Featured Partners


Photograph of Robert Heppenheimer Title: CEO
Name: Robert Heppenheimer
Organization: Guardianship Corp
Partner Interview

Please tell us about your organization and the population you serve.
Guardianship Corp is a new not for profit organization that was formed to fill the urgent need to serve as Court appointed Guardians. Courts are required to appoint someone to represent the interests of persons found to be incapable of managing their own affairs, due to mental or physical deficits, as it relates to their legal, financial, housing, health and/or other critical basic needs to live a safe and secure life. For those with no family or friends willing to serve in this capacity and have no funds or assets to pay for these services, there is no public reimbursement mechanism for these cases. Since New York State has no public guardianship program, the process of appointing private attorneys and/or social workers is challenging and dependent on pro bono work.

What are some of your best practices and how have they been identified?
One of CHS' best practices is the Pediatrics Asthma Home Based Program. Under this program nurses go into the home to evaluate patients' living environment, medication adherence, etc. Home visits provide ongoing patient and family education, recommendations for improvement of asthma management and communication with the patient's primary care provider to facilitate improved asthma management by the patient and family. The Asthma Home Based Program is a CHS program that existed prior to the PCCCC and DSRIP's implementation. Another best practice is a patient reminder process for annual physical/preventive exams, which is measured by the Access to Care metrics. Through the use of practice scorecards, Michael Sokol, Performance Implementation Manager, identified Dr. Daisy Baez's practice as a high performer across all age groups. Dr. Baez allowed us to work with her practice to map out their patient reminder process in a flowchart in order to replicate in other practices who have improvement opportunities.

Who do you collaborate with to meet your strategic goals?
Guardianship Corp utilizes volunteers to visit and monitor clients (also referred to as wards). A small administrative staff provides the required services of reporting to the Court and visiting and representing the often frail, fragile and/or dependent citizens. We collaborate with Retired Senior Volunteer Program (RSVP) to screen, train, deploy and coordinate trained volunteers that visit, monitor and support each assigned client. Through a relationship with the Senior Law Project at Touro Law School, supervised legal interns assist with needed legal work. Additionally, Social Work and Nursing students from Stony Brook University assist with visiting and assessing clients in the field.

Guardianship Corp goals include:
  • Assisting clients towards the highest practicable level of functioning and independence possible
  • Being a resource for volunteers to function as advocates
  • Providing the County, the Court System and the citizens of Suffolk with an ethical, professional administrative service for its most vulnerable population
How do you see this initiative making an impact on Suffolk County communities?
Once appointed by the Court as Guardian for an individual, Guardianship Corp ensures the client's needs are met through a comprehensive assessment, service planning, regular visits, on-going support and required reporting to the Court. Services include, but are not limited to, arranging for food, clothing, shelter, safety, health care and social needs, as well as managing individual's property and financial affairs.

RSVP volunteers, supported and supervised by Guardianship Corp staff, visit clients bi-weekly to assist with managing their personal, financial and/or health care affairs. This strategy ensures that clients maintain a healthy well-being and maximum independence.

For more information contact Robert Heppenheimer, CEO, Guardianship Corp, Touro Law School PAC, 225 Eastview Drive, Central Islip, NY 11722, 631-650-2325

Photograph of Charlene Greene Title: Project Manager, DSRIP
Name: Charlene Greene, MS, CPHQ
Organization: Catholic Health Services of Long Island
Partner Interview: Performance Improvement Best Practices at Catholic Health Services of Long Island

Please tell us about your organization's performance improvement activities.
Catholic Health Services' (CHS) DSRIP team created the Primary Care Chronic Conditions Committee (PCCCC) as part of our Performance Improvement Program. The committee focuses on improving health outcomes of Long Island communities with chronic conditions, as well as improving DSRIP metric performance. The committee monitors and prioritizes the performance of Diabetes, Access to Care, Cardiovascular and Asthma metrics in DSRIP, and identifies best practices and opportunities for improvement. Disease specific workgroups review and scale best practices across primary care practices and hospitals to improve care and decrease unnecessary hospital and emergency department utilization. The aim is to improve compliance with the DSRIP metrics, which will aid providers in the transition from fee for service to value based programs and contracts.

What are some of your best practices and how have they been identified?
One of CHS' best practices is the Pediatrics Asthma Home Based Program. Under this program nurses go into the home to evaluate patients' living environment, medication adherence, etc. Home visits provide ongoing patient and family education, recommendations for improvement of asthma management and communication with the patient's primary care provider to facilitate improved asthma management by the patient and family. The Asthma Home Based Program is a CHS program that existed prior to the PCCCC and DSRIP's implementation. Another best practice is a patient reminder process for annual physical/preventive exams, which is measured by the Access to Care metrics. Through the use of practice scorecards, Michael Sokol, Performance Implementation Manager, identified Dr. Daisy Baez's practice as a high performer across all age groups. Dr. Baez allowed us to work with her practice to map out their patient reminder process in a flowchart in order to replicate in other practices who have improvement opportunities.

How are you using data to inform your performance improvement initiatives?
During the first six months of the PCCCC, the committee reviewed the HUB's DSRIP performance data monthly to understand its performance with Asthma, Diabetes, Access to Care and Cardiovascular metrics at the system and PPS level. The data, along with additional information, was used to prioritize metrics the committee would focus on. Once metrics were selected, the PCCCC tasked the disease specific workgroups with drilling down the data at the practice level to identify best practices and improvement opportunities. The workgroups report their findings and recommendations to the PCCCC, where corrective actions are discussed and approved prior to development and implementation of improvement initiatives. During the development and implementation phases, workgroups provide monthly status reports. During implementation, real-time baseline and performance electronic health record (EHR) data are collected at the practice level to establish performance levels prior to, during and after implementation of a new process.

How has your organization been able to impact health outcomes in the community?
The PCCCC has impacted health outcomes in the community by identifying opportunities to refer pediatric patients to the Home Based Asthma Program and by improving providers' processes to increase the number of patients who complete their annual preventive physical exam. The Home Based Asthma Program decreases asthma exacerbations by identifying asthma triggers in patients' homes, improving medication adherence and asthma management through education and resources to patients, families and primary care providers. The annual preventive physical exam patient reminder impacts health outcomes in the community by implementing a process that improves providers outreach to patients in need of annual assessments. This enables chronic disease prevention and management or treatment of diseases before patients become acutely ill. As the PCCCC progresses, additional interventions will be identified and implemented.

Photograph of Barbara Rowe Title: Director, Specialty Services
Name: Barbara Rowe, DNP, FNP (APRN)
Organization: Catholic Home Care/Good Shepherd Hospice at Catholic Health Services
Partner Interview: Pediatric Asthma Home Visit Program

Please give a summary of your program.
The Pediatric Asthma Program at Catholic Health Service's (CHS) Catholic Home Care partners with system and community entities to decrease the burden of asthma on children and their families. The management of asthma is often a complex and multi-faceted challenge to both health care providers and families. Ineffective management can have dire consequences on the overall health and quality of life of affected children.

The program consists of carrying out evidenced-based practice proven to be crucial in the management of childhood asthma. Referrals are received from system and community hospitals, as well as health care practitioner practices. The home visits are performed by trained registered nurses, to provide patient and parental education on a level consistent with their ability to understand and process the information.

What are the key components to your pediatric asthma management program?
The key components of the Catholic Home Care Pediatric Asthma Program include a home visit by a trained registered nurse to provide a home environmental assessment with education on methods to eliminate or reduce triggers. The education uses standardized teaching materials, including an asthma flip chart (developed by the local asthma coalition, an entity of the American Lung Association), medication pictures, use of spacers and valved holding chambers, medications, inhalers, use of control and reliever medications, as well as differentiation between the two medications' actions. Clinicians also provide education on the Asthma Action Plan to assist families to understand green, yellow and red zones and take action upon identified changes in the level of asthma control. Education is provided specific to each family's educational needs and the teach-back method is used to ensure understanding. Written educational material is available to families in English and Spanish. The use of age specific asthma digital applications and evidence-based age specific materials, such as cartoons and coloring books, are dispensed to children to facilitate early engagement in the management of their chronic disease process.

At each home visit the Asthma Control Test is administered. It measures the elements of asthma control as defined by the National Heart, Lung and Blood Institute (NHLBI). In addition, a comprehensive interdisciplinary treatment plan is developed inclusive of a licensed medical social worker and/or behavioral health nurse if a need is identified by the home health nurse. Coordination is often initiated between the home health nurse and school nurse to facilitate the child's smooth return to school following a diagnosis of asthma. Coordination is maintained with child's provider to ensure continuity of care across the continuum. Follow up phone calls are made at 3, 6 and 12 month post-care to assess level of sustained asthma control and identify opportunities for follow-up and additional support.

How does your program reach and impact your community?
Coordination of care across the healthcare and community continuum is essential to address the unique needs of this population. Providing skilled nursing visits in the patient's home environment offers a unique opportunity to identify barriers to adequate asthma control and provide education on remedying these health concerns. Catholic Home Care partners with the Asthma Coalition of Long Island, a subsidiary of the American Lung Association, to address the health disparities across the county but specifically within the identified areas where pediatric asthma is most prevalent and health care needs are greatest. Partnerships with providers have allowed us to increase referrals and home visits.

Who do you partner with to promote increased pediatric asthma awareness?
The Catholic Home Care Pediatric Asthma Program partners with system and community hospitals, clinics and healthcare practices across Long Island and Queens. Asthma resource information is made available in local houses of worship. The program is incorporated into system wide community outreach initiatives providing education and administration of the Asthma Control Test, culminating in appropriate health care practitioner referral for follow up care.

Asthma Resources for Parents and Children
Photograph of Ginette Rows Title: Executive Director
Name: Ginette Rows
Organization: YAM Community Resource, Inc.
Partner Interview: Working to Improve Quality of Life for Those in Need

Please give a summary of your organization.
Yam Community Resource, Inc., (Yam) based in Huntington Station, is a non-profit organization dedicated to providing services to the underserved population in the Haitian community, persons with disability and the elderly. Our overall goal is to improve conditions of living for these populations or any person in need. We provide application assistance for Medicaid and Supplemental Nutrition Assistance Program (SNAP) by helping clients in preparing documentation needed for application submission. We also assist clients with the online application process for health insurance through New York State of Health Marketplace, and assist clients with referrals to appropriate services, including translation, escorting to interviews and providing follow up until the client's needs are met.

Who does your organization serve?
Yam provides outreach primarily to the Haitian community in Suffolk County but we welcome all community members in need of assistance. Most of the clients we serve live within the areas of Huntington, Greenlawn, Central Islip and Brentwood.

Describe your involvement with DSRIP and what you hope to accomplish.
DSRIP looks at the community at large and identifies needs and the determinants to good health. DSRIP also brings together partners in diverse sections of the community through collaboration to provide services needed. As partnerships develop, the community will become more active in their health activities and be able to improve health concerns at the community level for each individual. Yam's emphasis is on building bridges and minimizing gaps in services for the Medicaid population.

Why did you choose to participate as a partner of the SCC?
SCC implements programs to address the gaps assessed in our communities. Yam participates in the Community Health Activation Program (CHAP) by conducting Patient Activation Measure (PAM) Surveys in Suffolk County. The PAM Survey is a tool with 10 questions and takes only 3-4 minutes to answer the questions. This tool effectively assesses how active a client is in managing their health issues. Once the level of need is identified, there is also a component of coaching and a plan to assist the client in making appropriate choices for a positive health outcome. We are gradually introducing this tool in the Haitian community to assess the needs and provide assistance based on survey outcomes.

What has your organization done to make transformational changes?
Yam has partnered with Catholic Health Services to provide health education programs in the Haitian community through houses of worship. We are currently working in collaboration with Huntington Church of God as the central site for the Haitian Community Program. However, invitation is extended to all churches. We are working closely with one of the pastors to bring programs that address specific needs and are culturally appropriate. The programs include classes, health screenings, preventive care and demonstrations and are presented in both Haitian Creole and English.

How do you see your work making an impact on the communities and population served?
Yam has been working very closely with Pastor Edmonde Francks of the Huntington Church of God and we are now planning a fall program. We also have scheduled meetings with other churches in Suffolk County to bring awareness of the program and look forward to extending to other sites. Awareness and education are the key to making an impact.

Photograph of Maria Curcio Title: Diabetes Wellness Program Coordinator
Name: Maria Curcio, RDN, CDN, CDE
Organization: Long Island Community Hospital (formerly known as Brookhaven Memorial Hospital Medical Center)
Partner Interview: Diabetes Wellness Education for the Community

Please give a summary of your organization.
For more than 60 years, Long Island Community Hospital (formerly known as Brookhaven Memorial Hospital Medical Center) has served the diverse region of southern central Suffolk County as a patient-first community hospital. An important underpinning of the hospital's Community Service Plan is providing resources and services to at-risk members of the 400,000 community members and LI Community Hospital employees we serve, who are managing chronic diseases, including Diabetes.

As part of our three-year Plan of Action, LI Community is collaborating with various community organizations to offer educational programs and healthy living self-management services. With the support of the Suffolk County Lions Diabetes Education Foundation and Lions International, LI Community developed the Diabetes Wellness Center in 2006. The center offers Diabetes Self-Management Education services in partnership with the American Diabetes Association (ADA). Additionally, in partnership with The New York State Diabetes Prevention Program (NYS DPP), the Long Island Community Hospital Diabetes Wellness Center hosts free education programs provided by the Suffolk County Department of Health Services. Pre-diabetes is a serious health condition that can lead to diabetes, heart disease and stroke; most people with pre-diabetes do not know they have the condition.

What is the biggest challenge facing patients with diabetes and those at risk for developing diabetes?
Those who have diabetes and those who are at-risk for developing diabetes face many challenges. An important factor in determining a person's readiness and motivation to engage in diabetes self-care activities depends on their social situation. Potential barriers may include financial insecurity, lack of transportation, employment status, health insurance coverage, home environment and social support. An individual with diabetes facing one or more of these issues might feel like diabetes self-care management is an insurmountable goal. For example, one of our clients who was living in a shelter long-term only had access to a microwave for cooking. She consistently showed up to her scheduled appointments and was engaged and motivated to improve her health. Together we were able to develop a sensible diabetes self-care plan that took into consideration her environment and personal circumstances.

How do your education services reach and impact your community?
Our Diabetes Wellness Center provides diabetes wellness education services, such as one-on-one nutrition classes and ADA-accredited group diabetes education classes. We are currently implementing the Center for Disease Control's National Diabetes Prevention Program (NDPP) for individuals at-risk for developing type 2 diabetes. These services are promoted through various referral sources such as community physician practices, multiple MyHealth locations, Bellport Primary Care and during hospital discharge. Our Marketing Department also promotes the services at health fairs and local community events, as well as on our website, email blasts and social media postings. I coordinate with hospital care managers and registered dietitian nutritionists, Suffolk Care Collaborative care managers and physicians from MyHealth locations to tailor diabetes education services to meet the needs of their patients. Diabetes presentations are also offered in tandem with community partnerships such as the Boys & Girls Club of Bellport, senior citizen groups and the YMCA. Our goal is to be an effective resource for the community with diabetes by offering a variety of diabetes wellness education services.

Describe the benefits diabetes education provides to patients.
Proper diabetes wellness education provides patients with the skills they need to make informed daily decisions that help them live a healthier life. As they practice these new skills, they gain confidence that their disease can be successfully managed. They are also better prepared for the stresses that inevitably occur with the disease. Numerous epidemiology studies show the health benefits of diabetes education that considers the whole person - improved clinical outcomes, reduction in use of acute care services, better coping skills and enhanced quality of life.

How can providers send their patients to you for education services?
Individual nutrition classes, ADA-accredited group diabetes education classes and NDPP classes are held at several of our locations in Patchogue and Holbrook. You can find additional information on our Website. Patients can also contact us directly by email at diabetesservices@bmhmc.org or calling 631-687-4188.

Photograph of Lisa Romard Title: Nurse Practitioner
Name: Lisa Romard, CPNP, AE-C
Organization: Stony Brook Children's Hospital
Partner Interview: Asthma Education

Please describe your role in Asthma Education in your organization.
Since my earliest years of employment at Stony Brook (SB) as a Registered Nurse I was interested in working with children with asthma and respiratory diseases. I have worked at SB in the department of pediatrics since 1984, always including a focus with children's respiratory health. I worked in the SB pediatric ICU and was very much motivated to teach families of children with asthma about asthma and self-management to improve their quality of life. I started an asthma support group for parents of children with asthma and for the children to learn about asthma in the 1980s. I transferred to outpatient care and continued to work with this population through our division of pediatric allergy for a number of years, learning more about the effects of allergies and environmental exposure that can trigger asthma symptoms and affect a child's asthma control. After obtaining my advanced nursing graduate degree and NYS licensure as a pediatric nurse practitioner (NP) in 1999, I was hired as the NP for the Stony Brook Children's (SBC) pediatric pulmonary and allergy division. In 2010, I obtained the National Asthma Educator Certification Board (NAECB) national certification for asthma educators (AE-C) and have worked consistently as a pediatric NP and Asthma Educator throughout the years with asthma patients and their families at SBC Hospital.

What is a Certified Asthma Educator?
Certified asthma educators are those who have meet the requirements to sit for the national certification exam. They can be licensed healthcare professionals, or individuals who have provided direct asthma counseling/education/care coordination with a specified number of experiential hours in the field. These individuals have been specially trained and educated about all aspects of asthma, including asthma self-management strategies, addressing barriers and disparities that potentially add risk for a patient's asthma self-management, and strategies to communicate effectively with patients with asthma and their families. Asthma educators help patients learn the best ways to keep their asthma under control and focus on helping patients learn effective asthma self-management skills. After specialized training and passing the national comprehensive certification exam an asthma educator can then follow the guidelines of an AE-C provided by the NAECB for practicing in their area of expertise.

How do your education services reach the DSRIP population?
My role as the SBC's Pulmonary NP includes inpatient asthma consultation and education for children and families admitted with asthma who are identified as needing specialist care, care coordination, attention to high risk factors and a need for asthma education. I follow these patients both in the hospital, as well as in the outpatient office setting with the pulmonologists.

I provide asthma education sessions with patients and families at various points in their asthma care through SBC: inpatient, outpatient, telephonically and with the assistance of health programs in the community. In the hospital during the admission for asthma, families are encouraged to attend the asthma education class that is given daily by SB respiratory therapists. I offer and deliver asthma education depending on the needs of the patient and family after I assess their knowledge and needs. We have a one to one session, if needed an interpreter is present to assist to address language barriers. I adjust my education session for each to focus on the needs of each patient and delivery is based on what is felt to be best for their understanding of the material and information. I utilize asthma education materials that are approved by SB patient education committee and the Asthma Coalition of Long Island that are at appropriate health literacy levels and in different languages.

Describe the benefits asthma education provides to patients.
Asthma education has been shown to improve a person's ability for self-care and asthma management. The National Institute of Health (Guidelines for the Diagnosis and Management of Asthma - EPR-3) lists asthma education as a partnership in care as one of the 4 major components of the national guidelines. The benefits of asthma education includes the opportunity to provide a patient/family with information they may not have received, clarification of information provided at previous health encounters, or new information needed due to changes in their plan. The goals for asthma education are to increase a person/family member's knowledge about asthma & self-care management, improvement in medication adherence and symptom control, reduce risks for exacerbations and need for high level medical care, improve inhaler technique and proper use of medications prescribed, and ability to utilize a written action plan. In addition, asthma education aims to improve quality of life measures for those with asthma not well controlled, such as activity tolerance, sleep and the ability to participate in usual activities such as school and work.

How have you been involved in SCC'S Promoting Asthma Self-Management Program (PASP)?
I assist in the healthcare, care coordination and asthma education for DSRIP patients and families. I have participated in the development of the SBC asthma home visit program, the educational materials used, educating and certifying the community health workers for their ability to offer asthma education. This program offers a valuable in-home asthma assessment of needs and triggers, care coordination, education and identification of barriers that are addressed to ultimately improve asthma control and quality of life measures.

Photograph of Gwen O'Shea Name: Gwen O'Shea, President & CEO
Organization: Community Development Corporation of Long Island
Partner Interview: Addressing Community Needs

Please give us a summary of your organization.
Community Development Corporation of Long Island (CDCLI), a regional non-profit organization, was founded in 1969 by government, business, and civic leaders who came together to address the growing demand for affordable housing. CDCLI is a regional and national leader in community development, working to revitalize and build strong communities. We serve Nassau and Suffolk Counties and parts of Brooklyn, and provide a variety of programs and services that address the dynamic challenges faced by those who live and work on Long Island.

What is CDCLI doing to assist people in Suffolk County communities?
CDCLI has a variety of programs and services to assist people in Suffolk County communities. Through our Homeownership Center, we provide education, counseling, training, and coaching to help people achieve and sustain a healthy home, and to gain financial independence. Pre-purchase programs include homebuyer education and financial literacy. Post-purchase programs include foreclosure counseling, reverse mortgage counseling and home maintenance training. These services are available to all Suffolk County residents.

CDCLI administers over 6,000 Housing Choice Vouchers (Section 8 rental assistance subsidies) annually, almost all of which are located in Suffolk County. This enables approximately 14,000 very low-income, the elderly, disabled and veteran individuals and families to afford decent, safe and sanitary housing on the private market.

CDCLI administers the Weatherization Assistance Program on behalf of New York State Homes and Community Renewal, enabling Long Islanders to make their homes healthier, more energy efficient and structurally sound. CDCLI also provides construction oversight for accessibility improvements, home improvements and critical safety repairs.

Through real estate development, we increase affordable housing opportunities throughout Long Island that meet each community's needs, including single and multifamily homes for rent and sale. As an extension of our affordable housing activities, our resident services arm uses housing as a platform to help low-income, vulnerable populations build a stable life as they work toward self-defined goals on a journey to personal advancement and economic empowerment.

How does CDCLI work to address population health in Suffolk County?
CDCLI recognizes that affordable, safe, and stable housing positively impacts a person's overall health and well-being, enables families to afford other basic needs and supports economic vitality within the community. Our resident services initiative integrates health, human, housing and community development providers to holistically address resident needs by identifying service gaps and connecting them to appropriate supportive services.

