Issue 42
October, 2018
Welcome to Synergy
We are pleased to present the forty-second 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 Participates in Health Literacy Summit

During Health Literacy Month, the New York State Department of Health's Office of Minority Health and Health Disparities Prevention sponsored a Health Literacy Summit, October 2, 2018, at the University of Albany SUNY Campus Center. The keynote speaker was Helen Osborne, M.Ed, OTR/L, founder of the worldwide initiative, Health Literacy Month. Helen helps professionals communicate health information in ways that patients and the public can understand. Her presentation, "Health Literacy: What It Is, Why It Matters, Ways You Can Help,"  engaged the audience, utilized multiple teaching techniques, raised awareness and conveyed the importance of health literacy with a "call to action."
Althea Williams, MBA, PCMH-CCE, SCC Director of Community and Practice Transformation participated in a panel presentation entitled: "Performing Provider Systems (PPS) Initiatives and Lessons Learned" along with Montefiore Hudson Valley Collaborative and Finger Lakes PPS. The panel presenters discussed their Cultural Competency and Health Literacy work as well as shared insights, strategies and lessons learned.  The summit also included an informative presentation from Howard Zucker, MD, Commissioner of Health for New York State, on addressing health literacy entitled "Sick is Good."  The summit was well attended in spite of the heavy rains that day.  Dr. Zucker and Ms. Osborne praised SCC's program. Thanks to Wilma Alvarado-Little, Associate Commissioner, New York State Department of Health, and Director, Office of Minority Health & Health Disparities Prevention, and her team for organizing this very informative summit.
Innovative Trends in Community Partnerships 
Attendees at Innovative Trends in Community Partnerships

On October 11, 2018, SCC's Community Engagement team hosted Innovative Trends in Community Partnerships, a discussion on Community Based Organization (CBO) engagement in Value Based Payment (VBP) models.  The forum was inspired by the feedback received from SCC's CBO VBP Survey disseminated April-June 2018.  The goal of the CBO VBP Survey was to assess CBO partners' understanding of VBP as the health care industry increasingly transitions toward this model.  As a result of the responses, SCC recognized an opportunity to provide a platform for VBP education as well as encourage networking to further foster partnerships.
Innovative Trends in Community Partnerships featured a panel presentation to highlight diverse provider perspectives in health care and VBP arrangements.  Moderated by Denard Cummings, Director of NYS DOH's Bureau of Social Determinants of Health, the panel included Susan Beane, MD, Healthfirst's Vice President and Medical Director of Clinical Partnerships, Sabina Zak, Northwell Health's Vice President of Community Health and Health Service Resources, and Dorella Walters, God's Love We Deliver's Senior Director of External Program Affairs.  

Althea Williams, Director, Community and Practice Transformation at the SCC, presented CBO VBP Survey findings along with NYS DOH recommendations and resources to support CBOs next steps in pursuing VBP arrangements.   Each panelist described how their respective organizations address health needs and social determinants of health, as well as how they engage CBOs through the execution of VBP model arrangements.   Lastly, Health and Welfare Council of Long Island's Emily Rogan, Project Manager, CBO Planning Grant, briefly spoke about the NYS DOH grant their organization received to support coalition building among regional CBOs and their strategic planning activities for DSRIP.
SCC will continue to provide similar educational opportunities to engage and inform our partners as the health care landscape continues to evolve.  F
or questions please contact the Community Engagement Team, .

Click here to view the presentation from the event.
COMPASS Unity Awarded Drug-Free Communities Support Program Funding
Family Service League's Underage Drinking Prevention Program, funded by Suffolk Care Collaborative, assisted a local community coalition in becoming a first-time recipient of the Drug-Free Communities (DFC) grant. COMPASS Unity, South Country's drug and alcohol prevention coalition, is one of 731 nationwide Drug-Free Communities Program awardees for fiscal year 2018.

The Drug-Free Communities (DFC) Support Program, directed by the White House Office of National Drug Control Policy (ONDCP), was created by the Drug-Free Communities Act of 1997. This program is the nation's leading effort to mobilize communities to prevent substance use among youth aged 12-17. The DFC program provides grants to community coalitions to strengthen the infrastructure among local partners, in order to create and sustain a reduction in local youth substance use.  Since the program's inception, use of alcohol, tobacco, marijuana and prescription drug misuse has declined significantly among middle school and high school aged youth in DFC-funded community coalitions. 

Prevention Specialist, Cierra Corbett, of the Underage Drinking Prevention Program, will continue to provide training and technical assistance to COMPASS Unity as it progresses through the stages of implementation of the Drug-Free Communities Support Program. "COMPASS Unity has accomplished a lot prior to becoming a funded coalition. I look forward to further assisting the Coalition in creating positive changes within South Country Central School District and community", says Cierra Corbett.

The Drug-Free Communities Support Program is valid for new grantees for five years, with an opportunity to renew for an additional five years.
Care Transitions SNF/ED Communication Form

The Suffolk Care Collaborative (SCC) Care Transitions Team developed the Skilled Nursing Facility/Emergency Department (SNF/ED) Communication Form which went live November 27, 2017. This form was created with feedback received from Suffolk County SNF and hospital ED leadership who identified a need to increase communication between their facility's for shared patients. The form is used when a patient from the SNF requires a visit to the ED. The SNF provider completes the form, which then goes with the patient to the hospital ED.  It is bright yellow to call attention to the form and designed to provide the ED staff with the most pertinent clinical information to assess, treat and potentially release the patient back to the SNF to avoid an unnecessary hospitalization.  

