Issue 4
August 31, 2015

Welcome to Synergy


We are pleased to present the 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. 

In This Issue
The Suffolk Care Collaborative (SCC)
NYS DOH Quarterly Report Submitted
On August 7 2015, the SCC submitted the NYS Department of Health (DOH) DSRIP Quarterly Report. Please click here to access our report.    

XG Partnership
The Suffolk Care Collaborative (SCC) is pleased to announce xG Health Solutions (a Geisinger spinoff) has been retained to help design, build, support hiring, supervise and train Nurses, Social Workers and Community Health Workers in our Care Management Organization (CMO).  SCC's CMO will complement existing care management resources in Suffolk County such as Health Homes, Care Management (CM) Agencies and Managed Care Organizations (MCOs) - and will not duplicate any of these current efforts.  xG will collaborate with key stakeholders in Suffolk County to develop workflows, care paths, handoffs etc. to ensure effective care management.  xG will also support the interviewing, hiring and on-boarding process for SCC CMO resources.  Training will be provided through xG Learn, an online CM platform as well as through selective "immersion" of trainees in Geisinger practices and facilities.  We are excited to have xG Health Solutions on board to help us accelerate this journey by sharing lessons and best practices from Geisinger.

Domain 1 Patient Engagement Speed & Scale Data Request
The Project Management Office (PMO) conducted a webinar on August 14, 2015 for SCC hospital partners introducing the Domain 1 Patient Engagement Speed Data Report Request & Schedule. The presentation objectives included an overview of the DSRIP Project Domain 1 Patient Engagement Speed and Scale, an outline of the SCC Data Request schedule through year end, an outline of the SCC Data Requests and instructions to submit reports by DSRIP project and a Q&A. Domain 1 Patient Engagement speed and scale metrics tie directly to the Project Plan Application submitted by the SCC. Our initial data requests will be used to support forecasting efforts. The PMO will conduct another Domain 1 Data Request webinar early October for the October 31 quarterly report submission. 
NYS DOH - Medical Record Abstraction Update
The NYS DOH and the program's independent assessor have partnered with two medical record review abstraction firms to complete chart abstraction for all PPS' participating in the Delivery System Reform Incentive Payment (DSRIP) Program for Domains 2 and 3.  The two vendors, MedReview Inc. and Verisk Health Inc., will be contacting providers after September 1 to begin scheduling appointments for abstraction services.
Why are medical records requested for review?
Several of the Domain 2 and 3 HEDIS measures require non claims medical record data for calculation.  Collecting this data is essential to quality improvement and is linked to future performance reporting and payment. The medical record abstraction process applies to HEDIS measures such as screening for clinical depression and follow up, controlling high blood pressure and comprehensive diabetes care.  The results from the reviews will be used to calculate the PPS baseline for these measures as well as the improvement targets to be met for the subsequent measurement period.
What is the data collection timeline, measurement period and key milestones?
The abstraction process will begin after September 1 and conclude by November 27, 2015.  The measurement period covers patients seen from July 1, 2014 through June 30, 2015 i.e. Measurement Year 1 (MY1) timeframe. Validation of the abstraction data will occur December 15 through January 29, 2016.  Improvement targets will be set for MY2 by February 1, 2016 and PPS achievement scores for MY1 will be released on March 15, 2016.

Does this request meet the Health Insurance Portability and Accountability Act (HIPAA) regulations?
Yes. MedReview and Verisk Health are both subject to complying with HIPAA regulations. The DOH as well as a separate third party entity will monitor each vendor's abstraction process for HIPAA compliance throughout the collection period. 

Source : NYS DOH
DSRIP Project Engagements
Following is a summary of the progress of select DSRIP projects the Suffolk County Collaborative will be undertaking

Project 2.b.vii - Implementing the INTERACT Project (Inpatient Transfer Avoidance Program for Skilled Nursing Facilities (SNF)
The patient engagement metrics and definition has been a focus area for the INTERACT Project throughout the months of July and August.  According to the DOH, actively engaged is defined as "the number of participating patients who avoided nursing home to hospital transfer, attributable to INTERACT principles as established within the project requirements."  We have initiated a data request from key SNF stakeholders who've already implemented INTERACT to forecast and collect patient engagement metrics for the quarterly report due October 31, 2015. The Director of Nursing Workgroup for INTERACT has been meeting on a monthly basis, planning for implementation of the INTERACT principles, and has been exploring options to train each Director of Nursing and In-service Coordinators at each of our partner SNFs.  The SCC has received a proposal from Pathway Health, who has an exclusive global license from the owners of INTERACT TEAM Strategies (I-TEAM), to consult to deliver onsite 2-Day Certified INTERACT Champion Training to the Director of Nursing and In-service Coordinators.  This training would train these two individuals at each partner SNF who would then implement and train their staff on INTERACT.   

