Social Prescribing: a resource for health professionals

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This resource is designed to support health professionals working in the primary care sector to implement social prescribing into their practice. This resource draws from the best-available evidence and guidance on social prescribing.

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Introduction to social prescribing New

Social prescribing 1–3
What is social prescribing?

Social prescribing is a practical way for health professionals to address social determinants of health.

It expands the options available in primary care and connects people to a wide range of non-clinical services in the community to improve their health and well-being (e.g., mental health, social, financial, housing, physical activity, creative, self-expression).

Why is it beneficial?

It addresses social determinants of health, which is key to improving health outcomes.

It empowers people to take an active role in their health and well-being, build meaningful connections in their community, promotes autonomy and encourages a healthy lifestyle.

It allows for the provision of more holistic, person-centred care.

It ultimately reduces utilization of primary and emergency care, decreasing the overall stress on the healthcare system.

Who is it for?

Anyone with social factors that adversely impact their health.

Examples include (but are not limited to) people:

 

  • Who may skip a medication because they don’t have coverage and can’t afford it
  • Who may be lonely or socially isolated
  • For whom affordable childcare would mean the ability to focus on their health, participate in therapy, work, etc.
  • Who have trouble getting nutritious food because of income or limited mobility

Incorporating social prescribing into your practice2,4

There is no one-size fits all approach to incorporating social prescribing into your practice. Rather, it is a non-linear and iterative process that can be shaped to fit your needs and capacity.

Here are some general tips to help incorporate social prescribing into your practice:

  • 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.
  • Build a list of community resources – Make a list of social supports and resources available in your community that you can easily access when social prescribing.
  • Establish roles – Determine who will be involved in the social prescribing process. This will depend on capacity and needs that are individual to your practice.
  • Start small – Work collaboratively with individuals to determine priorities and initial focus.
Talking points
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Talking points

Discuss the idea of social prescribing with individuals using plain language2

  • “There are many things that affect our health – I 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 help connect you to services that can help you achieve better health.”

Assess and understand the social factors impacting health

Through discussion with individuals, assess their needs to understand the social determinants of health may be affecting their wellbeing. It is important to block out time to have open-ended conversations about their needs. Document identified social determinants of health in the individual’s health record (e.g., in the CPP).1,2,4

Lead with empathy and create a safe space for all – It is important to remember that everyone comes from a variety of social situations. Approach discussions with an empathetic mindset and create a safe space for individuals to feel comfortable talking about sensitive issues.

Talking points
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Talking points

Block time to have an open-ended discussion with individuals about their social situations5

  • “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 of your choice?”
  • “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 New

Pointing a person to a support1,2

Direct an individual to a social support 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 with individuals the social support options that will help address their identified need
    • Leverage 211 Ontario or Ontario Home and Community Care Support Services to find local social supports
    • Decide together on an appropriate social support option
    • Provide sufficient information for the individual to explore the option further by themselves
    • Make a plan for following-up to discuss their experience
    • Document the discussion, decision and follow-up plan in the person’s health record
Example social prescriptions

Isolation and social support: newcomer settlement support, bereavement groups, local older adult centre, cultural organizations or centres

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

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

Making a warm connection

Directly connect a person to a social support. This follows a similar process as ‘point a person to a support’, but it takes it one-step further by providing a warm hand-off or referral for a person to the social support. This form of social prescribing is good for individuals who are hesitant or are experiencing barriers to connecting with social supports.

Steps
  • Discuss and explore with individuals the social support options that will help address their identified need
    • Leverage 211 Ontario or Ontario Home and Community Care Support Services to find local social supports
    • Decide together on an appropriate social support option
    • Provide sufficient information for the individual to explore the option further by themselves
    • Make a plan for following-up to discuss their experience
    • 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 is often a social worker, psychological counsellor, system navigator, care coordinator, community connector, health coach or outreach worker. This form of social prescribing is good for any individual but availability of social prescribing navigators differs in communities across Ontario.

Steps
  • Discuss and explore with individuals the social prescribing navigator options that will help address their identified need or that are available in their community
  • Decide together on an appropriate social prescribing navigator option
  • Connect the individual with the social prescribing navigator by completing a referral form OR 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 the next step.Share sufficient information with the individual about the social prescribing navigator process so they understand the next step
    • Make a plan for following-up to discuss their experience
    • 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):6

      • TeamCare (available across multiple sites in ON) – provides support with conducting an assessment, and connecting an individual to a range of social and community supports
      • 211 Ontario Community Connection (available in Central East region) – provides support with social needs assessment, navigation, advocacy, care coordination, referrals and provide outcome reports
      • SCOPE (available in the GTA and other sites across ON) – provides support with community and hospital resource navigation, real-time consultation and support for complex and urgent cases, access to mental health supports and care coordination for structurally vulnerable cases through telemedicine
      • Ontario Caregiver Organization (available across ON) – helpline for caregivers to connect them with information, resources and referrals to supports
      • Social prescribing navigator (available in various Ontario family health teams, e.g., McMaster FHT, St. Michael’s Hospital FHT) – provides support with conducting an assessment through co-creative, strengths-based conversations, and connecting individuals to a range of social and community-based supports

After social prescribing: the follow-up

It’s important to follow-up with individuals after the social prescription. Check in with the individual to:

  • Determine if the individual pursued the prescription
  • Find out if they encountered any challenges and barriers along the way
  • Understand the individual’s level of satisfaction with the prescription
  • Gauge any changes in the person’s knowledge, health and general well-being
  • Document the follow-up in the individual’s health record
Talking points
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Talking points

Consider asking the following types of questions at follow-up:1

  • 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?
Practical tips

Follow-up may vary, but these tips are universally applicable:5

  • Social prescribing requires the same follow-up as medical prescriptions and referrals. Remind individuals of this. Stress to the individual that their social needs are equally as important as their medical ones.
  • After initiating a social prescription, be diligent in scheduling a follow-up appointment(s) to check-in on the effectiveness, and to provide an alternative if necessary. 
  • Provide further information and support for the individual where appropriate.
  • If you have the practice resources, continuously track, measure and evaluate social prescriptions and any resulting impact on the individual.

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]

    Expert opinion.

  • [6]

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