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.
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.