Enabling social care services for older adults during periods of long‐term social isolation: Service provider perspectives

To investigate how small, local organisations were impacted by and responded to COVID‐19 in their delivery of social care services to older adults (70 years and older). Lessons learnt and future implications are discussed.


| INTRODUCTION
Globally, the COVID-19 pandemic has forced social care services (such as local government, day care centres, meal delivery and social activities groups) to adjust their service delivery models significantly to safely meet the needs of their older adult clients. [1][2][3] Such social care services may play a critical role in meeting the needs of older adults whose risk of severe health complications and mortality associated with COVID-19 increases significantly over the age of 60, 4 as well as risk of exacerbated isolation and loneliness due to social distancing measures and lockdowns. 1,2,5 Members of the 'Silent' generation (born between 1927 and 1946) are also typically less experienced in using mobile technology and the Internet to obtain supplies such as food and medication 6 and are more susceptible to the spread of misinformation online. 6,7 Adjustments to service delivery range from tweaks such as providing frozen meals to reduce the number of trips and mitigate the shortage in volunteers for food delivery 3 to removing face-to-face services altogether. 8 In Western Australia, many small, local organisations that provide a range of social care services to older adults are run by volunteers with little funding. Although many of these organisations provide important services within their communities, little attention has been paid to how such organisations operate and adapt during times of restricted delivery of their usual services.
This study aimed at understanding lessons learnt and future implications of how small local organisations in Western Australia were impacted by and responded to COVID-19 and public health measures on their older adult clients and service delivery. This is part of a larger study to understand the impact of COVID-19 on older adults in Western Australia, which we report on elsewhere. 9 2 | METHODS

| Setting
Within Perth, social and work restrictions were implemented in 2020, with stay-at-home orders or 'lockdowns' in 2021. For older adults, both restrictions and stay-athome orders have been perceived as 'lockdowns', with older adults encouraged to stay at home to reduce the risk of being infected with COVID-19. As such, we refer to both restrictions and stay-at-home orders as 'lockdowns'. Interviews were conducted from January to March 2021, reflecting on 'lockdowns' that occurred in 2020.

| Study design and participants
A list of Perth-based organisations for purposive sampling was compiled in consultation with the consumer reference group and included both social care and mental health services. Email invitations were sent to 40 organisations. Initially, six of the 40 organisations agreed to participate, with two organisations later withdrawing due to time constraints and no longer feeling that their services fitted the requirements of the study. The four participating organisations primarily provided social care services and included: an advocacy service for adults ≥50 years; a charitable organisation run by volunteers that provides social groups and care plans for adults ≥70 years; a notfor-profit organisation that delivers Commonwealth programs and home care packages for adults ≥65 years; and a local government council that provides specific services for adults ≥55 years. Ten older adults (aged between 68 and 78) were also interviewed about their experiences of accessing services during the pandemic, which we report on elsewhere. 9 The study was approved through the Edith Cowan University Human Research Ethics Committee, approval number 2020-01693-STROBEL.

| Data collection and analysis
Six representatives participated in semistructured interviews at their places of work with the interviewer (CP), a clinical psychologist, who was not known to the participants. Interviews took between 26 and 46 minutes. Interview questions were developed in consultation with the consumer reference group, with focus directed on participants' experience with clients whose needs were perceived to be related to their age, typically ≥70 years old: • What, if any, organisational changes were made to the way you did business during the COVID-19 lockdown? • How did your demand for services change during this period? • Did you offer any additional services and/or make changes to your service delivery? • What worked? • What did not work? • Were there occasions when your clients' needs were not met? • Is there anything you would change for next time?
• Are there any changes you will keep?

Practice Impact Statement
During COVID-19, small social care organisations adapted well to being the point of contact and information for older adults. Supporting clients with domestic tasks and maintaining social connectedness online was a challenge due to limited preparation time and funding. This research highlighted the need for increased financial support for smaller organisations to provide older adults with adaptive social care services.

