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03 Dec 2025

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November Workgroups Highlight Mobile Health and Patient Storytelling

December 3, 2025 | 0 Comments | Cardiac Rehab, cardiac rehabilitation, CHF, Chronic Disease, HBOM, health outcome variation, Michigan Cardiac Rehabilitation Network, MiCR, non-medical drivers of health, post-discharge follow-up, rural hospitals

In November, MVC hosted two virtual workgroup presentations – the first, a rural health workgroup, featured Hillsdale Hospital’s mobile health unit initiative. The second, a post-discharge follow-up workgroup, continued a presentation started at MVC’s February 2025 health in action workgroup on patient journey mapping and introduced a joint patient storytelling project by Healthy Behavior Optimization for Michigan (HBOM) and Michigan Cardiac Rehab Network (MiCR). The MVC Coordinating Center hosts workgroup presentations twice per month covering a variety of topics including post-discharge follow-up, sepsis, cardiac rehab, rural health, preoperative testing and health in action.

Rural Health Workgroup – Hillsdale Hospital

The first workgroup of the month provided a review of Hillsdale Hospital’s mobile health unit, which aims to deliver essential health services to patients living in rural communities who may otherwise struggle physically or financially to reach traditional care settings.

As Lindsey Crouch, Director of Outpatient Clinics, Home Care, and Durable Medical Equipment for Hillsdale Hospital explained, rural communities face higher health outcome variation, transportation issues, limited accessibility to primary care providers, and high unnecessary emergency department (ED) utilization (Figure 1).

During the Covid-19 pandemic, Hillsdale County’s health department purchased a mobile health unit in an effort to close the gap in healthcare access for their community. However, despite continued need, utilization of the mobile unit has waned in recent years.

Hillsdale Hospital aimed to revitalize the mobile health unit to:

Bridge access gaps in rural areas. For many rural residents, distance to hospitals or clinics, limited transportation, and infrastructure challenges can hinder timely access to care. A mobile health unit can bring services to patients rather than requiring patients to travel long distances. This helps to reduce one significant non-medical barrier to care.
Focus on preventive and ongoing care. The mobile unit’s design supports not just acute care, but preventive services — screenings, check-ups, chronic disease management — especially helpful for rural populations that may have higher chronic disease burden and less frequent access to routine care.
Address gaps in health outcomes between communities. By delivering care directly to underserved communities, this model aligns with broader efforts to ensure that where a person lives does not determine whether they receive high-value, quality healthcare.

Throughout this program, Hillsdale Hospital aimed to improve health outcome variation with a goal to achieve a 15% improvement in selected chronic disease metrics (e.g., blood pressure control) while also establishing partnerships with local organizations for sustainability.

Throughout the presentation and follow-up discussion, participants addressed several key considerations related to implementing and operating the mobile health unit including:

Logistical planning & scheduling. Which rural towns or areas will be served? How often do visits occur? How to communicate the schedule to residents to maximize utilization?
Service offerings. What mix of services beyond basic triage should be included? Considerations may include screenings, chronic disease management, preventive care, and referrals when needed to ensure the mobile unit meaningfully supplements local rural healthcare capacity.
Coordination with local providers. What existing local hospitals, clinics, and community health organizations should be involved to ensure continuity of care? Consider these, especially follow-up and referrals, for more advanced services.
Addressing rural-specific challenges. What unique barriers impact your community? Consider transportation, limited staffing, and supply chain constraints.

Hillsdale Hospital’s mobile health unit embodies a vision for bringing high-value, high-quality care to rural Michigan. By lowering access barriers and delivering preventive and ongoing services directly to patients in their communities, this initiative can help improve health outcomes, reduce reliance on emergency services, and foster trust in healthcare among rural residents.

Insights from this workgroup have several practical implications for other rural hospitals and provider organizations across Michigan:

Expansion is possible through mobile care. Rural hospitals can leverage mobile health units as an extension of their current clinical outreach, helping to connect with populations that may rarely visit brick-and-mortar facilities.
Support chronic disease management. By delivery of routine care and screenings, mobile units can help stabilize chronic conditions earlier, reducing acute exacerbations and potentially reducing avoidable ED visits.
Enhance care coordination. Partnering with mobile health teams and community resources can help coordinate follow-up appointments, testing, and specialty referrals to create a more continuous care experience for rural patients.
Advance population health goals. Mobile services can function as a tool within a hospital’s broader population health strategy, align with value-based initiatives, community health needs assessments, and provide the opportunity for all people to achieve optimal health goals.
Gather meaningful community insights. Regular presence in rural communities can help hospitals better understand local barriers, non-medical drivers of health, and other care gaps which may inform program planning, grant proposals, and collaborative partnerships.

Post-Discharge Follow-Up Workgroup – MVC and HBOM

The second MVC workgroup of November featured a joint presentation by MVC’s Associate Program Manager, Jana Stewart, MPH and HBOM’s Informatics Design Lead, Noa Kim, MSI. The workgroup kicked off with an overview of the rationale behind placing a greater emphasis on post-discharge follow-up – particularly how timely and effective follow-up care can reduce readmissions, improve patient outcomes, and ease transitions from inpatient to outpatient or home settings.

