Issue 16
August, 2016

Welcome to Synergy


We are pleased to present the sixteenth 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
New Community Based Organization Partnership: Planned Parenthood 
The SCC will be expanding the Community Health Activation Program (CHAP) through a new partnership with Planned Parenthood Hudson Peconic!
The SCC has partnered with Planned Parenthood Hudson Peconic (PPHP) to expand the patient activation and community navigation efforts of DSRIP Project 2di, the SCC's Community Health Activation Program (CHAP).  Planned Parenthood Hudson Peconic (PPHP) provides primary and reproductive health care services at 10 health centers in Suffolk, Westchester, and Rockland counties. 
The SCC's Community Health Activation Program is a CBO-led in-reach and outreach program aimed to identify, engage, educate and integrate the uninsured and low/non-utilizing Medicaid populations into community based preventive care services. To date, the SCC has identified 4 CBO partners and celebrates 1 year of services this month. Over the past year, the program has identified and engaged over 20,000 individuals throughout the county. Through the on-boarding of PPHP we've expanded the programs' Community Health Worker (CHW), Community Navigator, and Wellness Coaching staff. We look forward to the value PPHP brings to the program, including longstanding and trusted relationships in the community.
PPHP will be implementing an in-reach program in the weeks ahead at their Health Centers throughout Suffolk County. As CHW's identify targeted populations the Patient Activation Measurement (PAM) survey will be completed, thereafter the appropriate level of follow-up wellness coaching and community navigation services will be determined. CHW's are tasked with ensuring that targeted populations are linked to a primary care provider, and in many cases will be scheduling an appointment. Further, uninsured individuals will be navigated to insurance enrollment centers and community services to access care and support continued wellness. CHWs will re-engage and re-assess individuals using the PAM survey on an annual basis to determine changes in activation and engagement.
"We are very excited about this new partnership with the SCC and look forward to engaging in this community health activation project to better serve and meet the needs of our patients." 
Vincent Russell, Chief Operating Officer, PPHP

