05 Aug 2026
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MVC July Workgroups Highlight Sepsis Discharge Planning in CAHs and MVC’s Follow-Up Push Report

MVC July Workgroups Highlight Sepsis Discharge Planning in CAHs and MVC’s Follow-Up Push Report

August 5, 2026 | 0 Comments | , , , , , , ,

In July, the Michigan Value Collaborative (MVC) hosted two virtual workgroup presentations. The first, a rural health workgroup focused on MyMichigan Health’s system-wide sepsis discharge planning follow-up initiative implementation at critical access hospital (CAH) sites. The second, a post-discharge follow-up workgroup, provided a walk-through of MVC’s recent Follow-Up push report including recommendations on practical applications of the report to identify opportunities for improvement. The MVC Coordinating Center hosts workgroup presentations once or twice per month, covering a variety of topics including cardiac rehab, post-discharge follow-up, sepsis, rural health, preoperative testing, and health in action.

Rural Health Workgroup: MyMichigan

During MVC’s first workgroup of July, Stephanie Pins-Schallip, MSA, CPHQ, Director of Value Based Care for MyMichigan Health System, shared how their health system developed and implemented a standardized post-discharge follow-up process for patients hospitalized for sepsis. Recognizing the lasting physical and cognitive effects many sepsis patients experience after discharge, Pins-Schallip explained how this initiative was designed to target care transitions, reinforce discharge education, and connect patients with appropriate follow-up care across all MyMichigan Health hospitals. Pins-Schallip also explained how this initiative aimed to drive at both MVC and Michigan Hospital Medicine Safety Consortium (HMS) goals and found ways to benefit sites within the system not engaged with these CQI incentive programs.

Rather than developing separate workflows at each hospital, MyMichigan Health pursued a standardized, system-wide approach. This allowed hospitals of varying sizes, including rural and critical access facilities, to implement consistent practices while also leveraging shared resources. The first step of the initiative was identifying a reliable phone number to provide on discharge paperwork that would connect patients to “on call” Hospitalist providers. By utilizing the health system’s existing 24/7 Transfer Center phone number and nurses already staffing this communication center hub, this minimized the need for additional personnel while also providing patients with a reliable point of contact after leaving the hospital.

Figure 1. Process for 24/7 Transfer Center Calls

A text-based process list outlining steps for patient follow-up after sepsis diagnosis, including discharge, post-discharge questions, 24/7 bed placement call, messaging to hospitalist, and hospitalist follow-up. The list is presented with a MyMichigan Health University of Michigan Health footer in blue and yellow colors.

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.

MVC Rural Health Workgroup: July 14, 2026

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.

Figure 2. MVC Follow-Up Push Report Details

Report details slide presents data parameters for a 30-day inpatient episode analysis covering four MVC conditions: CHF, COPD, Pneumonia, and Sepsis, with payer data date ranges for BCBSM PPO, MA, BCN HMO, BCN HMO MA, Medicare FFS, and Medicaid. Outcome measures include follow-up rates at 3, 7, and 14 days post-index, excluding visits after readmission, inpatient procedures, emergency visits, skilled nursing admissions, or inpatient rehabilitation..

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.

Figure 3. Screenshot of Follow-Up Intervention Interactive Discussion

Diagram of five color-coded sticky notes outlining steps to improve post-discharge patient care, including scheduling follow-ups, outreach workflows, discharge planning barriers, clinic coordination, and data analysis. Each note features check marks and symbols in various colors, highlighting high interest and key focus areas for high-risk patients and priority conditions.

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.

MVC Post-Discharge Follow-Up Workgroup: July 23, 2026

For MVC members seeking additional support related to claims data, please reach out to us by email. MVC welcomes workgroup presenters from across Michigan to share their expertise, success stories, initiatives, and solution-focused ideas with MVC members. If you are interested in being a workgroup presenter please submit a presentation proposal here.

20 May 2026
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Key Takeaways from MiCR’s First Telehealth Cardiac Rehab Forum

Key Takeaways from MiCR’s First Telehealth Cardiac Rehab Forum

May 20, 2026 | Comments Closed | , , , , , ,

Since 2019, the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2) and the Michigan Value Collaborative (MVC) have worked together to improve cardiac rehabilitation utilization in Michigan. This collaboration led to the founding of the Michigan Cardiac Rehabilitation network (MiCR) in 2022, a partnership that endeavors to increase participation in cardiac rehab for all eligible individuals in Michigan through clinical practice sharing, networking, data benchmarking, and the dissemination of resources.

On April 17, MiCR invited practitioners from across Michigan to discuss the evolving role of virtual and hybrid cardiac rehabilitation programming amidst recent legislative wins. In February, Congress advanced the Consolidated Appropriations Act, 2026 (H.R. 7148), which extends Medicare telehealth and in-home cardiopulmonary rehabilitation flexibilities through December 31, 2027. With this extension, cardiac, intensive cardiac, and pulmonary rehab programs in both hospital outpatient and physician office settings can continue delivering services virtually using two-way audio and video technology through the end of 2027. This two-year window gives programs the opportunity to launch or expand hybrid rehab models, try new approaches to reach patients who have difficulty attending in-person sessions, and plan with greater confidence while longer-term policy solutions are explored.

MiCR kicked off the forum emphasizing its mission and the progress made to date in statewide enrollment, with participation rates for eligible cardiac patients across the collaborative increasing from 24% in 2020 to 35% in 2024. Despite progress being made, the state is still short of the MiCR goal of 40% enrollment within 90 days of discharge from eligible procedures (Figure 1), as well as the Million Hearts goal of 70% enrollment.

Figure 1. Trends in cardiac rehab enrollment within 90 days of discharge from AMI, CABG, PCI, SAVR, or TAVR encounter

Line graph showing yearly trends in cardiac rehab participation within 90 days of discharge from various cardiac procedures between 2020 and 2024. The graph compares actual MVC participation rates, increasing from 24% in 2020 to 35% in 2024, against a constant MiCR goal of 40%, highlighting a gradual upward trend.

MiCR conducted a short survey in 2025 about telehealth programming in cardiac rehab to better understand opportunities to close the enrollment gap using telehealth, and how leaders and care teams feel about offering telehealth options. Of the 27 cardiac rehab sites that responded, only two were currently offering some form of virtual cardiac rehab, while some others expressed interest in launching or further investigating virtual service options.

