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The Senior Social Isolation Project (SSIP): a comprehensive response to a growing aging population

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The Senior Social Isolation Project (SSIP): a comprehensive response to a growing aging population

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Content RUNNING HEAD: SENIOR SOCIAL ISOLATION PROJECT (SSIP)
The Senior Social Isolation Project (SSIP):
A Comprehensive Response to a Growing Aging Population
Lisa Evans Powell
University of Southern California
Doctor of Social Work
2020 May
SOWK 722:
Professor Renee Smith-Maddox
March 23, 2020
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Executive Summary
The challenging problem of social isolation has been deemed one of the 12 Grand
Challenges of Social Work. Social isolation has now been researched and written about for
decades across multiple disciplines, including social work, sociology, public health, and
psychology. Social isolation can impact people of all races, genders, socioeconomic status, and
locations. It negatively influences the physical and mental well-being of individuals in
significant ways and has increased in prevalence in recent years. This capstone paper examines
the impact and prevalence of social isolation in an especially vulnerable population—the
elderly—and proposes an innovative solution for addressing the issue at the county level in
Ventura County, California.
Social isolation in the older adult population has been researched heavily in recent
decades, and the issue has begun to receive more attention. Academic institutions and
organizations such as the American Association of Retired Persons (AARP) have highlighted its
presence and implications. Social isolation in the elderly can be particularly problematic, as the
complexities of aging provide significant challenges for daily living. Conditions such as limited
mobility, illness, static income, mental health issues, and cognitive decline are all intersecting
and salient factors that add to the dimension of this problem. Given the fact that the United
States’ population aged 65 and older will double within the next 20 years (Nicholson, 2012),
devising coherent and comprehensive solutions for caring for the elderly has become more
critical.
The Senior Social Isolation Project (SSIP) is a comprehensive strategy for improving
services countywide to low-income, homebound elderly in Ventura County, California, which is
located adjacent to Los Angeles County (northwest). The SSIP is an initiative composed of three
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key programmatic components—advocacy, education, and research—that are rooted in a
collaborative model to address the issues faced by socially isolated seniors. The elderly, and
particularly socially isolated or homebound elderly, are underserved in Ventura County. This
population, however, is growing rapidly as elsewhere in the country, with the number of adults
75 and older expected to nearly double (to nearly 90,000 residents) within the next 10 years.
Through collaboration with partner agencies across the county, the SSIP will use advocacy,
education, and research to influence county leaders and communities to better serve this
vulnerable population and develop new programming. The SSIP’s design utilizes a well-
established structure called the Collective Impact Framework, a model consisting of five
components that bring structure to collaborative efforts for social change (Appendix C).
Long-term goals for the SSIP initiative include an increased level of in-home services,
increased levels of volunteering and philanthropy for programs supporting seniors, more regular
screening for social isolation in seniors by healthcare providers, and improved well-being of
seniors in the county. It is important to understand that this is not a neatly packaged solitary
program, but rather an initiative looking to influence systems and change culture.
The Greenhouse Theory of Social Innovation and the Precaution Adoption Process
Model are the two key theoretical frameworks utilized for the design of the SSIP (Appendix B).
The Greenhouse Theory uses different “lenses” to identify a norm that needs to be addressed in
order to help mitigate a social problem. The SSIP design addresses social norms and stereotypes
that currently exist about the elderly in order to more effectively address the problems they face
and to develop truly impactful solutions. The need to bring visibility to this population is
significant, and the SSIP intends to address this need through its advocacy, research, and
education. Additionally, the Precaution Adoption Process Model (PAPM) and its seven distinct
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stages will be applied. The stages of the PAPM increase awareness of a problem and center on
moving people from non-action to action as a result of that awareness. Social isolation—despite
the wealth of research and literature—is still not viewed in widespread fashion as a contributing
factor in health and well-being. Awareness in county leaders and the community at large must
grow in order to see action taken in addressing social isolation in the elderly.
The SSIP has purposely been designed with multiple components because a
comprehensive strategy is what is needed to truly address the complex mix of factors impacting
this frail and vulnerable population. Through implementation, county decisionmakers and the
general public will become more aware and educated, which will then lead to shifts in social
norms and behaviors. These shifts will then be operationalized through new programs and
funding priorities. Increasing the visibility of and awareness about socially isolated older adults
is critical to the success of the SSIP in making change.
SSIP’s strategy of increasing awareness and knowledge about the impact and prevalence
of social isolation in Ventura County’s elderly, as well as the utilization of evidenced-based in-
home programming, is intended to move decisionmakers to modify existing policy and practice.
The SSIP design also centralizes the concept of collective impact: an understanding that large-
scale social change comes from coordination across sectors rather than isolated individual
organizations. Given that Ventura County currently has substantial gaps in services for this
population, and is experiencing increasing numbers of elderly residents, a comprehensive
county-wide strategy is both imperative and innovative at this time. The long-term vision is that
one day the SSIP will be a model program for other communities wanting to undertake a
systemic approach to a pressing problem, whether it be social isolation or other challenges.

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Conceptual Framework
Statement of Problem and Grand Challenge
During the last decade, professionals in the field of social work have taken on the task of
identifying society’s most pressing challenges. In collaboration with colleagues from other areas,
social workers have crafted strategies and solutions to eliminate these challenges. The 12 Grand
Challenges of Social Work (GCSW) resulted and are now utilized as a framework for
understanding society’s most daunting social problems. Eradicating social isolation is one of the
12 Grand Challenges.
Social isolation can affect any human being, whether rich or poor, young or old, black or
white, or rural or urban. It is now well-documented—through years of research—that social
isolation negatively impacts the health and well-being of individuals across all ages, incomes,
and cultures. Social isolation can be defined as the “absence of social interactions, contacts, and
relationships” with family, friends, neighbors, and society as a whole (Berg & Cassells, 1992).
The impact of social isolation in communities is profound: study after study shows that social
isolation has a significant association with lower health outcomes and a host of other problems.
Isolation is more common now than it used to be, in part due to the lower birthrate and higher
rate of divorce of the Baby Boomer generation (The Week, 2019). Between 1985 and 2009, the
average American’s social network shrank by more than one-third. As stated in The Grand
Challenges for Social Work and Society, “social isolation is a potent killer” (Lubben, et al.,
2018). Some have argued that the association between social isolation and health is as strong as
that between smoking and health (Pantell, et al., 2013).

