Puzzle Healthcare

Ballad Health · Post-Acute Network Intelligence · TN & VA

Post-Acute Discharge Destination
and Performance Analysis

Executive Narrative — April 2026

8 Hospitals
~2,400 FFS SNF Patients
120+ SNF Destinations
Q4 2024–Q3 2025
Confidential
Prepared for Preetham Talari, MD, MBA, FACHE — VP & SMD, Clinical Transformation & Outcomes Optimization
~2,400
FFS SNF Patients
120+
Unique SNF Destinations
8
Hospitals Analyzed
13.39
Peak Facility Risk
Alert
75.7%
Peak Hosp. Rate
Alert
31.8%
Peak 90d Readmit
Alert
11
Cross-System SNFs

A Regional Post-Acute Network in View

Ballad Health operates eight acute care hospitals across northeast Tennessee and southwest Virginia. Our analysis of Medicare fee-for-service discharge data (Q4 2024–Q3 2025) identifies approximately 2,400 FFS patients discharged annually to more than 120 unique skilled nursing facility destinations. The data reveal a post-acute footprint with meaningful variation in performance, limited system-level visibility, and a concentration of risk in the highest-volume relationships that is invisible without unified monitoring.

This analysis is not a summary of problems. It is a map of opportunity. Across your eight hospitals, there is an active downstream SNF network — 120+ facilities, thousands of patient relationships, and an entirely unmanaged performance signal. Several high-volume SNF partners carry Very High facility-specific risk scores. Cross-system SNFs appearing at three or more hospitals present both the greatest risk concentration and the greatest opportunity for improvement.

Puzzle Healthcare can help Ballad gain visibility into that network, prioritize where intervention matters most, and establish a structured presence in the facilities where your patients are most at risk. Health systems that have taken this step — including OSF HealthCare, which introduced Puzzle to 60 of their downstream nursing home partners — have seen it transform their post-acute relationships into a shared performance feedback loop that neither organization could have built independently.


Five Signals That Define the Network

The analysis surfaces five findings that collectively define the risk profile of Ballad Health's downstream post-acute relationships.

01
Life Care Center of Elizabethton: 75.7% hospitalization rate and 31.8% 90-day readmission across six sending hospitals.

Receiving patients from six of eight Ballad hospitals, Life Care Center of Elizabethton posted a 75.7% hospitalization rate at JCMC (11 patients) with a 31.8% 90-day readmission rate. Facility-specific risk scores range from 2.56 to 6.98 (Very High) depending on the sending hospital. At Sycamore Shoals, 13 patients show a 58.5% hospitalization rate with a facility risk of 4.94. This pattern is consistent across hospitals and represents the highest-risk cross-system SNF relationship in the Ballad network.

02
Ridgecrest Manor: Facility risk score of 13.39 at Johnston Memorial — the highest in the entire Ballad system.

Ridgecrest Manor Nursing and Rehabilitation carries a facility-specific risk score of 13.39 when assessed through Johnston Memorial Hospital — more than triple the Very High threshold of 4.0. The facility also appears in the JCMC, Holston Valley, and Sycamore Shoals networks. While individual patient volumes are suppressed (<11), the extreme risk signal and cross-system presence warrant immediate review.

03
Mountain City Care & Rehabilitation: Facility risk of 9.77 at Holston Valley, appearing at five hospitals.

Mountain City Care carries the second-highest facility-specific risk score in the Ballad system (9.77 at Holston Valley), with a 25.0% 90-day readmission rate. The facility appears at five of eight Ballad hospitals with Very High risk scores at four of them (ranging from 3.53 to 9.77). This JJLA-operated facility presents a concentrated, cross-system quality concern that cannot be detected or managed from any single hospital's perspective.

04
SNF utilization varies significantly across the system — from 9.96% to 21.0% against state averages of 17.5–17.8%.

Four hospitals (JCMC, Holston Valley, Johnston Memorial, Greeneville Community) operate above their respective state average for SNF utilization, while four (Bristol Regional, Indian Path, Franklin Woods, Sycamore Shoals) operate below. Greeneville Community leads at approximately 21.0%, while Indian Path is at just 9.96%. This variation suggests different discharge practices and market dynamics across the system — and different types of opportunity for post-acute optimization at each hospital.

