Howard Epstein, MD, FHM
Chief Health Systems Officer
Institute for Clinical Systems Improvement

A Better State of Health Through the Triple Aim*
* The Triple Aim: Care, Health, And Cost. Berwick DM, Nolan TW and
Whittington J., Health Affairs, May 2008, Vol. 27, No. 3, 759-769.

https://www.icsi.org/_asset/hkt4a4/Accountable-Health-Communities-White-Paper.pdf

https://www.icsi.org/health_initiatives/accountable_health/videos/

$2.5
Trillion
A 2011 Institute of
Medicine report estimated 30% of healthcare spending is non-value added www.IOM.edu/vsrt

Wedge Model for US Health Care With Theoretical Spending
Reduction Targets for 6 Categories of Waste
1. Failures of Care
Delivery
2. Failures of Care
Coordination
3. Overtreatment
4. Administrative
Complexity
5. Pricing Failures
6. Fraud & Abuse
Source: Eliminating Waste in US Health Care, Berwick, D.,
Hackbarth, A. JAMA. 2012;307(14):1513-1516

Rehospitalization 30 Days after Discharge
Jencks S, Williams MV, Coleman EA. N Engl J Med 2009;360:1418-1428
20%
Range:
13-23%
$17B
50% no
PCP f/u

Roger Resar, MD Senior Fellow
Institute for Healthcare Improvement

• CMS announces penalties
• RARE Planning Committee
• RARE Campaign – Operating Partners
– 83 hospitals
– Supporting Partners: MMA, MNCM, VHA
– > 100 Community Partners

main contributors to avoidable hospital readmissions
1. Comprehensive discharge planning
2. Medication management
3. Patient and family engagement
4. Transition care support
5. Transition communications

7030
7030
> 28,000
> 78 years!
> $60,000,000.00
www.RAREreadmissions.org

Agenda
 Getting Out and Staying Out: A Patient's Perspective on Reducing Mental Health
Re-Admissions - Melissa Hensley, PhD.
 Family Perspective - Tracey Daniels

Family Perspective
– Sue Hanson
 Recommended Actions for Improved Care Transitions Document – Michael Trangle,
MD, Associate Medical Director, Behavioral Health for HealthPartners Medical Group

Patient and Family Engagement
– Sue Abderholden, Executive Director, National
Alliance on Mental Illness, Minnesota
 Medication Management – Craig Harvey, Director Pharmaceutical Services, Regions
Hospital and Daniel Rehrauer, Clinical Pharmacy Program Manager, HealthPartners
 Comprehensive Transition Planning – Paul Goering, MD, Vice President Allina Mental
Health
 Transition Support - Chris Walker, MSN, RN, MHA Director Inpatient Mental Health
Units & Behavioral Access Nurses
 Transition Communication - Nystrom and Associates
 PPR Data - Mark Sonneborn, MS, FACHE, Vice President, Information Services,
Minnesota Hospital Association

Team Action Plan
 Wrap Up & Next Steps

Recommended Actions Work Group
• Paul Goering, MD Allina Health
• Chris Walker, MSN, RN, MHA CentraCare Health System
• Cathy Brouwer, RN Chippewa County Montevideo
• Kathy Knight, RN, MA Fairview Health Services
• Karen Lloyd, PhD HealthPartners
• Terry W. Crowson, MD HealthPartners
• Michael A. Trangle, MD HealthPartners
• Paul Davis, PhD, LP Lakewood Health System
• Jennifer McNertney, MPP Minnesota Hospital Association
• Sue Abderholden, MPH National Alliance on Mental Illness
• Nancy Houlton, LICSW UCare
• Kathy Cummings, BSN, MA ICSI
• Joann Foreman, RN, BAN ICSI

RARE Mental Health Collaborative
Planning Committee
– Annie Walsh University of MN Medical Center, Fairview
– Jennifer McNertney, Minnesota Hospital Association
– Jill Kemper, ICSI
– Joann Foreman, ICSI
– Kathy Cummings, ICSI
– Martha J Aby, DHS
– Michael A Trangle, HealthPartners
– Nancy Houlton, Ucare
– Chris Walker CentraCare
– Sue Abderholden, NAMI MN
– Terry Crowson, HealthPartners
– Janelle Shearer, Stratis Health
– Niki Gjeri, UMMC, Fairview
– Paul Goering, Allina
– Greg Clancy, Allina
– Carol LaBine, DHS