Social Work/Transportation Resources

Social Work Resources

Each doctor at AIM has an assigned social worker, see the AIM modules document. Your assigned social worker is available via InBasket message or referral from the AIM common order set.

The purpose of Social Work in ambulatory care is threefold: 

  • To assist individuals/families’ function when illness or disability result in changes to their physical/mental state or social role.
  • To prevent social and emotional problems from interfering with physical/mental health or with necessary treatments. 
  • To identify gaps in community services and facilitate access.

Social work services are provided by appointment (using the standard Epic order). Patients with social work emergencies can be seen on a walk-in basis.  

Social Work Emergencies: Send to AIM Walk-in Social Worker (305-3078, send patient to room 205)

  • Housing emergency: undomiciled or in possession of 72- hour eviction notice. Homeless shelters are split based on single adult male/females, adult families, and families with children. Shelters often have strict intake times and limited availabilities.
  • Evidence/suspicion of domestic violence
  • Evidence/suspicion of elder or child abuse.
  • Inability to pay for/access medications essential to health (short-term gratis supplies can be arranged).
  • Dangerous home situation (e.g. frail elderly without adequate supervision). 
  • Same-day transportation crisis.

Non-urgent referrals (make a scheduled appointment with the social worker): 

  • Age 80 and above without prior psychosocial assessment 
  • Insurance problems impacting on medical care (e.g. lapsed benefits) Medicaid, Medicare 
  • Difficulty adjusting emotionally to medical condition 
  • Current substance abuse 
  • Financial concerns (e.g. difficulty paying rent, buying food)  
  • Medical condition impacting on ability to travel by public transportation  
  • Request for entitlements (e.g. Public Assistance, Food Stamps) 
  • Home care/equipment needs 
  • Objectively inadequate housing (e.g. serious overcrowding, violations; NOT for stable housing with which the patient is unsatisfied) 
  • Immigration issues 
  • Job options counseling 
  • Adult education (e.g. ESL, GED) 
  • Social isolation (assessment for day, recreation, luncheon programs) 

Common social work resources (should usually be arranged via nonurgent module SW referral):

  • Medicaid Offices - Complete list of local offices where residents can obtain in-person assistance with medicaid application. Most commonly used:
    Manhattanville Community
    520-530 W 135th St. (1st Fl.), New York, NY 10031
    Tel: 212-939-0207
    Monday – Friday 9:00am to 5:00pm
  • - A website that helps to find programs for people age 55 and over who may need help in paying for prescription drugs, health care, utilities and other essential items or services.
  • Meals on Wheels - Must be 60 and over have a physical or mental disability that prevents pt from shopping or preparing food. Cannot have Medicaid home care, home care worker, or family members who assit patient with meals or meal prep.
  • Senior Centers - Some centers provide free or minimal cost meals to those 60+
  • Electricity - Physicians can write a letter to electricity providers to avoid cut off with medical use (Az, OSA, meds needing refrig.)
  • Lifeline "Obamaphone" - Mobile phone assistance program for low income persons. A federal program but eligibility determined by states, candidates often have Medicaid/SNAP/SSI.
  • Housing resources - For undomiciled patients or those actively undergoing eviction, send to walk in social work. For patients with chronic, stable housing issues who are not homeless or currently being evicted, social work has only limited resources:
  • The provider can write a letter to landlord indicating impact of condition on pt’s health
  • Patient can file complaint with 311

Transportation Resources

  • Patient may be able to get a one-time Metrocard depending on insurance. Social workers can help with this determination.
  • Reduced fare Metrocards - For those over 65, on SSI/SSD. Form from MTA. Provider must attest to medical reasons.
  • Access-a-Ride - Provides semi-private transportation for patients who cannot take public transportation for medical reasons. Patient must call 877 337 2017 to schedule eligibility appointment. Contact social work (Emilia) for assistance in setting this up. See common forms section for paperwork.