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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - May 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.

Pillow Progress Chart

Previous Issues

In This Issue

  1. 4,570 Avoidable Readmissions Prevented Since Campaign Began!
  2. RWJF Grant Will Fund RARE Campaign Mental Health Collaborative
  3. Upcoming Events and News
  4. Highlights from April’s Action Learning Day
  5. Windom Hospital Achieves Notable Reduction in Avoidable Readmissions

4,570 Avoidable Readmissions Prevented Since Campaign Began!

Potentially Preventable Readmissions chartThe 2012 data is in and the Minnesota Reducing Avoidable Readmission Effectively (RARE) Campaign participants have collectively prevented 4,570 readmissions in the last two years, exceeding our goal of 4,000. You have successfully helped patients in Minnesota spend 18,280 nights of sleep in their own beds and reduced health care expenditures by more than $40 million. This is truly a reflection of your commitment to better care for our patients, innovative improvement and hard work.

Help us Celebrate! Send in Your Campaign Pictures by May 31

Participating hospitals: please help us recognize your accomplishments by submitting a photo or video of your RARE team members with pillows representing the number of avoidable readmissions prevented since the campaign began.

Please gather your RARE teams together for a celebration and photo/video shoot. Use the spreadsheet you received from Mark Sonneborn at MHA, which includes the total number of avoidable readmissions you have prevented since 2011, 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 readmission during the RARE Campaign. Feel free to include patients in your photos or videos if you have their permission. Need some inspiration? See how the campaign’s Operating Partners celebrated!

Submissions are due by Friday, May 31, 2013. Prizes will be awarded for the most creative photos and videos!

Submission Instructions
Please email your submission and completed permission 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 or Mary Beth Schwartz at ICSI, 952-814-8292.

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.

RARE Webinar: Patient Activation and Engagement – Understanding the Basics
Wednesday, May 29, 2013, Noon – 1 p.m. CT
Patient/family engagement is one of the five key areas of the RARE Campaign and it is known to reduce avoidable readmissions. This RARE webinar will provide information on the critical role patients and families play, the basics of patient/family activation and engagement and explore some of the available intervention tools in this key area. Learn more and register by May 24, 2013.

Learning Collaborative: Patient Activation and Engagement
Is your organization ready to go a little deeper with patient activation and engagement? This three-month learning collaborative sponsored by ICSI consists of a one-day, in-person workshop held regionally in Duluth (full), St. Cloud and Mankato, followed by two 90-minute virtual conversations on July 22 and August 21, 2013. Participants will learn the general principles of activation and engagement, along with specific ways to help your patients become meaningful and valuable partners in their health care. You’ll receive tools for your patient activation and engagement toolkit that you can use immediately. Space is limited for this affordable opportunity, so register today!


RWJF Grant Will Fund RARE Campaign Mental Health Collaborative
Minnesota’s Aligning Forces for Quality team, an alliance of nonprofit organizations focused on improving health care, announced on May 16, 2013 that it has been awarded a grant of $1 million over the next two years for the final phase of the Robert Wood Johnson Foundation’s (RWJF) Aligning Forces for Quality (AF4Q) initiative, a national effort to lift the quality and value of health care in communities across America. The statewide group, convened by MN Community Measurement, is one of 16 organizations across the country designated as an AF4Q community, and has been participating in the initiative since 2006. Read the press release.

The grant includes funding for a RARE Campaign learning collaborative focused on care transitions for mental health patients. Mental illness is a leading comorbidity contributing to avoidable hospital readmissions, and can compound the complexity of hospitalizations and transitions to the next level of care. This collaborative will help us implement the “Recommended Actions for Improved Care Transitions for Patients with Mental Illness and Substance Use Disorders” prepared in 2012 by the campaign’s mental health work group, in five to seven Minnesota communities.

This collaborative will engage hospitals, county case managers, ACT teams, mental health and primary care professionals on the five key areas known to reduce avoidable readmissions for this population: medication management, comprehensive discharge planning, patient and family engagement, care transition support and transition communication between care providers.

Each community will complete an assessment, create a plan to improve care transitions, and implement and evaluate the plan. The RARE campaign will provide the structure for the collaborative, including a workshop, webinars, conference calls and progress reports. 

Watch for additional information about this exciting collaborative and how you can participate in your email and future issues of this newsletter.

