Welcome to Synergy
We are pleased to present the eighth issue of Synergy, a monthly newsletter about the progress and processes of the Suffolk Care Collaborative (SCC).
The definition of synergy is the increased effectiveness that results when two or more entities work together. We are confident that the combined efforts of the many dedicated partners within the SCC will help the Collaborative reach its goals, leading to improved health for the residents of Suffolk County.
Happy New Year
2015 has been a landmark year at the Suffolk Care Collaborative as we have embarked on this unprecedented journey to transform our Healthcare Delivery System. We appreciate the input and contribution from all our partners in developing and creating a strategic roadmap to successfully implement the DSRIP initiatives in Suffolk County.
Thank you for your commitment and active participation to this collaborative partnership in striving to achieve the Triple Aim of Healthcare: improving the patient experience of care, the health of the population and reducing the per capita cost of healthcare. We look forward to strengthening our partnerships as we continue this trailblazing work together in 2016.
Warm wishes for a very Happy New Year.
Chief of Operations for Population Health
The Suffolk Care Collaborative (SCC) is moving from the planning phase to project implementation and is officially kicking off formal engagement with Coalition Partners through the SCC Coalition Partner On-boarding Program in the first quarter of 2016. The On-boarding Program is designed to enroll our Coalition Partners in the DSRIP program, establish payment procedures, clarify roles and responsibilities for participation and provide an orientation to DSRIP and the SCC.
There are four parts to the SCC On-boarding Program:
Part 1: Complete and Return the SCC Coalition Participation Agreement
Part 1 of the On-boarding Program introduces the SCC Coalition Partner Participation Agreement, the master services agreement for participation in the SCC. The body of the agreement sets forth key terms and conditions that define the role of the Coalition Partner, including participation in the 11 DSRIP projects. The agreement includes several exhibits, including but not limited to, project participation eligibility requirements, business associate addendum, and data exchange application and agreement confidentiality. Notably, Exhibit E will outline the Performance Payment Distribution Plan, setting forth performance factors which you are required to achieve, to qualify for performance payment funds flow. To learn more about the funds flow model please visit the recent recording of the
December PAC webinar
Part 2: Complete and Return Required On-boarding Documents
At the time of onboarding, the SCC will verify that each partner has a signed Coalition Partner Attestation on file with the SCC and recorded with the New York State Department of Health. If gaps are identified, SCC will work with the partner to complete or update the attestation.
All Coalition Partners are strongly encouraged to be connected to a Regional Health Information Organization (RHIO) although this is only a requirement for our Safety Net providers. Coalition Partners will be asked to submit a copy of the Qualifying Entity (QE) Agreement demonstrating participation with a RHIO. For partners without an agreement with a RHIO, the SCC will facilitate the enrollment.
Partners who receive $500,000 or more of Medicaid funds in a consecutive 12-month period will need to submit the certification of their Compliance Program by the New York State Office of the Medicaid Inspector General (OMIG) to SCC.
Coalition Partners will also be expected to complete and return the SCC Education Attestation acknowleding an understanding of the material covered and the standards and expectations.
Please use the SCC Partner Enrollment Checklist as a guide to completing the enrollment documentation.
Part 3: Complete the SCC Current State Assessment Survey
The SCC Current State Assessment Survey is a consolidated survey, evaluating important information regarding our partners current state with meeting specific DSRIP participation requirements. The survey gathers key demographic information regarding the partner organization and evaluates key resources including information technology infrastructure, workforce, training programs, cultural competency/health literacy practices and DSRIP Project Readiness. Surveys not completed prior to contracting are incorporated into the on-boarding requirements.
Part 4: Review SCC Education Materials
During the on-boarding process, partners will be provided with additional guidance and materials to help provide an orientation to SCC and DSRIP. In person as well as self-directed educational methods will be used to provide orientation to the program.
SCC encourages all of its potential Coalition Partners to review the on-boarding requirements in advance of contracting which will start in the first quarter of 2016.
