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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - August 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. New Data Is In: Campaign Prevents 5,441 Avoidable Readmissions
  2. Participating Hospitals in the News
  3. Upcoming Events, News and Website Updates
  4. Paynesville Medication Therapy Management Reduces Avoidable Readmissions by 50 Percent
  5. What a Difference a Community Makes!

New Data Is In! RARE Campaign Helps Prevent 5,441 Avoidable Readmissions

progress chart

The first quarter 2013 data is in, and the RARE Campaign has now helped prevent 5,441 readmissions since 2011 and allowed patients in Minnesota to spend 21,764 nights of sleep in their own beds instead of the hospital. The campaign’s ongoing goals for 2013 are to:

  • Prevent a total of 6,000 avoidable readmissions, extending the 2012 goal by 2,000
  • Continue to make progress toward our goal of reducing the percentage of avoidable readmissions by 20 percent
  • Help Minnesota residents sleep in their own beds 8,000 more nights this year, for a total of 24,000 more nights in their own beds
  • Save an additional estimated $20 million in health care expenditures

Thank you to everyone involved in the campaign that has contributed to this remarkable success!

RARE Participating Hospitals in the News

Granite Falls Care Transition Coaches Keeping Patients in Their Homes
In an effort to cut down on costly, unnecessary hospital readmissions, the Granite Falls Hospital has worked with the Minnesota Hospital Association (MHA) to aid in the development and implementation of free patient programming to assist individuals in maintaining their prescribed health regimens as they transition from hospital to home. (Granite Falls Advocate Tribune, July 22, 2013)

Medical Device Gives Heart Patients a Daily Link to Caregivers
A medical device gives heart patients at Essentia Health in Duluth, MN a daily link to caregivers, helping to reduce avoidable readmissions and get patients more involved in their own care. (Minnesota Public Radio, August 6, 2013)

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: Improving Care Transitions in Primary Care With COMPASS
Friday, August 23, 2013, Noon – 1 p.m. CT
Webinar participants will understand the role ambulatory care can play in preventing unnecessary readmissions and admissions and learn more about the COMPASS (Care of Mental, Physical and Substance Use Syndromes) primary care model of coordination and team-based care for patients with complex medical and behavioral health disease. Learn more.

Action Learning Day: Save the Date!
Monday, November 11, 2013, Plymouth, MN
A collaborative opportunity to share with and learn from other statewide RARE participants working on similar readmission topics. This educational/networking event will focus on improving care transitions and reducing avoidable readmissions. The keynote speaker is Mark V. Williams, MD, FACP, MHM from the Society of Hospital Medicine and Project BOOST (Better Outcomes for Older Adults Through Safe Transitions). Learn more.


CMS Announces Second Round of Hospital Penalties for Excess Readmissions
As reported on August 2, 2013 in Kaiser Health News, “Medicare will levy $227 million in fines against hospitals in every state but one for the second round of the government’s campaign to reduce the number of patients readmitted within a month, according to federal records... Medicare identified 2,225 hospitals that will have payments reduced for a year starting on Oct. 1. Eighteen hospitals will lose 2 percent, the maximum possible and double the current top penalty. Another 154 will lose 1 percent or more of every payment for a patient stay.”

Mark Sonneborn, vice president of information services for the Minnesota Hospital Association, notes that compared to the first year of Medicare's Readmissions Reduction Program, the number of Minnesota hospitals paying a penalty stayed the same – 29 of 52 eligible hospitals.

However, despite the maximum potential penalty doubling (from 1 percent to 2 percent), the Minnesota state average penalty decreased slightly from 0.10 percent in 2013 to 0.08 percent in 2014. This means performance did improve slightly overall. Most of the penalized hospitals received very minimal penalties – 24 of the 29 penalized hospitals had penalties of 0.15 percent or below.  Thirty-four of the hospitals improved or stayed the same.

Six New Community Partners Join the Campaign
Six Minnesota organizations recently committed their organization’s support for the RARE Campaign as Community Partners: Family Means, Stillwater; Interim HealthCare of Lake Superior, Duluth; Lakeview Ranch Inc., Darwin; Living At Home Network, St. Paul; Volunteers of America, Edina; and Wilder Foundation, St. Paul.


Strategies for Reducing Potentially Avoidable Hospitalizations for Ambulatory Care–Sensitive Conditions
Hospitalizations for ambulatory care–sensitive conditions (ACSCs) are seen as potentially avoidable with optimal primary care. Little is known, however, about how primary care physicians rate these hospitalizations and whether and how they could be avoided. This study explores the complex causality of such hospitalizations from the perspective of primary care physicians.(Annals of Family Medicine, July/August, 2013)

Simple Solutions Can Help Fill Gaps in Health Care
Martha Hitzeman is legally blind, and at 87, needs medication for pain and to prevent strokes. But sometimes she forgets to take her pills. “She was starting to miss doses, sometimes maybe four or five doses in 10 days,” said her daughter, Marie Fuchs. “So I knew she wasn’t getting the medication she needed.” Fuchs, who manages her mother’s medication, enrolled Hitzeman last August in MedSmart, a pilot project run by PioneerCare a long-term-care facility in Fergus Falls. (Minnesota Public Radio, August 8, 2013)

NC Cuts Readmissions by 20% Among Sickest, Poorest Patients
North Carolina hospitals reduced readmissions by 20 percent among the sickest and poorest patients in the state, thanks to a transitional care program that required intensive follow-ups with Medicaid patients, according to a study published in Health Affairs. Note: this article also references recent RARE Campaign results. (Fierce Healthcare, August 9, 2013)


Institute for Health Care Improvement Updates How-To Guides on Improving Care Transitions
IHI recently updated its four How-to Guides on improving transitions in care for community settings, home health care, office practices and skilled nursing facilities. A link to the guides is available on our website at Participant Resources under General Resources.

