Issue 6
October 31, 2015

Welcome to Synergy


We are pleased to present the sixth 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
Organizational Work Stream Engagement Highlights
In addition to the eleven DSRIP projects, there are organizational work streams as part of NYS DOH DSRIP Program Domain 1 requirements.

The SCC has submitted three of the nine organizational milestones within "Governance." This includes completing the governance structure, implementing charters across the governing sub-committees and establishing a clinical governance structure. In the months ahead, we'll be finalizing the Governance Guidelines & Governance Review Plan, which will outline the governance and committee two-way reporting processes and governance monitoring processes.

Included in this key organizational work stream are four Community Engagement milestones. This scope of work includes building a Community Engagement Plan and an Agency Coordination Plan. These plans will articulate engaging appropriate public sector agencies at state and local levels, community based organizations and other key community based representatives (eg. Schools, churches, law enforcement agencies).

Our Project Lead of the Community Engagement program, Althea Williams, Senior Manager for Provider & Community Engagement has collaborated with the Long Island Health Collaborative's Population Health Improvement Program, where we have found alignment with the DSRIP initiatives including community engagement, the 11 projects and other organizational work-streams. This collaborative is a coalition whose members represent CBOs, Long Island hospitals, two county health departments, colleges and schools. We look forward to continue alignment on county-wide initiatives.

Following an extensive Request for Proposal (RFP) process the Suffolk Care Collaborative (SCC) selected KPMG as the workforce consultant to assist the PPS with developing the workforce strategy deliverables.  An updated implementation plan has been entered into the MAPP tool which is aligned with the KPMG workforce engagement deliverables. The KPMG engagement kick-off meeting was held with both the Workforce Governance Committee as well as the Workforce Advisory Committee. SCC is currently developing a consolidated workforce and primary care provider survey to identify immediate information needs for workforce planning as well as the implementation of the DSRIP projects.  Budget meetings were also held throughout the DY1 Q2 reporting period identifying resource requirements across the DSRIP projects and Organizational Work Streams.  Several of these positions have been posted to the SCC website under the career opportunities section. Training needs have begun to be identified at the DSRIP project level and training plans are being developed.  

The Practitioner Engagement Workgroup held their kick-off meeting on September 21, 2015. The workgroup is chaired by Dr. Maria Basile, Assistant Vice President for Medical Staff Affairs at John T. Mather Memorial Hospital, Immediate Past President of the Suffolk County Medical Society and Member of the Medical Society of the State of New York on Value Based Purchasing. The Committee has brainstormed a framework for the Practitioner Engagement and Communication Plan and reviewed the SCC onboarding material and education plan. This plan shall include how we will develop standard performance reports, and plans to create a PPS-wide community training and education plan targeting practitioners and other professional groups, designed to educate them about the DSRIP program and our quality improvement agenda.

The NYS DOH has provided the SCC with a list of providers not yet attested partners in any Performing Provider System (PPS) across New York State, we have extracted a cohort of this list for Suffolk County and look forward to reaching out to these new potential partnerships through November 20. The open enrollment period has been open for all interested partners to be engaged in the program. In addition, we've now opened our enrollment to licensed behavioral health providers. Please click here to access our Open Enrollment webpage.

The SCC Performance Evaluation and Management Workgroup held monthly meetings throughout the DY1 Q2 reporting period to create the SCC Reporting Plan and the SCC Performance Reporting and Improvement Plan were approved by the Board of Directors on October 8, 2015. Both documents reflect the intellect of the SCC Performance Evaluation and Management Workgroup, were shared with all three HUBs and were endor
sed by the SCC Clinical Governance Committee. Both documents collectively, establishes the PPS reporting structure for performance reporting and communication and were uploaded to Medicaid Analytics and Performance Portal (MAPP) to fulfill the Milestone 1 requirement.

Key DSRIP Project Workgroups were engaged to finalize the Domain 1 Actively Engaged Patient definitions with guidance from the SCC Project Management Office (PMO) and our DSRIP Support Team (DST). On August 14, 2015 SCC hosted its first patient engagement data collection webinar, educating partners regarding the Domain 1 Actively Engaged Patient definitions and data specifications. Throughout the months of August and September partners began generating reports to assist SCC with forecasting anticipated patient engagement volume in preparation for the October 31, 2015 report. Concurrent with the data request process, SCC began executing Business Associate Agreements (BAA) with partners so that Protected Health Information (PHI) could be collected during the month of October. During the DY1 Q2 reporting period, the SCC PMO established a secure process so partners could begin sending PHI data effective the week of 10/12/2015. To learn more about our Domain 1 Actively Engaged Patient definitions please click here.

The Population Health Management (PHM) Operating Workgroup's current focus is aimed at directing the development of the deliverables across the PHM & CI organizational work streams. We're pleased to share a number of our Care Management (CM) career opportunities have been fulfilled and our new staff is currently undergoing training into the CM program.

A planning meeting with Suffolk County Health Home partners and Care Management partners was held on October 6, 2015 to initiate discussion among partners to ensure coordination of care with existing Care Management resources in the community and identification of gaps.

An IT Task Force has been assembled and has been meeting on a regular basis since August, 2015 initiating planning of the set of deliverables such as the development of the roadmap to achieving clinical data sharing and interoperable systems across the SCC partner network. Several key technical meetings whe re held on topics such as Population Management, Data Acquisition, User Experience, Data Security and User Authentication. The output of the meetings are being used to further refine the system architecture, data security, data acquisition and on-boarding strategies. 

In addition, the IT team has held a series of IT specific meetings with the clinical project teams in an effort to identify the functional requirements that will be developed within the HealtheRegistry application. The HealtheRegistry application is a tool which is designed to report how well a given organization or provider is performing against the DSRIP Domain 2 & 3 Measures.

Some progress has been made on the IT capability survey across Key PPS providers with additional work on-going. Preliminary data acquisition kick-off meetings have been held with a select set of PPS Partners. At the moment the provider specific data acquisition meetings are focusing on connectivity, test data analysis and the definition of interfaces required for technical integration with the providers EMR.

The Financial Sustainability Team has been formed and are currently organizing the SCC Finance Structure Chart. This chart will include descriptions of roles, responsibilities and functions. The Financial Sustainability Team will be directing the development of the network financial health current state assessment and developing a financial sustainability strategy to address key issues. A survey strategy will be deployed to meet this goal. This survey effort will integrate with the Value-Based Payment Workgroup who will be developing a list of survey questions to output a detailed baseline assessment of revenue link to value-based payment.
SCC Cultural Competency & Health Literacy Program Spotlight

Cultural Competency and Health Literacy is one of eleven organizational workstreams in DSRIP. The State has emphasized the importance of addressing cultural competence and linguistic appropriateness in our healthcare delivery system as an achievement of this organizational workstream to linked payment. The SCC gathered partners and organized a Cultural Competency and Health Literacy Advisory Workgroup. This Workgroup has been meeting since March, 2015 working toward achieving the DSRIP milestones and subtasks that are required in this organizational workstream. There are subtask deliverables that require approval of the Community Needs Assessment, Outreach and Cultural Competency and Health Literacy Committee, the "Committee." Additionally, all the DSRIP milestones must be approved by the Committee and the Board of Directors.

At the October 6, 2015 SCC PAC meeting, a progress report was presented to the SCC partners summarizing the Workgroup's activities around Cultural Competency and Health Literacy. Report highlights included: the development of the SCC wide definitions for cultural competency and health literacy; integration of cultural competency/health literacy with other organizational workstreams (i.e., Workforce, IT, Population Health) and the 11 DSRIP Projects; and an announcement of the upcoming survey that will provide a current state assessment of cultural competency and health literacy practices, resources and training. Furthermore, during the SCC PAC meeting, all our partners were educated on the newly approved definitions for cultural competency and health literacy.

There was a call to invite SCC partners to join the Workgroup. The response was overwhelmingly positive. By the close of the PAC meeting, five new members signed up for the Workgroup, followed by an additional three members later that week, totaling eight new members to the Workgroup. This is a demonstration of the importance of cultural competency and health literacy among our SCC partners. We encourage you, our partners, to consider becoming active participants in this Workgroup. You can contact Althea Williams at 631-638-1392 for further information and meeting dates and times.  

In conclusion, the Committee's approval of the PPS-wide definitions for cultural competent and health literacy, fulfills a subtask in the milestone to develop a cultural competent and health literacy strategic plan. These definitions will now service as a guide, equipping our SCC and its partner network - providers, staff and community - to provide culturally and linguistically appropriate services to the communities served. The SCC is proud of the work that has been done and with much enthusiasm, present these definitions in Synergy. You, our collaborators in care, are encouraged to print out the definition flyer and post the flyer.
Across our PPS
The SCC is encouraged to share our new definitions for CC & HL.

What is Cultural Competence?
A set of congruent behavior s, attitudes, and policies that come together in a system, agency, or among professionals, enabling the delivery of services that are respectful of and responsive to the health beliefs, practices and cultural and linguistic needs of diverse populations.

What is Health Literacy?
  • Health literacy is the degree to which individuals have the capacity to obtain, process and understand basic health information and services needed to make informed health decisions.
  • Individuals must possess the skills to understand information and services and use them to make informed decisions about their healthcare needs and priorities. 
  • Health Literacy is the product of individuals' capabilities and the health literacy related demands and complexities of the healthcare system.
Partner Interview
Name: Gwen O'Shea
Title: President/CEO
Organization: Health & Welfare Council of Long Island

Please give us a summary of your organization
We are a regional, nonprofit umbrella agency working closely with hundreds of health and human service providers to respond to the needs of those most vulnerable and at-risk on Long Island.

