SYNC-PREVENT™ is an 11-layer biomarker and device-based Clinical Status Monitoring platform for patients 50 years and older with two or more chronic conditions — built to close the gap standard care leaves open.
SYNC-PREVENT™ — Proactive Risk Evaluation, Vital Early Notification Tracking — is a clinical execution and coordination framework built to get the earliest signs of disease in front of the physician before it becomes symptomatic, before it drives a hospitalization, and before it becomes expensive to reverse. It is not a remote patient monitoring program or a chronic care management service, though it uses both.
Designed for patients aged 50 and older, the platform combines eleven clinical monitoring layers — spanning biomarkers, device-based diagnostics, and behavioral intervention — into a single, continuously updated picture of each patient's physiologic status, reviewed by the ordering physician.
Synchronize Health, LLC built SYNC-PREVENT™ on the foundation of the American Heart Association's cardiovascular risk model and expanded it substantially. Where the AHA model estimates future cardiometabolic risk from traditional factors at a single point in time, SYNC-PREVENT™ is designed to track actual physiologic change longitudinally, across multiple organ systems, in real time. BridgeCare Louisiana, LLC is the exclusive licensee for Louisiana.
A patient timeline from age 40 to 80. SYNC-PREVENT™ monitors continuously from roughly age 50 onward — the years leading up to a first hospitalization, which typically occurs around age 65 to 70.
Physicians decide. Cleared devices watch. The platform organizes. The physician retains full clinical authority at every step — BridgeCare LA supports, informs, and executes; it never directs care and never interprets in the physician's place. Every escalation exists solely to give the physician a more complete and timely picture, so their decisions are better informed, not made for them. Physician judgment is never displaced by platform outputs.
These objectives define how the platform is designed to create clinical and operational value for physicians, patients, payers, and care teams.
Give the ordering physician the clinical data to identify cardiovascular, renal, metabolic, neurologic, and endocrine conditions before symptoms emerge — ahead of what score-only or symptom-based models allow.
Extend beyond the AHA model by incorporating longitudinal biomarker trends, device data, renal-adjusted context, and cross-layer data presentation for physician review.
Every core clinical layer is designed around existing CMS billing pathways and integrated with RPM and CCM workflows, so advanced care does not create unfunded services.
Structured detection of CKD, diabetes, hypertension, heart failure, and diabetic eye disease is designed to close care gaps that affect quality scores and value-based contract performance.
Physician-established parameters and structured escalation pathways are designed to give physicians the clinical picture to intervene before acute events occur, rather than after a patient reaches the ED.
Primary care, specialists, and hospitals work from the same current clinical record through TEFCA/Carequality connectivity, closing care-transition gaps.
Each layer monitors a specific category of physiologic risk. Biomarkers are never presented in isolation — they are organized longitudinally, adjusted for renal physiology where applicable, and presented across layers for physician review.
Layers 1 through 8 are CMS-aligned and built around reimbursable laboratory and device testing. Layers 9 through 11 are addressed separately, with appropriate clinical context.
Present biomarker data that gives the physician the clinical picture of early arterial disease risk before clinical events occur.
FrequencyAnnual testing; every 6 months for high-risk patients. Lp(a) is a one-time baseline, repeated only if clinically indicated.
Identify early heart failure, renal stress, fluid imbalance, and mineral-driven cardiac risk — including PTH-mediated pathways particularly relevant in women over 50.
FrequencyAnnual; every 6 months for heart-failure-risk patients. Troponin quarterly for two cycles after an instability trigger, then every 6 months if stable. PTH, vitamin D, and serum calcium are ordered together as a mineral panel — annually, or when clinically indicated.
Detect insulin resistance and glycemic instability before clinical diabetes is established.
FrequencyHbA1c every 3–6 months; metabolic panel annually. HOMA-IR is derived from existing labs — no additional test required.
Insulin-dependent patients in the Moderate and Complex care tiers are provisioned a Dexcom G7 continuous glucose monitor. The Dexcom G7 generates continuous glucose readings within its FDA-cleared function. Glucose trend data is presented to the ordering physician between visits. Stable-tier insulin-dependent patients continue on standard fingerstick and HbA1c monitoring unless the treating physician directs otherwise.
Identify fatty liver disease and metabolic-driven inflammation — a risk the AHA model does not address.
