Solutions to loneliness elusive for hospitals

Do you have someone who loves you and cares for you? Do you have a source of joy in your life? Do you have a sense of peace today?

Since mid-2018, staff at AdventHealth have asked patients in outpatient settings those three questions in an attempt to identify health needs beyond the physical realm.

In response, patients often say that they don’t have anyone who cares for them, or they feel isolated from their community.

In other words, they’re lonely.

“A top trend (among our patients) is loneliness,” said Angela Augusto, director of mission integration at the Altamonte Springs, Fla.-based health system. “And we are not seeing it in any particular age demographic. It’s as prevalent with our young patients as our older generation of patients.”

The responses from AdventHealth patients are on par with trends nationally. Studies and surveys estimate between one-third to nearly half of the U.S. population is lonely.

And there is a strong body of research that feeling lonely impacts health and treatment outcomes. A commonly cited finding is that those who are socially isolated have a 50% higher chance of death compared with those who aren’t, likening it to smoking 15 cigarettes a day.

Given the clear connection between loneliness and health, some providers and insurers are trying to address loneliness among their patients and members, although it’s unclear what they can do. While the evidence on the impact of loneliness is strong, research on effective solutions is still scarce, so healthcare organizations are largely testing possible solutions without much understanding of what really helps.

“We’re trying some things, but we don’t know for sure what works. I hope that over time we will come to a better understanding of that by talking to our patients, by understanding their lives better, their issues better and what gives them hope and optimism,” said Dr. Ted Hamilton, chief mission integration officer at AdventHealth.

There is interest in the research community to study the effectiveness of efforts to address loneliness. The AARP Foundation, which has been investing in research into loneliness since 2010, has funded a forthcoming study from the National Academies of Sciences, Engineering, and Medicine that will explore the topic, which should help with the knowledge gap, said Lisa Marsh Ryerson, the foundation’s president.

Until more research findings are available, systems and payers are relying heavily on community partners to fill patients’ social gaps. For instance, caregivers at AdventHealth trained in chaplaincy are connecting patients with local faith-based organizations, grief support groups and volunteer opportunities if they admit to feeling lonely.

AdventHealth staff, after asking the three questions during the intake screening process at their outpatient clinics, note in the patient’s medical record if the indicated responses warrant follow-up. The questions can also be asked on an intake form. If they do need follow-up, that triggers a referral to the trained chaplain, who will call the patient. The physician is also alerted to the patient’s responses for consideration during the visit.

AdventHealth is investing $5 million annually in the program, which it calls Clinical Mission Integration. There are “no hard dollar returns” on investment for the health system to offer this service, said Terry Shaw, CEO of the system.

“The ROI for us is a much healthier and a much better prepared workforce to deal with” patients, he said.

Hamilton said he’s been surprised by how many physicians want to talk to patients about their responses. “Doctors were far more willing to engage in this kind of assessment of patients than we ever anticipated,” he said.

He said they feel empowered to talk about personal issues with patients because they know chaplains will be following up to help the patients further. Physicians also comment that they feel a closer relationship with their patients after discussing their responses with them.

If loneliness comes up during the phone conversations with chaplains, they are trained to understand what might be causing the feelings and what resources are available in the community that might help them.

Augusto said AdventHealth is only in the beginning stages of what she hopes the system can offer for lonely patients. As the system continues to learn more about the patients, she said there are ways to expand the offerings. For instance, she said there might be an opportunity to connect patients who express loneliness with each other, comparing it to pen pals.

“We are finding ways to be innovative and creative moving forward beyond the small scope of what we have started today,” she said.

For some health systems, addressing loneliness is a consequence of other work they are doing for patients. At Parkland Health & Hospital System in Dallas, efforts to decrease the number of high users of its emergency department led to the understanding that many use the ED because they lack social support systems. Patients would come to the ED simply to speak to others, get a meal or stay warm.

“One of the things we have found with our high utilizers is they don’t have this standard definition of family you and I would think of,” said Nicole Bernard, a complex case social worker at Parkland. “They don’t have caregivers, someone to bring them to their appointments, remind them to take their medications.”

Research funded by the AARP Foundation shows income is an indicator for loneliness. About 50% of midlife and older adults who earn less than $25,000 per year are likely lonely, according to a 2018 survey from the organization. “Those who are most underserved need to be served now in this area,” Ryerson said.

Parkland has partnered with not-for-profit and government institutions to help these patients. Housing and case management agencies, adult protective services, homeless shelters and rehab facilities are among Parkland’s partners.

One example of a patient who has been helped by Parkland’s efforts was a woman who came to the ED almost daily. After spending some time with her, Bernard learned she wasn’t connected with her family and would use the ED to socialize. Parkland set the patient up with a case management agency that helped her get Social Security benefits, a driver’s license and reconnect with her daughter. She since moved out of the area to be closer to her child.

The case management agency was “her family in the time when she wasn’t connected with her family,” Bernard said. “Our biggest goal is to find someone who takes the place of the patient’s family.”

It’s time-consuming to work with these patients to understand the resources they need. Bernard said she meets patients where they are in the community and tries to build a rapport with them.

“Most of my intervention is getting them to a point where they trust me and they are ready to access the help we are offering,” she said.

Commercial insurers also are interested in combating loneliness. UnitedHealthcare, Cigna and Humana have all invested in resources dedicated to understanding and addressing the issue.

Humana started its work in this area in 2015 when it launched the Bold Gold program, which is an effort to increase the number of self-reported healthy days of its Medicare Advantage members. To achieve that, Humana is focusing mostly on addressing loneliness and food insecurity.

During interactions with Humana members, employees have been trained to screen patients for loneliness. In 2019, 1 million members were screened and roughly 30% were lonely, said Dr. Andrew Renda, associate vice president of population health strategy at Humana.

Like AdventHealth and Parkland, Humana has been working with outside organizations to address loneliness. The insurer recently partnered with Papa, a company that connects college students with older adults to help with household chores, transportation and companionship.

The results from the pilot in the Tampa, Fla., region showed members looked forward to the visits and had improved outlooks on their mental and physical health, said Caraline Coats, vice president of population health strategy at Humana.

Still, there are skeptics regarding the effectiveness of such tactics. Solutions that rely on people to help lonely individuals with errands or companionship are a “red flag,” argues Elena Portacolone, assistant professor at the Institute for Health & Aging at the University of California at San Francisco who has studied loneliness and isolation.

Volunteers can get busy and stop showing up. It’s also not “dignified,” she said. The person in need of help is relying on someone else to feel better.

Better solutions are ones based on the person’s genuine interests such as playing bingo or getting involved in a church choir, Portacolone said. “There’s no cookie-cutter solution (to loneliness) because we are all different.”

Renda disagreed that solutions relying on individuals to help are undignified. He said the individuals at Papa aren’t volunteers but paid. “It’s incredibly dignified in the sense that we are offering support they can’t get elsewhere,” he said in an email.

He added that Humana recognizes solutions to loneliness are unique to the individual, so it’s exploring various tactics such as helping individuals with transportation barriers that keep them isolated.

A challenge for Humana is expanding solutions that show positive results. “We have to find solutions that are effective at addressing the root cause that are sustainable, that have clinical return on investment and are scalable,” Renda said.

Another problem is that investment in loneliness solutions hasn’t been strong, he said. “We need to build infrastructure and communities to address these kinds of things.”

Coats added that tackling loneliness “is a tough nut to crack,” and Humana will continue to adapt its efforts in this area as it learns more.