Reducing costs and increasing care with hospital discharge planning and coordination of home based support.

Syncare’s Secure Program targets avoidable hospital re-admissions, improving quality
of care and use of resources to:

   Reduce in-patient hospital re-admissions
   Reduce length of stay for patients that do require re-admission
   Reduce hospital costs and needless benefit expenses
   Increase patient satisfaction and coordination of care
   Ensure the smooth and successful transition from hospital to home


The SynCare Case for Cost Management

The transition from hospital to home can be risky -- particularly for patients with chronic conditions. Faced with complex, costly treatments, and sometimes conflicting and confusing instructions from different health care providers, patients and their families struggle to comply with instructions and are unable to coordinate appropriate care. This lack of coordination leads to medical errors, unnecessary tests and patient stress. It also drives up costs. In fact, avoidable re-admissions cost U.S. hospitals, public and private insurers billions of dollars each year. In a June 2007 report to Congress, the Medicare Payment Advisory Commission (medpac) noted that the annual cost of avoidable readmissions to Medicare alone averages $17.4 billion. Medpac, the Centers for Medicaid and Medicare Strategies (CMS) and other healthcare agencies have called for managed care that would not only reduce costs, but also improve quality of life for individual patients. SynCare’s Secure Program responds to that call.


Our Physician-Patient Partnership

SynCare extends the physician-patient partnership into the community, providing one-to-one interactions, health education, motivational interviewing and behavior modification. We help patients understand their conditions so they can make informed health decisions and set goals for managing their conditions.

Our unique case management model reduces in-patient re-admissions, lowers health care cost, and improves clinical outcomes by creating a broad and encouraging support system to keep patients motivated and engaged. Prior to hospital discharge, a SynCare RN visits the patient in the hospital to assist with discharge planning. When the patient is discharged, the SynCare RN visits the patient in their home or Skilled Nursing Facility within 48 hours. The Nurse continues to follow the patient telephonically or face-to-face as needed for at least 30 days post-discharge. Case management includes:

   Patient Risk Assessment and Stratification
   Face-to-Face Visits
   Coordination of Services
   Individualized Care Plans (discharge)
   Home Environment Assessments
   Medication reconciliation and self-management
   Development of a patient-centered record (a user-friendly booklet for the patient to
    record a brief patient history, medications, allergies, health goals and questions for
    the doctor).
   Assisting the patient with scheduling follow-up appointments with primary care physicians
    and specialists
   Providing training to the patient so that she/he has knowledge of “red flags” (signs that
    the patient's condition is getting worse and how to respond)
   Weekly Telephonic Interactions
   24 hour access to Case Manager
   Clinical Social Workers to help the patient and family deal with any stress/ emotional issues
   Enrollment assistance in Medicaid / Medicare for patients that have no insurance.
   Community resources
   Liaison services between patient and community resource
   Educational materials geared towards the patient’s educational level
   Interpretive Services as needed

Source: www.medpac.gov/documents/Jun07_EntireReport.pdf