04 Nov 2026
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MVC October Workgroup Highlights MVC Cardiac Rehab Push Report

MVC October Workgroup Highlights MVC Cardiac Rehab Push Report

November 4, 2026 | Comments Closed | , , , , , , , , , , , ,

In October, the Michigan Value Collaborative (MVC) hosted a cardiac rehab workgroup featuring MVC’s newly released cardiac rehabilitation (CR) push report. The MVC Coordinating Center hosts workgroup presentations once or twice per month, covering a variety of topics including cardiac rehab, post-discharge follow-up, rural health, preoperative testing, sepsis, and health in action. View the full MVC event calendar with registration links here.

Cardiac Rehab Workgroup: MVC’s Refreshed Cardiac Rehab Push Report 

Since 2019, MVC has prioritized cardiac rehab as a value coalition campaign providing members with focused workgroups, site visits, and data resources to support quality improvement. Since then, MVC has continuously offered multi-payer reporting and benchmarking on a variety of cardiac rehab focused measures, first by offering dedicated push reports refreshed twice each year, followed by the launch of multi-payer reports on the MVC registry and the incorporation of cardiac rehab measures in the MVC Component of the BCBSM Pay-for-Performance (P4P) Program.

MVC continued to update data for its members by refreshing cardiac rehab push reports in September (read September 2026 blog for report details). MVC shared a stand-alone cardiac rehab push report this year, whereas recent years incorporated these data within a larger process measures push report.

During this month’s cardiac rehab workgroup, MVC Associate Program Manager Jana Stewart, MPH, provided a report walkthrough to familiarize MVC members with its data and changes relative to prior versions. In addition to traditional measures of enrollment, the latest report included measures of adherence and completion, in alignment with AACVPR performance measures.

Stewart said this expanded approach highlighted important opportunities for quality improvement along the patient care journey, from initial referral and enrollment processes to downstream retention strategies and patient barriers to participation. The measures were defined as:

  • Enrollment: The percentage of eligible patients who attend at least one cardiac rehab session within 90 days (Main 5 patients) or 365 days (CHF patients) of hospital discharge
  • Adherence: The percentage of enrolled patients who completed at least 12 cardiac rehab sessions within 365 days of discharge
  • Completion: The percentage of enrolled patients who completed at least 36 cardiac rehab sessions within 365 days of discharge

Together, Stewart described how these measures can help hospitals and cardiac rehab partners identify where patients may be falling out of the care pathway, starting with initial referral and enrollment through continued program participation and completion. Stewart encouraged members to use the provided patient characteristics table (Figure 1) to assess differences in cardiac rehab outcomes between different patient groups as well as identify patient gaps driven by non-medical drivers of health. The report also provided hospital-level comparisons with statewide averages, allowing members to assess their performance relative to their peers.

Figure 1. Slide highlighting Table 1 patient characteristic data from September 2026 cardiac rehab push reports

Table infographic titled “Your Hospital’s Cardiac Rehab Rates Among Different Patient Populations,” comparing cardiac rehabilitation metrics across patient categories. Rows cover race/ethnicity, payer, and residence in an at-risk ZIP code, with columns for distribution, 90-day enrollment, 365-day enrollment, adherence, and completion; blue table and orange-on-blue title panel emphasize population differences.

After reviewing the specifics of the updated push report, Stewart provided a brief look at statewide performance on each of these measures for the Main 5 and CHF patient populations. Overall, the findings demonstrated some progress in enrollment while highlighting opportunities to strengthen adherence and completion.

The Michigan Cardiac Rehab Network (MiCR) reported on cardiac rehab adherence and completion rates one year ago at its fall 2025 meeting, which compared participant adherence and completion rates across CR programs. This data presentation revealed a positive association between adherence rate and completion rate, with more consistently higher adherence rates observed amongst sites with higher completion rates (Figure 2). However, there were also sites with high adherence rates and low completion rates, suggesting a high adherence rate does not guarantee a high completion rate.

