Issue 26
August, 2017
Welcome to Synergy
We are pleased to present the twenty-eighth 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


Tuesday, September 26, 2017
Registration 8:30 am
Program 9:00 am - 12:00 pm

Hyatt Regency Long Island
1717 Motor Parkway
Hauppauge, NY
New Partnership With Suffolk Independent Living Organization (SILO) Announced 

The SCC is pleased to announce a new partnership with the Suffolk Independent Living Organization (SILO) to offer the Better Choices, Better Health® Workshop Series for patients with diabetes and other chronic disease.  These programs are offered for free to participants and are designed to complement and enhance medical treatment and disease management.
SILO is one of 39 New York State Designated Center for Independent Living Services. It is a not-for-profit Human Services Agency dedicated to working with people with disabilities,elderly individuals and their families to provide the necessary support to live independently within their communities. SILO provides over 42 programs and services throughout the Long Island Region.
Living with a chronic disease requires a multitude of daily self-management decisions and complex care activities. Participants in the Better Choices, Better Health® workshops will have the ability to set their own goals, increase skills and make a step-by-step plan to improve their health. Two trained leaders will facilitate the workshops in a small group setting. Each workshop runs for 6 weeks with weekly sessions lasting 2 ½ hours per session.
The focused population for the SCC DSRIP programs are patients with a principle diagnosis of hypertension, hypercholesterolemia or diabetes, who are insured by Medicaid and are 18 years of age or older. However, programs are open to non-Medicaid insured individuals and the chronic disease programs are open to other chronic diseases, such as lung disease and stroke. SILO will be offering these programs in both English and Spanish. If interested in more 
information regarding SILO Programs and Services or the Better Choices, Better Health® self-management programs they host, please call (631) 880-7929. 
Suffolk Independent Living Organization (SILO) Celebrates the 27th Anniversary of the Americans with Disabilities Act
Written by Patrick Mitchell, SILO Board Member

On Saturday, July 22, the Suffolk Independent Living Organization (SILO) celebrated the 27th Anniversary of the American with Disabilities Act at SILO Headquarters located at 755 Waverly Ave. Holtsville, NY.  SILO was proud to introduce our New York State, Suffolk County and Brookhaven Town elected officials that attended our Americans with Disabilities Celebration.  Each one of our elected officials spoke about the successes brought about by the ADA and the need to do more in the future to advance the rights of the disabled.  This community event hosted families and partner agencies and included great food, entertainment, music and dancing.  A good time was had by all that attended and SILO hopes to continue to promote ADA Achievements in the future.
SILO is one of 39 New York State Designated Center for Independent Living Services. It is a not-for-profit Human Services Agency dedicated to working with people with disabilities, elderly individuals and their families. SILO provides over 42 programs and services throughout the Long Island Region. SILO's ultimate goal is to provide the necessary support for people with disabilities and the elderly to live independently within their communities. If interested in more information regarding SILO Programs and Services please call (631) 880-7929.
(Pictured Bottom L-R) Patrick Mitchell, SILO Board VP; Frank Krotschinsky, SC Director of Handicapped Services; Mary Ann Sciacca, SILO Board President and Dawn Cookler, SILO Board Member.  (Pictured Top L-R) Paul Hennings, Senator John Flanagan's Rep.; Brookhaven Councilman Neil Foley; Brookhaven Town Supervisor Ed Romaine; SC Legislator, Sarah Anker; Roger Smith, SILO Board Member; Gerri DePersio, SILO Board Secretary; Bernie Ferracane, SILO Board Member; Krista Giannak, SILO Board Member; Laurie Delgado, SILO ADA Event Chair; Joseph Delgado, SILO CEO; NYS Assemblyman Al Graf; Doug Smith, Asseblyman Graf's Chief of Staff; Eric Hofmeister, NYS Senator Croci's Chief of Staff and Jignesh Patel, SILO Landlord.
SCC Hosts Motivational Interviewing Training

On July 25th and August 9th, the SCC welcomed more than 40 participants, including care coordinators, nurse managers, social workers and community health workers, to training sessions on the Spirit of Motivational Interviewing. The training sessions were sponsored by Greater New York Hospital Association and funded by the New York State Department of Health's Health Workforce Retraining Initiative.
During the training sessions, led by Bryan Kutner, a member of the Motivational Interviewing Network of Trainers, participants learned collaborative, patient centered techniques to elicit and strengthen motivation for change. The techniques covered during the interactive training provide a framework for guiding discussion with patients and clients to help individuals identify priorities and engage in treatment and self-management activities.

