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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - November 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. RARE Campaign Reports New Data, Announces Extension
  2. Upcoming Events and News
  3. Eric Coleman Inspires Participants at Action Learning Day
  4. St. Gertrude’s Uses INTERACT Tools to Improve Resident Care

RARE Campaign Reports New Data, Announces Extension

pillow graphWe are pleased to report yet another quarter of good news! Thanks to your ongoing commitment to high-quality health care across Minnesota and specifically your work to reduce avoidable hospital readmissions, we have 12 percent fewer readmissions than expected through the second quarter of 2012, representing approximately 3,128 prevented readmissions. That means in order to achieve the goal of a 20 percent reduction statewide by December 31, 2012 we must prevent 872 additional readmissions, allowing for 3,488 more nights for patients in their own beds this holiday season!

2012 has been a great year of exploration and implementation for all of the organizations participation in RARE. In order to continue the work, share learnings and maintain the gains, we have decided to extend the RARE Campaign through 2013 and continue to support your ongoing efforts. All of the campaign’s core work will continue with a goal of maintaining our gains at the 20 percent reduction level.

We plan to develop an expanded role for our Community Partners, based on their strong desire to become more involved in the campaign and acknowledging the opportunities that exist to engage all providers across the continuum of care. Plans for this and other new work are still being developed, and more information will be shared in the near future.

Upcoming Events and News


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

Moving Research to Practice: Tailored Caregiver Assessment and Referral (TCARE)
Wednesday, November 28, 2012, Noon – 1 p.m. (CT)
Presented by Rhonda J.V. Montgomery, PhD. TCARE is an evidence-based care management protocol that efficiently targets resources to meet caregiver needs. The six-step triaging protocol is grounded in "Caregiver Identity Change Theory” and 25 years of research. Sponsored by the Minnesota Gerontological Society and the Center on Aging. Webinar is free, but registration is required. Learn more and register by November 26.

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, will provide detailed information on how to organize information on your PPR spreadsheet to help you identify potential trends in your ongoing efforts to reduce avoidable readmissions. Learn more and register by December 4.


Five More Community Partners Join the Campaign
Five Minnesota organizations recently joined the RARE Campaign as Community Partners: Comfort Keepers of Blaine/White Bear Lake, Comfort Keepers of Golden Valley, Minnesota Stroke Association, Minnesota Brain Injury Alliance, and St. Croix Hospice, Sartell. The complete list of Community Partners is available on the campaign website.

RARE Report Takes a Break in December
The RARE Report is taking a break for the holidays and will not be distributed in December. Stay informed by monitoring the campaign website and your email box. The next issue will be sent mid-January.


Thinking Outside the Pillbox: Improving Medication Adherence and Reducing Readmissions (Medicare Readmissions Update)
The New England Healthcare Institute (NEHI) has released an issue brief entitled “Thinking Outside the Pillbox: Improving Medication Adherence and Reducing Readmissions.” The brief, which is in part a response to the October 1, 2012 initiation of readmission penalties, argues that advanced discharge planning and transitional care are central to reducing readmissions, and medication management is a core function of discharge planning. Read more.

Predictive Tool Pinpoints Heart Patient Readmissions (Fierce Healthcare)
With readmissions a target under the health care law, hospitals are increasingly using predictive modeling tools to pinpoint patients who might be at risk for coming back to the hospital. Utah's Intermountain Medical Center, for instance, developed a computerized algorithm to identify heart attack patients at risk for readmissions, presented November 5, 2012 at the American Heart Association Scientific Sessions 2012 in Los Angeles. Read more.

Eric Coleman Inspires Participants at Action Learning Day

Eric Coleman with pillow
Eric Coleman
On November 8, 2012 approximately 170 people from participating organizations attended the third RARE Action Learning Day. Keynote speaker Eric Coleman, MD, MPH, professor of medicine and director of the Care Transitions Program at the University of Colorado, offered an inspirational look at what we’ve learned since we began our efforts. Coleman offered a synthesis of what appears to be working, stating that hospitals cannot be successful in reducing avoidable readmissions when acting alone. He took the group through the steps of building a cross-continuum care team to match care needs to care settings, prepare patients and family caregivers for self-care, and prepare the receiving team to assume care.

Dr. Coleman stressed the importance of physician engagement, and directed participants to two resources that have since been added to the RARE Campaign website:

  • Transitions of Care Consensus Policy Statement from the American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine. These consensus standards address the quality gaps in the transitions between inpatient and outpatient settings, based on 10 principles. The standards describe the necessary components for implementation: coordinating clinicians, care plans/transition record, communication infrastructure, standard communication formats, transition responsibility, timeliness, community standards, and measurement.
Coleman and Broich
Eric Coleman and Cara Broich

Cara Broich provided a patient’s perspective, and said that despite her nursing background, she was readmitted several times during the course of her complicated illness, noting that she was just too sick to properly advocate for herself. She suggested that physicians talk to patients about their wishes and needs before a hospitalization is required.

