Issue 25
May, 2017
Welcome to Synergy
We are pleased to present the twenty-fifth 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
A Message from Joseph Lamantia, SCC's Chief of Operations 
Dear PPS Partners, Friends and Colleagues,
As I transition from my leadership role with the SCC PPS to the next chapter of my professional career, I would like to express my sincere gratitude for all of your support, trust and friendship over the past several years as we have collectively worked towards systematically reengineering and redesigning our health care delivery system.  In a relatively short period of time we have leveraged the DSRIP process to build a foundation for value-based care with the critical and key component being collaboration across our provider network.  We learned very quickly that in order to improve performance ("value") all providers across various provider types must be aligned.  We must not only work towards aligning our efforts, but incentives for how we perform must also be aligned.  There's no doubt in my mind that our experience to date and the processes that we've built, primarily around DSRIP, is not only the kind of change that needs to take place in order to improve population health, it will also better help position providers for a future that will have a greater emphasis on reimbursement for value.
While this is a bittersweet transition, it's less on the bitter-side because I know that I will still be engaged with the SCC PPS.  I look forward to my new role at the Northwell Health System and the prospect of being able to help support the SCC on achieving its goal. 
I have full confidence that the SCC leadership team and staff will continue to organize and implement transformative, sustainable changes that will assure success for the PPS and serve as a best practice State-wide for healthcare transformation.
Thank you!
SCC's Leadership Transition
As we wish Joe Lamantia good luck in his new role at Northwell Health, we also thank him for establishing the SCC's strong foundation from which we will continue our trajectory of success.  As the founding member of the SCC, the growth and development of this organization is a testament to Joe's leadership and vision - and the talent of the dedicated team that drives the progress being made on a daily basis. 
As the SCC team continues to transform healthcare delivery in Suffolk County, we are poised to continue developing and bringing to fruition our sustainability plans.  To that end, we are committed to ensuring a smooth transition that will support the SCC staff and our partners in the years to come. 
The entire SCC team wishes Joe the very best in his new career opportunity.   We look forward to continued success and thank our staff and our partners for their ongoing contributions and efforts.

Linda S. Efferen, MD, MBA, FACP, FCCP, FCCM
Interim Chief of Operations & VP, Medical Director

Vice President, Population Health Management Services

You Are Invited to Join the SCC for the June 2017 
Project Advisory Committee (PAC) Meeting

Friday, June 23, 2017
8:30 a.m. to 12 p.m.
Hyatt Regency Long Island
1717 Motor Parkway
Hauppauge, NY

We are pleased to present this quarter's topics and keynote speakers:

Jill Golde, M.S., Partner & Senior Vice President at the Language of Caring

Joanne Lauten RN, BSN, SCRN, CPHQ, Director of Nursing Quality and the Stroke Coordinator at John T. Mather Memorial Hospital

Nancy Copperman MS, RD, CDN, Assistant Vice President at Northwell Health  

Click on the links below for more information or to register.

SCC's Transition of Care Program Presented at Greater New York Hospital Association (GNYHA) Workgroup 

The Suffolk Care Collaboartive's Care Transitions Team was invited to present our DSRIP Project 2.b.iv: Transition of Care Program for Inpatient & Observation Units Model at the Greater New York Hospital Association Post-Acute Workgroup meeting in April. This workgroup convenes on a quarterly basis, bringing together fellow Performing Provider Systems (PPS) across the state as well as key stakeholders along the care continuum, who are involved in care transitions. Our presentation highlighted our journey from inception and development to implementation and performance monitoring and improvement.  This was a great opportunity to hear feedback from other population health offices, implementing similar DSRIP projects, as well as showcase the collaborations taking place in Suffolk County. Along with our presentation, Westchester Medical Center PPS presented their model, highlighting their use of medical villages to engage community partners. Seeing the work of other PPSs is an invaluable resource allowing us to glean insight from a different perspective, working with a similar demographic. We look forward to continuing our partnership with GNYHA and attending future Post-Acute Workgroups to continue collaborations and gain knowledge to apply to our efforts here at the Suffolk Care Collaborative.
Primary Care Practice Transformation Update
Recognition Progress Across the PPS

As part of Suffolk Care Collaborative's practice transformation, the Practice Transformation Workgroup (formerly named PCMH Certification Workgroup) brings together experts and practice leaders that have significant experience in transforming practices under Patient Centered Medical Home (PCMH) 2014 standards.

The practice transformation efforts at SCC across its three (3) hubs, namely Stony Brook University (SBU), Northwell Health (NWH) and Catholic Health Services (CHS), have been progressing well.  Below illustrates the progress of practices by hub that have already achieved PCMH 2014 Level 3 recognition, are in progress or identified as good candidates for PCMH 2014 Level 3 recognition.  


Click here for the list of current PCMH 2014 Level 3 recognized practices in all three Hubs.  

The practices that are working towards transformation have support from PCMH Certified Content Experts (CCE) and practice transformation specialists. Transformation related trainings are offered to our partners in a cohort or a one-on-one format. The SCC has also engaged transformation specialty firms: Hospital Association of New York State (HANYS), Primary Care Development Corporation (PCDC) and NYC Reach.  

As our partners progress towards PCMH recognition achievement goals, we have worked closely with National Committee for Quality Assurance (NCQA) in identifying key submission deadlines, which would apply to practices that are participating in the DSRIP Program. Recently the DOH released deadline submission dates: 

In addition, the NYS Department of Health sponsored discount code has been issued in partnership with NCQA to clinicians who participate in Medicaid in New York and are applying to NCQA for new or renewed PCMH recognition. The discount code may be applied to pre-clinician submission fees for the 2014 PCMH recognition programs. Because NCQA offers multi-site practices of three or more independent sites a 50% discount per clinician application fees, such practices are not eligible for an additional discount through this sponsorship. For more information, contact Nitin Singh, Project Manager, Practice Transformation, at

The SCC will continue to support its practice partners by providing NCQA 2017 PCMH training, expected to take place in August 2017.   The training will be focused for personnel that have been identified as champions and have significant experience in transforming practices under the PCMH 2014 standards.

As we continue to progress through the PCMH practice journey, we are also identifying practices that would be best facilitated via Advanced Primary Care Model (APC), a model similar to PCMH.   At this time, SBU hub has identified 13% of its practices for this transformation model and plans are underway to initiate training. NWH is planning to work on APC transformation with practices that account for 69% of their total practices.
Congratulations Doreen Thompson, RN, CCTM, on Certification Success!

In the fall of 2016, 25 RNs, across Suffolk County's 11 hospitals, began their journey toward achieving  Care Coordination & Transition Management (CCTM) certification. Led by SCC's Director of Care Transition Innovation, the group completed 13 learning modules focusing on improving care coordination and transition of care for their patients. Through extreme dedication, the group has been attending evening review courses, held at the SCC, in preparation of their upcoming exam dates.
We are proud to announce that Doreen Thompson RN, CCTM, Huntington Hospital, has become the first in the group of 25 RNs to pass the CCTM Certification Exam!

When asked about her experience throughout the process, Doreen shared this,  "To begin, I'd like to thank the Suffolk Care Collaborative for this wonderful learning opportunity.  Also, Jennifer Kennedy, RN, BSN, MS, for the months of commitment and effort that she put into our CCTM experience, not to mention some pizza!   I have been a nurse for 40 years, with mainly 3 types of nursing background. I worked for 14 years in Medical ICU, 21 years in home care and the last 5 years in Case Management. I had planned to take the exam for the Certified Case Management Certification once I was finished with some college classes I am taking. Then my manager, Christine Kippley, RN, MBA, BC-NE, Director, Case Management at Huntington Hospital, offered the CCTM class to myself and another Case Manager. I will be frank, I was not expecting 13 weekly modules; and it seemed a bit daunting at first.  Once the class started, that feeling quickly went away. I like doing on-line classes, and being able to read, and listen or watch the modules, at my own time and pace, was so helpful.  This is a robust case management course, including some history about how we have come to where we are today. The course covers topics from engaging patients, patient-centered care planning, to population health management. These excellent modules, provide a strong picture of the significance of Case Management, and its power to impact patients' lives.  If you are considering becoming a Case Manager, or just honing your skills, I would highly recommend this course. One last thought, for myself, I found our review classes essential. It was very helpful to discuss the theories and processes presented in the class with other colleagues."
The SCC congratulates Doreen Thompson, RN, CCTM, and wishes  the remaining RNs good luck on their upcoming examination!
SCC Hosts Cultural Competency and Health Literacy Master Training

