According to an often-referenced 2002 Health Affairs research article, an estimated 60% of early deaths are caused by interconnected factors beyond genetic predisposition and shortfalls in medical care—namely individual behavior (40%), social circumstances (15%) and environmental exposures (5%). Over 15 years later, health systems and community services are increasingly partnering in an effort to address the broader determinants of poor health in the populations they serve.
In Health for hire: Unleashing patient potential to reduce chronic disease costs, Clayton Christensen, Andrew Waldeck and I suggest a framework that can help healthcare professionals in such partnerships. The key to this framework, according to our research, is uncovering patients’ Jobs to Be Done—that is, the progress patients are trying to make in their lives at a particular juncture. Knowing a patients’ Jobs to Be Done helps healthcare professionals work with them to define evidence-based, health solutions for those jobs that patients can fully embrace, given their unique circumstances, values and aspirations.
For instance, knowing that a patient suffering from anxiety and high blood pressure has the job, “excel at work so I can better support my family,” a healthcare professional might suggest (among other things) mindfulness-based stress reduction. The patient might be more successful engaging with that practice if she understands that, in addition to potentially helping her better manage her anxiety and blood pressure, it may also lead to better sleep, and more energy and focus for her work. Assistance in finding a course that aligns with her work and childcare schedules will also increase her chances of success with the practice.
The United Kingdom’s “social prescribing” movement illustrates the potential of the Jobs to Be Done framework. Social prescribing programs enable healthcare professionals to refer patients to qualified community services for help addressing non-medical, health-related needs, often in line with the life progress patients are already trying to make. Not-for-profit Age UK runs a program in cities across England, called the Personalised Integrated Care program, which makes extensive use of social prescribing.
Primary care physicians participating in the program identify older patients with multiple, long-term conditions and risk of unplanned hospital admissions, and refer them to an Age UK Personal Independence Coordinator (PIC). Through a carefully structured dialogue, the PIC helps the patient articulate the goals that matter most to them at that point in life. Then the PIC works with the patient to create a plan for achieving them, and introduces them to community health, social care and volunteer services that can help them do so. Importantly, the PIC also reconnects regularly with patients and their primary care teams to review progress against the plan.
Social prescribing referrals vary across programs, and represent the diversity of a patient populations’ health-related needs and goals. Socially isolated people suffering from depression might be “prescribed” art classes or a fishing group. Diabetics might be introduced to peer-support groups to assist in self-management, and overweight people might be referred to walking clubs or subsidized swimming classes. People struggling to pay utility bills or access public housing benefits could be connected with financial advisors and social service advocates.
But whatever activities or assistance offered, the practice of social prescribing recognizes that people need much more than medical care to be healthy. Many need help overcoming non-medical barriers to health, and making the progress they seek in life.
Studies suggest that social prescribing can help improve quality of life, alleviate depression and anxiety, reduce emergency hospital visits, and more. But the practice is still in its infancy, so more rigorous and systematic study is necessary to fully assess its health, cost and healthcare system capacity benefits. Yet, it is difficult to study complex interventions like social prescribing, which address varied issues through varied means.
There’s also much to learn about how to structure and scale the social prescribing models emerging today. Social prescribing is not a turn-key process that can simply be bolted onto a traditional healthcare delivery model. It requires new processes for identifying patients with health-related social needs, uncovering the unique factors impacting their ability to embrace certain solutions, and vetting community services to which patients would be referred. Underlying these processes must be the capability to understand the broader progress patients are striving to make in their lives, so that the referrals don’t conflict with what really matters to them.
Social prescribing also often requires new resources, in the form of patient navigators or health coaches who are specially trained to make referrals, and sometimes to follow up with patients to ensure they’re getting the support they need. And then of course the practice requires up-front investment, which is tough to come by in any healthcare environment.
But with accelerating innovation in primary care and value-based payment models, unprecedented cross-sector mergers designed to tackle healthcare costs, and the proliferation in digital solutions supporting patient self-care, there couldn’t be a better time to test the full potential of social prescribing in the U.S.
