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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - August 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, News and Web Updates
  3. Using Epic to Standardize Post-Discharge Follow-Up Calls
  4. Case Studies Illustrate the Role of Aging Networks in Support of Older Adults
  5. Executive Q&A: Communicating the Importance of RARE

The Data Is In!2012 Quarter 1 RARE Campaign Results

The RARE data is in and avoidable readmissions are down! The Minnesota Hospital Association recently released the latest Potentially Preventable Readmissions (PPR) data for first quarter of 2012, and since January 1, 2011 the RARE Campaign hospitals have prevented 2,607 avoidable readmissions. For the first quarter, the PPR data showed that the actual number of readmissions decreased by 13 percent over the expected number. We are well on our way toward our goal of decreasing avoidable readmissions by 20 percent by December 31, 2012 and providing 16,000 more nights of sleep at home!



Upcoming Events, News and Web Updates


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

Webinar: Meaningful Use and the RARE Campaign
Friday, August 24, 2012, Noon – 1 p.m. (CT)
Speaker: Paul Kleeberg, MD, Chief Medical Informatics Officer at Stratis Health and Clinical Director of the Regional Extension Assistance Center for HIT (REACH) for Minnesota and North Dakota. This presentation will help make the connection between meaningful use and the reduction of avoidable hospital readmissions and provide examples of how this can be accomplished. Registration closes on Tuesday, August 21.

Webinar: Improved Care Transitions for Mental Illness and Substance Use Disorder
Tuesday, October 2, 2012, Noon – 1 p.m. (CT)
Speakers: Paul Goering, MD, Vice President and Executive Medical Director at Allina Health, and Michael Trangle, MD, Associate Medical Director, Behavioral Health at HealthPartners Medical Group. Watch your email and the events calendar for details and registration information.

Introducing RARE Conversations
Beginning in October, the RARE Operating Partners will offer a new opportunity for participating hospitals and Community Partners to share, learn and network with one another: RARE Conversations. These one-hour webinar/conference calls will take place approximately every month and feature one or two organizations sharing for 10 minutes each on their work related to the selected topic. After the presentations, participants can ask questions and share ideas. These sessions will be recorded and posted on the RARE website, along with a summary of what was presented.

The planned topic for our first RARE Conversation is risk stratification and how it impacts care. Future topics may include post-hospitalization patient contact and the role of pharmacy in preventing avoidable readmissions. If you have topic ideas, you can contact your RARE Resource Consultant or send an email. Additional details about the first conversation, including the date and registration information, will be available soon.

Long-Term Care Consultation Expansion 2.0
August-September, 2012
During the 2012 legislative session the Long Term Care Consultation (LTCC) Expansion statute was amended, and as a result, hospitals and health care homes will be required to follow new referral protocols effective October 1, 2012. The Minnesota Board on Aging and the Minnesota Department of Human Services, Aging and Adult Services Division, have scheduled presentations where social workers/discharge planners in various health care and long-term care settings, LinkAge Line staff, social workers, services managers at senior housing and others can learn more about the changes and how the business process will be implemented when the law takes effect on October 1.

The LTCC Expansion 2.0 two-hour presentation is being offered at various locations across Minnesota during August and September. Additional information about this change and the complete schedule of presentations.

MAPS Annual Conference
October 24-26, 2012
The annual conference of MAPS, the Minnesota Alliance for Patient Safety, will be held October 25 – 26, 2012 at the Minneapolis Marriott Northwest in Brooklyn Center, with a preconference on October 24. The conference will feature a number of sessions relevant to preventing avoidable readmissions, including one focused specifically on the RARE Campaign, along with medication management, patient engagement, and communications. Additional information and registration.

Eric Coleman Keynotes November Action Learning Day
Thursday, November 8, 2012
The second of two RARE Action Learning Days for 2012 is set to take place at the Crowne Plaza in Plymouth. The agenda is taking shape, and Dr. Eric Coleman, director of the care transitions program at the University of Colorado in Denver, will be our keynote speaker. Registration and other information will be available soon.


