Social Prescribing: a Resource for Health Professionals

Last Updated: October 11, 2023

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This resource is designed to support health professionals working in primary care to implement social prescribing in their practice. This resource brings together the best available evidence and expert opinion to provide guidance on social prescribing. To accompany the resource, a 30 minute online training module (short registration required) with case studies is available to support implementation and enhance the learning experience.

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Introduction to social prescribing

Social prescribing 1–3, 6
What is social prescribing?

Social prescribing is a practical way for health professionals to address social determinants of health by connecting people with a range of resources that support their social, mental and physical well-being. 

It expands the options available in primary care and connects people to non-clinical services and programs in the community to improve their health and well-being. Social prescribing may help patients with their: 

  • Mental health/substance use 
  • Social support system 
  • Financial wellbeing 
  • Housing 
  • Physical activity 
  • Creative self-expression 
  • Activities of daily living and instrumental activities of daily living
Why is it beneficial?
  • It addresses social determinants of health, which is key to improving health outcomes.
  • Empowers people to take an active role in co-creating their health and well-being. 
  • Helps people build meaningful connections.
  • Promotes autonomy and sense of purpose. 
  • Enhances a partnership built on advocacy and accompaniment. 
  • Allows for  more holistic, person-centred care. 
  • Reduces utilization of primary and emergency care, decreasing the overall stress on the healthcare system. 

 

Who is it for?

Anyone, but it is most helpful for people with a high burden of social or systemic factors that adversely impact their health. 

Examples that may indicate a social prescribing need include:   

  • Skipping a medication because they don’t have coverage and can’t afford it. 
  • Those who may be lonely or socially isolated. 
  • Those for whom affordable childcare would mean the ability to focus on their health, participate in therapy, work, etc. 
  • Trouble getting nutritious food because of income or limited mobility. 
  • Those who have a limited or absent formal support system. 

How you are already implementing social prescribing: 

  • Connecting people with the Trillium Drug Program and disability-related income supports. 
  • Suggesting programs at an older adult centre. 
  • Connecting someone to the Alzheimer Society of Canada, Ontario Caregiver Org, etc. 
  • Museum passes for low income families. 
  • Sharing information about where to access free meals, when food security is an issue. 
  • Connecting someone who has low vision with the association for the blind so that they can get IT recommendations that will promote their independence and autonomy. 
  • Asking individuals about their social situation, who they live with, if they work or go to school, what their hobbies are, if they have pets and what matters to them. 

Being ready: incorporating social prescribing into your practice2,4-6

There is no one-size-fits-all approach to integrating social prescribing into your practice. Social prescribing practices are customized to individuals, your community, your resources and your capacity.  

This guide is designed to support healthcare practitioners in implementing small changes that require minimal additional resources. It offers a great starting point for introducing social prescribing into your practice and provides guidance on how to build your program with more resources if they can be found.  

Designing the pathway and preparation 

Determine who will be involved in the social prescribing pathway. This will depend on the capacity and needs of your practice. Here are some general steps to consider based on practice type: 

  • Build your social prescribing team – Determine which members of your practice will participate in the social prescribing pathway and what their assigned roles will be. 
    • Interprofessional teams (Family Health Teams (FHTs), Community Health Centres (CHCs), etc.) – consider allocating resources to create a social navigator role on your team if one does not already exist.
    • Non-interprofessional teams (solo doctors, larger family practices, etc.) – consider who in the practice would be the most effective touchpoint  to take on the role of social navigator. This decision is ideally made in collaboration with potential social navigators to identify who they are most comfortable interacting with. For example, the most effective touchpoint could be a nurse, social worker on staff or clinic receptionist. Primary care professionals in practices unaffiliated with teams could turn to the SCOPE program for assistance (i.e., SCOPE Health Coaches, TIP program) or consider partnering with a local CHC or FHT. 
  • Engage in training – After determining who will be  involved in the pathway, consider engaging the team in focused training on trauma-informed and culturally safe care if not previously done. Look into resources such as CAMH’s Trauma-Informed Practice handout  and Cancer Care Ontario’s Indigenous Relationship and Cultural Awareness Courses.  
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Talking points

What is a social prescribing navigator? 

A social prescribing navigator (also referred to as a link worker) helps people explore and connect to social supports. A social prescribing navigator could be a social worker, psychological counsellor, system navigator, care coordinator, community connector, health coach, outreach worker, etc. If resources allow, it is ideal to have a social prescribing navigator on staff to keep social prescribing interactions consistent, allow relationships and trust to build between them and individuals receiving a social prescription and help share the workload. 