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Literature, Practice, and Innovation Review
A robust body of research exists on the issue of social isolation in the elderly. According
to the National Academies of Sciences, Engineering, and Medicine, about one in four older
adults is socially isolated (National Academies, 2020). Researchers from NORC (National
Opinion Research Center) at the University of Chicago found that nearly half of older adults (62
and older) in the United States experience some degree of loneliness. They also found that lonely
older adults are more likely to have lower incomes and fewer assets than their non-lonely peers.
Complicating the situation is the fact that the population of older adults is currently increasing
due to demographic changes that are upon us with the aging of the Baby Boomer generation.
One in six Baby Boomers lives alone, and about one in 11 Americans age 50 or older has no
spouse, romantic relationship, or child. Julianne Holt-Lunstad (2010) found that those who are
socially connected have a 50% reduced chance of having an early death. Other studies have also
seen increased mortality risk as well as increased dementia risk in the socially isolated. Data
analyzed of more than 580,000 adults found that social isolation increases the risk of early death
for all races: 60 to 84 percent for white participants and double the risk for black participants
(Alcaraz, et al., 2019). Florida State University researchers examined data on more than 12,000
U.S. adults age 50 and older and found that social isolation and loneliness were associated with a
40% higher incidence of dementia (Sutin, et al., 2018).
With the numbers of elderly growing, communities will have more socially isolated older
adults, more disabled older adults, more older adults with dementia, and more older adults with
mental health needs. The number of adults age 65 or older in the United States will likely double
within the next 25 years (Nicholson, 2012). These trends are similar for the State of California
and the County of Ventura.
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Social isolation in the elderly is particularly challenging because of the specialized needs
of older adults; social isolation can either exacerbate or be exacerbated by mental illness,
physical ailments, and decreased cognitive function. The causes of social isolation in the elderly
are multidimensional, including any or all of the following: illness or disability, limited mobility,
limited sight or hearing, loss of work or purpose, and loss of independence. Social isolation and
loneliness in older adults have been shown to have a negative impact on both physical and
mental health. A majority of the older adult population experiences decreased functioning and
thus requires some assistance; the Congressional Budget Office estimates that more than two-
thirds of 65-year-olds will need support to deal with a loss in functioning at some point during
their remaining years of life.
A socially isolated older adult is more likely to be depressed or die by suicide. Death by
suicide among older adults is viewed as a significant public health problem (Choi, et al., 2016),
and the aging Baby Boomer generation has consistently had higher suicide rates than any other
cohort (Yeates, et al., 2011). The Centers for Disease Control has found that a key strategy in
preventing suicide is “the promotion and strengthening of connectedness at personal, family, and
community levels” (CDC, 2006). Addressing social isolation—and depression—in older adults
will not only increase overall well-being but will impact the suicide rate in this population.
Interventions addressing social isolation in elderly populations. There have been a
variety of responses that attempt to address the issue of social isolation in the elderly. The impact
of interventions has been mixed, in part due to the heterogeneity of socially isolated older adults
(Machielse, 2015). Additionally, approximately 100 studies of interventions addressing social
isolation in older adults have been undertaken, which is a small number considering the wide
variety of intervention types, target populations, and research designs (Elder & Retrum, 2012),
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so more study is needed. The types of interventions addressing social isolation in the elderly can
be grouped as follows: one-on-one interventions, group-focused interventions, and community-
focused interventions. Interventions have attempted to reduce loneliness and/or depression,
increase social network size, improve quality of supports, and increase the frequency of social
contact (Elder & Retrum, 2012).
One-on-one programs may include telephone support, home visiting, in-home medical or
mental health care, and technological/online supports. Friendly visitor programs have shown a
positive impact in the areas of self-worth and social integration of seniors (MacIntyre, 1999).
Intergenerational models have also been utilized to provide support for elderly populations
(Teater, 2016). A review of 27 studies of intergenerational programs involving children and
elderly found a positive impact on children and older adults, reporting that intergenerational
programs appear to be useful in fighting social isolation and keeping seniors more active
(Gualano, et al., 2017). Technology offers enormous potential in mitigating social isolation;
however, there is significant work to be done in terms of developing comfort with and access to
technology in the senior population. Older adults have difficulties in learning how to use
technology in contrast to younger generations (Breck, et al., 2018).
Group-focused interventions to combat social isolation in older adults include senior
center programs, support groups, and senior volunteer programs. Dickens, et al., (2011)
conducted a review that found a significant positive impact of support groups on seniors’ levels
of social isolation. It is often challenging for frail homebound seniors to access these types of
programs, however. The Adult Day Care model recognizes the benefit of the social connections,
as well as the lower cost as compared to in-home care, and often offers free transportation to
programs (CAADS website, 2018).
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Finally, community-focused interventions addressing this issue may include the Village
model, intergenerational housing models, and aging-friendly cities (Elder & Retrum, 2012). The
Village concept, in its typical format, is a membership-driven nonprofit organization that is
centered around the needs of a specific community. It coordinates access to services, provides
volunteer services by members, and offers discounts to service providers with the overall goal of
impacting the isolation, interdependence, health, and purpose of its members (Village to Village
Network, 2018).
There are existing evidence-based programs geared towards elderly aging in place that
have the potential to be replicated in Ventura County. For example, the Community Aging in
Place, Advancing Better Living for Elders (CAPABLE) program offers home visits combining
occupational therapy, nursing, and handyman support (Szanton, et al., 2011). The Positive
Solutions program, which utilizes the evidence-based Program to Encourage Active Rewarding
Lives (PEARLS), has been successful in the identification and treatment of socially isolated
seniors for depression (Positive Solutions, 2018). Given the challenges that frail homebound
seniors have in accessing programs that can help them, in-home supportive/therapeutic services
are ideal for many. Ultimately, however, although there are promising programs that show
potential for having a positive impact, a wider acceptance of the need for addressing social
isolation as well as a greater commitment to helping our homebound elderly are needed for true
broad-based change.
Environmental context. The proposed capstone project, the Senior Social Isolation
Project (SSIP), addresses the issue of social isolation in the older adult (60 and over) population
of Ventura County, California. An examination of the current environment in Ventura County
regarding its homebound elderly provides additional insight into why the proposed project is
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both important and innovative. The number of county residents age 75 and older is expected to
nearly double to more than 90,000 within the next decade. Nearly 40% of Ventura County’s
elderly residents do not have enough income to meet their basic needs. Despite these data,
programming to address the needs of this population falls far short of the need.
From June through December 2018, several data collection efforts were undertaken and
analyzed, with the results contributing to the design of the SSIP. These data collection
components include:
v In-depth interviews with practitioner stakeholders (county agency staff and
leadership, nonprofit organization managers with programs serving seniors, home
healthcare agency staff, and for-profit senior care managers).
v Survey asking for opinions and input on county programming for the target
population administered to approximately 15 practitioner stakeholders in Ventura
County.
v Review of the literature and past research on the issues of social isolation, social
isolation in the elderly, aging issues, and social determinants of healthcare.
v Design lab and prototype completed within the context of the USC DSW program’s
SOWK723 Design Lab course.
v Review of documents relevant to Ventura County programs, including annual reports,
evaluation reports, and strategic plans of agencies including Behavioral Health,
Health, Public Health, and the Area Agency on Aging.
Some highlights of the research findings on the local level that show the extent of this
problem in Ventura County include:
v The current supply of services does not meet the needs of homebound older adults.
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v Planning efforts at the county level for the impending demographic changes are
minimal.
v There is an overall lack of prioritization in funding and programming for frail/
homebound older adults.
v Few, if any, strong advocates exist in the county for this population, despite a well-
established Area Agency on Aging.
v The Ventura County Area Agency on Aging (VCAAA) is highly regarded yet can
only meet a fraction of the need.
v There are shortages in the caregiving workforce in California for the elderly and
disabled, resulting in strains on the system. Many of those working in programs
supporting/helping low-income seniors are overworked/stressed.
v There are limited mental health services available for older adults, especially those
offered in-home.
v The dementia issue has historically been ignored or has superficial/temporary
solutions only.
v The county’s Spanish-speaking population is underserved.
v Geographically, there is unevenness, with some areas of the county better served than
others.
v No healthcare providers in the county have been identified as screening geriatric
patients for social isolation or depression, and nowhere in the Ventura County Health
Agency planning reports is there an indication that screening for social isolation is a
practice in any of its community clinics.
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These findings continue to be accurate and relevant in early 2020. The most recent strategic
plan for the VCAAA highlights the finding that despite the good work the agency is able to do, it
does not have sufficient funding or the capacity to provide services to meet the current level of
need of Ventura County’s more frail and/or socially isolated older adults. A summary of the
VCAAA Draft Strategic Plan for 2020-2024 indicates that the VCAAA will provide the
following in-home services for seniors:
VCAAA In-Home Programming # of VC Seniors to Be Served, 2020
Meal delivery 1,190

Case management
850*
*This number has nearly doubled from the previous year
and includes 125 new Alzheimer’s disease/dementia
clients and 100 medically fragile clients.
Source: VCAAA Strategic Plan for 2020-2024 (draft).
While the increase in 2020 of numbers to be served is a much-needed development,
services still come nowhere near the need, as evidenced by the data uncovered in a recent report
from the Ventura County Community Foundation (VCCF). In 2019, the VCCF commissioned a
report examining the data on seniors and caregiving needs in Ventura County (VCCF, 2019).
The report included the following data regarding Ventura County seniors:
Residents Age 65 and Older Disability/Limitation
29,892 Ambulatory difficulty
23,781 Independent living difficulty
18,611 Hearing difficulty
14,330 Cognitive difficulty
12,451 Self-care difficulty
9,695 Vision difficulty
Source: The Future of Caregiving for an Aging Population, VCCF (2019).

Of the Ventura County population age 65 and older, 50,012 (about one-fourth) have some
sort of disability (VCCF, 2019). Additionally, approximately 50,000 of the county’s older adults
can be considered socially isolated, based on the well-regarded statistic that 1 in 4 older adults in
the United States is socially isolated (this number will increase along with the total number of
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elderly over the next couple of decades). Currently, nearly 30% of the older adults in Ventura
County are older than 75, and 15% of older adults residing in Ventura County live alone
(VCAAA Draft Strategic Plan, 2020). The needs of seniors, as evidenced by these data, are much
greater than what the VCAAA is able to provide for. While other agencies (nonprofit and for-
profit) across the county are able to address some of the gaps, the county is nowhere near serving
the need—a need that is growing continuously and quickly as the overall population ages.
Social significance. Addressing the issue of social isolation in the elderly is complex,
given the many challenges faced by this population. Because the SSIP is focused primarily on
homebound elderly, this innovation centers around the community supports that exist to improve
the lives of homebound elderly and help them develop connections. The SSIP focuses primarily
on senior citizens who may or may not qualify for Medi-Cal but are limited in their resources
and find it difficult or impossible to pay the minimum $25/hour that most care managers charge.
The SSIP’s services will also encompass homebound/socially isolated elderly who may not
qualify as low-income; the project’s design includes the development of programming that can
be either fee-based or provided at no cost.
Finding and receiving the needed support to live safely and with dignity, especially for
the socially isolated or homebound (and with limited income), are a constant challenge for many
Ventura County seniors. To what lengths a community goes in order to care for its most
vulnerable is ultimately a moral issue. The intent of the SSIP initiative is to change systems and
attitudes about the elderly, which will result in a higher likelihood of older adults living in safety
and with dignity.

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Conceptual Framework with Logic Model and Theory of Change
The strategy for the SSIP encompasses the following three overarching components:
v Advocacy: Provide consistent input on aging issues (including events, meetings, and
decisions) in the county, particularly as they pertain to socially isolated elderly. Work
with partner agencies to develop consistent and appropriate programming.
v Education: Develop materials (print, video, social media) and provide seminars and other
presentations to educate educational stakeholders/county leaders/community on the
prevalence and impact of social isolation.
v Research: Serve as a hub for research and data dissemination on aging issues and
evidence-based interventions. Develop and promote evaluation protocols to ensure
effective programming.
All of these strategies will take place within the framework of a collaborative model. As a newly
formed organization working in partnership with other agencies (and individuals), the SSIP will
gain and utilize buy-in and expertise from diverse stakeholders across Ventura County. The
ultimate goal is to influence county leadership to place more priority on the needs of low-income
homebound seniors, as evidenced through additional programming and funding. More
description of the components of the SSIP is provided in the Proposed Innovation section.
Theoretical Frameworks
The SSIP initiative is shaped by more than one theoretical framework. Two theoretical
frameworks that have been utilized for this project are the Greenhouse Theory of Social
Innovation and the Precaution Adoption Process Model (PAPM). These have impacted the
SSIP’s theory of change, which is demonstrated by the SSIP logic model in Appendix A.
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The Hypothesis Formulation Exercises that make up the Greenhouse Theory enable one
to examine a social problem through a variety of lenses, with the ultimate goal of uncovering
social norms that hold a problem in place (Greenhouse: Innovation website, 2020). Additional
description of the Greenhouse Theory is found in Appendix B.
In viewing the social problem of isolation of the elderly in Ventura County, California,
the six innovation dynamics (“lenses”) were applied, and several norms and deviants uncovered.
The fundamental social norm that ultimately has played a role in the design of the SSIP is: We
should respect and protect our elderly, but they are not easy (or interesting) to talk to or to
involve in our daily lives. The invisibility of the social problem of isolated elderly is largely due
to the invisibility of our senior population—in particular, those who are socially
isolated/frail/housebound. There are often limited opportunities to connect with older people, let
alone understand the challenges they face. The fact that so many people do not acknowledge or
interact with this population is one reason we see social isolation in the elderly.
Additionally, American culture—particularly white American culture—does not revere
its elderly as do many other cultures. In the United States, revered traits include personal
achievement and autonomy, and we live in a culture that values youth over old age (Berger,
2017). When a person ages, often they are no longer working or able to be as actively engaged in
their community, and American values do not align well with those realities. Using the
Greenhouse Theory as a framework, the behaviors to change include a lack of engagement of the
larger community (including decisionmakers) with homebound seniors as well as those living in
long-term care facilities. The next step of the theory is to develop a deviant to change or subvert
this norm, which in this case is the SSIP’s proposal to convene a collaborative team of local
agencies focused on the needs of the county’s homebound elderly. This deviant helps to subvert
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the norm above by amplifying the needs of low-income homebound elderly, which will elevate
their visibility and ideally result in increased awareness of and empathy for this population. The
heightened visibility of (and empathy for) homebound seniors will then lead to an increased
number of residents who are willing to interact with and help lonely seniors and influence county
leadership and decisionmakers to do more for this population.
In addition to the Greenhouse Theory, the Precaution Adoption Process Model (PAPM)
has been applied as a theoretical framework for the proposed capstone project. The PAPM is
useful when dealing with health-related issues that may not yet be recognized or seen as severe.
This model has seven distinct stages (Weinstein, et al., 2008): 1) Lack of awareness (in this case,
of the serious negative impacts of social isolation); 2) Becoming more aware but still
disengaged; 3) Faces decision about whether to do something; 4) Decides not to act; 5) Decides
to act; 6) Action; and 7) Maintenance.
Most Americans are unaware of the significant implications of living in social isolation,
especially for low-income older adults. There is also a considerable lack of awareness about the
prevalence within our communities, as socially isolated seniors tend to be an invisible
population. Many of those who work with vulnerable populations or in the healthcare community
may have some level of awareness (Stage 2 above) but are not yet engaged in actively addressing
the problem. Once dialogue and awareness on this issue among stakeholders and decisionmakers
develop/increase, various players must face whether to/how to act. Ideally, action will eventually
happen, which will be seen through new programming and additional funding, in addition to
more dialogue.

