Issue 7
November 30, 2015

Welcome to Synergy


We are pleased to present the 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. 

In This Issue
DSRIP Program Updates

Transition of Care Program for Inpatient & Observation Units  (TOC) (2.b.iv & 2.b.ix)
Together with our partners at xG Health Solutions, powered by Geisinger, supporting our Care Management Organization program development, the Suffolk Care Collaborative has interviewed each hospital partner to understand the current-state transitions of care practices. Included in this effort was the collection of social services agencies, home care organizations, and MCOs which our partner hospitals work closely with in support of our patient population. These relationships will be leveraged in the design of the future-state TOC partnerships for the SCC. Our next TOC Project Workgroup meeting is December 10th 2015.

The SCC is excited to announce the partnership with Dr. Amy Boutwell, MD, Founder, Collaborative Healthcare Strategies; STAAR Initiative co-founder, Institute for HealthCare Improvement; senior physician consultant to the National Coordinating Center for the CMS QIO Care Transitions Theme; attending physician, Massachusetts General Hospital; instructor in medicine, Harvard Medical School. Dr. Boutwell will engage with our SCC TOC program partners over the next few months as a strategic adviser to support stakeholder presentations and working sessions to develop the SCC TOC Model that is scheduled to be completed by March 31st 2016. To initiate this effort, we've engaged key Hospital stakeholders and the SCC TOC Project Workgroup to attend a presentation by Dr. Boutwell titled Reducing Avoidable Hospital Utilization Best Practices & Promising Strategies for Medicaid Patients on December 14th.

Community Health Activation Program  (CHAP) (2.d.i)
The CHAP Workgroup has facilitated brainstorming sessions to define the scope of work (SOW) for the CHAP Wellness Coaching & Navigation Program. It is anticipated that the program will be designed and initiated before the close of the first DSRIP year. The Workgroup has been expanding the CHAP Training Agenda/Program to build competencies of the following program components: overview of CHAP program and DSRIP, CHAP program objectives, CHAP decision tree, Insignia PAM survey and portal training, the wellness coaching model, the community navigation program, and customer service. Soft skills will be applied in training, to include: motivational interviewing, cultural competency & health literacy, reporting requirements, re-training opportunities, and escalation procedures.

On October 21, 2015, Trevor Cross, Community Liaison at HRHCare, held an CHAP Outreach Team meeting where Community Health Workers (currently engaged in PAM surveying efforts in the community) from each of the three partner CBOs (HRHCare, Association for Mental Health & Wellness, and the Economic Opportunity Council) had an opportunity to meet, share best practices and discuss next steps for the program. This open forum to allow our program staff to share and meet one another was a very successful engagement strategy that we will plan to continue in the future.

Primary & Behavioral Health Integrated Care Program (3.a.i)
SCC is excited to share the on-boarding of a Primary & Behavioral Health Integrated Care Program Coordinator Susan Jayson. Susan comes to SCC from South Oaks. While at South Oaks, Susan helped to develop and build an outpatient mental health clinic for children and adolescents. As director of that program, she was able to grow the program to serve 300 individuals and their families in a field which has a dearth of providers. Under her leadership, patients were able to access care not only in the clinic, but in schools, homes and primary care offices through collaborative integrated programs Susan helped to establish.

A strategy of our Project Management Office (PMO) is the on-boarding of implementation specialists to support implementation across our DSRIP projects. In a formal implementation specialist function, Susan Jayson will coordinate our program objectives to increase access to primary and acute physical health services, behavioral health care though our program. A key feature of this role is to act as a liaison between SCC and the PMO, community partners, specialty care, state and federal entities, and others related to supporting the IC model implementation.

In October experts from the North Carolina Center of Excellence for Integrated Care conducted 21 on-site practice assessments. In total, 72 Primary Care Physicians (PCP's) representative of 15 primary care sites and 55 behavioral health providers representative of 6 practice sites are engaged in our "Phase 1 Implementation Group." The goal of the site assessments was to gain an understanding of the current level of integrated care taking place among primary care providers and behavioral health sites to help design a customized SCC implementation training series and toolkit, tailored to the unique needs of our provider network. The lessons learned generated through these site visits was invaluable to our future-state implementation toolkit. Each participating site will receive a post-assessment summary which will include recommendations and assistance in preparing their site for integrated care as we move into the implementation phase. Over the next six months the sites will continue to receive ongoing technical assistance from our consultant partners and program coordinator to address the unique needs of each practice. The sites will also be invited to participate in a learning collaborative series to share challenges and lessons learned. The PMO continues to work to identify additional primary care and behavioral health providers in the PPS to participate in Phase 2 of our phased implementation schedule.

