SYSTEMS CHANGE & SUSTAINABILITY: REAL-WORLD PRACTICE INNOVATIONS

Innovators across the country are undertaking diverse approaches to improve health outcomes, reduce health risk, and promote health equity -
but even with collaborative and compassionate teams, real-world projects often fail
due to systemic barriers and administrative & implementation challenges.

In recognition of this, CHaSCI TESTS AND SCALES UP efforts to integrate health care and social services by focusing on SYSTEMS CHANGE and an eye toward intervention SUSTAINABILITY. We maximize our impact by:

  • testing our new referral mechanisms to capture more people, such as SYSTEM-WIDE SCREENING TOOLS to identify unmet patient needs

  • ROOTING WORK IN THE COMMUNITY, by reaching outside healthcare’s walls, engaging community-based partners as part of the care team, and strengthening community networks

  • incorporating CHANGE LEADERSHIP PRINCIPLES that engage diverse stakeholders in initiative design and execution

  • building in QUALITY ASSURANCE & QUALITY IMPROVEMENT mechanisms, including data dashboarding and clinical supervision

  • STUDYING OUR IMPACT on health & quality of life outcomes, quality measures, utilization patterns, cost of care, revenue opportunities, and patient & provider satisfaction

  • operationalizing both FEE-FOR-SERVICE & VALUE-BASED REIMBURSEMENT opportunities


Systems change projects underway at Rush include:

Rush is unrolling SCREENINGS FOR UNMET SOCIAL-DETERMINANT-OF-HEALTH NEEDS across primary care, the emergency department, and inpatient units. SOCIAL WORKERS & PATIENT NAVIGATORS 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,

The screenings are an integrated part of Rush’s Community Health Implementation Plan and institutional commitment to equity. Rush is an active participant in collaboratives to GROW PROJECTS & SHARE LEARNINGS - from local (West Side ConnectED) to national (Health Leads’s Collaborative to Advance Social Health Integration (CASHI) initiative and the Institute for Healthcare Improvement’s Pursuing Equity initiative),

Our COLLABORATIVE CARE TEAM integrates depression screenings into primary care visits across all of Rush’s primary care practices, and provides comprehensive wrap-around services to ensure patients and families get the support needed to address depressive symptoms and any other biopsychosocial needs.

Our approach builds on the efforts of many collaborative care initiatives across the country and specifically engages social work’s BROAD & DEEP SKILLSET to address various aspects of life that may be contributing to depressive symptoms, in addition to using a curated care plan to ensure patients are connected to the appropriate level of mental health support.
To do this, the social worker completes a person-centered assessment and engages DIVERSE & COLLABORATIVE INTERVENTIONS to manage each patient’s mood symptoms - including psychoeducation, brief cognitive behavioral therapy, connecting patients with long-term & accessible psychotherapy, resource provision for other biopsychosocial needs, family mediation, and/or promoting social connection. The collaborative psychiatrists are also key members of the team, often connecting back with the primary care team to support medication management in the clinic

Interested in learning more? Contact us!