Archive for the ‘Senior Housing & Care’ Category

UnSenior “Seniors Housing”

Earlier this month I toured The Stories at Congressional Plaza, a new type of “seniors housing” project designed to appeal to seniors as well as those of other ages looking for a high-tech, high-service environment in an urban mixed use setting.  The Stories opened in February 2016 and is a joint effort of Federal Realty Investment Trust and Ryan Frederick’s Smart Living 360.

Federal Realty is a publicly traded REIT (NYSE: FRT) that specializes in the ownership, operation, and redevelopment of high quality retail real estate in the country’s best markets and is increasingly developing mixed-use projects in connection with its retail holdings.   Ryan Frederick has long been known as one of the leading thinkers on the future of seniors housing through his Point Forward Solutions consulting company.   Ryan has now created a new company, Smart Living 360, to work with a retail/mixed use developer, rather than a seniors housing company or health care REIT, to bring us his vision of the future of “seniors housing” in a property designed to appeal to seniors but open to those of all ages.

The Stories is a new 48 units apartment building located at 1628 E. Jefferson Street in Rockville, Maryland.   It is part of Federal Realty’s Congressional Plaza redevelopment that includes a high-end shopping center, Federal’s corporate headquarters and an existing 150+/- unit apartment building with structured parking (The Crest), now about 10 years old.   The Stories was developed on a site long designated for residential use as phase 2 of the Crest. According to Ryan, Federal became interested in consciously designing The Stories to appeal to the seniors market because they wanted a way to differentiate the projection from other high-end rental projects in the same area of the Rockville Pike, northwest of Washington and Bethesda.

The Stories is designed to appeal to the baby boomer market, now passing age 67, and other seniors with a “younger” outlook, unlikely to consider independent or assisted living or even a continuing care retirement community (CCRC).   This market is large and rapidly growing and not well served by well served by conventional seniors housing. While those 75 and up are considered part of the senior housing markets in many market studies, the average entrance age for most dedicated senior housing communities is now closer to 85 than 75 (See Slow 80+ Pop Growth, Elevated Construction Spark Concern For Seniors Housing on this blog – http://03c242c.netsolhost.com/WordPress/?p=209.

Ryan and Smart Living 360’s vision for The Stories is derived from a view of what “younger” seniors want in a living environment to enhance their wellbeing and tries to anticipate the growing role of technology for enhancing seniors’ lifestyle and delivering the services they want and need.   It is also purposefully designed to be flexible so it can adapt to the needs of its target market as they are discovered over time.

To understand what Federal and Smart Living 360 have created at The Stories, you need to think outside the traditional seniors housing box regarding design, services and technology.

Physically, The Stories is a attractive 5-story modern apartment community located in high-income, high-wealth, high-education zip code with a unit mix favoring larger 2 and 3 bedroom units (75% 2 bdrms) over one level of structured parking.   With rents from $2,500 to $4,000, The Stories is priced at about half the cost per square foot of traditional IL properties in its market.  But unlike conventional IL properties, The Stories does not bundle food service and activity programs into its rent.   It is part of a mixed-use project including retail, office and other residential uses in a nice residential area a block off a heavily travel arterial street, the Rockville Pike, MD 355.   The property faces other residential uses and fronts on a relatively quiet suburban street.

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Units within The Stories look like high-end non-age-targeted residential rental units with small balconies that are designed with largely invisible accommodations for an aging senior market – wider doorways and master baths able to accommodate a wheel chair with higher toilets, easy entry showers, modest grab bars in the bath with studs behind the wall to allow more to be installed, roll out lower shelves in cabinets, electrical outlets further up on the wall, etc.   These are accessible units that intentionally look like conventional units.

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Common areas include a large fitness room with some specialized equipment for seniors that could also be used by personal trainers or rehab therapists, a central lounge with a refrigerator and cooking equipment and a self-serve coffee bar.  
There is a small conference room that is designed so that it can also be used for a visit by a health professional or for telemedicine care.   The entire building is pre-wired for high speed Verizon Fios internet with pre-installed routers; and service providers are available to install Sonos wireless speaker systems and other electronic amenities in the units.   The electronics designed into the building are intended to accommodate increased use of patient self-monitoring and wellness devices that Ryan believes will become increasingly prevalent, sophisticated and integrated over time.

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The building offers a secure electronic entry system, with an enhanced concierge called a Lifestyle Ambassador (services described below) manning the front desk during the day. The building is monitored in the evening by management personnel from the larger Crest Apartment building that is located at the other end of the block, across a parking lot from The Stories.   The number and length of coverage by on-site personnel is partly limited by the buildings relatively small size, only 48 units.

What really sets The Stories apart as a community that will appeal to seniors is its use of a Lifestyle Ambassador, in this case a hotel industry trained and certified concierge cross-trained in seniors housing design and services.   The role of the Lifestyle Ambassador is threefold – 1. Help residents connect with one another and with the outside community, 2. Provide access to any needed services, and 3. Simplify resident’s lives by taking care of pets and plants while residents are traveling and providing other services.   Smart Living 360 makes use of many off-the-shelf on-demand services, has prearranged for a wide range of additional services to be available to residents of The Stories and will provide referrals to providers, including:

  • Transportation
  • Pharmacy
  • Physicians
  • Food Delivery
  • Financial Advisors
  • Case Managers
  • Home Healthcare
  • Personal Trainers
  • Tech Services

The goal at The Stories is to offer attractive housing, location and services to enhance the well being of baby boomers and other “younger”, generally healthy seniors without the stigma of a traditional seniors housing community with a large percentage of very old, frail people; and to do it in a flexible way that allows it residents to order in any services they may need and to adapt to rapidly evolving technology for medical monitoring and wellness.

Smart Living 360 hopes to monitor residents of The Stories over time to see if the building’s design and the flexible services it offers will enhance residents’ well being compared to those living in other residential settings. This will be done using the Gallup-Healthways Well-Being Index that measures five factors:

  1. Purpose – Liking what you do each day and being motivated to achieve goals
  2. Social – Having supportive relationships in your life
  3. Financial – Managing your economic life to reduce stress and increase security
  4. Community – Liking where you live and having pride in your community
  5. Physical – Having good health and enough energy to get things done.

What is interesting to me about Smart Living 360’s approach compared to a traditional senior housing facility is that Smart Living 360’s Life Style Ambassador begins with the residents’ wishes and customizes activities and services the resident desires while a traditional senior housing facility has a menu of services into which it tries to fit a resident. I see the Smart Living 360 approach as more resident centric, more personalized and more adaptable over time.

The Stories occupies an interesting place somewhere between non-age-restricted market rate apartments and conventional seniors housing.   Interestingly, the project was voluntarily described as 55+ housing in pre-opening marketing material but the developers have now decided to market its advantages for seniors but without the age restriction, which they believe may be a turn-off for their primary but not only target market.   Of the first several residents moving in, two are seniors and one is age 29 but liked the amenities.

