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Making connections saves lives: social prescribing linking older adults to their communities

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Making connections saves lives: social prescribing linking older adults to their communities

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Content 1
MAKING CONNECTIONS SAVES LIVES: SOCIAL PRESCRIBING
LINKING OLDER ADULTS TO THEIR COMMUNITIES
Capstone Project Paper and Prototype
Jami Goldman
University of Southern California Suzanne Dworek-Peck School of Social Work
DSW Program
Dr. Harry Hunter
December 2023

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TABLE OF CONTENTS
I. Acknowledgements
II. Executive Summary
III. Abstract
IV. Positionality Statement
V. Problem of Practice and Solution Landscape
VI. Conceptual/Theoretical Framework
VII. Project Description
VIII. Methodology
IX. Implementation Plan
X. Conclusions and Implications
XI. References
XII. Appendices

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Acknowledgments
First, I wish to thank my Capstone course professor, Dr. Harry Hunter, for his support,
encouragement, and motivation during the last few semesters and throughout my graduate
program. As one of the first professors I had at the beginning of the DSW program, it was his
questions, recommendations, and insight that allowed me to learn and grow throughout the
program and were the reason I chose him to be the professor to help guide me through the final
three semesters in my DSW journey. His guidance helped me become a better researcher and
writer. It exposed me to new social work theories that provided additional ways to think about
bringing about positive change in the field.
I chose Professor Rick Newmyer as my internal design partner based on having him for
the three finance and data-driven courses during the DSW program. Because of Mr. Newmyer’s
social work and business background, his analytical thought processes helped me question, think,
and develop accurate and informative ways to present my intervention beyond social work to
educate diverse stakeholders about the importance of reducing social isolation on multiple levels.
I appreciate and thank him for allowing me to share and discuss ideas out loud, helping me
formulate better communication methods, and sharing my thoughts and program components
through the implementation manual created.
Through my research and exploration of how to better help older adults and reduce social
isolation, I met Delia Beck. I am incredibly grateful that Ms. Beck agreed to serve as my external
design partner, as she brought specific knowledge and experience regarding social prescribing to
help further expand the ideas, philosophy, importance, and positive results that come from
building relationships and promoting social connections that can make a difference in a person’s
life. Her questions and ideas prompted me to think about how I want to help people and bring

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others into the mix to share the person-centered approach to building a model that provides
support, encouragement, and resources to communities through healthcare opportunities.
By doing this, Ms. Beck introduced me to Dr. Alan Siegel in California, for which I am
grateful because I will get to test my prototype in a healthcare system with others who believe in
the social prescribing method of helping others improve their lives. I look forward to working
with Dr. Siegel and Ms. Beck and introducing my Social Prescribing Implementation Manual.
Thank you to all of the professors I have had throughout the DSW program for your
experiences, knowledge, and guidance. All of these helped me reach the final stage of this
fantastic program and this personal and professional journey. Also, thank you to my colleagues in
the DSW program for your questions, ideas, conversations, and one-on-one support that provided
continuous momentum to get through the program. It is greatly appreciated.
Continuing my education and pursuing master’s degrees, and now a doctorate, I think
about how proud my father, Bernard Goldman, would be of this accomplishment. I dedicate this
degree to his memory. His love is with me every day.
Executive Summary
Defining Social Isolation
Social isolation is not an issue in and of itself; it is essential to note that other components
impact a person’s life: loneliness and social connections. Most literature provides definitions of
social isolation and loneliness since the terms are often used interchangeably in research, but
they are two distinct concepts (Landeiro et al., 2017). Social isolation is an objective situation
demonstrated by few or infrequent social contacts, while loneliness is a subjective and disturbing
feeling of social isolation (Holt-Lunstad, 2020). Social isolation is situational, where feelings of
loneliness can develop from being socially isolated, and loneliness can result from social

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isolation. Donovan and Blazer (2020) state that the benefits, quality, and quantity people gain
from having social relationships and interactions (connections) with others are part of looking at
social isolation. In 1992, Berg and Cassells used the term social support, but now the term is
social connections. They are the same concept and are highly relevant to people.
Scope of the Problem
According to Frueh (2022), before the COVID-19 pandemic, approximately one-quarter
of people over 65 were socially isolated, with more than 40% over 60 reported feeling lonely.
Those with health issues are at an increased risk of other diseases and disabilities due to social
isolation (Berg & Cassells, 1992). This, unfortunately, has not changed in thirty years, and
current literature states the same fate. Due to the pandemic, social isolation and loneliness have
increased among people, especially older adults, and social connections have decreased,
compounding these issues.
People today live longer, which has increased research on social isolation, loneliness, and
social connections regarding older adults. Persons over 65 are the fastest-growing population in
the United States and are expected to double by 2050, less than 30 years away (Ungar et al.,
2022). Survey results from Unger et al. (2022) showed that loneliness among older adults over
the last few years of isolating themselves increased the severity and number of lonely people.
Before COVID-19, social isolation and loneliness were significant issues, but soon became an
epidemic with unique and devastating impacts on people. It has intensified for those who already
suffered before the pandemic.
Fakoya et al. (2020) stated that older adults are at a higher risk for social isolation,
loneliness, and lack of social connections due to decreased mobility, reduced income, poor

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health, and reduced family and friend interactions. Social isolation impacts everyone and
significantly strains health and mental health issues.
Noted in Understanding the Effects of Social Isolation on Mental Health (2020), social
isolation can increase anxiety and fear, the same for older adults as those from excluded,
disadvantaged, vulnerable, and marginalized groups. The Michigan State Advisory Council on
Aging (2020) identified obstacles that can isolate older adults, including minimal or no access to
transportation, limited or no access to broadband service, a computer, smartphone, or other
technology to stay in contact with others, as well as reduced access to healthcare, food,
volunteering, or mental healthcare.
Grand Challenge of Social Work: Social Isolation
One of the thirteen grand challenges of social work is eradicating social isolation, and
one of the most vulnerable and isolated groups of people is those aged 65 and older. Social
isolation devastates people’s family, friendships, health, mental health, and social structure.
Social isolation and loneliness have detrimental health impacts, including, but not limited to,
being a significant risk factor for increased mortality and all-cause morbidity. According to Berg
and Cassells (1992), social isolation measures a person’s quality of life, noting how important
social connections, meaningful relationships, and availability of resources are necessary for
reducing social isolation and loneliness and increasing social connectedness.
Design Thinking
Design thinking is about including the user's voice, making it a human-centered design.
The first step in design thinking is to empathize with the person you are trying to assist and to
honestly try to comprehend what they are going through before a solution can be developed
(Morgan & Jaspersen, 2022). Creating a solution to an issue or problem is unwise without

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interacting with the person who needs the assistance. Social prescribing is about developing
relationships between a link worker and an older adult to seek ways to improve a person’s life
with their input.
Through the iterative process, the concept of an implementation manual arose. The
manual is an all-inclusive training manual that can be used to train healthcare professionals, a
specific market at this time, on the entire social prescribing method, including the use of a link
worker, assessment tools, the pathway to assist older adult patients, identifying community
resources, and putting it to use in a healthcare setting.
Theory of Change and Impact on Population
Social prescribing through assistance with a link worker in a healthcare setting provides
recommendations and engagement of older adults to community and other resources,
prescriptions that can help improve social inclusion, mental well-being, physical activity, and
self-management of health (Bhatti et al., 2021). A patient would be referred to a link worker
through their primary care or other healthcare provider; working together, they will assess and
identify specific activities and resources that can help reduce isolation, loneliness, and social
disconnect. The use of self-determination theory as one for change can be applied and follows
the pathway set forth by the theoretical frameworks, self-determination, social cure, and
ecological systems previously mentioned.
Self-determination theory includes three psychological components to help with
motivation, well-being, vitality, and life satisfaction, which are autonomy (actions that come
from the self and reflect who that person truly is), competence (a sense of being able to create the
results desired in life, and mastery of this accomplished through activities), and relatedness (how
connected one feels to others in their relationships and within their community) (Martela &

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Riekki, 2018).
Proposed Solution
Social prescribing is a way to tackle loneliness and social isolation by promoting
connections with others through a non-medical, person-centered prescription that involves
referrals to or locating a link worker or community care coordinator that will address emotional,
practical, and social needs to help older adults (Bhatti et al., 2021; Kellezi et al., 2019). Key
objectives of the link worker include building and maintaining ongoing relationships with older
adults, connecting older adults to social activities, educating and introducing them to needed
community resources, and introducing them to one-on-one or group therapeutic services as
identified.
Social prescribing introduces multiple activities and resources that are beneficial to
socially isolated older adults, including but not limited to arts and crafts classes, dance and
exercise classes, financial resources, food and nutrition services, housing referrals, volunteer
opportunities, transportation resources, and walking groups. Razai et al. (2020) recommended
social prescribing because using non-medical interventions, including engaging in the arts,
exercise classes, choir singing, painting classes, or other community activities, will improve the
health and well-being of participants and make use of community resources. These interventions
can be done in person or via technology, providing numerous activities for people to spend time
with others and socially connect.
The creation of the Social Prescribing Implementation Manual is a way to bring training,
education, and how to employ this prescription method into the healthcare system and to older
adults to improve their physical and mental health and well-being through person-centered care
and support.

