Maintaining patient health after a hospital stay...
RARE - Reducing Avoidable Readmissions Effectively

RARE Action Learning DayNovember 8, 2012

The RARE Action Learning Day was designed for the RARE organizations' working teams and focused on the five key areas for improvement. Teams discussed their strategies and worked on plans, and participated in cross organizational networking.

  1. Agenda (1-page Word doc)
    Eric Coleman
    Eric Coleman, professor of medicine
    and director of the Care Transitions
    Program at the University of Colorado.
  2. Welcome and Campaign Update presented by Lorry Massa, President, Minnesota Hospital Association slides (7-slide PowerPoint)
  3. Keynote Presentation: Sustain the Gains and Moving Forward presented by Eric Coleman, MD, MPH, Professor of Medicine and Head of the Division of Health Care Policy and Research at the University of Colorado Anschutz Medical Campus
  4. Patient Story: Cara Broich
  5. Making the Most of Your Success
    • Steve Bergeson, MD, Allina Health handout (12-page PDF)
    • Karen Tomes, RN, MA, PHN Allina Health
    • Jennifer Rudolph, Hennepin County Medical Center slides (11-slide PowerPoint)
  6. Rapid Fire Sessions
    • Pennie Viggiano, Systems Director, Government and Special Populations, HealthEast slides (13-slide PowerPoint)
    • Denise Edgett, Manager Integrated Home Care, HealthPartners, Integrated Home Care, Regions Hospital and Josh Brewster, Director, Care Management, Regions Hospital
    • Dana Engelman, RN, Hutchinson Area Health
    • Karen Loscheider, RN, Nurse Manager Triage, and Kristen Kopski, MD, Park Nicollet Methodist Hospital slides (8-slide PowerPoint)
    • Julie Burkhardt, Performance Improvement Coordinator, Ridgeview Medical Center slides (9-slide PowerPoint)
    • Lois Opseth, Discharge Advocate, Essentia – St. Lukes slides (10-slide PowerPoint)
  7. Tying it All Together presented by Eric Coleman, MD, MPH

Eric Colemen recommended the following resources during his remarks:

Engaging Physicians in Improving Care Transitions and Reducing Readmissions: A Practical Guide for QIOs Engaging physicians has been identified as a challenge in efforts to mobilize key stakeholders to support community-based efforts to improve care transitions and reduce avoidable rehospitalizations. This guide was developed by the Integrating Care for Populations & Communities (ICPC) National Coordinating Center (NCC) and physician consultants to provide some practical strategies to engage physicians. (13-page PDF)

Transitions of Care Consensus Policy Statement. These consensus standards address the quality gaps in the transitions between inpatient and outpatient settings, based on 10 principles. The standards describe the necessary components for implementation: coordinating clinicians, care plans/transition record, communication infrastructure, standard communication formats, transition responsibility, timeliness, community standards, and measurement. Developed by the American College of Physicians, Society of General Internal Medicine, Society of Hospital Medicine, American Geriatrics Society, American College of Emergency Physicians, and Society for Academic Emergency Medicine.

Staff form Allina Health and HCMC   Eric Coleman and Cara Broich
Steve Bergeson, MD, and Karen Tomes, RN, MA, PHN Allina Health; and Jennifer Rudolph, Hennepin County Medical Center.
Eric Coleman and Cara Broich.


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.