JamesLHollyMD.com

	James L. Holly, M.D.

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Medical Home - Patient Document for Coordination of Care

In 21st-Century medicine, patients are not going to leave the clinic only with laboratory results, x-rays and a history and physical examination. They are going to leave with personalized information on risk assessment, LESS Initiatives, Disease Management Assessment and now with a summary of their Patient-Centered Medical Home Coordination-of-Care status. The tutorial on the Coordination of Care will review the details of the information which is currently collected on each patient and the quality measures which are being audited for each patient.

The following is a typical Coordination-of-Care document which will be given to a patient. It includes the information which we currently have AND it includes a list of the quality measures which are complete and up-to-date for the patient and another list of the quality measures which are either outdated or which have not been performed.

The patient will be given instructions to review this information, to bring it to their next visit and to ask their healthcare provider to bring their care into compliance with all quality measures. Some compliance issues on quality measures will require cooperation and even collaboration by the patient, such as cholesterol and blood pressure control.

This document will provide the patient the ability to “take charge” of their own care and to make sure that they are receiving the care they need and deserve.

SETMA I - 2929 Calder, Suite 100
SETMA II - 3570 College, Suite 200
SETMA West - 2010 Dowlen
(409) 833-9797
www.jameslhollymd.com

Medical Home Coordination Review

Patient	John Doe
DOB	12 15 1947
Sex	M
Age	62 Years
Encounter Date	December 28, 2009
Medical Power of Attorney	Information not provided
Primary Caregiver	Information not provided
Emergency Contact	Jane Doe
	(999)999-9999
Evacuation Options	SelfFamily
Evacuation Contact	Information not provided

Care Coordination Team
Primary MD - Vincent Murphy, (409)833-9797

Chronic Conditions
Heliobacter Pylori
DM II Renal Manifestat Control
Hyperten Benign Essential
Lipid Hypertrigly Type IV & V
Depression
Gouty Arthritis Foot Toe
Tobacco Use History Of
Urine Albuminuria
Renal Stage II Chron Disease
Elev Liver Func Or Abn Scan
CAD Unspecified Vesse
PVD Unspecified
Esophageal Reflux
Anemia Unspecified
Neuropathy Poly Diabetes
Spine, Degen Disc Cervical
Radiculopathy Cervical Brachial Neuritis
CHF Systo/Diastolic Unspeci
AV Block First Degree
Mineral Metabolism MagnesiumHypo

HEDIS Measures Compliance

The following are the HEDIS measures which apply to you and are in compliance...

Adult Body Mass Assessment
Your body mass index (BMI) was calculated today.

Colorectal Cancer Screening
You have had the appropriate colorectal cancer screening performed.

Appropriate Treatment for Children with Upper Respiratory Infection
You have had the appropriate treatment initiated for your acute upper respiratory infection.

Cholesterol Management for Patients with Cardiovascular Disease
Your cholesterol is being properly controlled.

Annual Monitoring for Patients on Persistent Medications
You are being adequately monitored for the long-term medications you have been prescribed.

The following are the HEDIS measures which apply to you and are NOT in compliance...

Controlling High Blood Pressure
Your blood pressure is not properly controlled. You have a chronic diagnosis of hypertension and your blood pressure is not being controlled to less than 140/90 mmHg.

     Comprehensive Adult Diabetes Care
     Your diabetes is not properly controlled. Given that you are a diabetic...
     Your HgbA1c should be evaluated at least yearly and controlled to less than 7.0%.
     Your blood pressure should be controlled to less than 130/80 mmHg.
     You should have a dilated eye exam yearly.
     Your LDL cholesterol should be evaluated at least yearly and controlled to less than 100 mg/dL.
     You should have a foot examination completed at least yearly.
     You should be evaluated for nephropathy at least yearly.

NQF Measures Compliance

The following are the NQF measures which apply to you and are in compliance...

Body Mass Index Measurement
Your body mass index (BMI) was calculated today.

Adult Immunization Status
You have been given the recommended immunizations for adults.

Blood Pressure Measurement
Your blood pressure was measured today.

Blood Pressure Classification/Control
Your blood pressure has been properly assessed and is being controlled adequately.

Documentation of Allergies/Reactions
Your allergies and reactions (or the absence of) have been documented.

LDL Drug Therapy for Patients with CAD
Your cholesterol is being properly controlled.

Comprehensive CHF Care
Your CHF is being properly controlled.

Colorectal Cancer Screening
You have had the appropriate colorectal cancer screening performed.

The following are the NQF measures which apply to you and are NOT in compliance...

Current Medication List
You have not been given a current list of your medications.

     Therapeutic Monitoring of Long Term Medications
     You are not being adequately monitored for the long-term medications you have been prescribed.
     If you are taking an ACE, ARB, digoxin or a diuretic, you should have a potassium, a creatinine and a blood
     urea nitrogen test at least yearly.
     If you are taking an anticonvulsant (phenobarbital, phenytoin, dilantin or carbamazepine), you should have the
     level checked at least yearly.

PQRS Measures Compliance

Diabetes Measures Compliance

Hemoglobin A1c
Most recent value between 7.0 and 9.0.

Systolic Blood Pressure
Most recent value over 140.

Diastolic Blood Pressure
Most recent value less than 80.

Foot Exam
Completed this visit.

Lipids
Most recent value less than 100.

Nephropathy
Patient prescribed ACE/ARB therapy.

Eye Exam
Dilated eye exam results reviewed.

Preventive Measures Compliance

Tobacco Use Assessment
Patient is a current tobacco smoker.

Tobacco Cessation Assessment
Patient is a tobacco user. Counseling cessation provided.

Body Mass Index
Body Mass Index measured/assessed.

Influenza Immunization
Influenza immunization administered within the last year.

Colorectal Cancer Screening
Appropriate screening performed.

Pneumococcal Vaccination
Influenza immunization administered within the last year.

Mammography Screening
Measure not applicable for this patient.

Urinary Incontinence Assessment
Measure not applicable for this patient.

Please review this document. Identify the information which is missing from your chart, such as power-of-attorney, etc. Please bring that with you to your next visit, e-mail your provider with the information or call your health care provider and give them this information.

Also, please review the quality measures listed. If any apply to you and are NOT completed, please ask your provider to address these issues the next time you come to the office.

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