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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - May 2012

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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. The Data is In!
  2. Upcoming Events and News
  3. Area Agencies on Aging: Key Community Organizations for Successful Transitions
  4. Action Learning Day a Rousing Success
  5. Webinar Summary: Challenging the Label of the Non-compliant Patient
  6. ICSI Colloquium Workshop Addresses Medication Management Systems
  7. Hospital Executive Talks About Implementation Barriers
  8. Campaign Updates: VHA Joins Campaign as Supporting Partner, Mini-Pillows in Roseau

The Data is In!

progress chart On May 8, the MHA released its quarterly Potentially Preventable Readmissions report. For the calendar year 2011, RARE Campaign organizations had 1,915 fewer avoidable hospital readmissions compared to the baseline. This means 7,660 more nights of sleep at home rather than in a hospital bed for Minnesota residents. Thank you for your ongoing work to reduce avoidable readmissions.
Read more >

Upcoming Events and News


Project RED Collaborative – Cohort II Applications Due May 25

Supports hospital teams as they implement strategies to improve patient safety and reduce hospital readmissions by focusing on processes related to discharge planning. Contact Kim McCoy, 952-853-8563.

Safe Transitions Collaborative – Cohort II Applications Due May 25

Improves patient safety by standardizing and improving communication during transitions of care between hospitals and across all settings of care, including other hospitals, skilled nursing facilities (SNF), long-term care, assisted living, home health, and primary care. Contact Mickey Reid, 651-603-3515.

National Readmissions Newsletter Features RARE Campaign

The May issue of Readmissions News, a new national newsletter focused on the work being done across the country to reduce hospital readmissions, contains a lead article about the RARE Campaign. Read more >


Details and registration for all events listed below are available on the calendar page.

Webinar: Medication Management in Ambulatory Care and Skilled Transitional Care Units

Friday, June 22, 2012, Noon – 1 p.m. (CT)

This RARE Campaign webinar will describe medication management in both ambulatory care and skilled transitional care unit settings. The presenters will describe a pilot project at Park Nicollet Health Services to improve transitions of care by evolving the role of the pharmacist, and how a consultant pharmacist and provider pharmacy can expand their roles and help reduce hospital readmissions by providing key services to patients during the transition from hospital to skilled nursing facility and skilled nursing facility to home. Speakers: Alison R. Knutson, PharmD, Pharmacist, Medication Management, Park Nicollet Health Services and Joe Litsey, PharmD, C.G.P., Director of Consulting Services, Thrifty White Pharmacy

Save the Date: November Action Learning Day

Tuesday, Nov. 8, 2012 – Date change!

The second of two RARE Action Learning Days for 2012 is set to take place at the Crowne Plaza in Plymouth. Additional information will be provided as it becomes available.


Quality Efforts Lift Facilities into Top 100 Hospitals (Modern Healthcare)

Hospice Care in ACOs Reduces Hospitalizations (Fierce Healthcare)

Study Links Hospital Infections to Readmissions (Modern Healthcare)

Area Agencies on Aging: Key Community Organizations for Successful Transitions

Lori Vrolson, Central MN Council on Aging and Dawn Simonson, Metropolitan Area Agency on Aging

Minnesota's aging network is ready and waiting to be tapped in local and statewide efforts to reduce avoidable hospitalizations of older adults. For years, Area Agencies on Aging have developed and delivered community-based services in concert with a field of provider organizations that help older adults remain independent at home. Many of these services are critical to health status following a hospital stay. Because what happens at home post-discharge often falls beyond the purview of the health care system, more older adults will bridge the hospital-to-home transition and avoid a repeat episode when hospitals and aging agencies work together.

Area Agencies on Aging provide a simple portal to find publicly subsidized, private and voluntary service networks. Engaging these networks and services in a coordinated strategy offers great potential to help older adults live well at home and avoid hospitalization altogether. Home-delivered meals and grocery delivery support adequate nutrition. Medication management services and assistance with Medicare Part D or other prescription drug payment issues help meet the intense medication compliance challenges faced by older adults at home. Transportation services ensure follow-up with the physician. Help with chores, homemaker services and home modifications create an environment essential to aid recovery and maintain health. Family caregivers need respite and coaching as they give hands-on care for loved-ones. It's not surprising that most supportive services are just as important over the long haul as they are immediately following discharge to reduce the overall risk of hospitalization when age and chronic disease combine to increase frailty.

