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 | 0 Comments | , , , , , , , , , ,

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!

15 Oct 2025
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MVC 2025 Fall Collaborative-Wide Meeting Summary – Adapting Together in 2025 and Beyond: High-value Care for All in a Changing Landscape

MVC 2025 Fall Collaborative-Wide Meeting Summary – Adapting Together in 2025 and Beyond: High-value Care for All in a Changing Landscape

October 15, 2025 | 0 Comments | , , , , ,

The Michigan Value Collaborative (MVC) held its fall 2025 collaborative-wide meeting on Friday, Oct. 10, in Livonia. A total of 91 attendees representing 64 hospitals, three physician organizations, and 13 healthcare systems from across the state of Michigan came together to share strategies for mitigating the impact of non-medical drivers on health outcomes.

MVC Director Mark Bradshaw, MSc, kicked off Friday’s meeting with updates on the MVC Coordinating Center [See slides]. He introduced MVC’s newest team members, Manager of Data Analytics Ian Raxter, MPH, and Project Manager Emily Woltmann, PhD, MSW, as well as announced the promotion of Julia Mantey, MPH, MUP, to Lead Analyst. Bradshaw encouraged sites to register for the 2025 Michigan Cardiac Rehab network (MiCR) fall meeting at Corewell Health Troy Hospital by the Oct. 31 deadline. He also provided an update on Phase II of the RITE-Size preoperative testing trial and recent MVC reporting since MVC’s spring meeting, including refreshed common conditions push reports, the new health outcome variation push report, and the P4P Program Year 2025 mid-year scorecards. Bradshaw provided insights on the content included in the health outcome variation push report and the P4P Program Year 2025 mid-year scorecards before reviewing Program Year (PY) 2026-2027 cycle changes and member selections (Figure 1 and Figure 2).

Figure 1.

vertical bar graph of PY 26/27 episode spending selections for CHF, COPD, PCI, CABG

Figure 2.

vertical bar chart of PY 26/27 value metric selections for seven metrics

Following Bradshaw’s announcement that MVC’s 2026 engagement point menu is now posted on MVC’s P4P webpage, MVC Engagement Manager Jessica Souva, MSN, RN, C-ONQS, highlighted the differences from previous versions of MVC’s engagement point menu. Souva noted that most of the changes to the engagement point menu were adjustments to the point values; however, Souva introduced the addition of a site coordinator education modules offering (Figure 3). Details on these modules will be shared with MVC site coordinators in the coming months via email.

Figure 3.

Site coordinator education modules

The meeting then featured a presentation from the MSHIELD CQI, including Program Manager Julia Weinert, MPH, and Bradley Iott, PhD, MPH, on implications of non-medical drivers of health for quality improvement. Weinert and Iott presented research evidence on the importance of addressing upstream drivers of health outcomes, MSHIELD implementation toolkits, and resources available on the MSHIELD website.

MVC’s keynote presentation was delivered by Gloria Rey, PA-C, MPH, Director of Post-Acute Care for Henry Ford Health/Populance. Her presentation detailed Henry Ford Health’s approach to developing and maintaining strong relationships with post-acute care providers [See slides]. Rey went on to demonstrate how these relationships have improved patient outcomes and cost savings (Figure 4).

Figure 4.

depiction of Henry Ford Health's rehospitalization rates lower for facilities in the post-acute network (PAN) than in the rest of the market

After a networking lunch, MVC Medical Director Hari Nathan, MD, PhD, and MVC Analyst Kushbu Narender Singh, MDS, MPH, delivered an MVC data presentation focused on MVC’s new health outcome variation measure [See slides]. During the presentation, Narender Singh supplemented Dr. Nathan’s explanation of the measure definition (Figure 5), benefits, and rollout timeline with MVC member unblinded data and case scenarios. An introductory video for the health outcome variation measure is available on MVC’s P4P webpage.

Figure 5.

explanation of the health outcome variation measure definition, benefits, and rollout timeline

Attendees spent time in the afternoon in various breakout sessions (Figure 6) learning about strategies from other MVC members to address non-medical drivers of health outcomes [See slides].

Figure 6.

breakout session titles and descriptions

The meeting closed with a reflection of the day spent together and reminders about upcoming meetings and events [See slides].

What are the attendees saying about the meeting?

“I gained a lot of insight and ideas to take back to my organization to review with others.”

“I learned that patients can be in home care and cardiac rehab at the same time which is a game changer for us.”

“Enjoyable to see the multi-faceted approaches that are being used throughout the state's regions for decreasing readmissions.”

“I really enjoyed the breakout sessions and discussions!”

“Loved the ability to talk with other groups and learn from each other. Like the unblinded data, it was more meaningful to what was being discussed.”

If you have questions about any of the topics discussed at MVC’s fall collaborative-wide meeting or are interested in following up for more details, email the MVC Coordinating Center. MVC’s next collaborative-wide meeting will be in person on Fri., May 8, 2026, in Traverse City.

24 Sep 2025
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Fall Collaborative-Wide Meeting Agenda, Speakers Announced

Fall Collaborative-Wide Meeting Agenda, Speakers Announced

September 24, 2025 | 0 Comments | , , ,

The MVC Coordinating Center is excited to announce the agenda for its fall collaborative-wide meeting on Fri., Oct. 10, 2025, from 10 a.m. – 3 p.m., at the Vistatech Center in Livonia, MI. This meeting’s theme is “Adapting Together in 2025 and Beyond: High-Value Care for All in a Changing Landscape.” This meeting will highlight the various ways in which MVC's members identify gaps in outcomes, adapt to ensure all patients receive the highest quality care, and establish partnerships and programs that mitigate non-medical drivers of health outcomes. Those interested in attending MVC's fall 2025 collaborative-wide meeting must register here by Thurs., Sept. 25.

