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RARE - Reducing Avoidable Readmissions Effectively

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RARE Report - March 2013

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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. Upcoming Events,News and Website Updates
  2. Discharge Advocate Helps Ease the Process for St. Luke's Patients
  3. PrimeWest Health Discharge Member Follow-Up Project Yields Exciting Results

Upcoming Events, News and Website Updates


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

Action Learning Day – Looking Beyond the Hospital to Improve Care Transitions
8:30 a.m. – 3:30 p.m., Tuesday, April 23, 2013, Marriott Minneapolis Northwest
Hospitals and Community Partners participating in the RARE Campaign are invited to gather at our next Action Learning Day in Brooklyn Park to learn and share with one another. You will hear from Cheri Lattimer, executive director of the National Transitions of Care Coalition, about the latest strategies for improving safety and quality of care for transitioning patients. In addition, you'll learn about innovative approaches to medication management, and hear how RARE partners are engaging in community-based efforts to coordinate care and reduce avoidable readmissions. The cost is only $40 per person, including meals. Learn more and register.

The day will include a series of Rapid Fire presentations where organizations have 10 minutes to share an aspect of their current work followed by 10 minutes for audience questions/comments. Please consider sharing your improvement strategies and projects as a Rapid-Fire presenter! It's easy – a formal presentation is not required. We are particularly interested in examples of reaching across the continuum of care to involve resources beyond the hospital. If you are interested, please contact Rochelle Hayes or call 952-814-7098 by April 5, 2013.

Schedule Note: There are no RARE webinars/conversations in April due to Action Learning Day. The next RARE webinar will take place in May; watch your email and the next RARE Report for information.


RARE Participating Hospital Featured in Washington Post Article
Ridgeview Medical Center in Waconia, MN was featured in a February 27, 2013 Washington Post article, "Health Law's Rules Help Hospitals Cut Patient Readmission Rate." The article, which discusses the impact of hospital penalties and other aspects of the Obama Administration's health care reform law, also describes the efforts of Ridgeview's dedicated team working to reduce avoidable readmissions. Read more.


RARE Webinars, Conversations Available Online
Slides and podcasts from February's RARE webinar on the role of community health workers in preventing readmissions, and from the March conversation on how health care homes can improve care transitions, are now available on the RARE Campaign website. Find them and all past webinars and conversations on the Recorded webinars page.

  • There and Home Again, Safely. The five patient safety principles for transitioning patients from inpatient to outpatient care recently released by The American Medical Association (PDF) has been added to the Transition Care Support Resources area of the RARE website.

Reducing Readmissions: It Takes a Village In a Reform in Action brief, lessons from Aligning Forces for Quality (AF4Q) and the Robert Wood Johnson Foundation demonstrate how hospitals and health care organizations are addressing the problem of avoidable readmissions by taking steps to help patients get the care they need. A link to the document has been added to the Participants Resources area of the RARE website.

A Path Forward on Medicare Readmissions The March 6, 2013 issue of The New England Journal of Medicine includes an analysis of the hospitals penalized under the CMS Hospital Readmission Reductions Program by Karen E. Joynt, MD, MPH, and Ashish K. Jha, MD, MPH, of the Department of Health Policy and Management, Harvard School of Public Health. The authors discuss possible reasons for recently reported reductions in readmissions and recommend several improvements to the program.

10 Things You Should Know About Care Transitions The Robert Wood Johnson Foundation Care About Your Care program includes a list of 10 facts patients should know about readmissions.

The Face Value of Hospital Readmissions As part of its work on the Robert Wood Johnson Foundation's Care About Your Care effort, the MLS Group wanted to tell the story that behind every "percent readmitted within 30 days of discharge" is a real person with a unique experience. Read more in this blog post.

Discharge Advocate Helps Ease the Process for St. Luke's Patients

Being discharged from the hospital can be a confusing and overwhelming time for patients. They may have new medications to take, new nutritional needs, follow up appointments, and information to learn about their health condition. Comprehensive discharge planning, one of five key areas identified by the RARE Campaign known to reduce avoidable readmissions, can help prepare patients to return home and prevent readmission down the road. At St. Luke's Hospital in Duluth, a discharge advocate is helping prepare patients well before it's time to leave the hospital.

After attending a RARE informational session in October 2011, a cross-functional team from St. Luke's set out to start the process of streamlining education and improving outcomes for patients with the creation of the discharge advocate role. Patients on the cardiac unit with congestive heart failure (CHF) were selected to participate in a pilot, which began in February 2012, because an educational plan for these patients was already in place. These patients are often at high risk for readmission and were receiving education from a lot of different sources. "When we met with the nursing council for our cardiac unit, we discovered that patients were leaving the hospital with too much information to wade through," said Heather Palladino, director, case management at St. Luke's. In addition to streamlining information, it became evident that discharge education needed to happen over the length of the hospital stay, not just at discharge.