Area Agencies on Aging offer access to networks of in-home and community-based services through their funded partners and via broader efforts that include a growing array of evidence-based chronic disease management and health promotion services. In addition to network connections, Area Agencies provide direct one-on-one consultation to older adults and family caregivers about service options through the Senior LinkAge Line partnership with the Minnesota Board on Aging. The Board contracts with Area Agencies to provide in-depth information and assistance services through one-on-one telephone consultation and in-person visits. Senior LinkAge Line specialists:

  • Know available service options
  • Understand which providers offer subsidized sliding fee arrangements
  • Can locate services in a patient's neighborhood
  • Use a person-centered approach to create a plan for using in-home supports
  • Link overwhelmed family caregivers with respite, support groups and coaches

The Senior LinkAge Line is available toll-free across the U.S. on weekdays at 1-800-333-2433. Hospital and other health care personnel are welcome to refer patients and to use the service as they create discharge plans and identify service needs. Another information source helpful to discharge planners and service coordinators at clinical health care homes is the state's searchable database,

Additionally, Area Agencies on Aging offer broad aging-related expertise, community connections, services and network development at the local level. For example, Area Agency Community Living Specialists help nursing home residents transition to home through the Return to Community program. Area Agencies are also expanding local evidence-based programs including the Chronic Disease Self Management Program, Chronic Pain Self-Management Program, Matter of Balance, Healthy Eating for Older Adults and other interventions to improve health and reduce falls.

Area Agencies view family caregivers as vital members of the health care team and provide leadership in understanding and addressing the needs of family caregivers. Some approaches include growing utilization of evidence-based tools and strategies to educate caregivers such as the Powerful Tools for Caregivers curriculum. Finally, Area Agencies can assist in convening community providers and participate in planning efforts to develop comprehensive community approaches to care transitions and other efforts that improve outcomes for patients. To contact your local Area Agency on Aging, go to:

Action Learning Day a Rousing Success

Stephen Jencks, MD, MPH On April 24, 2012 more than 180 people from 65 different organizations participated in the second RARE Action Learning Day. Readmissions expert Stephen Jencks, MD, MPH jump-started the day's activities with his thought-provoking remarks about the progress being made in reducing readmissions, challenging participants to, as Ghandi says, "Be the change you want to see in the world."

Jencks emphasized the importance of seamless communication, starting at the top; the need for patients and caregivers to understand what they need to do and be able to do it; and the imperative of not wasting time or resources. He also asserted that we should move from a provider-based to a population-based readmission rate, re-envisioning the hospital from an "isolated actor producing episodes of care to a community member invested in the success of all providers and the patient."

A panel discussion on "Care Outside the Hospital Walls" featured representatives from primary care, assisted living/home care, nursing homes, Area Agency on Aging/community services, skilled nursing facilities/transitional care units and a health plan care management organization. The focus was on the various types of services they provide and the role they play in helping to prevent avoidable readmissions. They also talked about how interactions between these organizations and hospitals can be improved, and what they're doing to improve transitions of care both to and from their facilities.

Allina Hospitals and Clinics, Fairview Health Services, Park Nicollet Health Services, Regions Hospital/HealthPartners and St. Cloud Hospital/CentraCare shared specific aspects of their progress, including leveraging an electronic health record to identify patients at high risk of readmissions; improving an electronic health record template summary of recommendations for outpatient providers; creating a care transitions coach to minimize confusion with multiple care coordinators; and developing care plans for high-risk patients with narcotic-seeking behavior.

