Issue 37
May, 2018
Welcome to Synergy
We are pleased to present the thirty-seventh 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
You're Invited to SCC's 
Project Advisory Committee (PAC) Meeting

Thursday, June 14, 2018
Registration 8:30 am
Program 9:00 - 11:30 am

Hyatt Regency Long Island
1717 Motor Parkway
Hauppauge, NY 

For Program Details and Registration Click Here
Community Based Organization Value Based Payment Survey
The Suffolk Care Collaborative (SCC) is requesting your assistance in completing our Community Based Organization (CBO) Value Based Payment Survey.  As health care increasingly moves toward Value Based Payment models, the SCC seeks to better understand and determine how to support our CBOs.  To participate in the brief 15 minute CBO Value Based Payment Survey, please use  this link using a Mozilla Firefox or Internet Explorer browser.  Kindly submit your survey as soon as possible, but no later than June 30, 2018.
The SCC thanks you in advance for your participation. For questions contact Stephanie Burke  ( or Neil Shah ( 

To learn more about Value Based Payment models we encourage you to visit our online Value Based Payment Training on the SCC Learning Center.
SCC Participates in Sixth Annual Gospel Fest 2018

On Saturday, April 21, 2018, Suffolk Care Collaborative (SCC) Community
Pictured behind table, L to R, Ginette Rows, Executive Director, Yam; Sofia Gondal, Community Engagement Liaison, SCC
Engagement Team and its Community Health Activation Program (CHAP) partner, Yam Community Resource, Inc. (Yam), presented SCC's community resources at the Sixth Annual Gospel Fest 2018.  Suffolk County Community College's Office of Multicultural Affairs hosted the event in collaboration with the Suffolk County Department of Health Services - Office of Minority Health. The event featured many of the county's Gospel choirs, dance ministries and groups in a musical event designed to inspire its attendees. Along with the melodious tunes the event brought in several community-based organizations to share health resources with the community.  Each vendor table shared health testimonials, screenings and special educational presentations in recognition of National Minority Health Month.

Participants at the Sixth Annual Gospel Fest 2018
SCC's Community Engagement Liaison Sofia Gondal and Yam partner Ginette Rows, Executive Director, supported the event by providing an overview of SCC's community programs, specifically highlighting the CHAP and conducting live demonstrations of the
Community Engagement webpage .  SCC Community Engagement Team will continue to participate in similar collaborative events to further expand knowledge of SCC's resources and DSRIP initiatives.  For questions about outreach and/or to arrange live webpage demonstrations, please contact our Community Engagement Team at .
SCC Continues Partnership With HITE to Enhance Resource Directory

  Heath Information Tool for Empowerment (HITE)  is a program of the Greater New York Hospital Association, and is a free online directory that lists health and social service organizations in New York City and Long Island.  SCC and HITE have partnered throughout the DSRIP program by making  the directory available on SCC's website , adding resources and providing a local forum for user feedback.

HITE routinely works with SCC's Community Engagement team to identify community-based organizations (CBOs) that are not listed in the HITE tool and also collect feedback from SCC partners. In 2017, HITE added approximately 150 new Long Island resources through this partnership, and will add more in the next several months. In addition, SCC has hosted Suffolk County HITE advisory groups which have provided feedback on website functionality, resulting in several improvements to the search capability and the overall user experience.

HITE now includes two new categories, "Education & Employment," which lists organizations that provide children, adolescents and adults with assistance in accessing academic and vocational support and "Hotlines," which lists phone numbers and websites that provide immediate assistance in areas such as mental health, housing and domestic violence.  HITE users can also find resources located within a specific county, city, town or borough using the "zip code" field. 

SCC and HITE continue to work together to ensure that organizations in the region are included on the site, and that users are able to easily find resources. Please contact the HITE team if you have suggestions for resources to be added to the directory, or if you would like to attend a future advisory group meeting.
From The Community, For The Community time_2_learn_vector.jpg
Northwell Health is excited to offer an innovative workforce development program called "From the Community, For the Community" through funding from the JP Morgan Chase Foundation.
The name of the program says it all. Committed to building a culture of health and equity of care, "From the Community, For the Community" trains job-seekers from traditionally disenfranchised communities and connects them with entry-level healthcare positions that focus on assisting individuals in overcoming access to care barriers. These positions include, but are not limited to, titles such as community health worker, outreach associate, health coach, health educator, patient navigator and peer specialist.
This past March a group of nine program participants successfully completed the training program that included instructional, in-classroom training and a preceptor-mentored apprenticeship in the field. From the initial graduating class, five graduates were hired by Northwell Health and four were hired at Choice For All, a community-based organization (CBO) in Roosevelt.
The seven-week training program seeks talented, committed individuals and equips participants with the necessary transferable skills to be successful frontline public health workers. The program offers participants a stipend, a mentor to support professional development and skills like motivational interviewing and patient navigation.
To qualify as a trainee, an individual must be over the age of 18, be comfortable in a health care setting and talking to people about their health, have valid New York State identification and preferably have a  high school diploma or GED.  In addition, the program is searching for individuals who are empathetic, know the community needs and assets and have a passion to give back.
Northwell is also seeking CBO and agency partners who are interested in hiring entry-level non-clinical healthcare staff. Northwell will be partnering with CBOs, public sector agencies and provider practices who are interested in receiving support with recruitment for non-clinical care coordination, patient navigation or outreach/health education staff.    
The training program is ongoing, with the next class set to begin in late June.   For more information contact Nuzhat Quaderi at or (516) 600-1495.
Partner Interview:  Strategies to Integrate Primary and Behavioral Health Care in Suffolk County
Name:    Allie Dubois, Executive VP/Chief Operating Officer
Organization:   Hudson River HealthCare 
Please give us a summary of your organization
Established in 1975, Hudson River HealthCare (HRHCare), a NYS licensed and federally qualified health center (FQHC), provides primary, preventive, behavioral and oral healthcare and enabling services, along with robust care coordination and management, especially for persons with chronic conditions, to 180,000 patients annually throughout the Hudson Valley and Long Island. Accredited by The Joint Commission since 1998, HRHCare is recognized by NCQA as a Level 3 PCMH and has Diabetes Recognition Program distinction for all of its eligible sites. The Health Center has been a trusted and reliable presence for decades in the communities targeted by the DSRIP 3ai project on behavioral health (BH) and primary care integration, and the populations being served are ones with which HRHCare has had considerable experience. HRHCare's health home, CommunityHealth Care Collaborative (CCC), is the largest in New York State, and its outreach office is embedded in HRHCare's Amityville health center.
How is HRHcare working to promote integrated care in Suffolk County?
HRHCare has developed a 3-pronged strategy to meet the needs of the populations with varying mental health needs in Suffolk County: (1) a Mobile Health Center to deliver services in the community; (2) primary care practices (PCP) embedded in Article 31 (behavioral health) locations; and (3) embedded behavioral health resources within HRHCare's primary care practices. HRHCare has used this multi-faceted approach, recognizing that people with behavioral health needs seek out services from a wide-range of providers whether primary care, specialty behavioral health, or other community-based organizations and it is important to meet those patients where it is most convenient for them.

HRHCare purchased a mobile medical van that became operational in March 2018. The van visits behavioral health locations, including Federation of Organizations, Family Service League, WellLife Network, Outreach Center, Skills Unlimited, and Association for Mental Health and Wellness, and provides screenings, referrals, and brief interventions.  In the first month of service delivery alone, the program served 154 more individuals than anticipated (40 individuals anticipated, 194 served).  We are well on your way to meeting our annual target of 600 individuals served!

HRHCare also brings experience from the Hudson Valley in implementing an embedded exam-room at sites in Suffolk County. Under this model, HRHCare will be operating Article 28 (primary care) compliant spaces within existing behavioral health partner sites; construction began in May 2018. In addition, HRHCare is collaborating with the Suffolk Care Collaborative to employ care managers at several sites in Suffolk to cover gaps in short-term transitions of care and facilitate warm transfers between individuals and health home care management services, if they are eligible.

Within primary care settings, HRHCare has been identifying and treating depression by both co-locating behavioral health resources onsite and implementing the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) model, a more intensive integrated model. We have seven co-located health centers where PCPs and BH providers have a system of bi-directional referrals with warm handoffs in place. We also have one IMPACT model site, where the depression care manager and consulting psychiatrist form part of the primary care team.
Why is integrated care important from a population health perspective?
Through our work with BH partners throughout the region, it has become clear that primary care providers may be missing patients with mental health issues who are unable to overcome barriers and walk into a health center for services.   The target population is clients being served by HRHCare's mental health partners at service sites throughout Suffolk County, with a special focus on patients with serious and persistent mental illness (SPMI). Persons with SPMI are disproportionately impacted by poor outcomes, including premature death due to social, physical and behavioral health (BH) co-morbidities.   Without integrated primary care, the physical health of those in BH settings are often not adequately addressed.

Additionally, in this targeted population, there is increased risk of diabetes and cardiovascular disease - risks that may be elevated by antipsychotic medications. Many of these clients are unaware of their chronic conditions, thus not receiving the care and disease management services needed to prevent complications that frequently lead to ED visits, inpatient admissions and mortality. We believe that linkage to a primary care medical home is key to addressing morbidity and mortality and achieving the triple aim for patients.
What types of challenges face primary care and behavioral health providers in integrating care?
Culture, recruitment and workflows are the biggest challenges facing primary care and behavioral health care partners as they move to integration. Educating both patients and staff about the impact of behavioral health care needs on health outcomes is a key component of the work. We believe it is critical that all members of the team are engaged in this work and supporting the referrals, warm handoffs and care plans of patients. Recruitment of knowledgeable, culturally competent and forward thinking behavior health and primary care clinicians is a key opportunity moving forward. Rethinking the settings and models for engagement requires teams that are aware of the behavioral changes and the new, evidence-based strategies for caring for individuals and a willingness to meet people where they are. And, with any new initiative and new approach, developing workflows and building a culture of reliability to adhere to those workflows, especially across organizations, is key.
How is HRHCare working to overcome these challenges?
HRHCare is utilizing Suffolk DSRIP funding to lift and support the operations of these three strategies, but we believe that meeting the members of our community where they are to access care in the setting most convenient to them is the first step. From there, refining bi-directional referral pathways and integrated care team workflows over time will produce the health and financial outcomes needed to sustain this work in a value-based world.
Where do you envision HRHCare's work, in integrating care, heading over the next few years?
We are focused on leading the healthcare delivery system toward population health management with a focus on continuity of care for individuals in the communities we serve. Strategies we plan to deploy include managing transitions of care by continuing to implement care coordination for high need populations; facilitating communication between HRHCare and hospitals, BH providers and community-based partners; facilitating follow-up for discharged patients, and reducing preventable emergency and hospital utilization and readmission through collaboration with the network of providers and services surrounding the individuals in our communities.
Exercise Can Improve Cognitive Symptoms of Alzheimer's Disease   
Written by Nikhil Palekar, MD, Medical Director, Center of Excellence for Alzheimer's Disease, Stony Brook Medicine

Approximately 5.3 million Americans are living with Alzheimer's disease of which more than 54,000 are on Long Island alone. The rates of Alzheimer's disease will more than double by 2050, creating a public health crisis. Current pharmacological treatments for Alzheimer's disease are limited to cholinesterase inhibitors and NMDA-receptor antagonists. These medications have shown limited effectiveness in slowing the progression of Alzheimer's disease, often only at early stages of the disease. Over the past decade, several clinical studies looking at new therapeutics to slow or halt the progression of Alzheimer's disease have been mostly unsuccessful.

Physical exercise has been shown to have significant health benefits including lowering risk of cardiovascular disease, metabolic syndrome and Type 2 Diabetes, decreasing risk of colon and breast cancer, improving mental health, increasing bone and muscle strength thereby reducing falls, and significantly increasing lifespan and quality of life. A recent meta-analysis published in the Journal of the American Geriatrics Society looked at the effects of physical exercise on cognitive symptoms in patients at risk of or who have Alzheimer's disease. They found that exercise training had a positive effect on cognitive function, whereas the control groups showed a decline in cognitive function. The study concluded that "moderate-intensity exercise training performed approximately three days per week for approximately 45 minutes per session resulted in modestly better cognitive function than in controls".

At the Stony Brook Center of Excellence for Alzheimer's Disease, our comprehensive multi-disciplinary team provides extensive education to both patients and families about the importance of increasing daily physical activity to slow the progression of cognitive impairment and improve overall functioning and quality of life. Visit the Center of Excellence for Alzheimer's Disease website for more information and resources to assist physicians and families.
Compliance Connection
Disclosure of Substance Use Disorder Patient Records

Substance Abuse and Mental Health Services Administration (SAMHSA) released two new fact sheets to help stakeholders understand rights and obligations under  Title 42 of the Code of Federal Requirements (42 CFR) Part 2.  Part 2 refers to Confidentiality of Substance Use Disorder Patient Records.

42 CFR Part 2 sets strict confidentiality requirements for substance use disorder treatment records.  Recently updated regulations address changes that have taken place in the healthcare system including:
  • New models of integrated care for supporting patient care.
  • An electronic infrastructure for managing and exchanging patient data.
  • The expansion of prescription drug monitoring programs.
  • A new focus on measuring performance in health care systems.
The two fact sheets were developed to help health information exchange (HIE) organizations and healthcare providers learn how Part 2 provisions can be used across different environments.  

The Disclosure of Substance Use Disorder Patient Records:  Does Part 2 Apply to Me? fact sheet explains how healthcare providers can determine if Part 2 applies to them and the  Disclosure of Substance Use Disorder Patient Records:  How Do I Exchange Part 2 Data? fact sheet outlines how Part 2 applies to the electronic exchange of health care records.  

For more information visit SAMHSA's website.   For compliance questions, or assistance, contact the SCC Compliance Office at
 Milestone Dates
 NYS DOH DSRIP Program Milestone Dates
June 14 
PPS Remediation of DY3 Fourth Quarter report
June 29
IA approval of DY3 PPS Fourth Quarter report

Frequently Asked Questions


To access NYS DSRIP FAQ, click  here.
Access previously published Synergy eNewsletters  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. Administrative Assistant
  2. Care Manager
  3. Social Worker
  For more information, please contact the Suffolk Care Collaborative via email