05
Extreme concentration risk: Top 2 SNF partners capture 32–58% of volume at individual hospitals.

Johnston Memorial concentrates 58.3% of its FFS SNF volume in just two facilities. Greeneville Community concentrates 54.0% in its top two. Franklin Woods sends 53.9% to two partners. This level of concentration creates both dependency risk and outsized impact opportunity — performance improvement at a single high-volume partner can move hospital-level readmission metrics. It also means that without monitoring, a quality decline at one facility exposes hundreds of patients before anyone on the hospital side has visibility.


Johnson City Medical Center

Johnson City, TN · 501 beds · Opportunity Score: 78

Immediate
724
FFS SNF Patients
70
SNF Destinations
19.4%
SNF Utilization
18.4%
30-Day Readmit
20
Very High Risk SNFs

JCMC is Ballad's highest-volume SNF-discharging hospital, sending 724 FFS patients to 70 unique destinations — creating significant monitoring exposure across the network. The top partner, Princeton Transitional Care (21.8% share), carries a Very High facility risk score (3.67) and Life Care Center of Elizabethton shows an alarming 75.7% hospitalization rate and 31.8% 90-day readmission on 11 patients. The 18.4% 30-day readmission rate exceeds both county (17.5%) and state (17.9%) benchmarks, signaling a preferred network optimization opportunity.

SNF Partner Pts Share Hosp Rate 30d Readmit FR Risk Cat
Princeton Transitional Care & Assisted Living 158 21.8% 35.4% 13.8% 3.67 Very High
NHC Healthcare-Johnson City LLC 76 10.5% 22.5% 6.8% 3.47 High
Abundant Christian Living Community LLC 53 7.3% 20.0% 7.3% 3.05 High
Hilllview Health Center 33 4.6% 32.4% 13.3% 2.98 Medium
Christian Care Center of Unicoi County LLC 32 4.4% 35.9% 12.8% 3.55 High
Lakebridge A Waters Community LLC 27 3.7% 42.6% 14.3% 4.36 Very High
Four Oaks Operating Group LLC 27 3.7% 32.8% 17.3% 4.38 Very High

Holston Valley Medical Center

Kingsport, TN · 303 beds · Opportunity Score: 65

Immediate
475
FFS SNF Patients
53
SNF Destinations
19.19%
SNF Utilization
18.9%
30-Day Readmit
12
Very High Risk SNFs

Holston Valley shows high SNF concentration: the top facility (NHC Healthcare Kingsport) alone accounts for 26.9% of volume, while Brookhaven Health & Rehabilitation — the #7 partner — carries a 58.8% hospitalization rate and a Very High facility risk score of 4.52. The hospital's 30-day SNF readmission rate (18.9%) exceeds the state average (18.0%), and Mountain City Care & Rehabilitation carries the system's highest facility risk at 9.77 — a critical red flag warranting immediate preferred network review.

SNF Partner Pts Share Hosp Rate 30d Readmit FR Risk Cat
NHC Healthcare, Kingsport 128 26.9% 24.7% 8.2% 3.2 High
Asbury Place Kingsport 57 12.0% 38.1% 16.5% 3.45 High
Holston Manor SNF Operations LLC 51 10.7% 40.2% 13.2% 4.35 Very High
Nova Health & Rehab Center 33 6.9% 36.1% 17.8% 3.74 Very High
Lee Health & Rehab Center 25 5.3% 30.2% 11.5% 2.76 Medium
Church Hill TN Opco LLC 24 5.1% 28.9% 10.0% 4.68 Very High
Brookhaven Health and Rehabilitation 23 4.8% 58.8% 17.9% 4.52 Very High

Johnston Memorial Hospital

Abingdon, VA · 116 beds · Opportunity Score: 59

Immediate
266
FFS SNF Patients
32
SNF Destinations
19.5%
SNF Utilization
12
Very High Risk SNFs

Johnston Memorial Hospital shows severe concentration risk: the top 2 SNF partners (Abingdon Health & Rehab and Valley Rehabilitation) account for 58.3% of all FFS SNF volume. Ridgecrest Manor carries the highest facility risk score in the entire Ballad system (13.39), while Durham-Hensley's 6.38 score is similarly alarming. The hospital's SNF utilization (~19.5%) exceeds the VA state average (~17.5%), making it a high-priority market for a structured preferred network strategy focused on quality and outcome improvement.

