Issue 30
October, 2017
Welcome to Synergy
We are pleased to present the thirtieth 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

Save the Date for the Next
Project Advisory Committee (PAC) Meeting

Friday, December 8, 2017
Registration 8:30 am
Program 9:00 am - 11:30 am

Hyatt Regency Long Island
1717 Motor Parkway
Hauppauge, NY
Learning Collaborative Spotlight -  The New Face of Healthcare, Part II: Refining the Referral System 
Primary Care, Behavioral Health and Hospital Providers Joined for the Second Event in the New Face of Healthcare Series

The first New Face of Healthcare meeting was held on March 24, 2017. That meeting called together primary care providers, behavioral health providers, hospital providers and health homes in order to facilitate the creation of a collaborative climate that will serve to improve population health in Suffolk County. In addition to listening to timely and informative presentations, attendees engaged in reflective workshop activities during which they were able to connect with other providers in their region to discuss topics related to building an integrated system of care in Suffolk County. During these activities, thorough notes were taken at each table, which were then aggregated and analyzed for common themes. From this analysis, two primary themes emerged, both pertaining to the current patient referral system: knowledge of specific services and clinical capabilities of Suffolk County Office of Alcoholism and Substance Abuse Services (OASAS) and Office of Mental Health (OMH) facilities is not easily accessible; lack of standardization between agencies regarding what is required to make a referral to substance use disorder/mental health treatment.
The second New Face of Healthcare event addressed these identified issues.  On October 27, 2017, the Suffolk Care Collaborative, Communities of Solutions, Quality Consortium of Suffolk County and Long Island Health Collaborative co-hosted a learning collaborative, at the Coram Fire Department, titled The New Face of Healthcare, Part II: Refining the Referral System. This meeting focused on examining the current patient referral process to OASAS and OMH facilities and overcoming barriers identified in this workflow. The three primary objectives of this event were for participants to recognize service availability in geographical regions, build capacity to determine appropriate level of care and workshop methods to streamline the patient referral process. To achieve these learning objectives, 4 distinct presentations were delivered, followed by collaborative activities. 

Attendees at the October 27, 2017, event
The presentations and group activities mapped the workflow to refer an individual to treatment.  The process was broken down into four primary operational steps: Identify a patient in need of a referral; Identify appropriate level of care; Identify agency that correlates to appropriate level of care; Deploy referral. As most of the providers in attendance are already identifying individuals in need of a referral through screening tools or other clinical means, the event focused on the latter three steps. These steps were addressed through a combination of presentations and collaborative discussion.
The presentation topics included Use of the LOCADTR 3.0 (Level of Care for Alcohol and Drug Treatment Referral), Secure Messaging and Calendar Sharing with Long Island Council on Alcoholism and Drug Dependence (LICAAD), Supportive Services Available for the Emergency Department and Child and Adolescent Psychiatry for Primary Care (CAP-PC) & Project Echo.  Each of these presentations was given by a partner or collaborating agency of the Suffolk Care Collaborative, who deliver care in our community. After these informative and interactive presentations, attendees participated in two collaborative activities aimed at creating an Electronic Capabilities Catalogue for OASAS and OMH providers and creating a universal referral form to access substance use and mental health treatment.
In advance of this learning collaborative, geographic cohorts were created; 14 cohorts grouped primary care, behavioral health and hospital providers by region.  These cohorts were mapped and participants were seated at the event according to their region.  Click  here  to view regional cohort maps.  This deliberate seating method allowed for discussion to take place between provider types located proximally, allowing for providers to learn of services available in their local region, fostering potential partnerships to initiate.
During the discussion portion of the day, participants worked in their cohorts through a series of guided activities related to addressing the aforementioned thematic barriers. The first activity aimed to determine the information fields that would be important in the building of an Electronic Clinical Capabilities Catalogue. The goal of this catalogue is to provide a platform for providers and member of the public to search for OASAS and OMH licensed facilities in Suffolk County and gain insight into the treatment services provided. To populate this platform, participants were asked to create a list of information fields related to the categories of standard facility profile, accessibility, services offered and population served.
The second activity aimed to create a list of essential information fields that are needed to refer an individual to substance use/mental health treatment. Feedback collected from the March meeting indicated that providers referring to behavioral health agencies felt that there is a lack of standardization between agencies regarding what is required to make a referral to treatment.   By creating a standardized document, it is the aim to reduce requirement differences amongst providers, which may result in reduced time required to collect information to refer a patient. It would also help to ensure that the receiving agency has complete and comprehensive information needed to see and treat an individual. After the information fields were discussed, the group was tasked with determining a format for this document.