First HITE Suffolk County Advisory Group Meeting Held at Island Harvest
SCC partner Health Information Tool for Empowerment (HITE) held their very first HITE Advisory Group Meeting in Suffolk County. Developed by the Greater New York Hospital Association (GNYHA) , HITE is a free online directory that lists health and social service organizations in New York City's five boroughs and Nassau and Suffolk counties. HITE is used by community members, hospitals, health centers, schools, not-for-profit organizations, managed care companies, public agencies, and other organizations working to help their clients find and access services. The goal of the advisory meeting is to gain HITE user insight and feedback which will aid the continued improvements to the HITE website. With the support of SCC's Community Engagement Team, Island Harvest hosted the meeting in their Hauppauge office on Wednesday, August 9th.  Members learned about HITE tool updates, discussed the tool's features, content, and usability, as well as shared their user experience with members of HITE.
From top left:  Kim Whitehead, LI Health Collaborative; Lyndsey Clark, SCC; Carmela Colpa-Lewis, Planned Parenthood; Taylor Cox, HITE; Christine Hendricks, Catholic Health Services; Pamela Mizzi, Family Service League-LI Prevention Resource Center.   From bottom left: Alexis Rodgers, Association for Mental Health & Wellness; Meagan McKeon, HITE; Zahrine Bajwa, Cornell Cooperative Extension of Suffolk County. 
Meagan McKeon, HITE Program Manager, and Taylor Cox, HITE Program Associate, led the discussion with SCC partners from hospitals, community providers, and community based organizations. Some of the highlights discussed included the creation of a HITE brochure and user guide as well as the recent addition of the Google translate feature. Both Meagan and Taylor walked away with great suggestions they hope to implement over the next couple of weeks and look forward to holding future HITE Suffolk County Advisory Group Meetings.
HITE is available on the SCC community webpage . To arrange a HITE demonstration for your organization, please contact Meagan at or email our Community Engagement Team at .
Staying Ahead of the HCAHPS Transition of Care Curve
By Joanne Lauten MSN, RN, CPHQ, SCRN, Director of Nursing Quality, at John T. Mather Memorial Hospital
Medication management is one of the seven foundations identified by The Joint Commission to support safe, quality transitions of care from one setting to another.  Identifying those patients at high risk, with incomplete medication reconciliation and polypharmacy is the first steps in the process.   The nurses at Mather Hospital, collaborating with our physician partners and the multidisciplinary team, identified opportunities to improve patient safety, quality and the service provided to patients with medication safety and transitions of care.

Based on the recommendations of clinical nurses, the development of an innovative, patient-focused Medication Education Board was developed, along with implementation of a "warm handoff" for patients transitioning to a rehab setting .

The medication education board was divided into sections and labeled with the classification of medication.  Each individual medication in that section has its own "pocket" with a slip of paper which states the trade/generic name, indication and the top three side effects of the medication. Once the board was completed, clinical nurses incorporated into their daily practice to ambulate patients to the board and for patients to "take" their medication education slips.

Research shows that one of the most effective ways to improve understanding of self-care instructions while simultaneously addressing health literacy is the "teach-back" method. This low cost innovation utilizes clear communication principles by using plain language, limiting information to three to five key points, and being specific and concrete in teaching patients what they need to know about their medications. Evidence based practice supports patient-centered education interventions using visual learning are successful in increasing patient satisfaction.

