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Social Work Care Management

To connect with a social worker, please call (800) 757-0202.

If you find yourself in immediate danger of harming yourself or others, before exploring the information below, please call 911 or go to your nearest emergency room.

Ambulatory Integration of Medical and Social (AIMS)

By integrating social work into primary and specialty care, Social Work and Community Health social workers address psychosocial barriers to wellness and improve health outcomes for patients and caregivers. The AIMS model utilizes a masters-prepared social worker to conduct a comprehensive biopsychosocial assessment and provide clinical case management and care coordination to older adults and their families. To learn more about the AIMS Model, please visit www.theaimsmodel.org.

Bridge Model of transitional care

As part of an interprofessional care team, Social Work and Community Health provides transitional care by supporting patients and caregivers after a hospital stay and addressing both medical and psychosocial barriers to wellbeing. Bridge Model of transitional care is designed to aid in patients’ transition from hospital to home. Transitional care is delivered by master's-prepared social workers who provide telephonic follow-up and short-term care coordination for recently discharged adults. To learn more about the Bridge Model of transitional care, please visit www.transitionalcare.org.

Collaborative Care Team

This program helps adolescents (ages 12 and up) and adults who are experiencing symptoms of depression gain access to mental health services by connecting them to a team of social work care managers, licensed clinical social workers, and consulting psychiatrists who collaborate with their primary care team. Rush patients are screened into the program through their primary care clinic only.