SNF Partner Pts Share Hosp Rate 30d Readmit FR Risk Cat
Abingdon Health & Rehab Center 101 38.0% 30.2% 8.9% 3.19 High
Valley Rehabilitation and Nursing Center 54 20.3% 39.3% 13.4% 3.6 Very High
301 Village Holdings LLC 30 11.3% 53.3% 17.4% 4.03 Very High
Deer Meadows Rehabilitation and Nursing 24 9.0% 44.2% 19.2% 4.17 Very High
Mountain City Care & Rehabilitation Center <11 Suppressed 16.7% 3.24 High
NHC Healthcare-Bristol LLC <11 Suppressed 4.5% 2.7 Medium
Maple Grove Healthcare Center <11 Suppressed 14.4% 4.55 Very High

Greeneville Community Hospital

Greeneville, TN · 140 beds · Opportunity Score: 50

Immediate
174
FFS SNF Patients
23
SNF Destinations
21.0%
SNF Utilization
6
Very High Risk SNFs

Greeneville Community Hospital's top 4 SNF partners account for ~88% of all FFS volume — the highest concentration ratio in the Ballad system. Durham-Hensley Health & Rehabilitation shows a troubling 58.9% hospitalization rate on 33 patients with a Very High facility risk score (4.04). The hospital's SNF utilization (~21%) exceeds the state average (17.82%), suggesting a highly SNF-dependent discharge pattern that warrants a strategic preferred network to redirect volume toward higher-quality partners.

SNF Partner Pts Share Hosp Rate 30d Readmit FR Risk Cat
Signature Healthcare of Greeneville 48 27.6% 46.9% 15.3% 3.51 High
Life Care Center of Greeneville 46 26.4% 35.5% 16.4% 3.36 High
Durham-Hensley Health and Rehabilitation 33 19.0% 58.9% 12.1% 4.04 Very High
Laughlin Healthcare Center 27 15.5% 26.5% 12.5% 2.99 Medium
Princeton Transitional Care & Assisted Living <11 Suppressed 13.8% 1.99 Very Low
NHC Healthcare-Johnson City LLC <11 Suppressed 6.8% 1.79 Very Low
Four Oaks Operating Group LLC <11 Suppressed 17.3% 1.77 Very Low

Bristol Regional Medical Center

Bristol, TN · 312 beds · Opportunity Score: 45

Immediate
390
FFS SNF Patients
51
SNF Destinations
14.23%
SNF Utilization
18.8%
30-Day Readmit
10
Very High Risk SNFs

Bristol Regional's top 4 SNF partners account for 65.1% of all FFS volume — extreme concentration risk in a limited set of facilities. The #1 partner, 301 Village Holdings LLC, shows a 48.7% hospitalization rate on 88 patients with a High facility risk score (3.57). Greystone Health Care Center carries a 63.6% hospitalization rate and Very High facility risk (4.41). The hospital's SNF utilization (14.23%) is well below the state average (17.82%), suggesting underutilized SNF capacity or premature discharge patterns.

SNF Partner Pts Share Hosp Rate 30d Readmit FR Risk Cat
301 Village Holdings LLC 88 22.6% 48.7% 17.4% 3.57 High
NHC Healthcare-Bristol LLC 70 17.9% 20.6% 4.5% 3.25 High
Waters of Bristol A Rehabilitation & Nursing Center LLC 52 13.3% 48.0% 17.1% 3.67 Very High
Abingdon Health & Rehab Center 44 11.3% 28.1% 8.9% 3.55 High
Maple Grove Healthcare Center 18 4.6% 38.3% 14.4% 3.68 Very High
Valley Rehabilitation and Nursing Center 13 3.3% 35.3% 13.4% 3.71 Very High
Greystone Health Care Center 11 2.8% 63.6% 15.7% 4.41 Very High

