By Logan Kelly, Center for Health Care Strategies and Nancy Wexler, The John A. Hartford Foundation
With social distancing and stay-at-home orders in place in states across the nation, many people are newly experiencing social isolation and loneliness. But for many of our nation’s older adults, these feelings are a day-to-day reality. There is strong evidence that older adults who are socially isolated and/or lonely may have a higher risk of poor health outcomes and or premature mortality. This risk is even higher among low-income and vulnerable subpopulations.
How can health care systems better support older adults experiencing social isolation and loneliness, particularly in today’s pandemic environment? The Playbook recently spoke to Terry Fulmer, PhD, RN, FAAN, president of The John A. Hartford Foundation, who shared her perspectives on the current situation, a recent National Academies of Sciences, Engineering, and Medicine (NASEM) report on social isolation, and the goals of the Age-Friendly Health Systems initiative.
Q: How do social isolation and loneliness affect quality of life and health outcomes for older adults, and how has the COVID-19 crisis affected the population at risk?
A: First, let me acknowledge the devastating toll that the current pandemic is having on all of us. Our thoughts are especially with older adults and people with complex conditions who are most at risk of severe illness, and the valiant health care providers who are making sacrifices for us all.
Everyone may be feeling the effects of social isolation — the objective state of having few contacts or relationships — and loneliness — the subjective feeling of being isolated — during this time of social distancing. For older adults, this is a relatively common experience. We know from the NASEM report that a quarter of older adults are considered socially isolated and more than 40 percent of people over age 60 report loneliness.
The COVID-19 crisis exacerbates these experiences exponentially. Both actual and perceived social distancing creates instant isolation and loneliness. Families cannot be together at the greatest time of need. The required separation of family caregivers creates a support vacuum for both the individual and the caregiver, leaving everyone vulnerable. Routine services that provide meals, therapy, transportation to activities, or assistance with daily living are heavily disrupted, leading to an abrupt loss of connection to these services and community networks. For those at home, they are disconnected from their outside world. For people living in residential care settings, they are now cut off from their visitors.
As the NASEM report shows, the effects of isolation and loneliness can have profound impact on peoples’ health and well-being over time. Social isolation is a contributing factor to a higher risk of all-cause mortality, possibly on par with obesity and smoking. Loneliness is associated with higher risk for chronic illnesses, such as dementia and heart disease, and higher rates of hospitalization and emergency department visits. An AARP Public Policy Institute study estimated loneliness to account for $6.7 million in annual Medicare expenses.
Q: What strategies can health systems use to address social isolation among older adults?
A: The NASEM report’s primary focus is engaging health systems to address isolation and loneliness. Recognizing the frequent interaction between older adults and their health care providers, the report outlines recommendations that include periodic assessment using validated tools to identify older adults experiencing social isolation or loneliness, making connections to needed social care, addressing the underlying causes when possible (such as hearing loss or mobility limitations), and documenting social isolation in the electronic health record.
The Age-Friendly Health Systems movement, one of the primary initiatives of The John A. Hartford Foundation, is one way that health systems can implement the NASEM report recommendations. This national effort, in partnership with the Institute for Healthcare Improvement, the American Hospital Association, and The Catholic Health Association and many stakeholders across the country, has developed the evidence-based 4Ms framework for age-friendly care: What Matters to the individual, Mentation, Medication, and Mobility.
The 4Ms function as an interactive set of responsibilities or guideposts for health systems to ensure that the unique needs of older adults are met. Identifying What Matters to the patient and making that integral to the documented plan of care can enable an interprofessional care team to assess and address isolation, loneliness, and their associated risk factors. By assessing Medications, Mentation (e.g., dementia and depression), and Mobility at each visit, health care teams can identify limitations contributing to isolation. Health plans and accountable care organizations (ACOs) can reinforce this type of care through practices, policies, and payment models that incentivize addressing the 4Ms and the social determinants of health. There are a number of ways for health systems to join the movement.
The 4Ms framework for age-friendly care is often deployed along with other interventions that health systems can use to address isolation and loneliness, such as telehealth, virtual networks, and community paramedicine. Many emergency departments are using the 4Ms framework to achieve accreditation as Geriatric Emergency Departments (GED) and leaders in the GED movement have noted the dangers of social isolation in the context of other COVID-19 clinical management issues for older adults. Age-Friendly Health Systems fit into a broader eco-system that includes Age-Friendly Communities and Age-Friendly Public Health Systems, which fosters cross-sectoral partnerships. In times of emergencies, these partnerships can be critical. Florida’s Lean on Me program, for instance, is a public health program designed to proactively help older adults prepare for disasters and can reduce social isolation, especially when needs and fears are high.
Q: The NASEM report notes that social isolation and loneliness are community-wide problems that health care systems and community-based service providers will need to form new partnerships to address. What are the challenges and opportunities for these partnerships going forward? How might the landscape change due to COVID-19?
