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Special Consideration Needed for Older Patients Using Telecare

Special Consideration Needed for Older Patients Using Telecare

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.

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2021 Surviving Sepsis Campaign Guidelines Reviewed at Workgroup

2021 Surviving Sepsis Campaign Guidelines Reviewed at Workgroup

On December 7, 2021, the Michigan Value Collaborative (MVC) held its bi-monthly virtual workgroup on sepsis featuring Dr. Hallie Prescott, Associate Professor at Michigan Medicine and the physician lead on the Michigan Hospital Medicine Safety Consortium (HMS) Sepsis Initiative. For this MVC and HMS co-sponsored workgroup, Dr. Prescott presented Updates in Sepsis: What is new in 2021 SSC Guidelines. Dr. Prescott is a pulmonary and critical care medicine specialist, and she practices clinically in the intensive care units at the University of Michigan Health and Ann Arbor Veterans Affairs hospitals. She is co-chair of the Surviving Sepsis Campaign Adult Guidelines and a council member of the International Sepsis Forum.

The workgroup began with an introduction to the International Surviving Sepsis Campaign (SSC) guidelines and bundles, which are resources and implementation tools used to reduce sepsis and septic shock worldwide. The SSC Guidelines were originally published in 2004 and have been updated every four years, with the most recent edition being published in October 2021. A large panel of experts collaborates to evaluate the evidence and make recommendations (scaled by the strength of recommendation). Since their initial publication, health systems from the United States to Spain have used the SSC guidelines and tools to improve sepsis and septic shock care and outcomes.

Dr. Prescott’s presentation describing the SSC 2021 Adult Guidelines highlighted several recommendations and detailed the reasoning behind some of the changes made since 2016. The highlighted guidelines included recommendations for infection (antibiotic timing, use of antimicrobials) (see Figure 1), hemodynamics (resuscitative fluids, vasopressor timing), ventilation (ECMO), and additional therapies (IV corticosteroids, IV Vitamin C). In addition, a new section for long-term outcomes (see Figure 2) was also added to the newest guidelines and reviewed during the workgroup, addressing patient education, health and social screenings, and post-discharge follow-up. Out of all the discussed recommendations, the MVC and HMS members in attendance were most interested in antibiotic use, resuscitative fluids, central line use, and treatment prioritization.

Figure 1.

Figure 2.

The updated SSC Guidelines offer informative and valuable recommendations that can be used to improve sepsis care and outcomes. If you were unable to attend the workgroup or are simply interested in reviewing the presentation and discussion, a recording of the workgroup is available here. To read the full published SSC 2021 Adult Guidelines and review additional resources, click here.

The MVC Coordinating Center is interested in hearing how your organization has utilized the SSC 2021 Adult Guidelines to improve sepsis care and outcomes. If you would like to present at or attend an upcoming MVC workgroup, please contact the MVC Coordinating Center at the michiganvaluecollaborative@gmail.com.

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MVC Coordinating Center Looking Back at 2021 and Forward to 2022

Let me begin the first MVC blog of 2022 by wishing you all a very happy new year on behalf of everyone at the MVC Coordinating Center. I’ve started my last two recaps with this line and ended with the hope of seeing you all in-person sometime soon. Since we still haven’t quite managed to get together in-person yet, I’d like to reiterate our thanks and gratitude to each of our collaborative members and those hospitals and physician organizations across the country who have continued to work tirelessly against the ongoing pandemic.

The MVC team has remained remote throughout 2021 and not only have we mastered the Zoom mute button, but we’ve continued to provide support to help MVC’s 100 hospital members and 40 physician organizations during this time.  In 2021, the MVC team held two virtual collaborative wide meetings, conducted 62 tailored registry webinars, undertook 58 virtual site visits, delivered 56 custom analytic requests, facilitated 34 workgroups, disseminated 21 push reports, and held five virtual regional networking events. As a result of this activity, the collaborative has welcomed 13 new hospital members to the collaborative.

In addition to these efforts, the MVC Coordinating Center has continued to adhere to our commitment to provide hospitals and POs with increased access to meaningful benchmarked performance data. In May of this year, MVC’s data portfolio grew with the addition of Michigan Medicaid data, and this was recently refreshed in early October. The data range for this data source currently covers 1/1/2015 – 9/30/2020, reflecting index admissions from 1/1/2015 – 6/30/2020. MVC Medicaid claims (Fee-for-Service and Managed Care) account for a total of 319,140 episodes (19.4% of all MVC episodes) and cover 256,889 beneficiaries. Overall, MVC data sources now comprise over 80% of Michigan’s insured population.

