This Population Doesn’t Understand: Rising to Covid-19 Challenges in Memory Care

The coronavirus pandemic poses new challenges by the day to long-term care providers across the continuum. But the challenges are even more pronounced for memory care operators.

Those challenges include limiting the ability of memory care residents to walk about freely and congregate with each other, and ensuring their daily routines are as unaffected by the response to the pandemic as possible in order to keep the chances of agitation low.

“When you have an Alzheimer’s or dementia resident, it’s very hard to keep them isolated.

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Seasons Living President and COO Dan Williams

Memory care communities have already been battered by years of declining census due to oversupply, and limitations on tours and any slow-down on move-ins caused by Covid-19 threaten to further suppress occupancy. The good news is that occupancy appears to be holding steady through the early stage of the Covid-19 outbreak in the United States, and as a needs-based product, memory care could weather an economic downturn better than other levels of care — but operators must prove that they can create safe, secure and enriching communities.

“In the long-run we expect this crisis to help many families realize that they need our help and that we can deliver a higher quality of life for their loved ones,” Senior Living Communities President Ben Thompson told Senior Housing News.

Improved communication

To meet Covid-19 challenges, caregivers are relying on their institutional knowledge of their charges and increasing communication between shifts to ensure seamless management and care, especially if a situation arises where a caregiver falls ill and creates a gap in workflow, Alzheimer’s Association Director – Mission Partnerships Doug Pace told Senior Housing News.

The Chicago-based industry association this week released guidance to long-term and community-based care settings to ensure the highest quality dementia care continues during the pandemic.

The Alzheimer’s Association collaborated with 34 long-term care and community-based care providers and affiliated associations to create the guidance, which was drawn from the group’s dementia care recommendations. More than 5 million people in the U.S. have some form of dementia. Among older adults in residential care settings, including assisted living, 42% or more have some form of Alzheimer’s or other forms of dementia.

“These guidelines can be used as a template to set up best practices,” Pace said.

If there is one ray of light poking through the din of the current landscape, it is that securing communities to only essential personnel have made them quieter overall, which allows staff to focus more on care, Anthem Memory Care COO Lewis McCoy told SHN.

“We can’t ethically restrict residents with dementia to their rooms without locking them in, which we are not going to do and can’t do without one to one companions, 24 hours a day.

Chancellor Health Care Chairman and CEO Michel Augsburger

Lake Oswego-based Anthem operates 11 communities in California, Colorado, Illinois and Kansas. McCoy flew to Denver twice in the past three weeks to assess situations at the community level.

At first, Anthem tried to stay ahead of evolving CDC guidance and placed more restrictive measures across its portfolio. Initial guidance from state and local public health agencies, however, were not consistent and sometimes confusing, resulting in a flurry of questions from residents’ families about maintaining care during the outbreak.

Anthem’s executive directors proactively ramped up communications to families, keeping them updated on what was happening on the ground and forwarding new guidance from state and local agencies as it became available. McCoy has been sending out weekly letters to families, as well.

As the guidance has become more consistent, the provider has been able to answer concerns from families, communities have fielded fewer calls and families are more confident in Anthem’s response.

“The goalposts have moved,” he said.

Better communication also reduces the stress placed on staff during this uncertain time. On that front, Anthem is erring on the side of transparency with its community leadership teams and front line staff, sharing new guidance as it becomes available and how the CARES Act stimulus package and other legislation working through Congress will impact the operator.

“Staff have naturally had questions. We are of a size where we don’t necessarily fit some of the guidance that’s coming out for [smaller] companies,” McCoy said.

Chancellor Health Care is constantly evaluating its communities for perceived vulnerabilities where the virus could be introduced. So far, no residents have tested positive cor Covid-19, so the provider turned its attention to staff and essential personnel such as vendors, Chairman and CEO Michel Augsburger told SHN.

Windsor, California-based Chancellor operates 16 senior housing communities in six states.

Chancellor is screening employees and essential visitors for signs of the virus, including temperature checks. Additionally, it issued a directive to its communities that all employees start wearing face masks, either surgical or hand-made cloth masks made by volunteers and families across the country, throughout their daily shifts.

