Making That Critical Connection

Abstract: 

An examination of programmatic approaches to reducing social isolation and loneliness among older adults. This article reviews a variety of programs in the United States and other countries, and looks at how they work in concert to alleviate loneliness, foster connectedness, and improve health among socially isolated older adults.

Key Words:

older adults, social isolation, loneliness, senior isolation, programmatic approaches

Humans have a well-documented need to connect with other humans. With age, such connections become more difficult to maintain. People retire and lose touch with co-workers. Children begin lives of their own, often in distant cities. Spouses and close friends pass away. For these reasons and others, 12 million Americans older than age 65 now live alone (Stepler, 2016).

Living alone in a state of social isolation, which “relates to the quantifiable numbers of relationships a person may have,” is not the same as loneliness, which is “the subjective feeling of being isolated—or the discrepancy between actual and desired relationships” (Perissinotto, 2020). Nevertheless, the former is often a predictor of the latter, especially among older adults.

The scope and harmful effects of loneliness on older adults have lately become widely known. But long before the problem made headlines, many programs were created to respond to the changes in social interaction that often lead older adults to feel lonely. Such programs seek to foster quality connections between elders and other people, and to create opportunities for them to have meaningful social interactions.

The article that follows is not exhaustive. Rather, it has been curated to demonstrate the depth and breadth of programmatic approaches to increase social connection among older adults across the country—and around the world. Most of the programs described are either national or offer their resources as models for other programs in other communities. Moreover, it is imperative to understand that these programs, by design, do not operate independently of one another. Instead, each is a piece of a much larger ecosystem of initiatives designed to alleviate loneliness, foster connectedness, and improve health.

Meals on Wheels

Since its inception in the 1950s in the United States, Meals on Wheels has been delivering more than meals (disclosure: author L. Carter Florence works for Meals on Wheels America). Meals on Wheels programs have been shown to provide services that adequately address nutrition and safety, and that connect clients to other community-based services (Thomas, Akobundu, and Dosa, 2015). The same study found the programs address loneliness and social isolation.

Recent work by Julianne Holt-Lunstad explains how social connection is a multi-factored construct including structural (connections to others), functional (perceived or actual social support), and quality components (positive/negative qualities of those connections) (2018). Meals on Wheels addresses each of these facets of social connection, through meal delivery and through expanded programming designed to combat social isolation and loneliness. In a randomized-control trial study, older adults receiving daily delivered meals reported improved feelings of connectedness as well as reductions in self-reported falls and worries about being able to remain independently in their homes. Overall, participants reported improvements in mental health (Thomas, Akobundu, and Dosa, 2015).

Meals on Wheels clients are often at greater risk for social isolation than are other older adults. Data from before the COVID-19 pandemic showed that 59 percent of home-delivered meal recipients live alone (Mabli et al., 2017). Living alone is one of the structural components of social connection that increases the risk of an individual feeling lonely (Holt-Lunstad, 2018). For many Meals on Wheels participants, the person delivering the meal may be the only person they see and interact with all day. Furthermore, a key component of the Meals on Wheels service model is intentional face-to-face conversation initiated during delivery (with clients who are willing).

Also, the More Than a Meal Comprehensive Network Study (2019), which was recently conducted by Trailblazer Research and Meals on Wheels America, found that more than half of Meals on Wheels America member organizations provide telephone reassurance and pet assistance to support social connection. The study also found that nearly a third of Meals on Wheels programs in the sample offer senior companion or friendly visiting programs.

Telephone Reassurance

Telephone reassurance services, which go by different names depending upon locality, generally are designed for a volunteer or staff member to make a regular phone call to an isolated, homebound older adult to socialize with them and check on their well-being. Typically, a volunteer caller and older adults are matched by interest, availability, or other key indicators.

In 2018, prior to the coronavirus outbreak, more than 170,000 older adults received telephone reassurances through local Meals on Wheels programs nationwide (Meals on Wheels America, 2020). This number has grown significantly larger during the coronavirus pandemic. Since March 2020, many Meals on Wheels programs have been relying on this type of check-in to augment the friendly interaction typically found during meal delivery. This is in part because many programs have reduced delivery frequency to protect older clients. These friendly social calls are a great way to engage volunteers who may be sheltering in place, but still want to check in on their friends and Meals on Wheels clients. 