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Problems of Practice and Innovative Solutions
Proposed Innovation
The Senior Social Isolation Project (SSIP) is made up of three primary components,
described in the previous section: 1) advocacy, 2) research, and 3) education, all within the
context of a collaborative framework. The following will be incorporated:
v Formation of a new organization, with the intent to achieve 501(c)(3) status by early
2021.
v Formation of a multidisciplinary collaborative network including healthcare
professionals, mental health professionals, agency staff, social workers, and caregivers,
all of whom have had direct experience with the project target population.
• The collaborative partners will develop a common mission and language and
challenge formerly held assumptions.
v Utilization of existing evidence-based/data-informed research and programming to
inform the ongoing work (SSIP’s advocacy and education efforts).
v Design and dissemination of education and training on the impact of social isolation
(print, video, social media).
v Regular participation in advocacy efforts across the county, to effect changes in policy
and increase overall awareness.
v Continuous evaluation and feedback measures throughout the process.
A key overriding framework of the SSIP is its reliance on collaborative work. To achieve
systemic change in Ventura County, a multidisciplinary group of stakeholders must be involved
in addressing the issues inherent in this problem. The Collective Impact Framework is a critical
tool for the development and success of the collaborative work of the SSIP. The Collective
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Impact Framework consists of five components that help provide structure to collaborative
efforts in solving a social problem (Hanleybrown, et al., 2012): Common Agenda, Shared
Measurement, Mutually Reinforcing Activities, Continuous Communication, and Backbone
Support. Refer to Appendix C for a detailed description of each component.Implementation of
the Collective Impact Framework across a diverse set of social problems thus far has shown
evidence indicating success in finding collaborative solutions for complex problems.
Innovation Effects on the Grand Challenge
“Eradicating social isolation” is one of the 12 Grand Challenges identified by the
American Academy of Social Work and Social Welfare (Lubben, et al., 2018). Eradicating social
isolation of seniors is the central piece of this capstone project. For systemic change to occur,
social norms must change, and the SSIP strives to change social norms regarding the elderly.
Through an increase in education and awareness of the problem, there will be eventual shifts in
social norms, and the intention is that changes in behaviors of county leaders, healthcare
providers, and the general public will then occur. Such behavioral shifts will, in turn, impact the
lives of thousands of socially isolated elderly living in Ventura County. County leaders will
become more aware of and educated on the issues facing homebound elderly and the impact of
social isolation on this population. Data on prevalence in the county as well as historical funding
and programmatic priorities will be re-examined, and different programming decisions will be
made. Healthcare providers will also be involved in discussions and information sharing about
this population and the impacts of social isolation. Healthcare providers will eventually become
more comfortable with implementing regular screening for issues related to social isolation in
their geriatric patients (this is one of the expected long-term outcomes of the SSIP). Finally, the
overall community will be impacted. Through countywide discussions and presentations, public
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awareness campaigns, and other forms of discourse, more Ventura County residents will better
understand what this population is facing and how they can help through volunteerism,
advocacy, and philanthropy. Stereotypes about the elderly, such as the belief they have low
competence and intelligence, are widespread and resistant to change (Cuddy, et al., 2005). Such
attitudes and norms are reflected in the fact that issues pertaining to the elderly do not receive
much interest or attention from the general public. The elderly—particularly low-income, frail,
homebound elderly—are a fairly invisible population to most. The SSIP’s work will strive to
decrease the invisibility of low-income homebound elderly and help change currently held
stereotypes, which will ultimately have an impact on eradicating social isolation.
Stakeholder Perspectives
Stakeholder surveys and interviews have been conducted as part of the review of the
current status of this issue in Ventura County, and the results have informed the findings reported
in this proposal. As shared in the Environment Context section, those interviewed and surveyed
formally thus far include: county agency staff and leadership, nonprofit senior service providers,
home health agency managers, for-profit senior care managers, program providers from other
counties, representatives from the AARP Foundation, and the director of the Ventura County
Area Agency on Aging. Additionally, there have been many informal conversations with others
working with the senior population, through networking and other types of meetings.
Importantly, while some of those interviewed are elderly themselves, stakeholders from the
target population have not been formally surveyed or interviewed yet for this project. Thus, one
of the first projects of the SSIP will be a small (15-20 respondents) qualitative research study
conducted in June-July 2020. The methods employed will be in-person interviews with older
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adults who live in Ventura County and have been identified by a service provider as socially
isolated.
The feedback from stakeholders on the issue of low-income socially isolated elderly in
Ventura County has been remarkably consistent. Nearly everyone interviewed/surveyed has
discussed the lack of prioritization by the county, the limited services, the shortages in the
workforce, and the level of unmet need that continues to grow as our elderly population grows.
All agree that more must be done to help support this population, yet there exists the awareness
that there are considerable hurdles in bringing that outcome to fruition. Open-ended responses
from the survey can be found in Appendix D.
Evidence and Current Context for Proposed Innovation
The Environmental Context section, as well as the considerable amount of research
literature presented here on the issue of social isolation in the elderly, paints a clear picture of the
impact of social isolation on older adults and the scope of the problem in Ventura County.
Extensive research shows that both physical and mental health are significantly impacted by
social isolation and it affects mortality negatively. Despite this, the issue does not frequently
appear in public discourse. Within the healthcare sector, social isolation is not viewed regularly
as a factor impacting the health outcomes of patients. In Ventura County, California, the elderly
population is growing at a rapid pace, much like what can be seen elsewhere in the United States.
However, there has not been an extensive or proactive effort to address the increased numbers of
elderly, let alone those who are homebound and socially isolated. Socially isolated elderly, one
of the frailest and most vulnerable populations, are now estimated to be approximately 50,000
individuals (using the standard estimate that 1 in 4 older adults is socially isolated) and will
continue to increase over the next couple of decades as this population grows. The services
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offered through public and nonprofit agencies (as well as paid senior care managers) are limited
and reach only a tiny percentage of those who need it. There is much to be done not only to
“catch up” to the current need but to develop a strategy for helping support this population.
Comparative Assessment with Other Opportunities for Innovation
The SSIP encapsulates multiple components, which is necessary for implementing
countywide systemic change. Many different types of interventions can be undertaken to address
social isolation in the elderly, some of which have been summarized in the Interventions section.
The programs all have various strengths and weaknesses in addressing social isolation in the
elderly. As part of the design process for the SSIP, evidence-based programs that have been
shown to be helpful for this population have been reviewed. An intent of the SSIP is to promote
the development of more in-home therapeutic interventions. Given the challenges for socially
isolated homebound elderly, many of whom may have limited mobility or other health issues,
bringing services to the individual is critical. The SSIP will play a crucial role, along with other
existing organizations, in devising, implementing, and evaluating new programming that fills the
service gaps.
Examples of existing programs elsewhere than Ventura County are described in the
Interventions section; these and others are listed below, with more details found in Appendix E.
All are programs that could be potentially implemented in Ventura County as a byproduct of the
SSIP initiative. Three of the programs receive their funding from the Mental Health Services Act
(MHSA). The MHSA is a California initiative that provides funding for mental health services
through a 1% personal tax on incomes over $1 million. The MHSA is a critical potential funding
stream for the SSIP. Ventura County receives, on average, $32.5 million annually (using data
from 2012 through 2017). Counties are expected to serve all subpopulations, including residents
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at all age ranges. However, the programming in Ventura County specific to older adults has been
limited, with older adults in Ventura County receiving small proportions of MHSA funds
allocated to the county. The MHSA has been instrumental in the expansion and improvement of
California counties’ mental health services. Other California counties are using MHSA funds in
creative ways to support and treat their homebound elderly residents. Appendix D provides data
on the limited proportions of Ventura County senior residents benefitting from MHSA funding.
Additionally, the aforementioned promising direct service programs (details provided in
Appendix E) include:
Ø Positive Solutions program, San Diego County Ø Community Aging in Place, Advancing Better
Living for Elders (CAPABLE) program
Ø ReConnect-Early Intervention Services for
Older Adults (EISOA)
Ø More Than a Meal: Pilot program leveraging meal
delivery programs
Ø Check in with You: Older Adult Hopelessness
Screening (OAHS) program
Ø Linkages: Former program funded through the
Department of Aging, California

In addition to these high-quality direct service programs, collaborative models working to
influence systemic change in the area of socially isolated elderly have been examined. One
example is the Hamilton Seniors Isolation Impact Plan (HSIIP). The Council on Aging in
Hamilton, a city in Ontario, Canada, which has a population of about 500,000, spearheaded a
collaborative effort in 2016 to address social isolation in its elderly residents (HSIIP website,
2020). The council brought together community partners (six organizations) that worked together
to develop goals for reducing social isolation in Hamilton’s elderly residents. Partners included
community-based nonprofit agencies, an academic research organization, and a home health care
organization. In order to reduce social isolation, the collaborative network focused on creating
research-based knowledge, improving community supports, and changing public attitudes about
social isolation in older adults (HSIIP website, 2020). The American Association of Retired
Persons (AARP)’s Connect2Affect campaign has supported and amplified programs in the
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United States that employ collaborative frameworks to combat social isolation in seniors (AARP
Foundation website, 2020). These programs and others serve as inspirational models for what the
SSIP design strives to accomplish.
Alignment with Theoretical Frameworks and Logic Model
Theoretical Frameworks. Two theoretical frameworks have been applied to the SSIP,
and they are described in detail in the Conceptual Framework-Theoretical Framework section,
as well as in Appendix B. The Greenhouse Theory’s Hypothesis Formulation Exercise (HFE)
process was applied to the problem of social isolation in Ventura County’s elderly, through
which a social norm was identified and a deviant developed to subvert that norm. This capstone
proposal has attempted to explain in detail the need for addressing current social norms and
stereotypes that exist about the elderly, in order to address the problems they face more
effectively and to develop genuinely impactful solutions. Most significant is the need to bring
visibility to this population. Additionally, the Precaution Adoption Process Model (PAPM) and
its seven distinct stages will be applied. The PAPM centers around the development of more
awareness about an issue—typically health-related—and moving people from non-action to
action as a result of that awareness. Social isolation, despite the wealth of research and literature,
is still not viewed in mainstream society or regularly in the healthcare sector as a significant
factor in health and well-being. Awareness must be heightened in order to see action taken in
addressing social isolation in the elderly.
SSIP Logic Model. The logic model for the SSIP can be found in Appendix A. The logic
model provides descriptions for the Inputs, Activities, Outputs, and Outcomes of the SSIP and
clarifies the theory of change underlying the SSIP innovation. Outcomes are broken down into
immediate outcomes, intermediate outcomes, and long-term outcomes. In the early stages, the
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project may lean heavily on volunteers as well as donated time, space, and materials from
participating agencies. Immediate outcomes include a collaborative membership with defined
goals, evidence of increased awareness of social isolation in the elderly from county leaders and
senior service providers, the development of a public relations/awareness campaign for the larger
community, and the formation of the new nonprofit organization. Long-term outcomes for the
SSIP include evidence of greater public awareness of social isolation, regular screening of
geriatric patients by the healthcare community, an increased number of volunteers for programs
serving seniors, and improved general well-being of seniors shown by self-reporting and fewer
crisis/APS calls in the county.
Likelihood of Success
When developing a problem-solving strategy that relies heavily on collaboration with
multiple partners, there are many unknowns. Will stakeholders be willing to expend time and
energy to take a role in such an effort? Once convened, will the coalition be successful in
working together to develop common goals—goals that are then realized? Can county
decisionmakers be swayed to increase the prioritization of Ventura County’s homebound
elderly? The shifting of mindsets is not likely to happen quickly; however, the number of elderly
residents is rising, and the growth will not cease for at least a couple of decades. One could argue
that Ventura County does not have a choice: it must develop more of a focus and priority on
developing programming that supports its homebound elderly population. Given the vast
increases in numbers of older adults in general, the numbers of socially isolated older adults will
see significant growth. The level of services in Ventura County is unable to meet the needs of the
current population; thus, a new outlook, strategy, and prioritization must be implemented. Will
this begin to happen in 2020, as envisioned by this capstone project? With the extreme
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worldwide public health crisis of COVID-19 currently in play, it remains to be seen how long it
will take for public health agencies and local government to recover once this crisis resolves. In
particular, the elderly population, caregivers, and the agencies and organizations serving them
will be struck hard by this potentially long-term crisis. Part of the implementation process for the
SSIP will be to evaluate the recovery process and how the SSIP’s work can help strengthen the
overall system in times of crisis as well as the everyday. It may very well be a situation that
offers opportunities as well as challenges. Additional limitations and alternatives will be
addressed in the Implementation Strategy section.
SSIP Structure, Methodology, and Action

