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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - June 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. RARE Campaign Hits the Big Time!
  2. Pictures, Videos Capture Creativity of RARE Teams
  3. Success Stories from Participating Hospitals
  4. Upcoming Events & News
  5. Improving Care Transitions Through Health Information Exchange in Post Acute Care Settings
  6. Campaign Gets Attention in AF4Q Spotlight

RARE Campaign Hits the Big Time: Times Square!

Pillow graphic in Times SquareTo announce the RARE Campaign’s exciting 2012 results, the operating partners put out a press release. As part of the distribution approach, more than 300 media outlets, including the Wall Street Journal and Yahoo, picked up our press release. Our signature pillow graphic was even displayed on PR Newswire’s Times Square electronic billboard in New York City.
In addition, a number of excellent bylined articles about the campaign’s results have appeared in various publications. To date, the list includes:

Preventing Hospital Readmissions Presents Financial Paradox, Health Leaders
MN Hospitals Avoid Return Visits, Star Tribune
Hospital-Community Collaboration Reduced Readmissions by 4,570, Fierce Healthcare
Communication & Engagement Helped Minn. Hospitals cut Avoidable Readmissions by 20%,
MedCity News
RARE Campaign Helps Minnesota Hospitals Avoid 4,570 Readmissions, Becker's Hospital Review

The success of the campaign and strong interest in its progress are a direct result everyone involved at participating hospitals and Community Partner organizations. Even more importantly, it is a testament to your unwavering belief that preventing avoidable readmissions is not only necessary; it’s the right thing to do.

We are confident that with your ongoing commitment, we will prevent an additional 2,000 avoidable readmissions in Minnesota through 2013!

Pictures, Videos Capture the Passion and Innovation of RARE Teams

Heads on pillows
Essentia St. Mary’s Winning
Two women embracing image
Rice Memorial’s Winning Video

Congratulations to the RARE Success in Pictures contest winners—Essentia St. Mary’s Detroit Lakes Hospital and Rice Memorial in Willmar! They each will receive a gift basket of sleeping peacefully themed items to share with their teams.

Thanks to everyone who submitted photos and videos. The creativity and positive energy reflected in these photos and videos convey the teams’ passion to improve patient care and their innovation, two traits needed for finding solutions to care transitions challenges. You can see all of the photos and videos on the RARE website.

Success Stories from Participating Hospitals

Jennifer Wilde and Steve Schneider
Jennifer Wilde, nurse manager,
and Steve Schneider, director of
operations at New Ulm Medical

New Ulm Medical Center created a social worker position to provide care coordination services to emergency department (ED) and clinic patients. The social worker provides care coordination for patients with excessive emergency department utilization, with the goal of referring them to appropriate community-based services and primary care to reduce the likelihood of readmission. In addition, patients who are identified by primary care as potentially benefitting from mental health and substance abuse services, or having social service needs that impact the health status of the patient and/or family, are referred to the social worker who connects the patient with the appropriate resources.

In the first six months of the program, 69 patients received a meaningful intervention by the social worker, resulting in a 41 percent reduction in ED visits and a 49 percent reduction in hospital admissions. Thirteen patients were admitted directly from the ED to a nursing home, preventing the cost of an inpatient hospital stay. Winner of the 2013 MHA Innovation of the Year in Patient Safety Award in the small hospital category.

Regions Hospital in St. Paul has implemented many interventions related to improved care transitions. It has focused on medication management and assisting patients with set up and understanding of their medications and referring those with complex medication regimes to their Medication Therapy Program. Regions also is working with chronic obstructive pulmonary disease (COPD) patients to improve the education they receive related to their condition.

Fairview Southdale in Edina led the way in reducing avoidable readmissions. It conducted a pilot with UCare on using a care manager to assist with transitions, and also targeted early post hospitalization follow-up appointments with the patient’s primary care doctor. Fairview continues to improve medication management and transitions to long-term care facilities. Watch their light-hearted video submitted to the RARE Success in Pictures contest, Lena’s Hotdish: A Minnesota Recipe for Reducing Readmissions.

Heads on pillows
Gail Olson, director of home care
services; Mary Eisenschenk,
transitions coach; and Linda
Chmielewski, vice president of
operations/CNO, St. Cloud Hospital.

At St. Cloud Hospital, congestive heart failure (CHF) patient readmissions within 30 days of discharge were nearly double the overall hospital readmission rate. In response, the hospital implemented the Transitions of Care pilot project in 2012 for CHF patients who were identified at medium or high risk of re-hospitalization. With a focus on the transition of care between the hospital and home, the pilot included interventions such as the addition of a pharmacist to the patient’s care team in the hospital to provide medication reconciliation at admission and discharge, disease-specific education and the introduction of a transition coach. The transition coach provided information and guidance to the patient and family for an effective care transition, improved self-management and enhanced patient-provider communication.

Results of the pilot were encouraging. Readmission rates for CHF pilot patients was 16.7 percent, compared to 26.9 percent for those non-pilot heart failure patients treated during the same time period. Not only did the Transitions of Care project decrease readmission rates, it improved the quality of care for patients and provided peace of mind for their loved ones. Due to the success of the pilot, similar interventions are now offered for heart failure patients on all units with plans to expand to patients with COPD and pneumonia in July 2013. Winner of the 2013 MHA Innovation of the Year in Patient Safety Award in the large hospital category.

Upcoming Events and News


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

RARE Webinar: Improving Patient Experience and Reducing Readmissions Through Better Communications
Friday, June 28, 2013, Noon – 1 p.m. CT
Learn about the “Good to Go” program at Cullman Regional Medical Center in Cullman, Alabama. This innovative program uses smart technologies to improve the patient discharge experience and reduce readmissions through better communication between staff and patients. Learn more and register by June 25, 2013. Register


Improving Care Transitions Through Health Information Exchange in Post Acute Care Settings
Two Minnesota communities are working to reduce nursing home to hospital readmissions through the use of the electronic health records (EHR) and health information exchange. In 2013, the Centers for Medicare & Medicaid Services (CMS) provided one-year special innovation project funding to the Medicare Quality Improvement Organizations in Minnesota (Stratis Health), Colorado and Pennsylvania to accelerate EHR adoption and use, and work toward achieving health information exchange in transitions of care and medication management. Nationwide, the adoption and use of EHRs in nursing homes is much lower than in hospitals.

Through this work, Stratis Health is assisting two communities of hospitals and nursing homes—one rural and one urban—in working collaboratively to develop and agree upon standardized language for discharged-patient assessments that can be used across systems and eventually be transmitted through a health information exchange. “One need that everyone agrees on is for a current, standardized medication list that follows the patient wherever they go,” said Candy Hanson, project manager for this Health Information Technology for Post Acute Care (HITPAC) project. “This can happen most effectively using health information exchange through transitions of care.”

Two communities of hospitals and their referring skilled nursing facilities are participating:

Rural Community
Fairview Lakes Hospital
Birchwood Health Care Center
Ecumen of North Branch
Golden Living Center Rush City
Margaret S. Parmly Residence

Urban Community
Fairview Ridges Hospital
Fairview Southdale Hospital
Augustana Health Care Center of Minneapolis
Benedictine Health Center at Innsbruck
The Colony of Eden Prairie
Ebenezer Ridges Care Center
Martin Luther Care Center
St. Gertrude’s Health & Rehabilitation Center

All agree it’s time to take the necessary steps to make health information exchange possible. “If the transition process is not well coordinated with open, clear communications, many things can go wrong as a patient moves between acute and post acute settings,” said Jonathan E. Lundberg, vice president of operations, Ebenezer Ridges Care Center. “Ebenezer is interested in identifying how leveraging the electronic record can improve the information exchange and create best practices which enhance the transition process and improve overall patient outcomes as a result.”

Stratis Health is providing participants with education and technical assistance in workflow redesign. Many challenges to electronic health information exchange and transitions in general are becoming evident as participants complete in-depth workflow analysis interviews and step-by-step process mapping around transitions of care and medication reconciliation. Stratis Health is sharing lessons learned from the project.

For more information about HITPAC, contact Stratis Health program manager Candy Hanson, or visit the HITPAC page on the Stratis Health website.

RARE Campaign Gets Attention in AF4Q Spotlight
The Robert Wood Johnson Foundation’s Aligning Forces For Quality (AF4Q) program recently developed a program summary, Minnesota: The Value of a Good Night's Sleep, for its national annual meeting. The summary provided conference attendees with a description of the RARE Campaign and highlights interventions implemented by campaign participants. Partial funding for the RARE Campaign was provided through AF4Q.

Understanding the New Transitional Care Management Codes
Effective on January 1, 2013, two CPT codes were added to report transitional care management. The American Academy of Family Physicians (AAFP) recently provided a Frequently Asked Questions document that is available on the Transition Care Support – Tools and Resources page of the RARE website or on the AAFP website.

Welcome New Community Partner
Firstat Nursing & Home Health Care in St. Paul recently joined the RARE Campaign as a Community Partner. See the complete lists of Community Partners and participating hospitals on the campaign website.


Medicare Readmission Rates Showed Meaningful Decline in 2012
Using Chronic Condition Data Warehouse claims, the study’s authors estimate unadjusted, monthly, readmission rates for the nation, within the Dartmouth Hospital Referral Regions (HRR), and compare participating and non-participating hospitals in the Partnership for Patients (P4P) program (overall and by number of inpatient beds at each facility). Although claims data are not yet final for 2012, their analysis indicates that hospital readmission rates for all Medicare FFS beneficiaries dropped noticeably during the year. (Medicare & Medicaid Research Review, May 2013)

All Readmissions May Trigger Penalties
It is likely that CMS will extend its Hospital Readmissions Reduction Program to include all health conditions for calculating penalties, not just those readmitted for acute myocardial infarction (MI), heart failure, or pneumonia within 30 days of hospital discharge. CMS has proposed expanding that program in FFY 2015 to include total knee replacement, total hip replacement, and chronic obstructive pulmonary disease, but that list is expected to grow to include all-cause readmissions. (medpage Today, May 17, 2013)

CMS Issues More In-Depth Survey Guidelines
CMS has revised the provider certification manual for hospitals, giving more in-depth guidelines around discharge planning. The goal is for hospitals to reduce readmissions by partnering with post-acute providers. The guidelines now say that discharge planning evaluations should assess whether a patient's post-discharge needs can be met in his or her next environment, such as a skilled nursing facility, the revision states. (McKnight’s Long-Term Care News, May 20, 2013)

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.