Issue 3
July 31, 2015

Welcome to Synergy



We are pleased to present the third 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 Organizational Project Engagements


A governance structure has been created for SCC that is representative of the varied provider types participating in SCC (the Suffolk County PPS) and the County's vast geography.  Given that SCC is an Independent Practice Association (IPA), an operating agreement rather than bylaws was created and approved for SCC.  Committee charters for each of the Performing Provider Systems' (PPS) committees have been prepared and approved by SCC's board.  SCC's leadership has also drafted partner agreements for Community Based Organizations (CBOs) and other participating organizations and a governance system review plan.  A list of participating CBOs has been created by SCC's Project Management Office (PMO) and partnership discussions between SCC and participating CBOs have commenced.



The workforce governance sub-committee and workforce advisory group have been established and meetings have been conducted throughout the application, implementation plan and Workforce Request for Proposal (RFP) process. The Suffolk Care Collaborative (SCC) distributed its RFP for solicitation for workforce consultant services to vendors identified in the initial DSRIP application filed with the Department of Health.  The RFP detailed the complete scope of work needed to meet the six workforce milestones.  Three complete responses were received and meetings were held on June 16th, June 22nd and June 26th to vet the proposals through the Workforce Governance Committee with staff from the Suffolk Care Collaborative.  An evaluation tool was utilized to objectively evaluate each of the proposals.  Based on the findings of the evaluation and vendor pricing, further exploration is underway to determine if the full or partial scope of work can be accomplished through support from the Center for Health Workforce Studies to keep costs to a minimum.  SCC expects to finalize the vendor strategy by end of August.



SCC has identified a physician champion to Chair the Practitioner Engagement Team with a kick-off meeting to be held in September. Members have been identified to serve as the initial team for the first meeting however, the initial scope of work for the team will be to identify additional practitioner champions. The SCC Central Service Organization has finalized the participating agreement, begun preparing onboarding materials for partners, initiated plans around the contracting strategy and will begin pre-contracting meetings later this month with providers to re-educate members about DSRIP and next steps.  Meetings were held with potential Patient Center Medical Home (PCMH) vendors and proposals are currently under review.



The Performance Evaluation and Management Team held its kick-off meeting on June 22nd. The committee is represented by all three health systems (NSLIJ, CHS and Stony Brook). The committee developed the scope of work and plans are underway to meet DSRIP reporting requirements.  A health system performance reporting plan has been developed delineating reporting responsibilities by health system versus individual provider and a quarterly reporting schedule has been established.  All patient engagement metrics have been defined and a bridge strategy for reporting has been developed until a more sophisticated IT platform is finalized to receive applicable data elements electronically.  Baseline performance data has been shared with more formal meetings underway to educate project leads and project managers.  Discussions are being held to operationalize the Domain 2 and 3 clinical metrics so that more current data may be reviewed for performance monitoring.      



The Cultural Competency and Health Literacy Advisory Workgroup has been established since March 24, 2015.  The Workgroup has developed a PPS-wide definition for cultural competency and health literacy.  It is anticipated that the definition will be approved at the August meeting.  The Workgroup plans to share the definition with all the PPS partners and post the definition on the SCC website.  In collaboration with the SCC, plans are to include this educational information as part of the partnership agreement/contracting process.  The Workgroup plans to revise and re-distribute the cultural competency and health literacy survey that had been conducted last year with our community partners.  The revised survey will gather additional information and engage more community partners in the PPS.  The survey is expected to be distributed in the next quarter. 



The composition of the Population Health Management (PHM) Operating Workgroup has been defined and operationalized.  Members of the Operating Workgroup have been meeting on a regular basis to develop the Information Technology (IT) infrastructure to support the Care Management (CM) Program via a bridge strategy for a care management documentation tool until the population health IT platform (HealtheIntentâ„¢) becomes fully operational in order to allow functionality of the CM staff as they are on-boarded.  The SCC has selected, following a series of meetings with different potential vendor partners, xG as the Care Management Vendor.  A 'kick-off' meeting to initiate the CM program is scheduled for July 22, 2015.  Evaluation of potential partners for facilitating and supporting providers to achieve PCMH 2014 Level 3 certification is ongoing.  Initial meetings with four vendors were held.  Following initial evaluation discussion with two vendors is ongoing.  Prioritization of providers and populations is ongoing, guided by safety net status and information from the Community Needs assessment.  The Performance Reporting Operating Workgroup will support the development of the performance reporting strategy. 



Members of the Population Health Operating Workgroup, in collaboration with the PMO, Project Managers and Leads, are developing baseline assessments for providers to complete, based on provider type and role/function within the PPS.  Results will provide current status of general and/or specific requirements which will inform the Clinical Integration needs assessment (gap analysis).  Mapping partners within the SCC based on function / role and location by region / local community will be ongoing and will inform partners of resources / partners within a geographic community to provide support across the continuum of care.  The clinical integration strategy will be created by the Population Health Operating Workgroup based on findings from the baseline assessments, with input from clinical projects, performance management and IT.  Discussions to address the barriers and risk with respect to achievement of an integrated IT system across the SCC are ongoing. 



