Issue 31
November, 2017
Welcome to Synergy
We are pleased to present the thirty-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.  

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
SCC's Care Transition Program 2018 Training Initiatives

The Suffolk Care Collaborative (SCC) is excited to announce two certified training programs being offered in early 2018!

SCC is working with Pathway Health to host a Certified INTERACT™ Champion (CIC) Training Program to reduce unnecessary hospitalizations as well as strategies for efficient and effective implementation. The CIC Program is designed to train clinical leaders who will serve as champions and co-champions to implement and sustain the INTERACT™ Quality Improvement Program (QIP) in their organization through education, embedding the INTERACT™ QIP into routing clinical care and QI processes, monitoring INTERACT™ QIP processes and outcomes and providing the facility team and leadership with continuous feedback on INTERACT™ (QIP) performance. Many Skilled Nursing Facility partners will be participating and nominating one employee to be trained. Training dates will be offered in January 2018. For further details on the Certified INTERACT™  Champion (CIC) Training Program, please click here .
In addition, Greater New York Hospital Association (GNYHA) has partnered with SCC to host an Antibiotic Stewardship Program (ASP) Initiative with our contracted SCC skilled nursing facilities. The goal of this certificate program is to provide the knowledge base and mentorship needed to help health care facilities develop or advance their current antibiotic stewardship policies to meet the Centers for Medicare and Medicaid Services ASP reforms for long term care facilities. This certification program focuses on reducing clostridium difficile and urinary tract infection rates and ensure the proper use of antibiotics.  For further details on GNYHA and the ASP Initiative, please click here.
If you have any questions about either of these initiatives, please contact Sara Azizi, Care Transitions Program Coordinator at 
Collaborating to Improve Behavioral Health Services

Congratulations to Stony Brook University's School of Social Welfare and School of Nursing for obtaining a grant through the Health Resources & Services Administration (HRSA) to improve the behavioral health services offered to underserved populations in Suffolk County.  Susan Jayson, Director of Behavioral Health Services Integration at the SCC, has been collaborating with staff from the two schools to apply for this $1.8 million grant and will now be working with the schools during implementation of the grant over the next four years. 
Specifically, this grant integrates the education and training of social work and nursing graduate students and expects to expand the existing services at select DSRIP sites and regional mental health agencies.  This initiative directly relates to two of SCC's DSRIP projects--Integrating Behavioral Health and Primary Care (3ai) and Screening, Brief Intervention and Referral to Treatment (SBIRT) (4aii).  Professionals and students will integrate SBIRT at existing team-based primary care settings and community behavioral health organizations with the goal to address unmet needs of vulnerable, underserved populations. 
SCC will provide its expertise to support the learning of 112 nursing students and 58 students in the School of Social Welfare during the course of the grant and is excited to be collaborating on this important initiative that provides a multi-disciplinary learning approach. 
Click here to read more about the grant in Stony Brook University's Press Release.  
Cultural Competency Health Literacy Endorsed Resources and Tools

Throughout the DSRIP program, the SCC has been involved in a variety of efforts to enhance awareness, collaborate and share Cultural Competency and Health Literacy (CCHL) best practices.  SCC's CCHL Advisory Workgroup meets monthly to review and discuss significant CCHL work stream specific updates and initiatives. In tandem with these efforts, the ongoing regional Cultural Competency Health Literacy Master Training Program has flourished, with goals to advance cultural and linguistic competence, promote effective communication to eliminate health disparities and enhance patient outcomes. During this quarter, the CCHL Advisory Workgroup endorsed a variety of recommended communication tools and resources for CCHL best practices. The content ranges from guidelines for improving readability scores to research-based tools that help to develop and assess public communication materials. These new resources will be available on SCC's online Learning Center soon.  For the current CCHL resources, visit the Learning Center on our website.  

