Issue 11
March 31, 2016

Welcome to Synergy


We are pleased to present the eleventh 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 Program Updates
Here is where you'll find highlights across our developing programs!

T ransition of Care Program for Inpatient & Observation Units (TOC) 
(2.b.iv & 2.b.ix)
A product of the last few months' engagement with our TOC Project Committee and subject-matter expert, Dr. Amy Boutwell is the new SCC TOC Model. This document includes an overview, description of the transition of care coordination services, five steps towards implementing the TOC services, communication methodology for care coordination, community navigation methodology, workflow diagrams, roles & responsibilities, training methodology, descriptions of building community based TOC partnerships, observation unit specifications, and the program reporting procedure to the SCC.
The SCC TOC Model was presented to the TOC Project Committee on March 15th 2016. The group without hesitation endorsed and recommended it for review by the Clinical Quality Governance Committee on March 21st, 2016 where it was endorsed. From there the model was presented and approved by the SCC Board of Directors on March 28th, 2016.
With a new SCC TOC Model as a guideline for program operations, the TOC Project Workgroup, comprised of Facility Champions from all Suffolk County Hospitals will be engaged  to begin designing the training curriculum, building their hospital-based implementation teams and determining their TOC services providers. The SCC PMO is looking forward to facilitating discussions with our partners to monitor and support program implementation. To request a copy of the model, please contact our Clinical Project Manager, Ashley Meskill via email,

Interventions to Reduce Acute Care Transfer Program (INTERACT) (2.b.v.ii)
This month, we would like to highlight the SCC PMOs approach for INTERACT program implementation at our 44 SNF partners. Late-2015, the INTERACT Program Facility Champions, co-Champions and many of the Directors of Nursing at each SNF, were identified and certified as Certified INTERACT Champions. Since then, they've been leading implementation at their facility. Each SNF will be using the SCC PMO's web-based project management software, Performance Logic, to document updates on an INTERACT Implementation work plan, which the SCC PMO has written for the program. If you are interested in obtaining a copy of the INTERACT work plan, please contact the Clinical Project Manager, Ashley Meskill via email,
Early this year, the SCC PMO in partnership with Performance Logic hosted a training for all participating SNF Performance Logic Users to orient them to the project management software tool and functionality. This training included an orientation to the content of the INTERACT work plan.

Another key program tool, used across many DSRIP programs, is the design and development of Implementation Toolkits. The SCC PMO and INTERACT Project Workgroup comprised of all 44 SNF Directors of Nursing, developed the toolkit to guide SNFs through implementation. The toolkit contains guidance on building an internal capacity to implement the program, engaging staff, minimum training requirements, standards of care, and project documents that must be returned to the PMO to demonstrate successful completion of the program.
Highlights from this month's Project Committee held on March 21, 2016, included an overview of the final INTERACT Implementation Toolkit, presented by Ashley Meskill, Clinical Project Manager. Alyssa Scully, Director, Project Management Office presented the SCC On-Boarding Program for contracting and extended all 44 SNFs SCC Coalition Partner Participation Agreements , and reviewed the performance-based funds flow model for participation. Lastly, Christine Gironda, Director of Enterprise Analytics at Stony Brook Medicine presented our IT Technical On-Boarding Process and explained our strategy in building an Integrated Delivery System which includes our SNF partners. Click here  for a copy of the presentation. 

Community Health Activation Program  (CHAP) (2.d.i)
The SCC is delighted to announce that, in concert with our CBO partners, we have conducted a total of 11,504 surveys, completing our DY1 commitments in advance of the March 31st deadline.  We would like to congratulate our partners and everyone involved in helping us to meet our goals!

The CHAP Workgroup is currently finalizing a future CHAP program design to integrate all community navigation service requirements across the DSRIP portfolio into the CHAP. At any point of an interaction with our attributed population, a need may be identified based on the following categories: access to health insurance, socioeconomic needs, behavioral health, substance use disorder, medical services, health home or HARP eligibility, and/or PCP navigation for existing Medicaid patients. CHAP is expanding its existing Community Navigation Training curriculum and community-resource directory to provide an avenue to facilitate referrals based on any identified need. We envision referrals being made to the CHAP community navigation services and we'll look to use CHAP community navigation services training curriculum across all DSRIP programs.