Figure 2. Cardiac Rehab Adherence and Completion Rates at Centers Across Michigan

Scatter plot compares adherence rate across 12 sessions with completion rate across 36 sessions, using gray filled dots and red open circles against a 0%–100% completion-rate axis. Gray adherence values remain mostly 60%–85%, while red completion values rise steadily from 0% to about 52%, with labels and legend identifying each series.

Benchmarking Statewide Enrollment, Adherence, and Completion

The statewide cardiac rehab enrollment rate provided for Main 5 conditions was 34%, up from approximately 24% when focused improvement efforts began in 2019. However, this remains below the MiCR statewide goal of 40% and well below the Million Hearts goal of 70% for all eligible cardiac rehab participants.

For patients with CHF, the statewide enrollment rate of 6% also still falls short of MiCR’s 10% goal. Unlike enrollment for the Main 5 conditions, CHF enrollment rates have seen little improvement over the last few years. These findings reinforced the importance of an effective referral process, patient education, and continued engagement on the initiation of cardiac rehab for CHF patients. During the discussion, participants emphasized that heart failure patients may need additional time and repeated referrals before they initiate cardiac rehab.

Stewart emphasized how the additional measures of adherence and completion rates offered further insight into patient participation and full benefit from the program after enrollment. For the Main 5 conditions, the statewide adherence rate was 75% for the report's timeframe, meaning that approximately three-quarters of enrolled patients completed at least 12 sessions. However, the statewide completion rate among Main 5 patients was just 24%, reflecting the proportion of enrolled patients who completed 36 sessions within one year. For CHF, rates were similar to those of the Main 5 population—the statewide CHF adherence rate was 68%, while the completion rate was 24%.

Identifying Barriers and Supporting Patient Participation

During the workgroup discussion, members explored several factors that may affect enrollment, adherence, and completion. Common themes of the discussion included:

  • Provider endorsement and patient education: A clear recommendation from a physician can help patients understand why cardiac rehab is an important part of their recovery journey.
  • Financial and transportation barriers: Copays and the challenges of traveling to multiple appointments are known barriers for certain patient populations that may show up as low adherence or completion rates. Further analysis of cardiac rehab performance across payer and demographic groups could help better understand where additional support may be needed.
  • Flexible scheduling and delivery options: Flexible appointment times and hybrid cardiac rehab delivery models may help patients overcome scheduling and transportation challenges to improve adherence and completion.
  • Patient stories and testimonials: Participants discussed that patients may not feel ready to participate in cardiac rehab immediately after discharge, making continued outreach and education especially valuable. For patients with CHF in particular, the timing of referrals and reminders can be important. MiCR’s newest Heart-to-Heart initiative offers patient-story videos and testimonials that programs can use to help recruit patients for cardiac rehab, available on MiCR’s YouTube page.

These strategies offer starting points for local quality improvement. Stewart encouraged members to use their new cardiac rehab report findings to identify opportunities, engage relevant clinical and operational partners, and determine which approaches may be most appropriate for their patient populations. Members can also use the MVC registry to explore additional breakdowns of their data. For hospitals interested in more detailed analyses, MVC is available to discuss custom report opportunities.

MVC Cardiac Rehab Workgroup: Oct. 20, 2026

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

21 Oct 2026
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MVC’s Updated Common Conditions Report Now Available to Hospital Members

MVC’s Updated Common Conditions Report Now Available to Hospital Members

October 21, 2026 | Comments Closed | , , , , , , ,

Earlier this month, the MVC Coordinating Center distributed a refreshed version of MVC’s common conditions report. This report delivered a comprehensive analysis of care episodes for six prevalent medical and surgical conditions frequently targeted for quality improvement initiatives within MVC hospitals. The included conditions were chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), pneumonia, and sepsis. MVC generated hospital-level reports for 106 members, with tailored versions for general acute care hospital (GACH) and Critical Access Hospital (CAH) members.

