CHaSCI Care Model 101: Background and History
CHaSCI is a training and policy center at RUSH University Medical Center (RUSH) that expands access to social care and improves the health and well-being of individuals, families, and communities. We advance our mission through two main avenues: training and policy advocacy.
On the training side of things, CHaSCI runs several training activities for the social care workforce and employers, including: trainings in the CHaSCI Care Model, customized education and technical assistance, continuing education offerings, and core competency trainings in health and social care integration for CHWs and other interprofessional providers.
As we kick off 2025, we’d like to take some time to focus on the CHaSCI Care Model—the bread and butter of our training work at CHaSCI! This post is the first of a two-part series intended to help the CHaSCI Community better understand and utilize the CHaSCI Care Model. Let’s dive in!
What is the CHaSCI Care Model?
The CHaSCI Care Model is a flexible care management approach that provides social care providers with a standardized protocol informed by evidence-based therapeutic techniques and interventions. Using the CHaSCI Care Model, social workers and other providers are given an adaptable roadmap used to navigate complex psychosocial, medical, and functional issues impacting health and well-being for patients with multiple chronic conditions and their families.
One primary aim of this model is to address social determinants of health and remove barriers to essential services. The CHaSCI Care Model has been implemented in an array of settings across the US and Canada, from transitional care to ambulatory and specialty care clinics. Data show that the CHaSCI Care Model improves patient health, value-based care outcomes and provider satisfaction.
The CHaSCI Care Model comprises two evidence-based models, which you may have heard or seen referenced in publications about our work:
The AIMS Model (Ambulatory Integration of Medical and Social), for use in primary and specialty care
The Bridge Model of transitional care, for use after hospital discharge
What does the CHaSCI Care Model look like?
Before beginning the CHaSCI Care Model Process, care managers complete the Referral and Pre-Intervention Planning phase to gather information from the patient’s previous care provider.
Once the care manager has gathered all the information needed to approach the patient’s case, they begin the five steps of the CHaSCI Care Model Process, which typically takes place over 4-8 weeks (depending on the patient setting and needs).
The five steps are:
Engagement: in this phase, the care manager initiates contact with the patient or caregiver to describe their role, set expectations, and begin building rapport.
Assessment: in this phase, the care manager carries out a clinical assessment to build an in-depth understanding of the patient and their needs.
Care planning: in this phase, the care manager works with the patient and their caregiver to build a plan that best suits their needs, following three main steps: assessment summary, goal identification, and goal planning. Throughout the care planning phase, care managers stress patient self-efficacy by encouraging and leaving space for patients to take on as much of the process as possible. This phase also requires care managers to balance four important elements: reason for referral, patient narrative, patient safety, and clinician judgment.
Care management: in this phase, the care manager follows through with the care plan by carrying out goals, assessing progress, and troubleshooting as needed. In the care management phase, the care manager reaches out to the patient or caregiver at least once per week, continuing to prioritize self-efficacy and patient engagement.
Goal Attainment and Loop Closure: in this phase, the care manager and patient and/or caregiver review the care plan progress together and close the loop on provider referrals. The care manager reinforces the patient’s strengths and achievements and ensures that long-term supports are in place, then explicitly terminates the intervention with the patient.
In addition to the five-step model process, CHaSCI Care Model prepares care managers to face complicated cases by addressing “real world” barriers that care managers may face when working with patients, equipping care managers with skills to succeed in difficult or complex situations.
The CHaSCI Care Model also includes many clinical skills for care managers to infuse into their daily practice, including: therapeutic alliance and rapport building, person-centeredness, empowerment, person-in-environment framework, relational approach, cognitive restructuring and mindfulness, and motivational interviewing.
History of the CHaSCI Care Model
The CHaSCI team and our partners have been developing, refining, and disseminating the CHaSCI Care Model for more than 15 years! Though we now use the term “CHaSCI Care Model” to refer to all settings of our care management approach, we originally developed our model for transitional care settings, supporting patients as they transitioned from inpatient or acute care settings to outpatient or home care. Our work came to fruition as the Bridge Model of transitional care, which we developed and tested from 2008-2015:
2008-2009: Randomized control trial about the Enhanced Discharge Planning Program, which ultimately was co-developed into the Bridge Model of transitional care with RUSH and 5 organizational partners across Illinois
2010-2012: Training and evaluation partnership with Illinois Health & Hospital Association, Telligen Quality Improvement Organization, and the Illinois Department on Aging
2012-2015: Center for Medicare and Medicaid Innovation – Community-based Care Transitions Program supports the Bridge Model of transitional care at six federally-funded demonstration sites across the country
During the later development of the Bridge Model of transitional care, we began adapting the same care management process for use in ambulatory settings, such as primary care clinics and other outpatient care settings. Based on the different demands and considerations of ambulatory settings, we developed the Ambulatory Integration of Medical and Social (AIMS) Model, which we began to test and implement from 2012-2018:
2012: Applied social work process to primary care integration, tested at RUSH patient-centered medical homes as the Ambulatory Integration of Medical and Social (AIMS) Model
2015-2018: Quasi-experimental study funded by The Commonwealth Fund
Since then, our team has continued to research, evaluate, enhance, and grow our care management process—which we now refer to as the CHaSCI Care Model—and to apply our methods in various settings, both in our home base at RUSH and in partner organizations nationwide:
2015-2019: Pilots and enhancements to our social work care model implementation, including longitudinal care management, a focused and longer-term intervention with people with multiple hospitalizations, AIMS in specialty care settings, a caregiver-focused program, collaboration with nurses and patient navigators, operationalizing chronic care management and transitional care management billing codes to support the work
2017-2019: National collaborations to train service coordinators, care navigators, community health workers (CHWs), and other non-clinical team members in diverse settings (e.g., community health advocates hired by Blue Shield of California, service coordinators in senior housing buildings)
2019: RUSH community health workers (CHWs) and AmeriCorps service members begin screening patients in the emergency department and in primary care clinics for unmet social needs and providing assistance to address concerns, including escalation to social worker using our care management model
2020: The CHaSCI Care Model evolves building on Bridge Model of transitional care, AIMS model, and collaboration model with CHWs and nurses
2022-2024: Evaluation of Oak Street Health’s implementation of CHaSCI Care Model
Learn more
Stay tuned next month for Part 2 of this series on the CHaSCI Care Model, in which we’ll describe the outcomes of the CHaSCI Care Model, case examples showing the model’s success, and policy implications and other considerations related to our work.
Collaborate with us!
Do you think the CHaSCI Care Model would be a good fit for your team? Send us an email – we'd love to discuss a tailored training approach with you!
Want to learn more? See our website for impact findings, publications, and additional background.