Senior Living Providers Expanding Services as Acuity Levels Spike

Senior living providers are finding it increasingly common to take care of patients with ever-rising acuity levels, and it’s causing them to revisit their staffing and services to ensure they’re able to provide adequate care.

“We’ve seen the acuity go up consistently for the past ten years, but now it’s getting to the point that for some of us, we’re running mini-hospitals,” said Jim Janicki, senior director of marketing for Riverside Health System’s Lifelong Health Division.

Many people are putting off entering any sort of senior housing, from independent living to assisted living to nursing homes, and the delay has gotten more noticeable as the economy has struggled.


“It’s definitely changed over the last six or seven years,” said Stephanie Handelson, chief operating officer for Benchmark Senior Living, a Wellesley, Mass.-based senior housing provider with both independent and assisted living facilities.

“It’s been most noticeable since the economy went sideways; people are waiting very, very long to move in, so the decision process is based on medical necessity versus a lifestyle change,” she said.

This means the people entering senior housing facilities are significantly older—and in need of more care—than they were several years ago, she added. For example, in 1999, the average age of those entering assisted living was 82 years old. Now, residents are coming in at age 87 or 88, and they already have 2-3 ADLs (activities of daily living). For independent living, the average age of incoming residents is 85, and while it’s still primarily a lifestyle choice, they’ve put it off longer than before.


“We do serve a frail population, and for some people who remember nursing homes in the 1970s, they might say it’s similar to nursing home care,” said Maribeth Bersani, senior vice president of public policy for the Assisted Living Federation of America (ALFA).

In fact, skilled nursing facilities are also seeing much higher acuity residents.

“It’s certainly being felt in the skilled nursing facilities where we do short-term rehab, and the care that we’re offering in our facilities today is equivalent to what would’ve been offered in the hospital just a few years ago,” said Janicki. “We’ve had to expand our services to be able to take care of folks who otherwise are discharged from the hospital and need care before they go home.”

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Expanding services is important, and Handelson said Benchmark has added $6 million worth of staff in the past couple of years to meet rising care needs.

Both Janicki and Handelson said they’ve had to hire more doctors and nurses, and they’ve also had to provide training to nursing assistants who aren’t prepared for more advanced levels of acuity.

“We changed our model in 2009 so our staffing patterns are based not only on occupancy but on acuity as well,” said Handelson. “We’re able to staff for the heavier care needs. We probably turn down 5% of folks that are just too medically complex or have behavior needs that we just can’t meet.”

Many facilities aren’t turning down seniors with increased care needs.

“In assisted living, we’re seeing folks who are a little more compromised, who are struggling to stay independent,” Janicki noted. “We maintain our standards, but there are competitors in the marketplace that have nursing home-level patients in assisted living.”

While admitting high acuity patients may give facilities a short-term boost in census, he said it can hurt marketability in the long term.

“If people see a more frail population living there, they’re going to want to wait longer. There’s a danger to keeping people at inappropriate levels of care,” he said.

In response to this higher acuity, Handelson says Benchmark has had to do “extensive training” with their staff along with a significant increase in staff to meet the acuity, and more associates combined with more extensive training drives a higher cost of care.

Benchmark’s payment system is based on two components, a basic “hospitality” package and care: the hospitality component only varies by unit size; however, care fees are separate and personalized to each resident’s needs.

“People are paying more depending on level of care,” she said.

Larger companies like Benchmark are likely more able to accommodate an older, frailer population than smaller companies with only one or two facilities.

“There is definitely an economy of scale,” said Bersani. “You have to have more staff, and a better-trained staff.”

It’s easier for senior housing facilities with a lot of residents, many of whom have higher acuity, to comply with requirements, she said, but “It doesn’t make good business sense if you only have a couple frail seniors.”

Written by Alyssa Gerace

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