Friendly Visiting

Friendly visiting programs are designed to offer human connection by providing companionship and emotional support to older adults who are socially isolated or lonely. In these programs, volunteers make in-person social visits to older adults—usually for one hour once a week. Volunteers and older adults are typically pre-matched based on interests and/or needs. Over the years, Meals on Wheels America has offered grantmaking opportunities for local programs to establish or expand in-person friendly visiting programs. In 2018, approximately 28,000 older adults benefited from these types of programs (Meals on Wheels America, 2020).

In Orange County, California, the Council on Aging of Southern California (COASC) involves community social workers in its friendly visitor program. When older adults join, social workers conduct a measurement of their psychological and mental health and look for signs of depression and suicidal ideation. Using this baseline intake measurement, COASC says that 98 percent of older adults in the program show marked improvement after twelve months. Also, food insecurity and health issues typically surface during visits; having a social worker tied to the program allows for speedy interventions. COASC has about 140 volunteers interacting with about 325 older adult participants. During COVID-19, the program has gone entirely telephonic.

Pet Assistance

Older adults with pets are 36 percent less likely to report loneliness than those without pets (Stanley et al., 2014). However, for some older adults, caring for a pet can be challenging. To encourage animal companionship, Meals on Wheels America since 2007 has supported pet programming through its Meals on Wheels Loves Pets initiative. Today, more than half of Meals on Wheels programs nationwide offer some form of pet assistance programming. These programs often leverage partnerships with shelters, veterinarians, pet food stores, and/or boarding services to provide holistic animal care.

Congregate Dining

Most Meals on Wheels programs offer home-delivered and congregate meals. Congregate meals provide an opportunity for older adults to gather and engage in social activities while sharing a nutritious meal. In addition to providing a forum for engagement, eating together has been shown to result in improved nutritional intake for older adults (Lochner et al., 2005). Furthermore, a recent proof of concept study by Dr. Laura Barre of Cornell University showed that “VideoDining” among older adults showed promise for reducing loneliness and improving dietary intake (Barre, Coupal, and Young, 2019). VideoDining programs have the potential to be scaled to benefit homebound older adults nationwide—especially during COVID-19 quarantines.

Promising New Programs Under Evaluation

Several other types of technology-enabled and skilled-volunteer initiatives are being piloted by local Meals on Wheels programs. Some have shown favorable results and can be scaled to reach a wider array of people.

A recent randomized control trial conducted in rural and urban settings evaluated the use of both tele-behavioral activation and tele-friendly visiting for Meals on Wheels clients. Tele-behavioral activation is a brief intervention designed to increase wellness-promoting behaviors and is especially well suited for increasing social connection for older adults (Lejuez et al., 2011). In this case, a lay individual is trained to guide older adults through a process of identifying tangible goals that can be achieved to increase health and well-being. Tele-friendly visiting is traditional friendly visiting (see above) delivered virtually. In the trial, participants who received tele-behavioral activation had greater increases in social interaction than those who received tele-friendly visiting (Choi et al., 2020).

Additionally, a study underway with Meals on Wheels Rhode Island, Brown University, Covia Well Connected (see below), and Meals on Wheels America is evaluating the implementation, effects, and acceptability of connecting older adults to a virtual senior center (in this case, Covia’s Well Connected program). This protocol has the potential to reduce social isolation and loneliness in older adults, as well as be scalable to other parts of the country.

Other Approaches

While Meals on Wheels is often thought of as a standalone program, it is, in fact, part of a larger ecosystem of highly integrated services for older adults. Meals on Wheels staff often refer clients to other programs and vice versa. In order to demonstrate this integrated ecosystem of care, we have identified myriad community programs focused on creating human connections that operate within it. Taken together, they provide a snapshot of the programs dedicated to alleviating the deleterious consequences of social isolation and reflect the potential such programs have to transform the experience of aging in community.