“Our mantra has been, we believe that employees and other essential visitors such as vendors or other health care providers such as hospice or home health agencies are the most likely source of infections,” he said.

Social distancing a challenge

The biggest caregiving challenge that memory care providers face is balancing the need to engage dementia residents with adhering to social distancing practices, Seasons Living President and COO Dan Williams told SHN. Lake Oswego, Oregon-based Seasons operates standalone memory care communities in Arizona, California, Kansas, Missouri and Oregon, and has a pipeline of upcoming facilities in California and Texas.

“When you have an Alzheimer’s or dementia resident, it’s very hard to keep them isolated,” he said.

SLC’s Thompson agreed.

“We’ve found social distancing within memory care to be the toughest challenge,” he said. “Our care remains focused on meeting [residents] wherever and whenever they are at throughout their day. We’ve combatted the social distancing challenge by increasing one on one programming and taking greater advantage of outdoor spaces. Our team members dedication and creativity makes all the difference.”

Based in Charlotte, North Carolina, SLC operates 15 communities in Connecticut, Florida, Georgia, Indiana, North Carolina and South Carolina, under the Senior Living Communities and Wellmore Communities brands.

Before the pandemic became widespread, Chancellor ceased communal dining and life enrichment activities for its memory care residents. Ending communal dining proved difficult, but the operator was able to spread out dining to its bistros, living rooms, dining rooms, activity rooms and hallways, while maintaining social distancing guidelines, Augsburger told SHN.

Of course, one of the biggest challenges in social distancing stems from the fact that memory care residents may not grasp the nature of the Covid-19 threat.

“This population doesn’t understand,” observed Cindi Raymond, principal, management consulting, healthcare strategy & operations at Plante Moran, an auditing, tax, advisory and wealth management firm.

But, residents’ lack of understanding comes with an upside as well.

“They are insulated from a lot of what you see in the media as well as what goes on behind the scenes for us during this time,” Thompson said.

Now is a time when a staff’s institutional knowledge of residents becomes important. If boredom, loneliness and a sense of helplessness creep into their daily routines, it will increase the chance of a disruptive incident happening, Pace told SHN.

Chancellor was concerned that requiring front-line staff to wear PPE daily would lead to an uptick in agitation and disruptive moments among residents. To minimize the shock, some Chancellor communities have instituted “dress up days” at some communities.

“While behaviors have not increased, residents don’t like our employees to wear their facemask because they can’t hear us as well. This is particularly difficult for residents who are hard of hearing,” Augsburger said.

Practicing person-centric care delivery methods in a consistent fashion is imperative as the crisis worsens and communities remain secured to non-essential personnel. And caregivers need to be on alert for every opportunity to engage with dementia residents.

“It is important for associates to put the person before the task. Every task is an opportunity for engagement,” Pace said.

Doing hourly rounds in a memory community is a good idea at any time but particularly in light of the pandemic. These visits provide an opportunity to monitor residents for the “four Ps” of pain control, placement, positioning and personal needs — and staff should now add a fifth P, of personal hand hygiene, recommended Cindi Raymond, principal, management consulting, healthcare strategy & operations at Plante Moran.

Washing residents’ hands or using hand sanitizer not only serves an indispensable infection control purpose but provides an opportunity for physical touch that can be therapeutic, she noted.

We’ve found social distancing within memory care to be the toughest challenge,

Senior Living Communities President Ben Thompson

Creating more opportunities for engagement and stimulation in residents’ rooms is another best practice to consider, with Raymond’s suggestions including manicures/pedicures; establishing a craft corner or reading nook; making a child care station; working with residents to redecorate their rooms; bringing in seed starters to celebrate spring, or a small fish tank for animal lovers.

Anthem is maintaining programs such as animal-assisted therapy, but it is moving others to virtual settings. In Denver, an intergenerational program involving high school students was moved online, and the students are excited to find ways to engage with residents in a virtual setting.

Dining presents a bigger challenge. Anthem is not sequestering memory care residents in their suites for meals, but is extending space between tables and adding extra meal service shifts in order to comply with social distancing guidelines. The provider has also removed table linens and switched to disposable serviceware, McCoy told SHN.

