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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - June 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. Upcoming Events and News
  2. Park Nicollet Piloting an EHR Tool to Identify Patients at High Risk for Readmission
  3. ConnectCare Brings Home Care Perspective to Hutchinson Area Health Care’s RARE Team
  4. Hospital Executives Share How Their Staffs Stay Motivated

Upcoming Events and News


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

Webinar: The Aging Network - Helping Older Adults Live Well at Home Today
Learn how Minnesota’s seven Area Agencies on Aging (AAAs) and their local service networks help older adults recover from acute illness, manage chronic conditions and prevent injurious falls.
Tuesday, July 24, 2012, Noon – 1 p.m. (CT)
Speakers: Dawn Simonson, MPA, Executive Director, Metropolitan Area Agency on Aging, Inc. and
Lori Vrolson, MA, Executive Director, Central Minnesota Council on Aging

Save the Date: November Action Learning Day
Tuesday, Nov. 8, 2012
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.


RARE Campaign Featured in The Hospitalist
The RARE Campaign is featured in the June 13, 2012 edition of The eWire, an online publication of The Hospitalist. The article includes comments by ICSI’s Kathy Cummings, project manager for the RARE Campaign and Howard Epstein, MD, ICSI’s Chief Health Systems Officer and a hospitalist at Regions Hospital in St. Paul, MN. Read more >

HCAHPS Survey Expanded
The expanded Hospital Consumer Assessment of Healthcare Providers and Systems Survey (HCAHPS), a national, standardized, publicly reported survey of patients’ perspectives of hospital care, includes three new questions related to discharge. The expanded survey is voluntary starting with July 1, 2012 discharges. The new questions are:

  • During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left.
  • When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.
  • When I left the hospital, I clearly understood the purpose for taking each of my medications.

The deadline to submit materials for approval to self-administer the survey was May 14, 2012. Hospitals that missed the deadline can submit revised materials. Hospitals need to work with an approved vendor to administer the expanded survey. The approved vendors are listed on the HCAHPS website. For assistance, contact HCAHPS Technical Support via email at or call 888-884-4007.

The Centers for Medicare & Medicaid Services publishes HCAHPS results on the Hospital Compare website four times a year, rolling the oldest quarter of patient surveys off and the newest quarter on each time.


Embedded Nurse Care Managers Curb Readmissions (Fierce Healthcare)

Piloting an EHR Tool to Identify Patients at High Risk for Readmission

Madeline Emahiser, project manager for readmissions at Park Nicollet Health Services, shares a summary of their pilot project presented at the April 24, 2012 Action Learning Day.

“I want to see something in January,” said David Abelson, MD, president and CEO of Park Nicollet Health Services. Those words in December 2011 set the readmissions team at Park Nicollet on a mission to develop a tool within its electronic health record (EHR) system that would help identify patients at high-risk for readmission. Once these patients were identified, Park Nicollet would fine-tune its resources and partner closely with patients to prevent avoidable readmissions.

Emahiser with pillow The team connected with local researchers, conducted a literature review and then worked with the application specialists for its EHR system, Epic. The team focused on four goals:

  1. Devise a working model that could be put in place quickly.
  2. The information provided should be as real-time as possible.
  3. The information needed to be visible to all care team members.
  4. The information used was to be obtained from the electronic patient record with no additional data collection by the nursing staff.

The result was a tool that utilized a flow sheet format in the EHR. The variables they chose to monitor are associated with a weighting system to determine if a patient is at high-, medium-, or low-risk for readmission. The flow sheet and scoring are updated each time the record is saved so the information is as current as possible. The electronic record of each high-risk patient is flagged with a bright red banner across the top.

The team then developed a process to focus Park Nicollet’s staff and resources to help the high-risk patients avoid readmission.

  • Every day, the care integration team (case managers and social workers) reviews patients in the hospital to understand which are deemed high-risk for readmission. They work closely with these patients throughout their discharge process and make sure they have a primary care provider.
  • Health unit coordinators use workstations on wheels to schedule post-discharge follow-up appointments right from the patient’s room. For any high-risk patient that plans to discharge to home, the follow-up appointments are scheduled within three to five days. The unit coordinators now have direct access to clinic schedules to make appointments themselves, rather than having to call an appointment line. There also is a specific code for post-discharge appointments and notations for ambulatory care teams indicating that the patient is at high risk for readmission.
  • All patients (not just those at high risk) receive a phone call from a nurse 24 hours after being discharged. This additional connection with the patient allows them to address any lingering questions or concerns about their post-discharge plan.

With this system in place, Park Nicollet is setting the stage for all care team members to effectively transition the patient between care environments and prevent avoidable readmissions from occurring. Madeline Emahiser, project manager for readmissions, is especially proud that the team met its goal of not adding to the workload of its nursing staff. “We didn’t add any additional documentation to the current nurse workload, nor have we requested that the nurses do anything differently at this time. Most of the burden is actually shouldered by our Care Integration Team,” Emahiser commented. However, she pointed out that since there are no ‘hard stops’ in the system to force documentation, the tool’s effectiveness is reduced if documentation isn’t complete.

The Park Nicollet team sees opportunities to improve the tool in its next iteration, and plans to implement an updated version before the end of 2012. “To increase our tool’s predictive accuracy, we are working to incorporate items related to coding and health care utilization,” Emahiser said. A future goal is to leverage the Epic User’s Group to standardize a similar risk assessment across all Minnesota users of the Epic EHR system.

For more information about Park Nicollet’s high risk of readmissions tool, contact Madeline Emahiser, Park Nicollet Health Services, Quality Improvement and Planning Support.

