OUR CARE MODELS

CHaSCI studies best practices related to integrating social work and social services into medical care. Informed by work done at Rush University Medical Center and diverse partners across the country. This has included developing care model protocol and tools to support implementation and quality assurance as programs scale.

CHaSCI shares learnings and dissemination of our care models and other care innovations through trainings and technical assistance and the CHaSCI Community.

Transitional

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 support medical stability after returning home to the community.

Learn more about Bridge.

 

 

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

AIMS social workers use CHaSCI’S standardized protocol to assess & address complex psychosocial and functional issues impacting people’s care plan adherence, health status, and qualify of life.

Learn more about AIMS.

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Depression: Under Rush’s Collaborative Care program, a universal screening helps identify patients with depressive symptoms, and social work care managers use their broad skillset to assess & address various aspects of life that may be contributing to depressive symptoms, in addition to using a curated care plan and consulting psychiatrist to ensure patients are connected to the appropriate level of mental health support. Learn more here and here.

Social needs: Universal screening can help identify patients with unmet social and economic needs. At Rush, patients are screened for unmet needs across primary care, the emergency department, and inpatient units. Patient navigators and social workers follow up on identified needs, whether sending patients home with a NowPow-curated resource list, sending them home with food, or a comprehensive care plan rooted in patient-identified goals and priorities to address complex and intersecting needs (using the AIMS Model). Learn more here.

 
 

Interested in learning more?
Join the CHaSCI Community, or contact us to learn more about replication and technical assistance opportunities.