COVID-19 Webinar Series Session 9 – Social Isolation and Loneliness

2:00 p.m. – 2:05 p.m.     Welcome and Introductions

Sarah J. Dash, MPH

President and CEO, Alliance for Health Policy, @allhealthpolicy

2:05 p.m. – 2:15 p.m.         Opening Remarks

Tanya Shah, MBA, MPH

Vice President, Delivery System Reform, The Commonwealth Fund, @commonwealthfnd

Matthew Pantell, M.D., M.S.

Assistant Professor, University of California San Francisco, @MatthewPantell

Robin Caruso, MSW, LCSW

Chief Togetherness Officer, CareMore Health, @robin_caruso

2:15 p.m. – 2:45 p.m.     Moderated Discussion

(This is an unedited transcript. For accurate quotes and presentations, please refer to the full-event video.)   0:41 Good afternoon, and welcome to week 5 of our covid-19 webinar series. I am Sarah – president and CEO of the Alliance for Health policy for those who are not familiar with the alliance welcome. We are non-partisan resource for the policy Community dedicated to advancing knowledge and understanding of Health policy issues. We launched the series to provide insight into the status of the covid-19 response and shed light on remaining gaps in the system that must be addressed to limit the severity in the United States. 1:11 The Alliance for Health policy gratefully acknowledges the National Institute for Healthcare Management foundation and the Commonwealth fund for supporting our covid-19 webinar series. You can join today’s conversation on Twitter using the hashtag. I’ll help live and follow us at all Health policy. 1:31 We want you all to be active participants. So please get your questions ready. Here’s how you do it. You should see a dashboard on the right side of your web browser that has a speech bubble icon with a question mark you can use that speech bubble icon in case you are having any technical issues as well as to submit questions that you have for the panelists at any time. We will collect these and address them during the broadcast. You will also find the materials that accompany this webinar on our website and a recording will be made available. 2:00 there soon I also want to note that we have a little extra time in today’s webinar and will be ending at 2:45. Well essential to combating the covid-19 pandemic stay at home and other social distancing policies are adding to the already present issue a social isolation and loneliness in America. This is especially true for the Thirteen point eight million adults over age 65 who are living on their own today. 2:29 We will discuss the physical and mental health implications of social distancing as well as Pencil interventions that Healthcare leaders and communities can Implement to help those who are most at risk now. I’m so pleased to introduce our distinguished panelists first. We will hear from Tanya Shaw vice president of delivery system reform at the Commonwealth fund where she manages the high-need high-cost population portfolio next. We’ll hear from dr. Matt Pentel assistant professor of pediatrics at the University of California San Francisco in addition to his work. 3:04 With children Matt research is morbidities associated with spacious social isolation among adults. And finally, I’m so pleased to introduce Robin Caruso the chief togetherness officer at care more Health. Robin has worked in the field of Behavioral Health and Medical social worker for over for older adults for over 30 years. Thank you all for joining us today. And now I’m going to turn it over to Tonya Shaw for some opening remarks on you. Go ahead. Hello everyone. My name is Tanya. 3:34 Child with the Commonwealth fund and I wanted to provide a quick overview about social isolation and offer under under discussed issue facing many adults in America today and one that is exacerbated in the current environment of social distancing and Sheltering in place in a nutshell social isolation, which is the objective statement having few social relationships and loneliness a subjective feeling of being isolated are serious health risks that affect a significant portion of the older adult population. 4:04 over 14 million community-dwelling Americans aged 65 and older are considered to be socially isolated we can go to the next slide and a significant portion of adults over 45 in the United States report feeling lonely loneliness is worse among older women and people with lower incomes and all these populations reporting social isolation or loneliness experienced worse outcomes in mental and physical health next slide, please the health damage caused by isolation and loneliness is estimated to increase the risk of early death by 26% some Research indicates that the effect of social isolation on mortality risk may be comparable to or greater than other well-established risk factors such as smoking obesity and physical inactivity AARP in a well-designed study estimated that Medicare spends roughly a hundred and thirty four dollars more per beneficiary per month if they are socially isolated than those who are not applied to a rough estimate of Medicare fee-for-service beneficiaries who are isolated this translates to 6.7 billion in additional spending for Medicare. Why are we spending so much more on those who are isolated research suggests that socially isolated individuals may be sicker when hospitalized or or may lack the support necessary to transition out of the hospital as quickly as socially connected individuals. 