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.

Our providers

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.