An eight-quarter review of FFS SNF discharge patterns, destination concentration, and FSHR performance across a 53-hospital national health system spanning Texas, Indiana, Wisconsin, Florida, Tennessee, Oklahoma, and Kansas — from Ascension Seton in Austin to Ascension Saint Thomas in Nashville, Ascension St. Vincent in Indianapolis, Ascension Wisconsin in Milwaukee, Ascension Sacred Heart in Pensacola, Ascension St. John in Tulsa, and Ascension Via Christi in Wichita.
Ascension National operates the seven-state national footprint, spanning 53 hospitals across seven states. Its post-acute discharge picture is one of meaningful scale — 8,708 Medicare fee-for-service patients flowing across 557 SNF destinations over eight quarters — with limited cross-hospital coordination and no unified preferred-network infrastructure to manage FSHR performance systematically.
Over eight quarters (CMS Medicare FFS Claims: 2025 Q1 – 2025 Q4), Ascension National hospitals collectively discharged 8,708 fee-for-service Medicare patients to skilled nursing facilities, reaching 557 distinct SNF destinations across seven-state national footprint. Ascension Saint Thomas Hospital West leads the system in post-acute volume with 935 patients across 25 SNF destinations — the single largest Ascension National post-acute relationship set in the analysis. Ascension Saint Thomas Rutherford is the second-highest volume hospital in the system, contributing 897 FFS SNF patients.
Aggregate state SNF utilization across Ascension National's seven-state footprint averages 16.5% (FFS). What the data reveals is a system-wide FSHR elevation and destination fragmentation story: across 38 active hospitals, 8,708 patients are distributed to 557 SNFs, most operating without a structured performance framework or preferred-network accountability from Ascension National care teams.
Within Ascension National’s existing discharge patterns is a structural starting point for coordination: 168 SNFs already serve two or more Ascension National hospitals simultaneously. These shared facilities are the organic preferred network — facilities that Ascension National hospitals have collectively chosen through discharge patterns without any formal coordination. Puzzle Healthcare’s role is to formalize that organic network, extend its reach, and make FSHR performance systematically measurable and accountable.
The 20 priority SNF targets identified in this analysis — facilities with elevated FSHR rates appearing across multiple Ascension National hospitals — represent the highest-impact starting cohort for an embedded clinical program. Together they account for significant patient volume and carry FSHR rates meaningfully above the system-wide average of 35.5%.
Ascension National operates 53 acute-care hospitals across the seven-state national footprint — a dense, single-state community hospital network spanning nine counties. Each hospital draws from a distinct patient population and sends patients to a partially overlapping, partially distinct set of SNF partners across the state.
Ascension National’s geographic span across seven states represents both a strategic complexity and a significant opportunity. The system’s hospitals serve distinct regional communities — from the Ascension Seton flagship in Austin, TX and the Ascension Saint Thomas hospitals in the Nashville metro, to Ascension St. Vincent in Indianapolis, Ascension Wisconsin in Milwaukee, Ascension Sacred Heart in Pensacola and Ascension St. Vincent’s in Jacksonville, Ascension St. John in Tulsa and northeast Oklahoma, and Ascension Via Christi in Wichita. This diversity means that post-acute discharge patterns, local SNF networks, and FSHR drivers differ meaningfully across facilities and markets. A coordinated preferred-network framework delivers the greatest operational value precisely in this kind of heterogeneous multi-state system: unified performance standards, embedded clinical presence, and real-time visibility that operates consistently across all 38 hospitals regardless of geography.
Ascension Saint Thomas Hospital West’s 25-facility SNF destination network illustrates a pattern common to high-volume academic medical centers: a small number of facilities receive outsized volume, while the majority consist of lower-volume relationships that are difficult to manage systematically. This concentration and fragmentation dynamic — replicated across 38 hospitals and 557 SNF destinations — is the core visibility challenge at the heart of Ascension National’s post-acute situation.
The concentration pattern at Ascension Saint Thomas Hospital West is characteristic of a large academic medical center in a geographically concentrated state. Its top SNF partners already have the volume to support an embedded clinical presence — and they clearly have established relationships with Saint Thomas Hospital West (Nashville)’s discharge planning teams. The coordination gap lives in the long tail: the facilities receiving smaller patient volumes with no systematic performance framework or preferred-network accountability.
Multiplied across 38 Ascension National hospitals and 557 total SNF destinations system-wide, that long tail represents hundreds of downstream facilities operating beyond the horizon of Ascension National’s visibility. That is precisely the structural problem a unified preferred-network framework addresses — starting with the 168 cross-system facilities that already appear in multiple Ascension National discharge networks simultaneously.
Florida state SNF utilization benchmark: 16.5% (CMS Medicare FFS Claims). The system-wide weighted-average FSHR of 35.5% serves as the primary internal reference point for identifying hospitals with elevated return-to-hospital rates and high-impact intervention opportunities across Ascension National.
Ascension Saint Thomas Hospital West discharged 935 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 35.0%, -0.5pp vs system average. The leading post-acute destination is Nhc Place At The Trace (138 patients, 10.3% share). The hospital’s SNF network includes 4 facilityies with a “Very High” risk category.
The Saint Thomas Hospital West (Nashville) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at Saint Thomas Hospital West (Nashville)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Nhc Place At The Trace | 138 | 10.3% | 33.3% | Elevated |
| Blakeford At Green Hills Corporation | 123 | 9.2% | 23.1% | Elevated |
| Advanced Health Care Of Nashville | 111 | 8.3% | 34.8% | High |
| Richland Place Inc | 102 | 7.6% | 37.5% | Elevated |
| Nhc Place At Cool Springs | 57 | 4.2% | 34.5% | High |
Ascension Saint Thomas Rutherford discharged 897 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 34.8%, -0.7pp vs system average. The leading post-acute destination is Adamsplace Llc (245 patients, 26.2% share). The hospital’s SNF network includes 6 facilityies with a “Very High” risk category.
