Income Security Health Promotion: Addressing Patients’ Unmet Income Needs in a Toronto Family Practice,a Qualitative Study

Abstract

Poverty is acknowledged as an important social determinant of health, and health care professionals are responding to it in some settings, most notably in the primary care setting. The Income Security Health Promotion service offered by the St. Michael's Hospital Academic Family Health Team in Toronto, Ontario, Canada, is an example of a primary-care intervention to address patients’ unmet income needs. Understanding the history and social conditions of existence of this service will be helpful to other primary care practitioners considering income interventions in their own setting. A qualitative case study was conducted to describe the origins, context and functioning of this intervention. Purposive sampling was used to recruit 12 key informants from the Family Health Team, including income security health promoters, clinicians and management. Interviews revealed the origins of the service as part of a new and well-resourced family practice, with a team of clinicians well-versed in the social determinants of health and with a strong social justice orientation. They described the required skill set of a promoter, and the importance of assimilating the role into the circle of care. Their experience offers important insights into how to create and sustain such a program in other primary care settings.

Keywords

poverty primary care income system navigator physician

Background

Poverty is acknowledged as an important social determinant of health (SDOH), carrying a higher risk of earlier death and worse health throughout the life course.^1,2 Amid growing awareness of the deleterious effects of poverty on health, physicians who witness this dynamic in their clinical interactions with patients have increasingly sought ways to address it.³ As they do not directly control the policy levers to ameliorate or eliminate poverty, some have sought instead to use their position in systems of care to refer people to services that can give them access to income and other supports that they had been unable to access previously.

Primary care in particular offers promise as a suitable site within the health care system for anti-poverty interventions. Primary care is designed to be “first-contact, continuous, comprehensive, coordinated care.”⁴ Ideally, primary care physicians are able to see their patients in the context of their family and community.^5,6 The continuous aspect of primary care enables physicians to establish trust with patients.⁷ At its best, primary care spans the life course of patients, and encompasses whole families in the circle of care.⁸ The appropriateness of the primary care setting as an arena to address SDOH has been affirmed by family physicians in many high-income countries.^9-13

While primary care may provide an excellent opportunity to address patients’ unmet economic needs, whether or not health professionals can or even should do this

is still contested. Patients may not expect or even welcome such interventions from a health care provider, and providers run the risk of unfulfilled patient expectations, or raising issues that they are not empowered to address, while taking time away from clinical care.^14-16

However, there are compelling reasons for primary care providers to find ways to address the health impact of poverty. They are uniquely situated to witness the manifestations of unmet income needs—such as food insecurity, inadequate housing and precarious employment—all of which can undermine providers’ efforts to improve their patients’ health.^17–21 Thus, there is a direct incentive for them to try and address these needs.

In some countries, including Canada, the United Kingdom (UK)²² and the United States (US), the primary care health sector has been actively engaged in performing social needs interventions, including those directly or indirectly related to unmet economic needs.^23,24

In both Canada and the US, community health centers (CHCs) have for decades been engaged in addressing SDOH, not least because their remit is typically to care for the most socially deprived and disadvantaged segments of society.^25,26

There is a growing body of research on primary care as a site for social needs interventions, especially given its role as the point of first contact, not just for medical treatment but for the broader conceptualization of primary care, encompassing disease prevention and health promotion.²⁷ In a previous study, we investigated the plethora of screening tools for unmet social and economic needs, ranging in scope and complexity from single-question tools to detailed questionnaires on multiple aspects of patients’ lives, and found that there were at least a dozen toolkits to help primary care physicians and other health care providers implement screening protocols and practices.²³ Studies have examined a wide range of income-needs-specific interventions, such as medical–legal partnerships, which have proven success in helping clients access external support and legal redress to poverty-related issues such as unpaid welfare payments.^28-30 Other interventions that have been widely researched include those focused on welfare rights, food insecurity and housing. These studies have examined a variety of outcomes, such as patient-reported quality of life and health improvements,³¹ hospitalization rates³² and income increases.^33,34

To overcome the barrier of limited time with patients, studies have found that if the care team is expanded to include those, usually non-physicians, specifically responsible for addressing patients’ non-clinical needs, such as income insufficiency, the role of the primary care team can be expanded.^35,36 Numerous examples of this approach can be found, demonstrating the efficacy and efficiency of dedicated welfare rights workers.^37-44 There is also a body of research on care providers’ perspectives on such interventions, which has shown that physicians value social needs screening and see it as a way to improve their understanding of their patients.^9,45-48 Routine or mandatory inclusion of the intervention; staff buy-in, typically led by a clinic champion; protected time and training; and integration into clinic workflows, have all been identified as key facilitators.^49-57 Implementation of a social needs screening and assistance process has been shown to be challenging and resource intensive.^47,58

Much of this body of research is focused on what programs do. Less is known about what might motivate a primary care practice to implement such a program, how such programs came about, how they operate, and how they are perceived by the staff responsible for managing, running and referring to them.

The objective of this study is to explore these very questions in the case of the Income Security Health Promotion (ISHP) service offered by the St. Michael's Hospital Academic Family Health Team (AFHT), within a large primary care practice in downtown Toronto, Ontario, Canada.

By examining this program, we sought to understand its context, including the wider political context of restructuring of Ontario's health system (such as attempts to cut costs and introduce elements of privatization into primary care services), the facilitators of its success, and its limitations and shortfalls.⁵⁹ This will usefully inform efforts to set up similar programs in other settings. It will help us understand the motivations of primary care practices and, potentially, the reasons why some might be reluctant to implement such programs. Furthermore, it will help us understand why and how these programs succeed or fail once implemented.

Given that the St. Michael's ISHP service is one of the longest-running and most well-established unmet income needs programs in the Canadian primary care setting, it is especially valuable to understand the service in the context of the “patient's medical home” concept, which has been promoted in the US, and in Canada by the College of Family Physicians of Canada.^60-62 A more nuanced understanding of the service can usefully add to our understanding of the pillars of the patient's medical home concept—especially “connected care,” and “community adaptiveness and social accountability.” The concept explicitly states that patient medical homes should strive to assess and address the SDOH (including income) as relevant.⁶²

The study gathers the perspectives of key informants involved in the SDOH committee within the AFHT to better understand the origins, context and functioning of the ISHP service. Income security health promoters (ISHPs) work as part of the interdisciplinary team, integrating income needs with other patient needs. Evaluations have found that the service is “acceptable and feasible within primary care”⁶³ and that it is successful in helping patients increase income (77.4%), reduce expenses (58.6%) or improve financial literacy, ie, discussing budgeting and explaining benefits eligibility (26.5%).⁶⁴ A randomized controlled trial (RCT) is currently underway to evaluate its impact on income, financial literacy, mental health and quality of life.⁶⁵ This study aims to investigate the impact of the ISHP service on the income security of people living in poverty, with primary outcome being income security, and secondary outcomes including quality of life, financial literacy and community integration. However, to date there has been limited examination of the experiences of those involved in managing, delivering and referring to the service.^18,66,67

What is not well understood is the experience of those who are involved in the creation, management, operation and use of the ISHP service. The insights of key informants on the origins and context of the service, the qualities of a good promoter, and the benefits of the promoter's integration within a multidisciplinary primary care team will offer useful lessons for others looking to establish similar programs. They can also help us understand and interpret the results of the RCT (impact on patients), which will allow us to go beyond the “it can work” of an RCT to the “this is why it works” that is necessary to generalize the intervention to other contexts.⁶⁸

Income Security Health Promotion at St. Michael's Hospital Academic Family Health Team

The SDOH-related work of the AFHT is an example of an established set of primary-care-based interventions to address patients’ unmet income needs.

