[Senate Hearing 115-363]
[From the U.S. Government Publishing Office]







                                                        S. Hrg. 115-363

 AGING WITHOUT COMMUNITY: THE CONSEQUENCES OF ISOLATION AND LONELINESS

=======================================================================

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS


                             FIRST SESSION

                               __________

                             WASHINGTON, DC

                               __________

                             APRIL 27, 2017

                               __________

                            Serial No. 115-4

         Printed for the use of the Special Committee on Aging






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                       SPECIAL COMMITTEE ON AGING

                   SUSAN M. COLLINS, Maine, Chairman

ORRIN G. HATCH, Utah                 ROBERT P. CASEY, JR., Pennsylvania
JEFF FLAKE, Arizona                  BILL NELSON, Florida
TIM SCOTT, South Carolina            SHELDON WHITEHOUSE, Rhode Island
THOM TILLIS, North Carolina          KIRSTEN E. GILLIBRAND, New York
BOB CORKER, Tennessee                RICHARD BLUMENTHAL, Connecticut
RICHARD BURR, North Carolina         JOE DONNELLY, Indiana
MARCO RUBIO, Florida                 ELIZABETH WARREN, Massachusetts
DEB FISCHER, Nebraska                CATHERINE CORTEZ MASTO, Nevada
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                 Kevin Kelley, Majority Staff Director
                  Kate Mevis, Minority Staff Director 
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                  
                                CONTENTS

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                                                                   Page

Opening Statement of Senator Susan M. Collins, Chairman..........     1
Statement of Senator Robert P. Casey, Jr., Ranking Member........     2

                           PANEL OF WITNESSES

Julianne Holt-Lunstad, Ph.D., Professor of Psychology and 
  Neuroscience, Brigham Young University.........................     5
Lenard W. Kaye, D.S.W., Ph.D., Director, Center on Aging, and 
  Professor, School of Social Work, University of Maine..........     7
W. Mark Clark, M.S.W., President and Chief Executive Officer, 
  Pima Council on Aging..........................................     9
Rick Creech, Educational Consultant, Pennsylvania Training and 
  Technical Assistance Network...................................    11

                                APPENDIX
                      Prepared Witness Statements

Julianne Holt-Lunstad, Ph.D., Professor of Psychology and 
  Neuroscience, Brigham Young University.........................    30
Lenard W. Kaye, D.S.W., Ph.D., Director, Center on Aging, and 
  Professor, School of Social Work, University of Maine..........    38
W. Mark Clark, M.S.W., President and Chief Executive Officer, 
  Pima Council on Aging..........................................    40
Rick Creech, Educational Consultant, Pennsylvania Training and 
  Technical Assistance Network...................................    45

                  Additional Statements for the Record

Chelsea Conaboy, Freelance Writer, The Agenda-Politico article, 
  They're Out There-If We Can Find Them..........................    50
Dhruv Khullar, M.D., M.P.P., Massachusetts General Hospital and 
  Harvard Medical School, New York Times Op-Ed, How Social 
  Isolation Is Killing Us........................................    52
Meals on Wheels, Statement for the Record........................    54

 
                      AGING WITHOUT COMMUNITY: THE
                       CONSEQUENCES OF ISOLATION
                             AND LONELINESS

                              ----------                              


                        THURSDAY, APRIL 27, 2017

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:48 a.m., in 
Room SD-430, Dirksen Senate Office Building, Hon. Susan M. 
Collins (Chairman of the Committee) presiding.
    Present: Senators Collins, Flake, Tillis, Fischer, Casey, 
Nelson, Gillibrand, Donnelly, Warren, and Cortez Masto.

    OPENING STATEMENT OF SENATOR SUSAN M. COLLINS, CHAIRMAN

    The Chairman. The Committee will come to order.
    Good morning. Today we are shining a light on a growing 
phenomenon: the consequences of isolation and loneliness on 
older Americans who are aging without a strong sense of 
community. This is the first of a two-part series. In our next 
hearing, we will explore solutions that reconnect older people 
to communities.
    One survey to assess isolation among seniors asks this 
question: If you had good news or an interesting story to tell, 
do you know someone with whom you could share it? Increasingly, 
older Americans are answering this question not with the name 
of a relative or a friend, but with the name of their cat or 
their dog. While studies have shown that pets can help to 
alleviate loneliness, they should not be an individual's only 
social contact. In fact, the science is clear that isolation 
and loneliness are dangerous to the health of our seniors. 
Having friends is as important for good health and well-being 
as food and water.
    Isolation and loneliness can result in negative mental, 
behavioral, and physical health outcomes. Seniors who are 
lonely have a 45 percent greater risk of dying. They have a 59 
percent greater risk of functional decline, causing 
deterioration in their mobility and ability to perform daily 
tasks. Isolation and loneliness are associated with higher 
rates of heart disease; a weakened immune system; more 
depression and anxiety; dementia, including Alzheimer's 
disease; and nursing home admissions. Prolonged isolation is 
comparable to smoking 15 cigarettes a day. I must say that was 
a statistic that really hit home to me.
    Older Americans who are isolated or lonely are also more 
susceptible to financial scams and elder abuse. Last Congress, 
we uncovered the tragic story of a 77-year-old man from Maine 
who turned to the Internet for companionship. Lured by scam 
artists, he ended up in a European prison as a convicted drug 
smuggler. Without the persistent work of this Committee and 
diplomatic negotiations, he would still be there today. The 
plight of this man and thousands of seniors in his shoes could 
have been avoided had he and others not been so susceptible due 
to their desire for simple companionship.
    A number of risk factors for isolation and loneliness are 
age related--including widowhood, chronic health conditions, 
and mobility impairments. The size of one's social network also 
decreases with age. I have heard seniors in my state compare 
this phenomenon to ``watching the world die before you,'' as 
they lose more and more of their friends.
    Maine is the oldest state in median age, is aging the 
fastest, and is among the most rural. An epidemic of loneliness 
and isolation is growing, and we face major challenges. Those 
who live in Maine year round can be left isolated. Winter can 
keep them indoors for long stretches, homes are often far 
apart, and transportation is often a barrier.
    Established programs such as Meals on Wheels are reaching 
seniors in important ways. For many, Meals on Wheels is not 
just about food. It is about social sustenance, also. Seniors 
look forward to greeting the driver and having a bit of 
conversation. That is why I am concerned that the 
administration's proposed budget cuts would affect programs 
like this one and many others that help keep our seniors 
connected. If you look at it, those cuts are really penny wise 
and pound foolish, because in the end they are going to cause 
more hospitalizations, more nursing home admissions, and poorer 
health outcomes.
    The fact is the consequences of isolation and loneliness 
are severe: negative health outcomes, higher health care costs, 
and even death. The root problem is one that we can solve--by 
helping seniors keep connected with communities. Just as we did 
when we made a national commitment to cut smoking rates in this 
country, we should explore approaches to reducing isolation and 
loneliness. Each has a real impact on the health and well-being 
of our seniors.
    I am now pleased to turn to our Ranking Member, Senator 
Casey, for his opening statement. Before I do so, however, I 
want to extend my thanks to our witnesses for being so flexible 
on this hearing. It seemed that every time it was scheduled, we 
had something intervene, most recently the briefing at the 
White House yesterday on North Korea. So I very much appreciate 
your staying over and being with us today.

  OPENING STATEMENT OF SENATOR ROBERT P. CASEY, JR., RANKING 
                             MEMBER

    Senator Casey. Chairman Collins, thank you very much for 
calling this hearing and for your opening statement.
    We, of course, want to begin a process today of examining 
both social isolation and loneliness. And as the chairman 
mentioned, this will be a two-part hearing series. Today we 
will focus on loneliness and social isolation, and in two 
weeks, we will be able to examine more macro solutions, 
focusing on livable communities.
    Taken together, these hearings will provide the Committee 
with the opportunity to examine the full scope of an issue 
facing seniors as well as others across the country.
    One of the most searing reminders of this came from a New 
York Times op-ed back in December by Dr. Khullar from Harvard 
Medical School and Massachusetts General Hospital, entitled 
``How Social Isolation Is Killing Us''. He was talking about an 
individual that he knew would be dying, and the individual knew 
they were dying, he said--and this is the doctor speaking--
``for me the sadness of his death was surpassed only by the 
sadness of his solitude.'' And I think that sums it up.
    We hope that this hearing, and the series of two hearings, 
will inform our engagement on other matters as well that may be 
coming before the Senate, like the President's budget request 
or potentially an infrastructure package.
    You might be asking how those two are related. Well, let me 
explain.
    Back in March, like a lot of parts of the country, my 
hometown of Scranton, in Lackawanna County, was hit hard by a 
last gasp of winter with a terrible blizzard. Meals on Wheels, 
of course, in that moment became even more important. The 
blizzard did not stop Meals on Wheels in northeastern 
Pennsylvania. One of the drivers that I met with a couple of 
days after he had been out in that snowstorm went to a home in 
Lackawanna County to drop off a weekly supply of meals. Upon 
arrival, the driver heard the homeowner calling out for help. 
This individual had fallen into a snow bank wearing shorts and 
just a T-shirt. He had fallen after going outside. That Meals 
on Wheels driver saved that man's life that day. There is no 
doubt about it.
    And when it comes to not only Meals on Wheels but also 
other programs, but especially a program like Meals on Wheels, 
I think the administration's cuts to that program are 
misguided, to say the least.
    I believe that Democrats and Republicans can agree on 
issues like that. We have a great deal to work together on to 
address our Nation's infrastructure in addition to that so that 
we have improved accessibility. This would include improving 
signage that makes it easier to read. It also includes 
constructing curb cut-outs so those who are aging or have 
disabilities can continue to get around in their communities; 
and, finally, enhancing access to technology and broadband so 
that those in rural communities can stay connected to their 
loved ones.
    I would say parenthetically another story that I read in 
Politico talking about loneliness and isolation in rural 
America is recommended reading for all of us.
    So improvements like the ones I just mentioned will help 
individuals venture outside of their homes and into their 
communities with success, as well as stay connected to those 
who are most important in their lives.
    So I look forward to the hearing and discussing the 
pressing issues with our witnesses today, who I thank, as well 
as the Chair, for being here and for rearranging your 
schedules.
    Chairman Collins, I am also told in the audience today we 
also have the Acting Director of the Administration on 
Community Living at the Department of Health and Human 
Services, Bob Williams. We want to acknowledge his presence as 
well.
    Thank you, Madam Chair.
    The Chairman. Thank you. We will now turn to our panel of 
witnesses.
    First I would like to introduce Dr. Julianne Holt-Lunstad. 
Dr. Holt-Lunstad is a professor of psychology at Brigham Young 
University in Utah and studies the influence of social 
relationships on long-term health. Her work has been nationally 
and internationally recognized.
    Next we are going to be very fortunate to hear from one of 
my constituents, Dr. Lenard Kaye. I first met Dr. Kaye some 17 
years ago. He is a professor of social work and director of the 
Center on Aging at the University of Maine. He is also the 
director of the Encore Leadership Corps, a statewide adult 
volunteer program that involves older residents in community 
service. He, too, is a nationally recognized leader in the 
field of health care and aging, and I am delighted that he 
could be here to join us today.
    I would like to next turn to my colleague Senator Flake to 
introduce Mr. Mark Clark.
    Senator Flake. Thank you, Madam Chair, and thank you for 
being here. And I just wanted to personally welcome Mr. Clark, 
an Arizonan traveling here to discuss this important issue of 
isolation and innovative programs that your organization has 
developed to help combat the issue. Mr. Clark currently serves 
as president and chief executive officer of the Pima Council on 
Aging as well as grass-roots coordinator for the National 
Association of Area Agencies on Aging. He has extensive 
experience in administrative advocacy and policy experience 
working for a variety of community service organizations in 
Tucson. He has also served as a faculty associate with Pima 
Community College's Social Services Program and ASU's School of 
Social Work.
    Welcome, Mr. Clark. Thank you for coming from Arizona. I am 
also glad that there is a fellow BYU alumni on the panel as 
well.
    Thank you, Madam Chair.
    The Chairman. Thank you, Senator Flake.
    And now I want to once again turn to our Ranking Member, 
Senator Casey, to introduce the final witness on this panel.
    Senator Casey. Thank you, Madam Chair. I am pleased to 
introduce Rick Creech from Harrisburg, Pennsylvania. Rick, I am 
going to use some of your own words to describe you. I hope 
that is okay.
    Rick, in your book you refer to yourself as a ``unicorn,'' 
and I know we will hear more about that. But we are grateful 
that you are here, and I do not think I could have come up with 
a single word like that. But I have also read your work. And I 
had an opportunity to meet with Rick today, and I have to say 
his spirit is inspiring and even magical, your ability to 
communicate. And we know that your cerebral palsy does not 
define you. Instead, you have defined cerebral palsy in your 
own way.
    Early on in life, Rick relied upon an alphabet board made 
of wood to communicate. Today, using his powered wheelchair and 
augmentive communication devices, Rick works at the 
Pennsylvania Training and Technical Assistance Network in 
Harrisburg. He is an educational consultant providing training 
and technical assistance on assistive technology and augmentive 
communication and assists schools, providers, parents, and 
administrators about how technology can promote inclusion. He 
is an author, and he is also a poet.
    Rick, I am certain that throughout your life people have 
second-guessed your ability. I am sure after today they will 
have a different point of view. This panel is excited to hear 
your story and hear how you have defied the skeptics and wound 
up here before the Special Committee on Aging discussing, among 
other things, how technology has enabled you to remain actively 
engaged in your community and how your work helps to combat 
loneliness and social isolation in others.
    Rick, thanks for being here.
    The Chairman. Thank you very much, Senator Casey.
    We will now turn to our witnesses, starting with Dr. Holt-
Lunstad.

    STATEMENT OF JULIANNE HOLT-LUNSTAD, PH.D., PROFESSOR OF 
     PSYCHOLOGY AND NEUROSCIENCE, BRIGHAM YOUNG UNIVERSITY

    Ms. Holt-Lunstad. Thank you, Chairman Collins, Senator 
Casey, and members of the Committee, for your interest in 
social isolation and loneliness and for the opportunity for me 
to present testimony today. My name is Julianne Holt-Lunstad. I 
am a professor of psychology and neuroscience at Brigham Young 
University, and my research focuses on the influence our social 
relationships have on our physical health outcomes. In my 
remarks today, I will be talking about the public health 
relevance of social isolation and loneliness, including data on 
prevalence rates, health and mortality risk, and potential risk 
factors.
    Being connected to others socially is widely considered a 
fundamental human need--crucial to both well-being and 
survival. Extreme examples show infants in custodial care who 
lack human contact fail to thrive and often die. And, indeed, 
social isolation and solitary confinement has been used as a 
form of punishment. Yet an increasing portion of the U.S. 
population now experiences isolation regularly.
    It is estimated that more than 8 million older adults are 
affected by isolation. However, if we consider social 
connection more comprehensively, this includes the extent to 
which relationships are present, can be relied upon, and one's 
satisfaction with them. And if we consider this, the prevalence 
of adults in the United States may be--or the prevalence of 
this may be much larger. So, for instance, a quarter of the 
population and 28 percent of older adults live alone, and over 
half the U.S. adult population is unmarried. Three in ten 
marriages are severely distressed, and the majority of adults 
do not participate in social groups. More than a third of older 
adults experience frequent and intense loneliness.
    There is also evidence that isolation or social 
disconnection is increasing. For instance, the average size of 
social networks has declined by one-third, and social networks 
have become less diverse. Census data also shows trends of 
decreasing marriage rates, fewer children per household, and 
increased childlessness and living alone.
    Taken together with an increasing aging population, smaller 
families and greater mobility reduces the ability to draw upon 
familial support in times of need and in older age.
    To estimate the prevalence--or the influence that this has 
on the risk for premature mortality, my colleagues and I have 
conducted two meta-analyses. We first examined the social 
connections, including a variety of indicators. Cumulative 
evidence from 148 studies revealed that greater social 
connection is associated with a 50 percent reduced risk of 
early death.
    The second focused specifically on social deficits, 
including social isolation, loneliness, and living alone. 
Cumulative evidence from 70 different studies, including over 
3.4 million participants, indicates that each of these have 
significant and independent effects on mortality risk.
    To contextualize this cumulative data on social connections 
relative to other leading health indicators, we created Figure 
1 (page 37) to benchmark the magnitude of the effect on overall 
mortality risk. Despite some variation across social 
indicators, there is a consistent and significant effect on 
mortality risk, and the magnitude is comparable and in many 
cases exceeds that of other well-accepted risk factors, 
including smoking up to 15 cigarettes per day, obesity, and air 
pollution.
    As seen in Figure 2 (page 36), prevalence rates or the 
proportion of the population affected are also comparable with 
other risk factors that receive considerable attention.
    Social isolation has also been linked to a variety of 
mental and physical health outcomes. For example, those who are 
isolated are at increased risk for depression, cognitive 
decline, and dementia.
    Social relationships influence health-related behaviors 
such as medication and treatment adherence and have a direct 
influence on health-related physiology such as blood pressure, 
neuro-endocrine and immune functioning, increasing the 
likelihood of the development and progression of a variety of 
chronic illnesses.
    Risk factors include living alone, being unmarried, no 
participation in social groups, fewer friends, and strained 
relationships. Retirement and physical impairments, including 
reduced mobility and hearing loss, may also increase the risk 
for social isolation.
    Why is it important among older adults? Chronic exposure to 
either protective or risk factors are more pronounced as 
individuals age; therefore, we are more likely to see the 
effects of lacking social connection in older adults. Further, 
there are a number of important life transitions among older 
adults that reduce social connection. These include retirement, 
widowhood, children leaving home, and age-related health 
problems.
    Given the incidence of loneliness is known to increase with 
age and social networks shrink with age, the prevalence of 
loneliness is estimated to increase with increased population 
aging.
    In conclusion, the World Health Organization explicitly 
recognizes the importance of social connections, and many 
nations around the world now suggest that we are facing a 
loneliness epidemic. The scientific evidence is clear that 
social isolation poses a significant risk to both older adults 
and public health more generally. The challenge we face now is 
what to do about it.
    I am very pleased to see that the Committee has recognized 
and is bringing attention to this important issue, and I am 
happy to assist in advancing an agenda to address social 
isolation and loneliness among older adults.
    Thank you again for the opportunity to comment, and I 
welcome your questions.
    The Chairman. Thank you very much.
    Dr. Kaye.

