JamesLHollyMD.com

	James L. Holly, M.D.

About SETMA Joint Commission Contact Information History Mission Statement Medical Home Scope of Services I-CARE Initiative Infusion Center The SETMA Way - What is it? SETMA's Model of Care Patient-Centered Medical Home The SETMA Approach to Patient Care	In The News Letters Vital Signs - Examiner Publication SETMA's Providers as of January, 2015 SETMA Knows - Abraham Lincoln and Healthcare Analytics SETMA – 1999 – Four Seminal Events PC-PCC Award January, 2015 Vital Signs Spring 2015 Vital Signs Q&A for PC-PCC Award Links to SETMA 2012 eHealth Innovator Award for LESS initiative Handout for Attendees eHealth Conference January 12, 2012 eHealth Initiative 2012 Award Program Application The eHealth Initiative's 2012 Award Letter 2012 National Quality Forum National Healthcare Improvement Award Effective prioritization of performance improvement goals Dashboard to Measure and Manage Whole System Performance Commitment to transparency Date-driven improvement of NQS priorities Demonstration of readiness to assume responsibilities of an ACO Demonstrated results on publicly reported performance measures Public Reporting Quality Metrics for 2009, 2010, 2011 Internally Tracked Reporting Quality Metrics for 2009, 2010, 2011 Complete Application in PDF Format SETMA's Medical Home Pilgrimage 2009 Medical Home Series I 2010 Medical Home Series II 2011 Medical Home Series Two 2009, 2010, 2011 Medical Home Miscellaneous Articles The Dr. and Mrs. James L. Holly Distinguished Professorship Universal American Letter of Transmittal for Support Dr. Holly's Acceptance Address for the 2012 Distinguished Alumnus Award CMS Medical Home Feedback Report Qualify & Cost SETMA questions Influenza Data SETMA I - October 2011 SETMA II - October 2011 Mark A. Wilson Clinic SETMA West - October 2011 SETMA and Fox 4 News - Healthy Living Videos SETMA Advertisements - Display and Video SETMA Announcements Featured Content Archive	Syllabus PC-MH Externship SETMA's MS4 Patient-Center Medical Home Selective Syllabus Introduction to SETMA's Senior Externship and Syllabus An Introduction to the Origins and Beginnings of Southeast Texas Medical Associates, LLP Patient-Centered Communication PC-MH Health Affairs August 15, 2013 Policy Brief -- Health Gap SETMA 8.20.13 Provider Training -- Health Affairs 2.14.13 -- Patient Engagement SETMA Provider Training 8.20.13 during First Senior Medical Student PC-MH Externship Medical Home Coordination Review Tutorial 2011 Medical Home Series Two Teaching Tool for PC-MH Course - Patient Care Activation, Engagement, Shared-Decision Making	Patient Information What Does Patient-Centered Medical Home Mean to You? What Does Patient-Centered Medical Home Mean to You? Health information exchange Patient Rights and Responsibilities Patient Directions Contact SETMA – Secure Texting What is HIPAA? Authorization To Release or Obtain Medical Records Complete Privacy Policy Website Privacy Policy	Presentations Invited Presentations SETMA Provider Training
Governance Board Governance Board Responsibilities Governance Board Leadership Training The SETMA Team and The SETMA Culture SETMA's Mission, Vision and Goals: Patient Safety and Quality Care Harassment, Neglect, Abuse, Exploitation - Role of HCAHPS & CAHPS Healthcare Provider Standards Providers Responsibility Medication Refills, Reconciliation and Maintenance Provider and Leadership Use of Data and Analytics Commitment To All Patients -- Ethnic Disparities Kaizen - Board Creates Culture of Safety and Quality SETMA's Policy and Practice for Advanced Directives SETMA's Policy on Completion of Medical Records Care Guidelines : Improve processes to evaluate and treat Integrated patient safety program (Sentinel Events) Effectively Manages all programs, services or sites Provides Patients with information about Primary-care Medical Home Organization-wide Planning to Maintain Focus on safety and quality Organization-wide Planning to Maintain Focus on safety and quality SETMA's Performance Quality & Safety Judged by CMS SETMA's Performance Quality & Safety Judged by CMS SETMA Awarded by HIMSS for Quality and Safety 2011 John M. Eisenberg Patient Safety and Quality Awards Application Healthcare Quality Award 2012 Principles of Quality and Metrics Principles Contacting SETMA & Secure Texting PC-MH Mission, Vision, Goal, Access, End-of-Life Communications and Public Reporting Change Existing