In addition to the "Teach Back" methodology, our nurses incorporated a "warm handoff" at discharge.  Inadequate transfer of information during care transitions plays a significant role in the problems of quality and safety for patients, contributing to readmissions.  Direct verbal communication is needed for those assessed as high-risk.  The discharging Nurse Facilitator at Mather confirms that the subsequent provider received the discharge summary and pertinent test results and responds to questions promptly. This brief telephone call can allow for dialogue about the patient's clinical status as well as opportunities for inquiry and clarification about the plan of care.  These few nurse-led interventions have helped Mather Hospital maintain a four-star rating from CMS for Transitions of Care.
Shocking the Bellport Community with Stickers:  COMPASS Unity's Sticker Shock Campaigns     
This summer the DSRIP Underage Drinking Prevention Program, sponsored by the Family Service League, focused on environmental strategies. Environmental strategies are prevention efforts that aim to reduce underage and binge drinking by changing the context in which alcohol use occurs within the community.
David Schultzer, Bellport Cold Beer & Soda
COMPASS Unity, an anti-drug coalition in the South Country area of Bellport, created a fluorescent orange sticker that reads, "Thank you for keeping our kids alcohol free!  Preventing Underage Drinking is everyone's responsibility!" The sticker is designed to raise awareness about underage alcohol use through positive messaging and increase awareness of COMPASS Unity. The stickers included contact information for the COMPASS Unity Coordinator, Lynette Murphy, and Family Service League's DSRIP Prevention Specialist, Cierra Corbett.


COMPASS Unity members, including students from
Alissa Tauriello, Papa Nick's Pizzeria
the community and local elected officials, kicked off the summer of environmental strategies with an Operation Pizza Box Campaign. The Campaign was held at Papa Nick's Pizzeria in Bellport Village, a popular town establishment and hang-out for youth. COMPASS Unity placed over a hundred stickers on pizza boxes for dissemination to local customers within the South Country community.
Using the same stickers, COMPASS Unity took part in a Sticker Shock Campaign. The Sticker Shock campaign was conducted at Dave's Bellport Cold Beer and Soda on Station Road in Bellport. This local retailer was found to be heavily patronized by members of the Bellport community. COMPASS Unity members placed stickers on over 300 alcoholic beverages being sold at the shop, including kegs, packs of beer and wine coolers.  
Cierra Corbett, Prevention Speicalist, Family Service League; Lynette Murphy, LMSW, Bellport High School holding an orange sticker used in the campaign.

This was the first year COMPASS Unity has taken part in these campaigns. The reception from community members and local businesses was so positive, that the Coalition plans to conduct them annually, with the hope of engaging other local businesses in these activities.  For information about Suffolk County's Social Host Law, click here.  
Enhancing the Quality of Life for those with  Dementia and Alzheimer's Disease
By Christopher Chirstodoulou, PhD., Clinical and Research Neuropsychologist, Center of Excellence in Alzheimer's Disease (CEAD), Stony Brook School of Medicine

Dementia refers to a long term and often gradual decrease in the ability to think and remember, which is great enough to interfere with a person's social and/or occupational daily functioning. Dementia can be caused by many brain diseases, and usually affects people over 65 years of age. Globally, more than 47 million people were living with dementia in 2015, at a worldwide cost of 818 billion dollars. Costs in 2017 for the United States alone were 259 billion dollars. Dementia has been called the greatest global challenge for health and social care in the 21st century.  

The most common form of dementia is Alzheimer's disease, which accounts for 60 - 80% of cases. It affects over 5 million people in the United States, almost 400,000 in New York, and over 50,000 here on Long Island.

Alzheimer's disease is an irreversible, progressive brain disorder. It slowly destroys memory and thinking skills and, eventually, the ability to carry out the simplest tasks. A typical first sign is a loss of memory for new information that is serious enough to disrupt daily life. However, different people may show different initial symptoms, such as: 1) new problems with words in speaking or writing, 2) confusion with time or space, or 3) withdrawing from work or social activities. There is no cure, but early detection and treatment can help. Medications may slow the progression of Alzheimer's symptoms, patients and families gain the opportunity to plan for the future, and programs can support caregivers to help reduce their burden and stress.

Want to know what you can do to maintain or improve your brain health?  A promising line of research suggests that strategies for overall healthy aging may help keep the brain healthy and reduce the risk of Alzheimer's. These measures include eating a healthy diet, staying socially active, reducing stress, avoiding tobacco and excess alcohol, treating hearing loss, and exercising both the body and mind.

