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

Your Life Your Health - Joslin Diabetes Center at Harvard University and The SETMA Foundation

James L. Holly,M.D.

February 28, 2008

Your Life Your Health - The Examiner

In 1898, Dr. Elliott P. Joslin began his private medical practice in Boston, Massachusetts. Today his name is associated with excellence in the treatment of diabetes and in cutting-edge research which is advancing the frontiers for the treatment of diabetes. The accompanying insert gives the history of the Diabetes Center of Excellence. In 1987, the Joslin Affiliated Centers Program began with initial centers opening in Florida and Indianapolis. Currently there are 25 Joslin affiliates located throughout the country and the world (for a list of those affiliates see the insert). In March of 2008, the latest Diabetes Center of Excellence affiliate location will be formalized. It is Southeast Texas Medical Associates, LLP (SETMA) in Beaumont, Texas through The SETMA Foundation. This spring, a formal press conference and open house will be held for both the Diabetes Center of Excellence Affiliate at SETMA and for The SETMA Foundation.

Diabetes Center of Excellence's Mission and Vision

Since its founding in 1898, Diabetes Center of Excellence has constantly evolved to meet the ever-changing challenges of diabetes. Diabetes Center of Excellence is an institution on the front lines of the world epidemic of diabetes, leading the battle to conquer diabetes in all of its forms through cutting-edge research and innovative approaches to clinical care and education.

Every person at Joslin is dedicated to realizing our vision of a world without diabetes and its complications. We will achieve this vision through a relentless pursuit of our stated mission: To improve the lives of people with diabetes and its complications through innovative care, education, and research that will lead to prevention and cure of the disease.

Joslin & Harvard Medical School

Joslin's affiliation with Harvard Medical School gives Joslin researchers opportunities to collaborate with other investigators with complementary interests and expertise through the Juvenile Diabetes Research Foundation (JDRF) Center on Immunological Tolerance in Type-1 Diabetes at Harvard Medical School and the Harvard Stem Cell Institute.

The JDRF Harvard Center opened in August 2004 under the leadership of Directors Diane J. Mathis, Ph.D., and Christophe Benoist, M.D., Ph.D., who hold the William T. Young Chair in Diabetes Research at Joslin and head Joslin's Section on Immunology and Immunogenetics.

JDRF Harvard Center researchers are studying how to re-establish immune tolerance through eight research projects and three supporting cores. Lastly, most Joslin researchers and clinicians have academic appointments at Harvard Medical School and several are involved in Ph.D. training at the medical school.

Diabetes Center of Excellence Affiliate at SETMA, Beaumont, Texas

The idea of a Beaumont affiliated location for the Diabetes Center of Excellence grew out of a presentation four years ago at the Diabetes Center of Excellence in Boston by one of SETMA's partners. In a desire to improve the care of patients with diabetes, SETMA presented its electronic diabetes disease management program to several Joslin staff members. Joslin uses the same electronic medical records software program as SETMA. Out of that meeting, a dialogue developed between Joslin and SETMA. In October, 2007, SETMA launch the SETMA Diabetes Center of Excellence and contacted Joslin about becoming an affiliate. After several conference telephone conversations, in January, 2008, a team from Joslin visited SETMA and extended an invitation for SETMA to become an affiliated location.

The SETMA Foundation

In February, the partners of SETMA voted unanimously to accept the invitation from Joslin and to initiate a Joslin affiliated location through The SETMA Foundation. The SETMA Foundation was also envisioned by the partners of SETMA four years ago. The original vision was to contribute and to receive tax deductible funds for the support of healthcare and healthcare education for SETMA's patients who could not afford their care. That vision was expanded to include the advancement of excellence in the care of diabetes in Southeast Texas through the SETMA foundation funding and supporting a Joslin affiliate in Southeast Texas at Southeast Texas Medical Associates, LLP. Thus far the partners of SETMA have contributed $50,000 to the Foundation and have plans to contribute another $50,000 this spring.

Diabetes Center of Excellence Affiliate at SETMA

The organization and structure of the Diabetes Center of Excellence affiliate at Southeast Texas Medical Associates will be as follows:

Medical Director - Dr. Ahmed, Endocrinology
Co-Director and Eye Center - Dr. Luviano, Ophthalmologist
Podiatry, Dr. Carmack, Podiatrist
Lipid Clinic - Dr. Murphy, Board Certified in Lipids
Cardiometabolic Risk Syndrome and Weight Management - Dr. Holly
Hypertension and Liaison with SETMA 1 - Dr. Aziz, Internal Medicine
Cardiovascular Disease and Liaison with SETMA II - Dr. Anwar, Internal Medicine
Preventative Health and Liaison with SETMA West - Dr. Satterwhite. Family Practice and Preventive Medicine
Participating Staff - all Physicians and CFNPs of SETMA
Nutrition - Ms. Satchfield
Diabetic Education - Ms. Smith,
Mr. Bryan Sims - CFNP - Research (Bryan will start work on his Nurse Practitioner's doctorate in the fall and will write his doctoral dissertation on the diabetes center)
Information Technology Support - Jon Owens
Administrator - Margaret Ross, MSN
Executive Director, SETMA's COO, Rick Bryant, MSN, MBA
Oversight - The SETMA Foundation Board of Directors (The Partners of SETMA)