5:36 The lack of Community Support may be driving the higher use of skilled nursing facilities for care and Recovery next slide, please 40 Years of research has pointed to a robust relationship between social isolation and increased risk for major chronic conditions and functional limitations evidence is emerging on the association between mortality and loneliness is well, Matt will provide more insights on these risk factors. 6:04 But I think it’s important to note that the causal Pathways here are less important did the social isolation caused the health issue or did the health issue? Cause the social isolation regardless solutions to address both will look very similar and we’ll talk more about programs at Technologies with our other panelists that are working on this problem next slide, please. 6:27 We see some clear policy opportunities to address this issue, which is being exacerbated by necessary and non-negotiable strategies to combat covid-19. First. We need to have this on our radar the healthcare sector can be a major partner in helping identify and address social isolation among our most vulnerable populations. We need to identify it as a risk factor as we would smoking or food insecurity. There are tools out there for care teams to Leverage. 6:57 And resources to connect those who are lonely or isolated via digital and Telehealth Services second. We need to make it easier for mental health providers to provide these Services virtually and telephonically even with new flexibilities to practice remotely Mental Health Providers are still struggling on multiple levels. 7:17 There are trying to adapt Telehealth visits without sacrificing the personal connection to people they help they’re trying to navigate a maze of Licensing rules while figuring out what the And see flexibility really means and they’re trying to accommodate growing numbers of online patients facing depression fear Panic grief isolation and economic distress on top of mental health conditions. 7:40 They had before the pandemic very ordered the rapid shift to technology and telephonic solutions is no use if our poor older adults cannot access them policymakers can consider ways to increase access to utilities like internet and smartphones that are critical for staying connected nearly half of older adults do not have broadband service or smartphones Medicare and Medicaid already subsidizes in certain cases for specific populations. 8:10 I’ll turn it back to Sarah so we can learn more about steroids being made to address social isolation and loneliness Hi everybody again. I’m mad pants hell and besser of Pediatrics Network. 8:49 so I’m going to talk to you a little bit more about relationships between social isolation and loneliness and also talk about some of the opportunities to implement interventions now and in the future and I’d like to thank the coalition to end social isolation and loneliness and Beyond differences both groups that educate people about these topics for providing the pictures for this slide next slide, please so Tanya already touched on this a little bit but What social isolation and loneliness have different definitions and represent unique Concepts? So whereas social isolation is the objective lack of or limited social contact with others loneliness is the perception of social isolation or the subjective feeling of being lonely. So, for example, I could have many friends or have a partner or have frequent contact but still feel lonely and then vice versa is possible as well. 9:45 And the reason that they’re I bring this up is that these terms are often over the use overlapping lie, but they actually represent distinct Concepts that have different implications for interventions next slide, please so is Tonya mentioned we know that there’s a lot of evidence showing associations between social isolation and health. We know it’s not only associated with health outcomes, but that they’re often appears to be a social gradient. 10:15 We’re increasing levels of social isolation confer increasing levels of risk of poor health. So for example in a study that we conducted using a national sample of over 16,000 adults ages 25 and older using the national health and nutrition examination survey. We found that higher levels of social social isolation were associated with increased levels of mortality risk over 14 years of follow-up, as you can see on this graph which on the y-axis shows the percentage of people live at the beginning. 10:44 And then over the months of follow-up on the x-axis the rate of death, you can see that woman’s risk of mortality over time shows that not only are those in red the most isolated it dying at faster rates than those least a legislator which are those in black but that with each level of isolation. You have an increasing rate of death overtime next slide, please. 11:09 Additionally in this study we to understand the magnitude of social isolation is a risk factor. We compared it to other traditional clinical risk factors, as you can see here. We found that social isolation was a similarly strong predictor of mortality when compared to smoking obesity high blood pressure and high cholesterol with the risk of death over the follow-up period being about one and a half times higher among those who are the most isolated compared to those who are the least isolated. 