[Senate Hearing 116-533]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 116-533

                       COMBATING SOCIAL ISOLATION
                         AND LONELINESS DURING
                         THE COVID-19 PANDEMIC

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

                                HEARING

                               BEFORE THE

                       SPECIAL COMMITTEE ON AGING

                          UNITED STATES SENATE

                     ONE HUNDRED SIXTEENTH CONGRESS


                             SECOND SESSION

                               __________

                             WASHINGTON, DC

                               __________

                             JUNE 11, 2020

                               __________

                           Serial No. 116-20

         Printed for the use of the Special Committee on Aging
         
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]         


        Available via the World Wide Web: http://www.govinfo.gov
        
                              __________

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
47-031 PDF                 WASHINGTON : 2022                     
          
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                       SPECIAL COMMITTEE ON AGING

                   SUSAN M. COLLINS, Maine, Chairman

TIM SCOTT, South Carolina            ROBERT P. CASEY, JR., Pennsylvania
RICHARD BURR, North Carolina         KIRSTEN E. GILLIBRAND, New York
MARTHA McSALLY, Arizona              RICHARD BLUMENTHAL, Connecticut
MARCO RUBIO, Florida                 ELIZABETH WARREN, Massachusetts
JOSH HAWLEY, Missouri                DOUG JONES, Alabama
MIKE BRAUN, Indiana                  KYRSTEN SINEMA, Arizona
RICK SCOTT, Florida                  JACKY ROSEN, Nevada
                              ----------                              
              Elizabeth McDonnell, Majority Staff Director
                 Kathryn Mevis, Minority Staff Director
                        
                        
                        C  O  N  T  E  N  T  S

                              ----------                              

                                                                   Page

Opening Statement of Senator Susan M. Collins, Chairman..........     1
Opening Statement of Senator Robert P. Casey, Jr., Ranking Member     3

                           PANEL OF WITNESSES

Carla Perissinotto, MD, MHS, Associate Chief for Geriatrics 
  Clinical Programs, Associate Professor, School of Medicine, 
  University of California, San Francisco, California............     6
Peter Reed, Ph.D, MPH, Director, Sanford Center for Aging, 
  Professor, Community Health Sciences, School of Medicine, 
  University of Nevada, Reno, Nevada.............................     9
Betsy Sawyer-Manter, MSW, President and CEO, SeniorsPlus, 
  Lewiston, Maine................................................    11
Najja Orr, MBA, President and CEO, Philadelphia Corporation for 
  Aging, Philadelphia, Pennsylvania..............................    13

                                APPENDIX
                      Prepared Witness Statements

Carla Perissinotto, MD, MHS, Associate Chief for Geriatrics 
  Clinical Programs, Associate Professor, School of Medicine, 
  University of California, San Francisco, California............    39
Peter Reed, Ph.D, MPH, Director, Sanford Center for Aging, 
  Professor, Community Health Sciences, School of Medicine, 
  University of Nevada, Reno, Nevada.............................    50
Betsy Sawyer-Manter, MSW, President and CEO, SeniorsPlus, 
  Lewiston, Maine................................................    53
Najja Orr, MBA, President and CEO, Philadelphia Corporation for 
  Aging, Philadelphia, Pennsylvania..............................    56

                        Questions for the Record

Carla Perissinotto, MD, MHS, Associate Chief for Geriatrics 
  Clinical Programs, Associate Professor, School of Medicine, 
  University of California, San Francisco, California............    63
Peter Reed, Ph.D, MPH, Director, Sanford Center for Aging, 
  Professor, Community Health Sciences, School of Medicine, 
  University of Nevada, Reno, Nevada.............................    64

                  Additional Statements for the Record

Alzheimer's Association AIM......................................    67
American Psychological Association...............................    69

 
                       COMBATING SOCIAL ISOLATION
                         AND LONELINESS DURING
                         THE COVID-19 PANDEMIC

                              ----------                              


                        THURSDAY, JUNE 11, 2020

                                       U.S. Senate,
                                Special Committee on Aging,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 9:35 a.m., in 
Room 253 Russell Senate Office Building, Hon. Susan Collins, 
Chairman of the Committee, presiding.
    Present: Senators Collins, McSally, Braun, Casey, 
Gillibrand, Blumenthal, Jones, and Rosen.

                 OPENING STATEMENT OF SENATOR 
                  SUSUAN M. COLLINS, CHAIRMAN

    The Chairman. The hearing of the Special Committee on Aging 
will come to order.
    Good morning, everyone. COVID-19 has claimed the lives of 
more than 110,000 Americans, about 80 percent of whom were 65 
or older. Older adults have been disproportionately affected by 
this health crisis, but they are not the only group.
    Last week, the CDC reported that black Americans make up 23 
percent of COVID-related deaths in this country. That is 
despite representing only 13 percent of the U.S. population.
    In Maine, 20 percent of diagnosed COVID cases have been 
black Mainers, although they represent less than 2 percent of 
the population in our State.
    COVID-19 has shed a light on long-standing health 
disparities in this country, and this Committee will hold a 
hearing next month to examine these racial disparities among 
older Americans and the health care that they receive.
    Today's hearing focuses on a danger that affects older 
adults of all races and ethnicities in this pandemic, and that 
is social isolation and prolonged loneliness.
    In 2017, this Committee held the first congressional 
hearing on the impact of social isolation and loneliness on 
older adults. We found that the silent epidemic has devastating 
physical and emotional health effects by increasing the risk of 
stroke, heart disease, depression, and dementia. One expert 
testified that prolonged isolation for seniors is comparable to 
smoking 15 cigarettes a day.
    Since March, the CDC has instructed us all to stay at home 
and to social distance, with the exception of essential 
workers. For the past 3 months, the ability to visit loved ones 
in hospitals, nursing homes, and senior facilities has been 
severely restricted or banned in most States. While such 
measures may have been necessary, they have also intensified 
the isolation and loneliness that were already an everyday 
struggle for many older Americans, and there is surely nothing 
sadder than a beloved parent or grandparent dying alone or with 
just a compassionate health care provider rather than with 
family members by their side.
    Before COVID, about a quarter of seniors reported being 
isolated, and 40 percent reported being lonely. A Tivity Health 
survey published last month indicates that since the pandemic 
began, the number of adults who feel isolated and lonely has 
tripled.
    Maine is the oldest State by median age. It is aging the 
fastest, and it is among the most rural. One in six Mainers 
lives in a rural area, and about 30 percent of the seniors in 
our State live alone.
    As the pandemic continues and the epidemic of loneliness 
and isolation worsens, we run the risk of an infectious disease 
causing a mental health crisis. Already, calls to Maine's 
mental health support line have increased an estimated 40 
percent since the beginning of the pandemic. I have heard from 
countless Mainers about the pain of talking with a much loved 
spouse, parent, or grandparent only by telephone or through a 
computer screen or waving through a nursing home window.
    While technology allows many families to stay connected, it 
is not the same as the human touch. I am asked again and again: 
When will my grandparents be able to hug their grandkids?
    In addition to the human costs I have just described, 
isolation and loneliness also have a fiscal cost. According to 
a 2017 paper published by AARP's Public Policy Institute, 
isolation among older adults increases Federal spending by an 
estimated $6.7 billion annually, as isolated people are often 
sicker and have to rely more heavily on skilled nursing care.
    Since our initial hearing on this subject, we have taken 
steps to combat isolation. In March, the President signed into 
law the Supporting Older Americans Act of 2020 that I authored 
with Ranking Member Casey and other members of this Committee. 
This law reauthorizes critical Older Americans Act services, 
such as nutrition, home care, health promotion, and caregiver 
support. In this year's reauthorization, we added grants 
specifically to combat social isolation and improve 
multigenerational collaboration.
    With congregate meal sites closing in the pandemic, we have 
also taken action to bolster the Meals on Wheels program, which 
provides more than a meal but social connectedness too.
    Through the CARES Act, I have worked to ensure that funding 
could be transferred from congregate meal sites to home-
delivered meals and to expand the definition of homebound so 
that older adults who are quarantined or observing social 
distancing could also receive meals.
    Overall, Congress has provided $1.2 billion in relief for 
nutrition and other community programs as part of our COVID-19 
response.
    Recently, a Meals on Wheels driver in my hometown of 
Caribou, Maine, posted online about her volunteer experience. 
She noted that when she asked seniors on her route what they 
needed help with in this difficult time, many said that they 
were running low on toilet paper and were worried about going 
to the store amidst the pandemic. Another member of the 
community saw that post and brought 96 rolls of toilet paper, 
which she donated and gave to the driver to distribute with the 
next meal delivery. The seniors on that route not only got a 
necessity but also confirmation that someone cared about them. 
This story illustrates perfectly the social value of the 
program and of that strong sense of community.
    We must continue to do more to support our seniors during 
this pandemic. Today we will hear from a geriatrician, a public 
health researcher, and two Area Agency on Aging directors, one 
serving a large rural area and the other an urban area. All of 
these individuals are on the front lines of reducing social 
isolation and loneliness among older adults. We will learn 
today about promising research, innovation, and technology that 
can make a big difference. It is imperative, now more than 
ever, that we find solutions.
    I am now pleased to turn to our Ranking Member, Senator 
Casey, for his opening statement.