CDCLI is working to expand services into the Wyandanch Village multifamily residential development; three residential developments for older adults in Patchogue, Deer Park and Port Jefferson; and the 43 scattered-site single family affordable rental homes in CDCLI's portfolio, targeting a total of over 1,000 households in Suffolk County. CDCLI's Resident Services staff deploys a multimodal research design to establish and analyze resident-level baseline data, develop a list of commonly identified needs, and determine interest in participating in a resident advisory group. The goal of guided focus groups and surveying is to assess what community residents need and want, and ideally bring some of those resources on site. Some of the gaps in services identified and interventions put in place may be health related.

Who does CDCLI partner with to address the needs of the community?
Specific to resident services, New York University is assisting in research design and the development of survey questions that will establish resident-level baseline data. CDCLI is also working toward a formalized arrangement with SUNY Stony Brook's School of Social Welfare. Student interns will assist with designing evidence-based interventions to address identified needs, and build upon the assets uncovered through the research component.

In general, CDCLI works with community advocates, other non-profits, elected officials at every level, financial institutions, businesses, government entities and community residents to fulfill its mission.

What are some of the challenges CDCLI faces? And how is CDCLI working to overcome these challenges?
One of the hallmarks of CDCLI's operations is our commitment to adapting our programs to the rapidly changing external environment by being nimble and maintaining a level of fluidity. Over the past several years, this has included expanding services in the face of the foreclosure crisis, Superstorm Sandy and most recently, in partnership with Suffolk County on its Septic Replacement Program.

In order to adapt our programs to long-standing and changing needs, we continually assess the impact of national and regional trends, Long Island specific challenges, and feedback and perspective from local stakeholders and clients through surveys, focus groups, CDCLI's Board of Directors and Council of Advisors, and other credible data sources. The trends in these areas and the interplay between them determine our approach to our work and our ability to address emerging needs as they are identified.

How do you see these initiatives impacting our communities, workforce and population you serve?
Though CDCLI was originally founded to address the severe lack of affordable housing on Long Island, we recognize that people need more than a home to build a stable life, and our programs and services have evolved accordingly. They are designed to help Long Islanders overcome situational and systemic barriers, promote stability, create pathways out of poverty and provide a voice to be engaged in their communities. These supports empower individuals to achieve personal advancement and economic empowerment. CDCLI has a long, successful history of meeting individuals and families where they are, empowering them to have a greater understanding of their situation and providing objective support and resources to assist them in achieving their dreams. These efforts impact our communities, our workforce and our overall economic stability.

Photograph of Allie Dubois Name: Allie Dubois, Executive VP/Chief Operating Officer
Organization: Hudson River HealthCare
Partner Interview: Strategies to Integrate Primary and Behavioral Health Care in Suffolk County

Image of Hudson River HealthCare Logo Please give us a summary of your organization.
Established in 1975, Hudson River HealthCare (HRHCare), a NYS licensed and federally qualified health center (FQHC), provides primary, preventive, behavioral and oral healthcare and enabling services, along with robust care coordination and management, especially for persons with chronic conditions, to 180,000 patients annually throughout the Hudson Valley and Long Island. Accredited by The Joint Commission since 1998, HRHCare is recognized by NCQA as a Level 3 PCMH and has Diabetes Recognition Program distinction for all of its eligible sites. The Health Center has been a trusted and reliable presence for decades in the communities targeted by the DSRIP 3ai project on behavioral health (BH) and primary care integration, and the populations being served are ones with which HRHCare has had considerable experience. HRHCare's health home, CommunityHealth Care Collaborative (CCC), is the largest in New York State, and its outreach office is embedded in HRHCare's Amityville health center.

How is HRHcare working to promote integrated care in Suffolk County?
HRHCare has developed a 3-pronged strategy to meet the needs of the populations with varying mental health needs in Suffolk County: (1) a Mobile Health Center to deliver services in the community; (2) primary care practices (PCP) embedded in Article 31 (behavioral health) locations; and (3) embedded behavioral health resources within HRHCare's primary care practices. HRHCare has used this multi-faceted approach, recognizing that people with behavioral health needs seek out services from a wide-range of providers whether primary care, specialty behavioral health, or other community-based organizations and it is important to meet those patients where it is most convenient for them.

HRHCare purchased a mobile medical van that became operational in March 2018. The van visits behavioral health locations, including Federation of Organizations, Family Service League, WellLife Network, Outreach Center, Skills Unlimited, and Association for Mental Health and Wellness, and provides screenings, referrals, and brief interventions. In the first month of service delivery alone, the program served 154 more individuals than anticipated (40 individuals anticipated, 194 served). We are well on your way to meeting our annual target of 600 individuals served!

HRHCare also brings experience from the Hudson Valley in implementing an embedded exam-room at sites in Suffolk County. Under this model, HRHCare will be operating Article 28 (primary care) compliant spaces within existing behavioral health partner sites; construction began in May 2018. In addition, HRHCare is collaborating with the Suffolk Care Collaborative to employ care managers at several sites in Suffolk to cover gaps in short-term transitions of care and facilitate warm transfers between individuals and health home care management services, if they are eligible.

Within primary care settings, HRHCare has been identifying and treating depression by both co-locating behavioral health resources onsite and implementing the Improving Mood-Promoting Access to Collaborative Treatment(IMPACT) model, a more intensive integrated model. We have seven co-located health centers where PCPs and BH providers have a system of bi-directional referrals with warm handoffs in place. We also have one IMPACT model site, where the depression care manager and consulting psychiatrist form part of the primary care team.

Why is integrated care important from a population health perspective?
Through our work with BH partners throughout the region, it has become clear that primary care providers may be missing patients with mental health issues who are unable to overcome barriers and walk into a health center for services. The target population is clients being served by HRHCare's mental health partners at service sites throughout Suffolk County, with a special focus on patients with serious and persistent mental illness (SPMI). Persons with SPMI are disproportionately impacted by poor outcomes, including premature death due to social, physical and behavioral health (BH) co-morbidities. Without integrated primary care, the physical health of those in BH settings are often not adequately addressed.

Additionally, in this targeted population, there is increased risk of diabetes and cardiovascular disease - risks that may be elevated by antipsychotic medications. Many of these clients are unaware of their chronic conditions, thus not receiving the care and disease management services needed to prevent complications that frequently lead to ED visits, inpatient admissions and mortality. We believe that linkage to a primary care medical home is key to addressing morbidity and mortality and achieving the triple aim for patients.

What types of challenges face primary care and behavioral health providers in integrating care?
Culture, recruitment and workflows are the biggest challenges facing primary care and behavioral health care partners as they move to integration. Educating both patients and staff about the impact of behavioral health care needs on health outcomes is a key component of the work. We believe it is critical that all members of the team are engaged in this work and supporting the referrals, warm handoffs and care plans of patients. Recruitment of knowledgeable, culturally competent and forward thinking behavior health and primary care clinicians is a key opportunity moving forward. Rethinking the settings and models for engagement requires teams that are aware of the behavioral changes and the new, evidence-based strategies for caring for individuals and a willingness to meet people where they are. And, with any new initiative and new approach, developing workflows and building a culture of reliability to adhere to those workflows, especially across organizations, is key.

How is HRHCare working to overcome these challenges?
HRHCare is utilizing Suffolk DSRIP funding to lift and support the operations of these three strategies, but we believe that meeting the members of our community where they are to access care in the setting most convenient to them is the first step. From there, refining bi-directional referral pathways and integrated care team workflows over time will produce the health and financial outcomes needed to sustain this work in a value-based world.

Where do you envision HRHCare's work, in integrating care, heading over the next few years?
We are focused on leading the healthcare delivery system toward population health management with a focus on continuity of care for individuals in the communities we serve. Strategies we plan to deploy include managing transitions of care by continuing to implement care coordination for high need populations; facilitating communication between HRHCare and hospitals, BH providers and community-based partners; facilitating follow-up for discharged patients, and reducing preventable emergency and hospital utilization and readmission through collaboration with the network of providers and services surrounding the individuals in our communities.

Photograph of Network IPA Team Name: Clinical Integration Network IPA Team
Organization: Northwell Health
Partner Interview: Hands-on Approach is Key to Successful Practice Transformation

Please tell us about your organization.
As New York State's largest health care provider and private employer, Northwell Health strives to improve the health of our communities. The Clinical Integration Network IPA (CIIPA), a division of Northwell Health, includes more than 7,500 community-based and employed physicians working together to deliver high quality, coordinated care for patients and their families. With healthcare's move toward value-based payment (VBP), CIIPA serves as a foundational element for new care delivery models and population health initiatives, including the Delivery System Reform Incentive Payment (DSRIP) program.

Who does your organization serve in Suffolk County?
CIIIPA serves thousands of patients across Suffolk County. Our team has partnered with community providers to help them successfully implement the DSRIP projects and create an integrated delivery system that meets the medical, behavioral and non-medical needs of patients. We support these providers so they can focus on providing high-quality, patient-centered care to vulnerable populations.

What DSRIP project(s) are you involved in?
Our team works on every DSRIP project that involves primary care, including Projects 2.a.i., Integrated Delivery System; 3.a.i., Primary & Behavioral Health Integration; 3.b.i., Cardiovascular Health; 3.c.i., Diabetes Care; 3.d.ii, Asthma Self-Management. We spend a lot of our time focused on practice transformation - both the Patient-Centered Medical Home and Advanced Primary Care models - as well as the integration of behavioral health, the adoption of evidence-based disease management protocols and connectivity to a Regional Health Information Organization (RHIO).

What is your strategy and approach to practice transformation?
Our hands-on approach to practice transformation is key to the team's strategy and success.

At the start of the program, we received feedback from our community partners that they do not have sufficient time to implement quality improvement programs. We had contracted with consultants to provide support, but many providers reported that remote support offered by consultants and technical assistance (TA) vendors wasn't adequate for small practices with limited resources.

In response, our team increased our individual engagement and communication with the practices. Many said that our physical presence made all the difference, we became an additional and valued resource for many of our partner practices.

How do you see DSRIP making an impact on the communities and populations you serve?
Through practice transformation efforts, our community partners have already made an impact on patient care. The practices have increased patient access by offering same-day appointments, extended office hours and 24/7 clinical advice. Further, we have seen tremendous progress toward patient-centered care through increased self-management support as well as information tracking and exchange among providers and facilities.

Going forward, we plan to continue to support the efforts made by our DSRIP partners to further address the behavioral health needs of their patients. Additionally, we intend to foster greater linkages and cooperation between primary care providers and community-based organizations.

We are lucky to work with dedicated, caring providers and office managers who want to continue to improve performance and provide patients a positive experience. Practice transformation is just the start of many ways we can work together for the remainder of the DSRIP program and ensure the progress continues beyond the program end date.

Photograph of PJ Tedeschi Title: Director
Organization: Tobacco Action Coalition of Long Island
Partner Interview: Partnering for a Healthier Long Island

Who does your organization serve?
The Tobacco Action Coalition of Long Island (TAC) is one of 25 Advancing Tobacco Free Communities grants funded by the NYS Department of Health's Bureau of Tobacco Control. The American Lung Association administers the grant. TAC is comprised of a community engagement component and a youth action component called Reality Check. TAC serves all of Long Island. Our work focuses on establishing tobacco-free policies to make Long Island a healthier place to live

Why did you choose to participate as a partner of the SCC?
TAC partnered with the SCC because we were working towards similar goals that support New York's Prevention Agenda. Through our policy work, TAC aims to reduce illness, disability and death related to tobacco use and secondhand smoke exposure and to alleviate the social and economic burdens caused by tobacco use.

On which DSRIP project(s) are you working?
TAC works on DSRIP project 4aii - Prevent Substance Abuse and other Mental Emotional Behavioral Disorders, which focuses on reducing the use of substances, such as alcohol, drugs and tobacco across the population in Suffolk County.

How do you see this project making an impact on our communities, workforce and population we serve?
Our collaboration with the SCC establishes a framework in which behavioral health sites can implement a comprehensive tobacco-free policy that includes tobacco cessation services and staff education. The ability to combine our resources allows us to offer additional assistance to organizations with the goal of promoting lasting change and reaching vulnerable populations

What do you hope the DSRIP program will accomplish in general?
Our goal is to make Long Island a healthier place to live, work and play. Having more tobacco-free places in Suffolk County will support those who have quit, encourage people to consider quitting and prevent our youth from becoming the next generation of smokers.

Photograph of Judith Montauban Title: Reality Check Manager
Organization: Tobacco Action Coalition of LI (American Lung Association)
Partner Interview: Tobacco Initiative Targeting Youth Community

Please give us a summary of your organization.
Reality Check LI  (RCLI) is the youth component of the Tobacco Action Coalition of LI (TAC). TAC is one of 25 Advancing Tobacco-Free Communities, grant funded by the NYS DOH's Bureau of Tobacco Control. The American Lung Association administers the grant that funds RCLI.

Reality Check is a statewide youth-led initiative that focuses on educating and empowering youth to address the tobacco industry and their deceptive marketing practices. Reality Check LI provides opportunities for youth to gain skills in leadership, team building, media training and public speaking.

Who does your organization serve?
Reality Check LI serves youth in Suffolk and Nassau counties. This year RCLI has been working with youth in Hempstead and Brentwood. Currently there is an active group at the North Middle School in Brentwood.

Why did you choose to participate as a partner of the SCC?
Reality Check LI partnered with the SCC because we have identified a shared goal to improve community health and to reduce health disparities. By raising awareness about the impact tobacco marketing practices have on communities, RCLI hopes to encourage youth to remain tobacco-free and realize that their voice matters.

On which DSRIP project(s) are you working?
Reality Check LI is not directly working on DSRIP projects. However, RC LI is a member of the Tobacco Cessation Coalition and works closely with the SCC's Community Engagement team.

How do you see this project making an impact on our communities and population we serve?
Our collaboration will demonstrate the importance of including the youth voice in conversations about improving community health. Reality Check LI believes the youth perspective and voice is important in creating sustainable change in our communities.

What do you hope the DSRIP program will accomplish in general?
Our hope is that together we can continue to work towards the goal of reducing youth initiation to tobacco use. Doing so will improve the overall health of the community. RCLI also hopes to raise awareness about tobacco industry marketing practices in various communities.

Photograph of Laura Lynch Title: Practice Administrator
Organization: Southampton Pediatric Associates
Partner Interview: Practice Transformation Experience

Please give us a summary of your organization.
Southampton Pediatric Associates is a practice of Stony Brook Children's Services, caring for the children on the South Fork of Long Island for over 35 years. We provide quality care from two locations, Southampton and Hampton Bays. Our patient population is estimated at 20,500 visits per year; 50% of those visits are patients on Medicaid and/or Child Health Plus (CHP).

Transformational Change: Explain the Patient Centered Medical Home (PCMH) journey to recognition and the benefits and challenges you and the practice team faced, up to your submission to National Committee for Quality Assurance (NCQA) for recognition.
The process to become PCMH recognized started with a recommendation by another practitioner in the area who already achieved PCMH Level 3 recognition. When it was decided that the practice would move forward on becoming a patient centered medical home, as the practice administrator, I knew we had a long journey with a lot of work ahead. We experienced some challenges, the first was moving from paper charts to electronic medical records (EMR).

One of the biggest challenges was resistance to change. After explaining to the staff the need for the practice to transform, we discussed the necessary changes that would need to take place to enhance workflow, and most importantly, provide our patients with a better experience and better quality, everyone involved became engaged in making the necessary changes.

In an effort to assist in the transformation, I reviewed our workflows and opportunities to further develop skills within our existing staff and identified an administrative coordinator, to assist with referrals and demographic maintenance, and a clinical care coordinator, to assist with diagnostic test maintenance and clinical integration of new policies and procedures. For about a year we worked as a team and set up the framework to meet the standards and guidelines for PCMH transformation. I created templates to track and identify our high risk patients in need of additional health services, enhanced their care plans and provided extra care management services.

A benefit of this journey was the support of the Suffolk Care Collaborative. They provided us with technical assistance from a consultant, Hospital Association of New York State (HANYS), that specializes in practice transformation and getting primary care practices recognized. Having the guidance of the consultants kept me focused and helped me to overcome some of the barriers the practice faced.

Another benefit that helped in this transformation was my attendance at a 3 day NCQA PCMH 2017 Conference, which was encouraged and supported by Stony Brook Administrative Services and SCC. Through the consultant support and education I received, I feel confident that our application submitted on December 8, 2017, will result in PCMH 2014 recognition.

Can you explain what a PCMH-Certified Content Expert (CCE) is? As the Practice Administrator, and now a PCMH-CCE, how do you feel your accomplishment will impact the transformation of the practice moving forward?
A PCMH-CCE is someone who is certified by NCQA through an exam process and understands the content of the model and has experience in transforming a practice in attaining PCMH recognition.

My accomplishment of becoming PCMH-CCE was a personal goal of mine. I had become very knowledgeable in the transformation under the PCMH 2014 standards and guidelines and after attending the NCQA PCMH 2017 Conference I felt I had gained the expertise needed to take the exam. This certification allows me to continue improving patient experience and outcomes in the practice.

Passing the exam and being certified will greatly assist the practice's commitment to quality. Being recognized is an on-going commitment which requires regular reporting and oversight from NCQA to ensure we are meeting and sustaining all requirements for PCMH 2017 standards. As an expert, I will be able to oversee and lead the process.


Image of Laura Giardino Title: Director, "Learn to be... Tobacco Free" Adult Cessation Program
Organization: Suffolk County Department of Health, Office of Health Education
Partner Interview

Please give a summary of your organization:
The "Learn To be...Tobacco Free" (LTBTF) cessation program is offered by the Suffolk County Department of Health Services, Office of Health Education, to provide educational and behavioral support for people who are considering a quit attempt. Although the prevalence of tobacco use has declined over the last 20 years, tobacco use continues to be the number one preventable cause of disease and death in the U.S. The free six week classes are conducted by Public Health Educators. Since medication and counseling increase the rate of successful quitting, all patients making a quit attempt are encouraged to use one or more of the 7 FDA approved pharmacotherapies. Since the inception of the program in June of 2000, there have been over 800 programs throughout the county with over 17,000 participants attending classes.

Who does your program serve?
The classes, which are conducted by public health educators, are open to all Suffolk county residents. There are locations throughout the county. Suffolk County Department of Health primarily serves underserved populations. Programs are conducted in or near the communities of need, as well as in libraries and hospitals. Tobacco use is higher in people with mental illness and substance use disorders.

In addition to cessation services, the staff of the "Learn To be...Tobacco Free" program provides education and support to many health professionals working with the target populations to increase knowledge and skills in providing tobacco dependence treatment to their clients.

Why did your organization choose to partner of the SCC?
The goals of the "Learn To be...Tobacco Free" program align with the goals of the SCC. Tobacco use is a major challenge to the health of individuals and society. It is a major contributor to chronic disease in the user and those around them. Every year more than 25,500 New Yorkers die prematurely as a result of tobacco use. More than twice that number live with tobacco-caused diseases and disabilities. In addition, there are about 3,000 premature deaths from diseases such as heart disease, lung cancer and stroke due to exposure to secondhand smoke.

Cessation of tobacco products improves the health of the individual and community. By improving the wellness of individuals, there will be a definite decrease in visits to emergency rooms and hospital admissions.

By working with the SCC, opportunities to collaborate with health partners serving our target populations are provided. The Collaborative provides educational forums for professionals to network, increase knowledge of services available to individuals and professionals, as well as educational information to enhance the services that partners provide.

Which DSRIP projects do you participate in?
I currently attend the SCC's Access to Chronic Disease Prevention Committee meetings which focuses on chronic disease prevention (Project 4bii). Lung cancer prevention is a major initiative of this committee. Tobacco use is the leading cause of lung cancer; therefore, working with the professionals on this initiative is key to decreasing lung cancer in the future.

I am more directly involved in the Tobacco Cessation Coalition meetings. Joining with the other partners in this group provides an opportunity for collaboration and looking at the "big picture." By working with medical practices and systems to implement system changes, referring patients to the NYS Quitline, fostering tobacco free campus initiatives and offering cessation services, tobacco use will continue to decrease in Suffolk County.

How do you see this project making an impact on the communities and population we serve?
By collaborating with a variety of partners in this project, there is the ability to address tobacco use from many different perspectives. By using a comprehensive approach to tobacco dependence, continued progress in decreasing tobacco use will be made. By working with youth and decreasing initiation of tobacco products, working with health care systems to improve the delivery of tobacco dependence treatment and referring people to appropriate health care services to support quit attempts are all part of the equation. Together, these efforts will lead to improved health for the residents of Suffolk County.

What do you hope the DSRIP program will accomplish in general?
I hope the DSRIP program will be able to continue the work that has been started. By addressing behaviors that lead to chronic disease such as smoking, substance use, obesity and inactivity, the notion of prevention of chronic disease is truly the key to increasing the health of our society.

Image of Anne Little Title: Director, Asthma Coalition of Long Island
Organization: American Lung Association, Northeast Region
Partner Interview

Please give a summary of your organization:
The Asthma Coalition of Long Island (ACLI) is funded by a grant from the New York State Department of Health to the American Lung Association to reduce the burden of asthma in Suffolk and Nassau Counties. There are approximately 300,000 people in our geographic area that suffer from this chronic disease. ACLI has been funded since 2000 and our mission is to link our community together to improve asthma care for children and families. We have grown to over 175 volunteers from the healthcare and schools' communities, many of whom serve on committees to support quality improvement projects implemented by ACLI. Our volunteers deliver professional trainings, review materials and publications for medical accuracy and health literacy, network to improve bi-directional referrals and brainstorm for solutions to barriers for guidelines-based care.

