The role of health professionals in Loneliness Assessments

1. The Role of the Health Professional
in Loneliness Assessments
Carla Perissinotto, MD MHS
Associate Professor of Medicine
Associate Chief, Clinical Programs
Division of Geriatrics
University of California, San Francisco
Division of
Geriatrics

2. What we’ll discuss:
(1) The individual health professional perspective:
• How to understand risk. What can we realistically expect of
health professionals?
(2) The health system perspective:
• Making the case for early identification of loneliness and social
isolation across populations. What should we be measuring and
how do we implement?
• How to integrate into electronic health records
• Measurement over time
(3) Impacting the bottom line:
• How do we capture the value of investing in prevention
strategies/interventions
• Opportunities for social prescribing

3. Framing the discussion:
My disclosures:
•I am a primary care physician practicing in an academic center,
community health center and in home based medical care
•I am an anthropologist and Public Health advocate
•I care deeply about older adults
•I am a first Generation American growing up in a multilingual and
multicultural household
•I am a utopian pessimist
•I like translating theory into pragmatic solutions

4. More Context: where I live….
San Francisco has the highest proportion of seniors
and adults with disabilities of any urban area in the
state
*20,000 are living alone (19%)

5. 2 Work Stories
1 Personal Story

6. Man, 102, dies of failure to thrive
California, 2012
Dies in hospital because he did not
have enough help at home
“Social admission/failure to thrive”
He was homebound—bc of stairs
Had family out of state
He had a visiting doctor, caring
neighbors and maximum in home
health (IHSS) hours
He does not describe himself as lonely
Other medical problems: hypertension,
wheelchair bound

7. Man, 102, dies of failure to
thrive
•Did loneliness or isolation contribute to his death?
•Is the health care provider expected to capture the risk of
loneliness and isolation in the chart?
• If so, where and how?
•What incentives are there currently for professionals to
examine loneliness and isolation (or other social
determinants of health)?
•If loneliness or isolation were identified, could we have
prevented his death?

8. 82 yo woman with 24 hr care
you see her at home and she has the following
concerns:
◦ 24 hour caregiving but feels lonely
◦ Extended Family is nearby
◦ Polypharmacy
◦ Visual and hearing problems
◦ Smokes
◦ She has limited mobility
◦ Initially, frequent social engagements at home

9. Understanding Health Risks
If you were her medical provider, psychologist,
or social worker, what would you focus on?
1. Hearing impairment
2. Visual Impairment
3. Hypertension
4. Polypharmacy
5. Falls risk
6. Loneliness
7. Smoking
8. Something else?

10. Mi madre y mi padre
 50th wedding anniversary December 26, 2018
 Both are immigrants
 Both have English as a second language
 My mothers family is all in Mexico
 Both are retired
 In true American way, our family is spread across the
country
 On September 22, 2018, my father died of a fall
 What can I advise my mom as she now experiences
loneliness and grief
 Does her GP/PCP need to be aware of her loneliness?
New York 1969
California 2018

11. How do we
estimate health
risks for older
adults?

12. FALLS
• EVERY 19 MINUTES AN ADULT AGE >65 DIES
OF A FALL
• ONE IN FOUR ADULTS FALL EACH YEAR

13. HYPERTENSION
-63% IN PEOPLE AGE >60
-DEATH RATES: 14.3 PER 1000

14. Loneliness
-43% IN PEOPLE AGE >60 IN THE US
-9% “ALWAYS” LONELY IN UK (VICTOR 2005)
-20-75% IN THE NETHERLANDS (VAN TILBURG)
-45% INCREASE RISK OF DEATH

15. Loneliness or Isolation?

16. Intersection of Loneliness and
Isolation
Figure from Dr. Ashwin Kotwal
Cornwell EY, Waite LJ. 2009;64(suppl_1):i38-i46

17. Does what we are measuring matter?
•Are the risks of social isolation and loneliness
different?
•Should we measure separately or together?
•Can there be a composite measure that looks
at structural, functional and qualitative
factors?
•Practically, for implementation, which
measures will be easier to use and which are
validated in clinical settings?

