27 Mar 2026
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March Workgroups Highlight Rural Remote Patient Monitoring and Post-Discharge Follow-Up Innovations

March Workgroups Highlight Rural Remote Patient Monitoring and Post-Discharge Follow-Up Innovations

March 27, 2026 | 0 Comments | , , ,

In March, the Michigan Value Collaborative (MVC) hosted two workgroups highlighting innovative strategies to improve care transitions and expand access to care across Michigan. A rural health workgroup explored how McKenzie Health System implemented remote patient monitoring to support patients with chronic conditions. MVC’s post-discharge follow-up workgroup featured a presentation from MyMichigan Health on the development of a continuing care clinic designed to improve post-discharge follow-up and reduce hospital readmissions.

Together, these presentations demonstrated how healthcare organizations can leverage care coordination, technology, and new care delivery models to improve patient outcomes across the continuum of care. The MVC Coordinating Center hosts one to two workgroup presentations per month covering a variety of topics including post-discharge follow-up, sepsis, cardiac rehabilitation, rural health, preoperative testing, and health in action.

Rural Health Workgroup – McKenzie Remote Patient Monitoring

The first workgroup of the month featured a presentation led by Heather Baumeister, BSN, RN, CRHCP, Director of Healthcare Practices at McKenzie Health System, who shared how her organization implemented a remote patient monitoring (RPM) program to better support patients living in rural communities.

McKenzie Health System includes a 25-bed critical access hospital (CAH) located in Sandusky, Michigan. The organization also operates six primary care clinics across multiple communities throughout the Thumb region offering several specialty services such as gastroenterology, orthopedic care, general surgery, and behavioral health. Like many rural health systems, McKenzie serves a geographically dispersed patient population where travel distance and limited healthcare resources can make frequent in-person visits difficult. To help bridge these gaps, Baumeister said, the organization relies heavily on care coordination.

McKenzie currently employs three full-time and one part-time registered nurse care coordinators who support primary care clinics across the system. Baumeister described how these coordinators conduct daily follow-ups with patients seen in the emergency department and help connect patients without an established primary care provider to appropriate outpatient care. Care coordinators also participate in monthly readmission review meetings to identify patients who may benefit from additional care management services and reduce avoidable hospitalizations.

Launching a Remote Patient Monitoring Program

To expand its ability to monitor patients between visits, McKenzie Health System participated in an 18-month pilot program focused on RPM for rural health systems. After completing the pilot, McKenzie established a long-term partnership with an RPM vendor to manage several operational aspects of McKenzie’s RPM program, including device shipping, monitoring, nurse outreach for readings outside clinical thresholds, uploading data into the electronic health record (EHR), and billing services. Baumeister said this helped clinicians at McKenzie to integrate RPM into their care model without needing to manage the technical infrastructure internally.

Providers refer patients to the program through the organization’s EHR. After receiving a referral, the RPM vendor enrolls the patient and distributes the appropriate monitoring devices. Patients enrolled in the program receive connected monitoring devices that automatically transmit readings directly to the monitoring platform after patients begin taking measurements. Devices currently used include blood pressure cuffs, weight scales, blood glucose monitors, and pulse oximeters. If readings fall outside predetermined ranges, a monitoring nurse contacts the patient to assess symptoms and determine whether clinical intervention is needed. If necessary, the nurse escalates the case to the patient’s provider according to established care protocols.

Implementing the program in a rural context presented several challenges. Baumeister described how unreliable internet near Michigan’s lakeshore, difficulty reaching patients by phone, and excessive measurement were challenges in delivering the program.

Benefits of RPM Program

Baumeister said the RPM program is particularly beneficial for patients managing chronic conditions like congestive heart failure, diabetes, hypertension, chronic obstructive pulmonary disease, and obesity. This is because remote monitoring enables care teams to detect early warning signs of health deterioration that might otherwise go unnoticed between routine visits so providers can intervene proactively. Baumeister gave examples such as adjusting medications, scheduling follow-up appointments, or providing additional education before conditions worsen.

She also noted that many patients became more engaged in their own care through the program, as regular monitoring helped them better understand how lifestyle choices affect their health. View the complete workgroup recording using the video below.

MVC Rural Health Workgroup: March 3, 2026

Post-Discharge Follow-Up Workgroup – MyMichigan Health Continuing Care Clinic

MVC’s second March workgroup featured a presentation by Steven Frazier, MHA, BA, RN, ACM-RN, Director of Quality and Patient Safety for Post-Acute Services at MyMichigan Health, and Dr. John Hagan, DO, Family Medicine Physician and Medical Director of the Continuing Care Clinic at MyMichigan Health. Their presentation highlighted the MyMichigan Health Continuing Care Clinic (CCC), a program designed to ensure patients receive timely follow-up care after hospitalization and to reduce hospital readmissions. Frazier previously presented about the establishment of the CCC program at MVC’s May 2024 collaborative-wide meeting, and this month provided a number of updates on progress in the program to date.

