It takes a village: Implementing Social Prescription during the Covid-19 pandemic
Background
While many faced loss of life during the COVID-19 pandemic, many more faced loss of livelihood and wellbeing (1). We know that socio-economic factors play a larger role in creating (or damaging) health than biological factors, accounting for 50% of health outcomes, and driving a huge proportion of annual Canadian healthcare budget (2). This was amplified during the pandemic, where a so-called ‘equal opportunity virus’ had vastly differently impact depending on who you were and where you lived.
Whistler, BC, is an all-season mountain resort that received visitors throughout the pandemic resulting in the regular importation of SARS-CoV2 and variants into the community. The community is reliant on a large population of rotating seasonal workers, from all over the world, comprising about 25% of the full-time population (~12,000). With low wages and scarce housing, many live in overcrowded accommodations.
Within this population, Covid was rarely medically serious but had a large impact on wider health and well-being. One seasonal worker testing positive for Covid required the entire household (e.g., 10-20 people in a 4-bedroom apartment) to attempt to self-isolate. Each time another roommate tested positive the quarantine clock was recalibrated.
As community General Practitioners, we observed that many of these young individuals were faced with difficult decisions. Unable to go to work, none received pay, and many stopped eating to preserve savings to pay the rent. Some chose to move into their car to reduce the risk of transmission and the overall quarantine time. These individuals did their best to follow public health rules, but this situation contributed to waves of transmission which had an out-sized impact on them, the community and eventually the entire province.
Before the Covid pandemic, family medicine was struggling as a discipline, with approximately 40% of the population in Whistler without a family physician and most of us under pressure. Like elsewhere, the initial focus of the pandemic response was on acute medical care and hospital resources. However, the fundamental problems in our population were not medical but social.
At the onset of the pandemic in Whistler, a group of Health Care Providers (HCP) established a COVID-19-testing unit and a virtual physician-intake/triage position to minimize in-person visits, and meet demand. It became apparent that while medical issues were straightforward, many were struggling to pay for rent, groceries and lacked a support network. Providing contact information to patients for community-run social services increasingly became a go-to intervention.
To address these gaps in health determinants, leaders in primary care and community services initiated a program to meet the need and to formally refer patients to social programs - an ad hoc experiment in ‘social prescription’had begun.
What is Social Prescription?
The experiment in Whistler joined a growing movement toward social prescribing, a way of intimately linking patients in primary care with sources of support within the community, and providing over-pressured physicians with other care options (3). This type of prescribing encourages physicians to write prescriptions for non-drug interventions, usually community services, that underlie health and well-being, to address the health outcomes driven by social determinants. The concept emerged in Europe in the past decade and was popularized in the UK as part of a national strategy against loneliness (4).
How was the Whistler Social Prescription delivered?
Whistler Community Services Society (WCSS) is a non-profit group that has provided a social safety net for more than 30 years. Starting with a food bank, in now offers over 30 programs. It is largely self-funded through two thrift stores that recycle and monetize on average 33 tons per month, as well as grant and philanthropic support.
During the fall of 2020, a partnership developed between the Whistler Medical Clinic and WCSS. Starting with an initial text to anyone seeking a COVID-19 test, it provided links to community resources.
The team established programs that arose from COVID-19 specific issues. Recognizing food scarcity, crowded housing and movement restriction for many, an enhanced food delivery service was developed, along with other deliverables. An Electronic Communication Program assisted those with barriers to accessing communication and information - for instance, by loaning tablets and laptops. A Temporary Isolation Housing Program was established using vacant properties.
What were the limitations of the Social Prescribing Program?
What became apparent with the rapid rollout of the program was the gaps in access to other services in a timely manner. The housing project took several months to become operational, allowing for continued spread. While there was quicker and effective support for low to moderate mental health symptoms, those with more severe disease or active addiction faced increased wait times to access higher level of care. There were no local crisis stabilization teams, including substance use rehabilitation beds, leaving patients in crisis with no imminent treatment. Likewise, there was no local crisis housing for clients suffering domestic violence.
What is the evidence so far?
Emerging evidence shows social prescribing may increase uptake of available services and provide free or low cost interventions that may improve mental health, general health and function while reducing burden on primary care, mental health and ED burden (3).
In our case, program uptake mirrored the mandated economic slowdowns and epidemiologic curves of COVID-19 in Whistler with economic and emotional hardship the top two reasons for visits. In a 4-week period during the 2nd wave(mid Jan 2021), WCSS food security programs served food and delivered hygiene kits over 800 times with the majorityreceiving their referral via a prescription/from our program.
Qualitative evidence of benefit was documented by direct comments. Patients/clients referred via social prescription reported feeling supported, connected, taken care of validated. For some, the reduced stigma of having a prescriptionremoved a critical barrier. Clinicians and staff involved with administering the program reported meaning from being part of a high functioning team and of being able to address key determinants of health efficiently and at a low cost.Some clinicians/staff described their involvement as “energizing” at a time when demands were high.
Conclusion
The COVID-19 pandemic highlighted social inequalities and changed the landscape of primary care - recovery will likely take years (5). Through social prescription, collaborations between health care teams, community social services, local governments and non-profit organizations will last beyond the pandemic. An opportunity exists to leverage these relationships, and to formally evaluate programs. Social Prescribing offers a pathway to optimize access to limited resources and ensure a peaceful and efficient recovery from COVID-19 is possible.
Charles Ratzlaff is in the Faculty of Medicine, University of British Columbia, Vancouver,
British Columbia
Marcia Clark is at the Cumming School of Medicine, University of Calgary, Calgary,
Alberta,
Jackie Dickinson is at the Whistler Community Services Society, Whistler, BC
Karin Kausky is at the Whistler 360 Health Care Collaborative, Whistler, BC
References
1. Dragi M. We face a war against coronavirus and must mobilise accordingly. Financial Times. 2020.
2. CMAJ. Health equity and the social determinants of health: A role for the medical profession Canadian Medical Association Journal; 2013.
3. Bickerdike L, Booth A, Wilson PM, Farley K, Wright K. Social prescribing: less rhetoric and more reality. A systematic review of the evidence. BMJ open. 2017;7(4):e013384.
4. Mercer C. Primary care providers exploring value of "social prescriptions" for patients. Cmaj. 2018;190(49):E1463-e4.
5. Jani A. Preparing for COVID-19's aftermath: simple steps to address social determinants of health. J R Soc Med. 2020;113(6):205-7.