About Planned Parenthood Hudson Peconic
Planned Parenthood Hudson Peconic (PPHP) provides reproductive and sexual health care at 10 health centers and on two SmartWheels testing and education vans in Suffolk, Westchester, Rockland, and Putnam Counties. The centers serving Suffolk County are located in Smithtown, West Islip, Patchogue, Huntington and Riverhead along with one of the SmartWheels. PPHP empowers individuals to determine their own sexual health and reproductive futures. For 83 years, PPHP has provided exceptional health services, accurate information and education, and fearless advocacy for reproductive rights and justice.
At PPHP, patients receive nonjudgmental, confidential, high-quality, and affordable care. Women, men, and young people come to PPHP for birth control, HIV testing, sexual transmitted infection (STI) testing and treatment, prenatal care, life-saving cancer screenings, gynecological care, and abortion services.
PPHP's education and training department offers programs that provide accurate, evidence-based, unbiased information about human sexuality and reproductive health. Programs are available for schools, colleges, residential facilities, community-based organizations, civic associations, and parents, as well as trainings for professionals and child care providers.
PPHP's advocacy efforts reach many fronts, from meeting with elected officials to discuss important legislation, to educating voters about issues impacting individuals' reproductive choices, to registering people to vote, and to assisting student groups on college campuses. Volunteers are recruited and assist with much of this work to ensure our communities are aware of the issues around them.
"Care. No matter what." This isn't just a slogan, it's what Planned Parenthood Hudson Peconic lives every day.
Substance Abuse Prevention & Identification Initiatives Throughout Suffolk County 
11 Hospitals Joined for a Learning Collaborative on Impacts of SBIRT Implementations
Thank you to our SBIRT Learning Collaborative presenters! Back row: Dr. Jonathan Merson, AVP Clinical Operations, Northwell Health; Antonette Whyte-Etere, OASAS; Mary Silberstein, Division Director, CN Guidance and Counseling; Kristie Golden, Associate Director of Operations, Neurosciences, Neurology & Psychiatry, Stony Brook Medicine; Christina Noonan, Samaritan Daytop Village. Front row: Alexandra Lemma, Program Coordinator, Town of Babylon Division of Drug and alcohol Services; Alyse Marotta, Project Manager, Behavioral Health, Suffolk Care Collaborative; Lynn Doris, Executive Director, Seafield Services, Inc.; Pamela Mizzi, Director, Long Island Prevention Resource Center; Brenda Harris-Collins, OASAS; Katie Sinnot, Addictions Counselor, Stony Brook Medicine
As the PMO moves from program design to program implementation, we've convened program committees in the form of Learning Collaboratives. The goal of the collaboratives is to create a community of knowledge that can help participants accelerate program implementation, systematic change and make lasting breakthroughs that meets or exceeds program expectations.
On August 22, the SCC hosted a Learning Collaborative connecting program participants of the Screening, Brief Intervention, and Referral to Treatment (SBIRT) Initiatives, all 11 Hospitals in Suffolk County along with OASAS Clinics and Community Based Organizations.
SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders. The Suffolk Care Collaborative has partnered with all 11 hospitals in Suffolk County to train their Emergency Department staff in SBIRT, and fully incorporate the screenings into their daily operations. The immediate goal of this program is to implement the program at the hospitals for patients 13 years of age or older, and the long term goal is to connect patients with treatment for substance use/ abuse and reduce the incidence of substance misuse in the County.
As all hospitals prepare for SBIRT implementation, screening individuals for risky alcohol and substance use, it is to be expected there will be an increase in number of individuals identified as needing behavioral health or substance abuse services. As access to addiction services has been an identified concern in Suffolk County, there have been questions as to how providers can meet the demand for these services with limited resources. This month's Learning Collaborative provided an opportunity to open the lines of communication between different provider types, and in a solution-focused manner, to discuss the issue of access to care in Suffolk County. During the collaborative, representatives from three Suffolk County Hospitals and three licensed OASAS clinics facilitated discussions about their referral relationship. This transparent dialogue acknowledged shared successes in placing patients into care, and the identification of opportunities for improvement in accessibility. After hearing from these groups, the dialogue transitioned to solution-focused approaches and prevention efforts. This discussion included the innovative approach of using secure electronic communications and secure shared calendars between hospitals and behavioral health providers to schedule patients for services in the behavioral health clinic.
