Maintaining patient health after a hospital stay...
RARE - Reducing Avoidable Readmissions Effectively

RARE Report banner

RARE Report - March 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. Upcoming Events, Web Updates and News
  2. Care Transitions Intervention: Putting it into Practice at Allina
  3. Community Partners: Key Players in Campaign’s Success
  4. Campaign Updates: Recommended Actions for Improved Care Transitions; Mental Health Work Groups; Conversations with Canadian Ministry of Health
  5. Hospital Executives Share Actions Taken to Engage Other Providers

Upcoming Events, Web Updates and News

Upcoming Events

Last Chance to Join the Care Transitions Intervention Collaborative. This collaborative supports hospitals and their Community Partners in implementing the Care Transitions Intervention (CTI), which provides patients with tools and support that promote knowledge and self-management of their condition following a hospitalization. There are only a few spots remaining in the CTI training session on April 12-13, 2012 – sign up today!

Webinar: Transitions to End-of-Life Care: Difficult Discussions
Wednesday, March 21, 2012, Noon - 1 p.m. (CT)
Speaker: Lores Vlaminck, RN, BSN, MA, CHPN

Webinar: Challenging the Label of the Non-Compliant Patient
Friday, May 4, 2012, 11 a.m. - Noon (CT)
Speaker: Eric Coleman, MD, MPH (This webinar will not be recorded)

RARE Action Learning Day, April 24, 2012
Featured Speaker: Stephen Jencks, MD, MPH, along with numerous RARE participants and Community Partners who will share their experiences.

Workshop: Co-creating a Medication Management System for the Triple Aim
May 7, 2012. Part of ICSI’s 15th Annual Colloquium
Speaker: Brian Isetts, Health Policy Fellow at the Centers for Medicare & Medicaid Innovation Center, and Professor, College of Pharmacy, University of Minnesota. See the Colloquium brochure for details and registration information.

New on the RARE Campaign Website
The home page of the website has been redesigned to make it easier to find the latest RARE Campaign news and events, including this monthly RARE Report newsletter. In addition, a map of hospitals participating in the RARE Campaign has been added to the progress page and the Community Partners information has been updated (see separate article below). As the website continues to grow, we encourage you to take advantage of its robust search functionality to help find what you’re looking for. Be sure to bookmark the website and check back frequently to stay informed and see what’s new!

Other Readmissions News
Curbing Readmissions Doesn't Have to be Costly. When Chicago's Mount Sinai Hospital embarked on reducing readmissions with the Project Reengineered Discharge model, otherwise known as Project RED, program leaders couldn't believe it lowered readmissions from 34 percent (from July 2010 to January 2011) to only 5 percent (from February 2011 to July 2011). Even better, it didn't require new staff or additional dollars. Follow the link to read more about this Chicago hospital’s success with Project RED, one of the RARE Campaign collaboratives, in this recent article from FierceHealthcare.


Care Transitions Intervention: Putting it into Practice at Allina

Many Minnesota hospitals in the RARE Campaign are participating in one of three optional collaboratives and thereby 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 – Care Transitions Intervention, known as CTI.

Allina logo Dr. Eric Coleman, MD, MPH, designed The Care Transitions Intervention™in response to the need for a patient-centered, interdisciplinary intervention that addresses continuity of care across multiple settings and practitioners. The overriding goal of the intervention is to improve care transitions by providing patients with tools and support that promote knowledge and self-management of their condition as they move from hospital to home.

Two of Allina’s hospitals participating in the RARE Campaign, Owatonna and Mercy in Coon Rapids, are taking part in a pilot of the CTI program. Allina shares its experience implementing CTI, along with tips for hospitals considering the program.

Why the Care Transitions Intervention?
As part of its participation in the RARE Campaign, Allina was able to examine its Potentially Preventable Readmissions data, which shed new light on which patients were actually coming back to the hospital as readmissions. Many were people not expected to come back because Allina believed they knew how to take care of themselves and navigate the health care system. Allina was also surprised at how quickly patients were being readmitted.

As a result, Allina realized it needed to empower its patients to manage their own health care. Allina chose to participate in the Care Transitions Collaborative because CTI is all about skills transfer, helping patients achieve their personal goals by taking charge of their own health care.

“The CTI model was intriguing to us because it could help us with a population we hadn’t always addressed in the past,” commented Karen Tomes, RN, MA, PHN, one of the CTI leaders at Allina. “It was also well-researched, there was evidence that it really works, and we could send a team to the two-day RARE-sponsored collaborative and implement quickly. The package was concise, with ‘plug and play’ tools already developed.”

Implementing CTI at Allina

Hospital Transitions of Care banner

Allina decided to implement CTI as a pilot program scheduled to end in May. Its goal is to make the biggest impact possible by focusing on a targeted population based on past readmissions. Allina chose two hospitals for the pilot: one regional (Owatonna) and one in the Twin Cities metro area (Mercy in Coon Rapids), and determined that it would need at least 150 patients to participate in order to evaluate its success and determine if the CTI model should be expanded across the Allina system.

