Issue 20
December, 2016
Welcome to Synergy
We are pleased to present the twentieth 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
Happy New Year from the entire staff at Suffolk Care Collaborative. 
Connecting partners to support DSRIP goals and initiatives continues to be a key to our collective success.  In 2016 the SCC contracted with over 100 organizations and have actively engaged roughly 60,000 patients through our DSRIP projects.  117 Primary Care Providers within their associated practices have transitioned to PCMH Level 3 and the SCC Care Management Organization has touched over 1,700 patients.  
We are looking forward to working closely with our partners and continuing to form new relationships, which is a vital part of our future growth and success.  We feel we are well positioned to continue our work to transform healthcare delivery in Suffolk County and in 2017 will do so by focusing on performance and project implementation to reach our mutual goals.  These are exciting times and the hard work we are doing together will shape the future of healthcare in our communities. We want to thank all of our collaborators for an exceptional 2016 and look forward to a prosperous 2017.
Joseph Lamantia
Chief Operating Officer for Population Health
Social Determinants of Health:  Your Zip Code Matters
Written by: Jacqueline B. Mondros, D.S.W., Dean and Assistant Vice President for Social Determinants of Health, Stony Brook University

Social determinants are the behavioral, social, and environmental factors or conditions that research has shown, influence positive or negative health outcomes. 
Some experts divide the social factors into sources of vulnerability-personal vulnerabilities (such as low education or disability), disruptive events (such as migration or job loss), life stage (children, youth, seniors), and system barriers (household debt, access to services).  However, social determinants frequently resist categorization.  For example, where does persistent poverty and racism fall? Sources of vulnerability often co-occur as when disability leads to job loss and debt.
We know that social factors are very powerful in determining one's life course. Health is determined 20% by one's genetic makeup, 20% by the health care we receive, and 60% by the social conditions we inhabit.  The association is even stronger for behavioral health. Beyond health, we know that 20% of educational success is attributed to one's intelligence, 20% to the education one receives, and 60% by social conditions.  The data looks similar for one's ability to age in place, and for involvement in the criminal justice system.  And poor health outcomes, poor educational outcomes, and involvement in the criminal justice do not appear independently. Health problems like diabetes and asthma cluster in geographic neighborhoods where poor educational outcomes, and involvement in the criminal justice system are also prevalent. In fact, it is said that your zip code may be more important to your overall health than your genetic code.  In truth, your zip code to a significant extent may determine both your wellness and your life success. 
What are the social determinants or inequalities that impact success? Most researchers include these factors:
  • A safe and healthy environment 
  • Reliable, consistent, and sufficient income
  • Standard housing
  • Food security
  • Social Engagement & Support
  • Transportation
  •  Caregiving for children and older adults
  • Access to Services
So what does an understanding of social determinants suggest we should do?  First, to effectively improve health outcomes we have to remove the boundaries between health and social care.  Second, we should respond to social conditions on three levels:  individual care, population health responses, and community care.
Individual care must utilize quicker, more focused screening, assessments, treatment planning, and care coordination that are informed by social conditions such as housing, transportation, and food security.  Population health responses must examine the structural social conditions that are obstacles for particular vulnerable populations like older adults or persons with mental health issues. Issues of access are significant at the population level.    Finally, work can be done in hot spot communities, using methods that public health has championed in health education, use of social networks, peer coaches, and social marketing to counter some of the deleterious effects of social inequality.  
Addressing Social Determinants of Health through SCC Program & Initiatives

The Suffolk Care Collaborative places a particular focus on the area of Social Determinants of Health with Dean Mondros as our Director of Social Determinants. The SCC Care Management Organization works collaboratively with Primary Care Physicians (PCP), patients and our Community Based Organization (CBO) partners to address these needs on an individual basis with each of our care managed patients. When a patient enrolls in Care Management, a comprehensive biopsychosocial assessment is completed with particular emphasis on needs such as housing, transportation and food stability. Once a person's basic needs are met, they are much more able to continue on the journey to improved health and are far more likely to be successful.

At the Population Health level, SCC is actively implementing eleven (11) programs geared at improving the health of our Suffolk County population. In particular, we have efforts underway to improve access to Primary Care through Patient Centered Medical Home (PCMH) recognition, as well as access to Behavioral Health care through our Behavioral Health and Primary Care Integration Program. Additionally, patients that are uninsured or non and low utilizers of care are being coached and navigated to healthcare through our Community Health Activation Program (CHAP). These are just some examples of our efforts to improve population health and identify barriers to improved outcomes. For more information on our Programs click here.

