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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - January 2012

Welcome to the RARE Report

In August 2011, Operating Partners—the Institute for Clinical Systems Improvement, Minnesota Hospital Association and Stratis Health—launched the RARE (Reducing Avoidable Readmissions Effectively) Campaign. Since then, 76 hospitals and 62 Supporting and Community Partners have joined the campaign and are working together to prevent 4,000 avoidable readmissions by the end of 2012. The monthly RARE Report is designed to support that effort. Its primary aims are to:

  1. Keep staff in participating hospitals and partner organizations abreast of campaign news, events, and progress toward goals.
  2. Demonstrate how hospitals and Community Partners can work better together across the continuum of care after hospital discharge to prevent avoidable readmissions.
  3. Share success stories and other best practices to accelerate progress.
  4. Provide tools and tips to keep staffs motivated, engaged and implementing changes to achieve their goals.

In This Issue

  1. This Is Your Publication. Tell Us How to Make It Most Valuable
  2. News, Web Updates, and Upcoming Events
  3. Hospital Executives Tell How They're Launching RARE Activities
  4. Community Partners Corner: 5 Things Hospitals Can Do Better In Working With Long-Term Care Facilities
  5. How 2 Hospitals Improved Care Transitions Communication
  6. RARE Idea Contest - Earn from What You Learn
  7. Helpful Links Concerning Readmissions

This Is Your Publication

To be of greatest benefit, the RARE Report needs to contain content most useful to you. Give us your thoughts on this first issue, and provide us with other ideas you want addressed in future issues. Send ideas to Jim Trevis.

News, Web Updates, and Upcoming Events

Current Status

  • 76 participating hospitals; 62 Community Partners
  • Hospitals participating in the RARE Campaign will each receive quarterly Potentially Preventable Readmissions (PPR) data. The report being sent out the end of January will cover the third quarter of 2011. This data will let organizations see how they have progressed against their established reduction goals.

New on the RARE Website

Check out Medications at Transitions and Clinical Handoffs (MATCH) Toolkit for Medication Reconciliation. It incorporates lessons learned by health care facilities that have implemented the MATCH strategies to improve their medication reconciliation processes.


Webinar: Using Potentially Preventable Readmissions (PPR) Data to Monitor Your Progress in Avoidable Readmissions, February 2, 2012, Noon – 1 p.m., CST. This Webinar will help hospitals understand how to use the PPR data provided quarterly by the Minnesota Hospital Association to measure their improvement in preventing avoidable readmissions as part of the RARE Campaign.

Webinar: Involving Patients and Families in Reducing Avoidable Readmissions, February 28, 2012, Noon – 1 p.m., CST. This webinar will help define how to get patients and families actively involved in establishing programs that assist in reducing hospital readmissions. Recruitment, selection of appropriate patient and family participants, training involved, staff responsibilities and more will be covered.

Action Learning Day. April 24, 2012. Details to come. Save the date.

Co-creating a Medication Management System for the Triple Aim Workshop. May 7, 2012. Part of ICSI's 15th Annual Colloquium. Brian Isetts, Health Policy Fellow at the Centers for Medicare & Medicaid Innovation Center, and Professor, College of Pharmacy, University of Minnesota, Isetts will lead a team that will apply an all-teach, all-learn networking style technique, pairing up audience members with individuals who've successfully addressed medication management challenges. More information on medication management

Hospital Executives Tell How They're Launching RARE

In each issue of the RARE Report, we will ask executives from participating hospitals or Community Partners questions about how they are engaged in the campaign. This issue we asked:

"Why is it important for your hospital to participate in the RARE Campaign, and what actions are you taking to focus your staff on reaching your readmission reduction goals?

Keith Okeson, President/CEO, LifeCare Medical Center, Roseau

As part of our mission at LifeCare Medical Center, we feel it is our responsibility to participate in quality initiatives that benefit our patients. The RARE Campaign, with its goal to reduce avoidable readmissions to hospitals, is an initiative that fits our mission. This statewide collaborative effort brings key stakeholders together to collectively share resources and best practices to reduce readmissions with the expected results of reducing cost and improving the care of patients throughout the continuum. We are confident our participation will help to improve the care delivery for our patients.

Our organization has committed the necessary resources to participate in this campaign and we are educating board members, physicians and staff. We are focusing efforts on improving the discharge process by enhancing education and patient follow-up. As part of this effort, we will focus on communication with patients post discharge and teach skills for self-management. Participating in two of the RARE Campaign's learning collaboratives—Project RED and Care Transitions—will enhance our work in these areas.

Dawn Drotar, MD, Hospitalist at Essentia Health St Mary's Medical Center, and physician champion in the ICSI RARE Collaborative.

