1. Welcome! Howard Epstein, MD, FHM Chief Health Systems Officer Institute for Clinical Systems Improvement

2. * 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*

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

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

5. A 2011 Institute of Medicine report estimated 30% of healthcare spending is non-value added www.IOM.edu/vsrt $2.5 Trillion

6. 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.Overtreatment 4.Administrative Complexity 5.Pricing Failures 6.Fraud & Abuse

7. 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

8. 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

9. Brief History of RARE CMS announces penalties RARE Planning Committee RARE Campaign – Operating Partners –83 hospitals –Supporting Partners: MMA, MNCM, VHA – > 100 Community Partners

10. 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

11. Preventable Services: Readmissions www.RAREreadmissions.org 7030 > 28,000 > $60,000,000.00 > 78 years!

14. 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

15. 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

16. 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

17. Thank You!