Issue 14
June, 2016

Welcome to Synergy


We are pleased to present the fourteenth 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
Community Based Partnership for Integrated Care Services 
The SCC is excited to announce a new community-based organization partnership with Family Service League under the SCC Primary & Behavioral Health Integrated Care Program

About Family Service League
Family Service League's mission: Family Service League helps individuals, children and families to mobilize their strengths and improve the quality of their lives at home, in the workplace, and in the community. 

Since its inception in 1926 as a grass roots social service agency, Family Service League (FSL) has grown dramatically-achieving national accreditation and expanding its scope of influence and support throughout Long Island. Today, more than 50,000 individuals, from newborns to centenarians, rely on the social safety net that Family Service League provides.

FSL manages one of the largest and most comprehensive networks of care across Long Island, serving infants to elders through Children and Youth Programs, Senior Services, Vocational Programs, Family Support Programs, Mental Health and Substance Abuse Programs, and Housing and Homeless Services. FSL's program model includes strategically placed family centers that provide a continuum of care to address the multitude of challenges faced by children, families and individuals in the various aspects of their lives. FSL is governed by an active 36 member Board of Directors and staffed by 700 (full and part time) skilled professionals, paraprofessionals and support personnel. More than 400 volunteers support the work of the agency as program volunteers, fund raisers, professional and community advisors. To learn more about the Family Service League, click here.

New Primary & Behavioral Health Integrated Care Services Partnership
Our new program is aimed at developing collaborative care models between PCPs and behavioral health organizations which involves direct co-location of interdisciplinary clinicians within a site, and/or the establishment of a level of collaboration between agencies based on geography, skill set, community needs, and other factors. Family Service League has longstanding valuable experience in providing integrated care and we look forward to adopting many best practices from their models. The new Primary & Behavioral Health Integrated Care Services partnership will arrange for co-locating behavioral health clinicians in our engaged primary care practices. These behavioral health clinicians will: 
  • Render solution-focused, short-term, counseling services to patients of the primary care practices
  • Participate in efforts to stratify patient risk, provide patient education, and assist in community-based referrals
  • Communicate and collaborate with the care team and its primary care clinicians by sharing session/contact notes and other relevant clinical information and ensuring its capture in the primary care practice's electronic health record system
  • Support implementation of responsibilities and evidence-based standards of care as outlined in the SCC Integrated Care Implementation Toolkit designed by the SCC 3ai Project Workgroup. 
Goals of our partnership include promoting the integration of behavioral health and primary care services for the purposes of:
  • Identifying behavioral health diagnoses early and allowing rapid treatment
  • Ensuring that treatments for medical and behavioral health conditions are compatible and do not cause adverse effects
  • De-stigmatizing treatment for behavioral health conditions  
  • Building a model of financial sustainability for the provision of integrated care services between FSL and our primary care practice sites

Having a partnership with the SCC is precisely what is needed at this time to help us all move forward in delivering best practices for primary and behavioral health integrated care services in various medical practices.  We are honored to partner with the SCC.          

-Karen Boorshtein, President & CEO-Family Service League

Primary & Behavioral Health Integrated Care Program update  
This past month, the Primary & Behavioral Health Integrated Care Program held an Integrated Care Kick-off Breakfast for participating Integrated Care Practice sites!
The goal of the engagement is to educate and inform our Integrated Care practices to the program, provide an opportunity for networking amongst participating providers and provide copies of the SCC Integrated Care Implementation Toolkit. Further the SCC's Director for Behavioral Health Services Integration oriented the group to next steps and the technical assistance we'll provide to support our sites integrated care efforts.

To date our Integrated Care practice sites are regionally spread throughout Suffolk County. In total there are 320 providers engaged across three phases.

Integrated Care Practice Sites Engagement Update:

Number of  Providers
Number of Sites
Phase 1
Phase 2
Phase 3
Grand Total

Suffolk Care Collaborative Director, Behavioral Health Services Integration, Susan Jayson leads general discussion of Integrated Care Implementation at the Integrated Care Kick Off Breakfast

Population Health Management Roadmap Publication
We are pleased to present our population health management roadmap!  