Building your base 
  • Know your community – Look into what social determinants of health are impacting your area of practice. A great resource for this is the 211 Ontario User Needs Dashboard which provides data on the most commonly reported needs in communities across Ontario. Start with what is realistic for your capacity and work collaboratively with your team to determine priorities and initial focus. 
  • Build a list of community resources – Make a list of locally available social supports and resources and  ensure the list is easily accessible when social prescribing. You can also find a list of services and resources available in your region through TheHealthline which is separated by health topic or need. Ideally, become familiar  with the intake procedures and requirements of the programs and services you are considering for your prescribing base. 

Assess and understand the social factors impacting health

Through discussion with individuals, assess their needs to understand how social determinants of health may be affecting their well-being. It is important to block off time for open-ended conversations to discuss their needs. Document identified social determinants of health in the individual’s health record (e.g., in the CPP).1,2,4,6

Lead with empathy and create a safe space for all – Remember that everyone comes with a unique social story. Approach discussions with an empathetic, welcoming mindset and create a safe space for individuals to feel comfortable talking about sensitive issues. Trust and openness is foundational to building relationships and successful social prescribing.

Setting the stage – Clarifying your intent with individuals before asking about their social stories is important. Introduce the concept of social prescribing and explain how it can help them. Acknowledge that this is a journey and no single clinician can know everything but can reach out to team members (e.g., FHT) or community organizations for guidance, both for themselves and individuals. 

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Discuss the idea of social prescribing with individuals using plain language 

  • “There are many things that affect our health – I can help you address your medical concerns, but there are other people in our community who may also be able to help you with other aspects of your health.”  
  • “In addition to treating the medical aspects of your health, I would like to  connect you to services that can help you achieve better health.”  
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Block time to have an open-ended discussion with individuals about their social story6 

  • “What would you like me to know about you?” 
  • “How has your experience been with our team’s care for you?” 
  • “What do you enjoy doing?”  
  • “Have there been times when you’ve felt lonely or isolated? Can you tell me about it?”  
  • “Are you able to access the food you’d prefer to be eating?”  
  • “Can you tell me a little bit about your current living situation? Do you feel comfortable and safe?”  
  • “Do you ever have trouble accessing health or social services?” 

Initiate social prescribing

Once an individual’s needs and the social factors impacting their health have been identified, work together to initiate social prescribing. Social prescribing should be tailored to an individual’s specific needs, context and identity, as well as time and resources available to the healthcare professional. There is no one-size–fits–all approach to social prescribing. Social prescribing can take the form of: 

Pointing a person to a support1,2,6

Direct an individual to a social support service or something an individual can engage in on their own. This can include anything from visiting a tax clinic to spending time outside. This form of social prescribing is good for individuals who are able to pursue these options by themselves.

Steps
  • Discuss and explore the social support options that will help address the individual’s identified need.
    • Leverage 211 Ontario or TheHealthline to find an appropriate social support option.  
    • Provide sufficient information for the individual to explore the option by themselves and manage expectations. 
  • Make a plan for a follow-up to discuss their experience, noting their preferred method of communication. 
  • Document the discussion, decision and follow-up plan in the person’s health record.     
Example social prescriptions

Food security and nutrition: community meal programs, food bank, community garden 

Education, learning and growth: participatory art making, physical activity, outdoor activities, museum and gallery visits 

Culturally specific: activities that help to connect people to their culture such as sharing food, literature, theatre 

Transportation: shared-ride services, subsidized ride programs, accessible transport 

Making a warm connection

Directly connect a person to a social support. This process is similar to ‘point a person to a support,’ but it goes a step further by making a warm hand-off or referral  to the social support. This type of social prescribing is helpful for individuals who are hesitant or facing barriers to connecting with social supports.

Steps
  • Discuss with individuals the social support options that will help address their identified needs.   
  • Decide together on an appropriate social support option.  
  • Provide a ‘warm hand-off’ by completing a referral (Ocean, electronic fax) to the social support OR by contacting them to confirm availability and the welcoming process. 
    • Share sufficient information with the individual about the referral or welcoming process so they understand next steps and manage expectations. 
  • Make a plan to follow-up to discuss their experience, leveraging their preferred method of communication. 
  • Document the discussion, decision and follow-up plan in the person’s health record.  

Connect a person to a social prescribing navigator. A social prescribing navigator (also referred to as a link worker) helps people explore and connect to social supports. A social prescribing navigator could be a social worker, psychological counsellor, system navigator, care coordinator, community connector, health coach, outreach worker, etc. This type of social prescribing is helpful for any individual but availability of social prescribing navigators differs in communities across Ontario.