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

    Senator Casey. Chairman Collins, thank you for this hearing 
on social isolation and loneliness.
    I wanted to start today with a reference to the American 
family, so many families in our country are hurting right now. 
For them, it is a dark night. We are over 3 months into a 
pandemic that continues to rage, and in some areas, as we know, 
it is re-intensifying.
    COVID-19 has claimed the lives of over 113,000 people in 
the United States, over 113,000 people dead, including well 
over 6,000 in the Commonwealth of Pennsylvania.
    Across the country, people continue to experience grievous 
suffering in hospitals, nursing homes, and at home, isolated 
and alone, away from their loved ones.
    Millions more are suffering extreme economic hardship. 
There are about 21 million Americans unemployed. In 
Pennsylvania, over 976,000 people are out of work, and yet that 
data does not even paint the full picture. The impact of this 
terrible virus has not been evenly felt across this country.
    By all accounts, you know this from what we have been 
witnessing the last number of weeks. By all accounts, people of 
color, particularly black Americans, are disproportionately 
impacted. Over 23,000 black lives have been lost to COVID-19 to 
date.
    African Americans account for 13 percent of our population, 
as Chairman Collins noted, but 24 percent of the deaths from 
COVID-19 where the race of the individual is known. This means 
that black people in America are dying at a rate nearly two 
times higher than their population share.
    The unemployment rate for the overall population is 13.3 
percent. It is 16.8 percent for black Americans. Consider this. 
For black men age 20 and older, only 54 percent are working, a 
10-percentage-point drop just since February.
    The murder of George Floyd was described by one NAACP 
leader as, ``A murder that shames us before the world.'' The 
only way--the only way to even begin to attempt to right all of 
these terrible wrongs is to take action. This action is 
demanded of all of us.
    The African American community, however, is not the only 
community demanding of action in Washington. Seniors are 
suffering disproportionately as well. As our hearing will 
explore today, seniors are living and dying, often scared and 
alone due to this virus.
    In Pennsylvania, nearly one third of COVID-19 cases have 
occurred among people over age 65. Even worse, most of the 
deaths, the deaths that have occurred in my home State, are 
among older Pennsylvanians.
    As I mentioned during our last hearing, people living in 
nursing homes represent a fraction of 1 percent of the 
population, yet more than 40 percent, 40 percent of all deaths 
nationwide have been either residents of long-term care 
settings or the workers in those long-term care settings.
    Those who have recovered from the virus or who are trying 
to remain healthy are isolated from their family and friends, 
their sons and daughters, granddaughters and grandsons. It is 
interaction with our loved ones that sustains all of us. We all 
understand that. Instead, the social isolation and loneliness 
that older adults are experiencing is causing greater cognitive 
decline.
    Experts tell us that it is contributing to greater 
difficulties accessing proper nutrition and wellness services 
for our seniors, and it is leading to a deterioration in both 
physical health as well as mental health.
    Before COVID-19, millions of seniors faced social isolation 
and loneliness every day. We know that. Now they are looking at 
relatives through windowpanes.
    In March and April, I met with 51 out of our 52 Area 
Agencies on Aging in Pennsylvania to discuss the needs of 
seniors during the pandemic. These AAAs are working double 
overtime to combat social isolation in the community.
    This work is being supported by over $1 billion in both the 
Families First Bill and the CARES Act to address the needs of 
seniors. Much of that funding stems from a bill I introduced 
back in March, Senate Bill 3544, the Relief for Seniors and 
People with Disabilities Act. This is an important first step, 
but we cannot not stop there.
    Since the start of the pandemic, I have proposed over a 
dozen policies to help seniors and to combat social isolation, 
policies ranging from dollars for nursing homes to institute 
better practices and to more funding for meal and grocery 
delivery services. These are sound policies with broad 
stakeholder support and support from Democrats in both 
chambers.
    Instead of passing these bills or any bills to address the 
pandemic, the U.S. Senate spent the month of May doing nothing 
but nominations except for one exception, the Foreign 
Intelligence Surveillance Act. Everything else was nominations 
the entire month.
    We cannot sit around in the Senate and just lament the 
impact of the pandemic. We cannot simply lament the deaths and 
the illness that have been caused by the virus, nor can we 
simply lament the devastating economic toll on our families. We 
cannot simply lament social isolation that people are 
experiencing, and finally, we cannot simply lament the racial 
injustice and police misconduct taking place all across this 
country.
    We have to take action. We have got to legislate.
    That is what the U.S. Senate is supposed to do. It is not 
supposed to be a nomination machine. It is supposed to be a 
legislative body, a body where we deliberate serious urgent 
issues, instead of just voting day after day and week after 
week on nominations.
    The Senate must continue to act to support our seniors and 
to support our families and to support all communities impacted 
by the virus.
    Chairman Collins, thank you very much for the hearing. I 
want to thank our witnesses.
    The Chairman. Thank you, Senator Casey.
    I would note that it has been the Senate that has been in 
session while the House has not been in session during this 
time. I think it is unfortunate if this Committee, which has 
always operated in a bipartisan manner and which is focusing on 
a very important issue today, to disintegrate into partisan 
squabbles, and I hope that can be avoided and that we can be 
respectful to our great panel of witnesses.
    I want to acknowledge, because it may not be evident to C-
SPAN or those who are watching, that we have excellent 
participation by Senators here today. Many of them are coming 
in remotely, but here in person, Senator Braun and Senator 
Blumenthal, and I very much appreciate your efforts. You both 
are extremely diligent members of this Committee, and I 
appreciate the efforts you make to be here.
    Our first witness today, Dr. Perissinotto, joins us from 
the University of California San Francisco School of Medicine, 
where she is an Associate Professor and Associate Chief for 
Geriatrics Clinical programs. Dr. Perissinotto oversees 
inpatient and outpatient clinical programs, and her research is 
focused on reducing social isolation among older adults.
    She has served on the committee that authored the National 
Academy of Sciences, Engineering, and Medicine report on Social 
Isolation and Loneliness in Older Adults, which was published 
in February.
    I would now like to turn to Senator Rosen to introduce our 
witness from her home State.
    Senator Rosen. Thank you, Senator Collins and Ranking 
Member Casey. I want to really thank you both for holding this 
hearing on COMBATING social isolation and the loneliness of 
older adults, and I especially want to thank all of the 
witnesses for being here today and for their work.
    I am so pleased to introduce one witness in particular, Dr. 
Peter Reed. Dr. Reed is the director at the University of 
Nevada, Reno School of Medicine's Sanford Center for Aging.
    In a rapid response to the unfolding crisis, Dr. Reed 
helped to convene a team of aging services providers in Nevada, 
and he developed a Nevada COVID-19 aging network, or Nevada 
CAN. This is a new initiative with the ambitious goal of 
mobilizing all the available resources to ensure that every 
elder Nevadan has access to medical, to social, and to daily 
essentials in their home.
    As we are going to hear today, this effort has just been a 
tremendous success, and we look forward to hearing about the 
great work that Dr. Reed and Nevada CAN that they are doing in 
our State.
    I just want to take this time on a personal note. I was a 
caregiver for my parents and in-laws as they aged and at the 
end of their lives, and I wish that I would have had access to 
something like Nevada CAN at that time. It was often difficult 
to find where to go to get the resources, who to talk to, and I 
am so grateful that it is there for anyone who is now going 
through some of the things that I went through.
    Thank you, and we look forward to hearing everyone's 
testimony.
    The Chairman. Thank you, Senator Rosen.
    Next, we will hear from Betsy Sawyer-Manter, who serves as 
the CEO of SeniorsPlus, an Area Agency on Aging based on 
Lewiston, Maine. She has both, Maine's second largest city as 
well as many very rural areas around it under her purview. For 
the last 11 years, Ms. Sawyer-Manter has overseen vital aging 
network services that have allowed our seniors to age 
independently in our communities. She is the president of the 
Maine Association of Area Agencies on Aging and serves on the 
board of the Maine Council on Aging. She has been leading 
efforts to combat isolation among seniors during this pandemic.
    We are very pleased to have Betsy joining us today.
    Next, I will turn to Senator Casey to introduce Mr. Orr, 
our witness from the Commonwealth.
    Senator Casey. Thank you, Chairman Collins.
    I am pleased to introduce Najja Orr. He is from 
Philadelphia, Pennsylvania. He has served as president and CEO 
of the Philadelphia Corporation for Aging and the Philadelphia 
Area Agency on Aging. This is the largest AAA in the State and 
serves the most diverse population in our State.
    Mr. Orr will share with us the work that the Philadelphia 
Corporation for Aging is doing to combat social isolation and 
the important role of nutrition programs, in preventing 
isolation, and sustaining mental and physical health. Prior to 
his current role, Mr. Orr worked for the Bucks County Area 
Agency on Aging for 15 years, serving as that agency's director 
since 2011.
    Thank you, Mr. Orr, for being with us today and for sharing 
your expertise with the Aging Committee.
    The Chairman. Thank you, Senator. We will start with Dr. 
Perissinotto.