Pictured (counterclockwise from top left): DSRIP Team at Stony Brook Family Medicine during their Current State Assessment visit: Richard Murdocco, Social Worker, Dawn Mignone Office Manager, Patricia Pederson, Nurse Manager, Catherine Ortiz, Patient Care Coordinator and Howard Sussman, MD, Practice Physician and Eric Christian, Consultant from the NC Center of Excellence for Integrated Care

Cardiovascular Wellness & Self-Management Program (CWSP) (3.b.i) 
With a detailed scope of work and new clinical guideline summary, a meeting of the Project Workgroup on November 24th, 2015 strategized a plan for training PCPs. Multiple workgroup members from Catholic Health System and North Shore-LIJ, drafted three lesson plans targeting providers, nurses, and unlicensed professionals. This effort will support a training strategy to include all of the SCC Domain 3 projects for primary care practitioners. 

The next Project Workgroup meeting will be held in December, where we plan to review and collaboratively discuss the draft lesson plans. To compliment the lesson plans, the Project Workgroup will initiate the development of a Project 3bi Toolkit, aggregating all project artifacts, to be used as a guide for PCPs during implementation of this clinical improvement program.  

As a project integration opportunity, the PMO and Project Lead initiated collaboration with the Diabetes Wellness & Self-Management Program to design a Stanford Model Self-Management Program (a DSRIP milestone in both 3bi and 3ci projects). On November 24th, 2015, we met with key Subject Matter Experts (SME's) to discuss the Stanford Model program design options. Next steps include sharing the curriculum of the Stanford Model with our Project Workgroup.
Diabetes Wellness & Self-Management Program (DWSP) (3.c.i)
The DWSP Workgroup has named Project 3ci the SCC Diabetes Wellness & Self-Management Program (DWSP). On November 10, 2015, the Workgroup selected the American Diabetes Association (ADA) as the source of patient education materials to be endorsed by the SCC. The Cultural Competency/Health Literacy Sub-Committee will review this decision at their meeting in December. Over the past three months, the DWSP Education Workgroup has added several new members to the group from a variety of SCC partners.

The DWSP Committee convened on November 17, 2015 to review the decision made by the Workgroup regarding the patient education materials selected. Committee members whose agencies have active Stanford Model programs, including the Chronic Disease Self-Management Program (CDSMP) and the Diabetes Self-Management Program (DSMP), have contributed proposals for Stanford Model programs for program development.

At the PMO, a meeting on November 24, 2015 engaged key stakeholders to discuss Stanford Model content and logistics for projects 3bi and 3ci, due to the overlapping requirements for both projects to initiate Stanford courses.

For DY1 Q2, 100% of Patient Engagement target (3,022 actively engaged patients as per DOH definition) was achieved. As part of the quarterly submission, the Project Manager, Amy Solar-Greco, completed a Quarterly Report Narrative Summary & Work Plan update.

Promoting Asthma Self-Management Program (PASP) (3.d.ii)
The PASP Workgroup has named Project 3dii the Promoting Asthma Self-Management Program (PASP). On November 13, 2015, the Workgroup and members of the Keeping Families Healthy (KFH) Program at Stony Brook Medicine reviewed the SOW for project deliverables through 12/31/15. Deliverables include developing a home-assessment intervention program, patient educational materials, staff training materials, SOW for vendors, workflow processes, monitoring and evaluation procedures, and plan for follow up services.

On November 9, 2015, care management and care coordination deliverables were reviewed with our partners at Geisinger Health System and internal stakeholders. On November 20, 2015 the Workgroup met with the IT PMO to discuss PASP Project IT requirements for Domains 2 and 3 measures.

