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Henry Ford Health System – Cardiac Rehab

Henry Ford Health System – Cardiac Rehab

At the most recent congestive heart failure MVC workgroup, Dr. Steven Keteyian, Section Head of the Cardiac Rehabilitation/Preventive Cardiology Unit at Henry Ford Medical Group, presented on exercise-based cardiac rehabilitation in patients with heart failure. Dr. Keteyian started out by discussing the importance of cardiac rehabilitation and adhering to a program in order to improve exercise tolerance and disease-specific outcomes. Exercise intolerance is measured and the information gathered can be used to stratify a patient’s future risk. If the measurement improves over time, Dr. Keteyian discussed the potential for a decrease in risk of death and re-hospitalization. This shows a tie to directly improving outcomes and symptoms in cardiac rehabilitation. Also, in the words of Dr. Keteyian, “functionally, the more they don’t do, the less they can do.”

Cardiac rehab is a Class I recommendation from The American College of Cardiology for all of the traditional cardiac disorders. Henry Ford has a 36-visit program that is anchored on exercise training. Between four and fifteen people are in each class and each person receives an individual treatment plan with a focus on bio-behavioral components. Six core components make up the program which include outcome assessments, supervised exercise, dietary/weight management, tobacco abuse, psychological support, and medication adherence. All participants participate in 30-minute behavioral education sessions which cover topics such as nutrition, dining out, proper exercise, medication compliance, and other relevant disease-management self-care activities. These same topics are also available on YouTube and can be found here, all of which are available for use in your cardiac rehab program. Currently, Henry Ford is working on bringing their time to enrollment after hospital discharge to less than 21 days and increasing adherence to the 36-visit program. The goal is to achieve a participation rate of 70% or more in cardiac rehab for Henry Ford’s patient population.

After discussing the program specifics at Henry Ford, Dr. Keteyian discussed the barriers that one may face in relation to participation in cardiac rehab. These barriers include:

  • Demographic
  • Difficulty contacting patient after hospitalization
  • Return to work demands
  • Transportation
  • Co-payment obligations
  • Dependent care responsibilities

Henry Ford is working at a system level in order to increase the percent of patients who gain access to cardiac rehab. This includes increasing the use of electronic medical record (EMR) driven automatic referrals, with an option for users to opt-out if necessary. Additionally, a member of the cardiac rehab team goes to the inpatient setting and talks to patients to establish a touchpoint before they leave the hospital. This five-minute conversation is all some patients need in order to see the importance and benefits of rehab. Lastly, Henry Ford is working to shorten the discharge to start time. Each day after discharge, the chance of getting patients started in rehab decreases by 1% for each day that passes. Henry Ford is working diligently in order to help decrease this risk.

In 2016, Henry Ford launched a hybrid home-based cardiac rehabilitation service. This includes some visits at the clinic and other virtual sessions. Previously being tied to a single visit at a time on their current streaming platform, Henry Ford will roll out a WebEx model in February 2021 that will allow up to six cardiac rehab appointments to occur at one time. This will provide more of a group setting. Currently, a randomized controlled trial is being done on center based cardiac rehab versus hybrid cardiac rehab. Improvements in fitness and the number of sessions attended are being assessed.

If you are interested in watching the entire workgroup, please click here.  If interested in any information about this workgroup, or other MVC workgroups please email michiganvaluecollaborative@gmail.com

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Learning Health Systems and Quality Improvement

Learning Health Systems and Quality Improvement

The mission of the Michigan Value Collaborative (MVC) is to improve the health of Michigan through sustainable, high-value healthcare with a vision to help provide the right care, at the right time, at the right cost. As part of this, MVC helps its members better understand their performance using robust multi-payer data, customized analytics, and at-the-elbow support. In addition, MVC fosters a collaborative learning environment to enable providers to learn from one another and share best practice. All of this is designed to help members respond to change, drive quality improvement, and improve performance.

