Insights (Essays)

Insights (Essays) October 2019

OHTs and Social Prescribing

Gary Bloch


The development of Ontario Health Teams (OHTs) presents a significant opportunity for health system leaders and providers to reconsider not just how we deliver patient care but also how we care for communities. Community governance and integration, and interprofessional teams, make OHTs the perfect venue to rethink what health and wellness means for communities. As teams around the province self-organize, the opportunity exists for us to expand care to include community and social services. A meaningful first step is considering social prescribing.

According to the Kings Fund, social prescribing enables primary care providers to refer people to local, non-clinical services including community and social services. Social prescribing moves beyond recognizing the importance of social determinants of health to enabling providers to help patients by linking them to resources aimed at addressing major health risk factors such as poverty and housing. Social prescribing is adaptable and varies across communities based on the local resources and services available. The U.K. has seen promising results from social prescribing including improved patient outcomes, provider satisfaction and community wellness. While there are examples of social prescribing around Ontario, including in some community health centres and in regions such as Guelph, the concept and its application is still relatively new in this province.

One simple starting point for social prescribing in OHTs is the Centre for Effective Practice’s tool – Poverty A Clinical Tool for Primary Care Providers. In Ontario, over 10% of individuals live in poverty. Primary care providers are well situated to act as an entry point to social service supports for individuals living in poverty.We know that there is a direct relationship between poverty and health, and primary care providers are often intimately aware of their patients’ social situations. Poverty puts patients at higher risk for most chronic diseases, mental illnesses, and even accidents and trauma. The tool enables primary care providers to screen patients to assess living situations and current benefits and includes links to key government and community resources to support positive interventions.

The tool is designed to be used over a series of visits to:

  • Facilitate consistent poverty screening for all patients using a key question identified as a good predictor of poverty.
  • Consider that new immigrants, those who are racialized, women, Indigenous peoples, children, seniors and LGBTQ+ people are among the groups at highest risk.
  • Understand that otherwise lower risk patients who live in poverty are at higher risk for certain health conditions.
  • Intervene, educate and support patients to access tax and other government benefits, and connect them with resources and services.

The tool has been adapted for each of the provinces, and adapted for Electronic Health Records (EHRs), to ensure resources and services for referral are localized. Pilot testing of the EHR form has shown that approximately 20%of patients screened indicated that they had difficulty making ends meet and received further support from their healthcare providers.

Ultimately, through this work, providers are now more knowledgeable about benefit programs and social services in their community, and patients are better connected to existing services within their community. As a result, patients living in or at risk of poverty have been connected with services that may help them improve their income, housing, education and employment.

Furthermore, the Poverty Tool has also been included in a medical textbook in the United States, a U.K. based book on social interventions, and is being adapted and evaluated in Japan. Some teams, such as the St. Michael’s Hospital Academic Family Health Team, have used the tool as a starting point to develop multi-pronged approaches to social determinants of health into their clinical programming and oversight.

The Poverty Tool’s success demonstrates that action on social determinants of health can be built into the core of clinical care. OHTs provide a unique opportunity for frontline providers to lead the health system in addressing the social factors that pose huge barriers to improving individual and community health. Most important, they provide the opportunity to address the needs of those most vulnerable to the health impacts of adverse social conditions. We can lead by rethinking the care we provide and addressing the biggest risks to the health and wellness of people and communities.

About the Author(s)

Dr. Gary Bloch, Project Investigator, Li Ka Shing Knowledge Institute, and Poverty Tool Clinical Lead, Centre for Effective Practice

Dr. Bloch is a family physician with St. Michael’s Hospital and Inner City Health Associates. He is also a co-founder of the Inner City Health Associates, a group of over 90 physicians working in homeless service settings across the Greater Toronto Area.


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