Founded in 1892, St. Michael's Hospital is a Catholic teaching and research hospital in downtown Toronto, where it operates five primary care clinics offering interdisciplinary team-based care.⁶⁹ While both family health team (FHT) and community health center (CHC) models of care in the Ontario context are interdisciplinary teams focused on primary care, the FHT model differs from that of the CHC in terms of its governance structure (the board is primarily physicians, for example). It also differs in its patient mandate, as the FHT strives to serve the majority of the population where it is located, rather than focusing on marginalized sub-populations. As a result, the ISHP service offered by St Michael's Hospital AFHT is novel because it is available to all patients who need it, within a wider patient population than may be found in a CHC setting. The clinics’ 264 staff—including family physicians, nurse practitioners, registered nurses, social workers, dietitians and other health professionals—serve more than 47 000 patients, with the lowest income quintile of the local population disproportionately represented.⁷⁰ In 2010, the family health team, which works across all five sites, introduced a screening tool for primary care physicians to routinely ask all patients whether they were “having trouble making ends meet at the end of the month” (ie, sufficient income to cover expenses). In 2013, the team established the Social Determinants of Health Committee, tasked with creating targeted specialized programs to address the negative health impacts of the SDOH.^71,72 This interprofessional committee meets regularly and includes members representing all clinical sites, team leadership, most clinical disciplines, family medicine trainees and patient advisors.⁷³

In December 2013, the ISHP service began, and in 2015, the team successfully advocated for funding from the Ontario Ministry of Health and Long-Term Care for health promoters, and chose to focus this role on income security. At the time of writing, the team had two full-time ISHPs. Patients are referred by physicians and other clinicians and the ISHPs are members of the clinical care team. They spend time at all five sites each week. The ISHPs work with patients on improving their income security, typically in a series of six face-to-face sessions. This can include, for example, assistance with tax filing, advocating on behalf of patients with social welfare agencies, and support with debt management and budgeting. The ISHP job description also includes education of staff on the services available and external advocacy on income issues that relate to health. A retrospective, descriptive chart review of all patients referred to the Income Security Heath Promotion service during the first year of the service (December 2013–December 2014 found that “a large proportion of individuals were receiving social assistance prior to referral, yet still needed help with increasing their income.”⁷⁴

Methods

The case study methodology applied Robert Yin's technical definition of the scope of a case study: “an empirical inquiry that investigates a contemporary phenomenon within its real-life context, especially when the boundaries between phenomenon and context are not clearly evident” and a research strategy that “relies on multiple sources of evidence, with data needing to converge in a triangulating fashion.”⁷⁵ The decision to pursue a case study design is in line with Yin's definition of case study components, from formulation of the question (asking how and why this service exists in this context, and to what extent it is effective), and the criteria for suitability of the case study methodology (the research question is a why and process question, investigating a contemporary phenomenon, with a focus on the detail of its context). It has clearly defined propositions, and a logical population of suitable informants to create a clearly defined and well bounded case study. The case was bounded by professionals associated with St. Michael's Hospital AFHT, the home of the income security health promotion service.

This study uses a qualitative descriptive design, chosen because it is intended to discover and understand a phenomenon from the perspective of those involved.^76,77 This design supports staying close to the surface of the data, and using easily understood descriptive language.^78,79 This approach facilitates the gathering of rich descriptions about a little-known phenomenon, and allows for flexibility in the path of inquiry in response to the real-world context, and naturalistic study methods.^80-82 The analytic technique used was consistent with Yin's version of the case study methodology, and sampled those who have professional interaction relevant to ISHP within that team.

Sampling and Recruitment

We employed a purposive sampling strategy to identify participants based on their expertise and experience in the creation, management and delivery of or referral to the ISHP service, or close professional association with the service. Key informant interviews have been recognized as an especially useful means to conduct an “initial assessment of an organization or community issue, allowing for a broad, informative overview of what the issues are.”⁸³ The objective of the recruitment process was to interview a sufficiently diverse selection of participants: the two current ISHPs, some colleagues within the team from related disciplines of social work and legal aid services (as their services could reasonably be expected to have some degree of overlap with the ISHP work), the senior management of the family health teams, and a sample of family physicians who are familiar with the service, and who refer their patients to it.

Potential interviewees were identified, based on prior professional collaboration between one of the authors (JP) and the health team's Social Determinants of Health Committee. This professional contact enabled the authors to capitalize on existing relationships with committee members with whom there was already an established basis of familiarity and trust, and to have a strong grasp of who would be in a good position to discuss the ISHP service. Requests for permission to contact were then sent to 14 potential interviewees, via a third party within the team known to them. Given the very specific nature of the research question and the requirement to be a key informant with a high degree of knowledge of the ISHP service, we identified all relevant key informants and interviewed all who were willing to participate.

Ethics approval was obtained from the McMaster University Research Ethics Board (MREB#: 5305) and the Unity Health Toronto Research Ethics Board (REB#: 54 21-081C) (St. Michael's Hospital is part of the Unity Health network), and all participants provided written informed consent.

Data Collection

In August and September 2021, semi-structured interviews were conducted by one author (JP). Prior to the interview, interviewees received a list of the proposed questions, and these were used to guide the conversation. Due to COVID-19-related restrictions, all interviews were conducted remotely, 11 using the Zoom videoconferencing service, and one, as requested by the interviewee, by phone. The duration of each interview was approximately 60 to 75 min. With the participants’ permission, all the interviews were recorded, the audio recordings were transcribed and the transcripts checked against the audio files for accuracy. The interviewer kept a journal in which she recorded process memos and engaged in reflection.