FrequencyAnnual; every 6 months where MASLD/MASH is suspected. FIB-4 is a computed output — no additional labs required.
Supported by the Sonic Incytes Velacur device for non-invasive liver elastography (CPT 76981) where deeper hepatic assessment is clinically indicated.
Detect the chronic inflammatory burden driving multi-organ disease progression.
FrequencyAnnual; more frequently where inflammatory burden is elevated or active.
Ensure adequate oxygen transport and detect anemia-related clinical risk.
FrequencyAnnual CBC; more frequently if anemia is identified or clinical status changes.
Identify dysautonomia and physiologic instability, particularly in diabetic and cardiac populations.
FrequencyAnnual; incorporated into standard visit workflows.
Detect peripheral artery disease and microvascular compromise before limb-threatening events.
FrequencyAnnual; every 6–12 months in diabetic patients or those with known vascular disease.
Detect silent brain injury and early cognitive decline risk before symptoms are apparent.
FrequencyOrdered only where the treating physician determines testing is clinically necessary.
Detect early functional decline, gait instability, and frailty risk before a fall or hospitalization forces the issue.
FrequencyAnnual; more frequently for patients 65 and older, post-fall, or flagged as frail by other layers.
Measure cognitive decline objectively, complementing Layer 9's blood-based biomarkers with functional performance data.
FrequencyAnnual; more frequently when Layer 9 biomarkers are elevated or trending, or where the physician identifies clinical concern.
Declining estrogen after menopause disrupts calcium metabolism and reduces PTH suppression, causing PTH to rise even without primary hyperparathyroidism. Elevated PTH — even within the high-normal range — promotes myocardial fibrosis, impairs ventricular relaxation, and activates the RAAS, all of which raise the risk of heart failure with preserved ejection fraction. This mechanism is often clinically silent and is not captured by standard cardiac risk models. Layer 2 addresses the gap by linking PTH, vitamin D, and serum calcium as a single mineral panel, interpreted in the context of renal function, menopausal status, and cardiac trajectory. The treating physician determines whether and when the panel is ordered.
Neurodegenerative biomarkers are not yet universally reimbursed by CMS. Layer 9 testing is included only where the treating physician determines it is clinically necessary, with education and supporting documentation — including cross-layer data from other layers — presented to the physician for review. Reimbursement pathways are evolving and CMS guidance is monitored. Kidney function must always be considered when interpreting these results, since reduced eGFR independently elevates NfL, GFAP, and pTau217 regardless of neurologic disease.
These extensions are not applied to every patient. Each is triggered by findings within the core layers, keeping testing targeted rather than universal.
In older patients, osteoporosis and fragility fractures are not simply orthopedic events — they accelerate loss of independence, trigger hospitalizations, and worsen cardiometabolic trajectories through immobility and deconditioning. This extension adds biologically responsive bone-turnover monitoring to help physicians detect high-turnover bone loss earlier, confirm treatment response sooner than DXA imaging can show, and manage CKD-related mineral metabolism accurately.
| Biomarker | What It Detects | Added Value Over Standard Care | Frequency |
|---|---|---|---|
| Intact P1NP | Bone formation rate; early biologic response to osteoporosis therapy | Confirms therapy adherence and response 3–6 months before DXA can show change | Baseline, then 3–6 months after therapy change; every 6–12 months if stable |
| Bone-specific ALP (bALP) | Bone formation; CKD-related mineral metabolism classification | Differentiates the bone contribution to elevated ALP; critical in CKD-MBD | Baseline; every 6–12 months for CKD-MBD risk; 3–6 months after therapy change in high-risk cases |
Activated when any of the following are present in the patient record: a known osteoporosis or osteopenia diagnosis; a prior fragility fracture; a frailty flag from Layer 7 or Layer 10 gait analysis; CKD stage 3 or higher (eGFR under 60) from Layer 2; an active or recent corticosteroid prescription; or BMI below 18.5. Renal adjustment applies here as well — in reduced kidney function, bone turnover markers can be distorted by clearance changes and secondary hyperparathyroidism, so results are integrated with eGFR, calcium, phosphate, and vitamin D status.
FH genetic testing is ordered only when the result is expected to change how the patient is managed — to support therapy escalation, justify biologic agents such as PCSK9 inhibitors, or enable cascade testing of family members. It is not a routine screen.