Defining Cardiac Rehab Delivery Models

Prior to initiating a discussion, MiCR reviewed several key definitions to clarify terminology surrounding evolving cardiac rehab delivery models:

  • Traditional in-center delivery: synchronous, in-person care
  • Virtual delivery: synchronous, real-time, audio-visual communication
  • Remote delivery: asynchronous communication between patients and providers
  • Hybrid delivery: use of more than one of the methods noted above.

The forum focused primarily on virtual and hybrid delivery approaches given insurance reimbursement stipulations. MiCR emphasized how hybrid models may offer optimal opportunities for organizations to balance flexibility, patient engagement, and clinical oversight.

Health Systems Share Real-World Virtual Cardiac Rehab Experiences

The forum next featured presentations from two Michigan hospitals currently offering virtual or hybrid cardiac rehab programming.

Henry Ford Health

Steven Keteyian, PhD, Bioscientific Clinical Staff in the Division of Cardiovascular Medicine, and Kat Steenson, MS, Clinical Exercise Physiologist, shared insights into Henry Ford Health’s hybrid cardiac rehab model, including their group virtual session structure.

Dr. Keteyian spoke to the importance of designing a virtual program as similar to current in-center facility programming as possible – including using the same forms, outcome measures, even times that the classes are offered. He noted that this simple mindset may help to streamline implementation and workflows. Additionally, Dr. Keteyian encouraged programs considering virtual care to engage physician champions and optimize internal billing support when getting started.

Steenson discussed her experience delivering both traditional in-center and virtual cardiac rehab care and highlighted the important opportunity virtual delivery offers to extend services to patients facing transportation, scheduling, or geographic barriers. She also encouraged sites to develop virtual programming in line with current in-person practices, noting that this makes it easier on the staff ultimately delivering the services.

Michigan Medicine

Next, Samantha Fink, Administrative Manager of Domino’s Farms Cardiology, and Diane Perry, MS, ACSM-CCEP, CHWC, Certified Clinical Exercise Physiologist, outlined Michigan Medicine’s participation in a research pilot for virtual cardiac rehab delivery over the last two years.

Fink highlighted the importance of combining operational planning, process improvement, and patient accessibility initiatives when initially building virtual programs. She noted that while their patients expressed significant interest in virtual options, not all were set up for success—lacking reliable technology, exercise equipment, or appropriate health screenings prior to starting virtual cardiac rehab. Fink also encouraged sites to establish clear emergency protocols and steps for assessing the appropriateness of virtual care.

Perry then shared her perspective as an exercise physiologist on adapting patient support, exercise guidance, and engagement strategies for the virtual environment. She also endorsed a hybrid program, and she spoke in more detail about the importance of in-person initial assessments to confirm the appropriateness of virtual cardiac rehab.

Telehealth as a Tool to Improve Access

After introducing example programs, MiCR Co-Directors Jessica Golbus, MD, MS, and Michael Thompson, PhD, MPH, facilitated a panel discussion on future implementation opportunities, reimbursement considerations, and collaborative learning across Michigan programs.

Throughout the discussion, the panelists repeatedly emphasized that virtual cardiac rehab is not intended to replace traditional in-center rehab but rather enhance access and reduce long-standing barriers to participation. The panelists pointed out that virtual and hybrid approaches may help programs better serve patients with access barriers, such as rural patients, individuals with transportation limitations, working adults, caregivers, and patients with scheduling challenges. Discussion also reinforced that flexibility in care delivery models may improve patient adherence and completion rates. Lastly, the panelists underscored that successful digital transformation in healthcare is less about chasing trends and more about building practical, individualized programs that improve visibility, efficiency, and accessibility.

The webinar concluded with a call for continued innovation and collaboration as health systems explore new ways to improve cardiac rehab participation. With the extension of federal telehealth flexibilities through the end of 2027, presenters encouraged hospitals to consider this time as an opportunity to pilot, expand, and evaluate virtual cardiac rehab programs. For those interested in learning more about virtual cardiac rehab, the following resources may assist your organization’s journey:

Additionally, you can reference the recording of this forum via YouTube.

MiCR will host a second virtual forum discussion on Tues., June 9, from 12-1 p.m. featuring a demonstration of Henry Ford Health’s group virtual cardiac rehab programming. Registration is available now.

28 Apr 2026
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MVC Push Report Benchmarks Follow-Up Rates for CHF, COPD, Pneumonia, and Sepsis Patients

MVC Push Report Benchmarks Follow-Up Rates for CHF, COPD, Pneumonia, and Sepsis Patients

April 28, 2026 | Comments Closed | , , ,

The Michigan Value Collaborative (MVC) distributed hospital-level follow-up push reports recently intended to support the evaluation of long-term trends as well as the identification of gaps in follow-up care across differing patient demographics. This report focused on follow-up care after hospitalization for congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), pneumonia, and sepsis—four of MVC’s value metrics for Program Years 2026-2027 of the MVC Component of the BCBSM Pay-for-Performance (P4P) Program.

While MVC also provides reporting on its P4P value metrics via scorecards and registry reports, this push report provided additional data on follow-up care at member hospitals by showcasing variability across a longer analytic timeframe and more detailed stratifications for its 30-day CHF, COPD, pneumonia, and sepsis episodes. MVC defined follow-up as episodes where a patient had an outpatient follow-up visit (in person or by telehealth) within 30 days or before a readmission, inpatient procedure, emergency department visit, skilled nursing facility admission, or visit for inpatient rehabilitation.

Contained in each hospital’s report was a page dedicated to follow-up following hospitalizations for each condition. On those report pages, MVC hospitals received comparisons to their peers on outpatient follow-up rates and 30-day risk-adjusted total episode payments, as well as their hospital’s outpatient follow-up rates stratified by payer.

The report also featured a patient population snapshot table that highlighted demographic data for patients in each condition cohort. These tables (see Figure 1) provided each hospital with information on race, mean age, common comorbidities, and several indicators of non-medical drivers of health.

Figure 1. Sociodemographic Overview of Patients Receiving Follow-Up Following Discharge for CHF, COPD, Pneumonia, or Sepsis at Hospital A

Table presenting sociodemographic overview of follow-up conditions at Hospital A, including CHF, COPD, pneumonia, and sepsis. It details age groups, race/ethnicity percentages, common comorbidities, and socioeconomic indicators such as diabetes prevalence and living conditions, with data organized in rows and columns for comparison across conditions.