Processes to Improve Performance Team Members Focused on Safety and Quality	Your Life Your Health View Articles by Subject Aging Well Behavioral Health Cardiovascular Disease Risk Care Coordination Care Transitions Children's Health COGNOS Project Diabetes Exercise Healthcare Reform:Public Policy HIPAA & Security Labor Day Less Initiative Medical Home Medical Records Men's Health Mental Health Nutraceuticals Nutrition Smoking Cessation Thanksgiving Weight Management Women's Health All Articles	Public Reporting Public Reports by Year (2009-2017) Public Reports by Type Fall Risk, Pain, Functional, Wellness, Stress Assessment Fall Risk, Pain, Functional, Wellness, Stress Assessment for 2011 AND 2012 Core Measures: SETMA & Baptist Hospital Core Measures for January to December 2011 PQRS Diabetes Measures - Blood Pressure Diabetes Measures - Glyco and LDL Diabetes Measures - Nephropathy Screening, Foot Exam, and Eye Exam Preventive Measures - Screening (BMI, Colorectal Cancer, Mammography, Osteoporosis) Preventive Measures - Influenza, Pneumococcal, Urinary Incontinence Preventive Measures - Tobacco Use NQF Care for Older Adults Comprehensive CHF Care Diabetes Measures Diabetes Measures - Blood Pressure Control Diabetes Measures - Glyco and LDL Diabetes Measures - Smoking Cessation Female Measures General Health Measures Medication Measures Persistent Medications Medication Measures Pediatric Measures HEDIS (NCQA) Effectiveness of Acute Care Effectiveness of Chronic Care - Clinic/Hospital Effectiveness of Chronic Care - Clinic Only Effectiveness of Chronic Care - Diabetes (Smoking Cessation) Effectiveness of Chronic Care - Diabetes (Glyco and LDL) Effectiveness of Chronic Care - Diabetes (Blood Pressure Control) Effectiveness of Preventive Care Effectiveness of Preventive Care - Older Adults Effectiveness of Chronic Care - Diabetes Measures Effectiveness of Chronic Care - Persistent Medications (MPM) NCQA Diabetes Recognition Program Audit LESS Initiative PCPI PCPI Hypertension PCPI Diabetes PCPI Chronic Stable Angina PCPI Care Transitions PCPI CHF PCPI Weight Management PCPI CKD Stages IV V SETMA Lipid Audit Lipids Treatment Audit Tutorial Lipids Tutorial AQA COGNOS Project SETMA Audit for CKD Stages I III Patient Satisfaction Survey	Accreditations/Awards Achievements which have Advanced SETMA: The Time-line, Philosophy and Principles which Underlie that Advancement Awards	Diabetes Center of Excellence Education Diabetes Order Referral Form Seven Stations 2011 Advances in Diabetes Diabetes Tutorial Diabetes Prevention
EPM Tools Association of Medication and Diagnosis Automated Team Function Behavioral Health Adult Weight Management Tutorial Annual Questionnaires: Fall, Functional, Pain, Stress, Wellness Behavioral Health in SETMA's Patient-Centered Medical Home Model of Care Depression Tutorial Fall Risk Tutorial Health Insurance Portability and Accountability Act (HIPAA) Privacy Tutorial Intensive Behavioral Therapy (IBT) Obesity and Cardiovascular Disease Medicare Preventive LESS Initiative Tutorial Medical Home Transtheoretical Model Assessment Stages of Change Tutorial Pain Management Tutorial Reduction of Antipsychotic Medications Toolkit Smoking Cessation Tutorial Stratifying End-of-Life Risk for Hospice Services Tutorial Chronic Conditions Tutorial Chronic Renal Disease Management Tool Tutorial Calculating the Stages of Renal Disease Proteinuria Disease Management Tools Acute Coronary Syndrome Tutorial Adult Weight Management Tutorial Angina Tutorial Cardiometabolic Risk Syndrome Tutorial Chronic Renal Disease Tutorial Congestive Heart Failure Tutorial Diabetes Tutorial Hypertension Tutorial Lipids Tutorial Lipid Quality Audit Tutorial Primary Pulmonary Hypertension Tutorial Framingham Cardiovascular Risk Cardiometabolic Risk Assessment Framingham Heart Study Risk Calculators Tutorial Frederickson Classification of Dyslipidemia LDL Level Lipid Disease Management Risk Assessment General principles about ICD-9 Codes and HCC/RxHCC Codes Charge Posting Tutorial Coding to Ensure Accurate Health Risk Scoring E & M Codes Tutorial HCC & RxHCC Risk HCC/RxHCC Risk Tutorial ICD-9 Code Training Manual Hepatitis Screening Hospital Based Tools Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan Tutorial Admission Orders Tutorial Daily Progress Notes Tutorial Care Transition Data Set from PCPI Tutorial Using The Clinic and Hospital Follow-up Call Templates Respiratory Failure