Issue 9
January 31, 2016

Welcome to Synergy


We are pleased to present the ninth 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
DSRIP Project Pages are Live!

We invite you to visit our website to view our new DSRIP program webpages. The webpage provides our objective statement, project manager, lead and workgroup/committee directories, project documents and key resources which inform program design. As our programs grow, we'll look to continue to post key resources to promote, engage and share pertinent information to the public. For more information about a particular program, please feel free to contact our DSRIP Project Managers highlighted on each page.

Click  here to navigate to the program page index. 
Organizational Work Stream Engagement Highlights
In addition to the eleven DSRIP projects, there are organizational work streams as part of NYS DOH DSRIP Program requirements.

The SCC has established a governance structure reporting and monitoring process, outlined in a new SB Clinical Network IPA, LLC Governance Guidelines & Governance Review Plan, which was approved by the SCC Board of Directors on November 16, 2015. The goal of this framework is to formalize the following: description of processes used by the PPS to establish reporting and ongoing monitoring progress and to identify potential risks, description of the frequency of reporting processes, description on monitoring processes to be carried out by the PPS, description of the DSRIP requirements as content for the performance dashboards, role of the Board of Directors in continuous improvement.  

The Suffolk Care Collaborative (SCC) reconvened the Workforce Advisory Group and Workforce Governance Committee to review our plan for achieving Workforce milestones and discuss the workforce strategic plan approach in collaboration with KPMG, the workforce consultant.
The SCC Current State Assessment Survey was administered across the partner network during the first two weeks of November.  The survey evaluates information regarding the partners' workforce current state, assesses specific DSRIP participation requirements, and key resources including information technology infrastructure, clinical integration, training programs, and cultural competency/health literacy practices. The SCC Current State Assessment Survey will inform the current state of the workforce and will provide information to begin building the future target state.
In addition to building the current and target state for the workforce, the SCC has been working with KPMG to initiate the development of the SCC Training Strategy and Workforce Communication and Engagement Plan. The framework for the training plan is designed to identify training programs available to address the training needs.  Where gaps are identified, the SCC will build strategies with our partners to formulate partnerships to meet the needs.   

The Practitioner Engagement Workgroup met and participated in a facilitated discussion by KPMG to share thoughts and perceptions regarding DSRIP change risk for practitioners. The information will be used to begin building the Workforce Communication and Engagement Plan.
The workgroup has been engaged in the development of the Practitioner Communication and Engagement plan. The purpose of the plan is to  provide a foundation for practitioner engagement efforts and a framework to guide future engagement activities. The plan provides a clear pathway for practitioners to have a voice in the planning and delivery of transformative health care services to SCC stakeholders so that the best possible patient outcomes are achieved now and in the future.  

The plan was presented and endorsed by the Clinical Governance Committee in January and will be presented to the SCC Board for approval in February. 

The Performance Evaluation and Management Workgroup has been engaged in reviewing further guidance from the De partment of Health on the patient engagement
definition s.  The SCC team converted the current patient engagement definitions that utilized ICD-9 codes to ICD-10 codes and the revised patient engagement definitions were shared with  the appropriate DSRIP project workgroups for further refinement.  Please click
here  to access our revised patient engagement definitions.
The workgroup has completed an initial review of the Domain 2 and 3 measures identifying the applicable provider type(s) for each measure in anticipation of supporting the performance reporting and monitoring practices of the SCC.  Members of the workgroup participated in a conference call with the KPMG/PCG DSRIP Support Team and advised the team of the level of data detail preferred from the DOH to support monitoring performance by provider. The SCC continues to work with our IT vendor to initiate the development of dashboards needed to support the intended concurrent quality monitoring program.      

The Population Health Operating Workgroup continues work to develop the Population Health Roadmap.   The approach to developing the Roadmap will utilize the completed Suffolk County Needs Assessment to define target populations and address health disparities by identification of populations and utilization of care management and care coordination services.  