The Saint Thomas Rutherford (Murfreesboro) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at Saint Thomas Rutherford (Murfreesboro)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Adamsplace Llc | 245 | 26.2% | 30.8% | Elevated |
| Stones River Advanced Care Center | 130 | 13.9% | 41.2% | Elevated |
| National Health Corporation | 93 | 9.9% | 27.8% | High |
| Life Care Center Of Hickory Woods | 50 | 5.3% | 34.5% | Elevated |
| Community Care Of Rutherford County, Inc. | 47 | 5.0% | 32.8% | High |
Ascension Sacred Heart Pensacola discharged 893 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 41.8%, +6.2pp vs system average. The leading post-acute destination is De Luna Operating Investments Llc (189 patients, 19.6% share). The hospital’s SNF network includes 15 facilityies with a “Very High” risk category.
The Sacred Heart Pensacola (Pensacola) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at Sacred Heart Pensacola (Pensacola)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| De Luna Operating Investments Llc | 189 | 19.6% | 40.3% | High |
| Olive Branch Operating Investments Llc | 148 | 15.4% | 39.5% | High |
| Pruitthealth - Pensacola, Llc | 131 | 13.6% | 29.5% | High |
| Arcadia Operating Investments Llc | 53 | 5.5% | 40.8% | High |
| Haven Of Our Lady Of Peace, Inc. | 49 | 5.1% | 37.4% | High |
Ascension St. Vincent Hospital - Indianapolis discharged 738 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 32.3%, -3.2pp vs system average. The leading post-acute destination is Retirement Living, Inc. (81 patients, 7.0% share). The hospital’s SNF network includes 7 facilityies with a “Very High” risk category.
The St. Vincent Hospital - Indianapolis (Indianapolis) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at St. Vincent Hospital - Indianapolis (Indianapolis)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Retirement Living, Inc. | 81 | 7.0% | 29.8% | Elevated |
| The Restoracy Of Whitestown | 74 | 6.4% | 28.0% | High |
| Copper Trace Health And Living, Llc | 60 | 5.2% | 28.4% | High |
| Wellbrooke Of Carmel | 46 | 4.0% | 29.2% | High |
| Hamilton Trace Of Fishers | 42 | 3.6% | 34.0% | High |
Ascension St. John Medical Center discharged 485 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 39.5%, +4.0pp vs system average. The leading post-acute destination is Ignite Medical Resort Bartlesville, Llc (53 patients, 7.1% share). The hospital’s SNF network includes 9 facilityies with a “Very High” risk category.
The St. John Medical Center (Tulsa) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at St. John Medical Center (Tulsa)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Ignite Medical Resort Bartlesville, Llc | 53 | 7.1% | 39.9% | Elevated |
| St Simeons Episcopal Home Inc | 49 | 6.6% | 46.5% | High |
| The Villages At Southern Hills | 48 | 6.4% | 34.7% | High |
| St John Sapulpa, Inc | 44 | 5.9% | 36.2% | High |
| Baptist Village Of Owasso | 31 | 4.2% | 41.9% | High |
Ascension St. Vincent Evansville discharged 472 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 27.8%, -7.8pp vs system average. The leading post-acute destination is Heritage Center (82 patients, 12.1% share). The hospital’s SNF network includes 9 facilityies with a “Very High” risk category.
The St. Vincent Evansville (Evansville) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at St. Vincent Evansville (Evansville)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Heritage Center | 82 | 12.1% | 17.1% | Moderate |
| Hamilton Pointe Health And Rehab | 65 | 9.6% | 27.1% | High |
| River Pointe Health Campus | 62 | 9.1% | 32.5% | High |
| North River Health Campus | 50 | 7.4% | 29.9% | Elevated |
| Evansville Protestant Home | 44 | 6.5% | 32.4% | High |
Ascension St. Vincent's Riverside discharged 418 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 35.7%, +0.2pp vs system average. The leading post-acute destination is Riverside Post Acute (109 patients, 20.1% share). The hospital’s SNF network includes 11 facilityies with a “Very High” risk category.
The St. Vincent's Riverside (Jacksonville) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at St. Vincent's Riverside (Jacksonville)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Riverside Post Acute | 109 | 20.1% | 33.5% | High |
| Normandy Opco Llc | 49 | 9.1% | 36.4% | High |
| Middleburg Rehabilitation And Nursing Center | 35 | 6.5% | 31.0% | High |
| Bartram Crossing | 34 | 6.3% | 29.9% | High |
| Macclenny Nursing & Rehab Center | 29 | 5.4% | 42.0% | High |
Ascension Sacred Heart Bay discharged 307 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 41.9%, +6.3pp vs system average. The leading post-acute destination is Pruitthealth - Panama City (104 patients, 29.8% share). The hospital’s SNF network includes 5 facilityies with a “Very High” risk category.
The Sacred Heart Bay (Panama City) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at Sacred Heart Bay (Panama City)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Pruitthealth - Panama City | 104 | 29.8% | 38.2% | High |
| Community Health And Rehabilitation Center | 78 | 22.4% | 47.3% | High |
| Panama City Fl Opco Llc | 38 | 10.9% | 42.7% | High |
| Aviata At Emerald Shores | 33 | 9.5% | 52.8% | High |
| Port St Joe Opco Llc | 25 | 7.2% | — | Moderate |
Ascension Columbia St. Mary's Hospital - Milwaukee Campus discharged 252 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 32.7%, -2.8pp vs system average. The leading post-acute destination is Newcastle Place Llc (55 patients, 17.5% share). The hospital’s SNF network includes 11 facilityies with a “Very High” risk category.
The Columbia St. Mary's Hospital - Milwaukee Campus (Milwaukee) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at Columbia St. Mary's Hospital - Milwaukee Campus (Milwaukee)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Newcastle Place Llc | 55 | 17.5% | 33.3% | Elevated |
| Eastcastle Place Bradford Terrace Convalescent Center | 46 | 14.6% | 25.0% | High |
| Milwaukee Catholic Home, Inc. | 40 | 12.7% | 38.0% | Elevated |
| Ascension Living Alexian Village Milwaukee | 29 | 9.2% | 33.9% | High |
| Jewish Home And Care Center | 26 | 8.3% | 35.4% | High |
Ascension SE Wisconsin Hospital - St. Joseph Campus discharged 252 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 32.7%, -2.8pp vs system average. The leading post-acute destination is Newcastle Place Llc (55 patients, 17.5% share). The hospital’s SNF network includes 11 facilityies with a “Very High” risk category.
