Care transitions, the process of moving patients between healthcare settings and back to the community, represent critical junctures in the patient journey. Patients with poor social determinants of health - such as low income, inadequate housing, weak social networks, and limited health literacy - face disproportionate risks of adverse outcomes during care transitions. These patients often experience fragmented care, medication non-adherence, and unmet social needs, leading to avoidable hospital readmissions and poorer health outcomes.
While healthcare systems have made significant progress in care integration within the healthcare system, many transitional care models remain inadequate in closing the last mile - the return to the community. The lack of systematic collaboration between health and social care providers leaves vulnerable patients unsupported once they leave the healthcare silo. This gap highlights the urgent need for health and social care integration to address both clinical and social needs during care transitions.
Community partnerships play a pivotal role in bridging this gap, enabling healthcare providers to tap into community resources that support patients beyond medical care. However, these partnerships are often underutilized due to the lack of structured and well-designed mechanisms for connecting patients to community-based support services.
Social Prescribing is emerging as a transformative solution to close this gap, offering a structured approach to link patients to community assets that address social determinants of health. By connecting patients to contextualized community services such as befriending programs, financial assistance, and wellness activities, social prescribing empowers patients, enhances social connectedness, and improves health and well-being.
Embedding social prescribing into transitional care models represents a significant paradigm shift, fostering collaboration between health and social sectors to build more person-centered, sustainable systems of care for patients in need. This integrated approach holds the potential to improve care transitions, reduce avoidable hospital utilization, and promote better health outcomes for vulnerable populations.
