The Alzheimer’s Association recently released a report that found patients with dementia were more likely to contract Covid-19 than their healthier counterparts. It’s a reality known all too well by memory care providers, which had endured several years of headwinds before the pandemic forced them to confront even more harrowing challenges.
Now, they are trying to build back — and although average occupancy in the sector has dipped to about 77%, there are reasons that providers are optimistic about how 2021 will play out.
One such provider is Radiant Senior Living. When the first wave of the coronavirus pandemic swept across the U.S. April, an unknowing asymptomatic carrier infected four memory care residents at a Radiant community in Nevada. The Portland, Oregon-based provider’s portfolio includes memory care segments in eight communities in Oregon, as well as two standalone memory care communities in Montana and Nevada.
Those residents, who were also asymptomatic, wound up spreading the virus across the community. Within a few weeks, Radiant had a full-scale outbreak, Owner and COO Jodi Guffee told Senior Housing News.
“It spread like wildfire,” she said.
The outbreak is emblematic of the fears memory care providers across the industry felt as the pandemic took hold. The challenges to keep memory care residents and staff safe from the virus are more pressing than in lower care settings, because the slightest disruptions to their daily routines can increase the chance of agitation and disruptive incidents.
And, standalone memory care providers in particular came into the pandemic after a rough few years, as oversupply and other challenges led to census declines. So, some memory care providers faced potentially dire situations from a financial perspective, if the pandemic led to further significant drops in occupancy.
But as the industry nears the one-year mark of the pandemic, memory care providers have adapted in their response to outbreaks, going to great lengths to stay nimble in order to keep staff and residents safe. And, memory care communities and segments have also experienced occupancy decreases, but the needs-based level of care of the product type has insulated it from more severe dropoffs.
Now, there is promise that vaccine clinics and vaccinations will restore consumer confidence in memory care, and spark a bounce back in occupancy.
But memory care providers are not out of the woods yet. For example, hopes are tempered due to lagging vaccination participation among staff, for a variety of reasons.
This is leading some providers to consider mandating staff vaccinations as a condition of employment. Notably, Silverado recently announced that staff must be vaccinated, Co-Founder and CEO Loren Shook told SHN.
“We have such a highly vulnerable population of people with dementia that have to be with us,” he said. “We cannot anticipate the next variation of this strain of [coronavirus] — we know there will be more variants coming.”
Needs-based demand helps occupancy
The pandemic has led to dramatic occupancy erosion across the senior living industry. On an industry-wide basis across primary markets, Q4 2020 occupancy was the lowest on record, at 80.7%, according to National Investment Center for Seniors Housing & Care (NIC) data.
The occupancy rate for memory care segments among the 31 primary markets tracked by NIC ended the fourth quarter at 76.9%, compared to 83.5% in Q1 2020. But the rate of decrease slowed as the pandemic continued, on a sequential basis.
The occupancy rate in memory care communities decreased 2.9% from the first quarter to the second quarter of 2021. Conversely, the decrease from the third quarter to the fourth quarter was only 80 basis points, compared to independent living’s 150 basis point drop, NIC Research Statistician Anne Standish told SHN.
The data suggest that despite their particular vulnerabilities to Covid-19 outbreaks, the precautions that memory care providers put in place were able to stabilize communities and prevent more catastrophic outcomes that seemed possible in the pandemic’s early weeks.
Still, in memory care as in other care levels, in-person tours and move-ins ground to a halt during the pandemic’s early weeks, and while some providers were able to offer smaller in-person tours and most have resumed move-ins, the velocity generated was not enough to mitigate attrition, either due to positive coronavirus cases or other factors.
“You can’t move people in, and over the course of a [given] month, a few people may pass away anyway,” Shook said. “[You’re going to] see a dip until you can get through that outbreak and start moving people in again.”
Mark McBride, vice president/general manager of the assisted living division for ProMedica Senior Care, concurs. He indicated that occupancy percentages and declines across the health system’s assisted living communities is consistent with industry averages since the pandemic began. Based in Toledo, Ohio, ProMedica’s assisted living portfolio includes Arden Courts, a memory care brand with 55 communities in 11 states.
Providers are reporting improvements in the pace of move-ins across independent living, assisted living and memory care, according to the latest executive survey insights report from the National Investment Center for Seniors Housing & Care (NIC). One a week-over-week basis, memory care exhibited the biggest surge in occupancy from mid- to late-January.
Conversely, more organizations with assisted living and/or memory care units reported accelerations in the pace of move-outs in the past 30-days than at any time since NIC began the survey series last spring, with 39% of respondents saying the pace memory care move-outs had increased over the previous 30 days. However, that time period included the winter Covid-19 surge that has begun to abate as vaccinations have increased.
Further memory care-related data also paints a mixed picture. Memory care inquiries decreased 17% in 2020 compared with 2019, but conversion from tour to move in actually increased slightly in 2020, and the length of the sales cycle was essentially unchanged, according to the Annual Sales and Marketing Benchmark Report from Enquire.
These stats suggest that the needs-based nature of memory care helped keep demand stable despite the pandemic. It’s an idea backed up by McBride, who explained that memory care has not seen the occupancy dropoff of independent living or assisted living, because the segment has a higher level of need associated with it. Covid-19 is accelerating move-ins for memory care residents who cannot live on their own without the services the communities provide.
“Those that have [significant cognitive impairments] have escalated,” he said. “Those are the people we’re seeing that are still coming through the door.”
Occupancy across Radiant Senior Living’s 10 communities with memory care segments have also experienced dropoffs. But those declines have not been as severe as in independent living, because it is so driven by need, Guffee told SHN.
“Any operator would not be completely truthful if they didn’t say there was a decline of some sort,” she said.
Constant adaptation, education
While needs-based demand continued to drive memory care inquiries during the pandemic, providers also had to take steps to safeguard their communities and inform the market about their efforts and outcomes.
Radiant decided early to err on the side of transparency with prospects and their families regarding the safety of the company’s memory care communities. Guffee recognized that the fears of prospects and their loved ones are valid, and believed that addressing those fears with facts was a better approach than reactive responses to bad press that confused senior living and nursing homes.
“The approach that we’ve taken is a point of education, making sure people understand what we are doing to keep their loved ones safe, and what would make us different as operators than as somebody else down the street,” she said.
Social distancing presented one of the toughest challenges for memory care providers during the early weeks of Covid-19. But they have adapted as new information about the coronavirus became available.
Guffee estimates that Radiant changed its Covid-19 response protocols at least 15 to 20 times during the first five months of the pandemic, based on updated guidance from the Centers for Disease Control and Prevention (CDC) and local public health authorities. At times, CDC and local guidance would contradict each other.
“To say that we changed our policies and procedures twice a week is not an exaggeration,” she said. “Sometimes it didn’t make sense.”
Guffee’s role has changed as the pandemic has evolved, as well. In addition to her normal responsibilities as COO, she has become a Covid-19 policy analyst and compliance officer to ensure Radiant’s response is uniform across the portfolio. In Oregon, where the majority of the provider’s communities are located, providers are required to work with the state Safety, Oversight and Quality as well as with Oregon Health Authority and local public health authorities, on compliance guidelines.
Radiant cohorts residents where it can. Additionally, it set up infection control guidelines to allow for visitations when possible, including “hug screens.”
“[Compliance] is probably 85% of my time now,” she said.
One area of response that providers are adopting creating Covid-19 cohorts within memory care neighborhoods. Silverado split its communities into cohorts last March for residents exhibiting symptoms or tested positive for the virus. Additionally, it reduced the size of its healthier population to reduce the threat of an outbreak.
Shook and his team recognized that doing this allowed frontline staff to provide care for Covid-19 positive residents, while maintaining the ability to move about and intermingle, thus reducing the chances of agitation and incidents.
