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How Chronic Care Management Programs Help Patients Suffering from Loneliness

Loneliness: An Expanding Health Epidemic

The percentage of elderly people who live alone is much larger in the U.S. than in other countries. In fact, nearly double the percentage of people aged 60 and older live alone in the U.S. compared to other countries. Elsewhere, it is common to live with family members as age progresses.

Living alone can contribute negatively to a senior’s overall state of health as it can take an emotional toll contributing to loneliness, depression, stress, and anxiety. As the elderly population continues to grow in the U.S. and the average life expectancy continues to lengthen, America will need to address these emotional challenges confronting our elderly population. The Chronic Conditions Data Warehouse reported that between 2008 and 2017, the rate of treatment for Medicare beneficiaries for depression alone increased from 13.1% to 18.4%. With this steadily increasing trend, we can only expect to see our elderly population continue to suffer from depression.

If you combine these negative emotions with the prevalence of chronic medical conditions, you no doubt recognize the perfect storm for health instability. In a survey report by Cigna, Douglas Nemecek, M.D., MBA, Chief Medical Officer for Behavioral Health stated that “Loneliness has the same impact on mortality as smoking 15 cigarettes a day, making it even more dangerous than obesity.” If loneliness truly is devastating to human health, how can healthcare providers address and intervene with their own patients’ isolation so their health does not worsen? With a growing elderly population, how can providers get ahead of the health damage that inevitably will come?

Chronic Care Management: A Lifeline Connection

A clear solution lies within Medicare’s Chronic Care Management (CCM) program. Medicare patients with multiple chronic conditions are eligible to participate in this program, which focused on putting a network of supportive services in place. Given that researchers see a link between chronic illness and loneliness, effective CCM programs are designed to activate the services designed to help assess and intervene with these issues.

The objective for the elderly suffering from loneliness is to build connections that reduce the rate and pace of negative outcomes. Providers committed to an effective Chronic Care Management program know that positive connections make a difference. The Public Policy & Agency Report stated that “There is now substantial evidence documenting that being socially connected significantly reduces the risk for premature mortality, and lacking social connection significantly increases risk, even more than the risks associated with many factors that currently receive substantial public health attention and resources (e.g., obesity, physical inactivity, air pollution).” Since research has shown that isolation and feelings of loneliness in the elderly can lead to worsened health, Chronic Care Management teams aim to address and intervene with those emotions as much as they can, before they get worse and cause additional problems.

A core tenet of the CCM service is a 24/7 nurse line. This around-the-clock access to a health professional typically provides a virtual tether for vulnerable patients to their providers. At ChartSpan, the largest, fully-managed CCM provider in the U.S., our clinicians reach out to every one of our 20,000+ patients each month to check on and assess their health status. Calls can vary from brief check-up calls to conversations that last extended periods of time. One clinician recorded the following story:

“My patient today was really appreciative of my phone call. He battles with short-term memory loss, and he reported that he is just "downright lonely." We spoke about things he could do every day to bring a little more joy into his life. He told me that he has family, but they do not check on him as much as he thinks they should. We talked about some companion services and aid for him since he does struggle with his memory and loneliness. He thanked me for calling and said that he really enjoyed speaking with me.”

This patient story is an example of how a care management team member examines the determinants of each patient’s social health to ensure they are aging well. ChartSpan’s clinicians follow a care plan and create SMART goals for patients who need to cope with change, find meaning and joy, stay connected, and get active. In this example, you can see how the clinician helped the patient feel connected, as well as suggested local agencies to help with some of his struggles. Clinicians frequently reference different organizations to meet economical and environmental needs such as exercise classes, senior centers, Silver Sneakers, financial assistance, coupons, transportation, and housing. These can help get patients back on track and feel more connected.

ChartSpan’s care management team is trained to address and intervene in a multitude of situations where a patient may feel isolated, anxious, stressed, or depressed. Part of our clinical screening includes a depression screening (PHQ-2) which is recorded in the patient health summary and sent back to the patient’s provider. The clinicians are prompted by a notification in our proprietary CCM software to alert them to perform the screening. Patients who test positive for depression from this screening can have a follow-up with their provider for the additional PHQ-9 testing.

ChartSpan’s CCM team not only proactively listens for signs of depression, but also addresses and reacts to grieving, loss, and even suicidal thoughts. They are thoroughly trained in the protocols for each situation. If a suicidal call occurs, they are trained to keep the patient engaged while a nurse is alerted and 911 is called.

COVID-19: The Implications of the Pandemic on Loneliness

Since the rise of COVID-19 in early 2020, there has been an increase in overall uncertainty which has brought loneliness, depression, and anxiety for all ages, especially the elderly who already experience isolation. Patients are worried about several consequences of the virus - for example, their own health, grieving the loss of others, experiencing quarantine, and the financial impact. Mental health challenges have only been exacerbated by the pandemic and the isolation that has been imposed upon many vulnerable populations. The Disaster Distress Hotline, sponsored by the Substance Abuse and Mental Health Services Administration, saw a 338% increase in the volume of calls from February to March, and in April, the federal government mental health hotline saw more than 1,000% more text messages. At ChartSpan, we experienced a 28% increase in inbound phone calls, during that same time period, from patients, and in 76% of those calls, COVID-19 was addressed. In addition, the overall length of all calls has increased by 12% as patients have more questions about the virus. See a few of the metrics ChartSpan has reported over the last few months.

Patients have shown a strong appreciation for their CCM program during the pandemic. One clinician reported her experience speaking to a patient - while she did not report any change in her physical health, the isolation she is experiencing was significant:

“[Redacted] said she really appreciated our call this month. The senior community she lives in is in an isolation period due to the coronavirus, and all activities have been canceled. She said she has been really bored, and that it was so nice to have someone to talk to. I reminded her that we are always here to talk to if she needs us. She was really sweet and appreciative of our service.”

A continued uptick in loneliness should be expected as COVID-19 continues to surge. The effects will be long-lasting from many angles - especially when it comes to the emotional toll on health. Data from a Household Plus Survey 2020 revealed that the percentage of the U.S. population who reported anxiety or depressive disorder during the pandemic was 30%, with some states reporting as high as 45%. As forced cases of isolation grow exponentially, providers need to take action to get ahead of the inevitable wave of loneliness, depression, and the effect on physical well-being that is coming in the elderly population. Connecting with patients during this time is critical to ward off a further, preventable decline in health. A Chronic Care Management program can add an additional level of support for patients, by being a “source of friendship” and a resource for better health.

For more information on ChartSpan’s CCM service visit our Chronic Care Management page .