Next, as a continuation of the February 2025 health in action workgroup presentation on patient journey mapping, Stewart showed how mapping can be used to highlight key moments in a coronary heart failure (CHF) patient’s journey where there may be opportunities for post-discharge care coordination improvement – e.g., medication reconciliation, patient knowledge, frequent rehospitalization, low follow-up rates, and lack of social and community support.

An important strategy for combating these challenges for CHF patients is engagement in cardiac rehabilitation. And yet, patients rarely optimize this opportunity. Patient storytelling can help patients recall details, model scenarios a patient may experience in the future, and reduce the burden of information provided during a visit and may be a strategy to optimize cardiac rehab enrollment.

Under the umbrella of Michigan Cardiac Rehab (MiCR), a collaboration between the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2), MVC, and HBOM, several initiatives have been developed aimed at optimizing guideline-directed medical therapy including the development of NewBeat materials and now the Heart-to-Heart storytelling campaign (Figure 2).

As Kim explained, the goals of the Heart-to-Heart project are to collect diverse first-person accounts of cardiac rehab in video, audio, and photo formats from patients and clinicians from across Michigan to produce a compelling, free, reusable story library for use by cardiac rehab advocates across Michigan and beyond.

For hospitals and health systems across Michigan seeking to improve post-discharge outcomes, insights from this workgroup offer the following next steps:

Use journey mapping and storytelling in quality improvement. By mapping patient journeys and capturing patient experiences, providers can better identify and address systemic barriers to safe discharge and recovery.
Adopt standardized discharge-to-follow-up workflows. Hospitals should ensure that discharge planning includes scheduling follow-up appointments, medication reconciliation, and clear communication of next steps before patients leave the hospital.
Prioritize high-risk patients for post-discharge support. Patients with chronic illness, limited social support, or social determinants that might hinder recovery deserve extra attention during discharge planning and follow-up scheduling.
Assign care coordinators or navigators. Especially for high-risk or complex patients, dedicated staff to oversee follow-up care – manage appointments, support communication, track adherence, and offer resources – may reduce readmissions and improve outcomes.
Leverage post-discharge care as part of value-based care strategy. Effective follow-up after discharge supports long-term patient health, reduces avoidable costs, and aligns with goals of high-value care frameworks.

27 Aug 2025

critical access hospitals Emergency Department Utilization MVC Coordinating Center MVC networking event virtual networking

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MVC Virtual Networking Event: Leveraging Claims Data for Rural & Critical Access Hospital Quality Initiatives

August 27, 2025 | 0 Comments | critical access hospitals, Emergency Department Utilization, MVC Coordinating Center, MVC networking event, virtual networking

On August 21, 2025, MVC Coordinating Center hosted a virtual networking event providing members from rural, critical access, and acute care hospitals with an opportunity to make professional connections and discuss strategies for leveraging claims data. Twenty-three MVC members from twenty different hospitals and eight health systems participated in the ninety-minute event.

The event began with an ice breaker activity and a brief interactive quiz reviewing the number of and CMS requirements for rural and critical access hospitals (CAHs). This portion of the event concluded with a survey of MVC value metrics most relevant to quality improvement (QI) at rural and CAHs revealing most sites are focused on sepsis follow-up (Figure 1).

The networking event continued with a presentation by MVC’s Engagement Manager Jessica Souva, MSN, RN, C-ONQS highlighting MVC’s history with critical access and rural hospitals and the addition of ED-based episodes. Starting in 2016, CAHs began joining MVC membership and today twenty-four different CAH sites are active MVC members.

Souva emphasized the need to better serve this group by understanding their unique challenges. She then shared unblinded data on hospital-level index emergency department (ED) visits with behavioral health ICD-10 code rates for 30-day ED-based episodes from January 1, 2021 to November 30, 2024. Prior to sharing the data, members were asked where they thought their hospital’s rate would fall compared to the MVC All average, most felt their rates would be higher than the average. After sharing the data, most members found their rates to be lower than expected.

Aggregate data for conditions with the highest ED episode and inpatient episode volumes across all rural and CAHs from January 1, 2022 to December 31, 2024 were also shared (Figure 2). Souva encouraged members to discuss opportunities for benchmarking and custom analytics during the breakout session with this data in mind.

The breakout discussions were structured to engage attendees in conversations about the challenges and strategies to address leveraging claims data for rural and CAHs. After breaking into two smaller groups, attendees were provided with three primary discussion prompts to reflect upon:

Data Possibilities: What data sources and metrics are frequently utilized to determine outcomes and impact of process improvements in the inpatient or ED setting?

MVC members reported that various internal data platforms and benchmarking tools such as Vizient, Premiere, and Q-Centrix are used by critical access and rural health sites. They also noted frequently using metrics provided by various collaborative quality initiatives (CQIs) (e.g., HMS, MEDIC, etc.) and Medicare Beneficiary Quality Improvement Project (MBQIP) Core Measure sets to evaluate process improvements. When asked how MVC can optimize benchmarking for rural and CAHs, attendees explored options for comparing data with similar-sized sites and increased alignment between CQI pay-for-performance (P4P) metrics.

