From Hospital to Community in Viet Nam: Where Could Social Prescribing and Care Navigation Add Value Across the Discharge Transition?

From Hospital to Community in Viet Nam: Where Could Social Prescribing and Care Navigation Add Value Across the Discharge Transition?

Category: Viet Nam Context

Hospital discharge is often recorded as a date and time. For the person leaving hospital, however, it is not a single event. It is a transition from a highly structured environment — where medicines, investigations, professional advice and practical support are close at hand — back into a home and community where much more depends on the person, their family, their everyday circumstances and the resources available around them.

Good discharge planning already recognizes that this transition extends beyond the hospital door. Contemporary discharge and transitional-care practice emphasizes interdisciplinary collaboration, person-centered education, clear communication, caregiver engagement, continuity across settings and appropriate linkage with community resources. A qualitative meta-synthesis of 53 studies similarly identified care coordination and continuity, communication, patient and family involvement, and individualized support and information exchange as central themes in hospital-to-home transition.

Social prescribing and care navigation may add something useful within this broader process, but their role needs to be defined carefully. They should not become new labels for discharge planning, professional social work, rehabilitation or clinical follow-up. The more useful question for Viet Nam is narrower: where do people move from hospital back into everyday life with non-clinical needs, practical barriers or community-support needs for which an additional navigation function could genuinely help?

The discharge transition is clinical, practical and social

Clinical discharge processes appropriately address issues such as medical stability, treatment instructions, medicines, warning signs, rehabilitation, follow-up appointments and the care required after leaving hospital. Good transitional care may also address communication with families, coordination with other services and linkage with community resources.

Returning home nevertheless exposes realities that can be difficult to resolve through a discharge summary alone. Can the person travel to follow-up appointments? Do they know where to go and whom to contact? Is someone actually available to help at home? Can they afford the practical costs associated with recovery? Has illness reduced their opportunities for social participation? Is a caregiver struggling? Is an appropriate community resource genuinely available, accessible and acceptable to them?

These questions do not mean that every hospital patient needs social prescribing. They show that hospital-to-community transition can include a navigation challenge alongside clinical and professional care. WHO's Western Pacific social-prescribing toolkit describes social prescribing as connecting people with non-clinical services in the community that may support health and well-being, while allowing implementation to be adapted to local contexts. In a Vietnamese hospital, social prescribing is therefore better understood as one possible component of community-connected care within or alongside good transitional-care processes, not as something that replaces the responsibilities hospitals and professionals already have.

Recent Vietnamese evidence highlights needs beyond clinical treatment

Two studies published in September 2026 provide particularly timely Vietnamese evidence about needs surrounding hospital care. A cross-sectional study involving 360 patients aged 60 years and older at Thu Duc General Hospital in Ho Chi Minh City found a moderately high overall perceived need for hospital social-work services. Policy, insurance and administrative guidance ranked highest, followed by resource linkage and post-discharge support, and then psychosocial support. Perceived needs differed according to factors including living arrangement, financial circumstances, self-care capacity and treatment or support conditions. The authors proposed a tiered response combining universal information, targeted identification of social needs and more intensive coordination for people experiencing particular functional, financial, treatment or caregiving vulnerabilities.

A second 2026 cross-sectional study involving 369 adult inpatients at Hanoi Medical University Hospital also identified substantial demand for support extending beyond immediate treatment. Among respondents, 85.4% reported a need for counseling about warning signs requiring follow-up care and appointment reminders, 77.5% for administrative guidance and treatment-cost counseling, 74.5% for financial assistance with hospital fees and 70.5% for support related to rehabilitation services.

These findings are important, but they need to be interpreted carefully. They concern hospital social-work and patient-support needs, not the effectiveness of social prescribing in Vietnamese hospitals. They do not show that every identified need should lead to a community referral, and they do not establish a Vietnamese model of hospital social prescribing. Their contribution is more fundamental: they show that some Vietnamese patients experience significant needs at the boundary between treatment, professional social work, administration, rehabilitation, family care and life after discharge. That is precisely where a carefully defined navigation function may sometimes add value.

