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Your Life Your Health - Patient Centered Medical Home Poster Child: An Update after Five Years of Treatment in a Medical Home
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James L. Holly,M.D.
February 27, 2014
Your Life Your Health - The Examiner

As the concepts and the details of patient-centered medical home (PC-MH) mature, even though only fifteen percent of primary care practices have qualified for recognition or accreditation, it is increasingly obvious that the patient/provider encounter mirrors the methods and ideals of PC-MH.  Perhaps nothing defines a patient-centric visit more than the wiliness of a healthcare provider to invite a patient to “tell his/her story,” and for the healthcare provider to listen to the patient’s “story” without interruption.

Similarly, an organization’s PC-MH journey will be characterized by a collection of stories of the impact of the new model of healthcare on individual’s lives.  SETMA has a growing list of stories which are the sign posts on our pilgrimage. One story started the first day after we started to think about Medical Home.  We call this story.  We call him SETMA's Medical Home "Poster Child."

On February 10, 2009, on rounds for a partner, I saw a patient in the hospital.. He was angry, hostile, bitter and depressed. It was impossible to coax him out of his mood, no matter how hard I tried.   Nurses did not want to go into his room because of his negative response to them.  On the 11th, he was discharged from the hospital and I gave him a follow-up appointment to see me.

He was seen on February 17th.  It had been on the 16th that five of SETMA’s staff attended a lecture on medical home.  On the 17th, we began writing an article a week about medical home.  Writing an article a week for sixteen weeks, we worked to understand what this new model of care meant.  We did not realize that while we were writing about medical home, we were experiencing medical home, as we were becoming a medical home.

At the appointment on the 17th, our patient’s affect had not changed.  During that visit, we discovered several things.  He was only taking four of nine medications because of expense. He could not afford gas to get the education he needed. He could not afford the fees for the diabetes education which he desperately needed.  His diabetes had improved since he had first been being seen at SETMA where on May 1, 2008, his hemoglobin A1c was 12.3%.  A normal value is less than 6% and a well-controlled patient with diabetes will have a value of less than 7%.  Any value above 7% and particularly 8% will result in damage to the eyes, the kidneys, the heart and vessels and to other systems. 

At his visit on the 17th his value was 7.1%. At that visit, it was obvious that he was genuinely disabled and could not work. He was also losing his eyesight and could not afford an ophthalmologist’s care. And, he did not know how to apply for disability. When he left that visit, he had an appointment to SETMA's American-Diabetes-Association (ADA) approved diabetes self-management education program. The fees for the education program were waived. He left with a gas card provided by The SETMA Foundation with which to pay for the fuel to attend the education classes which were critical to his care.

Before he left the office SETMA's staff negotiated a reduced cost for his medications with the patient's pharmacy and arranged for the pharmacy to bill The SETMA Foundation. (Note:  The year before the SETMA partners had formalized The Foundation and began giving $500,000 a year to the Foundation.  That money is used to pay for the care of SETMA patient’s who cannot afford care.  None of the money can profit SETMA but is used to pay for services which the patient cannot afford and which cannot be obtained without payment.) 

The patient's care also included SETMA’s Care Coordination department assisting him in his application for Social Security disability. He also 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, on April 2, 2009, he and his wife returned for a follow-up visit. As he walked into the clinic with a smile on his face, it was obvious that he had something which could not be prescribed for him; he had hope!  He was friendly and engaging.  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, his hemoglobin A1c, which had been improving since May of 2008 was now 6.1% and has remained controlled since.  On February 20, 2014, five years since our first encounter, his value was 6.4%, which is perfect.

Six after his February 17th visit, his Social Security disability application was approved but he still did not have insurance as the Federal policy is that even after being approved for disability, his Medicare eligibility was delayed for two years.  Unfortunately, without care for two years, he would be blind, on dialysis, or dead.  The SETMA Foundation continued to support his care.  Every three months his medications cost $2,200, which was the best arrangement we could make.  I continued to see him and SETMA continued to provide the support needed for his care to be ideal.

Was Hope to be Lost?

Eighteen months later, he was in for a scheduled visit; he seemed sad and I asked him what the problem was.  He said that he was afraid we would tire of helping him. As indicated above, he had applied for and had received disability, but he would not be eligible for Medicare for two years. He asked if we would stop helping him. I said, "Yes, we will stop helping you.”  With some trepidation, he asked, “When?”  I said, “The day after we go bankrupt."  I added, “Medical home is more than a name to us.  I would no more stop helping you if SETMA has the resources than I would not support my wife of 49 years, or my children and grandchildren.”

Five Years and Counting

It has been exactly five years since this patient joined SETMA’s medical home.  In the interim, 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 PC-MH 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 his visit yesterday (February 20, 2014), with a 4th Year Medical Student present, who is participating in SETMA’s PC-MH 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 February, 2011.  I then told him about Winston Churchill’s famous saying:  “You make a living by what you get; you make a life by what you give.”  I thanked him for giving SETMA, SETMA’s partners and all of our colleagues, the opportunity to make a life.

Patient Advisory Board

This spring, SETMA is forming a Patient Advisory Board which will meet three times a year.  The Board will review SETMA’s performance, plans and projects.  The Board will have a vote on what we do and don’t do.  The consumer and community members of this Board, which will occupy a majorly of the seats on the Board, will have access to confidential and private information, but will not include person health information, with which to help SETMA enter a new dimension of patient-centeredness.  As we continue to accumulate “stories” about PC-MH, we trust that patients will experience increasing medical-home care which will be satisfying to them personally and valuable to their personal health.


As SETMA has continued its journey to being a medical home; our Patient-Centered Medical Home Poster Child has taken a journey from being a stranger, to being a patient, to being a friend, to being a family member.  Each level of intimacy and relationship has brought with it increasing satisfaction of care, increasing quality of care and an increasing lower cost of care.  That is a microcosm of SETMA’s fulfillment of the Triple Aim.  And, unpleasant encounters have morphed into delightful, pleasant, anticipated encounters with handshakes, hugs and smiles all around.

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