The day concluded with a panel of patients who described their experiences of care throughout numerous hospitalizations. These moving stories brought many of the day's messages to life in a way that only patient experiences can, putting a human face on the processes and systems we work with every day:

  • Information and education mean power, for patients and their families.
  • Always remember the importance of the patient's family – however that patient defines family.
  • Our stories need to travel with us so all the different care providers understand our situations, even on a basic level.
  • Understand the importance of the gatekeepers, from waiting room receptionists to those who answer the phone. Their attitude and willingness to listen and try to help makes a huge difference in how the patient and their family feel about their care.

Jencks recommended everyone read the book The Checklist Manifesto: How to Get Things Right by Atul Gawande. Presentations and other materials from the day are available.

Webinar Summary: Challenging the Label of the Non-compliant Patient

Webinar presented by Eric A. Coleman, MD, MPH, AGSF, FACP, Professor of Medicine, Director of the Care Transitions Program, University of Colorado at Denver.

In our May 4, 2012 webinar, Dr. Eric Coleman cited the World Health Organization's estimate that patients do not follow medical advice 30 to 50 percent of the time. Pointing to the role of health care professionals in helping patients carry out their health care regimens, he suggested that providers and patients share the issue of "non-compliance."

Dr. Coleman talked about some of the factors he believes contribute to "non-compliance," including communication, the complexity of treatment regimens, and lack of trust between the physician and patient, as well as external pressures such as costs, time away from work, or no access to transportation. "All of us have been non-compliant at one time or another. Most patients are trying to be compliant," Coleman said. He believes patients comply with medical advice when it makes sense to them and seems effective, fits with their cultural beliefs, and can be carried out within the constraints of their lives.

Pointing to the "elephant in the room," Coleman described providers who blame the patient, then check out—"I did my job. I can't be responsible for the patient's behaviors." He suggested that we have to do a better job by taking more time with the patient and looking at the way we present information. He also encouraged providers to look at their own motivations. Restoring patient autonomy through shared decision-making and encouraging patients to create their own care plans may challenge the provider's agenda.

Meeting patients where they are– in other words, customizing their treatment according to their level of cognition, health literacy and activation– can help increase ownership of their own care. How much do they understand? What is their "workflow"? For example, does a patient's system of taking his pills when the TV show The Price is Right comes on work well enough? Would it necessarily be better to implement a 'standard routine' that may not fit his schedule?

Coleman recommended improving communication—and outcomes—by asking open-ended questions, using the teach back model, simplifying treatment regimens, and, most importantly, listening more and talking less. He advocated evaluating and documenting a patient's health literacy, cognition, language, and learning style in the electronic health record, right from the beginning. Coleman asked whether our lengthy, complex assessments, care plans, and patient education materials encourage or stifle patient activation. He offered suggestions such as establishing a patient simulation lab where patients can try out their discharge instructions and considering financial incentives and penalties for patients. Finally, he asked, "Isn't it time to retire the "non-compliant" label?"

ICSI Colloquium Workshop Addresses Medication Management

Brian Isetts, RPh, PhD, BCPS, Centers for Medicare & Medicaid Services and a Health Policy Fellow, facilitated a highly interactive ICSI Colloquium pre-conference workshop entitled "Co-creating a Medication Management System for the Triple Aim." Workshop attendees heard first from a patient with a significant medical history including two kidney transplants and two hip replacements that at one point was taking 26 different medications for the management of multiple conditions. This patient's experience highlighted the need for, and benefits of, comprehensive medication management.

Presenters addressed such topics as comprehensive medication management, medication therapy management (MTM) experiences in Minnesota, drug therapy challenges, and overall opportunities for improving health care related to medication therapy. A panel of Minnesota health care stakeholders engaged the audience in a discussion of provider, payer and employer perspectives related to medication management.

Finally, David Schulke, Vice President, Research Programs, Health Research and Educational Trust described two national initiatives to improve medication safety and reduce hospital readmissions, reviewed problems of medication safety and drug-related hospital readmissions and discussed effective approaches suggested by ongoing learning networks.

The presentations from this workshop are available

Hospital Executive Talks About Implementation Barriers

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. In this issue we asked:

"As your implementation progresses, what has arisen as your biggest barrier to success? How are you overcoming that barrier?"