*Patient zip codes categorized as prosperous, comfortable, mid-tier, at-risk, or distressed according to the Economic Innovation Group's Distressed Communities Index 2018-2022, which incorporates economic indicators such as education, employment, and income.

Each figure reflected index admissions between 1/1/2023-12/31/2024 in BCBSM PPO Commercial, BCBSM PPO Medicare Advantage, BCN HMO Commercial, BCN HMO Medicare Advantage, and Medicare Fee-for-Service claims, and between 1/1/2023-9/30/2024 in Michigan Medicaid claims. Individuals insured by both Medicare and Medicaid were categorized as dual-eligible in the payer-specific figures. Hospital reports included pages for each condition if they met the threshold of at least 11 qualifying episodes in each year of data for that condition.

There was wide variation in follow-up rates across the collaborative for all four conditions, with some member follow-up rates averaging less than 20% to greater than 60% among CHF, COPD, and pneumonia patients, and between less than 30% to greater than 70% among sepsis patients.

Among general acute care hospitals, there were consistent decreases in average follow-up rates across the collaborative compared to previous reporting; MVC provided reporting on these same follow-up measures in a Q1 2025 push report based on 2022-2023 claims. Using the updated 2023-2024 timeframe, the collaborative-wide average 14-day follow-up rate for patients hospitalized for COPD fell from 55.3% to 51%. A similar trend was observed for seven-day follow-up after CHF (decreased from 44.8% to 43.1%), seven-day follow-up after pneumonia (decreased from 42.7% to 41.6%), and 14-day follow-up after sepsis (decreased from 58% to 52.5%). Follow-up rates were often lowest among the Medicaid and dual-eligible patient populations (Figure 2), and are therefore a patient group that likely needs additional support and outreach. Additionally, across all four conditions the average risk-adjusted price-standardized total episode payment at general acute care hospitals was higher among patients who did not receive follow-up than among patients who received follow-up care (see COPD example in Figure 3).

Figure 2. 3-Day, 7-Day, and 14-Day Follow-Up Rate Among Patients Hospitalized for Sepsis by Payer for Hospital A

Bar chart comparing follow-up rates across five insurance categories with three time intervals: 3-day, 7-day, and 14-day follow-ups, represented by blue, gray, and orange bars respectively. Notable trends include consistently higher follow-up rates at 14 days, with Commercial insurance showing the highest rates.

Figure 3. Average 30-Day Risk-Adjusted, Price-Standardized Total Episode Payment Among Patients Hospitalized for COPD by 14-Day Follow-Up Status for Hospital A

Bar chart comparing 30-day total episode payments for 14-day and no 14-day follow-up periods across three categories: Your Hospital (blue), Your Region (gray), and GACH Average (orange). No 14-day follow-up shows higher payments overall.

MVC member hospitals who classify as Critical Access Hospitals (CAHs) received alternate versions of the report, which used the averages of other CAHs as their comparison group in addition to MVC region. Similar to general acute care hospitals, the collaborative observed decreases in average follow-up rates among its CAH members for patients hospitalized for CHF (decrease from 39% to 38.2%), pneumonia (37.4% to 32.5%), and sepsis (44.7% to 43.9%). Among patients hospitalized for COPD at a CAH, however, there was an observed increase in the average 14-day follow-up rate from 44.9% to 47.2%. CAHs also observed similar trends of lower follow-up rates among Medicaid and dual-eligible patients.

Members can similarly benchmark the values and data provided in their recent report pages to the previously distributed follow-up push report from Q1 2025.

In addition to providing data on follow-up care, the MVC Coordinating Center offers a regular post-discharge follow-up workgroup series where members and partners share strategies and insights to help improve follow-up performance. The next workgroup will take place on Thurs., July 23, from 12-1 p.m. More information about upcoming MVC events can be found on the MVC events page.

If you have any suggestions on how these reports can be improved or have additional data requests to help support your quality improvement projects, please reach out to the MVC Coordinating Center.

04 Mar 2026
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February Workgroup Highlights Increasing Cardiac Rehabilitation Utilization with a Member Panel and MVC Data

February Workgroup Highlights Increasing Cardiac Rehabilitation Utilization with a Member Panel and MVC Data

March 4, 2026 | Comments Closed | , , , , , ,

In February, the Michigan Value Collaborative (MVC) hosted a virtual cardiac rehabilitation workgroup presentation featuring a panel of cardiac care specialists. The panel focused on discussing chronic heart failure metrics related to the pay for performance (P4P) program and how cardiac rehabilitation (CR) can play a vital part in the recovery process for congestive heart failure (CHF) patients. The MVC Coordinating Center hosts workgroup presentations once or twice per month, covering a variety of topics including post-discharge follow-up, sepsis, cardiac rehabilitation, rural health, preoperative testing, and health in action.

Cardiac Rehabilitation Workgroup – MVC and Member Panel 

For this workgroup MVC was joined by panelists Tyelor Wymer, CEP, BS, Cardiology Supervisor at University of Michigan Health (UMH) Sparrow-Clinton; Laura Meiste, RN, BSN, Manager of Cardiac and Pulmonary Rehabilitation at Holland Hospital; Zach Johnson, BS, ACSM-CEP, Lead Exercise Physiologist for Cardiac and Pulmonary Rehabilitation Programs at Corewell Health; Greg Scharf, BS, CEP, CCRP, Cardiopulmonary Rehabilitation System Manager at MyMichigan Health; and Mike Thompson, PhD, MPH, Associate Professor of Cardiac Surgery at Michigan Medicine

CHF Goals and Metrics

MVC’s Site Engagement Coordinator Emily Bair, MS, MPH, RDN, CSP, began the workgroup by reviewing CHF P4P metrics for program years 2026 – 2027, which is part of MVC’s Cardiac Rehabilitation Value-Based Initiative. These included an episode spending metric focused on CHF episodes of care and a value metric that tracks the 7-day follow up care for CHF episodes of care. In addition to discussing the P4P CHF metrics, Bair reviewed current CR standards that MVC uses for measuring the CR value-based initiative, including Michigan Cardiac Rehabilitation Network (MiCR) standards and the Million Hearts Campaign CR goal for CHF patients (Figure 1).

Figure 1. MVC, MiCR and Million Hearts CR Goals for CHF Patients

Presentation slide titled "Goals & Metrics" outlining cardiac rehabilitation follow-up and start rate targets. It lists MVC P4P Metrics with a 7-day follow-up after CHF, Michigan Cardiac Rehab Network aiming for 10% of CHF patients to start CR within 365 days, and Million Hearts with ACC and AHA targeting 70% of eligible patients to start CR within 365 days.

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

Figure 2. Example of MVC Registry CR Utilization Rate within 365 Days After Discharge for CHF, Jan. 2024 – Mar. 2025 (MVC All, blinded):

Dotted line graph

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).

Figure 3. MVC Process Measures Report – 7-day follow up after CHF

example of MVC Process Measures Report for 7-Day Follow-Up After CHF content including vertical bar charts and line graphs

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).

Figure 4. CHF Follow-Up and Cardiac Rehabilitation Typical Patient Pathway

Diagram illustrating the typical CHF patient pathway with five key stages: Admission, Discharge, Follow-Up, Cardiac Rehab, and Readmission. Annotations highlight transitions such as patient diagnosis, care shift from inpatient to outpatient, appointment scheduling, referral placement, and follow-up care including rehab and emergency department utilization.

CHF Barriers to Care and Change Concepts

To help organize a solutions-based approach, Bair went on to introduce the Change Concepts Model, 2nd 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, 2nd 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

Figure 5. Million Hearts Change Concepts

Flowchart illustrating four stages of a process: Systems Change, Referrals, Enrollment and Participation, and Adherence.

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.

MVC Cardiac Rehabilitation Workgroup: Feb. 10, 2026

MVC welcomes workgroup presenters from across Michigan to share their expertise, success stories, initiatives, and solution-focused ideas with MVC members. Please email us if you are interested in being a workgroup presenter or submit a presentation proposal online.

25 Feb 2026
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Cardiac Rehabilitation Awareness Week Spotlighted Resources and Tools Improving Cardiac Rehab Enrollment

Cardiac Rehabilitation Awareness Week Spotlighted Resources and Tools Improving Cardiac Rehab Enrollment

February 25, 2026 | Comments Closed | , , , , ,

MVC and BMC2 took to LinkedIn recently to celebrate Cardiac Rehab Awareness Week, spotlighting the importance of cardiac rehabilitation for patients recovering from cardiovascular events. MVC and BMC2 collaborate to lead the Michigan Cardiac Rehab network (MiCR) and its related offerings. Across multiple posts, both teams highlighted stories, tools, collaborations, and insights designed to support providers, patients, and programs working to improve cardiac rehab outcomes in Michigan.

One of the central themes of the week was the voice of the patient. MiCR shared the first completed patient story from a new storytelling initiative called Heart-to-Heart, developed with the Healthy Behavior Optimization for Michigan (HBOM) team. This initiative amplifies real patient experiences, bringing to light why cardiac rehab matters — not just clinically, but personally — for those considering participation. Cardiac rehab week marked the launch of the first available patient story about a patient named Margaret from Covenant Healthcare.

Cardiac Rehab Week also offered opportunities for networking and knowledge exchange. MVC hosted a virtual cardiac rehab workgroup [view video] focused on optimizing congestive heart failure (CHF) follow-up and increasing rehab enrollment in this especially vulnerable patient population. Featuring panelists from Corewell Health, Holland Hospital, Michigan Medicine, MyMichigan Health, and University of Michigan Health-Sparrow, this session highlighted real-world strategies and insights for improving care transitions and referral practices.

Throughout the week, both organizations also shared posts featuring practical tools to strengthen cardiac rehab engagement, such as:

  • NewBeat Resources: BMC2 highlighted NewBeat materials — engaging, evidence-based education and referral tools designed to help care teams talk with patients about the benefits of cardiac rehab and support meaningful discussions that lead to enrollment (Figure 1). A new round of no-cost printing for MiCR sites was announced, offering flexible, ready-to-use materials that programs can request.
  • Cardiac Rehab Center Finder: Knowing “where to go” is a crucial earliest step. MVC and BMC2 reinforced the MichiganCR.org searchable directory that allows patients and providers to locate nearby rehab programs. This simple tool reduces a key barrier to engagement by connecting patients with access points across Michigan.
  • Resource Library Spotlight: The MiCR Resource Library was featured as a one-stop hub for tools — from evidence-based products to collaborative resources developed with partners throughout the state — supporting both providers and patients as they plan, refer, and participate in cardiac rehab sessions.

Figure 1. Cardiac Rehab Resource Materials

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Recognizing the evolving landscape of cardiac rehabilitation delivery, MiCR also took the opportunity to highlight its newest strategic efforts throughout cardiac rehab week, including its explorations into the role of telehealth in cardiac rehab as well as medication management opportunities. Updates on these efforts and more were summarized and linked in a summary blog to the MiCR website. To learn more, read the MiCR summary.

As the week wrapped, the MiCR teams thanked everyone for their role in advancing cardiac rehab throughout Michigan, and invited their active participation going forward—either by trying a MiCR tool in their daily work or sharing their experiences and stories. As MiCR continues its work, the momentum from this week sets the stage for meaningful improvement in patient outcomes and program engagement statewide.

03 Dec 2025
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November Workgroups Highlight Mobile Health and Patient Storytelling

November Workgroups Highlight Mobile Health and Patient Storytelling

December 3, 2025 | Comments Closed | , , , , , , , , , , ,

In November, MVC hosted two virtual workgroup presentations – the first, a rural health workgroup, featured Hillsdale Hospital’s mobile health unit initiative. The second, a post-discharge follow-up workgroup, continued a presentation started at MVC’s February 2025 health in action workgroup on patient journey mapping and introduced a joint patient storytelling project by Healthy Behavior Optimization for Michigan (HBOM) and Michigan Cardiac Rehab Network (MiCR). The MVC Coordinating Center hosts workgroup presentations twice per month covering a variety of topics including post-discharge follow-up, sepsis, cardiac rehab, rural health, preoperative testing and health in action.

Rural Health Workgroup – Hillsdale Hospital 

The first workgroup of the month provided a review of Hillsdale Hospital’s mobile health unit, which aims to deliver essential health services to patients living in rural communities who may otherwise struggle physically or financially to reach traditional care settings.

As Lindsey Crouch, Director of Outpatient Clinics, Home Care, and Durable Medical Equipment for Hillsdale Hospital explained, rural communities face higher health outcome variation, transportation issues, limited accessibility to primary care providers, and high unnecessary emergency department (ED) utilization (Figure 1).

