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	James L. Holly, M.D.

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Letters - Letter to NQF About SETMA’s Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan: NQF’s Helen Burstin’s Response and ABFM’s Bob Phillips Sharing SETMA’s Work with CMS and AHRQ Leadership and His Judgment of the Potential Value of SETMA’s Work to NQF, CMS and CMMI

Dr. Holly’s 9.15.13 September 15, 2013 7:06 AM note to NQF about Hospital Care Summer and Post Hospital Plan of Care and Treatment Plan

Helen Burstin’s September 15, 2013 7:38 response to number 1

Dr. Holly’s 9.15.13 September 15, 2013 8.40.13 response to number 2

This is Bob Phillips’ 9.16.13 7 AM response to Helen Burstin’s 9.15.13 7:38 AM note above

This is Bob Phillips’ 9.16.13 7:12 AM response to my 9.15.13 8:40 AM and to my 9.15.13 7:06 AM notes to Helen Burstin

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From: James L. Holly
Sent: Sunday, September 15, 2013 7:06 AM
To: 'Floyd Eisenberg'; 'Helen Burstin'; Janet Corrigan; 'kadams@qualityforum.org'; 'Lindsay Lang'; 'Michelle Robinson'; 'Nadine Allen'; Sarah Callahan; Shana Campbell; 'Sheera Rosenfeld'; Tom Valuck; 'Wendy Vernon'
Subject: The fruit of National Quality Forum's September 2010 Care Transitions Conference

Southeast Texas Medical Associates (SETMA) continues to benefit from the National Quality Forum’s work both in Transitions of Care and in the public reporting by provider name of NQF endorsed quality metrics. In September, 2010, at the National Priorities Partnership Convened by The National Quality Forum Care Coordination Convening Workshop, Washington D.C. September 1-2, 2010, SETMA determined to change the name of the Hospital Discharge Summary to the Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan. We succeeded in doing that.

In the ensuring 36 months, SETMA has discharged over 12,000 patients from the hospital. 98.7% of the time, this transition-of-care document has been prepared at the time the patient leaves the hospital. The following is the link to the tutorial which explains SETMA’s deployment of this new patient-activation and patient-engagement document: Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan Tutorial.

The annual cost to SETMA of this performance, along with the work of SETMA’s Care Coordination Department’s care-coaching-call the day after the patient leaves the hospital is over $1,550,000 (hospital care team €“ annual cost $1,200,000 €“ Care Coordination Department -- $350,000) . None of this cost was reimbursed prior to this year. With the advent in January, 2013 by CMS of the Transitions of Care Management Codes (see SETMA’s deployment at http://jameslhollymd.com/epm-tools/transition-of-care-management-code-tutorial), about a third of this cost is now compensated making this work more sustainable.

The following links direct you to SETMA’s public reporting by provider name of the Physician Consortium for Performance Improvement Transition of Care Quality Metric Set. This is a measure of our efficiency and consistency in fulfilling the standards of excellence in Transitions of Care. Along with over 300 other quality metrics, SETMA continues to increase our transparency of care for the welfare of our patients.

In addition to the Transition so Care Audit and others, we report on the following NQF Metrics:

We take NQF’s work along with that of IHI, AMA’s PCPI, and other publishers of standards of care seriously and have worked hard to translate them into our practice of medicine. It is our hope that in at least a small way our efforts are gratifying to you and that it represents our expression of appreciation of your mission and work.

