title: Improving transitions of care across the spectrum of healthcare delivery: A multidisciplinary approach to understanding variability in outcomes across hospitals and skilled nursing facilities.
abstract: BACKGROUND
  Improving coordination during transitions of care from the hospital to Skilled Nursing Facilities (SNF)s is critical for improving healthcare quality. In 2014, we formed (Improving Nursing Facility Outcomes using Real-Time Metrics, INFORM) to improve transitions of care by identifying structural and process factors that lead to poor clinical outcomes and hospital readmission.
  
  
  METHODS
  Stakeholders from 10 SNFs and 4 hospitals collaborated to assess the current hospital and system-level challenges to safe transitions of care and identify targets for interventions.
  
  
  RESULTS
  The INFORM collaborative identified areas for improvement including improving accuracy and timeliness of discharge information, facilitating congruent medication reconciliation, and developing care plans to support functional improvement.
  
  
  CONCLUSIONS
  Hospital and SNF stakeholder engagement prioritized the challenges in patient transitions from inpatient to skilled nursing facility settings. Innovative solutions that address barriers to safe and effective transitions of care are critical to improving clinical outcomes, decreasing adverse events and avoiding readmission.
authors.affiliation: Department of Surgery, University of Washington, Seattle, WA, USA; Department of Health Services, University of Washington, Seattle, WA, USA. Electronic address: ghd@uw.edu.
authors.forename: Giana H
authors.initials: GH
authors.lastname: Davidson
authors.affiliation: Department of Surgery, University of Washington, Seattle, WA, USA.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Austin
authors.affiliation: Department of Surgery, University of Washington, Seattle, WA, USA.
authors.forename: Lucas
authors.initials: L
authors.lastname: Thornblade
authors.affiliation: Chief Health Systems Office, University of Washington, Seattle, WA, USA.
authors.forename: Louise
authors.initials: L
authors.lastname: Simpson
authors.affiliation: Department of Medicine, University of Washington, Seattle, WA, USA.
authors.forename: Thuan D
authors.initials: TD
authors.lastname: Ong
authors.affiliation: Chief Health Systems Office, University of Washington, Seattle, WA, USA.
authors.forename: Hanh
authors.initials: H
authors.lastname: Pan
authors.affiliation: Department of Surgery, University of Washington, Seattle, WA, USA; Department of Health Services, University of Washington, Seattle, WA, USA.
authors.forename: David R
authors.initials: DR
authors.lastname: Flum
mesh_terms: D003697:Delphi Technique; D006739:Hospital Administration / Q000379:methods* / Q000592:standards; D006801:Humans; D033183:Interdisciplinary Communication; D010043:Outcome and Process Assessment, Health Care; D010359:Patient Readmission / Q000706:statistics & numerical data; D061214:Patient Safety; D010360:Patient Transfer / Q000458:organization & administration*; D017410:Practice Guidelines as Topic; D058996:Quality Improvement / Q000458:organization & administration*; D012866:Skilled Nursing Facilities / Q000458:organization & administration*; D014861:Washington