Why Adopt the AIMS Model

According to the World Health Organization (WHO), a growing body of research suggests that non­medical issues, such as psychological and social factors, are intricately linked to health. In a 2011 Robert Wood Johnson Foundation survey of 1,000 primary care physicians:

  • 4 out of 5 not confident they can meet social needs, hurting their ability to provide quality care
  • 85% feel social needs directly contribute to poor health
  • Rx for social needs, if they existed, would be 1 in 7 Rx’s written

As a result, patient’s psychosocial issues are often treated as physical concerns. The AIMS model connects the medical and social issues in order to provide the best care for patients.

Benefits of Social Work Integration into Outpatient Care Settings

  • Improve access to psychosocial supports and community resources
    • Assess patients’ psychosocial considerations and their impact on medical status
    • Provide connections with appropriate resources and mental health supports
    • Support patient self-management
    • Free up time for medical providers to focus on physical conditions
    • Educate providers how to support patient self-management
  • Relationship-based care that allows for improved communication and shared decision-making
    • Enhanced connectivity between patients and all care team members
  • Navigate community resources and develop partnerships to improve access to care and ease systems navigation
  • Impact the bottom line by preventing the exacerbation of medical issues and reducing unnecessary hospital/emergency department visits

Why get trained in AIMS?

Despite the benefits of social work involvement, there are challenges to integrating social workers within interprofessional teams in primary and specialty care settings. The AIMS model was developed to address these challenges and to support clinics interested in practice change.  The AIMS protocol and assessment are infomed by best practices and social work core competencies. They have been strengthened by clinical and administrative insights gained from implementing AIMS at Rush (since our first pilot in 2010) and replicating at other sites and communities. Our AIMS training shares these lessons-learned and all implementation materials with replication sites so that they do not spend their time recreating the wheel.

According to preliminary evidence, the AIMS model can reduce acute care utilization, including reduced hospitalizations, emergency department usage, and readmission rates. Feedback from providers indicates that they overwhelmingly feel that they are more confident that their patients’ non-medical needs are being addressed after referring to AIMS, and that they are able to spend more of their time with patients focusing on medical issues. AIMS matches up with several quality measures used in NCQA’s Patient-Centered Medical Home recognition and in the CMS Innovation Center’s Comprehensive Primary Care Plus initiative, and AIMS sites are well aligned to meet quality goals in Medicare’s new Part B payment mechanism resulting from the MACRA legislation.