The instructions for completing the on-boarding program as well as all referenced materials are available on the SCC Partner On-boarding Webpage
Certified INTERACT™ Champions
Congratulations to our new SCC Coalition Partners who received their INTERACT™ Champion Certifications
In early November, Ashley Meskill, RN, Clinical Project Manager, managing SCC's INTERACT™ Program, organized the first Certified INTERACT™ Champion (CIC) Training Program at Stony Brook Medicine. There were 40 Skilled Nursing Facilities (SNFs) that participated. Participation provided trainees with new competencies in the
INTERACT™ principals as well as prepared the participants for the INTERACT™ certification exam; established by INTERACT T.E.A.M. Strategies, LLC. We congratulate the eighty staff members, who have passed the exam and are now certified! All trainees will lead the INTERACT™ implementation at their SNFs as "Facility Champions." We would also like to thank the Project Leads, Dianne Zambori, Associate Executive Director for Eastern Region, Quality Initiatives, Northwell Health and Bob Heppenheimer, Executive Director for Nesconset Center for Nursing and Rehabilitation and Hilaire Rehabilitation & Nursing, for their guidance and efforts in organizing the CIC INTERACT™ training program.
Congratulations to all our SNF Partners:
- Affinity Skilled Living
- Apex Rehabilitation and Care
- Bellhaven Center for Nursing and Rehabilitation
- Berkshire Nursing Center
- Vincent Bove Health Center at Jefferson's Ferry
- Broadlawn Manor Nursing and Rehabilitation Center
Brookhaven Rehabilitation & Health Care Center
Carillon Nursing and Rehabilitation Center LLC
East Neck Nursing and Rehabilitation Center
Good Samaritan Nursing Home
Gurwin Jewish Nursing & Rehabilitation Center
Hilaire Rehabilitation and Nursing
- Huntington Hills Center for Health and Rehabilitation
- Island Nursing and Rehabilitation Center
- Lakeview Rehabilitation and Care Center
- Long Island State Veterans Home
- Maria Regina Residence
- Mills Pond Nursing and Rehabilitation Center
- Momentum at South Bay for
Rehabilitation and Nursing
- Nesconset Center for Nursing and Rehabilitation
- Oak Hollow Nursing Center
- Our Lady of Consolation Nursing & Rehabilitative Care Center
- Peconic Bay Skilled Nursing and Rehabilitation Center
- Peconic Landing at Southhold
- Riverhead Care Center
- Ross Center for Health and Rehabilitation
- San Simeon by the Sound Center for Nursing and Rehabilitation
- Sayville Nursing and Rehabilitation Center
- Smithtown Center for Rehabilitation and Nursing
- St. Catherine of Siena Nursing and Rehabilitation Care Center
- St. Johnland Nursing Center
- St.James Rehabilitation and Health Care Center
- Suffolk Center for Rehabilitation and Nursing
- Sunrise Manor Center for Nursing
- The Hamptons Center for Rehabilitation and Nursing
- Water's Edge at Port Jefferson for Rehabilitation and Nursing
- Westhampton Care Center
- White Oaks Nursing Home
- Woodhaven Center of Care
to learn more about the Certified INTERACT™ Champion program
Transition of Care Program for Inpatients and Observation Units
This month's DSRIP project spotlight features program development updates for DSRIP Project 2bix & 2biv, operating under the new SCC program name, Transition of Care Program for Inpatients & Observation Units (TOC).
Program Development Update
The TOC Workgroup met on December 10th, at which time, several project documents were introduced for feedback, including the TOC Program Milestone Timeline, the Hospital Partner Facility Champion Form, and the TOC Baseline Implementation Specifications. The SCC Project Management Office (PMO) reported the completion of all hospital TOC current-state assessments.
We would like to thank all TOC program stakeholders who participated in the TOC program current-state assessment from all Suffolk County Hospitals:
Each Hospital is in the process of identifying a "Facility Champion" for the TOC program. Although multiple stakeholders from each Hospital are represented on the TOC Workgroup, this key person will be the direct communication link between the hospital and the SCC PMO during program implementation. In addition, the Facility Champion or a designee will be trained in Performance Logic, the SCC PMO project management software tool to support managing their own TOC program implementation plan online. Although each hospital will follow the same set of tasks, we expect the method to which the Baseline TOC Program Model Specifications are implemented may vary and evolve.