For DY1 Q2, 100% of Patient Engagement target (674 actively engaged patients as per DOH definition) was achieved. As part of the quarterly submission, the Project Manager, Amy Solar-Greco, completed a Quarterly Report Narrative Summary & Work Plan update.

Substance Abuse Prevention and Identification Initiatives (4.a.ii)
Screening, Brief Intervention, and Referral to Treatment (SBIRT) Initiative
SBIRT is a comprehensive, integrated, public health approach to the delivery of early intervention and treatment services for persons with substance use disorders, as well as those who are at risk of developing these disorders. In October, the SCC SBIRT implementation committee participated in a webinar highlighting questions related to workflow and workforce. Sandeep Kapoor, MD, Director of SBIRT for North Shore-LIJ Health System addressed many FAQs associated with the project. The SBIRT Implementation Team also met this past week to review our implementation strategy and OASAS led-training program timeline. Brookhaven Memorial Hospital is one of our first partners scheduled to host a training on December 8th-9th to train their staff in preparation for implementation.

OMH Tobacco Cessation Initiative
The SCC Tobacco Cessation Workgroup has been diligently working to identify a training model for our partnering OMH facilities in Suffolk County to implement tobacco cessation treatment and tobacco free policies. The workgroup is representative of OMH providers and tobacco cessation experts who have experience implementing similar trainings and projects.

Underage Drinking Prevention Initiative
The SCC PMO has engaged with the Prevention Resource Center (PRC), currently operated through South Oaks Hospital, to develop the Underage Drinking Prevention Project framework. One of the goals of the project is to support the hiring of a Prevention Specialist to focus on prevention by providing effective prevention strategies and programs in the Bellport community. This focus will address behaviors that drive alcohol other drug abuse and will lead to positive changes in community attitudes, norms, and behaviors.

Access to Chronic Disease Preventive Care Initiatives (4.b.ii)
The 4b2 disease specific workgroups including Lung Cancer Screening, Breast Cancer Screening, Colorectal Cancer Screening Education, Obesity Prevention and Tobacco Cessation, have spent the last few months exploring patient and provider education materials related to each chronic disease, such as the CDC and those endorsed by The U.S. Preventive Services Task Force. In addition, the workgroups have successfully completed Clinical Guidelines Summary documents for each disease category which serve as an educational tool for PPS partners detailing screening protocols and recommended preventive services.

Other workgroup highlights include designing how SCC and its partners can engage PCPs to adopt strategies to implement the project successfully taking into account current workflow challenges, how a care manager or community navigator might provide support in connecting patients to resources, what social barriers will need to be considered when connecting patients with screening and preventive services, and what existing community resources and connections will help to eliminate the barriers identified. The project seeks to work closely with the CHAP (Community Health Activation Program) and other community initiatives related to DSRIP and in the Suffolk County community.
Featured Project
Project 2.b.vii Implementing the INTERACT Project
Pictured (left to right): Dianne Zambori, RN-C, MBA, LNHA, Associate Director for the Eastern Region Quality at NSLIJ & Project Lead; Dr. Joseph G. Ouslander, M.D., Project Director for the INTERACT Quality Improvement Program; Ashley Meskill, RN, BSN, Clinical Project Manager for Project 2.b.vii INTERACT; Dr. Linda Efferen, M.D., MBA, FACP, FCCP, FCCM, Medical Director for the Suffolk Care Collaborative.

On October 15th, the Suffolk Care Collaborative co-hosted a meeting alongside the Nassau Queens PPS at an Intercounty Health Facilities Association, Inc meeting, the Long Island Intercounty Health Facilities Association is a collection of over 60 long term nursing care or short term rehabilitation facilities in Nassau and Suffolk County and care for over 15,000 residents and patients. About 60 Skilled Nursing Facilities (SNFs) were represented at our presentation. The SCC presentation objectives included the following: reviewing the INTERACT  4.0 Toolkit, provided a project 2bvii overview, shared our data collection strategies & instructions, announced our Certified INTERACT  Training Program, and answered questions from SNF PPS partners. Thank you to all of our partners in your continued engagement and participation.