The SE Wisconsin Hospital - St. Joseph Campus (Milwaukee) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at SE Wisconsin Hospital - St. Joseph Campus (Milwaukee)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Newcastle Place Llc | 55 | 17.5% | 33.3% | Elevated |
| Eastcastle Place Bradford Terrace Convalescent Center | 46 | 14.6% | 25.0% | High |
| Milwaukee Catholic Home, Inc. | 40 | 12.7% | 38.0% | Elevated |
| Ascension Living Alexian Village Milwaukee | 29 | 9.2% | 33.9% | High |
| Jewish Home And Care Center | 26 | 8.3% | 35.4% | High |
Ascension Providence Hospital discharged 243 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 37.4%, +1.9pp vs system average. The leading post-acute destination is Ascension Living Providence Village (94 patients, 23.1% share). The hospital’s SNF network includes 11 facilityies with a “Very High” risk category.
The Providence Hospital (Waco) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at Providence Hospital (Waco)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Ascension Living Providence Village | 94 | 23.1% | 33.3% | High |
| Sunset Home | 21 | 5.2% | 22.0% | High |
| The Atrium Of Bellmead | 21 | 5.2% | 49.1% | High |
| Woodway Rehabilitation And Healthcare Center | 19 | 4.7% | 57.8% | High |
| Lakeshore Village Nursing And Rehabilitation. | 17 | 4.2% | 39.6% | High |
Ascension St. Vincent's Clay County discharged 206 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 38.9%, +3.4pp vs system average. The leading post-acute destination is Middleburg Rehabilitation And Nursing Center (123 patients, 52.3% share). The hospital’s SNF network includes 13 facilityies with a “Very High” risk category.
The St. Vincent's Clay County (Middleburg) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at St. Vincent's Clay County (Middleburg)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Middleburg Rehabilitation And Nursing Center | 123 | 52.3% | 41.0% | High |
| Life Care Center Of Orange Park | 24 | 10.2% | 31.3% | High |
| Pruitthealth - Fleming Island | 20 | 8.5% | 35.1% | High |
| Penney Retirement Community, Inc. | 14 | 6.0% | — | Elevated |
| Orange Park Rehabilitation And Nursing Center | 13 | 5.5% | — | High |
Ascension St. Vincent Kokomo discharged 202 FFS patients to 24 distinct SNF destinations over the analysis period. FSHR stands at 33.5%, -2.1pp vs system average. The leading post-acute destination is Wellbrooke Of Kokomo (103 patients, 44.8% share). The hospital’s SNF network includes 4 facilityies with a “Very High” risk category.
The St. Vincent Kokomo (Kokomo) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at St. Vincent Kokomo (Kokomo)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Wellbrooke Of Kokomo | 103 | 44.8% | 29.8% | Elevated |
| Waterford Place Health Campus | 63 | 27.4% | 36.0% | High |
| Century Villa Health Care | 21 | 9.1% | 44.1% | High |
| North Woods Village | 15 | 6.5% | 33.3% | High |
| Aperion Care Kokomo | <11 | — | — | High |
Ascension Sacred Heart Emerald Coast discharged 197 FFS patients to 24 distinct SNF destinations over the analysis period. FSHR stands at 42.2%, +6.7pp vs system average. The leading post-acute destination is Grand Boulevard Operating Investments Llc (76 patients, 36.2% share). The hospital’s SNF network includes 3 facilityies with a “Very High” risk category.
The Sacred Heart Emerald Coast (Miramar Beach) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at Sacred Heart Emerald Coast (Miramar Beach)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Grand Boulevard Operating Investments Llc | 76 | 36.2% | 41.7% | High |
| Destin Senior Care, Llc | 75 | 35.7% | 42.6% | High |
| The Manor At Blue Water Bay | 34 | 16.2% | 44.0% | High |
| Chautauqua Springs Health Center | 12 | 5.7% | 37.8% | High |
| Arabella Health & Wellness Of Pensacola | <11 | — | — | Elevated |
Ascension Via Christi Hospital in Manhattan discharged 195 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 27.5%, -8.1pp vs system average. The leading post-acute destination is Meadowlark Hills (78 patients, 31.8% share). The hospital’s SNF network includes 5 facilityies with a “Very High” risk category.
The Via Christi Hospital in Manhattan (Manhattan) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at Via Christi Hospital in Manhattan (Manhattan)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Meadowlark Hills | 78 | 31.8% | 27.1% | Elevated |
| Ascension Living Via Christi Village Manhattan | 61 | 24.9% | 23.8% | High |
| Wamego Health Center And Wamego Family Clinic | 23 | 9.4% | 33.3% | Elevated |
| Stoneybrook Retirement Community | 20 | 8.2% | 33.3% | Elevated |
| Clay County Medical Center | 13 | 5.3% | — | Moderate |
Ascension St. Vincent's Southside discharged 193 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 39.1%, +3.5pp vs system average. The leading post-acute destination is University Crossing (42 patients, 16.1% share). The hospital’s SNF network includes 10 facilityies with a “Very High” risk category.
The St. Vincent's Southside (Jacksonville) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at St. Vincent's Southside (Jacksonville)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| University Crossing | 42 | 16.1% | 39.7% | High |
| Life Care Center Of Jacksonville | 36 | 13.8% | 30.5% | High |
| Atrium Snf Operating Llc | 19 | 7.3% | 17.9% | High |
| Jax Fl Opco Llc | 19 | 7.3% | 51.8% | High |
| Woodland Grove Healthcare & Rehabilitation Center Llc | 19 | 7.3% | 58.1% | High |
Ascension St. John Jane Phillips Medical Center discharged 178 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 42.8%, +7.3pp vs system average. The leading post-acute destination is Ignite Medical Resort Bartlesville, Llc (91 patients, 41.4% share). The hospital’s SNF network includes 5 facilityies with a “Very High” risk category.
