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 at Rush’s 15 primary care practices, and provides comprehensive follow-up care management 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, engaging social work’s BROAD & DEEP SKILLSET to identify and address various aspects of life that may be contributing to depressive symptoms. The social worker completes a person-centered assessment and engages DIVERSE & COLLABORATIVE INTERVENTIONS to reduce depression and reach patients’ goals - whether psychoeducation, brief cognitive behavioral therapy, consultation with psychiatrists, ensuring patients are connected with long-term & accessible psychotherapy, resource provision, family mediation, and/or promoting social connection.