Policy Impact Statement
This research provides evidence for increased and expedient financial support for smaller organisations to provide adaptive mental health and social care services for older adults in times of crisis. This includes services to support older adults to use technology and social media to maintain social connectedness and access alternative services.
Three hours (186 min, 51 pages) of data were transcribed verbatim for analysis. Transcripts were coded by a second investigator (AB) using the NVivo software and a thematic analysis approach, according to the categories determined by the interview questions and further themes that emerged. 10 The two investigators discussed the main findings of the analysis for validity, saturation and cross-investigator agreement.

| RESULTS
The six interviewees were employees or volunteers in a range of policy, financial, administration and community development positions within their organisations (see Table 1). All participants had worked with their organisation for at least 5 years, and three were 60 years or older. Table 2 provides supporting evidence for the key themes outlined below.

| Key Theme 1: service providers' experience
Staff were encouraged or mandated to work from home where possible, and social distancing and hygiene measures were implemented in workplaces.
Service providers experienced emotional distress in response to the pandemic and lockdown, including fear of contracting COVID-19, the possibility of losing their job due to reduction in face-to-face services, distress about the isolation and loneliness of their older adult clients and the possibility of not being able to support these clients. Over time, service providers increased their confidence in their ability to cope with these stressors, both at work and personally.

| Key Theme 2: perceived needs of older adults
Service providers' greatest concern for their older adult clients was social disconnection and loneliness, motivating adaptations to their services, as discussed below. Such concerns were exacerbated by clients no longer being visited by their families, who were worried about putting them at risk and by the perceived limited ability of the oldest clients to utilise information technology and social media to stay connected. Service providers also noted that clients faced anxieties in terms of completing tasks of daily living, using public transport and procuring medication.
Some service providers also suggested that as older cohorts may be more familiar with community-wide crises, they were better equipped than younger people to deal with some of the difficulties of imposed social isolation. Furthermore, participants noted that while some clients were initially afraid of any contact with services, after a few weeks, they felt more confident in receiving services again (with appropriate hygiene measures).

| Wellness checks and information provision
To address concerns about clients' disconnection, service providers prioritised wellness checks through phone calls, necessitating updates to the providers' own communication technologies. One provider reported sending postcards. Some organisations also acted as a point of networking, connecting older adults to other services and providing information to their clients regarding the lockdown rules.

| Technology
Service providers explored the use of newer technology such as videoconferencing and social media to remotely facilitate activities such as physical therapy. These online options had low uptake by older adult clients. Service providers noted that they could play a role in providing

Anxiety
For Mall Walking, some people were quite concerned about getting back in a group, so numbers dropped, but they have risen again.

Online services and use of technology
Not all older people do not go online, but a significant number do not, and the older they get, the less they do.

Funding
Because it happened so quickly, we just did not have time to apply for grants, and when you do apply for a grant it is a very slow process anyway. B

Emotional distress
We could visit beforehand, but after, then we couldn't, and that was a little bit sad that we couldn't.

Demand for services
There wasn't really any change in the demand. We just did more phone work.

Adaptability
Those older ones deal with [restrictions] better than the younger ones. I think [younger adults would] knock you out, kill you and eat you. They just would not think twice about it, for a toilet roll. It beggars belief. I quite often wonder what these older women think, because they were brought up in an era with rationing.

Welfare checks
We got through 1500 [clients] in the first group, just ringing them, making sure that they were okay, they understood, and if they needed help, then we organise that for them. And then we will just go around through that again. Communication is the most important thing.

Anxiety, isolation
The families started to shelter the clients. They said "I can't visit Mum, because I am a teacher or am working in a hospital and I'm too much exposed." Adaptability Gradually, when we got used to the new situation and they stopped being so afraid, they started to call and say "Can I have one of the domestic assistants back?"

At-home assistance
We need to replace the family in terms of shopping […] and social support, visiting them, going for a small walk, going into the garden. Helping them with things they did not even have before, such as domestic assistance. D

Emotional distress
I'm a human and I have empathy for humans and for everyone and it's very hard to go there and to see that they're desperate. They say "Please don't go, we cannot talk with anyone."

Loneliness, isolation
Our clients say "We can survive if the dishes are not done or if the floor is dirty, but we cannot survive without talking with anyone for weeks." That is very depressing and that is very sad.