The St. John Jane Phillips Medical Center (Bartlesville) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at St. John Jane Phillips Medical Center (Bartlesville)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Ignite Medical Resort Bartlesville, Llc | 91 | 41.4% | 47.3% | High |
| Heritage Villa Healthcare, Llc | 44 | 20.0% | 45.4% | High |
| Bartlesville Health & Rehab Community | 31 | 14.1% | 26.0% | High |
| Medicalodges Dewey | 12 | 5.5% | — | Elevated |
| Americare At Montgomery Place Nursing Center Llc | <11 | — | — | Moderate |
Ascension Seton Williamson discharged 147 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 35.7%, +0.2pp vs system average. The leading post-acute destination is Bel Air At Teravista (41 patients, 16.5% share). The hospital’s SNF network includes 10 facilityies with a “Very High” risk category.
The Seton Williamson (Round Rock) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at Seton Williamson (Round Rock)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Bel Air At Teravista | 41 | 16.5% | 34.3% | Elevated |
| Georgetown Nursing And Transitional Care | 30 | 12.1% | 23.5% | High |
| The Center At Parmer | 22 | 8.9% | 53.1% | High |
| San Gabriel Rehabilitation And Care Center | 20 | 8.1% | 37.7% | High |
| The Springs Healthcare And Rehabilitation | 12 | 4.8% | — | High |
Ascension Via Christi St. Francis discharged 147 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 29.4%, -6.1pp vs system average. The leading post-acute destination is Ascension Living Via Christi Village Ridge (64 patients, 27.0% share). The hospital’s SNF network includes 6 facilityies with a “Very High” risk category.
The Via Christi St. Francis (Wichita) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at Via Christi St. Francis (Wichita)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Ascension Living Via Christi Village Ridge | 64 | 27.0% | 31.3% | Elevated |
| Family Health And Rehabilitation Center Llc | 31 | 13.1% | 32.9% | Elevated |
| Azw, Llc | 20 | 8.4% | 33.3% | Elevated |
| Wichita Presbyterian Manor | 20 | 8.4% | 14.0% | Elevated |
| Rolling Hills Health And Rehab | 12 | 5.1% | — | High |
Ascension Seton Medical Center Austin discharged 140 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 46.6%, +11.1pp vs system average. The leading post-acute destination is The Arbour At Westminster Manor (25 patients, 9.2% share). The hospital’s SNF network includes 10 facilityies with a “Very High” risk category.
The Seton Medical Center Austin (Austin) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at Seton Medical Center Austin (Austin)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| The Arbour At Westminster Manor | 25 | 9.2% | 28.1% | Elevated |
| Brookdale Westlake Hills | 24 | 8.8% | 43.1% | Elevated |
| The Center At Parmer | 22 | 8.1% | 71.4% | High |
| Ignite Medical Resort Round Rock, Llc | 16 | 5.9% | — | High |
| Legend Oaks Healthcare And Rehabilitation - North Austin | 16 | 5.9% | — | High |
Ascension All Saints Hospital - Spring Street Campus discharged 128 FFS patients to 21 distinct SNF destinations over the analysis period. FSHR stands at 40.4%, +4.9pp vs system average. The leading post-acute destination is Complete Care At Ridgewood Llc (44 patients, 28.0% share). The hospital’s SNF network includes 14 facilityies with a “Very High” risk category.
The All Saints Hospital - Spring Street Campus (Racine) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at All Saints Hospital - Spring Street Campus (Racine)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Complete Care At Ridgewood Llc | 44 | 28.0% | 35.8% | High |
| Ascension Living Lakeshore At Siena | 37 | 23.6% | 40.6% | Elevated |
| Lincoln Park Nursing And Rehab | 29 | 18.5% | 51.7% | High |
| Oak Ridge Care Center, Inc. | 18 | 11.5% | 33.3% | High |
| Alden-Park Strathmoor, Inc. | <11 | — | — | High |
Ascension Saint Thomas River Park discharged 123 FFS patients to 18 distinct SNF destinations over the analysis period. FSHR stands at 35.5%, -0.1pp vs system average. The leading post-acute destination is Nhc Healthcare-Mcminnville Llc (68 patients, 43.9% share). The hospital’s SNF network includes 5 facilityies with a “Very High” risk category.
The Saint Thomas River Park (McMinnville) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at Saint Thomas River Park (McMinnville)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Nhc Healthcare-Mcminnville Llc | 68 | 43.9% | 38.4% | High |
| Willow Branch Health And Rehabilitation | 43 | 27.7% | 30.8% | High |
| Life Care Center Of Sparta | 12 | 7.7% | — | Elevated |
| Adamsplace Llc | <11 | — | — | High |
| Bethesda Health Care Center Llc | <11 | — | — | Moderate |
Ascension SE Wisconsin Hospital - Elmbrook Campus discharged 121 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 32.7%, -2.8pp vs system average. The leading post-acute destination is Congregational Home Inc (32 patients, 12.7% share). The hospital’s SNF network includes 7 facilityies with a “Very High” risk category.
The SE Wisconsin Hospital - Elmbrook Campus (Brookfield) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at SE Wisconsin Hospital - Elmbrook Campus (Brookfield)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Congregational Home Inc | 32 | 12.7% | 29.3% | Elevated |
| Ascension Living Franciscan Place | 28 | 11.2% | 30.8% | High |
| Imr Oak Creek Opco, Llc | 16 | 6.4% | 42.9% | High |
| Care-Age Of Brookfield | 12 | 4.8% | 42.4% | High |
| Aria Of Brookfield Llc | 11 | 4.4% | — | High |
Ascension St. Vincent Carmel discharged 111 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 32.9%, -2.6pp vs system average. The leading post-acute destination is Copper Trace Health And Living, Llc (31 patients, 17.9% share). The hospital’s SNF network includes 7 facilityies with a “Very High” risk category.
The St. Vincent Carmel (Carmel) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at St. Vincent Carmel (Carmel)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Copper Trace Health And Living, Llc | 31 | 17.9% | 28.8% | High |
| Wellbrooke Of Carmel | 24 | 13.9% | 33.3% | Elevated |
| Majestic Care Of Carmel | 15 | 8.7% | 37.1% | High |
| Green House Cottages Of Carmel | 14 | 8.1% | — | Elevated |
| Wellbrooke Of Westfield | 14 | 8.1% | 36.8% | High |
Ascension Seton Cedar Park discharged 106 FFS patients to 17 distinct SNF destinations over the analysis period. FSHR stands at 30.1%, -5.5pp vs system average. The leading post-acute destination is The Springs Healthcare And Rehabilitation (32 patients, 27.4% share). The hospital’s SNF network includes 4 facilityies with a “Very High” risk category.