Covia Well Connected

Covia Well Connected is a national program designed to mimic the senior center experience online or via the telephone. It started in 2004 as a local program in Northern California and is run by Covia (formerly known as Episcopal Center Communities), a nonprofit that offers housing and community-based services.

Well Connected offers activities, education, friendly conversation, and an assortment of classes and support groups that older adults can access from their homes. It is available to anyone older than age 60 free of charge. Most activities have around twelve participants and last thirty minutes to an hour. Among the hundreds of offerings are virtual field trips, a Q&A with an attorney, and a Netflix film club. Well Connected is part of a larger international Without Walls Network of programs providing older adults with opportunities to participate in activities and classes over the phone. We have chosen to spotlight Covia’s program because of its national reach.

Covia regularly polls Well Connected participants about their experiences. According to data from 2018, 76 percent of respondents said they feel stronger social connections as a result of their participation in the program.

The Daily Call Sheet

The Daily Call Sheet is a program offered by the Motion Picture & Television Fund (MPTF), a charitable organization that provides healthcare, services, and retirement living for people who have worked in the entertainment industry.  

Each Daily Call Sheet participant undergoes an intake process. Data show that when they join the program, 55 percent of participants score at the highest level of risk for perceived loneliness, according to the UCLA Loneliness Scale. Likewise, 52 percent are at the highest risk for actual social isolation, with no in-person support, which is determined according to the Duke UNC Functional Social Support questionnaire. The average age of participants is 79; 23 percent are full-time caregivers; and 91 percent of participants fall into the low-income category.

Preliminary findings show that, while participants’ actual social interaction scores at intake do not change significantly after they enter the program, their perceived social support scores rise dramatically. Scott Kaiser, a physician who serves as MPTF’s chief innovation officer, attributes some of the success of the program to the fact that volunteers and participants come from an “affinity group”—that is, they share the experience of having worked in the entertainment industry. It is common, Kaiser says, for people to discover they worked on the same studio lots at various times in their careers. TV shows, movies, and life on set are frequent topics of discussion.

The Daily Call Sheet is a relatively small program. About 100 volunteers regularly conduct calls with about 300 MPTF members. (Requests to participate have gone up markedly since COVID-19 social distancing restrictions were put in place.) Nevertheless, the program is well known. That is partly because MPTF is actively sharing its know-how and telephonic “Call Hub” technology with other groups so they can set up similar programs and train volunteers.

TimeSlips

TimeSlips was started by Anne Basting, a scholar, educator, and artist who has written extensively on representations of aging in theater. Her organization uses what she calls “creative engagement” to connect lonely older adults. Some of the programs she has designed are specifically tailored to older adults experiencing dementia. Through storytelling, improv, and gathering responses to open-ended questions, the TimeSlips method seeks to connect older people with dementia to the people around them, without having to worry about frustrating memory lapses.

In 2009, Basting worked with other researchers to determine the effectiveness of TimeSlips’ approach. Writing in The Gerontologist, the researchers concluded, “Compared with residents in the control facilities, those in the [TimeSlips] facilities were more engaged and more alert. In [TimeSlips] facilities, there were more frequent staff–resident interactions, social interactions, and social engagement” (Fritsch et al., 2009).

AARP Connect2Affect Connected Communities Smart Speaker Program

Research indicates that about one in four senior housing residents is socially isolated (Taylor et al., 2016). In 2017, AARP Foundation studied the use of hands-free, voice-activated devices to maintain social connectedness among low-income older adults living in independent housing or federally subsidized rental properties.

Under a pilot program, 200 residents in five affordable housing communities in Washington, D.C., and Baltimore were given Google Voice and Amazon Alexa speakers. “Voice opened up a world of opportunity,” said Ryan Elza, AARP Foundation’s social entrepreneur in residence, Social Connectedness. The residents used the smart speakers to call their sons and daughters and to exchange text messages with their grandchildren.

Notably, the speakers also increased attendance at social functions inside the communities. In the past, information about events was posted on flyers in elevators and other common spaces. But with the smart speakers, staff were able to “broadcast” announcements about activities directly to older adults’ living rooms and send out electronic friendly reminders.

