Social determinants of health are the non-medical factors that influence health outcomes. They are the conditions in which people are born, grow, work, live and age and a wider set of systems that shape the conditions of daily life (social policies, political systems, etc.). Research shows that social determinants can be more important than health care or lifestyle choices in influencing health.
Social prescribing is often described as the bridge between clinical care and social and community services. Social prescribing uses a referral (or “prescription”) to connect patients to local, non-clinical services. While it seems simple, there are significant barriers: busy clinicians with limited time, a lack of knowledge about social and community services, and technical barriers to connecting patients to such a vast array of providers.
Our Health Navigation Team
Community Connection has established a virtual provincial team of Health Navigators that work closely with our many partners to support social prescribing and health navigation programs. As our partnerships expand across the province, navigators from the 211 Ontario network will be onboarded to our team. This team utilizes custom digital tools developed for cross-sector client data sharing.
Paramedics and Paramedicine Referrals
In 2015, a partnership with Simcoe County’s Community Paramedicine program established a referral process with Community Connection. When responding to a 911 call or conducting a home visit, patients identified as needing social and community services are referred to Community Connection. These referrals have consent from patients and are sent by electronic fax.
Our Health Navigators make outbound calls to assess patients’ needs and provide information, referrals, and advocacy to ensure connections to services are made. Follow-up calls are conducted, and further support is provided if needed. Our business intelligence data show that patients referred by paramedics also have an average of 3 needs each. The top needs are mobility, falls, household assistance, and caregiver support. Outcome reports are provided, documenting the details of our intervention.
The County of Simcoe has reported a 28% reduction in repeat 911 calls for patients who specifically received support through a referral to Community Connection.
Our partnerships with paramedic services have expanded to Grey and Northumberland Counties.
Primary Care and Closed Loop Referrals
In 2015, the Ontario College of Family Physicians developed a poverty screening tool for primary care, using key questions to assess their patients’ living conditions and current benefits and includes links to government and community resources (211) to support positive connections. In 2017, Dr. Gary Bloch and Dr. Ritika Goel narrated an animated video demonstrating how 211 can support people impacted by social determinants of health.
The Georgian Bay Family Health Team physicians began using a screening tool and referral form to refer patients to Community Connection. An outcome report on the results of our intervention is sent to the referring clinician and scanned into the patient’s chart (essentially closing the loop on the referral). These referrals have consent from patients and are sent by electronic fax.
Our closed-loop referral partnerships have expanded to ten family health teams and three hospitals (Collingwood, Barrie, and Orillia) in the District of Muskoka and Bruce and Simcoe Counties. Our business intelligence data show patients referred by physicians have an average of 3 needs each. The top five are financial, housing, food, social isolation, and basic personal or household needs.
Social Prescribing for Better Mental Health
Community Connection is involved in a provincial partnership project with the Alliance for Healthier Communities to promote mental health and prevent mental illness through social prescribing by clinicians for connections to community services and wellness activities. Over 18 months, Community Connection is building social prescribing relationships with the Alliance members, a community-governed primary health care organizations network.
Health System Navigation
Community Connection is an anchor partner of the Couchiching Ontario Health Team. Together, we partnered to provide a specialized 24/7 health system navigation toll-free line to offer live support to help patients, caregivers and providers find the services they need.
Ontario Caregiver Organization and Helpline
As part of the 211 Ontario network, Community Connection’s Community Navigators answer the 24/7 Ontario Caregiver Helpline, offering information about caregiver services and support to all caregivers regardless of age, diagnosis or where they live. In 2022, Community Connection assumed oversight of the partnership and is working with the Ontario Caregiver Organization team to explore how we can improve our impact on caregivers.
As part of the 211 Ontario Network, Community Connection’s Community Navigators answer the 24/7 Good2Talk helpline, a free, confidential support service for post-secondary students. After determining the caller’s need, our team connected the caller with a Connex Ontario or Kids Help Phone counsellor. Last year, our team played an important role in reducing the number of abandoned calls during the evening.
As part of the 211 Ontario network, Community Connection’s Community Navigators answer the 24/7 ReportON, a provincial line to report suspected abuse or neglect of adults with developmental disabilities.