Figure 1. Hillsdale County Community Health Needs Assessment (CHNA) Survey Data: Difficulty Finding or Getting Transportation to a Doctor in 2024, 2022, 2019, and 2016

vertical bar graph: Hillsdale County Community Health Needs Assessment (CHNA) Survey Data: Difficulty Finding or Getting Transportation to a Doctor in 2024, 2022, 2019, and 2016

During the Covid-19 pandemic, Hillsdale County’s health department purchased a mobile health unit in an effort to close the gap in healthcare access for their community. However, despite continued need, utilization of the mobile unit has waned in recent years.

Hillsdale Hospital aimed to revitalize the mobile health unit to:

  1. Bridge access gaps in rural areas. For many rural residents, distance to hospitals or clinics, limited transportation, and infrastructure challenges can hinder timely access to care. A mobile health unit can bring services to patients rather than requiring patients to travel long distances. This helps to reduce one significant non-medical barrier to care.
  2. Focus on preventive and ongoing care. The mobile unit’s design supports not just acute care, but preventive services — screenings, check-ups, chronic disease management — especially helpful for rural populations that may have higher chronic disease burden and less frequent access to routine care.
  3. Address gaps in health outcomes between communities. By delivering care directly to underserved communities, this model aligns with broader efforts to ensure that where a person lives does not determine whether they receive high-value, quality healthcare.

Throughout this program, Hillsdale Hospital aimed to improve health outcome variation with a goal to achieve a 15% improvement in selected chronic disease metrics (e.g., blood pressure control) while also establishing partnerships with local organizations for sustainability.

Throughout the presentation and follow-up discussion, participants addressed several key considerations related to implementing and operating the mobile health unit including:

  • Logistical planning & scheduling. Which rural towns or areas will be served? How often do visits occur? How to communicate the schedule to residents to maximize utilization?
  • Service offerings. What mix of services beyond basic triage should be included? Considerations may include screenings, chronic disease management, preventive care, and referrals when needed to ensure the mobile unit meaningfully supplements local rural healthcare capacity.
  • Coordination with local providers. What existing local hospitals, clinics, and community health organizations should be involved to ensure continuity of care? Consider these, especially follow-up and referrals, for more advanced services.
  • Addressing rural-specific challenges. What unique barriers impact your community? Consider transportation, limited staffing, and supply chain constraints.

Hillsdale Hospital’s mobile health unit embodies a vision for bringing high-value, high-quality care to rural Michigan. By lowering access barriers and delivering preventive and ongoing services directly to patients in their communities, this initiative can help improve health outcomes, reduce reliance on emergency services, and foster trust in healthcare among rural residents.

Insights from this workgroup have several practical implications for other rural hospitals and provider organizations across Michigan:

  • Expansion is possible through mobile care. Rural hospitals can leverage mobile health units as an extension of their current clinical outreach, helping to connect with populations that may rarely visit brick-and-mortar facilities.
  • Support chronic disease management. By delivery of routine care and screenings, mobile units can help stabilize chronic conditions earlier, reducing acute exacerbations and potentially reducing avoidable ED visits.
  • Enhance care coordination. Partnering with mobile health teams and community resources can help coordinate follow-up appointments, testing, and specialty referrals to create a more continuous care experience for rural patients.
  • Advance population health goals. Mobile services can function as a tool within a hospital’s broader population health strategy, align with value-based initiatives, community health needs assessments, and provide the opportunity for all people to achieve optimal health goals.
  • Gather meaningful community insights. Regular presence in rural communities can help hospitals better understand local barriers, non-medical drivers of health, and other care gaps which may inform program planning, grant proposals, and collaborative partnerships.

MVC Rural Health Workgroup: Nov. 4, 2025

Post-Discharge Follow-Up Workgroup – MVC and HBOM

The second MVC workgroup of November featured a joint presentation by MVC’s Associate Program Manager, Jana Stewart, MPH and HBOM’s Informatics Design Lead, Noa Kim, MSI. The workgroup kicked off with an overview of the rationale behind placing a greater emphasis on post-discharge follow-up – particularly how timely and effective follow-up care can reduce readmissions, improve patient outcomes, and ease transitions from inpatient to outpatient or home settings.

Next, as a continuation of the February 2025  health in action workgroup presentation on patient journey mapping, Stewart showed how mapping can be used to highlight key moments in a coronary heart failure (CHF) patient’s journey where there may be opportunities for post-discharge care coordination improvement – e.g., medication reconciliation, patient knowledge, frequent rehospitalization, low follow-up rates, and lack of social and community support.

An important strategy for combating these challenges for CHF patients is engagement in cardiac rehabilitation. And yet, patients rarely optimize this opportunity. Patient storytelling can help patients recall details, model scenarios a patient may experience in the future, and reduce the burden of information provided during a visit and may be a strategy to optimize cardiac rehab enrollment.

Under the umbrella of Michigan Cardiac Rehab (MiCR), a collaboration between the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2), MVC, and HBOM, several initiatives have been developed aimed at optimizing guideline-directed medical therapy including the development of NewBeat materials and now the Heart-to-Heart storytelling campaign (Figure 2).

Figure 2. Examples of MiCR Guideline-Directed Medical Therapy Campaigns

NewBeat materials and the Heart-to-Heart storytelling campaign

As Kim explained, the goals of the Heart-to-Heart project are to collect diverse first-person accounts of cardiac rehab in video, audio, and photo formats from patients and clinicians from across Michigan to produce a compelling, free, reusable story library for use by cardiac rehab advocates across Michigan and beyond.

For hospitals and health systems across Michigan seeking to improve post-discharge outcomes, insights from this workgroup offer the following next steps:

  1. Use journey mapping and storytelling in quality improvement. By mapping patient journeys and capturing patient experiences, providers can better identify and address systemic barriers to safe discharge and recovery.
  2. Adopt standardized discharge-to-follow-up workflows. Hospitals should ensure that discharge planning includes scheduling follow-up appointments, medication reconciliation, and clear communication of next steps before patients leave the hospital.
  3. Prioritize high-risk patients for post-discharge support. Patients with chronic illness, limited social support, or social determinants that might hinder recovery deserve extra attention during discharge planning and follow-up scheduling.
  4. Assign care coordinators or navigators. Especially for high-risk or complex patients, dedicated staff to oversee follow-up care – manage appointments, support communication, track adherence, and offer resources – may reduce readmissions and improve outcomes.
  5. Leverage post-discharge care as part of value-based care strategy. Effective follow-up after discharge supports long-term patient health, reduces avoidable costs, and aligns with goals of high-value care frameworks.