Projects 2.b.iv and 2.b.ix - Implementation of observational programs in hospitals and establishment of a Care Transitions Intervention Model to reduce 30-day Readmissions for Chronic Health Conditions
The main focus of engagement with our key workgroup members have included developing the SCC Transitions of Care (TOC) Guidelines, TOC Clinical Summary, and the Project Management Plan. A highlight from the Project Workgroup meeting early July included reviewing Domain 1 Project Requirements as well as discussing current practices already in place throughout the county. As we move forward with planning, the SCC will be hosting a project committee meeting, in late September, to highlight key deliverables to date, we look forward to discussions with Community Based Organizations (CBOs), SNFs, behavioral health, hospitals, Primary Care Physicians (PCPs), non-PCPs, Health Homes, and MCOs, to aid in the planning of the project.

The Suffolk Care Collaborative has been working closely with xG Health Solutions as the Care Management structure of our organization to offer guidance from the Geisinger Health System TOC Model to develop the framework to the TOC Project. xG will be providing extensive patient education resources, especially for high risk populations, which will be reviewed and approved by the Project Committee and Project Workgroup.

In the beginning of September, the PMO and xG will be meeting with each hospital within the SCC Health System to learn more about their existing TOC program, care management structure, health home, and social service partners. These meetings will give us a greater understanding on the current state of Transitions of Care within Suffolk County.

Project 3.a.i - Integration of Primary Care and Behavioral Health Services
The Project Workgroup, made up of various SCC partners including Brookhaven Memorial Hospital Medical Center, NorthShore-LIJ (NSLIJ), Hudson River HealthCare (HRHCare) Inc., Catholic Health Services (CHS), Stony Brook Medicine, Family Service League and Association for Mental Health and Wellness to name a few, was successful in completing and submitting the Clinical Guidelines Summary to the Clinical Governance Committee, a subcommittee of the Board of Directors. The goal of this clinical summary is to provide a snapshot of the project including which screening tools are acceptable to achieve patient engagement as defined by the DOH.

Additionally, the SCC has begun to develop the implementation strategy for the various models within this project. Recognizing that behavioral health provider capacity is a risk to the success of this project, we have begun to explore various opportunities to contract with vendors, within the SCC, in an effort to scale up the number behavioral health practitioners as we move towards project implementation. We've also identified key resources across the country with experience in building successful integrated care models, we hope to adopt best practices as we work to build a strong and sustainable project framework. The focus of our attention moving forward will include conducting an assessment the current state of integration practices in the SCC provider network, building the SCC's evidence based collaborative care guidelines such as clinical protocols for integration and a successful project implementation launch.

Project 3.b.i - Cardiovascular Disease: Evidence-based strategies for disease management in high risk/affected populations
The Project Committee Meeting was held on August 7, during which the SCC Clinical Guidelines were reviewed by the committee and recommended for review by the Clinical Governance Committee. On August 10, the Clinical Governance Committee reviewed and recommended it for approval by the SCC Board of Directors, the final step in the approval process.

Throughout August, we have started to introduce xG Health Solutions to key project stakeholders to strategize how care management will be supporting the cardiovascular project, collect patient education resources to be utilized within the project and developed milestones for the months ahead. The SCC care managers will interact with patients who have cardiovascular disease including congestive heart failure, coronary artery disease and poorly controlled hypertension. Although their interaction with patients will not be limited to these diseases, they will focus on patients who are at highest risk for chronic disease, readmission to the hospital, and uncontrolled hypertension within the community.

Project 3.c.i - Diabetes: Evidence-Based Strategies for Disease Management in High Risk/Affected Populations
The Diabetes Project Clinical Guidelines Summary, drafted by the project lead, and previously reviewed and approved by the Diabetes Project Workgroup and Project Committee, was reviewed by the Clinical Governance Committee, a sub-committee of the Board of Directors, on August 10. It will be used by engaged SCC Partner Providers as a guidance for implementing the project.  

There is an upcoming Diabetes Education Workgroup Meeting on September 1 to collect and discuss patient education materials, and grant workgroup members access to the SCC Partner Portal, a cloud-based site where our partners can store, organize, share, and access project-related information. We'll be engaging our Project Workgroup to prepare a list of existing diabetes self-management education programs in Suffolk County and develop a survey to learn more about existing resources in the County.

