EDITOR’S NOTE: This story was published with the permission of Build Healthy Places Network; it appears in Crosswalk, a gathering place for stories that illustrate the deep connection between health and place.

We probably haven’t met them. The neighbor on the third floor who never goes out. The gentleman down the street whose garage door stays shut. The elderly woman in the big house whose husband died a few years ago. They are among the roughly 28 million Americans over age 60 who are lonely.

A few weeks ago, Dr. Carla Perissinotto, associate chief for clinical programs in geriatrics at the University of California, San Francisco, visited one of her patients in a third-floor walkup in a public housing building in San Francisco. Her patient had not been out of her apartment for five years — not because she didn’t want to leave, but because she couldn’t.

The woman, now 80, has been wheelchair-bound for several years. Five years ago, she began to realize that she would need help — a situation that most U.S adults will find themselves in at some point. But her one-bedroom apartment — a design for low-income seniors favored by planners — had no extra space for her daughter to spend occasional nights as needed. There was a two-bedroom unit available, the housing officials said, but all two-bedrooms were third-floor walk-ups. This being San Francisco, the stairs were steep. But the woman still thought it would be a smart move.

“Don’t worry about me, I’m more of a loner anyway,” she told Perissinotto. But now, after five years of never leaving the apartment because of the stairs, she realizes she made a big mistake. She is lonely. Her daughter has her own family to care for and can rarely spend an overnight with her. Her daughter also can’t navigate the stairs with a wheelchair to take her mother to holiday dinners. Her mother can’t just hop in an Uber to go to the community center. She can’t go to the park and sit in the sun. As we’ve all now begun to realize in this age of COVID-19 social distancing and “shelter in place” dictates, it is personal connections that sustain us and add joy to our days. Some say that isolation has similar effects as solitary confinement.

Not coincidentally, the woman’s health is declining as well. She shows signs of cognitive decline and her other chronic conditions are worsening. As ample research has shown, there is a direct correlation between isolation, loneliness and poor health. Social isolation is associated with a higher risk of heart disease, dementia, immune dysfunction, functional impairment and early death, though it depends on the severity of the isolation and loneliness. As an oft-cited study put it, the effect on the health of a rich social network is comparable to quitting smoking.

Luckily for the ailing woman, under the guise of a unique home-visiting program, Dr. Perissinotto makes house calls. Though Dr. Perissinotto has brought a portable scanner to the apartment and consults via telemedicine (remote care via technology) with specialists, she still worries that she is not providing optimal care with her limited options.

“Medically we’ve been so limited in what we can do for her,” Perissinotto said recently. “In any other system, we could get an ambulance out here, take her to the hospital and get everything done in one day. But not in the U.S. Social isolation is not a condition that is considered important enough to warrant an inpatient admission,” she said.

“The change I see in her — from ‘I’m fine’ to this isolation — is so sad and so unnecessary,” Perissinotto said.

As America’s population ages, scenes like this will become commonplace. The population over age 65 is expected to double to 98 million by 2060. A new report by the National Academies of Science estimates that about 43 percent of those over age 60 are lonely and 24 percent of those over 65 are socially isolated. That’s those we see. “Invisible” elders no doubt raise those numbers. And communities are not ready.

It will take new investment, new partnerships and new thinking about how community is built and how connections are formed if we are to meet the rising demand of an aging population.

“Social prescribing” gains steam but more connections are needed

Today, health systems, community development organizations and others are beginning to take note of this growing issue. Most current approaches to quelling loneliness and social isolation aim to connect seniors to programs and supports. Doctors, for example, are beginning to do what they call “social prescribing,” which is just what it sounds like: making referrals for the isolated or lonely to programs and supports in community-based organizations.

Kaiser Permanente, for example, is connecting health care providers and social services agencies through its Thrive Local program in Oregon and southwest Washington. The program partners with local nonprofit and government agencies, and perhaps other health systems in the future. Thrive Local will be integrated into Kaiser’s electronic health record system as a way of tracking social needs and referrals to social providers.

