American Family Children's Hospital

UW Transitional Care Team

Learn how the members of your UW Health Transitional Care team help patients and family members by reading about the team members' roles below:


Registered Nurse


The Registered Nurse (RN) partners with patients who have high risk and complex medical conditions and helps to coordinate the patient's care as he/she discharges from the hospital. The RN first meets the patient and family in the hospital and then follows them by phone over the next 30 days. The RN works with the patient and health care teams to assure that patient's needs and goals are clearly communicated to all involved with the care. Each patient is partnered with a specially trained RN who serves as their resources person over the 30 days after discharge from hospital.


Clinical Social Worker

UW Health Transitional Care Team; Madison, Wisconsin


The Clinical Social Worker serves as a bridge between inpatient, outpatient and community, assessing and addressing the patient's physical and social needs. The social worker focuses on improving the discharge and transition process by working to understand the patient's needs, activating current service providers and connecting patients and families to community resources. With an emphasis on patient goals, the social worker is available to provide support to caregivers, complete basic cognitive testing, discuss advance directives and do home visits when appropriate. 


Nurse Practitioner


The Nurse Practitioner (NP) is an advanced practice registered nurse who through advanced education has increased decision-making skills and clinical skills and is able to order labs, tests, medications and referrals needed. The Transitional Care NP meets patients while hospitalized, reviews medical history, functional and cognitive status, and performs a physical exam prior to discharge. After discharge, the NP may visit the patient in their home or assisted living facility to review their hospital discharge plan, perform a follow up assessment, home safety evaluation and review of medications. All findings are communicated back to the primary care provider.


Medical Director


The Medical Director works with the other members of the transitional care team to ensure the healthcare providers provide high-quality service to our patients. In addition to collaborating with the team to develop standards of practice, the medical director addresses medical issues that arise in our most complex patients who have recently discharged home. 


Program Specialist


The Program Specialist is responsible for working with the director and interdisciplinary teams to coordinate system wide effort to improve transitions of care for patients. The program specialist serves as a nursing staff educator and consultant on issues related to transitions of care. The program specialist analyzes transitional care practices and evaluates patient outcomes to ensure practice standards and clinical programming meet excellence in patient outcomes.




The Director is accountable for developing, coordinating and evaluating transitional care initiatives across the UW Health System. The director assures coordination of efforts and assists with aligning strategic priorities in order to support patient-centered initiatives that promote quality of care transitions across healthcare settings and to avoid duplication of programs, staff and services. The director implements and evaluates transitional care initiatives across the healthcare continuum and makes recommendations for improvement based upon evidence-based research and protocols.