Since the initial launch of the form, there have been improvements made utilizing feedback from the SNF and ED leadership. Version 2 of the form was released on April 30, 2018.

Joining the collaboration to improve overall communications was Suffolk County Emergency Medical Services (EMS).  EMS has played an instrumental role in the success of the SNF/ED Communication Form as they manage the physical transfer of patients from SNFs to the EDs. The SCC Care Transitions Team worked with Robert Delagi, Suffolk County Director of EMS & Public Health Emergency Preparedness, to educate and inform the approximate 3,000 EMS providers about the use and purpose of the form.
SCC Hosts Cultural Competency & Health Literacy Master Training

A Cultural Competency and Health Literacy Train-the-Trainer (CCHL TTT) class was held on September 25, 2018, hosted by the SCC Community Engagement Team.  The objective of the CCHL TTT program is to advance cultural and linguistic competency, promote effective communication to eliminate health disparities and enhance patient outcomes.  Participants interactively learned concepts of regional health equity 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. The Teach-Back Method entails a four step process: explaining a process; assessing the person's knowledge by asking them to teach it back; clarifying any misunderstandings the person may have; repeating the cycle until there is a shared understanding. Upon completion of the full day class, the 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. For additional information about the CCHL Training Program and SCC's class dates, please visit the CCHL landing page hosted on LIHC's website or email

Bettina Yanez, Berkshire Farm Center & Services for Youth; Sherryann Rampersad-Lalchan, Gurwin Jewish Nursing and Rehabilitation Center; Lyndsey Clark (Class Instructor), SCC; Jennifer Rowland, Berkshire Farm Center & Services for Youth; Linda Monckton, Stony Brook Cancer Center
Partner Interview:  Pediatric Asthma Home Visit Program
Name:  Barbara Rowe, DNP, FNP (APRN)
Title:  Director, Specialty Services
Organization:  Catholic Home Care/Good Shepherd Hospice at Catholic Health Services

Please give a summary of your program. 
The Pediatric Asthma Program at Catholic Health Service's (CHS) Catholic Home Care partners with system and community entities to decrease the burden of asthma on children and their families. The management of asthma is often a complex and multi-faceted challenge to both health care providers and families. Ineffective management can have dire consequences on the overall health and quality of life of affected children.
The program consists of carrying out evidenced-based practice proven to be crucial in the management of childhood asthma.  Referrals are received from system and community hospitals, as well as health care practitioner practices. The home visits are performed by trained registered nurses, to provide patient and parental education on a level consistent with their ability to understand and process the information.
What are the key components to your pediatric asthma management program?
The key components of the Catholic Home Care Pediatric Asthma Program include a home visit by a trained registered nurse to provide a home environmental assessment with education on methods to eliminate or reduce triggers.  The education uses standardized teaching materials, including an asthma flip chart (developed by the local asthma coalition, an entity of the American Lung Association), medication pictures, use of spacers and valved holding chambers, medications, inhalers, use of control and reliever medications, as well as differentiation between the two medications' actions.  Clinicians also provide education on the Asthma Action Plan to assist families to understand green, yellow and red zones and take action upon identified changes in the level of asthma control.   Education is provided specific to each family's educational needs and the teach-back method is used to ensure understanding.   Written educational material is available to families in English and Spanish.   The use of age specific asthma digital applications and evidence-based age specific materials, such as cartoons and coloring books, are dispensed to children to facilitate early engagement in the management of their chronic disease process. 
At each home visit the Asthma Control Test is administered. It measures the elements of asthma control as defined by the National Heart, Lung and Blood Institute (NHLBI).  In addition, a comprehensive interdisciplinary treatment plan is developed inclusive of a licensed medical social worker and/or behavioral health nurse if a need is identified by the home health nurse.  Coordination is often initiated between the home health nurse and school nurse to facilitate the child's smooth return to school following a diagnosis of asthma.  Coordination is maintained with child's provider to ensure continuity of care across the continuum.  Follow up phone calls are made at 3, 6 and 12 month post-care to assess level of sustained asthma control and identify opportunities for follow-up and additional support.
How does your program reach and impact your community?
Coordination of care across the healthcare and community continuum is essential to address the unique needs of this population.  Providing skilled nursing visits in the patient's home environment offers a unique opportunity to identify barriers to adequate asthma control and provide education on remedying these health concerns.  Catholic Home Care partners with the Asthma Coalition of Long Island, a subsidiary of the American Lung Association, to address the health disparities across the county but specifically within the identified areas where pediatric asthma is most prevalent and health care needs are greatest.  Partnerships with providers have allowed us to increase referrals and home visits.

Click here to view chart

Who do you partner with to promote increased pediatric asthma awareness?
The Catholic Home Care Pediatric Asthma Program partners with system and community hospitals, clinics and healthcare practices across Long Island and Queens.  Asthma resource information is made available in local houses of worship.  The program is incorporated into system wide community outreach initiatives providing education and administration of the Asthma Control Test, culminating in appropriate health care practitioner referral for follow up care.
Asthma Resources for Parents and Childr en

Compliance Connection
Corporate Compliance and Ethics Week  

The first National Corporate Compliance and Ethics Week, developed by the Society of Corporate Compliance and Ethics & the Health Care Compliance Association, was held May 22-28, 2005. This year will be the 14th annual Corporate Compliance and Ethics Week celebration, November 4-10, 2018.

Recognizing this week is a good way to raise awareness and call attention to the topic of compliance and the importance of maintaining an ethical culture in your organization.

Visit the Health Care Compliance Association's website for ideas, resources and more information about celebrating Corporate Compliance and Ethics week at your organization.  

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

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