Kathy Cummings, RN, BSN, MA
Institute for Clinical Systems Improvement
Janelle Shearer, RN, BSN, MA
Stratis Health
George and Martha
What is happening?
What is the Impact?
• Almost 20% of Medicare patients in Minnesota are
readmitted within 30 days of discharge
• Huge opportunity to fix gaps in fragmented system
• Reduce unnecessary burden on patients, families
• Preventable readmissions are contributing to
unsustainable climb in health care costs
• CMS penalties for low-performing hospitals – “clock”
begins ticking Oct. 1, 2011
The RARE Campaign
• A campaign across the continuum of care to
reduce avoidable hospital readmissions across
Minnesota and surrounding areas
• Regional approach, supported by hospitals,
providers, health plans, other key stakeholders
• Campaign is engaging other care providers,
acknowledging that readmissions are the result
of a fragmented health care system
Triple Aim Goals
• Population health
– Prevent 4,000 avoidable readmissions within 30 days of
discharge OR in other words,
• Care experience
– Recapture 16,000 nights of patients’ sleep in their own
beds instead of in the hospital
– Improve by 5% on HCAHPS survey questions on
discharge
• Affordability of care
– Save an estimated $30 million for commercially insured
patients; additional savings for Medicare patients
Broad Community Support
• Operating Partners:
• Institute for Clinical Systems Improvement (ICSI)
• Minnesota Hospital Association (MHA)
• Stratis Health
• Supporting Partners:
• Minnesota Medical Association
• MN Community Measurement
Broad Community Support
• Community Partners:
– Endorse and actively support the campaign
• A growing list of providers, health plans, state health
agencies, home health agencies, nursing homes,
patient advocacy groups and other community
organizations
Five Focus Areas
• Comprehensive discharge plan
• Effective communication for transitions of care
• Engagement of patient and family in discharge
process
• Medication management
• Transition care
Support for Organizations
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Best practice toolkits
Face-to-face sessions
Webinars
Conference calls
Peer coaching
Data reporting
“Innovator” approach: intensive, rapid process
improvement work
Analysis and Measurement
• MHA Potentially Preventable Readmissions
(PPR) data used to establish each hospital’s
goal
• Progress monitored with quarterly PPR results
• Hospitals collect data on variety of process
measures; report their progress
Long Term Care
Monitoring and Measuring Readmissions:
Developed by the Long Term Care Committee
of the RARE Campaign as a tool to help
nursing facilities calculate two types of rehospitalization measures:
• The Minnesota Department of Human Services
Re-Hospitalization Measures
• Other Re-Hospitalization Measure
Why Track to Reduce
Readmissions?
• Reduce the burden on patient, family and
staff
• Reduce costs
• Improve quality and target improvement
activities
• Accountability
For more on long-term care, vist the RARE Campaign website
What can long term care do?
• Collect your data
• Analyze your data
• Analyze each readmission for opportunities
for improvement – which of the five focus
areas contributed to the readmission?
• Analyze your care for each of the five focus
areas
• Begin quality improvement projects to reduce
readmissions and include your community
partners – hospital, pharmacy, etc.
What can long term care do?
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Medication Management
Comprehensive Discharge Plan
Patient and Family Engagement
Care Transition Support
Care Transition Communication
www.RAREreadmissions.org
16,000 Nights At Home
Will Make Our Day.
Thank You For
Helping Everyone Sleep
More Peacefully.
Questions?
www.RAREreadmissions.org
Thank you.
kathy.cummings@icsi.org
jshearer@stratishealth.org