An eight-quarter review of FFS SNF discharge patterns, destination concentration, and the opportunity for systematic post-acute visibility across a 28-hospital, multi-state network spanning Pennsylvania, New York, and Maryland.
UPMC Health operates one of the largest integrated health systems in the country, with hospitals spanning Pennsylvania, New York, and Maryland. Its post-acute discharge picture is one of extraordinary scale — tens of thousands of Medicare patients flowing annually to hundreds of SNF destinations — with limited cross-hospital coordination and no unified preferred-network infrastructure to manage that volume systematically.
Over eight quarters (Q4 2024 – Q3 2025), UPMC hospitals collectively discharged 5,922 fee-for-service Medicare patients to skilled nursing facilities, reaching 375 distinct SNF destinations across Pennsylvania, New York, and Maryland. UPMC Western Maryland leads the system in post-acute volume with 720 patients across 25 SNF destinations — the single largest UPMC post-acute relationship set in the analysis. UPMC Pinnacle (Harrisburg), UPMC Hamot, and UPMC Presbyterian Shadyside collectively account for a substantial share of the system's total SNF volume.
Pennsylvania state SNF utilization benchmarks are not available in the current data extract; comparison uses national CMS averages where applicable. What the data does reveal clearly is a destination fragmentation and coordination story at scale: across 25 active hospitals, 5,922 patients are distributed to 375 SNFs, most of which operate without any structured performance framework, preferred-network accountability, or real-time clinical visibility from UPMC.
Within UPMC's existing discharge patterns is a structural starting point for coordination: 129 SNFs already serve two or more UPMC hospitals simultaneously. These shared facilities are the organic preferred network — facilities that UPMC 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 performance systematically measurable and accountable.
The 15 priority SNF targets identified in this analysis — facilities with elevated FSHR rates appearing across multiple UPMC 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 31.4%.
UPMC Health operates 28 acute-care hospitals across Pennsylvania, New York, and Maryland — from flagship academic medical centers in Pittsburgh to community hospitals in rural Appalachian communities. Each hospital draws from a distinct patient population and sends patients to a partially overlapping, partially distinct set of SNF partners across three states.
UPMC's geographic span across Pennsylvania, New York, and Maryland represents both a strategic complexity and a significant opportunity. Unlike single-state health systems managing one regulatory environment, UPMC's post-acute network must navigate distinct SNF markets across three states — each with its own certificate-of-need landscape, Medicaid environment, and community of SNF operators. This complexity is precisely where a coordinated preferred-network framework delivers the greatest operational value: a unified performance standard, embedded clinical presence, and real-time visibility layer that operates consistently across all 25 hospitals regardless of geography.
UPMC Western Maryland’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 is the visibility challenge at the heart of UPMC’s post-acute situation — replicated across 25 hospitals and 375 SNF destinations.
The concentration pattern at UPMC Western Maryland is characteristic of a large academic medical center. Its top SNF partners already have the volume to support an embedded clinical presence — and they clearly have established relationships with Western Maryland’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 25 UPMC hospitals and 375 total SNF destinations system-wide, that long tail represents hundreds of downstream facilities operating beyond the horizon of UPMC’s visibility. That is precisely the structural problem a unified preferred-network framework addresses — starting with the 129 cross-system facilities that already appear in multiple UPMC discharge networks simultaneously.
Pennsylvania state SNF utilization and readmission benchmarks are not available in the current data extract — Pennsylvania state benchmark not available; comparison uses national CMS average where applicable. The system-wide FSHR of 31.4% serves as the primary internal reference point for identifying hospitals with elevated return-to-hospital rates and high-impact intervention opportunities.
UPMC Western Maryland discharged 720 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 13.3%, -18.2pp vs system average. The leading post-acute destination is Frostburg Snf Operator Llc (138 patients, 8.7% share).