Tutorial Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS): Tutorial for SETMA's Internal HCAHPS Survey Master GP Suite of Templates Master GP Suite of Templates Tutorial Medical Home Support Materials Department of Care Coordination, Director of Care Coordination and Care Coordination Referral Template Electronic Tickler File Electronic Tickler File Tutorial Follow-up Calls Intensive Behavioral Therapy (IBT) Obesity and Cardiovascular Disease Medicare Preventive Services Medical Home Coordination Review Tutorial Medical Home Plan of Care and Treatment Plan Medical Home Transtheoretical Model Assessment Stages of Change Tutorial Patient-Centered Medical Home Annual Questionnaires Patient-Centered Medical Home: SETMA's Medical Home Coordination Review (MHCR) Tutorial Patient Document for Coordination of Care Transitions of Care Management Coding (TCM Code) Tutorial Merit-Based Incentive Payment System (MIPS) Quality Metric Tool Tutorial Nursing Home Depression Tutorial Fall Risk Tutorial Hydration Assessment Tutorial Nursing Home Guidelines for Care Tutorial Nursing Home Principal Suite of Templates Nutrition Assessment Tutorial Reduction of Antipsychotic Medications Toolkit Skin Care Tutorial Outpatient Infusion Center for Intravenous Antibiotic Therapy and Other Meds Preventive Health Tools Adult Weight Management Tutorial CHF Exercise Tutorial Diabetic Exercise Tutorial Diabetes Prevention Tutorial Exercise Prescription Tutorial Hypertension Prevention Tutorial Intensive Behavioral Therapy (IBT) Obesity and Cardiovascular Disease Medicare Preventive Initial Preventive Physical Exam & Annual Wellness Visit Tutorial LESS Initiative Tutorial Progression to Type 2 Diabetes Smoking Cessation Tutorial Progression to Type 2 Diabetes Quality Metrics ACO and Medicare Advantage Stars HEDIS: NCQA, History, Quality, Safety, STARS, ACO ACO Quality Measures Performance Tool ACO Quality Measures Performance Tool Tutorial STARs - A Tutorial for Utilizing SETMA's Deployment of the STARS MA Program Specialized Tools Annual Questionnaires: Fall, Functional, Pain, Stress, Wellness Association of Medication & Diagnosis Chronic Conditions Tutorial Chronic Care Management Code (CCM) Tutorial Depression Tutorial Drug Interactions Tutorial Electronic Tickler File Tutorial Evaluation Lower Urinary Tract Symptoms in the Male Fall Risk Tutorial Future Labs Tutorial Hydration Assessment Tutorial HCC Risk Training Tool Hypertension: Fulfilling Quality Metrics for the PCPI Program Laboratory Results - Signing Off: Why and How Medication Module Tutorial Medication Reconciliation Tutorial Nutrition Tutorial Pain Management Tutorial Problem List Reconciliation Tutorial Progression to Type 2 Diabetes Referral Skin Care Tutorial SOAAP Opioid Risk Assessment Stratifying End-of-Life Risk for Hospice Services Tutorial Texas State Reportable Infectious Diseases Tutorial Transitions of Care Management Coding (TCM Code) Tutorial	Transforming Your Practice Library Introduction to SETMA's TCPI Library Transforming Your Practice (TCPI) Summary Document of TCPI CMS Quality 12.2015 TCPI Leadership and Governance Care Coordination HIPPA and Security Data Analytics Care Transitions LESS Initiative Medical Records Clinical Decision Support Hospital Care Tools Disease Management Tools Preventive Health Tools Behavioral Health Transformation Tools New Transformation Tools Patient-Centric Care Nursing Home Medical Home Display and Explanation of SETMA's Patient-Centered Medical Home Tools	Medical Home The Story and the Ideals Introduction to Preventive Health Tools PC-MH Patient Engagement & Alternative Payment Models Preventive Care: The Best Way to Treat Illness is Don’t Get it Coordination of Care Patient-Centric Care Population Health Transition of Care - One form of Care Coordination HCAHPS - Hospital Consumer Assessment Of Healthcare Providers and Systems CAHPS - Consumer Assessment of Health Care Provider and Systems Teaching Tool for PC-MH Course – Patient Care Activation, Engagement, Shared-Decision Making Display & Explanation of PC-MH Tools SETMA's Medical Home Pilgrimage Concierge Medicine not Medical Home Medical Neighborhood Security & HIPPA Referrals Patient Web Portal Health Information Exchange Medication Reconciliation The Automated Team Coordination of Care Medical Home Description & Standards AAAHC Joint Commission NCQA Planetree URAC NCQA Interview February 14, 2014	Facebook	Letters