Another form of socialization came from the process of learning to use the speakers. Older adults who mastered the technology taught their fellow residents to use them, in an atmosphere that was engaging, convivial, and fun, according to AARP.

To measure outcomes from the pilot, participants completed baseline and post surveys that included questions from the Duke Social Support Index (DSSI), the UCLA Loneliness Scale, and questions about participants’ experiences, Internet and device usage, self-efficacy using voice-activated technology, and Net Promoter Score. More than half of participants who completed both surveys scored higher or equal to their baseline at follow-up in social interaction, perceived availability of support, and decreased feelings of loneliness.

Since the pilot program, AARP Foundation has expanded the Connected Communities program. Some 780 smart speakers have been distributed to twenty-eight properties in seven states and in Washington, D.C., and, in response to the COVID-19 pandemic, an additional 2,300 devices will be distributed by the end of 2020.

International Interventions

Senior isolation is not merely a domestic problem; across the globe, older adults report increased feelings of loneliness. In a 2017 Commonwealth Fund study of 11 high-income countries, between 10 percent and 30 percent of adults ages 65 and older reported feeling isolated from others (Osborn et al., 2017). To counter this trend, a variety of organizations across the globe–in the government and in nonprofits–have tested new ways to reduce older adults’ sense of isolation.

In the United Kingdom, reducing loneliness among elders has become a government priority. After a 2017 report showed that more than 9 million people in Britain often or always feel lonely (British Red Cross and Co-Op, 2016), then-Prime Minister Theresa May appointed that country’s first Minister for Loneliness, who was tasked with developing programs to increase social connectedness.

The U.K.’s Silver Line, which pre-dates the prime minister’s efforts, is one of the world’s best-known programs. Launched in 2013, older adults who call into the line connect to volunteers available to provide friendly conversations, advice, and connections to community resources. The program also offers weekly telephone calls with “Silver Line Friends” and “Silver Circles,” facilitated group conversations among six to eight people with common interests. The Silver Line receives more than 10,000 calls per week. Fifty-three percent of callers say they “have literally no one else to speak to.” Since social distancing measures were enacted to prevent the spread of COVID-19, calls to the Silver Line have increased dramatically.

The Multigenerational Approach

One approach to alleviate loneliness among older adults is to integrate elders more fully into communities where people from different generations gather–or even live–together. This approach stands out because of its prevalence in localities outside the United States. In the U.K., Shared Lives is a home-sharing program that matches older people struggling with loneliness with young people and families who have extra space in their home or who need a place to live.

In Singapore, The Kampung Admiralty is a senior housing facility designed to integrate residents into the surrounding community. An on-site child-care center is located next to eldercare facilities. Both open onto a public park that hosts fitness classes and cultural events.

In Germany, 540 federally funded Mehrgenerationenhaus, or multi-generational houses, double as senior centers and child-care centers.

And in Denmark, where in a 2015 study, 2.6 percent of adults between the ages of 65 and 79 reported feeling lonely, a national movement called Denmark Dines Together has led people to invite strangers from different generations to eat in their homes (Laasgard and Friis, 2015).

Conclusion

Innovative programs designed to alleviate the harmful effects of loneliness and social isolation among older adults are being deployed across the country and around the world. These programs are leveraging history, creativity, shared interests, and research to provide options for older adults to connect in meaningful ways. However, social isolation and loneliness are complex, multifaceted concepts that may coexist with other health concerns like clinical depression, making them challenging to address effectively at scale. As we continue to understand these concepts more fully, programs to address them will need to improve upon screening, tailoring, and measuring effectiveness.

Moreover, while many programs are using or starting to use assessments such as the three-item UCLA Loneliness Scale, the Duke-UNC Functional Social Support Questionnaire, and others, we must strive to understand how these research tools are being used effectively in community settings. Likewise, the long-term impact of participating in these programs is currently being studied.Additionally, as with any community-based program, creating a sustainability model is critical. What funding supports are there for these kinds of programming? Some strides have been made in terms of policy support for social isolation. The most recent reauthorization of the Older Americans Act—the Supporting Older Americans Act of 2020 (H. R. 4334)—supports screening for social isolation and coordination of supportive services and healthcare, promotes research, and increases the Assistant Secretary for Aging’s focus on social isolation through long-term planning. These specific policy levers will help move the work to combat social isolation and loneliness forward—and, one hopes, quickly. The nation as a whole has become intimately familiar with isolation. Now is the time to connect. 