On October 28th, 2015, National Health Care Associates hosted an event entitled Improving Long-Term and Post-Acute Care By Reducing Unnecessary Hospitalizations where Dr. Joseph G. Ouslander M.D., Project Director for INTERACT  QIP and Professor and Associate Dean of Flo rida Atlantic University in Boca Raton Florida, was the key note speaker. Dr. Ouslander presented the INTERACT Quality Improvement Program to reduce unnecessary hospitalizations as well as strategies for efficient and effective implementation. Many of our partner SNFs were in attendance and as well as some of our project team members. This provided our project team an exciting opportunity to learn more about the INTERACT  QIP first-hand from Dr. Ouslander, the creator of the intervention program.

We've completed our initial Certified INTERACT Champion Training Program hosted at Stony Brook Medicine on November 3rd to the 6th. Each participating SNF nominated two employees to be trained, in most cases the Directors of Nursing (DON) and In-service Coordinators were in attendance. Our program training strategy was to train internal staff in the program, so they may champion the INTERACT program implementation Each trained staff is currently preparing for a Certification Exam to solidify their new credential. In the meantime, the SCC PMO in concert with our Project Leads and Program workgroup are internally preparing our program implementation by designing an INTERACT  Program Implementation Manual. This manual will be introduced to the Program Committee in December and will include all pertinent materials to be utilized for INTERACT  Program Implementation at each participating SNF during the first quarter of 2016.

On November 16th, the Clinical Governance Committee reviewed and recommended the INTERACT  Program Clinical Guidelines Summary to be reviewed and approved by the PPS Board of Directors, scheduled for December 21, 2015. The INTERACT  Program Clinical Guidelines Summary will also require approval from the Project Committee scheduled to meet on December 17th, 2015.
Building a Suffolk County Integrated Delivery System (2.a.i)

The Stony Brook IT Project Management Office is pleased to announce that we have successfully deployed the Cerner HealtheCare™ application into our production environment. HealtheCare™ is a secure web based application that will be used by our Suffolk PPS Care Management Organization (CMO) to identify and manage high risk patients. 

The HealtheCare™ application provides a flexible workspace that is dynamically rendered at the time of login based on the user's role. There are two roles currently supported within the application, one for the Care Manager Supervisor and another that is specific to the Care Manager. The Care Manager Supervisor role allows supervisors to review the set of potential Medicaid cases identified by the HealtheCare™ High Risk Patient Identification algorithm and assign those cases to their respective care managers. The Care Manager role allows users to document patient cases, manage patient outreach and engagement.

General Application Functionality:
The list below summarizes some of HealtheCare™ functionality that is currently available once a case is assigned to a Care Manager:
  • Review a Patient's Encounters and Chronic conditions
  • View/Print their case list, change the status of a case, reassign a case
  • Document Patient Goals and Interventions
  • Complete Patient Assessments
  • Add/edit a Sticky Note
  • Create Outreach letters to Patients
  • Set reminders about a given case
  • Close cases
Medicaid Population Currently Visible to the HealtheCare™ Application:
At the moment the HealtheCare™application is configured to manage the Stony Brook Hospital Medicaid population which consists of approximately 37 thousand Medicaid lives of which, on average 1000 High Risk Patients are being identified daily on a rolling window basis.

HealtheCare™ Training:
In early October we completed our HealtheCare™ 'train the trainer' event at which time the entire SCC care management team attended a 2 day training course which focused on how the HealtheCare™ application will be used in the context of our SCC care management program. Each member of the care management team have now been assigned user accounts in both the training and production environments. The training environment allows care managers to test and validate the operational processes and procedures that they will be executing in the production environment.

Operationalizing HealtheCare™:
We are working with the Care Management team to further refine the case management workflows supported in the HealtheCare™ application. Keys items currently being discussed are enhancements to the Care Manager Supervisor workflows, further refinement of the criteria used within the High Risk Patient Identification Algorithm along with enhanced reporting specific to the DSRIP requirements.

Next Steps for Data Acquisition:
Following on from our previous IT update within the August, 2015 edition of this newsletter, the SCC IT Project Management office has started working with some of our PPS Coalition Partners to begin their IT on-boarding and data acquisition projects. In most all cases the technical on-boarding process requires participation from members of the PPS partner's IT team as well as their EMR vendor. All PPS partners currently involved with technical on-boarding have been extremely supportive and we are looking forward to working with other Partners as we continue to build out the Suffolk PPS Integrated Delivery System.

