Dealing with the Loneliness of Aging

by:  Howard Gleckman – Resident Fellow at The Urban Institute; a member of the Board of Trustees, Suburban Hospital (Bethesda,  MD) and co-chair of its Medical Quality Committee; member of the Board of The Jewish Council for the Aging of Greater Washington;  senior advisor to Caring from a Distance, a non-profit that provides Web-based and telephone assistance to long-distance caregivers. A veteran journalist, Mr. Gleckman was senior correspondent in the D.C. bureau of Business Week, covering health and elder care, as well as tax and budget issues, for nearly 20 years. He was a 2003 National Magazine Award finalist for a series of Business Week articles entitled The Coming Revolution in Health Care.  Mr. Gleckman is the author of Caring for Our Parents: Inspiring Stories of Families Seeking New Solutions to America’s Most Urgent Health Care Crisis

My dad, who had congestive heart failure, lived on the second floor of a garden apartment building that had no elevator. As the disease made him weaker, he could no long walk down the stairs. And for the last year of his life, he was trapped in his own apartment. An “outing” was a slow walk, and eventually, a wheelchair ride about 100 feet to the end of the outdoor catwalk outside his door. Continue reading

I got thinking about my dad when somebody called the other day asking about isolation among seniors. And it reminded me about what a huge–and widely ignored–challenge this is.  We worry, rightly, about our parents’ safety and financial security. But those of us who are caring for our parents may think too little about the pain of isolation in old age.

My parents never considered leaving their apartment. With the help of a home health aide, my mother made sure my dad was comfortable and well cared for. My wife and I visited regularly. But my dad, who was a gregarious guy, must have been terribly lonely.

While we all want to age in place, we forget that loneliness and isolation can be a huge problem. As we become more frail, our friends stop visiting (perhaps because they are slowing down too, or perhaps because they don’t want to see their own futures). It is a key reason why losing the inability to drive is so traumatic. Finally, like my dad, we may no longer be able to leave our home at all.

Yes, by remaining at home we are maintaining that all-important independence. But we may be paying a price. It is a particular problem for elderly widows but men suffer too. And the victims are often caregivers as much as those receiving assistance.

In Frances Norwood’s powerful book about death and dying in the Netherlands, The Maintenance of Life, she describes “social death,” where those nearing the end of life lose those personal connections to others that are so essential to living.

What can we, as family caregivers and as a society, do to ease this pain? Sadly, many traditional government-funded services are being shuttered in the wake of budget cuts. As I wrote recently, California will stop funding more than 300 adult day centers, a key resource that not only helps seniors but also provides much-needed respite for their caregivers. Similarly, public transportation, already insufficient, is being scaled back.

So what can communities do?

Volunteers can make a huge difference–making friendly visits or phone calls, or offering rides. Formal organizations such as senior villages, faith communities, and fraternal organizations, as well as informal groups of neighbors can help. Engaging seniors as volunteers, giving them an opportunity to stay active and contribute to their communities is a powerful defense against isolation. None of this requires much money, but it does take a bit of time.

Sometimes, staying at home is not the best option. Senior communities of all kinds, assisted living, continuing care communities, and–yes–even nursing homes, may be more appropriate, in part because they can be less isolating. The time may also come when some seniors need to leave their home and move closer to an adult child.

There are many cures for isolation but they all start by recognizing the problem.

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Satisfaction of Life Self-Assessment

With Sincere Appreciation to Professor Edward Diener, Josseph R. Smiley Distinguished professor of Psychology and Editor of Perspectives on Psychological Science, for granting us permission to share this:

This test is designed to identify your level of satisfaction with life Continue reading

 NOTE: To understand life satisfaction scores, it is helpful to understand some of the components that go into most people’s experience of satisfaction. One of the most important influences on happiness is social relationships. People who score high on life satisfaction tend to have close and supportive family and friends, whereas those who do not have close friends and family are more likely to be dissatisfied. Of course the loss of a close friend or family member can cause dissatisfaction with life, and it may take quite a time for the person to bounce back from the loss.

