Patient Care,Patient Services,

Departments & Programs,UW Hospital and Clinics

Coordinated Care

Coordinated Care - Departments & Programs, UW Hospital and Clinics

The Department of Coordinated Care collaborates with physicians and all care giving disciplines to coordinate the care of patients and families throughout illness and across the continuum of care settings, utilizing resources to maximize the benefit to patients in a cost-effective manner. Outcomes managers and case managers are accountable for these functions in collaboration with social workers and with the assistance of the Coordinated Care Resource Center specialists.


Case management services are provided to all inpatients, both adult and pediatric. Case management services include the initial assessment by a case manager within 24-48 hours of admission. The case manager assesses the patient, assures that a plan of care and target LOS are in place, and along with the multidisciplinary team initiates the discharge planning process. 

In addition to coordinating care and monitoring clinical outcomes during hospitalization, case managers assure that an appropriate discharge plan is in place. When a case manager or outcomes manager is unavailable, the care team leader and staff RN are accountable for assuring that the plan of care and appropriate discharge plan are in place. Referral to a case manager/outcomes managers for follow-up is required if there are any concerns or questions following discharge. 


Case managers and outcomes managers are available Monday thru Friday from 8am-5pm. A designated on-call social worker is available from 4:30pm-8am on weekdays and 4:30pm Friday to 8am Monday. A triage social worker is also available Monday-Friday, 8am-4:30pm, to assist with concerns/issues that need additional support.


Coordinated Care protocols after 5pm and weekends.

Helpful hints for security discharge.

Please call the service based Case Manager with questions regarding discharge. They should decide if the inmate needs to change location/Prisons. If the MD’s decide the inmate needs 24 hour nursing care the inmates need to go to Dodge Infirmary. It is the only 24 hour nursing facility.

Primary Nurses call the Correctional Institutions and give a report.


Need to send a packet of information to the Correctional Institutions.


Many times the Facility likes the information faxed to them, but they will ask.

After the primary nurse speaks with the Correctional Facility- Let the Pharmacist know what kind of meds that you need to have filled for discharge. Pharmacist will send a script to outpatient Pharmacy to fill. Then the Pharmacist will get the filled script and give it to the officers.

Primary Nurses let the Security Sergeant know that the paperwork is complete and whether or not there are meds to be sent to the Correctional Facility. The Security Sergeant will set up transportation for the inmate. The Primary nurse will contact security officers if an ambulance or wheelchair van is needed. The Officers should give an approximate time of arrival for the ride.

How to arrange CPM.

This procedure applies to UW Hospital patients from Dane County and ring counties:

  1. The patient will go home with the hospital (CS) issued machine that s/he has been using on the unit.
  2. Ortho will notify Michelle Sebastian (608-203-2216) at UW Home Care of the discharge.
  3. Tech will make a follow-up home visit to have pertinent paper work signed and to collect the TBR number from the machine.
  4. They will notify UHS of the machines transfer and begin billing UW Home Care Services instead of Central Supply.
  5. UHS will deliver a replacement to the hospital.


How to arrange for ACE team consults. 


To offer patients 65 and older a proactive and comprehensive interdisciplinary team geriatric evaluation directed toward preserving function and independence and preventing the hazards of hospitalization. 


How to Obtain an Ace Consult

  1. Physician orders an ACE consult, preferably on admission (or as early as possible after admission)
  2. Referral triggers a comprehensive interdisciplinary review of patient by ACE team 

How to arrange for durable medical equipment (DME). 

Use the procedure below to arrange for durable medical equipment (DME):

  1. You must first check with the patient and insurance company for preferred provider(s) and benefits.
  2. Call the DME provider to order the requested and appropriate equipment. You will nee the ordering doctor's name.
  3. Medicare will usually pay up to 80 percent and the patient is responsible for the remaining 20 percent.
  4. Possible DME providers in the area:
    • UW Health Home Care: (608) 203-2273
    • Home Health United: (608) 242-1516
    • Apria: (608) 221-5480
    • Meriter Home Health: (608) 327-3700
    • Walgreens: (608) 256-1212

How to arrange for home health care.

Use the procedure below to arrange for home health care:

  1. Check with patient and the insurance company regarding preferred provider(s) and benefits. 
  2. Medicare and private insurance companies generally use similar criteria.  These include:
    • Meet "homebound" definition
    • Be under the care of a doctor
    • Requires skilled nursing, PT or speech therapy
    • Needs service that is "medically necessary"
  3. Print a list of home health agencies in the patient's city/county.
  4. Call the preferred home health agency and give report on the patient's needs at discharge.
  5. Complete the PPOC and have it faxed to the agency the day of discharge. During the week, Continuity of Care Office, E5/620 is open weekdays 8am to 5pm and Saturdays 10am to 2pm. 
  6. UW Health has its own home health agency called UW Home Health.  Their telephone number is (608) 262-8116.
  7. Nurse liaisons are located in the hospital and can be reached at (608) 262-2654. Service area includes Dane County and surrounding areas. 

