Aims Handout Hands

KYC’s AIMS Pilot Program

KYC has received a gen­er­ous two-year grant from the Wein­berg Foun­da­tion to imple­ment the AIMS mod­el in part­ner­ship with the AMI­TA Med­ical Group Inter­nal Med­i­cine prac­tice in Elk Grove Vil­lage. The AIMS (Ambu­la­to­ry Inte­gra­tion of the Med­ical and Social Mod­el) pilot pro­gram seeks to unite social work­ers and med­ical pri­ma­ry care teams in the treat­ment of patients. This inte­grat­ed approach allows health­care pro­fes­sion­als to more ful­ly under­stand and acknowl­edge the ways that psy­cho­log­i­cal and social fac­tors impact phys­i­cal health and wellness.

Fol­low­ing the AIMS mod­el, a KYC Social Work­er will meet with eli­gi­ble patients with­in the AMI­TA Med­ical Group Inter­nal Med­i­cine prac­tice to iden­ti­fy var­i­ous needs and address psy­cho­log­i­cal and social con­sid­er­a­tions that direct­ly link to the patient’s over­all health. The social work­er and the pri­ma­ry care physi­cian then coor­di­nate to deter­mine a treat­ment strat­e­gy that is tai­lored to the patien­t’s needs as a whole.

To under­stand how the AIMS Mod­el works, here’s an exam­ple patient that may come through the program:

Hank is an 85-year-old gen­tle­man liv­ing in Elk Grove. He hasn’t been feel­ing well late­ly, so he sched­uled an appoint­ment with his pri­ma­ry care physi­cian. His doc­tor quick­ly real­izes that Hank has stopped tak­ing his blood pres­sure med­ica­tion reg­u­lar­ly, and so his phys­i­cal health is declin­ing. Hank’s doc­tor rec­om­mends that Hank also meet with the KYC social work­er who has part­nered with his med­ical prac­tice. The social work­er dis­cov­ers that Hank’s daugh­ter recent­ly moved away, and so he has now been hav­ing dif­fi­cul­ty find­ing trans­porta­tion. Hank has been feel­ing increas­ing­ly frus­trat­ed due to stress and not feel­ing well, and hasn’t felt up to vis­it­ing with his friends. The social work­er notes that Hank was start­ing to show signs of depression. 

When Hank’s pri­ma­ry care physi­cian and social work­er con­nect with each oth­er, they get the full pic­ture of Hank’s sit­u­a­tion, and can togeth­er rec­om­mend strate­gies that are more man­age­able for him. The social work­er makes a refer­ral to Hank for a trans­porta­tion ser­vice, grant­i­ng him access to his phar­ma­cy once again. Hank’s pri­ma­ry care physi­cian increas­es his pre­scrip­tion from one month of med­ica­tion to three, decreas­ing the num­ber of trips he’ll need to take to the phar­ma­cy. With reli­able access to his med­ica­tion, Hank once again takes it on sched­ule. He begins to feel less stressed as his phys­i­cal health improves. With more time to focus on his rela­tion­ships, Hank’s mood lifts as well. By address­ing all of his com­plex needs, Hank’s over­all health great­ly improves.

Psy­choso­cial care and phys­i­cal med­ical care have often been dis­con­nect­ed from each oth­er. This approach seeks to close­ly con­sid­er all fac­tors that could affect a patien­t’s health. By inte­grat­ing the social, func­tion­al, envi­ron­men­tal, cul­tur­al, and psy­cho­log­i­cal fac­tors that impact phys­i­cal health, the AIMS mod­el can deliv­er a much more holis­tic strat­e­gy that can ulti­mate­ly reduce or pre­vent hos­pi­tal­iza­tion or emer­gency room vis­its. KYC’s goal is to sus­tain avenues that enable us to con­tin­ue to pro­vide informed, com­pas­sion­ate care to our com­mu­ni­ty members.


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