Deliverables completed this quarter includes delineation of the key components / fram ework for the definition / requirements and creating the approach to be employed that will inform the completion of the first milestone.  The workgroup has endorsed definition(s), established the meeting schedule for 2016, established the timeline of subsequent deliverables and reviewed the work to date from the IT Task Force, PCMH Certification Work Group and Care Management strategy as key sub-steps. Development of the IT infrastructure will support care management and care coordination as well as performance reporting and quality improvement.  Dependencies, risks and contingencies have been preliminarily identified and will be further expanded as the Roadmap develops. 

Members of the Population Health Operating Workgroup are engaged in developing the Clinical Integration Needs Assessment & Strategy, which includes the capacity for clinical information sharing through care coordination, data sharing through interoperability, a transition of care strategy and training of providers across the care continuum regarding clinical integration, care coordination and communication strategies.  Members of the workgroup developed questions which formulated the Clinical Needs Assessment given to providers in the PPS through the SCC Current State Assessment Survey. Next steps include aggregating results to better inform our strategy in the months ahead. 

We're happy to report our Financial Sustainability Milestone 1 has been completed, comprise of the SCC Finance Structure Chart that has been developed and approved by the Finance Committee and the Board of Directors. The goal of this milestone is to finalize the PPS finance and reporting structure and ensure appropriate representation in the development of the PPS financial framework.  Two workgroups have been created under the Finance Committee, the Financial Sustainability Team and the Value Based Payment Workgroup. We've also identified key members to participate and they've initiated work on selected milestones. 

The Financial Sustainability Team has created a financial survey that was sent out to targeted network partners. The results will be used to perform the network financial health current state assessment and develop the financial sustainability strategy.

The Value Based Payment Workgroup is currently engaged in developing a survey for the network partners. Results will be used to develop a detailed baseline assessment of revenue linked to value based payment, preferred compensation modalities for different provider types and initializing the SCC MCO strategy.

The Community Engagement Workgroup met on December 22 2015.  The Workgroup reviewed an initial draft of the SCC Community Engagement Plan. This community engagement plan is designed to establish a community engagement framework to gather and share activity/event information; build and strengthen relationships; and promote input from community partners across the PPS.   The plan will provide a pathway for internal and external stakeholders to communicate and participate in community engagement activities/events; encourage patient engagement, and create a sustainable model of engagement between our community partners throughout our Suffolk County communities.    The Workgroup, comprised of representatives from health systems, hospitals, skilled nursing homes, CBOs and other collaborative partners, discussed the Plan and eagerly shared thoughts, ideas, and strategies to further inform the Plan. The insights provided by this Workgroup and other key stakeholders will be incorporated into the revised Plan and the Workgroup will reconvene in the next quarter The SCC continues to identify and develop relationships with partnering CBOs.  

The Cultural Competency and Health Literacy (CC & HL) Advisory Workgroup membership continues to expand with the engagement of even more community based organization partners! Key highlights from recent discussions include the CC & HL standards, the CC&HL strategic plan, and collective reviews of project-patient education materials.
The proposed CC&HL Plan was endorsed by the Community Needs Assessment, Outreach, and Cultural Competency and Health Literacy Governance Committee, as well as the PPS Board of Directors on December 21, 2015.
The framework for the cultural competency and health literacy training plan is being developed in conjunction with the Workforce training plan to meet the training needs. SCC is a collaborative partner with the Long Island Health Collaborative-Population Health Improvement Plan (LIHC-PHIP). Through this partnership, cultural competency and health literacy vendors are being identified for possible training opportunities for our SCC. The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (the National CLAS Standards) were reviewed. The Workgroup agreed that the SCC adopt these Standards across the PPS. The SCC plans to incorporate the Standards into the training and education plans for our partners. 
SCC PMO Highlight- Sharing INTERACT Implementation Strategies

On January 21st, Dr. Joseph G. Ouslander, M.D., Project Director for INTERACT ™ QIP and Professor and Associate Dean of Florida Atlantic University in Boca Raton Florida, presented as the key note speaker at an event titled "Successfully Implementing the INTERACT DSRIP Projects," at the NYU Kimmel Center.  
Ashley Meskill, Clinical Project Manager at the Suffolk Care Collaborative and Project Manager of the SCC INTERACT Program (Interventions to Reduce Acute Care Transfers) presented strategies for implementation, the SCC's approach for designing implementation, defining roles and responsibilities of key project stakeholders while following the DSRIP requirements. Ashley's presentation also included our experience and approach towards facilitating the Certified INTERACT Champion Training Program which was completed last November. 
The event also featured Tim Johnson, Executive Director at GNYHA Foundation who presented on a project called New York Reducing Avoidable Hospitalizations (NY-RAH), an INTERACT-based program which has been deployed in 30 skilled nursing facilities in New York City and Long Island.  

Several PPS representatives in attendance were able to learn best practices for implementation as well as the INTERACT T.E.A.M. Strategies, LLC. Certified INTERACT Champion Training Program.
SCC Primary Care and Behavioral Health Integration Program Spotlight

This month's DSRIP project spotlight features program development updates for DSRIP Project 3ai, operating under the new SCC program name Primary and Behavioral Health Integrated Care Program.

Current information indicates that individuals with mental health and / or substance use disorders (SUD) have a greater risk for a lower age of mortality than those without.  Often this is the result of untreated, undiagnosed or preventable chronic conditions such as diabetes, obesity, hypertension and cardiovascular disease.  The complexity of the health care system often presents a barrier to many individuals as they seek care.   Individuals with depression, anxiety or SUD may benefit from supports and resources that specifically address underlying needs in order to walk the path to wellness.

Primary care practitioners are often the entry point as individual's access services that they need.  Many mental health and substance abuse concerns are identified at an office visit with a primary care provider. Support for the primary care provider in the identification and care of complex patients with mental health and substance use disorders, in combination with physical healthcare needs, creates the opportunity to support an integrated, systematic coordination of general and behavioral healthcare.

Integration may occur by bringing resources to a primary care practice or to a behavioral health location.  Regardless of the specific model employed, all include a screening process to identify individuals in need of further services.  For some primary care practices, co-locating a behavioral health provider into their practice in order to ensure a quick and personal handoff to the behavioral health provider for those individuals who have screened positive and require services is the preferred model to ensure there is integration of care for affected individuals.  In behavioral health sites, providing primary care services on-site often proves most valuable in getting individuals the care they need efficiently, effectively and in a manner that produces the best outcomes. Lastly, for some, a third model of care, the IMPACT model, allows practitioners and prescribers the opportunity to consult with one another, coordinate care for complex patients, and share information identifying the highest risk patients on whom a focus should be shared. Regardless of the model and methodology, all patients and practices benefit when care is coordinated, integrated and systematic.

The SCC's Implementation Specialist is well informed on program implementation. Susan Jayson, Integrated Care Program Coordinator has initiated  work with each practice individually, as well as, convening the development of key procedures to advance integration at each individual site. Susan comes to SCC after a career working in the field of mental health.  As the Director of the Outpatient Mental Health Clinic at South Oaks Hospital, Susan worked across Long Island to identify gaps in care and find innovative ways to serve those who needed better access to services. There she was able to successfully integrate primary care and behavioral health in three practices across Long Island. With this knowledge she joined SCC in November, 2015 in order work with our team to further the efforts she had already begun.