The Seton Cedar Park (Cedar Park) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at Seton Cedar Park (Cedar Park)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| The Springs Healthcare And Rehabilitation | 32 | 27.4% | 44.5% | High |
| Cedar Pointe Health And Wellness Center | 23 | 19.7% | 40.0% | High |
| The Center At Parmer | 19 | 16.2% | 13.3% | Elevated |
| New Hope Manor | 16 | 13.7% | 22.5% | Elevated |
| Sagebrook Nursing And Rehabilitation | 16 | 13.7% | 14.3% | Elevated |
Ascension Seton Medical Center Hays discharged 102 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 29.6%, -5.9pp vs system average. The leading post-acute destination is Legend Oaks Health And Rehabilitation - Kyle (53 patients, 24.1% share). The hospital’s SNF network includes 17 facilityies with a “Very High” risk category.
The Seton Medical Center Hays (Kyle) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at Seton Medical Center Hays (Kyle)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Legend Oaks Health And Rehabilitation - Kyle | 53 | 24.1% | 33.1% | High |
| Parkview Nursing And Rehabilitation Center | 21 | 9.5% | 26.5% | High |
| San Marcos Rehabilitation And Healthcare Center | 16 | 7.3% | 22.0% | High |
| Deer Creek Nursing And Rehabilitation | 12 | 5.5% | — | High |
| Avir At Luling | <11 | — | — | High |
Ascension St. Vincent Anderson discharged 80 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 30.4%, -5.2pp vs system average. The leading post-acute destination is Bethany Pointe Health Campus (31 patients, 23.5% share). The hospital’s SNF network includes 7 facilityies with a “Very High” risk category.
The St. Vincent Anderson (Anderson) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at St. Vincent Anderson (Anderson)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Bethany Pointe Health Campus | 31 | 23.5% | 29.6% | High |
| Rawlins House Health & Living | 29 | 22.0% | 27.5% | High |
| Countryside Manor Health & Living | 20 | 15.2% | 35.7% | High |
| Alexandria Care Center | <11 | — | — | Elevated |
| Aperion Care Marion | <11 | — | — | Moderate |
Ascension Seton Medical Center Harker Heights discharged 78 FFS patients to 21 distinct SNF destinations over the analysis period. FSHR stands at 45.6%, +10.1pp vs system average. The leading post-acute destination is Harker Heights Nursing & Rehabilitation (30 patients, 28.0% share). The hospital’s SNF network includes 10 facilityies with a “Very High” risk category.
The Seton Medical Center Harker Heights (Harker Heights) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at Seton Medical Center Harker Heights (Harker Heights)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Harker Heights Nursing & Rehabilitation | 30 | 28.0% | 29.2% | Elevated |
| Rosewood Heights | 30 | 28.0% | 55.6% | High |
| Avir At Killeen | 18 | 16.8% | 56.3% | High |
| Adventhealth Rollins Brook | <11 | — | — | High |
| Avir At Adams | <11 | — | — | Moderate |
Ascension NE Wisconsin - St. Elizabeth Campus discharged 70 FFS patients to 24 distinct SNF destinations over the analysis period. FSHR stands at 33.1%, -2.4pp vs system average. The leading post-acute destination is Rennes Health Center - Appleton (33 patients, 27.5% share). The hospital’s SNF network includes 7 facilityies with a “Very High” risk category.
The NE Wisconsin - St. Elizabeth Campus (Appleton) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at NE Wisconsin - St. Elizabeth Campus (Appleton)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Rennes Health Center - Appleton | 33 | 27.5% | 18.1% | Elevated |
| St Paul Elder Services, Inc | 21 | 17.5% | 56.7% | High |
| Brewster Village | 16 | 13.3% | — | High |
| Appleton Nursing And Rehab Llc | <11 | — | — | Moderate |
| Ascension Calumet Hospital | <11 | — | — | High |
Ascension St. Vincent's St. Johns County discharged 61 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 32.5%, -3.0pp vs system average. The leading post-acute destination is Bartram Crossing (31 patients, 29.2% share). The hospital’s SNF network includes 12 facilityies with a “Very High” risk category.
The St. Vincent's St. Johns County (St. Johns) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at St. Vincent's St. Johns County (St. Johns)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Bartram Crossing | 31 | 29.2% | 38.6% | High |
| Dba Westminster St. Augustine | 30 | 28.3% | 26.3% | Elevated |
| Atrium Snf Operating Llc | <11 | — | — | Moderate |
| Avante Villa At Jacksonville Beach, Inc. | <11 | — | — | Moderate |
| Aviata At Green Cove Springs | <11 | — | — | High |
Dell Seton Medical Center at The University of Texas discharged 56 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 32.4%, -3.1pp vs system average. The leading post-acute destination is The Center At Parmer (19 patients, 9.0% share). The hospital’s SNF network includes 13 facilityies with a “Very High” risk category.
The Dell Seton Medical Center at The University of Texas (Austin) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at Dell Seton Medical Center at The University of Texas (Austin)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| The Center At Parmer | 19 | 9.0% | 45.7% | High |
| Brookdale Westlake Hills | 13 | 6.2% | 12.9% | High |
| The Arbour At Westminster Manor | 13 | 6.2% | — | Moderate |
| Riverside Nursing And Rehabilitation Center | 11 | 5.2% | — | High |
| Austin Wellness & Rehabilitation | <11 | — | — | Moderate |
Ascension Saint Thomas Highlands discharged 49 FFS patients to 9 distinct SNF destinations over the analysis period. FSHR stands at 31.0%, -4.5pp vs system average. The leading post-acute destination is Life Care Center Of Sparta (31 patients, 49.2% share). The hospital’s SNF network includes 4 facilityies with a “Very High” risk category.
