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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - September 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, News and Web Updates
  2. Impact of Hospital Readmissions Penalties in Minnesota
  3. Community Partners Implementing Best Practices; Want to Do More
  4. Work Group Tackles Improvements to Epic EHR
  5. Executive Q&A: Keeping RARE a Priority

Upcoming Events, News and Web Updates


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

Webinar: Improving Care Transitions for Patients with Mental Illnesses and/or Substance
Use Disorders

Tuesday, October 2, 2012, Noon – 1 p.m. (CT)
Patients with mental illnesses and substance use disorders face unique care coordination challenges following hospitalization. This webinar will describe factors that are associated with increased risk for readmissions in this patient population, along with specific interventions that can improve care transitions. 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. This webinar is full. The podcast will be available on this website a week after the event.

Identifying Patients Most at Risk for Readmission: Join the Conversation
Tuesday, October 30, 2012, Noon – 1 p.m. (CT)
In response to participant requests for more opportunities to informally share and engage in conversation with each other about readmissions, RARE is hosting RARE Conversations. Don’t miss this exciting new opportunity for participating hospitals and Community Partners to share, learn and network with one another. These one-hour webinar/conference calls will feature one or two organizations sharing for 10 minutes each on their work related to the selected topic. Afterward, the call will be opened to all participants to share their experience on the topic or ask questions of each other. The sessions will be recorded and posted on the RARE website, along with a summary.

The first RARE Conversation will focus on identifying patients at greatest risk for readmission, which can help target the delivery of resource-intensive interventions. Hennepin County Medical Center and Park Nicollet Health Services will share how they identify and deal with high-risk patients. Come prepared to talk about what your organization is doing in this area and what you are learning.  Sign up by October 26, 2012. More information.

Action Learning Day: “Sustaining the Gains and Moving Forward”
Thursday, November 8, 2012
This Action Learning Day will closely follow the format of April’s highly successful event. It is being held at the Crowne Plaza in Plymouth and will feature a keynote address by Eric Coleman, MD, MPH, director of the care transitions program at the University of Colorado in Denver. A patient panel will be included, and is earlier in the day based on your feedback. And because we know the value and importance of learning from each other, we are again including ‘Rapid-Fire’ presentations, and invite you to share your improvement strategies and projects.  It’s easy – a formal presentation is not required - and is a great way to highlight your organization’s accomplishments around reducing avoidable readmissions!

Selected organizations will have 10 minutes to share an aspect of their current work followed by 10 minutes for audience questions/comments. We are particularly looking for examples of reaching across the continuum of care to involve partners outside the hospital walls, and encourage participation from both Community Partners and participating hospitals.

If you are interested, please complete the Rapid-Fire application and return it to Rochelle Hayes by Friday September 28, 2012. For assistance or questions, contact Rochelle at 952-814-7098.

You won’t want to miss this key RARE Campaign event! You’ll come away with new ideas and renewed energy to tackle the work of reducing avoidable readmissions. Register today.

MAPS Annual Conference and Preconference
“Accelerate: Taking Patient Safety to the Next Level”
October 24-26, 2012

The Minnesota Alliance for Patient Safety (MAPS) conference provides practical strategies and tools to accelerate and sustain advances in patient safety. Health care providers interested in exploring patient safety issues and health care trends should plan to attend this conference at the Minneapolis Marriott Northwest in Brooklyn Park. Highlights include an opening keynote by Regina Benjamin, MD, U.S. surgeon general, and sessions led by national patient safety experts, including:

  • National speakers on patient safety, health care trends and leadership
  • Highlights of local patient safety improvements
  • Meaningful patient and provider stories

Additional information and registration


Hopkins Study: Nurses, Pharmacists Should Work More Closely (Baltimore Business Journal)
Hospitals that pair nurses and pharmacists in teams may have a better chance at reducing medication mix-ups, according to a study by Johns Hopkins University of School of Medicine researchers. This August 1, 2012 article notes that a study involving about 560 patients at Johns Hopkins Hospital showed that the hospital could reduce the risk of medication errors and save money by having nurses and pharmacists work together to look for discrepancies between drugs a patient is already taking at home and what is prescribed at the hospital. The study was published in the Journal of Hospital Medicine. Read the article

Beacon Trial Reduced Readmissions of Heart Patients to 3% Using Home Video Conferences (MedCity News, Indiana)
A nurse version of Max Headroom was the key to reducing hospital readmissions to 3 percent among some of the sickest patients in Indianapolis. In the September 12, 2012 article, Dr. Alan D. Snell, the chief medical informatics officer at St. Vincent Health in Indianapolis, said the focus of the Central Indiana Beacon Community project was a month of videoconferences between nurses and people with congestive heart failure and chronic obstructive pulmonary disease. The goal was to keep these patients out of the hospital. Read the article


