AIMS Model

The AIMS model, developed at Rush University Medical Center, assesses the needs of complex patients and then provides risk-focused care coordination by master’s prepared social workers guided by a standardized protocol. The AIMS social worker assists people with the biopsychosocial and functional issues impacting their medical care plan adherence or physical condition.

The intervention follows a five step process:

  • Patient/caregiver engagement:

    The AIMS social worker contacts the patient/caregiver to explain the intervention and schedule full assessment. The goal of the contact is to develop rapport and trust, ensure the patient/caregiver understands the rationale for the intervention, and begin to identify issues the patient /caregiver feels are important.

  • Assessment and care plan development:

    The AIMS social worker performs a standardized comprehensive biopsychosocial assessment with a focus on strengths and barriers in multiple domains including finances, functional abilities, cognition, mental health and many others. Care plan goals are developed collaboratively with the patient/caregiver using motivational interviewing techniques in order to select one to three person-centered goals based on complexity, safety concerns, and the patient/caregiver’s ability to independently work on a goal.

  • Telephonic or in-person case management:

    The AIMS social worker assesses progress on goals and provides support or shifts the goal attainment plan as necessary. The AIMS social worker and the patient/caregiver problem solve barriers to goal attainment using evidence-based motivational interviewing and psychoeducation techniques.

  • Goal Attainment:

    The AIMS social worker and patient/caregiver summarize goal achievement and ensure community-based resources are in place to support the patient/caregiver in the community. Resources and methods for additional goal attainment independent from active AIMS intervention are discussed, and patients/caregivers are encouraged to contact the AIMS social worker should new challenges emerge.

  • Ongoing care:

    If goals are not attained, the AIMS social worker will problem-solve patient barriers to goal attainment using motivational interviewing techniques and psychoeducation. If continued social work intervention regarding Care Plan agreed upon goals is warranted, the social worker and client with reevaluate care plan and reengage in active case management.

The model allows for additional chronic disease self-management education as well as transitional care for people returning to the community after a hospital stay. Activities build upon evidence-based social work core competencies of engagement and assessment, resource linkage, counseling, care coordination, motivational interviewing to promote self-management, and team interaction. Patients/caregivers direct their own care by identifying personal wellness goals, building a collaborative care plan for how to reach them, and assuming primary accountability for achieving those goals with the support and coaching of the AIMS social worker.

The AIMS model was built around the concept of shared resources across multiple practices with program services provided both face-to-face and virtually by phone or electronically. AIMS social workers are employed through a central department rather than individual practices, allowing small practices to benefit from the full-time availability of an AIMS social worker even if their individual client base would not support one in some settings. In other settings, community-based organizations partner with local primary care clinics to integrate social determinants of health and leverage resources. By centralizing resources, the AIMS model can work from a strong infrastructure for supervision, peer support, and case load distribution across many social workers. AIMS social workers are housed in their parent department outside the practices, combating the barrier of limited work space in the clinic, but are available to be on site at practices as needed.

RESULTS

The AIMS model has demonstrated success at Rush University Medical Center, contributing to the designation of seven primary care practices as Level 3 Patient Centered Medical Home by the National Committee for Quality Assurance. Moreover, consumer, provider, and caregiver feedback gathered through formal evaluation indicates high satisfaction with the program, resulting in better supported, less stressed, and better informed consumers and caregivers. Providers (n=28) reported they were able to spend more appointment time on medical issues (73%), and that people seemed less distressed (82%), showed a better sense of well-being (82%), and exhibited better self-management (73%).

Early evidence suggests an impact on avoided hospitalizations, emergency department usage, and 30-day readmissions. A retrospective analysis of the AIMS model at Rush University Medical Center showed statistically-significant lower rates of admissions, 30-day readmissions, and emergency department visits for AIMS participants as compared to a similar patient population. The impact of AIMS on utilization is currently being studied more rigorously via a two-year quasi-experimental study with the support of The Commonwealth Fund; results are anticipated by spring 2018.

Care settings

The AIMS model targets ambulatory care, with applicability to both primary and specialty care. The model was first developed in a primary care setting where individual-level needs related to psychosocial issues often appear, yet physicians may not have the time or awareness of community resources to address them. After a strong reception in primary care, the model was adapted and implemented in Rush-affiliated specialty care ambulatory clinics for conditions strongly impacted by long-term services and supports, such as movement disorders including Huntington’s disease and Parkinson’s disease, neurology, epilepsy, stroke, and multiple sclerosis.

Through support from The Harry and Jeanette Weinberg Foundation, the AIMS model has been replicated at community-based organizations in new and diverse geographic areas:

Patient population served

The AIMS model serves patients/caregivers at Rush University Medical Center-affiliated primary care or specialty care practice in Chicago, Illinois. The majority of patients served are Medicare, Medicaid, and dually-eligible beneficiaries, aged 18 years. Patients referred for services are those who are believed to be complex and vulnerable as a result of intersecting social and medical needs.

The population served is grounded in patient complexity research. Patient complexity is related to the lack of social supports and other factors that impact health utilization and outcomes, specifically, the amalgamation of environmental and social factors contributing to an individual’s ability to access timely care and make informed care decisions. The AIMS social worker, in collaboration with practice staff, systematically identifies, addresses, and monitors the social, functional, environmental, cultural, and psychological issues impeding medical care as they present for patients served at the designated practice.

Funding Sources

We thank the following sources for their support for this innovation:

  • Rush University Medical Center
  • Sanofi Aventis
  • Community Memorial Foundation
  • The Harry and Jeanette Weinberg Foundation, Inc.
  • The Commonwealth Fund

Rush University Medical Center received a $350,000 grant from The Commonwealth Fund to assess AIMS’s impact on patients’ health services use, health outcomes, and satisfaction with health care service delivery. They also aim to identify the core aspects essential to the success of the AIMS model. This study will conclude in April 2018.

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