Letters - Dr. Holly’s Final Note to SETMA Staff

December 21, 2018

When I arose at 4:30 this morning, I realized that due to circumstances while this is only December 21, 2018, it is the last day that I will have as the Founder and Chief Executive Officer of Southeast Texas Medical Associates to send a final note to the organization into which I have poured my life for the past twenty-three years. Carolyn’s mother is in the hospital following hip replacement due to aseptic necrosis. On the 26th, we will move her to a Skilled Nursing Facility for further rehab before hopefully going back home.

As of the end of the day December 31, 2018, I will no longer be a part of SETMA. My office is empty, everything related to me has been removed from SETMA, and as of the January 1 2019, I will no longer have access to SETMA computers, EMR, or offices. There is nothing unusual about this but it is sobering and to some degree saddening.

Everything that needs to be done has. My new e-mail address will be jholly@Jameslhollymd.com . Since the address www.setma.com will soon belong to another, the content which I wrote will be at www.jameslhollymd.com . My cell phone number will be the same and my home number is listed in the phone book.

All required notifications of my retirement have been made and Carolyn and I have enjoyed a retirement dinner which could not have been better. A summary of that evening will be found in the addendum at the end of this note.

Summary

As I leave, I wish to say to each of you and to all of you, I leave with no regrets. We did it right and we did it well. There are some experiences I would rather not have had, but as to those things over which we had control, I would not change anything It is my hope and prayer that all of you will have a future which will be equal to your past, or perhaps even better.

The Core Values Which Built SETMA

SETMA has always been a multispecialty, multicultural, multinational, multiethnic and multi-faith organization. I have always been respectful of this fact and have never allowed SETMA to be used for sectarian purposes. In respect to one group, we have never allowed pork to be served at a SETMA dinner or meeting.

Nevertheless, on May 30m 1996, less than a year after the founding of SETMA, August 1, 1995, I wrote a “personal note” to the staff of SETMA. This same message has been repeated publicly and in a published manner at least five times in the past twenty-three years.

Since that note was from me and it was designated as personal, I cannot think of a better way to end my time with SETMA than to make sure that everyone is keenly aware of who I am and of what I believe. With that intent, please read the following.

