Puzzle Readmission Intelligence
Predictive risk scoring for every patient at SNF admission. Continuously updated from the SNF EHR, ADT feeds, and Puzzle clinical activity.
The Platform
The clinical model runs on real feeds. Not a spreadsheet.
Predictive risk. Daily SNF tracking. Wearable-based post-discharge monitoring. Partner portals purpose-built for hospitals, ACOs, and SNF operators — all sitting on top of live ADT, EHR, and claims feeds.
The stack
Six purpose-built modules.
Every module is designed for one specific role in the post-acute transition — and works with the others as one system.
Post-Discharge Tracker
Follows every discharged patient through the SNF stay and 90 days home. Structured outreach, wearable vitals, and live escalation.
Partner Portals
Health-system, ACO, and SNF-chain portals with facility scorecards, network maps, and value-transparency reporting.
PDPM & MDS Support
Daily documentation verification helps SNF partners protect PDPM reimbursement and get MDS right the first time.
Facility Analytics
Return-reason analytics, cohort-level readmission trends, and functional-recovery benchmarking — refreshed daily.
Unified Care Plan
One plan across hospital, SNF, and home — with HIPAA-secure messaging that keeps the whole care team in the same document.
How the data flows
Live signals in. Clinical action out.
Every module runs on top of real-time feeds — not batch uploads. Signals come in from ADT, the SNF EHR, wearable sensors, and CMS claims. Puzzle's clinical team acts on them the same day.
- ADT ingestion from hospital and SNF EHRs
- Bamboo Health event feeds for real-time SNF admits and discharges
- Puzzle clinical activity from onsite physiatry and virtual care coordination
- Wearable RPM for high-risk patients during the 90-day post-discharge window
- Claims and CMS benchmarking for ACO-level performance tracking
Walk through the portals with our team.
Live demo of Puzzle Readmission Intelligence and the partner portal set matched to your role — hospital, ACO, or SNF chain.