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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - July 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. Upcoming Events, News and Website Updates
  2. Home Health Agency’s Transition Care Nurse Program Works
  3. RARE Tools, Community-Wide Partnerships Reduce Readmissions at Cloquet’s Community Memorial

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 Conversation: Health Plans and Hospitals Working Together to Prevent Readmissions
Tuesday, July 30, 2013, Noon – 1 p.m. CT
Speakers will be UCare quality improvement specialists Lorraine Cummings and Caroline Dietz-Carlson, RN, BS. Please watch for details and registration information.

First Contact: Pre-Admission Screening and Resident Review (PASRR) Redesign
August, various dates and locations
The Minnesota Board on Aging (MBA) has scheduled a statewide road show to introduce legislative changes made to the hospital discharge and pre-admission screening process. These changes, called First Contact, will mostly affect patients being discharged to a nursing home. Beginning Oct. 1, 2013, all individuals discharged to a nursing home will be referred to the Senior LinkAge Line for preadmission screening. Learn more.


Pharmacy Programs Can Reduce Readmissions
Avoiding adverse medication events through prevention programs may help lower hospital readmission rates. (Pharmacy Times, June 18, 2013)

MedPac Makes Recommendations on Readmissions Reduction Program
In a June 2013 report, the Medicare Payment Advisory Commission (MedPac) discusses the Medicare Readmissions Reduction Program and considers four refinements to the current policy. (Association of American Medical Colleges, June 21, 2013)

Limits of Readmissions Rates in Measuring Hospital Quality Suggest Need for Added Metrics
Policy makers should consider augmenting the use of readmission rates with other measures of hospital performance during care transitions and should build on current efforts that take a communitywide approach to the readmissions issue. (Health Affairs, July 2013)


AHRQ Offers New Guide to Help Hospitals Engage Patients and Families in Their Health Care
The Agency for Healthcare Research and Quality has developed an online resource to help hospitals improve care by bridging the communication gaps among patients and families and their health care providers. The guide provides four evidence-based strategies on how patients and family members can:

  • Advise and train clinicians and hospital staff to work effectively with them,
  • Promote better bedside communication to improve quality,
  • Participate in bedside shift reports, and
  • Manage tasks in preparing to leave the hospital.

Each strategy includes educational tools and resources for patients and families, training materials for health care professionals, and real-world examples that show how strategies are being implemented in hospital settings. A link to the guide is available at Patient and Family Engagement: Tools and Resources.

Care CoPILOT - Care Guide Model
Allina Health’s patient-centered care delivery model uses a care guide who is a non-clinically trained layperson having a collaborative role within a team-based clinical setting; and tasked with building longitudinal relationships with patients to help achieve evidence-based care goals. It focuses on prevention, wellness and chronic disease management. A link to more information is available at Transition Care Support: Tools and Resources.

Home Health Agency’s Transition Care Nurse Program Works

Professional Resource Network staffers
Professional Resource Network staffers at
April’s Action Learning Day: Tamara
Kappauf, Jennifer DeVille, and Kelly Styving.

Last fall, Professional Resource Network, Inc., a large Class A Medicare-certified home health agency and RARE partner, initiated its Transition Care Nurse Program. The goal of the program is to work effectively with hospitals and nursing homes to improve transitions from one care setting to another for its clients—then to ensure that when the clients are finally home, they are able to remain at home.

Transition care nurse Tamara Kappauf follows her clients from admission to discharge, including time spent at a rehab or other transitional facility, until they go home. She participates in the discharge planning and care conferences and works with the hospital and care coordinator to ensure that all services, equipment, and medications are in place when the client gets home.

“Talking with the client, family, therapists, and social workers at the care conference really makes the client more comfortable about going home,” Kappauf said. “We share with them the services we provide and they share with me their concerns about going back home.”

Kappauf described her biggest challenge as getting the discharge orders and other necessary information from the hospital or nursing home. “It’s getting better, but in the beginning neither the hospital nor the nursing home completely understood the role of the transition nurse. Now that many of the patient care units, rehabs, and nursing homes understand the role, “It’s getting easier. It can still be tough to get the information we need. We have to be persistent.” 

One common issue is that when a client receives personal care assistant (PCA) services ordered by the county, the hospital may assume its doctors are not involved in the client’s care. Also, hospital or nursing home employees may be reluctant to share their medication lists, thinking it would be a HIPAA violation. They may not realize that the agency needs a doctor’s order and updated medication list to provide PCA services. In those cases, the primary care doctor has to be involved—but that really doesn’t help the clients when they get home. Some hospitals are now training their social workers and care coordinators on effective transitions of care.

The agency also helps Medicaid and Medicare clients obtain additional services needed after a hospitalization or other inpatient stay. “What we are doing is working,” said Director of Nursing Jennifer DeVille. “Clients who are going home are staying home.  We want to make this work,” she added. “It will be really important down the road.”

Kappauf said her greatest satisfaction is helping her clients get home and stay at home. For example, last year a quadriplegic client who had only received PCA services from one agency had a tracheostomy placed and required nursing care. His previous agency did not offer skilled nursing services. After attending a care conference at the hospital, Kappauf was able to coordinate services so the client’s previous PCAs, whom he wanted to keep, were hired by her agency and trained on tracheostomy care.  The agency also added private-duty nursing to the plan of care. “It was really rewarding to be able to get him home in time for Christmas with the PCAs he had before. He’s still at home and is doing great.” 

The agency serves more than 450 clients throughout the seven-county metro area with 300 to 400 staff. It employs RNs, LPNs, personal care assistants, home health aides, and homemakers, as well as physical, occupational, and speech therapists.

For additional information, contact Jennifer L. DeVille, RN, MHA, Director of Nursing, or Tamara Kappauf, RN, BAN Transition Care Nurse, at 952-858-8827.

RARE Tools, Community-Wide Partnerships Reduce Readmissions at Cloquet’s Community Memorial

CMH building with logoCollaboration among community partners, staff buy-in and the use of key RARE tools has helped reduce avoidable readmissions at Community Memorial Hospital in Cloquet, Minnesota. From initial Potentially Preventable Readmissions (PPR) Actual to Expected Ratio rates as high as .83, they have reduced their rate to .46 for the past three quarters. The RARE Campaign’s statewide goal is .80.

The hospital’s patient teaching handbook for congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD) has been particularly well-received. In use since May, the three-ring binder is designed so items can be added or removed. It also has a sticker on the front to remind patients to take the binder with them to appointments. Staff explains the handbook to the patient’s family, home health provider, skilled nursing facility, clinic, pharmacist, and other members of the care team and encourages the patient to use it.

Kathryn Kuhlmey, social worker and RARE project lead at Community Memorial, has experienced firsthand the positive feedback the program is generating from patients, family members, and staff. One family member, after looking through her sister’s handbook, remarked that she wished she had been given something like this when she was hospitalized with CHF 10 years ago. “She even inquired about making copies for family and friends who also have been diagnosed with CHF,” said Kuhlmey.

Hospital staff is also using the teach-back technique and finding it to be an effective tool for making sure the patient understands instructions before leaving the hospital. The teach-back is documented in the comments section of CHF and COPD patients’ electronic health records (EHRs).

Extending the teach-back technique outside the hospital is another example of shared priorities and community collaboration aimed at lowering readmissions. Coordinating through an Arrowhead Area Agency on Aging (AAAA) grant, a University of Minnesota Duluth pharmacist meets with patients at the hospital and uses teach-back to go over their medications, then does follow-up home visits to look for potential medication issues. The pharmacist notifies the AAAA and the patient’s case manager if any problems are found.

In August, Community Memorial will begin partnering with the AAAA and the Senior LinkAge Line, a free statewide information and assistance service to bring community partners (mental health, county services, skilled nursing facilities, clinics, etc.) together to coordinate care.

Other highlights of Community Memorial’s readmissions reduction work include:

  • An assessment tool for the patient to use, part of the patient teaching handbook for CHF and COPD
  • Implementing a teaching assessment tool to document CHF and COPD interventions and teaching and incorporating it into the EHR
  • Follow-up phone calls within 48 hours of discharge, including calls to skilled nursing or long-term care facilities
  • Conducting interdisciplinary meetings with clinical and billing staff to track patient status

“Community Memorial’s care transitions and readmissions reduction work will continue as long as there are patients requiring our care and medical guidance,” said Kuhlmey. For additional information, contact Kathryn Kuhlmey at 218-878-7080.

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.