Improving performance is often easier said than done – a phenomenon often referred to as the “60.30.10 Challenge”. Following the review of health learning systems in Australia, this phenomenon was identified as a key challenge that the healthcare system has faced for three decades. Despite change and areas for improvement being identified throughout healthcare, only 60% of evidenced based care is provided to patients, 30% of care is identified as waste or duplication, and at least 10% of patients experience adverse events or medical harm. With this in mind, can the current healthcare system embrace the many new technologies and advancements in medicine on the horizon?

While these new advances in technology have the ability to improve care and prolong life, there is conversely an addition of complexity and increased risk with utilizing them. It is important to understand that healthcare systems are complex and typically do not respond in a linear way to change. A collaboration of healthcare providers set up in Australia realized some key activities for improvement   initiatives within health care systems . These activities were included in the setting up of the collaborative known as the Translational Cancer Research Network and involved incentives, resources, administrative support to provide encouragement, collaboration and reduced constraints, data support, and expertise in implementation science. A number of new projects such as increased consumer engagement and improvement in diagnosis for various cancers came out of involvement in this network.

While root-cause analysis has long been used to identify medical failures, this may not be the best method to effectively establish safety protocols to prevent further harm due to the complex pathways within healthcare that are infrequently repeated. Instead, healthcare needs to take a different approach by introducing models of care that promote collaboration, exceed independent specialties, and advocate for combining hospital, primary care, community agencies, and elder care to navigate well-informed patients through evidenced based healthcare pathways along the continuum of care. There is a need to shift the paradigm and learn from what is going well and those that are successful. By spreading good practices across all healthcare systems, allowing healthcare teams to effectively improve processes in real time, and teaching clinicians to manage data and understand continuous improvement methods, a learning system can be developed.

By creating a learning system, efforts to improve care can be better aligned. Drivers of the system include a commitment to improvement, being ready and prepared for change, being aware of the capacity of and barriers to progress, knowledge of implementation strategies, and lastly providing leverage and resources to learning. In addition, data can be utilized by these fluid learning systems to aid patient and clinician decision-making. It is hoped that a flexible system with relevant information and data to make the right decision, and the ability to adjust processes will help to reenergize clinicians, enabling them to provide increasingly appropriate, safer, and higher quality care with less waste.

The Michigan Value Collaborative (MVC) can help you by providing claims data across 40 different medical and surgical conditions. Additionally, we have regular workgroups that meet to share best practices. If you are interested in custom analytics for your institution, joining a workgroup or want to learn more about what MVC has to offer, please contact the Coordinating Center at michiganvaluecollaborative@gmail.com.

 

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Building Resilience

Building Resilience

Following on from last week’s blog discussing burnout in the healthcare profession, this week we look at resilience and how to build it in the workforce, particularly during times of high stress. Resilience can be defined as “the capacity to recover quickly from difficulties” (Oxford Languages), while the American Psychological Association believe resilience to be “the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress”. Due to recent events, resilience among healthcare workers has become a highly publicized topic and is often in the forefront of the news. Currently, everyone has a need to build resiliency and be treated with compassion and empathy.

Although a number of articles have depicted an increase in anxiety, depression and substance use, studies done following other traumatic events such as the attacks on the World Trade Center and the Severe Acute Respiratory Syndrome (SARS) outbreak have shown a common outcome to be long-term resilience in the majority of those impacted rather than post-traumatic stress disorder (PTSD). Resilience is not a one size fits all and everybody will respond to an event in their own way. However, taking steps to adapt behavior while struggling and experiencing intense grief, fear or anxiety will impact a person’s resilience. It is continuing to show up and move forward even while facing adversity.

Additionally, resilience is not something one has or not, it is an acquired and learned behavior that is constructed actively and created through dynamic behavioral, cognitive, and environmental processes. Resilience can be cultivated through the influence of individuals and communities. By propagating togetherness and behaviors that are beneficial to others, resilience can be built within a neighborhood and each other.