James (Larry) Holly, M.D.
C.E.O. SETMA
www.jameslhollymd.com

Adjunct Professor
Family & Community Medicine
University of Texas Health Science Center
San Antonio School of Medicine

Clinical Associate Professor
Department of Internal Medicine
School of Medicine
Texas A&M Health Science Center

This is Helen Burstin’s response to my 9.15.13 7:06 AM note above

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From: Helen Burstin [mailto:hburstin@qualityforum.org]
Sent: Sunday, September 15, 2013 7:38 AM
To: James L. Holly; Christine K. Cassel
Cc: Karen Adams; Michelle Robinson; Nadine Allen; Tom Valuck; Wendy Prins
Subject: Re: The fruit of National Quality Forum's September 2010 Care Transitions Conference

Dr. Holly,

Thanks so much for sharing the fruit of your labors. It is very gratifying to see how our work can help drive improvement. We really appreciate your feedback on the measures that have aided your transitions work. We have built a continuous feedback loop into the QPS and would welcome implementation comments on the measures that work as well as those that add burden rather than value to your work. I have copied Dr. Chris Cassel, NQF's new CEO on this note. I know she will greatly value this kind of input as we consider NQF's future directions.

Thank you so much for the connection to the front lines of measurement and improvement!

Best,
Helen

This is my response on Saturday morning 9.15.13 at 8:40 AM to Helen Burstin’s 9.15.13 7:38 AM note above

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From: James L. Holly
Sent: Sunday, September 15, 2013 8:40 AM
To: Helen Burstin
Cc: Christine K. Cassel; Karen Adams; Michelle Robinson; Nadine Allen; Tom Valuck; Wendy Prins
Subject: Re: The fruit of National Quality Forum's September 2010 Care Transitions Conference

Thank you for your response. The link below is to SETMA's 59-page response to the Robert Wood Johnson Foundation's request for information about SETMA as they selected 30 Exemplar practices to study. We have been selected for the LEAP Study funded by RWJF and conducted by The MacColl Institute.

This document is referenced because in section 2, 3 and 4, we address:

1. Quality Metrics Philosophy
2. Quality Metrics and Population Health
3. Limitations of Quality Metrics

http://jameslhollymd.com/letters/Robert-Wood-Johnson-Foundation-PCT-LEAP

The critical concepts of metrics for SETMA are:

1. Metrics should be fulfilled incidental to excellent care not as the intent of that care.
2. Metrics must be tracked at the point of care at the individual patient level.
3. Metrics must be audited at the population or panel level.
4. Trough Analytics and statistical analysis metrics must be studied at the practice level to find effective points of leverage through which to improve care delivery.
5. Provide Performance by name must be transparently and publicly published at the patient level individually and at the panel and practice level publicly.
6. Quality Improvement Initiatives must be driven by these concepts.

James (Larry) Holly, M.D.
C.E.O. SETMA
www.jameslhollymd.com

This is Bob Phillips’ 9.16.13 7 AM response to Helen Burstin’s 9.15.13 7:38 AM note above

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From: Bob Phillips [mailto:bphillips@theabfm.org]
Sent: Monday, September 16, 2013 7:00 AM
To: James L. Holly
Subject: RE: The fruit of National Quality Forum's September 2010 Care Transitions Conference

Larry

I just shared this with leadership at CMS/CMMI and AHRQ. Very interesting

Bob

This is Bob Phillips’ 9.16.13 7:12 AM response to my 9.15.13 8:40 AM 9.15.13 7:06 AM notes to Helen Burstin

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From: Bob Phillips [mailto:bphillips@theabfm.org]
Sent: Monday, September 16, 2013 7:12 AM
To: James L. Holly
Subject: RE: The fruit of National Quality Forum's September 2010 Care Transitions Conference

Larry

Your work in costing out the implementation of these measures is very unusual and creates a logical interface between NQF and CMS/CMMI. With the strong emphasis on moving to value-based purchasing, you may be one of the few places they can get a grip on what the costs and savings could be. Your philosophy, outlined below, is also very important to doing this right. I really do hope we can make that more visible and create a conversation with SETMA as the seed.

Bob

9.15.13 Letter to NQF About SETMA’s Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan - NQF’s Helen Burstin’s Response and ABFM’s Bob Phillips Sharing SETMA’s Work with CMS and AHRQ Leadership and His Judgment of the Potential Value of SETMA’s Work to NQF, CMS and CMMI

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