04 Dec 2024
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November Workgroups Highlight Preop Testing Project and Cardiac Rehab Access Initiative

November Workgroups Highlight Preop Testing Project and Cardiac Rehab Access Initiative

December 4, 2024 | 0 Comments | , , , ,

In November, MVC hosted two virtual workgroup presentations – the first on preoperative testing was led by a fellow Collaborative Quality Initiative (CQI), and the second on cardiac rehabilitation was delivered by an MVC member hospital. MVC hosts two virtual workgroups per month with topics rotating between post-discharge follow-up, sepsis, cardiac rehabilitation, rural health, preoperative testing, and health in action (ad hoc focused topics). Each month, the MVC Coordinating Center publishes key highlights from these presentations to support resource and best practice sharing across the state.

November Preoperative Testing Workgroup: Michigan Surgical Quality Collaborative (MSQC)

The first workgroup of November focused on preoperative testing and featured a presentation by Pamela Racchi, Clinical Site Coordinator with the Michigan Surgical Quality Collaborative (MSQC), and Susanna Fortney, Clinical Quality Specialist at ProMedica Charles and Virginia Hickman Hospital. To start, Racchi’s presentation provided an update on MSQC’s Preoperative Testing for Low-Risk Surgeries Project, including updated findings for 2024 and plans for 2025. Fortney then presented on ProMedica Charles and Virginia Hickman’s progress with reducing preoperative testing through the lens of participating in both the MSQC preop testing project and the RITE-Size pilot.

MSQC’s preoperative testing project is a continuation of a pilot started in 2022. The goals of the project include:

  1. To define the extent of routine preoperative testing in low-risk surgeries,
  2. To identify underlying reasons for overuse of preoperative testing in low-risk surgeries, and
  3. To implement interventions to heighten awareness and reduce variation among hospitals

Their project varies slightly from MVC’s preoperative testing offerings in that MSQC includes a slightly broader range of low-risk surgeries. The MSQC preop testing project includes abstraction for cases of minor hernia (abdominal hernias <3 cm and all inguinal/ femoral hernia repairs), laparoscopic cholecystectomy, and breast lumpectomy.

During the pilot, MSQC included all ASA classes in their analysis. Based on feedback from site participants, however, MSQC has since limited their evaluated cases to only ASA class I and II, elective cases, and low-risk surgeries identified as the intended primary procedure (based on CPT codes) for 2024. Patients falling into ASA classes I and II are expected to be stable with their comorbid conditions and therefore require less frequent testing.

Overall, results since September 2024 suggest ASA I and II cases are all trending in the right direction; abstracted data currently indicates preop testing rates of 18% among ASA I cases (with a goal of 25% or less) and 31% among ASA II cases (with a goal of 32% or less), as shown in Figure 1.

Figure 1.

Racchi also noted that the success of reducing preoperative testing is dependent on there being no further increases in unnecessary testing on the day of surgery. Historically, MSQC has calculated preoperative testing rates like MVC, up to 30 days prior to a surgery but not including the day of surgery. However, MSQC’s abstractors can additionally identify testing completed on the day of surgery. In 2024, MSQC abstractors are assessing cases that received testing on the day of surgery as well as those that received testing in the 30 days prior to a surgery. Preliminary performance results suggested there was an increase in day of preoperative testing when compared to baseline for both ASA I and II cases. Racchi noted that these analyses help determine whether testing was clinically necessary versus a result of physician habit.

Racchi and Fortney both spoke to the benefits of increasing engagement between surgery and anesthesiology to streamline preoperative testing protocols and processes. Between 2022 and 2023, ProMedica Charles and Virginia Hickman was able to reduce their preoperative testing rate by nearly 20% with just a few modifications to their testing protocol and additional onboarding of the anesthesiology providers.

A recent review of preoperative testing cases at ProMedica Hickman that were labeled unnecessary revealed nearly 40% were, in fact, medically justified and another 42% were due to protocol misinterpretation. Interestingly, the greatest rate of unnecessary preoperative testing was found to derive from ProMedica Hickman’s preadmission testing department. Fortney noted they had success embedding an adapted version of the RITE-Size program’s decision aid (Figure 2) within their anesthesiology preoperative protocols, and this helped to provide a more robust visual for their providers to reference when completing preop documentation.