Where could social prescribing and care navigation realistically contribute?

The strongest potential contribution is not another discharge checklist. It is helping move from “this person has a relevant non-clinical or community-support need” to “this person has a realistic opportunity to reach appropriate support.”

That process may begin before discharge with a conversation about what is likely to make recovery or everyday life difficult after returning home. For one person, the issue may be social isolation or loss of meaningful activity after illness. For another, it may be caregiver strain, transport, difficulty finding appropriate services, limited community support or uncertainty about where to obtain practical assistance.

Where community support is appropriate and the person wants assistance, a navigator may help identify realistic options, explain what those resources actually offer, check eligibility and accessibility, support an initial connection and follow up selectively when the connection does not occur. This is different from simply giving someone a telephone number or generic directory.

It is also different from assuming that every person requires professional case management. Some people need only information or light signposting. Others need active navigation. People with more complex psychosocial, clinical or safety concerns may need sustained professional social-work, rehabilitation or clinical involvement. A responsible pathway needs to recognize these differences.

The relevant window begins before discharge

Community navigation should not begin only after someone has returned home. By then, opportunities for planning and clarification may already have been lost. The hospital period may be an appropriate time to understand what concerns the person has about returning home, involve family or caregivers where appropriate and agreed, identify realistic community connections, clarify who will make the next contact and explain what should happen if the planned connection fails.

International research on hospital-to-home transitions supports this broader view. Patients, families and healthcare professionals consistently emphasize coordination across settings, tailored information, communication and involvement in planning. The practical implication for social prescribing is not that a navigator should take over the discharge process, but that any community-facing component should be designed as part of the transition rather than added after the person has already become disconnected.

For an early Vietnamese pilot, community-navigation needs could therefore be considered before discharge alongside — not instead of — clinical care, rehabilitation and professional social-work processes. The navigator does not need to solve every problem. The key function is to recognize where an appropriate community connection could help, agree what should happen next and make responsibility for that next step visible.

Social prescribing should complement transitional care, not absorb it

Clinical services should retain responsibility for clinical assessment and treatment. Medication reconciliation, decisions about clinical readiness for discharge, management of deterioration and rehabilitation assessment should remain within the appropriate clinical and professional systems. Functions that fall within professional social-work practice should similarly remain within the appropriate professional framework. Financial hardship, complex family circumstances, psychosocial assessment, counseling, case management or crisis-related needs may require professional social-work involvement rather than being reassigned to a navigator simply because they are described as “non-medical.”

Transitional-care processes coordinate continuity across settings. Social prescribing or community navigation may add value where a person's priorities or non-clinical needs can appropriately be supported through community resources and where the person wants that support. These functions can overlap at their boundaries, so good governance should clarify responsibilities, establish appropriate escalation and prevent work from quietly moving into roles that lack the necessary competence or authority.

Viet Nam already has a professional framework for hospital social work

This distinction is particularly important because Viet Nam now has a clearer regulatory framework for hospital social work. Circular No. 51/2024/TT-BYT, effective from 1 March 2025, applies to medical examination and treatment establishments licensed to operate in the form of hospitals. It regulates social-work services and processes and includes functions such as assessment of psychological and social risks and needs, support and coordination, intervention planning and connection or referral to appropriate organizations. Decision No. 1975/QĐ-BYT, effective from 1 July 2026, formally corrected the document number from Circular No. 51/TT-BYT to Circular No. 51/2024/TT-BYT.

Decree No. 110/2024/ND-CP on Social Work, effective since 15 October 2024, provides the broader national framework for social work and social-work practice. From 1 January 2027, people practicing social work must hold the required social-work practice registration certificate in accordance with the Decree. Circular No. 29/2026/TT-BYT, effective from 25 August 2026, further regulates social-work practice and the updating of social-work knowledge.

None of these instruments establishes social prescribing as a distinct national hospital service model. They do mean that a Vietnamese hospital should not create a role called “community navigator” and assume that changing the job title changes the professional nature of the activities assigned to it. The safer approach is to map functions first: what belongs to clinical teams, what falls within professional social-work practice, what belongs to rehabilitation or other services, and what additional community-navigation function is genuinely missing.

