Nonmedical needs are intricately linked to health. Unaddressed nonmedical needs often result in poorer health and increased healthcare costs. Although social workers are well positioned to address nonmedical needs, their role in healthcare environments to address nonmedical needs is limited. The limited role relates to a lack of reimbursement streams, which stems from poor articulation about their unique contributions. An analysis of a case study in which a social worker using AIMS, a protocolized care coordination model, was undertaken to highlight specific activities performed by social workers. Implications for patient health outcomes and healthcare costs are discussed.

An exploratory, retrospective evaluation of Ambulatory Integration of the Medical and Social (AIMS), a care coordination model designed to integrate medical and non-medical needs of patients and delivered exclusively by social workers was conducted to examine mean utilization of costly health care services for older adult patients. Results reveal mean utilization of 30-day hospital readmissions, emergency department (ED) visits, and hospital admissions are significantly lower for the study sample compared to the larger patient population. Comparisons with national population statistics reveal significantly lower mean utilization of 30-day admissions and ED visits for the study sample. The findings offer preliminary support regarding the value of AIMS.

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Purpose of the Study: The purpose of this study was to examine the time contribution of social workers in delivering AIMS (Ambulatory Integration of the Medical and Social), a care management protocol designed to address patients' nonmedical needs, and the association of time contribution with patients' depression outcomes. Primary Practice Setting: The study was conducted in 6 primary care provider clinics housed in a large, urban academic medical center located in the Midwestern United States. Methodology and Sample: A longitudinal, quasi-experimental study employing survey procedures and a retrospective review of patient records was conducted. The study included 340 patients 50 years and older with unmet nonmedical needs. Half of the patients received AIMS, which was delivered by social workers. The other half received usual care (UC), which was delivered by other health care providers. Results: Chi-square analysis and independent-samples t tests were performed to compare time spent addressing nonmedical needs with differences in patients' depression levels at 6 months postenrollment. The findings reveal that social workers spend significantly more time with patients than UC providers addressing patients' nonmedical needs (p < .0001). At 6 months postintervention, reduced levels of depression were observed for AIMS patients when compared with UC patients (p = .026). Implications for Care Management Practice: Including social workers as part of health care teams is valuable. Time spent with patients and engaging in care management activities to support patients' needs is linked with positive health outcomes. Given the benefits of care management, opportunities for reimbursement are enhanced.