A: Here are three challenging issues that operators will face during the year ahead:

• Operating expenses will increase – Labor costs, employee turnover, staff shortages, increased contract labor, wage competition and general inflation more likely will place increasing pressure on operating profits and cash flow proceeds.

• Property management is becoming more complex – Self-management is a growing challenge. More communities are converting to large, sophisticated, third-party management companies with significant economies of scale and purchasing power. 

• Size and scale of many older communities are facing pressure in the marketplace by new communities – These new properties are offering innovative state-of-the-art designs responding to increased consumer preferences.

Opportunities will continue to exist, but challenges and headwinds are increasing for the senior living industry.

That message is resonating more than ever in the senior living segment. Today, the most successful operators are leveraging IT solutions and the data captured to improve resident care and operational efficiencies and help communities gain an advantage in the increasingly competitive marketplace.

The adoption of IT applications has increased markedly in use and importance in senior living, says Jerry Wilmink, chief business officer for CarePredict. “Many senior living operators have installed high-speed wireless networks, cloud services and connected internet of things wearables and devices and have moved from paper to pixels with cloud-based electronic health records. The digitization of resident health data allows for the delivery of faster, more efficient and better care and outcomes.”

IT TRENDS

Web-based applications, including electronic health records and business solutions, and mobile devices used by caregivers to provide point-of-care documentation, are seeing some of the most widespread adoption in the senior living segment today.

“More senior living organizations are realizing they need to abandon paper documentation of care plans [and replace that with] electronic point-of-care, eMAR and nutrition management tools,” says Patrick Hart, vice president of senior living solutions for MatrixCare.

Capturing and analyzing timely data helps operators deliver more efficient care and ensure better outcomes, especially when interoperability and additional technology are effectively layered onto the EHR. As Simply Connect CEO Craig Patnode says, any successful operator will require the full EHR to be fully deployed. Some facilities are only using fragments of the EHR or none at all, he adds.

“The very first step is to fully implement EHR, including eMAR, and risk management modules for tracking resident equity. Most operators will need to invest additional capital in meeting these needs.” Simply Connect is launching a fully integrated Care Management app with a health information exchange to garner metrics, outcomes and focused care management. Greater efficiencies on the floor will be realized by connecting everyone at the community within a primary care team that includes the physician, nurse, pharmacy and family, Patnode adds.

Efficiencies of mobile charting can increase caregiver satisfaction by allowing them to focus more attention on hands-on resident care. User-friendly mobile devices also allow for quicker access to more accurate and valuable clinical data, including resident minimum data set interviews and eMAR, says Mark McIntyre, executive vice president and general manager of CareWorx.

Pegasus Senior Living has seen firsthand the benefits of handheld devices and more user-friendly documentation and reporting. As Pegasus president, Chris Hollister says, mobile technology that allows resident care team members to record the actual provision of care in real time helps solve one of the biggest challenges in assisted living: how to get paid for what you do. “When caregivers have to remember 10 to 15 care episodes and record it after the hallway is complete or even after the entire shift, nuances and details are lost. Handheld devices make their lives easier and more rewarding, and I know this for a fact by interviewing team members who have recently converted from pen-and-paper systems to hand-held devices.”

Effective IT application also can provide operators with information that can help them market their facility more effectively to prospective residents and their family members, and employees.

“Many consumers are very tech-savvy and data-driven and they are looking for points of differentiation or metrics that earlier generations of consumers may not have asked about,” Hart says. Twenty years ago, he says, the focus may have been on the aesthetics of the residence, whereas today, consumers may ask for data on resident falls or how the facility will ensure compliance with their loved one’s specific dietary needs.

To further improve marketing efforts, many senior living operators are adopting dedicated customer relationship marketing applications that allow them to market in the business-to-business space (such as to other referring providers) as well as to seniors and their family members. A robust CRM solution designed for the unique needs of senior living organizations can help operators track referral leads and customer information while also integrating with commonly used marketing automation tools, such as Mailchimp, Marketo or Pardot, Hart says.

