Social distancing is essential in helping flatten the COVID-19 curve but it’s also having a devastating effect on our patients’ physical, mental and spiritual health.
Nearly half of American adults are feeling socially isolated from family and friends and are struggling to maintain their health, according to the Social Distancing Survey by Harris Poll. Social distancing has had a negative impact on mental health for nearly 2 in 5 adults. One of the things most adults (7 in 8) miss most is spending time with friends. The survey was fielded online nationwide from May 5-8, 2020, and 2,051 adults age 18+ participated in the survey.
“Social support, especially from family and friends, is essential to health and healing. The pandemic has suddenly and severely disrupted our ability to get the support we need,” says Wayne Jonas, MD, president of Healing Works Foundation. Dr. Jonas is also a practicing family physician, an expert in integrative health and health care delivery and a widely published scientific investigator.
Even before the pandemic, loneliness and social isolation in the U.S. were at epidemic levels.
A 2018 study by Cigna found that 47 percent of Americans often felt alone, left out and lacking meaningful connection with others, and 47 percent felt isolated from others.[i]
The survey also found that older adults 65+ are more likely to feel socially isolated due to the pandemic than young adults age 18-34 (60% vs. 43%). But young adults are more likely to report a negative impact on their physical health than older adults (37% vs. 19%). Young adults and females were most likely to report a lack of energy (30%), difficulty sleeping (29%) and exercising less (29%).
Be Aware of the Dangers of Loneliness and Social Isolation
Evidence shows that loneliness and social isolation lead to chronic disease, an increased likelihood of dying early, more use of health care services and higher costs among adults ages 50 and older.[ii] A meta-analysis of 23 studies, for example, found that loneliness and social isolation increased the risk of developing coronary heart disease and stroke.[iii] Other studies have linked loneliness and social isolation to an increased risk of dementia and depression.[iv]
Loneliness and social isolation are also linked to more doctors’ visits, more hospitalizations, longer lengths of stay and more readmissions for older adults.1 Medicare spends about $6.7 billion a year more caring for older adults who are socially isolated compared to other adults, according to a study by AARP, Stanford University and Harvard University.[v] Few studies have looked at the link between loneliness and social isolation and access to health care, however, transportation, geographical location and socioeconomic status all facilitate or limit access. 1
Be Part of the Solution
Primary care providers are well positioned to help identify and lessen the health consequences of loneliness and social isolation. Here are four ways to do this:
- Talk about loneliness and social isolation
- Screen for loneliness and social isolation
- Use tele-medicine to connect with and care for patients
- Use virtual group visits to connect with and care for patients
Talk about Loneliness and Social Isolation
You can begin to address loneliness and social isolation by talking about them during routine office visits. The HOPE (Healing Oriented Practices & Environments) note provides an easy way to do this and can be used during telemedicine or in-person visits.
The HOPE note is a simple patient-guided process to identify social and emotional components that facilitate or detract from healing, particularly if the patient has any chronic diseases. “In managing complex chronic diseases, social support is key,” says Dr. Jonas, who developed the HOPE note.
Ask patients these questions about the social and emotional component of healing:
- How is your social support? What are your social connections and relationships?
- Tell me about your family and friends? Do you have someone you talk with in confidence and trust?
- Are there people you have fun with? How often do you just relax with others?
- How do you handle loneliness?
- Have you had any major social or physical traumas in the past? What was your childhood like?
Working through these questions helps you engage the patient in shared decision-making about health and healing.
The HOPE note also covers the behavioral, environmental and spiritual components of healing. It reframes the patient-physician orientation from one of disease treatment to one that emphasizes health promotion and self-healing while integrating evidence-based complementary and lifestyle approaches into conventional medical care.
Tools for Talking about Loneliness and Social Isolation
- The HOPE Note: A Tool for Adding Integrative Care to a Routine Office Visit
- The HOPE Note Guide (Long and short versions)
- The HOPE Note Questions (template)
Screen for Loneliness and Social Isolation
In Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System (2020), the National Academies of Sciences, Engineering, and Medicine recommends routinely assessing at-risk older adults for social isolation and loneliness. We recommend two brief and accurate tools for doing this: The Campaign to End Loneliness Scale or the UCLA 3-Item Loneliness Scale.
The Campaign to End Loneliness Scale is a newer tool with three positively-worded items:
- I am content with my friendships and relationships
- I have enough people I feel comfortable asking for help at any time
- My relationships are as satisfying as I would want them to be
“This tool does not expressly use the word loneliness, and is unlikely to cause any embarrassment or distress,” says Dr. Jonas. The Campaign to End Loneliness calls this “a short and sensitively-worded tool that is easy to use.”
