Issue 29
September, 2017
Welcome to Synergy
We are pleased to present the twenty-ninth 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
Identifying, Engaging & Activating the Uninsured & Low/Non Utilizing Medicaid Population in Suffolk County
Addressing Social Determinants of Health through Community-Based Organization Partnerships

The SCC  has designed and deployed a Community Health Activation (CHA) Model to achieve population health improvements for the uninsured and low/non utilizing Medicaid beneficiary population within the geographic region of Suffolk County. Since the inception, beginning August 2015, the program has performed over 46,000 CHA encounters.
The SCC's  Community Health Activation Program (CHAP), a CBO-led in-reach and outreach program aimed to identify, engage, educate and integrate participants into community-based preventive care services. Program objectives aim to improve health and well-being, as well as reduce health inequities. To support ongoing assurance of CHA, the program aims to re-engage each participant annually.
CHAP utilizes a Patient Activation Measurement┬« survey tool to assess a participant's knowledge, skill and confidence for managing one's health and healthcare. Thereafter the program offers Coaching for Activation┬«, a personalized wellness coaching model which focuses on establishing self-management goals. Services also include navigating participants to community-based primary and preventive care services, as well as identifying and addressing any unmet social needs through community resource referrals.  

Announcement of New CBO Partners
The SCC is pleased to announce two new community-based organization partnerships under CHAP, YAM Community Resources (YAM) and the Family Service League (FSL).
Through the addition of YAM and FSL, we've expanded the program's reach by welcoming new Community Health Worker (CHW), Community Navigator and Wellness Coaching staff to participate in program services. We look forward to the added-value YAM and FSL will bring to the program.  Through longstanding and trusted relationships in the community, our new partners enhance our ability to engage community members meaningfully. 

About Family Service League
The Family Service League, a grass roots social service agency, manages one of the largest and most comprehensive networks of care across Long Island, serving infants to elders through Children and Youth Programs, Senior Services, Vocational Programs, Family Support Programs, Mental Health and Substance Abuse Programs and Housing and Homeless Services. FSL plans to operationalize CHAP through an in-reach model at their Family Centers located in Riverhead, Huntington Station and Bay Shore. FSL currently partners with SCC on DSRIP  Project 3ai : Integration of Primary & Behavioral Health Services and the DSRIP Project 4aii: Underage Drinking Prevention Initiative.   To learn more about the Family Service League, click  here .

" Family Service League (FSL) is pleased to be joining SCC's CHAP.  We see this initiative fitting into the agency's array of advocacy, information and referral services, as well as the other DSRIP projects we are involved in.  Identifying those that are low/non utilizers of Medicaid and primary medical care, and motivating and coaching them to more fully participate in their health care, meshes with FSL's mission to help individuals and families mobilize their strengths and improve the quality of their lives at home, in the workplace and the community." - Karen Boorshtein, President and CEO, Family Service League

About YAM Community Resource
Yam Community Resource, Inc. is a non-profit 501(c)(3) organization dedicated to providing services to the underserved population in the Haitian community, persons with disability and the elderly. YAM conducts programs that bridge social and cultural barriers, while assisting with other resources available in the community. Partnership and collaboration, bridging gaps, linking communities and community assistance are at the core of all their programs. YAM Community Resource plans to operationalize CHAP through an outreach model targeting community organizations and faith-based organizations with a focus on the Haitian population through use of a Haitian-Creole PAM survey. To learn more about YAM Community Resource, click here.

Community Health Activation Achievements
Thanks to the efforts of all participating CBO partners, the SCC has surpassed the DY3Q2 PAM survey goal of 12,719 surveys. A special thanks to all of our partners for their hard work and commitment to ensuring the continued success of the program.
CHAP utilizes a web-based information system to document all wellness coaching and community navigation efforts. The SCC Project Management Office reviews progress summarized in monthly reports to track trends. Data collected informs targeted population needs, guides program development discussions and helps identify additional partnerships and workflows to assist in operationalizing referrals.

