Financing Approaches to Social Prescribing Programs in England and the United States

Early View Perspective Comparative Health Systems Social determinants of health

Policy Points:

  • The number of social prescribing practices, which aim to link patients with nonmedical services and supports to address patients’ social needs, is increasing in both England and the United States.
  •  Traditional health care financing mechanisms were not designed to support social prescribing practices, and flexible payment approaches may not support their widespread adoption.
  •  Policymakers in both countries are shifting toward developing explicit financing streams for social prescribing programs. Consequently, we need an evaluation of them to assess their success in supporting both the acceptance of these programs and their impacts.
  •  Investment in community-based organizations and wider public services will likely be crucial to both the long-term effectiveness and the sustainability of social prescribing.

Both England and the United States have long recognized that social determinants of health play a major role in shaping population health and health equity.1,2 The World Health Organization (WHO) defines the social determinants of health as “the conditions in which people are born, grow, live, and age,” which are “shaped by the distribution of money, power and resources.”3 Social determinants include income, employment, education, neighborhood conditions, social and community context, and other social and economic factors.4 In fact, research suggests that social determinants and related health behaviors may have a bigger impact on health outcomes than clinical care does.5-10 This research has also contributed to new initiatives in the health care sector that involve assessing and addressing patients’ social needs, such as food insecurity, housing instability, and social isolation, alongside the delivery of medical services.11

Forms of “social prescribing” have emerged as a common strategy for weaving attention to social conditions into the delivery of health care in both England and the United States. Broadly speaking, social prescribing refers to identifying patients’ social needs and connecting patients with relevant nonmedical services to improve their health and well-being.12 In England, social prescribing is typically used to describe efforts by general practitioners (GPs) to identify and refer patients who may benefit from nonmedical supports to a social prescribing “link worker.” Link workers assess patients’ needs and develop a “social prescription” to relevant services in the community.13 Social prescriptions may include referrals to exercise programs, nature activities, employment assistance, and a range of social services (e.g., welfare support and debt advice).14 Although little robust evidence exists regarding the effectiveness of social prescribing in England,15 recent reviews describe existing gaps in knowledge and factors that may influence the implementation16 and impact of interventions.17,18

Social prescribing programs in the United States are more commonly called “social needs” or “social care” interventions. These programs usually involve a social risk assessment or screening followed by efforts to connect patients with relevant social services or other resources. These resources may be on or off site and include health care–sponsored (e.g., on-site food pantries), government-sponsored (e.g., Medicaid-covered meal delivery programs), or community-based programs (e.g., Meals on Wheels).19 The staff for these types of activities varies across settings and may include traditional health care staff (e.g., physicians, nurses, and medical assistants) or nonmedical staff (e.g., social workers, community health workers, and volunteer navigators).20 Although the majority of studies evaluating social prescribing in the United States have focused on process measures and do not include comparison groups, a handful of randomized, controlled trials and strong quasi-experimental studies suggest that some social prescribing interventions can help reduce social needs, improve some health indicators, and, in some cases, reduce hospital utilization.21-24

The available evidence shows that the scope of services offered to patients in social prescribing schemes in the two countries have some similarities but also some notable differences (Figure 1).14,25-27 Programs in the United States typically concentrate on connecting patients to resources that help meet basic material needs, such as food insecurity and housing instability.28 Services in England also help address patients’ basic social needs, as well as enabling social prescribing practitioners to refer patients to other types of services, such as arts and crafts and volunteering programs, whose purpose is to improve the patient’s overall well-being and quality of life. The processes for identifying social needs and relevant services for community linkages also vary. Whereas interventions in the United States often use social risk screening tools, in England, interventions place less emphasis on standardized screening.29,30 As more social prescribing interventions are integrated into clinical care, policymakers in England and the United States are developing and testing a mix of policies to support adoption and scaling. Both countries are exploring how policy supports should be used to maximize programs’ uptake and effectiveness, by asking about which intervention components are most likely to affect health outcomes, core training and deployment strategies for the social prescribing workforce, the appropriate use of data and technology, sustainable financing models, and more.31

In this paper, we describe how public-financing approaches have progressed in both countries to support social prescribing. We highlight three models: (1) traditional health care and social service funding, which provides limited or no dedicated financial support for social prescribing activities; (2) flexible funding models that may encourage, but rarely directly finance, social prescribing; and (3) direct financing mechanisms for social prescribing (Table 1). Understanding the evolution of these governmental approaches to financing and ongoing challenges in England and the United States may advance the adoption of social prescribing in both countries and globally.