Finally, at a community care level, the SCC has conducted an "Areas of Need" strategy to identify areas of high need that may require specific focus and attention. Together with the Long Island Health Collaborative (LIHC), SCC has identified 20 "zones" that may benefit from interventions related to Social Determinants of Health and improved access to care. Work is now underway to develop strategies around improving health in these areas and screening for and addressing the Social Determinants of Health. 
Experiences with PCMH Transformation, A Collaborative Partner Interview: 
Name:  Susan Lee, MD, FACP
Title:  Associate Professor of Clinical Medicine, Medical Director of the PCMH
Organization:  Stony Brook Primary Care 

Tell us about your organization.
We are a busy faculty practice affiliated with SUNY Stony Brook Medicine.  We have 20 faculty members, including 7 Geriatricians and 1 Nurse Practitioner.  Our East Setauket office is a training site for residents and medical students as well as NP's. We are also home to Stony Brook's HIV Program.  We serve a diverse patient population, ranging from the uninsured and indigent to those with insurance and the ability to self-pay.  Most of our patients reside in Suffolk County. 
Why did you choose to partner with the Suffolk Care Collaborative (SCC)?
We were offered the opportunity to collaborate with SCC as part of the Delivery System Reform Incentive Payment (DSRIP) initiative that is led by Stony Brook. We were interested in the DSRIP initiative because it ties in closely with our philosophy of care in a Patient Centered Medical Home (PCMH). We had started our transformation as a PCMH under a Department of Health grant, and participating in the DSRIP initiative with SCC allows us to continue our mutual efforts at caring for our patients insured under Medicaid in a patient centered way.
What is PCMH and when did the National Committee for Quality Assurance (NCQA) first recognize you?
PCMH is transforming the way we deliver care. The emphasis is on patient-centered care, treating patients in a comprehensive way that helps them navigate today's complicated medical neighborhood.
We were recognized by NCQA as a Level III home (the highest level achievable) under the 2011 standards in 2014. Although we were still accredited, we opted to renew early for the more robust 2014 standards and we just became accredited as a Level III home again.  
What major changes were required in your practice when transitioning to the updated NCQA standards for PCMH?
We had to make a lot of workflow changes. Specifically, we had to train our staff to be more involved in care management, tracking, and our quality assurance initiatives. In addition, we started a very proactive transition of care program for patients being discharged from the hospital, nursing home or emergency room. We also initiated screening for depression, substance abuse and falls as part of our patient intake. 
As healthcare reimbursement changes from volume to value, how is your organization adapting to the new paradigm?   
As we move towards value-based reimbursement models, being a PCMH puts us at the forefront of the future of patient care.  We are already employing the tools of our Electronic Medical Records (EMR) to improve gaps in care for preventive health recommendations and chronic conditions such as diabetes. 
In addition, we will be using HealtheIntent, a special feature within our EMR, to generate scorecards that allow individual practices and providers to track how they are doing on measures that governmental and private insurers will use to assess quality. 
Already, becoming a Level III PCMH has given us recognition with certain insurers as a "Preferred" practice.  Moving forward, our institution as a whole is working towards caring for patients with the goal of achieving the Triple Aim. 
DSRIP's purpose is to fundamentally restructure the health care delivery system.  How is your organization evolving to meet this goal?
The PCMH philosophy of patient-centered team-based care is clearly the way to care for the patients who are indigent and insured under Medicaid.  Partnering with DSRIP has allowed us to expand our care management and Behavioral Health reach towards the goal of reducing avoidable hospital use.  Stony Brook is continually looking at ways to control costs and improve quality.  Dr. Fields, our Division Chief, is on a committee chaired by a Hospitalist, that is working to reduce 30-day re-hospitalization rates in Medicare patients.
What are your top three guiding principles for a successful population health management program? How does PCMH fit in?  
  1. Teach the foundations of team-based care
  2. Technical/IT support is key
  3. Celebrate your success and share the results
When employees understand and see the benefits of team-based primary care, they feel empowered to make a difference.  PCMH allows people to work at the highest level of their license and know that they are doing the most good. 
What value does the SCC bring to patients under the DSRIP program?
Tremendous value.  Having the support of a Care Manager embedded in the practice, as well as new partners in Behavioral Health in the community, has been a great resource for patients needing extra support.
What impact does PCMH recognition have on the communities, workforce and population we serve?
Becoming a PCMH has opened opportunities to collaborate with other departments and specialists at Stony Brook. Our staff has better job satisfaction and patients polled like the new model of care. 
Can you share some strategies in integrating PCMH standards in your practice?
  • Get support from the administration to allocate time for writing policies and procedures
  • Assure that staff and physicians understand the philosophy of team-based care -- then continually train and educate them
  • Share your success stories and help each staff member understand their importance as part of the team
  • Get patients and staff involved in QA projects using the PDSA (Plan, Do, Study, Act) Cycle technique
Who did you collaborate with to become PCMH recognized?
We met almost monthly with the departments of Family Medicine, Pediatrics and IT/Population Health to share ideas about how to change policy and procedures in the office, train staff, and collect data.  SCC was also an important partner as they provided much administrative support and expertise. 
What obstacles did you encounter meeting the updated PCMH standards?
  • Initially, staff resistance to change
  • Time constraints
  • Limited administrative support
  • Our EMR was not capable of meeting the updated PCMH standards so we had to create work-arounds, customized tracking lists, customized chart templates and customized individualized care plans
How has the PCMH model benefited your patients?
Navigating today's medical neighborhood is very complicated for patients; especially those who are elderly, learning disabled or have no social support.  Our patients appreciate having continual care even after they leave the office and like being involved in making educated decisions about their care.
And we do have a really impressive measurable outcome: Before we started the PCMH initiative, our 30-day re-hospitalization rate for Medicare patients was about 15.6 %. After initiating PCMH, we were able to get that number down to 3.6%.
How do PCMH standards align with DSRIP projects in your experience?
Very well. In choosing our QA projects, we were able to align some to the benefit of our patients.  For example, Caring for Diabetics and trying to reduce re-hospitalization rates were projects that overlapped. 
Anything else you'd like to add?
Transforming your practice is a big task, and it requires a lot of dedication, but it can be done if you establish a leadership team who really believes in the concept of team care and PCMH. We were able to engage our staff and help them understand what role they play in patient care. We have a lot of people who scan charts and file papers. We tried to show them that if papers don't get filed into the right place or if we don't get our lab results scanned into the system, we can't take care of patients, and we won't be able to meet certain goals we're trying to achieve. When they saw how important their role was in caring for patients, they really had much better job satisfaction. Even our janitor -- who keeps the facilities neat and organized and who's always trying to help patients out by opening the door -- he's part of our team, too!

