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
Presentations - Texas HIV Coalition Meeting Anatomy of a Public Health Journey
Texas HIV Coalition Meeting Anatomy of a Public Health Journey
May 03, 2013
Austin, Texas
View the Presentation in Power Power 2007 Presentation Mode
View the Presentation in Power Power 97 - 2003 Mode
View the Presentation as a PDF
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
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