Issue 22
February, 2017
Welcome to Synergy
We are pleased to present the twenty-second 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
Suffolk County Diabetes Prevention Program (DPP) Targets Community at Risk for Developing Type 2 Diabetes
Trained Lifestyle Coaches Play a Key Role

In 2013, the Suffolk County Department of Health Services' Office of Health Education began offering the National Diabetes Prevention Program (DPP) to residents who are at risk for developing type 2 diabetes.  DPP is based on a research study led by the National Institutes of Health that concluded in the year 2000.  The study showed that with intensive counseling and motivational support, participants were able to make behavioral changes, reducing their risk for developing type 2 diabetes by 58 percent compared to the placebo group.  For participants 60 years of age and older, risk was reduced by 71%. 

Eligibility for the DPP is based on the diagnosis of pre-diabetes, as defined by a fasting blood sugar between 100-125 mg/dL, a HbA1c of 5.7% - 6.4% or two-hour plasma glucose (after a 75 gm glucose load) between 140-199 mg/dl or a history of gestational diabetes.  In addition, participants must have a BMI of at least 24 (or 22 for Asians).  According to the CDC, 86 million Americans have pre-diabetes and 90% of them are unaware of it.  A simple test can help determine pre-diabetes.  Patients can be directed here to take the test. Their score will determine if follow up is needed. 

In the DPP, trained Lifestyle Coaches work with participants for an entire year, 16 weekly sessions followed by 8 monthly sessions.  The goal is for each participant to lose 7% of their body weight and increase brisk physical activity to 150 minutes per week. 
Participants learn strategies for healthful eating and incorporating physical activity into daily life.  The coach helps group members identify emotions and situations that can sabotage their success, and the group offers support and encouragement to one another as they discover strategies for dealing with challenging situations. 

The Department was recently added to the CDC's registry of recognized diabetes prevention programs.  The award was based on demonstrating effectiveness by achieving all of the performance criteria detailed in the Diabetes Prevention Recognition Program Standards. 

In a new study in the American Journal of Preventive Medicine published online in November 2016, researchers found the benefits of the DPP are long-lasting.  After more than 10 years, the levels of moderate to vigorous physical activity were generally higher among DPP participants than a representative sample from another national survey. 

Two new DPP programs are scheduled to begin in Suffolk County in the Spring of 2017.  On Friday, March 17, an afternoon class will begin in Patchogue and on Monday, April 17, an evening class will begin in Hauppauge.  Participants must meet eligibility criteria and pre-register by calling 631-853-2928. 

In addition, the Department has received Master Training Status and will be offering the opportunity for individuals to become Lifestyle Coaches.  Anyone interested in this training should also call 631-853-2928 to learn more about what is required to become a coach. 

There may be financial incentives for health care institutions to have employees trained as DPP Lifestyle Coaches.  Starting in January 2018, Medicare will cover costs of the DPP for eligible at-risk beneficiaries with pre-diabetes 65 and older.  In addition, Medicaid patients and the agency providing the DPP may be eligible for incentives.

For more information, please contact Leslie Vicale, Project Manager, Clinical Improvement Strategy at the Suffolk Care Collaborative at 631-638-1398.  


Tuesday, March 21, 2017,
8:30 a.m. to 12 p.m.
Hyatt Regency Long Island
1717 Motor Parkway
Hauppauge, New York 

We're thrilled to share this quarter's keynote presentations and speakers:  
Alan Cooper, Ph.D, MBA, the founder and President of the Tudor Advisory Group, has over 25 years of experience in the area of strategic organizational transformation. His work is consistently aligned with an overarching emphasis on the achievement of an organization's strategic mission and goals.
In pursuit of the Statewide Health Information Network for New York's (SHIN-NY) mission to ensure fast, secure, and accurate access to patient data across the state to support the "triple aim," NYeC interacts with a diverse group of stakeholders, including regional health information organizations (RHIOs), government agencies and policymakers, health plans, providers, and consumers.  As Executive Director for the New York eHealth Collaborative (NYeC), Valerie Grey brings deep knowledge of these groups from her wide-ranging experience in both the public and private sectors.
Additional presentations by the SCC will provide membership with DSRIP program progress reports and performance measurement updates.   Click  here  for further details, meeting program and to register.

Register here today!  Space is limited. 
SCC Teams Up with Northwell Health's Center for Tobacco Control

The Northwell Health's Center for Tobacco Control (CTC) delivers tobacco dependence treatment programs to community members and employees in Nassau and Suffolk County. The CTC is grant funded by the NYS Department of Health Tobacco Control Program and engages healthcare organizational leaders to develop policies requiring that healthcare providers comprehensively treat their tobacco dependent patients.