SSIP Prototype

The SSIP prototype is a visual graphic compiling essential information about the SSIP. It
describes the SSIP’s design and its impact on users in a way that is both attractive and digestible.
The information is in a brochure-type format that can be described as a user-friendly Lean
Canvas, which is a single-page template for a business model. The prototype can be found in
Appendix F, and for actual usage it will be printed professionally on cardstock paper. The
current prototype consists of three pages:
• Page 1: Outlines the problem using national and county-level data. Many of those
working with seniors, and county leadership, do not understand the seriousness of the
issue, so it is imperative to have easily digestible data to help develop this awareness.
• Page 2: Describes the design of the SSIP. It also provides a mission statement along
with details on each of the project components.
• Page 3: Provides a year-one timeline with intended outcomes as well as a diagram
that reflects the underlying theory of change.
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At the center of the SSIP initiative is the idea of collective impact: an understanding that
large-scale social change comes from coordination across sectors rather than isolated individual
organizations (Kania & Kramer, 2011). This prototype will help to initiate and fuel essential
discussions with a variety of stakeholders as this project continues to evolve and roll out
implementation. Because the success of the project is dependent on how well the partnerships
develop, these early discussions of the problem and the SSIP design will only ensure the strength
of the ultimate organization that forms.
Market Analysis

As part of the design process for the SSIP, a competitive market analysis was completed
(Appendix G). Direct competitors include the major agencies providing direct services to
Ventura County’s most needy seniors, the Ventura County Area Agency on Aging (VCAAA)
and the array of nonprofit senior service providers. These agencies are the providers of in-home
case management programming and other on-site programming. Indirect competitors include the
network of geriatric care managers, who are generally for-profit, and long-term care facilities
that house and care for the frailest seniors. None of these provides the advocacy and education
programming that the SSIP offers.
SSIP Financial Plan and Implementation Strategy

SSIP Financial Plan. The SSIP program budget is based on a July 1 through June 30
budget cycle and utilizes a line-item budget. The SSIP will utilize a diverse array of revenue
sources. Revenue sources are a combination of government grants, foundation grants, private
donations, and fee-based services. Upcoming government grant opportunities through the
Ventura County Area Agency on Aging (VCAAA) and the Ventura County Behavioral Health
Agency (VCBH) will be pursued for this project. The VCBH funding opportunity comes through
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26
Mental Health Services Act (MHSA) funding. Because Ventura County has recently
acknowledged that it has not utilized an appropriate amount of its MHSA funds for older adults
since MHSA programming was first implemented in 2004, there is an expectation that a new
Request for Proposal focused on older adults will be designed in the near future. The SSIP has
been involved in a process over the past several months focused on working with VCBH to
gather community input and design such an RFP.
Foundation grants and private donations will also be targeted. Grantmakers in Aging is a
resource providing information on grants that are available to nonprofits working with seniors.
The Archstone Foundation is an example of a foundation that offers both small and large grants
to nonprofit organizations and is currently focused on funding programs that help seniors
continue living independently and that combat elderly depression. The AARP Foundation also
offers grants for services to older adults and has a focus on addressing social isolation.
Since the SSIP intends to engage a large swath of the community to support low-income
homebound seniors, private donations will be solicited through mail campaigns and special
events. There are many local models for special events used for fundraising purposes that are
under examination to develop for funding the SSIP’s work. Finally, it is likely that the SSIP will
offer consulting/care services to seniors on a sliding-scale system. Thus, the fees from those
clients who are able to pay for services will provide yet another revenue stream for this project.
Refer to Appendix H for the SSIP year-one budget (which makes note of the reliance in the
SSIP’s early stages on donated space and time from partner agencies).
Implementation Strategy: ERIC. Refer to Appendix I for a timeline of year-one
implementation. The SSIP implementation plan utilizes the Expert Recommendations for
Implementing Change (ERIC), a framework that was initially developed by gathering input from
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a wide range of stakeholders who have expertise in implementation science and clinical practice
(Powell, B., et al., 2015). The following list includes key strategies from ERIC that will be
employed as part of the implementation of the SSIP.
Ø Build a coalition. A collaborative process is one of the core components of the SSIP and
encompasses an additional ERIC implementation strategy: conduct local consensus
discussions. Local agencies and individuals who work with seniors will have the
opportunity to explore interventions in collaboration with other agencies.
Ø Inform local opinion leaders. Key to the SSIP is the dissemination of information about
socially isolated elderly. Informing local opinion leaders will be a critical piece of
successful implementation.
Ø Conduct educational meetings. The development and dissemination of educational
information about the socially isolated elderly population in Ventura County are a core
component of the SSIP. There will be meetings and presentations as part of this education
and awareness campaign.
Ø Increase demand; Use mass media. These are two discrete implementation strategies, yet
it is appropriate to discuss them at once. While SSIP efforts will be concentrated on
increasing the visibility of socially isolated elderly, there is also the goal of influencing
the market so that more services are developed and offered for this population. The use of
mass media will help in those efforts: op-eds, brochure/white paper publications,
presentations, social media, and film will all be utilized.
Ø Provide local technical assistance. The provision of technical assistance will be a key
activity of the new nonprofit currently being developed and planned for incorporation by
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early 2021. The staff of this new entity will help new agencies in their implementation
and evaluation of evidence-based programming such as PEARLS.
Ø Develop and implement tools for quality monitoring. Monitoring tools are included in the
implementation and evaluation design of the SSIP (see Assessment of Impact section).
Ø Access new funding. The next year, which is the planning and pilot year, will depend on
in-kind donations from partner agencies and fee-based services, along with the potential
for donations and a grant. Once the new nonprofit is established, funds will be solicited
through private donations (special events and mail/social media campaigns), private
foundations, and additional government grants.
Ø Mandate change. The current status of Ventura County and its senior population requires
that change happen. The SSIP and its work with its partners will lead to changes in
programming as well as changes in mindsets and awareness across the county.
Implementation Strategy: RE-AIM. In addition to ERIC, the evaluation framework
known as RE-AIM (Reach, Effectiveness Adoption, Implementation, and Maintenance) has been
utilized by this project. RE-AIM is one of many key evaluation frameworks that are useful in
identifying implementation barriers and facilitators (Brownson, et al., 2017). RE-AIM’s five
components (Reach, Effectiveness, Adoption, Implementation, and Maintenance) have been
utilized to explore the potential barriers and facilitators for implementation of the SSIP.
Appendix J offers a detailed listing of the barriers and facilitators in each area. Using RE-AIM is
a critical step for both the program and evaluation planning processes. Barriers related to
forming and maintaining an effective collaborative body may include the diversity and
representation of those involved, dependence on donated time and space, communication and
trust challenges, and the competing demands that various agencies face. Additional barriers may
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include the invisible/hard-to-reach nature of the target population, volunteer turnover, cost, the
limited capacity of potential partner agencies, limited funding opportunities, and cultural
attitudes about the elderly. While these barriers seem formidable, identifying them is an
important step in preparing for SSIP implementation.
Ultimately, the early stages of implementation require flexibility in making necessary
modifications to the model as needed. The SSIP, while designed around the intention of
collective impact, has the ability to function in its early stages as a consultancy, which would not
require extensive upfront overhead costs such as staffing, office space, and equipment.
Assessment of Impact
The SSIP’s core components are advocacy, education, and research, all within a
framework of collaborative impact/partnerships. The evaluation design for SSIP is focused on
the overall impact of the collaborative work as well as the advocacy and education for socially
isolated seniors.
SSIP Evaluation Design. The evaluation design for the SSIP will use multiple methods,
including both quantitative and qualitative measures. It will be, for the most part, descriptive
with some quasi-experimental pieces having a one-group pre-test/post-test design. Changes may
be made to evaluation design based on input from collaborative partners.
Overarching research question regarding collaborative work: How effectively did the
collaborative/partner agencies come together, stay engaged, and work together?
v Process sub-questions (implementation): What agencies were involved and to what
extent? What types of processes did the collaborative group establish? What actions
or events did the collaborative group undertake?
SENIOR SOCIAL ISOLATION PROJECT (SSIP)

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v Outcome sub-questions (impact): Did the collaborative group achieve the outcomes it
set forth (see logic model for intended outcomes)?
Evaluation Measures. In order to answer the above research questions, measures for both
process and outcome goals have been identified.
Process measures:
Ø Number/type of agencies involved Ø Number of actions taken/initiatives started
Ø Number and frequency of meetings Ø Coalition member satisfaction (pre/post surveys)

