American Family Children's Hospital

In health care, a patient's care is "the story" that gets repeated as they go from one provider or health care environment to another… and another. Unfortunately, the stakes are high if the facts/history of each patient's care across time isn't maintained and 100 percent accurate.


Making sure that every hand off or "transition" in a patient's care is handled with precision and detailed documentation is the charge of the UW Health Transitional Care initiative at UW Health in Madison, Wisconsin.


"A transition of care occurs every time a patient's care changes hands," says Peter Newcomer, MD, physician lead for the Transitions Coordination Team. "From a home setting to the emergency department, from one inpatient unit to another, from a primary care provider to a specialty care provider, from hospital to home or to a post-acute facility - during each of these transitions, miscommunications could result in an adverse event, complication or unnecessary hospitalization."


The interest in improving transitions of care has increased due to Centers for Medicare & Medicaid Services (CMS) payment changes for hospital readmissions. Starting in 2012, hospitals have been penalized for excessive 30-day readmission rates for patients over 65.


UW Health has recognized this as a time of opportunity to improve transitions through education, communication, and collaboration between health care facilities and patients and their families.  Reducing avoidable readmissions will improve quality of care, improve patient and family satisfaction, increase inpatient bed availability, improve utilization of resources, encourage primary care provider (PCP) follow-up visits, and avoid excess costs.


"I'm excited to be working with a team that is committed to ensuring safe and timely transitions for our patients, and has voiced strong support for the success of our initiatives," says Maria Brenny-Fitzpatrick, DNP, RN, FNP-C, GNP-BC, Director of Transitional Care at UW Health. "Given the expertise of everyone involved, I feel confident that as a system, we will be able to improve transitions of care for our patients and families through education, communication and collaboration across the continuum of care."


UW Health Transitional Care Vision


UW Health provides a holistic, patient- and family-centered transition of care experience that seamlessly spans across the continuum of care. Through proactive planning, looking at all aspects of the patient situation and utilizing strong community partnerships, UW Health delivers safe, timely, efficient, effective transitions of care while optimizing the use of resources.