The Science of Happiness, Health & Well-being During COVID-19

Kathryn Santoro (00:00:00): Thank you and good afternoon, everyone. I'm Kathryn Santoro, Director of Programming at the National Institute for Health Care Management Foundation. On behalf of NIHCM Foundation, we first want to extend our sincerest thanks to the health care and essential workers on the front lines of the COVID-19 pandemic for keeping us safe. This is a challenging time and our goal today is to share information and evidence-based strategies to manage loneliness and increase well-being.

Kathryn Santoro (00:00:30): Prior to COVID-19, 20% of the population experienced loneliness and social isolation, and our current world of physical distancing and quarantine restrictions has only heightened these feelings. A lack of meaningful social connections can have a serious impact on an individual's mental and physical health. Fortunately, the Science of Happiness provides insights into how intentional actions and strengthen social connections, boosts happiness and in turn, health and well-being.

Kathryn Santoro (00:01:04): To explore strategies to address loneliness and improve social connection, we're so pleased to have a prestigious panel of experts with us today. Before we hear from them, I want to thank NIHCM's President and CEO, Nancy Chockley, and the NIHCM team who helped to convene this event today. You can find biographical information for all of our speakers along with today's agenda and copies of slides on our website. We also invite you to live tweet during the webinar today using the #COVIDwellbeing.

Kathryn Santoro (00:01:37): I am now pleased to introduce our first speaker, Dr. Don Berwick. Don began his career as a pediatrician and as a leading authority on healthcare quality and improvement. He is a former administrator of CMS and currently serves as President Emeritus and Senior Fellow of the Institute for Healthcare Improvement, which he co-founded. Don also serves as an advisor to NIHCM and we're so fortunate to have him with us today. Don?

Don Berwick (00:02:07): Thank you so much, Kathryn. Thank you for the chance to join you all. I'm stunned by the level of interest in this topic, and I can't wait to hear my co-speakers. And let me also extend my thanks to Nancy Chockley for her incredible leadership of NIHCM and NIHCM Foundation. It's a privilege to be associated with this great education and research organization. I'm going to basically lay a groundwork. My colleagues are going to, I think, offer the good news. I'm going to start with some of the bad news. I want to talk a bit about the challenges we have around happiness, health and well-being in especially social isolation, and give you a little bit of a peek at the scientific underpinnings of the problem we're trying to solve.

Don Berwick (00:02:46): I want to give credit to my mentor, Sir Michael Marmot, from the UK. Michael is one of the world's experts on the issues we're dealing with, basically the social determinants of health. And if you have not read, Sir Michael's book called The Health Gap, which appeared in 2015, it is my text, my Bible on this field. It's a wonderful book and it lays out not just issues around happiness, isolation and well-being but also the greater terrain of what we really now call social determinants of health.

Don Berwick (00:03:21): So determinants to health is a widely used term right now, you're hearing it a lot. The question is, what does it mean? And that's what I want to unlay and what I want to connect back to our topic today about isolation, loneliness, health and well-being. The phenomenology is disturbing. We know from research, this most recent paper, especially by Steve Woolf and Heidi Schoomaker, that appeared in JAMA. But it really summarizes growing of epidemiologic data on life expectancy, mortality and well-being in the United States. And the basic news is, we have lost ground.

Don Berwick (00:03:56): For the first time in my lifetime, life expectancy decreased for people in their middle years in the United States. That got leveled off last year. But for the three prior years, for the first time on record, life expectancy decreased steadily. And that's not an accident, nor is it minimal. The overall pattern of life expectancy has taken a turn. It's important, though, to realize that life expectancy growth has always been an unevenly distributed benefit in the growth of American society.

Don Berwick (00:04:32): This graph between the 1920s and nowadays shows that although life expectancy improved quite quickly for people in middle income and the wealthy, if you were at the lower end of the spectrum, as a man or as a woman, your life expectancy did not increase during that period. In fact, if you were born in 1950, your life expectancy was lower than if you were born in 1920. If you were a woman in the poorest part of our economy. What's going on here has very little to do with health and healthcare, has to do with factors in people's lives that are very, very strong determinants of life expectancy. Let me show you how this looks.

Don Berwick (00:05:15): For example, in the city of New York, now one of the epicenters for the COVID epidemic. If you are a New Yorker in Midtown Manhattan, boarding the subway, one second, I got to make this word properly, boarding the subway say at 85th Street in Manhattan, Midtown Manhattan. People walking in the sidewalk above you are making about $180,000 a year, they're mostly white, they're well-dressed, their kids are in good schools and your life expectancy is high. It's about verging towards 80 ... Excuse me. Messing up my slides. I apologize. Here.

Don Berwick (00:06:03): Life expectancy in that Midtown Manhattan area is ... Sorry. Here we go. Is about 85 years, close to what is in Japan. If you travel north about two and a half miles to the South Bronx, the epicenter of the COVID epidemic right now in New York, your life expectancy is much shorter. The Delta, the difference in life expectancy is about 10 years. That means on the D train traveling from Midtown Manhattan to South Bronx, you're losing about six months of life expectancy for every minute you're on the D train, about 2.3 years per mile trip. That's an extraordinarily big effect compared to anything healthcare ever does.

