Imagine leaving the hospital after a health scare and returning home to an empty fridge.
The electricity bill is overdue.
Your next medical appointment is across the city with no easy way to get there.
And the paperwork needed to apply for benefits feels impossible to figure out alone.
None of these challenges are medical.
But they can have a powerful impact on health and well-being.
For many older adults, health challenges don’t begin in a doctor’s office, and they don’t end there either. When everyday needs become unstable, health often follows.
This is where social prescribing comes in.
Research shows that more than 80% of health outcomes are shaped by social factors [1] such as housing, food security, income, and social connection.
For older adults, these realities often determine whether they can remain healthy and independent.
Across Calgary, many of the older adults (55+) referred to the In Place Social Prescribing Network:
- live alone
- are managing multiple health conditions
- have limited income
- are navigating complex systems without strong natural supports
When these pressures go unaddressed, people are more likely to experience worsening health, increased stress, and repeat visits to emergency departments.
Social prescribing recognizes that improving health often means addressing the social conditions affecting it, not just treating symptoms.
What Is Social Prescribing?
Social prescribing connects healthcare providers with community-based supports that address the non-medical factors affecting health.[2]
Across Canada and internationally, social prescribing is increasingly recognized as part of healthcare modernization, strengthening person-centered care and better integrating medical and community supports. (2)
It can support people at many stages of life. Programs across Canada have shown benefits for older adults, youth experiencing mental health challenges, and people facing social factors that affect health, such as isolation, financial stress, or difficulty accessing community supports. (2)
In Calgary, the In Place helps make that connection possible for older adults (55+).
When a physician, nurse practitioner, or other regulated healthcare professional recognizes that a patient’s health is being affected by challenges like housing instability, financial strain, food insecurity, or social isolation, they can refer that patient to the network.
Within 48 hours of receiving a referral, the team begins outreach
A trained Outreach Worker connects directly with the older adult, often meeting in their home, to understand their situation and co-create a personalized service plan.
From there, the focus becomes practical and hands-on.
What This Support Actually Looks Like
Support looks different for everyone, but an Outreach Worker might help with things like:
- Sitting down at a kitchen table helping someone apply for Canada Pension Plan (CPP), Old Age Security (OAS), Alberta Seniors Benefit, or Assured Income for the Severely Handicapped (AISH)
- Assisting with subsidized housing applications and follow up with housing providers
- Arranging escorted transportation to medical appointments
- Connecting someone to food supports or Meals on Wheels
- Helping complete Disability Tax Credit or Access Calgary forms
- Coordinating in-home supports
- Advocating to prevent utility disconnection
- Connecting individuals to mental health or addiction supports
These supports may sound simple.
But when someone is already managing health challenges, navigating multiple systems alone can feel overwhelming.
Outreach Workers act as a bridge between healthcare and community services, helping reduce barriers, coordinate support, and build trust.(2)
The goal isn’t just to provide information. It’s to ensure older adults don’t have to navigate these challenges alone.
For one client living with several types of cancer, staying active was an important part of supporting both mental and physical health.
But during the winter, walking their dog outdoors became increasingly difficult. Without that daily routine, both mobility and wellbeing were at risk of declining.
Through social prescribing:
- program funding covered 10 YMCA indoor track sessions so the client could safely walk their dog indoors
- Fair Entry was secured, allowing the client to afford a reduced YMCA membership after the initial sessions ended
- the client was supported in registering their dog as a service animal, allowing them to continue using the indoor track
Later, the client shared the exciting news that their service dog registration had been approved, allowing them to continue the routine that supported both their mobility and wellbeing.
A Coordinated Network Across Calgary
The Network is a partnership between Carya, JFSC, and Calgary Seniors.
Together, the network works closely with:
- Primary Care Networks
- Acute Care teams
- Community-based organizations
This collaboration ensures that when healthcare providers identify social needs, there is a trusted community response ready to follow through.
As the backbone organization for the network, Carya helps coordinate these partnerships, strengthening the connection between healthcare and community supports across Calgary.
Does it Work?
Yes, and the evidence extends beyond Calgary.
Evaluation findings from the In Place program show improved awareness of services, better access to supports, and reductions in emergency room visits for many clients.
National research also highlights the broader impact social prescribing can have.
Research suggests social prescribing for older adults could prevent over 245,000 hospital days annually due to falls alone, while also reducing emergency department visits and hospitalizations. (2)
The same research estimates that for every $1 invested in social prescribing, approximately $4.43 in social and economic value may be generated through improved wellbeing and reduced system costs. (2)
Healthcare providers also report that social prescribing helps align social and medical needs, allowing them to focus on clinical care while knowing their patients’ broader needs are being addressed.
When social factors are stabilized, health outcomes improve, and strain on emergency systems decreases.
Why this matters now
Canada’s healthcare system is under strain. The population is aging. And many adults fall into service gaps, particularly those aged 55–64, who may not yet qualify for seniors-specific programs.
Social prescribing offers a practical way to shift from reactive care to preventative, person-centered support.
It shifts the focus from responding to crisis to preventing it.
How to Take the First Step
Social prescribing referrals are made through healthcare professionals.
If you are an older adult or caregiver:
• Speak with your family doctor or nurse practitioner
• Ask whether a referral to the In Place Social Prescribing Network could help
If you are a healthcare provider:
- If you’re interested in referring a patient, contact Megan Hincks (MeganH@CaryaCalgary.ca) for more information.
Sometimes the hardest part is knowing where to start.
A conversation with a healthcare provider can open the door to coordinated, practical support.
Health Begins at Home
A prescription can manage symptoms.
But safe housing, stable income, nutritious food, reliable transportation, and meaningful connection protect health at its foundation.
By addressing social needs early, we don’t just reduce hospital visits.
We help older adults remain independent.
We restore stability.
And we build stronger, healthier communities, together.
[1] Hood CM, Gennuso KP, Swain GR, et al. County health rankings: relationships between determinant factors and health outcomes. Am J Prev Med 2016;50:129–35.doi:10.1016/j.amepre.2015.08.024
[2] A Healthier Canada: An Analysis of the Potential Economic and Social Impacts of Social Prescribing (Canadian Institute for Social Prescribing)