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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - February 2012

RARE Report

The RARE Report updates participating hospitals and Community Partners on news and events related to the RARE Campaign, demonstrates how hospitals and Community Partners can work together across the continuum of care, shares best practices, and provides tools to keep all stakeholders engaged and implementing improvements to achieve RARE goals. Please send your feedback to: Mary Beth Schwartz.

Previous Issues

In This Issue

  1. Minnesotans Spent 5,000 More Nights in Their Beds, Thanks to Your Efforts
  2. News, Web Updates, and Upcoming Events
  3. RARE Hospitals’ Organizational Assessments: What Are We Learning?
  4. Hospital Executives Share Their Organizational Assessment Discoveries
  5. Community Partners Corner: How to Reduce COPD Readmissions
  6. How Two Hospitals Implemented Project RED
  7. RARE Website Featured Content: Health Literacy Resources
  8. Helpful Links Concerning Readmissions
  9. RARE Ideas Earn RARE Rewards!

Minnesotans Spent 5,000 More Nights in Their Beds, Thanks to Your Efforts

progress chartCongratulations! Hospitals participating in the RARE Campaign are making progress toward preventing 4,000 avoidable readmissions by Dec. 31, 2012, based on the Potentially Preventable Readmissions (PPR) data for the third quarter of 2011, which was recently shared with individual participating hospitals by the Minnesota Hospital Association (MHA). The campaign’s goal is to reduce avoidable readmissions by 20 percent from 2009 baseline data, and results to date indicate a reduction of approximately 7 percent, which means we are about one-third of the way to our goal. This equates to helping Minnesotans spend 5,000 more nights in their own beds to date.

These are very preliminary results and reflect progress made by hospitals prior to the RARE Campaign kick-off and during the initial campaign period of July-September 2011 when hospitals were signing up, forming teams and completing organizational assessments. Hospitals, ICSI, MHA and Stratis Health had multiple readmission prevention activities underway before this campaign brought them together in a coordinated fashion.

To easily visualize and track the aggregate results of all 77 participating hospitals as the campaign proceeds, keep an eye on this progress chart. It is posted on the home page, and will be updated as each quarter’s results are compiled.

Current Actions
To help participating hospitals advance their current work, all have been sent their individual PPR data. They have also received a run chart that graphically displays progress toward achieving their readmission reduction goals and provides a benchmark for quality improvement purposes moving forward.

Hospitals have been asked to fill out a quarterly progress report and return it to their RARE Resource Consultant by Feb. 20, 2012. This will help determine what technical assistance or other resources the RARE Operating Partners can provide to support their quality improvement efforts.

Congratulations to everyone involved on such a promising start! The RARE Operating Partners look forward to continuing to support participating hospitals and Community Partners so that Minnesotans will spend an additional 11,000 nights in their own beds before the end of the year.

News, Web Updates, and Upcoming Events

Webinar: Involving Patients and Families in Reducing Avoidable Readmissions, Feb. 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. Register by Feb. 23.

Upcoming webinars in March and April will focus on end of life conversations and “noncompliant” patients. Watch for the flyers in your email and online.

RARE Action Learning Day, April 24, 2012, Features Stephen Jencks, MD, MPH
The second RARE Action Learning Day takes place on April 24 at the Earle Brown Heritage Center in Brooklyn Center, MN. Working teams from all participating organizations are encouraged to attend this event, which features readmissions expert Dr. Jencks as the keynote speaker. Jencks will address the progress being made nationally in reducing readmissions. The day also will include panel discussions on the patient’s perspective and care outside the hospital walls.

One of the main objectives for the Action Learning Day is to provide a forum for campaign participants to learn from one another. The format for this collaboration will include a series of presentationswhere organizations will have 10 minutes to share an aspect of their current work followed by 10 minutes for audience questions/comments. Please consider presenting your improvement strategies and projects with others on our RARE Action Learning Day! If you are interested, complete the application and return to Rochelle Hayes by March 2, 2012.

You won’t want to miss this opportunity for best practice sharing, networking and inspiration! Save the date and watch for registration information and more details soon.

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. Register today!

More information on medication management

RARE Hospitals’ Organizational Assessments: What Are We Learning?

All hospitals participating in the RARE Campaign complete an organizational assessment to recognize the main gaps contributing to their avoidable readmissions so they can identify improvement opportunities and maximize resources to achieve their readmission reduction goals. The majority of the 77 participating hospitals have now completed their assessments, giving us a clearer picture of the main gaps across all systems.