Allina developed a number of documents and workflows for the program, including an “elevator speech” for general staff and a patient version that explains the program in plain language. Detailed documentation and workflows for coaches and other hospital staff were also prepared based on CTI’s standard tools. One of the biggest accomplishments was creation of an electronic “dashboard” that takes information from patient electronic medical records and identifies those who are eligible for the program, based on the criteria Allina established for its pilot. With one click, coaches can easily identify which patients they should contact.

Addressing Hurdles
Bev Dehn, RN, the CTI program manager, said one of Allina’s biggest hurdles is patient participation. “Patients may agree while in the hospital to participate in the program, but by the time they get home they’ve changed their mind or something has come up,” Dehn commented. Allina has met with CTI’s consultants on ways to engage the patient while still in the hospital – it’s a skill that coaches need to learn.

Dehn also stressed the importance of contacting the patient as soon as possible after discharge to schedule the in-home visit. Allina is utilizing its electronic systems to improve communications and ensure the coach is notified when an eligible patient is discharged.

Another challenge has been CTI’s recommendation that coaches be full-time. While this may be ideal, it is common for care transition coaches to have other responsibilities, as they do at Allina. In order to become more comfortable with the coaching techniques, Allina’s coaches attend regular meetings to find out which patients have enrolled and which haven’t, and have the opportunity to role-play and shadow each other so they can get feedback and learn what techniques are working well.

Although Allina hasn’t had enough patients go through the program yet to assess results, Tomes commented that they’re seeing great collaboration and have a coaching team that is very engaged and believes strongly in the program.  They hope to show a steady gain in number of patients coached and be able to extend the pilot through June or July.

Advice to Others Considering CTI
When asked what advice she would give to hospitals considering CTI, Dehn said, “If at all possible, dedicate staff to coaching, at least half-time if not full-time. It will really make a difference in how quickly you’ll start seeing positive results.” She also advocates following CTI’s recommendation to stay true to the program, adding, “If you tweak it too much to fit your organization, you run the risk of decreasing its effectiveness.”

Taking a different perspective, Tomes commented: “Many people in health care think they’re already coaching, but after going through this training, they realize that this type of coaching is very different. The model is built on skills transfer – teaching patients to do for themselves rather than the more traditional model where the health care worker assumes the responsibility.”

“As health systems are redesigning care processes, this is a dimension of coaching that needs to be fully understood,” Tomes added. “When a hospital chooses to implement the CTI model, it is looking at nothing less than a paradigm shift.”


Community Partners: Key Players in Campaign’s Success

The RARE Campaign seeks to prevent 4,000 avoidable readmissions by Dec. 31, 2012 by engaging hospitals and providers across the continuum of care to focus on this effort. We know that hospital readmissions are not a hospital problem, but rather a delivery system problem. The RARE Campaign acknowledges that fact by its focus on the continuum of care, and its inclusion of Community Partners to help achieve campaign goals.

We have more than 60 Community Partners who have agreed to endorse and support the RARE Campaign. Recently, the RARE Advisory Committee more clearly defined the criteria for becoming a Community Partner, and identified specific ways they can actively participate based on their role in the care continuum.

To be a Community Partner, an organization must provide services or support that helps improve care transitions and patient care following hospital discharge. Proprietary vendors of products such as durable medical equipment, drugs, and/or technology software/hardware are not eligible. Our Community Partners must fall into one of the following categories:

  • Professional/Trade/Membership Associations
  • Payer Organizations
  • Providers and Provider Groups
  • Community Service Organizations
  • Patient Advocacy Groups

We encourage all Community Partners to support the RARE campaign by participating in relevant events; educating their constituents on the RARE Campaign and its components; disseminating RARE resources and materials, including the monthly RARE Report, to their constituents; lending their skills/expertise to projects as needed; educating campaign leaders and participating hospitals about their services, needs and challenges; encouraging patients/consumers to participate in RARE activities or teams; and supporting health reforms that align with the Triple Aim of improving the quality of care, the care experience and the affordability of care.

We have also identified specific ways that the various types of Community Partners can best support the campaign. Details are available on the RARE Campaign website, where you’ll also find a current list of Community Partners. A communication was recently sent via email to our Community Partners with additional information and supporting materials.

Watch for progress reports and success stories from our Community Partners in upcoming issues of this newsletter. If you have questions about this part of the campaign, please contact any of the Operating Partner representatives:

Kathy Cummings, Project Manager, Institute for Clinical Systems Improvement
(952) 814-7086

Tania Daniels, Vice President Patient Safety, Minnesota Hospital Association
(651) 603-3517

Karla Weng, Program Manager, Stratis Health
(952) 853-8570


Campaign Updates

Recommended Actions for Improved Care Transitions

Part of the RARE Campaign’s work is to provide recommendations and associated tools and resources that can be used for improvement. The Operating Partners, together with the RARE Advisory Committee, have drafted the Recommended Actions for Improved Care Transitions. This document includes recommendations that are based on best practice, evidence and consensus, and are considered to be key practices that organizations should be working to implement. This document also includes other strategies that organizations may consider given their unique issues, needs and resources.