STATEMENT OF LENARD W. KAYE, D.S.W., PH.D., DIRECTOR, CENTER ON 
  AGING, AND PROFESSOR, SCHOOL OF SOCIAL WORK, UNIVERSITY OF 
                             MAINE

    Mr. Kaye. Chairperson Collins, Ranking Member Casey, and 
members of the Senate Special Committee, thank you so much for 
inviting me to be here today. I appreciate it. And I also 
applaud your willingness to be addressing what is a very, very 
troubling issue but, unfortunately, an under-recognized issue 
of the day, and that is social isolation.
    As director of the Center on Aging at the University of 
Maine, it has become clear to me that aging Mainers across the 
oldest and the most rural state in the Nation are a stoic and 
fiercely independent lot. But like millions of their 
counterparts in other rural states, they may be losing the 
battle when it comes to protecting themselves against the 
devastating consequences of isolated living and loneliness.
    The fact is social isolation is a silent killer, and it is 
lethal in its impacts. More Americans are dying of isolation 
and loneliness than ever before. The prevalence, in fact, may 
be as high as 43 percent if you break out certain subgroups of 
older adults who are at particularly high risk. And let me 
remind you that risk is high as well for caregivers of older 
adults given that when they engage in elder caregiving, as if 
it were a career, it can become a very, very isolating 
experience.
    Perhaps that is why multiple national social work 
associations have identified social isolation as one of 12 
grand challenges to societal well-being and why AARP, NIH, and, 
as you heard, the WHO have also recognized that social 
isolation requires it be placed on a high-priority list of 
concerns.
    I will only add a couple of risk factors that perhaps were 
not mentioned as much as they might be. One would be facing 
critical life transitions in the lives of older adults, and I 
am referring to divorce, death of a spouse, an abrupt 
retirement, a health crisis, and even children moving out and 
away from under the roof in which older adults live.
    Also, I want to highlight the lack of instrumental 
supports, and here I am talking about the absence of Internet, 
of available transportation, even of telephones in the case of 
some older adults who live in extremely rural and even frontier 
communities.
    The importance of having a social support network cannot be 
overstated in this discussion. Family, friends, and neighbors--
what we call ``informal supports''--and professional caregivers 
together provide not only social support, but please know they 
are socially influential; they create a buffer against stress; 
they increase one's access to resources; they can even 
stimulate the immune system of older adults. Social 
interaction, like a breakthrough medication or balanced low-fat 
diet, extends life.
    Solutions to preventing social isolation and loneliness are 
presenting themselves both locally and nationally and need not 
be excessively costly. Many of them simply require that we 
mobilize local citizens and existing community organizations.
    At the local level, combating social isolation entails 
bringing the older adult either out into the community or 
bringing the community to them. Area Agencies on Aging remain 
one of the first lines of defense, and I will tell you, the 
University of Maine, in partnership with the Eastern Area 
Agency on Aging, is supporting, for example, a student-led 
program called ``Project Generations'' that brings college 
students into the homes of older adults for friendly visiting 
and lending a helping hand. Programs like this offer students 
the opportunity to interact with elders and for older adults to 
serve as role models for those younger people as they grow 
older themselves.
    In at least one Maine community--namely, Augusta--postal 
service workers are trained to ask questions of homebound older 
adults and to check in on them and ensure their well-being. 
Doctors, too, if they so choose, are able to screen for social 
isolation during routine doctor's appointments. These solutions 
are often called ``sentinel approaches,'' and they provide 
gatekeepers--gatekeepers who offer an extra set of eyes and 
ears in the community to identify and address social isolation.
    Many communities have begun to organize programs as well 
where volunteers and law enforcement officers provide regular 
calls and wellness checks to older adults who are known to be 
frail or homebound. One example is in Franklin County, which 
sends sheriff's deputies to regularly check on older adults to 
not only help reduce their risk of falling victim to a scam, 
but also to increase their social contact and ultimately well-
being.
    Creative housing solutions like co-housing where older 
adults live with younger adults can also help to combat social 
isolation and help create a sense of purpose among both the 
young and old.
    If you add to that the availability of smart technologies 
in those homes, you can further enable regular communication 
and contact between older adults and the outside world.
    Remember also that information empowers people and that 
local informational clearinghouses that keep older adults 
informed of services, entitlements, and benefits, and other 
programs available to them and their family caregivers, enables 
them to more easily stay connected with the world around them.
    Several federal programs add to the support infrastructure 
available, and I am referring here to the Meals on Wheels 
Program. That network reaches 800,000 homebound older adults 
across the Nation. They provide not only home-delivered meals, 
they also provide socialization. And the Senior Companion 
Program--part of the national network of Senior Corps 
programs--pairs older adult volunteers with homebound older 
adults in their communities for ongoing socialization and 
support.
    We also know there are ways to prevent social isolation 
before it even occurs, and here I am referring to the 
importance of encouraging older adults to be involved as 
volunteers in their communities through churches and civic 
groups, which can be important avenues for ensuring that they 
stay healthy but also feel vital and needed by the communities 
in which they live. Programs like RSVP, another Senior Corps 
program, and Senior Colleges, of which Maine is proud to say we 
have 17 such lifelong learning programs, offer older adults 
opportunities to meet people and have a purpose.
    Older adults residing in small towns and rural communities 
may be especially vulnerable to the dangers of isolated living, 
but such communities, with relatively modest levels of local 
and federal support, can be mobilized to take action against 
what, in fact, is the lethal threat to their well-being.
    Thank you.
    The Chairman. Thank you very much, Dr. Kaye.
    Mr. Clark.

    STATEMENT OF W. MARK CLARK, M.S.W., PRESIDENT AND CHIEF 
            EXECUTIVE OFFICER, PIMA COUNCIL ON AGING

    Mr. Clark. Good morning. Thank you, Chairman Collins, 
Ranking Member Casey, and members of the Aging Committee, for 
your interest in this topic and the opportunity to testify 
today.
    As Senator Flake noted, I have the honor of serving as 
president and chief executive officer of Pima Council On Aging, 
the Area Agency on Aging serving Pima County, Arizona, since 
1976. Area Agencies on Aging, of which there are 622 across the 
country, were created by the Older Americans Act in 1973. We 
serve as local planning, development, and delivery systems, 
providing home and community-based services to older adults so 
that they may age successfully with maximum health, 
independence, and dignity.
    Pima County is roughly the size of the State of Vermont, 
and one in four of our residents is age 60 or older. But the 
fastest-growing segment of our population is people 85 years of 
age and older, up 35 percent in the past decade.
    Every four years, we collect information about the issues 
of most concern to older adults. Nearly 2,300 people completed 
our survey last fall, almost half of whom lived alone. The 
ability to continue to live independently in one's own home was 
a significant concern of nearly 67 percent of responses. Other 
indicators of isolation, such as loss of a spouse, depression, 
and anxiety, also appeared as significant issues. Social 
isolation itself was cited as a concern by 46 percent of 
responses.
    While aging at home is cited as a top priority by a 
majority of older people and doing so has both emotional and 
economic benefits, it can also lead to isolation. And so meal 
delivery drivers or direct care workers who come into the home 
to drop off lunch or assist with giving a bath, changing 
linens, or shopping can become a social network. Such regular 
contact can help stave off the depression and ill health 
effects that accompany isolation. In fact, these Older 
Americans Act home and community-based programs were 
intentionally designed to meet those socialization needs, as 
well as other needs, including safety, independence, and 
nutrition.
    As we have heard, the causes of social isolation are many. 
What we witness happening is isolation even in the midst of 
community. Long-time residents often have no connection to the 
younger families in their neighborhoods. People retiring from 
other states move to communities like ours and leave behind 
their families, friends, and support systems. We have become in 
a very real sense communities where the garage door is the 
front door, and many come and go without ever seeing neighbors 
except through the car window.
    Other challenges include isolation from the community by 
language or cultural barriers as well as by fear. Many older 
people do not reach out for assistance for fear of losing their 
ability to remain in their homes. Changes to mobility, 
cognitive ability, or health status can cause an individual to 
hold back from previously enjoyed social activities. Older 
adults in rural areas who can no longer drive are at incredible 
risk of physical and social isolation unless transportation 
options are available. And as has been noted, acting as a 
caregiver can itself also be isolating.
    Reaching out to all older people with messages that 
resonate and suggestions they will embrace is critical. That is 
why we participated in last year's ``Expand Your Circles: 
Prevent Isolation and Loneliness As You Age'' campaign, a 
national effort of the Federal Eldercare Locator to boost 
public awareness and education of social isolation among 
seniors.
    While PCOA will continue to tackle the problems as best we 
can at home in Pima County, we offer several policy 
recommendations for consideration by Congress and the 
administration.
    First, public education needs to be increased. Current 
national efforts to raise awareness, assessment, and remedy 
should be strengthened and new interventions developed so that 
we can elevate the issue with more older adults and their 
families. In tandem with national campaigns, local communities 
like ours and the aging and community groups that serve them 
need effective messages and resources to deploy at the ground 
level.
    We also believe that all Older Americans Act programs 
should be increased in fiscal year 2018. We urge you to pay 
particular attention to the Older Americans Act Title III B 
Supportive Services, which provides flexible funding for a 
range of services from in-home supports to transportation, as 
sequestration has eroded III B funding to levels not seen since 
before fiscal year 2002.
    Programs that get older adults engaged in serving the 
community help reduce social isolation for both volunteers and 
those they serve, and we support funding the Corporation for 
National and Community Service's Senior Corps programs.
    Transportation is one of the most pressing needs for all 
older adults who are trying to remain at home and in the 
community, so we need more investment in affordable, accessible 
transportation options.
    We also need to create livable communities for all ages. 
Although there is much that individuals can and should do to 
maximize their independence as they age, public policymakers 
make critical decisions about issues such as transportation 
systems, housing opportunities, and land-use regulations that 
affect whether older adults can live successfully and 
productively at home and in their communities.
    Finally, the problem of social isolation can be reduced 
with better coordination between acute health care systems, 
such as hospitals, doctor's offices, and managed care 
organizations, and the social and human services systems of 
which Area Agencies are a key part.
    Thank you again for the opportunity. I look forward to 
answering questions.
    The Chairman. Thank you, Mr. Clark.
    Mr. Creech.

