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 - Aging Well

Learning from the Death of a Parent	11/13/2014
In Celebration of John Vardiman’s 50-Year Medical Career and His Farewell from SETMA	02/21/2013
A Workshop: Leading for Health: Realizing Better Health, Better Care and Lower Cost Through Systems Leadership	03/17/2011
Labor Day 2010: Work, Workers, Hands	09/06/2010
You Can Get There but You Have to Walk Part VI: The Elderly and Exercise and Your Walking Speed and your Heart	12/10/2009
Why I Like Getting Older	11/05/2009
You can get there, but you have walk - Part V - 4 x 13 becomes 3 x 17.334 which become 2 x 26	10/22/2009
You Can Get There But You have to Walk - Part II - ApoE and Alzheimer's Disease	10/01/2009
You Can Get There but You have to Walk - Part I - "4 x 13" Project	09/24/2009
An Analysis and Response to President Obama's Health Care Reform Address to the American Medical Association: Part I	06/18/2009
Seeking and Finding a Good Death	04/09/2009
The Healing Touch	12/11/2008
Metaphors for your Life	11/20/2008
November 4, 1943 - November 4, 2008	10/30/2008
Memories Part I: Storing and Sharing	06/19/2008
Lessons from a Tree:Excellence in the Practice of Medicine; Excellence in Being a Patient	11/08/2007
Facing Death With The Worth of One's Life	10/25/2007
Physical Activity and Public Health - Part I	09/06/2007
Facts About Hair Loss	08/16/2007
Learning Shema Target Theory Cardiovascular Disease Risk Factors	07/19/2007
Healthcare Policy and Hope Part II	06/28/2007
Healthcare Policy and Hope	06/21/2007
Learning and Accidents - Changes which improve your heath	05/17/2007
It's Personal Now: West Nile Virus	05/10/2007
Is America's Health Care System "Sick"?	04/19/2007
Cardiometabolic Risk Syndrome Part XI - Healthy Eating: The Age of Nutrionism	02/22/2007
Cardiometabolic Risk Syndrome Part X: Inflammation Altered by Diet	02/15/2007
Cardiometabolic Risk Syndrome Part IX: Pro-inflammatory and Anti-inflammatory Diet	02/08/2007
Cardiometabolic Risk Syndrome Part VIII: C - Reactive Protein	02/01/2007
Cardiometabolic Risk Syndrome Part VII: Inflammation - chronic, low-grade	01/25/2007
Cardiometabolic Risk Syndrome: Part VI: Plasminogen Activator Inhibitor I	01/18/2007
Cardiometabolic Risk Syndrome Part V: Fibrinolytic Dysfunction	01/11/2007
Relating to Others with Dignity and Respect	01/04/2007
Cardiometabolic Risk Syndrome Part IV: Endothelium Dysfunction	12/28/2006
Christmas Gifting	12/21/2006
Chronic Disease - Effects of Exercise and Diet - Part VII Conclusions	08/31/2006
Chronic Disease - Effects of Exercise and Diet - Part VI Cancer	08/24/2006
Chronic Disease - Effects of Exercise and Diet - Part V Metabolic Syndrome	08/17/2006
Futile care-law Letter to the Editor	08/16/2006
Chronic Disease - Effects of Exercise and Diet - Part IV - Diabetes	08/10/2006
Chronic Disease - Effects of Exercise and Diet - Part III - Hypertension	08/03/2006
Chronic Disease - Effects of Exercise and Diet - Part I	07/20/2006
Falls and Factures in the Elderly	07/13/2006
Celebration of Religious Freedom	06/29/2006
Improving Your Health at 75 - Part III	06/22/2006
Father's Day, 2006 The Father and the Son	06/15/2006
Improving Your Health at 75 - Part II	06/08/2006
Improving Your Health at 75 - Part I	06/01/2006
Omega 3 Fish Oil - The JELIS Study	04/27/2006
Influenza Pandemic Part III - Protection of my family	04/20/2006
Influenza Pandemics Part I: Definitions and Concepts	04/13/2006
Influenza Pandemics Part II - Assumptions in the HHS Plan for Dealing with a Pandemic	04/13/2006
A New Year's Resolution: Being Peculiar, Like My Father	01/05/2006
End of Life Decisions: Choices Which Make A Difference	10/28/2005
Cardiovascular Disease Risk Factors - Part XV - Addendum: Questions and Answers About Estrogen Replacement and Heart Diesase	09/22/2005
Cardiovascular Disease Risk Factors - Part XI - Age	09/08/2005
Cardiovascular Disease Risk Factors - Part X - Psychosocial Stress	09/01/2005
Cardiovascular Disease Risk Factors - Part IX - Family History	08/25/2005
Cardiovascular Disease Risk Factors - Part VIII - C-Reactive Protein	08/18/2005
Cardiovascular Disease Risk Factors - Part VII - Combined Factors which Begin in Childhood	08/11/2005
Cardiovascular Disease Risk Factors - Part VI - Hypertension	08/04/2005
By Your Bedside 2005	07/07/2005
Advanced Directive Act of Texas Part IV	04/28/2005
Advanced Directive Act of Texas Part III	04/21/2005
Advanced Directive Act of Texas Part II	04/14/2005
Advanced Directive Act of Texas Part I	04/07/2005
Health: Twelve Facts for Improving Your Health	03/17/2005
Tobacco -- Appeal for Banning	01/13/2005
Omega 3 Fatty Acids and Arthritis	11/11/2004
Healthy Aging: Integrity and Wisdom	11/04/2004
Healthy Aging -- Part IV	10/21/2004
Healthy Aging -- Part III	10/14/2004
Healthy Aging -- Part II	10/07/2004
Healthy Aging -- Part I	09/30/2004
By Your Bedside: Part III: Father's Illness	08/12/2004
By Your Bedside: Part II: Father's Illness	08/05/2004
By Your Bedside: Part I: Father's Illness	07/29/2004
Activities of Daily Living and Exercise: Walking For Health	05/20/2004
Exercise: It's Never Too Late To Start	04/22/2004
Aging, Inactivity and Exercise	04/08/2004
Aging Well: Part IX: Changing Your Basal Metabolism Rate	01/22/2004
Aging Well: Part VIII: Body Composition	01/15/2004
Aging Well Part VII - Water - Its Crucial Role in Health	01/08/2004
Water: It’s Crucial Role in Health	01/08/2004
Aging Well Part VI - Growth Hormone (HGH)	01/01/2004
Aging Well: Part V: Hormone Modulation -- Growth Hormone and Testosterone	12/11/2003
Aging Well: Part IV: Thanksgiving, Gratitude and Mental Health	11/27/2003
Aging Well: Part III: Basal Metabolism Rate	11/20/2003
Aging Well: Part II: Finding Out Where You Are - Body Composition	11/13/2003
Aging Well: Part I: A Matter of Changing and of Choices	11/06/2003
Blood Tests: What Do All These Laboratory Numbers Mean	07/10/2003
Coumadin: The Story of a Drug	12/05/2002
Aging - What Can I Do?	11/21/2002
Alzheimer's Disease: Is There Anything You can Do?	11/14/2002
Exercise: Something Is Better Than Nothing	10/03/2002
Health: A Matter of Choices for Good Health	09/19/2002
Alzheimer's Disease: Part II: Causes and Treatments	08/23/2001

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