The Suffolk Care Collaborative is excited to announce the completion of the SCC Population Health Management Roadmap which will be used to continue and enhance our efforts in improving the health of populations in Suffolk County. This document highlights the key areas necessary for operationalizing Population Health Management which include: 
  1. Data Collection, Storage and Management
  2. Use of Technology to Monitor & Stratify Populations     
  3. Identification of Patient Populations
  4. Team Based Interventions & Care Team Coordination
  5. Measuring Outcomes
The development of this Roadmap was done collaboratively with our partners from CHS, Northwell and SBUH and content was developed and endorsed by the Population Health Management/Integrated Delivery System (PHM/IDS) Workgroup as well approved by the Board of Directors.
Ultimately, Population Health Management in the Suffolk Care Collaborative looks to drive better outcomes, measure these outcomes and design quality improvement and performance reporting measurement plans to ensure sustainability. We can do so by investing in information systems, utilizing robust technology applications to continually identify and stratify patient populations, and leveraging data to enable care teams to manage patients more efficiently and effectively.
To review our Population Health Management Roadmap, click here.

Care Coordination & Care Management Workgroup Highlight
The SCC's Care Coordination and Care Management Workgroup is at the forefront of our care coordination developments

Effective Population Health Management cannot be done without the efforts of those    organizations providing care management to identified patient populations and assisting them in managing their healthcare goals. Similarly, Clinical Integration relies on the coordination of care throughout the continuum and aims to create seamless transitions for patients through communication exchange, namely clinical interoperability. The focus of both of these initiatives relies heavily on Care Management and Care Coordination and out of this need, the SCC Care Management and Care Coordination Workgroup was born.
The Workgroup, led by Kelli Vasquez, Senior Director of Care Management and Care Coordination, held its 3rd meeting on June 3, 2016 and this session was focused on navigating care throughout the continuum. Approximately fifty partners attended this meeting with representatives from CHS, Northwell, and Stony Brook University as well as from Suffolk County providers in Health Homes, Home Care, Behavioral Health, Skilled Nursing Facilities, and government agencies. The charge of this group is to collaborate on ways in which all organizations in Suffolk County can communicate effectively so that a patient receives the right care, at the right time, from the right resource. To view the workgroup charter, click here.

The Workgroup has come together to identify key areas for improvement needed in the care continuum as well as has had some quick wins in our session. Below are some highlights of our work:
Early Collaborative Wins:
  • A Suffolk County Manual of Care Management and Care Coordination Services has been developed with descriptions of each participating organization included. This was meant to be a starting point to understanding the available services in Suffolk County and knowing who to call when a patient is in need. To view this document click here. To contribute to this document please email your "one pager" to
  • A contact list has been created and distributed to all members of the Workgroup with the intention of getting in touch with one another when additional information is needed. New relationships have already been formed and the Suffolk Care Collaborative Care Management Organization has already taken advantage of in-services and tours of our partners' facilities and programs! To do the same for your organization, click here to access the contact list.
  •  Collaboration with the SCC Community Engagement Workgroup is underway as there is clear synergy between the missions of the two groups. We look forward to working together on some new and innovative ideas.
 Team Collaboration has identified the following areas of need in Suffolk County:
  • Access to nutritious foods for our patients so that they may follow recommended diets and improve health outcomes
  • Availability of safe, affordable housing on Long Island
  • Access to transportation for needs outside of Medicaid covered non-emergent transport and mechanisms to eliminate three day wait times for medical appointment transports
  • Availability of psychiatric medication management appointments, specifically those that offer culturally and linguistically appropriate services
If you or your organization can assist the Workgroup in developing the needed resources in these areas please contact 
Over the next few months we hope to work together with the Community Engagement Workgroup and develop strategies to mitigate some of the barriers listed above. IT solutions will also be explored in order to make resources readily available and communication seamless. We thank the participants of this Workgroup for their continued engagement and enthusiasm and we look forward to advancing the agenda of this group while creating the foundation for the Integrated Delivery System that is developing in Suffolk County.
What is the MAX Series?
Medicaid Accelerated eXchange (MAX) Series

Designed by KPMG for the NYS Department of Health Delivery System Reform Incentive Payment (DSRIP) Program the Medicaid Accelerated eXchange Series focuses on  process improvement principles to implement re-design efforts for a specific patient population. The goal is to accelerate transformation (speed of change) and instill lasting change with participating partners. The engagements are lead by an Action Team, an interdisciplinary front-line team comprised of 8-10 individuals that are directly involved in meeting the target population's diverse medical, behavioral and social issues.

