Improving Transitions of Care Across the Spectrum of Healthcare Delivery: A Multidisciplinary Approach to Understanding Variability in Outcomes Across Hospitals and Skilled Nursing Facilities

Am J Surg. 2017 May;213(5):910-914. doi: 10.1016/j.amjsurg.2017.04.002. Epub 2017 Apr 5.


Introduction: 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.

Discussion: 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.

Publication types

  • Consensus Development Conference

MeSH terms

  • Delphi Technique
  • Hospital Administration / methods*
  • Hospital Administration / standards
  • Humans
  • Interdisciplinary Communication*
  • Outcome and Process Assessment, Health Care
  • Patient Readmission / statistics & numerical data
  • Patient Safety
  • Patient Transfer / organization & administration*
  • Practice Guidelines as Topic
  • Quality Improvement / organization & administration*
  • Skilled Nursing Facilities / organization & administration*
  • Washington