           STATEMENT OF CARLA PERISSINOTTO, MD, MHS,

       ASSOCIATE CHIEF FOR GERIATRICS CLINICAL PROGRAMS,

            ASSOCIATE PROFESSOR, SCHOOL OF MEDICINE,

      UNIVERSITY OF CALIFORNIA, SAN FRANCISCO, CALIFORNIA

    Dr. Perissinotto. Chairman Collins, Ranking Member Casey, 
and distinguished members of the Committee, thank you for the 
opportunity to testify today on the topic of social isolation 
and loneliness during the COVID-19 pandemic, and thank you for 
allowing me to testify remotely, given these unprecedented 
times.
    I am a geriatrician and a palliative medicine physician at 
UC-San Francisco and have devoted my career to the clinical 
care of older adults, many of whom, as you noted, are 
underserved, vulnerable, and homebound.
    I am also a first-generation American of Mexican and 
Italian descent who cares deeply about the care of our older 
adults, those who have diverse backgrounds, and I profoundly 
respect the immigrant roots of our Nation.
    In addition to providing clinical care, I have been 
researching the health effects of loneliness and isolation in 
older adults specifically over 10 years. In 2012, I published a 
seminal paper demonstrating that older adults who are lonely 
have a 59 percent increased risk of losing their independence 
and a 45 percent increased risk of death.
    Most recently, my work is focusing on incorporating 
loneliness and isolation assessments to health care systems in 
evaluating community-based programs.
    Indeed, loneliness and isolation are a national and global 
public health problem whose widespread effects may be even more 
pressing now in the midst of this COVID-19 pandemic.
    As my friend and colleague, Julianne Holt-Lunstad, 
previously reported to you in 2017, being connected to others 
is widely considered a fundamental human need, crucial to both 
well-being and survival. Yet as described in the National 
Academy of Sciences consensus report, which is titled ``The 
Health and Medical Dimensions of Social Isolation and 
Loneliness in Older Adults,'' prevalence rates for loneliness 
and isolation range from 20 to 50 percent cross the United 
States, and the corresponding health effects are disquieting, 
thus, raising this to the level of a public health crisis.
    Prior research formed the justification for this report. 
There are five key outcomes from the report that are worth 
bringing to this Committee's attention: 1) develop a more 
robust evidence base for effective assessment, prevention, and 
intervention strategies for both loneliness and isolation; 2) 
translate current research into health care practices; 3) 
improve awareness; 4) strengthen ongoing education and 
training; and 5) strengthen ties between health care systems 
and community-based networks.
    Given the findings from this research and the National 
Academy's report, like many, I have been incredibly concerned 
about the downstream effects that we would see during the 
COVID-19 pandemic. Seemingly overnight, we saw our social 
structures dissolve as we were all forced to socially or, 
rather, physically distance ourselves.
    The challenges is that to protect our lives now, we have 
had to subject ourselves and others to the potential of 
worsening our health and shortening our life expectancies in 
the future by enforcing isolation.
    To some extent, we are actually in a data-free zone right 
now, where we do not know how long we have to be lonely or 
isolated or how severe this must be for us to have lasting 
negative consequences, either economic or health-wise.
    Unfortunately, it is even more apparent that ageism runs 
deep, and the needs of older adults and the health effects of 
COVID-19 on older adults has largely been an afterthought, so 
together with my colleague, Dr. Ashwin Kotwal, we have rapidly 
designed a study to understand the experience of loneliness and 
isolation over time during the pandemic. As geriatricians, we 
are also interested in understanding where physical distancing 
has had other unintended consequences.
    Our study is currently ongoing and, sadly, unfunded, but I 
will share some preliminary findings, so far, our sample is 
remarkably ethnically diverse, given that it is predominantly 
in San Francisco. It is also predominantly women, and 64 
percent of our sample lives alone.
    What we have found is that a high percentage of 
participants in our study had loneliness at a baseline up to 73 
percent, which is higher than it has been reported in other 
studies, and during the pandemic, 41 percent have experienced a 
worsening because of COVID-19. We have also seen a worsening of 
both depression and anxiety at 33 percent and 29 percent worsen 
respectively.
    Not surprisingly, we have seen reduced socializing and 
community participation, and most concerning is that we have 
seen a decrease in the number of volunteers supporting people 
and case management during the pandemic.
    Eighty percent of participants had difficulty obtaining 
medications, and there are unmet functional needs such as with 
activities of daily living and transportation. Surprisingly in 
our sample, food security was not a predominant concern, and 
also interesting to this Committee is that 77 percent of our 
sample had video contact - zero to two times a week, and 29 
percent of the sample did not use the internet at all.
    Though our findings are preliminary, there are some areas 
that are already giving us evidence of what may be happening 
across the country and where we might expect to see downstream 
effects.
    There are three key findings which are in line and can be 
addressed by some of the recommendations from the National 
Academy's report: 1) social isolation and loneliness are worse, 
yet 67 percent of older adults that we sampled are not 
concerned or are only somewhat concerned about their health 
worsening because of not being able to see their health care 
providers. This highlights the importance of the National 
Academy's Recommendation 8.1 and 8.2, which suggest including 
measures of social isolation and loneliness in large-scale 
health strategies, including more public awareness; 2) the 
effects of unmet needs are concerning, especially the 
functional needs and medication access. This highlights another 
recommendation from the report, which states that there is a 
need for health care systems to partner with social service 
organizations and promote tailored community-based services; 
and 3) a large proportion of older adults may not have access 
to technology, video or internet, and this highlights another 
recommendation from the National Academy's report that states 
that those who are developing and deploying technology and 
interventions should be sure that technological innovations 
related to social isolation and loneliness are properly 
assessed and tested so as to understand the full range of 
benefits and potential adverse consequences in order to prevent 
harm.
    This last point is concerning because, as has been noted by 
the Committee, physical distancing policies have forced many 
health care and social programs to shift to technological 
solutions, and this may be leaving out many older adults who do 
not have access to these technologies and these may be more 
difficult for those with vision and hearing impairments.
    We also know that underrepresented minority groups and 
other marginalized people already were at risk for loneliness 
and isolation and poor health out comes prior to the pandemic, 
and these are the exact groups that are disproportionately 
being affected the most by COVID-19.
    There are still many gaps in the evidence, predominately 
around telephone-and computer-based programs, but it is 
understanding of how to rapidly scale some of these because of 
the urgency, but we still do not know what the long-term 
effects are.
    There are some areas drawing directly from the report that 
will help us learn from the pandemic. A couple areas for us to 
move forward on are thinking about funding, which includes 
ensuring adequate funding not just on some of the solutions, 
but on ensuring that research and evaluation of these programs 
occur so that we understand the lasting effects.
    We also need to ensure accountability. Again, this means 
clearly evaluating and ensuring that the solutions that are 
proposed actually do what they propose to do and have a focus 
on improving the lives of older adults.
    Last, with education and learning, we may have 
opportunities to learn from our colleagues abroad and see what 
has worked and consider the concept of assessing social 
isolation and loneliness and of social prescribing.
    Understanding the needs of marginalized populations is one 
of the largest areas of gaps, and this is an area for us to 
continue our national discourse.
    The solutions ahead of us may not be readily apparent, but 
starting with addressing the underlying ageism and other 
discrimination will need to be part of our response. Our 
challenge will be in making systematic changes that are 
evidence based, equitable, and timely.
    I am incredibly grateful that a topic and population that I 
care deeply about is being recognized by this Committee. I 
welcome any opportunity to further advance to knowledge base 
and improve the care of older adults.
    Thank you again for the opportunity to testify before you, 
and I will welcome any questions.
    The Chairman. Thank you very much, Doctor.
    Dr. Reed?

         STATEMENT OF PETER REED, Ph.D, MPH, DIRECTOR,

         SANFORD CENTER FOR AGING, PROFESSOR, COMMUNITY

              HEALTH SCIENCES, SCHOOL OF MEDICINE,

               UNIVERSITY OF NEVADA, RENO, NEVADA

    Dr. Reed. Good morning, and thank you, Chairman Collins, 
Ranking Member Casey, and members of the Senate Special 
Committee on Aging.
    My name is Peter Reed of the Sanford Center for Aging at 
the University of Nevada, Reno, School of Medicine. I am a 
public health gerontologist dedicated to enhancing the quality 
of life of older adults. Throughout my career, I have never 
seen a crisis with the potential to cause as much harm to older 
adults as COVID-19.
    To enable older adults to stay home and stay safe, while 
remaining connected to needed resources, the State of Nevada 
launched Nevada CAN, or the Nevada COVID-19 Aging Network Rapid 
Response. It is the story of Nevada CAN that I will share today 
as an example of ways that we can mobilize community and State 
resources to enable elders to stay home.
    In mid-March, a group of aging services leaders came 
together with grave concerns over the health and well-being of 
Nevada's older adults, who had all become homebound. We 
expected a dramatic increase in demand for aging services from 
the already-strained providers; therefore, we set out to 
mobilize the statewide network in a coordinated effort to 
identify and respond to elder needs by targeting three priority 
focus areas: one, daily essentials such as food and medication; 
two, telehealth services; and three, social support.
    Under the leadership of Dena Schmidt, the administrator of 
Nevada's Aging and Disability Services Division, each of Nevada 
CAN's priority focus areas is supported by its own action team: 
the Food and Medication Action Team, led by Jeff Klein of 
Nevada Senior Services in Las Vegas; the Telehealth Action 
Team, which I lead; and the Social Support Action Team, led by 
Dr. Jennifer Carson of the Dementia, Engagement, Education, and 
Research Program at the University of Nevada, Reno, School of 
Community Health Sciences.
    On April 1st, after a rapid planning process, Nevada CAN 
launched its new website, connected to Nevada 2-1-1, through 
which older adults can request help using a simple elder needs 
survey. Aging and Disability Resource Center case managers then 
connect elders to the appropriate action teams for support. The 
Food and Medication Action Team engages a network of county-and 
community-based agencies in delivering food, medications, and 
other essential items to the doorsteps of older adults. The 
Telehealth Action Team brings together existing health care and 
social service providers into an integrated statewide 
telehealth network, offering geriatrics, social work, primary 
care, and other services.
    This telehealth network includes training efforts to 
bolster capacity of primary care providers to deliver 
telemedicine, with support from Nevada's two HRSA-funded 
Geriatrics Workforce Enhancement Programs.
    Finally, the Social Support Action Team, led by Dr. 
Jennifer Carson, launched the truly innovative NEST 
Collaborative. Standing for ``Nevada Ensures Support 
Together,'' the NEST Collaborative recruits volunteers, 
including many college students, who are committed to 
delivering social support to reduce social isolation.
    After a background check and 7 hours of training, 
volunteers offer one of four social support programs: one, 
calling older adults twice weekly to have a friendly 
conversation and monitor their needs; two, convening a virtual 
peer group of older adults for regular group discussions; 
three, offering technical assistance to enable existing groups 
of friends to come together; or four, providing technical 
assistance to enable older adults to effectively use technology 
to access telehealth services or to connect with family members 
across the country.
    Each of these volunteer services is designed to reduce 
social isolation and build reciprocal support, embracing the 
idea that elders are themselves a valuable resource to the 
community. These opportunities help fulfill one of the most 
basic needs in an elder's life: the need to be known by and 
meaningfully connected to other people.
    Clients of NEST have stated that they are grateful for the 
services, saying that because without someone calling to check 
on them, no one would know if they are even still alive. 
Further, as the pandemic continues, the NEST collaborative, in 
partnership with the State long-term care ombudsman program, is 
extending virtual social support opportunities to reduce 
isolation among skilled nursing home and assisted living 
residents.
    In the first 2 months of Nevada CAN, there were 757 
requests for help, resulting in 1,235 referrals to services. 
These included 448 referrals for food delivery, 148 for social 
support, 89 for telehealth services, as well as 550 other 
general services requested from the Aging and Disability 
Resource Center, including emergency financial assistance.
    In addition to the requests through Nevada CAN, Nevada has 
seen a 57 percent increase in requests for assistance due to 
the COVID-19 pandemic. Nevada CAN reflects the true spirit of 
the ``no wrong door'' philosophy of aging services.
    This time of social and physical distancing does not mean 
elders must be socially isolated. Nevada CAN and the NEST 
Collaborative are examples of how to help elders stay 
meaningfully engaged and connected to their communities during 
this pandemic.
    Thank you very much.
    The Chairman. Thank you, Dr. Reed.
    We will next turn to Ms. Sawyer-Manter for her testimony.

             STATEMENT OF BETSY SAWYER-MANTER, MSW,

        PRESIDENT AND CEO, SENIORSPLUS, LEWISTON, MAINE

    Ms. Sawyer-Manter. Thank you.
    Good morning, Chairman Collins, Ranking Member Casey, and 
members of the Special Committee on Aging.
    I am Betsy Sawyer-Manter. I am the CEO of Western Maine's 
Agency on Aging, SeniorsPlus. I appreciate the opportunity to 
speak before you today.
    Maine has a very old population, as Senator Collins said 
earlier. The COVID-19 pandemic disrupted the service delivery 
system that older Mainers have come to rely on for services and 
answers on aging. I can assume this is reflected across our 
entire Nation.
    We have continued to provide services since our public 
closure in mid-March. We have quickly moved to adapt our 
services to telephonic and a virtual platform.
    Many of our clients rely on the friendly volunteer who 
delivers their meals or the class in our education center that 
gives them purpose and socialization or the home visit with a 
care coordinator checking in to ensure that their home care 
services are still intact.
    I would like to share with you some of what we have done to 
address the service delivery needs and to combat social 
isolation.
    A hallmark program for us is Meals on Wheels. We cannot 
deliver meals virtually, so we needed to keep our meals on the 
road. We instituted a drop-and-go strategy to avoid direct 
contact and began making reassurance calls to all the clients 
to ensure that they are doing well and they still feel 
connected.
    Our kitchen went into overdrive and produced an extra 3 
weeks of shelf-stable and frozen meals for every client in case 
our kitchen went down due to illness. We also produced 2,000 
extra meals but found we needed additional freezer space. We 
contacted our local Walmart distribution center, and they 
dropped off a freezer trailer for us to use, which we are 
continuing to use.
    UnitedHealthcare came through with additional food 
products, but just as importantly, pet food. We deliver the 
food along with the meals so that they do not give their people 
food to their pets, as we know pets are incredibly important 
companions for older isolated people.
    Our home-delivered meal count is up 46 percent right now 
and climbing.
    We have been inundated with calls on our helpline. Our 
staff is fielding around 100 calls a day, and that is climbing.
    We have three administrative staff answering the phone 
live, and they report receiving calls from folks who just 
really want to chat. They are lonely. They are reaching out, 
and we have identified these clients and we have volunteers who 
are doing friendly visitor calls, checking in with them to make 
sure they are okay.
    Our Community Services staff are pretty tech savvy, and 
they immediately went into the mode of how do we use Zoom to 
delivery our services. They are offering Zoom 101 training 
every week to clients and staff.
    One client recently called after taking a class. He was 
very grateful for all the work we put into changing how we do 
business, and that he just wants to stay connected with other 
people. He feels that he is able to do this because now he has 
learned how to use Zoom, such a testimony to the power of 
lifelong learning.
    We are offering many Zoom services using Zoom technology. 
Some of these include caregiver support at a time where 
caregivers are more isolated than ever, a grief support group 
at a time when we are deferring services and do not have the 
ability to say goodbye and get that closure, and an all-
important Coping During COVID support group.
    A client recently shared that she started taking a class. 
She was struggling with depression and spending most of her day 
in bed. The weekly class has brought so much positivity into 
her life. She has been walking, spending time outside, and has 
been so much happier.
    In addition to our work in Western Maine, we are a 
statewide service coordination agency working to support over 
4,400 Mainers who remain at home. We are part of the long-term 
services and support system in our State.
    Our care coordinators are based throughout the State, and 
our 10 Zoom accounts are in frequent use as we conduct virtual 
home visits with clients. We also have the ability to get eyes 
on some of our most vulnerable clients.
    One care coordinator shared that people are wanting to talk 
longer, and they have a lot of disinformation that we help them 
unravel. They appreciate the time we are taking with them.
    We have found our clients to be receptive and welcoming of 
new ways of doing business. For those with technology and 
connectivity, it works well, but many do not have it. To that 
end, we have secured some private funds from the Maine 
Community Foundation and we are using some of our CARES Act 
funding to purchase tablets and hotspots. We have found tablets 
to be easier and less threatening technology for older people 
who are not used to using technology.
    Social isolation is detrimental to our health. We can feel 
the need for human interaction in every call and virtual 
contact that we have. We will continue to look at our business 
model to see how we can enhance it and enhance the opportunity 
to serve people in new ways.
    I live in a State with many rural and even frontier areas. 
This new normal could serve as a means to help us reach those 
underserved areas and further combat social isolation in the 
future.
    I thank you for the opportunity to speak with you today, 
and I would be glad to take questions when we get to that 
point.
    The Chairman. Thank you very much. I very much appreciate 
the work that you do in the State of Maine.
    Mr. Orr?

