‘Extraordinary Achievement’: Care Transition Program in Nursing Homes Reduced Hospital Readmission Rates by 20%

Despite operational and financial headwinds affecting the nursing home sector currently, a transitional care program and physiatry partnership has been able to cut readmission rates from 29% to 9% among a group of facilities.

OSF HealthCare, a 17-hospital system in Illinois and Michigan, partnered with physiatry and care coordination management group Puzzle Healthcare to deliver a care transition program to more than 50 nursing homes across its footprint. One of those operators was Allure Healthcare Services.

Katie Hughes, regional nurse consultant with Allure Healthcare Services, called the program an “extraordinary achievement.” OSF reached out to Allure in May 2023 with the opportunity to partner with Puzzle. Allure now has Puzzle physiatrists in all 15 of their facilities, expanding beyond the OSF partnership.


“The one component for me that I think is hugely beneficial is that they do follow-up care during their time here, bridging that gap between therapy and needs whether it’s pain control or things [residents] need to be able to be fully effective in therapy to progress,” she said.

OSF launched the care transition program about a year ago, Matt Nieukirk, director of OSF’s SNF practice told Skilled Nursing News.

Prior to the program, OSF was seeing a major bounce back after about four days, where a patient discharged from the hospital to the nursing home was brought back to the hospital. Ideally, the SNF stay lasts between 14 and 18 days, and then they’re sent home, said Nieukirk.


Ahzam Afzal, co-founder and CEO of Puzzle, said the group has been embedded in value-based care for the last decade. When they engage with a health system, they take a closer look at readmission penalties overall.

“Typically, what we find is that a high proportion of these readmissions are coming from the post-acute space,” said Afzal. Inadequate staffing has made it very challenging for the SNF to conduct discharge planning, he said. It became difficult for OSF to see how patients were doing post discharge and any followup wasn’t happening in a way that could target potential exacerbations, Afzal said.

Moving ahead, Afzal said groups like Puzzle will be integral to cost share programs like Accountable Care Organization (ACO) Realizing Equity, Access and Community Health (Reach) and the Transforming Episode Accountability Model (TEAM). TEAM, for one, is a bundled payment model which will cover all costs associated with a 30-day episode of care. That’s within the timeframe that OSF and Puzzle are focused on with their care transition program.

“The goal of physiatry is being able to provide a lot of preventative care to help patients meet their physical rehabilitation needs and make sure that they achieve their maximum level of function before discharge,” said Afzal. “That proactive approach not only improves patient outcomes, but also reduces the likelihood of those readmissions.”

Effects on outcomes, staff collaboration

There was no cost to having the physiatrists on site, or to participate in the care transition program, Hughes said. Groups like Puzzle generate revenue off of their billing for services. It doesn’t impact any financial portion of Allure.

That’s on top of following the patient for 30 days after their skilled nursing visit as well, Hughes said. Physiatrists use remote patient monitoring, and they’re constantly checking to see if there’s been a change in functional status or if there’s been a decline in function.

“Ideally, in a skilled nursing facility that is the goal of our social service director, but we all know that at the building level we get inundated very fast depending on what’s going on,” Hughes said. “[Puzzle offers] an additional layer to make sure that we have multiple people checking in on those people post discharge.”

Allure’s directors of rehabilitation and directors of nursing (DONs) can feel the benefits from that additional layer of support, she said, because it alleviates the strain somewhat of other tasks.

Comprehensive Rehab Consultants, an Illinois physiatry group, says little interventions add up to better outcomes. The group helps identify risks which could lead to readmission and helps patients identify common concerning symptoms like a UTI.

In terms of a successful care transition program, physiatrists should be facilitating “bi-directional communication,” meaning clinical consultations with clinicians that treated the patient in order to identify these risks, said Sarah Cameron, vice president of care transitions for Comprehensive.

Comprehensive hopes to expand its client base beyond skilled nursing facilities to include hospitals as well, similar to what Puzzle is doing, in an effort to improve care coordination services. Comprehensive currently showed a 3.9% patient-reported readmission rate, compared to the national average of 14%.

As for OSF, the hospital system was able to get Puzzle into partnering facilities within a half year by allowing the facilities to be in their preferred network. Currently, there are about 57 nursing homes participating in the program facilitated by OSF. And out of OSF’s 17 hospitals, there are about three to seven nursing homes participating within the area.

“The whole goal of this program was, how can we work with the nursing homes, really try and hold them accountable,” said Nieukirk. “When those patients got there, they were doing everything that they could to really keep them there and not have them get readmitted to the hospital.”

Physiatry and cost share programs

Physiatry as a practice aims to get those high acuity patients, rehab patients, to their highest level of functionality so they can get stronger, do therapy and really improve activities of daily living.

On top of that, groups like Puzzle and Comprehensive aim to reduce costly readmissions while improving patient health among underserved populations, and reducing the cost of care across the continuum, Afzal said, pillars of cost share programs like ACO and TEAM.

The ACO Reach model uses more of an innovative payment approach to support care delivery coordination particularly in underserved communities, he said. Physiatry groups contribute to these efforts.

“​​And then from a provider leadership and governance perspective, the ACO Reach model requires 75% control of each ACO’s governing body to be held by providers,” added Afzal. “Physiatry groups, because they have that specialized expertise, they’re really uniquely specialized to lead these care initiatives, and drive a lot of that clinical excellence.”

The program has impacted quality measures as well, Hughes said, in terms of functionality and mobility since Puzzle physiatrists work with different patient populations in the building, those that are more post-acute and those that are more long-term care.

There appears to be a better team approach to collaborative care, Hughes noted, and better outcomes within and outside of the facility.

“It almost escalates the immediacy of care by having them on site in our buildings. Typically, a medical director is not rounding daily, and having Puzzle Health be those eyes, those boots on the ground for us has really, really helped those outcomes.

Having physiatrists in-house means less trips to specialists, to the cardiologist or nephrologist, again helping outcomes, said Hughes.

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