- Brookhaven Memorial Hospital Medical Center
- Eastern Long Island Hospital
- Good Samaritan Hospital Medical Center - Catholic Health Services of Long Island
- Huntington Hospital - Northwell Health
- John T Mather Memorial Hospital
- Peconic Bay Medical Center
- Southampton Hospital
- Southside Hospital - Northwell Health
- St. Catherine of Siena Hospital - Catholic Health Services of Long Island
- St. Charles Hospital - Catholic Health Services of Long Island
- Stony Brook University Hospital
Program Implementation Strategy for 2016
Program Implementation Kick-off Held on December 14, 2015
The SCC is excited to share the engagement of Amy Boutwell, MD, MPP, Founder, Collaborative Healthcare Strategies; STAAR Initiative co-founder, Institute for Healthcare Improvement; senior physician consultant to the National Coordinating Center for the CMS QIO Care Transitions Theme; attending physician, Massachusetts General Hospital; instructor in medicine, Harvard Medical School.
Beginning 2016, our TOC program stakeholders will be engaged to develop the future-state TOC model, initiate program implementation and support monitoring program implementation across Suffolk County. To kick-off this initiative, the SCC engaged Amy Boutwell, MD, MPP, who presented a learning symposium program entitled, Reducing Avoidable Hospital Utilization, to key internal and external program stakeholders on December 14, 2015.
The program explored the use of best practices and promising strategies for Medicaid patients in the transition of care. Amy Boutwell, MD, MPP, emphasized "Key Messages" and "Key Actions" highlighting best-practices.
"Key Messages" of TOC modeling includes:
- This can be done!
- What are hospitals with hospital-wide results doing?
- Medicaid adults have high readmission rates
- Know the factors that identify your Medicaid patients at high-risk of readmission
- Readmission reduction efforts must include the Emergency Department
- Don't over-medicalize why people return to the hospital
"Key Actions" of TOC modeling includes:
- Know your data!
- Ask your patients, their caregivers and providers, "why"
- Develop a portfolio of strategies
- Improve hospital-based transitional care for all
- Collaborate with cross-setting providers & payers
- Provide enhanced services for high risk patients
Amy Boutwell, MD, MPP also featured a publication called
Hospital Guide to Reducing Medicaid Readmissions, which our program participants received as reference material. Contents include 13 tools for TOC modeling, which the SCC TOC program stakeholders will begin exploring.
Click the links below to access the meeting materials from the program:
- Reducing Avoidable Hospital Utilization, Best Practices and Promising Strategies for Medicaid Patients, presented by Amy Boutwell, MD, MPP, December 14, 2015.
- Hospital Guide to Reducing Medicaid Readmissions, prepared for Agencey for Healthcare Research and Quality by Collaborative Healthcare Strategies, Inc. Amy Boutwell, MD, MPP, et. al.
|SCC TOC Learning Symposium
"Reducing Avoidable Hospital Utilization"
December 14, 2015
Additional Information about the TOC Program
TOC Program Stakeholder Groups
Network of Hospital partner staff representing the OBS & TOC Project from every hospital in Suffolk County. Will be engaged regularly to support program development through implementation of the TOC program. Including reviewing final drafts of project plan content, documents & output of the project plan.
TOC Committee: Multidisciplinary team of stakeholders across the continuum of care (including the TOC Workgroup, SNF, home care and health homes). Will be engaged regularly to support the development of the TOC program, advising on program implementation lessons learned, and monitor the program.
Baseline Transition of Care Program Model Specifications
During the December TOC Workgroup meeting, participants reviewed a list of baseline specifications that will become operating principles of the TOC Model:
- Hospital policies and procedures reflect implementation of a 30 day transition of care period for high risk inpatient and OBS patients at PPS hospitals
- Care Transition Plan is standardized for the PPS and includes the following minimum requirements: follow up appointments, patient self-education, and medication reconciliation
- Care Transition Plan to include care record transition protocols with timely updates to primary care provider
- Early notification of planned discharge is established and maintained in hospital protocols emphasizing early identification/response to high risk patients to avoid adverse events that lead to acute care visits
- Hospitals allow care managers to visit patients in the hospital and provide care transition services and advisement prior to discharge
- Implement hospital risk stratification tool and logistics/work-flow to operationalize identification of high-risk patients
- Partnerships with Home Care and Social Service Agencies & Medicaid Managed Care
- Establish appropriately sized and staffed observation (OBS) units in close proximity to ED services, unless the services required are better provided in another unit. When the latter occurs, care coordination must be provided
- Implement methodology or a set of criteria of identifying ED patients who need further care but whose anticipated stay makes the patient a candidate for OBS.