MVC Post-Discharge Follow-Up Workgroup: Nov. 20, 2025

If you are interested in pursuing a healthcare quality improvement project, MVC has data specialists available to help you navigate our data resources and create custom analytics reports to support your efforts. Please reach out to us by email [LINK] if you would like to learn more about MVC data or engagement offerings!

05 Mar 2025
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February Workgroups Highlight Hybrid Cardiac Rehab Delivery and Patient Journey Mapping

February Workgroups Highlight Hybrid Cardiac Rehab Delivery and Patient Journey Mapping

March 5, 2025 | Comments Closed | , , , ,

In February, MVC hosted two virtual workgroup presentations – the first focused on hybrid cardiac rehab program delivery and the second a health in action session focused on patient journey mapping. The MVC Coordinating Center hosts workgroup presentations twice per month with topics rotating between post-discharge follow-up, sepsis, cardiac rehabilitation, rural health, preoperative testing, and heath in action (ad hoc focused topics). Each month, the MVC Coordinating Center publishes key highlights from the past month’s presentations to support practice sharing across the state.

Cardiac Rehab Workgroup February 11, 2025

MVC’s first cardiac rehab workgroup of 2025 featured a presentation by Dr. Steven Keteyian, PhD, Director of Cardiac Rehabilitation/Preventive Cardiology at Henry Ford Health System. The presentation focused on the development and implementation of a non-traditional hybrid model of care delivery.

During the COVID-19 pandemic many healthcare facilities had to transition to virtual platforms to continue providing essential medical care to patients. Henry Ford Health’s cardiac rehabilitation programs, like many other services, pivoted to meet the needs of patients by establishing an evidence-based hybrid delivery model.

Dr. Keteyian emphasized that cardiac rehabilitation is more than just physical exercise. It is a comprehensive health improvement plan containing several core components (Figure 1) such as nutritional counseling, psychosocial management, weight management and body composition, tobacco cessation counseling, and more. All of these components are combined to establish an individualized treatment plan for the patient.

Figure 1. AACVPR/AHA Cardiac Rehab Performance Measures

seven AACVPR/AHA Cardiac Rehab Performance Measures

Dr. Keteyian explained that their patients begin their program in-person to establish baseline assessments and a treatment plan. Once established, cardiac rehab patients have the option to participate virtually for remaining sessions or return on-site depending on their preferences and the need to assess them in-person. Dr. Keteyian noted several factors that drive the use of hybrid cardiac rehab such as patient needs (returning to work, family care responsibilities, travel distance/transportation limitations), limited resources within the health system for a fully on-site program, and limited patient availability during the on-site hours of operation.

To be eligible for participation in cardiac rehabilitation, patients need to have a qualifying event such as acute coronary syndrome (ACS), heart valve repair/replacement (TAVR), cardiac transplant, or stable heart failure (with less than 35% ejection fraction). Henry Ford uses MVC data to track the percent of eligible patients enrolled in cardiac rehab within 90 days, and compares rates across different qualifying events (e.g., AMI, CHF, TAVR, etc.) to see where cardiac rehab is being underutilized compared to averages for the state and Centers for Medicare & Medicaid Services (CMS). The Henry Ford team began incorporating virtual cardiac rehab delivery as a strategy to increase enrollment and attendance among eligible patients.

Dr. Keteyian also discussed some common questions and concerns he hears when discussing hybrid program delivery, such as needed equipment, patient safety, and program efficacy. He shared information from the iAttend randomized control trial that Henry Ford Health participated in from 2019 – 2024, which tracked cardiac patient demographic data, eligibility, participation, and outcomes for hybrid and facility-based cardiac rehab programming (Keteyian, 2024). Data showed that none of the hybrid participants were required to go on-site due to clinical concerns, no virtual visits required physician intervention, and there were no mechanical falls requiring medical attention indicated in either group. A second randomized trial, HF-ACTION, tracked 2,331 heart failure (HFrEF) patients and found that hospitalizations during or within 3 hours after exercise occurred for 2% of the hybrid participants versus 3% for on-site patients. The mortality rate for patients in both study groups was very low (approximately 0.4%) indicating safety was not an issue. Though the data did show hybrid patients not progressing as quickly through the program as on-site patients, this lag became a teaching moment for cardiac rehab staff and an opportunity for improvement.

Attendance for both programs was comparable, and patient outcomes were statistically similar with patients showing improvement in desired performance measures such as peak oxygen uptake, exercise duration, and walking distance (Keteyian, 2024). Staff burden as a result of running a hybrid program was a key concern. To mitigate the potential for burnout, Henry Ford Health aligned services and materials with how the on-site cardiac rehab program is managed.

Dr. Keteyian closed by pointing out that the number of patients who qualify for cardiac rehabilitation each year outnumbers the available spaces in on-site programs throughout the United States. Even if these programs were running at full capacity, only ~ 50% of the eligible patients could be seen. He argued, therefore, that there is a significant need to increase the number of best-practice cardiac rehabilitation programs and the methods available to patients to access them (Balady, 2011).

MVC Cardiac Rehab Workgroup Feb. 11, 2025

Health in Action Workgroup February 27, 2025

MVC’s health in action workgroup this month included a presentation and workshop on patient journey mapping with MVC’s Associate Program Manager Jana Stewart, MS, MPH. This workshop was a continuation from the October 2024 collaborative-wide meeting’s post-discharge follow-up breakout session. Following the fall workshop, MVC collated member feedback on common barriers to follow-up for heart failure patients, which Stewart summarized as part of the February workgroup presentation. Participants of the workgroup also engaged in polls and two guided breakout discussions aimed at improving outcomes for patients with congestive heart failure.

Using Patient Journey Mapping to Improve Patient Outcomes

Stewart explained that the purpose of patient journey mapping is to understand the patient’s experience and pain points as they manage their health. This practice looks at service delivery by providers as well as the patients’ steps beyond healthcare appointments, providing useful data for root cause analyses and developing effective interventions. Stewart shared examples of patient journey maps that described what a patient might do, think, and feel as they seek healthcare services as well as maps illustrating a hospital’s workflow for enrolling eligible cardiac rehab patients. By generating maps from both the patient and provider perspective, one can identify opportunities for efficiencies and necessary interventions points.

