American Family Children's Hospital

About the UW Transitional Care Program

Related Information

Transitional Care Team


The University of Wisconsin Transitional Care program's goal is to assist patients coping with multiple conditions to successfully transition from University 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.


The Transition Process

  • 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.
  • After meeting the patient and family in the hospital, one of registered nurses will call the patient 24 to 48 hours after discharge and then maintain contact throughout 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.
  • The patient's primary care provider is kept informed of the progress every step of the way.

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
  • Prevents avoidable hospital readmissions

Patient Eligibility

  • The Medical and Surgical Transitional Care Programs are designed to target vulnerable patients who are at a high-risk for negative post-hospital outcomes.
  • Core program enrollment criteria include patients discharged to non-institutional community settings, such as home or assisted living facilities and a working telephone.
  • Program enrollment exclusions consist of patients with primary diagnosis of alcohol and drug abuse, psychiatric and/or a scheduled cardiac procedure admits. Additional exclusion are patients with a managed care provider such as Care WI, Central Wisconsin Center, UW Health's Complex Case Management, patients with care manager such as Transplant Coordinator, CHF Coordinator, Wisconsin Dialysis Incorporated, active chemotherapy, hospice/palliative care, prisoners and outpatient short stay status patients
  • Program enrollment is prioritized based upon the following patient conditions: lives alone, inadequate supports, caregiver not identified, hospitalized in preceding 12 months, documentation of dementia, delirium or other cognitive dysfunction, recommended support declined (e.g. home health) or clinical judgment.

Medical Transitional Care Program (MTCP) Core Enrollment Criteria


The MTCP consists of three registered nurses, a nurse practitioner and a social worker who, with the interdisciplinary health care team, identify hospitalized patients meeting criteria. The needs of the patient determine whether a home visit is needed and the frequency of follow up telephone calls.


Core enrollment criteria include the following:

  • Patients on the general medicine, hospitalist, cardiology and family medicine services
  • ACE consult patient referred by ACE team

Surgical Transitional Care Program (STCP)


The STCP consists of two registered nurses and a social worker who identify patients at risk for rehospitalization. The program staff works closely with providers, ambulatory and inpatient nurses, coordinated care staff and other clinical supports to determine discharge goals and assure coordination of care. After discharge, the team works with the patient and family, caregivers, medical team (MD, NP, PA), home health and other providers as needed to coordinate care.


Core enrollment criteria include post-operative patients on the General Surgery or Emergency General Surgery services with the following:

  • Pancreatectomy
  • Gastrectomy
  • Emergent small bowel resection
  • Bowel perforation
  • New ostomy patient
  • Drain upon discharge
  • Pre-discharge infection or any other major complication