The Saint Thomas Highlands (Sparta) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at Saint Thomas Highlands (Sparta)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Life Care Center Of Sparta | 31 | 49.2% | 31.6% | Elevated |
| Nhc Healthcare, Sparta | 18 | 28.6% | 30.0% | Elevated |
| Bethesda Health Care Center Llc | <11 | — | — | Moderate |
| Life Care Center Of Crossville | <11 | — | — | High |
| Mabry Health Care & Rehab Center | <11 | — | — | High |
Ascension Saint Thomas Three Rivers discharged 46 FFS patients to 6 distinct SNF destinations over the analysis period. FSHR stands at 14.6%, -21.0pp vs system average. The leading post-acute destination is Ascension Saint Thomas Three Rivers (32 patients, 80.0% share). The hospital’s SNF network includes 1 facilityy with a “Very High” risk category.
The Saint Thomas Three Rivers (Waverly) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at Saint Thomas Three Rivers (Waverly)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Ascension Saint Thomas Three Rivers | 32 | 80.0% | 16.2% | Elevated |
| Humphreys County Care And Rehabilitation | 14 | 35.0% | 10.8% | Elevated |
| Life Care Center Of Bruceton-Hollow Rock | <11 | — | — | High |
| Nhc Healthcare-Dickson Llc | <11 | — | — | Elevated |
| Perry County Nursing Home | <11 | — | — | High |
Ascension St. Vincent Williamsport discharged 22 FFS patients to 11 distinct SNF destinations over the analysis period. FSHR stands at 25.0%, -10.5pp vs system average. The leading post-acute destination is Ascension St. Vincent Williamsport (22 patients, 62.9% share). The hospital’s SNF network includes 3 facilityies with a “Very High” risk category.
The St. Vincent Williamsport (Williamsport) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at St. Vincent Williamsport (Williamsport)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Ascension St. Vincent Williamsport | 22 | 62.9% | 25.0% | Elevated |
| Creasy Springs Health Campus | <11 | — | — | High |
| Harbour Manor Health & Living | <11 | — | — | Moderate |
| Heritage Healthcare | <11 | — | — | Elevated |
| Rosewalk Village At Lafayette | <11 | — | — | Moderate |
Ascension Seton Northwest discharged 17 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 50.0%, +14.5pp vs system average. The leading post-acute destination is The Center At Parmer (17 patients, 22.7% share). The hospital’s SNF network includes 7 facilityies with a “Very High” risk category.
The Seton Northwest (Austin) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at Seton Northwest (Austin)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| The Center At Parmer | 17 | 22.7% | 50.0% | High |
| Austin Wellness & Rehabilitation | <11 | — | — | High |
| Avir At Burnet | <11 | — | — | High |
| Avir At Kingsland | <11 | — | — | Elevated |
| Avir At Magnolia | <11 | — | — | Moderate |
Ascension Saint Thomas DeKalb discharged 16 FFS patients to 5 distinct SNF destinations over the analysis period. FSHR stands at 18.9%, -16.6pp vs system average. The leading post-acute destination is Nhc Healthcare, Smithville (16 patients, 76.2% share). The hospital’s SNF network includes 2 facilityies with a “Very High” risk category.
The Saint Thomas DeKalb (Smithville) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at Saint Thomas DeKalb (Smithville)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Nhc Healthcare, Smithville | 16 | 76.2% | 18.9% | Elevated |
| Life Care Center Of Sparta | <11 | — | — | High |
| Nhc Healthcare-Mcminnville Llc | <11 | — | — | Moderate |
| Signature Healthcare Of Putnam County | <11 | — | — | High |
| Willow Branch Health And Rehabilitation | <11 | — | — | High |
Ascension St. John Nowata discharged 13 FFS patients to 6 distinct SNF destinations over the analysis period. FSHR stands at 22.6%, -12.9pp vs system average. The leading post-acute destination is Jane Phillips Nowata Health Center (13 patients, 72.2% share). The hospital’s SNF network includes 1 facilityy with a “Very High” risk category.
The St. John Nowata (Nowata) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at St. John Nowata (Nowata)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Jane Phillips Nowata Health Center | 13 | 72.2% | 22.6% | Elevated |
| Bartlesville Health & Rehab Community | <11 | — | — | Moderate |
| El Reno Health Care, Llc | <11 | — | — | High |
| Medicalodges Dewey | <11 | — | — | Moderate |
| Nowata Nursing Center, Inc. | <11 | — | — | Moderate |
Ascension Seton Edgar B. Davis discharged 12 FFS patients to 11 distinct SNF destinations over the analysis period. FSHR stands at 25.0%, -10.5pp vs system average. The leading post-acute destination is Ascension Seton Edgar B Davis (12 patients, 42.9% share). The hospital’s SNF network includes 8 facilityies with a “Very High” risk category.
The Seton Edgar B. Davis (Luling) post-acute network illustrates the broader Ascension National pattern: a small number of high-volume SNF relationships account for the top discharge share, while the remaining volume is distributed across a long tail of facilities that operate without systematic performance oversight. A preferred-network framework anchored at Seton Edgar B. Davis (Luling)’s highest-volume destinations — with embedded clinical presence at the most critical facilities — would immediately extend coordinated care management across the majority of this hospital’s post-acute volume.
| Top SNF Partners | Pts | Share | FSHR | Risk |
|---|---|---|---|---|
| Ascension Seton Edgar B Davis | 12 | 42.9% | 25.0% | High |
| Avir At Luling | <11 | — | — | High |
| Avir At Magnolia | <11 | — | — | High |
| Bastrop Lost Pines Nursing And Rehabilitation Center | <11 | — | — | High |
| Diversicare Of Luling | <11 | — | — | High |
Of the 557 SNF destinations across the Ascension National network, 168 already serve two or more Ascension National hospitals simultaneously. These shared facilities are the structural backbone of any preferred-network strategy — existing relationships that can be elevated and formalized without requiring new partnerships to be built from scratch.
The Center At Parmer is among the most connected SNFs in the Ascension National network — serving 6 hospitals with 99 total patients. The other high-volume cross-system facilities represent the tier of shared relationships where a coordinated embedded clinical presence delivers immediate and demonstrable impact across multiple Ascension National hospitals simultaneously.
Of particular note are cross-system facilities with elevated FSHR: SNFs that already appear in multiple Ascension National discharge patterns are precisely the facilities where an embedded clinical presence and preferred-network performance standards create the accountability needed to drive measurable FSHR improvement across the system’s post-acute continuum.