IT Task force representatives from a collection of disciplines have been identified and we are now in the process of formalizing the team which will begin meeting on a regular basis in August.   The task force representatives can effectively be viewed as the IT champions for each of their respective work streams.   To date, the following work streams have been identified within the scope of the broader IT Systems and Processes Operational work stream:

  • Provider IT Survey and Current State Assessment
  • Population Health Platform Development
  • Data Acquisition & Provider On-Boarding
  • Data Security and Confidentiality 

Some progress has been made on the IT capability survey across Key PPS providers with additional work on-going.   The logical architecture for the Population Health Platform and its associated data acquisition strategy for supporting the Integrated Delivery System has been created and shared with the IT task force and other key stakeholders.    Data security and confidentiality requirements have been considered throughout the process to assure that Department of Health (DOH) security and confidentiality requirements are satisfied.

Task force representatives also meet with Population Health Project Management team (from Suffolk Care Collaborative) on a regular basis to provide IT support and temporary workaround solutions required for collecting Patient Engagement metrics until the strategic longer programmatic reporting solutions are completed.     



KPMG has been engaged to assist the SCC to design and put in place a funds flow plan that will help the SCC to ensure financial stability of the PPS. This plan will help to promote and fund required change, reward performance and incentivize behavior and establish the architecture for payment reform. The SCC and KPMG are currently interviewing all the project leads/project managers to discuss their individual project budgets and any possible issues that may arise.


Recently, the SCC hosted a kick-off meeting for all the key stakeholders to introduce them to KPMG, who presented a general overview of the funds flow process. As a follow up to the overview session, the SCC and KPMG are also interviewing the finance committee, board members and key stakeholders to get their input on how they envision the funds flow plan will roll out.

Partner Interview


Name: Gail Schonfeld, MD, FAAP

OrganizationEast End Pediatrics, PC

Focus or Specialty: Pediatrics

Number of Practitioners in Organization: three full-time pediatricians


Please give us a summary of your practice.

We are a well-established, general private pediatric practice.


Who does your practice serve?

Local residents as well as urgent care services to people visiting the community.


Why did you choose to participate as a PPS as part of DSRIP?

I have always felt that there was a lack of adequate mental health services and wanted to do something to make them available to my patients. A few years ago, I began holding meetings in my building with mental health professionals and others who were interested in initiating mental health change in our community. We came up with some great ideas. You put a bunch of people together and it's amazing what can be done.


It took time and effort but we obtained a grant and were able to start incorporating mental health services into our practice. It was fantastic having social workers available to co-manage patients. The patients loved it. Outcomes were better. It became clear to me that this was the way things should be done. But, once the grant ended so did the services. I then decided to hire the mental health workers myself and convince the insurance company to pay me for their services as a member of my staff. The challenge has been to get the payments to be adequate to pay for the costs of the care.


When I learned about the opportunities the Suffolk Care Collaborative offered, our practice was ready. There was very little we had to change. Now we can have social workers and a psychiatrist within our practice, and it will be much easier to care for people who can't afford these types of services.


On which DSRIP project/s will you be working?

Our focus is on integrated mental health with physical health and we will be involved in many of the projects.


What do you hope the DSRIP program will accomplish in general?

A lot of times when people can't afford mental health services and until a catastrophic event happens, they don't get care and  therefore end up in the ER. There's simply a lack of access and too many bad outcomes.


I hope that this program will help keep patients out of the hospital when it's not necessary for them to be there, by coordinating their care and providing services before it's too late and early enough for the problems to be easier to treat.


What do you hope the DSRIP program will accomplish for your practice in the future?

Instead of seeing patients end up the hospital when there's no reason for them to be there, we can see them intensively on an outpatient basis, and provide more personal care.


By being able to provide these services to children we can give them a healthy start in life, which can make all the difference for them. The real proof will be watching these children grow up into functional adults.


In your experience, what are the top three guiding principles of a successful population health management program?

Providing medicine, dentistry, and mental health in an integrated fashion. Clinical integration is part of it, the financial integration is the other part. We need to break down the silos and manage the patient together. We need to find what works best to keep the patient healthy. I also agree that screening, early diagnosis and timely treatment will be cost effective and with better outcomes.

Milestone Dates
NYS DOH DSRIP Program Milestone Dates 

6/18/2015            Updated Domain 1 Project Metrics and Milestones Document

6/18/2015            Domain 2-4 Achievement Value Presentation (Live)     

Week of June 19 Funds Flow Webinar (Pre-Recorded)  

6/24/2015            Medical Record Review Webinar (Pre-Recorded)           

6/26/2015            Domain 2-4 Achievement Value Presentation (Pre-Recorded) 

6/29/2015            Further Information on earning payments based on Domain 1-4 AVs    

Early July            Claims Extract 

Late July             De-duplicated attribution by provider 

7/01/2015            Feedback on June 1st Implementation Plan submissions to PPS

                            from IA              

7/01/2015            Quarterly Reporting Training and MAPP Functionality User Guide          

7/06/2015            Medical Records Review Operator Assisted Webinar (Live Q&A)             

7/07/2015            Project Implementation Plans and Reporting Requirements Webinar

7/31/2015            Updates to the June 1st Implementation Plan submissions and Initial

                            Project (non 2.a.i) Implementation Plan Submissions          

8/7/2015              April 1, 2015 - June 30, 2015 Quarterly Report Submission          

8/31/2015            IA Feedback on June 1st Implementation Plan submissions and July 31st

                            Initial Project (non 2.a.i) Implementation Plan Submission

10/01/2015          Final Implementation Plans posted to DSRIP Website  

TBD                     Updated Provider Classifications


More dates: NYS DOH 



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.