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Professional Significance
The Social Prescribing Implementation Manual was developed to provide education,
information, tools, and resources to train healthcare and other professionals on implementing
social prescribing in their systems. Many factors, including respect and embracing the patient’s
input in determining what interventions they think, will be beneficial, creating an educational
tool and support for healthcare professionals to implement personalized non-medical care to
reduce unnecessary visits to a doctor and still improve overall health and well-being, and having
an access point that brings multiple resources, community programs, services, and people
together led to looking at the following theoretical frameworks.
Implementation and Challenges
The Social Prescribing Implementation Manual is a training tool a social worker will use
to educate healthcare professionals and, in the future, other service industries on creating and
implementing a social prescribing program in their offices. It also is a tool to educate those
outside of a healthcare system on how to refer, incorporate programs and activities, and
coordinate efforts with healthcare offices through a link worker as a method for helping older
adults.
In-person or Zoom training will include sharing the manual, providing exhibits and actual
situations that describe how to implement social prescribing, discussing the positive outcomes,
how community, state, federal, and city agency programs and services should be included in
service provision and support, and how the link worker is the liaison between the medical
professionals, community and other resources, and the older adult. The link worker is also
getting to know and providing support and guidance to the older adult.

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The costs associated with implementation include bringing the consultant/trainer in to
conduct trainings in healthcare settings and other collaborating organizations that provide the
resources, programs, and activities necessary for social prescribing services for older adults. The
cost is also associated with hiring a link worker or reallocating staff to implement social
prescribing within the healthcare setting. Also included will be marketing, education, and
engaging with multiple stakeholders to show how successful this non-medical prescription
method can be in reducing social isolation, loneliness, and social disconnect. Suppose it appears
that there is pushback after the proposed marketing techniques described in the paper are
implemented. In that case, the consultant can make the manual available in more cost-effective
ways to get the program into healthcare settings because the belief in this method as a “cure” is
so strong. The goal is to associate social prescribing with the manual as a cost-saving measure
worth implementing.
Abstract
Social isolation is one of the most detrimental health challenges our country and world
face today. People aged sixty-five years and older are the fastest-growing demographic and will
become one-third of the entire population in less than thirty years. Social isolation can impact
any person, no matter their ethnic, cultural, racial, religious, sexual orientation, living situation,
income, or any other characteristic a person may possess. To help combat this devastating mental
and physical health challenge, social prescribing is a solution gaining recognition to connect
people with other individuals, activities, resources, and programs on an ongoing, personcentered, self-determination. Social prescribing is a preventative and non-reactive intervention to
help improve the health and well-being of older adults.
Unlike countries where a National Health Service pays for healthcare and implements

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social prescribing as such, the United States does not systematically implement healthcare.
Therefore, social prescribing will be introduced through primary care physician offices by a
licensed social worker, who will train all healthcare staff using a Social Prescribing
Implementation Manual. This manual includes all necessary education, information, and tools for
implementing a social prescribing service through their offices with dedicated and trained staff
members. Social prescribing provides collaboration among healthcare professionals, local area
agencies on aging, senior and community centers, other service providers, and stakeholders to
promote social, educational, and supportive personalized activities for older adults through nonmedical approaches to reduce loneliness and social isolation and increase interactions to improve
their quality of life, health, and well-being.
Positionality Statement
I am a second-generation American-born woman whose family immigrated from Russia
around World War I. My family was of Conservative Jewish ancestry, but during my youth, the
family identified as Reform Jews. I am not religious and do not consider religion essential to my
life, but I respect and understand that faith is meaningful and relevant to others.
While my father earned a good living and we lived in a predominantly white, middleclass neighborhood, my individual experiences were less than ideal. As the youngest of four
children and the only child who lived at home when her parents divorced as a teenager, this was
a tough time. Moreover, I often felt lonely and isolated, having few friends and not fitting in well
at school. My high school included students from various ethnic, economic, racial, and religious
backgrounds, representing fifty-two nationalities at graduation. Others might see me as
privileged due to my upbringing; however, outward appearances can be deceiving.
In my adult years, while caring for my parents during terminal illnesses, I experienced

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disgraceful, hurtful, and significant financial loss and emotional distress due to other family
members’ actions. I experienced social isolation, loneliness, and social disconnect. I processed
the mental health challenges through therapy, worked hard to accept the decisions others made,
maintained a positive outlook, and realized that unhappiness in others does and will not impact
how I live my life going forward. From my childhood, college, working, traveling, and
adulthood experiences, both good and bad, there is always room for growth, change, and making
a positive difference in the life of another.
Furthering my education and taking on the grand challenge of social isolation, I can take
my personal and professional experiences and put them to work to help older adults. I plan to do
so through social prescribing. Social prescribing is a way to reduce social isolation and
loneliness and improve social connections for people from all demographic backgrounds. It helps
to build more supportive and engaging communities.
Problem of Practice and Solution Landscape
Statement of the Problem
Eradicating social isolation is one of the thirteen grand challenges of social work. Social
isolation is a potent killer, and there is significant evidence that even more people today are
socially isolated and feel lonely (Lubben et al., 2015). When social restrictions and stay-at-home
advisories were mandated due to the COVID-19 pandemic, it brought this devastating health and
mental health societal issue to the foreground, making it something that cannot be ignored any
longer.
Wilkerson (2021) stated that the increase in social isolation is not an individual problem
or a personal choice but a significant issue rooted in community design, systematic injustices,
and social norms. The National Academies of Sciences, Engineering, and Medicine (2020)

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highlighted that social isolation, especially in older adults, could lead to loneliness, increased
rates of anxiety, depression, and suicide, premature death from multiple causes, a 60% increase
in hospitalization, a 50% increase in developing a form of dementia, increase risk of stroke, and
an abundance of emergency room visits that could otherwise be avoided. Social isolation's
negative impact on a person’s health resembles smoking 15 cigarettes daily, obesity, not
exercising, and high blood pressure (Buffel et al., 2015; Smith et al., 2021).
Social factors, including healthy nutrition, safe housing, access to healthcare and social
service resources, income, volunteer opportunities, education, mental health services, fresh
water, jobs, and engagement with others, influence 60-70% of the health and well-being of an
individual (The Michigan State Advisory Council on Aging, 2020).
According to Holt-Lunstad (2020), there has been little research conducted on social
isolation and the impact it can have on at-risk, ethnically diverse, racial, underserved, people
with disabilities and those who identify as bisexual, gay, lesbian, transgender, or queer
(LGBTQ+) populations. It is not the first time these populations have been overlooked regarding
social issues and their impacts when they are often at greater risk for mental, physical, and social
problems due to social isolation. Older adults also fall into this category, an overlooked
population regarding social isolation, loneliness, and social connections. Much of the literature
mentioned the need to look at equity, diversity, and inclusion of diverse populations, those
suffering most from social isolation, loneliness, and lack of connections with others.
When the COVID-19 pandemic began, stay-at-home mandates were put into place;
people were told to isolate themselves and keep a specific distance from others, keeping older
adults from being with friends and family or engaging with outside visitors (Verbeek et al., 2020;
Wu, 2020). For older adults who reside in nursing care, assisted living, or other adult

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communities, social connections disappeared for over a year and continue in many places or for
many people. People residing in these communities may already have had limited or no
interaction with family or friends. Older adults' social connections and engagements with family,
friends, and even healthcare providers, whether living independently, in a care facility, or a
community, ended abruptly or were severely reduced, taking away the necessary means to stay
engaged with others. Also, internal activities were canceled, so residents were not permitted to
socialize or spend time with other residents or caregivers as previously done (Paananen et al.,
2021). According to Hwang et al. (2020), the impact of disconnected older adults further
increased feelings of loneliness, depression, and other adverse effects on health-related issues,
including premature death.
Even those living alone were even more isolated due to fearing getting ill due to COVID19, and with the pandemic regulations and remaining isolated, older adults avoided spending
time with friends, family, and potential caregivers who would check in regularly (Wu, 2020). The
pandemic also affected older adults who care for or are friends with other older adults, creating a
domino effect of loneliness, social isolation, and lack of social connections.
Another significant issue was that many older adults are caregivers for their parents (as
people live longer) and suffered incredibly from the pandemic (Wu, 2020). Being unable to
engage with others, staying home, and not having respite or support puts additional strain and
isolating impacts on the adult caregivers, those who also want and need to feel socially
connected.
Stakeholder Understanding
Everyone has a stake in reducing social isolation because it is something we all face as
we age. Reviewing hundreds of articles, reading through books, and seeking information online