Franklin Woods Community Hospital

Johnson City, TN · 80 beds · Opportunity Score: 39

Near-Term
141
FFS SNF Patients
26
SNF Destinations
16.1%
SNF Utilization
10
Very High Risk SNFs

Franklin Woods discharges 38.3% of its FFS SNF patients to a single facility — Princeton Transitional Care — creating significant concentration risk (High facility risk score: 3.20). Multiple Very High risk SNFs appear in the tail of the network including Ivy Hall Nursing Home (fac risk 5.57), Life Care Center of Greeneville (7.60), and Four Oaks Operating Group (6.66). Despite below-average SNF utilization (~16.1% vs 17.82% state), the quality risk in the existing network makes Franklin Woods a priority for preferred network development.

SNF Partner Pts Share Hosp Rate 30d Readmit FR Risk Cat
Princeton Transitional Care & Assisted Living 54 38.3% 29.1% 13.8% 3.2 High
NHC Healthcare-Johnson City LLC 22 15.6% 22.9% 6.8% 3.17 High
Abundant Christian Living Community LLC 12 8.5% Suppressed 7.3% 2.55 Medium
Christian Care Center of Unicoi County LLC <11 Suppressed 12.8% 2.99 Medium
Hilllview Health Center <11 Suppressed 13.3% 3.46 High
Hermitage Health Center <11 Suppressed 13.9% 3.88 Very High
Ivy Hall Nursing Home <11 Suppressed 15.8% 5.57 Very High

Sycamore Shoals Hospital

Elizabethton, TN · 121 beds · Opportunity Score: 37

Near-Term
196
FFS SNF Patients
28
SNF Destinations
16.1%
SNF Utilization
7
Very High Risk SNFs

Sycamore Shoals sends the majority of its SNF volume to local Elizabethton-area facilities, with Hillview Health Center (21.9%) and Ivy Hall Nursing Home (18.4%) dominating referrals. Life Care Center of Elizabethton — a key local partner — posts a 58.5% hospitalization rate and 31.8% 90-day readmission with a Very High facility risk score (4.94). Berkeley Springs Healthcare Center carries the highest fac risk in the hospital's network (7.70). Below-average SNF utilization (~16.1%) combined with high-risk partners creates a clear case for a curated preferred network in this market.

SNF Partner Pts Share Hosp Rate 30d Readmit FR Risk Cat
Hilllview Health Center 43 21.9% 41.5% 13.3% 2.97 Medium
Ivy Hall Nursing Home 36 18.4% 37.4% 15.8% 2.91 Medium
Princeton Transitional Care & Assisted Living 21 10.7% Suppressed 13.8% 3.15 High
Hermitage Health Center 15 7.7% 55.9% 13.9% 3.9 Very High
Christian Care Center of Unicoi County LLC 15 7.7% Suppressed 12.8% 2.95 Medium
Life Care Center of Elizabethton 13 6.6% 58.5% 20.9% 4.94 Very High
Signature Healthcare of Elizabethton Rehab & Wellness Center 13 6.6% Suppressed 11.6% 3.36 High

Indian Path Community Hospital

Kingsport, TN · 239 beds · Opportunity Score: 6

Monitor
5
FFS SNF Patients
8
SNF Destinations
9.96%
SNF Utilization
11.6%
30-Day Readmit
0
Very High Risk SNFs

Indian Path Community Hospital has the lowest SNF utilization in the system (~9.96% vs 17.82% state average), sending FFS patients to only 8 SNF destinations — all with <11 patients each due to CMS suppression. The hospital's 30-day FFS readmission rate (11.61%) is well below the state average (15.04%), indicating strong overall performance. Despite low current volume, the hospital's Kingsport location — shared with Holston Valley — presents an opportunity to formalize a high-quality preferred SNF network as FFS volume grows.