“Senior living providers are realizing the significant gains that come from having key information about potential or current residents in one location — and easily accessible by a number of staff members day or night,” he says. “This is especially important during transitions of care and facilitates a smooth handoff during shift changes or when substitute caregivers are needed.”

DIGGING DEEPER

The ongoing integration of new connected and smart technologies is gaining momentum as practical applications are realized. “Communication, monitoring, therapy, medical diagnosis, physical safety and more are being enhanced by hardware and software solutions,” says Jim Stormoen, chief clinical informatics officer for VCPI. The firm offers a range of IT services, including strategic IT consulting, network design and management, and data security.

Well-implemented time and attendance modules and staffing solutions can offer great return on investment as well, industry experts say. As the healthcare segment continues to face a caregiver shortage, software that streamlines the process of hiring and managing caregivers is especially in demand, Hart adds.

Scheduling software that gives staff members at-a-glance details of their schedules, the ability to trade shifts and more can lead to improved employee satisfaction. Although the return on investment may be less obvious, outcomes that lead to lower turnover are generally worth the cost in the long run,” Hollister says. Pre-screening software solutions for employee interviewing also help operators develop a short list of viable candidates more quickly, he says. Pegasus Senior Living uses MatrixCare for an integrated IT solution that covers everything from CRM to billing to payables. Another example of a real and measurable return on investment, Hollister says, is the adoption of automated time clocks.

“When we first implemented these at another company in the mid-2000s, we got an immediate and measurable return on investment in real dollars. A lot of people cheat a little by clocking in five minutes early, so automated time clocks are an easy ROI to measure.”

Artificial intelligence and predictive analytics applications also are being tapped with growing frequency in the senior living segment, allowing providers to track, assess and monitor subtle changes in a resident’s daily activities and behavior patterns. Proprietary connected remote-sensing technologies, wearables and deep learning platforms create a reactive and proactive solution that empowers staff to rapidly provide care and predict health conditions such as urinary tract infections, depression and increased fall risk days ahead of visible symptoms or clinical diagnosis, Wilmink says. Facilities that deployed the CarePredict solutions saw up to 25% fewer falls and up to 61% faster staff response time, she said.

AI solutions also are helping deliver a new way to engage, educate and entertain residents, according to Stormoen. “In the near future, we’ll see increasingly widespread application of artificial intelligence [that will] play a critical role in providing improved caregiving and expanded lifestyle options for residents.”

LAYING THE FOUNDATION

For all IT’s potential benefits, senior living operators will see their investments fall short if they don’t allocate adequate time, attention and resources to their infrastructure and planning phases.

Operators need a good basic IT backbone to make everything work, and IT planning, strategy and a solid Wi-Fi network are key, McIntyre says. “Basic infrastructure still is a problem for many facilities. Many of today’s innovative technology solutions for senior care and resident services depend on having really solid, enterprise-quality Wi-Fi networks, so facilities need to get back to basics and ensure their Wi-Fi setup is adequate and can handle new demands placed on it.”

Many operators also are missing a dedicated applications specialist who can drive the applications — not just an IT director but a full-time applications specialist as a project manager who can drive the compliance, deal with staff turnover, and more, Patnode says. “It’s a challenge, but unless this happens, operators will become beholden to staff turnover, and this will not meet the results for outcomes. Any operators not charting outcomes will see a drastic change in referral management.”

What’s more, only IT solutions that are user-friendly and will work well for the senior living provider’s team and residents should be considered for adoption, Hollister adds. He urges IT vendors that are new to the space to find operators that will let the vendor shadow caregivers and other workers to better understand how life works in a community. “Too many solutions are too complex and take too much time to manage, so they just don’t work for the sector,” he says.

Facilities looking to expand their IT adoption but daunted by all the options and requirements will benefit from technology planning and strategy assistance. This will help them identify needs and goals and more effectively pinpoint which solutions — and infrastructure improvements — will garner the greatest return on investment.

“We often recommend starting with a technology assessment to get a baseline of where you are today to help guide decisions and set up a long-term plan for proper IT implementation,” McIntyre says.

Operators can use various employment practices to become a “destination employer,” ranging from little perks to flex time. Ultimately, it comes down to showing interest, compassion and empathy toward employees, says Teresa Remy, director of consulting at LeaderStat.

“Good old-fashioned TLC and letting employees know they are cared about,” she explains. “Understand their needs, show interest in what is important to them, mentor them and form relationships.”

As most senior living professionals are proud to say, providing services for people is more than just another job — it is a calling and an identity. Expecting employees to make that deep investment in their work requires some reciprocity from management for staffers to feel appreciated. Otherwise, they are likely to seek job satisfaction elsewhere.

“While employees leave their employers for a variety of reasons, some of the biggest reasons include a feeling that their direct supervisor doesn’t care about them, a desire to earn more money, lack of flexibility in scheduling and issues with their management team,” says Peter Corless, executive vice president of business development at OnShift. “When employees feel that their contributions to their employer are not valued, we often see them seeking employment elsewhere.”

REASONS FOR LEAVING

Keeping employees happy means investigating and understanding why they become unhappy. Uncovering potential systemic problems takes initiative, diligence and, most importantly, communication. Management issues are at the top of the dissatisfaction list, Corless says, and organizations often are unaware of the conflicts that exist until an employee leaves.

“This provides little or no time to address the issue,” he says. “Sometimes this can be as simple as a lack of communication with the manager, especially if they work different shifts. By facilitating communication and conversation between managers, teams and employees, these issues can be corrected at the beginning.”

The senior living industry can be a career destination, and operators need to nurture those employees who want to grow in their profession. Too often, however, Corless says, workers don’t have clearly defined paths for advancement or a true sense of purpose in the organization.

“Instead of highlighting how employees can increase their income and grow into management roles, they are left guessing how to advance based on what they see around them,” he says. “They need critical feedback on how to succeed, and it begins with onboarding employees the right way.”

FEELING OVERWHELMED

The financial component certainly is important to an employee’s happiness and some workers will leave for more money elsewhere, even if it means switching industries. Offering a competitive salary is important, but operators also need to look at the work environment they provide so that employees can experience the fulfillment that comes from making a difference in residents’ lives.

Stress is a given for those who work in senior living — the nature of the business is demanding, and the workload can be exhausting. Yet there are ways to temper the work climate so that employees don’t feel consumed by their jobs.

The “low-hanging fruit” for relieving overwork is to always have enough staff on hand to fill every shift and to make sure the workload is equally distributed among everyone. More complex is creating a system that enables employees to achieve a “work-life balance” that gives them flexibility and options to handle the demands of family and employer.

“Implement work-life balance and really live it — don’t just say your company has it,” Remy says. “Be sure all divisions in your organization have it. Nothing is more demeaning than to not have a work-life balance when the perception is that everyone else in the organization does.”

Understanding each worker’s life demands is essential to determining how best to deploy them, Corless says.

“Employees will leave their job if their work schedule is a poor fit for their lives,” he says. “If the employee has children or serves as a caretaker to a family member, it could pose a conflict with work, causing that employee to seek another job more suitable to that lifestyle.”

Best-fit scheduling is a process OnShift advocates to ascertain each employee’s work preferences and availability so that shift coverage and workload is optimized.

INCENTIVES, PERKS

Staffing specialists note that one of the most positive trends in senior living is that incentives and perks are becoming more commonplace. And employees are appreciating these morale boosters, viewing them as the equivalent of — and sometimes even preferred over — pay raises. Offering perks provides operators with a blank canvass for creativity in showing appreciation for each employee’s hard work. Perks can range from gift cards to subsidized education and professional training, depending on each employee’s needs and career goals.

“When it comes to employee incentives, we’ve seen a variety of benefits and perks employers use,” Corless says. “From tuition reimbursement and more paid time off to dress down days and pay advances, employees are seeking perks that make their day more enjoyable and help alleviate stress. One of the more innovative incentives is giving employees access to their earned wages, between paychecks, to better manage expenses.”