The area where the most work needs to be done is discharge planning, with hospitals indicating that tools, templates and technical assistance are needed to help them improve all aspects of the discharge process. Some of the most pressing needs are:

  • Establishing processes to ensure staff has key information about a patient’s pre-hospitalization clinic visits and treatment, as well as post-discharge follow-up care
  • Standardization of discharge summaries, inter-agency referrals and clinic processes

Ranking second as a barrier is assessment and measurement, with the focus on how data is measured, tracked and analyzed so that it can be used effectively to identify improvement opportunities. Help is also needed to develop effective assessment tools and scorecards, particularly in the medication reconciliation process.

Education of both patients and staff is another area ripe for improvement, including developing standardized patient materials written in plain language, and the use of teach-back and train-the-trainer techniques for maximum effectiveness and efficiency. Staff members also are looking for new ways to help patients better understand and remember the information they are given.

While electronic health record systems (EHRs) were listed as a barrier, hospitals noted that work was underway to improve connectivity across multiple systems and deliver more patient-centered output. For example, St. Cloud Hospital and EHR vendor Epic have developed a Safe Transition of Care report. Finally, there is a pressing need for better collaboration across care settings and disciplines, more opportunities for best practice sharing and finding ways to involve family members and caregivers in support of the patient.

RARE Resource Consultants are working closely with participating hospitals to ensure they have the appropriate resources and tools. The RARE Campaign also will use this organizational assessment summary information to target additional tools and educational opportunities to best meet the needs of participating hospitals.

Check out a complete summary of the assessment findings.

Hospital Executives Share Their Organizational Assessment Discoveries

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

“What has been the most surprising discovery to come out of your organizational assessment regarding the main causes of your avoidable readmissions, and what steps have you initiated to address them?”

Steve Bergeson, MD, Medical Director, Quality, Allina Health
Participating in the RARE Campaign has expanded our focus beyond patients with the three conditions identified by the Centers for Medicare and Medicaid Services (CMS): heart failure, acute myocardial infarction, and pneumonia. The PPR methodology has helped us learn about additional populations experiencing avoidable readmissions including patients younger than the CMS population, and patients with specific medical and surgical diagnoses. We were surprised at how quickly some of these patients return to our hospitals. The RARE data has helped individual Allina hospitals to focus on the reasons patients are returning to that hospital.

After completing the organizational assessment we identified a new Allina infrastructure to support the full range of performance improvement (PI) required to analyze and interpret data and facilitate improvement teams. The interdisciplinary PI teams are designing new care processes to improve transitions that are repeatable and reliable for all Allina patients. Teams include:

  • Discharge disposition: Create standardized clinical assessment tools, documented in the electronic health record, for executive function and clinical stability to be used to plan the transition of care after hospitalization.
  • The discharge package: Redesign the package of written instructions given to the patient at discharge with concise and relevant information to promote patient self-management post-hospitalization.
  • Provider transitions: Create consistent and reliable communication between Allina and non-Allina providers (MD, NP, PA) at the time of discharge to augment the plan of care.
  • Readmission predictive model: Create a predictive model accessible for clinicians to identify patients who would benefit from a transition conference to identify resources for the next level of care.

Bryan J. Fritsch, DO, Internal Medicine, Glencoe Medical Clinic
The most surprising discovery to come out of our assessment was how fractured, non-standardized and varying our discharge process is from patient to patient. Each physician seems to have their own way of doing things and it often leads to confusion among the nurses about what is expected. 

Using Project RED guidelines, we are working to streamline and improve our medication reconciliation process, improve patient education throughout the hospital stay and ensure better follow up at discharge. Hopefully this will lead to less avoidable hospital readmissions, fewer calls from patients and families post discharge and improved patient satisfaction.

Community Partners Corner: How to Reduce COPD Readmissions

Jill Heins-Nesvold, MS, Director of Respiratory Health, American Lung Association of the Upper Midwest

Mary ManningIn 2008, chronic obstructive pulmonary disease (COPD) became the third leading cause of death in the U.S., affecting more than 12 million Americans with another 12 million who have yet to be diagnosed. The Lancet reported in September 2011 that 25 percent of people ages 35 and older will develop COPD in their lifetime, making the risk of developing COPD greater than heart failure, breast cancer or prostate cancer. In Minnesota, 7.8 percent of those 65 years of age and older have been diagnosed with COPD—and the rate is rising.

In March 2011, MHA used 3M’s PPR software to run a data set at the request of the Minnesota COPD Coalition, led by the American Lung Association. We discovered that COPD had a statewide readmission rate of 12.53 percent, behind only heart failure and pneumonia. The actual rate is probably much higher because the software only includes readmissions to the same hospital within 30 days.

