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 - Exercise: It's Never Too Late To Start

James L. Holly,M.D.

April 22, 2004

Your Life Your Health - The Examiner

Regular exercise has been shown to decrease mortality and age-related morbidity in older adults. Despite this, up to three fourths of the older adult population do not currently exercise at recommended levels. The relative risk (RR) for cardiovascular disease caused by sedentary living has been estimated to be 1.9, compared with other modifiable risk factors such as:

Hypertension (RR = 2.1) and
Cigarette smoking (RR = 2.5)

But sedentary living occurs at a much higher prevalence. Fewer than 10 percent of women over age 75 smoke cigarettes while greater than 70 percent are insufficiently active.

Benefits of Exercise in Older Adults

Cardiovascular
- Improves physiologic parameters improvement in the body's ability to utilize oxygen which slows the heart rate and improved the heart's health.
- Improves blood pressure
- Decreases risk of coronary artery disease
- Improves congestive heart failure symptoms and decreases hospitalization rate
- Improves lipid profile
Diabetes mellitus, type 2
- Decreases incidence
- Improves glycemic control
- Decreases hemoglobin A1C levels
- Improves insulin sensitivity
Osteoporosis
- Decreases bone density loss in postmenopausal women
- Decreases hip and vertebral fractures
- Decreases risk of falling
- Osteoarthritis
- Improves function
- Decreases pain
Neuropsychologic health
- Improves quality of sleep
- Improves cognitive function
- Decreases rates of depression, improves Beck depression scores.
- Improves short-term memory
Potential decrease in risk of colon, breast, prostate, rectum cancer
Improves quality of life and decreases fatigue
Other
- Decreases all-cause mortality
- Decreases all-cause morbidity
- Decreases risk of obesity
- Improves symptoms in peripheral vascular occlusive disease
Death and Disease Decreased with exercise

Never Too Late -- NEVER

Regular exercise and/or increased aerobic fitness are associated with a decrease in all-cause mortality and morbidity in middle-aged and older adults. Subgroup analysis of the Harvard Alumni study found that modest increases in life expectancy were possible even in those patients who did not begin regular exercise until age 75. Mortality rates were also lower in those patients who did not begin regular exercise until late in life compared with patients who were active only in younger years and then subsequently stopped exercising. Thus, it is never too late for patients to benefit from physical activity.

Those patients who go from none to some exercise receive the greatest health benefits, while further increases in activity levels bring progressively smaller improvements. Physicians can have the greatest overall impact by helping their sedentary patients to become active.

No Pill

There is no pill or group of pills pharmaceutical or nutraceutical which can provide the benefit to your health which regular, aerobic exercise provides.

Getting Started -- Screening

Before initiating an exercise program, most older adults should undergo a history and physical examination directed at identifying cardiac risk factors, exertional signs/symptoms, and physical limitations. There are few contraindications to aerobic exercise or resistance training. Even patients with these conditions can safely exercise at low levels once appropriate evaluation and treatment have been initiated. For example, early exercise-based cardiac rehabilitation has become a mainstay of post myocardial infarction care.

Contraindications to Aerobic Exercise and Resistance Training

Absolute Contraindications

Recent ECG change or myocardial infarction
Unstable angina
Third-degree heart block
Acute congestive heart failure
Uncontrolled hypertension
Uncontrolled metabolic disease

Relative contraindications to exercise in the elderly

Cardiomyopathy
Valvular Heart Disease
Complex Ventricular ectopy

Treadmill Exercise Testing

The American College of Sports Medicine recommends exercise stress testing for all sedentary or minimally active older adults who plan to begin exercising at a vigorous intensity. Most elderly patients, however, can safely begin a moderate aerobic and resistance training program without stress testing if they begin slowly and gradually increase their level of activity. A community-based walking program in Massachusetts involving almost 8,000 elderly patients reported no incidence of myocardial infarction or other adverse cardiac events during exercise over an eight-year period. Patients should be counseled to discontinue exercise and seek medical advice if they experience major warning signs or symptoms (e.g., chest pain, palpitations, or lightheadedness).

The Exercise Prescription

The exercise prescription consists of three components: aerobic exercise, strength training, and balance and flexibility.

Cardiovascular

Moderate aerobic activity for a combined total of at least 30 minutes, most days of the week. Individual bouts of activity may be as brief as 10 minutes.

Strength training

A single set of 10 to 15 repetitions using eight to 10 different exercises, performed two to three times per week. Each repetition should be performed slowly through a full range of motion while avoiding holding one's breath (Valsalva maneuver). The training program should involve all major muscle groups.

Balance and flexibility

Stretch major muscle groups once per day after exercise when muscles are more compliant. Balance training and weight transfer program twice per week.