If you have questions about dementia, the Center of Excellence for Alzheimer's Disease (CEAD) at Stony Brook University Hospital is here to help (631-954-2323). We are one of 10 CEADs supported in part by a grant from the New York State Department of Health. Our multidisciplinary team is engaged in an ambitious program to expand knowledge about Alzheimer's disease and related dementias, to act as a resource for Suffolk and Nassau County health care providers, and to improve access to screening, diagnosis, and treatment for patients and their families.
SCC Hosts 4th Cultural Competency and Health Literacy Master Training
On July 25th, SCC's Community Engagement Team hosted another Cultural Competency and Health Literacy (CCHL) Train-the-Trainer class for Nassau, Queens and Suffolk County healthcare providers and community leaders. Eighteen participants were in attendance from a wide range of backgrounds, such as social work, nursing, care management, homecare and community based organizations.  The class curriculum included topics of health equity, unconscious bias, cultural competency and humility, health literacy barriers and the "Teach-Back" method.  The "Teach-Back" method entails a four step cycle to support a client's health literacy: Explaining a process; Assessing the client's level of understanding by asking them to teach the process back; Clarifying any misunderstandings the client may have; Repeating the cycle until there is a shared understanding.  As part of the training, the class divided into groups and participated in an interactive exercise of the "Teach-Back" method.  Each group shared their interactive experience of the "Teach-Back" method and had the opportunity to act out scenarios, visually depicting the specific teaching elements and take away points.  Participants of the class shared personal stories and expertise fostering synergy and peer learning. At the conclusion of the training, the participants were awarded certificates demonstrating their successful completion of the program and a trainer's toolbox of resources to recreate the CCHL training in their workplace.  Congratulations to the new CCHL Master Trainers!
From top left:  Colleen Merlo, LI Against Domestic Violence; Joan, Good Samaritan Hospital; Eva, Nassau Suffolk Law Services; Pascale Fils-Aime, LI PHIP; Osman Canales, LI Center for Independent Living Inc.; Janet DeMarzo, RSVP; Sarah, Good Samaritan Hospital; Oscar Bruce, ASK for Your Life; Jere' Freeman, Stony Brook University Hospital, Department of Care Management; Jasmine, ACP; Kathleen Kursar, Acadia Center; Mary Greco, Acadia Center; Bonnie Neidecker Soukup, LI Against Domestic Violence; Miguel Rivera, Advantage Care Health Center; Daisy Diaz, SILO; Jacqueline Ramirez, Children's Village.  Bottom: Lindsey Clark, SCC (co-instructor).

To  learn more about the CCHL Training Program and how your organization can participate, please contact our Community Engagement Team at
Community Engagement Important Milestones  

The SCC  Community Engagement Team concentrates its efforts on engaging and fostering interactive community relationships by connecting with healthcare providers, community based organizations, various non-profit organizations and faith based organizations.  During the past few months, the Community Engagement Team has enhanced its communication and collaboration efforts in Suffolk County.

Since February 2017, the Community Engagement Team has grown with the addition of two new staff members: Stephanie Burke, Administrative Manager, Community Engagement and Cultural Competency and Lyndsey Clark, Community Engagement Liaison.   SCC has attended or hosted over 70 community interactions and events. A major focus of the Community Engagement Team is its ongoing effort to provide an organized resource forum for its community members to continually access.  Accordingly, the SCC community engagement webpage was launched on March 18th, which features community facing elements communicating SCC project overviews, health and social resources such as the HITE resource directory, Long Island Health Collaborative community calendar and patient education materials.
Partner Interview with Research and Development Expert for Self-Management Programs
Name:  Kate Lorig, Dr.P.H.
Title:  Partner
Organization:  Self-Management Resource Center

Please tell us about your organization and why you developed the Chronic Disease Self-Management (CDSM) course.
The CDSM course was originally developed at Stanford University as a sequel to an arthritis self-management program I worked on.  Some arthritis participants told us, "This is a great course, but you are telling me one thing and my cardiologist is telling me something else, and I also have pulmonary disease and diabetes..."  Most people don't have just one disease, they have two or three or more, so we decided to see if there were any domains that really crossed chronic diseases. We did an extensive literature review and talked to lots of patients and doctors, and discovered that about 80-85% of the material covered in all of the patient education programs was pretty much the same. Out of that we developed the CDSM course to help people live with multiple chronic conditions. We have now moved the program outside of Stanford University to the Self-Management Resource Center (SMRC), an independent organization, in order to disseminate it even more broadly.
People like to learn in different ways, so we offer the course in 3 different modes: The original program was developed and still is very widely given face-to-face to small groups of 10-12 people. The programs are taught by patient leaders who have been trained in a very structured way. Anybody interested can go to a website called Evidence Based Leadership Council, where they'll find an app that lets them put in their zip and locate a program nearby. The program is also made available online under the name Better Choices, Better Health® by Canary Health to members of organizations that have purchased it for their patients.   A print version, the Self-Management Tool Kit, is available through the mail from Bull Publishing.
In addition to the CDSM course, we offer diabetes and pain self-management programs, and one for cancer survivors. We will also be releasing a caregiver self-management program.
How does the CCDSM course align with the NYS DOH DSRIP goals of reducing hospital admissions and readmissions?
We know that we are reducing hospital days and Emergency Department visits. Those are the cost data that we have. We've never looked at readmissions. My guess is that we are cutting readmissions, but we don't have the data.
Theoretically, the more help people have to manage their conditions on a day to day basis, the less they should have to depend on very expensive interventions such as hospitalization and Emergency Department visits.
We know that we are increasing adherence to medications and decreasing depression, which drives a whole lot of things including hospitalizations and nonadherence, so in these ways we may be reducing costs.  We also know that we are giving people more confidence in their abilities to manage their conditions and that may help, too.