Because education is the best pathway to career advancement, subsidizing employees’ tuition for job-related college or certification courses is an investment that pays dividends, staffing specialists agree. Internally, creating a mentoring program that assigns experienced employees in an instructional role can be very beneficial in helping new hires get acclimated to the required tasks and become familiar with the organization’s culture. The mentor can serve as a key contact for questions and professional support as the new employee learns what is expected on the job. Reward programs that provide cash bonuses to employees for referrals also are gaining momentum as a job perk, Corless says.

“Not only does this encourage positive behavior; it also helps motivate and encourage employees for a job well done,” he says.

Gift cards and “freebies” such as complimentary meals at work may seem like minor perks, but the positive feelings they generate are tremendous. Inexpensive gift cards for gas, groceries, pet day care — even a “spa day” — have proven to be popular among employees.

“Gift cards can be exceptionally valuable when given out as incentives,” Corless says.

SHOW APPRECIATION

It may seem like a no-brainer, but showing employees that their efforts are valued is a cornerstone to building their loyalty and devotion to the organization and the residents it serves. It gives them a sense of shared purpose, of belonging and being part of a team that is doing meaningful work.

“I really like the concept of ‘servanthood leadership,’” Remy says. “This involves the desire to serve others first and has little to do with power or position. People have a tendency to follow leaders who in their hearts have a true desire to serve and do what’s right.”

As mixed as these blessings are for the healthy and afflicted, the explorations into cognitive fitness are now peeling away seemingly endless layers of mystery cloaking this dreadful disease. In the process, they are energizing the rehab community with equal amounts of hope and vigor.

In memory care, the tools of the therapy trade often have been a mixed bag. Literally. That’s what Laura Mock remembers as a novice therapist years before joining IN2L as the company’s customer success manager.

“When I started in the field of therapeutic recreation, I would spend 10 minutes setting up, not including the planning beforehand, for a specific resident. And often, for whatever reason, they were not into it,” Mock recalls. “You had to be pretty good at punting and being flexible.”

Those frustrations soon prompted Mock to come to her therapy sessions with “armloads and carts” full of therapy tools in hopes at least one of them would light a resident up.

Fast forward to now, and the task of finding that spark in a dementia-clouded mind still is hit or miss for Mock and other therapists. But thanks to research and the problem-solving moxie that memory care therapy now demands, there are more hits than misses.

Mock attributes that fact to better technology and her years of experience treating dementia.

“Finding what an individual responds to is always the way to provide interventions for success,” says Mock, a certified therapeutic recreation specialist. “My mantra is simple: If you make it fun or something they are interested in, they will participate. I’ve often been able to get residents working on strength and endurance to stand longer than my counterparts in physical therapy. How? Standing in parallel bars for five minutes is ‘yawnsville.’ How about standing while we play one a resident’s favorite games, like ‘Kings in the Corner,’ at an elevated bedside table?”

Brain games

Some may find it difficult to reconcile the seriousness of dementia with anything labeled “fun,” but that is precisely what research now has identified as a powerful therapeutic weapon. Two fairly recent studies show why and how.

In a 2010 study published in the Journal of the American Geriatrics Society, researchers set out to find how to prevent agitated behaviors among nursing home residents with dementia. In the process, they found that “structured activities, which range from trivia games to puzzles, have also been shown to have a positive impact.”

A year later, researchers, in a study published in The Journals of Gerontology, identified what they believed to be a link between cognitive stimulation and functional decline in Alzheimer’s disease, echoing the benefits of what earlier efforts had found in “later life engagement in intellectually and socially stimulating activities” such as crossword puzzles and card games.

In short, research has shown conclusively that interventions such as brain games can be a contributing factor in preventing dementia.

“There is growing clinical evidence that targeted cognitive stimulation / rehabilitation may be beneficial in improving baseline cognitive performance and offering protective qualities related to future cognitive status,” says Robert Maxwell MA, CCC-SLP, regional clinical director for Genesis HealthCare and chair of the Genesis Rehab Services Dementia Special Interest Group.

