DETROIT & PEORIA, Ill.--(BUSINESS WIRE)--Puzzle Healthcare, a nationally recognized post-acute readmission prevention company, in collaboration with OSF HealthCare, a non-profit integrated health care network serving patients of all ages across Illinois and Michigan, today announced their successful continued collaboration in significantly reducing hospital readmissions for OSF HealthCare patients across its 16 hospitals. By addressing gaps in continuous care during transitions between care settings, OSF patients are experiencing improved health outcomes and lower readmission rates to the hospitals post-discharge.
Before this partnership, OSF HealthCare identified an urgent need to address gaps in transitions of care between care settings. Patients discharged from hospitals to skilled nursing facilities (SNFs) were readmitted at a rate of 29% due to complications that could have been prevented with better monitoring and more proactive management.
Puzzle Healthcare’s extensive experience in readmission prevention in post-acute care, specifically during the transition between hospital, skilled nursing facility, and home, provided OSF the support services necessary to meet the unique needs of complex patients. Leveraging Puzzle’s care management and post-discharge monitoring program, OSF more effectively integrated physiatry, care coordination, patient monitoring, patient tracking, and reporting technologies to bridge continuous care gaps and reduce the number of preventable readmissions often seen within post-acute care transitions.
“Our partnership with Puzzle Healthcare has greatly reduced the high readmission rates we have seen in the past while also transforming the way we treat patients with chronic and complex conditions that require tailored and extensive care,” said Matt Nieukirk, Director of SNF Practice at OSF HealthCare. “Since the beginning of our collaboration with Puzzle, our readmission rates for patients admitted to a SNF are down from 29% to 9% for discharged patients who are monitored by Puzzle for 90-days after leaving a facility. Puzzle Healthcare’s expertise is ensuring patients receive the best possible care while avoiding further complications, both elevating our services and allowing us to achieve better health outcomes for all.”
Puzzle Healthcare’s Readmission Reduction Program involves a comprehensive, two-pronged approach. Trained physiatrists are first embedded in skilled nursing facilities to provide specialized care, ensuring interventions for at-risk residents are effective and at the right time. As patients transition from SNFs back to their homes, Puzzle Healthcare’s multidisciplinary care management team continues to engage with them for 90 days post-discharge. They utilize risk-stratification algorithms, disease-specific assessments, remote patient monitoring, and frequent check-ins to identify early signs of deterioration, to ultimately prevent complications that could lead to readmission.
In partnership with health systems, Puzzle Healthcare develops readmission avoidance pathways, triaging patients to the appropriate care setting to further reduce the risk of readmission. All this work is integrated into a post-discharge tracker that risk stratifies discharged patients. This tracker is shared with health systems and SNFs and serves as a central tool in readmission meetings, driving awareness and behavioral change at both the health system and SNF levels.
“Puzzle Healthcare is committed to enhancing care quality for patients by providing health systems and SNFs with seamless care transitions, exceptional patient outcomes, and reduced readmissions,” says Puzzle Healthcare CEO Dr. Ahzam Afzal. “OSF HealthCare continues to be a highly valued partner, and we are excited to work alongside them in continuing to make an impact on the lives of patients through value-based care that’s not only accessible but also exceptional in its delivery.”
For more information on Puzzle Healthcare and how they impact patient care for vulnerable patient populations, visit https://puzzlehealthcare.com/. To learn more about OSF HealthCare visit https://www.osfhealthcare.org/.
About Puzzle Healthcare:
Puzzle Healthcare is a nationally recognized leader in value-based care, specializing in post-acute care coordination. The organization is dedicated to transforming healthcare delivery through innovative, patient-centered interventions. Puzzle Healthcare offers tailored programs for hospitals, skilled nursing facilities, and payors designed to reduce hospitalizations, lower readmission rates, and minimize overall healthcare costs. Puzzle Healthcare has earned praise from top health systems and Accountable Care Organizations (ACOs) nationwide. Committed to reshaping the future of healthcare, Puzzle Healthcare continues to set new standards in care coordination and value-based care. To learn more, please visit https://puzzlehealthcare.com.
About OSF HealthCare:
OSF HealthCare is an integrated health system founded by The Sisters of the Third Order of St. Francis. Headquartered in Peoria, Illinois, OSF HealthCare has 16 hospitals – 10 acute care, five critical access, one continuing care - with 2,131 licensed beds throughout Illinois and Michigan. OSF employs nearly 24,000 Mission Partners across 150+ locations; has two colleges of nursing; operates OSF Home Care Services, an extensive network of home health and hospice services; owns Pointcore, Inc., comprised of health care-related businesses; OSF HealthCare Foundation, the philanthropic arm for the organization; and OSF Ventures, which provides investment capital for promising health care innovation startups. In 2020, OSF OnCall was established, a digital health operating unit, including a hospital-at-home. OSF OnCall delivers care and services when, where and how patients prefer to receive them. OSF HealthCare has been recognized by Fortune as one of the most innovative companies in the country. More at osfhealthcare.org.
