Social Prescribing
Social Prescribing
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「在家會頭痛、腰痛、通通痛，
每天來這裡煮菜給大家吃，止痛藥都不用了。」
“At home, my head hurts, my back hurts—everything hurts. Since I started coming here every day to cook for everyone, I haven’t needed painkillers.”
— A 90-year-old patient, in conversation with me
How can healthcare connect with communities for care and support beyond the clinic?
Connecting geriatric care with community life
Connecting geriatric care with community life
Health is shaped by everyday relationships, meaningful activities, and a sense of belonging. Healthcare is one part of this wider picture. Social prescribing connects people with community activities and non-medical support that matter to them.
Yet an invitation or referral does not always lead to participation. Limited mobility, transport difficulties, unfamiliar surroundings, or having no one to go with can make the first step difficult.
In Taiwan, frequent contact with healthcare offers an opportunity to recognise these needs. A clinical consultation can reveal concerns that extend beyond medical treatment: feeling isolated, managing caregiving responsibilities, losing confidence, or struggling to take part in community life. Community universities and local organisations offer spaces for learning, contribution, and connection.
Our work explores how healthcare can connect older people with opportunities for learning, relationships, and participation in their communities. Working with healthcare professionals, community universities, and local partners in Taiwan, we are developing social prescribing that responds to different levels of frailty and the realities of everyday life.
What we are exploring
What we are exploring
What does it take to make community participation possible, meaningful, and sustainable?
We focus on three connected questions:
What matters to different older people? How do interests, everyday circumstances, social support, and levels of frailty shape the participation people value and the support they need?
What stands between referral and participation? How do capability, opportunity, and motivation influence whether someone can reach, join, and continue an activity?
Who helps make the connection work? What roles, relationships, and support are needed to connect geriatric care with community life?
Our approach combines persona development, participation barrier mapping, and co-design workshops with healthcare and community partners. Together, we translate identified barriers into service responses, from personalised matching to supported transitions and ongoing feedback.
How we are developing social prescribing within geriatric care
How we are developing social prescribing within geriatric care
We use a participatory service-design approach to develop social prescribing that responds to older people’s everyday lives and different levels of frailty.
We begin with persona development to understand their circumstances and participation needs, then map barriers using the COM-B framework of capability, opportunity, and motivation.
Through co-design workshops, healthcare professionals and community partners translate these insights into a care pathway. It works from recognising social needs and matching community opportunities to supporting participation and maintaining follow-up.
These steps inform our Social Prescribing within Geriatric Care Model and the development of a Link Worker Education Programme, preparing the ground for testing and refining the approach in practice.
What this work is producing
What this work is producing
This work brings together community-based research, service development, and link worker education.
Personas
Frailty-sensitive personas illustrate how older people’s circumstances, abilities, and support needs differ. They help partners consider what participation could look like for each person, and what would make it accessible, meaningful, and dignified.
Barrier mapping
A participation barrier map, informed by the COM-B framework of capability, opportunity, and motivation, identifies where engagement can break down. It brings physical, practical, social, and psychological barriers into view, helping partners identify where support is needed.
Co-design insights
Insights from collaborative workshops identify the work needed to turn a referral into participation. This includes explaining available opportunities, finding a suitable match, supporting registration and transport, arranging companionship, and maintaining communication across settings. These insights inform a locally grounded link-worker role.
The Social Prescribing within Geriatric Care Model
A co-designed model connects five stages: recognising social needs, personalised referral, supported transition, community participation, and follow-up. It builds attention to frailty, individual preferences, practical support, and feedback into the pathway between healthcare and community partners.
Link Worker Education Programme
An education programme translates the model into learning for volunteers (including medical students) taking on link-worker functions. It focuses on understanding what matters to older people, recognising social needs, navigating community resources, and making supported transitions, and follow-ups. The aim is to build the skills and relationships needed to help people take the next step into community life.
Where this work is going
Where this work is going
From a co-designed model to a pathway that works in everyday practice.
With the initial design work complete, our next focus is link-worker education and preparation for testing the model in practice.
We aim to examine whether the pathway is feasible for healthcare and community partners, acceptable to older people, and accessible across different levels of frailty. Future evaluation will consider whether people can begin and sustain participation, whether that participation matters to them, and who remains excluded.
The longer-term goal is to make connections between geriatric care and community life part of routine support for ageing, creating more opportunities for older people to learn, contribute, and belong.
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