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Conference Abstracts

Integrating primary care and community social services through Social Prescribing


Grace Park

Fraser Health Authority, CA
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Through partnership with community primary care providers and their older adult patients, Fraser Health is working to promote healthy aging and prevent frailty.  A holistic geriatric assessment tool is provided to the PCPs and during care planning, social services referral is created through socialo prescribing.  Unite Way has provided grants to fund local Seniors' Community Connectors who receive these referrals from PCP and connect with seniors to identify appropriate community programs to increase exercise and social engagement.  The social prescription provides a vehicle to ensure social factors that contribute to frailty development are addressed.

Aims Objectives Theory or Methods

Primary Care providers identify vulnerable seniors during their yearly complex care planning session.  Their frailty index is measured using an electronic Comprehensive Geriatric Assessment tool in their EMR. The careplan includes a wellness plan to address goals of care and social factors based on what is important to the senior.  The local Seniors' Community Connector located at a chosen Non Profit Agency helps to set goals for the senior to increase their activity and social engagement.  Local community resources including volunteer drivers and friendly visitors are deployed to help overcome any barriers for seniors to attend activities.

Highlights or Results or Key Findings

Integration of health and social services through the social prescribing scheme has led to better awareness of activities in the community.  As the desire to age in place and promotion of independence in the community for seniors, the holistic approach including social factors that contribute to healthy aging has been highlighted. Primary Care providers have a point of contact for the critically valuable community services for their seniors while the added resource of a seniors' community connector helps to overcome barriers for seniors and increase social interactions.  The Canadian Frailty Network AVOID strategy is deployed by the physicians and the seniors community connectors to help motivate the seniors to engage in the health protective behaviors.  Working with the Divisions of Family Practice in the FH region helps the project team to reach all primary care practitioners to bring the education on frailty prevention and social prescribing.



While the work has been somewhat curtailed by the Covid 19 pandemic, the primary care prevention of frailty through social prescription is based on evidence and leverages the primary care providers' unique position to intervene as their patients start becoming vulnerable to implement services and programs that will prevent frailty.

Implications for applicability/transferability sustainability and limitations

Throughout its development the primary care frailty prevention work called CARES has developed a toolkit that is available for any other health service delivery providers.  Webinars have been provided and are available through Doctors of BC Shared Care Services for other jurisdictions who wish to learn more about CARES.

How to Cite: Park G. Integrating primary care and community social services through Social Prescribing. International Journal of Integrated Care. 2022;22(S2):11. DOI:
Published on 16 May 2022.


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