Amy Solar-Greco, Project Manager, has engaged key project stakeholders to initiate an analysis of communities in need and determine data sources available to support Community Outreach/Navigation Program Development.  In conjunction with the Stony Brook University Hospital Biomedical Informatics team, she has developed maps of these communities in need to support the strategy for contracted/engaged CBOs and their respective trained Community Health Workers for fieldwork.  These maps have been shared with the CBOs to identify specific locations where the program can be delivered within these areas of need (e.g. food pantries, shelters, etc.). If you are interested in viewing these maps for your organization, please email Amy Solar Greco at  

Primary & Behavioral Health Integrated Care Program (3.a.i)
As the SCC moves into the implementation phase, Integrated Care Implementation Toolkits have been created for all 3 models. These toolkits will be shared with our partners in order to assist them as they move forward in behavioral health/primary care integration. The toolkits include information regarding standards of care, billing, training resources, required project documentation as well as additional resources. While these toolkits will provide information and a framework for our partners, they are not meant to take the place of the technical support that the SCC will offer to its partners with the Behavioral Health Implementation Specialist, Susan Jayson. Together, these resources should help us all as we move into DY2!

Some other exciting news are both the parity laws and the CMS decision to reimburse for two E&M codes in one day! The parity laws that went into effect on January 1, 2016 are beginning to open the doors for not only the discussions, but the practice of telepsychiatry.  As of July 1, 2016, any site that provides two E&M services in one day will be able to be reimbursed for them as long as they have filled out the appropriate DSRIP waiver application.  Reimbursements for these services will be retroactive to the date of the submission of the application.  We anticipate that more information will be forthcoming as reimbursement and regulations continue to evolve. For any questions please contact Susan Jayson at 631-683-1383 or by email at

Cardiovascular Wellness & Self-Management Program (CWSP) (3.b.i) 
On February 23rd, the Project Committee met and endorsed the SCC Care Coordination Model outlining care coordination practices and strategies across the PPS network. In addition, the SCC PMO presented the approach to design the CWSP Training Strategy and accompanying Training Curriculum, which will initiate this quarter.
Over the next few months, the Project Workgroup will be developing a CWSP Implementation Toolkit and training curriculum for all providers and care team members who will be engaged in the program. The toolkit will outline how to meet the DSRIP project requirements, define standards of care for CWSP as well as strategies to implement the Million Hearts Campaign. This toolkit will house all training curriculum as well as instructions to fulfill all training requirements and educational opportunities. Primary care, non-primary care and behavioral health practice sites will be engaged in this program. We'll plan to engage each practice administrator or office manager to orient them to the program and officially initiate implementation.

We're excited to share our new Project Leads, Marie Frazzitta, DNP, FNP-C, MBA, Senior Director Chronic Disease Management, Northwell Health Solutions and Dr. Jean Cacciabaudo, MD, Chief of Cardiology at Southside Hospital, Northwell Health Solutions. Both have been active and involved in the CWSMP for over a year and have offered their expertise as committee and workgroup members. They will now be taking on a larger role and helping to facilitate clinical program collaboration with the other clinical projects.

Diabetes Wellness & Self-Management Program (DWSP) (3.c.i)
Program content development and design is nearing completion under DWSP. Recently, DWSP Project Lead, Dr. Joshua Miller, MD, Director of Diabetes Care, Stony Brook Medicine, and Amy Solar-Greco, Project Manager represented the SCC at the New York Diabetes Coalition, charged with updating the Diabetes Prevention and Management Toolkit for Providers focusing on the Guidelines for Adult Diabetes Management. This Toolkit, which is a summary of guidelines for diabetes management resourced from the American Diabetes Association's Clinical Practice Recommendations will serve as a resources for supporting the implementation of DWSP. 

Next, progress has been made in identifying patient education materials for DWSP. The American Diabetes Association (ADA) will be the source of patient education materials, a step toward identifying best practices for the SCC resource library.  ADA materials are unbranded, free of charge, nationally vetted, and regularly updated - all qualities that were desired by the Workgroup. Patients can improve their self-management skills and stay healthy with the professionally written and illustrated education materials.  Topics may include Living with Diabetes, How to Choose Foods, Meal Ideas, etc. The materials will be endorsed by the SCC and identified to our partner providers in the onboarding process.

Another notable highlight is the program integration occurring with the SCC's care management efforts. Amy has engaged the SCC Medical Director and Care Management Director to determine policies and procedures to develop the DWSP care coordination model for the management and control of diabetes. Clear work flow processes for the care management/care coordination function were developed that will support the DWSP program. We look forward to aggregating all of these tools to support integrating these clinical improvement programs at our participating practice sites.

Promoting Asthma Self-Management Program (PASP) (3.d.ii)
In preparation to implement the Asthma Home Environmental Trigger Assessment, the PASP Project Workgroup, in collaboration with internal stakeholders, has drafted the following documents, which will be formalized into a PASP Implementation Toolkit:
  • Work flow diagram for home environmental trigger reduction program
  • Roles and responsibilities of the Community health worker and coordination staff
  • Community Health Worker training curriculum
  • PASP reporting procedure to monitor the program
  • PASP selected evidence-based trigger reduction interventions
  • PASP procedures to navigate clients to resources for evidence-based trigger reduction interventions
  • PASP patient education materials for evidence-based trigger reduction interventions to be used
  • PASP patient education materials for self-management education services
The PASP Project Manager has engaged the SCC Medical Director and Care Management Director to determine policies and procedures to develop the PASP care coordination model for the management and control of asthma.  
Featured Program
Project 4.a.ii Screening, Brief Intervention, and Referral to Treatment (SBIRT) Program 

The SCC is pleased to announce that efforts to implement SBIRT - Screening, Brief Intervention, and Referral to Treatment - in the Emergency Department across all 11 Suffolk County Hospitals is fully underway. This month, we would like to highlight the value of SBIRT by sharing two perspectives from our hospital partners. SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders.

S - Screening
Everyone who enters the Hospital emergency department to seek treatment, ages 13 years and older, will be given a short set of evidence based questions which ask about their substance use (alcohol, drug, and tobacco). If a person scores over a certain threshold on this pre-screening, they will be administered a full screening, and may participate in a brief intervention.
BI - Brief Intervention
The brief intervention is an opportunity for healthcare workers to interact with the patient and provide feedback about his or her substance use. The healthcare worker will use various motivational interview techniques to increase awareness and insight related to the health risks of unhealthy substance use, provide education, and enhance motivation to foster a health behavior change.
RT - Referral to Treatment
For individuals needing additional care beyond what is provided in the brief intervention, they may be referred to treatment. Hospital staff will help to facilitate this transition of care and access to treatment, including OASAS licensed clinics.
The SCC PMO is committed to supporting workforce training for this initiative. We've designed an in-person monthly SBIRT training schedule to facilitate on-site SBIRT trainingfor ED staff at each hospital on-site. To date, three Suffolk County Hospitals have hosted SBIRT trainings for their ED staff members. We congratulate Brookhaven Memorial Hospital, John T. Mather Memorial Hospital, and Stony Brook Medicine for completing their SBIRT Hospital ED go-live.  

Below are perspectives and experiences with SBIRT from two of SCC's partner organizations. 

Name : Kristie Golden, PhD
Title: Assoc iat e Director of Operations, Neurosciences, Neurology, Neurosurgery & Psychiatry
Organizatio n: Stony Brook Medicine
On a broader scale, all hospitals in Suffolk will go live over the next 12-18 months as a part of the Delivery System Reform Incentive Payment Program (DSRIP) initiative. At Stony Brook, this is a large-scale project that involved many people and departments who deserve special thanks for bringing the project to fruition. It is also a chance for Stony Brook to shine for being a driving force behind encouraging other Suffolk County hospitals to move in the same direction.
With population health a major focus of the healthcare industry, and the move toward Accountable Care Organizations and performance-based payments, prevention and early intervention are at the forefront of potential healthcare savings and positive patient outcomes. There is significant research which demonstrates that a brief intervention is a catalyst in helping people change their behavior around substance use even when they are not even thinking about making change. It also can:
  • Reduce ED visits 
  • Reduce readmission rates 
  • Improve public health over time 
  • Address/Treat the "whole" person 
  • Improve family outcomes 
  • Improve patient/family satisfaction
The SBIRT protocol will help ensure our patients with substance use difficulties are connected to the appropriate community resources at the time of discharge, beyond simply providing information about where they can seek services. Because of the nature of addiction, the motivational interviewing techniques used in the assessment process and the timeliness of a follow-up appointment are crucial to the success of a patient's connection to a substance use treatment program when they are actively ready to receive help. Identifying and connecting the patient to a community-based or inpatient program when they are in our facility can make a life and death difference in the patient's recovery.
Stony Brook has partnered with a multitude of community organizations to prepare for this roll out. Although the community system of care is building in this area, work still needs to be done to create capacity. In addition, legislative advocacy continues to take place in an effort to ensure appropriate insurance coverage is available for those needing treatment.

Name : Richard T. Margulis
Title: President, CEO
Organizatio n: Brookhaven Memorial Hospital Medical Center 

Brookhaven Memorial Hospital Medical Center (BMHMC) is pleased to announce the implementation of the SBIRT program in our Emergency Department.

The pr evalence of substance abuse in our community is a paramount issue and BMHMC is strongly co mmitted to addressing it. With the use of evidence based screening surveys, our interdisciplinary staff  will help identify early signs and symptoms of substance abuse and behavioral health conditions, to ensure patients receive the most clinically appropriate interventions in an expeditious manner.
Drug and alcohol addiction destroys lives, tears apart families and harms society. The SBIRT program is an important initiative which supports Brookhaven Hospital's mission to provide quality, integrated care and promote prevention and wellness in our community. Our focus has always been and always will be, on delivering compassionate healthcare to our patients and their families.
Medicaid Beneficiaries Joining CHAP Discussions
CHAP Workgroup
(Left to Right)
Mark Kessner, MHAW Sarah McGowan, Team Leader, MHAW; Ligia Soto, Senior Community Care Partner, HRHCare Suffolk Migrant Voucher ProgramPaula Fries, COO /CCO, MHAWTrevor Cross, Community Liaison, HRHCareAndrew Lehto, Director, Community Outreach & Engagement of Special Populations, HRHCareDaniel (Brian's friend)Halim Kaygisiz, Director of Health Outreach Services, EOC Tara Larkin-Fredricks, Director of Special Projects, MHAW Brian (Beneficiary) Amy Solar Greco, Project Manager, SCC Gwen O'Shea, President/CEO, HWCLIAdrian Fassett, President/CEO, EOC

On March 23rd, the CHAP Workgroup was pleased to welcome three CHAP participants from the community to join a discussion about program development.  Brian, Daniel, and Wendy, are currently directly and indirectly involved in the CHAP program.  They have had first-hand experience with the services we offer, including the PAM survey as well as Community Navigation.  The Workgroup asked them to join the meeting to learn more about the specific challenges (e.g. social determinants of health) they face in obtaining health and/or social services, how they came to be involved in our program, and learn how we may continue to evolve our program to better meet the needs of the community.

To briefly summarize, the CHAP project is focused on persons who are uninsured or under- or not utilizing the health care system and works to engage and activate those individuals to utilize primary and preventive care.  The SCC is implementing patient activation activities in these populations through cooperation and interaction with Community Based Organizations (CBOs), health care providers, and managed care organizations.  CHAP comprises the following services: the PAM survey to assess an individual's activation level and score, Community Navigation to help direct individuals to appropriate services and resources, and Wellness Coaching for individuals that require additional support in order to seek preventive care.

At the meeting, our discussion centered on the challenges faced when seeking health or social services in the local community. The issue of locating services in the area, and who to contact for information was identified as a major challenge.  Eligibility and the question of health care costs was also a concern.  Additionally, long wait times and not always knowing what questions to ask were brought up as barriers to access. 

While there are clearly many obstacles still left to overcome, all noted that their situation was improved through involvement in CHAP.  Wendy, who was previously uninsured before participating in the program, is now a Medicaid beneficiary, and has been navigated to providers and services by Community Health Workers in her area.  Daniel, Brian's friend, said he has a much clearer picture now of the services Brian is eligible for and how to attain those services.  In the brief two months that he has been engaging in CHAP with Brian, he feels his friend's situation has improved and that he is better able to help Brian manage his care.

The SCC would like to thank our CBO partners, the Economic Opportunity Council, Hudson River Healthcare and the Mental Health and Wellness Association, for leading and facilitating these discussions.  We plan to continue to engage Wendy, Brian and Daniel, and others, as we look for new and additional ways to improve the program and receive feedback from people that CHAP is serving throughout Suffolk County.
Consumer Perspective: Interview with Newly Enrolled Medicaid Beneficiary
The Suffolk Care Collaborative met Wendy through our Community Health Activation Program (CHAP, DSRIP Project 2ai) outreach efforts. Our partner Community Based Organization's community health worker initiated a conversation which led to the PAM survey and community navigation services, ultimately resulting in enrollment into the NYS Medicaid Program, among other benefits. Here is Wendy's perspective: 

Can you share the experience of being introduced to the SCC CHAP Program? (How, where, when, was it warm/ welcoming)
One day I mentioned to a friend of mine who works for the Health Homes Outreach program, that I didn't have health insurance and needed to have some medical tests.
She told me that she could help me. She briefly explained the program that she worked with and said that her supervisor would be in touch shortly. He called me an hour later.
I explained my situation to the supervisor and a day later I had health insurance. He helped me choose an insurance company that he thought might be the best provider for me, and gave me a temporary ID number to use in case I needed it before I received my cards in the mail.

How long had you been without insurance?
For over 20 years. If I had a job, it would be part-time and they wouldn't offer insurance. Paying for my own coverage was something that I have never been able to afford.
Any time I did get sick I would go to a walk-in clinic, pay the fee, and also pay for prescriptions. I didn't even think to pursue anything further because I didn't know there were programs available.
Sometimes I would get a mailed notice about the free mammogram that they would offer from a Scan Van and would take advantage of that. There is also a mobile health van that is parked in the area where I work in Patchogue. So that would have been my next step if I hadn't spoken to my friend.  

How has the CHAP program helped you?
It just made me feel comfortable knowing that I had my plan and I could go to the doctor when I needed to. Just recently I went to get some baseline blood tests, and see a gynecologist. So I'm just starting to take advantage of the insurance now.

What are/ Were the challenges in the current health system you faced? Did the CHAP program address a few of those challenges?
Being self-employed and not having the financial ability to enroll in a program on my own. And also the overwhelming process of dealing with the paperwork.
So for my friend's supervisor to just ask me a couple of questions and help me get insurance was a big relief. He was very professional about it. He didn't make me feel uncomfortable about anything.

Would you recommend this program to other individuals facing similar circumstances?
Yes, and I've already done that. A friend's daughter, who was eight months pregnant, had moved from New Jersey to Long Island and lost her health coverage. I mentioned that I knew somebody who could help her get insurance more quickly. I reached out to my friend who had helped me earlier, and my friend's daughter called, and in three days she was covered.
That really gave me more joy than anything. More even than getting my own insurance. It was nice to be able to help someone else. 
Compliance Connection

Timely restricted party screening of your organization's employees, officers, vendors and contractors is one of the basic functions of an effective compliance program.  In the DSRIP Medicaid context, the SCC and its coalition partners have an obligation to conduct timely screening to identify individuals or entities that have been excluded from participating in federal or state programs. This means screening before a business relationship with an individual or entity is commenced and at least monthly afterward, since their status could change.  The idea is to avoid directing public monies to parties who have lost the privilege of eligibility to receive them through unethical, illegal, or noncompliant conduct.  The SCC screens prospectively and then daily through a dynamic screening service.  Screening is a pre-requisite of a coalition partner being able to agree to Section 1.6, Exhibit G of the SCC Participation Agreement.  For details about the SCC restricted party screening requirements, see Compliance Policy #6 (p. 18) and the Compliance Program and Guidelines
(p. 19, section d).  As always, you may find helpful information at our compliance program webpage.  If you have questions about restricted party screening in the SCC context, please contact SCC Compliance Officer, Sarah Putney, at or (631) 638-1393.  Thanks for keeping us ethically sound and compliant!   
Milestone Dates
NYS DOH DSRIP Program Milestone Dates 
March 31
DSRIP Year 1 ends
April 1
DSRIP Year 2 begins
April 7 Final PPS Year 1 Third Quarterly Reports posted to DSRIP website
April 18
Public Comment Period for Value Based Payment Roadmap closes
April 30
PPS Year 1 Fourth Quarterly Reports (1/1/16 - 3/31/16) 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.

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.