 Another factor that influences the life satisfaction of most people is work or school, or performance in an important role such as homemaker or grandparent. When the person enjoys his or her work, whether it is paid or unpaid work, and feels that it is meaningful and important, this contributes to life satisfaction. When work is going poorly because of bad circumstances or a poor fit with the person’s strengths, this can lower life satisfaction. When a person has important goals, and is failing to make adequate progress toward them, this too can lead to life dissatisfaction.

 A third factor that influences the life satisfaction of most people is personal – satisfaction with the self, religious or spiritual life, learning and growth, and leisure. For many people these are sources of satisfaction. However, when these sources of personal worth are frustrated, they can be powerful sources of dissatisfaction. Of course there are additional sources of satisfaction and dissatisfaction – some that are common to most people such as health, and others that are unique to each individual. Most people know the factors that lead to their satisfaction or dissatisfaction, although a person’s temperament – a general tendency to be happy or unhappy – can color their responses.

 There is no one key to life satisfaction, but rather a recipe that includes a number of ingredients. With time and persistent work, people’s life satisfaction usually goes up when they are dissatisfied. People who have had a loss recover over time. People who have a dissatisfying relationship or work often make changes over time that will increase their dissatisfaction. One key ingredient to happiness, as mentioned above, is social relationships, and another key ingredient is to have important goals that derive from one’s values, and to make progress toward those goals. For many people it is important to feel a connection to something larger than oneself. When a person tends to be chronically dissatisfied, they should look within themselves and ask whether they need to develop more positive attitudes toward life and the world.

There is no computer-related interactive component to this instrument in an effort to protect your anonymity. No one has access to your results; they are for your review only.

Below are five statements that you may agree or disagree with. Using the 1-7 scale below, indicate your agreement with each item by placing the appropriate number on the line preceding the item. Be open and honest in your responses. 

  • 7 – Strongly Agree
  • 6 – Agree
  • 5 – Slightly Agree
  • 4 – Neither Agree nor Disagree
  • 3 – Slightly Disagree
  • 2 – Disagree
  • 1 – Strongly Disagree

_____ “In most ways, my life is close to my ideal.”

_____ “The conditions of my life are excellent.”

_____ “I am satisfied with my life.”

_____ “So far, I have gotten the important things I want in life.”

_____ “If I could live my life over, I would change almost nothing.”

30 – 35 Very high score; highly satisfied
Respondents who score in this range love their lives and feel that things are going very well. Their lives are not perfect, but they feel that things are about as good as lives get. Furthermore, just because the person is satisfied does not mean she or he is complacent. In fact, growth and challenge might be part of the reason the respondent is satisfied. For most people in this high-scoring range, life is enjoyable, and the major domains of life are going well – work or school, family, friends, leisure, and personal development.

25 – 29 High score
Individuals who score in this range like their lives and feel that things are going well. Of course their lives are not perfect, but they feel that things are mostly good. Furthermore, just because the person is satisfied does not mean she or he is complacent. In fact, growth and challenge might be part of the reason the respondent is satisfied. For most people in this range, life is enjoyable and the major domains of life are going well – work or school, family, friends, leisure and personal development. The person may draw motivation from areas of dissatisfaction.

20 – 24 Average score
The average of life satisfaction in economically developed nations is in this range – the majority of people are generally satisfied, but have some areas where they very much would like some improvement. Some individuals score in this range because they are mostly satisfied with most areas of their lives but see the need for some improvement in each area. Other respondents score in this range because they are satisfied with most domains of their lives, but have one or two areas where they would like to see large improvements. A personal scoring in this range is normal in that they have areas of their lives that need improvement. However, an individual in this range would usually like to move to a higher level by making some life changes. 

15 – 19 Slightly below average in life satisfaction
People who score in this range usually have small but significant problems in several areas of their lives, or have many areas that are doing fine but one area that represents a substantial problem for them. If a person has moved temporarily into this level of life satisfaction from a higher level because of some recent event, things will usually improve over time and satisfaction will generally move back up. On the other hand, if a person is chronically slightly dissatisfied with many areas of life, some changes might be in order. Sometimes the person is simply expecting too much and life changes are needed. Thus, although temporary dissatisfaction is common and normal, a chronic level of dissatisfaction across a number of areas of life calls for reflection. Some people can gain motivation from a small level of dissatisfaction, but often dissatisfaction across a number of life domains is a distraction, and unpleasant as well.

