JMIR FORMATIVE RESEARCH

Cailhol et al

Original Paper

Quality Improvement Intervention Using Social Prescribing at
Discharge in a University Hospital in France: Quasi-Experimental
Study
Johann Cailhol1,2, MD, PhD; Hélène Bihan1,3, MD, PhD; Chloé Bourovali-Zade2, MPH, ASN; Annie Boloko2, ASN;
Catherine Duclos4,5, MD, PhD
1Laboratoire Educations et Promotion de la Santé, University Sorbonne Paris Nord, Bobigny, France

2

Infectious Diseases Unit, Groupe Hospitalo-Universitaire Paris Seine Saint Denis, Assistance Publique des Hopitaux de Paris, Bobigny, France

3

Diabetology Unit, Groupe Hospitalo-Universitaire Paris Seine Saint Denis, Assistance Publique des Hopitaux de Paris, Bobigny, France

4

Laboratoire de recherche en informatique pour la santé, University Sorbonne Paris Nord, Bobigny, France

5

Public Health Department, Groupe Hospitalo-Universitaire Paris Seine Saint Denis, Assistance Publique des Hopitaux de Paris, Bobigny, France

Corresponding Author:
Johann Cailhol, MD, PhD
Laboratoire Educations et Promotion de la Santé
University Sorbonne Paris Nord74 rue marcel cachin
Bobigny, 93007
FrancePhone: 33 148955426
Email: johann.cailhol@aphp.fr

Abstract
Background: Social prescription is seen as a public health intervention tool with the potential to mitigate social determinantsof health. On one side, social prescription is not yet well developed in France, where social workers usually attend to social needs,
and historically, there is a deep divide between the health and social sectors. On the other side, discharge coordination is gaining
attention in France as a critical tool to improve the quality of care, assessed indirectly using unplanned rehospitalization rates.
Objective: This study aims to combine social prescription and discharge coordination to assess the need for social prescription
and its effect on unplanned rehospitalization rates.
Methods: We conducted a quasi-experimental study in two departments of medicine in a French university hospital in a
disadvantaged suburb of Paris over 2 years (October 2019-October 2021). A discharge coordinator screened patients for socialprescribing needs and provided services on the spot or referred the patient to the appropriate service when needed. The primary
outcome was the description of the services delivered by the discharge coordinator and of its process, as well as the characteristicsof the patients in terms of social needs. The secondary outcome was the comparison of unplanned rehospitalization rates after
data chaining.
Results: A total of 223 patients were included in the intervention arm, with recruitment being disrupted by the COVID-19
pandemic. More than two-thirds of patients (n=154, 69.1%) needed help understanding discharge information. Slightly less thanhalf of the patients (n=98, 43.9%) seen by the discharge coordinator needed social prescribing, encompassing language, housing,health literacy, and financial issues. The social prescribing covered a large range of services, categorized into finding a generalpractitioner or private sector nurse, including language-matching; referral to a social worker; referral to nongovernmentalorganization or group activities; support for transportation issues; support for health-related administrative procedures; and support
for additional appointments with nonmedical clinicians. All supports were delivered in a highly personalized way. Ethnic datacollection was not legally permitted, but for 81% (n=182) of the patients, French was not the mother tongue. After data chaining,rehospitalization rates were compared between 203 patients who received the intervention (n=5, 3.1%) versus 2095 patients who
did not (n=51, 2.6%), and there was no statistical difference.
Conclusions: First, our study revealed the breadth of patient’s unmet social needs in our university hospital, which caters to anarea where the immigrant population is high. The study also revealed the complexity of the discharge coordinator’s work, whoprovided highly personalized support and managed to gain trust. Hospital discharge could be used in France as an opportunity
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in disadvantaged settings. Eventually, indicators other than the rehospitalization rate should be devised to evaluate the effect ofsocial prescribing and discharge coordination.
(JMIR Form Res 2024;8:e51728) doi: 10.2196/51728
KEYWORDS
social prescription; discharge coordination; language barriers; readmission rates; ethnic matching; trust; personalized care;discharge; social determinant; social need; tool; quality of care; readmission; quality improvement

Introduction
Worldwide, social inequalities are increasing, as well as theweight of the social and economic determinants on healthoutcomes [1]. Social prescribing (SP) has been proposed as apublic health intervention to tackle social determinants of healthin a pragmatic way [2,3]. SP is defined as a link worker
providing a set of nonclinical services. First implemented in the
United Kingdom in primary health care, SP has expanded toother countries [3-6] and is increasingly experimented with, but
not yet in France. In the United Kingdom, SP link workers were
integrated into the National Health System in 2019 [7]. Other
countries, such as Canada, are also implementing SP in theirprimary health care system, whose actors call for an increased
uptake [8]. SP is seen as a model integrating social and healthsectors, and builds on the trust of the “prescription”-based
relationship [9]. So far, evaluations of SP’s impact on population
health have shown mixed results and have fueled debates on
which outcomes to measure [6,10-12]. There seems to be aconsensus that evaluations should use both quantitative andqualitative methods, assessing process, experience, andoutcomes [6,10,13]. Outcomes considered health and more
broadly well-being, and were related to patients and healthsystems [12]. Since SP’s goal is to favor well-being without
focusing on a specific health outcome, the time scale for
evaluation might also be much longer than usual [14].
Eventually, a scoping review conducted in Wales revealed alack of consensus on the terminology used in social prescription
practice, leading to miscommunication among professionals,
public health decision makers, and the public [15].
In parallel to primary health care, another entry point of SP
could be hospital discharge time. Hospital discharge is atransition period of paramount importance, both in terms of
hospital efficiency/effectiveness [16] and quality of care [17].
Discharge coordination (DC) has been tested for years,
especially in North America and Japan, to reduce the rate ofreadmission within 30 days, also with mixed results [18-20]. In
Europe, concerns over readmission rates are less of a financial
concern, but the same lack of coordination issue at discharge
remains [21]. Diseases and related treatments are becoming
increasingly complex, and multimorbidities represent a challenge
in coordination.
This study sought to combine SP and DC in France for the firsttime and describe its operationalization. A personalized SP/DCintervention was implemented in two departments of medicine
at a university hospital. The intervention consisted ofcoordinating discharge; screening; and, when needed, tacklingsome of the unmet social needs related to health. We also

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measured the impact of the combined SP/DC intervention on
readmission rates.

Methods
The SQUIRE (Standards for Quality Improvement Reporting
Excellence) guidelines were followed to describe theintervention and to write the paper.

Context
Avicenne University Hospital, located in an underserved suburbof Paris (Seine-Saint-Denis department), caters to adisadvantaged population comprising the highest proportion of
migrants in mainland France. Two departments of medicine
were included in this study, one with a chronic disease profile(Diabetology Department [DD]) and one with an acute careprofile (Infectious Diseases Department [IDD]). The IDD
manages a variety of infections such as community infections(pneumonia, upper urinary tract infections, etc) andimmunodepression-related infections. In both units, inpatients
had many comorbidities, including a high prevalence of mental
health conditions. For transmissible and nontransmissible
diseases, there is a well-known link between deprivation and ahigher risk of complications, also known as syndemics [22,23].
Rates of readmission within 30 days for inpatients of these two
departments as of 2017, the year of project conception, were
5.9% and 1.3% in the IDD and DD units, respectively.

Intervention
An intervention was defined as a discharge coordinator (DCo)visiting a patient at the time of discharge, delivering a set of
nonclinical services tailored to improve patient discharge
instruction understanding and uptake (DC), screening the social
needs, and setting personalized goals to meet some of thepatient’s social needs that could undermine care (SP). Care wasdefined holistically including its social determinants.
The intervention was delivered in a quasi-experimental way to
reduce inclusion bias: the intervention was delivered the same
day of the week in each department. Patients who weredischarged on other days of the week from the 2 departmentsor those not interested in the intervention were automatically
included in the nonintervention group.
The details of the intervention delivered by the DCo consistedof the following, which were labeled basic DC, DC, SP, or both
SP and DC:•

Reviewing diagnosis and postdischarge instructions,ensuring understanding and providing explanations if
necessary (basic DC)

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•
•

•

•

•
•

Checking whether the patient had a general practitioner(GP) and, if not, helping him with identifying one (DC)Checking whether the patient had financial constraints withfollowing medical prescriptions and, more generally, if
there was any social deprivation delivering support services(SP)
Inquiring how the patient would attend postdischarge
hospital visits and prescribed examinations and, if any
constraint was identified, helping the patient (SP)Checking living conditions (housing, loneliness), substanceabuse, mental health, and other perceived needs related tohealth, and referring patients according to goals set (SP)Checking the feasibility of the treatment on a practical level
and, if needed, delivering support services (SP/DC)
Communicating DCOs’ contact information to the patient
for them to call the DCo if needed (SP/DC)

If the patient was not fluent in French, the DCo used a translator
over the phone and together with the patients identified a trusted
person to whom important discharge information would be
passed, with the patient’s approval.
The DCo was recruited on a part-time basis for this study. She
was a graduated nurse with long experience in patient support
in the oncology unit of the same hospital. She wasknowledgeable about the context of the hospital patients. She
also pursued a postgraduate university diploma in healthnavigation in 2020. She was under the supervision of 2 medical
doctors (one specialized in public health and infectious diseases,
and one in endocrinology) for her interventions.

Data and Population
Eligibility to the DCo Intervention
All eligible patients were discharged on Wednesday or Friday
in the DD or IDD from October 1, 2019, to June 30, 2021, andon Monday or Thursday for DD or IDD from July 1 to October30, 2021. The day changed once during the period ofintervention due to changes in the units’ organization.

DCo Intervention Exclusion Criteria
Patients were excluded if they refused to participate or werealready seen before the study.

Data
A paper-based questionnaire on sociodemographics and literacy
items was provided at the beginning of the DCo visit(Multimedia Appendix 1); a paper-based record was kept on
the type of support provided by the DCo and on the type andduration of follow-up when needed. Data were then entered into
an Excel (Microsoft Corporation) spreadsheet by the DCo.
Data on the SP/DC process was collected through regularfollow-up meetings held between the DCo and the 2 medical
doctors in charge of the study.
A list of all patients hospitalized in the 2 units during the study
period was extracted from the hospital database, with thevariable unplanned hospitalization. Only the first hospitalization(nonintervention group) or the hospitalization during which theintervention occurred (intervention group) was kept if several
hospitalizations occurred for the same patient. The data set of
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Cailhol et al
all patients was chained with the data set of patients who
received the SP/DC intervention, using the patient unique
identifier number.

Analysis
The design of our study being quasi-experimental, any differencein outcome is inferable only to the intervention. The sample
initially computed for the protocol was 380 patients in theintervention group to be able to show a 5% decrease inreadmission rate in the IDD. The readmission rate was calculated
for all patients hospitalized in DD or IDD for more than 1 night
between October 1, 2019, and October 10, 2021, and who weredischarged to home. The outcome was compared between
patients in the intervention group versus those who did notreceive an intervention. Patients transferred to another facility
during or at the end of their stay and patients previously seenby the DCo, in cases of readmission, were not included in thesample.
Characteristics of patients included in the intervention groupand type of support services provided were described using
descriptive statistics, and chi-square tests were used to run allcomparative statistics. The software used was R Studio(2021.09.01; Posit, PBC), and P values were consideredsignificant when below the threshold of .05. The process of theinterventions, including reflexivity, was analyzed continuously
during the study via regular meetings between the 2 supervisors
and the DCo and other health professionals involved in thepatients’ care when needed.

Ethics Approval
The Ethical Review Board of the French National Institute for
Health and Medical Research (Inserm) reviewed and approved
the protocol (IRB00003888, approval 18-534, November 2018).
Patients who were informed about the intervention by the DCogave their informed consent orally. They were all informed
about the possibility of not receiving the intervention and thatthey could stop the intervention without any consequence on
further care. The questionnaire and patient information sheet
are presented in Multimedia Appendices 1 and 2, respectively.
Data were fully anonymized for the purpose of the study. Only
the patient identifier was kept in a file to keep record of those
who received the intervention. When the DCo and patientdecided on a follow-up intervention, an additional record wascreated for the DCo to perform the follow-up. There was nocompensation provided to participants.

Patient and Public Involvement
The selecting committee of the funding agency (Agence
Régionale de Santé) comprised representatives of the public.
At the university hospital level, the project implementation wasmonitored by a pilot committee constituted of, inter alia,
patients’ representatives.