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led to numerous information on the extreme detriments caused by social isolation, loneliness,
and social disconnect. However, there was no mention of stakeholders other than the need for
healthcare professionals and policy-makers to make changes to help solve the problem. Not
much is being done, but it can and needs to change.
The National Institute for Aging (NIA) in the United States is aware that social isolation
is a severe issue, and available on their website is a tool kit with information, videos,
infographics, links to social media sites, and articles to read about social isolation, depression,
and loneliness. The challenge is that not all older adults have access to Internet access, a
computer, or a smart device to access these tools. Also, all of the information is online and does
not include personal engagement with others, and the information is tailor-made and not
individualized.
The National Council on Aging (NCOA) website is similar to the NIA, with resources for
individuals and professionals. Further research led to finding local affiliates with scheduled
meetings in various locations across states. Promotion of these meetings and other activities is
limited, and again, while many people are online, there are still quite a few who are not,
including vulnerable, marginalized, and often left-out populations. The NCOA, like the NIA, can
provide more significant assistance to older adults by being trained and educated on social
prescribing and becoming an active part of the solution.
Solution Landscape
COVID-19 created a unique and devastating impact on people and intensified social
isolation far beyond what it had been. Not much was done to combat social isolation until the
COVID-19 pandemic isolated everyone. Still, even before the pandemic, one of the most
significant issues exacerbating social isolation and any attempts at fixing this problem is that we

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do not treat each other with equity, respect, dignity, and inclusion overall. Much research is on
older adults and social isolation, but there is limited research on diverse or marginalized
populations and social isolation (including older adults within those populations). One common
theme mentioned throughout the study and, again, created a widespread acknowledgment
because of the pandemic is the need for people to feel and be socially connected with others
(Donovan & Blazer, 2020). This need continues beyond COVID, as it existed before the
pandemic, and remains a challenge to address.
There is a great deal in the literature about the importance of people having social
connections because those isolated have limited or non-existent social interactions. Two
interventions Fakoya et al. (2020) identified that can help reduce social isolation and loneliness
are one-on-one or group-based therapies. The use of one-on-one interventions can provide
emotional support to individuals, while group interventions provide social support through group
activities (Fakoya et al., 2020).
One-on-one and group interventions tend to be more therapeutic in style, helping people
to gain strategies and coping mechanisms while receiving mental health support geared at
helping to reduce symptoms of social isolation, loneliness, and social disconnectedness and
reduce the negative psychological and physical health risk factors for those who participate
(Landeiro et al., 2016). Counseling in person or via technology is helpful, as it provides muchneeded interaction, education, and support for those who are isolated, have reduced access to
transportation, or have other challenges but can still get assistance to help reduce anxiety and
depression associated with social isolation. Providing one-on-one or group interventions in
counseling, computer training, educational courses, exercise classes, playing games, art classes,
discussion groups, companionship, and visiting volunteers are immensely helpful. They can be

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introduced at home, community centers, or residential facilities (Landeiro et al., 2020). Of
course, these interventions can also be created for diverse populations, families, communities,
etc., to meet individual needs.
Therapists and practitioners use, encourage, and believe in CBT because it focuses on
changing maladaptive thoughts and feelings that socially isolated and lonely older adults need to
improve their feelings of self-worth. CBT empowers the person and challenges negative
thoughts, including what others may think, and provides personalized cognitive messaging
shown to last over time, decreasing loneliness and increasing social connections.
For people hospitalized for heart-related issues, using cognitive-behavioral therapy shows
promise in reducing the negative impact social isolation has on a person’s health, including
lowering mortality rates (Holt-Lunstad, 2020). Cognitive-behavioral therapy helps older adults
challenge their thoughts and feelings and change negative cognitions with positive ones to
encourage positive messaging and reduce psychological distress (Jarvis et al., 2019; Gorenko et
al., 2021).
In a study by Santini et al. (2020), self-reporting loneliness and social isolation scales
were used in a sample of over three thousand participants to establish correlations with social
disconnectedness, perceived isolation, and depression symptoms. Results indicated significant
connections among the factors and their effects on mental and physical health. Santini et al.
(2020) identified one intervention, Act-Belong-Commit (ABC), being used at universities as a
potential solution to social isolation, disconnectedness, and loneliness. This intervention and
those noted in other research articles are not part of any mainstream effort to combat social
isolation and the populations impacted.

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On the heels of the pandemic, there was a move to technology-based interactions since
social distancing and isolation recommendations became the norm for everyone, not just those
who previously were socially isolated due to other reasons. More specific to the aging
population, as expressed by Dassieu and Sourial (2021), the development of more online and
telephone-based interventions to address health and social support needs.
Dick (2021) introduced the concept of augmented and virtual reality (AR/VR)
technologies as a method to promote equity and inclusion by leveraging its potential as a tool for
encouraging empathy, easing barriers occurring from physical distance to strengthen
communities and enhance one-on-one interactions, and adapting its capabilities to address the
needs of people with disabilities. The idea is that using AR/VR can put people into situations that
allow users to feel as though they are genuinely in the environment and can experience what
others think. While not a solution to reduce social isolation, this technology can provide
individuals with experiences that marginalized, diverse, and disabled people go through in a
virtual environment, which is copying reality for those populations. AR/VR technology aims to
provide people with an empathy-driven experience that could lead to more equitable, inclusive,
accessible interventions and engaging employment and community surroundings (Dick, 2021).
While Buffel et al. (2015) recommended the use of Community Navigators to conduct
face-to-face visits to more frail older adults to discuss and identify needed social, emotional, and
practical support needs, these concepts can be used in multiple settings, including those in more
rural, diverse, or communities with limited access to technology or transportations. Reaching out
to people in person and using necessary social distancing precautions provides a more effective
method for gathering information and engaging community members otherwise isolated.
Programs such as Community Navigators require immense, skilled person-power and funding,

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but as with any program or service, gaining stakeholders’ buy-in is critical. Those stakeholders
could be policymakers, private industry agencies or personnel, health care systems, family
members, religious organizations, or neighbors, all to reduce social isolation and engage people
in their environment.
Many interventions have been suggested to help with social isolation, loneliness, and
social disconnect, but none are recognized as better than others. Interventions need to meet the
diverse emotional, language, situational, familial, living, and other individual differences and
challenges older adults facing social isolation may need to address. In helping individuals,
healthcare professionals and community organizations must help identify and implement
programs to help, have trained staff or volunteers, and have the funding to implement and sustain
helpful solutions. One of these solutions is a relatively new way to help that can be implemented
with training and administered to many more easily than many other solutions: social
prescribing.
Conceptual/Theoretical Framework
Social prescribing is a non-medical, personalized intervention that links older adults to
services and resources. It is a process where the “link” worker helps clients identify their unmet
social needs through a collaborative process, encouraging participation in social activities and
community resources. The link worker meets with older adults one-on-one, providing inspiration
and reassurance to help the person make their own decisions. Social prescribing involves
establishing an ongoing relationship with the individuals and community resources.
Social prescribing works through the use and collaboration of link workers, resources,
healthcare professionals, and the willingness of older adults to improve their quality of life,
health, mental health, and overall well-being. Because social prescribing leads to positive

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changes through relationship development, motivation, and engagement, these dependent
variables can be measured by the positive outcomes and improvements in the older adult's health
and well-being. Through the ongoing relationship between the link worker and the individual,
modifications to activities, programs, and services can be changed or altered as needed.
The creation of a Social Prescribing Implementation Manual (independent variable) was
developed and created to provide education, information, tools, and resources to train healthcare
and other professionals on how to implement social prescribing in their systems. Many factors,
including respect and embracing the patient’s input in determining what interventions they think,
will be beneficial, creating an educational tool and support for healthcare professionals to
implement personalized non-medical care to reduce unnecessary visits to a doctor and still
improve overall health and well-being, and having an access point that brings multiple resources,
community programs, services, and people together led to looking at the following theoretical
frameworks.
Self-determination theoretical framework can be used to implement social prescribing
since it helps explicitly to identify and change behaviors, allowing individuals and professionals
to make informed choices. Self-determination theory can assist in increasing an individual's
motivation, autonomy, relatedness, and competence. O’Hara (2017) reiterated what Richard
Ryan and Edward Deci, the creators of self-determination theory, identified as the theory in a
nutshell, focusing on the basic needs of autonomy, competence, and relatedness. The positive
choices made benefit individuals through group memberships, which improve self-esteem,
connectedness, resources, and support from others (Kellezi et al., 2019). This framework
recognizes the importance of quality relationships and connecting older adults and the systems
necessary for improving motivation, well-being, vitality, and life satisfaction (Martela & Riekki,

21
2018).
The social cure framework comes from the social identity approach within social
psychology, applied through clinical health perspectives to understand the impact of social
groups and how it impacts the thoughts and behaviors of those members (Wakefield et al., 2022).
Social cure as a theoretical framework posits that social interactions and memberships are
essential for a person’s social life, health, and well-being since identifying as part of a group can
reduce loneliness, enhance self-esteem, and provide emotional support when needed (Kellezi et
al., 2019). The concept of social cure also includes the link worker building relationships and
identifying needs in the community based upon the resources available and what older adults
might need. The link worker's role is to get to know who and what is provided within the
community. Helping older adults gain access to opportunities to engage in activities enhances
social connections and reduces loneliness and social isolation.
Ecological Systems theory views the person’s micro, meso, and macro systems, which
impact health, behavior, and physiological factors, and we must include family, friends,
neighborhoods, agencies, stakeholders, and the larger society (Andrew & Keefe, 2014). These
components can ensure positive and increased experiences through meeting, engaging,
supporting, and attending to individuals to help the person and build active and enjoyable
communities. Applying a framework that involves understanding an individual’s needs is
influenced by their interactions with many environments. The opposite is also true.
Understanding the systems in which a person lives and their surroundings can help improve or
add available resources to benefit the person, benefiting the whole system.
Bringing about positive change means looking at people and their environments
separately and together; there are multiple theories to help achieve desired results. Social

