_{By Michelle Newman, Bonnie Ewald, and Robyn Golden, Center for Health and Social Care Integration at Rush University Medical Center}

Many studies have highlighted the importance of effective interprofessional care teams to improve health outcomes for people with complex needs.

But many programs do not take advantage of the special training of social workers to meet these needs on their primary health care teams, particularly when working with racial and ethnic minorities and people with lower socioeconomic status.

Social workers have specialized training in systems navigation, care coordination, and behavioral health counseling. For example, social workers use the ecological systems framework to engage and understand people within their social contexts — social and professional networks, neighborhoods, and communities — providing insight into health behaviors and outcomes that is useful for achieving quality care. Informed by their understanding of how physical health conditions and psychosocial processes interact, social workers can help devise effective and realistic care plans, and provide communication and supports that enable safe living in the community for individuals with complex needs.

A Model for Integrating Social Work into Primary Care

At Rush University Medical Center in Chicago, social workers provide the Ambulatory Integration of Medical and Social (AIMS) intervention to primary and specialty care patients. The goal of AIMS is to address social needs by integrating medical and non-medical services to improve patient outcomes and, in turn, reduce the use of costly health care services. Another goal is to improve patients’ experience with health care. Preliminary results from a prospective study supported by The Commonwealth Fund showed that depression and health risk scores decreased in patients receiving AIMS compared to patients who did not receive the intervention. In addition to being implemented at Rush, AIMS has been replicated by community-based social service organizations in partnership with local primary care practices.

The five steps of the model are:

1. Patient engagement — The social worker establishes rapport and trust, ensures the patient understands the need for social work intervention, and asks the patient what health-related issues are most important to him or her.
2. Assessment — The social worker conducts a comprehensive psychosocial assessment that is conversational in nature and seeks to identify strengths and factors that may affect medical care plan compliance, utilization of health care services, and health outcomes. The assessment covers the following domains:
   • Presenting problem (provider’s reason for referral)
   • Patient strengths and values
   • Physical health and medical care
   • Access to care and insurance
   • Functional ability and in-home supports
   • Mental health and coping
   • Social history and community supports
3. Care planning — With the assessment information, the social worker and the patient develop three to four goals using motivational interviewing techniques. They collaborate on a care plan that outlines the roles of the patient, caregiver, providers, and social worker in working toward the goals. The social worker updates and involves the medical care team as needed.
4. Care management — After creating the care plan, the social worker assists the patient with implementing the plan, which may include providing information or education, coordinating activities, and linking the patient with community resources. The social worker continues to use therapeutic techniques to support and encourage the patient and family, and revises the care plan as needed to ensure progress toward goals.
5. Goal attainment — As the patient makes progress toward goals or as the case wraps up for other reasons, the social worker brings closure to their work together, ensuring community resources are in place to support the patient moving forward and encouraging the patient to contact the social worker if new issues arise. Our experience has shown that affirming patients’ efforts toward their goals can encourage them to continue improving their health. To that end, the social worker makes a point to celebrate each patient’s accomplishment, whether in achieving a goal or, if the goal wasn’t reached, for the effort toward achieving it. At this point, the social worker also informs the medical care team about the accomplishment and any need for social work involvement moving forward.

How Patients Benefit from Social Work Interventions

The integration of social workers into the primary care is an important way to make care more responsive to the social, economic, and environmental factors that influence people’s health. For an example, let’s look at Mr. W, who received services from an AIMS social worker at Rush. The full case study can be found in the article, The role of social workers in addressing nonmedical needs in primary health care.

During the assessment with Mr. W, the social worker learned that Mr. W’s main concern was paying for his Medicare Supplement plan. Mr. W also shared that he was experiencing some symptoms of depression and anxiety. The full case study highlights the specific skills and activities the social worker used to meet the needs of Mr. W. After their work together, Mr. W was approved for Medicaid, prescription assistance, and SNAP benefits, bringing him significant financial relief. He was also accepted from the behavioral health services waitlist by a social worker specializing in gerontology.

An important contribution to highlight is the social worker’s role in interprofessional collaboration with other health care professionals. In this case, the social worker shared Mr. W’s goals and the services provided with the PCP, which allowed the PCP to guide his future work with Mr. W. The social worker also used the Electronic Health Record (EHR) to document ongoing work with Mr. W, which provided the opportunity for other health care professionals to be informed about Mr. W’s work with the social worker.

Results So Far: Building a Value Proposition

While many providers know the value of social work as part of the team, we still have work to do to study and demonstrate the value to secure the buy-in of all providers and health care leaders.

Here are a few of the benefits of integrating social work we’ve seen so far:

• Reduction in depressive symptoms for patients
• Reduction in emergency department visits, hospitalizations, and readmissions
• Less burden on medical providers to address patients’ social needs, which can cause providers to have lower productivity, less time to address health needs, and stress.
• Additional services for patients, especially assessment of social and mental health needs, and coordination of community-based social services
• Bringing perspective to the care team on each patient’s social and environmental context

There is great promise for the integration of social needs toward primary care transformation, but we need the workforce and care models to do it. By expanding initiatives that integrate social workers into primary care to more communities across the country, primary care can become more responsive to the needs of individuals with complex care needs.

To learn more about the AIMS model or replication opportunities at your sites, please visit http://theaimsmodel.org or contact Matt Vail at Matthew_Vail@rush.edu.

Learn more at the 2018 Grantmakers in Health Annual Conference on Health Philanthropy at a session titled "Innovative Strategies and Solutions for Complex Care Populations."