Project 3.d.ii - Expansion of asthma home-based self-management program
The Asthma Project Clinical Guidelines Summary was reviewed on June 15 by the Clinical Governance Committee, a sub-committee of the Board of Directors. This Summary was developed by the project leads, approved by both the Project Workgroup and Committee, and submitted to the Clinical Governance committee for review. It will be used by engaged SCC Partner Providers as a guidance for implementing the project.   

At the PMO level there has been ongoing collaboration with xG Consultants to develop the care management model for the project, specifically working to develop a process of how a high-risk patient can get referred from the asthma home-assessment program if additional care management support is needed. Our project focus for the coming months includes designing a scope of plan for Community Health Workers (CHWs) performing home assessments and initiate formal agreements to begin the home assessment program.

Project 4.a.ii - Prevent Substance Abuse and other Mental Emotional Behavioral Disorders
The Project Workgroup which is made up for various SCC partners was successful in completing and submitting the Screening, Brief Intervention, Referral to Treatment (SBIRT) Clinical Guidelines Summary to the Clinical Governance Committee, a subcommittee of the Board of Directors. The SCC has collaborated with two SCC network partners who have applied to send staff to an Organization of Alcoholism and Substance Abuse Services (OASAS) SBIRT Train the Trainer in October. Training SCC members will allow our hospital partners to access local training resources as we work to roll out the SBIRT protocol in all Emergency Departments across the county.

The SCC has engaged with the Prevention Resource Center to begin planning the implementation of the Underage Drinking Prevention program under project 4.a.ii. The goal of the Underage Drinking Prevention program is to address the negative social and environmental conditions which expose the youth to risk related to widespread alcohol-related problems.

Project 4.b.ii - Increase Access to High Quality Chronic Disease Preventive Care and Management in Both Clinical and Community Settings
The various workgroups including Lung Cancer Screening, Breast Cancer Screening, Colorectal Cancer Screening Education, Obesity Prevention and Tobacco Cessation continue to meet to further develop the 4.b.ii implementation plans. The goal is to increase awareness among Suffolk County providers and patient populations of existing available prevention resources. The workgroups have spent the last month vetting various patient education materials related to the scope of the individual project such as the Centers for Disease Control and Prevention's (CDC's) materials. In addition, the workgroups have begun to develop Clinical Guidelines Summary documents which serve as an education tool for SCC partners about which screening protocols SCC stakeholders have approved and suggest as best practice. Since the recent engagement of xG, who has been charged with standing up the SCC Care Management Organization, the PMO has had the opportunity to begin a dialogue about how we see the care managers supporting the patient navigation aspect of this and other projects. In the coming months, we look to expand our reach and call for information regarding available resources to develop a comprehensive community resource guide.
Creating an Integrated Delivery System
In the May 2015 Synergy Newsletter publication we provided an overview of our objectives around creating an Integrated Delivery System (IDS). This issue of Synergy highlights progress made to date as well as identifying some of the next steps we will be executing in order to achieve our overall project goals.

As mentioned in our first issue of Synergy, accurately obtaining Clinical Data from all providers across the PPS will be a key driver towards successfully building out the Suffolk PPS. To this end, the SCC IT Project Management Office has created a dedicated workgroup, referred to as 'Data Acquisition IT On-boarding', to manage this process.

The charter of the Data Acquisition IT On-Boarding workgroup is quite wide in scope however below we have outlined two key tasks of immediate priority which we have started and will continue to work on with each of our DSRIP partners.

1. Completion of the IT Current State Assessment across each DSRIP Participating Provider: Most participants should have received a communication from our IT PMO office outlining the set of IT Survey questions which we require to successfully integrate your EMR into the IDS.
In some cases we have not received responses from our Suffolk PPS participants. Please note that completion of the IT Survey / Current State Assessment is a key milestone within our Implementation plan which was resubmitted to the DOH on August 7th, 2015. We cannot start your Data Acquisition project without receipt of the IT Survey.

If you have not received or if you have not completed the IT Survey to date please reach out to our Population Health or IT Project Management offices today. Contact numbers are provided on the SCC Website.

2. Integration of Your EMR with the Suffolk PPS Integrated Delivery System:
Next steps include reviewing and signing the Data Use Agreement and Business Associate Agreements to allow for proper flow of information. Once the applicable documents have been signed, the IT On-boarding team will be reaching out to you to schedule our first Data Acquisition kick-off meeting.

At that time, the Data Acquisition process will be outlined in the form of a mini-project plan, accompanied by an On-boarding User Guide that will help each partner estimate their resourcing and time line commitments.