Don Berwick (00:06:55): What's going on between the Midtown Manhattan and South Bronx, well, that's what we call social determinants of health. It has to do with the circumstances of your life way beyond the accessibility of health care. This has been given even more force as you've been reading lately, a wonderful summary, by the way, by Atul Gawande in New Yorker of the book, Deaths of Despair, which marks the research of Angus Deaton and Anne Case, two Princeton University economists.

Don Berwick (00:07:27): Angus Deaton himself who's a Nobel Prize winner, who has studied a really interesting phenomenon, a tragic phenomenon, which is this surge of deaths in the United States from conditions which they call conditions of despair. Drug abuse deaths, alcohol related deaths, suicide deaths, numbering close to 50 or 60,000 deaths a year now, something we've never seen before in this country. Not as Deaton and Case had documented it. This is a particular kind of version of social determinants of health.

Don Berwick (00:08:00): Now, among the components of this, the Deaths of Despair, the loss of life expectancy, especially for people who are impoverished, is the issue of social engagement. It has to do with whether people feel connected to, empowered by in relation to their society and to others in society. This slide shows a study published just in 2010, not that long ago, about social relationships and risk of mortality. Just take a look at the magnitude of this effect. You're seeing risk ratios ... I think we need someone to mute their phones.

Don Berwick (00:08:41): The risk ratio is like a 1.5 times race risk ratio for better survival for people who are socially integrated, whereas social isolation living alone and loneliness are associated with a decrement of one and a half fold for survival. That's an incredibly large impact on the probability of survival to this study. A particularly interesting study that I showed in a prior NIHCM webinar was this one published in the journal Heart in 2016 relating social relationships to cardiovascular risk.

Don Berwick (00:09:24): Incidents of coronary heart disease went up 29% among people who scored high on loneliness and social isolation. Stroke risk goes up 32%. Those are massive numbers. I want to emphasize, we don't know any medical research or intervention on either coronary heart disease or stroke that even vaguely approaches this level of impact of this toxic effect of loneliness. It's a very, very severe cost of poor health. The mediator, we don't know. It's the mind. It's that somehow there are connections between our state of mind and our well-being.

Don Berwick (00:10:00): The obvious connection is mental illness. That's a state of mind issue of illnesses that are treated through [inaudible 00:10:09] interventions. But the psychosocial pathways themselves, the psychology of loneliness, the psychology of stress, we know are very strongly related to physical illnesses you just saw. Now I have to get a little political, which is why does this happen? Why in a wealthy society do we see this phenomenology of despair, deaths of despair, loneliness and isolation and its consequent effects on health? And the answer is poverty.

Don Berwick (00:10:38): The associations between despair and loneliness and poverty are not 100%. You can be wealthy and quite lonely also. But there is a really interesting and strong connection in our country between being of lower income or poor and these conditions. And you can see that this kind of poverty is heavily concentrated in people in underrepresented minorities, in black, Latino and Native American race. This is racism at work. And this is where I have to get clear. This is a 1937 guidance from the Home Owners' Loan Corporation around mortgages. Who is okay to give mortgages to?

Don Berwick (00:11:23): More than half of the negro population of San Francisco says this government manual, are located in the red area is considered a highly hazardous area. This is what you know is redlining. Its racially constructed redlining, which is part of our nation's history in law. The other thing I want to ... One second. If you take that redlining and you now look today, at what's happening with poor academic performance in schools or in age-adjusted preventable hospitalization rates, for example, the redlining characteristics on the racism map from the 1930s corresponds directly to the morbidity patterns and the poor education patterns in San Francisco. This is the legacy of racism being played out through all these social factors in terms of the health and well-being of the population.

Don Berwick (00:12:24): Now, part of this is mediated by our attitudes toward poverty, and this is something I stumbled on thanks to Alice Chen in San Francisco last year. This has to do with our federal poverty line. As you probably know, under the Affordable Care Act, for example, whether you're eligible for exchanges and exchange subsidies, depends on where you are with respect to some multiple federal poverty line. States and the federal government use the federal poverty line to determine whether you're eligible for Medicaid.

Don Berwick (00:12:57): This is a woman named Mollie Orshansky who worked in the Social Security Administration in 1963. She was responsible for overseeing a project to define poverty, the federal poverty line. And it's interesting to see how it was done. There was at the time the Department of Agriculture a definition of the emergency need for food. If you were in desperate shape, what was the minimum amount of food you needed? The so called Thrifty Food Plan. At that time, it was estimated that the average family spent about a third of their post-tax income on food.

Don Berwick (00:13:27): And so what Mollie Orshansky did was multiply the minimum food requirements budget by three and defined that as the poverty line. That more or less is still the way we define poverty in this country. Meanwhile, with a very stringent definition of poverty is something that nobody on this phone could possibly live on comfortably. We have continued with regressive financing policies. This was the US tax rate by income in 1950. This is the same in 1980, 60, I mean. This is what it became in 2016. This is what it is in 2018. US tax rates by income have remained the same or higher for people of low income and have gone dramatically down for people of high income.

Don Berwick (00:14:17): We have regressive taxation policy hard at work in this country to continually redistribute money from the poor to the wealthy. The change in effective tax rates is shown here. Notice between 1962 and 2018, the richest 400 people in our country used to pay 54% of their income taxes, they now pay 23%. The top 10% used to pay 43% of their income, they now spend 30%. The bottom 50% used to spend 22% in 1962, now spend 24%. We are in a country which is the opposite of progressive redistribution of wealth. And why is that important? It's important because it affects our ability to invest in the social determinants of health.