Deuteronomy 8 was a favorite passage of our Lord Jesus Christ, as was the entire book of Deuteronomy. In verses 2 and 3, chapter eight addresses the importance of humility on the part of men. Verse 3 declares that that humility will lead men to understand the central place which the Word of God, the Bible, has in the life of the believer. Deuteronomy 8 principally reminds us that it is God Who gives us the power to “get money.” Verses 11-17 state:

“Beware that thou forget not the LORD thy God, in not keeping his commandments, and his judgments, and his statutes, which I command thee this day: Lest when thou hast eaten and art full, and hast built goodly houses, and dwelt therein; And when thy herds and thy flocks multiply, and thy silver and thy gold is multiplied, and all that thou hast is multiplied; Then thine heart be lifted up, and thou forget the LORD thy God, which brought thee forth out of the land of Egypt, from the house of bondage; Who led thee through that great and terrible wilderness, wherein were fiery serpents, and scorpions, and drought, where there was no water; who brought thee forth water out of the rock of flint; Who fed thee in the wilderness with manna, which thy fathers knew not, that he might humble thee, and that he might prove thee, to do thee good at thy latter end; And thou say in thine heart, My power and the might of mine hand hath gotten me this wealth.”

Here is the beginning of the corruption of what any man has received, the pride of believing that he achieved it by himself, and in arrogance believing that he deserved it to begin with. Deuteronomy 8 concludes with the solution to this pride, which is humility. It states:

“But thou shalt remember the LORD thy God: for it is He that giveth thee power to get wealth, that He may establish His covenant which He sware unto thy fathers, as it is this day. And it shall be, if thou do at all forget the LORD thy God, and walk after other gods, and serve them, and worship them, I testify against you this day that ye shall surely perish.”

I personally wish to affirm that it is God Who has blessed me and my participation in SETMA, LLP, and to remember that it is “He that gives us power to get wealth.” And, I wish to acknowledge that the purpose of that wealth is that through God’s blessings others might see that living by God’s rules is good.

As I have often told you, this is not a religious organization and you do not have to believe what I have said in order to be a part of this organization. Nevertheless, I do want you to know that the benefits which you are receiving through SETMA, LLP are a product of God’s blessing. I also want you to know that I believe that those benefits and blessings will continue as long as we do not forget the Lord in not keeping His commandments. For SETMA, LLP “keeping His commandments” means:

Being true to the founding principles which in the corporate documents.
Being true to our motto of “Health Care Where Your Health is the Only Care.”
Being true to the associates’ commitment to “doing good while we are doing well.”
Humbly acknowledging those who have made us successful, that particularly being God.
Treating everyone with whom we deal, whether colleague, co-worker, client, customer, or company, with dignity, courtesy and kindness.
Avoiding profanity in both our language and in our “use” of others.

In SETMA, LLP, we have an opportunity to do something really important, which is much more than just making money. We have the opportunity to show Southeast Texas that respect for the dignity of every individual and a desire to do good for others are not inconsistent with prosperity. At strategic moments in this corporation’s life, we have prayed for God’s wisdom and favor. He has abundantly given both, for which we give Him thanks, and publicly acknowledge His grace and mercy.

In a recent letter to the President of the Southern Baptist Convention, I said:

“As a Christian business man, I am very sensitive to maintaining biblical standards in my medical practice. As the managing partner of the largest, private, primary health care group in Southeast Texas, I am careful to make certain that no activity of this partnership violates God’s standards, to the best of my ability. Our corporate documents include prohibitions preventing anyone in this practice from ever performing an abortion, referring a patient for an abortion, or recommending an abortion. We also have prohibitions against beverage alcohol being used in any meeting, gathering, dinner, luncheon, banquet, picnic, or barbecue sponsored by, paid for by or associated with Southeast Texas Medical Associates, LLP.

“Southeast Texas Medical Associates, LLP maintains three standards of measuring any decision, all three must be met before we undertake any action. First, we ask the question:

‘Is it legal?’ - this involves ethics. If an action is not legal, we need go no further in our evaluation; we will not do it. But, even if an action is legal, we are not yet at the point of decision; we move to the second step of our evaluation, which applies a higher standard. We ask the question,
‘Is it right?’ - this involves equity, i.e., is it fair to all parties. However, even if a decision is right, this does not get us to a final decision. Before we decide anything, we go one step further and ask the question,
‘Is it righteous,’ - this involves eternity. If it is not righteous, no matter how legal and right an action may be, Christians should not be involved in it.

