Issue 26
June, 2017
Welcome to Synergy
We are pleased to present the twenty-sixth 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
SCC's Community Engagement Team Hosts Community Based Organization Learning Collaborative 
SCC is proud to announce the strides they are making to address Social Determinants of Health (SDH). On June 13, the Community Engagement team hosted a Community Based Organization (CBO) Learning Collaborative at Stony Brook University, Health Science Center.  Topics discussed included the role of social determinants of health, areas of need analysis findings and New York State Department of Health's payment reform efforts to value based payments.

CBOs provide services that bridge the gaps between the client/patient and healthcare providers and address the social determinants of health that can, at times, become barriers in accessing health services. The Learning Collaborative created an opportunity for attendees to discuss potential CBO partnerships and opportunities to collaboratively address the findings presented and discuss the value of alignment with payment reform efforts.  

Recognizing the need for partnerships, the SCC introduced a new agreement entitled "Affiliate Agreement" intended to engage more CBOs to participate in DSRIP.  CBOs had the opportunity to ask questions as well as sign up to become an affiliate member.  Also, participants were able to sign up for additional programs offered by SCC, including Cultural Competency and Health Literacy Training, and participate in partnering opportunities on Project 2di - Community Health Activation Program and Better Choices, Better Health® workshops.

SCC continues to work towards achieving DSRIP goals and welcomes interested CBO's to submit an Affiliate Agreement and participate in any of our 11 projects. For more information please email:
Free Motivational Interviewing Training Opportunity for SCC Partner Organizations
The SCC invites you to participate in a one-day training session on Motivational Interviewing (MI), an engagement technique that can be used by health care and social service professionals to support patients and clients in self-management and assist with health and social needs. The training is sponsored by the Greater New York Hospital Association (GNYHA), and is funded by the New York State Department of Health's (DOH) Health Workforce Retraining Initiative (HWRI).  

Dates :             Tuesday, July 25, 2017 OR Wednesday, August 9, 2017
Time :               9:00 a.m. - 4:00 p.m.
                         Breakfast and lunch will be provided
Location:         1393 Veterans Memorial Highway, Hauppauge, NY 11778

Participants will receive a Certificate of Training.  Space is limited to 25 per class. For training details, who should attend the training and links to register, click here.
Community Health Activation Program (CHAP) Calls for 
CBO Participation in Survey Efforts
We're looking for interested community partners to join our efforts in Community & Patient Activation.  We welcome interested organizations to reach out to us directly.

The SCC's Community Health Activation Program (CHAP) (DSRIP Project 2di) is a CBO-led in-reach and outreach program aimed to identify, engage, educate and integrate the uninsured and low/non-utilizing Medicaid populations into community based preventive care services.

Our current program includes an in-reach and outreach model and has engaged 5 organizations to participate in community activation activities to date.

Performance measures will annually score the program's ability to:
  • Move an individual up in Patient Activation Measurement (PAM) Score;
  • Reduce avoidable emergency department use by CHAP participants, and
  • Increase the number of individuals who have a Primary Care Practice well visit if classified as a Low- or Non-Utilizer of Medicaid services within the past 24 months.
Some program highlights to date include:
  • 4,100 surveys completed since January 2017
  • Over 30,000 individuals engaged since August 2015
  • Over 250 individuals have been trained in Patient Activation Measurement
The annual survey goal for Demonstration Year (DY) 3 (April 1, 2017-March 31, 2018) is 34,000. Beginning DY4, the annual goal will increase to 45,000.

Organization engagement may include:
  • Hosting PAM Surveyors on-site to engage clients as a "Survey Site".
  • Becoming a "PAM Provider" of surveys for the program in Suffolk.
  • Becoming a "Navigation & Coaching" provider for the Program in Suffolk. 
If your organization is interested in participating in the CHAP program, please contact Amanda Chirco, Project Manager, Community Health Initiatives, at or by phone at 631-638-1774.
Lean Project Status Update   sand_hands_update_hdr.jpg

At the March Project Advisory Committee (PAC) meeting, the SCC invited partners to participate in Lean training.  Lean is a philosophy based on proven principles and practices aimed at the elimination of waste, employing practices that will improve an organization through an evidence-based methodology.  Five partner organizations applied for the opportunity to learn the Lean methodology and participate in a Lean project at their organization.  SCC Leadership reviewed the applications and awarded three diverse organizations to participate this quarter. This first wave of training includes a hospital, a primary care practice and a behavioral health community based organization.  

Kick-off meetings at the awarded organizations are planned to take place over the next month at Southampton Hospital, East Hampton Family Medicine and Association for Mental Health and Wellness.   The projects  chosen will directly align with DSRIP initiatives that target metrics/outcomes improvement, eliminate waste and/or address workflow improvements.   Progress and updates will be reported regularly and featured at future PAC meetings.  

We are continuing to take applications for the next wave of training.  If you have a project that aligns with DSRIP initiatives, need to improve metrics/outcomes to drive DSRIP measures or want to eliminate waste and/or address workflow improvements to key DSRIP processes, apply for consideration by filling out the form found  here.
Catholic Home Care's Telemonitoring Program Success
Catholic Home Care was awarded finalist honors at Catholic Health Services' (CHS) Pinnacle Award ceremony for its Reduction of Preventable 30-Day Re-hospitalizations for Patients with Heart Failure through Home Telemonitoring program.  

National heart failure (HF) guidelines on key provider activities prior to hospital discharge emphasize that post-discharge systems of care, such as telemonitoring, help facilitate the transition to effective outpatient care and disease management. As the health care climate shifts toward Value-Based Purchasing and Pay for Performance, telemonitoring, or telehealth, has gained national recognition as a valuable partner in the post-hospital discharge management of HF patients. Health care organizations are striving to "do more with less", faced with the challenge to cut costs, while simultaneously delivering high-quality, cost-effective, patient-centered care.  
Catholic Home Care Team
Patients and caregivers are often given the responsibility of taking control over their respective chronic disease processes with minimal perceived preparation. This perception contrasts with the Institute for Healthcare Improvement's Triple Aim. With specialty trained registered nurses and support staff, the agency's telehealth program provides education and support for patients diagnosed with HF, using advanced biometric technology, minimizing the potential for additional clinical complications. Admission to this program increased from 499 patients in 2015 to 800 in 2016.
Outcomes achieved include: For telehealth patients, HF-related 30-day re-admissions were below 7% and the all-cause re-hospitalization rate with a primary diagnosis of HF was 13.3% (versus agency average of 26.6% for the same) in 2016; 91% patient satisfaction rating in 2016, with a 70-75% return rate of patients surveys; through instantaneous integration into the EMR, enhanced access to data by all clinicians involved in patient care has been achieved.
COMPASS:  Unity Through Strength and Diversity Engages Community in Mapping and Mining Activities

COMPASS: Unity Through Strength and Diversity hosted community mapping and mining activities to assess the risk and protective factors of the South Country community. The purpose of mapping and mining activities is to develop data that highlights the community's areas of concern, while making note of safety areas.

Cierra Corbett, Prevention Speicalist, Family Service League; Lynette Murphy, LMSW, Bellport High School
The original mapping activity took place at South Country Library. In an effort to increase participation, small mapping activities were held throughout the town of Bellport at Bellport Hagerman East Patchogue Alliance (BHEP), Boys and Girls Club of the Bellport Area and during a Civic Association meeting. A mapping activity was also conducted during a Miramar Beach Association meeting by the coordinator of COMPASS, Lynette Murphy. Upon completion of the mapping activity, COMPASS was able to highlight areas of concern within the community such as, recreational parks during certain times of the year, gas stations that allegedly sell alcohol to minors and Miramar Beach as a popular location for youth to congregate and engage in unlawful activities. Despite some areas of concern, plenty of areas of safety were also noted throughout the activity. Community organizations such as the Bellport Hagerman East Patchogue Alliance (BHEP), Boys and Girls Club of the Bellport Area, Lighthouse Mission and local churches were identified as safe or supportive places in the community.

Once the mapping activity was complete, Cierra Corbett, the Prevention Specialist at the Family Service League, compiled the raw data from the mapping activity into a mining report that outlines the identified areas, along with the reported issues, possible related risk or protective factors and suggested solutions. The coalition then disseminated the data from the mining report to the community. Ms. Corbett, along with Long Island Prevention Resource Center, the Coalition and community members, prioritized the components of the mining report according to achievable long/short term goals. Furthermore, they worked to identify issues that are of top priority to the community and its members.

The information provided by the community during the mapping and mining activities verified known issues, such as substance abuse in South Country as well as the root causes of these issues and the enabling factors.  The data obtained from these activities served to show how valuable data is when developing strategies to create community level change. Going forward, the data will be used to create a community needs assessment and community resource assessment report. Ultimately, this information will be used to establish a logic model, action plan, evaluation plan and sustainability plan to improve the overall health and safety of the South Country community.
COMPASS is a coalition serving the communities that comprise the South Country School District--Bellport, Brookhaven, East Patchogue, Medford and Yaphank. Its primary goal is the prevention of drug and alcohol abuse through education and community activities.  Cierra Corbett is the Prevention Specialist for Family Service League and an active member of the COMPASS Coalition.
Partnering to Prevent Underage Drinking:  A Collaborative 
Partner Interview
Name:  Cierra Corbett, MA 
Title:  Prevention Specialist
Organization:  Family Service League

