Senior living providers have responded to enormous challenges since the Covid-19 pandemic reached the United States in mid-March, but the hardest weeks might now lie ahead.
“I do think that the next 30 days are going to be the most crucial time for our company,” Milo Pinkerton, founder and CEO of Heritage Senior Living, told Senior Housing News.
Based near Milwaukee, Heritage operates 14 communities in Wisconsin — where the state’s Supreme Court last week struck down the governor’s stay-at-home order. This ruling is resulting in a swift re-opening of Badger State businesses, but Wisconsin is not the only state that is starting to reboot its economy.
As states re-open, senior living communities face difficult dilemmas. Infection control protocols will become harder to enforce as staff and residents — especially in independent living — have more ability and desire to mingle with other people. This situation makes it trickier than ever for providers to strike the balance between keeping residents safe while making communities appealing for future consumers. But the viability of some senior living businesses and the health of the industry as a whole may depend on getting that balance right in the coming weeks, while providers also manage ongoing financial burdens and keep up with other emerging challenges.
‘Our jobs become harder’
As of May 18, thirty-four states were in the process of reopening their economies after shutdowns due to Covid-19, according to a New York Times analysis. The newspaper considers a state to be reopening once its stay-at-home order is lifted, or a major sector such as restaurants or retail stores are allowed to operate, or a number of smaller sectors can resume business. Even more states are in a “regional reopening” process, in which some counties or geographic areas are allowed to reopen while others are not.
The problem for senior living providers is that they cannot move at the same pace as the broader economy, because they are caring for such a vulnerable population. The situation is highlighted in local news reports like a May 18 Arizona Daily Star article that stated: “Even as Arizona’s stay-home order is lifted, long-term-care facilities are being told to prepare for what could be a surge of new Covid-19 cases.”
Public health experts in Arizona are “encouraging” senior housing and care communities to keep their stringent infection control protocols in place even as the state as a whole begins to normalize. The same message is being delivered in other states and even on the federal level, as the Centers for Medicare & Medicaid Services (CMS) on Monday released guidance to nursing homes, saying that they should be among the last locations to reopen.
But holding the line as the wider economy shifts gears is easier said than done for senior living providers.
“Our relaxation will not go at the same pace [as states], and that’s difficult for residents and staff to understand,” Kris Ward, vice president of operations for Dial Senior Living, told SHN. Omaha, Nebraska-based Dial operates communities across six states.
It’s a sentiment shared by Heritage’s Pinkerton as well as Steve Fleming, president and CEO of The Well-Spring Group, which operates a life plan community and offers other housing and services in the Greensboro, North Carolina area.
“Our jobs become harder because of this,” Fleming said, referring to the momentum around states reopening.
Asking more of staff
Several challenges lie on the staffing side. Senior living associates have in many instances performed heroically during the pandemic, including by curtailing their social interactions to prevent bringing Covid-19 into a community. Some workers have even been living on site.
However, this type of self-isolation will become a bigger ask as restaurants, salons, gyms, bars and other businesses re-open around the nation. Senior living providers fear that workers will begin to patronize these businesses in the weeks ahead, become infected, and bring the virus into communities in larger numbers than they have up to this point.
At the same time that states are reopening, public health authorities are pushing mandated testing in assisted living communities. While providers have been clamoring for more testing, these mandates have raised many questions about how tests will be accessed and paid for; more widespread testing also could mean that many more asymptomatic staff members will be diagnosed with Covid-19.
Identifying cases of asymptomatic Covid-19 is crucial to safeguarding communities, but could mean that operators face sudden and acute worker shortages as large numbers of team members go into quarantine — a possibility that seems especially plausible in states that are reopening.
“If we had, say, 10% to 20% of staff test positive for asymptomatic Covid, we’d be in a pickle,” Fleming said.
In one ominous sign of what can happen to a community when such a staffing crunch occurs, a Transforming Age assisted living community in Minnesota recently was evacuated and then permanently closed after testing revealed a high proportion of infected staff members. Similar situations are sure to occur elsewhere as testing increases, Transforming Age CEO Torsten Hirche told SHN.
With these worst-case scenarios in mind, providers are employing a variety of strategies to keep the risk of infection as low as possible among their teams.
Georgia was among the first states to reopen, and some providers there asked workers to sign a pledge that they would continue to abide by strict self-isolation measures. It’s an approach that is gaining more traction as other states reopen. Ward expects that an employee pledge is “coming down the pike” for Dial, and Pinkerton was preparing to discuss such a pledge with Heritage’s HR attorney on Monday afternoon.
In particular, Pinkerton would like to prohibit team members from going to bars, given how difficult it is to maintain social distancing in these environments, he told SHN. He believes there might be more flexibility around restaurants or other environments that can limit the number of patrons and keep them physically distant.
Ongoing staff education is another key strategy, with frequent communication about the dire consequences that could result if team members let down their guard too early. Fleming described the concerted effort at Well-Spring as a “PR campaign.”
The campaign included a message that he shared with staff members, in which he compared Covid-19 with an experience he had in the past, of attending a loved one’s funeral where dozens of people were infected with norovirus. He hopes that making it a “personal message” helped drive the point home.
“We’ve also hammered away at personal responsibility,” he said. “We talk about, in order to exceed [residents’] needs, we have to be exceptional in our ability to avoid crowds. If we have to shop, shop at off-hours … if you go to the gas station, make sure you have a plastic bag in your car or make sure the gas station has a plastic mitt that you can use as a barrier between yourself and the gas handle.”
Many providers are also still paying premium wages to frontline workers and are looking for other ways to recognize their contributions and keep spirits up. Dial is doing “anything we can” to enhance team member morale, Ward said.