Suffolk PPS Interface Specifications:
As a reminder we have created two interface specifications (supporting Flat File and HL7 formats). These specifications were created to help assure that we have a consistent representation of clinical data across all Participating Providers within the PPS. We encourage you to review the specifications which can be found here. If you have any questions on the specifications or any other technical aspects of the program, please feel free to contact the SCC IT Project Management Office.
Partner Interview
Name: Deborah Schafmeyer, RN, RAC-CT
Title: Director of Nursing
Organization: Island Nursing and Rehab Center
Provider Type: Nursing Home

Please give us a summary of your organization
We're a 120-bed, not-for-profit skilled nursing facility located in the middle of Long Island. Our residents are from the north shore, the south shore - from a number of different hospitals.

Who does your organization serve?
We predominantly care for geriatric patients, but we do get a younger population on the sub-acute unit. Approximately one third of our patients are here for short-term rehab, while the other two-thirds are long term.

Why did you choose to participate as a partner of the SCC?
The main reason we chose to participate was to improve the quality of care that we provide to our residents. To decrease readmissions, but also to improve communications across transmissions throughout the healthcare setting. To improve patient outcomes. And ultimately to improve the patient experience short term and long term.

What do you hope the DSRIP program will accomplish for your organization in the future?
I'm hoping that it will strengthen a lot of the collaboratives that we have with area hospitals and other nursing homes, by improving the communications for these patients that are coming to us, should we have to send them back to the facility, as well as for acute illness, for example. I'm also hoping that this collaborative is going to help us improve and develop processes that will be longstanding; that we'll be able to carry on for years to come. And again, to make sure that we're providing the quality care that the residents really deserve.

What do you hope the DSRIP program will accomplish in general?
I'm hoping that it will provide us with guidance and a means of developing those protocols and processes that will ultimately decrease readmissions across the continuum of care. I think one of the big points as well is that I'm really hoping it will continue, because we've already seen an improvement in communications across the continuum of care with the facilities that we are affiliated with, who send us patients and that we also send back to. I'm hoping that will continue to occur and become stronger over time so we can develop protocols that meet all the needs of the patients across the transition of care.

The SCC organized a two-day training for the INTERACT in early November for all the SCC SNF partners. What did you find most valuable from the training program?
The information on the INTERACT tools that are utilized and how they coordinate - how they could be and should be utilized throughout the facility and across the continuum of care, I felt was the most beneficial. They went through a lot of the INTERACT program: changing conditions, care paths, the SBAR tools- how all of those tools, when utilized together, could improve care processes. I felt that was the most beneficial piece of the certification training - that they were able to tie some of those concepts together for facilities and nursing directors that will be implementing or have implemented these protocols.

Were you able to network with other SNFs to discuss shared experiences and best practices?
Yes, absolutely. There was a lot of discussion at the program during both days among different nursing directors and different nursing homes. Some have implemented the tools, others haven't, and still others have utilized some tools and not others - so it was good to learn from other partners what's worked, what hasn't worked, and where the challenges are. Being able to see some of the similar challenges that other facilities are having as well - such as the whole readmission prevention, and also use of the INTERACT tools was very helpful. So it was a very good networking experience.

What are your expectations of the "facility champion" role for your SNF?
Being one of them myself - as well as my Assistant Director who also attended one of the training sessions- the expectation for that role is that we're going to really do it. We're going to champion this whole program for the use of INTERACT tools, provide ongoing education, be resources for the staff - particularly the nursing staff that is required to utilize these tools and may have questions. To provide feedback to the staff on data statistics, how the completion of these tools is going. We're setting our goal to be a constant resource.

How do you think implementing INTERACT will improve the quality of patient care? 
I really feel that it's going to improve care. We have already implemented and utilized a number of the INTERACT tools and we have seen a lot of improvement because it's a standardized means - an evidenced-based means of communicating and documenting. It provides a standard process for all of the staff to follow in any given situation - and provides guidance as well.

