Rural primary care settings lack integrated tools to address isolation, substance use, and suicide risk in older adults.

Social isolation, loneliness, substance use, and suicide risk are deeply interconnected challenges that disproportionately affect older adults in rural communities. In rural New York, suicide rates among adults 55 and older have risen 82 percent over two decades, reaching nearly 18 per 100,000 in 2023. Nationally, more than a third of adults ages 50-80 report experiencing loneliness or social isolation.

Primary care offers a critical opportunity to identify and address these interconnected risks, but most clinical approaches treat them separately. Screening and intervention protocols for substance use and suicide risk exist, as do community-based programs that reduce isolation, yet they are rarely implemented together. This gap presents an opportunity to test whether an integrated primary care model could more effectively support rural older adults facing these challenges.

NORC is piloting an integrated screening and social prescribing model in 12 rural New York primary care clinics.

Our pilot integrates two evidence-based approaches. The first—Screening, Brief Intervention, and Referral to Treatment with Suicide Care (SBIRT-SC)—equips primary care providers to screen patients for substance use and suicide risk and deliver brief interventions or referrals as needed. NORC developed SBIRT-SC and has trained thousands of professionals across New York, Colorado, North Dakota, and Florida to implement it in primary care clinics, emergency departments, and schools.

The second component, social prescribing, extends beyond clinical care by connecting patients to community resources that foster social connection—from group activities and classes to volunteer opportunities. While each approach has demonstrated effectiveness independently, they have rarely been implemented together to address the interrelated challenges of isolation, substance use, and suicide risk among older adults.

NORC is piloting this integrated model in 12 primary care clinics across five counties in western New York: Genesee, Livingston, Orleans, Wyoming, and Steuben (sometimes referred to as the GLOWS region). The project also includes developing undergraduate and graduate coursework to prepare future health care professionals to deliver integrated screening and social prescribing.