             STATEMENT OF NAJJA ORR, MBA, PRESIDENT

          AND CEO, PHILADELPHIA CORPORATION FOR AGING,

                   PHILADELPHIA, PENNSYLVANIA

    Mr. Orr. Good morning.
    I would first like to thank Senator Collins, Senator Casey, 
and the remaining members of the Special Committee on Aging for 
convening this hearing. I would also like to extend my 
gratitude for the reauthorization of the Older Americans Act 
and several bills that increase supports during COVID-19.
    Philadelphia has the second highest proportion of 
impoverished older adults and is the poorest overall of the 10 
largest cities in the United States. As the Area Agency on 
Aging for Philadelphia County, PCA has been coordinating a 
broad range of services for more than 140,000 older 
Philadelphians annually for nearly 50 years.
    According to the National Institute on Aging, isolation 
increases risk of decline in cognitive impairments, depression, 
comorbidities, nutrition, and physical activity. Approximately 
40 percent of Pennsylvania's linguistically isolated households 
are in Philadelphia, and I appreciate that Senator Casey has 
been championing increased funding to Area Agencies on Aging to 
support seniors with limited English proficiency.
    As focal points in the community, senior centers play an 
integral part in engaging active older adults. As a result of 
the pandemic, senior centers have had to make significant 
adjustments to their services. Staff have had to make more than 
9,000 wellness calls to ensure safety, provide information and 
resources, encourage response to the Census, and complete 
nutrition screenings.
    Many centers have also transitioned health and wellness 
programs to online platforms and social media outreach. 
Unfortunately, due to the high rates of poverty in 
Philadelphia, many older adults do not have access to the 
technology required to participate in online programming.
    It is also important to note the impact of isolation on 
elder abuse. PCA operates the Older Adult Protective Services 
Unit for Philadelphia, and unfortunately, our numbers of 
investigations have nearly doubled since 2013.
    As pandemic-related restrictions ease, we are concerned 
about an increase in allegations of abuse, neglect, financial 
exploitation, and abandonment.
    Many older Philadelphians live on fixed incomes and 
struggle to pay for food. According to the Public Health 
Management Corporation, of the approximately 301,000 older 
adults in Philadelphia, more than 56,000 are unable to shop for 
themselves, 32,000 need assistance preparing a meal, and 36,000 
report skipping a meal due to lack of money.
    Senior nutrition programs like home-delivered and 
congregate meal programs provide isolated seniors with a 
regular form of social engagement through safety checks and a 
friendly neighbor to engage with.
    During the pandemic, the senior center network has risen to 
the challenge by providing grab-and-go meals and partnering 
with community organizations, including fire and police 
stations, to make deliveries to older adults who are unable to 
pick them up. Since March 18th, PCA has provided over 110,000 
meals through the senior centers. As restrictions are lifted 
and people are returning to work, we do anticipate a decrease 
in available volunteers and a possible increase in need due to 
less availability from family members.
    Through PCA's meal distribution center, nearly 1.9 million 
meals were delivered to homebound older adults last year. The 
agency has worked closely with a variety of organizations also 
addressing the nutritional needs of older adults during the 
pandemic, but the need in Philadelphia is great.
    I was grateful to learn on Friday, Pennsylvania SNAP 
recipients now have the flexibility to utilize online 
purchasing for grocery delivery or curbside pickup. This 
benefit adds another option for isolated Philadelphians in 
need.
    We are fortunate for a strong community and the 
organizations dedicated to serving the most vulnerable among 
us. PCA is proud to be counted among those organizations and 
are grateful for the support of Senator Casey as a champion of 
older Pennsylvanians and the continued support from the Senate 
Special Committee on Aging.
    A few recommendations to enhance services to older adults 
during the pandemic as it relates to social isolation include, 
one, the pandemic has expedited the trend of moving programs 
and online services, and the coming generations of older adults 
will now have familiarity and expectations of digital 
platforms. However, current older adults, particularly in low-
income communities, do not have access to technology needed to 
stay connected. Increased funding and education is needed to 
bridge the digital divide.
    Number two, COVID-19 has taught us the importance of 
agility to meet evolving needs of older adults. Providing 
States and AAAs the ability to be more flexible with Older 
Americans Act funding. For example, reimbursement for meals of 
consumer choice including ethnic meals, rather than strict 
adherence to one-third registered daily allowance, this will 
create the opportunity for innovation and the capacity to meet 
the needs specific to their community, and number three, 
incorporating additional funding for AAAs in the next relief 
package will allow the provision of essential Older Americans 
Act services to be adapted to telephonic or online options. 
This will keep older adults socially connected, safe, and as 
independent as possible while unexpectedly homebound.
    Thank you.
    The Chairman. Thank you very much, Mr. Orr, for your 
excellent testimony.
    We will now turn to questions. I want to thank all of our 
witnesses for provocative and interesting statements.
    Dr. Perissinotto, I would like to start my questions with 
you. Many hospitals have instituted no-visitor policies in 
order to reduce the spread of COVID-19. While such policies 
have helped to mitigate the spread of the virus, this 
experience can be isolating for those with long hospital stays.
    In addition, for patients with Alzheimer's disease or other 
forms of dementia, having a family caregiver in the room can be 
a critical part of the effectiveness of the care team.
    As a doctor on the frontlines, can you speak to the impact 
of these restrictive visitor policies on vulnerable older 
adults' health? and, in particular, do you have suggestions for 
dealing with patients with Alzheimer's or other dementias?
    Dr. Perissinotto. Senator Collins, thank you for the 
excellent question, and it is incredibly relevant to the work 
that I do because, literally, in the last 2 weeks, I have faced 
these issues with my patients.
    I had a patient who was monolingual, Spanish speaker, 
hospitalized, and where, unfortunately, even though the 
hospital policy had changed, this was not made clear to the 
family that they could be present because he had cognitive 
impairment and severely delirious.
    This is such an important topic, and I do think that there 
are some things we need to think about. Number one, it returns 
to this idea of ageism. Many hospital policies have actually 
still allowed children to be at the hospital with a parent, and 
if we wanted to be equitable across age groups, it does mean 
thinking about dependent adults and allowing a family member to 
be there exactly in the cases you describe, which are patients 
with dementia and in patients who are having severe delirium, 
where we know that presence of a family member and familiar 
environment actually help reduce lengths of stay and as you 
know from the research that you quoted, length of stay is one 
of the reasons why Medicare costs are rising for people who 
have isolation and loneliness.
    Other ideas to think about are, there is actually pretty 
widespread evidence of the benefits of hospital at home 
nationally. One idea is to think about how can we expand these 
services, which could also think about reducing the number of 
people that are exposed and of PPE use.
    Other things that I am hopeful for, I am hopeful that as we 
get improved point-of-case testing, which right now 
unfortunately has been problematic, as many of you know, we 
will be able to test more rapidly so that we can test family 
members and caregivers so that they allow visitors to be more 
present.
    The other two ideas are, as I spoke earlier in my 
testimony, the use of video is a little bit problematic because 
we do not exactly know how helpful it can be, but in the 
absence of nothing, it may be something that is reasonable. We 
have to think about what are the resources that hospitals have 
to facilitate the telemedicine or the video visits with family 
members. It is not just having the device, but what is the 
staffing need?
    Then, last, I am hoping that as we think about 
understanding the science better, as we understand 
transmission, I am hoping that these visitor policies will 
start to be lifted some. At our own institution at UCSF, we are 
seeing changes in the policies. Thankfully, we have a different 
level of pandemic here, and so we have been able to create 
exceptions, as I noted, for people with dementia and other 
situations.
    We do know that there is, for example, a paper in The 
Lancet a week or two ago that demonstrated a reduction, a 
pretty significant reduction in transmission, as little as 3 
feet, so that that starts to make us think a little bit about 
how we can think about space between people.
    The Chairman. Thank you very much for those very 
interesting and helpful suggestions.
    Ms. Sawyer-Manter, in addition to providing $750 million in 
the Federal COVID response packages for the AAAs to expand 
senior nutrition programs, Senator Casey and I worked to expand 
flexibilities in the Older Americans Act, as Mr. Orr mentioned, 
to ensure that AAAs can meet the growing needs during this 
pandemic.
    In the brief amount of time that I have left for my 
questions, could you expand on how this increased flexibility 
has enabled your agency to better meet the growing nutrition 
and social connection needs of the seniors you serve?
    Ms. Sawyer-Manter. Thank you. Absolutely.
    We found that the flexibility was incredibly important to 
us. We have been able to continue to serve those congregate 
meals through home-delivered meals now. Those folks needed the 
nutrition just as well, but obviously, we could not be doing 
congregate sites and we do not know when we will ever get back 
to that for a number of months.
    Additionally, the ability to reach people who were socially 
isolating, that did not necessarily meet the traditional Older 
Americans Act restrictions. What we found is we have really 
discovered that the need out there is so much greater than what 
the traditional resources were able to cover. We are finding 
that it is about doubling everybody's caseload in terms of who 
needs our assistance with nutrition, and what we are also 
finding is that many of them could actually meet the 
traditional Older Americans Act guidelines.
    I think what we are really doing is discovering the true 
size of the population that really needs nutrition assistance, 
so it has really opened doors in ways that we would not have 
been able to do in the past.
    The Chairman. Thank you.
    Senator Casey?
    Senator Casey. Thank you, Chairman Collins.
    I wanted to start my questioning with Mr. Orr. Mr. Orr, in 
your testimony, you shared that senior nutrition programs like 
Meals on Wheels are important not only to decrease hunger and 
food insecurity in seniors but also to alleviate social 
isolation and loneliness.
    As I mentioned, part of the provisions of my bill was 
included in the CARES Act and the Families First bill. Those 
two bills combined provided over $730 million for nutrition 
programs and getting new flexibilities.
    Many older adults, as you and others have noted, are afraid 
to leave their homes to go to the grocery store, so they are 
buying groceries online. For most seniors on SNAP throughout 
the country, this is not an option. Traditionally, SNAP just 
does not support delivery.
    As you noted as well, Pennsylvania announced participation 
in the online purchasing option that allows participating 
retailers to accept SNAP for online purchases. We know this is 
a good step in the right direction, but it only accounts for 
one State and only for retailers that are participating in the 
program.
    I have introduced a bill, 3563, the Food Assistance for 
Kids and Families during COVID-19, and the separate bill, 
Senate Bill 3736, which is Increasing Access to SNAP Delivery. 
Both of these would provide the Department of Agriculture with 
the funding to expand access to delivery options for all SNAP 
recipients and support independently owned and operated 
retailers, so here is the question. Based on your experience, 
Mr. Orr, how would expanding SNAP delivery options help keep 
seniors both well nourished as well as how it would address 
social isolation?
    Mr. Orr. Thank you, Senator Casey, for your question.
    As I mentioned earlier, the Older Americans Act funding 
that we are utilizing has gone toward supporting our nutrition 
programs during the pandemic, ensuring that we are getting 