!
Data Note: All FFS patient counts are suppressed (<11 per facility)

Indian Path's FFS SNF volume is the lowest in the Ballad system. All 8 SNF destinations show fewer than 11 patients each, triggering CMS privacy suppression for most metrics. The hospital's overall 30-day FFS readmission rate (11.61%) is well below the state average, indicating strong overall performance. Despite limited current actionability, the hospital's Kingsport location — shared with Holston Valley — presents an opportunity to formalize preferred SNF relationships as volume grows.

SNF Partner Pts Share Hosp Rate 30d Readmit FR Risk Cat
NHC Healthcare, Kingsport <11 Suppressed 8.2%
Nova Health & Rehab Center <11 Suppressed 17.8%
Asbury Place Kingsport <11 Suppressed 16.5%
Holston Manor SNF Operations LLC <11 Suppressed 13.2%
Brookhaven Health and Rehabilitation <11 Suppressed 17.9%
Life Care Center of Elizabethton <11 Suppressed 20.9%
The Wexford House <11 Suppressed 0.0%
Lee Health & Rehab Center <11 Suppressed 11.5%

SNFs Receiving Patients from 3+ Ballad Hospitals

These facilities represent the greatest concentration of system-level risk — and the greatest opportunity for Puzzle to create measurable impact through coordinated quality improvement.

SNF Partner Hospitals Peak Hosp Rate 30d Readmit 90d Readmit Peak FR Priority
NHC Healthcare, Kingsport 8 24.7% 8.2% 12.4% 3.57 High
Princeton Transitional Care & Assisted Living 7 35.4% 13.8% 16.4% 4.27 High
Life Care Center of Elizabethton 6 75.7% 20.9% 31.8% 6.98 Immediate
Durham-Hensley Health and Rehabilitation 6 58.9% 12.1% 21.2% 6.38 Immediate
Brookhaven Health and Rehabilitation 5 58.8% 17.9% 26.8% 8.7 Immediate
NHC Healthcare-Johnson City LLC 6 22.5% 6.8% 9.9% 3.62 Near-Term
NHC Healthcare-Bristol LLC 5 20.6% 4.5% 9.3% 5.51 Near-Term
Asbury Place Kingsport 4 38.1% 16.5% 22.6% 5.34 Near-Term
Waters of Bristol A Rehabilitation & Nursing Center LLC 4 48.0% 17.1% 22.7% 3.67 Near-Term
Signature Healthcare of Greeneville 3 46.9% 15.3% 19.0% 3.64 Near-Term
Mountain City Care & Rehabilitation Center 5 Suppressed 16.7% 25.0% 9.77 Immediate

The 11 cross-system SNFs listed above represent Ballad Health's most interconnected downstream relationships. Three carry Immediate priority designations based on extreme risk signals: Life Care Center of Elizabethton (75.7% hospitalization rate, 6 sending hospitals), Mountain City Care & Rehabilitation (facility risk 9.77, 5 sending hospitals), and Brookhaven Health and Rehabilitation (58.8% hospitalization rate, facility risk 8.70 at Bristol). These are the relationships where Puzzle's embedded quality improvement model would generate the most immediate and measurable impact — precisely because the risk is concentrated, cross-system, and currently invisible at the hospital level.


From Signal to Partnership

Ballad Health discharges to 120+ unique SNFs across Tennessee and Virginia — this creates a structured post-acute partnership opportunity.

For Puzzle to establish a meaningful operational presence in your downstream SNF network — dedicated staff, performance feedback loops, facility-level data relationships — we need sufficient facility coverage to justify that investment. Based on our experience, 10 or more facilities is the threshold where embedded resources become economically viable and clinically impactful.

Ballad Health's network of 120+ SNF destinations across eight hospitals provides that scale — many times over. Even focusing only on the facilities where you send meaningful volume, there are dozens of relationships where a Puzzle presence would improve post-acute performance and give your clinical transformation teams real-time data they currently do not have.

When OSF HealthCare introduced Puzzle to 60 of their downstream nursing home partners, it created a shared performance infrastructure that neither organization could have built independently. Ballad Health has the same opportunity — a regional network of downstream partners, active patient relationships spanning two states, and the scale to make it matter.