Lois OpsethAs a member of the case management department, St. Luke's Discharge Advocate Lois Opseth began meeting with heart failure patients on the cardiac unit, and later pneumonia and heart failure patients on two medical units. She tries to meets with the patient within 24 hours of admission and interviews both the patient and family. During this time she assesses the discharge and educational needs of the patient so a plan can be determined to meet the needs of that patient. She provides condition-specific education to patients using the teach-back method to ensure they understand. When a patient is hospitalized with a serious condition such as heart failure, "all the medications and changes in care can be overwhelming to patients," said Opseth.

Opseth, who is currently the only discharge advocate on staff at St. Luke's, also discusses and collaborates the plan of care and educational plan with the provider, primary nurse, social worker and case manager, and collaborates with the pharmacist for review and education of medications. Case management staff documents the patient discharge needs and plan in St. Lukes's electronic health record (EHR) and Opseth adds her documentation there as well.

Since it is not feasible for Opseth to meet with all patients, St. Luke's implemented the LACE tool in January 2013 to alert the facility to patients at high risk of readmission. LACE scores the patient and refers them to work with the discharge advocate. Patients who score an 11 or higher get referred to Opseth. LACE stands for:

  • Length of stay (has the patient been admitted within the last 30 days?)
  • Acuity (inpatient versus outpatient)
  • Comorbidities
  • Emergency room visits (has the patient visited the ER recently, even if not admitted?)

Once the patient is discharged, the discharge advocate provides a follow up phone call within 3 days. If needed, Opseth coordinates a phone call with the pharmacist to review medications and answer questions. According to Palladino, patients appreciate the follow up phone call and the consistency in dealing with one person. It has also improved communication across the continuum to make sure everyone is on the same page.

Early results are promising. Since the discharge advocate position was created, St. Luke's has experienced a decrease in congestive heart failure patients who were readmitted, from 37 in 2011 to 26 in 2012. The number of pneumonia patients readmitted decreased as well, from 23 in 2011 to 17 in 2012. Many patients with congestive heart failure also suffer from other conditions, and the discharge advocate program has been able to impact the number of readmissions for pulmonary edema and respiratory conditions, from 17 in 2011 to 13 in 2012.

"It works. It's effective, if it's utilized properly," said Palladino.

For additional information, contact Heather Palladino at 218-249-5202.

PrimeWest Health Post-Discharge Member Follow-Up Project Yields Exciting Results

Jordan Klimek, MS, PIP/HEDIS Coordinator for PrimeWest Health, a RARE Community Partner

PrimeWest Health logoThe goal of PrimeWest Health's Performance Improvement Project (PIP), Post-Discharge Member Follow-Up, is to coordinate services with contracted focus hospitals to improve the outcomes of discharge planning for members and to reduce readmissions. The three contracted focus hospitals are Douglas County Hospital, Hutchinson Community Hospital, and Sanford Hospital Bemidji. PrimeWest Health works with these hospitals to improve the timeliness of notification of member discharges and increase the number of discharge plans the hospital sends to PrimeWest Health.

Following discharge, PrimeWest Health calls members to ensure they are doing well and understand their discharge instructions; also that they have a follow-up appointment scheduled and have any necessary medications and the appropriate support and equipment. In addition, PrimeWest Health nursing staff calls members at specified intervals to ensure they keep follow-up appointments with primary care providers. PrimeWest Health's medical director also evaluates the discharge plans to see if modifications could be beneficial.

Readmission Rate is Dropping

Beginning the third year of this PIP, PrimeWest Health has reported a reduction in member readmissions from the focus hospitals. From 2010 to 2011, the readmission rates for members in our Families and Children and MinnesotaCare programs dropped from 6.84 to 4.73 percent. Rates for Minnesota Senior Health Options (MSHO)/Minnesota Senior Care Plus (MSC+) members dropped from 12.91 to 6.99 percent. Both of these populations met the 10.8 percent relative improvement goal in measurement one. Measurement two data for 2012 will be available in April 2013.

Information from the post-discharge follow-up assessments also shows positive signs.

  2011 2012
Members meeting criteria for inclusion were reached by telephone to complete a follow-up assessment 21% 20%
Percentage reached who understood their discharge instructions 96% 96%
Percentage reached who indicated a post-discharge appointment with their primary care provider was recommended in their instructions 94% 95%

Focus hospitals share records electronically with their affiliated clinics. If the records are not shared electronically, PrimeWest Health faxes them to the clinic, improving communication between facilities. Another encouraging finding from the 2012 sample of discharge instructions was that in 97.3 percent of the cases, the member was discharged with a current list of medications. That list was to be delivered to the member's primary care provider at the follow-up visit or would be part of a discharge summary that was available electronically for reconciliation in the clinic.

There have been some challenges with this PIP, including reaching members for the follow-up assessment and receiving complete discharge information. Overall, however, this PIP shows exciting improvements for members and providers. PrimeWest Health nursing staff indicates that most members are pleased to receive follow-up phone calls. And, the focus hospitals report that the results of the assessments are helpful. PrimeWest Health is continuing interventions in 2013 and seeks sustained improvement.

For additional information, contact Jordan Klimek at 320-335-5364.

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.