Figure 2.

ProMedica Hickman additionally implemented a process for one-on-one training with preadmission testing (PAT) nursing staff, re-education, and the inclusion of case studies. The PAT nurses have also been included in MSQC/RITE-Size project update meetings and are given access to push reports so they can better understand their progress and impact.

The RITE-Size project is a collaboration between several CQI organizations – the Michigan Program on Value Enhancement (MPrOVE), the Michigan Value Collaborative (MVC), MSQC, and the Anesthesiology Performance Improvement and Reporting Exchange (ASPIRE). Each organization has individual projects underway to address unnecessary preoperative testing, but also collaborate under the umbrella of RITE-Size to support de-implementation with additional customized support and coaching. Learn more about RITE-Size by visiting the program website here.

November 5 Preoperative Testing Workgroup

November Cardiac Rehab Workgroup: Marshfield Medical Center – Dickinson

The second November workgroup focused on cardiac rehabilitation – another of MVC’s value-based initiatives. This workgroup featured a joint presentation by Carolyn Hoy, BSN, Director of Quality; Courtney Swanson, BSN, RN, Heart Care Clinic and Cardiopulmonary Rehab Manager; and Lacey Schjoth, BS, Cardiac Rehab Coordinator at Marshfield Medical Center – Dickinson. Hoy, Swanson, and Schjoth’s presentation introduced Marshfield – Dickinson’s cardiac rehab Patient Access Improvement Project, an initiative rooted in one of their core values of patient-centered care.

Although part of a much larger system, Marshfield Medical Center – Dickinson is a relatively small hospital with about 49 general med/surgical beds. To support a significantly rural population in the Upper Peninsula, the Marshfield – Dickinson team identified the need to modify their cardiac rehab program to improve access. Their three main goals included:

  • Increase the volume of patients seen,
  • Accurately track referrals,
  • Expand services to include a supervised exercise therapy (SET) peripheral artery disease (PAD) program

Swanson and Schjoth described how the Northern Michigan landscape and weather contributed to some of the barriers patients faced in accessing cardiac rehab care. Outside of Marshfield – Dickinson’s cardiac rehab center, the next rehabilitation facility is nearly 45 miles away. To support patients driving a long distance to receive cardiac rehab, the team worked to coordinate with their patient’s other appointments. They also flexed their schedules to accommodate earlier or later availability and were willing to shift the appointment times as needed pending weather conditions.

Ultimately, the team was able to increase their class size to five patients per class and increased their class offerings by one cardiac rehab (and one pulmonary rehab) class per day by December 2023. They saw a nearly 27% increase in patient enrollment between 2022 and 2023 (Figure 3). Thus far in 2024, their patient volumes are on track to match or exceed 2023.

Figure 3.

Since Marshfield – Dickinson is unable to support a Phase 1 cardiac rehab program, most of their referrals come from outside facilities located in Wisconsin. Connecting with patients quickly after referrals are received is helpful to reduce the duration of time between referral and enrollment. With adjustments to their workflow, the team was able to reduce the average time from referral to initial contact to an average of just 3.5 days as of November 2024. The team also observed a corresponding reduction in the time to first cardiac rehab visit of just 16.5 days on average.

However, rectifying referral documentation from multiple outside sources can slow down this process. Additionally, surveyed patients reported that one of the largest barriers to starting cardiac rehab was a lack of insurance coverage or high copays, with nearly 9% of patients identifying this as the primary reason they did not schedule their initial cardiac rehab appointment in 2024.  The team has recently brought on a financial counselor to assist in contacting insurance companies and ensuring adequate and accurate referrals documentation.

Lastly, the Marshfield – Dickinson cardiac rehab team worked to develop close partnerships with local cardiology providers. Ensuring local cardiology providers are aware of and supportive of cardiac rehab is a critical step that generates additional opportunities for program endorsement and patient education by the provider. Marshfield – Dickinson has additionally added Dr. Massabni, an interventional cardiologist specializing in peripheral artery disease, to their staff. This allowed them to further develop their SET PAD program in January 2024 and they are seeing increasing enrollment in this specialized vascular program.