Data collection for these measures will include member surveys administered periodically
(instrument not yet developed) as well as all coalition records, reports, and event logs.
Outcome measures: Measuring the impact of the SSIP’s work (in conjunction with its
partners), in particular on issues such as awareness about socially isolated elderly, improved
programming for this population, and increased community support for initiatives for this
population, will be examined as part of the coalition’s work together in the first year. Outcomes
laid out in the SSIP logic model may be modified based on the development of shared goals with
collaborative partners.
Stakeholder Involvement
Stakeholder involvement in the design of the SSIP has been addressed in the Stakeholder
Perspectives section. The collaborative nature of the SSIP project itself requires the constant and
relevant involvement of stakeholders. Senior service providers, county leaders, funders,
caregivers, older adults, and the greater community will all have the chance to be engaged and
involved in this project. Genuine and sustained involvement and input from the SSIP’s end users,
socially isolated elderly, will likely be challenging to obtain at times, as is often the case with
SENIOR SOCIAL ISOLATION PROJECT (SSIP)

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more vulnerable populations. A commitment to soliciting regular input from socially isolated
senior clients (through surveys and interviews) is a cornerpiece of the evaluation plan of the
SSIP.
Communications Plan
A core component of the SSIP is increasing awareness of the impact of social isolation in
the elderly. The communications plan for the SSIP is a vitally important piece of its work and
will be ongoing throughout all aspects of the SSIP. Currently, the SSIP operates a website,
Facebook page, and Twitter account all under the name “Connected Existence.” Information on
social isolation is communicated regularly through these platforms. As SSIP activity increases,
the content will change, and all content will be aligned across platforms. The SSIP website will
offer links to download informational materials in both print and video formats. Through its
partners, the SSIP will have many pathways through which to disseminate information about its
work and the issues impacting Ventura County’s elderly.
Communication Method Type of Information
Public awareness campaign Short-form videos and an active social media presence
(Facebook, Twitter, Instagram, SSIP website).
Print brochure(s) SSIP information in a digestible and attractive format.
Frequent reports and policy briefs Education/information on a range of aging issues
connected to social isolation.
Goals: Inform and educate/gain buy-in from stakeholders/attract volunteers and funders.

Addressing the Problem
Social isolation is a public health challenge that, despite extensive research, has not been
acknowledged or addressed adequately thus far. Community-level solutions must be systemic
and comprehensive. The SSIP is both comprehensive and collaborative by design. The SSIP
provides a framework to begin to build awareness and understanding as well as to design
strategies to meet the need. The SSIP has been designed with the knowledge in mind of the
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complexities of this population, including the intersection of aging, deteriorating health, potential
cognitive decline, and mental health issues (late-life depression and more serious issues). The
current design components should all be viewed as essential pieces of a comprehensive strategy
for improving services countywide to primarily low-income, homebound elderly. Ideally, it will
eventually serve as a model for addressing social isolation in elderly populations in other
communities, as well as in other age groups.
Ethical Concerns
As with any new program working with vulnerable populations, potential ethical
concerns must be thoroughly explored. The SSIP’s implementation will incorporate the ethical
principles and standards of the National Association of Social Workers (NASW). Much of the
direct service work with homebound elderly will be in their homes. Thus, it is imperative that all
protocols for working with elderly clients, as well as clients in the home environment, are
followed. Ethical responsibilities to clients that also align with the NASW standards include
maximizing client self-determination, obtaining informed consent, practicing cultural
competence, and ensuring privacy and confidentiality (NASW website, 2020).
Working in a collaborative nature with other agencies can pose issues regarding privacy
and data sharing. Adherence to privacy and confidentiality standards will be critical in decision
making, for example, regarding whether client information may or may not be shared across
agencies. Also, common training on accepted case management and therapeutic techniques with
elderly clients will be shared and implemented across collaborative partners.

Conclusions, Actions, and Implications

Social isolation is a social problem that has only continued to increase in prevalence in
recent years, and the increasing numbers of older Americans over the next couple of decades will
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result in rising numbers of socially isolated elderly. Communities must rethink and restructure
how they care for their aging populations. Socially isolated older adults are especially vulnerable
due to the complex mix of challenges many may be facing in later life, including physical
ailments, loss of independence, and cognitive impairment.
Context of Practice
The foundation and framework for the SSIP are based within the social work field of
practice, utilizing NASW standards and principles as well as programming and evaluation
guidelines from the social work perspective. This social work perspective on the issue of social
isolation in seniors will work hand in hand with the nursing and overall healthcare lens, which is
often what is applied when working with elderly populations.
Implications for Further Action/Practice
The SSIP logic model includes clearly defined outcomes and long-term goals. Ultimately,
the SSIP intends to have a long-term impact on social norms and systems in Ventura County,
California. As a nonprofit focused on advocacy and education, it will evolve with time and with
the needs of the senior community in the county. It will have influence and impact on county
decisionmakers, which will create change in county funding and programming priorities. Future
decisions and actions in this county regarding its senior population will be affected. While its
first year of operations will depend on the use of a home office, volunteers, and just one or two
staff members, the intent is for the organization to grow over time. Long-term outcome goals,
such as the healthcare community providing regular screening for social isolation in seniors, for
example, may not reach full implementation for at least a couple of years.

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Limitations and Risks
The implementation of the SSIP faces potential limitations and risks. The application of
the RE-AIM framework to address barriers and facilitators is detailed earlier (and also in
Appendix J). Authentic and sustained engagement by partners, healthcare providers’ limitations
in addressing social determinants of health, and cultural norms about the elderly are just a few
potential barriers that could affect SSIP implementation. Specifically, the challenges of working
within a collaborative framework have been discussed in the section Problems of Practice and
Innovation Solutions (with additional information in Appendix J).
Social Isolation in the Elderly: Future Work Recommendations
Communities across the country need successful models for system and culture change in
addressing issues related to social isolation in the elderly. Like the Hamilton Senior Isolation
Impact Program referenced earlier, the SSIP will serve as a model for effecting culture change
and systems change on the issue of social isolation in elderly populations, as well as other social
problems. As communities grapple with solutions for addressing increasing numbers of senior
populations and caregiving strains, cross-disciplinary solutions will become more and more
needed. Policymakers, the public health and health communities, and social workers/social
service organizations must work together to develop ways to support our aging populations. In
addition, more research is needed on effective programming for seniors who may be socially
isolated. Finally, more schools of social work and medical schools need to include these topics in
their curricula.
Next Steps and Final Thoughts
As the project timeline moves into implementation mode, the next steps have been laid
out clearly in the Implementation Plan/Timeline found in Appendix I. Continued planning will
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35
take place into the fall, at which point more regular and formal meetings with collaborative
partners will begin. The initial steps for planning fundraising event(s) as well as grant application
completion will take place in the summer and early fall, as will the qualitative study of socially
isolated elderly. Also in the fall, the intent is to complete and submit the formal paperwork to
secure nonprofit status. This timeline will need to be flexible, as the environment for the rest of
2020 remains to be seen given the current COVID-19 pandemic. County and nonprofit agencies
may very well be grappling with the dynamics of the pandemic through the end of 2020, and this
may push some of these activities into 2021. Regardless, there is still considerable work to do
related to socially isolated elderly that will inform the SSIP’s future and current partnerships and
activities.
The Senior Social Isolation Project (SSIP) provides a comprehensive framework for
addressing the issue of social isolation in older adults living in Ventura County. The need for an
innovation is demonstrated through both the existing programming (or lack thereof) and the
major demographic shifts faced by the county. This innovation holds great promise for Ventura
County’s socially isolated elderly to receive the attention and services they need, for now and for
the future.

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SENIOR SOCIAL ISOLATION PROJECT (SSIP) 44

Appendix A: The Senior Social Isolation Project (SSIP)
Logic Model

Inputs
Activities/Outputs Outcomes
Activities Outputs Immediate Intermediate Long-Term

SSIP staff

Ventura County senior
service providers
(collaborative partners)

Existing research on aging
issues

Meeting/office space

Volunteers

Meet regularly with
collaborative partners:
focus on low-income
homebound elderly in VC.

Provide consistent
input/voice to aging issues
(events, meetings,
decisions) in the county.

Create and disseminate
educational materials
(print, video, social media)
info to stakeholders/county
leaders/community.

Design and implement
county-level research.

Design trainings for
organizations working with
seniors.

Develop detailed
fundraising plans—special
events, mail campaign, fee-
based services.

# of those involved in
collaborative impact work.

# of meetings/agendas and
minutes.

# of additional
stakeholders/partners
coming on board.

# and scope/type of
decisions made in new
funding and programming.

# of products created and
presented/# of
presentations and events.

# of completed studies and
reports summarizing the
research and results.

# of trainings with
organizations.

Committed collaborative
partners solidified; group
has defined its goals on
addressing social isolation
in elderly in VC.

