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

Transforming Your Practice - Summation of SETMA's TCPI Website

Index

Transforming Your Practice TCPI

Overview and the Philosophical Underpinnings to SETMA’s Website (www.jameslhollymd.com) which is SETMA’s “Offer” to the Center for Medicare and Medicaid Services’ (CMS) Transforming Clinic Practice Initiative (TCPI)By James L. Holly, MD

Summation of SETMA’s TCPI Website

Complete copy, with Index composed of hyperlinks, of all sections of SETMA’s TCPI website

Transforming Your Practice - CMS Quality 12.2015 TCPI

SETMA’s Description of the TCPI Program

Transforming Clinical Practices Initiative

The CMS Transforming Clinic Practice Initiative

Prepared prior to the 2015 CMS Quality Conference and the TCPI Meetings

CMS's Transforming Clinical Practice Initiative

November 13, 2015 Acceptance of Invitation to Address the Transforming Clinical Practice Initiative at CMS December 1-3 Healthcare Quality conference

December 1-3, 2015 TCPI and CMS Quality Meeting

CMS' Transforming Clinical Practice Initiative, Response to December 1, 2015 Session in Baltimore, Maryland at the CMS Quality Conference

Contributing to the library required for the success of TCPI, December 2, 2015

TCPI information which may be helpful to PTNs and SANs

Disparities and Hope

TCPI, Director, Center for Clinical Standards and Quality, CMS

SETMA’s Prior Contacts with CMS

SETMA has experienced three overall functionalities required to meet the goals identified by CMS/ONC in this conference

SETMA's Solution for CMS and ONC Meeting on Health IT to support ACO

Letter to CMS Staff of April 23, 2015 ONC/CMS Joint Meeting Requesting Introduction to Person or Department to Discuss CMS Compliance with Physician Hospital Team Membership

The Value and the Power of the Healthcare Team: Answering Dr. Amy Townsend's Imperative

Medical Home Magno CMS Question Medical Home Servicers Delivered by James L Holly, MD

CMMI Care Innovation Summit, Washington, D.C. January 26, 2012: Observations of an Attendee

CMS Medical Home Feedback Report Qualify & Cost

Payment Model Discussion with Texas Insurance Commissioner - November 1998

Description of November 28, 1998 Testimony to Texas Insurance Commissioner

Responses to my September 25, 1998 Testimony to the Texas Department of Insurance Commissioner's Public Hearing

Testimony before Texas Department of Insurance Proposed Financial Incentive Guidelines Austin, Texas, September 24, 1998

Prepared in the Past Relevant to Practice Transformation

The Joy of Medicine - The Imperative of Celebration:: The History of SETMA's Preparation for and Journey to ICD-10

CMS's Transforming Clinical Practice Initiative Michael Kinne Star Medicaid Introduction to SETMA

Transformation Introductory Concepts

Leadership: Character Traits Needed for Healthcare Transformation - The need for change by The Joint Commission

Transforming 21st Century Healthcare Through The Power of Electronic Patient Management

The Place and Spirit of Accreditation Activities for Improving Healthcare which is Sustainable

Managed Care and Electronic Patient Records

Value-Based Payment Model

Value-Based Payment Models, Questions for the Industry, Health Leader Media, Answers By James L. Holly, MD April 2, 2015

Value-Based Payment Models, Questions for the Industry, Health Leader Media, Answers by James L. Holly, MD April 15, 2015

Transforming Your Practice - Leadership and Governance

Governance Board - the keys to a successful practice transformation are clear chains of command, identification of leadership, leadership responsibilities and leadership training:

Governance Board defines the corporate team, culture, mission, vision and goals

Governance Board establishes Healthcare Provider Standards

Governance Board establishes duties of Executive Management

Governance Board established organization-wide Planning to Maintain Focus on Safety and Quality

Governing Board establishes care guidelines, responds to sentinel events, manages all sites, and provides patients information about PC-MH

Transforming Your Practice - Care Coordination

Introduction

Medical Home Transitions of Care: One Form of Care Coordination

Coordination is the process of continuity of care. In the case of all documents created in the care of a patient, whether:

Transforming Your Practice - Care Coordination

A Care System for Effecting Reductions in Preventable Readmission Rates

SETMA’s Care Coordination Department’s Functions

SETMA’s Care Coordination and Transitions of Care: Part I

Patient-Centered Medical Home - Care Coordination and Coordinated Care

Medical Home Series Two: Part VII Care Coordination

Medical Home Series Two: Part XII - National Quality Forum and Care Coordination

Medical Home Series Two: Part XIII - National Quality Forum and Care Coordination Part II

SETMA's Inpatient Team Based Process Analysis: The Interaction of SETMA’s Hospital Care Team - Collegiality and "Electronic Huddles

Medical Home Part IV: Help and Hope in Healthcare

From Homicidal Threat to Reciprocal Caring: A Patient-Centered Journey

Medical Home Part III: Requirement Number 1 of 28

Transforming Your Practice - HIPPA and Security

Medical Records: Is it Secure?

