Issue 43
November, 2018
Welcome to Synergy
We are pleased to present the forty-third 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
Please join us for the Suffolk Care Collaborative's
Quarterly Project Advisory Committee (PAC) Meeting


Hilton Garden Inn - Stony Brook
1 Circle Road, Stony Brook, NY


Health and Recovery Program (HARP)
Home and Community Based Services (HCBS)
Association for Mental Health and Wellness

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Sustaining Change in the Community:
The Underage Drinking Prevention Program
Cierra Corbett, MA
Prevention Specialist, Family Service League

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Measuring Success and Identifying Opportunity
Chief of Operations, VP Population Health Management Services, SCC

Registration Starts at 8:30 AM
Program 9:00 AM to 12:00 PM

Long Island Select Healthcare, Inc. Participates in SCC's Tobacco Free Campus Initiative

Long Island Select Healthcare (LISH), Inc. is one of several organizations that has participated in the Suffolk Care Collaborative's (SCC) Tobacco Free Campus Initiative. As part of the initiative, Behavioral Health Organizations are supported
Janet Pepper, Practice Director, and Lindsay Fudim, Project Analyst, from LISH
throughout their journey in transforming from "smoke free" campuses to "smoke free" and "tobacco free" campuses. The SCC collaborates with the Northwell Center for Tobacco Control and the Tobacco Action Coalition of Long Island to provide staff training on tobacco dependence, tobacco free signage for facilities and assistance in creating and editing tobacco free policies. Janet Pepper, Practice Director, and Lindsay Fudim, Project Analyst, at LISH are pictured outside of LISH's Central Islip facility next to one of several new tobacco free signs that can be found outside of each LISH's facility across Suffolk County.  Metal signs are provided by the Tobacco Action Coalition of Long Island.  

For more information about the Tobacco Free Campus Initiative or the Suffolk Care Collaborative's Tobacco Cessation Coalition, please contact Alexandra Kranidis, Project Manager at
SCC Presents at New York Care Information Gateway's Annual Membership Meetings

The SCC was invited to present at  New York Care Information Gateway's (NYCIG)  Annual Membership Meetings.  Samuel Lin, Director of Strategic Operations, SCC, presented at the Bellevue Hospital meeting on October 16, 2018, and Bill Bishop, Director of Clinical Programs Innovation, SCC, co-presented at the Long Island State Veterans Home on October 18, 2018, with Meeting House Lane Medical's Corporate Compliance and Quality Manager, Candice Hulse, and Education and Care Coordinator, Diana Cappabianca. 

Attendees included NYCIG members and representatives from various surrounding health care facilities including hospitals, primary care practices and skilled nursing facilities. The presentations  Leveraging RHIO Alerts to Improve Outcomes gave  the opportunity to share the collaborative efforts between the SCC, Meeting House Lane Medical and NYCIG in implementing RHIO Alerts.

RHIO Alerts notify providers in real time when their patients are admitted to or discharged from an emergency department or inpatient care, enhancing the ability of providers to engage patients in follow-up care and improve outcomes.  

Click here to view the presentations.  
Cultural Competency & Health Literacy Master Training Hosted by SCC
Suffolk Care Collaborative hosted a Cultural Competency & Health Literacy Train-the-Trainer (CCHL TTT) class on November 13, 2018.  Ten regional partners participated in the interactive program with the objective of advancing cultural and linguistic competency, promoting effective communication to eliminate health disparities and enhancing patient outcomes.  During the full day program participants learned concepts of regional health disparity data, unconscious bias, social determinants of health, cultural competency and humility, National Culturally and Linguistically Appropriate Services (CLAS) Standards, health literacy barriers and strategies, as well as the Teach-Back Method.  Upon completion, all participants received certificates of completion and a toolkit to help prepare them to deliver the CCHL Training Program in their organizations.  Congratulations to the new CCHL Master Trainers!   

The CCHL Training Program is provided through collaboration of the SCC, Nassau-Queens Performing Provider System, Long Island Health Collaborative (LIHC) and curriculum creator Dr. Martine Hackett, an Assistant Professor at Hofstra University. 

Front row (left to right):  Ha N., Nassau-Queens Performing Provider System; Nicole Conway, Cold Spring Hills Center for Nursing & Rehabilitation; Jody Felice, Able Health Care Services.
Back row: (left to right):  Teresa Delgado, Long Island Community Hospital; Mary Beth Heinicke, Cold Spring Hills Center for Nursing & Rehabilitation; Antonella Bojanich, Northwell Health System; Mary Beth, West Islip Youth Enrichment Services; Shenniff Armandi, Long Island State Veterans Home; Mercedes Barre-Williams, Shinnecock Health Center; Dana Wedin, Berkshire Farm; Sofia Gondal (Class Instructor), SCC.