“As long as they come to work and feel safe and feel relatively happy, they pass that on to the residents,” she said.
And, providers can in many cases point to the successful outcomes that their policies have achieved up now. Well-Spring has not had any confirmed cases of Covid-19 in its life plan community and just one in its PACE program, while Heritage and Dial have logged just a handful of cases among staff and residents.
Friction grows between residents, providers
Staff members are not the only ones who have been living in a state of isolation. Residents also have been confined to their units for weeks and are eager to have visitors and venture outside of the community walls. This situation could present particularly thorny issues for senior living providers in the weeks ahead, particularly with regard to independent living residents.
Providers may have to accept that some independent residents will begin to go shopping, visit salons or engage in other activities once stay-at-home orders are lifted. Pinkerton believes that without the governmental order in place in Wisconsin, Heritage probably lacks the authority to limit residents’ ability to come and go. So, he is contemplating putting barriers up to limit interaction between IL residents and frailer residents in assisted living and memory care.
Dial has been asking all residents who leave a senior living community to self-isolate for 14 days on their return, is communicating the importance of maintaining precautions, and is keeping its communal areas closed and activities suspended. However, Ward acknowledges Dial’s limits — many IL residents have cars, communities have underground parking, and there is not a feasible way, nor an appetite, to pursue policies that limit people’s basic freedom.
“We don’t lock them in,” she said.
Well-Spring also has a 14-day self-isolation policy in place for anyone who leaves the campus, but Fleming acknowledges that this is to some extent an honor system, as it is physically possible for residents to come and go.
Amenities and wellness programs at Well-Spring have been largely closed due to Covid-19, but normally are very popular. So, the organization is stressing to residents that the more often they leave the community, the longer it will take to restore those programs, as well as communal dining.
“We’re delivering the message that the more you go out and mingle, the more we have an obligation to socially distance you,” Fleming said. “… It’s not a great message to deliver, but it’s one I’m delivering.”
Well-Spring is also doubling down on rules around wearing masks whenever in public, as well as on signage and tape to indicate restricted areas.
This situation with independent living residents coming and going is causing providers consternation from an infection control standpoint, particularly as more vulnerable people could be exposed to danger in communities with multiple levels of care. However, providers also appreciate the desire among independent living residents to live life to its fullest, and are sensitive to the damage that overly tight restrictions could have from a marketing standpoint.
Fleming offers the example of golf courses opening, and senior living residents not being able to play a round with friends who are still living in their single-family homes. Such scenarios worry him.
Other providers should be giving serious thought to these situations as well, according to Bobby Sumner, president of senior living marketing and sales firm Retirement Dynamics.
“I’ve had several friends who’ve said, ‘I was interested before but I will never move to a community where I’ll be sequestered in independent living like this,’” Sumner told SHN. “My concern is that there may be a lot more people feeling like that.”
In particular, he’s concerned about “one-size-fits-all” policies that place the same limitations on every level of care, while independent living in particular needs to “loosen up.”
Expecting people to self-quarantine for 14 days after going to the grocery store is not viable, he believes, particularly if the pandemic stretches into mid-summer and then surges again the fall, as some predict. If this occurs, residents could be living in lock-down for the better part of a year, and Sumner warns that this situation will lead to waning interest in senior living among potential consumers.
And, providers can ill afford further tightening of the sales pipeline. Already, new inquiries have declined and occupancy has dropped since the pandemic took hold, taking a bite out of providers’ revenue at the same time that expenses are soaring. Operators have pursued measures to shore up finances, including rent deferrals, but there are signs that distress will deepen in the weeks ahead, starting with thinly capitalized companies or those that were already on the brink before Covid-19 struck.
At least nine borrowers in the senior housing and care sector have drawn from debt service reserve funds, violated bond covenants, or requested a discussion with bondholders to renegotiate terms since March, according to a recent Moody’s analysis. And Fitch Ratings cautioned that continuing care retirement communities have weathered Covid-19 so far but are facing greater tests in the weeks and months ahead. For senior housing portfolios held by real estate investment trusts, Fitch anticipates monthly occupancy declines of 200 basis points to 400 basis points due to the coronavirus.
Suffice it to say, senior living providers should be taking all reasonable steps to shore up occupancy and nurture demand. The smart approach, in Sumner’s view, is to develop policies that allow for some measure of visitation and that maximize resident autonomy, especially in lower acuity settings.
Dial and Well-Spring are taking this approach. They plan to allow scheduled visitations with proper social distancing and disinfection procedures. For example, Well-Spring might create a dedicated visitation room that is separate from resident units and activity spaces, where visits could happen at 15-minute intervals, with deep cleaning using an ionizer in between, Fleming said. A plexiglass barrier might also be installed. Now that the weather is getting nicer, Dial is starting to offer outdoor family visits, Ward said.
The forecast for senior living is not entirely dire. Occupancy is showing some signs of stabilizing, according to the latest weekly provider survey from the National Investment Center for Seniors Housing & Care (NIC). And independent living demand has held up so far through the pandemic, survey results from Enquire suggest. The House of Representatives last week passed a $3 trillion aid package that could provide support for senior living providers, including through a hazard pay fund for essential workers — although the bill faces an uphill Senate battle.
Fleming, Ward and Pinkerton all say that their organizations have been able to control costs through operating efficiencies while also drawing on capital reserves, and are not in any immediate danger from a financial perspective. Heritage even secured a new construction loan on Monday.
Pleased though he is with that financing and with Heritage’s performance to date during Covid-19, Pinkerton is going into the next month in a state of high alert.
“I’m very, very concerned that the good record we’ve made so far could be very much at risk,” he said. “I can’t fathom seeing bars and restaurants opening up … so, I’m very, very nervous for the next 30 days.”