1. Maintaining patient health after a hospital stay…

2. …So We All Sleep More Peacefully.

3. www.RAREreadmissions.org

4. The RARE Campaign A campaign across the continuum of care to reduce avoidable hospital readmissions across Minnesota and surrounding areas Statewide approach, supported by hospitals, providers, health plans, other key stakeholders Campaign is a community effort, acknowledging that readmissions are the result of a fragmented health care system

5. 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

6. Broad Community Support Operating Partners: Institute for Clinical Systems Improvement (ICSI) Minnesota Hospital Association (MHA) Stratis Health

7. Broad Community Support Supporting Partners: Minnesota Medical Association MN Community Measurement VHA Upper Midwest

9. Five Key Areas Comprehensive discharge planning Medication management Patient and family engagement Transition care support Transition communications

10. Recommended Actions Report Core strategies and key practices in the 5 focus areas Based on best practice, evidence and consensus Working document that will be modified as the campaign progresses

11. Recent Supporting Activities Medication Management Workgroup Mental Health Workgroup MN Epic Users Measurement Workgroup

12. Data source – MHA Database All-payer inpatient claims for all MN hospitals Only includes readmit to same facility (22% of readmits are to different facility) 3M Potentially Preventable Readmissions Each record designated as admission or readmission Calculates severity-adjusted PPR rates by condition and by hospital Potentially Preventable Readmissions

14. 16,000 nights at home… Together we can make a difference for patients in Minnesota

15. Thank you for helping everyone sleep more peacefully.