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1.Briefly describe your social prescribing program and the communities it serves.

Social Rx is a community-based social prescribing initiative launched by UJA-Federation of New York to address loneliness and isolation among older adults. The program connects individuals to meaningful social, cultural, and supportive resources through trusted local organizations.

The model is implemented through a network of community-based organizations—primarily Jewish Community Centers—across New York City, Long Island, and Westchester. It serves a diverse population of older adults, including those who are socially isolated, managing health challenges, experiencing life transitions such as bereavement or retirement, or facing barriers to accessing services. Many participants are not engaged in traditional systems of care and benefit from culturally competent, community-rooted support. 

2.Who serves as the link worker or connector in your program, and how is that role designed? 

The link workers in Social Rx are called Connections Specialists, and they are embedded within community-based organizations rather than clinical settings.

This role is intentionally designed to sit in trusted, accessible community institutions while maintaining strong relationships with healthcare providers. Connections Specialists receive referrals from a range of sources, including healthcare providers (such as Northwell Health), synagogues, other Jewish institutions, and hospital systems. Self referrals are also accepted.

They help participants navigate a wide range of barriers, including transportation, access to benefits and services, social anxiety, language and cultural barriers, and system complexity. Their work goes beyond referral—they provide “warm handoffs,” following up to ensure participants successfully engage.

Connections Specialists typically have backgrounds in social work, community engagement, or human and/or legal services. They participate in ongoing training and a structured community of practice, with additional guidance from the National Academy for Social Prescribing.

3. What types of social prescriptions are referred to and how are participants connected to those resources?

Social prescriptions are highly individualized and based on the question, “What matters to you?”

They may include:

• Social and cultural programming (e.g., group activities, classes, excursions)

• Health and wellness programs (e.g., fitness, chronic disease support)

• Mental health and bereavement support

• Volunteer and purpose-driven opportunities

• Caregiver support and disease-specific services (e.g., dementia, Parkinson’s)

• Practical supports such as transportation, benefits access, or case management

Connections Specialists work collaboratively with participants to co-create a plan and then facilitate a warm handoff—often personally introducing the individual to a program or provider and following up to ensure meaningful engagement. When needs extend beyond the host organization, specialists connect participants to external community resources across a broad network.

3.How is your program funded?

Social Rx is funded through a combination of philanthropic investment and strategic partnerships.

UJA-Federation of New York serves as the lead funder and architect of the model, with additional support from partners including the Cabrini Foundation. Total annual investment is approximately $500,000.

Funding supports Connections Specialists embedded in community organizations, as well as central coordination, training, data collection, and partnership development. The model is designed to be a catalytic philanthropic investment, with the long-term goal of leveraging healthcare partnerships and public funding to support sustainability.

4.How has social prescribing impacted the health and well-being of the people you serve, and which outcome measures do you use to capture that impact?

Social Rx has served over 4,000 older adults, with the majority receiving support specifically aimed at reducing loneliness and isolation. The program emphasizes “successful connections”—not just referrals, but sustained engagement in community resources.

We use a shared measurement approach across sites, including questions adapted from the UCLA Loneliness Scale administered at intake and follow-up.

Analysis of data from 2021–2025 (n=656 with matched baseline and follow-up surveys) shows that:

• 63% of participants experienced improvement in at least one measure of loneliness or isolation

• Participants with the highest levels of loneliness at entry saw the greatest gains

• Socialization and mental health supports are among the most effective interventions used by Connections Specialists

We define improvement as a positive shift in self-reported experience over time (e.g., from “often lonely” to “rarely lonely”). Participants already reporting the highest level of connection at baseline were excluded from improvement analysis.

These findings reinforce that targeted, relationship-based support can meaningfully reduce isolation—particularly for those most at risk.

Through our partnership with Northwell Health, we are now working to assess how these improvements in social connection translate into broader health outcomes and healthcare utilization.

5.What advice would you give to others looking to start a social prescribing program?

Start by recognizing that social prescribing is not just a program—it is a coordination function that sits between systems.

Key lessons include:

• Invest in the role, not just the referrals: The link worker is essential. Warm handoffs, follow-up, and relationship-building are what drive impact.

• Anchor in trusted community institutions: Participants are more likely to engage when support is rooted in familiar, culturally competent settings.

• Build partnerships early, especially with healthcare: Referral pathways and alignment take time to develop.

• Standardize measurement but allow local flexibility: Shared metrics are critical, but implementation should reflect community context.

• Plan for sustainability from the start: Philanthropy can catalyze the model, but long-term success will require integration with healthcare and public funding streams.

Most importantly, focus on what matters to the individual. The strength of social prescribing lies in its ability to center choice, dignity, and connection.