Although the CTC attempts to engage all organizations, those who serve patients with low income, low education, and behavioral health disorders are specifically targeted. The CTC also provides tobacco dependence treatment education, training, and other resources for medical and behavioral health practitioners. The Center for Tobacco Control is working in collaboration with the Suffolk Care Collaborative on a number of DSRIP tobacco control initiatives, including increasing awareness and educating healthcare providers in behavioral health facilities about the evidence-based strategies designed to help their clients quit, including tobacco dependence treatment, tobacco-free environments, referrals to the NYS Smokers' Quitline, Medicaid benefits related to treating tobacco dependence, and the use of electronic health records to prompt providers to complete the 5A's of counseling. For more information about services provided by Northwell's Center for Tobacco Control or for assistance with tobacco cessation policies at your organization, contact Patricia Folan, Director at

To watch the recently recorded WebEx training entitled,  Tobacco Dependence and Cessation Treatment in Individuals with Mental and/or Behavioral Disorders, go to the  SCC's Learning Center and click on the Interventions for Tobacco Cessation Learning Module.  
Partner Interview
Name:  Andrea Spatarella, DNP, RN FNP-BC, CTTS
Title:  Nurse Practitioner
Organization:  Northwell Health Center for Tobacco Control

Please give us a summary of your organization.
The Northwell Health Center for Tobacco Control (CTC) is part of Northwell's Health Solutions. Northwell Health Solutions is responsible for Northwell Health's care management programs to support physicians and patients in coordinating care and delivering quality outcomes. Care managers include nurse practitioners, nurses, social workers, and other staff who assess patients to proactively identify needs, educate patients, and work collaboratively with providers to coordinate services. Tobacco cessation is one of the quality outcomes that will result in better management of chronic conditions.

The CTC receives grant funding from the NYS DOH Bureau of Tobacco Control. The main deliverable is to work with healthcare organizational leaders to develop policies requiring that healthcare providers treat their tobacco-dependent patients - especially those with the highest smoking rates, low income and education, and/or poor mental health - with evidence-based care. We then work with these organizations to implement these policies and provide technical assistance and resources. We are encouraged by the Bureau of Tobacco Control to work with our local PPSs on their tobacco-related projects. We also provide direct cessation assistance for groups or individuals, including practical counseling, FDA -approved cessation medications, relapse prevention strategies, and ongoing support.

How many PPSs are you working with and on which DSRIP projects?  
We are currently working with the Nassau/Queens and Suffolk County PPSs on DSRIP projects in Domains 3 and 4 with the following objectives:
  • Implementation of evidence-based best practices for disease management in adults with cardiovascular conditions and diabetes.
  • Initiate, promote, and drive opportunities for high quality tobacco cessation resources and services in both clinical and community settings, especially amongst low socioeconomic status populations and those with poor mental health.
  • Reduction in the use of substances such as alcohol, drugs and tobacco and other mental/emotional/ behavioral disorders across the population. 
In all of these DSRIP projects we are working with IT so that electronic health records (EHR) prompt providers to complete the 5 A's of counseling: Asking your patient about tobacco use, Advising them to quit,  A ssessing whether they're ready to quit, A ssisting them in quitting, and then A rranging for follow-up.

How do your organization's goals and mission align with the DSRIP program? 
Like DSRIP, our overall mission is to decrease tobacco use rates, particularly among individuals with low socioeconomic status and those with poor mental health, through the development of evidence-based treatment policies and tobacco-free environmental policies, incorporation of the 5A's into EHRs, education and training for healthcare professionals and other staff, facilitation of referrals to the NYS Quitline and other local resources, and promotion of Medicaid tobacco cessation benefits. By decreasing tobacco rates, patients will be less likely to develop other chronic and acute conditions that negatively impact their lives.

What types of educational/training programs does your organization offer for healthcare providers? 
The CTC has facilitated tobacco dependence and cessation treatment training programs in a variety of venues, with a singular purpose: To help health care providers become better acquainted with the evidence-based clinical practice guidelines for addressing the needs of their patients who use tobacco.

These include on-site, full-day programs as well as one- and two-hour training programs for nurses and MDs during Grand Rounds, Nurse Practitioners, medical residents on Long Island, nursing students from Molloy, Adelphi, Farmingdale and Stony Brook, diabetic educator champions, various FQHC's throughout Suffolk County, behavioral health professionals at Northwell Health and Zucker Hillside Psychiatric Hospital and their satellites, and agency-sponsored behavioral health facilities.

