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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - April 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. Share Your RARE Campaign Success in Pictures
  2. Upcoming Events, News and Website Updates
  3. Park Nicollet Methodist Hospital Implements Post-Discharge Follow-Up Calls
  4. Modified Resident Log Tool and Physician Education Help Reduce Readmissions at Ebenezer Ridges Care Center

Share Your RARE Campaign Success in Pictures

In early May, we will have RARE Campaign impact numbers from 2011 through all of 2012.  To help mark this important milestone, we are asking all participating hospitals to take a moment to recognize your accomplishments by submitting a photo or video of your RARE team members with pillows representing the number of avoidable readmissions you have prevented since the campaign began. Photos and videos are due Friday, May 31.

progress chartWe will showcase the photos and videos on the RARE website, and some may be featured in the RARE Report, used in newspaper articles or other publications, or on the websites of RARE Operating Partners.

We hope you will also use your photo or video within your hospital and in communications with your community – both your health care partners and the patients and families you support – to share your success and discuss the continuing work to prevent avoidable readmissions.

We encourage you to use the campaign's pillow theme to represent your prevented avoidable readmissions. For your hospital, one pillow could equal one, 10, 25 or more readmissions. Just include the key, such as:

  • Each (person/pillow) represents __XX__ prevented readmissions, and ____ (4 x number of readmissions)__ more nights of sleep in their own beds.

We ask that you plan now to gather your RARE teams together in mid-May for a celebration and photo/video shoot. When you receive your spreadsheet from Mark Sonneborn at MHA (expected by approximately May 10), it will include the total number of avoidable readmissions you have prevented since 2011, which you can then use to calculate how many pillows you need.

Feel free to be creative! Find the way you'd like to showcase all those who have worked so hard to reduce readmissions during the RARE Campaign. You may include patients in your photos or videos, but only if you have their permission.

Prizes will be awarded for the most creative photos and videos!

Submission Instructions
Please email your submission and completed release form to Bryce Fischer at Stratis Health. Use “RARE Celebration Submission” in the email subject line. If you need assistance, please contact Bryce. General questions can be directed to Deb McKinley, at Stratis Health, 952-853-8576.

Submissions are due by Friday, May 31, 2013.

File Requirements:

  • Files should be no larger than 10 MB
  • Choose your best photo and/or video and send only one of each file type
  • Videos should be MP4 files

Upcoming Events, News and Website Updates


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

Action Learning Day – Looking Beyond the Hospital to Improve Care Transitions
Deadline Extended Through Friday, April 19
8:30 a.m. – 3:30 p.m., Tuesday, April 23, 2013, Marriott Minneapolis Northwest, Brooklyn Park
We look forward to seeing everyone at the Action Learning Day next week! You will hear from Cheri Lattimer, executive director of the National Transitions of Care Coalition, about the latest strategies for improving safety and quality of care for transitioning patients. In addition, you’ll learn about innovative approaches to medication management, and hear how RARE partners are engaging in community-based efforts to coordinate care and reduce avoidable readmissions. The registration deadline has been extended through Friday, April 19 so sign up today! Please direct any questions to Matt Ellis at Stratis Health or call 952-853-8503.

RARE Conversation: Purposeful Post-Hospitalization Follow-Up
12 – 1 p.m., Wednesday, May 29, 2013
Save the date for the next RARE Conversation! More details, including speakers and registration information, will be available soon. Watch your email and the RARE website for updates.


RARE Campaign in the News: It Takes a Village to Reduce Readmissions
A brief article about the RARE Campaign was included in the April 2013 edition of the American Hospital Association’s publication, Hospitals & Health Networks. The article, “It Takes a Village to Reduce Readmissions,” summarizes the campaign and includes comments by Pat Peschman, RN, director of Allina SeniorCare Transitions, about one of Allina’s rapid process-improvement projects involving skilled nursing facilities. Read more.

