The most frequent comment I heard at our inaugural BRAIN conference two weeks ago was: This event was badly needed, because memory care is given scant attention at most industry gatherings.
I’ve observed this to be true. At most events, perhaps one or two panels — if that — will be devoted to memory care.
That is, memory care is treated as a discrete, relatively small part of the senior living industry, which might seem to be the case; the 10 largest assisted living companies encompass nearly 111,500 units, while the 10 largest memory care providers count only about 37,300 units, according to 2021 Argentum data.
But our BRAIN event drove home the fact that memory care already infuses every part of the senior living continuum and will do so even more in the future.
In this week’s exclusive, members-only SHN+ update, I expand upon this idea, sharing analysis and takeaways from BRAIN, including:
- Active adult and independent living providers are on the cusp of a massive opportunity
- Considering assisted living and memory care as separate categories is increasingly flawed thinking
- Higher-acuity memory care providers are on a tightrope, needing to both innovate and return to basics
Active adult and IL opportunities
Within senior living, “early-stage memory care” is a somewhat misleading phrase, Juliet Holt Klinger, senior director of dementia care for Brookdale Senior Living (NYSE: BKD), said at BRAIN.
Her point was that people in early-stage programs such as Brookdale’s Clare Bridge Crossings often have been living with a diagnosis for some time and already have progressed to a stage at which a higher level of support is appropriate.
So, true “early-stage memory care” would reach people even sooner in their journey with dementia, while they are still living more independently.
Holt Klinger was not the only person to make this case during BRAIN. Memory care pioneer Loren Shook, CEO and Co-Founder of Silverado, broached the topic in the day’s first session.
Some of the most exciting breakthroughs in memory care are happening in the area of diagnostics, Shook believes. He has heard of one particularly promising test to tell if an individual has dementia before developing symptoms, and he anticipates breakthroughs in this area in the coming years.
Such diagnostics are “going to be a game-changer,” Shook said.
Armed with earlier diagnoses, providers can offer people a way to slow the progression of dementia through offerings such as Silverado’s Nexus program, which has been shown to enhance cognitive functioning by 60% and slow the progression of cognitive decline, as documented by University of California, San Diego researchers.
If such diagnostics come to market, it’s easy to envision memory care operators like Silverado breaking out of their current lane in order to serve pre-symptomatic individuals with dementia who are living in their homes — including active adult or independent living communities.
And it’s even easier to imagine providers such as Brookdale, which already have a major IL footprint, extending true early-stage memory care to pre-symptomatic residents in their own communities.
While this is still on the horizon, I believe there already is a tremendous opportunity for active adult and independent living providers to offer memory care as a facet of their wellness programs. As we’ve reported extensively on SHN, senior living is undergoing a paradigm shift as operators across the care continuum shift toward fostering resident wellness rather than basing operations primarily around providing care and services for health conditions that they already have or that they develop.
This shift is being motivated in part by consumers who are driven to maintain their wellness — and this extends to their brain health. Consider Canyon Ranch’s “30 Days to a Better Brain” program, or SHA Wellness, which offers neurocognitive consultation as part of its “integrative method.”
As Holt Klinger put it at BRAIN: “Brain health is wellness.”
To me, the case seems obvious for making brain health a key pillar of active adult and independent living wellness models, with providers offering relevant educational resources and supporting brain healthy lifestyles, including through culinary offerings.
Providers that already offer more advanced memory care have a wealth of expertise to tap into, while those that are focused more exclusively on active adult or IL should consider partnerships with memory care operators or organizations in their local communities to offer knowledge and resources.
In particular, I think that active adult and IL providers should seriously consider offering educational resources on brain health to the community at large, not just residents. Resources and care management often are sorely lacking for people who have recently diagnosed dementia, and their families are overwhelmed. Providing educational sessions and materials, and perhaps even care management, is a way for senior living companies to reach potential future residents while possibly creating new sources of revenue.
Startup Bella Groves offers one model, based around membership tiers in which people pay set amounts to receive various types of services and supports — from information to care coordination to residing in the company’s small memory care community.
The shift to value-based payment models also should precipitate more focus on brain health earlier in the continuum, and before people even receive diagnoses or develop symptoms of decline. As payers recognize the costs associated with dementia and the potential to avoid or reduce those costs through wellness initiatives and earlier interventions, active adult and IL communities will become more of a frontline for memory care.
Consider these figures from the Alzheimer’s Association: $1 out of every $5 paid out by Medicare goes to someone with Alzheimer’s disease, and the cost to Medicare and Medicaid associated with Alzheimer’s disease is estimated to balloon from $206 billion in 2020 to $777 billion by 2050 — and that’s not adjusting for inflation.
Now consider that Silverado credits its Nexus approach for these statistics: an emergency transfer rate of 3.6`%, compared to industry averages of around 11.9% for nursing homes and over 25% for assisted living, and a 3.4% rate of acute hospitalizations compared to averages of over 20% for nursing homes and assisted living communities. There are obviously substantial cost savings to be achieved by reducing hospitalizations and ER visits among those with dementia.
