Deb Evans is the MVC Site Engagement Manager
The Michigan Value Collaborative (MVC) Congestive Heart Failure (CHF) workgroup has had a productive year of virtual meetings and many useful discussions about a variety of topics that can influence reducing readmissions. Every other month, in collaboration with I-MPACT, another Blue Cross Blue Shield of Michigan quality improvement collaborative focusing on transitions of care, the group has held discussions on a variety of topics pertaining to CHF. The MVC Coordinating Center will be opening up the workgroup for other hospitals to join in 2018 and additional information can be found below. A synopsis of the findings of each 2017 workgroup discussion is detailed below, although more details can be found on the MVC registry under the resource tab or by contacting the Coordinating Center.
Using Skilled Nursing Facilities: This discussion encouraged working closely with skilled nursing facilities to help provide education to staff, patients, family members and care givers in respect to fluid intake and nutrition. Additionally, the discussion included how to allow staff to facilitate medication administration and finding alternative ways of medication delivery such as giving Lasix via intramuscular injection rather than intravenously.
CHF Referrals to Palliative Care: The discussion centered around getting this patient population referred to palliative care as soon as possible in the course of their disease process. The conversation included triggers for referral along with some benefits of being in a palliative care program and initiatives that Michigan hospitals had implemented or were working on implementing in relation to palliative care programs in their facilities.
Use of Outpatient Heart Failure (HF) Clinics: The group discussed the effectiveness of having a HF clinic to refer their CHF patients too and how attendance at these clinics had helped reduce CHF readmission rates. Some hospitals discussed the collaborative work they had done to implement a HF clinic in their facility. Templates of business plans were provided and members provided information on how they had presented and made the case to open a HF clinic at their facility. An interview with a Michigan hospital ranked number 3 in the country was utilized for a blog post.
Diet and Nutrition Education: Some dieticians from member hospitals joined us to discuss the tools and information they share with HF patients at their facilities. Information sheets containing information on alternative spices to use instead of salt were shared and also initiatives and education on how to provide heart healthy meals to patients either by the facility or via a vendor such as Meals on Wheels.
Medication Reconciliation: Pharmacists joined the discussion about their role or potential role in medication reconciliation and also provided some recommendations for the use of different stakeholders in the medication reconciliation process, not only for CHF patients but for other patient populations too. Some facilities discussed how they have also integrated parts of the reconciliation process into their electronic health record systems.
The CHF longitudinal workgroup will be continuing into 2018 with more discussion topics pertaining to CHF and opportunities for collaboration. If you are interested in joining the workgroup, please sign up here. Further details will be provided in 2018.
If you have any questions about the workgroup or 2018 workgroup registration please contact Abeer Yassine (firstname.lastname@example.org) or Deb Evans (email@example.com)
Chad Ellimoottil MD, MS is Director of Analytics for MVC and is an Assistant Professor and urologist at the University of Michigan.
Telemedicine use is rapidly growing in the state of Michigan and is increasingly gaining the attention of health system leaders, payers and policymakers as a way to improve value in quality of care for patients. Telemedicine is defined as the delivery of healthcare services and clinical information using telecommunications technology. Telemedicine can be synchronous (real-time) or asynchronous (also called store-and-forward). There are several commonly used telemedicine modalities:
- Video visit: A form of provider-to-patient telemedicine whereby a clinician conducts an office visit with a remotely located patient using live video
- eConsult: A form of provider-to-provider asynchronous telemedicine whereby a primary care physician sends a specialist a brief question to avoid a formal consultation
- eVisit: A form of provider-to-patient asynchronous telemedicine whereby a patient submits a question or photo and a clinician answers it a later time
- Remote patient monitoring: A form of provider-to-patient synchronous telemedicine whereby a patient is monitored by clinical staff at home using a device
- mHealth: All forms of telemedicine that are conducted using mobile applications
The growth of telemedicine in Michigan has been fostered by forward-thinking commercial payers including Blue Cross Shield of Michigan and Blue Care Network who have been telemedicine friendly. For example, in January 2016, Blue Cross Blue Shield of Michigan began reimbursing for telemedicine visits conducted by patients at home. As we move beyond the early adoption phase, it is helpful to think about ways that telemedicine may be able to help reduce episode spending. For more information click here.
Telemedicine interventions such as post-hospitalization video visits and remote patient monitoring may help reduce readmissions for conditions such as congestive heart failure. For example, by engaging the patient one-week after discharge using a video visit, clinicians can ensure that the patient is complying with discharge medications and that he/she understands important dietary recommendations. A video office visit may be more convenient for a patient who has transportation issue. In addition, daily remote monitoring of the weight of patients with congestive heart failure may help clinicians intervene before a hospitalization occurs. While the opportunities are promising, it is important for health system leaders to know that many studies have shown mixed results on the association between telemedicine use and readmissions [1-2].
Reducing emergency rooms visits
Telemedicine is used in two main ways in the ER. First, telemedicine can be used in the ER itself to help connect ER physicians to specialists. Second, telemedicine can be used to prevent patients from arriving in the ER by offering them a faster solution at home. This latter promise of reduced expensive emergency room visits has been driving much of the momentum for telemedicine adoption. Several studies have shown that telemedicine has the potential to reduce unnecessary, low-complexity, ER visits, however, the verdict is still out there [3-4].
Telemedicine offers a number of opportunities to help reduce episode spending. As the technology gains traction with payers and health systems, it will be important to build an evidence base to support its use in an optimal way.
- Feltner C, et al. Transitional care interventions to prevent readmissions for persons with heart failure: a systematic review and meta-analysis. Ann Intern Med. 2014 Jun 3;160(11):774-84.
- Comín-Colet J et al. Impact on clinical events and healthcare costs of adding telemedicine to multidisciplinary disease management programmes for heart failure: Results of a randomized controlled trial. J Telemed Telecare. 2016 Jul;22(5):282-95.
- Ward MM. Systematic review of telemedicine applications in emergency rooms. Int J Med Inform. 2015 Sep;84(9):601-16.
- Uscher-Pines L, Mehrotra A. Analysis of Teladoc use seems to indicate expanded access to care for patients without prior connection to a provider. Health Aff (Millwood). 2014 Feb;33(2):258-64.