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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - October 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. Improving Care Transitions for Patients with Mental Illnesses
  3. AXIS Healthcare: Improving Care Transitions for People with Disabilities
  4. Executive Q&A: RARE and Accountable Care Organizations

Upcoming Events, News and Web Updates


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

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. Additional information and registration

Action Learning Day: “Sustaining the Gains and Moving Forward”
Thursday, November 8, 2012
There is still time to sign up for the upcoming Action Learning Day at the Crowne Plaza in Plymouth! The event will feature a keynote address by Eric Coleman, MD, MPH, director of the care transitions program at the University of Colorado in Denver and recent recipient of a McArthur “Genius Grant” (see story below). We’ll also have a patient panel and ‘Rapid-Fire’ presentations by RARE participants. Don’t miss this key RARE Campaign event! You’ll come away with new ideas and renewed energy to tackle the work of reducing avoidable readmissions. Additional information and registration

Engaging Consumers in Using Health Information Technology
Thursday, November 15, 2012, 8 a.m. – 12 Noon, Minnesota Department of Health
Meaningful use Stage 2 requires eligible hospitals and providers to engage consumers in accessing their electronic health information. Learn from experts how you can meet this requirement. You’ll also hear from e-Patient Dave, a motivational international speaker and voice of consumer engagement in the use of health information technology. Sponsors of this event include RARE Operating Partners ICSI and Stratis Health. Event is free but space is limited. Register today!

Webinar: Analyzing your Potentially Preventable Readmissions (PPR) Portal Data
Friday, December 7, 2012, Noon – 1 p.m. (CT)
Presenter: Mickey Reid, RN, BSN, MSM, Patient Safety/Quality Manager at the Minnesota Hospital Association. Additional information and registration will be available soon.


StarTribune Article Focuses on Readmissions, Role of Care Transitions Coaches
An October 11, 2012 article in the StarTribune focuses on the role of care transitions coaches in the work Minnesota hospitals are doing to prevent avoidable hospital readmissions as new Centers for Medicare & Medicaid Services (CMS) penalties take effect this month. The story includes the perspective of a hospital care transitions coach and others talking about their efforts as part of the RARE Campaign. Read the article.

RARE Campaign Featured on
The RARE Campaign was recently featured in a blog post titled, “RARE Campaign Measuring Success One Pillow at a Time.” The goal of the MediCaring project is to have a health care system in the United States that works well for patients who are living with serious and complex illness. Read the article.

Alexandria Hospital, Community Partners Join the Campaign
Douglas County Hospital in Alexandria, MN recently joined the RARE Campaign, along with three new Community Partners: Comfort Keepers in Inver Grove Heights, MN; Golden Living Center in Superior, WI and International Quality Homecare in Rochester, MN.


Stratis Health to Lead Project on Health Information Technology for Post-Acute Care Providers
Stratis Health was selected to lead the CMS Special Innovation Project: Health Information Technology for Post-Acute Care Providers. This project will assist post-acute care providers in Minnesota—focusing on skilled nursing facilities—to improve quality and coordination of care through the effective use of health information technology (HIT) during care transitions, leverage standardized patient assessment content to facilitate health information exchange with hospitals, and reduce medical errors by improving the medication management process. Read more.

Eric Coleman Named a 2012 MacArthur Foundation Fellow
Eric Coleman, MD, MPH and director of the Care Transitions Program at the University of Colorado in Denver, was named a 2012 MacArthur Foundation Fellow. Dr. Coleman will receive a $100,000 “genius grant” in recognition of his Care Transitions Intervention to reduce avoidable hospital readmissions. This intervention is an important part of the work of many participating RARE Campaign hospitals. Read more.

Medicare Revises Hospitals’ Readmissions Penalties (Kaiser Health News)
Kaiser Health News reported in an October 2, 2012 article that CMS has discovered errors in its initial calculations in August. As a result, 1,422 hospitals with comparatively high readmission rates will lose slightly more money than they were expecting, according to a Kaiser Health News analysis of the revised penalties. Fifty-five hospitals will lose less than were previously told. Kaiser Health News had earlier published the penalties for all hospitals and has updated its PDF chart and downloadable csv file with the previous and corrected readmission penalties. Read more.

