Puzzle Healthcare is committed to championing value-based care and medicine across the healthcare continuum.

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Through innovative and tailored programs, we strive to significantly reduce hospitalizations, improve readmission rates, and minimize the total cost of care. Our services are meticulously designed to cater to Hospitals, Skilled Nursing Facilities (SNFs), and Payors.

Readmission Prevention, Seamless Transitions, and Enhanced Post-Discharge Visibility

Proactive Care Management

Our specialized care managers, proficient in disease-specific domains, guide each patient from the moment of hospital discharge, throughout their SNF stay, and continue to offer support for 90 days post-SNF discharge. This ensures smooth transitions and sustained, uninterrupted care.

Readmission Reduction

  • Our innovative programs have consistently delivered remarkable results in reducing readmission rates, improving patient outcomes, and heightening patient satisfaction. 
  • Proprietary Post-Discharge Tracker: This unique tool grants comprehensive visibility into each patient's well-being post-discharge. It empowers health systems with in-depth insights into patient health during the SNF stay and for 90 days post-SNF discharge, enabling timely interventions and further diminishing readmission risks.

Partnered Care Approach

Collaborating closely with hospital teams, we provide a reinforced support structure proficient in risk stratification, precise discharge planning, and comprehensive post-discharge follow-up.

Benefits

Tangible improvements in hospital metrics, robust partnerships with SNFs, and a significant reduction in readmission penalties, all converge to uplift the patient care experience from admission to post-discharge.

Enhanced Patient Care and Facility Support

Integrated Care Management

Through detailed care strategies, instant HIPAA-secure messaging, and a collaborative team framework, we quickly pinpoint and address patient needs to minimize readmissions and curb exacerbations.

On-Site Support

With on-site physiatry providers, we facilitate pain management, therapy progress, and coordinate effectively with the post-discharge care teams.

Facility Enhancement

Active participation in Medicare meetings, support in length of stay management, and driving accuracy in risk stratification.

Benefits

With Puzzle, SNFs will experience improved patient care, streamlined admission processes, and enhanced facility metrics.

Value-Based Care That’s Cost-Efficient

Total Cost Reduction

Our proactive and coordinated approach not only improves patient outcomes but also efficiently reduces the overall cost of care.

Risk-Adjusted Care

Through meticulous risk stratification and readmission diversion strategies, we ensure that the care provided is cost-effective and value-driven.

Collaborative Partnerships

We foster collaborative efforts with urgent cares, medical centers, and outpatient providers to enhance the care network's efficiency and effectiveness.

Benefits

Invest in care that is value-based and outcome-focused, ensuring that patients receive the best care without the financial strain.

Elevating SNF Care and Reducing Readmissions

Our specialized on-site physiatry providers not only enhance patient care but play a pivotal role in actively reducing readmissions and hospitalizations in SNFs. With their rigorous assessments, active participation in key SNF meetings, and holistic approach to patient care, our physiatrists are instrumental in reducing readmissions and adding immeasurable value to the SNF care process. At Puzzle Healthcare, we believe in the power of expertise combined with proactive care to transform the post-acute care landscape. Here's a closer look at the multifaceted approach our physiatry team employs:

In-depth Assessments

  • Disease-specific Evaluations: Utilizing specialized assessments tailored to individual diseases, our physiatrists identify early signs of potential exacerbations, allowing for proactive interventions.
  • Risk Stratification: By analyzing patient data, they meticulously determine the risk factors that could lead to readmissions, and devise strategies to mitigate these risks.

Active Participation in SNF Meetings

  • SNF Readmission Meetings: Our physiatrists bring their insights to these meetings, highlighting potential high-risk patients and suggesting targeted interventions. Their clinical expertise is pivotal in shaping decisions that preemptively address risks.
  • Medicare Meetings: Engaging in these meetings ensures that the care provided aligns with quality standards and protocols. Their input aids in refining care processes, ensuring that they're effective in preventing readmissions.

Comprehensive Pain Management

Address and manage pain effectively, reducing one of the primary triggers for readmission. Techniques, including trigger point injections, are employed to manage pain at its source.

Guided Therapy Protocols

Direct collaboration with therapy teams aids in crafting individualized rehabilitation pathways, ensuring patients progress optimally, reducing setbacks and potential hospitalizations.

Early Intervention and Care Continuity

  • The physiatry team's ability to swiftly pinpoint and address potential complications minimizes the need for hospital transfers.
  • Their seamless coordination with post-discharge care teams ensures continuity and consistency in patient care, reducing post-discharge issues.

Educational Initiatives

By equipping patients and families with knowledge about conditions, treatments, and self-management, our physiatrists reduce the risk of complications and readmissions.

Addressing Social and Medical Risks

  • Beyond medical care, they identify social determinants or factors that might lead to readmission, ensuring a holistic approach to patient well-being.
  • Their strategies, such as length of stay management, add value by optimizing each patient's SNF stay duration, balancing care needs with risk mitigation.

Readmission Prevention, Seamless Transitions, and Enhanced Post-Discharge Visibility

Proactive Care Management

Our specialized care managers, proficient in disease-specific domains, guide each patient from the moment of hospital discharge, throughout their SNF stay, and continue to offer support for 90 days post-SNF discharge. This ensures smooth transitions and sustained, uninterrupted care.

