The Ambulatory Integration of the Medical and Social (AIMS) Model: Social Work Care Coordination in Patient Centered Medical Homes

Background and purpose:  The Ambulatory Integration of the Medical and Social (AIMS) model acknowledges that medical and social services are fragmented, despite clients’ intertwining needs. The majority of health care expenditures support those with chronic conditions. While health related complexities are frequently discussed, important social factors that influence physical health are less recognized. As a result, many patients face difficulty adhering to their medical care plans due to social and environmental barriers that are not addressed when treating their physical conditions.  The AIMS model assesses psychosocial needs and provides risk-focused care coordination by master’s prepared social workers using a standardized protocol. Social workers assists patients or their caregivers with the Biopsychosocial/functional issues impacting their medical care plan adherence or diagnosis. AIMS activities build upon social work core competencies and patients collaboratively direct their own care.

Methods: Intervention data with the patient/caregiver is documented in an Access database and the electronic medical record (EMR).  Within one month of a completed intervention, recipients participate in telephonic qualitative surveys exploring their experiences and outcomes with AIMS model services. Referring clinicians complete qualitative surveys on a quarterly basis to assess their utilization of the model and the outcomes observed in referred patients. Healthcare utilization data is obtained from the EMR for analysis.

Results: The AIMS model has demonstrated success in one medical system, contributing to National Committee for Quality Assurance Patient Centered Medical Home Level 3 status designation for five primary care practices. Between March 2010 and January 2014, 576 patients 60 years and older were referred for intervention. Top reasons for referral included a comprehensive social work assessment, insurance assistance, in-home services, chronic disease self-management classes, and mental health resources.  Providers report they were able to spend more appointment time on medical issues (78%), and patients were less distressed (82%), reported a better sense of well-being (82%), and exhibited better self-management (73%).  The top two factors eliciting a referral were: assessment that the patient’s non-medical needs were negatively impacting the medical plan; and the provider did not have the expertise to assist with the presenting issues.  Patients and caregivers indicated similar findings, including increased ability to focus doctor appointment time on medical issues and increased ability to talk about medical needs (82%).  Eighty-six percent indicated an increased understanding of their medical care plans and 68% reported an improved opinion of the medical system after working with the social worker.  Preliminary evidence suggests impact on avoided hospitalizations, emergency department usage, and nursing home placement.

Conclusion and Implications:  Primary care practitioners lack the time, knowledge, and resources to recognize and address psychosocial factors impacting patients care. They have little opportunity to access social workers and community-based services.  By utilizing social workers as care coordinators in patient centered medical homes, complex patients have an increased sense of well-being, understanding of their medical care plan and connection to vital community resources.  Through the support of the AIMS model, patients and clinicians experience more holistic care that ultimately may impact patient health outcomes, satisfaction and utilization.