary objectives of this event were for participants to learn about integrated delivery system initiatives in the State/County, recognize service availability in geographical regions/enclaves, and begin to workshop collaborative agreements between providers. To achieve these learning objectives, 5 distinct presentations were delivered, followed by collaborative workshop. The presentation topics included Medicaid Redesign & DSRIP Overview, Bridging Referral Gaps: Collaboration in the Community, Peer Navigation, Integrated Care Success in the Community, and SBIRT in the Emergency Department & Community. Each of these presentations was given by a partner or collaborating agency of the Suffolk Care Collaborative, who deliver care in our community. After these informative and interactive presentations, participants worked in their cohorts through a series of guided questions, rooted in the themes of the presentations. The goal of this workshop time was to engage participants in critical reflection of the information presented, focusing on the applicability to their institutions, and how their own patient care work could be furthered through collaborations with local external partners.

For this event, the Blueprint for Collaboration was created and distributed to all participants. The Blueprint is a resource guide which provides actionable information to providers, related to the presentations given during the event, including information about three related DSRIP projects (TOC, SBIRT, and Primary Care and Behavioral Health Integration), substance use and depression screening tools, a sample agreement between a hospital and behavioral health provider, an integrated care site self-assessment tool, information regarding peer support services, billing for integrated care services, the Community of Solutions (COS) Community Resource List, and the maps of the geographic cohorts. In addition to receiving this resource, CASAC and Social Work CEU hours were also awarded to eligible attendees. 

It is our intention to aggregate the participant feedback collected from the workshop session and event evaluation forms, and provide targeted and solution-focused programming for this group in the near future. The turnout for this event and the level of engagement of the attendees is certainly indicative of the commitment of these providers to bettering patient care, and their openness to share with, and learn from, one another. Thank you to all who joined us for this event, and we hope to see you at the next one!  
Thank you to all who supported the planning of this event!  
(L to R) Nancy Beckett-Lawless, Seafield Center; Alyse Marotta, SCC; John Venza, Outreach House; Mary Silberstein, Central Nassau Guidance and Counseling Services; Kristie Golden, Stony Brook Medicine; Susan Jayson, SCC; Pamela Mizzi, LI Prevention Resource Center; Sarah Ravenhall, Nassau-Suffolk Hospital Council; Kimberly Whitehead, LI Health Collaborative; Pascale Fils-Aime, LI Health Collaborative.
Hospitals Share Transition of Care Model Journey at Round Table Learning Collaborative
Janet Woo, Southampton Hospital

March 31, 2017, marks a monumental day for the 11 Suffolk County Hospitals as it is the end of the implementation phase of the Transition of Care (TOC) Project. For the past two years, each hospital's implementation team, hand in hand with Suffolk Care Collaborative, designed, built and implemented a TOC model to better care coordination for the Medicaid population in Suffolk County. With the ultimate goal of reducing unnecessary 30-day hospital readmissions, hospitals worked to build a sustainable infrastructure to support patients on their journey. A 30-day supported transition period after a hospitalization was put in place. The patient is approached prior to being discharged from the hospital and connected to a care manager to assist with follow up, post-discharge education and instructions and medication reconciliation. While the medical needs are being tended to, the care manager also discusses any social needs, such as transportation and housing issues, that are often obstacles for patients to carry out their care plan. Hospitals leveraged their internal care management and social work teams as well as utilized support from the SCC's Care Management Organization, by way of embedded care managers, to kick start this effort. Extending communication into the community by connecting with community based organizations and other providers along the care continuum is another next step for success of the program.

During the April 4, TOC committee meeting, representatives from all 11 Suffolk County hospitals joined the hospital round table learning collaborative to discuss challenges, successes and future opportunities for the TOC project. Each hospital presented their transition of care model allowing for other hospitals to pinpoint best practices to potentially adopt in their facility. Additionally, past and current challenges with implementing the model were discussed. These conversations raised the bar and lead to the future success of the program. Please click here to see the presentation.

