Illustration: Tiago Galo
Global movement puts a process around referring patients to non-clinical and community-based programs and services
By Stuart Foxman
For more than 15 years, Dr. Gary Bloch, a family physician in Toronto, has helped a patient named Patrick (a pseudonym) through all sorts of challenges. Patrick has dealt with cancer, diabetes, and mental illness, and has benefitted from good connections to specialists, pharmacists, and a hospital. “He has been very well served medically,” says Dr. Bloch, a co-founder of Inner City Health Associates.
But, Patrick, now in his 50s, had other challenges. He lives alone in low-income housing in a tiny apartment that Dr. Bloch learned was poorly maintained. And he described himself as isolated, with little-to-no social supports.
“We spent a lot of time on his medical conditions, but what were we missing?” says Dr. Bloch, who chairs the Family Health Team’s Social Determinants of Health Committee at St. Michael’s Hospital. “So let’s look at this from a more holistic perspective and get an understanding of what health and well-being mean beyond blood work and a physical exam.”
DR. GARY BLOCH chairs the Family Health Team’s Social Determinants of Health Committee at St. Michael’s Hospital (Photo credit: Unity Health Toronto)
About nine years ago, Dr. Bloch referred Patrick to community agencies that helped put him back in touch with family members and facilitate social connections. One of the agencies also brought income security specialists aboard to help Patrick access tax credits, and more disability and social assistance supports. They also arranged cleaners for Patrick’s apartment and furniture donations. For Patrick, it has all been therapeutic.
The work with Patrick illustrates what’s possible through social prescribing. That’s a global movement that puts a process around referring patients to non-clinical and community-based programs and services. These could include anything from peer networks to skills development, an art class to grief support, a community garden to a hiking group – whatever meet a patient’s interests, needs and goals.
Often, these offerings help to address the social determinants of health, i.e., the non-medical factors the influence health outcomes – things like income, food security, social integration, education, access to recreation, housing, disability, race, and more.
“There’s always a need for acute care, but the vast majority of our health and well-being is determined by social and environmental factors,” says Dr. Kate Mulligan, a senior director, Canadian Institute for Social Prescribing and assistant professor, Social and Behavioural Health Sciences, at the University of Toronto’s Dalla Lana School of Public Health.
She says most clinicians understand the social determinants of health and the wisdom of addressing them. “But their systems aren’t structured to do the work,” she says.
While many doctors already offer non-clinical recommendations informally, social prescribing formalizes connections with community supports and helps to remove barriers for patients so they can fill the prescription. “It’s a specific and supportive referral,” says Dr. Mulligan.
As she explains, a health care professional gets things started. A link worker (also known as a community connector, navigator, coordinator, etc.) gets at the root of what the person needs, and a partner from the community or volunteer sectors offers the support.
Social prescribing isn’t a common term in Canada yet. But it has been around in the UK since the 1990s, and several other countries are implementing the practice to better join the medical and social models of health.
Research shows that those receiving social prescribing gain feelings of empowerment, greater confidence, and an improved sense of wellness overall. The health care system benefits too. UK research found that social prescribing resulted in decreases of 40 percent in physician visits, 14 percent in emergency room visits, and 21 percent in costs to the system.
Individuals who face inequities are prime beneficiaries of social prescribing, with many of these patients not even able to access the “clinical machinery”. For those experiencing homelessness, for example, social prescribing can take hold with outreach at community sites, away from a clinical environment.
The Guelph Community Health Centre calls social prescribing “a new spin on an old idea” – i.e., that a sense of belonging can have a positive impact on health and well-being. One of the Centre’s social prescribing projects has involved giving participants vouchers to access fresh fruits and vegetables.
When you can’t afford nutritious food, or when you feel socially isolated, it can be hard to follow even the most basic medical advice. Health suffers. “People can feel that they’re not seen and heard,” says Ms. Natasha Beaudin, social prescribing project lead at the Alliance for Healthier Communities.
Having patients get the right support for the well-being can mean fewer medical interventions. “A tiny bit of work at the beginning will lead to less work in the end,” says Ms. Beaudin.
This past summer, the federal government announced nearly $4 million in funding for the Alliance to expand their Social Prescribing for Better Mental Health project across Ontario.
Go from “what’s the matter” to “what matters”
Within medicine, the link between health status and the social conditions and situations we live in have long been known. What’s new is the push to make social interventions a routine part of the care physicians provide. “More and more, we see other social support services not as outside our realm but part of our realm,” says Dr. Bloch.
Incorporating social prescribing into a practice begins with a deeper understanding of the patient. “The focus goes from what’s the matter with you to what matters to you,” Dr. Mulligan says, adding that it’s part of patient-centred care. “A lot of this is shifting the locus of control over definitions of health from providers to health system users, to allow people to self-determine what they want,” she says.
That means going beyond a medical and social history to understand the patient’s social context, says Dr. Ritika Goel, a family physician at St. Michael’s Hospital, and the social justice, anti-oppression and advocacy theme lead at the Temerty Faculty of Medicine, University of Toronto.
What kinds of questions can that entail? It could be as basic as “What does a typical day look like for you?” Dr. Goel has developed a social history tool using the mnemonic IF-IT-HELPS1. “I keep this on the side of every single patient chart.”
There are almost 50 questions under the headings of identity, family and friends, income, trauma, housing, education, legal, personal safety, substances, and sexual health. Examples: Are there people in your life you can count on for support? Do you ever have difficulty making ends meet? Have you experienced or witnessed violence? Where are you staying now? How far did you go in your education?
IF-IT-HELPS isn’t a checklist, says Dr. Goel. She calls it “a learning exploration tool,” which can be used over several visits. The information can help practitioners think of the best management plan. It can also guide possible social prescribing, with the answers suggesting how patients might benefit from interventions like drop-in services, or literacy classes, legal clinics, parenting centres, employment counselling, etc.
Making more of a difference
Getting involved in social prescribing doesn’t add to a doctor’s burden; it eases it. “The goal is for it to be less time consuming,” says Dr. Mulligan.
It takes a little time up front for practitioners to learn the range of non-clinical supports available from local agencies. Depending on the capacity of the practice, doctors may want to appoint a member of the team to be the social prescribing touchpoint.
Getting to know the social needs of patients is part of a routine conversation. Even a few minutes of discussion can open the door, and screening tools like IF-IT-HELPS and others guide such conversations. Then it’s a matter of keeping a list of resources, pointing patients to the appropriate one, and perhaps making a warm referral for the handoff.
And doctors who engage in social prescribing feel like they’re making even more of a difference, says Dr. Bloch. “There’s research that physicians are more satisfied in their work when they have the ability to support their patients’ social needs,” he says.
That addresses a big frustration and source of stress for doctors, i.e., the feeling that despite their best efforts, a patient isn’t thriving as they could. “The same kind of things that are transformative for recipient are transformative for prescriber too,” says Dr. Mulligan. “You can find your sense of meaning again.”
• The Canadian Institute for Social Prescribing includes resources like best practices, the journey of a patient through a social prescribing pathway, and a World Health Organization (WHO) toolkit on how to implement social prescribing.
• The Alliance for Healthier Communities has a social prescribing hub that includes a look at ongoing projects, presentations and webinars, and screening and intake tools.
• The Centre for Effective Practice offers a social prescribing resource for health professionals, with advice on assessing and understanding the social factors impacting health, how to initiate social prescribing and follow-ups.