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 - Follow-up to Drs Maxwell and Bourgoin telephone conversations on August 16th

August 17, 2017

Drs. Maxwell and Bourgoin:

This is a follow-up to our telephone conversations on August 16th.

Project REV -- Reduce Readmissions From the Primary Care Perspective -- This link is to our recent correspondence which is now preserved on our website. After our conversation yesterday, I realized that are several important matters to address:

The ideas of PC-MH apply equally to patients in the transition of care from the inpatient to the ambulatory settings as well as to patients from visit to visit and other points of transition. In addition to the principle points of prevention of readmissions which are a follow-up care coaching call the day after discharge and the follow-up visit within 72 hours of discharge, the patients activation (knowledge and preparation for self-care), engagement (actually participating in their own care) and share-decision making (understanding, embracing and agreeing to the care plan) are critical. One of the principal means of executing these three critical steps in the process of fulfilling the HCAPHS measures. The following is the tutorial for SETMA.com | EPM Tools | Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS): Tutorial for SETMA’s Internal HCAHPS Survey which can be found at the following link: Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS): Tutorial for SETMA’s Internal HCAHPS Survey. This detail, annotated index guides to the understanding of the value of this tool in patient care. Couple with the fulfillment of the Hospital Core Measures, HCAPHS is a good start to preventing readmissions.

The other key issues to preventing readmissions are:

Care coaching and rapid follow-up visits
Dealing with issues which address the need for admission in the first place such as dental care. Story below is about a patient who had been hospitalized seven times in three years, was on nine medications and her health was deteriorating. After the below events transpired, in the past eight years she has not been back in the hospital; is on one medication and her health is excellent.

In February 2009, the first mention was made of The SETMA Foundation in relationship to Medical Home. SETMA began discussing the formation of a charitable foundation in 2003. The intent was to create a vehicle through which SETMA could help our patients obtain care when they could not otherwise afford it. In the February 26, 2009 article, it was stated: “(In) the Medical Home model, the provider has NOT done (his/her) job (by)… simply prescribing…care which meets national standards. Doing the job of Medical Home requires the prescribing of the best care which is available to the patient…” (Emphasis added)
“…assisting patients in finding the resources to help (them get the care they need)… (is)…a part of medical home. And, when those resources cannot be found, Medical Home will be ‘done’ by modifying the treatment plan so that what is prescribed can be obtained; the ordering of tests, treatments, and/or prescriptions which we know our patients cannot obtain is not healthcare, even if (that)…plan of care is up to national standards.”
In a Medical-Home article published June 3, 2010 article and which was quoted in series two on Medical Home, August 19, 2010, the Foundation was addressed again: “The genius of PC-MH is to discover the true implications of SETMA’s motto which was adopted in August, 1995…: ‘Healthcare Where Your Health is the Only Care.’” It is to put the patient and their needs first… SETMA…placed the patient…at the center of… (as) we developed The SETMA Foundation, through which we help provide funding for the care of our patients who cannot afford it.”
Medical Home and Healthcare Resources: There have been many heroes in SETMA’s Foundation experience. Other, non-SETMA healthcare providers have contributed their skills and time to the care of our patients. One of the first patients the Foundation helped had very bad teeth. Beaumont dentist, Dr. Dave Carpenter, was consulted and he determined that repair of the patient’s teeth would cost $10,400. The patient’s health could not be helped without resolving her dental issues. It has long been known that dental care is a critical part of general health. In the case of patients with diabetes, dental care is so important; it has become one of the quality measures for SETMA’s care. SETMA proposed to Dr. Carpenter that he make a $4,000 contribution to the Foundation and the Foundation would pay him $10,400 to do the dental work. Without hesitation, he agreed. The result is remarkable. First of all the patient’s gratitude made the effort worth it, if there were no other benefit, but the real benefit is that the patient is off all medications and all health problems have resolved. The patient’s life has been permanently changed and the patient’s future has been made bright. That’s Medical Home and in that a non-SETMA healthcare provider was key to its success, it really is Medical Neighborhood.
Another patient, who had no insurance, was virtually crippled due to degenerative disease in the hip. Surgery was not possible because there were no funds. The Foundation negotiated a payment to a local hospital for the patient’s care. That same day, I approached Dr. Carl Beaudry and said, “We have a patient that needs a hip replacement and we’d like for you to do the surgery.” I then said, “There’s only one problem; we would like for you to do the surgery free.” In the same breath, without asking any questions, Dr. Beaudry said, “OK!’ The surgery has changed this patient’s life.
Concerns about the Foundation: There have been concerns about the Foundation. One of them is about “setting precedents.” This really is a question about if you help one person and can’t help another, how will you deal with that. In a recent discussion about this, I said: “The fear of setting precedents is only valid if we become victims of our own beneficence. The ability to say, ‘Yes,’ when appropriate must be balanced by the willingness to say, ‘No.’ when appropriate. I enjoy saying, ‘Yes,’ but find it easy to say, ‘No,’ even when it is not welcomed. If we become shackled by those fears, we will do…nothing.” What about those we can’t help? After we have done all that we can do, we’ll still try to help others. When at last we can do no more; we can confidently say, “We did all we could.”

