Issue 49
September/October  2019
Welcome to Synergy
We are pleased to present the forty-ninth issue of Synergy, a 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
New Screening Tool Helps Discharged Patients Avoid Readmission
Reprinted from Northwell Health's Press Release

Northwell Health has implemented a social determinants of health screening tool that will help newly discharged hospital patients get the support they need to recover successfully and avoid readmission.
The tool, a 15-item questionnaire, provides care teams with information about patients' social determinants of health-socioeconomic conditions that can make it harder to get healthy, such as lack of transportation that prevents people from getting to the doctor for an appointment or to a pharmacy to fill a prescription.  A patient who screens positive for one or more social determinants is connected to resources that can address those needs, helping to improve health outcomes.
"We know that non-medical factors can account for as much as 80 percent of health outcomes," said Sabina Zak, vice president of community health and health services research at Northwell.  "This screening tool allows us to take a targeted approach to addressing social determinants so we can more effectively help our most vulnerable patients get well."
The majority of the 300,000-plus inpatients treated annually at the 19 hospitals that Northwell owns and operates in the New York area will be screened within 48 hours of admission.  (Patients admitted to Northwell's maternity units and other specialty services are not part of the screening program.)
Patients who screen positive for a social determinant may be helped in a variety of ways.  For instance, they may be connected with a community-based organization that can provide resources, or assisted in applying for benefits such as the Supplemental Nutrition Assistance Program (also known as food stamps), or Access-A-Ride, which provides transportation for people who are unable to use mass transit because of age or disabilities.  Northwell's transitional care management team may also schedule home visits by a nurse after a patient is discharged, so that any problems can be quickly addressed.
Social determinants will be documented in patients' electronic medical records, with codes that are used to note non-medical factors influencing health status and health care (Z codes) included within the International Classification of Diseases, 10th Revision (ICD-10). This ensures that physicians and other health care providers are aware of factors that may impact their patients' health, and allows interventions to be tracked and assessed.  It also provides a rich resource for research, and helps Northwell identify the most pressing socioeconomic issues facing its communities and adjust its population health efforts accordingly.
The screening tool has already performed well in a pilot program at Long Island Jewish Forest Hills Hospital, where it has been used since February 2019 to identify social determinants among patients whose hospital stays occurred within 30 days of an earlier discharge.  In these patients, 64 percent screened positive for at least one social determinant, with transportation problems ranking highest-issues that could have played a role in patients' readmissions by preventing them from getting their medications or seeing the doctor for post-discharge care.  Other common social determinants seen among these patients include a lack of safe or secure housing, inadequate social support and limited health literacy.
"Social determinants screening has already clearly demonstrated the impact of non-medical conditions of life on the health of our patients," said Ram Raju, MD, senior vice president and community health investment officer at Northwell.  "As we implement this tool across Northwell, it will empower us to address the root causes of our patients' ills, reduce health disparities and ultimately create communities that thrive."
Collaborating to Build Healthcare Careers Pipeline

Over the past year, Suffolk Care Collaborative (SCC) and Suffolk County Community College (SCCC), Office of Continuing Education, have been working together to promote programs for community members that will build a workforce pipeline with skills to  fill emerging titles and upgrade skills of workers already in the healthcare field.

This past spring, 12 students participated (tuition free) in classroom and online instruction to develop career skills for the healthcare field through a Tech Hire workforce grant. The course, Health Information Boot Camp, was designed to prepare students with practical knowledge to strengthen time management skills, develop organizational skills and introduce them to the use of Electronic Health Record (EHR). Students also completed a module that introduced them to the Community Health Care Worker career and received CPR Certification. Students earned a National Workforce Readiness Credential (NWRC) upon completion and were able to take the Health IT online course, making them eligible for the HIMSS Health IT certification.

