Rush University: Implementing the Ambulatory Integration of the Medical and Social (AIMS) Model
Rush University Medical Center
Member Since: September 2016
Intervention: Implementing the Ambulatory Integration of the Medical and Social (AIMS) Model: Addressing non-medical influences to transform health care delivery
Partners:
- Six Rush University Medical Center Primary Care Practices:
- Associates in Internal Medicine
- Earvolino & Associates
- Lifetime Medical Associates
- Rush University Family Physicians
- Rush University Internists
- Rush University Physicians at Lincoln Park
- University of Wisconsin –Whitewater and Binghamton University (Evaluation)
Occupations represented: Students, residents, and professionals from nursing, primary care medicine, and social work.
Overview: This project provides Rush University Medical Center interprofessional providers, residents, and students an opportunity to work collaboratively to best meet the needs of their patients. At partner clinics, any member on the care team can place referrals to the Rush Health and Aging Department (RHA) for social work follow-up if they identify their patient (18+, public or private payer) has a psychosocial need or is facing barriers to following their health care plan. The social worker provides wrap-around supports that engage various interprofessional healthcare and service providers in ensuring a patient’s range of biopsychosocial needs are addressed. This collaboration will reinforce the paradigm shift within primary care of treating a patient holistically, and the inclusion of social work students and medical residents in this project is significant because it exposes them to important practices and competencies in integrating primary care with care management and psychosocial supports.
The project focuses specifically on the Ambulatory Integration of Medical and Social (AIMS) model as implemented in several primary care clinics at Rush. The AIMS model is a protocolized five-step model which includes the following steps: patient engagement; assessment and care plan development; case management; goal attainment; and ongoing care. Development of the AIMS model has been an iterative process, using Plan-Do-Study-Act cycles to create a model that best meets the needs of patients and providers in an urban academic medical center. The AIMS model continues to be replicated in various healthcare settings, including in specialty care clinics at Rush (e.g., Neurology, Huntington’s Disease, Movement Disorders), and by community-based social service organizations in IL and MD in partnership with primary care providers – demonstrating not only the importance of interprofessional teams, but also of the connection between community-based social services with healthcare entities.
Outcome measures for this study include examining the impact of addressing non-medical influences on individual patients’ health care utilization, health outcomes, and satisfaction with health care service delivery in both intervention and comparison sites. An additional outcome of the project is to identify elements of the AIMS model that integrate medical and non-medical patient needs. This study of AIMS’ impact in primary care settings is generously supported by The Commonwealth Fund.
To learn more about the AIMS model, please visit: www.theaimsmodel.org.
Intervention Study Question:
- To what extent does addressing non-medical issues affect patient level health outcomes?
- To what extent does addressing non-medical issues affect health care utilization?
- What is the individual level patient satisfaction with health care service delivery as a result of addressing non-medical issues in primary care using the AIMS model?