UW Medicine Post-Acute Care Network

Getting the right care after hospital discharge

Post-acute care (PAC) refers to care provided to patients recently discharged from the hospital and can take place in many settings including skilled nursing facilities and rehabilitation centers, in your home with a Home Health Agency or at a center providing Adult Day Health Care. Some patients do not need "skilled care" (care provided by a licensed professional such as a registered nurse or physical therapist) once they go home, but they may need support with daily tasks such as bathing, chores or setting up transportation to appointments. Home Care or Private Duty Care can assist with these tasks.

While patients and families often look to their hospital care team to help choose a facility or agency, they are free to select any facility they wish. UW Medicine has a Post-Acute Care Network that includes skilled nursing and rehabilitation, home health, home care, and adult day health services. Our partners have passed a detailed evaluation process, met our service and quality requirements, and are continuously monitored to ensure that all of our patients have a positive experience after they leave the hospital.

Benefits of selecting a UW Medicine PAC Network Partner:

  • Aligned goals – Our partners are dedicated to providing better patient care, timely access and patient satisfaction
  • Quality & Coordination – Partners have access to UW Medicine electronic medical records and have better coordination with your hospital and physician. Partners meet with UW Medicine hospitals regularly to share best practices, develop clinical guidelines and review quality data.

UW Physicians & Nurse Practitioners on site (SNF ONLY) – Many skilled nursing facility (SNF) sites have our providers on site. They will coordinate your transition to the facility, are available overnight and on weekends for urgent issues, coordinate specialty appointments and provide medical care that is tailored to each patient's needs and condition(s).

Skilled nursing facilities

Skilled nursing facilities and rehabilitation centers support continued recovery through nursing care and therapy provided by registered nurses, certified nursing assistants, physical therapists, occupational therapists and speech therapists. Where the focus in a hospital is to treat and stabilize acute care needs, skilled nursing and rehabilitation aid in your recovery phase by providing wound care, intravenous (IV) therapy, physical therapy and continual monitoring of symptoms and vital signs.

If hospital providers think you or someone you know will benefit from care services at a skilled nursing facility, they will develop a plan for your recovery and provide guidance to the facility to work with you to carry out that plan.

Most stays at skilled nursing facilities are temporary but the duration is different for everyone and determined by such factors as physical condition and support at home.

How skilled nursing facilities differ from hospitals:

  • You may share a room with another patient.
  • Beds are smaller than those in hospitals.
  • Meals often are served in a dining room, though accommodations can be requested.
  • Staffing ratios are different: There are fewer registered nurses and more certified nurse assistants, and nurses are responsible for more patients than they would be in a hospital setting. Physicians oversee care plans but will not make rounds to see patients every day.
  • Most facilities use off-site pharmacies, laboratories and radiology services.
  • There are rooms for socializing, as well as planned activities, for patients to enjoy. 

When your hospital provider thinks you are ready for this next care environment, the hospital's social work staff will assist you in selecting a skilled nursing facility. There are many facilities to choose from and numerous considerations to take into account. It's a good idea to visit the facility first and bring a checklist like this one to help evaluate the quality of a nursing home. Medicare and Medicaid beneficiaries may obtain health services from any institution that accepts Medicare and/or Medicaid; however, there may be limitations due to bed availability, specific medical specialty services and your insurance coverage.

Factors to consider include:

  • The quality of care and rehabilitation
  • Specialized medical care and staff
  • Private versus shared room
  • Choice of doctor
  • Distance to family or friends to allow for visits
  • Distance to follow-up appointments 

For more information about Skilled Nursing Facilities, visit: https://www.medicare.gov/nursinghomecompare

Home Health

Patients leaving the hospital are often in a weakened state and it is normal to need assistance with transitioning home. Home Health may be part of an overall care plan or ordered by a physician when certain tasks need to be performed by a licensed medical professional in order for a patient to stay safely at home. These services may include medication management and teaching, disease progression education and medical condition management, wound care and dressing changes, IV infusions, lab draws, physical therapy, etc.

