The Patient-Centered Medical Home Poster Child

| James (Larry) Holly

Southeast Texas Medical Associates’ (SETMA’s) pilgrimage toward Patient-Centered Medical Home (PCMH) began in 1999 as a result of our study of Peter Senge’s The Fifth Discipline. In that study, we identified ten principles which would guide our development in both our practice and in the electronic medical record (EMR) tool which we would design.  (see SETMA: May, 1999 - Four Seminal Events)  Ten years into our development, we realized that those ten principles were also the principles of PCMH.

The Patient-Centered Medical Home Poster Child

In my morning clinic on February 17, 2009, I saw a patient whom I had seen in the hospital the previous Saturday and Sunday. He would soon earn the title of SETMA's Medical Home “Poster Child.”

In the hospital, he was angry, hostile, bitter and depressed. When he was ready to leave the hospital, I gave him an appointment to see me, even though he was not my patient. In his follow-up visit, his affect had not changed. In that visit, I discovered that he was only taking four of nine medications because of expense.  He could not afford gas to get the education he needed about his condition. He was genuinely disabled and could not work. He was losing his eyesight and could not afford to see an ophthalmologist. He did not know how to apply for disability. His diabetes had never been treated to goal.

When he left that visit on the 17th, he had an appointment to SETMA's American Diabetes Association-approved diabetes self-management education program.  The fees for the education program were waived.  He also left with a gas card with which to pay for the fuel to get the education which was critical to his care. SETMA's staff negotiated a reduced cost with the patient's pharmacy and made it possible for the pharmacy to bill The SETMA Foundation. The patient's care included our assisting him in his application for Social Security disability. He had a visit that day with SETMA's ophthalmologist who arranged a referral to an experimental eye-preservation program in Houston, which was free.

Six weeks later, he returned for a follow-up visit. He had something which I could not prescribe for him; he had hope. He was smiling and happy. Without anti-depressants, or sedatives, he was no longer depressed as he now believed there was life after being diagnosed with diabetes for ten years. And, for the first time, his diabetes was treated to goal.  

In the years since this patient joined SETMA’s medical home, we have learned a great deal more about medical home.  And, he and his wife have enjoyed the benefits of The SETMA Foundation and of SETMA’s model of care.  SETMA has enjoyed the benefit of caring for a family which is grateful for the care they have received and whose health has benefited from the PCMH method of care.  His health is stable, as is his vision.  He has health issues but caring for him is a joy and a delight. 

During one visit in 2014, with a 4th Year Medical Student present, who was participating in SETMA’s PCMH Externship endorsed by the University of Texas Health Science Center at San Antonio School of Medicine, I read to him and his wife an earlier version of his story which was published in 2011. I then quoted Winston Churchill’s famous saying: “You make a living by what you get; you make a life by what you give.”  And I thanked him for giving SETMA, SETMA’s partners and all of our colleagues, the opportunity to make a life. 

January 2017, SETMA enters our 23rd year of existence – personally, I enter my 44th year of medicine – as SETMA looks back on those early days, and as we see what has lasted, we are encouraged that the vision and aspirations we had in the beginning are still with us today.  

This article is excerpted with permission from SETMA’s website.  Dr. Holly has written a weekly healthcare column for the past 20 years. All columns are found on SETMA’s website under Your Life Your Health.


James (Larry) Holly, M.D., CEO, Southeast Texas Medical Associates.

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