Since the start of the pandemic, Mirna Cortez hasn't had a typical day. She used to go out consistently, taking brisk walks and riding the bus to browse at Macy's or JCPenney. Now, she spends her days watching Spanish-language news to learn about COVID-19 and participating in organized programs at her Retirement Housing Foundation building in the Boyle Heights neighborhood of Los Angeles.
"When there isn't a pandemic, I go out wherever I want, and I'm happy," she said in Spanish. "But now I don't feel good."
Cortez, who lives on her own, does not leave home anymore unless she absolutely has to. She sometimes goes days without seeing family or friends, urgently awaiting access to a COVID-19 vaccine or future medicine.
Cortez's experience is not uncommon for aging communities in the Los Angeles area, among whom social isolation and loneliness have increased dramatically since California's first stay-at-home order in March 2020. For low-income, Spanish-speaking seniors in Boyle Heights, this challenge is compounded by food insecurity, a digital divide, and language barriers that inhibit access to essential services. Through new initiatives, however, seniors are talking to doctors over Zoom and navigating online forms with coaching over the phone. From individualized technology training, to virtual social clubs, to new exercise routines, these programs aim to last for years beyond the pandemic.
"I have never experienced things like this"
Cortez came to Los Angeles from El Salvador in 1987, but she has lived in the Retirement Housing Foundation's Colonia Jess Lopez senior housing building for nine years.
Her daughter, son-in-law, and two grandchildren also live in the area. Sometimes she sees them every eight days, staying over for a long weekend; other times, every two weeks. Most days, she follows her family's pleas to stay home and ignores the friends who tell her the virus isn't real or not to wear a mask.
"I am afraid of the pandemic," Cortez said. "But each time I feel like I have the virus, I'm not sick."
Moreover, Cortez has had trouble accessing consistent follow-up medical care. With her doctor's office closed, she has felt her depression increase and had appointments delayed, relying on the pharmacy for prescription refills.
"For me, that has been terrible," she said.
Cortez does not know how to use the Internet or make Zoom calls on her own, so to cope with such challenges, she frequently makes phone calls to her church's pastor for guidance and to her close friends, who refer to one another as "sisters."
"They begin to counsel me," Cortez said, which helps her "calm down."
By maintaining connection through programs and phone calls, Cortez has not felt lonely. Though she usually only goes for walks, a recent exercise program offered at Retirement Housing Foundation became one of her favorites. Cortez and other residents sat physically distanced and masked in the community room or called in from their own rooms, often laughing and conversing with the instructor.
"We all leave feeling calm," she said.
Retirement Housing Foundation houses low-income seniors at "the beginning or the end of Boyle Heights"
These types of program adaptations have become essential to maintaining the mental and physical health of senior communities.
As Cortez recounted her experiences behind a pink mask and Zoom screen in her building's community room, Michelle Ornelas organized bags of brightly colored holiday donations behind her. For some seniors, the bags—filled with Snuggies and socks from the Hollenbeck Community Police Station Detective's Division, disposable masks from The Office of L.A County Supervisor Hilda L. Solis, and holiday cards from residents of the Rio Vista Village family building—may have been the only holiday gifts they received this year.
A Social Services Coordinator for the Retirement Housing Foundation, Ornelas divides her time between the Colonia Jess Lopez senior building and the Rio Vista Village family building in Boyle Heights. Both buildings follow the U.S. Department of Housing and Urban Development (HUD) standards, and residents must qualify as low-income, Ornelas said.
In the Rio Vista Village building, two-to-four bedroom apartments house multi-generational families, 98 percent of whom are Hispanic and Spanish-speaking by Ornelas's estimate. She said this includes 75 to 80 children under the age of 18. In the Colonia Jess Lopez building, Ornelas estimates that 75 percent of seniors identify as Hispanic and Spanish-speaking, while roughly 25 percent identify as Asian or Pacific Islander.
Amid industrial factories and companies, the two buildings stand one block from Sears Tower and half a block from the bridge connecting Boyle Heights with Downtown L.A. While the area is beginning to see signs of gentrification—the arrival of Weird Wave Coffee sparked immediate protests in June—the neighborhood surrounding Retirement Housing Foundation hasn't changed much over time.
Like the rest of Los Angeles, Ornelas said the buildings have seen cases rise in recent months. She attributes this trend to both an increase in testing available to residents and the rise in positivity rates among the region's general population.
As of January 22, 2021, the Los Angeles County of Public Health reported 15,704 cases and 189 deaths in Boyle Heights, relative to a total of 1,009,493 laboratory confirmed cases and 14,364 deaths in L.A. County as a whole. Hispanic and Latino populations have experienced a disproportionate number of cases, making up 473,486 of L.A. County's total.
