Recorded Webinars and Shared Learnings

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. Part 1 (24-minute podcast), Part 2 (27-minute podcast)

• Handout (32-page PDF)

Fairview Southdale Hospital’s Success Story in Reducing Avoidable Readmissions
Fairview Southdale Hospital and UCare health plan partnered to reduce avoidable readmissions. William Nersesian, MD, chief medical officer, Fairview Physician Associates, and Russel Kuzel, MD, M.M.M., senior vice president and chief medical officer, UCare, share their experiences, the key changes they implemented, and the program’s outcomes. Part 1 (20-minute podcast), Part 2 (15-minute podcast)

• Handout (9-page PDF)

Hennepin County Medical Center Medication Reconciliation at Discharge
Bruce Thompson, director of pharmacy, describes Hennepin County Medical Center’s award-winning medication reconciliation pilot project, plus the financial model behind it. Part 1 (21-minute podcast), Part 2 (23-minute podcast)

• Handout (25-page PDF)

Safe Transitions of Care Pilot by the Minnesota Hospital Association
Building on hospitals’ ongoing work to reduce readmissions, the Minnesota Hospital Association (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. Part 1 (21-minute podcast), Part 2 (23-minute podcast)

• Handout (35-page PDF)

Nursing Home Approach for Reducing Hospital Readmissions
Nellie Johnson, CEO, and Susan Peterson, Project Director of CareChoice Cooperative—a cooperative of nonprofit providers of aging services—describe their organization’s involvement in a three-year program to develop a resident-centered system of care transition that empowers residents and their families as they navigate chronic/complex medical issues. (56-minute podcast)

• Handout (20-page PDF)

Introductory Webinar on the RARE Campaign
This webinar educates hospital staff as well as others across the continuum of care on the following RARE Campaign topics: Why the campaign is needed, campaign Triple Aim goals, campaign design and key focus areas, requirements of participating hospitals and support provided through collaborating partners. (15-minute podcast)

• Handout 1 (19-page PDF)

Understanding PPR Reports
From the second half of the Introductory Webinar on the RARE Campaign, this recording helps hospital staff as well as others across the continuum of care understand how to interpret potentially preventable readmissions data. Presented by Mark Sonneborn, Minnesota Hospital Association. (23-minute podcast)

• Handout (25-page PDF)

Reducing Hospital Readmissions by Transforming Chronic Care
This program describes Harold Miller’s work with the Pittsburgh Regional Health Initiative to reduce preventable hospital admissions and readmissions through improved care for chronic disease patients. A community hospital and two large primary care physician practices achieved significant reductions in readmissions for patients with chronic obstructive pulmonary disease (COPD). (60-minute podcast)

• Handout (30-page PDF)

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. (46-minute podcast)

• Handout 1 (9-page PDF)
• Handout 2 (16-page PDF)

Medication Therapy Management in Pharmacy Practice
The Medication Therapy Management (MTM) service model in pharmacy practice includes five core elements: medication therapy review, personal medication record, medication-related action plan, intervention and/or referral, and documentation and follow up. This model focuses on the provision of MTM services in settings where patients or their caregivers can be actively involved in managing their medications. Speakers are Amanda Brummel, Fairview Health Systems and Haley Holton, Hennepin County Medical Center. (47-minute podcast)

• Handout (25-page PDF)

Home Care and Reducing Hospital Readmissions
This webinar discusses the role of home care in reducing hospital readmissions. Home care encompasses a wide range of health and social services delivered to recovering, disabled, chronically, or terminally ill persons in their own homes. The webinar speaker is Jennifer Sorensen, Executive Director, Minnesota HomeCare Association. (47-minute podcast)

• Handout (12-page PDF)

Quarterly PPR Data
This webinar provides detailed information on how to use the Potentially Preventable Readmissions (PPR) data in conjunction with ongoing improvement efforts aimed at reducing avoidable readmissions. The webinar speakers are Mark Sonneborn, MS, FACHE, Vice President of Information Services, Minnesota Hospital Association and Kathy Cummings, RN, MA, Project Manager, Institute for Clinical Systems Improvement. (39-minute podcast)

• Handout (26-page PDF)

Involving Patients and Families in Reducing Avoidable Readmissions
This webinar will help define how to get patients and families actively involved in establishing programs that assist in reducing hospital readmissions. Topics covered include recruitment, selection of appropriate patient and family participants, training involved, staff responsibilities and more. The webinar speaker is Marlene Fondrick, MSN, BSN, RN, Independent Consultant, Institute for Patient and Family-Centered Care. (51-minute podcast)

• Handout (37-page PDF)

Medication Management in Ambulatory Care
This webinar introduces the pharmacist’s role in improving transitions in care and describes the preliminary outcomes of the Creekside pilot project The webinar speaker is Alison Knutson, PharmD Park Nicollet Creekside Clinic medication management pharmacist. (52-minute podcast)

