• Comprehensive Support

• Providers Responsibility

• Teamwork

• 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

• Eisenberg Award Summary Document

• James Holly, MD Curriculum Vitae

• Letters of Support - William Henrich

• Letters of Support - Wayne Reaud

• Letters of Support - Paul Grundy

• Letters of Support - Scott Decker(NextGen)

• Letters of Support - Amy Gibson

• Letters of Support - Rudy Sotolongo

• Ted Carpenter, Letter of Transmittal

• SETMA questions Influenza Data

• SETMA I - October 2011

• SETMA II - October 2011

• Mark A. Wilson Clinic SETMA West - October 2011

• Aging Well

• Cardiovascular Disease Risk Factors

• Care Coordination

• Care Transitions

• Children's Health

• COGNOS Project

• Diabetes

• Exercise

• Healthcare Reform:Public Policy

• Labor Day

• Less Initiative

• Medical Home

• Medical Records

• Men's Health

• Mental Health

• Nutraceuticals

• Nutrition

• Smoking Cessation

• Thanksgiving

• Weight Loss

• Women's Health

• Master GP Suite of Templates

• Angina Tutorial

• Diabetes Tutorial

• Lipids Tutorial

• Lipid Quality Audit Tutorial

• Hypertension Tutorial

• Primary Pulmonary Hypertension Tutorial

• Congestive Heart Failure Tutorial

• Adult Weight Management Tutorial

• Acute Coronary Syndrome Tutorial

• Cardiometabolic Risk Syndrome Tutorial

• Chronic Renal Disease Tutorial

• Discharge Summary 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

• LESS Initiative Tutorial

• Smoking Cessation Tutorial

• Exercise Prescription Tutorial

• Diabetic Exercise Tutorial

• CHF Exercise Tutorial

• Preventing Diabetes Tutorial

• Preventing Hypertension Tutorial

• Weight Management Tutorial

• Principal Suite of Templates

• Hydration Assessment Tutorial

• Nutrition Tutorial

• Skin Care Tutorial

• Fall Risk Tutorial

• Depression Tutorial

• Guidelines for Care Tutorial

• Chronic Conditions Tutorial

• Drug Interactions Tutorial

• Electronic Tickler File Tutorial

• Hydration Assessment Tutorial

• Nutrition Tutorial

• Future Labs Tutorial

• Pain Management Tutorial

• Skin Care Tutorial

• Fall Risk Tutorial

• Depression Tutorial

• HCC Risk Training Tool

• Evaluation Lower Urinary Tract Symptoms in the Male

• Referral

• Association of Medication & Diagnosis

• Medication Module Tutorial

• Electronic Tickler File Tutorial

• Less Initiative Tutorial

• Follow-up Calls

• HCC/RxHCC Risk Tutorial

• Cardiometabolic Risk Assessment

• LDL Level

• Frederickson Classification of Dyslipidemia

• Lipid Disease Management Risk Assessment

• Framingham Heart Study Risk Calculators Tutorial

• Proteinuria

• Calculating the Stages of Renal Disease

• 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 - Diabetes (Smoking Cessation)

• Effectiveness of Chronic Care Diabetes - Diabetes (Glyco and LDL)

• Effectiveness of Chronic Care Diabetes - 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

• Medical Home Coordination Review

• Care Coordination Department of Care Coordination

• NCQA Standards Elements

• Follow-up Calls Clinic Visit

• Using The Clinic and Hospital Follow-up Call Templates

• Plan of Care and Treatment Plan

• Diabetes Tutorial

• Lipids Tutorial

• Hypertension Tutorial

• CHF Tutorial

• Pre-Visit Patient Appointments (Preventive Measures and Elderly Patients)

• NCQA PC-MH Applications Documents for Each Standard, Element, Data Point

• NCQA PPC-1
  • NCQA PPC-1 Element A 1

  • NCQA PPC-1 Element A 2,3,5,6

  • NCQA PPC-1 Element A 2,4

  • NCQA PPC-1 Element A 4

  • NCQA PPC-1 Element A 7,8

  • NCQA PPC-1 Element A 9,10

  • NCQA PPC-1 Element A 12

  • NCQA PPC-1 Element B 1,2,3,4,5

• NCQA PPC-2
  • NCQA PPC-2 Element A Description

  • NCQA PPC-2 Element B Description

  • NCQA PPC-2 Element C COGNOS Audit

  • NCQA PPC-2 Element D Description

  • NCQA PPC-2 Element F

• NCQA PPC-3
  • Element A
    • NCQA PPC-3 Element A 1

    • NCQA PPC-3 Element A 2

    • NCQA PPC-3 Element A 3

  • Element B & C
    • NCQA PPC-3 Element B Description

    • NCQA PPC-3 Element B note and comment

    • NCQA PPC-3 Element C

  • Element D
    • NCQA PPC-3 Element D 2,3,4,5

    • NCQA PPC-3 Element D General

    • NCQA PPC-3 Element D 11

    • NCQA PPC-3 Element D 1

    • NCQA PPC-3 Element D 2

    • NCQA PPC-3 Element D 2,3 plan of care and treatment plan for dyslipidemia

    • NCQA PPC-3 Element D 2, 3 Plan of Care Treatment Plan Hypertension

    • NCQA PPC-3 Element D 2,3 plan of care and treatment plan for diabetes

    • NCQA PPC-3 Element D 6,7,8,9,10

    • NCQA PPC-3 Element D Coordination of Care document

    • NCQA PPC 3 Element D audit

  • Element E
    • NCQA PPC-3 Element E 1

    • NCQA PPC-3 Element E 2,3,5

    • NCQA PPC-3 Element E 4

    • NCQA PPC-3 Element E 5

    • NCQA PPC-3 Element E 9

• NCQA PPC-4
  • NCQA PPC-4 Element A 1,2

  • NCQA PPC-4 Element B 2,4,5,7

• NCQA PPC-5
  • NCQA PPC 5 Element A Audit

  • NCQA PPC-5 Element A 2

  • NCQA PPC-5 Element B 1-15 Element C 1

  • NCQA PPC 5 Element B audit A

• NCQA PPC-6
  • NCQA PPC-6 Element A 1,2,3

  • NCQA PPC-6 Element A 4,5,6

  • NCQA PPC-6 Element B 1,2,3,4,5,6

• NCQA PPC-7
  • NCQA PPC-7 Element A 1,2,3,4

• NCQA PPC-8
  • NCQA PPC-8 Element A 1,2,3,4

  • NCQA PPC-8 Element B 1,2,3,4

  • NCQA PPC-8 Element C 1,2

  • NCQA PPC-8 Element D 1,2

  • NCQA PPC-8 Element E

  • NCQA PPC-8 Element F

• NCQA PPC-9
  • NCQA PPC-9 Elements A B C