Wellness Inclusion Nursing

WIN nurses collaborate with providers of care for individuals with disabilities and the frail elderly. This includes families, paid and non-paid caregivers, direct service workers, and health care providers. We focus on restoring, maintaining and promoting maximal health and independence for individuals so they can achieve the best life possible.

The WIN nurses provide individualized consultations with clients, support brokers and agency staff. We work together to identify and connect with community resources appropriate for individual clients including physicians, therapists and other medical specialists, home health services and hospice. WIN provides consultation for:

• Nursing assessments
• Training and health education to residential and vocational support staff and family
• Advocacy and planning for end of life care
• Coordination of hospital stays and discharges to facilitate a smooth and positive process
• Healthy living
• Education and advocacy to medical staff in medical setting
• Working together with teams to support individuals with complex medical needs
• Common Health Problems of Adults with Developmental Disabilities
• Dehydration, not enough fluids
• Constipation, not enough fiber and fluids
• Aspiration, swallowing issues, adaptive feeding, g-tubes
• Epilepsy, seizures
• Weight changes, obesity, weight loss, unhealthy diet
• Orthopedic problems, arthritis, osteoporosis and some genetic syndromes
• Bladder and kidney problems, UTI’s, other complications
• Pain
• GI problems, GERD, vitamin and mineral losses
• Mental health and behavioral problem
• Falls, balance issues, spasticity

Please make a referral to the WIN nurses when the following consultation and training is required.

• WIN consultation for healthy eating, urinary health and bowel programs including procedure preparations such as bowel preps or fasting (NPO protocols)
• WIN consultation for skin assessments, education on healthy skin promotion and prevention of pressure ulcers as well as, wound care assessment, treatment, monitoring and follow-up
• WIN consultation to support teams for individuals with complex medical needs
• WIN consultation as needed for:
  • mobility issues
  • risk assessments for falls and prevention
  • individuals with complex seizure disorders including development of seizure plans of care and training on rectal Diastat usage (diazepam)
• Education and advocacy to medical staff at hospitals, nursing homes and clinics regarding the individualized needs of the developmentally disabled WIN/consultation to individual agencies for development of medical protocols such as bowel and seizure protocols and additional educational materials

The WINProgram will accept referrals for individuals with developmental disabilities participating in the Dane County Supported Living Program. Referrals can be made by Care Managers, Support Brokers, Residential Support Agencies, Dane County Case Managers, families, and even the clients themselves.

Please complete a referral form and send it to us.

It is as simple as calling one of the WIN Nurses and making what is called an inquiry. If you aren’t sure if the individual is appropriate for WIN, or if you just want direction on a specific problem or concern, just call and speak to a WIN Nurse. What types of conditions may warrant a call to WIN?

• Lengthy hospitalization or nursing home stay
• Changing long-term maladaptive behavior
• Exacerbations of health conditions over time
• Multiple hospitalizations
• Complex and/or multiple medical conditions
• Mental status changes including dementia
• Uncontrolled and/or anyone insulin dependent should be referred to /WIN/
• Non-healing wounds/sores
• Severe Constipation
• Rapid changes in weight (plus or minus)
• Recurrent urinary problems
• Recurrent respiratory problems

WIN nurses must manage multiple complex cases at once. This involves learning about a client’s past history, and current information related to their physical and psychological well-being. It means building relationships with a client’s residential and vocational team, their support broker and primary care physician as well as with medical specialists when possible. How quickly a client is served depends on the urgency (see Criteria) and the WIN nurses schedules.

On the last page of the WIN Referral form there is a direction stating:

Please check if action on this referral is:
• Urgent (within 2 -3 days)
• Next week OK
• Within 1 month

Please check the most appropriate action time you are requesting for a WIN nurse to respond, the case will be triaged and the referral will be responded to as soon as possible. There have been times that a WIN nurse has responded in person within the same day that an urgent request has been received and triaged.

• Soon to be discharged to community from CWC, Mendota, Winnebago, Southern or Northern Center
• Admission to or acute change in status to an acute care hospital (St. Mary’s, Meriter, UW-Hospital and Select Specialty) with a complicated  (i.e. ICU) or possible lengthy stay including need for assistance with discharge planning needs
• Nursing home admissions , possible lengthy stays and need for discharge planning
• Hospice Care admissions or sudden change in status requiring consultation
• Weak team support (i.e. recent turnover of staff, challenging team dynamics, poor communication and/or follow thru, etc.)
• Physician lacking of awareness of client’s individualized needs
• Complexity of multiple diagnoses
• New diagnosis or condition with which the team is unfamiliar

In addition to training residential and vocational support staff on various issues associated with individual clients, the WIN nurses time is also spent developing and regularly training participants at the Waisman Outreach Center on a number of medically related topics. Theseare available on the Waisman Community Outreach Wisconsin (COW) website at: