While he has always been adaptable based on a changing operating environment, 2020 truly served as a test for ALG Senior President and CEO Charlie Trefzger.
In conjunction with its response to the COVID-19 pandemic, the company implemented a name change from Affinity Living Group to ALG Senior on July 1, as well as a complete reorganization of its operational structure, to give its 130 communities nationwide more autonomy.
But this is just the latest change that Trefzger has driven. In recent years, he has put ALG Senior on the forefront of creating a more affordable assisted living product with an innovative approach to care delivery and payment.
And throughout his career, Trefzger has prompted, accepted and led change, with more efforts on the way. SHN spoke with Trefzger about his approach to change, now and in the future for ALG Senior.
What have been the biggest changes that ALG Senior has made since COVID-19 hit in mid-March?
Gosh, what hasn’t changed?
There have been been so many things that we’ve had to adapt to, such as visitation; narrowing our network of health care professionals; gathering data and having a greater reliance on data; the screening of our employees; using technology, both for visits as well as data-gathering and for activity programs; the need to address loneliness in our residents and trying to be innovative with visits.
Probably our biggest change is communication with our constituencies, our families, our residents, our staff, and our regulators and our public. Additionally, pivoting to ensuring the wellness of our residents by deploying infection control practices throughout our business has been extraordinarily important. Psychological health needs have also been extraordinarily important.
What lasting changes do you believe COVID-19 will bring to ALG or to the industry overall?
The further medicalization of assisted living. I think you’re going to see a greater and greater reliance on the health care support and care coordination that our business has to provide. I think you’re going to see the continued narrowing of the network of health care professionals coming into our buildings, and we have to narrow it.
The continued reliance on data and the ability to collect data by new means. I think all of us as an industry are going to have to become very adept at understanding what our data is telling us.
Marketing is changed forever. We are not going to be marketing like we have in the past with our sales folks. The world has shifted, and we pivoted early. I think that protective equipment and infection control will remain a very important part of the care of our residents and the expectation of our constituencies. Visits by our families are changed forever. We’re constantly thinking about how we do it.
What has been the biggest lesson learned so far during COVID-19, and how have you changed ALG’s operations as a result?
Expect the unexpected. And this has been an awakening to not just our pandemic challenges, but challenges across the spectrum. I think we’ve learned this not just at ALG, but in our country and in our world. You have to be prepared for things you never dreamed could occur. We always had protective equipment, but we never had the volume of protective equipment that is required today. And having those supply chain relationships and the ability to gather that material quickly will help us ensure that this will never happen again.
We had zero flu outbreaks this year [as a result of our infection control protocols]. That is the sort of thing that we learned, and we’ll continue to learn and follow.
Data-gathering technology is so important. Right now, we’re using tablet computers to screen all of our employees coming into the buildings. And we know from a global perspective here at ALG Senior how they answered their questions, what their temperature and pulse oximeter readings were. But we also were able to compare that with our payroll records and ensure that everybody is screening properly. If you’re on the time clock, you better be through the screen.
Describe a change or changes that you’ve led at ALG Senior or in the senior living industry that you are most proud of.
I am proud of the focus that we have had on not just being a senior housing provider, but a health and wellness provider within the senior living industry.
Most of our residents are elderly, 80 plus years of age, and have multiple health conditions. They and their families have decided on an assisted living community, because their loved ones have functional or cognitive impairments that make it no longer safe for them to live at home.
Quite often, they need assistance with their daily living activities or managing their medications.
In order to provide the best quality care to our residents, we have health care providers onsite to deliver medical care, including physicians, nurse practitioners and physician assistants. This obviates the need for our family members to transport their loved ones to a doctor’s office. If there’s a change in the resident’s condition, we can intervene quickly and hopefully mitigate the need for unnecessary transfers to the emergency room.
We have been able to reduce avoidable hospitalizations, and we know that hospitalizations for older adults can be associated with adverse events, including delirium, hospital-acquired infections and false unnecessary medications. We have on-site therapy, including physical therapy, occupational therapy, and speech therapy. We work very closely with home health services, as well as hospice services.
We provide these services inside of a proactive approach, so that we can reduce the need for skilled care in the future. I would say those things leading up to an integrated health care model is what I’m most proud of. That’s moving a mountain. It takes a team.
When you say it’s moving a mountain — creating that integrated system — what are some of the challenges that make it hard?
It’s a human challenge. It’s a technical challenge. It’s a cultural challenge. Trying to get various disciplines, including physicians, nurses, and the assisted living professionals, to come together and accept that there’s a need for this integrated health care model is not easy.
It’s evidenced by the fact that the doctors and their PAs and NPs can be our greatest source of growing our census and also our greatest deterrent from growing our census. We face unnecessary transfers to the hospital and unnecessary transfers to nursing homes when we could do all of those services in our communities already.
We have to adapt and change the culture of the health care profession to recognize what it is that we’re capable of doing, but it’s also incumbent upon us as industry members to train, to share and to explain to our constituencies and to our brethren in the health profession that we can do these things.
Aging in place is very real. People don’t want to move if they can avoid it. We need to do everything we can to fight for the right of our residents to remain in their homes, which we are, as long as they possibly can.
That’s one of the challenges. Then, technology is another. I’ve worked very hard on trying to bring technology to our industry and to our relationships with our health care partners to create this integrated model, but the integrated model only works if you’re communicating. The best way to communicate is with technology. There are platforms out there that are improving all the time and making it easier, but we’re not there yet. We have to continually strive to get there and improve our communication for the betterment of our residents.
Can you update us on some of the changemaking efforts that are going on at ALG Senior right now?
We’ve always been focused on the middle and lower-income individuals, as you know. More than 50% of our residents in our North Carolina communities are dual-eligible beneficiaries. We are proud that we can provide a home and care for these very deserving residents. We’re actively positioning for value-based care, especially as a reimbursement model. Not only from government payers, but also the insurance world.
We’re actively positioning for value-based care.
We intend to be valued partners to hospitals, managed care organizations and ACOs. We’ll do this by demonstrating our value, and this requires data. Without data, there is no trust. We have implemented electronic health records when we are collecting data, not only on our quality measures, but on hospital readmissions, unplanned hospitalizations, the care experience and the cost of care. That’s one of the biggest things that we’ll continue to be focused on over the next few years.
We have worked real hard on clinical innovation hubs in our various markets, where we can pilot and test innovative care models. We try to find out what is working and what isn’t, and learn how to create an effective model that we can disseminate to all communities. The culture of each community is very much determinative of what we’re able to accomplish.
Now, we have our ALG Reduction In Serious Fall Events. That’s called our Arise Program. That is a multifactorial assessment and targeted intervention to reduce the risk of falls and fall-related injuries. This was based on clinical guidelines from the American Geriatric Society. Then we have our INTERACT ALG Interventions to reduce acute care transfers. This is a very big initiative that we’re working on.
It uses the INTERACT program, which is the Interventions to Reduce Acute Care Transfers program, that was modified for the assisted living setting. This program consists of a suite of communication, decision support and quality improvement, and frankly, advanced care planning tools. The goal is to reduce avoidable hospital readmissions and unplanned hospitalizations through earlier recognition by our staff of changes in condition.
Then we have our person-centered toolkit that we’ve developed. We implemented this toolkit, which was developed by the Center for Excellence in Assisted Living, or CEAL, in collaboration with Dr. [Sheryl] Zimmerman from my home state here, UNC Chapel Hill, and several of our assisted living communities, and it’s going great. This toolkit helps us identify areas where we improve the care experience for our residents and our associates as well.
We also have the ABCD: the ALG Bug Control Demo. It’s ironic that we’re implementing this during this period of COVID-19. This project is focused on infection control and antimicrobial stewardship. This is something that we are extraordinarily focused on right now as you can imagine.
We implemented a pandemic flu policy some time ago. Since, we have tailored it to the COVID-19 policy, which is founded upon the CDC guidelines. We’ve been drilling and practicing that for a good portion of the last year, and Lord have mercy, here we are right now dealing with it. We continue with our Medicare Advantage planning. Of course, everything’s taken a backseat to the pandemic right now. But we continue to talk with stakeholders and innovators in this area. The longer this goes on, the more data we collect, and the better at it we become.
You mentioned what you are doing with Medicaid and reimbursements in general. Do Medicaid rates or just reimbursements in general affect cash flow or create financial challenges? What do you do to mitigate them?
We live in a very progressive state here in North Carolina. We’re very fortunate to have a forward-thinking leadership, and we have so far been extraordinarily blessed with the payment of our fees that were due to us. That has fortunately not been a challenge.
