Issue 19
November, 2016
Welcome to Synergy
We are pleased to present the nineteenth 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
New Community Based Organization Partnership:    
Federation of Organizations to Promote Asthma Self-Management Program (PASP) partnership_puzzle_drawing.jpg

The Suffolk Care Collaborative has initiated a new community-based partnership under the   Asthma Home Environmental Trigger Reduction Services. We've partnered with Federation of Organizations to oversee the recruitment, on-boarding, training and supervision of Community Health Workers (CHWs) who will be facilitating the Asthma Home Environmental Trigger Assessments and Services. The SCC and program administrators at Stony Brook Children's Keeping Families Healthy Program (KFH), have begun to work with Federation of Organizations to pair CHWs with eligible patients and their families to expand current services county-wide to improve asthma self-management. 

About the Asthma Home Environmental Trigger Reduction Services
In the September edition of Synergy the Suffolk Care Collaborative shared its new partnership with Stony Brook Children's Keeping Families Healthy Program. Asthma patients 0-25 years old, insured under Medicaid will be stratified into three risk categories: high, moderate and low. Eligible high-risk patients and their families will receive home visits from Community Health Workers (CHWs), with calls/text reminders as needed between visits, especially after ED/hospital visits. A patient-centered root cause analysis will also be conducted during each visit to help prevent future asthma related incidents. CHWs will follow a protocol to guide visit content focused on home environmental trigger reduction, self-monitoring and self-management of asthma symptoms, asthma medication use, and medical follow-up. CHWs will link patients to resources for trigger reduction interventions, especially to change the patient's indoor exposures to potential triggers. A visit summary will be sent to all health care team members (e.g., primary care physician, sub-specialist) in the future via interoperable EHR and PPS-wide care management platforms created to support integrated care delivery.

Home visits provided by the CHWs will include an evaluation of home environmental triggers for asthma, providing health education materials pertinent to promoting asthma self-management, reviewing asthma action plans with families and responding to their asthma related concerns and questions. Further, CHWs will link patients and their families with appropriate community resources based on need, including additional healthcare services, food assistance, transportation services, childcare services, family services, and counseling, in accordance with the SCC Community Navigation Program.

Community Health Worker Training & Development
The KFH CHW training curriculum was developed by the KFH team along with a team of Stony Brook pediatricians, specialists, and nurses. Community Health Workers (CHWs) complete a comprehensive two-week classroom-based training followed by a period of field shadowing to prepare them for their new positions once hired. In addition, CHWs complete an orientation training provided by Federations of Organizations. After their initial training, the CHWs attend monthly meetings with their supervisor, these monthly meetings serve as a time to provide additional training and continuing education on various topics. 

Through the PASP program developments this year, we have supplemented KFH CHW training curriculum with the Association for Asthma Educators (AAE) CHW asthma training. The AAE training includes modules on: Scope of Asthma, Triggers and Environmental Control, Medications, Medication Delivery Devices, and Assessment and Monitoring. With the help of our PASP Project Committee members, Anne Little and Claudia Guglielmo from the Asthma Coalition of Long Island, and Lisa Romard a Nurse Practitioner in Pediatrics Pulmonary at Stony Brook Children's, all of whom are Certified Asthma Educators, all CHWs will be trained in the AAE curriculum. This training has been piloted, revised, and published; click here to learn more.
About the Federation of Organizations   

Federation of Organizations (Federation) is a multi-service, community-based social wellness agency and is a major provider of mental health and wellness, senior and support services in Suffolk, Nassau, Queens, Brooklyn, Bronx and Manhattan. For over forty years, Federation has developed innovative, successful programs that are designed to meet the needs of vulnerable populations, such as individuals in recovery, those living with chronic medical conditions, adult home residents, the homeless, low-income seniors and at-risk children. Since 1977, Federation's mission has been to engage people with disabilities in community service and provide a wide range of programs including care coordination, housing, clinical treatment, employment, peer advocacy, and other rehabilitative services. One of Federation's main goals is to improve the lives of people with disabilities and their families through education, information and referral services, legislative action and program development.
Northwell Health's "Snapshot" Optimizes Caregiver Workflow
Submitted by: Debra Cooper, AVP, Organizational Change Management & Marketing

Physicians and their care teams are seeing a growing number of patients on a daily basis and are expected to provide more comprehensive care at each visit. Advanced, team-based care models such as the Patient Centered Medical Home (PCMH) offer ways to deliver this, but require more powerful care tools to efficiently support the process.  With electronic health records, primary care providers have access to an abundance of information - sometimes too much information.  "The charts are so clogged with data - the information is in the record somewhere, but to pull it all together in one easy-to-look-at view is a priority," said Joanne Gottridge, MD, an internist and executive vice chair of the Department of Medicine at Northwell Health.
How can the care process be supported so that doctors are able to spend the necessary time with their patients while delivering the appropriate care needed?   "Historically, electronic health records haven't always been designed to support efficient, team-based primary care, resulting in the difficulties of seeing what the patient needs all on one screen," said Barry Goetz, MD, an internist and director of clinical information systems at Northwell Health. 
At Northwell Health, Dr. Goetz led a team of clinical and information technology professionals who collaborated on the creation of an "at a glance" tool that displays key patient information in one place within their Allscripts ambulatory electronic health record.   Clinical Snapshot - Snapshot for short, is very specific and differentiates each patient based on their known condition(s), aiding in identifying gaps in care, recommending screenings, and helping to recognize where the patient may need additional counseling for self-management of health issues. 
Snapshot is available for use by the entire care team, and can help support the daily huddle that occurs in PCMH practices to quickly review the condition and needs of each patient, such as chronic disease problems, screenings, and immunizations.  Any care needs that must be addressed with the patient are highlighted in red.
Clinical Snapshot has already been deployed to over 400 clinical users including primary care physicians and their care teams.  So far the response has been overwhelmingly positive - "Clinical Snapshot is clearly a home run. The beauty of it is it's in one screen shot" said Dr. Gottridge, who also provided clinical design guidance.  Other physicians have made comments such as "this is a great tool Northwell IT has delivered" and "this is going to make a huge difference in care." 

Partner Interview: 
Name: Jay Enden, MD
Title:  Medical Director, Eastern Region 
Organization: Northwell Health

Please give us a summary of your organization: Northwell Health, formerly North Shore-LIJ Health System, is a network of 21 hospitals and thousands of healthcare providers dedicated to clinical care and community health. It covers the New York metropolitan area, including Long Island, New York City and Westchester County, and incorporates multiple regions. I was made the Medical Director of the Eastern Region in May. The new structure offers, among other things, a means of defining, consolidating and leveraging best practice across a large geographic area.  

Who does your organization serve? The Eastern Region of the Northwell Health system includes Glen Cove Hospital, Huntington Hospital, Peconic Bay Medical Center, Plainview Hospital, Syosset Hospital and Southside Hospital. I was formerly the Medical Director of Southside.

How has your organization begun to experience the shift to value-based payment? We all embrace the opportunity to deliver more patient-centric care, but the current healthcare environment still makes it challenging to provide integrated care for many types of complex patients. Northwell's Health Solutions, for example, is aligning organizational resources, such as analytics, care coordination, and best practices models to enhance clinical integration. Since defining and establishing optimal ways to deliver value-based care is a journey, innovation is important.  It is necessary to test new ideas and to explore new partnerships.  
When I was Medical Director at Southside, we looked at groups of patients frequently using the emergency department. We discovered that there was a lack of alternatives, or a lack of knowledge of alternatives to using the ED. We also realized that we did not have a complete understanding of the underlying drivers of health care utilization, and how we could best address them. Through programs like DSRIP and MAX, I am hoping we can take these insights to a wider audience.

What is the difference between DSRIP and MAX? DSRIP (Delivery System Reform Incentive Payment program) provides the overall funding for improved Medicaid services via Performing Provider Systems (PPSs), while the MAX Series Program (Medicaid Accelerated eXchange) is a program being offered by the New York Department of Health as part of the DSRIP program. Where DSRIP focuses on a statewide delivery system reform, MAX is set up as a local process improvement for specific patient populations to impact DSRIP quality measures and improve patient health.

