Issue 12
April 30, 2016

Welcome to Synergy


We are pleased to present the twelfth 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. 

In This Issue
Organizational Work Stream Highlights
In addition to the eleven DSRIP projects, there are organizational work streams as part of NYS DOH DSRIP Program Domain 1 requirements.

The SCC has completed and submitted two Community Engagement milestones: Finalize community engagement plan, including communications with the public and non-provider organizations (e.g. schools, churches, homeless services, housing providers, law enforcement); and Finalizpartnershiagreementor contractwitCBOs.   The Community Engagement Leadership Workgroup met on February 16, 2016 and March 15, 2016 to collaborate on the development and design of the SCC Community Engagement Plan.  The plan reinforces SCC's commitment to building ongoing relationships with community partners assuring information is communicated through a bi-directional flow of information.  Our goals/objectives include developing strong relationships and collaborations with key internal and external stakeholders, building trust through participation; establishing methods for communication with community partners as well as for community engagement activities, outreach, navigation, training, forums, etc. and developing innovative engagement approaches, learning from each engagement experience and using lessons learned to improve our approaches to future engagement.   The proposed plan was approved by the Community Needs Assessment, Outreach and Cultural Competency and Health Literacy Committee on February 22, 2016.  In addition, the Committee engaged in discussions on the activities of the Community Engagement Workgroup including new expanding partnerships and collaborations, and the new community resources directory partnership with HITE.  
We are pleased to announce Amy Solar-Greco, Project Manager for Project 2di, has joined the Community Engagement Workgroup to align the common objectives of the Community Health Activation Program with our community engagement efforts.

The SCC continued to engage the Workforce Advisory Committee and Workforce Governance Committee through March 31st to complete the implementation plan deliverables. Activities of the SCC and consultants from KPMG included facilitation of current and target state meetings with key stakeholders from all eleven DSRIP projects. During the meetings job titles were identified for each project as well as the competencies and skills needed to meet the job requirements.  This information will be used during DSRIP program implementation to support resourcing/recruitment efforts and training efforts. 

The SCC is now planning the final target state, gap analysis and transition roadmap, which will be informed by our partner organizations incumbent position allocation data we've collected for each DSRIP project.  To further support these deliverables, the SCC and KPMG will be conducting working sessions in early May to continue developing target state projection models, the current state assessment report and the gap analysis.  

KPMG will be coordinating a compensation and benefits survey for our partners through June 2016.  The NYSDOH requires each PPS to conduct a Compensation and Benefit Analysis as part of the DSRIP initiative.  The purpose of the survey is to capture a snapshot in time and examine workforce trends within the PPS.   

The Workforce Communication and Engagement Plan is in draft form and reflects input from key stakeholders from across the PPS as well as from members of the Practitioner Engagement Workgroup and Workforce Advisory Committee. The Workforce Communication and Engagement Plan is designed to assist the SCC with the development and execution of communication and engagement activities to support DSRIP implementation across the SCC partners.

Training development has been a priority at the SCC.  The SCC Training Strategy and Plan was approved by the Workforce Governance Committee on March 30th.  This plan was designed through a facilitated needs assessment across all DSRIP projects and Organization Work Streams. The needs assessment helped to identify the courses, skills and processes that would need to be acquired in order to successfully participate in the DSRIP projects.  The SCC will be utilizing a blended learning approach to training and is currently building a learning center on the SCC website.  Resources related to Cultural Competency, Health Literacy, and PCMH are available on the Learning Center as well as e-learning modules initially focused on DSRIP 101 education and Performance Improvement.  The SCC Training Strategy and Plan will be updated as needed as we learn more about our partners and their training needs through the contracting process.

