Many patients, particularly those experiencing socioeconomic disadvantage, present to GP’s with a range of issues that are non-medical, but which impact their health and wellbeing. Social prescribing is an integrated care approach that is designed to complement traditional health care by providing social prescriptions to assist people to address these issues and build their capacity to self-manage. The approach is widely implemented in the United Kingdom in General Practice. Early evaluation has shown these programs to have some benefit for patients. To date there has been little development of SP models in Australia. A test model of Social Prescribing is currently being trialled by IPC Health, in partnership with the Northwest Melbourne Primary Health Network (NWMPHN) and the Brimbank Collaboration (Brimbank City Council and Australian Health Policy Collaboration, Victoria University)


IPC Health is a General Practice and community health centre in Melbourne’s West. In this model, referrals from GPs, nurses and Allied Health staff are made to a Community Linkworker, a new position, who works with the client to understand their needs and goals, and to develop a plan around these goals, and facilitate local sources of support. These support services may include but are not limited to local community groups, legal or financial services, group exercise classes or parenting support. Referrals may also come from service agencies and individuals in the community. The Linkworker maintains contact between the client and the GP to ensure consistent, and integrated care, rather than simply referring to external services.

This trial project is comprised of three stages: research, testing and a full implementation at IPC Health Deer Park community health centre. The aim of the project is to develop the service pathways by understanding the client journey through referrers, Linkworkers and community partners, and to identify the most effective interventions and connections for relevant population groups.

The project will be delivered to IPC Health patients in the testing phase and will then be expanded within the Brimbank area.

Project Timeline: 01 July 2018 - 30 June 2020

To date the project has completed community asset mapping (identification and engagement of local community-based services) and has commenced direct client support.

The testing phase will support the development of a sustainable model of care that will underpin the full implementation of the model for all patients who meet the inclusion criteria and wish to participate.

It is anticipated that this project will test a model of social prescribing in an Australian setting which can be transferred to other regions.

To date the project has established a strong partnership to support development of the pilot model and connections with community assets necessary to appropriately prescribe social and community connections and interventions. Early client engagement is beginning to shed light on the practical implementation of social prescribing. More will be known by November 2019.

Lessons learned will focus on themes such as the development of service pathways, developing/updating internal processes to support Social Prescribing, and the client cohort, their needs and their journey through the service.

Introduction
The community-based integrated care system was introduced as a nationwide public service in Japan approximately ten years ago. The system has been focused mainly on cooperation between health care and social services. Combined services have been implemented in some “integrated care centers” to reach more areas of the population; not only the elderly, but also abused or neglected children; people with disabilities; and those with poor living standards. The centers became hubs connecting vulnerable citizens, and had a new role in community-based disaster responses.
Many municipalities in Asia-Pacific countries must prepare for and respond to natural disasters such as earthquakes and typhoons. It is critical that we plan for the evacuation and security of those who need assistance, by working with neighborhood associations; community social workers; nursing homes; welfare offices; and in-home care services; among others.

Methods
The survey was conducted by questionnaire, targeting all 2,013 community-based integrated care centers in Japan, with the approval of the Ethics Committee at Tohoku University. Participants were asked questions about the current status of disaster preparedness and response; and what problems need to be addressed in the future.

Results
There were responses from 1,101 community-based integrated care centers. The response rate was 54%. Eighty percent of the centers had a manual for disaster response. Only 10% had a Business Continuity Plan (BCP). One third had mobile phone and social networking site (SNS) plans for communication between staff members, and 22% had criteria for using the centers in cases of emergency. Approximately 30% of centers had no stockpiling. However, 21% had more stockpiling than they needed. Very few centers were collaborating with local medical institutions. More than half did not know about the community map indicating residents who need support in an emergency; although many had a medical and social care resource map. Staff at nearly 80% of the centers had never received training. The privacy protection law prohibited the team from obtaining precise information about the people who need the most support during disasters.

Discussion
There were significant differences in disaster preparedness plans among the centers. Plans varied depending on the priorities of each center’s administration. Additionally, support services can be different depending on the type of disaster; i.e., an earthquake rather than a tsunami.

