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 - The Place of Patient-Centered Medical Home in the Future of Healthcare Delivery

James L. Holly,M.D.

July 23, 2009

Your Life Your Health - The Examiner

In our ten-part series on patient-centered medical home, recently published in the Examiner, we have examined the concepts and content related to the old, now new, concept of Medical Home. The interest in this re-formation of healthcare delivery is accelerating, as is evidenced by the following.

The 795-page, U.S. House of Representatives' marked up heath reform bill has been made public (July 15, 2009). It includes language which begins the process of rewarding healthcare providers who are practicing Medical Home. The following is part of Section 224 entitled, "Modernized payment initiatives and delivery system reform," which addresses innovations which are hoped will bring increased value, improved quality and decreased cost to healthcare delivery in the United States. It states in part:

"the Secretary may utilize innovative payment mechanisms and policies to determine payments for items and services under the public health insurance option. The payment mechanisms and policies under this section may include patient-centered medical home and other care management payments, accountable care organizations, value based purchasing, bundling of services, differential payment rates, performance or utilization based payments, partial capitation, and direct contracting with providers. (emphasis added)

"...The Secretary shall design and implement the payment mechanisms and policies under this section in a manner that seeks to-

improve health outcomes;

reduce health disparities (including racial, ethnic, and other disparities);

provide efficient and affordable care;

address geographic variation in the provision of health services; or HOLCPC

prevent or manage chronic illness; and

promotes care that is integrated, patient centered, quality, and efficient."

The bill further identifies the metrics on the basis of which permanent funding of Patient-Centered Medical Home will be considered by the Secretary of the Department of Health and Human Services. Addressing this point, the bill states that the secretary will implement a pilot program for the evaluation of cost and quality in order to determine:

"...the extent to which medical homes result in

improvement in the quality and coordination of health care services, particularly with regard to the care of complex patients;

improvement in reducing health disparities;

reductions in preventable hospitalizations;

prevention of readmissions;

reductions in emergency room visits;

improvement in health outcomes, including patient functional status where

applicable;

improvement in patient satisfaction;

improved efficiency of care such as reducing duplicative diagnostic tests and laboratory tests; and

reductions in health care expenditures; and

"...the feasibility and advisability of reimbursing medical homes for medical home services under this title on a permanent basis."

SETMA's involvement in Patient-Centered Medical Home began at a lecture in February, 2009. Since that time, we have expended a great deal of time and energy in working toward the development of Medical Home functions within SETMA. The week of July 20th, representatives from SETMA will be attending a meeting in Washington, DC presented by the National Committee for Quality Assurance (NCQA) on Patient-Centered Medical Home. This conference is the last step in SETMA's preparation for applying for designation by NCQA as a Patient-Centered Medical Home.

Other interest in Medical Home and SETMA's involvement in this movement are:

July 14, 2009, SETMA made a two-hour presentation to the national sales meeting of a major electronic medical records vendor on Patient-Centered Medical Home. This EMR Company, NextGen, is making strides toward providing the functionalities needed to support the requirements of recognition by NCQA as a patient-centered Medical Home.
August 4, 2009, a group of physicians and staff visiting SETMA from Scott and White Clinic will be spending the day to review SETMA's preparation for becoming a patient-centered Medical Home.
August 18, 2009, a group of physicians and staff from SETMA will be visiting the Texas A&M University School of Medicine in College Station to discuss their interest in EMR and in Patient-Centered Medical Home.
September 18-19, SETMA has been invited to join a conference of family medicine leaders from around the country. Representatives of SETMA will participate in this conference of physician leaders in Dallas to discuss Patient-Centered Medical Home. The official title of the group is "Family Medicine Leaders in Large Multi-specialty Groups." They meet twice a year to discussion advancements in healthcare delivery. Large groups who are members of this group include: Scott and White, Marshfield Clinic, Geisinger, Oschner, Mayo, Group Health, Duluth Clinic, Austin Regional Clinic, Kelsey Sebold, Park Nicolette, St. Johns Clinic and Sharp Reese Stealy.
November, 2009, SETMA will make a presentation to the NextGen User Group meeting in Washington, DC on Patient-Centered Medical Home and Chronic Disease Management.

These and other opportunities indicate the growing momentum for this transformative initiative in healthcare delivery.

In context, Patient-Centered Medical Home may represent another in innovative changes which have transformed how SETMA is delivering healthcare. The first was the formation in 1995 of the foundations of a multi-specialty medical group in Southeast Texas. It had never been successfully done and it has proved to be a benefit to our patients and community.

The second was the adoption of electronic patient records (EMR) in 1997. At the time, it seemed that this effort might be a very expensive and difficult experiment in futility, but it has proved to be a critical and necessary step toward the transforming of healthcare. In the section Your Life Your Health on this website, there is a great deal of information about the process of our transforming SETMA through EMR.