Why is your organization participating in the MAX Program? We are participating as part of an effort to better coordinate clinical care, to better understand what ultimately drives high-risk patients to resorting to high utilization behavior, and to share best medical practices throughout the Eastern region of Northwell.  

Right now the MAX Series program focuses on process improvement for those "super utilizers" who spend a lot of time in hospital emergency departments and as in-patients. We are looking at all patients fitting the definition of a "super utilizer"--someone who has been admitted at least 4 times. The goal is to reduce avoidable hospital admissions and ED use by 25% over the next 5 years.

What do you hope the MAX program will accomplish for your organization in the future? We need to understand the drivers and characteristics of healthcare "super users." That way, we can develop a longitudinal history that can give us the insight to break the cycle, and provide an alternative to admissions. This sort of information can help us solidify a team-based approach to this particular population. By identifying and strategically mitigating the drivers of excess utilization (and they are not all clinical), we may be able to help patients before they become "super utilizers". Participating in MAX will allow us to test things that may help.

Explain processes your organization has put in place and their outcomes.  We have found that "Super Utilizer" patients may need moderately inexpensive people to help them, not necessarily health care providers, but resource coordinators to help link patients to outpatient resources, such as transportation or other community services. A local health information exchange helped to immediately identify patients and to send an alert to an interdisciplinary team.  Frontline members of this team would quickly meet the patient in their current setting. Team members were trained to conduct structured individualized risk assessments, to define drivers and mitigation strategies for admission and readmission (through interdisciplinary patient-centric huddles), and to establish and maintain linkages to clinical and non-clinical services after discharge. The linkages may include establishing a stable connection between high risk patients and appropriately resourced providers, such as Medical Homes. This strategic "bridging" of inpatient and outpatient care is critical, yet difficult.

We started with a limited cohort--about 150 patients--but since we started in early 2016 we have reduced hospital readmissions by about 50% and emergency department use by about 60%.

What value does the SCC bring to patients under the MAX/DSRIP program? SCC has been wonderful! Among many things, it has allowed us to have medical homes for a number of these patients. SCC helps identify resources for us and the patients.  Hospitals haven't traditionally been set up as preventive health institutions. By integrating community resource information with clinical information, and providing feedback, SCC is making our job easier. 

What, in your experience, are the top (three) guiding principles of a successful population health management program?
  1. Patients need access to a structured multidisciplinary care model that has the right combination of clinical (including behavioral health) and non-clinical talent. The individuals involved should be readily available, at appropriate levels of care, to high-risk patients.
  2. Infrastructure should include some sort of information exchange, and have defined team members who can use this health information to track compliance with individualized risk mitigation strategies as well as utilization patterns.
  3. There should be a commitment to a sustainable payment model that leads to the ability to implement this kind of organizational commitment on a large scale. High-risk patients need to see that they have an effective alternative to seeking acute care services. Similarly, providers of acute care services need to be confident that they can safely hand patients off to an effective partner. 
Is there anything else you would like to add about MAX or DSRIP? We only started with the MAX Program early this year. Our early efforts are good-but I would like to see a more stable infrastructure. We are learning valuable things, and will continue to until the funds run out, but the payment model is illogical. We will only be able to improve our health care delivery if we can rely on a stable funding base.
INTERACT Spotlight:  Gurwin Jewish Nursing & Rehabilitation Center
David Siskind, MD, Medical Director

Gurwin Jewish Nursing & Rehabilitation Center in Commack, an engaged participating Skilled Nursing Facility in the INTERACT Program, is being applauded for their use of INTERACT's Review of Acute Care Transfer Quality Improvement Tool. 
Gurwin is one of the Phase 1 NY-RAH facilities, and has been using INTERACT tools for several years.  What makes Gurwin unique is the commitment of the Medical Director,  David Siskind, MD, in reviewing every resident hospital transfer.  