Analysis

Data analysis was conducted by JP. She began by immersing herself in the interview data, creating initial thematic categories, and subsequently identifying sub-patterns and sub-themes. The initial construction of themes was deliberately tentative, and remained so throughout the process of data analysis. The analytic strategy borrowed from the constant comparative analysis method whereby patterns are identified and refined as the information from each transcript is coded and compared across categories, an established method of analysis used within qualitative descriptive research.^84,85

The research methods and findings were assessed according to five quality criteria for qualitative research: credibility, dependability, confirmability, transferability and reflexivity.^86,87 The chosen method of data collection is credible because it is appropriate for the research question by supporting in-depth engagement with key informants who were intimately familiar with the ISHP service, and who had a good knowledge of its evolution. The criterion of dependability requires that there is enough information provided to enable another researcher to follow the same procedural steps (although the conclusion may be different), and this information has been provided. With ample use of direct quotes and reported speech in the research findings, the criterion of confirmability was met. As for transferability, one stated purpose of the research was to examine the extent to which the experience of this service could be replicated elsewhere, and what contextual factors affect this. For the purpose of reflexivity, the interviewer engaged in continuous reflection on potential for bias and was transparent about her prior experiences and how they influenced research decisions and interaction with participants.

Results

Twelve of the 14 potential interviewees who granted consent to contact and were subsequently interviewed (table 1); two did not respond. They comprised management, family physicians, the two current ISHPs, and other non-clinical professionals

Table 1.

Profile of Participants.

Role	No of Interviewees
Management	4
Income Security Health Promoters	2
Other non-clinical professionals	3
Family physicians	4

Note: One interviewee was both a manager and a family physician.

Non-physician clinicians were not identified as key informants.

The results are presented in three sections: the origins and context of the ISHP service, the qualities of a good ISHP service provider, and the benefits of integration within a multidisciplinary primary care team.

Origins and Context of the Income Security Health Promotion Service

St. Michael's Hospital and Health Equity

The context around the ISHP service is significant because it grew out of an existing social justice orientation (with social justice defined as striving for fair and equitable access to resources, opportunities, and benefits, and addressing systemic inequalities) within the family health team, which then led to the team identifying an unmet need within its patient population. Participants spoke of the work to address SDOH, including the ISHP service, in the context of the culture and values associated with the team's mission of equity-focused care (defined as being when individuals have the fair opportunity to reach their fullest health potential). Several participants explicitly stated that the family health team's social justice reputation—characterized by the formation of the SDOH committee—was one of the reasons they sought employment there. The team has long attracted socially progressive primary care clinicians who are particularly attuned to the social conditions of their patients and how these impact health.

“There's a stream of activism among members of the department and a desire to create targeted clinical programs to address particular needs of individuals and groups that experience social marginalization.” (P11)

This equity focus extended beyond the frontline medical staff, and included management, participants said. This strong orientation toward social justice at all levels of the organization was crucial to the establishment of the ISHP service as part of a suite of SDOH interventions, under the aegis of the SDOH committee, participants said.

“I think the leadership is also a key piece, in our strategic planning and in all of our messaging across the department, really emphasizing that equity is the heart of what we do.” (P02)

Participants spoke of the high visibility of poverty within their patient population, frustration with the limitations of medical care services to help patients achieve optimal health, and a desire to do more.

“We were starting to screen people, asking if they were struggling but then what? We had a very robust comfort fund where we can help people with a one-off food voucher, but that's not a sustainable model of trying to increase income.” (P03)

Finding Opportunities Within the Existing System

In 2015, a fifth family health team clinic, the Sumac Creek Health Centre, was resourced to open in the high-needs Regent Park neighborhood of downtown Toronto. This presented a window of opportunity: the funding application for the new site offered the opportunity to apply for funding for innovative services that could then be used by the family health team as a whole, across all five clinics. This new funding presented an opportunity to gain resources for innovative program delivery.

“[This work] is resource intensive, and you have to have specific funding or programs that cater to these alternative approaches.” (P01)

Two new positions, called ISHPs, were included in the funding request for the interprofessional team. The choice of job title was a pragmatic one: generic health promoter positions were already an established occupation in both CHCs and family practice teams, and this helped the funding request to go through without challenge.

“I don’t think the funder saw this as an innovative program, they just saw they were giving us health promoter positions.” (P04)

In a typical family practice, it would be unusual to have an in-house social worker, let alone a role as specific as an ISHP, participants said. The decision to hire and fund the ISHP positions gets around the issue of how to bill for non-clinical services were this role fulfilled directly by a physician. The blended team-based care funding model supported the practice to be able to take on patients with complex needs, and the team-based care funding model, which includes ISHP, in turn enabled the team to better serve the needs of those complex patients, participants said.

“There's a huge structural component to the question of why physicians do this, and it's not just about physician role. It's not just about time, it's also about billing structures….I think broadly, the idea of having any allied health professional, particularly income security, or social work, allows us, I think it increases our capacity to roster more socially complex people.” (PO9)

An Intervention with Financial Limits

The ISHP service can only work within the limits of the financial supports that are available to its patients. The service on its own could not fix the dysfunction of the existing social safety net, and one of the most challenging aspects of the work was managing patients’ expectations, participants said. As such, one of the most common presenting problems—lack of adequate and/or affordable housing—frustratingly falls outside the scope of what they can do.

“We try our best to really manage expectations from the beginning but it can be tough sometimes, when they still want our support, but there’re no other resources to connect them to. So it becomes a challenge in those instances.” (P07)

However, even when, post-intervention, a patient is still on income that keeps them below the poverty line—for example, going from C$700 a month to C$1100 a month—this can be positively impactful. Adding that the same is true of most primary care interventions, one participant said:

“We’re not going upstream to a lot of what we do, we’re patching things up and putting on Band-Aids all over the place, so it very much fits within that medical mindset. It's important to recognize that limitation, but I think it at least expands what the potential of what the medical mindset is.” (P11)

The original intent of the ISHP service was to combine patient support, physician education and advocacy, but the advocacy has not fully developed, with the bulk of the health promoters’ time being taken up with individual patient-focused work, especially in the last two years due to the COVID-19 pandemic. This represented a missed opportunity to take what the ISHPs were seeing on the frontlines of their work, and using that as a catalyst for social change, one participant said. Others commented that it was incumbent on all of them, especially physicians, to do this advocacy work.

“As physicians have a great ability to do that [advocacy] as well, and we should see our greatest impact as being about advocating for social policy change that will address upstream concerns, to make all of this unnecessary.” (P09)

Qualities of a Good Income Security Health Promoter

Participants described the qualities essential for an effective income security health promoter. A genuine passion for the work, combined with strong counselling skills, were the most commonly cited qualities. The role requires skills in empathy, active listening, trust-building, de-escalation and being non-judgmental. They must also be sufficiently reflexive to recognize their own potential for bias when interacting with patients.

“It's quite hard to pull this kind of information out of someone without making them feel uncomfortable.” (P05)

Lived experience could be helpful, participants reported, but was no substitute for education, preferably in health and/or social work, and for some time the service had implemented hiring practices that required certain credentials. Past hiring missteps gave way to this new requirement, to ensure the staff in this role were well equipped to deal with the complexity of patients’ problems. ISHPs need an in-depth knowledge of the resources available in their community, and must be tenacious and persistent when advocating for patients with, for example, social welfare system case officers.