Don Berwick (00:15:02): This is Michael Marmot summary, "Inequalities in power, money and resources and regressive policies give rise to inequities of the conditions of life, which leads to inequities in health." This is the chain of effect that I can't get away from when I look at the data. Regressive financing social and tax policies, deepening poverty and inequality, leading to more isolation, which reduces despair, which is directly related to poor health. So this is reflected in our country's status in the world. Our child poverty rate is the second highest of 35 nations in OECD studies. And our child well-being index in the United States ranked in the 2013 rankings, this has not changed. We are last among 20 nations.

Don Berwick (00:15:52): We are not a nation which invests in providing supports at the level that other countries do to mitigate these vexive social disparity. The effect on children is dramatic. This is the decline in percentage of children earning more than their parents year on year. Again, regressive financing network. Healthcare is part of the problem, not the only part. This is Betsy Bradley's study, which you've all seen many, many times showing that compared to other countries, the United States invests far less in social determinants and far more in health care than other countries do, when you look at the total investment in determinants of health. What we get is what we have invested in, a high level of disparity and the consequences mediated through poverty and isolation. It doesn't have to be this way.

Don Berwick (00:16:52): This is the policy of the treasury in New Zealand. "A well being approach can be describes enabling people to have the capabilities they need to live lives of purpose, balance and meaning for them." We're not doing that well. And if we want change, we're going to have to understand the strong connections between social policy, redistribution of taxation policy, and the well-being of our society through many mechanisms, not just loneliness and isolation. With that stage setting, hopefully not too depressing, I'll turn it back to you Kathryn and look forward to hearing comments from people that are actually trying to do something about this.

Kathryn Santoro (00:17:30): Thanks so much, Don, for your leadership on the social determinants of health and for sharing the effect of social isolation and health and all of your insights on the impact of inequity on health outcomes. While many factors do feel beyond our control right now, our next speaker, Emiliana Simon-Thomas, will share some evidence-based strategies you can use to improve happiness and well-being. Emiliana is the Science Director of the Greater Good Science Center at UC Berkeley, and she's co-instructor of its popular Science of Happiness online course. Emiliana?

Emiliana Simon-Thomas (00:18:11): Thank you so much. It's such an honor to be included in this webinar. Don, I am moved in stunned and inspired by your presentation. Thank you for giving us such an insightful and empirical review of the contextual and policy level issues that we're grappling with. I say that because I want to acknowledge the fact that what I'm going to talk about really has little bearing on that in terms of a collective solution to the problems that we're all grappling with. But more is about how individuals can shift habits or patterns of behavior or priorities in ways that can serve their own happiness and also contribute to the happiness of the people that they interact with in their communities.

Emiliana Simon-Thomas (00:19:04): Of course, the hope is that through this personal shift and work and prioritization, people might also realize the importance of these bigger policy level and collective changes that are also absolutely necessary to addressing the challenges that we're facing. So just to get us all on the same page of what I mean and what most scientists who study happiness mean when they say the word happiness. It's an overarching characteristic of one's life, how you typically tend to feel and think about yourself in the context that you live in. It's also called subjective well-being.

Emiliana Simon-Thomas (00:19:48): I like to share Sonja Lyubomirsky's definition. Sonja is one of the pioneers in happiness research. Wrote a book called the how of happiness, if you are really interested in more detail. She defines it as the experience of joy, contentment or positive well-being combined with a sense that one's life is good, meaningful and worthwhile. This gets me to also share what happiness is not. Research does not support the idea that happiness is somehow a genetic affordance. It's not something that you either end up with because of your family lineage or end up without. In fact, there's lots of evidence that individual happiness levels can change over the course of life as a result of activities, exercises, priorities. We'll talk about these as I continue with this presentation.

Emiliana Simon-Thomas (00:20:43): It's also a mistake to equate happiness with specific moments of positive emotional experience. We often make that mistake. Our media and advertising powers that be sort of invite us to believe Happiness is about material possessions or accomplishments, about achieving the list of goals that we may have made for ourselves. In fact, it's perfectly possible to be an unhappy person with an accompanying great degree of success and privilege in the world. Of course, it's a lot easier to not worry about life circumstances if you do have your basic needs met.

Emiliana Simon-Thomas (00:21:34): But again, the point here is that if you think that happiness means trying to string together a constant sequence of joyful emotional experiences, you actually end up being less happy than a person who thinks of happiness in the way that I shared earlier, as this broad overarching aspect of life. That includes the grief, the anger, the fear that are important when we experience setbacks or difficulties, which often actually end up being quite meaningful. And as you remember or may recall, happiness sort of rests on this sense that your life is meaningful.

Emiliana Simon-Thomas (00:22:15): So, there are lots of different factors that contribute to happiness. This is a recent review by Andrew Steptoe. Rather than go through them one by one, what I'd like to really argue here is that every single one of them has a veneer of social connection upon them. So we know for instance, from cutting-edge genetic studies that your social experiences early in life and throughout life actually impose an influence on an epigenetic influence on how your genes express themselves. So if you are a lonely person, if you report being lonely, the genes that your control your immune response express in a way actually puts you at greater risk for hyper inflammatory disorders. So these are some of the social issues that that Don was pointing to.

