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RARE - Reducing Avoidable Readmissions Effectively

Mental Health Collaborative

The RARE Collaborative: Mental Health Care Transitions is a yearlong learning collaborative for organizations with inpatient mental health units. It is designed to support organizations in reducing readmissions for these patients and to improve their transition into post-acute care.

Using best and promising practices as well as evidence-based interventions; each organization’s team will be coached through the process of improvement. The collaborative will primarily use virtual meetings with a daylong session at the beginning and end of the year. Content will focus on the five key areas known to reduce avoidable readmissions.  Participating organizations will be able to network with other participants as well as learn from national experts.

Participating Organizations

  • Essentia Health East, Duluth
  • Fairview Southdale Hospital
  • Hennepin County Medical Center
  • Mayo Clinic
  • North Memorial Medical Center
  • Regions Hospital
  • St. Cloud Hospital
  • St. Joseph's Hospital, HealthEast Care System
  • St. Luke’s, Duluth
  • State of Minnesota/Anoka-Metro Regional Treatment Center and Community Behavioral Health Hospital - Rochester
  • United Hospital
  • University of Minnesota Medical Center, Fairview

Benefits of Participation

  • Coaching tailored to your organization from your own resource consultant
  • Opportunities to learn from state and national experts
  • Share lessons learned with your peers in a supportive, collaborative environment
  • Access to data on your hospital’s potentially preventable readmissions for this specific patient population
  • Interventions based on best and promising practices as well as evidence-based interventions
  • Interventions tailored to the needs of your organization

Expectations Include

  • Attend two all-day learning sessions and monthly webinars. The first learning day is February 19, 2014. The second will occur in February of 2015
  • Perform an assessment to identify your organization’s improvement opportunities
  • Work on at least one of the five focus areas for reducing avoidable readmissions
  • Share your outcomes and lessons learned
  • Collect data as needed based on identified focus area
  • Commit to sharing, learning and supporting others!

Roadmap of Collaborative Activities

Getting Started

Organizational Assessments

Recommended Actions for Improved Care Transitions: Mental Illnesses and/or Substance Use Disorders, a document intended for health care professionals who provide care for patients in a variety of settings. It provides basic recommendations in five key areas that are well-recognized core strategies for care transition improvement as well as recommendations specific to mental health populations. It also identifies key recommendations that are important specifically for care transitions improvement when working with patients with new or existing mental illnesses. It does not specifically focus on delirium or dementia, but many of the recommendations will also help support these patients and their families.

RARE Mental Health Collaborative Learning Day, February 19, 2014

Webinar January 14, 2014. Mental Health Collaborative Kick-off webinar. (49-minute webinar) Slides (10-page PowerPoint)

Webinar March 25, 2014. Reducing Readmissions through Re-engineered Discharges - Project RED. Project Re-Engineered Discharge is a research group at Boston University Medical Center that develops and tests strategies to improve the hospital discharge process in a way that promotes patient safety and reduces re-hospitalization rates. The RED (re-engineered discharge) intervention is founded on 12 discrete, mutually reinforcing components and has been proven to reduce rehospitalizations and yields high rates of patient satisfaction. (56-minute webinar) Slides (49-slide PowerPoint)

Webinar April 21, 2014. Care Transitions Interventions in Mental Health. The objectives are to describe current problems related to mental health care transitions, describe three models to improve care transitions, and describe the care transition intervention components. Speaker is Harold Pincus, MD, Department of Psychiatry, Columbia University. (54-minute webinar) Slides (38-slide PowerPoint)

Webinar May 19, 2014. In-Reach Program. The objectives are to discuss the objectives of the In-Reach program, describe the components of the program, and discuss the results of the In-Reach program in Owatonna. Speaker is Elizabeth Keck, Allina Health - Owatonna Hospital. (51-minute webinar) Slides (22-slide PowerPoint)

Webinar June 26, 2014. The New York State Behavioral Health Readmissions Quality Collaborative. The objectives are to learn about the NY Office of Mental Health's project on reducing readmissions for the mentally ill and to compare the NY Office of Mental Health project with our RARE MH Collaborative, and seek best practices and lessons learned. Speakers are Molly Finnerty, MD; Edith Kealey, PhD; and Kate M. Sherman, LCSW; all of New York State Office of Mental Health. (58-minute webinar) Slides (49-slide PowerPoint)

Webinar July 23, 2014. Care Transitions for the Homeless. The objectives are to learn about available programs and resources, understand the challenges, and learn about opportunities to connect with others working on care transitions for the homeless in Minnesota. Speakers are Julie Grothe, Guild Incorporated; Dawn Petroskas, Catholic Charities of St. Paul and Minneapolis; Kelby Grovender, Hearth Connection; John Petroskas, Minnesota Department of Human Services; and Kristine Davis, Minnesota Department of Human Services. Handouts:

Webinar September 22, 2014. RARE PPR for Mental Health. The objectives are to describe the PPR methodology, describe how to interpret PPR reports, and describe how to use PPR data to monitor overall progress on reducing avoidable readmission. Presented by Mark Sonneborne, Minnesota Hospital Association. (21-minute webinar) Slides (16-slide PowerPoint)

Face-to-Face Session, October 15, 2014. Learning sessions where colleagues share experiences in reducing avoidable readmissions. Teach Back: Engaging Patients and Evaluating Learning (37-page PowerPoint) presented by Patricia Maus and Jane Clobe, Mayo Clinic. Patient Engagement through Patient Centered Goals (13-page PowerPoint) presented by Chris Walker, St. Cloud Hospital/CentraCare Health. Handout (4-page PDF). Agenda (1-page Word doc)

Webinar November 3, 2014. Patient and Family Advisory Councils. The objectives are to describe the principles of patient and family focused care, outline a strategy for developing and using a patient and family advisory council, and coordinate the use of an advisory council with readmission work. Presenters are Melissa Hensley, Augsburg College and Wendy Waddell, Regions Hospital. (51-minute webinar) Slides (29-slide PowerPoint)

Webinar January 20, 2015. Crisis Clinic and Paramedics The objectives are to describe the community paramedics program and its application to mental health patients, describe factors that prevent patients from timely discharges based on community resources, and discuss the factors contributing to a shortage of inpatient psych beds. (50-minute webinar) Community Paramedic Program presented by Rebecca Fessler, Saint Joseph’s Hospital, and June Hove, Saint Joseph’s Hospital, slides (11-slide PowerPoint). Psychiatric Flow presented by Michael Trangle, HealthPartners, slides (33-slide PowerPoint)


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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.