Welfare checks
Welfare checks instead of visits; we have been looking for options. Sending postcards, for example, we made, last year, around 720 hours of phone calls, we sent around 900 postcards in different languages.

Perceived needs of older adult clients
Adapting services E

Working from home restrictions
We had full restrictions on our volunteers visiting our beneficiaries. Simply because most of them are elderly, so they're high risk.

Demand for services
Me being on the frontline receiving the calls, I would have to say particularly during significant event times, like Anzac Day, was quite a mental health issue for a lot of people.

Anxiety
When people ring up and they are in that state of mind, they want to talk to someone straight away. They do not want to be told, "Oh, I'll get Mary to call you" and then be anxious and wait by the phone.

Restrictions
Unable to maybe get out because a lot of them take public transport.

Technology
We now have a cloud-based system. If you can actually transfer that call immediately to one of the welfare officers or community services officer, you get better results.

At-home assistance
Food packaging and delivery services, if they required it. F

Emotional distress
It's more internal than external. We are caring for our community and the businesses and everything else, but also self care and how we can help each other to do more for that.

Essential services
We also asked that senior services, which is our reception area, be kept open because we were deemed to be essential services. Everything we do is connected to people.

Loneliness, isolation
We had one person who is unwell and has an immunodeficiency issue and could not get out.
He rang and said "Please, help me to connect with just one person. I'm really lonely."

Restrictions, limitations
Seniors would ring us up and say, "I'm running out of my medication."

Communication, confidence using technology
It is our biggest identified gap. The information, communication, technology is huge for seniors.

Information provision
We informed [older adults] about those basic things of having food, medical assistance, and their medication. Our town updated our website with a lot of good information. Technology [The physio] put her stuff online and had a few people but not half as many, because a lot of them do not have the equipment. So, we have a 'building basic digital skills' campaign we started this year with the library.

T A B L E 2 (Continued)
hands-on technology training and support to clients. However, to meet clients' needs for connection, familiar technology such as phone calls and postcards proved a valuable and effective option.

| At-home assistance
Service providers identified additional in-home needs that older adults were not able or confident to undertake during lockdown, such as grocery shopping and paying bills, particularly as their families no longer felt safe to visit.

| Funding
While government-funded organisations had some flexibility in how they could change their funding to adapt their services, the organisations that relied on community grants (e.g. LotteryWest) felt limited in that they did not have time to apply for grants for alternative programs.

| DISCUSSION
Concern about social isolation and loneliness was the primary motivator for service providers, including advocacy groups, community services, domestic assistance and local government councils to adapt their services and keep older adults connected. The challenge of responding to this concern caused some emotional distress, and whilst service providers were able to adapt fairly quickly to the 'lockdowns', they could have benefitted from additional resources to support their clients. For example, services such as wellness checks, increased domestic assistance and upskilling clients in technology were of particular concern to organisations. Some organisations, however, did not have the preparation time or capacity to support this undertaking without additional financial assistance. This suggests the benefit of expedited resourcing for such organisations to continue to provide and adapt their services during times of crisis, such as during the COVID-19 pandemic.
A strength of this study is that it supports the finding that globally, non-health-care workers face similar anxieties and vulnerabilities to health-care workers during the pandemic, including exhaustion, isolation, psychological distress, anxiety and burnout. [11][12][13][14] A limitation of this study is the small sample size, although it must be noted that the six participants represent an interesting range of social care services with different levels of direct involvement with older adults.

| Policy implications
Local service providers, including advocacy groups, community services, domestic assistance and local government councils, are in a prime position to support the social connectedness of their older adult clients as trusted and established organisations in their communities. This highlights the benefit of greater and more expedient funding to adequately resource and adapt these organisations for sustainable service provision during times of crisis.

| CONCLUSIONS
This study explored the impact of COVID-19 on the response and delivery of social care services to older adults in the Perth metropolitan area. It highlighted the ways that service providers may position themselves as frontline essential workers during a crisis and their adaptive responses, albeit with limited resources available to them. It provides evidence for increased resourcing and support to these services to continue to provide sustainable service provision during times of crisis.