The Potential Health Impact of Isolation and Loneliness in Facility Settings

How can we ensure the well-being of our loved ones at any age and with any illness – but especially those in facility care settings? The key words are “Avoid”, “Prevent” and “Lessen” risk factors, including isolation and loneliness, that lead to negative outcomes. Remember, physical outcomes impact on emotional outcomes and emotional outcomes impact on physical outcomes.

Learn more as you read below.

Placing someone in a professional care setting, be it a day program, short term or long-term care facility or hospital can be stressful for all involved but most importantly for the person medically diagnosed with a medical and/or a behavioral health disability whereby the patient’s autonomy may be at stake.

Care Model of the Past – We know what you want and what you need model

In the past, care was provided within in a “paternal” or “surrogate” context meaning patient autonomy was often marginalized, compromised or overridden by family members, para-professionals, medical personnel or facilities in models of care disregarding the needs, values and most importantly the voice of the patient.

Care Model of the Past – Social Isolation

In the past, medical and behavioral health services were more often than not provided in the context of a social isolation model, at home or in a facility, believing those affected had little if anything to contribute to the quality of their care or to their families and community.  Isolation in a health-care setting was often defended as a administration or management decision, behavior modification technique or considered medically necessary.

Isolation was often the answer to addressing the stigma associated with dementia, behavioral health or physical  disabilities.

The Negative Impact of the Social Isolation Model and Paternal/Surrogate Care Models

In the last 20 years or more, evidence-based studies of the “paternal” or “surrogate” care models, which disregarded the voice of the patient and imposed various forms of social isolation, found such care models produced negative outcomes impacting on the quality of the patient’s life including unwillingness to comply with care, increased hopelessness, excessive costs to the health care system and ultimately impacting on mortality.

Today’s Care Models – Promoting Justice and a Voice for Hope and Opportunity

As a result of evidence-based knowledge, there is a culture shift across the entire spectrum of international medical and behavioral health care serving persons with disabilities including the elderly, those with dementia as well those with physical, behavioral and emotional disabilities – from a voiceless, isolation model to a patient-centered/family centered “active” life model valuing the individual’s right to have voice in his or her care and to be active part of family and community.

Today, justice in medicine and access to care are recognized as civil liberties and the rights to be afforded all Americans including those with dementia, physical and/or behavioral disabilities.

Today, active inclusion of people with disabilities, including the aged with dementia, in medical and behavioral health decisions is considered a human right and ethical standard.

Today, the standards of care for home care, short-term and long-term care facilities including group homes, nursing homes and hospitals are redesigned to be “patient centered” believing care providers, both family and professionals, play an integral role in ensuring safety as well as the highest medical and ethical standards are met.

Today, persons with disabilities including those with dementia, have a voice in their care and the fullest opportunities to remain connected to family and friends.

Today, persons with disabilities including those with dementia have a voice in ensuring they have opportunities to play a vital role in our community.

 What to look for in Facility Care and Facility Care Professionals

  1. Look for a facility licensed by the health department in Rhode Island and is nationally accredited. Check with the health department to determine the facilities licensure status as well as national accreditation standing. Also, check the website of the accreditation organization to see if still in compliance. Two national accreditation associations are: Joint Commission and CARF.

Note: Facilities accepting Medicare and Medicaid patients meet not only meet state licensing requirements but also national accreditation and federal Medicare standards. To check a facilities status and Medicare rating visit state and Medicare websites.

Note: In Rhode Island, assisted living and other residential facilities, that are private pay, and  NOT accepting Medicare or Medicaid may not by law have to meet all of the standards of licensure and Medicare required of nursing home and hospitals and accordingly, if not accredited may not have the same level of outside oversight and peer review.  While state law may not require accreditation, facilities may voluntarily choose accreditation.

  1. Look for a facility that provides a Resident Handbook explaining all patient care policies and procedures. The handbook should include policies regarding the circumstances and use of emergency room services and visitor policies/restrictions, coordination of medical care. Ask for copies of all forms provided to physicians and medical care facilities.
  2. Carefully read all handbooks and contracts to understand the conditions under which your love one will receive medical and personal care individualized to your loved ones needs.
  3. Look for a facility that can provide and demonstrate the implementation of a Patient or Resident Bill of Rights which places emphasis on the four commonly accepted standards of health care ethics:
  • Principle of respect for autonomy

(Patients voices are heard, respected, and honored through implementation and practice.)