The third was the realization in May, 1999 that an electronic means of documenting a patient encounter was an inadequate goal. What SETMA really wanted to do is to develop electronic patient management (EPM). EPM meant that the EMR would be a tool to provide leverage for improving the quality of care and thus the outcomes of healthcare delivery. It meant that it was imperative that we develop disease management tools which would standardize the care all patients received from SETMA.

It meant that the same data base, and consequently the same decision-making information would be must be utilized at all points of care. SETMA realized that continuity of care involved all providers using the same data base at every encounter with every patient. Thus SETMA developed the ability to use the EMR and thus EPM in the clinic, in the emergency room, in the hospital, in the nursing home, in physical therapy and in any other venue where our patients received care. Electronic patient management provided excellent continuity of care in that all data and the same information was available everywhere.

This was illustrated in 2000, when a patient was admitted to one hospital. The history and physical examination (H&P) was prepared in the EMR. Subsequently, a few hours later, the patient was transferred to another hospital. The patient's condition has rapidly changed, in this instance for the better. Instantly, the H&P from the first hospital was available at the second. A subsequent evaluation was done at the second hospital and four hours later, the patient's condition had changed so dramatically that even thought he had been in the ICUs of two hospitals, he was able to be discharged to home the same day.

The patient's record included:

An H&P from the first hospital
An H&P from the second hospital
A follow-up note from the second hospital
A discharge summary from the second hospital.

The quality and continuity of care was excellent, principally based on the availability of information and data at every point of care. The cost of the patient's care was efficiently managed without any sacrifice in quality. The patient's satisfaction was high in that he wanted to go home when it was safe. The patient's follow-up care was outstanding in that all of the information was available to his physician at his follow-up visit in the clinic.

The benefit of SETMA's EMR and EPM initiatives was seen in 2008, when SETMA was able to query our EMR to analyze the quality of care our patients with diabetes had received. The data reviewed that there had been steady and progress improvement in the outcomes of our care over the past eight years. The data showed that there were three points at which that care had dramatically improved within a year.

Review of this data showed that the dramatic improvements had come when:

SETMA created a diabetes disease management tool in the EMR which enabled us to leverage the power of the EMR for electronic patient management.
SETMA developed an American Diabetes Association accredited Diabetes Self-Manement Education program.
SETMA recruited an Endocrinologist.

Now we come to Patient-Centered Medical Home. SETMA believes this will be the next major innovation and advancement in healthcare. Done properly Medical Home can e transformative in healthcare delivery at least as much as EMR, EPM and effecvtige continuity of care.

Currently, the only complete description of Medical Home is that of NCQA. In that description, there are 9 Standards, 30 Elements and 183 data points. SETMA has spent a great deal of time determining whether we are fulfilling each of these standards, elements and data points. For us, it is our apprehension that it is possible to meet all 183 data points and not to achieve the promise of Medical Home.

In our judgment, the success of Medical Home will be measured by:

how engaged the individual patient is in this/her own care
how effectively providers are in helping patients make life-style changes which actually improve health and prevent illness
how rational the healthcare choices are which are made by patients and families as healthcare choices will be made rationally by patients and families are surely care will be "rationed" by the health insurer which may become the government.
How consistently evidenced-based medical therapies are utilized with all patients.
Whether Medical Home does result in improved care, decreased cost and prevention of chronic disease.
How successful we are in education of people and in convincing people that if they make a change in their habits and/or choices that that change will make a difference in the quality and quantify of their lives.

A true Medical Home will go far beyond tradition interests and responsibilities of healthcare providers. A true Medical Home will have to begin to address the social, cultural, sometimes ethnic, financial, and even religious barriers to good health and rational healthcare choices and decisions.

Medical Home must engage the recipient as an active agent and as a responsible participant. The question is what do we do about the millions of people who will not cooperate with their own health and/or who either will not, or cannot begin to make healthy choices in their lives? Changes in the administration, financing or access to medical care cannot correct and make up for all of the "bad choices" people have made and/or continue to make in their lives.

In SETMA's Medical Home initiative, we have begun to discuss, 'How can we get people to make the right choices?' The reality is that we can't threaten them. Of course, with smokers, we have been telling them that if they don't stop smoking we will not continue to care for them. As a result many have stopped. Yet, when you begin to deal with nutrition and activity habits, it is probably not possible to make that bargain.

Our frustration -- and it is a frustration -- has arisen from the fact that we KNOW how to help people improve their health. Nonetheless, many patients' health does not improve because they are unwilling or unable consistently to make the choices which are required to become healthy. What do you do with a person who knows, that if they continue to overeat and under exercise that they will die, and yet they don't change? What do you do with a person who knows, if they don't stop drinking alcohol, that they will lose their family and their life, but they don't? What do you do with a person who knows if they don't take their medication, they will become sicker, but they don't?

Healthcare problems for most people are not in their heart, their arteries, their intestines or their joints; the problem is in their heads. There is no simple solution, but a great deal of it has to do with hope and/or the lack of hope. Without hope, human beings begin to die. And, while it is true physically, it is also true mentally, emotionally and spiritually, human beings begin to die from the inside out. If our Medical Home is going to be anything but a form, it must address these non-medical issues.

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