Social Prescribing Lead, Alliance for Healthier Communities
An Integrated Way to Address Health & Social Needs of Older Adults During COVID-19 & Beyond
August 2020 blog post by Sonia Hsiung
Across the world, the experience of being quarantined at home, alongside images of families desperate to connect across the glass of long-term care homes and the sounds of neighbours singing across the balconies of small apartments, have reminded societies of the mental and physical strain of social isolation, and our profound biological and social need for human connection.
Older adults are particularly at risk of social isolation and loneliness during this pandemic being especially requested to self-isolate and continue to practice physical distancing even as communities begin to ease restrictions. Meanwhile, there is mounting evidence that social isolation and chronic loneliness are as important as inadequate food or housing to overall wellbeing, with significant links to physical and mental conditions, increased mortality, and increased healthcare utilization.
A missing link
In Canada, governments have responded to COVID-19 with a range of measures, from income supports to funding for community responses and expansion of Seniors’ Centres Without Walls programs. Grassroots “care-mongering” and neighbourhood-level mutual aid have also provided heartening examples of the capacity people and communities already possess to keep one another healthy and well.
But a vital link is still missing: a direct connection between healthcare and community supports.
Primary care providers have established relationships with individuals who are most vulnerable to illnesses in a community, including older adults, those who are immunocompromised, and those with chronic medical conditions. Not leveraging the ability of primary care and other health providers to identify and screen for social needs during regular healthcare appointments or COVID-19 tests is a grievous missed opportunity.
The continued disconnect and lack of proactive social screening and outreach results in vulnerable individuals not accessing available resources, while health providers face burnout from being unable to address social isolation, loneliness, material needs, and other complex social determinants of health in medical practice.
Learning from the United Kingdom
We have much to learn from the United Kingdom, which has made the profound link between community capacity and health systems. Prior to COVID-19, the U.K.’s National Health Service (NHS) invested the equivalent of $850-million in a proactive strategy called social prescribing, an innovation that empowers healthcare providers to use the health appointment to connect clients to appropriated non-clinical, social services, supported by dedicated link workers and navigators.
Social prescribing is a co-creative effort between a health care provider and a client designed to recognize and respond to strengths, interests and health needs. The client takes a lead in their own health by being supported to co-create solutions, and give back through volunteerism. Social prescribing complements traditional clinical treatments while shifting away from medicalizing social needs.
When the pandemic struck, the NHS already had the integrated structures and human resources in place to be able to quickly identify and support the social and material needs of those impacted by COVID-19 through the social prescribing framework.
Promising path forward in Canada
In Ontario, Community Health Centres (CHCs) implemented Rx: Community, an 18-month pilot project to develop a made-in-Canada approach to social prescribing. Results of the pilot demonstrated promise in reducing sense of loneliness, increasing participation in social activities, improving mental wellness, and increasing sense of connected and belonging in participants.
Leveraging existing strengths and applying the lessons from Rx: Community in response to the pandemic, CHCs’ teams of interprofessional healthcare providers identified clients who are at higher risk of social isolation and impacts of COVID-19, made wellbeing check-in calls to assess emergent health and social needs, activated telephone trees for older adults to check in on one another, delivered phones and tablets to older adults without devices, mailed care packages to people without internet access, held exercise classes and coffee chats online, and more. Centres also called on their volunteers – many of whom are older adults engaged in co-creating and leading in-person social prescription programs – to make regular social check-in calls, helping to reduce the sense of isolation for both those receiving the calls and callers themselves.
It’s time to build an integrated system
From the Social Prescribing for Older Adults at Risk of Frailty grant stream in British Columbia, to emerging conversations in the Greater Edmonton Area and Nova Scotia, the demand for using social prescribing as a framework for integrated health and social care is building across Canada.
The importance of integrating health care and social supports is critical now, for older adults at higher risk of social isolation and for our health system. As we begin to prepare for possible future waves of the pandemic and the eventual recovery, social prescribing’s framework for community-led, proactive, collaborative interventions can help to protect the long-term health and wellbeing of individuals and communities.
- Recognize that social isolation and loneliness are key social determinants of health, similar to food, housing, and income.
- Proactively reach out to and check-in with older adults and other at risk populations; regularly screen for non-medical needs and refer to appropriate supports during outreach and healthcare appointments.
- Ask clients, “What matters to you?” instead of “What’s the matter with you?”
- Engage and support older adults as volunteers to co-design and lead activities and programs.
- Find intentional opportunities to partner across sectors, building intentional communities of practice and foster advocates/champions locally.
Policy influencers, funders, and Ontario Health Teams:
- Invest in structured pathways and human resources that support social prescribing referrals between clinical care, interprofessional teams, and social, community and voluntary services.
- Leverage existing initiatives such as TeamCare, regional tables, and community networks to strengthen cross-sectoral collaboration.
- Advocate for and invest in digital equity to ensure that older adults who face barriers to connecting digitally have access to appropriate devices, public and subsidized data plans and access to internet, and support for digital literacy.
Researchers and academic institutions:
- Develop screening and evaluation tools, conduct data analysis, and provide research support to health care and social support organizations to expand the evidence base and best practices for integrating healthcare and social support systems.
 National Institute on Aging. (2019). Featured research: Social isolation, loneliness in older people pose health risks. https://www.nia.nih.gov/news/social-isolation-loneliness-older-people-pose-health-risks
 Hoogendijk, E.O., Smit, A.P., van Dam, C., Schuster, N.A., de Breij, S., Holwerda, T.J., Huisman, M., Dent, E. and Andrew, M.K. (2020). Frailty Combined with Loneliness or Social Isolation: An Elevated Risk for Mortality in Later Life. J Am Geriatr Soc. doi:10.1111/jgs.16716; and Holt-Lunstad, Julianne & Smith, Timothy & Baker, Mark & Harris, Tyler & Stephenson, David. (2015). Loneliness and Social Isolation as Risk Factors for Mortality: A Meta-Analytic Review. Perspectives on Psychological Science. 10. 227-237. doi:10.1177/1745691614568352.
 Kerstin Gerst-Emerson and Jayani Jayawardhana. (2015). Loneliness as a public health issue: the impact of loneliness on health care utilization among older adults. American Journal of Public Health. 105. 5: 1013-1019. doi:10.2105/AJPH.2014.302427.
 Kidd, Michael R. (2020) “Five principles for pandemic preparedness: lessons from the Australian COVID-19 primary care response.” British Journal of General Practice. 70 (696): 316-317. doi: 10.3399/bjgp20X710765
About the Author
Sonia Hsiung is the Social Prescribing Lead at the Alliance for Healthier Communities. Sonia is experienced in managing projects and partnerships across corporate and non-profit sectors, and coordinates Ontario’s first social prescribing project, implemented in Community Health Centres across diverse urban, rural, Francophone, and Northern regions in the province. This initiative aims to improve health outcomes for marginalized and socially isolated people and to reduce health systems utilization by creating a clinical pathway between mainstream health systems and community and voluntary supports, which has shown promising results and galvanized wide interest nationally.