Creating a healthier, better connected Gippsland.

Social Prescribing

Gippsland Primary Health Network (Gippsland PHN) works to improve health and wellbeing of people across Gippsland.

Social Prescribing

Social Prescribing supports healthcare professionals to improve people’s health and wellbeing by addressing social determinants of health.

What is Digitally Enabled Social Prescribing?

Social Prescribing provides healthcare professionals with a non-medical referral option, complimentary to existing clinical treatments to improve health and wellbeing.

General practices in Gippsland use a digital platform called Kaleidoscope to support healthcare professionals to link health consumers with social, therapeutic and practical support provided by volunteer and community support organisations that already exist in their local area.

The Kaleidoscope digitally enabled social prescribing solution is designed to support co-designed (between health providers and consumers) psychosocial care plans with measurable goals, tangible actions such as health interventions and the ability to create social prescriptions and referrals to community organisations.

Healthcare professionals support people to monitor progress against their goals over time. They assist consumers define actions, which are agreed tasks for the consumer to undertake to achieve the goal.

 Actions can include reading and understanding health literacy information, contacting a third-party organisation for support, using an app and a variety of other interventions.

Kaleidoscope offers a comprehensive pre-built library of actions and an in-built Social Service Directory of local community and social organisations for referral.

Having defined goals, actions and referrals, health providers can print or email a social prescription to the consumer, creating a formal and written record to measure their progress.

Assessment of need for social prescribing

Louise struggled daily with her drinking. She tried to keep her battle private but over the years, her addiction had gradually overtaken and coloured most of her life. Her work had become spasmodic and her contact with friends and family was diminishing. At her local general practice, Louise and the practice nurse discussed Louise’s desire to get out and start moving more.

Work with patient to develop personalised social care plan

The practice nurse suggested a walking group might help Louise adhere to these new goals. The practice nurse worked with Louise, taking her through Kaleidoscope assessments on mental health, loneliness and alcohol usage.

Refer patient to community-based services

After discussing Louise’s assessment results together, they evaluated the options available on Kaleidoscope. The practice nurse and Louise uncovered a great psychologist at a local Women’s Health Centre who offered free appointments with a mental health care plan. Louise felt safe and comforted at the Women’s Health Care Centre, and importantly, ready to make some significant changes in her life.

Include individual and group activities

Louise felt her life had a plan for the first time in years – she was beginning to see light at the end of the tunnel. She was working on her mental health with her psychologist and she decided to start a language class; Louise finally felt the courage to do something different. Her confidence was growing.

Progress and outcomes

As Louise’s health improved, her alcohol intake dropped. She found she didn’t smoke as much either. Surprisingly, Louise’s smoking stopped completely not long after she joined the walking group found through Kaleidoscope.

The walking group provided Louise with a great social outlet that helped her mental health on many fronts. Not only had her outlook improved, her physical health had too. She looked healthy, which helped with her confidence. Louise’s interest in her work returned. Her employers noticed an air of positivity they had not seen in years.

Sylvia was desperately lonely. Aged 70, she had watched as her social circle slowly diminished. Living in a rural community can be isolating, especially given Sylvia’s mental health concerns. With seemingly all her friends either moving away or passing away, Sylvia felt that her life was at a crossroads. She was alone and felt helpless.

Despite her depression, Sylvia knew she had to make a positive change in her life; meet other people and move out of her comfort zone

Sylvia’s general practice staff had become a great confidantes during this time. The practice nurse helped Sylvia by brainstorming some ideas through Kaleidoscope and discussed some practical ways that Sylvia could take control of her situation. But for Sylvia, none of the activities in Kaleidoscope felt quite right. They were either too far away or didn’t feel like the right activities for her at this stage in life.

With the practice nurse’s support, they started to talk about how they could create changes in Sylvia’s life that worked for her. They decided that starting a coffee and chat group at her local café could potentially work. To the practice nurse’s surprise, this was just the challenge Sylvia needed. She went to the local café and approached the manager about her vision for the social group. The café manager, Martin, was not only supportive but liked the idea so much, they offered a group discount for her initiative to ensure its success.

At the inaugural coffee and chat group, Sylvia was anxious no-one would come. But Martin’s support and reassurance helped give Sylvia the support she needed. The practice nurse knew of some other locals who felt the same social isolation as Sylvia. Sylvia soon realised there were other people in her community that felt like she did. It was a revelation for Sylvia – she wasn’t alone for the first time in many years.

The benefits

Evidence suggests that people who are active in and connected to their community are more likely to have better health. Research on social prescribing models has found:

  • 28% decrease in demand for general practitioner services
  • Increases in patient self-esteem and confidence, improved mental wellbeing and positive mood and a reduction in anxiety, depression and negative mood.
  • 50% reduction in emergency department presentations.


Links to research

[1] Royal College of General Practitioners. (2018). RCGP calls on government to facilitate ‘social prescribing’ for all practices. [online] Available at:

[1] Helen J. Chatterjee, Paul M. Camic, Bridget Lockyer & Linda J. M. Thomson (2018) Non-clinical community interventions: a systematised review of social prescribing schemes, Arts & Health, 10:2, 97-123, DOI: 10.1080/17533015.2017.1334002

[1] Merton Clinical Commissioning Group – NHS UK. (2018). Evaluation of the East Merton Social Prescribing Pilot. [online] Available at:


Interested in a Digitally Enabled Social Prescribing demonstration? Contact the Digital Health team to schedule a walk through

Contact us

If you would like further information, please contact the Digital Health team

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