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Service Delivery Innovation Profile

Social Workers Support Outpatients in Dealing With Psychosocial Issues, Leading to High Patient and Practitioner Satisfaction and Better Patient Self-Management


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Snapshot

Summary

Through Rush University Medical Center’s Ambulatory Integration of the Medical and Social (more commonly referred to as AIMS) program, master's-level social workers support primary care and specialty clinic patients in addressing psychosocial, functional, and environmental factors that influence their physical health and well-being. Eligible patients are referred to a central department that employs social workers and assigns them to individual cases across the various practices. Using a standardized protocol based on core principles of social work, the social workers work in partnership with patients to identify high-priority needs, develop a care plan with specific goals related to those needs, and monitor and support adherence to the plan and progress toward the goals. The program has enhanced patients’ access to psychosocial support and generated high levels of satisfaction among patients, their caregivers, and providers. Providers also believe it has improved their patients’ self-management skills and overall well-being. Anecdotal reports suggest that AIMS may be reducing hospitalizations, emergency department visits, and nursing home placements.

Evidence Rating (What is this?)

Suggestive: The evidence consists primarily of results from post-implementation surveys of patients, caregivers, and providers participating in the program.
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Developing Organizations

Rush University Medical Center
Chicago, ILend do

Use By Other Organizations

Working with program leaders at Rush, a community-based agency in La Grange, IL, (Aging Care Connections) has implemented the program in partnership with a local primary care clinic. Rush program leaders recently received funding from the Weinberg Foundation to support replication of the program in Illinois and Maryland. These leaders are also involved in conversations with representatives of an organization in Michigan who are interested in implementing AIMS. Rush has applied for other grants that, if awarded, will be used to support replication of the program elsewhere throughout the Nation.

Date First Implemented

2011
Components of the program began operating on an informal basis in 2008; the more formal AIMS program began in 2011.begin ppxml

Patient Population

The program primarily serves primary care and specialty clinic patients 18 years of age and older who have complex, intersecting social and medical needs, often related to one or more chronic conditions; many of those served are Medicare and/or Medicaid beneficiaries, including “dual eligibles” covered by both programs.Vulnerable Populations > Medically or socially complexend pp

Problem Addressed

The fragmented nature of the health care system typically leads to the separation of medical and social services. This separation leaves many complex and vulnerable patients with little support in dealing with psychosocial and environmental factors and barriers that have a major impact on their physical health, functional status, and overall well-being.
  • Importance of social and environmental factors: Many vulnerable, complex patients who have chronic conditions face important behavioral, social, and environmental factors and barriers that have a significant impact on their physical health, functional status, and well-being, including but not limited to substance use/abuse, depression and anxiety, financial concerns, and transportation issues.
  • Inability to address these factors: Patients with psychosocial needs often seek care from the medical system rather than going directly to community-based services that can help. However, the fragmented nature of the current health care system generally separates the provision of medical care from social support services. As a result, complex and vulnerable patients often get little help in dealing with the factors outlined above, thus impeding their ability to follow their care plans and/or otherwise improve their physical and mental health and well-being. Clinicians in most primary care and specialty practices lack the time, knowledge, and resources to recognize and address the social and environmental factors affecting patients (e.g., by making referrals to community-based resources) and generally have little opportunity to access support from social workers. Even when clinicians make referrals to community-based social workers, patients often do not follow up on these referrals for multiple reasons, including competing demands on their time and the social stigma associated with seeking help.

What They Did

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Description of the Innovative Activity