Readmission Reduction

  • Our innovative programs have consistently delivered remarkable results in reducing readmission rates, improving patient outcomes, and heightening patient satisfaction. 
  • Proprietary Post-Discharge Tracker: This unique tool grants comprehensive visibility into each patient's well-being post-discharge. It empowers health systems with in-depth insights into patient health during the SNF stay and for 90 days post-SNF discharge, enabling timely interventions and further diminishing readmission risks.

Partnered Care Approach

Collaborating closely with hospital teams, we provide a reinforced support structure proficient in risk stratification, precise discharge planning, and comprehensive post-discharge follow-up.

Benefits

Tangible improvements in hospital metrics, robust partnerships with SNFs, and a significant reduction in readmission penalties, all converge to uplift the patient care experience from admission to post-discharge.

Enhanced Patient Care and Facility Support

Integrated Care Management

Through detailed care strategies, instant HIPAA-secure messaging, and a collaborative team framework, we quickly pinpoint and address patient needs to minimize readmissions and curb exacerbations.

On-Site Support

With on-site physiatry providers, we facilitate pain management, therapy progress, and coordinate effectively with the post-discharge care teams.

Facility Enhancement

Active participation in Medicare meetings, support in length of stay management, and driving accuracy in risk stratification.

Benefits

With Puzzle, SNFs will experience improved patient care, streamlined admission processes, and enhanced facility metrics.

Value-Based Care That’s Cost-Efficient

Total Cost Reduction

Our proactive and coordinated approach not only improves patient outcomes but also efficiently reduces the overall cost of care.

Risk-Adjusted Care

Through meticulous risk stratification and readmission diversion strategies, we ensure that the care provided is cost-effective and value-driven.

Collaborative Partnerships

We foster collaborative efforts with urgent cares, medical centers, and outpatient providers to enhance the care network's efficiency and effectiveness.

Benefits

Invest in care that is value-based and outcome-focused, ensuring that patients receive the best care without the financial strain.

Elevating SNF Care and Reducing Readmissions

Our specialized on-site physiatry providers not only enhance patient care but play a pivotal role in actively reducing readmissions and hospitalizations in SNFs. With their rigorous assessments, active participation in key SNF meetings, and holistic approach to patient care, our physiatrists are instrumental in reducing readmissions and adding immeasurable value to the SNF care process. At Puzzle Healthcare, we believe in the power of expertise combined with proactive care to transform the post-acute care landscape. Here's a closer look at the multifaceted approach our physiatry team employs:

In-depth Assessments

  • Disease-specific Evaluations: Utilizing specialized assessments tailored to individual diseases, our physiatrists identify early signs of potential exacerbations, allowing for proactive interventions.
  • Risk Stratification: By analyzing patient data, they meticulously determine the risk factors that could lead to readmissions, and devise strategies to mitigate these risks.

Active Participation in SNF Meetings

  • SNF Readmission Meetings: Our physiatrists bring their insights to these meetings, highlighting potential high-risk patients and suggesting targeted interventions. Their clinical expertise is pivotal in shaping decisions that preemptively address risks.
  • Medicare Meetings: Engaging in these meetings ensures that the care provided aligns with quality standards and protocols. Their input aids in refining care processes, ensuring that they're effective in preventing readmissions.

Comprehensive Pain Management

Address and manage pain effectively, reducing one of the primary triggers for readmission. Techniques, including trigger point injections, are employed to manage pain at its source.

Guided Therapy Protocols

Direct collaboration with therapy teams aids in crafting individualized rehabilitation pathways, ensuring patients progress optimally, reducing setbacks and potential hospitalizations.

Early Intervention and Care Continuity

  • The physiatry team's ability to swiftly pinpoint and address potential complications minimizes the need for hospital transfers.
  • Their seamless coordination with post-discharge care teams ensures continuity and consistency in patient care, reducing post-discharge issues.

Educational Initiatives

By equipping patients and families with knowledge about conditions, treatments, and self-management, our physiatrists reduce the risk of complications and readmissions.

Addressing Social and Medical Risks

  • Beyond medical care, they identify social determinants or factors that might lead to readmission, ensuring a holistic approach to patient well-being.
  • Their strategies, such as length of stay management, add value by optimizing each patient's SNF stay duration, balancing care needs with risk mitigation.
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qoute Patient

After being discharged from the nursing home, having my care manager with me every step of the way gave me so much comfort. I knew exactly what I needed to do. It felt like I had a personal assistant to help with any issues getting what I needed.

qoute Doctor

My patients are oftentimes provided very little information at the time of discharge. Providing education and information about their hospital and SNF stay, and pointed discharge instructions is key to helping them adhere to their treatment plan. Also, when I connect with all of the patient’s outpatient providers and give them insight into their patient’s recent experience, they are super appreciative, receive a much clearer picture, placing them in the best position to take care of their patient.

qoute Patient

It takes me quite a bit of time to review the packet that a hospital sends along with the admission details. The DC snapshot that Puzzle provides gives me a true picture as to what is going on with my patient in a clear and concise manner.

qoute Doctor

Being able to focus on direct care to my patient is key in not only being efficient but improves the interaction I have with my patients. I love that I can leverage the care management team to take care of appointment scheduling, peer-to-peer scheduling, obtaining DME and everything else that they do. It is super helpful.