Hospitals Face Penalties if Patients Quickly Return (Star Tribune, Newspaper of the Twin Cities)
This August 14, 2012 article provides an overview of the new Medicare program that penalizes hospitals for higher-than-average rates of readmission. The penalties were part of the 2010 Affordable Care Act and take effect on October 1, 2012. Read the article

A Plan for Post-Acute Care Providers Looking to Better Coordinate Care ( via Readmissions Update E-newsletter)
The Medicare Hospital Readmission Reduction Program (HRRP), which will lower Medicare payment rates for hospitals with greater-than-expected 30-day readmission rates for specific conditions, goes into effect October 1, 2012. This change will make hospitals increasingly interested in partnering with high-performing post-acute providers. In this June 26, 2012 article, the author recommends four steps for post-acute providers to take advantage of this opportunity: 1) follow the data on readmissions, 2) design and document readmission-reducing programs, 3) communicate results to hospitals, and 4) initiate collaborations with hospitals. Read the article.

AHRQ Releases Training Modules to Help Improve Safety in Nursing Homes (AHRQ Newsletter)
In its August 10, 2012 newsletter, Agency for Healthcare Research and Quality (AHRQ) announced a new set of training modules to help educate nursing home staff on key patient safety concepts to improve the safety of nursing home residents. Each module features an instructor's guide and a student workbook. Training of nursing home staff, including support for teamwork across specialties, is likely to be effective in reducing medical errors and improving patient safety and can help reduce the number of falls and fall-related injuries. Training modules

Perceptions of Readmitted Patients on Transition from Hospital to Home (Journal of Hospital Medicine)
This August 7, 2012 article reports on the results of a survey that asked readmitted Pennsylvania patients about the challenges they faced in the transition from hospital to home. Read the article

Study Profiles Patients Likely To Be Readmitted to the Hospital for Congestive Heart Failure (AHRQ Newsletter)
A new AHRQ-funded study suggests characteristics of patients likely to be readmitted to the hospital after an admission for congestive heart failure. Analyzing data from 14 states that participate in AHRQ's Healthcare Cost and Utilization Project (HCUP), researchers determined that congestive heart failure patients with the strongest likelihood of readmission were: discharged against medical advice; covered by Medicaid; and had more severe loss of function and certain comorbidities such as drug abuse, renal failure, or psychoses. High readmission rates for Medicaid patients suggest that state and federal governments should target these populations for better care coordination to reduce readmissions and health care costs, according to study authors. The study, "Congestive Heart Failure: Who Is Likely to be Readmitted?" was published in the May 31, 2012 online issue of Medical Care Research and Review. Read the article

Using Epic to Standardize Post-Discharge Follow-Up Calls

Andrea Altmann, RN, MS, Director, Essentia Telecare Services

Essentia Health's Nurse Care Line in action, Heather Erickson, RN, Cammie Jezierski, RN, and Leanne Becker, RN.

In December 2011, Essentia Health decided to standardize how we make post-discharge follow-up calls to help reduce avoidable readmission rates. We created a centralized approach that allows for collection of meaningful data that is then analyzed to determine where opportunities exist to reduce readmissions. The process owner for the follow-up calls is the Essentia Health Nurse Care Line department, which is staffed 24/7 by registered nurses who have expertise performing patient assessment, triage, and education over the phone.

Essentia Health utilizes Epic for our electronic health record (EHR), which allows us to leverage technology to capture data and standardize the process. Patient registries, pulled from Epic, identify the patients that should be contacted following a hospitalization. This includes patients with a diagnosis of congestive heart failure, acute myocardial infarction, cardiopulmonary disease or pneumonia at some point during their inpatient admission. However, these patient registries are only as good as the accuracy of inpatient diagnosis codes. Proper diagnosis coding by the clinician is necessary to capture all patients who should be contacted following discharge.

Opportunities still exist for our physicians and clinicians to more accurately and completely capture diagnosis codes during the inpatient stay, but as a result of this program we are now better able to identify where the coding deficits are taking place, and educate clinicians on how to more accurately code the diagnosis.

In order to meet our goal of creating a standardized, measurable and centralized approach, a documentation and data collection tool for post-discharge calls was created using Epic's Telephone Encounter category. In order to maintain a standard approach to documentation, a smart phrase was created that is used in the documentation of each call. The team worked to determine what assessment questions and teach back methods were necessary during the post-discharge follow-up call, and then embedded discreet data points within the smart set that the nurse uses to document the outcomes of the call.

Use of this smart phrase is an example of how we were able to leverage Epic to provide standardized documentation that also gives us the data we need to analyze outcomes. As a result, we know where we have opportunities for further improvement, such as more timely scheduling of follow-up appointments as part of the discharge process.

Overall, this centralized approach and standardized documentation supports downstream data collection and analysis and is helping Essentia Health uncover opportunities to improve discharge planning, helping us meet our ultimate goal of reducing avoidable readmissions and improving patient outcomes.

Case Studies Illustrate the Role of Aging Networks in Support of Older Adults

The July 24, 2012 podcast The Aging Network - Helping Older Adults Live Well at Home Today is available.

Metropolitan Area on Aging 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. The AAAs act as regional hubs for a nationwide home- and community-based service system that develops and delivers non-medical services to help older adults maintain independence at home. Short or long-term services and support are essential to maintaining elders in their homes with dignity and safety—and can help avoid hospital readmissions. The AAAs are able to assess elders in need and provide links to community-based services including those related to medication management, meals, health care payment issues, memory loss, lack of follow-up with primary care provider, safety, home health care services, caregiver respite, caregiver training, environmental modifications, and concurrent health conditions.

Written summaries of the case studies presented in the webinar are posted as well. They cover three scenarios:

Minnesota Council on Aging logo
  • A call by an overwhelmed caregiver to the Senior LinkAge Line. The local aging network provides extensive assistance to evaluate the older adult's home situation and ability to self-manage chronic illness. Family members are educated about Medicare reimbursement, home care resources, and community long-term care options.
  • An elder living alone is recently released from the hospital and is at high risk of readmission. The local aging network creates an action plan to address each risk factor.
  • An older adult who is in danger of needing to leave her home due to lack of basic support systems. The local aging network works with agencies and neighbors to create support systems for this elder.

Find the podcast and related materials on the recorded webinars page of the RARE website.

Executive Q&A: Communicating the Importance of RARE

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:

"How are you communicating your RARE activities, and the importance of the campaign, within your organization?"

Kathryn Correia, President & CEO, HealthEast Care System

HealthEast Care System kicked off communications about the RARE Campaign in fall 2011. Rahul Koranne, MD, medical director at Bethesda Hospital, and Pennie Viggiano, system director, government and special populations, have been the champions of HealthEast's efforts..

HealthEast has been a pioneer in how hospitals can innovate the patient transition from in-patient care to the community. The RARE Campaign aligned with these same goals: better preparing patients for home or self-care, and improving communication and coordination as the patient transfers from the hospital to another care provider.

After introducing the campaign to our employees through our online employee newsletter, we have shared monthly results from the Minnesota Hospital Association (MHA), data from internal scorecards and other information from our organization to the hospitals' care management leadership teams. The data is reviewed at the care management/length of stay steering committee that includes short-term acute care hospital leadership (the care management manager, medical director and patient care executive) as well as system leadership including our chief medical officer, chief nursing officer and chief medical quality officer.

Those committee members carry forward information to others in HealthEast. For example, some data has been shared with the physician hospitalists, medical director committees and quality committees. I believe that broad communication about the RARE Campaign's progress will contribute to its success, both at HealthEast and among all participating organizations.

Steven Mulder MD, President & CEO, Hutchinson Area Health

Hutchinson Area Health Care's participation in the RARE Campaign will play an important role in our transition from the world of pay-for-volume to pay-for-value, and we are working to communicate to all staff what is happening with this effort.

The first line of communication is with the service areas directly involved, especially the medical/surgical service. RARE has been an important and ongoing agenda item for service area meetings. It has also been discussed at the Medical Staff Medicine Committee, informing physicians about what is happening, how it affects them, and how they must be part of the process. There are binders that chronicle the story of RARE and our participation in it, which are distributed to service areas and in the Medical Staff lounge. Future plans include a presentation to our Board of Directors and to our Hospital Auxiliary.

The collaborative learning model of the RARE Campaign has been of great value to Hutchinson Area Health Care, and we look forward to building on the foundation that is being established to enhance preventive and coordinated care.

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.