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RARE - Reducing Avoidable Readmissions Effectively

RARE Work Group Reports

Measurement Work Group Summary and Recommendations

In support of the RARE Campaign, a group of health care stakeholders with measurement interest and expertise convened in February of 2011 with responsibilities for reviewing and advising on publically reported measures related to reducing avoidable readmissions, aligning with national measures impacting readmissions, providing measurement information to campaign participant hospitals, and exploring attribution methodology and advising on data sources. This effort was a collaboration of the RARE Operating Partners and MN Community Measurement (MNCM) to try to identify the measurement needs for public reporting and to support the RARE Campaign.

MN Epic Users Group Selects Medication Management as Improvement Focus

During the past few months, participating RARE hospitals have identified a variety of opportunities to better use electronic medical records (EMRs) in support of their work to reduce readmissions. To build on these ideas, Stratis Health convened representatives from the Minnesota hospitals and health systems that are using the Epic EMR to identify, define, and prioritize strategies to improve its ability to serve as a tool to reduce avoidable readmissions.

RARE Operating Partners staff came together with health informatics representatives and members of the MN Epic Users Group to recommend one priority area for action in the coming year. Areas of need identified included discharge planning, care coordination, medication management, risk assessment, user-friendly documentation, patient education and patient record standardization. At a meeting on April 9, the group agreed to focus its initial proposal on medication management. A proposal will be presented to the entire MN Epic Users Group that will include recommendations to improve areas such as providers’ access to complete and accurate medication information, documentation of medication use and patient education, and user-friendly materials for patients and their families. 

The MN Epic Users Group will consider the proposal in the context of its work for the next year and will also work with Epic to assess feasibility and next steps. The RARE Operating Partners will continue to work with hospitals and the MN Epic Users Group to support implementation of the medication management proposal and to develop an approach for addressing the other opportunities for improvement.

Recommended Actions for Improved Care Transitions: Mental Illnesses and/or Substance Use Disorders

The result of this workgroup was 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.

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.