We've provided a summary of findings during August 2017: 
  • 5% of participants agreed to be enrolled in wellness coaching. This module contains PAM Level appropriate goals and activities designed to increase a participant's knowledge, skills and confidence in managing their healthcare.
  • Of those enrolled in wellness coaching, 22% of participants were Level 1 (participants lacking knowledge, skills and confidence in managing their health), 61% Level 2, 17% Level 3 and 0% at Level 4 (participants already having knowledge, skills and confidence in managing their health).
  • During the month of August, roughly 400 participants were referred to a Primary Care Physician for medical services.  Referrals were primarily sent to Federally Qualified Health Centers (FQHC) throughout Suffolk County.
  • In addition, approximately 130 participants received a referral for community resources based on an identified unmet social need.  To date, top community referrals includes medical services, food pantries, housing assistance, behavioral health services, domestic violence services and employment assistance.  During the month of August, 65% of community referrals were for food assistance.
  • As we look at the cultural demographics of CHAP participants, 56% of surveys were conducted in English and 43% were conducted in Spanish.
  • During the month of August, 55% of PAM survey participants resided in Brentwood, Bay Shore, Riverhead, Amityville or Patchogue, all recognized as areas of high need in Suffolk County, NY. 
The following map demonstrates the progress of CHAP engagement efforts to date, as it relates to the location of the uninsured population in Suffolk County. The SCC aims to engage areas of high need or areas with larger populations of uninsured individuals to operationalize outreach services. 
Data Source:  American Community Survey 2014:  5-Year Estimates for Suffolk County by Zip Codes

Growing the Community Health Activation Eligible Population  
As of August, CHAP deployed a Self-Identifying Screening Tool to identify low/non utilizing Medicaid members. The Self-Identifying Screening Tool allows a Medicaid beneficiary to self-attest to being a low or non-utilizer and thus eligible for a PAM survey and CHAP services. This screening tool enables the project to greatly expand the population of potentially eligible participants.  Previous survey efforts had been exclusively focused on the uninsured population.
If you have questions regarding CHAP or wish to become a participating CBO, please contact our program representative, Amanda Chirco, Project Manager for Community Health Initiatives at
SCC Hosts Quality Improvement Training for Partners
Ashlee McGlone, Provider Relations Liaison,SCC

Earlier this month, the Suffolk Care Collaborative hosted the first of two Quality and Performance Improvement trainings sponsored by the Greater New York Hospital Association (GNYHA). This training was attended by over 30 participants, including nurses and practice managers.   

Led by Regina Neal of Qualis Health, this training aimed to provide ambulatory care staff with formal improvement skills. Maintaining an interactive and enthusiastic environment, Regina reviewed the Institute for Healthcare Improvement's Model for Improvement and rapid cycle improvement plans with the Plan-Do-Study-Act framework. 

The timing of this training complements the Suffolk Care Collaborative's Corrective Action Plan process, which aims to improve outcome measures in primary care practices. In preparing for this meeting the SCC, GNYHA and Regina met to pull in pieces of the action planning process into the training as a way of supporting these practices with their action plans. The training also included presentations by Kevin Bozza, Vice President, Population Health Management Services, and Ashlee McGlone, Provider Relations Liaison. The day ended with the development and sharing of an improvement process using the Model for Improvement principles to impact the practice sites's performance on measures related to the DSRIP program.
Participants working on group project
Feedback from the first training was very positive. Attendees expressed that they felt confident and enthusiastic about their ability to carry out improvement initiatives.  This training is a great opportunity for front-line staff to receive formal training in quality and performance improvement.

Space is still available for the October 10th training which will be held at the Holiday Inn Express Hotel & Suites East End in Riverhead. Click here to register. 
New York State Smokers' Quitline Continues Important Service

For many smokers fighting tobacco addiction, an encouraging voice on the other end of the phone can be the difference that helps them to quit smoking for good - often after a series of unsuccessful quit attempts. For the last 17 years, New Yorkers have relied on support available on demand, when they needed it most, at the other end of a phone connection or through a wealth of online cessation resources. Thanks to the continuing efforts of the New York State Department of Health and the recent awarding of a contract to Roswell Park Cancer Institute on May 1, 2017, the services of the New York State Smokers' Quitline (NYSSQL) will be there for New Yorkers to turn to for years to come.

