Robyn Golden, associate vice president of social work and community health at Rush University Medical Center in Chicago, knows her health system is in a unique position. Isolation and loneliness among patients is at an all-time high nationwide and much talked about in light of COVID-19, but it’s also not something providers en masse are tackling yet.
But it doesn’t have to be that way. There are low-cost options providers can use to help move the needle for these patients.
Rush started a few months ago screening patients for isolation and loneliness, a feature integrated into its electronic health record system. Rush originally added a social determinants of health screening in 2018. When a patient scores high on their screening, they’re assigned to a team that creates a plan for them, and they receive periodic check-in phone calls.
“It’s rare for a hospital to have a social services agency built in,” Golden said. “But social isolation doesn’t happen in isolation. Often people will have other comorbidities: depression, anxiety, increased risk of substance use and other health conditions.”
She added that some of Rush’s solutions do cost money for services that insurers usually don’t cover. But there is a tie to the bottom line: Providers can see progress in measures like readmissions, patient utilization and provider burnout, all which are directly connected to the social determinants of health, including isolation and loneliness. And often addressing one social determinant like isolation can also impact others; providers might find through interventions that a patient needs better access to transportation, food or housing assistance.
The solutions don’t have to break the bank. They can include low-tech phone calls or partnerships with community organizations to help those patients.
Golden and other experts say the pandemic has increased the imperative for health systems to address isolation and loneliness. More people are receiving care at home, including older adults after a hospital discharge, or others who seek virtual care to avoid potential COVID-19 exposure.
That shift can lead to isolation and loneliness, factors that can have the same negative health mortality and health cost impact as smoking 15 cigarettes a day, according to the federal Health Resources and Services Administration.
Historically, the task of targeting loneliness and isolation has been left to community senior centers and area agencies on aging. The growth in health systems providing patient solutions has mainly been within risk-based organizations, or academic medical centers and other integrated care providers.
Research shows physicians and other providers are among the most trusted individuals in an older adults’ lives, so they are a logical focal point to at least identify and monitor loneliness and isolation. That’s how Katherine Suberlak, Oak Street Health’s vice president of clinical programs, sees her organization’s doctors, nurse practitioners and on-the-ground medical staff.
“Health systems don’t have to be the entire solution, but I think we’re one part of it: we’re uniquely positioned,” Suberlak said. “One thing all older adults do is usually go see the doctor. So we are in a great place to be the screener. I think that’s enough of a business case, because we know it exists.”
Loneliness, according to University of Maine Center on Aging Director Lenard Kaye, is the feeling of having limited contact with others. Isolation, meanwhile, is physically having limited contact with others. They don’t necessarily always occur together. But coupled, they can be deadly. Kaye points to research that shows a wide range of significant negative health consequences, like more risk for heart conditions and cancer.
“Even the common cold is experienced more severely by folks who are isolated and lonely, in part, because they don’t see their care provider as frequently on a regular basis; they’re more likely not to have preventive care; they’re more likely to be hospitalized; they’re at greater risk of falls; they’re more likely to use the emergency room,” Kaye said. “So there’s a long list of associated risks that are elevated for those who are who are isolated, and/or lonely.”
Health leaders can also look at solutions through an inclusion lens. Four in 10 low-income adults age 50 and over reported facing challenges accessing various resources during COVID-19, including a fifth who had challenges accessing food and a similar number who had issues accessing healthcare services, according to AARP. Low access to food, healthcare and transportation—among the most critical social determinants of health, are also strong signals that someone is at risk or already is socially isolated and lonely.
“The other hook now is through equity: if you recognize that the people we’re talking about are the ones who have the greatest health disparities,” Golden said.
Screening for loneliness/isolation can be a first step for healthcare providers to address the issue and improve outcomes and potentially reduce costs. A year ago, Oak Street Health added an evidence-based screening tool , the UCLA Loneliness Scale, to its annual patient health risk assessment.
But just asking the question—without a recommendation or treatment that a provider can offer—can leave providers with a “now what?” quandary.
Cindy Jordan, CEO of Pyx Health, which offers a platform designed to reduce loneliness and social isolation, said many organizations haven’t ventured into handling this part of a patient’s life for a couple of reasons. Healthcare delivery is still largely using a medical model based on treatments. And there’s not an abundance of obvious treatments a hospital or primary-care group can offer.
“When you do tell your doctor you’re lonely, there’s a bit of, ‘Well, what am I supposed to do with that information?’ ” Jordan said.
She contends that loneliness should be a treatable, billable condition to entice providers to start helping their patients address it.
But Suberlak doesn’t think loneliness and isolation should be pathologized, mainly because that would just create more stigma, and the solutions are often low-cost.
“We are using low-tech interventions, which include proactive wellness calls, and then creating an individual care plan with a patient to say, ‘What are you able to do right now, what are your strengths and resources,’ and tapping into that,” Suberlak said, adding that Oak Street employs social workers or community health workers to help target these patients.
Rush University Medical Center also employs a similar risk screening, and integrated the question into its EHR system, sold by Epic Systems Corp. Eve Escalante, manager of program innovation at Rush, said the hospital started off with having physicians and other providers do the screening manually, but didn’t have great results.
“If it’s not in Epic, it’s not going to get done because it’s not integrated in the typical flow of a visit,” Escalante said, adding that the EHR system also helps calculate a risk score and provide predictive modeling on a patient-population level. When a patient scores high, they’re enrolled in the provider’s “Friendly Caller” program, which has made over 700 calls to older adults since April 2020 when it first piloted.
Then there’s telemedicine, which UMaine’s Kaye said could be beneficial in fighting loneliness and isolation. He said it’s an area ripe for investigation because there’s scant research looking at a connection.
Like most health providers in the past year, primary-care provider ChenMed pivoted to telemedicine visits after much of the U.S. shut down in-person care in March 2020. Dr. Giana Neil, ChenMed’s market chief medical officer for Broward and Palm Beach counties in Florida, said she’s not sure that virtual healthcare visits are making a dent because they’re seeing such a greater degree of isolation, even as telemedicine use has soared.
“I have not seen evidence that telemedicine has helped overall loneliness,” Neil said. “The folks who were alone and remained alone still needed the same level of support, but we found more loneliness among the folks who were used to their community being external. Even telemedicine doesn’t quite seem to bridge that gap.”
ChenMed, which operates under at-risk arrangements, offers a “love call” program in which providers are given a list of patients to call each week to check in, and more frequently for patients who screen positive through the loneliness and isolation screening tool. She said they do have evidence that the calls make a difference.
These solutions, even for organizations that take on risk and have an imperative to keep their costs low, requires buy-in from leadership. It doesn’t take much to sell the finance team of a hospital or primary-care provider to start doing screenings, which falls under a patient-focused risk assessment. Those are paid under a fee-for-service model, which the majority of payments in the U.S. still are under.
But health providers can also team up with community organizations that have traditionally been the agencies to help address isolation and loneliness. Oak Street Health, for instance, partners with the Foundation for Art & Healing, which sends art supplies to their patients to then use in virtual group art classes.
Dr. Gordan Chen, chief medical officer at ChenMed, said healthcare providers that mainly are in fee-for-service pay arrangements should look more aggressively at value-based pay arrangements, which can create a larger financial incentive to integrate loneliness and isolation solutions into their care processes.
“It allows doctors and clinicians to do the right things for patients, regardless of the circumstances,” Chen said.