SOCIAL PRESCRIBING IN MEDICAL CLINICS
A simple, clinic-ready model that connects patients to non-medical supports while reducing GP admin load.
What is social prescribing?
An evidence-informed approach where GPs and primary care teams refer patients to non-clinical supports via a trained link worker.
Why now (for your clinic)?
An evidence-informed approach where GPs and primary care teams refer patients to non-clinical supports via a trained link worker.
HTS service model (clinic-based)
Roles
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GP / Registrar / Nurse: identify eligible patients, obtain consent, send brief referral
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Practice Manager: scheduling, rooming space (optional), oversight of visitor policy
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HTS Social Prescribing Link Worker (Navigator): assess non-clinical needs, co-design action plan, connect to services, follow-up, and report back to GP
Patient eligibility (typical)
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Frequent attenders with non-medical drivers (isolation, housing/finance stress, employment/education barriers)
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Mild-to-moderate anxiety/low mood; LTC self-management challenges; carer strain
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Ready and able to engage (with carer involvement if needed)
The Nuts & Bolts of Social Prescribing
Social Prescribing -What is it?
Model of care that involves referring people to non-medical and community-based supports, to assist in reducing isolation, disadvantage and other unmet needs:
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Non-clinical
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Patient directed
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Holistic
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Sustainable
Health care provision can’t address many of the socioeconomic and environmental factors that result in ill health
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The siloed funding of health, social and welfare service systems further complicates this
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There are time and capacity restraints for GPs and Primary Care Nurses on assisting individuals to address their non-medical needs and take greater control of their own health and wellbeing.
Social Determinants of Health (SDOH) Domains:
Addressing SDOH Domains
Basic Human Needs Resources –including food and clothing banks, shelters, access to Centrelink / financial assistance
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Work Support –including financial assistance, job training, transportation assistance and education programs
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Support for Older Australians and Persons with Disabilities –including assistance accessing NDIS and My Aged Care, respite care, community meals, home health care, transportation, and homecare services
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Children, Youth and Family Support –including childcare, after-school programs, educational programs for low-income families, tutoring and child protection
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Physical and Mental Health Resources –including healthcare, DVA, helplines, crisis services, support groups, therapy, AOD interventions
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Access to Services in Non-English Languages –including language translation and interpretation services to help non-English-speaking
Patient Identification for Social Prescribing:
Easier to…
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Provide a physical examination
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Check BP / vital signs
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Provide education about health
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Ask about and encourage exercise
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Encourage someone to lose weight
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Be put off when people don’t show
Harder to…
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Know if a person struggles to pay bills
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Screen for loneliness, mental health
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Ask if a person can read or about schooling
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Ask about housing safety and tenure
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Ask about the ability to secure health food
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Know about a person’s access to transport
Services offered Australia wide:
Anyone of any age including children and young people whose mental health is suffering because of factors related to COVID and the management of the pandemic such as:
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Loneliness, Stress, Anxiety, or Depression
Major adjustments (loss of job, family issues, AOD usage, housing insecurity, etc.)
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Who would benefit from Information and assistance accessing mental health supports
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Personalised assessment and planning.
A Holistic Tree Services (HTS) - Navigator
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Works directly with clients referred through GPs, My Aged Care, NDIS, or mental health services.
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Assesses a client’s social, emotional, and community needs.
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Connects clients with appropriate local services, activities, or community supports.
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Provides ongoing care coordination and follow-up to ensure the support is effective.
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Works alongside clinicians, case managers, and families to provide a holistic care pathway.
In short, this role blends case management, community navigation, and wellbeing support, aiming to reduce isolation, improve quality of life, and complement clinical care.
Head to Health – Key Benefits Summary:
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Improves inclusion, equity for all patients
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Better access to services (e.g., reduced time waiting for services, better access to low or no cost services for people with financial challenges)
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Quicker time to supports (and reduced distress, pain, loneliness, and unmet social and welfare needs)
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Provides access to social prescriptions, community navigation and social work services outside the clinic setting
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Access to limited OT services to provide assessments and assist people to access needed supports
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Improves connectivity between health, social, welfare, and community services