The 168 cross-system facilities represent the natural starting cohort for a coordinated Ascension National preferred network. A structured engagement beginning with these shared partners would immediately extend coverage across the broadest reach of Ascension National hospitals and create the governance layer for performance tracking across the most consequential downstream relationships in the system.
Ascension operates as a federation of state-level markets — Seton in Texas, St. Vincent in Indiana, Saint Thomas in Tennessee, Sacred Heart/St. Vincent’s in Florida, Wisconsin in Wisconsin, St. John in Oklahoma, Via Christi in Kansas. Each market has its own referral patterns, its own SNF partners, and its own weighted-average FSHR. Priority targets are therefore ranked within each state against the local weighted-average FSHR — not against the national blended number — so the top-priority SNF in each market is the one where a local Ascension operator can move the needle first.
Together the 63 priority targets span 7 state markets and cover relationships with the majority of Ascension’s active hospital portfolio. Each row is a SNF where the local Ascension market has real referral volume and the FSHR sits above that state’s own weighted-average — not a national list flattened across geographies. A market-by-market rollout, starting with the highest-scored SNF in each state, gives every regional Ascension operator a concrete first-move without waiting for a national program to stand up.
Ascension’s endorsement in each market opens those doors, and Puzzle’s embedded clinical model provides the sustained presence to drive FSHR improvement over time.
Every active Ascension National hospital is scored on a composite of discharge volume, destination breadth, FSHR elevation, and destination-level facility risk. The index surfaces relative priority — not a critique of any individual hospital’s care quality, but a guide to where systematic post-acute infrastructure delivers the greatest immediate return. FL state SNF utilization benchmark: 16.5% (FFS).
| Hospital | Beds | SNF Pts | Dests | FSHR % | Score | Priority |
|---|---|---|---|---|---|---|
| Ascension Sacred Heart Pensacola | 547 | 893 | 25 | 41.8% | 59 | Immediate |
| Ascension Saint Thomas Rutherford | 354 | 897 | 25 | 34.8% | 57 | Immediate |
| Ascension Sacred Heart Bay | 202 | 307 | 25 | 41.9% | 57 | Immediate |
| Ascension St. John Medical Center | 567 | 485 | 25 | 39.5% | 56 | Immediate |
| Ascension St. Vincent Evansville | — | 472 | 25 | 27.8% | 56 | Immediate |
| Ascension St. Vincent Hospital - Indianapolis | — | 738 | 25 | 32.3% | 54 | Near-Term |
| Ascension St. Vincent's Riverside | 528 | 418 | 25 | 35.7% | 54 | Near-Term |
| Ascension Saint Thomas Hospital West | 643 | 935 | 25 | 35.0% | 53 | Near-Term |
| Ascension Providence Hospital | 278 | 243 | 25 | 37.4% | 50 | Near-Term |
| Ascension Sacred Heart Emerald Coast | 76 | 197 | 24 | 42.2% | 47 | Near-Term |
| Ascension St. Vincent's Clay County | 98 | 206 | 25 | 38.9% | 46 | Near-Term |
| Ascension Via Christi Hospital in Manhattan | — | 195 | 25 | 27.5% | 46 | Near-Term |
| Ascension St. John Jane Phillips Medical Center | 114 | 178 | 25 | 42.8% | 46 | Near-Term |
| Ascension Columbia St. Mary's Hospital - Milwaukee Campus | — | 252 | 25 | 32.7% | 45 | Near-Term |
| Ascension SE Wisconsin Hospital - St. Joseph Campus | 298 | 252 | 25 | 32.7% | 45 | Near-Term |
| Ascension St. Vincent Kokomo | — | 202 | 24 | 33.5% | 45 | Near-Term |
| Ascension SE Wisconsin Hospital - Elmbrook Campus | 166 | 121 | 25 | 32.7% | 44 | Near-Term |
| Ascension St. Vincent's Southside | 313 | 193 | 25 | 39.1% | 43 | Near-Term |
| Ascension Via Christi St. Francis | 421 | 147 | 25 | 29.4% | 43 | Near-Term |
| Ascension All Saints Hospital - Spring Street Campus | 222 | 128 | 21 | 40.4% | 41 | Near-Term |
| Ascension Seton Medical Center Hays | 112 | 102 | 25 | 29.6% | 41 | Near-Term |
| Ascension Seton Williamson | 181 | 147 | 25 | 35.7% | 40 | Near-Term |
| Ascension St. Vincent Anderson | 149 | 80 | 25 | 30.4% | 40 | Near-Term |
| Ascension Seton Medical Center Harker Heights | 83 | 78 | 21 | 45.6% | 40 | Near-Term |
| Ascension Saint Thomas River Park | 82 | 123 | 18 | 35.5% | 39 | Near-Term |
| Ascension St. Vincent Carmel | 195 | 111 | 25 | 32.9% | 39 | Near-Term |
| Ascension NE Wisconsin - St. Elizabeth Campus | — | 70 | 24 | 33.1% | 39 | Near-Term |
| Ascension St. Vincent's St. Johns County | — | 61 | 25 | 32.5% | 39 | Near-Term |
| Ascension Seton Medical Center Austin | 399 | 140 | 25 | 46.6% | 38 | Near-Term |
| Dell Seton Medical Center at The University of Texas | 210 | 56 | 25 | 32.4% | 38 | Near-Term |
| Ascension Saint Thomas Highlands | 26 | 49 | 9 | 31.0% | 38 | Near-Term |
| Ascension Seton Northwest | 124 | 17 | 25 | 50.0% | 37 | Near-Term |
| Ascension Seton Cedar Park | 126 | 106 | 17 | 30.1% | 34 | Monitor |
| Ascension Seton Edgar B. Davis | 25 | 12 | 11 | 25.0% | 32 | Monitor |
| Ascension St. Vincent Williamsport | — | 22 | 11 | 25.0% | 28 | Monitor |
| Ascension Saint Thomas DeKalb | 18 | 16 | 5 | 18.9% | 25 | Monitor |
| Ascension Saint Thomas Three Rivers | — | 46 | 6 | 14.6% | 24 | Monitor |
| Ascension St. John Nowata | — | 13 | 6 | 22.6% | 23 | Monitor |
| Ascension Saint Thomas Rutherford Stones River | 43 | — | 4 | — | — | No Data |
| Ascension St. Vincent Fishers | — | — | 20 | — | — | No Data |
| Ascension Calumet Hospital | — | — | 1 | — | — | No Data |
| Ascension NE Wisconsin - Mercy Campus | — | — | 14 | — | — | No Data |
| Ascension Sacred Heart Gulf | 19 | — | 8 | — | — | No Data |
| Ascension Saint Thomas Hickman | — | — | 4 | — | — | No Data |
| Ascension Seton Highland Lakes | 25 | — | 10 | — | — | No Data |
| Ascension Seton Smithville Hospital | 25 | — | 3 | — | — | No Data |
| Ascension Seton Southwest | 28 | — | 3 | — | — | No Data |
| Ascension St. Francis Hospital | 270 | — | 17 | — | — | No Data |
| Ascension St. John Broken Arrow | 68 | — | 25 | — | — | No Data |
| Ascension St. John Owasso | 36 | — | 12 | — | — | No Data |
| Ascension St. John Sapulpa | 25 | — | 6 | — | — | No Data |
| Ascension St. Vincent Randolph | 25 | — | 7 | — | — | No Data |
| Ascension St. Vincent Warrick | — | — | 3 | — | — | No Data |
Ascension Sacred Heart Pensacola leads the opportunity ranking with a score of 59 — driven primarily by its FSHR elevation and the breadth of its SNF destination network. A high-volume hospital with elevated FSHR and a large, largely unmanaged SNF network is precisely where a preferred-network infrastructure delivers maximum return on clinical investment.