Responses are scored from 0 (strongly agree) to 4 (strongly disagree), with a possible range of 0 (least lonely) to 12 (most lonely). People with scores of 0 to 3 are unlikely to be lonely while people with scores of 10 or 12 are likely to be intensely lonely. The Campaign to End Loneliness has not defined the other scores.
The UCLA 3-Item Loneliness Scale is a more established and widely-used tool that asks:
- How often do you feel that you lack companionship?
- How often do you feel left out?
- How often do you feel isolated from others?
“Like the Campaign to End Loneliness Scale, the UCLA 3-Item Loneliness Scale does not expressly use the word loneliness, but the negative phrasing makes it more difficult for people to ask face-to-face,” says Dr. Jonas. The Campaign to End Loneliness calls the UCLA 3-Item Loneliness Scale a “short and academically rigorous tool, with a simple scoring system.”
Three response categories are usually used with the UCLA 3-Item Loneliness Scale: Hardly ever, Some of the Time or Often. Response scores are: Hardly ever (1), Some of the Time (2) and Often (3). Possible scores range from 3 to 9, with scores of 3 to 5 defined as “not lonely” and scores of 6 to 9 defined as “lonely.”
Tool for Screening for Loneliness and Social Isolation
Measuring Your Impact on Loneliness in Later Life, which includes more information on:
- Campaign to End Loneliness Scale
- UCLA 3-Item Loneliness Scale
Use Telemedicine to Connect with and Care for Patients
Telemedicine—the diagnosis and treatment of patients using smartphones, tablets, or computers—enables you to address loneliness and social isolation and provide patients with safe and efficient care. Also known as virtual visits, video visits or online doctor visits, the American Academy of Family Physicians supports expanded use of telemedicine.[vi] Under policy changes in response to the pandemic, virtual (video) visits and audio-only (telephone) visits are now billable.
While telemedicine isn’t a replacement for in-person visits, it does have one major advantage. Like the HOPE note, telemedicine facilitates the physician-patient relationships that are essential to health and healing.
“Since we can’t order imaging studies, lab tests and procedures, we have to use the tools we have: listening, talking and connecting with our patients,” says Elena Rosenbaum, MD, an integrative medicine physician at Albany Family Medicine who has been using tele-medicine since shortly after the start of the pandemic. Albany Family Medicine is a division of Community Care Physicians PC and a teaching facility for Albany Medical Center. Dr. Rosenbaum is also an associate professor at Albany Medical College and medical director of the Alliance for Better Health.
“People are lonely and emotionally strained. They have a lot of anxiety and depression. We can do something about these things if we have the time,” says Dr. Rosenbaum. Without the distractions of the clinic, you can ask those questions. Just connecting with a patient in a virtual or telephone visit provides some relief from loneliness and social isolation.
During virtual or telephone visits, primary care providers also offer treatments, advice and resources. Treatments for loneliness and depression used by Dr. Rosenbaum include mindfulness meditation, exercise, referrals to therapy and medication. She teaches mindfulness meditation during the visit and suggests apps and courses patients can use on their own. Other ways to address loneliness and social isolation include connecting patients to organizations that provide check-in calls, peer support and practical help with grocery shopping and other needs.
Telemedicine can be done using video or telephone. “The preferred method is video. But our patients don’t all have smart phones or enough data to spend a half hour with a doctor, and many seniors don’t have smart phones or aren’t comfortable using video,” says Dr. Rosenbaum. Also, in rural areas, lack of high-speed broad band access is an issue.
Albany Family Medicine uses Doxy, a HIPAA-compliant, video-based telemedicine software that is easy to use, says Dr. Rosenbaum. Video and telephone visits can now be billed like in-person visits, using new codes developed in response to the pandemic.
Dr. Rosenbaum recommends keeping video and telephone visits simple and focusing on connecting with patients. Patience is necessary, since telemedicine is also new to patients. “Try to focus on understanding where the patient is at the moment and the main issue at hand,” she says. “Don’t expect too much and leave enough time between patients.” Finally, she says, accept that video and telephone visits are different than in-person visits.