Hospitals Need Networks to Prevent Readmissions (Kaiser Health News)
This October 2, 2012 story reports on a model in place at Denver Health that works to prevent avoidable readmissions. Through its own network of neighborhood clinics linked by a computerized record system, the hospital can notify a clinic that a patient who needs follow-up care is coming and help them get a priority appointment. Read more.


New resources related to those with limited English proficiency have been added to the Patient and Family Engagement Tools and Resources section of the RARE website:

  • Improving Patient Safety Systems for Patients With Limited English Proficiency: A Guide for Hospitals. This guide focuses on how hospitals can better identify, report, monitor, and prevent medical errors in patients with limited English proficiency (LEP). Developed by The Disparities Solutions Center.
  • TeamSTEPPS Enhancing Safety for Patients With Limited English Proficiency Module. This Agency for Healthcare Research and Quality (AHRQ) evidence-based training module provides insight into the core concepts of teamwork as they are applied to your work with patients who have difficulty communicating in English, and includes an interpreter briefing exercise for patient discharge.

Improving Care Transitions for Patients with Mental Illnesses

The transition period between care settings is the most vulnerable time for patients and their caregivers. The unique vulnerabilities for patients with mental illnesses such as depression, mania, anxiety, schizophrenia and/or substance use disorders heighten the need for coordinated transitions and aftercare. In 2010, depression was the fourth diagnosis by volume for readmissions in Minnesota according to the Potentially Preventable Readmissions data collected by the Minnesota Hospital Association.

The RARE Campaign’s mental health work group has been working to identify opportunities to improve care transitions for these patients. In addition to completing a literature review, the work group identified aspects associated with care of some mental health patients that can further challenge care transitions.

The result was Recommended Actions for Improved Care Transitions: Mental Illnesses and/or Substance Use Disorders, a document intended for health care professionals who provide care for patients in a variety of settings. It provides basic recommendations in five key areas that are well-recognized core strategies for care transition improvement as well as recommendations specific to mental health populations. It also identifies key recommendations that are important specifically for care transitions improvement when working with patients with new or existing mental illnesses. It does not specifically focus on delirium or dementia, but many of the recommendations will also help support these patients and their families.

Recommendations in Action
Work group member Chris Walker, director of inpatient mental health units at St. Cloud Hospital, decided to pilot calling discharged patients at home within 72 hours as recommended. After calling two patients whose transitions were going smoothly, her third call was to a patient whose transition was not going well and was on the verge of a severe setback.

This patient, who has schizophrenia and was starting to hear voices again, could not afford his medications. Although he had Medicare insurance, it did not include Part D coverage. Chris connected the patient to a pharmacy that offered $4 prescriptions and he was able to start his medications.

In addition, Chris discovered that the patient was unable to make an outpatient appointment because the mental health unit did not have the necessary release form to send the discharge summary to the new provider. Chris helped the patient go in to sign the release and a follow-up appointment was made.

In only 45 minutes, Chris discovered specific issues for this patient and put in place actions that avoided a possible re-hospitalization. The patient’s wife was very appreciative of the assistance, which kept her from taking him to the emergency room.

Read the complete document, available on the RARE Campaign website. A companion document, Recommended Actions for Improved Care Transitions, is also available. The October 2, 2012 webinar was also focused on this topic. The slides and podcast are available online.

AXIS Healthcare: Improving Care Transitions for People with Disabilities

Randall W. Bachman, Executive Director of AXIS Healthcare, St. Paul, MN

Axis logoEveryone is looking for a formula for successful care transitions post-hospital discharge in order to reduce avoidable readmissions. One is SCT = E + K + P/T, where SCT is Successful Care Transitions, E is Engagement, K is Knowledge and experience, P is Processes and protocols, and T is Time and resources. 

At AXIS Healthcare, we believe a key to successful transitions is patient engagement through development of trusting working relationships. We also bring knowledge and experience not only in management of patients’ health conditions but also in their living conditions and social support systems.  We follow standard processes and protocols to increase the likelihood of successful transitions. We analyze our caseloads to determine who needs more attention, and allocate our time and resources accordingly.

AXIS provides care coordination and case management to adults with disabilities. People with disabilities are eight and a half times more likely to be hospitalized two or more times in a year than those without disabilities. It is clear that managing conditions in the community that can cause a hospital readmission saves money and helps those with disabilities to maintain their health.

We engage people through our assessment process, and then develop a plan of care that includes all parties involved.  Because we engage people before, during and after hospitalization, we are effective in reducing avoidable readmissions. Our staff has been trained in motivational interviewing (MI) which enhances our ability to engage people where they are. We also assess their level of activation through patient activation measures (PAM). Both of these processes allow us to better calibrate our approach in working with each person.

Two practices we follow to reduce avoidable admissions and readmissions are “Call AXIS First”—educating our members to use our after-hours nurse line—and the “Four Steps and Five Calls” transitions protocol. Our after-hours nurse line has demonstrated a significant cost savings through reduced avoidable admissions. Our Four Steps are:

  1. A home visit is scheduled within 24 hours of discharge
  2. Medication reconciliation
  3. Care plan review
  4. A post-discharge follow-up medical appointment is scheduled

We also make five calls to the member to check in—one call every other day for 10 days. 

For many of our members, we provide case management services to allow those with disabilities to live in the community. We know that challenges in living conditions or the social support network often cause rehospitalizations. Medicare waiver services can help address those challenges and, by coordinating them with services covered by health plans, we are able to address these challenges in a more comprehensive and holistic way.

There is no magic formula that will reduce all avoidable readmissions. However, we believe that AXIS Healthcare’s processes, experience and engagement are all important ingredients in helping people with disabilities maintain their health and continue to live in the community. Learn more about AXIS Healthcare.

Executive Q&A: RARE and Accountable Care Organizations

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 month we asked:

“How do you see your hospital’s work on hospital readmissions in relation to your work to become an accountable care organization?”

Dan Anderson, President, Fairview Community Hospitals
With more than 73,000 inpatient admissions each year in Fairview’s six community and academic hospitals/medical centers, you better believe we’ve been focusing on avoidable admissions across our entire system. Is it because of the penalties being waged by the Centers for Medicare & Medicaid Services (CMS)? Sure.

Is it because Fairview is one of only 32 Pioneer Accountable Care Organizations (ACOs) across the country working with CMS to improve quality, improve patient experience and reduce costs? Yes, that’s also a factor compelling us to reduce avoidable admissions.

At the root, however, I believe the real reason Fairview and so many others are focusing on reducing avoidable admissions, particularly excessive readmissions, is because it is the responsible thing to do for those we serve. Employers, payers, federal and state governments and individuals have effectively shifted their focus – and therefore the focus of hospitals – from volume to value. 

It has been estimated that one in every five elderly patients discharged from a hospital is re-hospitalized within 30 days. While some re-hospitalizations are necessary and appropriate, many are not. Reducing these avoidable readmissions is possible through enhanced care and support during care transitions; patient education and self-management support; end-of-life planning and team-based management of care. Avoidable readmissions increase the cost of health care, extend the recovery time for patients and their families, and consume health care talent that could otherwise be directed toward patients in need of our services.

While the Accountable Care Act focused on the cost of health care, it has become apparent that in the process of addressing health care costs, health care providers can actually deliver more effective care with better outcome for our patients. While the financial models associated with accountable care are still confusing, it’s clear that we are able to deliver better care to our patients, which is why we are here in the first place. Whether it’s called accountable care or responsible care, it’s the right thing to do.

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, MN Community Measurement and VHA Upper Midwest.

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.