It remains to be seen whether The Stories will be successful in attracting baby boomers and other seniors with a “younger” outlook and how Ryan Frederick’s vision of meeting residents’ needs and increased use of electronic devices to monitor and enhance health and wellness will come to pass.   But I believe, even at this stage, The Stories has some interesting lessons for seniors housing and multi-family developer/operators and institutional real estate investors.   These include:

  1. Non-age restricted housing and un-senior “seniors housing”, as I categorize the Stories, may be more appealing to under 80s seniors, and even those over 80 in good health with younger outlook, than more conventional seniors housing projects.   For a significant portion of the senior population today and I believe for even a larger portion of the baby boomers, living in mixed aged neighborhoods or even in mixed age buildings like The Stories may be preferable to living in a senior ghetto or in an isolated age-restricted community.
  2. We have already seen obsolescence in seniors housing communities, such as IL projects without sufficient provisions for handicapped residents, IL and CCRC projects without AL and memory care units, AL communities with insufficient common space for gyms or rehab care and IL and AL buildings with too many small units.   This history suggests that building flexible design into seniors housing communities, which The Stories has very deliberately tried to do, may be an advantage for the community over time.
  3. Seniors housing located in mixed use projects or higher density urban areas, where services and amenities are close-by, while often more difficult and more expensive to develop than stand-alone conventional IL or AL communities, would seem to offer a lot of appeal for the baby boomer age cohort and other active seniors.
  4. In an age of on-demand services, such as Uber and Foodler, planning seniors housing around services delivered by outside vendors may prove both cost effective and better able to meet seniors desires and needs than the service packages typically available in seniors housing communities.
  5. Seniors, particularly the baby boomer age cohort, are increasingly tech-savvy and should be able to adapt to electronic delivery of health and wellness services, as well as other on-demand services, and may see projects designed to accommodate more high-tech amenities as more appealing than conventional care models.
  6. The resident centric and holistic approach to meeting resident’s needs built into the Lifestyle Ambassador approach that incorporates both social and care needs, seems to offer some advantages over the way conventional seniors housing services are organized with responsibility fragmented between healthcare, activities, dining and caregiving personnel, each of whom may only see themselves responsible for a slice of a senior’s needs.   While the staff in any well managed seniors housing project should get to know the “whole resident”, making resident on-demand centric services the organizing principal of your care delivery system appears to offer some advantages and a have a better chance of assuring a residents need are met.

 

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Confessions of a Recent CCRC Mover

The question I most encounter when speaking with friends, family members and acquaintances about seniors housing is: How do you get a reluctant family member of advanced age living alone to agree to move to seniors housing? It doesn’t seem to matter if the family member is 79 or 99, there is still a strong reluctance on the part of many of today’s seniors to move to any type of seniors housing despite objective information that such a move improves socialization, nutrition and overall health and wellness, and may increase longevity.

While “How to get a reluctant family member to move?” may be the quintessential question to which families would like an answer, I find very little useful information on the web and from seniors housing organizations on how to address this question.   In order to seek an answer for myself and for those who ask me about it, I interviewed a 97 year-old friend and former neighbor who made the decision to move to a CCRC about 18 months ago.   I wanted to understand her decision to move, what finally convinced her to move and how her experience has been since moving to her CCRC.   For the purpose of this blog, we will call her Ms. F.

Ms. F is a remarkable person in many ways but I believe her decision to move to seniors housing and her experience after she arrived are still illustrative for others.   As I indicated, Ms. F is 97 years old. She moved from the large, single family home where she raised her family to a condominium in 1979, when she was only 60, partly due the health of her husband who died seven years later.     She continued to live in a full-service elevator-served condominium with a wide-range of resident ages until 2014, when she made the move to a CCRC. In her condo, Ms. F had occasional cleaning help but lived independently and drove. When living at her condo, Ms. F attended a Pilates class once a week, played 9-holes of golf regularly through 2013 and had an active social and cultural life. Ms. F is college educated, cultured, very well dressed and had enough wealth so that all housing and care options were available to her.

The discussion of a move to seniors housing started with Ms. F’s children, the oldest of whom is 74, about three years before Ms. F’s decision to move.   Her children, who live in another city at least six month of the year, were concerned about her living on her own and continuing to drive.   Ms. F indicated she finally agreed to move to a CCRC to make her children happy and because after a bout of pneumonia in the winter of 2013 she did not bounce back completely to her previous stamina.   The discussions for her to move also began after her significant-other, with whom she had a very long-term relationship, died.

Ms. F’s reluctance to move to a CCRC or another type of seniors housing primarily arose from the fact that moving to such a facility would require her to “admit she was old”, something she had never really done despite being 95 at the time of her move.   Ms. F, like many in the current generation of Roaring Twenties Babies in their 80s and 90s, also saw moving to seniors housing in a negative light because it indicated to her that she could no longer live on her own and she saw it as giving up some of her independence.

One of the key lessons I took from Ms. F’s experience is that us Baby Boomers, the children of today’s 80 and 90 year-olds, tend to see their parents as very old, frail people in need of care while many seniors do not view themselves as old and cherish their independence. This suggests that any conversation about a move to seniors housing should not begin with the senior’s frailties but how such a move could enhance and prolong independence.   It would be better for us Boomers to approach these discussions thinking about the attributes of senior housing that we would find attractive because a seniors’ view of him or her self, if still healthy and not cognitively impaired, sees 80 or even 90 as the new 60.

The other clear lesson from Ms. F’s experience, and that of other seniors and their families that I have observed, is that the decision to move to seniors housing, if made voluntarily, is often a prolonged process that can stretch to a year or more. It is also important to realize that senior housing facilities offer a broad range of housing and lifestyle choices and may involve trade-offs between housing and lifestyle amenities, something that seniors and, in many cases, their children may not understand.   Visits and short-term stays, which many facilities offer, can help a senior and their families get to know a facility well before committing to move.

It is also worth noting that a mixed-age full-service condominium served Ms. F very well as a housing choice for 35 years, from the time she was 60 until she was 95.    With the growing availability of smart-phone accessed transportation, grocery and food delivery and home care services, it is important for the seniors housing industry to realize that well-designed, mixed-age apartments and condominiums can be a very viable option for many seniors and that seniors may prefer such options that don’t require them to “admit they are old”.

Ms. F and her family did not undertake an exhaustive search of senior housing facilities because they were looking for something high-end and were familiar with many of the choices because Ms. F, at 95, knew people living at a number of the likely choices.   The facility Ms. F chose was relatively close to her condominium, offered extensive educational and cultural programming, which appealed to her, and had friendly and welcoming staff.   The downside of the community Ms. F chose was that it dates from 1984 and did not offer some of the amenities within its units and common areas of other facilities that were newer or which had undergone extensive renovations.   Ms. F looked at a number of different units before she found one on an upper floor that had enough natural light to make it appealing. Ms. F moved from a modern three-bedroom, two-bath condo with larger windows and lots of light to an oversized one-bedroom, one-bath senior housing unit.   She believes the size of the unit is fine but would prefer a larger bath and a separate powder room for when she has quests.     Ms. F’s focus on a welcoming staff, light in units and other factors dovetail well with industry studies of independent living customer satisfaction.   (See my blog on Finding Happiness In Seniors Housing http://03c242c.netsolhost.com/WordPress/2015/08/20/finding-happiness-in-senior-housing/).