• Handout (32-page PDF)

The Aging Network – Helping Older Adults Live Well at Home Today
This webinar discusses how Minnesota’s seven Area Agencies on Aging (AAAs) and their local service networks help older adults recover from acute illness, manage chronic conditions and prevent injurious falls. Speakers are Dawn Simonson, MPA, Executive Director, Metropolitan Area Agency on Aging, Inc. and Lori Vrolson, MA, Executive Director, Central Minnesota Council on Aging. (55-minute podcast)

• Handout (15-slide PowerPoint)
• Case studies (2-page PDF)

Meaningful Use and the RARE Campaign
This webinar provides health information technology (HIT) services to assist clients with their electronic health records (EHR) planning, implementation and achieving meaningful use of their EHR. Speaker is Paul Kleeberg, Chief Medical Informatics Officer at Stratis Health and Clinical Director of the Regional Extension Assistance Center for HIT (REACH) for Minnesota and North Dakota. (59-minute podcast)

• Slides (26-page PDF)

CMS final rule

• CMS final rule (42 CFR Parts 412, 413, and 495)
• Fact sheet on CMS’s final rule

ONC standards and certification criteria final rule

• ONC final rule (45 CFR Part 170)
• Fact sheet on ONC’s standards and certification criteria final rule – forthcoming

More information on the Stage 2 rule

• HHS news release
• CMS EHR Incentive Programs website

All of these materials also can be found on the REACH website.

Improved Care Transitions for Mental Illnesses and Substance Use Disorder
Patients with mental illnesses and substance use disorders face unique care coordination challenges following hospitalization. This webinar describes factors that are associated with increased risk for readmissions in this patient population, along with specific interventions that can improve care transitions. The webinar speakers are Paul Goering, MD, Vice President and Executive Medical Director at Allina Health and Michael Trangle, MD, Associate Medical Director, Behavioral Health at HealthPartners Medical Group. (60-minute webinar)

• Slides (26-page PowerPoint)
• Slides: In Reach Hospital Program (15-page PowerPoint)

RARE Conversation: Risk Stratification
There is a great deal of interest and work in the area of readmission risk assessment, which can help target the delivery of resource-intensive interventions to patients at greatest risk for readmission. Such strategies can provide clinically relevant stratification of readmission risk early enough in the hospitalization to trigger appropriate interventions. This program describes the current risk assessment and stratification activities at Park Nicollet Methodist Hospital and Hennepin County Medical Center. (55-minute audio file)

• Slides (35-page PowerPoint)

Improving Nursing Home Care and Reducing Unnecessary Hospital Transfers, Admissions, and Readmissions
Presented by Laurie Herndon, MSN, GNP-BC, Massachusetts Senior Care Foundation, and Joseph G. Ouslander, MD, Florida Atlantic University. (80-minute webinar)

• Transcript (18-page PDF)

Understanding your Potentially Preventable Readmissions (PPR) Reports
Presenter is Mickey Reid, RN, BSN, MSM, Patient Safety/Quality Manager at the Minnesota Hospital Association. (40-minute webinar)

• Organizational Assessment Guide and Tools (6-page Word doc)
• PPR report data sample (12-page PDF)
• Slides (9-slide PowerPoint)

RARE Conversations: Caregiver Awareness and Support
A recent study showed that only 19% of people actively caring for a friend, family member or neighbor identified themselves as a caregiver. Family members and friends who provide care to a loved one often think of themselves as daughters, husbands, partners, and friends first–not caregivers. But anyone actively taking care of an older or disabled adult is a caregiver. Identifying oneself as a caregiver is the first, and often most important, step a person playing this important role can take. The goal of the ‘Capacity to Care’ campaign is to increase self-awareness and access to support that can help caregivers take better care of their loved ones and themselves. Work shared from the Amherst H. Wilder Foundation. (60-minute audio file)

• Slides (27-slide PowerPoint)

Role of Community Health Workers in Preventing Avoidable Readmissions
Provides an overview of the community health worker work force, including Minnesota’s community health worker scope of practice and certificate program. Participants learned how hospitals can integrate community health worker strategies to help prevent avoidable hospital readmissions and meet the Triple Aim. Webinar speakers are Joan Cleary, MM, Executive Director-Interim, Minnesota Community Health Worker Alliance, St. Paul, and Patricia A. Duthie, RN, BSN, Director of Community Health Education, Spectrum Health System, Grand Rapids, MI. (58-minute audio file)

• Slides (59-slide PowerPoint)

RARE Conversations: Health Care Homes – Improving Care Transitions
Health care homes have been implemented in primary care across the state and the country to assist patients with complex or chronic medical needs to work in partnership with their medical team. The goal of the health care home model is to bring together comprehensive, coordinated, and patient-centered care, with a commitment to high quality and safety, all in one place. When these efforts are aligned, the health care home offers another positive strategy to support comprehensive efforts aimed at reducing avoidable readmissions. This session explores how the health care home model is being used to facilitate care transitions and reduce readmissions. Fairview Medical Group shares their work. (57-minute audio file)

• Slides (19-page PowerPoint)

Patient and Family Engagement Webinar: Understanding the Basics
Patient and family engagement is one of the five key areas of the RARE campaign and it is known to reduce avoidable readmissions. This webinar provides information on the critical role patients and families play, the basics of patient/family activation and engagement and explores some of the available intervention tools in this key area. (41-minute webinar)

• Slides (21-page PowerPoint)

Improving Patient Experience and Reducing Readmissions Through Better Communications
Learn about the “Good to Go” program at Cullman Regional Medical Center in Cullman, Alabama. This innovative program uses smart technologies to improve the patient discharge experience and reduce readmissions through better communication between staff and patients. (57-minute webinar)

• Slides (23-page PDF)

RARE Conversation: Health Plans and Hospitals Working Together to Prevent Readmissions
This RARE Conversation explores how health plan care coordinators are partnering with hospital discharge planners to prevent duplication, increase efficiency and improve the patient experience. (62-minute webinar)

• Slides (22-slide PowerPoint)

Improving Transitions of Care for Uninsured and Low-income Publicly Insured Adults: Lessons from Oregon’s C-TraIn
Dr. Honora Englander, Oregon Health & Science University, discusses the Care Transitions Innovation (C-TraIn) program in Oregon. C-TraIn initially started as a hospital-supported transitional care program for uninsured and low-income publicly insured adults. Support from the Health Commons grant has enabled the program to increase its capacity and impact. (55-minute webinar)

• Slides (46-slide PowerPoint)

Beyond “Engagement” Webinar: Family Caregivers as Partners in Preventing Readmissions
Next Step in Care is a multiyear, multidimensional campaign, hosted by the United Hospital Fund in New York, to change practice so that family caregivers are routinely involved in planning, decision making, and coordinating care, particularly around transitions from one care setting to another. While transitions are key points at which patient safety and care coordination are at risk, most efforts to address associated problems have focused on provider-to-provider communications, essentially excluding family caregivers from the solution. Speakers are Jennifer L. Rutberg, MSW, senior program manager, Families and Health Care Project, United Hospital Fund and Carol Levine, MA, project director, Families and Health Care Project, United Hospital Fund. (57-minute webinar)

• Slides: Carol Levine (38-slide PowerPoint)
• Slides: Richard Siegel and Fiona Larkin (24-slide PowerPoint)

A Community-Based Approach to Prevent Avoidable Hospital Readmissions
Stratis Health is leading “Improving Transitions of Care,” a community-based initiative to improve care coordination within and between care settings in order to reduce avoidable readmissions. In this session you hear directly from one multiple-setting community team that is collaborating to improve care transitions. (59-minute webinar)

• Slides (64-slide PowerPoint)

Team Care For Chronic Disease Patients: Using Lay “Care Guides”
Allina Health and the University of Minnesota designed and implemented a randomized-controlled trial of more than 2,100 chronic disease patients that integrated trained laypersons called “care guides.” This approach to team care was proven to be a pragmatic way to improve care quality at a reasonable cost in the primary care setting. Speakers are Kim Radel, operations director, Division of Applied Research, Allina Health and Sochenda Nelson, program manager, Care CoPilot, Allina Health. (56-minute webinar)

• Slides (21-slide PowerPoint)

The Role of Health Information Exchange in Reducing Avoidable Hospital Readmissions
Stratis Health has been facilitating a CMS Special Innovation Project called Health Information Technology for Post Acute Care Providers (HITPAC). In this project hospitals and skilled nursing facilities have been working to improve transitions of care and medication management between hospitals and skilled nursing facilities through the use of their electronic health record (EHR) and to achieve health information exchange. (54-minute webinar)

• Slides (46-slide PowerPoint)

Winona Health Community Care Network Program
In this challenging time of health care reform, we need innovative and collaborative strategies to meet the health care needs of our communities. Winona Health has developed the Community Care Network, a community-based program that targets individuals with chronic health conditions who are at high risk for frequent emergency room visits and hospital readmissions. The program also provides a health coach in the home through a collaboration with Winona State University. (57-minute webinar)

• Slides (24-slide PowerPoint)

A Perfect Partnership: Ensuring a Safe Patient Transition With a Post-Discharge Firefighter Visit
Transition support occurs in that critical time after hospital discharge. How do you follow up quickly with patients to make sure they are doing well and will continue to do so? In this program we learn about a joint effort between the St. Louis Park Fire Department and Park Nicollet Health Services, who are collaborating to help people make this transition from hospital to home safely and prevent further problems and avoidable readmissions.(57-minute webinar)

• Slides (41-slide PowerPoint)