The Practitioner Engagement Workgroup finalized the Practitioner Communication and Engagement Plan which was endorsed by the Clinical Governance Committee in January and approved by the SCC Board on February 22nd.  The plan provides a foundation for practitioner engagement efforts and a framework to guide future engagement activities. The Practitioner Engagement and Communication plan also addresses the initial training plan for providers related to "DSRIP 101" education and an overall orientation to the SCC DSRIP projects and quality improvement agenda.  For contracted partners the SCC has developed an onboarding program which provides education regarding the DSRIP projects, performance reporting requirements and other essential need-to-know topics for our partners.  The onboarding program is available on the SCC website and can be found here
The Population Health Management/Integrated Delivery System (PHM/IDS) Workgroup continues to meet monthly to work on the development of the Population Health Management Roadmap which is projected to be completed by June. Collaboration and shared information related to the work completed through the Information Technology Task Force and the PCMH Certification Workgroup continues to inform further development of the roadmap. The IT Task Force received endorsement of the "Clinical Data Sharing and Interoperable Systems across the PPS" report which speaks to the technical onboarding of partner providers and key data points for shared access.  These elements are crucial factors in the ability to perform Population Health Management and to utilize a variety of individual, organization and cultural interventions to help improve patient self-care, morbidity patterns, and the health care use of defined populations. The PCMH Certification Workgroup has also completed and presented to the Workgroup the "PCMH Current State Assessment" and the Workgroup will utilize this information to populate the roadmap. Additionally, representatives from the Value Based Payment Team, Performance Reporting and Management Workgroup, the Care Management and Care Coordination Workgroup, the Transitions of Care Workgroup and the Community Engagement Leadership Workgroup participate in discussion and report progress in their respective areas to further enhance and develop the approach to Population Health Management. 

Members of the PHM/IDS Workgroup, in collaboration with the PMO, Project Leads continue to meet regularly and have completed the Clinical Integration Needs Assessment. Data was collected from multiple sources including surveys in the area of Transitions of Care, Behavioral Health and Primary Care Integration Readiness, access to care, PCMH recognition status, RHIO connectivity, EHR utilization, and current state care management models and compiled to inform and understand current functionalities and capabilities of partner providers. Members of the leadership teams for CHS, Northwell Health and Stony Brook University Hospital worked together to provide details on the partner providers that will be or currently are clinically integrated. The IT Task Force collaborated on the development of the Clinical Integration Needs Assessment by providing the "Clinical Data Sharing and Interoperable Systems across the PPS" report which highlights key data points for shared access, the plan for how to connect providers, as well as the key interfaces that will have an impact on clinical integration. The Clinical Integration Needs Assessment was reviewed and endorsed by the Clinical Governance Committee. This Assessment will now be used to inform the development of the Clinical Integration Strategy.

The Community Needs Assessment, Outreach and Cultural Competency Health Literacy Committee conducted their quarterly meeting on February 22, 2016. The Committee reviewed the activities of the Cultural Competency and Health Literacy Workgroup to date as well as the targeted population needs assessment survey tool, and organizational workstream and project specific deliverables across the SCC portfolio. The Committee accepted the targeted population needs assessment survey tool which is expected to be utilized in the Project 2di CHAP program initiatives.

The Cultural Competency and Health Literacy Advisory Workgroup met on February 19, 2016 and March 18, 2016. The Workgroup identified an opportunity to leverage the expertise of the members and effectively manage the strategies to achieve CCHL in our communities and developed subgroups to address patient education, CCHL training, and CCHL education. The Workgroup activities during this reporting period included reviewing and making recommendations on the following items: project specific patient education materials, patient assessment surveys, Workforce/CCHL current state assessment survey initial findings, and training resources including vendors, online learning modules, videos and the PPSs' Learning Center platform for our website. The Workgroup accepted the targeted population needs assessment survey tool and some project specific patient education materials. 

The SCC Workforce Current State Assessment Survey findings has provided preliminary information identifying potential gaps and focus areas. This information is being used to develop future training programs. The framework for the cultural competency and health literacy training plan has been developed in conjunction with the Workforce Training Plan. 

SCC is a collaborative partner with the Long Island Health Collaborative-Population Health Improvement Plan (LIHC-PHIP) and their leadership staff participates in our Workgroup. This collaboration has resulted in an extensive interview process researching CCHL training vendors to support the workforce educational needs for SCC partners (hospitals, local department of healths, CBOs, etc.).