RARE Campaign to Partner With Community Organizations to Improve Care Transitions

In January 2013, the RARE Campaign hosted a focus group conversation with nursing homes, home health agencies and hospice providers who had signed on as RARE Community Partners. The conversation was meant to increase understanding of how providers in care settings outside the hospital could help reduce avoidable readmissions. Conversation topics included work that is ongoing to improve care transitions, barriers to effective transitions, and recommendations for improvements to care transitions.

Similar to hospitals, other community providers are working diligently to improve quality and safety during care transitions. Examples of efforts that are being implemented by focus group participants include patient-centered care plans, Teach Back, transitions management staffing, and discharge planning that starts at admission. A cornerstone of much of the work to improve transitions is increased communication with other care providers. Nursing homes, home health agencies and hospice providers are reaching out to hospitals and each other to facilitate dialogue with patients and families about the care transitions process. 

Focus group participants also identified a variety of barriers to smooth transitions of care such as lack of communication across settings, insufficient information exchange at the time of transfer, inability to analyze data in a meaningful way, and limited staffing. For instance, home health agencies often don’t find out that their clients have been in the hospital until after they are discharged, and nursing homes frequently receive discharge orders without signed prescriptions. These types of issues lead to delays in care that can be uncomfortable or even dangerous for patients. 

The group suggested a number of ways to improve transitions of care:

  • Educate providers about the unique needs and regulations of other settings of care
  • Provide two-way access to health information in electronic records
  • Encourage staff to shadow a provider in another setting of care
  • Develop standard questions to be asked of all patients at hospital admission and discharge to identify support services

To accomplish these goals, the group recommended facilitated conversations at the community level to build relationships among community providers and identify strategies for change. 

Campaign Will Offer Facilitated Care Transitions Assistance
In response to this request, the RARE Campaign will be partnering with community-based organizations to offer facilitated care transitions assistance in six to eight communities around the state. RARE Campaign staff and their partners will engage hospitals, clinics, nursing homes, home health agencies, hospice providers, pharmacists and others in a community dialogue about the root causes of poor transitions and targeted interventions that can be implemented to improve quality of care and patient safety. Staff will work with communities to develop an action plan that includes improvement aims, activities, and measures. These conversations are intended to foster sustainable models for community engagement that will lead to long-term collaboration among providers across the continuum of care.

If you are interested in being one of the communities that will benefit from this care transitions assistance, please notify your RARE Resource Consultant. Look for more information about this opportunity in future RARE communications.

Welcome New Community Partners
Three organizations have come on board as Community Partners: Assumption Community, Minnesota Community Health Worker Alliance, currently part of the American Cancer Society/Midwest Division, and Senior Community Services of Minnetonka. See the complete lists of Community Partners and participating hospitals on the campaign website.


Health Care's 'Dirty Little Secret': No One May Be Coordinating Care
Betsy Gabay saw a rotating cast of at least 14 doctors when she was hospitalized at New York Hospital Queens for almost four weeks last year for a flare-up of ulcerative colitis. But the person she credits with saving her life is a spry, persistent 75-year-old with a vested interest -- her mother. This article in the April 30, 2013 edition of Kaiser Health News looks at the still too common communication failures in today’s health care system, despite wide recognition that coordinated care is key to better and more cost-effective care. Note: Care transition communication is one of the five focus areas of the RARE Campaign.

County Meals on Wheels Program Aims to Prevent Hospital Readmissions
The Johnson County (Kansas) Meals on Wheels plans to begin a program to reduce hospital readmissions by the end of the month. The program is being funded in part by a $50,000 grant from the Walmart Foundation, which will fund two part-time staff members who will coordinate with discharge planners to provide meals as well as facilitate arrangements for other services such as home care that may prevent readmissions. (Kansas Health Institute, April 18, 2013)

Medicare Effort to Cut Readmissions Isn’t Counting Patients Who Come Back to ER
A recent article in the Annals of Emergency Medicine entitled Emergency Department Visits after Hospital Discharge: A Missing Part of the Equation, reports that of the 11,976 patients discharged, one quarter of them returned to the Emergency Department at least once during the 30-day post discharge period but 54% did not lead to a readmission. The authors conclude, "Excluding a return to the ED misses more than 50% of all returns to the acute level of care after discharge. Inclusion of ED visits as a return to the acute care setting may enhance providers' efforts to identify opportunities to improve care transitions and intervene in a cycle of frequent rehospitalizations." (Kaiser Health Foundation, April 9, 2013)

