Issue 1
May / 29 / 2015

Welcome to Synergy


We are pleased to present the first 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/Medicaid Redesign Overview


DSRIP, or Delivery System Reform Incentive Payment program, is a federally funded statewide initiative focused on transforming the way medical care is delivered to Medicaid and uninsured patients by establishing networks of collaborating healthcare providers called a Performing Provider System (PPS). A PPS is responsible for leading regional provider partnerships to accomplish DSRIP program objectives.


The Suffolk Care Collaborative (SCC) is the PPS for Suffolk County with Stony Brook University Hospital serving as the lead. The SCC is comprised of thousands of healthcare delivery partners across Suffolk County, NY.


The goal of the SCC is to meet the requirements of the Triple Aim Initiative - improving the patient experience of care, improving the health of populations and reducing the per capita cost of healthcare. Our goal will be met by successfully implementing the DSRIP initiative - focusing on system transformation, clinical improvement projects and population health projects over a five-year period. 

The Suffolk Care Collaborative (SCC)


Initiatives are also moving forward at a fast pace. The Suffolk PPS DSRIP application to the NYS Department of Health (DOH) scored #1 in 55% of the projects. The PPS utilizes a collaborative model to build project implementation plans for all DSRIP projects and project committees have been engaged in the program design. Implementation plan drafts were completed for the 11 DSRIP projects and posted to the SCC website for public comment in March of 2015. Thank you to all PPS partners who contributed by providing feedback to the plans.  The organizational work stream project plan are drafted and programmed to begin mid-May of 2015. These include Workforce Strategy, Governance, Financial Sustainability, Cultural Competency, IT systems and Processes, Performance Reporting, Practitioner Engagement, Population Health Management and Clinical Integration.



The SCC has made significant progress in many areas.  There are currently more than 500 Partner Organizations in the Suffolk PPS and approximately 4,500 individual providers.  Visit our website for a full directory


Governance Committee Development 

Seven Governance Committees, which include (i) Clinical; (ii) Finance; (iii) Community Needs Assessment and Outreach; (iv) Health Information Technology and Biomedical Informatics; (v) Workforce; (vi) Compliance; and (vii) Audit have been appointed and initial meetings held to review the draft implementation application due to the state on June 1.


Project Management Office (PMO)

The functions and purpose of the PMO include: having Staff Project Managers with full-time responsibility for managing the DSRIP project portfolio to champion consistent project management practices and methodologies; to help the SCC and Office of Population Health fulfill the mission, strategic goals and projects; to support the DSRIP project teams as a source for project management leadership and expertise; to keep the project stakeholders informed through a robust communication strategy; and to deliver required status reports to stakeholders including the NYS DOH.


Performance Logic 

Performance Logic (PL) is a sophisticated project management software tool utilized by the SCC PMO to manage DSRIP projects. PL will be used to monitor progress, share information and communicate project status updates to project leads and Suffolk county providers. Project leads can more effectively communicate real-time information to Suffolk county providers by using PL tools such as web forms, project templates and status dashboards. The organizational work stream project plan and provider contacts are currently being migrated to PL in preparation for project lead training.



The SCC website launched in early May. The website provides a wealth of resources with educational information on SCC projects and highlights on featured partners. Additionally, a partner portal will be launched by early summer, allowing the PMO to share vital documents with SCC partners. Since your ideas and thoughts are needed to make SCC successful, to access a designated area on the website for you to provide feedback and suggestions, please click here.

Project Highlights


Following is a summary of the progress of select DSRIP projects the Suffolk County Collaborative will be undertaking



Project 2.b.vii - Implementing the INTERACT? Project (Inpatient Transfer Avoidance Program for Skilled Nursing Facilities (SNF)

INTERACT? (Interventions to Reduce Acute Care Transfers) involves using clinical/educational tools and strategies at long-term care facilities to prevent avoidable patient transfer to hospitals. Current research shows that the use of INTERACT? tools can reduce readmission rates by 17-24%. The PPS is currently designing the plan to use INTERACT? tools at all SNFs in Suffolk. A survey was used to collect baseline data from all SNFs within the PPS to assess INTERACT? implementation readiness. At the same time, the Project Management Office (PMO) has been developing a training program and a team of potential INTERACT? trainers to facilitate INTERACT? adoption and use among the SNFs. This is being designed in conjunction with the Project Leads and Project Committee, which includes representation from the majority of SNFs within the PPS.