On May 6, 2016 Althea Williams, Sr. Manager for Provider and Community Engagement participated in the 'Reviving Haiti/YAM Health Fair' held at St. Ann's church. Althea presented an overview of the Suffolk Care Collaborative and its CCHL initiatives to the community. She also presented in the All PPS meeting held on February 17, 2016 the following topics: Overview/History of the All PPS Statewide CCHL Collaboration Workgroup, the milestone one strategies on CCHL Integration into Organizational Workstreams and Projects, and milestone two strategies on CCHL Training.

The two workgroups of the Finance Committee, Financial Sustainability Workgroup and Value Based Payment (VBP) Workgroup, are established. The Financial Sustainability Workgroup has developed and secured Board of Directors approval of the SCC Finance Structure Chart which includes descriptions of roles and responsibilities of the Finance Committee and its two workgroups. The Financial Sustainability Workgroup has also performed the network financial health current state assessment. This assessment with take place on an annual basis. In addition, this workgroup has developed the financial sustainability strategy to address key issues. This strategy has been approved by the Board of Directors. The VBP Workgroup is working to develop a detailed baseline assessment of revenue linked to value based payment, preferred compensation modalities for different provider types and functions, and MCO VBP strategies. They have created a VBP survey that has been distributed to network providers. Once the survey results are in and analyzed, a VBP plan will be developed and submitted for Board of Directors review and endorsement. 
Building a Suffolk County Integrated Delivery System  (2.a.i)

SCC IT Project Management Office is pleased to announce the successful completion of the following project specific and organizational milestones:  
  • Production deployment of our Phase 2 High Risk Patient Identification algorithm used within the SCC HealtheCare™ application.
  • Production deployment of the Stony Brook Hub Enterprise Data Warehouse (EDW)
  • Clinical definition of our SCC Registries and associated measures that will be deployed within our phase 1.5 HealtheRegistries™ application.
  • Completion of our Clinical Data Sharing and System Interoperability Roadmap
  • Completion of the required set of System Security Plans (SSPs).  The SSPs documents which controls have been implemented and how for all systems that are used to house and process the DOH provided Medicaid Data. 
  • Initial draft publication of the SCC Change Management Strategy document
  • Initial draft publication of the SCC IT Current State Assessment document
In addition to completing the project milestones and sub-steps outlined above we are meeting regularly with project stakeholders to refine our existing Population Identification and Provider Attribution algorithms that will be used within the SCC HealtheRegistries™ and EDW applications.      

Care Management and HealtheCare™ Application Updates
We continue to work with SCC's Care Management Organization (CMO) to further refine the care management workflows supported in the HealtheCare™ application.   Key enhancements have been prioritized by the SCC CMO and are now being reviewed by the IT staff for estimation and project planning purposes.  One of the high priority enhancements identified by the CMO was further refinement to the High Risk Patient Identification (HRPI) algorithm.  To this end, a new HRPI algorithm was developed, tested and released into production in early March 2016.  This new algorithm is now being used by all SCC care management staff. 

Production Deployment of the Stony Brook Hub Enterprise Data Warehouse
The Stony Brook instance of the HealtheEDW™ was successfully deployed into production in February, of this year.  The deployment of the Stony Brook Enterprise Data Warehouse (EDW) is a key foundational building block within our clinical data integration strategy as it will ultimately provide one of the three hub specific datafeeds into the PPS wide SCC EDW.  
The SCC EDW will be the source of truth for all of SCC reporting requirements, including but not limited to patient engagement reports required for quarterly submission to the DOH.  As we continue to sign on additional providers and integrate their clinical data into the Integrated Delivery System (IDS) the SCC EDW will also play a significant role in proactively providing reports to SCC's network performance team in advance of semi-annual or annual performance reports that will be published by the DOH.
Highlighting Performance Reporting & Measurement Developments