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prescribing is a holistic approach and is considered a comprehensive model of personalized care
(Calderon-Larranaga et al., 2022).
Project Description
Proposed Solution: Social Prescribing
One of the thirteen grand challenges of social work is eradicating social isolation, and
one of the most vulnerable and isolated groups of people is those aged 65 and older. Social
isolation devastates people’s family, friendships, health, mental health, and social structure.
Social isolation and loneliness have detrimental health impacts, including, but not limited to,
being a significant risk factor for increased mortality and all-cause morbidity. According to Berg
and Cassells (1992), social isolation measures a person’s quality of life, noting how important
social connections, meaningful relationships, and availability of resources are necessary for
reducing social isolation and loneliness and increasing social connectedness.
Social prescribing has many definitions, but one that fits most is that it is a non-medical,
personalized intervention that links older adults to services and resources. Social prescribing is a
process where a link worker helps clients identify their unmet social needs through a
collaborative process, encouraging participation in social activities and community resources.
The link worker meets with people one-on-one, providing inspiration and reassurance to help
enable the person to make their own decisions. Unlike other referral methods, social prescribing
involves developing ongoing, supportive relationships with individuals and community
resources.
Positive aspects of social prescribing include viewing the person from a holistic point-ofview, considering the needs of the person, respecting an individual’s perspective and opinion,
looking at the health and well-being of the individual, providing opportunities for positive and

23
meaningful connections through activities, programs, and services within the community, and
engaging multiple professionals, resources, and stakeholders that can lead to inter-organizational
alignment and policy decisions to improve care coordination that benefits older adults and our
society (Highfield & Ferguson, 2020). Social prescribing also has significant potential through
behavior change and connecting older adults to their communities; it is another opportunity to
facilitate recovery from the COVID-19 pandemic (Cunningham et al., 2022).
While social prescribing has been implemented successfully to tackle multiple mental
and physical health issues in other countries, it is a newer concept in the United States. In 2020,
United States Surgeon General Vivek Murthy embraced social prescribing (community referral
programs) due to the significant rise in social isolation and loneliness in our country. Surgeon
General Murthy recognized, endorsed, adopted, and is encouraging healthcare professionals to
refer patients to community resources and agencies that can provide recreation, financial,
housing, volunteering, and other ways for people to find the assistance and support they need,
primarily to enrich their lives (Jacobson, 2022).
Social prescribing, especially when healthcare professionals are involved in the
recognition and referral pathway (see Appendix A), is an effective and efficient method that
allows people to reconnect with society and rebuild community networks to help reduce social
isolation and loneliness and improve health outcomes. Training for social prescribing to be
implemented through primary care practitioner offices and staff increases the capabilities for
establishing a link worker and for other staff to understand how this can be an essential part of
patient treatment (Calderon-Larranaga et al., 2021). As a result, introducing social prescribing in
the healthcare system, beginning with primary care offices, creates a significant opportunity for
engaging them as critical stakeholders.

24
Theory of Change
Social prescribing through assistance with a link worker in a healthcare setting provides
recommendations and engagement of older adults to community and other resources,
prescriptions that can help improve social inclusion, mental well-being, physical activity, and
self-management of health (Bhatti et al., 2021). At the beginning of the process, when a patient is
referred to a link worker through their primary care or other healthcare provider, they work
together to assess and identify the specific activities and resources needed to reduce isolation,
loneliness, and social disconnect. The use of self-determination theory as one for change can be
applied and follows the pathway set forth by the theoretical frameworks, self-determination,
social cure, and ecological systems previously mentioned.
According to Bhatti et al. (2021), people who can make choices and take control of their
lives are more motivated to take action that enhances their psychological health and well-being.
Self-determination theory includes three psychological components to help with motivation,
well-being, vitality, and life satisfaction, which are autonomy (actions that come from the self
and reflect who that person truly is), competence (a sense of being able to create the results
desired in life, and mastery of this accomplished through activities), and relatedness (how
connected one feels to others in their relationships and within their community) (Martela &
Riekki, 2018).
Healthcare professionals and systems implementing social prescribing and using link
workers as part of their staff and services encourage the self-determination theory of change,
especially for marginalized, vulnerable, and in need of more significant assistance, which
includes older adults, to build their confidence, introduce them to activities and resources to
provide connections with others and within the community, and strengthen their thoughts while

25
building inclusion (United Nations Development Group, n.d.). The relationship that develops
between the link worker and the older adult will provide guidance, support, and encouragement;
as the older adult learns more about themselves and begins to participate in community activities,
they become more confident and part of a more extensive system, leading to greater overall wellbeing. Also, the link worker helps build on the available resources, develops relationships with
service providers, and can provide valuable insight and assistance to help build upon current
programs and activities to increase community development.
Prototype Description
The prototype created for reducing social isolation for people 65 years and older is a
Social Prescribing Implementation Manual. The manual includes information and descriptions
on the need for social prescribing, how it works, the need for personalized, non-medical services
and support, how community resources, healthcare professionals, and other stakeholders can
assist, tools to assess thoughts and feelings, and an example of a journey an older adult goes
through after discussions and deciding the right prescription of interventions to address their
social isolation and loneliness.
The manual is an all-encompassing training tool to provide healthcare and other
professionals on how and what is needed to implement social prescribing within their systems,
the role of a dedicated link worker in providing person-centered support and encouragement, and
the process necessary to help engage older adults in programs and activities to improve their
mental and physical well-being.
Why the Prototype is an Appropriate Project for this Project
Social prescribing and the extremely proactive benefits of its use can quickly be brought
to healthcare professionals' attention, and it can easily be implemented through a few hours of

26
training. Training using this manual will provide specific information and education on how to
implement social prescribing, how to either train, repurpose, or hire a link worker who can
facilitate improved health and well-being for individuals, communities, and society by
collaborating and developing resources encouraging physical activity, healthy nutrition, social
engagement, volunteering, and positive mental health. It can be done in a reasonable amount of
time so as not to interrupt busy offices.
This prescription method can easily be incorporated into any healthcare system. It helps
create a specific plan to connect individuals to resources and activities to meet identified goals
(Jopling & Howells, 2018).
How the Prototype will be Used
The Social Prescribing Implementation Manual is a training tool a social worker will use
to educate healthcare professionals and, in the future, other service industries on creating and
implementing a social prescribing program in their offices. It also is a tool to educate those
outside of a healthcare system on how to refer, incorporate programs and activities, and
coordinate efforts with healthcare offices through a link worker as a method for helping older
adults.
In-person or Zoom training will include sharing the manual, providing exhibits and actual
situations that describe how to implement social prescribing, discussing the positive outcomes,
how community, state, federal, and city agency programs and services should be included in
service provision and support, and how the link worker is the liaison between the medical
professionals, community and other resources, and the older adult. The link worker is also
getting to know and providing support and guidance to the older adult.
Future Testing of the Prototype

27
The prototype will be tested in a healthcare setting in Northern California per an
agreement with Dr. Alan Siegel (see Appendix B) soon after the new year. Conversations have
taken place about testing the prototype with staff and possible county workers to train and
encourage putting social prescribing into place in the community. Appendix C is the logic model
describing the necessary inputs, activities, outputs, and short, mid-term, and long-term outcomes
of social prescribing and using the implementation manual.
Methodology
To create an intervention that addresses the needs of the population to be served, older
adults aged 65 years and older, it is necessary to empathize and understand the issues, needs, and
desires of not just the population as a whole but what will work for each individual. Social
prescribing provides an innovative solution that addresses and reduces social isolation,
loneliness, and social disconnect of older adults by looking at individual needs through working
with a link worker. The process of connecting an older adult through the healthcare system (or
another referral pathway) via a link worker offers personalized, non-medical solutions through
one-on-one engagement and relationship development to then refer the person to community
resources, activities, and programs that will improve the person’s well-being, health, and mental
health as a result.
Using a human-centered model encourages the development of effective, innovative, and
person-centered solutions, integral to individually improving each patient's health, mental health,
and well-being to address their specific needs (Gottgens & Oertelt-Prigione, 2021). Design
thinking is a human-centered method leading to innovation that integrates a person’s specific
needs by first trying to understand the problem before identifying a solution through a process

