Albany Internal Medicine Embraces New Approaches to Patient Care

Barbara Kieker

Monday, May 5th, 2014

With the upheaval in health care created by the Affordable Care Act (ACA) and the shift away from fee-for-service payment models, independent medical practices face an uncertain future.  Albany Internal Medicine (AIM) grabbed the bull by the horns over two years ago and set about identifying the most likely future scenario for primary care as well as the skills needed to thrive in that environment. 

"In many ways we're on the leading edge.  Many people talk about new ways of delivering care but we're putting it into practice by developing plans, protocols and policies to improve quality of care and reduce costs," said AIM Administrator Bruce Trickel, CMPE. 

Founded in 1954, AIM is a physician-owned independent primary care practice, one of the largest in southwest Georgia.  It serves adults who typically live within a 100-mile radius of Albany.  The practice has nine physicians – seven general internists and two family practitioners – as well as a physician assistant and a nurse practitioner. 

Becoming a patient-centered medical home

"Two and half years ago, our physicians and I sat down to determine where we thought things were headed because there is no clear roadmap for the future," Trickel said. "We wanted to identify and acquire skillsets to take into the future when payment models are likely to be based on quality, value and preventive care." 

Examples of the skillsets needed to succeed in the future are new methodologies, organizational approaches and tools that focus on quality of care and value.  Communication and coordination of care with the patient, caregivers and other physicians and pharmacists is a critical component to improving quality of care and reducing costs. 

In September 2012, AIM set about developing these skills by gaining recognition by the National Committee for Quality Assurance (NCQA) as a Patient Centered Medical Home.  According to NCQA, NCQA-Patient Centered Home Recognition is the most widely used way to transform primary care practices into medical homes.  Achieving the recognition took 15 months after which AIM demonstrated "it had the tools, systems and resources to provide patients with the right care at the right time," according to NCQA President Margaret E. O'Kane. 

"In February 2014, we became the first medical practice in southwest Georgia to achieve Level 3 recognition from the NCQA, which is the highest level of recognition.  Now we're putting it into practice," Trickel said. 

"In April, we became part of the Blue Cross Blue Shield Primary Care Patient Centered Medical Home program that recognizes us and rewards us as a medical home practice." 

Patients will experience more coordinated care and care management in a patient-centered medical home, according to Trickel, and patients and caregivers will be more involved in decision-making.  Technology will be used more heavily to track performance measures that equate to improved care and better outcomes. 

Taking a next step: transition care management

According to Trickel, AIM is getting ready to work on the next step toward "value-based" medicine – medical providers that improve quality while reducing costs. AIM is working with the Georgia Hospital Association (GHA), Medical Association of Georgia (MAG), and Phoebe Putney Memorial Hospital on a pilot project that focuses on hospital readmission reduction through the use of care transition principles and practices.  

"Objectives of the pilot are to work together to support innovative solutions designed to reduce harm, promote care coordination and improve health outcomes at the patient and ultimately, the population level," Trickel said. 

Transition care management can include a call to the patient within two business days of being discharged from the hospital and depending on the complexity of the hospitalization, an office visit to the primary care physician within one to 14 days of discharge. 

"In these interactions, we ask the patient if they are doing okay, review their medications and discuss any barriers they may be facing to adhere to the post-discharge care plan," Trickel explained. 

Reducing hospital readmissions is a priority locally and nationally and Medicare has begun reimbursing physicians for defined transition care processes, according to Trickel. 

"Readmissions are a big concern.  They heavily task the health care system," Trickel said. 

More information on Albany Internal Medicine is available at

About Barbara Kieker

Barbara Kieker is a freelance writer who writes on business-related topics for a number of web-based properties. She also provides communications services to Fortune 500 corporations, small businesses and nonprofit organizations.