Issue 26
July, 2017
Welcome to Synergy
 
We are pleased to present the twenty-seventh 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:  www.suffolkcare.org.

In This Issue

SAVE THE DATE FOR THE NEXT 
PROJECT ADVISORY COMMITTEE (PAC) MEETING

Tuesday, September 26, 2017
Registration 8:30 am
Program 9:00 am - 12:00 pm

Hyatt Regency Long Island
1717 Motor Parkway
Hauppauge, NY

DSRIP Progress Update from NYS Reports Positive Statewide Performance

At the recent All-PPS Meeting held in New York City on July 12, 2017, Jason Helgerson, NYS Medicaid Director, gave a DSRIP Progress Update. He reported that DSRIP Year 2 (DY2)  closed on March 31, 2017, with positive statewide performance results. 

Through DY2, PPSs have earned a total of $2.4 billion , which is 95% of all available funds. Notable progress towards the DSRIP program goal of achieving a 25% reduction in avoidable hospital use by DSRIP Year 5 was demonstrated through a 14.9% reduction in Potentially Preventable Readmissions and an 11.8% reduction in Potentially Preventable ER Visits . Additionally, PPSs have successfully met all requirements for 31 projects in total and have successfully implemented 95% of all DY2 project requirements.
 
While there is work to be done, the results from DSRIP Year 2 are a reason to be optimistic that the DSRIP goal will be achieved. Click here for the DSRIP Progress Update presentation. 
Managed Long Term Care Workforce Investment Program Opportunities

The Medicaid Redesign Team (MRT) Waiver Amendment, approved April 2014 by the Centers for Medicare and Medicaid Services (CMS) to amend the State's 1115 waiver, makes available funds through March 2020 for initiatives to retrain, recruit and retain healthcare workers in the long term care sector, referred to as the Workforce Investment Program. The Workforce Investment Program targets direct care workers, with the goals of supporting the critical long term healthcare workforce infrastructure through retraining, redeployment and enhancing skillsets. Through this program the NYS Department of Health (DOH) will require Managed Long Term Care (MLTC) plans, which include Fully Integrated Dual Advantage (FIDA) plans (collectively MLTC/ FIDA plans), to contract with DOH-designated workforce training centers, to:
  • Invest in initiatives to attract, recruit and retain long term care workers in the areas they serve
  • Develop plans to address reductions in health disparities by focusing on the placement of long term care workers in medically underserved communities
  • Consistently analyze the changing training and employment needs of the area that the program serves
  • Provide for broad participation and input from stakeholders
  • Support the expansion of home care and respite care, enabling those in need of long term care to remain in their homes and communities and reduce New York's Medicaid costs associated with long term care

The DOH is now accepting applications for entities to become Long Term Care Workforce Investment Organizations (LTC WIO).  Applications are posted on the DOH website for organizations interested in the LTC WIO designation and must be submitted by 3 pm, August 28, 2017.  For more information, click here.

 

Announcements are expected to be made September 28, 2017, however, all further dates are subject to change. Any questions concerning the application process should be directed to the Office of Health Insurance Programs, Division of Long Term Care by e-mail at MLTCWorkforce@health.ny.gov.
Cornell Cooperative Extension and SCC Partnering to Promote Diabetes Self-Management Program  
 
Cornell Cooperative Extension of Suffolk County (CCE) and Suffolk Care Collaborative (SCC) are happy to begin partnering to promote the Diabetes Self-Management Program (DSMP).  CCE's Family Health and Wellness Program has been giving excellent evidenced based nutrition/health information to the residents of Suffolk County since 1926. Due to the dramatic increase in prevalence of Diabetes, CCE's Diabetes Education Program was established in 1999 in collaboration with the Suffolk County Department of Health. Their team of educators consist of Registered Nurses, Registered Dietitians, Certified Diabetes Educators and Bilingual Outreach Workers. In addition to working one-to-one with patients in health centers around the county, CCE offers free Diabetes Self-Management Programs to those living with or caring for an individual with Diabetes. 

The Better Choices, Better Health® Diabetes Self-Management education workshop is given 2½ hours once a week for six weeks, in community settings such as churches, community centers, libraries and hospitals.  People with type 2 diabetes attend the workshop in a group setting. Workshops are facilitated from a highly detailed manual by two trained Leaders.

Subjects covered include: 1) techniques to deal with the symptoms of diabetes, fatigue, pain, hyper/hypoglycemia, stress and emotional problems such as depression, anger, fear and frustration, 2) appropriate exercise for maintaining and improving strength and endurance, 3) healthy eating, 4) appropriate use of medication and 5) working more effectively with health care providers. 

Participants will make weekly action plans, share experiences and help each other solve problems they encounter in creating and carrying out their self-management program. Classes are highly participative, where mutual support and success build the participants' confidence in their ability to manage their health and maintain active and fulfilling lives.

