Continuing care retirement communities face unique challenges in responding to the Covid-19 pandemic. Their large sizes, multiple entry points, varying levels of care acuities and layers of government regulations place added pressures on ensuring the safety of residents and containing the spread of the virus if someone tests positive.
But providers can adapt their communicable disease outbreak plans to secure their communities, ensure the safety of residents and still allow for move-ins. Many of the largest CCRC providers in the nation already have, and in fact implemented protocols well ahead of the virus’ explosion in the United States.
CCRCs — also known as life plan communities — are also among the sectors most exposed to the effects of the coronavirus from a financial perspective, although solid operators with strong credit ratings appear to be well-positioned to weather the crisis.
Lower-rated CCRCs at risk
As the outbreak grows, CCRCs — like all senior living providers — will feel added pressures to workforce retention, staffing costs and overtime. Medical or nursing staff may become subject to isolation or furlough, and communities may face higher costs from supply chain disruptions.
Moreover, residents’ and prospects’ financial conditions can be significantly impacted due to declines in the stock market and real estate values, which can put a damper on short-term move-in rates as prospects sell their homes to facilitate moves to CCRCs, according to Fitch Ratings.
“Lower-rated [CCRCs] that are currently undergoing expansions in areas heavily affected by the outbreak may come under the most pressure, as they have the least financial cushion to weather a period of weak operations and are most exposed to cost pressures, namely labor and supplies, which could arise from this outbreak,” Fitch’s Margaret Johnson and Sarah Repucci said in a credit market commentary.
However, investment-grade CCRCs in Fitch’s portfolio generally had “sizable liquidity cushions,” averaging 500 days cash on hand, prior to the current Covid-19 situation. This should enable them to handle increased expenses and a potential slow-down in move-ins, as stock market shocks and overall uncertainty hurt independent living sales.
The ultimate length of a Covid-19 slowdown is uncertain, of course, but Fitch does anticipate a complete recovery to ultimately occur. In the meantime, the agency notes that many CCRCs are rising to the challenges of coronavirus through swift and comprehensive actions.
“Most LPCs have protocols in place for viral outbreaks and Fitch’s initial conversations with issuers revealed that they generally took decisive action in the early weeks of the viral spread to limit the risk of resident exposure,” Johnson and Repucci wrote.
Asbury applies norovirus lessons
Last December, a norovirus outbreak forced Asbury Communities to close one of its CCRCs and implement a communicable disease outbreak plan that is now being used in response to the Covid-19 pandemic, Vice President of Clinical Excellence Skip Margot told SHN. The Frederick, Maryland-based nonprofit operator operates eight CCRCs in Maryland, Pennsylvania and Tennessee.
The plan, designed by Margot and Director of Clinical Education Martha Gurzick, establishes guidelines for isolating one or more residents testing positive for a virus, identifies residents and caregivers who have been in close contact with those infected, and institutes protocols for securing entry points, community areas and shared amenities.
“We deliberately made it airtight,” Margot said.
If a resident contracts a virus, Asbury places the resident in isolation, alerts staff, does deeper cleaning throughout a community and executes protective measures to contain the spread. An outbreak is called when two or more individuals test positive for a virus. When that happens, signage goes up warning the community of a potential outbreak and communication occurs with local public health authorities on the outbreak and the actions being taken.
Isolation protocols extend to staff that become infected, as well. If a caregiver tests positive for a virus but is asymptomatic, that staffer works “sick-on-sick” with residents carrying a virus.
“The work done with the norovirus [outbreak] heightened the awareness across the system. It served as the foundation [of our response]. As the [coronavirus] ramped up, it allowed us to stay a step ahead of CMS and CDC guidance. We had everything in place,” Asbury Senior Vice President of Health Care Services Henry Moehring said.
Limiting visitors, controlling entrances
As part of their responses, CCRCs are reducing entry points to their buildings. This allows staff to monitor caregivers and essential medical personnel for signs of contracting Covid-19, as well as vendors and delivery personnel bringing supplies to a campus.
The Kendal Corporation provided guidance to its affiliate communities to begin soft closures at the beginning of March, Chief Marketing Officer Colleen Ryan Mallon told SHN. The Kennett Square, Pennsylvania-based company operates on a federal system, its 13 communities operating independently of each other but with the support and guidance of the shared parent entity. Kendal is now recomming hard closures as the number of positive cases grows across the country.
Essential visitors are being asked to consent to temperature checks, and independent living residents at a couple Kendal affiliates have been asked to bring their own thermometers with them for checks.