Senior service providers &
county leaders/key
departments gain awareness
on prevalence/impact of
social isolation in VC
elderly.

PR campaign developed to
develop awareness/
visibility countywide.

Formation of new nonprofit
organization.

Funding efforts (special
events, private donations,
grants, some fee-based
services) underway.

Increased visibility in
public discourse on the
issue of social isolation (in
elderly as well as other age
categories).

Increased numbers of
volunteers for programs
serving seniors.

Additional programs
developed to address needs
of low-income elderly,
including expansion of
county mental health
programming for older
adults.

Increased number of
seniors receiving in-home
services.

Nonprofit organization is
financially stable.

Social isolation is
regularly discussed in
discussions re seniors.

Healthcare community
screens for social isolation
in elderly patients.

Volunteering for
programs serving seniors
is at a high level.

Philanthropic dollars for
aging/senior causes has
increased.

Fewer crisis/APS calls
countywide.

Increased well-
being/decreased
depression of seniors
being served.
SENIOR SOCIAL ISOLATION PROJECT (SSIP) 45

Appendix B: Theoretical Frameworks
Greenhouse Theory/Precaution Adoption Process Model (PAPM)

Greenhouse Theory: The Greenhouse Theory’s Hypothesis Formulation Exercise (HFE) process is designed around six
innovation dynamics through which to view a social problem. These innovation dynamics can be considered different “lenses”
that offer different ways of looking at the problem.

Innovation Dynamics
Actors The people related to a problem (1
st
order and 2
nd
order)
Limits Written or formal constraints to the problem that have been codified
History Stories people tell about a problem
Future Actors’ expectations of how the problem will evolve
Configuration How one categorizes the problem; grouping and labeling within a problem
Parthood How the problem fits into other problems (and vice versa)
Source: https://www.ghouseinnovation.com/

*********************************************************************************************

Precaution Adoption Process Model (PAPM)

Source: Weinstein, N., et al. (2008)
SENIOR SOCIAL ISOLATION PROJECT (SSIP) 46

Appendix C: Collective Impact Framework

Collective Impact Framework
Component Description Alignment to SSIP
Common Agenda Shared vision for change/common
understanding of problem.
SSIP and partners will develop common
goals for county.
Shared Measurement Data collection and measurement
across participants is consistent.
Partners will have common outcome
targets/measures and share data
outcomes.
Mutually Reinforcing
Activities
Participant activities are differentiated
yet coordinated.
Partner organizations have their own
missions and activities; one goal of the
collaborative effort will help increase
coordination.
Continuous Communication Consistent and open communication. SSIP will facilitate regular meetings and
communication.
Backbone Support Setting up a separate
entity/organization that provides
support and coordination to the
initiative.
SSIP incorporation into new nonprofit
organization.
Source: Hanleybrown, F., Kania, J., & Kramer, M. (2012). Channeling change: Making collective impact work. Stanford Social Innovation Review.
SENIOR SOCIAL ISOLATION PROJECT (SSIP) 47

Appendix D: Ventura County Data (Stakeholder Survey Results/MHSA Funding Levels)

VC Senior Service Provider Survey, 2018 (n=15), Open-Ended Responses (“What are your concerns regarding this population?”):
Ø “In-home services are out-of-pocket expenses and low-income folks can’t afford this service often.”
Ø “There are many seniors who fall in the gap, are not quite low income enough to qualify for in-home support yet lack family
support and cannot afford home care or Assisted Living.”
Ø “If someone does not qualify for Medi-Cal [Medicaid] but is low income and cannot afford $25 an hour for home care there is no
in-between available.”
Ø “We don’t have services people can afford. Home care is too expensive; after limited grant funds they cannot afford the services
they need.”
*******************************************************************************
VCBH Programs Funded by MHSA Funding: Senior Service Levels, Ventura County, 2016-2018
Total
Number
Clients
Served
Percent of
Clients 60
and Older
Program Notes
Prevention Programs
(9 total programs)

2,283

6%
Only 2 of these programs are equipped to serve older adults at this time (Wellness
Everyday and Adult Recovery and Wellness Center).
Early Intervention Programs
500

6%
Early Intervention Programs provide treatment, services, and interventions, including
relapse prevention, to address and promote recovery and related functional outcomes for a
mental illness early in its emergence.
Other PEI (Program & Early
Intervention) Programs

2,237

6%
These programs include: stigma and discrimination reduction programming, suicide
prevention, and outreach for increasing recognition of early signs of mental illness.
RISE (Rapid Integrated Support
and Engagement)
1,848 142 (8%)
For those “unwilling or unable to access treatment.” Serves homeless, homebound, and
people w/severe and mild psychiatric issues who are not getting treatment.
STAR (Screening Triage Assessment
and Referral)
2,144 5%
Provides comprehensive assessment and diagnosis for those new to VCBH system.
Full-Service Partnership (FSP) 485 172 (35%)
Comprehensive mental health services for those with persistent mental illness.
Crisis Team/COMPASS/
Crisis Residential/Children’s Crisis
Stabilization Unit

2,986
256
(8.5%)

Older adults can be served by the Crisis Team, COMPASS, or Crisis Residential program.
Source: VCBH MHSA Fiscal Year 2019/2020 Annual Update (note: some data are from 2016-17 and some from 2017-18; the assumption is that most recent
available were used for report). Additionally, MHSA funds are used for housing for clients receiving mental health treatment, which includes residential housing for
the elderly (70 beds), although there may be more elderly clients in regular Board and Care that are funded by MHSA.
SENIOR SOCIAL ISOLATION PROJECT (SSIP) 48

Appendix E: Model Programs (Direct Service) for Social Isolation in Older Adults
Program Description
Positive Solutions program, San Diego
County
The Positive Solutions program is fully funded by Mental Health Services Act (MHSA) funds in San Diego County. The
county contracts with a nonprofit organization called the Union of Pan-Asian Communities to administer the program,
which has now been in operations for 10 years and is considered very successful in identifying and treating socially
isolated seniors for depression. The program utilizes the Program to Encourage Active Rewarding Lives (PEARLS), a
nationwide evidence-based program treating late-life depression of seniors in their homes (Positive Solutions website,
2018).
ReConnect-Early Intervention Services
for Older Adults (EISOA)
Another MHSA-funded program developed and administered by the Southern California Council on Aging, which
provides services in Orange, Riverside, San Bernardino, Inyo, and Mono Counties. ReConnect “is a county-wide program
that benefits isolated adults 60+ and/or displaying symptoms of depression or other mental health issues. The program’s
objective is to help individuals sustain emotional well-being through case management intervention and consistent
exposure to meaningful activities, education, and support groups.” EISOA services to a client are intended to be short-
term (up to 12 months) (ReConnect website, 2018).
Check in with You: Older Adult
Hopelessness Screening (OAHS)
program
MHSA-funded program of Tulare County Health and Human Services Agency (TCHHSA) that has been identified as a
best practice. The TCHHSA and partners developed this program in response to the high suicide rates seen in older
residents in the region. The program uses the Beck Hopelessness Scale (BHS) to screen patients at their doctor’s visits at
a local healthcare agency. Individuals who score moderate to severe on the BHS screening are offered services such as
case management, brief therapy, and warm linkage to services to help improve social, physical, environmental,
emotional, and financial wellness. By June 2013, over 2,500 screenings were administered among the older adults via the
OAHS program. A preliminary evaluation has shown that the program was successful in significantly decreasing the
scores of the BHS among older adults in subsequent visits (Tulare County Health & Human Services Agency, 2018).
Community Aging in Place, Advancing
Better Living for Elders (CAPABLE)
program
Developed at Johns Hopkins University; combines occupational therapy, nursing, and handyman support and offers up to
10 home visits over 6 months (Szanton, et al., 2011). CAPABLE was developed to support older adults living
independently who have recently returned from being hospitalized. The program has been showed to improve ADLs,
decrease the number of falls, and reduce healthcare costs (Szanton, et al., 2014).
“More than a Meal”
Pilot program: Routine meal delivery service (2 programs) were leveraged to identify changes in older adult meal
recipients’ health, well-being, or safety and to address unmet needs. Meal delivery personnel (drivers) were trained to use
a mobile application to submit electronic alerts when they had a concern or observed a change in a client’s condition.
Alerts were received by care coordinators, who followed up with clients to offer support and help connect them to health
and community services. Findings indicate this is a feasible innovation for observing and addressing the needs of
homebound older adults, with the most frequent alerts being sent for health changes (Morris, et al., 2019).
Linkages
Former program funded through the Department of Aging, California. Linkages was a well-respected program focused on
providing care management services to frail homebound elderly at risk of institutionalization. Clinical assessments were
performed in the home by case managers and were developed to help develop independent living care plans. With the
economic downturn of 2008, funding for the Linkages program was cut. The program was generally viewed as
worthwhile and successful in meeting its goals, and some sort of reinstatement may be worth exploring.
SENIOR SOCIAL ISOLATION PROJECT (SSIP) 49

Appendix F: SSIP Prototype

SENIOR SOCIAL ISOLATION PROJECT (SSIP) 50

SENIOR SOCIAL ISOLATION PROJECT (SSIP) 51

Appendix G: Competitive Market Analysis
COMPETITOR 1 COMPETITOR 2 COMPETITOR 3 COMPETITOR 4
Direct Competitors Indirect Competitors

Organizational
Highlights
Organizational
Profile
Ventura County Area Agency
on Aging (VCAAA)
Nonprofit senior care
organizations*
For-profit geriatric
care managers
Long-term care (LTC)
facilities
Key Competitive
Advantage
Central hub for senior services
in county; recipient of various
grant funds due to status as
AAA; free services.
Geographical focus;
flexibility in determining
mission and focus; free/low-
cost services.
Flexibility in how they run;
little to no oversight; high
demand for services.
Offer residential care for
range of elderly clients.

