Post-Acute Network
Analysis

All SNF utilization, volume, and readmission metrics are derived from CMS Medicare FFS Claims data (8Q trailing window: Q4 2023 – Q3 2025). The dataset covers fee-for-service Medicare beneficiaries discharged from acute-care hospitals to skilled nursing facilities during the analysis period. Facility metadata (bed count, NPI, CCN, ownership) is sourced from CMS Care Compare and CMS PECOS provider records.

FSHR is the all-cause rehospitalization rate among Medicare FFS patients discharged to a given SNF, measured at the SNF level over the 8-quarter analysis window. We lead with FSHR — rather than 30-day acute readmission — because FSHR is the metric most directly influenced by the structured SNF-level interventions Puzzle deploys (transitions of care, real-time admission/discharge visibility, in-SNF nurse practitioner coverage, and proactive complication management). The 30-day acute readmission rate sits one layer upstream and is affected by clinical complexity, discharge planning, and SNF performance combined; FSHR isolates the SNF-attributable component where intervention moves the needle.

Calculation: For each hospital, FSHR is reported as a volume-weighted average of SNF-level FSHR values across that hospital’s reportable SNF destinations, weighted by FFS patient volume. SNFs falling below the CMS minimum reporting threshold (<11 FFS patients per cell) are suppressed at source and excluded from the weighted calculation; aggregate destination counts still reflect them. System-wide weighted FSHR across the NGHS network: 40.0%.

Where the data lives: Raw 30-day readmission values remain stored alongside every SNF in this dashboard for analytical completeness, but they are not surfaced in the default view to keep focus on the metric most actionable for SNF network management.

Georgia state averages are derived from the same CMS Medicare FFS Claims data window: SNF utilization rate 14.23% (share of acute discharges routed to a SNF) and 30-day all-cause readmission rate 16.43% (readmission from SNF within 30 days of discharge). These figures represent the Georgia-weighted average across all reporting acute hospitals during Q4 2023–Q3 2025. 30-day readmission remains a supporting signal; FSHR (see preceding section) is the lead metric surfaced throughout the dashboard.

The Opportunity Index is a composite score (0–100) designed to surface where structured post-acute network engagement has the highest expected impact. Components:

• Volume (25 pts) — FFS SNF patient count, scaled relative to system peers
• Utilization vs. GA benchmark (20 pts) — Delta between hospital SNF utilization and GA state average
• SNF hospitalization signal (20 pts) — FSHR-weighted SNF rehospitalization rate combined with 30-day acute readmission, blended into a composite signal vs. GA state benchmark
• Destination fragmentation (15 pts) — Number of unique SNF destinations (more = more complex)
• Top-2 concentration risk (10 pts) — Share of volume in top 2 SNF partners
• Very-high-risk SNF exposure (10 pts) — Count of SNFs with elevated facility risk scores

Priority tiers: Immediate (≥60), Near-Term (≥35), Monitor (<35).

NGMC Braselton (NPI 1962727206) shares its CMS provider record with NGMC Gainesville, meaning all FFS discharge volume from the Braselton campus is reported under the consolidated Gainesville record. Braselton is shown in the hospital roster for transparency and is marked as a consolidated entity; its volume is captured within Gainesville's metrics and is not double-counted.

A SNF is classified as “cross-system” if it appears as a discharge destination for 2 or more NGHS hospitals during the analysis period. Cross-system SNFs are identified through NPI-level matching across all NGHS hospital discharge records.

Each hospital’s SNF destination table lists every facility with reportable FFS volume during the 8Q window. Facilities below CMS minimum reporting thresholds (typically <11 patients per cell) are suppressed by CMS at the source and therefore do not appear in the destination tables, though they may contribute to the “SNF Destinations” count shown in the stats strip.

This report is prepared exclusively for NGHS leadership by Puzzle Healthcare and is Confidential & Proprietary. It is intended solely for internal use by authorized NGHS personnel. Do not distribute externally without written authorization from Puzzle Healthcare.