28
that will help to uncover and inform to guide what that solution should be (Morgan & Jaspersen,
2022).
In the early stages of trying to find the right innovation to assist this vulnerable and often
forgotten population and to address at least one of the grand challenges of social work, looking at
the design criteria (see Appendix D) identified, the conclusion led to the implementation manual
creation as one solution. Identifying specific design goals that can educate, improve multicommunity member communication, address social isolation, provide personalized care, and
reduce non-medical visits to healthcare professionals is an extreme undertaking. To reach
multiple organizations, diverse and culturally different populations, and produce positive results
led to looking at social prescribing and creating a manner to reach many populations.
Often, interventions are devised without considering the needs and wants of the people
the solution is trying to assist. Design thinking is about including the user's voice, making it a
human-centered design. The first step in design thinking is to empathize with the person you are
trying to assist and to honestly try to comprehend what they are going through before a solution
can be developed (Morgan & Jaspersen, 2022). Creating a solution to an issue or problem is
unwise without interacting with the person who needs the assistance. Social prescribing is about
developing relationships between a link worker and an older adult to seek ways to improve a
person’s life with their input.
Social prescribing is a method to address social isolation and loneliness, but each person
may have different perspectives and needs. In the design criteria, viewing and gathering user
perceptions is part of the process. Finding out the type of support, engagement, resources, and
activities an older adult would find helpful guides the process. Also involved is what the
healthcare industry can do to help reduce unnecessary visits to the doctor or the emergency room

29
and possibly reduce medication use by finding non-medical solutions for patients who can
benefit from more interaction and engagement with others and their community. Defining those
who benefit from social prescribing, including the community at large, helps to promote the
integration of a person-centered, innovative design.
Moving through the design process, many different ways of implementing social
prescribing occurred, including possibly starting a non-profit that caters to social prescribing
implementation. This would take time, including building a business from the ground up, and
would need substantial resources for administration, staff, building, advertising, and other
resources that take time to develop and implement. Through the iterative process, the concept of
an implementation manual arose. The manual is an all-inclusive training manual that can be used
to train healthcare professionals, a specific market at this time, on the entire social prescribing
method, including the use of a link worker, assessment tools, the pathway to assist older adult
patients, identifying community resources, and putting it to use in a healthcare setting.
The final decision was to create an implementation manual, as a result of the design
thinking process, including extensive research on social prescribing, assessment instruments,
financial needs, healthcare industry standards, and the need for personalized patient treatment
and care, engaging multiple community and agency resources, activities, and social programs,
and most of all a way to educate large groups of people at a time about the need to reduce social
isolation, loneliness, and social disconnect for a highly fragile population.
There may be financial constraints to contend with. However, by creating and using a
training manual, an entire non-profit does not need to be created, and to start, one trained
professional can advertise more easily, educate and train using the manual, encourage word-ofmouth support, and help identify the community resources that can assist the link workers in

30
engaging the community and supporting older adult patients in an individualized and meaningful
manner.
Testing of the final prototype will provide insight into how the healthcare industry
receives social prescribing as a tool to help patients, whether changes to the design need to take
place, whether bringing on and training link workers is easy or a challenge, and do patients
benefit from the use of this innovation to assist in helping to improve their overall well-being.
Evaluating the training, process, and benefits to all involved will be conducted, and continuous
improvements will be made to ensure older adults receive the quality and quantity of
relationships and engagements they choose.
Implementation Plan
As mentioned, the Social Prescribing Implementation Manual will first be tested in a
community health center in Northern California. The professionals participating in the training
will include social workers, community health workers, and enhanced care managers. There also
is an opportunity to include community-based organizations; all of these participants have been
noted as staff who could be trained to become link workers in this healthcare setting and are key
stakeholders who can assist in promoting, engaging, and funding social prescribing in the larger
community.
Positive outcomes from this initial test can lead to referrals and invitations for the
consultant to train in other healthcare and community settings using the Social Prescribing
Implementation Manual. This can happen through word-of-mouth promotion, social media
reviews, and additional advertising from those who initially received the training. When social
prescribing is implemented, and results from training, improved health, mental health, and

31
patient well-being are positive, it will be a true testament to the importance of bringing social
prescribing to other healthcare provider settings.
The goal is to increase awareness of social prescribing, how it can be implemented in any
number of healthcare (and other) settings, and provide proof of successful outcomes to patients
by bringing in an expert who will provide the necessary training, tools, and ongoing support to
establish this intervention in other locations. A few methods for promoting awareness include
using an infographic (see Appendix E), a one-page information sheet that can be posted online
via social media platforms handed out at community and senior centers, older adult living
facilities, healthcare offices, and resource agencies. This infographic also provides contact
information for the consultant who created and tested the implementation manual, making it easy
to get in touch, learn more, and arrange for training.
A domain has been purchased, Making Connections Saves Lives, with a website to be
created specifically to promote the Social Prescribing Implementation Manual, and ways to
connect with the consultant for training will be available soon after the prototype test in
California. Social media campaigns will be used to promote the website via Facebook,
Instagram, and YouTube. Plans will be made for calls and visits to PCP offices in the Phoenix,
AZ area after the prototype test to introduce social prescribing and the benefits of moving toward
making it a part of the healthcare pathway through consulting and training using the Social
Prescribing Implementation Manual. Applicable during marketing will include statistics,
references, and information gathered that shows the success of social prescribing in countries
where it is being effectively used and the movement in the United States.
A sample line item budget for the income and expenses specific to the consultant can be
found in Appendix F. Another budget, Appendix G, shows a sample line item budget that

32
includes bringing the consultant into a PCP office to train and provides costs associated with
reassigning or hiring a link worker.
The prototype testing area in California involves one of the people helping to bring the
concept and implementation to our country. The manual created is unique and can be quickly
implemented because it holds all the key components and explains how to move forward in one
written document. The manual is a unique and all-encompassing tool explicitly created to
promote the implementation of social prescribing beginning in healthcare settings. Additional
encouragement will be provided throughout the larger community, especially in areas where
more older adults live.
EPIS Framework
It is important to consider implementation science, specifically the exploration,
preparation, implementation, and sustainment (EPIS) framework, which aims to enhance health
outcomes by studying how to deliver the best available interventions while overcoming barriers
and leveraging individual, community, and system strengths to meet the needs of older adults to
improve their quality of life (Moullin et al., 2020; Smith et al., 2021).
The introduction of the Social Prescribing Implementation Manual, including and beyond
healthcare settings, will rely on the consultant engaging with organizational, healthcare, and
community leaders, making the right connections, looking at inner and outer facilitators and
barriers, and working hard to address the needs of those inside and outside the organization.
Commitment to using the framework and all its components can help guide this process and
ensure the success of implementing and sustaining a vital resource that is proven to make a
positive impact and difference in the population served.

33
The use of the EPIS framework for moving forward with this intervention, the
importance of the leader/owner in the healthcare office as the facilitator bringing in an expert to
train, is crucial at all stages of the framework for it to be successful. As stated by Aarons et al.
(2014), leaders, through strong, consistent, and fair leadership, are essential facilitators who
create and support strategic initiatives across multiple systems and other organizations to engage
support for the intervention to move forward. It is essential in the inner context that the
organizational culture that leaders (PCPs in healthcare settings) advocate, set policy,
communicate, and espouse the values they want their employees, stakeholders, and clients to see,
understand, and know to be true (Aarons et al., 2014). Not only does this support the
implementation of social prescribing, but it also guides those involved and those who need to be
engaged by example through the EPIS framework's exploration, preparation, implementation,
and sustainment phases to help ensure success.
The consultant bringing the Social Prescribing Implementation Manual will work with
and encourage leaders to embrace and include social prescribing as an intervention, inviting team
members, stakeholders, and patients to share and incorporate their ideas to help improve patient
mental and physical outcomes. Leadership will communicate continuously with staff via memos,
meetings, or other methods to demonstrate the priority of this intervention (Aarons et al., 2014).
In preparation for the intervention, leaders will look at challenges and ways to overcome them,
include staff in conversations, and gather feedback to address potential pitfalls and successes to
help guarantee the success of the intervention. Leadership will continue to be involved
throughout the training and implementation process, including ongoing monitoring, showing
staff support, providing continuing education, communicating openly, and adjusting to ensure the
success and needs of staff, clients, and stakeholders are satisfactorily met (Aarons et al., 2014).

