Learn about our care model 

Since 2008, CHaSCI has innovated to develop effective models of care that leverage social workers and community health workers to improve quality of care and ultimately improve health and health equity.  

The CHaSCI care model leverages social workers and other social care providers to follow a flexible yet standardized protocol to assess and address complex psychosocial and functional issues impacting people’s care plan adherence, health status, and quality of life. They leverage care management and therapeutic techniques to increase patient activation, engage home- and community-based service providers, and support medical stability after hospitalizations. 

Outcomes & publications

As demonstrated by our impact findings, integrating medical and social care contributes to many positive outcomes: 

  1. Increased engagement with primary care

  2. Lower hospitalization and readmission rates

  3. Decreased depressive symptoms and lower stress for patients & family caregivers

  4. Reduced stress among healthcare providers 

  • Greene, R., & Cummings, E. (2023). Transitioning from Hospital to Home: Resilience-Enhancing Skills for Health Care Social Workers. In Resilience Enhancement in Social Work Practice: Anti-Oppressive Social Work Skills and Techniques (pp. 81-97). Cham: Springer Nature Switzerland.

    Rizzo, V. M., Rowe, J. M., Han, W., Kang, S. Y., Ewald, B., Rothschild, S. K., & Golden, R. (2022). The effect of the Ambulatory Integration of the Medical and Social (AIMS) model on health risk and depression. Social Work in Health Care, 61(5), 353-368.

    Rowe, J. M., Jang, E., Rizzo, V. M., Kim, Y., Ewald, B., Vail, M. R., & Drechsler, K. (2021). Supporting free clinic patients’ social needs with MSW interns: A pilot study. Social Work in Health Care, 60(4), 334-353.

    Rowe, J. M., Rizzo, V. M., Kang, S. Y., Kukowski, R., Ewald, B., Newman, M., & Golden, R. (2019). Time contribution of social workers in care management: Value for older adults. Professional Case Management, 24(6), 306-316.

    Xiang, X., Zuverink, A., Rosenberg, W., & Mahmoudi, E. (2019). Social work-based transitional care intervention for super utilizers of medical care: a retrospective analysis of the bridge model for super utilizers. Social Work in Health Care, 58(1), 126-141.

    Rowe, J., Rizzo, V. M., Guthrie, D., Vail, M. R., Kang, S. Y., & Golden, R. (2019). The electronic health record: Documenting the unique contributions of social workers. Health & Social Work, 44(2), 123-128.

    Xiang, X., Robinson-Lane, S. G., Rosenberg, W., & Alvarez, R. (2018). Implementing and sustaining evidence-based practice in health care: The Bridge Model experience. Journal of gerontological social work, 61(3), 280-294.

    Alvarez, R., Ginsburg, J., Grabowski, J., Post, S., & Rosenberg, W. (2016). The social work role in reducing 30-day readmissions: the effectiveness of the bridge model of transitional care. Journal of Gerontological Social Work, 59(3), 222-227.

    Rowe, J. M., Rizzo, V. M., Shier Kricke, G., Krajci, K., Rodriguez-Morales, G., Newman, M., & Golden, R. (2016). The ambulatory integration of the medical and social (AIMS) model: A retrospective evaluation. Social Work in Health Care, 55(5), 347-361.

    Rizzo, V. M., Rowe, J. M., Shier Kricke, G., Krajci, K., & Golden, R. (2016). AIMS: A care coordination model to improve patient health outcomes. Health & Social Work, 41(3), 191-195.

    Altfeld, S., Pavle, K., Rosenberg, W., & Shure, I. (2012). Integrating care across settings: The Illinois transitional care consortium's bridge model. Generations, 36(4), 98-101.

    Fabbre, V. D., Buffington, A. S., Altfeld, S. J., Shier, G. E., & Golden, R. L. (2011). Social work and transitions of care: Observations from an intervention for older adults. Journal of Gerontological Social Work, 54(6), 615-626.

    Altfeld, S. J., Shier, G. E., Rooney, M., Johnson, T. J., Golden, R. L., Karavolos, K., ... & Perry, A. J. (2013). Effects of an enhanced discharge planning intervention for hospitalized older adults: a randomized trial. The Gerontologist, 53(3), 430-440.

Background

The CHaSCI Care Model is grounded in over 15 years of experience developing, testing, and disseminating two social work-led care management models:  

  • The Bridge Model of transitional care  

  • The AIMS Model (Ambulatory Integration of Medical and Social) 

Bridge

From adjusting to new care routines or diagnoses, to troubleshooting unanticipated needs or unreliable providers, patients and those who care for them may have a lot to juggle after an inpatient stay, and it is common for discharge plans to fall apart.

The Bridge Model of transitional care uses social workers and other care providers to provide transitional care services to support older adults and adults with complex medical and social needs as they go home from the hospital or a skilled rehab stay.

AIMS

The AIMS Model (The Ambulatory Integration of the Medical and Social) integrates social workers into primary and specialty care teams to support individuals with complex biopsychosocial and functional challenges - and their caregivers.

Developed at RUSH initially in 2010 to meet patient-centered medical home criteria, the AIMS model has been leveraged within dozens of ambulatory care sites, community-based organizations, and in-home providers to structure their chronic care management and social care integration initiatives.

Social worker - community health worker collaboration

Since 2017, CHaSCI has supported and trained sites implementing social care leveraging community health workers in collaboration with social workers. The CHaSCI care model process can be implemented effectively by this collaborative team - leveraging clear structures for bi-directional SW-CHW referrals, consultation, and training to maximize collaboration and impact.

We have seen and heard tremendous benefit from this collaborative approach, and are currently studying its implementation at RUSH and at a national training partner.