As we head into the performance phase of this DSRIP project, collaborations are already forming between our hospital partners, skilled nursing facilities and other community-based providers and organizations. The Suffolk Care Collaborative is hard at work to support our hospital partners to continue to break down care silos, nurture interdisciplinary provider relationships and achieve performance goals. As a next step, our hospital partners will be hosting local skilled nursing facilities at regional "Care Transitions Workgroups," to open the communication lines and work on joint initiatives.

We would like to congratulate all 11 hospitals on their success thus far and thank each of you for your continued partnership to better the care of Suffolk County residents!
Family and Children's Association Recovery Community & Outreach Center, THRIVE

Family and Children's Association (FCA) is a not-for-profit agency helping more than 20,000 of our Long Island neighbors each year.  For more than 130 years, FCA has worked to protect and strengthen vulnerable children, seniors, families and communities on Long Island.

Through an integrated network of services, FCA provides help and hope to under-served and disadvantaged individuals struggling to build better lives. FCA invests in children by offering early childhood intervention, educational mentoring, youth development, college scholarships and counseling. FCA's Home Based Community Services (HCBS) program offers children's behavioral case management services and family support. Family success is further achieved through family crisis management; addiction prevention, treatment and recovery programs for substance use; parenting skills training, vocational education, and court diversion. FCA helps neighbors in need through a robust senior care division and innovative runaway and homeless youth programs for those dealing with unique challenges.

In Suffolk County, FCA opened Long Island's first recovery community and outreach center, THRIVE. Along with partnering agencies Long Island Council on Alcoholism and Drug Dependence (LICADD), Long Island Recovery Association (LIRA), and Families in Support of Treatment (F.I.S.T.) and with funding from NYS Office of Alcoholism and Substance Abuse Services (OASAS), THRIVE will provide the crucial recovery services and positive environment to help combat the opioid
NYS Governor Andrew M. Cuomo at THRIVE Recovery Center
epidemic on Long Island. On April 19, 2017, NYS Governor Cuomo visited THRIVE to announce new legislation investing over $200 million to fight the heroin and opioid epidemic in New York.

In addition to THRIVE, FCA's presence in Suffolk County includes ensuring that youth between the ages of 14-21 who are in foster care, or discharged from foster care, are able to live and work independently in the community when they are no longer eligible for foster care. FCA's Project Independence (PI) program has changed the lives of countless foster children for the better, steering them towards a path to success. In 2016, 96% of Suffolk PI clients were deemed able to live successfully in the community with less frequent supports in place.

Visit Family and Children's Association's website to learn more, subscribe to their e-newsletter, or to get involved with FCA's mission. Contact them at or (516)746-0350.

Nursery Co-Op Youth and Parents
The Center of Excellence for Integrated Care
Promoting Evidence-Based Models to Integrate Primary Care and Behavioral Health Care

The Center of Excellence for Integrated Care (COE) assists health care clinics and systems in integrating their physical and behavioral healthcare. The COE team's philosophy is simple: build buy-in across the organization and use evidence-based approaches flexibly to fit local needs. The COE's mission is to spur the creation of evidence-based integrated care Models across health systems to improve the mental and physical health of primary care patients and clients of mental health homes.  The COE team believes these models have great potential to decrease inappropriate utilization of healthcare resources such as some emergency department visits, and, therefore, impact costs, especially among segments of the population that traditionally over-utilize resources. The COE uses systematic tools and processes to help practice sites determine their current state and needs, and provide the technical assistance needed from the board room to the exam room.

Working with the COE means working with experienced professionals with both clinical experience and technical assistance expertise. The COE usually begins their engagement with clients by defining the scope of work and a timetable. They quickly mobilize to get on the ground as quickly as we can in order to promote fast learning across the organization. They use a variety of tools including project management software and online learning module software to promote this learning. Work can take many shapes but can include:
  • Presentations to clinic leadership/staff
  • Development of cross-site/statewide learning collaboratives
  • Shadowing of clinical personnel; observation of work flow
  • Evaluation of integration level using the MeHAF tool
  • Curriculum development for training programs or health agencies
  • Facilitating state-wide workgroups
To learn more about the Center of Excellence for Integrated Care (COE) click here.
Partner Interview:  Intergrating Physical and Behavioral Health Care
Name:  Christine Borst, PhD, LMFT
Title:  Interim Executive Director
Organization:  Center of Excellence for Integrated Care, A Program for the Foundation for Health Leadership & Innovation

