Hospital-Nursing Home Cost-Cutting Collaborations Grow, Lowering Readmissions but Driven by Referral Volume and Geography

A specific type of collaboration between skilled nursing facilities (SNFs) and hospitals is gaining traction due to the financial benefits and quality improvements it can deliver.

Known as the Post Acute Network (PAN) program and focused on patients discharged to SNFs, these initiatives are prompting nursing home operators to partner more closely with hospital systems to improve care coordination. The result has been lower rehospitalization rates, shorter lengths of stay and improved quality outcomes.

Efriam Weinfeld, CEO of Illinois-based ALIYA Healthcare, which participates in PAN SNF programs with several hospital systems, praised Advocate Health and Northwestern Medicine’s PAN models in particular as being among the more effective examples of hospital-SNF integration, supported by consistent communication and measurable improvements in rehospitalization and length-of-stay performance.

“[Advocate] has a very matured post-acute structure that gives an open line of communication and collaboration,” Weinfeld told Skilled Nursing News.

Advocate partners with various nursing home organizations across Illinois, Wisconsin and Charlotte, North Carolina, is one example of such growing initiatives led by hospital systems such as Northwestern Medicine, Rush University Medical Center and Froedtert Health as well as others.

Advocate’s PAN SNF program works by embedding doctors and advanced practice nurses (APNs) in participating SNFs, towards the goal of improving coordination of care transitions and reducing unnecessary SNF days, according to Patricia O’Dea-Evans, executive director of the PAN program at Advocate.

Advocate launched its PAN program for nursing homes in Illinois in 2010 to align with the Centers for Medicare and Medicaid Services’ (CMS) goals for value-based care. Its focus on reducing total Medicare spending through shorter SNF stays, fewer hospital readmissions and improved care coordination has borne fruits, both for Advocate and for its SNF partners.

For Advocate, the PAN SNF program has meant $13 million in Medicare Shared Savings Program (MSSP) ACO savings in 2024, with similar savings expected in 2025.

“When there are fewer readmissions, for example, that helps us have better quality outcomes and it helps us with savings because readmission costs 1000s of dollars to the overall cost of care for a patient,” O’Dea-Evans told SNN. “By working closely with the patients when they’re in a subacute setting, we’re helping with the savings, but we’re also helping with the quality indicators.”

In 2025, the Illinois-Wisconsin PAN network achieved a 15.8% 30-day readmission rate among Advocate-affiliated facilities, outperforming the CMS benchmark for the top 10% of providers while maintaining an average SNF length of stay of 16.6 days, well below the national average of 27.5 days.

‘A true partner’

Advocate’s PAN SNF program currently operates in 62 skilled nursing facilities across Illinois and Wisconsin and expanded into the Charlotte market in 2025 with an initial cohort of eight SNFs. Current participants in Advocate Health’s network include ALIYA Healthcare, Ignite Medical Resorts, Legacy Healthcare, Pearl Healthcare, Franciscan Ministries and Omnia Healthcare Group, among others, O’Dea-Evans said.

Network participation is driven by both provider interest and patient demand. While nursing homes may seek to join the network, Advocate also evaluates factors such as referral volume, location and proximity to its physician practices, she said. Even high-quality facilities may not be added if they are located in areas where Advocate has limited patient demand or referral opportunities.

“We prioritize working with SNFs where some of our volume of patients is already ending up,” she said. “And then, then we look at, ‘can we deploy a medical team to go there?’”

For SNF partners such as ALIYA Healthcare, the program has improved care quality and reduced rehospitalizations, Weinfeld said, even if it has occasionally pushed providers outside their comfort zones.

“A nurse practitioner or a physician is rounding and collaborating within the facility – and sometimes you get the annoying one who’s a little pokey, but they’re actually trying to help you do a better job of taking care of people, and not just the residents that are associated with Advocate,” he said. “In general, they’re looking at you as a true partner.”

ALIYA’s improved metrics

For ALIYA’s facilities participating in Advocate’s PAN SNF program, rehospitalization rates were approximately 10% to 12%, with high-performing sites averaging about 11.1%, and some variation across facilities, Weinfeld said. He also noted that the average length of stay was typically around 10 to 12 days, reflecting strong care coordination and efficient discharge planning. These outcomes compare favorably to both internal benchmarks and national averages.

Shawn Crawford, ALIYA’s chief growth officer, highlighted the success of the Advocate program through a former resident of one of ALIYA’s facilities.

“He has been continuing his home health care now [but] he had a pretty bad leg wound to the point where they were going to have to do a skin graft, but they don’t have to anymore,” Crawford noted. “This is an example of reducing costs of care … he trusted his care team and the network that’s been put in place by these two organizations, and he has had the most optimal outcome possible.”