10 – 14 Dissatisfied
People who score in this range are substantially dissatisfied with their lives. People in this range may have a number of domains that are not going well, or one or two domains that are going very badly. If life dissatisfaction is a response to a recent event such as bereavement, divorce or a significant problem at work, the person will probably return over time to his or her former level of higher satisfaction. However, if low levels of life satisfaction have been chronic for the person, some changes are in order – both in attitudes and patterns of thinking, and probably in life activities as well. Low levels of life satisfaction in this range, if they persist, can indicate that things are going badly and life alterations are needed. Furthermore, a person with low life satisfaction in this range is sometimes not functioning well because his or her unhappiness serves as a distraction. Talking to a friend, member of the clergy, counselor, or other specialist can often help the person get moving in the right direction, although positive change will be up to the person.

5 – 9 Extremely dissatisfied

Individuals who score in this range are usually extremely unhappy with their current life. In some cases this is in reaction to some recent bad event, such as widowhood or unemployment. In other cases, it is a response to a chronic problem such as alcoholism or addiction. In yet other cases, the extreme dissatisfaction is a reaction due to something bad in life, such as recently having lost a loved one. However, dissatisfaction at this level is often due to dissatisfaction in multiple areas of life. Whatever the reason for the low level of life satisfaction, it may be that the help of others is needed – a friend or family member, counseling with a member of the clergy, or help from a psychologist or other counselor. If the dissatisfaction is chronic, the person needs to change, and often others can help.


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Where Is the Patient in the Patient-centered Medical Home?

by Holly Korda, Altarum Institute, Deputy Director for Strategy and Growth. –

The patient-centered medical home (PCMH) has grabbed the limelight as a new model of health care that offers an alternative to fragmented, impersonal and wasteful care that has become the norm throughout much of the U.S. The PCMH model promises each patient a primary care provider leading an interdisciplinary care team, with the intent of delivering seamless care across services and settings, keeping the patient at the center. A substantial evidence base is building for improved quality, patient experience, and reduced health care costs associated with medical homes. Continue reading

One of the key features of medical homes is a focus on coordinated, collaborative, continuous care. Primary care practitioners, specialists, nurses, and other health care professionals are expected to work closely together in “flat” teams that discourage medical hierarchy and encourage cooperation, collaboration, team work. This team is supposed to include the patient as an active participant in health care decision making. After all, care in the medical home is patient centered … or is it?

Patient-Centered Care Teams
PCMHs can take a variety of organizational arrangements: nested within integrated health systems like Kaiser and Geisinger; operating across providers through physician and hospital organizations; in the emerging accountable care organizations called out by the Affordable Care Act; leveraging networks of independent providers; based in community health centers, clinics and other safety net providers; and more.

Integrated care delivered by interdisciplinary teams is a core concept, but who leads and who is included on the team can vary considerably. While the PCMH opens the door to bring new players and professional disciplines to the patient care team, the division of labor and responsibility has been a source of considerable angst, often pitting professional groups at odds over who is in charge. Physicians may assume dominion as primary care team leaders, but nurse leaders, in particular, have been fast to question this role.

Sometimes physicians will lead, but not always. New roles and identities for physicians and other health professionals that require new competencies that emphasize collaborative practice styles are emerging. Other health professionals are also queued up to lead these interdisciplinary, interprofessional teams. Nurse practitioners are experienced primary care coordinators and team leaders, and health reform legislation expands these roles. Advanced-practice registered nurses are called out to increase their roles providing primary and preventive care, chronic care management and care coordination, and to step up as managers of community health centers. Physician assistants, pharmacists, and community-based providers are also ready collaborators for patient centered care teams. They are typically less costly and more available than physicians, and important contributors to the primary care workforce.

