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.