CCE is excited to continue this endeavor with other vested partners in Suffolk County. Click here for a Provider Guide to the program.  A Provider Referral Form can be found here.  Please contact jsj79@cornell.edu for additional information.

SCC Launches Online Skilled Nursing Facility Capabilities Communication Tool

During the Regional Care Transitions Workgroup meetings that took place in February and May, 2017, key stakeholders identified a need to improve the communication lines and workflows between the acute care, long term care and other settings throughout the care continuum. Specifically, it was recognized that staff members were unaware of all the clinical capabilities within their neighboring skilled nursing facilities (SNF). With this gap identified, we were able to survey the skilled nursing facilities within our partner network to create a tool that shows their clinical capabilities. This tool can be used within the emergency department, during the care planning process, by the social work department during discharge and anywhere in between. By having a centralized location for this information, staff has access to a wealth of information to aid in the transition of patients to a long term care setting in just a few clicks.  Staff has the ability to search by clinical capability or facility name. Each SNF profile includes clinical capabilities reported by the SNF partner.  To access this information, visit the SCC website.  
Congratulations on CCTM Certification Exam Success!
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The SCC would like to congratulate the following RNs from across Suffolk County's 11 hospitals on passing their Care Coordination & Transition Management (CCTM) Examination! After months of hard work and preparation, they each sat for the 3-hour exam to become certified in care coordination & transition management. This certification course focuses on nine dimensions of the RN's CCTM role and related competencies for care coordination and transition management, including advocacy, education & engagement of patients and families, coaching & counselling of patients and families, patient-centered care planning, support for self-management, nursing process, teamwork & collaboration, cross-setting communications and care transitions, population health management and informatics & telehealth nursing practice.
 
CONGRATULATIONS
 
Cynthia Riddick-Hall - Huntington Hospital
Doreen Thompson - Huntington Hospital
Jane Seligman Domney - Northwell Health Solutions
Janet Alger - Catholic Health Services
Lorraine Farrell - J.T. Mather Memorial  Hospital
Maura Shovlin - Stony Brook University Hospital
MaryAnn Lind - Stony Brook University Hospital
Craig Bhoorasingh - Suffolk Care Collaborative
Jennifer Kennedy - Gurwin Jewish Nursing & Rehabilitation Center
Dellanor DiLorenzo - Suffolk Care Collaborative
 
Good luck to those nurses who are still preparing and taking the exam in the coming months!
Congratulations to SCC's Cultural Competency/Health Literacy Workgroup
Click here to view poster.

The Community Engagement team is excited to share the work of SCC's  Cultural Competency/Health Literacy workgroup and its collaborative partners. We have been recognized and selected to present at the International Conference on Communication in Healthcare & Health Literacy Annual Research Conference. The presentation is in a poster form and titled  "Bridging the Gap to Deliver Culturally Competent, Health Literate Care: A Collaboratively Developed Train-the-Trainer Program Designed for Community-Serving Individuals."

The poster presents an overview of key components of this training, including the regional need for CC/HL training, the collaborative experience, curriculum highlights (including health literacy), evaluation plans, evaluation results and key findings. The sustainable program produces Master Trainers, who are certified to host two types of sessions: 2-hour CC/HL training sessions for workforce professionals and full-day master training sessions for future master trainers.  Each training session produces evaluations and results that provide a snapshot of regional cultural competency and health literacy progress.

In addition, the poster highlights and dissects the many facets of the Cultural Competency and Health Literacy Train-the-Trainer program, developed in conjunction with Dr. Martine Hackett, Assistant Professor at Hofstra University's Department of Health Professions, and hosted by Suffolk Care Collaborative (SCC) and Nassau Queens PPS (NQP) with the administrative arm of LIPHIP/Long Island Health Collaborative.  The poster presentation will be held at the conference in Baltimore, Maryland, October 8- 11, 2017.  We are honored to be selected to discuss our key components with researchers, health professionals and students.
Partner Interview From a Community-Based Primary Care Practice Perspective
Name:  George Dempsey, MD, AAFP
Title:  Medical Director
Organization:  East Hampton Family Medicine

Please give us a summary of your organization and the population you serve.
We are a community-based practice in Family Medicine that I started here in East Hampton in 2002. We serve a very diverse patient population, ranging from the undocumented and uninsured to people from New York City who come out for weekends. The East Hampton Healthcare Foundation was able to support the practice to provide services to the population without insurance. They are a local group supported by people who saw a need for improved access to healthcare out here. They built the East Hampton Healthcare Center and collaborated with Southampton Hospital to provide X-ray and laboratory services in the same building.  I was asked to develop the primary care for their project. We devised a voucher system for patients without insurance, based on a flat fee. That was for an office visit, and it really brought people into the practice. Then we had to figure out how to get the labs and medicines, etc., for them. It worked out fantastic for these patients. Over time, many became documented and qualified for Medicaid, and from that I developed a large Medicaid population as well. And then along came the DSRIP program and it just kind of focused on this population and my ability to do more for them.
 
