Juniper Communities was an early proponent of widespread Covid-19 testing in senior living — but testing doesn’t come cheap, either.
The Bloomfield, New Jersey-based provider spends about $100,000 each week on Covid-19 testing, according to Founder and CEO Lynne Katzmann. That has allowed the company to baseline test its residents and associates, and in turn help reduce its Covid-19 case count to zero on Aug. 3 after discovering dozens of positive cases among residents and staff in early April.
In short, Katzmann believes senior living providers must test residents and associates early and often in order to develop a battle plan for limiting the virus’s spread. But doing so is expensive, which is why she also believes the federal government needs to step up its level of support for private-pay senior living providers.
“We are essential health care providers,” Katzmann said during a recent appearance on the Senior Housing News podcast, Transform. “But because we are largely private-pay, people forget that we are part of that system. And I believe that needs to change.”
On Juniper’s infection prevention and control strategy:
Our goal is to prevent the spread of disease by being proactive about its transmission. Covid-19 is the second SARS-type virus.The first was in 2003. So, we’ve had 17 years since the first SARS outbreak, which was spread by people who were symptomatic. So when Covid-19 broke out, people thought, ‘Okay, it’s another SARS virus, let’s let’s deal with it the same way.’
And so all of the guidance from the [U.S. Centers for Disease Control and Prevention] initially suggested that people who spread the disease spread it while they were symptomatic. So, while they had a fever, were coughing, sniffling or they had difficulty breathing. Juniper followed all of that guidance, which suggested screening and temperature checks early on in March.
We decided shortly thereafter that we would begin testing. Why? We looked to other examples of countries that were dealing with it before us, and realized that most of the successful countries appeared to be testing regularly while doing contact tracing and isolating people with the disease.
So, Juniper went about getting a commercial lab agreement to test all of our residents and staff, and we did baseline testing at our communities in hotspots on April 1, which you may recall is a little bit earlier than most people. And what we found was very disheartening. We didn’t have anyone at the time who was showing Covid-19 symptoms in our communities, not measurably.
And yet at the time, roughly 50% of those two communities tested positive.
Now, the vast majority of those people were asymptomatic. Ninety-four percent of our staff were asymptomatic. No sniffles, no nothing. About 72% of our residents were asymptomatic, and the majority of them remained asymptomatic during their course of the disease.
What we learned is that this disease was not spread only by people who were symptomatic, but by people who were pre-symptomatic and asymptomatic. That’s a huge difference between what we thought would be the case with this virus, and it has changed markedly not only Juniper’s strategy, but since then, the strategy of the CDC and the country.
So, at the heart of Juniper’s strategy in dealing with Covid-19 has been proactive testing to provide us the data to develop a battle plan. We also employ good use of PPE, handwashing, disinfecting, cleaning, social distancing and we’ve ceased visitors. But most important to our strategy has been testing, and we have been testing since April 1.
We had hoped it would be a one-shot deal, but that proved an erroneous thought, and we are now testing all of our staff weekly, because they are the ones coming from the outside and who in turn can potentially expose our residents.
We’re finding that a combination of testing and good use of PPE, particularly masking, and cohorting — that is, creating small neighborhoods of residents that eat together, visit together to do things together, but don’t necessarily mix with the entire community — is the best strategy for minimizing the disease and deaths.
On “Camp Wellspring” and “bubbling up” senior living communities:
When we tested all of our communities early on, the vast majority of them had no Covid. We decided that the simplest way to keep it that way was to create a figurative “bubble” around the community to effectively shelter in place. This was not only for the residents, but our team members, as well.
“Camp Wellspring” is one of those examples. Wellspring is the name we give to all of our memory care communities. They tend to be smaller, and we believed and recognized — as others did — that memory care residents were the hardest to keep safe, because they tend to wander, and don’t always listen to isolation policies in the same way that others may.
In our first community that we were able to bubble up, we actually went out and rented a bunch of RVs for small staff teams. I mentioned cohorting before. And so what you do if you want to keep people safe is, you divide your building into small neighborhoods — most of our buildings are in small neighborhoods already — and you assign staff that only can be in those areas, and they don’t go to other parts of the building.
So, if you think about a camp, Wellspring was like having your own little tent community. And they were all in their little area. And when the staff were off, they went out to their RV. And so it was a lot of fun for people. Most people thought of it as a vacation, and I’m talking not only about our staff members who got a big kick out of what we were doing, but also our residents. We got everybody matching t-shirts, we did all kinds of fun activities within these small neighborhoods, and people were thrilled.
At that time, families and other loved ones were not permitted to come into the community at all. But we were able to send them lots of pictures, just like you do when you send your children to camp.
On why Juniper tests its residents and staff weekly, while other providers might not:
I believe that strategy is part of a series of steps which you must do to protect your residents, your staff, and frankly, your community. So that was the decision I made. My decision is one that’s based on an operating strategy we have at Juniper, which is to have as much data as possible to make the best decisions possible. Testing gave us the kind of data we felt we needed to make the best battle plan.
Juniper is in an advantageous position for a small company. We have the ability, because we’re small, to do things, and other companies that are much larger would have a harder problem in accessing testing. We were able to work on a partnership with Magnolia Labs early on, which provided us with the number of tests that we needed. And that was very, very helpful.
As testing has become more prevalent in the U.S., I think there are more tests that are available now and more people are using them. And the biggest hurdle right now, frankly, is not only access to quick turnaround tests, but the cost of testing. Most of us in senior housing don’t have a funding source for the testing of our associates. Most residents are covered by Medicare, but staff typically are not. Those that have private insurance can get that, and we do bill private insurance. But for the amount of testing that we’re doing, we’re spending about $100,000 a week. That will come down, particularly as we switch to the cheaper type tests and work more with Dascena.
But, it’s a very expensive thing to do. And we’ve been in a very lucky position not only to be able to access testing, but to have the cash available from our operations department. So, I do believe it’s the right thing for everyone to do, but different people have different opinions about that, and have different access to resources. And I think that’s a big part of it.
If the federal government and state governments would provide funding for testing for everyone, I think it would be wonderful. It would be advantageous not only to us as communities, but to us as society. Older adults with chronic illness are the ones most susceptible not only to getting Covid, but to being hospitalized with Covid. And hospital beds, particularly in hotspots, are hard to find. And the cost to all of us as a society of Covid care in the hospital is very high. So to the degree you can keep our communities free from massive outbreaks, you protect not only us and our residents and our businesses, but also society as a whole.
On the way forward with Covid-19:
I wish I was as optimistic as some of the news reports you hear. I do not believe that this will be over this quarter. I do not believe it will be over before the end of the year. Although I do expect that we’ll see some kind of vaccine that will get its approval, whether it will be scaled, whether people will really be safe, whether the right people will be prioritized for distribution, I can’t say.
But I see [dealing with Covid-19] at least another six months, and it could be considerably more. What do we do operationally? What do we do financially? I think there are a number of things we do in how we deal with Covid.
I think we all have learned that the people we serve need some help and need health care services. And while many of us did not need to think about infection control in the way that the skilled sector of our industry has always done, or certainly hospitals have, we’ve learned that we have to be more proactive. We have to utilize PPE in different ways than we ever did. And we have a lot of time in making sure that our buildings remain homelike rather than institutional, in light of all of these new practices. Operationally, infection, prevention, cleaning, disinfecting, how you organize activities, how you deliver food, and what you do with food, all of those things have changed markedly.
So, you’re going to see people spending more money on PPE. In March, April and May, it was very difficult to get anything, and the prices that you paid were much higher. That’s beginning to subside, we’ll see if that continues. Testing, as I mentioned before, is expensive. So you’ll have some ongoing financial costs. I believe that we can be successful to essentially keep the disease outside of our community via testing and good infection prevention, and that we will be a safe, secure and life-affirming place for people who need extra care and assistance to live throughout the pandemic. But depending on how we shape our story, and how we are able to talk about our successes, business can improve and we can operate through that.
Staffing has been a huge issue during the pandemic. As communities become part of a hotspot and have outbreaks, staffing is very difficult. Staff, just like anyone, gets afraid. Some of them get sick and they go home. Some of them were exposed. And so overnight, your staffing numbers can reduce. You have got to be ready and you have got to be prepared to have additional people come in, and you’ve got to be able to repurpose folks in your community. So, servers in your dining room might become housekeepers. Obviously, they’re not going to replace health care professionals. But we’ve been using universal worker strategies and training programs to fill in where we need to.
We’ve also done something really fun. At the height of the pandemic, which for us was in April and early May, we used our sales team to start recruiting staff. They’re just as good doing that as they are at bringing new people in the door.
On the financial side, I think that the key is going to be keeping our buildings safe and convincing people that they are safe. Improving our occupancy, which we’re starting to see, is about messaging properly. I don’t know if you saw the recent ProMatura report, but they’ve done some work to show what people want to move into senior living [during the pandemic]. And what they want is really interesting. They want it to be clean. So, being able to show your cleaning and disinfecting protocols is really important. They want to see that you’re testing, and they would also like primary care on site; they want to make sure that their loved one has access to regular medical care. So, if you can do all of those things, I think you can increase occupancy, which then improves your financial picture.
Ultimately, some of these costs are going to have to be offset, just as they are offset for hospitals and other places. The costs have to be offset for us too. And the government needs to help in that process. We are essential health care providers. But because we are largely private pay, people forget that we are part of that system. And I believe that needs to change. I think that all of our national associations are doing a great job working on our behalf to make that happen. I hope they’re almost there in getting us an allocation of money from the CARES Act.
So, we’ll see where that goes. I’m cautiously optimistic about it. There is one other thing that I’m concerned about, and that is liability. I think the number of lawsuits that will result from this are many. I do believe that it’s appropriate and necessary for people that have gone the extra mile and done their best. This is a pandemic. There’s no reason to believe that we should have been able to snap our fingers and keep everyone safe from harm. Although I will say that all of us, myself included especially, we’re incredibly dismayed because we didn’t understand enough about this disease early on to keep it entirely at bay from our industry.