We expect this document to be modified as the campaign progresses based on the real-world experiences of participating hospitals, Community Partners and others involved in working to reduce avoidable readmissions. We ask participating hospitals to review and disseminate this information within your organizations, and as you put them into practice, share your feedback with your RARE Resource Consultant.

Check out the “Recommended Actions for Improved Care Transitions” document.

Mental Health Work Group

The RARE Mental Health Work Group was initiated by the RARE Advisory Committee to investigate the effect mental health conditions have on readmissions to the hospital. The group is charged to identify typical discharge failures, contributing factors, strategies for improvement, best practices and literature to support organizations that are engaged in the RARE Campaign to reduce avoidable readmissions.

The mental health work group has identified three populations of mental health readmissions:

  • Patients who are admitted to mental health facilities and are readmitted to those facilities.
  • Patients with mental health disorders who are admitted to acute care medical/surgical services whose course of care is complicated by their mental health disorder and who are readmitted to medical/surgical care.
  • Patients who have a medical/surgical issue who then develop a mental health issue in response and are admitted to a mental health facility.

A literature search has been completed and the group is investigating work that has been done locally and nationally to reduce readmissions for these populations.

The group will be focusing its work on identifying recommendations for action for each of the five key RARE Campaign areas as it relates to these three populations.

RARE Campaign Gets International Exposure

Earlier this month, a representative of the Ministry of Health and Long-Term Care in Ontario, Canada contacted the RARE Operating Partners, asking to learn more about the RARE Campaign.

Similar to the United States, Ontario recently introduced legislation that outlines its commitment to a measurable enhancement of the quality of care across the continuum by applying consistent, evidence-based standards and practices to improve patient outcomes and increase value.

They have begun by exploring the possibility of using “campaigns” as a way to increase the adoption of evidence-based standards and practices, with a specific emphasis on reducing avoidable readmissions. The Ministry had heard about the RARE Campaign and was interested in learning more about the approach we had taken in Minnesota to see if there are opportunities to benefit and learn from our experiences.

Our collective work is having a powerful impact, not only on patients in Minnesota who are spending more nights in their own beds, but possibly on patients outside our state. It is exciting to know that the RARE Campaign has the potential to improve the health care experience for people in other countries.


Hospital Executives Share How They’re Engaging Other Care Providers

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:

"The success of RARE hinges on hospitals working with other care providers across the care continuum. What actions have you taken to date to engage other providers, and what have been the results?" 

Daniel A. Trajano, MD, MBA, Senior Medical Director of Quality, Care Innovation, and Population Health, Park Nicollet Methodist Health Services

At Park Nicollet Methodist Hospital, our Inpatient Care Coordinators and Health Unit Coordinators assist in all transition needs of patients who are at a high risk for readmission. All hospitalized patients undergo a standardized risk assessment. Patients who have high readmission risk receive personalized care coordination that includes evaluation of the services and needs that patients will require after discharge. Methodist Hospital Care Coordinators will connect patients to pharmacy services, home care, hospice, physical and occupational therapy, community organizations, social services, high-risk care consultation (i.e., case management) and outpatient follow-up. 

At discharge from Methodist Hospital, our Health Unit Coordinators ensure timely follow-up by scheduling appointments for patients with their Park Nicollet primary care clinicians within three to five days. Methodist Hospital care coordinators will monitor the success of these interventions in real time doing regular team huddles to help understand the root causes of readmissions. We are confident these interventions will improve the quality of care in transitions, leading to fewer readmissions and more nights for patients sleeping in their own beds at home.  

Michael Schramm, CEO, Rice Memorial Hospital in Willmar

Our work with RARE has involved many members of our local medical community. We were fortunate to have an established quarterly meeting with our local long-term care (LTC) facilities and that served as a great vehicle to share the work we were doing with reducing avoidable readmissions. Three of the long-term care facilities in Willmar served as a pilot group for targeted communication between the discharging nurse at Rice Memorial and the receiving nurse at the LTC facility. This communication occurred prior to the patient leaving the hospital so that questions could be answered up front and the LTC facility is better prepared to meet any special needs of the patient.  The LTC facilities have also adopted a form used when their patients are brought to the emergency room. The form serves as a checklist to provide pertinent information to the physician and staff, while decreasing the amount of non-essential information.

In addition, we have partnered with our two local clinics to decrease the interval from hospital discharge to follow-up appointment. Rice Memorial staff members routinely make the appointment prior to inpatient discharge to occur within five to seven days post-hospitalization. Both clinics have been very supportive of the process and are able to provide us with information on appointments kept. We have established a monthly meeting of hospital and clinic staff who discuss opportunities for improving movement of patients and patient information between our organizations.


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
Copyright © 2017 ICSI, MHA, Stratis Health Home | Privacy Policy | Email RARE
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.