Can you describe the general action plan with how the INTERACT Quality Improvement Program was rolled out within Island Nursing and Rehab?
We started with the "Stop and Watch" tool - a form that was utilized and continues to be utilized by the non-clinicians - whether CNAs, or housekeepers, or engineering - whoever it might be. We provided house-wide education to all of the staff on what the tool was, the intent of the tool, the meaning behind it and how it was shown to improve care process. We rolled that piece out first - we also incorporated family members and residents into that as well, so if they noticed changes we encouraged them to fill out the "Stop and Watch" tool.

Once we implemented that, we began with the SBAR tool. All of the licensed nurses were educated on the SBAR with the same principles: the research behind it, the evidence behind it, how it was a standard of practice and an effective communication tool. We rolled that out over a year ago and we've been utilizing that as well. 

We're also right in the middle of re-education because we're now adding more tools. So we're re-educating on the completion and use of the SBAR and we're also adding the Chain of Condition and Care Path from INTERACT for all of the nurses to also utilize because, after the training, we feel it's really beneficial to use these tools in collaboration with the others to have better outcomes.

A lot of it is ongoing education, getting feedback from the staff to find out what's working and what the challenges are, and trying to modify the processes from there going forward to see how we can best continue to utilize these tools in the best ways possible.

Since your facility has implemented the INTERACT Quality Improvement Program, can you share some best practices for a successful implementation of the program?
Ongoing education is key for all of the staff - from the directors all the way down to the direct care staff and non-clinicians. It's important that all of the staff continues to know that we're utilizing these tools and are part of this practice initiative, I think, to keep the awareness going - as well as maintain compliance with all the tools. Our administration also has regular team meetings with our affiliated hospitals specifically regarding readmission and SBAR tools, and that has been what I feel has become best practice.

What we do now is utilize the SBAR even with our transfers. So, for example, if we're sending a resident out to a hospital, that SBAR tool goes with that resident. We send a copy of that form to the receiving hospital - and we also call and give a warm hands-off report based on that SBAR tool. What has occurred now as a result of all of our meetings with our affiliated community hospitals is that a number of them now have dedicated phone lines for SNFs to use when they're calling to provide a warm hands-off report based on the SBAR. That really initiated between Island and Mather, which is our main partner for the IMPACT program. But now it's being rolled out to a number of a facilities because it's been proven to be effective. Now when a nursing home calls a hospital they can give a really thorough report to a nurse manager or a physician explaining what's really going on with that resident, and what exactly it is that that resident needs.

Can you share some general challenges you experienced during implementation?
One of the challenges we feel and that I've also heard through networking and at the certification class is the amount of time that it takes to use SBAR. The SBAR was initially two pages long, but now, with all of the modifications, it's a four-page form. So the concern is that it's getting so long that it's almost counter-productive - it takes too long to fill it out and read it so it's almost defeating the purpose of the SBAR. It was meant to be a quick communication - but now it's become so long that there's a fear that it's not going to become as useful as it has been.

I also know some facilities have been very successful with the Stop and Watch, as far as utilization. But we'd still like to see better participation with the Stop and Watch - it's been a little more challenging among non-clinicians. So we continue to do education about the importance of that tool.

Transformational Change
As healthcare reimbursement changes, hospitals, health systems and providers must adapt to a new paradigm in which providers are rewarded for meeting quality objectives for their patient populations. The emphasis is 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?
Again, from an organizational standpoint, through developing specific protocols with readmissions being one, we're starting to see a decrease in readmission rates to the hospital. So we're able to focus more on full case reviews; determining what's avoidable and not avoidable. We can change protocols if needed. So in that respect I think, although this initially had a financial drive behind it with potential penalties, we've already seen a significant increase in quality because of the protocols that have developed out of this program. We're able to keep residents in the facility longer, and sometimes not send them out at all, and early recognition of changing conditions has been an ongoing process for us along with re-education of the staff. So overall we're really seeing a shift in everything we do.

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?
We've also had to look at staffing patterns, adding more practitioner hours to the day. We've extended our evening hours, and looked at restructuring the nursing staff hours to really try to meet the needs of when we're seeing a lot of these re-admissions. We looked back at the prior year to see when we saw more patients going out to the hospital, and saw we needed more support from a practitioner level in the evenings, so we added practitioners during those hours to help support the nurses and help prevent readmissions.  