home-delivered meals and grab-and-go meals to older adults. We 
are also using it to ensure that we have PPEs for the staff 
that are on the frontlines and making sure that it has 
appropriate resources to our Older Adult Protective Services 
unit.
    However, regarding nutrition services, we knew that one 
meal a day is really not enough to support an older adult, so 
any additional supports that could continue to add to the 
supports and services that we are providing is tremendous.
    We know that statistics tell us that about 60 percent of 
older adults that report to the hospital are at risk for 
malnutrition, and that also increases hospital stays by 4 to 6 
days, so any additional supports that can carry forth the 
supports from the Older Americans Act nutrition programs like 
the SNAP program, especially during the pandemic where there 
could be delivery, is tremendous for older adults that are 
sheltering in place.
    Senator Casey. Thank you very much.
    I wanted to in my remaining time get one question in about 
limited English-proficient seniors. You highlighted in your 
testimony the diverse makeup of seniors that you serve in the 
Philadelphia Corporation for Aging, and we know that the Census 
Bureau tells us that over 25.5 million individuals who speak 
English, less than, very well, that there are that many in the 
country.
    I want to applaud your efforts to ensure that every senior, 
regardless of the language they speak at home, has access to 
timely, accurate information.
    Accessing translation services, as you know, can be 
challenging and costly. I have introduced a bill to focus on 
this that would provide Area Agencies on Aging funding to 
partner with the relevant community-based organizations to help 
limited English-proficient seniors.
    If you would just tell us--and I know we only have about 30 
seconds left--how could this funding enhance your ability and 
the ability of AAAs to assist seniors in this fashion?
    Mr. Orr. Thank you.
    I would say that language translation is a significant 
support and service for Philadelphians. We know that 57 percent 
of older Adults in Philadelphia come from a diverse background, 
and 14 percent have limited English proficiency.
    Having the opportunity to expand collaboration of 
partnerships with those organizations that are within the 
community is a tremendous support to us. This allows us, once 
again, to make sure that we are using our resources and 
stretching our resources with shared partnerships, making sure 
that we are collaborating with people that are also within the 
community, and ensuring that we are expanding nutrition 
programs, for being able to provide shelf-stable meals, and 
older adult protective services to those older adults, so 
expanding our reach through collaboration of partnerships 
really is an extension of the services that we are able to 
provide, and it provides greater need to the community.
    Senator Casey. Thank you, Mr. Orr.
    Mr. Orr. Thank you.
    Senator Casey. Thank you, Chairman Collins.
    The Chairman. Thank you, Senator.
    Next, I am going to call on Senator Braun, who was the 
first person here. After him, I will be calling on Senator 
Gillibrand, just so people can start getting ready who are 
remote. Thank you.
    Senator Braun?
    Senator Braun. Thank you, Madam Chair.
    First of all, I want to commend all the witnesses for 
dedicating your careers to such a noble pursuit. It also sounds 
like if there is any good news out of this that we are going to 
have enhanced communication technology and tools and 
telehealth, which I am one who has been so out front in trying 
to reform health care. That is not needed not only for the care 
of elderly but across the board.
    I am going to reminisce back to 2004 and 2007 when I had a 
mother and father, respectively, the last 3 to 4 months of 
their lives in a nursing home, and I had the benefit of living 
in my hometown where they were. I cannot imagine how 
frustrating it would be today to where you have family members 
that are in the area of a nursing home with a mother or father 
or a close relative and you cannot visit.
    I would like each witness to tell us, Since COVID, what 
best practices have come along? How many nursing homes have 
found ways to actually let close relatives in safely, and if 
that has not occurred, if you think here in the next few 
months, if we have a resurgence, that will be there to where 
you eliminate that most frustrating thing, where you have 
people in their own communities that cannot see a loved one? I 
would like each witness to weigh in maybe with a minute or less 
to tell me what you think.
    Dr. Perissinotto. This is Dr. Perissinotto.
    I think that there is a couple things we need to think 
about here, and I want to broaden the discussion a little bit, 
not just to nursing homes, which has been the predominant 
discussion nationally, but we need to think about long-term 
care facilities in general.
    As Senator Collins noted, I believe, only 1 percent of the 
population is nursing homes, but there is an even greater 
population of people who live in assisted living, supporting 
care, and who are homebound and are receiving the care from 
direct workers and it is understanding the risk in all of these 
situations.
    What I anticipate that we need to be able to move safely 
into the next round of the pandemic and to keep both our 
workers and our family members of patients safe is better 
understanding the epidemiology, which means better tracking 
symptoms.
    One of the things that has been challenging is that we have 
probably missed cases because we did not originally include in 
the definition of COVID symptoms many of the geriatric symptoms 
we see in older adults, which are falls, change in cognition, 
weakness, so that is part of it, and it is also again really 
understanding better the transmission that would safely allow 
visitors and safely allow such workers.
    Dr. Reed. If I may, I would like to share first just a 
quick disclosure that long-term care is an area of passion of 
mine, and I currently serve on the Governing Board of the 
National Consumer Voice for long-term care as well as the board 
of directors for Eden Alternative International. Those are two 
nonprofit organizations focused on resident and long-term care 
advocacy, training, and education.
    Drawing on that experience, I can tell you in terms of 
social isolation within not just nursing homes but, as Dr. 
Perissinotto said, also assisted living and group home 
communities, any congregate or residential care community.
    Loneliness, helplessness, and boredom are extreme 
challenges. In fact, those three concepts were described by the 
Eden Alternative founders, Drs. Bill Thomas and Jude Thomas, as 
the plagues of elderhood and the manner in which we can combat 
those plagues is by fostering and forming authentic, 
meaningful, proactive relationships with all elders 
irrespective of their cognitive or physical limitations.
    I think it is important that we find ways to keep elders 
connected to their families as well as communities. Technology 
is obviously a solution for that, and as I mentioned, the NEST 
Collaborative within Nevada CAN is working with our Ombudsman 
Office to leverage getting tablets into nursing homes so that 
we can have volunteers connect and provide social engagement to 
residents.
    I want to comment that as I think was mentioned earlier, 
there is no substitution for person-to-person contact with 
humans, and I think that it is incumbent upon CMS and the 
States while protecting elders and maintaining their safety to 
also find the right guidelines and procedures that they can 
require for nursing homes to be able to begin allowing families 
and community members to engage with elders and that might 
include requirements such as wearing masks, using hand 
sanitizers, using separate areas within the communities, 
maintaining social distancing with family members, but doing so 
really in a safe way.
    I will say nursing homes have experience with this. They 
are infection control experts and have been for many decades, 
and this is just another challenge that while we leverage 
technology to address social isolation, we can also start to 
provide the guidance and the guidelines from the Federal and 
State levels to enable visits to begin happening again in a 
safe way that protects elders.
    Ms. Sawyer-Manter. This is Betsy Sawyer-Manter.
    I heard yesterday here in Maine that--can you hear me? I 
think so. Things with creating spaces that are safe, but that 
family members and the older adult can come together with some 
kind of a created barrier between them that makes that safer 
for them, so that is one idea.
    Of course, during warm weather, they are looking at doing 
outside social distancing activities between family members and 
older people, so those are a couple ideas that I have heard 
here in Maine.
    Senator Braun. Thank you.
    Mr. Orr. I would agree with the previous comments related 
to there is no substitute for face-to-face contact; however, as 
we continue to looking at ways to increase supports and ensure 
that we are connecting with folks that are at risk for social 
isolation, I think that resources available to ensure that 
people have the appropriate technology is going to be critical.
    Just looking at Philadelphia alone with the digital divide, 
our statistics tell us that about 82 percent of white 
households have access to the internet, the older adults in 
Philadelphia. Whereas, 67 percent of African Americans in 
Philadelphia have access to the internet, so making sure that 
we are doing our part and having flexible resources in there to 
support technology during this time and ensure that doing 
something to tackle the digital divide is going to be 
important.
    Senator Braun. Thank you.
    The Chairman. Thank you, Senator.
    Senator Gillibrand?
    Senator Gillibrand. Thank you, Madam Chairwoman for this 
hearing.
    I would like to talk about the intersection between social 
isolation and nutrition. We have amazing organizations in New 
York that are delivering food to our older adults. Meals on 
Wheels deliver both goods and visit seniors, so it creates that 
social contact.
    We took steps in the CARES Act, the Families First 
Coronavirus Response Act to provide $1.2 billion specifically 
for older adults living in community, including specific 
funding for nutrition programs and home delivery.
    I believe we need much more funding for nutrition. We need 
to prioritize nutrition for our older adults in needs. Food 
banks, as you have seen in the news, are experiencing 
skyrocketing demand. You have seen photographs and pictures of 
cars lined up for miles just to get a bag of food. We have seen 
pressure at food banks in every part of my State, and we need 
to close this meal gap.
    I did introduce legislation called Closing the Meal Gap 
that would increase the baseline for SNAP benefits by 30 
percent.
    Dr. Reed, I wanted to ask you. Given this growing need for 
nutrition programs, how important is it from your perspective 
that we raise the baseline of SNAP benefits, and what other 
policy approaches should we be considering to address food 
insecurity for older adults?
    Dr. Reed. Well, thank you, Senator Gillibrand, for that 
question.
    There is no doubt that this pandemic has shined a light on 
the challenges of food insecurity among older adults and the 
questions about where the eligibility criteria should be set 
for how people can access those benefits, and certainly, the 
flexibility that has been provided through the emergency 
funding bills and the Administration for Community Living for 
the nutrition programs has been extremely helpful to 
communities and being able to serve a larger number of people.
    I think that one of the important innovations that we have 
seen is popup organizations throughout. At least in Nevada, we 
are seeing that very much so and I think probably across the 
country as well, where to supplement and complement the SNAP-Ed 
and other nutritional program funding that is available through 
our county agencies as well as through the States, there are 
private and nonprofit organizations and restaurants that are 
forming collaborations to come together to deliver meals to 
people's homes in ways that can help to address that. I think 
that is really critical in supplementing it during this 
pandemic, but to your point, I think that it is possible many 
of those pop-up agencies that are committed or interested in 
supporting this now may start to fade away over time as the 
crisis begins to abate, and it is going to be important that we 
recognize the need for sustained and increased financial 
resources to ensure that all people have food available to 
them.
    Senator Gillibrand. Do you know what the impact of the USDA 
SNAP online purchasing pilot has been on food insecurity in 
older adults, and how do you think we could improve this 
program to be more effective?
    Dr. Reed. I am not aware of the specific details of that 
bill or the impact that it may be having. I can tell you that 
in Nevada, we have delivered almost 400,000 meals just in the 