11:37 Next slide please. And not only is social isolation associated with with health outcomes that we measure on the surface, but it’s also associated with biomarkers of the disease. So for example loneliness is associated with altered genome transcriptional activity with under expression of genes promoting anti inflammatory responses and over expressions of Jesus James, promoting pro-inflammatory receptors and social isolation. 12:07 is associated with increased levels of C-reactive protein, which is a marker of inflammation associated with cardiovascular disease, and then social isolation is even associated with increased susceptibility to the common cold and next slide, please you can see here in a study where they actually gave exposed people to cold viruses that increasing level of Association was associated with increased risk of developing symptoms next slide, please certain populations appear to be at higher risk of social isolation and loneliness compared to others at National Academy of Sciences engineering and Medicine report that just came out this year did a great job of synthesizing some of this literature and showing that certain immigrant communities are at higher risk as well as LGBT individuals people living with chronic diseases as Tanya alluded to and also people who have experienced hearing loss in a commonwealth fund study that we did recently Liz I’m glad and found that people experiencing Financial strain are also at increased risk of social isolation and those experiencing intimate partner violence are as well. 13:15 A lot of the effort has been on looking at these associations old and older adults that we don’t know as much in sort of younger populations next slide, please because of this evidence that’s been developing over many many years there have been a lot of endorsements for screening for or Defying social isolation and loneliness in healthcare settings the National Academy of Medicine in 2014 actually endorsed several social and behavioral determinants to capture an electronic health records, including social isolation. And again the National Academy of Sciences engineering at MIT. 13:58 And loneliness and clinical settings. 14:03 And next slide, please. 14:07 Other things that this report highlighted that came out this year is was for several recommendations in accordance with five goals Each of which addresses an aspect of enhancing the role of the Health Care system in addressing the health impacts of social isolation and loneliness in older adults. So go along was to develop a more robust evidence base. Go to was to translate current Research into Healthcare practices. Go three was to improve awareness of the health and medical impact of social isolation. 14:36 And loneliness across the healthcare Workforce and among members of the public go for was to strengthen ongoing Education and Training related to isolation and loneliness in older adults and the healthcare Workforce and go five ways to strengthen ties between the healthcare system and Community Based networks and resources where a lot of this work goes on as well next slide, please. 14:58 We’ve also been conducting research thanks to funding from the Commonwealth fund looking at what stakeholders involved not only in the US but abroad where social isolation interventions are more common in certain countries. And what we found is some common themes that came up from these stakeholders are that social isolation and loneliness are definitely cross-sectoral issues in the Healthcare System alone should not be the only one to address it another theme was that the Healthcare System should be proactive rather than reactive and and help sort. 15:28 Identify preventive strategies to prevent social isolation and loneliness there’s also enthusiasm for government involvement and accountability and also an increasing recognition of the importance of social isolation and loneliness to healthcare plans. 15:41 We also identified in this work that there are a lot of emerging Technologies and both the philanthropic and private sectors to address social isolation and loneliness including mobile apps and online programs next slide, please Given the current situation with covid. We also wrote about a couple of recommendations about how to address social isolation and loneliness during this time and given the environmental restrictions. So important things are maintaining social contact and even though the term social distancing this come about it’s really more physical distancing and now more than ever social connection is very important. It’s important to support those unfamiliar with ways to connect through technology. 16:24 So if people don’t have the internet using landlines it’s important to Get new connections if you’re able to and there are a lot of variety of programs out there that are covid friendly that can connect you with people. No one to ask for help. There’s a lot of national and local hot lines that are either warm friendship lines or mental health hotlines for people in crisis and also during this time. 16:43 I think it’s a great opportunity for providers when they are conducting Telehealth visits to screen for isolation and loneliness and refer patients to appropriate resources in their area and next slide, please Just want to thank everybody for the time and please email me if you have any questions. 17:09 care more hi. 17:19 Everyone, this is robin Crusoe. I always start out by saying I do have the best job ever and the best title of the chief togetherness officer at care more and it’s that title is really opened up a lot of opportunities to really address how important it is, especially in healthcare to address loneliness and isolation on next Slide. 