This five-year, $20.6 million contract will enable Roswell Park Cancer Institute to provide comprehensive telephonic services for smokers and online resources and services for healthcare providers, all geared to help tobacco users successfully quit. The grant will support approximately 50 jobs, including 15 new positions created to address an expanded need for services to help meet high-priority needs, such as helping those who have additional challenges in overcoming tobacco dependence because of income, education and/or mental and behavioral health issues. The Quitline team will also work to expand outreach and resources for health providers toward the goal of helping more users quit tobacco successfully.

"Our goal is to motivate and help as many New Yorkers as possible to quit smoking and stop using other tobacco products," says New York State Department of Health Commissioner Dr. Howard Zucker. "The New York State Smokers' Quitline provides people with the tools and support necessary to help them break their addiction to nicotine, preventing smoking-related disease and early death. The Smokers' Quitline is a key component of our tobacco cessation initiatives, which along with the state's anti-smoking ad campaign and Health Systems for a Tobacco-Free NY program, has helped New York State achieve record low youth and adult smoking rates, 4.3% and 14.2% respectively."

Important Facts:  
  • Roswell Park Cancer Institute has operated this free statewide resource since 2000
  • Services include phone and online assistance, tools for healthcare providers
  • NY Quitline reaches nearly 3 times as many people as quitlines in other states

Click here to read the full press release from Roswell Park Cancer Institute.

About Roswell Park:
The mission of Roswell Park Cancer Institute (RPCI) is to understand, prevent and cure cancer. Founded in 1898, RPCI is one of the first cancer centers in the country to be named a National Cancer Institute-designated comprehensive cancer center and remains the only facility with this designation in Upstate New York. The Institute is a member of the prestigious National Comprehensive Cancer Network, an alliance of the nation's leading cancer centers; maintains affiliate sites; and is a partner in national and international collaborative programs. For more information, visit Rosewell Park's website, call 1-877-ASK-RPCI (1-877-275-7724) or email Follow Roswell Park on Facebook and Twitter.
About the New York State Smokers' Quitline:
The New York State Smokers' Quitline is a service of the New York State Department of Health and based at Roswell Park Cancer Institute. New Yorkers can call the Quitline at 1-866-NY-QUITS (1-866-697-8487) Monday through Thursday from 9 a.m. until 9 p.m., and Friday through Sunday from 9 a.m. until 5 p.m.; outside those times, taped messages offer support and help to quit smoking. Resources are available anytime day or night through the Smokers' Quitsite.    
Annual Youth Summit at Bellport Middle School
The 4th Annual Youth Summit for students at Bellport Middle School was the focus of Family Service League's DSRIP Underage Drinking Prevention Initiative. The summit was organized with leadership of COMPASS Unity through Strength and Diversity and Bellport/South Country School District's alcohol and drug prevention and awareness coalition. COMPASS covers the towns of Bellport, Brookhaven and parts of East Patchogue, Medford and Yaphank.

The Youth Summit was held at Bellport Middle School on May 18, 2017. Throughout the day, a randomly selected group of 75 eighth grade students attended workshops that held the common theme of making healthy decisions. The day began with keynote speaker, Kym Laube from HUGS Inc. who spoke to the student attendees about making healthy decisions. Students then participated in a series of three workshops. The first one entitled, "Becoming an Upstander" was conducted by Senior Public Health Educator, John Martin from Suffolk County Department of Health Services. Students learned through a variety of participatory exercises how to be an upstander rather than a bystander when it comes to bullying. The second workshop was facilitated by Charles Fox, Senior Coordinator for Community Services for the Economic Opportunity Council, Inc. His workshop assisted students in learning the most effective steps to take to make healthy decisions. The third workshop entitled "Balancing Act" was conducted by Stephanie Sloan, Senior Drug Abuse Educator with Suffolk County Department of Health, Division of Community Mental Hygiene. Participating students learned how to balance their priorities and responsibilities via active participation using balls of various sizes. Lastly, Police Officer, Nancy Ward did a presentation on "Social Media Safety." Students learned various ways to conduct themselves safely when using technology and social media.

The day concluded with a survey.  The survey included five questions that aimed to assess the youth's perception regarding alcohol use by their peers, alcohol availability within the community, and risk and protective factors within the community.

Out of the 62 students that participated in the survey, 43 students reported that they did not know anyone in their grade that has consumed alcohol within the last 30 days. The remaining 19 students reported that they did. When asked if they think adults in the community serve alcohol to underage individuals, 27 students reported they did and the remaining 35 students did not. When asked if they thought it was easy for underage individuals to access alcohol from adults in the community outside of their home, 49 students answered yes.  The remaining questions were open-ended questions. The students were asked what they thought was the biggest problem in their community. The majority reported that drug and alcohol use was the biggest problem, along with drug sales, bullying, and violence - specifically gang violence. The students were also asked what they liked most about their community. The majority answered sports, school, diversity within the community, geographical size of the community and community unity at difficult times. 

The results from this survey indicate that alcohol availability within the community is a risk factor.  Based on those results, the Family Service League's DSRIP program and COMPASS Unity will shift additional focus toward its prevention efforts.  Furthermore, the program and coalition will strive to establish more protective factors within the community, while strengthening existing protective factors, such as youth and family recreational activities.

COMPASS Unity strives to keep the youth of the South Country area safe and alcohol/drug free. The coalition is thriving, with representation from the 12 sectors within the community including youth, parents, business community, media, schools, youth-serving organizations, law enforcement agencies, religious or fraternal organizations, civic and volunteer groups, healthcare professionals, state, local or tribal agencies. Each sector has expertise in the field of substance abuse and/or involvement in reducing substance abuse. Family Service League's DSRIP's project provides support to the Coalition in an effort to reduce underage drinking and substance use in the community. 
Partner Interview 
Name:  Vivek Taparia
Title:  Deputy Executive Director, DSRIP
Organization:  Catholic Health Services of Long Island

Please tell us about your organization 
Catholic Health Services is celebrating its 20th anniversary as a system. Our network, operating throughout Long Island, consists of 6 hospitals, but also a variety of other services including nursing homes, ambulatory surgery centers and endoscopy centers, as well as partnerships with organizations such as Urgent Care Centers.

Who does your organization serve?
Our target population is the Long Island community. Because our hospitals have tremendous reputations, we attract patients from all over the greater New York area. We are committed to serving patients across different communities and economic groups.

Why did you choose to participate as a partner of the SCC?
We have three hospitals in Suffolk County: St. Charles, St. Catherine and Good Samaritan. These hospitals all play a major role in serving the Medicaid population. Our participation in the Suffolk Care Collaborative (SCC) and Delivery System Reform Incentive Payment (DSRIP) program enables us to accelerate our ability to serve these vulnerable populations and position our organization for value-based delivery paradigms.
What DSRIP project(s) are you involved in?
Currently I lead network development and performance for our ambulatory footprint.  The initiatives for which I am responsible span a variety of DSRIP projects ranging from Patient Centered Medical Homes (PCMH) and Regional Health Information Organization (RHIO) connectivity to behavioral health integration and performance improvement. We monitor provider performance across a variety of measures including behavioral health, cardiovascular disease, diabetes, asthma and avoidable hospital readmissions. We work closely with our partners to close gaps in care.
What do you hope the DSRIP program will accomplish for your organization in the future?
I am hopeful the DSRIP program will accelerate a collective mindset shift toward value-based healthcare delivery. Historically, hospitals have been paid for keeping "heads in beds", but in the future, health systems will succeed through managing the health of the populations we serve. The DSRIP program accelerates our journey to create an integrated clinical network that succeeds in closing gaps in care and thus creating the building blocks of a value-based delivery system.
What do you hope the DSRIP program will accomplish in general?
Despite the many debates surrounding healthcare, I think there's universal acknowledgement that costs are spiraling in an unsustainable path and something needs to be done to achieve the triple aim of healthcare in terms of better access, better quality and lower cost.  DSRIP was initiated to help put New York on a sustainable footing and the results so far show that it seems to be on track to achieve its goal of reducing avoidable hospital use.

