What We Tried

We realized we needed someone to own the readmission prevention/transition process so that nurses and case managers could focus on clinical duties and patients would also have a continuous point of contact throughout their stay. The result was the patient discharge advocate role. Previously, the case managers had clinical care coordinators who assisted with discharge preparation. They ordered DME, arranged transfers to lower levels of care and set up Home Health. We revised that position to include a patient/family contact component and developed the Patient Discharge Advocate position. The Patient Discharge Advocates attempt to complete a discharge screening within 48 hours of a patient’s admission. They maintain contact with the patient/family during the hospital stay, and set up discharge needs. They also complete the follow-up phone calls for the high-risk patients to help with their transition to the community setting.

Through trial and error we’ve found that the patient discharge advocate needs to be a very specific type of person. They are not clinical, are not RNs or social workers, and the position does not require a college degree. The ideal candidate is very customer service oriented—someone who really enjoys talking to people and wants to make their recovery as smooth as possible. They also need to be detail-oriented because transitions involve multiple issues. They also need to understand when to bring in a nurse, social worker, or other clinician to address patient questions or needs.