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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - January 2013

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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. Campaign's 2013 Plans Taking Shape
  2. Upcoming Events and News
  3. EMTs Help Make Transitions to Home Safer
  4. Closing the Loop with Teach-back

Campaign's 2013 Plans Taking Shape

In late 2012, the RARE Campaign Operating Partners – Minnesota Hospital Association (MHA), Institute for Clinical Systems Improvement (ICSI) and Stratis Health – announced that the RARE Campaign has been extended through 2013. As a reminder, the original goals of the campaign were:

  • Prevent 4,000 avoidable readmissions within 30 days of discharge by December 31, 2012, equating to 16,000 more nights of sleep in their own beds for patients.
  • Reduce the overall readmission rate by 20 percent as measured by MHA's Potentially Preventable Readmissions (PPR) data.
  • Improve by 5 percent results of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey questions related to hospital discharge by the end of 2012.
  • Decrease health care costs, estimated at more than $30 million annually in the commercially insured population.

Through the second quarter of 2012, we reported 3,128 prevented readmissions, with a 12 percent reduction in the second quarter. To reach the goal of 4,000, participating hospitals must have prevented at least 872 additional readmissions through December 31, 2012. Final results for 2012 will be reported in May 2013, including the total number of prevented readmissions and the percentage rate reduction as measured in the fourth quarter. More information on the HCAHPS and cost savings will be available later this year.

A look at 2013

In 2013, the RARE Campaign will have two measures of success:

  • Maintain the percentage reduction in avoidable readmissions at or above 20 percent each quarter.
  • Continue to track the cumulative number of prevented readmissions and report the number of nights sleep patient will have in their home.

All of the campaign's core work will continue, including:

  • Data will continue to be published and distributed quarterly. MHA will send composite PPR data for all hospitals to participating RARE hospitals, and ICSI will provide individualized run charts for each participating hospital.
  • Two Action Learning Days will be held, in the spring and fall.
  • RARE Resource Consultants from the three operating partners will continue to support participating hospitals as needed, including a quarterly review of data and progress toward campaign goals.
  • Two types of virtual learning opportunities – RARE webinars and RARE Conversations – will continue to be offered on resources, methods and best practices, providing opportunities for participants across the care continuum to network on vital topics.
  • The RARE website will continue to be developed as a repository of information for the RARE Campaign.
  • The monthly RARE Report will continue communications to the community at large about reducing avoidable readmissions, sharing success stories, upcoming events, articles of interest and new resources.

Plans for new work also are underway, including enhancing the participation of provider Community Partners, supporting the readmission performance improvement work of health plans, developing a RARE roadmap, and more. Watch for additional information in future editions of the RARE Report.

Upcoming Events and News


Details and registration for all events listed below are available on the calendar page of the RARE Campaign website.

RARE Conversations: Caregiver Awareness and Support
Thursday, January 24, 2013, Noon – 1 p.m. (CT)

The focus of our second RARE Conversation is on the "Capacity to Care" campaign, which aims to increase self-awareness and access to support that can help caregivers take better care of their loved ones and themselves. Learn more and register by January 21.

Webinar: Role of Community Health Workers in Preventing Avoidable Readmissions
Tuesday, February 26, 2013, Noon – 1 p.m. (CT)
This webinar will provide an overview of the community health worker work force, including Minnesota's community health worker scope of practice and certificate program. Learn how hospitals can integrate community health worker strategies to help prevent avoidable hospital readmissions and meet the Triple Aim. Learn more and register by February 21.


One Hospital and Six Community Partners Join the Campaign
Regina Medical Center in Hastings has joined the RARE Campaign, bringing the total number of participating hospitals to 82. In addition, six more Minnesota organizations have come on board as Community Partners: Comfort Keepers of Osseo; Comfort Keepers of Waite Park; Renville County Public Health Services, Olivia; Knute Nelson of Alexandria; Our Lady of Peace Hospice and Home Care of St. Paul and Saving Grace Home Health of Waite Park. Complete lists of Community Partners and participating hospitals are available on the campaign website.

The Institute for Healthcare Improvement's (IHI)Spreading the Word about RARE at IHI's National Forum
The Institute for Healthcare Improvement's (IHI) annual National Forum is an event that draws nearly 6,000 health care leaders, executives and others from around the world. At the 2012 Forum, we were honored to display a storyboard sharing the great work of the RARE Campaign. There was a great deal of interest and many viewers were intrigued with the collaboration and support for the campaign throughout the state of Minnesota. The energy and enthusiasm to improve health care was palpable throughout the event. View the storyboard here.

Readmissions Newsletter Features RARE Campaign
The January 8, 2013 issue of the Medicare Readmissions Update eNewsletter included an overview of Minnesota's RARE Campaign. To read more and subscribe, visit the newsletter website.


Communicating Discharge Instructions to Patients: A Survey of Nurse, Intern, and Hospitalist Practices (Journal of Hospital Medicine, January 2013)
Original research: Comprehensive discharge education can improve patient understanding and may reduce unnecessary rehospitalization.

Reducing CMS Readmission Penalties: Stay Two Years Ahead of the Data (Healthcare Intelligence Network 11/19/12)
Because penalties under the CMS Hospital Readmission Reduction Program are based on a three-year rolling average of readmission data, today's performance will be just one-third of the 2016 score used to determine penalties. Read more.

Palliative Care, End-of-Life Discussions Curb Readmissions, Aggressive Care (Fierce Healthcare 11/19/12)
According to the Center to Advance Palliative Care (CAPC) hospital palliative care has increased 138 percent in the past decade. Palliative care is focused on serious illness, end-of-life care and pain relief in order to improve patient experience but also quality outcomes. But palliative care can create readmission issues for hospitals. Read more.

Cardiologist vs. Hospitalist: Who Curbs More Readmissions? (Fierce Healthcare 11/12/12)
According to a study by the Minneapolis Heart Institute Foundation, cardiologists curb more readmission of heart failure patients than hospitalists. This is viewed as a controversial finding given that an increasing percentage of heart patients is discharged by hospitalists. Read more.

Study: Higher Patient Satisfaction is Linked to Lower Hospital Readmissions (Beckers Hospital Review 12/12/12)
Hospitals with low readmission rates tend to have high patient satisfaction scores, according to a report by Press Ganey Associates. The report, "The Relationship Between HCAHPS Performance and Readmission Penalties," is the first in a series of studies that will examine aspects of patient experience. Press Ganey used data on hospitals' readmission penalties and hospitals' scores on CMS' Value-Based Purchasing program to determine the connection between patient satisfaction, clinical performance and readmission rates. Read more.

Medicare Advantage Patients More Likely to be Readmitted
An AHRQ-funded study, "Likelihood of Hospital Readmission after First Discharge in the Year: Medicare Advantage vs. Fee-for-Services Patients," was published November 9, 2012 in Inquiry. A print copy is available by sending an email to

EMTs Help Make Transitions to Home Safer

Easing the transition to home is one of the five key areas known to reduce avoidable readmissions and is critical to ensuring that patients spend more nights at home in their own beds. Among the challenges patients face are multiple medications, uncertainty about follow-up care, and coordination with multiple providers, all while trying to recover from an illness or procedure. Home visits like those by Ridgeview Medical Center's paramedics help ensure patients are on the road to recovery, not back to the hospital.

Sara Burton reviews medications
Ridgeview Medical Center paramedic Sara Burton reviews medications with her 81-year-old Chaska patient.

After learning about Dr. Eric Coleman's Care Transitions Intervention program, Ridgeview Medical Center's RARE team became passionate about the role that a transition coach could play in helping patients navigate transitions in care. Ambulance medical director Dr. Kevin Sipprell envisioned using the unique skill set of paramedics to fill this role. Although there is significant variability in demand for emergency medical services, it is staffed for peak utilization, creating an opportunity to better utilize the inherent down time.

"Paramedics are comfortable going into someone's home, they are already out in the community, they frequently communicate with providers, and are proficient with algorithms," Sipprell noted. There would also be little additional expense.

Armed with the knowledge that the discharge plan is not consistently followed once the patient has transitioned back into the home, Ridgeview Medical Center developed goals and guidelines and began using paramedics to perform home visits in late summer 2012. The purpose of the paramedic home visits is to establish and/or re-establish the hospital discharge plan with the patient within 48-72 hours of discharge. Four paramedics were trained initially, with the goal of adding more paramedics as the program expands.

The program has four specific components:

  • Medication reconciliation
  • Coach disease-specific self-management skills
  • Review disease-specific symptoms that might occur and provide guidance on what to do if experiencing certain symptoms
  • Preparation for the follow-up visit with patient's primary care provider to ensure patient is aware of the visit, transportation is arranged and topics to discuss are highlighted

The program is targeted at patients with three high-risk readmission diagnoses: heart failure, pneumonia and chronic obstructive pulmonary disease (COPD). Patients also need to be discharged to a home within the Ridgeview Ambulance service area, and be without home care services. The patient's primary care provider must practice with Ridgeview or an affiliated system. Prior to discharge, the patient is informed about the potential follow-up home visit and told that the paramedics will arrive in an ambulance.

Julie Burkhardt, Ridgeview's performance improvement coordinator, noted that reconciling the medications the patient is actually taking with the discharge medication list is a key element of the program. "Medication discrepancies have been identified on a majority of the visits. Some of these discrepancies involve disease-specific therapies that are critical to maintaining a healthy state," she said. In fact, Ridgeview identified medication discrepancies in 75 percent of the visits.

It is too early in the process to determine the program's impact on readmissions, but patient satisfaction with the program has been very high. Ridgeview Medical Center has been able to create a value-added patient experience at no additional cost.

To learn more about the program, contact Julie Burkhardt at (612) 581-7062, or

Closing the Loop with Teach-back

Minnesota Health Literacy Partnershiph

Alisha Ellwood, Blue Cross and Blue Shield of Minnesota, a founding partner of the Minnesota Health Literacy Partnership

Miscommunication happens all the time. You and your spouse both get milk on the way home. You ask for directions at the gas station and then realize you have no idea what "just go out and take a right" means. Most of the time, consequences are small, but when we are talking about health, seemingly simple misunderstandings can lead to serious harm and even death. In fact, the Joint Commission reports communication breakdowns as one of the primary causes of adverse events.

One of the most effective ways to close this communication gap is by using the teach-back technique. The Agency for Healthcare Research and Quality (AHRQ) considers teach-back to be one of the top 11 patient safety strategies that facilities can use to improve their practice and ensure understanding between physician and patient.

What is teach-back?
Teach-back is a health literacy technique in which a health professional confirms patient understanding by asking the patient to explain in their own words what they need to do or what they heard. This is critical when we think about the complexity and amount of health care information that patients are given. An effective teach-back utilizes open-ended questions, which often begin with how or what. They make it hard for someone to simply answer yes or no. Teach-back provides the opportunity to confirm understanding and if there are gaps, re-teach the information in real-time, before the patient leaves the office or hangs up the phone.

When should you use teach-back?
Think about using the teach-back technique any time you are tempted to ask, "Do you understand?" This is a common question that doesn't help you know what the patient really understands. Instead ask questions like:

  • "What are you going to do when you get home?"
  • "Can you explain to me how/when you are going to take your meds?"
  • "I want to be sure I explained everything correctly, can you explain it back to me in your own words?"

Ultimately you can use teach-back everywhere and in any situation. Use teach-back to confirm understanding of new medications, treatment regimens, discharge instructions, after-care plans, procedure preparation instructions, etc.

A physician quoted in the AHRQ Health Literacy Universal Precautions toolkit said, "I decided to do teach-back on five patients. With one mother and her child, I concluded the visit by saying, 'So tell me what you are going to do when you get home.' The mother just looked at me without a reply. She could not tell me what instructions I had just given her. I explained the instructions again, and then she was able to teach them back to me. The most amazing thing about this 'ah ha' moment was that I had no idea she did not understand until I asked her to teach it back to me. I was so wrapped up in delivering the message that I didn't realize that it wasn't being received."

To learn more about the teach-back technique and how to implement it in your own practice, visit the Minnesota Health Literacy Partnership website at Click on resources, then presentations and trainings and look for the teach-back program materials.

Additional resources on patient-provider communication and health literacy are also available on the RARE Campaign website here.

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.

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.