In the fall of 2015 SCC embarked upon the process of assessing both primary care and behavioral health providers for the current state of readiness for integration.  Both primary care and behavioral health sites were assessed with the help of the North Carolina Centers of Excellence (NCCOE), consulting experts in integrated care. This first phase of assessment and implementation is well underway and each site is now being provided with vital information about current state, goals, and the best ways to achieve integration.  Susan is meeting with sites, creating plans of action, and together they are developing new and unique ways of making integrative care work in each setting.  In addition, the project workgroup, which is comprised of members from primary care, behavioral health, and regulatory bodies, is meeting regularly to discuss the ever-changing landscape of healthcare, changes in legislation and lessons learned. 

Many web based tools are available for those who want to learn more.  Current developments, models, research and resources are available on the SAMHSA and SCC website.
Partner Interview
Name: Jeff Steigman, Psy.D.
: Chief Administrative Officer
Organization : Family Service League
Please give us a summary of your organization
Family Service League (FSL) is a not-for profit, non-sectarian, community based human service agency that has served Long Island since 1926. This year is our 90th anniversary. We have more than 20 locations, primarily throughout Suffolk County, as well as a few small programs in Nassau County .
We provide a comprehensive network of care across Long Island with a full continuum of services, including mental health and substance abuse, clinics, children and youth programs, senior services, vocational programs, family support programs and housing and homeless services.

Who does your organization serve?
FSL helps about 50,000 Long Islanders each year. We operate strategically placed family centers that offer a continuum of care to address the multitude of challenges faced by children, families and other individuals - from infants to elders.

On which DSRIP project(s) are you involved in and why? 
We're most involved with Project 3ai - integrating behavioral health and primary care. That's something that we've been doing as an agency since 2011 in terms of really making a concerted effort to implement integrated care programs in a bi-directional manner.
Since 2011, we've partnered with Northwell - specifically Southside Hospital - where we brought in primary medical care services to our Bayshore site. I refer to it as our behavioral health home, because that's our flagship site where we have over 20 programs just in that building.
Many of the clients are severely and persistently ill, with significant mental health or chemical dependency issues - so they're some of our most vulnerable clients.
It's been a wonderful partnership that has grown over the years. We have over 300 clients who we serve in this particular model, where we have primary care services offered at Bayshore. Our various programs make referrals for this service, and we also more recently partnered with Southside's family medicine residency program, so we also have residents there who see the clients.
Based on the success of this program we are planning to build a 10,000-square-foot health and wellness center, adjacent to the property of our Bayshore site, which will focus on integrated care. This will allow us to scale the efforts even further, and we have the full commitment and support from Northwell to continue to be our partner in this endeavor.
Also, over the years, and we were on the cutting edge with this just before DSRIP, we've embedded social workers in pediatric and primary care offices, so we have social workers on site able to provide increased access and improve outcomes, because as we know, many times they're the gatekeepers for clients who are in need of services from primary care physicians. So we do it bi-directionally.

How has the population you serve benefited from Behavioral Health and Primary Care integration?
Whether it's the primary care in our behavioral health site, or behavioral health providers in our primary care sites - it has absolutely improved access to care. Having someone there as part of the team - working with them - has resulted in better outcomes.
The program where we have the primary care in our Bayshore site -that's called the Community Health Care Collaborative. Over the years we've been tracking key performance indicators - collecting data - and using business intelligence tools to analyze that data. And we have been able to objectively show that the outcomes have improved based on pre- and post- participation in the program.
To give you a couple of examples, we've increased the number of A1C screenings for those who meet certain criteria and who should be screened. And perhaps most importantly, we've been able to reduce the annual rate of ER visits for this cohort by about a visit per year among those who we were tracking, as well as make a significant difference in stabilizing medical conditions for those who were previously uncontrolled.
And the other benefit has been improved communication - sharing of information and treatment planning - in terms of being able to track and discuss the most vulnerable who we serve.