STATEMENT OF RICK CREECH, EDUCATIONAL CONSULTANT, PENNSYLVANIA 
           TRAINING AND TECHNICAL ASSISTANCE NETWORK

    Mr. Creech. Chairwoman Collins, Ranking Member Casey, and 
other members of the Committee, thank you for inviting me to 
speak today.
    There can be no social engagement with others without 
interactive communication.
    As someone who was born with cerebral palsy and was without 
the ability to speak in the accepted way, I grew up lonely and 
isolated--except for my parents and grandmothers. It was not 
until I received my first vocal output communication device 
that people began to realize that they could speak to me and I 
could speak to them--well, at least, some people did.
    I was born in 1954 in Smithfield, North Carolina. Back then 
babies like I was were not expected to live, and if we did 
live, we were not expected to be out in public, we were not 
expected to be educated, and we were certainly not expected to 
become independent adults. However, I had extraordinary parents 
who trusted in God, and not in all the doctors, the therapists, 
the social workers who said I would never do that, or that, or 
certainly not that.
    My father told me once--and I never forgot this--that he 
wanted me to learn math so that I would be able to manage my 
own money. He wanted me to read so that I would be able to read 
and understand anything that someone might write about me and 
what should be done to and for me. And he wanted me to be able 
to communicate so that I could have control over my life.
    My parents presumed competence in my ability to learn to do 
those things. They insisted that I learn. Boy, did they push 
me. When it came to teachers, I would always prefer to have my 
mother because with her I could slack some. With my father, the 
Baptist preacher, there was no way I could slack. He was more 
demanding than God was with Moses.
    [Laughter.]
    Mr. Creech. However, they taught me that I was competent. I 
was competent enough to go beyond their goals--and their 
dreams--for me. This is what great parents, great teachers, and 
great schools do.
    Supporting individuals who need to use AAC is not simple. 
The person may want to communicate; however, the person will 
have to be taught how to use an augmentative and alternative 
communication device for his or her expressive communication. 
The vocal-impaired person will not know how, what, when, or why 
to express thoughts, feelings, ideas without being encouraged, 
without being pushed.
    I am speaking from experience. Initiating a conversation 
and carrying on a conversation is the hardest thing I do in 
life. To put it simply, I am no good at chit-chatting. I 
believe that there is an optimal age to learn communication 
skills, that age being as young as possible. However, I was 28 
when I got my first voice output communication device, and 
although I still have deficits, I can expressively communicate 
my ideas in conversations.
    I had to work extremely hard, and I work long hours to 
learn to communicate with an AAC device. I used to read 
passages from the Bible and newspapers aloud to practice with 
my AAC device. My point is that we cannot provide a person with 
assistive technology or AAC and expect people to use it.
    I recently got the Amazon Echo to help me to control the 
lights in the house. Sometimes I am ready to throw Alexa out 
the window, and I will not tell you the names my wife has 
called the thing. Amazon Echo is simple compared to AAC 
devices. I started telling people many years ago that assistive 
technology without training is not assistive.
    Even today, as proficient as I am with my AAC device, I 
cannot talk to some people because they are too much in a hurry 
or too caught up in my Accent1400, saying things such as, 
``What can you say?'' ``Can you say my name?'' or they are 
hollering at me as if I am deaf, saying, ``it--is--good--to--
meet--you. What--are--you--doing?'' I get tempted to reply, 
``Talking to an idiot.''
    [Laughter.]
    Mr. Creech. But my parents taught me that if you cannot say 
something nice, say nothing at all, so I do not.
    As I get older, I feel my body slowing down. My bones snap, 
crackle, and pop--like Rice Krispies. My muscles hurt. Right 
now, I have my best friend and my protector, my wife, but she 
is almost my age and has a bad back, arthritis, and diabetes. I 
know that I might not always have my wife by my side. One day I 
will probably be in the care of a minimum wage worker, who will 
have 24 other patients all requiring less time and care than I. 
The only way I have to individualize myself to my caretakers 
will be through my ability to communicate with them so that 
they will be able to see me as a person rather than just 
another patient.
    Of course, if that does not work, I could always call one 
of my three 250-pound sons and say, ``Son, I need help.''
    I would like to thank the Committee on Aging for giving me 
this opportunity to speak here, although I do not think I am 
that old. I would like to thank the Association of Assistive 
Technology Programs for sponsoring my trip here. Before I 
started working for Pennsylvania Training and Technical 
Assistance Network, I worked with Pennsylvania Initiative on 
Assistive Technology. I started PIAT's Short Term Loan of 
assistive technology to adults nearly 30 years ago, so maybe I 
am that old.
    The communication device I use, the Accent1400, costs in 
the neighborhood of $10,000. It is one of the more 
sophisticated AAC devices. However, even simpler augmented 
communication devices with speech output cannot be found for 
less than $5,000. The AAC devices with eye tracking so that 
people can speak with them using only their eyes cost in the 
neighborhood of $20,000.
    All of my assistive technology, my AAC device, my van 
converted for a powered wheelchair passenger, my smart home 
equipment, my powered wheelchair all cost upward of $200,000. 
Still, ladies and gentlemen, that is cheap compared with a 
lifetime of taking care of me in a nursing facility.
    For my work at PaTTAN, Pennsylvania Training and Technical 
Assistance Network, I help manage its Assistive Technology 
Short-Term Loan Program that provides assistive technology to 
school therapists and teachers statewide to try with their 
students. Each year the Pennsylvania Department of Education 
generously provides around a third of a million dollars for 
equipment. To a poor North Carolina country boy, that sounds 
like a lot, but we have constant waiting lists of students, and 
at the end of every school year, there are requests that I have 
to cancel or delay until the next school year because we do not 
have enough inventory to meet the requests. These students need 
appropriate assistive technology to receive education so that 
they can grow to be productive and independent adults who can 
be social members of our society.
    I want to leave the Committee with this thought: Living 
without being able to communicate is like being behind four 
glass walls. You are able to see others and people can see you, 
but you are ignored, or worse, talked down to, until you stop 
remembering who you are and why you are important.
    The Chairman. Mr. Creech, forgive me for interrupting you. 
I have to go cast a vote just across the hall. I will be right 
back. You can continue while I am gone because Senator Tillis 
is going to take over temporarily as the Chair of the 
Committee. Senator Casey may have to go and cast that vote 
also, but I did not want you to think I was one of those idiots 
that you talk to.
    [Laughter.]
    The Chairman. Or that I was disrespectful. And I will 
return very quickly. Thank you.
    Senator Tillis. [Presiding.] You can continue, Mr. Creech.
    Mr. Creech. I have finished.
    Senator Tillis. Well, I hope I did not cut you off, but I 
am from North Carolina, and it is nice to see another North 
Carolinian here before us. Welcome.
    I will, acting in the chair, defer to Senator Casey for the 
first questions.
    Senator Casey. Well, thanks very much. I want to thank our 
panel. And, Rick Creech, thank you in particular. I am, of 
course, showing deference to Pennsylvania. I am sure the other 
witnesses will grant me that privilege, at least for part of 
the hearing.
    Rick, I will start with you. You mention in your testimony 
that your assistive technology keeps you connected to others, 
that it combats isolation and allows you to interact with those 
around you. You also tell us that for you your technology costs 
about $200,000, which is quite an investment. So here is my 
question.
    First of all, how do you pay for your technology, and what 
would life be like without it? That is one question. And maybe 
I will continue on so we have it all in one. And since you work 
with so many other people who need assistive technology to keep 
them connected, how should the Federal Government be supporting 
the costs of assistive technology so that others may stay 
connected for their communities and live independently?
    Mr. Creech. My employer's insurance paid for my powered 
wheelchair and my Accent1400, my communication device. That is 
one reason that I am not planning on retiring anytime soon, 
that and the mortgage on my house.
    The Office of Vocational Rehabilitation in Pennsylvania 
helped pay for my van conversion. The Office of Vocational 
Rehabilitation only will help pay if I am working or I wanted 
to work, another reason I am not retiring anytime soon.
    My personal care aide, who is not technology but certainly 
is assistive, is subsidized by a state program. My smart home 
technology I am paying for piece by piece.
    One of the biggest breakdowns is in transportation. Too 
often paratransit buses are unreliable. I have been told that 
drivers can be rude, although I have never experienced that 
myself. What I have experienced are vans being late or not 
coming; being taken on a 90-minute ride when where I needed to 
go was 10 minutes from my home; my powered wheelchair not being 
fastened down properly. I absolutely love this one. My van 
breaks down, so paratransit is called. Someone tells my wife 
that I cannot use paratransit because I am not registered. You 
have to register every 6 months. If you do not, you are dropped 
from registered users. I guess they figure you are dead.
    So my wife says, ``How can I re-register?'' They say first 
I will have to get a doctor's note saying that I need 
paratransit. Then I will have to go down to the paratransit 
office in person to get a photo ID. My wife stopped them right 
there and asked, ``How about if I rent a U-Haul trailer, load 
my husband and his powered wheelchair in it, and drop him off 
at your front door?'' They replied, ``Oh, no, you cannot do 
that. It takes 4 to 6 weeks to process his registration and put 
him on the schedule.'' My wife hung up.
    So the short answer to your question: Get us decent and 
reliable transportation.
    Senator Casey. Rick, thank you very much for your answers.
    I will yield back to Senator Collins, the Chair.
    The Chairman. [Presiding.] Thank you very much, and I want 
to thank Senator Tillis for taking over the gavel. How did it 
feel?
    Senator Tillis. It was a tough job.
    [Laughter.]
    The Chairman. Dr. Holt-Lunstad, I understand that you flew 
here directly from a conference in Germany--for which I want to 
thank you for making that kind of effort to be with us. I am 
curious whether you find that there is a difference between 
other countries and our country when it comes to issues related 
to isolation and loneliness among our seniors.
    Ms. Holt-Lunstad. Thank you. That is a very good question. 
So there are a couple of different ways in which we can 
approach that. First I will mention that when we look at actual 
data from the meta-analysis that we conducted on risk for 
mortality, we did not find significant differences across 
country of origin. However, I should mention that most of the 
data comes from Western nations, and there is less data from 
developing nations.
    However, we also know that there are some similarities in 
terms of other nations that have also in essence called for a 
loneliness epidemic, so nations such as Germany, the U.K., 
Australia, North America, and Europe have all reported similar 
trends and are considering efforts to alleviate this.
    Another way to consider this, though, is also some of the 
different norms across nations. So in Western nations, we tend 
to value independence. Other nations and cultures tend to value 
collectiveness and being part of a group. And our national 
value on independence to some extent may come at our detriment 
in terms of desire for connecting in older age and the desire 
for independence; and that perhaps if we can change some of the 
national dialogue around the value of interdependence and 
relying upon others as well as being someone to be relied upon, 
that could be a potential solution that we could strive for.
    The Chairman. Thank you.
    Dr. Kaye, you made a very interesting point, and I am 
reminded of it by the testimony we have just heard about people 
wanting to be independent. Your point focused on the caregivers 
and that we have in our state fiercely independent seniors, and 
it is not at all uncommon to find a spouse in her 80s taking 
care of her husband who may be in his 90s, living down at the 
end of a rural road in an old, big farmhouse, and their 
children have moved away, their friends have died, they no 
longer are well enough to go to church each week, and they 
really are cut off.
    Could you talk a little bit more about the impact on 
caregivers and what we could do to try to assist the caregiver 
who may end up being just as isolated as the person for whom 
she is caring?
    Mr. Kaye. That is a crucially important question, Senator 
Collins. The fact is America's families and friends and 
neighbors--again, what we call the ``informal support 
network''--are unsung heroes. These are the very individuals 
who provide the lion's share of care in this country. It is not 
doctors or nurses or social workers. They provide supplemental 
assistance. But 80 percent or more of care in this country, and 
certainly in Maine, is provided by primarily family members, 
and they, as I said, are at risk of living isolated lives. They 
are also likely to be less healthy than members of the general 
population. They themselves are aging. They themselves are 
struggling with chronic illnesses and know that the burden they 
feel when it comes to caregiving is multidimensional. And so it 
is not just a burden on them physically. It is also a burden on 
them socially and emotionally and financially.
    And so caregiving is dangerous business, especially for 
those who are involved in it literally for years at a time. For 
them it becomes a career. And for all too many of them, it is 
their second or third career, because they are also employed. 
And so they are caught between a rock and a hard place. They 
need to hold down employment and at the same time manage the 
responsibilities of caring for a spouse or a grandparent or 
other member of the family.
    So caregivers need as much of our attention and support 
through a comprehensive network of benefits and entitlements 
and programs as older adults themselves.
    The Chairman. Thank you. Senator Tammy Baldwin and I have a 
bill that we have introduced known as the ``Raise Family 
Caregivers Act,'' which we hope we will be able to get through 
this session of Congress.
    Mr. Kaye. I am aware of that bill, and what is very 
inviting and attractive about it, in my view, in particular, is 
that it addresses this comprehensively and it aims to establish 
a national infrastructure, and it realizes that caregiving 
needs responses that are broad-ranging, from information to 
respite care to training and preparation to assessment. And 
that bill appears to recognize all such needs.
    The Chairman. Thank you.
    Senator Tillis?
    Senator Tillis. Thank you, Madam Chairman.
    Mr. Creech, again, thank you. I am from North Carolina. I 
am from a different part of the state, but I thank you for 
being here.
    Mr. Clark, you mentioned Senior Corps earlier. As I 
understand Senior Corps, it is primarily focused on 55 and over 
adults getting engaged in the community, more or less engaging 
them, but the focus is on a younger population, foster 
parenting and other kinds of programs. Is that program or other 
programs out there focused on engaging seniors to engage with 
other seniors?
    Mr. Clark. Chairman Collins, Senator Tillis, the Senior 
Corps programs, in fact, do focus, several of them, on older 
adults. The RSVP program, the historic Retired and Senior 
Volunteer Program, the Senior Companion Program, which I 
referenced in my written material, is a program where low-
income older adults are actually placed and stipended, but 
placed with specific older adults who have support needs. And 
so there is a commonality between those two folks who work very 
closely together.
    So, yes, in fact, the Corporation for National and 
Community Service programs do a lot of good for older adults.
    Senator Tillis. Mr. Kaye, I think you alluded in your 
opening comments to some use of technology. My mother is 84 
years old. If it is on C-SPAN, she is probably watching this 
right now. My father passed away 20 years ago. She is also one 
of the most politically astute people that I know. But we got 
her engaged in something as simple as Facebook probably 10 
years ago, and it has had a remarkable impact on her feeling 
engaged in our daily lives. Sometimes, when somebody engages me 
on my Facebook page, she engages a little bit too much.
    [Laughter.]
    Senator Tillis. She still takes care of her kids. But, you 
know, to what extent are best practices arising to where we are 
leveraging--you know, there are bad parts to the Internet, but 
there are a lot of good uses to connect people when geography--
particularly in my case, six kids spread out all over the 
Southeast, the few that live near her. But are there best 
practices out there or states that are doing, you know, 
particularly better than others that were instructive?
    Mr. Kaye. I am so delighted, Senator Tillis, that you 
raised the technology question. We in Maine take that very 
seriously, and I am pretty proud to tell you the University of 
Maine system has a major aging initiative underway, and I am 
thinking of other universities--I know for a fact in other 
states as well--who have identified and recruited scientists 
and researchers who are aiming to put devices and products that 
enable older adults to age in place and stay connected and 
advance those products on the fast track and get them 
commercialized and available. But what we do know is our best 
practices need to accompany that process, that the best 
technology is going to be that which is responsive to the needs 
of the consumer.
    We in Maine think that means what we have called ``engaging 
older adults in co-design functions''--that is asking consumers 
how that product or that device needs to be styled, what design 
should it reflect, how much should it cost, where should it be 
available for purchase, what should the user interface look 
like; that is, is it easily utilized and taken advantage of by 
older adults.
    And so principles of co-design are driving the research we 
are doing at the University of Maine in our aim to put that 
technology into the homes on as fast a track as possible.
    Senator Tillis. I absolutely believe--I have become just 
obsessed with making sure seniors that I interact with spend a 
moment to go on Facebook--they probably have family members on 
there--to expose them to this interaction tool. And I think the 
more that we use these tools to connect people maybe first 
through the network, that it will naturally foster 
relationships that may result in actual touch and presence, 
which is also very important. So I would be interested in 
getting any feedback you have on the program in Maine or any 
other states.
    Dr. Holt-Lunstad, I am going to ask my last question of 
you. The health impacts of isolation and loneliness I think are 
very compelling. Do you know of any research out there that is 
focused on programs that have affected or maybe bent the curve 
in a positive direction and, if so, whether or not we have 
tried to dollarize them? I think one of the things that we need 
to do--and I kind of pound this in a number of our hearings 
here, or focus on it--is that we need to understand that, on 
the one hand, this is a good thing to do for someone who is 
isolated, but at the same time, it is also, I think, a fiscally 
sound investment of dollars because it reduces cost of health 
and other bad outcomes, whether it is illnesses or similar 
things that tend to cost more if we do not invest.
    Is there any research out there or information you can 
point me to on the subject?
    Ms. Holt-Lunstad. Thank you. Yes, so I want to briefly 
mention one thing about the technology, and then I will also 
talk about effectiveness as well as costs.
    One thing that we need to have some caution about in terms 
of technology is that we need to recognize that it can be a 
tool to bring people together----
    Senator Tillis. And it can become isolating.
    Ms. Holt-Lunstad. Absolutely. And we really need to do more 
research on this and determine to what extent that this can 
facilitate social connection versus bringing people apart.
    Senator Tillis. That is why I made the point of also using 
technology and knowledge of who you are interacting with in 
close proximity to ultimately get them to the point to where 
there is a human connection or a connection with someone else. 
That is why I asked the question earlier.
    Ms. Holt-Lunstad. Right, and there are some that are 
certainly very concerned about particularly younger generations 
that will be our future aging adults, and thus reducing the 
ability to connect face to face and may substitute connections, 
potentially leading to greater isolation. And so certainly more 
attention needs to be paid to that.
    In terms of effectiveness, my colleagues and I, we are 
currently working on another meta-analysis looking at 
interventions and their effectiveness in terms of reducing risk 
for mortality. This is currently still in progress, so we do 
not--this is not published yet. But what I can tell you from 
