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 - Letter to NQF about Person Centered. Measures after introduction from Meaningful Use Medical Director. March 27, 2014

Thank you for the introduction. We are very interested in the development of patient- centric quality metrics. The most important things to measure are often the most difficult to measure We are currently using HCAHPS and CAHPS , along with a Community Council (see here) to get at person-centered measures. We would enjoy working on. Person centric measures.

SETMA is a member of The NQF. SETMA is recognized/accredited for ambulatory care and PC-MH by NCQA tier 3 (2010-2016). AAAHC (2010-2017), URAC (2014-2017), and The Joint Commission (2014-2017). We are also recognized by NCQA for Diabetes, Heart/Stoke, and PC-MH CAHPS Distinction.

In 2010, I was an invited participant in NQF's Workshop on Transitions of Care Since 2009, SETMA has reported on PCPI's Transition of. Care Quality Metric Set. We have reported publicly on over 21,000 discharged. The following is a series of correspondence with and about NQF and Transitions of Care.

http://jameslhollymd.com/Letters/pdfs/NQF-SETMAs-work-on-Transisitions-of-Care-and-response-to-Helen-Burstin-91513-and-91613.pdf

In December, I was appointed to the NQF Endocrine Standing Committee. The following is my letter of acceptance. Unfortunately, in late January I had to withdraw because we discovered that while our EHR is 2014 MU2 certified, being an early adopter (1998), we have to make changes to meet MU2. We will but I have to focus on that. I hope to rejoin the committee next year.

http://jameslhollymd.com/In-The-News/letter-of-introduction-to-the-nqf-endocrine-standing-committee

This is my application for the 2012 NQF National Healthcare Quality Award. I did not receive the award but this answers many questions about SETMA

http://jameslhollymd.com/In-The-News/pdfs/NQF-National-Quality-Healthcare-Award-2012-Parts-1-6-Full-Application-Priorities-for-Performance-Improvement.pdf
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

SETMA’s Community Council

James L. Holly,M.D.
April 03, 2014
Your Life Your Health - The Examiner

For over one year, SETMA has wanted to start a patient-centered council from which we could get feedback from our patients about how we can improve the services they receive. For many years, we have asked patients to complete “patient satisfaction surveys.” Those are helpful and we shall continue to collect that information.

In the past year, we have added two other tools to our efforts to “hear’ from our patients about the care they are receiving. These are completed by external audit agencies to maintain their objectivity; they are:

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS, hospital care)
Consumer Assessment of Healthcare Providers and Systems (CAHPS, ambulatory care)

Yes even these tools which ask the patient to “assess” their care still are very similar to patient satisfaction surveys. In SETMA’s February provider training session, we studied the Institute for Healthcare Improvement’s paper entitled, High-Impact Leadership Improve Care, Improve the Health of Populations and Reduce Cost. One of the major aspects of that paper is the encouragement for the adoption of new “mental models” which functionally are different ideals about healthcare delivery. Fundamentally, the change in mental models which is needed in healthcare is the move from a focus on “volume” to a focus on “value.”

The significance of this for our current discussion is that value and quality when focused on “volume” are measured with patient satisfaction, while quality when focused on “value” is measured by patient centeredness with patients as partners in their care. The following table contrasts the elements of the mental models of “volume” and “value.”

The HCAHPS and CAHPS use of the word “consumer” led SETMA initially to name the Council, the Consumer Council. The following critique from the holder of the Dr. and Mrs. James L. Holly Distinguished Professorship of Patient-Centered Medical Home at the University of Texas Health Science Center in San Antonio resulted in the change of that name. He said:

“My only concern is with the term ‘consumer.’ Knowing what I know about SETMA, I know that you are more about partnerships and healing relationships than selling goods and services. How about ‘Patient and Community Partners Council’? I try to avoid using medical care as a commodity since it cheapens and devalues what we do in primary care.” (Dr. Carlos Jaen)

With this very good advice, the name became Community Council. The intent of the Council is spelled out in the following letter which has gone to those who are being asked to serve for an initial two-year term.

“The partners and Executive Management of Southeast Texas Medical Associates, LLP (SETMA, LLP), invites you to join the SETMA Community Council. Your term of service will be for two years with the possibility of accepting renewal for two additional terms. The Council will meet quarterly except at the beginning it will meet monthly for three months. Each Council member who is not a SETMA employee will receive a $50 stipend for attending a meeting to cover any associated expenses.

“The Council will be comprised of patients of SETMA, community leaders and SETMA colleagues. The majority voting membership of the Council will be patients. All SETMA Partners and Executive Management will be ex officio members of the Council and can attend the meetings but will not have voting rights except for two who are specifically designated with that responsibility. Any actions taken by the Community Council will be binding on SETMA with the limitation that anything which violates SETMA’s published principles, the rules of the Texas Medical Board or State or Federal statutes, will be disallowed.

“The Council’s purpose is to increase SETMA’s sensitivity to the needs and desires of those who entrust us with their care. It is to facilitate patient use of SETMA’s patient portal and health information exchange as well for patient’s to help SETMA learn how to get patients more involved in their own medical decision making and in their adhering to the decisions make by them in collaboration with their healthcare providers. The council will be asked to review patient complaints (with identifying information removed) and to give us advice on how to respond. The Council will work to expand SETMA’s Medical Home to a functioning and effective Medical Neighborhood in Southeast Texas.

“As a beginning, SETMA will introduce the Council to:

Patient-centered Medical Home and what it means to patients.
Hospital Consumer Assessment of Healthcare Providers and Systems
Consumer Assessment of Healthcare Providers and Systems
SETMA’s website and how patients and the community can use this tool to learn about SETMA and SETMA’s culture.
The SETMA Model of Care
The SETMA Way
SETMA’s Governance, mission, vision and goals
The concepts of patient activation, patient engagement and shared-decision making
SETMA’s Hospital Care Team
SETMA’s I-Care Team

“The majority of the Council’s time will be spent with patients and community leaders giving SETMA feedback on how we can meet patient needs and for SETMA to listen to the Council about what they would like for SETMA so pursue and to offer in the future.

“We sincerely want the Community Council’s active participation in SETMA. While your personal health information will never be disclosed, we would like permission to use your name in public acknowledgment of the Council and in periodic reports of the Council’s work. If we should want to quote you personally, we would ask your permission before doing so.

“Please use the enclosed self-addressed and stamped envelope to indicate your acceptance of this invitation. Also, give us the most convenient telephone number and e-mail address for communication purposes. We would like to schedule the first meeting in April. Your acceptance of this invitation by April 4, 2014 would be greatly appreciated.”

Recently, I wrote a member of the healthcare business community and said:

“I am delighted with your interest in serving on SETMA’s Community Council. The Council will be an excellent addition to SETMA’s tracking of the patient satisfaction surveys identified above.

“Coupled with SETMA and your organization working together to help change cultural and community attitudes about hospice among various ethnic groups, this is an excellent example of the collaboration between professionalism and entrepreneurism. As we discussed on the telephone, the Medical Home’s mission is only fulfilled as its reach extends into what has been called the Medical Neighborhood.”

In the coming months and years, we will transparently let the community know how this experiment is going. And, if someone would like to attend one of these meetings, they can contact SETMA’s CEO.

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