Social prescribing connects people to assets within their community, to improve their social determinants of health. As many seniors are socially isolated amidst the COVID-19 pandemic, electronic social prescribing has emerged as a way to keep these vulnerable groups meaningfully engaged. SingHealth Community Hospitals seeks to collaborate with general practitioners (GPs) and other community partners to maximise this impact.

INTRODUCTION

We all know that the 80/20 rule can apply to most things in life. The rule observes that 20% of the input creates 80% of the outcomes. In healthcare, guess where the 80% lie in terms of health outcomes? If you are in family medicine or working in the community, you would probably get it right. 80% of health outcomes is not determined by the healthcare received. If you include iatrogenesis, the percentage is probably lower than 20%.

SOCIAL DETERMINANTS OF HEALTH

Research has shown that 80% of healthcare outcomes is influenced by one’s social determinants of health (SDH). Examples would include an individual’s housing environment, literacy, food security, social support and access to health and social care. These factors are the circumstances and environment in which someone is born into, grows up, lives, works and plays in.

For the longest time, because these social determinants are outside the realm of healthcare, they had been relegated to high-level public health and government policy interventions. They were seen as issues to be solved at the macro level, beyond the reach of the individual healthcare worker.

This view has changed since evidence emerged that clinicians and social care providers can more than move the needle in SDH, if we acquire the right competencies and receive appropriate support from the system.

One key competency that has emerged is social prescribing. It is the process of connecting a person to assets within his or her community, with the specific aim of improving their SDH.

SOCIAL PRESCRIBING AT SINGHEALTH COMMUNITY HOSPITALS

Since October 2019, SingHealth Community Hospitals (SCH) has started a social prescribing pilot with a small group of wellbeing coordinators. They are nonclinical staff who work as part of the clinical team to identify and support patients with adverse SDH, which put them at risk of poor outcomes.

The social prescribing process
Upon admission to SCH, patients are screened for risk factors of poor SDH-related outcomes and enrolled into the social prescribing programme. The patient is then activated through participation in in-house activities that promote wellbeing, such as gardening, exercising, singing, and reading. Just before discharge, they are linked to community care providers to sustain the improvements to their wellbeing.

Collaboration with community partners
One key partner that had demonstrated good outcomes with us is the Community Network for Seniors (CNS), where their case managers work very closely with our wellbeing coordinators to link patients with community partners offering social activities, re-integrating them back into their own communities. Initial results were very promising and plans are on the way to scale this up, to conduct social prescribing at SingHealth Polyclinics and eventually with interested GPs.

Benefits
Early evidence is showing improvements in quality of life measures as well as reduction in hospital and even primary care utilisation.

Not surprisingly, evidence also shows that those who benefit the most from social prescribing are patients who are likely to be most at risk of poor SDH. These include patients who:

• Require support to manage long-term conditions
• Are vulnerable, socially disadvantaged or at high risk of mental health issues
• Are lonely or socially isolated
• Frequently attend either primary or secondary healthcare

Social Prescribing:
Going E to Engage Seniors Amidst a Pandemic

In this COVID-19 pandemic where social distancing is encouraged, many seniors suddenly find themselves isolated at home. To them, the new world is confusing and scary with complicated regulations that keep changing. Staying home to keep themselves safe from the virus might lead to unintended consequences, such as physical and cognitive inactivity, possibly introducing new health risks.

The Infocomm Media Development Authority (IMDA) Annual Survey on Infocomm Usage in Households and by Individuals in 2019 reported that 13% of those aged 60 and above are completely disconnected from the digital world. Digital exclusion during the pandemic prevents these seniors from connecting with their friends and family, increasing their social isolation.

