American Family Children's Hospital

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 Forms


Heart Failure and You


The Dane County Care Transitions Community Coalition is working to prevent hospital readmissions due to congestive heart failure. Use the resources below to recognize the symptoms of heart failure, learn how to manage it and know when to call your doctor.


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 or (608) 890-5894.


Dane County Coalition Active Participant Members


None at this time


In-Home Care and Community Resources


ADRC of Wisconsin (Aging & Disability Resource Center)

A Place for Mom


Cairasu Home Care

Care Wisconsin

Comforcare Home Care Services

Comfort Keepers

Community Living Alliance

Golden Heart Senior Care

Heritage Senior Living

Home Instead Senior Care

Independent Living, Inc.

Nazareth Health & Rehabilitation Center

Safe Communities of Madison - Dane County

SAIL (Supporting Active Independent Lives)

Senior Helpers

South Madison Coalition of the Elderly

The City of Fitchburg Senior Center

Village of McFarland Senior Outreach

Visiting Angels Living Assistance Services

Wisconsin Department of Health Services


Home Health, Hospice and Palliative Care


Agrace Hospice and Palliative Care

Heartland Hospice Services

Home Health United

Independent Health Care, Inc.

Interim HealthCare

Marquardt Home Health and Hospice

Midwest Home Care

UW Health Home Health Agency


Other Resources


Meriter Hospital


Pharmacy Society of Wisconsin

Prairie Clinic – Sauk City

Ryan Brothers Ambulance Service

Stoughton Hospital