SETMA's Steps Toward Joslin Affiliate Status

In 1999, SETMA began using the NextGen electronic medical record program, the same system used at Joslin. Over the past nine years, we have customized that program to include disease management in diabetes, lipids, hypertension, cardiometabolic risk, CHF, angina pectoris, acute coronary syndrome, weight management, renal disease, asthma, headaches, and diabetic education, as well as tools for the specialties of rheumatology, nursing home management, podiatry, and ophthalmology.

SETMA continually updates these tools and has incorporated extensive information from Diabetes Center of Excellence in the diabetes-disease-management program. In March 2006, in a review of the 2006 Clinical Practice Recommendations by the American Diabetes Association, our Your Life Your Health article addressed the following aspects of SETMA's Diabetes care. In part that article stated:

"The American Diabetes Association has published its Clinical Practice Recommendations 2006. SETMA is currently reviewing the 100-pages of recommendations to make certain that all are incorporated into SETMA's Diabetes Treatment and Prevention program….

"And finally, the Clinical Practice Recommendations for 2006 offer the following strategies for improving diabetes care. SETMA's response to these recommendations is noted following each point.

Improving health care professional education regarding the standards of care through formal and informal education programs. SETMA continues to provide point-of-care education and provider evaluation functions to assure that all SETMA providers are continually upgrading their skills in treating diabetes.
Delivery of Diabetes Self Management Education (DSME), which has been shown to increase adherence to standard of care. SETMA's ADA Certified Diabetes Education program majors on DSME as a partnership is created between the provider and the patient for the improving of diabetes care.
Adoption of practice guidelines, with participation of health care professionals in the process. Guidelines should be readily accessible at the point of service on office computer systems. SETMA's Diabetes Treatment and Prevention Suite of templates make it possible for every provider to perform at a standard of excellence every time a patient is seen with diabetes.
Use of checklist that mirror guidelines have been successful at improving adherence to standards of care. These check lists are already part of SETMA's diabetes treatment program.
Systems changes, such as provision of automated reminders to health care professionals and patients, reporting of process and outcome date to providers, and especially identification of patients at risk because of failure to achieve target values or a lack of reported values. SETMA audits provider performance and provides the means for providers to evaluate their own performance measuring themselves against national standards of care.
Quality improvement programs combining continuous quality improvement of other cycles of analysis and intervention with provider performance date. This is a natural consequence of SETMA's functions which are identified above.
Practice changes, such as clustering of dedicated diabetes visits into specific times within a primary care practice schedule and/or visits with multiple health care professionals on a single day and group visits. SETMA's diabetes clinic led by a board-certified endocrinologist employs this method for improving diabetes care.
Tracking systems with either an electronic medical record or patient registry have been helpful at increasing adherence to standards of care by prospectively identifying those requiring assessments and/or treatment modifications. They likely could have greater efficacy if they suggested specific therapeutic interventions to be considered for a particular patient at a particular point in time. As already mentioned SETMA's Diabetes Treatment and Prevention program already does this.
Dietitians and nurse educators using MNT guidelines have been demonstrated to improve glycemic control. SETMA's ADA approved education program works hand-in-hand with clinicians to improve diabetes care.
Availability and involvement of expert consultants, such as endocrinologists and diabetes educators. SETMA does both. SETMA's Metabolism Task Force includes Ophthalmology, Nephrology, Endocrinology, Podiatry, Diabetes Educators and Nutritionist, Lipid Clinic, Diabetes Clinic, Hypertension Clinic, Metabolic Syndrome Clinic, Weight Management, and Exercise Counseling. All work together to provide the highest standard of care and the highest quality of life possible.

SETMA is very proud of both the Foundation and the Diabetes Center of Excellence affiliate agreement. We believe that both will enable SETMA to continue to grow and improve in the medical care which we provide to our friends and neighbors in Southeast Texas and particularly those who have diabetes. Both of these initiatives are a fulfillment of our "private" motto, "We want to do good while we do well," and of our "public" motto, "Healthcare where your health is the only care."

Related Articles

	Summary and Comments Upon American Diabetes Association Clinical Practice Recommendations 2006

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