ELECTRONIC SOCIAL PRESCRIBING

To address this, SCH wellbeing coordinators developed electronic social prescribing (eSP), a simple senior-friendly digital skills programme comprising three lessons:

1. Connecting to Wi-Fi/Wireless@SG
2. Using WhatsApp (including text/voice messages and voice/video chat)
3. Scanning QR codes (for SafeEntry or accessing different URLs)

These topics were deliberately chosen as they are the most basic and widely-used functions that help to address the negative social impact brought about by safe distancing measures. WhatsApp allows seniors to stay socially connected, while scanning QR codes allows seniors to access online content and gain entry to familiar places in the community to continue their daily routines.

The eSP lessons were conducted in a group setting of three seniors, with one-to-one coaching provided by the wellbeing coordinator. This group setting enabled peer sharing and influence, increased motivation for participation, as well as opportunities for social interaction and friendship building.

During one of the lessons on the use of WhatsApp, participants were asked to create a WhatsApp group among themselves, to communicate with one another through the group chat. At the end of the three lessons, a pictorial booklet with simple instructions was provided for participants to use as a reference for self-practice.

CHALLENGES TO eSP

1. Cost
   IMDA and telecommunications companies in Singapore recently announced a few initiatives to enable seniors to go digital, such as offering affordable smartphones and data plans to seniors who are financially needy. This addresses the cost barrier of embracing technology.
   
2. Lack of motivation
   Another challenge was the lack of motivation in some patients. Age, anxiety, and perceived difficulty were often given as reasons for declining to participate in the lessons.
   
3. Concerns of family members
   Some family members were concerned that seniors may make mistakes due to the complex features of smartphones, or fall prey to fraudulent scams targeting seniors.

BUILDING CONFIDENCE OF SENIORS

To build confidence among the seniors to embrace technology, we followed these principles of the unified theory of acceptance and use of technology (UTAUT):

• Performance expectancy
  Convincing them of the benefits that WhatsApp will bring. For example, they could connect with their favourite grandchild while keeping safe at home.
  
• Effort expectancy
  Demonstrating to them that it is within their capability. For example, bringing them to observe the lessons and see how other seniors were able to learn without difficulty.
  
• Social influence
  Building alliances with their loved ones to help encourage them to participate. For example, getting the buy-in of the patient’s family member to help encourage participation.
  
• Facilitating conditions
  Ensuring that resource barriers like availability of smartphones and Wi-Fi access are overcome. For example, securing a pool of donated smartphones from staff who have spare phones at home.

POSITIVE RECEPTION

The eSP lessons received very positive feedback from all participants after the launch. Seniors were very satisfied that they could contact their loved ones freely without the need to travel, and access various places independently to maintain their daily routines. Most patients who attended the lesson shared that they experienced a newfound independence that they never had before.

Caregivers also gave feedback that they could stay connected with their parents without taking too much time off work for physical visits.

CONCLUSION

Disruption has always unravelled new opportunities of growth. Social prescribing may become more important now than ever in these uncertain times caused by COVID-19, as we strengthen the links between health and social care.

SCH continues to strive to be the conduit and platform for linkage to the community. It aims to provide a seamless care transition and ensure that patients stay well in the community, by working with partners such as the Silver Generation Office and Institute of Adult Learning to advance our cause in this area.

Assoc Prof Lee Kheng Hock is an Associate Professor of Family Medicine at Duke-NUS Medical School. He is the Past President of the College of Family Physicians Singapore and is currently the Chairman of the Chapter of Family Medicine Physicians of the Academy of Medicine Singapore. In 2006, Prof Lee was invited to set up a clinical department of family medicine at Singapore General Hospital. In 2011, he was concurrently appointed as the Medical Director of the 317-bed Bright Vision Hospital, under SingHealth Community Hospitals (SCH).

From 2006 to 2016, Prof Lee and his team experimented with different care models using the principles of family medicine and integrated care. The effectiveness of their care model was proven in two landmark randomised controlled trials and has since been scaled up and implemented as the Communities of Care approach in the SingHealth Regional Health System. Prof Lee is now leading the social prescribing programme at SCH.