“They need knowledge of community resources, to know who to go to and for what, and really know how to support patients in navigating these different pathways.” (P02)

They also must have a clear understanding of the boundaries of their role, where they fit within their team and who they can go to for support when patients’ needs are out of their scope.

“You just can't have somebody who is siloed in their economic platform because when you put this individual in front of a patient who has complex issues and, in most cases, mental health [issues], it becomes very overwhelming. Through our development of this position, what type of skill set will excel was also a learning process for us.” (P01)

The recruitment and retention of good ISHPs has been difficult, in part related to the sophisticated skillset required, confusion about scope, and a perception that the role was undervalued.

“I think people don’t respect health promotion or health promoters, and they also don’t pay them as well as they pay other positions, so we have people who are social-work-trained who are not getting paid at the level of their colleagues. It's been problematic for retention, not surprisingly. And it's problematic just for respect from others in the team. In some ways, it's problematic for scope.” (P11)

Benefits of Integration Within a Multidisciplinary Primary Care Team

Participants cited advantages for patients, the ISHPs and the clinicians in the integration of ISHP services into the clinical team. This goes beyond co-location, and includes ISHPs’ access to patient charts. Integration enables quick and direct communication between the clinical staff and the ISHPs through the patient chart chat function. Clinicians can easily stay up to date post-referral, and the ISHPs are also able to share information that can help flesh out their picture of the patient. As one physician participant said:

“Oftentimes, the health promoter will say, ‘Let's touch base, I just had some questions about this,’ and I’ll do the same for them. So it's much more collaborative in that sense, and, and we’re able to do more and we’re able to do it faster than if it was someone who was external to the team.” (P06)

High Levels of Patient and Physician Acceptance

There were reported high levels of acceptance of the offer of referral to the ISHP. Patients were often surprised that the service existed, but almost all of those who accepted a referral would then follow through with meeting with the ISHP.

“I don’t get as much resistance as I initially anticipated. I do get surprise, but it's more, ‘Oh, yes, I would love some help with this.’ I haven't really had any bad reactions or any resistance to it.” (P06)

The health promoters reported widespread use of the service by physicians referring from all five clinics. Physician participants said that they had a responsibility to address their patients’ poverty, yet they were constrained by the limited amount of time they spent with patients and their lack of specialist knowledge in this area. They liked having an on-site ISHP because they could ask their patients about their income specifically, and then address it through a form of specialist referral to someone who could spend more time with the patients and look closely at their financial situation. As one ISHP said:

“It's not that doctors aren’t capable, but with their caseload they don’t have time to get insight into that. They’ll tell me something about their patient, and I’ll say: ‘No wonder [the patient's] been so stressed out; did you know she's making $500 payments to her Visa [credit card] each and every month?’”(P08)

A significant mediator of that acceptance is the relationship of trust between patients and physicians. This is a significant enabler of referral, with ISHPs benefitting from a “transfer of trust” [IV08] to them, based on trust in the referring clinician.

Role of the SDOH Committee

Advocacy for ISHP needed to come from within the practice itself, according to participants, and also required full management buy-in, with the intervention situated within the practice's strategic planning. The fact that the service is incorporated into the practice's strategic planning was cited as important by several participants. Such services came about because there was a practice champion, participants said (and there was clearly a practice champion in their team), but it was important to formalize this interest in social justice from within the care team. The formation of an SDOH committee was frequently cited as a particularly important step in this regard. This structure is needed to bring together a large, interprofessional group, to create a culture that supports this work.

“My suggestion is to first understand the passion within your organization and who's passionate about doing this type of work, and bring those folks together.” (P01)

Discussion

The results of this study show how an intervention to address patients’ unmet income needs grew out of a pre-existing commitment to social justice, supported by an SDOH committee, with funding made possible through the advent of a new health care facility in a politically high-profile area with high rates of poverty. It showed what characteristics were needed for someone to be effective in the ISHP role, and described how that service benefited everyone involved when it was fully integrated into the circle of care.

Since its inception in 2013, the St. Michael's ISHP service has become well-established and is now at a mature stage of development. From this vantage point, it is possible to look back at its origins and understand why the service emerged in this setting; what it has in common with similar interventions in other settings, but also its context-specific enablers; and to what extent this modality for addressing patients’ unmet income needs can be replicated in another setting.

The ISHP service emerged as part of an evolutionary process of addressing health equity within this primary care practice, and its origins lie, firstly, in a longstanding culture of equity-focused, social-justice-oriented work. The experience of this team suggests that such an equity focus is in the vision and mission of the organization, and that, for it to translate into action, it also needs to be a core element of the organization's strategic plan. This creates the framework for specific initiatives to come into being. Studies of other settings support this, identifying management and clinician buy-in as key to the success of social needs interventions.^56,57 Having a clinic champion is another common theme from studies of other settings, and this was also apparent at St. Michael's, where there was a clearly identifiable champion for this work, in addition to overall staff interest.^55,88

The steady funding for the ISHPs is crucial to the sustainability of this program. It could be argued that there was an element of luck in the creation of the ISHP post, as it was nested in a far larger funding application for a new health centre in a high-profile area that the government of the time was amenable to resourcing well. As one participant noted, the site probably had better funding than any other family health team in the province. When the funding opportunity rose, the preparatory work had been done in the form of an equity focus already woven into the organizational culture, and an SDOH committee that had been established two years earlier.

The family practice team's equity focus informed a decision to screen patients for poverty, which in turn led to an identified need to intervene that could not be met by screening alone. This organic growth in response to observed need in clinical encounters reflects what is seen in other settings, such as community health centers in the US, where initiatives to address the SDOH have evolved over many decades and have more recently increased in momentum and scale.²⁶ It also echoes the experience of the Bromley by Bow Centre in London, UK: arguably the most significant takeaway from their model is the importance of grounding any social needs intervention in person-centered, grassroots demand.⁸⁹

Integration rather than simple co-location of income security and clinical services is one of the defining features of the St. Michael's service. Whereas co-located services share the same physical space, integration goes beyond this to consider income security as one of the team's functions, alongside clinical care. It grants access to patient records and the ability to add to the records and communicate directly with other team members through the patient record messaging function. The advantages of this have also been identified in other settings, such as the Deep End Advice Worker Project in Glasgow, UK, where embedding the advice worker into the care team is seen as enabling greater reach and service efficacy, and enabling them to benefit from the established relationship of trust between a patient and a doctor.^38,90

How the ISHP role is named is very important. In fact, non-clinical staff whose role is to help patients connect to social or economic supports have numerous titles in other organizations, including link worker, navigator, welfare rights officer and community links practitioner.^91–94 The importance of what that name means in the context in which it is used is underlined by concerns that the ISHP title creates some problematic limitations and assumptions.

The funding model for both physicians and the ISHPs plays a crucial role in the service's sustainability. The practice's physician funding model is a blend of FFS and capitation. This overrides the typical disincentive of pure FFS, since the typical scope of the physician's service does not include screening for unmet income needs, even less addressing it. On its own, the capitation model may also present disincentives to such programs because it encourages cherry picking of more healthy patients. Arguably though, it is not the primary care funding model per se that determines the feasibility of having a line item on the budget for an ISHP, but whether or not the family practice has adopted team-based care and is willing to fund an ISHP role. There are other examples where funding for social care programs such as this one are patchworked together from a range of sources, including patient revenue streams, grants and non-traditional methods of revenue generation in the health care setting, such as social enterprises, but this makes long-term planning difficult, unlike the St. Michael's model.⁹⁵ In the US, the rapid proliferation of accountable care organizations and explosive growth in the adoption of the patient-centered medical homes concept (which the AFHT has also adopted) are an expression of a wider movement toward value-based care, which may be more supportive of efforts to address SDOH inequities, as it rewards health care providers for healthier patients via financial accountability mechanisms.^96,97

It is clearly possible to replicate the “St. Michael's model”—a similar service has been set up in Winnipeg, for example.⁹⁸ However, in considering whether to set up a similar service, it is important to consider the unique factors described above that were instrumental in the emergence of this program. It is also important to be clear about what it can and cannot achieve. An ISHP service can help patients get more money, which may or may not lead to measurable improvements in health.⁹⁹ Moreover, the ISHP service works within the limitations of the existing social welfare system, its level of benefits, and against a backdrop of ongoing political pressure to reduce public spending on health and social welfare in Ontario.⁵⁹ The ISHP service seeks to help patients who are on the receiving end of these efforts to persistently defund social welfare services, and are those most affected by the province's widening inequality.¹⁰⁰ This is evidenced by the fact that welfare benefits under the Ontario Works and Ontario Disability Support Programme have not kept pace with inflation.^101,102 In line with the country as a whole, in Ontario child poverty continues to increase, reversing earlier gains in the late 2010s.¹⁰³ At the more local level Toronto has one of the highest child poverty rates in the country, at 36.6%.¹⁰³ By its own admission federal poverty reduction strategies have failed to reach those most marginalized.¹⁰⁴ However, there is evidence from this and other social needs interventions that it does lead to improved patient-reported well-being, even within these external constraints.

Strengths and Limitations

The strengths of this study are that through open-ended conversational interviews with key informants, it was able to uncover some of the less tangible reasons why this program exists in this setting rather than in other family practices in the same place. However, one limitation was that the recruiting process made it difficult to include strongly dissenting voices, of those who, for example, may have been unsupportive or highly critical of the service. Another limitation was the lack of opportunity to include first-hand patient perspectives. This was beyond the scope of this study, but a study of this kind would be a valuable contribution to the literature on the efficacy of primary care-based income interventions.

Conclusion

This study explored how key informants viewed a service within their primary care practice to help patients address their unmet income needs. Eliciting these views can shed light on what factors lead to the creation of such a service, and what elements need to be in place for it to be financially sustainable and well-used. Understanding these factors can be helpful to other primary care practitioners considering social needs interventions, specifically those related to income, in their own setting.

Footnotes

Acknowledgements

The authors acknowledge the generous contribution of the interviewees to this research, without whom it would not have been possible.

ORCID iD

Jane Parry

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Author Biographies

Jane Parry is an independent researcher with a special interest in poverty and health in developed country urban settings, particularly in Asian mega-cities such as Hong Kong. She works as a specialist development and health analyst and writer, predominantly in Asia and the Pacific. She completed her doctoral studies at McMaster University, researching income-related interventions in primary care. She is an Adjunct Assistant Professor and Advisor in the School of Nursing and Health Sciences, Hong Kong Metropolitan University, an Honorary Assistant Professor in the Department of Family Medicine and Primary Care, School of Clinical Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, and an Adjunct Assistant Professor in the Jockey Club School of Public Health and Primary Care at the Chinese University of Hong Kong.

Michel Grignon is a Health Economist and Associate Professor in the Department of Health, Aging and Society. He looks to assess and improve Canada's healthcare system with regard to Canada's aging population, which increasingly relies on public services. Michel's work intends to bridge the divide between efficiency and equity by allocating health resources more effectively. He has found that Canada's healthcare is constructed to serve acute conditions. Older people, though, are more likely to have permanent chronic conditions. He believes that a healthcare system looks very different when a large percentage of the population it serves will never return to full health. Michel also serves as a public commentator on issues of aging and health equity and is helping Canadian policymakers improve how they serve our aging population.

Meredith Vanstone is Professor in the Department of Family Medicine, where she holds a Canada Research Chair in Ethical Complexity in Primary Care and the David Braley and Nancy Gordon Chair in Family Medicine. Dr Vanstone is also the Director of McMaster's MD/PhD educational program. Dr Vanstone researches primary care. Her research program aims to help patients, clinicians, and policy-makers navigate the provision of care in areas where evidence doesn't exist, is ambiguous, or is not the main decision determinant. She uses health policy and health professional education strategies to translate this knowledge into health system improvement. Dr Vanstone is also a member of the Centre for Health Economics and Policy Analysis.

James R. Dunn PhD (Jim) a Professor in the Department of Health, Aging & Society and Associate Dean Research in the Faculty of Social Sciences at McMaster University. He holds the Senator William McMaster Chair in Urban Health Equity and is a Fellow of the Canadian Academy of Health Sciences. Trained in urban health geography and social epidemiology, he has published widely in geography, public health, urban planning and epidemiology and his research addresses the effects of income security, housing, urban development on health, aging and healthy child development. Methodologically, much of his research can be described as population health intervention research, as it involves examining the effect of interventions in housing, neighbourhoods and social policies (like cash transfer programs) and their impact on population health. His research also involves close partnerships with organizations including governments at the municipal, provincial and federal level, as well as non-profit organizations.

References

Benzeval

Bond

Campbell

, et al. How Does Money Influence Health? Joseph Rowntree Foundation; 2014.

Marmot

. The Health Gap. Bloomsbury Publishing; 2015.

Gottlieb

Wing

Adler

. A systematic review of interventions on patients’ social and economic needs. Am J Prev Med. 2017;53(5):719-729. doi: 10.1016/j.amepre.2017.05.011

Starfield

. Is primary care essential? Lancet. 1994;344(8930):1129-1133.

Donaldson

Yordy

Vanselow

, eds. Defining Primary Care: an Interim Report. National Academies Press (US); 1994.

World Health Organization and United Nations Children’s Fund. A Vision for Primary Care in the 21st Century: towards Universal Health Coverage and the Sustainable Development Goals. World Health Organization & United Nations Children’s Fund; 2018.

Starfield

. Primary Care: concept, Evaluation, and Policy. Oxford University Press; 1992.

Hart

. A new kind of doctor. Merlin Press; 1988.

College of Family Physicians of Canada ePanel Report: Social Determinants of Health. College of Family Physicians of Canada; 2016.

10.

American Academy of Pediatrics Council on Community Pediatrics and Committee on Nutrition. Promoting food security for all children. Pediatrics. 2015;136(5):e1431-e1e38. doi: 10.1542/peds.2015-3301

11.

Wood

. Poverty and child health in the United States. Pediatrics. 2016;137(4):1-14.

12.

Daniel

Bornstein

Kane

; for the Health and Public Policy Committee of the American College of Physicians. Addressing social determinants to improve patient care and promote health equity: An American college of physicians position paper. Ann Intern Med. 2018;168(8):577-578. doi: 10.7326/m17-2441%m 29677265

13.

Butkus

Rapp

Cooney

, et al. Addressing social determinants to improve patient care and promote health equity: An American college of physicians position paper. Ann Intern Med. 2018;168(8):577-578. doi: 10.7326/m17-2441%m<otherinfo> 29677265</otherinfo>

14.

De Marchis

Alderwick

Gottlieb

. Do patients want help addressing social risks? J Am Board Fam Med. 2020;33(2):170-175. doi: 10.3122/jabfm.2020.02.190309

15.

Solberg

. Theory vs practice: Should primary care practice take on social determinants of health now? No. Ann Fam Med. 2016;14(2):102-103. doi: 10.1370/afm.1918

16.

Runyan

. Assessing social determinants of health in primary care: Liability or opportunity? Families Syst Health. 2018;36(4):550-552. doi: /dx.doi.org/10.1037/fsh0000377

17.

Seligman

Jacobs

López

, et al. Food insecurity and glycemic control among low-income patients with Type 2 diabetes. Diabetes Care. 2012;35(2):233-238. doi: 10.2337/dc11-1627

18.

Parry

. A prescription for poverty. Br Med J. 2016;353:i3370. doi: 10.1136/bmj.i3370

19.

Garg

Butz

Dworkin

, et al. Improving the management of family psychosocial problems at low-income children's well-child care visits: The WE CARE project. Pediatrics. 2007;120(3):547-558. doi: 10.1542/peds.2007-0398 [published Online First: 2007/09/04]

20.

Garg

Marino

Vikani

, et al. Addressing families’ unmet social needs within pediatric primary care: The health leads model. Clinical Pediatrics (Phila). 2012;51(12):1191-1193. doi: 10.1177/0009922812437930

21.

Billioux

Verlander

Anthony

Alley

. Standardized screening for health-related social needs in clinical settings: The Accountable Health Communities Screening Tool. In: Perspectives: Expert Voices in Health & Health Care. National Academy of Medicine; 30 May 2017.

22.

Fiori

Patel

Sanderson

, et al. From policy statement to practice: Integrating social needs screening and referral assistance with community health workers in an urban academic health center. J Prim Care Community Health. 2019;10:1-8. doi: 10.1177/2150132719899207

23.

Parry

Vanstone

Grignon

, et al. Primary care-based interventions to address the financial needs of patients experiencing poverty: A scoping review of the literature. Int J Equity Health. 2021;20(1):219. doi: 10.1186/s12939-021-01546-8

24.

Bloch

Rozmovits

. Implementing social interventions in primary care. CMAJ. 2021;193(44):E1696-EE701. doi: 10.1503/cmaj.210229

25.

Collins

Resendes

Dunn

. The untold story: Examining Ontario’s community health centres’ initiatives to address upstream determinants of health. Healthcare Policy. 2014;10(1):14-29.

26.

Institute for Alternative Futures. Community Health Centers Leveraging the Social Determinants of Health. Institute for Alternative Futures; 2012.

27.

Muldoon

Hogg

Levitt

. Primary care (PC) and primary health care (PHC). what is the difference? Canadian J Pub Health / Revue Canadienne de Santé Publique. 2006;97(5):409-411. doi: /doi.org/10.1007/BF03405354

28.

Klein

Beck

Henize

, et al. Doctors and lawyers collaborating to HeLP children—: Outcomes from a successful partnership between professions. J Health Care Poor Underserved. 2013;24(3):1063-1073. doi: 10.1353/hpu.2013.0147

29.

Taylor

Bernstein

Carroll

, et al. Keeping the heat on for children's health: A successful medical–legal partnership initiative to prevent utility shutoffs in vulnerable children. J Health Care Poor Underserved. 2015;26(3):676-685. doi: 10.1353/hpu.2015.0074

30.

Weintraub

DMD

Rodgers

MAJD

Botcheva

, et al. Pilot study of medical–legal partnership to address social and legal needs of patients. J Health Care Poor Underserved. 2010;21(2):157-168.

31.

Hsu

Cruz

Placzek

, et al. Patient perspectives on addressing social needs in primary care using a screening and resource referral intervention. J Gen Intern Med. 2020;35(2):481-489. doi: 10.1007/s11606-019-05397-6

32.

Kangovi

Mitra

Norton

, et al. Effect of community health worker support on clinical outcomes of low-income patients across primary care facilities: A randomized clinical trial. JAMA Intern Med. 2018;178(12):1635-1643. doi: 10.1001/jamainternmed.2018.4630

33.

Coppel

Packham

Varnam

. Providing welfare rights advice in primary care. Public Health. 1999;113(3):131-135.

34.

Greasley

. Welfare advice in general practice: A resource for community nurses. Br J Community Nurs. 2005;10(8):368-372.

35.

Kaufman

. Theory vs practice: Should primary care practice take on social determinants of health now? Yes. Ann Fam Med. 2016;14(2):100-101. doi: 10.1370/afm.1915

36.

Garg

Jack

Zuckerman

. Addressing the social determinants of health within the patient-centered medical home: Lessons from pediatrics. J Am Med Assoc. 2013;309(19):2001-2002. doi: 10.1001/jama.2013.1471

37.

Bromley By Bow Centre, ed. Bromley By Bow Centre Social Prescribing Service: Your Doctor isn’t the only Person who can Help you Feel Better.

38.

Sinclair

. The Deep End Advice Worker Project: embedding an Advice Worker in General Practice Settings. Glasgow Centre for Population Health; 2017.

39.

Harding

Sherr

, et al. Welfare rights advice in primary care: Prevalence, processes and specialist provision. Fam Pract. 2003;20(1):48-53.

40.

Greasley

Small

. Establishing a welfare advice service in family practices: Views of advice workers and primary care staff. Fam Pract. 2005;22(5):513-519.