Covenant Living Communities and Services is conducting screening of all employees reporting to work at its communities within all levels of living, Senior Vice President, Enterprise Operations Bill Rabe told SHN. Skokie, Illinois-based Covenant operates 14 CCRCs in nine states. Additionally, it operates two senior rental communities and two “Covenant Care at Home” locations.
Screenings extend to essential visitors or contractors and vendors who step foot in Covenant’s communities. The screenings consist of answering health assessment questionnaires and temperature screenings. Communities maintain logs of everyone who has been screened. If the visitor, employee or contractor fails in any area of the screening, they will not be allowed to enter. To ensure everyone is screened, they are given a small colored sticker for their badge, and the sticker is a different color each day.
“If anyone doesn’t have that appropriate sticker, they will be screened or must leave,” Rabe said.
Kendal is recommending one entrance point for smaller communities, and two or three for larger campuses, and health-related deliveries are being dropped off at loading docks, where staff members pick up the supplies and move them inside.
“We have to be mindful of where supplies are going. If [independent living] residents can help us there, we want to do that,” Mallon said.
Covenant has limited the number of entrances at its communities, but each one is different in terms of layout and entry points.
“On some campuses, we’ve closed certain entrances to funnel as much traffic to one central location. The screening stations are set up in health care entrances and also within residential living,” Rabe said.
Erickson Living has restricted all visitation, except for certain compassionate care situations, such as end-of-life circumstances. In those cases, visitors will be limited to the specific resident’s room only, the Catonsville, Maryland-based operator said in an email to SHN. Erickson owns and operates 22 CCRCs in 11 states.
In addition to restricting access, staff is screened for Covid-19 symptoms, including a temperature check. Essential visitors are undergoing a temperature check before entering, and wear a surgical mask while in continuing care to prevent the spread of germs. They are also being asked to limit the surfaces they touch and use good hand hygiene to prevent the spread of germs, and to avoid contact with residents and staff.
Acts Retirement-Life Communities is following guidance from state and local public health authorities in restricting access to its communities, Executive Vice President and Chief Administrative Officer Jeff Kaighn told SHN. The Fort Washington, Pennsylvania-based owner and operator is the third-largest nonprofit operator in the country, with a portfolio of 23 campuses in nine states.
“Many are currently closed to visitors except staff and essential services. We anticipate the remaining communities will be closed to all visitors, ensuring staff that need access have access,” he said.
The providers interviewed for this story are still conducting group activities, but those groups are noticeably smaller as a result of CDC guidance on social distancing. For instance, Covenant restricted large group activities and limited any activity to no more than 10 residents in a space with proper social distancing, Rabe said.
The pandemic has significantly altered what is arguably the most social aspect of any senior living community — dining. As of March 20, Erickson Living closed all its dining facilities and implemented an in-home meal delivery and dining program so residents can safely enjoy breakfast, lunch, dinner, and snacks in their apartments.
Covenant is preparing meals from a limited menu that are either delivered at no fee to resident apartments or available for takeout. Having a more limited menu helps in preparing the volume of meals needed for both lunch and dinner, Rabe told SHN.
“Our dining teams, who would normally be working in the dining rooms are making those deliveries,” he said.
Most of Kendal’s affiliates have moved to takeout or room delivery, and most of the common areas are closed for the time being, with the exception of pools in a couple affiliates, Mallon said.
All of the operators interviewed agree that the response is necessary to ensure the safety of residents. But it is contributing to a growing sense of isolation among residents who are confined to their apartments for most of the day, unable to me in face-to-face contact with family.
Steps are being taken to ensure that residents can still be in contact with each other, their families and the outside world, and continue to be kept informed of updates. Asbury is putting into place tools and resources to support interconnectivity in its neighborhood, helping connect residents with their families via platforms such as Skype and FaceTime, Moehring told SHN.
Acts is making tech available to residents at higher acuity levels of care. Staff are helping residents with using the platforms to connect them with their families, Kaighn said.
Kendal has WebX implemented across its affiliates, and some are looking at services such as Zoom to bridge the gap. Some residents have already taken other steps to maintain contact.
“Several residents already had their own websites, chat rooms and listservs for communication,” Mallon said.
One affiliate, Kendal at Oberlin, worked with the corporate office to set up a portal so people can go online and make virtual cards for residents in higher acuity settings.
Overall, residents at these communities are thankful that operators are taking steps to keep them safe.
“The vast majority of residents have been hugely supportive of all of the preventive measures we are putting into place. They are cooperative, understanding and grateful that these measures are being implemented with their best interests in mind,” Rabe told SHN.