It is worth noting that the CCRC to which Ms. F moved is about to undertake a major expansion and renovation that will add larger independent living apartments in response to demand, add a memory care section and renovate public areas to update the look and add casual café-style dining in addition to the formal dining room.

Ms. F’s transition to a CCRC has been relatively easy for her. She only knew one person well at the CCRC when she moved but Ms. F was able to make friends quickly.  Today Ms. F gets around without a walker but does worry about falling and is careful when she walks. Ms. F was still driving at the time she moved to a CCRC but not long after she arrived she had a minor traffic accident and decided to give up driving.   However, using the CCRCs and private transportation services, Ms. F still gets to her Pilates class once a week and to cultural events (She will be traveling to New York soon to see Hamilton) and she has added personal fitness training at the CCRC and is attending many of the programs that the facility offers, including a current lecture series on the Supreme Court planned before Justice Scalia’s death.

I believe Ms. F’s attitude toward her move to a CCRC also eased her transition.   Rather than focus on the space she was giving up and the things she was leaving behind, Ms. F chose to view her move as an opportunity.   She got help from a decorator to design and furnish her new home, bought some new things and recovered some of the furniture she chose to move from her condominium.   So she made it a new beginning rather than a move down.

Ms. F is very positive on her CCRC now that she has moved and agrees that she may have benefitted from moving sooner. But Ms. F doubts she could have made the decision to move until she started to notice herself slowing down following her pneumonia, had lost her significant other and was ready to admit she was old.  One of the benefits she sees at the CCRC is knowing other couples that are older than her but still mentally active and able to get around.   Her close friends at the facility include a couple that are 102 and, while he uses a walker, are still in very good health and very alert.

Top on Ms. F’s list of what makes her CCRC a good place to live are:

  • Activities/Programming – special events (St. Patrick’s Day and Easter Dinners for example), movies including first run movies such as Spotlight and Brooklyn, Lectures that cost residents $25 and outsiders $125, religious services, entertainment every Wednesday and other events like a forum for local mayoral candidates.
  • Volunteer Opportunities
  • In-House Exercise Programs and therapy
  • Housekeeping Services that include weekly linen service, biweekly cleaning and an annual complete unit cleaning as part of the base rate and PAL service that for $21 per hour provide additional light cleaning, laundry and making the bed.
  • Friendly Staff who know you by name and friendly residents. Many of the staff are African American high school students interested in careers in healthcare or food service/hospitality industry that the facility trains.
  • Someone Looking Out For You – It is comforting knowing there is always someone there for you. The facility has an electronic monitoring system that can tell if you are not up moving around your unit by a certain time and uses other checks such as attending meals and taking in your paper to check to be sure you are all right, as well as emergency alert system.
  • A Healthy Future – Ms. F can see that she is not the oldest and certainly healthier than some others.
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Observations from NIC 25th National Conference

The National Investment Center for Seniors Housing and Care (NIC) http://www.nic.org held its 25th National Conference this week at the Gaylord National Harbor, just south of Washington.   I attended the first NIC Conference, which was a much smaller affair at a hotel in Crystal City, also just south of Washington but on the Virginia side of the Potomac.    Having spent much of my career in seniors housing and care as a real estate analyst, stock analyst, investment banker and now occasional consultant, it was very gratifying to see how much the industry has grown and matured in 25 years.

My only official role at the conference was to address the Future Leader’s Council (FLC), which is a carefully selected group that goes through three years of NIC leadership development activities before “graduating”, with a third of the group rotating each year.    I was impressed with the FLC members with whom I interacted and with the thoughtful way NIC is helping talented professionals grow into leadership roles at their organizations and in the industry.

My address to the FLC group was entitled “Back To The Future” and focused on lessons learned about the impacts of overbuilding and higher interest rates in the severe 1999/2000 industry downturn.   Most FLC members were still in primary or secondary school when this downturned occurred.

I would say the overall atmosphere of the industry at NIC’s 25th National Conference was “nervous optimism”.

The nervousness comes from:

  • generally unsettled economic conditions in the U.S. and around the world that could lead to higher interest rates and growing wage pressures on an industry for which labor is 50% or more of costs,
  • recent softness in private-pay senior housing occupancy,
  • a increase in the number of units being developed (particularly assisted living and memory care) and signs of overbuilding in select markets,
  • integration stumbles at the largest and largest publicly traded senior housing operator, Brookdale Senior Living (BKD),
  • some signs of a plateau in senior housing property capitalization rates and pricing,
  • a late summer sell off in healthcare REITs and generally unsettled conditions in the equity and debt markets, which appear to be driving the pause or potentially a backup in cap rate compression.

The optimism comes from:

  • a 15 year rebound in fundamentals from the last major industry downturn,
  • generally outperforming other real estate sectors through the Great Recession,
  • still strong consumer acceptance of newly open properties, particularly in high barrier to entry markets,
  • plentiful availability and still growing interest in the industry from both debt and equity capital providers, if perhaps at higher prices that were seen a year ago,
  • knowing that the industry continues to get closer to the holy grail of  75M + Baby Boomers becoming seniors housing and care customers (although still 10 – 15 years away).

Unless you are concerned about substantial overbuilding in private-pay seniors housing, which most thoughtful insiders are not (there will be some), the recent pullback in both healthcare REIT and operator pricing is making me more interested in investing in publicly traded healthcare REITs and private pay operators but there are few publicly traded operators to buy.    On the care side of seniors housing and care, there has also been a pull back that makes skilled nursing and post acute care company stocks attractive from a valuation standpoint.    Here, however, the slow evolution of a more integrated healthcare delivery system and new value-base purchasing and an uncertain political situation through the next Presidential election may keep a lid on valuations for another year or two.    Either way, it feels like a time to be considering investments in seniors housing and care for the long term investor.   I will leave it to those still working as equity analysts in the space to recommend specific stocks.

There are also signs at the conference that innovations in technology, property location and design are alive and well.  At least two efforts are underway to develop new senior housing properties in Manhattan.   The most interesting new building model I saw at the conference is a mid-rise product located in an urban main street location that looks more like an upscale yuppie rental project or W hotel, with services delivered on demand by the likes of Uber, Amazon Fresh and online home health providers.     This project is being developed by Smart Living 360 and Federal Realty Trust (FRT) in Rockville, MD and is scheduled to open in the Spring of 2016.   See website http://www.thestories.com/ for more information.

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Finding Happiness In Senior Housing

Three things came together to spark this blog:

  • A January 17, 2015 New York Times article entitled “Mean Girls in the Retirement Home” (http://nyti.ms/1KStZ4j),
  • A 2014 study by the American Seniors Housing Association (seniorshousing.org) entitled Unlocking the Mystery Behind Very Satisfied Independent Living Customers – Make Them “Feel at Home” and
  • A dinner conversation with a couple who are friends and former neighbors about choosing among several retirement communities in Boston, where they plan to relocate to be closer to their children.

