Issue 36
April, 2018
Welcome to Synergy
We are pleased to present the thirty-sixth 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
Continued Collaboration Between SCC Partner Hospitals and Skilled Nursing Facilities

This round of quarterly regional care transitions workgroup meetings kicked off at Southside Hospital, where they hosted five local skilled nursing facilities (SNF) and engaged in a collabortive multi-disciplinary discussion. Key members of each facilities' team were in attendance, including nursing, care management, social work, administration, emergency and hospital medicine departments. Laurie Blom, RN, BSN, MBA, Director of Care Transition Innovation at Suffolk Care Collaborative, facilitated the discussion, which focused on the "ideal state" workflow between the local skilled nursing facilities and Southside Hospital. By mapping out the model workflow, members of the workgroup were able to discuss gaps and barriers in the process. Two specific topics of discussion were, palliative care patients in the emergency department and skilled nursing facility capabilities after the patient is discharged from the hospital.

Participants at Huntington Hospital's Care Transition Workgroup Meeting on March 27, 2018.
The next workgroup meeting was hosted by Huntington Hospital and attended by six skilled nursing facilities. To start off the meeting, Anthony Intintoli, MD, Director of the Hospitalist Program at Huntington Hospital, presented a recent pilot that was launched at Carillon Nursing and Rehabilitation Center. The group learned about the designated hospitalist unit created in Carillon and staffed by Huntington Hospital. Highlighted was the partnership between the two facilities and the joint effort to work through different processes to make this pilot a success. In addition to this discussion, the group also focused on barriers created by medications, as well as communication about shared patients going from the skilled nursing facility to the emergency department.

Participants at Peconic Bay Medical Center's Care Transition Workgroup Meeting on March 28, 2018.
Peconic Bay Medical Center hosted four of their local skilled nursing facility partners. During the meeting, the group began to look at transitions of care at a more granular level and discussed disease-specific interventions. Jean Cacciabaudo, MD, Medical Director of Peconic Bay Medical Center, presented one of Northwell's readmission reduction initiatives, specific to managing chronic heart failure patients, and how they could partner with skilled nursing facilities and other downstream providers on this effort. Similarly, pneumonia and chronic obstructive pulmonary disease are other diagnoses being focused on. The group discussed barriers pertaining to medication, including medication reconciliation, expensive medications and medication adherence.

The last workgroup of the quarter was hosted by Mather Hospital and attended by seven local skilled nursing facilities. Lorraine Farrell, FNP, RPAC, CCCTM, Assistant Vice President of Medical Affairs of Mather Hospital, presented a new procedure for skilled nursing facility residents coming in to get radiological testing and/or blood infusions at the hospital. This effort is a way to circumnavigate the emergency department for these procedures by providing an alternative method to deliver these services and avoid unnecessary utilization of the emergency department. During this presentation, both hospital and SNF staff discussed potential barriers and ways to make the process successful. Additionally, the group discussed sub-acute rehabilitation patients that are leaving the skilled nursing facility back to the community and the support that these patients are offered. This opened up discussion about the engagement of patients outside the facility and to explore potential opportunities for more partnerships between the hospital and SNF.

While each workgroup was tailored to the specific nuances, service area and facility, each group worked to increase the communication between providers to better the coordination of care for their shared patients. We would like to thank Robert Scanlon, MD, Medical Director of Southside Hospital; Michael Grosso, MD, Medical Director of Huntington Hospital; Jean Cacciabaudo, MD, Medical Director of Peconic Bay Medical Center, and Lorraine Farrell, FNP, RPAC, CCCTM, Assistant Vice President of Medical Affairs of Mather Hospital, for hosting this round of regional care transition workgroups and for their continued support!
Save the Date for the Next
Project Advisory Committee (PAC) Meeting

Thursday, June 14, 2018
Registration 8:30 am
Program 9:00 - 11:30 am

Hyatt Regency Long Island
1717 Motor Parkway
Hauppauge, NY 
SCC Hosts Cultural Competency and Health Literacy Train-the-Trainer Class

The SCC's Community Engagement Team recently hosted a Cultural Competency and Health Literacy (CCHL) Train-the-Trainer class.  The CCHL Training Program is provided in partnership with Nassau-Queens Performing Provider System (NQP), Long Island Health Collaborative (LIHC) and curriculum creator Dr. Martine Hackett, an Assistant Professor at Hofstra University, to advance cultural and linguistic competency, promote effective communication to eliminate health disparities and enhance patient outcomes through a number of training concepts.  These concepts include health equity data analysis, unconscious bias, social determinants of health, cultural competency, cultural humility, the National Culturally and Linguistically Appropriate Services Standards, health literacy barriers, and the "Teach-Back" method.  