If an action is not ethical, equitable and eternally acceptable, we do not enter into any business agreement. Thus far, God has blessed our practice beyond our comprehension.”

I pledge to you not to forget from whence our blessing comes. I pledge to you that I personally will continue to seek to conduct myself ethically, equitably and eternally, as I pursue the goals which we have established together. I pledge to you to bring no destruction upon your livelihood by forgetting that it is God Who allows me to be a part of what we are doing, and that it is He Who allows us to succeed.

In conclusion, this is a very personal note. That is why I have signed it personally and not as the CEO of SETMA, LLP. I will never attempt to force my faith upon you. But, I would be negligent, if I did not tell each of you that no matter what you face, no matter who you are, Jesus Christ, God Himself, has the power and desire to give you eternal life, which includes victory over the trials of your life, hope for the future, and joy in all circumstances. Incredibly, all of this is available by the same act to which God has led me in these past few hours. It is available by humbling yourself, acknowledging Who God is, and asking Him to make a difference in your life.

God bless you. It is my prayer today, as it is each time I sign your pay check, that your association with SETMA, LLP will be the best occupational experience of your life, and that it will be an experience which will encourage you ‘to come to Jesus.”

Conclusion

As I have thought of what I would and should say to you upon this occasion, I cannot think of any better way to end my association with each of you than to say to you, no matter how much money you make, no matter how long you live, no matter how notable you are, or how high of praise you receive from men, without a personal relationship with Jehovah God, in the Person of His Son, Jesus Christ, the summary of your life will be incomplete.

God bless you and I hope to hear that you do well, always.

James L. Holly, M.D.
CEO, SETMA

Adjunct Professor
Department of Family and Community Medicine
UT Health San Antonio
Joe R. and Teresa Lozano Long School of Medicine

Associate Professor
Department of Internal Medicine
Texas A&M University
School of Medicine

Addendum

The following are the u-tube videos of the Retirement Dinner in four parts:

Video 1 - Introduction, Invocation and Rebecca Andrews Address and the President of NSU’s address

https://youtu.be/wnlaY-yh4Xc

Video 2 - UT Health San Antonio President Address and Carolyn Holly’s Address

https://youtu.be/sSrRwLEn9Ac

Video 3 - Dr Holly and the beginning of the public comments with David Stone, Muhammad Aziz, Rusty Mathis, Robert Culbertson, Theresa Bailey,

https://youtu.be/qyZTZAUsMUI

Video 4 Public Comment Joe Bill Holland, Carolyn Holly, Charles Vessels, David Parmer, Hannah Katherine McMahan, Carrie Holly McMahan, Mark Toups, Dr Holly about LaNell.

https://youtu.be/aapZVjR-_Hc

Most of the responses to Carolyn and me leaving SETMA have been collected into a document at the following link:

http://www.jameslhollymd.com/Letters/retirement-notice-and-responses .

One response which has not been posted as of this writing is from Joe Bill Holland, MD. On November 29, 2018, he wrote:

“1978 seems like a long time ago, when we first met â€” Retirement was the last thing either of us was thinking about. God has been good to both of us, and I give Him thanks for that and your friendship. You have been the dominant leader and innovator of health care in South East Texas. You have positively touched thousands of lives in Southeast Texas and abroad, and He is truly proud of you. I have treasured your advice, wisdom and guidance through the years and don’t think that will cease! Thank you for everything! May He continue to bless you, Carolyn your family! Job well done! Joe Bill”

About SETMA	In The News	Syllabus PC-MH Externship	Patient Information	Presentations
Governance Board	Your Life Your Health	Public Reporting	Accreditations/Awards	Diabetes Center of Excellence
EPM Tools	Transforming Your Practice Library	Medical Home	I-CARE Initiative	NextMD