Collaborative Opportunities to Support Improvement Efforts

Participating hospitals in the RARE Campaign can chose to participate in one of the three different RARE sponsored learning collaboratives, focused on making improvements in the five key areas known to reduce avoidable readmissions. The collaboratives offer a structured process and model for approaching improvement.

• Care Transitions Collaborative
• Project RED Collaborative
• Safe Transitions Collaborative

Each of the collaboratives aligns with all five of the key areas known to reduce avoidable readmissions, but the primary focus differs. The following table indicates the emphasis of each collaborative.

3 checks indicates primary focus

A short summary of each of the collaboratives follows. For more information on a specific collaborative, contact your RARE resource consultant or the contacts listed below. Printable overview of RARE collaboratives (4-page Word doc)

Each of the collaboratives may be offered a second time starting spring 2012, if there is enough hospitals express interest in participating

RARE – Care Transitions Collaborative

The Care Transitions Collaborative will support hospitals and their community partners in implementing the Care Transitions Intervention. The Care Transitions Intervention was designed by Dr. Eric Coleman in response to the need for a patient-centered, interdisciplinary intervention that addresses continuity of care across multiple settings and practitioners. The overriding goal of the intervention is to improve care transitions by providing patients with tools and support that promote knowledge and self-management of their condition as they move from hospital to home.

Key Aspects
The Care Transitions model is composed of the following components:

• A patient-centered record that consists of the essential care elements for facilitating productive interdisciplinary communication during the care transition (referred to as the Personal Health Record or PHR)
• A structured checklist (Discharge Preparation Checklist) of critical activities designed to empower patients before discharge from the hospital or nursing facility
• A patient self-activation and management session with a transitions coach in the hospital-designed to help patients and their caregivers understand and apply the first two elements and assert their role in managing transitions
• Transitions coach follow-up visits in the home and accompanying phone calls designed to sustain the first three components and provide continuity across the transition

The intervention focuses on four conceptual areas referred to as The Four Pillars, and utilizes care transitions coaches to support these areas:

1. Medication self-management
2. Use of a dynamic patient-centered record: the patient or informal caregiver manages the PHR
3. Primary care and specialist follow up
4. Knowledge of red flags: patient is knowledgeable about indications that their condition is worsening and how to respond

Collaborative Timeline

* All organizations are required to submit an application due to limited space. Each training session can accommodate up to 35 participants.

Additional Information

Contact: Kathy Cummings, Institute for Clinical Systems Improvement, email or 952-814-7086

Recorded Webinar- HealthEast Care Navigation Strategy
Rahul Koranne, MD, MBA, FACP, medical director, HealthEast Care System of St. Paul, describes HealthEast’s Care Navigation Strategy including its components, how it was developed and the outcomes it has achieved.

RARE – Project RED Collaborative

Potentially avoidable hospital readmissions can frequently be attributed to poorly understood discharge instructions, poor transfer of information to ambulatory caregivers, lack of timely post-discharge physician visit and poor medication reconciliation that yields duplication or interaction. The Project RED Collaborative supports hospital teams as they implement strategies to improve patient safety and reduce hospital readmissions by focusing on processes related to discharge planning.

Key Aspects
Project RED uses proven strategies such as explicitly delineating staff roles and responsibilities, initiating the discharge process upon admission, engaging patients early in their hospital stay, providing patient education throughout hospitalization, and supporting the patient after discharge to help ensure they understand and can follow through on discharge instructions. Aligned with the National Quality Forum’s Safe Practice 15: Discharge Planning Systems, Project RED includes three primary components:

• Designated discharge advocate to ensure comprehensive discharge planning process has occurred
• Patient focused care plan to support patient follow-through with discharge instructions
• Post discharge follow-up with patient to answer questions and provide support

Collaborative Timeline Cohort I

Collaborative Proposed Timeline Cohort II

Additional Information

Contact: Karla Weng, Stratis Health, email or 952-853-8570

Project RED (Re-Engineered Discharge). Project RED strategies to reduce hospital readmissions include explicit delineation of hospital staff roles and responsibilities, initiating the discharge process upon admission, engaging patients early in their hospital stay, providing patient education throughout hospitalization, and supporting the patient after discharge. (Recorded September 29, 2011) Part 1 (46-minute podcast) Handout 1 (9-page PDF) Handout 2 (16-page PDF)

RARE – Safe Transitions Collaborative

Studies show poor communication during transitions leads to increased rates of hospital readmissions and medical errors. The goal of the Safe Transitions Collaborative 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 (SNF), long-term care, assisted living, home health, and primary care. The framework includes a roadmap of best practices to address patient safety gaps with core elements of information. Thirteen Minnesota hospitals that implemented this process in early 2011 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 with use of the Minnesota Hospital Association (MHA) core elements of information.

Key Aspects
The goal of the Safe Transitions Collaborative is to improve patient safety by standardizing transitions of care between hospitals and across settings. With implementation of safe transitions strategies, patients should experience improved care including fewer incidents of delayed care or redundant tests, less medication events or missed doses, and reduced readmissions to the hospital. Participating facilities should experience fewer follow-up phone calls from receiving facilities, as communication is clearer and better meets the needs for continuity of care.

Collaborative Timeline Cohort I

Collaborative Timeline Cohort II

Additional Information

Contact: Tania Daniels, Minnesota Hospital Association, 651-659-1441

Recorded Webinar – Safe Transitions of Care Pilot by the Minnesota Hospital Association
Building on hospitals’ ongoing work to reduce readmissions, the MHA focused on improving patient safety by standardizing core elements of information during transitions of care between hospitals and across settings. MHA identified patient safety gaps due to transitions of care and core elements of information to close these gaps. Thirteen hospitals participated in MHA’s pilot to incorporate the core elements into the discharge process. This webinar shares the lessons learned from the MHA Safe Transition pilot.