With the submission of the DY1 Q4 Report (period ending March 31st), the SCC has completed all required elements to fulfill the Performance Reporting Organizational Work Stream milestones. The SCC's Performance Reporting Organization Work Stream is currently transitioning from the process design phase to program implementation.  The SCC's Performance Reporting and Improvement Plan is in place and the training strategy is being executed during the onboarding phase of its partners.  In addition, the SCC recently launched the Learning Center on the SCC website to supplement the in-person learning opportunities that are currently underway.  The initial e-learning training modules focus on topics such as DSRIP 101 and the SCC Quality Improvement Agenda as well as common performance improvement tools and methodologies. 
The overall goal of the SCC performance reporting and improvement program is to improve the patient experience of care (quality and patient satisfaction), improve the health of the populations we serve and reduce the per capita cost of providing healthcare services, thus achieving the Triple Aim.  The SCC will be relying on data from two decision support tools to guide action planning across the PPS to meet its performance goals.  These decision support tools include the DSRIP Performance Dashboards and the Cerner HealtheAnalytics Standard Reports.
Decision Support Tools to support the Performance Improvement Program

On January 29, 2016, NYS released the DSRIP Performance Dashboards, found in the Medicaid Analytics Performance Portal (MAPP), to all 25 PPS'. The interactive dashboards provide the SCC with feedback regarding its progress with meeting gap-to-goal targets.  PPS' are expected to reduce the gap-to-goal for most measures by 10% and 20% for the High Performance measures.  The dashboards to-date reflect 12 months of data through February of 2015. The SCC has begun reviewing the interactive dashboards, identified areas for improvement and will begin working with the DSRIP Project Clinical Committees this month to provide an orientation to the dashboards and discuss some actionable next steps.      
The SCC is also working with each of our Hubs to standardize the data ingestion of our partners on a common enterprise data warehouse (EDW).  The SCC EDW will be used for Hub specific and PPS-wide generation of more timely performance reports.  Although the DSRIP Performance Dashboards are a valuable tool to review retrospective performance, the data is currently more than 12 months old and may not be indicative of current performance.
The SCC is looking forward to working more closely with partners to achieve system-wide excellence by improving existing systems and processes
Partner Interview
Name: Joseph Schulman
Title: Executive Director
Organization: Northwell Health Solutions- Northwell Health's Care Management Organization
Please give us a summary of your organization
We are the C are Management Organization for Northwell Health with responsib ility for the performance, management, and implementation of our system's value-based programs, demonstrations, and risk-based populations.
Northwell Health (formerly North Shore-LIJ Health System) is New York State's largest health care provider and private employer with 61,000 employees. With 21 hospitals and nearly 450 outpatient practices, we serve more than 1.8 million people annually in the metro New York area and beyond.

What do you hope the DSRIP program will accomplish in general?
The goals of the program are consistent with our organization's overall triple-aim strategy of high-value care delivery for all the populations we serve as a system. Aligned with DSRIP, we are focused on reducing health disparities, improv ing the experience, and having exceptional patient outcomes result in improvement on the total cost of care.

What in your experience are the top guiding principles of successfully managing the health of a population?
The first is engagement - our ability to engage beneficiaries , their families and, importantly, providers . By creating a network of care with access and methods to engage at-risk populations and their respective providers , we can reach people who otherwise have been left with few options and are lacking information about how to access needed care for an early , chronic, or severe condition. And, as mentioned, in parallel, to engage beneficiaries, we need to align efforts with the provider network.
Another critical domain is data management and analytics . Our efforts are focused on building a four-dimensional view of the populations we serve through the data so that we can tailor our c are c oordination activities and resources to meet their needs . T he goal is to provide support to the beneficiaries, alleviate suffering and maintain individuals in their own homes. In order to do that in a highly organized and efficient way, you need to have capabilities and a level of sophistication around data analytics , data management and reporting .

How are performance outcomes measured within your organization and how do the DSRIP measures align with current efforts?
T he outcomes measures housed inside of the DSRIP program are well aligned with our overall value-based population health activity. Among the most common is preventable/avoidable e mergency r oom visits, in addition to 30-day avoidable and all-cause readmission rates. As I mentioned earlier, we are also heavily measuring outcomes linked to discharge-to-home rates and a more progressive measure of days-at-home. 

