27 Oct 2022
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First Annual MiCR Meeting Draws Cardiac Rehab Stakeholders

First Annual MiCR Meeting Draws Cardiac Rehab Stakeholders

October 27, 2022 | 0 Comments | , , ,

Since its inception earlier this year, the Michigan Cardiac Rehabilitation Network (MiCR) has sought to equitably increase cardiac rehabilitation (CR) participation for all eligible individuals in Michigan. A key step in this process has been to assemble an engaged group of stakeholders that share this vision from around the state, which culminated in the first MiCR Annual Meeting on October 7, co-hosted by MVC and the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2). Over 40 attendees representing institutions throughout Michigan came to Ann Arbor to present and discuss ongoing challenges facing CR utilization, and to brainstorm solutions that could be implemented across the state.

The first session of the meeting discussed strategies to cultivate buy-in from clinicians and administrators to support CR for their patients and health systems. Dr. Frank Smith, MD, from Trinity St. Joseph Mercy Ann Arbor discussed the importance of identifying and educating the key administrators and clinicians within the organization and developing a rigorous financial plan for a growing CR program. Jacqueline Harris, BS, CCEP, from McLaren Northern Michigan discussed how she developed small, laminated cards that mapped out the process to get eligible patients to CR, which she distributed to clinical teams within her institution. Rob Snyder, EP, MSA, from McLaren Greater Lansing emphasized the importance of continual monitoring and engagement with clinical and administrative leadership to ensure CR program growth.

Following the presentations, small group discussions among attendees identified other challenges related to achieving buy-in from clinicians and administrators. The referral phase was a consistent source of frustration for many attendees, including delays in referral from qualifying events, inefficient referral processes that require physician action, and limited staffing to close the gap from referral to enrollment. The session panelists noted that implementing automatic referrals and recruiting a physician champion can help facilitate referrals among colleagues with lower referral rates.

The second session of the day focused on navigating challenges with insurance coverage for CR programs. Robert Berry, MS, ACSM-CEP, FAACVPR, from Henry Ford Health discussed strategies to minimize insurance delays in starting CR. It is critical to know the regulations and policies that guide CR so that staff can work within them to reduce delays to enrollment. Like the prior session, implementing automatic discharge order sets that include CR for eligible patients can minimize delay, but more work may be needed within an institution to work through pre-authorizations that often accompany CR use. Dedicated liaisons can be a critical resource for addressing insurance issues and securing enrollment during the hospital stay. Jacqueline Evans of Covenant HealthCare reiterated the importance of understanding the regulations and policies of major insurers and developing tools to educate colleagues and patients. Being the local expert can ensure the financial health of the CR program and minimize the insurance burden for patients.

The day's final session featured discussions about how to better engage patients and providers in CR. Greg Merritt of Patient is Partner discussed his experience with CR—having survived a cardiac event and benefitted from participating in CR—and how patients could be involved to improve the CR experience. Integrating former graduates of CR programs into the orientation process may help alleviate fear and concerns facing new attendees. He also challenged the group to think about how CR could be reshaped to reflect the patient population or foster better adherence through engaging with community partners such as dog shelters or social groups. Patients are often an untapped resource and can help innovate CR to improve participation.

The Healthy Behavior Optimization for Michigan (HBOM) collaborative closed out the day with a brainstorming session on how attendees might innovate the current CR system to create better experiences and outcomes for all patients. Attendees raised challenges that face vulnerable populations, such as access to nutritional foods and health literacy. Solutions to these issues could include standardized and accessible resources for patient education and opportunities to provide nutritional support to patients such as grocery delivery services. Developing peer support systems and community-building among CR graduates may also facilitate a better introduction to new patients and improve long-term adherence to behavior changes developed during the program.

Several next steps were identified at the conclusion of the meeting. First, the MVC and BMC2 collaboratives will continue to work towards broader dissemination of CR reports to relevant stakeholders in Michigan. MVC’s latest CR reports were distributed to MVC and BMC2 members this week. In these reports, members can see how their CR utilization rates compared to their peers throughout Michigan within 90 days of discharge following transcatheter aortic valve replacement (TAVR), surgical aortic valve replacement (SAVR), coronary artery bypass graft surgery (CABG), percutaneous coronary intervention (PCI), acute myocardial infarction (AMI), and congestive heart failure (CHF). The reports also included figures for the mean number of days to a patient’s first CR visit and the mean number of CR visits within 90 days. Since these reports were the first version released following the May announcement of new collaborative-wide CR goals, the reports also include figures detailing a hospital’s rates relative to those goals (see Figure 1). The first goal is to reach 40% CR utilization for TAVR, SAVR, CABG, PCI, and AMI patients. Currently across the collaborative, 30% of patients utilize CR following one of these “main five” procedures. The second statewide goal is a collaborative-wide utilization rate of 10% for CHF patients since only about 3% of CHF patients currently utilize the program.

