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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - May 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. Final Campaign Data Shows 7,975 Avoidable Readmissions Prevented
  2. Upcoming Events and News
  3. HealthEast and Skilled Nursing Facilities Share Expertise on Reducing Readmissions
progress chart using pillows

RARE Campaign Prevents 7,975 Avoidable Readmissions

The data for the fourth quarter of 2013 has been released, and shows that the campaign exceeded its goals. Minnesota has collectively prevented 7,975 readmissions and helped patients spend 31,900 nights at home instead of in the hospital. In the last quarter of 2013, Minnesota hospitals reached a collective reduction in readmissions of 19 percent. Congratulations to all involved for your contributions to this impressive achievement! 

As the RARE Campaign comes to an official close in June, we recognize that the work will continue and sustaining the gain will be our goal. Participating hospitals will continue to receive quarterly data from the Minnesota Hospital Association so they can gauge their progress. We will provide additional information about the transitioning of this work in next month’s RARE Report.

Upcoming Events and News


Details and registration for all events listed below are available on the calendar page of the RARE Campaign website.

pillow with RARE logoRegister Now for Final Action Learning Day and Celebration
Tuesday, June 17, 2014, Crowne Plaza, Plymouth, MN
Round 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. Be sure to bring your pillow for a special photo opportunity!

Our keynote speaker is 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. The agenda will include patient engagement, end of life care, and learning more about how motivational interviewing, shared decision-making and health coaching can work together in a “synergy and symphony” of care.

Following the learning day program, we'll celebrate your accomplishments with a reception, including a brief program, a team photo opportunity with the Eisenberg award and Eric Coleman, and more. We hope you can participate in both events, but you are welcome to attend just the learning day or reception. Register by June 12, 2014. Cost for the learning day is just $45; there's no charge for the reception. For questions about the learning day, contact MHA's Kattie Bear-Pfaffendorf at 651-659-1404. Contact ICSI's Patty Staack at 952-814-7063 with registration questions.

Statewide MN Community Health Workers (CHW) Alliance Conference
Thursday, June 5, 2014, Minneapolis
This one-day statewide conference will share lessons and best practices to help achieve health equity and improve health access through the engagement of community health workers including community health representatives, MNsure navigators and others. Learn more and register today.


Improving Care Transitions: Collaboration by Organizations Cuts Readmissions
This article in the May 2014 issue of Minnesota Physician, co-authored by Stratis Health’s Janelle Shearer and Kim McCoy, describes the organization’s initiative to improve care transitions in a variety of settings. The article summarizes results for three Minnesota communities: Brainerd, Duluth and the north metro in the Twin Cities. Read the article.


MDH Emerging Professions Integration Grant Program
The goal of the Minnesota Emerging Professions Integration Grant Program is to foster the integration of emerging professions into the work force in roles that support the broad goals of the Minnesota Accountable Health Model related to providing coordinated care, across settings, for complex patients, populations and models of accountable care. Three rounds of grant funding will be available to support the integration of an emerging professional. Eligible applicants are any type of organization that has the capacity to employ an emerging professional. Applications are due by June 4, 2014. Learn more.

NAMI Minnesota Releases Videos for Hospital Staff
The National Alliance on Mental Illness (NAMI) Minnesota recently helped produced two short videos to assist with efforts to increase the awareness and empathy of hospital staff towards people with mental illnesses and their families, and also to bring hope and information to patients. They feature several people living with mental illness and living in recovery, and were sent to all Minnesota hospitals. Note: NAMI Minnesota Executive Director Sue Abderholden presented at the RARE Mental Health collaborative learning day in February of this year. Learn more.

Gallup: 6 Steps to Enhance Patient Engagement
With wider access to and transparency of quality and care data, health care providers need to focus on improving patient engagement and the patient experience, according to this Gallup Business Journal report, which outlines six steps to improved patient engagement. (Becker’s Infection Control & Clinical Quality, May 2, 2014)

Association of Impaired Functional Status at Hospital Discharge and Subsequent Rehospitalization
This research shows that for patients admitted to an acute inpatient rehabilitation facility, functional status near the time of discharge from an acute care hospital is strongly associated with acute care readmission, particularly for medical patients with greater functional impairments. The authors conclude that reducing functional status decline during acute care hospitalization may be an important strategy to lower readmissions. (Journal of Hospital Medicine, May 2014)

Federal Report Sheds Light On Readmission Rates
A new report from the Agency for Healthcare Research and Quality provides insight for hospitals struggling to reduce 30-day readmissions. It lists the top conditions associated with approximately 3.3 million readmissions in 2011 and analyzes how conditions vary depending on insurance coverage.  (Health IT Outcomes, April 28, 2014)

Preventing 30-Day Hospital Readmissions: A Systematic Review and Meta-analysis of Randomized Trials
Mayo Clinic researchers reviewed 47 randomized studies that assessed several methods to reduce readmissions to identify intervention features—including their impact on treatment burden and on patients’ capacity to enact post-discharge self-care—that might explain their varying effects. The researchers found that the rate of 30-day readmissions can be reduced by nearly 20 percent when specific preventive measures are taken.  (JAMA Internal Medicine, May 12, 2014)

Episcopal Homes logoHealthEast and Skilled Nursing Facilities Share Expertise on Reducing Avoidable Readmissions

Episcopal Church Home is a RARE Community Partner.

“Better together” is the way that leaders at Episcopal Church Home describe work to reduce hospital readmissions for its skilled nursing residents. The St. Paul organization is grateful to HealthEast Care System for bringing its value-based improvement principles to a process for care improvements that help residents at risk for requiring hospital services avoid unnecessary transfers.

The Episcopal Church Home - HealthEast Care System partnership started two years ago even as hospitals and health systems were gearing up for changes associated with the Affordable Care Act.

HealthEast invited post acute care (PAC) organizations to “town hall” meetings where the participants from senior care, home care and hospice care organizations held authentic conversations and learned about each other’s worlds.

“We were invited to Bethesda Hospital to see how staff and physicians use value-based improvement in their everyday work,” said Mike Karel, chief operating officer for Episcopal Homes of Minnesota. “Because of limited resources, this is not the kind of initiative that our organization can undertake from scratch.”

Value-based improvements are frontline staff led processes and suggestions that help organizations to continuously improve efficiency while maintaining high-quality care.

HealthEast uses “gemba,” a lean principle term that describes using direct observation at the front line where value is created. The goal of gemba is for leaders and other key employees to understand the current reality of a situation more clearly. “HealthEast PAC business unit leaders and executives have regularly gone to the gemba at PAC campuses in order to better understand the work and processes of our partners, while innovating on care models together,” said Rahul Koranne, MD, HealthEast vice president. “These visits have led to many more connections with a variety of post acute care partners – including proving physician leadership and on-site dedicated medical directors.”

Karel says that its HealthEast medical director has helped to give the organization a laser-sharp focus on readmissions using value-based improvement principles. In turn, staff members now dissect the processes for transfers and transitions. The facility uses run charts to watch for real-time trends, especially for patients who are most at risk for hospitalization.

“Within the first several months of our initiative, Episcopal Church Home saw readmissions drop from 13 percent to 7 percent,” said Karel.

Cerenity Senior Care – Marian of Saint Paul, another post acute care organization, has also benefitted from HealthEast’s expertise and medical direction. Cerenity recently partnered with HealthEast PAC business unit leaders and Medical Transportation to offer a lung sounds and Code Blue simulation course for its nursing staff. 

“Cerenity has been trained in value-based improvement initiatives and has been monitoring readmission rates daily,” said Lynn Fossen, director of nursing at Cerenity Marian. Congestive heart failure and pneumonia are two leading causes for readmission; with this special training the team can better evaluate the residents and start interventions.

“The answer to reducing readmissions doesn’t always reside in the medical model,” said Dr. Koranne. “Sometimes there are social or emotional reasons – homelessness, loneliness, anxiety and others – that need to be uncovered by astute staff members who can ask the right questions and are willing to persevere. Together we can share our experiences and ideas to the benefit of everyone – especially our communities.”

For more information, contact Mike Karel or Janna Kovach.

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.