Medication Therapy Management Helped Reduce Paynesville Readmissions by More Than 50 Percent

Paynesville staff
Front row: Todd Lemke (Pharmacist), Melissa Dols
(Dietitian), April Stadtler (Social Worker), Vickie
Schmitz (Nurse Manager), Sharon Olson (Discharge
Planner). Back row: Dennis Miley (CEO), Sharon
Olson (Infection Control), Tammy Stanger (Quality
Manager). Not pictured: Tim Lane (Physical
Therapist), and Randy Zimmerman (Physician).

Medication therapy management (MTM) is a key area of focus in efforts to reduce avoidable readmissions. Todd Lemke, PharmD, CDE, of the Paynesville Area Health Care System, a small rural critical access hospital, was able to quantify the success of his team’s MTM efforts with 70 Medicare fee-for-service patients (out of a group of 222 anticoagulation patients with two to five chronic conditions, including atrial fibrillation, blood clots and strokes).

His analysis of these high-risk patients from January 2008 through May 2012 showed that they have a much lower readmission rate than the national average for Medicare patients: 8.8 percent (a 50 percent improvement), compared with the national average of about 18 percent.

Paynesville, a RARE Campaign participant, is part of the Patient Safety and Clinical Pharmacy Services Collaborative (PSPC), an effort of the Health Resources and Services Administration (HRSA) to improve the quality of health care by integrating evidence-based clinical pharmacy services into the care and management of high-risk, high-cost, complex patients. Paynesville’s medication therapy management program involves seeing the patient in clinic, including ordering necessary blood tests, reviewing all medications, performing a condition-specific physical exam and modifying the patient’s medication regimen if necessary. The patient’s primary provider is right down the hall, so medication adjustments are easy to coordinate.

Paynesville has been involved in the RARE Campaign for two years. Its team includes representatives from across the continuum of care, and involves daily RARE rounds in-hospital and discussions about the discharge plan well before a patient goes home. The RARE team also makes connections with home care and other care settings as needed, and recently met with representatives of 40 local agencies to discuss how they can work together more effectively. 

“We have found that when we involve a pharmacist proactively as part of the interdisciplinary patient care team, our health system provides better care to patients—and it shows in our numbers,” Lemke said.

For additional information, contact Todd Lemke at 320-243-7772.

Read more in this December 2012 profile of the Paynesville PSPC on the Alliance for Integrated Medication Management (AIMM) website. (Article content reproduced with permission of AIMM.)

See also, Pharmacy Programs Can Reduce Hospital Readmissions in the July 2013 RARE Report.

What a Difference a Community Makes!

Home Care hand iconBy Beth Wiggins and the Aging Services Leadership Network, which includes seven RARE Community Partners.

Mary lives in the home she loves, determined to stay there despite being alone since her husband's death several years ago. Mary is 84 years old and has one son in the area. She has macular degeneration, diabetes, and has fallen three times in the past year, once resulting in a hospital stay. She was discharged from the hospital with a list of resource phone numbers but little else. On the drive home, Mary’s son realized she would need more care than he could provide while working full-time, but he didn’t know what to do. As he helped her out of the car and into the house, Mary’s neighbor came over to lend a hand. She knew about a local community-based organization that could help. 

And help it did. The organization sent an outreach nurse who met with Mary and her son in her home environment. She found that Mary would qualify for Medicare home care, contacted the primary care physician for the appropriate referral, and arranged transportation to follow-up appointments. She connected Mary and her son to a number of other community services as well, including home delivered meals, affordable homemaking help, and a volunteer visitor to provide weekly companionship. When Mary had regained some strength, she was connected to a falls prevention program. Her son was referred for caregiver coaching and consultation, where he learned ways to cope with the emotional and practical challenges of caring for his mother, how to be a good advocate and care coordinator, and how to maintain his own health and well being in the process.

Home care ended after five weeks, but Mary and her son are now successfully supported by a local network of community-based providers who are used to working together. She has had no emergency room visits or hospital stays in the past six months.

Mary’s story illustrates the support provided by numerous community-based organizations working across Minnesota. But what if Mary hadn’t had a knowledgeable neighbor? Would any of that effective support have been initiated?

  • Imagine how much more reliable support would be if those referrals were made prior to discharge.

Without access to health systems’ electronic health records, community-based organizations find it difficult to keep health systems informed of health status changes, and patients themselves are not always able to be good reporters.

  • Imagine the benefits that could come from automated and coordinated communication among the medical and community-based providers involved in someone’s care.

Much of this community-based support is invisible to the health care system, and nearly all of it is under-resourced.

  • Imagine if we could measure the impact of community-based care on hospital admissions and readmissions and support it as part of care delivery.

These are things to work toward together to reduce avoidable readmissions and improve the quality of life in our communities. 

The Aging Services Leadership Network includes FamilyMeans, Jewish Family and Children’s Service of Minneapolis, Jewish Family Service of St. Paul, Living At Home Network, Senior Community Services, Volunteers of America-Minnesota, and Wilder Foundation.

For additional information, contact Beth Wiggins at 612-636-6493.

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.