Programs & Initiatives

Through this DSRIP program, the Suffolk Care Collaborative is working with primary care providers (like doctors, nurses, and pediatricians), behavioral health providers (like psychiatrists, psychologists, social workers, and substance abuse counselors), hospitals, nursing homes, community-based organizations, local government agencies and many others.

By working with these different healthcare providers, the SCC will work to accomplish our three main goals, known as the “Triple Aim”:

  1. Improving the Patient Experience of Care
  2. Improving the Health of Populations
  3. Reducing the Cost of Healthcare

To meet these three main goals, the SCC has been working on 11 programs for Suffolk County. Each program targets a specific area in healthcare that needs to be improved in the County. Let’s take a look at these 11 DSRIP Programs.

project 2ai icon Building a Suffolk County Integrated Care Delivery System (Project 2ai) In Suffolk County, there are many providers like hospitals, doctors, nursing homes and social-service companies that may not always work well together. The goal of this program is to bring all of these different providers together to share tools and resources that can help them take better care of you and your healthcare needs.
project 2biv icon Transition of Care Program for Inpatient & Observation Units (TOC) (Project 2biv) This program has been designed to help you after you leave the hospital. The Suffolk Care Collaborative will be working with the hospitals in Suffolk County to better understand your needs when you are discharged from the hospital. Before you leave the hospital, we will make sure you understand your medications, and help you with any food, shelter and transportation needs.
project 2bix icon Transition of Care Program for Inpatient & Observation Units (OBS) (Project 2bix) Sometimes the emergency room can get very crowded, and we want to make sure you get the care you need without long wait times. This program was designed to help you have a shorter wait time in the emergency room. An observation unit is used as a medical waiting area for people who do not need to stay many nights in the hospital. This unit has many doctors and nurses who will take care of you. The Suffolk Care Collaborative has been working with the hospitals in Suffolk County to create these units.
project 2bvii icon Interventions to Reduce Acute Care Transfer Program (INTERACT) (Project 2bvii) Transfers from a skilled nursing facility to the hospital are costly, and can be emotionally and physically difficult. The overall goal of the INTERACT program is to reduce the frequency of transfers to the hospital emergency room. The INTERACT program works to prevent these transfers by improving the identification, evaluation, and communication about changes in a patient’s health status. In order for the INTERACT project to be successful, all members of the care team, including care providers, patients, & family members, are encouraged work in partnership.
project 2di icon Community Health Activation program (CHAP) (Project 2di) Sometimes it can be difficult to find good health care, such as a doctor or other service. If you are having trouble finding a doctor or health service, the Community Health Activation Program (CHAP) can help connect people in Suffolk County to the services they need. For people without insurance, CHAP staff will assist in connecting you with resources to enroll. For those people that have Medicaid, CHAP can help connect you with your doctor and schedule an appointment. Some people may also be eligible for additional health coaching services to build confidence and knowledge for a healthy lifestyle. The bottom line is that you will get the help you need to stay healthy!
project 3ai icon Primary & Behavioral Health Integrated Care Program (Project 3ai) To meet your healthcare needs, you may go to a primary care provider, like your doctor, and a behavioral health provider, like a psychiatrist. Usually, these two providers are in two different locations, and you need to make separate appointments to see them both. We know that getting both types of care is important to your health, and this project aims to make that easier. In this project, we are working to place primary care providers into behavioral health clinics, and behavioral health providers into primary care clinics. With your behavioral health provider and primary care provider under the same roof, your primary care and behavioral health providers will be able to work together and plan your treatment, and you can get the care you need in a single visit to the office.
project 3bi icon Cardiovascular Health Wellness & Self-Management Program (CWSP) (Project 3bi) Heart disease, like high blood pressure and high cholesterol, is a serious concern in Suffolk County. Certain behaviors, like poor diet, lack of physical activity, and tobacco use, can worsen heart disease. By addressing these concerns, we will help to decrease the number of people that go to the hospital because of heart disease. We are also partnering with community organizations to help people in Suffolk County learn more about how to manage heart disease and how to stop using tobacco.
project 3ci icon Diabetes Wellness & Self-Management Program (DWSP) (Project 3ci) Many people in Suffolk County are living with diabetes and pre-diabetes. Some challenges for people with diabetes include not being able to get healthy food, not being educated about diabetes and making healthy choices, and managing the amount of sugar in their blood. We will help to make sure people can get to the doctor, partner with community organizations to help people learn how to manage diabetes, and decrease the reasons why people end up at the hospital from diabetes.
project 3dii icon Promoting Asthma Self-Management Program (PASP) (Project 3dii) Childhood asthma for Medicaid patients is very high in Suffolk County. For children under 26 with severe asthma conditions, the Promoting Asthma Self-Management Program offers home-based assistance. A trained Community Health Worker (CHW) can visit your home to review your doctor’s Asthma Action Plan and offer suggestions for how to make your home better for your child. Dust, pets and mold are examples of what may cause asthma problems, and the CHW will teach patients, parents and caregivers ways to reduce these triggers in the home. The visits are done in partnership with the child’s doctor, so that when you have an appointment with your doctor she/he will discuss the visit with you and you can plan ways to make your home a healthy and safe place for your family.
project 4aii icon Substance Abuse Prevention and Identification Initiatives: Screening, Brief Intervention, and Referral to Treatment (SBIRT) Initiative (Project 4aii) This project will help to prevent alcohol, tobacco, and drug use in Suffolk County. To reach this goal, this project has three parts.

The first part of the 4aii project is the Screening, Brief Intervention, and Referral to Treatment (SBIRT) Initiative. When you go to the emergency room at any of the 11 Suffolk County hospitals, you will be given a short list of questions to answer about your alcohol, tobacco, and drug use. This screening will be given to everyone, ages 13 years and older. This screening will identify people who are drinking at risky levels, or using other substances, like drugs, in a dangerous way. Once a person is identified, they can be counseled on how to reduce their alcohol use to lead a healthier lifestyle, or referred to treatment facility if they need help with addiction.

project 4aii icon Substance Abuse Prevention and Identification Initiatives: Suffolk County Tobacco Cessation Initiative (Project 4aii) The Smoking Cessation initiative is the second part of the 4aii project. Many people living in Suffolk County smoke cigarettes and use other forms of tobacco. Smoking and using tobacco has many negative health effects, including increasing the likelihood of lung cancer and other types of cancers. Our tobacco cessation program will help community members get the help they need to quit smoking or to prepare to quit smoking. This will involve your primary care doctor and connecting you to great resources in Suffolk County.
project 4aii icon Substance Abuse Prevention and Identification Initiatives: Underage Drinking Prevention initiative (Project 4aii) The Underage Drinking Prevention Initiative is the third part of the 4aii project. We are partnering the Long Island Prevention Resource Center to work to prevent and reduce underage drinking among youth in Suffolk County. The program is taking place in the South Country area of Suffolk County, and will work to promote positive changes in community attitudes and behaviors.
project 4bii icon Access to Chronic Disease Prevention Care Initiatives (Project 4bii) In Suffolk County, there are many people who struggle with chronic health issues such as obesity, tobacco use, and cancer. This project will offer more health educational information, programs, and services available for both you and your doctor. These resources will help you manage your health better and decrease the risk of developing these diseases. The Suffolk Care Collaborative will work with doctors, care managers, community based organizations, and your local health department to make these health resources easier to find within your neighborhood! You will hear about community health fairs and events where all Suffolk County residents are invited to come get free health screenings and learn about decreasing chronic disease within our community!