Pins-Schallip reviewed a selection of sepsis patient calls to the Transfer Center noting that the volume of calls since initiation of the program have been fewer than five. However, the time between a patient calling and resolution of their question is estimated to be on average less than one hour. To date, patient concerns primarily revolve around antibiotic prescription questions.

Throughout implementation, Pins-Schallip noted that the team emphasized collaboration across departments, including hospitalists, nursing, care management, information technology, and executive leadership. Strong physician engagement and support from MyMichigan’s chief medical officer were instrumental in successfully implementing standardized workflows across the health system. With a relatively recent “go live” for this program of July 2026, Pins-Schallip explained that regular feedback gathered from frontline staff and patient data will allow the team to continue to refine the process over time and adapt workflows based on operational experiences.

During the discussion portion of the workgroup, participants enquired about adapting the workflow for other patient populations, implementation at smaller or independent hospitals, and strategies for gaining physician buy-in. Pins-Schallip encouraged organizations to begin with existing resources whenever possible, noting that many hospitals already have personnel or infrastructure that can be leveraged for post-discharge outreach. The importance of executive sponsorship and continuous evaluation were also identified as key strategies to ensure new workflows remain sustainable and effective.

Post-Discharge Follow-Up Workgroup: MVC Coordinating Center

The second workgroup in July featured a walkthrough of MVC’s new Follow-Up push report, presented by Janet Zhang, MPH, MVC Data Analyst, and Rachel Folk, MHA, MVC Site Engagement Coordinator. Developed to support hospitals interested in further understanding opportunities for improvement, the report provides hospital- and system-level insights into post-discharge follow-up patterns for patients hospitalized with congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), pneumonia, and sepsis. The report evaluates patterns of follow-up completed within three, seven, and 14-days after discharge using claims data from Blue Cross Blue Shield of Michigan and the Centers for Medicare & Medicaid Services.

To begin, Zhang reviewed the design of the report outlining how hospitals can use the system-level report to identify variation in follow-up performance across hospitals within the same system. At the system level this report can help leaders recognize opportunities to share successful practices across sites. At the hospital level, the report provides additional context through patient demographic information, non-medical drivers of health, and analyses stratified by payer and follow-up status. Together, these visualizations help members identify where opportunities to optimize follow-up may exist and prioritize improvement efforts.

Next, using a blinded sample report, Folk demonstrated how members can translate their own report findings into actionable quality improvement opportunities. Using the sample blinded report as a template, the remainder of the presentation guided participants through the next steps to finding actionable insights including the identification of areas of opportunity. In this particular report, Folk identified the following areas of opportunity:

1. Sepsis has the lowest overall follow-up rates at three, seven and 14-days after discharge.
2. All conditions show lower rates of seven and 14-day follow-up for Medicaid FFS and Dual Eligible payers.
3. COPD and sepsis patients that attend follow-up within 14-days after discharge have lower 30-day risk-adjusted, price-standardized total episode payments.

As a next step, Folk walked participants through samples of related goal setting and suggested action items for two priority metrics: COPD 7-day follow-up and sepsis 14-day follow-up.

Between COPD and sepsis, the evidence-based action items reviewed included:

• Schedule follow-up appointments before discharge
• Confirm medication and follow-up provider access prior to discharge
• Referral placement for smoking cessation and rehab as indicated
• Document and review medical care action plans
• Connect high-risk patients to care management follow-up
• Flag patients discharged to home without home health as high priority

As part of an interactive discussion, participants were asked to vote on the follow-up intervention they’d most likely implement to drive further discussion.

Throughout the discussion, participants shared experiences and challenges related to improving post-discharge follow-up within their organizations. While several members identified building structured outreach workflows for high-risk patients and scheduling follow-up appointments before discharge as high-priority areas, others discussed practical barriers to these interventions including coordinating care with independent primary care practices, transportation challenges, and difficulty reaching patients by telephone after discharge. Participants also exchanged ideas such as utilizing nurses on light duty to conduct follow-up calls, incorporating virtual and remote monitoring for rural populations, and partnering with home health agencies to reinforce patient education.

The discussion also highlighted opportunities to maximize the value of MVC reports by combining claims data-based insights with internal quality dashboards and other collaborative initiatives. Members expressed continued interest in additional education on integrating MVC reports with other quality improvement efforts and using benchmarking data to communicate opportunities and progress with organizational leadership.