What does it mean to you that Southeast Texas Medical Associates, LLP (SETMA, www.jameslhollymd.com) is a “medical home”?  First, it means that SETMA has voluntarily been subjected to rigorous standards and examination by:

1. The National Committee for Quality Assurance (NCQA -- http://www.ncqa.org/Programs/Recognition/PatientCenteredMedicalHomePCMH.aspx) and has received the highest designation, Tier III, for 2010-2013 and 2013-2016.
2. The Accreditation Association of Ambulatory Health Care ((AAAHC -- http://www.aaahc.org/accreditation/primary-care-medical-home/) and has received the highest designation by AAAHC for 2010-2011, 2011-2014.
3. URAC (Known only as URAC -- https://www.urac.org/accreditation-and-measurement/accreditation-programs/all-programs/patient-centered-medical-home-achievement/) and has received the highest designation as PCMH Certification with Electronic Health Records. Both AAAHC and URAC included multiple-day, on-site visits.
4. March 3-5, SETMA will be surveyed by the Joint Commission for ambulatory care and patient-centered medical home -- http://www.jointcommission.org/accreditation/pchi.aspx.

If we are successful in the Joint Commission survey, SETMA will be the only practice in the United States and for that matter in the world which will simultaneously possess recognition and/or accreditation by all four organizations which evaluate practices for medical home.  Even with this remarkable achievement, we continue to learn about medical home and about how to serve our patients better with this remarkable method of healthcare delivery.

Second, it means that fifteen years ago,  in May, 1999, SETMA began  transforming the care SETMA’s patients receive by defining ten principles on the basis of which our use of electronic health records (EHR) would be built.  That month, SETMA published a booklet entitled, 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.   This booklet was SETMA’s declaration of our intent of transformation healthcare delivery with electronic health records (EHR).  Before the federal concept of “meaningful use” of EHR was published, SETMA was about the process of “using the EHR meaningfully.”

Based on Peter Senge’s “systems thinking,” (see Designing an EMR on the Basis of Peter Senge's The Fifth Disciple by James L. Holly, M.D.), these principles stated that SETMA would:

1. Pursue electronic patient management rather than electronic health records, leveraging the power of electronics to improve individual and population health.
2. Bring to bear upon every patient encounter that which is known rather than what an individual provider knows.
3. Make it easier to do it right than not do it at all.
4. Continually challenge providers to improve their performance.
5. Easily infuse new knowledge and decision-making tools throughout an organization.
6. Promote continuity of care with patient education, information and plans of care.
7. Enlist patients as partners and collaborators in their own health improvement.
8. Evaluate the care of patients and populations longitudinally.
9. Audit provider performance based on the Consortium for Physician Performance Improvement (PCPI) Data Sets. (Other measure sets have been added since then)
10. Create multiple disease-management tools which are integrated in an intuitive and interchangeable fashion giving patients the benefit of expert knowledge about specific conditions while they get the benefit of a global approach to their total health.

Third, ten years later on February 16, 2009, with the tools which had been developed in the interim, SETMA began the formal process of transforming your care into a Medical Home model. In 2009, 2010, 2011, SETMA published three series of articles which described and defined medical home and which documented our progress toward being a medical home. (see 2011 Medical Home Series Two).

A Partial List of Services Available in your Medical Home

Being a patient in SETMA’s patient-centered medical home means you have access to a wide range of other clinical support services. These services include:

1. Dietary Education through SETMA’s American Diabetes Association approved Diabetes Self Management Education program. SETMA’s education department also trains patients in dietary weight management, cholesterol control, the Dietary Approach to Stopping Hypertension (DASH), Renal Dietary management, and others.
2. Cardiovascular Laboratory in which you can be tested for heart disease with stress test, dobutrex stress test, echocardiograms, arterial Doppler, carotid Doppler, holter monitors, etc.
3. Pulmonary Function testing
4. Bone Densitometry for osteoporosis
5. Allergy Testing
6. Cardiovascular Risk Stratification with Carotid Intima Thickening testing
7. Ultrasonography for abdomen, pelvis, venous, oeripheral vasculature, etc.
8. Laboratory services - SETMA’s reference laboratory provides an extensive array of testing, all of which are link with the electronic medical record.
9. Radiologic services including Mobile x-ray
10. Physical Therapy which provides state-of-the-art to all patients for cardiac rehab, conditioning and all other modalities of physical therapy.
11. Infusion Center
12. Specialty Diabetes care through the Diabetes Center of Excellence at Southeast Texas Medical Associates.

The Mission of Your Medical Home

The mission of SETMA and now of SETMA as a medical home was formalized into SETMA’s Mission Statement inn 1997. It states:  “To build a multi-specialty clinic in Southeast Texas which is worthy of the trust of every patient who seeks our help with their health, and to promote excellence in healthcare delivery by example.”  A framed copy of this statement is displayed in all public places within SETMA’s clinics. The statement is supported by SETMA’s:

Public Motto: Healthcare Where Your health is the only care
Private Motto: We want to do good while we do well

The Vision of Your Medical Home

SETMA’s medical home’s vision is to participate in the transformation of healthcare in the United States. This means that we understand that “transformation” comes from an internal, generative passion which drives us beyond the requirements of “reform” which is based upon regulations, rules and requirements. SETMA’s vision is defined by our wiliness to face our current reality and our willingness to honestly and straightforwardly face the gap between our reality and our vision.

In his book, The Fifth Discipline, Peter Senge addresses “creative tension” as that which is created by the difference between our reality and vision. Our ability to hold that creative tension between our reality and our vision is the force which will drive us to the successful achievement of our mission, the reaching of our goals and the fulfillment of our vision.

In reality because of transformation and generative passion which is internalized our vision will continually expand and change. Our vision is a society in which all have access to excellent healthcare, in which healthcare is seen as a human right. It includes our collaboration with our patients as team members on their healthcare team where the patient is activated, engaged and participating in shared-decision making. It is a healthcare delivery system which is coordinated and integrated, and which is sustainable financially.