Building resilience within a community takes individuals, but how can resilience be nurtured within these individuals? In a systematic literature review looking at the factors affecting resilience, the following themes were identified:

  • Influence of individual factors such as a sense of purpose, identifying the need for self-care, and holding a positive outlook
  • Influence of environmental and organizational factors indicated by workplace culture, and including identification and measurement of resilience especially within high-risk groups
  • Individual approaches to professional circumstances covering workload management, work-life balance, social support, and use of coping strategies
  • Educational interventions

Effective educational interventions may include resilience workshops along with cognitive behavioral training, stress reduction programs using mindfulness techniques, and healthcare simulation.

While we continue to undergo challenges and face adversity, it is important we take the time for self-care and also to support work colleagues and neighborhoods to build individual and community resilience. The MVC Coordinating Center is available to support, please feel free to reach out at michiganvaluecollaborative@gmail.com

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Healthcare Burnout and Possible Solutions

Healthcare Burnout and Possible Solutions

More recently than ever, healthcare workers may be faced with the potential for burnout and a decreased quality of life. The Agency for Healthcare Research and Quality defines burnout as “a long-term stress reaction marked by emotional exhaustion, depersonalization, and a lack of sense of personal accomplishment”. From the busy work days, to the intense pace and time sensitive pressures, the healthcare environment places individuals at a high risk. All of this has the potential to impact the delivery of high-quality, compassionate care within an institution. The risk for staff to develop burnout may increase as changes to the work environment result in a poor fit for healthcare workers. :

  • Technological advances
  • Compliance with regulatory measures
  • Difficult electronic medical records (EMRs)
  • Issues with insurance coverage and reimbursement
  • Increased volume and patient acuity

In order to help decrease the risk of burnout, a quality improvement project was put into place in a 37-bed ICU between February and June 2019. Registered nurses, medical assistants, and physician assistants were the targeted population. The Mini-Z Burnout survey was given to those participating in the study to assess for factors contributing to burnout, as well as job related stress and job satisfaction. After completing the survey, interventions were put into place in order to address such risks. These interventions included:

  • Identifying scheduling opportunities (e.g. stacking days when possible)
  • Determining special needs for patients while in the ICU setting
  • Identifying staff backup based on acuity of assignments
  • Staff events to foster a positive team culture and increase collaboration

After three months of applying the above interventions, the Mini-Z Burnout survey was administered again. The findings revealed a higher percentage of staff reporting no burnout after the intervention (57.7% vs. 75%). Additionally, “satisfaction with current job” went from 70.6% pre-intervention to 82.8% post intervention. Finally, open ended questions revealed that stressors that still remained focused heavily on staffing and patient ratios. The sustainability and long-term impact of these interventions on preventing burnout continue to be monitored.

Overall, implementing quality improvement initiatives in order to promote staff wellbeing has the potential to impact the delivery of high quality and compassionate care. The Michigan Value Collaborative (MVC) is committed to helping our collaborative members implement quality improvement projects in order to increase patient and provider satisfaction. If you have any questions or wish to learn more, please reach out to the collaborative at michiganvaluecollaborative@gmail.com

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MVC Coordinating Center

MVC Coordinating Center

First of all, let me begin by wishing you all a happy new year on behalf of everyone at the MVC Coordinating Center. I started my last recap in January last year with the same line and proceeded to share what the MVC team had in store for the year ahead…little did we all know what was just around the corner. The year 2020 has been one like no other and the whole MVC team is truly grateful to each of our collaborative members, and those hospitals and physician organizations across the country who have worked tirelessly to tackle the current pandemic.

Like many organizations around the world, the MVC team has now been working remotely for over ten months. During this time, we have adapted to new ways of working, wrestled with the zoom mute button on a daily basis, and got to know each other’s families and pets very well. However, the one thing that has remained constant during this time is the support on offer to each of our member sites.

Over the past ten months, the MVC team has used our current infrastructure to help MVC hospitals and physician organizations navigate the pandemic. This included the creation of a new statewide and hospital level Resource Utilization Report, providing historical resource utilization metrics for 17 different elective surgical procedures to inform surgical ramp-up at member facilities. The MVC Coordinating Center has also been working closely with the wider CQI community on the Mi-COVID19 initiative - a joint CQI venture collecting extensive clinical data on COVID-19 patients to provide insight into best practices in treating patients with the virus.

