When the Remedy Is Belonging (Kingston, ON): How Kingston Community Health Centres Practices Social Prescribing

Introduction

In Kingston, Ontario, thousands of residents navigate daily life without a family doctor. For those who do reach a clinic, the visit often ends the same way: a prescription, a referral, and an unspoken acknowledgment that the loneliness, poverty, or housing stress that brought them in cannot be treated with medication. This gap between what clinical medicine offers and what people actually need is precisely what social prescribing was designed to address.

Social prescribing is a healthcare approach that formally connects patients to non-clinical community resources: walking groups, arts programs, peer support, newcomer circles, and community gardens, tailored to each person’s circumstances and goals [9, 10]. At Kingston Community Health Centres (KCHC), social prescribing is not a new initiative or a pilot. It has been the organizing logic of the organization’s work since 1988 [1].

Kingston Community Health Centres is a multi-site, community-governed, not-for-profit organization providing primary and community health care in Kingston and the surrounding region since 1988 [1]. Operating across multiple locations, KCHC offers a wide spectrum of services spanning primary health care, mental health counselling, harm reduction, dental care, newcomer services, youth programming, and food access programs [2].

What distinguishes KCHC from a standard medical clinic is its founding philosophy. The organization operates according to eight core attributes of the Community Health Centre (CHC) model: comprehensiveness, accessibility, client and community focus, recognition of social determinants of health (SDH), community development, inter-sectoral collaboration, interdisciplinary teamwork, and commitment to health promotion [1]. At KCHC, health is understood as a community achievement, not merely a clinical outcome.

KCHC’s vision is straightforward and ambitious: a community that is inclusive, resilient, and healthy [1]. This publication documents KCHC's social prescribing model as a community-driven response to three interconnected challenges: Ontario's deepening primary care crisis, the social determinants of health that clinical medicine cannot address, and the compounding health inequities facing newcomers, racialized communities, and marginalized residents in Kingston.

Background: Three Key Community Challenges

Ontario’s Primary Care Crisis and Inequitable Access

Ontario is experiencing a deepening primary care crisis that disproportionately affects equity-deserving populations. As of September 2023, more than 2.5 million Ontarians lacked a regular family doctor, a figure that had grown by more than 160,000 people in just six months [3]. The Registered Nurses’ Association of Ontario (RNAO) has since updated this estimate to approximately 3.3 million Ontarians, identifying newcomers, racialized communities, and individuals living in poverty as the groups most likely to be unattached from primary care [4]. In Kingston, growing waitlists, strained emergency departments, and populations cycling through walk-in clinics without continuity of care reflect the local dimensions of this provincial crisis.

The structural roots of this problem extend beyond physician supply. Ontario's healthcare system, structured primarily around OHIP's fee-for-service schedule, continues to be organized around one-on-one clinical encounters, which are poorly suited to the complex, intersecting needs of people living in poverty, navigating settlement, or managing chronic and mental health conditions. KCHC’s Community Health Centre model exists precisely to address these structural gaps [1]. Research on free transit as a social determinant of health in Kingston further illustrates how local policy interventions targeting income and mobility have had measurable effects on health access for people receiving social assistance [5].

The Social Determinants of Health and the Limits of Clinical Medicine

A well-established body of evidence demonstrates that clinical care accounts for only 10–20% of population health outcomes; the remaining 80–90% is driven by social factors, including income, housing, employment, food security, social connection, and community belonging [6, 7]. Despite this evidence, healthcare delivery in Canada remains heavily weighted toward clinical encounters. Physicians across the country have estimated that up to 50% of primary care visits are driven not by medical needs but by social and emotional ones (such as, loneliness, financial stress, social isolation, and unemployment) for which the clinical encounter offers no adequate response [7].

Housing instability is a particularly significant driver of poor health in Kingston and across Ontario. Research consistently identifies housing insecurity as associated with elevated rates of mental illness, chronic disease, and emergency service utilization [8]. Social prescribing as practiced at KCHC directly addresses this mismatch by integrating community connection, peer support, and social participation as formal components of care [9, 10]. The ARC (Access to Resources in the Community) model in Ontario, a bilingual social prescribing program with a non-clinical navigator, further demonstrates how these approaches can be systematically implemented and evaluated in primary care settings [11].

Health Inequities Among Newcomers, Racialized Communities, and Marginalized Populations

Marginalized populations in Kingston face compounding barriers to health that reflect broader patterns of systemic inequity. Newcomers and refugees are a significant and growing demographic in Kingston who arrive with unaddressed health needs, limited language proficiency, and settlement stressors that profoundly affect their mental and physical health [12]. Structural barriers including inadequate services and funding, cultural tensions in healthcare encounters, and a lack of prevention-oriented supports, have been documented across Ontario as particular challenges for newcomer families [13].