Obviously, this is the right thing to do for our patients. Every step we take to reduce avoidable hospital readmissions improves care. Our patients and families deserve this, and they and their insurers are watching to make sure we're doing everything to prevent readmissions.

As a member of an ICSI Committee charged with looking at this issue (prior to the broader launched RARE Campaign), I worked with physicians, nurses and other health care providers to identify specific steps hospitals can take to reduce avoidable readmissions. We identified four priority initiatives for several Essentia Health hospitals.

  1. Medication reconciliation: We are educating nurses on the need to carefully verify all medications upon patient admission.
  2. Using the "teach back" method: We are teaching nurses to make sure patients can repeat back all of their discharge instructions. This ensures patients understand what they are being taught and what they need to do after leaving the hospital.
  3. Timely discharge summaries: We are creating a policy that mandates 24-hour turnaround on all summaries.
  4. Follow-up calls to patients: We have been doing this for some time, but are reinforcing its importance as part of this initiative.

signed poster



Many hospitals participating in the RARE Campaign have ordered internal promotional items such as a launch "signing poster." The poster on the right above was signed by hospital and community partner leaders at a state RARE launch event in September to show the broad commitment to the campaign.

Order similar posters or other support materials >




Community Partners Corner: 5 Things Hospitals Can Do Better In Working With Long-Term Care Facilities

By Patti Cullen, President/CEO, Care Providers of Minnesota

Care Providers of Minnesota is a statewide trade association representing providers of older adult services. It is a RARE Campaign Community Partner because of the critical role our members play in successful transitions.

There are many--very individualized--reasons why patients are readmitted into hospitals. Below is a "Top 5 Wish List" that hospitals can address to improve their working relationship with long-term care providers (whether nursing facilities, assisted living or senior housing).

  1. Health records. A fully interoperable health care system is needed to ensure accurate and timely access to the individual's health care information immediately upon admission to a long-term care setting—whether a nursing facility or an assisted living setting. Unfortunately, we are a long way from that ultimate goal. In the interim, it is important to discharge patients with simple, accurate and timely paperwork; there are evolving forms and checklists to accomplish this.
  2. Timing of discharge. While improvements are being made, we can't stress enough that a hurried hospital discharge on a late Friday afternoon to a setting that may not have key staff available to receive the admission is a recipe for an unnecessary readmission. This is especially true of the elderly, who may or may not have some cognitive issues, and for whom all of these moves increase their confusion.
  3. Regulatory trepidation. Long-term care providers serve a frail population—seniors often in declining health, and/or with progressive co-morbidities. Hundreds of state and federal regulations cast a shadow over clinical instincts—as a result, fear of a citation causes many clinical nursing staff to note and deal with condition changes. This means after-hours calls to on-call physicians, whose frequent response to questions about the health status of persons they are unfamiliar with is: "Send them to the E.R." The ability of clinical staff at long-term care settings to have a detailed discussion about changing health conditions of a resident with a physician is key to preventing unnecessary re-admissions.
  4. Complexity of discharge instructions. Consider the ability of the patient and/or caregiver to understand post-discharge care instructions. It is not unusual for elderly patients to have increased confusion during transitions. Details about care needs, health expectations, and possible side effects will not all be understood at the time of discharge. It would be helpful to not only have written information, but also verbal post-discharge follow-up from hospital staff.
  5. Timing of medication changes. Don't change the medication regime and then discharge the patient shortly after the change. Give the patient's body time to adjust to the changes in the medications. Time is also needed for staff to ascertain if there are any side effects, and to ensure the patient understands the new dosage and medications.

RARE Idea Contest - Earn from What You Learn

The strength of the RARE Campaign stems from the fact that more than 130 organizations and their staffs are working to solve a common, though complex, problem. With so much energy and brainpower focused on preventing readmissions, we bet many of you are learning lessons or taking actions that are reaping positive results.

We want to hear about your top lessons learned and actions taken, and share them with your peers. So we are starting the RARE Idea Contest. Here are the criteria:

  1. All participating hospitals and Community Partners can participate
  2. To participate, your organization must submit a description (300 words or less) of your idea, innovation or activity for preventing avoidable readmissions.
  3. Description must include the challenge your organization faced, the approach or idea to address it, what actions were taken, and any results to date (if available).
  4. Challenges can range from how you've engaged staff in the campaign, to technical or adaptive changes you've implemented to prevent readmissions. Whatever you feel is innovative and an implementable best practice.
  5. Send submissions to Jim Trevis by the 20th of each month. Submissions will be judged monthly by the RARE Operations Team, which is comprised of representatives from Operating Partners ICSI, MHA, Stratis Health, and Supporting Partners the Minnesota Medical Association and MN Community Measurement.
  6. Winning entries will appear in subsequent issues of the RARE Report to provide lessons learned to other campaign participants
  7. Winning organizations will receive free gifts for up to five staff people designed around the campaign's goal of "helping patients spend 16,000 nights in their own beds." Gift options for your RARE team are:
    • Set of RARE logo coffee mugs with the phrase: "I'm a RARE Leader"
    • Plush robes with the RARE logo
    • Sweet Dreams Sleep Mask
  8. All monthly winners will be eligible for a grand prize at the end of 2012. In addition to their earlier submission, the contestant's percent reduction in readmissions over the course of the year will also be factor in.

How 2 Hospitals Improved Care Transitions Communication

"Safe Transitions of Care" encompasses wide range of tools Many Minnesota hospitals in the RARE Campaign are adopting one of three structured models for approaching improvement in any of the campaign's five key focus areas known to reduce avoidable readmissions. This article addresses one of the models—Safe Transitions of Care.

Minnesota's Safe Transitions of Care initiative began in fall 2010 after research showed that poor communication when patients are transferred or discharged to another care setting can lead to a communication breakdown and subsequent patient safety issue. For example, a recent study of Medicare patients after hospital discharge found that an estimated 60 percent of medication errors occur when patients are being transitioned.

The Minnesota Hospital Association (MHA) Patient Safety Committee commissioned a Safe Transitions of Care Workgroup to identify potential safety gaps in care and devise a roadmap of best practices and core elements of information to address such potential safety gaps. From September 2010 to April 2011, pilot programs took place at 13 Minnesota hospitals — both large and small, urban and rural organizations.

The following stories describe how pilot sites from both a small hospital and a large hospital are continuing to implement Safe Transitions of Care in their facilities today. The hospitals share tips for organizations that are considering or are just beginning the program.

St. Cloud: Emphasize key patient information at hand-offs

As marketing experts will tell you, sometimes the way information is presented is almost as important as the content itself.

At St. Cloud Hospital, the Safe Transitions of Care program has helped emphasize that "packaging concept" to clinicians and administrators—all to the benefit of patients. Under the initiative, for instance, discharge nurses now list important details about each patient's medical history and future care needs at the front of the often-lengthy report they prepare upon a patient's discharge. Such reports can be more than 60 pages long. Nursing homes, assisted-living facilities and others use the documents to determine what the patient needs when the patient arrives from the hospital.

In the past, such salient facts were often mentioned near the end of the discharge papers. And sometimes, such key information was not listed at all, said Kay Greenlee, R.N., CNS, director of clinical utilization and quality resources at St. Cloud Hospital. Greenlee was a member of the MHA Safe Transitions of Care Workgroup that studied the care transitions issue.

"Suppose the patient had a skin issue that the hospital had taken care of, and the hospital wanted the receiving facility to continue to take care of it," she said. "Before, such information might have been buried on page 50 of the patient's discharge papers. Now, we pull that information up front and put emphasis on it. That change helps ensure that the continuum of care is not interrupted."

Key contact people at the hospital for the patient are also now listed at the beginning of the document, the Safe Transitions "tool."

Since beginning its Safe Transitions of Care work focusing on heart failure patients in October 2010, St. Cloud Hospital has experienced a slight decline in such readmissions. Specifically, 30-day readmissions for patients with a primary diagnosis of heart failure decreased from 21.2 percent for October-December 2010 to 20.3 percent for July-September 2011.

In January, the hospital launched a pilot to test whether additional interventions will further reduce readmissions among heart-failure patients. The interventions include: focused education; medication reconciliation by a pharmacist at admission and at discharge; scheduled follow-up appointments, and transitions coach visits and phone calls. If successful, those interventions will be spread to the entire organization for other patient populations at high risk for readmission.

Overall, Safe Transitions of Care "took information that St. Cloud had always provided previously but put it in a way that was more organized and directed to key elements," Greenlee said. Now, the hospital has a systemized way to try to determine why a patient might have been readmitted and whether the hospital could have done anything to prevent the readmission.

As a whole, the initiative reminded Greenlee of the importance of building strong relationships with those at nursing homes and other "receiving" organizations — even when those organizations are part of the same health system as the hospital.

"The relationship is just so important," Greenlee added. "For example, one of the things I do and had done for several years was meet with the director of nursing at area nursing homes and skilled-nursing facilities. But I didn't meet regularly with the director of St. Cloud Hospital Home Care [which is also owned by CentraCare Health System]. With entities within our own system, we just assumed a relationship was there. And it wasn't. Talking with them about Safe Transitions, it just reinforced that everyone is interested in what's best for the patient. It allows you to work for that common goal. Now you have that relationship, and you know who's across the table from you."