Through Rush University Medical Center’s AIMS program, master's-level social workers support primary care and specialty clinic patients in addressing psychosocial, functional, and environmental factors that influence their physical health and well-being. Eligible patients are referred to a central department that employs social workers and assigns them to individual cases across the various practices. Using a standardized protocol based on core principles of social work, the social workers work in partnership with patients to identify high-priority needs, develop a care plan with specific goals related to those needs, and monitor and support adherence to the plan and progress toward the goals. Key program elements are outlined below:
  • Identification of eligible patients: Anyone over the age of 18 can participate in AIMS. Although a few patients self-refer, in most cases physicians, nurse practitioners, or other staff within the 11 participating practices (5 primary care practices and 6 neurology clinics) identify individuals who could benefit from the program during the course of routine medical visits. Typically these individuals have unmet psychosocial needs and/or face other social or environmental factors that have the potential to negatively influence access to timely care and the ability to self-manage their health conditions. Many of those referred have one or more chronic conditions that require ongoing management.
  • Electronic ordering, with notification to patient: Once a potential participant has been identified, the practitioner fills out an order form through a customized template built into Rush’s electronic medical record (EMR) system. The individual ordering the service can either make a general referral or check off specific boxes built into the form to highlight key issues facing the patient, such as problems with transportation, coping, caregiving, or self-management of chronic conditions. In most cases, the provider briefly informs the patient about the program and the referral during the visit, telling him or her to expect a call within a few days from a social worker who will explain more.
  • Assignment of social worker from central department: To maximize efficiency and better serve small practices that cannot justify a dedicated, onsite social worker, the program employs social workers through a central department, allowing their services to be shared across participating practices. Two or three times a day, the program manager generates a report within the EMR system to find newly referred patients and then assigns a social worker from the department to each new case. Because it is ideal for a single social worker to serve a specific practice, new cases typically are given to the social worker assigned to the referring practice. Occasionally, a different social worker may be assigned if the patient has a particular need that can be best met by another clinician (e.g., language concordance) or to balance caseloads. As part of the case assignment process, the program manager also identifies any patients who may be facing urgent issues, such as suicidal ideation, so that they can be contacted immediately.
  • Social worker case review: Prior to reaching out to an assigned patient, the social worker accesses the EMR to review the order form and patient’s medical record. This step allows the social worker to thoroughly understand the medical issues facing the patient along with the provider’s perceptions of any relevant psychosocial and/or environmental issues.
  • Initial contact within 2 business days: Within 2 business days of the referral, the assigned social worker contacts the patient to explain the program and its rationale. If the patient is not able to have this conversation, this contact may be with a caregiver (e.g., family member). During this introductory call, the social worker seeks to develop a rapport and build trust with the individual. For those who agree to participate (the vast majority of all those contacted), the social worker begins to identify issues that the patient and/or caregiver feel are important and schedules a time for a more indepth assessment.
  • Comprehensive assessment and goal-oriented care plan: This indepth session usually takes place over the phone, but in roughly 10 percent of cases patients prefer that it be conducted in person. In these instances, the session usually takes place at the social worker's office, but on occasion the social worker will travel to the clinic to meet with the patient. Over a period of 60 to 90 minutes, the social worker and patient/caregiver work together to identify the most important issues and barriers facing the patient and develop a goal-oriented care plan designed to address them. Additional details on this process are outlined below:
    • Biopsychosocial assessment: The social worker assesses the patient’s strengths and barriers in multiple domains. The assessment includes a brief review of the patient’s medical conditions and related concerns (including medications), with a goal of understanding the degree to which medical issues affect aspects of everyday life. The social worker pays particular attention to basic and instrumental activities of daily living (ADLs), such as feeding, dressing, grooming, bathing, walking, shopping, meal preparation, use of the phone and other communication devices, and handling of transportation and finances. The social worker also evaluates the degree to which patients understand how to manage their own health (including chronic conditions) and their medications and assesses substance abuse and mental health issues (using a standard tool to assess levels of depression and anxiety), the level of social support available, competing demands on the patient (such as being a caregiver to another individual), and the potential for abuse, neglect, or domestic violence.
    • Customized, goal-oriented care plan: After the assessment, the social worker develops a care plan to address psychosocial issues that may have the biggest impact on medical management and outcomes. Using motivational interviewing strategies, the social worker encourages the patient to commit to between one and three goals. In most cases these goals relate to high-priority areas such as managing and improving mental health, supporting ADLs, and dealing with important safety and/or medical issues that have been identified. (When present, safety concerns generally trump other issues.) Specific goals often include securing in-home services to help with ADLs; signing up for insurance coverage or available prescription drug assistance programs; and/or accessing transportation services. Again, using motivational interviewing strategies, the social worker gauges the patient's confidence in taking the necessary steps to pursue the goals independently. If the patient lacks confidence after further support, the social worker provides active case management to help him/her achieve the goals. In most cases, the tasks necessary to achieve the goals are shared between the patient and social worker. At the end of the assessment, the social worker reviews the care plan and who will take responsibility for what tasks, and schedules a followup call approximately a week later. The social worker will also consult with mental health providers, primary care providers, or other referring clinicians if new orders are needed.
  • Weekly calls to monitor progress, address issues: In most cases, the social worker and patient talk by phone on a weekly basis to monitor progress toward established goals and make any needed adjustments. As necessary, the social worker will provide additional support if the patient faces a barrier in reaching an established goal, including clinical support, psycho-education (e.g., encouragement, motivation), and functional assistance (e.g., making a call, providing helpful tools and resources). If things are proceeding smoothly, these calls may take only 5 minutes; if not, they can take significantly longer. If a patient continually struggles to achieve a goal, the social worker and patient will negotiate whether the social worker will complete the tasks necessary to achieve the goal. As appropriate, the social worker and patient may agree to add goals to the care plan, something that typically occurs with those who have been successful with their initial set of goals but still have other high-priority needs.
  • Additional support in event of hospital stay: Patients participating in the AIMS initiative who are hospitalized can receive additional support in transitioning back to the community through a different Rush program that uses social workers. More information on this program can be found in a separate profile, available at: http://www.innovations.ahrq.gov/content.aspx?id=3344.
  • Hand-off to community-based services and support: Because the AIMS model is designed to provide short-term support in connecting patients to community-based services that can help them over time, the program concludes once these connections have been successfully made. In primary care, this point is typically reached 30 to 40 days after the initial contact, while in specialty clinics it tends to occur later, usually after about 60 days. Throughout the process, the social worker has been connecting the patient to a variety of community-based resources and support. When this formal discharge stage occurs, the social worker reviews the care plan and goals achieved and ensures the patient feels completely comfortable moving forward. As part of this process, the social worker informs the patient that the weekly calls will end, but encourages the patient to call at any time if new challenges or issues emerge.
  • Ongoing EMR-based communication and summary report for referring clinic: Throughout the process, social workers enter key information from their interactions with patients into the EMR system, thus ensuring that the referring practitioner and other clinic-based staff can access this information prior to medical visits. After a patient is discharged from the program, the social worker prepares a summary report (also available through the EMR) that highlights key problem areas and the solutions developed for each.