Please give a brief summary of your organization.
The Center of Excellence for Integrated Care (COE) is a core program of The Foundation for Health Leadership & Innovation, which houses a variety of programs related to health and wellness. We grew out of the I-CARE Partnership, developed in 2006, to educate providers across North Carolina about integrated care. Our goal today is integrating physical and behavioral health care in various health systems including primary care practices, hospitals and community health centers both locally and nationally. 

How does the COE work to promote integrated care?
We build buy-in across the organizations and then we use evidence-based approaches flexibly.  It's important not just to provide tools and materials, but also to personalize the delivery of them.  

We coach and shape each practice on the ground. In order to really understand the practice, we go in and shadow the providers, get a really good sense of the work flow, and then do our assessment and tailor our recommendations to the practice.

We assist primary care practices in the recruitment and training of behavioral health specialists. Often times, a significant amount of training is needed. T raditionally, therapists are trained to do a 50 minute or an hour-long session in a calming, comfortable space. The culture in a medical setting is very different. So, part of what we do is help the sites adapt to these cultural differences.

It's vitally important to provide training not just for the behavioral health clinician but for the whole site, so that everyone, from the receptionist to the provider, are all on-board and understand why integrated care is important and how they can help make it happen.

Why is integrated care important?  
Despite understanding that, at the most basic level, the mind and body are connected, we have allowed them to become completely fragmented in our health care delivery system. Even conditions like diabetes and depression, that seem very different, are often interrelated. It's vital that we start addressing the whole person or we are going to continue to see healthcare costs rise.

When mental health crises happen, individuals usually don't go to specialty mental health specialists. They go to their primary care provider, if they are asking for help at all. Primary care providers understand that, but they don't always feel comfortable addressing mental health issues. However, even if they do, it can be too time consuming when they have only a brief amount of time with a patient. Primary care providers do not always want to ask about it because they don't want to open Pandora's box. That is to say, they may uncover an issue that is not in their scope of care to treat.

Our goal is to reduce the burden of the primary care provider. We want to be able to free them up to do what they were trained to do and then hand the patient off and say, for example, "I'm going to have our behavioral health clinician talk to you about some of the ways to manage stress, which can influence high blood pressure." And then the provider can move on to the next room and the patient is still getting wonderful care that's team based, and later the behavioral health and primary care providers can loop back up to create a plan for that patient.  

What types of challenges face primary care and behavioral health providers in integrating care?
There are clinical, operational and financial challenges.   At the clinical level, there's the lack of a trained workforce of behavioral health clinicians. Few clinicians are trained to do a 10- to 20-minute intervention. Having clinicians who know how to do that is vital to the success of integration.

The operational issue is adapting workflow to provide integrated services; setting up policies and procedures to assure that the way integration is implemented is standardized throughout the whole clinic.

Obviously, the financial, billing and reimbursement varies by payer. Unfortunately, sometimes the reimbursement dictates the level of integration that happens, as opposed to what is best for patients.

How is the COE working to overcome these challenges?
Clinically, we are working to train the workforce. We are recruiting and training traditional therapists (psychologists, clinical social workers, professional counselors, etc.) to do these brief interventions, to ask about things like diet and sleep hygiene. There may be times when sleep medication is needed, but it is important to talk about the behavioral issues too. 

We have a bi-monthly work group, the Behavioral Health Clinician Hangout. It's an opportunity for the various clinicians we are working with, to get on a call all together to discuss some of the problems they have run into and do some troubleshooting.

Regarding operational concerns, we help each site map and adapt workflow from the front door to the back.  Protocols, procedures and policies can help assure everyone is on the same page and integration is something that the entire practice is doing. For example, implementing a universal pre-screening for depression/anxiety is one way to ensure utilization of the behavioral health clinician.