Steps
  • Discuss with individuals the social prescribing navigator options that will help address their identified needs or that are available in their community.  
    • Leverage one of the resources mentioned below or explore funding options.
  • Decide together on an appropriate social prescribing navigator option. 
  • Connect the individual with the social prescribing navigator by completing a referral form OR by contacting them to confirm availability, the welcoming process and provide a ‘warm hand-off’ to the individual. 
    • Share sufficient information with the individual about the social prescribing navigator process so they understand next steps.  
    • Establish communication mechanisms with the navigator. 
  • Make a plan to follow-up to discuss their experience, leveraging their preferred method of communication. 
  • Follow-up with the navigator to learn whether they successfully linked the individual to a resource, reasons for not being able to connect the individual to a resource or any additional needs identified. 
  • Document the discussion, decision and follow-up plan in the person’s health record.  

    Resources

    Current social prescribing navigator programs (any regional availability is noted below):7

    To explore opportunities to resource a local navigator for your community, connect with your Ontario Health Team or community partners (e.g., educational institutions, older adult centres, other organizations). 

Billing for social prescribing 

Use the general family practice OHIP codes or condition specific codes to bill for social prescribing, where applicable, as part of their care. Just like there is often no specific code for a prescription or referral as part of a person’s visit, there is no OHIP billing code specific to social prescribing. 

Examples: 

  • K005 – Primary mental health care 
  • K013, K033 – Counselling 
  • K030 – Diabetes management 
  • K037 – Fibromyalgia/myalgic encephalomyelitis care 

After social prescribing: follow-up and follow through

After initiating a social prescription, be diligent in scheduling a follow-up appointment(s) to check-in on its effectiveness. Just like other prescriptions and referrals, best practice in social prescribing requires follow-up. Be sure to emphasize to the individual that their social needs are equally as important as their medical ones. The follow-up gives the healthcare professional or navigator an opportunity to assess the fit of the prescription, to redefine goals and to identify any barriers to access.

Following through demonstrates a long-term commitment to the patient, and should be the standard of care. It ensures that the patient feels supported throughout the entire process and that they’ve been connected with the resources that best meet their needs.

The nature and length of follow-up may depend on a variety of factors such as:  

  • patient need 
  • level of intervention implemented 
  • goals to achieve 
  • types of approaches to address needs, etc. 

*Make sure to ask the individual about their preferred method of communication for follow-up outside of office appointments. (e.g., email, text, phone call, or even regular mail). 

Also, make note of individuals’ experiences with specific social support options to reference during future social prescribing. Keep track of successful programs, classes, and other opportunities in your individual communities. Check to see that they’re still being offered before you share the information with future patients.  

Practical tips

Follow-up will vary depending on context, but these tips are universally applicable:6 

  • Determine if the individual pursued the prescription and find out if they encountered any challenges or barriers. 
  • Understand the individual’s level of satisfaction with the prescription.  
  • Gauge any changes in the person’s knowledge, health and general well-being.  
  • As you move through the follow-up appointment, consider asking general questions like:  
    • How are things going?  
    • What has gone well for you and what hasn’t gone well?  
    • What else do you need from me to help you meet your goals?
  • Build in time to acknowledge and discuss the emotional impact of the social prescription on the patient. 
  • Provide further information and support for the individual where appropriate. If the first social prescription was not successful, work together to find an alternative. 
  • Document the follow-up in the individual’s health record.  
  • If you have the practice resources, continuously track, measure and evaluate social prescriptions and any resulting impact on the individual


*How to follow-up and follow through when there are no easy answers or solutions 

  • There may be some systemic social issues, such as housing and food insecurity, for example, that are harder to solve for individuals. It’s important to acknowledge when there may not be an easy fix and that some issues may require a bigger commitment. If time allows, consider reaching out and advocating on behalf of individuals to social service organizations in your community, government agencies, or directly to your local political representatives.  

References

  • [1]

    World Health Organization. A toolkit on how to implement social prescribing. 2022.

  • [2]

    Alliance for Healthier Communities. Social prescribing guidebook for team: based primary care providers in Ontario. n.d.

  • [3]

    Napierala H, Krüger K, Kuschick D, Heintze C, Herrmann WJ, Holzinger F. Social prescribing: Systematic review of the effectiveness of psychosocial community referral interventions in primary care. Int J Integr Care. 2022 Aug 19;22(3):11.

  • [4]

    Bloch G, Rozmovits L. Implementing social interventions in primary care. CMAJ. 2021 Nov 8;193(44):E1696–701.

  • [5]

    Thomas G, Lynch M, Spencer LH. A Systematic Review to Examine the Evidence in Developing Social Prescribing Interventions That Apply a Co-Productive, Co-Designed Approach to Improve Well-Being Outcomes in a Community Setting. Int. J. Environ. Res. Public Health 2021, 18, 3896. 

  • [6]

    Expert opinion. 

  • [7]

    Nowak DA, Mulligan K. Social prescribing: A call to action. Can Fam Physician. 2021 Feb;67(2):88–91.