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Transitional careA smooth adjustment to home

Helping patients and families make a smooth transition between health care settings and home.

Overview

Here for you every step of the way

UW Health transitional care makes sure every handoff or "transition" in a patient's care is handled with precision and detailed documentation.

More about transitions of care

  • A transition of care occurs every time a patient's care changes hands 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.

  • 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.

Learn about how UW Health manages transitions 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.

Watch this video to learn more about the importance of transitional care

Meet our team

A team focused on your well-being

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

Director

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.

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

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.

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 manager

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

Bridges newsletter

Topics relevant to you

Find useful information in our twice-yearly newsletter that deals with topics related to transitional care.



Issues

Winter 2020 Bridges Newsletter (Volume 10, Issue 1)

Inside this issue:

  • UW Health provides house calls to home bound older adults through a new program - Home Based Primary Care (HBPC)

  • How to Recognize a Dementia Patient in Health Link and Where to Find Their Patient Specific Dementia Information (PSDI)

  • UW Health Welcomes Dementia Friendly Training

  • Acute Care for Elders (ACE) Interdisciplinary Team

  • Patient Care After Transitional Care

Summer 2019 Bridges Newsletter (Volume 9, Issue 2)

Inside this issue:

  • Implementation of a System-Wide Awareness and Educational Campaign to Prevent Readmissions

  • Readmission Review Team: Expanding the Continuum of Care

  • Remarkable Teamwork Saves Patient from Readmission

  • Sometimes it Takes a Village (or a nice neighbor)

  • Patient Engagement Using Teach Back and Plain Language

  • Program Evaluation: Assessing the Relationship Between Medication Discrepancies and Readmissions within the UW Health Medical Transitional Care Program

  • What Does a Good After Hospital Care Plan Look Like?

  • What's it Like to Shadow a Transitional Care Case Manager?

  • Highlights: Presentations/Awards/Recognition

Winter 2019 Bridges Newsletter (Volume 9, Issue 1)

Inside this issue:

  • The Conversation – Understanding the "why" Behind the Readmission

  • Remarkable Surgical Care by Everyone on the Patient's Team!

  • Early Identification of Dehydration with Orthostatic Blood Pressure Monitoring in High Output Ileostomy Patients

  • The Hearing Aid Fairy: A Low-Cost, High Impact Intervention

  • Readmission Risk Screening Tool Evaluation

  • ACE Awarded Grant for "Tinkering" Projects - Again!

  • Sending a Consistent Message When Scheduling Appts After Hospitalization

  • Transitional Care/ACE 2018 Awards and Presentations

Coalitions

A community of help

The UW Health Transitional Care program participates in the following coalitions:

ALF Acute Care Coalition

The state of Wisconsin has more than 3,600 Assisted Livings Facilities (ALFs) which care for nearly 52,500 residents. University Hospital serves as the acute health care setting for more than 1,100 of these residents yearly. The majority of these residents are aged, frail and disabled with complex health care needs.

Recognizing the need to address communication surrounding transitions across the continuum of care and ALF staff education, in October 2014 UW Health's Director of Transitional Care Maria Brenny-Fitzpatrick, DNP, RN, FNP-C, GNP-BC, established the University Hospital Acute-Care Assisted Living Care Coalition.

Membership of the coalition is comprised of 20-30 ALFs most from the surrounding area but some as far away as 200 miles. Outputs of the meetings include such things as the development of a telephone hotline to be used by the ALFs to coordinated care with inpatient staff, provision of telephone numbers for the emergency department, respiratory therapy, nutrition and pharmacy departments; and multiple educational sessions surrounding clinical issues to improve the clinical care of the ALF residents. One of the many highlights of the coalition meetings is the sharing of best practices and evidence-based transition tools. The coalition is currently working with the Wisconsin Division of Quality Assurance to develop a Facility Capabilities Tool, which will alert hospital staff to the clinical capabilities of each facility.

The coalition meets as a group working on improving communication between sites, improving ALF staff early recognition of patient change in health condition and reducing avoidable readmissions by implementing several Interventions to Reduce Acute Care Transfers for Assisted Living (INTERACT) tools. 

The coalition has been involved in several initiatives to date:

Mission statement

The mission of the UW Acute Care-Assisted Living (AL) Transitions Coalition is to improve the quality of care for AL residents who transition among health care settings. This will happen through a comprehensive coalition effort including improving cross-setting communication, care coordination, the use of standardized communication and assessment tools and the education of staff in both settings.

If you have questions or your agency would like to become a member of the coalition, please contact Kim Loun at kloun@uwhealth.org or (608) 828-8542.

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 coalition meets quarterly as a large group, rotating the host site amongst the member agencies. Since its formation in 2012 there are roughly 70 active agencies including representation from UW Hospital, UnityPoint Health - Meriter, Stoughton Hospital, Aging and Disability Resource Center, local pharmacies and ambulance services and many others. Meetings include informative sessions presented by the members and 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

  • 2016 focus included working with MetaStar on the prevention of adverse drug events (ADE)

  • Development of resource guides to assist agency members with referrals for caregiving, transportation, home safety, medication management and nutrition

Community services resource guides

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.

Preventing Adverse Drug Events (ADE)

The Preventing Adverse Drug Events initiative is a way we, as a community, can help prevent ADEs such as accidental poisonings, falls, overdoses and allergic reactions due to taking expired, wrong or too much of a medication.

With the help of 25 coalition agencies who distributed bags between November 2016 and April 2017, and 11 local police departments who counted and weighed each bag at their Medication DropBox, the result was 50 pounds of medication disposed of by people in the community in just six months.

If you have questions or your agency would like to become a member of the coalition please contact Kim Loun at kloun@uwhealth.org or (608) 828-8542.

SNF Acute Care Coalition

In July 2012, the University of Wisconsin Hospital Transitional Care Department began bringing together representatives of skilled nursing facilities (SNF) to address the needs of the facilities and the hospital in regards to hospital readmission, transitions in care, improving communication between sites and shared educational needs. In 2015, UW Hospital and UnityPoint Health - Meriter Hospital staff began collaborating and co-hosting the coalition meetings.

The coalition includes over 20 skilled nursing facilities and community organizations with the potential to grow to a network of over 50 skilled nursing facilities from Dane County. The goals of the coalition's work are designed to strengthen relationships and communication between SNFs and area hospitals, standardize clinical treatment pathways and communication methods, and provide a forum for open discussion between sites.

Mission statement

The mission of the Skilled Nursing Facility Acute Care Coalition is to address the needs of acute care facilities and SNFs with emphasis upon the reduction of hospital readmissions, improve transitions in care, enhance communication and promote education.

Coalition members have been instrumental in developing what is known as the Blue Transfer Envelope Process that is being used by SNFs and ALFs in the community.

In addition, the members created a "What to Expect When Going to a Skilled Nursing Facility" handout to provide to patients transferring from the hospital to a SNF. The handout is available in both English and Spanish.

If you have questions or your agency would like to become a member of the coalition, please contact Kim Loun at kloun@uwhealth.org or (608) 828-8542.