How Michigan Hospitals Utilize Technology to Track and Target Heart Failure Care

With the ultimate goal of helping Michigan hospitals achieve optimal patient outcomes at the lowest reasonable cost, Michigan Value Collaborative (MVC) provides a variety of services and resources to hospitals including a data registry and engagement opportunities, such as clinically focused workgroups.

The MVC heart failure workgroup provides hospital leaders with an accessible virtual platform to share best practices and gain a better understanding of current issues facing hospitals throughout the state of Michigan. Each 90-minute workgroup discussion is focused on a specific topic and hospital representatives from across Michigan engage in a collaborative dialogue reviewing data, best practices, resources, and challenges. In 1 workgroup discussion, hospital participants shared how they have utilized technology to enhance care for heart failure patients. Below are some highlights of these resources and initiatives.

Enhancing Existing Electronic Medical Record Systems

One participating hospital, an avid workgroup and collaborative participant shared how it worked to enhance technology by developing tracking tools for focused efforts, such as a Readmission Reduction Module located within the electronic medical record system. This module helps clinical staff identify and stratify patients at risk for readmission and is focused on medical conditions such as heart failure, chronic obstructive pulmonary disease, acute myocardial infarction, and pneumonia.

Within this module, each patient receives a readmission risk score. This risk score is developed using factors derived from the evidence-based Better Outcomes for Older adults through Safer Transitions (BOOST) model, a national initiative led by the Society of Hospital Medicine. The clinical staff identifies patients with high risk scores and consequently works more closely to address social determinants of health that may bring them back to the hospital. Once patients go home, there are follow-up questions based on discharge status that are communicated via telephone with them for a minimum of 30 days. As a result of this effort, the hospital has seen a downward trend for readmissions.

Telehealth for Better Health

A couple of Michigan hospitals have also worked to implement telehealth opportunities for chronic disease management. One hospital developed a program to help enhance home healthcare postdischarge by providing patients with telemonitors and supporting equipment for 30 days. At home, nurses help provide support to the patient through education and tracking of outcomes and vitals. This not only helps strengthen an understanding of disease management at home but has also helped better educate patients and build stronger provider-patient relationships. Outcomes such as readmission rates have been observed throughout the use of this technology and show a positive impact on patients.

Similarly, another hospital uses the WellOpp telehealth program to develop a tool to follow patients after they are discharged via text messages. Upon discharge, patients receive a survey and associated text messages with health education videos embedded within them. A referral system for a local 2-1-1 agency is also incorporated into the application, which is used to assist with accessing food resources, transportation, or mental health resources. Hospital staff utilizes a dashboard to help inform them of the text message schedule and patient interaction within the program.

In all, hospitals are constantly striving to find ways to best integrate technology into workflows. Although some barriers naturally exist, hospital clinical staff and administrators should work towards addressing these barriers in an effort to best support patients. Michigan hospitals participating in the MVC heart failure workgroup have nonetheless shared valuable insights to initiatives, challenges, and how they work to address barriers within their hospitals when instituting new initiatives or technology. This workgroup’s best practice sharing has been helpful to a better understanding of how hospitals are working towards improving the care experience for patients.