Covid-19 proved, above all, that senior housing is a health care product.
As the industry moves toward a post-pandemic environment, however, many assisted living providers still grapple with balancing health care with hospitality.
Striking the right balance is imperative as more seniors enter the space with multiple chronic conditions. Assisted living providers with standardized approaches to care can bolster operations, improve lengths of stay among residents, and manage multiple comorbidities longer so that they do not progress.
And the time is perfect for assisted living providers of all sizes to implement such programs, Dr. Steven Fuller, president of Illumination Analytics, told Senior Housing News. The Raleigh, North Carolina-based company provides “at a glance” health profiles for assisted living providers, identifies the chronic conditions of residents, and creates plans that lead to better health outcomes for residents and operations for communities. Fuller previously served as vice president and corporate medical director of Presbyterian Senior Living.
There are barriers to implementing standardized care in assisted living — notably, licensure regulations for providers, and enforcement, vary by state. According to Fuller, executive leadership, particularly among larger providers, continues to prioritize hospitality over care. This harkens back to assisted living’s origins as a hospitality-forward product. Adding medical leaders to C-suites can lay the foundation to standardized care in assisted living, but few actually do.
“It still boggles my mind that [providers] come to me to guide their health care, and yet have no one [in leadership] to do that,” he said.
Few successful models
There are successful models in which assisted living providers have implemented a standardized approach to care for residents. “Standardized” does not mean that each resident receives cookie-cutter care, but rather that there is a unified program in place across a portfolio that defines best practices and consistently drives high-quality outcomes.
Perhaps the most notable example is Juniper Communities, with its “Connect4Life” integrated care program. The Bloomfield, New Jersey-based provider has placed the program front and center in all aspects of operations, from sales and marketing to daily care. In 2019, AllyAlign licensed Connect4Life, to serve as the foundation for provider-led Medicare Advantage plans that AllyAlign helps launch and manage.
Connect4Life is so successful, Fuller cites it as an example of how a provider can successfully integrate care with services.
But, an increasing number of providers have created more integrated models to address whole-person health and wellness.
Eclipse Senior Living also takes a standardized approach to clinical care in its assisted living cohort, Chief Clinical Officer and Senior Vice President Sharon Roth Maguire told SHN. A gerontological nurse practitioner, she heads the Lake Oswego, Oregon-based provider’s wellness, care and quality division. Eclipse’s portfolio encompasses over communities in 25 states.
Since joining Eclipse in 2020, Maguire adapted slimmed-down nurse practitioner protocols, or pathways, which can be utilized by staff to establish baseline health profiles and monitor changes in condition.
For example, if a resident is prone to falls, information is collected for evaluation and interventions are introduced to reduce the frequency of falls. Additionally, community clinicians maintain contact with a resident’s primary care provider to collaborate on care.
“We want to modify [residents’] care so that there is balance between [reducing] the serious negative consequences of those health conditions, while also weaving in the element of a very person-centered approach that also honors residents’ choice,” she said.
Revera Living takes a holistic approach to managing chronic conditions, said Dr. Rhonda Collins, chief medical officer for the Mississauga, Ontario-based provider, which operates a portfolio of 175 communities. Revera focuses on six dimensions of wellness: physical, emotional, social, intellectual, environmental, and spiritual needs. This allows the provider to ensure residents receive the care they need while managing chronic conditions.
This involves multiple departments working together: culinary, recreation, and nursing and personal support staff, to assist residents in achieving their health goals.
“[A successful wellness program] can’t just be about nurses who take blood pressures and administer medications,” she said. “It has to be about a culinary staff, interested in ensuring that their offerings meet the needs of our residents.”
Polypharmacy plays a substantial role in Revera’s approach. A 2019 report released by the Public Health Agency of Canada revealed over one-third of seniors live with two or more chronic diseases. In 2018, 27.2% of U.S. seniors had multiple chronic conditions, and 39% take five or more prescriptions daily.
Collins and other physicians believe that some medications may no longer be effective for particular residents, and that combining some medications leads to interactions and side effects that seniors may not be able to articulate. Other prescriptions, such as proton pump inhibitors found in acid reflux medication, are only supposed to be prescribed for short periods of time.
Creating a baseline health assessment for residents, in conjunction with primary care physicians and family, can determine necessary medications and proper dosages. Combined with Revera’s wellness-centered approach, this contributes to more positive health outcomes.
“Those are the kinds of educational pieces that we try to have with our residents,” she said.
Partnership opportunities expanding
Covid-19 presents providers of all sizes with a range of opportunities to bring standardized care into assisted living communities.
Those opportunities range from partnerships with health systems, expanding home- and community-based service offerings, and using telehealth platforms, said Dr. Sarah Howd, associate professor of medicine at the University of Rochester Medicine Geriatrics Group. She is also the medical director of the university’s senior living practice.
Howd personally provides clinical services for eight separate assisted living facilities across the Rochester, New York area — each associated with a different operator with varying expectations on how to implement standardized care in their buildings.
She acknowledges that it is difficult, but not impossible, to lay the foundation for a successful care plan in separate communities. The key is giving staff agency in the program. Everyone, from nurses and care aides to hospitality and dining staff, is around residents daily, and they are the first to recognize signs of declining health.
It also makes coordinating care simpler, especially if clinicians can examine residents and work with care aides, on site.
“[This provides] a ton of insight that you don’t otherwise get when the patient is coming across town to your office,” she said.
Howd believes that the pandemic will open the door for providers to entertain establishing standardized care plans in their communities in the future, and for many it is imperative that they do so, because more people are moving to senior housing with multiple chronic conditions.
“The assisted living resident of today is the nursing home resident of 15 years ago, yet [some providers] are still trying to maintain that social model with sicker patients,” she said. “They’re not going to be able to retain them.”
There are notable efforts to bring more care on site in senior living, including an initiative from real estate investment trust Welltower (NYSE: WELL) and Anthem affiliate CareMore. And organizations such as Oak Street Health, which are driving more integrated care for Medicare Advantage beneficiaries, are also starting to work with assisted living providers.
Still, the reticence of providers to accept that health care is more prominent in today’s assisted living settings is one of the main obstacles to establishing care partnerships, Fuller told SHN.
Complicating matters, executives with clinical experience are lacking in the C-suites of providers, and those that are in positions to make decisions do not recognize that there are health care groups looking to partner with providers on standardized care plans.
Still others have not evolved their thinking about the assisted living business model. Some providers insist that the product is still primarily one rooted in hospitality, even as Covid-19 proved that a balance between services and clinical care can be achieved.
“It is unbelievable, the resistance that some providers have to physician groups that want to come in and provide onsite care,” he said.