“Research has shown that when people keep their minds active with brain games such as puzzles, trivia and problem-solving activities, they are less likely to develop signs and symptoms of dementia,” notes Sarah Ziegler OTR/L, occupational therapist at Emerald Crest by Cassia, a ministry of Augustana / Elim Care. Their Learning Lab for Eldercare Technologies received a Silver Award in the senior living track of the 2018 McKnight’s Excellence in Technology Awards.

Unlike others, however, Ziegler is not convinced that brain games and other forms of mental stimulation can ward off a dementia or Alzheimer’s diagnosis, saying, “If someone is predisposed to the diseases that cause dementia, these types of activities may only delay the onset.”

“Research data have been reliable and consistent enough to force care providers and the senior living space out of their horribly old cone-stacking, pegboard habits,” says Paul Riccio, vice president of finance and development for Vertis Therapy. Riccio views this new “professional burden” as a positive step toward therapists’ shared quest of knowing how to truly connect with their patients.

Although it is difficult to identify precisely when this conclusion around prevention was reached, Riccio traces it to SAIDO Learning, a working memory training program developed in Japan. SAIDO uses systematized basic problems in arithmetic and language, including reading aloud, as well as writing.

“SAIDO objectively proved this and has held up to scrutiny that brain games absolutely aid in the prevention of dementia,” Riccio says. A multi-year study identified four categories of so-called “brain games,” a greater variety of which seem to directly correlate with greater success in prevention, he added.

A clue might be found in the brain’s neuroplasticity, or ability to form new connections, says Kathleen Weissberg, OTD, OTR/L, CDP, CMDCP, education director for Select Rehabilitation. “Anytime you learn a new skill or practice a skill, your brain develops new connections,” she says. “The more you use the connections, the stronger they become.”

Another clue may be found in the brain’s work in sequencing, says Maria Oliva, chief operating officer of Chicago-based Pathway to Living, a Chicago-based senior living provider. “Games that require sequencing are the most successful. Using repetition and procedural memory allows people with dementia to relearn or learn new tasks,” she says. Other interventions should focus on daily living tasks like cooking and folding clothes.

Interventions abound

Therapists often used the term “interventions” to describe what is a “break in routine” to the layperson. And when it comes to memory care, a number of interventions are showing tremendous promise in delaying the onset of dementia, if not preventing it altogether.

Christopher Krause, director of rehab at IN2L, believes interventions of all kinds – from social participation and well-being, to engagement, mental health and cognition – can help ease the journey of living with dementia, and he said he has witnessed firsthand the most profound effect in residents with dementia who are in the later stages of decline.

Early successes also are being discovered in robotic therapy, according to Tom Canterino, co-founder and vice president, business development and B2B sales, Ageless Innovation. Companion robotic pet therapy is a nonpharmacologic therapy that consists on the use of robots as an element of play and company, he adds.

Weissberg believes the best intervention of all is normal, everyday activity, or “things that are familiar and things that bring enjoyment.” She also mentions the Montessori Method, which uses everyday activities to successfully engage those with dementia.

Others believe in a holistic approach.

“A memory care therapist’s role is to be focused on the whole person through active, therapeutic, nonpharmacologic interventions,” says Jennifer LaVoi OTR/L, director of cognitive care at Emerald Crest by Cassia. “The therapist utilizes a whole host of approaches including reminiscence, reality orientation, physical activity / exercise, sensory stimulation and aroma therapy.”

Christy Kyrus, a recreation therapist with Sentara, a large healthcare provider, says her associates have had success with a program called LEAP, a dementia specific sensory program. “We use a lot of different interventions in that program, such as recalling, reminiscing, and music and aroma therapy, and we even have sensory lights in the room that mimic the sky,” she says. “These have value because they utilize cognition, long-term memory and short-term memory and stimulate the senses for relaxation.”

The power of connection

Memory care technology companies are among a growing list of entities that are passionate about the link between engagement and improved cognitive health.

