Issue 21
January, 2017
Welcome to Synergy
We are pleased to present the twenty-first 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

Cultural Competency and Health Literacy 
Going Beyond CCHL 101 Master Training

Long Island communities are growing in diversity.  The need to incorporate cultural competency and health literacy standards into practice has become essential in providing exceptional patient-centered care. The Long Island Health Collaborative (LIHC), Population Health Improvement Program (PHIP), Nassau Queens PPS (NQP) and Suffolk Care Collaborative (SCC) have partnered with Dr. Martine Hackett from The National Center for Suburban Studies at Hofstra University, Suburban Health Equity Institute, to implement a regional Cultural Competency and Health Literacy (CC&HL) training program for community-based and social service organizations, local health departments, hospitals, health professions and providers.

The program is aimed at enhancing CC&HL awareness and providing additional resource information and tools to our partners. The curriculum includes the role of social determinants of health, unconscious bias, how the National CLAS standards can help reduce health disparities, how to apply cultural humility in community-serving organizations, the components of health literacy and the utilization of health literacy strategies.
This FREE CC&HL Master Training provides participants with a cultural competency and health literacy toolkit, access to didactic presentations and valuable resources to induce positive culture change within organizations. Master Trainers are certified to host two types of training sessions: 2 hour CC&HL training sessions for workforce professionals and full-day Master Training sessions for future Master Trainers. Due to the interactive nature of this training, a maximum of 30 participants per session will be selected to attend. Preference will be given to those applicants who work regularly with under-served populations within their professional roles, allowing for a diverse network of organizational leads to be trained. 

Earlier last month, CC&HL Master Trainer, Halim Kaygisiz, Director of Health Outreach Services of the Economic Opportunity Council (EOC) of Suffolk, led a successful workforce training session. Halim shared some of the positive results, "Based on feedback, training was successful. Even in one of the evaluations, someone commented that they liked how I made them apply it to their everyday workflow. I have learned that when you know your audience, you can personalize the training to them...and that goes a long way!"

The next CC&HL Master Training class will take place on March 22 at the SCC office in Hauppauge.  Registration for upcoming classes will be available soon.
Core Curriculum Guidelines for Practice Sites Published

The SCC is proud to announce the publication of our new Core Curriculum Guidelines for all participating Primary Care Provider Practices.  This document includes training requirements  for participating practice sites with many of the learning modules linked directly to the SCC Learning Center, enabling completion online.   Each learning module has an overview, and each training topic has learning objectives with recommended audience to be trained.  PCP sites may utilize the curricula to train practice staff in a "Train the Trainer" approach.  In that case, the practice site utilizes a Sign-in Sheet and when all required training is fulfilled, the practice completes the Training Attestation Form and returns to SCC.  Both documents are found in the Core Curriculum.  

Most of the curricula was designed based on national literature reviews of training provided around the country and vetted through appropriate key internal stakeholders.  This  g uide has both required learning topics and recommended resources for practice site training and was designed to position primary care organizations for successful participation in the DSRIP program. It will serve as a training foundation to foster a consistent base of knowledge on the system transformation, clinical improveme nt, population-wide programs, patient education, care coordination, and many more. We believe using this tool and completing the training topics will enhance the effectiveness of the services provided at the practice site. 
The Core Curriculum Guidelines for Practice Sites is available on the Publications and Plans page of our website.  This page also includes plans and toolkits for the SCC's many projects and initiatives.
Partner Interview
Name:  Patricia Bax, RN, MS
Title:  Marketing and Outreach Coordinator, New York State Smokers' Quitline, Roswell Park Cessation Services,  Department of Health Behavior
Organization:  Roswell Park Cancer Institute

Please give us an overview of your organization and its role in the NYS Smokers' Quitline Initiative.

Roswell Park Cancer Institute (RPCI) in Buffalo, New York, has operated the New York State Smokers' Quitline (NYSSQL) since its inception in 2000. Currently all states have a Quitline, with the NYSSQL being one of the first and busiest state Quitlines in the US. We have responded to over 2.2 million calls, providing cessation services, including evidence-based telephonic coaching and access to nicotine replacement therapy (NRT).  

The NYSSQL's accompanying Quitsite at provides easily accessed tools and resources including videos, downloads, chats and forums to help tobacco users quit. In addition, cessation support information is available for health care providers, employer groups and the general public.

We also work with an array of NYS health care providers, assisting with and promoting NYSSQL services as a source for cessation expertise and support for health care systems change.

What Delivery System Reform Incentive Payment (DSRIP) projects have you been working on?

Although not all DSRIP programs have selected tobacco cessation as one of their projects, we have worked directly with over 10 projects in Domain 4 specific to tobacco use to meet deliverables. In addition, because the health effects of tobacco are extensive, we've been able to help DSRIP projects that have selected goals around cardiovascular health.  

We're poised and ready to assist any NYS DSRIP project that has need for information about tobacco cessation and we continue to receive interest from our DSRIPs and Performing Provider Services (PPS) on a regular basis.

How do your organization's goals and mission align with the DSRIP program?

