Transitional Care Program: A Year in Review

By Kristine Leahy-Gross, MSN, RN, CPHQ, and Peggy Troller, MS, RN


Transitional Care Program nurse, Peggy Troller, MS, RN, discusses discharge goals with a patient to ensure coordination of care before, during and after the hospital stay. Transitions of care occur each time a patient moves from one health care provider or health setting to another. These care transitions are the highest risk phases of care for patients and may result in preventable readmissions. In fact, nearly one in five Medicare patients readmits to the hospital within 30 days.¹ Transitional care programs have been shown to improve outcomes by bridging care between providers and health care settings.


UW Hospital and Clinics implemented an evidence-based Transitional Care Program in 2013 that utilizes a low-resource, telephone-based model designed to improve care transitions of patients and reduce 30-day re-hospitalizations. Patients enrolled in the Transitional Care Program are at least 65 years old, have a working telephone and are discharging home or to an assisted-living facility. Patients must be from general medicine, hospitalist, cardiology and family medicine services or referred by the Acute Care for Elders (ACE) team if they are coming from surgical services.


The program consists of registered nurses, a nurse practitioner (NP), and a social worker who identify patients at risk for rehospitalization. Patients enrolled in the program receive postdischarge follow-up phone calls for 30 days and may receive NP home visits. The Transitional Care Program staff work closely with inpatient nurses, coordinated care staff and medical teams to determine discharge goals and assure coordination of care.


After discharge, the team works with the patient and family, caregivers, primary care provider, home health and other providers as needed to coordinate care.




In its first year, the Transitional Care Program enrolled 915 patients. There was an average of three calls per patient (total of 2,524 calls), and a total of 859 calls to providers, nurses, social workers and other clinical supports. During the postdischarge telephone medication reconciliation, 36 percent of patients had at least one medication discrepancy. Nearly one fourth of medication discrepancies were with cardiovascular medications.


Risk criteria and consults assist the transitional care nurses in prioritizing enrollment in the program. The enrollment risk criteria are: lives alone, hospitalized in previous 12 months and documentation of dementia, delirium or other cognitive issues. More than 53 percent of patients enrolled in the program were hospitalized in the previous 12 months.


¹ Jencks, S.F., Williams, M.V., Coleman, E.A. (2009). Rehospitalizations among patients in the Medicare fee-for-service program. The New England Journal of Medicine, 360(14), 1418-1428.