Many healthcare providers were never trained to treat patients with tobacco dependence, so we're working hard to ensure that for the next generation this is just an accepted part of their routine. A lot of this training occurs in-person, but we also have on our Northwell Health internet platform an educational program where people can get continuing education credit online. The SCC provides online education on their Learning Center geared toward specific populations, including behavioral health patients, pediatricians, pregnant women and adolescents.

What are some challenges faced by providers when it comes to treating tobacco dependence and how can they overcome them?
Many healthcare providers see "lack of time" as their greatest challenge, so it is important to share with them that even a very brief intervention at each visit can increase the chances of a patient making a quit attempt. Educating healthcare providers about the 5A's, the framework for the Clinical Practice Guidelines for Treating Tobacco Use and Dependence, and providing them with resources for follow-up can help them overcome this challenge.

Another challenge is healthcare providers don't know what to prescribe, and we can help them with that.  They often think that patients don't want to quit, yet research shows that 70% of people who smoke say they want to quit but they're afraid it's going to be too hard. But we know that with a combination of counseling and cessation medication, tobacco users are 2-3 times more likely to succeed at quitting.

Describe some of the special populations physicians and healthcare providers should be aware of when it comes to promoting tobacco independence.   
The highest prevalence of tobacco users is among individuals with low education, low income, mental illness, or a history of other substance abuse. There is also a high prevalence among the LGBT community and the HIV-infected population.

How do you see the Suffolk County Tobacco Cessation Coalition initiatives making an impact on how providers treat their tobacco dependent patients?
Through the work of the Suffolk County TCC, we can increase awareness and educate healthcare providers in behavioral health facilities about the evidence-based strategies designed to help their clients quit, including treatment and tobacco-free grounds. Through education and ongoing dialogue, we can also help them change the culture around tobacco use in the behavioral health setting, which historically encouraged smoking in this population. 

The Suffolk Care Collaborative would like to invite anyone interested in working on tobacco control initiatives within Suffolk County to contact:
Alexandra Kranidis by phone, 631-638-1772 or email
Community Health Activation Program Training Goal Met Through CBO Partner Collaboration

The SCC is proud to announce that through our partnerships with several community-based organizations, over 350 health care workers have become PAM Providers as as part of our Community Health Activation Program (CHAP) .

CHAP is focused on persons not utilizing the health care system and works to engage and activate those individuals to utilize primary and preventive care services. Community H ealth Workers (CHW), have been educated on Patient Activation Measure ( PAM®), the PAM® Survey Tool, PAM® Coaching for Activation and the Community Navigation Program.  CHWs assess individuals using PAM® to determine their knowledge, skills and confidence for managing their health and health care.

A special thanks to our partners that performed the training classes:

Halim Kaygisiz, Director of Health Outreach Services
Economic Opportunity Council of Suffolk, Inc.

Julie Niemann, Strategic Account Executive
Insignia Health

Tara Fredericks, LMSW, Director of Special Projects
Association for Mental Health and Wellness

Trevor Cross, Community Liaison

C ongratulations to everyone that was involved in reaching this goal!
SCC's INTERACT Program Regional Performance Improvement Workgroups Making Strides
An In-person Setting for Collaboration Amongst Hospitals and Nursing Homes

2017 brings changes in the way the INTERACT Project Workgroup
Southside Hospital Workgroup Meeting
meetings are facilitated.  We have been conducting INTERACT Workgroups through monthly WebEx meetings, with participation by all skilled nursing facilities implementing the 
INTERACT Program. 

Beginning 2017, the SCC has initiated Regional Performance Improvement (PI) Workgroups.  The goal of these workgroups is to further relationships and communication lines, dive into the issues impacting re-hospitalizations, collaborate on solutions, and identify best practices.  Further, the Regional PI Workgroups set the stage for performance improvement activities at the most practical level to support improvement across the SCC's clinical outcome metrics.
Peconic Bay Medical Center  Workgroup Meeting
Workgroups include Emergency Department Physicians, Hospitalists, and Care Management on the hospital side; Administrator, Director of Nursing and Medical Director on the SNF side.   The initial agenda was universal, based on take-aways from prior Learning Collaboratives.  Future agendas will  be generated from next steps, intiatives and topics the workgroups identify regionally.

We would like to thank the following hospitals for hosting this quarter's workgroups:  Southside Hospital, Huntington Hospital,  Peconic Bay Medical Center and Mather Hospital.   We will be reaching out to the other Suffolk County hospitals to host next quarter.  In addition, we will be integrating the Transition of Care Project Workgroup (DSRIP project 2biv & 2bix) into these meetings beginning May 2017.

Quality Assurance & Improvement Program Action Plan Results
The Suffolk Care Collaborative Interventions to Reduce Acute Care Transfer (INTERACT) Program had initiated Quality Improvement & Assurance Activities in the fall of 2016, as described in the SCC Quality Improvement & Assurance Plan.