TOC Program Milestone Timeline
Please click the image to access a PDF Version of the TOC Program Milestone Timeline.
: Geralyn Randazzo, RN, MS, NEA-BC
: Vice President for Care Coordination
: Northwell Health
Please give us a summary of your organization
Northwell is an integrated health system consisting of 21 hospitals, many specialty programs and institutes including Long Term Care, Home Care and Hospice Care, and more than 400 ambulatory and physician practices. We also own and operate CareConnect, a health insurance company.
Who does your organization serve?
We serve virtually every type of patient population in Manhattan, Queens, Staten Island, Nassau, Suffolk and Westchester.
Why did you choose to participate as a partner of the SCC?
There are several reasons. As we're all moving towards valued-based care, we were interested in seeing what we could do to improve Transitions of Care for all of our patients but particularly our most vulnerable populations. It made sense for us to partner with the SCC as well as several other PPS organizations as we all embark on the journey of care redesign.
On which DSRIP project(s) will you be working and why?
I am leading a team for the Northwell hub on implementation of the Care Transitions project. I am also involved in behavioral health integration, and the PCMH team. As a system we are participating in almost all of the projects and have established a project management office to ensure coordination and integration of the various teams and workgroups.
Can you share some current TOC strategies that have been successful at your Health System?
Over the last two years, we've noticed that if we can have contact with inpatients during their stays, or if we can get introduced to them through providers they trust, that having that face-to-face engagement really helps patients to participate.
It's also critical to really understand risk stratification and who is the target audience. We look at making sure that the strategies we're deploying are aimed at those at the highest risk - the ones who need it the most. We are seeing better outcomes when we are able to include high-touch strategies among the higher risk populations.
What are some obstacles you've encountered with the TOC strategies that are currently in place?
What stands out the most - what we find the most challenging - is the IT infrastructure, and the ability to communicate across the continuum. With multiple systems in use across the various hospitals and community-based providers, communication from one location to the next can be challenging. As a result, workflows are sometimes cumbersome and lead to lack of staff efficiency.
How do you see the DSRIP TOC Program affecting or adding to the strategies in place?
I think the primary difference is that the program brings in a lot more diversity, which forces us to work with different partners. This is a great benefit. It gets all the stakeholders aligned, and gets everyone to move faster.
Can you share how was your experience in participating with the TOC Program Workgroup and the recent presentation from Dr. Amy Boutwell on Strategies to Reduce Avoidable Hospital Readmissions?
I found it extraordinarily helpful. It was nice to put faces with names. But mostly it was great being able to sit at the table and connect to the resources we will be working with on these projects.
Since this initiative is so new, we don't yet have all the answers. But, because there are many people working on it, being able to share knowledge and collaborate makes a huge difference. It puts all the stakeholders together and builds and fosters relationships that were previously established.
NYS DOH DSRIP Program Milestone Dates
||Final Approval of PPS Second Quarterly Reports
||Final PPS Second Quarterly Reports posted to DSRIP Website
|January 21 & 22
||DSRIP Project Approval & Oversight Panel Bi-Annual Meeting (NYC)
||Implementation of Phase I MAPP Performance Dashboards
||Second Performance DSRIP Payment to PPS
||PPS Third Quarterly Report (10/1/15 - 12/31/15) due from PPS
Office of Population Health
The SCC is pleased to invite qualified career seekers to apply for open positions. Whenever opportunities become available they will be posted
Job postings are available for the following career opportunities within the Office of Population Health at Stony Brook University Hospital administering the Suffolk Care Collaborative.
For more information, please contact the Suffolk Care Collaborative via
To access NYS DSRIP FAQ, click
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 DSRIP@stonybrookmedicine.edu then watch for the answer in a future issue of Synergy.