Joanne Parisi, Associate Administrator at Gurwin, said, "Under the leadership of Dr. Siskind, we have embraced the use of the Interact Quality Improvement Tool for Acute Care Transfers. Dr. Siskind analyzes every hospital admission using this tool and presents his findings at morning report for discussion and analysis among the clinical team.  This has proven to be invaluable in our efforts to reduce avoidable hospital admissions and emergency department visits."  
Dr. Siskind said, "I review all transfers to the hospital resulting in an admission using the Acute Care Transfer Quality Improvement tool.  I review their medical history, transfer history, the events leading up to the transfer, treatments and interventions initiated in the facility, presumed discharge diagnosis and admitting diagnosis."
He identified that he, specifically, looks for areas for improvement related to:
  • Improved earlier detection of acute changes in condition, such as overlooked changes in laboratory values, vital signs or functional status.
  • Therapy that could have been more aggressive or initiated earlier.
  • Changes in advance directives or goals of care.
"I review each hospitalization to determine whether, in my opinion, it was avoidable or unavoidable."   If he feels the transfer was avoidable, he reviews his findings with the practitioner involved as an educational tool.
Dr. Siskind was an active participant in the INTERACT Project's first quarterly Medical Director conference call, hosted by Dr. Linda Efferen, Medical Director at Suffolk Care Collaborative. 
Community Consumer Advisory Council  
Engagement Through the "Community Voice" 

As the SCC continues to expand its efforts to be more community facing and patient engaging, the Community Consumer Advisory Council is an exciting new development.  This Council is comprised of engaged community members and healthcare professionals; and it will provide input in the SCC's efforts to achieve health outcomes across populations and the effectiveness of patient engagement efforts across the DSRIP portfolio. The Council encourages a broader perspective of improving healthcare delivery systems, which includes the "community voice" in order to work towards meeting multifaceted DSRIP initiatives.
The first Community Consumer Advisory Council meeting took place on November 30 at 6:30 pm at the Suffolk Care Collaborative office in Hauppauge. During this meeting, the Council was presented with an overview of DSRIP, SCC's mission and vision, and discussed several of its population health projects and SCC's Communication projects. The projects aim to introduce access to a variety of health and community oriented services and resources for members and patients of the community. The members of the Council provided thorough feedback on ways to improve these projects, as well as shared ideas on future projects, such as increasing use of personal Electronic Medical Records for self-management and ways to enhance participation in preventive care prior to a medical crisis (i.e. through early screenings and patient education.)  The meeting adjourned with the goal to further improve community engagement efforts and patient care experiences. 
Primary Care Practice Orientation Provided by SCC
Alyse Marotta, Project Manager and Susan Jayson, LCSW, Director, Behavioral Health Integration at SCC

The SCC was excited to host an orientation program for primary care practices on November 16th.  The orientation program focused on the Clinical Improvement DSRIP projects and training plan for partner practice sites. It provided an opportunity to meet members from the SCC team, who work directly with the practice staff.  In addition, the orientation provided an opportunity to meet other organizational leaders across the PPS who are undergoing similar DSRIP transformation efforts. 

Orientation Topics included: 
  • DSRIP 101 Re-cap
  • Review of the Onboarding Process
  • DSRIP Project Review - Clinical Improvement projects
    • Program Implementation Overview--What's Next?
    • Quarterly Patient Engagement Requirements
    • Meet the Program Implementation Team
    • Training & Next Steps
  • "Bringing it all Together" with PCMH Model
  • Partner Reporting Requirements & Schedule
Suffolk County Community College Offers Free Online Health IT Training

Thanks to a grant and in collaboration with Columbia University's Department of Biomedical Informatics, Suffolk County Community College (SCCC) is excited to offer a unique healthcare training program, Health IT Update for physicians, nurses, other clinical professionals, care coordinators, social workers, administrators, managers, and health IT professionals.  This training is made freely available to qualified candidates via a grant from the Office of the National Coordinator for Health Information Technology (ONC).   Training cohorts begin each month and are FREE for the first 500 qualified participants!   After June 2017, these courses will cost $800-$1,100.

