Community Resources in Social Prescribing: What Should Be in Place Before a Referral Is Made?

Community Resources in Social Prescribing: What Should Be in Place Before a Referral Is Made?

Social prescribing depends on community resources. A walking group, cultural activity, volunteer program, caregiver network, social support service or local organization may offer exactly the kind of support that matters to someone. But knowing that a resource exists is not the same as knowing that it is appropriate to connect someone to it.

This distinction becomes increasingly important as social prescribing moves from informal signposting toward a more structured pathway. Once healthcare organizations, social services or other partners begin regularly connecting people with community resources, practical questions arise. Is the resource accessible? Does it have capacity? Is it suitable for this person? Who is responsible for the activity? What information needs to be shared? What happens if someone's needs exceed what the organization can reasonably provide?

The aim is not to turn every community group into a healthcare provider or impose clinical bureaucracy on ordinary community life. Doing so would undermine one of social prescribing's greatest strengths. The challenge is more practical: how can we preserve the openness, diversity and community character of these resources while making structured connections responsibly?

Recent international evidence suggests that this “receiving side” of social prescribing matters greatly. A 2026 global scoping review of 115 peer-reviewed empirical studies found that community-sector capacity, the availability of appropriate community assets, socioeconomic and access barriers, workforce pressures, funding and local implementation conditions all influenced how social prescribing worked in practice.[1] For Viet Nam, where formalized social prescribing remains at an early stage and the published evidence base is still very limited, these questions are worth addressing before large referral networks are developed.

Key Points

• A resource appearing in a directory does not automatically make it suitable for structured social prescribing connections.

• Readiness should be proportionate to the activity and population. A low-risk social group does not need the same arrangements as a service supporting people with complex or higher-risk circumstances.

• Suitability, accessibility, affordability, capacity, safety, communication and clear role boundaries should be considered before routine referrals begin.

• Community organizations should be treated as partners, not simply destinations for referrals or unlimited sources of free capacity.

• Personal information should be limited to what is genuinely necessary for the connection and handled in accordance with applicable Vietnamese data protection requirements.

• Community resources should not be expected to undertake medical examination, treatment or other regulated professional activities unless the organization and relevant professionals are legally authorized to do so.

• Readiness is not a one-time status. Programs, capacity, eligibility, staffing and accessibility can change and should be reviewed over time.

What do we mean by a community resource?

Social prescribing can connect people with a wide range of non-clinical support. The World Health Organization's implementation toolkit includes examples such as physical activity, arts and cultural activities, volunteering, social groups and practical or welfare support, depending on people's needs and what is available locally.[2] International research reflects similar diversity, including cultural venues, green and blue spaces, physical activity programs, community groups, voluntary organizations and services addressing practical or social needs.[1]

A community resource therefore does not need to be a health organization. It might be a local club, nonprofit organization, public service, cultural organization, exercise program, volunteer network, peer group or another structured opportunity that supports participation, social connection or practical needs.

That breadth is one of the strengths of social prescribing, but it also means that readiness cannot sensibly be reduced to a single checklist or accreditation standard. A neighborhood reading group and a structured program supporting people experiencing significant mental health difficulties can both be relevant community resources, yet the level of competence, risk management and operational infrastructure reasonably expected of them will be very different.

In this article, “referral” refers to the social prescribing practice of introducing or connecting someone with non-clinical community support. It should not be interpreted as a medical referral or transfer between healthcare facilities under Vietnamese healthcare law.

Asset mapping is necessary, but it is only the beginning

Before people can be connected with community resources, implementers need to know what exists. Community asset mapping is therefore an important part of building a social prescribing pathway. But a directory answers only the first question: What is available?

A responsible pathway needs to know more. Is the activity still operating? Who is it intended for? Can this person realistically access it? Are there fees? Is there a waiting list? Does the organization currently have capacity? Who is responsible for the activity? Are there circumstances it cannot safely manage? What happens if the connection does not work?

