• SETMA's Model of Care
  Patient-Centered Medical Home              

• The SETMA Approach
  to Patient Care

• 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

• Handout for Attendees eHealth
  Conference January 12, 2012               

• eHealth Initiative 2012 Award
  Program Application

• The eHealth Initiative's
  2012 Award Letter

• 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

• 2009 Medical Home Series I                  

• 2010 Medical Home Series II

• 2011 Medical Home Series Two

• 2009, 2010, 2011 Medical Home
  Miscellaneous Articles

• Universal American Letter
  of Transmittal for Support           

• SETMA questions Influenza Data               

• SETMA I - October 2011

• SETMA II - October 2011

• Mark A. Wilson Clinic SETMA
  West - October 2011

• 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

• 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

• Fall Risk, Pain, Functional,
  Wellness, Stress Assessment
  for 2011 AND 2012                          

• Core Measures for January
  to December 2011                       

• 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

• 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

• 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)

• PCPI Hypertension                      

• PCPI Diabetes

• PCPI Chronic Stable Angina

• PCPI Care Transitions

• PCPI CHF

• PCPI Weight Management

• PCPI CKD Stages IV V

• Lipids Treatment Audit Tutorial              

• Lipids Tutorial

• 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

• Calculating the Stages
  of Renal Disease                  

• Proteinuria

• 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

• Cardiometabolic Risk Assessment                                    

• Framingham Heart Study
  Risk Calculators Tutorial

• Frederickson Classification
  of Dyslipidemia

• LDL Level

• Lipid Disease Management
  Risk Assessment

• 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

• 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

• Master GP Suite of Templates Tutorial

• 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

• 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

• 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

• 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

• 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

• Security & HIPPA                                 

• Referrals

• Patient Web Portal

• Health Information Exchange

• Medication Reconciliation

• The Automated Team

• Coordination of Care

• AAAHC                     

• Joint Commission

• NCQA

• Planetree

• URAC