The SCC has been working closely with staff from the GNYHA on the launch of the INTERACT? project. In 2012, the GNYHA was awarded a four year cooperative agreement by CMS to implement New York-Reducing Avoidable Hospitalizations (NY-RAH), a demonstration project that is using INTERACT? tools at 29 SNFs within the New York City and Long Island regions to improve communication and the care transition process with hospitals. Tim Johnson, the Executive Director of the GNYHA and Project Director for NY-RAH, assisted the SCC in the development of the INTERACT? project application. The NY-RAH project management team have provided their insights and guidance throughout the planning phase of DSRIP and will continue to do so to help ensure the SCC's successful implementation of the INTERACT? project. According to Mr. Johnson, "the strong engagement and commitment of the SCC SNFs will serve these organizations and their affiliated hospitals well in meeting the goals of DSRIP."



Projects 2.b.iv and 2.b.ix - Implementation of observational programs in hospitals and establishment of a Care Transitions Intervention Model to reduce 30-day Readmissions for Chronic Health Conditions

A major cause of avoidable readmissions to acute care facilities are attributed to non-adherence with the discharge plan. The main reasons for this among the patient populations within Suffolk County include issues related to health literacy, language barriers, and lack of engagement with community resources. In addition, clear communication of the care plan needs to be given to the providers who care for patients after discharge. 


The PMO recently administered a baseline survey to all hospital partners to assess their current observation program and transitions of care practices. Highlights from the survey revealed:

  • 92.9% of Suffolk County Hospital respondents provide Observation Care
  • During current Observation Program patient stays, Care Management and Physicians were the top two provider types that routinely assess patients for transition readiness
  • 71% of Suffolk County Hospital respondents utilize the Millman Criteria for observation programs
  • 80% of Suffolk County Hospital respondents have standardized protocols in place to manage transition of care practices
  • 90% of Suffolk County Hospital respondents currently have a process in place to track readmissions to the hospital

The PMO continues to collaborate with the Project Leads and Project Committee, which includes representatives for all partner hospitals and providers across the care continuum, to design and standardize principles of a Care Transitions Intervention Model for all participating hospitals, home care agencies, and other appropriate community agencies within the PPS. This model focuses on providing patient education before the patient is discharged, care record transition to the receiving provider, along with care management and community-based support for the patient for a 30-day transition period after hospitalization.   



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

The goal of this project is focused on individuals not utilizing the health care system and works to engage and activate those individuals to utilize primary and preventive care services. Simply having health insurance is not enough to ensure improved health outcomes or appropriate use of the health system. To reduce avoidable ER visits and admissions, individuals must actively engage in managing their own health. The PPS, in collaboration with Community Based Organizations (CBOs), will train providers on the use of PAM? (Patient Activation Measures).


The PPS has identified three community-based partner organizations in target areas to pilot the project, and is working closely with them to prepare for rollout. Within their local communities, Community Health Workers (CHWs) will survey individuals who meet the project's criteria. Once the patient's level of activation has been identified and that person is engaged in the system, the goal will be to move the patient along the spectrum towards increasing activation and facilitate access to care.


Next steps include finalizing a contractual agreement with the PAM? vendor, Insignia, initiate training and begin to engage patients.



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

The goal of this project is to integrate Primary and Behavioral Health (BH) Care using three models:embedding a BH Specialist in a Primary Care Site, embedding a Primary Care Practitioner in a BH Care Site, or implementing the Improving Mood-Providing Access to Collaborative Treatment (IMPACT) Model in the Primary Care setting. The latter program screens patients for depression, assigns a depression care manager, and refers patients to BH services in a stepped care model.


