Issue 10
February 29, 2016

Welcome to Synergy


We are pleased to present the tenth 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
Care Management Organization Spotlight
The SCC has initiated care management and care coordination efforts

In July of 2015, the Suffolk Care Collaborative (SCC) entered into a strategic arrangement with xG Health Solutions, the consulting firm associated with Geisinger Health System, to support the development of the SCC Care Management Organization (CMO). The purpose of the SCC Care Management program is to provide care management/care coordination services to SCC partners who are not already engaged in a care management program for their patients. The SCC care management team will focus on high risk, complex needs populations including behavioral and social determinants of health.  

Kelli Vasquez, LCSW, joined the SCC in December as Director of Care Management and Care Coordination in conjunction with the SCC Medical Director, Linda S. Efferen, MD and xG Health Solutions, established a patient centered, collaborative approach to connecting patients with the services they need across the entire continuum of care while reducing barriers to care. The CMO has adopted an Embedded Care Management model which places a RN Care Manager in high need partner provider sites. Patients are identified for enrollment into the program through a risk assessment strategy as well as by direct referral from providers. A comprehensive assessment as well as social histories screen are completed on all referred patients.   The embedded model allows for the Care Managers to meet with patients and families while they are in the provider office, as well as to deploy community outreach as necessary to address social determinants of health .  A team approach to care is used with both Community Health Associates and Social Workers available to meet with patients in the community, whether in their homes or at local community based organizations.  The embedded Care Manager becomes an integral member of the practice team and works directly with patients identified by providers as having unmet needs. This is a personalized, patient centric approach which fosters enhanced communication and coordination amongst the care team.

The SCC Care Management team participates in a comprehensive care management training prior to being deployed to a practice site. All staff receive a two day orientation, followed by eight days of modular based learning with content provided by xG Health Solutions/Geisinger Health System. Care Managers are then immersed in a two week training at Geisinger in Pennsylvania where they have an opportunity to shadow experienced care managers and gain insights that can be translated to their work with SCC. The Community Health Associates and Social Workers receive one week of this training in their respective disciplines.  

To date, the SCC CMO has deployed care managers to three practice sites, Stony Brook Family Medicine (East Setauket and Patchogue locations) as well as Stony Brook Children's Services (Islip Terrace). Early successes in patient outcomes and patient satisfaction have already been noted. We are excited to continue our growth and develop new partnerships as we support patients throughout the continuum of care.

In addition to the embedded model, the SCC CMO is embarking on a 30-day Transition of Care (TOC) Service model. This model will embed a RN Care Manager with partner hospitals allowing for a face to face interaction with patients pre-discharge.  Based on need, the TOC CM may support the patient during the 30 day post-discharge period or support warm hand offs to Health Homes, Managed Care Organizations, or other care management providers across the PPS. The purpose of this TOC Service model is to assist in the prevention of avoidable readmissions, while offering patients support, education, and assistance during this transition.

SCC Partners Care Coordination & Care Management Workgroup
The Suffolk Care Collaborative will be hosting the second meeting of the Care Coordination and Care Management workgroup this month. This group is comprised of key stakeholders in the field which include representation from partner hospitals, SNFs, Health Homes, Home Care, CBOs, Care Management Organizations, and social services organizations. Together, this group is charged with informing the Population Health Management/Integrated Delivery System Steering Committee regarding strategies for implementation of a coordinated care model across the care continuum for Suffolk County patients. The goal of this workgroup is to develop a program that allows patients to be transitioned effectively throughout the entirety of the continuum of care including through acute care, SNF transfers, home care, Health Homes, hospice and palliative care, Accountable Care Organizations, and Care Management Organizations.

Building a Suffolk County Transition of Care Model
As previously shared, the SCC has engaged Dr. Amy Boutwell, founder of Collaborative Health Strategies, to assist with the development of a PPS-wide TOC and Observation Model. Dr. Boutwell is the co-founder of the STAAR (State Action on Avoidable Re-hospitalizations) Initiative of the Institute for Healthcare Improvement as well as a senior physician consultant to the National Coordinating Center for the CMS QIO Care Transitions Theme. She has been working to engage in community-based transitions efforts across the 50 states and has published several reports on reducing readmissions and barriers to care. It is with this wealth of experience in the area of Transitions of Care, that Dr. Boutwell comes to SCC to assist in the development of a strategy that can be implemented in each of the SCC partner hospitals.