The Action Plan Results Report 1 reflects the performance improvement activities for participating Skilled Nursing Facilities (SNFs) of the INTERACT program for DY2Q3-Q4.   Each participating SNF had submitted an Action Plan, results are aggregated and shared amongst the project community. The report includes SNFs identified area for improvement, performance improvement focus areas and action plan tasks created to operationalize improvement activities in 2017.
Key highlights from the report include: 
  • 23 participating SNFs completed the Quality Action Plan between December 2016 - January 2017.
  • Through the Regional PI Workgroups, on-site visits and calls, SNFs submitted the PI Action Plan. 
  • The quantitative data represent findings compiled from the data submitted via Qualtrics.
  • Approximately 50% of participating SNFs reported areas of improvement in decreasing sepsis hospitalizations or reduction of falls.
  • 65% of participating SNFs reported areas of improvement related to decreasing hospitalizations.
  • A total of 66 performance improvement focus areas were identified across all participating SNFs. Early warning signs of sepsis/UTI, Communication and INTERACT Tools were the most frequently selected PI focus areas accounting for 65% of the total.
  • In total there were 49 action tasks identified. Staff In-service/Education was the most prominent action task category at 25% of the total, followed by Sepsis Interventions at 7% of the total.  
In future publications, the INTERACT Program will share progress across the INTERACT Quality Assurance & Improvement Program. We would like to thank all participating skilled nursing facilities for completing the initial Action Plan and participating collaboratively in performance improvement efforts.
Compliance Connection
Take the test to see if your organization is required to have a Compliance Program. 

1.    Is your organization subject to Article 28 or 36 of the NYS Public Health Law?
Yes ___           No ___

2.    Is your organization subject to Article 16 or 31 of the NYS Mental Hygiene Law?

Yes ___           No ___


3.    Does your organization claim or order at least $500,000 from Medicaid in any consecutive 12-month period?

Yes ___            No ___

4.    Can your organization reasonably expect to claim or order at least $500,000 from Medicaid in any consecutive 12-month period?

Yes ___        No ___

5.    Does your organization receive Medicaid payments-directly or indirectly-of at least $500,000 in any consecutive 12-month period?

Indirect means any payment or portion of a payment made under Medicaid and received by a person or affiliate that comes from a source other than directly from the New York State Department of Health, such as, but not limited to, a Managed Care Organization payment, whether or not it is in return for care, services, or supplies furnished to an individual who is a recipient under Medicaid.
Yes ___        No ___

6.    Can your organization reasonably expect to receive Medicaid payments-directly or indirectly-of at least $500,000 in any consecutive 12-month period?

Indirect means any payment or portion of a payment made under Medicaid and received by a person or affiliate that comes from a source other than directly from the New York State Department of Health, such as, but not limited to, a Managed Care Organization payment, whether or not it is in return for care, services, or supplies furnished to an individual who is a recipient under Medicaid.
Yes ___        No ___

7.    Does your organization submit Medicaid claims of at least $500,000 in any consecutive 12-month period on behalf of another person or persons?

Yes ___       No ___

If you answered Yes to any of the above questions, then you are required to have a compliance program under New York State Social Services Law Section 363-d and 18 NYCRR Part 521.  Please click here to go to the Frequently Asked Questions (FAQs)-NYS Mandatory Compliance Programs.

If you answered No to all of the above questions, then you are not required to have a compliance program under New York State Social Services Law Section 363-d and 18 NYCRR Part 521.

This chart is a self-assessment tool and is not meant to be submitted to OMIG.  Contact the SCC Compliance Office at if you need help or have any questions.
Milestone Dates
NYS DOH DSRIP Program Milestone Dates

 March 3               Independent Assessor provides feedback to PPS on PPS Year 2
                             Third Quarterly Reports; 15-day Remediation window begins

 March 10             PPSs complete Mid-Point Assessment Action Plans for Mid-
                             Point  Assessment Project Plan modifications and submit for 
                             IA review  and approval

 March 17             Revised PPS Year 2 Third Quarterly Reports due from PPS; 
                             15-day Remediation window closes

 April 1                  Final Approval of PPS Year 2 Third Quarterly Reports

 April 1                  DSRIP Year 3 begins

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. Director, Care Management
  2. Director, Care Transition Innovation *Revised Job Description
  3. Compliance Officer
  4. Care Manager
  5. Data Visualization Analyst
  6. Social Worker
  7. Community Health Associate
  8. Project Manager (PCMH Practice Facilitation)
  9. Population Health Platform Training and Support Specialist
  10. Data Acquisition Analyst
  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.