Recommended Actions Work Group
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Welcome! Howard Epstein, MD, FHM Chief Health Systems Officer Institute for Clinical Systems Improvement
A Better State of Health Through the Triple Aim*
* 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 2011 Institute of Medicine report estimated 30% of healthcare spending is non-value added www.IOM.edu/vsrt
Wedge Model for US Health Care With Theoretical Spending Reduction Targets for 6 Categories of Waste 1. Failures of Care Delivery 2. Failures of Care Coordination 3. Overtreatment 4. Administrative Complexity 5. Pricing Failures 6. Fraud & Abuse Source: Eliminating Waste in US Health Care, Berwick, D., Hackbarth, A. JAMA. 2012;307(14):1513-1516
Rehospitalization 30 Days after Discharge
20% Range: 13-23% $17B 50% no PCP f/u Jencks S, Williams MV, Coleman EA. N Engl J Med 2009;360:1418-1428
Hospital Discharge “Random events connected to highly variable actions with only a remote possibility of meeting implied expectations.”
Roger Resar, MD Senior Fellow Institute 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. 2. 3. 4. 5.
Comprehensive discharge planning Medication management Patient and family engagement Transition care support Transition communications
Preventable Services: Readmissions 7030
> 28,000 > 78 years! > $60,000,000.00 www.RAREreadmissions.org
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 Director Inpatient 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 Collaborative Planning 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