Hospitals Are Quietly Embedding Doctors Inside Nursing Homes — and the Readmission Numbers Are Hard to Ignore

Chicago, Illinois — A growing number of hospital systems are placing their own physicians and nurse practitioners directly inside skilled nursing facilities, and the early data on readmissions is reshaping how operators pursue hospital partnerships.

The model, often called a Post Acute Network or PAN program, focuses on patients discharged from hospitals into skilled nursing care. According to industry reports, the approach is driving down rehospitalizations, shortening lengths of stay, and helping hospitals capture meaningful Medicare savings — all while pushing nursing homes to operate at a tighter clinical pace.

The Advocate model

Advocate Health, which launched its PAN program in Illinois in 2010 to align with CMS value-based care goals, now runs the network across 62 skilled nursing facilities in Illinois and Wisconsin. It expanded into the Charlotte, North Carolina market last year with an initial cohort of eight SNFs.

The structure is simple on paper but demanding in practice. Advocate embeds doctors and advanced practice nurses inside participating SNFs to tighten care transitions and cut unnecessary skilled nursing days, said Patricia O’Dea-Evans, executive director of the PAN program at Advocate.

The financial case is showing up in the numbers. Advocate booked $13 million in Medicare Shared Savings Program ACO savings in 2024 through PAN, and officials expect a similar haul for 2025. In 2025, the Illinois-Wisconsin network logged a 15.8% 30-day readmission rate among Advocate-affiliated facilities, beating the CMS benchmark for top-decile providers. Average length of stay sat at 16.6 days, well below the national mark of 27.5.

“When there are fewer readmissions, that helps us have better quality outcomes and it helps us with savings, because readmission costs thousands of dollars to the overall cost of care for a patient,” O’Dea-Evans said. The model dovetails with broader CMS efforts to pull SNFs deeper into accountable care arrangements.

Why some SNFs get in — and others don’t

Hospital systems aren’t adding facilities purely on quality scores. Advocate weighs referral volume, location, and proximity to its physician practices when picking partners, O’Dea-Evans said. Even strong operators can be left out if they sit in markets where the hospital doesn’t send much volume.

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

For operators that get in, the upside is real. Efriam Weinfeld, CEO of Illinois-based ALIYA Healthcare, said his facilities in the Advocate program are running rehospitalization rates of roughly 10% to 12%, with top sites near 11.1%. Average lengths of stay have run 10 to 12 days, he said.

“A nurse practitioner or a physician is rounding and collaborating within the facility,” Weinfeld said. “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.”

Other major systems running PAN-style programs include Northwestern Medicine, Rush University Medical Center, and Froedtert Health, with operators like Ignite Medical Resorts, Legacy Healthcare, and Franciscan Ministries among Advocate’s partners.

The takeaway for SNF leaders is becoming harder to dodge. Hospitals can move volume, and they’re increasingly willing to plant clinical staff inside facilities that play along. The operators that sit out may find themselves watching the referral pipeline narrow.