Jason Breuer, Administrator, LakeWood Health Center, Baudette, MN

We had identified a need to improve our transition care and communication between departments within and outside of our facility, based not only on the RARE Campaign organizational assessment, but also on our AHRQ Patient Safety Culture Survey from the fall of 2011. Each of our departments currently utilizes its own patient hand-off form, so changing to one standard transfer form has proven to be a bit of a challenge. Each department had both similar and different ideas about what should be incorporated into the form. We knew we couldn't have a three or four-page document, so the team had to compromise.

Along with RARE, we are participating in the Safe Transitions program through the Minnesota Hospital Association (MHA), and both programs have provided many helpful resources. Our Safe Transitions team, which includes leaders from acute care (including the emergency department), long-term care, assisted living/home health, clinic, health information management and quality/patient safety, developed a preliminary patient transfer form using MHA's core elements as safety absolutes. In addition to these absolutes, the team also compromised on many "must haves" such as assistive devices, immunization status, and activities of daily living. The final document is two pages, front and back, and will provide patient care workers a quick reference while still incorporating all the "must have" elements of each department.

Once the rollout is complete this document will be a great improvement, because not only will all staff be familiar with it, it will also decrease the time spent searching to locate important patient information. Currently we are still documenting on paper, although we are slotted to go live with Meditech 6.0 in June of 2013. The document will improve our current hand-off process until that time. Overall, this program is and will be a great asset to all the work that we are doing around patient safety, not only with MHA and the RARE Campaign but also with Catholic Health Initiatives, our parent company.

Campaign Updates

VHA Joins RARE Campaign as Supporting Partner

VHA Upper Midwest (VHAUM), a member-owned and driven health care organization focused on assisting members to achieve top performance scores in economic, clinical, and operational indicators, has become a supporting partner of the RARE Campaign. VHAUM is a regional office of VHA, Inc. and serves members in Minnesota, Wisconsin, South Dakota, North Dakota, Illinois and Pennsylvania. Many of its Minnesota hospital members are currently enrolled in the RARE Campaign.

"VHAUM is very happy to become actively involved in the RARE Campaign. Stratis Health, ICSI and MHA have taken great steps in coordinating data, expertise, and resources to reduce avoidable readmissions," commented Rob Welch MD, Vice President of Clinical Affairs at VHAUM.

"We share the commitment to improvement, collaboration of like-minded partners, and the efficient use of our collective resources in support of the health systems we serve. We are committed to the Centers for Medicare & Medicaid Services Partnership for Patients (PfP) goals and to accelerating the rate of improvement as an outcome of the collaboration. VHA's mission is to consistently deliver expert guidance and solutions that drive exceptional performance for its members. Engagement in the RARE Campaign aligns with our mission, serves participating health systems, and, most importantly, helps make care safer for patients," Welch added.

VHA Inc., based in Irving, Texas, is a national network of not-for-profit health care organizations that works together to drive maximum savings in the supply chain arena, set new levels of clinical performance, and identify and implement best practices to improve operational efficiency and clinical outcomes. Since 1977, VHA has leveraged its expertise in analytics, contracting, consulting and networks to help members achieve their operational, clinical and financial objectives.

Mini-Pillows Helps Roseau Physicians Keep RARE Efforts Top-of-Mind

Colleen Klamar, RN, RARE Project Leader, LifeCare Medical Center, Roseau, MN

Mini pillows We all know that physicians have a lot to remember. Our RARE team wanted to be able to talk to our physicians more easily about RARE, so when we presented the RARE Campaign and our local plan to reduce avoidable readmissions, we gave them each a token mini-pillow. Our administrative assistant sewed the little pillowcases out of plain white cotton. We printed the RARE logo in reverse to iron-on fabric transfer, ironed the logo onto each pillow, and placed a travel size pack of tissues inside. Although we can't prove that this is helping improve physicians' awareness of the RARE Campaign, we plan to highlight the little pillows in future presentations, instead of carrying our own big pillows with us. This was a fun little project to help brighten the RARE way!

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:

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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.