“[Communities] have to have social space. It has to be able to allow people to move around,” he said.
Silverado also installed high-intensity lights to simulate outdoor settings in most of its communities. Research from the University of California at Santa Barbara (UCSB) determined that high-intensity light from outside significantly reduces sundowning behaviors in the afternoon. Light therapy has also been shown to reduce the prevalence of depression and increase the quality of life of people in memory care settings.
“[Our] environments were structured to have the social spaces and access outside, and we had to do it immediately,” Shook said of the lighting initiative.
As part of a comprehensive health system, ProMedica Senior Care had access to top medical professionals including Chief Medical Officer Kent Bishop to provide guidance in its Covid-19 response, McBride told SHN.
There are several elements to the response, including cohorting when possible. ProMedica also established antechamber rooms for employees to don and doff uniforms and safety gear as necessary, when entering rooms with Covid-19 infected residents. Furniture in common areas such as sofas were removed, replaced by seating that allows a balance between safe social distancing and interaction with employees. And programming was modified to accommodate smaller group settings.
“This was all geared towards minimizing the impact on the resident, and also allowing them to still flourish and thrive with the services that we provide,” he said.
‘We can’t take that risk’
With vaccine clinics underway, memory care — like the senior living sector as a whole — is hoping to return to more normalized operations and rebuild census. But one obstacle is a disparity in the rate of resident participation versus staff participation when it comes to vaccination.
According to data from the American Health Care Association (AHCA), the overall vaccination rate among residents so far is 77%, versus 37% for staff across all levels of senior housing and care. Information from publicly traded providers also reflects disparities in staff versus resident vaccination. About 90% of residents of Brentwood, Tennessee-based Brookdale Senior Living (NYSE: BKD), which operates more than 700 communities across the country, have at least had their initial vaccine shot, CEO Cindy Baier said on Feb. 26. About 50% of Brookdale associates have been vaccinated, and Baier noted that this is higher than senior living staff vaccination rates that have been reported in the press. At Dallas-based Capital Senior Living (NYSE: CSU), 89% of residents and 42% of staff had received at least one vaccine dose as of Feb. 18.
Numbers like these have providers such as Silverado taking action to ensure compliance. Shook cites the availability of misinformation online, amplified by the country’s fractured political climate, as the driving factors behind lagging staff vaccination rates.
Silverado has seen staff participation rates as low as 50% in some of its communities, compared to over 97% of its resident population. With three major coronavirus variants identified in the U.S. which are transmissible at faster rates than the original strain, more likely to be identified, and with staff infection rates across the industry outpacing resident infections, Shook believes mandatory vaccinations are a matter of safety for its vulnerable resident population.
Moreover, as more new strains of Covid-19 are identified, Shook believes that it will be at least a year before life, and senior care, return to some semblance of normalcy. Another factor driving Silverado’s decision to mandate vaccinations: The company did so with flu vaccines last fall and saw participation rates in the 90% to 95% range, depending on the community.
“It is incumbent upon us, as leaders in the company, to make the hard decision that says, ‘We’re sorry. You have to be vaccinated to work here in our population,’” he said.
Radiant is seeing similar vaccination rates, but better disparities, between residents and staff. The company’s overall goal is to have a 90% overall vaccination rate, and 95% and higher among its residents. So far, resident vaccination rates are above 95%, while staff vaccination rates are just above 70%, company wide.
Guffee concurs that the political climate and availability of misinformation may be a contributing factor. She also noted that there is a geographic connection between more politically conservative areas of the country where the provider operates communities, and staff participation. But she hopes ongoing education efforts on the part of Radiant will overcome employee objections to being vaccinated, and not force the provider’s hand and mandate vaccines.
“We want to respect our employees’ personal liberties,” she said. “But we’re also responsible for peoples’ lives. We can’t take that risk.”