TOC Project Committee Meeting
February 10, 2016
On February 10th, a meeting of the TOC/OBS Committee was held at the Islandia Marriott. The committee represents each of the 11 partner hospitals as well as key stakeholders in the areas of skilled nursing facilities, home care , CBOs, pharmacy and care management organizations. Together, and led by Dr. Boutwell as the Subject Matter Expert, the committee engaged in a 4hour working session to develop a means to identify high risk patients as they present to the hospital and navigate them through their 30-day transition of care. The work completed in this committee demonstrated a true collaboration and this model will be finalized and ready for implementation in the coming quarter.

The SCC CMO Transitions of Care model will align with efforts created in the TOC/OBS Committee and help support our partner providers in navigating their patients through the crucial 30 day post-hospitalization period.
AHRQ Releases 2nd Edition of Health Literacy Toolkit

The AHRQ (Agency for Healthcare Research and Quality) Health Literacy Universal Precautions Toolkit, 2nd edition, can help primary care practices reduce the complexity of health care, increase patient understanding of health information, and enhance support for patients of all health literacy levels.  The SCC's cultural competency and health literacy efforts are aligned to the toolkit.  Our priorities include developing a culturally competent organization, a culturally responseive system of care, and promote health literacy.  

New with the 2nd edition of the toolkit are:
To download a copy of the AHRQ Health Literacy Universal Precautions Toolkit, 2nd edition, go to 

Find out about more AHRQ health literacy resources at Health Literacy Topics
Capital Restructuring Finance Program 
Awards Announced

This week, the State-funded capital awards under the $1.2 billion Capital Restructuring Finance Program (CRFP) and $355 million Essential Health Care Provider Support (EHCPS) Program were announced by the Governor's office.  Click here to view all award recipients throughout the State.
Partner Interview
Name: Patricia Pederson, RN
: Nurse Manager 
Organization : Stony Brook Family, Population, and Preventive Medicine

Please give us a summary of your organization
We're a family medicine practice as well as a residency program training site currently. We handle everything, as the saying goes, from womb to tomb. Which is from low-risk obstetrics, bringing those patients into our practice as babies, all the way through end-of-life care.

How many doctors are in your practice? 
We have a total of 16 attending providers at two practice sites and 5 residents in their third year of training.  We are recruiting for two additional physicians and two Nurse Practitioners or Physician Assistants.  We also have two Social Workers and two nutritionist who see patients in our department.  Stony Brook is transitioning its family medicine residency to Southampton to better serve the population farther out east and provide primary care which they are in need of on the east end. So the last five residents, who started in our site here in Setauket, will graduate in June and we'll then be a fully attending practice. 

Who does your practice serve? 
We have patients from many diverse ethnic and socioeconomic groups. It's really a varied population, because we serve the university and that's a multicultural, multi-ethnic university and the communities at large. Long Island is a melting pot so we see a lot of different patients, which is nice.

What do you hope the DSRIP program will accomplish for your organization in the future?
Well, I hope in general, not just for my organization, that DSRIP will basically be able to deliver more comprehensive healthcare to our patient population. Because DSRIP's population is small, and from what I would think, it is just a step for a bigger model. Basically, I think it helps us to provide highly individualized care and more comprehensive care for our patients and I think it helps a particular population, at this point in time, navigate a sometimes very confusing health care system.

Your Practice has embedded Care Managers through the Suffolk Care Collaborative Care Management Organization. Can you speak to the benefits you've seen in your practice since this addition? 
Yes, it's great! We have our own Care Managers, or Care Coordinators, as we refer to them. Because we're a patient-centered medical home we perform those services that the embedded Care Managers provide. The DSRIP program supports Medicaid, Managed Medicaid and dual eligible patients and the SCC Care Managers work with high-risk patients within that group. And they work hand-in-hand with our Care Coordinators, which is great because it has really allowed, at the patient level, for patients to have their specific needs addressed. Because there's different gaps in care and different barriers that prevent patients from obtaining services that they need, a provider can walk right down to the embedded Care Manager and say "Listen, I have this patient, I just got these results, they need to have this, this, and this done but they don't have transportation or they just don't know where to go or they don't have the technological savvy to navigate through online systems or whatever the issue may be. Can you reach out to this patient?"