The Western Maryland post-acute network illustrates the broader UPMC 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 Western Maryland’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 |
|---|---|---|---|---|
| Frostburg Snf Operator Llc | 138 | 8.7% | 19.7% | Moderate |
| Allegany Health Nursing And Rehabilitation | 127 | 8.7% | 18.2% | Moderate |
| Devlin Manor Nursing And Rehabilitation Center | 90 | 8.9% | 12.9% | Moderate |
| Peace Healthcare At Lions Center | 89 | 9.2% | 12.7% | Moderate |
| Cumberland Healthcare Center | 87 | 9.5% | 12.4% | Moderate |
UPMC Pinnacle (Harrisburg / Community Osteopathic / West Shore) discharged 587 FFS patients to 30 distinct SNF destinations over the analysis period. FSHR stands at 36.2%, +4.8pp vs system average. The leading post-acute destination is Spring Creek Rehabilitation And Nursing Center (117 patients, 17.0% share). The hospital’s SNF network includes 10 facilityies with a “Very High” risk category.
The Pinnacle Harrisburg post-acute network illustrates the broader UPMC 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 Pinnacle Harrisburg’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 |
|---|---|---|---|---|
| Spring Creek Rehabilitation And Nursing Center | 117 | 17.0% | 48.5% | High |
| Capitol Rehabilitation And Healthcare Center | 109 | 15.8% | 34.2% | High |
| Messiah Lifeways At Messiah Village | 46 | 6.7% | 18.4% | High |
| Vibra Rehabilitation Center | 42 | 6.1% | 41.2% | High |
| Camp Hill Skilled Nursing And Rehabilitation Center | 38 | 5.5% | 31.9% | High |
UPMC Hamot discharged 462 FFS patients to 30 distinct SNF destinations over the analysis period. FSHR stands at 36.1%, +4.7pp vs system average. The leading post-acute destination is Presbyterian Homes In The Presbytery Of Lake Erie (50 patients, 8.5% share). The hospital’s SNF network includes 9 facilityies with a “Very High” risk category.
The Hamot post-acute network illustrates the broader UPMC 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 Hamot’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 |
|---|---|---|---|---|
| Presbyterian Homes In The Presbytery Of Lake Erie | 50 | 8.5% | 22.3% | Elevated |
| Erie Snf Operations Llc | 49 | 8.3% | 47.4% | High |
| Millcreek Manor | 37 | 6.3% | 32.1% | High |
| Heritage Park Rehab & Skilled Nursing | 30 | 5.1% | 51.0% | High |
| Dba Saint Mary'S At Asbury Ridge | 24 | 4.1% | 28.1% | Elevated |
UPMC Presbyterian Shadyside (incl. Montefiore) discharged 431 FFS patients to 21 distinct SNF destinations over the analysis period. FSHR stands at 32.9%, +1.4pp vs system average. The leading post-acute destination is East End Health & Rehab Center, Llc (42 patients, 4.3% share). The hospital’s SNF network includes 7 facilityies with a “Very High” risk category.
The Presbyterian Shadyside post-acute network illustrates the broader UPMC 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 Presbyterian Shadyside’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 |
|---|---|---|---|---|
| East End Health & Rehab Center, Llc | 42 | 4.3% | 25.6% | Elevated |
| Penn-Allegheny Nursing And Rehabilitation Center Llc | 37 | 3.8% | 35.6% | High |
| Canterbury Place | 34 | 3.5% | 35.6% | High |
| Upmc Magee-Womens Hospital | 29 | 3.0% | 43.1% | Elevated |
| Harmony Physical Rehabilitation | 27 | 2.8% | 19.6% | High |
UPMC Passavant – McCandless discharged 357 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 33.1%, +1.7pp vs system average. The leading post-acute destination is Vincentian Home (105 patients, 22.0% share). The hospital’s SNF network includes 12 facilityies with a “Very High” risk category.
The Passavant–McCandless post-acute network illustrates the broader UPMC 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 Passavant–McCandless’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 |
|---|---|---|---|---|
| Vincentian Home | 105 | 22.0% | 30.2% | Elevated |
| Concordia At Rebecca Residence | 51 | 10.7% | 36.3% | High |
| Cranberry Place | 33 | 6.9% | 39.5% | High |
| St. Barnabas Nursing Home, Inc. | 33 | 6.9% | 25.0% | Elevated |
| North Hills Skilled Nursing And Rehabilitation Center | 28 | 5.9% | 60.0% | High |
UPMC Jameson discharged 302 FFS patients to 30 distinct SNF destinations over the analysis period. FSHR stands at 54.3%, +22.9pp vs system average. The leading post-acute destination is Avalon Place (71 patients, 16.2% share). The hospital’s SNF network includes 9 facilityies with a “Very High” risk category.