One of the signature quality improvement projects of the ACLI and the Asthma Coalition of Queens for Nassau, Suffolk and Queens Counties is the BREATHE (Bringing Resources for Effective Asthma Treatment through Health Education) program. The goal of BREATHE is to implement a systems and culture change to embed evidence-based guidelines using a multi-disciplinary approach to reduce hospital readmits and emergency department visits for pediatric asthma patients. It includes education of all clinical staff and self-management education for patients with uncontrolled asthma. To date, over 2,500 children have been enrolled in BREATHE projects.

Who does your organization serve?
While ACLI does not provide direct services for patients with asthma, we focus on providing asthma education, educational materials and some resources for primary care, hospitals, schools and community-based organizations across Nassau and Suffolk Counties who serve patients with asthma.

Why did you choose to participate as a partner of the SCC?
ACLI and the American Lung Association chose to participate as a partner of the SCC because our goals align: reducing avoidable hospitalizations and emergency department visits. Many of our community partners participate as SCC partners as well, joining together to work toward the Triple Aim: improving the patient experience of care, improving the health of populations and reducing the per capita cost of health care.

On which DSRIP project(s) are you working?
The Asthma Coalition works on DSRIP's 3.d.ii Expansion of Asthma Home-Based Self-Management Program, providing trainings for home care nurses and community health workers on asthma basics and home environmental trigger reduction, self-monitoring, medication use and recommending medical follow-up to reduce avoidable emergency department and hospital care. In addition, ACLI has provided low-literacy, bi-lingual educational materials and some resources to support the work of the three hubs, Stony Brook Children's Hospital's Keeping Families Healthy; Catholic Home Care, Catholic Health Services and Northwell Health Home Care Program.

How do you see this project making an impact on our communities, workforce and population we serve?
The work of DSRIP's 3.d.ii project aligns with home asthma management projects that have been a large part of the Asthma Coalition of Long Island's quality improvement work for the past five years and have the potential to make a strong impact on our communities, workforce and children with asthma. Home visit programs are also proven to be effective to improve overall quality of life and productivity, by reducing asthma symptoms and the number of school days missed due to asthma. A home visit provides an ideal setting to educate, review medication plans and help families identify environmental triggers in their homes that may contribute to the severity of this chronic condition.

What do you hope the DSRIP program will accomplish for your organization in the future?
It is our hope that the DSRIP program partners will collaborate with the Asthma Coalition of Long Island and avail themselves of all of the rich educational resources that ACLI staff and volunteers have developed. Our asthma education tools have been provided to organizations across New York State by the New York State Department of Health because of their low literacy, culturally sensitive content.

Image of Marton Dioszegi Title: Outreach Specialist
Organization: Health and Welfare Council of Long Island
Partner Interview: Making Important Connections and Referrals Through Partnerships

Please give a summary of your organization:
The Health and Welfare Council of Long Island (HWCLI), established in 1947, serves the interests of at-risk and vulnerable families and children on Long Island through advocacy, direct services, research, policy analysis and as an umbrella agency for health and human services agencies.

Who does your organization serve?
HWCLI serves at-risk and vulnerable families and children on Long Island. Our Targeted SNAP (Supplemental Nutrition Assistance Program) program focuses on seniors, working families, veterans and immigrants in both Nassau and Suffolk counties.

Why did you choose to participate as a partner of the SCC?
As part of a Targeted SNAP Program, we connect with pediatricians and other health care providers to assist their patients in accessing SNAP benefits and other food assistance programs. Because SCC's care managers have the opportunity to identify patients struggling with food insecurity, we met with the Care Management staff to create a streamlined referral system to ensure patients get connected to these benefits. Once referred, trained HWCLI staff assists clients with the SNAP application process and accessing other food assistance programs.

What do you hope the DSRIP program will accomplish in general?
Apart from significantly reducing avoidable hospital use in New York State, with the possibility to integrate health care with health and human services work, we hope to leverage important connections with social determinants of health. A renewed holistic approach towards patients and the care they receive can lead to better nutrition outcomes as well as better health outcomes, overall.

What has your organization done to make transformational changes?
As New York State and the health care field have recognized the importance of looking at patients in a holistic way, we aim to integrate our services to support this new approach. We found that having a connection to clients through pediatricians has been the most effective way to identify and make referrals. We have food insecurity screenings in pediatric clinics that are combined with referrals to HWCLI for assistance with SNAP. Integrating health care with human services is an important element of creating patient-centered quality health care. By screening for food insecurity in the health care setting, we not only make an important connection between a need and a service, but we can also bring to light the very important relationship between nutrition and overall health. Children who are enrolled in SNAP have better results in school and better long term health outcomes, which is why creating these connections and referrals is so vital.

What in your experience are some guiding principles of a successful population health management program?
In our field we view gratitude as our top guiding principle. Many of our clients are going through difficult situations on many different levels. When we are connected with a client, we are grateful for the trust in our services and the opportunity to provide those client-centered services. The basis of a referral system is to transfer the established trust between patient and provider. We believe that the best way to maintain and build trust with clients is through a welcoming environment every step of the way. I would also mention cultural competence as a guiding principle. It is very important to not only be aware of the different backgrounds of our clients, but to celebrate the diversity of our clients as well. Language access is a huge part of this, along with an understanding of regional differences within the population.

What value does the Suffolk Care Collaborative bring to patients under the DSRIP program?
From my experience with SCC's Care Management team and the clients that have been referred to us, I feel that the Suffolk Care Collaborative demonstrates a great commitment to the well-being of patients. While the program that I focus on is SNAP, I am always happy to connect clients with other services that they need. Many times the care managers reach out to me personally regarding a client that they would like to connect with another HWCLI service, which shows their commitment and passion in ensuring quality care for everyone. I believe that is the best approach and I am happy to have the opportunity to partner with SCC's team.

Photograph of Vivek Taparia Title: Deputy Executive Director, DSRIP
Organization: Catholic Health Services of Long Island
Partner Interview

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.

Photograph of Kate Lorig Title: Partner
Organization: Self-Management Resource Center
Partner Interview with Research and Development Expert for Self-Management Programs

Please tell us about your organization and why you developed the Chronic Disease Self-Management (CDSM) course.
The CDSM course was originally developed at Stanford University as a sequel to an arthritis self-management program I worked on. Some arthritis participants told us, "This is a great course, but you are telling me one thing and my cardiologist is telling me something else, and I also have pulmonary disease and diabetes..." Most people don't have just one disease, they have two or three or more, so we decided to see if there were any domains that really crossed chronic diseases. We did an extensive literature review and talked to lots of patients and doctors, and discovered that about 80-85% of the material covered in all of the patient education programs was pretty much the same. Out of that we developed the CDSM course to help people live with multiple chronic conditions. We have now moved the program outside of Stanford University to the Self-Management Resource Center (SMRC), an independent organization, in order to disseminate it even more broadly.

People like to learn in different ways, so we offer the course in 3 different modes: The original program was developed and still is very widely given face-to-face to small groups of 10-12 people. The programs are taught by patient leaders who have been trained in a very structured way. Anybody interested can go to a website called Evidence Based Leadership Council, where they'll find an app that lets them put in their zip and locate a program nearby. The program is also made available online under the name Better Choices, Better Health® by Canary Health to members of organizations that have purchased it for their patients. A print version, the Self-Management Tool Kit, is available through the mail from Bull Publishing.

In addition to the CDSM course, we offer diabetes and pain self-management programs, and one for cancer survivors. We will also be releasing a caregiver self-management program.

How does the CCDSM course align with the NYS DOH DSRIP goals of reducing hospital admissions and readmissions?
We know that we are reducing hospital days and Emergency Department visits. Those are the cost data that we have. We've never looked at readmissions. My guess is that we are cutting readmissions, but we don't have the data.

Theoretically, the more help people have to manage their conditions on a day to day basis, the less they should have to depend on very expensive interventions such as hospitalization and Emergency Department visits.

We know that we are increasing adherence to medications and decreasing depression, which drives a whole lot of things including hospitalizations and nonadherence, so in these ways we may be reducing costs. We also know that we are giving people more confidence in their abilities to manage their conditions and that may help, too.

How does the CDSM course support population health transformation?
We support population health in a number of ways. First, the programs are generally given in the communities where people live and work. So, those who are often underserved or won't go to a hospital or clinic to take a course, can do it in their own community, on their own time, in a comfortable setting. This means that we can get to many more people than traditional patient education programs. Also, because they are very standardized and peer-led, we can do thousands of programs nationwide. We serve about 100,000 people a year.

Furthermore, when you educate part of the community, they in turn pass on some of that knowledge to others in the community. Our 8-10 thousand trained patient leaders also pass on their knowledge to family and friends. There's a networking effect which we've never measured, but I imagine it's quite large. By offering the programs in many different languages and communities, we are reaching other traditionally underserved groups.

Finally, we know that people with chronic mental health problems have many other chronic diseases, and these people are also very seldom reached by traditional programs. When we educate about chronic disease, we don't care whether it's a mental or physical condition, so that also helps destigmatize mental health conditions.

What is the biggest challenge facing people in the current health care system and how can CDSM courses help?
I think it's fragmented care, people with 6 different conditions going to 6 different doctors, none of whom puts together the whole person. The course helps the individual tackle this very fragmented knowledge and put it together and apply it to themselves. It also helps them work with the health system and their healthcare providers. We do a lot of work around problem solving and decision making and how to deal with this fragmented system.

What is the future of the Self-Management Resource Center?
We see ourselves continuing the work that we've done in the past--continuing to work nationwide. Traditionally these programs have been given by lots of small community organizations and we're beginning to see a coalition occurring in many states, including New York, whereby there's a supporting organization for these many small ones so they can be more efficient when it comes to training, monitoring fidelity and offering the programs in a systematic way to health care systems. Traditionally the programs have been given largely outside of healthcare systems, and I think we're seeing a movement towards this coalition of community-based organizations and health care systems working together. And I think that's really healthy. So, I see the programs probably becoming more available to more people in the future.

We're here to help folks in any way we can and we welcome inquiries. For more information, visit SMRC's Website or Email: smrc@selfmanagementresource.com or kate@selfmanagementresource.com.

Photograph of George Dempsey Title: Medical Director
Organization: East Hampton Family Medicine
Partner Interview From a Community-Based Primary Care Practice Perspective

Please give us a summary of your organization and the population you serve.
We are a community-based practice in Family Medicine that I started here in East Hampton in 2002. We serve a very diverse patient population, ranging from the undocumented and uninsured to people from New York City who come out for weekends. The East Hampton Healthcare Foundation was able to support the practice to provide services to the population without insurance. They are a local group supported by people who saw a need for improved access to healthcare out here. They built the East Hampton Healthcare Center and collaborated with Southampton Hospital to provide X-ray and laboratory services in the same building. I was asked to develop the primary care for their project. We devised a voucher system for patients without insurance, based on a flat fee. That was for an office visit, and it really brought people into the practice. Then we had to figure out how to get the labs and medicines, etc., for them. It worked out fantastic for these patients. Over time, many became documented and qualified for Medicaid, and from that I developed a large Medicaid population as well. And then along came the DSRIP program and it just kind of focused on this population and my ability to do more for them.

Why did you choose to participate as a partner with Suffolk Care Collaborative?
One of the main reasons was the hope for survival as a practice. Any small, private primary care practice is extremely challenged. Unique to my situation is that the cost of living here is so high, I have to pay employees more. But reimbursements are the same anywhere on Long Island. So, I teach residents and do research on Lyme disease in order to make ends meet as a practice.

SCC has been very helpful. Their consultants provide assistance in achieving Patient Centered Medical Home (PCMH) accreditation. It involves a huge amount of work and an expense that I don't think we would have ever taken on ourselves. We wouldn't have been able to afford it.

What do you hope the DSRIP program will accomplish for your organization in the future?
I got involved with DSRIP because the current fee-for-service model for community-based practice is not sustainable. It's helped me meet certain credentialing requirements for PCMH, which qualifies for better reimbursement through the quality incentives. We just attained PCMH accreditation and that means next quarter we will receive a patient-per-month incentive payment, in addition to the fee-for-service, for delivering on the PCMH model.

Specifically, how has your organization begun to experience this transformation of health care delivery and what are your successes?
The experience is transforming our documentation process and the work we put into documentation to meet the qualifications of the PCMH. But meeting quality measures doesn't necessarily translate into patient benefits.

These quality measures are administrative measures. They aren't about medicine, but patient compliance goals. It's really about doing what the patient does not do--making their appointment for a mammogram, getting their pap smear done, getting their sugars under better control. In the past, the patients were wholly responsible for these things. But now we're doing more work to help patients reach their goals and navigate a complex system.

This all sounds good, but we don't yet have data to show that it's making a difference to the overall population's health. We do have evidence of a decrease of close to 15% in hospital admissions in some areas, which saves the system money, and we are picking up more abnormalities due to more aggressive screening for early detection of certain cancers and chronic diseases, but it will take time to know the effect on our patient population.

How do you envision your organization adapting/evolving to meet the needs of this health care delivery model transformation?
This has always been the goal of primary medicine but it's been under-funded and under-supported. Primary Care doctors have always believed that we could do more if we had more support, because we know the patient, their social situation, what their needs are, and how that varies the care. But we can't do everything, so we need more people in the background getting things done. That allows us to focus on seeing patients, not doing reports and applications for services at the same time. Because that is very distracting.

Traditionally, a Medical Assistant just took patient vitals, but now they do a lot of the prep work -- patient histories, language needs, etc. -- before we come into the room, so they have to be a lot more sophisticated. And we need someone who focuses on the electronic medical records (EMR) and help to manage them. Not just an Office Manager who's already wearing 10 hats and running around like crazy.

We need people with clear job titles and clear responsibilities, and they have to perform in a way that minimizes the impact on what goes on in the room with the patient. Because that's the quality that you have to really preserve.

What value does the Suffolk Care Collaborative bring to patients under the DSRIP program and how do you see this project making an impact?
DSRIP helped me stay in the game, for me, my practice and my patients. It allows me to continue to do some of the things I've done that were relatively innovative a few years ago, but are now almost a mandate, like the integration of mental health and primary care. That is something I started years ago by having a social worker come into the practice, so I'm able to give the classic "warm handoff" of my patients to see someone right away for mental health counseling. I'm now hoping that DSRIP will help me get psychiatric support. This is the biggest need the U.S. has and it will have the biggest impact on the health of the country, because mental health affects everything.

Photograph of Cierra Corbett Title: Prevention Specialist
Organization: Family Service League
Partnering to Prevent Underage Drinking:  A Collaborative Partner Interview

Please describe your role with the Family Service League and the SCC's Underage Drinking Prevention Program.
The Family Service League is a 90-year-old organization with over 60 programs, including substance abuse treatment, primary substance abuse prevention services and the Long Island Prevention Resource Center. As the prevention specialist, I am able to bring these resources to enhance the SCC's Underage Drinking Prevention Program. Together we have been able to provide training for the Compass Unity through Strength and Diversity Coalition on topics that include capacity building, how coalitions work and all aspects of the Strategic Prevention Framework, in order to strengthen the efforts of the Coalition within the South Country School District community.

How has your partnership with the Compass Unity Community Coalition enhanced your work?
The Compass Coalition, headed by Lynette Murphy, a social worker and coordinator at Bellport High School, has been around since 2009. It's a coalition with representatives from 12 sectors of the community. What we do is implement environmental strategies throughout the community and in the schools in order to reduce underage drinking. I provide training and technical assistance to the Coalition.

I am able to bring my knowledge, skills and passion for underage drinking prevention to the Coalition. And through my work with the Coalition I have been able to see the Strategic Prevention Framework in action as community representatives of all types work together to stop underage drinking. I've been able to co-coordinate mapping and mining activities that tell us specific areas of concern within the community. Members of the sectors of the community weighed in on what they know to be geographic areas of concern, and using this data we're able to develop action plans to address these areas of concern.

First, we look at what we can do and what is out of our hands. Once we come up with the things that we're able to handle, we prioritize them. For example, there's a park where, during the summer, there's not enough police activity, so there's a lot of underage drinking and drug use going on. We contacted the police department and they came out to one of our meetings and agreed to beef up security. So, we're able to connect with different entities within our community in order to address these areas of concern.

What are you hoping to achieve through this work?
Through our work with Compass Unity Coalition, we're looking to achieve a reduction of underage drinking through increased knowledge of the Social Host Law (whereby adults over 18 hosting a party where there is underage drinking are held legally responsible) and increased participation of parents and community members toward these efforts. We also hope to decrease areas where illegal drugs are sold, which will free up more spaces where children can play in a safe environment. Our goal is to eliminate illegal drug and alcohol use in our community.

What is the importance of involving community members in your work?
Community members are one of the most important aspects in the work that we do. They need to be involved in the prevention efforts in order for them to be effective. If community members actually own the process, if they are a part of the process, they are most likely to be motivated to follow through with the commitments of the process. Also, community members have numerous resources, skills and strengths. And by putting all of these things together we are able to have a much stronger response.

We are always looking to increase the capacity of the coalition. Whenever we have an activity we look for people in the community who would like to get involved. It could be parents of children in the community or other adults. No participation is too small. Even if it's just forwarding a flyer through email or handing out flyers, that's helpful.

What are some of the upcoming activities?
We're looking forward to doing a few campaigns. One is the Sticker Shock campaign, an environmental strategy designed to prevent people 21 and over from purchasing alcohol and providing it to underage individuals. Working with local liquor retailers, we're going to put positive messages on stickers, and then put these stickers on alcohol-containing bottles in alcohol retailers throughout the community. For instance, a sticker on a bottle of wine might say, "This bottle of wine will not end up in the hands of an underage individual." It could be something as simple as that, to create awareness in the community that alcohol should not be given to underage individuals.

Another campaign we're looking to do is the NOYL Campaign, which stands for Not On Your Life. The goal of this campaign is to work in partnership with local businesses to ensure that they commit to not selling alcohol to anyone under 21 years of age. One of the things we have to do with the NOYL campaign is to connect with the Chamber of Commerce and the local police and let them know that we're going to be doing this. Then we'll reach out to alcohol retailers in our community and create a contract between these retailers and the coalition wherein they pledge not to sell alcohol to anyone under 21 years of age.

A third activity is Operation Pizza Box, which is similar to the Sticker Shock campaign. It's an initiative where we place positive norm messages on pizza boxes in pizzerias throughout the South Country community. The message could be something like "I want to remain drug free." It's a sticker or a flyer we tape to the pizza boxes, and every pizza that goes out in our community will have that message on it.

Photograph of Benson Yeh Title: Chair, Emergency Department
Organization: Southside Hospital, Northwell Health

Please give us a summary of your organization.
Southside Hospital is a member of the Northwell Health System. It is a tertiary care referral hospital, receiving patients from a variety of specialties. Our services include a trauma center, stroke center, STEMI center, open-heart services, comprehensive cardiovascular services, orthopedics, neurosurgery, OB GYN, pediatrics, and a myriad of other medical subspecialties. The hospital is located in Bayshore, NY, and is quickly expanding its operations, both on and off-campus with development of outpatient centers, such as the recently opened Imbert Cancer Center. The emergency department has about 72,000 patients per year. We have received numerous awards including Stroke Gold Plus, Target: Stroke Elite Plus Honor Roll Award from the American Heart Association for our stroke care. Our STEMI center has among the best door-to-balloon times for emergency angioplasty in the Northwell system.

You worked with Affinity to develop a skilled nursing facility to hospital transfer form. What led up to this?
When the emergency department (ED) expanded back in September of 2016, one of the main challenges that we experienced was communication between providers within the department, as well as from external providers. At roughly the same time, we had been contacted by the folks at Affinity Skilled Living & Rehabilitation Center and realized that we had an opportunity to develop a close partnership with our external stakeholders, such as these skilled nursing facilities (SNFs).

We developed a process that facilitated a direct conversation between the ED provider and the SNF Medical Director. This included development of a specialized form to accompany the patient from the SNF. In the past, there was never really an overt request from the SNFs to have patients returned back to their facilities for things that they could treat. In addition, skilled nursing facilities did not want to have sick patients return; however, these days many SNFs increased their medical capabilities and are capable of caring for patients with illnesses that once would have meant admission to the hospital.

Our specialized form bridges significant communication gaps, creating a patient safe and HIPPA compliant warm hand-off from the ED physician back to the SNF physician. The form is a vehicle for the communication that needs to occur between the SNFs and the ED, so that care is coordinated. Our transfer back to the SNF is the equivalent of us providing a direct warm hand-off to an admitting physician in the hospital. For physicians, the ability to provide a warm hand-off of patient responsibility between providers provides the ED with options to prudent practice of medicine. In the past, it was very difficult to make that communication with SNFs.

We have learned through this program that many of the illnesses we diagnose in the emergency department are conditions which the SNFs are now capable of treating. Many of their needs are access to the technology in the hospital, such as CAT scans, MRIs, and sonograms. Overall, this is a win-win situation for the patients and their families. Our program complements the DSRIP program which is trying to reduce hospital admissions without sacrificing quality and patient safety.

What brought about implementation of the mobile phone to accept external calls?
When we had a smaller department, communication between physician, ward clerk, and nurses by landline was easy. When you have a large ED, communication becomes an issue. One of the problems we encountered was being able to take a call from an outside agency, such as a SNF, a Medical Director, or even a private physician calling in about a patient. It became very difficult for us to communicate because sometimes the clerks would be in one nursing station and the physician would be in another. Our action plan included an external cell phone number whereby the external physician could call directly into the ED via cell phone. The cell phone is mobile, HIPPA secure, and it can be brought to the ED physician who may be in a distinct area of the ED.

The cellular line has been very successful. Physicians have been calling in and we have had many anecdotal reports by our physicians as well as by SNFs that the line facilitates the call directly because it has a different, distinctive ring that brings attention to the fact that this is an external physician calling.

What are some of the opportunities/barriers to increasing physician to physician communication and warm hand-offs?
One of the barriers has been generating awareness of our programs among our external stakeholders and all of the SNFs. We have been trying to disseminate information to these SNFs. Back in February of 2017, Southside hosted a regional workgroup initiated by SCC where a number of the SNFs were present. It was very helpful to get the medical directors together to discuss the strategy and alignment of goals of their facilities with ours. The SNFs were very happy to hear about our program. We also shared the communication forms with the SNFs, so that they can all use one standardized form when sending us patients.

