Abstract
High quality comprehensive primary care is essential for the health and well-being of individuals and communities, but the provision of health services is inadequate to fully address these needs. Social isolation and loneliness are associated with poor health outcomes and are increasingly prevalent among older adults. The St. Michael’s Hospital Academic Family Health Team, a large interdisciplinary primary care organization that serves approximately 55,000 people in the downtown east of Toronto, Ontario, developed and implemented a social prescribing program to support socially isolated and lonely older adults. This article reports the development of that program—called SEED (Seniors, Equity, Engagement, and Dignity)—and describes opportunities and challenges and some preliminary results from the first year. By supporting people in new ways, this program aims to reduce loneliness and social isolation, increase capacity within the family health team, and support diverse older adults to live fulfilling lives.
Introduction
Primary care includes treatment and prevention of illnesses and injuries, mental health services, health promotion, referrals to other types of healthcare services (such as medical and surgical specialists), and antenatal, obstetrical, and postpartum care. 1 Healthcare services alone are inadequate to addressing challenges that stem from the circumstances in which individuals live. 2 These social determinants of health include factors like food security, housing affordability, and social inclusion. 3
The eastern section of downtown Toronto, Ontario (Canada’s largest city) is highly diverse; approximately 44% of people living in the downtown east side are from racialized, non-Indigenous populations. 4 These areas manifest substantial health inequities, notably experienced by older adults. Among the older adults (defined as those 55 years of age or older) living in these neighbourhoods, 38% live alone, over 22% (more than double the Canadian average) 5 are low income, and 15% live in poverty. 4
Loneliness and social isolation are risk factors for other health conditions, particularly among older adults.6-8 Clinical guidelines on social isolation and loneliness in older adults in Canada recommend that health and social service providers screen for and document identified social isolation and loneliness medical records, as they would other medical conditions. 8 Mental illnesses are common among older adults and across different studies, mental illness and loneliness/social isolation have been shown to act synergistically to impact health. 9 The intersectional nature of these factors results in a higher use of healthcare services. 10
In Canada, concurrent crises are impacting health services including the availability of healthcare workers, funding, and a lack of support for an increasing population of older adults with complex health and social care needs. 11 A stronger Canadian health system ready to face these challenges requires a reform of primary care services and delivery that is ready to support the complex health and social needs of older adults.
Social interventions launched through primary care have been found to improve socialization and connection, while decreasing loneliness and isolation both in and outside of Canada. 12 Social prescribing is an umbrella term for community-based interventions that enable healthcare providers, often primary care providers, to indirectly refer individuals to social services and community resources.13,14 Successful examples of social prescribing have been launched already in Canada. For example, the Alliance for Healthier Communities launched a social prescribing pilot named Rx: Community in Ontario, which provided 3,300 social prescriptions to 1,100 different clients. 15 Clients were referred to programs that served both material—including housing and food—and social needs. Healthcare providers found that this program led to improved well-being and fewer repeat visits among their clientele. 15 The Fraser Health Authority in British Columbia hired “senior community connectors” to help older adults develop well-being plans and connect older adults to physical and recreational activities in the community. 16 Similarly, in Guelph, Ontario, a social prescribing initiative targeting food insecurity was created for people living with low incomes, disabilities, or other barriers to health. 16 In international settings, social prescribing has been implemented with older adults to improve physical and mental health through nature walks 17 and through the use of a “link worker” (defined as “a non-health or social care professional based in primary care practices or community and/or voluntary organizations, who support access to a range of community-based resources and supports for health and social care.” 18 ) to help patients with chronic illnesses navigate and access different social services, including income support, career guidance, health promotion programs, and housing support. 19
The St. Michael’s Hospital Academic Family Health Team (SMHAFHT) in Toronto piloted a social prescribing intervention for older adults. In this article, we describe the implementation of this social prescribing program, including opportunities and challenges and preliminary data from the first year of the program.
Methodology and setting
The SMHAFHT is an interdisciplinary primary care organization serving approximately 55,000 rostered patients, based in downtown east Toronto. The SMHAFHT has previously developed and sustained programs targeted at social determinants of health, including embedding income security specialists within the team; a medical-legal partnership embedding lawyers within the team; a children’s literacy program; and projects addressing racism, Indigenous cultural safety, and inclusion and accessibility. These roles all directly address diverse social determinants of health.
Intervention
The new social prescribing program—named SEED (Seniors, Equity, Engagement, and Dignity)—targeted loneliness and social isolation among older adults, 55 years of age and up. The launch of the social prescribing intervention required interdisciplinary cooperation from healthcare professionals embedded in the family health team. The program instituted new roles within the Family Health Team: Link Workers (LWs) and Community Health Workers (CHWs). The social prescribing project can be described in three interconnected processes 1 : community asset mapping and connections made by the CHWs, 2 referral of individuals to the LWs for social needs assessments and social prescriptions, and 3 the training provided to the SMHAFHT about the social prescribing intervention. The program started in mid-2023, with the first individual patients/clients (we use these words interchangeably in this article) seen by the LW in January 2024.
