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Published on June 11, 2013

St. Cloud Hospital Works to Prevent Avoidable Readmissions

Patients do best when surrounded by friends and family at home.

Working as part of a broad-based coalition of hospitals and care providers, St. Cloud Hospital has been focused on keeping them there and preventing avoidable hospital readmissions since 2011. The hospital also is participating in the RARE (Reducing Avoidable Readmissions Effectively) Campaign working to achieve the Triple Aim of improving population health, the experience of care, and the affordability of care.

Many people can tell a story of a loved one who was sent home from the hospital only to be readmitted a few days or weeks later. St. Cloud Hospital understood some of these readmissions could be prevented through better management of key areas such as medication.

Congestive heart failure (CHF) patient readmissions to St. Cloud Hospital within 30 days of discharge were nearly double the overall hospital readmission rate. To decrease readmission rates, St. Cloud Hospital implemented the Transitions of Care pilot project in 2012 for CHF patients who were identified at medium or high risk for re-hospitalization. The project focused on the transition of care between hospital and home with an overall goal of reducing readmissions by 10 percent.

Patients were assigned a Transitions Coach who provided information and guidance to the patient and family for an effective care transition, improved self-management skills and enhanced patient-provider communication. The Transitions Coach encourages the patient and family caregiver to assume a more active role in their care.  The readmission rate for patients enrolled in this program was reduced by 15 percent.

“By improving communication and the coordinated delivery of care, St. Cloud Hospital was able to help patients maintain their health after leaving the hospital and spend more nights of sleep in their own beds instead of the hospital,” said Gail Olson, St. Cloud Hospital, Home Care Services director and Transitions of Care project leader.

The RARE Campaign involves 83 hospitals and 93 community partners across Minnesota and is one of the largest coordinated improvement initiatives undertaken by the Minnesota health care community. Statewide, the campaign prevented 4,570 avoidable readmissions and reduced inpatient costs by an estimated $40 million.

The RARE Campaign is led by three operating partners: the Institute for Clinical Systems Improvement, the Minnesota Hospital Association and Stratis Health. Supporting partners include the Minnesota Medical Association, MN Community Measurement and VHA Upper Midwest.

To learn more about the RARE campaign, visit

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