Do you see an increase in SNF physician presence/involvement with ED transfers?
Both indirectly when we receive the patient with the form and directly when the SNF calls the department, we are able to have effective communication to coordinate the care of the patient. Again, effective communication is essential. In the 21st century we expect everyone to be digitally linked, but given the constraints of working within siloed systems, regulated by the federal government through HIPAA, it is difficult to build communication systems.

If anyone at a skilled nursing facility is interested in our programs, please email byeh@northwell.edu or call 631-968-3970.

Photograph of Andrea Spatarella Title: Nurse Practitioner
Organization: Northwell Health Center for Tobacco Control

Please give us a summary of your organization.
The Northwell Health Center for Tobacco Control (CTC) is part of Northwell’s Health Solutions. Northwell Health Solutions is responsible for Northwell Health’s care management programs to support physicians and patients in coordinating care and delivering quality outcomes. Care managers include nurse practitioners, nurses, social workers, and other staff who assess patients to proactively identify needs, educate patients, and work collaboratively with providers to coordinate services. Tobacco cessation is one of the quality outcomes that will result in better management of chronic conditions.

The CTC receives grant funding from the NYS DOH Bureau of Tobacco Control. The main deliverable is to work with healthcare organizational leaders to develop policies requiring that healthcare providers treat their tobacco-dependent patients - especially those with the highest smoking rates, low income and education, and/or poor mental health - with evidence-based care. We then work with these organizations to implement these policies and provide technical assistance and resources. We are encouraged by the Bureau of Tobacco Control to work with our local PPSs on their tobacco-related projects. We also provide direct cessation assistance for groups or individuals, including practical counseling, FDA - approved cessation medications, relapse prevention strategies, and ongoing support.

How many PPSs are you working with and on which DSRIP projects?
We are currently working with the Nassau/Queens and Suffolk County PPSs on DSRIP projects in Domains 3 and 4 with the following objectives:
  1. Implementation of evidence-based best practices for disease management in adults with cardiovascular conditions and diabetes.
  2. Initiate, promote, and drive opportunities for high quality tobacco cessation resources and services in both clinical and community settings, especially amongst low socioeconomic status populations and those with poor mental health.
  3. Reduction in the use of substances such as alcohol, drugs and tobacco and other mental/emotional/ behavioral disorders across the population.
In all of these DSRIP projects we are working with IT so that electronic health records (EHR) prompt providers to complete the 5 A’s of counseling: Asking your patient about tobacco use, Advising them to quit, Assessing whether they're ready to quit, Assisting them in quitting, and then Arranging for follow-up.

How do your organization’s goals and mission align with the DSRIP program?
Like DSRIP, our overall mission is to decrease tobacco use rates, particularly among individuals with low socioeconomic status and those with poor mental health, through the development of evidence-based treatment policies and tobacco-free environmental policies, incorporation of the 5A’s into EHRs, education and training for healthcare professionals and other staff, facilitation of referrals to the NYS Quitline and other local resources, and promotion of Medicaid tobacco cessation benefits. By decreasing tobacco rates, patients will be less likely to develop other chronic and acute conditions that negatively impact their lives.

What types of educational/training programs does your organization offer for healthcare providers?
The CTC has facilitated tobacco dependence and cessation treatment training programs in a variety of venues, with a singular purpose: To help health care providers become better acquainted with the evidence-based clinical practice guidelines for addressing the needs of their patients who use tobacco.

These include on-site, full-day programs as well as one- and two-hour training programs for nurses and MDs during Grand Rounds, Nurse Practitioners, medical residents on Long Island, nursing students from Molloy, Adelphi, Farmingdale and Stony Brook, diabetic educator champions, various FQHC’s throughout Suffolk County, behavioral health professionals at Northwell Health and Zucker Hillside Psychiatric Hospital and their satellites, and agency-sponsored behavioral health facilities.

Many healthcare providers were never trained to treat patients with tobacco dependence, so we’re working hard to ensure that for the next generation this is just an accepted part of their routine. A lot of this training occurs in-person, but we also have on our Northwell Health internet platform an educational program where people can get continuing education credit online. The SCC provides online education on their Learning Center geared toward specific populations, including behavioral health patients, pediatricians, pregnant women and adolescents.

What are some challenges faced by providers when it comes to treating tobacco dependence and how can they overcome them?
Many healthcare providers see “lack of time” as their greatest challenge, so it is important to share with them that even a very brief intervention at each visit can increase the chances of a patient making a quit attempt. Educating healthcare providers about the 5A’s, the framework for the Clinical Practice Guidelines for Treating Tobacco Use and Dependence, and providing them with resources for follow-up can help them overcome this challenge.

Another challenge is healthcare providers don’t know what to prescribe, and we can help them with that. They often think that patients don’t want to quit, yet research shows that 70% of people who smoke say they want to quit but they’re afraid it’s going to be too hard. But we know that with a combination of counseling and cessation medication, tobacco users are 2-3 times more likely to succeed at quitting.

Describe some of the special populations physicians and healthcare providers should be aware of when it comes to promoting tobacco independence.
The highest prevalence of tobacco users is among individuals with low education, low income, mental illness, or a history of other substance abuse. There is also a high prevalence among the LGBT community and the HIV-infected population.

How do you see the Suffolk County Tobacco Cessation Coalition initiatives making an impact on how providers treat their tobacco dependent patients?
Through the work of the Suffolk County TCC, we can increase awareness and educate healthcare providers in behavioral health facilities about the evidence-based strategies designed to help their clients quit, including treatment and tobacco-free grounds. Through education and ongoing dialogue, we can also help them change the culture around tobacco use in the behavioral health setting, which historically encouraged smoking in this population.

Photograph of Nazarra Rodriguez Title: President and Chief Medical Officer
Organization: AdvantageCare Physicians

Please tell us about your organization.
AdvantageCare Physicians is a multispecialty practice focused on population management and coordination of care. We have 36 offices across the New York metropolitan area, including Manhattan, Staten Island, Brooklyn, Queens and Long Island, which includes practices in Babylon and Ronkonkoma, serving Suffolk County. Along with a large primary care contingent, our practice includes OB/GYN, gastroenterology, ophthalmology, cardiology, hematology, oncology, podiatry, and other specialties that support patient population management.

We are recognized by the National Committee for Quality Assurance (NCQA) as a Patient Centered Medical Home (PCMH). Our patient population consists of about 500,000 New Yorkers, and we serve about 10,000 patients a day.

Why did you choose to participate as a partner of the Suffolk Care Collaborative (SCC)?
Our organization has been focused for many years on care coordination, patient-centric care, quality improvements and access improvement. The work of the SCC as well as several other Performing Provider Services (PPSs) that we participate in, reinforces that commitment to quality, access and patient-centered care delivery.

When were you first recognized by NCQA?
Our physician group was formed in 2013, through a consolidation of 4 legacy practices, each of which had PCMH recognition for many years prior to the consolidation.

What major changes in your practice sites took place when transitioning from the former standards to the updated NCQA standards for PCMH?

We were already committed to quality improvement, but a few of the things that we’ve done over the past couple of years involve implementing a new electronic health record (EHR) that provides patients with a new engagement platform, launching an online scheduling tool, and spending a lot of time training our care teams to deliver an improved patient experience.

How is your organization adjusting from volume to value based healthcare and evolving to meet DSRIP goals?
We’ve had a long commitment to value and quality and managing populations. Where we see change is in the tenor of the conversation with external parties and partners to collaborate and coordinate care. There’s a lot more interest from hospitals and payers on how we can improve health care delivery by looking at value and quality as components, and not just volumes and shifts or pure numbers.

There are a couple of areas where we have adapted as an organization in the past year to meet DSRIP goals. One is our emphasis on patient access and patient engagement to reduce avoidable hospital use.

By making online scheduling available, expanding our hours of operation, and expanding our weekend hours we have made an effort to become more accessible to patients. We are also using tools like our patient portal to help patients connect with their provider to ask questions, request refills, and identify and resolve issues that may not require a patient visit to the office or an emergency department (ED).

Another way we’ve been adapting is by really focusing on chronic conditions and their management. We are engaging patients so that they are active participants in their own care teams to manage conditions like diabetes, heart failure and asthma. We’re educating them about prevention and management, so that they can avoid a precipitous event that may cause an ED visit or hospital admission down the line.

What are your top three guiding principles for a successful population health management program? How does PCMH fit in?
Successful population health is focused on:
  1. Improving quality
  2. Improving patient access
  3. Improving patient experience of care
The PCMH process really creates a formal structure to identify opportunities for improvement in those three target areas.

What value does the SCC bring to patients under the DSRIP program?
The SCC helps practices focus on population health initiatives in a very structured fashion, and in that way it fosters improved quality, access, and patient experience. It is providing the guidelines and structure for practices to move forward with more patient-centric care.

How do you see PCMH recognition making an impact on our communities, workforce and the population we serve?
The commitment to the PCMH process while seeking recognition really cements practice and provider commitment to continuously look for improvements in process, quality, and patient experience. So, it is not so much the recognition that is making the impact, but rather the commitment to more patient-centric care and continuous quality improvements that will be most impactful to our communities and workforce.

Can your share some strategies for integrating PCMH standards in your practice?
One of the core components of the PCMH process and standards is looking at quality measures and improvements in performance of quality measures. Being able to track performance and share results and trends allows providers and their care teams to interact in a more meaningful way with their patients.

What obstacles did you encounter meeting the updated PCMH standards?
As with any change, especially considering our large workforce and geographies as a practice, educating individuals on the care teams about new workflows or new processes, and making sure those things stick, was a challenge. It's hard to change habits. As we think of more nuanced ways of engaging patients and being more comprehensive in our processes around patient care, we need to educate our teams and ensure that they are incorporating new workflows or processes that are supportive of better patient care.

How do PCMH standards align with DSRIP projects in your particular practice/patient population?
They are very closely aligned and often overlap. Our practice really views process improvements and quality improvements, whether it be for DSRIP projects or PCMH recognition or other value-based programs, as one. We appreciate having a structured approach to addressing all needed quality and process improvements.

Specifically, Diabetes Management has been a big project from a PCMH perspective, as well as from a DSRIP perspective. We’ve been able to show process improvement in point of care hemoglobin A1c testing, early identification and more timely management of patients with diabetes; things that help us in the PCMH model but also the DSRIP process.

Photograph of Christine Borst Title: Interim Executive Director
Organization: Center of Excellence for Integrated Care, A Program for the Foundation for Health Leadership & Innovation

Please give a brief summary of your organization.
The Center of Excellence for Integrated Care (COE) is a core program of The Foundation for Health Leadership & Innovation, which houses a variety of programs related to health and wellness. We grew out of the I-CARE Partnership, developed in 2006, to educate providers across North Carolina about integrated care. Our goal today is integrating physical and behavioral health care in various health systems including primary care practices, hospitals and community health centers both locally and nationally.

How does the COE work to promote integrated care?
We build buy-in across the organizations and then we use evidence-based approaches flexibly. It’s important not just to provide tools and materials, but also to personalize the delivery of them.

We coach and shape each practice on the ground. In order to really understand the practice, we go in and shadow the providers, get a really good sense of the work flow, and then do our assessment and tailor our recommendations to the practice.

We assist primary care practices in the recruitment and training of behavioral health specialists. Often times, a significant amount of training is needed. Traditionally, therapists are trained to do a 50 minute or an hour-long session in a calming, comfortable space. The culture in a medical setting is very different. So, part of what we do is help the sites adapt to these cultural differences.

It’s vitally important to provide training not just for the behavioral health clinician but for the whole site, so that everyone, from the receptionist to the provider, are all on-board and understand why integrated care is important and how they can help make it happen.

Why is integrated care important?
Despite understanding that, at the most basic level, the mind and body are connected, we have allowed them to become completely fragmented in our health care delivery system. Even conditions like diabetes and depression, that seem very different, are often interrelated. It's vital that we start addressing the whole person or we are going to continue to see healthcare costs rise.

When mental health crises happen, individuals usually don’t go to specialty mental health specialists. They go to their primary care provider, if they are asking for help at all. Primary care providers understand that, but they don’t always feel comfortable addressing mental health issues. However, even if they do, it can be too time consuming when they have only a brief amount of time with a patient. Primary care providers do not always want to ask about it because they don't want to open Pandora's box. That is to say, they may uncover an issue that is not in their scope of care to treat.

Our goal is to reduce the burden of the primary care provider. We want to be able to free them up to do what they were trained to do and then hand the patient off and say, for example, “I’m going to have our behavioral health clinician talk to you about some of the ways to manage stress, which can influence high blood pressure.” And then the provider can move on to the next room and the patient is still getting wonderful care that's team based, and later the behavioral health and primary care providers can loop back up to create a plan for that patient.

What types of challenges face primary care and behavioral health providers in integrating care?
There are clinical, operational and financial challenges. At the clinical level, there's the lack of a trained workforce of behavioral health clinicians. Few clinicians are trained to do a 10- to 20-minute intervention. Having clinicians who know how to do that is vital to the success of integration.

The operational issue is adapting workflow to provide integrated services; setting up policies and procedures to assure that the way integration is implemented is standardized throughout the whole clinic.

Obviously, the financial, billing and reimbursement varies by payer. Unfortunately, sometimes the reimbursement dictates the level of integration that happens, as opposed to what is best for patients.

How is the COE working to overcome these challenges?
Clinically, we are working to train the workforce. We are recruiting and training traditional therapists (psychologists, clinical social workers, professional counselors, etc.) to do these brief interventions, to ask about things like diet and sleep hygiene. There may be times when sleep medication is needed, but it is important to talk about the behavioral issues too.

We have a bi-monthly work group, the Behavioral Health Clinician Hangout. It’s an opportunity for the various clinicians we are working with, to get on a call all together to discuss some of the problems they have run into and do some troubleshooting.

Regarding operational concerns, we help each site map and adapt workflow from the front door to the back. Protocols, procedures and policies can help assure everyone is on the same page and integration is something that the entire practice is doing. For example, implementing a universal pre-screening for depression/anxiety is one way to ensure utilization of the behavioral health clinician.

Finally, the financials. We have worked with policy issues that limit integrated care sustainability by hosting policy summits and groups and holding regular meetings. For example, in many states, billing for both a behavioral health and a medical provider on the same day is prohibited, defeating the purpose of having both services in one place. We work to bring awareness (and eventually change) to such limitations.

How are you working with SCC to integrate care?
We physically go out to about 24 sites at a time, as identified by SCC, to conduct baseline practice assessments. These practice assessments help us identify areas of growth, strategic opportunities, and potential for integration. We speak to as many representatives as possible--front desk staff, administration, clinical staff, providers. Then we provide site-specific feedback in dashboard form, so that individuals at the site can see a snapshot of where they are on the continuum of integrated care. We identify some areas of strength, and opportunities for improvement. By maintaining the current areas of strength, and working to support the opportunities for improvement, we aim to aid a site in increasing their level of integration. We also hold bi-monthly webinars to provide information and an opportunity for the participants to collaborate. Finally, we make pre-recorded training modules available on the SCC’s Learning Center on their website.

Photograph of Patricia Bax Title: Marketing and Outreach Coordinator, New York State Smokers' Quitline, Roswell Park Cessation Services, Department of Health Behavior
Organization: Roswell Park Cancer Institute

Please give us an overview of your organization and its role in the NYS Smokers’ Quitline Initiative.
Roswell Park Cancer Institute (RPCI) in Buffalo, New York, has operated the New York State Smokers' Quitline (NYSSQL) since its inception in 2000. Currently all states have a Quitline, with the NYSSQL being one of the first and busiest state Quitlines in the US. We have responded to over 2.2 million calls, providing cessation services, including evidence-based telephonic coaching and access to nicotine replacement therapy (NRT).

The NYSSQL's accompanying Quitsite at www.nysmokefree.com provides easily accessed tools and resources including videos, downloads, chats and forums to help tobacco users quit. In addition, cessation support information is available for health care providers, employer groups and the general public.

We also work with an array of NYS health care providers, assisting with and promoting NYSSQL services as a source for cessation expertise and support for health care systems change.

What Delivery System Reform Incentive Payment (DSRIP) projects have you been working on?
Although not all DSRIP programs have selected tobacco cessation as one of their projects, we have worked directly with over 10 projects in Domain 4 specific to tobacco use to meet deliverables. In addition, because the health effects of tobacco are extensive, we’ve been able to help DSRIP projects that have selected goals around cardiovascular health.

We’re poised and ready to assist any NYS DSRIP project that has need for information about tobacco cessation and we continue to receive interest from our DSRIPs and Performing Provider Services (PPS) on a regular basis.

How do your organization’s goals and mission align with the DSRIP program?
DSRIP’s statewide initiative aims to significantly improve the way medical care is delivered to Medicaid and uninsured patients by establishing a large network of collaborating health care providers. The NYSSQL is an evidence - and population-based program that aligns with these DSRIP principals.

Tobacco use is one target of the DSRIP program and the NYSSQL is a hub for tobacco cessation information, resources and access for all NYS residents. Although adult smoking rates in NYS have declined, prevalence of tobacco use remains disproportionally high among Medicaid members, the uninsured, and those with mental health and chronic health conditions; and these are the people most frequently accessing Quitline services. This is the same group that DSRIP is trying to work with, so we also align in working with the same population.

Additionally, RPCI’s outreach for the NYSSQL has focused on building relationships with NYS health care providers and stakeholders, including health care sites, Medicaid Managed Care Plans, Commercial Health Plans, County Health Departments and DSRIP programs. We recognize the need for collaboration in working with entities all across the state to meet the requirements of a Triple Aim Initiative: improving the patient experience of care, improving the health of populations and reducing the per capita cost of health care.

Tell us more about the Quitline and where to find more information about the Quitline.
The NYSSQL is a lifeline for NYS smokers wanting to quit, providing free, confidential services including information, tools, evidence-based coaching and an offer of free NRT for those eligible. Services are offered in English and Spanish, with access to a language translation line, as needed.

Quit Coaches offer tobacco users help for all stages of the quit process: motivation, relapse support, education on NRT, and eligibility screening for a free 2-week nicotine patch starter kit. Our coaches are trained in motivational interviewing, using an empathetic approach and open-ended questions to increase dialogue around their quit plan. They help tobacco users feel connected to the Quitline, so in addition to support from their provider, family and friends, they can also reach out for reinforcement to become and stay tobacco free.

With the advent of the Affordable Care Act, more health plans are covering stop smoking benefits like medications and provider counseling, and more people are insured to utilize these services. Our coaches provide education and stress the importance of tobacco users accessing their health plan benefits in addition to receiving Quitline services. Coaches also do their best to encourage participants to discuss their quit plan with their provider(s) for additional cessation support and follow-up.

The Quitline also works with employers, health plans and health care providers - anyone in NYS with any interest in tobacco control and tobacco cessation - to ensure all New York tobacco users have access to effective cessation treatments. Whatever the need, the Quitline is a good place to start, because if we don't have the answer or solution, we can connect individuals to someone who can help.

Tobacco users can contact the Quitline directly at 1-866-NY-QUITS (1-866-697-8487) or be referred by their provider. Further information on the Quitline is available on our website.

How have you collaborated with the Suffolk County Tobacco Cessation Coalition?
RPCI works with DSRIP Project Teams, including the Suffolk County Tobacco Cessation Coalition, to implement Provider Referral Programs as a component of Public Health Service Clinical Practice Guideline implementation and health systems change.

PPSs across the state are adopting and implementing our Opt-To-Quit™ referral program, in which a sustainable system-driven policy ensures all patients identified as tobacco users are referred to the NYSSQL for post-care cessation help, unless they opt out. It is an adjunct program to enhance onsite cessation interventions. We work with each facility to set up the program, assisting with training, policy development and data exchange. We can even work to incorporate it into a system's Electronic Health Record (EHR) as an automatic data exchange to facilitate follow-up.

Collaboration with the coalition has resulted in more providers and healthcare systems prioritizing tobacco cessation interventions and learning about RPCI services, including the Quitline and Provider Referral Services.

How do you see the Suffolk County Tobacco Cessation Coalition project making an impact on the communities, workforce and population we serve?
We all share the same goal: to create a healthier environment by motivating tobacco users to make a quit attempt and providing access to services to make it successful.

To achieve these goals using a population-based approach, we have to stretch our resources as far as we can to reach as many people as possible. Through collaboration, members of the Coalition can leverage resources, avoid duplication of effort, and maximize the skills and talents of members to achieve "Best Practices" in tobacco cessation.  Tobacco users in Suffolk County will benefit from increased awareness and access to cessation resources, thus helping support a decrease in tobacco use prevalence. Reinforcement of key cessation messages by all involved in the Coalition project especially enhances the ability to reach under-served populations, including Medicaid members and those with mental and behavioral health issues.


Photograph of Patricia Bomba Title/Organization: Vice President & Medical Director, Geriatrics, Excellus BlueCross BlueShield & MedAmerica Insurance Company, Chair, MOLST Statewide Implementation Team & eMOLST Program Director, & Chair, National Healthcare Decisions Day NYS Coalition

How you first got involved in with MOLST?
In 2001, I established the Community-wide End-of-life/Palliative Care Initiative (Initiative) with a diverse group of 150 professionals and consumers. Improving advance care planning was among the key goals of the Initiative. Two programs emerged as a result of the Initiative:
  1. Community Conversations on Compassionate Care (CCCC) encourages everyone 18 years of age and older to have a conversation about values, beliefs & goals for care and complete a health care proxy.
  2. Medical Orders for Life-Sustaining Treatment (MOLST) is a clinical process that emphasizes discussion of the patient's goals for care and shared medical decision-making between health care professionals and patients who are seriously ill or frail, for whom their physician would not be surprised if they died within the next year. The result is a standardized set of medical orders documented on the MOLST form that reflect the patient's preferences for life-sustaining treatment.
What has surprised you most about working with MOLST?
Many physicians and other clinicians do not recognize that cardiopulmonary resuscitation (CPR) means that all medical treatments will be done to prolong life when the heart stops or breathing stops, including being placed on a breathing machine and being transferred to the hospital. As a result, incompatible medical orders such as CPR and Do Not Intubate (DNI) have been written on MOLST forms creating issues in an emergency.