The Jameson post-acute network illustrates the broader UPMC 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 Jameson’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 |
|---|---|---|---|---|
| Avalon Place | 71 | 16.2% | — | Moderate |
| Jameson Care Center, Inc. | 65 | 14.8% | — | Moderate |
| Jamc Opco Llc | 42 | 18.2% | 50.7% | High |
| Ava Opco Llc | 23 | 10.0% | 52.8% | High |
| Golden Hill Nursing And Rehab Lp | 23 | 10.0% | 61.0% | High |
UPMC Carlisle discharged 302 FFS patients to 30 distinct SNF destinations over the analysis period. FSHR stands at 32.3%, +0.8pp vs system average. The leading post-acute destination is Cumberland Crossings (49 patients, 15.8% share). The hospital’s SNF network includes 12 facilityies with a “Very High” risk category.
The Carlisle post-acute network illustrates the broader UPMC 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 Carlisle’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 |
|---|---|---|---|---|
| Cumberland Crossings | 49 | 15.8% | 25.5% | Elevated |
| Carlisle Skilled Nursing And Rehabilitation Center | 48 | 15.4% | 40.2% | High |
| Claremont Nursing & Rehabilitation Center Llc | 44 | 14.1% | 31.8% | High |
| Fp 700 Operations Llc | 36 | 11.6% | 43.0% | High |
| Swaim Health Center | 34 | 10.9% | 36.6% | High |
UPMC Northwest discharged 292 FFS patients to 30 distinct SNF destinations over the analysis period. FSHR stands at 38.0%, +6.5pp vs system average. The leading post-acute destination is Upmc Northwest (83 patients, 35.0% share). The hospital’s SNF network includes 12 facilityies with a “Very High” risk category.
The Northwest post-acute network illustrates the broader UPMC 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 Northwest’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 |
|---|---|---|---|---|
| Upmc Northwest | 83 | 35.0% | 36.9% | High |
| The Caring Place | 48 | 20.3% | 30.4% | High |
| Sugarcreek Station | 38 | 13.5% | — | Moderate |
| Scs Opco Llc | 37 | 15.6% | 40.4% | Elevated |
| Oakwood Heights Village | 33 | 13.9% | 47.1% | High |
UPMC Washington discharged 292 FFS patients to 30 distinct SNF destinations over the analysis period. FSHR stands at 33.3%, +1.9pp vs system average. The leading post-acute destination is Southmont Of Presbyterian Senior Care (114 patients, 34.3% share). The hospital’s SNF network includes 6 facilityies with a “Very High” risk category.
The Washington post-acute network illustrates the broader UPMC 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 Washington’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 |
|---|---|---|---|---|
| Southmont Of Presbyterian Senior Care | 114 | 34.3% | 27.4% | High |
| Transitions Healthcare Washington Pa | 36 | 10.8% | 34.6% | High |
| Washington Operating Llc | 36 | 10.8% | 50.6% | High |
| Rolling Meadows Operating Llc | 34 | 10.2% | 33.3% | Elevated |
| Greenery Center For Rehab And Nursing | 20 | 6.0% | 16.7% | High |
UPMC Hanover discharged 285 FFS patients to 30 distinct SNF destinations over the analysis period. FSHR stands at 33.0%, +1.5pp vs system average. The leading post-acute destination is Homewood At Hanover, Pa Inc (77 patients, 25.4% share). The hospital’s SNF network includes 6 facilityies with a “Very High” risk category.
The Hanover post-acute network illustrates the broader UPMC 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 Hanover’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 |
|---|---|---|---|---|
| Homewood At Hanover, Pa Inc | 77 | 25.4% | 31.5% | Elevated |
| Hanover Hall For Nursing And Rehabilitation | 52 | 17.2% | 52.1% | High |
| Cross Keys Village - The Brethren Home Community | 35 | 11.6% | 24.1% | Elevated |
| Gettysburg Center | 32 | 10.6% | 33.8% | High |
| Spiritrust Lutheran The Village At Utz Terrace | 31 | 10.2% | 18.0% | High |
UPMC Altoona discharged 283 FFS patients to 30 distinct SNF destinations over the analysis period. FSHR stands at 42.6%, +11.2pp vs system average. The leading post-acute destination is Valley View Health And Rehabilitation Center (57 patients, 16.3% share). The hospital’s SNF network includes 10 facilityies with a “Very High” risk category.