34
Barriers in the inner context of the EPIS framework that can harm the organization and
effective use of the intervention can come from staff members who do not clearly understand the
emergent need to address social isolation for older adults and are not open or accepting of the
cultural sensitivity needed for treating diverse clients, may impose their values in ways that
undermine those of leadership and the agency, do not follow the implementation strategy for
effective use of social prescribing, and are not open to feedback or improvements to further the
processes and programs successfully (Aarons et al., 2011; Becan et al., 2018). Any challenging
situations can be addressed through the continuing involvement of the consultant, an expert in
social isolation and social prescribing, and a licensed social worker with skills to help instill and
engage teams to work together.
According to Becan et al. (2018), successfully facilitating collaborations and partnerships
with other agencies, such as community leaders, various older adult living facilities, senior
centers, and other resource agencies, is essential to reinforcing, promoting, and adopting social
prescribing in the community. During the exploration phase of the EPIS framework,
understanding and sharing crucial information about this new intervention and its necessity to
help reduce social isolation, loneliness, and social disconnect for older adults living in their
communities and working with shared values can foster these partnerships and bring outside
agencies on board. This is also crucial to a link worker's role in establishing a successful social
prescribing approach to the PCP office and collaborating agencies.
Interorganizational partnerships sharing a common goal to help older adults can facilitate
growing the network to encourage the lead organization's adoption, implementation, and
effective intervention delivery during the preparation stage (Aarons et al., 2011). When leaders
and organizations share similar values, common interests, and goals for helping the diverse

35
populations living in their communities, the success of moving from exploration and preparation
into the implementation stage of the EPIS model allows for positive changes in people’s lives.
According to Moullin et al. (2019), when there is recognition, strong relationships, and
interactive communication among the consultant, the first healthcare system trained (a leader
organization), and the larger community, this can propel social prescribing further into healthcare
practices and lead to greater the chances of successful implementation. The strength of
community partnerships can provide support, help with any adaptations needed, and ensure
positive outcomes, allowing for the sustainment of the intervention for those in need.
Barriers to implementing the EPIS framework can be that healthcare practitioners and
organizational partners are not strong advocates for their older adult populations due to a lack of
organization among community leaders and staff, a lack of understanding of the importance of
providing this proven intervention to help reduce social isolation, loneliness, and social
disconnect, or they are not interested or supportive of the treatment to form partnerships with
those outside their network. If network partnerships cannot be created or are hesitantly entered
into at the exploration phase, support or encouragement to move forward with a successful EBP
to help residents in their communities will not make it to the preparation, implementation, and
sustainment phase to create the positive changes or hinder the proper application of the
intervention that will help the vulnerable population of older adults. Additional barriers due to
not being able to create inter-organizational networks or those not entirely on board with
embracing social isolation will reduce information sharing, lead to fewer people engaging in the
program, and can result in less than favorable outcomes of the intervention. This intervention
will be hindered with reduced or no new programs implemented when networks are not formed
or aligned. Again, this is where the expert consultant can help bridge communication gaps,

36
explain positive outcomes, and how important collaboration is to make a difference in the
population needing to be served.
Stakeholder Involvement
Social workers are often in key positions to bring stakeholders and other professionals
together to help identify, create policies, develop interventions, and evaluate and implement the
necessary components to reduce social isolation, loneliness, and social disconnectedness within
society. Including professionals in the healthcare industry can significantly eliminate the
detriments of social isolation and the symptoms that can arise from its occurrence in all
populations. Healthcare personnel value beneficence and nonmaleficence; like social workers,
they aim to avoid harm and do good for their patients. This is significant since professionals
working together can have the most significant impact when helping older adults overcome
social isolation and loneliness and gain further social connections (Barsky, 2019).
Healthcare personnel can assist in person or via telehealth to develop new relationships or
maintain existing relationships to oversee people of all ages' physical and mental health. They
are in the position to be trained and include link workers in their offices to provide social
prescribing to their patients. The healthcare system is a vast and critical component since they
have the potential and the reach for gathering information, identifying additional support
networks, providing necessary resources, and, most importantly, they may be the only people
trusted or to come in some form of contact with older adults afraid to come forward and express
their loneliness, sadness, or lack of connections (Husk et al., 2019).
Engaging other stakeholders such as front-line individuals and groups, city planners, nonprofit organizations, religious organizations, residential facilities, individuals, families, social
service providers, and community-based organizations, is imperative to address and reduce social

37
isolation (Ladden, 2019). While this list of stakeholders may not have similar values as guiding
principles like the healthcare and social work professions, it is necessary to work to bring them
on board to help reduce this fatal predicament and the vulnerable populations it impacts the most.
According to Brown and Munson (2020), educating the public about the intense negative
impact of social isolation, which can bring on significant multifaceted health hazards, is one way
to help bring others forward to assist in helping the movement. People who influence to help
make policy recommendations and changes that improve social connections will be assisting to
better the overall health and well-being of human beings. For greater effectiveness and increased
possibilities of success in creating and implementing equitable policies, education, and
successful interventions to combat social isolation, it is necessary to gather input from people
representing multiple demographics, those older adults impacted the most by social isolation.
Other stakeholders include local, state, and federal agencies that should come together to
provide guidance, policies, proposals, and implementation to impact all populations, especially
those who create public policy initiatives resulting in actionable plans. Because the United States
does not have a national healthcare system, it has been suggested that to help bring social
prescribing to the forefront of healthcare treatment, Medicare for older adults and Medicaid
should be used as a method of mainstreaming social prescribing, especially for the millions of
Americans without health insurance coverage (Khan et al., 2023; National Academies of
Science, Engineering, and Medicine, 2019).
The healthcare industry is linked to policymakers and private sector stakeholders who can
implement technological assistance to engage diverse, marginalized, and other populations
effectively. Building relationships, especially among healthcare professionals, will provide more
significant opportunities for success. Additional stakeholders include universities and colleges

38
with programs and institutes, their staff, and information on social isolation, including the
University of Southern California Edward R. Roybal Institute on Aging.
Evaluating positive partnerships would include seeing multiple stakeholders coming
together to address social isolation, identifying common themes relevant to affected populations,
engaging vulnerable and other people, creating interventions specific to diverse populations,
engaging all stakeholders to provide implementation, and continuing to evaluate outcomes to
amend or maintain interventions that work. Results that reduce social isolation and loneliness
and improve social connections for those suffering will be the proof needed to judge success.
Measurement and Outcomes
Ongoing assessment of the social prescribing process should be done throughout the
engagement process of the link worker with the older adults being assisted. Helping map out
their needs referral pathways, and monitoring for changes or modifications is ongoing. The
assessment tools within the Social Prescribing Implementation Manual can be used during
interventions to ensure that older adults' engagements are successful. Also, measuring the
outcomes provided by the assessments includes self-reporting, link worker input, and could
include comments and insights from community partners providing support and resource
services. Appendix H displays measurable outcomes and success of social prescribing as a
treatment method through improvements in positive aspects and reductions in negative ones,
implying how much better an older adult is feeling and engaged in their life.
Ethical Considerations and Design Justice Principles
Ethical issues may arise when bringing different stakeholders together if diversity,
inclusion, and equity, at a minimum, are not considered part of the process; again, it is up to
social workers to help bridge the gaps and work to make relationships beneficial for all so that

39
there is cohesion and differences created. Social isolation and its severe impact on health and
well-being are not discriminatory. Social workers often are in positions to ensure intersectional
discrimination does not occur, that policies and interventions created will be based on
inclusiveness and appropriateness and that approaches are equitable and participatory based to
include social contexts of all populations (Dassieu & Sourial, 2021).
The COVID-19 pandemic disproportionately impacted the most vulnerable populations
(Baumann & Long, 2021). Beginning with primary care practitioner offices, which for many
older adults may be their only connection to engaging with other people, is a way to ensure
equitable implementation of social prescribing for these vulnerable, socially isolated populations
in many settings. Engaging and educating healthcare providers from all types of communities on
implementing social prescribing, especially those who service ethnically diverse, immigrant, atrisk, underserved, people with disabilities, racial, and LGBTQ+ populations, no matter their
economic or social status, since all people are at risk of being socially isolated. Vulnerable
populations tend to be the ones that are at the most significant risk of feeling lonely, socially
isolated, and socially disconnected from others, leading to adverse health and mental health
impacts that social prescribing can help alleviate and bring communities together (Brown &
Munson, 2020).
There are extreme disparities among socially isolated older adults besides the physical
and mental health challenges, including living in unsafe neighborhoods, having lower incomes,
language barriers, or having no family or friends to rely upon, adding to the inequities felt by
these populations even before the COVID-19 pandemic (Hill, 2021; Sanchez, n. d.; “7 Tips to
Help, 2022).

