American Family Children's Hospital

Dane County Care Transitions Community Coalition

Dane County Transitions of Care

UW Health Transitional Care works with Dane County hospitals, skilled nursing facilities, home health agencies, home care agencies, pharmacies, and area agencies on aging, hospices to assure safe transitions between sites for the people of Dane County.


The Dane County Care Transitions Community Coalition meets every other month as a large group, rotating the host site among member agencies. Since its formation in 2012 there are roughly 50 active members including representation from UW Hospital, Meriter Health and Stoughton Hospital. 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


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.

Coalition Members


If you have questions, would like to come to one of our meetings, or your agency would like to become a member of the coalition please contact Kim Loun at (608) 828-8542 or


Assisted Living and Skilled Nursing Facilities

In-Home Care and Community Resources

Home Health, Hospice and Palliative Care

Other Resources