Welcome New Community Partners
Four organizations have come on board as Community Partners: Comfort Keepers of Hudson, WI, Jewish Family and Children’s Service of Minneapolis, Jewish Family Service of St. Paul and Prairie River Homecare in Hutchinson. See the complete lists of Community Partners and participating hospitals on the campaign website.


Resources for Community Health Workers Added to February Webinar Slides
As a follow-up to February’s RARE webinar, resource contacts for community health workers have been added to the slides. The updated presentation and podcast are available on the RARE Campaign website.

Revised Project RED Toolkit Addresses Diverse Populations
The Agency for Healthcare Research and Quality (AHRQ) Re-Engineered Discharge (RED) Toolkit can help hospitals reduce readmission rates by replicating the discharge process that resulted in 30 percent fewer hospital readmissions and emergency room visits. Developed by the Boston University Medical Center, the expanded toolkit provides guidance to implement RED for all patients, including those with limited English proficiency and from diverse cultural backgrounds. RED employs health literacy strategies to ensure that patients know how to care for themselves when they get home. You can access the toolkit on the RARE website.


Interventions to Decrease Hospital Readmissions: Keys for Cost-effectiveness
Physician leaders seeking to reduce readmission rates will find that proven interventions often require substantial up-front financial and organizational investment. To reduce readmissions while minimizing the investment, leaders need to develop new and creative strategies guided by the evidence. This article in the March 25, 2013 online edition of JAMA Internal Medicine describes five proposed strategies or “best practices” derived from critical evaluation of prior interventions and experience in the field. Read more.

Readmissions Penalty Presents Business Opportunity for Home Care Companies
This article in the April 1, 2013 issue of Healthcare Finance News discusses the opportunity for home care companies to expand their businesses and shape coordinated care efforts by offering their services to hospitals seeking to avoid patient readmissions. Read more.

Potentially Avoidable 30-Day Hospital Readmissions in Medical Patients: Derivation and Validation of a Prediction Model
Because effective interventions to reduce hospital readmissions are often expensive to implement, a score to predict potentially avoidable readmissions may help target the patients most likely to benefit. This article in the March 25, 2013 online edition of JAMA Internal Medicine reports on a study of readmissions at an academic medical center in Boston, MA. Read more.

Long-term-care Facilities Lagging in Health IT Adoption
The rate of EHR adoption among long-term care and post-acute care facilities has been described as “dismally low,” according to this article in the April 9, 2013 online edition of American Medical News. Unlike their short-term acute care and physician practice counterparts, these organizations are not eligible for meaningful use incentive money. They are, however, a critical piece to the connected health care system the meaningful use program is aimed at creating. Read more.

Implementing Post-Discharge Follow-Up Calls at Methodist Hospital

Transition care support is one of five key areas known to reduce avoidable readmissions. Interventions that include close coordination of care in the post-acute period along with early post-discharge follow-up care have lowered readmission rates.

Park Nicollet logoOne intervention that has proven to be successful for many hospitals is phone calls made to patients 24-48 hours after discharge to identify any concerns, ensure there are no medication issues, review the patient’s discharge plan and ensure that a timely follow-up appointment is scheduled.

At Park Nicollet Methodist Hospital in St. Louis Park, MN, RARE team members, Karen Loscheider, RN and Kris Kopski, MD, PHD participate in a multi disciplinary cross-service line transition team, formed in November 2011. The goal of this team was to establish a standardized process for these calls.  The team developed and employed several tools and associated processes in an effort to identify the patients who required a follow-up call, to be made by the most appropriately aligned Park Nicollet nursing representative, within the desired window of 24-48 hours of their recent discharge. The efforts of this team included:

  • Identified and standardized evidenced-based call questions
  • Designed and embedded processes for responses to question variances
  • Built standardized flowsheet documentation tools in Epic to extract data for monitoring and further improvement
  • Identified, trained and provided ongoing support for all nursing staff to facilitate these calls
  • Engaged the hospital care teams around awareness and purpose of these calls to fold into their daily work with the patients
  • Established reports to define process and outcome measures of this new process.