In particular, plans are needed for those requiring electricity to power respirators or at-home oxygen machines; and to operate electric vehicles. It is vital to collect data on vulnerable residents while respecting privacy protection laws. It is also crucial that local organizations work together to create a map of each community’s health and social care services.

Conclusion
This study shows the current status of community-based integrated care systems, and the problems that must be addressed in the future.

Limitation
The low response rate may be due to the fact that many centers are not currently considering disaster preparedness.

Suggestions for future research
Based on the current system for disaster response, it is necessary to add a community-based, integrated BCP to risk-management plans.

Background

Like many other developing countries, Singapore is facing the convergence of an ageing population, increasing chronic disease, escalating healthcare costs and increasing complexity in the delivery of health and social care. Also like other countries, Singapore is making the transition from a health system designed for episodic acute care of a relatively young and healthy population to one that must continuously and coherently manage, support and provide health and social care for many persons with one or more ongoing morbidities and varying levels of functional ability through a network of independent care providers within the community and even within their clients’ own homes.

While it may be generally accepted that some form of Population Health would have to be implemented, it remains unclear how it can eventually be architected or operated. This is particular so for the community of care providers where the very concept of Population Health is nascent and somewhat vague. Individual persons have the freedom of choice of providers, and many indeed have not only more than one primary care provider (including a private general practitioner for acute coughs and colds and a government polyclinic for cheaper drugs for chronic diseases), the same person may also be seen at more than one acute hospital in both the public and private sectors. A patient register seems to be a far-off eventuality, however critical it is to a true Population Health approach.

The Population Health approach, beyond considering the social determinants of health in addition to the treatment of known diseases, also addresses inequalities of access and utilisation of appropriate health and social care and its outcomes. To measure how a community fares necessarily assumes a definition of that community.

Presentation

This presentation summarises the efforts of one community-based charitable organisation, in the midst of what might be called a Population Health-unfriendly environment, to adopt and care for an underprivileged locality that it defines, enrolling all willing persons within that locality into a care programme that includes health education, lifestyle advice, social support and engagement, regular health screening and follow-up, patient activation, and ongoing care and monitoring of chronic disease, supplemented by more conventional episodic care for incidental acute conditions.

The presentation will then propose how this model of care for one locality can be scaled across different constituencies by this and other organisations under the umbrella of the regional health systems, and potentially gradually transform the foundational construct of the health and social care delivery system.

Introduction: Social isolation and living alone are perceived as potential risk factors for poor health outcomes and inappropriate and/or inadequate service use. It is estimated that the prevalence of social isolation and living alone among older people in Australia is 17% and 25% respectively and increasing. The role social isolation, living alone play in health service use, morbidity and mortality for older Australians is not clear, nor is the magnitude of its effect.
Problem statement: What are the factors associated with social isolation and living alone? What is the impact on health service use, morbidity and mortality in Central and Eastern Sydney (CES), Australia?
Methods: A record linkage study using Social Economic and Environmental Factors (SEEF) Study questionnaire data (45 and Up Study sub-study), Medicare Benefit Scheme (MBS) claims (Department of Human Services), hospitalisations and deaths (Centre for Health Record Linkage) was undertaken. Social isolation was defined as the lowest quintile using the Duke Social Support Index: social interaction sub-scale. Frequency of general practitioner (GP) and specialist visit calculated using the specific item numbers from the MBS data base, and frequency of hospital admission, and Emergency Department (ED) visits were calculated by counting records from the respective data bases. Risk ratios (RR) were used as the measure of association and multivariable Poisson regression models were used to adjust for the potential confounders.
Results: Of the 6,176 CES participants 1,213(19.6%) were socially isolated and 1,263(20.5%) lived alone (3.6% were both). After adjusting for all other factors: working full-time, current smoking, poor quality of life, having heart disease or anxiety were all more likely to be associated with social isolation; and being older, female, working full-time, and adequate physical activity were all more likely to be associated with living alone. There was a protective association between living alone and social isolation [AdjPR(95%CI):0.69(0.57-0.83)]. Participants who lived alone used health services more (GP 10% increase, ED visits and hospitalisations 5% increase) than those who didn’t. Health service use did not vary by social isolation status. Crude mortality rates, using a 7-year follow-up, were 106/1000 for social isolation and 139/1000 for living alone. After adjusting by age and sex social isolation and living alone were not associated with any increased mortality [AdjRR(95% CI):1.08(0.88-1.32) and 1.18(0.98-1.43) respectively].
Discussion and Conclusion: We found that social isolation and living alone have different associations with service use, with living alone potentially being a measure of functional independence in older people. Social isolation and living alone, when adjusted by age and sex, were not predictors of increased mortality in CES. However, we have found associations for social isolations for New South Wales overall [AdjRR(95%CI):1.09(1.01-1.18)], but not for living alone [AdjRR(95%CI):1.05(0.94-1.18)].
Limitations and suggestions for future research: Loneliness is another construct of interest, defined as the mismatch between living arrangements and social interactions and what is desired. Our current data collections did not include a measure of loneliness. We are currently planning further research to better understand the interaction between loneliness, health service use, morbidity and mortality over time.