Data Sharing: Which stakeholders are commonly engaged in determining strategies and indicators of successful QI initiative implementation?

The discussions in both breakout rooms highlighted the importance of involving clinical leads, physician champions, and quality improvement oversight boards for the success of QIs. One hospital noted that they additionally include an executive sponsor for each QI which they find helps to drive QI forward. Others noted a shift in culture towards encouraging ownership of QI implementation to front line staff. They noted that with adjustments to quality departments’ scope and capacity, quality leadership can focus more on the “why” versus the “how” of QI.

Conditions & Follow-Up Care: Are there specific conditions currently focused on reducing ED return visits and/or inpatient readmissions?

Key conditions of focus identified by MVC members include readmissions, chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), pneumonia, sepsis and diabetes. When asked if the data shared today inspired interest in new conditions or processes to investigate in the future, members noted interest in continuing to explore the utilization of behavioral health in ED-based episodes.

Feedback from members on MVC’s August Virtual Networking Event included:

“I enjoyed participating and sharing during this event.”
“This was very helpful. I would love more meetings like this specific to critical access hospitals and small rural hospitals.”
“These networking events are always great and provide great insight into what is happening across the state. It allows us to share ideas but there is also a validation component that we are all experiencing a lot of the same challenges and barriers.”
“This was a great networking event. As a member of an organization going through multiple ‘changes’, it was awesome to see how larger acute or rural hospitals tend to their QI projects.”
“There was a lot of great dialogs about changing culture and how we approach quality improvement.”

MVC looks forward to hosting additional networking events in the future to increase collaboration and connection with MVC’s members. The next networking opportunity will be an in-person networking dinner on October 9, 2025, the evening before MVC’s Fall Collaborative-Wide meeting. If you are interested in attending, please register for this event here. Please note that space is limited.

06 Aug 2025

Michigan Value Collaborative MVC Coordinating Center MVC workgroup rural hospitals sepsis

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July Workgroups Highlight Sepsis Compliance Process Improvements and Patient Satisfaction Excellence

August 6, 2025 | 0 Comments | Michigan Value Collaborative, MVC Coordinating Center, MVC workgroup, rural hospitals, sepsis

In July, MVC hosted two virtual workgroup presentations – the first, a rural health workgroup focused on how a sepsis compliance initiative was developed and implemented in a critical access hospital setting. The second, a post-discharge follow-up workgroup, presented a small acute care hospital’s journey to patient satisfaction excellence. The MVC Coordinating Center hosts workgroup presentations twice per month, covering a variety of topics including post-discharge follow-up, sepsis, cardiac rehab, rural health, preoperative testing and health in action.

Rural Health Workgroup July 8, 2025

MVC hosted a rural health workgroup with a presentation by Victoria Durr, BSN, RN, Infection Prevention Coordinator from Scheurer Health. The presentation spotlighted a targeted sepsis compliance initiative and shared key strategies, lessons learned, and outcomes tailored to rural healthcare.

Meeting sepsis bundle compliance requirements set by the Centers for Medicare & Medicaid (CMS) is not only vital for reimbursement and regulatory alignment but also directly tied to improved patient mortality outcomes. As Durr explained, rural hospitals face unique challenges to improving sepsis compliance including agency coverage, fewer staff, and limited diagnostic tools.

As a part of her initial assessment of SEP-1 bundle compliance at Scheurer Health, Durr evaluated her staff’s understanding of the sepsis bundle components and found significant knowledge gaps. Other challenges faced by Schurer Health included limited space to admit directly from the emergency department (ED), an inconsistent sepsis census, and changing admitting privileges. These challenges contribute to downstream impacts to sepsis compliance including limited staff awareness and training, changes to lab orders, and transitions in continuity of care.

In July of 2024, Durr began working through each issue one-by-one with the help of department leadership. She outlined specific strategies Scheurer Health has used to improve compliance including:

Implementation of structured training and process changes to standardize sepsis detection across emergency, inpatient, and inpatient care units
Employed a team-based strategy, pairing clinicians and quality improvement leads to reinforce consistent sepsis protocols across inpatient workflows
Leveraged data analytics to identify gaps and monitor compliance in real time

One key proactive tool Durr developed was a step-wise sepsis worksheet for nursing staff to follow in the case of a sepsis patient (see Figure 1, access PDF here). While this form is not required, in those cases when it has been utilized, Durr has found 100% SEP-1 compliance. A similar summary guide was created for physicians to optimize work flows (see PDF here).

While Durr notes she has only evaluated data for sepsis cases dating back to July of 2024, she has seen a shift in the areas of SEP-1 non-compliance over time. Analysis revealed that some areas of non-compliance have improved while others have worsened (Figure 2). For example, between Q3 2024 and Q4 2024, non-compliance with antibiotic delivery within a three-hour window significantly declined, while non-compliance with blood cultures being drawn after antibiotic administration increased. However, by Q1 2025 when almost all the strategies outlined above had been implemented, the distribution of SEP-1 non-compliance areas became relatively even. Durr notes that real-time tracking has allowed her team to pinpoint manageable areas of improvement and inform their next steps.

In the future, Durr notes Scheurer Health will continue to improve SEP-1 compliance through the implementation of a SEP-1 orientation with newly hired ED and acute care unit nurses, the creation of a standardized nurse handoff report, and continued tracking and team report outs on various metrics including length of stay (LOS), mortality, and sepsis related readmissions.

The workgroup presentation and follow-up discussion not only emphasized specific challenges to improving SEP-1 compliance at a rural health center but also offered solutions. Some of the solutions shared with attendees included recommendations to:

Standardize workflows and checklists to build consistency across units
Create on-demand education modules
Utilize checklists available through the electronic medical records (EMR)
Optimize nursing and physician champions
Use data dashboards for real-time feedback

Post Discharge Follow Up Workgroup July 24, 2025

MVC’s second workgroup in July featured a presentation by Sara Hagerman BSN, RN, Quality Performance Improvement Specialist for University of Michigan Health-Sparrow at the Clinton, Carson, and Lansing sites. The presentation outlined the various pathways UMH Sparrow Carson has taken to improve their Hospital Consumer Assessment of Healthcare Providers and Systems survey (HCAHPS) scores.

HCAHPS is a tool developed by CMS that measures patient satisfaction. The survey consists of 27 questions that measure different aspects of patient care, including communication with providers, hospital environment, medication management, transitions from hospital to home care, and discharge planning. The survey is administered at various points throughout a patient’s stay, and results are used to compare hospitals on a national level.

Hagerman explains that starting about one year ago, the University of Michigan Health-Sparrow Carson devised a plan to not only improve HCAHPS scores but also to decrease readmissions. To do this, they focused on three primary areas:

Evaluation of social determinates of health (SDoH)
Individualized discharge planning
Care facilitator follow-up

After collecting SDoH metrics in the Electronic Health Record (EHR) for about a year, the team aggregated this data to determine the greatest needs within their patient population. They also specifically looked for corresponding readmission cases to determine if readmissions were contributed to by social needs. Hagerman notes they found food insecurity (3.9%), housing instability (4.2%), and transportation needs (3.9%) to be the most common social factors impacting their community.

Transitioning from a micro to a macro-level, University of Michigan Health-Sparrow Carson senior executives next worked with their community partners to support improved transportation and food assistance resources at the local level. They collaborated with local programs to identify new resources for transportation and food assistance and developed pathways to connect patients directly with these resources prior to discharge.

With these resources in place, the team turned to tailoring individualized patient discharge plans. At UMH Sparrow Carson, nearly 90% of patients discharged have a scheduled follow-up appointment with their primary care provider (PCP) prior to leaving the hospital. And for those without a confirmed PCP, teams set a goal to follow-up within 3-7 days or less. Other components of the individualized discharge plans include:

Review of SDoH screening and arrangement for appropriate support services
Review of home care instructions, medications, and patient education
Post-discharge contact information and call-back within 72 hours

Lastly, Hagerman described the third component of their program triad: care facilitators. Care facilitators are nurses embedded in primary care offices whose primary goal is to identify and support chronically ill patients. They can support care transitions, medication management, patient education, and enhance overall experience. Care facilitators can also enroll patients in UMH Sparrow’s Chronic Care Management Program.

Benefits to enrollment in the Chronic Care Management Program include improved care coordination, increased patient engagement, and reduced hospitalizations. Hagerman points to a readmission rate of 5.9% thus far in 2025, compared to a readmission rate in 2024 of 6.95% as evidence of the positive impact this program has had. However, Hagerman notes there are limitations to the availability of this program to patients due to the cost of patient copays.

When it comes to improving HCAHPS scores, Hagerman noted that perhaps the most important lesson learned in this process has been to ensure team members are aware of the content of HCAHPS surveys. “It’s important to understand what patients will be asked about in order to better address potential issues up front”, noted Hagerman and she’s encouraged her team to become more knowledgeable about the survey. Additionally, engaging an interdisciplinary team and sharing data is especially useful to ensure communication and continued progress. The UMH Sparrow Carson leadership team meets in person at their strategy huddle board every other week to discuss progress and next steps (Figure 3).

MVC’s July workgroups specifically highlighted successful quality initiatives at small rural and acute care hospitals in Michigan. Their insights provide a basic understanding of the unique struggles these hospitals face to implement and maintain quality improvement.

MVC welcomes workgroup presenters from across Michigan to share their expertise, successes, initiatives and solution-focused ideas with fellow MVC members. Interested in presenting? Please reach out to us by email or submit a presentation proposal here.

02 Apr 2025

Chronic Disease Chronic Disease Management CKD MVC Coordinating Center MVC workgroup post-discharge follow-up

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March Workgroups Highlight Chronic Kidney Disease Detection in Primary Care and Population Health Program

April 2, 2025 | 0 Comments | Chronic Disease, Chronic Disease Management, CKD, MVC Coordinating Center, MVC workgroup, post-discharge follow-up

In March, MVC hosted two virtual workgroup presentations – the first, a rural health workgroup focused on enhancing early detection of chronic kidney disease (CKD) in primary care and the second, a post-discharge follow-up workgroup focused on the impact of launching a population health program. MVC hosts two virtual workgroups per month with topics rotating between post-discharge follow-up, sepsis, cardiac rehabilitation, rural health, preoperative testing, and health in action (ad hoc focused topics). Each month, the MVC Coordinating Center publishes key highlights from the past month’s presentations to provide resources and support best practice sharing across the state.