Learn more about the SCC's PCMH Practice Transformation Program here.
INTERACT Spotlight:  Nesconset Center for Nursing and Rehabilitation "Excels"
Nesconset's Interdisciplinary Team

Nesconset Center for Nursing and Rehabilitation in Nesconset, an engaged participating Skilled Nursing Facility in the INTERACT Program, has implemented the INTERACT Excel Hospitalization Rate Tracking Tool.  The Excel workbook consists of twenty-three worksheets to assist in tracking and evaluating hospital transfers in nursing homes.  The tool can create customized monthly reports to assist leadership in identifying trends in their readmissions.

Bob Baranello, Administrator at Nesconset said, "I am thrilled to be working with SCC on the Interact tracking tool pilot. The training provided made it very simple to follow to get the process started."  Nesconset began the pilot in November. Once their census data was input, they began to utilize the tool.  Bob said, "We are able to print out reports that gave us a lot of information that we would have had to calculate manually. The reports will now become part of our Quality Assurance Performance Improvement (QAPI) program. We will review the information from the reports and be able to hone in on trends of ER and hospitalization transfers such as time of day, day of week, physician or NP practice patterns, by signs and symptoms and by presumed diagnosis.  This information is invaluable in our effort to reduce avoidable hospitalizations." Crystal Thomas, Director of Nursing, said,  "As we move forward we will fine tune our internal process of coding signs and symptoms and diagnosis so that we can better understand which chronic diseases we need to focus our efforts on."

We would like to give a shout out to Nesconset as they continue to work closely with SCC on performance improvement initiatives, and identifying creative avenues to reduce their hospital and ED transfers!
Performance Improvement Action Plans in Action for INTERACT
One of the INTERACT Project Requirements is to measure outcomes, including quality assessment/root cause analysis of transfers in order to identify additional interventions. This allows administration and clinical leadership to identify opportunities for quality improvement, use rapid cycle improvement  methodologies, develop implementation plans and evaluate results of quality improvement initiatives.

Performance Improvement is not new to Skilled Nursing Facilities (SNFs).  The Affordable Care Act requires that all SNFs develop Quality Assurance and Performance Improvement (QAPI) programs.  Many of the facilities accomplish their root cause analysis by using INTERACT's Review of Acute Care Transfer Quality Improvement Tool.  The QAPI team reviews completed transfer tools to identify trends in hospital transfers, which become the focus of their quality improvement initiatives.

