At the Center for Health and Social Care Integration (CHaSCI), we believe that improving health outcomes means addressing the full spectrum of patient needs—including the social factors that shape health. That’s why we’re excited to share details about a new research project led by Dr. Teresa Moro and supported by CHaSCI, which aims to strengthen the integration of social workers (SWs) and community health workers (CHWs) across Chicago’s healthcare systems.
Why This Research Matters
Chronic conditions remain a leading cause of health disparities, particularly among marginalized populations. Many individuals with chronic illnesses also face unmet social needs—such as housing instability, food insecurity, and lack of transportation—that worsen their health and increase healthcare costs. Social care management, a team-based approach that includes SWs and CHWs, is designed to address these needs in a patient- and family-centered way.
While both SWs and CHWs bring valuable expertise to healthcare teams, their roles, training, and scopes of practice differ significantly. Despite growing evidence of their individual impact, there is currently no standardized model for how these professionals collaborate within healthcare settings. This research project seeks to fill that gap.
What the Study Will Do
Thanks to generous funding recently awarded by the Institute for Translational Medicine (ITM), this mixed-methods study will explore how SW and CHW teams are trained, structured, and integrated across two major Chicago health systems—RUSH University Medical Center and The University of Chicago Medicine—as well as in community settings. The research team will:
- Survey 70 participants, including SWs, CHWs, administrators, and patients.
- Conduct in-depth interviews with a subset of participants to understand their experiences.
- Analyze both quantitative and qualitative data to identify best practices and barriers to effective collaboration.
- Use established frameworks like CFIR 2.0, the SIREN Social Care Logic Model, and SAMHSA’s Six Levels of Collaboration to guide the study design and analysis.
This research builds on our evidence-informed social care management model, which has been implemented in both acute and community settings and tailored for both SWs and CHWs. You can read more about our care model in our CHaSCI Care Model 101 and CHaSCI Care Model 102 blog posts. This study will not only inform future training and deployment strategies for SW and CHW teams, but will also support CHaSCI’s long-term goal of establishing a national evidence hub for social care. Findings will be shared through a community summit and used to pursue additional funding for broader research and model refinement.
Looking Ahead
As we continue to advocate for whole-person care, this research represents a critical step toward ensuring that social care teams are effectively integrated, supported, and sustainable. By identifying what works—and what doesn’t—we can help healthcare systems better serve patients with complex health and social needs.
Stay tuned for updates as the study progresses, and thank you for supporting CHaSCI’s mission to advance health equity through integrated social care.
For any questions about this project, you can contact Dr. Moro at teresa_moro@rush.edu.