Charles de Vilmorin, CEO and co-founder of Linked Senior, conducted more than 400 interviews in 2018 to distill what he believes are the necessary ingredients of engagement. He says many providers are only partly successful engaging all of their residents by “providing a stimulus and occupying someone to create an outcome. What’s missing is a sense of purpose — the idea of engaging people and helping people find purpose regardless of their age, who they are and where they are cognitively. People dying today can still find a purpose until their very last minutes of their lives. That is what engagement is about.”

Connected Living’s platform is built around the premise of social engagement as a recipe for both cognitive and physical health. For memory care residents, regaining some measure of control is paramount, says Sarah Hoit, CEO and co-founder.

Connected Living recently incorporated the Amazon Alexa voice assistant into its digital and mobile platform and views it as a vital, emerging intervention. “I think we’ve been at the forefront of bringing voice to our residents in communities,” she says. “Alexa can ask to share music with the family or find out what is on the menu. She is a constant companion when others are not there.”

Erum Azeez Khan, CEO of SoundMindIntelligence, believes voice assistants such as Alexa can access information and content to help with memory recall rather than having to reach for an iPad or smartphone. InspiredMemory Care, a client, uses voice assistants, under Kahn’s supervision, to play music and show videos (through the Echo Show device) to assess what capabilities someone with dementia has to recall certain songs and images. Caregivers also easily can call other rooms to request help simply by speaking, so they can stay in the moment when providing care, Khan adds.

“Our focus in using technology is often on overcoming learned helplessness and promoting engagement that empowers the individual living with memory impairment to connect in a strengths-based way,” adds Nettie Harper, MSRS, CTRS, COTP, co-founder of Inspired Memory Care.

A reminder about assessments

“When looking at the memory care therapist’s arsenal today, the most important component is the use of a standardized cognitive assessment,” says Beth Reigart, MPH, OTR/L, a clinical operations specialist for Functional Pathways. Reigart favors the Brief Cognitive Assessment Tool, or BCAT, which can provide a means to capture early onset changes leading to decline in function and safety for the individual.

Pam Brooks, OTR/L, clinical occupational therapy specialist for Centrex Rehab, echoes the value of assessments.

“Knowledge of an individual’s cognitive level through interdisciplinary assessments and team consultations allows you to identify interventions for best approaches, interactions, decreased behaviors and promoting successful and realistic participation and function,” she says. “Patient-centered interventions focus on meaningful activities. If the individual was a homemaker, for instance, ask them questions related to homemaking.”

‘Breakthroughs’ in activity therapy?

Vertis Therapy was one of several providers that participated in a nationwide rehab therapy program pilot using the MicrosoftKinect, a motion-sensing camera used widely in newer-generation XBOX games.

The pilot showed Riccio just how new technology is being used to prompt dementia residents to do familiar tasks while unmasking their life story, “or what I call muscle memory.” This is one example of how the Kinect was used in gamified therapy keep Alzheimer’s at bay.

To Riccio, it illustrates the stark contrast between low- and high-tech approaches to treating the disease.

“For some who have worked in dementia rehab, low-tech means taking a box full of screws, emptying it on a table and going, ‘Uh oh. Can you sort these, Bill?’ ” Riccio says. “Next thing you know, he’s doing occupational therapy and doesn’t even know it.”

High-tech efforts with tools such as Kinect are revealing new possibilities. “They basically changed the games 10-year-olds had into something an octogenarian would enjoy and used that high-tech camera to physically and accurately measure things such as weight bearings and the angles of 32 different joints,” he said. If anything, the Kinect experiment provided an invaluable measuring tool dementia rehab therapists could use without interrupting the cognitive therapy portion of care, Riccio added.

Linked Senior recently completed a large research study with Baycrest that successfully reduced antipsychotic use by 20% while simultaneously boosting engagement activities in mid- to high-level dementia residents. Among other results: An 18% decrease in aggressive behaviors, 20% increase in social engagement and 3% increase in cognitive functioning.