The Health IT Update training includes essential topics for the changing healthcare landscape: Healthcare Data Analytics, Population Health, Care Coordination and Interoperability, Value-Based Care, and Patient-Centered Care.  SCCC's training program is led by Professor Diane Fabian, MS, MBA, RHIA, Academic Chair for Commerce and Health, and Dean Nina Leonhardt, MS, MBA. This comprehensive training is informed by policy and developed by nationally recognized subject matter experts. 

Health IT Update training was designed with the busy professional in mind, and is available to individuals in a flexible, online format using Blackboard. Training materials include PowerPoint lectures, interactive discussion boards and short scenarios.  Training is estimated to take a total of 10 hours to complete over a two-week period, culminating in an online evaluation survey.  Upon submission of the survey, participants will receive a certificate of completion from Suffolk County Community College.

Those interested in participating must complete the application and authorization form and submit them with a resume to Michael Riggio at For additional information kindly contact Andrea Dunkirk at 631-451-4552.
Compliance Connection

Janus was the two-faced Roman god of transitions, endings and beginnings - simultaneously looking back and forward.  Our months of December and January (which may have been named for him) are good times to take stock of what you have done and still need to do for your compliance program.  Many items have a yearly cycle, and slacking on timely action can have negative consequences if you are audited.  So here is a handy list to help you get started. 
  • OMIG SSL 363(d) recertification (if applicable). The  online system  is open only from  December 1 through December 31, 2016 . Organizations should be sure to follow  OMIGs recent guidance  on who may/may not certify!  The SCC will request a copy of your 2016 certification from each of our on-boarded, contracted partners.
  • DRA recertification (if applicable).  Use the same launch page to access the DRA online certification system during December.  The SCC does not require a copy of this one.
  • Annual refresher compliance and HIPAA training.  Who needs refreshers?  Does your tracking system need updating with new data?  Is your method of prompting refreshers effective or does it need improvement?  Do people take it seriously?  Are the consequences for noncompliance set forth in a policy real?  Are they enforced fairly across all personnel?
  • Conflict of Interest disclosure update.  Same questions as above.  Does your COI management process need adjusting?
  • Code of Conduct refresher.  Again, same questions.  Is your Code as straightforward and clear as it can be?  Does it emphasize the expectations for ethically sound behavior at your office?
  • Report to the Governing Body.  The Compliance Officer should be reporting on program activities at least annually.  What schedule do you use for the CO to report to the Board?  Is it enough?  Should it be revised?
  • Risk Assessment/InventoryWhat's your plan for revisiting your Risk Inventory?  When do you plan to do your next Risk Assessment?  Have these tools been shared with the people who need to know?
  • Compliance Work Plan update.  This is a living, dynamic document, so dust it off and see where you stand.  Does it too need revising?  Who needs to be looped in on your progress?
Let us know if you need help with any aspect of your compliance program.  Good luck and Happy New Year from the Compliance Office at SCC!,(631) 638-1393.
Milestone Dates
NYS DOH DSRIP Program Milestone Dates

 December 15       Revised PPS Year 2 Second Quarterly Reports due from PPS; 
                              15-day Remediation window closes

 December 21       Public comment period for Initial Mid-Point Assessment
                              recommendations and Primary Care Narratives ends

 December 30       Final Approval of PPS Year 2 Second Quarterly Reports

 January 2017       Anticipated Independent Evaluator contract start date

 January 3             Release Final Mid-Point Assessment recommendations for
                              30-day public comment

 January 6             Final PPS Year 2 Second Quarterly Reports posted to DSRIP

 January 23           Public Comment period for Final Mid-Point Assessment
                              recommendations ends

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, Clinical Programs Innovation
  2. Care Manager
  3. Project Manager, Acute Care Transitions
  4. Project Manager, Integrated & Managed Care
  5. Project Manager (PCHM Practice Facilitation)
  6. Date Visualization Analyst
  7. Data Governance Manager
  8. Community Engagement Liaison
  9. Administrative Manager, Community Engagement & Cultural Competency
  10. Provider Relations Manager
  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.