How has your organization begun to experience the shift from volume to value in order to provide quality health care across your population?
The main way to succeed in value-based healthcare is to create an integrated delivery network.  We're doing a number of things to achieve this goal: PCMH practices, RHIO connectivity and behavioral health integration; all very essential tenants of the DSRIP program. PCMH practices provide patients greater access to primary care and enable them to play a central role in their care journey. RHIO connectivity enables Electronic Medical Record (EMR) systems to be interoperable. Total cost of care goes up two to three times with chronic disease and an underlying behavioral health condition. So, being able to address the behavioral health issues on the front line will position us well for value-based care. We're keeping people healthy and delivering better outcomes at a lower cost.

How do you envision your organization adapting/evolving to meet the needs  of the new healthcare delivery model?
We have fully embraced the key initiatives of DSRIP. We are not only driving practice PCMH/Advanced Primary Care (APC) transformation for our Medicaid network but also for our broader Independent Physician Association (IPA) and employed network.  We are excited about incorporating behavioral health in the primary care setting and have seen tremendous demand for such integration. We are exploring how we can help practices connect to the RHIO through compatible EMRs, so we can partner in managing the health of their populations. Going forward, I see us increasingly leveraging data and analytics platforms to identify care gaps and closing them on a real-time basis. I see us holding ourselves accountable to performance measures and seeking to continuously improve.

How do you see this project making an impact on our communities and population we serve?
I believe some of the most powerful impacts of our projects will be seen over the long term. Almost our entire pediatric ambulatory network in Suffolk County has participated in PCMH practice transformation.  We already see effects such as a potential reduction in avoidable pediatric ED visits. Imagine the long-term effects that we'll be able to have on major healthcare challenges such as childhood obesity!
We feel fortunate to be a member of the Suffolk Care Collaborative which has been highlighted as one of the most successful PPSs in the state. SCC's data and performance initiatives have helped us serve our communities with cutting edge thought leadership and processes.
Compliance Connection
Corporate Compliance & Ethics Week

The week of November 5-7, 2017, marks the 13th Annual National Corporate Compliance and Ethics Week.  Start planning to celebrate Corporate Compliance and Ethics Week at your organization.  It is a good way to raise awareness and call attention to the topic of compliance and the importance of maintaining an ethical culture. 

Educating staff is one of the critical elements of a comprehensive compliance and ethics program.  Such education includes ensuring that all employees know and understand your program's standards which they are expected to meet.  The week of November 5th gives organizations a great opportunity to:
  • Raise employee awareness about the Code of Conduct, compliance policies, relevant laws and regulations, compliance hotlines and other ways for reporting concerns.
  • Reinforce the culture of compliance and ethical behavior.
For ideas, resources and more information about Corporate Compliance and Ethics Week, visit the Health Care Compliance Association's Website .  

For compliance questions, or assistance, contact the SCC Compliance Office at
 Milestone Dates
 NYS DOH DSRIP Program Milestone Dates
October 1
Response made to PPS Lead Regulatory Waiver Requests - Round 6
October 2
Release PPS Primary Care Project Narratives for 30 day public comment period
October 6
Final PPS Year 3 First Quarterly Reports posted to DSRIP Website
October 31
PPS Year 3 Second Quarterly Reports (7/1/17-9/30/17) due from PPS

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. Social Worker
  3. Community Health Associate
  For more information, please contact the Suffolk Care Collaborative via email