The following new resources have been added to the RARE website: 

Impact of Hospital Readmissions Penalties in Minnesota

Mark Sonneborn, Vice President of Information Services at the Minnesota Hospital Association

The Hospital Readmissions Reduction Program (HRRP) measures 30-day readmissions for Medicare patients when the first admission was for pneumonia, heart failure, or heart attack. The current report is based on Medicare claims data for the three-year time period of July 2008 through June 2011. Penalties are assessed when the measurement shows a hospital has excess readmissions from the risk-adjusted average. The maximum penalty this time period is one percent, which is applied to all Medicare inpatient payments, not just those for the three conditions that are measured. The maximum penalty will increase by 0.25 percent each year until it reaches two percent.

Only Prospective Payment System (PPS) (larger hospitals) are measured. Of the 52 PPS hospitals in Minnesota, 29 must pay a penalty. The penalties for Minnesota hospitals range from 0.01 percent to 0.81percent. The average penalty, not counting the hospitals that received no penalty, is 0.18 percent. This translates to around $2.5 million in penalties. Minnesota has the 14th lowest average penalty at 0.10 percent (including the 23 hospitals with no penalty). The average penalty nationwide was 0.28 percent.

In looking at the two data sources (Potentially Preventable Readmissions (PPR) and the CMS HRRP), we believe there is a correlation, but there are some key differences. PPR is all-payer; CMS is Medicare-only. PPR only measures same-hospital readmissions, but CMS measures readmissions to any hospital. PPR excludes readmissions deemed unpreventable; CMS does not. We believe that reductions in PPRs will eventually result in reductions in the CMS data. We say ‘eventually’ because CMS uses three years of data and only one-third of the data is updated each year.

The impact of the RARE Campaign in Minnesota can be seen in fewer observed readmissions compared to expected readmissions since 2009, using PPR as our measure. However, the goal of reducing PPRs by 20 percent hasn’t been met yet. Reducing readmissions is a multi-faceted issue, but the RARE Campaign has helped to focus our efforts.

Although many efforts to reduce readmissions had been underway over the last several years, the HRRP was one of the first large-scale efforts to attempt to align payment policies with actual performance. There are now other payment policies and penalties that incent providers to reduce readmissions, so the RARE Campaign is very well timed.

We are confident that the work of the RARE Campaign will not only give Minnesotans 16,000 more nights of sleep at home, but will also help to minimize hospital penalties under the Hospital Readmissions Reduction Program.

Community Partners Implementing Best Practices; Want to Do More

In August, RARE Community Partners responded to an engagement survey to help us learn from their successes, assess the impact of the campaign to date, and plan for future work to improve transitions across the continuum of care and reduce avoidable readmissions. Of the 27 respondents, 44 percent represented provider groups such as assisted living, home health agencies or nursing homes. Other respondents included health plans, professional and trade associations, and state agencies.

All of the provider groups indicated that their leadership had a high awareness of the factors that impact readmissions. Based on their feedback, additional efforts to increase awareness among pharmacists, providers and other staff could be beneficial.

Rate your organization’s awareness about factors that impact readmissions







Not applicable

Care managers







Leadership (e.g. CEO, COO)














Providers (direct care providers, i.e. physicians, nurses)







Staff (e.g. nurses aides)







The majority of provider groups have implemented practices in the five key areas to improve care transitions/reduce hospital readmissions. Future issues of the RARE Report will share their success stories.

Practices implemented by Community Partner provider groups



Not implemented

Comprehensive discharge planning



Medication management



Patient and family engagement



Transition care support



Transition communication



Community Partners expressed an interest in having greater involvement in the RARE Campaign and in working more closely with participating hospitals to help people avoid unnecessary hospital visits. A sampling of the input provided:

  • “Provide some venue to get hospitals (discharge planners or their operations managers) to meet with MCO care management and problem solve together and identify better means of communication/collaboration.”
  • “Convene opportunities for joint discussion of hospitals with Community Partners outside of hospital’s current partner models.”
  • “Any teaching materials for families that could be shared would be awesome.”

The RARE Operating Partners are evaluating the information received through this survey and will work to identify the best ways to extend the impact of the RARE Campaign beyond the walls of the hospital. For more information about the RARE Campaign’s Community Partners, including how to add your organization to the list, go to the Community Partners page.

Work Group Tackles Improvements to Epic EHR

RARE Campaign Resource Consultants consistently hear from participating organizations that electronic health records (EHRs) can be both a benefit and a barrier to the work of reducing avoidable readmissions. EHRs enable providers to more easily access and share patient information, but functional limitations can make it difficult to effectively document and communicate that information. To address these issues, partners and participants in the RARE Campaign agreed that Minnesota would benefit from a shared approach to improving the utility of EHRs to reduce readmissions.

The work group determined that focusing on hospitals and health systems that use Epic’s EHR would impact the largest number of patients. Earlier this year, we brought together representatives from these organizations and the Minnesota Epic Users Group (MNEUG) to jointly identify improvements to the Epic EHR. Participants included pharmacists, nurses, discharge planners, health educators, physicians, Epic builders and others.

The group decided to focus initial efforts on developing patient-friendly documentation on medications and medication use upon discharge from the hospital. This focus was selected because medication issues are substantial contributors to hospital readmissions and because documentation and management of medication information in the EHR is challenging for many Epic users.

Stratis Health staff met with Epic user organizations in July and August. Discussions primarily focused on documentation and processes related to the After Visit Summary (AVS), third party medication materials, patient education, medication reconciliation, and patient discharge.

These meetings revealed a variety of opportunities for improvement, including the need for an AVS that is short, simple, and includes key information that patients need at home; a more straightforward way to document patient education and integrate third party medication materials into the EHR; and a better discharge order process that will result in a complete, accurate medication list on the AVS.

Findings were shared with the MNEUG and the full work group in August. Next steps include a meeting with subject-matter experts to identify best practices and finalize technical recommendations, and a subsequent meeting with all RARE hospitals to discuss broader issues related to process, culture and roles as they relate to EHR use. Watch for more information in future issues of the RARE Report and other communications.

Executive Q&A: Keeping RARE a Priority

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 do you ensure that RARE remains a priority within your organization, considering all of the initiatives going on?”

Loren L. Taylor, CEO, North Memorial Medical Center
North Memorial has provided health care services in the northwest metro and beyond for more than 50 years through North Memorial Medical Center, a Level I Trauma Center, as well as a network of primary, urgent care, and specialty care clinics. We also operate one of the largest hospital-based ambulance services in the country with eight helicopters and 125 ground ambulances.

Whether patients use our services to stay healthy or recover from illness or injury, our purpose is clear – to give them a health care experience that is remarkable. In order to provide remarkable health care experiences for our patients and their families, services must be coordinated across the continuum of care, and this is a strategic imperative for North Memorial.

This patient-centered approach is at the heart of everything we do and is a constant priority for everyone working at North Memorial. Participation in the RARE Campaign is a natural extension of our care coordination work. Affecting readmissions is a complex proposition that requires a multifaceted approach. In order to make progress, the whole system must work together.

At North Memorial we strive to provide our clinicians with high-quality, reliable tools and skills for informed and shared decision-making with patients and families. We leverage technology to identify patients at higher risk for readmission and allocate staff to make follow-up calls to patients. 

The organization is committed to developing an infrastructure to capture clinical information, care delivery processes, outcomes and financial data to better understand our practices and improve our systems. To this end, we have developed a reporting “universe” to assist us with capturing readmission data in real time, which helps promote transparency across the system.

Physician leadership is vital to any significant change in a health care system. At North Memorial we are   fortunate to have experienced physicians and medical groups working with us on improvement efforts.  Dr. Brad Bialcyzk at North Clinic leads the RARE team efforts to prevent avoidable readmissions.

Actively seeking and building community partnerships affords us additional opportunities to improve the care and services provided to our patients and families. From coordinating dental appointments with community clinics, to working on a demonstration project for a new care transitions model with state and federal agencies, to designing and creating an innovative program for community paramedics, North Memorial is actively working towards improving the care and care experiences for our patients, their families, and the community.

Peter Jacobson, President, Essentia Health St. Mary’s, Detroit Lakes
The RARE initiative at Essentia Health St. Mary’s in Detroit Lakes began almost a year ago with an organizational assessment to determine where our efforts should be focused. Our facility is multi-disciplinary, with home health services, long-term care, and assisted living all on the same campus as the hospital and clinic. This enabled us to maximize the continuum of care focus for our patients. Our RARE committee includes key leaders from across the organization, including but not limited to nursing, long-term care, assisted living, pharmacy and home health. This initiative ties together many quality improvement efforts across our system, such as medication reconciliation and discharge phone calls, which has been a driving force in keeping it at the forefront. We also utilize a daily care conference where social work, physical and occupational therapy, dietary, nursing and quality departments gather and discuss care for each patient in the house.

The RARE committee also reports out to our board, medical staff and utilization committees to stress the importance of reducing avoidable readmissions by doing what is best for the patient throughout the continuum of 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:

Patients and family members
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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.