Rural Health Workgroup March 11, 2025

In support of National Kidney Month, MVC’s first rural health workgroup of 2025 featured a presentation by Mary Wozniak, Program Manager for the National Kidney Foundation of Michigan (NKFM) and Jill Oesterle, Director of Provider Solutions for Michigan Center for Rural Health (MCRH). The joint presentation focused on the partnership between NKFM and MCRH on a 2024 Medicaid Impact and Expansion grant.

Low recognition of CKD is a chronic health problem. Nearly 35.5 million Americans are projected to have CKD but according to the Centers for Disease Control and Prevention (CDC) up to 90% of patients are unaware of their CKD status. Additionally, among Medicaid beneficiaries with CKD, the average estimated healthcare costs per year is more than six times the average cost per person when compared to patients without CKD.

Despite the availability of diagnostic tests like estimated glomerular filtration rate (eGFR) and albumin: creatinine ratio (ACR), fewer than half of individuals with diabetes and less than 10% with hypertension receive annual CKD screenings, even though both groups face heightened CKD risk. For more information about testing, Wozniak recommended the guidelines for CKD screening and management from KDIGO and KDOQI.

Knowing that CKD can be diagnosed with two simple evidence-based laboratory tests, NKFM and MCRH teamed up to combat low CKD screening rates. To start, Wozniak and Oesterle explained that the partnership established a CKD Learning Collaborative Initiative made up of four rural health clinics: Cass City Family Practice, Cass City Medical Practice, St. Helen Mclaren Primary Care, and Clare McLaren Central. These sites were identified based on data indicating a high CKD prevalence or low CKD screening rates within their Medicaid patient populations.

The collaborative aimed to increase awareness of the importance of early detection and management of CKD among Medicaid eligible populations at Rural Health Clinics (RHCs) using a three-pronged approach:

Increase provider and clinical education
Promote referrals to evidence-based lifestyle change programming (through NKFM)
Provide support and guidance to implement screening into clinical workflows

Each pilot site participated in an initial assessment including the collection of baseline data. NKFM then provided one-hour tailored clinical education sessions on various CKD topics from diagnosis and staging to lifestyle and nutrition approaches for prevention and management. Wozniak and Oesterle attribute the collaborative’s ability to adapt these trainings to each clinic based on their identified needs, capabilities, and goals to the successes observed in increased screening and diagnoses made at these pilot sites when compared to baseline data.

Amongst the four pilot sites, the collaborative found CKD screening rates in patients with diabetes increased on average by 27%, while in patients with hypertension (HTN) screening increased on average by 17% (Figure 1). Overall, CKD diagnosis increased by an average of 6.5% when compared to baseline.

Empowering the healthcare team and patients with actionable recommendations was another strategy identified to be especially helpful in moving the needle on screening rates. Ensuring laboratory representation from the beginning of the project was especially helpful in overcoming challenges related to laboratory test ordering and reporting. Moving forward, the presenters note that the project timeline may need to be adjusted to build in enough time to identify clinic champions and develop buy-in with clinic staff.

Throughout the project, NKFM and MCRH met monthly with all the pilot sites together, as well as separately. This allowed them the opportunity to collaborate on shared successes and barriers while also offering an opportunity to cater education and guidance of interventions to each site’s needs. While each pilot site ended the project with different next steps, all will continue to receive support from NKFM and MCRH as they progress on their journeys to diligently increase CKD screening, diagnosis, and referrals to lifestyle management programs.

Using the remaining funds from this grant, NKFM and MCRH built on their successes by developing a CKD toolkit for rural providers. The toolkit allows them to broaden the reach of the CKD Learning Collaborative’s impact to more clinics across Michigan. While the toolkit does cater to a rural health clinic audience, any clinic interested in learning more about enhancing CKD care can access the suite of provider and patient education resources, workflows, and screening tools on MCRH’s website.

Post-Discharge Follow-Up Workgroup March 20, 2025

This month, MVC’s post-discharge follow-up workgroup featured a presentation by Morgan Albright, Director of Case/ Care Management and Population Health at Oaklawn Hospital and Zach Chapman, Executive Director of Oaklawn Medical Group. Their co-presentation centered on Oaklawn Hospital and Oaklawn Medical Group’s collaboration to integrate Medicare Annual Wellness Visits (MAWVs) into their population health program.

MAWVs focus on preventive care and health maintenance and include a health risk assessment, review of medical history, and development of a personalized prevention plan (Figure 2). Unlike a preventive physical exam (IPPE) or routine physical exam, MAWVs do not include a comprehensive physical exam. Albright explained that while MAWVs are a standard benefit for Medicare beneficiaries, these visits were infrequently completed due to the limited time available during a PCP visit. Additionally, since these visits are hands off assessments and previously stand-alone appointments, patient satisfaction following these visits was generally low.