Additionally, all participants in this event received  Tying It All Together, a resource guide created exclusively for this event, which provides actionable information to providers related to the presentations delivered.  Information in this document includes training opportunities and  steps to access the LOCADTR via the Health Commerce System (HCS), the LICAAD Substance Abuse Hotline (631-979-1700) and Long Island Guide to Help and Treatment (Suffolk LIGHT) phone application.   In addition, there is a Project Echo Q&A Factsheet, poster and brochure, the Community of Solutions (COS) Community Resource List and the maps of the geographic cohorts. 
As with the first event, notes were taken at each table during the activities.  These table notes will be aggregated and analyzed for common themes and will serve as the basis from which an initial draft of both the Electronic Clinical Capabilities Catalogue and Universal Referral Form will be created.  This group of providers will convene again in the Spring and work towards moving these ideas into implementation.  Thank you to all who joined us for this event and we hope to see you at the next one!  
Forging Bonds Between Hospital & Skilled Nursing Facility Partners
Special Highlight:  SNF to ED Communication Form

September brought the second round of Regional Care Transition Workgroups hosted by Northwell Health Hospitals: Southside Hospital, Huntington Hospital and Peconic Bay Medical Center.  This round, each hospital hosted their local skilled nursing facility (SNF) partners to dissect essential elements in the transition from the skilled nursing facility to the emergency department (ED). To make these forums a success, key stakeholders from both the SNF and hospital were present to have face-to-face interactions and discuss both best practices and barriers in this transition .

Since the inception of these workgroups in early 2017, ideas from the initial workgroups were captured and brought to life in smaller focus groups. Most notably, both SNF staff and ED physicians expressed a need to communicate in a more streamlined fashion, when shared patients are transferred from the SNF to the ED. From there, focus groups met to create, edit and draft a  SNF to ED Communication Form. The purpose of this form is to be a quick overview of the imperative information for an ED physician to assess and treat and potentially release the patient back to the SNF.  By utilizing this communication form, the goal is to decrease preventable inpatient admissions of SNF residents who can be treated back at their home facility.  During this quarter's regional workgroups, a draft of the form was reviewed by both hospital and SNF staff. From these meetings, improvements were made and a final draft of the communication form was finalized. Dianne Zambori of Northwell Health comments, "I have been working with hospitals and their SNF partners for many years, and I have never seen these two groups come together as I did during the regional workgroups this September while working on the SNF to ED Communication form.  Everyone was on the same "page" knowing that improved communication would result in improved outcomes for the patients.  This form is the best way to provide EDs with what they need to diagnose a patient and return them to the SNF for treatment. It will also provide the ED with the name of a physician or mid-level provider to speak with during the ED visit and prior to return to the SNF.  We are, frankly, expecting great things coming from this work." With that, we are happy to announce this form will be going live on November 27, 2017. In the coming weeks, both SNF and hospital staff are being educated on the intended use of the form and workflow associated with its use.  As we move forward with this tool, we are hopeful to see decreased preventable admissions and more SNF residents being sent back to their home facilities to be treated in place.

We would like to thank Southside Hospital, Huntington Hospital and Peconic Bay Medical Center for hosting this round of workgroups, as well as Dianne Zambori, Associate Executive Director, Eastern Region & Quality Management Initiatives, Northwell Health, for her support and collaboration in making these workgroups successful.
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 participates include: Nurses, registration and admitting staff, medical assistants, social workers, care managers, patient experience staff, health education, discharge planning, 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:  Making Important Connections and Referrals Through Partnerships
Name:  Marton Dioszegi
Title:  Outreach Specialist
Organization:  Health and Welfare Council of Long Island

Please give a summary of your organization:
The Health and Welfare Council of Long Island (HWCLI), established in 1947, serves the interests of at-risk and vulnerable families and children on Long Island through advocacy, direct services, research, policy analysis and as an umbrella agency for health and human services agencies.
Who does your organization serve?
HWCLI serves at-risk and vulnerable families and children on Long Island.   Our Targeted SNAP  (Supplemental Nutrition Assistance Program) program focuses on seniors, working families, veterans and immigrants in both Nassau and Suffolk counties.

Why did you choose to participate as a partner of the SCC?
As part of a Targeted SNAP Program, we connect with pediatricians and other health care providers to assist their patients in accessing SNAP benefits and other food assistance programs.  Because SCC's care managers have the opportunity to identify patients struggling with food insecurity, we met with the Care Management staff to create a streamlined referral system to ensure patients get connected to these benefits.  Once referred, trained HWCLI staff assists clients with the SNAP application process and accessing other food assistance programs. 

What do you hope the DSRIP program will accomplish in general?
Apart from significantly reducing avoidable hospital use in New York State, with the possibility to integrate health care with health and human services work, we hope to leverage important connections with social determinants of health. A renewed holistic approach towards patients and the care they receive can lead to better nutrition outcomes as well as better health outcomes, overall. 

What has your organization done to make transformational changes?
As New York State and the health care field have recognized the importance of looking at patients in a holistic way, we aim to integrate our services to support this new approach.  We found that having a connection to clients through pediatricians has been the most effective way to identify and make referrals.  We  have food insecurity screenings in pediatric clinics that are combined with referrals to HWCLI for assistance with SNAP.  Integrating health care with human services is an important element of creating patient-centered quality health care. By screening for food insecurity in the health care setting, we not only make an important connection between a need and a service, but we can also bring to light the very important relationship between nutrition and overall health. Children who are enrolled in SNAP have better results in school and better long term health outcomes, which is why creating these connections and referrals is so vital. 

What in your experience are some guiding principles of a successful population health management program?
In our field we view gratitude as our top guiding principle. Many of our clients are going through difficult situations on many different levels. When we are connected with a client, we are grateful for the trust in our services and the opportunity to provide those client-centered services. The basis of a referral system is to transfer the established trust between patient and provider. We believe that the best way to maintain and build trust with clients is through a welcoming environment every step of the way. I would also mention cultural competence as a guiding principle. It is very important to not only be aware of the different backgrounds of our clients, but to celebrate the diversity of our clients as well. Language access is a huge part of this, along with an understanding of regional differences within the population.

What value does the Suffolk Care Collaborative bring to patients under the DSRIP program?  
From my experience with SCC's Care Management team and the clients that have been referred to us, I feel that the Suffolk Care Collaborative demonstrates a great commitment to the well-being of patients. While the program that I focus on is SNAP, I am always happy to connect clients with other services that they need. Many times the care managers reach out to me personally regarding a client that they would like to connect with another HWCLI service, which shows their commitment and passion in ensuring quality care for everyone. I believe that is the best approach and I am happy to have the opportunity to partner with SCC's team. 
Health and Welfare Council of Long Island
Serving the Vulnerable Population on Long  Island

The mission of the Health and Welfare Council of Long Island (HWCLI) is to serve the poor and vulnerable people on Long Island by convening, representing and supporting the organizations that serve them, and through illuminating the issues that critically impact them; organizing community and regional responses to their needs; advocacy; research; policy analysis and providing services, information and education.
Since 1947, HWCLI and its members have responded to the needs of the most vulnerable.  As an umbrella organization of a network of over 200 health and human service agencies, HWCLI has learned and built the organization's strategic approach on the premise that no single organization can solve a community's problems alone.  On Long Island, the nature of poverty and the needs of the most vulnerable are growing and changing, driven by the region's evolving economy and demographics. Addressing the social challenges faced by Long Island's most vulnerable is only possible through innovative strategies, the destruction of silos and the forging of strong partnerships between organizations and individuals across all of society's sectors: government, business, nonprofit and private individuals. HWCLI strives to lead by example, building bridges between agencies, clients and government to ensure that the most vulnerable receive the most comprehensive, effective, efficient and respectful services possible.  Collaboration with member agencies and other partners has been the highest priority for HWCLI as it worked on sector-wide coordination and planning, programs and client services and public policy and advocacy to effect change in each of its five areas of focus: disaster recovery; economic stability; health care access; nutritional security and regional planning.

To learn more about Health and Welfare Council of Long Island click here
Compliance Connection
Tips to Help Ensure Cultural Competence & Language Preference Compliance

An important component in addressing Cultural Competence and Language Preference needs is establishing a comprehensive, well-defined and clear policy.  Having a good policy can help an organization demonstrate good-faith intentions in compliance with mandated government regulations.  But having well-written policies that include government requirements does not go far enough.  Evidence that policies have been communicated to staff and that staff can show they are knowledgeable and understand how to implement the policy in their particular position will be the key to demonstrating staff competency. 

Addressing patients' and clients' cultural needs and language preference requires training and understanding of policies and regulations, which is not always easy.  Competing training priorities coupled with a limited amount of time, makes it challenging for organizations.  However, healthcare providers need to consider making an extra effort to adequately address the topics of cultural competency and linguistically appropriate healthcare.  By doing so not only shows a commitment to doing the right thing during a government audit, it can also improve patient engagement and patient safety, which in turn promotes patient-centered care and can ultimately improve healthcare outcomes.  The SCC has a number of useful resources on the Partner Resources tab of its Learning Center.  Resources include information and links to other agencies, such as Agency for Healthcare Research and Quality (AHRQ) and the Center for Linguistic and Cultural Competency in Health Care (CLCCHC), as well as useful toolkits and training resources to help our partner organizations.  Click here to access SCC's Learning Center.  

For compliance questions, or assistance, contact the SCC Compliance Office at
 Milestone Dates
 NYS DOH DSRIP Program Milestone Dates
Opt Out Phase IV Mailer
Annual update to Value Based Payment Roadmap submitted to PPS
November 15
Value Based Payment Bootcamp - Long Island Marriott, Uniondale
November 16
1115 Waiver Public Comment Day NYC - New York Academy of Medicine
November 30
PPS annual update to Primary Care Project Narrative due 

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. Care Manager
  2. Community Health Associate
  For more information, please contact the Suffolk Care Collaborative via email