Welcome!

Howard Epstein, MD, FHMChief Health Systems Officer

Institute for Clinical Systems Improvement

* The Triple Aim: Care, Health, And Cost. Berwick DM, Nolan TW and Whittington J., Health Affairs, May 2008, Vol. 27, No. 3, 759-769.

A Better State of Health Through the Triple Aim*

https://www.icsi.org/_asset/hkt4a4/Accountable-Health-Communities-White-Paper.pdf

https://www.icsi.org/health_initiatives/accountable_health/videos/

A 2011 Institute of Medicine report

estimated 30% of healthcare spending is

non-value added

www.IOM.edu/vsrt

$2.5 Trillion

Wedge Model for US Health Care With Theoretical Spending Reduction Targets for 6 Categories of Waste

Source: Eliminating Waste in US Health Care, Berwick, D., Hackbarth, A. JAMA. 2012;307(14):1513-1516

1. Failures of Care Delivery

2. Failures of Care Coordination

3. Overtreatment4. Administrative

Complexity5. Pricing Failures6. Fraud & Abuse

Jencks S, Williams MV, Coleman EA. N Engl J Med 2009;360:1418-1428

Rehospitalization 30 Days after Discharge

20%

Range:13-23%

$17B

50% no PCP f/u

Hospital Discharge

“Random events connected to highly variable actions with only a remote possibility of meeting implied expectations.”

Roger Resar, MD Senior FellowInstitute for Healthcare Improvement

Brief History of RARE

• CMS announces penalties

• RARE Planning Committee

• RARE Campaign – Operating Partners

– 83 hospitals– Supporting Partners: MMA, MNCM, VHA– > 100 Community Partners

main contributors to avoidable hospital readmissions

1. Comprehensive discharge planning

2. Medication management

3. Patient and family engagement

4. Transition care support

5. Transition communications

Preventable Services: Readmissions

www.RAREreadmissions.org

7030

7030

> 28,000

> $60,000,000.00

> 78 years!

Agenda Getting Out and Staying Out:  A Patient's Perspective on Reducing Mental Health

Re-Admissions - Melissa Hensley, PhD. Family Perspective - Tracey Daniels Family Perspective – Sue Hanson Recommended Actions for Improved Care Transitions Document – Michael Trangle,

MD, Associate Medical Director, Behavioral Health for HealthPartners Medical Group Patient and Family Engagement – Sue Abderholden, Executive Director, National

Alliance on Mental Illness, Minnesota Medication Management – Craig Harvey, Director Pharmaceutical Services, Regions

Hospital and Daniel Rehrauer, Clinical Pharmacy Program Manager, HealthPartners Comprehensive Transition Planning – Paul Goering, MD, Vice President Allina Mental

Health Transition Support - Chris Walker, MSN, RN, MHA DirectorInpatient Mental Health

Units & Behavioral Access Nurses Transition Communication - Nystrom and Associates PPR Data - Mark Sonneborn, MS, FACHE, Vice President, Information Services,

Minnesota Hospital Association Team Action Plan Wrap Up & Next Steps

Recommended Actions Work Group

• Paul Goering, MD Allina Health• Chris Walker, MSN, RN, MHA CentraCare Health System• Cathy Brouwer, RN Chippewa County Montevideo• Kathy Knight, RN, MA Fairview Health Services• Karen Lloyd, PhD HealthPartners• Terry W. Crowson, MD HealthPartners• Michael A. Trangle, MD HealthPartners• Paul Davis, PhD, LP Lakewood Health System• Jennifer McNertney, MPP Minnesota Hospital Association• Sue Abderholden, MPH National Alliance on Mental Illness• Nancy Houlton, LICSW UCare• Kathy Cummings, BSN, MA ICSI • Joann Foreman, RN, BAN ICSI

RARE Mental Health CollaborativePlanning Committee

– Annie Walsh University of MN Medical Center, Fairview–  Jennifer McNertney, Minnesota Hospital Association–  Jill Kemper, ICSI–  Joann Foreman, ICSI– Kathy Cummings, ICSI– Martha J Aby, DHS– Michael A Trangle, HealthPartners–  Nancy Houlton, Ucare–  Chris Walker CentraCare–  Sue Abderholden, NAMI MN–  Terry Crowson, HealthPartners–  Janelle Shearer, Stratis Health–  Niki Gjeri, UMMC, Fairview– Paul Goering, Allina–  Greg Clancy, Allina–  Carol LaBine, DHS

Thank You!