In January of 2023, three population health nurses were integrated across Oaklawn’s outpatient offices with the goal of conducting dual and/or phone-prep MAWV appointments. Combining an MAWV with another regularly scheduled visit has helped to alleviate the barriers that existed for the Medicare patient population. Benefits of completing the MAWV include increased care planning, depression screening, and patient satisfaction.

An additional benefit to the integration of the population health nurses and MAWVs has been in the improvement of billing and revenue. Albright explained that while an initial MAWV does not necessarily generate revenue, any subsequent MAWVs, such as those focused on depression screening or social determinants of health (SDoH) concerns, are billable. Champman notes that in 2022, only 66 depression screenings were billed, compared to close to 4,000 in 2024. Similarly, billing for advanced care planning has increased from 94 cases in 2022 to 1,100 in 2024. Chapman estimates the return on investment is about 150% of the cost of a dedicated population health RN. He also noted the impact the introduction of population health support staff has had on reducing the primary care physician’s workload.

In addition to the MAWV assessments, Albright and Chapman note Oaklawn has initiated a chronic care management program. This program is a collaborative effort between Oaklawn’s care managers and a third-party chronic care management vendor. These check-ins take place between regularly scheduled appointments to ensure patients have the resources (access to medications, transportation, etc.) to be successful in management of their chronic conditions. The depth and breadth of the resources available between these two groups allows them to reach out to over 800 patients monthly. Identified downstream effects of this program have been reduced emergency department (ED) utilization and reduced length of stays (LOS).

Paired together, the addition of MAWVs and the chronic care management program have robustly increased Oaklawn Hospital and Medical Group’s ability to reach their aging Medicare patients. Overall, roughly 50% of Oaklawn’s eligible population completed MAWVs in 2024, compared to just 11% in 2021. This translates to about 1,800 wellness visits in 2021 versus 5,500 in 2024. Oaklawn’s next steps include intentionally working to engage with the remaining 50% of eligible Medicare patients to ensure they do not miss out on valuable healthcare resources.

To learn more about Medicare Wellness Visits including coding and billing requirements, visit the Centers for Medicare and Medicaid Services education website.

07 Jan 2025

Emergency Department Utilization MVC workgroup post-discharge follow-up rural health

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December Workgroups Highlight MI-POST End-of-Life Medical Order and ED Throughput Project

January 7, 2025 | 0 Comments | Emergency Department Utilization, MVC workgroup, post-discharge follow-up, rural health

In December, MVC hosted two virtual workgroup presentations – the first a post-discharge follow-up workgroup focused on end-of-life care, and a rural health workgroup focused on emergency department (ED) throughput quality improvement processes. MVC hosts two virtual workgroups per month with topics rotating between post-discharge follow-up, sepsis, cardiac rehabilitation, rural health, preoperative testing, and health in action (ad hoc focused topics). Each month, the MVC Coordinating Center publishes key highlights from the past month’s presentations to support resource and best practice sharing across the state.

Post-Discharge Follow-Up Workgroup December 3, 2024

The first workgroup of December focused on post-discharge follow-up and end-of-life care choices supported by Michigan Physician Orders for Scope of Treatment (MI-POST) legal documentation. This workgroup featured a presentation by Crystal Young, a Quality, Safety, & Experience Program Manager at Corewell Health, and Natalie Holland, Senior Advisor with the Michigan Department of Health & Human Services (MDHHS) Strategic Alignment and Engagement Team. The presentation reviewed Michigan’s MI-POST legal and healthcare guidelines, detailing options patients have when they are eligible for end-of-life services and care options.

MI-POST is an option for patients in their advance care planning (ACP) process. The ACP process includes discussing patient wishes for care, deciding how they want their needs met if they are unable to communicate, and documenting these decisions so that they are accessible for healthcare professionals when the patient is unable to speak for themselves. The presenters identified several ACP documents available in Michigan such as Durable Power of Attorney for Healthcare, Living Will, and Medical Orders such as the MI-POST and Out-of-Hospital Do-Not-Resuscitate Order (OOH-DNR).

The presenters described the history behind MI-POST as a portable medical order, starting as a pilot program in several Michigan counties in 2011 and then established through legislation and utilized across the state. This standardized form allows adult patients who require end-of-life services to establish specific guidelines for care in their last year of life. The presenters detailed the sections and fields included within the form, which can be found on the Michigan Department of Health and Human Services website. The presenters explained that the MI-POST form must be updated each year and has some similarities and differences to other ACP documents. Below is a table provided by the presenters comparing the MI-POST document to the other forms of ACP (Table 1).

Rural Health Workgroup December 12, 2024

On Dec. 12, MVC hosted its final rural health workgroup of 2024. Toni Moriarty-Smith, RN, MSN, Director of Quality and Clinical Risk at McLaren Northern Michigan Hospital, presented on their emergency department (ED) throughput quality improvement process.

Moriarty-Smith commented that many of the challenges faced by rural hospitals after the COVID-19 pandemic are still being dealt with today. McLaren Northern Michigan found that after the pandemic lifted, their ED experienced a significant uptick in patient volume and patient acuity, with increased wait times in the ED and patients leaving without being seen by a physician.