As the professionals sort out roles and responsibilities, the patient is at the center of this team … but where?

Patient-Centered Care Delivery
Patients have not been all that happy with the PCMH, according to early research. Pauline Chen’s New York Times article brought patients’ dissatisfaction with the PCMH to the public discussion last July. Citing reports from 36 practices participating in the PCMH National Demonstration Project, she noted that patients felt disoriented, displaced as team care replaced the one-to-one patient-doctor interactions. The article asserts that patient satisfaction fell because few patients were aware of or involved with the changes going on around them.

Patients and providers don’t always see eye to eye, and tend to value different aspects of relationship in the medical encounter. It’s the patient-centered medical home … and the patient isn’t included in managing and running it … what is to like?

Consumer preferences are changing. Sure, some patients will prefer the traditional one-on-one relationships with their physicians that are increasingly hard to find. Some patients will expect to play an active role in their health care, engage with transparency in their relationships with primary care practitioners, and will rely on their health information savvy thanks to the Internet, social networking and other new media. These individuals will manage their health care as proactive, engaged consumers—not as patients to be acted upon. They want to work with their providers, and use them as consultants to support our personal health and health care decision making.

These consumers also want choice. In a recent article in the American Journal of Managed Care, author Tim Hoff suggests that many patients, especially younger and healthier ones, may not find the PCMH model an attractive one. Other forms of health care delivery, e.g., retail clinics staffed by non-physician providers, might better suit some consumers. Still other consumers will choose a combination of self-care and professional consultation as a cornerstone of their health care.

Setting the Ground Rules for Patient Centeredness
The PCMH is not a one-size-fits-all, and neither are the patients or providers who live, work and play within its walls. PCMH models are new, diverse, dynamic and evolving. We need to understand them, work with them, and design them from blueprints that meet patients’ needs. Ideally, the PCMH helps to empower patients who can participate fully in their care — and places the patient at the center as part of the care team.

What new skills are needed, and how can we prepare competent patients in the PCMH? Patients do have responsibilities: meeting appointments and follow up visits, filling and refilling prescriptions, communicating frankly about health concerns, and more. Notably, many will fall short, and disparities will advantage or disadvantage specific patient groups. Low income, culturally diverse and other special populations will likely require enabling support to meet their patient responsibilities in the PCMH.

Experience shows that health care professionals can play better with others on collaborative, interprofessional teams when they understand and appreciate the shifting roles and how they fit together in a patient-centered medical home. Groups like the Interprofessional Education Collaborative, including representatives of medical, dental, nursing, pharmacy and other health professions, are tackling PCMH practice dynamics head on, identifying competencies and training goals for team-based care. These are the new rules for collaborative, interdisciplinary care coordination.

Just as patients have responsibilities, providers can support the patient-provider relationship by providing basic information to navigate the encounter, e.g., how to make appointments and seek care, outlining insurance and payment arrangements, and laying out the conditions under which diagnostic testing is conducted, among others.

The Center for Advancement of Health proposes Rules and Terms of Engagement that make explicit previously assumed expectations about responsibilities of both patients and providers and a pact describing a process for mutual decision making in the PCMH. It sounds simple, though speaking up to one’s physician or other primary care practitioner admittedly can be intimidating. But it’s a start.

Location, Location, Location
In the end, patient-centered care is about respect, engagement and choice. Respect among providers on the interdisciplinary care teams, respect among patients and providers, and a willingness for all to engage in truly shared decision making. In shared decision making we have better outcomes, less waste and more affordable care.

The beauty of the PCMH lies in its flexibility, its potential, and its dynamic nature as a tool for primary care transformation. It is as much a process as a foundation and structure for care delivery. We are reminded,

it is more about learning how to be a learning organization that creates an emergent future than it is learning from experts…the level of change needed is daunting and requires tremendous motivation of all practice participants, defining new roles, understanding the local landscape, and paying attention to multiple relationships.

The patient’s in the center, somewhere, in the PCMH. Where?

When established players complain …THAT’s where to start looking. That’s where we’ll find patient centeredness. It means change is coming, and sometimes change is a good thing.

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