The New York Times “Mean Girls in the Retirement Home” article documents the presence of cliques in senior housing communities that sometimes make it very difficult for a new resident to fit in.  Some new residents face outright hostility from existing residents who are already part of well established social groups.   It also documents the steps taken by a 97-year-old new resident and her daughter to help the new resident fit in and make friends.

ASHA’s “Feel at Home” study of very satisfied independent living residents also identifies cliques as a problem in established senior housing residents but it goes on to study factors that are most important for making a senior housing resident feel at home and be very satisfied in an independent living community.   The ASHA study is intended to help operators of independent living communities make their residents feel at home and boost satisfaction levels, resident retention and resident referrals, all of which can have a meaningful impact on the bottom line.

Last month, as I spoke with my friends in their late 80s about their move to a senior housing community in a new city, it occurred to me that the New York Times article and, particularly, the ASHA study can provide potential senior housing residents with an excellent list of what will be most important in making them happy in senior housing and a data-driven check list of what to look for as they consider various communities.   This blog attempts to reformulate the ASHA study into a compact guide to happiness in senior housing for potential residents.   My thanks to David Schless, Executive Director of ASHA, for giving me permission to use the study results in this manner.

What’s Most Important For Happiness?

How frequently and how strongly a senior housing resident feels at home accounted for nearly half of the overall satisfaction of senior housing residents in a 2012 ASHA study.   The 2014 study explored what caused independent living residents to “Feel at Home”.   ASHA’s “Feel at Home” study was based on a survey of 6,858 predominantly rental independent living residents in 11 metropolitan areas who completed a 55 question survey.   ProMatura Group, a well-respected survey research firm based in Oxford, MS that specializes in senior housing and care research, conducted the survey, evaluated the survey results and authored the ASHA study.  I want to thank Margaret Wylde Ph.D., CEO of ProMatura Group and her staff since for this blog I have borrowed liberally from the ASHA study, which was the product of their work.​

 

ASHA Feel At Home Graph

Key factors contributing to “Feel at Home” identified in the 2014 ASHA study include satisfaction with private residence (32%), camaraderie with others (31%), sense of control (14%) and staff know them well (5%).  Other items contributing less that 5% of “Feel at Home” included:

  • Number of friends in the community
  • Decorated residence the way they like
  • Know the things they need to know about the community
  • Quality of daily activities and programs
  • Dining program
  • Dining schedules
  • Frequency of seeing friends outside the community
  • Transportation provided by the community

What To Look For When You Visit?

ASHA’s “Feel at Home” study and this blog focus on satisfaction of independent living residents.   Someone moving to independent living is about 85 years old, is moving from their a private residence they have occupied for an average of 19 years, usually a single family home, and is healthy enough to live with minimum outside help with the activities of daily living (See Senior Housing Options above for a more detailed description).   The prospective resident is typically active in making the decision about whether and where to move.

Private Residence – Most senior housing communities are designed to wow you with their façade, grounds and the common areas you see just inside the front door, what marketers call “curb appeal”. While the ASHA study indicates the quality of common areas contributes to resident satisfaction, the study indicates attributes of the private residence are more important to residents feeling at home and being very satisfied.   Key factors in making a private residence satisfying include:

  • Unit size – Just like with Goldilocks, the most satisfying independent living residence was not too big or too small, with 841 sq. ft. on average being “just the right size”.
  • Decor and Storage Space – Being surrounded by familiar things, having a décor that you liked and the ability to store possessions where you can access them were important for overall satisfaction with one’s private residence.
  • Natural Light – In the ASHA surveys more than half of the “I’m Home” customers strongly agreed with the amount of natural light in their residence, so looking for multiple windows that allow for plenty of natural light is a feature prospective residents and their families should consider.
  • View from the Windows in Private Residence – Along with natural light, “I’m Home” customers were likely to have a nice view from the windows in their private residence.   More than half (54%) of “I’m Home” customers strongly agreed they enjoy the view from the windows of their residence.   A view doesn’t have to include beaches, mountains, parks or rivers; a nice view can be as simple as a tree, a small garden area, a fountain, or a bird feeder.

Camaraderie With Others – Camaraderie with others was nearly tied with “satisfaction with private residence” as the most important factor making senior housing residents feel at home and very satisfied.  Other factors, such as having close friends and the number of friends also contributed to residents’ satisfaction.   Gauging how well you or a loved one will fit in at a senior living residence can be difficult to do during a visit. Things you can ask about or do during a visit for how welcoming a community will be include:

  • Warmth of Greetings – Make it a point to notice if you are greeted warmly by staff and other residents.
  • Cliques – Ask staff specifically about the presence of cliques in the building and the specific measures staff takes to address cliques and the off-putting behavior that may be associated with them.
  • Steps To Help New Residents Fit In – A senior housing community cannot impose friendships on new or existing customers, but staff can and should facilitate that eventuality. According to the ASHA study, staff from the very beginning of association with a new customer need to learn who they are, what they like, identify and help them form links with other customers. Items noted in the ASHA study that might help include staff sponsoring house warming coffees for a small group of residents in a new resident’s unit after they settle in and having a mentor from among the existing residents help acclimate newcomers.  You should ask what specific steps each community takes to help new residents fit in.
  • Cultural Fit – Try to assess how you or your love one’s economic and social background compares with that of other residents and how the future resident’s age and physical and mental capacity match up. New residents that are on the slightly younger side, more mentally alert and better dressed may find it easier to fit in according to the New York Times article.
  • Interests – What are your interests and are there any others at the facility that have similar interests or some other connection that might make it easier for you to make one or two friends.
  • Try It Out – You should definitely try the dining and do it in the residents’ dining room not in a private dining room while meeting with the marketing staff.   This will give you an ideal of the quality of the food and how it is served as well as how receptive existing residents are to newcomers. Many senior housing communities also allow for short-term respite stays or give prospects a chance to try out the community.   This may offer a better way to assess your compatibility with a community than a visit or two of a hour or so.   You may also want to visit in the evening to see what staffing and the activity level is like after prime viewing hours.

Sense of Control – Sense of control was about half as important to resident satisfaction and feeling at home than a resident’s unit and camaraderie with other residents but did matter. Factors affecting a sense of control included:

  • Information – Knowing where things are, how things work and what is going on can be important for residents to feel in control.   The orientation and communication process between the building and its staff with residents is worth asking about. Sales counselors should explore the social preferences of prospects and ensure they understand the communal nature of the community. They should discuss group activities, dining, and the many interactions with others that occur during a typical day.
  • Scheduling Flexibility – New residents moving from a private home where they may have few visitors to a senior housing community with scheduled meals and activities and its own daily routine can experience a loss of control   Flexibility on meal times, when to get up and go to bed and options for transportation and activities can contribute to a resident maintaining a sense of control.
  • Options – Not Requirements – Residents should be encouraged to be out of their residences and participating in activities but should feel that have the option to pass on activities that aren’t of interest.

Staff Knowing Residents – How well the staff knows a resident accounted for about 5% of residents feeling at home and being very satisfied.   You should get a sense of staff interaction with residents during a visit and should explicitly ask existing residents if they believe the staff know them well.

