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Network baseline
We map your current SNF discharge network, quantify your bounce-back rate by facility, and identify the buildings where a Puzzle deployment moves the numbers fastest.
For Hospitals
What if you could see every patient the moment they leave?
Hospitals lose visibility the moment a patient discharges — but they still own the readmission. Puzzle rebuilds that line of sight and puts a physiatry-led safety net inside every SNF you send to.
The gap you're paying for
Roughly 1 in 4 SNF patients bounce back to the hospital.
The days between hospital discharge and SNF admission are where most preventable readmissions begin — and where most hospitals' visibility ends. Puzzle closes that gap with people on the ground and data flowing back to you.
~ 24%
National SNF 30-day readmission rate
$17B
CMS estimate of avoidable readmissions annually
0
Cost to the hospital for a Puzzle deployment
What hospitals get
The dashboard your discharge planners have been asking for.
Post-Discharge Visibility
Real-time view of every patient in a SNF.
Puzzle Readmission Intelligence gives your team a live census of every discharged patient — with clinical status, care plan, readmission risk, and the Puzzle team's notes attached to each record.
- Daily SNF census and status for every discharged patient
- Discharge snapshot in a format primary care can actually use
- Return-reason analytics on every readmission
- Facility scorecards to inform your preferred-provider network
Clinical Safety Net
A Puzzle team rounding inside every SNF you send to.
Puzzle physiatry providers work inside the SNFs in your discharge network, backed by a care coordination team. They stratify each patient at admission, catch clinical deterioration early, and escalate to the appropriate care setting — often the ED nearest to the SNF, not yours.
- Per-patient readmission-risk scoring at SNF admission
- Disease-specific care coordinator assigned from day one
- Onsite physiatry rounding on high-risk patients
- Live escalation triaged to the appropriate care setting
The engagement
What the first 90 days look like.
02
On-site deployment
Puzzle physiatry providers work inside priority buildings, backed by a care coordination team. Puzzle bills its own clinical services separately, so your hospital doesn't invoice for the program.
03
Live outcomes reporting
Your discharge planners, quality team, and ACO leaders get a single view of readmissions by facility, cohort, and condition — updated daily, not quarterly.
Case Study
OSF HealthCare: SNF readmissions 29% → 9% across 50+ facilities.
A 17-hospital system, a 20-point readmission reduction, and a clinical program built to lift outcomes across the SNF network.
See Puzzle deployed in your network.
Send us your SNF discharge list. We'll come back with a bounce-back benchmark for each facility and a 90-day deployment plan for the ones that move the numbers most.