Issue 18
October, 2016
Welcome to Synergy
We are pleased to present the sixteenth 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 Co-Hosts Building Bridges Event

A s the need for cross regional/county communication has grown, the Community Engagement Team at Suffolk Care Collaborative (SCC) has responded with collaborative efforts to reduce the silos that exist within our surrounding community. The SCC partnered with the Long Island Health Collaborative (LIHC) and Nassau-Queens PPS to host, the Building Bridges: Communications, Data & Networking events, one in Nassau County and one in Suffolk County. These two events were scheduled in the month of October and were open to community leaders, community based organizations, faith-based organizations, care managers, discharge planners and providers.

Building Bridges addressed opportunities identified at the LIHC Community-based Organization Summits that took place in February 2016 and Suffolk County DSRIP Collaborative CC/HL Community Breakfast in November 2014.  Such opportunities included, gaps in communication among CBOs and various provider systems, as well as a lack of knowledge of major healthcare resources.  On October 20th the Suffolk County Building Bridges  event took place at the Riverhead Firehouse to address the identified needs specific to Suffolk County.  Two resource directories were introduced and reviewed with the attendees.  Megan McKeon shared the Greater New York Hospital Association's Health Information Tool for Empowerment (HITE) and Betty Eberhart and Laurie Abbatepaolo shared the United Way's  211 Long Island  tool.  

These resource tools are very powerful and possess time efficient functionality that not only community leaders can access, but also the general public can utilize to connect to healthcare resources and services within their community. In fact, the representatives from HITE and 211 presented on their respective directories, demonstrated how to utilize the online resource, and answered specific questions from the audience. All participants left with a communication resource tool.The event successfully connected multiple community organizations, with over 100 participants from 80 organizations at the Suffolk County event.

Moving forward the goal is to reduce the isolation of independently working organizations, which often result in limited collaborations and inter-connectivity of community health. In the near future, plans include hosting annual networking events and creating more opportunities for all types of community organizations and community leaders across the region to showcase and share their resources. 
Click below to view the presentation from October 20th Building Bridges event.

Betty Eberhart (left) and Laurie Abbatepaolo (right) presenting  211 Long Island Tool


On October 21st the SCC welcomed over 50 participants including CASACs, social workers and nurses working with the behavioral health and substance abuse populations; who attended the Treating Tobacco Dependence Training program facilitated by the Suffolk County Department of Health Services' "Learn to be... Tobacco Free" (LTBTF) Campaign in cooperation with NYS OASAS.

The Treating Tobacco Dependence Training program is targeted to providers who are interested in obtaining education on how to facilitate on-site Community Cessation Programs on behalf of their organizations to their patient populations. In addition to learning how to facilitate the Community Cessation Programs, participants gained competencies to enable participants to describe the three aspects of nicotine dependence, provide appropriate motivational counseling, assist clients/consumers to make a quit plan, learn behavior change strategies, discuss the 7 FDA approved medications to treat nicotine dependence and integrate relapse prevention techniques.

Participants at Treating Tobacco Dependence 
Training Program on October 21
Supporting Chronic Disease Management through use of HealtheRegistries
Submitted by:  Erin J. Healy, RN, MS, MPH, Asst. Director, Population Health, Stony Brook Medicine Information Technology
Three core principles of the Suffolk Care Collaborative's Population Health Roadmap are population health management, clinical integration, and clinical data sharing. Critical to the success of any program designed to support these principles is the implementation of a robust IT population health platform. The platform used by Stony Brook Medicine is Cerner's HealtheIntent™. It is a cloud based system designed to scale up to the population level while facilitating health and care at the person and provider level. It receives and interprets shared patient data across multiple providers and health information data systems, such as insurance claims, laboratory results, clinical information from electronic medical records, and many others. 

HealtheRegistries™ ("Registries") is an application within this platform. Registries is a comprehensive disease and wellness registry solution that uses clinical and financial data from various sources across the continuum of care to qualify, attribute, measure, and monitor members. Registries is where population health management, clinical integration, and clinical data sharing converge.

Stony Brook physicians and their care teams began using HealtheRegistries™ in the Fall of 2015. It has enabled our providers to track their quality metrics and scorecard performance in near real time. HealtheRegistries™ is an actionable patient record giving the provider the ability to identify critical gaps in care at the patient level. It empowers the care team to intervene in a timely manner, providing the right care, at the right time, and in the right place.

There are several disease and wellness registries available within HealtheRegistries™. Stony Brook chose to adopt the disease and wellness registries and their related outcome and process measures that align with many of DSRIP's Domain 3 reporting requirements. For example, the Diabetes, Coronary Artery Disease, Hypertension, Pediatric Asthma, Depression, and Age Specific Wellness Registries encompass evidence based process and outcome measures consistent with assuring a healthy population by caring for one person at time.
INTERACT Spotlight:  A ccolades to Acadia

Kathy Kursar, Assistant Director of Nursing and Mary Greco, Director of Nursing Acadia's INTERACT Champions