Strategies For A Successful Transition and Finding Happiness

To ease the transition and find happiness in a move to a senior housing community, the studies suggest the following:

  • Recognize The Move Will Be Stressful – It is important for a senior moving into a community and their family to recognize that such a move is a major transition and will be challenging and somewhat stressful under the best of circumstances.
  • It Will Take Time To Adjust – Very satisfied residents who “Feel at Home” have an average tenure of four years, versus three years for those that sometimes feel at home and two years for those who don’t feel at home. So the longer a resident lives in a senior housing community, the more likely they are to “Feel at Home”.   Give yourself some time to adjust and stop missing your former home.
  • Identify Some Positives – Despite the magnitude of the change, there are usually real advantages for a senior previously living on their own.   These include: greater social interaction, better nutrition, more physical activity and potential greater freedom of action if you take advantage of community provided transportation and support services.
  • Incorporate Familiar Items – A resident’s own furniture and other familiar and personal items can help make the new residence “Feel At Home”.
  • Visit Often – The quality of visits by family members is important to overall satisfaction and can help ease the transition and the feelings some new residents may have of being isolated in their new surroundings.
  • Get Out and About – Opportunities to visit places and friends outside the community is also an important factor differentiating very satisfied residents.   Excursions with family members or friends, using transportation offered by the community, or Uber or taxi may all be beneficial in easing a transition to a new senior housing community.

 

 

 

 

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Repositioning Older Assisted Living Properties

Background

With NIC-MAP data starting to report an upturn in senior housing development activity, many older senior housing properties are or can soon be expected to face a more competitive market for new residents.    Senior housing, and particularly purpose built assisted living and memory care, are relatively young industries and most early assisted living properties were developed in the mid-1990s.    Nevertheless, early assisted living properties, particularly those that did not receive substantial capital infusions during the recession, are becoming dated in comparison to newly constructed buildings.   As a result, repositioning of older assisted living and memory care properties is likely to become increasingly important for the senior housing industry as more new units are constructed and competition increases.

Because many, but certainly not all, early assisted living and memory care properties are located in very attractive, hard-to-duplicate infill locations, repositioning good 1990s vintage properties may prove a very attractive investment alternative if such properties decline in value because of occupancy declines in a more competitive environment.   In this blog, I focus on repositioning opportunities for the classic Sunrise Mansion property as a proxy for all older assisted living and memory care properties.   I focus on Sunrise properties not because I believe the company has underinvested in their assets relative to other operators but because the Sunrise Mansion is the prototype for almost all of the mid- to late-1990s assisted living and memory care buildings.  As I write this, it has been 3 – 4 years since I toured a Sunrise mansion. So some of my observations may be dated.   However, over the course of my consulting, equity research and investment banking careers I easily toured dozens of Sunrise Mansions and similar vintage properties operated by national companies, regional and local operators.   I had the opportunity over the years to meet with several generations of Sunrise senior and operational management as well as senior and operational management of many other national and regional senior housing operators.   I also have had many informal discussions advising family and friends about senior housing options and getting feedback on their senior housing experiences and was actively engaged with the placement and experiences of my own parents in both assisted living and skilled nursing care.

Sunrise Mansion Pros and Cons

Before providing my thoughts on repositioning Sunrise Mansions and properties of similar vintage, I wanted to list the pros and cons I see for these Sunrise Mansions as a proxy for well located, good quality 1990s vintage assisted living properties:
 

Sunrise chart

Suggestions For Repositioning Sunrise Mansions and Properties Of Similar Vintage

Location – Most locations are very good.  However, some may have become less viable because of changing neighborhood conditions, because some site locations were forced at height of late-1990s development push or because newer competition has come on the market.  You can’t move the buildings but in most cases existing locations work and some existing sites may offer redevelopment or new construction options.

Design – Property sizes range from 75+/- resident capacity to 120+ resident capacity.   While I conceptually agree that residents should be out interacting with other residents and staff, not in their units, some Sunrise and other early assisted living units may be too small for current affluent senior preferences, which I summarize as independent living size apartments with assisted living + level services.   I continue to like pricing flexibility that flexible single/dual occupancy units provide but some may need to be reconfigured into more interesting larger units given demand.

Since, in most cases, buildings are on in-fill sites and cannot be enlarged, the practicality of combining some existing units to increase average room size, reduce total unit count and add some common space elements should be explored.   Given building size, an opportunity may exist to differentiate a Sunrise Mansion type property as the boutique/exclusive/personalized sized provider with somewhat smaller buildings than competitors if the economics will work.  I do not know the economic impact of reducing residents/increasing unit size but believe these options need to be explored and believe that there may be pricing flexibility for more exclusive, more personalized services in smaller buildings.

I believe the basic building design in Sunrise Mansion type properties is excellent but I would add room for a personal trainer and possibly some weight equipment, and perhaps more dedicated space for classes like yoga/palates, more space for a spa (facials/pedicures/massage, etc.) rather than just a beauty shop and perhaps space for a rehab therapy provider, which might be combined with personal trainer space.   If rooms are being enlarged and number of residents reduced, I believe it should be possible to convert a few smaller rooms to the uses noted above.   I believe these changes should appeal to affluent consumers and their children and can be used to offer more personalized care options than three levels of care that have traditionally been used by Sunrise and many other operators.   Personal trainer, yoga classes, extra beauty treatments could all be offered on fee for service or club membership plan.   I believe personalized services like those described above could all be offered in relatively small spaces and still make Sunrise type buildings much more competitive with larger AL and IL properties with services.

I believe space for Internet café within building and a broader look at use of technology for patient interaction with families, staff monitoring, etc. is important.   See my blog on “Technology In Seniors Housing” for a more extensive discussion of how technology can be used to increase resident and family engagement, interaction, mobility and evaluation.   But FaceTime or Skype interaction between residents and families, regular email or video reports to families on the condition of loved ones, computerized links to physicians and other care providers, computerized tools for patient monitoring and stimulation and things like Uber for more flexible transportation services are all things that might reasonably be incorporated into existing senior housing communities.   Some of these require dedicated space and all require trained or specialized staff.

Overall decor, which in early Sunrise properties I remember as being a bit fussy “Laurel Ashley-like” may need to be updated.

The levels of cap ex spending by operator varied, particularly during the recession but I expect basic-cap ex and infrastructure investment will be needed for mid-90s vintage properties to remain competitive as new properties are introduced to the market.

After a fire last year in senior housing facility in Canada, the importance of life safety standards, which I believe is high at Sunrise Mansion properties but not all 1990s vintage properties, should be emphasized.

Services – Service has and will continue to be more important than space for high quality senior care.   Sunrise was a trendsetter in quality and personalized care compared to traditional skilled nursing properties and I believe continues to have a strong commitment to resident independence, dignity and quality care. However, patient wellness and treatment standards for memory care have evolved since the core Sunrise care concepts were developed in the 1990s and I believe a complete review of Sunrise’s memory care service offerings and those of many other AL/memory care operators with an eye to setting a new standard for quality and personal attention is likely needed. Key elements in a revision to services that I see include:

  • A wellness program that provides individualized and integrated exercise, nutrition and mental health services for each resident.   This would incorporate a personal trainer rather than the group exercise programs now seen at Sunrise Mansion and other facilities, even more personalized meal planning and both computer assisted and staff provided mental agility and health services screening and stimulation.   This assumes additional staff on contract or employed with specialized training not now found in Sunrise facilities to the best of my knowledge.
  • More active review of medication management, particularly for memory care residents.   This may require a more active link between Sunrise facilities and healthcare or mental healthcare providers.  I am no expert in this area but believe that some dedicated memory care providers, such as Silverado, are more active in reviewing medications and medication management than most AL operators, are more likely to recommend changes in medication regimens and have more active involvement by attending physicians in reviewing their resident’s medications.  I believe over medication and adverse medication interaction remains a bit issue for seniors and this is an area with AL operators may be able to distinguish their service offerings.
  • A review of the memory care program. My sense is that providers like Silverado, with links to leading healthcare researchers at many of its facilities, have developed more comprehensive memory care treatment protocols than Sunrise any other operators who have been in the business for a while and Sunrise and other national AL operators should again set the standard.
  • I believe respite care is offered at many Sunrise communities but not certain if this is considered an integral part of the service offering that could be coordinated with a more robust therapy offering to position Sunrise as a post-acute or recovery option in a more integrated healthcare system. My recollection is that respite care is just used where units are vacant as a marketing and supplemental revenue generation tool.   I am not certain that Sunrise or other assisted living providers should be in the post-acute or respite business but these options should be evaluated and a business decision made.   Focusing some buildings on respite/post-acute care may make sense and it may be possible to combine on site respite care with rehab therapy to offer a more attractive and lower cost post-acute care alternative for some seniors and insurance providers.
  • Other ancillary services, in addition to rehab therapy and medications management noted above, such as hospice and home healthcare care have been at times offered by Sunrise and other operators both in and outside their properties with company staff.  I believe home healthcare and hospice care continue to be offered by third parties at some Sunrise properties.   I believe Sunrise’s commitment to let residents age and ultimately die in place is an important part of the Sunrise culture and a differentiated element of the Sunrise brand and is also an important part of some other operators culture.   However, there are a range of ancillary care options for assisted living operators ranging from: avoiding supplemental ancillary services to make their buildings more appealing to healthier seniors, to allowing residents to purchase services from third parties, to having approved partners, to directly providing ancillary services. My sense is that directly providing of ancillary services would be a significant distraction for many assisted living operators but a clear policy about the use of ancillary services in all of a company’s properties should be made if this has not already been done and using different levels of ancillary care at different buildings may be a way to differentiate a particularly property within a market.
  • Medicare managed care for residents is another option that Sunrise and other operators may wish to consider, likely teamed with a partner.   The only senior housing operator to operate its own Medicare Advantage plan, to the best of my knowledge, is Erickson Retirement and only at some of its communities.   Sunrise, Brookdale and some regional operators may have the resident density in some markets to either operate a MA plan themselves or team with a managed care or healthcare provider partner to operate one.   This could be an important differentiator if it helps ease the burden of coordinating healthcare services for residents and their families and is seen an providing quality care.  It might also be a more effective way of providing other ancillary services rather that teaming with various hospice, healthcare or therapy providers. In some markets it may be possible for multiple operators with links to a single healthcare REIT to join in a Medicare Advantage or other type of ACO plan to gain sufficient scale to be effective.
  • Transportation – Mobility is an important factor for many seniors.   A review of transportation options with multiple vehicles and multiple drivers available in lieu of the single bus should be considered. I envision each repositioned property having or having access to two or more of the new small SUV cab-type vehicles increasingly seen in major cities, and becoming standard in New York, that can readily accommodate a wheel chair and perhaps up to four passenger in total.  In addition, I envision each facility having something more akin to Uber to schedule cars and pick ups as needed, giving residents much more flexible mobility.   It may even be possible to use an outside Uber or Lyft like service specially tailored to seniors for this. The traditional facility bus might or might not still be needed for group outings.
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Layman’s Guide To Post Acute Care

I had a conversation with a friend today who has a relative that is comatose after a surgical procedure.   The patient has recently been shifted from a feeding tube though the nose to one connected to the stomach and is about to be transitioned from oxygen through a breathing tube to a ventilator connected directly to the throat via a tracheotomy.   This progression is typical for someone who is unable to eat or breath on their own because temporary breathing and feeding tubes over time begin irritate the throat and must be replaced with more direct connections.     Once these more permanent breathing and feeding connections are completed, the patient will likely be transitioned from an ICU to a transitional care unit within the hospital and then the hospital and Medicare or a private insurer will likely soon want the patient relocated to from the hospital, which is designed to provide short-term acute care.

While hospital discharge planners or social workers and the patient’s health insurance provider may all have suggestions or recommendations or preferences about where the patient’s post-acute care should be provided, under Medicare and some types of private health insurance the family will have a choice about where post-acute care is provided.    This short guide summarizes the options to help you achieve the best result for a loved-one at a stressful time for all concerned.

Types of Facilities – There are four types of post-acute care options, which are typically stand-alone facilities but can also be co-located within a general acute care hospital in some cases.   The four types of post-acute care facilities are:

  1. Rehab Hospital, also called an IRF- Inpatient Rehabilitation Facility
  2. Long Term Acute Care Hospital, LTAC, sometimes LTACH
  3. Nursing Home, also called a SNF – Skilled Nursing Facility or in some cases a Transitional Care Facility, which is essentially a SNF located within a hospital
  4. Hospice, which can be provided in a specialized hospice facility, within a SNF or other medical facility or in someone’s home.

A Rehab Hospital or IRF is designed to provide post-acute care for patients who require and are physically able to participate in a minimum of three hours a day of physical therapy (PT), occupational therapy (OT), and/or speech therapy at least five days per week.   Requirements for IRFs call for registered nurse (RN) oversight and availability 24 hours a day and between five and seven and a half nursing hours per patient per day, while the standard for nursing homes is usually between two and a half and four nursing hours per patient per day.   IRFs are also going to have regular physician visits and supervision and extensive rehabilitation gyms and specialized rehab equipment and staff.     So IRFs generally offer a higher level of care than nursing homes but only those patients who are able to handle at least three hours of therapy per day are able to transition to a IRF.   Medicare and most private insurers will pay for IRF care for patient who needs and can tolerate relatively intense therapy following an episode of care in a general acute care hospital.

A Long Term Acute Care Hospital (LTAC) is licensed as a acute care hospital but is designed to care for patients with a 25 – 30 day average length of stay versus less than 5 days in a general acute-care hospital.   Typical LTAC patients have multiple co-morbidities, multi organ system failure, and significant loss of independence, most following a traditional hospital stay.   LTACs are designed to care for critically ill patients who require specialized, aggressive, goal-directed care over an extended recovery period.   So patients on feeding tubes, with tracheotomies and complex, difficult to treat medical conditions are well-suited for care in an LTAC provided there are expectations that the patient’s condition can improve or that their condition needs to be stabilized before stepping down to another setting offer less intense care, such as a SNF or home healthcare.  Medicare and most private insurers will pay for LTAC care for medically complex patients who need ICU level care for an extended period following an episode of care in a general acute care hospital and have some prospect for recovery or being stabilized so they can ultimately be cared for at home or in a SNF.

