OUR CARE MODELS

CHaSCI’s SOCIAL-WORK-LED CARE MANAGEMENT models - provide PROTOCOL and an EVIDENCE BASE to help sites with their efforts to integrate psychosocial assessment and care management into medical care. CHaSCI’s models emphasize hospital-community collaboration and can be implemented by healthcare entities or community-based organizations. CHaSCI’s care model evolves as we continue learning best practices from experience at Rush University Medical Center, Aging Care Connections in partnership with AMITA Health Adventist Medial Center La Grange, and the experiences, successes, and challenges faced by the 100+ hospital and community-based organization sites trained in the models.

As DEMONSTRATED BY AIMS AND BRIDGE, integrated efforts to address medical and social issues leads to many positive outcomes, including INCREASED PRIMARY CARE ENGAGEMENT, significantly LOWER HOSPITALIZATION & READMISSION RATES, and DECREASED DEPRESSIVE SYMPTOMS AND STRESS for patients and family caregivers.

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The Bridge Model of transitional care uses social workers to provide transitional care services to support older adults and adults with complex medical and social needs as they go home from the hospital or a skilled rehab stay.

Using CHaSCI’s standardized protocol, Bridge LEVERAGES CARE COORDINATION & THERAPEUTIC TECHNIQUES to increase patient activation and follow-through, and to SUPPORT MEDICAL STABILITY and healing after returning home to the community.

Learn more about Bridge.

The Ambulatory Integration of the Medical and Social (AIMS) model integrates social workers into primary and specialty care settings to support individuals with complex biopsychosocial & functional issues and their caregivers.

AIMS social workers use CHaSCI’S STANDARDIZED PROTOCOL TO ASSESS & ADDRESS COMPLEX NEEDS, including risk-focused care coordination and intervention to assist people with psychosocial and functional issues impacting their medical care plan adherence or physical condition.

Learn more about AIMS.

Interested in learning more about replication and our trainings? Contact us - we’d love to chat!