DSRIP's statewide initiative aims to significantly improve the way medical care is delivered to Medicaid and uninsured patients by establishing a large network of collaborating health care providers. The NYSSQL is an evidence- and population-based program that aligns with these DSRIP principals. 

Tobacco use is one target of the DSRIP program and the NYSSQL is a hub for tobacco cessation information, resources and access for all NYS residents. Although adult smoking rates in NYS have declined, prevalence of tobacco use remains disproportionally high among Medicaid members, the uninsured, and those with mental health and chronic health conditions; and these are the people most frequently accessing Quitline services. This is the same group that DSRIP is trying to work with, so we also align in working with the same population.

Additionally, RPCI's outreach for the NYSSQL has focused on building relationships with NYS health care providers and stakeholders, including health care sites, Medicaid Managed Care Plans, Commercial Health Plans, County Health Departments and DSRIP programs. We recognize the need for collaboration in working with entities all across the state to meet the requirements of a Triple Aim Initiative: improving the patient experience of care, improving the health of populations and reducing the per capita cost of health care.

Tell us more about the Quitline and where to find more information about the Quitline.  

The NYSSQL is a lifeline for NYS smokers wanting to quit, providing free, confidential services including information, tools, evidence-based coaching and an offer of free NRT for those eligible.  Services are offered in English and Spanish, with access to a language translation line, as needed.

Quit Coaches offer tobacco users help for all stages of the quit process:  motivation, relapse support, education on NRT, and eligibility screening for a free 2-week nicotine patch starter kit. Our coaches are trained in motivational interviewing, using an empathetic approach and open-ended questions to increase dialogue around their quit plan. They help tobacco users feel connected to the Quitline, so in addition to support from their provider, family and friends, they can also reach out for reinforcement to become and stay tobacco free.

With the advent of the Affordable Care Act, more health plans are covering stop smoking benefits like medications and provider counseling, and more people are insured to utilize these services. Our coaches provide education and stress the importance of tobacco users accessing their health plan benefits in addition to receiving Quitline services. Coaches also do their best to encourage participants to discuss their quit plan with their provider(s) for additional cessation support and follow-up.

The Quitline also works with employers, health plans and health care providers - anyone in NYS with any interest in tobacco control and tobacco cessation - to ensure all New York tobacco users have access to effective cessation treatments. Whatever the need, the Quitline is a good place to start, because if we don't have the answer or solution, we can connect individuals to someone who can help.

Tobacco users can contact the Quitline directly at 1-866-NY-QUITS (1-866-697-8487) or be referred by their provider. Further information on the Quitline is available on our website.

How have you collaborated with the Suffolk County Tobacco Cessation Coalition?

RPCI works with DSRIP Project Teams, including the Suffolk County Tobacco Cessation Coalition, to implement Provider Referral Programs as a component of Public Health Service Clinical Practice Guideline implementation and health systems change.
PPSs across the state are adopting and implementing our Opt-To-Quitâ„¢ referral program, in which a sustainable system-driven policy ensures all patients identified as tobacco users are referred to the NYSSQL for post-care cessation help, unless they opt out. It is an adjunct program to enhance onsite cessation interventions. We work with each facility to set up the program, assisting with training, policy development and data exchange. We can even work to incorporate it into a system's Electronic Health Record (EHR) as an automatic data exchange to facilitate follow-up.
Collaboration with the coalition has resulted in more providers and healthcare systems prioritizing tobacco cessation interventions and learning about RPCI services, including the Quitline and Provider Referral Services.
How do you see the Suffolk County Tobacco Cessation Coalition project making an impact on the communities, workforce and population we serve?

We all share the same goal: to create a healthier environment by motivating tobacco users to make a quit attempt and providing access to services to make it successful.
To achieve these goals using a population-based approach, we have to stretch our resources as far as we can to reach as many people as possible. Through collaboration, members of the Coalition can leverage resources, avoid duplication of effort, and maximize the skills and talents of members to achieve "Best Practices" in tobacco cessation.  Tobacco users in Suffolk County will benefit from increased awareness and access to cessation resources, thus helping support a decrease in tobacco use prevalence. Reinforcement of key cessation messages by all involved in the Coalition project especially enhances the ability to reach under-served populations, including Medicaid members and those with mental and behavioral health issues.
Smoking is the No. 1 preventable cause of death. Over 28,000 adults in New York die each year due to tobacco-related disease.  In addition to lives lost, the annual smoking-attributed costs in NYS* include $10.4 billion in health care costs, $3.3 billion in health care expenditures covered by NYS Medicaid, and $7.3 billion in lost productivity.

*Campaign for Tobacco-Free Kids. (September 25, 2015). The Toll of Tobacco in New York facts can be found here.