Feel free to send us questions or comments by emailing the Community Engagement Team at
Expansion Plans for Regional Cultural Competency and Health Literacy Training Program

The current CCHL Training Program curriculum developed by Professor Dr. Martine Hackett of Hofstra University includes topics addressing health equity, unconscious bias, cultural competency and humility, health literacy barriers and the "Teach-Back" method for providers serving racially and economically diverse populations. To date SCC has provided CCHL education to 322 professionals since the training program's inception in November 2016. SCC has established tentative 2018 dates for Train-the-Trainer classes.  The schedule can be found on the CCHL landing page on LIHC's website.  To further the expansion of culturally and linguistically appropriate healthcare in the region, SCC along with our partners Nassau-Queens Performing Provider System (NQP) and Long Island Health Collaborative (LIHC), have begun developing strategies for the free Cultural Competency and Health Literacy (CCHL) Training Program for 2018. 

Plans are currently underway to further expand the program throughout the region. One of the strategies include the creation of tools to aid Master Trainers in gaining leadership support and participant interest in their respective organizations.  Click here for the CCHL One Sheet flyer; the CCHL FAQS can be found here.  

Furthermore, together with our aforementioned collaborative partners, SCC has begun exploration of supplemental education to address health disparities affecting various populations across Queens, Nassau and Suffolk Counties. Curriculum development focusing on cultural and linguistic appropriate healthcare for the Lesbian, Gay, Bisexual, Transgender and Queer (LGBTQ) population is currently underway. 
To learn more about the regional CCHL Training Program and how your organization can participate, please contact our Community Engagement Team at 
COMPASS Unity Participates in South Country School District's Harvest Festival
COMPASS Unity through Strength and Diversity is Bellport/South Country School District's alcohol and drug prevention and awareness coalition. Over the last year, the group has been supported by Family Service League's Underage Drinking Prevention Program through DSRIP funding from the Suffolk Care Collaborative.
COMPASS Unity continued to strengthen its school and community engagement by joining Bellport Middle School for its annual Harvest Festival on October 21, 2017. COMPASS Unity had a table at the Harvest Festival with the theme of wellness. The table served as an information station for festival attendees, including copies of South Country's community resource guide, brochures and educational booklets on substance use prevention. The table also included Red Ribbon Week pledges for youth and adults to kick off the week-long recognition.  Red Ribbon Week is a national alcohol, tobacco and other drug and violence prevention awareness campaign that is observed annually in October. This year's theme was YOLO (You Only Live Once): Making Healthy Choices for a Healthier Life. Pledging encourages participants to strive to be healthy, safe, respectful and responsible by making healthy choices, respecting themselves and spreading the word to family and friends about the importance of being healthy. Over 100 pledges were signed and ultimately placed on display at the South Country Central School District's administration building.
Held on a fairly warm day in October on the front lawn of the school, Harvest Festival goers had a fun-filled day. The day included all-day access to inflatable slides and bounce houses, carnival games and face painting. There was music, food and a video game truck. COMPASS Unity also held a raffle, with a chance to win a mountain bike and a host of other prizes. The winners were randomly drawn during COMPASS Unity's monthly meeting. Four lucky Bellport residents won the prizes.
"The Harvest Festival is a staple school-based community event that happens annually. Such events are considered protective factors, which COMPASS Unity Coalition and the Underage Drinking Prevention project fully support and strive to sustain," say's Cierra Corbett, Family Service League's Prevention Specialist. COMPASS Unity has already been invited back to participate in next year's Harvest Festival, in which they plan to have more prizes to raffle and information to share with the community.

To read more about this event and other COMPASS Unity news, click here for the Directions Newsletter.  
Gurwin Jewish Nursing & Rehabilitation Center Opens Social Adult Day Care Program

A ribbon cutting ceremony was held recently for a new Social Adult Day Care program at the Gurwin Jewish Nursing & Rehabilitation Center in Commack.  An extension of the long-established, award-winning Adult Day Health Program at the Center, Gurwin's Social Adult Day Care program focuses on providing participants with Alzheimer's disease or other dementias a safe and stimulating environment while providing respite to their caregivers.

