As of this week, the COVID-19 coronavirus pandemic has afflicted close to half a million people worldwide, putting an unprecedented strain on health systems and healthcare workers as they tend to the sick and also get sick.
But countless others – perhaps millions – are affected by the virus in a different way: Locked into isolation, they're lonely. And that's a problem in and of itself.
As a social determinant of health, loneliness and social isolation can exacerbate other health issues. More people than ever are dealing with this very predicament. Social distancing, forced quarantines, the widespread shutdown of businesses and strict travel restrictions are producing a concurrent epidemic of loneliness, which can increase the risk for other adverse health outcomes and put further strain on an already overburdened health system.
Dr. Gary Call, chief medical officer for HMS, said that about one in three adults over the age of 45 in the U.S. report being lonely at some point – numbers that reflect a pre-coronavirus world. Those that report loneliness have a 64% increased risk of injuries or dementia, and are 39% more likely to develop coronary artery disease.
"That obviously is pretty startling," Call said. "It could lead to depression-type issues, which as a comorbidity makes things worse. Patients tend not to stick to medications, tend not to access healthcare systems as much. You also see an increase in hospitalizations, and they often end up in nursing homes."
The potential financial impact to the healthcare system is significant, and it creates a further headache for healthcare workers and caregivers whose jobs have grown infinitely more complex and stressful due to the global pandemic.
"You've got people who may or may not be coming in with coronavirus issues who may be lonely," Call said. "People come into the ER with minor things because they're looking for social interaction, as strange as that may seem. More than that, these folks are really at a risk of increased depression, suicide, things like that. We worry about this group. We want to make sure we use healthcare personnel in a way that makes the most sense."
THE IMPORTANCE OF SCREENING
What makes loneliness and social isolation a tricky thing to pin down is that it cuts across all demographic groups -- young or old, healthy or sick, wealthy or poor, loneliness can afflict anyone.
Dr. Jacob Reider, CEO of the Alliance for Better Health, said those factors make tackling the problem of loneliness an especially challenging proposition.
"Even before all of this happened, social isolation has been recognized as something that cuts across boundaries of how we traditionally stratify members of our communities," said Reider. "We think of serving the underserved, and we think of the middle class. The key is, isolation and loneliness are tightly correlated with morbidity and mortality. People are sicker and they die sooner if they're isolated in ways where they identify as lonely."
Another challenging aspect of this particular social determinant is the stigma associated with it. Stigmas around other issues are slowly evaporating; food insecurity has less of a stigma attached to it than it once had, and progress has been made on the depression front as well, with more people prone to report depression today as compared to 10 or 15 years ago.
Social isolation, said Reider, "is actually hiding." That makes it a challenge to identify the people who are most at risk.
It's evident already that the coronavirus situation is making this problem worse. But the extent to which it will make it worse has yet to be determined in any meaningful way, and so it's tough to pin down the appropriate interventions.
"We've started to think about what the interventions could be … but we're all sort of reeling still from the sudden onset of these challenges. We know it will be bad and in fact worsen. And this will be especially hard for introverts."
A good first step – and a simple one, at least theoretically – is to start screening for social isolation.
"We need to ask questions in a nonjudgmental way, and then make a referral in the community so the community can help address some of these challenges," said Reider. "If (providers) had access to a screening protocol that would be fantastic. But we also need an intervention, and so far we don't have compelling interventions in this domain.
"Until we have a food pantry network, I can't appropriately screen for food insecurity," he said. "If I don't have a way to address housing shortages or homelessness, I can't effectively address those challenges. We need to build the infrastructure to address these needs."
THE ROLE OF TECHNOLOGY
Increasingly, people are relying on technology to help connect them to others. If health systems, hospitals and providers want to effectively address the problem of loneliness, they'll have to start using technology as well – in their case, using it as a force multiplier to support overburdened staff. That, said Call, can help take some of the load off the system.
He suggests using a multi-modal approach: first pinpointing the relevant populations, and then figuring out the best way to reach those people, whether through automated phone calls, texts or emails.
Artificial intelligence technology makes it possible to conduct outreaches in an automated way, and Call said this has proven popular so far with the elderly population in particular. Even though they're not speaking with a real person, they still come away from the experience feeling like they've had a meaningful interaction.
These automated, tech-enabled screenings can also be extended to those dealing with transportation issues, medication-adherence challenges or food insecurity.
"You could do some screening with an interactive voice call system, but if someone answers a question in kind of a red-flag way, they can be transferred to a live person at the healthcare facility or health plan," said Call. "Or if they need some food assistance, it triggers conversations about some of the food they can access. Doing those on a regular basis really generates a sense of well-being. Somebody's calling; somebody cares."
If AI and automation is the steering wheel, then predictive analytics are the engine. It's a necessary component of effective messaging since messages have to be tailored for different parts of the population. When assessing what factors might make a person identify as someone with loneliness or social isolation, it's helpful to cross-check that with SDOH data to create targeted messaging in a way that engages people. Experts in social science and behavioral health are needed to help care teams understand these kinds of things.
"It's important to have behavioral health experts," Call said. "Having that aspect to your messaging is critical to having an effective outreach. You're trying to engage with people and try to change some behaviors."
It's also important to have a feedback loop. If a provider is trying to reach out to someone through an interactive voice-response call, but they don't respond to it, and respond to text messages instead, that has to be factored into outreach efforts. Likewise, if they only answer the phone after 6 p.m., then calling them multiple times during the day doesn't make sense.
Feedback loops also allow healthcare workers to track the outcomes of their interventions, and determine which approaches resonated with certain populations. Building that into an outreach strategy can yield dramatically improved results.
And results are important now more than ever. There are wildly conflicting answers as to how long the coronavirus crisis will last, and so the healthcare industry needs to shepherd all of its available resources to ensure that social isolation doesn't become a long-term headache, either for the industry or for the patients it serves.
It's important for individuals to find ways to connect as well, and prevent social isolation from happening in the first place.
"My grandparents sent each other letters, and that was a personal way to connect with each other," said Reider. "There's personal letters, there's email. I interact with my mom using Amazon Alexa with a video camera, and it's very easy to use. We should think of what are the plug-and-play opportunities of connecting humans, so they can engage with each other when they can't do so physically."