“We need to be talking about all of this in our ILs and our ALs and our home care companies and hospitals and doctors offices,” Holt Klinger said.
Assisted living blurs with memory care
At a lunch for SHN+ members who were attending BRAIN, one hot topic was that it will become impossible to separate assisted living from memory care, given the preponderance of residents with some sort of cognitive impairment.
Already, the percentage of AL residents with some form of dementia is high. As of 2016, about 42% of residents in AL and similar residential care communities were diagnosed with dementia, according to a CDC report issued two years ago.
That percentage surely has climbed since 2016 and will increase further in the years ahead, as life expectancy is extended. As of 2015, about 5% of adults aged 70 to 79 had “probable dementia,” while that percentage was 16% for people aged 80 to 89 and 31% for those 90 or older, according to data published in the Journals of Gerontology.
I thought of those statistics last week, listening to Stellar Senior Living Co-Founder Adam Benton on SHN+ TALKS, when he said: “I think everyone can agree that now that you have like a handful of people that are over 100 in each one of [your] properties, when before meeting somebody who was over 100 was an amazing day.”
The proportion of assisted living residents with memory care needs also will increase as advancements in technologies, changes in health care payment models and other factors make it easier for more older adults to age in their single-family homes or independent living apartments, even as they need assistance with activities of daily living. Cognitive issues may already be the dominant factor precipitating moves to assisted living, some attendees argued.
There are various implications of these statistics and trends. On the staffing front, specialized dementia training for the entire AL workforce will become necessary. Many providers are creating more intensive career ladders and lattices in response to the current workforce crisis, and it seems clear that they should be incentivizing workers to advance their memory care skills with recognition, promotions and pay increases.
Providers also must recognize that as dementia becomes more prevalent in assisted living, workers have a heavier lift even to do standard ADL care. Aide hours per resident day increase notably as the percentage of residents with dementia increases.
As assisted living providers consider their wage rates and their competitiveness as employers, they should be factoring in the dementia-related acuity of their resident population.
And as the lines blur between assisted living and memory care, the need for more robust behavioral health services will become acute. This was another theme of the SHN+ lunch at BRAIN, and is backed up by data: Depression becomes more prevalent in communities with a higher proportion of residents who have a dementia diagnosis, with nearly 40% of residents having depression in communities where more than 75% of residents have a dementia diagnosis.
At the BRAIN lunch, someone observed that consumers are increasingly candid about the mental and behavioral health needs that assisted living and memory care residents have, such as substance abuse or post-traumatic stress issues, which may be separate from their dementia.
As of 2016, about 50% to 57% of assisted living/residential care providers offered mental health services — this was a higher percentage than I expected. But I think mental and behavioral health care will become a non-negotiable facet of assisted living and memory care, and providers will have to consider the options for providing these services, whether that means hiring psychologists and other clinicians directly and/or partnering with behavioral health organizations.
Furthermore, the presence of behavioral health issues can trigger a “red flag” on whether a community should accept a prospective resident, someone pointed out at the BRAIN lunch.
Of course, providers should not accept residents who they are unequipped to care for, but as the stigma around behavioral health needs continues to fade and the accessibility of services increases — as the federal government is pushing for — assisted living providers should rethink how they approach behavioral health services rather then trying to screen out residents with particular diagnoses, needs and expectations for support.
A balancing act
As to the future of memory care provided in secure environments for people with more advanced symptoms, I’ll focus here on one key takeaway from BRAIN.
The event highlighted so many exciting pathways for innovation — from tech like virtual reality, to new approaches in staffing and dining, to the therapeutic potential of cannabis, and more.
But I keep thinking about a key lesson that Symphony Senior Living CEO Lisa Brush learned from the Covid-19 lockdowns: Despite all the challenges of that frightening period, being forced to simplify operations not only helped Symphony remain Covid-free but led to some benefits for residents.
Buildings were quieter, with fewer people coming and going but a steady presence of key staff, and residents’ behaviors calmed down in “so many different aspects,” Brush said.
“As we’ve opened up, we’ve really taken that into consideration,” she said.
Symphony is more cognizant now about the volume of traffic through its memory care communities — being more selective about outside entertainers coming in, for instance. And the provider is doubling down on basic, proven memory care practices.
“All the things we know as good memory care providers — guess what? They work, they really work,” Brush said.
This is the balancing act that the senior living sector as a whole, including memory care, is trying to strike: Pushing for much-needed innovation without losing sight of time-tested practices that accomplish the most important objective, of enhancing residents’ wellness and quality of life.
I was heartened at BRAIN to see so many memory care leaders trying to gracefully walk this tightrope.
One example is Bella Groves CEO and Co-Founder James Lee. He shared the stage with Holt Klinger and expressed gratitude for the lessons he learned from her during the earliest stage of his senior living career, when he worked at Brookdale. Lee obviously has tremendous respect for Holt Klinger and is trying to remain true to what he learned from her, even as he tries to take memory care in a new direction.
I only hope that we hear more often from leaders like Lee and Holt Klinger on the industry’s biggest stages, because BRAIN made it abundantly clear that breakthroughs and best practices in memory care will play a large role in shaping the future of senior living across the entire continuum.