Report pages focused on 30-day total episode payments, post-acute care utilization, readmission rates, and common reasons for readmissions. The report continued to highlight payments and outcomes for a two-year window, but the date range was updated to reflect claims from Jan. 1, 2024, through Dec. 31, 2025, for Blue Cross Blue Shield of Michigan (BCBSM)/Blue Care Network (BCN) Commercial, BCBSM/BCN Medicare Advantage (MA), and Michigan Medicaid; Medicare Fee-for Service (FFS) claims from the period of Jan. 1, 2024, through June 30, 2025, were used.

To ensure member reports had a sufficient sample from which to draw meaningful conclusions, MVC continued to apply case count inclusion criteria for the condition-specific pages. Previously, MVC required a site to have 11 episodes per year for both years to receive a condition-specific page; this year, condition-specific pages were included for all conditions with at least 20 episodes in the reporting period. This update expanded both the number of hospitals eligible for their report and report pages per hospital. For CAH members, MVC also expanded the reporting period for the CAH reports to Jan. 1, 2023, through Dec. 31, 2025, for all conditions.

The report began with a summary of patient population characteristics (Figure 1), comparing demographics, risk factors, readmission diagnoses, and comorbidities across each eligible cohort. The table was provided to help hospitals better understand the patient populations underlying the reporting for these six conditions/procedures.

Figure 1. Sample Blinded Table for a Hospital’s Patient Population Snapshot, Common Reasons for Readmission, and Frequent Comorbidities

Comparison table summarizes demographics, risk factors, readmission diagnoses, and comorbidities across COPD, CHF, CABG, PCI, pneumonia, and sepsis patient categories. Mean age ranges from 63.5 years for sepsis to 71.5 for CHF; frequent readmission reasons include respiratory failure, heart failure or shock, gastrointestinal hemorrhage, myocardial infarction, and septicemia, while common comorbidities include CHF, diabetes, COPD, and chronic kidney disease.

The remainder of the report was comprised of condition-specific pages. MVC provided benchmarking figures for average 30-day risk-adjusted, price-standardized total episode payment and 30-day inpatient readmission rate for each condition. MVC price standardized total episode payments to Medicare FFS amounts so that comparisons could be made across hospitals and over time. Payments were risk-adjusted for patient age, gender, payer, comorbidities, and high or low prior healthcare utilization/payments. These figures showcased a given hospital’s position relative to all other eligible MVC hospitals in the collaborative and provided the average total episode payment within a hospital’s region and statewide.

Across the collaborative, CABG had the highest average total episode payment at $53,183 (Figure 2), followed by sepsis and CHF. The collaborative-wide average total episode payment for all conditions did not vary significantly between the 2025 report and the 2026 report. Readmissions were observed to be highest across the collaborative at 19.1% for patients hospitalized for CHF (Figure 3), followed by patients hospitalized for sepsis or COPD. Readmission rates were lowest across the collaborative at 5.4% among patients who underwent a PCI procedure.

Figure 2. Average 30-Day Risk-Adjusted, Price-Standardized Total Episode Payment Among Patients Hospitalized for CABG (Blinded Report)

Caterpillar plot compares average 30-day risk-adjusted, price-standardized total episode payments for CABG patients across MVC hospitals. Orange circles show other hospitals trending upward from about $45,000 to $70,000, while markers identify Your Hospital at $53,454, Your Region at $53,937, and MVC All at $53,183.

Figure 3. 30-Day Readmission Rate Among Patients Hospitalized for CHF (Blinded Report)

Caterpillar plot compares 30-day CHF readmission rates across MVC hospitals, with orange open circles rising from about 6% to 28%. Blue marker shows Your Hospital at 19.8%, while horizontal reference lines mark Your Region at 19.7% and MVC All at 19.1%.