Referral is not the same as community connection

A hospital can make a referral and still leave the person effectively unsupported. A 2026 qualitative U.S. study interviewed 25 caregivers of hospitalized children with social needs about their experiences after referral from hospital to community organizations. Families described feeling overwhelmed, slow access to resources, poor communication and referrals that did not match their needs. They wanted support that was more humanistic, longitudinal, timely and matched to their circumstances. Spanish-speaking caregivers particularly emphasized hands-on and in-person assistance in overcoming language barriers.

This was a small pediatric study conducted at a U.S. quaternary hospital, and most participants were mothers, Spanish-speaking and insured through Medicaid. It should therefore not be generalized directly to Viet Nam. Its implementation lesson is nevertheless useful: there are several steps between a referral being made and support actually being reached.

For a Vietnamese pathway, the relevant questions begin after the referral leaves the hospital. Could the community organization accept the person? Was the person contacted? Did they understand the offer? Was transport possible? Did cost or eligibility become a barrier? Was the resource genuinely suitable?

Not every referral requires intensive tracking, and people remain free to decline support. The important distinction is between a person who understood the option and chose not to proceed and a referral that disappeared without anyone knowing why. This matters especially at discharge, when people may already be dealing with new medicines, appointments, symptoms, paperwork and uncertainty about returning home.

What can international experience with social prescribing at discharge tell us?

Direct evidence on social prescribing specifically at hospital discharge remains limited. One particularly relevant study was conducted in a French university hospital and published in 2024.

The quasi-experimental quality-improvement study included 223 patients in the intervention arm. More than two-thirds needed help understanding discharge information. Within the intervention model, 98 patients, or 43.9%, required additional social-prescribing and/or discharge-coordination support beyond basic discharge coordination. The discharge coordinator delivered highly individualized assistance involving combinations of healthcare coordination, social-work referral, nongovernmental and group activities, transport, administrative procedures and access to other services.

This intervention should therefore not be interpreted as social prescribing in isolation. It combined social prescribing with discharge coordination and operated within a particular French hospital and community context. The study also did not detect a statistically significant difference in unplanned rehospitalization between patients receiving the intervention and the comparison group. The authors argued that indicators other than rehospitalization are needed to assess social prescribing and discharge coordination.

This is an important warning for Viet Nam. Hospital social prescribing should not be promoted as a proven strategy for reducing readmissions. Current evidence does not justify that claim. A more defensible proposition is that navigation may help identify unmet non-clinical needs, improve the appropriateness of community connections and make parts of the discharge transition more understandable and workable for some people. Whether that ultimately improves functioning, quality of life, healthcare use or other outcomes needs proper evaluation.

Family capacity matters to the discharge transition

Many discharge plans depend heavily on family members. They may organize transport, collect medicines, accompany the person to appointments, help with mobility, prepare meals, monitor symptoms and provide practical or emotional support. International discharge research repeatedly identifies patient and family involvement as an important part of continuity, while recent review evidence also identifies gaps in caregiver engagement.

For Viet Nam, a community-connected pathway should therefore ask whether a discharge plan quietly assumes more family capacity than is actually available. This does not mean treating family caregivers as unpaid extensions of the hospital. Their willingness and capacity matter, and they may have support needs of their own. Where appropriate, navigation may help families identify community information or support, while more substantial caregiver distress or complex psychosocial needs may require professional assessment. The patient's autonomy and privacy remain central; family involvement should not automatically mean unrestricted access to personal information.

Community capacity has to be real, not theoretical

A resource directory can make a discharge pathway appear well connected even when the receiving side cannot actually support people. Before a hospital routinely connects patients with a community organization, it should understand what that organization genuinely provides, who can participate, whether there are costs, whether there is a waiting list, how people make contact and whether current capacity exists. A resource that was available six months ago may no longer operate in the same way, while an activity that is technically available may remain inaccessible to someone with mobility limitations, limited transport or financial constraints.