Tools for Doing Telemedicine
American Academy of Family Physicians resources, including:
- CMS General Telemedicine Toolkit
- AMA Telemedicine Quick Start Set-up Guide
- COVID-19 Coding Scenarios
Academy of Communication in Healthcare COVID-19 Telehealth guide
Center to Advance Palliative Care CAPC COVID-19 Response Resources
Use Virtual Group Visits to Connect with and Care for Patients
Another way to address loneliness and social isolation while providing safe and effective medical care is virtual group visits. Like telemedicine, virtual group visits are now billable. Also, it is easy to offer HIPAA-compliant virtual group visits. The American Academy of Family Physicians, CMS and Medicare all promote group visits.[vii]
“Virtual group visits ease loneliness, help people share difficult times and provide a sense of community,” says Jeffrey Geller, MD. A national expert in group visits, Dr. Geller is director of Integrative Medicine and Group Programs at Kronos Health and president and creator of the non-profit organization Integrated Medical Group Visits. He created the largest group visit program in the U.S.
Dr. Geller’s group visits—in-person and virtual—focus on improving health outcomes by reducing loneliness. “When you feel like part of a group, you reduce loneliness and feel special and important. When you feel special and important, you take better care of yourself,” he says.
Using Zoom, Dr. Geller conducts virtual group visits usually around an activity such as yoga or exercise or symptoms such as insomnia. Virtual group visits can also focus on a diagnosis, such as chronic pain, diabetes or heart disease. Dr. Geller’s group visits include small group facilitated discussions, facilitated discussion among the entire group, the activity or education, short-targeted individual physical exams and solution development.
Letting people complain “is the easiest way to reduce loneliness,” says Dr. Geller. In the yoga group, for example, patients might complain about how the pandemic has made self-care and relaxing difficult. During the yoga class, Dr. Geller takes individual patients into a separate confidential electronic room for the physical exam, which enables him to bill for the group visit. At the end of the group, he asks patients to choose one thing they can do to make things better.
The billing document for a virtual group visit needs to state the technology and software vendor used and why the visit is being held virtually instead of in person. “To prevent the spread of COVID-19” is a valid reason for a virtual group visit.
Dr. Geller recommends Zoom for virtual group visits, which offers breakout rooms and makes HIPPA compliance easier. Most practices use a medical authorization disclosure form with a HIPAA clause, either annually or for each visit. A group of 6 to 12 patients is easiest to manage.
Tools for Doing Virtual Group Visits
- Virtual Group Medical Visits
- Documenting and Billing tips for Integrative Medical Group Visits
- Virtual visit HIPAA consent forms in English and Spanish
- Establishing and Maintaining Successful Chronic Pain Group Medical Visits Using an Empowerment Model, applicable to other chronic diseases
- Chronic Disease Management with Group Visits
Support Your Patients and Prevent Health Problems
As the pandemic and social distancing continue, loneliness and social isolation will increase. Tools such as the HOPE note, screening tools, telemedicine and virtual group visits can help you support your patients and prevent or reduce further declines in physical, mental and spiritual health.
“Virtual medicine and group visits are not just a passing phase because of COVID-19,” says Dr. Jonas. “They are here to stay and are the right thing to do to help patients be healthier and create a better health system. I urge all physicians to learn about them and incorporate them into their routine practice.”
[i] Cigna. “Research Puts Spotlight on the Impact of Loneliness in the U.S. and Potential Root Causes.” May 2018. Accessed 5/25/20.
[ii] National Academies of Sciences, Engineering, and Medicine 2020. Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. Chapter 7. Role of the Health Care System. Washington, DC: The National Academies Press. https://doi.org/10.17226/25663.
[iii] Valtorta, N. K., M. Kanaan, S. Gilbody, S. Ronzi, and B. Hanratty. 2016a. “Loneliness and social isolation as risk factors for coronary heart disease and stroke: Systematic review and meta-analysis of longitudinal observational studies.” Heart 102(13):1009–1016.
[iv] Blazer DG and Ryerson LM. The Health Care System Is An Untapped Resource In Combating Social Isolation And Loneliness In Older Adults. Health Affairs. April 30, 2020. Accessed 5/25/20.
[v] Flowers L, Houser A, Noel-Miller C, Shaw J, Bhattacharya J, Schoemaker L, Farid M. Medicare Spends More on Socially Isolated Older Adults. AARP Insights on the Issues. November 27, 2017. Accessed 5/22/20.
[vi] American Academy of Family Physicians. Using Telehealth to Care for Patients During the COVID-19 Pandemic. Accessed 5/22/20.
[vii] BILLING, CODING and HIPAA in the Group Visit Model,” Lifestyle Matrix Resource Center webinar. No longer available online.