Issue 2
June 30, 2015

Welcome to Synergy



We are pleased to present the second 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
Delivery System Reform Incentive Payment Program (DSRIP)
SCC Submits Implementation Plan


On June 1st 2015, the SCC submitted the NYS DOH DSRIP Implementation Plan. Please click here to access our Plan. 

Three main functions of the Implementation Plan are:

Define the structure and content for the quarterly reports

  • PPSs' quarterly reports will represent an update on each aspect of the implementation plan.
  • Certain aspects will be directly linked to the awarding of DSRIP funds (e.g. progress toward patient engagement commitments).
  • Provide qualitative insight and basis for discussion with DOH and other state units regarding process and challenges.

Collect the baseline information that the Independent Assessor (IA) will need for ongoing monitoring and scoring of Domain 1 process measures

  • This suite of information will include project-specific (e.g. speed of patient engagement) and organizational measures (e.g. workforce impact numbers).
  • For Domain 1 process measures -Domain 1 Funding is significant, representing approximately 40% of all payments across the waiver.
  • Progress against outcome measures will be captured and monitored in the Medicaid Analytics Performance Portal (MAPP) tool, separately from the implementation plan and quarterly reports.

Set out key milestones in each organizational area to give DOH and the IA insight into the implementation timelines of various initiatives across PPSs

  • The implementation plan template will prescribe high-level headings. PPSs will then set out the work steps under each of these that are specific to that PPS.
  • Progress against these milestones and key steps will be tracked through the quarterly reports but these steps are not individually linked to process payments.
  • These key steps and milestones effectively represent an 'Executive Summary' of the more extensive implementation planning PPSs will undertake for each project.

Source: NYS DOH

DSRIP Project Engagements


Project 2.b.vii INTERACT
We are collecting data from the ten Skilled Nursing Facilities (SNFs) within the SCC who have been part of the New York -Reducing Avoidable Hospitalizations (NYRAH) project, who have implemented INTERACT at their facilities. The baseline engagement data will provide a general understanding of the scale to which INTERACT interventions are already in place. In the coming months, we plan to collect similar data from all SNFs within the SCC. The PMO continues to work closely with the NYRAH Project Management and Data Analytics team to better understand their successes within their project as it relates to INTERACT. Their experience with rolling out the INTERACT training program has been a great asset to SCC as we are developing our program. 


Project 2.b.iv Transition of Care (TOC) & 2.b.ix Hospital Observation (OBS) Program Development

Hospital Partner baseline survey results were shared at a recent Hospital Partner Project OBS/TOC workgroup held at Southside Hospital on June 22nd.  Each hospital had representation at the meeting and all participants contributed valuable information to the working meeting. The baseline results have been used to develop a gap analysis against Domain 1 DSRIP project requirements for all Suffolk County Hospitals.  At the workgroup meeting, discussions centered around challenges the hospitals currently face and sharing best practice interventions already in place to organize implementation design.   The workgroup will begin building the Transition of Care protocol for the SCC DSRIP program. 


Project 3.a.i Integration of Primary Care and Behavioral Health Services

This past month, the PMO held a Project Committee meeting at Brookhaven Memorial Hospital where the patient engagement definition topped the agenda. The SCC has committed to engaging 45,059 patients by the end of Demonstration Year 4 (May 31, 2019). The SCC Patient Engagement definitions are: Model 1 and Model 3: Number of patients screened using the PHQ-2; Model 2: Number of patients receiving primary care services (well visit, sick visit and/or screening for chronic medical conditions such as cardiovascular disease, diabetes, etc.).  Next up, the Project Committee will evaluate and refine the primary care and behavioral health scope of services, as well as decide on evidence based clinical protocols for each model. The SCC will utilize all 3 models for this project. 


Project 3.b.i Cardiovascular

The Project Committee meeting was held on June 5, during which the SCC Patient Engagement Definition was approved by the committee.  The Clinical Protocols which are being adopted from the Million Hearts Campaign, have been approved by the Project Workgroup and will be on the agenda for approval by the Project Committee at the next meeting. The Clinical Protocols will act as the foundation for the Cardiovascular Project, enabling providers to incorporate these guidelines into their practice to meet project requirements. The PMO team, in concert with our partners in the Biomedical Informatics Department of Stony Brook Medicine, aggregated Salient data and Stony Brook University Hospital data to determine areas with the highest prevalence of disease in the County. This information will be used to identify and engage partners to support project implementation.  


Project 3.c.i Diabetes

On May 2, Pegi Orsino, Executive Director of the Retired Senior Volunteer Program (RSVP) of Suffolk met with the Project Workgroup to discuss Diabetes Self-Management Training in Suffolk County. RSVP currently has a very successful Stanford Model Program in place, with 7 Master Chronic Disease Self-Management Trainers, 5 of whom have been cross-trained in the Diabetes Self-Management Model. A demonstration is planned of Cerner's HealthE Intent Diabetes Registry with the SCC Information Technology PMO. The registry will assist in the identification and monitoring progress of diabetic patients who are participants in the DSRIP program. Meetings in June included The Diabetes Project Committee where the group reviewed and approved the Clinical Guidelines Summary for the project, and The Certified Diabetes Education workgroup meeting with North Shore-LIJ (NSLIJ) addressing strategies for increasing the complement of Certified Diabetes Educators (CDE) in Suffolk.


Project 3.d.ii Asthma

The Asthma Workgroup, comprised of 8-10 members, has been organizing a strategy to collect the Patient Engagement data from engaged SCC partners. The Patient Engagement definition is the number of participating patients based on home assessment log, patient registry, or other IT platform. The Workgroup has been working with the PMO IT team to develop a data repository in order to collect this data from partners.  The Asthma Project Committee has also approved the Clinical Guidelines Summary.  The Clinical Summary includes the long term goals of providing patients with asthma care consistent with National Heart, Lung, Blood Institute (NHLBI) guidelines including: classification of severity, risk and control of asthma at each visit; appropriate prescription  of asthma control medications; provide an Asthma Action Plan (AAP) at each visit carrying a primary diagnosis of asthma;  home-based strategies to address asthma triggers; and reduce avoidable asthma-related ED and hospital visits. 


Project 4.a.ii Prevent Substance Abuse and Other Mental Emotional Disorders

The PMO initiated a baseline survey assessing our hospital partners to determine current substance abuse screening practices. On June 4th, the Project Committee meeting focused on an information sharing webinar, featuring partners who are currently utilizing the SBIRT (screening, brief intervention, referral to treatment) protocol. One of the goals of this project is to support the implementation of the SBIRT protocol in each Emergency Department. Implementation guidelines are in the work queue to support SBIRT project implementations. 


Project 4.b.ii Increase Access to High Quality Chronic Disease Preventative Care and Management in Both Clinical and Community

The PMO has engaged with Long Island Health Collaborative (LIHC), to learn about the Population Health Information Program (PHIP) Grant. The PHIP will promote the Triple Aim - better care, better population health and lower health care costs - through regional contractors that will convene stakeholders and establish neutral forums for identifying, sharing, disseminating and helping implement best practices and strategies to promote population health and reduce health care disparities in their respective regions*. The PHIP will help achieve improvements in population health through stakeholder collaboration, data-driven prioritization, and regional or local strategies for addressing health disparities. 


As a next step, the Project's four workgroups - Obesity Prevention, Tobacco Cessation, Breast and Lung Cancer Screening, Colorectal Screening Education - will be collaborating on a SCC Chronic Disease Prevention plan. This will include culturally competent evidence-based educational materials to be incorporated into partner practices, health fairs and Community Based Organizations (CBOs). 

Featured Project

Project 2.d.i. Operationalizing Patient Activation Measures (PAM?)


The Suffolk Care Collaborative is undertaking the 11th project: 2.d.i Implementation of Patient Activation Activities to Engage, Educate and Integrate the uninsured and low/non-utilizing Medicaid populations into Community Based Care. To be eligible for this project, the SCC had to already be pursuing 10 projects, demonstrate its network capacity to handle an 11th project, and evaluate that the network is in a position to serve the target populations, as only the uninsured, non-utilizing, low-utilizing Medicaid member populations will be attributed to this project. Based on the Attribution for Performance received in March 2015 from NYS DOH, total attribution for Project 2di includes 93,694 Non-Utilizing and Low-Utilizing Medicaid Enrollees, and 168,618 Uninsured; a total combined population of 262,312.