CPET

If an elderly person is serious about improving their health with exercise, a CPET (cardiopulmonary exercise test) would be a good place to start. Moderate activity can be defined using heart rate and VO2 max ranges, rating of perceived exertion, and work load for specific activities. More simply, patients should exercise at the maximal intensity at which they are still able to comfortably carry on a conversation (the "talk test"). This may require some trial and error for patients. Warm-up and cool-down periods consisting of five to 10 minutes of less intense activity (e.g., slow walking, stretching) should be included to decrease the risk of hypotension, and musculoskeletal and cardiovascular complications.

Activities Requiring Moderate Intensity Exercise

Walking briskly (3 to 4 mph)
Cycling leisurely (¾10 mph)
Swimming with moderate effort
Doubles tennis
Golf--using a pull cart
Fishing--stand and cast
Canoeing leisurely (2 to 4 mph)
Mowing lawn with a power mower
Home repair, painting

As in aerobic exercise, initially sedentary or irregularly active older adults beginning resistance training should start slowly and gradually advance the intensity of their training regimen. Patients should start with resistive bands/tubing, light weights (e.g., 2 lb hand weights or a can of food), or simple exercises such as repeatedly rising from a chair. Although health benefits are achievable with less intense training, significant strength gains require patients to train at an intensity in which they can complete 10 to 15 repetitions per set before reaching fatigue. Training needs to be progressively more intense with increasing weight to continue to derive additional strength gains and, possibly, to prevent the long-term loss of previous strength gains.

The evidence for balance and flexibility training is inconclusive. Nevertheless, empiric evidence suggests that balance programs, such as repeatedly standing on one leg, can improve stability and decrease the risk of falls.

The complete exercise prescription includes increased daily activities and regular aerobic, resistance, and balance exercises. Any exercise prescription, however, is a dynamic process that should be structured to fit an individual patient's current goals and comorbidities and be responsive to changes over time.

Overcoming Barriers to Exercise

Elderly patients face an array of personal, socioeconomic, and environmental barriers to exercise that are common to the general population, as well as barriers that are unique to the elderly.

One half of older adults cite musculoskeletal discomfort or disability as a reason for not exercising. Decreasing exercise intensity and using a range of exercises can help avoid discomfort. It is often helpful to prescribe a range of exercise intensities that patients can match to their energy or functional level on any given day. Cross-training, using a combination of activities, balances the risks and benefits of weight- and non-weight-bearing activities, uses a wider range of muscle groups, decreases the risk of overuse injury, and is less boring.

Habit

Habit is the single best predictor of inactivity across all age groups. Older persons often must overcome a lifetime of ingrained behavior. Some older persons may be comfortable in a role of dependence and feel threatened by the charge of increased activity. Building on previous activities can help overcome the dominant influence of habit on activity levels. For example, patients may be encouraged to move the treadmill or stationary cycle in front of the television, or consider having a low step-aerobics box in the kitchen. An active lifestyle also has health benefits comparable with formal exercise regimens, but with improved rates of long-term compliance.

Incorporating exercise into a prior routine also makes it easier to remember, especially in very old and cognitively impaired persons. Exercises should be simple; any new skills will require specific instructions and repetition.

Self-efficacy--the confidence in one's ability to carry out a planned behavior--has been shown to be a predictor of stair-climbing ability, balance (i.e., risk of falling), and general functional decline in the elderly. In addition, it is also a strong predictor of exercise participation, especially in women. Efficacy scores increase across the stages of change (i.e., patients become more confident of their abilities as their level of activity increases). Patients with low self-efficacy should begin exercising with easily accomplished goals and receive frequent encouragement.

Additional Considerations

Physicians should match their advice to the patient's perception of how physical activity may be beneficial (e.g., weight loss, improved fitness, reduced coronary risk). Identify and focus on individual beliefs rather than on general health benefits. Help the patient set specific goals and avoid the discouragement of unrealistic expectations.

Understanding a patient's personality is also helpful. Whether patients are extroverted or introverted will greatly affect their compliance with a group exercise class versus a home program. As they become more functionally dependent, they often have less influence over when and how they exercise. This can be discouraging for those who have previously had a strong internal locus of control.

For most patients, any additional activity beyond their current level will be beneficial. Patients should be encouraged to add to exercises that they are already performing such as climbing an additional flight of stairs or walking to a further light post or other distance marker each week. More frail elderly patients should increase intensity by adding hills, hand weights, or arm movements rather than increasing velocity.

Finally, patients are more likely to do activities they consider enjoyable. They are also more likely to resume pleasurable activities following inevitable periods of relapse caused by illness, hospitalization, or travel. Social dancing, for example, is a great exercise and most nursing homes use games as a proxy for exercise. Patients can be helpful in designing their own exercise programs.

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