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Social Prescribing Boot Camp Community Health Connections Conference June 12, 2019

Presenter Disclosure Presenters: Sonia Hsiung, Stephanie Skelding, Meghan Shanahan Thain, Allison Hewitt

Relationships to commercial interests: Grants/Research Support: The Social Prescribing Pilot Project is funded by the Health and Wellbeing Grant from the Ontario Ministry of Health and LongTerm Care. The views expressed in the publication are the views of the Recipient and do not necessarily reflect those of the Province.

Social isolation and loneliness are unhealthy. • 50 per cent greater risk of dying early • Same negative impact on health as smoking 15 cigarettes a day • Twice as deadly as obesity and as big a killer as diabetes • Increases the risk of dementia by 64 times • More likely to be in the top 5% of users of health care services

Enter Rx Community: Social Prescribing in Ontario The Principle: Model of Health and Wellbeing The Tool: An intentional, structured way of connecting people with a range of local, non-clinical services, to address the determinants of health and wellbeing for people accessing primary care. Adaptive to different communities, with core components.

Pilot Locations • Belleville & Quinte West CHC

• Centretown CHC

• CSC Témiskaming

• Gateway CHC

• Guelph CHC • NorWest CHC

• South Georgian Bay CHC • Stonegate CHC

• Country Roads CHC • Rexdale CHC • West Elgin CHC

Model of Social Prescribing

Pilot Evaluation • Impact on Individual

• Increase access to social and community supports • Improve outcomes: health and well-being, greater control, improved experience, reduced social isolation, etc.

• Impact on Provider

• Increase PCP awareness of what is happening in the community and vice versa. • Increase capacity of PCPs & decrease visits to PCP for issues better dealt with by others (right provider, place and time).

• Impact on Systems/Community

• Increase integration between clinical and nonclinical departments. • Increased capacity to provide social and community supports. • Policy transfer, conditions for success and how-to guide

What are we tracking? EMR Data

Key Pieces: 1. 2. 3. 4. 5.

Client Identification Referral(s) Referral Uptake Health Outcomes Client and Provider Experiences

HOW? Surveys

Focus Groups

Rx: Community at West Elgin CHC Stephanie Skelding, Nurse and Systems Navigator


Getting Started • Current System Navigator project lead at WECHC • Administrative tasks August-November 2018 • Process Map, SP intake Assessment form and tracking process/guide developed • Staff Engagement Aug/September + ongoing • UK mentor site visit September (staff and partners) • Identification and tracking of clients began November • Community Resource Booklet creation 10


System Navigator to Link Worker Evolution • System Navigation • Reactive • downstream with some midstream approaches • complex social and medical issues

• Link Worker • • • •

Proactive upstream approach broadened vision requires social inclusion 12

Stories Zara Cooper • 21 years old Female • isolated • Autism Spectrum Disorder

David Beer • 71 Years old Male • Lonely • Brain Injury Cathy Hart • 74 Year old Female • Disconnected • Widow


Rx: Community at Belleville & Quinte West CHC Meghan Shanahan Thain, Social Worker


History of Provider/Staff Engagement to Date • Summer 2018 - Social Prescribing Lead and Director Programs & Services attended training • Summer 2018 - Intro to Social Prescribing in Staff Newsletter • Summer 2018 - Intro to Primary Care Provider (PCP) engagement: Survey - Tracked clients for 1 week; asked to identify if PCP appointment needed for issue? Would any other resource be helpful? Might social activities help? Provider feedback: most clients did need to see PCP, but did identify other staff or organizations who could have substituted ~ early insight; ++ number of complex clients/++issues addressed per appointment • Fall 2018 - Staff Circle assembled (internal staff champions – reps from PC, SW, allied health team, reception, complex case workers) • Winter 2019 - Provider Engagement continued – Reviewed “frequent attenders” data. Each provider got a list of clients in previous year with 10+ visits. Discuss those who might benefit from SP. Result: +++ new referrals to social prescribing • Spring 2019 - working on roles/responsibilities of staff circle for ongoing promotion and spread

Collaborative Practice and Health Champions • Clients invited to be “health champions” (HC) - to gift their time based on those things they are passionate about. Different from traditional volunteer role: limited bureaucracy; informal screening; confidentiality agreement but no position descriptions, reviews, hours tracking, etc. HC’s work alongside staff on what matters to them. Not ‘top down’ or provider centric, but supports the creative, out-the-box thinking of HC.

• 17 active Health Champions – both sites • New HC Programs: Craft Group, Walking Club, Learning to Live Again-Life Beyond Grief (social group for widows), Breakfast and Dinner Clubs, Song Circle • Individual HC contributions: re-organizing the lobby (starting a lending library, putting out games and colouring activities on tables); monitoring/updating their HC whiteboard for upcoming activities; reaching out to community partners; contacting referrals made to SP; providing feedback on client/community need; conducting lobby surveys to gather feedback on client need "I'm comfortable in this kitchen and in this building. When I'm here, I'm part of the family.”


