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Evolution of a Patient-Centered Medical Home

Carrie Vaughan, for HealthLeaders Media, February 10, 2011

For the past two years, Southeast Texas Medical Associates (SETMA) has been on a journey to be recognized as a patient-centered medical home (PCMH)—although, in truth, the journey began more than a decade ago.  

The Beaumont, TX–based multispecialty practice began aggressively working with managed care in 1997, says CEO James L. Holly, MD. “This was an effective way to address many of the needs of our patients, especially the cost, quality, and access to care by our medically most vulnerable friends and neighbors.” 

SETMA then became involved in Medicare Advantage, which enabled the practice to extend care to many patients who previously could not afford or obtain it.

In 1998, SETMA adopted electronic health records, but soon realized that they were too expensive and difficult to manage if the only benefit was an electronic method of documenting a patient encounter. So the following year, SETMA redirected its efforts to electronic patient management and began developing disease and data management tools. 

In 2000, SETMA determined that to provide excellent care, it needed to track the quality of care, audit the care given to populations of patients, and statistically analyze its outcomes. “We began tracking and auditing various quality metrics, including diabetes, hypertension, care transitions, congestive heart failure [CHF], and chronic stable angina—most of which were published by Physician Consortium for Performance Improvement. In time, we expanded that to include other nationally recognized metrics,” says Holly.

Finally in 2009, SETMA embarked on its journey to be recognized as a PCMH. 

Recently, Holly discussed with HealthLeaders his views on SETMA’s care model, healthcare reform, and the lessons learned along the way:

HealthLeaders: What were driving forces behind your decision to adopt a PCMH model of care?

Holly: The features of medical home which intrigued, attracted, and challenged us were:

  • The process of coordination of care and the outcome of coordinated care.
  • The further development of our team approach to healthcare, including a truly collegial relationship between nurses, medical assistants, administration, information technology, nurse practitioners, and physicians.
  • The realization that the “patient-centered” element of medical home was the ultimate reality of the principle we have stated to our patients for the past fifteen years.
  • We have long given our patients report cards telling them what they should expect from their healthcare provider. Now, we have added outcomes transparency to those expectations with our decision to publicly report process and outcomes metrics.
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