Why did you choose to participate as a partner with Suffolk Care Collaborative?
One of the main reasons was the hope for survival as a practice. Any small, private primary care practice is extremely challenged.  Unique to my situation is that the cost of living here is so high, I have to pay employees more.  But reimbursements are the same anywhere on Long Island. So, I teach residents and do research on Lyme disease in order to make ends meet as a practice.
 
SCC has been very helpful. Their consultants provide assistance in achieving Patient Centered Medical Home (PCMH) accreditation. It involves a huge amount of work and an expense that I don't think we would have ever taken on ourselves. We wouldn't have been able to afford it.
 
What do you hope the DSRIP program will accomplish for your organization in the future?
I got involved with DSRIP because the current fee-for-service model for community-based practice is not sustainable. It's helped me meet certain credentialing requirements for PCMH, which qualifies for better reimbursement through the quality incentives. We just attained PCMH accreditation and that means next quarter we will receive a patient-per-month incentive payment, in addition to the fee-for-service, for delivering on the PCMH model.
 
Specifically, how has your organization begun to experience this transformation of health care delivery and what are your successes?
The experience is transforming our documentation process and the work we put into documentation to meet the qualifications of the PCMH. But meeting quality measures doesn't necessarily translate into patient benefits.
 
These quality measures are administrative measures. They aren't about medicine, but patient compliance goals. It's really about doing what the patient does not do--making their appointment for a mammogram, getting their pap smear done, getting their sugars under better control. In the past, the patients were wholly responsible for these things. But now we're doing more work to help patients reach their goals and navigate a complex system.
 
This all sounds good, but we don't yet have data to show that it's making a difference to the overall population's health. We do have evidence of a decrease of close to 15% in hospital admissions in some areas, which saves the system money, and we are picking up more abnormalities due to more aggressive screening for early detection of certain cancers and chronic diseases, but it will take time to know the effect on our patient population.
 
How do you envision your organization adapting/evolving to meet the needs of this health care delivery model transformation?
This has always been the goal of primary medicine but it's been under-funded and under-supported. Primary Care doctors have always believed that we could do more if we had more support, because we know the patient, their social situation, what their needs are, and how that varies the care. But we can't do everything, so we need more people in the background getting things done. That allows us to focus on seeing patients, not doing reports and applications for services at the same time. Because that is very distracting.
 
Traditionally, a Medical Assistant just took patient vitals, but now they do a lot of the prep work -- patient histories, language needs, etc. -- before we come into the room, so they have to be a lot more sophisticated. And we need someone who focuses on the electronic medical records (EMR) and help to manage them. Not just an Office Manager who's already wearing 10 hats and running around like crazy.
 
We need people with clear job titles and clear responsibilities, and they have to perform in a way that minimizes the impact on what goes on in the room with the patient. Because that's the quality that you have to really preserve.
 
What value does the Suffolk Care Collaborative bring to patients under the DSRIP program and how do you see this project making an impact?  
DSRIP helped me stay in the game, for me, my practice and my patients. It allows me to continue to do some of the things I've done that were relatively innovative a few years ago, but are now almost a mandate, like the integration of mental health and primary care. That is something I started years ago by having a social worker come into the practice, so I'm able to give the classic "warm handoff" of my patients to see someone right away for mental health counseling. I'm now hoping that DSRIP will help me get psychiatric support.  This is the biggest need the U.S. has and it will have the biggest impact on the health of the country, because mental health affects everything.
Compliance Connection

The Department of Justice (DOJ) Fraud Section has developed a tool to help organizations evaluate the effectiveness of its corporate compliance program.  This guidance entitled, "Evaluation of Corporate Compliance Programs" (Guidance) can be found on the DOJ website

It provides some important topics and questions that the Fraud Section has frequently found relevant in evaluating a compliance program.  

Although the topics and questions covered in this guidance do not encompass a comprehensive checklist or formula, it does give insight into how the DOJ views an effective compliance program.  This information not only assists in evaluating your own program, but can also be helpful in educating senior leadership and board of directors on the DOJ's expectations of a comprehensive program.  

For compliance questions, or assistance, contact the SCC Compliance Office at SCC-Compliance@stonybrookmedicine.edu.
 Milestone Dates
 NYS DOH DSRIP Program Milestone Dates
 
August
Opt Out Phase IV Mailer
August 1
Additional PPS Lead Regulatory Waiver Requests - Round 6 Due
August 14
1115 Waiver Public Comment Day Albany - SUNY Albany School of Public Health
August 31
Independent Assessor provides feedback to PPS on PPS Year 3 First Quarterly Reports; 15 day Remediation window begins
September Annual update to Value Based Payment Roadmap submitted to PPS

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, Clinical Programs Innovation
  2. Director, Care Transition Innovation
  3. Project Manager, Practice Transformation
  4. Care Manager
  5. Social Worker
  6. Community Health Associate
  7. Program Coordinator, Care Transitions
  For more information, please contact the Suffolk Care Collaborative via email