The National Assisted Living Quality framework released last month by health care real estate investment trust Welltower (NYSE: WELL) and Johns Hopkins Medicine (JHM) has the potential to establish a uniform set of best practices in assisted living and memory care communities across the country, and not just Welltower-owned properties.
If that does indeed come to pass, it may be thanks in part to Welltower’s efforts to downplay its involvement and gain industry support early in the process. While prominent Welltower operating partners such as Silverado and Sunrise Senior Living helped shape the quality framework, the stakeholder group consisted of owners, operators, insurance providers, industry associations and even the adult child of senior housing residents.
Whatever form it ultimately takes, however, having a broadly accepted quality framework could be crucial to senior living’s future, as the U.S. health care system becomes increasingly integrated and current silos between government-reimbursed providers and private-pay organizations break down.
A 3-year process
The framework can be traced back to 2015, according to Mark Shaver, Welltower senior vice president, strategy. Shaver spent 18 years as VP of business development at JHM before joining Welltower last January.
Welltower CEO Tom DeRosa and EVP – Business & Relationship Management Mercedes Kerr approached Hopkins’ research team, led by Dr. Bruce Leff, with a vision for establishing a set of best operational practices that could be adopted by the senior housing industry at large, not just Welltower.
“Tom started to think through that Welltower and operators should take a proactive role in shaping national quality standards,” Shaver said. “In order to do that, he wanted to bring together some of the best minds related to public health and policy, which is why he approached the faculty at Hopkins.”
Welltower found the ideal researcher in Leff, who is considered to be one of the foremost thought leaders in health services research, and who has focused on bringing more robust care to people outside of institutional settings. For instance, he is known for work in developing “hospital at home” models of care. His team formulated the framework’s methodology and how its standards could be set.
Welltower’s industry reputation was a selling point in getting Hopkins on board, Leff told SHN.
“Welltower has a good and strong interest in being a leader in the field, and getting the industry to think in a more deliberate way in creating a culture of quality in assisted living,” he told SHN.
With JHM on board, Welltower distanced itself from the research process, so as not to give the impression that the research was influenced by a commercial partner. The REIT did not participate in any interviews or research, and left it to JHM to identify the framework’s participating stakeholders.
“There is fidelity in this report,” Shaver said.
A unique opportunity
The stakeholders who spoke with SHN for this article all agreed Welltower presented a unique opportunity to steer a conversation about the future of the senior living.
Welltower approached Irvine, California-based Silverado — which operates 37 memory care communities and 11 hospices — early in the process to take a leading role in the initiative from an operator perspective.
“Here we have the opportunity to work with other leaders to establish these common outcome measures across our industry, while also recognizing key quality of care measures that are important to achieving quality of life,” Silverado President/CEO and Chairman Loren Shook told SHN.
Silverado also played a role in bringing in a consumer voice to the framework. Stakeholder Susan Yedor’s father has lived at Silverado Newport Mesa in Costa Mesa, California for three years. Her mother is a five-year resident at Silverado Tustin Hacienda in Tustin, California. Yedor serves as a Family Champion at each of her parents’ communities, providing outreach and support to family members of residents.
Welltower approached Argentum, the Alexandria, Virginia-based national association of senior living providers, about participating as a stakeholder in November 2017, COO Maribeth Bersani told SHN. She was attracted to the range of voices being offered seats at the table, and noted the project tied in nicely to Argentum’s ongoing efforts to establish best operating practices, such as its Senior Living IQ initiative.
“What was appealing early on was that this network would consist not only of operators and industry representatives, but family members, gerontologists, researchers and other quality focused organizations,” Bersani said. “The John Hopkins team also provided an interesting perspective and expertise.”
Sunrise Senior Living Chief Clinical Officer Sue Coppola was able to provide an operator’s perspective as well. McLean, Virginia-based Sunrise is one of the largest operating companies in the nation, with 266 communities across the U.S.
“We need to be able to manage key indicators and have meaningful ways to measure the impact we make to each life,” Coppola told SHN. “This was an exciting opportunity to collaborate among our sector, as we all work toward establishing a framework to guide quality indicator development, quality of care measurements, and service.”
Another stakeholder is American Health Care Association/National Center for Assisted Living (AHCA/NCAL) Associate Vice President of Workforce and Quality Improvement Lindsay Schwartz.
Schwartz, who is also the chair of the Center for Excellence in Assisted Living (CEAL), said the domains identified in the Welltower-JHM framework are also found in CEAL’s 2016 report, Measures and Instruments for Quality Improvement in Assisted Living.
“It’s encouraging to see REITs like Welltower invested in the future of assisted living, as well as the resident experience,” Schwartz said.
With the framework completed, attention now turns to determining the next phase of research.
Leff’s team is scheduled to meet with Welltower this week to plot that next phase, Shaver said. That will include working with operators to identify two domains to implement and measure, and work with a third party to gather data.
As with the first phase of the framework’s development, Welltower and JHM want to include a larger subset of individuals with whom to partner, like Argentum or NCAL.
“We’re looking to create a set of standards the entire industry can use,” Shaver said. “Our goal is to advance the whole sector.”
This goal is increasingly urgent, considering ongoing changes to the U.S. health care system, Silverado’s Shook believes.
He points out that quality measures for skilled nursing facilities and other Medicare-certified care settings already have been set by government agencies such as the Centers for Medicare & Medicaid Services (CMS).
Meanwhile, there aren’t commonly adopted measures to show that senior housing and care providers like Silverado — which can offer robust clinical services along with a socialization focus to enhance quality of life — are actually helping to drive down costs to the health care system overall, Shook said.
“There is plenty of evidence of research that shows the value of the socialization model, along with the many other protocols and systems we have in place, to produce the lowest utilization of emergency room visits, the lowest 30 day readmission rates, among the highest use of hospice care at end of life — all of which appreciably reduces the cost of care and improves resident and family satisfaction,” he told SHN. “However, there’s no recognition of the value of it within the current CMS payment structure. Setting these standards will allow for more interplay between CMS reimbursement models and non-nursing home licensed groups.”
Silverado itself is an example of a company where the lines are blurring, as it is growing its Medicare-reimbursed hospice division alongside its private-pay memory care model. Sunrise provides another example, as it has launched its own Medicare Advantage plan, and has seen physician referrals pick up as a result.
Written by Chuck Sudo