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Dane County Care Transitions Community Coalition

Dane County Transitions of Care

Recognizing that safe transitions and readmission prevention truly "takes a village," Sue Sanford-Ring (UW Health Vice President of Quality and Patient Safety) and Maria Brenny-Fitzpatrick (Director of Transitions of Care) agreed to invite Dane County stakeholders to an informational meeting in March 2012. At that time, the group decided to join together as a community to assure safe transitions between sites for the people of Dane County, Wisconsin.

 

Invitees included all Dane County hospitals, skilled nursing facilities, home health agencies, home care agencies, pharmacies, and area agencies on aging, hospice, and more. The interest, response and support of the attendees were phenomenal. As a result, the Dane County Care Transitions Community Coalition was formed.

 

The coalition meets monthly as a large group, rotating the host site amongst the member agencies. Since its formation in 2012 there are roughly 50 active members including representation from UW Hospital, Meriter Health and Stoughton Hospital. Monthly meetings include informative sessions presented by the members and large and small group work sessions to work on projects.

 

 The group has had great successes in a number of areas including:

  • Information sharing and networking among members
  • Confidential reviews of readmission and transfer data provided by MetaStar Quality Improvement Organization
  • Development and dissemination of a community emergency medical form patients/families can complete and bring along with them to an Emergency Room
  • Networking and agreement amongst local home health agencies to follow a standardized visit and educational protocol for patients with congestive heart failure
  • Development and dissemination of an informational brochure related to how community home care agencies can help clinicians and families with safe transitions and readmission prevention

 

Coalition Transfer Forms

 

Transitions of Care Emergency Medical Information Form


The purpose of the form is to help assure that important information is given to emergency room/hospital staff at the time of admission.

 

Transitions of Care Emergency Medical Information Form (pdf)

 

Supportive Home Care Services Information Sheet


Supportive care services are an affordable option for patients and families who need additional day-to-day support while they are recovering from sickness, injury or surgery.

 

About Supportive Home Care Services (pdf)

 

Supportive Home Care Services Recovery Assistance - Request for Information (pdf)

 

Coalition Members

 

If you have questions or your agency would like to become a member of the Coalition, please contact Kim Loun at kloun@uwhealth.org or (608) 890-5894.

 

Dane County Coalition Active Participant Members

 

Karmenta Center Skilled Nursing & Rehabilitation

Oakwood Village

 

In-Home Care and Community Resources

 

ADRC of Wisconsin (Aging & Disability Resource Center)

BrightStar

Care Wisconsin

Comforcare Home Care Services

Comfort Keepers

Community Living Alliance

Home Instead Senior Care

Independent Living, Inc.

Madison Parent Care, LLC

Nazareth Health & Rehabilitation Center

Safe Communities of Madison - Dane County

SAIL (Supporting Active Independent Lives)

Senior Helpers

The City of Fitchburg Senior Center

Village of McFarland Senior Outreach

Visiting Angels Living Assistance Services

 

Home Health, Hospice and Palliative Care

 

Agrace Hospice and Palliative Care

Home Health United

Interim HealthCare

Midwest Home Care

SouthernCare

UW Health Home Health Agency

 

Other Resources

 

MetaStar

Pharmacy Society of Wisconsin

Stoughton Hospital

Walgreen's Infusion Services