Providers that have memory care as a wing within a larger must contend with isolating the section from the rest of the building. Westport, Connecticut-based Maplewood Senior Living established dedicated entry/exit points for its memory care wings and requires staff to use full personal protective equipment at all times, COO Shane Herlet said.

These moves were made with maintaining memory care residents’ routines in mind.

“Residents in memory care neighborhoods don’t have the ability to understand social isolation,” he said.

Chancellor has taken additional steps to keep residents in contact with their families. It provided Facebook Video monitors and ordered It’s Never 2 Late learning platforms at each community, both of which allow scheduling of video visits between residents and families, Augsburger said.

The provider also scheduled window visits with telephones so residents can see their loved ones through windows, and drive-by visits where they can visit from their cars with their loved one outside the building, with appropriate social distancing being maintained at all times.

Controlling move-outs, expenses

Senior living is contending with a shutdown in physical tours of communities during the pandemic and memory care is no exception.

Anthem responded to the new landscape by ramping up its marketing efforts. Marketing and sales teams are spending time cleaning up referral databases, keeping in touch with prospects who will require memory care services sooner and their families, and doing some virtual tours.

It is important for associates to put the person before the task. Every task is an opportunity for engagement.

Alzheimer’s Association Director – Mission Partnerships Doug Pace

The operator is still accepting move-ins, but with deeper vetting to ensure new residents are not bringing the virus with them. And, as a needs-based service, McCoy does not expect to have many move-outs except for a decline in acuity.

“We do a good job of reducing dissatisfied move-outs. This is a time where if folks don’t have to pick up and move, they won’t,” he said.

Chancellor requires new admissions and readmissions to undergo 14-day quarantines upon arrival, but it is not accepting new move-ins in its memory care wings because this is virtually impossible to execute for people with dementia.

“We can’t ethically restrict residents with dementia to their rooms without locking them in, which we are not going to do and can’t do without one to one companions, 24 hours a day. The only exceptions are residents who require a wheelchair to get around the community or those who need assistance with transferring,” Augsburger said.

Still, occupancy very well might decline in the weeks ahead.

“In the short run, we expect Covid-19 to impact occupancy negatively in memory care as well as all other care settings,” SLC’s Thompson said. “We are continuing to admit new residents, but we are not allowing physical tours and we have seen a reduction in inquiries.”

Memory care providers will also contend with rising expenses due to staffing shortages and supply costs, mostly in replacing PPE. Seasons Living is adding staff to keep communities clean and disinfected.

“It’s going to change our margins for all of our investors,” he said.

Anthem saw some slight cost increases early in the pandemic due to finding a lab that could provide it with Covid-19 test kits. The operator is holding the line on labor expenses so far but is looking at bringing in front-line staff that can fill a variety of roles in communities, in order to buttress what is already working well. This will be considered on a community-by-community basis, McCoy told SHN.

This is a time where if folks don’t have to pick up and move, they won’t.

Anthem Memory Care COO Lewis McCoy

This month, Anthem is also rolling out an incentive program for front-line workers, and looking at other alternatives to thank them for their efforts during this crisis.

“We were in a good spot prior to [Covid-19] that allowed for us to have kind of a more stable staffing footprint,” he said.

Chancellor is ramping up its efforts to procure as much PPE as it can get its hands on, which will impact the P&L ledger.

In response, it is looking at staffing alternatives such as 12-hour shifts, restructuring tasks, authorizing overtime and double time, hiring new employees who can pass Covid-19 screenings and reducing hours, if this doesn’t negatively affect its ability to pass medications or assist residents with ADLs, cleaning, sanitizing and feeding.

“These restrictions are not about saving any money, it is all about saving the lives of our residents and employees. It is our objective to keep everyone healthy to the end of this pandemic,” Augsburger said.

Although there is much uncertainty and concern about how long the Covid-19 crisis will last, when the pandemic wanes, memory care occupancy could rebound more dramatically than other types of care. Seasons’ Williams believes it will outperform independent living and assisted living, as an even more needs-based offering. Thompson is similarly optimistic.

“Covid-19 is certainly a unique crisis, but we typically see a boost in occupancy after crises,” he said. “We have a lot of coastal communities and see an occupancy boost after hurricanes every year. The key is delivering safety, security, and a high quality of life despite the crisis.”

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