The Altoona post-acute network illustrates the broader UPMC 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 Altoona’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 |
|---|---|---|---|---|
| Valley View Health And Rehabilitation Center | 57 | 16.3% | 43.8% | High |
| Homewood Living Martinsburg, Inc. | 48 | 13.7% | 24.0% | High |
| Presbyterian Home Of Hollidaysburg | 45 | 12.9% | 52.9% | High |
| Epworth Rehabilitation And Healthcare Llc | 29 | 8.3% | 41.4% | Elevated |
| Midtown Oaks Health & Rehab Center, Llc | 29 | 8.3% | 68.2% | High |
UPMC Williamsport discharged 253 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 33.0%, +1.5pp vs system average. The leading post-acute destination is Williamsport Home (66 patients, 23.0% share).
The Williamsport post-acute network illustrates the broader UPMC 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 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 |
|---|---|---|---|---|
| Williamsport Home | 66 | 23.0% | 25.8% | Moderate |
| Rose View Nursing And Rehabilitation Center | 40 | 13.9% | 45.5% | Moderate |
| Valley View Nursing Center | 36 | 12.5% | 41.4% | Moderate |
| Sv Opco Llc | 28 | 9.8% | 29.8% | Moderate |
| Loyalsock Operating Llc | 24 | 8.4% | 22.8% | Moderate |
UPMC Horizon (Greenville / Shenango Valley) discharged 203 FFS patients to 30 distinct SNF destinations over the analysis period. FSHR stands at 26.5%, -5.0pp vs system average. The leading post-acute destination is St. Paul Homes (46 patients, 20.2% share). The hospital’s SNF network includes 8 facilityies with a “Very High” risk category.
The Horizon post-acute network illustrates the broader UPMC 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 Horizon’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 |
|---|---|---|---|---|
| St. Paul Homes | 46 | 20.2% | 19.6% | Elevated |
| Hermitage Nursing And Rehabilitation | 29 | 12.7% | 35.2% | High |
| Jamc Opco Llc | 23 | 10.1% | — | High |
| John Xxiii Home | 21 | 9.2% | 27.5% | High |
| The Grove At Greenville | 20 | 8.8% | 20.0% | High |
UPMC Chautauqua discharged 201 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 27.4%, -4.0pp vs system average. The leading post-acute destination is Heritage Park Rehab & Skilled Nursing (77 patients, 7.2% share).
The Chautauqua post-acute network illustrates the broader UPMC 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 Chautauqua’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 Park Rehab & Skilled Nursing | 77 | 7.2% | 34.5% | Moderate |
| Heritage Green Rehab & Skilled Nursing | 74 | 7.0% | 33.2% | Moderate |
| Warren Manor | 22 | 7.3% | 9.9% | Moderate |
| Sarnc Operating Llc | 16 | 7.2% | 7.2% | Moderate |
| Chautauqua Nursing & Rehabilitation Center | 12 | 7.6% | 5.4% | Moderate |
UPMC East discharged 163 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 35.1%, +3.6pp vs system average. The leading post-acute destination is Harmony Physical Rehabilitation (43 patients, 16.2% share). The hospital’s SNF network includes 8 facilityies with a “Very High” risk category.
The East post-acute network illustrates the broader UPMC 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 East’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 |
|---|---|---|---|---|
| Harmony Physical Rehabilitation | 43 | 16.2% | 22.7% | High |
| Concordia At The Cedars | 31 | 11.7% | 34.9% | High |
| Woodhaven Health & Rehab Center, Llc | 17 | 6.4% | 59.0% | Elevated |
| The Rehabilitation & Nursing Center At Greater Pittsburgh | 16 | 6.0% | 52.5% | High |
| Redstone Presbyterian Senior Care | 15 | 5.7% | 29.0% | Elevated |
UPMC St. Margaret discharged 158 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 27.5%, -4.0pp vs system average. The leading post-acute destination is The Willows Of Presbyterian Medical Center (52 patients, 22.3% share). The hospital’s SNF network includes 9 facilityies with a “Very High” risk category.