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References

  1. Braveman P, Gottlieb L. The social determinants of health: it’s time to consider the causes of the causes. Public Health Rep. 2014;129(Suppl.2):19-31. https://doi.org/ 1177/00333549141291S206.
  2. Marmot M, Bell R. Fair society, healthy lives. PublicHealth. 2012; 126(Suppl.1):S4-S10. https://doi.org/10.1016/j.puhe.2012.05.
  3. World Health Organization (WHO). Social determinants of health. https://www.who.int/health-topics/social-determinantsof-health#tab=tab_1. Accessed May 14, 2021.
  4. Koh HK, Piotrowski JJ, Kumanyika S, Fielding JE. Healthy people: a 2020 vision for the social determinants approach. Health Educ Behav. 2011;38(6):551-557. https://doi.org/10. 1177/1090198111428646.
  5. Hood CM, Gennuso KP, Swain GR, Catlin BB. County health rankings: relationships between determinant factors and health outcomes. Am J Prev Med. 2016;50(2):129-135. https://doi.org/ 1016/j.amepre.2015.08.024.
  6. McGinnis JM, Williams-Russo P, Knickman JR. The case for more active policy attention to health promotion. Health Aff (Millwood). 2002;21(2):78-93. https://doi.org/10.1377/hlthaff. 2.78.
  7. Braveman P, Egerter S, Williams DR. The social determinants of health: coming of age. Annu Rev Public Health. 2011; 32(1):381-398. https://doi.org/10.1146/annurev-publhealth031210-101218.
  8. Stringhini S. Association of socioeconomic position with health behaviors and mortality. JAMA. 2010;303(12):1159. https://doi. org/10.1001/jama.2010.297.
  9. Jemal A, Thun MJ, Ward EE, Henley SJ, Cokkinides VE, Murray TE. Mortality from leading causes by education and race in the United States, 2001. Am J Prev Med. 2008;34(1):1-8.e7. https: //doi.org/10.1016/j.amepre.2007.09.017.
  10. Galea S, Tracy M, Hoggatt KJ, DiMaggio C, Karpati A. Estimated deaths attributable to social factors in the United States. Am J Public Health. 2011;101(8):1456-1465. https://doi.org/10. 2105/AJPH.2010.300086.
  11. Alderwick H, Gottlieb LM. Meanings and misunderstandings: a social determinants of health lexicon for health care systems. Milbank Q. 2019;97(2):407-419. https://doi.org/10.1111/146812390.
  12. Alderwick HAJ, Gottlieb LM, Fichtenberg CM, Adler NE. Social prescribing in the U.S. and England: emerging interventions to address patients’ social needs. Am J Prev Med. 2018;54(5):715718. https://doi.org/10.1016/j.amepre.2018.01.039.
  13. Drinkwater C, Wildman J, Moffatt S. Social prescribing. BMJ. 2019;364:l1285. https://doi.org/10.1136/bmj.l1285.
  14. Chatterjee HJ, Camic PM, Lockyer B, Thomson LJM. Nonclinical community interventions: a systematised review of social prescribing schemes. Arts Health. 2018;10(2):97-123. https: //doi.org/10.1080/17533015.2017.1334002.
  15. Bickerdike L, Booth A, Wilson PM, Farley K, Wright K. Social prescribing: less rhetoric and more reality: a systematic review of the evidence. BMJ Open. 2017;7(4):e013384. https://doi.org/10. 1136/bmjopen-2016-013384.
  16. Pescheny JV, Pappas Y, Randhawa G. Facilitators and barriers of implementing and delivering social prescribing services: a systematic review. BMC Health Serv Res. 2018;18(1). https: //doi.org/10.1186/s12913-018-2893-4.
  17. Tierney S, Wong G, Roberts N, et al. Supporting social prescribing in primary care by linking people to local assets: a realist review. BMC Med. 2020;18(1):49. https://doi.org/10.1186/ s12916-020-1510-7.
