Fewer readmissions.
Better transitions.
Real impact.
Puzzle physiatry providers work inside skilled nursing facilities, backed by a care coordination team, following every patient from hospital discharge through 90 days home. Hospitals and ACOs see measurable improvements in readmission rates and post-acute outcomes.
A growing footprint across the US.
From coastal chains to Midwest health systems, Puzzle's care-transition network keeps expanding — one hospital, one SNF, and one region at a time.
Puzzle is building coast-to-coast — and moving fast.
Aligned incentives with everyone in the transition.
Puzzle is designed to work for hospitals, SNFs, and payors at the same time — without asking any of them to pay for it up front.
A physiatry-led model that works inside the building, not around it.
Physiatrists as the quarterbacks of care.
Puzzle physiatrists round in the SNF, evaluating the patients at highest risk for readmission and directing the medical plan alongside the facility's existing clinical team. Pain management, medical complexity, DME and therapy orders — handled on site.
- In-depth admission and interval assessments
- Active participation in Medicare and interdisciplinary meetings
- Comprehensive pain and complex-medical management
- Guided therapy protocols and PDPM/MDS documentation support
One care team from hospital bed to home.
A dedicated, disease-specific care coordinator is assigned at the moment of hospital discharge and follows the patient through the SNF stay and into the home. HIPAA-secure messaging keeps hospital, SNF, and family aligned on a single plan.
- Unified care plan across the transition
- Managed-care peer-to-peer support and authorizations
- HIPAA-secure messaging with hospital and SNF staff
- Escalation pathways triaged to the appropriate care setting
The follow-through most programs skip.
Puzzle keeps working after the SNF discharge. Care coordinators stay in touch by phone; the highest-risk patients are outfitted at home with wearables that stream vitals and mobility data back to the Puzzle clinical team — closing the last, most-costly gap in the transition.
- 60–90 day structured post-discharge outreach
- Wearable-based vitals and mobility monitoring for high-risk patients
- Live clinical escalation to prevent avoidable ED visits
- Continuous data feedback to the discharging hospital
SNF readmissions cut from 29% to 9% at OSF HealthCare.
Across more than 50 nursing homes in OSF HealthCare's Illinois and Michigan footprint, Puzzle's care transition program reduced readmissions by nearly 20 points — without asking SNFs to add staff or training.
Reported by Skilled Nursing News and Today's HospitalistPartners who've done the work with us.
With SNF patients, we now see 30-day readmission rates under 7%. The rate at 60 days is under 10%, and even at 90 days, we're under 18%. We've seen our readmission rates drop drastically.
Those facilities that are utilizing Puzzle are showing statistics of improved readmission rates compared to the other ones. As the SNFs start to understand how Puzzle works and the reduction in readmissions, the buy-in has been greater.
Ready to see what Puzzle can do inside your network?
We'll walk through the model, the data, and the value-based framework — and show you what the first 90 days would look like in your buildings.