Activating those inactive: the case of Social Prescribing for young people in a NEET
situation in Italy
Background: The research investigates how Social Prescribing intervention can be a valuable approach for young people aged 15-34 who are in a NEET situation (Not in Education, Employment or Training) and how was their experience with Link Workers.
Approach: We interviewed fifteen young people in a NEET situation from Italy who have participated in the pilot study of C.O.P.E. (Capabilities, Opportunities, Places and Engagement). The study is the first pilot in Italy specifically developed to address social and health needs of these young people through a Social Prescribing model. Link Workers and young people co-designed an Individual Action Plan, based on needs and aspirations, to support one or more of the following pathways: employment, education, training, socialisation, and health/wellbeing
Results: Young people participating in the study represented a heterogeneous population. They were divided into two main groups: those already supported by services and those who were not. The willingness to exit their social isolation was the main driver to access the intervention. The Link Workers, compared to other similar roles in existing support networks, represented the missing link in providing a stepped approach to enter or re-enter the labour market, educational and training programmes, socialisation and health/wellness opportunities, thanks to an increase of self-esteem in the young people. All participants have mentioned having received great support and achieved their goals, feeling more accountable and prepared to confront empowered and ready to face and embrace job and other opportunities. They valued this approach and recommended making it accessible at an earlier stage, among school students, to support them in the transition toward adulthood and avoid inactivity and social isolation.
Implications: The study reports the perceptions of young people in a NEET situation of Social Prescribing, as proposed by the project C.O.P.E.. It is the first research focusing on the implementation of this model in the Italian context, targeting this group of young people. The paper contributes, therefore, to extend the existing knowledge on Social Prescribing as an opportunity to co-design personalised pathways to support young people to reach their own ambitions and to find their place in their own community.

Background
The demand for healthcare is rising in many countries, while the simultaneous shortage of healthcare workers creates an overburdening of healthcare professionals. Also, non-medical issues like loneliness, low literacy, and financial struggles increasingly contribute to health problems that lead people to consult general practitioners (GPs). To address this, alternative care models involving collaboration with welfare professionals and community initiatives are needed. In the Netherlands, social prescribing (Welzijn op Recept) has emerged as an approach where GPs refer patients to welfare coaches, aiming to bridge healthcare, social work, and in particular community support.

Approach
We monitored the implementation of the positive health concept and social prescribing (in Dutch, Welzijn op Recept) in twenty-five GP-practices in the south of the Netherlands. The objective was to establish whether collaboration between general practitioners (GPs) and welfare coaches, as well as between welfare coaches and citizen initiatives, was established, and to identify which factors influenced this collaboration. Questionnaires were sent to all relevant collaboration partners (GP-practices, welfare coaches, community support workers, and citizens) at baseline and after 12 months, and twenty semi-structured interviews were conducted with professionals and citizens in seven purposively selected locations out of the twenty-five included in the study.

Results
Questionnaires revealed that collaboration between the welfare coaches and the GPs was established. However, better agreements on referral criteria were needed, and GPs wanted to be informed about the patient after referral. GPs appreciated having the welfare coach as a single point of referral instead of a variety of citizen initiatives. However, with the presence of the welfare coach, direct contact between the GPs and citizens (e.g. informal caregivers) decreased. At 12 months, collaboration between welfare coaches and citizen initiatives was limited. Community support workers, who are strongly connected to the community, were hardly recognized as collaboration partners. The number of referrals was 1-2 patients per GP per month but decreased to 0-1 patients between 12 and 24 months.
Interviews showed that GPs often did not apply the concept of positive health during consultations and, consequently, may have missed non-medical factors. Overall, self-efficacy regarding the application of positive health was moderate. Additionally, due to daily routines, they regularly forgot about the possibility of social prescribing. Welfare coaches need to develop a network with citizen initiatives but do not automatically possess networking capabilities. Many welfare coaches also combined this role with a profession as social workers or as community support workers. This dual role was sometimes confusing for themselves and for the patients.

Implications
GPs need to feel competent and require support in applying positive health to recognize underlying non-medical problems. Active implementation strategies based on a needs assessment are required. The possibility of social prescribing should be regularly brought to their attention to make it a routine. To involve citizens in the provision of care and support, welfare coaches need help to develop networking capabilities and should present themselves to GPs to strengthen their position. If available, community support workers are valuable partners in the collaboration.

Background
In a caring community, individuals work together to provide care and support, particularly for those in vulnerable situations. In the Netherlands, we have seen a rapid increase in the number of active caring communities in recent years. Given the ageing population, limited care capacity, and a withdrawing government, this development seems both necessary and inevitable.

However, integrating caring communities as a thriving part of our health and support system presents significant challenges. Our research highlights key bottlenecks, such as difficulties in collaboration with formal institutions, the struggle for sustainable financing, and the challenge of defining the movement due to the broad use of the term ‘caring community.’ Likewise, (health)care organizations recognize the rise of caring communities but find it difficult to engage with them while maintaining focus on their own organizational needs.

Audience
This presentation is aimed at professionals and citizens involved in caring communities, as well as professionals from healthcare organizations looking to collaborate with these initiatives. Anyone interested in the role of citizen-led initiatives in shaping a sustainable healthcare system is welcome to attend.

