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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - Febuary 2014

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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. Campaign Receives 2013 Eisenberg Award
  2. New Data is In – 7,030 Avoidable Readmissions Prevented
  3. Upcoming Events and News
  4. There’s Still Time! Care Transitions Intervention: Collaborative Opportunity
  5. Improving Communication, Teamwork Makes RARE Effective for Tealwood Senior Living
Eisenberg recipients
Representatives of the three RARE operating partners
received the award at NQF’s annual conference in
Washington, D.C. on Feb. 13. L to R, Mrs. John Eisenberg;
Christine Cassel, CEO of the National Quality Forum; Kathy
Cummings, ICSI; Tania Daniels, MHA; Vicky Olson, Stratis
Health; Margaret VanAmringe, Joint Commission.

RARE Campaign Receives National John M. Eisenberg Patient Safety and Quality Award

The RARE Campaign has received the 2013 John M. Eisenberg Patient Safety and Quality Award for Innovation in Patient Safety and Quality, one of the most prestigious quality and safety awards in the country. This national recognition is a reflection of the campaign participants’ commitment to better care for our patients, innovative improvement strategies and hard work.

The willingness of all involved to work together to tackle the five key areas known to reduce avoidable readmissions, both inside and outside hospital walls, has been key to the campaign’s tremendous success and to the recognition it has received. This award truly belongs to all of us – congratulations! Read our press release. News coverage to date includes:

New Data is In! RARE Campaign Helps Prevent 7,030 Avoidable Readmissions

RARE pillow chartThe third quarter 2013 data is in, and the RARE Campaign participants have now helped prevent 7,030 readmissions since 2011 and allowed patients in Minnesota to spend 28,120 nights of sleep in their own beds instead of in the hospital. Although the campaign has surpassed its 2013 goal, we continue our work to achieve a 20 percent decrease in readmissions and to maintain our noteworthy gains.

In addition to continuing to support participants in this work, we look forward to identifying other areas where this statewide, collaborative approach can make meaningful improvements to improving the health of Minnesotans. Thank you to everyone involved in the campaign for your contributions to this remarkable success!

Speaking of the Data…
RARE progess line graphThe graphic at left offers another way to look at our data. It shows the number of prevented readmissions by quarter, and is one of the few times when you want the trend line to go up! In addition, the RARE Campaign had planned to switch to the newest version of the potentially preventable readmissions (PPR) software when it was to be released in late 2013. However, following a two-month delay in the release, we decided to continue using the same version through the end of the campaign rather than making a change that would be effective for only two quarters. This also gives us the advantage of maintaining the same trend lines throughout the entire campaign.

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: Health Information Technology in Post-Acute Care Settings
Friday, March 28, 2014, Noon – 1 p.m. CT
Please save the date for this March webinar and watch your email for details and registration.

Save the Date for Action Learning Day and Celebration
Tuesday, June 17, 2014, Plymouth, MN
We will gather at the Crowne Plaza Hotel in Plymouth for our last Action Learning Day and a special celebration! Additional information will be available soon.


Two Minnesota Hospitals Join the Campaign
Please welcome Grand Itasca Clinic & Hospital in Grand Rapids and Cuyuna Regional Medical Center in Crosby to the RARE Campaign.

There’s Still Time! Care Transitions Intervention: Collaborative Opportunity
As part of the Partnership for Patients Hospital Engagement Network (HEN), the Minnesota Hospital Association, in partnership with the RARE Campaign, is pleased to offer a Care Transitions Intervention (CTI) collaborative training session for committed hospitals. The training will be held June 18 and 19, 2014 in Minneapolis.

MHA logoThe collaborative will support hospitals and their community partners in implementing the CTI. Dr. Eric Coleman and his team designed the CTI in response to the need for a patient-centered, interdisciplinary intervention that addresses continuity of care across multiple settings and practitioners. The overriding goal of the intervention is to improve care transitions by providing patients with tools and support that promote knowledge and self-management of their condition as they move from hospital to home. The RARE Campaign sponsored two other CTI collaboratives in 2012 with participants from across the state. Additional information.

Participating organizations must commit to:

  • Plan to implement the Care Transitions Intervention in 2014
  • Participate in required pre-implementation activities
  • Allocate required resources to support program success
  • Coordinate and align care transitions work with other activities aimed at reducing avoidable readmissions


Nursing Homes Are the Solution on Readmissions
A recent report from the Office of the Inspector General (OIG) within the Department of Health and Human Services (HHS) argues that skilled nursing care centers, or “nursing homes,” should be better monitored by the federal government when it comes to how frequently they send patients back to the hospital. OIG recommended that the Centers for Medicare and Medicaid Services (CMS) develop a quality measure to track and publicly report nursing centers’ hospitalization rates and to have state survey agencies review the measure as part of the survey and certification process. (Health Affairs Blog, January 17, 2014)

30-Day Hospital Readmission Following Discharge From Postacute Rehabilitation in Fee-for-Service Medicare Patients
This research study looked at 30-day readmission rates for the six largest diagnostic impairment categories receiving inpatient rehabilitation. These included stroke, lower extremity fracture, lower extremity joint replacement, debility, neurologic disorders, and brain dysfunction. Among post acute rehabilitation facilities providing services to Medicare fee-for-service beneficiaries, 30-day readmission rates ranged from 5.8% to 18.8% for selected impairment groups. The authors noted that further research is needed to understand the causes of readmission. (JAMA, February 12, 2014)

Patient-Centered Community Health Worker Intervention to Improve Posthospital Outcomes
Patient-centered community health worker (CHW) intervention improves access to primary care and quality of discharge while controlling recurrent readmissions in a high-risk population. Health systems may leverage the CHW workforce to improve posthospital outcomes by addressing behavioral and socioeconomic drivers of disease. (JAMA Internal Medicine, February 10, 2014) Note: The RARE Campaign offered a webinar on the role of community health workers on February 26, 2013. RARE webinar materials.

Factors Contributing to Emergency Department Care Within 30 Days of Hospital Discharge and Potential Ways to Prevent It: Differences in Perspectives of Patients, Caregivers and Emergency Physicians
Identifying needs in patients who utilize the emergency department (ED) soon after being discharged from inpatient care is essential for planning appropriate care-transition interventions. This study examined differences in stakeholder perspectives on reasons for ED care soon after hospital discharge and interventions that could be useful to prevent these ED visits. (Journal of Hospital Medicine, February 5, 2014)

Tealwood Senior Living logoImproving Communication, Teamwork Makes RARE Effective for TWSL

Tealwood Senior Living is a RARE Community Partner

An initiative to reduce unnecessary rehospitalizations for nursing home residents can have added benefits: better staff communication and improved teamwork. That’s what Tealwood Senior Living (TWSL) discovered in looking back at RARE work that started in its Minnesota facilities in 2011.

Tealwood Senior Living and TWSL, LLC, a management company with skilled nursing facilities owned by Senior Care Communities, worked collaboratively on the TWSL rehospitalization reduction project.  The organizations received a grant from the Minnesota Department of Human Services to incorporate protocols for reducing hospitalizations for its residents who’ve had a previous stay in a hospital. At the same time, TWSL joined the RARE Campaign.

“Our first step in 2011 was to assure that electronic medical records were up and running in all of our Minnesota facilities. Many had online charting, but not all of them,” said Culleen Charles, a Tealwood nurse consultant with a long history in senior health care. Charles led the organization’s effort to reduce readmissions in its more than 30 nursing homes and assisted living facilities in four states – starting with the 11 facilities in Minnesota.

TWSL incorporated INTERACT as part of the medical record. INTERACT stands for “Interventions To Reduce Acute Care Transfers” and is an initiative that has been adopted by many post acute care organizations. INTERACT includes electronic and non-electronic tools to improve the early identification and communication of changes in the status of nursing home residents.

“INTERACT’s Stop-And-Watch tool has a log for tracking clues that something is just not right with a patient,” said Charles. “Our nursing assistants are the closest to patients and are best at detecting small changes. Does the resident have new pain? Not eating well? Assistants document issues that can then be monitored.”

When a hospitalization occurs, nurses can see if Stop-And-Watch was used or if an intervention could have been done sooner. “We can run reports on the use of Stop-And-Watch. Our staff members are more apt to use the tools when they can see their effectiveness,” Charles noted.

Charles said that improving communication has been one of the biggest benefits of TWSL’s work to reduce rehospitalizations. “Nurses go back to the nursing assistants to commend them for taking the time to note a Stop-And-Watch issue. Assistants see that they play a big part in excellent care,” she said.

In addition, TWSL’s facilities have RARE staff “champions” who participate in weekly conference calls and share ideas on what works and where to improve.

Community physicians also noticed communication improvements when TWSL began using SBAR standards. When doctors receive a call from nursing home caregivers, knowing the Situation, Background, Assessment and Recommendation help them make more informed decisions. “Physicians have a better understanding of our facilities’ capabilities, too,” said Charles. “X-rays that can be done right at the facility, for example, may save a resident a trip to the hospital or clinic.”

Charles knows that rehospitalizations are reduced, but is even more gratified by the improvements in care for residents. “The increased communication from this effort has empowered employees to meet our residents’ needs with much better coordination of care.”

For more information, contact Culleen Charles at (651) 260-2958.

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.