MOLST requires an understanding of the benefits and burdens of each life-sustaining treatment and the medical evidence supporting the medical decision making given the individual's health status and prognosis.

Can you share successful strategies to keep the momentum of advance care planning dialogue alive across the patient's continuum of care?
A multidimensional community approach to advance care planning is effective.
  1. Culture change is critically important. Start by normalizing the importance of advance care planning as a wellness initiative, as important as quitting smoking. Focusing on losing the ability to make medical decisions and the potential for recovery, as well as death is important. Recognize advance care planning is a key element of future care planning and engage attorneys, financial planners, funeral directors, etc.
  2. Training physicians, clinicians & other professionals is critically important.
  3. Public education and engagement is best accomplished by using a consistent simple message in media, print, web, video, educational and promotional material. This is the approach used with the CCCC and MOLST toolkits.
  4. MOLST is an end-of-life care transitions program with a consistent process (8-Step MOLST Protocol) that includes thoughtful discussions and shared, informed medical decision-making and a care plan that supports MOLST decisions.
  5. System implementation, policies and procedures, workflow align with the work being done on care transitions, reducing readmissions, palliative care.
  6. Dedicated system and physician champions are needed in all care settings (hospitals, nursing homes, physician offices, home care & hospice and EMS.)
Across the geographic areas, how do you see the hospitals and SNF's partners rolling out e-MOLST together?
When MOLST was first implemented in 2004, hospitals, nursing homes, hospices worked together to ensure a common approach across the community. Physician leaders, including geriatricians, internists, emergency room physicians, intensivists and palliative medicine specialists, in partnership with system leaders, including quality & patient safety specialists, directors of nursing, social work, etc., served to ensure a collaborative approach.

What might (someone) be shocked to know about you?
I don't plan to work forever and will retire. I have a long bucket list including, but not limited to, skydiving with my son, learning to play the piano, traveling, being part of my grandchild's life, buying a horse that wins the Alabama Stakes at Saratoga, writing a cookbook (cooking & baking is a passion and stress reliever) and my life as a social entrepreneur.

Photograph of Susan Lee Title: Associate Professor of Clinical Medicine, Medical
Director of the PCMH
Organization: Stony Brook Primary Care

Tell us about your organization:
We are a busy faculty practice affiliated with SUNY Stony Brook Medicine. We have 20 faculty members, including 7 Geriatricians and 1 Nurse Practitioner. Our East Setauket office is a training site for residents and medical students as well as NP’s. We are also home to Stony Brook's HIV Program. We serve a diverse patient population, ranging from the uninsured and indigent to those with insurance and the ability to self-pay. Most of our patients reside in Suffolk County.

Why did you choose to partner with the Suffolk Care Collaborative (SCC)?
We were offered the opportunity to collaborate with SCC as part of the Delivery System Reform Incentive Payment (DSRIP) initiative that is led by Stony Brook. We were interested in the DSRIP initiative because it ties in closely with our philosophy of care in a Patient Centered Medical Home (PCMH). We had started our transformation as a PCMH under a Department of Health grant, and participating in the DSRIP initiative with SCC allows us to continue our mutual efforts at caring for our patients insured under Medicaid in a patient centered way.

What is PCMH and when did the National Committee for Quality Assurance (NCQA) first recognize you?
PCMH is transforming the way we deliver care. The emphasis is on patient-centered care, treating patients in a comprehensive way that helps them navigate today's complicated medical neighborhood.

We were recognized by NCQA as a Level III home (the highest level achievable) under the 2011 standards in 2014. Although we were still accredited, we opted to renew early for the more robust 2014 standards and we just became accredited as a Level III home again.

What major changes were required in your practice when transitioning to the updated NCQA standards for PCMH?
We had to make a lot of workflow changes. Specifically, we had to train our staff to be more involved in care management, tracking, and our quality assurance initiatives. In addition, we started a very proactive transition of care program for patients being discharged from the hospital, nursing home or emergency room. We also initiated screening for depression, substance abuse and falls as part of our patient intake.

As healthcare reimbursement changes from volume to value, how is your organization adapting to the new paradigm?
As we move towards value-based reimbursement models, being a PCMH puts us at the forefront of the future of patient care.  We are already employing the tools of our Electronic Medical Records (EMR) to improve gaps in care for preventive health recommendations and chronic conditions such as diabetes.

In addition, we will be using HealtheIntent, a special feature within our EMR, to generate scorecards that allow individual practices and providers to track how they are doing on measures that governmental and private insurers will use to assess quality.

Already, becoming a Level III PCMH has given us recognition with certain insurers as a “Preferred” practice.  Moving forward, our institution as a whole is working towards caring for patients with the goal of achieving the Triple Aim.

DSRIP's purpose is to fundamentally restructure the health care delivery system.  How is your organization evolving to meet this goal?
The PCMH philosophy of patient-centered team-based care is clearly the way to care for the patients who are indigent and insured under Medicaid.  Partnering with DSRIP has allowed us to expand our care management and Behavioral Health reach towards the goal of reducing avoidable hospital use.  Stony Brook is continually looking at ways to control costs and improve quality.  Dr. Fields, our Division Chief, is on a committee chaired by a Hospitalist, that is working to reduce 30-day re-hospitalization rates in Medicare patients.

What are your top three guiding principles for a successful population health management program? How does PCMH fit in?
  1. Teach the foundations of team-based care
  2. Technical/IT support is key
  3. Celebrate your success and share the results
When employees understand and see the benefits of team-based primary care, they feel empowered to make a difference.  PCMH allows people to work at the highest level of their license and know that they are doing the most good.

What value does the SCC bring to patients under the DSRIP program?
Tremendous value.  Having the support of a Care Manager embedded in the practice, as well as new partners in Behavioral Health in the community, has been a great resource for patients needing extra support.

What impact does PCMH recognition have on the communities, workforce and population we serve?
Becoming a PCMH has opened opportunities to collaborate with other departments and specialists at Stony Brook. Our staff has better job satisfaction and patients polled like the new model of care.

Can you share some strategies in integrating PCMH standards in your practice?
  • Get support from the administration to allocate time for writing policies and procedures
  • Assure that staff and physicians understand the philosophy of team-based care -- then continually train and educate them
  • Share your success stories and help each staff member understand their importance as part of the team
  • Get patients and staff involved in QA projects using the PDSA (Plan, Do, Study, Act) Cycle technique
Who did you collaborate with to become PCMH recognized?
We met almost monthly with the departments of Family Medicine, Pediatrics and IT/Population Health to share ideas about how to change policy and procedures in the office, train staff, and collect data.  SCC was also an important partner as they provided much administrative support and expertise.

What obstacles did you encounter meeting the updated PCMH standards?
  • Initially, staff resistance to change
  • Time constraints
  • Limited administrative support
  • Our EMR was not capable of meeting the updated PCMH standards so we had to create work-arounds, customized tracking lists, customized chart templates and customized individualized care plans
How has the PCMH model benefited your patients?
Navigating today's medical neighborhood is very complicated for patients; especially those who are elderly, learning disabled or have no social support. Our patients appreciate having continual care even after they leave the office and like being involved in making educated decisions about their care.

And we do have a really impressive measurable outcome: Before we started the PCMH initiative, our 30-day re-hospitalization rate for Medicare patients was about 15.6 %. After initiating PCMH, we were able to get that number down to 3.6%.

How do PCMH standards align with DSRIP projects in your experience?
Very well. In choosing our QA projects, we were able to align some to the benefit of our patients. For example, Caring for Diabetics and trying to reduce re-hospitalization rates were projects that overlapped.

Anything else you’d like to add?
Transforming your practice is a big task, and it requires a lot of dedication, but it can be done if you establish a leadership team who really believes in the concept of team care and PCMH. We were able to engage our staff and help them understand what role they play in patient care. We have a lot of people who scan charts and file papers. We tried to show them that if papers don’t get filed into the right place or if we don’t get our lab results scanned into the system, we can't take care of patients, and we won’t be able to meet certain goals we're trying to achieve. When they saw how important their role was in caring for patients, they really had much better job satisfaction. Even our janitor -- who keeps the facilities neat and organized and who's always trying to help patients out by opening the door -- he’s part of our team, too!

Learn more about the SCC’s PCMH Practice Transformation Program here.
Photograph of Patricia Pederson Title: Nurse Manager
Organization: Stony Brook Family, Population, and Preventive Medicine

Please give us a summary of your organization:
We’re a family medicine practice as well as a residency program training site currently. We handle everything, as the saying goes, from womb to tomb. Which is from low-risk obstetrics, bringing those patients into our practice as babies, all the way through end-of-life care.

How many doctors are in your practice?
We have a total of 16 attending providers at two practice sites and 5 residents in their third year of training. We are recruiting for two additional physicians and two Nurse Practitioners or Physician Assistants. We also have two Social Workers and two nutritionist who see patients in our department. Stony Brook is transitioning its family medicine residency to Southampton to better serve the population farther out east and provide primary care which they are in need of on the east end. So the last five residents, who started in our site here in Setauket, will graduate in June and we’ll then be a fully attending practice.

Who does your practice serve?
We have patients from many diverse ethnic and socioeconomic groups. It’s really a varied population, because we serve the university and that’s a multicultural, multi-ethnic university and the communities at large. Long Island is a melting pot so we see a lot of different patients, which is nice.

What do you hope the DSRIP program will accomplish for your organization in the future?
Well, I hope in general, not just for my organization, that DSRIP will basically be able to deliver more comprehensive healthcare to our patient population. Because DSRIP’s population is small, and from what I would think, it is just a step for a bigger model. Basically, I think it helps us to provide highly individualized care and more comprehensive care for our patients and I think it helps a particular population, at this point in time, navigate a sometimes very confusing health care system.

Your Practice has embedded Care Managers through the Suffolk Care Collaborative Care Management Organization. Can you speak to the benefits you've seen in your practice since this addition?
Yes, it’s great! We have our own Care Managers, or Care Coordinators, as we refer to them. Because we’re a patient-centered medical home we perform those services that the embedded Care Managers provide. The DSRIP program supports Medicaid, Managed Medicaid and dual eligible patients and the SCC Care Managers work with high-risk patients within that group. And they work hand-in-hand with our Care Coordinators, which is great because it has really allowed, at the patient level, for patients to have their specific needs addressed. Because there’s different gaps in care and different barriers that prevent patients from obtaining services that they need, a provider can walk right down to the embedded Care Manager and say “Listen, I have this patient, I just got these results, they need to have this, this, and this done but they don't have transportation or they just don't know where to go or they don’t have the technological savvy to navigate through online systems or whatever the issue may be. Can you reach out to this patient?”

And the embedded Care Managers are paired with a Community Health Associate (CHA) who is someone in the community who is not necessarily a healthcare professional. They can help patients at the community level and they work together. If the Care Manager identifies an issue they can reach out to the CHA for support. As an example, if a patient needs to have medications, and they’ve been phoned into the pharmacy but the patient hasn’t picked it up and the patient has no transportation we can move those prescriptions to a pharmacy that delivers. For other patients housing or access to healthy food may be an issue. They find out what the barriers are and look to find solutions. You take away that barrier to that patient's healthcare.

What do you feel the benefits of the Care Management are your patients specifically in your practice since this addition?
I think it’s beneficial to the patient at the provider level and at the care delivery system level in that it helps that patient navigate the system that could otherwise be too overwhelming. For someone who may be homeless - how can they search for programs or find a solution? So someone who has that wherewithal is able to do that for them and they also make assessments as to what additional needs the patient has.

Identifying literacy issues. As we bring a patient in for a visit we share forms with them. Asking someone “Would you like me to read it to you?” may allow for someone to share that they cannot read. The provider and other members of the team being aware of this as an obvious obstacle to receiving comprehensive healthcare alerts the team to deliver information verbally or visually because written instructions are not helpful.

If we know what the barriers are it goes a long way toward helping us help the patient overcome it.

What Gaps and barriers, if any, you feel will be closed through the DSRIP program and Care Management?
Well, gaps in care are really barriers such as language, technology, education, and socioeconomic concerns that the patients face. Providing access to good medical care and working to close those gaps, the Care Managers work to get patients “hooked-up,” for lack-of a better term, with the services that they need, so that they can be healthier. And if you’re healthier, then life’s better.

It’s a philosophy that, in practice, is absolutely ideal. It’s the way healthcare should be delivered. Each person should have individualized, comprehensive healthcare available to them, regardless of language, of education level, or socioeconomic background. This works to overcome barriers and evens the playing field for everyone.

Is there anything you'd like to add?
Only that this program is how we should deliver healthcare, always. There is, obviously, an underserved population. We’re all healthcare providers here, and we do what we do because we want to take care of and support our patients. That’s what we want to do and for any program that makes that better, for us, and for the patients, that’s a win right there.
Photograph of Joseph Schulman Title: Executive Director
Organization: Northwell Health Solutions - Northwell Health's Care Management Organization
Please give us a summary of your organization:
We are the Care Management Organization for Northwell Health with responsibility for the performance, management, and implementation of our system’s value-based programs, demonstrations, and risk-based populations.

Northwell Health (formerly North Shore-LIJ Health System) is New York State’s largest health care provider and private employer with 61,000 employees. With 21 hospitals and nearly 450 outpatient practices, we serve more than 1.8 million people annually in the metro New York area and beyond.

What do you hope the DSRIP program will accomplish in general?
The goals of the program are consistent with our organization’s overall triple-aim strategy of high-value care delivery for all the populations we serve as a system. Aligned with DSRIP, we are focused on reducing health disparities, improving the experience, and having exceptional patient outcomes result in improvement on the total cost of care.

What in your experience are the top guiding principles of successfully managing the health of a population?
The first is engagement - our ability to engage beneficiaries, their families and, importantly, providers. By creating a network of care with access and methods to engage at-risk populations and their respective providers, we can reach people who otherwise have been left with few options and are lacking information about how to access needed care for an early, chronic, or severe condition. And, as mentioned, in parallel, to engage beneficiaries, we need to align efforts with the provider network.

Another critical domain is data management and analytics. Our efforts are focused on building a four-dimensional view of the populations we serve through the data so that we can tailor our care coordination activities and resources to meet their needs. The goal is to provide support to the beneficiaries, alleviate suffering and maintain individuals in their own homes. In order to do that in a highly organized and efficient way, you need to have capabilities and a level of sophistication around data analytics, data management and reporting.

How are performance outcomes measured within your organization and how do the DSRIP measures align with current efforts?
The outcomes measures housed inside of the DSRIP program are well aligned with our overall value-based population health activity. Among the most common is preventable/avoidable emergency room visits, in addition to 30-day avoidable and all-cause readmission rates. As I mentioned earlier, we are also heavily measuring outcomes linked to discharge-to-home rates and a more progressive measure of days-at-home.

How is performance outcome data used to identify areas for quality improvement?
It actually answers itself. You need to have highly effective measurement and reporting capabilities so you’re able to have an ongoing continuous process of reviewing the outcomes - frankly this is a very new space in terms of sophisticated care management efforts and demonstrated outcomes.

Some things that will be engineered and designed will work quite well and the outcomes will reflect that. Others will be modest to moderate in terms of performance. And other approaches may not work. In order for you to know what to do more of, what to do less of, and what to re-engineer, you rely on the outcomes relative to where they were, where you predicted the outcomes would be, and what the actual was.

How is Northwell using performance outcome data to achieve its vision for the future?
By identifying individuals who are at high-risk, aligning and partnering with the providers, and then engaging the individuals towards bettering the management of their condition - whether its diabetes, asthma, COPD, or other chronic conditions of that sort - that’s important. It’s an ongoing process. The mission is to continue to marry the clinical information systems data with the claims-based utilization data.

What mechanism(s) do you use to share results with key stakeholders?
Our system’s network team is working hard on our provider and physician portal, which will enable our providers to have a succinct and very clear view of the individuals who are eligible and covered in our value-based arrangements and our value-based pools, in addition to providing important quality indicators and outcomes.

These types of mechanisms and these views are very powerful but need to be coupled with other conventional means, such as face-to-face meetings and informational sessions. We need to keep in mind that our activities are at scale so you have to develop systems where you’re providing information without overwhelming the providers and practices. We’re trying to get views that are meaningful.

What tools do you use to engage patients to improve outcomes i.e. patient portals etc.?
We’re continuing to look at our patient-facing and beneficiary-facing portals and analytics engines, as well as our content and methods to ensure they provide a view that makes sense to our patients, beneficiaries and caregivers.

How do you influence providers to improve their outcomes?
We view our relationship and role with providers as a resource and supportive partnership. The mechanisms are the provider portal I mentioned earlier and other tools that help providers with their decision-making. We are also working on scaling the practice and hospital-based deployment of our care managers in cases where we have a very high density of high-risk patients and beneficiaries. We also support these efforts through our 24/7 clinical call center as well as through a community paramedicine programs, disease management and advanced illness services and sites.

Do you utilize standardized care processes to promote evidence-based medicine?
We rely on our health system’s service lines that power the evidence-based care pathways organization-wide.

Is there anything you want to add?
We’re excited about what DSRIP and these Medicaid redesign efforts represent, and again, I just want to punctuate that this program and these efforts are fully aligned with the Northwell Health vision about transitioning from a traditional model of fee-for-service into a value-based, outcomes-oriented model.

DSRIP is bringing together the members of the provider community in a way that’s really encouraging. I want to recognize Joe Lamantia for his extraordinary leadership along with his team who have established such a well-organized PPS that has energized efforts for redesign throughout the region.
Photograph of Janine Logan Title: Senior Director, Communications and Population Health
Organization: Nassau-Suffolk Hospital Council (NSHC)
Additional Website: https://www.lihealthcollab.org/

What is the Long Island Health Collaborative's (LIHC) vision and some key objectives of the Long Island Population Health Improvement Program?
The collaborative is the main work group for the Long Island Population Health Improvement Program (PHIP). We𔄩re focused on the reduction of obesity, particularly chronic diseases that are related to obesity, and also on enhancing access to chronic disease management and treatment programs in both clinical and community settings.

How do you think the LIHC’s goals and mission align with the DSRIP program?
The DSRIP program is looking, as ours is, to help patients become more active in their own health - more engaged and more aware of their nutritional habits and their physical activity habits.

The DSRIP program is focused on the Medicaid population. Our collaborative looks at the Medicaid population but also at all populations outside of Medicaid and what can be done to help them improve their health.

Which DSRIP initiatives do you foresee the LIHC and the SCC collaborating on and how will this take steps towards bettering the health of our community?
Patient engagement and community outreach is an area where there’s a lot of overlap. We’re also assisting the SCC with some data collection and data needs, as well, and vice versa. It all begins with a base of understanding. Patients, of course, need to understand that those behaviors that they do and do not do affect their outcomes both in the short and long term. And also why it’s important to have a Primary Care Practitioner Provider who coordinates their care.

We also realize now that a lot of the social determinants of health, such as transportation, access to care, the cost of care, education level, and poverty all factor into a person's ability to become well and stay well.

What are some strategies that both the LIHC and the SCC can maintain to satisfy the sustainability of community engagement?
The collaborative developed a community health assessment survey that we distributed to thousands of Long Islanders. A lot of the data and mapping that we have done at a very local level has also been very helpful to the Suffolk Care Collaborative.

Suffolk County faces several barriers to optimal health (e.g., transportation). How do you think the SCC and the LIHC can work towards overcoming these barriers?
Transportation is a tough one. It requires working with transportation partners and influencing transportation policy in whatever way we can, such as getting one municipality to add another bus for seniors, and trying to work with the many cab companies that are out there now. I know that we do have to address that problem and, short of being able to build a monorail system, we have to find ways around it.

There are other barriers as well. There are pockets of extreme poverty on Long Island. If you're living in poverty you're not eating properly, so that affects your disease outcome. You might be working a couple of jobs and not making much money so physical activity is not your number one priority.

Those are the obstacles we have to try to overcome in some communities. Poverty, language barriers and cultural barriers.

The collaborative staff sits on the cultural competency committee at the Suffolk Care Collaborative. They're working on identifying organizations that can train members of the Care Collaborative as well as professional members of the LIHC in cultural competency and cultural sensitivity so that they can then train their staff. That will trickle down to ultimately treating and approaching the patient consumer in appropriate ways.

How have DSRIP activities aligned to the mission of the LIHC?
We’re really completely aligned in just about every respect. We’re using the same ways to reach people. We’re partnering with faith-based organizations, with social service organizations, and with other small organizations that are out there in the community that are seeing what people need and interacting with people on a daily basis. So it’s establishing all those relationships and we’re doing that together.

How do you envision Population Health changing within the next five years?
I think this very patient-centered model of healthcare, which focuses on Primary Care and trying to catch illnesses and problems before they become more acute, is going to predominate our healthcare delivery system in the next five years.

It’s connecting healthcare more to lifestyle and prevention rather than just remedying or writing a prescription. That’s a different way for the United States to look at healthcare.

Is there anything else you would like to add?
I’m personally very excited about the direction that healthcare is taking. I’m pleased that we’ve realized that those social determinants that are outside of the clinical setting have a very important impact on health outcomes.

Although we can’t provide everybody with bus transportation or buy everybody who needs one an air conditioner, we can certainly, as a professional industry, sit down and figure out ways that together we can perhaps meet those needs in an economical way that helps everyone.
Photograph of Julie Vinod Title: Assistant Director of Nursing Operations
Organization: Brookhaven Memorial Hospital and Medical Center

Please describe the MAX Series Project Charge your organization participated in?
Medicaid Accelerated eXchange (MAX) Series is part of the NYS Department of Health Delivery System Reform Incentive Payment (DSRIP) Program 2015. Brookhaven Memorial Hospital participated in reducing the preventable COPD Super Utilizer ED visits.