Social prescribing team personnel: CHWs
The SMHAFHT employed two CHWs. They were hired based on their local community knowledge and their experience in social and community development. The job posting for the CHW roles outlined the following key qualifications: 2+ years experience in community outreach/social services, strong connections to local communities (especially priority neighbourhoods), cultural competency working with diverse populations, excellent communication and relationship-building skills, and the ability to take initiative. These qualifications were prioritized over formal clinical accreditation, as the CHW roles were envisioned to draw upon deep community knowledge and lived experience to bridge connections between residents and health/social services.
They laid the foundation for the program pilot and completed the bulk of community engagement work, including but not limited to: community outreach and consultation, partnership development and program planning, implementation, and evaluation. The CHWs further led the consolidation of community resources to develop a community asset map to be used by clients and service providers in the SMHAFHT. They also led community consultations by presenting the social prescribing program to different community agencies and receiving concerns and overall feedback.
Social prescribing team personnel: Link worker
The SMHAFHT employed one LW. They were hired based on their substantial existing familiarity with community resources, experience working in the target communities, and skills in social needs assessment and relationship-building. While the CHWs were focused on community engagement and the relationship between the program and community organizations and ensuring its alignment with community needs, the LW was focused on interactions with individual clients. The LW’s roles were 1 : developing a deep knowledge of the community and its resources and 2 connecting clients (referred from primary care providers embedded in the SMHAFHT) with social services and community resources to reduce loneliness and improve their health and well-being.
Process of social prescribing
Patients were referred to the LW from their primary care provider (i.e., a family physician or nurse practitioner within the SMHAFHT). Primary care providers described the program to the patients to obtain informed consent. All primary care providers in this project were part of the SMHAFHT. All referred clients must have lived in the catchment area, been 55 years of age or older, and been evaluated as socially isolated.
Once a client met the eligibility criteria for the SEED Program, the LWs scheduled a meeting with them to help them create their own goals regarding what they hope to improve from participating in the program. An encounter form was developed within the electronic medical record (which is used by all members of the interdisciplinary team other than the lawyers, who hold their own records independently) for the LWs to report details of their appointments with clients. The form required the LWs to provide a summary of the appointment, identify the client’s social needs, assess the client’s loneliness according to the three-item UCLA Loneliness Scale (which is a validated scale to identify whether someone is experiencing loneliness, including the following questions: how often do you feel you lack companionship; how often do you feel left out; and how often do you feel isolated from others?), 20 record the type of social referral prescribed to the client, briefly describe the client’s prioritized plan, and record how many encounters they had with that client.
The LWs individually met clients in a variety of locations, including but not limited to the clients’ homes or apartment lobbies, parks and coffee shops in their neighbourhoods, and the local SMHAFHT clinic (which has five clinics across the downtown east side of Toronto, so the LWs would sometimes attend the “home” clinic where the patient gets their usual primary care to meet with them). The LWs then scheduled a meeting (that was usually in-person) every other week with the clients to support them in reaching their goals, provide companionship, and connect them to programs and services in the community, when appropriate. Most of the first encounters lasted approximately 90 minutes each, with variable length of follow-up sessions.
Advisory structures
The CHWs introduced the social prescribing program to seven different community agencies. Feedback from the agencies asked that the CHWs include the 2SLGBTQ+ community in their work, consider solutions to language barriers in the community, and ensure that the social prescribing program did not duplicate services already being provided by these agencies.
The CHWs also launched a community advisory committee composed of seven older adults living in the SMHAFHT catchment area. The committee was designed to ensure that the project took into account perspectives of older adults living within these neighbourhoods. The committee shared their knowledge on the gaps in health and social services experienced by older adults in this community, and the challenges that resulted from them. Examples of the feedback they gave were to 1 ensure that recommended programs, services, and resources for the many older adults living with mobility issues were within their neighbourhoods 2 increase the amount of services that could be provided to seniors within their own home (to minimize moving older adults into assisted living facilities), 3 improve transportation available for older adults, and 4 take a wholistic approach to health that respects clients and their needs. They also came up with the SEED name for the program.
Training and education
Short educational modules were developed to teach and train the rest of the SMHAFHT (including current staff, new hires during onboarding, and students from a variety of health professions education programs including medical students, nursing students, psychology students, and others) about social prescribing and how it can be implemented in the Family Health Team setting. Subjects covered by the modules included, but were not limited to SMHAFHT and catchment area, current social care programs, social prescribing, LWs and CHWs, and a community health orientation.
Results
Thirty patients thought to be highly socially isolated were referred to the LW for an initial interview. Approximately twenty-five were referred to the program; the others did not live in the hospital’s catchment area and were therefore ineligible to be enrolled.
From the 25 retained participants, five people were successfully referred to a community agency dedicated to helping seniors, and were able to establish ongoing engagement with that agency. At least 10 clients were referred for other social supports. Several of these clients are currently on the verge of being connected to long-term social supports. Although the LW has linked these patients to different agencies and support services, some of these agencies already have a waitlist of other clients to attend to first; but it was noted without the social prescribing program, these patients would not have ended up on the waitlist at all.