A Nursing Home or Skilled Nursing Facility (SNF) in most cases offers two types of care.    One is true post-acute care that includes therapy services similar to what is provided in an IRF and some may accommodate complex patients including patients with tracheotomies similar to what may be provided in an LTAC.   Some nursing homes have extensive rehab gyms and therapy staff and will have 24/7 RN care and attending physicians.  But not all nursing homes provide post-acute care services or take medically complex patients and requirements for nursing hours and physician supervision are typically lower in a SNF than an IRF or LTAC.    Nursing homes also offer longer-term nursing care, sometimes call custodial care, for patients who have health conditions that require enough nursing care to make care at home infeasible or who do not have a home or family situation that will allow care at home.    Custodial patients may staff for years and there is little expectation that they will recover and return home.    Medicare and private insurers will generally pay for a limited period of post-acute care in a SNF following an episode of care in an acute care hospital.  But the amount of time for which Medicare will fully cover SNF care is 20 days, after which a co-pay kicks in, and Medicare will not cover long-term custodial care for a patient who is not making progress toward recovery.   For patients without long term care insurance the only option for paying for long-term custodial care in a SNF is Medicaid, which generally will only cover payments after all of a patient’s own funds are exhausted.

Home Healthcare is non-facility based option that provides post-acute care for some patients.   It can deliver wound care, PT, OT and speech therapy and other types of skilled care but will not provide 24/7 patient monitoring and generally requires support from family members in order for this to be a viable option immediately following a general acute care hospital treatment.   Home healthcare often comes into the picture is to provide followup therapy or nursing care after a patient transitions from an IRF, LTAC or SNF to home but is only relatively healthy patients with supportive living situations and families are typically able to get all of their post-acute care from home healthcare.   Medicare and private insurances will pay for home healthcare but only for specific skill nursing and therapy services.

Hospice Care provided in a specialized facility, within a senior housing, nursing home or other health facility, or in one’s own home, is intended for patients who are expected to live for six months are less.    The care is design to keep the patient comfortable and free from pain and to help family member cope with a loved-ones impending death.   While most healthcare providers are reluctant to conclude that additional medical treatment will not allow a patient to get better, hospice care is a very good option once the family and their healthcare providers reach this conclusion.  Medicare and most private insurers will pay for hospice care in a variety of settings.

Deciding Where a Love-One Should Receive Post-Acute Care – Important factors to consider include: the type and level of care the patient needs, the quality and location of the facility.     The type of care that each facility offers is summarized above and you can discuss the appropriate placement with the care team at the hospital including your physicians, nurses, discharge planners and social workers who usually take primary responsibility for transitioning a patient to post-acute care.    There is a tendency to favor facilities offering the highest level of care, such as an LTAC or rehab facility over a nursing home.   However, if the patient will does not need or will not be able to tolerate the level of therapy these facilities can provide it may be better to to directly to a nursing home rather than spend a few days or a week in another type of facility and have to move the patient a second time.    Many patients will prefer home healthcare to facility-based care but it is important to be realistic about whether the physical conditions of the home and the amount of support family members can provide make this the best first post-acute care option.    Location matters because it is important for family members to visit during what may be a multiple week or month period of post-acute care and family members are more likely to visit if a facility is conveniently located.     Finally, quality can be assessed by visiting a facility, speaking with discharge planners and social workers, checking online (The Centers for Medicare and Medicaid Services (CMS) has a 5-star quality rating system that isn’t perfect but can help – https://www.medicare.gov/nursinghomecompare) and in the case of skilled nursing, check with the state Office of Aging ombudsman about any prior complaints.

It will be much easier to evaluate and find space in a facility of your choice if you start looking before your loved-one is about to be discharged.    However, if you need more time it is possible to appeal a hospital discharge and generally buy yourself one-three days if you need more time to evaluate and decide upon your best option for post-acute care (see appeals on the Medicare.gov website).
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Relationships Key to Happiness In Retirement & Seniors Housing

I spent a recent weekend on the Rhode Island shore with a eight friends I have known for over 40 years and several of their spouses/significant others.     We try to get together every two or three years and it is amazing how quickly we are able to reconnect and how reminiscences we have all been over many times before are still a pleasure to hear.

This weekend experience reminded me of the importance of relationships – with a spouse or significant other, with your children and family and with friends and neighbors – for happiness.     I believe the importance of relationships in making us happy is too often overlooked when seniors contemplate a move from work to retirement, in relocating to a new location for all or part of the year, and in thinking about and executing a move to a seniors housing community.

Relationships In Retirement – One important aspect of moving from full time work to full time retirement is that many of our friends and social relationship revolve around our work.   We all have business colleagues inside or outside our organizations that we interact with socially as well as professionally for lunches, dinners, conferences and meetings, charity events, golf and other activities.   These relationships are hard to maintain when you no longer see these colleagues on a regular basis.   If you want to maintain these relationships you, as the retiree, will have to work hard to maintain active contact with former colleagues.

Even if you make the effort to keep connected with former colleagues, many of these work-connected relationships will slip away when you retire because you simply won’t be moving in the same circles as former colleagues.   To supplement these relationships, you need a plan of action to build alternative social relationships, particularly some that are intellectually stimulating.

Once you do retire, some of the most significant challenges you encounter in your social relationships may involve your spouse, significant other, children and other family members.   The relationship with your spouse, if you are married, may be the most important post-retirement relationship you have.   But the nature of your relationship with you spouse may change dramatically as one or both of you has more time at home and you negotiate new responsibilities on household chores, financial management, planning vacations and social activities.     It is important to anticipate and discuss these changes in advance and to maintain an active dialogue as you settle in to your post-retirement lifestyle.

Relationships with children are another important aspect of happiness for retirees but can also create challenges.   Children may live far away, may want more of your time for childcare than you want to give or may not want your advice or help now that you have more time to offer it. For many of us baby boomers our retirement may coincide with our children marrying, getting traction in their careers, establishing families and generally feeling more independent from parents and less in need of parental advice. It is important for the parent/retiree to be sensitive to these changes in roles and to adapt to changing conditions.   It is also important to let your children know if you believe they are claiming more of your time for childcare or other responsibilities than you want to give.

Relationships As We Age – Another aspect of relationships that I believe is very important for happiness and underappreciated as we age is the loss of connectivity to others as your mobility and that of friends is reduced, you or friends relocate to new locations or a spouse or other close friends die.     Many seniors face a gradual narrowing of social relationships and human interaction for the reasons just noted.     Most of the literature that discusses a senior moving to senior housing, including a July 10, 2015 New York Times article entitled “Team Effort In Making Decisions on Elder Housing” focus on a senior’s cognitive and physical abilities, as well as financial considerations, in determining when a move from a home to seniors housing is appropriate.   I believe an equal or more important reason to consider seniors housing, and one that I believe is a good predictor of future health, is a senior’s social network and level of social interaction.   If a senior has lost a spouse, has a shrinking network of social relationships and has very little interaction with peers, family or friends when living at their home or apartment, I believe a move to seniors housing should be actively considered as a way of putting a senior in a position to re-establish meaningful social relationships and interactions.  It may be appropriate to adopt for seniors the same rule I recently saw advocated for children – if they are spending more than two hours a day in front of a screen, be it TV, PC, videogame or tablet it may be time to examine their level of social interaction consider intervention.