How is performance outcome data used to identify areas for quality improvement?
It actually answers itself. You need to have highly effective measurement and reporting capabilities s o you're able to have an ongoing continuous process of reviewing the outcomes - frankly this is a very new space in terms of sophisticated care management efforts and demonstrated outcomes.
Some things that will be engineered and designed will work quite well and the outcomes will reflect that. Others will be modest to moderate in terms of performance. And other approaches may not work. In order for you to know what to do more of, what to do less of, and what to re-engineer, you rely on the outcomes relative to where they were, where you predicted the outcomes would be, and what the actual was.

How is Northwell using performance outcome data to achieve its vision for the future?
By identifying individuals who are at high-risk , aligning and partnering with the providers, and then engaging the individuals towards bettering the management of their condition - whether its diabetes, asthma, COPD, or other chronic conditions of that sort - that's important. It's an ongoing process. The mission is to continue to marry the clinical information systems data with the claims-based utilization data. 

What mechanism(s) do you use to share results with key stakeholders?
Our system's network team is working hard on our provider and physician portal, which will enable our providers to have a succinct and very clear view of the individuals who are eligible and covered in our value-based arrangements and our value-based pools , in addition to providing important quality indicators and outcomes .
These types of mechanisms and these views are very powerful but need to be coupled with other conventional means, such as face-to-face meetings and informational sessions . We need to keep in mind that our activities are at scale so you have to develop systems where you're providing information without o verwhelming the providers and practices . We're trying to get views that are meaningful.

What tools do you use to engage patients to improve outcomes i.e. patient portals etc.? 
We're continuing to look at our patient-facing and beneficiary-facing portals and analytics engines, as well as our content and methods to ensure they provide a view that makes sense to our patients, beneficiaries and caregivers.

How do you influence providers to improve their outcomes?
We view our relationship and role with providers as a resource and supportive partnership. The mechanisms are the provider portal I mentioned earlier and other tools that help providers with their decision-making . We are also working on scaling the practice and hospital-based deployment of our care manage rs in cases where we have a very high density of high-risk patients and beneficiaries.   We also support these efforts through our 24/7 clinical call center as well as through a community paramedicine programs , disease management and advanced illness services and sites .
Do you utilize standardized care processes to promote evidence-based medicine?
We rely on our health system ' s service lines that power the evidence-based care pathways organization-wide. 
Is there anything you want to add?
We're excited about what DSRIP and these Medicaid redesign efforts represent, and again, I just want to punctuate that this program and these efforts are fully aligned with the Northwell Health vision about transitioning from a traditional model of fee-for-service into a value-based, outcomes-oriented model. 
DSRIP is bringing together the members of the provider community in a way that's really encouraging . I want to recognize Joe Lamantia for his extraordinary leadership a long with his team who have established such a well-organized PPS that has energ ized efforts for redesign throughout the region.
Milestone Dates
NYS DOH DSRIP Program Milestone Dates 
April 1
DSRIP Year 2 begins 
April 7
Final PPS Year 1 Third Quarterly Reports posted to DSRIP website
April 18
Public Comment period for Value Based Payment Roadmap closes
April 30 PPS Year 1 Fourth Quarterly Reports (1/1/16-3/31/16) due from PPS
Round Two Regulatory Waiver responses completed
May 3
PPS Regional Learning Symposium (Downstate)
May 4
1115 Waiver Public Comment Day (Downstate)
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. Whenever opportunities become available they will be posted here.
Job postings are available for the following career opportunities within the Office of Population Health at Stony Brook University Hospital administering the Suffolk Care Collaborative.

For more information, please contact the Suffolk Care Collaborative via email



To access NYS DSRIP FAQ, click here

Stay Informed


SCC communications currently include bi-weekly "DSRIP in Action" emails, the monthly "Synergy" eNewsletter, and the recently launched SCC website, which houses a wealth of resources including PowerPoint 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.