40
Of critical importance is to ensure that the populations served are treated equally,
equitably, with fairness, sincerity, dignity, and respect, as all human beings deserve.
Implementing social prescribing to help reduce social isolation, loneliness, and social disconnect
can be done by understanding that each person comes from a different and diverse background
and needs treatment to enhance their quality of life, mental and physical health, and be connected
to other people. Social prescribing is by nature, a person and human-centered approach to
treatment.
Financial Plans
Social prescribing, a newer concept in the United States, makes it challenging to
determine personnel and other expenses for implementation in a healthcare setting and put
together cost savings for the healthcare industry. Appendix I provides an example from an
economic analysis of healthcare costs and savings conducted by Lynch and Jones (2022), with
pounds converted into dollars for comparison. The appendix provides N = 78, with all
participants using social prescribing activities and programs and 21 being more frequently
engaged in reducing social isolation, loneliness, and social disconnect. It provides a relevant
comparison of PCP appointments and prescriptions for those who do not and those who
participate in social prescribing as a treatment method.
While this study is just one example, additional research on social isolation continues to
grow. The study includes a sample of 78 participants in one PCP office, and involvement in
social prescribing for five months produced a $19,520 savings in-office visits and prescriptions.
Most PCP practices have more than 78 patients and even more who can benefit from social
prescribing, leading to substantial decreases in healthcare costs.
Conclusions and Implications

41
One of the most critical considerations in implementing social prescribing is that it is a
prescription model; it is proactive and not reactive. The goal is to facilitate improved health and
well-being for older adults, communities, and society. This can be achieved through
collaboration, using and developing resources encouraging physical activity, healthy nutrition,
social engagement, volunteering, and positive mental health. Also, educating older adults, family
members, friends, healthcare professionals, community and senior center staff, front-line
workers, agencies on aging, care facilities, and neighborhood associations about social
prescribing and its benefits. Social prescribing leads to positive impacts that can occur much
quicker due to creating specific goals that are person-centered and include ongoing relationships
between the link worker and the older adults.
Social prescribing is a holistic, person-centered, non-medical approach to reduce social
isolation, loneliness, and social disconnect. It is needed now in our country and beyond more
than ever. It can reduce inequities and improve the delivery of healthcare to older adults. The
healthcare system is one of the most effective and efficient ways to provide this service for the
well-being of our society (“Social prescribing,” 2021).
For social prescribing to be implemented successfully to meet the needs of many, as
progress is made in getting healthcare practitioners and others on board, future manuals,
assessments, and information will be translated into other languages to be culturally sensitive to
practitioners and patients; as well as any additional training to help promote understanding and
learning about ethnic, racial, LGBTQ+, immigrant, and other diverse factors to expand services
and promote positive health and well-being.
Recognized detrimental health and mental health impacts social isolation can cause,
including high mortality rates, increased hospitalizations, increased potential for suicide,

42
depression, and the heightened potential for developing dementia, the healthcare system should
be at the forefront of identifying, screening, providing service, and educating patients,
stakeholders, and community organizations to begin change efforts (Holt-Lunstad, 2020; Razai et
al., 2020; Donovan & Blazer, 2020; Buffel et al., 2015).
Also, due to the significant individual health, economic, and societal ramifications, social
isolation change needs to start with stakeholders who see the impact social isolation, loneliness,
and social disconnect have on older adults; the healthcare industry, again, is crucial in helping to
reach additional stakeholders to share the benefits, and help to create and implement public
policy initiatives that include all populations through community, state, and federal pathways so
that government agencies and social service organizations become the key ingredients to educate,
intervene, and address this wicked problem.
Engagement in the healthcare industry begins with testing the Social Prescribing
Implementation Manual prototype and garnering success; the multiple partners included in this
trial can provide a starting point for propelling the recognition, engagement, and implementation
of social prescribing in other communities. Engagement of all populations in multiple locations
will strengthen our ability to create socially connected communities everywhere. We all are
susceptible no matter our racial, ethnic, socioeconomic, gender, age, gender identification,
disability, religion, location of where we live, political affiliation, or any other demographic
categorization. Now is the time to eradicate social isolation from impacting individuals,
communities, and society.

43
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52
Appendix A
Social Prescribing Journey Map

53
Appendix B
Prototype Testing Agreement Letter

54
Appendix C
Logic Model: Social Prescribing & Implementation Manual
INPUTS ACTIVITIES OUTPUTS SHORT-TERM
OUTCOMES
MID-TERM
OUTCOMES
LONG-TERM
OUTCOMES
Human Resources:
• Social prescribing
trainer
• Primary healthcare
providers (PCP)
• External design
partner
• Link worker(s)
• Community
partners & 1st
responders
Financial Needs &
Materials:
• Advertising:
social media,
brochures &
infographics,
word-of-mouth,
sign-posting
• Consulting/Trainin
g (implementation
manual & link
workers)
• Link worker(s)
• Training
materials/handouts
Consulting/Training:
• Provide
education on
social
prescribing to
primary care
practitioners,
senior &
community
centers, clinics,
other
healthcare
providers &
organizations,
referral sources
& programs,
activities, &
support
resources
• Train primary
care physician
office staff
about social
prescribing and
how to
implement
through the use
• Increase in #
of link
worker(s) in
PCP offices
• Increase in #
of
community
partners &
stakeholders
aware of
social
prescribing
• Increase in #
of
community
partners &
stakeholders
engaging in
social
prescribing
• Increase in
older adults
participating
in
community
programs,
• Start to see
improvements
in older adults'
health, mental
health, & wellbeing
• Increased
engagement of
older adults in
their
community’s
programs,
resources, &
activities
• Increase in
awareness of
social
prescribing as a
successful way
to help older
adults
• Increase in
communication
and
collaborations
with link
workers, their
• Link worker
assessments of
older adult
patients show
greater
attendance in
social
engagement &
activities
• Increased
community &
healthcare
community
awareness of
social
prescribing &
the benefits to
older adult
patients
• Improved
relationships
with PCP, link
worker, &
other
healthcare staff
with patients
• Decrease in nonmedical PCP
visits & ER
visits
• Increase in
resource savings
in PCP offices &
overall
healthcare
system
• Increased
community
knowledge
of social
prescribing
& the
benefits to older
adults, the
community, &
healthcare
providers
• Increased
referrals to
community
resources to
engage older
adults

55
Financial Resources: • PCP offices • Large healthcare
organizations, e.g.,
AETNA, United
Healthcare, CVS,
Walgreens, Kaiser
Permanente,
Dignity, etc.
• Foundations &
Non
-profit social
service agencies
Community Resources:
Community partners,
referral sources, &
program implementers: • Area Agencies on
Aging
• Senior centers • Community
centers
• Senior housing
(independent, lowincome, assisted,
etc.)
• Local
neighborhoods &
communities
• Volunteer agencies
of the Social
Prescribing
Implementation
Manual
• Provide
training to
reallocate, hire,
or job-share of
staff to assess,
build rapport,
& provide
personcentered care to
help patients
engage in
social
prescribing
resources &
activities
• Consultant will
monitor &
follow-up with
physician
offices to
ensure proper
& effective
social
prescribing
implementation
After Training: • Link worker
builds a list of
resources, &
activities
• Increase in
types of
community
services
available to
meet patient
needs
• Increase in
the number
of people,
community
partners, &
stakeholders
inquiring
about social
prescribing
• Increase in
number of
PCP offices
& other
agencies
being
educated
about &
trained to
implement
social
prescribing
• Increase in
the number
of PCP
PCP offices, &
stakeholders &
community
resources
• Older adults
feel more
support from
PCP staff
• Improved
mental &
physical health
& well-being
of older adults
patients
• Reduced social
isolation,
loneliness, &
social
disconnect
• Increased
activities
provided by
community,
senior center,
& other
resources for
older adults
• Less reliance
on medications
• Less nonmedical visits
to PCS offices
& emergency
rooms
• Increased &
improved
relationships
with link
workers, the
PCP office, &
• Improved social
support,
motivation,
health, mental
health, & well
-
being
in older adults
participating in
social
prescribing
services through
PCP/link
workers
• Reduction in
social isolation,
loneliness, &
social disconnect
in older adults
• Reduction in
medication use
due to improved
health & mental
health
• Increased
financial &
community
support to add
link workers to
more PCP
offices &
potentially with
other service
providers

56
resources:
activities,
programs, and
services in the
local area
• Link worker
goes into the
community to
build
relationships
with current &
potential
service
providers
• Link worker
completes
assessments
with patients &
monitors
progress
through the
pathway
• Link worker
works with
patients to
ensure positive
progress
• Communicate
with primary
care physician
on progress
with patients
referrals to
link workers
for non
-
medical
interventions
• Increase in
advertising
about social
prescribing
throughout
communities
the larger
community
• Increased
opportunities
for social
prescribing
implementation
with the
consultant
• Improved
measurable
quality of life
for participants
• Increase in
outside referrals
to use of social
prescribing
services
• Increase in use
of community
resources,
activities, &
programs
• Improved
communication
among link
workers &
community
resource staff &
volunteers
• Increase in
community
awareness &
necessity of
social
prescribing as a
solution to
reduce social
isolation,
loneliness, &
social
disconnect

57
• Consultant will
continue to
speak &
engage
healthcare
organizations,
service &
program
providers, &
communities
-
at
-large about
social
prescribing
• Improvements in
PCP office
efficiency
• Acceptance of
non
-medical
interventions to
assist older adult
patients to meet
their needs
• Social
prescribing
consultant is
training more
PCP offices &
other sources to
implement social
prescribing in
their
environments
• Overall
improved
effectiveness &
efficiency in
providing
personalized
care & support
to older adult
patients,
improving
communities,
families, &
society
-at
-large

