Addressing Social Isolation in Primary Care using Digital Patient Engagement
The COVID-19 pandemic revolutionized healthcare delivery, emphasizing the need for digital platforms to optimize patient engagement and outreach. As primary care providers adopt these tools, it is crucial to assess their effectiveness in improving healthcare integration, accessibility, and patient experience. The Canadian Primary Care Information Network (CPIN) offers a scalable, practice-based solution for engaging patients in small, independent primary care practices where most care and care coordination occur.
The Brain-Heart Interconnectome (BHI) Social Isolation project evaluates the implementation of CPIN to measure and improve patient experience in healthcare integration and access, while piloting its use for addressing social isolation—a risk factor for brain and heart conditions—among seniors.
Recruitment Process
We will opportunistically recruit at least 20 primary care providers across Canada to deploy CPIN. Providers will use CPIN to send outreach messages and questionnaires to their adult patients, capturing data on patient experiences with healthcare integration, preferred sources of health information, unmet information needs, and engagement with tailored health messages.
A sub-study will focus on CPIN’s potential to reduce social isolation in seniors by connecting patients with community resources. Eligible patients will be recruited from 20 practices in Ontario, including the Archipel and Grand River Ontario Health Teams. Practices will be financially compensated for their involvement in the project. Focus groups with patients and advisory groups will inform the design and evaluation of health messages. Providers will complete surveys on CPIN’s utility, and qualitative data will be analyzed using thematic analysis. Quantitative survey data will be analyzed descriptively and compared by patient characteristics, aggregated across providers.
Expected Outcomes
The study will generate insights into CPIN’s effectiveness in improving routine practice operations, patient engagement, and access to tailored information. The sub-study will evaluate CPIN’s impact on reducing social isolation among seniors, with downstream effects on brain and heart health, by linking patient data to health administrative records.
CPIN offers a scalable, low-burden approach for enhancing patient engagement and addressing social isolation in primary care. Outcomes include a virtual library of patient-rated health messages and an integrated framework for aligning CPIN with regional health system governance.
Project Updates
Quarter 4 – 2025
The fourth quarter of 2025 saw significant progress in community engagement, recruitment, survey sending and adjustments to communication strategies related to social isolation.
Key points:
- Strengthened engagement with the community advisory committee, with their feedback progressively incorporated into messaging and survey tools to avoid stigmatizing language and promote social connections.
- Sustained progress in validating the social isolation scale, with over 300 participants recruited for the first phase and recruitment continuing to ensure robust analyses.
- 33 primary care providers agreed to participate in the study, exceeding initial expectations and supporting the rollout of digital interventions.
- In December 2025, a first patient survey was sent to four primary care clinics in Ontario. Patients in the intervention group received a message on the health benefits of 2-1-1 and social connection, while patients in the control group received one of the following messages: Ways to Prevent Dementia, Better Sleep, or New Evidence About Alcohol.
- Funding approval for years 2 and 3 of the project.
January 2026
In January 2026, the project reached important milestones in data analysis, optimizing patient engagement, and preparing for the next phase of scientific dissemination.
Key points:
- Initial consolidated results from patients: Surveys generated response rates ranging from 2% to 7%, comparable to those observed in similar clinical settings, with positive reception of messages and nearly 1 in 2 patients indicating a willingness to share the information received.
- Better understanding of the profiles reached: Preliminary analyses show a majority participation of patients aged 60 and over.
- Strengthening the scientific and strategic positioning of the project: Work is underway to prepare submissions to conferences (Destination Recherche Montfort 2026, CAHSPR 2026) and to prepare for new funding opportunities, in line with provincial priorities in community engagement and population health.
February 2026-April 2026
- Project Status & Milestones
- Survey 2 Analysis: Descriptive analysis is complete; clinic-specific reports were sent.
- Survey 3 Planning: Topics for the upcoming spring session have been identified. for the Intervention group: Outside Together, Belonging Starts Small, Get outside, Stay Connected, May: Community and wellness; and Control group: Protect yourself from Lyme disease, How to Avoid Misinformation Online, and Safe Disposal of unused medications, and Plan ahead for this summer’s hot weather in Ottawa and Eastern Ontario
- Randomized Control Trial (RCT) Progress: The team will proceed with the RCT crossover by the end of summer 2026, following the first cycle of message dissemination.
- Research & Tool Development
- Risk Prediction: Currently developing a project on a digital risk prediction tool targeting dementia and cardiovascular prevention.
- Patient Communications: Messaging has been finalized following Community Advisory Board feedback. Quality control testing is under consideration.
- Administrative & Ethics Updates
- Participant Incentives: Ethical Amendments are in progress to include a $100 gift card incentive in the upcoming messages to be sent in both control and intervention groups.
- Survey Participation: Current response rates are trending between 3.6% and 6.3%.
- Team Highlights
- Fellowship & Growth: Umerdad shared successful fellowship outcomes and new career opportunities.
- Collaborations: Exploring a new partnership with a Saskatchewan-based team and identifying future funding opportunities.
April 2026 – October 2026
- A waiting-room survey was conducted on-site, in one BHI participating clinic, to assess the visibility of CPIN health promotion messages among patients.
- 174 people responded to the survey.
- 55% were aware that they had received at least one CPIN message in the past 12 months.
- In June 2026, Survey 3 was conducted with a test of a $100 gift card incentive across participating clinics. No increase in survey response rates was observed following the introduction of the incentive. The messages sent were:
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- For the intervention group: “Belonging starts small”, “Get outside and stay connected “
- For the Control group: “How to avoid false information online”, “Colon Cancer screening”, “Lyme disease – summer 2026”
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- A Community Advisory Board (CAB) meeting was held on September 14th to share project updates, present preliminary findings, and gather feedback on future messaging topics. CAB members suggested future topics on AI and social connection, technology and staying connected, and avoiding AI-related scams. They also recommended strategies to improve survey completion, such as email-only distribution and sending the survey 24 hours after the resource message rather than simultaneously.
- For Survey 4 (September 29), a new dissemination strategy was implemented in which the health message was sent first, followed by the survey link 48 hours later. This recent wave generated approximately 1,000 responses, representing the highest number of responses obtained from a single survey wave to date. Statistical analyses are still ongoing. The messages sent were:
- For the intervention group: “Building a support network”, “Fall: a time of change for many”
- For the Control group: “Stressed? You’re not alone”, “This Fall, protect yourself from the flu”
- For the intervention group: “Building a support network”, “Fall: a time of change for many”
- After 4 survey campaigns, across the four participating clinics, the project has accumulated approximately 3,600 survey responses.
- Beginning with Survey 5, the study will implement the planned crossover design, whereby participants in the control group will begin receiving the social isolation intervention messages.
- The BHI Social Isolation project will be presented as an oral communication at the Trillium Conference (October 23) and as a poster at NAPCRG (November 21). Other presentations were given earlier this year during the ACFAS Conference.
- A manuscript regarding the BSSNI-RD (including progress on psychometric validation analyses in French and English) was prepared by Michel Dewar and is under submission.
- A poster with the findings of the BSSNI-RD study was presented at the CPA conference in Montreal on June 4.
- Conferences presentations:
- Dewar, M. & Johnston, S. (May 11-15, 2026). Un outil bilingue pour réduire les inégalités liées à l’isolement social: validation du BSSNI –RD [Présentation orale]. ACFAS conference, Trois-Rivières, QC, Canada.
- Khudadad et al. (May 22, 2026). Reducing Social Isolation through Digital Messaging: Preliminary Findings from Four Ontario Clinics [Poster presentation]. Student Conference JGH, Montreal, QC, Canada.