This project aims to engage individuals who are not utilizing or underutilizing health care services and works to engage and activate them to partner with primary and preventive care services.  Simply having health insurance is not enough to ensure improved health outcomes or appropriate use of the health system. A lack of familiarity with the system, coupled with social and cultural barriers to care, can lead to unnecessary utilization of high-cost health care resources.


To reduce avoidable ER visits and admissions and address the overall DSRIP goal of a 25% reduction in avoidable hospital use, individuals must actively engage in managing their own health. The implementation of this project will help individuals to take charge of their health ("activation") and to move along a continuum to better health, thus reducing avoidable ER use and hospital admissions.


Training on the Patient Activation Measures (PAM?) program, along with baseline and regularly updated assessments of communities and individual patients are program requirements.  This project encapsulates three primary concepts:

  • Patient activation
  • Financially accessible health care resources
  • Partnerships with primary and preventive care services

The Community Needs Assessment, performed pre-application, documented barriers to access among uninsured and Medicaid recipients. By comparing Medicaid and uninsured respondents to countywide findings, significant disparities became evident:

  • Difficulty accessing healthcare due to the cost of physician visits and prescriptions, inconvenient office hours/appointment availability, difficulties finding physicians, and lack of transportation
  • Cultural and linguistic barriers
  • Higher frequency of mental health challenges and childhood obesity
  •  Lack of leisure time
  • More likely to skip/stretch prescription doses, use the ER and difficulty getting child care

The success of the PPS CBOs in partnering with uninsured and under or low health care utilizers will strengthen this project.  In collaboration with CBOs, community health workers (CHWs) in the community will identify settings (housing sites, welfare offices, clinics, etc.) within targeted need areas, to reach individuals who have limited contact with the healthcare system.  CHWs will assess individuals using the PAM? program to determine their knowledge, skills and confidence for managing their health and healthcare, and monitor over time their level of activation.  CHWs and peer counselors, trained in the Coaching for Activation method, will work with individuals to build awareness of the importance of prevention and early intervention and increase their confidence in using health care resources and managing their care.


CHWs will connect individuals with care management as necessary, and with their existing or a new PCP. Culturally competent PPS CBOs will collaborate with and train other PPS members to ensure that, once these linkages have been made, the connection is successful and individuals make progress in their activation and engagement. In addition, uninsured individuals will be guided to appropriate insurance resources to improve financial accessibility to care.


The SCC has initiated the PAM? Pilot Program with three partner CBOs: the Association for Mental Health and Wellness (AMHW), the Economic Opportunity Council (EOC) and HRHCare Inc. The program is currently under design, and rollout is planned. On June 3, the SCC and some PAM? Program CBO partners completed training with Insignia in the PAM? and Coaching for Activation (CFA) tools. The training was the first one performed for any NY State PPS, and the project will begin its official rollout during the month of July. 

Partner Interview


Name: Michael Stoltz

Title: Chief Executive Officer

Organization: Association for Mental Health and Wellness

Focus or Specialty: Mental health issues

Number of Practitioners in Organization: 125 staff members including professionals, paraprofessionals and peers

Please give us a summary of your organization:

The Association for Mental Health and Wellness is an organization offering services that address mental health issues. We have statewide and national affiliations and are one of 28 chapters of Mental Health Association (MHA) in NY State.


Our mission is to empower people and communities to pursue and sustain enriched, healthy, and self-directed lives.


Who does your organization serve?

We provide a range of mental health access to care and psychiatric rehabilitation and support services including care management to Suffolk County residents. A focus in the PPS is care management where right now we're actively serving 1,100 people, but can provide services to 1,700 at any time. The people we serve are those who live with two or more chronic health conditions or a serious mental health condition.


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

People with mental health challenges used to be viewed only from the neck up. In the past there was a widespread belief that mental health and physical health were separate. We now know that's not true. A person's mental health state is often linked to his or her physical health, which means that people with chronic health conditions may need mental health care management to help them follow through with their medical care.


DSRIP emphasizes the relationship between physical and mental health. So it was important for us, as a predominantly mental health agency, to be part of an initiative that addressed the physical and mental challenges of health at the same time.


On which DSRIP project(s) will you be working?