The final figures on the condition-specific pages worked in tandem to display the utilization and cost components that made up a hospital’s average price-standardized, risk-adjusted post-acute care (PAC) payments in the 30 days following discharge. Most hospitals received a figure displaying the breakdown of 30-day risk-adjusted, price-standardized post-acute care payments by payer categories (Figure 4). All payer categories with at least 11 episodes during the reporting period were reflected, including a “Dual-Eligible” category representing patients eligible for both Medicare and Medicaid coverage; as such, Medicare and Medicaid categories did not include dual-eligible patients when that category was included. The post-acute care categories for both figures included home health care, skilled nursing facility (SNF) care, inpatient rehab, outpatient rehab, emergency department (ED) care, long-term acute care hospitals (LTACH), and outpatient services.

Figure 4. Breakdown by Payer of 30-Day Risk-Adjusted, Price-Standardized Total Post-Acute Care Payments Among Patients Who Had a CABG Procedure (Blinded Report)

Stacked bar chart compares payer-specific shares of risk-adjusted, price-standardized 30-day post-acute care payments following CABG. Seven color-coded services show SNF dominating Commercial and Medicare Advantage payments, outpatient services prominent for Medicare Only, Medicaid Only, and Dual Eligible groups, and Home Health comprising most Dual Eligible payments.

Beyond offering insights into payments by payer and post-acute care category, this figure can offer additional insights and context when considered alongside Figure 5 showing post-acute care utilization rates. The two figures together served to provide a clearer understanding of the relationship between rates of utilization and percent of episode spending for each post-acute care category, illustrating whether spending aligns with utilization frequency. For example, payment categories with a high percentage of post-acute care payment in Figure 4 and a low overall utilization rate in Figure 5 may be indicative of low volume, high-cost outliers within a given condition at that hospital.

Figure 5. 30-Day Post-Acute Care Utilization Among Patients who had a CABG Procedure (Blinded Report)

Dot plot compares 30-day post-acute care utilization after CABG across SNF, Home Health, IP Rehab, OP Rehab, ED, Outpatient Services, and LTACH. Blue, gray, and orange markers represent Your Hospital, Your Region, and MVC All; Outpatient Services shows highest utilization, while LTACH and IP Rehab remain near 0%.

MVC is dedicated to regularly updating its commons conditions report, aiming to equip collaborative partners with insightful data that can drive and reinforce meaningful advancements in healthcare quality. Please contact MVC with any questions or related analytic requests. If you require any digital accessibility accommodation, please let us know and we will be happy to provide alternative formats.

30 Sep 2026
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MVC Push Report Benchmarks Cardiac Rehab Enrollment, Adherence, and Completion Rates

MVC Push Report Benchmarks Cardiac Rehab Enrollment, Adherence, and Completion Rates

September 30, 2026 | Comments Closed | , , , , , , , ,

Since 2019, the MVC Coordinating Center has emphasized the value and importance of cardiac rehab with its member hospitals, offering claims-based data reporting, workgroup presentations by experts and peers, incentive-based metrics, and other resources to drive improvement. MVC distributed refreshed cardiac rehab push reports this month that continued to benchmark utilization among MVC member hospitals—reports that complement the multi-payer registry pages by incorporating adherence and completion metrics not available on the registry.

The primary motivator behind this work is the ever-growing cohort of patients with cardiovascular disease. Every year in the US, for example, nearly 6.7 million adults manage congestive heart failure (CHF) and more than one million patients undergo cardiac surgical procedures. Cardiac rehab can help patients regain strength and confidence, manage their cardiovascular health, and return to a healthier, more active life. It also has a dose-response relationship—attending more cardiac rehab sessions is associated with lower mortality and morbidity.

The evidence of benefit is clear in the literature, and patient stories affirm its impact and benefit.

“In a sense, the initial heart surgery saved my life the first time, but cardiac rehab saved it a second time,” shared John, a former cardiac rehab participant. “The rehab people performed a small miracle by restoring my self-confidence.”