The St. Margaret post-acute network illustrates the broader UPMC 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. Margaret’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 Willows Of Presbyterian Medical Center | 52 | 22.3% | 25.0% | High |
| Concordia At Rebecca Residence | 29 | 12.4% | 29.1% | Elevated |
| Longwood At Oakmont, Inc | 21 | 9.0% | 10.4% | High |
| Seneca Place | 21 | 9.0% | — | High |
| Concordia Lutheran Health And Human Care | 19 | 8.2% | 41.7% | High |
UPMC Memorial discharged 152 FFS patients to 30 distinct SNF destinations over the analysis period. FSHR stands at 27.5%, -3.9pp vs system average. The leading post-acute destination is Normandie Ridge (42 patients, 20.1% share). The hospital’s SNF network includes 5 facilityies with a “Very High” risk category.
The Memorial post-acute network illustrates the broader UPMC 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 Memorial’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 |
|---|---|---|---|---|
| Normandie Ridge | 42 | 20.1% | 31.2% | High |
| York North Skilled Nursing And Rehabilitation Center | 35 | 16.7% | 31.2% | Elevated |
| York South Skilled Nursing And Rehabilitation Center | 24 | 11.5% | 22.2% | Elevated |
| Dallastown Skilled Nursing And Rehabilitation Center | 23 | 11.0% | 25.0% | Elevated |
| Kingston Court Skilled Nursing And Rehabilitation Center | 16 | 7.7% | 21.6% | High |
UPMC Mercy discharged 121 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 30.9%, -0.5pp vs system average. The leading post-acute destination is Asbury Health Center (20 patients, 4.2% share). The hospital’s SNF network includes 3 facilityies with a “Very High” risk category.
The Mercy post-acute network illustrates the broader UPMC 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 Mercy’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 |
|---|---|---|---|---|
| Asbury Health Center | 20 | 4.2% | — | Elevated |
| Bethel Park Skilled Nursing And Rehabilitation Center | 20 | 4.2% | 45.8% | High |
| Vincentian Home | 19 | 4.0% | 12.1% | Elevated |
| East End Health & Rehab Center, Llc | 17 | 3.6% | — | Elevated |
| Whitehall Borough Skilled Nursing And Rehabilitation Center | 16 | 3.4% | 33.3% | High |
UPMC Lititz discharged 111 FFS patients to 30 distinct SNF destinations over the analysis period. FSHR stands at 25.2%, -6.3pp vs system average. The leading post-acute destination is Luther Acres Manor (29 patients, 18.0% share). The hospital’s SNF network includes 2 facilityies with a “Very High” risk category.
The Lititz post-acute network illustrates the broader UPMC 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 Lititz’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 |
|---|---|---|---|---|
| Luther Acres Manor | 29 | 18.0% | 29.0% | High |
| Rehabilitation Center At Brethren Village Llc | 25 | 15.5% | 29.3% | Elevated |
| United Zion Retirement Community | 21 | 13.0% | 22.6% | Elevated |
| Hamilton Arms Center Opco Llc | 13 | 8.1% | — | Elevated |
| Landis Homes Retirement Community | 12 | 7.5% | 11.8% | High |
UPMC Wellsboro discharged 72 FFS patients to 10 distinct SNF destinations over the analysis period. FSHR stands at 44.0%, +12.6pp vs system average. The leading post-acute destination is Broad Acres Health & Rehabilitation Center (42 patients, 5.4% share).
The Wellsboro post-acute network illustrates the broader UPMC 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 Wellsboro’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 |
|---|---|---|---|---|
| Broad Acres Health & Rehabilitation Center | 42 | 5.4% | 50.0% | Moderate |
| The Green Home | 30 | 5.0% | 35.7% | Moderate |
| 15900 Us 6 Opco Llc | – | — | — | Moderate |
| Charles Cole Memorial Hospital | – | — | — | Moderate |
| Darway Healthcare And Rehabilitation Center | – | — | — | Moderate |
UPMC Somerset discharged 51 FFS patients to 21 distinct SNF destinations over the analysis period. FSHR stands at 30.5%, -1.0pp vs system average. The leading post-acute destination is Patriot Village (27 patients, 5.5% share).