58
Appendix D
DESIGN CRITERIA
Social Prescribing for Older Adults: 65 years and older
• Social isolation for older adults is significantly devastating
• Older adults are at a higher risk for experiencing loneliness and isolation
• Population is vulnerable and marginalized due to age
• Population more easily suffers from social disconnect
• Largest growing population in the country
Design Goal
• Facilitate the provision of non-medical support services for
older adults
• Improve social connections and engagement, reduce social
isolation, and reduce loneliness for older adults
• Educate healthcare providers and the community at large
about social prescribing as a preventative alternative to
healthcare options
• Educate healthcare providers and the community at large
about the positive benefits to health, mental health, and
overall well-being by engaging in social prescribing
• Engage older adults, link workers, and healthcare providers
with community resources
• Create more sustainable community unity, collaboration,
communication, services, and resources through social
prescribing
User Perceptions
• Older adults receive encouragement, engagement, and support
from healthcare providers and link workers
• Receipt of non-medical, personalized interventions and
resource information
• One-on-one, ongoing relationship and guidance providing
inspiration and reassurance to help enable the person to make
decisions
• Encourages autonomy, competence, and relatedness
• Collaborative process among healthcare, older adults, and
community agency services
• Decrease in social isolation, loneliness, and social disconnect
• Improved health and mental health conditions
• Reduction in medication use and doctor visits

59
• Healthcare providers have resources to assist patients that will
reduce healthcare costs and improve patient well-being
Physical Attributes
• Creating a new service opportunity for healthcare providers,
older adults, and community programs, activities, and
resources
• Social Prescribing Implementation Manual provides training
to healthcare professionals on use, benefits, need, and costeffectiveness
• Manual can be used in multiple other settings to train
professionals and lay-people on the implementation of social
prescribing
• Social service professionals can learn to implement this
intervention through training by one who is an expert in social
prescribing and familiarity with the use of the manual
• Ease in use of manual
• Multiple ways to engage and increase the use of this model:
advertising, sign-posting, word-of-mouth, and previous
experience with the process
Functional Attributes
• Implementation manual is an all-inclusive educational tool
that can be taught in professional and community settings
• An expert in social prescribing and social isolation provides
training in all settings
Constraints
• Introduction and acceptance of a new concept of non-medical
intervention to help older adults
• Budgeting for training
• Budgeting for a link worker(s) in the implementation setting
• Limited resources in a community
• Time for a link worker to build a network of necessary
resources for patients
• Ensuring a method of tracking success or opportunities for
improvement

60
Appendix E
Infographic

61
Appendix F
Consultant’s Estimated Yearly Budget
Line Item Budget
Personnel
Rate/Hour Hours/Month Monthly
Total
Annual
Total
Consultant/Trainer Earnings $125 20 $2,500 $30,000
Gross Earnings $30,000
Expenses
Administrative Costs (12 months)
* Home office (20% of expenses)
* Space $3,644
* Utilities $3,120
* Telephone $264
Postage $700
Copying $1,000
Office Supplies $200
* Computer & Accessories $500
Attorney Fees $2,500
* Accountant Fees $800
Taxes (28%) $6,300
Total Expenses $19,028
Travel
Gas $600
Airfare $1,200
Hotel $2,500
* Car $1,700
Meals $700
Rental Cars $800
Total $7,500
Net Income/Loss
(total earnings – total expenses) $3,472
* The goal is to charge customers for travel expenses after prototype testing in California.
* This is a 2024 estimated consultant budget including paying fees for travel for the prototype testing in
January. Additional trainings will include the contractor paying consultant’s travel expenses, so future
year’s budgets should provide more earnings.

62
Appendix G
Budget for Consulting/Training to Implement Social Prescribing
Training & Consultant
Fees
Consultant $1,000 *$125 per hour for 8-hour training
Travel $500 * Air flight to location
Lodging $500 * Two-night stay at hotel
Food $100 * Meals as needed
Meals @ training $500
Personnel
Link Worker $50,000 * Average link worker annual salary
Benefits & Taxes $3,500 *7% of pay towards health insurance
$3,825 * FICA employer pays 7.65%
$1,000 * FUTA employer pays 2%
* A PCP office may choose to repurpose another staff member who already is being paid, or
may
choose to hire a new employee as the link worker.
* This is an example of some of the costs associated with hiring and training for social
prescribing to be
included in a PCP office

63
Appendix H
Outcome Measures
Outcome Measures for Patients
(Improvements in positive aspects & reductions in negative aspects due to Social Prescribing)
General Physical Psychological Social Spiritual Welfare
Overall well-being Nutrition Depression Social isolation
Sense of
purpose Access to services
Quality-of-life Exercise Anxiety Loneliness Fulfillment
Ability to deal with
stress
Empowered Alcohol Hope Independence Inspired
Engagement in
activities & programs
Social connections
& connectedness
Quality &
quantity of
sleep
Ability to cope &
resilience Self-worth Enlightenment
Concern for self &
others
Self-care Medications Decision making
Supported &
engaged Happiness
Relationships &
friendships
Engagements Blood pressure Positive feelings Self-awareness Enjoyment Housing
Weight Loneliness
Knowledge &
education Relaxed Transportation
Smoking Self-esteem
Relationships &
friendships
Open &
accepting Support services
Stamina Control of life
Social connections
& connectedness More informed
Confidence
Important &
listened to Volunteering
Sense of control Trusted & Trust Education
Empowered Sense of achievement
Encouragement Coping skills
Suicide ideation
Ability to identify &
fix issues
* Outcome measures come from reassessing patients using the assessment tools used at the beginning and throughout
the social prescribing treatment for older adults.

64
Appendix I
Healthcare Costs Associated with 5 Months of Social Prescribing (English Study: GBP to $)
Healthcare unit costs for N = 78 participants in this study
* Exchange rate 1.18 USD to 1.00 GBP (only $ shown)
N
Total preintervention
visits (12
months)
Total cost
for 12
months
Total
average
monthly cost
Total cost
after 5
months of
SP
Total
monthly
average cost
Average cost
per person
over 5 months
of SP
Anticipated cost
per person-for
12 months post
SP
Anticipated
total cost for
12 months
post SP
PCP appointments 78 979 $61,240 $5,120 $23,140 $4,640 $300 $720 $55,500
Prescriptions
(unspecified social
activity **) 78 342 $17,360 $1,460 $6,600 $1,320 $100 $220 $15,880
Total 78 1321 $78,580 $6,560 $29,740 $3,600 $400 $920 $71,360
* All 78 participants from this study engaged in some form of social prescribing activity or program.
Pre and post social prescribing cost analysis
N
Total preintervention
visits (12
months)
Total cost
for 12
months
Total
average
monthly cost
Average
cost per
year
Average cost
for N = 21
during 5
months of
SP
Anticipated
cost per
person for 12
months post
SP
Anticipated cost
for N = 21 for
12 months post
SP
PCP appointments 21 631 $33,460 $2,800 $1,600 $480 $1,140 $23,880
Prescriptions
(unspecified social
activity **) 21 173 $7,460 $640 $360 $100 $240 $4,760
Total 21 820 $40,920 $3,420 $1,960 $580 $1,380 $28,620
* In this group, 21 participants were more frequently involved in social prescribing activities and programs.
* For those who participated in social prescribing on some level, there were cost savings in both PCP and prescription costs due to less visits and
less prescriptions written, for just five months of engagement with cost savings of just over $7,000.
* For those who more frequently made use of social prescribing services, the savings were even greater for PCP visits and prescriptions projected
for the following year of over $12,000.
** The study that these numbers come from does not indicate what activities or programs were prescribed, but it is a start, and shows that there
are healthcare cost savings in bringing social prescribing into PCP offices and beyond. Link workers in PCP offices also provided positive benefits to economic
results.

Abstract (if available)

Abstract Social isolation is one of the most detrimental health challenges our country and world face today. People aged sixty-five years and older are the fastest-growing demographic and will become one-third of the entire population in less than thirty years. Social isolation can impact any person, no matter their ethnic, cultural, racial, religious, sexual orientation, living situation, income, or any other characteristic a person may possess. To help combat this devastating mental and physical health challenge, social prescribing is a solution gaining recognition to connect people with other individuals, activities, resources, and programs on an ongoing, person-centered, self-determination. Social prescribing is a preventative and non-reactive intervention to help improve the health and well-being of older adults.

Unlike countries where a National Health Service pays for healthcare and implements social prescribing as such, the United States does not systematically implement healthcare. Therefore, social prescribing will be introduced through primary care physician offices by a licensed social worker, who will train all healthcare staff using a Social Prescribing Implementation Manual. This manual includes all necessary education, information, and tools for implementing a social prescribing service through their offices with dedicated and trained staff members. Social prescribing provides collaboration among healthcare professionals, local area agencies on aging, senior and community centers, other service providers, and stakeholders to promote social, educational, and supportive personalized activities for older adults through non-medical approaches to reduce loneliness and social isolation and increase interactions to improve their quality of life, health, and well-being.

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Asset Metadata

Creator Goldman, Jami (author)

Core Title Making connections saves lives: social prescribing linking older adults to their communities

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Degree Conferral Date 2023-12

Publication Date 11/27/2023

Defense Date 11/20/2023

Publisher Los Angeles, California (original), University of Southern California (original), University of Southern California. Libraries (digital)

Tag link workers,Loneliness,OAI-PMH Harvest,older adults,social connectedness,social disconnect,social isolation,social prescribing

Format theses (aat)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Hunter, Harry (committee chair), Beck, Delia (committee member), Newmyer, Rick (committee member)

Creator Email jamigold@usc.edu,jamisgoldman@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-oUC113778042

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