MVC Director Mark Bradshaw, MSc, will kick off the day with Coordinating Center updates as well as announcements about the MVC Component of the Blue Cross Blue Shield of Michigan (BCBSM) Pay-for-Performance (P4P) Program. This will be followed by updates about 2026 engagement offerings presented by MVC Engagement Manager Jessica Souva, MSN, RN, C-ONQS.

MVC will then invite its first guest speakers of the day to the podium: Julia Weinert, MPH, MSHIELD Program Manager, and Brad Iott, PhD, MPH, MSHIELD Content Expert in Health Informatics and Social Care Integration. The MSHIELD team will lay the foundation for the day by discussing non-medical drivers of health and related implications for quality improvement teams, including examples of metrics that help evaluate care across all patients and interventions that can help reduce gaps in patient outcomes.

The event keynote will follow with a presentation by Gloria Rey, PA-C, MPH, Director of Post-Acute Care, Henry Ford Health. She will present on Henry Ford’s post-acute care (PAC) transition program, and the ways in which their team partners with PAC groups to ensure effective, individualized handoffs and care delivery for all patients.

Following lunch and networking, MVC Medical Director Hari Nathan, MD, PhD, will co-present with MVC Analyst Kushbu Narender Singh, MDS, MPH, for MVC’s Data in Action presentation. This data presentation will focus on MVC’s newest health outcome variation measure, including how it was developed, its use cases and benefits, a timeline for related data sharing, and unblinded data. This measure was a new addition to the MVC Component of the BCBSM P4P Program, with scoring on this measure beginning in Program Years 2026-2027.

Attendees will then transition into the afternoon breakout sessions, all led by guest hospital presenters. To showcase how members are addressing variation in outcomes, MVC invited presenters to discuss recent initiatives and successes across a range of focus areas, such as partnerships with community-based organizations, systematic approaches to referrals, and predictive analytics and assessment tools in EPIC. View a summary of all five breakout presentations here. Attendees will attend two breakout sessions before returning to the main ballroom for closing remarks and next steps.

The deadline to register for MVC’s fall 2025 collaborative-wide meeting is tomorrow, Sept. 25. We look forward to seeing you there!

10 Sep 2025
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Push Report Details New MVC Measure that Quantifies Gaps in Patient Outcomes

Push Report Details New MVC Measure that Quantifies Gaps in Patient Outcomes

September 10, 2025 | 0 Comments | , , , ,

MVC distributed a new push report on Aug. 28, highlighting the components and methods for MVC’s newest measure: health outcome variation for all-cause readmissions. The goals of the recently distributed push reports are to familiarize hospital members with the measure methodology as well as provide a first look at their hospital’s performance.

This measure was developed with the goal of addressing common challenges by MVC’s members in identifying and addressing gaps in health outcomes within their patient populations. A survey distributed to the MVC collaborative in 2024 identified barriers such as insufficient data and insufficient financial investments as key causes for lingering variation across their patient population. With the introduction of MVC’s health outcome variation measure, MVC seeks to quantify the magnitude of hospital-level variation in all-cause readmission rates between payer groups using an index of variation calculation. Readmission rates are risk adjusted for patient demographic and comorbidity data, as well as for non-medical drivers of health.

The first two pages of the push report provide a step-by-step walkthrough of the index calculation, beginning with the calculation of absolute differences in hospital-level readmission rates by payer group compared to the hospital-level average readmission rate. The five payer groups included in these calculations are BCBSM and BCN Commercial, BCBSM and BCN Medicare Advantage, Medicaid only, Medicare FFS only, and patients dual-eligible for Medicaid and Medicare; dual-eligible patients have been pulled out of the Medicaid only and Medicare only categories. This initial step helps to highlight which payer group(s) have a higher readmission rate than the hospital’s average rate (Figure 1).

Figure 1.

vertical bar chart of calculation of absolute differences in hospital-level 30-day readmission rates by payer group compared to the hospital-level average readmission rate

The next step in the methodology is to calculate a hospital’s index of variation using absolute differences in payer-specific risk-adjusted readmission rates compared to the hospital’s risk-adjusted average readmission rate. These payer-specific absolute differences are multiplied by the respective payer population proportion to yield weighted differences (Figure 2). The sum of those weighted differences across all five payer groups yields the hospital’s index of variation. This index calculation indicates the magnitude of payer-specific differences in risk-adjusted readmission rates within a hospital. A higher value indicates a larger spread in a hospital’s payer-specific risk-adjusted readmission rates as well as opportunities to develop strategies that reduce gaps in care across patient groups. A lower value is desired and indicates less variation in a hospital’s risk-adjusted readmission rates across payers.

Figure 2.

table: demonstration calculation a hospital’s index of variation using absolute differences in payer-specific risk-adjusted readmission rates compared to the hospital’s risk-adjusted average readmission rate

MVC first announced this measure at its fall 2024 collaborative-wide meeting, where Senior Advisor Jim Dupree, MD, MPH, announced its inclusion in the next cycle of the MVC Component of the BCBSM Pay-for-Performance (P4P) Program. Scoring on this measure will be offered in the Program Year (PY) 2025 scorecards with no points attached and thereafter will be worth one point in the PY 2026-2027 cycle.

Similar index or composite measures have been utilized by other health organizations, and MVC’s risk-adjusted measure can help identify hospital-level preventable differences in readmissions. Hospitals will earn the health outcome variation point by improving relative to their own baseline index or by performing well relative to their peers (i.e., having an index at or below the collaborative-wide median index).

As hospitals review their provided push report and become familiar with this new health outcome variation measure, they are encouraged to reach out to MVC with any questions.