We are involved in several project areas:


Project 2.a.i: Create an integrated delivery system

Project 2.b.iv: Care transitions intervention model to reduce 30-day readmissions

Project 2.d.i: Implementation of Patient and Community Activation Activities to Engage, Educate, and Integrate the uninsured and low/non-utilizing Medicaid populations into Community based care

Project 3.a.i: Integration of primary care services and behavioral health

Project 4.a.ii: Prevent Substance abuse and other Mental/Emotional Behavioral Disorders


In addition to workgroups for the above, we are also represented on the SCC Board of Directors and on the SCC Information Technology workgroup.


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

We're very proud of our wide range of services, which include Care Management and Specialty Care, and hope that the PPS will recognize our strengths and see us as a key part of the services of the network. We're also looking forward to partnering with Community Based Organizations to extend the reach of our services. We're proud to be an innovative organization and pleased to see that DSRIP offers opportunities for innovation as well.


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

Reduced hospitalization and reduced emergency room usage. We'd like to see a seamless network of care and support for everyone within Suffolk County, regardless of ability to pay.


Transformational Change

As healthcare reimbursement changes, hospitals, health systems and providers must adapt to a new paradigm in which providers are rewarded for meeting quality objectives for their patient populations. The emphasis is clearly shifting from volume to value and organizations that focus on providing patient-centered, quality health care across a population will come out ahead. How has your organization begun to experience this shift?

The shift started for us before the DSRIP initiative and even predates the governor's Medicaid redesign. We knew that we needed to be able to quantify our value, both financially and to be able to bundle services in a way that was more responsive to people looking for mental health services. We started the process of shifting to value-based care about five years ago so we're already well positioned to work in this environment.


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?


There are several ways. One is through the broad use of peers who have dealt with or are dealing with similar health issues, and through community health workers. There are many pockets throughout the county where people don't have ready access to care. These liaisons can help people by reaching out to them where they live and helping them to overcome their barriers to creating and sustaining healthy lifestyles. For example, people with serious mental illness have a high rate of smoking and, as a result, can have a life that's shortened by 20 years. We have an approach that uses smoke-free people to help smokers reduce their use of tobacco.


Another is by using emerging technology to strengthen our engagement with people. We happen to already use the same electronic health record system as Stony Brook Medicine but other technologies including those that reach and engage our clients are exciting. 


What in your experience are the top three guiding principles of a successful population health management program?

Shared technology, a commitment to behavioral health integration, and engagement through partnerships of institutional care and community-based organizations.


What value does the Suffolk Care Collaborative bring to patients under the DSRIP program?

Stony Brook is the hub for tertiary care in Suffolk County. Bringing that to DSRIP is huge.


As a pilot partner in the launch of Project 2.d.i for the Suffolk PPS, how has your involvement in the program development gone thus far?

It's been fascinating and challenging. It's creative in terms of reaching people who are uninsured or low utilizers - who touch the system only for emergency care - and engaging, educating and integrating them into community based care. We're looking forward to getting them to activate and take better care of themselves physically, mentally and emotionally.


We are still in the planning stages, but conceptually ready to go. There are still some administrative issues to resolve but we're making progress.  Hopefully within a month we will be starting the pilot.


How do you see this project making an impact on our communities, workforce and population we serve?

For people who live with chronic health conditions, and struggle to follow through with medical care or who end up in emergency rooms, this project has the potential to make a huge difference in their lives. We can help them with their health, educate them, help to eradicate the stigma of mental health, and make sure they get the care they need.

Milestone Dates
NYS DOH DSRIP Program Milestone Dates 

6/01/2015     Initial Organizational and Project 2.a.i Implementation Plans                                                Submitted
6/8-6/9/2015 Baseline Data for Domain 2/3 measures and additional Attributio n                                        Details to PPS
6/09/2015       Baseline Webinar -Domain 2/3
6/18/2018      Presentations from All PPS Meeting in NYC:
6/23/2015      Funds Flow Webinar 
6/26/2015      Medical Record Review Webinar 
6/26/2015      Domain 2-4 Achievement Value Presentation 
6/29/2015      Further Information on earning payments based on Domain 1-4 AVs
7/01/2015      Feedback on June 1st Implementation Plan submissions to PPS                                          from IA
7/07/2015      Project Implementation Plans and Reporting Requirements Webinar



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.