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
Promoting Integration and Engagement through Partnership with NYS Smokers'  Quitline
The New York State Smokers' Quitline is a free and confidential program providing evidence-based stop smoking services to New York State residents who want to stop smoking or using other forms of tobacco. This lifeline for NYS smokers allows potential quitters to access live coaching support over the phone, seven days week. The Quitline is based at Roswell Park Cancer Institute in Buffalo, NY, and is funded by the New York State Department of Health Tobacco Control Program.  The Suffolk County Tobacco Cessation Coalition, a group formulated by the Suffolk Care Collaborative (SCC), has partnered with the NYS Smoker's Quitline to promote its services through the SCC's integrated delivery system. With assistance from Patricia Bax, RN, MS, Marketing and Outreach Coordinator, NYS Smokers' Quitline and Roswell Park Cessation Services, the SCC has begun targeted efforts to engage our partner primary care practices. The Suffolk County Tobacco Cessation Coalition, which meets bi-monthly, is continually gathering promotional  educational materials for our partners and the Suffolk County community.  Ms. Bax serves as an expert and content lead on the Coalition and has recently conducted a webinar regarding the NYS Smokers Quitline, which can be found on the SCC Learning Center . More information about the Quitline can also be found  online .
SCC Wants to Hear from You
Upcoming PAC Meetings

We are planning future Project Advisory Committee (PAC) meetings and would like to hear your suggestions on topics of interest and importance to you and your organization.   Your input is vital.  Please email us your ideas at
INTERACT Spotlight:  CMS Recognizes Good Samaritan Nursing Home
Frank Misiano, MPA, CAO/Administrator, and Diane Guidone, RN, Director of Nursing

Good Samaritan Nursing Home in Sayville, an engaged participating Skilled Nursing Facility in the  INTERACT Program, has received an award from Centers for Medicare & Medicaid Services (CMS) for extraordinary effort and outstanding work in implementing the Centers for Medicare and Medicaid Services' Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents through Greater New York's Hospital Foundations New York-Reducing Avoidable Hospitalizations (NY-RAH) Model.

Out of their 100 beds, Good Samaritan has 85 long-term residents.  Diane Guidone, RN, Director of Nursing, said "The Certified Nurse Aides (CNA) and nursing team know and treat their residents like family."  She attributes their success to her team's ability to recognize early changes in their residents' condition.  Diane also said, "We have developed sub-committees to monitor weight loss and falls.  Once we recognize the resident is beginning to fail, we engage the family on palliative care discussions."

Frank Misiano, MPA, CAO/Administrator said, "Our stable staff knows the residents incredibly well.  When the CNAs notice deterioration in their resident, the communication to the nurses is so tight."

Congratulations to the Good Samaritan Nursing Home Team on this recognition!!
Preparing for CCTM Certification Exam
Review, Repeat, Review, Repeat.....

In September, The Suffolk Care Collaborative engaged 25 RNs to participate in the American Academy of Ambulatory Care Nursing (AAACN) Care Coordination & Transition Management (CCTM) certification course review, in preparation to sit for the certification exam sometime in March. The curriculum consists of 13 modules which the group completed in December.
Suffolk County's 11 hospital partners selected RNs to participate in the certification process. Jennifer Kennedy, RN, BSN, MS, Director for Care Transition Innovation at the Suffolk Care Collaborative coached the group thr ough the online modules and preparation for the exam.
The group now meets for evening review sessions held at SCC. They have found it to be a positive way to reinforce their own preparation.
Jen Kennedy said, "These ladies and gentleman have shown such commitment to this course and exam preparation, even as it extends past their long, busy work hours.  I know each of them will be taking hom e the certification!"
As you march towards this mission, SCC would like to wish you victory!!

Care Coordination Transition Management RN
Review Group
Compliance Connection
Data Integrity: A Contractual and Compliance Expectation

We have been sending the message to our partners in our quarterly Data Request webinars that data integrity is a compliance issue.  Why?  Here are 3 key reasons:
  • Because partners are paid based in part on patient engagement reports.
  • Because ethical stewardship of DSRIP dollars requires ensuring that payment is based on accurate data.
  • Because errors, weaknesses (and fraud) can be identified through quality assurance/quality control measures.
Did you know that partners "sign up" to the promise of data integrity?  It's true.  In the Participation Agreement that each partner signs with the SCC, the following provisions address data integrity:
1.3 Truthful Reporting
In this section, partners agree that all data related to quality, performance and other DSRIP purposes shall be true, accurate and complete.  Upon SCC's request, partners shall certify to the truth, accuracy and completeness of the data they submit.
5.2 PPS Audits
Partners agree to assist SCC with audits of their operations to ensure compliance with the Participation Agreement, including satisfaction of performance measures, right to DSRIP funds, data security, etc.  Note that audits can include data-related and other reporting processes, not just financial information and internal controls.
6. Record Retention
Partners agree to keep complete and accurate records and supporting documentation sufficient to enable audits, that is 3 years after Agreement ends or longer if required by law.
Partners also agree to furnish SCC information concerning any compliance issues you identify and to work cooperatively with SCC to remediate any compliance issues, giving reasonable access to your operations for this purpose.
Milestone Dates
NYS DOH DSRIP Program Milestone Dates

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

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

 Late January       DY2 First DSRIP Payment to PPS

 March 3               Independent Assessor provides feedback to PPS on PPS Year 2
                             Third Quarterly Reports; 15-day Remediation window 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. Care Manager
  2. Data Visualization Analyst
  3. Social Worker
  4. Community Health Associate
  5. Project Manager (PCMH Practice Facilitation)
  6. Population Health Platform Training and Support Specialist
  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.