Formal referral arrangements should therefore be used selectively. Not every walking group, social club or informal community activity needs to receive formal hospital referrals or identifiable health information. Supported signposting may sometimes be more proportionate.

Community organizations should also help shape the pathway. Hospitals should not design eligibility criteria, information requirements and feedback expectations solely from the sender's perspective and then expect community organizations to absorb the resulting workload. Community-connected care works only when both sides of the connection are workable.

Information should cross the boundary only when it needs to

Hospital-to-community navigation inevitably involves questions about personal information. Viet Nam's Law No. 91/2025/QH15 on Personal Data Protection has been in force since 1 January 2026. Article 26 requires the data subject's consent for the collection and processing of personal data relating to health, except in the circumstances specified in Article 19(1). Decree No. 356/2025/ND-CP, also effective from 1 January 2026, includes health status among categories of sensitive personal data.

Health information therefore attracts specific requirements, while other personal data used within a hospital-to-community pathway, including names, contact information, family circumstances and other identifiable information, also remain subject to the broader requirements of the Law and implementing Decree.

The practical question should not be, “How much information can the hospital send?” It should be: “What does this organization genuinely need in order to make the intended connection work?”

A community activity may need a person's name, contact details and enough context to understand the support being requested. It may not need a discharge summary, full diagnosis list, professional social-work assessment or detailed medical history. The appropriate information will depend on the pathway, but purpose, necessity, consent where applicable, access controls, security and retention should be considered before referrals begin.

More integrated care does not require unrestricted data flow.

Who might be appropriate for an early Vietnamese pilot?

A hospital does not need to offer intensive community navigation to every person being discharged in order to learn whether the approach is useful. An early pilot could focus on a clearly defined population in which recurring non-clinical barriers are already visible. Older people with reduced self-care capacity are one possible starting group, particularly given recent Vietnamese evidence showing substantial perceived need for resource linkage and post-discharge support.

Other possible groups might include selected people with long-term conditions whose recovery depends heavily on community support, people who repeatedly struggle to navigate follow-up or patients for whom care teams identify particular practical or social barriers that existing services do not adequately address. The starting population should be chosen because there is a defined implementation problem, not simply because it falls under a broad category such as “patients with social needs.”

An early pathway might identify relevant needs before discharge, determine whether the appropriate response belongs to clinical care, professional social work, rehabilitation, administrative assistance or community navigation, agree with the person what should happen next, share only the necessary information and follow up selectively where there is a meaningful risk that the connection will fail. The pilot should remain small enough that the team can understand where reality differs from the design.

Measure connection and transition quality, not just readmission

Readmission is important, but it is influenced by many factors and may be too distant an outcome to tell us whether community navigation itself worked. The French study illustrates this clearly. It identified a broad range of unmet social and practical needs and required substantial individualized coordination, yet it did not detect a significant difference in unplanned rehospitalization. A narrow focus on readmission could therefore miss whether the navigation process itself was feasible, acceptable or useful.

An early Vietnamese pilot should pay close attention to outcomes nearer to the pathway. Were appropriate people offered navigation? Did they want it? Were proposed community connections suitable? Did receiving organizations respond? Did people actually reach support? How quickly? Why did connections fail? Did patients and caregivers understand what would happen next? Did community organizations consider the referral process workable? Did the pathway create excessive workload? Did safety, privacy or professional-boundary problems emerge?

Equity also matters. If a pathway works for people who live near the hospital, use smartphones and have strong family support but repeatedly fails for people facing mobility, transport, language, digital or financial barriers, an overall connection rate can hide an important implementation problem.

Health, well-being, functioning and healthcare-use outcomes may still be valuable. The first question, however, is more immediate:

Can the pathway reliably help appropriate people make workable community connections across the discharge transition?

What could responsible implementation look like?

A sensible first step in Viet Nam would be to choose one hospital setting and one bounded discharge problem rather than trying to create a comprehensive hospital social-prescribing service. The hospital could first map its existing discharge process and identify where patients currently encounter non-clinical or community-facing gaps. Clinical teams, hospital social workers, rehabilitation professionals, potential navigators, patients, caregivers and selected community partners could then co-design any additional navigation pathway so that it complements rather than duplicates existing services.