the preliminary data is that the data is mixed. There are some 
interventions that are effective, and there are others that are 
not effective. And so we do need to be careful and not assume 
that any kind of intervention will be effective.
    Senator Tillis. That information--and I have gone way over, 
but that information is critically important because it is 
instructive to the extent that the federal government gets 
involved in funding or promoting any programs that you are 
going to be--you are naturally inclined to do it because of the 
subject matter, but we want to make sure that we are putting 
the limited dollars into the ones that have the most 
empirically based--positive results empirically based so that 
we--we are going to continue to struggle to have enough money 
even for the good ones. What we do not want to do is spread it 
out, and I think at the expense of drilling down on ones that 
can produce more transformative results.
    Thank you, Madam Chair, for indulging me for going over. 
And my mother is watching. Hey, Mom.
    [Laughter.]
    The Chairman. Thank you very much.
    Senator Cortez Masto?
    Senator Cortez Masto. Thank you.
    Thank you all for being here, and this is such an important 
topic. I am so happy we are having this conversation. I am from 
the State of Nevada and have worked most of my career fighting 
against neglect and exploitation for many in our senior 
community. And just recently, when I was home over the break, I 
had the opportunity to deliver a meal with a Meals on Wheels 
driver. I had an incredible conversation, not only with the 
Catholic Charities who provides the programs in Nevada for 
Meals on Wheels, but also with the driver, as well as the 
senior who was the recipient. And one thing I did learn--and we 
are talking about this now--is it addresses and helps with the 
issue of social isolation and more particularly, medical needs. 
The driver that I was riding with actually responded to a 
medical need of a senior who had fallen. Thank goodness he 
showed up that morning with the meal and was able to help that 
individual.
    I am curious--and I do not think we have heard it yet 
today--are your thoughts on pets and animals, to address 
isolation. Is this something that we should be looking at as 
well. I know many of the seniors that this gentleman talks with 
and delivers Meals on Wheels to, have animals that they treat 
just like their children.
    And then, more importantly, I think we should be funding 
programs like this at the front end. I do not support any cuts 
to any funding for Meals on Wheels or any senior programs, 
because I think in the long-term it saves dollars for Medicaid, 
medical care costs, things that we would be looking at had we 
not had these front-end programs.
    I'd like your thoughts with respect to animals and 
isolation, and front-end programs. How we save money, which is 
really what they say, penny wise, pound foolish, if we are 
going to go down this path of cutting the funding.
    Mr. Kaye. I would like to begin, if I may. There is no 
doubt about it that the availability of pets and companion 
animals makes an enormous difference in the lives of older 
adults. In my experience, in fact, it is those programs that 
may be the most popular and most utilized programs offered in 
the community through Area Agencies on Aging. Pets are known to 
reduce the blood pressure and calm anxiety in older adults. In 
fact, more than a few pets are far more popular than many 
relatives when it comes----
    [Laughter.]
    Mr. Kaye. [continuing]. To providing support for older 
adults in the community. There is no question about it. There 
is a natural tie and connection when animals are brought into 
assisted living facilities and nursing homes. There is an 
immediate response. It is visceral, it is observable. Older 
adults are immediately engaged, and it makes it clear and 
drives home the point for me that that should be among the 
arsenal of programmatic responses that we offer in fighting 
against social isolation.
    Mr. Clark. Madam Chairman, if I might also, Senator Cortez 
Masto, absolutely, pets are important. One of the issues that 
we hear about from our Meals on Wheels drivers is the concern 
that sometimes our meal recipients are actually feeding their 
meals to their pets or sharing their meals with their pets. And 
so we are actually working with local pet stores and securing 
pet food donations with our animal welfare organizations in the 
community and actually exploring ways that we may be able--you 
know, with the health requirements and everything, that we may 
be able to deliver some pet food at the same time we are 
delivering lunch. So it is definitely an issue that we are 
concerned about.
    We also are working with our older adults between our 
social service agencies and our animal welfare agency to try to 
develop a notification system, sort of an end-of-life-care plan 
for my pets, not when the pets die but what is going to happen 
with my pet when I die. And so through end-of-life-care 
planning processes, we are working on that as well.
    Senator Cortez Masto. Thank you, and I am glad you brought 
that up because recognizing that many of the seniors are giving 
their food to their pets, the program that I was able to ride 
along with started obtaining pet food to also give to the 
seniors, and then the driver has little treats that he gives to 
the animals when he shows up to deliver the food as well. So I 
appreciate that. Thank you so much.
    The Chairman. Thank you.
    Senator Warren?
    Senator Warren. Thank you, Madam Chair.
    It is hard to maintain social relationships when you cannot 
communicate very well, and a big reason that older adults have 
trouble communicating is hearing loss. When people cannot hear, 
they do not just drop out of a conversation in a noisy 
restaurant. They often drop out of social life altogether. 
Research shows that seniors with hearing loss are more likely 
to experience loneliness and they score higher on measures of 
social isolation, meaning, for example, reporting that they do 
not have any close friends, not having anyone to talk over 
problems with if they face a difficult situation. And this is a 
really big deal on the numbers. More than two-thirds of people 
in their 70s have hearing loss, and that figure jumps to 90 
percent of people over the age of 80.
    So, Dr. Kaye, in your experience studying healthy aging, 
does untreated hearing loss play a role in people's ability to 
stay active and engaged in their communities?
    Mr. Kaye. Of course it does. Senator Warren, it is a 
critical issue. Sensory impairment is a frequent and 
commonplace chronic impairment, and I would argue that hearing 
loss may be the most crucial sensory impairment because, as you 
said, it cuts off the ability of one individual to communicate 
with another. And the fact is not only is it untreated, but 
initially it is undiagnosed. As I understand it, over 9 million 
individuals over 65 suffer from hearing loss, and my 
understanding is some three out of five of them have not had it 
treated, which means they are not taking advantage of the rapid 
advance in the quality and the efficacy of hearing aids.
    Senator Warren. So let us talk about that for a second, 
because there is the good news. The good news is we can treat 
hearing loss, and hearing aid technology has just gotten better 
and better and better. The bad news is that the vast majority 
of people with hearing loss, more than 80 percent according to 
the estimates I have read, are not using hearing aids, and one 
of the principal reasons is they cannot afford them. Out-of-
pocket costs for a single hearing aid average more than $2,000, 
and most people do not need one, they need two.
    So the question becomes: Why are hearing aids so expensive? 
And the reason in part is because state and federal regulations 
restrict this market. They limit competition and channel all of 
the business to licensed hearing aid dispensers, even though 
evidence shows that with some oversight from the FDA, hearing 
aids could be made directly available to consumers in a way 
that is safe, effective, and far less costly.
    So, Dr. Kaye, let me ask you this one: The National 
Academies of Science, Engineering, and Medicine have 
recommended changing regulations to permit over-the-counter 
sales of hearing aids to bring down prices dramatically. Do you 
think this would make a difference for seniors, and 
particularly for seniors in rural areas who are closed out of 
markets more often?
    Mr. Kaye. My knee-jerk reaction is that any policy that 
makes devices, technologies, programs, services more readily 
available is to be applauded.
    Senator Warren. Good.
    Mr. Kaye. In rural communities, lack of access is a major 
issue. Lack of affordability, of course, is as well.
    Senator Warren. Good. Thank you. And if I could ask, Mr. 
Creech, you do not use hearing aids, but you do use technology 
to help you communicate. Could you just say a brief word about 
the importance of access to technology so that you can stay 
engaged with your friends and colleagues?
    Mr. Creech. If I did not have access to technology, I would 
be in a nursing home in my pajamas, being pushed in a manual 
wheelchair in front of a television until my brain turned to 
mush that not even zombies would eat.
    [Laughter.]
    Senator Warren. Thank you, Mr. Creech.
    Mr. Creech. Assistive technology has to be affordable, and 
it is not.
    Senator Warren. Yes.
    Mr. Creech. I am trying to build a smart home system 
through Amazon Echo and my smartphone. I will be paying $30 a 
month for three years for the phone; the Amazon Echo, $175. The 
Echo Dot, which I will need in every room, is $40 each. A smart 
thermostat will be $275 plus installation. Smart keyless lock, 
$250. Smart ceiling fans and lights, $400 each. I have not even 
checked into smart televisions and appliances. This wonderful 
smart home thing holds a lot of promise, but just like any 
other assistive technology, people with disabilities cannot 
afford this amazing technology without funding assistance. The 
cost of not providing assistive technology would be more than 
the country could afford in lost productivity, in lost 
creativity, in lost humanity, and in increased medical cost, in 
increased personal care cost, and in increased cost to family 
members who would have to stay home to care for their loved 
ones instead of being free to work outside of the home.
    Senator Warren. Thank you very much. It is a powerful 
statement about the importance of technology. And on hearing 
aids, I just want to say they should not be reserved for the 
privileged few who can afford $5,000 in order to have some 
assistance. I just want to say this is why I have introduced 
bipartisan legislation with Senator Grassley, Senator Isakson, 
and Senator Hassan that would implement the recommendations of 
the National Academies panel and create an FDA-regulated 
category of safe and effective over-the-counter hearing aids. 
It has been endorsed by the AARP, by the Gerontological Society 
of America, and by the American Doctors of Audiology, a leading 
group of health practitioners who deal in hearing aids.
    One way to tackle the problem of loneliness and isolation 
and depression for some older adults is to cut the cost of 
hearing aids so they have a chance to participate in 
conversations with other people.
    Thank you, Madam Chair, and thank you for letting me have a 
little extra time.
    The Chairman. Thank you.
    Mr. Clark, when I was listening to your testimony and read 
your written testimony, I was reminded of an important fact, 
and that is that we should not only talk about how we can get 
services to our seniors but also our seniors have a lot to 
offer, and I do not think we should forget that part of the 
equation.
    I was thinking, when Dr. Kaye was talking about the senior 
companion program, for example, and also our Senior Colleges in 
Maine, of which there are 17, I think you said, and oftentimes 
the courses for those colleges are taught by people who are 
retired. So you talked about certain programs, the Aetna model, 
for example, that can be useful to change our perception of 
seniors as solely needing service but, rather, looking at the 
fact that they can serve others, too. And, of course, that is a 
wonderful way to end isolation and loneliness. Could you talk a 
little bit more about that?
    Mr. Clark. Well, at Pima Council on Aging, we have been 
working with older adult volunteers for a number of years. We 
were one of the original RSVP programs. We are not doing that 
program anymore, but we work very collaboratively with the 
Senior Corps program, which is the program that Aetna 
participated in, which is where older adult volunteers are 
paired--they are actually stipended volunteers--with older 
adults who need some in-home assistance, and so they both 
benefit.
    But I also want to reference the Neighbors Care Alliance, 
which I also mentioned in my testimony. That is a program that 
PCOA began 10, 12 years ago, I think, as part of a compassion 
connection grant, and that really is a collection of 
neighborhood-based, but also faith communities and a couple of 
social service agencies, volunteer organizations like the one 
in the neighborhood I live close to, the Old Fort Lowell Live-
at-Home Program. That program is neighbors actually caring for 
each other, and so they are driving--and most of them are older 
adults who are doing the caring, so they are driving people to 
physician appointments; they may be taking people shopping, 
stopping by for friendly visiting, or maybe placing a call, 
occasionally bringing a meal in if somebody needs one on a 
short-term basis, maybe somebody coming in and changing a light 
bulb; you know, not so much yard work, maybe once a year sort 
of major cleanup. And then another neighbor allows his or her--
his, I think--garage to be used as a durable medical equipment 
lending library, so if somebody has a short-term need for a 
potty chair or a wheelchair they can get it rather than having 
to buy it.
    So we have about 15 of those Neighbors Care Alliance 
affiliates in the community, and they serve thousands of folks. 
We have a little bit of money from our regional transportation 
authority for senior volunteer driving, and so we are able to 
reimburse their driving volunteers on a per mile basis for the 
driving. And driving is a big piece of what those NCA 
affiliates do, but they do all those other things. And so it is 
a way--we know that people age much more healthfully, if I can 
make up a word, if they stay active and involved. And those 
kind of programs are really helpful in allowing people to stay 
active and involved.
    The Chairman. Thank you.
    Mr. Creech, first of all, I want to thank you for sharing 
your story. In addition to the technology that has been so 
important to you and it has allowed you to connect with people 
and communicate, are there other steps that you have taken to 
overcome isolation?
    Mr. Creech. The loneliest time in my life was during 
childhood. I had no friends. My outings out of my home was 
limited to the churches my father pastored. My days were spent 
in my home trying to find ways to fight boredom. I had plenty 
of toys; with some I could actually play. I was always able to 
bamboozle my parents into letting me have a dog or a cat, the 
same way I bamboozled my wife into letting my youngest son have 
a dog, and we have had dogs in the house ever since. There was 
nothing for me to do except watch TV or read books. I found 
that I much preferred my books over TV. Back then, my 
communication was limited to the typewriter and an alphabet 
board. Have you tried to communicate with someone who used an 
alphabet/word board? Most people cannot. My experience has been 
after you finish spelling the third word, they forget what was 
the first word you spelled. You dare not use words that have 
over two syllables else you will completely mess up your 
communication partner's mind.
    I do not know if you have watched the television show 
``Speechless.'' JJ on that show supposedly uses an alphabet/
word board with an optical head pointer, and he is able to 
point to a few squares on the board, and his aid comes out with 
these correct sentences. That is not how it works in the real 
world, folks. When I used an alphabet board, I was lucky to get 
three simple words together before blowing the other person's 
mind. And what teenager wants to talk with friends through a 
grown adult reading over his or her shoulder? I am 
flabbergasted every time I see that in the show.
    The Chairman. Thank you.
    Senator Casey?
    Senator Casey. Madam Chair, thanks very much.
    Rick, I was thinking as you were giving testimony today and 
telling your own story, you know, you said in your testimony, 
``I am no good at chit-chatting.'' After all this time, Madam 
Chair, chit-chatting is so yesterday, isn't it?
    [Laughter.]
    Senator Casey. But I have two final questions, two serious 
questions that involve, Rick, part of your family's story. You 
shared with the Committee that your mother has Alzheimer's 
disease. The Committee recently held a hearing on the topic and 
continues to advocate for medical research funding that will--
will one day--lead to a cure, for funding to support those who 
are caring for family members with Alzheimer's. However, the 
disease can also lead to isolation for the individual diagnosed 
and their family.
    So two questions in one. How has your mother's diagnosis 
changed your interaction with her? And has it resulted in any 
feelings of isolation for you?
    Mr. Creech. This is hard for me to put into words. For 28 
years my mom was life. She fed, she dressed, she bathed me. For 
28 years, she was the first face I saw in the mornings and the 
last face I saw at nights. Ever since she went to a nursing 
facility, I have not been able to call her on the phone. This 
afternoon, I will be going down to North Carolina to visit mom. 
I do not know if she is going to recognize me. This is the 
woman who a few years ago gave my wife a box full of old papers 
of everything that I had typed since I was 8 years old. I 
thought, ``OMG, what other potentially embarrassing things has 
she kept?''
    [Laughter.]
    Mr. Creech. This is the woman who during my first year of 
college, because I had gotten a mouthful of mouth ulcers and 
could not eat, came and stayed in my dorm for a month and 
nursed me back to health so that I would not have to drop out 
and go back home.
    Mom is not here anymore. What lingers is the shell that 
used to contain my precious mother. Mom is gone as certainly as 
dad is gone. I feel like a captain of a sailing ship after the 
stars have fallen and the sun will not show itself. All I have 
is my memory of them and the principles they instilled in me to 
guide me through.
    Senator Casey. Rick, thank you very much.
    Thank you, Madam Chair.
    The Chairman. Thank you very much, Senator Casey.
    I want to thank all of our witnesses for being here today, 
for your patience as we maneuvered the time and date of the 
hearing. To my knowledge, this is the first hearing on Capitol 
Hill to address the issue of isolation and loneliness among our 
seniors, and it is such an important issue when you look at the 
impact on our seniors' health and well-being. When I learned 
the startling statistic that we heard today from Dr. Holt-
Lunstad about the mortality risk of isolation and loneliness, 
something that Dr. Kaye also talked about, it tells us that 
this problem is a serious one and it is pervasive, and yet it 
has received very little attention outside of the work done by 
the experts in the field and in academia.
    So one of my hopes today is that we have raised public 
awareness of this problem and we can start to explore some of 
the creative solutions that you all have talked about, whether 
it is greater use of technology or having Meals on Wheels 
drivers specifically check on the health of the seniors or 
pairing college students and seniors, which I love that 
program, Project Generations, that Dr. Kaye has started in 
Maine, or helping seniors be of service to others as well. As I 
said, I think it is really important that we remember that this 
problem can be addressed from both directions in many cases. 
And using the resources that we have, we can come up with some 
creative solutions to reach out and connect seniors with 
communities. ``Connections,'' it seems to me to be the word, 
whether you are connected with your family, your neighbor, your 
community, your church, your college. That seems to be what 
helps to keep people healthy and strong and increases their 
well-being.
    So now today we have learned a lot about the problem. We 
have all heard the phrase that it takes a village to raise a 
child. Well, I think the flip side of that is the village can 
also care for our seniors, and our seniors need to be an 
integral part of that village.
    So at our next hearing, we are going to look at some of the 
solutions across the country, and I am very proud that my State 
of Maine is really leading the way. Dr. Kaye, you get a great 
deal of credit for that.
    I want to thank our staff for their hard work, all of our 
witnesses, and all of the Committee members who are here today. 
Many of them had conflicts so could only be here briefly, but 
we actually had an excellent turnout, and I think that shows 
that people are very interested in this issue.
    Committee members will have until Friday, May 5th, to 
submit any questions for the record, which we will forward 
along to you.
    Senator Casey, do you have any closing comments?
    Senator Casey. Just briefly. Madam Chair, thank you for 
convening the hearing. I want to thank our witnesses for being 
with us, Rick especially, and we are grateful for your presence 
here and your message.
    Despite the challenge of this issue, isolation and 
loneliness, we know what works. We know that drop-by programs 
work, whether it is Meals on Wheels or some other program. 
Group interventions work. And we know, of course, that 
assistive technology works. So we are looking forward to more 
discussion on these issues and are grateful to have the 
opportunity today. Thanks very much.
    The Chairman. Thank you, and this hearing is now adjourned.
    [Whereupon, at 11:26 a.m., the Committee was adjourned.]