Health Insurance Portability and Accountability Act (HIPAA) Privacy Tutorial

Is Your SETMA Medical Record Secure?: Part I

Is Your SETMA Medical Record Secure?: Part II

SETMA's Provider Training for September, 2013

Notice of Privacy Practices

Principles Contacting SETMA & Secure Texting

SETMA September Provider training HIPAA and Security

Transforming Your Practice - Data Analytics

The Importance of Data Analytics in Physician Practice

Abraham Lincoln and Modern Healthcare

Patient-Centered Medical Home: The Power of Data in Designing the future of healthcare

Patient-Centered Medical Home and Care Transitions: Part I

Business Analytics and Your AQ

Transforming Healthcare: Public Reporting of Provider Performance on Quality Measures

2010 - SETMA and the Future

Patient-centered Medical Home SETMA's COGNOS Project

COGNOS and SETMA - Why and What is our goal?

AHRQ - Ethnic Disparities in Care

SETMA -- HIMSS Stories of Success: Part I -- Improving Population Healthcare and Safety Through Real-time Data access, Auditing and Reporting

SETMA HIMSS Stories of Success: Part II -- Improving Population Healthcare and Safety Through Real-time Data access, Auditing and Reporting

Transforming Your Practice - Care Transitions

Introduction

Medical Home Transitions of Care: One Form of Care Coordination

Transition of Care - One form of Care Coordination

HiMSS-2012 Care Transitions: The Heart of Patient-Center Medical Home

HIMSS 2012: Leaders and Innovators Breakfast Meeting

SETMA's video submitted to the Robert Wood Johnson Foundation's Video Contest

A Care System for Effecting Reductions in Preventable Readmission Rates

SETMA and the National Quality Forum

Patient-Centered Medical Home and Care Transitions: Part I

Patient-Centered Medical Home and Care Transitions: Part II

Passing the Baton: Effective Transitions in Healthcare Delivery

SETMA's Inpatient Team Based Process Analysis: The Interaction of SETMA’s Hospital Care Team - Collegiality and "Electronic Huddles"

Reducing Preventable Readmissions to the Hospital

Medical Home Series Two: Part VI Care Transitions

CMMI Care Innovation Summit, Washington, D.C. January 26, 2012: Observations of an Attendee

The Future of Healthcare - SETMA's View

Transforming Your Practice - LESS Initiative

Less Initiative: SETMA

LESS Initiative Tutorial

SETMA's LESS Initiative and AHRQ Health Care Innovations Exchange

LESS Initiative: Response to Beaumont Enterprise Article on the Less Initiative

Less Initiative: Response to Letter to the Editor about Less Initiative Article

The Less Initiative is critical to the care of patients with diabetes, hypertension and Cardiometabolic risk syndrome. The following materials address details of Cardiometabolic Risk:

Cardiometabolic Risk Syndrome Part I: Introduction

The following articles carry the Cardiometabolic risk syndrome and the Less Initiative into specific cardiovascular risk factors.

Cardiovascular Disease Risk Factors - Part I - Introduction

Transforming Your Practice - Medical Records

More Than a Transcription Service: Revolutionizing the Practice of Medicine: And Meeting the Challenge of Managed Care With Electronic Medical Records (EMR) which Evolves into Electronic Patient Management

May, 1999 -- Four Seminal Events in SETMA's History

Designing an EMR Guided by The Fifth Discipline by Peter Senge, PhD

Healthcare: EMR only distantly related to 'real' electronic patient management

Don't Load Both Barrels - The Story of SETMA's Implementation of NextGen EMR and EPM

March 30, 1998 - March 30, 2012: SETMA's Journey Toward Electronic Health Records

Pursuing Excellence in Healthcare Delivery: Personal Mastery and Electronic Medical Records as Tools of Excellence

Principles of Change Agents: If you are going to make a change, it had better make a difference

Healthcare: Metanoia -- A Shift of Mind

The Titanic: Technology, Temerity and Tradition - What Healthcare Can Learn From the Titanic

Abraham Lincoln and Modern Healthcare

Transforming Your Practice - Clinical Decision Support

Introduction

Texas State Reportable Infectious Diseases Tutorial

Electronic Tickler File Tutorial

Problem List Reconciliation: The Tools Required to Facilitate the Maintenance of a Current, Valid and Complete Chronic Problem List in an EMR

Transitions of Care Management Coding (TCM Code) Tutorial

Nutrition Assessment Tutorial

Skin Care Tutorial

Hydration Assessment Tutorial

Fall Risk Tutorial

Depression Tutorial

Future Labs Tutorial

Stratifying End-of-Life Risk for Hospice Services: Tutorial for SETMA's Deployment of Four Risk Calculators for Hospice Care