The ask is simple: introduce us to your SNF partners. We will take it from there.

Priority Tiers

IMM
Immediate Priority — 5 Hospitals (JCMC, Holston Valley, Johnston Memorial, Greeneville Community, Bristol Regional)

These hospitals carry Opportunity Index scores of 45–78 and collectively represent the largest volume, highest risk concentration, and greatest downstream quality improvement potential. JCMC alone sends 724 FFS patients to 70 SNF destinations. Immediate engagement with these hospitals' top SNF partners — and system-level review of cross-system high-risk facilities — is the recommended starting point.

NT
Near-Term Priority — 2 Hospitals (Franklin Woods, Sycamore Shoals)

Both hospitals score 37–39 on the Opportunity Index, with below-state-average SNF utilization but notable quality risk in their existing networks. Franklin Woods shares the Johnson City market with JCMC, creating natural preferred network leverage. Sycamore Shoals' Elizabethton market links directly to several of the system's highest-risk SNFs. Engagement should follow the Immediate tier.

MON
Monitor — 1 Hospital (Indian Path Community Hospital)

Indian Path's FFS SNF volume is fully suppressed (<11 per facility). The hospital's overall 30-day readmission rate (11.61%) is well below the state average, and SNF utilization (~9.96%) is the lowest in the system. Indian Path is not an immediate engagement target, but its Kingsport location — shared with Holston Valley — positions it to benefit from any system-level preferred network formalization.


Three Steps Forward

A structured path from current-state visibility to active network management.

1
Initiate a system-level review of the highest-risk cross-system SNF partners.

Life Care Center of Elizabethton, Mountain City Care & Rehabilitation, Brookhaven Health and Rehabilitation, and Durham-Hensley carry Immediate priority designations based on extreme hospitalization rates, elevated facility risk scores, and cross-system presence. These reviews should establish consistent performance expectations, applied uniformly across all Ballad hospitals. Puzzle's network prioritization capability provides the data structure and monitoring logic to operationalize this without adding burden to existing staff.

2
Establish a system-level post-acute monitoring dashboard spanning all eight hospitals.

Eight hospitals independently routing patients to overlapping SNF networks — with no shared visibility — makes it impossible to detect system-level patterns before they become adverse event patterns. A unified view of facility risk, hospitalization rates, and readmission trends at the network level is the foundational capability that every other step depends on — and it is the core of what Puzzle delivers.

3
Introduce Puzzle to your downstream SNF partners — starting with your highest-volume, highest-risk facilities.

This is the step that creates leverage. A warm introduction from Ballad Health gives Puzzle the credibility to begin building data relationships, embedding quality improvement resources, and creating the performance feedback loop that hospitals cannot build from the hospital side alone. Ballad's 120+ downstream SNF relationships provide more than sufficient scale for a meaningful Puzzle presence. We are not asking to replace existing relationships — we are asking for the introduction that lets us make them better. The facilities where your patients go most frequently are the right place to start.


Puzzle Healthcare

Puzzle Healthcare is a post-acute intelligence and quality improvement company that works at the intersection of health systems and skilled nursing facilities. We embed quality improvement resources directly inside downstream SNF partners, creating a shared performance infrastructure that reduces readmissions, improves patient outcomes, and gives health systems real-time visibility into the facilities their patients rely on after discharge.

Our model has been implemented with health systems including OSF HealthCare, where Puzzle was introduced to 60 downstream nursing home partners to create a structured post-acute performance network. The result is a feedback loop that neither the hospital nor the SNF can create independently — one that transforms post-acute oversight from a reporting exercise into an active management capability.

Puzzle works because it starts where the patient goes — not where the patient was.


The Conversation We Are Asking to Have

Ballad Health's eight-hospital system discharges approximately 2,400 Medicare FFS patients per year into a post-acute network with meaningful variation, limited system-level visibility, and no shared performance management infrastructure. The findings in this analysis represent what is visible from the hospital side. What becomes possible — for your patients, your clinical transformation teams, and your downstream SNF partners — when Puzzle is embedded in that network is the conversation we are asking to have.

We are ready to move quickly. The next step starts with an introduction.