MyMichigan Health serves more than one million Michigan residents across a 26-county region, with multiple medical centers and roughly 1,100 hospital beds. Despite this extensive network, MyMichigan recognized that many patients faced barriers to obtaining timely follow-up care after leaving the hospital, citing limited appointment availability with primary care providers as well as patients without established providers struggling to navigate the healthcare system.

Frazier and Hagan said internal MyMichigan data revealed hospital readmissions were often occurring 12-13 days after discharge, highlighting a critical window when follow-up care could potentially prevent complications. Research also suggested that follow-up with a physician within seven days of discharge could significantly reduce both readmission and mortality risk for patients hospitalized with conditions such as heart failure, myocardial infarction, and COPD.

Launching and Evolving the Continuing Care Clinic

To address these gaps in care, MyMichigan Health opened the CCC in Midland, Michigan in August 2023. The clinic now operates with two locations (Midland and Alma) and three providers, supported by a multidisciplinary care team. The clinic was designed to function as a transitional care bridge, ensuring patients receive follow-up care within seven days after discharge while they wait to reconnect with their primary care providers. Services currently range from follow-up visits and assistance with establishing a primary care provider to behavioral health support and advance care planning.

Since its launch, the clinic’s role has expanded beyond its original focus on hospital discharge visits to support patients who are transitioning between primary care providers, are new to the community’s providers, need additional support navigating the healthcare system, or are seeking follow-up after emergency or urgent care visits. This evolution has allowed the clinic to function as a comprehensive transitions-of-care hub within the MyMichigan Health system.

Early Results and Impact

According to Frazier and Hagan, the CCC has already demonstrated encouraging results, saying that the program helped the health system achieve lower readmission rates compared to peers and maintain short scheduling lead times for follow-up appointments. Additionally, MyMichigan has seen an improvement in operational efficiency and budget performance with the expansion of services to additional geographic regions within the system. The program has also helped bring new patients to the MyMichigan Health network by connecting individuals without primary care providers with internal ongoing care relationships.

Patient feedback has been an important indicator of the clinic’s success, the presenters noted. Patient testimonials were shared during the presentation that emphasized how the clinic helped patients better understand their diagnoses, feel supported during recovery, and access care more easily after discharge. Patients described the clinic as a valuable resource that provided compassionate care and guidance during a vulnerable time in their healthcare journey. View the complete workgroup recording using the video below.

MVC Post-Discharge Follow-Up Workgroup: Mar. 19, 2026

Key Takeaways for MVC Members

The March workgroups highlighted two practical approaches to improving patient outcomes across the care continuum, with several key themes emerging. For one, remote patient monitoring is expanding access to care by helping teams identify early warning signs and better manage chronic conditions—especially in rural communities. At the same time, dedicated transition clinics are strengthening post-discharge care by ensuring timely follow-up and support after hospitalization.

Across both models, strong care coordination remains essential, supported by multidisciplinary teams, clear communication, and sometimes newer technologies. Just as important, patient engagement continues to drive better outcomes by empowering individuals to take a more active role in their care.

Through these shared examples, MVC workgroups continued to support collaboration and help organizations across Michigan identify actionable strategies to improve quality, outcomes, and value. If you are interested in pursuing a healthcare quality improvement project, MVC has data specialists available to help you navigate our data resources and create custom analytics reports to support your efforts. Please reach out to us by email [LINK] if you would like to learn more about MVC data, engagement offerings, or would like to present at a future MVC workgroup.

 

21 Jan 2022
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Special Consideration Needed for Older Patients Using Telecare

January 21, 2022 | 0 Comments | , , ,

When most people think about healthcare, the images that come to mind include a trip to their local provider’s office, lab, or hospital for services such as physicals, blood tests, and procedures. However, medical professionals and their patients are increasingly transitioning to more remote services that leverage our advances in communication technologies, resulting in the burgeoning “tele” world of healthcare. But are these services reaching everyone?

Telemedicine, telehealth, and telecare are three examples of remote, interactive services that allow patients to receive healthcare from within their own homes. Although these terms are often used interchangeably, they in fact refer to different aspects of healthcare delivery. Telemedicine applies to physicians who use technology to support the delivery of medical, diagnostic, or treatment-related services. Telehealth is like telemedicine but applies to a broader collection of providers, such as nurses or pharmacists. Telecare (see Figure 1) is generally more consumer-oriented by providing the patient with technology to manage their own care safely from home, such as health apps or digital monitoring devices.

Figure 1. Telecare Slide from MVC Workgroup Presentation

The adoption of “tele” services saw incredible growth in 2020 in response to the pandemic. A report found that Medicare telehealth visits increased 63-fold recently, from 840,000 in 2019 to 52.7 million visits in 2020. However, now that adoption of these services (and the platforms needed to host them) are more commonplace, providers are asking whether it benefits their most vulnerable patients and who may be left behind.

These questions drove the discussion of the most recent MVC workgroup on chronic disease management. Over the course of the session, attendees were particularly interested in how telecare improves elderly care, and whether patients over the age of 65 could adequately access such services. For those older adults utilizing telecare, evidence from the ongoing COVID-19 pandemic identified convenience and affordability as telecare’s primary strengths. In addition, research evidence suggests that the two most effective telecare interventions in this population are automated vital sign monitoring and telephone follow-up by nurses.