The Somerset post-acute network illustrates the broader UPMC 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 Somerset’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 |
|---|---|---|---|---|
| Patriot Village | 27 | 5.5% | 32.1% | Moderate |
| Meadow View Nursing Center | 24 | 5.8% | 28.6% | Moderate |
| Arbutus Park Manor | – | — | — | Moderate |
| Beacon Ridge | – | — | — | Moderate |
| Bethlen Home Of The Hungarian Reformed Federation Of America | – | — | — | Moderate |
UPMC Bedford discharged 44 FFS patients to 11 distinct SNF destinations over the analysis period. FSHR stands at 29.6%, -1.8pp vs system average. The leading post-acute destination is Bedford Skilling Nursing And Rehabilitation Center (18 patients, 4.5% share).
The Bedford post-acute network illustrates the broader UPMC 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 Bedford’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 |
|---|---|---|---|---|
| Bedford Skilling Nursing And Rehabilitation Center | 18 | 4.5% | 35.3% | Moderate |
| Homewood Living Martinsburg, Inc. | 14 | 4.9% | 27.5% | Moderate |
| Pennknoll Village | 12 | 4.5% | 23.5% | Moderate |
| Chambersburg Skilled Nursing And Rehabilitation Center | – | — | — | Moderate |
| Gettysburg Center | – | — | — | Moderate |
UPMC Magee-Womens Hospital discharged 30 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 30.3%, -1.1pp vs system average. The leading post-acute destination is Upmc Magee-Womens Hospital (30 patients, 31.3% share). The hospital’s SNF network includes 11 facilityies with a “Very High” risk category.
The Magee-Womens post-acute network illustrates the broader UPMC 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 Magee-Womens’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 |
|---|---|---|---|---|
| Upmc Magee-Womens Hospital | 30 | 31.3% | 30.3% | Elevated |
| Bethel Park Skilled Nursing And Rehabilitation Center | – | — | — | High |
| Bethlen Home Of The Hungarian Reformed Federation Of America | – | — | — | High |
| Brightwood Center | – | — | — | Elevated |
| Caring Heights Community Care And Rehabilitation Center | – | — | — | High |
UPMC McKeesport discharged 28 FFS patients to 25 distinct SNF destinations over the analysis period. FSHR stands at 31.9%, +0.4pp vs system average. The leading post-acute destination is Riverside Health & Rehab Center, Llc (28 patients, 32.2% share). The hospital’s SNF network includes 7 facilityies with a “Very High” risk category.
The McKeesport post-acute network illustrates the broader UPMC 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 McKeesport’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 Health & Rehab Center, Llc | 28 | 32.2% | 31.9% | Elevated |
| Baldwin Health Center | – | — | — | High |
| Bethel Park Skilled Nursing And Rehabilitation Center | – | — | — | Elevated |
| Concordia At Rebecca Residence | – | — | — | Moderate |
| Concordia At The Cedars | – | — | — | High |
UPMC Kane discharged 22 FFS patients to 11 distinct SNF destinations over the analysis period. FSHR stands at 66.7%, +35.2pp vs system average. The leading post-acute destination is Lutheran Home At Kane Pennsylvania (22 patients, 4.8% share).
The Kane post-acute network illustrates the broader UPMC 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 Kane’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 |
|---|---|---|---|---|
| Lutheran Home At Kane Pennsylvania | 22 | 4.8% | 66.7% | Moderate |
| Bradford Ecumenical Home Inc | – | — | — | Moderate |
| Bradford Manor | – | — | — | Moderate |
| Guy And Mary Felt Manor, Inc. | – | — | — | Moderate |
| Kadima Rehabilitation & Nursing At New Castle | – | — | — | Moderate |
Of the 375 SNF destinations across the UPMC network, 129 already serve two or more UPMC 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.
Harmony Physical Rehabilitation is among the most connected SNFs in the UPMC network — serving 6 hospitals with 70 total patients. Concordia at Rebecca Residence, Heritage Park Rehab, and 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 UPMC hospitals simultaneously.