How does the CDSM course support population health transformation?
We support population health in a number of ways. First, the programs are generally given in the communities where people live and work. So, those who are often underserved or won't go to a hospital or clinic to take a course, can do it in their own community, on their own time, in a comfortable setting. This means that we can get to many more people than traditional patient education programs. Also, because they are very standardized and peer-led, we can do thousands of programs nationwide. We serve about 100,000 people a year.
Furthermore, when you educate part of the community, they in turn pass on some of that knowledge to others in the community. Our 8-10 thousand trained patient leaders also pass on their knowledge to family and friends. There's a networking effect which we've never measured, but I imagine it's quite large.   By offering the programs in many different languages and communities, we are reaching other traditionally underserved groups.
Finally, we know that people with chronic mental health problems have many other chronic diseases, and these people are also very seldom reached by traditional programs. When we educate about chronic disease, we don't care whether it's a mental or physical condition, so that also helps destigmatize mental health conditions.
What is the biggest challenge facing people in the current health care system and how can CDSM courses help?
I think it's fragmented care, people with 6 different conditions going to 6 different doctors, none of whom puts together the whole person. The course helps the individual tackle this very fragmented knowledge and put it together and apply it to themselves. It also helps them work with the health system and their healthcare providers. We do a lot of work around problem solving and decision making and how to deal with this fragmented system.
What is the future of the Self-Management Resource Center?
We see ourselves continuing the work that we've done in the past--continuing to work nationwide. Traditionally these programs have been given by lots of small community organizations and we're beginning to see a coalition occurring in many states, including New York, whereby there's a supporting organization for these many small ones so they can be more efficient when it comes to training, monitoring fidelity and offering the programs in a systematic way to health care systems. Traditionally the programs have been given largely outside of healthcare systems, and I think we're seeing a movement towards this coalition of community-based organizations and health care systems working together. And I think that's really healthy. So, I see the programs probably becoming more available to more people in the future.
We're here to help folks in any way we can and we welcome inquiries.  For more information, visit SMRC's  Website or  Email: or
Compliance Connection
HIPAA Patient Right of Access

The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) announced that it has a new video training module for health care providers.  According to HHS, the new training module provides an "in-depth review of the components of the HIPAA Right of Access and ways in which it enables individuals to be more involved in their own care." The training module provides helpful suggestions about how health care providers can integrate aspects of the Health Insurance Portability and Accountability Act ( HIPAA) access into medical practice. This activity is intended for primary care physicians, obstetricians and gynecologists, pediatricians, and nurses.  

The goal of this activity is to review components of HIPAA Right of Access and ways in which it enables individuals to be more involved in their own care.  HHS offers training materials to help entities implement privacy and security protections. Click here to visit their website for HIPAA Right of Access training video and information on  receiving free Continuing Medical Education (CME) or Continuing Education (CE) credit.

For compliance questions, or assistance, contact the SCC Compliance Office at
 Milestone Dates
 NYS DOH DSRIP Program Milestone Dates
Annual update to Value Based Payment Roadmap submitted to PPS
September 14
Revised PPS Year 3 First Quarterly Reports due from PPS; 15-day remediation window closes
September 29
PPS annual update to Primary Care Project Narrative due
September 30
Final Approval of PPS Year 3 First Quarterly Reports

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. Care Manager
  2. Social Worker
  3. Community Health Associate
  For more information, please contact the Suffolk Care Collaborative via email