Topping the agenda was the integration of the Communities of Solution group presentation, sharing the mission of their organization, with an emphasis on their robust Access to Care subgroup. Presentation highlights included creative approaches to treatment and the role of Peer Advocates and their ability to connect with patients struggling with addiction, and support their treatment. In closing representatives from the New York State Office of Alcoholism and Substance Abuse Services (OASAS) discussed the Bed Availability Dashboard and the LOCADTR (Level of Care for Alcohol and Drug Treatment) tool.
The Learning Collaborative was an opportunity to highlight the dedicated and impassioned work of those in Suffolk County championing substance use prevention and treatment. We hope to continue fostering strong relationships and communications between all partners and key stakeholders throughout the County. 
About Suffolk County Communities of Solutions
Established in 2008, Suffolk County Communities of Solutions (COS) focus es on improving outcomes through
 education, information dissemination and cross-systems activities pertaining to improving  access to and quality of prevent ion and certified treatment services for substance use disorders. The COS structure includes Task Committees designed to carry out activities and report accomplishments regularly to COS and to the community-at-large.  COS' mission is to provide a strength based system of care that ensures access to developmentally and culturally appropriate prevention, treatment and recovery services for Suffolk County communities.
COS Stakeholders include but are not limited to:  NYS Office of Alcoholism & Substance Abuse Services; Suffolk Count (SC) Department of Health, Division of Community Mental Hygiene; NYS Senate, SC Prevention and Treatment Providers, SC Legislators, SC Probation, SC Treatment Alternatives to Street Crime (TASC), SC Police Department, SC School Districts, consumers, family members, SC Community Coalition Members, pharmacists, medical doctors, Town of Smithtown Youth Bureau, Town of Huntington Youth Bureau, Stony Brook University Hospital, Northwell Health, SC Community College Chemical Dependency Counselor Training Program, Response Hotline, Long Island Council on Alcoholism & Drug Dependence (LICADD) , Long Island Recovery Association (LIRA), and Family in Support of Treatment (F.I.S.T.).
COS Task Committees include:
  •  Open Access Committee - To address and improve patient same day/open access to licensed treatment providers in Suffolk County.
  • LICADD Hotline - in collaboration with Suffolk County Department of Health, LICADD, COS assists with the monitoring, promotion and success of the hotline to provide 24/7 immediate access to treatment.
  • Community Resource List Committee - To create and sustain distribution of a comprehensive quick-reference list of licensed substance use disorder agencies that can be used in emergency or non-emergency situations.
  • Advocacy - To create and sustain grass roots advocacy efforts to increase access to care and to provide community education and awareness for substance use disorders.
  • Parent Forum Committee - To support parental awareness and empowerment with information, knowledge and effectiveness through skill building and resources.
  • School Outreach Committee - To address the prevention needs of the school community and to foster linkages to services. The school outreach committee disseminates the speaker's bureau brochure highlighting prevention education services available to Suffolk County schools and residents.
  • Screening, Brief Intervention, Referral to Treatment (SBIRT) Committee - To educate the Suffolk County community on the SBIRT model as a cost-saving health promotion intervention that can uncover and reduce risky use and to spread knowledge and understanding of SBIRT throughout Suffolk County.
  • Public Health Education Committee - To advocate for and disseminate accurate and appropriate information regarding prevention and treatment resources.
  • Marketing Committee/COS Website - To develop marketing strategies and COS website that will highlight work of COS and support the work of the other committees.
Join SC COS on the 3rd Monday of each month from 9:30 am to 11:30 am at
SC Division of Community Mental Hygiene, North County Complex,
725 Veterans Memorial Highway, Building C928, Classroom.

