1. Maintaining patient health after a hospital stay…

2. …So We All Sleep More Peacefully.

3. RARE Action Day October 18, 2011

4. Statewide Triple Aim Goals Population health –Prevent 4,000 avoidable readmissions within 30 days of discharge OR, in other words, –Reduce overall readmissions rate by 20% from 2009 base by 12/31/12 Care experience –Help patients and their families spend 16,000 more nights 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

5. Broad Community Support Campaign Operating Partners Role –Design and lead the effort, manage operations, coordinate partner and stakeholder involvement, and support, and provide the majority of staffing and resources to support participating hospitals Institute for Clinical Systems Improvement (ICSI) Minnesota Hospital Association (MHA) Stratis Health

6. Broad Community Support Supporting Partners Role –Provide resources and support to develop and implement specific aspects of the campaign Minnesota Medical Association MN Community Measurement Community Partners Role –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

7. Why Is Campaign Needed? Almost 20% of Medicare patients in Minnesota are readmitted within 30 days of discharge Great opportunity to improve care delivery by correcting 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 began ticking Oct. 1, 2011

8. RARE Overview Video

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

11. Participating Hospital Requirements –Commit to specific readmission reduction goals set based on MHA analysis –Conduct an organizational assessment of its readmissions –Commit to improving performance in key areas –Agree to publicly disclose participation in the campaign

12. Support for Participating Hospitals –RARE Resource Consultant assigned to each hospital –Work with hospital on analysis to identify key improvement areas –Assist in selecting and implementing interventions most likely to accelerate their work and achieve success

13. Support for Hospitals Learning collaborative options Best practice toolkits Face-to-face sessions Webinars Conference calls Networking opportunities Data reporting Innovator approach: intensive, rapid process improvement work

14. Analysis and Measurement MHA data for establishing individual hospital goals –Hospitals receive quarterly Potentially Preventable Readmissions (PPR) data from MHA Hospitals collect data on variety of process measures; report their progress CMS Hospital Compare readmission measures monitored over time 30-day all cause readmission rates for select clinical conditions will be publicly reported on Minnesota HealthScores for hospitals and provider groups in 2012

15. Campaign Timeline August/SeptemberHospitals commit to participation September/OctoberHospitals complete organizational assessment and identify key opportunities for improvement October 31, 2011Learning collaborative agreements/applications due October/November 2011Hospitals identify key opportunities and launch improvement activities OngoingToolkits, webinars, networking opportunities, resource consultant support, optional learning collaboratives QuarterlyPPR data reports provided by MHA Through Dec. 31, 2012Improvement work, measurement continues

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

17. Thank you for helping everyone sleep more peacefully.

18. Questions? For more information: Kathy Cummings kathy.cummings@icsi.orgkathy.cummings@icsi.org Tania Daniels tdaniels@mnhospitals.orgtdaniels@mnhospitals.org Karla Weng kweng@stratishealth.orgkweng@stratishealth.org www.RAREreadmissions.org