Results
Characteristics of Patients in the Intervention GroupA total of 228 patients were eligible for the intervention group,
5 patients refused to be included, amounting to 223 included
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patients. Reasons for noninclusion consisted of 1 patient statingthat he had no need for the intervention and 4 who had to leavesince the transportation taking them home had arrived by thetime the DCo went to see them.
Socioeconomic and demographic characteristics are presented
in Table 1.
Health literacy, access to care, and perceived needs are presented
in Table 2.

Cailhol et al
Regarding language characteristics, the most frequent mothertongues were Arabic (n=56, 25%), French (n=40, 18%), Tamil(n=18, 8%), and Bambara (n=13, 6%). Other mother tongues(n=96, 43%) were scattered between 36 different languages or
dialects. When considering patients whose mother language
was not French (n=83), the proportion of those not fluent in
French increased to 45.6% (n=38). Patients who were not fluent
in French originated mostly from Asia (n=27, 33%), sub-SaharanAfrica (n=25, 30%), and Northern Africa (n=21, 25%).

Table 1. Socioeconomic characteristics (N=223).
Participants, n (%)
Education levelNone

36 (16.1)

Primary39 (17.5)

Secondary104 (46.6)

Tertiary

44 (19.7)

Income level <€950 (US $1105)
Yes

104 (47.5)

No

115 (52.5)

Housing conditions (n=211)
Tenant111 (52.3)

Hosted (by family, friends, or other)51 (24.2)

Owner

45 (21.2)

Homeless

5 (2.3)

One or more children to support (n=201)
Yes

77 (38.3)

No

124 (61.7)

Living alone (n=212)
Yes

53 (25.0)No

159 (75.0)

Complementary health coverage (n=189)
None

13 (6.9)

Mutuelle

136 (72.0)

Solidarity insurance

40 (21.1)

Source of income (n=202)
Employment

81 (40.1)

Retirement pension

55 (27.2)

Unemployment benefit

32 (15.8)

Disability allowance

25 (12.4)

Other

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Table 2. Perceived health-related needs and health literacy characteristics (N=223).
Participants, n (%)
Need help to understand medical prescription
Yes

154 (69.1)

No

69 (30.9)

Need any type of support at discharge to improve health managementYes

88 (39.4)

No

135 (60.6)

Fluent in FrenchYes

140 (62.8)

No

83 (37.2)

French is the mother tongueYes

41 (18.4)

No

182 (81.6)

Need help to collect medical prescription at pharmacy (n=207)
Yes

101 (48.2)

No

106 (51.9)

Perception of financial hardship (n=199)
Yes

87 (43.7)

No

112 (56.3)

Transportation issues with attending the next medical visit (mobility, financial, etc; n=214)
Yes

17 (7.9)No

197 (92.1)

DC and SP Process Analysis
At the beginning of the study, the DCo had to obtain the list ofpatients who were being discharged from the two departments.
The staff responsible for making this list available to the DCo
was not fully cooperative, especially in the DD. However, after
the 2 supervisors intervened to re-explain the DCo’s role andtrust was built between the staff and the DCo, the situation
improved.
The DCo managed to establish an empathic relationship withpatients at their discharge time. Her presenting as a nurse but
acting as a DCo facilitated the relationship. The DCo felt thatpatients were satisfied meeting her and reviewing the discharge
information. The DCo felt that she was always welcome, as if
she filled in a vacuum, taking up a role that was missing. She
felt useful each time she met a patient.
The DCo shared an ethnic background with a large proportionof patients, which also increased her trustworthiness [24,25].
Her training as a nurse enabled her to discuss with physicians
when she faced incomplete medical prescriptions. She liaisedwith a wide range of actors: social workers and clinicians andadministrative staff at the hospital level, social workers of thepatients’ hometowns at the community level, nurses providing
home visits, patients’ GPs, numerous local nongovernmentalorganizations (NGOs), and administrative staff. The DCo
accompanied each referral to a support service with a cover
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the facility/NGO what was most likely to meet the patient’s
needs. She ended her support once the goal was reached, yetpatients were free to call her in case another need emerged. The
DCo had to adapt her support services over time, depending on
the changing span of hospital social worker duties and theiravailability.
Finally, on the financial side, the intervention costed a total of€35,000 (US $40,698; €31,000 [US $36,046] for a part-time
DCo during the 2 years and €4000 [US $4652] for medical
supervision time).

Type of Support Provided by the DCoAmong the 223 patients included in the intervention group,
43.9% (n=98) needed a SP/DC support service, and 125 had
only basic DC services. Among the 98 patients, 77 needed a
postdischarge follow-up. The median follow-up duration was
8 (IQR 1-25) days. The duration of the DCo intervention at thetime of discharge was more than 1 hour for 30% (n=29) of
patients and between 30 and 60 minutes for 49.2% (n=48) of
patients.
The DCo delivered a total of 119 support services, either on the
day of discharge or during the following days. These support
services were roughly categorized between DC (n=22), mixed(n=25), and SP (n=72): finding a GP (n=12) or private sector
nurse (n=10; DC), referral to a social worker (n=24; SP), referral
to NGO or group activities (n=19; SP), support for transportation
issue (n=18; DC or SP), support for health-related administrative
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Cailhol et alprocedure (n=10; SP), and support for additional appointment
with nonmedical clinicians (n=19; SP). The referrals to a social
worker included addressing health coverage issues, allowing
patients to access medications that were otherwise unaffordable.
Each service was personalized, for example, for associationreferral, looking at the right association near the patient’s home,
checking if it was still receiving new beneficiaries and writinga referral letter, applying for complementary health insurance,
applying for a health-related residence permit, seeking a GP
speaking the same language, etc. Support for administrative
procedures meant that the DCo would at times physicallyaccompany the patient to the appropriate facility.

Comparison Between DCo and Non-DCo Groups
We monitored the implementation of other interventions on SP
and DC in the two departments during the study period andidentified one specific DC intervention for patients diagnosed
with COVID-19 from May 2020. This implied excluding 496
patients with a COVID-19 diagnosis from our study. Afterexcluding them, a total of 2706 patients were extracted for the
study period; among those, there were 408 multiple
hospitalizations, which were excluded. Among the remaining

patients, 203 who received the DCo intervention could be
identified via data set chaining, leaving 2095 who did not receive
the DCo intervention.
The characteristics of patients in these 2 groups were comparedaccording to their age, gender, residential area, vulnerability
score, and duration of hospitalization. No significant differenceswere found (Table 3 and Multimedia Appendix 1).
Rates of rehospitalization were 3.1% (5/203) in the intervention
group and 2.6% (51/2095) in the nonintervention group, withno significant difference (P=.99).
The 5 cases of rehospitalization among the patients who received
the intervention were reviewed; these cases were related tosevere drug side effects (n=2), complications of chronic illness
after discharge unrelated to adherence (n=2), and COVID-19
infection (n=1). We also reviewed 5 random patients
hospitalized in the nonintervention arm: 3 pertained tocomplications of chronic illnesses unrelated to adherence, 1 todrug side effects, and 1 initial medical diagnosis error. Hence,the causes of rehospitalization did not differ between the twogroups.

Table 3. Comparison of characteristics between intervention group (n=203) versus nonintervention (n=2095) group.
Intervention, n (%)

No intervention, n (%)

Hospitalization department.35

Endocrinology

135 (66.5)

1465 (70.0)

Infectious diseases

68 (33.5)

630 (30.0)

Age categories (years)

.47

16-24

12 (5.9)109 (5.2)

25-45

48 (23.6)495 (23.6)

46-65

90 (44.3)

839 (40.0)>65

53 (26.2)

652 (31.2)

Gender.77

Female87 (42.9)870 (41.5)

Male

116 (57.1)

1225 (58.5)

Social deprivationa

.31

Yes

133 (65.5)

1450 (69.2)

No

70 (34.5)645 (30.8)

Living in Seine-Saint-Denis

.16

Yes

180 (88.7)

1776 (84.8)

No

23 (11.3)

319 (15.2)

Length of hospitalization (days)a

P value.70<10

157 (77.3)

1667 (79.6)

11-30

41 (20.2)374 (17.9)>30

5 (2.4)54 (2.5)

If patients declared a specific health assistance coverage.

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Discussion
Findings Synthesis
Combining SP needs screening and DC at discharge time
identified that more than one-third of our sample needed SP.
The DCo managed to set goals with patients according to theirperceived priorities in a personalized way. Needs were
heterogeneous and included wider social needs, which by theirnature, impacted the access to and quality of care, with low
health literacy levels and a high proportion of language issues.
Our study did not show any difference in readmission rates
between the DCo and non-DCo groups.

SP at Discharge: For Whom?
The sample of our study, which is representative of the patientsin the two departments, is socially deprived. In France in 2021,
8% of the population lived below the poverty threshold (set at
50% of median income; ie, €950 [US $1105] per month) [26],whereas the proportion in our sample reached 47.5% (n=105).
Similarly, the proportion of property owners in France was 58%
in 2018 [27], whereas this proportion was only 21.2% (n=45)
in our sample. Eventually, the proportion of the French
population using the solidarity-based insurance was 10.6% in
2021 [28], and in our sample, this proportion was 21.1% (n=40).
The social deprivation of our hospital area population explains
the breadth of needs that they face and the proportion needing
SP, in addition to the basic DC that everyone received. The highproportion of immigrants (around 30% of the department
population) also accounts for the high proportion of patients
whose mother tongue was not French. A cost-effectivenessevaluation conducted in a disadvantaged North England area
among patients with type 2 diabetes showed that the highest
benefit was seen among the most disadvantaged population[29]. This result shows that the SP/DC intervention in our
university hospital could be similarly cost-effective given the
deprivation level. Moreover, some communities seem to struggle
more with understanding French than others, such as those from
Asia. Standardized screening tools could be applied at hospitalentry to help distinguish patients with complex social needs
who require more intensive support from those with only alanguage issue. Some tools have been validated abroad [30] orin France [31] and could be tested in France.

DC/SP: By Whom?
Several DC initiatives have flourished worldwide, but theireffectiveness tends to be limited or limited to specific categories
of patients [32,33]. In France, some public hospitals outsource
private companies for DC nurses to facilitate certain types ofservice delivery around patient discharge [34]. However, thoseprivate companies provide only a limited and standardized setof services, and do not provide SP. Additionally, suchstandardization of DC might not be adaptable to all andespecially to some underrepresented populations such as thosemost deprived who are not eligible for these private companies’
services. SP has not been implemented as such in France andis rolled out under other names like health navigators or healthmediators. Their entry point is via a specific disease (HIV,diabetes, etc) [35,36] or via a category of population (lesbian,gay, bisexual, transgender, queer; Romani; etc) [37]. One of thehttps://formative.jmir.org/2024/1/e51728

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reasons might be the structural divide between the social andhealth sectors in France. The consequence is a lack of holistic
and comprehensive care, with each worker attending only tolimited needs. The question of the nature of the worker comesnext along with questions about training background, gender,and ethnicity of others and the DCo. In the United States, Kahn
et al [38] described diverse missions of nurse case management
and reported the complex needs of patients with diabetes andmental illness, as in our study. Is it important that the link
worker or the DCo is trained as a clinician? From our study,
the DCo used her experience as a nurse at times—more asleverage to talk with physicians and analyze prescriptions. This
could be categorized as a medication reconciliation, which is
generally provided by a pharmacist. Her knowledge of patients’context and her professional networks were essential to find thebest way to support/empower patients. The DCo missions tended
to overlap those of health navigator [39], discharge or carecoordinator, and link worker.

DC/SP: Which Indicators Provide Measurable Impact?
In the published literature, SP has been evaluated using a range
of indicators (eg, health related, satisfaction, knowledge, or useof services) [5,12,13,40]. Mixed methods protocols considering
process and outcomes, and qualitative and quantitative data, are
now increasingly being invoked, making use of the highly
personalized and person-centered nature of the practice [6,10].
In our study, readmission rates were not different in the twogroups. We could have missed readmissions that occurred inother hospitals, but those would have been equally distributed
across the two groups. The absence of difference is due either
to low statistical power or to a real absence of difference. Many
studies failed as well to show any difference in readmission
rates, either for SP or for DC interventions, questioning therelevance of this indicator [41,42]. Moreover, the extremely
wide scope of social needs addressed by SP leads to aheterogenous set of outcomes, which adds to the difficulty instructuring the practice of SP. Other indicators such as resilience,well-being [43], and social reconnection were proposed [44].

Study Limitations
The study started in October 2019 and was disrupted by the
COVID-19 pandemic. Subsequent activities were againinterrupted by successive pandemic waves. Since patientsdiagnosed with COVID-19 received specific DC, the total
number of patients included in the DCo group was lower than
expected. However, the readmission rate decreased due to thedecrease in bed availability. Due to the end of funding for the
DCo after 2 years, the study ended prematurely. Therefore, ourstatistical power might be lower than planned. Finally, the twounits have different pathways for patients’ care between acuteand chronic disease.
Nonetheless, our study is the first study measuring systematicneeds for SP in a university hospital in France. The
quasi-experimental design provides rigor to our study. Patients
receiving the DC intervention might thus be considered as
representative of the patients in the two departments, revealing
the depth of their unmet needs. The relationship between DCo
and the patient was facilitated by the fact that the patient has
been hospitalized and gained trust in the hospital, enabling the
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collection of social needs data in detail and without raising
ethical issues since a subsequent support service was provided.
Overall, our study provided a thorough analysis of the process
of SP implementation at the time of discharge and contributed
to the question of which outcome to measure. Our findings will
enrich the current discussion on the structure of socialprescription.

Conclusions
SP is becoming more important in Europe and is considered an
innovative tool to switch from a biomedical care tobiopsychosocial model of care, with the potential for alleviating

Cailhol et alsocial determinants of health. Past evaluations found only low
levels of SP effectiveness with regard to health care use. Somestudies started to show the complexity of services provided by
DCo who also act as social prescribers [45]. Engaging patientsin their own DC could also contribute to empowering them [21].
More longitudinal studies are needed to measure other indicatorssuch as well-being, social connectedness, and costs to guidepolicy makers more effectively. Combining SP in a hospitalsetting and more generally during health care could be a way
to close the gap between the health and social sectors in France.
More generally, social prescription at different levels of healthcare, including in a hospital setting, could be a tool to addresssocial inequalities that are globally on the rise.

Acknowledgments
We wish to thank all the health professionals who supported the DCo during her missions and Prof Pierre Lombrail who provided
substantial advice on a draft version of the paper.
This work was supported by the Agence Régionale de Santé d’Ile de France (grant AAP 2017: interventions innovantes pourfaciliter le virage ambulatoire dans les établissements de santé).

Data Availability
The data set is included in Multimedia Appendix 3.

Authors' Contributions
JC conceptualized the study, supervised the discharge coordinator (DCo), analyzed the data, and wrote the paper. AB acted as
DCo throughout the study, read the draft, and contributed to significantly improving the manuscript. HB supervised the DCo,analyzed the data, and contributed to significantly improving the manuscript. CD and CBZ analyzed the data and contributed tosignificantly improving the manuscript.

Conflicts of Interest
None declared.

Multimedia Appendix 1
Information sheet.
[DOCX File , 13 KB-Multimedia Appendix 1]

Multimedia Appendix 2
Questionnaire.
[DOCX File , 14 KB-Multimedia Appendix 2]

Multimedia Appendix 3
Data set.
[XLSX File (Microsoft Excel File), 120 KB-Multimedia Appendix 3]

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Abbreviations
DC: discharge coordination
DCo: discharge coordinator
DD: Diabetology Department
GP: general practitioner
IDD: Infectious Diseases Department
NGO: nongovernmental organization
SP: social prescribing
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Cailhol et al

SQUIRE: Standards for Quality Improvement Reporting Excellence

Edited by A Mavragani; submitted 09.08.23; peer-reviewed by G Tofler, A Richard; comments to author 07.10.23; revised version
received 24.10.23; accepted 01.02.24; published 13.05.24
Please cite as:
Cailhol J, Bihan H, Bourovali-Zade C, Boloko A, Duclos C
Quality Improvement Intervention Using Social Prescribing at Discharge in a University Hospital in France: Quasi-Experimental
Study
JMIR Form Res 2024;8:e51728
URL: https://formative.jmir.org/2024/1/e51728
doi: 10.2196/51728
PMID:©Johann Cailhol, Hélène Bihan, Chloé Bourovali-Zade, Annie Boloko, Catherine Duclos. Originally published in JMIR Formative
Research (https://formative.jmir.org), 13.05.2024. This is an open-access article distributed under the terms of the Creative
Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The
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