CHaSCI Care Model 102: Vignettes and Outcomes
Welcome back! In our previous post titled CHaSCI Care Model 102: Background and History, we introduced the CHaSCI Care Model, a flexible care management approach developed by the Center for Health and Social Care Integration (CHaSCI) at RUSH University Medical Center (RUSH).
To recap, the CHaSCI Care Model equips social care providers with a standardized protocol informed by evidence-based techniques to address complex psychosocial, medical, and functional issues. By focusing on social determinants of health, the CHaSCI Care Model aims to remove barriers to essential services and improve patient outcomes. Implemented across various settings in the US and Canada, the model has shown significant improvements in patient health, value-based care outcomes, and provider satisfaction.
Now that you’ve learned about the background and history, let’s take a deeper dive into the CHaSCI Care Model in action by exploring case vignettes and outcomes.
Case 1: From Isolation to Connection
Patient Description: A 42-yr old female-identifying patient was referred from primary care, with the initial referral reason being social isolation. The patient had a stroke at age 41 and has partial paralysis on the left side of her body, needing assistance with everyday tasks.
Engagement phase: To implement the CHaSCI Care Model, the social worker contacted the patient and explained the role of social work on her team.
Assessment phase: The social worker then proceeded to complete a comprehensive social work assessment. In addition to the social isolation caused by her stroke, other identified needs included housing assistance/advocacy, food insecurity, urgent need for mental health services for her and her teenage daughter, transportation, care coordination for her medical appointments and connection to social programming.
Care Planning phase: the social worker and patient identified which of these needs required follow-up from the social worker and which could be completed by patient with the guidance of the social worker along the way (such as follow up with her housing).
Care Management phase: The social worker was able to help establish physical and occupational therapy, connect both the patient and her daughter to psychiatry and psychotherapy at RUSH, help the patient learn how to use medical transportation for all of her appointments, assist with her understanding of navigating the medical system, stabilize her housing, help with her food insecurity benefits, and connect her to a program that helped her meet other women her age with chronic conditions.
Goal Attainment & Loop Closure phase: Most remarkably, after completing their work together, the patient called the social worker and said she will be starting a position at a local hospital as a “peer support person” to encourage others to “stay strong” post-stroke and traumatic brain injury. She hopes this will lead to employment. Following the CHaSCI value of longitudinal care, the patient contacts the social worker from time to time for “booster” care management and connection to resources.
Case 2: Facilitating Access to Vital Care
Patient Description: A 52-yr old Spanish-speaking, female-identifying patient was referred from a health promotions program to get connected to primary care and insurance options.
Engagement & Assessment phase: A Spanish-speaking social worker contacted the patient over the phone and learned that the patient previously had a cancer diagnosis but had been unable to follow up on regular checks with oncology due to a lack of insurance coverage. The social worker learned the patient was also interested in psychotherapy to address past trauma and insomnia.
Care Planning phase: The patient and social worker collaborated and identified that a first step in the intervention would be to connect with RUSH financial services so the patient could be seen without cost, then connect to medical and behavioral health care.
Care Management phase: The social worker assisted the patient with applying for financial assistance. Upon approval, the social worker modeled how to make medical appointments and how to renew financial assistance for the patient, thus emphasizing the patients’ long-term autonomy.
Goal Attainment & Loop Closure phase: The social worker and patient discussed the achievements of their work together. These include connection to Spanish-speaking primary care doctor, connection to testing and other specialists, and establishment with a Spanish-speaking therapist.
Outcomes
CHaSCI Care Model social workers are uniquely trained to address psychosocial needs that positively impact patient health status, satisfaction with care, and health outcomes, (5, 10, 14) including:
Reduced hospital admissions (12, 17)
Reduced 30- and 60- day hospital readmissions (1-3, 12, 17)
Reduced emergency department visits (12, 17)
Reduced depression symptoms and health risk scores (9)
Increased medication adherence, appointment attendance, and other patient-led illness care strategies (1-2, 12)
You can find a brief bibliography of research published to date on the CHaSCI Care model, including corresponding reference numbers for the above data points, here.
When we have a skilled and culturally sensitive social care workforce addressing patient priorities and needs, both patients and systems benefit. As we continue to implement and train on our CHaSCI Care Model, we continue to refine our processes to best meet the needs of patients.
Conclusion
In this post, we've taken a closer look at the CHaSCI Care Model in action. This model has proven to be a powerful tool in addressing the complex needs of patients by focusing on social determinants of health and removing barriers to essential services. The positive outcomes we've highlighted, such as reduced hospital admissions and improved medication adherence, demonstrate the model's effectiveness in enhancing patient health and satisfaction.
As we continue to implement and refine the CHaSCI Care Model, our commitment to training a skilled and culturally-sensitive social care workforce remains strong. By prioritizing patient needs and fostering a collaborative approach, we can ensure that both patients and healthcare systems benefit from our efforts.
Thank you for joining us on this journey to better understand the CHaSCI Care Model. Stay tuned for more updates and insights as we continue to advance our mission of improving health and well-being for individuals, families, and communities.