For additional information about the CCHL Training Program and SCC's class dates for 2019, please visit the CCHL landing page hosted on LIHC's website or email .
Partner Interview:  Performance Improvement Best Practices at Catholic Health Services of Long Island
Name:  Charlene Greene, MS, CPHQ
Title:  Project Manager, DSRIP
Organization:  Catholic Health Services of Long Island

Please tell us about your organization's performance improvement activities. 
Catholic Health Services' (CHS) DSRIP team created the Primary Care Chronic Conditions Committee (PCCCC) as part of our Performance Improvement Program. The committee focuses on improving health outcomes of Long Island communities with chronic conditions, as well as improving DSRIP metric performance. The committee monitors and prioritizes the performance of Diabetes, Access to Care, Cardiovascular and Asthma metrics in DSRIP, and identifies best practices and opportunities for improvement. Disease specific workgroups review and scale best practices across primary care practices and hospitals to improve care and decrease unnecessary hospital and emergency department utilization. The aim is to improve compliance with the DSRIP metrics, which will aid providers in the transition from fee for service to value based programs and contracts.
What are some of your best practices and how have they been identified?
One of CHS' best practices is the Pediatrics Asthma Home Based Program. Under this program nurses go into the home to evaluate patients' living environment, medication adherence, etc. Home visits provide ongoing patient and family education, recommendations for improvement of asthma management and communication with the patient's primary care provider to facilitate improved asthma management by the patient and family. The Asthma Home Based Program is a CHS program that existed prior to the PCCCC and DSRIP's implementation. Another best practice is a patient reminder process for annual physical/preventive exams, which is measured by the Access to Care metrics. Through the use of practice scorecards, Michael Sokol, Performance Implementation Manager, identified Dr. Daisy Baez's practice as a high performer across all age groups. Dr. Baez allowed us to work with her practice to map out their patient reminder process in a flowchart in order to replicate in other practices who have improvement opportunities.
How are you using data to inform your performance improvement initiatives?
During the first six months of the PCCCC, the committee reviewed the HUB's DSRIP performance data monthly to understand its performance with Asthma, Diabetes, Access to Care and Cardiovascular metrics at the system and PPS level. The data, along with additional information, was used to prioritize metrics the committee would focus on. Once metrics were selected, the PCCCC tasked the disease specific workgroups with drilling down the data at the practice level to identify best practices and improvement opportunities. The workgroups report their findings and recommendations to the PCCCC, where corrective actions are discussed and approved prior to development and implementation of improvement initiatives. During the development and implementation phases, workgroups provide monthly status reports. During implementation, real-time baseline and performance electronic health record (EHR) data are collected at the practice level to establish performance levels prior to, during and after implementation of a new process.
How has your organization been able to impact health outcomes in the community?
The PCCCC has impacted health outcomes in the community by identifying opportunities to refer pediatric patients to the Home Based Asthma Program and by improving providers' processes to increase the number of patients who complete their annual preventive physical exam. The Home Based Asthma Program decreases asthma exacerbations by identifying asthma triggers in patients' homes, improving medication adherence and asthma management through education and resources to patients, families and primary care providers. The annual preventive physical exam patient reminder impacts health outcomes in the community by implementing a process that improves providers outreach to patients in need of annual assessments. This enables chronic disease prevention and management or treatment of diseases before patients become acutely ill. As the PCCCC progresses, additional interventions will be identified and implemented.
Compliance Connection
New York State Office of the Medicaid Inspector General Compliance Program Certification 

December 31st of each year is the deadline for New York State (NYS) Medicaid providers who make claims/bill at least $500,000 in any consecutive 12 month period to the Medicaid Program and Managed Medicaid payors to certify their compliance program meets the requirements of SSL 363-D and 18 NYCRR Part 521, referred to as the "SSL Certification."  The submission certifies that your organization meets the obligation to establish and operate an  effective compliance program aimed at detecting and preventing fraud, waste and abuse of Medicaid funds.  

The NYS Office of the Medicaid Inspector General (OMIG) recently posted an educational webinar on their website which provides updates to the program and tips for completing the 2018 form.  The webinar can be accessed here.

For more information on who must have a compliance program, NYS's rules and regulations and the required 8 elements of a compliance program, visit OMIG's website.  The website also includes requirements for those Medicaid providers who are subject to the federal Deficit Reduction Act of 2005 (DRA) and required annually to complete the "DRA Certification." 

For compliance  questions or assistance, contact SCC's Compliance Office at and visit the compliance page on our website for helpful information.
 Milestone Dates
 NYS DOH DSRIP Program Milestone Dates
November 30
IA completes review of PPS DY4 Second Quarter report
December 15 PPS Remediation of PPS DY4 Second 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. Community Health Associate
  For more information, please contact the Suffolk Care Collaborative via email