Transforming Star 1 & Star 2 Hospitals
NDVIP’s CareSync drives post-discharge follow-through and outcome gains—no cost to hospitals.
The Problems
- High readmissions driving penalties and avoidable cost
- Low HCAHPS patient-experience scores
- Care-transition gaps and weak 7-day follow-up
- Staff capacity limits for RPM/CCM touchpoints
- Inconsistent documentation for quality and billing
The Solution
Every patient gets three essentials—
Dedicated SmartCare Coordinator (~90 days)
One consistent person patients know by name; warm handoffs and daily check-ins, with approved family/caregivers looped in (with consent).
Weekly Progress Reports
Concise updates for clinicians (and family, with consent) to keep recovery on track. Informational only; not for diagnostic purposes.
Red-Flag Alerts & Escalation
Same-day triage when symptoms worsen or tasks (BP checks, meds) are missed.
Trust → Action → Participation
Daily contact builds trust, which drives completion of home tasks and a higher likelihood patients complete the hospital’s official CMS patient-experience survey (administered by the hospital’s CMS-approved vendor). CareSync adds neutral reminders and a survey status checkbox (Completed / Declined / Unable) before episode closure—pushing participation from the ~23% national baseline toward near-universal recorded status, while responses remain with the vendor.
TEAM Pathway
Per TEAM guidance, non-hospital organizations may collaborate with TEAM Model Hospitals as a collaborator/agent under 42 CFR §§ 512.565, 512.568, 512.570.
Following CMS TEAM Support’s review of our NDVIP SmartCare Plus program (ref. Ticket CS3941465), we were advised that the appropriate mechanism is to engage directly with participating TEAM hospitals through the collaborator/agent pathway, and we were encouraged to coordinate directly with hospital teams using this route.
NDVIP follows this pathway with written, fair-market-value, compliance-aligned arrangements.