Please describe your role with the Family Service League and the SCC's Underage Drinking Prevention Program.
The Family Service League is a 90-year-old organization with over 60 programs, including substance abuse treatment, primary substance abuse prevention services and the Long Island Prevention Resource Center. As the prevention specialist, I am able to bring these resources to enhance the SCC's Underage Drinking Prevention Program. Together we have been able to provide training for the Compass Unity through Strength and Diversity Coalition on topics that include capacity building, how coalitions work and all aspects of the Strategic Prevention Framework, in order to strengthen the efforts of the Coalition within the South Country School District community.
How has your partnership with the Compass Unity Community Coalition enhanced your work?
The Compass Coalition, headed by Lynette Murphy, a social worker and coordinator at Bellport High School, has been around since 2009. It's a coalition with representatives from 12 sectors of the community. What we do is implement environmental strategies throughout the community and in the schools in order to reduce underage drinking. I provide training and technical assistance to the Coalition.
I am able to bring my knowledge, skills and passion for underage drinking prevention to the Coalition. And through my work with the Coalition I have been able to see the Strategic Prevention Framework in action as community representatives of all types work together to stop underage drinking. I've been able to co-coordinate mapping and mining activities that tell us specific areas of concern within the community. Members of the sectors of the community weighed in on what they know to be geographic areas of concern, and using this data we're able to develop action plans to address these areas of concern.
First, we look at what we can do and what is out of our hands. Once we come up with the things that we're able to handle, we prioritize them. For example, there's a park where, during the summer, there's not enough police activity, so there's a lot of underage drinking and drug use going on. We contacted the police department and they came out to one of our meetings and agreed to beef up security. So, we're able to connect with different entities within our community in order to address these areas of concern.
What are you hoping to achieve through this work?
Through our work with Compass Unity Coalition, we're looking to achieve a reduction of underage drinking through increased knowledge of the Social Host Law (whereby adults over 18 hosting a party where there is underage drinking are held legally responsible) and increased participation of parents and community members toward these efforts. We also hope to decrease areas where illegal drugs are sold, which will free up more spaces where children can play in a safe environment. Our goal is to eliminate illegal drug and alcohol use in our community.
What is the importance of involving community members in your work?
Community members are one of the most important aspects in the work that we do. They need to be involved in the prevention efforts in order for them to be effective. If community members actually own the process, if they are a part of the process, they are most likely to be motivated to follow through with the commitments of the process. Also, community members have numerous resources, skills and strengths. And by putting all of these things together we are able to have a much stronger response.
We are always looking to increase the capacity of the coalition. Whenever we have an activity we look for people in the community who would like to get involved. It could be parents of children in the community or other adults. No participation is too small. Even if it's just forwarding a flyer through email or handing out flyers, that's helpful.
What are some of the upcoming activities?
We're looking forward to doing a few campaigns. One is the Sticker Shock campaign, an environmental strategy designed to prevent people 21 and over from purchasing alcohol and providing it to underage individuals.  Working with local liquor retailers, we're going to put positive messages on stickers, and then put these stickers on alcohol-containing bottles in alcohol retailers throughout the community.  For instance, a sticker on a bottle of wine might say, "This bottle of wine will not end up in the hands of an underage individual." It could be something as simple as that, to create awareness in the community that alcohol should not be given to underage individuals.
Another campaign we're looking to do is the NOYL Campaign, which stands for Not On Your Life. The goal of this campaign is to work in partnership with local businesses to ensure that they commit to not selling alcohol to anyone under 21 years of age.  One of the things we have to do with the NOYL campaign is to connect with the Chamber of Commerce and the local police and let them know that we're going to be doing this. Then we'll reach out to alcohol retailers in our community and create a contract between these retailers and the coalition wherein they pledge not to sell alcohol to anyone under 21 years of age.
A third activity is Operation Pizza Box, which is similar to the Sticker Shock campaign. It's an initiative where we place positive norm messages on pizza boxes in pizzerias throughout the South Country community. The message could be something like "I want to remain drug free." It's a sticker or a flyer we tape to the pizza boxes, and every pizza that goes out in our community will have that message on it.
Compliance Connection
Incentive Programs and Compliance

Incentives are integral to the compensation plans of a wide range of workers. CEOs, senior management, sales executives and even rank-and-file employees may have them. Many experts point to their value in rewarding behavior that is in the interest of the organization and for keeping workers focused on activities that help the bottom line.
At the same time, however, the incentives can pose great risks.  Many corporate scandals have shown that workers and corporate leaders may give in to the temptation and cheat to make their numbers, doing whatever they can to achieve their goals and reap the rewards. As a consequence, incentive plans may turn out to be a roadmap for compliance risk.
This danger argues for the compliance department having a role in reviewing incentive plans, in order to develop controls that ensure objectives are met properly, without violating policies, procedures, the law and ethical norms.
In April 2017 the Society of Corporate Compliance and Ethics and the Health Care Compliance Association (HCCA) fielded a survey among compliance professionals. The results indicate that despite the risks, compliance professionals rarely play a role in evaluating incentive programs before their company implements such plans. In order to have a solid program and process around your incentive plan, compliance overview is an important aspect to include.  For more information and to access the results of t he Incentive Programs and Compliance Survey, visit the HCCA website or download the survey  here .  

For compliance questions or assistance, contact the SCC Compliance Office at
 Milestone Dates
 NYS DOH DSRIP Program Milestone Dates
DSRIP Measurement Year 3 Guide posted to website
July 1
Response made to PPS Lead Regulatory Waiver Requests -Round 5 
July 6
Final PPS Year 2 Quarterly Reports posted to DSRIP Website
July 28
DSRIP Year 2 Second DSRIP Payment to PPS
July 31 PPS Year 3 First Quarterly Reports (4/1/17-6/30/17) due from 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
  For more information, please contact the Suffolk Care Collaborative via email