Figure 1.

In addition to report dissemination, several other next steps were identified at the conclusion of the recent MiCR meeting. A second next step was to collate resources that have been developed by individual institutions for broader dissemination. In addition, continued collaboration between the MiCR and HBOM teams will seek to develop solutions that address key behavioral factors and barriers to CR. Lastly, the MiCR team will continue to develop relationships and provide content that works towards its mission of improving CR participation for all eligible individuals in Michigan. If you are interested in collaborating with the MiCR team, please reach out to MVC or BMC2.

05 May 2022
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MVC, BMC2 Launch Michigan Cardiac Rehab Network & Toolkit

MVC, BMC2 Launch Michigan Cardiac Rehab Network & Toolkit

May 5, 2022 | 0 Comments | , ,

This year in the United States, cardiovascular disease will be responsible for one in every four deaths. Despite its prevalence, few cardiac patients eligible for cardiac rehabilitation utilize this life-changing program. In response, the Michigan Value Collaborative (MVC) and the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) recently established the new Michigan Cardiac Rehab Network (MiCR) to collaborate on efforts that heighten awareness of these programs and support meaningful improvement in Michigan.

Cardiac rehabilitation (CR) is a comprehensive program encompassing supervised exercise, nutrition education, smoking cessation, mental health resources, skills training for heart-healthy lifestyles, and peer support from others who are experiencing a similar life event. It has a Class IA indication for recent cardiac-related events or procedures, meaning there is high-quality evidence that it is beneficial to patients. In fact, individuals who complete the full program of 36 sessions have a 47% lower risk of death and a 31% lower risk of heart attack than those who attend only one session. The evidence is clear that CR extends life and improves quality of life for patients with a recent cardiac-related event or procedure. Unfortunately, only one in three eligible Michiganders participates—a rate well below the Million Hearts nationwide goal of 70% participation.

Using claims data, MVC can assess both initiation and adherence – whether and when someone starts CR, and how long they keep going. There is wide variability in CR rates between MVC’s member hospitals (see Figure 1 for a sample plot from a recent blinded report). The site with the highest rate of cardiac rehab after coronary artery bypass graft surgery (CABG), for example, succeeds at sending 75% of their CABG patients to CR, while another only sends 28% of their CABG patients. This variation shows that it is possible to reach high CR rates, and hospitals can learn from each other to make improvements that save lives and reduce costs.

Figure 1. Collaborative-Wide CR Use Following CABG Discharge

MiCR was developed for this reason and will work to equitably increase CR participation for all eligible individuals in Michigan. Serving as Co-Directors of MiCR are Mike Thompson, Co-Director of MVC, and Dr. Devraj Sukul, Associate Director of BMC2 PCI. MiCR will distribute regular CR utilization summaries to relevant providers, convene regular meetings with its stakeholder and advisory groups, create resources that help hospitals and CR facilities optimize CR utilization, and continue to leverage the expertise of both CQIs.

In one of its first coordinated efforts, MiCR worked with CR providers and content experts to create a Cardiac Rehab Best Practices Toolkit, which was launched in April. It outlines initiation, maintenance, and innovation strategies for increasing the utilization of CR (see Figure 2 for a sample page). MVC encourages members to turn to this tool as they work to encourage the enrollment of more patients.

Figure 2. Sample Page from MiCR Best Practices Toolkit

The partner CQIs behind MiCR also released new statewide goals for improved CR utilization. Currently, 30% of patients utilize CR following transcatheter aortic valve replacement (TAVR), surgical aortic valve replacement (SAVR), coronary artery bypass graft surgery (CABG), percutaneous coronary intervention (PCI), and acute myocardial infarction (AMI). The first goal is to reach 40% CR utilization for TAVR, SAVR, CABG, PCI, and AMI patients. In addition, only about 3% of congestive heart failure (CHF) patients currently utilize CR. The second statewide goal is a collaborative-wide utilization rate of 10% for CHF patients. Progress on these goals will be shared by MVC in its CR reports sent every six months.

The two CQIs will also continue with their respective activities in the CR space. MVC supports CR participation in two primary ways. One is providing opportunities for MVC members to collaborate, and the second is the preparation of reports using its unique multi-payer data sources. The MVC team supports collaboration through stakeholder meetings and workgroups, which allow sites and clinicians to share solutions for common challenges. The reports MVC prepares analyze member claims data with time-specific hospital-level information on CR enrollment and completed visits within one year of discharge. This allows hospitals to benchmark their performance against peers and identify areas for improvement. MVC will also share unblinded data on CR rates with members at its May semi-annual meeting in one week, which is meant to drive conversation and encourage best practice sharing across the collaborative. The MVC team hopes that its outreach and resources help members to save lives by providing strong endorsements for CR and addressing barriers that may limit patient participation.

For more information on MVC’s CR efforts, visit MVC’s Value Coalition Campaign webpage. For more information about CR, view this MVC video or visit the Million Hearts website. If you have questions about any of the above activities or resources, reach out to the Coordinating Center at michiganvaluecollaborative@gmail.com.

15 Apr 2021
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Cardiac Rehab Stakeholder Meeting Motivates Improvements in Care

April 15, 2021 | 0 Comments | , , ,

On Monday, March 22, 2021, a “stakeholder meeting” was hosted by the Michigan Value Collaborative (MVC) Coordinating Center with multiple key players in cardiac rehabilitation (CR) from around Michigan. As MVC has written about before, cardiac rehabilitation is a highly valuable but underutilized service and is the focus of one of MVC’s ongoing value coalition campaigns. The goal of the stakeholder meetings is to bring together key constituents to work towards solving the problem of underutilization. Attendees included managers of cardiac and pulmonary rehab facilities, quality improvement leaders and executives from  several MVC members, our payer partners from Blue Cross Blue Shield of Michigan, and representatives from the Michigan Society for Thoracic and Cardiovascular Surgeons (MSTCVS), the Michigan Society for Cardiovascular and Pulmonary Rehab (MSCVPR), and the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2).

The stakeholder meeting occurred the week after MVC distributed new Master Cardiac Rehab reports, which detail several metrics on cardiac rehabilitation after percutaneous coronary intervention (PCI), coronary artery bypass grafting (CABG), transcatheter aortic valve replacement (TAVR), and surgical aortic valve replacement (SAVR) procedures. The collaborative-wide average cardiac rehab utilization varied by procedure: 52.6% for SAVR, 30.1% for TAVR, 56.3% for CABG, and 32.3% for PCI (see Figure 1). The mean days to first cardiac rehab visit also varied by procedure: 46 days for SAVR patients, 43 days for TAVR patients, 45 days for CABG patients, and 34 days for PCI patients (see Figure 2).

Figure 1

Figure 2

The Master Cardiac Rehab reports were also distributed by our partners at MSTCVS and BMC2. The aim is to increase awareness of hospital-level CR utilization and encourage as many players as possible (cardiologists, cardiac surgeons, cardiac rehab staff, quality improvement staff, and executive leadership) to work together to increase CR utilization at every hospital. These reports were well-received at the March 22nd stakeholder meeting, with one attendee emphasizing that the information contained in the reports was “the envy of other states,” speaking to the utility of MVC data and the success of BCBSM Value Partnerships. Attendees also provided excellent suggestions for improvement which will be taken into account during the next report refresh later this year.

The data is distributed, and the stakeholder meeting is over, but the value coalition campaign is just getting started.  There’s still a lot of work to do in order to equitably increase cardiac rehabilitation use in our state, including studying barriers to entry, exploring the intricacies of benefit design, and making various operational changes hospital by hospital, health system by health system. Nevertheless, that Monday afternoon showed that sometimes, when you have the right people around the same (virtual) table, everyone can walk away connected, motivated, and ready to carry out their respective roles to improve health care.

The next cardiac rehab stakeholder meeting is scheduled for Monday, June 28, 2021 from 4:00-5:00pm. If you have an interest in joining this group, or if you have not received your Master Cardiac Rehab report, please email michiganvaluecollaborative@gmail.com.