The full day training held on March 27, 2018, included 13 provider partners from diverse backgrounds such as health care, community-based organizations, academia and legal advocacy serving Queens, Nassau and Suffolk Counties.  At the conclusion of the interactive CCHL Train-the-Trainer class, the partners received certificates of completion and  a resource toolkit to help prepare them to deliver t he CCHL Training Program in their organization.  Congratulations to the new CCHL Master Trainers!   
Back row, standing (left to right): Adrian Adams, Setauket Primary Medical Care, P.C.; Gina Sardell, Stony Brook Medicine; Cristy Dwyer, Outreach Training Institute; Patricia Gremillion-Burdge, Western Suffolk BOCES; Adfredo Rosario, The Retreat Inc./Suffolk County Fatherhood; Hector Sepulveda, Suffolk County Community College.  Middle row, standing (left to right): Jessica Schreck, Cornell Cooperative Extension of Suffolk County; Melissa Callis, Association for Mental Health & Wellness; Julie Yereks, Gurwin Jewish Nursing & Rehabilitation Center.  Front row, sitting (left to right): Cheryl Keshner, Empire Justice Center; Stacie Caplan, Gurwin Jewish Nursing & Rehabilitation Center; Sofia Gondal (Class Instructor), Suffolk Care Collaborative; C.R. Adelante of Suffolk County.  
For SCC's 2018 Train-the-Trainer class dates, please explore the CCHL landing page hosted on LIHC's websiteTo learn more about the CCHL Training Program and how your organization can participate, please contact our Community Engagement Team at
Primary Care Transformation Update

The practice transformation efforts at SCC across its three Hubs, Catholic Health Services (CHS), Northwell Health (NWH) and Stony Brook Medicine (SB), have continued to demonstrate a strong commitment to providing essential services to populations in a patient centered medical home model of care.

As of March 31, 2018, over 600 primary care provider partners have successfully transformed their practice sites by achieving PCMH 2014 Level 3 Recognition and/or NYS APC Gate 2 designation. The SCC congratulates all of the primary care providers and their practice teams for their hard work and commitment to both models of care.

The SCC acknowledges the amazing collaboration and participation from all three Hub Teams:  CHS, NWH and SB, the Hub Leaders, Project Managers, the Practice Transformation Workgroup and the Technical Assistance Transformation Vendors, as we worked as a cohesive team on the practice transformation journey. Thank you to the practice sites, providers, and partners  for your support, dedication and commitment.

Click here for the list of partner organizations across all 3 Hubs that have completed PCMH 2014 Level 3 Recognition or NYS APC Gate 2 designation since our last update  in January, 2018. The entire list of PCMH 2014 Level 3 recognized and NYS APC Gate 2 designated partner organizations partners can be accessed  here. For more information contact Shanna Williams, Project Manager, Practice Transformation, at 631-638-1371 or email:
Partner Interview:  Hands-on Approach is Key to Successful Practice Transformation
Name:  Clinical Integration Network IPA Team
Organization:  Northwell Health 
Left to right. Clinical Integration Network IPA Team:  Stacey Mallin, MPA, Director of Program Operations; Sharda Persaud, MPA, Project Manager; Leo Perez Saba, MBA, Senior Project Manager; Jeanne Nissen, BS, Senior Project Manager; Katherine, Mota, BS, Project Coordinator.

Please tell us about your organization.
As New York State's largest health care provider and private employer, Northwell Health strives to improve the health of our communities. The Clinical Integration Network IPA (CIIPA), a division of Northwell Health, includes more than 7,500 community-based and employed physicians working together to deliver high quality, coordinated care for patients and their families. With healthcare's move toward value-based payment (VBP), CIIPA serves as a foundational element for new care delivery models and population health initiatives, including the Delivery System Reform Incentive Payment (DSRIP) program.

