Transitional care: A smooth adjustment to home

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.

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.

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