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RARE - Reducing Avoidable Readmissions Effectively

Participant Resources

Through a collaborative approach, the RARE partnership provides a RARE Resource Consultant, recognized experts, and best practice toolkits to assist hospitals to improve and redesign their care processes to achieve their reduction goals. Below are general resources to support organizations participating in the RARE Campaign. Each of the five key areas hospitals can work on throughout the campaign have a designated list of activities to complete. Find specific resources for each of the five key areas through the links on the left.

RARE Campaign Implementation Overview. Diagram overview of the resources available to hospitals participating in the campaign.

Recommended Actions for Improved Care Transitions

The Operating Partners, together with the RARE Advisory Committee, have drafted the Recommended Actions for Improved Care Transitions. This document includes recommendations that are based on best practice, evidence and consensus, and are considered to be key practices that organizations should be working to implement. This document also includes other strategies that organizations may consider given their unique issues, needs and resources. It is a working document and we expect it to be modified as the campaign progresses. Recommended Actions for Improved Care Transitions (7-page PDF)

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.

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. A kick-off call is planned for Tuesday, January 14, 2014.

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.

Action Learning Days

The Operating Partners are developing and facilitating opportunities for participating organizations to come together for collaborative learning, planning and networking, and are making additional resources available on this website. They will provide technical assistance to each organization as it develops an action plan for reducing readmissions, along with process measures to support achievement of the Triple Aim target. Each participating hospital has a designated RARE Resource Consultant to serve as the primary contact person to provide ready access to program resources.

Action Learning Day June 17, 2014

Action Day materials


Action Learning Day November 11, 2013

Action Day materials


Action Learning Day April 23, 2013

Action Day materials


Action Learning Day November 8, 2012

Action Day materials


Action Learning Day April 24, 2012

The RARE Action Learning Day is for the RARE organizations' working teams. Teams will discuss their strategies and successes, and participate in cross organizational networking. Action Day materials


Action Learning Day October 18, 2011

This 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. Action Day materials

RARE Report

The monthly RARE Report is designed to: RARE report

  1. Keep staff in participating hospitals and partner organizations abreast of campaign news, events, and progress toward goals.
  2. Demonstrate how hospitals and Community Partners can work better together across the continuum of care after hospital discharge to prevent avoidable readmissions.
  3. Share success stories and other best practices to accelerate progress.
  4. Provide tools and tips to keep staffs motivated, engaged and implementing changes to achieve their goals.

See all issues of the RARE Report >

Quarterly PPR Data

Participating hospitals receive quarterly Potentially Preventable Readmissions (PPR) data from the Minnesota Hospital Association. Hospitals will collect data on a variety of process measures for quality improvement and report their progress. PPR data will be used for this campaign instead of Hospital Compare data. Hospital Compare data uses three years of Medicare-only data, shows all-cause readmission rates, shows readmissions to any facility, uses a risk adjustment methodology that cannot be replicated with publicly available data, and is published only once per year. PPR data uses one year of all-payer data, portrays only readmissions that might be avoided, shows readmission to the same facility only, uses risk adjustment software from 3M, and can be updated quarterly. The data source available for PPR consists of all inpatient administrative claims data from Minnesota hospitals. The data is insufficient to identify when a patient is readmitted to a different facility. The advantages of PPR are that it is all-payer, allows the provider to focus improvement efforts on those readmissions that could have been avoided, and can be updated frequently. Given the limitations of the data sources and methodologies available, we believe using PPR data is the best choice.

Quarterly PPR Data. This webinar provides detailed information on how to use the Potentially Preventable Readmissions (PPR) data in conjunction with ongoing improvement efforts aimed at reducing avoidable readmissions. The webinar speakers are Mark Sonneborn, MS, FACHE, Vice President of Information Services, Minnesota Hospital Association and Kathy Cummings, RN, MA, Project Manager, Institute for Clinical Systems Improvement. (Recorded February 2, 2012) (39-minute webinar) Handout (26-page PDF)

Understanding PPR Reports. From the second half of the Introductory Webinar on the RARE Campaign, this recording helps hospital staff as well as others across the continuum of care understand how to interpret potentially preventable readmissions data. Presented by Mark Sonneborn, Minnesota Hospital Association. (Recorded August 4, 2011) (23-minute podcast) Handout (25-page PDF)

Recorded Webinars

Many regional hospitals, as well as proven national intervention programs, have successfully prevented avoidable readmissions. These recorded webinars share their work. Plan to attend live webinars offered through the RARE Campaign. Calendar >

Work Group Reports

See the resources developed by RARE work groups.

  • Measurement Work Group Summary and Recommendations
  • MN Epic Users Group Selects Medication Management as Improvement Focus
  • Recommended Actions for Improved Care Transitions: Mental Illnesses and/or Substance Use Disorders

General Resources

Hospital Guide to Reducing Medicaid Readmissions can help acute care facilities adapt or expand existing Medicaid readmission reduction efforts; develop Medicaid reduction strategy using the guide’s roadmap featuring 13 customizable online tools; comply with CMS’ Conditions of Participation requirements for a standard, improved, and transitional care for all patients; and develop partnerships across other settings of the healthcare continuum. AHRQ

Institute for Health Care Improvement How-To Guides on Improving Care Transitions. The guides include key recommendations for improving transitions; review of the necessary leadership support and fundamental improvement methods and resources for testing changes before they are implemented and spread more widely throughout the organization; case studies; and measures, resources, and references.

Reducing Readmissions: It Takes a Village In a Reform in Action Brief. lessons from Aligning Forces for Quality (AF4Q) and the Robert Woods 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.

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.