Table 1 Characteristics of included studies (n = 21)

Boult 2013 [32, 53, 54]

RCT

USA

I: Nurse-led Guided Care intervention including assessment of patient needs, care-planning and coordination, transitional care, monitoring, self-management, caregiver support and access to community-based services

C: UC

 ≥ 65yrs, covered by fee-for-service Medicare, potentially eligible if HCC risk ratios were in the highest quartile of older patient population covered by own insurer

Caucasian: I, 51.1; C, 48.9

African American: I, 45.6; C, 46.3

Other: I, 3.3; C, 4.8

Monthly finances:

Some money left: I, 57.9; C, 51.1

Just enough money: I, 32.8; C, 34.2

Not enough money: I, 9.3; C, 14.5

904 (477)

I, 77.2;

C, 78.1 (SD NR)

I, 54.2;

C, 55.4

Burger 2019 [40]

Mixed methods: Single group, pre-test/post-test

USA

I: Health-coach led self-management including care team communication, scheduling reminders, medication refills, referral to social services, emotional support and review of care plans

C: Baseline

Adults with HTN or DM, at risk for ineffective health maintenance; physical and psychological capacity to meet self-management goals, speak English or Spanish, access to telephone

NR

NR

19 (16)

Range: 44–59

 ~ 60

Carnes 2017 [47]

Mixed methods: Two groups, non-randomized

UK

I: Social prescribing service coordinated by social workers with volunteer support, including action planning and referral to community services

C: Matched patients from neighbouring area

GP patients with frequent visits and/or are socially isolated

NR

NR

486 (196)

Median:

I, 56; C, 58

I, 58.9;

C, 54.5

Dolovich 2016 [33, 55]

RCT

Canada

I: Health TAPESTRY, volunteer-led home visit to assess health status and goals, action planning with healthcare team including links to community support

C: Wait-list control (UC)

 ≥ 70yrs, family health team patients not residing in LTC or receiving palliative/end-of-life care, English-speaking

European or white: I, 88.8; C, 86.5

High school: I, 38.0; C, 45.5

 ≥ Post-secondary: I, 58.9; C, 48.7

312 (278)

I, 78.1 ± 6.3;

C, 79.1 ± 6.6

I, 63.9;

C, 60.4

Dye 2018 [48]

Two groups, non-randomized

USA

I: Volunteer health coach intervention, including needs assessment, home visits, self-management, education on use of self-monitoring equipment, linking to external services based on client needs

C: Matched patients who chose not to participate

 ≥ 60yrs, residing in rural census, has a diagnosis of CVD, CHF, HTN, or DM

NR

NR

89 (69)

Range: I, 61–96; C, 62–91

61.5

Franse 2018 [49]

Two groups, non-randomized

UK, Greece, Croatia, Netherlands, and Spain

I: Care coordinator-led (variable by setting including social worker, nurse, nurse practitioner, physician assistant) Urban Health Centres Europe approach, including health assessment, shared decision making in development of care plan and referral to appropriate care pathways including health and social services

C: UC

 ≥ 75yrs, living independently, comprehends local language, and make an informed decision on participation in the study, according to physician

NR

NR

2325 (1844)

I, 79.3 ± 5.7;

C, 79.7 ± 5.5

60.8

Kangovi 2016 [35, 56]

RCT

USA

I: Goal setting plus IMPaCT, standardized intervention led by community health workers. Includes tailored coaching, social support, navigation, and advocacy

C: Goal setting plus UC

1 visit at a study clinic in the prior yr and an upcoming appointment; lived in a high-poverty 5-ZIP code region in Philadelphia; diagnosed with ≥ 2 of the following CDs (HTN, diabetes, obesity, asthma/COPD with tobacco dependence)

Excluded: worked with CHW before

African American: 94.7

Hispanic: 2.7

Household income

 < 15 000: I, 42; C, 47.4

Household income ≥ 15 000: I, 38; C, 33.6 Unknown: I, 20; C, 19.1

302 (NR)

