It's no secret that health systems in the United States (US) are in need of major transformations. While some agents are trying to improve efficiency of current operations or promote better experiences for patients, others are embracing broader social factors influencing health outcomes. Many are developing new ways of working that are a better fit for people's homes and social structures than medical environments. Very few deny the COVID-19 pandemic laid bare how larger social determinants such as housing, employment, mental health, social isolation, and access to safe areas for physical activity impact the overall health and well-being of individuals and communities.

It was in this context the Design Laboratory at the Harvard T.H. Chan School of Public Health (D-Lab) collaborated with the Center of Arts and Medicine at the University of Florida and Social Prescribing USA to undertake the Design for Social Prescribing: Bridging Silos for Health Promotion project. This six-month project was divided into three phases and leveraged design knowledge to expand and accelerate the adoption of social prescribing initiatives in the US.

Social prescribing is a growing area of research and practice that offers a promising approach to addressing social determinants of health. It has been integrated into the national health systems of countries such as the United Kingdom, Canada, Australia, and Japan, currently taking the form of health professionals referring people to social activities in their communities. Examples include but are not limited to nature walks, ballroom dance classes, visits to museums, and cooking classes.

Phase One involved secondary research and interviews with key stakeholders across sectors and industries to learn about interest, viability, and implementation of social prescribing initiatives in the US. This phase surfaced six action areas critical for expanding and accelerating the movement in the US. Phase 2 brought together 40+ participants from across the US, Canada, and the UK to co-design and prototype systemic interventions in support of this agenda. Representatives from the public, private, social, and academic sectors working in public health, health care, design, digital health, arts and culture, community development, environmental conservation, education, volunteerism, and philanthropy worked in multidisciplinary teams and conceptualized platforms that included and supported diverse stakeholders influencing public health and well-being. Phase Three focused on recommending ways forward given the data collected during the previous phases. Our analysis surfaced four themes and related social tensions that needed to be considered when expanding and accelerating social prescribing initiatives in the US. A final report was published outlining the findings, the approach taken, immediate impacts, and next steps.

This was a first-of-its-kind project in the US. While the transformations it ignited will be surfaced in the years to come, some of its immediate impacts include the Center for Arts and Medicine expanding their program evaluation strategy to include and prioritize anti-racist criteria, a conference proposal made to the office of the Mayor of New York City interested in driving forward social prescribing, and a physicians working group organizing themselves to push the movement in the US.

Social Prescribing: Advancing an Audacious Idea

The COVID-19 pandemic laid bare how larger social determinants such as housing, employment, social support structures, mental health, social isolation, and access to safe areas for physical activity impact the overall health and well-being of individuals and communities. Design for Social Prescribing: Bridging Silos for Health Promotion is a project that leverages design knowledge to help address some of these and other society's most pressing challenges by expanding and accelerating the social prescribing movement in the United States of America (US).

Social prescribing is a growing area of research and practice in the US that offers a promising approach to promote paradigm shifts in US health systems. Social prescribing currently takes the form of healthcare professionals referring patients to non-clinical community and social services that support the individual's larger social needs, and bolster their overall health and well-being. These might include nature walks, ballroom dance classes, visits to museums, cooking classes, or any other ways that people can engage to achieve their social aspirations. While social prescribing is integrated into the national health systems of countries such as the United Kingdom (UK), Canada, Australia, and Japan, it has only recently begun to take root in the US through pilots in at least 21 cities across six states.

It was in this context that Reena Shukla, a Builder Fellow at the D-Lab, thought to explore the value design brings to the early stages of complex initiatives. While at the D-Lab, Reena experienced the usefulness of design in helping organizations navigate the uncertainty of complex endeavors laden with concrete factors driven by technology and economics, and with ambiguous behavioral factors driven by emotion and culture. She then engaged two leading institutions pushing social prescribing in the US as key collaborators to team in this project: the Center of Arts and Medicine at the University of Florida and Social Prescribing USA. Additional collaborators included the World Health Organization, National Academy for Social Prescribing, and the Global Social Prescribing Alliance.

Approach

The project was structured around the Whole View, a conceptual model developed by Patrick Whitney and Andre Nogueira, co-founders of the D-Lab. The model offers a set of advanced frameworks and methods strategically connected to show the relationships among various forces influencing a project. These forces are revealed as teams use the model to integrate viewpoints of strategy, value, operations, offerings, and users around the purpose for making change. The Whole View has supported organizations across sectors in beginning exploratory initiatives with a broader understanding of problems—and opportunities—in a fraction of the time compared to traditional management processes.

Activities and Findings

The overall goal of the project was to help diverse stakeholders working in social prescribing initiatives in the US use design knowledge to expand and advance their efforts. The project was carried out in three phases: Understanding Context, Broadening Perceptions, and Exploring Pathways. Following we present a brief description of each phase.

Phase I: Understanding Context

During Phase I, researchers conducted secondary research and interviewed key stakeholders to learn about interest, viability, and implementation of social prescribing initiatives in the US. Content gathered through these methods was analyzed using frameworks from the Whole View. Together, the team uncovered six action areas that diverse organizations have prioritized in their agendas. While not extensive, these action areas present common intervention spaces where stakeholders can continuously advance their own agendas while contributing to a shared purpose. The action areas briefly described below informed activities in Phase II.