Of particular note are cross-system facilities with elevated FSHR: facilities that already appear in multiple UPMC hospital discharge patterns with FSHR above the system average are precisely where an embedded clinical presence and preferred-network performance standards create the accountability to drive measurable FSHR improvement.
The 129 cross-system facilities represent the natural starting cohort for a coordinated UPMC preferred network. A structured engagement beginning with these shared partners would immediately extend coverage across the broadest reach of UPMC hospitals and create the governance layer for performance tracking across the most consequential downstream relationships in the system.
The priority target analysis identifies SNFs with elevated FSHR rates, meaningful patient volume, and cross-hospital presence. These facilities represent the intersection of high clinical risk and strategic leverage: where an embedded Puzzle clinical presence would deliver immediate impact across multiple UPMC hospitals simultaneously.
Spring Creek Rehabilitation And Nursing Center leads the priority target list with a priority score of 19.9 — an FSHR of 48.5% across 3 UPMC hospitals and 117 patients. This facility, and others like Jamc Opco LLC, Lutheran Home At Kane, and Hanover Hall for Nursing and Rehabilitation, represent precisely the kind of high-volume, high-FSHR, multi-hospital relationships where an embedded Puzzle clinical presence delivers immediate and measurable return.
Together, the 15 priority targets cover relationships across most of UPMC’s active hospital portfolio. A coordinated engagement beginning with these facilities would immediately extend Puzzle’s embedded presence into the highest-risk corner of UPMC’s post-acute network — without requiring a facility-by-facility cold-call campaign. UPMC’s endorsement opens those doors, and Puzzle’s embedded clinical model provides the sustained presence to drive performance improvement over time.
Every active UPMC 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. Pennsylvania state SNF utilization benchmark not available; utilization component defaults to a neutral score of 8 for all hospitals.
| Hospital | Beds | SNF Pts | Dests | FSHR % | Score | Priority |
|---|---|---|---|---|---|---|
| UPMC Western Maryland | 213 | 720 | 25 | 13.3% | 53 | Near-Term |
| UPMC Chautauqua | 199 | 201 | 25 | 27.4% | 46 | Near-Term |
| UPMC Pinnacle (Harrisburg / Community Osteopathic / West Shore) | 704 | 587 | 30 | 36.2% | 38 | Near-Term |
| UPMC Jameson | 133 | 302 | 30 | 54.3% | 36 | Near-Term |
| UPMC Passavant – McCandless | 394 | 357 | 25 | 33.1% | 34 | Monitor |
| UPMC Northwest | 171 | 292 | 30 | 38.0% | 34 | Monitor |
| UPMC Altoona | 380 | 283 | 30 | 42.6% | 33 | Monitor |
| UPMC Hamot | 412 | 462 | 30 | 36.1% | 32 | Monitor |
| UPMC Carlisle | 165 | 302 | 30 | 32.3% | 32 | Monitor |
| UPMC Washington | 244 | 292 | 30 | 33.3% | 31 | Monitor |
| UPMC Somerset | 99 | 51 | 21 | 30.5% | 31 | Monitor |
| UPMC Hanover | 93 | 285 | 30 | 33.0% | 30 | Monitor |
| UPMC Wellsboro | 25 | 72 | 10 | 44.0% | 30 | Monitor |
| UPMC Magee-Womens Hospital | 335 | 30 | 25 | 30.3% | 30 | Monitor |
| UPMC Presbyterian Shadyside (incl. Montefiore) | 1420 | 431 | 21 | 32.9% | 29 | Monitor |
| UPMC St. Margaret | 250 | 158 | 25 | 27.5% | 29 | Monitor |
| UPMC Bedford | 40 | 44 | 11 | 29.6% | 29 | Monitor |
| UPMC Horizon (Greenville / Shenango Valley) | 228 | 203 | 30 | 26.5% | 28 | Monitor |
| UPMC McKeesport | 213 | 28 | 25 | 31.9% | 28 | Monitor |
| UPMC East | 156 | 163 | 25 | 35.1% | 27 | Monitor |
| UPMC Memorial | 98 | 152 | 30 | 27.5% | 27 | Monitor |
| UPMC Williamsport | 224 | 253 | 25 | 33.0% | 23 | Monitor |
| UPMC Lititz | 55 | 111 | 30 | 25.2% | 23 | Monitor |
| UPMC Mercy | 404 | 121 | 25 | 30.9% | 22 | Monitor |
| UPMC Kane | 31 | 22 | 11 | 66.7% | 20 | Monitor |
| UPMC Passavant – Cranberry | 35 | — | — | — | — | No Data |
| UPMC Greene | 23 | — | — | — | — | No Data |
| UPMC Muncy | 158 | — | — | — | — | No Data |
UPMC Western Maryland leads the opportunity ranking with a score of 53 — driven primarily by its dominant patient volume and the breadth of its SNF destination network. This is a scale-of-opportunity story: a high-volume hospital with a large, largely unmanaged SNF network is precisely where a preferred-network infrastructure delivers maximum return.