Directories can become outdated quickly. Opening hours change, programs lose funding, eligibility criteria are revised, volunteer leaders leave and waiting lists develop. A group that could comfortably welcome new participants six months ago may no longer be able to do so. A social prescribing directory should therefore be treated as a living source of information rather than a static database.

Recent research is beginning to make this process more structured. The COMPASS™ community resource mapping tool, published in 2026, contains 21 items covering areas such as the resource itself, target population, accessibility, costs, referral and coordination mechanisms and evaluation.[3] The tool remains at an early stage of development and validation and should not be treated as a universal standard, particularly without local adaptation. Its development nevertheless illustrates an important principle: meaningful resource mapping involves understanding more than a program's name and location.

Digital platforms can help maintain this information, but technology does not solve the underlying problem. A sophisticated directory containing inaccurate or incomplete information can simply make inappropriate connections happen more efficiently.

Suitability, accessibility and equity need to be considered together

The closest resource is not necessarily the right resource, and the activity most commonly offered may not be the activity that matters to a particular person. A useful connection starts with the person's priorities, circumstances and preferences. Someone experiencing loneliness may not want a large social group. A person who wants to become more active may dislike organized exercise but enjoy gardening. An older adult may be interested in an activity but unable to reach the venue. Someone facing financial stress may need practical support before participation in another activity becomes realistic.

Suitability therefore has both a person side and a resource side. On the person side, the question is whether the activity fits what matters to them and whether participation is realistic. On the resource side, the question is whether the organization is willing and able to support someone in those circumstances. This is one reason social prescribing is more than giving someone a list of services. The 2026 global review found that person-centered tailoring, flexibility and access to appropriate community assets were recurring facilitators, while socioeconomic hardship, transport difficulties, digital exclusion, language and literacy barriers and cultural mismatch could limit engagement.[1]

Accessibility should therefore be understood in practical terms. An activity can technically be available while remaining inaccessible to the person concerned. Participation fees may be small but still unaffordable. Transport can cost more than the activity itself. Timing may exclude people who work or have caring responsibilities. Stairs can prevent access for someone with mobility limitations. Digital-only registration can create difficulties for people without suitable devices, connectivity or confidence using technology. Language, literacy and cultural familiarity can also affect whether someone feels able or willing to participate.

This does not mean that every resource must work for every person. That would be unrealistic. The more useful question is whether the overall network of community resources offers meaningful choices for different populations. If every physical activity requires payment, all services are concentrated in one part of a city, or no suitable option exists for people with limited mobility, the problem is not simply that individuals are “failing to engage.” It may indicate a gap in local community infrastructure.

Capacity and sustainability matter before referral volume grows

A small community organization may be excellent at what it does and still have very limited capacity. This creates an important tension in social prescribing. A resource becomes known to healthcare professionals because it is welcoming and useful. More people are sent there. Staff and volunteers become stretched, waiting times increase and the quality of the activity may eventually suffer.

International evidence repeatedly identifies limited community-sector capacity, unstable funding and workforce pressures as implementation challenges.[1] The 2026 Western Pacific review similarly identified resource constraints and inconsistent or fragmented referral processes among common challenges across the region.[4]

NHS England's 2026 Workforce Development Framework reflects this broader understanding of social prescribing. Link workers are expected not only to support individuals but also to understand local communities, identify gaps and contribute to stronger and more sustainable community connections.[5] The lesson for Viet Nam is not that the NHS model should be copied. It is that demand generated by a referral pathway needs to be considered alongside the capacity of the organizations expected to receive that demand.

Community partners should be able to say when they are full, when an activity changes, when particular referrals are unsuitable or when additional resources would be needed to accommodate greater participation. A directory entry should never be interpreted as an unlimited commitment to receive referrals.

Sustainability belongs in the same conversation. Many community activities depend on short-term funding, a small number of staff or volunteers, donated facilities or uncertain income. This does not make them unsuitable. Some of the most valuable community assets are small and locally organized. But a healthcare organization planning to connect dozens of people each month with one program should understand whether that level of demand is realistic and whether it creates additional costs.

Community resources should not become an unlimited free extension of the healthcare system.