One of the challenges SCC faced was finding a user-friendly way for the skilled nursing facilities to submit their required action plans, as there is variation in the way each facility executes QAPI.  Chris Ray, MS, Data Analyst at SCC was instrumental in bringing forth a solution through his experience with Qualtrics survey software.

Chris said, "I turned to Qualtrics for the quality improvement initiative based on my past experience. In the past, I've leveraged Qualtrics to systematically capture data from patients. I picked up on the need for a centralized, customizable, and organized platform to capture quality improvement plans from various facilities and immediately turned to Qualtrics. By designing your customized surveys and implementing features such as data validation and skip logic, you can ensure consistent and accurate data capture across many respondents."

Five geographically friendly Performance Improvement workshops were hosted by Affinity Skilled Living, Gurwin Jewish Nursing & Rehabilitation Center, Bellhaven Center for Nursing & Rehabilitation, Huntington Hills Center for Health & Rehabilitation, Nesconset Center for Nursing & Rehabilitation, and Peconic Bay Skilled Nursing & Rehabilitation Center.  The workshops were attended by Directors of Nursing and Administrators from surrounding SNFs.  Jen Kennedy, Director of Care Transitions Innovation, coached the groups on the project's requirements for the Performance Improvement Action Plan and introduced the Qualtrics QI Action Plan.  Each facility knew the root cause of hospital transfers they wanted to focus on in their action plan. The attendees brought their laptops and accessed their facilities' customized link that Chris created. By the end of the workshops, attendees were able to complete their action plan.  Jen said, "It was wonderful to see how these competing facilities worked together and shared their knowledge and ideas."  All of the attendees agreed that working in the geographical cohorts was very beneficial.

Suffolk Care Collaborative would like to thank the above facilities for their hospitality in hosting the Performance Improvement Workshops!!!!
SCC Surveys Home Care Providers & Engagement Goals for 2017   enter-key-keyboard.jpg

The Suffolk Care Collaborative recognizes the vital role that Home Care providers play in the Integrated Delivery System. As each of the eleven (11) SCC Programs evolve, the system in which patients access care will shift from primarily hospital/institution-based care to ambulatory, community-based care. As such, care received in the home will become more and more vital to the health and well-being of our patient populations.

During the first two years of DSRIP, the SCC focused on building an infrastructure that will allow for delivery system reform and Program sustainability while creating plans for successful implementation of the DSRIP Programs. As we enter the final quarter of DSRIP Year Two, the SCC is focused on operationalizing these Programs and measuring the outcomes and successes of our efforts. It is with these goals in mind that the SCC launched a Home Care Provider Initiative to engage providers of care in Suffolk County.

The SCC created a Home Care Provider survey which will allow us to collect intelligence around the types of services and populations that Certified Home Health Agencies, Licensed Home Care Service Agencies and Managed Long Term Care Agencies provide to residents of Suffolk County. The survey was sent to over 100 providers with a request for completion by December 23rd. While we have had a very enthusiastic response to this survey, we would welcome continued engagement. If you are a Home Care Provider and have not already responded to this survey, we want to hear from you.  Please click here and you will be taken to the survey page.

After completion of the survey, the SCC intends to aggregate results and understand the full service capabilities offered in Suffolk County. We will also look to better understand agencies that may be well equipped to care for Medicaid patients that are identified through our DSRIP Program implementation. In the next month or two, the SCC will host a Home Care Learning Collaborative which will be open to all Home Care Providers interested in learning more about the Suffolk County Programs and the increased patient activity they can expect at their agencies due to transformations in the delivery system.  For example, this can include an increase in referrals through effective care transitions, or perhaps a need for home blood pressure monitoring as a result of our Cardiovascular Health and Wellness Program.

SCC feels strongly that building partnerships with Home Care Agencies is a key to successful Program implementation and improved outcomes for our patient populations. 
SCC's DSRIP Mid-Point Assessment Results

The Independent Assessor (IA) for New York's Delivery System Reform Incentive Payment (DSRIP) Program has completed its Mid-Point Assessment of all twenty-five Performance Provider Systems (PPS).  The public has been invited to participate in the review of their initial and final reports now available.