Emiliana Simon-Thomas (00:23:10): I could go around this whole circle and tell a similar story about how important our social interactions are to all of these factors, and how they contribute to the potential for each of them to actually drive up or down our happiness levels. I'll share a couple more key findings, and this one's pretty similar to one that Don shared. Which is to say that when we look overall at people's sense of social trust, connection, common humanity, willingness to take risks, knowing that they'll be supported, also holding in mind that others rely on them in meaningful ways for support. What I've just summarized is what would be considered being someone who is securely attached. It means you really feel confident in your sense of belonging.

Emiliana Simon-Thomas (00:24:05): Roy Baumeister wrote about how important and intrinsic the need to belong is to humans. So people who have that, who have that as opposed to feeling anxious or always wanting to avoid or suppress their emotional opportunities, they are at much lower risk with substantially lower risk of number of psychiatric disorders in addition to health challenges. So this is a kind of early life social experience influence on lifelong health and well-being. Maybe some of you have heard about or read about the Harvard study of Adult Development, which for 80 years has been following a cohort of people to try to figure out like what matters? What's most important to our health and well-being?

Emiliana Simon-Thomas (00:24:51): And as the quote suggests, "The key to healthy aging, ultimately turns out to be relationships," and then this is not a typo, "relationships, relationships." These researchers just kept finding again and again when they looked at the data, that individuals who leaned in to their relationships with family, friends and community, were protected against chronic disease, mental illness, even memory declines. And all of these are associated with your willingness to claim that you are someone who is happy in life.

Emiliana Simon-Thomas (00:25:26): So what's going on right now and what's making it hard for us to connect socially in the face of COVID19? First off, is the uncertainty, the ambiguity, being in a state where we don't know what's going on makes us more vigilant, makes us feel less trusting. Our sense of agency, of capacity to do anything is challenged. And all of this sort of is at odds with our sense of affiliation or generosity or being outgoing. Secondly, we are facing really specific mandates to stay physically separate from people, to shelter in our homes. This is preventing us from having the typical sort of contact with our communities, rubbing elbows. This typical contact is always giving us implicit information about how trustworthy other people are and how much we belong. And so being denied that we are left in a position of feeling more isolated and feeling more separate.

Emiliana Simon-Thomas (00:26:21): Video conference modalities. Thank you for joining us today, as we're desperately trying to use this modality to still maintain connections. Regardless, it is not the same as face to face interaction. We can't touch one another. We don't have the same synchrony of biological signals that happens according to the work of Ruth Feldman. When we are in close proximity to one another, it's just not as fulfilling because we don't have the spontaneous synchrony that we have in, in person conversations. And then finally, this whole experience of co-quarantining is challenging for our relationships.

Emiliana Simon-Thomas (00:27:00): Suddenly being faced with homeschooling for those of us who are parents. Being sensitive to the fact that some people are considered essential, some may not feel like they're so essential. Some of us have access to resources, some of us don't. All of this is just making it more difficult for us to have those meaningful, connected moments of social contact. So now I'm going to get into the practical tools, some of the practical strategies we can employ to try to correct for these challenges that we have, to bring more social connection and meaningful interaction into our day-to-day lives.

Emiliana Simon-Thomas (00:27:36): Number one, we just have to deliberately prioritize it. It's very easy to go through our days just scheduling a series of obligations and tasks that don't involve those meaningful connections. Because they're not happening spontaneously through our sports events, through our team, through our socializing, through our community events, through our extracurricular activities. We need to prioritize them. We need to make phone calls, arrange informal video and dates with our friends and family, and even other avenues where we might be able to connect with people with common interests or occupational focus.

Emiliana Simon-Thomas (00:28:20): One of the things that we can do to make these interactions more rich and interpersonally fulfilling is ask people about what's going well, and that's what's meant by capitalizing on positive events. And while we're doing this, utilize what we call active listening. And that means, instead of waiting for the pause where you can interject or planning how you're going to reply to what someone's saying, really just listening to the words that they are sharing with you and understanding them in an empathic and focused way. Empathy is one of these affordances that we are born with and it gets stronger if we use it and it becomes atrophied if we don't. And active listening is a way of strengthening our empathy. Just noticing and getting better at taking other people's perspectives.

Emiliana Simon-Thomas (00:29:11): Expressing gratitude is a way to strengthen our sense of connection. It's called the find, remind and bind emotion, because it helps us connect with others who are potential collaborators, people we might coordinate our efforts with to accomplish bigger goals. I have an asterix because I want to give you some details about how exactly to express it in a way that's most powerful. I also wanted to highlight small talk, when you find yourself waiting in line even at a six-feet distance and there's a stranger in front of you and behind you. It's important again to correct for this socially distance time by having a few fun, friendly and informal questions in your pocket to share with someone.

Emiliana Simon-Thomas (00:29:54): You can ask them if they've listened to a podcast that they think is fascinating or what was the best book that they've read, or any number of ways to just highlight that sense of common humanity can really bring back into your awareness and your habit of thinking that sense of connection. So to get really good at gratitude, be specific and targeted. It involves describing what a person did, that you're thanking them for. What did they do that actually resulted in a positive outcome for you. Acknowledge their effort. What did they forego? What energy did they put into doing this for you? And then finally explain how they benefited you.

