1. Discharge Advocate Duluth

2. . St. Lukes Discharge Advocate Discharge Advocate position is part of the Case Management Department In February a pilot study was started and completed on Cardiac Unit for Heart failure patients Currently Discharge Advocate is seeing Heart Failure and Pneumonia patients on the medical units and just Heart failure on the Cardiac (Telemetry unit)

3. DA meet with patient within 24 hours of admission (except weekends and holidays. DA reviews patients chart.. DA interviews the patient and family: Introduces role of Discharge advocate. Performs initial review. Assesses the discharge and educational needs of patient Applying Process at St. Lukes

4. . DA discusses plan -of -care and educational plan with Provider, Primary Nurse, Case Manager and Social worker. Collaborates with Pharmacist for review and education of medications

5. . Applying Process at St. Lukes DA provides patient with educational binder which remains in the patients room. Krames handouts are added by different disciplines Patient takes Education binder home upon discharge DA begins patient education on disease process using the teach back process. Patient Education Binder for: Joe Doe

6. Discharge Advocate Communication Education sheet that hangs in patients room for education continuity Chart marked with Discharge Advocate sticker Discharge Advocate

7. Project RED Staff Nurse has primary responsibility of patients discharge. Krames is our source of patient education.

8. Project RED Discharge Advocate performs a post discharge call within 3 days. If needed, coordinates a follow up call with Pharmacist to review medications A second or third phone call may be needed. Patients who are discharged over the weekend will be followed up by the DA on Monday with a phone call,etc.

9. Nursing Home Access to Electronic Medical Records Skilled Nursing Facilities in Duluth – Superior have access to St. Lukes electronic Medical records Admission Coordinator at Skilled Nursing Facility has access to EMR. SNF can only access electronic medical records of a referred patient or current client. Nursing

10. Future Goals: Working with IT to make Discharge Medication list and discharge instructions patient friendly Have other disciplines add to Discharge instructions. Project RED Project in process