We look forward to continuing this growth in 2022 as we strive to improve the health of Michigan through sustainable high-value healthcare. There are a number of new developments in the pipeline for the coming year and I excited to be able to share some of these with you.

New Hospital Push Reports

A number of new reports will be added to MVC’s suite of reporting in 2022, focusing on topics such as COVID-19, Pneumonia, and Health Equity. The Coordinating Center will work closely with members, the wider CQI community, and other stakeholders to ensure the introduction of other new and novel approaches to sharing our data.

New Physician Organization Reporting

Driven by continued communication with members, the Coordinating Center disseminated its first PO-specific report focused on joint replacement towards the end of last year and has identified two new conditions of interest for future development (gastroenterology and hysterectomy). The Coordinating Center will also be working closely with PO members to inform the development of new metrics for the MVC online registry.

Increased Custom Analytics

Over the last year, the MVC team has devoted effort to raising awareness of MVC’s custom analytic offering to members. This has proved successful, with 56 custom projects undertaken for members in 2021 alone. This support will continue into 2022 – if you are interested in learning more, please contact the MVC Coordinating Center (michiganvaluecollaborative@gmail.com).

Emphasizing Equity in Healthcare

Most measures of overall health are worse in the US compared to any other developed country. The state of Michigan in particular ranks poorly in measures of population health, including tobacco use and the inter-related issues of inactivity, poor nutrition, and obesity. The relationship between these poor health behaviors and social determinants of health are closely interlinked and represent a huge opportunity to improve health and healthcare outcomes for targeted patients. In the coming year, MVC will be exploring how best to use its data and engagement platforms to emphasize equity in healthcare.

Collaborative Wide Meetings

The MVC team will continue to hold two flagship semi-annual collaborative wide meetings. These will take place on Friday, May 13th and on Friday, October 28th. The MVC team will also be holding five regional networking events throughout the year and plans to pilot a new ‘Northern Meeting’ in Summer 2022. More details to come.

New MVC Workgroups

The Coordinating Center’s suite of peer-to-peer virtual workgroups will continue to provide a highly accessible online platform for hospital and PO leaders to come together, collaborate, and share practices. In addition to MVC’s Chronic Disease Management, Sepsis, Joint, and Diabetes workgroups, two new groups will be added in 2022. This includes forums focused on ‘Health Equity’ and ‘Health in Action’.

As these activities and other planned developments come to fruition, we will be sure to share updates with you through our various engagement platforms. If you have any questions in the meantime, please do not hesitate to contact the MVC Coordinating Center at michiganvaluecollaborative@gmail.com. Happy New Year, and we look forward to a great 2022 together.

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Happy New Year from the MVC Coordinating Center

The Michigan Value Collaborative Coordinating Center wishes you peace, joy, and prosperity throughout the coming year. Thank you for your continued support and partnership. MVC looks forward to working with you in the years to come and wishes you all the best as you embark on the new year ahead. Happy New Year!

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Happy Holidays from the MVC Coordinating Center

As the holiday season is upon us, Michigan Value Collaborative staff reflect on the past year and those who helped to shape healthcare in 2021. It’s been quite a year for us all! The MVC Coordinating Center appreciates working with you and hopes that the holidays bring you health and happiness.

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MVC Shares National Action Plan with COPD Workgroup Attendees

MVC Shares National Action Plan with COPD Workgroup Attendees

The Michigan Value Collaborative (MVC) held a bi-monthly virtual workgroup recently on chronic obstructive pulmonary disease (COPD), a condition that accounts for the majority of deaths from chronic lower respiratory diseases and is continuously a leading cause of death in the United States. Notably, COPD is nearly two times as prevalent in rural areas as it is in urban areas; therefore, MVC members in rural areas may be dealing with significant inequities within their patient populations. The workgroup presentation and discussion focused on the COPD National Action Plan (CNAP). To the Coordinating Center’s surprise, many workgroup participants had not previously heard of the CNAP, making this event a great opportunity for practice sharing and discussion among members.

Overcoming barriers to prevention, early diagnosis, treatment, and management of COPD is necessary to improve quality of life and reduce mortality. To address these barriers, the U.S. Congress; National Heart, Lung, and Blood Institute; and Centers for Disease Control and Prevention convened a town hall where they asked federal and nonfederal partners to develop an action plan. These partners were tasked with identifying the efforts needed to change the course of COPD. The result was the development of the COPD National Action Plan (CNAP), which was released in 2017 and updated in 2019. It consists of five goals, which were outlined and discussed during the workgroup (see Figure 1).