months of March and April to older adults, and that does not 
include the organizations that have been stood up to provide 
services particularly in the urban areas that have delivered 
tens of thousands of other meals as well.
    There is a lot of activity that is happening, but I would 
defer to particularly my colleagues from the AAAs in terms of 
the impact of that bill on food security.
    Senator Gillibrand. I would like to address access to 
technology as well. Obviously, before this pandemic, we knew 
that there was about 65 percent of older adults who used the 
internet overall, but about half of older adults did not have 
access that they needed. Many rely on computers in senior 
centers or community centers or the libraries, a lot of which 
are closed now and they are not able to access.
    Improving access to telehealth visits to increase support 
would help protect older adults from being at risk of COVID 
while still receiving the care they need and connecting with 
families and friends. During this pandemic, CMS has provided 
telehealth waivers in an effort to make telehealth more 
accessible.
    Ms. Sawyer-Manter, what are the most is benefits on health 
outcomes of older adults by closing the broadband access gap?
    Ms. Sawyer-Manter. Thank you, Senator.
    I will just say that we are doing telehealth on our agency. 
We are a care coordination agency under Medicaid to ensure that 
people living at home are getting the care that they need and 
that they are getting their needs met.
    What we are finding is only about 20 percent of the 
population that we are reaching even wants to be connected 
through computers. I think some of that is the era of 
technology, and that can be overcome with education.
    The other piece is much like my colleague in Philadelphia. 
Folks do not either have broadband--there is an inequity in 
terms of the rurality of the State of Maine, for example--and 
also that the poverty rate is pretty high among older adults, 
and they just simply cannot afford the fees. It is not just 
getting them the technology, but it is keeping them connected 
because there is a monthly cost for people to have internet. I 
think sometimes we think just about getting out the equipment 
is the way, but it is really beyond that and we are trying to 
think through how do we support people by more than just giving 
them the equipment that they need so that they can get the 
telehealth they need, but also how do we help them stay 
connected.
    Senator Gillibrand. Thank you.
    Thank you, Madam Chairwoman. Thank you, Mr. Ranking Member.
    The Chairman. Thank you.
    Senator Rosen?
    Senator Rosen. Thank you, Madam Chairwoman. Thank you, 
Ranking Member again. Thank you to all of the witnesses for 
being here.
    You know, with the emergency of the novel coronavirus 
earlier this year, public health officials instructed Americans 
to stay home and social distance in order to prevent the spread 
of the disease. These guidelines have been especially important 
for adults age 65 and older, so for Nevada, this means that 
approximately half a million elder Nevadans are now primarily 
homebound and at a risk of experiencing social isolation, a 
figure that makes Dr. Reed's goal to ensure that every elder 
Nevadan has access to medical, social, and daily essentials to 
their home all the more critical.
    Dr. Reed, as you have noted, our State's Aging Services 
Organization, Nevada's Aging and Disability Services Division, 
the Sanford Center for Aging, UNR's Dementia Engagement, 
Education, and Research program quickly came to launch 
together, Nevada CAN, that integrated service response we are 
so proud of, working to ensure that our senior service 
providers can collaboratively support every older Nevadan who 
is now homebound, so like we have been talking about, social 
isolation, so we have to think about getting essential services 
to our seniors. Dr. Reed, I know you have leveraged everything 
you can to help create that Nevada--or work with the Nevada 2-
1-1 hotline to make Nevada CAN a COVID response section as well 
as all the other services, but how do you think these new 
relationships and integrated approach can be beneficial in the 
long term after the coronavirus crisis abates, and how can we 
bolster the success and then export it hopefully to other 
States that can use our model?
    Dr. Reed. Thank you very much for that question, Senator 
Rosen, and also, thank you for your advocacy on behalf of older 
Americans as well as elder Nevadans. Your engagement with this 
Committee and the hard work that you do is impacting lives 
every day, and we in Nevada are grateful for your hard work.
    I will say that the relationships that we formed really are 
the central, sustainable component of what we have done with 
Nevada CAN. We stood up this statewide integrated coordination 
of efforts in order to address the pandemic.
    However, by bringing together our State unit on aging with 
community-based providers, with county providers, and thinking 
about how to triage requests for help from elders directly 
through a centralized program to those providers, there is now 
a new network of support that has been created, and that 
network of support can be sustained in the long term. I will 
say that resources are going to be required to help to achieve 
that at multiple levels.
    The first relates, as you mentioned, to 2-1-1 and what is 
called the ``no wrong door'' approach to providing services to 
elders through aging and disability resource centers. We have 
to have the funding necessary to ensure that no matter what an 
elder needs or where they access the aging services system, 
they are able to get connected with the broad range of services 
that can help them to meet their needs, so that entry point and 
that triage to those other services becomes critical at the 
highest level.
    The next level are the individual functional areas, so 
thinking about how we can put resources specifically into 
addressing social isolation, resources specifically into 
bolstering the technology and the connectiveness for 
telehealth, and resources obviously into food security and 
continuing to provide nutritional assistance. Those core 
functions of this network also need to be sustained at their 
own individual level, so it is the connectedness between all 
those different elements and the relationships that we have 
created that--I guess you could call this as a silver lining to 
come out of this because we have always tried to work together, 
but this pandemic has forced us to really streamline and 
coordinate efforts in an efficient manner.
    Senator Rosen. How exciting. I just cannot wait to keep 
telling everyone about it and let your In Box be full so people 
can copy our model.
    I want to speak briefly about--Senator Gillibrand talked 
about the digital divide as it relates to broadband, but we 
know that seniors oftentimes have difficulty even using 
equipment because of their eyesight. They might have a hand 
tremor, just the physical limitations of sometimes being a 
senior.
    What do you think are some of the new and innovative ways 
that we can help seniors use the technology if we are going to 
provide them telehealth, et cetera, et cetera? How do we 
overcome those physical limitations?
    Dr. Reed. Right. I think that issue is important, both in 
terms of providing social support as well as through 
telehealth.
    I am going to speak very briefly about telehealth first. It 
is interesting. The Sanford Center for Aging at the School of 
Medicine at UNR has been providing telemedicine services for 
several years, but that was a telemedicine cart talking to a 
telemedicine cart in a rural clinic and that is no longer 
possible because very few elders have telemedicine carts 
sitting in their living rooms.
    What we have been able to leverage are new online 
platforms, and also, we are able to potentially get tablets to 
people that do not have the technology, but that does not 
address the barrier of people not being able to use technology. 
If you hand an iPad to an older adult who has never held an 
iPad, they are not going to know what to do with it. We have 
tried to stand up our back-office support within the clinics to 
provide pre-visit technical assistance to ensure that they are 
able to access the technology, get online, before connecting 
them directly with our providers and some of that work, as I 
mentioned, is being supported by the CARES Act emergency 
funding that went to the Health Resources and Services 
Administration to support the Geriatric Workforce Enhancement 
Programs nationwide and bolstering their telemedicine and 
telehealth services.
    On the social isolation side, it is a similar situation, 
and so what we have done through the NEST Collaborative is to 
engage volunteers in reaching out and specifically just 
providing technical assistance to older adults to connect with 
their existing groups of friends as well as to learn how to use 
technology to be able to access telehealth and have social 
connectedness.
    It is essentially IT support for elders to learn how to use 
the technology effectively in addition to providing the 
technology and providing the services via technology. All three 
of those elements have to be present. Thank you.
    Senator Rosen. I am so grateful for your innovation. We 
have all had our challenges with the Zoom calls. That is for 
sure, but we look forward to seeing you back home in Nevada and 
continuing supporting the good work that you do.
    Thank you.
    The Chairman. Thank you, Senator.
    Senator Jones?
    Senator Jones. Thank you, Chairman Collins, and thank you 
for holding this hearing, you and Ranking Member Casey. This is 
an important hearing, and I appreciate all the witnesses not 
only for being with us today but also your dedication to 
seniors across the country.
    Ms. Sawyer-Manter, I would like to ask you a little bit, a 
question about personal protection equipment. You mentioned in 
your testimony that you had difficulty finding PPE during the 
beginning of the pandemic in order to safely serve clients.
    I have heard that across Alabama as well, and I have a bill 
pending to try to get more PPE manufactured in this country, to 
give tax incentives, because I firmly believe that we are going 
to need more going out of this than we had coming in. In other 
words, it may not have been as much on your radar heading into 
this pandemic.
    My view--and I would like for you to address whether I am 
right or wrong. My view is that we are going to need more PPE 
coming out of this, that I think folks are going to be taking 
extra precautions even if this particular crisis abates, so if 
you could address how we see going forward the use of PPE with 
your agency?
    Ms. Sawyer-Manter. Thank you, Senator, for the question.
    I believe that PPE is going to be standard operating 
procedure from this point forward for the foreseeable future, 
anyway, and I do think that one of the things that we do is we 
have statewide home-based care in our State, where many, many 
personal care workers are in homes all the time helping people 
with activities of daily living. Those folks need personal 
protective equipment, as do the clients that they are serving. 
It is a two-way street, so it is not only getting it to the 
workers, but it is also getting it to the clients. We do not 
see that we will see people in our physical office space 
without PPE, and so I think that is going to be an ongoing 
issue.
    We have had a really hard time getting masks. Gloves have 
been a little easier, but masks have been a real issue. I 
recently was able to place an order and get some of just the 
surgical masks, so it is an ongoing issue, and I do not see it 
going away anytime soon.
    Senator Jones. Thank you. Well, that is kind of the way I 
see it. I hope we can get some support for this bill I have got 
that would give incentives to businesses to make that in the 
United States and not be so dependent on foreign vendors in 
foreign countries for the manufacturer.
    I would like to kind of ask the panel. It is a general 
question, but I am just going to be candid about this. Each one 
of you have dedicated your lives to working for seniors, and I 
so applaud that. You have made it your life's work.
    I will be honest that at some point during this pandemic, 
we have seen as people got frustrated and wanted to open back 
up and get out into the world--and rightly so--and so things, 
there seemed to be to me upon not a few public officials but 
also some in the general public that had more of a cavalier 
attitude about the health of our seniors, the potential 
expendability of our seniors. I have heard it over, ``Well, 
they are going to die anyway. They have got these preexisting 
conditions. We need to live our lives,'' and that has been very 
troubling to me, having lost a dad in December, having a mom 
who just turned 89 years old.
    I would like for each of you to address that a little bit 
to see what can we do as we get toward the end of this, 
hopefully this health care crisis, but about the attitude for 
our seniors in general and if anybody has any thoughts on that, 