Context of the Innovation

Rush University Medical Center is a 664-bed hospital in Chicago that serves adults and children. It is affiliated with one of the oldest medical colleges in the Midwest and one of the Nation's top-ranked nursing colleges. In 1999, the Rush Health and Aging Department opened the first of two resource centers staffed by social workers who provide consultations, health education, and information about and connections to available community resources. (The second center opened a few years later.) These centers serve as a resource both for Rush patients and members of the local community. During the centers’ early years of operation, patients generally learned about them from Rush-affiliated providers, who gave the name and phone number for the center to patients with potential psychosocial issues. More often than not, however, patients did not follow up with the resource center, due in large part to competing demands on their time and the social stigma associated with seeking support.

Over time, resource center staff and the referring providers from several practices began to recognize this problem and decided to adopt a different, more proactive strategy. Beginning in late 2008 and early 2009, the centers began to forge informal relationships with several primary care clinics that routinely referred patients to them. Rather than relying on the patients to contact the center, practice-based staff completed formal referral forms for patients to receive social worker support. Social workers within the centers then began proactively reaching out to these patients, using core principles of social work to engage and support them. Since that time, the program has expanded and evolved into the formal AIMS program offered by the Health and Aging Department. Much of this standardization effort coincided with the decision of Rush leaders in 2010 to pursue accreditation from the National Committee for Quality Assurance (NCQA) as a patient-centered medical home (PCMH). More information on this evolution appears in the Planning and Development Process section below.

Did It Work?

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Results

The program has enhanced patients’ access to psychosocial support and generated high levels of satisfaction among patients and their caregivers and providers. Providers also believe it has improved their patients’ self-management skills and overall well-being. Anecdotal reports suggest that AIMS may be reducing hospitalizations, emergency department (ED) visits, and nursing home placements.
  • Enhanced access to psychosocial support: Prior to formal implementation of the AIMS program, clinic-based physicians were not always attuned to their patients’ psychosocial issues or aware that social workers were available to help. Even when they were, referred patients were typically instructed to contact Rush social workers on their own and often did not follow that advice. Since the launch of AIMS, more patients are being referred to social workers. All of those referred receive a call from a social worker, and the vast majority accept support.
  • Highly satisfied patients and caregivers: In surveys, patients and caregivers report very high levels of satisfaction with the program, with 96 percent indicating they would recommend it to others and that the social worker met all or most of their needs. Nine out of ten patients felt the program helped them learn where to turn for services and resources outside of the doctor's office, and 79 percent felt that it provided information they could not otherwise have obtained. Most patients (82 percent) believe the program allowed them to spend more time on medical issues with their doctors.
  • Highly satisfied providers: A survey of providers at participating clinics found that 93.5 percent were very satisfied with the program and 87.2 percent felt it allowed them to spend more time with their patients on medical issues. Most also believe that the program has reduced levels of distress among patients (95.7 percent) and improved patients’ self-management skills (80.8 percent) and sense of well-being (87.3 percent).
  • Anecdotal reports of reduced use: In the aforementioned surveys, several patients and caregivers reported instances in which the program helped to avoid the need for a hospitalization, ED visit, and/or nursing home placement.

Evidence Rating (What is this?)

Suggestive: The evidence consists primarily of results from post-implementation surveys of patients, caregivers, and providers participating in the program.

How They Did It

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Planning and Development Process

Key steps included the following:
  • Winning support of institutional leaders: Clinic-based practitioners and managers within the resource centers met with institutional leaders to gain their support for the program. During these sessions they explained the importance of addressing psychosocial issues in patients and how doing so effectively could serve as an important piece of Rush’s application to NCQA for PCMH accreditation.
  • Developing AIMS model: An experienced masters-level social worker developed the standardized AIMS protocol based on social work core competencies, adapting it to the work processes employed by social workers and clinic practitioners at Rush. Over a period of roughly 9 months, a team of three social workers within the center repeatedly tested the model and provided feedback on how well it worked, allowing the model to be improved over time in advance of the program’s formal launch.
  • Raising awareness of program services: While the model was being developed, a different individual took charge of developing a promotional plan for the program, including hosting workshops and otherwise establishing linkages with practitioners and other programs that could serve as referral sources.
  • Revamping EMR system: Program leaders worked with information technology staff to create an electronic order form integrated within Rush’s EMR system. As noted, the form included a checklist of potential psychosocial issues and environmental factors that practitioners use to identify patients who could benefit from the program and to communicate their impressions of these patients’ needs to the social workers.
  • Engaging and educating primary care practices: As noted, the leaders of several primary care practices already had relationships with the social workers within the resource centers, leading them to quickly sign on to be part of the more formal program. A few additional primary care practices also agreed to participate as part of the NCQA PCMH initiative. These five primary care practices served as the initial sites for the formal AIMS program. Before this launch, program leaders visited each practice to educate clinicians and staff on psychosocial issues that can affect health, including social determinants of health, self-management, mental health, and cultural competency. On an ongoing basis, program leaders meet with the leaders of other primary care practices to explain the program and gauge their interest in it. To date, no other primary care practices have formally joined, due in part to financial considerations. While the initial group of five practices do not pay for the service, Rush now asks practices to pay a monthly fee to cover the costs of program services.
  • Expanding to specialty clinics: After a strong reception in primary care settings, the model was adapted and implemented in six Rush-affiliated neurology clinics. Each of these clinics pays a monthly fee for program services; the fee varies based on volume of referrals and clinic resources. These services include access to an assigned social worker, backup support from another social worker as needed, supervision and management of the social workers, and program evaluation, including regular surveys with clients and practitioners. Rush-affiliated clinics in several other specialties have also expressed interest, including cardiology, rheumatology, and gastroenterology. These clinics are currently evaluating the financial feasibility of becoming part of the program.