Total, 56.3 ± 13.1; I, 56.6 ± 13.6; C, 56.1 ± 12.6

I, 76.7;

C, 74.3

Kangovi 2018 [34]

RCT

USA

I: Goal setting plus IMPaCT, standardized intervention led by community health workers. Includes tailored coaching, social support, navigation, and advocacy

C: Goal setting plus UC

 ≥ 18 yrs with appointment in the previous yr; living in identified high-poverty zip codes; uninsured/publicly insured; diagnosis for ≥ 2 CDs (≥ 1 in poor control), able to provide consent

African American: 94.3

Household income

 < 15 000: I, 65; C, 65

Household income ≥ 15 000: I, 23; C, 24

Unknown: I, 13; C, 12

592 (470)

52.6 ± 11.1

62.5

Kellezi 2019 [41]

Mixed methods: Single group, pre-test/post-test

UK

I: Health coach and link worker-led intervention that involved a needs assessment and then subsequent referral to relevant third sector groups

C: Baseline

 ≥ 18 yrs, live or registered with GP in Nottingham), managing ≥ 1 long-term health conditions and feel isolated, lonely or anxious

NR

NR

630 (178)

52.7 ± 14.8

54.0

Loftus 2017 [42]

Single group, pre-test/post-test

Northern Ireland

I: Social worker-led social prescribing activities focused on health and well-being, emotional and practical support, education and self-help

C: Patients who declined to participate

 > 65 yrs with a chronic condition (i.e., falls, social isolation, depression/anxiety); poly-pharmacy (≥ 5 repeat medications) or a frequent GP attender

NR

NR

68 (28)

72.9 ± 7.3

70.6

Loskutova 2016 [43]

Mixed methods: Single group, pre-test/post-test

USA

I: Cities for Live Program, patient navigators assessed needs, barriers, limitations, stage of change and linked to 2–3 community programs

C: Baseline

English-speaking, residing in Birmingham and receiving services at enrolled practices; type 2 diabetes diagnosis/risk or had prediabetes

Non-Hispanic: 76.5 Hispanic: 2.8

NR: 20.7

Some high school: 11.2;

High school graduate: 20.1; Some college/ technical school: 11.7;

College graduate: 14.5;

Postgraduate/professional: 1.7; Unknown: 40.8

179 (179)

53.1 ± 12.2

73.2

Mayhew 2009 [44]

Single group, pre-test/post-test

UK

I: Integrated Care Coordination Service led by a care coordinator, includes identification of needs and liking to relevant health, social security or other organizations

C: Baseline

 > 65yrs, at risk of avoidable hospital admission, premature admission to institutional care, or concern due to medical, physical, emotional, or social issue

NR

NR

340 (93)

 ≅ 70% of participants > 75yrs; 50% > 85yrs

NR

Mercer 2019 [36]

RCT

Scotland

I: Community Links Practitioner intervention including assessing patient needs, linking to community organizations and if necessary, providing support to ensure attendance

C: UC

 ≥ 18yrs, registered with intervention or comparator practice. Excluded if PC physician perceived participation is contraindicated

NR

Deprived: I, 79.3; C, 58.1

Employed: I, 24.1; C, 48.7

900 (775)

I, 49; C, 56

I, 59.2;

C, 61.1

Pescheny 2019 [45, 57]

Single group, pre-test/post-test

UK

I: Social prescribing service led by trained non-clinicians that linked patients in primary care with sources of support within the community sector to improve their health, well-being, and care experience

C: Baseline

PC patients with non-medical needs/psychosocial symptoms. Target groups included people with high risk/diagnosis of type 2 diabetes and COPD, mild to moderate mental health issues, experiencing loneliness and/or social isolation

NR

Not working: 61.8

186 (56)

51.2 ± 15.7

70.4

Spoorenberg 2018 [37]

RCT

Netherlands

I: Embrace, population-based integrated elderly care model (physician, nurse, social worker) including self-management support, introduction to community resources, and case management for those with complex care needs

C: UC

 ≥ 75yrs, registered at participating GP, living at home/home for the elderly (not LTC)

NR

Low education: I, 49.9; C, 53.4

Low income: I, 44.1; C, 42.4

1456 (1131)

I, 80.6 ± 4.5;

C, 80.8 ± 4.7

I, 54.2;

C, 55.6

Taube 2018 [38]

RCT

Sweden

I: Registered nurse and physical therapist-led case management including monthly home visit, care plan development, healthcare system navigation, health information, information about local activities

C: UC

 ≥ 65yrs, needing assistance in ≥ 2 self-reported ADLs, ≥ 2 hospital admissions or ≥ 4 outpatient care visits in last 12mos, no severe cognitive impairment

NR

Primary school: 46.4

Secondary school: 11.8

Vocational school: 35.9

Higher education: 5.9

153 (27)

81.5

66.7

Tung 2020  [50, 58]

Two groups, non-randomized

USA

I: “HealtheRx” intervention, electronic-medical record generated personalized list of local community resources with access to community health information specialist as needed

C: UC

45-74yrs, insured by Medicaid and/or Medicare, sought care in the PC Clinic or ED, and resided in study area. Excluded: non-English speaking, lacked cognitive or physical capacity, recalled receiving a HealtheRx prior

African American: I, 89.5; C, 90.6

Annual household income: < $25,000: I, 48.3; C, 56.5

$25,00–49,999: I, 29.7; C, 21.1

420 (411)

45-54 yr: I, 25.8%; C, 30.7%

55-64 yr: I, 36.4%; C, 32.2%

65-74 yr: I, 37.8%; C, 37.1%

I, 72.7;

C, 63.9

Vanderboom 2014 [51, 59]

Two groups, non-randomized

USA

I: Nurse-led Community Connections Program, including strengths assessment, action planning, crisis prevention plan, and circle of support, comprised of community and informal resources for self-management

C: UC

 ≥ 55yrs, multiple chronic conditions, English speaking, and receiving PC from a health care home

Excluded: cognitive impairment, untreated psychiatric condition, or terminal illness. Individuals identified by patient as someone supportive in their lives included as support persons

All Caucasian, non-Hispanics

 ~ 2/3 attended college

Patients: 62 (56)

Support persons: 31 (NR)

NR

F > M

Wang 2015 [52]

Two groups, non-randomized

USA

I: Community health worker-led patient navigation including education, appointment scheduling, assistance with overcoming barriers to health care access

C: Participants not reached by patient navigators

Type 2 diabetes and/or HTN diagnosis, unengaged with their medical care (not seen by PC physician in last 6mos)

Hispanic/Latino: 57.7

Race

White 66%

Black 30.2%

Other 3.7%

NR

215 (206)

63.4 ± 12

54.9

Woodall 2018 [46]

Mixed methods: Single group, pre-test/post-test

UK

I: Social prescribing via wellbeing coordinators, including needs assessment and referral to local community health and wellbeing resources

C: Baseline

 ≥ 14yrs, registered with a GP clinic

White: 90.6

Black (Caribbean, African, other): 3

Other 6.5

NR

434 (342)

53.1 ± 18

63.9

Zhang 2018 [39]

RCT

China

I: Older person-centred and integrated health management model programme intervention led by community health centre staff and multidisciplinary care team including self-management, health management, referral to community programs, and family participation

C: Bimonthly health education

 ≥ 60yrs, lived in the community for ≥ 2 yrs. Excluded: cognitive deficits, severe chronic illnesses, multiple life-threatening comorbidities, and life expectancy < 1 yr, current or previous participation in another trial within the past 30d

NR

 ≤ Primary school: I, 57.9; C, 58.1

iddle school: I, 28.2; C, 26.6

 ≥ College: I, 13.9; C, 15.3

671 (637)

70.5 (SD NR)

51.9