Who was part of your team?
It was an interdisciplinary team composed of Hospital Leadership Team, Nursing, Physicians, Primary Care Provider, Respiratory Therapy, Care Management, Education Department, IT, Pharmacy, and Patient Centered Medical Home Coordinator Collaborative Care. As well as community agencies including Health Homes, Home Care and Community based organizations.

Photograph of Brookhaven Memorial Hospital and Medical Center Group
Brookhaven's MAX Series Team. (Left to Right): Samuel Beckles, BSN, RN, Nurse Manager, COPD Unit; Monica Schlie, Social Worker ED; Ciresi Darlene, Care Manager, COPD Unit; Kevin Ramdeen, BSN, RN, Clinical Coordinator, COPD Unit; Steven Sanderson, Decision Support Analyst; Jessica Philius, Social Worker, COPD Unit; Karen Shaughness, LCSW, Senior Director, Ambulatory Services; Brianne Rizzo, Director of Care Management; Dr. Julie Vinod, DNP, MS, ANP-C, RN, Senior Director, Ambulatory Services; Jody Felice, RN, Home Care Nurse; Stanley John, MHA, BS, RT, RRT-NPS, Director Respiratory Care & Support Services; Elfriede Weiss-Paquette, LCSW, Director Collaborative Care, PCMH; Tameka Squire, BSN, Clinical Instructor.
Not Pictured: Dr. Nejat Zeyneloglu, MD, CQMO, Clinical Lead; Keisha Wisdom, VP, CNO,Clinical Lead.

What was the goal?
To reduce the number of COPD Super Utilizer ED visits by 10% in one year.

What was the groups approach?
Early identification and notification of the COPD super utilizers via the flagging system. Establishing a standard plan of care of COPD super Utilizers, Education and creating awareness on COPD; Internal communication to all the interdisciplinary team about the project, Cohorting COPD patients, Multidisciplinary Collaborative Approach with weekly team meetings with Brookhaven Action Team and KPMG. Contact or escalation of challenges via phone or email on a daily basis. Expert Advice during meetings and on MIX IT website. Interdisciplinary Collaboration and coordination with community outreach and Health Homes. Utilization of motivational interviewing techniques and establishing support and rehabilitation services for COPD patients. Graduation handoff using the graduation protocol created for this project, and persistence and dedication of the Team. Future Scaling of this project to include other disease conditions (Heart Failure, MI...).

What was implemented?
Created COPD Super Utilizer List, Created a Flagging System; Created 62 patient profiles. Opened a COPD Unit. Created a secured shared drive to document and communicate within the action team. Educated the frontline staff. Created a multidisciplinary COPD Plan of Care Created a workflow for COPD patients. Created a care coordinated note template and a Home Assessment tool. Created a Graduation Protocol Created Health Home enrollment spread sheet. Established a Brookhaven Better Breathers Club. Established a handoff culture between hospital care management team and the health home coordinator.

What was your impact/findings?
We reduced the, ED Visits by 44% and reduced our In Patient Admissions by 45%
And the Readmissions rate by 29%.

How did you engage health homes in care coordination and navigation of patients?
Health Home representatives met with staff and educated them about Health Home application process, and established key contacts. Conducted one on one case study in a collaborative approach involving the patient, care giver/residential representatives, Brookhaven team and health home coordinators. Depending on the need assessment, escalated patients to high touch cases. Maintained frequent contact with Health Homes to ensure patients are enrolled.

Please describe a patient experience?
This is a patient with multiple chronic conditions, including depression, who contributed to 14 hospital visits in a 6 month period including, 5 admissions and 3 readmissions. Most of these visits were not related to COPD but a feeling of insecurity. As the first patient of the program, the patient received a needs assessment which uncovered a need for frequent education with medications, BIPAP use, and support for follow-up appointments. In spite of all the education and support, the patient still came to the ED. Soon we realized that the patient needs community outreach support and coordination. We conducted a case study meeting with the residential representatives and Health Home coordinator. After the meeting, we along with Health Home decided that the patient needs intensive case management (ICM). And the patient was upgraded to ICM. The patient is now receiving care coordination services, which has helped the patient to connect to primary care, Medicaid transportation, and alternatives to the ED. This patient has been given the opportunity to engage to an Adult Day Care center. This particular patient did not return to the ED for 3 months and had graduated in May. Since March 2015, the patient had only one ED visit in June which was for heart failure and was appropriate.

How do you feel this effort will support the DSRIP goals?
The goal of DSRIP is to reduce avoidable hospital use by 25% over 5 years. This effort will meet the DSRIP goal for better care, better health and lower costs. We have created a foundation for enhanced, patient-centric holistic assessments, and strong communication and collaboration amongst all providers involved in each patient's care. This project can be replicated, implemented and applied as best practice in other institutions among super utilizers.

Photograph of Brookhaven Memorial Hospital and Medical Center Group
MAX Series Team Success Celebration.
(Left to Right): Elfriede Weiss-Paquette, LCSW, Director Collaborative Care, PCMH; Dr. Julie Vinod, DNP, MS, ANP-C, RN, Senior Director, Ambulatory Services; Karen Shaughness, LCSW, Senior Director, Ambulatory Services; Gerald Garland, Social Worker, Northwell Health Home.

Photograph of Pamela Mizzi Title: Director
Organization: Long Island Prevention Resource Center, Family Service League

What is the LIPRC’s vision and some key objectives of your work in the South Country School District?
Our vision involves a general ownership of the issue of the importance of health and safety. The first round against substance abuse is a wellness perspective and promotion of health. Our overall objective is to reduce the incidence and prevalence of substance abuse, including alcohol and other drugs, in the community. Specifically, we want to reduce binge drinking, a documented problem recognized by the school district and the community. Finally, we want to work on reducing the risk factors for these behaviors. Results of the Youth Development Survey done in the school district for the 2014-2015 school year provide a baseline, so all of this is evidence-based and data-driven. Our methodology is about reducing risk factors and increasing protective factors. Identified risk factors include availability of drugs, perceived availability of drugs and favorable attitudes towards antisocial behavior.

From an individual perspective, we want to change that attitude. Then there are the family issues - one of the lowest protective factors was family attachment across the board from 7th grade all the way to 12th. From a community perspective, we have to work on perceived availability as well as laws and norms favorable to drug use — the highest risk factor among 11th to 12th graders. In the survey, they indicated that they wouldn’t really get in trouble, and their parents wouldn’t really do anything, if they were caught. The South Country School District is a major partner in this. They are beginning to recognize and address the issues around substance abuse, instead of leaving it behind to focus exclusively on educational curricula and content. Ultimately, in terms of a vision, we’d like for this economically disparate community to recognize their diversity as an asset, instead of taking an “us vs. them” attitude.

How do you think the LIPRC’s goals and mission align with the DSRIP program?
One of the priorities of the DSRIP program is to increase the overall health of populations, and this project has that same goal, to increase overall health in this neighborhood. We will be using the Public Health Model and will focus on the environment, or context, in which individuals make the decision to use or not use drugs and alcohol. We want to intervene in that context, so that that decision becomes easier and easier towards no use instead of use. Right now the context is there’s a lot of availability and norms that are favorable to use; there’s also low commitment to school and high family conflict. And that all points to an individual’s decision to use. So our target is that environment, instead of the drug itself or focusing on the individual. The Public Health Model has three facets to it: the host, the vector and the agent. We’re focusing on the vector -- the environment or context.

DSRIP also has an initiative integrating health and wellness. Their integration is about physical health and behavioral health, our integration is much more: overall wellness as a choice for individuals and for communities. This project envisions the community as the Identified Patient. So you work with individuals, but the overarching goal, the measurement of success, is in how well the community responds. This is a research-based model and it’s proven to be effective. We’re using this Strategic Prevention Framework that’s really a business plan for producing positive outcomes in terms of health and wellness. The features of the Strategic Prevention Plan are to do a thorough assessment and get everybody in on the assessment process. You hear a lot of complaining during that assessment process, but you turn those complaints into, “Okay, now what can we do about it and who’s going to be responsible for it?” It’s a community action plan. So it goes from assessment to capacity building, then planning, intervention, evaluation and sustainability.

The proposal that I submitted to DSRIP included each of those features. That’s part of the selection process for DSRIP; it’s very rigorous. But the LIRPC has been in business seven years and we’re using this Strategic Prevention Framework in communities all over Nassau and Suffolk. While the LIPRCs overall goals are spread out by county, employing at-large staff who go in and out of different communities, the DSRIP proposal is for this one specific community and the plan is to hire a Prevention Coordinator who will work only in this community.

What are some strategies that the LIPRC utilizes to engage with the community?
One strategy involves community events mining and mapping concerns such as garbage, violence, needles on the ground, kids drinking in the park or seniors being devalued. Whatever it is, we draw a physical map of it and then we turn that kind of data into an action plan. It’s a participatory process; everybody is in on it. We take all the information on all of the maps and bring it back to the office and put it on a grid and project manage it and figure out our priorities. One priority is always the substance abuse problem. And then we go from there.

Other strategies include taking enough time to do a good assessment of the strength of the community. We need to see the resources and the resource gaps. Town hall meetings can be useful, both to get politicians to buy in, and to bring people together and assess the strength of the area. We also plan a social media campaign, targeting underage drinking and drug usage among 18-25 year-olds.

Another important strategy is participating in other local activities. The Prevention Coordinator, who will be largely responsible, needs to be a member of the community. We will remain in the background and assist that person and the community, so that the Prevention Coordinator becomes a community champion, getting involved in as many different facets of the community as they can to try and bring people together. They can’t be above going door-to-door talking to people who won’t come out to a Town Hall meeting to learn how substance abuse affects their lives. This South Country area is an impacted area, on this issue and many other issues, which is why it was selected.

What are some of the challenges that the LIPRC faces in facilitating behavior change in the adolescent population?
Facilitating behavior change is a long-term process. This project is really only for four years, but the long-term change we’re talking about may be further down the line. That’s why we have a sustainability plan.

We’re looking to change norms, and that’s a challenge right there. And some changes are easier than others. Adolescents are all about change. And we just want to make sure that their change is in a positive way, and not a negative way. Unfortunately some of these kids really don’t see a big picture for their future. They don’t envision themselves holding a college diploma, and that makes it easier to make short-term decisions in the here and now than decisions that really support long-term goals. So trying to get adolescents to look a little beyond the four years of high school is one of our goals. We want to get them to see that gaining a high school education is a positive thing and it’s worth their time and effort.

One of the other data points that we’re going to be working with is parental involvement. Looking at the protective factors, we’re going to be concerned with parental involvement, parental supervision, parental monitoring. The goal is behavior change in the adolescent, but we’re going to hope for behavior change on the adult level as well as the school and community level, in support of that individual or peer-level change.

How is the LIPRC working to overcome these challenges?
We’ll be working closely with the South Country School District and the Bellport Boys and Girls Club as well as an existing community coalition, called COMPASS: UNITY. The coalition has been around for a while and we will support their efforts.

One of our strategies to address these challenges is to create a youth group for the coalition. Right now the coalition is all adults and we meet during school hours. Twice a year, they do have night time hours, and there have been some youths attending those meetings, but we hope to institutionalize a youth group working out of the Bellport Boys and Girls Club to be the champions for this kind of change in the school-age group

Also, by providing evidence-based data, we will hopefully get this coalition to a level of professionalism where they have influence over the school and can get the school district to recognize that they need to include substance abuse prevention programs in their regular daily operation.

We’re trying to change the paradigm to seeing this as a health and safety issue in the community, to side step the“not my kid” attitude. (ie, “I have a good kid and drugs and alcohol prevention is not my issue.”) We see prevention as a community issue with a need for buy-in from the businesses and faith-based communities, the school, and the parents. Everybody that has a stake in the community needs to understand that it’s a health and safety issue, not an “us vs. them” issue. It’s everybody’s neighborhood and the bottom line is for the neighborhood to be healthier and safer.

We know that there are shared risk factors for substance abuse, delinquency, school dropouts and violence. When you reduce the risk factors for substance abuse, you reduce the risk factors for these other activities as well. Research done by the Social Development Research Group in the University of Washington indicates that reducing underage drinking will also reduce delinquency, school dropouts, and violence in the community.

Where do you envision LIPRC programming heading over the next 5 years?
That’s the sustainability plan that’s part of this project: To get the community organized enough to make an application to the federal government for continued funding for substance abuse prevention.

There is a longstanding funding stream called Drug Free Communities (DFCs). It’s a very, very competitive process with all of the US states and territories involved in an annual bid for federal funding to continue this work. You have to be at a very high level of functioning as a community coalition to make application and compete for these funds. But if you do get the funds, they are for five years at a time, and you can reapply once for another 5 years. The end goal of this project is to get the community up and running to enter into that competition and get the DFC funding. So they’ll have this first 4 years of district funding and then another 10 years of federal funding. And I think the community can do it. I’ve been doing this for quite a while, I’ve seen communities apply again and again for DFC funding and I think I have a pretty good sense when they’re ready. It’s a big deal to get federal money, but I think this community can get there. They have a lot of potential in the community that hasn’t been organized or coordinated. And that will be the job of our community Prevention Coordinator, with the rest of the LIPRC staff working behind the scenes.
Photograph of Mary Silberstein Title: Chair, Suffolk County Communities of Solutions; Division Director, Integrated Care & Behavioral Health Treatment Services
Organization: CN Guidance and Counseling Services
Additional Website: http://centralnassau.org/

What is the COS’s mission and some key objectives of your work in Suffolk County?
Our mission is to provide a strength-based system of care that ensures access to developmentally and culturally appropriate prevention, treatment and recovery services for Suffolk County communities. Our key objective is to improve access to and quality of prevention and treatment service for substance use disorders.

We do this by designing Task Committees for key issues to support change and improvements. For example, we have a school outreach committee that has created a Speaker’s Bureau Brochure that provides free key-note speakers about prevention and treatment for schools or libraries for the community. We also have a Public Health Education committee and Data Committee who identifies and gathers data relevant to our mission, so we can measure the accomplishments of the various COS activities.

The COS and our Task Committees are made up of our stakeholders, not just treatment providers, but very important stakeholders. For example, Stony Brook University Hospital, physician representatives, parents, the Suffolk County Police, Probation, and the Police Commissioner’s aide. We have Suffolk County legislators and their aides that come to the meetings and also sit on some of the Task Committees and participate. Further, various youth bureaus and the Suffolk Community College Chemical Dependency Counseling training program come. We have families come, people in recovery come. And we’re all working together, it’s so invaluable to have this partnership, and our only agenda is to help.

What are some of the challenges that the COS faces in the area of substance use disorder prevention and advocacy?
People don’t know where to go for help, they don’t know how to access services, and they don’t know about the 911 law. People use drugs and alcohol until they’re sick and tired. And when they’re sick and tired, when the consequences have become so great, they’re apt to say, “I want help.” And we as treatment providers, hospitals, doctors, nurses, etc., need to be able to say, “This is where you can go to get help. ” My own vision is that one day when somebody goes into the ER, there’s somebody right there who can talk to them and get them connected right away to a treatment program. And they don’t even have to pass go; they just walk in, they get help. Period.

Our system, and this goes for all systems: They’re difficult. And I think that it’s our responsibility to make sure that the systems are easy for folks to be able to use when they’re in crisis. We need to have it out there as much as possible, so that when somebody is in crisis, they can go to a police officer, they can go to a priest, a rabbi, a doctor, a coach, a parent or a school teacher, and they all know where to get help. And that’s our main objective, how do we communicate, and how do we improve that communication, in order to make it possible for somebody to access treatment.

Another challenge is getting people to call 911 when there’s an overdose situation. People don’t know where to call for help, or they don’t know if there’s going to be a legal problem when someone is using an illegal substance, so they’re not that quick to call 911. This really speaks to raising awareness about the NY State Good Samaritan Law, which provides protection from arrest and prosecution for those seeking help for the victim in the event of an overdose.

How is the COS working to overcome these challenges?
From the beginning, recognizing that people who are in crisis need to know where to go for treatment. So we came up with the Community Resource List. It’s a comprehensive quick reference list of all the substance abuse disorder agencies that can be used in emergency or non-emergency situations in Suffolk County. We’ve distributed and educated the tool to every police precinct in Suffolk County. We also reached out to EMTs, ERs, school districts, libraries and various other organizations to share it with our community.

Today, you can find the list on the Suffolk County web site, which we update and maintain. You can now search by location and access the phone number, and the ages that the particular program will see. It also has a legend that indicates who will see somebody who is pregnant, who works with families, etc.

We’ve put on Parent Forums to empower parents with an understanding and information about substance abuse issues. We also brought together school kids and did a whole day of exercises with them regarding addiction and how to prevent it. We asked some very easy specific questions, such as: “If you had a friend or if you yourself were having a problem with drugs or alcohol, who would you go to?” We put it up all around the gymnasium that we were in, and 9 times out of 10 the kids were saying that the person they would go to would be their coach. So if the coach is the person that the kids are going to, what we have to do as treatment and prevention specialists, to make sure that the kids get access to treatment or learn how to prevent, is meet with the coaches. We put on a forum and met with coaches and provided education.

To address the overdose issue, we developed “Don’t Run - Call 911” flyers. The message is, the sooner you get help for somebody who might be overdosing or experiencing alcohol poisoning, the better. So as soon as you see that, call 911. They will come and you will not get in trouble. This campaign brings awareness to this challenge.

We also were involved in promoting Narcan® (naloxone) and how Narcan saves people from overdoses. Suffolk County has a big push to make sure that there’s training and providing information on where training can take place, so that if you’re a family member you can learn how to dispense Narcan. If you’re somebody who uses, you can learn how to use Narcan on the person next to you if they’re overdosing. And we’ve created flyers about that and gotten them out into the community. We reach out to as many people as we can. So there’s a lot that we’re doing. And we’re doing it together.

What have been your biggest accomplishments so far as an organization?
Our biggest accomplishment has been the Suffolk County Community Resource List, as it improves access to treatment. The one page list provides contact information on all the licensed drug and alcohol treatment programs in Suffolk County, as well as the 24/7 hot line information where individuals can receive immediate help (631-979-1700).

Another big accomplishment was our Screening Brief Intervention, Referral to Treatment (SBIRT) implementation and awareness, about 5 years ago, COS took on the task of educating the healthcare community on SBIRT. We visited hospitals in Suffolk County and met with the Administrative and Emergency Room staff, to talk about their implementation of SBIRT in the ER. We also outreached to doctor’s offices to educate them about SBIRT and the value of using SBIRT, and also that they could bill for it.
Photograph of Carla Nelson Title: Senior Director, Ambulatory Care & Population Health
Organization: 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 tha’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.
Photograph of Jay Enden Title: Medical Director, Eastern Region
Organization: Northwell Health

Please give us a summary of your organization:
Northwell Health, formerly North Shore-LIJ Health System, is a network of 21 hospitals and thousands of healthcare providers dedicated to clinical care and community health. It covers the New York metropolitan area, including Long Island, New York City and Westchester County, and incorporates multiple regions. I was made the Medical Director of the Eastern Region in May. The new structure offers, among other things, a means of defining, consolidating and leveraging best practice across a large geographic area.

Who does your organization serve?
The Eastern Region of the Northwell Health system includes Glen Cove Hospital, Huntington Hospital, Peconic Bay Medical Center, Plainview Hospital, Syosset Hospital and Southside Hospital. I was formerly the Medical Director of Southside.

How has your organization begun to experience the shift to value-based payment?
We all embrace the opportunity to deliver more patient-centric care, but the current healthcare environment still makes it challenging to provide integrated care for many types of complex patients. Northwell’s Health Solutions, for example, is aligning organizational resources, such as analytics, care coordination, and best practices models to enhance clinical integration. Since defining and establishing optimal ways to deliver value-based care is a journey, innovation is important. It is necessary to test new ideas and to explore new partnerships.

When I was Medical Director at Southside, we looked at groups of patients frequently using the emergency department. We discovered that there was a lack of alternatives, or a lack of knowledge of alternatives to using the ED. We also realized that we did not have a complete understanding of the underlying drivers of health care utilization, and how we could best address them. Through programs like DSRIP and MAX, I am hoping we can take these insights to a wider audience.

What is the difference between DSRIP and MAX?
DSRIP (Delivery System Reform Incentive Payment program) provides the overall funding for improved Medicaid services via Performing Provider Systems (PPSs), while the MAX Series Program (Medicaid Accelerated eXchange) is a program being offered by the New York Department of Health as part of the DSRIP program. Where DSRIP focuses on a statewide delivery system reform, MAX is set up as a local process improvement for specific patient populations to impact DSRIP quality measures and improve patient health.

Why is your organization participating in the MAX Program?
We are participating as part of an effort to better coordinate clinical care, to better understand what ultimately drives high-risk patients to resorting to high utilization behavior, and to share best medical practices throughout the Eastern region of Northwell.

Right now the MAX Series program focuses on process improvement for those “super utilizers” who spend a lot of time in hospital emergency departments and as in-patients. We are looking at all patients fitting the definition of a “super utilizer”— someone who has been admitted at least 4 times. The goal is to reduce avoidable hospital admissions and ED use by 25% over the next 5 years.

What do you hope the MAX program will accomplish for your organization in the future?
We need to understand the drivers and characteristics of healthcare “super users.” That way, we can develop a longitudinal history that can give us the insight to break the cycle, and provide an alternative to admissions. This sort of information can help us solidify a team-based approach to this particular population. By identifying and strategically mitigating the drivers of excess utilization (and they are not all clinical), we may be able to help patients before they become “super utilizers.” Participating in MAX will allow us to test things that may help.

Explain processes your organization has put in place and their outcomes.
We have found that “Super Utilizer” patients may need moderately inexpensive people to help them, not necessarily health care providers, but resource coordinators to help link patients to outpatient resources, such as transportation or other community services. A local health information exchange helped to immediately identify patients and to send an alert to an interdisciplinary team. Frontline members of this team would quickly meet the patient in their current setting. Team members were trained to conduct structured individualized risk assessments, to define drivers and mitigation strategies for admission and readmission (through interdisciplinary patient-centric huddles), and to establish and maintain linkages to clinical and non-clinical services after discharge. The linkages may include establishing a stable connection between high risk patients and appropriately resourced providers, such as Medical Homes. This strategic “bridging” of inpatient and outpatient care is critical, yet difficult.