Other clients were connected to social workers, income and security health promoters, or back to their family doctor to be referred to a personal support worker for additional assistance in the home environment with personal care.
Discussion
In the SEED program, family physicians in the SMHAFHT identified and referred older adults they believed to be socially isolated, who met with a LW to connect them with resources identified and cultivated by the CHWs. Historically, the downtown east neighbourhoods of Toronto have had more people living alone and more people living below the poverty line than the rest of Toronto 4 —and this is expected to have worsened after the onset of the COVID-19 pandemic.
Although the program pilot was only recently initiated at St. Michael’s Hospital, there were several notable implications and considerations. Challenges were noted throughout the implementation of the program pilot. First, was the difficulty in getting a major healthcare organization to hire people in roles that do not require regulated health professionals, like the LW and CHW roles. Initial pushback centred on concerns over professional liability and a lack of standardized training/credentialling for CHWs. However, the program leaders highlighted the CHWs’ cost-effectiveness compared to clinical staff, their unique ability to leverage community relationships, and their complementary scope in addressing social determinants of health. Securing buy-in from executive leadership and clearly defining CHW responsibilities distinct from clinical roles was instrumental in making a case for these positions within the family health team structure. Despite these challenges, the program was still able to successfully hire and embed two CHWs and a LW within a primary care hospital-based setting. As well, there was a quick turnaround time from starting to create the program in July 2023, to providing support to individual patients in January 2024. Moreover, the community asset mapping and outreach done by the CHWs was a crucial step in developing the social prescribing pilot, because it allowed for the project team to not only learn and map where different community resources were but also slowly build up community connections with the SMHAFHT.
While CHWs have begun to be more recognized within international literature and research,21,22 these roles remain unaccredited in Canada. The lack of standardized training and accreditation remains an ongoing challenge for formalizing CHW roles across healthcare settings. 23 While some provinces and local initiatives have developed CHW certification programs, no nationally recognized credential exists in Canada currently. Integrating CHW curriculum into established community health worker/health promotion programs at colleges and universities could provide a path toward formalized education. However, there are concerns that over-credentialling may create financial barriers and deter individuals from pursuing CHW roles that have traditionally drawn upon lived experience in impacted communities. 24 Exploring alternative credentialling models that value both academic training and community-based competencies may help professionalize these roles while maintaining their grassroots nature. The overarching goal of the program—decreasing social isolation among older adults without directly providing clinical or mental healthcare—had to be explained to different agency groups and clients to obtain their participation. Community outreach done by the CHWs was therefore instrumental in helping educate the wider community about the social prescribing program and its links to a major urban hospital. In addition, many of the agencies within the catchment area already had long waitlists of clients, and often had their own referral processes that the LWs needed to learn and take into account. As well, some clients hesitated to disclose the other types of support that they had received from community agencies and social services, because they feared losing that support.
Overall, we found some key similarities and differences between our program pilot and others that had been implemented in Canada. Like the Rx social prescribing program in community health centres in Ontario, 25 our program pilot also emphasized providing attention and individualized care to each client while building closer bonds to the local community. However, while our program did strive to motivate clients in setting goals for ourselves like the Rx social prescribing program, 25 we found that many clients were not used to setting their own goals. This became an important project with our LWs, who encouraged clients to design goals for themselves.
Not all programs in other settings hired staff to connect with older adults; for instance, one program had health professional students call older adults weekly to foster connections and health-promoting activities. 14 In contrast, our program specifically hired a LW to communicate with older adults, set goals, and help clients achieve better well-being. We tried to directly foster connections with older adults by having them keep in touch with a LW.
Limitations
Several limitations were also noted in the implementation of the program. For instance, the pilot was only able to support clients living in SMHAFHT’s catchment area and had access to a primary care provider affiliated with the SMHAFHT. In addition, there was only one LW, which limited the number of clients that could be seen. Because of how new the program is, there are still plenty of steps that have yet to be evaluated and improved for future. For instance, the referral and encounter forms have not yet been evaluated; as well, a home visit protocol has yet to be established.
Next steps
Although the pilot is still ongoing, plans have already been made to continue and expand the program. Our team has received substantial new funding from a generous donor to continue this work into the future. Future goals include expanding the referral process such that clients who are not currently seen by the SMHAFHT can benefit from program resources.
Conclusion
The innovative SEED Program at the SMHAFHT has expanded the capacity of the primary care team to address social determinants of health experienced by older adults living in downtown Toronto. We believe that the process and program described in this manuscript may be helpful to other healthcare organizations looking to venture into social prescribing, particularly to target loneliness among older adults.
Footnotes
Declaration of conflicting interests
The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Team Primary Care was supported by Employment and Social Development Canada through a grant to the Foundation for Advancing Family Medicine, co-lead by the College of Family Physicians of Canada and the Canadian Health Workforce Network.
Ethical approval
Institutional Review Board approval was not required.