Research documents that racialized immigrants in Canada face compounded disadvantages in accessing mental health services, including stigma, language barriers, discrimination, and lack of culturally competent care [14]. For Black communities specifically, Afrocentric and culturally safe approaches to social prescribing have been shown to significantly improve engagement, trust, and health outcomes, underscoring that generic service models are insufficient for populations whose health needs are shaped by structural racism [15]. KCHC’s equity mandate and community development approach position it to respond to these patterns in ways that mainstream healthcare cannot.

Also, the mental health of newcomers follows a well-documented deterioration trajectory: while recent arrivals often exhibit better initial health than Canadian-born populations, this advantage erodes over time due to unemployment, family separation, discrimination, language barriers, and lack of social support

[16]. Community-based, culturally responsive care models like KCHC’s social prescribing approach represent an evidence-informed response to this pattern.

The Affected Community and Its Needs

KCHC serves a broad cross-section of Kingston’s most marginalized residents. While the organization provides care across multiple sites, its social prescribing programs at the Midtown and Weller sites each serve distinct but overlapping communities characterized by intersecting vulnerabilities and strengths.

Individuals and Families Living in Poverty

The Weller Site is located in Kingston’s Rideau Heights neighbourhood, one of the city’s most economically disadvantaged areas [2]. Residents in this catchment face concentrated poverty, limited transportation access, food insecurity, and high rates of housing instability. Many clients accessing KCHC’s services here have multiple intersecting vulnerabilities , low income, mental health challenges, and limited social networks , that require an integrated, relational approach to care. Kingston’s transit assistance program for social assistance recipients demonstrates the degree to which income-related barriers to health access remain an active and documented public health concern in this city [5].

Newcomers and Refugees

Kingston receives significant numbers of newcomers and refugees annually through federal and provincial settlement pathways. These individuals and families often arrive with unaddressed health needs, limited knowledge of Canada's health system, and settlement stressors that compound pre-existing vulnerabilities. As of the 2021 census, immigrants and permanent residents constituted approximately 23% of Canada's population, a proportion that continues to grow [31]. Many newcomers in Kingston are initially settled in neighbourhoods distant from health services, rely on transit routes not designed for settlement areas, and encounter a health system that operates primarily in English at the point of first contact, creating layered access challenges that begin the moment they arrive [12]. KCHC's newcomer services provide culturally responsive care, interpretation supports, and connections to settlement services in partnership with community organizations, including Kingston Immigration Partnership (KIP) [2].

Youth in Under-Resourced Neighbourhoods

Young people in North Kingston, particularly in Rideau Heights, face significant barriers to educational attainment and positive health trajectories. Adolescents in Kingston have been documented as holding limited knowledge of social determinants of health, a gap with direct implications for health literacy and self-advocacy [17]. KCHC’s Pathways to Education program provides tutoring, mentoring, financial support, and community connection to youth at risk of school disengagement, addressing the upstream conditions that shape health across the life course [2].

Older Adults Facing Social Isolation

Social isolation and loneliness among older adults are major public health concerns, associated with elevated risk for depression, cognitive decline, and cardiovascular disease. Provincial evidence from Ontario’s Links2Wellbeing social prescribing initiative for older adults found that participants

experienced decreased loneliness within six months and made 48% fewer primary care appointments and 32% fewer emergency department visits after one year [18]. A KCHC community programs lead recalls a senior who came to a weekly group and shared that her son had finally visited and changed a light bulb that had been out in her bedroom for a month. For her, that was the highlight of her week (personal communication, May 2026). KCHC’s programs specifically targeting seniors (including Penguins, a drop-in social group for adults over 55, and Feel Good Fridays, offering weekly exercise and music programming) reflect this evidence base [2].

People Who Use Drugs

KCHC operates Ontario’s Harm Reduction Program through its Street Health Centre, providing evidence-based, non-judgmental care to people who use drugs. This population faces acute barriers to conventional healthcare, including stigma, criminalization, housing instability, and trauma histories. KCHC’s harm reduction model (including needle exchange, naloxone distribution, and connection to wraparound supports) operationalizes the principle of meeting people where they are [2].

Individuals Seeking Gender-Affirming Care

KCHC’s Transgender Health Program is the only program of its kind in South East Ontario, providing gender-affirming primary care, hormone therapy, specialist referral, and mental health supports in an explicitly inclusive environment [2]. Transgender individuals face disproportionate rates of discrimination in healthcare settings and significant barriers to accessing appropriate care, making KCHC’s program both regionally unique and critically necessary.

Kingston Community Health Centres’ Programs and Initiatives Addressing Local Challenges

KCHC's programming directly addresses the challenges identified above through an integrated model of primary care, community development, and social prescribing. Across its sites, the programs described below do not operate in isolation. Together, they reflect a coherent implementation logic: Reach is maximized by removing cost, referral, and geographic barriers; Adoption is deepened by embedding social prescribing across every program area rather than housing it in a single service; and the soft handoff, walking someone down the hall and making a warm introduction, is the Implementation mechanism that makes connection more likely to stick (19, 20; personal communication, May 2026).

Social Prescribing at Midtown and Weller

KCHC’s flagship social prescribing program operates at both the Midtown Kingston Health Home and the Weller Site. Clinicians and community development workers collaborate to connect clients to more than 300 non-clinical community programs, including recreational activities, walking groups, community gardens, arts programs, peer support groups, newcomer assistance services, and social gatherings [2]. No referral is required, all services are free, and the program addresses geographical, financial, interpersonal, and psychological barriers simultaneously [2]. This reflects what the Alliance for Healthier Communities describes as the core of equitable social prescribing: listening deeply, removing barriers, and empowering people as co-creators of their own health [2, 6].

Social prescribing at KCHC is grounded in evidence. Research by Muhl et al. [9] defines social prescribing as a formal, systems-level approach to linking patients with non-clinical community resources based on their individual goals and circumstances [9]. The model aligns with Canada’s Quintuple Aim of improving health outcomes, patient experience, provider experience, equity, and cost-effectiveness

simultaneously [10]. A quality improvement study at Queen’s University, led by Dr. Rylan Egan, further documented the local impact of social prescribing on patient outcomes in Kingston’s primary care settings [7].

In RE-AIM terms, this program demonstrates strong Reach, connecting people across six distinct population groups at two sites, and deep Adoption, embedded as the organizing logic across all of KCHC's programming rather than operating as a standalone service [19, 20].

Penguins and Feel Good Fridays

Penguins is a weekly drop-in social group for adults over 55. Feel Good Fridays operates at a municipal recreation centre two blocks from KCHC's main site, bringing together up to 15 to 20 service providers under one roof at no cost: a talking café with board games and coffee, a VON-led exercise program, a music lending library offering instrument lessons, and programming from the Alzheimer Society, among others [2]. Seniors move freely between these offerings at their own pace. Evidence from social prescribing evaluations confirms that group-based programs of this kind are among the most effective formats for reducing isolation and improving wellbeing, particularly when they offer structured entry points alongside informal social space [30]. In implementation terms, these programs extend KCHC's Reach to older adults who may not present through clinical channels, creating low-barrier community touchpoints into KCHC's broader network of supports.

Thrive: Perinatal Support for Individuals with Substance Use Histories

Thrive provides wraparound support for pregnant and parenting individuals with substance use histories. Delivered through the Weller Site, the program integrates harm reduction principles with maternal health support, peer connection, and social prescribing referrals [2]. Social prescribing frameworks specifically identify this kind of intersectional, non-clinical support as essential for populations whose needs cut across multiple systems simultaneously [9, 24]. Thrive illustrates how KCHC's Implementation model extends beyond referral: it builds relationships within the program itself, creating the social connection that is both the means and the outcome of the work.

Pathways to Education

Pathways to Education is a nationally recognized program supporting youth at risk of dropping out of high school. At the Weller Site, KCHC provides tutoring, mentoring, and financial incentives to young people in Rideau Heights [2, 17]. By investing in school retention and community connection for young people, Pathways to Education extends KCHC's Reach across the life course, engaging a population whose health needs will otherwise surface later and at greater cost to the system.

Circles Kingston and Bridges Out of Poverty

Circles Kingston brings together people living in poverty and community allies in structured relationships designed to build social capital and economic mobility. Bridges Out of Poverty offers workshops and training to help individuals, service providers, and employers understand and respond to the systemic causes of poverty [2]. The Bridges Out of Poverty model is grounded in evidence that sustainable exit from poverty requires relational support and systemic literacy across multiple levels of a community, not individual behaviour change alone [32]. These programs also demonstrate how Adoption of the social prescribing model extends beyond clinical staff: facilitators, peer supporters, and community volunteers all function as social prescribers within Circles and Bridges, broadening reach without requiring a medical encounter as the entry point.

Harm Reduction and Street Health

KCHC's Street Health Centre delivers Ontario's Harm Reduction Program, providing needle exchange, naloxone distribution, and wraparound supports to people who use drugs in Kingston [2]. Non-judgmental, relationship-based care for this population has been shown to reduce harm, build trust, and create pathways to broader health and social supports over time [24]. Within KCHC's implementation model, Street Health functions as a Reach strategy for people least likely to present through conventional primary care channels, opening connections to the full range of KCHC's programming when clients are ready.

Transgender Health Program

As the only gender-affirming health program in South East Ontario, KCHC's Transgender Health Program provides primary care, hormone therapy, specialist referral, and mental health supports in an explicitly safe and inclusive environment [2, 14]. This program fills a regional gap that no other organization in South East Ontario addresses, reflecting the kind of equity-oriented Reach that distinguishes the CHC model from standard primary care provision.

Newcomer Services and Settlement Supports

KCHC's newcomer programming includes primary care with interpretation supports, health system navigation, and social prescribing connections to cultural organizations, language programs, employment supports, and peer networks. Delivered in partnership with KIP and other settlement organizations, these services ensure that the social prescribing connections available to long-term residents are equally available to those who arrived most recently [2, 13].

AI Use

Generative AI tools (Claude, Anthropic) were used to support structural drafting and language editing during the preparation of this Community Knowledge Publication. All content was reviewed, verified, and approved by the author.