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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - September 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 in the News
  2. Upcoming Events and News
  3. MAAA Program Helps Patients Take Charge of Their Health, Avoid Return to Hospital
  4. Minnesota Pharmacists Working to Reduce Readmissions

RARE Campaign in the News

St. Paul Pioneer Press Looks at Hospital Readmissions in Minnesota, U.S. Hospitals
The St. Paul Pioneer Press recently explored hospital readmissions in an article titled, "Readmissions Prove Costly for Minnesota, U.S. Hospitals." It includes information about the success of Minnesota’s RARE Campaign. (St. Paul Pioneer Press, September 2, 2013)

“Our Pillow or Yours? Rice Memorial Hospital Project Takes Aim at Avoiding Readmissions”
Rice Memorial Hospital and its winning video produced for the RARE Campaign’s recent celebration was the focus of a recent article in the local newspaper. (West Central Tribune, August 14, 2013)

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 Transitions of Care for Uninsured and Low-income Publicly Insured Adults: Lessons from Oregon’s C-TraIn
Friday September 27, 2013, Noon – 1 p.m. CT
Dr. Honora Englander will discuss the Care Transitions Innovation (C-TraIn) program in Oregon. C-TraIn initially started as a hospital-supported transitional care program for uninsured and low-income publicly insured adults. Support from the Health Commons grant has enabled the program to increase its capacity and impact. Registration closes September 24. Learn more.

Mark WilliamsJoin Us at the Next Action Learning Day!
Monday, November 11, 2013, Plymouth, MN
Don’t miss this 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). Registration closes November 4. Cost is $40 per person, including continental breakfast and lunch. Contact hours will be available. Learn more.


RARE Collaborative on Mental Health Care Transitions is Underway
The RARE Collaborative: Mental Health Care Transitions is a yearlong learning collaborative for organizations with inpatient mental health units. It is designed to support organizations in reducing readmissions for these patients and to improve their transition into post-acute care.

Using best and promising practices as well as evidence-based interventions, each organization’s team will be coached through the process of improvement. The collaborative will primarily use virtual meetings with a daylong session at the beginning and end of the year. Content will focus on the five key areas known to reduce avoidable readmissions, with a concentration on the mental health population. Participating organizations will be able to network with other participants as well as learn from national experts.

We are recruiting five to seven organizations to join the collaborative. If you are interested in participating, or would like more information, please contact Kathy Cummings at 952-814-7086.


Simple Rules That Reduce Hospital Readmissions
To overcome system failures, health care organizations should implement a few simple rules of complex adaptive systems. This article by Thomas Kottke, MD, MSPH, senior clinical investigator for HealthPartners Research Foundation, describes Kaiser Permanente Southern California's ‘Transition in Care’ program to reduce hospital readmissions as an example of a program design that meets the principles of complex adaptive systems. (The Permanente Journal, Summer, 2013)

MAAA logoMetropolitan Area Agency on Aging Program Helps Patients Take Charge of Their Health, Avoid Return to Hospital

Metropolitan Area Agency on Aging (MAAA) is a RARE Community Partner

Care transitions occur when a patient moves from one health care provider or setting to another, and have been a prime focus of the work to reduce avoidable readmissions. The Community-based Care Transitions Program (CCTP), which was created with funding from the Affordable Care Act, is testing models throughout the country that can improve care transitions from the hospital to other settings, including skilled nursing facilities and home. The goal is a better experience, reduced costs and fewer avoidable readmissions among high-risk Medicare patients.

CCTP TeamCCTP was launched in 2011 with up to $500 million in funding and has 102 participating organizations. In Minnesota, the Metropolitan Area Agency on Aging (MAAA) is the only community-based organization to receive this funding. MAAA is providing care transition services in Minneapolis’s urban center and the surrounding seven-county metro area.

MAAA is partnering with Hennepin County Medical Center, North Memorial Hospital and nine nursing homes on this demonstration project to reduce avoidable readmissions among Medicare fee-for-service patients of any age, with any diagnosis (there are limited exceptions).

Participating nursing homes include Augustana Health Care Center, Catholic Eldercare on Main, Redeemer Residence, St. Olaf Residence, St. Therese Home, Northridge Care Center, Maranatha Care Center, Crest View Lutheran Home, and Colonial Acres Health Care Center. They are all part of the CareChoice Cooperative, the nation’s first cooperative of not-for-profit, mission-driven providers of aging services.

The program’s goals are to:

  • Reduce avoidable readmissions
  • Improve patient engagement
  • Increase attendance at follow-up clinic visits
  • Increase use of home and community-based services

The model uses the Care Transition Intervention® developed by Dr. Eric Coleman, MD, MPH, University of Colorado. CTI involves  a transition coach working with the patient and any care partners to help them be better prepared to take care of their health conditions following return home from the hospital or nursing home.

In this model, certified transition coaches are knowledgeable about available services in the patient’s community but don’t make referrals. They encourage patients to recognize their needs, set their own goals and know how to access services as needed. Key focus areas include:

  • Medication self-management – patients understand their medications and have a system in place to take medications appropriately
  • Dynamic patient-centered record – patients understand and manage a Personal Health Record
  • Primary care and specialist follow-up – patients schedule and complete follow-up visits
  • Red flags – patients are knowledgeable about indications that a condition is worsening and how to respond.

Coaches had served 470 people by the end of August. The cumulative readmission rate at partner hospitals was 21 percent last summer; the rate for coached clients in this program is 9.8 percent. MAAA continues to expand the program, possibly adding another hospital and more skilled nursing facilities.

“The work of this partnership adds to the body of knowledge that is helping to reduce avoidable readmissions in Minnesota,” said Dawn Simonson, executive director for MAAA. “By connecting them with support services available in their communities, people are more likely to achieve their personal health goals and maintain independence at home.”

For more information, contact Dawn Simonson at 651-917-4602.

MPhA logoMinnesota Pharmacists Working to Reduce Readmissions

Minnesota Pharmacists Association (MPhA) is a RARE Community Partner

"Historically pharmacists haven't worked across the continuum of care, where patients fall through the cracks. We’re now undertaking new and exciting work, interfacing hospital to hospital, hospital to clinic, and hospital to retail," said Jill Strykowski, MPhA president and director of pharmacy for Mercy Hospital and Unity Hospital.

Gary RainesStatewide, pharmacists are trying to figure out how they can assist with medication management to reduce readmissions. According to a recent publication1 that describes best practices in transitions of care, the common elements of most successful comprehensive medication review (CMR) programs are: 

  • Structured and consistent processes for communication between inpatient pharmacists and outpatient pharmacists
  • Documentation of a reduction in readmissions
  • Using pharmacy personnel in innovative ways (pharmacy technicians, student pharmacists, and pharmacy residents). 

Pharmacy interns are helping with admits in emergency departments and on floors. Pharmacy residents have helped kick off medication reconciliation efforts. Pharmacy techs are collecting medication lists and gathering complete medication histories.

More advanced elements in CMR programs include:

  • Structured and consistent processes for communication between pharmacists and other health care providers (e.g. identified point of contact at each transition point)
  • Documentation of improved Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) score
  • Ability for outpatient organization to view inpatient data or vice verse.

MPhA is advocating for changes to the Pharmacy Practice Act during the 2014 legislative session. They are looking for a shift from the historic focus on distribution to expanded rights for pharmacists to manage or modify medication therapy. The association is working on these changes in conjunction with the Minnesota Society for Health-System Pharmacists, Minnesota College of Clinical Pharmacy, Minnesota Medical Association, Minnesota Nurses Association, University of Minnesota College of Pharmacy, and others.

The association also makes several Medication Therapy Management resources available on its website, including collaborative practice agreements, a sample patient letter, and a sample business plan.

For additional information, contact Jill Strykowski at 763-236-4137.

1. Cassano, A et al. Best Practices from the ASHP-APhA Medication Management in Care Transitions Initiative. ASHP APhA. February 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:

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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.