Today’s Blog is written by Jeffrey Sumpter of Piedmont Health Services, Inc.
Social isolation has been a common experience for everyone during this pandemic. Lockdown, quarantine, physical distancing, mask wearing – all created a perfect storm for social isolation. But before the pandemic, it was a significant problem for a number of people. People who are socially isolated or feel alone are at higher risk for poor physical and mental health outcomes, including falls, depression, heart disease, stroke, and dementia. With loss of independence and mobility, the death of a spouse, relatives, or friends, older people are particularly at risk for social isolation and loneliness. Social isolation is defined as “an objective lack of social contact with others.” Loneliness is defined as the “subjective feeling of being isolated.”[i] A model of care that is well designed to address social isolation in the elderly population is the Program of All-Inclusive Care for the Elderly (PACE).
A program under the Centers for Medicare and Medicaid Services, PACE is a comprehensive, community-based medical and social model of health care for people who are 55 years or older and meet nursing home eligibility requirements. As such, it is an alternative to institutionalized care: PACE participants (the term used in PACE for “patients”) live at home and as independently as possible, with the goal of optimizing quality of life. Most PACE participants benefit from Medicare and Medicaid. An eleven member interdisciplinary team (IDT), the core element of PACE, provides and coordinates the care and services for participants. It is a full-risk model — a program receives fixed payments monthly from Medicare and Medicaid and in turn are expected to provide all care and services a participant may need — which gives the IDT greater flexibility in determining the right care and services for each participant. Currently, there are 139 PACE programs in 30 states, including North Carolina, where Piedmont Health Services started its program in 2008.
Piedmont Health Services Inc. (PHS), one of North Carolina’s first non-profit Federally-qualified community health center (FQHC) organizations, was founded in 1970 by health care professionals from UNC-Chapel Hill and local community members concerned about health care access for underserved populations. Governed by community boards, FQHCs like PHS across the nation focus on providing comprehensive primary care access to diverse low-income populations. The PHS Board pursued and developed a Program of All-Inclusive Care for the Elderly (PACE), Piedmont Health SeniorCare, as a natural extension of its health access mission in order to provide a truly comprehensive community-based geriatric care option to its community.
Some key components of the PACE model include an outpatient clinic, rehabilitation gym, transportation, and an adult day health center. Needless to say, PACE centers’ operations have changed significantly during the pandemic, with adult day health center attendance having been either closed completely for some time, especially at the beginning of the pandemic, or reduced significantly. Because the adult day health center is a major resource or intervention for social engagement of participants, the IDT members have had to rethink how to address participants’ increased risk of social isolation during the pandemic.
Early in the pandemic, Piedmont Health SeniorCare made the decision to close its two PACE centers to attendance. Immediately, the interdisciplinary team members went to work to develop a communication, care and service delivery, and operations’ plan, not to mention a robust infection control plan, with the objective of continued high quality care and services to participants. Right away, the teams recognized that the risk of social isolation to all participants was high. Participants who lived alone, had a mental health diagnosis, or lived in a more remote area could have a higher risk.
The adult day health center in the PACE model enables members of the interdisciplinary team to monitor the medical, functional, psychosocial, and cognitive health of participants on a regular basis and intervene in a timely manner with the right care, support, or service. Creating ways to continue to monitor participants’ health and overall wellbeing was vital to the IDT’s ability to provide the right care and services and realize good health outcomes. To this end, the teams created a phone script of health- and wellbeing-related questions for participants and/or caregivers, including ones relevant to a participant’s social isolation. Questions such as, “How are your spirits?”, “Are you being active during the day at home?”, “Have there been any changes with the people who are providing you support?” often prompted broader conversations about feelings of isolation and loneliness. These calls, along with “Wellness Calls” to participants at higher risk, were made (and continue to be made) once or twice a week to participants and caregivers. IDT members reviewed and discussed the answers to these and other questions daily to determine if they needed to provide additional interventions or supports. For example, social workers scheduled telemental health services to those with reported or identified psychosocial needs such as depression and anxiety.
In addition, IDT members continued to conduct scheduled assessments of participants, but did so, for the most part, remotely, by phone or videoconferencing. Moreover, participants were brought to the center, under strict infection control protocols, for urgent care needs. In these ways, IDT members could learn about any changes in participants’ health status and recognize if social isolation played a part in any of them, such as in falls, depression, changes in nutritional status, and respond accordingly.
The adult day health center offers significant support for social engagement and for emotional, physical, and mental health. Throughout much of this pandemic, the PACE program has provided activities remotely, either through telephone conference calls or video: Bingo on Facebook Live; caregiver support groups; mindfulness groups; conversation groups for Spanish-speaking participants; a men’s conversation group; exercise activities; daily “social” calls to participants at high risk for isolation. Moreover, individualized monthly activities’ packets and exercise packets, created by activities’ staff and therapy staff respectively, were delivered to participants by PACE drivers. PACE drivers also delivered medications, DME, incontinence supplies, and meals to participants.
The IDT also increased in-person support and engagement for participants. The team focused on visits to participants in their homes. It increased home care services to participants for assistance with ADLs and for social engagement as well. Nurse aides were scheduled to “check-in” on a regular basis with participants who were at high risk for social isolation. Medical care, by a provider or RN, was provided in the home when needed. Social workers visited participants with more acute mental health needs in their home. Physical and occupational therapists did home visits to provide needed DME, treatments, training, and post-hospital discharge assessments. A mobile medical van was outfitted for certain medical needs. Of course, all of these staff visits were made according to strict infection control protocols.
In the fall of 2020, PACE was able to open day center attendance to a limited number of participants, 15-20 per day, with schedules based on each participant’s plan of care. As the COVID vaccine became available earlier this year and PACE participants and staff were getting their shots, PACE was able to increase participant center attendance, and has continued to bring more participants to the center. For several months now, the PACE day centers have been operating at 40-50% of pre-COVID capacity, or 35-45 participants per day.
(Of note, Piedmont Health Services has been fully committed to providing access to COVID-19 vaccines for everyone in the community from the beginning: To date, PHS has administered a total of 32,257 vaccines. The vaccination rate for Piedmont Health SeniorCare participants is 94 %.)
This increase in attendance has opened the door more for the IDTs to utilize the centers to address social isolation. In-person activities, such as crafts, games, and exercises are provided in physically distanced arrangements. Participants are seated for lunch in a configuration that follows infection control guidelines, but the participants really enjoy, once again, eating and socializing together. Every day the rehab gyms are busy with participants getting skilled therapy, participating in group exercises, receiving alternative therapies for pain, and at the same time, socializing with staff and other participants. Drivers are picking up and taking home more and more participants, who are able to get out of the house on a regular basis.
In this pandemic, PACE staff have learned a great deal about different ways to communicate with and to deliver care and services to participants. The experience has taught the team more about the importance of intervening effectively to address social isolation and loneliness in the elderly population – and the team had a firm understanding of its significance before COVID! Each week, participants meet for the “Healthy, Happy, and Hopeful” group, facilitated by a licensed clinic social worker and dietician, to learn about, discuss, and plan for healthy nutrition, mental health hygiene habits, and other healthy ways of living. The participants have so much benefited from the social interaction in this group that they exchanged phone numbers and have been making social calls to each other. The benefits ramify in the community!
[i] National Academies of Sciences, Engineering, and Medicine. 2020. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. Washington, NC: The National Academies Press. https://www.nap.edu/read/25663/chapter/1#xi
Click here for more information about the Program for All-Inclusive Care for the Elderly (PACE)