For further information, contact Mary Silberstein, LCSW, CASAC (g), Chair of Suffolk County Communities of Solutions and Division Director of Integrated Care & Behavioral Health Treatment Services at CN Guidance & Counseling Services at 516-396-2749 or 

Partner Interview          
Name:  Mary Silberstein, LCSW, CASAC(g), CADC
Title/ Organization:  Chair, Suffolk County Communities of Solutions; Division Director, Integrated Care & Behavioral Health Treatment Services, CN Guidance and Counseling Services 

What is the COS's mission and some key objectives of your work in Suffolk County?
Our mission is to provide a strength-based system of care that ensures access to developmentally and culturally appropriate prevention, treatment and recovery services for Suffolk County communities. Our key objective is to improve access to and quality of prevention and treatment service for substance use disorders.
We do this by designing Task Committees for key issues to support change and improvements. For example, we have a school outreach committee that has created a Speaker's Bureau Brochure that provides free key-note speakers about prevention and treatment for schools or libraries for the community. We also have a Public Health Education committee and Data Committee who identifies and gathers data relevant to our mission, so we can measure the accomplishments of the various COS activities. 
The COS and our Task Committees are made up of our stakeholders, not just treatment providers, but very important stakeholders.  For example, Stony Brook University Hospital,  physician representatives, parents, the Suffolk County Police, Probation, and the Police Commissioner's aide. We have Suffolk County legislators and their aides that come to the meetings and also sit on some of the Task Committees and participate. Further, various youth bureaus and the Suffolk Community College Chemical Dependency Counseling training program come. We have families come, people in recovery come. And we're all working together, it's so invaluable to have this partnership, and our only agenda is to help.
What are some of the challenges that the COS faces in the area of substance use disorder prevention and advocacy?
People don't know where to go for help, they don't know how to access services, and they don't know about the 911 law.  People use drugs and alcohol until they're sick and tired. And when they're sick and tired, when the consequences have become so great, they're apt to say, "I want help." And we as treatment providers, hospitals, doctors, nurses, etc., need to be able to say, "This is where you can go to get help." My own vision is that one day when somebody goes into the ER, there's somebody right there who can talk to them and get them connected right away to a treatment program. And they don't even have to pass go; they just walk in, they get help. Period.
Our system, and this goes for all systems: They're difficult. And I think that it's our responsibility to make sure that the systems are easy for folks to be able to use when they're in crisis. We need to have it out there as much as possible, so that when somebody is in crisis, they can go to a police officer, they can go to a priest, a rabbi, a doctor, a coach, a parent or a school teacher, and they all know where to get help. And that's our main objective,  how do we communicate, and how do we improve that communication, in order to make it possible for somebody to access treatment.
Another challenge is getting people to call 911 when there's an overdose situation. People don't know where to call for help, or they don't know if there's going to be a legal problem when someone is using an illegal substance, so they're not that quick to call 911. This really speaks to raising awareness about the NY State Good Samaritan Law, which provides protection from arrest and prosecution for those seeking help for the victim in the event of an overdose. 
How is the COS working to overcome these challenges?
From the beginning, recognizing that people who are in crisis need to know where to go for treatment. So we came up with the Community Resource List. It's a comprehensive quick reference list of all the substance abuse disorder agencies that can be used in emergency or non-emergency situations in Suffolk County. We've distributed and educated the tool to every police precinct in Suffolk County. We also reached out to EMTs, ERs, school districts, libraries and various other organizations to share it with our community.
Today, you can find the list on the Suffolk County web site, which we update and maintain. You can now search by location and access the phone number, and the ages that the particular program will see. It also has a legend that indicates who will see somebody who is pregnant, who works with families, etc.
We've put on Parent Forums to empower parents with an understanding and information about substance abuse issues. We also brought together school kids and did a whole day of exercises with them regarding addiction and how to prevent it. We asked some very easy specific questions, such as: "If you had a friend or if you yourself were having a problem with drugs or alcohol, who would you go to?" We put it up all around the gymnasium that we were in, and 9 times out of 10 the kids were saying that the person they would go to would be their coach. So if the coach is the person that the kids are going to, what we have to do as treatment and prevention specialists, to make sure that the kids get access to treatment or learn how to prevent, is meet with the coaches. We put on a forum and met with coaches and provided education.
To address the overdose issue, we developed "Don't Run - Call 911" flyers. The message is, the sooner you get help for somebody who might be overdosing or experiencing alcohol poisoning, the better. So as soon as you see that, call 911. They will come and you will not get in trouble. This campaign brings awareness to this challenge.  
We also were involved in promoting NarcanĀ® (naloxone) and how Narcan saves people from overdoses. Suffolk County has a big push to make sure that there's training and providing information on where training can take place, so that if you're a family member you can learn how to dispense Narcan. If you're somebody who uses, you can learn how to use Narcan on the person next to you if they're overdosing. And we've created flyers about that and gotten them out into the community. We reach out to as many people as we can. So there's a lot that we're doing. And we're doing it together.
What have been your biggest accomplishments so far as an organization?
Our biggest accomplishment has been the Suffolk County Community Resource List, as it improves access to treatment. The one page list provides contact information on all the licensed drug and alcohol treatment programs in Suffolk County, as well as the 24/7 hot line information where individuals can receive immediate help (631-979-1700).