Much of MVC’s work with its members and partners in the space of cardiac rehab is delivered under the umbrella of the Michigan Cardiac Rehab network (MiCR), a collaborative partnership with the Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2). You can see the MiCR website and offerings here. MVC also offers a robust registry of medical insurance claims data and data specialists that can help navigate and create custom analytic reports on cardiac rehab utilization metrics. Please reach out to the Coordinating Center by email if you would like to learn more about MVC data or engagement offerings.

November 21 Cardiac Rehab Workgroup

To learn more about the efforts showcased by November’s workgroup presenters, or other past workgroup presentations, please visit MVC’s YouTube Channel here.

December’s workgroups will feature a post-discharge follow-up presentation on December 3 led by Crystal Young of Corewell Health Trenton and Natalie Holland of MDHHS. Additionally, on December 12, Toni Moriarty-Smith of McLaren Northern Michigan will present a rural health presentation. The complete 2024 and 2025 MVC event calendars and workgroup registration links are available here.

04 Sep 2024
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MVC, BMC2, HBOM Announce New Cardiac Rehab Materials & Opportunities at MiCR Meeting

MVC, BMC2, HBOM Announce New Cardiac Rehab Materials & Opportunities at MiCR Meeting

September 4, 2024 | 0 Comments | , , ,

In partnership with BMC2 and HBOM, the Michigan Value Collaborative recently co-hosted the Michigan Cardiac Rehab network (MiCR) virtual summer meeting, which brought together providers, quality improvement staff, rehab staff, and patients with a shared interest in improving participation in cardiac rehabilitation. Over 70 attendees from across the state joined the meeting on Aug. 9, where they heard updates from the MiCR leadership, previewed new MiCR resources, and heard from a panel of hospital representatives who discussed their experience using the MiCR NewBeat materials.

NewBeat Success and Re-Orders

One key announcement from the meeting included the launch of a second round for placing NewBeat material print orders [ORDER FORM LINK]. The MiCR team will accept submitted order forms through Tues., Sept. 24. Those who request the free printed materials can either pick them up at the fall in-person MiCR meeting in Midland or have them mailed to an address they designate. Early survey evidence suggests that implementation of the NewBeat program is associated with an increase in confidence across a number of metrics (Figure 1).

Figure 1. NewBeat Survey Results Pre- and Post-Implementation

Speaking to the value of these materials was a panel of representatives from Corewell Health South, Holland Hospital, and Michigan Medicine—three sites who ordered NewBeat materials in the first round at the start of 2024. Each shared their experience using the materials and advice on their integration. HBOM also recorded virtual interviews with the Corewell Health and Holland Hospital site contacts for use in a NewBeat success story video (Figure 2), which was played for the meeting’s attendees.

Figure 2. Implementing NewBeat Feedback Video

Those who wish to place an order for NewBeat materials in the current round will again have the opportunity to request the MiCR patient/provider educational handout (available in English, Spanish, and Arabic), the cardiac rehab liaison postcard, and the cardiac care cards. Some customizations are possible to the handout and postcard design to include local hospital or rehab center contact information. Additionally, there is a new offering included in this round of ordering that was launched at the meeting: a new discharge packet sticker. These new sticker designs (Figures 3 and 4) can be affixed to the outside of a patient’s discharge folder and are meant to stand out to patients and families who are often inundated with discharge paperwork. They alert the patient that their discharge paperwork includes a referral to cardiac rehab as the next step in their care.

Figure 3. NewBeat Sticker Journey Design

Figure 4. NewBeat Sticker Golden Ticket Design

MiCR Mini Grant RFP Opens for Second Round

The summer meeting also included an announcement that MiCR’s mini grant program to fund small, local cardiac rehab quality improvement projects will similarly be re-opened for a second round of submissions. The first round resulted in the funding of projects at MyMichigan Midland, DMC Huron Valley Sinai, and Ascension Rochester. MiCR is accepting new submissions through Fri., Sept. 13 for up to $5,000 per project. Full details on the RFP and application are available on the MiCR website.

