Long-Term Care

Improving Nursing Facility Outcomes
using Real-Time Metrics (INFORM)

An increasing number of patients are being discharged to skilled nursing facilities (SNFs) following acute care admissions, but large proportion of these patients never return to the community. In fact, more than 25% of post-acute care admissions to SNFs result in unplanned hospital readmissions. 

Our mission is to improve the health of patients receiving specialized post-acute care following hospitalization. Understanding this period is essential to improving healthcare for the increasing proportion of patients requiring SNFs following discharge from the hospital. The multi-disciplinary INFORM collaborative will evaluate the variability in patient, structural, and process factors that contribute to patient-centered outcomes. Through research and quality improvement initiatives for benchmarking standards of care, INFORM is decreasing variability in care delivery and improving the outcomes that matter most to patients.

Partner with INFORM

There has been increased focus on improving the care for patients after they leave the hospital.  Washington State is developing strong recommendations for SNFs to participate in quality improvement collaboratives to improve patient care and decrease readmissions to the hospital. INFORM offers SNFs and hospitals a forum to lead the charge, and in shaping those a program to develop best practices in the transition for patients in the post-acute care period.

To learn more about how to get involved please contact informpt@uw.edu.


It is challenging for physicians and patients who are admitted to a skilled nursing facility to predict how their recovery will continue following discharge from the hospital. The INFORM collaborative has developed a tool called INFORM SCORE that providers can use to help inform patients and their families of the likelihood of return to the hospital, death within the year, and ultimate discharge home from a skilled nursing facility.