Building Partnerships with Primary Care to Become a Hub for Service Delivery for Older Adults in Our Community

This blog entry describes a care model that community-based organizations (CBOs) working as part of the Aging Network can implement when partnering with local primary care providers.  

The last decade has seen health systems move toward payment reforms that incentivize outcomes. There has also been a substantial growth in Medicaid managed care across the country that is focusing on rebalancing care toward the community, in conjunction with significant growth in initiatives that enable individuals to age at home and in the community. While partnerships between Aging Network providers and primary care practices offer great promise, these partnerships often don’t grow naturally—due to historic fragmentation, varying funding streams, and differences in organizational culture. The Ambulatory Integration of the Medical and Social (AIMS) Model helps bridge this gap and provides patients with a continuum of care.

Developed at Rush University Medical Center and replicable by CBOs, the AIMS Model integrates masters-prepared social workers into primary care teams. Once referred to a primary care team, the social worker uses a standardized protocol and assessment to systematically identify, address and monitor various psychosocial needs that influence a patient’s health and wellbeing. Findings to date indicate that patients receiving care based on the AIMS Model experience reductions in depressive symptoms compared with patients who receive usual care, which suggests that the use of the AIMS Model may reduce emergency department visits, hospitalizations and patient readmissions.


AIMS at Aging Care Connections

Aging Care Connection (ACC), a private nonprofit organization located outside of Chicago, Illinois, has used the AIMS Model since 2013. ACC offers a comprehensive range of social work services, including education, health, and wellness programs, and works as part of the federal and state Aging Network. With 30 years of experience working directly with older adults and their caregivers, ACC has experience building partnerships with others to create a community that allows older adults to age in place. In 2007, ACC began partnering with a local hospital that had an Aging Resource Center to provide transitional care services to older adults returning home after leaving a hospital or skilled nursing facility. Through this work, ACC recognized that many of its clients could benefit from an intervention as part of their primary care experience, so replicating AIMS in partnership with local clinics was a natural next step in enhancing the care available to older adults in the community.

In the past five years, ACC has partnered with primary care practices to implement the AIMS Model. Currently, ACC works with two practices that are part of the same health system for which it provides transitional care. Under the AIMS Model, primary care providers or other members of a clinical team proactively refer clients to AIMS if they identify a patient or caregiver who may benefit from the program. ACC’s AIMS social worker then initiates the AIMS protocol, which includes identifying the patient’s own goals for their health and health care, which often are related to managing chronic conditions and increasing functional capacity. ACC’s AIMS social worker is on-site weekly at each practice, facilitating communication and their integration into the primary care teams. In addition to offering the AIMS Model of care, the social worker trains and consults with the practice’s medical staff to address barriers that may prevent patients from remaining compliant and often educates medical staff about non-traditional ways to meet the needs of patients, such as home visits.


AIMS: An Integral Part of Aging Care Connections’ Offerings

AIMS expands ACC’s reach to additional aspects of the care continuum, ensuring older adults are connected with relevant resources and programs that ACC offers, while also helping ACC act as the hub of the service delivery system for older adults in the community. In addition to receiving referrals from provider partners, referrals can also come from another ACC department if a client is a patient at an ACC AIMS partner clinic and if the staff member feels the client may benefit from the AIMS Model of care. When this occurs, ACC staff will discuss with the care team before initiating the AIMS protocol.

The below client story illustrates how the use of the AIMS Model strengthens ACC’s ability to serve as a hub of the service delivery system for older adults in the community.

Looking Ahead

Like most organizations undertaking this work, the biggest challenge for ACC has been in sustaining the program and maintaining provider buy-in. Grant funding has been critical to allowing ACC to implement AIMS for the last five years. Diversifying funding streams beyond state contracts and grant funding is an important way for organizations to ensure they can weather the financial uncertainty. ACC is making progress in terms of conversations about sustainability, but it is a long road. Constant changes with health care leadership, hospital mergers and restructuring, practice sales, etc. have been a major challenge, with ACC often needing to start from scratch with new administrators and medical staff. However, ACC’s partner clinics have seen value in the work and trust the agency’s involvement, which has helped to maintain partnerships. ACC hopes to leverage that success to eventually secure reimbursement contracts with primary care partners through new Medicare FeeforService opportunities that allow providers to have the ability to get reimbursed for these services.

ACC, along with Rush University Medical Center’s Center for Health and Social Care Integration recently received grant funding from the Harry and Jeanette Weinberg Foundation to support other CBOs implementing the AIMS Model of care. With this contribution, ACC is able to offer no-cost implementation training and support to select sites interested in bringing AIMS to their organizations to support vulnerable older adults in their communities. AIMS can be implemented in partnership with health systems, private practices, Accountable Care Organizations, house calls practices and/or federally qualified health centers. If your organization is interested in more information about AIMS and this opportunity, please contact Matt Vail at


Learn more about the AIMS Model in this related Business Institute webinar, The AIMS Model: An Approach to Addressing the Social Determinants of Health in Primary Care, which was presented by leaders of this initiative from Aging Care Connections and Rush University Medical Center.