MiCR Updates & Meeting Materials

Finally, the MiCR leadership team announced the development of a neutrally-branded, customizable patient education video that can be shared with hospitals or rehab programs to play on their own websites or waiting room monitors. The video was developed in response to feedback from partner sites that online materials need to be improved and that neutral video content about the value of cardiac rehab is limited. MiCR developed a video for use by network partners and also identified several existing videos published by MillionHearts, Mayo Clinic, and others.

The MVC and BMC2 teams are looking forward to the Michigan Cardiac Rehab Network's fall in-person meeting on Fri., Nov. 8, from 10 a.m. to 3 p.m., at the H Hotel in Midland. MyMichigan is serving as co-host for the event in collaboration with MiCR. Additional event details will be shared in the coming weeks. Those who were unable to attend the summer meeting can view the meeting recording [LINK] or meeting slides [LINK]. Please reach out to info@michigancr.org with any questions.

12 Jun 2024
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MVC Introduces New Multi-Payer Cardiac Rehab Registry Reports

MVC Introduces New Multi-Payer Cardiac Rehab Registry Reports

June 12, 2024 | 0 Comments | , , ,

The MVC Coordinating Center added four new multi-payer reports to its online registry in April. These new reports evaluate cardiac rehabilitation utilization and encompass all metrics previously provided annually in MVC’s hospital-level cardiac rehab push report for acute myocardial infarction (AMI), percutaneous coronary intervention (PCI), heart valve repair or replacement (SAVR or TAVR), coronary artery bypass graft (CABG), and congestive heart failure (CHF). Each report reflects the most up-to-date available claims data from Blue Cross Blue Shield of Michigan (BCBSM) PPO Commercial, BCBSM PPO Medicare Advantage (MA), Blue Care Network (BCN) HMO Commercial, BCN MA, Medicare Fee-for-Service, and Medicaid insurance plans. Users may select any combination of cardiac conditions and insurance plans to assess in each report.

In addition to allowing dynamic selection of cardiac conditions and payers, the reports allow for customization of report date range (the span of episode start dates), episode length (the time period following each index event), and index place of service (e.g., inpatient, outpatient, emergency department). Users may also filter by patient characteristics including gender, age, and comorbidities (diagnoses prior to the index event). Other patient-level characteristics related to the reflected episode can also be filtered, including whether the patient was transferred during their index event, was diagnosed with COVID-19 during the index event or within 30 days post-discharge, and by certain diagnoses during the index event or within 90 days. Up to four comparison groups are offered for each figure: the collaborative-wide measure, MVC All; the measure among other hospitals in the region, Hospital Region; the measure among only hospitals of the same type, Acute Care/Critical Access Cohort; and the measure among other rural hospitals (if applicable), MHA Rural Hospital Cohort.

Cardiac Rehab Utilization Rates

The first of the four new report provides data on cardiac rehab utilization rates (Figure 1). This report includes a description of cardiac rehab benefits followed by two figures reflecting utilization rates among episodes of the desired condition and payer combinations after all selected filters have been applied. The first figure shows the overall rate of cardiac rehab compared to utilization goals set by the Michigan Cardiac Rehab network (MiCR) and Million Hearts®. The second figure shows utilization trends over time at the user’s hospital(s) and a selected comparison group. This full report and all other reports can be downloaded as a ready-to-print PDF or image file.

Figure 1. Cardiac Rehab Utilization Rates Report

Cardiac Rehab Utilization Rankings

The next report provides data on cardiac rehab utilization rankings, showcasing the ranked order of hospital-level utilization rates for a selected comparison group. For example, in Figure 2 there are data points for cardiac rehab utilization rates during AMI, CABG, PCI, SAVR, and TAVR episodes originating at MVC Hospitals A, B, and C between December 1, 2018, and November 30, 2023 compared to all other MVC general acute care hospitals. The average rate across all comparison hospitals is about 31%, and each point outlined in orange represents the rate at an individual comparison hospital. Again, this report and all others may be downloaded in a ready-to-share format.

Figure 2. Cardiac Rehab Utilization Rankings Report

The remaining new cardiac rehab registry reports provide visual hospital rankings in the same format as the utilization rankings report, but for two other measures: 1) mean days to first cardiac rehab visit, which ranks the average number of days from index discharge to patients’ first cardiac rehab visit (up to 365 days); and 2), mean number of cardiac rehab visits, which ranks the average number of cardiac rehab visits completed within a selected episode length. These reports offer the same dynamic filters and output capabilities.

