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MVC Registry and Data Reports Resources

Bair highlighted some of MVC’s relevant data reports and how the episodes of care are built within the MVC data registry. Bair noted that MVC episodes of care have a slightly different post-discharge window for CHF patients in CR, 365 days (Figure 2), versus the 30 – 90-day windows for patients with cardiac conditions such as percutaneous coronary intervention (PCI)/coronary artery bypass grafting (CABG). The MVC data registry has several useful cardiac related reports including,

Multi-payer CR reports which evaluate CR utilization and other metrics provided in MVC’s hospital-level reports:

• CR Utilization Rates
• CR Utilization Rankings
• Mean Days to First CR Visit
• Mean Number of CR Visits

Payer specific reports which allow registry users to investigate utilization, readmissions rates, and cost of care including:

• Episode Payment Report
• Episode Utilization Rate Report
• Readmissions Report
• CR Report

The graph above shows that from Jan. 2024 – Mar. 2025, the MVC All average was  6% for CR participation within 365-days post-discharge for CHF patients. With the MiCR goal being a 10% CR utilization for CHF patients and the overall utilization range being 0% to 19%, it is clear there is room for improvement across the MVC member portfolio.

Push reports are another useful resource offered by MVC. The Process Measures Report that MVC shared with members in January 2025 had helpful visuals of site and system 7-day follow up data for CHF episodes of care (Figure 3).

Panel Discussion

The focus for the panel discussion centered around how CR services can be utilized to support rehabilitation of CHF patients who may not be able to participate in rehabilitation as quickly as those that have conditions such as PCI or CABG. Bair began the discussion by leading participants through a common care pathway for CHF patients who utilize CR (Figure 4).

CHF Barriers to Care and Change Concepts

To help organize a solutions-based approach, Bair went on to introduce the Change Concepts Model, 2^nd Ed. (Figure 5) adapted from the Million Hearts Initiative to address some of the common barriers seen in CHF care.

From the Million Hearts Change Package, 2^nd Ed., some notable barriers to care for CHF follow-up in CR include:

• Patient or provider lack of awareness
• Lack of clear and consistent communication
• No integration of CHF cardiac rehabilitation needs into cardiovascular services or workflows
• Limited capacity of CR programs
• Patient transportation, financial burden, competing responsibilities or cultural/language barriers

Systems Level Change

Bair shared some of the ways systems change could be implemented including establishing a hospital CHF champion, engaging hospital administrators and senior staff, securing and maintaining a multidisciplinary workforce, engaging the cardiac care team in the follow-up care and rehabilitation planning, tracking follow-up/CR referrals, enrollment rates, and patient participation as quality-of-care indicators.

UMH Sparrow-Clinton’s Tyelor Wymer shared that they have had success with appointing CHF champions in their centralized cardiac care team. Team members rotate through four to five different UMH Sparrow hospitals, fostering consistent care practices across the health system. MyMichigan Health System’s Greg Scharf shared that they have a similar system wide collaborative team for heart failure care, and they have had great success as well.

At Holland Hospital, Laura Meiste shared that they have a care transitions team that works in the cardiology department and focuses specifically on patient follow-up within seven days of discharge, while also working on maintaining consistent communication with the administrative staff that schedules patient appointments.

Optimizing Referrals

Another opportunity to reduce barriers to care is by improving the referral process itself. This can be done by using data to drive improvements and incorporating referrals into standardized processes. Some examples include:

• Adding CHF cardiac rehabilitation language to echo reports for patients with reduced ejection fraction (EF) that meet the appropriate criteria for CR
• Including a referral to CR in order sets for patients with CHF
• Adding CR to guideline-directed medical therapy algorithms for patients with CHF

Scharf shared that optimizing referrals is an ongoing challenge in MyMichigan Health’s system where there might be a standardized best practice advisory (BPA) for CHF in general, but there is no built-in trigger for flagging a CHF case as CR appropriate. Working in the Epic electronic health record (EHR) program, they can create custom BPAs for this, but it takes time and education.

Meiste shared that at Holland Hospital, an auto-referral process through an order set triggers a case in the system to be sent to clinical staff for CR eligibility screening. If the case meets eligibility criteria, the staff will set up an in-person visit with the patient. Similarly, workgroup participant Karolina Kaser, BSN, RN, MBA, CIC, Quality, Safety and Experience Director for Corewell Health Dearborn, shared that their site utilizes standardized clinical pathways for their cardiac cases. Included in the pathway is an order set that automatically includes a CR referral even for CHF cases. Some other effective processes have been to utilize the cardiac nurses to ensure CHF patients have CR offered if they meet criteria, as well as training administrative and call center staff on the importance of scheduling these follow-up appointments.

Enrollment and Participation

Increasing enrollment is a key goal in the Million Hearts change concept. This may include methods of optimizing care coordination for patients by promoting enrollment into CR at follow-up appointments and reducing delay from discharge to their first CR appointment. This can be done by using data to drive improvement in follow-up appointments and enrollment numbers, and by developing flexible delivery models such as hybrid CR programs. MiCR tools and resources also help to boost CR enrollment.

Supporting Adherence and Reducing Non-Medical Barriers

The next step in the change concept process is finding ways to reduce inconsistent adherence to a CR program. Some recommendations to address this issue included identifying populations at risk for low engagement, accounting for patient needs such as lack of transportation, incorporating motivational incentives, and utilizing automated communications and reminders.

Zach Johnson from Corewell Health System shared that they have a successful support group established that meets quarterly. The group includes a range of patients who have either completed the CR program or those who are just beginning their journey to recovery. To address some of the common barriers for patients, Corewell has partnered with Michigan Rehabilitation Services to help cover a patient’s copay with a contingency that the patient plans to return to work for a minimum of 20 hours per week in the future.

To address transportation barriers, Corewell has partnered with True North which is funded by a family donation fund. If a patient meets the criteria for being at or below poverty level, they will qualify to receive financial assistance to cover the cost of transportation to and from visits. Holland Hospital’s Meiste shared they have utilized a mini grant awarded from the MiCR initiative to fund their heart failure orientation and to offer copay assistance to patients in need.

Opportunities for Further Improvement

Bair rounded out the panel discussion by asking panelists to describe unique challenges they identified when trying to incorporate CHF patients into CR programs. In response to Scharf’s inquiry about strategies to connect with patients who have CHF but have not yet met the 35% EF criteria, MVC Faculty Advisor, Mike Thompson shared that cardiac clinicians at Michigan Medicine are having CR conversations with CHF patients earlier in the disease process.

Additionally, lack of a standardized approach to discussing cardiac rehab for patients at 40% - 35% EF range is a common concern. Wymer shared that UMH Sparrow-Clinton addressed this by encouraging clinicians to urge patients who fall within the 35 – 40% EF range to begin participating in CR before their condition deteriorates further. MVC members can raise awareness by following and reposting BMC2 and MVC on LinkedIn.