Emiliana Simon-Thomas (00:30:36): When we share gratitude with this specificity, and this work of Sarah Algoe, we actually cause a greater release of oxytocin, which is a neuropeptide that makes us feel connected and trusting and affiliative. Okay, one more set of ideas that you can bring into your day to day life during COVID-19, random acts of kindness. It's not just a bumper sticker in Berkeley, California. It is a real strategy for uplifting your own happiness, for making somebody else feel more happy in a given day. And even more interestingly, people who witness random acts of kindness between others feel morally elevated and uplifted, and are more likely to turn and be kind in their own life circumstances.

Emiliana Simon-Thomas (00:31:25): So it might feel a little bit different because COVID-19 has the challenges of interacting with people that we're all familiar with. But if you want to get inspired, there are many groups that are trying to highlight what you can do. Check out #COVIDkindness, for example, there are ways that we can still go out and be involved in the world in ways that are helpful to others. Our skills in extending compassion and consoling each other are really important to bring to the forefront in this time.

Emiliana Simon-Thomas (00:32:01): For some of us, meditation practices, contemplative practices, maybe even centering prayer practices that really get us to touch base with that innate urge to care and concern ourselves with the welfare of others. We call this pro-sociality. This is a really important part of maintaining our sense of meaningful connection with others during COVID-19. And then finally, for those of us who are co-quarantining with other people, or even trying to maintain relationships through virtual channels, working on our skills of managing conflict is a really promising strategy.

Emiliana Simon-Thomas (00:32:41): This might mean that we let go of anger. When we feel frustrated towards the person, can we think of that person as a human who's simply made a bad decision in that moment, as we might have in our own lives at different times. And through that feel a sense of compassion for them having made that mistake, and figure out where we can begin at cultivating some kind of shared understanding. Apologizing, holding ourselves accountable, we're notoriously bad at that in the US as very individualistic, selfrighteous personas. And then forgiveness, deciding that we're not going to hold on to and maintain a perpetual angst and fear around the past offense is a really valuable way to uplift our own happiness. And also contribute to the welfare of our community when we have ongoing conflict or disagreement.

Emiliana Simon-Thomas (00:33:38): I'll close with a slide that is a study that looked at the effects of engaging in the kinds of practices that I just shared with you, which I would call socially engaged because they involve kind of connecting with others, interacting with others in benevolent and pro-social ways. The effect of them on life satisfaction over the course of a year compared to other strategies for self-improvement, which we'll call non-social. This could include like setting goals or stress management, and really compare the impact of these two different kinds of practices. This team showed that the socially engaged strategies just had more, they had more power to change life satisfaction than the non-social strategies when it comes to happiness.

Emiliana Simon-Thomas (00:34:24): So overall, what we know from the Science of Happiness is that when we learn about what really matters to happiness, and how to think about happiness, when we explore these research backed practices and activities and exercises that help us form and strengthen social connections. And we exercise them, we don't just learn about them and then just think, okay, now they're going to work. We exercise them, much like we would exercise our muscles in order to get stronger in a fitness routine, we actually can improve our happiness as well as contribute to the happiness of the people around us. This is just really important in the time of COVID-19. Thank you so much. Again, I hope that what I've said is useful and can contribute to your well-being moving forward.

Kathryn Santoro (00:35:11): Thank you so much Emiliana for sharing the power of positive emotions on health and some really great strategies for how we can connect during this time. Under the leadership of Pat Geraghty, Florida Blues President and CEO, Florida Blue is leading a comprehensive approach to prioritize access to behavioral health and improve social connection during these challenging times, as well as ensuring access to testing and treatment for COVID-19. Florida Blue has also pledged $2 million to support the critical needs of local communities. To share more about these efforts, we're now joined by Dr. Kelli Tice wells, Senior Medical Director of Medical Affairs at Florida Blue.

Kelli Tice Wells (00:36:00): Good afternoon, everyone. It certainly is a pleasure to be with you today. I have to say that one of the things that is helping as we move through this, I understand that because this is new, we are literally building a plane while in flight. What I found to be a tremendous value is the opportunity to come together and talk about our shared experience and leverage the insight that other experts have. And so I'm so thrilled to have had the opportunity to hear from my co-presenters, the information is extraordinarily valuable.

Kelli Tice Wells (00:36:39): Having done some work in the areas of social determinants, one of the things that I am critically and urgently aware of is the impact of those issues in the setting of an intense new stressor. So pre-COVID, we talked about concentrated poverty and financial toxicity that occurs. And now we've added a situation that disrupts normal social change and hasn't increased that financial strain. There is an urgency with which we must respond to this for members of our communities in order to be sure that we can prevent what really could be catastrophic outcomes. So I'll talk a little bit about what we have done at GuideWell and Florida Blue.

Kelli Tice Wells (00:37:31): I want to talk specifically about some things we did for our employees, and then I'll talk a little more specifically about what we've done for members. It's clear that our employees, we have a company that employs more than 14,000 people, and our employees become a population that we manage. Both in terms of their health as many of them are members of our own employee group, but also their day-today stress, their awareness, we have responsibility for them. I'm happy to say that we take that seriously and really treat them as the first and primary population that we want to try to address.

Kelli Tice Wells (00:38:18): And as a health solutions company, we decided early on that it was information, clearly presented information, updated often. That was going to be our key to ensuring that our members and our employees felt supported. We know that our employees want to feel seen and heard, and we also know that to be true for our members. So how do you take 14,000 people and move them home? It was quite an undertaking, as you might imagine, and our goal as an enterprise was to ensure that we were ahead of the curve in terms of making that transition. So we pulled the trigger early in trying to address the needs of a large employee population and support them as they transition their work settings. And we discovered a lot.