  • Principle of non-maleficence

(All decisions regarding patient care are made with the goal of first and foremost “doing no harm” to the patient physically or emotionally).

  • Principle of beneficence

(All medical and behavioral health decisions should promote “good”.)

  • Principle of justice

(Care decisions should promote fairness, equality and access to beneficial care.)

Note: The four commonly accepted health care ethics principles listed above provide guidance in developing programs and policies aimed at ensuring wellness and preventing any and all forms of emotional and physical abuse. No abuse or injury is acceptable in a facility care setting and should be thoroughly evaluated, treated and investigated. Any report of medical or physical observations or abuse should not result in a suggested care model of isolation from family and friends.

Care Models Never Replace Family for Facility

Care models should never supplant family for facility. Look for a facility actively demonstrating it does not recommend or implement social isolation as a care model at any time during the continuum of care including daily life as well as admission/readmission/transition from home to facility or from hospital to facility.

Social isolation is not acceptable medical care model in hospitals and should never be a care model in any other facility setting. Around the clock, 24/7 access to family members in the resident care, ensures observation of quality of care, facility practices as well as patient physical and emotional safety.

Isolating Patients for Emergency Purposes – Informing All Care Providers

If the doctor, nurse, program staff or administrator of a facility implements a social isolation care model, as medically necessary for emergency purposes, because a resident is a danger to themselves, the community or unable to care for themselves, all of the patient’s care family and care providers should be made aware of this care model including primary care doctors, specialists and any emergency care personnel such as rescue and hospital emergency rooms.  Resident or patient handbooks should have written policies and professional standards as to how such emergencies will be handled.

Ongoing Review of Care Plans by Primary Care and Specialists

Social isolation has serious health implications impacting on all facets of the patient’s care. Accordingly, just as you would ask any health care provider to share their medical findings with your primary care or other specialty care providers, to ensure continuity of care, any care plan suggesting or mandating denial of access to the patient, by family and friends as a care policy, should be coordinated, reviewed, vetted and signed off by the patient’s primary care doctor as well as the resident’s medical and behavioral health providers.  If you believe a facility’s policies or care plan recommendations are not in keeping with the best interests of the patient or reflect the patient’s desires, values and care goals,  consider a review by the state ombudsman for long term care.

Disagreements Regarding Access to Residents

If family members or others are in disagreement regarding social isolation/access to a patient or any part of the residents medical and/or behavioral well-being, facilities should demonstrate a written policy of actively outreaching to and engaging the services of an ombudsman from the RI Alliance of Long Term Care to serve as mediator and ensure the patient or resident’s voice is heard, honored and the patient is safe.

Coordination of Care – Medical Justice is a Two-Way Street

When a resident in a short or long-term care facility is scheduled for a doctor’s appointment, the facility provides forms for the outside health care provider to complete. At the same time, the facility should provide the doctor with the patient’s complete care log as well as care plans recommended by the facility and signed off by the family. All medical and behavioral incidences should be included. Providing a complete care log ensures all care providers have access to the same information and can make informed medical and behavioral health decisions that are in the patient’s best interest and meet the four principals of health care ethics listed above.


Related Web Links:

Alliance for Better Long Term CareRI State Long Term Care Ombudsman Program

RI Department of Elderly AffairsAdult Protective Services

RI Department of Health – Center for Health Facility Regulations

U.S. Center for Disease Control – Understanding Elder Abuse Fact Sheet.

American Bar Association Commission on Law and Aging/US Bureau of Justice AssistanceLaw Enforcement Guide to Elder Abuse

Stanford University School of MedicineSuspected elder and dependent adult abuse

Nursing Home Abuse GuideEffects of Emotional Abuse

Global Journal of Nursing and Forensic Studies – Screening and Interventions for Elderly Abuse

U.S. Agency for Healthcare Research and QualityWelcome Policy Eliminates Visitor Restrictions

U.S. Office of the Assistant Secretary of HealthPerson and Family Centered Care

American Medical Association Journal of EthicsTranscending the Tragedy Discourse of Dementia: An Ethical Imperative for Promoting Selfhood, Meaningful Relationships, and Well-Being”

McMaster UniversityLoneliness and social isolation are important health risks in the elderly.

AARPFramework for Isolation in Adults over 50

 Additional elder and disability care information can be found on the following links:

The World Health Organization

Centers for Disease Control and Prevention

National Institute on Aging

National Institutes of Health

American Medical Association

American Psychiatric Association

American Psychological Association