FH genetic testing is not ordered when LDL-C is already at target without a premature ASCVD history, when the patient is not a candidate for therapy escalation, or when a secondary cause explains the hypercholesterolemia and has not yet been corrected. When any of these conditions apply, the ordering criteria are not met and testing is not presented for the physician's consideration.
This extension activates only for patients with a confirmed IBD diagnosis — Crohn's disease or ulcerative colitis — rather than across the general population. It tracks disease activity between gastroenterology encounters using a panel of inflammatory ratios calculated from labs the patient is already giving, so no additional specimen collection is required.
Six ratios are calculated: NLR (neutrophil-lymphocyte), PLR (platelet-lymphocyte), SII (systemic immune-inflammation index), LMR (lymphocyte-monocyte), and LHR (lymphocyte-hemoglobin) come from the CBC; NPAR (neutrophil-platelet-albumin) also draws on serum albumin from the metabolic panel. All six are calculated from each draw — typically every 3 to 6 months, and more often during an active flare — and presented to the treating physician for review alongside the physician's established parameters, with the underlying values always visible.
Cancer screening is not a core layer. It is a conditional, physician-directed extension that activates based on age, gender, and clinical risk factors surfaced elsewhere in the protocol — keeping oncologic screening targeted and evidence-based rather than applied uniformly.
Low-dose CT and FIT/Cologuard follow standard CMS age- and risk-based screening eligibility. PSA and CA-125 are never triggered automatically — they are ordered strictly by physician direction, informed by age, gender, family history, and findings surfaced elsewhere in the protocol. Results are presented to the physician alongside the patient's broader risk profile.
The RPAL composite is a published index calculated from CRP and serum albumin (Layer 5) and lymphocyte count (Layer 6) whenever all three are present in the current draw, and presented to the treating physician for review with the underlying values always visible. The physician's established parameters govern when the care team brings it forward for attention — for example, in the 90 days after a TAVR or major cardiac or surgical intervention, when serum albumin falls below 3.5 g/dL, or when the physician's assigned care tier carries a frailty or high-infection-risk designation. No additional testing is required at any point.
Kidney function is not treated as a secondary finding. It is an active physiologic modifier that changes how the physician reads every clinical layer. Reduced kidney function alters the circulating levels of inflammatory markers, vascular injury signals, and neurodegenerative biomarkers in ways that lead to misclassification if renal physiology is ignored.
Failing to account for it creates real clinical risk: overestimation of neurodegenerative risk, premature specialist referral, inappropriate therapy escalation, and unnecessary cost without benefit to the patient. So renal context is presented alongside every affected result — assembled for the physician's review, with the underlying values always visible.
| Biomarker Pattern | Kidney Function Context | Clinical Context Presented to Physician |
|---|---|---|
| Elevated neurodegenerative biomarkers | Preserved eGFR | Higher likelihood of actual neurodegenerative pathology — proceed with clinical evaluation |
| Elevated neurodegenerative biomarkers | Reduced eGFR | Renal clearance effect is likely contributing — prioritize longitudinal trending before escalation |
| Stable biomarkers | Reduced eGFR | Lower near-term neurodegenerative risk — monitor physiologic contributors to kidney decline |
| Rising biomarkers over time | Stable or declining eGFR | Adjust slope interpretation; correlate with cognition, function, and device data before escalating |
A single elevated biomarker reading in a patient with CKD does not mean the same thing as the same reading in a patient with normal kidney function. Biomarkers are never presented in isolation. Renal-adjusted trend data gives the physician the context to differentiate stable renal-related elevation from pathologic progression — a more accurate clinical picture rather than a false alarm.
The protocol is built around FDA-cleared diagnostic devices operated on-site under physician supervision, with results transmitted to the physician within minutes of testing — enabling immediate clinical decision-making without disrupting clinic workflow or adding staff burden.
Each device integrates with the platform's clinical workflows and operates under existing CMS billing pathways. Device findings feed directly into the relevant biomarker layer.
Measures left ventricular end-diastolic pressure non-invasively. Detects early heart failure physiology — including HFpEF — before symptoms develop, providing hemodynamic data unavailable from standard clinical examination.