Much like the Retirement Housing Foundation building demographics, 63 percent of the Boyle Heights population identifies as Hispanic, and 72 percent are Spanish-speaking, according to the U.S. Census Bureau's 2019 American Community Surveys of 1-year and 5-year estimates.
Ornelas has coordinated with Bach Diagnostics to offer on-site testing for residents and caregivers twice per month since August 18, 2020. Because the Retirement Housing Foundation is not a licensed care facility, she said she was initially unable to secure a testing partnership with L.A. County—but she believes at-home testing is crucial for high risk senior populations with limited mobility.
"You're asking someone to go take a bus and then stand in line with 500 other people," she said, referencing a resident's recent experience with testing prior to travel.
Programs adapt to help seniors manage COVID-19 guidelines
With stay-at-home orders instructing L.A. County residents to avoid going out, Ornelas says many seniors have felt a diminished sense of freedom. For the first few months of the pandemic, the Retirement Housing Foundation buildings had to cut off programming.
To maintain connection with residents, Ornelas began doing telephone wellness checks in March to let them know she was there for them even if she couldn't see them in the office. She provided updates through monthly newsletters and fliers to communicate key information about COVID-19 protocol and provide reassurance.
When it became clear the pandemic would continue for much longer, Ornelas began to reimagine programs.
"I collaborated with the Mexican-American Opportunity foundation to come up with ways that we could do health and wellness workshops over the phone through conference calls," she said. "I was surprised at how many did want to still participate because it gave them an outlet; it gave them something to do."
The six-week exercise program, in which Mirna Cortez participated, concluded during November and ran twice a week for residents who could either join over Zoom or in small, physically distanced groups. Upon completion, Ornelas said participants received a certificate that brought them a sense of pride while helping to reduce depression and anxiety.
"Even though it was a physical exercise program, it really boosted their emotional health because they were able to see their fellow residents and friends," Ornelas said.
Virtual forms of connection remain a challenge for many, however. Neither building has WiFi for all residents, according to Ornelas. She identified the digital divide as a primary area in need of support—many seniors either do not have access to technological devices or do not have the skills to use them independently.
While Ornelas has found accommodating strategies, she says re-certifications for government programs are all virtual or have saturated phone lines that can be difficult to navigate for seniors who do not speak English.
"There's no in-person appointments for Social Security," she said. "It would be nice for them to have a computer they could use to set up their accounts, update their information, and provide the information that managers need to recertify them so that their subsidized housing and rent can continue."
Many seniors require her assistance to apply for programs online, so she guides them over the phone or with physical distance—but she's seen online barriers negatively impact residents' mental health.
"If seniors qualify but they can't apply themselves, then they miss out on those resources, and they might feel left out," she said.
Department of Aging doubles meal services to address food insecurity
The Retirement Housing Foundation is not the only resource assisting low-income seniors in Boyle Heights.
When California Governor Gavin Newsom issued a stay-at-home order on March 19, 2020, Laura Trejo had to move at lightning speed. As general manager for the Los Angeles Department of Aging, Trejo helps organize the department's meal service program. Her mobilization could not wait.
"You eat three meals a day, every day," Trejo said.
With congregate dining centers closed, Trejo saw a surge in clients in need of home delivery. "Older adults that otherwise would have been managing well without our help began to call us and ask for assistance," she said.
Trejo estimates that her department provided lunch to 4,500 seniors in January 2020, with about half coming to the 80 congregate dining centers five days per week. The remaining 2,500, who were frail and homebound, received home-delivered meals.
In March 2020, that number doubled.
"We were getting somewhere around 4,000 calls a day from seniors in the community requesting assistance," Trejo said.
She observed that many of these calls were related to food insecurity, so her department committed to serving two meals per day. Transportation vehicles became food delivery vehicles, and Trejo coordinated program transitions with a sister department in L.A. County to minimize confusion among seniors and their families.
The Department of Aging's meal program has brought a key source of relief to residents in buildings like Retirement Housing Foundation's Rio Vista Village, where families may have lost jobs or hours and are awaiting delayed unemployment income.
Trejo emphasized the connection between food security and mental health, stating, "Anything that affects your physical body affects your mental status. I can tell you, as a gerontologist, my concern is always that if somebody isn't well hydrated and well nourished, we may see signs of mental deterioration that may be misunderstood."
In addition to nutrition programs, Trejo is currently prioritizing efforts to minimize the digital divide for seniors. By collaborating with partners, she hopes to address long-term issues of connectivity.
Trejo understands that no singular device will work for all clients, so she is taking time to understand diverse needs and offer coaching for seniors.
"People have smartphones, that's not the problem," she said. "The problem is they don't know how to use them."
Most of all, she wants to create programs that will last far beyond a few months from now. "We build for sustainability and for improving our systems of care," Trejo said.