Suffolk PPS Interface Specifications:
In an effort to increase the accuracy of our Data collection process, we have created two interface specifications (supporting Flat File and HL7 formats). These specifications were created to help assure that we have a consistent representation of clinical data across all Participating Providers within the PPS. We encourage you to review the specifications which can be found here. If you have any questions on the specifications, please feel free to contact the SCC IT Project Management Office.
Featured Project
Project 2.d.i. Patient Activation Measures (PAMĀ®)

Project 2di Workgroup
( left to right)
Front row: Michael Miller, Intern, HRHCare;  Roberta Leiner, Chief, Patient Engagement, HRHCare; Amy Solar-Greco, Project Manager, SCC; Tara Larkin-Fredricks, Director of Special Projects, MHAW; Anne Stewart, Director of Programs, EOC; Gwen O'Shea, President/CEO, HWCLI  Back row:  : Halim Kaygisiz, Director of Health Outreach Services, EOC; Andrew Lehto, Director,Community Outreach & Engagement of Special Populations, HRHCare; Michael Stoltz, CEO, MHAW  Not Pictured: Adrian Fassett, President/CEO, EOC; Paula Fries, COO, MHAW; Pedro Martinez, Outreach Worker, EOC; Sarah McGowan, MHAW; Trevor Cross, Community Liaison, HRHCare; Nalini Purvis, VP Community Initiatives, HRHCare 
The SCC is excited to announce the August launch of the 2.d.i project. To date, nearly 1000 surveys have been administered by more than 15 Community Health Workers (CHWs) under the direction of our Community Based Organization (CBO) partners, the Association for Mental Health & Wellness, the Economic Opportunity Council, and Hudson River HealthCare, Inc. 

As the program rolls out in the County, CHWs in the field will visit local neighborhoods with the goal to achieve the following objectives:
*Conduct the PAM Survey, to assess an individual's 'activation' level
*Implement the Community Navigation Program & Referral System
*Reconnect Medicaid recipients with their Primary Care Physician
*Track and assess patient activation and progress

One of the most innovative benefits of the PAM project is a holistic look at a patient's health care needs. The CHW will be able to coach on a variety of topics and concerns, from chronic conditions to care management coordination.

The CHWs make healthcare self-management available and inclusive. They are there to answer questions, many are bilingual (English and Spanish), and will work with an individual to ensure their health care needs are addressed.

As this program gets off the ground, the SCC has been establishing links with community organizations as potential resources and locations where our CHWs can be based when out in the field. The community connection is essential for the success of the PAM project, as the target populations are often transient and can be difficult to locate.

To date, the Project Workgroup has developed a number of important project documents, including a Project Decision Tree to guide CHWs conducting surveys, Communication Letters to inform organizations throughout the county about DSRIP and Project 2.d.i, as well as a Community Navigation Resource List of our partners to whom survey participants can be referred, spanning a variety of primary care, behavioral health and socio-economic services.

A Project Committee Meeting was held on August 20 to recap the project launch and identify next steps, including adding additional resources and organizations to the Community Navigation Program. The SCC is also initializing an engagement with a technological tool to add another medium for surveying in partnership with the Stony Brook University Hospital Emergency Department. Phone surveys will be delivered to patients that have been discharged within the past five months and continuing going forward.
Partner Interview
Name : Halim Kaygisiz
Title : Director of Health Outreach Services
Focus or Specialty: Uninsured
Number of Practitioners in Organization: More than 20