The Mid-Point Assessment is a required component of the DSRIP Program and is intended to evaluate the progress made by each PPS through the end of the second quarter of DSRIP Year 2 (DY2, Q2).  Assessments were conducted by an Independent Assessor (IA) and, specifically, evaluated progress made towards establishing the necessary organizational foundation and the implementation of the project requirements consistent with the PPS approved DSRIP Project Plan.  Assessments took place over a number of months consisting of several components which included:  
  • Mid-Point Assessment Project & Organizational Narratives (submitted July 31)
  • 360 Survey sent to a sample of PPS partners intended to measure partners' experience with the PPS (completed August 31; SCC's response rate was 56%)
  • PPS Lead Financial Stability Test (Completed August 31)
  • PPS On-site Review by Independent Assessor (SCC's visit took place on October 19)
For more information, please visit the NYS DOH Mid-Point Assessment webpage found here.

SCC's Report and Recommendations
On November 22, the IA's Initial Mid-Point Assessment Recommendations were released for PPS and public review through December 21.
The SCC was encouraged by the IA's initial report highlighting, "The IA's review of the Suffolk Care Collaborative covered the PPS organizational capacity to support the successful implementation of DSRIP and the ability of the PPS to successfully implement the projects the PPS selected through the DSRIP Project Plan Application process.  SCC has achieved many of the organizational and project milestones to date in DSRIP.  The PPS has made positive strides to develop the infrastructure to run a successful PPS in their region."
The SCC received one recommendation pertaining to Partner Engagement.  We recognize that Partner Engagement was a focus for the IA as 14 of 25 PPSs, or 56%, shared in the same recommendation.  With this, we do recognized the IA is specifically looking for greater overall Partner Engagement across the Integrated Delivery System as an indicator for our potential success under DSRIP.

Partner Engagement Recommendation
Recommendation 1: "The IA recommends that the PPS review its Partner Engagement reporting and develop a plan for engaging network partners across all projects to ensure the successful implementation of DSRIP projects."

On December 21, 2016, the SCC responded in writing to the one Initial Recommendation from the IA pertaining to Partner Engagement.  The formal response letter can be found here.  

The IA has now completed its review of PPS responses and public comments to the initial recommendations and has posted the final reports on the DSRIP website, which can be found here.  These are now posted for a second comment period through January 23, 2017.  The final recommendations will then be presented to the Project Approval Oversight Panel (PAOP) from January 31, 2017 to February 3, 2017.
If you have questions about SCC's Mid-Point Assessment, please contact us at  For the full Mid-Assessment timeline visit the DSRIP Website.  Reports for all NYS PPS's can be found by clicking here. 
Compliance Connection

Get Your Free Security Risk Assessment Tool!
Doing a Security Risk Assessment (SRA) is an important part of any healthcare compliance program.  Believe it or not, you don't have to be an IT guru to conduct one!  Although not quite as easy as a paint-by-numbers kit, you can now use a simple, free tool developed by the federal Office of the National Coordinator for Health Information Technology (ONC) and two other federal agencies.  It is easy to access, download, and use and can be accessed by clicking here.

The tool itself walks you through the process of reviewing the administrative, physical, and technical control environment of your healthcare organization.  You can save information to it, making it a tidy package for documentation purposes. So there are very few excuses left for not doing an SRA.  The goal is to ensure compliance with HIPAA Security requirements and to minimize the risks to your patients' e-PHI.  Put an SRA on your 2017 Compliance/HIPAA Work Plan today!   Contact the SCC Compliance Office at
Milestone Dates
NYS DOH DSRIP Program Milestone Dates

 January 2017       Anticipated Independent Evaluator contract start date

 January 3             Release Final Mid-Point Assessment recommendations for
                              30-day public comment

 January 6             Final PPS Year 2 Second Quarterly Reports posted to DSRIP

 January 23           Public Comment period for Final Mid-Point Assessment
                              recommendations ends

 January 31           PPS Year 2 Third Quarterly Reports (10/1/16 - 12/31/16) 
                              due from PPS

 January 31-         DSRIP Project Approval Oversight Panel (PAOP) convenes 
 February 3           to review Mid-Point Assessment recommendations

 Late January        DY2 First DSRIP Payment to 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. All job descriptions for current opportunities are posted here.

Current Job Opportunities:
  1. Compliance Officer
  2. Care Manager
  3. Project Manager, Integrated & Managed Care
  4. Project Manager (PCHM Practice Facilitation)
  5. Data Visualization Analyst
  6. Community Engagement Liaison
  7. Administrative Manager, Community Engagement & Cultural Competency
  8. Provider Relations Manager
  9. Social Worker
  10. Community Health Associate
  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.