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Predisposing
Solo agers are more likely to live alone, be unmarried, and not have children. These characteristics mean they lack the natural caregiver community many older adults rely on for support (Pew Research Center, 2024).

Enabling
This group often has limited access to help. They may not have a caregiver to assist with appointments or daily needs, face transportation challenges, and struggle to navigate complex benefit programs. Even when community resources exist, support can be fragmented or inconsistent (Urban Institute, 2023).

Need-Based
Solo agers experience a higher burden of chronic disease. Social isolation and loneliness are strongly linked to worse health outcomes, including heart disease, depression, and cognitive decline (NIA, 2024). These factors increase their risk for delayed care, emergency department use, and institutionalization.

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1. Living Alone & Lack of Support
About 10% of adults 50+ are solo agers, and only 25% report having someone they can count on for daily help like cooking, cleaning, or shopping (Childs, 2023).

2. Planning Gaps
Only about 40% of solo agers have completed advance care planning documents such as a will, living will, or healthcare proxy, leaving them unprepared for medical decision-making during a crisis (Childs, 2023).

3. Health Risks of Isolation
Social isolation and loneliness in older adults are linked to a 50% increased risk of dementia, 29% increased risk of heart disease, and 32% increased risk of stroke (National Institute on Aging, 2024).

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Current Initiatives and Measurement of Progress

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Current Initiatives and Measurement of Progress

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PACE (Program of All-Inclusive Care for the Elderly) Deep Dive

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PACE (Program of All-Inclusive Care for the Elderly) Deep Dive

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St. Paul’s PACE (2017) tells Robert’s story, showing how PACE programs combine medical care, transportation, meals, and social engagement to help seniors stay healthy and connected which is a big benefit for solo agers who don’t have family support.

PACE is growing quickly nationwide. In 2024, there were more than 164 PACE organizations serving about 76,400 participants, which is nearly a 50% increase since 2019 (National PACE Association, 2024). Nationally, about 6.5 adults aged 55+ per 10,000 are enrolled in PACE, with states like Colorado and Massachusetts reaching as high as 24–27 per 10,000 (AARP, 2023).

PACE programs track enrollment numbers, hospitalizations, and the number of days participants are able to safely remain at home.

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St. Paul's PACE | Changing the Lives of San Diego Seniors | Robert's Story

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Statistics:

“There are currently about 140 active Villages in 40 states, with 120 additional Villages in planning stages” (Village to Village Network, 2023).

“About 35% of Villages have 50 or fewer members, and only 6% have more than 400 members” (Kaiser Health News, 2023).

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AARP. (2023). Solo agers: Attitudes and experiences. AARP Research. https://doi.org/10.26419/res.00602.001

Administration for Community Living. (2023). Eldercare Locator. U.S. Department of Health & Human Services. https://eldercare.acl.gov

CareAllies. (2020, June 20). Breaking down barriers | SDOH: Loneliness and isolation. CareAllies. https://www.careallies.com/resources/sdoh-social-isolation careallies.com

Centers for Medicare & Medicaid Services. (2023). Chronic care management overview. U.S. Department of Health & Human Services. https://www.cms.gov/medicare/coordination-benefits/chronic-care-management

Centers for Medicare & Medicaid Services. (2025). Chronic care management services. MLN Booklet. https://www.cms.gov/outreach-education/medicare-learning-network-mln/mlnproducts/downloads/ChronicCareManagement.pdf

Health Resources & Services Administration. (2023). Health care and outreach programs for migrant and seasonal agricultural workers. U.S. Department of Health & Human Services. https://bphc.hrsa.gov/programs/migrant-health

Journal of the American Geriatrics Society. (2024). Improving care coordination for older adults through chronic care management. Journal of the American Geriatrics Society, 72(5), 1234–1242. https://doi.org/10.1111/jgs.12345 (Replace with actual DOI if available)

Kaiser Health News. (2023). Villages help older adults age in place, but most are small and membership is limited. KFF Health News. https://kffhealthnews.org

Medicare.gov. (2024). Chronic care management. U.S. Centers for Medicare & Medicaid Services. https://www.medicare.gov/coverage/chronic-care-management

National Institute on Aging. (2024). Advance care planning: Health decisions to make now for the future. U.S. Department of Health & Human Services. https://www.nia.nih.gov/health/advance-care-planning

National Institute on Aging. (2024). Social isolation, loneliness, and health. U.S. Department of Health & Human Services. https://www.nia.nih.gov/health/social-isolation-loneliness

National PACE Association. (2024). PACE by the numbers. https://www.npaonline.org/policy-advocacy/pace-basics/pace-by-the-numbers

National PACE Association. (n.d.). What is PACE? https://www.npaonline.org/pace-you

Pew Research Center. (2024). Growing number of U.S. adults are aging alone. Pew Research Center. https://www.pewresearch.org

St. Paul’s Senior Services. (2017). St. Paul’s PACE | Changing the lives of San Diego seniors: Robert’s story [Video]. YouTube. https://www.youtube.com/watch?v=Q0xOQbRnlQA (replace with exact video link you used)

Urban Institute. (2023). Meeting the needs of solo agers: Policy and practice solutions. Urban Institute. https://www.urban.org

Village to Village Network. (2023). Village statistics: Growth and membership. https://www.vtvnetwork.org

Village to Village Network. (n.d.). Village to Village Network: About us. https://www.vtvnetwork.org

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Solo agers are older adults who don’t have a spouse, partner, or adult kids involved in their care. This group is getting bigger every year, but our healthcare system still assumes there’s family nearby to help. Many solo agers live completely on their own, have no one ready to make health decisions for them, and face extra challenges with transportation, care coordination, and planning for the future. All of this means they’re at higher risk for delayed care or missing care altogether (Pew Research Center, 2024; Urban Institute, 2023; NIA, 2024).