The steps taken so far to achieve these goals include: surveying PPS partners to determine what integration practices are currently in place, developing partner lists to explore geographical collaborations, and educating PPS partners about project requirements. Next steps include finalizing the timeline for partner engagement, contracting with partners and identifying workforce and training needs.



Project 3.b.i - Cardiovascular Disease: Evidence-based strategies for disease management in high risk/affected populations

Cardiovascular disease (CVD) is the third leading cause of avoidable admissions to the hospital and a significant issue within Suffolk County. The focus of this project is to ensure that strategies for evidence-based care are incorporated into the clinical protocols for our PPS partners. The Project Committee and Project Leads have been delineating the clinical protocol to ensure best practice, improve patient outcomes and meet project requirements utilizing elements of the Million Hearts? Initiative.


This project requires developing care coordination teams, including nurses, pharmacists, dieticians and community health workers, to address medication adherence, health literacy issues, and lifestyle changes for patients. It also addresses empowering the patient to become more effective and confident in the handing of his or her own health issues. Since the project requires an interdisciplinary approach to the management and care of CVD, the Project Committee has representation from all disciplines. The following organizations have provided clinical guidance and expertise to this project: Stony Brook University Hospital, North Shore-LIJ (NSLIJ), Hudson River HealthCare (HRHCare), Eastern Long Island Hospital, King Kullen Pharmacies, Peconic Bay Medical Center, Visiting Nurse Service of New York, John T. Mather Memorial Hospital, Belle Mead Pharmacy Inc., and the Long Island Pharmacists Society.


The PPS is currently finalizing a survey that will be distributed to all Primary Care Physicians (PCPs) within our PPS to establish a baseline of current care practices and tools. HRHCare has implemented the Million Hearts? Campaign in counties outside of Suffolk with great success and plans to roll out this campaign to its Suffolk County sites in the near future.



Project 3.c.i - Diabetes: Evidence-Based Strategies for Disease Management in High Risk/Affected Populations

The number of Medicaid beneficiaries who have diabetes and related long-term complications is significantly higher in Suffolk County when compared to the rest of New York State. Unfortunately, access to diabetes education and the use of secondary screening practices in Suffolk County is limited.


The 3.c.i Project Committee is a multidisciplinary team of experts involved in diabetes education, community engagement, care management and clinical care. The project aims to identify high-risk diabetics, increase access to and use of secondary prevention, expand available education resources and support primary care clinicians with the tools needed to care for complex patients with diabetes, including care management, access to clinical guidelines, educational resources for patients and providers, and point-of-care testing.


The Project Committee has charged a team of subject matter advisors within the SCC Diabetes Education Workgroup to aggregate resources and curriculum that will undergo a literature review for the Diabetes Education Program roll-out. The goal is to identify best practices in diabetes self-management, and ultimately synthesize a unified set of materials for the SCC to use across the PPS.



Project 3.d.ii - Expansion of asthma home-based self-management program

In Suffolk County, the percentage of pediatric Medicaid patients with asthma is 13.3% compared to 4.5% in the general population. This project uses a medical home program enriched with home visits provided by trained community health workers (CHWs) and leverages the strengths of the existing pediatrics' Keeping Families Healthy (KFH) program at a current Level 3 Patient-Centered Medical Home (PCMH) site. The CHWs will be equipped with secure tablet devices and mobile phones. This will help CHWs provide appropriate services to patients and families by allowing them to communicate remotely with health care team members.


To date, the asthma project team has worked diligently to produce a detailed project design and begun to prioritize providers who will be among the first to incorporate the program into their practices. In conjunction with the Stony Brook University Hospital Information Technology (IT) Department, the team is working to develop a patient registry platform that will interface with provider practices.



Project 4.a.ii - Prevent Substance Abuse and other Mental Emotional Behavioral Disorders

This project's initiatives include putting substance abuse screening tools in place in all Suffolk Hospital Emergency Departments, implementing tobacco cessation efforts among select high-risk populations, and working to prevent/reduce underage drinking among Suffolk County residents under the age of 21 who live in the greater Bellport region (which includes Bellport, North Bellport, parts of East Patchogue, Medford and Yaphank, and Native Americans from the Shinnecock Nation).