18. Why else does it matter?
Interventions for different aspects of loneliness and
isolation may be different
For the health care provider and from a public health
perspective, we need a concept that can be understood
and that provider can feel comfortable asking about
◦ Comparable examples:
◦ GAD-7 (Anxiety)
◦ PHQ-9 (Depression)
◦ AUDIT-C (Alcohol use)

19. Capturing the Risks of
Loneliness and Isolation
Risks of isolation on health comparable to
smoking
Will this matter to Physicians and other
professionals? Do they believe the data?

20. Moving past loneliness myths
in order to create action
It is a normal part of aging
It is synonymous with depression
It cannot occur if you live with others
and have friends
This is not something doctors need to
focus on
We can’t do anything about it
Other health risks are more important

21. Screening and
Integration into
Health Systems

22. The Health System Perspective
If you are a health care provider, or a health system
administrator, or a public health advocate……
Who do you worry about?
How can you determine if there is social isolation and
loneliness?
How does this affect the person, and your bottom line
or distribution of your staff and other resources?
Are there guidelines for health care professionals?

23. Loneliness is a Warning Sign
“People must belong to a tribe. They yearn to have a
purpose larger than themselves” ~EO Wilson
Isolation [and loneliness] deprive us of both our
feeling of tribal connection and our sense of purpose.
On both counts, the results can be devastating for
individuals and societies. (Cacioppo 2008)

24. What We Know and Don’t Know
•There are many ways to measure social isolation and
loneliness
•Different measures are used in different parts of the
world
•Loneliness and isolation are not routinely or
systematically asked about in health care encounters
•There are no accepted US national guidelines on
assessments in health care settings that have been
systematically adopted

25. The Institute of Medicine
•Recommends the inclusion of the Berkman-Syme Index in electronic
medical records
The Berkman-Syme Social Network Index (SNI) is a self-reported questionnaire for use
in adults aged 18–64 years old that is a composite measure of four types of social
connections:
-marital status (married vs. not)
-sociability (number and frequency of contacts with children, close relatives, and
close friends)
-church group membership (yes vs. no)
-membership in other community organizations (yes vs. no)
**SNI allows researchers to categorize into four levels of social connection: socially
isolated, moderately isolated; moderately integrated; and socially integrated.

26. Health Outcomes
•Outcomes:
◦Death –45% increased risk
◦Decline in Function—59% increased
risk
•Increased risk of:
• Dementia, Diabetes, Cardiovascular
disease
• Longer hospitalizations
Perissinotto C. JAMA (Archives) Internal Medicine 2012

28. Population Level
Framework
Primary Prevention: Identify patients at risk for
loneliness and Isolation
◦ Women, lower SES, older, LGBT
Secondary Prevention: decrease the consequences
for those who are lonely and or isolated
◦ Requires screening
◦ Knowing which interventions work

29. The Public Health Perspective
The study of loneliness and social isolation
expands our focus to social-determinants of
health
◦ THE CHALLENGE:
◦Social and emotional influences don’t
show up easily on blood tests or xrays
Cacciopo 2008

30. Spectrum of Risk:

31. Loneliness Screening
Question Hardly
Ever
Some of
the Time
Often
1. I feel left out 1 2 3
2. I feel isolated 1 2 3
3. I lack
companionship
1 2 3
3-item Loneliness Scale:
Max score 9: higher score=more lonely
http://psychcentral.com/quizzes/loneliness.htm

32. Social Isolation Screening
•There are many tools but no gold standard
•Lubben Social Network Index
•Duke Social Isolation Scale
•Berkman-Syme Social Network Index

33. In practice….
1. Ask (Screen)
2. Document

34. In practice…
As a PCP I must:
-Ask about Pain
-Ask about gender and language around gender
-Ask about language preference
-Ask about learning style
-Ask about Intimate Partner Violence (IPV)
-Screen for depression
-Check for immunizations
-Manage chronic conditions (DM, HTN)
-See a certain number of patients per day regardless of complexity
…..and more
Sometimes I can ask about what really matters

35. In practice…
As a PCP I get “credit” for:
-keeping my patients out of the hospital
-checking Diabetes markers (regardless of age or life expectancy)
-checking for cancer regardless of age or life expectancy)
-Immunizing
-screening for and treating depression
…..I do not get credit for….
-asking about function, goals, or food or economic insecurity
- and certainly not for asking about Loneliness of social isolation

36. Management of Loneliness
Complex because of the complex ways people become lonely
General approach
◦ Improve social skills
◦ Enhance social support
◦ Increase opportunities for social interactions
◦ Address maladaptive social cognition
Masi et al. Pers Soc Psychol Rev. 2011

37. In reality: Social Prescriptions
1. FOCUS on
CONNECTION
2. AND talk about other
health risks
3. Advanced care planning

38. Implementing Social
Prescribing
Grouping loneliness and isolation with “social
determinants”
Understanding IF pts want help
Understanding what interventions work
Who are our partners
Primary Care: 1 SW: 6,000pts
Geriatrics 1 SW: 200 pts (600pts)
Community based partners

39. The challenge: As a Clinician
What Can I Recommend?
•RIGHT NOW:
•No controlled trials (do we need them?--pragmatism)
•Many small studies
Minimal long term follow-up
Where there are outcome data, how do we move to
implementation and scalability?
•MOVE AWAY from one size fits all

40. A word of caution
HOW DO WE CREATE VISIBILITY AND IMPORTANCE
WITHOUT OVER-MEDICALIZING THIS AS A DISEASE?

41. Financial Implications

42. Current Topics in Health Care
The triple aim
◦Lower Cost
◦Population Health
◦Higher Quality
This is an opportunity to focus on what really matters to people
in health and focus on the “social determinants of health”

43. Achieving the Triple Aim
Alternative Payment Models
This is an opportunity to focus on what really
matters to people in health and focus on the
“social determinants of health”

44. Social isolation
increases Medicare
costs by at least
$6.7 billion every
year.
Financial Implications
AARP Public Policy Institute 2018

45. Costs to Medicare
AARP Public Policy Institute 2018

46. Pilot Interventions

47. • Examine the feasibility of using
the a device engineered for
older adults (hardware,
software, service) in
telemedicine.
• Effects on loneliness
• Effects on health care
utilization
GrandPad Pilot

48. GrandPad proprietary and confidential
● Frequent Hospitalizations and ER visits
● Lonely and Isolated
● Avoided a hospital visit
● 3 companions in her GrandPad trusted
circle
● Loves calling GrandPad member
experience team to chat
● Twice a week video visits with
PCP
Pilot Study: Mary

49. GrandPad proprietary and confidential
Pilot Study: Margaret
Average GrandPad Use: 3 hours per day

50. GrandPad proprietary and confidential
Pilot Study: Margaret
All time usage
Calls: 82 hours
Email: 16 hours

51. Telemedicine and HealthCare
Utilization and Satisfaction
Key Point: Face to Face
◦ 2 touch solution
◦ Respond when the patient
needs it not when it is
convenient for the provider

52. Summary

53. Hope and the Future
DISRUPT AGING
•2014 Institute of Medicine recommended screening and follow-up for
loneliness and isolation and made recommendation to include in EHR
•AARP committed to addressing loneliness and isolation
•National Academies of Sciences convening to make evidence based
recommendations on prevention, risks and interventions
Health Plans and Organizations delving into loneliness and isolation
◦ Caremore
◦ United Health Plan
◦ Wider Circle
Why?
◦ Getting older can be costly
◦ Focusing on connections increase member satisfaction
◦ Opportunities for return on investment
◦ Isolation and loneliness matter

54. 3 Cases—Revisited
102 yo with failure to thrive:
◦ Not Lonely but is isolated
• What could the health care system have done?
82 yo with 24-hr care:
◦ Lonely, but not isolated
◦ Did her loneliness lead to more functional decline and
premature death?
My mom:
• Time

55. In Summary:
-We can make a personal and financial
impact by integrating assessments into
medical care
-We will develop a consensus on how to
measure and how to document in EHRs
cross-nationally
-We will have international, federal, state and
local policies that place loneliness and
isolation at the forefront of public heath
-We will evaluate interventions so that health
care providers and give evidence-based
guidelines on prevention and treatment
There are ways to help adults
feel more connected