SCC's Community Engagement Team recently hosted a Cultural Competency and Health Literacy (CCHL) Train-the-Trainer class for Nassau, Queens, and Suffolk County healthcare providers and community leaders. Fifteen participants were in attendance from a wide range of backgrounds, including social work, nursing, transportation, homecare, and community based organizations. This full day training covered a curriculum pertaining to health equity, cultural competency and humility,
Pictured from left to right: Steve Wilson, National Medtrans Network; Lyndsey Clark, SCC; Melody Pierre-Gilles, ProHEALTH Care; Richard Poveromo, JT Mather Memorial Hospital; Cathleen Roster, JT Mather Memorial Hospital; Angela Desposito, Utopia Homecare; Clifford Hymowitz, Brookhaven Dept. of Housing & Human Services; Mayra Medina, National MedTrans Network; Alison Abrams, Suffolk County Bureau of Public Health Nursing; Rachel Seiler, LMSW, Ph.D, Community Development Corporation of Long Island; Sofia Gondal, SCC; Mariam Jean, MZL Home Care Agency; Roberta Duke, Able Health Care Services
health literacy issues and the Teach-Back method in an interactive format. The Teach-Back method entails a four step cycle: explaining a process; assessing the person's knowledge by asking them to teach it back; clarifying any misunderstandings the person may have; repeating the cycle until there is a shared understanding. The interactive class included participatory moments for the attendees to share insightful stories and expertise fostering synergy and peer learning. At the conclusion of the training, the participants walked away with a resource toolkit to recreate the CCHL training in their workplace and certificates demonstrating their successful completion of the program.  
To learn more about the CCHL Training Program and how your organization can participate, please contact our Community Engagement Team at
Connecting Providers through Regional Health Information Organization (RHIO) analytics_computer.jpg

The SCC has worked closely with our Regional Health Information Organization (RHIO) partners, NY Care Information Gateway (NYCIG) and Healthix to connect our contracted partners to a RHIO.  RHIOs collect electronic health records from participating healthcare providers and connects that data to a network of RHIOs through the Statewide Health Information Network for NY (SHIN-NY).  With patient consent, records can be securely shared with other providers who deliver care for that patient throughout the State.  The visibility of the services a patient received at various locations, (e.g. hospitals, imaging centers, etc.) will provide a longitudinal view for our provider partners and allow for more informed care plans for the patient. To date, the SCC has 11 Hospitals, 37 Skilled Nursing Homes, 27 Primary Care Provider (PCP) contracting entities consisting of 295 PCPs and 10 Behavioral Health (BH) contracting entities consisting of 85 BH providers contracted with a RHIO.  SCC will continue to facilitate RHIO agreements with our partners as well as monitor the training and adoption of the RHIO at their practices.
In order to fully realize the value of a RHIO, patient consent is required to allow healthcare providers to view patient records.  Strategies are being developed to communicate with the community about the importance of consenting with their healthcare providers. There are ongoing collaborations between SCC's IT Taskforce, RHIO partners, and the Cultural Competency and Health Literacy Workgroup to create culturally and linguistically appropriate information to engage and educate community members on the significance of RHIOs.  SCC's goal is to see an increase in patient participation in RHIOs by empowering our Suffolk County communities with knowledge.
Bringing Partners Together:  Care Transitions Regional Workgroups
A Forum for Hospitals and Skilled Nursing Facilities to Collaborate
Photo from St. Charles Hospital Regional Care Transitions Workgroup
May 2017 marked the second round of regional care transitions workgroups between hospital and skilled nursing facility (SNF) partners. These workgroups are geographically-defined Learning Collaboratives hosted by hospitals quarterly and attended by network providers along the care continuum. Efforts are focused on building communication lines and relationships with key representatives at the facilities involved in transitions of care, setting a stage for communication and collaboration amongst stakeholders and identifying areas of opportunity and implementing special projects to support best practices between acute care, ambulatory and long-term care providers.
The first May workgroup was held at Stony Brook Medicine, included regional SNF partners, and topping the agenda was a discussion on potentially preventable readmissions. Stony Brook Medicine presented readmission and referral data from each SNF that guided discussion around areas of need. Additional agenda items included updates on Stony Brook Medicine's Project RED (Re-Engineered Discharge), efforts to standardize the Hospital/SNF transfer form and an initial discussion surrounding palliative care and the use of advanced directives. The group will be meeting again in 3 months to share progress on their care transitions special projects.
The second workgroup was held at St. Charles Hospital and led by Sunil Dhuper, MD, Chief Medical Officer.  The workgroup was attended by approximately 40 individuals from both the hospital and six surrounding SNFs. The agenda included an overview of our Regional Care Transitions Workgroup Charter , a description of the SCC Care Transitions Special Projects Portfolio and a facilitated discussion led by Jennifer Kennedy, RN, BSN, MS, Chief Marketing Officer of Gurwin Jewish Nursing & Rehabilitation Center. Key themes included a focus on streamlining communication workflows between the Emergency Department and SNFs, emphasizing the importance of palliative care in the goals of care discussions, staff education and increasing awareness for staff on health home eligibility and referral processes. The SCC PMO has scoped these concepts into special projects to support the implementation of these initiatives. 

St. Catherine's of Siena Medical Center hosted our last regional workgroup this quarter. The workgroup meeting agenda and discussion covered communication opportunities and modes between facilities, staff education and patient/family education. A key take away from this particular workgroup was the use of telemedicine in both the hospitals and the SNFs. One SNF shared their experience using telemedicine for the last 18 months, resulting in a significant reduction of avoidable emergency department use by their patients. The group plans to continue working on opportunities to learn more of local SNF experiences and best practices related to the use of telemedicine in hope to spread adoption to neighboring SNFs.  

Photo from St. Catherine's Regional Care Transitions Workgroup

We would like to thank Stony Brook Medicine, St. Charles Hospital and St. Catherine's of Siena Medical Center for hosting this round of workgroups as well as Gloria Mooney, DSRIP Project Manager, from Catholic Health Services and Jennifer Kennedy, RN, BSN, MS, Chief Marketing Officer of Gurwin Jewish Nursing & Rehabilitation Center, for their support and collaboration in making these workgroups a success.
Partner Interview:  Southside Hospital Emergency Department Implements Tools for Better Communications 
Name:  Benson Yeh, MD
Title:  Chair, Emergency Department
Organization:  Southside Hospital, Northwell Health

Please tell me about your organization.  
Southside Hospital is a member of the Northwell Health System. It is a tertiary care referral hospital, receiving patients from a variety of specialties. Our services include a trauma center, stroke center, STEMI center, open-heart services, comprehensive cardiovascular services, orthopedics, neurosurgery, OB GYN, pediatrics, and a myriad of other medical subspecialties. The hospital is located in Bayshore, NY, and is quickly expanding its operations, both on and off-campus with development of outpatient centers, such as the recently opened Imbert Cancer Center. The emergency department has about 72,000 patients per year. We have received numerous awards including Stroke Gold Plus, Target: Stroke Elite Plus Honor Roll Award from the American Heart Association for our stroke care.  Our STEMI center has among the best door-to-balloon times for emergency angioplasty in the Northwell system. 

You worked with Affinity to develop a skilled nursing facility to hospital transfer form. What led up to this?
When the emergency department (ED) expanded back in September of 2016, one of the main challenges that we experienced was communication between providers within the department, as well as from external providers. At roughly the same time, we had been contacted by the folks at Affinity Skilled Living & Rehabilitation Center and realized that we had an opportunity to develop a close partnership with our external stakeholders, such as these skilled nursing facilities (SNFs).
We developed a process that facilitated a direct conversation between the ED provider and the SNF Medical Director. This included development of a specialized form to accompany the patient from the SNF. In the past, there was never really an overt request from the SNFs to have patients returned back to their facilities for things that they could treat. In addition, skilled nursing facilities did not want to have sick patients return; however, these days many SNFs increased their medical capabilities and are capable of caring for patients with illnesses that once would have meant admission to the hospital.
Our specialized form bridges significant communication gaps, creating a patient safe and HIPPA compliant warm hand-off from the ED physician back to the SNF physician. The form is a vehicle for the communication that needs to occur between the SNFs and the ED, so that care is coordinated. Our transfer back to the SNF is the equivalent of us providing a direct warm hand-off to an admitting physician in the hospital. For physicians, the ability to provide a warm hand-off of patient responsibility between providers provides the ED with options to prudent practice of medicine.  In the past, it was very difficult to make that communication with SNFs.
We have learned through this program that many of the illnesses we diagnose in the emergency department are conditions which the SNFs are now capable of treating. Many of their needs are access to the technology in the hospital, such as CAT scans, MRIs, and sonograms. Overall, this is a win-win situation for the patients and their families. Our program complements the DSRIP program which is trying to reduce hospital admissions without sacrificing quality and patient safety.

What brought about implementation of the mobile phone to accept external calls?
When we had a smaller department, communication between physician, ward clerk, and nurses by landline was easy. When you have a large ED, communication becomes an issue. One of the problems we encountered was being able to take a call from an outside agency, such as a SNF, a Medical Director, or even a private physician calling in about a patient. It became very difficult for us to communicate because sometimes the clerks would be in one nursing station and the physician would be in another. Our action plan included an external cell phone number whereby the external physician could call directly into the ED via cell phone. The cell phone is mobile, HIPPA secure, and it can be brought to the ED physician who may be in a distinct area of the ED.
The cellular line has been very successful. Physicians have been calling in and we have had many anecdotal reports by our physicians as well as by SNFs that the line facilitates the call directly because it has a different, distinctive ring that brings attention to the fact that this is an external physician calling.  
What are some of the opportunities/barriers to increasing physician to physician communication and warm hand-offs?
One of the barriers has been generating awareness of our programs among our external stakeholders and all of the SNFs. We have been trying to disseminate information to these SNFs. Back in February of 2017, Southside hosted a regional workgroup initiated by SCC where a number of the SNFs were present. It was very helpful to get the medical directors together to discuss the strategy and alignment of goals of their facilities with ours. The SNFs were very happy to hear about our program. We also shared the communication forms with the SNFs, so that they can all use one standardized form when sending us patients. 
Do you see an increase in SNF physician presence/involvement with ED transfers?
Both indirectly when we receive the patient with the form and directly when the SNF calls the department, we are able to have effective communication  to coordinate the care of the patient. Again, effective communication is essential. In the 21st century we expect everyone to be digitally linked, but given the constraints of working within siloed systems, regulated by the federal government through HIPAA, it is difficult to build communication systems. 
If anyone at a skilled nursing facility is interested in our programs, please email or call 631-968-3970.
Key Collaborations Open Lines of Communication Between Skilled Nursing Facilities and Emergency Departments  
Submitted by:  Dianne M. Zambori, MBA, BSN, RN-BC, NE-BC, LNHA, FACHE, Associate Executive Director of Quality Initiatives, Northwell Health's Eastern Region

Huntington Hospital, Peconic Bay Medical Center and Southside Hospital comprise Northwell Health's Hub in the Suffolk Care Collaborative's (SCC) Performing Provider System (PPS).   Since February 2017, these three hospitals have each hosted a geographical work group with their area Skilled Nursing Facilities (SNFs) as part of an effort to address DSRIP goals of both the INTERACT and Transition of Care projects.  These workgroups were organized and facilitated by the SCC along with Health Solutions, which manages and administers Northwell Health's DSRIP activities.  These workgroups successfully brought medical, nursing, and case management leadership from the hospitals and SNFs together to gain a better understanding of the impact of readmissions on their patients and for their facilities from a regulatory standpoint.  Commonalities were identified in these meetings so that more global solutions could be explored. 

In addition to the SNF to emergency department communication form and M.D. to M.D. phone line initiated by Benson Yeh, MD, chair of emergency medicine at Southside Hospital, other innovations have emerged including one from Michael Grosso, MD, chief medical officer at Huntington Hospital.  Dr. Grosso has reached out to the medical directors of the five local Huntington area SNFs to set up a series of conference calls to discuss best practices and identify areas for improvement. 

The success in opening lines of communication has prompted this type of geographical workgroup to be initiated in Nassau as well.  The first workgroup was held in April with Plainview and Syosset hospitals and their area SNFs with similar success to those groups held in Suffolk County.  Saquib Ibrahim, MD, hospitalist director at Plainview and Syosset hospitals, immediately identified how antibiotic end dates could be better documented to improve communication and create a more effective medication reconciliation for the receiving SNF.  The next Nassau County hospital to have a regional workgroup with their area SNFs will be Glen Cove Hospital in June. 

All of the innovative work via DSRIP in both Nassau and Suffolk Counties is a testament to the hospitals and SNFs working together to ensure that their patients are receiving the right care in the right setting while focusing on the patient's goals and minimizing unnecessary admissions and readmissions to acute care.
Compliance Connection

The New York State Office of the Medicaid Inspector General (OMIG) announced the release of its 2017-2018 Work Plan. The Plan details OMIG's program integrity focus areas in the Medicaid program for the State Fiscal Year April 1, 2017 to March 31, 2018.
For providers, suppliers, managed care organizations (MCOs), and other stakeholders, the Work Plan provides a roadmap of OMIG's intended areas of review for the year.
The Work Plan is informed by OMIG's 2018-2020 Strategic Plan, which focuses on three overarching goals: 
  • Enhancing compliance
  • Fighting fraud, waste and abuse 
  • Promoting innovative analytics
These three major goals are not listed in any order of priority, as each goal has equal significance and weight in helping OMIG achieve its mission.  

The first goal focuses on provider compliance and the work OMIG does to monitor compliance programs in the Medicaid program.  The second goal focuses on identifying and addressing fraud, waste and abuse within the Medicaid program.  In addition to its on-going program integrity activities, OMIG will direct its efforts in areas including, but not limited to:  prescription drug and opioid abuse; home health and community-based care services; transportation; long-term care services; and Medicaid managed care (MMC).  The third goal focuses on OMIG's efforts to develop and employ innovative analytic capabilities to detect fraudulent or wasteful activities.  This includes data mining and analysis, cost savings measures and pre-payment reviews.  

To access the  2017-2018 Work Plan, click here.   For questions or assistance, contact the SCC Compliance Office at
 Milestone Dates
 NYS DOH DSRIP Program Milestone Dates
End of May
Response made to PPS Lead Regulatory Waiver Request
Round 4
June 14
Revised PPS Year 2 Fourth Quarterly reports due from PPS; 
15 day remediation window closes
1115 Waiver Public Comment Day
June 30
Final Approval of PPS Year 2 Fourth Quarterly Reports

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, Care Transition Innovation
  2. Care Manager
  3. Data Visualization Analyst
  4. Social Worker
  5. Community Health Associate
  6. Population Health Platform Training and Support Specialist
  7. Data Acquisition Analyst
  For more information, please contact the Suffolk Care Collaborative via email