Who does your organization serve?
The most vulnerable and at-risk residents on Long Island. There are many factors that put people at risk, including social injustice, chronic poverty. The symptoms they create, like: poor health outcomes or homelessness are more different to address on Long Island because of the high, regional cost of living. The make-up of those most in need is always evolving, For example, Long Island has the third-largest number nationally, of newly arrived children from Central and South America who have left as a result of civil unrest and violence in their counties. Many children come to Long Island - some to connect with their parents who came previously, while others are sent by their parents to connect with another family member who is already here. These children and their families face many barriers in accessing things that they are lawfully eligible for: like education and health care. HWCLI's role is to facilitate the coordination of these critical services: education, legal and mental health supports. Our organization's goal is to ensure that people have access to the services they need so they can live self-sufficiently.

Why did you choose to participate as a partner of the SCC?
While the goals and outcomes certainly seem daunting, there is a tremendous amount of opportunity. There is an opportunity to transform the health care system so that it puts the patient at the center and comprehensively addresses their needs. A key part of that includes reforming the payment and financial structure to ensure the capacity of all providers that touch a patient. SCC recognizes the role of social determinants of health on individuals' and communities' overall well-being. The SCC partnership brings together a cross section of providers-who previously, might have been seen as "unlikely partners".

On which DSRIP project(s) will you be working?
Our organization is the Project Lead on 2di - Patient Activation Measures® (PAM), and we're on the Cultural Competency Committee as well. I also serve on the SCC PPS Board of Directors.

What do you hope the DSRIP program will accomplish for your organization in the future?
Our hope, from an organization's perspective, is to see the foundation built for an ongoing respectful relationship where we work collaboratively and recognize each other's strengths. I hope the program will provide comprehensive care in ways that the individuals we serve find acceptable. And I hope that there will be recognition and acceptance of the costs - for physical care, mental health care, and housing supports for example, that are funded at the cost in which they are incurred. That we recognize the value of all the services. This has been happening already with our long-standing relationships - and we hope to see it within the program as well.

What do you hope the DSRIP program will accomplish in general?
DSRIP provides an opportunity to reshape health care services for at-risk Long Islanders to be community based, patient-centric and outcomes driven . Our hope is that we actually do that--create a comprehensive health system which provides care that is culturally competent, accessible, and affordable. That there is equitable care regardless of community in which it's provided.

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're not a direct service provider. We are a unique convener of many of the different entities which are key to the PPS's success. Our charge is staying involved in the conversation at a national, state and local level, while bringing lessons learned to our providers. As well, to communicate the importance of Community Based Organizations (CBO's) and their long-standing, trusted relationships within low-income communities and among high need individuals. Simultaneously, CBO's will need to build staff capacity and infrastructure to meet the requirements of the DSRIP projects.

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 shifting 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?
From an organizational perspective this has been a conversation that we have been having for quite a while with our member organization. Rather than being paid to simply provide a service, CBOs will be paid based on reporting and then for performance. This requires a good amount of CBOs to think completely differently than they have before related to outcomes, payment and risk. By using data to drive what we do, looking at outcomes to measure success, and sharing that data, we can better serve our target populations. However, not all of the communities' needs can be reflected in data goals. There will be times when additional resources need to be directed toward a community need in order to best serve the population.

Cultural Competency and Health Literacy are important to reducing health disparities and improving access. Where are the opportunities for the DSRIP program to develop a more culturally competent and linguistically appropriate responsive health care delivery system?
Everywhere! While health literacy issues affect all people, it disproportionately affects those most vulnerable and at-risk--the target population of the DSRIP project. As a collective, we have a responsibility to not only practice cultural competency, but to empower individuals through health literacy. Throughout all of the different committees we have opportunities to train, engage and ensure that we are doing all that we can to meet the needs of our diverse communities. Which includes people with chronic diseases, the LBGT community, immigrants and the limited English proficient population. But to really be cultural competent, it's not just checking off a box that says we did "x" number of training. It's an ongoing commitment to key components, such as: valuing diversity, having the capacity and willingness for cultural self- assessment and developing adaptations to service delivery which reflects an understanding of cultural diversity. The leadership of the SCC has made it clear that focusing on cultural competency and health literacy is a top priority

How do you see cultural competency and health literacy making an impact on our communities, workforce and population we serve?
As I stated above, your zip code is more likely to determine your health outcome that your genetic code. Truly achieving cultural competency among the PPS providers, coupled with raising the level of health literacy of our patients? That would completely transform the health of our communities.
Milestone Dates
NYS DOH DSRIP Program Milestone Dates 
Phase I DSRIP Notice and Opt out letters mailed to Medicaid members
October 31
PPS Second Quarterly Report (7/1/15 - 9/30/15) due from PPS
October 23
Network Reopening Period begins 
November 9 & 10
DSRIP Project Approval & Oversight Panel Bi-Annual Meeting
November 20
Network Reopening Period closes at 4 PM
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


SCC communications currently include weekly "DSRIP in Action" emails, the monthly "Synergy" eNewsletter, and the recently launched SCC website, which houses a wealth of resources including PowerPoint presentations, videos, and key documents. To directly sign up for our newsletter, click here 


Have a question? Please send it to then watch for the answer in a future issue of Synergy.