I believe there are also practical advantages to discussing a senior’s potential need for seniors housing in terms of social interaction, rather than cognitive or physical limitations.   In the discussion of social interaction, there is a presumption and a focus on a senior being alert, active and in need of human interaction rather than a focus on declining mental and physical abilities.   A move to a senior housing community to make new friends and increase social interaction is a much more positive discussion than a move to prevent falls or keep a senior from harming themselves through mental lapses.   It is also a discussion that can and should happen sooner in a senior’s life when they will gain much more out of a move to a seniors housing facility and before a life incident forces consideration of a move under crisis conditions.

In a future blog, I will discuss the challenges to fitting in and establishing positive social interaction after a move to seniors housing based on some recent industry research.

 

 

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Technology In Seniors Housing

Stereotypes view anyone over 50 as barely able to keep up with technology and unable to use smartphones, Skype or Netflix. But technology already plays an important role in the lives of many seniors, even those over 75. It is reshaping the ways seniors live and interact in their homes and within senior housing communities.

Today, most senior housing communities offer wifi access to residents and many provide a computer center and computer training and support for residents.    Wii and other gaming systems are widely used for bowling and other socially and physically engaging activities.  But the use of technology to enhance resident’s lives and improve the quality and efficiency of care delivery is still in its early stages.

I strongly believe the use of technology will continue to grow in seniors housing, particularly as the baby boom generation, now 51 to 69, age into seniors housing.   The baby boomers were the first generation to being interacting with computers during their school years and are generally much more comfortable using technology than the Roaring Twenties and Depression Era babies using technology in senior housing communities today.

Much has been made of the ability of technology to enable a greater proportion of old, frail seniors to living independently and I believe we will see continued progress in this area. But I also see technology increasingly being used within senior housing communities to enhance 1) communication and interaction, 3) engagement, 3) evaluation and 4) mobility.

Communication and Interaction

FaceTime, Skype and similar services are a vital link between grandparents and grandchildren and may be the biggest single driver spurring current senior housing residents, generally 75 years of age or older, to use smartphones and computers.   These same tools, along with more conventional email, are now and will increasingly be used to link adult children and other family members with senior housing residents and, for the savvy senior housing operators, to link adult children with caregivers and administrators to get more timely and more interactive information on how their loved ones are faring in senior housing communities.   These same tools will also become an increasingly important link between senior housing communities and other caregivers outside the community, including physicians and hospitals.   Healthcare IT and data interoperability among facilities and caregivers is still in its infancy but some forward thinking operators are building data links between their facilities, hospitals and other healthcare providers.   The goal here is to improve communication, reduce unnecessary hospitalizations and adverse drug interactions but the technology also has the potential to greatly improve communication with seniors themselves and with their families regarding healthcare issues.

Engagement

Use of Wii and other video games to engage seniors socially and mentally barely crack the potential of technology to enhance engagement and mental stimulation for seniors, who often feel isolated in senior housing facilities today.     Why not use technology to deliver high quality courses, concerts, yoga and other activities with better trained and more professionally produced programs than are possible with local volunteers and on-site staff.   Most senior housing residents in my observations are bored in their communities and would welcome more stimulating programming that technology can likely deliver better and less expensively.   There is also emerging technology, such as robots of various types, that has the potential to engage residents much more actively and much more regularly than can be done today by human staff.   As the cost of this technology declines, a robot companion for every resident that wants one is a realistic near-term possibility and robots, in addition to engaging residents directly, could also offer video links to family members and care givers and friends potentially in a more seamless way than is possible with current smartphone and computer software.

While I was on vacation this past month, there was an article on July 2, 2015 in the “Personal Journal” section of the Wall Street Journal about a dating service for seniors started by the Hebrew Home in Riverdale to connect its residents.   While this dating service appears to be more staff than technology driven, it points out another potential use of technology for engaging senior housing residents that even most professionals working in the field would not have considered.

Evaluation

Seniors housing facilities are regularly evaluating residents to determine what level of services and support is appropriate and a range of caregivers inside and outside senior housing facilities are regularly evaluating seniors mental and physical conditions to ideally adjust care and medications levels to avoid falls and other adverse health conditions.   Technology is emerging, including devices such as the Apple Watch and Fitbit, to monitor various health parameters.   To date this technology has been focused on younger, healthy, tech savvy adults, not seniors.   But I see significant opportunities for seniors’ health conditions to be monitored in greater detail in real time in an unobtrusive manner and to alert caregivers when key vital signs, like blood sugar or blood pressure, deviate from established norms.   Using technology to monitor cognitive ability on a regular basis is already possible via online tests and will be using increasingly in seniors housing communities, I believe.    Also, as noted above under communication, some degree of remote patient assessment and diagnosis is already happening in some senior housing communities as on site staff reach out to on-call physicians or nurse practitioners. Expanded use of remote technology for resident healthcare evaluation has the potential to significantly enhance the ability of facilities to address resident needs without resorting to an ambulance call or hospital visit.

Mobility

An entrance fee CCRC in Baltimore, near where I live, recently added a Zipcar site in its parking lot.   The service is available to residents and staff and has the benefit of reducing demand for parking from seniors holding on to their cars, improving mobility options for residents still able to drive and for staff, many of whom rely on public transportation to get to and from work.   I haven’t seen details about how Zipcar may qualify seniors to drive its vehicles but this concept seems to be to offer greatly enhanced mobility options for seniors and staff.   The other options that I see significantly enhancing mobility options for seniors are Uber and Lyft type services, which can provide much better and more flexible mobility options for senior housing residents that the typical senior housing facility van.   Seniors are already using Uber and Lyft from their homes but I have not yet seen senior housing communities formerly engage Uber and Lyft in lieu of or in addition to offering the conventional van. Nor have I seen these services target senior housing communities by training drivers to deal with senior residents or equipping vehicles with handicapped access but these accommodations would seem to offer great potential to enhance senior housing resident mobility. I believe there is a significant opportunity both for Uber and Lyft and for senior housing operators to develop a ride sharing service specifically designed for and targeted to seniors living on their own and in senior housing facilities.

Guidance for Operators

It is unlikely in my view that grand integrated technology solutions will appear for communication/interaction, engagement, evaluation and mobility.   Rather innovation by operators and technology companies will likely create technology to address specific issues and operator will be left to integrate these into their operations. The best way for operators to prepare for new technology, in my view, is to build innovation and experimentation into their operations, working with small groups of staff or individual properties.   Try things, some will work, some won’t but over time technology offers the potential to significantly enhance the resident experience in seniors housing and to increase care quality and delivery.   Operators able to innovate will be able to differentiate themselves from competitors and offer services that will not be available in seniors’ homes.

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