Another patient, Belinda, shared that her cardiac rehab care at Henry Ford Hospital in Detroit helped her to improve across a variety of health behaviors. “They are so supportive… it encourages you to be faithful in every area with your medication, the exercise. And plus, it helps to elevate your attitude too. It makes you just feel better; it makes you feel more alive… and then you do have something to look forward to.”

Patients like John and Belinda have continued to inspire the MVC Coordinating Center to continually support quality improvement in cardiac rehab utilization. With its latest push report, MVC continued to focus on eligible patients treated for heart attack (AMI), percutaneous coronary intervention (PCI), heart valve repair or replacement (SAVR or TAVR), or coronary artery bypass grafting (CABG), collectively referred to as the “Main 5,” as well as patients with CHF.

The report included MVC 90-day and 365-day episodes of care for adult patients with index cardiac care encounters for Main 5 or CHF conditions. MVC included all its available payer claims between Jan. 1, 2022, and March 31, 2025 (through Sept. 30, 2024 for Medicare). The report provided hospitals with benchmarking data, allowing comparisons in cardiac rehab performance with other eligible MVC hospitals across the state.

Each eligible hospital’s report included a dedicated page highlighting cardiac rehab rates across different patient populations (Figure 1). This table provided an opportunity to examine variation in cardiac rehab participation by race, insurance payer, and Distressed Community Index (DCI) categories to help hospitals better understand which patient populations were experiencing utilization gaps and may benefit from additional support.

Figure 1. Sample Blinded Table Describing Hospital’s Cardiac Rehab Rates Among Different Patient Populations

Two stacked benchmark scatter charts compare MVC hospitals’ CHF care adherence and completion rates within 365 days after discharge. Teal lines mark collaborative averages of 68% and 24%, hollow blue circles show other hospitals, and red dots mark your hospital at 58% adherence and 17% completion, while peer rates generally rise across both charts.

Following the patient population snapshot, MVC also provided benchmarking figures for the Main 5 and CHF patient cohorts, allowing hospitals to compare their cardiac rehab enrollment rates with those of other eligible MVC hospitals. For the Main 5 conditions, the collaborative-wide average 90-day enrollment rate during the reporting period was 34%, below the statewide goal of 40%. Hospital-level enrollment rates ranged from nearly 0% to nearly 60% (Figure 2). For CHF, the collaborative-wide average 365-day enrollment rate was 6%, also below the statewide goal of 10%, with hospital-level rates ranging from 0% to 16% (Figure 3).

Figure 2. 90-Day Cardiac Rehab Enrollment Rate After Discharge from Main 5 Cardiac Care Encounter (Blinded Report)

Line chart compares enrollment rates within 90 days after discharge from five cardiac care encounters across MVC hospitals. Hollow blue circles show other hospitals, black line marks statewide goal at 40%, teal line marks collaborative average at 34%, and red marker identifies your hospital at 44%, with rates generally rising from near 0% to 55%.

Figure 3. 365-Day Cardiac Rehab Enrollment Rate After Discharge from CHF Cardiac Care Encounter (Blinded Report)

Scatter plot shows CR enrollment rate within 365 days after discharge for CHF cardiac care encounters across MVC hospitals. Hollow blue circles rise from near 0% to 16%, teal line marks collaborative average at 6%, black line marks statewide goal at 10%, and red marker identifies Your Hospital at 10%.

In addition to traditional reporting of enrollment rates, MVC incorporated two new measures in the report—adherence and completion—to provide a more comprehensive view of patients’ engagement with cardiac rehab over time. Adherence is an AACVPR performance measure defined as the percentage of enrolled patients who completed at least 12 cardiac rehab sessions within 365 days of the index cardiac care encounter. Completion was defined as the percentage of enrolled patients who completed at least 36 sessions within 365 days of the index cardiac care encounter. Together, these measures provided insight into whether patients continued participating in cardiac rehab after their initial enrollment.