All MVC registry users will have access to these reports to view the data for their site(s). If you do not have registry access and are interested in using the registry to view these data, you should complete MVC’s user access request form. If you have any questions or feedback about the new registry reports, please contact the Coordinating Center.

30 Nov 2023
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Michigan Cardiac Rehab Network Hosts In-Person Stakeholder Meeting at Trinity Health

Michigan Cardiac Rehab Network Hosts In-Person Stakeholder Meeting at Trinity Health

November 30, 2023 | 0 Comments | ,

The Michigan Value Collaborative (MVC) and the Blue Cross Blue Shield Cardiovascular Consortium (BMC2) recently held a successful 2023 Fall Michigan Cardiac Rehab Network (MiCR) Stakeholder Meeting on Fri., Nov. 17. This was the second in-person MiCR Stakeholder Meeting since MVC and BMC2 founded the MiCR partnership in 2022. The meeting brought together 63 individuals representing 28 organizations and was co-hosted by Trinity Health Ann Arbor’s cardiac rehab team.

The day’s agenda accounted for a variety of topics, including updates and material releases by the MiCR team, presentations and panel discussions about the new MVC and BMC2 pay-for-performance measures for cardiac rehab (see slides), advice and updates about cardiac rehab billing (see slides), recent findings about liaison-mediated referrals and their impact on cardiac rehab participation after percutaneous coronary intervention (see slides), and breakout groups to help brainstorm opportunities within various focus areas.

One unique and memorable aspect of the day was the ability to learn from the meeting’s hosts, Trinity Health Ann Arbor. Professional representatives from the site included Frank Smith, MD, Medical Director of the Intensive Cardiac Rehabilitation Program for the Ann Arbor and Livingston locations, and Mansoor Qureshi, MD, Medical Director of the Cardiac Catheterization Lab and Structural Heart Program for Ann Arbor, who provided opening remarks about the importance of facilitating provider buy-in and referrals. They emphasized cardiac rehab as a key high-value service to improve patient lives. Their slides can be viewed here.

They were also joined by Amy Preston, BS, CEP, Cardiac Rehab Manager and Exercise Physiologist, who organized optional tours of the Trinity Ann Arbor rehab space. Nearly all the meeting’s attendees opted to participate in the tours to learn about the unique spaces and strategies utilized at Trinity.

The MiCR team was also thrilled to announce the launch of New Beat, a multi-component intervention developed in partnership with the Healthy Behavior Optimization for Michigan (HBOM) team (see slides). The New Beat program’s interventions address specific barriers to patient participation, such as gaps in patient or physician knowledge about benefits, the need for stronger physician endorsement, and access issues resulting from transportation barriers. The offerings developed by MiCR and HBOM to support these New Beat strategies include MiCR’s new website (MichiganCR.org), patient- and provider-facing educational materials, cardiac care cards that can be signed by providers and delivered to patient rooms prior to discharge (Figure 1), and an Uber Health pilot. In particular, please note that the interest form on the MiCR website is now open for those interested in accessing these resources or requesting others.

Figure 1.

As of the Nov. 17 meeting, the 2024 CMS reimbursement rules for cardiac rehab had not been announced. Once they are, MiCR will help share those updates and related resources with its contacts. Please reach out to info@michigancr.org with any questions.

01 Jun 2023
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MVC’s 2023 Cardiac Rehabilitation Reports Shared with Hospitals

MVC’s 2023 Cardiac Rehabilitation Reports Shared with Hospitals

June 1, 2023 | 0 Comments | , ,

Participation in cardiac rehabilitation (CR) programs is a crucial strategy for improving cardiac health outcomes. Participation reduces the risk of all-cause and cardiovascular-specific mortality, reduces readmissions, and enhances the patient’s quality of life. Despite the identifiable benefits, Michigan patients underutilize this high-value program, falling well below the 70% participation goal set by the Million Hearts Initiative. Therefore, the Michigan Value Collaborative (MVC) and several of its partners have identified CR as a high-value service for which they endeavor to drive improvement.

