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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - February 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. Third Quarter 2012 Results: 3,603 Avoidable Readmissions Prevented
  2. Upcoming Events and News
  3. Closing the Home Care Funding Gap at Regions Hospital
  4. Helping People Stay Happy and Healthy in their Own Homes

Third Quarter 2012 Results: 3,603 Avoidable Readmissions Prevented

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Third quarter 2012 results are now available, and show we have again reduced avoidable readmissions and since 2011 have prevented 3,603 readmissions. This means 14,412 more nights of sleep at home for patients. Congratulations to all participants for this continued progress on behalf of patients and their families throughout Minnesota. This is challenging and meaningful work that affects the lives of many.

As previously announced, the RARE Campaign has been extended through 2013 with the goals of maintaining the gains achieved and continuing to reduce readmissions. Throughout the year we will work with participating hospitals to engage partners across the continuum of care in community-based approaches to improving care transitions.

Increasing Coordination with Community Partners
On February 1, 2013, the RARE Operating Partners met with representatives from 16 skilled nursing facilities, home health agencies and hospice providers to talk about increasing coordination across the continuum of care to reduce readmissions. The organizations, all RARE Community Partners, shared their ideas about how RARE could strengthen community-based efforts to improve care transitions and keep people from returning unnecessarily to the hospital. Their primary recommendations were to:

  • Facilitate meetings at the community level that bring all settings of care around the same table
  • Develop a toolkit to be used by providers at admission and discharge to collect key information from patients and families
  • Help community providers make the best use of their data to identify issues, target improvement efforts, and show success.

A second meeting is planned with additional Community Partners to help inform this work.

Health Plans Focus on Reducing Avoidable Readmissions
Each year the Minnesota health plans that offer publicly subsidized health care programs conduct performance improvement projects (PIPs) aimed at improving the health of their program members. RARE Campaign Operating Partner Stratis Health provides facilitation and consultation services to the health plans.

In 2013, health plans are continuing their work on a variety of projects, including partnering with hospitals to reduce avoidable readmissions by focusing on effective discharge planning. Interventions emphasize improved care coordination and communication, post-discharge follow-up appointments and medication reconciliation, support for care coordinators, and member education.

Teams evaluate current hospital processes, discharge forms, and communication practices, and revise procedures and tools as needed. Providers are encouraged to communicate discharge in a timely manner, provide clear, legible discharge instructions, and complete medication reconciliation within 30 days of discharge. Care coordinators are encouraged to ensure the members receive and understand their discharge instructions and medications, and that they have scheduled a follow-up visit.

A revised transition-of-care log and tools have been created to support care coordinators, along with training and annual audits to monitor the process and sustain improvement. The log provides prompts to better assess key reasons for readmissions and provides guidance when red flags are raised during follow-up. Interventions may include pharmacy prescription fills prior to discharge, utilization of a transition coach program, adoption of Project RED principles, and continued involvement with the RARE Campaign.

Upcoming Events and News


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

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.

RARE Conversations: Health Care Homes – Improving Care Transitions
Friday, March 15, 2013, Noon – 1 p.m. (CT)
Health care home models have been implemented in primary care sites across the state and the country to assist patients with complex or chronic medical needs to work in partnership with their medical teams. In this session, we will explore how the health care home model is being used to facilitate care transitions and reduce readmissions. Learn more and register by March 12.

Action Learning Day
Tuesday, April 23, 2013, Marriott Minneapolis Northwest
Save the date for our next daylong event for RARE Campaign participants to gather and share their work. Watch for an announcement of the keynote speaker and additional information soon.


RARE Highlighted at National Care About Your Care Conference
Representatives from the three RARE Operating Partners recently attended Care About Your Care in Washington D.C., a one-day event focused on care transitions and readmissions funded by the Robert Wood Johnson Foundation. Representatives from leading organizations around the country shared the work they are doing to improve care transitions, and participants were part of the studio audience for a live session moderated by Dr. Nancy Snyderman, chief medical editor for NBC News. Speakers included Eric Coleman, MD from the University of Colorado, who acknowledged the great work of Minnesota’s RARE Campaign and called attention to its focus on more nights of sleep at home for patients, as represented by our heads-on-pillows theme.