We started with a limited cohort—about 150 patients—but since we started in early 2016 we have reduced hospital readmissions by about 50% and emergency department use by about 60%.

What value does the SCC bring to patients under the MAX/DSRIP program?
SCC has been wonderful! Among many things, it has allowed us to have medical homes for a number of these patients. SCC helps identify resources for us and the patients. Hospitals haven’t traditionally been set up as preventive health institutions. By integrating community resource information with clinical information, and providing feedback, SCC is making our job easier.

What, in your experience, are the top (three) guiding principles of a successful population health management program?
  1. Patients need access to a structured multidisciplinary care model that has the right combination of clinical (including behavioral health) and non-clinical talent. The individuals involved should be readily available, at appropriate levels of care, to high-risk patients.
  2. Infrastructure should include some sort of information exchange, and have defined team members who can use this health information to track compliance with individualized risk mitigation strategies as well as utilization patterns.
  3. There should be a commitment to a sustainable payment model that leads to the ability to implement this kind of organizational commitment on a large scale. High-risk patients need to see that they have an effective alternative to seeking acute care services. Similarly, providers of acute care services need to be confident that they can safely hand patients off to an effective partner.
Is there anything else you would like to add about MAX or DSRIP?
We only started with the MAX Program early this year. Our early efforts are good-but I would like to see a more stable infrastructure. We are learning valuable things, and will continue to until the funds run out, but the payment model is illogical. We will only be able to improve our health care delivery if we can rely on a stable funding base.
Photograph of Jeff Steigman Title: Chief Administrative Officer
Organization: Family Service League
Focus or Specialty: Family Medicine
Number of Practitioners in Group: Over 100

Please give us a summary of your organization
Family Service League (FSL) is a not-for profit, non-sectarian, community based human service agency that has served Long Island since 1926. This year is our 90th anniversary. We have more than 20 locations, primarily throughout Suffolk County, as well as a few small programs in Nassau County. We provide a comprehensive network of care across Long Island with a full continuum of services, including mental health and substance abuse, clinics, children and youth programs, senior services, vocational programs, family support programs and housing and homeless services.

Who does your organization serve?
FSL helps about 50,000 Long Islanders each year. We operate strategically placed family centers that offer a continuum of care to address the multitude of challenges faced by children, families and other individuals - from infants to elders.

On which DSRIP project(s) are you involved in and why?
We’re most involved with Project 3ai - integrating behavioral health and primary care. That’s something that we’ve been doing as an agency since 2011 in terms of really making a concerted effort to implement integrated care programs in a bi-directional manner.

Since 2011, we’ve partnered with Northwell - specifically Southside Hospital - where we brought in primary medical care services to our Bayshore site. I refer to it as our behavioral health home, because that’s our flagship site where we have over 20 programs just in that building.

Many of the clients are severely and persistently ill, with significant mental health or chemical dependency issues - so they’re some of our most vulnerable clients.

It’s been a wonderful partnership that has grown over the years. We have over 300 clients who we serve in this particular model, where we have primary care services offered at Bayshore. Our various programs make referrals for this service, and we also more recently partnered with Southside’s family medicine residency program, so we also have residents there who see the clients.

Based on the success of this program we are planning to build a 10,000-square-foot health and wellness center, adjacent to the property of our Bayshore site, which will focus on integrated care. This will allow us to scale the efforts even further, and we have the full commitment and support from Northwell to continue to be our partner in this endeavor.

Also, over the years, and we were on the cutting edge with this just before DSRIP, we’ve embedded social workers in pediatric and primary care offices, so we have social workers on site able to provide increased access and improve outcomes, because as we know, many times the’re the gatekeepers for clients who are in need of services from primary care physicians. So we do it bi-directionally.

How has the population you serve benefited from Behavioral Health and Primary Care integration?
Whether it’s the primary care in our behavioral health site, or behavioral health providers in our primary care sites - it has absolutely improved access to care. Having someone there as part of the team - working with them - has resulted in better outcomes.

The program where we have the primary care in our Bayshore site - that’s called the Community Health Care Collaborative. Over the years we’ve been tracking key performance indicators - collecting data - and using business intelligence tools to analyze that data. And we have been able to objectively show that the outcomes have improved based on pre- and post- participation in the program.

To give you a couple of examples, we’ve increased the number of A1C screenings for those who meet certain criteria and who should be screened. And perhaps most importantly, we’ve been able to reduce the annual rate of ER visits for this cohort by about a visit per year among those who we were tracking, as well as make a significant difference in stabilizing medical conditions for those who were previously uncontrolled.

And the other benefit has been improved communication - sharing of information and treatment planning - in terms of being able to track and discuss the most vulnerable who we serve.

Can you share some current strategies in integrating Behavioral Health and Primary Care?
One thing we try to do, when we have social workers in our pediatric and primary care offices, is we really try to present it as one face. When a patient comes in they don’t see it as two separate practices. This means the same support staff is welcoming the client, the support staff has access to a shared calendar, so there’s no difference in making appointments for behavioral health or primary care. We try to make it as seamless as possible.

Another strategy is information sharing. Some of the social workers in the medical practices are given access to the EMR - so they have access to medical information. The social workers there will print out relevant information, whether it’s a conference assessment, a treatment plan, or the progress notes, on a real-time basis when the’re completed, which will be scanned into the EMR. So when the doctors see a mutually shared client who is seeing a social worker, they’ll have real-time information at their fingertips so they’ll know what’s going on with them.

We also try to be consistent with regard to the fidelity of integrated care models by focusing on utilization management. So, for example, if someone needs longer-term care, or if a case is very complex, we will transition them to our primary specialty clinic, where they’ll have a full team as compared to just having services in the primary medical office.

We really try to keep movement within the census - we attempt not to have bottlenecks despite the demand often outpacing resources. In general, it’s a faster pace and aligns with the pace of the medical practice, which also means the length and duration of treatment may be shorter, unless we need to transition the client to one of our clinics.

The last strategy, which has been really critical, is being able to have an operational process to provide psychiatric services for those patients who have more complex medication needs. So the primary care physicians or the pediatricians will often prescribe the front line medication - but if there’s a more complex case, there are different ways to handle it. This includes having the client evaluated by our prescriber at the respective clinic and having him/her prescribe the medication until the client is stable and can be referred back to the primary care physician. It may also involve consultation type services that serve to assist the medical practitioner.

What are some obstacles you’ve encountered in integrating Behavioral Health and Primary Care that are currently in place?
Technology - we currently don’t have one platform or one database where we have a shared EHR. But I think in the future they’ll be more options for having a shared record and that will help with developing a unifying treatment plan.

Currently, we also are billing separately which presents certain challenges. But in the future, as we move toward value based and bundled payments - I think there will be some opportunity for different models that will translate to shared accountability, further integration and greater sustainability.

Another obstacle - also based on the current fee for service fiscal model - is that you’re not getting reimbursed for certain things like finding the time to have interdisciplinary team meetings and providing care management, which is crucial to the success of integrated care. A lot of the current meetings are informal - so being able to have carved out time that is outside of direct service to discuss cases is vital.

And finally, being able to pull out necessary info from each of the disparate EHRs and being able to use that information in an informed way is currently a challenge.

DSRIP’s purpose is to fundamentally restructure the health care delivery system by reinvesting in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25% over five years. How do you envision your organization adapting/evolving to meet the needs of this health care delivery model shift?
We’re not a direct service provider. We are a unique convener of many of the different entities which are key to the PPS’s success. Our charge is staying involved in the conversation at a national, state and local level, while bringing lessons learned to our providers. As well, to communicate the importance of Community Based Organizations (CBO’s) and their long-standing, trusted relationships within low-income communities and among high need individuals. Simultaneously, CBO’s will need to build staff capacity and infrastructure to meet the requirements of the DSRIP projects.

How do you see DSRIP 3ai Behavioral Health and Primary Care Program affecting or adding to the strategies you have in place?
DSRIP will help with providing the IT infrastructure and resources that will allow for the secure exchange of information that will be important for reporting and performance monitoring. The Suffolk Care Collaborative will also be instrumental in driving and allocating resources to scale integrated care efforts throughout Suffolk County, and adhering to evidence-based models and approaches. The technical assistance that has been, and will be, provided translates to uniformity in approach, which is essential for such a project.

Along with that, they’re going to define measures that will be used for screening, so different measures won’t be used by different providers, which will help to identify those clients who are in need earlier in the trajectory. I think DSRIP will be very critical for monitoring treatment response and outcomes.


Photograph of Geralyn Randazzo, RN, MS, NEA-BC Title: Vice President for Care Coordination
Organization: Northwell

Please give us a summary of your organization
NorthShore-LIJ is an integrated health system consisting of 17 hospitals, many specialty programs and institutes including Long Term Care, Home Care and Hospice Care, and more than 400 ambulatory and physician practices. We also own and operate North Shore-LIJ CareConnect, a health insurance company.

Who does your organization serve?
We serve virtually every type of patient population in Manhattan, Queens, Staten Island, Nassau, Suffolk and Westchester.

Why did you choose to participate as a partner of the SCC?
There are several reasons. As we’re all moving towards valued-based case, we were interested in seeing what we could do to improve Transitions of Care for all of our patients but particularly our most vulnerable populations. It made sense for us to partner with the SCC as well as several other PPS organizations as we all embark on the journey of care redesign.

On which DSRIP project(s) will you be working and why?
I am leading a team for the NorthShore-LIJ hub on implementation of the Care Transitions project.  I am also involved in behavioral health integration, and the PCMH team. As a system we are participating in almost all of the projects and have established a project management office to ensure coordination and integration of the various teams and workgroups.

Can you share some current TOC strategies that have been successful at your Health System?
Over last two years, we’ve noticed that if we can have contact with inpatients during their stays, or if we can get introduced to them through providers they trust, that having that face-to-face engagement really helps patients to participate.

It’s also critical to really understand risk stratification and who is the target audience. We look at making sure that the strategies we’re deploying are aimed at those at the highest risk - the ones who need it the most. We are seeing better outcomes when we are able to include high-touch strategies among the higher risk populations.

What are some obstacles you’ve encountered with the TOC strategies that are currently in place?
What stands out the most - what we find the most challenging - is the IT infrastructure, and the ability to communicate across the continuum.  With multiple systems in use across the various hospitals and community-based providers, communication from one location to the next can be challenging. As a result, workflows are sometimes cumbersome and lead to lack of staff efficiency.

How do you see the DSRIP TOC Program effecting or adding to the strategies in place?
I think the primary difference is that the program brings in a lot more diversity, which forces us to work with different partners. This is a great benefit. It gets all the stakeholders aligned, and gets everyone to move faster.

Can you share how was your experience in participating with the TOC Program Workgroup and the recent presentation from Dr. Amy Boutwell on Strategies to Reduce Avoidable Hospital Readmissions?
I found it extraordinarily helpful. It was nice to put faces with names. But mostly it was great being able to sit at the table and connect to the resources we will be working with on these projects.

Since this initiative is so new, we don’t yet have all the answers. But, because there are many people working on it, being able to share knowledge and collaborate makes a huge difference. It puts all the stakeholders together and builds and fosters relationships that were previously established.
Photograph of Deborah Schafmeyer, RN, RAC-CT Title: Director of Nursing
Organization: Island Nursing and Rehab Center

Please give us a summary of your organization
We’;re a 120-bed, not-for-profit skilled nursing facility located in the middle of Long Island. Our residents are from the north shore, the south shore - from a number of different hospitals.

Who does your organization serve?
We predominantly care for geriatric patients, but we do get a younger population on the sub-acute unit. Approximately one third of our patients are here for short-term rehab, while the other two-thirds are long term.

Why did you choose to participate as a partner of the SCC?
The main reason we chose to participate was to improve the quality of care that we provide to our residents. To decrease readmissions, but also to improve communications across transmissions throughout the healthcare setting. To improve patient outcomes. And ultimately to improve the patient experience short term and long term.

What do you hope the DSRIP program will accomplish for your organization in the future?
I’m hoping that it will strengthen a lot of the collaboratives that we have with area hospitals and other nursing homes, by improving the communications for these patients that are coming to us, should we have to send them back to the facility, as well as for acute illness, for example. I’m also hoping that this collaborative is going to help us improve and develop processes that will be longstanding; that we’ll be able to carry on for years to come. And again, to make sure that we’re providing the quality care that the residents really deserve.

What do you hope the DSRIP program will accomplish in general?
I’m hoping that it will provide us with guidance and a means of developing those protocols and processes that will ultimately decrease readmissions across the continuum of care. I think one of the big points as well is that I’m really hoping it will continue, because we’ve already seen an improvement in communications across the continuum of care with the facilities that we are affiliated with, who send us patients and that we also send back to. I’m hoping that will continue to occur and become stronger over time so we can develop protocols that meet all the needs of the patients across the transition of care.

The SCC organized a two-day training for the INTERACT in early November for all the SCC SNF partners. What did you find most valuable from the training program?
The information on the INTERACT tools that are utilized and how they coordinate - how they could be and should be utilized throughout the facility and across the continuum of care, I felt was the most beneficial. They went through a lot of the INTERACT program: changing conditions, care paths, the SBAR tools- how all of those tools, when utilized together, could improve care processes. I felt that was the most beneficial piece of the certification training - that they were able to tie some of those concepts together for facilities and nursing directors that will be implementing or have implemented these protocols.

Were you able to network with other SNFs to discuss shared experiences and best practices?
Yes, absolutely. There was a lot of discussion at the program during both days among different nursing directors and different nursing homes. Some have implemented the tools, others haven’t, and still others have utilized some tools and not others - so it was good to learn from other partners what’s worked, what hasn’t worked, and where the challenges are. Being able to see some of the similar challenges that other facilities are having as well - such as the whole readmission prevention, and also use of the INTERACT tools was very helpful. So it was a very good networking experience.

What are your expectations of the “facility champion” role for your SNF?
Being one of them myself - as well as my Assistant Director who also attended one of the training sessions- the expectation for that role is that we’re going to really do it. We’re going to champion this whole program for the use of INTERACT tools, provide ongoing education, be resources for the staff - particularly the nursing staff that is required to utilize these tools and may have questions. To provide feedback to the staff on data statistics, how the completion of these tools is going. We’re setting our goal to be a constant resource.

How do you think implementing INTERACT will improve the quality of patient care?
I really feel that it’s going to improve care. We have already implemented and utilized a number of the INTERACT tools and we have seen a lot of improvement because it’s a standardized means - an evidenced-based means of communicating and documenting. It provides a standard process for all of the staff to follow in any given situation - and provides guidance as well.

Can you describe the general action plan with how the INTERACT Quality Improvement Program was rolled out within Island Nursing and Rehab?
We started with the “Stop and Watch” tool - a form that was utilized and continues to be utilized by the non-clinicians - whether CNAs, or housekeepers, or engineering - whoever it might be. We provided house-wide education to all of the staff on what the tool was, the intent of the tool, the meaning behind it and how it was shown to improve care process. We rolled that piece out first - we also incorporated family members and residents into that as well, so if they noticed changes we encouraged them to fill out the “Stop and Watch” tool.

Once we implemented that, we began with the SBAR tool. All of the licensed nurses were educated on the SBAR with the same principles: the research behind it, the evidence behind it, how it was a standard of practice and an effective communication tool. We rolled that out over a year ago and we’ve been utilizing that as well.

We’re also right in the middle of re-education because we’re now adding more tools. So we’re re-educating on the completion and use of the SBAR and we’re also adding the Chain of Condition and Care Path from INTERACT for all of the nurses to also utilize because, after the training, we feel it’s really beneficial to use these tools in collaboration with the others to have better outcomes.

A lot of it is ongoing education, getting feedback from the staff to find out what’s working and what the challenges are, and trying to modify the processes from there going forward to see how we can best continue to utilize these tools in the best ways possible.

Since your facility has implemented the INTERACT Quality Improvement Program, can you share some best practices for a successful implementation of the program?
Ongoing education is key for all of the staff - from the directors all the way down to the direct care staff and non-clinicians. It’s important that all of the staff continues to know that we’re utilizing these tools and are part of this practice initiative, I think, to keep the awareness going - as well as maintain compliance with all the tools. Our administration also has regular team meetings with our affiliated hospitals specifically regarding readmission and SBAR tools, and that has been what I feel has become best practice.

What we do now is utilize the SBAR even with our transfers. So, for example, if we’re sending a resident out to a hospital, that SBAR tool goes with that resident. We send a copy of that form to the receiving hospital - and we also call and give a warm hands-off report based on that SBAR tool. What has occurred now as a result of all of our meetings with our affiliated community hospitals is that a number of them now have dedicated phone lines for SNFs to use when they’re calling to provide a warm hands-off report based on the SBAR. That really initiated between Island and Mather, which is our main partner for the IMPACT program. But now it’s being rolled out to a number of a facilities because it’s been proven to be effective. Now when a nursing home calls a hospital they can give a really thorough report to a nurse manager or a physician explaining what’s really going on with that resident, and what exactly it is that that resident needs.

Can you share some general challenges you experienced during implementation?
One of the challenges we feel and that I’ve also heard through networking and at the certification class is the amount of time that it takes to use SBAR. The SBAR was initially two pages long, but now, with all of the modifications, it’s a four-page form. So the concern is that it’s getting so long that it’s almost counter-productive - it takes too long to fill it out and read it so it’s almost defeating the purpose of the SBAR. It was meant to be a quick communication - but now it’s become so long that there’s a fear that it’s not going to become as useful as it has been.

I also know some facilities have been very successful with the Stop and Watch, as far as utilization. But we’d still like to see better participation with the Stop and Watch - it’s been a little more challenging among non-clinicians. So we continue to do education about the importance of that tool.

Transformational Change
As healthcare reimbursement changes, hospitals, health systems and providers must adapt to a new paradigm in which providers are rewarded for meeting quality objectives for their patient populations. The emphasis is clearly shifting from volume to value, and organizations that focus on providing patient-centered, quality health care across a population will come out ahead. How has your organization begun to experience this shift?
Again, from an organizational standpoint, through developing specific protocols with readmissions being one, we’re starting to see a decrease in readmission rates to the hospital. So we’re able to focus more on full case reviews; determining what’s avoidable and not avoidable. We can change protocols if needed. So in that respect I think, although this initially had a financial drive behind it with potential penalties, we’ve already seen a significant increase in quality because of the protocols that have developed out of this program. We’re able to keep residents in the facility longer, and sometimes not send them out at all, and early recognition of changing conditions has been an ongoing process for us along with re-education of the staff. So overall we’re really seeing a shift in everything we do.

DSRIP’s purpose is to fundamentally restructure the health care delivery system by reinvesting in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25% over five years. How do you envision your organization adapting/evolving to meet the needs of this health care delivery model shift?
We’ve also had to look at staffing patterns, adding more practitioner hours to the day. We’ve extended our evening hours, and looked at restructuring the nursing staff hours to really try to meet the needs of when we’re seeing a lot of these re-admissions. We looked back at the prior year to see when we saw more patients going out to the hospital, and saw we needed more support from a practitioner level in the evenings, so we added practitioners during those hours to help support the nurses and help prevent readmissions.

What in your experience are the guiding principles of a successful population health management program?
The Centers for Disease Control and Prevention (CDC) identifies 5 factors that contribute to population health: biology/genetics; individual behavior; social environment; physical environment; health services. Your zip code is more likely to determine your health outcomes than your genetic code. We clearly see this by looking at Long Island data. Healthcare providers have focused heavily on providing health services and less on access to them or socio economic factors-like the social and physical environment effects. This has led to inequitable health outcomes for at-risk communities at a high cost to the health care system and society.

What value does the Suffolk Care Collaborative bring to patients under the DSRIP program?
For so long on Long Island, care was delivered in silos. The majority of health care was not provided in the community and there was a lack of integration-related to critical resources and services. Through the SCC, a cross-section of leadership is working together to figure out how we can be more innovative, while achieving better outcomes. I think that the importance of this collaborative can’t be highlighted enough.

How do you see this project making an impact on our communities, workforce and populations we serve?
To improve health outcomes of low income individuals and reduce healthcare costs, the Centers for Medicare and Medicaid Services created incentive programs for states (like DSRIP) to restructure the way healthcare is paid for so that the other determinants of health are addressed and incorporated into service delivery. If the project is successful on bringing in and partnering with those that have a long standing presence and relationship with the community, the impact will be unprecedented.

Transformational Change. 
As healthcare reimbursement changes, hospitals, health systems and providers must adapt to a new paradigm in which providers and CBOs are rewarded for meeting quality objectives for their patient populations. The emphasis is clearly sifting from volume to value and organizations that focus on providing patient-centered, quality health care that is culturally sensitive and linguistically appropriate across a population will come out ahead. How has your organization begun to experience this shift?
Again, from an organizational standpoint, through developing specific protocols with readmissions being one, we’re starting to see a decrease in readmission rates to the hospital. So we’re able to focus more on full case reviews; determining what’s avoidable and not avoidable. We can change protocols if needed. So in that respect I think, although this initially had a financial drive behind it with potential penalties, we’ve already seen a significant increase in quality because of the protocols that have developed out of this program. We’re able to keep residents in the facility longer, and sometimes not send them out at all, and early recognition of changing conditions has been an ongoing process for us along with re-education of the staff. So overall we’re really seeing a shift in everything we do.

What in your experience are the top three guiding principles of a successful population health management program?
Education, communication and collaboration. With any of those lacking it’s difficult to have a successful practice or protocol for any one initiative.

What value does the Suffolk Care Collaborative bring to patients under the DSRIP program?
In a general sense it brings a lot of value. It’s a driving force behind a lot of facilities coming together to collaborate on patient care. Id’ say patients are receiving more focused care now. Through effective communication we’re able to say "this is what we’re seeing and we already did these three tests, they’re on the SBAR." I think, ultimately, the benefit to the residents is that, through more effective collaboration, we’re able to better serve the population and cut down on the redundancies. The better we become at communicating with each other across the continuum of care I think the better care the residents get.

