Addressing Loneliness to Boost Chronic Care Management

June 9 – 15 was Loneliness Awareness Week, a campaign led by the UK-based Marmalade Trust to normalize conversations around this feeling and reduce its stigma. This year’s theme, “Meeting Loneliness Together,” is especially relevant in health care, where loneliness is not just a mental health concern, but also a critical barrier to successful chronic care management. 

Social isolation can cause patients to reduce or cease using prescribed medications, become disengaged with their care teams, and increase their risks for hospitalizations and premature death. These effects are particularly dangerous for older adults who are managing multiple chronic conditions like diabetes, heart disease, and COPD.

Here at HCRS, we believe that effective health care must address the full spectrum of a patient’s needs — including their emotional health. That’s why our Chronic Care Management (CCM) program is specifically designed to reduce isolation through proactive, relational support. We emphasize human connections so that providers foster trust and promote continuity of care for vulnerable patients.

Loneliness Is a Clinical Risk Factor

Loneliness in and of itself may not show up in lab results, but its physiological side effects can be measured. Research indicates that chronic loneliness can activate stress pathways that elevate blood pressure, weaken immune responses, and contribute to depression and cognitive decline. Patients who feel isolated are less likely to attend their follow-up appointments, engage with their treatment plans, or report early warning signs of deteriorating health.

In the context of chronic care management, this disengagement is particularly problematic. Successful care depends on sustained, open communication, as well as patient participation and regular health checkups. When those patients choose to withdraw for too long, even the most thorough clinical plans can fail.

The HCRS Model: Proactive, People-First Care

Our CCM program directly addresses these challenges by establishing regular, structured touchpoints between patients and their dedicated care teams. Under the supervision of referring providers, HCRS becomes an extension of their office — a trusted partner that patients can rely on between visits.

Each patient receives at least one monthly outreach from our care coordinators via phone or HIPAA-secure video chat. These check-ins include personalized education, care plan reviews, symptom analysis, and lifestyle coaching that is related to diet, exercise, sleep, and medication. More importantly, we offer consistent, compassionate conversations that help combat the isolation that so many patients may experience as a result of their chronic illness.

We are trained to recognize and document changes in emotional and social well-being; and, when needed, to either escalate these issues to the appropriate providers, or help patients connect with local community resources.

Ease of Implementation for Practices

We understand that providers are often stretched thin and may not have the capacity to manage CCM in-house. That’s why we offer a turnkey solution that includes:

• A dedicated care team manager and licensed clinical staff.
• A secure software platform (1bios) that tracks care time and pushes notes directly to your EMR.
• Support with patient enrollment, billing documentation, and monthly summaries.
• A flexible communications infrastructure that mirrors your office’s phone number and allows for inbound/outbound calls, texting, and video sessions.

Billing is Medicare-compliant and based on time increments (20, 40, or 60 minutes per patient per month). Patients with Medicare and secondary insurance are typically covered at 100%, and we help practices communicate clearly with patients about any coinsurance responsibilities when applicable.

Why Loneliness Awareness Matters

This past week was one of many opportunities to acknowledge that loneliness is a widespread and under-addressed factor in poor health outcomes — particularly for aging populations. Campaigns like Loneliness Awareness Week aim to normalize how we address this feeling, encouraging individuals and organizations to speak openly and seek support.

When it comes to treating chronic disease, loneliness shows us how important it is to manage more than just symptoms. CCM requires relationship-based care that meets patients where they are, physically and emotionally. That’s why we see our services as part of a broader solution to the loneliness epidemic. By embedding our team into your patient care strategy, we ensure that no one falls through the cracks due.

Let’s Improve Health Through Human Connections

Loneliness undermines health. Consistent engagement restores it. We can help you build lasting relationships with patients who need them most. 

Let’s commit to meeting loneliness together — with care, compassion, and clinical excellence. Contact us to schedule a consultation and learn more about a program.