Please describe your knowledge of the community and the target population for the project.
Our agency is focused on reaching the uninsured population in the Western region of Suffolk County. Through local census data we've been able to identify a number of towns with large populations of uninsured. Some towns have around 8,000; others more than 10,000.
We focus our efforts on hotspots in those towns where the uninsured are likely to congregate. Many are day laborers who wait in town centers hoping to find work with laborers and contractors.
How is the PAM Project aligned with the Economic Opportunity Council's (EOC) mission and vision?
Our goal is to help people attain a level of self-sufficiency. The PAM project helps people do this by increasing awareness of services that are available to them.
The EOC then helps them access the resources they need. We try to connect them with service providers who can help them and make them self-sufficient over time.
Describe your approach to the PAMĀ® Survey and how you introduce it to people.
We present it in different ways. We have about 21 staff members who are trained to conduct the survey. Two of them are dedicated CHWs who go directly to the areas where people are likely to congregate. I also go into the field on a part-time basis. The rest of the staff members present the survey during their regular contact with clients in the target population.
We use Apple iPads to administer the survey, which makes it easy to get the answers input immediately. Depending on how people answer the questions we get a feeling for their role in their own healthcare. Even though the survey has a health intro - it also goes into social and economic arenas, which gives us a wider breadth of information.
We're getting a good response. Many people are willing to talk to us.
How do you train staff to be able to conduct the surveys?
We do a general training in a conference room using the PowerPoint training materials provided by Insignia Health. We do practice surveys on each other. And our staff is also trained on how to deliver the results.
What are lessons learned in the field? What works the best to find/identify people who would qualify for the survey?
You have to know where they are and meet them there. Uninsured are likely to be undocumented or unemployed. So we may go to a Department of Labor office, day laborer sites and soup kitchens. Places where people are likely to access other services that are complementary.
What are people asking the most for?
Access to insurance. For example, if we're talking about undocumented individuals, they usually know where to get low-cost or free emergency and primary preventive care. But let's say they need specialists for a chronic health condition like diabetes. They might need an endocrinologist, a foot specialist and an eye doctor. The type of specialized care that insurance would cover. But the clinics they normally visit aren't able to give them access to these specialists.
That's where we come in. We're able to connect people with chronic health conditions to the specialized services they need.
Our goal is to help people become self-sufficient about their health. But you have to remember, you can't get people to be self-sufficient if there's no food in the refrigerator, no roof over that refrigerator, and no steady source of income to even keep that roof over their heads. And in the meantime their health takes a back seat.
Where do you anticipate need in the community?
I don't think there's one community in Suffolk County that doesn't need help. The need does vary from town to town - but it would be nice to see more assistance provided. There are some huddled masses in Suffolk County that really need some help.
How has the survey's been received by the community?
Overall, we've seen a lot of participation in the survey. We started about three weeks ago and already we've helped four people access Medicaid coverage.
Describe an encounter and how it made you feel to be able to help someone.
Yesterday I was asked to help someone with a cocaine and alcohol problem who was trying to access inpatient substance abuse services. I met the person in a public spot in a neighboring town and tried to find out what kind of help was needed.
Turns out this person thought insurance was needed to get into an inpatient treatment program not realizing there were options available to him even though he was uninsured. 
I'm the connection. I explained the options and what could and couldn't be done. I followed up today and the plan is to enter into the program on Monday. If there's no bed space available we can at least get this  individual  to the top of the waiting list. We're going to have contact every day.
That's my job - that's what I do. It feels good that I can do my job and help people. It's become a routine for me. Follow up is important - it shows commitment - and proves support. It makes you feel invaluable.
What partnering Community Based Organizations/Social Services agencies has EOC engaged with so far?
We have partnered with the Association for Mental Health and Wellness and also partnered with Hudson River Health Care Inc., which is a Federally Qualified Health Center.
How are you leveraging existing CBO resources?
W e use the existing relationships we already have with other agencies and service providers as well as knowledge of areas we know where we can reach those individuals who need insurance and offer them our services. It's not only what you know but also who you know.
What is the biggest value proposition of the program?
Creating awareness that there are resources in the community that can help. You may have people who don't need help now. But they have our contact information so, in the future, if they need help they know where to find it. We may not be able to offer everyone insurance, but they need to know that there is a local CBO that can help.
Where do you see the program going?
It's still so early in the program so it's hard to say. The potential is that the uninsured population among eligible individuals will dramatically go down - and more and more people would be helped regardless of insurance coverage.
Access to services is beginning to increase and funding for those services should increase. Human Service providers should become as valuable as a medical professional, because they can help a person in a state of crisis.
Milestone Dates
NYS DOH DSRIP Program Milestone Dates 
PPS First Quarterly Report (4/1/15 - 6/30/15) / Domain 1 (revised)  & Project Implementation Plans due from PPS Public comments on draft  Medicare Alignment Paper due
VAPAP Transformation Plans due
PPS receive feedback from Independent Assessor on PPS First Quarterly Report / Domain 1 and Project Implementation Plans; 15-day Remediation window begins
Additional Regulatory Waiver requests due
Open PPS Performance Networks in MAPP for edits and additions
PPS Statewide Learning Symposium
Revised PPS First Quarterly Report / Domain 1 & Project Implementation Plans due  from PPS; 15-day Remediation window closes       
Late Sept 
Close PPS Performance Networks in MAPP for edits and additions
D SRIP Notice and Opt out letters mailed to Medicaid members
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.



To access NYS DSRIP FAQ, click here

Stay Informed


SCC communications currently include 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.