The MAX series has supported three MAX Series engagements with our partners with the following themes: Super Utilizers: Meeting Complex Patient Needs and Integrating Behavioral Health and Primary Care Services. For each topic the MAX series is delivered in three phases: Assessment and Preparation, Clinics and Improvement Cycles, and Reporting. Click here to learn more.

The Suffolk Care Collaborative has been fortunate to have teams participate in all three cycles: Brookhaven Memorial Hospital and Medical Center, Stony Brook Family Medicine, and Southside Hospital. In our Partner Interview we hear from the Brookhaven team.

Partner Interview        
Name:  Julie Vinod, DNP, MS, ANP-C, RN
Title: Assistant Director of Nursing Operations
Organization:  Brookhaven Memorial Hospital and Medical Center

Please describe the MAX Series Project Charge your organization participated in?
Medicaid Accelerated eXchange (MAX) Series is part of the NYS Department of Health Delivery System Reform Incentive Payment (DSRIP) Program 2015. Brookhaven Memorial Hospital participated in reducing the preventable COPD Super Utilizer ED visits.

Who was part of your team?
It was an interdisciplinary team composed of Hospital Leadership Team, Nursing, Physicians, Primary Care Provider, Respiratory Therapy, Care Management, Education Department, IT, Pharmacy, and Patient Centered Medical Home Coordinator Collaborative Care. As well as community agencies including Health Homes, Home Care and Community based organizations.

Brookhaven's MAX Series Team.
(Left to Right): Samuel Beckles, BSN, RN, Nurse Manager, COPD Unit; Monica Schlie, Social Worker ED; Ciresi Darlene, Care Manager, COPD Unit; Kevin Ramdeen, BSN, RN, Clinical Coordinator, COPD Unit; Steven Sanderson, Decision Support Analyst; Jessica Philius, Social Worker, COPD Unit; Karen Shaughness, LCSW, Senior Director, Ambulatory Services; Brianne Rizzo, Director of Care Management; Dr. Julie Vinod, DNP, MS, ANP-C, RN, Senior Director, Ambulatory Services; Jody Felice, RN, Home Care Nurse; Stanley John, MHA, BS, RT, RRT-NPS, Director Respiratory Care & Support Services; Elfriede Weiss-Paquette, LCSW, Director Collaborative Care, PCMH; Tameka Squire, BSN, Clinical Instructor.
Not Pictured: Dr. Nejat Zeyneloglu, MD, CQMO, Clinical Lead; Keisha Wisdom, VP, CNO, Clinical Lead.

What was the goal?
To reduce the number of COPD Super Utilizer ED visits by 10% in one year.

What was the groups approach?
Early identification and notification of the COPD super utilizers via the flagging system.
Establishing a standard plan of care of COPD super Utilizers, Education and creating awareness on COPD; Internal communication to all the interdisciplinary team about the project, Cohorting COPD patients, Multidisciplinary Collaborative Approach with weekly team meetings with Brookhaven Action Team and KPMG. Contact or escalation of challenges via phone or email on a daily basis. Expert Advice during meetings and on MIX IT website. Interdisciplinary Collaboration and coordination with community outreach and Health Homes. Utilization of motivational interviewing techniques and establishing support and rehabilitation services for COPD patients. Graduation handoff using the graduation protocol created for this project, and persistence and dedication of the Team. Future Scaling of this project to include other disease conditions (Heart Failure, MI...).

What was implemented?
Created COPD Super Utilizer List, Created a Flagging System; Created 62 patient profiles, o Opened a COPD Unit. Created a secured shared drive to document and communicate within the action team. Educated the frontline staff. Created a multidisciplinary COPD Plan of Care Created a workflow for COPD patients. Created a care coordinated note template and a Home Assessment tool. Created a Graduation Protocol Created Health Home enrollment spread sheet. Established a Brookhaven Better Breathers Club. Established a handoff culture between hospital care management team and the health home coordinator.

What was your impact/findings?
We reduced the, ED Visits by 44% and reduced our In Patient Admissions by 45%
And the Readmissions rate by 29%.

