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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - February 2012

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 gaps can be grouped into seven areas: 1) discharge planning, 2) assessment and measurement, 3) patient education, 4) staff education, 5) IT/electronic health records, 6) best practices, and 7) collaboration.

Discharge Planning

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
  • Assistance modeling a discharge advocate position and assessing the impact on other staffing
  • Standardization of scheduling, clinic processes and staffing to better support RN follow-up calls

Assessment and Measurement

Ranking second as a barrier is assessment and measurement, with the focus is 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. Additional priorities are:

  • Access to timely, accurate reports
  • Avoidable readmission data broken down by hospital and diagnosis summary
  • A common definition of "preventable readmission"
  • Assistance identifying financial metrics and determining the return on Investment (ROI) for a case management system
  • Developing a high-risk readmission assessment tool
  • Build a process to identify real-time readmission patients for concurrent reviews

Patient Education

Patient education is an area ripe for improvement, including development of standardized patient materials that are written in plain language to facilitate patient teaching early in their hospitalization. Other needs identified include:

  • Clearly defined available resources in varied formats, including video and online
  • Tools and techniques to engage patients at their literacy level
  • Better end-of-life conversations
  • A simpler teaching system for medication management
  • Access to chronic care management resources
  • Take-home materials for patients and families about their diagnosis and condition
  • Tools to help increase patients' understanding and retention of education materials

Staff Education

Many participating hospitals advocated the use of teach-back and train-the-trainer techniques for maximum effectiveness and efficiency for staff education. Additional needs include:

  • Patient management education for long-term care and skilled nursing facility staff
  • Transition coach training
  • How to utilize pharmacy staff for medication teaching
  • More information on case management for the highest risk patients

IT/Electronic Health Records

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. Specific issues include:

  • How to optimize Epic to best connect all those involved in patient transitions
  • Need an after-hospital care plan for the EHR that is clear and easy for the patient to read and understand
  • Medication reconciliation tools for an EHR

Collaboration and Best Practice Sharing

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. Other frequently mentioned issues are:

  • Timely access to new best practices and resources
  • Help sorting through conflicting recommendations in literature and research findings
  • How to work together as an interdisciplinary team

RARE Resource Consultants are working closely with participating hospitals to ensure they have the appropriate resources and tools, many of which are currently available on the RARE website. The RARE Campaign is using this organizational assessment summary information to target additional tools and educational opportunities to best meet the needs of participating hospitals.


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.

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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.