Reducing COPD readmissions involves addressing a number of issues, including:

  1. Medication management. Prescribe the best medication regimen for the stage of a patient’s COPD. The regimen should be manageable with as few types of delivery methods as possible. The patient should receive education on what the medications do and how and when to take them. The patient care team also should make sure patients are able to access and refill medications, if needed. In addition, they need to reconcile the medications a patient was taking before their hospitalization with their new prescriptions to make sure the medications are appropriate for their disease stage and are consistent with the American Thoracic Society guidelines.
  2. Communication. Communication should not be saved for the end of the hospitalization; rather, it is a process. Conversations at the beginning of the hospitalization can help determine the reason for admission, which is not the diagnosis (COPD exacerbation), but the reason the patient exacerbated. Self-management is a very important part of COPD management, so the patient and family need to be actively involved in identifying barriers and needs, as well as goals and solutions. It does no good for the patient care team to make decisions for the patient if he or she is unwilling or unable to follow the transition plan. The patient and family must be primary members of the transition team, as they will have the greatest impact on a successful transition.
  3. Transition planning. In COPD, we have moved away from the wording “discharge” planning. “Discharge,” by definition, means “unload” or “release.”  “Transition” planning, on the other hand, indicates traveling through interconnected phases of health care, whether self-managed at home, hospitalized, using ambulatory services, or living at a short- or long-term care facility. The patient care team, along with the case management team and the patient/caregiver, should create a transition plan that addresses all of a patient’s needs including follow-up appointments, medications, oxygen therapy, pulmonary rehabilitation, transportation, and support systems outside the hospital. By involving the patient/caregiver from the beginning, good transition communication and sharing of information among providers and other settings can occur.

The Minnesota COPD Coalition has focused on hospital readmissions and transitions of care for the past two years. The coalition’s trainings, webinars and tools are made available to all hospitals and health care professionals. Check out the webinar highlighting successful COPD readmission programs. The coalition also is working on creating tools for providers to ease transitions from one care setting to another. For more information check out the Minnesota COPD Coalition or contact Jill Heins-Nesvold.

How Two Hospitals Implemented Project RED

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—Project RED.

RED stands for re-engineered discharge. Project RED emphasizes building and maintaining a relationship with the patient during and after discharge, as well as having a discharge advocate shepherding the discharge planning process.

Two hospitals participating in the RARE Campaign, one large and one small, share tips for organizations that are considering or are just beginning the program. Both hospitals learned that they could not merely add the discharge advocate role to someone’s current workload. They needed to carefully assess workloads and plan for the new work volume.

Hennepin County Medical Center: Three Pilots Lead to Departmental Model

Hennepin County Medical Center logo Following three pilot projects conducted from November 2010 to December 2011, Hennepin County Medical Center (HCMC), Minneapolis, is starting to put the tactics from Project RED into a departmental model for discharge planning. The hospital participates in Project RED with guidance from Joint Commission Resources and the Agency for Healthcare Research and Quality (AHRQ).

Each of HCMC’s pilots—for congestive heart failure (CHF), psychiatric care, and medicine services—advanced its understanding of which patients to focus on, which processes and systems were impacting readmissions, and which tactics would lead to the greatest improvements. A Pareto analysis (also known as the 80/20 rule—a technique for choosing the most important changes to make) showed that medication management was the top reason for its readmissions. All three pilots included medication reconciliation prior to discharge, discharge teaching using the teach-back method, post-discharge follow-up phone calls, and home visits if needed.

During its first pilot, HCMC had problems identifying CHF patients upon admission. Other conditions, such as pneumonia, masked CHF and the discharge advocate (DA) would not know to start working with the patient on admission. HCMC learned the importance of physician input and to select a focus area based on the primary cause for readmission, not on a diagnosis such as CHF.

The second pilot, in psychiatric services, taught HCMC to include all diagnoses for increased discharge communication, and to dedicate time for discharge advocate functions, including the critical follow-up calls within three to 10 days of discharge. The hospital began to address system barriers that were leading to readmissions. Half of readmissions to HCMC were within the first seven days, which led to the tactic of implementing a transition group. A contributing factor that led to this approach was the shortage of psychiatrists in the Twin Cities area, which forced follow-up appointments a month out. The transition group was added to the day-treatment area, and included access to a provider, medication review, group sessions and more services. Pilot results showed a reduction in readmissions from 13 percent to 7.9 percent.

The third pilot was with medicine patients. Medication Services was the area with the highest number of readmissions and second highest percentage by readmission rate. Contributing factors for readmission reduction included access to a primary care physician (PCP) and clinic system. Twenty-nine percent of HCMC patients do not have a PCP and a significant number failed to make a follow-up appointment with a PCP after discharge. The average time for follow-up was three to four weeks. Getting an appointment within five days was challenging, especially at clinics. To address this challenge, during the pilot HCMC added a discharge clinic appointment or visit with a primary care physician within five days of discharge.

“HCMC is taking the lessons learned from the three pilot projects, and will incorporate them into a department model. Our intention is to improve the patient discharge process and the patient experience—while reducing preventable readmissions,” said Bruce D. Johnson, performance excellence project manager at HCMC.