Moriarty-Smith said several factors played a part in the increased wait times and ED overcrowding at McLaren Northern Michigan. In addition to regular inpatient boarders, there were lengthy bed holds for skilled nursing patients because facilities were limiting admissions with selective criteria, behavioral health patients (especially pediatric) were being held longer in ED beds, and beds were being held for outside facility direct admits.

In addition to the influx of patients, she said, the hospital experienced an unprecedented reduction in staff (approximately 50%) either from retirements or resignations post-pandemic. This directly impacted the efficiency of moving patients through the ED in a timely manner. McLaren Northern Michigan completed root cause analyses to begin pinpointing areas of opportunity for improvement. After completing a review of current literature, Moriarty-Smith said hospital leadership identified multiple strategies to address their challenges.

One of the first adjustments made was implementation of a fast-track triage process with ED physicians and advanced practice providers working in the triage area. The fast-track triage process was triggered when all registered nurses (RNs) were in full assignment, a triage RN or other support staff were able to start protocol orders, and an ED provider was available to work in triage. Figure 1 below shows the Median ED throughput for patients from arriving to the ED to discharge before and after the fast-track process was implemented.

Prior to the implementation of this new triage process, McLaren Northern Michigan struggled to complete timely blood draws. Due to diminished staffing the hospital was pulling nurses from the ED or from the floor to help do lab draws in the ED. This slowed the triage process and affected other areas within the hospital. In response, they developed a strategy to reduce the load on nurses by cross training patient care techs (PCTs) to do lab draws, offering a more senior position with increased pay to improve efficiency and processing.

McLaren Northern Michigan also worked in collaboration with their family advisory committee to establish a volunteer presence in the ED. These volunteers helped educate and inform patients about what to expect coming into the ED, provided warm blankets and words of encouragement, and generally supported those waiting to be seen. The extra care and attention helped patients feel seen and listened to and improved their experience (Figure 2). The addition of volunteers also helped reduce the number of patients who left without being seen (Figure 3).

Moriarty-Smith said they also sought to address issues related to staff recruitment. McLaren Northern Michigan raised the base pay of all RNs, transitioned contracted RNs to temporary status (approximately 70%), implemented a recruiting initiative to re-hire past employees, and expanded traveling provider contracts to open more beds for ED boarding patients.

The improvement measures McLaren Northern Michigan implemented have had an overall positive impact on the hospital. Over the course of her presentation, the challenges shared by Moriarty-Smith resonated with other attendees and inspired robust discussion about strategies being implemented across the state to address barriers to QI.

02 Oct 2024

COPD MVC workgroup post-discharge follow-up rural health

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September MVC Workgroups Highlight Initiatives for COPD Readmissions, High-Value Care for All

October 2, 2024 | 0 Comments | COPD, MVC workgroup, post-discharge follow-up, rural health

Since its founding, a core component of MVC’s strategy has been organizing opportunities to collaborate with and learn from peers, leading to the ongoing facilitation of MVC workgroups. MVC has hosted workgroup presentations twice per month in recent years, and this year’s workgroups are focused on six topic areas: post-discharge follow-up, sepsis, cardiac rehabilitation, rural health, preoperative testing, and health in action. Going forward, MVC will publish a monthly blog to highlight key takeaways and shared resources from the prior month’s presentations. In doing so, all MVC members and partners may utilize and benefit from the content regardless of their live participation.

September Post-Discharge Follow-Up Workgroup

MVC hosted a post-discharge follow-up workgroup on Sept. 10 featuring a presentation by Brian Leideker, RRT, COPD Navigator for Trinity Health Oakland Hospital. Leideker’s presentation summarized Trinity Heath Oakland Hospital’s progress since initiating an A3 COPD readmission committee in June 2021, including the key interventions their team has implemented to date.

One initial intervention was the hiring of a COPD navigator. Leideker described how his unique role as a respiratory therapist involved in case management has allowed him to be “a middleman between respiratory physicians and other entities trying to deliver and support services” for COPD patients.

Following several root cause analyses, the COPD committee identified that nearly 90% of patients readmitted for COPD at Trinity Health Oakland Hospital had an interruption in intended continuation of pharmacotherapy and/or non-pharmacotherapy treatments. This finding encouraged Leideker’s team to work to improve the education of patients, providers, and the greater healthcare community on ambulatory treatment for COPD as well as reviewing the testing and documentation needed to ensure coverage of durable medical equipment (DME) post-discharge.

With the help of an MVC custom analytic report, Leideker was able to trend DME utilization rates for patients hospitalized with COPD since the initiation of these interventions, as seen in Figure 1.

Generally, the utilization rate of post-discharge non-bi-level home ventilators (E0466) was found to increase over time, while bi-level home ventilator (E0470) utilization has decreased. Leideker noted that this was somewhat expected since patients routinely report difficulty with the utilization of bi-level home ventilators (BiPAP) and often move on to non-bi-level home ventilators (CPAP). Additionally, based on Trinity Health Oakland’s internal analyses as of May 2024, their COPD three-day readmission rates have been reduced to <18% for all payers.

