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Carla Perissinotto The role of health professionals in Loneliness Assessments

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Carla Perissinotto The role of health professionals in Loneliness Assessments

  1. 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. 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. 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. 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. 5. 2 Work Stories 1 Personal Story
  6. 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. 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. 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. 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. 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. 11. How do we estimate health risks for older adults?
  12. 12. FALLS • EVERY 19 MINUTES AN ADULT AGE >65 DIES OF A FALL • ONE IN FOUR ADULTS FALL EACH YEAR
  13. 13. HYPERTENSION -63% IN PEOPLE AGE >60 -DEATH RATES: 14.3 PER 1000
  14. 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. 15. Loneliness or Isolation?
  16. 16. Intersection of Loneliness and Isolation Figure from Dr. Ashwin Kotwal Cornwell EY, Waite LJ. 2009;64(suppl_1):i38-i46
  17. 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. 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. 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. 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. 21. Screening and Integration into Health Systems
  22. 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. 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. 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. 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. 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
  27. 27. 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
  28. 28. 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
  29. 29. Spectrum of Risk:
  30. 30. 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
  31. 31. Social Isolation Screening •There are many tools but no gold standard •Lubben Social Network Index •Duke Social Isolation Scale •Berkman-Syme Social Network Index
  32. 32. In practice…. 1. Ask (Screen) 2. Document
  33. 33. 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
  34. 34. 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
  35. 35. 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
  36. 36. In reality: Social Prescriptions 1. FOCUS on CONNECTION 2. AND talk about other health risks 3. Advanced care planning
  37. 37. 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
  38. 38. 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
  39. 39. A word of caution HOW DO WE CREATE VISIBILITY AND IMPORTANCE WITHOUT OVER-MEDICALIZING THIS AS A DISEASE?
  40. 40. Financial Implications
  41. 41. 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”
  42. 42. 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”
  43. 43. Social isolation increases Medicare costs by at least $6.7 billion every year. Financial Implications AARP Public Policy Institute 2018
  44. 44. Costs to Medicare AARP Public Policy Institute 2018
  45. 45. Pilot Interventions
  46. 46. • 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
  47. 47. 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
  48. 48. GrandPad proprietary and confidential Pilot Study: Margaret Average GrandPad Use: 3 hours per day
  49. 49. GrandPad proprietary and confidential Pilot Study: Margaret All time usage Calls: 82 hours Email: 16 hours
  50. 50. 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
  51. 51. Summary
  52. 52. 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
  53. 53. 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
  54. 54. 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

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