How did you engage health homes in care coordination and navigation of patients?
Health Home representatives met with staff and educated them about Health Home application process, and established key contacts. Conducted one on one case study in a collaborative approach involving the patient, care giver/ residential representatives, Brookhaven team and health home coordinators. Depending on the need assessment, escalated patients to high touch cases. Maintained frequent contact with Health Homes to ensure patients are enrolled.

Please describe a patient experience?
This is a patient with multiple chronic conditions, including depression, who contributed to 14 hospital visits in a 6 month period including, 5 admissions and 3 readmissions. Most of these visits were not related to COPD but a feeling of insecurity. As the first patient of the program, the patient received a needs assessment which uncovered a need for frequent education with medications, BIPAP use, and support for follow-up appointments. In spite of all the education and support, the patient still came to the ED. Soon we realized that the patient needs community outreach support and coordination. We conducted a case study meeting with the residential representatives and Health Home coordinator. After the meeting, we along with Health Home decided that the patient needs intensive case management (ICM). And the patient was upgraded to ICM. The patient is now receiving care coordination services, which has helped the patient to connect to primary care, Medicaid transportation, and alternatives to the ED. This patient has been given the opportunity to engage to an Adult Day Care center. This particular patient did not return to the ED for 3 months and had graduated in May. Since March 2015, the patient had only one ED visit in June which was for heart failure and was appropriate.

How do you feel this effort will support the DSRIP goals?
The goal of DSRIP is to reduce avoidable hospital use by 25% over 5 years. This effort will meet the DSRIP goal for better care, better health and lower costs. We have created a foundation for enhanced, patient-centric holistic assessments, and strong communication and collaboration amongst all providers involved in each patient's care. This project can be replicated, implemented and applied as best practice in other institutions among super utilizers.
MAX Series Team Success Celebration.
(Left to Right): Elfriede Weiss-Paquette, LCSW, Director Collaborative Care, PCMH; Dr. Julie Vinod, DNP, MS, ANP-C, RN, Senior Director, Ambulatory Services; Karen Shaughness, LCSW, Senior Director, Ambulatory Services; Gerald Garland, Social Worker, Northwell Health Home.

Value Based Payment Developments
Program sustainability through value-based payment arrangements is a key function of our DSRIP work. 

To ensure the long-term sustainability of the improvements made possible by the DSRIP programs the DSRIP program requires the State and all PPSs to submit a multiyear Roadmap for comprehensive Medicaid payment reform including how the State/PPS will engage Managed Care Organizations (MCOs) to include value-based payment arrangements.

The SCC Value-Based Payment (VBP) Workgroup has been engaged and charged in the DSRIP VBP program deliverables, to include the design of a SCC Value Based Payment Plan. Some of the elements of such plan will complement the previously published New York State Department of Health's DSRIP Value Based Payment Plan, which include the following themes:
  • How can alternative payment systems deployed by MCOs will reward performance consistent with DSRIP objectives?
  • How the NYS DOH will use DSRIP measures and objectives in their contracting strategy approach for managed care?
  • How can the state ensure providers participating in and demonstrating successful performance through DSRIP will be included in provider networks?
  • How managed care rates will reflect changes in case mix, utilization, cost of care and enrollee health made possible by DSRIP? 
To date, the Workgroup is currently designing a detailed baseline assessment of revenue linked to value based payment, preferred compensation modalities for different provider types and functions, and Managed Care Organizations (MCO) VBP strategies. To achieve this strategy, the Workgroup had deployed a VBP survey, distributed to select SCC network providers and due back on June 3rd. We received an approximate 42% response rate to the survey, which has been analyzed by the VBP workgroup. The results highlight that many of our partners currently have VBP Level 0 to Level 3 contracts in place with various MCOs. Next up, the Workgroup is developing the VBP plan which will be submitted to the Board of Directors to review and approve in September of 2016.  