17:42 The reason why I came to care more 13 years ago caramel really has this Shall we do deal with a lot of chronic illness patients that do need a lot of high touches. So we really go to where the patient is and we have shifted from treatment to prevention and we really are about treating the whole person and that’s three years ago when I came in discussion with our then president, dr. Jane. 18:12 He said Robin like you to help us develop a disease management program, and when he said that that would be about loneliness in Isolation my heart just do loved and knowing that was all the work that had been doing as a social worker there that this was the right time for us to really address loneliness and isolation. So next slide. 18:33 And when we decided purposely that we were going to make a disease management programs or somewhere is how you would address diabetes. We said it was because it’s already been kind of touched upon but it’s been increased mortality rate and it’s also the amount of of our seniors over 43 percent experiencing loneliness and isolation on a regular basis. And as we saw earlier in the statistics of of the negative help out with that you’re more likely to die. 19:03 Obesity than more likely to die of loneliness and obesity that we set out that we’re purposely going to develop a psychosocial program to really wrap around these patients next lie. So when we started it wasn’t that we needed to create a new surgery or needed a new medication. 19:22 It’s really about that power of human connection and our three goals were really simple is one to really engage our members into Healthcare and that could be something as simple as helping them navigate the system helping someone get a portable oxygen but it also could be about really developing that relationship. It’s not something that always would happen right off the bat and that we would be talking to someone that really has significant mental health issues, but because of the stigma they are really resistant to address that but maybe by us planting the seeds and talking about they might go better in talking to a behavioral health counselor. 20:03 On the line they say I know that you really care about me. And because you do if you think this will help me I’ll be willing to do that. And then our second goal is really connecting to those Community Based organizations. 20:15 There’s so many wonderful organizations that are out there already having social programs, you know Meals on Wheels has been addressing social isolation and loneliness just by delivering meals and having that friend like connections with people, but our real goal was to Find ways to get them connected and have connections in the community like senior centers finding people’s like interest voluntary organizations, but we know that if we call someone and they’re crying because the roof is leaking. There’s no way we’re going to impact their overall help if we can’t start out where their social needs are so my staff for community health workers. 20:55 And so we really work not just connecting them to resources to really help them get connected socially, but also to address all the social need And then our third goal is one that I’ve seen incredible changes in members lives and this is just getting them to increase their physical activity and at care more we have our Nifty after Fifty gyms and also our silver sneakers and we know when we get them to exercise. This is also not just going to impact their overall well-being but these programs are very social and so these are just our three goals to really try to impact our members overall well-being next slide. 21:35 So that’s kind of talks about who will reaching out when we first started out. We started out with the helpers assessment data where people said they lived alone and they had little support but as we grew our program we did a lot of Education with our clinicians we put assessment tools into our EMR so that every touch whether it’s a dietitian Social Work nurse practitioner someone could assess them. 22:01 So we have people with that they live alone, but we have others that live alone but spend the majority of their day and isolation their family may work early in the morning and not be home till late at night. And then sometimes they have social support but their family lives very far away. So again, they’re spending the majority of their day and isolation. Also, we have people that self refer to our program they know about our program and they can call and then we also really support caregivers. 22:29 We know that 40 to 70% of Eric Evers experience clinical depression it comes from that experience of being isolated as a caregiver. So we actually make all the person who is Our member could be the husband who may have dementia, but our phone calls are to give the support to the wife. And then of course, we work a lot with those that are newly widowed and connecting them and it’s really about building those relationships and where that we might initially talked to them about going out and going to a senior center. 