I would sure like to hear it because it has been very troubling 
to me.
    Dr. Perissinotto. This is Carla.
    I can touch on a few topics, where we are essentially 
discriminating against ourselves, because we are all aging, and 
we will all be in this place at some point, so it is 
fascinating to me the discriminatory language that we have 
used.
    I said this a couple times during my testimony. Ageism is a 
huge part of this, and so it does require a reframing and a 
national focus on how we talk about respect and how do we bring 
back value to older adults.
    If that does not work, which is a culture war which does 
not always work, it is also thinking about the finances. Older 
adults are costly, and if we do not focus on some of the things 
that we know prevent costs down the line, that ultimately 
affects all of us, so it is not just about dying. It is the 
people that lose their independence and become more dependent 
and end up in nursing homes and other places which are costly 
to Medicare.
    Senator Jones. Thank you.
    My time is almost out. Anyone else that wants to add to 
that?
    Ms. Sawyer-Manter. This is Betsy Sawyer-Manter.
    I had the same conversation a couple days ago with someone. 
In a time when we are really talking about social justice in 
this country, it seems to me that ageism has to enter into that 
conversation as well, and that there is this Dixie Cup 
mentality that older people are expendable and we need to stop 
that, and we need to address it, and we need to confront it 
when we hear it.
    Dr. Reed. I would say that is exactly right. Ageism is one 
of the preeminent issues in the field of gerontology and 
geriatrics, and it affects our society, our communities, as 
well as our health care delivery system.
    I think what is critical is that we start to educate the 
public as well as health care providers about ageism as a form 
of discrimination, just like the other forms of discrimination 
that are so socially unacceptable. For some reason, making 
jokes about older adults is perfectly fine, and it is a 
socially acceptable form of discrimination right now and that 
is what needs to be addressed.
    As has been said, people are discriminating against their 
own future selves, and to get them to recognize that there 
really is no age at which they would choose to be diminished in 
their value or their abilities to self-determination and 
decisionmaking in their own lives.
    I would just add that discrimination against people living 
with dementia is also a form of discrimination that needs to be 
addressed as well. It is judging people based on their 
cognitive abilities and making assumptions about what they are 
and are not capable of doing for themselves, and both ageism 
and dementia-ism are forms of discrimination that we should try 
to educate the public about because I think if they knew about 
these to a greater degree, they would be less willing to engage 
in that discrimination so readily.
    Senator Jones. Great.
    Mr. Orr. I would also agree that ageism and reframing aging 
is absolutely critical.
    We continue to stress the importance of following the 
guidelines of the CDC and health department for our older 
adults because they are some of the most vulnerable in the 
community.
    I think back to a time when one of my predecessors wrote an 
article--this is probably about 10, 15 years ago--in how we 
view ageism in the United States, and when we think about aging 
things in other areas of our lives, we talk about vintage cars 
and we talk about aged wine, it tastes better, but when we talk 
about older adults, you her things like ``geezer'' and ``old 
fogey,'' so we really have to think about how we frame ageism 
and reframe it in our society.
    Senator Jones. Great.
    Well, thank you all. Thank you, Madam Chairman. I know I 
went over my time a little bit, but I think that those were 
very, very important comments from our panelists today, so 
thank you for that indulgence.
    The Chairman. I agree.
    I know that there is at least one other Senator who wants 
to be here. I am going to go to my second round and give 
Senator Casey the opportunity for his second round in the hope 
that the Senator will be able to get here before we wrap up the 
hearing.
    There are so many important issues that we covered today. 
Mr. Orr, you touched on one that I want to explore more with 
you. You noted the potential increase for elder abuse scams and 
exploitation during this pandemic. We have already seen one 
COVID-related scam in which individuals were called, 
particularly seniors, and told that they had to pay now to get 
a vaccine against COVID-19.
    Well, of course, while there is a lot of research that is 
promising and under way, there is not currently a vaccine even 
available for the coronavirus.
    Seniors who are socially isolated are particularly 
vulnerable to scams. We know that from more than 20 hearings we 
have held exploring various scams that target our seniors.
    As scammers seek to prey off the most isolated and 
vulnerable seniors during this pandemic, during a time where 
they may be more isolated, not have people to consult with, 
what preparations is your agency doing to help protect this 
truly vulnerable population?
    Mr. Orr. Thank you for your question, Chairman Collins.
    I would say that we are ensuring that we are adding the 
appropriate resources to our Older Adult Protective Services 
unit so that we can address abuse and neglect, financial 
exploitation, and abandonment.
    We also want to make sure people know other resources that 
are available to them, like the Ombudsman Unit which supports 
those individuals in long-term care, receiving long-term care 
services, but we are also continuing to work with collaborative 
partners and with our local legislators like Senator Casey who 
has continued to stress the importance of educating older 
adults on scams and what resources are available to them, so 
just making sure that we not only have resources available to 
investigate and try to mitigate abuse and support people with 
resources, but also connecting them to opportunities to become 
educated.
    The Chairman. Thank you for that very important work that 
you are doing.
    I want to turn back to Dr. Reed and an issue that I raised 
earlier about Alzheimer's disease. How does your portal or does 
your portal help those with Alzheimer's and their caregivers to 
connect with social supports? Do you have any special program 
there that would help people who are living with dementia and 
particularly their caregivers?
    Dr. Reed. Right. Thank you, Senator Collins, for that 
question and, again, I feel I am full of disclosures. I should 
say that I do serve as the chair of the Nevada Task Force on 
Alzheimer's Disease and have also been involved with the 
Alzheimer's Association in one way or another for over 20 
years, including currently serving on the board of directors 
for the Northern California and Northern Nevada chapter of the 
Alzheimer's Association.
    The Nevada CAN effort has taken great steps to try to 
ensure that people living with dementia are able to access and 
benefit from the services as well as their family caregivers. 
That started in the social isolation element by connecting with 
people living with dementia themselves who helped to develop 
the portal that we offer, helped to develop and review the 
website to ensure that it is dementia friendly.
    The NEST collaborative, as I mentioned, is housed within 
the Dementia Engagement Education and Research Program at our 
School of Community Health Sciences, and Dr. Jennifer Carson, 
the director of that center, also leads Dementia Friendly 
Nevada. She has connected our Nevada CAN social support efforts 
with both volunteers and participants living with dementia from 
our rural Dementia Friendly communities around the State that 
has gone to great lengths to ensure that all of the services 
that we offer are supportive of people living with dementia.
    I think that is a critical component is the input and the 
advice from people living with dementia. As I said earlier, we 
often make assumptions about what people with dementia can and 
cannot do, and in our initiative in Nevada, we recognize the 
value that elders bring into the discussion, and recognize the 
value that people living with dementia bring in sharing their 
own perspectives on what will and will not be best to help to 
support them in the community.
    The Chairman. Thank you so much for the good work that you 
do.
    In the interest of full disclosure to you, I founded the 
Alzheimer's Task Force in the Senate. Hillary Clinton was my 
first co-chair. Mark Warner is my current co-chair. I worked 
over the years with Evan Bayh and others. We have been able to 
gravely increase the funding for research, and that is 
something that I have been very proud of. There is a long ways 
to go, but I am so pleased that you are so active in that area. 
I think it is really critical.
    Senator Casey?
    Senator Casey. Chairman Collins, thanks very much.
    I wanted to turn my attention to Dr. Reed for a question 
about nursing homes. As we know, we have seen the horror unfold 
in COVID-19 where, as I mentioned earlier, just about 40 
percent of all deaths are in long-term care settings when you 
combine the number of resident deaths--and, of course, that is 
the higher number, unfortunately, but when you combine resident 
deaths and the deaths of workers in those settings.
    We know that just as the pandemic has isolated seniors 
living within communities across the country, it is also, of 
course, isolated seniors in nursing homes. They have been 
locked down, in essence, for months now without outside 
visitors and family members, as I mentioned, seeing them 
through windowpanes that we have all seen over and over again.
    I had an opportunity with Senator Klobuchar and Senator 
Capito to introduce Senate Bill 3517 called the ACCESS Act. It 
was pretty simple, but it would just provide help to nursing 
homes so they can purchase the technology to ensure residents 
can stay connected. It complements a new pilot program, 
actually, a Pennsylvania program, the Department of Aging in 
Pennsylvania and AARP in Pennsylvania, giving cell phones and 
tablets to nursing homes for residents in about 40 counties in 
our State.
    My question, Dr. Reed, do you agree that efforts like these 
are necessary to help nursing home residents stay connected to 
both family and friends and to reduce the incidence of both 
social isolation and loneliness?
    Dr. Reed. Thank you, Senator Casey.
    Absolutely. I think one of the benefits of the ACCESS Act 
that you have proposed is not only that it enables nursing home 
and assisted living communities to gain the technology that 
they need in terms of the tablets and computers, but also that 
the language is broad enough, at least as I understand it, that 
it can provide support for homes to get internet services, so 
it is not just the hardware, but it is also the connectiveness 
as well, which I think is another really important component of 
this, and opening that up so that the internet is available 
along with the technology and then I mentioned earlier, I think 
also it is important to provide the technical assistance to 
older adults for them to be able to effectively use the 
technology, which is another leg to that stool.
    Gaining access to technology and the services necessary are 
an essential step toward reducing social isolation in long-term 
care communities, and I would mention again that it is also 
important for CMS to begin providing guidance on how to engage 
in effective infection control within those communities, so 
that they can start to have person-to-person visits in a way 
that is cautious and protective of the elders. Bringing those 
two things together can, I think, have a meaningful impact in 
reducing social isolation between the technology and the 
cautious protected visits.
    Senator Casey. Doctor, thanks.
    I think one thing the Senate should do is to consider 
legislation. I happen to have a bill, but I am not referring 
just to that bill. We have got to provide, I think, more 
resources to nursing homes, even as we want to hold them 
accountable, as we have to for violations. We also have to help 
them with resources so they can separate, so-called 
``cohorting,'' separate residents with COVID-19 from residents 
that do not have it, and that cohorting works and it should be 
in place in every single nursing home in addition to the costs 
of PPE and other expenses they have to incur.
    We should not allow another group of nursing home residents 
and workers to die because we do not have the strategy and a 
funded strategy to help nursing homes across the country, so I 
hope we can act in the Senate on that.
    Thanks, Dr. Reed.
    Chairman Collins, I will go back to the other questioners.
    The Chairman. Thank you.
    Senator McSally?
    Senator McSally. Thanks, Chairwoman Collins. I appreciate 
you holding this important hearing. Thanks to all of our 
panelists.
    We are all experiencing, our constituents are experiencing 
the challenges of the isolation that we have been talking about 
