Lodi Memorial created a new role to work with patients toward their discharge.
As we developed our Readmission Prevention Program, the case managers and discharge support staff shared roles with nursing staff. We trialed the BOOST Readmission Prevention Program on one med surg floor. We developed a good rhythm getting high-risk patients identified, addressing the high-risk concerns, preparing for discharge, and completing the related paperwork. However, the process fell apart on weekends and holidays, or when staff floated from different floors. We decided that a readmission prevention process needed a specific role assigned to it to ensure it was working consistently.
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.
This role has been very successful for our program. Nurses and case managers can focus on the clinical care of our patients, ensuring that they have the best care possible. Our discharge advocates can take the time to get to know patients and provide the resources and support they need to have a healthy transition. We believe this position is helping to reduce readmissions and build a stronger transition to health care in the community.
Increased patient satisfaction
When planning for readmission prevention, be willing to think creatively and out of the box for ideas that will work at your particular facility.