Figure 2. Sample Patient Journey Map for Enrollment in Cardiac Rehab Following a Heart Procedure

Sample Patient Journey Map for Enrollment in Cardiac Rehab Following a Heart Procedure

In the first of two breakout sessions, attendees provided feedback and edits on a patient journey map for cardiac rehab enrollment following heart surgery. Attendees reimagined how the patient experience and hospital steps might change for a heart failure patient. Some interventions that were discussed included staff reviewing discharge lists frequently to keep track of patients, having a nurse navigator to help patients prepare for cardiac rehab, and keeping a consistent treatment plan between inpatient and outpatient providers.

Patient Experience – Key Barriers That Impact Patients

Stewart also outlined some key considerations regarding a patient’s experience and some of the barriers that may impact their ability to manage their health. One key barrier discussed was the limitations of our brain's processing capacity and the ways in which mental fatigue make it harder to remember and cope with information. Famed environmental psychologist George Miller once posited that a typical person is able to process and store to memory 5 – 9 pieces of information at a time. When a person is mentally fatigued (e.g., sleep deprived, burned out, cognitively burdened), their ability to understand and store information decreases.

Stewart cited a research study on patient recall after specialty care visits (Laws et al, 2018), which found only half of patients remembered the recommendations they received from a provider, and only about half of what they remembered was recalled correctly. This can have a significant impact on how well a patient follows their treatment plan after they are discharged or sent home. These recall difficulties are further exacerbated in patients with more extensive mental fatigue, such as those experiencing minority stress, unmet social needs, older age, lower health literacy, and other factors. Stewart argued that a patient’s current mental capacity and literacy are key considerations when journey mapping, as they are often the culprit for not following treatment plans.

One strategy Stewart shared that can reduce cognitive burden is the use of storytelling. Used as a framework for delivering information, stories allow patients to better understand and remember details. This can be done through patient story videos as well as case studies that demonstrate the progression of an illness or treatment plan. During one of the breakout discussions, participants brainstormed how they might use storytelling to communicate information to CHF patients. Ideas included establishing private community groups on social media for patients to share their stories, patient story pamphlets, and videos to play on hospital televisions or linked in patient discharge materials.

The feedback and ideas generated by participants during February's health in action workgroup will be used to draft resources for MVC member sites. MVC plans to bring those draft materials to future meetings or workgroups to gather feedback prior to dissemination. Participants also received a copy of the patient journey mapping template so they can utilize this approach at their site(s).

MVC Health in Action Workgroup Feb. 27, 2025

If you are interested in pursuing a healthcare improvement initiative, MVC has a robust registry of claims data that can be utilized as well as site specialists who can help facilitate connections with peers doing similar work. Please reach out to us here if you would like to learn more about MVC data or engagement offerings.

11 Sep 2024
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MVC Publishes its 2024 QECP Annual Report as a Qualified Entity

MVC Publishes its 2024 QECP Annual Report as a Qualified Entity

September 11, 2024 | Comments Closed | , , , ,

Recently, the MVC Coordinating Center published its annual Qualified Entity Certification Program (QECP) public report for 2024. This report [PDF] was published in a new QECP section on the MVC website’s Data/Registry page and is an annual requirement for MVC as a qualified entity with the Centers for Medicare & Medicaid Services (CMS). This was MVC’s third public QECP report and continued to provide unidentified aggregated data about Michigan hospital performance on two measures: rates of 30-day rehospitalizations following start of home health care, and rates of outpatient follow-up received after hospitalization for congestive heart failure (CHF) or chronic obstructive pulmonary disease (COPD).

All measures in the report were created using data from MVC claims-based episodes of care initialized by inpatient hospitalizations or surgeries between Jan. 1, 2018 and Dec. 31, 2022. Claims were incorporated from all MVC payer sources, including Medicare Fee-for-Service, Blue Cross Blue Shield of Michigan, Blue Care Network, and Michigan Medicaid.

The reported overall rate of 30-day unplanned rehospitalizations after the start of post-acute home health care among episodes beginning at MVC hospitals in Michigan was 11.6% for 2018-2022. Risk-adjusted rates by index hospital ranged from 2.5% to 17.2%. By home health provider, risk-adjusted rates ranged from 0.0% to 23.5% (Figure 1). Patients whose episode of care began with an index event for endocarditis, COPD, CHF, or percutaneous coronary intervention (PCI) were more likely than patients with other index conditions to experience an unplanned rehospitalization in the 30 days after they started home health care. Patients with a joint replacement episode of care were least likely to have an unplanned rehospitalization following the start of home health care.

Figure 1. Risk-Adjusted Rates of 30-Day Unplanned Rehospitalization from Home Health, by Home Health Provider

Results for the outpatient follow-up metrics remained similar to findings from previous annual reports. Across episodes of care for index events in 2018-2022 at the 106 MVC hospitals in Michigan, the unadjusted rate of patients receiving outpatient follow-up within 7 days after hospitalization for CHF was 44% (Figure 2). Following index hospitalizations for COPD, 36% of patients received outpatient follow-up within 7 days (Figure 3). For both conditions, there was wide variation across hospitals in Michigan in their 7-day follow-up rates after hospitalization, with rates ranging between less than 10% to over 60%. Rates of follow-up were fairly steady over time.

Figure 2. 7-Day Follow-Up After CHF Hospitalization by MVC Hospital

Figure 3. 7-Day Follow-Up After COPD Hospitalization by MVC Hospital

For more information and the entire set of findings we invite you to read the full 2024 report, available here.

QE certification status allows MVC to provide hospital members with additional data from Medicare Fee-for-Service (FFS) claims at a level of granularity which would not otherwise be available under standard CMS data use agreements. Reports located under the “QE Medicare” icon on the MVC registry allow hospital registry users to see unsuppressed Medicare data including case counts <11 as well as utilization rates and average payments based on case counts <11. In addition, on any QE Medicare registry report, members can click on specific data points to load a list of all episodes underlying that data point. From that episode list it is possible to view drilldown information on individual episodes to learn more about the claims and price-standardized payments comprising that episode.

Members may contact the MVC Coordinating Center by emailing Michigan-Value-Collaborative@med.umich.edu to learn more about data available through MVC’s QECP reports and to receive the forms necessary to gain access on the registry.

13 Mar 2024
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Refreshed Hospital-Level, ED-Based Episode Push Reports Coming Soon to Members

Refreshed Hospital-Level, ED-Based Episode Push Reports Coming Soon to Members

March 13, 2024 | Comments Closed | , , , ,

The MVC Coordinating Center will soon distribute refreshed hospital-level versions of its push report utilizing emergency department-based episodes (“ED-based episodes”). MVC generated separate versions for acute care hospitals and Critical Access Hospitals (CAHs) with tailored comparison groups. In addition to reflecting more recent data across all included payers, these refreshed hospital-level reports differ from prior versions due to the addition of three high-volume ED conditions and the incorporation of Michigan Medicaid claims.

