Magic or mayhem: What’s ahead? Part 2

Editor’s note: Last month, Long-Term Living readers were treated to five of Richard Peck’s predictions for the industry in the coming years (Long-Term Living, November 2011, page 26). Here are more of his forecasts.

DESIGN: ‘HOMELIKE’ ARRIVES

It’s been a long time coming, but homelike LTC design is starting to become mainstream. According to Margaret P. Calkins, PhD, president of the design consulting firm I.D.E.A.S and long a spearhead of

Long-Term Living’s design coverage, the once groundbreaking “household” concept is no longer exceptional, particularly for the newer not-for-profit facilities. “We’re still seeing linear hallways, side-by-side rooms and amorphous social spaces in for-profits,” she says, “but the household of private rooms clustered around common social and dining areas is now generally seen as promoting resident comfort and staff interaction with residents, leading to better quality of care.”

And the private room itself isn’t going away, Calkins says, despite apparent economic constraints versus shared rooms. “My research five years ago showed the added cost could be amortized at $2.50 a day over 30 years,” she notes, “while the reduced turnover from the increased staff satisfaction would lead to savings of $13,000 per rehire-$16,000 per rehire if you include staff training.”

Economic reality being what it is, though, there’s no escaping the fact that most aging facilities lack funding for major makeovers. Gene Guszkowski, AIA, principal of the Wauwatosa, Wisc.-based LTC design firm AG Architecture, notes that “of the 392 CCRCs in the nonprofit world, 38 percent opened before 1986 and 35 percent are 10 to 25 years old. By today’s standards, these older communities appear dated and tired. But a new generation of seniors is coming and owner/operators know it-they’re showing an intense interest in upgrading. Still, even though some are incredibly clever in improving living units by combining apartments and incorporating high-end millwork enhancements, when you approach it from the outside it still looks like an old building.”

Guszkowski is seeing more and more requests from owners not only for modest renovations but for master plan updates. “That’s because we’re going to need another 400 CCRCs alone in the next 10 years, and the for-profits are very aware of this and are gearing up.”

Meanwhile, Calkins has seen hard evidence-from the world of code regulation-that the household concept is settling in. Thanks to an ongoing collaboration by the Pioneer Network, the Rothschild Foundation’s Rob Mayer and a coalition of leading LTC associations, the National Fire Protection Association Life Safety Code for 2012 (see page 30) will feature four breakthroughs in code-acceptable LTC design: (1) kitchens may have residential equipment and hoods as opposed to commercial-grade, may be open to sleeping compartments (as in the Green House model) and may serve as many as 30 residents, as long as the buildings are sprinkled and contain smoke detectors; (2) gas fireplaces are to be considered as heating devices, not as solid fuel, and as such can be located in the same smoke compartment as resident rooms; (3) furniture is allowed in hallways, although it must be confined to one side of the hallway and allow six-foot clearance; and (4) the percentage of wall space allowed to be covered by non-treated, potentially flammable wall decorations is to be 30 percent rather than 20 percent, not only for rooms occupied by four or fewer people, but for hallways and spaces with higher occupancies.

Such enlightened building and fire codes may signal a breakthrough era for LTC design, a fortunate and timely development for future generations of LTC residents.

DEMENTIA CARE: THE DRIVE TO PERSONALIZE

“New drug found to cure Alzheimer’s!” That’s a headline the world yearns to see-particularly with Alzheimer’s cases projected to increase 85 percent by 2050, affecting 16 million Americans and costing more than $1 trillion. There seems little reason to believe we’ll see it any time soon, though, as the basic pathophysiology of the disease continues to defy scientific understanding. The medications we do have, while briefly slowing progression, are costly, and the antipsychotics used to control its behavioral manifestations have come justifiably under a cloud.

All of which leaves the field open, now and for the foreseeable future, to behavioral interventions. And here, LTC facilities are making inroads with behavioral interventions of various kinds. The underlying approach has been summed up most eloquently by the Beatitudes facility in Phoenix, Ariz., a pioneer in Alzheimer’s management, which states: “To listen, let patients make their own decisions, and show them love.”

The programs come with various “flavors,” including Montessori-based intervention focusing on residents’ fine-motor skills to maintain cognition; behavior-based ergonomics therapy using customized audio/visual interventions to calm and positively stimulate residents; brain fitness programs to stave off mental deterioration; and Snoezelen, a highly tactile sensory stimulation program involving all the senses.

The challenge to facility care lies in the staffing required to provide these modalities. The successful memory care unit will have staff who appear to be doing nothing but hanging out with individual residents all day. It’s what works. The question for LTC providers: Is it workable?