September Rural Health Workgroup

MVC hosted a rural health workgroup on Sept. 26 featuring a presentation by Brent Mikkola, MBA, PMP, Manager of Community Health at MyMichigan Health. Mikkola’s presentation summarized MyMichigan Health’s strategic approach to ensuring high-value care for all and an overview of some specific community programs currently in place. MyMichigan Health’s strategic approach is currently focused on evaluating opportunities to overcome non-medical drivers of health in an “assess, analyze, and address” model.

Some unique community partnerships that resulted from this process include:

Gratiot County Public Transit voucher program
Rx 4 Health – partnership with Michigan State Extension and specific grocery suppliers including SpartanNash, SaveALot, and Meijer
Food Pharmacies & Weekend Kits - partnership with the Greater Lansing Food Bank and the Food Bank of Eastern Michigan
Bridge to Belonging - virtual series on loneliness and social connection
Continuing Care Clinic Pilot with Community Health Workers (CHWs)
Intervention for Nicotine Dependence: Education, Prevention, Tobacco and Health (INDEPTH) Suspension Diversion Program

In addition, Mikkola described how MyMichigan Health delved into the data collection, analysis, and quality improvement work surrounding gaps in healthcare outcomes. For example, after initially integrating CHWs into community practices and inpatient services, MyMichigan Health further integrated CHWs following the WHO’s CHW Lifecycle Approach. CHWs have become instrumental to MyMichigan’s assessment of non-medical drivers of health as required by CMS and JCAHO mandates; they have done so by filling gaps in system workflows and in the expansion of the Continuing Care Clinic Pilot. To date, nearly 500 well visit appointments have been completed by CHWs at MyMichigan. Of those patients, 34% were identified as experiencing gaps in care and 50% of those positive screens have now reportedly been met through connections to community support services.

To learn more about the efforts showcased by Trinity Health Oakland and MyMichigan Health, or to view past workgroup presentations, visit MVC’s YouTube channel here.

October’s workgroups will include a health in action presentation on Oct. 8 about the University of Michigan’s Hospital Care at Home program, as well as a sepsis presentation on Oct. 17 by Garden City Hospital. You can view the complete 2024 calendar of events and register for workgroups here. To learn more about MVC workgroups or other presentation opportunities, contact the MVC Coordinating Center by emailing us here.

Archive

November Workgroups Highlight Mobile Health and Patient Storytelling

Rural Health Workgroup – Hillsdale Hospital

Figure 1. Hillsdale County Community Health Needs Assessment (CHNA) Survey Data: Difficulty Finding or Getting Transportation to a Doctor in 2024, 2022, 2019, and 2016

MVC Rural Health Workgroup: Nov. 4, 2025

Post-Discharge Follow-Up Workgroup – MVC and HBOM

Figure 2. Examples of MiCR Guideline-Directed Medical Therapy Campaigns

MVC Post-Discharge Follow-Up Workgroup: Nov. 20, 2025

MVC Virtual Networking Event: Leveraging Claims Data for Rural & Critical Access Hospital Quality Initiatives

Figure 1. Most relevant MVC value metrics to QI at your site

Figure 2. Conditions with the highest ED and inpatient episode volumes

July Workgroups Highlight Sepsis Compliance Process Improvements and Patient Satisfaction Excellence

Rural Health Workgroup July 8, 2025

Figure 1. Step-Wise Sepsis Worksheet for Nursing

Figure 2. Tracking Areas of SEP-1 Non-Compliance

Rural Health Workgroup July 8, 2025 Recording

Post Discharge Follow Up Workgroup July 24, 2025

Figure 3. Tier 2 Strategy Huddle Board

Post Discharge Follow Up Workgroup July 24, 2025 Recording

March Workgroups Highlight Chronic Kidney Disease Detection in Primary Care and Population Health Program

Rural Health Workgroup March 11, 2025

Figure 1. CKD Learning Collaborative Data Findings

MVC Rural Health Workgroup Mar. 11, 2025

Post-Discharge Follow-Up Workgroup March 20, 2025

Figure 2. Comparison of Medicare Physical Exam Coverage

MVC Post-Discharge Follow-Up Workgroup Mar. 20, 2025

December Workgroups Highlight MI-POST End-of-Life Medical Order and ED Throughput Project

Post-Discharge Follow-Up Workgroup December 3, 2024

Table 1. Comparing Advance Directive, OOH-DNR, & MI-POST

MVC Post-Discharge Follow-Up Workgroup Dec. 3, 2024

Rural Health Workgroup December 12, 2024

Figure 1. ED Throughput - Median Time (Minutes) for Patients from ED Arrival to ED Departure for Discharged ED Patients Before and After Implementation of the Fast-Track Process

Figure 2. McLaren Northern Michigan ED Wait Time & Staff Cared Top Box Scores

Figure 3. McLaren Northern Michigan ED Left Without Being Seen

MVC Rural Health Workgroup Dec. 12, 2024

September MVC Workgroups Highlight Initiatives for COPD Readmissions, High-Value Care for All

Figure 1. Annual Select* DME Utilization Rates During the Index and 30-Day Post-Discharge Period Among Patients Hospitalized for COPD at Trinity Health Oakland (2020-2023)**

Sept. 10 Post-Discharge Follow-Up Workgroup

Sept. 26 Rural Health Workgroup

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