Steps towards these goals so far have included surveying PPS partners to determine what screening practices are currently used or planned, developing a Screening, Brief Intervention, and Referral to Treatment (SBIRT) implementation team with representation from each Suffolk Hospital, and collaborating with the North Shore-LIJ SBIRT Team and Office of Alcoholism and Substance Abuse Services (OASAS) to develop an implementation webinar for partners to be used across the state.


Next steps include conducting Implementation Team meetings, finalizing the timeline for partner engagement, contracting with partners, and addressing workforce needs.



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

Initiatives under this project include lung and breast cancer screening, colorectal screening education, obesity prevention and tobacco cessation. Specific goals include providing colorectal screening education, offering access to screening for lung and breast cancer, assisting in the adoption of the electronic NYS Quitline "Opt to Quit?" protocol by all PPS providers, using Care Managers to help with Tobacco Cessation, offering Body Mass Index (BMI) screenings, and arranging for HRHCare Nutrition and/or other evidence based obesity prevention programs.


We plan to improve awareness among the community about local screening events, educational activities and health fairs via the Suffolk Care Collaborative website. The collaborative approach planned to pursue this project includes the development of committees and a number of workgroups (Obesity Prevention, Lung Cancer Screening, Breast Cancer Screening, Colorectal Screening Education, and Tobacco Cessation) and representation from HRHCare, Cornell Cooperative Extension, Peconic Bay Medical Center, Mather Hospital, the Suffolk County Department of Health, Long Island Health Collaborative (LIHC) and North Shore-LIJ.

Creating an Integrated Delivery System


The objective of an integrated delivery system is to create an organized structure with committed leadership, clear governance and communication channels, a clinically integrated provider network, and financial levers to incentivize and sustain interventions to holistically address the health of the attributed population and reduce avoidable hospital activity. 


Data will be a key component to the success of our DSRIP projects.  This issue of Synergy addresses frequently asked data-related questions.


There are two different platforms that require data from our SCC Partners. The first is the Population Management Platform (PMP) containing the patient longitudinal record that will be used by our care mangers and will populate the Patient Portal that will be used by our patients. The second is the Regional Health Information Organization (RHIO) that will be used by providers accessible from their Electronic Medical Records (EMRs).


The two data types needed from our partners EMR systems are clinical and claims. The clinical data will go into the RHIO allowing providers to have direct access to the data while in their EMRs. The clinical and claims data will go into the PMP, which will supply the data to Care Managers and Patients (through the Patient Portal).


To build multiple interfaces from EMRs to RHIOs and the PMP would be expensive, resource intensive and time-consuming. To circumvent these obstacles, IT has architected a data ingestion system that will take all the data from our EMRs and feed both the RHIOs and PMP with the desired data.


Some providers have asked the RHIOs to enable connections to commence immediately. However, it would be preferable that providers wait to be contacted to start the combined process.  This will ensure the right data is properly obtained and normalized.

We are organizing an effort to assess your practice for the following: 

  1. Inform us if you're on an EMR and which one
  2. Inform us which organization you are associated with
  3. Inform us if you are currently connect to a RHIO, and which one

Next steps include reviewing and signing the Data Use Agreement and Business Associate Agreement to allow for proper flow of information.  A draft of the data specifications can be found here.


The foundation of getting quality data for our decision making in the projects is the first step towards using our state-of-the-art IT platform to improve our outcomes. 

Building the Team

The SCC is pleased to welcome new staff members, Kevin Bozza, MPA, FACHE, CPHQ, RHIT, Director, Network Development and Performance, and Althea Williams, Senior Manager, Provider & Community Engagement to initiate the Community & Patient Engagement function of the SCC. These team members will work in collaboration with all PPS partners to facilitate the provider, patient and community engagement and assist in the rollout of all DSRIP related communication and education. 

This includes launching a
campaign to provide all PPS partners and providers with an in-depth understanding of the DSRIP initiative and the goals associated with the 11 projects, providing support to the provider community related to meeting PCMH recognition, ensuring a comprehensive focus is maintained on all provider engagement initiatives, supporting academic relations to build future student programs to develop training programs to support new health care delivery system, developing a robust network and partner contract management program, and performance reporting - developing and implementing scorecards to identify achievement towards benchmarks.

Partner Interview


Name: Sophia McIntyre

Title: MD, MPH, CPE

Chief, Clinical Quality and Physician Leadership Development



Focus or Specialty: Family Medicine

Number of Practitioners in Group: Over 100



Please provide a summary of your practice.

HRHCare is a federally qualified community health center celebrating its 40th year of service caring for the most vulnerable in our communities. We started as one ambulatory center - and have expanded to 29 centers, including several in Suffolk County. What makes us unique is that we subscribe to the Planetree Philosophy, which means all of our services, hours of operations and other decisions are centered around the needs of our patients.


We have a primary care focus as well as some subspecialties, including women's health, HIV, Hep C, Infectious Disease, Diabetes Care, cardiology, GI, ENT, podiatry, nutrition, social work, psychiatry, and substance abuse.


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

Fundamentally, HRHCare is aligned with the aims of DSRIP. We provide medical care for underserved patients, look for ways to reduce redundancies by collaborating and coordinating healthcare and seek to prevent unnecessary hospitalizations. Participating seemed like a natural synergy.


On which DSRIP projects will you be working?

We're involved in quite a few: chronic care, diabetes, hypertension, asthma, and Integration of Behavioral health services into primary care.


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

What I hope for is really truly improving how we can continue to provide care throughout the continuum. I believe the program will allow us to think much more broadly - through a shared vision.


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

I hope that it will accelerate the process of standardization across the network, align all our partners to cooperatively achieve the Triple Aim: better health for individuals, better health for population and lower per capita cost.


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

We're in the early stages of understanding what it means. Even though the model is changing, we still live within a fee-for-service environment and are trying to transition to value based. We need more time to do this. We're hoping that the DSRIP project will financially support that transition.


Reimbursement for better care is coming, but in the meantime we have to figure out how to sustain our practice as we make the transition.


As a federally qualified health center we understand that our goal is to provide the highest quality care. We're looking forward to getting recognized for the work we're already doing.


DSRIP's purpose is to fundamentally restructure the health care delivery system by reinvesting in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25% over five years. How do you envision your organization adapting/evolving to meet the needs of this health care delivery model shift?

HRHCare is already involved in hospitalization reduction. With DSRIP, We envision better collaboration among partners, as well as having systems where we can extend our hours of operation - 7 am to 11 pm to help eliminate barriers to care.


In your experience, what are the top three guiding principles of a successful population health management program?

Patient-centricity. To listen, understand and adapt to our patients' needs.

Collaboration with partners to provide the necessary resources.

And to look at the whole patient, in terms of their whole continuum of care.

Milestone Dates

  • May 7?: Release of Attribution for Valuation Award Letters sent to PPS 
  • TBA: Release Baseline Performance data to PPSs
  • TBA: Release PPS DSRIP member roster to PPS leads 
  • TBA: Payment made to Public Hospital PPSs
  • TBA: Payment made to Safety Net PPSs
  • Late May: PPS Partner Networks posted to Website
  • May 31: Implement 2-Factor Authorization in MAPP
  • June 1: Domain 1 Implementation Plan due from PPSs




When will the next PAC meeting take place?

 The next PAC Meeting is scheduled to take place on June 30, 2015.


Where can I find the project calendar of project committees?

Our Calendar of Events is located on our recently launched website, 


To access our Calendar of Events directly, click here

Stay Informed


SCC communications currently include weekly "DSRIP in Action" emails, the monthly "Synergy" eNewsletter, and the recently launched SCC website, which houses a wealth of resources including PowerPoint presentations, videos, and key documents. To directly sign up for our newsletter, click here 


Have a question? Please send it to then watch for the answer in a future issue of Synergy.