BUSINESS MODEL: PERSONAL SERVICE FIRST

Are you a captain or a coach? Your answer determines where you stand on the continuum of today’s evolving LTC business model. The top-down organization of yore, with the business leader issuing crisp orders and staff responding with snappy salutes and “yes, sir!” has taken a turn of late. The move is toward a collaborative, team-based model focused on promoting personalized service for residents and independent decision making by staff.

Obviously, this is a major organizational challenge. For a budget-challenged facility trying to employ staff and other resources as economically as possible, the operational adjustments of person-centered care can be daunting-for example, bathing and feeding residents in bunches vs. allowing for individual choice in these matters. Yet facilities continue to move in that direction.

There may, however, still be a need for a captain who, while sensitive to new organizational priorities, has a firm set of guiding principles-a captain, for instance, like William V. Day, president of the St. Barnabas Health System in Gibsonia, Pa. An LTC business model innovator who developed a full-service, multilevel senior care campus well before its time, Day sees three guiding lights for today’s operators: “(1) Focus on what we do best-in our case, clinical care. We are a healthcare organization, first and foremost. (2) Communicate what we do to the community every day. (3) Recognize that cash is king. Our goal is to be big enough on the residential and service side not to be dependent on Medicare or Medicaid-not an easy thing to do and needing constant attention to growth.”

CLINICAL CARE: ‘BEST FRIENDS FOREVER’ WITH HOSPITALS

Many observers believe that SNFs have no choice but to form close relationships with hospitals if their post-acute market is to survive. Medicare’s new focus on reducing hospital readmissions places the financial onus on hospitals for unnecessary and wasteful services, but hospitals that see SNFs as the cause of the problem are unlikely to continue doing business with them for very long.

Newly forming accountable care organizations (ACOs) call upon hospitals to partner with local physicians, SNFs and others to deliver care for fixed or bundled payments. Once again, SNFs that can’t toe the line clinically will very likely see their Medicare participation reduced or eliminated altogether.

Says Glen Roebuck, vice president, business development for Health Dimensions Group, “SNFs face a new barometer of quality: avoidance of unnecessary readmissions. Those that tend to readmit Medicare patients because of a low-grade fever will be expected to manage that change of condition without a transfer to the ER or an acute care setting.”

SNFs shouldn’t be afraid to engage with ACOs, either, he suggests. “In our area we have hospitals with attached nursing homes approaching us for support, consultation and overall management,” Roebuck says, “because they’re struggling with how to manage post-acute care appropriately. Hospitals that SNFs have wanted to have conversations with for years are now approaching the SNFs to investigate partnerships.”

But SNFs will have to get their clinical skills and operations up to speed to make the cut. “If skilled centers grade their clinical performance a B-plus right now,” says Roebuck, “they need to get to the A-level performance quickly.”

PRIVATE FINANCING: SHORT-TERM WORRY, LONG-TERM BOOM

It’s simple: Once we get past the housing crisis and the Medicare crackdown, long-term care looks to be an investment bonanza. Independent living, assisted living, skilled nursing-all levels of senior housing and care are poised to accommodate surging baby boomers and their Silent Generation predecessors. Even with retirement being put increasingly on hold and average age for facility occupancy hovering around the early 80s, savvy providers are gearing up for some potential boom years.

“We’re seeing this upswing starting right now in assisted living (AL),” says Michael Hargrave, vice president of NIC MAP, a data and analysis service of the National Investment Center for Seniors Housing & Care Industry (NIC). “AL has weathered the recession the best of all property types. Developers are favoring AL development over independent living (IL) and, as aging in place becomes an issue, IL operators are converting their units to AL units, with a movement toward a catered care healthcare model and away from luxurious IL suites.”

Although much of the focus these days seems to be turning toward the home-based model of care, Hargrave doesn’t see this replacing the need for seniors housing and care. “Providing services in the home can be cost-prohibitive compared with organization-based care. Although keeping people at home is highly attractive politically, seniors housing and care communities provide a specialization component that is essential to quality of life-especially as people age and lose spouses, neighborhood friends or mobility.”

These bright prospects are overshadowed momentarily, though, by the aforementioned two crises: a decline in home prices undermining savings available to invest in long-term care, and Medicare reductions forcing providers to rely even more on dwindling Medicaid programs in their cash-strapped states. “Investors are seeing parallels in this sector with the PPS [Prospective Payment System] experience of the late 1990s,” says Hargrave, “and many are wary of underwriting transactions in the skilled sector right now.”

Some say these are the most tumultuous times financially that the seniors housing and care sector has ever faced. But the Promised Land awaits those who can survive the storm.

Long-Term Living 2011 December;60(12):26-29

Richard Peck

Richard L. Peck was editor in chief of I Advance Senior Care / Long-Term Living for 18 years. For eight years previous to that, he served as editor of the clinical magazine Geriatrics. He has written extensively on developments in the field of senior care and housing.