Acadia Center for Nursing and Rehabilitation in Ri verhead, is a participating Skilled Nursing Facility in the INTERACT Program.  Acadia is also a New York-Reducing Avoidable Hospitalizations (NY-RAH) facility. This CMS Initiative seeks to reduce avoidable hospitalizations for long-stay, Medicare fee-for-service nursing facility residents, improve transitions between nursing facilities and hospitals, and strengthen palliative care.  The INTERACT Project has similar achievement goals which makes it essential to have engaged teams at the facilities.
Mary Greco, Director of Nursing, and Kathy Kursar, Assistant Director of Nursing,
are doing an outstanding job educating their team on INTERACT.  They have created a "DSRIP INTERACT Workbook."
Tasked with educating their facility staff members on INTERACT, Mary and Kathy wanted to create a resource for their team.  The DSRIP INTERACT Workbook contains the INTERACT tools the facility is using, along with a list of acute change of conditions. Mary said, "What started out as a tool the team could reference outside of a lecture, became their little bibles."   All staff is educated on INTERACT, and the workbooks are ongoing and growing with relevant materials.  The team's response to the workbooks has been very positive.
INTERACT Team Champions (from left to right) Michael Bunce, RN, Mary Greco, RN, Barbara Bigam, RN, Colin Barr, RN, Carol Riley, RN, Daniel Mazzone, RN and Kathy Kursar, RN

Any Stop & Watch or SBAR that is filled out is reviewed at morning report.  The team is also using the INTERACT Care Paths.  Kathy said, "our care plans are now based on the INTERACT Care Paths, this helps us close the whole circle."
In addition to INTERACT Education, they feel it important to have their team understand DSRIP, and other changes in the health care environment.  They have done in-services that include an overview of DSRIP and other  changes taking place in health care that are relevant to the skilled nursing world..  Mary said, "It is important for them to understand why we are asking them to do these things."  In addition to their in services, they have creative bulletin boards on the nursing units that highlight the SBAR and Stop & Watch tools, and DSRIP too!
The facility's commitment to the goal of DSRIP is evidenced by the dedication Mary and Kathy put into attending Suffolk Care Collaborative's INTERACT work groups,  learning collaboratives, sharing their best practices, and actively participating in dialogue focusing on next steps.  Wonderful job in creating a quality-focused culture!
SCC Hosts INTERACT WebEx Series

In order to meet the facility training requirements for the INTERACT Project, after receiving feedback from the INTERACT Workgroup Committee, Jen Kennedy, Director of Care Transition Innovation, assisted by Ralph Thomas, Project Manager, hosted a live round-the-clock WebEx Series for the Skilled Nursing Facilities.  The series included an INTERACT Quality WebEx geared towards Administrators, Directors of Nursing and Medical Directors.  This WebEx focused on the current landscape of healthcare, rehospitalization rates, and training on identifying the root cause of facility hospital readmissions using the INTERACT Quality Improvement Review of Acute Transfers tool.

There was also an INTERACT Overview and Tool Highlight WebEx.  This WebEx focused on the principles of INTERACT and highlighted two communication tools, the SBAR and Stop & Watch.  This WebEx was very interdisciplinary, facilities had nurses, CNAs, housekeepers, maintenance staff and therapists on the call.   The WebEx's were hosted for the day, evening and night shifts and participation was terrific !

Both WebEx's were recorded and can be viewed by clicking on the below links:

Free On-line Health IT Training

Suffolk County Community College's Office of Continuing Education and Department of Health Information Technology are providing online courses for healthcare professionals.  Courses are for primary clinical support, care managers and social support professionals, as well as front office personnel.
Course topics include:
  • Population Health
  • Care Coordination and Interoperable Health IT Systems
  • Value-Based Care
Requirements for admission are, experience working with an EHR system, employed in healthcare, high school diploma or equivalency diploma, access to the internet and a computer with Flash software.   These courses are being offered by Suffolk County Community College through a grant and partnership with Columbia University.  

For further information you can contact Michael Riggio at 631-451-4892 or  
Compliance Connection

Can you list the top 15 languages spoken in New York aside from English?  And why are we asking?  
If you are aware of the final rules implementing the Affordable Care Act's non-discrimination provisions (known as  Section 1557 ), you will know the answers to these questions.  If you aren't and you don't, read on!  

Entities covered by Section 1557 include those engaging in health activities receiving federal funds (like the SCC), not just healthcare providers.  We urge our network partners to learn about Section 1557 right away, get legal advice if appropriate, and get into compliance with this part of the ACA.  While the law has been in place since 2010, the implementing regulation was just finalized in the past few months and the deadline of October 16, 2016 only recently set.  Compliance will be enforced by the U.S. Office of Civil Rights .  

The clock is ticking!  Healthcare organizations with over 15 employees must conspicuously post taglines about the availability of free language assistance services for Medicaid members with disabilities and low English proficiencies in the top 15 non-English languages, effective October 16, 2016!  
We have given you the summary here but read on for more important information to see what you need to do to be in compliance.   The SCC Compliance Officer is here to help if needed: contact Sarah Putney at (631) 638-1393 or .  Or our 24/7 Compliance Hotline: (631) 638-1390.
Milestone Dates
NYS DOH DSRIP Program Milestone Dates

November 17
Release Initial Mid-Point Assessment recommendations and PPS Primary Care Project Narratives for public comment
December 1
Independent Assessor provides feedback to PPS on PPS Year 2 Second Quarterly Reports; 15-day Remediation window begins
December 10
Public comment period for Initial Mid-Point Assessment recommendations and Primary Care Narratives ends
December 15
Revised PPS Year 2 Second Quarterly Reports due from PPS; 15-day Remediation window closes
December 23
Release Final Mid-Point Assessment recommendations for 30-day public comment
December 30
Final Approval of PPS Year 2 Second Quarterly Reports

Frequently Asked Questions


To access NYS DSRIP FAQ, click 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. 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 Medicine administering the Suffolk Care Collaborative.
Click the links below to access job descriptions.
For more information, please contact the Suffolk Care Collaborative via email

Stay Informed


SCC communications currently include bi-weekly "DSRIP in Action" emails, a monthly "Synergy" eNewsletter, and the SCC website, which houses a wealth of resources including individual program webpages, 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.