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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - March 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. Mental Health Collaborative Kicks Off with Successful Learning Day
  2. Upcoming Events and News
  3. Adult Day Services are Uniquely Able to Reduce Avoidable Readmissions for Participants
Learning Day collage
Pictured L to R, top row: Melissa Hensley, Chris Walker,
Eric Peterson; middle row: Paul Goering, Michael
Trangle, Sue Hanson; bottom row: Dan Rehrauer, Meg
Moen, Craig Harvey, Mark Sonneborn, Sue Abderholden.

Mental Health Collaborative Kicks Off with Successful Learning Day

More than 100 participants filled the Maplewood Community Center on February 19, 2014 for the first learning day of the RARE Mental Health Collaborative. Although the group of 13 Minnesota hospitals had already attended a January webinar, this gathering served as the official kick-off and gave participants the opportunity to meet face-to-face, laying the groundwork for open sharing of best practices and lessons learned throughout the 13-month collaborative.

The day began with the stories of mental health patients and their families. Melissa Hensley, a patient who was in and out of the hospital for many years but is now doing well and became a social worker, shared her thoughts on how to keep people with mental illness out of the hospital. She said key factors are a belief that recovery is possible for all, the importance of coping and self-care techniques, the need for safe places to live, and having faith in ourselves and in our patients. Sue Hanson offered one family’s perspective, sharing the experiences with her son, who began having serious mental health issues while in college. In her view, the hospital social worker plays a key role with the patient and family; she also emphasized the importance of the discharge planner/case worker and a psychiatrist who is willing to go the extra mile.

Michael Trangle, MD, associate medical director, behavioral health for HealthPartners Medical Group, led off the rest of the program by giving an overview of the Recommended Actions for Improved Care Transitions document, which details best practices in the five key areas known to prevent avoidable readmissions and is specifically tailored to the needs of mental health patients. You can view all the presentations from the day in the Mental Health Collaborative section of the RARE Campaign website.

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: The Role of Health Information Exchange in Reducing Avoidable Readmissions
Friday, March 28, 2014, Noon – 1 p.m. CT
Stratis Health has been facilitating a Centers for Medicare and Medicaid Services (CMS) Special Innovation Project called Health Information Technology for Post Acute Care Providers (HITPAC). In this project hospitals and skilled nursing facilities have been working to improve transitions of care and medication management between hospitals and skilled nursing facilities through the use of their electronic health record (EHR) and to achieve health information exchange. Register for this webinar by March 25, 2014. More information.

Come Together at the Final Action Learning Day and Celebration
Tuesday, June 17, 2014, Plymouth, MN
Pillow with RARE logoRound up your RARE team – and your pillows – and make plans to join us at the Crowne Plaza Hotel in Plymouth for our last Action Learning Day. The event will include remarks by Eric Coleman, MD, MPH, professor of medicine and director of the Care Transitions Program at the University of Colorado, and a strong supporter of our RARE Campaign. After a day of sharing success stories and lessons learned, we’ll celebrate the official end of the campaign with a reception and some surprise activities you won’t want to miss. Hint: Plan to bring your pillow – a world record could be on the line! An email invitation will be sent soon, and more details will be shared as they become available.


The Minnesota Model – and RARE – Featured in Health Data Management Article
An article entitled “First Steps for Population Health” in the March 1, 2014 issue of Health Data Management looks to “the Minnesota model,” including the RARE Campaign, in its overview of population health, which it calls “…a cornerstone of both the Affordable Care Act and the larger effort to reduce costs by preventing the preventable and managing chronic illnesses better.” In addition to highlighting RARE’s success, the article talks about participant Allina Health’s enterprise data warehouse, being used now to predict the likelihood of readmission within 30 days and which in the future may help identify potential patients before they need to be hospitalized. The article is available on the RARE website and on the Health Data Management website (free registration required).


Risk Factors for Potentially Avoidable Readmissions Due to End-of-life Care Issues
Repeated hospitalizations are frequent toward the end of life, where each admission should be an opportunity to initiate advance-care planning to high-risk patients. This research study identified four main risk factors that were significantly associated with 30-day potentially avoidable readmission due to end-of-life care issues, producing a model with very good to excellent discrimination. Patients with these risk factors might benefit from palliative care consultation prior to discharge in order to improve end-of-life care and possibly reduce unnecessary rehospitalizations. (Journal of Hospital Medicine, February 14, 2014)

Observation and Inpatient Status: Clinical Impact of the Two-Midnight Rule
In response to growing concern over frequency and duration of observation encounters, the Centers for Medicare and Medicaid Services enacted a rules change on October 1, 2013, classifying most hospital encounters of fewer than two midnights as observation, and those greater than two midnights as inpatient. However, limited data exist to predict the impact of the new rule. This research concluded that the two-midnight rule adds new challenges to observation and inpatient policy, and suggests a need for rules modification.  (Journal of Hospital Medicine, February 14, 2014)

MADSA logoAdult Day Services are Uniquely Able to Reduce Avoidable Readmissions for Participants

Minnesota Adult Day Services Association is a RARE Community Partner

Like many other professional associations, Minnesota Adult Day Services Association (MADSA) works to rally its member organizations around standards that push those organizations to provide the highest quality of services.

MADSA applied for and received a grant from the Otto Bremer Foundation. Starting this month, MADSA intends to use the grant funding to begin strategic planning on how adult day services can help to improve transitions and reduce avoidable hospital readmissions in the population its member organizations serve.

“Adult day services programs and employees are uniquely positioned to be very effective in working to improve transitions and in reducing readmissions after a participant’s hospitalization,” said Gail Skoglund, MADSA co-president and director of adult day services for Augustana Open Circle. “We have a complete picture of our participants’ health and well-being. We also know their caregivers very intimately. When something seems out of the ordinary, we’re on it – getting a nurse or physician involved when needed.”

This is a particularly important RARE initiative for adult day services providers, according to Skoglund, who has worked in adult day services for 28 years, because too often adult day services are not even part of the conversation of what to do with Mom or Dad or Grandma or Grandpa after a medical diagnosis or hospitalization.

“We want to be seen as an optimal alternative to transitional care, nursing homes, memory care units, assisted living – because we allow participants to stay in their homes and where they want to be,” she said. Adult day services include rehabilitation therapies and, at minimum, must have nurse consultants who can manage a host of medical issues – like diabetes, hypertension, urinary tract infections, dementia, and others. Many centers have RNs on staff.

As good stewards of financial resources, adult day services want to demonstrate their effectiveness in reducing avoidable readmissions and be considered along with other care options.

Skoglund has many examples of how adult day services have made a difference for participants and recalls an 85-year-old veteran who enrolled last summer. He had a history of chronic heart failure, diabetes, depression, early stage dementia, hypertension, and COPD and had been hospitalized three times earlier in the year. “This gentleman attends our center two days per week,” said Skoglund. “While at the center, he receives health monitoring, socialization, proper nutrition and he faithfully exercises at the YMCA both days. He’s had no hospitalizations since his enrollment in adult day services. With increased strength and balance, he has put his cane away. Our services have helped him stay out of the hospital and have given his life a new purpose.”

For more information, contact Gail Skoglund, director of adult day services, at (612) 843-4940. 

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.