MVC Welcome & P4P Updates
Mark Bradshaw, MSc
Director, Michigan Value Collaborative
Jessica Souva, MSN, RN, C-ONQS
Site Engagement Manager, Michigan Value Collaborative
Welcome to MVC's 2025 Fall Collaborative-Wide Meeting, Data Driven Excellence: Adapting Together in 2025 and Beyond. MVC will share updates and announcements from the Coordinating Center followed by a presentation about the MVC Component of the BCBSM P4P Program PY 2026-2027 cycle.

Non-Medical Drivers of Health: Implications for QI Teams
Brad Iott, Ph.D., M.P.H., M.S.
Content Expert in Health Informatics and Social Care Integration, MSHIELD
Julia Weinert, MPH
Program Manager, MSHIELD
The MSHIELD team will lay the foundation for the day by discussing non-medical drivers of health and related implications for quality improvement teams, including examples of metrics that help evaluate care across all patients and interventions that can help reduce gaps in patient outcomes.

Driving Excellence in Health Care Through Post-Acute Care Initiatives
Gloria Rey, PA-C, MPH
Director of Post-Acute Care, Populance Henry Ford Health
Gloria Rey will present on Henry Ford’s post-acute care (PAC) transition program, and the ways in which their team partners with PAC groups to ensure effective, individualized handoffs and care delivery for all patients.

MVC Data Presentation: Identifying and Addressing Variation in Healthcare Outcomes
Hari Nathan, MD, PhD
Medical Director, Michigan Value Collaborative
Kushbu Narender Singh, MDS
MPH Analyst, Michigan Value Collaborative
This data presentation will focus on MVC’s newest health outcome variation measure, including how it was developed, its use cases and benefits, a timeline for related data sharing, and unblinded data.

Breakout Sessions
Beyond the Emergency: Integrating Community Paramedicine with Hospital Care
Amanda Biskner, RN, Paramedic, CP-C
Community Paramedicine Coordinator, Tri-Hospital EMS
Holly N. Gould, MSN, CNM, RN
Director of Quality Improvement and Organizational Excellence, McLaren Port Huron
Community Paramedicine leverages partnerships between hospitals and EMS to expand access to care beyond emergency response, focusing on prevention, follow-up, and chronic disease management. This collaboration helps reduce hospital readmissions, improve patient outcomes, and strengthen continuity of care within the community.

Enhancing Health Through Community Partnerships
Nicole Luczak
President and CEO, United Way Bay County
McLaren Bay Region’s Family Health and Wellness Center is a primary care office serving a population in which more than 80% of patients are struggling with non-medical drivers of health. Learn how a pilot program with United Way Bay County identifies variation in healthcare needs in the community and ensures non-medical needs are met.

Cardiac Rehab Referrals: After the Click
Greg Scharf BS, ACSM-CEP, AACVPR-CCRP
Cardiopulmonary Rehab System Manager, MyMichigan Medical Center - Midland
After a cardiac rehab referral is placed, delays can contribute to barriers in initiating care. Learn factors that contribute to those delays including location, external referrals, and organizational structure, and explore collaborative solutions to ensure all patients get high-quality care. An MVC led review of live cardiac rehab data registry reports will provide members with key insights to their site's cardiac rehab utilization.

Traverse City Street Medicine: Meeting Patients Where They Are
Kelly Clark, MD
Faculty, Munson Family Medicine Residency Program and Clinical Assistant Professor, Department of Family Medicine at Michigan State University
The Traverse City Street Medicine program began in 2016 through a unique partnership with Munson Healthcare, Goodwill Northern Michigan, Traverse Health Clinic, and MSU College of Human Medicine’s Traverse City campus. Learn how a multidisciplinary team can serve its community, teach, and improve access to primary care for people living with housing insecurity.

The Roadmap to Success: Engaging Physicians in Avoiding Hospital Readmissions
Belinda Dokic, CPhT, BA, MBA
Clinically Integrated Network Program Manager, Trinity Health Livonia
Michael Gatt, MD
Gynecologist, Trinity Health Livonia
Predictive analytics and risk assessment tools in EMRs enable physicians to proactively identify gaps in care and tailor interventions. Learn how this approach impacts readmission rates, post-discharge rates, and comprehensive care transition plans.

Closing Remarks
Emily Woltmann, PhD, MSW
Project Manager, Michigan Value Collaborative
MVC will close out the session with reminders about upcoming meetings, key dates for the PY2026-2027 P4P metric selection process, and post-event survey information.