Health navigators are also being put to use. While health navigators have been helping chronically ill patients navigate through the health care system for some time now, UnitedHealthcare expanded its Navigate4Me program in 2018 to individuals at risk for social isolation.

These efforts are a start and with time, the National Academies’ report argues, roles that health care providers are already performing — such as discharge planning, case management and transitional care planning — can also address social isolation and loneliness.

Yet for now, the National Academies’ report finds, this type of support is not yet commonplace due to the weak or nonexistent link between health care practitioners and community-based services. “Despite the profound health consequences — and the associated costs — the health care system remains an underused partner in preventing, identifying and intervening for social isolation and loneliness among adults over age 50,” said the report’s authors.

Rebuilding communities from the ground up

Beyond programs and supports, communities and the built environment can foster connections.

“We designed so much in the 20th century to create independence and autonomy,” said Linda P. Fried, dean of Columbia’s Mailman School of Public Health and chair of the International Loneliness Research Network, “but human beings are social animals who really need intimate personal connections.”

The good news is that the infrastructure we’ve inherited doesn’t have to define us. We can design a different future just like we designed the 20th century’s independence and autonomy.

Already, examples of different forms of housing and community life are emerging. Shared housing, for example, matches people who have unused space with people who need housing. The programs, however, can be hard to sustain. The prospect of a stranger moving in, despite background checks, is a major hurdle. Currently only 39 official programs nationally are listed on a national clearinghouse for home-sharing.

Co-housing is another option. With co-housing, a group of people buys land and builds a housing complex. They live in their own home but share a common house for communal meals, meetings and other functions. “The joke is, in co-housing you go check your mail and you’re gone for half an hour,” Karin Hoskin, executive director of the Co-housing Association of the United States, told the New York Times. Fifteen of the more than 200 co-housing communities serve older residents specifically. The first co-housing development for LGBT seniors is under construction near Durham, North Carolina, with plans to open this spring. Yet while promising, co-housing is also hard to sustain and can take up to seven years to get off the ground. And neither option has yet expanded broadly to low-income communities.

Community development organizations are also taking note. As we reported, Green Homes are built for modest-income seniors but in a new mold — smaller and more communal than institutional. Though not designed specifically to curb social isolation, an affordable housing development in Arizona built specifically for grandparents raising grandchildren features many elements of good design to help grandparents feel less isolated and to address the many physical demands of raising children. The community’s built environment inherently encourages engagement, socializing and overall well-being, with ample play areas, a swimming pool, a public garden, a community center and good sight lines from front porches so grandparents can keep an eye on their grandchildren playing outside.

Critical to success in addressing social isolation among the elderly will be to develop partnerships between builders and service providers early on in the planning process, said Candace Robinson, director of Strategy for Aging Initiatives at Capital Impact Partners, a CDFI that focuses both on capacity-building and lending. Plan, in other words, to prevent social isolation while the design is still in blueprint with features like higher density living, more sidewalks, limited stairs, small front porches, group mailboxes and transportation services, all of which help people connect to one another. For low-income seniors, who are at the highest risk for isolation and loneliness but who lack the resources that can buy companionship and interaction, third spaces like parks and community centers are also essential.

“If developers built for the [service] providers to begin with,” said Robinson, “then they could think about a quiet space for meditation, for example. They could align activity at the beginning instead of the end.”

But it’s easier said than done. For starters, the Low Income Tax Credit — the key funding source for building affordable housing and other amenities in low-income communities — limits the amount of “unleasable” space, which often puts the kibosh on social spaces like community centers because they cannot generate income. Developers, too, resist, worried that incorporating age-centric design and other features will turn their development into a nursing home, Robinson said.