The AEYE-DS device generates an automated diabetic retinopathy screening result from a single retinal image within its FDA-cleared autonomous AI function. The result is presented to the ordering physician within approximately one minute. The physician makes all referral decisions. Closes the HEDIS diabetic eye exam care gap without a separate specialist visit.
Automated measurement of ankle-brachial and toe-brachial index. Identifies peripheral arterial disease, arterial stiffness, and limb ischemia risk before symptoms become limiting.
Assesses heart rate variability, sudomotor function, and parasympathetic/sympathetic balance — detecting autonomic dysfunction, an early marker of diabetic neuropathy and cardiovascular instability.
Non-invasive liver elastography quantifying hepatic stiffness and steatosis for staging of fibrosis and MASLD/MASH. Ordered on physician direction where clinical indicators are present, including elevated FIB-4 or abnormal Layer 4 biomarkers. CMS medical necessity criteria apply.
Synchronize Health supplies the Eko Core 500 AI digital stethoscope to participating physicians for their exclusive independent clinical use. The Eko Core 500 is operated by the physician during their own clinical examination and is not a component of the SYNC-PREVENT™ monitoring platform.
Real-time continuous glucose monitoring for insulin-dependent patients in the Moderate or Complex care tier, giving the physician continuous glycemic trend data between visits rather than a single point-in-time reading. Feeds Layer 3 interpretation.
| Device | Manufacturer | What It Detects | Frequency |
|---|---|---|---|
| Bluedrop OneStep | Bluedrop Medical | Plantar temperature asymmetry data generated by the Bluedrop device within its cleared function, presented to the ordering physician. The physician reviews asymmetry data and determines clinical significance. | Daily (high risk); weekly (moderate risk) |
| Wesper At-Home Sleep Study | Wesper | Sleep assessment data generated by the Wesper device within its FDA-cleared function — including respiratory pattern data, sleep stage data, and oxygen saturation data — presented to the ordering physician for clinical review. | Annual, or when symptomatic |
| Digital cognitive testing | Creyos | The Creyos platform administers standardized cognitive assessment tasks and produces scored results within its cleared function. Scored results are presented to the ordering physician for clinical review and interpretation. Formalized as Layer 11; corroborates Layer 9 blood-based biomarkers. | CPT 96116 — annual |
| Frailty & gait analysis | KinetikOS | The KinetikOS platform measures gait parameters — speed, stride, and balance — and generates a functional assessment output within its cleared function. Results are presented to the ordering physician for clinical review. The physician makes all clinical determinations regarding frailty and fall risk. Formalized as Layer 10. | CPT 97750 — annual |
| Continuous glucose monitoring | Dexcom G7 | Real-time glycemic trend data for insulin-dependent patients, supporting Layer 3 interpretation between visits. | Moderate/Complex tier — continuous |
SYNC-PREVENT™ organizes every biomarker result, device reading, and longitudinal data point into one continuously updated clinical record — presented to the ordering physician in context. Lab values are presented alongside prior results. Device outputs are presented alongside relevant biomarker findings. Computed indices like FIB-4 are calculated automatically from existing labs and presented for physician review. The physician sees the complete picture. The physician makes every clinical determination.
Age, AST, ALT, and platelets — computed automatically from existing labs.
A fibrosis risk index presented to the ordering physician alongside metabolic, cardiac, and renal context. The physician reviews the FIB-4 result and makes all clinical determinations regarding fibrosis risk and MASLD/MASH progression. Updated every 6–12 months alongside ALT/AST testing.
Remote Patient Monitoring and Chronic Care Management are the operational infrastructure that carries SYNC-PREVENT™ findings to patients and care teams between physician visits. They enable personalized engagement, medication adherence support, tiered alerting, and the longitudinal follow-through that turns a clinical insight into a measurable outcome.
Enrolled patients are supported by trained BridgeCare LA coordinators — people, not software — who review incoming data against physician-established parameters and understand conditions, medications, symptoms, and escalation pathways. What reaches the physician has been reviewed by clinical staff, is clinically relevant, and is free of noise.
Structured escalation pathways connect the care team to the treating physician when collected data falls outside physician-established parameters — the right person hearing from the care team at the right level.
Adherence verification and medication reconciliation through TEFCA/Carequality data, aimed at reducing medication-driven readmissions and care gaps.