Resources Used and Skills Needed

  • Staffing: On average, a full-time social worker can handle roughly 50 active cases at a time. At present, three social workers support the five primary care practices, spending most but not all of their time on AIMS. One full-time social worker supports the five neurology practices. (Program leaders hope to add an additional social worker to support the neurology clinics.) In addition, one experienced social worker spends approximately 40 percent of her time on program management, including supervision of the other social workers.
  • Costs: The program’s total annual operating budget is approximately $400,000 (although this figure varies significantly from year to year), which covers staffing, data management, and program administration.
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Funding Sources

Sanofi-Aventis; Rush University Medical Center; Community Memorial Foundation
Sanofi Aventis provided funding for patient and provider education about diabetes and self-management. Community Memorial Foundation provided funding to support development and replication of the formal AIMS model. Rush University Medical Center covers the cost of the program for the five participating primary care practices as part of its NCQA PCMH initiative.end fs

Tools and Other Resources

Program leaders are creating a training manual that others will be able to use to assist with implementation of the AIMS model; interested organizations can contact the innovators for additional details.

Adoption Considerations

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Getting Started with This Innovation

  • Employ social workers through central department: This approach creates economies of scale by sharing social work resources across multiple practices. Cost sharing is particularly important for small practices that do not have adequate resources, space, or patient volumes to justify dedicated social work staff. This strategy also allows for development of a substantial infrastructure to support the social workers, including supervision, peer support, and program evaluation.
  • Identify and win support of practice-based champions: Program champions at the local level make a huge difference in getting practice-based clinicians and staff to embrace the program and effectively identify and refer patients who could benefit from it.
  • Provide upfront education to practices: Clinic-based practitioners need to understand how to identify psychosocial issues and their potential effect on patient health and well-being. To that end, provide education about these issues as the program is being implemented, including what types of patients should and should not be referred.
  • Identify metrics for evaluation: Program leaders should decide upfront what metrics will be used to evaluate the program’s impact. In addition to gauging patient, caregiver, and provider satisfaction, consideration should be given to setting up systems to monitor the impact on functional status and resource utilization (e.g., inpatient admissions, ED visits, nursing home placements).

Sustaining This Innovation

  • Consider integrating program into EMR: An EMR is not necessary to run the program effectively; in fact, during the program’s initial informal stage, Rush social workers did not have access to the EMR and consequently orders and communications occurred by fax, e-mail, and other methods. However, an integrated EMR can make the program more efficient and effective because it allows practitioners to refer patients with the click of a button and social workers to review clients’ medical history in advance of their communications with them. It also facilitates ongoing communication and information transfer between the social workers and clinic-based practitioners. In cases where an EMR is not accessible to the social workers, the ability to contact referring clinicians directly through pagers or telephone numbers is beneficial.
  • Maintain relationship-building efforts with practices: Set up mechanisms for regular communications with participating practices to remind physicians and staff about the program, share data and anecdotes that demonstrate its positive impact on their patients, and allow for open-ended conversations about how the program can be improved. To that end, program leaders at Rush try to meet with each participating practice on a quarterly basis, although some practices prefer written updates via e-mail rather than face-to-face meetings.

Use By Other Organizations

Working with program leaders at Rush, a community-based agency in La Grange, IL, (Aging Care Connections) has implemented the program in partnership with a local primary care clinic. Rush program leaders recently received funding from the Weinberg Foundation to support replication of the program in Illinois and Maryland. These leaders are also involved in conversations with representatives of an organization in Michigan who are interested in implementing AIMS. Rush has applied for other grants that, if awarded, will be used to support replication of the program elsewhere throughout the Nation.

Additional Considerations

This program played an important part in Rush-affiliated primary care practices being designated as Level 3 PCMHs by NCQA.

More Information

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Contact the Innovator

Kate Krajci, LCSW
Manager of Social Work Services, Health and Aging
Rush University Medical Center
710 South Paulina Street, Suite 436
Chicago, IL 60612
(312) 563-2703
E-mail: kate_a_krajci@rush.edu

Innovator Disclosures

Ms. Krajci reported no financial or business/professional relationships related to the work described in this profile, other than the funders listed in the Funding Sources section.
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: March 26, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: April 09, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.