Frequently hospital admissions and increased healthcare cost are due to stress. An elderly patient’s blood pressure and diabetes could not be controlled not matter how much medication was used. When I discovered that her grandson was living with her and causing great stress, it was in helping the grandson, relieving the stress that the patient’s care was treated to goal and her quality of life improved. Often, the solution to admissions and readmissions has little to do with the patient’s diagnoses but with their sense of worth, security and hope. For more about this see: Value, Virtue, Trust and Hope - The Foundation of Health Improvement. The relationship between, value, virtue, trust and hope are critical in this whole process.
Medications are critical. Medication reconciliation is pivotal to admissions and readmissions. Our patients receive a medication reconciliation on admission, on discharge, during their care coaching call and at their post hospital follow-up visit. Coupled with electronic prescribing of routine medications and controlled substances, the management of medications has become much more accurate and easier than it once was.
One of the important pieces to preventable readmissions is “access.” This is both by the care coaching call, the quick follow-up visit and the ability of the patient to see the healthcare provider as the safety value and not the emergency room. Wittingly or not, the ER Physician has a principal goal of finding a reason to admit or to readmit patients. That is the safest thing for them. Being the governor of continuity of care and of access to care the primary care provider can make sure the patient gets timely, even immediate, care often making reemission not necessary. When the patient is confident that his/her provider will answer the phone or answer their questions or “be there,” many unnecessary and preventable admission will be avoided. This is the responsibility of the provider and of the patient.
The power of stories must be understood. Two stories which illustrate this can be read at the following links: From Homicidal Threat to Reciprocal Caring: A Patient-Centered Journey, Medical Home Series Two: Part XVIII - Introduction to SETMA’s 2009, 2010 and 2011 Series of Articles on Medical Home, Patient Centered Medical Home Poster Child: An Update after Five Years of Treatment in a Medical Home. (Note these two patients have been readmitted to the hospital only once each in the past eight years.) The power of coordination of care is illustrated in both of these cases.
Connectivity and contact with patients outside of traditional patient/provider venues, i.e., appointments and other formal visits, is important. The following link is to the tutorial for SETMA’s telephone follow-up for the hospital and clinic: Using The Clinic and Hospital Follow-up Call Templates. It would be interesting to measure the reduction in readmissions in patients enrolled in he Chronic Care Management program: see Chronic Care Management Code (CCM) Tutorial. Weekly or monthly calls to chronically ill patients addresses almost all of the above principles.

This is enough for the moment. If other issues of importance arise, I will send you a note. Many of the above are not intuitive, particularly dental care and family counseling, but they are all important for success, not just a function of healthcare cost but as a function of quality of life. For your free time reading,

I note the following which is not related to your research: UT Health Historical Summary in Response to Drs. Henrich and Berggren.

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

Adjunct Professor
Family & Community Medicine
University of Texas Health San Antonio
The Joe R. and Teresa Lozano Long School of Medicine

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

Related Letters

	Project REV -- Reduce Readmissions From the Primary Care Perspective

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