The SUNY Stony Brook University Hospital/Suffolk Care Collaborative (SCC) PPS serves 437,896 attributed members in Suffolk County. The PPS consists of three hubs headed by three organizations: Northwell Health, Stony Brook University Hospital (SBUH) and Catholic Health Services of Long Island (CHS). There are over 2,200 physicians, 277 NPs and 379 PAs in the network. The PPS assessment of current capacity identified a small gap in access to care.

Overall assessment: Well written plan focused on the primary care needs of the PPS. Includes description of robust training platform that is up and running to support training initiatives as well as PCMH certification. Have implemented strategies to include primary care in an integrated delivery system. Could include more detail on specific assistance that will be given to PCPs on VBP contracting. Provided funds flow strategy for primary care and details on dollars flowed to date to PCPs.

FUNDAMENTAL #1: Assessment of current primary care capacity, performance and needs, and a plan for addressing those needs.
  • There are 777 PCPs enrolled in the PPS, 41% offer after–hours care, 94% accepting new Medicaid members. 14.7% have achieved PCMH 2011 Level 3; no information on any currently having achieved 2014 Level 3 recognition.
  • Northwell Health created a loan forgiveness program for graduating residents and training and employment opportunities for nurse practitioner students to work in primary care in their network. PPS has two patient navigation/activation strategies:
    • Direct outreach through contracted CBOs to non–utilizers; and
    • Population Health Management planning which will navigate patient from using specialists for PC and back to PCP.
FUNDAMENTAL #2: How will primary care expansion and practice and workforce transformation be supported with training and technical assistance?
  • SCC has a robust training platform which includes the building of a forward facing Learning Center on the SCC website to supplement in person training. Several e–learning modules are currently active with many more being developed.
  • A PCMH Certification Workgroup, comprised of PCMH specialists, SMEs and practice staff, meets monthly to provide education on healthcare transformation and industry trends. Dedicated PCMH staff at each hub also provide support to the PCPs in addition to the PCMH vendors (PCDC and HANYS) contracted to assist with PCMH recognition.
  • SCC has made arrangements to connect providers without EHR with the NYeC for support. Northwell is developing a workgroup to connect the NYS Smoker's Quitline to SHIN–NY through Healthix.
FUNDAMENTAL #3: What is the PPS´s strategy for how primary care will play a central role in an integrated delivery system (IDS)?
  • PPS has strategies developed for successful integration including PCMH, BH integration, IT connectivity, risk stratification and support for patients leaving acute care to navigate back to the community.
  • PCPs are included in 21 of 38 boards, committees and workgroups of the PPS. No numbers or percentages of PCPs in the groups were provided. Each hub provides an open invitation to each on–boarding PCP to join a committee or workgroup.
  • Mechanisms in place to assist providers in care coordination including health home care management, MCO care management and CBOs. In addition to these, all three hubs have Care Management Organizations:
    • SBUH CMO assists PCPs in managing complex conditions, comorbid BH/SUD and SDH
    • Northwell CMO deploys care managers to practices
    • CHS provides care management services for practices to help manage chronic/high risk conditions
FUNDAMENTAL #4: What is the PPS´s strategy to enable primary care to participate effectively in value–based payments (VBP)?
  • In this section, plan focuses on the larger scope of assistance and needs for PCPs to transition to VBP (care management, IT interoperability, BH integration, data analytics, etc.) and not the strategy to be used by the PPS to assist in this transition.
  • For small practices with no leverage with MCOs, the PPS will help them transition from FFS to VBP through alignment with the IPA. No further information provided on what type of assistance will be available beyond the larger scope of assistance.
FUNDAMENTAL #5: How does your PPS´s funds flow support your Primary Care strategies?
  • Two sources of funding to support PCPs: 60% ($179m) is cost incurred by the PPS on behalf of PCPs and 40% ($60m) directly to PCPs in a performance payment pool, distributed based on weighted performance factors (included in the Plan).
  • To date, of $1.1m distributed in performance payment pool funding, $754k was distributed to PCPs.
FUNDAMENTAL #6: How is the PPS progressing toward integrating Primary Care and Behavioral Health (building beyond what is reported for Project 3.a.i)?
  • SCC is creating a network of collaborative care providers and expanding county resources to meet the ongoing needs of its communities to provide patient–centered care. Integrating BH providers into the PCPs, to be employed directly by the practice. Involved in community outreach and participation to help support integration efforts.
  • All hospital EDs are implementing SBIRT programs. Social workers are being placed in the EDs and PCPs are involved in decisions made in the ED as patients are referred to treatment.