I think of them as some of the loneliest people in America.
They are older adults cut off from family, friends and even casual acquaintances. They seem to have lost basic social skills, are stymied making small talk and can have difficulty reading social cues and facial expressions.
When asked superficial details about their health and healthcare, they tend to grow defensive and push away whoever may be asking.
At SCAN Health Plan, we are embarking on a peer-to-peer intervention program to combat loneliness, which we believe can reach this isolated group of elders.
Based upon our experience with prior peer-to-peer initiatives, we know our members respond positively when they’re contacted by someone who can express empathy and relate on a personal level. What begins as chitchat about the weather, a favorite sports team or a hobby leads to significant, behavior-changing conversations about family relations, mental health and medical care.
Why is SCAN Health Plan focusing on loneliness? Because the condition has reached epidemic proportions. And because it’s a health problem.
Among older adults, more than 40 percent report feeling lonely, according to a 2020 National Academies of Sciences, Engineering, and Medicine (NASEM) report. About a quarter of adults ages 65 and older are considered to be socially isolated. (Loneliness is a subjective measure, whereas social isolation is the objective state of having few social relationships or infrequent social contact with others.)
Moreover, social isolation and loneliness have been linked to increased risk of dementia, heart disease, stroke, depression and suicide. Prolonged loneliness poses as great or greater a health risk than obesity, substance abuse and poor access to healthcare.
SCAN Health Plan’s first peer-to-peer intervention project, the Member2Member (M2M) program, began in 2016. It focused on four areas: bladder control, physical activity, falling (losing balance) and flu shots.
We had no trouble finding peer advocates from among our members. They all had relevant personal experiences that made them want to share what they had learned with others. In all, we chose 10 candidates and asked them to attend 12 two-hour classes for a month.
‘She never wanted to share with anyone that she puts on a happy face all the time.’
They learned about the health topics discussed, but they also learned motivational interviewing techniques to pose open-ended questions designed to spur older adults to talk about their healthcare and medical status.
There was also a practical side to the classes, as the trainees were taught about SCAN Health Plan’s telephone and case management systems and the healthcare resources and information we offer members.
Once they were up to speed, the peer advocates began reaching out to elders we had pre-selected as potentially benefiting from a peer intervention. A typical phone call lasted 10 to 15 minutes, but could sometimes run up to an hour. Anywhere from five to seven calls were made across the span of three months.
The conversations ranged from small talk to intense, emotional discussions about the respondent's health. In a survey we conducted after the M2M program ended, one peer advocate told us about a call where a woman talked about her depression and broke down sobbing.
“She never wanted to share with anyone that she puts on a happy face all the time,” the peer advocate said. “By the time she and I finished, she wanted help from a counselor and wanted therapy. I referred her to a case manager, and after three weeks, I called her, and she said the counseling had really helped, and she was so happy that she had someone bring that part of her out.”
In all, our callers reached out to nearly 30,000 members. We consistently saw positive results:
- Nearly 70 percent of members with urinary incontinence contacted by peer advocates subsequently talked to a provider about the condition.
- A third of outreached members talked with their doctors or other health providers about falling or problems with balance or walking, compared to 29 percent in a control group that didn't receive outreach.
- 77 percent of outreached members received a flu shot, compared to 73 percent in the control group.
Applying Lessons Learned
We expect combatting loneliness to be an even more difficult challenge, which is why we’re starting small. We plan to enroll four peer advocates (PAs) working with 560 older adults for six months.
Because our goal is to reestablish social skills, we thought it was critical, when possible, to conduct outreach via videoconference rather than phone. This will make interactions feel more personal and allow members to focus on facial cues, increasing their social cognition.
Over time, we hope outreached members will share details and concerns about their life, personal relationships and healthcare. If all goes well, the PA will suggest the member join one of the many affinity groups we have created for our members to meet and discuss shared interests. We will have one affinity group for those that need help managing pain, for example, and another for members who like sports.
The PA also will encourage the older adult to reconnect with a friend or relative. In my experience, older Americans resist reaching out to others because they fear being a burden. They assume, often incorrectly, that their loved ones are incredibly busy and will resent being contacted.
Peer advocates will work with 560 older adults for six months.
Older Americans also worry that if they ask for help, they will be seen as being unable to take care of themselves and will be forced into nursing care.
The PA will work through all these concerns and anxieties. They will also explore the underlying tensions in a member's relationship with family members or friends that made them fall out of contact in the first place.
Peer-to-peer outreach is by no means the only way to deal with loneliness and social isolation. Pet-assisted therapy, leisure skill development, psychological help and using technology have all shown success in helping those who are isolated or experiencing loneliness.
But SCAN's experience with M2M makes us think that peers bring a unique personal touch to care and treatment that can be highly effective in changing behavior and improving health outcomes.
I was pleased to see a study released last month in the Journal of the American Geriatrics Society showing the results of a two-year-long peer-outreach program to reduce loneliness in a senior center in San Francisco. Participants reported decreased loneliness scores (on average, 0.8 points over 24 months), reduced depression and greater ease at socializing. “Participants reported strong feelings of kinship, motivations to reach out in other areas of life, and improved mood,” the authors of the study wrote.
We are just beginning what will have to be an all-out national effort to confront social isolation. We must be willing to innovate and try new approaches and, just as importantly, build on what works.
Lisbeth Roberts, MS, is the chief togetherness officer at the SCAN Health Plan in Santa Ana, Calif.