Can you share some current strategies in integrating Behavioral Health and Primary Care?
One thing we try to do, when we have social workers in our pediatric and primary care offices, is we really try to present it as one face. When a patient comes in they don't see it as two separate practices. This means the same support staff is welcoming the client, the support staff has access to a shared calendar, so there's no difference in making appointments for behavioral health or primary care. We try to make it as seamless as possible.
Another strategy is information sharing. Some of the social workers in the medical practices are given access to the EMR - so they have access to medical information. The social workers there will print out relevant information, whether it's a conference assessment, a treatment plan, or the progress notes, on a real-time basis when they're completed, which will be scanned into the EMR. So when the doctors see a mutually shared client who is seeing a social worker, they'll have real-time information at their fingertips so they'll know what's going on with them. 
We also try to be consistent with regard to the fidelity of integrated care models by focusing on utilization management. So, for example, if someone needs longer-term care, or if a case is very complex, we will transition them to our primary specialty clinic, where they'll have a full team as compared to just having services in the primary medical office.
We really try to keep movement within the census - we attempt not to have bottlenecks despite the demand often outpacing resources. In general, it's a faster pace and aligns with the pace of the medical practice, which also means the length and duration of treatment may be shorter, unless we need to transition the client to one of our clinics.
The last strategy, which has been really critical, is being able to have an operational process to provide psychiatric services for those patients who have more complex medication needs. So the primary care physicians or the pediatricians will often prescribe the front line medication - but if there's a more complex case, there are different ways to handle it. This includes having the client evaluated by our prescriber at the respective clinic and having him/her prescribe the medication until the client is stable and can be referred back to the primary care physician. It may also involve consultation type services that serve to assist the medical practitioner. 

What are some obstacles you've encountered in integrating Behavioral Health and Primary Care that are currently in place?
Technology - we currently don't have one platform or one database where we have a shared EHR. But I think in the future they'll be more options for having a shared record and that will help with developing a unifying treatment plan.

Currently, we also are billing separately which presents certain challenges. But in the future, as we move toward value based and bundled payments - I think there will be some opportunity for different models that will translate to shared accountability, further integration and greater sustainability.

Another obstacle - also based on the current fee for service fiscal model - is that you're not getting reimbursed for certain things like finding the time to have interdisciplinary team meetings and providing care management, which is crucial to the success of integrated care. A lot of the current meetings are informal - so being able to have carved out time that is outside of direct service to discuss cases is vital.

And finally, being able to pull out necessary info from each of the disparate EHRs and being able to use that information in an informed way is currently a challenge.

DSRIP's purpose is to fundamentally restructure the health care delivery system by reinvesting in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25% over five years. How do you envision your organization adapting/evolving to meet the needs of this health care delivery model shift?
We're not a direct service provider. We are a unique convener of many of the different entities which are key to the PPS's success. Our charge is staying involved in the conversation at a national, state and local level, while bringing lessons learned to our providers. As well, to communicate the importance of Community Based Organizations (CBO's) and their long-standing, trusted relationships within low-income communities and among high need individuals. Simultaneously, CBO's will need to build staff capacity and infrastructure to meet the requirements of the DSRIP projects.

How do you see DSRIP 3ai Behavioral Health and Primary Care Program affecting or adding to the strategies you have in place?
DSRIP will help with providing the IT infrastructure and resources that will allow for the secure exchange of information that will be important for reporting and performance monitoring. The Suffolk Care Collaborative will also be instrumental in driving and allocating resources to scale integrated care efforts throughout Suffolk County, and adhering to evidence-based models and approaches. The technical assistance that has been, and will be, provided translates to uniformity in approach, which is essential for such a project.
Along with that, they're going to define measures that will be used for screening, so different measures won't be used by different providers, which will help to identify those clients who are in need earlier in the trajectory. I think DSRIP will be very critical for monitoring treatment response and outcomes.
Milestone Dates
NYS DOH DSRIP Program Milestone Dates 
Release Mid-Point Assessment Tool for Public Comment
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
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



To access NYS DSRIP FAQ, click here

Stay Informed


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 then watch for the answer in a future issue of Synergy.