Responsibilities should be explicit before launch. Who identifies potential navigation needs? Who decides whether a community connection is appropriate? What remains the responsibility of professional social work? What circumstances require clinical reassessment? Who communicates with community organizations? What happens when a resource cannot accept the person? How will unsuccessful connections become visible? What information can legitimately and appropriately be recorded or shared?

Early cases should be reviewed closely. The purpose is not to prove immediately that the model reduces hospitalization. It is to understand whether a proposed bridge between hospital and community actually functions under Vietnamese conditions, where it fails and what needs to change. Expansion should come only after that learning.

The goal is not to extend the hospital into the community

Community-connected care does not mean turning community organizations into extensions of the hospital, nor does social prescribing mean medicalizing every difficulty in everyday life. People have relationships, interests, communities and sources of support that exist independently of healthcare.

The role of a responsible hospital pathway is more modest. It can recognize when recovery or well-being may be affected by circumstances that clinical treatment alone cannot resolve, help people understand realistic options and provide a bridge to appropriate support when they want and need that bridge.

For Viet Nam, discharge may be a particularly important point at which to test this approach because it is where the limits of hospital care become visible again. Inside the hospital, many needs can be temporarily managed within a structured environment. Back at home, transport, finances, family capacity, community relationships and the accessibility of services become part of whether the plan developed in hospital is actually workable.

The question is therefore not whether hospitals should “prescribe the community” to everyone they discharge. It is:

When someone moves from hospital back into everyday life, have we done enough to make the next part of the journey workable, and, where community support could genuinely help, have we created a safe and realistic way to connect them to it?

That is where social prescribing and care navigation may add value across the discharge transition in Viet Nam.

References

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

2. Williams MV, White-Williams C, Li J. Hospital Discharge: Best Practices for a Seamless Transition. Medical Clinics of North America. 2026;110(4):535–553. doi:10.1016/j.mcna.2025.11.012.

3. van Grootel JWM, Collet RJ, van Dongen JM, et al. Experiences with hospital-to-home transitions: perspectives from patients, family members and healthcare professionals. A systematic review and meta-synthesis of qualitative studies. Disability and Rehabilitation. 2025;47(7):1644–1658. doi:10.1080/09638288.2024.2384624.

4. Vu-Hong Hanh, Nguyen-Thi-Kim Hoa. Hospital social work needs among older patients in Vietnam: priorities for a tiered service response. Working with Older People. 2026:1–10. doi:10.1108/WWOP-09-2026-0129.

5. Vu Thi Lan Anh, Ho Thi Kim Thanh, Pham Thi Ngoc Bich, et al. Need for social work services among inpatients at Hanoi Medical University Hospital in 2025–2026. Vietnam Journal of Community Medicine. 2026;67(CD13). doi:10.52163/yhc.v67iCD13.6524.

6. 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 Formative Research. 2024;8:e51728. doi:10.2196/51728.

7. Kovaric K, Pham Q, Earp A, Wellman N. Navigating the Journey From Hospital to Help: Family Perspectives on Overcoming Barriers to Connecting With Resources to Address Social Needs. Hospital Pediatrics. 2026;16(2):124–133. doi:10.1542/hpeds.2025-008706.

8. Government of Viet Nam. Decree No. 110/2024/ND-CP on Social Work. Effective 15 October 2024.

9. Ministry of Health of Viet Nam. Circular No. 51/2024/TT-BYT on the implementation of social work in medical examination and treatment establishments. Effective 1 March 2025.

10. Ministry of Health of Viet Nam. Decision No. 1975/QĐ-BYT correcting the document number of Circular No. 51/TT-BYT to Circular No. 51/2024/TT-BYT. 1 July 2026.

11. Ministry of Health of Viet Nam. Circular No. 29/2026/TT-BYT on social-work practice and updating social-work knowledge. Effective 25 August 2026.

12. National Assembly of Viet Nam. Law No. 91/2025/QH15 on Personal Data Protection. Effective 1 January 2026.

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