      
      
      
      
      
      
      
      
      
      
      
      
      
      
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                                APPENDIX

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                      Prepared Witness Statements

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 Prepared Statement of Lenard W. Kaye, D.S.W., Ph.D., Director, Center 
  on Aging, and Professor, School of Social Work, University of Maine
    Aging Mainers across the oldest and most rural state in the Nation 
are a stoic and fiercely independent lot. But like their millions of 
counterparts in other rural states across the Nation, they may be 
losing the battle when it comes to protecting themselves against the 
devastating consequences of living a socially isolated and lonely life. 
Let there be no doubt, social isolation is a killer and more Americans 
are living in isolation than ever before. The prevalence may be as high 
as 43% among community dwelling older adults. And, the risk is high as 
well for caregivers of older adults given that caregiving can be a very 
isolating experience. Perhaps that is why the National Association of 
Social Workers, the World Health Organization, AARP, and the National 
Institutes of Health, among others, have recognized the need to place 
social isolation on their lists of major challenges and high priority 
threats to societal well-being. It is a perplexing, potentially lethal 
problem, impeding a successful and productive old age. The bad news is 
that the challenge is perhaps greatest for older adults living in small 
towns and rural communities where individuals are separated 
geographically, children and grandchildren have often left for the 
bright lights of the big cities, and critical community supports are in 
short supply.
    I've come to realize that stoicism and a fiercely independent 
spirit can be overrated qualities and not always something to aspire 
to. Not when we learn that such individuals are at higher risk of 
living social isolated and lonely lives which, in turn, research 
confirms, will place them at higher risk of a variety of poor outcomes 
including disability, high rates of mortality and morbidity, dementias, 
hospitalizations, falls, not surviving natural disasters, poor health 
practices, psychological distress, neglect and exploitation, lower 
self-reported health and well-being, and even the common cold.
    Who is at greatest risk? That would be LGBT older adults, those 
with physical, sensory, and functional impairments, who live alone, are 
80 years of age and older, are geographically isolated, living on 
limited income, lacking instrumental supports (access to 
transportation, the Internet, telephones, etc.), with poor mental 
health, weak social networks, and facing critical life transitions 
(i.e., divorce, death of a spouse, an abrupt retirement, a health 
crisis, children moving out, etc.).
    The importance of having available a social network cannot be 
overstated in guarding against social isolation. Family, friends, 
neighbors, and professional caregivers provide social support, social 
influence, create a buffer against stress, increase your access to 
resources, and can even stimulate your immune system.
Local Solutions That Make a Difference
    Solutions to preventing social isolation and loneliness are 
presenting themselves both locally and nationally and need not be 
excessively costly. We do, however, need to remain vigilant and 
especially mindful of those conditions that put older adults at risk.
    The University of Maine Center on Aging recently gathered 200 
professionals and community members together at a conference to discuss 
older adult social isolation. Their front-line experience suggests 
additional factors can increase the risk of social isolation including 
ageist views and stigma about aging, a lack of transportation to get 
older adults out into the community, lack of access to technology which 
could bridge communication gaps with loved ones, poor health, 
alcoholism, and increasing lifespans which mean that many older adults 
outlive their friends and family. Responding to these challenges, the 
University of Maine has identified aging research as an emerging area 
of excellence and is especially encouraging its scientists to focus on 
developing user friendly, accessible, and affordable technologies that 
will keep older adults safe, secure, and mobile not only in their 
homes, but in their communities.
    At the local level, combating social isolation entails bringing the 
older adult out into the community or otherwise bringing the community 
to them. The University of Maine in partnership with the Eastern Area 
Agency on Aging, is supporting a student-led program, Project 
Generations, that brings college students into the homes of local older 
adults for friendly visiting and lending a helping hand. Programs like 
this offer students the opportunity to interact with and learn from 
older adults while providing elders with a much needed source of 
support.
    In at least one Maine community (Augusta), postal service workers 
are trained to ask questions of homebound older adults to check in on 
them and ensure their well-being. Doctors, too, if they choose, are 
able to screen for social isolation during routine doctor's 
appointments. These solutions, often termed sentinel approaches, 
provide an extra set of eyes and ears in the community to identify and 
address social isolation through screening and referral.
    Many communities have begun to organize programs where volunteers 
and law enforcement officers provide regular calls and wellness checks 
to older adults who are known to be frail, homebound, and isolated. One 
such program in Franklin County, Maine, sends sheriff's deputies to 
regularly check in on older adults to not only help reduce the risk 
that an older adult would fall victim to a scam, but also to increase 
social contact and well-being for the older adult.
    Creative housing solutions like co-housing where older adults live 
with younger adults can also help to combat social isolation and help 
to create a sense of purpose among older adults.
    Several federal programs are providing lifelines to older adults 
who are homebound including the Meals on Wheels Program, a network that 
reaches over 800,000 homebound older adults across the Nation, 
providing not only home-delivered meals but also socialization. The 
Senior Companion Program, (part of the national network of Senior Corps 
programs), pairs older adult volunteers with homebound older adults in 
their communities for ongoing socialization and support. One such 
Senior Companion volunteer shared a story of Mrs. C, a woman whom she 
visits, and how she supported Mrs. C after the death of her husband. 
The loss of a spouse is a particularly critical time for supporting 
older adults and ensuring that they do not become shut off from those 
around them:

        ``Mrs. C experienced the loss of her husband after a long 
        terminal illness. Having devoted her life to the continuous 
        care of Mr. C, she was left without purpose in her life. Mrs. C 
        had no family in this area and felt completely alone. As her 
        Senior Companion, I was able to assist her through arrangements 
        to be made for Mr. C's cremation and celebration of life. Other 
        difficult areas included finances, health, and well-being. It 
        has been nearly two years since the passing of Mr. C. With 
        continuous compassion and understanding, I have been able to 
        help Mrs. C connect again to the world around her. She has made 
        great progress spiritually, emotionally and with socialization. 
        As a Senior Companion, I am always at hand for comfort and 
        support or simply just to listen.''

    We also know there are ways to prevent social isolation before it 
occurs. Encouraging older adults to be involved in their communities 
through churches, civic groups, and volunteer roles can be important 
avenues for ensuring that older adults stay healthy and connected to 
the world around them. Programs like Retired and Senior Volunteer 
Program (RSVP) and Senior College offer older adults opportunities for 
meeting new people and learning new skills.
    Dr. Kelley Strout at the University of Maine has developed a pilot 
program called GROW which sets up garden beds at low-income congregate 
housing sites. Originally intended to increase the consumption of 
healthy foods, the program also increased social ties between residents 
who would not have otherwise interacted and formed friendships despite 
living within the same housing complex. There are numerous examples of 
programs like this throughout the country that provide an outlet for 
older adults to naturally connect with others.
Summary of the State of Current Research
    There is still significant progress to be made in determining what 
works for helping to reduce social isolation. Lack of rigor in studies 
of interventions aimed at reducing loneliness make it difficult to 
evaluate some of these strategies.
    Due to the various life events that can trigger social isolation, 
from death of a significant other, to loss of transportation, to health 
decline, effective interventions will need to be diverse and they will 
need to be tailored to the personal circumstances of the isolated 
individual.
    AARP's Framework for Isolation in Adults Over 50 states that 
``Reviews support that effective interventions target specific groups, 
use representative samples of their target population, use more than 
one method of intervention (target more than one aspect), allow 
participants an element of control, include individual participation in 
intervention planning, and have facilitators who have adequate training 
and resources.''
Other Community-Level Strategies
    The Maine Health Access Foundation has initiated a significant 
grant program in the State of Maine called ``Thriving in Place'' which 
supports individuals with chronic conditions and disabilities in 
remaining in their homes as they age. Although the activities being 
undertaken to support aging-in-place are diverse, reducing isolation is 
a key component of Thriving in Place activities. In a review of 
Thriving in Place initiatives in the state, project evaluators 
identified promising strategies and lessons learned related to reducing 
isolation that were emerging from these community change efforts. These 
include the importance of developing systems of care whereby people who 
may have contact with isolated older adults, such as EMTs, Meals on 
Wheels drivers, and other individuals who are knowledgeable enough 
about community resources and referral processes, can act as 
gatekeepers and key points of access to supportive services which can 
reduce isolation and meet other needs.
    Another finding was that services promoting older adult well-being 
have added benefits in reducing social isolation. Examples include 
morning check-in calls from law enforcement programs, which often have 
a primary stated purpose of ensuring physical safety for homebound 
adults. This finding has been borne out in conversations conducted by 
the Center on Aging with coordinators of check-in programs who have 
indicated that participants have become less isolated due to these 
brief daily contacts. Additionally, through a research partnership with 
a local Village to Village model organization, At Home Downeast, 
interviews with volunteer drivers have indicated that volunteer 
provided rides to health and non-health related destinations serve also 
as an opportunity for members of the Village to receive much need 
social contact.
    AARP's Age-Friendly community initiative is another community-level 
strategy for supporting aging-in-place and reducing social isolation. 
Like the Thriving in Place initiative, it examines aging-in-place 
holistically through a framework called the ``eight domains'' that 
contribute to a livable and age-friendly community including:

      Outdoor Spaces and Buildings
      Transportation
      Housing
      Social Participation
      Respect and Social Inclusion
      Communication and Information
      Community and Health Services, and
      Civic Participation and Employment

