Helps patients spend 18,280 more nights of sleep in their own beds

A broad-based coalition of hospitals and care providers working across the continuum of care has prevented 4,570 avoidable hospital readmissions between Jan. 1, 2011 and Dec. 31, 2012. As a result of the RARE Campaign (Reducing Avoidable Readmissions Effectively), it is estimated that patients spent 18,280 more nights sleeping comfortably in their own beds instead of the hospital. It’s better for patients and their families. The campaign is also estimated to have reduced inpatient costs by more than $40 million.  

The RARE Campaign involves 83 hospitals and 93 community partners across Minnesota and is one of the largest coordinated improvement initiatives undertaken by the Minnesota health care community.  

The campaign was initiated to address the fact that in Minnesota, nearly one in five Medicare patients is readmitted within 30 days. According to the Health Research and Education Trust, unplanned readmissions cost Medicare $17.5 billion. “Improving care transitions is part of the Minnesota health care community’s effort to mend the fragmented delivery of care and achieve the Triple Aim of improving population health, the experience of care, and the affordability of care,” said Jennifer Lundblad, president and CEO of Stratis Health, one of the campaign’s operating partners.  

The campaign has gathered momentum since its launch. In the most recent time period measured, the 4th quarter of 2012, hospitals achieved a roughly 17 percent reduction in avoidable readmissions compared to baseline. These results are attributed to participants in the RARE Campaign honing their work 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  

For example, Swift County-Benson Hospital has achieved success through a combination of interventions including a focus on patient education, increased communication with primary care providers and improved patient transfer communication and collaboration with the area nursing home, assisted living and assisted living plus facilities, and home care agencies. Any time the hospital does have a readmission, staff conducts a thorough assessment to determine the reason for readmission and to identify what could have been done differently before the patient was discharged from the hospital.   

At Essentia Health-St. Mary’s Medical Center in Duluth the Nurse Care Line program contacts patients with select diagnoses within 24-48 hours of discharge to answer questions, review medications and discuss the importance of attending scheduled follow-up appointments. The hospital is also working with its community partners including home health agencies, nursing homes and the other hospitals to improve communication across the continuum of care.    

Energized by the progress to date, the operating partners have extended the campaign through 2013. “We’re excited about our progress, but we know the improvements can spread even further. We’re challenging ourselves to think beyond the ­hospital system and beyond a focus on disease-specific efforts,” said Lawrence Massa, president and CEO of the Minnesota Hospital Association. “Hospitals are taking specific steps to ensure a culture that is supportive of collaboration and that supports this readmissions work.”  

In 2013, the campaign partners will focus on further engaging community partners beyond hospital walls.  Preventing avoidable readmissions requires improved patient care coordination between hospitals and community partners such as long-term care facilities, home care organizations and primary care clinics. In that regard, the RARE Campaign is helping to increase communication and improve care transitions across the health care system.  

“In health care today, there is increasing emphasis on the value of care patients receive and rewarding providers for delivering high quality care as efficiently as possible,” said Sanne Magnan, president and CEO, Institute for Clinical Systems Improvement. “The value of the RARE Campaign is that, rather than individual medical associations or hospitals tackling readmissions separately, partners from various health care settings are working together. This collaborative approach enables us to accelerate positive change across Minnesota.”  

The RARE Campaign is led by three operating partners: the Institute for Clinical Systems Improvement, the Minnesota Hospital Association and Stratis Health. Supporting partners include the Minnesota Medical Association, MN Community Measurement and VHA Upper Midwest.  

To learn more about the RARE campaign, visit www.rarereadmissions.org.