Patient Care,Quality,

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UW Health Transitions in Care Program

UW Health Transitions in Care Program - Departments & Programs, Programs and Initiatives


Transitions in Care Program Brochure Cover UW Health Transitions in 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.

Transitional Care support exists for high risk medical and surgical patients who are discharging from the University and TAC hospitals. Patients are followed telephonically by trained RN’s for 30+ days post hospital discharge. Utilization of transitional care services will result in improved quality of care, improved patient and family satisfaction, increased utilization of resources, decreased costs, and improved post discharge PCP and Specialty appointment adherence.

UW Health Transitions in Care Goals

  1. Timely and direct support of patient/family self-care activities post- discharge
  2. Improved communication and coordination among health professionals involved in patient care; including PCP, Specialty, Home Health and Community services
  3. Medication Reconciliation across the continuum
  4. Patient/family education and engagement
  5. Decrease in avoidable readmissions and ED usage
  6. Referral to appropriate longitudinal case management resources as needed

Transitional Care (uwhealth.org)


What is C-TraC?

UWHC officially rolled-out the Coordinated Transitional Care (C-TraC) model in July, 2013. The C-TraC program, designed by Dr. Amy Kind was originally designed to improve care transitions and outcomes among veterans with high-risk conditions. Consults for a Transitional Care screening can be ordered through Health Link.

Does my patient qualify for a Transitional Care consult?

The Medical and Surgical Transitional Care Programs are designed to target vulnerable patients who are at a high-risk for negative post-hospital outcomes. Core program enrollment criteria include patients discharged to home or assisted living facility and have a functional telephone.

Additionally, program enrollment is prioritized based on the following patient conditions: lives alone, inadequate supports, caregiver not identified, hospitalized in preceding 12 months, documentation of dementia, delirium or other cognitive dysfunction, recommended support declined (e.g. home health) or clinical judgment.

Medical Transitional Care Program Core Enrollment Criteria

Surgical Transitional Care Program Core Enrollment Criteria

Post-operative patients on the General Surgery (blue or orange service) or Emergency General Surgery (red service) with the following:

Program enrollment exclusions

Excludes patients with primary diagnosis of:

Excludes patients:

How do I place a consult for Transitional Care services?

  1. Open “Inpatient Chart”
  2. Click on “Manage Orders” and search “transitional” in the “place new order” section
  3. Enter info, click “accept”
  4. Consult forwards and prints in the Transitional Care office

What is the Surgical Transitional Care (STC) program?

The STC program consists of two registered nurses and a social worker who identify patients at risk for rehospitalization. Patients enrolled in the STC program receive follow-up phone calls for 3-6 weeks post-discharge utilizing the Coordinated-Transitional Care model.

Emphasis is placed upon patient-led medication reconciliation, patient education with identification of 3 red flags, post-discharge follow-up with surgeon and/or PCP, and addressing a cadre of other patient issues. The program staff works closely with providers, ambulatory and inpatient nurses, coordinated care staff and other clinical supports to determine discharge goals and assure coordination of care. After discharge, the team works with the patient and family, caregivers, medical team (MD, NP, PA), home health and other providers as needed to coordinate care. 


Bridges Newsletters

Find out what’s been happening in Transitional Care by reading the Bridges Newsletter

Bridges Newsletter Story Ideas?

Contact Kim Loun at (608) 828-8542 or kloun@uwhealth.org.

Related Resources

Transitional Care Posters 2016

Transitional Care Posters 2014


Population Health

UW Health Bundled Care