    Although all domains have implications for reducing isolation and 
loneliness, two of the eight domains are particularly important: Social 
Participation, and Respect and Social Inclusion. Key elements of these 
domains that can impact social isolation are ensuring accessibility of 
local gatherings in terms of transportation, affordability, and 
physical accessibility; ensuring that outreach for events in a 
community are targeted at those at risk of isolation, and combating 
negative stereotypes of aging individuals.
    We should not minimize the lessons learned from the age-friendly 
community movement in terms of what individual towns and communities 
can be encouraged to do to reduce the risk of social isolation among 
its older citizens, and all its citizens for that matter. The 
University of Maine Center on Aging recently conducted a series of 
community focus groups with citizens of Bangor, ME and discovered the 
following high priority action steps that can be taken to fight 
isolation, include: developing and maintaining robust transportation 
programs geared to meeting the needs of older adults, making the 
community walkable, offering senior center/community center 
programming, ensuring that outdoor spaces and buildings are accessible, 
maintaining opportunities for meaningful volunteer and civic 
engagement, and establishing a more comprehensive and timely 
informational clearinghouse that reaches elders and their caregivers 
with available resources and programs. I'm proud to say that Maine 
leads the Nation in the number of towns and communities that have 
formally joined the age friendly community movement--some 35 of the 163 
such communities across the U.S.
    Older adults residing in small towns and rural communities may be 
especially vulnerable to the dangers of isolated living, but such 
communities, with modest levels of support, can be mobilized to take 
action against this threat to well-being in later life.
                               __________
 Prepared Statement of W. Mark Clark, M.S.W., President and CEO, Pima 
                            Council On Aging
    Good afternoon. Thank you, Chairman Collins, Ranking Member Casey 
and members of the Aging Committee, for the opportunity to testify 
today on the problem of social isolation and loneliness among older 
adults.
    My name is W. Mark Clark and I have the honor of serving as 
President and CEO of Pima Council On Aging, the Area Agency on Aging 
serving Pima County, Arizona. Since 1967, Pima Council On Aging (PCOA) 
has identified the needs of older adults in our planning and service 
area, and responded to those needs with community-based programs and 
services. In our role as the Area Agency on Aging for Arizona Region 
II, PCOA has served generations of older adults and their families in 
communities across Pima County, through planning, advocacy and 
providing and contracting for services. Area Agencies on Aging, of 
which there are 622 across the country, were created by the Older 
Americans Act in 1973 to serve as the local planning, development and 
delivery system providing home and community-based services to older 
adults so that they may age successfully with maximum health, 
independence and dignity.
The Aging of Pima County
    Pima County is home to the city of Tucson, the second-largest metro 
area in Arizona. Because of our mild winters, thriving hospitality 
industry, natural desert beauty and relatively low cost of living, 
Tucson and other parts of Pima County are primary destinations for new 
retirees and older winter visitors, contributing to it being among the 
fastest aging regions in the Nation. Pima County covers 9,184 square 
miles--roughly the size of the State of Vermont--and is home to more 
than 248,000 people who are 60 years of age or older. That means one in 
four County residents is age 60 or older today. The population growth 
among those under 50 years old has remained stagnant in the last 5 
years in the County, while the population in their 60's grew by 16%. 
The fastest growing segment of the population were people over 85, 
which has increased by an astonishing 35% in the past decade. We are 
not alone in these remarkable numbers--while Arizona is one of the most 
rapidly aging states, every single state in the Union is growing older 
as the baby boomers age and people live longer. By 2030, one in five 
Americans will be age 65 or older.
PCOA's Role in the Community
    Pima Council On Aging's 50 year history of supporting older adults 
in their homes and communities means we are one of the nation's 
longest-serving providers of the critical home and community-based 
services that are the mandate of every Area Agency on Aging. In fact, 
we began providing these vital supportive services even before Area 
Agencies on Aging were formally established in the 1973 reauthorization 
of the Older Americans Act.
    Today this coordinated system of services provides supportive 
programs including home-delivered meals, congregate meals and 
socialization, transportation, in-home care, home repair and 
adaptations, legal services, evidence-based health promotion programs, 
and assistance for family caregivers. The federal dollars we receive 
through the Older Americans Act are the foundation of this system, as 
we leverage state and local dollars to increase our ability to meet the 
need and help older adults meet their goals of aging at home and in the 
community, remaining healthy, and retaining their independence for as 
long as possible. To accomplish these lofty goals, we work in 
partnership with approximately two dozen service provider partners to 
provide an array of services, programs and options for older adults, as 
well their caregivers.
    But to stay healthy and to age well, older adults need to remain 
engaged. The home-and-community-based services we offer, such as home-
delivered meals through the Pima Meals on Wheels program, senior lunch 
programs, senior center programming and in-home services, increase or 
maintain self-sufficiency and independence and reduce social isolation 
for the people we serve. In our last fiscal year, PCOA delivered just 
shy of 204,000 meals, utilizing 20 routes to cover metro Tucson--and 
the outlying rural communities where people are at even greater risks 
for isolation--to nearly 1,500 individuals who are homebound, unable to 
prepare a nutritious meal because of health or physical limitations and 
have no one to assist them. For many, the driver who delivers their 
meals may be the only person they see regularly during the week. It is 
not uncommon for our delivery drivers to find people who have been 
experiencing medical emergencies for a day or longer, and have to 
provide crisis assistance.
    In collaboration with our community partners, PCOA also provides 
nutrition programs in community settings, and these congregate meals 
have, since inception, had a twin goal of enhancing seniors' nutrition 
and encouraging socialization. We served nearly 87,000 meals through 
lunch programs to around 2,000 older adults at our network of 13 
community and neighborhood-based centers; 91% of them tell us that the 
program gives them someone to talk to each day. The majority of our 
home-delivered meal clients live alone (67%) and all are frail or 
disabled. More than half (55%) of congregate meal participants live 
alone, and nearly 30% are frail or disabled. Our home-and-community-
based system of services known as the Community Services System 
includes not only these two types of meals programs, but also other 
supports and services that allow people unable to perform basic tasks 
of daily living for themselves to remain living in their own homes. 
Common in-home services include homemaker services (laundry, cleaning), 
personal care services (bathing, dressing) and personal safety systems, 
while community supports include transportation, legal services and 
caregiver supports.
Social Isolation Harms Health, Independence
    Data from our local communities tell us that social isolation and 
related factors significantly impact the lives of our older friends and 
neighbors, which is validated by national data and emerging research on 
the significant negative health effects of becoming isolated or lonely. 
In our role as the Area Agency on Aging, since 1975 PCOA has conducted 
the only community needs assessment of its kind to identify the needs 
of older adults age 60 and older. Every three to 4 years, PCOA collects 
information about the issues of most concern to older adults in our 
communities through a written survey, public listening sessions and 
focus groups with professionals in the field. Through our most recent 
community needs assessment process in the fall of 2016, nearly 2,300 
seniors completed surveys in English and in Spanish, with nearly half 
of those respondents reporting they lived alone. The second-highest 
ranking concern for older people in our community, only slightly 
outranked by falls and fear of falling, was being able to continue 
living independently in their own homes. Remaining independent and 
aging in place was expressed as an issue of some or serious concern by 
nearly 67% of the people we surveyed. Other significant concerns 
included loss of a spouse, depression, mental health issues and related 
indicators of isolation, as well as social isolation itself, which was 
specifically cited as an issue by 46% of respondents.
    While aging at home is cited as a top priority by a majority of 
older people, and doing so has both emotional and economic benefits, 
aging in place at home can also lead to isolation. As socialization 
that occurs naturally throughout much of adult life through work, 
raising children, volunteerism, and connection to family wanes in one's 
life, without opportunities to build new social networks, including 
having the health and mobility to do so, living independently can lead 
to that person becoming nearly entirely isolated over time. And so, 
Area Agency on Aging funded service providers, such as meal delivery 
drivers or the direct care workers who come into the home to assist 
with giving a bath, changing linens and shopping, become their social 
network, providing not only services that allow the person to remain in 
their home, but also regular contact that can help to stave off the 
depression and ill health effects that accompany isolation.
    Yet not every senior needs those particular programs, so how do we 
do our part to combat and respond to social isolation among a broader 
aging population in our community?
    First, we have to understand the causes of the problem. What we as 
service providers witness happening in our society is isolation even in 
the midst of community. People are aging in place in many of our older 
neighborhoods, while the composition of those neighborhoods has changed 
to younger families with whom they have no connection, so they no 
longer know their neighbors. Our communities continue to see a decades-
long influx of retired people from other states who have left behind 
their families, friends, and support systems. Depending on the area 
they move to, the social opportunities that are available, and their 
ability to navigate the community, they may or may not start rebuilding 
a social network in their new community. Living in gated communities 
often leads to isolation among a relatively homogeneous group of 
people. We have turned into communities where the front door is the 
garage door and that for many, especially those without small children, 
it is possible to come and go without ever seeing neighbors except 
through the car window. We also noted that for some of our longtime 
retirement communities like Green Valley, a community of about 22,000 
people 20 miles outside of Tucson where individuals aged 85 years and 
older make up more than 10% of the population, those who moved there in 
the early years of their retirements have often outlived their savings 
and their vitality. We hear stories about the fact that since the home 
owners' associations maintain the exteriors of the housing units and 
landscaping, hidden behind a facade of normalcy is the despair that 
exists inside where people simply can't take care of themselves and 
don't reach out to others.
    These community patterns and structural challenges contribute 
greatly to the problem of social isolation, but there are other 
challenges we see regularly too, including seniors isolated from the 
community by language or culture barriers, as well as by fear. Living 
alone with increasing frailty can be terrifying, and it's easy for 
these vulnerable older adults to stay inside and resist asking for 
help. And, given the prevalence of elder abuse and the perception of 
crime and violence, we understand their caution. Many older people 
don't reach out for assistance for fear of losing their ability to 
remain in their homes.
    Finally, we know that there are other risk factors that put some 
older adults at greater risk for having their health compromised by 
increasing isolation. Changes to mobility, cognitive ability, or health 
status, which happen frequently in the lives of older adults, can cause 
an individual to hold back from previously enjoyed social activities. 
Older adults in rural areas who can no longer drive are at incredible 
risk of physical, and thus social isolation, unless other 
transportation options are available. The loss of a spouse or a new, 
difficult role as a family caregiver may also lead to a withdrawing 
from the community at a time when more engagement is needed the most.
Solutions to Reach and Engage Isolated or At-Risk Seniors
    Reaching out to all older people with messages that resonate and 
suggestions they will embrace is critical. That's why we participated 
in last year's ``Expand Your Circles: Prevent Isolation and Loneliness 
As You Age'' campaign, a national effort of the Federal Eldercare 
Locator (Endnote 1) to provide a new consumer awareness tool to boost 
public awareness and education of social isolation among seniors. 
Funded by the Administration for Community Living and in partnership 
with AARP Foundation and its' social isolation reduction online 
platform, Connect2Affect (Endnote 2), the National Association of Area 
Agencies (n4a), which operates the ACL-funded Eldercare Locator and of 
which we are a member, created a simple, consumer-friendly brochure on 
the problem of social isolation, risk factors, negative health 
consequences and a self-assessment checklist. The campaign provided 
additional materials for aging providers to ensure that the national 
effort's leveraged media attention was mirrored locally across the 
country. Like our Area Agency on Aging peers around the Nation, we 
found the new brochure a great tool and resource to raise the issue 
locally.
    In addition to sharing the resource itself, a member of our staff 
devoted her monthly column in the Arizona Daily Star, the second-
largest newspaper in the state, to the issue, reaching 200,000 print 
and online readers with specific tips to stay engaged, access supports 
and services and reduce isolation. We saw a significant boost in calls 
coming into PCOA the day the story ran and for the next few days.
    To supplement and build upon our core Older Americans Act services, 
Pima Council On Aging developed the Neighbors Care Alliance to 
encourage neighbors to reach out to one another and formally organize 
volunteers who could provide transportation, friendly visits and calls, 
meals, and run errands. These include many of the top concerns and 
unmet needs voiced by our community in prior-year surveys of the most 
pressing issues facing older adults. The 15 active Neighbors Care 
Programs and their 120 partners are dedicated to helping their aging 
neighbors remain independent, safe, and less isolated in their homes 
for as long as possible. Our communities need to continue to seek 
innovative, often low-cost, neighborhood-based solutions such as this 
effort to address the challenges of aging in our society.
    We have seen first-hand how social isolation impacts quality of 
life and overall well-being, and the dramatic effects that breaking 
down that isolation can have in people's lives. I'm reminded of Edna, a 
woman in her late 60's, who lived alone, suffered from multiple chronic 
health conditions and depression, and received several services from us 
including home-delivered meals, housekeeping help and grocery shopping 
assistance. She rarely left her home. Her concerned case manager 
suggested that she consider volunteering through the Corporation for 
National and Community Service funded Senior Companion Program, which 
at the time had recently been brought to Pima County by community 
partner, Our Family Services. Over time, Edna began volunteering to 
offer companionship to other isolated older adults receiving in-home 
services from us, and within a year, she discontinued most of her own 
services because she simply no longer needed them. She said that going 
to visit with older people in the community every day and a newfound 
sense of purpose had led her to getting around better and doing more 
than she had in a long time. Edna volunteered as a Senior Companion and 
benefited from the boost in vitality that social interaction gave her 
for 8 years, contributing significantly to her ability to maintain 
independent living and her overall quality of life.
    In the course of five decades of service to older people and their 
families, Pima Council On Aging has recognized that social isolation is 
an issue that not only requires intervention to improve overall health 
and well-being, it demands prevention, as well. Encouraging people as 
they age to engage in continuing health-related education, 
volunteerism, and community engagement are critical to reducing 
systemic social isolation in later years. And so, our challenge as a 
society becomes not only continuing to provide and expand critical home 
and community-based supports and services that ensure safety and 
promote independence like those supported by the Older Americans Act, 
but also to break down systemic barriers to lifelong good physical and 
mental health and meaningful engagement. It is our role as an Area 
Agency on Aging to both find ways to reduce social isolation for older 
people like Edna, forestalling the need for deeper interventions, and 
to ensure that those interventions are in place and adequate for those 
who eventually need them.
Policy Recommendations
    Unfortunately, the problem of social isolation is widespread and 
knows no race, gender, income or geographic boundaries. According to 
our national association, n4a, our fellow Area Agencies on Aging share 
our concern, our willingness to respond and our desire to see greater 
awareness and resources deployed to address this problem that, with a 
nation that's aging as fast as ours is, cannot be ignored.
    While PCOA will continue to tackle the problem as best we can at 
home in Pima County, we offer several policy recommendations for 
consideration by Congress and the Administration.
            1. Increase Public Education
    Current national efforts to raise awareness, assessment and remedy 
should be strengthened and new interventions developed. Our agency 
knows what to look for and how to respond, but we don't have the 
capacity to serve every older person in Pima County. The issue needs to 
be elevated so that more older adults and their families understand 
that social isolation is a public health issue and should not go 
unaddressed. In tandem with national campaigns, local communities like 
ours and the aging and community groups who serve it need effective 
messages and resources to deploy at the ground level. The Eldercare 
Locator and Connect2Affect campaigns have been extremely helpful but we 
need more national emphasis on this critical issue.
            2. Expand Services that Promote Health, Engagement, Aging 
                    at Home and in the Community
    As our population ages, it's essential that life-saving, 
independence-maintaining and isolation-reducing home and community-
based services are expanded to meet the incredibly growing need. The 
Older Americans Act's critical services and supports must grow as we 
adjust to this age wave. If we don't meet the need, many older 
Americans will lose their independence and health, resulting in higher 
costs for taxpayers in the form of increased Medicaid nursing home 
costs and avoidable Medicare expenditures. PCOA believes that all Older 
Americans Act (OAA) programs should be increased in FY 2018. OAA Title 
III B Supportive Services--which provides flexible funding for a range 
of services from in-home supports to transportation--needs particular 
attention, as sequestration and other budget cuts have reduced it to 
spending levels not seen since before FY 2002, 15 years ago! This same 
title supports Area Agencies on Aging information and referral (I&R) 
efforts, so that consumers have someone to call for information on and 
access to aging services in that community. While the OAA meals 
programs of Title III C Nutrition have seen restoration from 
sequestration, much more needs to be done to meet growing community 
need now and in the future.
    As Edna's story showed, programs that get older adults engaged in 
serving the community help reduce social isolation for both volunteers 
and those they serve. We support funding for the Corporation for 
National and Community Service's Senior Corps programs, which are 
specifically designed to engage and serve older adults.
    Transportation is one of the most pressing needs for all older 
adults who are trying to remain at home and in the community--
especially those who are isolated, and yet it can be difficult to find 
reliable, accessible, and affordable options to get to the doctor, the 
grocery store, religious services, or social events--all of which are 
critical to staying healthy and independent and prevent isolation. 
Lawmakers must invest in federal, state and local programs that create 
a wider array of affordable, accessible transportation options.
            3. Build Livable Communities for All Ages
    As the population of older adults grows so does the desire and need 
for communities to support people of all ages to ensure that they can 
grow up and grow old with maximum independence, safety, and well-being. 
Although there is much that individuals can and should do to maximize 
their independence as they age, public policymakers make critical 
decisions about issues such as transportation systems, housing 
opportunities and land-use regulations that affect whether older adults 
can live successfully and productively at home and in their community. 
That's why Tucson, through the leadership of Mayor Jonathan Rothschild 
and Council Member Steve Kozachik, recently joined the World Health 
Organization (WHO)/AARP Age-Friendly Communities List, as the 144th 
city in the Nation to join; we are currently deeply involved in the 
planning work to make our community even more age-friendly.
    Federal leadership in livable and sustainable communities is 
vitally needed, yet federal investments in promoting sustainable and 
livable communities has lagged significantly since 2010. In the 
meantime, states and local governments tasked with developing and 
implementing broad long-term community infrastructure and service 
systems have increasingly recognized the value of ensuring that these 
systems meet the needs of the ever-growing aging population. These 
community efforts will only be cost-effective and efficient if they 
reflect our aging reality. This means directing a portion of any new 
infrastructure spending to community agencies and nonprofit 
organizations by encouraging states and local governments to embrace 
livable-communities-for-all-ages principles and make them central to 
the core work of all government departments.
    The more livable a community is, the easier it will be to prevent 
isolation among older adults. If seniors have appropriate housing 
options, can get around smoothly and safely, are tapped as a resource, 
and are vital to the life of the community, it will do a great deal to 
prevent social isolation and loneliness.
            4. Create Stronger Connections Between Health Care Systems 
                    and Community Systems
    The problem of social isolation can also be reduced with better 
coordination between acute health care systems (hospitals, doctor's 
offices, managed care organizations) and the social and human services 
systems. According to the Robert Wood Johnson Foundation, nearly 90 
percent of physicians indicated they see their patients' need for 
social supports, but unfortunately 80 percent of doctors said they do 
not fully know how to link patients to these networks. Clearly, there 
is still a wide gap to bridge between these very different social 
services and medical systems, and it is imperative that new 
intersections, partnerships and coordination processes are created 
rather than allowing the medicalization of social services, which will 
undoubtedly lead to higher costs and reduced consumer satisfaction.
    This list is just a great starting point for a longer list of 
policy prescriptions that this Committee and all of us who care about 
older adults should develop; we know there's more to be done.
    I thank you for shining a spotlight on this critical issue and for 
inviting me here to share Pima Council On Aging's perspective, and I 
look forward to taking any questions you may have.
Endnotes
    1. The Eldercare Locator is the only national information and 
referral resource to provide support to consumers seeking assistance 
across the spectrum of issues affecting older Americans. The Locator 
was established and is funded by the U.S. Administration on Aging, part 
of the Administration for Community Living, and is administered by the 
National Association of Area Agencies on Aging (n4a). Through its 
National Call Center (1-800-677-1116), which operates 5 days a week 
from 9 o'clock a.m. to 8 o'clock p.m. ET, and website 
(www.eldercare.gov), the Locator serves as a trusted gateway for older 
adults and caregivers searching for information and resources which can 
be crucial to their health, well-being and independence.
    2. Because the issue of social isolation is so complex, AARP 
Foundation spearheaded Connect2Affect to seek out solutions. Through 
research and innovative efforts, the AARP Foundation and its partners 
are working to create a deeper understanding of loneliness and 
isolation, draw crucial attention to the issue, and catalyze action to 
end social isolation among older adults. The goal of Connect2Affect is 
to create a network of resources that meets the needs of anyone who is 
isolated or lonely, and that helps build the social connections older 
adults need to thrive. Website www.connect2affect.org.
                               __________
Prepared Statement of Rick Creech, Educational Consultant, Pennsylvania 
               Training and Technical Assistance Network
    Chairwoman Collins, Ranking Member Casey, and other members of the 
Committee, thank you for inviting me to speak before you today.
    There can be no social engagement with others without interactive 
communication.
    As someone who was born with cerebral palsy and was without the 
ability to speak in the accepted way, I grew up lonely and isolated--
except for my parents and grandmothers. It was not until I received my 
first vocal output communication device that people began to know that 
they could speak to me and I could speak to them, well, at least, some 
people did.
    I was born in 1954 in Smithfield, North Carolina. Back then babies 
like I was were not expected to live, and if we did live, we were not 
expected to be out in public, we were not expected to be educated, and 
we were certainly not expected to become independent adults. However, I 
had extraordinary parents who trusted in God, and not in all the 
doctors, the therapists, the social workers who said I would never do 
that, or that, or certainly--not that.
    My father told me once, and I never forgot this, that he wanted me 
to learn math, so that I would be able to manage my own money. He 
wanted me to read, so that I would be able to read and understand 
anything that someone might write about me, and what should be done to, 
and for me. And he wanted me to be able to communicate, so that I could 
have control over my life.
    My parents presumed competence in my ability to learn to do those 
things. They insisted that I learn. Boy, did they push me. When it came 
to teachers, I would always prefer to have my mother because with her, 
I could slack some. With my father, the Baptist preacher, there was no 
way I could slack. He was more demanding than God was with Moses. 
However, they taught me that I was competent. I was competent enough to 
go beyond their goals--and their dreams--for me. This is what great 
parents, great teachers, and great schools do.
    Supporting individuals who need to use AAC is not simple. The 
person may want to communicate, however, the person will have to be 
taught how to use an augmentative and alternative communication device 
for his or her expressive communication. The vocal impaired person will 
not know how, what, when, or why to express thoughts, feelings, ideas 
without being encouraged, without being pushed.
    I am speaking from experience. Initiating a conversation and 
carrying on a conversation is the hardest thing I do in life. To put it 
simply, I am no good at chit-chatting. I believe that there is an 
optimal age to learn communication skills. That age being as young as 
possible. However, I was 28 when I got my first voice output 
communication device, and, although I still have deficits, I can 
expressively communicate my ideas in conversations.
    I had to work extremely hard, and I work long hours to learn to 
communicate with an AAC device. I used to read passages from the Bible 
and newspapers aloud to practice with my AAC device. My point is that 
we cannot provide a person with assistive technology or AAC, and expect 
people to use it.
    I recently got the Amazon echo to help me to control the lights in 
the house. Sometimes I am ready to throw Alexa out the window, and I 
will not tell you the names my wife has called the thing. Amazon Echo 
is simple compared to AAC devices. I started telling people many years 
ago that assistive technology without training is not assistive.
    Even today, as proficient as I am with my AAC device, I cannot talk 
to some people because they are too much in a hurry, or too caught up 
in my Accent1400, saying things such as, what can you say?, can you say 
my name?, or they are hollering at me as if I'm deaf, saying ``it-is-
good-to-meet-you, what-are-you-doing?'' I get tempted to reply, 
``talking to an idiot'', but my parents taught me that if you cannot 
say something nice, say nothing at all, so I don't.
    As I get older, I feel my body slowing down. My bones snap, crackle 
and pop--like Rice Crispies. My muscles hurt. Right now, I have my best 
friend and my protector, my wife, but she is almost my age and has a 
bad back, arthritis, and diabetes. I know that I might not always have 
my wife by my side. One day I will probably be in the care of a minimum 
wage worker, who will have 24 other patients all requiring less time 
and care than I. The only way I have to individualize myself to my care 
takers will be through my ability to communicate with them, so that 
they will be able to see me as a person rather than just another 
patient.
    Of course, if that does not work, I could always call one of my 
three 250 pound sons, and say, son, I need help.
    I would like to thank the Committee on Aging, for giving me this 
opportunity to speak here, although I do not think I am that old. I 
would like to thank the Association of Assistive Technology Programs 
for sponsoring my trip here. Before I started working for Pennsylvania 
Training and Technical Assistance Network, I worked with Pennsylvania 
Initiative on Assistive Technology. I started PIAT's Short Term Loan of 
assistive technology to adults nearly 30 years ago, so, maybe I am that 
old.
    The communication device I use, the Accent1400, costs in the 
neighborhood of $10,000. It is one of the more sophisticated AAC 
devices. However, even simpler augmented communication devices with 
speech output cannot be found for less than five thousand dollars. The 
AAC devices with eye tracking, so that people can speak with them using 
only their eyes, cost in the neighborhood of $20,000.
    All of assistive technology, my AAC, my van converted for a powered 
wheelchair passenger, my smart home equipment, all cost upward of 
$200,000. Still, ladies and gentlemen, that is cheap, compared with a 
life time, of taking caring of me in a nursing facility.
    For my work at PaTTAN, Pennsylvania Training and Technical 
Assistance Network, I help managed its Short Term Loan of assistive 
technology program that provides assistive technology to school 
therapists and teachers statewide, to try with their students. Each 
year the Pennsylvania Department of Education generously provides 
around a third of a million dollars for equipment. To a poor North 
Carolina country boy, that sounds like a lot, but we have constant 
waiting lists of students, and at the end of every year, there are 
requests that I have to cancel or delay until next school year because 
we don't have enough inventory to meet the requests. These students 
needs appropriate assistive technology to receive education so that 
they can grow to be productive and independent adults, who can be 
social members of our society.
    I want to leave the committee with this thought. Living without 
being able to communicate, is like being behind four glass walls. You 
are able to see others, and people can see you, but you are ignored, or 
worse, talked down to, until you stop remembering who you are and why 
you are important.
    Thank you, have a blessed day.



      
      
      
      
      
      
      
      
      
      
      
      
      
      
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                  Additional Statements for the Record

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                   Chelsea Conaboy, Freelance Writer

The Agenda-Politico, 04/12/2017
They're Out There-If We Can Find Them

In rural America, social isolation isn't just a private woe. It's 
increasingly seen as a public health crisis, with new ideas for 
tackling it.

    FRIENDSHIP, Maine--Robin Overlock worries about Elizabeth Brown. 
That's his job.

    The retired paramedic checks in frequently with Brown, 94, who 
lives in the same farmhouse in rural Maine where she's lived since 
1940, where she raised sheep and her four children as well as cared for 
her own mother for the last two decades of her life. The white 
clapboards have weathered to gray and the barn, the sheep long gone, is 
beginning to collapse in on itself.
    Congestive heart failure and a stroke, plus other consequences of 
aging, have left Brown housebound and largely confined to a recliner, 
watching TV to pass the time or talking by phone with friends or her 
oldest son, who lives about 100 miles away and has health issues of his 
own. Brown hasn't seen her son in more than a year, she said; her other 
children are dead or estranged. Overlock, who works for a small startup 
that helps low-income seniors stay in their homes, has become the 
person in her life who monitors her swollen legs for infection.
    As he drives toward Brown's home, on a finger of land bordering 
Muscongus Bay, Overlock passes houses with logging equipment parked in 
the driveway or lobster traps stacked outside. Some, like Brown's home, 
show signs of neglect, and Overlock worries that the people who live in 
them also might be elderly and isolated.
    ``They're out there,'' he said, pointing out the windshield toward 
rolling hills that lead quickly to the bay and the Atlantic Ocean. ``If 
we can find them, help them, keep them safe . . . ''
    Overlock is part of a vanguard of health care workers tackling what 
researchers say is a growing health risk: social isolation. Researchers 
increasingly are convinced that living alone and losing contact with 
family and friends can be as much a threat to people's health as more 
physiological factors, like high blood pressure or obesity.
    And the problem is set to get worse in coming decades. Baby 
boomers, who had fewer children than previous generations, are living 
longer, often with chronic diseases that can reduce their mobility. 
Family networks that traditionally cared for older generations are more 
dispersed or have unraveled altogether. The trend is already acute in 
rural regions like those in Maine hard hit by the collapse of the paper 
industry and other manufacturing losses, where young people continue to 
leave for jobs to the South.
    Social isolation is not only unpleasant; it can be deadly. Someone 
who lacks social relationships has the same risk for early death as 
someone who is severely obese, according to a 2015 analysis by 
researchers at Brigham Young University. The feeling of loneliness, or 
a person's perception of being isolated, has been linked to higher 
blood pressure and cognitive decline. Taken together, social isolation 
and loneliness were associated with a 29 percent increased risk for 
coronary heart disease and a 32 percent increased risk for stroke, 
according to another large-scale analysis led by researchers at the 
University of York in Great Britain.
    Just how isolation erodes health is a matter of some speculation. 
Scientists have long thought that interaction with others is beneficial 
because of ``social control.'' Friends and family members prop each 
other up, encouraging good behavior and healthy habits. When those 
relationships break down, so can a person's health.
    But in recent years, research has found that something more is at 
work: Loneliness, often thought of as a matter of the heart, may 
actually change the brain. The authors of a 2015 paper published in the 
Annual Review of Psychology theorize that chronic loneliness increases 
activity in a network of glands that control stress responses and 
create an inflammatory effect that raises the risk for chronic 
illnesses.
    The reason for this may be a product of evolution. Loneliness may 
be meant to motivate us, when a spouse dies or when we move to a new 
city, to seek out new connections that can sustain us physically and 
emotionally. But when a person can't act on the feeling in a way that 
resolves it, loneliness can make people more sensitive to threats and 
less likely to seek out meaningful relationships for fear of negative 
consequences.
    ``We aren't, by our evolution, designed to be solitary survivors,'' 
said Louise Hawkley, who studies social relationships at NORC, an 
independent research organization at the University of Chicago. ``We 
need to have others around us.''
    When Sandra Lane, 79, was growing up in Bristol, Maine, where the 
local newspaper regularly printed the names of people in the hospital 
so friends and neighbors could call, an elderly aunt lived next door. 
Afraid of thunderstorms, the aunt would pull on rubber boots and run to 
Lane's family home to wait out each squall.
    Lane now lives with her husband, Russell, 85, a former lighthouse 
keeper and lobsterman disabled by post-traumatic stress disorder and 
depression, in a home they built down a rutted gravel road on a remote 
pond. More homes have been built nearby in the years since, but most 
are seasonal. When a blizzard comes during the quiet winter months, 
Lane said, she feels so isolated ``I almost go crazy.''
    The Lanes, whose son moved back to Maine from Pennsylvania to help 
care for them, are working with Overlock through Access Health, a 
nonprofit launched this year by their longtime doctor, Allan ``Chip'' 
Teel, who regularly performed house calls before he closed his 
practice. Now Teel is working with a local hospital group to pair video 
calls from a doctor with home visits and phone calls from people like 
Overlock, who not only checks on medical issues but listens to his 
patients' stories, takes out their trash, or couriers a broken hearing 
aid across the state for a speedy repair. When he called recently and 
learned Russell Lane was having hallucinations, he took quick action to 
get Teel on the phone to adjust his medication. The aim of Access 
Health is to restore some of the attention that a ``country doctor'' 
once provided, Overlock said, as well as provide a small sense of 
community.
    Nearly half of Mainers 65 and older--about 46 percent--live alone, 
slightly higher than the national rate, according to 2015 U.S. Census 
data; fewer than one-third lived alone in 1990. Older adults who are 
lonely are less likely to be married and more likely to have annual 
household income of $25,000 or less, according to a report conducted 
for the AARP Foundation by Hawkley and others at NORC using 2010 data. 
Experts say shifts in family dynamics have compounded other factors 
that are part of rural life that contribute to isolation, including 
poor public transportation and long travel times to grocery stores, 
doctors, community centers or even neighbors' homes.
    It used to be that grandparents ``moved into the spare room, and 
they were there until they left--until they died, I'll be blunt--and 
that was part of life's lesson,'' Overlock said. ``In today's society, 
we all are busy. We all have careers, and we move around.'' Access 
Health, he said, is taking ``a step to be a surrogate.''
    The reach of Access Health, which will cost about $99 a month per 
patient when the program is fully rolled out, is relatively small. 
Overlock serves 12 patients now, though Teel hopes each of the 
program's health advocates eventually will serve up to 100 people. The 
need is great.
    That's apparent in the hospital emergency department in Augusta, 
the state capital, where Rob Boudewijn works as a physician's 
assistant. About once or twice a week, he admits a patient who has no 
acute diagnosis but who lacks the support at home to manage ongoing 
chronic conditions, such as lung disease and obesity, or simple 
frailty. ``Social admissions,'' a frowned-upon reality in many 
hospitals, allow social workers time to contact family members or to 
enroll a patient in support services. Sometimes, Boudewijn said, a 
patient will come to the emergency department showing signs of 
dementia. Then they spend time with nurses and doctors, just connecting 
with other people, and their whole disposition changes.
    In those patients, he said, he can see the harmful effects of 
social isolation. ``Everybody likes to feel worthwhile.''
    Oxford County, A paper-making region stretching along much of 
Maine's border with New Hampshire, was named the state's least healthy 
county by a Robert Wood Johnson Foundation analysis in 2010. That 
prompted a broad group of public health organizations and community 
groups to undertake a years-long assessment, looking at the root causes 
of the county's poor health. They eventually settled not on access to 
healthy food or exercise or even poverty but on something deeper: 
disconnection, a feeling of being undervalued, and social isolation.
    ``Everything we have done since then has been with an eye toward . 
. . reducing that root cause,'' said Jim Douglas, director of Healthy 
Oxford Hills, a public health program of the local hospital that 
facilitated the process.
    But what to do about it? While research has made progress in 
identifying the problem, solutions remain few and far between.
    Some studies have found that targeted psychotherapy can help people 
cope with loneliness in older age. That is unlikely to be a widely 
adopted strategy in rural communities with limited resources. In the 
meantime, countless social service agencies are working, much like 
Overlock, to address the needs of isolated individuals by providing in-
home support, meal delivery, transportation or group activities. 
However, many lack the resources for rigorous research necessary to 
persuade policymakers to invest in their work.
    Oxford has come up with a few local initiatives. A plan to expand 
community gardens became a means of teaching young people leadership 
skills. A group concerned about the opioid crisis organized a 
``recovery rally'' in one town and put together a how-to to help other 
towns do the same. Others organized community conversations about 
broadband internet access to improve lobbying for its expansion, an 
important step for job growth and the use of telemedicine.
    ``It's a very long-term strategy,'' Douglas said. ``This is not 
something we're expecting to be able to point to in two, three, even 
seven years and say, `This happened because of that.' It's really a 
long-term investment in the county-wide community.''
    Julianne Holt-Lunstad, a health psychologist at Brigham Young 
University and lead author on the 2015 mortality analysis, said 
reducing social isolation on a national level likely will require 
something bigger, a societal change prompted by something like the 
public health campaigns that altered public perception of tobacco use 
and dramatically reduced smoking rates over the past four decades.
    A few efforts are getting underway. In December, the AARP 
Foundation launched Connect2Affect.org, a website aimed at raising 
awareness of social isolation as a major determinant of health. It 
includes links to research and a searchable data base of local and 
national resources. President Lisa Marsh Ryerson said she hopes it will 
help inspire more communities to take a broad-based look at how to 
improve health generally while putting isolation front and center.
    ``The reality is that social isolation cuts across the lifespan,'' 
she said.
    John Gale, a researcher at the University of Southern Maine's 
Muskie School of Public Service who grew up working on his 
grandparents' Maine farm and is a national expert on behavioral health 
in rural communities, said the answer lies in finding new ways to 
rebuild the community fabric lost over the years. Such efforts, he 
said, don't need scientific proof.
    ``The fact that someone is living out on a farm in the middle of 
nowhere, can't get enough food . . . that seems to be a problem in and 
of itself,'' Gale said. ``We all fall into the trap of wanting an 
evidence base, but sometimes, at the end of the day, [it's about] doing 
the right thing. We have to get started.''
    Which is where people like Overlock come in. During his visit, 
Brown reminisced about the days when televisions first arrived in town 
and she served as a member of the Friendship Women's Ambulance Corps. 
As she sat in her recliner in what used to be the dining room, where 
she spends her days and nights, Overlock checked on her legs, swollen 
enough that she could be admitted to the hospital. But she won't go.
    ``This is my life,'' she said, sweeping her arms across her lap and 
over side tables overflowing with newspapers and letters, cans of food 
for her white-pawed Miss Alley Cat, and a television remote. ``This 
room is my life.''

Chelsea Conaboy is a freelance writer focused on health care and was 
features editor at the Portland Press Herald in Maine when this article 
was published.
                               __________
      Dhruv Khullar, M.D., M.P.P., Massachusetts General Hospital 
                       and Harvard Medical School

New York Times Op-Ed, 12/22/2016
How Social Isolation Is Killing Us

My patient and I both knew he was dying.

    Not the long kind of dying that stretches on for months or years. 
He would die today. Maybe tomorrow. And if not tomorrow, the next day. 
Was there someone I should call? Someone he wanted to see?
    Not a one, he told me. No immediate family. No close friends. He 
had a niece down South, maybe, but they hadn't spoken in years.
    For me, the sadness of his death was surpassed only by the sadness 
of his solitude. I wondered whether his isolation was a driving force 
of his premature death, not just an unhappy circumstance.
    Every day I see variations at both the beginning and end of life: a 
young man abandoned by friends as he struggles with opioid addiction; 
an older woman getting by on tea and toast, living in filth, no longer 
able to clean her cluttered apartment. In these moments, it seems the 
only thing worse than suffering a serious illness is suffering it 
alone.
    Social isolation is a growing epidemic--one that's increasingly 
recognized as having dire physical, mental and emotional consequences. 
Since the 1980's, the percentage of American adults who say they're 
lonely has doubled from 20 percent to 40 percent.
    About one-third of Americans older than 65 now live alone, and half 
of those over 85 do. People in poorer health--especially those with 
mood disorders like anxiety and depression--are more likely to feel 
lonely. Those without a college education are the least likely to have 
someone they can talk to about important personal matters.
    A wave of new research suggests social separation is bad for us. 
Individuals with less social connection have disrupted sleep patterns, 
altered immune systems, more inflammation and higher levels of stress 
hormones. One recent study found that isolation increases the risk of 
heart disease by 29 percent and stroke by 32 percent.
    Another analysis that pooled data from 70 studies and 3.4 million 
people found that socially isolated individuals had a 30 percent higher 
risk of dying in the next seven years, and that this effect was largest 
in middle age.
    Loneliness can accelerate cognitive decline in older adults, and 
isolated individuals are twice as likely to die prematurely as those 
with more robust social interactions. These effects start early: 
Socially isolated children have significantly poorer health 20 years 
later, even after controlling for other factors. All told, loneliness 
is as important a risk factor for early death as obesity and smoking.
    The evidence on social isolation is clear. What to do about it is 
less so.
    Loneliness is an especially tricky problem because accepting and 
declaring our loneliness carries profound stigma. Admitting we're 
lonely can feel as if we're admitting we've failed in life's most 
fundamental domains: belonging, love, attachment. It attacks our basic 
instincts to save face, and makes it hard to ask for help.
    I see this most acutely during the holidays when I care for 
hospitalized patients, some connected to I.V. poles in barren rooms 
devoid of family or friends--their aloneness amplified by cheerful 
Christmas movies playing on wall-mounted televisions. And hospitalized 
or not, many people report feeling lonelier, more depressed and less 
satisfied with life during the holiday season.
    New research suggests that loneliness is not necessarily the result 
of poor social skills or lack of social support, but can be caused in 
part by unusual sensitivity to social cues. Lonely people are more 
likely to perceive ambiguous social cues negatively, and enter a self-
preservation mind-set--worsening the problem. In this way, loneliness 
can be contagious: When one person becomes lonely, he withdraws from 
his social circle and causes others to do the same.
    Dr. John Cacioppo, a psychology professor at the University of 
Chicago, has tested various approaches to treat loneliness. His work 
has found that the most effective interventions focus on addressing 
``maladaptive social cognition''--that is, helping people re-examine 
how they interact with others and perceive social cues. He is 
collaborating with the United States military to explore how social 
cognition training can help soldiers feel less isolated while deployed 
and after returning home.
    The loneliness of older adults has different roots--often resulting 
from family members moving away and close friends passing away. As one 
senior put it, ``Your world dies before you do.''
    Ideally, experts say, neighborhoods and communities would keep an 
eye out for such older people and take steps to reduce social 
isolation. Ensuring they have easy access to transportation, through 
discounted bus passes or special transport services, can help maintain 
social connections.
    Religious older people should be encouraged to continue regular 
attendance at services and may benefit from a sense of spirituality and 
community, as well as the watchful eye of fellow churchgoers. Those 
capable of caring for an animal might enjoy the companionship of a pet. 
And loved ones living far away from a parent or grandparent could ask a 
neighbor to check in periodically.
    But more structured programs are arising, too. For example, Dr. 
Paul Tang of the Palo Alto Medical Foundation started a program called 
linkAges, a cross-generational service exchange inspired by the idea 
that everyone has something to offer.
    The program works by allowing members to post online something they 
want help with: guitar lessons, a Scrabble partner, a ride to the 
doctor's office. Others can then volunteer their time and skills to 
fill these needs and ``bank'' hours for when they need something 
themselves.
    ``In America, you almost need an excuse for knocking on a 
neighbor's door,'' Dr. Tang told me. ``We want to break down those 
barriers.''
    For example, a college student might see a post from an older man 
who needs help gardening. She helps him plant a row of flowers and 
``banks'' two hours in the process. A few months later, when she wants 
to cook a Malaysian meal for her boyfriend, a retired chef comes by to 
give her cooking lessons.
    ``You don't need a playmate every day,'' Dr. Tang said. ``But 
knowing you're valued and a contributing member of society is 
incredibly reaffirming.''
    The program now has hundreds of members in California and plans to 
expand to other areas of the country.
    ``We in the medical community have to ask ourselves: Are we 
controlling blood pressure or improving health and well-being?'' Dr. 
Tang said. ``I think you have to do the latter to do the former.''
    A great paradox of our hyper-connected digital age is that we seem 
to be drifting apart. Increasingly, however, research confirms our 
deepest intuition: Human connection lies at the heart of human well-
being. It's up to all of us--doctors, patients, neighborhoods and 
communities--to maintain bonds where they're fading, and create ones 
where they haven't existed.