  18. Husk K, Blockley K, Lovell R, et al. What approaches to social prescribing work, for whom, and in what circumstances? A realist review. Health Soc Care Community. 2020;28(2):309-324. https: //doi.org/10.1111/hsc.12839.
  19. Gottlieb L, Cottrell EK, Park B, Clark KD, Gold R, Fichtenberg C. Advancing social prescribing with implementation science. J Am Board Fam Med. 2018;31(3):315-321. https://doi.org/ 3122/jabfm.2018.03.170249.
  20. Sandhu S, Xu J, Eisenson H, Prvu Bettger J. Workforce models to screen for and address patients’ unmet social needs in the clinic setting: a scoping review. J Primary Care Community Health. 2021;12:215013272110210. https://doi.org/10. 1177/21501327211021021.
  21. Gottlieb LM, Hessler D, Long D, et al. Effects of social needs screening and in-person service navigation on child health: a randomized clinical trial. JAMA Pediatr. 2016;170(11):e162521. https://doi.org/10.1001/jamapediatrics.2016.2521.
  22. Pantell MS, Hessler D, Long D, et al. Effects of in-person navigation to address family social needs on child health care utilization: a randomized clinical trial. JAMA Netw Open. 2020;3(6):e206445. https://doi.org/10.1001/jamanetworkopen. 6445.
  23. Garg A, Toy S, Tripodis Y, Silverstein M, Freeman E. Addressing social determinants of health at well child care visits: a cluster RCT. Pediatrics. 2015;135(2):e296-e304. https://doi.org/10. 1542/peds.2014-2888.
  24. Berkowitz SA, Hulberg AC, Standish S, Reznor G, Atlas SJ. Addressing unmet basic resource needs as part of chronic cardiometabolic disease management. JAMA Intern Med. 2017;177(2):244-252. https://doi.org/10.1001/jamainternmed. 7691.
  25. Kreuter MW, Thompson T, McQueen A, Garg R. Addressing social needs in health care settings: evidence, challenges, and opportunities for public health. Annu Rev Public Health. 2021;42(1):329-344. https://doi.org/10.1146/annurevpublhealth-090419-102204.
  26. Sokol R, Austin A, Chandler C, et al. Screening children for social determinants of health: a systematic review. Pediatrics. 2019;144(4):e20191622. https://doi.org/10.1542/peds. 2019-1622.
  27. Zurynski Y, Vedovi A, Smith K. Social prescribing: a rapid literature review to inform primary care policy in Australia. Consumers’ Health Forum of Australia. https://chf.org. au/publications/social-prescribing-literature-review. Published February 10, 2020. Accessed March 1, 2022.
  28. Kreuter M, Garg R, Thompson T, et al. Assessing the capacity of local social services agencies to respond to referrals from health care providers: an exploration of the capacity of local social service providers to respond to referrals from health care providers to assist low-income patients. Health Aff (Millwood). 2020;39(4):679688. https://doi.org/10.1377/hlthaff.2019.01256.
  29. Andermann A. Screening for social determinants of health in clinical care: moving from the margins to the mainstream. Public Health Rev. 2018;39(1). https://doi.org/10.1186/s40985-0180094-7.
  30. Moscrop A, Ziebland S, Bloch G, Iraola JR. If social determinants of health are so important, shouldn’t we ask patients about them? BMJ. 2020;371:m4150. https://doi.org/10.1136/bmj.m4150.
  31. Sandhu S, Sharma A, Cholera R, Prvu Bettger J. Integrated health and social care in the United States: a decade of policy progress. Int J Integrated Care. 2021;21(4):9. https://doi.org/10.5334/ijic.

Citation:
Sandhu S. Alderwick H. Gottlieb LM. Financing Approaches to Social Prescribing Programs in England and the United States. Milbank Q. March 29, 2022. https://doi.org/10.1111/1468-0009.12562