+ Broadening referral systems: The digitalization of health systems can allow physicians to systematically screen patients and refer them for social services accordingly.

+ Building capacity of social services systems: Investing more in the social services ecosystem can strengthen overall capacity to promote better health outcomes.

+ Making the economic case: Analyzing financial and health outcomes data from ongoing and new social prescribing initiatives is key to informing sustainable financing models for future expansion.

+ Linking to parallel movements: Connecting to existing patient-centered care movements can fuel learning and bolster momentum for the social prescribing movement.

+ Disseminating knowledge: Increased dissemination and awareness of social prescribing can bolster the practice and generate evidence for implementation.

+ Centering around the community: Social prescribing needs customization based on the community assets and sociocultural characteristics across diverse communities.

Phase II: Broadening Perceptions

In Phase 1, it became evident that while all stakeholders recognized the need to transform the current state of health care, none had a comprehensive understanding of the challenges and opportunities across all the possibilities for influence.

This complex and often conflicting understanding of best ways forward was used to design a first-of-its-kind convening of 40+ stakeholders across sectors and industries. Between October 27 and 28, 2022, people from the public, private, social, and academic sectors working in public health, health care, design, digital health, arts and culture, community development, environmental conservation, education, volunteerism, and philanthropy came together at Harvard's Innovation Lab to broaden their perspectives towards expanding and accelerating social prescribing efforts in the US. Participants included the Director of the Division of Extramural Research from the National Center for Complementary and Integrative Health of the National Institute of Health, the Clinical Champion Lead from the National Academy of Social Prescribing in the UK, the Chair of Geriatric Innovation from the Cleveland Clinic, Co-Founders of the Harvard Undergraduate Initiative for Social Prescribing, and the Director Community Health and Equity from Blue Cross Blue Shield.

Co-design activities were structured to help participants explore the broader purpose of social prescribing. Participants were organized into cross-sector groups. Each group co-created a platform concept in response to the considered aspirations, needs, and related problems of a specific stakeholder group. The following six platform concepts were developed:

+ Integrating Health: connecting health providers with community assets to expand their medical practices beyond conventional one-to-one clinical interactions.

+ Collective Community Care: enabling patients to access emotional, practical, financial, and social support services to create a culture of health.

+ Link Co-Creators: building the capacity of community members to become anti-oppressive and trauma-informed links to community-based well-being services fit to individuals' needs and aspirations.

+ Interconnectivity: supporting partnership formation across community organizations to increase access to resources, diversity, visibility, and impact in the community.

+ Community-Based Ecosystems: bridging silos across government agencies to increase efficiencies in resource allocation and create feedback loops in response to community priorities.

+ Neighbors in Health: helping insurance companies justify coverage parity in service delivery through the rigorous use of data to design low-cost and culturally-sensitive social interventions.

Phase III: Exploring Pathways

During Phase III, researchers integrated data collected during the convening—including conceptual prototypes, audio recordings, participant interviews, photos, field diaries, and direct observations—with data collected from Phase 1. The resulting analysis surfaced four themes and related social tensions that underlie social prescribing debates in the US, presented here as paradoxes to be considered by leading agents when designing interventions.

+ Language: Locking in a definition <> Agreeing on a Meaning

While some prioritize defining social prescribing in the US context, others argue for harnessing the momentum of the movement to broaden the notion of health, and promote a shift in current care paradigms.

+ Governance: Control of the System <> Autonomy of the Parts

While some seek to establish a common policy framework and control over various factors influencing success before intervening, others recognize the role of numerous multi-sectoral agents acting independently.

+ Process: Enabling Bottom-up <> Enforcing Top-Down

While some strive to pull change by focusing on ongoing initiatives happening on the ground, others argue that change must be pushed through top-down mechanisms.

+ Evaluation: Benchmarking the Past<>Prototyping Futures

While many wait for evidence from pilots in existing systems before making decisions about future directions, others recognize that the novelty of this work requires exploration and experimentation.

Next Steps

Design for Social Prescribing: Bridging Silos for Health Promotion explored a new care paradigm to help address some of society's most pressing challenges affecting the health of the public. Our work thus far suggests that transformation in US health systems will require an in-depth understanding of the ways in which diverse stakeholders have arranged themselves to seek, deliver, and experience care services, including but not limited to those belonging to health systems.

This project has resulted in greater openness of participants involved to consider diverse ideas that can impact their work. It also accelerated learning across stakeholder groups about new opportunities in this space. The convening allowed several voices leading social prescribing initiatives in the US to come together as a group, learn from one another, and explore non-traditional multi-sectoral collaborations.

These explorations have been advanced through different pathways, which we highlight in the immediate impact section of the attached report. In parallel to supporting these and other activities, the collaborators of this project are currently exploring ways to structure a long-term initiative, involving diverse stakeholders alongside participants of the convening to expand and accelerate the social prescribing movement in the US.