What makes Social Prescribing Unique?

Photo by John Cameron on Unsplash

What if doctors prescribed not just pills, but also nature walks, a knitting group, or volunteering? This practice is called “Social Prescribing”.

If you are unfamiliar with Social Prescribing, watch this 2 minute video to get an overview:

A Social Prescribing “Community Link Worker” connects patients to the local community activities. Link Workers shares qualities common with US health worker roles (community health workers, health coaches, patient navigators).

Their similarities:

• Both make referrals to social services
• Both are (ideally) from the local community and culture: many of these workers have grown up in the same neighborhoods as their patients. Many face the same lifestyle challenges and illnesses as their patients.
• Both grow patient agency: they often begin a conversation with a patient by asking, “What is most important to you?” This framing empowers patients to achieve their own goals, rather than belabor the need to change a bad behavior or simply fill a lack of resources. This is an “asset based” approach. It grows what is good, rather than seek to change what is bad.

The role of today’s community health worker, however, must evolve. Technology platforms, such as Unite Us and NowPow, are displacing the need for expertise on social service qualification and navigation. These prescriptions can now be automated.

I believe the next iteration of Community Health Worker will encompass the responsibilities of the UK’s “Community Link Worker” role.

The Link Worker’s role is distinct from a Community Health Worker’s role in a few ways:

1. Micro networks of support

Prescribing social relationships is a unique aspect of SP. This might involve prescriptions to local volunteer opportunities, or social groups that venture into nature or create art together. The Link Worker collects a master list of these local outlets that are both public (i.e. a “meet up” posted online) and private (i.e. a group of neighbors who informally meet at a neighbor’s house to plays cards on Sundays). Link workers are members of the local culture and form light relationships with these groups to broker communities access for patients.

Small social groups can reinforce healthy habits more powerfully than isolated attempts. I, for instance, will be 10 times more likely to develop an exercise habit if my friend drags me to the gym every morning and I’m met with smiling faces, warm support, and positive reinforcement. As Dr. Paul Uhlig says, “Culture is the health intervention”. This support can foster confidence and a sense of security that affects all areas of one’s life.

The group activities themselves can promote health too — there’s growing evidence on the health creating power of arts, volunteering, and nature exposure. All prescriptions are tailored to the lifestyle, preferences, and interest of patients. They are all custom-matched suggestions — none are forced.

Social connection is also an increasingly important outright category of health. The health impacts of loneliness are as lethal as smoking 15 cigarettes a day or obesity, and have been a noted driving force behind the opioid epidemic and rise in deaths of despair. Socially isolation costs Medicare and additional $6.7 billion annually. Research shows that our own behaviors are tightly correlated with those in our surrounding social network; anybody’s step towards health or altruism will likely increase similar behavior within their network.

2. Interplay of Social Service and Social Relationship Needs:

At a glance, a doctor’s highest priority should be to help patients meet the base of Maslow’s Hierarchy of Needs (housing, food, etc) before addressing higher level needs (relationships, belonging, etc). That may not not always be the case. Social relationships can be an avenue to better address baseline needs. Here are some examples:

• A woman cooks food for her friend after hearing he is struggling financially. Over dinner, they identify two other ways she can support him.
• One family drives all 8 neighborhood kids to school in a big van, while other parents have extra time to earn money and destress.
• A formerly incarcerated man is drinking excessively because he is constantly discriminated against and ostracized. Though he has enough basic resources, the social rejection has badly damaged his mental health.
• In a rehousing initiative in Boston, people experiencing homelessness were given living arrangements in a housing complex. Despite this gain, many relapsed on drugs because they were distant from their social support networks and way of life.

Our relational and baseline needs are more intertwined than one might expect. We need to address both in tandem. Still, the pursuit of true health equity will also require broader policy changes.

3. Relationship Capacity Building

Depression and loneliness often make people more reclusive and reticent to seek the support they need. Link Workers help patients overcome these emotional hurdles and break the downward cycle. They coach patients, helping them build confidence to engage. Link Workers also can support async before and after events, and sometimes even usher group of patients to gatherings. These dynamics are fundamentally different from social service prescriptions which increasingly tend to be transactional (and even favored as so, according to some RCTs)

Some patients are so deeply impacted by social prescribing that they volunteer to be Link Workers themselves, or create their own social groups. Health systems can bolster these efforts by giving small grants to patients to lead community benefiting initiatives. On a policy level, the UK’s ministry of loneliness issued £11.5 million to fund 120 initiatives working on projects to strengthen community ties.

4. Society Wide Benefits

A social service prescription often only benefits the recipient. Conversely, community-related social prescriptions have a “virality,” with one prescription often affecting multiple people. For example:

• An unemployed patient got access to job training services, eventually lifting their family out of poverty.
• An affluent patient volunteered at their neighborhood civic organization, working on projects to benefit his community. 100 people now benefit from the refurbished public park.
• An newly retired woman worked with a Link Worker to identify what matters to her. She now volunteers in an arts class at a pre school. She benefits from a greater sense of purpose (which is evidenced to improve health) and the children have more loving relationships in their life.
• A retired banker reconnects to her sense of altruism by doing pro bono financial consulting work for a local Goodwill chapter. The chapter is now able to invest in staff training, and the banker benefits from the health impacts of volunteerism.

This weaving of relationships can bridge social divides and restore America’s sense of collective kindness. Social Prescribing is therefore of interest to politicians, publics health officials, and the social and volunteer sector alike.

5. Rich feedback loop with partners

Link Workers maintain an ever growing list of partners. Sometimes they collaborate with partners to strengthen each other’s practices and exchange data. Social Prescribing can therefore help all collaborating organizations better achieve their goals.

6. Supporting health equity

To support systems change, social prescribing programs should be coupled with screening for social needs including food and housing insecurity. This new data can help policy makers better allocate resources and ensure that funding for new social prescribing programs is prioritized for populations with the greatest needs.

7. End goal: change our default culture of health

This scaled offering can change how our culture thinks about health. People will proactively see new “cures” to their emotional woes. Their new “medication” will be community, altruistic care, purposeful activity, connection and resources outside the clinic. They will look back and think, “I can’t believe that in the 1900s our concepts of health ended at nutrition, exercise, hygiene, and stress.”

This cultural shift begins with structural change. We need to not just solve the downstream problems of illness. We need to create upstream solutions to prevent illness from even happening. Social Prescribing is one of the best structural way to scale health promotion and address social determinants of health nationwide.

The end game is reimbursement for Social Prescriptions from managed care organizations and Medicare. It took Dean Ornish 16 years for Medicare and Medicaid to reimburse his revolutionary program to reverse heart disease through lifestyle changes. We are in a similar fight to empower the upstream causes of health in our country. And our country is in desperate need.

Today, 18% of the US GDP is spent on healthcare, nearly double the percent of the UK and Canada. Imagine if one percent of that spending went to reimburse Social Prescribing. Just 1%! Imagine all the society wide benefits. Imagine all the costs saved. Imagine all the aching hearts healed. Imagine the social divides bridged. Imagine the hope created.

Thank you Rebecca Goldman for the edits.

Additional Readings: Here is the UK’s NHS’s guide to Link Workers, my Link Worker Job Description, CHW techniques and a fantastic summary of Penn’s leading CHW program. Here are my previous posts on why relationships are the future of healthcare and tech for social prescribing in the US.