That makes it important to make the case for building differently. “No one is yet saying that certain design elements specifically address social isolation,” said Robinson. But as more evidence emerges that a particular intervention works well in achieving a certain aim, it will open up funding options and lower barriers. An art program in a shared community space won’t just be an art program if it prevents social isolation and improves health, in other words.

Partnering across sectors to create a true system of support

To build a true system of support for those at risk for social isolation, we need richer partnerships across sectors, from health care to public housing authorities, to community development finance and community-based organizations, to philanthropy and research. Similar partnerships in other realms are getting underway and can be a model for efforts to prevent social isolation. (For more on emerging partnerships to build financial and health security, see our latest case studies.)

As anchor institutions, health care systems are already forming cross-sector partnerships to address social determinants of health, particularly in low-income neighborhoods. In Toledo, ProMedica — a regional health care network — is investing $50 million over ten years in the Ebeid Neighborhood Promise. It is partnering on job-training opportunities, a grocery store and a health clinic among other features. These partnerships could readily include support for seniors at risk for isolation, such as transit supports or group activities like Silver Sneakers, a fitness program for older adults. They could also partner with the U.S. Post Office to have postal workers check in on seniors, as they do in parts of the UK.

Health systems can turn to Federally Qualified Health Centers (FQHCs) in low-income neighborhoods to act as a quarterback in aligning supports and services for low-income residents. Many already act as connectors, such as in the Dorchester neighborhood of Boston, where DotHouse Health FQHC screens patients at intake for social needs and connects them to a range of supports beyond health care. FQHCs are well-positioned to help connect doctors who are social prescribing to needed support and services.

Public health departments will be integral partners as well. In Chicago, the Alliance for Health Equity is one of the largest hospital–community partnerships in the country. The members set shared health priorities, which could include screening for and addressing social isolation. They also advocate for supportive policies and conduct regular joint training sessions, which for organizations with very different languages, cultures and financial incentives can help bridge differences and set coordinated agendas.

Public housing authorities are another source of partnerships, as their experience in financial literacy and jobs programs partnerships show. A nonprofit in Boston, for example, partnered with the public housing authority to provide coaches to public housing residents to improve financial literacy and help families save. Adding social isolation as a target among its large senior population would be a logical extension of such partnerships.

Systemic change doesn’t happen without supportive policy. Creating a shared policy agenda can have an enormous impact. Geriatrics, community development, architecture, green building, public health, health care — all have incentives to work toward better policies to address this growing issue. Each group has its own policy collaboratives. Expanding these collaboratives strategically to include other sectors can better align goals and policies.

Finally, to begin to develop a true system of care, said Dr. Perissinotto, organizations large and small must make the case. A first step is to assign a value to social connection, she believes, and that takes evidence. The field does not yet know which interventions truly work and can be expanded at a scale needed to address the issue.

“When I prescribe a medication for blood pressure,” said Perissinotto, “research tells me this is how it will benefit patients. We don’t have the same thing for social isolation or loneliness.”

It is not enough to say that a program connecting seniors is the right thing to do, “you have to show why and how, show what it’s worth,” said Perissinotto. “If you pay us x amount it’ll decrease loneliness by x and have this effect on health.” But for now, few community-based groups have the training or financial support to do that.

“We need two things: Health plans need to take a risk and invest, and community-based organizations need to make the case,” said Perissinotto.

No One Should be Lonely

One thing is certain: loneliness and social isolation are a reality for far too many people in society today. No one should be trapped in a third-floor walkup because of an outdated policy. No one’s health should be compromised because they can no longer drive. Our neighborhoods should not exacerbate an elderly person’s diminishing circle of friends. If the COVID-19 pandemic has taught us anything, it is that isolation is bad for us, mentally and physically. Yet however hard it was, we were confined for only a relatively short time. For too many older Americans, social isolation is never-ending.

Thriving and aging are not two words we often hear together, said Tim Carpenter, CEO of Engage. But with partnerships and new thinking, communities can build a richer and healthier community for everyone, making social isolation a thing of the past.