23:02 It’s something that might be interested in the beginning but through developing those strong relationships that we have and one of the things is that we wanted to take a look at how could we reach more people and we reached out to our greatest ask that care more is part of the anthem family. So anyone that is a care more or Anthem associate in any of our divisions could volunteer during their work week to be a phone pal. 23:29 So as we go in and assess our men As for loneliness and isolation are high-risk members are community health workers. We call them social Care Partners really manage them and coordinate it. But if they are medium or low risk, we assign them to a phone call who’s going to call them actively every week just to really have those friendly conversations where there’s no judgement and it’s really developing those relationships again where they feel cared about and we’re also helping them to get connected to what gives them meaning and purpose in life. 24:02 And giving them social connections and so we see now is a great time for us to be talking about addressing loneliness and isolation. I think all of us where we all have had to kind of physically isolate ourselves. We all can kind of experience what that experience is, but imagine for those who have very little support or anyone to talk to you during the day that these phone calls. Sometimes they answer the phone and they’ll say my name and it’s not that they have call. 24:33 Friday we may be the only person calling them that day next slide. 24:39 So over we launched our program in 2017 and May and so these are some of our statistics from that time and so you can see that we have a large number of patients right now. We’re working primarily virtually because we’re unable to make our home visits but we do have social work interns and going into homes. We also have social groups into our Care Centers. 25:03 So with the the covid-19, we’ve had to really shift and change everything to All virtual and then we’re also can see we’ve connected people to over 6,000 resources in the community. And as I said before one of the things that we’ve seen a really great income people that were in our program a year before they came into the togetherness program. 25:26 We’ve seen an increase of 57% of them engaging and exercise and like I said, this isn’t only improving their physical well-being, but we’re also increasing their social Social connections as well. I met one member who had started going to the Nifty after 50 and she had been a caregiver for her mom’s starting at 14 and then she cared for her husband. And so when we got her going to exercise she really didn’t want to go she was kind of embarrassed for people to see her use a walker and she had a lot of pain but by starting exercise within six weeks, she wasn’t using that Walker her pain has gone away. But the thing when I met her the social group, she says Robin I have friends now that come to my house. 26:10 And our friends from the Nifty gym. And then also I’m going to their house. I haven’t had that since I was 14 and then we’ve also seen a reduction of acute hospitalization by a 21% So you can see that our program is definitely had a big change and our members live next slide. 26:36 I know now will probably be going to have our questions. 26:42 Thank you so much Robin. So yes, it’s a reminder for those in the audience. If you’d like to ask a question, you can use the question mark button on your attendee interface to send us a question the robin I’d love to start with you. You know, you really talked about how you build up this infrastructure over the last few years to really address social isolation and loneliness and can you give us a sense of how covid is affecting your beneficiaries remember populations? Obviously. 27:10 They can’t go to an exercise program right now that kind of thing. What kind of increased demand are you seeing? And how are you coping with it? Well one we have seen an increased demand. Our referrals have tripled since the covid 19 and then those patients that are in our program already. Some of them are even saying they’re starting to feel like they did when we first call them that they’ve been in the program. So we’re really working to help them find you. 27:40 Place to connect a lot of them have were they been resistant. Do you think technology some of the phone calls or even teaching our members how to zoom and you use technology and then the other thing is that we’re seeing one of the things is a lot of increase in anxiety that fear the unknown, you know, one of our members who said is it okay for me to go into the backyard. So we’ve also had to do a lot of Education to them. 28:08 But we also try to be really creative and things, you know, we’ve mailed out things where our members can play checkers over the phone with their phone Pals. So we are seeing a big demand and so one of the things is it’s really impacted as in a great way that we’ve also had a lot more people signing up to be phone paused. So we’re we had the the triple and referrals coming in. We’re also seeing a high increase and Willie have ramped up our phone how program as well. 28:39 Right and one quick follow-up question on that and then I want to get some more of the digital Technologies. Can anyone signed up to be a phone pal or is there a screening program is that just like the general public? How does that work? Well, unfortunately for that to be a phone call, you actually have to be an Anthem associate. It’s kind of part for patient health information protection and things like that, but I will be talking later on about ways that people can volunteer and there are a lot of things that people can be doing. 