Finally, the financials.  We have worked with policy issues that limit integrated care sustainability by hosting policy summits and groups and holding regular meetings. For example, in many states, billing for both a behavioral health and a medical provider on the same day is prohibited, defeating the purpose of having both services in one place. We work to bring awareness (and eventually change) to such limitations.

How are you working with SCC to integrate care?
We physically go out to about 24 sites at a time, as identified by SCC, to conduct baseline practice assessments. These practice assessments help us identify areas of growth, strategic opportunities, and potential for integration. We speak to as many representatives as possible--front desk staff, administration, clinical staff, providers. Then we provide site-specific feedback in dashboard form, so that individuals at the site can see a snapshot of where they are on the continuum of integrated care. We identify some areas of strength, and opportunities for improvement. By maintaining the current areas of strength, and working to support the opportunities for improvement, we aim to aid a site in increasing their level of integration. We also hold bi-monthly webinars to provide information and an opportunity for the participants to collaborate. Finally, we make pre-recorded training modules available on the SCC's Learning Center on their website.
Compliance Connection

Auditing and Monitoring
Members of the Health Care Compliance Association (HCCA) and Association of Healthcare Internal Auditors (AHIA) work together to continuously explore opportunities to better define and explain auditing and monitoring and develop guidance and reference materials on key aspects of health care auditing and monitoring processes.  A joint task force of these two organizations published a whitepaper entitled, Defining the Meaning of 'Auditing' and 'Monitoring' & Clarifying the Appropriate Use of the Terms.  While consisting of similar tasks, auditing and monitoring are separate concepts and activities.  To learn more about the usage of the terms "auditing" and "monitoring," why distinction is important, where auditing and monitoring intersect and benefits each other, and the need to retain evidence of auditing and monitoring efforts, click here for the whitepaper.

SCC's Patient Engagement Audit Plan
As part of the SCC's Compliance Program, we are committed to conducting on-going monitoring and auditing and have developed a formal Patient Engagement Audit Plan.  The SCC will audit contracted partners' patient engagement reports to ensure the integrity of the data reported to the Department of Health (DOH). During DY2, Q4 the SCC piloted the patient engagement audit process.  From the pilot, audit tools were refined, a communication template to memorialize findings and a formal corrective action planning template were developed.  An audit schedule has also been developed for all the SCC PPS.  Starting DY3, reported patient engagement data provided to the SCC will be audited the first and third quarter of each DSRIP year, so that findings can be corrected prior to submitting data to the DOH in the second and fourth quarter of each DSRIP year.  For questions or assistance, contact the SCC Compliance Office at
Milestone Dates
NYS DOH DSRIP Program Milestone Dates

 May 1                  Additional PPS Lead Regulatory Waiver Requests - Round 5 due

 May 31                Independent Assessor provides feedback to PPS on PPS Year 2
                             Fourth Quarterly Reports; 15 day Remediation window begins

 June 14               Revised PPS Year 2 Fourth Quarterly reports due from PPS; 
                             15 day remediation window closes

Frequently Asked Questions


To access NYS DSRIP FAQ, click here

Job woman showing hiring sign. Young smiling Caucasian   Asian businesswoman isolated on white background.
Office of Population Health
Career Opportunities
The SCC is pleased to invite qualified career seekers to apply for open positions. All job descriptions for current opportunities are posted here.

Current Job Opportunities:
  1. Director, Care Transition Innovation
  2. Compliance Officer
  3. Care Manager
  4. Data Visualization Analyst
  5. Social Worker
  6. Community Health Associate
  7. Population Health Platform Training and Support Specialist
  8. Data Acquisition Analyst
  For more information, please contact the Suffolk Care Collaborative via email

Stay Informed


SCC communications currently include bi-weekly "DSRIP in Action" emails, a monthly "Synergy" eNewsletter, and the SCC website, which houses a wealth of resources including individual program webpages, presentations, videos, and key documents. To directly sign up for our newsletter, click here 


Have a question? Please send it to then watch for the answer in a future issue of Synergy.