In March, the Michigan Value Collaborative (MVC) hosted two workgroups highlighting innovative strategies to improve care transitions and expand access to care across Michigan. A rural health workgroup explored how McKenzie Health System implemented remote patient monitoring to support patients with chronic conditions. MVC’s post-discharge follow-up workgroup featured a presentation from MyMichigan Health on the development of a continuing care clinic designed to improve post-discharge follow-up and reduce hospital readmissions.
Together, these presentations demonstrated how healthcare organizations can leverage care coordination, technology, and new care delivery models to improve patient outcomes across the continuum of care. The MVC Coordinating Center hosts one to two workgroup presentations per month covering a variety of topics including post-discharge follow-up, sepsis, cardiac rehabilitation, rural health, preoperative testing, and health in action.
Rural Health Workgroup – McKenzie Remote Patient Monitoring
The first workgroup of the month featured a presentation led by Heather Baumeister, BSN, RN, CRHCP, Director of Healthcare Practices at McKenzie Health System, who shared how her organization implemented a remote patient monitoring (RPM) program to better support patients living in rural communities.
McKenzie Health System includes a 25-bed critical access hospital (CAH) located in Sandusky, Michigan. The organization also operates six primary care clinics across multiple communities throughout the Thumb region offering several specialty services such as gastroenterology, orthopedic care, general surgery, and behavioral health. Like many rural health systems, McKenzie serves a geographically dispersed patient population where travel distance and limited healthcare resources can make frequent in-person visits difficult. To help bridge these gaps, Baumeister said, the organization relies heavily on care coordination.
McKenzie currently employs three full-time and one part-time registered nurse care coordinators who support primary care clinics across the system. Baumeister described how these coordinators conduct daily follow-ups with patients seen in the emergency department and help connect patients without an established primary care provider to appropriate outpatient care. Care coordinators also participate in monthly readmission review meetings to identify patients who may benefit from additional care management services and reduce avoidable hospitalizations.
Launching a Remote Patient Monitoring Program
To expand its ability to monitor patients between visits, McKenzie Health System participated in an 18-month pilot program focused on RPM for rural health systems. After completing the pilot, McKenzie established a long-term partnership with an RPM vendor to manage several operational aspects of McKenzie’s RPM program, including device shipping, monitoring, nurse outreach for readings outside clinical thresholds, uploading data into the electronic health record (EHR), and billing services. Baumeister said this helped clinicians at McKenzie to integrate RPM into their care model without needing to manage the technical infrastructure internally.
Providers refer patients to the program through the organization’s EHR. After receiving a referral, the RPM vendor enrolls the patient and distributes the appropriate monitoring devices. Patients enrolled in the program receive connected monitoring devices that automatically transmit readings directly to the monitoring platform after patients begin taking measurements. Devices currently used include blood pressure cuffs, weight scales, blood glucose monitors, and pulse oximeters. If readings fall outside predetermined ranges, a monitoring nurse contacts the patient to assess symptoms and determine whether clinical intervention is needed. If necessary, the nurse escalates the case to the patient’s provider according to established care protocols.
Implementing the program in a rural context presented several challenges. Baumeister described how unreliable internet near Michigan’s lakeshore, difficulty reaching patients by phone, and excessive measurement were challenges in delivering the program.
Benefits of RPM Program
Baumeister said the RPM program is particularly beneficial for patients managing chronic conditions like congestive heart failure, diabetes, hypertension, chronic obstructive pulmonary disease, and obesity. This is because remote monitoring enables care teams to detect early warning signs of health deterioration that might otherwise go unnoticed between routine visits so providers can intervene proactively. Baumeister gave examples such as adjusting medications, scheduling follow-up appointments, or providing additional education before conditions worsen.
She also noted that many patients became more engaged in their own care through the program, as regular monitoring helped them better understand how lifestyle choices affect their health. View the complete workgroup recording using the video below.