A: The basis of any high-functioning health system should be a strong relationship with its community-based organization partners. Area Agencies on Aging, for example, have long specialized in family support services aimed at the social needs of the community and helping older adults remain connected. There has been a persistent disconnect between community-based organizations and health systems, in large part because each has distinct processes and payment systems. There have been misaligned incentives that create barriers to partnerships. Many community-based organizations need support developing the business functions to prepare them to demonstrate their value to health systems. The National Association for Area Agencies on Aging (n4a), has created the Aging and Disability Business Institute to help the community organizations and health systems partner and the trend is improving.
Medicare Advantage plans and ACOs have a central role and unique opportunity to facilitate these partnerships as a means to preventing isolation. Changes in Medicare Advantage supplemental benefits to pay for and provide non-medical services impacting overall health have just begun.
Now with COVID-19, many regulations have been relaxed to facilitate alternative contracting and service provision. Community-based organizations will be more important than ever as partners to health systems during this crisis, and in its aftermath. New telehealth measures, such as the remote monitoring of milder symptoms and video visits to increase contact with patients in their home, are rapidly emerging as a widespread alternative to manage COVID-19 and other health conditions.
Q: What training and education is necessary to support the health care workforce — and other professionals who interact with older adults — to address social isolation?
A: A set of recommendations from the NASEM report focus on improving the education and training of the health care workforce. Educational curricula should include content related to social isolation and loneliness and information on clinical approaches to assessment and intervention.
One program that presents an opportunity for widespread training is the Geriatrics Workforce Enhancement Program (GWEP) of the federal Health Services and Resources Administration (HRSA), which in March 2020 was reauthorized with $40 million dollars in funding for a new five-year cycle. The aim of GWEP is to increase geriatrics skills among 48 primary care-academic partnerships in 37 states and U.S. territories.
The John A. Hartford Foundation and the American Geriatrics Society partnered to create a national coordinating center to support best practices across the sites and in 2019, HRSA integrated the Age-Friendly Health Systems 4M framework directly into the program. Primary care is being transformed by these programs to create routine, standard ways of developing person-centered care plans and partnerships with community-based organizations. Introducing and educating on social isolation screening tools in these programs would be very natural.
Q: For family caregivers who provide care for older adults, how are they at risk for social isolation, and what are the opportunities to better support these caregivers?
A: Thank you for asking this question, because so often family caregivers aren’t recognized as a critical factor in care. Caregiver strain is common and isolation and loneliness in this group is an underrecognized cause of depression and health problems.
There are excellent resources available from organizations including the Family Caregiver Alliance (FCA), which provides information on local and national programs and services. The resources offered by these types of organizations are often overlooked by health plans and ACO care managers as a tool for their care planning and family support.
Family caregivers of people with dementia are particularly at very high risk for isolation and loneliness. The recently launched Best Practice Caregiving database is designed to help health care organizations compare and select evidence-based programs for dementia family caregivers that can reduce loneliness and isolation.
Identifying ways to address these issues among diverse populations is critical. The Diverse Elders Coalition, with funding from The John A. Hartford Foundation and others, has conducted an extensive literature review and a national survey of understudied groups of family caregivers. The Coalition is currently working with its member organizations to develop a training curricula that will help health care and social service providers better address the needs of diverse family caregivers, providing more opportunities to decrease isolation and loneliness and promoting better health outcomes for all.
Q: Moving beyond health system-led interventions, what policy opportunities do you see to mitigate social isolation? What long-term implications of COVID-19 may shape these policy opportunities moving forward?
A: Some of the most immediate policy opportunities will come from our partners in the public health field. The Age-Friendly Public Health Systems initiative led by the Trust for Americas Health (TFAH) is piloting state-based standards that will change the way the needs of older adults are addressed in statewide health goals and strategies. Addressing social isolation is a natural fit.
At the federal level, TFAH is working to educate congressional staff about the importance of creating a designated program at the Centers for Disease Control and Prevention to focus on the social determinants of health, including grants to states to build expertise within public health departments, and to foster collaboration with the aging sector.
The COVID-19 pandemic has also prompted TFAH, in coordination with more than 35 organizations (including The John A. Hartford Foundation), to call for the prioritization of older adults’ needs during the COVID-19 response. Social isolation is specifically called out as an area that requires coordinated federal action and partnership with experts and organizations.
Finally, I would close by saying that COVID-19 will change much about our world. Social distancing, isolation, and loneliness are a daily experience right now for millions of people around the globe. The disproportionate impact of the pandemic on older adults is creating dialogue about how we should be valued and cared for as we age. This will create new opportunities for us to address social isolation and loneliness among older adults, which will improve health outcomes, save lives, and is the right thing to do.