Who does your organization serve in Suffolk County?
CIIIPA serves thousands of patients across Suffolk County. Our team has partnered with community providers to help them successfully implement the DSRIP projects and create an integrated delivery system that meets the medical, behavioral and non-medical needs of patients. We support these providers so they can focus on providing high-quality, patient-centered care to vulnerable populations. 

What DSRIP project(s) are you involved in?
Our team works on every DSRIP project that involves primary care, including Projects 2.a.i., Integrated Delivery System; 3.a.i., Primary & Behavioral Health Integration; 3.b.i., Cardiovascular Health; 3.c.i., Diabetes Care; 3.d.ii, Asthma Self-Management.  We spend a lot of our time focused on practice transformation - both the Patient-Centered Medical Home and Advanced Primary Care models - as well as the integration of behavioral health, the adoption of evidence-based disease management protocols and connectivity to a Regional Health Information Organization (RHIO).

What is your strategy and approach to practice transformation?
Our hands-on approach to practice transformation is key to the team's strategy and success.

At the start of the program, we received feedback from our community partners that they do not have sufficient time to implement quality improvement programs. We had contracted with consultants to provide support, but many providers reported that remote support offered by consultants and technical assistance (TA) vendors wasn't adequate for small practices with limited resources.

In response, our team increased our individual engagement and communication with the practices. Many said that our physical presence made all the difference, we became an additional and valued resource for many of our partner practices.

How do you see DSRIP making an impact on the communities and populations you serve?
Through practice transformation efforts, our community partners have already made an impact on patient care. The practices have increased patient access by offering same-day appointments, extended office hours and 24/7 clinical advice. Further, we have seen tremendous progress toward patient-centered care through increased self-management support as well as information tracking and exchange among providers and facilities.

Going forward, we plan to continue to support the efforts made by our DSRIP partners to further address the behavioral health needs of their patients. Additionally, we intend to foster greater linkages and cooperation between primary care providers and community-based organizations.

We are lucky to work with dedicated, caring providers and office managers who want to continue to improve performance and provide patients a positive experience. Practice transformation is just the start of many ways we can work together for the remainder of the DSRIP program and ensure the progress continues beyond the program end date. 
Compliance Connection
NYS Office of the Medicaid Inspector General (OMIG) 2018-2019 Work Plan Released  
The New York State Office of the Medicaid Inspector General (OMIG) announced the release of its 2017-2018 Work Plan.   The Plan details OMIG's program integrity focus areas in the Medicaid program for the State Fiscal Year April 1, 2018, to March 31, 2019.  

OMIG has outlined three over-arching goals in its 2018-2019 Strategic Plan that supports its mission to enhance the integrity of the NYS Medicaid program by preventing and detecting fraudulent, abusive and wasteful practices within the Medicaid program and recovering improperly expended funds while promoting high-quality patient care.  
Click here to see outline of OMIG's Strategic Plan

The three over-arching goals of the plan are to:
  1. Collaborate with providers to enhance compliance.
  2. Coordinate with partners, including law enforcement and managed care organizations, to identify and address fraud, waste and abuse.
  3. Develop innovative analytic capabilities to extract high-level data on fraudulent or wasteful activities.
This work plan will be updated throughout the year to adapt to the changing Medicaid landscape.  Updates will be posted on OMIG's website.  To receive update alerts via email, subscribe to the listserve here .  

For compliance questions, or assistance, contact the SCC Compliance Office at
 Milestone Dates
 NYS DOH DSRIP Program Milestone Dates
May 30
MAX Series Symposium; Metropolitan West, 639 W. 46th St., New York, NY
May 30
IA Completes Review of PPS DY3 Fourth Quarter Report

Frequently Asked Questions


To access NYS DSRIP FAQ, click  here.
Access previously published Synergy eNewsletters  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. Program Assistant
  2. Administrative Assistant
  For more information, please contact the Suffolk Care Collaborative via email