During the reporting period, the statewide average among Main 5 patients was 75% for adherence, meaning that three in four patients completed at least 12 sessions (Figure 4). The statewide average completion rate was 24%, meaning that nearly one in four enrolled Main 5 patients completed at least 36 sessions. Among patients with CHF, 68% completed at least 12 sessions, while 24% completed at least 36 sessions (Figure 5).

Figure 4. Cardiac Rehab Adherence and Completion Rates Within 365 Days After Discharge from Main 5 Cardiac Care Encounters (Blinded Report)

Two-panel dot chart compares MVC hospitals’ cardiac rehabilitation adherence and completion rates within 365 days after discharge from a main five cardiac care encounter. Open circles show other hospitals, blue lines mark collaborative averages of 75% adherence and 24% completion, and red markers show Your Hospital at 77% and 27%, with rates generally increasing across hospitals.

Figure 5. Cardiac Rehab Adherence and Completion Rates Within 365 Days After Discharge from CHF Cardiac Care Encounter (Blinded Report)

Two stacked benchmark scatter charts compare MVC hospitals’ CHF care adherence and completion rates within 365 days after discharge. Teal lines mark collaborative averages of 68% and 24%, hollow blue circles show other hospitals, and red dots mark your hospital at 58% adherence and 17% completion, while peer rates generally rise across both charts.

For hospitals with insufficient case counts, some figures and tables were omitted from the report. Hospitals interested in exploring their cardiac rehab enrollment data further can use the MVC Registry to analyze their hospital’s enrollment rates over time, average number of sessions completed within 90 days, and average time to enrollment (mean days to cardiac rehab). Hospitals interested in examining their cardiac rehab data beyond the information included in the report and the registry can reach out to MVC to request a custom report.

In addition to providing data on cardiac rehab, the MVC Coordinating Center offers a cardiac rehab workgroup where members and partners share strategies and insights to help improve performance. The next workgroup will take place on Tues., Oct. 20, from 12-1 p.m., focused on the content and applications of this push report. More information about upcoming MVC events can be found on the MVC events page.

MVC is a contributing partner of the Michigan Cardiac Rehab Network (MiCR), which is co-led by MVC and the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2). MiCR aims to increase statewide 90-day cardiac rehab enrollment rates to 40% among Main 5 patients, and 365-day cardiac rehab rates to 10% among eligible CHF patients. To learn more about MiCR and its resources visit https://michigancr.org/.

23 Sep 2026
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Hospitals Receive PY 2026 Mid-Year Scorecards for MVC Component of BCBSM P4P Program

Hospitals Receive PY 2026 Mid-Year Scorecards for MVC Component of BCBSM P4P Program

September 23, 2026 | Comments Closed | , , , , , , , ,

Earlier this month the Michigan Value Collaborative (MVC) distributed mid-year scorecards for Program Year (PY) 2026 of the MVC Component of the Blue Cross Blue Shield of Michigan (BCBSM) Pay-for-Performance (P4P) Program. PY 2026 marks the first year of the two-year (PY 26-27) P4P cycle, and includes Medicaid claims as well as the newly introduced health outcome variation measure in the scoring. This report provided hospitals with their current standing for PY 2026.

Each participating hospital received a mid-year score out of a total of 10 points, including 0 to 3 points for their selected total episode payment metric, 0 to 4 points for their selected value metric, 0 to 1 point for health outcome variation measure and 0 to 2 points for completed eligible engagement activities. PY 2026 scores achievement and improvement points for each metric using index admissions from 2025 performance year data against admissions in 2023 as the baseline year. Hospitals are awarded the higher of their achievement and improvement point scores.