41.

Adams

White

Moffatt

, et al. A systematic review of the health, social and financial impacts of welfare rights advice delivered in healthcare settings. BMC Public Health. 2006;6(1):81. doi: 10.1186/1471-2458-6-81

42.

Abbott

Hobby

. Welfare benefits advice in primary care: Evidence of improvements in health. Public Health. 2000;114(5):324-327.

43.

Abbott

Hobby

Cotter

. What is the impact on individual health of services in general practice settings which offer welfare benefits advice? Health Soc Care Community. 2005;14(1):1-8.

44.

Hoskins

Tobin

McMaster

, et al. Roll-out of a nurse-led welfare benefits screening service throughout the largest local health care co-operative in Glasgow: An evaluation study. Public Health. 2005;119(10):853-861.

45.

Orr

Chauvenet

Ozgun

, et al. Caregivers’ experiences with food insecurity screening and impact of food insecurity resources. Clin Pediatr (Phila). 2019;58(14):1484-1492. doi: 10.1177/0009922819850483

46.

Palakshappa

Doupnik

Vasan

, et al. Suburban families’ experience with food insecurity screening in primary care practices. Pediatrics. 2017;140(1). doi: 10.1542/peds.2017-0320

47.

Tong

Liaw

Kashiri

, et al. Clinician experiences with screening for social needs in primary care. J Am Board Fam Med. 2018;31(3):351-363. doi: 10.3122/jabfm.2018.03.170419

48.

Swamy

Monterrey

Wood

, et al. Caregiver and pediatric health care provider views on social needs identification. J Prim Care Community Health. 2020;11:2150132720923085. doi: 10.1177/2150132720923085

49.

Purkey

Bayoumi

Coo

, et al. Exploratory study of “real world” implementation of a clinical poverty tool in diverse family medicine and pediatric care settings. Int J Equity Health. 2019;18(1):200. doi: 10.1186/s12939-019-1085-0

50.

Schickedanz

Hamity

Rogers

, et al. Clinician experiences and attitudes regarding screening for social determinants of health in a large integrated health system. Med Care. 2019;57(62):S197-S201. doi: /doi.org/10.1097/MLR.0000000000001051

51.

Babbel

Mackenzie

Hastings

, et al. How do general practitioners understand health inequalities and do their professional roles offer scope for mitigation? Constructions derived from the deep end of primary care. Crit Public Health. 2019;29(2):168-180. doi: 10.1080/09581596.2017.1418499

52.

Popay

Kowarzik

Mallinson

, et al. Social problems, primary care and pathways to help and support: Addressing health inequalities at the individual level. Part II: Lay perspectives. J Epidemiol Community Health. 2007;61(11):972-977.

53.

Patel

Bathory

Scholnick

, et al. Resident documentation of social determinants of health: Effects of a teaching tool in the outpatient setting. Clinical Pediatrics (Phila). 2018;57(4):451-456. doi: 10.1177/0009922817728697

54.

Fiori

Patel

Sanderson

55.

Gold

Bunce

Cowburn

, et al. Adoption of social determinants of health EHR tools by community health centers. Ann Fam Med. 2018;16(5):399-407. doi: 10.1370/afm.2275

56.

Meyer

Lerner

Phillips

, et al. Universal screening of social determinants of health at a large US academic medical center, 2018. Am J Public Health. 2020;110(S2):S219-SS21. doi: 10.2105/AJPH.2020.305747

57.

Southby

Gamsu

. Factors affecting general practice collaboration with voluntary and community sector organisations. Health Soc Care Community. 2018;26(3):e360-ee69. doi: 10.1111/hsc.12538

58.

Williams-Roberts

Neudorf

Abonyi

, et al. Facilitators and barriers of sociodemographic data collection in Canadian health care settings: A multisite case study evaluation. Int J Equity Health. 2018;17(1):186. doi: 10.1186/s12939-018-0903-0

59.

Ontario Health Coalition. Quick Facts & Analysis. What is the Ford government doing re. health funding & what it means. November 11, 2024. https://www.ontariohealthcoalition.ca/index.php/quick-facts-analysis-fact-checker-ford-governments-health-care-funding/. Accessed July 30, 2025. Government of Canada. About primary health care. 2012. https://www.canada.ca/en/health-canada/services/primary-health-care/about-primary-health-care.html. Accessed March 6, 2022.

60.

Cassidy

. Patient-centered medical homes: health policy brief. Health Affairs Health Affairs. 2010 No volume or issue no, only date: September 14 2010, pages 1-6.

61.

The Commonwealth Fund. Primary Care: our First Line of Defense. The Commonwealth Fund; 2013.

62.

College of Family Physicians of Canada. A New Vision for Canada: family Practice—the Patient’s Medical Home. College of Family Physicians of Canada; 2019.

63.

Pinto

Bondy

Rucchetto

, et al. Screening for poverty and intervening in a primary care setting: An acceptability and feasibility study. Fam Pract. 2019;36(5):634-638. doi: 10.1093/fampra/cmy129

64.

Pinto

Da Ponte

Bondy

, et al. Addressing financial strain through a peer-to-peer intervention in primary care. Fam Pract. 2020;37(6):815-820. doi: 10.1093/fampra/cmaa046

65.

Upstream Lab. AddressInG iNcome securIty in primary carE (IGNITE) Integrating Health & Social Care: Upstream Lab. https://upstreamlab.org/project/addressing-income-security-in-primary-care-ignite/. Accessed June 17, 2022.

66.

De Leeuw

. Physician activism and prescribing against poverty. Canadian Family Physician. 2016;62(April):332-335.

67.

Porter

. St Michael’s Hospital health team offers prescription for poverty. Toronto Star. May. 2015;23.

68.

Deaton

Cartwright

. Understanding and misunderstanding randomized controlled trials. Soc Sci Med. 2018;210(August):2-21. doi: /doi.org/10.1016/j.socscimed.2017.12.005

69.

Unity Health Toronto. St. Michaels’ Hospital, 2022. https://unityhealth.to/locations/st-michaels-hospital/. Accessed June 17, 2022.

70.

Unity Health Toronto. Family Health Teams, 2022. https://unityhealth.to/areas-of-care/programs-and-clinics/family-and-community-medicine/#st-michaels-hospital-department-of-family-and-community-medicine-academic-family-health-team-strategic-plan-2020-25-0. Accessed January 13, 2022.

71.

Centre for Effective Practice. Poverty: a clinical tool for primary care providers, 2016.

72.

Unity Health Toronto. Social determinants of health. https://unityhealth.to/social-determinants-of-health/. Accessed June 17, 2022.

73.

Practising equity-focused health care. How St. Michael’s Hospital Academic Family Health Team Works to Address the Social Determinants of Health. Department of Family and Community Medicine and St. Michael’s Academic Family Health Team; 2020.