Correction: December 24, 2016

An Upshot article on Thursday about the health risks of social 
isolation misstated the purpose of a grant by the Robert Wood Johnson 
Foundation to a program, linkAges, dedicated to fighting the problem. 
The grant to linkAges was for testing a new project connected to the 
program; it was not meant to help linkAges expand across other areas of 
the country.

Dhruv Khullar, M.D., M.P.P., is a resident physician at Massachusetts 
General Hospital and Harvard Medical School.
                               __________
                            Meals on Wheels
                  Additional Statement for the Record
    Chairman Collins, Ranking Member Casey and Members of the 
Committee:
    We first want to commend you for your bipartisan leadership and 
commitment to improving the lives of, and protections for, our nation's 
older adults. Second, we want to express our appreciation to you for 
holding this important hearing and bringing to light the serious issue 
of social isolation and loneliness among this population. Meals on 
Wheels of America is grateful for the opportunity to submit this 
statement for the record and eager to work with you as we continue to 
seek solutions to address the growing problems of senior hunger and 
isolation. We offer our perspectives on the risks and consequences of 
social isolation and loneliness as they relate to the individuals 
served through Meals on Wheels, as well as our thoughts about how this 
nationwide network is delivering a cost-effective and vital 
intervention for America's most at-risk seniors every day.
    In a recent speech to healthcare journalists, Ellie Hollander, our 
President and CEO, highlighted an alarming statistic originally 
presented by Dr. Julianne Holt-Lunstad, both a leader in loneliness 
research and a witness at the hearing, that the effects of loneliness 
and isolation are comparable to the impact of well-known risk factors 
such as obesity and substance abuse, and are the equivalent of smoking 
15 cigarettes a day. Loneliness is prevalent among older adults, and 
the statistic of one in three older adults over the age of 60 
experiencing loneliness is thought to be an underestimate, as witness 
Dr. Lenard Kaye presented in his testimony. We echo Dr. Holt-Lunstad's 
assertion that senior social isolation and loneliness is an epidemic 
and a growing public health concern amidst demographic, geographic and 
societal shifts toward smaller, more isolated families.
    The factors that make older adults more susceptible to social 
isolation and loneliness are commonly found among individuals receiving 
Meals on Wheels. According to AARP Foundation's Isolation Framework, 
living alone, having lower incomes, and having more physical 
impairments make already vulnerable older adults susceptible to 
loneliness. Data from the Administration for Community Living's State 
Program Reports and National Survey of Older Americans Act (OAA) 
Participants indicates that seniors receiving meals at home and in 
congregate settings, such as senior centers, are primarily women, age 
75 or older, who live alone, have multiple chronic conditions, take six 
or more medications daily and are functionally impaired. Significant 
numbers of OAA meal recipients are also impoverished, live in rural 
areas and belong to a minority group, making them more at-risk for 
social isolation and loneliness.
    Findings from a 2015 study entitled More Than a Meal, conducted by 
our organization in conjunction with Brown University and AARP 
Foundation, found that those receiving and/or requesting Meals on 
Wheels services are significantly more vulnerable compared to a 
nationally representative sample of comparably-aged Americans. 
Specifically, seniors who are on Meals on Wheels waiting lists were 
significantly more likely to:

      Report poorer self-rated health (71% vs. 26%)
      Screen positive for depression (28% vs. 14%) and anxiety 
(31% vs. 16%)
      Report recent falls (27% vs. 10%) and fear of falling 
(79% vs. 42%) that limited their ability to stay active

    Moreover, functional impairment is not just a risk factor but also 
a consequence of social isolation and loneliness (Luo, Hawkley, Waite, 
& Caccioppo, 2012), along with mortality and chronic illnesses like 
cardiovascular disease (Holt-Lunstad & Smith, 2016). The good news, 
however, is that Congress' foresight 45 years ago to authorize a 
nutrition program demonstration for older adults in the greatest 
economic and social need has since grown into a highly effective 
community-based, nationwide network of 5,000 senior nutrition programs 
(e.g., Meals on Wheels). Today this network is successfully fulfilling 
its purposes outlined in the OAA and carrying out what it was intended 
and designed to do by:

      Reducing hunger and food insecurity among older 
individuals
      Promoting socialization of older individuals
      Promoting the health and well-being of older individuals
      Delaying adverse health conditions for older individuals
Delivering More Than Meals
    During the hearing, Senators drew from their own experiences of 
delivering Meals on Wheels and shared compelling testimonials from 
constituents about how volunteer drivers often identify medical issues 
before they became serious problems. It was also noted that Meals on 
Wheels provides opportunities for meaningful social engagement among a 
particularly vulnerable older adult population. In his testimony, Mark 
Clark, Director of Pima Council on Aging and Member of Meals on Wheels 
America, reiterated anecdotal evidence that Meals on Wheels volunteers 
can become important members of seniors' social networks, helping to 
deter loneliness. Below are some additional quotes gathered from recent 
news articles or were shared with our organization that illustrate the 
social benefits of Meals on Wheels services, as told by older adults 
receiving Meals on Wheels or family members or local programs:

      Meals on Wheels delivers more than food; they deliver 
companionship and friendship five days a week. I think that's vital for 
people who are shut-ins or semi-shut-ins. That's our visitor. Food and 
friendship and pleasantness. It's more than food.
      I am served nourishing meals and enjoy being able to eat 
with friends. Socialization is almost as important as the food.
      We hear story after story of people who are hungry and 
have nobody to help. Often times, our clients tell us that the driver 
is the only person they see throughout the week. It breaks my heart to 
think about the number of people who are on our waiting list because we 
don't have the funding to feed them.
      I have a reason to live now. I need to be up and dressed 
in time to greet my Meals on Wheels delivery person when they arrive.
      Both my mother and father were fortunate to be able to 
receive this service starting on 2012 until my mother's death at age 85 
in 2014 . . . my father still enjoys this service today at 88 years 
old. Not only does the service provide him with a good nutritious meal 
but the added benefit of having the delivery person touch basis with 
him is a blessing.

    Along with compelling personal stories of the health benefits of 
Meals on Wheels, the same More Than a Meal study referenced above found 
that seniors who received daily home-delivered meals (the traditional 
Meals on Wheels model of a daily, home-delivered meal, friendly visit 
and safety check), experienced the greatest improvements in health and 
quality of life. Specifically, between baseline and follow-up, seniors 
receiving daily home-delivered meals were more likely to report or 
exhibit:

      Improvements in mental health (i.e., levels of anxiety)
      Improvements in self-rated health
      Reductions in the rate of falls and the fear of falling
      Reductions in hospitalizations
      Improvements in feelings of isolation and loneliness
      Decreases in worry about being able to remain in home

    Meals on Wheels can be used to reduce the social isolation that 
occurs due to functional decline and also help prevent costly 
hospitalizations and nursing home placement (Valtorta & Hanratty, 2012) 
that, in and of themselves, lead to social isolation. In addition to 
being a preventative measure for emergency department visits and 
hospital admissions, Meals on Wheels is also a proven way to reduce 
readmissions to the hospital and other post-discharge costs. Based on 
the results of a pilot for a five-year program that eventually spanned 
36 states and more than 135,000 Medicare Advantage beneficiaries, post-
discharge costs were reduced by one-third on average per patient who 
was served by Meals on Wheels, as compared to those who did not 
participate. Furthermore, several other pilot projects showed seniors 
receiving short-term nutrition interventions from Meals on Wheels post-
hospital discharge, ranging from a daily hot meal to a combination of 
different meal types (i.e., lunch, dinner, snack, hot or frozen meals), 
resulted in readmission rates of 6%-7% as compared to national 30-day 
readmission rates of 15%-34%.
    As noted above, Meals on Wheels programs deliver so much more than 
nutritious meals to the seniors they serve. Many programs are providing 
social isolation interventions beyond the daily visit and safety check. 
In his testimony, Dr. Kaye summarized AARP's Framework for Isolation in 
Adults Over 50, highlighting the importance of drawing on multiple 
methods of intervention. Below are some examples of creative 
interventions currently being used by Meals on Wheels programs to 
address social isolation and loneliness among their clients:

      Many Meals on Wheels programs across the country are 
offering extended or follow-up visits with clients beyond the mealtime 
delivery. Others conduct regular wellness checks that incorporate 
casual conversation, and still others have volunteer befriending or 
friendly visitor programs to accompany home-delivered meal services. 
The efficacy of these types of interventions is supported by research 
which finds that the addition of volunteer visitors to planned 
homemaking and nursing care made a difference for elderly in the 
community (MacIntyre, 1999).
      Numerous Meals on Wheels programs across the country are 
helping to support older adults with pets by also delivering pet food 
along with the seniors' meals. As noted by Senator Cortez Masto and Dr. 
Kaye, pets can alleviate social isolation, feelings of loneliness and 
doctor visits among older adults, especially among individuals who live 
alone (Stanley et al., 2014).
      Dr. Kaye discussed the importance of technology as a 
potentially powerful tool for connecting socially isolated older adults 
and introduced the University of Maine's initiative to develop these 
tools. Some Meals on Wheels programs are, in fact, partnering with 
businesses and other local community organizations to install 
technologies in clients' homes that would help facilitate both social 
connections and telehealth. Although leading to some positive outcomes, 
we must also reiterate Dr. Holt-Lunstad's caution that more research is 
necessary to better understand which interventions are most effective 
and under what conditions, as we do not fully understand the adverse 
effects of some of these newer technologies (Chen et al., 2016).
      An important strategy for addressing social isolation is 
getting homebound seniors out into their communities. One particularly 
innovative and exciting program called ``Outings to Your Taste'' took 
older adults receiving home-delivered meals to a restaurant of their 
choosing. The program seemed to attract socio-demographically diverse 
clients, and older adults who participated seemed satisfied with the 
endeavor (Richard et al., 2000).
      In a multifaceted approach to addressing both social 
isolation and health, one initiative trained Meals on Wheels volunteers 
in health literacy coaching (Rubin et al., 2013). Loneliness has been 
associated with poor health behaviors, which adversely impacts health 
outcomes. This type of intervention also appeals to the call for more 
preventative work in the areas of both health and social isolation 
(Nicholson, 2012).
Challenges Holding Meals on Wheels Back
    As outlined throughout this statement, Meals on Wheels programs are 
already doing much to address the issues of isolation among the 
nation's elderly, but more can and should be done. The issues of senior 
isolation and hunger is grave and growing, with 1 in 4 seniors living 
alone and 1 in 6 struggling with hunger, a 65% increase since the start 
of the recession in 2007. Federal funding through the OAA has not kept 
pace with either inflation or need, and the network overall is serving 
23 million fewer meals today than we were in 2005. In 2014, funding 
provided through the OAA supported the provision of meals to 2.4 
million seniors, yet there are millions more in need. In fact, a 2015 
Government Accountability Office report found that about 83% of food 
insecure seniors and 83% of physically impaired seniors did not receive 
meals [through the OAA], but likely needed them. This gap, coupled with 
an increasing demand as the senior population grows at an unprecedented 
pace, portends a serious national dilemma. With this backdrop, we urge 
your consideration of the following policy priorities:
            1. Fund, Protect and Strengthen the Older Americans Act 
                    Nutrition Program
    The OAA has been the primary piece of federal legislation 
supporting social and nutrition services to Americans age 60 and older 
since 1965. In 2014, the last year for which data exists, the OAA 
enabled 218 million meals to be provided to 2.4 million seniors. 
Despite the longstanding bipartisan, bicameral support for the Act, it 
remains woefully underfunded. As such, we ask Congress to:

      Provide, at a minimum, a total of $874.6 million for all 
three nutrition programs authorized under the OAA (Congregate Nutrition 
Program, Home-Delivered Nutrition Program and the Nutrition Services 
Incentive Program) in FY 2018. Current funding is $36.8 million below 
the levels authorized under the Older Americans Act Reauthorization Act 
and unanimously passed by Congress last year.
      End sequestration for FY 2018 and beyond and replace it 
with a balanced plan. OAA programs, among others, were hit hard by the 
unnecessary and harsh cuts in 2013 and waiting lists for Meals on 
Wheels continue to climb in every state.
            2. Modify Medicare and Medicaid plans, as recommended by 
                    the National Commission on Hunger, to improve 
                    nutrition assistance options for our most 
                    vulnerable
    The health consequences of inadequate nutrition are particularly 
severe for seniors. Proper nutrition, on the other hand, averts 
unnecessary visits to the emergency room, reduces falls, admissions and 
re-admissions to hospitals, saving substantial Medicare and Medicaid 
expenditures. It is notable that a senior can receive Meals on Wheels 
for an entire year for about the same cost of 1 day in the hospital or 
10 days in a nursing home. Accordingly, we recommend the following:

      Expand Medicare managed care plans to include coverage 
for home-delivered meals prepared and delivered by a private nonprofit 
for seniors with physician recommendation.
      Expand Medicaid managed care plans to include coverage, 
with a physician recommendation, for home-delivered meals prepared and 
delivered by a private nonprofit for individuals who are too young for 
Medicare, but who are at serious medical risk or have a disability.
      Allow doctors to write billable Medicare and Medicaid 
``prescriptions'' for nutritious and medically appropriate meals 
prepared and delivered by a private nonprofit for individuals prior to 
being discharged from a hospital.

    Across the nation, we already see some outstanding initiatives to 
address social inclusion through Meals on Wheels services, but more 
systematic research and evaluation is necessary. In this effort, Meals 
on Wheels is beginning a research project that will test the effects of 
various types of loneliness interventions, including those that are 
technology-based, employed through Meals on Wheels programs. We again 
applaud Chairman Collins and Ranking Member Casey for holding the first 
congressional hearing on social isolation and loneliness among older 
adults. We cannot emphasize enough the timeliness of raising public 
awareness on this hidden issue.
    We look forward to working with every Member of the Committee to 
advance this agenda and ultimately, to not only eradicate senior hunger 
in our country, but also to make sure no older adult feels alone or 
left behind. We hope this information has been instructive and are 
pleased to offer our assistance and expertise at any time.
  

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