Community organizations should be partners, not destinations

It is easy to imagine social prescribing as a one-way pathway: a person leaves healthcare and is referred into “the community.” In practice, a stronger model requires a relationship between both sides.

Community organizations often understand issues that are less visible to the referring organization. They know who can realistically benefit from their activities, what prevents people from participating, what their staff or volunteers can manage, when capacity is becoming stretched and where important gaps exist locally. Their experience should inform the design and improvement of the pathway.

This changes the relationship from one-directional referral to partnership. Healthcare and social care organizations need to understand the community resources they rely on, while community organizations need to understand what participation in a structured pathway may involve. Neither side should make assumptions about the other's capacity or responsibilities.

People using the pathway are also partners. Their experience can reveal problems that organizational documents cannot. A program may appear accessible on paper but be difficult to reach. Staff may consider an environment welcoming while a new participant feels uncomfortable or unsure what to do. Simple feedback about whether the person made contact, felt welcomed, could participate and would return can provide information that a directory cannot.

Roles, safety and escalation need to be clear

A community organization should understand what it is being asked to provide and, equally importantly, what it is not being asked to provide. A walking group does not become responsible for clinical monitoring because a participant has diabetes. A social group should not be expected to manage a mental health crisis. A volunteer should not be placed in a position where they are expected to make clinical judgments because someone reports new symptoms. Peer support should not gradually become an unregulated substitute for professional treatment.

This distinction is particularly important in Viet Nam. The Law on Medical Examination and Treatment No. 15/2023/QH15, effective from 1 January 2024, regulates medical examination and treatment, practitioners, healthcare facilities and related professional activities.[6] Social prescribing does not itself authorize a community organization, staff member or volunteer to undertake activities that fall within the regulated scope of medical examination and treatment. Where an activity enters a regulated professional domain, the applicable Vietnamese legal and professional requirements continue to apply.

This does not mean community organizations should be reluctant to include people living with health conditions. People with chronic diseases, disabilities and mental health needs participate in ordinary community life every day. The important distinction is between supporting someone as a community participant and assuming professional responsibilities that belong to appropriately qualified and legally authorized providers.

The term “safeguarding” is widely used in international social prescribing practice, particularly in the United Kingdom. In Viet Nam, it is more useful to understand the underlying principle rather than import a separate UK regulatory framework. The practical question is: if a significant concern arises, does the organization know what to do?

For a low-risk community activity, the arrangements may be simple. People responsible for the activity should know how to respond to an immediate emergency, who to contact when additional help is needed and what to do when a concern is clearly beyond their role. Activities involving children, older adults with high support needs, people experiencing significant mental health difficulties or other potentially vulnerable populations may require more structured arrangements in accordance with the nature of the activity and applicable Vietnamese law.

Escalation is therefore as important as referral. Someone may become acutely unwell during an activity. A participant may disclose abuse, serious distress or thoughts of self-harm. A volunteer may notice a significant deterioration in someone's condition. A responsible pathway needs a proportionate way of responding when this happens.

The community resource does not need to manage every possible problem. It needs to know where its role ends and where responsibility should move next.

Share only the information that is actually needed

Structured referral systems can create a tendency to share more information than necessary. A healthcare organization may assume that providing a community partner with a detailed medical history will help them support the person. In many situations, it will not be needed.

A community resource may require little more than a person's name, contact information, interest in participating and any information genuinely necessary to enable safe and appropriate access. Some programs may reasonably need more, depending on the activity and the person's circumstances, but this should be determined deliberately rather than by routinely transferring clinical information.

This is especially important under Viet Nam's current personal data protection framework. The Law on Personal Data Protection No. 91/2025/QH15 took effect on 1 January 2026, with Decree No. 356/2025/ND-CP providing detailed provisions and implementation measures from the same date.[7,8] Article 26 of the Law provides that the collection and processing of personal data relating to health require the data subject's consent, except in the circumstances specified in Article 19(1), together with compliance with other applicable personal data protection requirements.[7]

For social prescribing, the practical principle is simple: share what is genuinely needed for the connection, not everything that happens to be available.

