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Post Acute Network

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Advocate at Home, Advocate’s home health care division, provides comprehensive home care, hospice, infusion and home medical equipment services. Advocate at Home consistently ranks among Illinois’ top performers in achieving health outcomes and is recognized nationally for its success in helping reduce hospital readmissions. In 2015, Advocate at Home ranked in the top decile nationally with a readmission rate of just 16%. Advocate’s post-acute model also includes a transition coach program, Advocate Physicians at Home, and palliative care services provided in multiple settings. In 2015, the home-based palliative care program had an average daily census of 220 and yielded favorable results. An analysis of patients in a Medicare Advantage plan showed a reduction in hospital admissions and length-of-stay, and a 65% reduction in total cost of care. To further support the goal of providing high-quality post-acute care, Advocate has developed a preferred network of community-based skilled nursing, longterm acute care, and rehabilitation providers who meet Advocate’s standards for quality. This Post-Acute Network (PAN) includes 41 skilled nursing facilities (SNFs) that have partnered with Advocate to provide optimal care through its SNF Care Program. In this care model, SNF patients are seen by an on-site provider—an Advocate employed advanced practice nurse (APN) or physician— three to five days per week. The APN helps ensure a smooth transition, communicates with the SNF physician, is closely involved with the SNF staff to facilitate medical care coordination and discharge planning, and is responsible for relaying medical information back to the referring PCP. Following a pilot at Advocate Lutheran General Hospital in 2010, the program has now been successfully replicated throughout the Advocate system; both across the Chicago Featured AdvocateCare® Program: Post-Acute Care 11 2016 Value Report | 12 Featured AdvocateCare® Program: Post-Acute Care metropolitan area as well as in Central Illinois. Results are impressive: In 2015, with a patient volume of more than 9,400, the adjusted length of stay was 15.5 days (reduced from a 2014 average length of stay of 17) and the readmission rate was just 13.5%. This compares to a national average covered length of stay of 27.6 days for fee-for-service Medicare beneficiaries, according to the most recent report.1 CMS has taken notice and has singled out Advocate’s SNF Care Program as a national model for achieving goals of improved care and reduced cost.