29:08 Lee Great. Thank you. So let’s get to this question around digital digital health and digital connectivity. Obviously something we’re all using a lot more of over the last few weeks panya. You mentioned it and Matt as well. Can you start us off Tonya as far as how do you see that working? How do you see the role of policy makers in the private sector and enhancing the use of digital tools? And do you see these initiatives extending beyond the crisis? 29:38 Guess I’ll start with you tan and then I’d love to hear from that. Sure. I mean the Matt and I have been working together actually to help identify these across countries and I think he can give some promising examples of digital tools. I think from a you know, barriers and facilitation standpoint. 30:03 I mentioned this in my slides, we really need to make sure that the devices And the utilities are available, especially to those that are lower income and more susceptible to being isolated so that they can engage in these telephonic Services. I think Medicare is ramping up flexibility, especially around Health Services making those a reimbursable to Providers through telephonic care or virtual care, and we just need to see some of that parody on the mental health side. 30:38 Side some of those Services need to be more flexible as well as the modes in which they’re delivered and by whom they’re delivered. 30:48 I think you know Robin gave it example of the types of people that go into the home and are really the partners with the patient’s they’re not necessarily doctors, but they’re licensed professionals and we need to allow the same kind of flexibility of some of those other licenses in the mental health space to be able to provide some of these virtual It so I think thinking about the access piece along with the the digital Technologies is important. 31:17 The last point I’ll make before turning it over to Matt is that I think we also see, you know, we have all seen an explosion in devices as well as Technologies and apps but I think really thinking about you’re centered design principles for older adults would really encourage kind of the private sector to think about them as the user and there are some vendors out there developing very easy to use incredibly understandable Technologies for that population. And so we really need to see that kind of innovation as well and I’ll turn it over to Matt for specific examples. Thanks and Maddie you as you were. 32:08 As these examples. Thanks Matt as you address these examples to we also had a related question from the audience around whether there are any Trends or innovations that you’re noticing in the technology to address social isolation and particularly in the wake of covid. So, I’ll throw that in as you put your answer together. Yeah. 32:30 No, no great question and I completely agree with what Tanya is saying and I sort of think of these Technology based or Digital Innovations as far as several different types, you know, there’s there’s some that are were digital technology is used to facilitate connections via other methods like their apps where you can sign up and you use that to then find sort of friends that then you can set up, you know phone calls with and it might not be that the digital connector anymore. 32:59 You know, for example, there’s something that does a little bit of both is this app called Papa that pairs older adults with college students to facilitate connections and While that usually involves meeting in person. They were also launching more phone friends situation. And I know when I was contacting the last week, that’s what they were focusing on obviously now during social distancing and then there’s there’s there’s other things that I think serve them digital technology that serve as the sort of connector themselves or as the connection, you know, for example, and I think tiny was alluding to this there’s there’s a an innovation called comp which is this sort of one button computer. 33:38 her that’s actually designed and more user-friendly for older adults who probably haven’t been exposed to as much technology or mobile mobile applications before and it’s something that you can use to connect to a power outlet and then set up to scream photos or send and receive messages and conduct video calls with your family, but it’s just much more focused on that and it’s not a lot of it’s not a lot of energy to sort of learn it particularly for someone who might not have necessarily been using a mobile phone before even even the internet before, you know, then there are other technologies that A sort of serve the role as helping you connect or help you cope with what’s happening in the wake of loneliness and social isolation. They’re sort of like these Bots apps that use AI to provide sort of counseling or talk you through things that are actually developed by psychologists and artificial intelligence computer scientists that are out there. 34:29 And you know, we’ve been seeing those even before covid come up as a means to sort of address some of the symptoms that come up with isolation and loneliness and I’ll one last bit before answering the question about the trends. 34:41 You know, I think Telehealth is something that’s interesting right now because you know is we’ve essentially gone from practicing, you know, minimal Telehealth to only Telehealth and for a lot of primary care visits in a very very short amount of time and I think that provides, you know, the platform to try some