ConnectCare Brings Home Care Perspective to Hutchinson Area Health Care’s RARE Team

Monica Stanton of ConnectCare describes how this Hutchinson, MN home health agency is partnering with Hutchinson Area Health Care, a RARE participating hospital, to provide better care for their mutual patients.

ConnectCare logo Medication lists for a discharged hospital patient can be hard to reconcile for a home health agency. This issue launched a strong problem-solving relationship between Hutchinson Area Health Care, a 66-bed hospital, and ConnectCare, a home care and hospice agency with an average daily census of 100 clients.

Hutchinson RARE Team “We started meeting prior to RARE, having a few very basic discussions about medication lists,” said Monica Stanton, ConnectCare COO. “When RARE came along, it took us into an entirely new direction, expanding our work together.”

Participating together in a Care Transitions Collaborative in early 2011, the two organizations identified a list of opportunities for improvement so they could provide better care for their mutual patients.

“Our ideas just flowed like water,” noted Stanton. “It was important for us to see how our work creates challenges for each other—whether it’s between the hospital and home care, or between individuals at each of the systems. We all had things we could learn about the other.”

ConnectCare participates on the hospital’s RARE Team (pictured at left), serving as a representative for all home care agencies working with the hospital. The team has made great headway on a number of issues they identified.

Opportunities for Improvement


Success Strategies Implemented

Transition to hospital:

  • Hospital unaware of the home care services patients received prior to hospital admissions
  • Home care unaware of the admission
  • Inconsistent discharge planning resulting from hospital’s lack of knowledge of baseline services prior to admission

Post transition from hospital:

  • Medication errors
  • Confusing discharge instructions
  • Patient follow up was too long after hospitalization
  • The hospital’s medical record will include documentation of baseline care needs of patients age 65 and over 90% of the time.
  • Home care agencies will be notified 90% of the time when a client has been hospitalized.
  • Discharge medication reconciliations will be accurate 90% of the time based on double verification of the discharge medication list per the clinical pharmacist or nursing.


  • Baseline care needs/ services screening tool
  • Home care notification/ communication tool to request home care plan of care, medication list and advance directive
  • Discharge risk screening tool to identify low-, medium- and high-risk discharges
  • Post-discharge feedback tool


One of the first steps the team took was to develop the home care communication tool to notify home care agencies when their patients are admitted to the hospital. ConnectCare wants the hospital to be aware of the services the patient was receiving prior to admission. Also, the hospital’s new risk screening tool allows it to make more appropriate referrals to home care agencies.

Most recently, the hospital educated its staff on how to teach its chronic obstructive pulmonary disease (COPD) patients about inhalers using teach-back techniques. Stanton put that information into a packet and used it to review the materials at the agency’s nurses meeting to provide the same education. The RARE team’s future work includes advanced care planning and Honoring Choices.

“Home care and hospitals each need the other to be successful to achieve the best outcomes for our mutual patients,” said Stanton. “I feel so strongly that this is how we can better serve our patients. These are our relatives, friends and neighbors. Everyone has an important story and a family who loves them. Everyone deserves to be well cared for.”

Hospital Executives Share How Their Staffs Stay Motivated

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:

“Do you have a personal readmissions story that motivates you and your hospital staff to keep working on this issue?”

Mike Hagen, CEO, EdD, Riverwood Health Center, Aitkin, MN

When we started this project, our RARE team selected congestive heart failure (CHF) as the patient group that we would work with to identify and address care issues that prevent avoidable readmissions and improve our patients’ quality of life. The team invited representatives from home health care, hospice and nursing homes to participate.

It has been an exciting project as it also involves many internal services, including dietetics, physical and occupational therapy, cardiopulmonary, pharmacy, nursing, social services and medicine. A patient teaching tool was developed to address all aspects of care, and a pathway was designed to provide this education over a three-day period.

One of the first things the team discovered was that many patients do not own a scale and don’t have the resources to purchase one. Monitoring daily weight gives an important measure of how patients are doing and offers early recognition of when to seek treatment in the clinic, preventing an ER visit that could lead to hospitalization. To ensure that patients are able to monitor their weight at home, scales are now given to those who otherwise would not have the resources to obtain one. The team starts the teaching in the hospital and the external agencies continue it when the patient is discharged.

This project has brought everyone to the table with a common goal of improving the quality of life for our CHF patients. It is truly rewarding to see a newly diagnosed CHF patient work with the team and take ownership of managing their health care, and helps keep us all motivated to continue working to prevent avoidable hospital readmissions.

Bruce Johnson, BSN, MA, Performance Excellence Project Manager, Hennepin County Medical Center, Minneapolis, MN

Hennepin County Medical Center chose to participate in the Project RED collaborative. As a result of changes we are implementing as part of that work, we are confident that we are able to prevent many avoidable readmissions. One case stands out involving a patient we’ll call Joan who was admitted to the hospital due to worsening depression. She also was dealing with a leg fracture and suffered from other chronic health problems.

The Saturday prior to her planned discharge, scheduled for Monday, Joan left the hospital with her husband on a pass and did not return. The physician called in her prescription to the pharmacy, and the discharge advocate (DA) called her the next day. She was not doing well, and reported that although she had picked up her medications, she had not started them. The DA strongly encouraged Joan to take her medications, go to her doctor appointments and attend the transitions group meeting that is part of the medication therapy management (MTM) program. The DA also made a home visit, where he encouraged the patient, reviewed her appointments and made a referral for a visiting nurse.

While Joan has missed some appointments, she was able to follow up in the psychiatric clinic with most of her providers and obtained her medication. Without Project RED, Joan probably would not have restarted her medications and her condition likely would have worsened. Without the follow-up phone calls and home visit, she may have missed many follow-up appointments and been readmitted to the hospital. Stories like this are a powerful motivator to all of us at HCMC to continue our work that helps patients spend more nights in their own bed.

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.