This national recognition of the campaign’s work was very gratifying, and the exposure and connections made at the event will undoubtedly contribute to its continued success and even more nights of sleep at home for patients, not only in Minnesota but around the country.

More information about the program and the recorded webinar.

RARE Webinars, Conversations Available Online
Slides and the podcast from January’s RARE Conversation, which featured the Amherst H. Wilder Foundation sharing its work on caregiver awareness and support, are now available on the RARE Campaign website. Find this and all past webinars and conversations on the Recorded webinars page.


JAMA Focuses on Hospital Readmissions
The January 23, 2013 issue of the Journal of the American Medical Association (JAMA) included numerous articles about hospital readmissions, including "Do Quality Improvement Organizations Improve the Quality of Hospital Care for Medicare Beneficiaries?" which presents findings demonstrating a six percent reduction in hospitalizations and readmissions in regions where a QIO (quality improvement organization) made efforts to improve transitions from hospitals to home or post-acute facilities. Read more.

AMA Releases Five Patient Safety Guidelines (HealthLeaders Media, 2/11/13) The American Medical Association (AMA) has released five patient safety principles for transitioning patients from inpatient to outpatient care. "Patients leaving the hospital too often return to ambulatory care settings that are not well connected to the hospital team and this can result in inefficient, confusing and sometimes unsafe conditions," the report's authors wrote. Evaluating patient heath, supporting self-management and medication management, as well as goal setting were among the responsibilities outlined in the report. Read more.

Post-Hospital Syndrome — An Acquired, Transient Condition of Generalized Risk (New England Journal of Medicine, 1/10/13) To promote successful recovery after a hospitalization, health care professionals often focus on issues related to the acute illness that precipitated the hospitalization. Their disproportionate attention to the hospitalization's cause, however, may be misdirected. Patients who were recently hospitalized are not only recovering from their acute illness; they also experience a period of generalized risk for a range of adverse health events. Thus, their condition may be better characterized as a post-hospital syndrome, an acquired, transient period of vulnerability. Read more.

Care Transitions: Is There Still Room for Innovation? (Generations, Winter 2012-13) An article about innovation in care transitions by Gary Oftedahl, chief knowledge officer for ICSI (one of the RARE Operating Partners) has been published in Generations, a journal from the American Society on Aging. Read more.

Closing the Home Care Funding Gap at Regions Hospital

Care transitions are a key area of focus to prevent avoidable hospital readmissions, and home care is an integral part of this work. Regions Hospital in St. Paul identified one area that needed particular attention: high-risk patients who are unable to access home care services due to lack of insurance coverage for home care services, high deductibles or co-pays, or disqualification because they are not considered “homebound” by Medicare.

In late 2011, Regions partnered with HealthPartners’ Integrated Home Care on a pilot project with congestive heart failure patients to identify and intervene in issues that may contribute to readmission, such as delayed follow-up with the primary care provider, plan of treatment concerns, and self-management deficits.

Results of original pilot were promising
The project, which included at least one home visit by a registered nurse (RN) and telephone follow-up until the patient was stable and established with the primary community provider, was funded by a $1,000 grant from the Regions Foundation. Before the pilot began, three high-risk patients were identified that had experienced nine emergency department (ED) visits and eight hospitalizations. After the pilot, there was only one ED visit and no 30-day readmissions.

Second, expanded pilot also showed good results
Based on these results and input from hospitalists and care management staff, they received additional funding (approximately $5,000) to include all diagnoses and additional services of up to five visits by an RN, physical therapist (PT), occupational therapist or social worker, plus telephone support. This pilot ran from February through July of 2012 and served 19 patients. Many didn't speak English and had numerous co-morbidities. Eight patients had mental health issues, two were homeless and four had significant financial concerns.

During the second pilot, patients received 35 nursing visits, 21 PT visits, and seven social worker visits. Before the grant, there were 23 ED visits and 19 admissions. Afterward, there were 18 ED visits and four admissions (but with a shorter length of stay). ED usage decreased by 28 percent. Although 21 percent of the high-risk patients were re-hospitalized within 90 days, this is below state and national rates reported by the Centers for Medicare & Medicaid Services.