And the embedded Care Managers are paired with a Community Health Associate (CHA) who is someone in the community who is not necessarily a healthcare professional. They can help patients at the community level and they work together. If the Care Manager identifies an issue they can reach out to the CHA for support. As an example, if a patient needs to have medications, and they've been phoned into the pharmacy but the patient hasn't picked it up and the patient has no transportation we can move those prescriptions to a pharmacy that delivers. For other patients housing or access to healthy food may be an issue. They find out what the barriers are and look to find solutions. You take away that barrier to that patient's healthcare.

What do you feel the benefits of the Care Management are your patients specifically in your practice since this addition?
I think it's beneficial to the patient at the provider level and at the care delivery system level in that it helps that patient navigate the system that could otherwise be too overwhelming. For someone who may be homeless - how can they search for programs or find a solution? So someone who has that wherewithal is able to do that for them and they also make assessments as to what additional needs the patient has. 

Identifying literacy issues. As we bring a patient in for a visit we share forms with them. Asking someone "Would you like me to read it to you?" may allow for someone to share that they cannot read. The provider and other members of the team being aware of this as an obvious obstacle to receiving comprehensive healthcare alerts the team to deliver information verbally or visually because written instructions are not helpful. 

If we know what the barriers are it goes a long way toward helping us help the patient overcome it.

What Gaps and barriers, if any, you feel will be closed through the DSRIP program and Care Management? 
Well, gaps in care are really barriers such as language, technology, education, and socioeconomic concerns that the patients face. Providing access to good medical care and working to close those gaps, the Care Managers work to get patients "hooked-up," for lack-of a better term, with the services that they need, so that they can be healthier. And if you're healthier, then life's better. 

It's a philosophy that, in practice, is absolutely ideal. It's the way healthcare should be delivered. Each person should have individualized, comprehensive healthcare available to them, regardless of language, of education level, or socioeconomic background. This works to overcome barriers and evens the playing field for everyone.

Is there anything you'd like to add? 
Only that this program is how we should deliver healthcare, always. There is, obviously, an underserved population. We're all healthcare providers here, and we do what we do because we want to take care of and support our patients. That's what we want to do and for any program that makes that better, for us, and for the patients, that's a win right there.
Compliance Connection

In the healthcare provider context, compliance programs focus heavily on billing, coding, and contracting.  But a PPS is a unique and new kind of health organization, so what does SCC's Compliance Program do?  Of course, we cover the 8 elements required by SSL 363(d) and 18 NYCRR 521, and as DSRIP evolves, our program adapts to program phases.  Please visit our webpage for hotline information, policies & procedures, compliance tra ining materials, and HIPAA documents.  Starting with this issue, Synergy will feature key compliance program information in this column.  Questions or concerns?  Contact SCC Compliance Officer Sarah Putney at (631) 638-1393 or .   
Milestone Dates
NYS DOH DSRIP Program Milestone Dates 
Mid-Late February
Phase II DSRIP Notice and Opt out letters mailing to Medicaid members begin
March 1
Deadline for Independent Evaluator RFP Submission of Proposals 
March 2
Independent Assessor provides feedback to PPS on PPS Third Quarterly Reports; 15-day Remediation window begins
Mid March
Public Comment period for Mid-Point Assessment closes
March 16
Revised PPS Third Quarterly Report due from PPS; 15-day Remediation window closes
Late March
Release revised draft Value Based Payment Roadmap for Public Comment
March 31
Final Approval of PPS Second Quarterly Reports
March 31
DSRIP Year 1 ends
April 1
DSRIP Year 2 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. Whenever opportunities become available they will be posted here.
Job postings are available for the following career opportunities within the Office of Population Health at Stony Brook University Hospital administering the Suffolk Care Collaborative.

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 recently launched SCC website, which houses a wealth of resources including individual program webpages, presntations, 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.