The performance data timeframes included in mid-year PY 2026 scoring were index events 1/1/2025 – 12/31/2025 for BCBSM PPO Commercial, BCBSM Medicare Advantage (MA), BCN HMO Commercial, BCN HMO MA, Medicaid and index events from 1/1/2025 – 6/30/2025 for Medicare FFS. For the health outcome measure, the performance data included were index events from 1/1/1015 – 6/30/2025 to reflect the most recent date range for all payers. The engagement points accrued represent all completed activities from 1/1/2026 – 9/2/2026. All scores are subject to change in the final scorecards as the remaining 2025 performance data becomes available and additional 2026 P4P engagement activities are completed and recorded for this year.

Figure 1 illustrates the current distribution of total points out of 10 across the collaborative. The average points scored across the mid-year scorecards was 5.2 out of 10 and ranged between 0.5 and 10 points. This average is 1.5 points lower than the average points scored at the conclusion of PY 2025.

Figure 1. PY26 Mid-Year Distribution of Total Points Out of 10 Across the Collaborative

Dot plot ranks MVC Hospitals participating in PY26–27 P4P Program by PY26 mid-year score, with scores ranging from roughly 0.5 to 10. Blue hospital markers rise steadily across rankings, while an orange horizontal line marks mean and median at 5.2.

Figure 2 illustrates the breakdown of scoring on average by each program component (i.e., episode spending metric, value metric, health outcome variation measure and engagement points). Hospitals could earn up to three points for their episode spending, four points for their value metric selections, one point for health outcome variation measure and up to two points for engagement activities completed in 2026. Across collaborative, the average points scored for episode spending and value metrics were 1.0 point, and 2.2 points respectively. For the newly introduced health outcome variation measure, the average was 0.6 points and the average for engagement activities was 1.4 points.

Figure 2. PY26 Mid-Year Scoring on Average by Each Program Component

Bar chart showing average points scored across hospitals by category, with y-axis ranging 0–10 points. Blue bars show Episode Spending 1.0/3, Value Metrics 2.2/4, Health Outcome Variation 0.6/1, Engagement 1.4/2, and Total Points 5.2/10.

Figure 3 illustrates the breakdown of the average points by episode spending conditions. Coronary Artery Bypass Grafting (CABG) and Congestive Heart Failure (CHF) were both the highest scoring episode spending conditions with an average of 1.3 points, and this was followed by chronic obstructive pulmonary disease (COPD) with 1 point. The lowest scoring episode spending condition was pneumonia with hospitals earning 0.4 points on average.

Figure 3. PY26 Mid-Year Average Points by Episode Spending Conditions

Bar chart compares average points scored across episode spending conditions: CABG 1.3, CHF 1.3, COPD 1.0, and PCI 0.4. Blue patterned bars use a 0–3 vertical scale, with mean and median both marked as 1.0.

Figure 4 illustrates the breakdown of average points by value metrics. Consistent with PY 2025, the highest scoring value metric was preoperative testing with 3.5 points, followed by 90-day cardiac rehabilitation after CABG with 3.0 points. All follow up metrics had an average score of below 2 points with the lowest scoring value metric being 14-day follow up after COPD with 1.1 points.

Figure 4. PY26 Mid-Year Average Points by Value Metrics

Bar chart compares average points scored across value metrics for preoperative testing and follow-up categories. Dark blue bars decline from 3.5 for preoperative testing to 1.1 for 14-day follow-up after COPD, with mean 2.2 and median 2.0 marked at upper right.

These PY 2026 P4P mid-year scores are subject to change as new data is added. The final scores will be distributed after all 2025 claims are incorporated into the calculations. The full methodology for this program cycle can be found in the PY2026-2027 technical document. Hospitals can also track their score via the P4P PY 2026-2027 dashboard reports on the MVC registry, which provides all relevant scoring information for both improvement and achievement points. These registry reports can be filtered by selected conditions/metrics to make tracking of P4P points easier. You can also contact the MVC Coordinating Center by email for a walkthrough of your hospital’s PY 2026 mid-year scorecard or P4P registry reports.

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

decorative

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!