HCC/RxHCC Risk Tutorial

Pain Management Tutorial

Transforming Your Practice - Hospital Care Tools

Hospital Care Summary and Post Hospital Plan of Care and Treatment Plan Tutorial

Physician Consortium for Performance Improvement Care Transition Data Set Tutorial

Transitions of Care Management Coding (TCM Code) Tutorial

Using The Clinic and Hospital Follow-up Call Templates

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS): Tutorial for SETMA’s Internal HCAHPS Survey

Admission Orders Tutorial

Hospital Daily Progress Note Tutorial

Care Transitions Data Set from Physician Consortium for Performance Improvement

Transforming Your Practice - Disease Management Tools

Introduction

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

Transforming Your Practice - Preventive Health Tools

Introduction to Preventive Health Tools

Adult Weight Management Tutorial

LESS Initiative Tutorial

Diabetes Prevention Tutorial

Hypertension Prevention Tutorial

Intensive Behavioral Therapy (IBT) Obesity and Cardiovascular Disease Medicare Preventive

Initial Preventive Physical Exam & Annual Wellness Visit Tutorial

Exercise Prescription Tutorial

CHF Exercise Tutorial

Diabetic Exercise Tutorial

Smoking Cessation Tutorial

Transforming Your Practice - Behavioral Health

Behavioral Health in SETMA's Patient-Centered Medical Home Model of Care

Medical Home Transtheoretical Model Assessment Stages of Change Tutorial

Intensive Behavioral Therapy (IBT) Obesity and Cardiovascular Disease Medicare Preventive

Smoking Cessation Tutorial

Fall Risk Tutorial

Depression Tutorial

Annual Questionnaires: Fall, Functional, Pain, Stress, Wellness

Adult Weight Management Tutorial

LESS Initiative Tutorial

Stratifying End-of-Life Risk for Hospice Services Tutorial

Pain Management Tutorial

Reduction of Antipsychotic Medications Toolkit

Transforming Your Practice - Transformation Tools

Introduction - Concept of Transformation versus Reformation

The Ultimate Hope of the Future of Healthcare is Transformation

Process Analysis and How Many Tasks Can You Get A Provider to Perform at Each Encounter?

Teaching Tool for PC-MH Course Ã¢â‚¬“ Patient Care Activation, Engagement, Shared-Decision Making

Tutorial for the EMR Automated Team Function

SETMA's Model of Care Patient-Centered Medical Home: The Future of Healthcare Innovation and Change

NCQA Interview February 14, 2014: Written Answers to Questions Submitted by Ashley Carter NCQA, Communications Specialist

Health IT to Support ACO and Group Reporting

The Primary Care Team: Learning from Effective Ambulatory Practices (PCT-LEAP): Performance Measures Worksheet - Robert Wood Johnson Foundation

Transforming Your Practice - “NEW” Transformation Tools

Chronic Care Management Codes Tutorial

ePCS and High Intensity Drug Trafficking Areas (HIDTA) Program

Prescribing Pain Medications: A Conundrum for Patient and Provider

SETMA's letter with Inclusions sent to 105 Pharmacies About e-Prescribing

Transforming Your Practice - Patient-Centric Care

The following are links to some of our “stories:”

Paternalism or Partnership - the Dynamic of the PC-MH

Learning From One’s Mistakes

Medical Home Poster Child

Patient Centered Medical Home Poster Child: An Update after Five Years of Treatment in a Medical Home

Evolution of Health Care

Homicidal Threat to Reciprocal Caring

Medical Home Pilgrimage - Stories

Medical Home Series Two: Part I The Movie -- People Will Talk (1951)

Medical Home Series Two: Part II The Caution Lights

Citadel - A 1937 Introduction to the Spirit of Patient-Centered Medical Home

Paternalism or Partnership: The Dynamic of the Patient-Centered Transformation

What is patient-centered communication? Have you really addressed your patient's concerns?

SETMA 8.20.13 Provider Training -- Health Affairs 2.14.13 -- Patient Engagement

Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS): Tutorial for SETMA’s Internal HCAHPS Survey

The Conversation Project - IHI and Maureen Bisognano

Patient and Family Engagement: Part I

Transforming Your Practice - Nursing Home

EPM Tools - Nursing Home

Nursing Home Suite of Templates Tutorial

Nursing Home Guidelines for Care Tutorial

Tutorial for SETMA's Deployment of the Texas Department of Aging and Disability Services' Reduction of Antipsychotic Medications Toolkit

Nutrition Assessment Tutorial

Skin Care Tutorial

Hydration Assessment Tutorial

Fall Risk Tutorial

Depression Tutorial

Medical Home SETMA, LLP The Story and the Ideals

Medical Home

Medical Home - Display and Explanation of SETMA’s Patient-Centered Medical Home Tools

Display and Explanation of SETMA's Patient-Centered Medical Home Tools

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