Approach
In this session, we will present findings from multiple research projects on the governance and collaboration of caring communities. The presentation will be structured as follows:

- Defining Caring Communities: Insights from scoping research on how caring communities are understood and positioned in the broader health and social care landscape.
- Governance and Sustainability: Key findings from ethnographic research within five different caring communities, focusing on governance models, internal organization, financing, and external collaborations.
- Collaboration with Healthcare Organizations: A discussion on how (health)care organizations can effectively engage with and support caring communities without compromising their own objectives.

Throughout the presentation, we will provide concrete examples and practical approaches for bridging the gap between formal healthcare structures and grassroots community initiatives.

Outcomes
Attendees will gain:
- A clearer understanding of the definition and role of caring communities.
- Insights into different governance structures and the challenges they face.
- Practical strategies for strengthening collaboration between caring communities and (health)care organizations.
- Inspiration to apply these insights in their own work and contribute to the broader movement towards a sustainable, community-driven healthcare system.

Background: Initiated in 2017, the Caring Leuven project addresses the challenge of creating sustainable, integrated care by uniting diverse stakeholders around a shared vision to improve health outcomes and contribute to the Sustainable Development Goals (SDGs).

Approach: In 2025, Caring Leuven will transition into a living lab co-designed with academic partners, patients, caregivers, and community representatives. Key stakeholders include KU Leuven's Population Health Management (PHM) Unit, local general practitioners (GPs), pharmacists, other primary care representatives, regional hospitals, and a local medical center. Citizen involvement is central, ensuring alignment with community needs and values.
The living lab involves multidisciplinary teams, including integrated neighborhood teams, specialist teams focused on specific conditions, and a dedicated integrator team to align efforts. Vertical disease-specific care pathways are integrated with horizontal preventive and lifestyle actions, supported by population health management techniques.
Digital tools are a cornerstone of this initiative, enabling real-time data collection and analysis to support care coordination and generate real-world evidence. These tools are developed and tested in collaboration with KU Leuven’s PHM Unit. Additionally, the living lab seeks to uncover the microprocesses and systemic changes that contribute to successful integrated care.

Results: Caring Leuven has built a robust stakeholder consortium comprising over 73 partners, including healthcare organizations, social services, academic institutions, and community representatives. A total of 410 primary caregivers - representing approximately 60% of GPs, pharmacists, nurses, and other primary care professionals in the region - are actively engaged in eight integrated neighborhood teams.
Furthermore, 8723 patients have participated in at least one innovative action through Caring Leuven. These efforts have significantly enhanced interdisciplinary collaboration and enabled the effective implementation of integrated care pathways. Visionary and managerial leadership at both micro and meso levels has been instrumental in harmonizing leadership across medical and social care sectors and fostering coordination through a central Integrator team.

Implications: Caring Leuven demonstrates a scalable and replicable model for collaborative, community-driven healthcare innovation. Lessons include the importance of co-design, distributed leadership, and transparent locoregional planning in fostering multidisciplinary teamwork and advancing integrated care. Chronic care program coaching and strong liaison roles have been key facilitators in achieving these outcomes.
The living lab’s success highlights its potential for broader application across regions and sectors. By leveraging sustainable, partnership-driven models, Caring Leuven showcases how health systems can deliver value to diverse stakeholders while driving system-wide transformation in alignment with the SDGs.

Background:

Connect North is the Northern Health and Social Care Trust area wide integrated, needs led, person-centred social prescribing service. It is the result of a comprehensive lens co-design process with stakeholders, service users and carers. Uniquely delivered in partnership by 2 organisations across 2 sectors working as one team combining leadership, resources and expertise for maximum impact.

Approach:

Our review of services delivering signposting, navigation or social prescribing functions found services to be disconnected; clients could be known to multiple providers for similar issues where others in need were unsupported. Directories offering helpful information were closed, targeted specific age or health condition and out of date. Support provided took the form of signposting relying on high levels of health literacy and client activation to take action.

We also held a series of stakeholder, public, service user and carer engagements (face-to-face, virtual workshops, interviews, phone calls and surveys). These highlighted shared needs and a collective call for change and integration.

We procured software enabling data collection and evidence based reporting to drive client, service and system level outcomes and created a publicly available online directory of services enabling more people to have more timely access to support along their care journey.

“Connect North – your pathway to wellbeing” was named by service users, our holistic needs assessment tool was selected by users and our resources are user led and co-produced.

Results:

Our shared directory lists more than 900 services and activities with users accessing around 17,000 pages/month. 20% of users are returning users. Our directory enabled us to develop a stepped model of care to support more clients earlier, at the level they need and throughout their care journey.

Each month we support 74 new client referrals, conduct 913 client interactions and make 148 signposts and 52 social prescriptions/month. We have trained over 240 referral agents from 25 organisations. Our top referral reasons include: dementia, connecting to groups/activities, befriending and loneliness and isolation. 87% of referrals are for clients over 65years. 75% of clients report an improvement in their primary wellbeing concern and 89% of clients report an overall improvement or maintenance of their health and wellbeing, despite the majority living with a long-term and progressive illness. 100% of clients report a positive experience finding the service helpful and informative.

Implications:

A health literate, needs led and true co-design process works. Pooling knowledge and skills from all partners including providers, communities, service users and carers has maximised impact beyond the sum of our respective parts. Digitalisation has released time to be directed to client care while simultaneously maximising care quality, value for money and the user experience.

Next steps include progression of a network of people within the community and information access points to direct more people to connect with local services encouraging earlier action to manage health and wellbeing. A further initiative to connect people directly with a range of supports linked to a common theme e.g. dementia, via a single appointment (community appointment days) are also in development.