Referrals to Social Prescribing • All staff are encouraged to consider social determinants of health when intersecting with clients and refer to “social prescribing” • GOAL: increase participation of rostered clients in social and wellness programs – either pre-existing or health champion-led (data has shown us that pre-existing programs have >50% participation by non-rostered clients, however concerns continue to be identified re: complexity, challenged to meet needs of clients)

• Clients referred to social prescribing are contacted by a health champion or staff member and invited to attend a program that may reduce social isolation and increase social connections. • Script provided to ensure conversation is client-centered and based on client’s desires • Needs identified by referred clients: participate in a program; participate in becoming a HC themselves • Some referred clients are reluctant. We are reviewing new/better ways to support/engage them


Social Prescribing Referral Pathway Identify client who could benefit from a social or wellness program or other non-clinical service

Send TASK to “Social Prescribing” (resource built in EMR) Inform client that someone will contact them via phone

Add Type of Referral (e.g., internal-social activities; internalphysical activities, etc.) to Services and Language Template (at the bottom)

Add Social Prescribing ENCODES to encounter (see below – e.g.)

A Social Prescribing Identifier added to the client’s chart for tracking and follow-up

Examples of Social Prescribing ENCDODES 5138

Feeling Lonely


Inadequate family supports


Social Isolation


Inadequate social supports


Feeling Old


Feeling down


Health Champions: Transforming the culture at BQWCHC HC Lobby Singers Frank: "I think our music went very well today. Lots of smiles and a relaxed waiting room. Small indicators are important: one fellow never looked at us but he was tapping his foot; one gentleman told us about his dying father in the UK; another told us about his own guitar. When people tell their stories, that’s a large part of healing. I think our format has fallen into sync in a relatively short time. It will continue to morph of course, but we’re off to a good start." Where words fail, music speaks (Hans Christian Andersen)

Charlene: "I felt like we really accomplished exactly what we needed to do today by just playing music and listening to their stories." 19

Health Champion: Giving their time and talents

Hosting ‘Drop In’ at Addictions Clinic

Donated home-made scarf

Sharing crafting talents


Health Champions connecting

“I just love coming to it. Everybody’s got a different story and it’s interesting because you think you’re going through hard times, but they’re just going through it as hard as you.” - Health Champion


Stories, successes and impacts • An NP noticed a "same-day" (urgent or semi-urgent) client spent most of the session discussing his late wife of over a year. NP made referral to SP. Client joined "Learning to Live Again: Life Beyond Grief" (social support group for widows) and is now socializing with group members outside of scheduled group. Primary care appointments since group: 1. Primary care appointments in two months prior to referral: 5

“It was really hard because I wish I would have had a connection in the beginning with somebody, just anybody to talk to me, you know, because you really don’t want to talk to your loved ones because you have so much emotion, eh, so it’s hard.”


Staff successes • PCP at outset:“I still don’t know how this applies to primary care” • PCP <1 yr later: “I can see now that Provider encouragement to participate in a program that may improve someone’s quality of life, can carry influence for clients who are socially isolated” • Providers are having hallway chats about social prescribing, talking to clients about their talents and referring them in greater numbers all the time • More staff becoming involved in HC initiatives.


Sustainability • Organizational commitment to the time/resources of work • Expand responsibilities for promoting/ensuring uptake beyond SP Lead and Staff Circle • Continue to share impacts and success stories – benefits to clients are truly inspiring • If you don’t measure it, you can’t improve it! Evaluate and consider implementing various internal SP measures - QIP, PDSAs, client experience, frequency of PCP visits, provider experience, utilization of primary care

• Create internal processes to support the energy and autonomy of HC


Rx: Community at Centretown CHC Allison Hewitt, RN, Primary Care Outreach to Seniors 25

My background and how I came to social prescribingâ&#x20AC;¦


Defining resilience The American Psychological Association defines resilience as â&#x20AC;&#x153;the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stressâ&#x20AC;?

American Psychology Association (n.d.). The road to resilience. Retrieved 05 31 2019 from American Psychological Association. https://www.apa.org/helpcenter/road-resilience.

Resilience is an adaptive process Resilience

SelfEfficacy Physical Health

Social Support McClain, J., Gullatt, K., Lee, C. (2018). Resilience & Protective Factors in Older Adults. Dominican University of California. Masters Theses and Capstone Projects, page 40.

Quotes and stories from Centretown CHC “I enjoy getting thoughts out, I enjoy getting feedback, I enjoy the comradery, the families that we seem to be making and friends and, that’s so important to me” “When you have an injury, people tend to focus on your physical aspect, but there’s also a mental aspect. With this kind of social gatherings... you put your mental back with our physical and rebalance things.” “Its empowering, and gives you some hope and some tools, to do that for yourself, which is really rewarding and that builds self esteem in itself, and it builds self trust as well.” “It’s not just unpacking stress, it’s the friendships there that I’ve seen, the community, the laughter.”

How clients are identified • Having longstanding relationships with clients. Having an understanding of their vision of health. Offering options and putting them in the driver’s seat. • Using information my senses give me when seeing client at the clinic our in their home. • Self report.

Growing Edges • Time constraints for (RN’s, OT, PT, MD, Nurse practitioners) that hinge upon college standards which must be met. • Competing priorities

• Access is a big issue for frail, isolated seniors. • Strengthen the follow-up support and feedback loop: what happens after a client is referred?


Partnership and Sustainability


Social Prescribing resonates widely! • Partnerships • Arts & culture • Environment • Community organizations

• Ontario Health Teams • National interest • What does sustainability and scaling look like?


Thank You Visit our website https://www.allianceon.org/Rx-Community-SocialPrescribing Introductory video on social prescribing https://youtu.be/VTYT2XTEquc

Contact: Sonia Hsiung, Social Prescribing Pilot Lead Sonia.Hsiung@allianceon.org

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