Kelli Tice Wells (00:39:11): One of the things that I have shared over and over is that much of what we are addressing in our communities and in our members in terms of social determinants exists in our employee population as well. So right away, we noticed that there were those who wanted to work from home and couldn't, because they did not have appropriate internet connectivity. There were those who didn't have proper equipment. There are many more that don't have a quiet office type space to work in, then there are those that do. And so we had to make allowances for and adjustments for all of those things.

Kelli Tice Wells (00:39:50): At the same time, we've got to, as was mentioned, have now become their child's primary educator. So we had to make some adjustments in terms of allowing employees to shift their work schedule, adjust to productivity, at least initially, in order to allow them to incorporate these new requirements into their workday. And we were very specific and detailed with how we did that. And we surveyed our employees very early in the process to try to be certain that we understood what was important to them. One of the things I think that contributes to isolation is a feeling of disconnection.

Kelli Tice Wells (00:40:32): So the physical disconnection is one thing, but to feel disconnected in terms of thought processing, prioritization of information and issues is also very important. And it's a huge driver of the disconnect that can exist between employees and management. So we surveyed our employees and then we were intentional about responding to what we got back. We made concessions in terms of the subsidy ability. We have people who are working split shifts and that sort of thing in order to try to meet their productivity goals. And then we quickly had to make specific plans for certain subsets and groups. We've got contractors, we've got sales employees, we have clinicians, we have a customer support personnel, and all have a slightly different set of needs.

Kelli Tice Wells (00:41:23): We also wanted to be certain during this time that we leveraged and maintained a great rapport and relationship with our employees. The primary reason for that is we wanted, as we want for our members who want to be seen as a trusted adviser, we wanted our employees to feel comfortable reporting illness to us, reporting worrisome exposures, so that that could be managed and so that we could ensure that they and their colleagues were kept safe from the spread of infections. We also address very directly the potential stigma of diagnoses, and made certain that we created a dialogue that was comfortable and easy on a one-on-one basis with employees. And that any information shared in managing that in follow-up was they identified and protected the employee's identity.

Kelli Tice Wells (00:42:17): Also, we had to acknowledge and then address that the policies put in place, for instance, for paid time off, related to COVID-19 were useful. But we had a number of employees who had very low balances. And so we moved quickly to address those that had less PTO, and put some quick policies in place to be sure that folks felt confident that they could have paid time off if they became ill, rather than have them feel like they needed to sort of push through. We also quickly identified funds that could be leveraged to assist employees who are in need, should they again have issues related to new things financial impacts.

Kelli Tice Wells (00:43:07): We've been intentional too about demonstrating our commitment to employees. You'll see through the remainder of our presentation that we have focused on video conferencing and video messaging, as an important part of our communications methods both to members and employees. Again, to try to establish a more personal interaction versus the things that are sort of printed and written material that gets pushed out by email or posted on the website. Again, trying to ensure that folks feel connected to leaders and they can hear from the leaders on mouth their concerns are being met, addressed and validated.

Kelli Tice Wells (00:43:50): We also have leveraged relationships with members of our team that would have been impacted as we move 14,000 people into a work from home status. Our cafeterias and the productivity of those areas was significantly impacted. There would have been difficulty trying to maintain work for that group of employees that were our food staff. What we did, however, was that we did a couple of things that kept them working. And that was that we partnered with local food banks and did food bank, food preparation rather, for our community producing now 3,000 meals a day out of our cafeteria kitchen.

Kelli Tice Wells (00:44:36): And the other thing we did was we built very quickly a menu of to-go items that can be purchased by your employees at significantly discounted rates. So ready to go meals. So you can purchase meals for a family of four. You order it online and then you can drive through and pick it up. And also very, very early on we established that they could also purchase helpful, essential, through the same manner. And I can tell you, given the limitations of things like toilet paper early on, we were certainly be a great resource for at least a few of our employees.

Kelli Tice Wells (00:45:20): Now, I want to be certain that we have to talk about benefits. We did what we should do related to benefits. That was not the heavy lift. Communicating the changes, however, is quite important. We have created messaging, revised messaging, relaunched messaging and provided a number of different fora for our members and employees to ask us questions about their coverage and benefits. That's really key because this landscape has changed so quickly, and often what they're seeing in the news, and what they're hearing or seeing from us may be a bit different. And so we wanted to be quite intentional about providing an opportunity to ask specific questions.

Kelli Tice Wells (00:46:09): On this slide, I'll highlight the last two bullets. And that is that we, again, in trying to be sure that we engage folks in one-on-one conversations. For our members, we use our nurses and our social workers, some of whom had been transitioned out of face-to-face interactions into a more virtual setting. We engage them to proactively reach out to members, check on their health, help with food and rent and utilities and those kinds of things. Because we have a team of social workers who are already engaged in that work. The other thing that we do is any member who has a COVID diagnosis does get a call from us in order to ensure that they have What they need both to complete their isolation and quarantine period, and in order to connect to whatever services might be indicated.

Kelli Tice Wells (00:47:00): And then finally, very early on, we will a toll-free hotline that's staffed 24 hours. That's not just for our members, but open to anyone in the community who might feel the need to engage and connect to get some assistance with stress management. We began to hear very early on just how anxious our members were about what they were seeing and their own fears about their health as the number of cases across the country began to increase. I've spoken about how we really work to make personal connections with our employees and members and I want to preface that what I will say that our webinar strategy with the fact that we did do survey of our members as well. And we have paid attention to the questions that are being asked.