When you’re working inside of the value-driven, cost-conscious world that we do, you run into periods of time where the Medicaid rates can lag behind the market. The government tends to step those rates up incrementally over longer periods of time than you would like, and you have to be very adept at controlling your costs and being extraordinarily efficient in order to adapt to those changes.
Here in North Carolina, we’ve struggled with our legislature in our administration to come up with a budget. We have been working on previous budgets, which have not included rate increases for us for a period of about 18 months to 24 months. It does make it a little bit challenging.
If you’re going to be in this government-supported world, you have to be attentive to not only your costs and being value-driven and cost-conscious, but you also have to be a great advocate for your residents, and the need to hold your legislator or your leadership accountable for the needs of those residents.
Do you think that the COVID-19 crisis will lead to any longer-term changes in this industry? If so, what?
I think a couple of things are going to happen. First, the value-based, cost-conscious consumer, as we move into this new world that we’re in, will become increasingly concerned about the cost of the care and the ability to pay. I’m sure you’re seeing it.
The ability to charge what historically were the rates, I think you’re going to see a contraction of those rates.
But moving away from the financial side of it, where I think the industry is going is an integrated health care model, which forces us as senior housing providers to be within the post-acute network in a much more dramatic role. It’s already happening, but it’s not happening fast enough, and it’s not being accepted by enough providers.
What do I mean? Care coordination and integration of the health care model into our space is here, it’s now, and people are expecting it. My residents and their families expect it. I’m certain other people are experiencing the same thing. We have to quit fighting it and start accepting it and embracing it.
Is the industry-changing fast enough to keep up with what you see are the pressures that are shaping it?
Not really. I think we tend to be followers instead of leaders. We let other people take the lead, when we need to do it. It’s the perception of the medical industry that the AL industry is reluctant to embrace medical professionals and incorporate them into the senior housing world. This isn’t coming from just me, I’m a member of the American Medical Directors Association’s Committee on Assisted Living, and I hear this directly from chief medical officers all over the country.
I think we tend to be followers instead of leaders.
They believe that the only way to solve this is with federal oversight. I, of course, don’t agree with that concept. I think that we, as an industry, have to encourage one another to adapt to this integrated care model. We can tap into the medical expertise of our care partners and integrate our record-keeping and our communication and create interoperable models that allow us to seamlessly transfer information and data to one another. That’s what the future is all about.
Do you have any advice for other leaders in senior living as they embark on their own changemaking efforts?
I think we need to think about the eight-step model for leading change from Dr. John Kotter at Harvard.
One, we need to create a sense of urgency to get the job done. Number two, we need to get the buy-in of our leadership and build guiding coalitions. Number three, we need to form a strategic vision and initiative. Number four, enlist a volunteer army in putting together the project teams. Number five, enable action by removing barriers. Six, generate short term wins. Seven, sustain acceleration. Then finally number eight, institute change. Make them part of our bloodstream.
Changemaking means you need to take risks. How do you describe your tolerance for risk?
I have a pretty high tolerance for risk. However, it’s risk with a calculation that I’m quite certain that we will be successful. Sometimes, it takes longer than I would like to be successful, but when you’re in charge of your destiny, you have to be able to take those risks. If it takes a little longer than you first thought, you have to have perseverance to get it accomplished.
How do you think about timing, to be ahead of the curve but not too far ahead of the market?
Timing is everything. I try to be in front of the curve, but sometimes you’re too far ahead of the curve, and you’re making decisions based on information that isn’t fully processed. Be out too far ahead, and the technology and the processes haven’t been fully developed. One thing that I would tell folks is, there’s a lot of technology, a lot of great ideas out there. But if you don’t have a systems process engineer, systems engineering, you can get caught real quick.
Describe a time when you tried to lead a change, and it didn’t go well. What happened and what did you learn?
We tried to roll out some software that was complex and difficult for the communities to learn how to use, and we did it in an inelegant fashion. Rather than the advice I just gave you about changemaking, I skipped some steps and it didn’t work. That’s why I follow those eight steps very carefully. Systems engineering for the implementation technology is incredibly important. You cannot have enough of it. I would encourage everybody who’s thinking about implementing change to learn about systems processing and how it works and what you need to do.
I am passionate about this industry and the care of seniors. I’ve seemingly done it my entire career, my adult life. Now my children are in it with us, and I’m very proud of that. We’ve been very blessed with a great team here at [ALG Senior]. Our company is founded on this concept of making the world a better place for folks who can’t or are unable to take care of themselves, either physically or financially. So thank you for this opportunity.