Lowell Goodman is a writer and journalist who writes about healthcare and life sciences for a variety of publications. He can be contacted at lowell@corbomitecomms.com. L. Carter Florence, DrPH, MPH, is Senior Director, Strategy & Impact at Meals on Wheels America in Arlington, Virginia. She can be contacted at carter.florence@mealsonwheelsamerica.org.

References

Barre, L. K., Coupal, S., and Young, T. “Videodining in Older Adults Aging in Place: A Feasibility and Acceptability Study.” Innovation in Aging 3(Suppl 1): S972.

British Red Cross and Co-Op. 2016. “Trapped in a Bubble: An Investigation into Triggers for Loneliness in the UK.”  Retrieved July 22, 2020.

Choi, N., et al. (In Press). “Improving Social Connectedness for Homebound Older Adults: Randomized Controlled Trial of Tele-Delivered Behavioral Activation Versus Tele-Delivered Friendly Visits.” American Journal of Geriatric Psychiatry.

Fritsch, T., et al. 2009. “Impact of TimeSlips, a Creative Expression Intervention Program, on Nursing Home Residents with Dementia and Their Caregivers.” The Gerontologist 49(1): 117–27.

Holt-Lunstad, J. 2018. “Why Social Relationships Are Important for Physical Health: A Systems Approach to Understanding and Modifying Risk and Protection.” Annual Review of Psychology. 69: 43758.

Laasgard, M., and Friis, K. 2015. “Ensomhed i Befolkningen—Forekomst og Metodiske Overvejelser.” Temaanalyse 3. Retrieved May 29, 2020.

Lejuez, C., et al. 2011. “Ten Year Revision of the Brief Behavioral Activation Treatment for Depression: Revised Treatment Manual.” Behavior Modification 35(2): 11161.

Lochner, J. L., et al. 2005. “The Effect of the Presence of Others on Caloric Intake in Homebound Older Adults.” Journal Gerontology: Series A. 60(11): 1475-8.

Mabli, J., et al. 2017. “Evaluation of the Effect on The Older Americans Act Title III-C Nutrition Services Program on Participants’ Food Security, Socialization and Diet Quality.” U.S. Department of Health and Human Services. Retrieved May 15, 2020.

Meals on Wheels America. 2020. “More Than a Meal Comprehensive Network Study.” Retrieved May 15, 2020.

Osborn, et al. 2017. “Older Americans Were Sicker and Faced More Financial Barriers to Health Care Than Counterparts in Other Countries.” New York: The Commonwealth Fund. Retrieved July 22, 2020.

Perissinotto, C. 2020. “Testimony Re: Combatting Social Isolation and Loneliness During the COVID-19.” Presented to the Senate Special Committee on Aging, Washington, D.C. Retrieved July 10, 2020.

Stanley, I. H., et al. 2014. “Pet Ownership may Attenuate Loneliness Among Older Adult Primary Care Patients Who Live Alone.” Aging & Mental Health 18(3): 394–9. doi.org/10.1080/13607863.2013.837147. 

Stepler, R. 2016. Smaller Share of Women Ages 65 and Older Are Living Alone: More Are Living with Spouse or Children. Washington, DC: Pew Research Center.

Taylor, H., et al. 2016. “Assessing Social Isolation: Pilot Testing Different Methods.” Journal of Gerontological Social Work 59(3): 228-33.

Thomas, K., Akobundu, U., and Dosa, D. 2015. “More Than A Meal? A Randomized Control Trial Comparing the Effects of Home-Delivered Meals Programs on Participants’ Feelings of Loneliness.” Journal of Gerontology Series B Psychological Sciences & Social Sciences. 71(6): 1049-58.