Ascension Saint Thomas Rutherford (57 score, Immediate) and other Near-Term hospitals represent the tier where FSHR elevation merits structured attention. Their geographic position across the Ascension National system means that a preferred-network framework anchored at the top hospitals naturally extends coverage to the Near-Term tier.
Puzzle Healthcare’s engagement model is built around one core insight: the most effective way to improve post-acute outcomes at a health system is to establish an embedded presence inside the SNF network itself. That requires the health system’s endorsement to open the door. When OSF HealthCare did exactly that, it changed the economics of the entire engagement.
The OSF Precedent — 29% to 9%: When OSF HealthCare partnered with Puzzle Healthcare, the system introduced Puzzle to approximately 60 nursing homes across their post-acute network. Puzzle’s embedded physician-led care model drove SNF 30-day readmissions across the network from 29% to 9% — a 20-percentage-point reduction that translated directly into fewer avoidable admissions, better STAR performance, and stronger downstream referral loyalty. That single act of health-system introduction — OSF telling its downstream SNF partners that Puzzle had the system’s trust and support — opened relationships that would have taken years to build through conventional vendor outreach.
Puzzle’s current partner footprint: Ascension National would join a national footprint that includes OSF HealthCare, Corewell Health, and CommonSpirit Health, alongside 100+ additional health-system and ACO partners across post-acute markets nationally. Ascension National signals the priority; Puzzle owns the clinical execution.
Ascension National has 557 unique SNF destinations — a network of meaningful scale across seven-state national footprint. Ascension National’s 168 cross-system shared facilities represent the natural introductions cohort: SNFs that already know and trust multiple Ascension National hospitals, and where a coordinated Puzzle presence would have an immediate and demonstrable impact on FSHR performance. That is 168 introductions — many times the minimum needed to make the engagement economics work — before Puzzle has made a single cold call.
The engagement economics of Puzzle’s model require a minimum scale to be operationally viable: an embedded presence in a facility that receives only 8–10 patients per year cannot be sustained. Ascension National’s cross-system SNF concentration solves this elegantly. The top cross-system facilities collectively receive enough volume across multiple Ascension National hospitals to support a full embedded clinical program from day one — and their FSHR elevation makes the case for urgency clear.
The explicit ask mirrors the OSF model: Ascension National introduces Puzzle to its downstream SNF partners — particularly the 168 cross-system facilities where the relationship already exists — so that Puzzle can establish a coordinated presence across the network. With OSF, 60 such introductions built the foundation for a system-wide preferred network. Ascension National’s 168 cross-system facilities represent a comparable starting point, with a clear path to expanding across the full 557-destination network as the preferred-network framework matures.
The following sequence is designed to move efficiently from this initial analysis to a working preferred-network engagement, with no disruption to existing care pathways during the design phase.
Ascension National has built one of the country’s most expansive faith-based community hospital networks, spanning 53 hospitals across seven states nationally. 8,708 FFS patients, 557 SNF destinations, 38 active hospitals, and 168 facilities already embedded in multiple Ascension National care pathways simultaneously. That is not a system with a post-acute crisis. It is a system with a post-acute opportunity that has not yet been systematically activated.
Ascension National’s 38-hospital post-acute network currently operates as 38 largely independent discharge patterns, each sending patients to their own set of SNF destinations without shared FSHR standards, systematic accountability, or a unified visibility layer connecting Ascension National care teams to downstream SNF performance. The 20 priority SNF targets — facilities with FSHR rates significantly above the system average of 35.5% appearing across multiple Ascension National hospitals — represent the highest-urgency intervention points. But they are part of a larger structural story: 557 SNF destinations, most operating beyond the horizon of Ascension National’s systematic oversight.
The 168 cross-system SNFs — facilities that already serve multiple Ascension National hospitals and have demonstrated their relevance to the system’s post-acute continuum — are the proof of concept. These are not hypothetical preferred partners; they are already functioning as the de facto preferred network across seven-state national footprint. Puzzle’s role is to formalize it, extend it, and make FSHR performance systematically measurable and accountable.
The explicit ask: Introduce Puzzle to Ascension National’s downstream SNF partners — beginning with the 168 cross-system facilities and 20 priority targets that already serve multiple hospitals — so that Puzzle can establish a coordinated embedded presence across the network. When OSF HealthCare made that introduction across approximately 60 nursing homes, the result was a system-wide preferred-network program built on existing trust. Ascension National has the same structural foundation — at a scale that makes the opportunity commensurately significant for the seven-state national footprint.
We look forward to the conversation — and to what Ascension National’s post-acute program looks like with the visibility, FSHR accountability, and coordination infrastructure to match the system’s clinical ambition across seven-state national footprint.