Organizations developing structured pathways should determine what information each party needs, why it is needed, whether consent or another applicable legal condition is required, who may access the information, how it will be protected and how long it should be retained. These arrangements will depend on the parties involved and the specific pathway.

A community organization should not become an informal extension of a healthcare record simply because it participates in social prescribing.

Communication should continue after the referral

Sending a referral does not necessarily mean that a connection has occurred. The person may never make contact. The service may be full. The activity may not suit their circumstances. They may attend once and decide not to return.

Some form of feedback can therefore improve a structured pathway, but it should be proportionate. Not every community organization needs to send detailed reports back to healthcare, and unnecessary reporting can create administrative burden and additional privacy risks.

Depending on the pathway, useful feedback may be limited to basic operational information: whether contact was made, whether the resource was able to accept the person, whether the service is temporarily full, or whether its eligibility or operating arrangements have changed. Where information about an individual is communicated, the purpose and applicable data protection requirements should be clear.

Participant experience matters as well. Was the person welcomed? Did they understand what would happen? Was the activity what they expected? Could they participate? Was there anything that made attendance difficult? Would they return?

Readiness is therefore not something that can be established once and assumed to continue indefinitely. It is something that can be tested, learned from and improved over time.

What might this look like in Viet Nam?

Viet Nam already has substantial formal and informal community infrastructure. Exercise and cultural activities, social organizations, volunteer networks, community groups, local public services and other forms of community participation exist across many settings. Community actors also contribute to health-related activities without those activities necessarily being social prescribing.

A useful current example comes from community-level management of hypertension and diabetes. In September 2026, WHO described how commune health stations can identify people who have missed follow-up appointments and contact them by telephone or Zalo, or ask a community outreach team to encourage them to return. WHO notes that these teams are often made up of local residents from youth unions, community organizations or the Red Cross.[9]

This is not social prescribing, and it should not be relabeled as such. Its purpose is continued engagement with clinical care for hypertension and diabetes. It does, however, illustrate something relevant: collaboration between formal healthcare services and community actors is already part of Vietnamese health practice in some settings.

The challenge for social prescribing would be different. It would involve identifying community resources that could appropriately respond to non-clinical needs, understanding their accessibility, capacity and boundaries, and creating person-centered connections between formal services and community life.

The published evidence base specific to Viet Nam remains very small. A 2026 scoping review of social prescribing and related interventions across the Western Pacific Region included 42 peer-reviewed studies, of which only one was from Viet Nam. The Vietnamese intervention included in that review was community-originated.[4] This is important evidence of activity, but one study is not enough to define a Vietnamese model of social prescribing or determine how community-resource readiness should operate nationally.

For this reason, a sensible starting point for Viet Nam would be small-scale implementation and learning rather than premature standardization.

What should be known before a resource receives routine referrals?

A practical readiness discussion does not need to become a certification exercise. Before a resource begins receiving people routinely through a structured social prescribing pathway, implementers should nevertheless understand several basic things:

What does the resource actually provide, and for whom? Can people realistically access it? What does participation cost? Does it currently have capacity? Who is responsible for the activity? What lies outside its role? What would happen if an urgent or higher-risk concern arose? What information, if any, needs to be shared? How can an unsuccessful or inappropriate connection be communicated? Can the organization sustain the anticipated level of participation?

The depth of this assessment should reflect the nature of the activity, the population and the level of risk involved. A neighborhood social group should not need the same governance arrangements as a structured program working with people experiencing significant mental health difficulties. Proportionality is essential if social prescribing is to strengthen community life rather than medicalize it.

At the same time, a resource should never be assumed to be suitable simply because it appears in a directory.

From directory to partnership

Moving from identifying community assets to using them within social prescribing is ultimately less about building a database and more about building relationships.

Healthcare organizations need to understand the community resources they connect people with. Community organizations need realistic information about what participation in a referral pathway may involve. Both sides need clear expectations and ways to communicate when circumstances change. Most importantly, people using the pathway need meaningful choice and an opportunity to say whether the connection actually worked for them.