74.

Jones

Bloch

Pinto

. A novel income security intervention to address poverty in a primary care setting: A retrospective chart review. BMJ Open. 2017;7:e014270. doi:10.1136/ bmjopen-2016-014270.

75.

Yin

. Case Study Research Design and Methods (3rd ed.). Sage; 2003.

76.

Bradshaw

Atkinson

Doody

. Employing a qualitative description approach in health care research. Global Qualitative Nursing Research. 2017;4:2333393617742282. doi: 10.1177/2333393617742282

77.

Caelli

Ray

Mill

. ‘Clear as mud’: Toward greater clarity in generic qualitative research. Int J Qual Methods. 2003;2(2):1-13. doi: 10.1177/160940690300200201

78.

Sandelowski

. Whatever happened to qualitative description? Res Nurs Health. 2000;23(4):334-340. doi: /doi.org/10.1002/1098-240X(200008)23:4<334::AID-NUR9>3.0.CO;2-G

79.

Sullivan-Bolyai

Bova

Harper

. Developing and refining interventions in persons with health disparities: The use of qualitative description. Nurs Outlook. 2005;53(3):27-133. doi: /doi.org/10.1016/j.outlook.2005.03.005

80.

Patterson

Morin

. Methodological considerations for studying social processes. Nurse Res. 2012;20(1):33-38. doi: doi: 10.7748/nr2012.09.20.1.33.c9306

81.

Holloway

. Qualitative Research in Health Care. Open University Press; 2005.

82.

Sandelowski

. What's in a name? Qualitative description revisited. Res Nurs Health. 2010;33(1):77-84. doi: /doi.org/10.1002/nur.20362

83.

Encyclopedia of Survey Research Methods. 2008. doi: 10.4135/9781412963947

84.

DePoy

Gitlin

. Chapter 21 - analysis in naturalistic inquiry. In: DePoy

Gitlin

, eds. Introduction to Research (Fifth Edition). Mosby; 2016: pp.311-323.

85.

Constant comparative analysis. APA Dictionary of Psychology. American Psychological Association; 2022. https://dictionary.apa.org/constant-comparative-analysis .

86.

Stenfors

Kajamaa

Bennett

. How to … assess the quality of qualitative research. Clin Teach. 2020;17(6):596-599. doi: /doi.org/10.1111/tct.13242

87.

Thomas

Magilvy

. Qualitative rigor or research validity in qualitative research. J Spec Pediatr Nurs. 2011;16(2):151-155. doi: /doi.org/10.1111/j.1744-6155.2011.00283.x

88.

Bleacher

Lyon

Mims

, et al. The feasibility of screening for social determinants of health: Seven lessons learned. Fam Pract Manag. 2019;26(5):13-19.

89.

Personal communication with Dan Hopewell, Director of Knowledge and innovation, Bromley by Bow Centre, October 10, 2018.

90.

Sinclair

. Glasgow’s Deep End Advice Worker project: improving accessibility of advice services. Policy in Practice; 2018.

91.

Moffatt

Steer

Lawson

, et al. Link worker social prescribing to improve health and well-being for people with long-term conditions: Qualitative study of service user perceptions. BMJ Open. 2017;7(7):e015203. doi: 10.1136/bmjopen-2016-015203

92.

Pescheny

Randhawa

Pappas

. Patient uptake and adherence to social prescribing: A qualitative study. BJGP Open. 2018;2(3):bjgpopen18X101598. doi: 10.3399/bjgpopen18X101598

93.

Powell

Langley

Kirwan

, et al. Welfare rights services for people disabled with arthritis integrated in primary care and hospital settings: Set-up costs and monetary benefits. Rheumatology (Oxford). 2004;43(9):1167-1172.

94.

Mercer

Fitzpatrick

Grant

, et al. Effectiveness of community-links practitioners in areas of high socioeconomic deprivation. Ann Fam Med. 2019;17(6):518-525. doi: 10.1370/afm.2429

95.

Gottlieb

Razon

Aboelata

. How do Safety Net Clinics Pay for Social Care Programs? Social Interventions Research & Evaluation Network; 2019. https://sirenetwork.ucsf.edu/tools-resources/resources/how-do-safety-net-clinics-pay-social-care-programs. Accessed June 5, 2022.

96.

Onie

Lavizzo-Mourey

Lee

, et al. Integrating social needs into health care: A twenty-year case study of adaptation and diffusion. Health Aff. 2018;37(2):240-247. doi: 10.1377/hlthaff.2017.1113

97.

Center for Health Care Strategies Inc. Medicaid Accountable Care Organizations: State Update. Center for Health Care Strategies Inc; 2018.

98.

Lesperance

. Exploring Income Security Offered Through Primary Care: a Mixed-Methods Process Evaluation. University of Manitoba; 2019.

99.

Siddiqi

Sod-Erdene

. Social Assistance is not Improving Health Income Support Recipients are in Worse or no Better Health than their Peers. Why is Social Assistance Failing at this Important Objective? Policy Options. IRPP; 2018.

100.

Policy Options. The troubling rise of income and wealth inequality in Canada. July 18, 2024. https://policyoptions.irpp.org/2024/07/income-wealth-inequality/#:∼:text=The%20disparity%20in%20levels%20of,same%20quarter%20a%20year%20earlier. Accessed October 13, 2025.

101.

Income Security Advocacy Centre. ISAC’s Analysis of Ontario’s 2024 Economic Outlook and Fiscal Review, November 15 2024. https://incomesecurity.org/isacs-analysis-of-ontarios-2024-economic-outlook-and-fiscal-review/#:∼:text=Ontario%20Works%20(OW)%2C%20upon%20which%20about%20473%2C000,a%20month%20for%20single%20individuals%20since%202018. Accessed October 13, 2025.

102.

Income Security Advocacy Centre. OW and ODSP rates and OCB as of July 2025, July 8, 2025. https://incomesecurity.org/isacs-analysis-of-ontarios-2024-economic-outlook-and-fiscal-review/#:∼:text=Ontario%20Works%20(OW)%2C%20upon%20which%20about%20473%2C000,a%20month%20for%20single%20individuals%20since%202018. Accessed October 13, 2025.

103.

Campaign 2000: End Child and Family Poverty in Canada. 2024 Report Card on Child and Family Poverty in Canada, 2024. https://campaign2000.ca/wp-content/uploads/2024/11/Ending-Child-Poverty-The-Time-is-Now-2023-Report-Card-on-Child-and-Family-Poverty-in-Canada-Nov-18-2024.pdf. Accessed October 13, 2025.

104.

Government of Canada. A Time for Urgent Action: the 2024 report of the National Advisory Council on Poverty, 2024. https://www.canada.ca/en/employment-social-development/programs/poverty-reduction/national-advisory-council/reports/2024-annual.html. Accessed October 13, 2025.