Social Vital Sign Program brings together hospitals, community organizations to address social isolation
02/04/2026
A new cross-sector partnership is taking a bold step to address one of the most pressing challenges facing older adults across Canada: social isolation and loneliness. While older adults who are socially isolated are more likely to require hospital care, extended hospital stays can further disconnect patients from their communities. The transition home from hospital represents a critical opportunity for the health care and community sectors to work together to break the cycle of isolation and support meaningful reconnection.
The Social Vital Sign Program is a new initiative that brings together health care providers and community organizations to build integrated pathways that recognize and respond to social isolation as a critical determinant of health, launching with $1 million in support from The Waltons Trust and an additional $900,000 in partner contributions.
"Our long-term vision is to fundamentally transform how health and community systems work together to address the interconnected nature of medical and social well-being," said Michelle LA Nelson, PhD, Senior Investigator at Bruyère Health Research Institute and principal investigator of the project. "By considering social connection the same way we think about other vital signs, we create opportunities for health care and community partners to collaborate in supporting older adults' holistic health, making assessing social well-being as routine and essential as monitoring blood pressure or heart rate."
Through Nelson’s recently launched Care in Common Living lab, the program establishes a collaborative network of health care and community expertise. Anchored at Bruyère Health, and working in partnership with Niagara Health and Seniors Newfoundland and Labrador, each hospital will implement social isolation screening across rehabilitation, emergency medicine, and general internal medicine settings. The Canadian Institute for Social Prescribing, the Ontario Alzheimer's Society, and the Canadian Red Cross bring deep expertise in community connection, social prescribing, and addressing isolation among vulnerable populations, ensuring pathways are truly responsive to older adults’ needs and preferences. Together, this network is co-designing new protocols, shared referral pathways, and bidirectional communication systems that enable seamless coordination between clinical and community settings.
Although screening for social isolation and loneliness is recommended in the Canadian Coalition for Seniors’ Mental Health’s clinical guidelines, clear implementation strategies and partnership processes for acting on screening results are lacking, making it challenging to translate recommendations into coordinated support for older adults.
“After a stroke, we see how physical, cognitive, and communication changes and decline can easily lead to social isolation for our patients,” said Dr. Jaqueline Cochrane, Stroke Physiatrist and Clinical Research Affiliate at Bruyère Health. “The transition to the community after stroke rehabilitation is a particularly vulnerable period for many of our patients, and while community organizations are well placed to support patients and their families after discharge, our patients struggle to find and access them. Cultivating connection and community access is a great step toward building a system that really works for our patients.”
The Social Vital Sign Program's emphasis on cross-sector learning and knowledge mobilization ensures that innovations developed collaboratively at one site—whether in clinical screening protocols or community connection strategies—quickly inform practice improvements across the entire network. This creates exponential progress toward a future where older adults receive not only medical treatment, but also the social support essential for their well-being, delivered through coordinated partnerships that bridge health and community.
Funding from The Waltons Trust is provided in memory of John and Susanne Graham.