Figure 1. Slide from COPD Workgroup Presentation

Goal 1 calls for promoting more public awareness and understanding of COPD, especially among patients and their caregivers. Key opportunities include patient and caregiver education that is sustainable and culturally appropriate, technological support mechanisms, and connecting patients and caregivers to local and state resources.

Goal 2 focuses on increasing the skills and education of healthcare providers so they are better equipped to provide comprehensive care. This goal is supported by the development and dissemination of patient-centric, clinical practice guidelines for care delivery, the use of technological support mechanisms, and consideration of home-based pulmonary rehabilitation programs. It’s important to note that studies have found no statistically or clinically significant differences for health-related quality of life and exercise capacity among patients who have completed home-based vs. outpatient-based pulmonary rehabilitation.

Goal 3 encourages increased data collection, analysis, and sharing to create a better understanding of disease patterns. Opportunities within this goal include supporting pharmaceutical and clinical COPD research; identifying and delivering comprehensive, evidence-based, culturally appropriate interventions; and disseminating findings to a variety of audiences (from patients to national policymakers).

Goal 4 aims to increase and sustain COPD research to improve understanding of the disease and its diagnosis and treatment. It’s vital that clinicians, researchers, and health policy experts foster research across the COPD continuum (prevention, diagnosis, treatment, management). Workgroup attendees agreed that there are opportunities to improve equity among COPD patients through more data on diagnosed and undiagnosed COPD in disadvantaged patients. Another vital component of this goal is supporting and sustaining pharmaceutical research for COPD medications since none of the existing medications for COPD have been shown to reduce the progressive decline in lung function.

Goal 5 calls for federal and nonfederal partners to collaborate to meet the objectives of the CNAP and translate its recommendations into research and action. Workgroup attendees highlighted the importance of implementing CNAP equitably among both urban and rural regions and implementing COPD strategies at all health policy levels (national, state, local). Such opportunities could improve access to cost-effective and affordable COPD support services and expand support for and access to pulmonary rehabilitation services (including home-based PR), thus reducing health inequities among COPD patients.

Each of the five CNAP goals is equally important and vital in reducing COPD health disparities. Although many of the MVC workgroup participants had not heard of the CNAP before, they were interested in sharing its goals and opportunities with others in their healthcare organization. If you would like to learn more about this patient-centered national action plan, you can read the full published report here. If your organization has addressed the CNAP goals or implemented any of the discussed opportunities, the MVC Coordinating Center would like to hear about the successes, challenges, and lessons learned. If you would like to share this information or present at an upcoming MVC workgroup, please email MVC at michiganvaluecollaborative@gmail.com.

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Reports Identify Opportunity to Reduce Preoperative Testing

Reports Identify Opportunity to Reduce Preoperative Testing

MVC distributed its final push report of 2021 this week when the Coordinating Center distributed preoperative testing reports to members. It provided recipients with refreshed data using only Blue Cross Blue Shield of Michigan claims in order to provide the most up-to-date and granular preoperative testing information available.

In general, the report demonstrated significant variation in testing rates between members, with preoperative testing rates ranging from 20% to over 90%. The average overall testing rate was 56% when looking at only the BCBSM payers, whereas the rate was 62% when looking at all payers in the earlier version of the report from February of 2021. The report included overall testing rate (Figure 1), preoperative testing rate trends over time (Figure 1), and rates for specific tests and procedures.

Figure 1. Blinded Preoperative Testing Push Report Graphs

Due to the amount of variation, MVC suspects that preoperative testing is overused at the state level such that even hospitals that are average or below average may still have significant opportunities to safely reduce preoperative testing.

Preoperative testing, especially in low-risk surgical procedures, often provides no clinical benefits to patients. Despite this, these services continue to be ordered regularly at hospitals across Michigan. Eliminating unnecessary and, in some cases, potentially harmful preoperative testing represents a clear opportunity to improve value in surgery. The MVC Coordinating Center uses administrative claims data and engagement with MVC members to try and reduce the use of unnecessary preoperative testing for surgical procedures to improve quality, reduce cost, and improve equity of care delivery throughout Michigan. The MVC Coordinating Center’s work on this issue is supported by a stakeholder working group to advise ongoing activity and provide insights on the best approaches to improve member awareness and practices.

