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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - November 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.

Note: The RARE Report will take a break in December. Watch for the next issue in mid-January.

Previous Issues

In This Issue

  1. New Data is In - 6,211 Avoidable Readmissions Prevented
  2. Upcoming Events and News
  3. Engaging Speakers, Networking Highlight a Successful Action Learning Day
  4. Get to Know Your Community Mental Health Programs
progress chart with pillows

New Data is In! RARE Campaign Helps Prevent 6,211 Avoidable Readmissions

The second quarter 2013 data is in, and the RARE Campaign participants have now helped prevent 6,211 readmissions since 2011 and allowed patients in Minnesota to spend 24,844 nights of sleep in their own beds instead of the hospital. The Campaign has surpassed its goal to prevent a total of 6,000 avoidable readmissions through 2013 and to help Minnesotans sleep 24,000 more nights in their own beds.

However, there is more work to be done to reach the goal of a 20 percent decrease in readmissions and to maintain our gains. The campaign will continue to work toward our goal of saving an additional $20 million in health care expenditures, and to identify other areas where this statewide, collaborative approach can make meaningful improvements. Thank you to everyone involved in the campaign that has contributed to this remarkable success!

Upcoming Events and News

There are no events scheduled for December. Materials from October’s webinar, Beyond ‘Engagement’ – Family Caregivers as Partners in Preventing Readmissions, are now available on the recorded webinar page. Please watch your email and the calendar page for information about January’s webinar.


MN Healthcare News Article Helps Patients Understand Their Role in Avoiding a
Return Trip to the Hospital

An article entitled “Reducing Readmissions: How to Stay Out of the Hospital” in the November 2013 issue of Minnesota Healthcare News, highlights the RARE Campaign and focuses on what patients can do to reduce avoidable readmissions. The article in this consumer publication, found in many clinic waiting rooms, focuses on the patient’s role in the five factors known to increase readmission (inadequate discharge planning; a patient’s inability to manage medications; lack of patient/family engagement in self-care; insufficient transition planning; and poor transition communication between different care settings) and offers resources to help them learn more. Read the article.

Campaign Receives Award for Marketing Efforts
The RARE Campaign’s marketing and communications work has received an MHSCN Award of Excellence. The Minnesota Health Strategy and Communications Network (MHSCN) is a nonprofit, membership organization whose purpose is to improve the professional skills of those involved in health care strategic planning, marketing, and public relations. This award recognizes excellence in health care marketing, communications, web-based strategies and public relations.


Applying Analytics to the Problem of Patient Readmissions
Data Alliance Collaborative members (including RARE participant Fairview Health Services) are pooling resources to develop solutions all providers can use. Among the first is an all-cause predictive readmissions model that analyzes both EMR and administrative data to identify patients who are most likely to be readmitted before they are discharged. Current readmissions models can’t analyze all conditions while accessing both EMR and the administrative data used by payers. (A Smarter Planet Blog, October 25, 2013)

Baroma ACO and Walgreens Collaborate to Reduce Readmissions and Drive Medication Adherence
As an Accountable Care Organization (ACO), Baroma has chosen to further develop Walgreens WellTransitions as an ACO-specific tool, with the Walgreens pharmacy team working in collaboration with Baroma Care Navigators and participating physicians to reduce preventable hospital readmission by improving medication adherence. (Wall Street Journal Online, October 22, 2013)

Study: Patient Engagement Linked to Lower Odds of Readmission
Patient activation is linked to better health outcomes and lower rates of health service utilization. Hospitalized adult medical patients in an urban academic safety net hospital with lower levels of Patient Activation had a higher rate of post-discharge 30-day hospital utilization. (Journal of General Internal Medicine, October 2013)

Engaging Speakers, Participant Networking Highlight a Successful Action Learning Day

Sanne Magnan and Mark Williams with pillows
Sanne Magnan, Mark Williams

On November 11, 2013 more than 135 people from participating organizations attended the fifth RARE Action Learning Day, which was kicked off by keynote speaker Mark Williams from the Society of Hospital Medicine and Project BOOST (Better Outcomes for Older Adults Through Safe Transitions). Dr. Williams talked about some key themes of what has been learned from BOOST to date, including an understanding that change is really hard and slow; mentors (preferably doctors) are the “secret sauce”; the need for true leadership support and commitment of resources; and the importance of preparing patients and their caregivers for what happens when they leave the hospital.

Victor Montori with RARE pillow
Victor Montori

Essentia Health’s Amy Vanderscheuren and patient representative Mary Jackson spoke about engaging patients as partners through patient advisory councils, and Allina Health’s Gregory Clancy shared information about a performance improvement project to implement mental health services for patients on a hospital surgical unit. ICSI’s Kathy Cummings facilitated a networking activity that grouped people by organization type to share “bright spots” they have discovered or created. Participants appreciated the opportunity to interact with others in a similar situation, and were excited about returning to the work of reducing avoidable readmissions armed with new connections and new ideas.

Closing speaker Victor Montori from the Mayo Clinic challenged the audience as he identified a key problem – two of five patients do not follow their doctor’s advice because they only have so much capacity to do the “work” of being a chronic patient. As he described the concept of minimally disruptive medicine, Dr. Montori talked about the balance between workload and capacity, and insisted that the most important thing we can do is to help people more fully return to the role they play in life.

Presentations and more photos from the day are available on the RARE Campaign website.

MACMHP logoGet to Know Your Community Mental Health Programs

Minnesota Association of Community Mental Health Programs is a RARE Community Partner

It is well known that mental health conditions contribute to the ability to effectively manage health conditions, but many hospitals and primary care providers do not understand how much they need community mental health to support the overall health of people with mental illnesses. Most health care providers are not trained to effectively engage people with mental illness; many of these patients say their health care providers do not listen to them and they often have poor experiences.

Community mental health programs provide an array of behavioral health services, including outpatient therapy, psychiatry, community support, inpatient, and residential. Many provide chemical dependency treatment, crisis outreach, employee assistance, forensic evaluation and other special services. These programs fulfill the county requirement to ensure that an array of mental health services is available regardless of people’s ability to pay.

Many community mental health programs are like the mental health version of home health. Unlike mental health services provided by a hospital or large medical clinic, they offer an abundance of services provided by non-licensed staff working under a licensed mental health professional. In-home services provide support and skill building to mental health clients. Staff may be in the homes multiple times per week to monitor and teach skills such as medication management, health condition treatment plan compliance, how to cook healthier meals, and helping clients increase their physical activity.

“Most within the health care system don't yet realize how much they need community mental health services to achieve the desired goals of health care system savings, improved patient experience, and improved health outcomes,” said Rick Lee, Ph.D. L.P., MACMHP board president and chief executive officer at Woodland Centers in Willmar. “Repeat hospitalizations and Emergency Room (ER) visits are just part of the picture.”

“Mental and physical health are intricately connected, as are mental health and many hospital admissions or ER visits. If we are going to truly reform the health care system in the way it’s desired to achieve the Triple Aim, we need to focus on mental health,” Lee added.

What’s changing?
Electronic Health Records: The behavioral health community is working to adopt EHR systems to allow for health information exchange. In the future, when someone with a mental illness presents at the ER, the hospital can share that information in real time. This will allow the community mental health program to engage more closely to when a patient exits an ER or hospital and work to prevent another episode of care, like a panic attack.

Behavioral health home: The state of Minnesota is developing criteria for behavioral health home—a health care home for people with a primary diagnosis of a mental illness and chemical dependency or a secondary diagnosis of a chronic condition. In this model, the mental health provider is responsible for care coordination. The Minnesota Department of Human Services is expected to submit its plan to CMS after the first of the year.

Collaboration: Community mental health programs are beginning to be part of discussions about improving population health. Community mental health providers are increasingly being recognized as necessary partners in the development of ACOs in Minnesota and across the country. As an example, Woodland Centers is among the key service providers at the table in the South Prairie Community Care Project, a collaboration of 12 counties in Southwest Minnesota using an ACO model focusing on primary care to coordinate care services.

“Hospitals should know about the community mental health programs in their area, what they do and who they do it with,” Lee said. “We want to be at the table—literally—to make sure the patient gets the support of the mental health provider.”

Read more: Bringing Behavioral Health into the Care Continuum: Opportunities to Improve Quality, Costs and Outcomes, American Hospital Association, January 2012.

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.