In support of this effort, MVC recently distributed the 2023 version of its CR reports to members with data on CR-eligible patients following discharge for heart attack (AMI), heart valve repair or replacement (TAVR or SAVR), coronary artery bypass procedure (CABG), percutaneous coronary intervention (PCI), and congestive heart failure (CHF). These reports were generated using MVC claims-based episodes of care with patient index admissions between 1/1/19-12/31/21 for multiple insurance plans, including Blue Care Network (BCN) HMO Commercial, BCN Medicare Advantage, Blue Cross Blue Shield of Michigan (BCBSM) PPO Commercial, BCBSM Medicare Advantage, and Medicare Fee-for-Service.

Hospitals received data on a specific procedure or condition if they had no fewer than 20 cases in the reporting period for that condition/procedure. The report pages include figures for a variety of CR metrics, including participation rates after discharge, quarterly trends in participation between 2019-2021, mean days to first CR visit among participating patients, and the mean number of visits completed among participating patients.

MVC generates these hospital-level reports as a product of the Michigan Cardiac Rehabilitation (MiCR) Network, a partnership between MVC, Blue Cross Blue Shield of Michigan Cardiovascular Consortium (BMC2), and the Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative (MSTCVS-QC). The MiCR Network strives to increase participation in CR for all eligible individuals in Michigan.

Given the current status of CR participation across the state, the MiCR Network is tracking progress toward two utilization goals: 1) for 40% of all eligible AMI, TAVR, SAVR, CABG, and PCI (referred to as the “Main 5”) patients to attend at least one CR session within 90 days of their hospital discharge, and 2) for 10% of all eligible CHF patients to attend a single CR session within one year of a CHF-related hospitalization.

In developing these reports, MVC found that the collaborative-wide average participation rate within 90 days of discharge for the "Main 5" procedures was approximately 36%, below the statewide goal of 40%. Similarly, MVC’s analysis found 3.2% of eligible CHF patients participated within 365 days of discharge, 6.8% below the statewide MiCR goal of 10%.

The report also offers patient population demographics intended to help hospitals identify disparities in participation. Research evidence suggests that white males are more likely to utilize CR than women or patients of color, likely due to several socioeconomic and cultural factors. Hospitals are encouraged to consider any gaps showcased in their demographic snapshot and consider the provision of additional, tailored strategies that increase referral and participation among those patients.

Other high-level findings from the report included varying averages in CR participation by the procedure type. CABG and SAVR, more clinically invasive procedures, had the highest utilization rates at 54.9% and 51.3% respectively, whereas patients being treated for the chronic condition of CHF were the least likely to attend (3.2%). There is also wide interhospital variation in utilization rates for each procedure. For example, the collaborative-wide CR utilization rate after PCI is 32%, but hospital rates range from just above 10% to nearly 60% (Figure 1).

Figure 1.

This variation aligns with published research on hospital-level variation in CR referral, even after accounting for patient characteristics, insurance status, and clustering within operators and hospitals. It also demonstrates that quality improvement is possible, with multiple sites in the collaborative excelling.

Several of the Collaborative’s top-performing sites and experts worked together last year to develop the MiCR Best Practices Toolkit. It includes several evidence-based strategies for increasing enrollment and participation, with step-by-step guidance and resources. Among the various best practices, there are pages dedicated to automating inpatient referrals, early and flexible scheduling approaches, and strategies that help reduce participation barriers for patients (e.g., lack of transportation, lack of reimbursement for CR sessions, etc.).

MVC encourages those working in this space to save the date for the MiCR Fall Stakeholder Meeting in Ann Arbor on Friday, October 27, from 10 a.m. to 3 p.m. It is a valuable opportunity to connect with peers and experts who can offer support or resources. Please contact the MVC Coordinating Center if you are interested in attending and haven't received the event's Save the Date, or if you would like more details on this report and other upcoming CR events.

27 Oct 2022
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First Annual MiCR Meeting Draws Cardiac Rehab Stakeholders

First Annual MiCR Meeting Draws Cardiac Rehab Stakeholders

October 27, 2022 | 0 Comments | , , ,

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

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

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

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

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

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

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

Figure 1.

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