Over time, these relationships can also reveal what is missing. Repeated difficulty finding affordable physical activity, caregiver support, culturally appropriate activities or accessible opportunities for people with mobility limitations is not simply a referral problem. It is information about gaps in community capacity.

International experience increasingly recognizes this broader dimension of social prescribing. NHS England's current workforce framework, for example, includes community development alongside individualized support, with link workers expected to understand local assets, identify gaps and support accessible and sustainable community provision.[5] The specific NHS model should not be assumed to fit Viet Nam, but the principle is relevant.

A more mature social prescribing system would therefore ask not only:

“Where can we connect this person?”

It would also ask:

“What community resources do people need, where are the gaps, and how can health, social and community partners strengthen those resources together?”

Key Takeaway

Community resources are not interchangeable destinations at the end of a referral pathway. Their relevance, accessibility, capacity, sustainability and readiness can determine whether social prescribing becomes a meaningful connection or merely an administrative referral.

A directory tells us what exists. Responsible social prescribing also needs to understand whether a particular resource is appropriate for this person, whether the organization can realistically receive them, and what happens if the connection does not work or the person's needs change.

For Viet Nam, the goal should not be to create a complicated certification system for every community activity, nor should ordinary community groups be transformed into extensions of healthcare. A more practical approach is to understand the resource, clarify roles and boundaries, consider accessibility and capacity, establish proportionate safety and escalation arrangements, protect personal information, listen to community partners and participants, and keep information current.

Most importantly, community organizations should be treated as partners in social prescribing, not simply as destinations for referrals.

A strong social prescribing pathway is only as strong as the community connections it is able to make and sustain.

References

1. Kisa A, Kisa S. Models, implementation, and reported outcomes of social prescribing interventions: a scoping review. Frontiers in Public Health. 2026;14:1871347. doi:10.3389/fpubh.2026.1871347.

2. World Health Organization Regional Office for the Western Pacific. A toolkit on how to implement social prescribing. Manila: World Health Organization Regional Office for the Western Pacific; 2022.

3. de Sul S, Santos-Costa P, Costa A. A standardised instrument for community resource mapping in social prescribing: development and content validation of the COMPASS™ tool. Archives of Public Health. 2026;84:172. doi:10.1186/s13690-026-01982-4.

4. Lwin KS, Wong MSJ, Tan MH, et al. Organization and implementation of social prescribing in the Western Pacific Region: a scoping review. The Lancet Regional Health – Western Pacific. 2026;67:101714. doi:10.1016/j.lanwpc.2025.101714.

5. NHS England. Workforce Development Framework for Social Prescribing Link Workers. Version 2. Updated July 2026. Published 13 August 2026.

6. National Assembly of the Socialist Republic of Viet Nam. Law on Medical Examination and Treatment No. 15/2023/QH15. 9 January 2023. Effective 1 January 2024.

7. National Assembly of the Socialist Republic of Viet Nam. Law on Personal Data Protection No. 91/2025/QH15. 26 June 2025. Effective 1 January 2026.

8. Government of Viet Nam. Decree No. 356/2025/ND-CP detailing certain provisions and measures for implementation of the Law on Personal Data Protection. 31 December 2025. Effective 1 January 2026.

9. World Health Organization Viet Nam. Strengthened grassroots health care brings NCD services to 10 million in Viet Nam. 8 September 2026.

Article Information

Published: 25 September 2026
Last reviewed: 25 September 2026
Publisher: Social Prescribing Vietnam

Disclaimer

This article is provided for educational and informational purposes. It does not constitute medical advice, clinical guidance, legal advice, accreditation criteria or official policy. The term “referral” is used here in the context of social prescribing and non-clinical community connection and should not be interpreted as a medical referral or transfer under Vietnamese healthcare law. Community resources vary considerably in purpose, structure, population served and level of risk, and readiness arrangements should be proportionate to the activity and local context. Organizations developing referral, information-sharing or other structured social prescribing pathways should determine the applicable Vietnamese legal, professional and personal data protection requirements before implementation.