Kelli Tice Wells (00:47:56): So we created a forum that allows for review by our interdisciplinary team, what questions are being asked by members and what answers are being provided? In order to be sure that we're responding with clarity. And that if there are questions that we have not well addressed, that we can incorporate that information into other communications and other activities are touching members. Finally, I think it's key that we acknowledge the fact that in this situation, we may have the same question asked many, many, many, many times. I think that some of it has to do with the anxiety that members are feeling. But a lot of it has to do with a feeling of wanting to hear their specific question answered.

Kelli Tice Wells (00:48:48): So rather than read a bit of information and glean from that information what applies to me, a one-onone response, I think, members are finding quite valuable. And we explore ways we can accomplish that. And so our webinars are one of the tactics that we use. And we've now done eight-hour long webinars that have evolved over the course of the COVID responses. Initially, we covered very general contents. Now we are much more targeted and specific in what we share in the webinars.

Kelli Tice Wells (00:49:25): And each session is concluded with a long Q&A session where participants can introduce their question into the chat box. The moderator will read the question and we get to as many as we can get to during the allotted time. But all of the questions that are in queue at the time that we disconnect are provided for response. And then that goes back out to all participants so that everyone, again, has the opportunity to feel as though their question was heard.

Kelli Tice Wells (00:49:56): We also use multiple channels to distribute our video messaging and we use small snippets. So we did specific things about hand washing, we talked about social distancing, one at a time to allow, again, consumption of information in a way that was easy and actionable. We didn't want critical information to be buried in a list of new things to do. We also found very early on that our members were falling victim to scams. There is a great deal of that going on now. So we began to monitor that and we put out specific messaging to our members related to that to try to help keep them safe. It's certainly a way that we can help them avoid stress and feeling more disconnected if something untoward like that were to occur.

Kelli Tice Wells (00:50:53): You can't have a conversation about healthcare without talking about specific at risk populations. We very early on recognized as elective procedures were postponed, there were a number of members who were not seeking services because they were fearful and did not understand how to access their care provider during these changing times. We pulled all of our providers, called every one of our provider offices in our network and assess their status. Are you open? Are you close? Are you doing virtual services? Do your patients know? And we compiled that information and begin to address certain groups of patients in order to be sure they had actionable information. Again, we wanted to be sure that they were connected to care.

Kelli Tice Wells (00:51:42): We also very specifically called out the groups who had chronic disease diagnoses that we knew put them at risk for catastrophic consequences from a COVID-19 infection, and we created messaging directly for those groups. And we talked specifically about what it is you should be doing in this moment in order to protect yourself. I think the other thing that that is key is if we've had the opportunity to specifically address fear and its impact. We do so in plain language, hoping that we can then arm people with the information they need to really sort of relax and relieve some of those fears, but continue to encourage them to connect into care.

Kelli Tice Wells (00:52:31): I have a grave concern as we talk about disparities of seeing a host of preventable complications from chronic disease that directly correlate to this period of time, because people are so reluctant to seek services. We can't rely on people's intuition at this moment. We have to really speak in plain language and outline for them what it is we're trying to address and why. The final population that we'll talk about in this last slide is the seniors.

Kelli Tice Wells (00:53:06): We have grave concern about the older members of our population for obvious reasons. And that's specifically related to the infection itself. But more primarily and more critically is the work that was already in flight to address social isolation issues in our Medicare population. The advice that I have here is, be certain as you look around to partner with organizations in order to achieve goals like this, choose the partner whose mission is in alignment with what the messaging is you're hoping to advance. And so in our case, we had long partnered with the Council on Aging, and we're able to leverage that relationship to craft some specific messaging and host some events, which allowed us to talk specifically, speak specifically about some of the issues that the older folks in our community face.

Kelli Tice Wells (00:53:59): Again, I will say being very specific is probably the most important thing. And one of the things we gathered very quickly in some of those first conversations was just how difficult it was for many of our seniors to make the transition to a more digital virtual way of receiving services and care. I'll say that having, and my dad keeps telling me to stop talking about him in my presentations, but having walked an 80-year-old through the download of an app for grocery delivery, it took the better part of a week. I fully understand the need for us to move the ability to provide that support into a virtual capacity.

Kelli Tice Wells (00:54:43): So it's through a partnership that already existed with a program called Papa. The Papa program I sort of affectionately refer to it as the grandchild program. It's geared toward addressing social isolation. But what you get is a grandchild, a young person who come by and helps, it may be chores at home, it may be simple companionship or playing a game, but it's connection. And very organically when you create something like that for the senior population, those young folks begin to fix the television remote and help with some of those digital things. And so, that program now is fully virtual and we continue to provide support to seniors in that tangible manner, which I think is just critical for them.

Kelli Tice Wells (00:55:33): We have a number of employees with older parents who are out of state and we want to continue to leverage things like that in order to have them feel connected and supported. We again are very, very specific in what we do related to that. I'll close with just, again, a final concern. We're working to address this but it is certainly top of mind for me, and that is food insecurity. As supply chains were interrupted, and as our routines were interrupted as restaurants have shifted their business or closed entirely. The sources for a lot of the supplemental food services in our communities literally went away.