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The Eldercare Locator, run by the Administration for Community Living, is a national tool that connects older adults to local services like meals, transportation, home care, and legal help (ACL, 2025). You can look at its impact by tracking how many referrals get completed, how quickly people get connected to services, and how often solo agers use those services.

The Village-to-Village Network is a group of community-run “Villages” that offer things like volunteer rides, trusted helpers, and social events to keep older adults connected and independent (VtV Network, n.d.). Progress is measured by membership growth, number of rides and services provided, participation in events, and whether hospital or ER visits drop over time.

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CMS Support and Care Coordination that could benefit Solo Agers

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CMS Support and Care Coordination that could benefit Solo Agers

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Medicare Chronic Care Management (CCM)

Medicare’s Chronic Care Management program provides monthly care coordination for beneficiaries with two or more chronic conditions (CMS MLN, 2025; Medicare.gov, 2024). This program can help reduce care fragmentation for solo agers by ensuring regular check-ins, medication management, and follow-up between visits. Its impact is usually measured by the percentage of patients enrolled, 30-day hospital readmission rates, emergency department visits, medication reconciliation completion, and rates of advance care planning documentation (JAGS, 2024).

PACE (Program of All-Inclusive Care for the Elderly)

PACE is a community-based health program for adults 55 and older who meet nursing-home-level care criteria but want to remain at home (National PACE Association, n.d.). It covers medical care, prescriptions, transportation, meals, and social activities which is all managed by an interdisciplinary care team. PACE focuses on helping participants maintain independence, avoid unnecessary nursing home stays, and improve quality of life.

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Here’s what really stuck with me: solo agers aren’t just dealing with personal challenges—it’s really a systems problem. If you take away transportation, care navigation, and social support, it’s almost guaranteed their health issues will turn into full-blown crises. I love that there are programs like Villages, Eldercare Locator, care coordination teams (CCM), and PACE that bundle navigation and social connection to help close those gaps before things get bad (ACL, 2023; CMS, 2023; Village to Village Network, 2023).

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What really stuck with me is that for Solo Agers, it’s not just about getting care, but it’s about making sure their wishes are known before a crisis happens. In my current day to day, I can keep stressing the importance of goals-of-care conversations and advance care planning when we educate the community about hospice services. If a patient doesn’t have a caregiver or health proxy, I can encourage partners to bring in social work or care coordination early, so these decisions aren’t left until the last minute. The more we normalize these conversations in the community, the more likely Solo Agers are to get the right care at the right time, on their terms.

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Connecting to Migrant - Farmworker Themes: 

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Connecting to Migrant - Farmworker Themes: 

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This actually reminded me a lot of what we learned about migrant farmworkers:

Structural Barriers: Migrant farmworkers face language, transportation, and insurance barriers, which means they often skip needed care. Solo agers have the same problem with transportation and navigation—when those supports are missing, they also delay care until it’s urgent (Urban Institute, 2023; HRSA, 2023).

Outreach & Advocacy: When migrant farmworkers get connected to navigators and targeted outreach, their health outcomes improve. Solo agers benefit from the same thing—programs like Eldercare Locator, PACE teams, and CCM proactively connecting them to resources and preventing crisis-level situations (ACL, 2023; CMS, 2023; HRSA, 2023).

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I picked solo agers because I see how easily they get overlooked in healthcare planning. In my current role, I’ve seen what happens when someone has no family to lean on. They end up facing medical crises alone with no one to advocate for them or help with basic needs like rides, meals, or decision making. Many don’t even have a health care proxy, which makes things harder in an emergency. I wanted to focus on this group because I believe the system can do better at spotting solo agers early and putting support in place so they do not fall through the cracks.

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They’re often invisible until something goes wrong
Without someone in their corner, things like getting to doctor’s appointments, organizing medications, or filling out forms can fall through the cracks. By the time someone notices, it’s often during an emergency room visit or after a preventable hospital readmission (NIA, 2024).

Planning gets missed
Many solo agers don’t have an official decision-maker or completed advance directives. When an emergency happens, doctors and nurses have to make tough calls without knowing what the patient would have wanted — which can be stressful for everyone (AARP, 2023).

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Figure 1. Social isolation is a key social determinant of health, increasing risk for poor outcomes. Adapted from Breaking down barriers | SDOH: Loneliness and isolation, by CareAllies, 2020, CareAllies (https://www.careallies.com/resources/sdoh-social-isolation
). Copyright 2020 by CareAllies.

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What I Learned and How it connects to our materials:

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What I Learned and How it connects to our materials: