American Family Children's Hospital

About the UW Transitional Care Program

The University of Wisconsin Transitional Care program's goal is to assist patients coping with multiple conditions to successfully transition from University of Wisconsin Hospital back to their home. The program is designed to assure open, accurate communication and collaboration between the patient and all involved health care providers.


After meeting the patient and family in the hospital, one of the specially trained Registered Nurses will call the patient 24-48 hours after discharge and then maintain contact throughout the next 30 days. The patient's primary care provider is kept informed of the progress every step of the way.


The UW Transitional Care program is modeled after Madison physician and researcher Dr. Amy Kind's Coordinated Transitions of Care (C-TraC) program. As part of the program, the Transitional Care RN meets the patient and family shortly before the patient leaves the hospital. During this visit, discharge instructions are reviewed, and a discharge plan of care is developed with the patient and family. The plan includes three "red flags," which are signs or symptoms to be watched for at home. Also during this visit, a telephone call with the patient is scheduled to occur within the next 24-48 hours. At this time, the nurse reviews medications with the patient and discusses any concerns or questions. The RN will stay in contact with the patient and family over the next 30 days.


Patients who have a more complicated recovery plan may also receive a home visit from a Transitional Care Nurse Practitioner. At this home visit, the Nurse Practitioner will perform a physical exam, review medications, and answer any questions the patient may have. All findings are communicated to the patient's primary care provider so that the patient's care remains coordinated between all involved.

Depending on the needs of the patient, the Transitional Care staff may suggest additional home support, arrange for additional telephone calls or suggest other community resources to help.


"I have been able to witness firsthand the benefits that Transitional Care provides for vulnerable elderly patients as they discharge from the hospital," says Medical Director Elizabeth Chapman, MD, "including the promotion of safety, empowerment of patients in disease self-management, prevention of readmissions, and – most importantly – improvement in patient satisfaction."


The Benefits of Transitional Care

  • Allows patients to better understand and follow discharge instructions
  • Helps patients obtain a better understanding of their medications and how to manage them
  • Assists patients in communicating with their primary care providers about concerns or changes in condition

Transitional Care supports ACO (pdf)