In an effort to introduce high school students and recent graduates to healthcare careers, SCC and SCCC collaborated with Superintendent of Hampton Bays Union Free School District, Lars Clemensen, to launch a pilot program that took place this summer. The Health Information Boot Camp was conducted, tuition free, in a classroom at Hampton Bays Schools with classroom training for the community health worker module provided by SCC staff member, Anne Barrett, Director of Communications and Workforce Transformation.   This type of collaboration and introduction of healthcare careers to community members provides  opportunity and future career growth, and creates a pipeline of workers for healthcare providers in Suffolk County.
SCC Participates in the First Outreach Expo at the Suffolk Cooperative Library System  

On Tuesday, October 1, 2019, Suffolk Care Collaborative (SCC) Project Manager, Sofia Gondal, participated in Suffolk Cooperative Library System's (SCLS) First Outreach Expo.  The event, organized by Valarie Lewis, Administrator of Outreach Services (SCLS), focused on sharing programs and services information with the administration and staff of the public libraries serving Long Island communities.  Representatives from various community service organizations participated in this event and provided educational materials for the attendees.

Ms. Gondal provided an overview of SCC's community programs and conducted live website demonstrations of the Community Engagement webpage for over 70 registered attendees.  The event presented an opportunity for the library staff to connect with representatives from programs and service organizations across Long Island.  SCC looks forward to supporting future collaborative events.

To learn about how your organization can participate in similar events, please contact our Community Engagement Team at
COMPASS Unity Year In Review

The past year has proved to be a success for COMPASS Unity through Strength and Diversity, Bellport/South Country School District's alcohol and drug prevention coalition.  As it strives toward making community level change, the Coalition continues to be supported by Family Service League's Underage Drinking Prevention Initiative (funded by Suffolk Care Collaborative) and its federal grant from the Drug Free Communities (DFC) Support Program. Since inception of the DFC grant, COMPASS Unity has engaged in multiple events and activities that have taken place within the South Country Central School District and surrounding community, including;  
  • Providing training to South Country Central School District's social workers in Teen Intervene. Teen Intervene is an early intervention program for youth that are experimenting with substances.
  • Hiring Epiphany Community Services (ECS) for evaluation services. ECS is a practical evaluation and technical assistance firm that specializes in working with community coalitions.
  • Launching a social media marketing campaign by way of hashtags, graphic artwork, branded photos and informative promotional videos, hosted on the Coalition's website and social media platforms.
  • Hosting environmental strategies such as Operation Pizza Box and Sticker Shock, which are initiatives that aim to raise awareness about underage drinking by way of placing stickers with positive messaging on pizza boxes and alcoholic beverage packaging.
  • Increasing the capacity of the Coalition by engaging in activities such as: networking, obtaining membership in the Bellport Chamber of Commerce, and through the formation of COMPASS Youth Coalition- the youth sector of COMPASS Unity. The Coalition also hired its first employee for clerical duties and secured an intern from Stony Brook University to assist with daily planning and implementation.
  • Providing support for four Bellport Middle School students to attend Long Island Teen Institute (LITI) Middle School Conference. LITI is hosted by HUGS, Inc., a not-for-profit agency that provides prevention education strategies aimed at reducing high risk behaviors among youth while fostering positive attitudes to improve all areas of life.
  • Attending The National Coalitions Academy (NCA), a year-long comprehensive training program developed by Communities Anti-Drug Coalitions of America (CADCA), which teaches coalition leaders and members what they need to know and do to establish and maintain a highly effective anti-drug coalition.
  • Attending  CADCA's Annual National Leadership Forum, a four-day event packed with opportunities to learn the latest strategies and hear from prevention experts, federal administrators, and policymakers.
  • Hosting informational tables at community events such as: Bellport Day, National Night Out, Bellport High School's 9th grade orientation, and Senator's Monica Martinez Back-to-School Block Party event.
  • Hosting a 1st Annual Awareness Day during Bellport High School's 9th grade student orientation. The Coalition hired two public speakers, Kym Laube from HUGS Inc. and bicycle stunt man Chris Poulos to speak to parents and students about substance use prevention topics.
  • Hosting COMPASS Unity's 6th Annual Youth Summit at Bellport Middle School, an all-day summit that consists of a keynote speaker and three workshops geared towards teaching 8th graders about making healthy decisions.
  • Collaborating with the Long Island Prevention Resource Center on trainings for the Coalition and its sectors.  The focus included prevention topics from Substance Abuse and Mental Health Services Administration's (SAMSHA) Strategic Prevention Framework.
To learn more connect online on Facebook, Instagram and YouTube.
SCC Hosts Cultural Competency & Health Literacy Master Training