Mexican-American Opportunity Foundation offers insight to community needs
Adapting to unique needs not only requires factoring for an individual's age, but it also means accounting for different income levels, language proficiencies and demographics.
Because Los Angeles is so diverse, Trejo says the Department of Aging could never understand the exact needs of all of the communities they work with.
"That's why we work with mission-driven organizations," she said. "They are on the ground every day, working with communities and understand their needs better than we could ever hope to."
Like Michelle Ornelas, Trejo also collaborates with the Mexican-American Opportunity Foundation (MAOF) for her work in Boyle Heights. A community-based organization, MAOF offers an Information and Assistance program for the entire City of Los Angeles as well as nutrition, transportation and case management programs to Boyle Heights area residents.
Elizabeth Jimenez, the Senior Services Coordinator at MAOF, works with a variety of partners to serve seniors and their families, but the pandemic has turned her work upside down.
"It's a new case, or a new challenge, for our seniors every single day," she said.
Jimenez coordinates with the Department of Aging to serve 3,000 meals—now primarily frozen—per week and provide training for social workers.
Like Trejo, she also observed an increase in isolation among clients who used to socialize at meal centers. When drivers make deliveries, they call to check in with seniors who may not have any family or speak to others regularly.
Jimenez stressed that the pandemic has not only resulted in psychological and physical impacts, but also financial ones.
In the Boyle Heights area, where MAOF primarily works, the median household income is $46,691, and 28.6 percent of people live below the federal line, according to the U.S. Census Bureau's 2019 American Community Surveys of 1-year and 5-year estimates. Specifically, the poverty rate in the population of seniors (ages 65 and over) is 31 percent—more than double the average 10 percent in the state of California.
By conducting surveys, MAOF found that many seniors were not prepared to participate in programs virtually, and they still have not figured out how to run their evidence-based programs.
"I really think that we were not prepared for something like this to happen to provide the services to seniors that they're entitled to," Jimenez said.
To address loneliness and social isolation, "you can't expect that one solution is going to work for everyone"
Dr. Carla Perissinotto, Associate Chief for Geriatrics Clinical Programs at UCSF, expanded on strategies for addressing unique senior needs during the pandemic. While many programs immediately moved to virtual platforms, she observed a lack of research on safe alternatives to technology, particularly for seniors who have disabilities or sensory difficulties.
"Having people be devoid of any contact is not a good thing. We are seeing in nursing homes, people's physical and mental health decline," she said.
Dr. Perissinotto, who has researched loneliness and its effects in older adults for over 10 years, emphasized the increase in loneliness and social isolation in older adults since the start of the pandemic. While the two conditions are related, she highlighted their key differentiations.
"Isolation is really about the number of relationships and the number of people we may be seeing," she said. "Loneliness in contrast is how that makes us feel."
Like Trejo, Dr. Perissinotto underscored the importance of finding a variety of programs that work for different types of people. For instance, seniors who express themselves through the arts might find community through the Foundation for Art and Healing's UnLonely Project—but that's not going to work for everyone.
A person's sense of purpose can often determine loneliness, and Dr. Perissinotto highlighted the resilience she has observed in many older communities. Sometimes this comes through intergenerational relationships, such as between younger residents at the Rio Vista family building in Boyle Heights who wrote holiday cards to seniors at the Colonia Jess Lopez building. When relationships are bidirectional, Dr. Perissinotto said, they can help provide a sense of purpose.
"Where things don't work is because we still live in an incredibly ageist country where we don't value older adults. Depending on the family structure and make-up, that's going to really impact whether someone feels connected or not—whether they're being valued in their own family," she added.
In order to systematically address loneliness and isolation in older adults, Dr. Perissinotto says proactive outreach from healthcare providers is key. In particular, she identified "a huge evidence gap" in research among communities of color, likely leading to a greater risk of loneliness.
At the Retirement Housing Foundation, Mirna Cortez relies on Social Services Coordinator Michelle Ornelas to help her fill out forms, access meal deliveries and find entertaining pastimes.
According to Cortez, Ornelas—who is "number one with everyone"—does "everything possible to ensure the building stays calm."
But not everyone in Boyle Heights has access to a coordinator like Ornelas, who agreed that more government outreach is crucial to minimizing the virus's spread. At nearby housing complexes without HUD funding, residents don't have access to a coordinator to provide critical information, Ornelas said. And when community members ride the bus together or go to the grocery store, one individual's actions can impact many residents if they aren't well informed.
As COVID-19 rates continue to surge in L.A. County, Ornelas urged community members to think about seniors who live alone and who likely would not survive the virus.
"When you go to the store, when you go to the gas station, when you ride the bus and when you're at work, your actions can help save lives," Ornelas said.
[Editor's note: A quote by Dr. Carla Perissinotto was corrected on January 26, 2021, to clarify "a huge evidence gap" in research among communities of color.]