Not-for-profit healthcare system OSF HealthCare, serving Illinois and Michigan, has teamed up with Puzzle Healthcare, a specialist in post-acute care coordination, to tackle the challenge of hospital readmissions.

In this context, OSF pinpointed a critical need to improve care transitions and a 29% readmission rate from skilled nursing facilities (SNFs) despite preventable complications.

Puzzle Healthcare's expertise in readmission prevention is said to be helping OSF address the unique requirements of complex patients.

By implementing Puzzle's care management and monitoring programme, OSF is integrating various technologies and services to provide continuous care and reduce preventable readmissions.

Puzzle Healthcare's Readmission Reduction Program employs a dual approach. It places trained physiatrists in SNFs to deliver timely, specialised care and continues patient engagement for 90 days post-discharge.

The programme uses algorithms, assessments, and remote monitoring to detect early signs of patient deterioration and prevent readmissions.

This partnership also focuses on developing readmission avoidance pathways, directing patients to suitable care settings to minimise readmission risks.

A post-discharge tracker, central to this initiative, stratifies patient risks and is a key tool in readmission meetings, promoting awareness and behavioural change within health systems and SNFs.

OSF director of SNF Practice Matt Nieukirk said: “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.

“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.”

Earlier this year, OSF was in the news for its announcement to build a new inpatient hospital in Ottawa, US with an investment of over $180m.