SCC hosted a Cultural Competency & Health Literacy Train-the-Trainer (CCHL TTT) class on September 24, 2019.  Twelve regional partners participated in the interactive program with the objective of advancing cultural and linguistic competency, promoting effective communication to eliminate health disparities and enhancing patient outcomes.  During the full day program participants learned concepts of regional health disparity data, unconscious bias, social determinants of health, cultural competency and humility, National Culturally and Linguistically Appropriate Services (CLAS) Standards, health literacy barriers and strategies, as well as the Teach-Back Method.  Upon completion, all participants received certificates of completion and a toolkit to help prepare them to deliver the CCHL Training Program in their organizations.  Congratulations to the new CCHL Master Trainers!  
The CCHL Training Program is provided through collaboration of the SCC, Nassau-Queens Performing Provider System, Long Island Health Collaborative (LIHC), and curriculum creator Dr. Martine Hackett, an Assistant Professor at Hofstra University.  

Front row (left to right):  Alyssa Sreppaguercio, Northwell Health Community Relations; Vanessa Best, Precision Health Care Consultants; Diane Seaman, Life Skills & Psychotherapy Services/Good Samaritan Ministries, Inc.; Michelle Pizaro, Long Island Select Healthcare; Amanda Chirco (Class Instructor), SCC.  Back row (left to righ):  Risco Mention-Lewis, Suffolk County Police Department; Darlene Lewis; Elizabeth Mayoka, Long Island Select Healthcare; Dayanara Perez, Stony Brook University Medicine; Blanca Franco; Gail; Evangeline Boutin, Westhampton Primary Care of Stony Brook Medicine.
T hird Annual Health Fair 
Long Island Select Healthcare, Inc.

Long Island Select Healthcare, Inc. (LISH) celebrated its 3rd annual health fair on August 8, 2019. 200 attendees, including patients, community members and students from Wyandanch Rising were all able to enjoy the free giveaways, food and health screenings from 34 tables of vendors and LISH staff.  Guests from local government were also present.  


Master Training
December 3, 2019
8 am - 4 pm
Hauppauge, NY 

Project Advisory Committee (PAC) Meeting 
December 12, 2019
9 am - 12 pm

Compliance Connection

The Solutions to Reduce Fraud, Waste and Abuse in HHS Programs: OIG's Top Recommendations is an annual publication of the Department of Health and Human Services (HHS) Office of Inspector General (OIG).  This edition focuses on the top 25 unimplemented recommendations that, in OIG's view, would most positively affect HHS programs in terms of cost savings, program effectiveness  and efficiency and public health and safety, if implemented.

To view Solutions to Reduce Fraud, Waste and Abuse in HHS Programs: OIG's Top Recommendations: July 2019, click here.  Visit HHS OIG website for OIG's top recommendations overview.  

For compliance  questions or assistance, contact SCC's Compliance Office at and visit the compliance page on our website for helpful information.
 Milestone Dates
 NYS DOH DSRIP Program Milestone Dates
October 31, 2019          PPS Year 5 Second Quarterly Report (7/1/19-9/30/19) 
                                      due from PPS  

November 30, 2019      IA completes review of PPS DY5 Second Quarter report

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