Kelli Tice Wells (00:56:12): We have had to step in and try to address that in a manner that keeps folks out of crisis. That was the case, certainly with schoolchildren, for whom some percentage of them, those are their only meals of the day. We had to do the same thing for seniors. And so we've tried to be very intentional about the connections that we could make with organizations like Meals on Wheels, to be sure that we could keep those things spinning for our senior population, for whom meal delivery and even momentary connection with someone were critically important, both from a nutrition standpoint, but also some personal interaction standpoint. I'll stop there. Thank you so much.

Kathryn Santoro (00:56:54): Thank you so much for sharing Florida Blues leadership and commitment to preventing social isolation and all the great work that you're doing to ensure access to care for vulnerable populations. Thank you to all of our speakers for joining us today. If you want to come off of mute, we'll try to take a couple quick questions. We had a lot of questions coming in about early childhood, children and youth and the impact of COVID-19. One specific question for Don, could you talk about your thoughts on adverse childhood events and their impact on social determinants of health, and any concerns right now given children ... Emiliana, sort of lack of social connection for children right now being out of school or having families that they're isolated from.

Don Berwick (00:57:50): Thank you. Can you hear me okay, Kathryn?

Kathryn Santoro (00:57:52): Yes.

Don Berwick (00:57:53): Yes. Adverse childhood experiences is one of the major areas of research and understanding about social factors that affect health not just in children, but in adults who were children subjected to adverse childhood experiences, sometimes called toxic stresses. This is a list of about 10, originally defined by the Kaiser health plan and CDC together. Things that kids get exposed to that if they have multiple exposures lead to illness and psychological and physical illness both in childhood and when those people become adults, the risk factors are phenomenally high. Two or three times the rate of lung cancer, believe it or not, for kids with four or more adverse childhood experiences.

Don Berwick (00:58:36): Among those experiences include witnessing or being subjected to violence in families. And so one direct risk of COVID, we know from that the isolation circumstances of COVID are associated with increases in episodes of domestic violence, and I suspect also child injuries, child abuse. And that's only part of it. I'm quite sure that the loneliness that is experienced in families especially under economic stress, and more and more families are with COVID also were down to hurt children.

Don Berwick (00:59:08): And many children live in schools as part of their own safety net. That's where they get their subsidized breakfast or lunch. That's where they get the social supports that they may not be able to find sometimes at home. So it can't be good for kids. I suppose Emiliana and others will have other more specific statistics. I'm on a National Academy of Medicine committee that's looking at consequences of COVID. Just yesterday, we were talking about consequences for children, and I suspect we'll be doing more on that.

Kathryn Santoro (00:59:39): Thank you. Emiliana, do you have anything to add? A follow-up question was about, is happiness proportional to one's resilience and how can we help children and families develop resilience during this time?

Emiliana Simon-Thomas (00:59:52): That's a great question. To just briefly nod to the ACEs question, I would just confirm and agree with what Don shared. Yeah, I don't have more sophisticated and current stats on the increased rates of ACEs occurring in connection with COVID-19. But I would advocate for parents as many tools as they can bring themselves to utilize that can help them connect with their kids in more benevolent and supportive ways. And in the context of communities, if there are ways that your "random acts of kindness" can be attuned to other families who are suffering from not having their needs sufficiently met. This is a great opportunity space for alleviating some of the stress and anxiety and unmet need that can be sort of precursors to increased dysfunction and abuse.

Emiliana Simon-Thomas (01:01:00): Okay. Now back to the question about resilience. Certainly, people's ability to manage setbacks and difficulties and challenges is a big part of happiness. One of the ways to maintain resilience does involve managing emotions in a more constructive way. This means not trying to suppress them, not trying to avoid them, but instead using them to understand the relevance and salience of the situation that you're facing, and communicating them to others. Disclosing emotions. Naming and disclosing emotions, which again, sounds so simple. I am afraid or I am worried or I am upset or I'm frustrated, those simple expressions when shared with other people about a particularly challenging emotion immediately reduces the physiological signature of a challenge, of being in distress, and for a couple of different reasons.

Emiliana Simon-Thomas (01:02:03): One, you're connecting with another person. Two, you're taking a kind of outside perspective on the emotional experience rather than dwelling in it and ruminating upon it. So there are certainly a host of different skills that people can use to strengthen their resilience in the time of COVID-19, and a lot of them fall under this category of emotional intelligence. Knowing what your emotions are, what they're for, being able to talk about them, share them, and then employing different regulation strategies. Reappraisal is a leading one and any and all of the sort of awareness, contemplative, mindfulness variety of practices are really valuable to emotion regulation during this time also. And parents can certainly do that with their kids.

Kathryn Santoro (01:02:58): Thank you, Emiliana. Thank you, Don. Thank you, Kelli, for your great presentations today. We will follow-up. The audience had some specific questions for you, all that. We'll try to answer or share with you for clarification on some resources and for more information about some of the great programs that you shared today and Florida too, Kelli. So, for our audience, if you could take a moment to share feedback from this event, there's a brief survey that can be found on the bottom of your screen. And following up on Kelli's point and their great work in Florida on food insecurity.

Kathryn Santoro (01:03:36): NIHCM's next webinar will be on Monday, May 11th, where we're bringing together experts to provide insights on food insecurity and growing concerns during COVID-19. You can register now for that on our website. Thank you all again so much for joining us today and we hope everyone stays safe.