This effort started in May 2012 and has continued to roll out across the enterprise in phases, focusing initially on our primary care patient population, gradually including more surgical and specialty-specific patient populations. Patients and staff both report a high degree of satisfaction with these follow-up calls and the team continues to utilize the monitoring report to identify improvement opportunities.

Loscheider and Kopski identified three main challenges with the process:

Challenges Countermeasure
Accurate primary care provider (PCP) attribution, which determines who makes the call to the patient The organization at large is undergoing a change toward a standardized approach to better define accurate PCP attribution.
Confusing information vehicle to relay which patients require calls to those conducting the calls The Epic reports used to provide this information are undergoing further enhancement to ensure accuracy.  In addition, if patients require assistance from other departments supporting their care, a cross service line nurse-to-nurse contact resource was implemented to facilitate a smooth handoff from one department to another when appropriate.
Resourcing the calls seven days a week across the enterprise Additional staff has been identified within primary care. Other specialty areas are also understanding the volumes and making determinations of how they can support this activity for their aligned patients.

“We are making great strides since May 2012, and are looking forward to continued progression towards calling all post-acute care patients,” Loscheider commented.

For additional information or questions, contact Karen Loscheider at 952-993-1104.

Modified Resident Log Tool and Physician Education Help Reduce Readmissions

Ebenezer Ridges Care Center in Burnsville, MN is a RARE Community Partner

Ebenezer logoEbenezer Ridges Care Center, a provider of long- and short-term transitional skilled nursing care with more than 100 suites, is experiencing success using the INTERACT Quality Improvement Tool in its work to reduce avoidable hospital readmissions.

For three years, Ebenezer Ridges has been working to reduce avoidable hospital readmissions by reviewing all hospitalizations. In the beginning, its data showed that some hospitalizations could be avoidable. The data was tracked to look for trends. When these trends showed that unnecessary hospitalizations were linked to a process or specific staff, Ebenezer Ridges worked to coach staff and make modifications to processes.

Erin Hilligan, campus administrator, and Roxanne Van Horn, director of nursing, modified their resident log tool to include columns for Necessary and Unnecessary Admissions. They review all hospitalizations at their Quality Assurance meetings and with the medical director. If they determine that a particular hospital admission was avoidable, the nurse manager reviews with the nurse additional clinical interventions that could have been provided. They’ve also added a column to the log tool for Admitting Diagnosis to the Hospital so that the readmission reason is made part of the resident’s full circle of care at the nursing home and can be seen at a glance.

Arbors at RidgesAnother finding was that some doctors were unaware of the services that the Care Center could provide to residents onsite. For example, one doctor insisted that a resident experiencing severe pain be admitted to the hospital, not realizing that Ebenezer Ridges could provide sufficient pain management care onsite.

“Physician education is a piece in reducing avoidable readmissions,” Van Horn said. “We made a cheat sheet list of services that we can provide onsite,” added Hilligan. “Now, our nurses are calling doctors, saying this is the resident’s situation, here’s what we can do onsite; a hospital readmission may not be necessary in this case,” Van Horn added.

One of Ebenezer Ridges’ goals is patient and family engagement, one of the five key areas the RARE Campaign is focused on to reduce avoidable readmissions. They are working toward having more open conversations with families, including relieving a family’s anxiety about the nursing home providing care to their loved ones instead of the hospital. Staff is enhancing family engagement by discussing the resident’s advance directives that are contained in the Physician Orders for Life-Sustaining Treatment (POLST), and explaining when hospitalizations may or may not be appropriate based on care needs.

“Sometimes families want to change a POLST at the last minute and have the resident admitted to the hospital,” said Van Horn. “And we have to honor that. That can be frustrating.” She added, “On the other hand, we do want families to know that we are not trying to eliminate all hospitalizations. Sometimes hospitalizations are still appropriate.”

Ebenezer Ridges’ process is working. Its hospital readmission rate was 1.05 percent last month and its tracking shows that 100 percent of those readmissions were appropriate.

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:

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.