Issue 17
September, 2016
Welcome to Synergy
We are pleased to present the seventeenth 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 Us
SCC is an alliance of healthcare providers in Suffolk County, Long Island, NY, formed to support New York States Delivery System Reform Incentive Payment (DSRIP) initiative. Under the guidance and leadership of Stony Brook Medicine, SCC established the Office of Population Health 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.
In This Issue
Asthma Home Environmental Trigger Assessment Program Brings Community-Based Asthma Care to Pediatric Populations
The SCC has partnered with the Clinical Practice Management Program at Stony Brook Medicine, in conjunction with Stony Brook's Children's  to initiate Asthma Home Environmental Trigger Assessment Services of DSRIP Project 3dii, also known as the Promoting Asthma Self-Management Program (PASP) . 
This is an asthma self-management program including home environmental trigger reduction, self-monitoring, medication use, and medical follow-up to reduce avoidable emergency department and hospital visits. The goal is to develop population-based services to address asthma exacerbation factors. 
Under the PASP program, asthma patients 0-25 years old with Medicaid will be stratified into three risk categories: high, moderate and low. Eligible high-risk patients and their families will receive home visits from Community Health Workers (CHWs), with calls/text reminders as needed between visits, especially after ED/hospital visits. Root cause analysis will also be provided to avoid future incidents. CHWs will follow a protocol to guide visit content focused on home environmental trigger reduction, self-monitoring and self-management of asthma symptoms, asthma medication use, and medical follow-up. CHWs will link patients to resources for trigger reduction interventions, especially to change the indoor environment. A visit summary will be sent to all health care team members (e.g., primary care physician, subspecialist) via interoperable EHR and PPS-wide care management platforms created to support integrated care delivery when available.
The SCC will work with Stony Brook Children's to pair CHWs with eligible high-risk patients and their families to provide services required for the program, including:
  1. Identification of home environmental triggers for asthma.
  2. Provide health education materials pertinent to promoting asthma self-management.
  3. Review the asthma action plan with the family and respond to families' concerns and questions.
Stony Brook Children's will be overseeing the administration and supervision of the CHWs for the home assessment program and will also link patients and their families with appropriate community resources based on need, including additional healthcare services, food assistance, transportation services, childcare services, family services, and counseling, in accordance with the SCC Community Navigation Program.
About Keeping Families Healthy Program at Stony Brook Medicine
Clinical efforts are being led by Susmita Pati, MD, MPH , a pediatrician and health services researcher who joined Stony Brook Children's Service in November 2010 as Division Chief of Primary Care Pediatrics and Associate Professor of Pediatrics.  Dr. Pati's team created and launched Keeping Families Healthy (KFH) home assessment program in 2011, a program that helps families follow clinical care recommendations with support services tailored to meet the specific needs of each patient, including those with asthma. Since its inception, the KFH team has provided more than 10,000 visits to over 900 families throughout Suffolk County. Families are referred to the KFH program if they are broadly deemed "at risk" for poor health outcomes by their clinician. KFH participation has shown positive results: newborns and infants participating in the KFH program have a 15-20% increase in up-to-date vaccine status compared to a convenience control group,1 and children participating in KFH have a 50% reduction in emergency department visits for preventable reasons compared to a convenience control group.2
For the past three years, the KFH program has worked closely with Stony Brook Children's pulmonary specialists to refine the services provided to patients with asthma. Together, they created an Asthma Tool Kit which is given to each participating family with an asthmatic child to help track, control, and manage their asthma. The Keeping Families Healthy program will be scaled up to meet the needs of the DSRIP PASP Program.
Click here to read more about the KFP Program: English & Spanish.
1 Pati S, Ladowski KL, Wong AT, Huang J, Yang J. An enriched medical home intervention using community health workers improves adherence to immunization schedules. Vaccine 2015: Oct 2.
2 Anugu M, Braksmajer A, Huang J, Yang J, Ladowski KL, Pati S. Enriched medical home interventions using community health workers reduces ED use. Poster Presentation. Children's Hospital Association Annual Leadership Conference. Phoenix, AZ. (November 7-9, 2016).
Make a referral, contact the KFP Program Coordinator, Giuseppina Caravella
Phone: (631) 444-7307
Care Transitions Learning Collaborative Recap
Implementation of Care Transition Interventions through Suffolk County's Hospital & Skilled Nursing Facilities participation in the Delivery System Reform Incentive Payment (DSRIP) Program.
Suffolk Care Collaborative hosted the first Care Transitions Learning Collaborative on September 8th. It was attended by all 11 Suffolk County Hospitals and over 20 Suffolk County Nursing Homes currently participating in the DSRIP System Transformation programs.
Hospital & Skilled Nursing Facility
Care Transitions Learning Collaborative
The SCC Transition of Care (TOC) program aims to provide a 30-day supported transition period after a hospitalization to ensure discharge directions are understood and implemented by the patients at high risk of readmission. The aim of the program directly supports the overall DSRIP goal to reduce potentially avoidable hospital readmissions, or ED use, by focusing on identifying high risk patients during the hospital admission, connecting with a transition of care service or care manager and coordinating care.
Feedback gathered to date by the SCC during visits to partner Skilled Nursing Facilities (SNF) and Hospitals and meetings with respective Implementation Teams led to the design of the agenda for the Care Transitions Learning Collaborative. Objectives for the Learning Collaborative included:
  • Enhance the existing partnerships and communication lines between acute care facilities and skilled nursing facilities in care transitions intervention programs.
  • Promote best practice sharing that will aid in the development of collaborative solutions.
  • Design opportunities to empower and educate patient/caretaker and families to participate in planning of care.
  • Partner to coordinate the transition of care period.
Winners of the Care Transitions Jeopardy Game, tied for first place John T Mather Hospital and Brookhaven Hospital!
A Care Transitions Jeopardy game was played as an ice breaker and introductory exercise. The categories of the Jeopardy games were "Who's Who, Speak my Language, Mumble Jumble, To Be Continued, and Should I Stay or Should I Go Now." Within the topics of the game, were questions that addressed the INTERACT Quality Improvement Program tools, key players in care delivery transformation, Value Based Purchasing, DSRIP Acronyms, Discharge Summary and High Risk Criteria.
The SCC organized the room into tables, each hospital across Suffolk County (11 in total) had a table, and nursing home representation was strategically placed at the hospital table that they receive patients from. Each table had a scribe to record the conversations and a facilitator who engaged attendees in focused conversations for a specific time frame. Focus group topics were, Nursing Home Clinical Capabilities; Hospitals Current Transition of Care Program Implementation; Admissions; Discharges and Transfers; Warm Hand-Offs and Care Coordination; Clinical and Advanced Care Planning Opportunities; and lastly, Patient/Family Education Opportunities.
John T. Mather Hospital Table Facilitated by Alyssa Scully, Sr. Director, Project Management Office
Some preliminary lessons learned by the participants were that both the hospitals and nursing homes faced similar challenges related to communication, family/patient expectations and goals of care. Each level of care faced these challenges from different angles, but realized they shared common goals to be able to deliver patient-centered care.
Further, SNFs identified primary reasons for sending patients to the emergency department due to patients and families misunderstanding of the SNF clinical capabilities, timeliness of receiving patient admissions, access to specialty medical physicians, such as cardiologist and pulmonologists. Hospitals acknowledged opportunities on nursing homes' referral acceptance procedures, hospital transfer procedures, and medical personnel contact information. Nursing home to hospital warm hand-off communication was another key take-away from the session.
Stony Brook Medicine Table Facilitated by Joseph Lamantia, Chief of Operations for Population Health
Next steps will be to identify smaller work groups that can implement action plans to move toward goal attainment.   
There was a lot of positive feedback on the Learning Collaborative amongst participants. Participants were truly there in the spirit of inquiry to seek solutions to better relationships to benefit the patients and their families. Much interest was shown for future opportunities in this type of setting.
We look forward to extending this type of collaboration to Home Care Providers and Health Homes as we move forward in continuing to host Learning Collaboratives for all participating providers.
Transitions of Care Program Implementation Highlights from Brookhaven Memorial Medical Center
Written by: Brianne Rizzo, LCSW, Director of Care Management Department; and Karen Shaughness, LCSW, ACSW, BCD, Senior Director of Ambulatory Services
Our TOC Team is comprised of representatives from various departments including Physicians, Care Managers, Cardiology, Home Care, Nursing, Behavioral Health, Administration, Performance Improvement, Outpatient Services, Respiratory Services, and Information Technology. Following the success of the MAX Series COPD re-admission project, in which our Team reduced ED visits by 50%, our Team has utilized and implemented several methods and procedures to identify high risk patients early on, and subsequently provide preventive and support services for them in the community.
With the collaborative efforts of our Information Technology and Emergency Department, the ED software program now flags patients who have been discharged from the inpatient service within the last 30 days and places them on the census. Specifically, COPD and Heart Failure patient cohorts are flagged; and an e-mail notification is sent to Team members for interventions to begin.
Our organization has enhanced our strong relationships with local Nursing Homes through multiple site visits with Medical Directors and Directors of Nursing to engage them in the transition of care process. We have seen improvements in relationships and look forward to enhanced collaboration that will ultimately benefit our patients. Our clinical staff conducts thorough evaluations at the time of the ED visit that helps to identify key social determinants of health. This enables care managers to develop comprehensive discharge plans that may include support services, health home, or home care etc.  Follow up calls are made for 30 days to the patients post discharge to ensure they are able to follow through with their plans.
Health Home Engagement
We reached out to Federation of Organizations, Northwell, and Hudson River Health Homes, to meet with our team. Through various meetings, our staff increased their knowledge base about the benefits of Health Home services, which helped to increase referrals and strengthen community relationships. In addition, patients and their families have been involved in clinical team meetings with health home and hospital staff to maximize patient/family engagement and team effectiveness. This has been a positive experience to date and one which continues to grow.
Brookhaven Memorial Hospital is actively engaged and committed to reducing avoidable ED visits and re-admissions through a myriad of multidisciplinary relationships within the community.
Greater New York Hospital Association Partnership on Upcoming Community Webpage Launch
The Suffolk Care Collaborative (SCC) has partnered with Greater New York Hospital Association to embed and integrate the Health Information Tool for Empowerment (HITE) on the SCC webpage. HITE is a free online resource directory that connects low-income, uninsured, and underinsured residents across NYC and Long Island with over 5,000 free and low-cost health and social services. SCC has worked with HITE to add more local resources to the directory so Suffolk County residents have easier access to community services information. HITE helps patients and clients find and access services, learn about new resources and tools to coordinate care, and connect with programs, organizations and community groups. This online, user-friendly directory will serve as a great tool for not only referral professionals but also community members!
About Health Information Tool for Empowerment (HITE)
HITE is an online directory at  that offers information on free and low-cost services for people in need throughout New York City and Long Island. Free and immediately accessible, HITE is used in hospitals, health centers, not-for-profit organizations, managed care companies, public agencies, and other settings where staff may be required to connect people to a variety of social supports. HITE originally launched in 2005 as one of the first tools of its kind in the greater New York area, aiming to centralize resource information and reduce time spent searching on behalf of clients and patients.
Resources listed in HITE's searchable database include medical care, behavioral health, wellness, social services, financial assistance, and many other services. Each page in the directory offers basic details needed to initiate referrals, such as location, eligibility, application information, hours of operation, languages spoken, and fees and insurance policies. All information in HITE is verified directly with listed organizations.
HITE also engages in outreach to organizations, including free presentations for frontline and leadership staff, building connections with local provider groups and coalitions, and efforts to improve accuracy and coverage of New York City and Long Island resources. HITE has also served as a tool to evaluate community needs and identify potential community partnerships.
HITE is a program of the Greater New York Hospital Association (GNYHA), a trade association providing over 160 member hospitals and health systems in New York, New Jersey, Connecticut and Rhode Island with advocacy, technical assistance, training, and other forms of support. As access to social needs becomes further prioritized in healthcare, GNYHA will continue to seek opportunities for HITE to assist in efforts to serve communities, improve care and population health, and meet programmatic goals.
For more information on HITE, please contact HITE Program Manager Francesca Padilla at
Carla Nelson, Senior Director, Ambulatory Care & Population Health, HITE
Featured Interview         
Carla Nelson, Senior Director, Ambulatory Care & Population Health, Greater New York Hospital Association 
Please give us a summary of your organization:
HITE (Health Information Tool for Empowerment) is a free online resource directory covering New York City, and Nassau and Suffolk County. HITE is primarily used by social workers, caseworkers, discharge planners, and other information and referral professionals. HITE is part of the Greater New York Hospital Association (GNYHA), a trade organization that represents over 160 member hospitals and health systems throughout New York State, New Jersey, Connecticut, and Rhode Island. GNYHA provides a number of services for our members, including HITE, which is also available to the public. HITE includes information on medical care, behavioral health programs, social services such as housing, food assistance, transportation, and detailed information about programs, such as where they're located, eligibility, hours of operations, and languages spoken. These services are geared mostly for low-income, uninsured, and underinsured people in the Greater New York area. Our goal is to make sure that our database is well utilized, because it is free, it is up to date, and accurate.
What are some examples of the ways that HITE collaborates with organizations around Suffolk County?
HITE staff are active with community groups and their meetings. We usually make contacts through these groups to get information, but that's been limited for us on Long Island. We were really excited to be partnering with the Suffolk Care Collaborative (SCC) because we knew that we would be able to expand our database in Suffolk County. In fact SCC was one of the first organizations to actively approach us to share resource information. Also, we have just started working with the Long Island Health Collaborative, the Nassau and Suffolk counties' Population Health Improvement Program and a partner of SCC. They run a lot of different initiatives out on Long Island, and they are a big convener of community-based organizations.
In what capacity have you worked with SCC and the DSRIP program?
One big collaboration is that HITE will be available directly through the SCC website. So if someone on Long Island is searching for a resource and they're on the SCC website, they won't be redirected to another site. We thought it was a really good opportunity when SCC proposed it, because it increases the access to and visibility of information that would be helpful for the community. SCC has also been an important partner in helping us to build up our resource listings in Suffolk County--they shared information on Suffolk County services they have linked patients to previously to make sure they were incorporated in the HITE directory. So far, SCC has helped us add at least 100 new resources to our database. Access to their community partners, like the Long Island Health Collaborative, has helped us stay on top of what community meetings are going on and additional services to add to HITE.. Working with SCC has helped connect us to organizations that we didn't know about, or only knew about a little bit, and we were really able to expand our coverage.
What do you hope the DSRIP program will accomplish for your organization in the future?
At GNYHA, we want to see that hospitals succeed in DSRIP; we want them to meet their milestones; we want them to avoid unnecessary hospital utilization. We know that in order to do that, these community partnerships are really important. We hope to grow the database to include information that we may not have captured, and that PPSs [Performing Provider Systems, the organizations that run the DSRIP programs], including SCC, are out there collecting community resource information. We want to work with PPSs to add that information to our database. Also, once we bring this information into HITE, we want to take the burden of managing and updating this information off the PPSs.
That's why we are really interested in getting more visibility. We want the PPSs to know that they have a trusted source of information in HITE and we want as many people as possible to access this free information.
How can people in Suffolk County add resources or their organizations to HITE to help further develop the database?
It's easy to add resources to HITE. On the HITE homepage, there is not only a "Contact Us" button, but also a button on the menu called "Suggest a Resource" where you can fill in an online form with information about a resource. The HITE staff will follow up directly with people at that resource to complete the full HITE listing. That's the way to add 1 or 2 resources or a particular program, but if there are organizations out there that run many different programs, or organizations that have many different locations, we can also take that information in a spreadsheet or a Word document and do a larger-scale addition. We're really excited to get new resources, and a lot of information at once.
Another way of getting additional information is having organizations share information with us on the resources they know and have utilized before, as SCC has done.
What are some challenges you face as an organization in your everyday endeavors, and how have you worked to overcome these challenges?
One of our challenges at HITE is identifying existing programs that we didn't know about. We are finding that the partnerships we have with PPSs are really important, because other organizations know about resources that we don't necessarily know about. Finding the right contact people to verify information like hours and services at an organization has also been challenging. It wasn't really until we were more active with community outreach that we started to overcome some of these problems through networking. But our biggest challenge is increasing our visibility and having other organizations share information about HITE, especially large organizations or organizations with high turnover.
As much as we can, we are out there spreading the word, especially to our core users, social service professionals who really need this information. We network, we have pamphlets about our website, and we do HITE training and demonstrations for free so that people within organizations can learn how to do HITE searches.
What have been your biggest accomplishments so far as an organization?
Although GNYHA is a larger organization, HITE is very small. When we launched HITE in 2005, our goal was to pull together resource information that social workers and different kinds of care professionals would have in binders and spreadsheets, and house them in one place. Now HITE offers information on more than 5,000 health and social services. We update HITE at least annually and sometimes more often, so we know that it is good quality information and that is accurate. Over the past year or so, we've seen more web traffic, and it's steadily increasing, so our outreach is working. We have about 20,000 servers per month accessing the site, which has grown from around 2,000.
But our biggest accomplishment is our good reputation. Right now, we are seen as a trusted source of data, and we've been approached by some PPSs and other organizations because they know that our data is comprehensive, accurate, and up-to-date. 

INTERACT Spotlight at Brookhaven Health Care Facility
The Brookhaven Health Care Facility in East Patchogue, and an engaged participating Skilled Nursing Facility in the INTERACT Program, dedicated a 4-day, around-the-clock INTERACT training seminar to their interdisciplinary team members in mid-September.
Brookhaven Rehabilitation & Health Care Center presenting INTERACT at new hire staff orientation. (Left to Right) Kellie Burridge, RN, Director of Nursing, Debi Gaines, Administrator & Nancy Culp, RN, Nurse Educator
Nancy Culp, RN, Nurse Educator, who was supported by Debbie Williams, RN, Associate Director of Quality & Education, and Kellie Burridge, Director of Nursing, trained 295 employees during the seminar.  The education focused on building awareness of the INTERACT Quality Improvement Program, and educating Brookhaven's team on the processes they have instituted for successful implementation and sustainability of the INTERACT Program.
Debi Gaines, Administrator, participated in the training as well. Debi stated, "Team members said they were so happy to be included in this training, it was very valuable." Brookhaven has a very low staff turnover rate, which Debi attributes to the open culture and interdisciplinary team approach of the facility.
Debi said, "We are working with our physicians, interdisciplinary team and community partners on rehospitalization efforts, as they are all key partners to its success."  Their efforts are reflected in their September's rehospitalization rate of 8.9%.
We would like to congratulate Debi and her team for their hard work and dedication to the INTERACT Project!  

Suffolk County Tobacco Cessation Coalition & Initiatives
The SCC is excited to announce the commencement of the Suffolk County Tobacco Cessation Coalition. The Coalition will be pursuing tobacco cessation initiatives that span across three DSRIP Projects: (1) Cardiovascular Health Wellness & Self-Management Program (CWSP), (2) Substance Abuse Prevention and Identification Initiatives and (3) Access to Chronic Disease Preventive Care Initiatives.
About the Coalition
A few Members of the Suffolk County Tobacco Cessation Coalition gathered following the September 29th Meeting
The Suffolk County Tobacco Cessation Coalition is a group of representatives and subject matter experts  in the field of preventive-medicine, community health and tobacco cessation charged with reducing tobacco use among residents of Suffolk County, NY, including those who have behavioral health needs. The Coalition will achieve this through implementation of evidence-based best practices and standards in healthcare provider settings, connecting the community to accessible and trustworthy resources to help them successfully quit smoking and tailoring culturally competent and health literate campaigns and education programs for the public.
Introduction to the Coalition Leads
Patricia Folan, RN, DNP, CTTS, Director, Center for Tobacco Control, Northwell Health, Health Systems for Tobacco Free NY, NYS DOH Bureau of Tobacco Control
Patricia Folan has been a nurse at North Shore University Hospital for over 30 years with experience in Pediatrics, Critical Care, Occupational Health and the Center for Tobacco Control (CTC). She has a Masters in Nursing Education and a Doctorate in Nursing Practice from Case Western Reserve University, focusing on education and leadership. She is also a certified tobacco treatment specialist. With grant funding from the New York State DOH Bureau of Tobacco Control, she works with healthcare organizational leaders to establish policies ensuring that all providers screen patients for tobacco use, treat and counsel them, as well as provide follow-up. In order to assist with implementation of these polices, she and her staff train healthcare professionals in hospitals, clinics and offices to treat patients for tobacco dependence with evidence-based practice in Nassau and Suffolk Counties. In addition, she and her staff educate students about tobacco dependence treatment in nursing programs, Physician Assistant programs and medical schools on Long Island. Dr. Folan has also engaged in tobacco control research studies, presented at national and international conferences, and coordinated community tobacco cessation programs.
Marcy Hager, MA, Project Director, Center of Excellence for Health Systems Improvement for a Tobacco-Free New York, CAI (Change and Inspiration) Global
Marcy Hager is the Project Director of the Center of Excellence for Health Systems Improvement for a Tobacco-Free New York at CAI Global. In this role, she provides technical assistance to grantees to support systems-level approaches to implementing US Public Health Service recommendations for treating tobacco use within federally qualified health centers, community health centers, and behavioral health organizations. Through her work supporting grantees, she has drawn upon the science of implementation to streamline the integration of best practices to improve patient quality of care around tobacco dependence treatment in New York State. Before joining CAI, she oversaw various projects including a New York State Department of Health funded project using practice facilitation skills to implement evidence-based practices within health care organizations in New York City to decrease health disparities among vulnerable populations. Additionally, she has experience managing research projects testing the implementation of a clinical decision support tool within dental clinics and improving medication adherence rates within HIV+ patient populations. Ms. Hager holds her Master's degree in International Development from the University of Manchester and received her Certificate in Practice Facilitation from the University of Buffalo.
The Coalition Initiatives
To date, the SCC has identified five initiatives that support our program objectives:
  • Tobacco Cessation at Primary Care Practices: The goal of this initiative is to ensure and encourage primary care providers address tobacco cessation with their patients via the 5 A's of Tobacco Dependence Treatment in electronic medical record systems (EMR). Marcy Hager, Project Director, Center for Excellence for Health Systems Improvement will be supporting this initiative in leading a Statewide Super User IT Workgroup to further EMR developments in the 5 A's of Tobacco Dependence Treatment.
  • Facilitation of Referrals to NYS Smokers' Quitline (NYSSQL): The goal of this initiative is to increase the number of Suffolk County referrals to the NYS Smokers' Quitline and to ensure patients are being contacted and offered free cessation services after they are referred. Patricia Bax, RN, MS, Department of Health Behavior and Marketing and Outreach Coordinator for Rosewell Park Cessation Services and the NYSSQL at Rosewell Park Cancer Institute, will assist the SCC to monitor County-wide referral metrics and develop tools to support promotion of the referrals to our PPS-network.
  • Tobacco-free Campuses at Behavioral Health Sites: The SCC will be supporting partnering OMH licensed behavioral health sites to become tobacco-free. PJ Tedeschi, Coordinator for the Tobacco Action Coalition of Long Island, American Lung Association of the Northeast, has partnered with the SCC to bring implementation assistance, training opportunities, resources and tools to behavioral health sites participating.
  • Tobacco Cessation Community Engagement & Education: The goal of this initiative is to provide a tobacco cessation and prevention community resource guide, campaigns and education for community members. Resources will include how to obtain medications, prevention strategies, NYS Smokers' Quitline information, etc. This document will be accessible on SCC's website. Pat Folan, Director, Center for Tobacco Control at Northwell Health will be supporting the connectivity of the Coalition to resources that can be promoted through our network.
  • Tobacco Cessation Training Courses: The goal of this initiative is to provide community members and healthcare professionals with education surrounding tobacco cessation and prevention. Under this initiative, the SCC has partnered with Laura Giardino, MS, NP, Suffolk County Department of Health Services to offer Treating Tobacco Dependence Train the Trainer Workshops. The program will enable trained persons to host Community Cessation Programs within their facilities.   
Calling for Membership
If you would like to become a voluntary member of the Suffolk County Tobacco Cessation Coalition and design or lead your own Tobacco Cessation Initiative or participate on an existing initiative, please contact Alyssa Scully, Sr. Director, Project Management Office via email at
SCC's Area of Need Strategy & Analytics
We have partnered with the Long Island Health Collaborative on an area of need analysis of high utilization of healthcare around Suffolk County

The Suffolk Care Collaborative (SCC) along with the Long Island Health Collaborative collaborated in conducting an area of need analysis to identify geographical areas with high utilization of health care and to better understand the characteristics of that population.  This analysis will provide contextual information for developing strategies in how to best deliver care that is equitable, timely, effective and patient-centered.   
A small percentage of the American population contributes to a large proportion of healthcare spending. An analysis performed by the Kaiser Family Foundation using data from the Agency for Healthcare Research and Quality quantified that 5% of the American population consumed 50% of total healthcare spending and are considered high utilizers of health care [1].  SCC looks to identify high utilizers of health care by geo-mapping data from the Statewide Planning and Research Cooperative System (SPARCS) database and data from the Salient Interactive Miner (SIM) to determine areas of high Medicaid utilization as well as areas of high prevalence with specific diseases. 
Once communities with high utilization of health care are identified, further analysis of the population will be performed to understand the regional characteristics of those communities.  Analysis of the characteristics of the communities will include, but are not limited to: race, ethnicity, language, and socioeconomic factors.  This data will contribute in planning targeted interventions to improve the health of the identified communities.    
Healthcare asset mapping of the identified communities with high utilization will also be conducted.  Geo-mapping SCCs partners, and the type of services provided will be created to determine available resources for these communities as well as assess any gaps between available resources and community needs. 
The artifacts produced from the analysis will provide actionable intelligence to develop strategies for improving the health of communities with high utilization.  Due to the multifaceted dimensions of these communities, various stakeholders will need to contribute to this study.  These stakeholders will include SCC's Project Management Office (PMO); SCC's Community Needs Assessment, Cultural Competency and Health Literacy workgroup; SCC's Care Management Organization; SCC's Community Engagement workgroup; the Long Island Health Collaborative; and Stony Brook's Biomedical Informatics department.
Building Bridges: Communications, Data & Networking
The SCC has partnered with the Long Island Health Collaborative and Nassau-Queens PPS in hosting this event!

The SCC has partnered with the  Long Island Health Collaborative and Nassau-Queens PPS in hosting Building Bridges: Communications, Data, & Networking event! 
The Building Bridges: Communications, Data & Networking Event is scheduled for this October 2016 and is for community leaders, faith-based organizations, community-based organizations, care managers, discharge planners and providers.
This will be an opportunity for all organizations who serve community members in Nassau and Suffolk and those who attended the LIHC Community-Based Organization Summit events in February 2016 and the Suffolk County DSRIP Collaborative CCHL Community Breakfast in November 2014 to network, discuss community improvement strategies and obtain a communication tool that will improve the work you are doing to serve communities on Long Island.
Two events are scheduled:
  • October 5, 2016; 9-11:30am, Hofstra University Multi-purpose Conference Room, Student Center, 1000 Fulton Ave, Hempstead, NY 11549
  • October 20, 2016; 9-11:30am, Riverhead Volunteer Fire Department, 540 Roanoke Ave, Riverhead, NY 11901
Click here for more information.
To register, visit: 
If you have any questions, please contact the Long Island Health Collaborative at
Compliance Connection
If you work for one of the SCC's provider partners, you may have been wondering:
Q: May a SCC provider Partner (Covered Entity) share PHI with the SCC without specific patient authorization and without naming SCC or the specific purposes of sharing in their Notice of Privacy Practice (NPP)?
A: Yes, assuming that the Covered Entity/Partner has met the regulatory requirements (45 CFR §164.520) for the content of its NPP and has otherwise met the requirements for providing its NPP to patients.  Specifically, the Partner should have described the types of uses and disclosures it is permitted to make under the HIPAA Privacy Rule for Treatment, Payment, and healthcare Operations (TPO), using at least one example for each of these three purposes.
The Covered Entity/Partner has the option of using the SCC as an example in the NPP, but does not have to.  The DSRIP program serves the general purposes of Treatment (improving quality and access to care), Payment (lowering costs, Medicaid/DSRIP payments made by SCC), and Operations (aggregating pop health data, connectivity with the RHIO, transforming practices, etc.).  Therefore, as long as the Partner meets the regulatory requirement of describing purposes for TPO, with at least one example for each (which doesn't have to be SCC), the Partner does not have to mention SCC/DSRIP specifically.  See 45 CFR §164.520.
The DSRIP Program does not require specific mention of the SCC in a Partner's NPP, nor do the SCC's policies and procedures. 
If a Partner's patient has restricted the sharing of there PHI in a way that affects the SCC's ability to provide services to Partner under its Participation Agreement, the Partner must inform the SCC.  Similarly, if the Partner's NPP restricts sharing of PHI in a way that affects the SCC's provision of services, the Partner must inform the SCC.  (See Section 3, Responsibilities of Covered Entity, Business Associate Agreement, Exhibit C of Participation Agreement.)
Note: this FAQ is not intended to serve as legal advice. Partners should consult their legal counsel for legal advice.
For more information, please contact the SCC Compliance Officer at or (631) 638-1393.
Milestone Dates
NYS DOH DSRIP Program Milestone Dates 
Sept. 30
Final Approval of PPS Year 2 First Quarterly Reports
Implementation of Phase II Payment Scorecard in MAPP Performance Dashboards
October 1
Anticipated Independent Evaluator contract start date
October 6
Final PPS Year 2 First Quarterly Reports posted to DSRIP Website
October 31
PPS Year 2 Second Quarterly Reports (7/1/16 - 9/30/16) due from PPS
Job woman showing hiring sign. Young smiling Caucasian   Asian businesswoman isolated on white background.
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.

Frequently Asked Questions


To access NYS DSRIP FAQ, click here

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.