UPMC Chautauqua (46 score, Near-Term) and other Near-Term hospitals represent the tier where FSHR elevation merits structured attention. Their geographic proximity to high-volume UPMC markets means that a preferred-network framework anchored at the top hospitals naturally extends coverage to the Near-Term tier as well.
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: When OSF HealthCare partnered with Puzzle Healthcare, the system introduced Puzzle to approximately 60 nursing homes across their post-acute network. That single act of introduction — OSF telling its downstream SNF partners that Puzzle had the health system’s trust and support — opened relationships that would have taken years to build through conventional vendor outreach. The embedded clinical presence that followed enabled real-time visibility, coordinated care management, and measurable FSHR improvement across all 60 facilities simultaneously.
UPMC Health has 375 unique SNF destinations — a network of significantly greater scale than what OSF brought to that engagement. UPMC’s 129 cross-system shared facilities represent the natural introductions cohort: SNFs that already know and trust multiple UPMC hospitals, and where a coordinated Puzzle presence would have an immediate and demonstrable impact. That is 129 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. UPMC’s cross-system SNF concentration solves this elegantly at scale. The top cross-system facilities — Vincentian Home, Concordia at Rebecca Residence, Heritage Park Rehab — collectively receive enough volume across multiple UPMC hospitals to support a full embedded clinical program from day one.
The explicit ask mirrors the OSF model: UPMC introduces Puzzle to its downstream SNF partners — particularly the 129 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. UPMC’s 129 cross-system facilities represent a comparable starting point, with a clear path to expanding across the full 375-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.
UPMC Health has built one of the most geographically expansive, organizationally integrated health systems in the country, spanning Pennsylvania, New York, and Maryland. 5,922 FFS patients, 375 SNF destinations, 25 active hospitals, and 129 facilities already embedded in multiple UPMC care pathways simultaneously. That is not a system with a post-acute crisis. It is a system with a post-acute opportunity of extraordinary scale that has not yet been systematically activated.
UPMC’s 25-hospital post-acute network currently operates as 25 largely independent discharge patterns, each sending patients to their own set of SNF destinations without shared performance standards, systematic accountability, or a unified visibility layer connecting UPMC care teams to downstream SNF performance. The 15 priority SNF targets — facilities with FSHR rates significantly above the system average appearing across multiple UPMC hospitals — represent the highest-urgency intervention points. But they are part of a larger structural story: 375 SNF destinations, most operating beyond the horizon of UPMC’s systematic oversight.
The 129 cross-system SNFs — facilities that already serve multiple UPMC hospitals and have demonstrated their relevance to the system’s post-acute continuum — are the proof of concept. Vincentian Home serves five UPMC hospitals. Concordia at Rebecca Residence serves five. These are not hypothetical preferred partners; they are already functioning as the de facto preferred network across Pittsburgh, Central Pennsylvania, and the UPMC system footprint. Puzzle’s role is to formalize it, extend it, and make it systematically measurable.
The explicit ask: Introduce Puzzle to UPMC’s downstream SNF partners — beginning with the 129 cross-system facilities and 15 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. UPMC has the same structural foundation — at a scale that makes the opportunity commensurately larger.
We look forward to the conversation — and to what UPMC Health’s post-acute program looks like with the visibility and coordination infrastructure to match the system’s clinical ambition across Pennsylvania, New York, and Maryland.