Social isolation (having few or infrequent social contacts) and loneliness (not feeling fulfilled by one’s available social contacts) are prominent public health issues with serious morbidity and mortality consequences. Long-term care nursing home (LTC-NH) residents ages 50 and older report some of the highest levels of social isolation and loneliness (SIL), despite living in communal settings.
Insufficient data continues to be a significant barrier to developing best practice approaches to minimize SIL and its related outcomes in these residents, and evidence-informed innovations to reduce SIL are critically needed. This article describes the development and implementation of the Community Providers and Local Students (PALS) program, which is a novel, evidence-informed innovation model to mitigate SIL in adults ages 65 and older living in underserved LTC-NHs.
Participant and LTC-NH Site Recruitment
The PALS program was a 1-year Centers for Medicare & Medicaid (CMS)–funded, quality-improvement innovation project. It was implemented in a large metropolitan city and targeted 18 English-speaking adults ages 65 and older living in LTC-NHs who CMS had designated as underserved. Residents with known cognitive impairments, psychosis, or behavioral disorders that included physically or verbally aggressive behaviors were excluded.
‘One-on-one, in-person visits were scheduled for 1 hour every other week for 3 months.’
The PALS program partnered with a local LTC Ombudsman’s program to identify three LTC-NH sites interested in participating. PALS program specialists visited the LTC-NH sites to present the program, address program-related questions, and gain administration buy-in for full program implementation. Agreeable sites designated staff member(s) to identify eligible residents that could benefit. Together, designated site staff and the PALS program specialist conducted in-person recruitment visits to each potential participant to ensure full disclosure about the program and to obtain resident assent to participate.
In alignment with CMS’s goal to develop a geriatric-trained workforce, health professional students from three local universities, including one Historically Black University, were recruited to deliver the PALS program. This initiative builds on evidence highlighting the benefits of intergenerational social connection programs. The PALS program specialist coordinated in-person, online, and word-of-mouth recruitment approaches with designated site champions at each university.
Student Training
Each participating student completed 4, 30-minute asynchronous pre-intervention trainings on SIL and health, geriatric health topics, health equity, and empathy-based communication. One month prior to the last visit, students joined a synchronous training, led by two PALS program specialists, on social prescribing and how to say goodbye ethically and emotionally.
Each student provided the resident with a social prescription at the end of the program to encourage feasible, low-cost social engagement ideas for LTC-NH residents to help meet their social needs. At the end of the programs, students were allowed to continue visiting the resident if both agreed to continue the connection.
Social Visits
The PALS program followed the educate, assess, and respond (EAR) framework. Students were taught to educate the older adult on the importance of being socially connected/disconnected, conduct brief SIL assessments and respond to resident SIL needs using social prescribing techniques. Two cohorts of health professional students delivered the 3-month intervention.
One-on-one, in-person visits were scheduled for 1 hour every other week for 3 months. Students and residents agreed on dates and times for the visits. In the first visit the students conducted a brief sociodemographic and health survey, including SIL assessments. The remaining visits focused on implementing evidence-informed strategies for building meaningful social connection consisting of storytelling supplemented with optional discussion prompts and the “Hey You” tool kit—a set of strategies developed by the Foundation for Social Connection, designed to strengthen rapport by facilitating intimate and vulnerable conversations and opportunities for bi-directional mentoring.
Targeted Outcomes and Measurements
Student and resident pre- and post-intervention assessments were conducted. Students completed the 14-item UCLA Geriatrics Attitude Scale. Students administered the 3-item UCLA loneliness scale and the 6-item Lubben Social Network Scale at the first and sixth visit. Students also completed journal entries after each visit to convey the topics discussed and any visit challenges, barriers, and/or successes. These journals entries, along with post-program student and resident satisfaction questions, were used to modify the program between cohorts 1 and 2.
Descriptive Program Outcomes
Participants were, on average, 70 years old and the majority were male (66%) and African American (78%). The majority (89%) had no spouse, lived with a roommate (88%), and had living children (55%). Students were, on average, 24 years old and the majority were female (55%) and Asian (44%). Student health professions were nursing (55%), medicine (33%), and pharmacy (11%). On average students reported more positive attitudes toward geriatrics following the intervention. Overall, resident feelings of loneliness were steady, but they reported decreased social isolation in both cohorts. All of the students and residents reported satisfaction with the PALS program.
Discussion
The PALS program offers a structured approach to delivering SIL interventions for underserved LTC-NH residents. A key objective of PALS was to implement evidence-based strategies to reduce SIL without being overly directive, fostering natural and meaningful relationships rather than a clinical dynamic. Given its in-person, intergenerational model involving health professional students, student burden was an important consideration. Satisfaction scores indicate a low burden for students and residents, suggesting that increasing the number of visits could enhance program intensity and potentially yield greater improvements in SIL scores.
Even in screening responses that didn’t show improvement, I sensed a more positive and optimistic outlook.
Although overall loneliness did not decrease—and even increased for a few participants—students believed this was due to residents becoming more comfortable and open about their feelings by the sixth visit. One student said, “While conducting the assessment, she admitted to feeling lonelier and more isolated than she had initially. It seems that it’s not because she worsened, but rather, she felt more comfortable acknowledging these feelings to me.”
Another student noted, “Even in screening responses that didn’t show improvement, I sensed a more positive and optimistic outlook.” These findings are encouraging and warrant further study.
Overall, the PALS program provides valuable insights into the development and implementation of SIL interventions for underserved older LTC-NH residents. More rigorous studies of PALS and similar programs are needed to evaluate their impact on SIL, health, and overall well-being for lonely and isolated older adults.
Funding
This special innovation project was funded by the Centers for Medicare & Medicaid Services, an agency of the U.S. Department of Health and Human Services. Views expressed in this material do not necessarily reflect the official views or policy of CMS or HHS, and any reference to a specific product or entity herein does not constitute endorsement of that product or entity by CMS or HHS.
Contributions
RAZR solutions and Cyber Security Solutions supported the administration and coordination of the project. The Foundation for Social Connection assisted with the scientific direction and implementation of the PALS project. UTHealth Houston assisted with scientific direction and project implementation.
Acknowledgements
We would like to extend special acknowledgements to the residents who courageously participated in this project and spent time with the PALS students and staff. We also would like to thank the ambitious and kind-hearted students who see the topic of social connection as a worthy pursuit in the context of healthcare. And we’d like to thank the LTC nursing homes for supporting their residents and opening their doors to us to complete this project. Lastly, we would like to thank the UTHealth Houston LTC Ombudsman’s Program for supporting us in locating and accessing local LTC Nursing Homes.
Jason Burnett, PhD, is an associate professor in the Joan and Stanford Alexander Division of Geriatric and Palliative Medicine at McGovern Medical School, UTHealth Houston. Edward Garcia III, MPH, is founder and secretary of the Foundation for Social Connection in Washington, DC. Carla Perissinotto, MD, MHS, is professor of medicine in the UCSF School of Medicine.
Photo credit: Shutterstock/Freeograph