According to Jeraldine Fedoriw, LMSW, Director of Adult Day Care at Gurwin,
Pictured:  Gurwin Executive Vice President/CEO, Herbert H. Friedman; Board President, Bert E. Brodski; Administrator/COO, Stuart B. Almer; Board Vice President, Phyllis N. Charash; Director of Adult Day Care, Geraldine Fedoriw, LMSW; and Honorary Board Member, Rosalyn C. Gordon
"Millions of people in the United States suffer from Alzheimer's disease, and their caregivers - often family and friends - provide countless hours of care for them.  On Long Island, the crisis is getting worse with the aging of our population.  We need more programs not only for those suffering from the disease, but also to provide respite for those caring for them."

Gurwin's Social Adult Day Care Program, which is housed in the Center's Weinberg Pavilion, provides a caring environment that is safe and social.  Frail elderly individuals, including those with Alzheimer's disease or other dementias, thrive with the support they need to remain living in the community.  The program operates from 10:00 AM to 4:00 PM and includes meals and snacks, a variety of creative and social activities, cognitive stimulation, and access to a gift shop, beauty/barber salon and a private outdoor courtyard.  Transportation is also available.

"Providing a safe place for those with Alzheimer's disease or other dementia to engage in activities while safeguarding their health and well-being is vital to our community," said Herbert H. Friedman, Executive Vice President/CEO.  "We are pleased to add this important component to our Adult Day Care services." 

For more information about Adult Day Care services at Gurwin, call (631) 715-2520.
Health Literacy Training for Frontline Staff 

SCC will be co-hosting with the Greater New York Hospital Association (GNYHA) and the Continuing Care Leadership Coalition (CCLC) a half-day health literacy training opportunity for frontline primary care, hospital, continuing care, community and faith based organization staff and managers.  

When: Thursday, December 14, 2017
Registration and lunch starts at 12:30 pm
Training 1:00 pm - 5:00 pm
Where: Suffolk Care Collaborative
1393 Veterans Memorial Highway, Hauppauge

The session is designed to provide frontline staff with baseline information about health literacy and to support organizations in their efforts to engage frontline staff in their health literacy initiatives. The curriculum includes training on the definition of health literacy and the introduction of basic health literacy concepts; a discussion on the importance of addressing health literacy for patients who are aged, have chronic diseases or have special communications assistance needs.  Staff participation can also assist members with meeting Delivery System Reform Incentive Payment (DSRIP) program Health Literacy training expectations.

Recommended participants include: Nurses, registration and admitting staff, medical assistants, social workers, care managers, patient experience staff, health educators, discharge planners, dieticians, pharmacists, community health workers, Public Affairs and others who interact with patients.

Hospital employees are encouraged to register directly on the GNYHA website here .  If you are not a hospital employee, you may register   here If you have questions about registration, please contact Elizabeth Wilson at
Partner Interview
Name:  Anne Little, MPH, AE-C
Title:  Director, Asthma Coalition of Long Island
Organization:  American Lung Association, Northeast Region

Please give us a summary of your organization.
The Asthma Coalition of Long Island (ACLI) is funded by a grant from the New York State Department of Health to the American Lung Association to reduce the burden of asthma in Suffolk and Nassau Counties. There are approximately 300,000 people in our geographic area that suffer from this chronic disease.  ACLI has been funded since 2000 and our mission is to link our community together to improve asthma care for children and families. We have grown to over 175 volunteers from the healthcare and schools' communities, many of whom serve on committees to support quality improvement projects implemented by ACLI.  Our volunteers deliver professional trainings, review materials and publications for medical accuracy and health literacy, network to improve bi-directional referrals and brainstorm for solutions to barriers for guidelines-based care.

One of the signature quality improvement projects of the ACLI and the Asthma Coalition of Queens for Nassau, Suffolk and Queens Counties is the BREATHE (Bringing Resources for Effective Asthma Treatment through Health Education) program. The goal of BREATHE is to implement a systems and culture change to embed evidence-based guidelines using a multi-disciplinary approach to reduce hospital readmits and emergency department visits for pediatric asthma patients. It includes education of all clinical staff and self-management education for patients with uncontrolled asthma. To date, over 2,500 children have been enrolled in BREATHE projects.

