Buoyed by the success of their first 18 months, leaders of the RARE — Reducing Avoidable Readmissions Effectively — Campaign in Minnesota have extended the effort through 2013.

The goal: to prevent 4,000 avoidable hospital readmissions within 30 days of discharge during an 18-month period that started in July 2011. By mid-2012, Minnesota hospitals were three-quarters of the way to their goal, with 3,128 prevented readmissions. Because of a data-reporting lag, full-year results are not yet known.

About 90 of the state's 144 hospitals are participating, but some are just getting started with their RARE initiatives. So the campaign's three partners — the Institute for Clinical Systems Improvement, Minnesota Hospital Association and Stratis Health, the quality improvement organization in Minnesota — extended the push another year to keep momentum building.

Participating hospitals agree to a formal process that involves dozens of top executives, physicians, clinical and administrative staff members, patients, family members, and such representatives of community resources as nursing homes and home health agencies. Each hospital agrees to tackle one or more of five key areas — discharge planning, medication management, patient and family engagement, support and communications during transitions of care — that are widely known to influence readmission rates.

MHA President and CEO Lawrence Massa says convening so many stakeholders reflects the reality that a successful transition out of the hospital requires many individuals to work together.

"It's important to have lots of stakeholders at the table so you can work through that blame-game —'It's not our fault, it's your fault'— that is a natural part of the process," he says. "You have to get through that to get down to 'What can we change so we can effect some more positive outcomes?' "

Allina Health, an 11-hospital system based in Minneapolis, is participating in the RARE campaign through several initiatives, including a pilot that focused on the transition from one hospital to one skilled nursing facility. Pat Peschman, R.N., director of Allina SeniorCare Transitions, says a rapid process-improvement project and detailed chart audits helped team members understand the existing process, spotlight gaps in care and identify root causes and possible solutions. The pilot also helped team members build relationships and understand differences between the environments of the hospital and the skilled nursing facility.

"We learned that a lot of our communication was around the logistics of the transfer as opposed to the clinical specifics of the care for that specific patient," she says. "So we have been piloting some fixes, including a redesign of the discharge order set."