In addition to these efforts, MVC Coordinating Center activity has continued to expand. In 2020, the MVC team held two virtual collaborative wide meetings, facilitated 32 workgroups, delivered 30 tailored registry webinars, undertook 18 virtual site visits, disseminated

We look forward to continuing this growth in 2021 as we strive to improve the health of Michigan through sustainable high-value healthcare. There 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.

Data Expansion: Medicaid Data

The MVC Coordinating Center is committed to expanding patient populations on the MVC registry to increase the level of meaningful, timely, benchmarked performance data that is available to aid our member’s quality improvement activities. Over the last two years, the MVC team has been working to add Medicaid claims data to the MVC registry. This dataset was received in late November 2020 and will add approximately 1.8 million covered lives to the MVC registry. As a result, this means that MVC data sources now comprise over 80% of Michigan’s insured population. It is projected Medicaid data will be available on the MVC registry for members to access by the end of Q1 2021.

New Push Reports

A number of new reports will be added to MVC’s portfolio in 2021, focusing on topics such as COVID-19, Preoperative Testing, and Social Determinants of Health. 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. As always, the Coordinating Center is here to help so please let us know if you have any custom data requests or reports you would like to see.

New Physician Organization Metrics and Reports

As part of MVC’s organizational strategy and planned growth, Jeffrey Jameel (MD, MHA) joined the MVC team in the role of Site Engagement Coordinator in early November. In the coming year, Jeff will be working closely with each of our physician organization members to develop new measures and metrics to support ongoing activities.

Value Coalition Campaigns

In October 2020, the MVC Coordinating Center launched two new Value Coalition Campaigns (VCCs) focused on Cardiac Rehabilitation and Preoperative Testing. These VCCs can essentially be thought of as specific focus areas in which member collaborations are concentrated to drive improvement. By using our 90-day episode claims data to provide time-specific hospital-level information on CR enrollment and completed visits, and partnering with the Blue Cross Blue Shield Cardiovascular Consortium (BMC2), the Coordinating Center is aiming to equitably increase participation in cardiac rehabilitation for all eligible individuals in Michigan. In addition, the MVC team also plans to use claims data and engagement with MVC members to reduce the use of unnecessary preoperative testing for surgical procedures to improve quality, reduce cost, and improve the equity of care delivery in Michigan.

The MVC team will develop these new campaigns further in the coming year, sharing new push reports and launching new reports on the MVC registry to support member activity in this area. If you are interested in taking part in the development of MVC’s new VCCs, please reach out to the MVC Coordinating Center (michiganvaluecollaborative@gmail.com).

Collaborative Wide Meetings

The MVC team will continue to hold two flagship semi-annual collaborative wide meetings. These will take place on Friday, May 7th and on Friday, October 29th. As part of the MVC Component of the BCBSM P4P Program, hospitals will now be awarded an additional bonus point for attending BOTH semi-annuals in 2021. More details on each of these meetings will follow in the coming months.

Virtual Site Visits

MVC site visits are designed to provide members with a more in-depth understanding of MVC and its offering, as well as providing the opportunity to learn about best practices in operation at Michigan hospitals to share with the rest of the collaborative. Feedback is also sought from sites to ensure the Coordinating Center is able to continually improve the data, analytic support, and engagement resources available to members. This offering will continue in 2021.

As with attending both collaborative wide meetings, hospitals will now be awarded an additional bonus point for undertaking a virtual site visit with the Coordinating Center as part of the MVC Component of the BCBSM P4P Program. If you are interested in setting up a virtual site visit, please let us know (michiganvaluecollaborative@gmail.com).

If you have any questions on the above, please do not hesitate to contact the MVC Coordinating Center at michiganvaluecollaborative@gmail.com. Happy New Year, and we look forward to a great 2021 together.