How do you see this project making an impact on our communities, workforce and population we serve?
I could see it potentially increasing the workforce because to provide quality care you need appropriate staffing. Part of that challenge, particularly for long-term care facilities is the funding and reimbursement. When you want to provide quality care, you need appropriate staff to do that. One of the biggest challenges to SNFs for example, is that reimbursement rates are low, which makes it hard to be able to afford the staffing.
Photograph of Gwen O'Shea Title: President/CEO
Organization: Health & Welfare Council of Long Island

Please give us a summary of your organization
We are a regional, nonprofit umbrella agency working closely with hundreds of health and human service providers to respond to the needs of those most vulnerable and at-risk on Long Island.

Who does your organization serve?
The most vulnerable and at-risk residents on Long Island. There are many factors that put people at risk, including social injustice, chronic poverty. The symptoms they create, like: poor health outcomes or homelessness are more different to address on Long Island because of the high, regional cost of living. The make-up of those most in need is always evolving, For example, Long Island has the third-largest number nationally, of newly arrived children from Central and South America who have left as a result of civil unrest and violence in their counties. Many children come to Long Island - some to connect with their parents who came previously, while others are sent by their parents to connect with another family member who is already here. These children and their families face many barriers in accessing things that they are lawfully eligible for: like education and health care. HWCLI’s role is to facilitate the coordination of these critical services: education, legal and mental health supports. Our organization’s goal is to ensure that people have access to the services they need so they can live self-sufficiently.

Why did you choose to participate as a partner of the SCC?
While the goals and outcomes certainly seem daunting, there is a tremendous amount of opportunity. There is an opportunity to transform the health care system so that it puts the patient at the center and comprehensively addresses their needs. A key part of that includes reforming the payment and financial structure to ensure the capacity of all providers that touch a patient. SCC recognizes the role of social determinants of health on individuals’ and communities’ overall well-being. The SCC partnership brings together a cross section of providers-who previously, might have been seen as "unlikely partners".

On which DSRIP project(s) will you be working?
Our organization is the Project Lead on 2di - Patient Activation Measures® (PAM), and we’re on the Cultural Competency Committee as well. I also serve on the SCC PPS Board of Directors

What do you hope the DSRIP program will accomplish for your organization in the future?
Our hope, from an organization’s perspective, is to see the foundation built for an ongoing respectful relationship where we work collaboratively and recognize each other’s strengths. I hope the program will provide comprehensive care in ways that the individuals we serve find acceptable. And I hope that there will be recognition and acceptance of the costs - for physical care, mental health care, and housing supports for example, that are funded at the cost in which they are incurred. That we recognize the value of all the services. This has been happening already with our long-standing relationships - and we hope to see it within the program as well.

What do you hope the DSRIP program will accomplish in general?
DSRIP provides an opportunity to reshape health care services for at-risk Long Islanders to be community based, patient-centric and outcomes driven. Our hope is that we actually do that--create a comprehensive health system which provides care that is culturally competent, accessible, and affordable. That there is equitable care regardless of community in which it’s provided.

DSRIP’s purpose is to fundamentally restructure the health care delivery system by reinvesting in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25% over five years. How do you envision your organization adapting/evolving to meet the needs of this health care delivery model shift?
We’re not a direct service provider. We are a unique convener of many of the different entities which are key to the PPS’s success. Our charge is staying involved in the conversation at a national, state and local level, while bringing lessons learned to our providers. As well, to communicate the importance of Community Based Organizations (CBO’s) and their long-standing, trusted relationships within low-income communities and among high need individuals. Simultaneously, CBO’s will need to build staff capacity and infrastructure to meet the requirements of the DSRIP projects.

What in your experience are the guiding principles of a successful population health management program?
The Centers for Disease Control and Prevention (CDC) identifies 5 factors that contribute to population health: biology/genetics; individual behavior; social environment; physical environment; health services. Your zip code is more likely to determine your health outcomes than your genetic code. We clearly see this by looking at Long Island data. Healthcare providers have focused heavily on providing health services and less on access to them or socio economic factors-like the social and physical environment effects. This has led to inequitable health outcomes for at-risk communities at a high cost to the health care system and society.

What value does the Suffolk Care Collaborative bring to patients under the DSRIP program?
For so long on Long Island, care was delivered in silos. The majority of health care was not provided in the community and there was a lack of integration-related to critical resources and services. Through the SCC, a cross-section of leadership is working together to figure out how we can be more innovative, while achieving better outcomes. I think that the importance of this collaborative can’t be highlighted enough.

How do you see this project making an impact on our communities, workforce and populations we serve?
To improve health outcomes of low income individuals and reduce healthcare costs, the Centers for Medicare and Medicaid Services created incentive programs for states (like DSRIP) to restructure the way healthcare is paid for so that the other determinants of health are addressed and incorporated into service delivery. If the project is successful on bringing in and partnering with those that have a long standing presence and relationship with the community, the impact will be unprecedented.

Transformational Change.
As healthcare reimbursement changes, hospitals, health systems and providers must adapt to a new paradigm in which providers and CBOs are rewarded for meeting quality objectives for their patient populations. The emphasis is clearly shifting from volume to value and organizations that focus on providing patient-centered, quality health care that is culturally sensitive and linguistically appropriate across a population will come out ahead. How has your organization begun to experience this shift?

From an organizational perspective this has been a conversation that we have been having for quite a while with our member organization. Rather than being paid to simply provide a service, CBOs will be paid based on reporting and then for performance. This requires a good amount of CBOs to think completely differently than they have before related to outcomes, payment and risk. By using data to drive what we do, looking at outcomes to measure success, and sharing that data, we can better serve our target populations. However, not all of the communities’ needs can be reflected in data goals. There will be times when additional resources need to be directed toward a community need in order to best serve the population.

Cultural Competency and Health Literacy are important to reducing health disparities and improving access. Where are the opportunities for the DSRIP program to develop a more culturally competent and linguistically appropriate responsive health care delivery system?
Everywhere! While health literacy issues affect all people, it disproportionately affects those most vulnerable and at-risk--the target population of the DSRIP project. As a collective, we have a responsibility to not only practice cultural competency, but to empower individuals through health literacy. Throughout all of the different committees we have opportunities to train, engage and ensure that we are doing all that we can to meet the needs of our diverse communities. Which includes people with chronic diseases, the LBGT community, immigrants and the limited English proficient population. But to really be cultural competent, it’s not just checking off a box that says we did "x" number of training. It’s an ongoing commitment to key components, such as: valuing diversity, having the capacity and willingness for cultural self- assessment and developing adaptations to service delivery which reflects an understanding of cultural diversity. The leadership of the SCC has made it clear that focusing on cultural competency and health literacy is a top priority

How do you see cultural competency and health literacy making an impact on our communities, workforce and population we serve?
As I stated above, your zip code is more likely to determine your health outcome that your genetic code. Truly achieving cultural competency among the PPS providers, coupled with raising the level of health literacy of our patients? That would completely transform the health of our communities.
Photograph of Halim Kaygisiz Title: Director of Health Outreach Services
Organization: Economic Opportunity Council of Suffolk, Inc.
Focus or Specialty: Uninsured
Number of Practitioners in Organization: More than 20

Please describe your knowledge of the community and the target population for the project.

Our agency is focused on reaching the uninsured population in the Western region of Suffolk County. Through local census data we’ve been able to identify a number of towns with large populations of uninsured. Some towns have around 8,000; others more than 10,000.

We focus our efforts on hotspots in those towns where the uninsured are likely to congregate. Many are day laborers who wait in town centers hoping to find work with laborers and contractors.

How is the PAM Project aligned with the Economic Opportunity Council’s (EOC) mission and vision?
Our goal is to help people attain a level of self-sufficiency. The PAM project helps people do this by increasing awareness of services that are available to them.

The EOC then helps them access the resources they need. We try to connect them with service providers who can help them and make them self-sufficient over time.

Describe your approach to the PAM® Survey and how you introduce it to people.
We present it in different ways. We have about 21 staff members who are trained to conduct the survey. Two of them are dedicated CHWs who go directly to the areas where people are likely to congregate. I also go into the field on a part-time basis. The rest of the staff members present the survey during their regular contact with clients in the target population.

We use Apple iPads to administer the survey, which makes it easy to get the answers input immediately. Depending on how people answer the questions we get a feeling for their role in their own healthcare. Even though the survey has a health intro - it also goes into social and economic arenas, which gives us a wider breadth of information.

We’re getting a good response. Many people are willing to talk to us.

How do you train staff to be able to conduct the surveys?
We do a general training in a conference room using the PowerPoint training materials provided by Insignia Health. We do practice surveys on each other. And our staff is also trained on how to deliver the results.

What are lessons learned in the field? What works the best to find/identify people who would qualify for the survey?
You have to know where they are and meet them there. Uninsured are likely to be undocumented or unemployed. So we may go to a Department of Labor office, day laborer sites and soup kitchens. Places where people are likely to access other services that are complementary.

What are people asking the most for?
Access to insurance. For example, if we’re talking about undocumented individuals, they usually know where to get low-cost or free emergency and primary preventive care. But let’s say they need specialists for a chronic health condition like diabetes. They might need an endocrinologist, a foot specialist and an eye doctor. The type of specialized care that insurance would cover. But the clinics they normally visit aren’t able to give them access to these specialists.

That’s where we come in. We’re able to connect people with chronic health conditions to the specialized services they need.

Our goal is to help people become self-sufficient about their health. But you have to remember, you can’t get people to be self-sufficient if there’s no food in the refrigerator, no roof over that refrigerator, and no steady source of income to even keep that roof over their heads. And in the meantime their health takes a back seat.

Where do you anticipate need in the community?
I don’t think there’s one community in Suffolk County that doesn’t need help. The need does vary from town to town - but it would be nice to see more assistance provided. There are some huddled masses in Suffolk County that really need some help.

How has the survey’s been received by the community?
Overall, we’ve seen a lot of participation in the survey. We started about three weeks ago and already we’ve helped four people access Medicaid coverage.

Describe an encounter and how it made you feel to be able to help someone.
Yesterday I was asked to help someone with a cocaine and alcohol problem who was trying to access inpatient substance abuse services. I met the person in a public spot in a neighboring town and tried to find out what kind of help was needed.

Turns out this person thought insurance was needed to get into an inpatient treatment program not realizing there were options available to him even though he was uninsured.

I’m the connection. I explained the options and what could and couldn’t be done. I followed up today and the plan is to enter into the program on Monday. If there’s no bed space available we can at least get this individual to the top of the waiting list. We’re going to have contact every day.

That’s my job - that’s what I do. It feels good that I can do my job and help people. It’s become a routine for me. Follow up is important - it shows commitment - and proves support. It makes you feel invaluable.

What partnering Community Based Organizations/Social Services agencies has EOC engaged with so far?
We have partnered with the Association for Mental Health and Wellness and also partnered with Hudson River Health Care Inc., which is a Federally Qualified Health Center.

How are you leveraging existing CBO resources?
We use the existing relationships we already have with other agencies and service providers as well as knowledge of areas we know where we can reach those individuals who need insurance and offer them our services. It’s not only what you know but also who you know.

What is the biggest value proposition of the program?
Creating awareness that there are resources in the community that can help. You may have people who don’t need help now. But they have our contact information so, in the future, if they need help they know where to find it. We may not be able to offer everyone insurance, but they need to know that there is a local CBO that can help.

Where do you see the program going?
It’s still so early in the program so it’s hard to say. The potential is that the uninsured population among eligible individuals will dramatically go down - and more and more people would be helped regardless of insurance coverage.

Access to services is beginning to increase and funding for those services should increase. Human Service providers should become as valuable as a medical professional, because they can help a person in a state of crisis.
Photograph of Gail Schonfeld, MD, FAAP Organization: East End Pediatrics, PC
Focus or Specialty: Pediatrics
Number of Practitioners in Organization: Three full-time pediatricians

Please give us a summary of your practice.
We are a well-established, general private pediatric practice.

Who does your practice serve?
Local residents as well as urgent care services to people visiting the community.

Why did you choose to participate as a PPS as part of DSRIP?
I have always felt that there was a lack of adequate mental health services and wanted to do something to make them available to my patients. A few years ago, I began holding meetings in my building with mental health professionals and others who were interested in initiating mental health change in our community. We came up with some great ideas. You put a bunch of people together and it’s amazing what can be done.

It took time and effort but we obtained a grant and were able to start incorporating mental health services into our practice. It was fantastic having social workers available to co-manage patients. The patients loved it. Outcomes were better. It became clear to me that this was the way things should be done. But, once the grant ended so did the services. I then decided to hire the mental health workers myself and convince the insurance company to pay me for their services as a member of my staff. The challenge has been to get the payments to be adequate to pay for the costs of the care.

When I learned about the opportunities the Suffolk Care Collaborative offered, our practice was ready. There was very little we had to change. Now we can have social workers and a psychiatrist within our practice, and it will be much easier to care for people who can’t afford these types of services.

On which DSRIP project/s will you be working?
Our focus is on integrated mental health with physical health and we will be involved in many of the projects.

What do you hope the DSRIP program will accomplish in general?
A lot of times when people can’t afford mental health services and until a catastrophic event happens, they don’t get care and therefore end up in the ER. There’s simply a lack of access and too many bad outcomes.

I hope that this program will help keep patients out of the hospital when it’s not necessary for them to be there, by coordinating their care and providing services before it’s too late and early enough for the problems to be easier to treat.

What do you hope the DSRIP program will accomplish for your practice in the future?
Instead of seeing patients end up the hospital when there’s no reason for them to be there, we can see them intensively on an outpatient basis, and provide more personal care.

By being able to provide these services to children we can give them a healthy start in life, which can make all the difference for them. The real proof will be watching these children grow up into functional adults.

In your experience, what are the top three guiding principles of a successful population health management program?
Providing medicine, dentistry, and mental health in an integrated fashion. Clinical integration is part of it, the financial integration is the other part. We need to break down the silos and manage the patient together. We need to find what works best to keep the patient healthy. I also agree that screening, early diagnosis and timely treatment will be cost effective and with better outcomes.
Photograph of Michael Stoltz Title: Chief Executive Officer
Organization: Association for Mental Health and Wellness
Focus or Specialty: Mental health issues
Number of Practitioners in Organization: 125 staff members including professionals, paraprofessionals and peers

Please give us a summary of your organization:
The Association for Mental Health and Wellness is an organization offering services that address mental health issues. We have statewide and national affiliations and are one of 28 chapters of Mental Health Association (MHA) in NY State.

Our mission is to empower people and communities to pursue and sustain enriched, healthy, and self-directed lives.

Who does your organization serve?
We provide a range of mental health access to care and psychiatric rehabilitation and support services including care management to Suffolk County residents. A focus in the PPS is care management where right now we’re actively serving 1,100 people, but can provide services to 1,700 at any time. The people we serve are those who live with two or more chronic health conditions or a serious mental health condition.

Why did you choose to participate as a PPS as part of DSRIP?
People with mental health challenges used to be viewed only from the neck up. In the past there was a widespread belief that mental health and physical health were separate. We now know that’s not true. A person’s mental health state is often linked to his or her physical health, which means that people with chronic health conditions may need mental health care management to help them follow through with their medical care.
DSRIP emphasizes the relationship between physical and mental health. So it was important for us, as a predominantly mental health agency, to be part of an initiative that addressed the physical and mental challenges of health at the same time.

On which DSRIP project(s) will you be working?
We are involved in several project areas:

Project 2.a.i: Create an integrated delivery system
Project 2.b.iv: Care transitions intervention model to reduce 30-day readmissions
Project 2.d.i: Implementation of Patient and Community Activation Activities to Engage, Educate, and Integrate the uninsured and low/non-utilizing Medicaid populations into Community based care
Project 3.a.i: Integration of primary care services and behavioral health
Project 4.a.ii: Prevent Substance abuse and other Mental/Emotional Behavioral Disorders

In addition to workgroups for the above, we are also represented on the SCC Board of Directors and on the SCC Information Technology workgroup.

What do you hope the DSRIP program will accomplish for your organization in the future?
We’re very proud of our wide range of services, which include Care Management and Specialty Care, and hope that the PPS will recognize our strengths and see us as a key part of the services of the network. We’re also looking forward to partnering with Community Based Organizations to extend the reach of our services. We’re proud to be an innovative organization and pleased to see that DSRIP offers opportunities for innovation as well.

What do you hope the DSRIP program will accomplish in general?
Reduced hospitalization and reduced emergency room usage. We’d like to see a seamless network of care and support for everyone within Suffolk County, regardless of ability to pay.

Transformational Change
As healthcare reimbursement changes, hospitals, health systems and providers must adapt to a new paradigm in which providers are rewarded for meeting quality objectives for their patient populations. The emphasis is clearly shifting from volume to value and organizations that focus on providing patient-centered, quality health care across a population will come out ahead. How has your organization begun to experience this shift?

The shift started for us before the DSRIP initiative and even predates the governor’s Medicaid redesign. We knew that we needed to be able to quantify our value, both financially and to be able to bundle services in a way that was more responsive to people looking for mental health services. We started the process of shifting to value-based care about five years ago so we’re already well positioned to work in this environment.

DSRIP’s purpose is to fundamentally restructure the health care delivery system by reinvesting in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25% over five years. How do you envision your organization adapting/evolving to meet the needs of this health care delivery model shift?
There are several ways. One is through the broad use of peers who have dealt with or are dealing with similar health issues, and through community health workers. There are many pockets throughout the county where people don’t have ready access to care. These liaisons can help people by reaching out to them where they live and helping them to overcome their barriers to creating and sustaining healthy lifestyles. For example, people with serious mental illness have a high rate of smoking and, as a result, can have a life that’s shortened by 20 years. We have an approach that uses smoke-free people to help smokers reduce their use of tobacco.
Another is by using emerging technology to strengthen our engagement with people. We happen to already use the same electronic health record system as Stony Brook Medicine but other technologies including those that reach and engage our clients are exciting.

What in your experience are the top three guiding principles of a successful population health management program?
Shared technology, a commitment to behavioral health integration, and engagement through partnerships of institutional care and community-based organizations.

What value does the Suffolk Care Collaborative bring to patients under the DSRIP program?
Stony Brook is the hub for tertiary care in Suffolk County. Bringing that to DSRIP is huge.

As a pilot partner in the launch of Project 2.d.i for the Suffolk PPS, how has your involvement in the program development gone thus far?
It’s been fascinating and challenging. It’s creative in terms of reaching people who are uninsured or low utilizers - who touch the system only for emergency care - and engaging, educating and integrating them into community based care. We’re looking forward to getting them to activate and take better care of themselves physically, mentally and emotionally.
We are still in the planning stages, but conceptually ready to go. There are still some administrative issues to resolve but we’re making progress. Hopefully within a month we will be starting the pilot.

How do you see this project making an impact on our communities, workforce and population we serve?
For people who live with chronic health conditions, and struggle to follow through with medical care or who end up in emergency rooms, this project has the potential to make a huge difference in their lives. We can help them with their health, educate them, help to eradicate the stigma of mental health, and make sure they get the care they need.
Photograph of Sophia McIntyre MD, MPH, CPE Title: Chief, Clinical Quality and Physician Leadership Development
Organization: HRHCare
Focus or Specialty: Family Medicine
Number of Practitioners in Group: Over 100

Please provide a summary of your practice.
HRHCare is a federally qualified community health center celebrating its 40th year of service caring for the most vulnerable in our communities. We started as one ambulatory center - and have expanded to 29 centers, including several in Suffolk County. What makes us unique is that we subscribe to the Planetree Philosophy, which means all of our services, hours of operations and other decisions are centered around the needs of our patients.

We have a primary care focus as well as some subspecialties, including women’s health, HIV, Hep C, Infectious Disease, Diabetes Care, cardiology, GI, ENT, podiatry, nutrition, social work, psychiatry, and substance abuse.

Why did you choose to participate as a PPS as part of DSRIP?
Fundamentally, HRHCare is aligned with the aims of DSRIP. We provide medical care for underserved patients, look for ways to reduce redundancies by collaborating and coordinating healthcare and seek to prevent unnecessary hospitalizations. Participating seemed like a natural synergy.

On which DSRIP projects will you be working?
We’re involved in quite a few: chronic care, diabetes, hypertension, asthma, and Integration of Behavioral health services into primary care.

What do you hope the DSRIP program will accomplish in general?
What I hope for is really truly improving how we can continue to provide care throughout the continuum. I believe the program will allow us to think much more broadly - through a shared vision.

What do you hope the DSRIP program will accomplish for your practice in the future?
I hope that it will accelerate the process of standardization across the network, align all our partners to cooperatively achieve the Triple Aim: better health for individuals, better health for population and lower per capita cost.

Transformational Change.
As healthcare reimbursement changes, hospitals, health systems and providers must adapt to a new work in which providers are rewarded for meeting quality objectives for their patient populations. The emphasis clearly shifting from volume to value and organizations that focus on providing patient-centered, quality health care across a population will come out ahead. How has your organization begun to experience this shift?

We’re in the early stages of understanding what it means. Even though the model is changing, we still live within a fee-for-service environment and are trying to transition to value based. We need more time to do this. We’re hoping that the DSRIP project will financially support that transition.

Reimbursement for better care is coming, but in the meantime we have to figure out how to sustain our practice as we make the transition.

As a federally qualified health center we understand that our goal is to provide the highest quality care. We’re looking forward to getting recognized for the work we’re already doing.

DSRIP’s purpose is to fundamentally restructure the health care delivery system by reinvesting in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25% over five years. How do you envision your organization adapting/evolving to meet the needs of this health care delivery model shift?
HRHCare is already involved in hospitalization reduction. With DSRIP, We envision better collaboration among partners, as well as having systems where we can extend our hours of operation - 7 am to 11 pm to help eliminate barriers to care.

In your experience, what are the top three guiding principles of a successful population health management program?
Patient-centricity. To listen, understand and adapt to our patients’ needs.

Collaboration with partners to provide the necessary resources.

And to look at the whole patient, in terms of their whole continuum of care.
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