Minnesota Hospital Association

Quality & Patient Safety

Reducing Avoidable Readmissions Effectively Campaign

The Reducing Avoidable Readmissions Effectively (RARE) Campaign is engaging hospitals and care providers across the continuum of care to prevent 6,000 avoidable hospital readmissions within 30 days of discharge across Minnesota between July 1, 2011 and Dec. 31, 2013. The original goal of collectively reducing 4,000 readmissions by Dec. 31, 2012 was exceeded. Reducing readmissions will alleviate the burden placed on patients and their families and will allow them the comfort and well being of staying in their own beds. The fourth quarter 2013 data is in, and RARE Campaign participants have helped prevent 7,975 readmissions and allowed Minnesotans to spend 31,900 nights of sleep in their own beds instead of in the hospital. In the last quarter of 2013, Minnesota hospitals reached a collective reduction in readmissions of 19 percent.

Participating hospitals are working to reduce their own readmission rates by 20%, from the 2009 baseline, as measured by the MHA's Potentially Preventable Readmissions (PPR) data. According to the Health Research and Education Trust, unplanned readmissions cost Medicare $17.5 billion.

Currently, 85 hospitals and 93 community partners are participating in RARE. The RARE Campaign builds upon and expands work that has been going on for several years by many hospitals, medical groups, health plans and the campaign’s operating, supporting and community partners. The campaign focuses on five key areas that, if not managed well, are known to be 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

Learn more about the RARE Campaign

RARE Campaign prevents 7,975 avoidable hospital readmissions

This video highlights how the 86 hospitals and more than 100 community partners involved in RARE have improved the health of our communities, provided better care and reduced costs. 

ReadmissionS and SAFE Transitions of Care

Studies show poor communication during transitions of care leads to increased rates of hospital readmissions and medical errors. In fact, nearly one in five Medicare patients discharged from Minnesota hospitals is readmitted within 30 days.

photo of patient and nurse

To address this problem, hospitals across Minnesota are participating in SAFE Transitions of Care. This goal is to improve patient safety by standardizing and improving communication during transitions of care between hospitals and across all settings of care, including other hospitals, skilled nursing facilities, long-term care, assisted living, home health, and primary care. With implementation of safe transitions strategies, patients should experience improved care including fewer incidents of delayed care or redundant tests, fewer medication events or missed doses, and reduced readmissions to the hospital. The framework includes a road map of best practices to address patient safety gaps and a tool kit of resources to implement the recommendations.

call to action logoThirteen Minnesota hospitals participated in the pilot project; another 14 formed the first cohort early in 2011 and found this framework to be a template for smooth, safe transitions, which is one component of reducing readmissions. Participating hospitals also experienced fewer follow-up calls from community providers. A second cohort of hospitals is currently completing gap analyses using the Road Map to Safe Transitions.

Minnesota Hospital Association is part of the Reducing Avoidable Readmissions Effectively (RARE) campaign, which aims to prevent 4,000 avoidable hospital readmissions.

ReadmissionS and SAFE Transitions of Care

Studies show poor communication during transitions of care leads to increased rates of hospital readmissions and medical errors. In fact, nearly one in five Medicare patients discharged from Minnesota hospitals is readmitted within 30 days.

photo of patient and nurse

To address this problem, hospitals across Minnesota are participating in SAFE Transitions of Care. This goal is to improve patient safety by standardizing and improving communication during transitions of care between hospitals and across all settings of care, including other hospitals, skilled nursing facilities, long-term care, assisted living, home health, and primary care. With implementation of safe transitions strategies, patients should experience improved care including fewer incidents of delayed care or redundant tests, fewer medication events or missed doses, and reduced readmissions to the hospital. The framework includes a road map of best practices to address patient safety gaps and a tool kit of resources to implement the recommendations.

call to action logoThirteen Minnesota hospitals participated in the pilot project; another 14 formed the first cohort early in 2011 and found this framework to be a template for smooth, safe transitions, which is one component of reducing readmissions. Participating hospitals also experienced fewer follow-up calls from community providers. A second cohort of hospitals is currently completing gap analyses using the Road Map to Safe Transitions.

Minnesota Hospital Association is part of the Reducing Avoidable Readmissions Effectively (RARE) campaign, which aims to prevent 4,000 avoidable hospital readmissions.

Tool Kit for Hospital Staff

SAFE Component

Specific Action

Tools

SAFE SITE TEAM
  • Provide support and expectations for SAFE TRANSITIONS champions
  • Adopt an interdisciplinary team approach to SAFE TRANSITIONS with a designated coordinator
  • Engage key stakeholders
Transitions team form
ACCESS to INFORMATION
  • Verify the completion of SAFE TRANSITIONS
  • Audit the effective completion of SAFE TRANSITION
  • Measure the outcomes of SAFE TRANSITIONS
  • Evaluate the SAFE TRANSITIONS efforts for learning opportunities
Safe Transition Gap Analysis

Sample Policies

Medication reconciliation resources:

Recommended tools:

FACILITY EXPECTATIONS
  • Set expectations for implementation of SAFE TRANSITIONS for any transition
  • Expect staff to "speak up" when they become aware of a patient safety issue related to transitions of care.

Sample Forms:

Sample Discharge/Transition Checklists:

EDUCATE STAFF & PATIENTS
  • Provide SAFE TRANSITIONS education for all staff involved in transitions, including practitioner.
  • Educate patients and families on their role in SAFE TRANSITIONS. rd Stop policie
Staff Education

Patient Education and Checklists

Safe Transitions Tool Kit for Hospital Staff

SAFE Component

Specific Action

Tools

SAFE SITE TEAM
  • Provide support and expectations for SAFE TRANSITIONS champions
  • Adopt an interdisciplinary team approach to SAFE TRANSITIONS with a designated coordinator
  • Engage key stakeholders
Transitions team form
ACCESS to INFORMATION
  • Verify the completion of SAFE TRANSITIONS
  • Audit the effective completion of SAFE TRANSITION
  • Measure the outcomes of SAFE TRANSITIONS
  • Evaluate the SAFE TRANSITIONS efforts for learning opportunities
Safe Transition Gap Analysis

Sample Policies

Medication reconciliation resources:

Recommended tools:

FACILITY EXPECTATIONS
  • Set expectations for implementation of SAFE TRANSITIONS for any transition
  • Expect staff to "speak up" when they become aware of a patient safety issue related to transitions of care.

Sample Forms:

Sample Discharge/Transition Checklists:

EDUCATE STAFF & PATIENTS
  • Provide SAFE TRANSITIONS education for all staff involved in transitions, including practitioner.
  • Educate patients and families on their role in SAFE TRANSITIONS. Hard Stop policies
Staff Education

Patient Education and Checklists