Several RARE participants shared their strategies for how to engage leaders and spread improvements throughout the organization. Steve Bergeson MD and Karen Tomes RN, MA, PHN, both with Allina Health, spoke about leading change as they recently implemented a new discharge process that puts the responsibility on physicians. Jennifer Rudolph of Hennepin County Medical Center detailed how they implemented teach-back throughout HCMC.

The afternoon featured six rapid-fire sessions as participants heard from their colleagues about interventions and lessons learned on the journey to avoid readmissions. The interventions spread across the continuum of care and involved cross-functional teams representing all stakeholders. For many, the focus is on improving the way patients and their care teams communicate. From providing access to records for care center personnel to providing follow-up phone calls soon after discharge so that problems can be identified early, improving communications is making the transition to home easier.

Others are rethinking how they can better utilize existing resources, such as Ridgeview Medical Center’s use of emergency medical technicians to provide home visits for high-risk patients. Another hospital focused on helping patients and families prepare for end-of-life decisions, reducing ethics conflicts and preventing undue stress for all parties involved. As Dr. Coleman commented, “Sometimes the best transitions are those that did not happen.”

Presentations and other materials from the day are available on the RARE Campaign website.

St. Gertrude’s Uses INTERACT Tools to Improve Resident Care

INTERACT stands for Interventions to Reduce Acute Care Transfers. It’s a no-fee ­­quality improvement program designed to improve the early identification, assessment, documentation, and communication about changes in the health status of residents in skilled nursing facilities. The goal of INTERACT is to improve care and reduce the frequency of potentially avoidable transfers to the hospital.

St. Gertrude's logoSt. Gertrude’s Health and Rehabilitation Center is one RARE Community Partner utilizing INTERACT. In June 2012, Jane Goebel, a nurse administrator, attended several INTERACT training sessions. She trained the nurse managers at St. Gertrude’s, and they in turn trained the nursing assistants. “One of our training methods for the certified nursing assistants (CNAs) was to incorporate the Early Warning “Stop & Watch” tool into our CNA Skills Fair Day,” says Goebel. “It was a good way to introduce something new and to see how nursing assistants would react.”

INTERACT Communication Tools Help Avoid Hospital Transfers
In August 2012, St. Gertrude’s staff started using additional INTERACT tools. “So far, the tool that has given us the most significant assistance is SBAR,” says Goebel. SBAR stands for Situation, Background, Assessment/Appearance and Request. Nurses fill out the SBAR Communication Tool and Progress Note after noting a change in a resident’s condition that requires follow up by a physician or nurse practitioner.

At St. Gertrude’s, SBAR has proven invaluable when nurses need to contact an on-call physician about a resident. St. Gertrude’s enjoys the benefits of being connected, literally, to St. Francis Regional Medical Center. However, an on-call physician is unlikely to be familiar with the resident’s history, so SBAR gives the information the physician needs to understand the big picture. “This form enables the nurse to give the doctor an understanding of the condition change in terms of overall context,” says Goebel. “SBAR—that’s a difference maker.”

The Transfer Envelope and Checklist is another INTERACT tool that St. Gertrude’s is using with success. “We were using our own transfer form and envelope, but it wasn’t good enough to provide information to the Emergency Room,” said Goebel. “The INTERACT envelope and checklist were better, so we switched.”

Nurses Manage Multiple Chronic Care Issues
St. Gertrude’s director of case management, Annette Lundy, points out that SBAR is so valuable because people arrive at the nursing home with multiple, complex health conditions. Past audits at St. Gertrude’s have shown residents arrive with an average of 17 diagnoses. “Residents arrive with this very complicated picture. Nurses have to be chronic care specialists,” says Lundy. “Seeing nursing home staff as chronic care specialists is an unfamiliar mindset for some nurses, but to reduce avoidable readmissions, it’s a shift in thinking that must be made.”

The immediate reason for a person’s stay in a nursing home may be to recover from a joint replacement. But, in most cases, the person arrives with other care issues as well, such as congestive heart failure, diabetes, or urinary tract infections. “We have to use tools that help us identify all the chronic conditions and see the overall person,” says Goebel. “If their other chronic care issues aren’t managed well while they are here, that’s what sends them back to the hospital.”

Data is Key to Reducing Readmissions
St. Gertrude’s is experimenting with INTERACT auditing tools, but doesn’t have enough data yet to evaluate their effectiveness. They’ve been using the RARE Campaign’s readmission tracking tool for a year, and analysis of their data shows that weekend day shifts are when the most calls are made to on-call physicians and the highest number of transitions to the hospital occur. St. Gertrude’s is working to reduce these numbers.

Goebel believes that SBAR’s ability to give a “whole picture” view of the resident will play a role in reducing avoidable readmissions. “Now that we are using SBAR, nurses notice more things,” she says. “They’re asking the on-call doctor, ‘Can we handle this [at St. Gertrude’s]? Can we do something more on-site?’” In addition, Goebel has attended physician meetings at St. Francis Regional Medical Center to educate doctors on St. Gertrude’s many capabilities.

St. Gertrude’s intends to continue to use the INTERACT tools. “I haven’t seen a better set of communication tools than INTERACT,” said Goebel. “It has the best potential to make a difference for nurses, increase overall assessment, and decrease readmissions. I highly recommend it.”

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:

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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.