How to arrange for home infusion therapy.

Use the procedure below to arrange home infusion therapy:

  1. Contact your Chartwell representative for home therapies:
    • IV
    • SQ
    • IM
    • Enteral
    • Other services they provide: antibiotics, pain management, TNA, enteral nutrition, chemotherapy, blood products, hydration, anticoagulation therapy, growth hormone, gamma globulin
  2. Chartwell will coordinate all details of the patient's home therapy, including referral to a home health agency if needed and insurance verification.


How to arrange for Meals on Wheels.

Use the procedure below to arrange Meals on Wheels: 

Home-delivered meals are a community service for people who are homebound and unable to prepare a meal for themselves and other family members. Patients are responsible for the costs, but several agencies are able to charge using a sliding scale fee. 

If the patient lives in the area a referral can be made to:

When the patient lives outside of the local area other agencies can help us find the appropriate meal program. Calling a home health agency, nursing home or hospital can lead us in the right direction.

How to arrange for medical transport.

Use the procedure below to arrange for medical transport. 

Medical transport is used to transfer a patient who needs a wheelchair of stretcher due to their medical or functional condition. The primary nurse, with patient input, should assess the method (wheelchair, stretcher, cardiac chair, etc.) required.

  1. Consult with the patient and family to inquire about prior arrangements.
  2. If there is a need to arrange transport:
    • Refer to the transportation list of medical transport agencies.
    • Remember to ask your patient if they have a preference or choice of transportation company.
  3. The drivers are generally not medically trained and typically travel alone.
  4. This form of transportation is generally not covered by private insurance, i.e., Unity, Dean.
  5. Remind the patient that they will be responsible for cost not absorbed by insurance. It is also helpful if you can give the family an estimate of the cost.
  6. Medical Assistance may cover medical transport.
  7. The SMV form must be completed and given to the driver.
  8. Order oxygen as required.

How to arrange for patient transportation.

Bus Information 

If a patient is having difficulty securing transportation to their home the hospital does have provisions for bus travel. Please call Patient Relations at (608) 263-8009 for travel information and Bus voucher information for specific patients.

Between 8am and 4:30pm contact your social worker or case manager. They can speak with patient relations. After hours, please call the nurse supervisor for arrangements. On weekends, page the case manager on call from 8:00-4:30pm. After hours, call the nurse supervisor. 

Cab Vouchers 

If a patient is having difficulty securing transportation to their local home the hospital does have provisions for cab vouchers. During work hours please contact your social worker or case manager and they will assist with this process. After hours, contact the nurse supervisor. page the case manager on call from 8:00-4:30pm. After hours, call the nurse supervisor.

How to arrange for personal response systems.


How to order home or transport oxygen.

Use the procedure below to order home or transport oxygen:

  1. The patient's pulse ox at rest or during ambulation on room air must be 88 percent or less. This must be documented in the chart within 48 hours of discharge.
  2. With this information and a qualifying illness (the respiratory therapist can help with this) you can call UW Home Care services at (608) 203-2273.
  3. Have the patient's name, medical record number, anticipated discharge date and liter flow available.
  4. The intake respiratory therapist will check with the patient and the insurance company regarding preferred provider.
  5. UW Home Care will help with the arrangement even if they are not the provider. They will provide the transport oxygen or remind the appropriate agency to do the same.

    Special note: Patients with Medicare going home with hospice do not require qualifying oxygen sats.

How to refer to Hospice Care, Inc.


*Patients with Medicare can be reimbursed for medications related to management of terminal diagnosis when enrolled in hospice program. To qualify, prescriptions must be filled on or after the day that patient enrolls in hospice. 

If the patient/family fill prescriptions here or on the way home from the hospital, they need to save receipts and give to HCI when enrolling later that day. After enrolled with HCI, families pick up meds and pay $5 co-pay, and pharmacy will bill Hospice Care, Inc. for the balance.



Certification Forms for Home Care Services


KCI Prescription and Letter of Medical Necessity for Restart of KCI VAC Therapy System

Restart LMN for V.A.C.

VAC Ready HHAs 4/2010

VAC Therapy Fast Form

Important Message (IM)

Insurance Company Issues

Insurance Company Issue Tracking Form

Medicaid Plans/Coverage Details within Health Link


Medicare Part D PDP Organizations 

Outside Organizations

GHC Care Management Contact List 


Home Oxygen-Criteria for Medicare 

Preadmission Screen and Resident Review (PASAAR) 

Prescription for Ambulance Service

Regional Resources

Social Work

Advanced Directives

Social Work Manual


Social Work Services