Social determinants of health account for 30-55% of health outcomes (World Health Organization, 2008). These include policy, education, environment, and any non-medical factors that influence health outcomes. Among those health outcomes, social activity is particularly connected to cognitive function, mental health, and longevity, among all age groups including older adults (Jeste, 2022; Jester et al., 2023). And when it comes to dementia, social isolation has been identified as one of the modifiable risk factors for the disease (Samtani et al., 2022).
For the increasing global population of elderly patients, access to social care services can meet crucial social and emotional needs to improve health outcomes. For primary care providers, supporting these patients’ needs means potentially integrating social services into primary care, connecting patients with social workers, and improving continuity of care.
Data from cognitive and mental health assessments can point to age-related and/or health conditions that may affect (and be affected by) patient social health. Identifying these conditions allows practitioners to provide the care patients need, and they can also connect them with other services (such as social workers).
In this article, we will explore the benefits of social care, examples of social services for older adults, and the best tools to improve quality of care.
Social care refers to the support and services provided to individuals who need assistance with daily living, often due to age, illness, or disabilities. These services take a whole person care approach, addressing social, emotional, and practical needs as well as medical needs.
In one survey, 92% of older adults said they would prefer to age in place rather than in an assisted living facility (Forbes, 2024). Social care services aim to help people live as independently and comfortably as possible, while also providing a supportive network for their well-being.
Social care services include programs that address patients’ practical needs, as well as provide social interaction, mental stimulation, and emotional support.
Social care services for older adults can include:
Activities of daily living (ADLs) refer to the fundamental skills and tasks people require to live independently (Edemekong et al., 2023). In the United States, 70% of people over 65 require assistance for the rest of their lives due to ADL losses (Johnson, 2019), and experience a negative impact on overall social wellness (Khalili et al., 2023). For individuals diagnosed with dementia, this lack of independence is at least partially caused by cognitive deficits.
Social care programs that provide assistance with these essential activities include:
The CDC has found that social isolation significantly increases a person’s risk of premature death from all causes, and is associated with an increased risk of dementia (Kuiper et al., 2015). With approximately one in four adults over 65 experiencing social isolation, loneliness is a major factor in population health for seniors (National Academies, 2020).
Meeting patients’ social needs is just as important as meeting their physical health needs, and can be achieved through:
Over 55 million people have dementia worldwide, and every year, 10 million new cases arise (World Health Organization, 2024). With these rising numbers, cognitive healthcare is more important than ever.
A few resources and programs for integrating cognitive and social care include:
Behavioral and mental health are key parts of brain care for older adults. Challenging behavioral symptoms can isolate seniors, and get in the way of effective medical treatment.
Some care services for behavioral and mental health include:
Along with helping older adults maintain their physical health and well-being, incorporating social care into their healthcare can also:
According to the World Health Organization, 1 in 6 people will be over the age of 60 by the year 2030 (World Health Organization, 2024). Putting social care into practice with this growing demographic can improve outcomes for individual and population health.
Here are four practical steps for integrating social care into primary care for older adults:
Standardized, scientifically-backed cognitive and behavioral health assessments measure the needs and capabilities of each individual patient. These tools can also identify comorbidities, which helps doctors identify if symptoms such as depression are also indicators of cognitive decline (Alzheimer’s Society, 2024).
Along with this, easy-to-understand reports help healthcare providers interpret data for patients. Effective communication helps educate patients and direct them to appropriate health services and resources, and can improve patient compliance with their care plan.
According to a 2024 report from the Canadian Medical Association (CMA), 60% of physicians report that administrative burden is a direct contributor to the deterioration of their mental health (Canadian Medical Association, 2024). However, that same report notes that 38% of administrative tasks do not need the expertise of physicians to be completed.
A directory of social care resources and referrals to social services programs can reduce this burden, where providers can guide patients towards members of the health team that specialize in social care services.
These social services programs could include:
One report found that social isolation was associated with a 50% increased risk of developing a neurocognitive disorder or other serious condition (AMA, 2023). Along with establishing physical health goals, addressing patients’ social needs is essential to improving patient welfare.
Many programs that are designed for patients’ physical health can also have a social component, such as:
Prompt follow-up from providers is essential to positive health outcomes for patients. In fact, a one-month increase in time between primary care appointments makes it 13% less likely for patients to be able to access routine care when it’s needed (Price et al., 2020).
Establishing a system for regular follow-ups makes it easier to monitor the effectiveness of social care interventions. Taking a measurement-based approach to social care gives providers key insights into patients’ well-being, and regular check-ins keep that data up to date.
From there, connecting with other members of the care team ensures that patients are receiving consistent and integrated support. Tools that integrate with patients’ electronic health records can take the administrative burden off of communicating as a larger team.
In a primary care context, social care can look like:
A good time to apply social care to primary care is during the Annual Wellness Visit (Medicare, 2024). This visit is required by Medicare, is reimbursable, and is designed to review the current state of a patient’s health. From there, the patient and physician can establish health goals and focus on preventive care strategies.
If signs of cognitive impairment arise, providers can schedule an appointment for cognitive care planning, which can be reimbursed with CPT Code 99483.
Annual wellness visits are usually completed in about 30 minutes, leaving providers with limited time to connect with patients and address all of their concerns (CMS). This challenge can be addressed through the use of standardized screening tools, which gather crucial data without sacrificing patient-centered care.
At Creyos, our suite of cognitive, mental, and behavioral health assessment tools:
Our assessments and questionnaires help providers accurately measure cognition and mental health, detect early signs of dementia, and deliver care plans that are tailored to patients’ needs.
Positive patient-provider relationships are proven to improve health outcomes for patients (Olaisen et al., 2020). By reducing the amount of time spent gathering data, providers can take extra time to foster a relationship with patients and understand their unique needs and circumstances. From there, providers can understand which social care services and resources would be the best fit for individuals.
Connect with us today to learn how Creyos can improve your clinic’s delivery of social care.
Having one’s social needs met is a key factor in human health, especially when it comes to older adults (Fernandez-Portero et al., 2023). By identifying patients’ unique wants, needs, and social determinants of health, physicians can successfully guide them towards the right social care services—and build a network of providers in the process.