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The AIMS Model

An Evidence-Based Practice

Description

The Ambulatory Integration of the Medical and Social (AIMS) model seeks to address social and environmental barriers that affect plans of care by embedding a master's prepared social worker into primary and specialty care teams. The AIMS model follows a five step process including: patient/caregiver engagement, assessment and care plan development, telephonic or in-person case management, goal attainment, and ongoing care.

Goal / Mission

The Ambulatory Integration of the Medical and Social (AIMS) model aims to address social and environmental factors patients face that may prevent them from following their plan of care, thus impacting their health.

Impact

The AIMS model helps create better supported, less stressed, and better informed consumers and caregivers. There is also evidence to suggest that this model reduces ED usage and 30-day readmissions in participants.

Results / Accomplishments

The model was tested at Rush University Medical Center where it demonstrated success. Providers (n=28) noted they were able to spend more appointment time on medical issues (73%), and that people seemed less distressed (82%), showed a better sense of well-being (82%), and exhibited better self-management (73%).

Evidence also suggests that this model has an impact on emergency department usage, and 30-day readmissions. A retrospective analysis at Rush University that compared national averages to individuals in the study showed a statistically significant reduction in 30-day readmissions (mean of participants=0.15 vs. national=2.45, p=0.000) and ED visits ( mean of participants=0.10 vs national=0.26, p=0.000). However, the study failed to support that AIMS participants have lower hospital readmissions (mean=0.51) compared to national populations (mean=0.16, p=0.000).

About this Promising Practice

Organization(s)
The AIMS Model
Primary Contact
https://www.theaimsmodel.org/
Topics
Health / Older Adults
Organization(s)
The AIMS Model
For more details
https://www.theaimsmodel.org/
https://www.ncbi.nlm.nih.gov/pubmed/27111526
Target Audience
Adults, Older Adults

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An Evidence-Based Practice meets the following HCI criteria:

  1. The program description includes at a minimum: the sponsoring organization, program goals, program implementation steps, and outcomes that have demonstrated program success in achieving the program goal in one or more localities.
  2. The results from an evaluation of the program include quantitative measures showing improvement in the outcome(s) of interest after the implementation of the program (i.e. increase in smoking cessation, not just the delivery of a smoking cessation program). The outcome measure(s) is/are compared at relevant time periods before and after the intervention or program implementation. Alternatively, the evaluation study compares the outcome(s) between an intervention group and an appropriate control group.
  3. The study is of peer-review quality and presents numbers in a scientific manner; measurements of precision and reliability are included (e.g. confidence intervals, standard errors), results from statistical tests show a significant difference or change in the outcome measure(s), and relevant point estimates and p-values are presented. Note: if the results from an evaluation of a program are presented in a scientific manner and the outcome measure is improved compared to the baseline measurement or the control group but the difference is not statistically significant, the practice is classified as effective and not evidence-based.
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