Inclusion Criteria:  the study team uses 7 categories of SDOH, namely Housing, Food, Economic Stability, Cognition and Learning, Social Environment, Access to Healthcare, and Digital Technologies. If there are care needs related to at least one category of SDOH, the patients will be deemed eligible for the Social Prescribing intervention. In addition, the patient must have the mental capacity to consent and participant in thesurvey.  Exclusion Criteria:  The following group of patients will be excluded from the study:  Patients who will be discharged to Nursing Homes; Patients who are unable to complete the required survey used in this study due to physical/sensory/cognitive impairment; and/or Patients who are diagnosed with a life-limiting condition with a prognosis of equal or less than 3 months.