Home CareLessons learned
Project co-leaders Josh Brewster, Director of Care Management, and Denise Edgett, Manager of Integrated Home Care, believe this work offers a good reminder of the valuable perspective home care brings to preventing avoidable readmissions.

“You can’t underestimate the power of a home visit to understand the patient’s needs, especially when it comes to medication reconciliation,” Brewster noted. “What you hear from the patient may not be what you see in the home.”

Other lessons learned included:

  • The team didn’t anticipate the extent of language and other cultural challenges faced by these patients, and recognized the need to better understand and address social, environmental and economic determinants of health.
  • Behavioral health diagnoses (more than 40 percent) and other unmet needs played a bigger role than anticipated. Because the social workers were generalists, there was a gap in their ability to assist those with behavioral health issues or at least get them connected to the services they need.

Next steps
While the search continues for a more stable source of funding, in late 2012 another grant was received to continue this work, with the addition of interpreter services. The team is also making a concerted effort to connect with all the services available throughout their community of care, and in January 2013 expanded to Lakeview Homecare in Stillwater to better serve patients in Washington County and western Wisconsin.

“This work has really helped us articulate to case managers and others just how important home care services are, and how critical it is to get the patients the services they need, even when creative solutions are sometimes needed to pay for it,” Edgett commented. “Relatively low-cost interventions can do great things.”

For additional information, contact Josh Brewster at 651-254-3780 or Denise Edgett at 651-415-4005.

Helping People Stay Happy and Healthy in their Own Homes

Comfort Keepers logo

Joan Wurzer had been looking for a more meaningful career, something to be passionate about. When her dad got sick, she became aware of an often-unmet need for families—help caring for their sick or elderly parents who wanted to be able to remain in their own homes. Joan is now the owner of Comfort Keepers In-Home Care Service in Inver Grove Heights, MN.

As an in-home care service, Comfort Keepers addresses the physical, mental, social, and emotional needs of its clients, while providing support and relief for family caregivers. Joan described how staff works as an integral part of patient care and assists in keeping clients from being readmitted to the hospital, “We work regularly with home health agencies, hospice, and physicians to make sure clinical orders and the wishes of the client and family are being met—and that unnecessary hospitalizations are avoided. Because we are often there as much as the family, we know what is happening with the client and are able to communicate what we see to the physician.”
Caregivers often attend doctor appointments with the client and can work closely with the physician office to make sure weight, blood pressure, blood sugar, and other vital measures are being monitored. They may intervene when something unusual is happening, such as when a urinary tract infection or medication problem is suspected that could lead to hospitalization. Recognizing when the client needs to see the primary care physician is key.

Healthy at Home Program
Healthy At HomeComfort Keepers in Inver Grove Heights participates in the Minnesota Comfort Keepers Cooperative, a group that meets monthly to share best care practices, develop strategies for improving care, collecting data, and marketing. For the last nine months it has been tracking falls and near falls based on criteria developed by Kaiser Permanente. It recently developed the Healthy at Home Program, an approach that focuses on patients working with their primary care physician rather than going to the hospital. The program targets five areas of interactive care:

  • Mind: engaging the mind in meaningful conversations to stimulate memory, combat depression, and help clients feel better about themselves
  • Body: maintaining an active body by encouraging movement, walking, and in-home exercise
  • Nutrition: assisting the client in making healthy food choices
  • Safety: using technology to manage safety in the home (emergency response systems, video monitoring, safety locks, medication management systems)
  • Care Coordination: coordinating client care (making doctor appointments; maintaining ongoing communication with the primary care physician and other health care providers)

The program uses risk assessment tools for nutrition, falls, and home safety. Comfort Keepers Corporation recently partnered with Abbott Nutrition on a project to monitor what clients were eating and to assist them in making healthy choices. The study showed that monitoring nutrition can significantly reduce hospital readmissions. The cooperative is now looking for hospitals and clinics to partner with to help roll out the program and provide tools and support to help reduce readmissions.

To learn more about Comfort Keepers and the Healthy at Home Program, contact Joan Wurzer at 651-330-3071.

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.