Sep 242012

The Minnesota-wide RARE (Reducing Avoidable Readmissions Effectively) Campaign is tracking success one pillow at a time: Its metric is whether or not a patient sleeps in his own bed, with his own pillow. The RARE website ( tells the story. A graphic shows individuals, sleeping soundly. Each face represents 250 prevented readmissions, and 1,000 nights at home.  The RARE Campaign aims to prevent 4,000 avoidable hospital readmissions within 30 days of hospital discharge between July 1, 2011 and December 31, 2012. Achieving this goal would reduce Minnesota’s overall hospital readmission rate by 20% as measured by the Minnesota Hospital Association’s Potentially Preventable Readmissions (PPR) data. All 82 hospitals participating in the RARE Campaign have signed on to each reduce their overall readmissions by 20%.

The campaign relies on three operating partners to organize collaboratives, collect and analyze data, and provide coaching to participating hospitals. The Institute for Clinical Systems Improvement (ICSI) (, the Minnesota Hospital Association (MHA) ( Stratis Health (which serves as the state’s Medicare Quality Improvement Organization, and can be found at: manage operations. A growing base of some 75 community partners, including long-term care, home health, professional associations, and hospice, are supporting the work.

Deb McKinley, RARE communications manager for Stratis Health, explains that the group began its planning process two years ago. Each organization had been leading some work in the area of reducing readmissions: Stratis Health focused on Project RED, MHA on the Safe Transitions of Care, and ICSI on the Eric Coleman’s Care Transitions model. McKinley says, “Minnesota has a long history of collaboration in health care, and good working relationships among partners. The RARE Campaign is a natural relationship. We had the foundation that we’d built and nurtured over time, and this builds on that.”  Organizations around the state were involved in different care transitions models; the operating partners decided to join forces, rather than to force organizations to choose among them.

Participating hospitals are making progress toward preventing 4,000 avoidable readmissions by Dec. 31, 2012, based on the Potentially Preventable Readmissions (PPR) data for the first quarter of 2012. Results show a reduction of approximately 13%. To date, the Campaign is about two-thirds of the way to its goal.

Mickey Reid, Patient Safety Quality Manager and RARE Project Manager for MHA explains that the hospital association has been using a roadmap format in its efforts, helping organizations conduct self-assessments to understand more about where opportunities for improvement lie in their work, and how they might best approach problem-solving. The hospital association collects and analyzes data, which it shares with participating hospitals. “All of the data for potentially preventable readmissions are collected by MHA. We get the data and send it out to ICSI, which creates run charts for each hospital in the campaign. Hospitals use the individual PPR data to see their progress.”

Reid notes that while hospitals are concerned with the pending Medicare penalties for avoidable readmissions, they are actually driven more by staff wanting to “do the right thing for patients.” There is also, she suggests, some peer pressure to participate in the work, and to improve processes. “We’re just not communicating well enough across levels of care and not doing enough to keep patients out of the hospital. We are looking at what we are missing in the process. Did we miss stressing to the patient how important it is to get followup appointments? Did we change drugs and not followup? There are so many things that can happen. Everyone does their part, but we are just not communicating that information.”

Reid’s colleague at Stratis Health, Kim McCoy, echoes these ideas. “We want to remember why we are doing this work, we want to emphasize keeping the patient at the center of the focus. We want to improve the quality of life for our patients, keeping them in their own homes. We want to give them the best quality of life that we can.”

Kathy Cummings, RARE project manager for ICSI, says, “We wanted hospitals to be the instigators of change, recognizing that readmissions are not just a hospital problem, but a continuum of care problem.”

To that end, the RARE Campaign helps hospitals engage more with partners in the community, to understand where gaps in care are, and to develop and implement ways to close them. As Reid says, “We don’t want [patients] to have to be in the hospital. If we can get people community resources, we can help them. People haven’t used these resources, and don’t know the abundance of them. We need to connect patients to their available resources, especially those with complex chronic disease. Our focus is really communicating with out-of-hospital groups.”

Cummings explains that hospitals who sign up for the project engage in an organizational self-assessment to understand just where problems lie in their current care transitions. RARE encourages hospitals to focus on at least one of five common problems: medication management, a comprehensive discharge plan, patient/family engagement, transition support for the patient, and improved communication among providers. Hospitals declare an area in which to work, and the Campaign partners then provide them with tools and resources they need to develop a plan. The cost of participating is covered by the three operational partners, with some funding from the Medicare Quality Improvement Organization program, Aligning Forces for Quality, the Partnership for Patients, and the Health Research and Education Trust.

Each hospital is assigned a RARE resource consultant affiliated with one of the operating partners. Consultants work with hospitals quarterly to review data, what’s happening with the project, and how they are adapting their plans to be more effective. A twice annual RARE Action Learning Day brings participants together to share experiences, ideas, and lessons learned. In addition, monthly webinars cover an array of topics, from conversations about the end of life to medication management in ambulatory settings.

To learn more about RARE—to see the pillows at work!—visit the Campaign’s website at:


Key words:  care transitions, readmissions, Coleman model, community collaboration

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