Symposium 3 - Medical-Social Collaboration and Patient Empowerment

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.

We are in an exciting time in medicine. Many new medications will become game-changers, and more and more technologies are allowing miracles to be performed, in the dark, through keyholes. These medications and technologies alone however will not be enough to fully curb the global burden of disease, and achieve better health and well-being for all who live with chronic diseases. Also important for achieving these goals is the gaining, deserving and maintaining of a patient's trust, by their clinicians and their health systems. As societies, we need to move on from the paradigm of medical paternalism to explore and achieve true care partnerships. People living with chronic diseases manage their disease every day, their interaction with the health system is intermittent – they are therefore their own primary health care givers. As such it is important to recognize that each patient is their own best "expert". A true care partnership will be one where the clinician and the patient come together as "experts" on equal footing, to carve out the right route together through the chronic illness, by identifying goals and obstacles, and understanding perspectives. Medical paternalism may still have a role in some settings, but in general, the  building of effective care partnerships is more holistically aligned with all of the biomedical ethics principles - autonomy, promoting benefit, avoiding harm, and achieving fairness. In Africa there is a well known saying "umuntu ngumuntu ngabantu" - a human is a human because of other humans. This highlights how we cannot thrive as individuals. Clinical medicine is breaking down more and more technical barriers – to retain the humanity in medicine we need to function as communities and partners to collectively continue to strive towards achieving the highest attainable state of health for all.

The role of consumers in health policies, programs and services has evolved significantly over the past decades and is now viewed as a basic element in governance, design, implementation and evaluation. It is considered so vital to assuring safe and quality health service provision that partnering with consumers is a fundamental standard in the accreditation of services.


However, the methods for engaging consumers are diverse - from large codesign processes to consumer representation on committees to the adoption of real-time, patient-reported measures. For a system confronted by sustainability challenges – how do we make sure we are engaging consumers at the right time and in the right way for effective decision-making?


Kylie will share insights and experiences from the Australia health system to meaningfully engage consumers.