Each page of the report is dedicated to a specific condition with the same metrics throughout, such as risk-adjusted, price-standardized 30-day total episode spending, inpatient admission rates, and rates of post-ED utilization. Reports feature each hospital’s own attributed ED-based episode data for eight high-volume ED conditions: abdominal pain, cellulitis, chest pain (nonspecific), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes with long-term complications (including renal, eye, neurological, or circulatory), diabetes with short-term complications (including ketoacidosis, hyperosmolarity, or coma), and urinary tract infection (UTI). The three new conditions included in this year’s refresh include diabetes with long-term complications, diabetes with short-term complications, and UTI.

Among general acute care hospitals receiving a report, the average risk-adjusted, price-standardized 30-day total episode payment (Figure 1) for the reported conditions is highest for diabetes with long-term complications ($20,568), CHF ED-based episodes ($17,245), diabetes with short-term complications ($12,087), and COPD ED-based episodes ($10,289). The collaborative-wide average is lowest for chest pain ($3,111) and abdominal pain ($3,123) ED-based episodes. Within each condition, MVC 30-day total episode payments are consistently higher for episodes in which the patient had a same-day inpatient admission compared to episodes in which the patient did not have an inpatient stay beginning on the date of their ED visit. With that information in mind, hospital members can also use their individualized reports to track their same-day inpatient admission rate at six-month intervals using trend graphs for each included ED-based condition (Figure 2).

Figure 1.

Figure 2.

A key goal for these ED-based episode reports is to provide insight into healthcare utilization following index ED visits. Therefore, reports continue to include a dot plot (Figure 3) comparing patient post-ED utilization at a member hospital against their peer comparison group. Dot plots provide information on what percent of episodes had a same-day inpatient admission, what percent did not have a same-day inpatient admission but did see the patient admitted in the 1 to 30 days following the index ED visit, and the percent of patients who had two or more inpatient admissions (thus, at least one readmission) during the episode of care. Also provided are rates of subsequent ED visits, receipt of outpatient services, home health, skilled nursing facility care, and inpatient or outpatient rehab.

Figure 3.

These ED-based episodes are built using MVC’s most recent medical claims data from Medicare FFS, Blue Cross Blue Shield of Michigan PPO Commercial and Medicare Advantage plans, Blue Care Network HMO Commercial and Medicare Advantage plans, and Michigan Medicaid.

ED-based episodes utilize MVC’s newest episode of care data structure, which was developed last year in collaboration with the Michigan Emergency Department Improvement Collaborative (MEDIC), a BCBSM-funded Collaborative Quality Initiative with the goal of improving care and patient outcomes in Michigan emergency departments. MVC and MEDIC team members worked closely to develop 30-day episodes of care initialized by a patient’s visit to the ED and including all claims-documented care received in the 30 days following a patient’s index ED visit.

Please share your feedback with the MVC team if certain report measures are helpful or if you wish to see additional ED-based episode reporting for certain conditions and metrics. MVC is now also accepting custom report requests using its new ED-based data. Contact MVC to learn more.

12 Oct 2023
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MVC’s Refreshed Common Conditions Report Coming to Hospital Members Soon

MVC’s Refreshed Common Conditions Report Coming to Hospital Members Soon

October 12, 2023 | Comments Closed | , ,

MVC members will receive their next batch of updated push reports in the coming days with a refreshed version of MVC’s common conditions report. These reports provide insight into episodes of care for eight medical and surgical conditions that are commonly a focus for quality improvement efforts at MVC hospitals: acute myocardial infarction (AMI), chronic obstructive pulmonary disease (COPD), colectomy (non-cancer), congestive heart failure (CHF), coronary artery bypass graft (CABG), total knee and hip (joint) replacement, pneumonia, and spine surgery. MVC’s general acute care hospital and Critical Access Hospital (CAH) members will receive tailored versions of the report, with each group receiving benchmark data specific to their own category of hospitals.

Although the metrics provided vary by condition and case count, report pages generally focus on 30-day total episode payments, readmission rates, common reasons for readmissions, and post-acute care utilization. MVC price standardizes total episode payments to Medicare FFS amounts so that comparisons can be made across hospitals and over time. Payments are risk adjusted for patient age, gender, payer, comorbidities, and high or low prior healthcare utilization/payments.

Post-acute care utilization benchmarking for each of the eight medical and surgical conditions includes graphs displaying the percentage of each hospital’s patients who used home health care, inpatient/outpatient rehab, skilled nursing facility care, outpatient services, or emergency department care in the 30 days following their index hospitalization or surgery. Across the collaborative, reports show high use of 30-day home health care and outpatient services for these common conditions. For patients initiating their episode of care at a general acute care hospital within the collaborative, the home health care utilization rate was highest following CABG (69%) and joint replacement (50%).

Patients with a CABG episode were also high utilizers of outpatient services in the 30 days post-index (Figure 1), with a 73% average utilization rate. Patients with episodes for CHF (58%) and AMI (53%) were also high utilizers of outpatient services. Across conditions, use of outpatient services in the 30 days post-index was generally higher among episodes originating at CAHs than among episodes originating at general acute care hospitals.

Figure 1.

Reports also assess the setting of care for joint replacements and spine surgeries. For total knee and hip replacements, MVC data shows that the percent of joint replacements performed in an outpatient setting at general acute care hospitals across Michigan continued to rise from January 2021 through September 2022 (Figure 2).

Figure 2.

The patient population in these reports comprises adult patients who had surgery or an inpatient hospitalization at an MVC-participating hospital between January 2021 and September 2022. Measures are based on 30-day inpatient and surgical-based episodes of care data, incorporating paid claims from Blue Cross Blue Shield of Michigan and Blue Care Network Commercial and Medicare Advantage plans as well as paid claims from Medicare Fee-for-Service. Episodes meeting any of the following criteria were excluded from calculations: patients transferred to another acute care hospital or to hospice, patients who died during their index stay, and patients with a primary diagnosis of COVID-19 received in an inpatient setting at any point during their 30-day episode.

We hope our collaborative participants find these reports valuable, and as always, we welcome MVC members to contact MVC with any questions or analytic requests.