Ready-to-sign reports aligned with CMS requirements, designed to reduce administrative burden without adding staff workload.
Missed readings, non-compliance, and engagement gaps are treated as clinical variables addressed through structured behavioral intervention, not simple reminders.
TEFCA/Carequality integration gives clinicians the complete picture of the patient — not just device readings — with full data security and HIPAA compliance.
SYNC-PREVENT™ establishes a patient-centric Health Information Exchange that dynamically links every professional involved in a patient's care — primary care, specialists, hospitals, ancillary services, and care management teams — into a single, continuously updated clinical network.
Through TEFCA/Carequality connectivity and event-based messaging, meaningful changes are shared across the care team as they happen: hospital admissions and discharges, ED visits, abnormal laboratory results, findings reported by cleared monitoring devices, and care team escalations made under physician-established parameters.
Because every clinician works from the same current record, care gaps during transitions are closed, duplicative testing is reduced, and conflicting treatment decisions become visible before harm occurs.
SYNC-PREVENT™ is built on the foundation of the American Heart Association's cardiovascular risk model and expands it across every dimension. The two are distinct: the AHA model is a published risk equation; SYNC-PREVENT™ is a monitoring platform licensed from Synchronize Health, LLC.
| Clinical Dimension | AHA Risk Model | SYNC-PREVENT™ |
|---|---|---|
| Risk assessment timing | Static — a single point in time | Longitudinal, continuously updated |
| Organ system coverage | Cardiometabolic only | Cardiac, renal, metabolic, hepatic, neurologic, vascular, hematologic, autonomic, functional/frailty, cognitive, oncologic |
| Biomarker context | Fixed threshold values | Renal-adjusted, cross-layer, longitudinal data presented for the physician's interpretation |
| Data sources | Traditional labs and clinical data | Labs, devices, RPM, EHR, medications, behavioral data, TEFCA/Carequality feeds |
| Kidney function role | Treated as a downstream diagnosis | Embedded as an active physiologic modifier across all layers |
| Escalation pathway | Clinician-initiated at next visit | Care team escalation under physician-established parameters, with structured follow-up |
| Physician support | Risk score delivery only | Full clinical context organized across organ systems, with workflow-integrated escalation support |
| CMS / value-based alignment | Partial | CMS-reimbursable structure, HEDIS/STARs gap closure, RPM/CCM integration |
FDA-cleared devices and longitudinal biomarkers give the ordering physician a continuously updated picture of physiologic status — across cardiac, renal, metabolic, and neurologic systems.
Findings across all eleven monitoring layers are organized into one clinical record, adjusted for renal context, and presented to the ordering physician with the full picture they need.
The treating physician — and only the treating physician — decides. SYNC-PREVENT™ delivers the picture; it never delivers the decision.
SYNC-PREVENT™ isn't built around one disease. It organizes the entire trajectory of deterioration for the physician — before symptoms begin, before hospitalization occurs, before outcomes become difficult to reverse.
As new diagnostic technologies are validated, as additional FDA-cleared devices are integrated, and as CMS coverage evolves, SYNC-PREVENT™ expands accordingly. That commitment to ongoing refinement is what keeps the protocol current, clinically meaningful, and trustworthy.
Every element is designed around one governing principle: the physician is at the center of every clinical decision. The platform's role is to ensure that physician has the most complete, most accurate, and most timely clinical picture available — so that when they act, they act with confidence.
“Biology changes before symptoms begin. SYNC-PREVENT™ organizes that change for the physician — the complete picture they need, at the moment it matters most.”
This page describes the design of the SYNC-PREVENT™ clinical protocol. It is provided for informational purposes only and is not medical advice, a diagnosis, or a treatment recommendation. SYNC-PREVENT™ does not interpret clinical data or provide treatment recommendations; the platform collects data from FDA-cleared monitoring devices, organizes it, and transmits it to the treating physician, and all clinical interpretation, assessment, and treatment decisions are made exclusively by the treating physician based on their independent review of the transmitted data. All testing, device use, referral, and escalation described here occurs at the direction and discretion of the treating physician. CPT codes are listed to identify the category of service and do not constitute a representation that any service will be covered or reimbursed in a given case. Biomarker frequencies reflect protocol design and may differ for an individual patient. SYNC-PREVENT™ is a trademark of Synchronize Health, LLC.
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