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 - NQF - Summary of Dr. Holly's Comments - September 2nd, 2010

National Priorities Partnership
Convened by The National Quality Forum
Care Coordination Convening Workshop
Washington D.C. September 1-2, 2010

Comments by James L. Holly, MD
September 2, 2010

Principle: The Only way we can validly address re-admissions is to accurately establish admission diagnoses.
Common diagnoses which are charted in the emergency department which have to be modified or eliminated during the admission are:

Sepsis – this diagnosis is often established because the patient has fever but without culture proved septicemia.
CHF – there are precise diagnostic criteria but this diagnoses is often established on the basis of past medical history and imprecise symptoms of shortness of breath.
Pneumonia -- this diagnoses is often established in the elderly due to cough and fever without clinical or radiographic support for the diagnosis of pneumonia as opposed to chronic bronchitis or acute bronchitis.
Acute Coronary Syndrome – this diagnosis is often established on the basis of atypical chest pain and is not supported by clinical or laboratory evaluation.

Continuity of Care – this is often discussed in terms of the patient being seen by the same provider at each encounter. In the real world, that is not a realistic or obtainable standard:

Provider Centric
Data Centric – this is when each patient encounter is documented in the same data base, which data base is available to every provider who sees and contributes to the care of a patient regardless of the site of care.

Clinic
Telephone
Electronic
Emergency Department
Nursing Home
Hospital
Physical Therapy
Home Health
Hospice

The Data Centric continuity of care allows for the development of a “Patient Portrait,” a granular, precise, in-depth, health picture of a patient rather than the “Patient Silhouette” of a patient which has been the result of medical records for the past 150 years. It allows for the growth and refinement of that “portrait” with each encounter, as each provider contributes new insights to the patients' health picture.

Systemic Solutions to Complex Problems

In his seminal work, The Fifth Disciple, MIT Professor, Dr. Peter Senge, said, “The more complex a problem, the more systemic the solution must be.” He was not talking about computer systems but all of the principles of his work apply to healthcare delivery.
Many of the complex problems of healthcare are solved by the Data Centric continuity of care, including:

Medication Reconciliation
Complete and current chronic problem list
Collaborative fulfillment of Preventive health and Screening health quality metrics
Assess to all prior laboratory and diagnostic testing and reports
Others

When the same data base is used at the Nursing Home and medication reconciliations are done and audited at regular intervals, and the same data base is used in the hospital, and medication reconciliations are done at every transition of care, whether within the hospital or at the point of transition from the inpatient to the nursing home site of care, this complex and difficult problem can be solved.

Transforming healthcare

There are three methodologies which will contribute to the transformation of healthcare as opposed to the reforming of healthcare.

(Transforming comes form internal vision, passion, and generative energy; reforming comes from external pressure which squeezes an organization or activity into a pre-determine pattern with rules, regulations and restrictions. Reform makes no permanent, self-sustaining changes. Transforming is creative and self-sustaining.)

Content of care – evidenced based medicine
Payment for care – Medicare Advantage
Organization of care – Patient-Centered Medical Home.

The complexity of the patient conditions which affects the care of patients and which should be included in the payment model for that care is solved by the Hierarchical Condition Codes (HCC and RxHCC, see SETMA’s tutorial at www.jameslhollymd.com under “Electronic Patient Management Tools”)

Plans of Care and Treatment Plans

A simple, systemic solution in SETMA which increased the consistency of patients receiving these critical documents was the placing of laser printers in each examination room.

Care Coordination and Coordinated Care

The distinction in these two concepts may be the most important thing I learned at this conference. Care Coordination is the process of the Transition of care and Coordinated Care is the outcome of the Transition of Care. Each can be described and evaluated by process and outcomes quality metrics with which the standard of care for each can be established and evaluated.

Nomenclature Can Confuse Function

Discharge Summary versus Hospital Care Summary – Post Hospital Plan of Care and Treatment Plan

As discussed at the conference, the “Discharge Summary” has historically fulfilled an administrative and billing function for the hospital without it being a dynamic document for the improvement of patient management. The “Discharge Summary” is the most important documented created during an inpatient stay, but it’s real function is concealed by the name.

The “discharge summary” needs to be a transition-of-care document which not only summarizes the patient’s care during the hospitalization but guides the patient’s post-hospital care with a plan of care and treatment plan.

A name change would clarify and focus the intent of this critical document. We propose changing the name to: “Hospital Care Summary. Post Hospital Plan of Care and Treatment Plan.” The following will become important parts of this new document:

Follow-up – appointments with all healthcare providers who participated in the patient’s inpatient care. These appointments should be made before the patient leaves the hospital and the following information given to the patient and/or family or other principle care giver: time and date of appointment, name, address and telephone number of the provider or providers involved and the reason for the appointment.
Referrals – appointments with new healthcare providers who have not been involved in the patient’s care but who will participate in care post-hospital. An example might be an oncologist who will treat the patient’s newly diagnosed prostate cancer but who did not see the patient in the hospital encounter. The same information as in the “follow-up” should be given to the patient in writing.
Procedures – any testing or examinations which are to be done after the hospital should be scheduled before the patient leaves the hospital and all contact information included in the “Post Hospital Plan of Care and Treatment Plan.”
Testing which is un-resulted at the time of discharge – a definite plan must be established prior to discharge for the reporting to and discussing with the patient any test results which have not complete at the time of discharge.

Caregivers – Post Hospital Plan of Care and Treatment Plan

An acknowledgment that a follow-up telephone call has been scheduled for the day following discharge which will include at least the addressing of the following information:

The name and contact information for the principle caregiver, if other than the patient must be included in the follow-up document.
An acknowledgement that the patient’s condition, diagnoses, medications and care needs have been discussed with the patient and/or caregivers.
An acknowledgment that they understand the plan of care and treatment plan and that they accept the responsibility of the patient’s care.
An acknowledgement that the patient and/or caregiver has been given the contact information for the principle healthcare provider who is to follow-up the patient.
An acknowledgement that any barriers to care – financial, physical, understanding, transportation, -- have been addressed and resolved.
An acknowledgement of any ancillary care which has been arranged an why – home health, physical therapy, hospice, etc.
An acknowledgement that a Plan of Care and Treatment Plan document has been given to the care giver.

Content of follow-up visit

The immediacy of the follow-up call and then the follow-up visit will significantly decrease unnecessary visits. The ability o the patient to get same-day appointments if they have anxiety or unanswered questions from the hospital will also decrease the use of the ED as a “safety net.

The willingness of the primary-care provider to receive “walk-in” visits will increase the patient’s confidence that they have access to “their” doctor and will decrease ED visits and/or re-admissions which are unnecessary.

The Post-Hospital Visit should include at least the following:

Medication Reconciliation with a review of whether the patient has the medications and is talking the medications.
Answering of all questions about the hospitalization and the plan of care and treatment plan for avoiding re-admissions for the same or related problems.
Evaluation of all primary reasons for admission and the significant co-morbidities with Review of Systems, Physical Examination and Assessment.
Assessment of patient’s risk for re-admission in the next 60 days and a plan for intervening.
Review of all follow-up appointments referrals, procedures, etc.
Request for the patient to address their:

Feelings about their care in the hospital
Sense of whether they feel that their care is well organized
Ability to fulfill their care responsibilities and their follow-up care
Barriers to care – financial, transportation, willingness to undertake care, understanding
Confidence in their care and in their immediate future.

Clear instructions for follow-up care beyond the first visit.

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