What in your experience are the guiding principles of a successful population health management program?
The Centers for Disease Control and Prevention (CDC) identifies 5 factors that contribute to population health: biology/genetics; individual behavior; social environment; physical environment; health services. Your zip code is more likely to determine your health outcomes than your genetic code. We clearly see this by looking at Long Island data. Healthcare providers have focused heavily on providing health services and less on access to them or socio economic factors-like the social and physical environment effects. This has led to inequitable health outcomes for at-risk communities at a high cost to the health care system and society.

What value does the Suffolk Care Collaborative bring to patients under the DSRIP program?
For so long on Long Island, care was delivered in silos. The majority of health care was not provided in the community and there was a lack of integration-related to critical resources and services. Through the SCC, a cross-section of leadership is working together to figure out how we can be more innovative, while achieving better outcomes. I think that the importance of this collaborative can't be highlighted enough.

How do you see this project making an impact on our communities, workforce and populations we serve?
To improve health outcomes of low income individuals and reduce healthcare costs, the Centers for Medicare and Medicaid Services created incentive programs for states (like DSRIP) to restructure the way healthcare is paid for so that the other determinants of health are addressed and incorporated into service delivery. If the project is successful on bringing in and partnering with those that have a long standing presence and relationship with the community, the impact will be unprecedented.

Transformational Change.
As healthcare reimbursement changes, hospitals, health systems and providers must adapt to a new paradigm in which providers and CBOs are rewarded for meeting quality objectives for their patient populations. The emphasis is clearly sifting from volume to value and organizations that focus on providing patient-centered, quality health care that is culturally sensitive and linguistically appropriate across a population will come out ahead. How has your organization begun to experience this shift?
Again, from an organizational standpoint, through developing specific protocols with readmissions being one, we're starting to see a decrease in readmission rates to the hospital. So we're able to focus more on full case reviews; determining what's avoidable and not avoidable. We can change protocols if needed. So in that respect I think, although this initially had a financial drive behind it with potential penalties, we've already seen a significant increase in quality because of the protocols that have developed out of this program. We're able to keep residents in the facility longer, and sometimes not send them out at all, and early recognition of changing conditions has been an ongoing process for us along with re-education of the staff. So overall we're really seeing a shift in everything we do.

What in your experience are the top three guiding principles of a successful population health management program?
Education, communication and collaboration. With any of those lacking it's difficult to have a successful practice or protocol for any one initiative.

What value does the Suffolk Care Collaborative bring to patients under the DSRIP program?
In a general sense it brings a lot of value. It's a driving force behind a lot of facilities coming together to collaborate on patient care. Id' say patients are receiving more focused care now. Through effective communication we're able to say "this is what we're seeing and we already did these three tests, they're on the SBAR." I think, ultimately, the benefit to the residents is that, through more effective collaboration, we're able to better serve the population and cut down on the redundancies. The better we become at communicating with each other across the continuum of care I think the better care the residents get.

How do you see this project making an impact on our communities, workforce and population we serve?
I could see it potentially increasing the workforce because to provide quality care you need appropriate staffing. Part of that challenge, particularly for long-term care facilities is the funding and reimbursement. When you want to provide quality care, you need appropriate staff to do that. One of the biggest challenges to SNFs for example, is that reimbursement rates are low, which makes it hard to be able to afford the staffing.
Milestone Dates
NYS DOH DSRIP Program Milestone Dates 
November 30
Network Reopening Period closes at 4 PM for template submissions
December 1
Independent Assessor provides feedback to PPS on PPS Second Quarterly Reports; 15-day Remediation window begins
December 15
Revised PPS Second Quarterly Report due from PPS; 15-day Remediation window closes
December 30
Final Approval of PPS Second Quarterly Reports

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. Whenever opportunities become available they will be posted here.
Job postings are available for the following career opportunities within the Office of Population Health at Stony Brook University Hospital administering the Suffolk Care Collaborative.

For more information, please contact the Suffolk Care Collaborative via email



To access NYS DSRIP FAQ, click here

Stay Informed


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