MVC Rural Health Workgroup: March 3, 2026
Post-Discharge Follow-Up Workgroup – MyMichigan Health Continuing Care Clinic
MVC’s second March workgroup featured a presentation by Steven Frazier, MHA, BA, RN, ACM-RN, Director of Quality and Patient Safety for Post-Acute Services at MyMichigan Health, and Dr. John Hagan, DO, Family Medicine Physician and Medical Director of the Continuing Care Clinic at MyMichigan Health. Their presentation highlighted the MyMichigan Health Continuing Care Clinic (CCC), a program designed to ensure patients receive timely follow-up care after hospitalization and to reduce hospital readmissions. Frazier previously presented about the establishment of the CCC program at MVC’s May 2024 collaborative-wide meeting, and this month provided a number of updates on progress in the program to date.
MyMichigan Health serves more than one million Michigan residents across a 26-county region, with multiple medical centers and roughly 1,100 hospital beds. Despite this extensive network, MyMichigan recognized that many patients faced barriers to obtaining timely follow-up care after leaving the hospital, citing limited appointment availability with primary care providers as well as patients without established providers struggling to navigate the healthcare system.
Frazier and Hagan said internal MyMichigan data revealed hospital readmissions were often occurring 12-13 days after discharge, highlighting a critical window when follow-up care could potentially prevent complications. Research also suggested that follow-up with a physician within seven days of discharge could significantly reduce both readmission and mortality risk for patients hospitalized with conditions such as heart failure, myocardial infarction, and COPD.
Launching and Evolving the Continuing Care Clinic
To address these gaps in care, MyMichigan Health opened the CCC in Midland, Michigan in August 2023. The clinic now operates with two locations (Midland and Alma) and three providers, supported by a multidisciplinary care team. The clinic was designed to function as a transitional care bridge, ensuring patients receive follow-up care within seven days after discharge while they wait to reconnect with their primary care providers. Services currently range from follow-up visits and assistance with establishing a primary care provider to behavioral health support and advance care planning.
Since its launch, the clinic’s role has expanded beyond its original focus on hospital discharge visits to support patients who are transitioning between primary care providers, are new to the community’s providers, need additional support navigating the healthcare system, or are seeking follow-up after emergency or urgent care visits. This evolution has allowed the clinic to function as a comprehensive transitions-of-care hub within the MyMichigan Health system.
Early Results and Impact
According to Frazier and Hagan, the CCC has already demonstrated encouraging results, saying that the program helped the health system achieve lower readmission rates compared to peers and maintain short scheduling lead times for follow-up appointments. Additionally, MyMichigan has seen an improvement in operational efficiency and budget performance with the expansion of services to additional geographic regions within the system. The program has also helped bring new patients to the MyMichigan Health network by connecting individuals without primary care providers with internal ongoing care relationships.
Patient feedback has been an important indicator of the clinic’s success, the presenters noted. Patient testimonials were shared during the presentation that emphasized how the clinic helped patients better understand their diagnoses, feel supported during recovery, and access care more easily after discharge. Patients described the clinic as a valuable resource that provided compassionate care and guidance during a vulnerable time in their healthcare journey. View the complete workgroup recording using the video below.
MVC Post-Discharge Follow-Up Workgroup: Mar. 19, 2026
Key Takeaways for MVC Members
The March workgroups highlighted two practical approaches to improving patient outcomes across the care continuum, with several key themes emerging. For one, remote patient monitoring is expanding access to care by helping teams identify early warning signs and better manage chronic conditions—especially in rural communities. At the same time, dedicated transition clinics are strengthening post-discharge care by ensuring timely follow-up and support after hospitalization.
Across both models, strong care coordination remains essential, supported by multidisciplinary teams, clear communication, and sometimes newer technologies. Just as important, patient engagement continues to drive better outcomes by empowering individuals to take a more active role in their care.
Through these shared examples, MVC workgroups continued to support collaboration and help organizations across Michigan identify actionable strategies to improve quality, outcomes, and value. 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, engagement offerings, or would like to present at a future MVC workgroup.