We have received guidance this month from the NYS DOH that the Financial Sustainability milestones pertaining to VBP now have the following due dates:
  • DOH Milestone 5: Finalize a plan towards achieving 90% value based payments across network by year 5 of the waiver is due DY2 Q4 (3/31/17).
  • DOH Milestone 6: Implement Level 1 VBP arrangement for PCMH/APC care and one other care bundle or subpopulation is due DY3 Q4 (3/31/18).
  • DOH Milestone 7: Contract 50% of care costs through Level 1 VBPs and greater than or equal to 30% of these costs through Level 2 VBPs or higher is due DY4 Q4 (3/31/19).
  • DOH milestone 8: Greater than or equal to 90% of total MCO-PPS payments (in terms of total dollars) captured in at least Level 1 VBPs and greater than or equal to 70% of total costs captured in VBPs has to be in Level 2 VBPs or higher is due DY5 Q4 (3/31/20). 
NYS Department of Health VBP Resources
NYS DOH has published a number of resources for value-based payment education:
  • DSRIP Value Based Payment Reform Webpage: part of the NYS DOH DSRIP webpage, a dedicated section to include VBP quick overview videos, news, VBP Roadmap and future planning for VBP and Medicare alignment.
  • Value Based Payment Bootcamp Series: a regional learning series that will be provided by the Department of Health to plan and provider communities within the State to deliver necessary information about VBP and ensure a successful transition to its implementation.
  • Value Based Payment Roadmap & Subcommittees: in order to develop detailed design of the payment reform and transition towards VBP, the state has leveraged the NYS DOH Value Based Payment workgroup to create five subcommittees.
  • A Path toward Value Based Payment: Annual Update June of 2016 marked year two of the New York State's Roadmap for Medicaid Payment Reform. This newly published document provides the first annual update to the VBP Roadmap.
Kicking off Engagement of Healthfirst Medicaid MCO Non & Low Utilizing Medicaid Members
The Suffolk Care Collaborative (SCC) and Healthfirst, a managed care organization, are collaborating to assist the Community Health Activation Program (CHAP) in its outreach to low and non-utilizing Medicaid members. In conjunction with our partner Community Based Organizations (CBOs), SCC is engaging and activating Healthfirst members to utilize primary and preventive care. Low and non-utilizing member rosters are shared by Healthfirst on a regular basis with its sponsor hospital contacts. The PPS, through coordination with its provider network, receives and shares this information with the CBOs, who will then outreach to the members. Eligible participants may be enrolled in wellness coaching and/or community navigation efforts to connect patients to their PCP and community health resources. We are very excited to launch this effort, with Healthfirst's support, as a first step in engaging patients of our MCO partners, and we believe this is a great step forward in providing quality services to Medicaid recipients through DSRIP initiatives.
Compliance Connection
Medicaid Member Fraud

Compliance programs tend to focus their Medicaid fraud detection and prevention activities on providers. But fraud may also be committed by patients enrolled in Medicaid (also called recipients or members), much as we may want to hope otherwise, and our compliance activities should also address this risk. Examples of enrollee fraud include:
  • Lying about eligibility for Medicaid (such as not reporting assets);
  • Lending a Medicaid Identification card to another person;
  • Forging or altering a prescription or fiscal order;
  • Using multiple Medicaid ID cards;
  • Intentionally receiving duplicative, excessive, contraindicated, or conflicting health care services or supplies; and
  • Re-selling items provided by the Medicaid program.
Enrollee fraud costs taxpayers money and can waste valuable healthcare resources. A number of governmental agencies investigate member fraud, and the consequences can be severe. SCC partners and their employees should be alert to signs of potentially fraudulent Medicaid member activities.  We have a duty to report actual or suspected concerns affecting DSRIP funds or arising under any local laws, rules, regulations, standards, guidelines, policies and procedures relating to DSRIP. To report fraud directly to the state, call 1-877-873-7283 or use the online submission option . When in doubt, talk to your compliance officer or call the SCC Compliance Hotline at 1-631-638-1390. Learn more at the OMIG Fraud/Abuse webpage . Thank you!

Milestone Date
NYS DOH DSRIP Program Milsetone Dates

July 6
Final PPS Year 1 Fourth Quarterly Reports posted to DSRIP Website
July 12
1115 Waiver Public Comment Day (Upstate)
Late July
DY1 Third DSRIP Payment to PPS
August 1
Initiate Mid-Point Assessment for PPS
August 1
PPS Lead Regulatory Waiver Requests - Round 3 due
August 5
PPS Year 2 First Quarterly Reports (4/1/16 - 6/30/16) 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. 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.
Click the links below to access job descriptions.
For more information, please contact the Suffolk Care Collaborative via email

Stay Informed


SCC communications currently include bi-weekly "DSRIP in Action" emails, a monthly "Synergy" eNewsletter, and the SCC website, which houses a wealth of resources including individual program webpages, 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.