Introduction: Multimorbidity is associated with increased mortality, reduced physical functioning and quality of life, and increased healthcare utilization. Organizational models for providing integrated care in multimorbidity exist, but evidence on the effectiveness of specific interventions is limited. Previous systematic reviews have only considered interventions in the primary care sector. We examined the effectiveness of interventions with an organizational or patient-oriented focus designed to improve outcomes for people with multimorbidity in general practices, communities, and hospitals. Multimorbidity was defined according to the WHO definition of two or more chronic conditions in the same individual.
Methods: We systematically searched PubMed, Embase, and CENTRAL in November 2018, supplementing two earlier systematic reviews in terms of time periods and data-bases. We also searched for interventions in the hospital sector. We included randomized controlled trials reporting outcomes of organizational and/or patient-oriented interventions with the purpose of supporting clinical care provision for patients with multimorbidity. We applied the risk of bias criteria developed by the Cochrane group, Effective Practice and Organization of Care. We extracted data on study participants; duration, and follow-up; intervention elements; primary outcome(s); and results. Finally, we undertook a narrative synthesis, grouping findings by sector and primary outcome measure(s). (PROSPERO registration number: CRD42019119490.)
Results: Forty articles were included, covering a total study population of 11,713 participants. Thirteen studies took place in general practice settings, 19 in community settings, and eight in hospital settings. The overall risk of bias was acceptable, with the studies in general practice and hospital settings generally having a lower risk than the community-based studies. Findings are inconsistent, and the outcomes assessed are too heterogeneous to draw clear conclusions. However, some tendencies emerge from our synthesis. In general practice settings, organizational interventions could potentially improve outcomes for mental health, selected clinical parameters, and mortality, while patient-oriented interventions could potentially improve outcomes for mental health. In community settings, organizational interventions appear effective in improving mental health outcomes, and patient-oriented interventions could potentially improve health-related quality of life and reduce mortality. Organizational interventions based in hospital settings could potentially reduce mortality, and improve mental health, selected clinical parameters, and treatment. Overall, the potentially effective intervention elements in the organizational interventions are team-based care, care managers, and telemedicine, while it in the patient-oriented interventions is to target the self-management capacities of patients.
Discussions/Limitations: Interventions targeting multimorbidity hold promise in improving various outcome measures. By including the hospital sector, we have provided a comprehensive overview of the evidence-base existing on interventions for multimorbidity. However, the inconsistency in the outcome measures used makes it difficult to draw firm conclusions, and the complexity of the interventions does not allow for isolation of the effective components.
Conclusions/Lessons learned: We see potentially clinically relevant effects of patient-oriented and, especially, organizational interventions. Also, we identified promising results of interventions taking place in hospital settings.
Suggestions for future research: To streamline the outcome measures used, future research should apply the core outcome set developed for interventions targeting multimorbidity.