Who does your organization serve? 
While ACLI does not provide direct services for patients with asthma, we focus on providing asthma education, educational materials and some resources for primary care, hospitals, schools and community-based organizations across Nassau and Suffolk Counties who serve patients with asthma.

Why did you choose to participate as a partner of the SCC?
ACLI and the American Lung Association chose to participate as a partner of the SCC because our goals align:  reducing avoidable hospitalizations and emergency department visits. Many of our community partners participate as SCC partners as well, joining together to work toward the Triple Aim: improving the patient experience of care, improving the health of populations and reducing the per capita cost of health care.  

On which DSRIP project(s) are you working?
The Asthma Coalition works on DSRIP's 3.d.ii Expansion of Asthma Home-Based Self-Management Program, providing trainings for home care nurses and community health workers on asthma basics and home environmental trigger reduction, self-monitoring, medication use and recommending medical follow-up to reduce avoidable emergency department and hospital care. In addition, ACLI has provided low-literacy, bi-lingual educational materials and some resources to support the work of the three hubs, Stony Brook Children's Hospital's Keeping Families Healthy; Catholic Home Care, Catholic Health Services and Northwell Health Home Care Program. 

How do you see this project making an impact on our communities, workforce and population we serve?
The work of DSRIP's 3.d.ii project aligns with home asthma management projects that have been a large part of the Asthma Coalition of Long Island's quality improvement work for the past five years and have the potential to make a strong impact on our communities, workforce and children with asthma. Home visit programs are also proven to be effective to improve overall quality of life and productivity, by reducing asthma symptoms and the number of school days missed due to asthma. A home visit provides an ideal setting to educate, review medication plans and help families identify environmental triggers in their homes that may contribute to the severity of this chronic condition.

What do you hope the DSRIP program will accomplish for your organization in the future?
It is our hope that the DSRIP program partners will collaborate with the Asthma Coalition of Long Island and avail themselves of all of the rich educational resources that ACLI staff and volunteers have developed. Our asthma education tools have been provided to organizations across New York State by the New York State Department of Health because of their low literacy, culturally sensitive content.
Compliance Connection
Tips and Resources for OMIG's Certification Process
NYS Office of the Medicaid Inspector General (OMIG) has posted a webinar entitled,  OMIG's Certification Process: Mandatory Compliance Programs & Deficit Reduction Act of 2005 on it's website.

This webinar provides links to resources for the Social Services Law Section 363-d and 18 NYCRR Part 521 (SSL) compliance program and certification obligations and the federal Deficit Reduction Act of 2005 (DRA) obligations that are codified in 42 United States Code Section 1396a(a)(68).  These resources can help you understand your obligations to certify.  Tips for completing the SSL and the DRA certification forms are also included in the presentation.  For providers that are required to submit certification forms, the deadline to do so is December 31 of each year. Information and access to the certification forms is available on the OMIG website.   

If you have  questions, you may contact OMIG's Bureau of Compliance at (518) 408-0401 or via email at: .   For compliance questions, or assistance, contact the SCC Compliance Office at
 Milestone Dates
 NYS DOH DSRIP Program Milestone Dates
Post PPS Primary Care Plan Update documents
December 1
Independent Assessor provides feedback to PPS on PPS Year 3 Second Quarterly Reports; 15 day Remediation window begins
December 1
Response made to PPS Lead Regulatory Waiver Request - Round 6
December 15
Revised PPS Year 3 Second Quarterly Reports due from PPS;  15 day Remediation window closes
December 30
Final Approval of PPS Year 3 Second Quarterly Reports

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. Administrative Manager, Performance Reporting & Management
  3. Care Manager
  4. Community Health Associate
  For more information, please contact the Suffolk Care Collaborative via email