To qualify for home health, patients must:

  1. Be homebound (meaning that leaving your home isn’t recommended because of your condition, or it takes a considerable effort to leave your home; you may leave your home for medical treatment or short, infrequent absences for non-medical reasons such as attending religious services, a special event, etc.)
  2. Have a medically necessary need, which may include intermittent skilled nursing care or therapy (physical therapy, speech therapy, or occupational therapy)
  3. Be under the care of a physician to determine if patient meets home health criteria
  4. Have services provided under a plan of care that is established by and periodically reviewed by patients’ physician

If a patient qualifies for home health services provided by nurses or physical therapists, other secondary services are also available from the same agency such as: occupational or speech therapy, social services, and home health aides (chores, bathing, dressing, meal preparation, etc.).

For more information about home health agencies, visit: https://www.medicare.gov/homehealthcompare

Home Care or Private Duty Care

Home Care or Private Duty Care is provided by in-home caregivers who assist with non-medical tasks that a patient cannot safely or comfortably do alone. Services may include bathing and personal care, medication reminders, meal planning and preparations, shopping, errands and/or housekeeping.

Adult Day Health

Adult Day Health programs provide caregivers a break while fostering the patient's well-being and independence. Program participants enjoy educational and recreational programs, limited skilled rehab and nursing therapies, and the opportunity to socialize with peers in a safe, disability-friendly environment.

Skilled nursing facilities

Avalon Care Center-Federal Way
Avalon Care website
Location: Federal Way 
Contact: 253-835-7453

Burien Nursing & Rehabilitation Center
Burien Nursing website 
Location: Burien 
Contact: 206-631-0222

Columbia Lutheran Home
Columbia Lutheran website 
Location: North Seattle 
Contact: 206-632-7400

CRISTA Rehab & Skilled Care
CRISTA Rehab & Skilled Care website 
Location: Shoreline 
Contact: 206-5467443

Foss Home & Village
Foss Home website 
Location: North Seattle 
Contact: 206-364-1300

Ida Culver House Broadview
Ida Culver website 
Location: North Seattle 
Contact: 206-361-1989

Issaquah Nursing & Rehabilitation Center
Issaquah Nursing website
Location: Issaquah 
Contact: 425-392-1271

Judson Park Health Center
Judson Park website
Location: Des Moines 
Contact: 206-361-1989

Kline Galland Home
Kline Galland website 
Location: South Seattle 
Contact: 206-725-8800

Life Care Center of Federal Way
Life Care Center website
Location: Federal Way 
Contact: 253-946-2273

Park Ridge Care Center
Park Ridge website 
Location: South Seattle 
Contact: 206-363-5856

Park West Nursing & Rehab
Park West Nursing website 
Location: West Seattle 
Contact: 206-937-9121

Providence Mount St. Vincent
Providence Mount St. Vincent website 
Location: West Seattle 
Contact: 206-937-3700

Queen Anne Healthcare
Queen Anne Healthcare website 
Location: Seattle 
Contact: 206-284-7012

Shoreline Health & Rehabilitation Center
Shoreline Health website 
Location: Shoreline 
Contact: 206-418-2903

Stafford Healthcare SeaTac
Stafford Healthcare website
Location: Des Moines
Contact: 206-824-0600


Home health & hospice agencies

EvergreenHealth Home Care
EvergreenHealth Home website
Serves: King & Snohomish County
Contact: 425-899-3300

Providence Home Services
Providence Home website
Serves: King County
Contact: 425-525-6800


Home care agencies

CareForce website
Serves: King & Snohomish County
Contact: 425-712-1999


Adult day health centers

Full Life Care
Full Life website
Locations: Seattle, Kent, Everett
Contact: 425-712-1999

The UW Medicine Post-Acute Care Clinical Service is available at most Network partner SNF locations. These UW clinicians will coordinate your care, are available overnight and on weekends for urgent issues, and provide medical care that is tailored to each patient's needs and condition(s),

  • Assisted living communities
  • Subsidized senior housing
  • Continuing care retirement communities (CCRCs)
  • Home and community- based services including adult day services, adult day healthcare, meal programs and senior centers
  • Programs of All inclusive Care for the Elderly (PACE): pace4you.org