It is widely recognized that medical and social services are fragmented, despite clients’/patients’ intertwining needs. While chronic conditions and their symptoms are frequently discussed in healthcare settings, important social factors that influence physical health including substance use/abuse, depression and anxiety, financial concerns, and environmental factors are less recognized. As a result, many patients face difficulty meeting their medical plan of care due to social and environmental barriers that are not taken into account when addressing their physical needs.
The Ambulatory Integration of the Medical and Social (AIMS) model, developed at Rush University Medical Center, addresses this gap by embedding a master’s prepared social worker into primary and specialty care teams. AIMS social workers use a standardized protocol to assess the needs of complex patients and provide risk-focused care coordination and intervention to assist people with the biopsychosocial and functional issues impacting their medical care plan adherence or physical condition.