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 the Ontario province, 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
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.
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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.
- Advancement of discussions on funding for years 2 and 3 of the project and launch of preparatory work for a scientific article on the impact of community engagement.