This latest preoperative testing report also marked the conclusion of one year’s worth of activity in support of MVC’s Preoperative Testing Value Coalition Campaign. As part of MVC’s commitment to improve the health of Michigan through sustainable, high-value healthcare, the Coordinating Center developed specific focus areas to drive improvement. These are termed ‘Value Coalition Campaigns’ (VCCs).

In an effort to communicate progress on its Preoperative Testing VCC, the Coordinating Center recently compiled a 2021 Preoperative Testing Progress Report (see Figure 2) and included it as an attachment with the most recent report communications. Accomplishments included the development of educational flyers and resources, a published manuscript, partnerships with fellow Collaborative Quality Initiatives (CQIs), and custom analytics prepared for members. In addition, the Coordinating Center set several goals for 2022, such as developing provider-level reporting and hosting a dedicated symposium or workgroup, among others.

Figure 2. MVC 2021 Preoperative Testing VCC Progress Report

The Michigan Value Collaborative is eager to reduce unnecessary preoperative testing. If you are interested in a more customized report on preoperative testing practices at your hospital or physician organization or you want to learn more about the stakeholder working group, please contact the MVC Coordinating Center at michiganvaluecollaborative@gmail.com.

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Studies Find Value in Virtual Reality for Pain Management

Studies Find Value in Virtual Reality for Pain Management

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.

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Happy Thanksgiving!

Happy Thanksgiving!

The Michigan Value Collaborative wishes you a happy Thanksgiving holiday. Thank you to our partners and members for working tirelessly every day to improve healthcare quality across Michigan.

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CHF Workgroup Discusses Value of Outpatient Intravenous Diuresis

CHF Workgroup Discusses Value of Outpatient Intravenous Diuresis

The Michigan Value Collaborative (MVC) holds bi-monthly virtual workgroups on six different clinical areas of focus. The goal of these workgroups is to bring collaborative members together to discuss current quality improvement initiatives and challenges. These six different clinical areas include chronic disease management (CDM), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), diabetes, joint, and sepsis. At the most recent MVC CHF workgroup, the discussion centered around inpatient versus outpatient intravenous diuresis for the acute exacerbation of CHF.

The prevalence of heart failure in the United States is increasing, with one study indicating it affects more than 5.7 million people. The study reports that up to 80% of patients with acute decompensated heart failure (ADHF) visit their emergency departments and that 91.5% of those patients were thereafter readmitted to the hospital for diuresis.

With increasing prevalence comes greater direct and indirect healthcare costs associated with CHF, accounting for approximately $40 billion annually in the United States. For patients over the age of 65, it is a leading cause of hospitalization with annual costs of $11 billion.

Despite significant costs and healthcare burden associated with this condition, the same study finds that no official guidance exists regarding an appropriate location for therapy. Since hospital readmission reduction programs seek to incentivize reductions in readmissions, it is important to simultaneously provide guidance to providers and patients on safe and effective options for outpatient treatment and therapy.

To address this concern, the workgroup discussed the benefits and safety of outpatient intravenous (IV) diuresis and how the outpatient administration of furosemide can be safe and effective. MVC members shared their experiences with setting up these clinics, their inclusion criteria, and other protocols. A standard diuretic protocol could include each patient being given an IV furosemide bolus with continuous infusion within the most appropriate outpatient setting, which could include the patient’s home or in a mobile clinic.

While in the outpatient setting, patients undergoing this treatment would be monitored via cardiac telemetry and appropriate blood panels before and after the infusion. Patients on maintenance medications are instructed to continue their standard dose in the outpatient setting as appropriate based on their individualized treatment protocol. Patients should follow up with their cardiology and primary care teams to maintain their treatment and care maintenance plans. Following the outpatient IV diuresis encounter, the study reported patients had lower costs, fewer hospital stays, and lower mortality risk than CHF patients who did not receive outpatient IV diuresis.

Overall, studies indicate that outpatient CHF IV diuresis treatment is a safe and effective method of relieving CHF symptoms with a low risk of adverse events. The MVC members in attendance had positive thoughts and experiences regarding outpatient IV diuresis clinics and would recommend further discussion on them. The outpatient mobile CHF diuresis clinic was of notable interest to the MVC members in attendance and will be considered for a specialty topic in future workgroups and blog posts.

The MVC Coordinating Center is interested in hearing how your organization is improving CHF patient care and reducing CHF hospital readmissions. If you would like to present at or attend an upcoming MVC workgroup, please contact the MVC Coordinating Center at the michiganvaluecollaborative@gmail.com.