Market
Information
Target Market Seniors and disabled (all
income levels).
Seniors (all income levels). Seniors with ability to pay
for services.
Seniors who cannot live
independently.
Marketing
Strategy
Website, senior service
directory, partnerships.
Websites, occasional print
and social media advertising,
special events.
Word of mouth, some
internet/print advertising,
networking.
Local referral services,
referrals from health
providers.

Product
Information
Products &
Services
Array of programs including
referral and information, case
management, nutrition/food
delivery, fall prevention, and
caregiver support.
Array of program depending
on org: case management,
food delivery, adult day care,
and caregiver support.
Personalized one-on-one
services and support:
referrals, personal care,
transportation help.
Housing, medical, and
personal care for seniors with
a range of health and
cognitive status.
Pricing No cost for most services. Mix of no cost and low cost. Fee-based; minimum of
$25/hour is common.
Costs vary by location.

SWOTT
Information
Strengths County agency/service hub.
Connections with other public
agencies.
Cost-free/low-cost array of
services. Less constrained by
governmental
regulations/grants.
Provide personalized
service.
Essential service to care for
vulnerable population.
Weaknesses Services driven/designed by
funding streams; limited
funding that can serve only a
fraction of need.
Financial variability.
Philanthropy for senior/aging
services is limited. Reliance
on volunteers.
Often not equipped to serve
the most difficult issues;
40% of VC seniors cannot
afford basic needs.
Often understaffed; expensive
method for care; high quality
is often too expensive for
most seniors.
Opportunities Recent dementia case
management grant; new
partnership/funds with County
Behavioral Health.
COVID-19 helping highlight
needs of seniors; influx of
volunteers.
Increased # of seniors =
increased demand for
services.
More elderly means more
housing/care needed.
Threats Now serving disabled –
services/mission too stretched?
Can services keep up with
increased numbers?
ACA threshold raised –
may lose clientele.
Major staffing shortages in
this field.
*Senior Concerns, Older Adults Support and Intervention System (OASIS), Conejo Valley Village, Caregivers (volunteers assisting elderly)

SENIOR SOCIAL ISOLATION PROJECT (SSIP) 52

Appendix H: SSIP Year-One Budget
(July 2020-June 2021)

Revenue
Community donations from
individuals/businesses*
$10,000
Foundation grant(s) $5,000
Government grants $10,000
*Includes revenue from fundraising events

Total Revenue $25,000

Expenses
Personnel Expenses $20,000
(SSIP Administrator)

Operating Expenses
Training $1,500
Materials/Supplies/Printing $2,000

Total Operating Exp. $3,500

Total Expenses $23,500

Surplus/Deficit
+$1,500

Notes: This is a year-one budget. As the SSIP expands operations,
its exposure grows in the community, and work products and outcomes are
produced, foundation and community support will be improved for year two.
Also, this budget does not reflect in-kind support from partner organizations.
SENIOR SOCIAL ISOLATION PROJECT (SSIP) 53

Appendix I: SSIP Implementation Plan/Timeline

Initial Phase: Through December 2020
Activity Timeframe
Continued coordination and outreach to potential collaborative partners. Ongoing
Ongoing outreach to county agency leadership and stakeholders; test
marketing/outreach/educational materials.
June-September 2020
Fundraising calendar/plan finalized. September 2020
Conduct interviews with seniors (qualitative study); generate report. June-September 2020
Finalize SSIP nonprofit board and application materials. September 2020
Meetings begin regularly (monthly) with partners. September 2020
Education/public awareness campaign underway (presentation materials
finalized, regular schedule of presentations in place).
October/November 2020

Full Implementation: Looking ahead to 2021
Activity Timeframe
Nonprofit status is realized. January/February 2021
Implement fundraising plan (includes special event and/or mail campaign
for early 2021).
January 2021
Ongoing education/public awareness campaign. Ongoing
Begin planning for additional programming. February 2021

SENIOR SOCIAL ISOLATION PROJECT (SSIP) 54

Appendix J: Barriers and Facilitators for the SSIP Using RE-AIM

Barriers Facilitators
Reach
(Those served/
benefitting)

v Engaging appropriate partners.
v Hard-to-reach population;
challenges in gaining trust.
v Culture/norms around aging.
v Engaging appropriate partners.
v Culturally appropriate materials and
methods.
Effectiveness
(Delivery/outcomes)

v Diverse array of stakeholders
can make communication and
common goals challenging.
v Volunteer turnover.
v Development of common goals and
continuous communication
channels.

Adoption
(Settings/organizations
involved)

v Organization engagement;
inconsistent involvement.
v Limited agency capacity.
v Local emergencies such as
COVID-19; fires.
v Strong/persuasive leadership.
v Strong interest and understanding of
needs by local providers for
services.
Implementation
(Fidelity and costs)

v Insufficient/poor
communication; cost of
implementation.
v Financial feasibility.
v Common goals and continuous
communication among partners.
v High-quality materials, research.
Maintenance
(Long-term
sustainability)

v Insufficient/poor
communication (potential of).
v Sustainable funding.

v Continued coordination through
formal lead agency.
v Continuous improvement practices
(data collection and evaluation).

Abstract (if available)

Abstract The wicked problem of social isolation has been deemed one of the twelve Grand Challenges of Social Work. Social isolation has now been researched and written about for decades across multiple disciplines including social work, sociology, public health, and psychology. This capstone project examines the impact and prevalence of social isolation in one of the most vulnerable populations—the elderly—and proposes a framework for addressing the issue at the county level. The Senior Social Isolation Project (SSIP) is a comprehensive strategy for improving services countywide to low-income, homebound elderly in Ventura County, California, which is located adjacent to Los Angeles County. The SSIP is an initiative composed of three key programmatic components—advocacy, education, and research—that are rooted in a collaborative model to address the issues faced by socially isolated seniors. The elderly, and particularly socially isolated or homebound elderly, are underserved in Ventura County. This population, however, is growing rapidly as elsewhere in the country, with the number of adults 75 and older expected to nearly double (to nearly 90,000 residents) within the next 10 years. Through collaboration with partner agencies across the county, the SSIP will use advocacy, education, and research to influence county leaders and communities to better serve this vulnerable population and develop new programming. Long-term goals for the SSIP initiative include an increased level of in-home services, increased levels of volunteering and philanthropy for programs supporting seniors, more regular screening for social isolation in seniors by healthcare providers, and improved well-being of seniors in the county. The SSIP is not a stand alone solitary program, but rather an initiative looking to influence systems and change culture. Given that Ventura County currently has substantial gaps in services for this population, and is experiencing increasing numbers of elderly residents, a comprehensive County-wide strategy is both imperative and innovative at this time. The long-term vision is that one day the SSIP will be a model program for other communities wanting to undertake a systemic approach to a pressing problem, whether it be social isolation or other challenges.

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Asset Metadata

Creator Powell, Lisa Evans (author)

Core Title The Senior Social Isolation Project (SSIP): a comprehensive response to a growing aging population

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Publication Date 07/26/2020

Defense Date 05/15/2020

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag collaborative,elderly,OAI-PMH Harvest,seniors,social isolation,Ventura County

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Bolar, Eleanor (committee chair), Rank, Michael (committee member), Smith-Maddox, Renee (committee member)

Creator Email lepowell@usc.edu,lisaesings@hotmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-342846

Unique identifier UC11663604

Identifier etd-PowellLisa-8700.pdf (filename),usctheses-c89-342846 (legacy record id)

Legacy Identifier etd-PowellLisa-8700.pdf

Dmrecord 342846

Document Type Capstone project

Rights Powell, Lisa Evans

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA