Publications & Plans

Through various programs and initiatives, the SCC and its project community contribute community-wide ranging knowledge published on health care redesign and development through system transformation, clinical improvement and population-wide objectives. The SCC disseminates research, data, and lessons learned through its print and electronic publications.

Agency Coordination Plan
(Version 1 August 2016)

The Agency Coordination Plan will establish a framework that identifies and acknowledges public sector agencies (at state and local levels) that play a significant role in project development, community engagement and care management. The purpose of this plan is to provide a sustainable model for collaboration and engagement with public sector agencies, create a pathway to engage and keep contact with these agencies, understand the different programs/services offered and continue to involve these sectors across the DSRIP portfolio.

Cardiovascular Disease & Diabetes Clinical Improvement Program Implementation Toolkit
(Version 10, February 27, 2017)

The purpose of the Cardiovascular & Diabetes Wellness and Self-Management Programs Implementation Toolkit is to assist all internal and external program stakeholders during the implementation phase and throughout the life cycle of the CWSP & DWSP. It provides an overview of the Cardiovascular and Diabetes and Wellness Self-Management Programs, including key directory of SCC PMO contacts, Program Charter, tools and resources for implementation, program protocols, patient engagement requirements, instructions on how to submit documents and maintain project documents and valuable program resources. It is meant to act as a guide and information source in which you can refer to for all your DSRIP needs.

Clinical Data Sharing and System Interoperability
(Version 8, October 2016)

The Suffolk Care Collaborative, in partnership with SCC IT Task force, strategizes to coordinate care between provider types in order to demonstrate true system integration as part of the Delivery System Reform Incentive Payment (DSRIP) program. The SCC IT Task force which consists of technical and project management representatives from each of the three Hubs: Northwell Health, Catholic Health System and Stony Brook Medicine, recognizes that within each of the clinical pathways to care, workflows need to be created to demonstrate the care coordination and evidenced based decision making that occurs to facilitate positive clinical outcomes. This document provides an overview of the technical strategy needed to achieve clinical data sharing and interoperability across the PPS.

Clinical Documentation Improvement Program Guide
(Version 1, 2017)

As a care gap closing strategy, the Suffolk Care Collaborative's Clinical Documentation Improvement (CDI) Program was developed.  The CDI Guide is a condensed and comprehensive resource outlining "Primary Care Provider (PCP) Impacted" performance metrics.  This tool is meant to be utilized by several different intended end-users, such as care management, performance improvement, PCP practitioners and PCP office staff.  For each metric, the measure definition, required documentation, applicable ICD-10-CM, CPT Category I & II and HCPCS Codes, role of care management, role of PCP practice, metric data source (measure type) and age cohort are all identified on one page.  Certain metrics have a hyperlink to a medication list or reference page.  The CDI Guide will be updated the beginning of each Measurement Year (MY).  

Clinical Integration Strategy
(Version 1, June 30, 2016)

The Clinical Integration Strategy for the Suffolk Care Collaborative establishes a plan to provide care coordination across a continuum of services within the SCC’s Integrated Delivery System. The goal of Clinical Integration is to create a system that allows a patient to transition across the care continuum through activation, navigation and coordination without fragmentation. Providers will have access to interoperable point of care clinical data that will allow for consistent and effective evidenced based medical decisions. The SCC’s Clinical Integration Strategy identifies key drivers of successful integration, which include improved access to care and Patient Centered Medical Home providers, integration of behavioral health and primary care, effective care management strategies, efficient transitions of care, a core set of clinical quality metrics and measurement, and clinical interoperable systems. In order for this Strategy to be fully implemented, the SCC has utilized Community and CBO Engagement techniques, as well as ensured that PCPs, Hospitals, Skilled Nursing Facilities, Behavioral Health providers, Non-PCPs, Health Homes, Home Care Agencies, Pharmacies, Hospice Organizations and Care Management Agencies are all engaged in the development of our Integrated Delivery System.

Community Engagement Plan
(Version 1, March 2016)

The Community Engagement Plan will establish a community engagement framework to gather and share activity/event information, build relationships and promote input from community partners across the PPS. The purpose of this plan is to provide a pathway for internal and external stakeholders to communicate and participate in community engagement activities/events, encourage patient engagement, and build a sustainable model of collaboration and engagement between our community partners throughout our communities to address health disparities.

Core Curriculum Guidelines for Participating Practice Sites
(Version 01, March 2017, Web Edition)

The Core Curriculum Guidelines for Primary Care Practice Sites include training requirements for participating practice sites in the Suffolk Care Collaborative (SCC).  Most of the curricula was designed based on national literature reviews of training provided around the country and vetted through appropriate key internal stakeholders.  This guide recommends topics for practice site training and was designed to position your organization for successful participation in the DSRIP program. It will serve as a training foundation to harvest a consistent base of knowledge on the system transformation, clinical improvement, population-wide programs, patient education, care coordination, and many more. We believe using this tool and completing the training topics will enhance the effectiveness of the services provided by your practice site.

Cultural Competency & Health Literacy Education and Training Plan
(Version 2, June 2016)

The Cultural Competency and Health Literacy education strategy and training plan is a subset of the more comprehensive SCC Training and Workforce Development Strategy. The Plan utilizes similar training methods including web-based training, instructor-led in person training, instructor-led virtual training, on-the job in-person training, on-the-job virtual training, train the trainer, and job aids to promote and further cultural competency and health literacy education.

Cultural Competency & Health Literacy Strategic Plan
(Version 1, November 2015)

The Cultural Competency and Health Literacy Strategic Plan provides a foundation for promoting cultural competency and health literacy, which are essential to address healthcare issues and disparities in the SCC community. The purpose of this plan is to provide a framework for: 1) cultural competence, which enables systems, agencies, and groups of professionals to function effectively, understanding the needs of groups accessing health information and healthcare; and, (2) health literacy, which enables individuals to understand information and services and uses them to make informed decisions about their health.

Evidence-based Clinical Guideline Summaries

To aide in the communication of our Delivery System Reform Incentive Payment Program’s Projects, the Suffolk Care Collaborative has designed Clinical Summaries. Clinical Summaries were designed to give our partners an overview of each clinical DSRIP project. Each summary illustrates the projects’ immediate and long-term goals, interventions, metrics, helpful tools and useful reference materials, in order to successfully implement your projects.

Interventions to Reduce Acute Care Transfers (INTERACT) Implementation Toolkit
(Version 2, February 6, 2017)

INTERACT is a quality improvement program designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents in skilled nursing facilities. The goal of INTERACT is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital. Such transfers can result in numerous complications of hospitalization, and billions of dollars in unnecessary health care expenditures. The purpose of this toolkit is to assist all internal and external program stakeholders during the implementation phase and throughout the life cycle of the program described herein. It provides an overview of INTERACT, including key directory of SCC project management office contacts, Program Charter, tools and resources for implementation, program protocols, patient engagement requirements, instructions on how to submit documents and maintain project documents and valuable program resources. It is meant to act as a guide and information source in which you can refer to for all your DSRIP needs.

Performance-based Funds Flow Model

The SCC’s DSRIP funds flow model was developed through guiding principles approved by the SCC’s Board of Directors. As an overview, this high-level presentation walks through the process and approach taken in the development of the funds flow distribution plan. It breaks down the Award Letter to SCC from NY State and describes elements considered in the design of the plan, including Hub allocation/expectations, model mechanics, attribution, performance, budgets and payments. The DSRIP Funds Flow – Payment Process Overview illustrates distribution of funds to SCC and the Hubs, ultimately resulting in distribution to Hub downstream providers. Such provider level distribution is based on provider type and distribution factors.  This model developed from the collaborative efforts of SCCs key stakeholders.

Performance Reporting & Improvement Plan

The Performance Reporting and Improvement Plan for the Suffolk Care Collaborative establishes a planned, systematic, organization-wide approach to performance reporting, performance measurement, analysis, and improvement for the health care services provided. The plan will assist the SCC in actively achieving our mission and vision of becoming a highly effective, accountable, integrated, patient-centric delivery system through performance measurement and process improvement.

Population Health Management Roadmap
(Version 1, June 30, 2016)

The Population Health Management Roadmap for the Suffolk Care Collaborative defines the strategy for improving the health and wellness of our communities. This document highlights the key areas that the SCC identified as necessary for operationalizing Population Health Management in Suffolk County. The strategy includes data collection, storage and management, use of technology to monitor and stratify populations, identification of patient populations, team based interventions and care team coordination, and measuring outcomes. This Roadmap sets forth a clear plan to drive better outcomes, measure these outcomes and design quality improvement and performance reporting measurement plans to ensure sustainability. As such, this is possible through investments in information systems, utilization of robust technology applications, such as population health registries to continually identify and stratify patient populations, and leveraging data to enable care teams to manage patients more efficiently and effectively.

Practitioner Engagement & Communication Plan

The Practitioner Communication and Engagement Plan for the Suffolk Care Collaborative (SCC) provides a foundation for practitioner engagement efforts and a framework to guide future engagement activities. The purpose of this plan is to provide a clear pathway for practitioners to have a voice in the planning and delivery of transformative health care services to SCC stakeholders so that the best possible patient outcomes are achieved now and in the future.

Primary & Behavioral Health Integrated Care Implementation Toolkit
(Version 2, October 2016)

The purpose of these toolkits are to assist our participating Primary Care and Behavioral Health partners during the implementation phase and during the life cycle of the 3.a.i project, throughout the DSRIP years. It is meant to act as a guide and information source to which our partners can refer to for all of their 3.a.i. DSRIP project needs. The general content in each toolkit includes overview of the DSRIP project requirements for implementation, overview of the Primary & Behavioral Health (PCBH) Integrated Program, and instructions regarding how to submit documents and maintain binder. While some of the content in each toolkit is specific to the Model that will be adopted in each location, the aforementioned general format still applies.

Three Integrated Care Implementation Toolkits; one for each model of the project.

Promoting Asthma Self-Management Program Implementation Toolkit
(Version 5, March 2017)

The objective of this program is to implement an asthma self-management program, which includes home environmental trigger reduction, self-monitoring, medication use, and medical follow-up to reduce avoidable ED and hospital care. The purpose of this toolkit is to assist all internal and external program stakeholders during the implementation phase and throughout the life cycle of the program, described herein. It provides an overview of the Promoting Asthma Self-Management Program, including key directory of SCC project management office contacts, Program Charter, tools and resources for implementation, program protocols, patient engagement requirements, instructions on how to submit documents and maintain project documents and valuable program resources. It is meant to act as a guide and information source in which you can refer to for all your DSRIP needs.

Regional Health Information Organization (RHIO) Global Plan

The RHIO Global Plan describes the SCC’s goal to integrate with our Regional Health Information Organizations and share healthcare information across many provider organizations. The SCC consists of three HUBs, namely, Northwell Health, Catholic Health Services of Long Island and Stony Brook Medicine. The SCC recognizes that each HUB has their own unique data sets, technology and business requirements and, therefore, allows each HUB to select the RHIO based on their business and technology connectivity requirements. This document provides an overview of the RHIO Integration Strategy that has been adopted across each HUB and how each implementation will ultimately be interoperable under the wider initiatives of the Statewide Health Information Network of New York (SHIN-NY).

SBIRT in Hospital Emergency Departments Implementation Toolkit

The Screening, Brief Intervention, and Referral to Treatment (SBIRT) Implementation Toolkit has been designed to assist our SBIRT Hospital Partners during the implementation phase and during the life cycle of the SBIRT project, throughout the DSRIP years. This toolkit acts as a guide and information source to which our partners can refer to for all of their SBIRT DSRIP project needs. The general content in each toolkit includes an overview of the DSRIP project requirements for implementation, an overview of the SBIRT initiative, and instructions regarding how to submit documents and maintain the binder. This toolkit was designed to be amendable; therefore, we expect the toolkits to undergo several iterations as the project expands and progresses.

Tobacco Free Grounds Implementation Toolkit
(Version 1, April 2017)

The overall goal of the Tobacco Free Campus at Behavioral Health Site Initiative is to partner with the Office of Mental Health (OMH) and community based tobacco cessation programs in Suffolk County to assist sites through their transition in becoming tobacco free campuses. Through this initiative, the SCC and its partners hope to create healthier and safer environments for all clients, staff and visitors at behavioral health sites and ensure that tobacco dependence is addressed with all clients at behavioral health sites. The purpose of this toolkit is to act as a guide for sites as they expand upon their existing smoke free policies or create new tobacco free policies. The toolkit highlights the Suffolk Care Collaborative’ s partnerships with Northwell Health’s Center for Tobacco Control and the Tobacco Action Coalition of Long Island, as both organizations provide technical assistance to the behavioral health sites. The type of assistance offered to the sites is outlined in the toolkit as is a step by step guide on becoming a tobacco free campus. Additionally, the toolkit includes a Tobacco Free Site Readiness Survey for organizations to complete based on their current practices and policies. With the results of the survey, project leads then personalize their feedback and assistance to each site’s needs. The toolkit also includes local tobacco cessation resources as well as ones that are specific to the behavioral health community.

Training & Workforce Development Strategy
(Version 1, March 31, 2016)

The SCC’s Training Strategy Plan is a comprehensive, detailed approach to training design, development and delivery, which illustrates timelines, roles and responsibilities and outlines program components. The Plan aims to ensure that individuals have the knowledge and skills to perform their roles in order to achieve SCC’s goal to become a highly effective, accountable, integrated and patient-centric delivery system.

Transition of Care Model
(Version 2, February 2017)

As a committed innovator in healthcare reform, the Suffolk Care Collaborative has developed a Transition of Care Model focused on improving the identification of people at higher risk for readmissions and improving the discharge and post-hospital process to reduce future readmissions. This model was crafted by a true grassroots approach through the collaboration of many stakeholders committed to the improvement of healthcare in our Suffolk County communities. Together we can improve healthcare for our most vulnerable populations; through teamwork, we can improve transitions of care to expand care beyond the hospital walls to meet the needs of high-risk patients.

Transition of Care Program for Inpatients & Observation Units Implementation Toolkit
(Version 2, February 2017)

The purpose of this toolkit is to assist all internal and external program stakeholders during the implementation phase and throughout the life cycle of the Transition of Care Model. The objective of the TOC Program is to provide a 30-day supported transition period after hospitalization that ensures discharge directions are understood and implemented by patients at high risk for readmission. Another objective of the plan includes the establishment of appropriately sized observation units (either a dedicated unit or scattered-bed approach) in all Suffolk County hospitals to reduce short stay admissions, thereby minimizing Potentially Preventable Readmissions. The Toolkit provides an overview of the Transition of Care Program for Inpatient & Observation Units, including key directory of SCC PMO contacts, Program Charter, tools and resources for implementation, program protocols, patient engagement requirements, instructions on how to submit documents and maintain project documents and valuable program resources. It is meant to act as a guide and information source in which you can refer to for all your DSRIP needs.

For additional information regarding any of these plans, please contact us at [email protected]

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