Granite Falls: Discharge process now more standardized, thorough

At Granite Falls Municipal Hospital & Manor, patients these days receive a "traveling care plan" upon their discharge. The packets include details about each patient's medications, as well as how their medical condition should be managed away from the hospital, if applicable. The information is designed to help patients, their families, and patients' regular doctors and caregivers understand the patient's needs going forward.

Such materials have helped Granite Falls bridge the communication gap that often occurs when patients transition from hospital to home, clinic or nursing home, said Discharge Planner Cindy Cross, R.N. The Transitions in Care team at the hospital got the idea for the traveling care plans by participating in the Safe Transitions of Care initiative.

"When we looked at the challenges that we have here in our small facility, we recognized what we wanted to improve was patient and family education, and thereby improve the transition from hospital to home," said Cross, who served on the MHA Safe Transitions of Care Work Group, which guided the initiative. "Part of that was medication reconciliation, which we have been doing a long time. Another part was to have the patients be more involved in their care and to understand what their medications are and what they're for, and to understand their disease processes more so that once they get home they'll be able to manage their condition more effectively. So our goal was to improve communication between the hospital staff and the patient and family and also with the home care, nursing home or clinic staff."

The tool has paid off, Cross said. Many patients take the plans to their follow-up doctor appointments, improving such visits and decreasing the risk for medication errors.

The traveling care plans were only one of many actions Granite Falls undertook as part of the Safe Transitions of Care initiative. In another effort to better communicate discharge orders, Cross met with area nursing home directors and nurses to discuss the Safe Transitions program and their goals under the project. Such discussions have helped ensure that employees at both ends of a transition of care are working toward the same end.

Also under the program, Cross now faxes each patient's discharge instructions to the nursing home, if applicable. A hospital nurse then calls to conduct a nurse-to-nurse report, thus allowing the nursing home nurse to see if he or she has any questions. Before, sometimes discharge instructions were sent with the patient or sent in a fax with no follow-up call to the receiving organization. Nothing was formalized or standardized, Cross said.

Such stepped-up efforts have meant an end to multiple phone calls from the nursing home or other receiving facility, asking for clarification about prescriptions or physical therapy instructions, for example, Cross said.

"It just allows the care to flow more effectively," she said. "Then you don't have the nursing home needing to contact the doctor at the clinic to get those orders."

Granite Falls also now has a standardized process for follow-up phone calls to discharged patients. At discharge, nurses ask patients when the best time would be for such calls. Patients who will later be seen by a doctor are also asked when they'd like an appointment and whether they have transportation for the visit. Even those small acts have improved patients' participation in follow-up care, Cross said.

The hospital began its work through Safe Transitions of Care in 2009 and completed it in spring of 2011. The program worked so well because it allows hospitals to tailor resources to the hospital's specific needs, she said.

"Safe Transitions helps you to identify areas of weakness where you can improve patient safety, and ways your facility can customize the processes to meet your needs," she said. "I think Safe Transitions was very successful in helping us identify areas we could improve the care we provide and help patients transition more safely to home, home care or to the nursing home."

Helpful Links Concerning Readmissions

What's Driving Costs? Did you know that between 1997 and 2008, aggregate inflation-adjusted costs of inpatient community hospital stays grew by 4.4 percent annually, and that the largest component of growth (71%) was change in the intensity of services (cost per stay)? Find out what other components have been driving the growth in in-patient hospital costs by checking out data from the Healthcare Cost and Utilization Project.

Admissions More than Discharge Planning Source of Readmissions. Researchers at Boston's Harvard School of Public Health found that high readmission rates in certain regions of the country don't necessarily have to do with the severity of the patients' conditions or quality of care, but rather the overall use of hospital services. (New England Journal of Medicine, Dec. 15, 2011)

The RARE Report is brought to you by the RARE Campaign's Operating Partners: Institute for Clinical Systems Improvement, Minnesota Hospital Association and Stratis Health, with contribution by the campaign's Supporting Partners, Minnesota Medical Association and MN Community Measurement.

Launched in September 2011, the RARE Campaign seeks to achieve Triple Aim goals by preventing 4,000 avoidable readmissions in Minnesota by Dec. 31, 2012. We thank all stakeholders in this regional initiative for their ongoing support.

If you have any questions related to the content of the RARE Report, contact:

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RARE is a campaign lead by the Institute for Clinical Systems Improvement, the Minnesota Hospital Association, and Stratis Health, which represents Lake Superior Quality Innovation Network in Minnesota.