Some of the challenges often cited for this population include lack of appropriate internet access or devices, limited digital literacy, medical conditions that may impede participation (i.e., hearing or vision impairments, dementia, etc.), and the need to regularly monitor vitals in very high-risk patients. Although the authors compiling these challenges specifically reference older adults, they could just as easily apply to people experiencing poverty, people with disabilities, and people with more limited language and literacy skills.

Some recommended strategies to address common challenges include tablet delivery services, “mobile medical assistants” who perform video set-up for the patient, assistance from an on-site caregiver, practice or “mock” video visits prior to the appointment date, partnerships with community health workers to support or train patients in their homes, and providing self-monitoring devices. Other simple considerations include the size of the text displayed on the page (use larger text to enhance readability), providing adequate instructions in advance and in multiple languages, and engaging experts in user experience design.

In addition to these considerations, some researchers suggest that, in general, the adoption of new technologies can be predicted in part by Everett Rogers’ Diffusion of Innovation Theory. One study incorporating this theory found that the chances of telecare adoption were highest for three types of older adults: those already receiving long-term or nursing care, those living alone, and those who have fixed daily telecare points of contact.

Increased integration of technology in healthcare is inevitable as advancements continue and we shift to a more digital world. Since the number of people in the U.S. who are age 65 or older will more than double over the next 40 years, it is imperative that older adults are not left behind when transitioning to such services. Rather than fear the challenges, researchers and practitioners are seeking ways to find solutions and help all patients benefit from healthcare access within their own homes.

The MVC Coordinating Center encourages its members to collaborative with one another to benefit from peers’ success stories and lessons learned. If your hospital or physician organization has developed an age-friendly telecare protocol, please consider sharing your story with the MVC Coordinating Center at michiganvaluecollaborative@gmail.com. To catch up on the recent MVC workgroup discussion about telecare, watch the chronic disease management workgroup recording here.

02 Dec 2021
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Studies Find Value in Virtual Reality for Pain Management

December 2, 2021 | 0 Comments | , ,

Pain management is a critical component of effective care for patients. Amidst the opioid epidemic, however, pain management is highly nuanced for clinicians balancing their patient’s needs and wishes with state and hospital guidelines for prescribing. Although these guidelines are designed to curb opioid misuse—over 10 million patients misused prescription opioids in 2019—they are sometimes at odds with patient-based considerations. One research article, for example, found that, “many physicians expressed appreciation for opioid prescribing guidelines and simultaneously voiced concern about opioid restrictions that obviate the application of clinical reasoning.” In addition, some studies have called into question whether policies aimed at curbing overprescribing of opioids have a meaningful effect. One study noted that joint replacement surgeries from 2014 to 2017 saw increases in the percent of patients receiving opioids without clinically meaningful improvements in post-operative pain.

Therefore, when non-opioid pain management methods emerge in the medical literature as efficacious, there is a significant potential for impact coupled with great interest in its feasibility. Around the time the opioid epidemic was declared a public health emergency by the U.S. Department of Health and Human Services, one such pain management method emerged within medical research: virtual reality therapy.

Virtual reality therapy entails wearing virtual reality goggles and participating in an immersive, three-dimensional computer environment that distracts the patient from their pain. In some instances, it was proven effective for decreasing opioid use during painful wound procedures, and in other cases for helping patients learn how to manage chronic pain and achieve decreases in reported pain scores. Amid this excitement, one research team endeavored to measure the, "cost and effectiveness thresholds [virtual reality] therapy must meet to be cost-saving as an inpatient pain management program." They found that inpatient virtual reality therapy could reduce costs for a hospital if the length of stay was reduced because of its use; reductions in opioid use and related reimbursements were not enough in isolation to overcome the costs of virtual reality. This study found cost savings achieved in 89% of the trials it investigated.

Once studies have determined that a treatment is effective, the next question is whether it is effective for a more heterogeneous population—often, the patients included in medical research are white, relatively advantaged patients with higher-than-average education and literacy. With a growing focus in healthcare on health equity, it is important to determine whether virtual reality therapy also has potential in diverse patient populations. Just two months ago, a study from UC San Francisco was published that investigated the use of virtual reality among frontline pain management clinicians, particularly those in safety-net healthcare settings. The study found that clinicians and leadership in these healthcare settings were very interested in virtual reality therapy as a safer alternative to opioids. However, they also noted a need for significant tailoring for various cultures, languages, and technical abilities. They also expressed concerns about obtaining reimbursements and integrating the technology into complex workflows.

Virtual reality may offer potential savings as well as greater patient satisfaction for some hospitals and health systems right now. For others, it may take time and collaboration before virtual reality therapy is a feasible pain management alternative. The MVC Coordinating Center is interested in documenting how its members are approaching pain management and rising technologies like virtual reality. If your hospital or physician organization has found success in offering virtual reality therapy to patients or implemented other successful opioid-reduction interventions, please share your story with the MVC Coordinating Center (michiganvaluecollaborative@gmail.com) so other MVC members may benefit from your experience.