Issue 50
November/Decembe 2019
Welcome to Synergy
We are pleased to present the fiftieth issue of Synergy, a 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
Utilizing Regional Health Information Organization (RHIO) Hospital Notifications to Support Care Transitions

The Suffolk Care Collaborative (SCC) partnered with Meeting House Lane Medical Practice (MHLMP) and New York Care Information Gateway (NYCIG) to execute a project that supports acute level care transitions through leveraging Regional Health Information Organization (RHIO) hospital notifications. RHIO hospital notifications inform providers when their patients utilize hospitals so that timely follow-up care can be addressed. The objective of the project was to improve care transitions from acute hospital level care to community care by developing an actionable report that could be utilized in the community practice setting in an efficient and sustainable manner employing RHIO hospital notifications.

The SCC and MHLMP worked collaboratively to develop and incorporate RHIO hospital notification reports, based from the alerts, into the workflows at MHLMP primary care sites. To test impact of changes made to the workflow, the Plan, Do, Study, Act (PDSA) cycle methodology was used as the foundation for the project. During each of the three 30-day PDSA cycles, quality control activities were performed to ensure the overall quality of the daily notification reports and MHLMP utilized these reports to identify, outreach and schedule patients for follow-up appointments post-discharge. The reports served as the catalyst in strengthening care coordination throughout this project because "by receiving the RHIO alerts and proactively reaching out to our patients, we were better able to meet their needs," says Candice Hulse, Corporate Compliance and Quality Manager at MHLMP. Throughout each cycle, MHLMP collected data including the total number of notifications, patient outreach attempts, patients scheduled for an appointment and patients seen within fourteen days of discharge. The SCC analyzed the data collected in each cycle to evaluate process changes and impact.

Results from cycle one of the project demonstrated 85% of patients kept their appointment when scheduled. However, only 27% of patients were successfully scheduled. Improvement activities focused on increasing the number of patients scheduled by improving the accuracy of the daily notification reports and piloting new workflows. As a result, a 45% increase was observed in the total number of patients scheduled for a follow-up appointment within fourteen days of discharge in cycle two. Cycle three involved two change ideas for improvement. The first was the addition of patient date of birth (DOB) and medical record number (MRN) columns to the notification reports in order to increase accuracy in identifying patients to outreach. The second change idea was implementing a second outreach call in MHLMP's workflow to increase the number of patients contacted and scheduled for follow-up appointments. At the conclusion of cycle three, the number of patients contacted and scheduled within fourteen days of hospital discharge increased by 118% from cycle two with 85% kept appointments, therefore, increasing transitional care management (TCM) revenue.

Aside from an increase in TCM revenue, this project has "provided the tools and circumstance to truly begin integrating patient-centered workflows into our practice locations," says Candice. Timely patient information to provide the right care, at the right place and by the right provider is essential to improve patient care. RHIO hospital notifications can inform provider practices when their patients are accessing acute hospital level care, which enhances both communication and care coordination with their patients. The collaboration between the SCC, MHLMP and NYCIG, along with the persistent focus on care transitions for patients who were discharged from the hospital, contributed to the project's successes. Lessons learned from improvement activities to improve data quality and workflow optimization will be shared as the SCC scales this project with other provider practices.
Long Island Select Healthcare, Inc. Implements Project to Decrease Hospitalizations 
After eight months of preparation and workshops, Long Island Select Healthcare, Inc. (LISH) has moved into the continuous improvement phase of their Medicaid Accelerated eXchange (MAX) Series project.  This project aimed to reduce hospitalizations for a high needs cohort of individuals living at an Intermediate Care Facility (ICF).  LISH invited a nursing team from the ICF to collaborate on the project.  The teams worked together to address barriers and identify ways to improve communication between the two facilities.

Team's ideas on how to improve timely linkages.
The teams identified an opportunity to improve the timeliness of scheduling general appointments, transition of care appointments and obtaining medication refills for individuals at the ICF.  The teams streamlined communication by leveraging care managers at LISH. As a result of this project, the ICF now contacts the care managers at LISH when a patient may need higher levels of care or is being transported to the hospital.  This project enabled LISH to hone in on the value of their newly established care management team. Once the ICF understood the value of the assigned care manager, they noted improved communication and timely access to care.

The MAX project reinforced the importance of building and maintaining relationships with the nursing staff at ICFs with shared patients.  This project enabled the LISH team to develop a focused project around a high needs cohort of patients and test changes.  During the continuous improvement phase of the program, the teams plan to establish monthly provider rounds at the ICF and explore expansion of the program to other ICFs with high needs residents.
Red Ribbon Week 2019

COMPASS Unity, Bellport/South Country's drug and alcohol prevention coalition
Sgt. Carissa Siry and Sgt. Sean Cassidy, Civil Operations Specialists, NY Army National Guard Counter Drug Task Force, at Narcan Training
celebrated Red Ribbon Week by hosting prevention-based activities within the South Country Central School District and community.  Red Ribbon Week is a national alcohol and other drug prevention awareness campaign that is observed annually in October.  Red Ribbon Week serves as a catalyst to mobilize communities, educate youth and encourage participation in drug prevention activities.

John T. Martin, Senior Public Health Educator, Suffolk County Department of Health, conducting vaping presentation

The Coalition recognized the week by providing Red Watch Band training to Bellport High School seniors. Red Watch Band training, an initiative created by Stony Brook University, is a comprehensive bystander intervention program designed to provide college and high school students with the knowledge, skills and awareness to prevent death by toxic drinking. Through education and elaborate role plays, students learn to recognize the signs of alcohol overdose and when and how to call for help.  This year is the third year in a row that COMPASS Unity provided this life-saving training to high school seniors.

COMPASS Unity also hosted a Red Ribbon Week parent presentation called "The Truth about Vaping and E-Cigarettes" at Bellport High School.  The presentation was given by John T. Martin, Senior Public Health Educator of Suffolk County Department of Health Services.  The event also included Narcan training, presented by Sargent Sean Cassidy of the National Guard Counter Drug Task Force.  Childcare was also made available by the Coalition during this event to accommodate parents of young children.
SCC Hosts Cultural Competency & Health Literacy Master Training

SCC hosted a Cultural Competency & Health Literacy Train-the-Trainer (CCHL TTT) class on  December 3, 2019.  Nine 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!  
Front row (left to right):  Alexandra Kranidis, SCC, (Class Instructor); Denise Twining, St. James Healthcare Center, Claudette Spence, Metropolitan Association New York Conference UCC; Althea Mills, Stony Brook Southampton Hospital.  Back row (left to right):  Shauna Lee, Brookside Multicare Nursing Care; Regina Harrington, St. James Healthcare Center; PJ Tedeschi, Tobacco Action Coalition; Michael LaRock, Community Housing Innovations; Christine Cantrell, Stony Brook Southampton Hospital; Maidaya Maldonado, Adelante of Suffolk County.

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.  
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.

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."  Click here for Certification Requirements Frequently Asked Questions (FAQs). 

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
December 30, 2019      IA approval of PPS DY5 Second Quarter report

January 31, 2019          DY5 first payment to PPS

January 31, 2020          PPS Year 5 Third Quarterly Report (10/1/19 - 12/31/19)
                                      due from PPS

Frequently Asked Questions


To access NYS DSRIP FAQ, click  here.
Access previously published Synergy eNewsletters  here