The hospital will launch its departmental model in one department and expand its discharge clinic from two to three days a week, to ensure follow up visits for patients who do not have a primary care physician and those who cannot get a timely appointment. HCMC also aims to standardize discharge appointments to include review of a discharge plan, medications, outstanding tests and current clinical state.

Lakewood Health System: Seeing from the Patient’s Perspective

Lakewood Health Systems logoLakewood Health System started working on Project RED in April 2011 in a collaborative for rural hospitals led by Stratis Health. In looking at their core measures and HCAHPS data, they saw opportunities to reduce readmissions and enhance the discharge process.

The hospital has worked to initiate communication about discharge early in a patient’s stay. A pharmacist reviews medications with patients, especially any new medications, at the start of their stay. During daily rounds, patients are asked if they have questions about their medications. Staff now completes a discharge sheet electronically on the network throughout a patient’s stay, instead of at the end. At discharge, they review orders for duplicate therapies and drug-drug interactions. With the patients, they point out any changes in medications and suggest patients throw away old medications at home.

Lakewood staff wants to start the discharge planning process right away, looking at patient needs related to medications and rehab, so patients and their families know what they need to be able to do to be eligible for discharge and to go home successfully. The hospital wants this to become the standard of care for all of their patients.

In addition to patient education, Lakewood will educate its nurses on the teach-back method.

Of all of the strategies within Project RED, the biggest challenge was how to support the discharge advocate role. Initially, Lakewood’s nurse case manager was going to fill the role. The hospital wanted to work with CHF patients first but found this added too much onto the nurse case manager’s plate, especially with the launch of a new computer system. “She had no time for the discharge advocate role,” said Alissa Kuepers, clinical pharmacist at Lakewood Health System and Project RED team leader. “We had done everything else in Project RED; then we stalled out.”

Subsequently, two management level staff each had family members in the hospital at the same time. Both went through the discharge process—this time from the patient’s perspective.

One family member had been at the hospital as a swing bed patient for a couple of weeks. On the day of discharge, they were bombarded with information. “We can’t throw all of that at a patient in the two hours before leaving the hospital,” Kuepers commented.

The other staff member observed that some of the pieces were not falling into place as expected. They were missing educational opportunities like helping patients make good dietary choices. “When a CHF patient is ordering a breakfast of bacon and eggs, that’s a good time for education on a low salt diet,” Kuepers shared.

These insights from the patient perspective provided the spark to reinvigorate the discharge advocate role. Lakewood Health System is just starting to use a multidisciplinary discharge team that includes the case manager, doctor, the nurse in charge working on the floor, the patient’s floor nurse, pharmacist, and rehab and nutritionist as appropriate, instead of a sole discharge advocate. They all will meet with the patient together within one to two days after the patient is admitted, during the doctor’s standard rounds. The team will map out what the patient needs for education and to support going home.

“We are seeing improvement in data with the few things we’ve done so far,” Kuepers noted.

RARE Website Featured Content: Health Literacy Resources

Did you know that only 12 percent of literate Americans are proficient in understanding health information? Studies show that low health literacy affects a person’s health status more than any other factor, including education, income, employment and race. Health literacy plays an important part in the work we are all doing to reduce readmissions, and there are many resources available on the RARE website to help you improve patient and provider communications. Check out the information currently available.

Helpful Links Concerning Readmissions

  • Hospitals know they have to care about readmissions to improve patient care, and that there are reimbursements changes tied to performance. But do they know what really causes readmissions and what they can do to avoid them? Read more.
  • Starting this fall, hospitals that readmit the same patients over and over in a short period of time will be fined. That has medical providers looking for better ways to keep people healthy when they’re off hospital grounds. American Public Media’s Marketplace program focused on one Philadelphia hospital’s effort to address the issue in a Feb. 7, 2012 story. Read more.

RARE Ideas Earn RARE Rewards!

We know that there is a great deal of energy and brainpower focused on preventing avoidable readmissions, and the power of those efforts is multiplied many times over when you share those successful ideas and actions with your peers. That’s the power of RARE.

Because this type of sharing is so valuable, we want to reward your teams with free gifts for submitting an idea to the RARE Idea Contest. If your idea is selected, you’ll 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 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

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 factored in.

There are just a few simple rules:

  1. The contest is open to all participating hospitals and Community Partners.
  2. Submit a description (300 words or less) of your idea, innovation or activity, including the challenge your organization faced, how you addressed it, and any results to date.
  3. Send your submission to Mary Beth Schwartz by the 20th of each month. The RARE Operations Team will review them at its monthly meeting.

Watch for winning entries in future issues of the RARE Report. Don’t wait—submit your idea today and help us unleash the power of RARE!

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 contributions 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:

Patients and family members
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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.