today. My mom is in independent living. I know she does not 
like me talking about her on Capitol Hill, but just trying to 
stay connected with her and help her through the process and 
getting eyes on her virtually, she is again in independent 
living but has been basically isolated for months now.
    I did a window visit with a mentor in assisted living in 
Tucson, and just the challenges are very real in trying to stay 
connected with people, as we have been talking about, when the 
technology is just not the same and sometimes the technology is 
overwhelming.
    Then we had one constituent contact me whose mother was 
isolated, had dementia, basically felt totally cutoff, scared, 
and afraid, and she passed away in this timeframe. I think this 
is part of the cruelness of this virus that we have individuals 
who are already vulnerable, who are isolated, and if they get 
the virus or have some other serious health condition, they are 
alone and the nurses are doing amazing jobs to stay with them, 
but it is not the same as the face of your loved one, your 
family member.
    As we move forward and we have increased our capacity for 
testing, I know there are concerns for bringing in visitors 
because we cannot have this population be more at risk.
    I feel like we cannot afford not to have the ability for 
visitors and family members to be tested so that they can be 
with their loved ones and have that human touch as they go 
visit them.
    I also think there is an element of preventing elder abuse. 
It is underreported. The number of cases that are reported is a 
shocking number in America, and one of the best oversight 
mechanisms in addition to inspections in the government is the 
family showing up and being able to check in on their loved one 
and see how they are doing and focus on their care and see any 
signs and symptoms where there may be neglect happening, so if 
you could all share. It is not just about isolation. I think it 
is also about preventing elder abuse and just providing that 
there is a humanity of a loved one being with you. There is 
nothing that replaces that. Can we not get to that place where 
we can safely allow people to visit and hug with high 
situational awareness while protecting these most vulnerable 
from this awful virus?
    Dr. Perissinotto. This is Carla Perissinotto.
    Thank you, Senator, for bringing up these topics. I had two 
things. Related to the elder abuse, one of the challenges has 
been around our understanding of cognitive impairment and how 
we define that and how our local agencies respond.
    There is often this assumption that people have the right 
to decline services and the right to self-determination. Self-
determination goes out the window with the cognitive 
impairment, so part of this going forward as we understand 
elder abuse is understanding the interplay of cognitive 
impairment and giving our agencies room to work with that.
    Related to assisted livings or independent living, thank 
you for bringing that up. Where we are here is that, as I 
mentioned earlier in my testimony, we are in a data-free zone, 
and we need to work nationally to provide better guidance to 
these locations because they are having to go to extreme 
measures because of fear of what families are going to say if 
someone is infected, fear of the media, and no guidelines, so 
the work ahead of us is really to develop those guidelines so 
we can safely allow you to see your mother, not just through a 
window.
    Where that policy came from is a little bit beyond me. I 
think it has been fear-based. We have had to do that to keep 
people safe, but there is a middle ground. I hope in these 
couple months if we see a little bit of downtrends of 
transmission, we will have some time before the next pandemic 
starts.
    Senator McSally. Great.
    Any other panelist want to share your perspectives?
    Dr. Reed. This is Peter Reed.
    I would just share I think it goes back to that sort of 
ethical or philosophical tension that exists in really all 
areas, but balancing physical safety with personal autonomy and 
thinking about how we can maintain safe environments for elders 
while also enabling them to engage with family and friends, as 
you said, to get hugs, which are so critical. Physical touch is 
so important.
    Senator McSally. Yes.
    Dr. Reed. This is true not only in long-term care 
communities but also in community-based supports and services 
and this is a really challenging situation with the pandemic 
because we have heard the data. This has a dramatic impact on 
older adults, and as a public health professional, my advice is 
for all elders to continue to stay home, no matter what their 
States are doing, in opening up opportunities to go out and to 
take advantage of the technology and the services and resources 
that are being provided in their communities to help to 
maintain access to all of those essentials of everyday life 
that they need, but bringing families together in a safe and 
appropriate way, providing guidance on how to do that can help 
us to balance that need of autonomy and personal safety and 
connectedness and physical safety. It is a challenge, though.
    Senator McSally. Great. Thank you.
    I do not know where the time clock is here. I do not know 
where I am, but I do want to also just ask really quick about 
the issue of telehealth.
    Senator Jones and I will be introducing legislation today. 
This is again a pilot project to increase the access, 
especially in rural areas, to remote patient monitoring. I 
mean, we have seen the benefits of telehealth. That keeps you 
isolated, but it still gets access to the health care, but even 
people with diabetes and other things, if they can have that 
remote monitoring and it is under 2G or 3G or cellular coverage 
to be able to do that, just having that additional situational 
awareness to be able to keep the senior healthy and monitored, 
so any comments on expanding telehealth to include remote 
patient monitoring like our bill has?
    Dr. Perissinotto. This is Carla Perissinotto.
    Two things real quick. One, it is thinking about is that 
technology accessible for older adults. Has it been tested? Has 
it bee adapted to them?
    Two, over-monitoring can be somewhat dangerous in older 
adults, so it is the balance between what are we monitoring for 
and what are our goals, and then just keeping autonomy and 
privacy in mind as we develop these things. There is a lot of 
room, and it is great to be thinking about this moving forward.
    Senator McSally. Great.
    Anyone else?
    Mr. Orr. Sure. I would say that making sure that we do our 
part too to try to eliminate the digital divide.
    Earlier, I shared some statistics in Philadelphia that with 
the older adults in my community who have access to the 
internet, it is about 82 percent, and those in the African 
American community, it is 67 percent. That does not even touch 
on those that are impoverished.
    We are looking at people who are in Philadelphia that are 
at the 100 percent of the Federal poverty level. They have 
about 52 percent internet connectivity, so anything we can do 
to make sure that we break that digital divide so more people 
can have access to telehealth at this time would be tremendous.
    Senator McSally. Great. Thank you.
    I am pretty sure I am over my time, even though I cannot 
see a clock. Thanks a lot, Madam Chair. I appreciate it.
    The Chairman. Thank you.
    I want to thank all of our witnesses today for their 
research, their work, their commitment to serving our seniors 
and for joining us today. Considering the technological 
constraints we had to work with, I think it went 
extraordinarily well, and I want to thank both our technical 
staff as well as the Committee staff for their hard work on 
this hearing.
    Today's hearing has highlighted the stark reality that 
while social distancing has become a core tool in our effort to 
save lives and to help flatten the curve of COVID-19, social 
isolation cannot become the new normal, especially for our 
older adult population. We know that social isolation and 
loneliness creates significant but underappreciated health 
risks for older adults. The pandemic has only magnified these 
detrimental effects.
    While the issues related to social isolation affect people 
of all ages, older adults are more susceptible due to physical 
ailments or life circumstances such as living alone or having a 
smaller social network.
    As we work to understand and reduce the impacts of this 
silent epidemic, today's witnesses certainly provided us with 
valuable insights, practical solutions, and reasons for hope 
that we can overcome some of the strict restrictions and 
carefully and safely unite families with their loved ones in 
hospitals and nursing homes and particularly those who are 
living with Alzheimer's or other dementias.
    Three years ago, I wrote a column for a Maine newspaper in 
which I wrote, ``The anecdote to isolation is connection,'' and 
that is even truer today during this pandemic. Solutions to 
this issue come in many forms. Technology clearly is important, 
but the common thread is human connection.
    We will continue to search for meaningful ways to listen, 
learn, and connect with older adults to help give them the 
assistance that they need and to make their lives more 
meaningful and more enjoyable, and so that we too can learn 
from them.
    I would like to now yield to Senator Casey for his closing 
remarks.
    Senator Casey. Chairman Collins, thank you very much for 
the hearing. I think it was a critically important set of 
topics to be able to explore at this time, especially when we 
consider the challenges faced by seniors and their families in 
the aftermath of the spread of COVID-19 as well as the economic 
crisis on top of it.
    I hope that we can do more beyond this hearing. I hope that 
the Senate in the next couple of weeks will act on a whole 
range of issues, but if we just focus on these senior issues, 
there is still a long way to go. As much as we came together 
with the virtually unanimous consensus to pass what now I think 
is five pieces of legislation, there is still more to do. The 
Senate still has work to do to help seniors.
    I would just mention one issue, and that is food security, 
which we know is directly connected to the issue of social 
isolation.
    Mr. Orr mentioned just in the--consider this, just in the 
city of Philadelphia, one city, 56,000 people in that city who 
happen to be seniors who cannot shop for themselves, so food 
security in and of itself is a huge issue directly related to 
social isolation.
    I hope that we do not go through the rest of June and the 
rest of July--we have a break in July, as everyone knows--
without taking action on a whole range of issues, but I will 
limit it to just food security and issues that can better 
assist our seniors and their families with social isolation.
    I think there are a lot of good ideas that our witnesses 
presented today, and I hope those ideas can be effectuated by 
way of legislation passing the U.S. Senate in the near term 
because I do not think families can wait months for this kind 
of support, but we are grateful. We hope that the spirit that 
undergirded the reauthorization of the Older Americans Act that 
Chairman Collins and I work together on, we hope that that 
spirit will animate and create some urgency behind near-term 
legislation to help seniors.
    Thank you, Chairman Collins, and I want to thank our 
witnesses for their testimony. I want to commend and salute the 
work of the staff to make this hearing possible in this 
fashion. Thanks very much.
    The Chairman. Thank you, Senator.
    Committee members will have until Friday, June 19th, to 
submit additional questions for the record. If we get any, we 
will be sending them to our witnesses and appreciate their 
willingness to respond to them.
    I want to thank our witnesses. You were absolutely 
terrific, and I appreciate your putting up with the 
technological challenges of today to join us.
    I was thinking that prior to the pandemic, I had never 
heard of Zoom or WebEx, and now every single day, they rule my 
life, but at least we do have that technology to take advantage 
of.
    One of you made a very good point that for her seniors, 
sometimes the ability to use that technology is limited by poor 
vision or by inadequate hearing, even if they have the access 
to the technology, and I think that is something for us to give 
some creative thought to as well.
    I do want to again thank all the members of the Committee 
for participating in the hearing, and this concludes our 
hearing. Thank you.
    [Whereupon, at 11:35 a.m., the Committee was adjourned.]
  
      
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                                APPENDIX      
      
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                      Prepared Witness Statements

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                        Questions for the Record

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                  Additional Statements for the Record

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