The Discharge Advocate’s (DA) role at HRMC is to improve the discharge process and reduce preventable readmissions by providing patient centered education and improving continuity of care. The Discharge Advocate will focus on high risk discharges including patients in the following categories: readmission in last 30 days, new/chronic diagnosis of heart disease, COPD, diabetes, asthma, obesity, cancer and other chronic or complex conditions.
MAJOR TASKS DUTIES AND RESPONSIBILITIES:
The Discharge Advocate (DA) will work with the multidisciplinary hospital team consisting of the patient’s primary nurse, hospitalist, case manager, social worker, and adjunct therapies to coordinate care.
The Discharge Advocate (DA) will educate patients about their disease processes. The DA will determine the diagnosis by review of the medial record and discussion with the hospital team. Among the tools the DA will use is the After Hospital Care Plan. With the aid of the After Hospital Care Plan, a customized description of the patient’s principle diagnosis and other secondary diagnoses will be given to the patient for easy understanding and reference.
The Discharge Advocate (DA) is responsible for educating patients about their medication. Accurate medication reconciliation is an important part of this process. The DA will include all pre-hospital medications, discontinued medications and new medications in the detailed medication teaching part of the After Hospital Care Plan.
The Discharge Advocate (DA) will use evidence based practice to determine if patient’s diagnosis plan meets national guidelines. The DA with help from the hospital team will reconcile the any discrepancies in the patients discharge plan. The DA will assist in measuring data to support program goals. The DA will use data analysis for planning and improving by using PDCA to help reduce readmissions.
The Discharge Advocate (DA) will organize post-discharge services. The DA will make follow-up appointments with physicians, organize adjunct therapies (home health, physical therapy, cardiac rehab, DME, etc.), and arrange any pending tests or studies to be reported to the follow- up physician. The DA will work with the patient, family and hospital team to arrange post-discharge services.
The Discharge Advocate (DA) will provide the patient with a written discharge plan at the time of discharge. One tool the DA will use is the After Hospital Care Plan. The After Hospital Care Plan will have information including diagnosis, medication, diet, activity, follow-up appointments, and adjunct therapies.
The Discharge Advocate (DA) will provide telephone reinforcement of the discharge plan and problem solving 2-3 days after discharge.
Required: Graduate from an accredited school or college of nursing.
Required: Current Texas Registered Nurse licensure.
Required: Current CPR certification
Required: two years in acute care nursing position.
Demonstrates knowledge of quality and performance improvement principals
Effective written and verbal communication and negotiating skills with all levels of internal and external customers.
Must demonstrate positive relationship building with patients, peers, medical staff and other members of the clinical care team.
Must demonstrate the ability to effectively implement changes