Another big accomplishment was our Screening Brief Intervention, Referral to Treatment (SBIRT) implementation and awareness, about 5 years ago, COS took on the task of educating the healthcare community on SBIRT. We visited hospitals in Suffolk County and met with the Administrative and Emergency Room staff, to talk about their implementation of SBIRT in the ER.  We also outreached to doctor's offices to educate them about SBIRT and the value of using SBIRT, and also that they could bill for it.
Transitions of Care Program Implementation Highlights from John T. Mather Hospital
Written by: Lorraine Farrell, FNP, RPAC, Assistant VP, Medical Affairs and Cathleen Roster, LMSW, Director of Case Management
Value of a Hospital Observation Program
 (From left to right): Adam Wos, Emergency Dept; Richard Poveromo, Case Management; Lorraine Farrell, Administration; Nirupa Ramjisingh, Hospital Medicine; Cathleen Roster, Case Management; Phyllis Macchio, Readmission Prevention Coordinator; Julie Tegay, Emergency Department.
The idea of using Observation Status to avoid potentially preventable 30 day readmission is attractive and although a relatively simple concept, can be quite complex to implement. Mather's Observation implementation journey began in 2012 as a way to prevent admission for short stay chest pain patients; many of these cases traditionally resulted in payment denials.
The Radiology Department at Mather offers computerized coronary transluminal angiography (CCTA), which combined with serial EKG and troponin testing, could rule out coronary stenosis within an Emergency Department (ED) visit. Patient satisfaction was high with this approach and the ED clinicians became adept at managing this patient group. A chest pain observation protocol was then developed defining inclusion and exclusion criteria for discerning which patients could be placed in Observation Status versus admission and education of all ED staff began. This initial success combined with bed flow difficulties with getting admitted patients to inpatient units, led to the decision to house the Observation Unit in the ED. Analysis of other short stay diagnostic categories was undertaken and additional Observation protocols were developed for management of COPD exacerbations, cellulitis, TIA, and alcohol withdrawal. Observation status can also be assigned to patients deemed eligible for Skilled Nursing Facility care while authorizations and care plans are determined. This avoids re-hospitalization of those with a recent inpatient stay.
Observation Status disposition on the ED tracking board triggers automatic notification of the ED registrar who delivers the Observation notification to the patient. The individual patient field on the tracking board is programmed to change color, signaling the ED clinician to enter progress notes in accord with timing requirements. Specialty consults are also called as appropriate. ED Case Managers are involved in discharge plan development which may include follow-up phone calls to ensure that the patient does not return to the ED unless warranted.
One of the challenges with Observation Status is the determination of which patients are appropriate. This is an art as well as a science and can only come with experience. The development of robust treatment and management protocols outlining Observation Status inclusion and exclusion criteria are a must to avoid friction between ED clinicians and admitters.
Building a Transition of Care Model for Inpatient and Observation Status
We recognize that a key component to the health and well-being  of our patients is a successful transition of care to our after-care partners in the communit y. In working with the Suffolk Care Collaborative, we have learned that this transition begins w ith early education to the patients and families, particularly regarding discharge options, resou rces, and insurance guidelines. 
Our policy has been to screen patients, according to our extensive high risk criteria, and for those who meet the criteria (approximately 90+ %), to conduct a full psycho/social assessment within the first 2 days of a patient's stay. This assessment includes education about discharge services and a tentative discharge plan. This year, we have moved toward conducting this assessment within the first day of a patients stay and are now successfully completing the assessments and education 93% of the time.  As part of that initial assessment, the social workers make contact with the patient's Medicaid case manager, group home liaison, or a contact person at the skilled nursing facility or assisted living.  Another part of the assessment process is obtaining the patient/family choice of home care agencies and/or skilled nursing facilities. This allows the social worker to make referrals to these entities within the first day of stay, so that the onsite representatives can follow the patient throughout their stay. We also provide onsite home care and skilled nursing representatives with read-only access to the patient's medical record, so they can be sure to have the information they need to care for the patient after discharge. Upon discharge to a skilled nursing facility, we provide a comprehensive package of information, via eDischarge, including physical therapy notes, physician notes, consults, labs, medications, and social work notes. This allows the skilled nursing facilities to have a full picture of the patient's treatments and care needs, both medical and psycho-social. 
Our focus on transitions of care starts with our emergency department social workers, who cover the ED from 9am to 8pm 7 days a week. Our ED tracking board has badges that alert all clinicians when a patient has arrived from a group home, skilled nursing facility, assisted living, or when they are a 30-day return from inpatient or a 24 or 48 hour return from the ED.  The ED social worker addresses all these cases, communicates with the patient's community providers, and provides education, resources, and transition of care services to any patient in the ED who is in need of these services.
We are continually trying to improve our transitions of care for all patients. To this end we are combining our social work and care management departments into a case management department. Our goal is to meet with all patients, even those who don't meet high risk criteria, and to follow patients more closely throughout their stay.  Our nursing staff will be providing 'warm hand-off' calls to skilled nursing facilities when patients are discharging to this destination.  We will also be implementing a call-back case manager who will provide follow up calls for all discharged patients who are identified by our case managers  as needing  this service.  We will be employing a transitions of care nurse practitioner, who will make home visits to patients who present as needing hands-on follow up following discharge.   We will also be welcoming a Suffolk Care Collaborative case manager, who will be embedded into our hospital, to follow those Medicaid and dually eligible patients who are in need of case management services.   In partnership with Suffolk Care Collaborative and our many after-care partners in the community, we hope to continually improve our transitions of care in order to maximize the healthy outcomes for our community.
INTERACT Spotlight:
St. James Rehabilitation and Healthcare Center
St. James Rehabilitation and Healthcare Center, located in St. James is an engaged participating Skilled Nursing Facility in the INTERACT Program, and has dedicated the month of August to an organization-wide campaign called "INTERACT Education Month."
KellyAnn Lunghi, RN, Director of Nursing and the INTERACT Implementation Team is using the month of August to build awareness, education and communicate the SCC's INTERACT Program. Jennifer Kennedy, SCC Director of Care Transitions Innovation, spoke with KellyAnn about strategies that St. James uses to facilitate the program.  
  Strategies include:

From left to right: June Anderson, CNA; Matthew Thorp, RN Nurse Manager; Samantha Farquharson, CNA; Kimberly Matz, RN Nurse Manager; Marisol Ore, CNA; and Gina Dereme, LPN. 


Bulletin Board at St. James promotes the

INTERACT program!

  • Training! Every employee will be participating in an in-service this month on INTERACT. 
  • Engagement! Each department was given INTERACT responsibilities -- to engage staff, a phrase was created to show the importance of each person to the success of the program, for example: C.N.A. - "You are our eyes and ears, please help us help our patients." or R.N. - "Be an INTERACT Specialist." or L.P.N. - "Help to ensure early intervention."
  • Leadership! Each Department Head received a memo explaining the INTERACT program goals and that of their staff.
  • Organization-wide Engagement! Focusing on how each employee makes a difference - as each employee touches the residents in very different ways, that is why it is important that everyone participates and assists in keeping the residents in the facility.
KellyAnn says, "St. James is a team, if we work together we can continue to provide the outstanding care that St. James is known for and keep our patients home."
The SCC recognizes this organization-wide engagement approach as a best practice and look forward to hearing more about this month's successes! 
Advanced Care Planning Initiatives:
IPRO's role as the Medicare Quality Improvement Organization for NYS, in contract with the Centers for Medicare & Medicaid Services, is to collaborate with hospitals, skilled nursing facilities, home health agencies, physicians and community service pr oviders and stakeholders across New York State to facilitate cross-setting c ollaboration and partnerships to improve transitional care through improved communication, information transfer and care coordination for Medicare beneficiaries.  One of the important areas of focus i s to improve the quality of care that people receive at the end of their lives by honoring their preferences, values and beliefs through an informed decision-making communication process with their families and healthcare professionals. 
In 2015, IPRO was awarded a two year CMS Special Innovation Project Award to transform End of Life Care in Nassau and Suffolk County.  The goals of this project are to promote community based healthcare adoption of MOLST & eMOLST, a secure, web-based application linked to the New York State eMOLST registry, provide training and technical support to healthcare providers for adoption and implementation of eMOLST and facilitate education and understanding of Medicare beneficiaries, families and caregivers on the importance of End Of Life Care  planning. For this effort, our valued partners are Patricia Bomba, MD, FACP, Vice President & Medical Director, Geriatrics at Excellus BlueCross BlueShield & MedAmerica Insura nce Company, Chair of the MOLST Statewide Implementation Team & eMOLST Program Director and Chair of the National Healthcare Decisions Day NYS Coalition and Beth van Bladel, CPA, Six Sigma Green  Belt and Patient Advocate. 
For information on how the project can support your community, contact IPRO Quality Improvement Specialist Carolyn Kazdan at
Featured Interview
Pat ricia A. Bomba, M.D., F.A.C.P. educates healthcare providers on the MOLST and eMOLST during the Launch event for IPRO's CMS Special Innovation Award for Transforming End of Life Care on Long Island.  
Name: Patricia Bomba, M.D., F.A.C.P
Title/ Organization: Vice President & Medical Director, Geriatrics, Excellus BlueCross BlueShield & MedAmerica Insurance Company, Chair, MOLST Statewide Implementation Team & eMOLST Program Director, & Chair, National Healthcare Decisions Day NYS Coalition
How you first got involved in with MOLST?
In 2001, I established the Community-wide End-of-life/Palliative Care Initiative (Initiative) with a diverse group of 150 professionals and consumers.  Improving advance care planning was among the key goals of the Initiative.  Two programs emerged as a result of the Initiative:
  1. Community Conversations on Compassionate Care (CCCC) encourages everyone 18 years of age and older to have a conversation about values, beliefs & goals for care and complete a health care proxy.
  2. Medical Orders for Life-Sustaining Treatment (MOLST) is a clinical process that emphasizes discussion of the patient's goals for care and shared medical decision-making between health care professionals and patients who are seriously ill or frail, for whom their physician would not be surprised if they died within the next year. The result is a standardized set of medical orders documented on the MOLST form that reflect the patient's preferences for life-sustaining treatment.
What has surprised you most about working with MOLST?
Many physicians and other clinicians do not recognize that cardiopulmonary resuscitation (CPR) means that all medical treatments will be done to prolong life when the heart stops or breathing stops, including being placed on a breathing machine and being transferred to the hospital. As a result, incompatible medical orders such as CPR and Do Not Intubate (DNI) have been written on MOLST forms creating issues in an emergency.
MOLST requires an understanding of the benefits and burdens of each life-sustaining treatment and the medical evidence supporting the medical decision making given the individual's health status and prognosis.
Can you share successful strategies to keep the momentum of advance care planning dialogue alive across the patient's continuum of care?
A multidimensional community approach to advance care planning is effective. 
  1. Culture change is critically important. Start by normalizing the importance of advance care planning as a wellness initiative, as important as quitting smoking. Focusing on losing the ability to make medical decisions and the potential for recovery, as well as death is important. Recognize advance care planning is a key element of future care planning and engage attorneys, financial planners, funeral directors, etc.
  2. Training physicians, clinicians & other professionals is critically important.
  3. Public education and engagement is best accomplished by using a consistent simple message in media, print, web, video, educational and promotional material. This is the approach used with the CCCC and MOLST toolkits.
  4. MOLST is an end-of-life care transitions program with a consistent process (8-Step MOLST Protocol) that includes thoughtful discussions and shared, informed medical decision-making and a care plan that supports MOLST decisions.
  5. System implementation, policies and procedures, workflow align with the work being done on care transitions, reducing readmissions, palliative care.
  6. Dedicated system and physician champions are needed in all care settings (hospitals, nursing homes, physician offices, home care & hospice and EMS.)
Across the geographic areas, how do you see the hospitals and SNF's partners rolling out e-MOLST together?
When MOLST was first implemented in 2004, hospitals, nursing homes, hospices worked together to ensure a common approach across the community.  Physician leaders, including geriatricians, internists, emergency room physicians, intensivists and palliative medicine specialists, in partnership with system leaders, including quality & patient safety specialists, directors of nursing, social work, etc., served to ensure a collaborative approach.
What might (someone) be shocked to know about you?
I don't plan to work forever and will retire.  I have a long bucket list including, but not limited to, skydiving with my son, learning to play the piano, traveling, being part of my grandchild's life, buying a horse that wins the Alabama Stakes at Saratoga, writing a cookbook (cooking & baking is a passion and stress reliever) and my life as a social entrepreneur.
Compliance Connection
New OMIG Guidance Clarifies Who Can Certify (SSL)

New guidance is here! Released by the NYS Office of the Medicaid Inspector General August 31, 2016, it clarifies who qualifies as the Certifying Official for online certification of a compliance program under SSL 363(d) and 18 NYCRR Part 521. It also clarifies who should be identified as the Compliance Officer. Two different individuals must participate in the online certification:
1. The Compliance Officer (the person the organization has designated to oversee the daily operations of the compliance program); and
2. The Certifying Official, who must be in a senior executive/administrative/governing body position and to whom the Compliance Officer reports on the activities of the program. Furthermore, the Certifying Official should be the person who completes and submits the certification on OMIG's website.
This guidance eliminates OMIG's previous recommendation that the Certifying Official be someone to whom the Compliance Officer reports. Directions on the certification form to reflect this new direction will be made when the certification form is updated starting on December 1, 2016.
We've given just a nutshell version here so do read it all, i t's only about a page long-and check your last SSL cert. Will you need to do things differently next time? If so, don't wait 'til the last minute, get those conversations happening now! The SCC Compliance Officer is here to help if needed: contact Sarah Putney at (631) 638-1393 or . Or our 24/7 Compliance Hotline: (631) 638-1390.
Milestone Dates
NYS DOH DSRIP Program Milestone Dates 
Sept. 30
Final Approval of PPS Year 2 First Quarterly Reports
Implementation of Phase II Payment Scorecard in MAPP Performance Dashboards
October 1
Anticipated Independent Evaluator contract start date
October 6
Final PPS Year 2 First Quarterly Reports posted to DSRIP Website
October 31
PPS Year 2 Second Quarterly Reports (7/1/16 - 9/30/16) due from PPS

Frequently Asked Questions


To access NYS DSRIP FAQ, click here

Job woman showing hiring sign. Young smiling Caucasian   Asian businesswoman isolated on white background.
Office of Population Health
Career Opportunities
The SCC is pleased to invite qualified career seekers to apply for open positions. 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 Medicine administering the Suffolk Care Collaborative.
Click the links below to access job descriptions.
For more information, please contact the Suffolk Care Collaborative via email

Stay Informed


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


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