Contribution of Psychiatric Illness and Substance Abuse to 30-Day Readmission Risk
The purpose of this study was to evaluate the role of psychiatric illness and substance abuse in unselected medical patients to determine their relative contributions to 30-day all-cause readmissions (ACR) and potentially avoidable readmissions (PAR). The authors’ data suggest that patients treated during a hospitalization for depression and for schizophrenia are at higher risk for potentially avoidable 30-day readmissions, whereas those prescribed more psychiatric medications as outpatients are at increased risk for all-cause readmissions. (Journal of Hospital Medicine, April 15, 2013)

Highlights from April’s RARE Action Learning Day

Magnan, Lattimer, LundbladOn April 23, 2013 nearly 90 people from participating organizations attended the fourth RARE Action Learning Day. The keynote speaker was Cheri Lattimer, Executive Director, National Transitions of Care Coalition, a group of concerned organizations and individuals who have joined together to address problems associated with transitions of care. Lattimer highlighted the breadth of care transitions work happening across the country, keying in on developing best practices and emerging models. Pictured with Cheri, center, are the president and CEO of ICSI, Sanne Magnan (L) and of Stratis Health, Jennifer Lundblad (R).

Participants expressed particular interest in:

  • Seven Essential Intervention Categories, which adds two essential intervention categories to the five key areas known to reduce avoidable readmissions identified by RARE: 1) health care provider engagement and 2) shared accountability across providers and organizations.
  • Medicare Transitional Care Codes. Participants were eager to learn more about the new Medicare billing codes for care transitions. National reimbursement averages for face-to-face visits after discharge are $142.96 for visits within 14 days and $231.11 within seven days.
  • Transitions of care clinic model being implemented by Tallahassee Memorial Healthcare Transition Center, a safety net for people at high risk for readmittance, regardless of insurance status or disease. The center is seeing a 61 percent reduction in emergency room visits and admissions.

ICSI’s Carmen Hansen demonstrated the power of storytelling and encouraged its use, paired with measurement data, to motivate people to improve care transitions. Three organizations shared their work to manage medications:

  • Shannon Reidt: Hennepin County Medical Center’s interventions aimed at frail elderly who are Transitional Care Unit patients
  • Joe Litsey: Thrifty White Pharmacy Consulting’s secure video-conferencing for medication counseling with a pharmacist
  • First Light Health System: their team shared how the critical access hospital implemented its medication management program.

To stimulate networking connections and spark ideas, all participants were asked to share any readmissions project they have in the works, regardless of results; more than 25 people spontaneously offered brief summaries of diverse efforts across the continuum of care.

This was followed by four Rapid Fire sessions:

  • Ecumen Lakeshore is training long-term care nurses to use an SBAR (situation, background, assessment and recommendation) tool before they contact a physician to better understand the condition of residents and communicate more effectively with physicians.
  • The Metropolitan Area Agency on Aging is using the Coleman coaching model in conjunction with HCMC and North Memorial; the Senior Linkage Line and VA Linkage Line each maintain a database of dual eligibles using their care manager services.
  • Stratis Health is leading a project to 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.
  • UCare shared its work on care coordination for frail elderly and adults with disabilities.

Presentations and more photos from the day.

Windom Hospital Achieves Notable Reduction in Avoidable Readmissions

Windom Hospital, a participant in the RARE Campaign, has worked methodically throughout the campaign to provide the highest quality care to its patients as it endeavors to reduce avoidable readmissions. In fact, hospital staff are so committed to improving care coordination that they include readmissions metrics on their organization-wide scorecard.

Windom Hospital staffers worked together as a care team to refine discharge instructions, and have capitalized on their community assets to build and foster working relationships with local home health agencies and nursing homes. Thus far, Windom Hospital has reduced their avoidable readmissions rate from 0.85 in 2009 to multiple quarters in 2012 at or near zero.

Windom Trend

The staff is committed to continuing the challenging and complex work of preventing avoidable readmissions, and plans to continue working on Teach Back techniques and enhancing the use of their electronic medical record to further advance their readmissions work.

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.