A: Yes, both now and later. The national minimum wage is currently $7.25 per hour. In early 2018, Walmart increased its minimum wage to $11 while adding new employee benefits. Amazon raised its minimum to $15 in November.

Walmart and Amazon are the top two private employers in the United States. The likely challenging impacts to most employers, including senior living, will be significant. Here are just three: 1) increased employee turnover and related costs, creating 2) hiring challenges and 3) reduced operating profit and cash flow.

You likely also will be pressured to raise hourly wages of some of your other lower paid employees. These employees typically expect to earn about $1 to $1.50 per hour more than their minimum wage peers. When minimum wages increase, so do the expectations of this employee group.

The solution involves three basic strategies: 1) reducing operating expenses you can control, 2) enhancing existing revenues and 3) optimizing organic growth through increased occupancy and expanded services within your community.

National Center for Assisted Living Executive Director Scott Tittle recently took the time to answer some of our pressing questions.

Q: Now that the midterm elections are over, do you think senior living is safe from additional Medicaid reform efforts by Congress?

A: For the time being, thankfully, yes. With a Democratic majority in the House, it is unlikely Congress will take another stab at repealing and replacing the Affordable Care Act.

We’ll still need to continue to keep an eye on larger budget deals. Sometimes, Medicaid issues, like providers’ assessments or other supplemental payments, could be slipped in as a pay-for.

Q: Will NCAL and its members continue to advocate for adequate Medicaid financing?

A: Absolutely, but Medicaid battles will primarily be fought at the state level. We’ll continue to support our affiliates should they face any challenges on that front.

While adequate rates are key in covering the cost of care, that’s only one piece of the puzzle. We also need to make sure accessibility to Medicaid home- and community-based services (including assisted living) is preserved, if not expanded.

The HCBS Settings Rule is an example of this, where the intention of the rule is a noble one — to promote integration and empower the individual. But in doing so, the Centers for Medicare & Medicaid Services could exclude certain assisted living communities that do not meet rigid criteria under that rule. The concerning result will be a lack of consumer choice, especially in rural areas. NCAL is going to continue to advocate that assisted living communities be recognized as a critical HCBS setting.

Q: What other issues concern NCAL at the federal level?

A: With a divided Congress, it’s unclear how much bipartisan legislation will be able to reach the president’s desk. If they can take up a meaningful discussion about immigration reform, we hope to see policies that will help us address the workforce crisis many senior living providers are facing. But we’ll probably turn much of our attention toward the administration where policies can be issued and implemented impacting the profession.

For instance, we are still waiting on additional guidance from CMS about the HCBS Settings Rule regarding the heightened scrutiny process. We’re also waiting for a final rule from the IRS clarifying whether certain assisted living providers and all nursing homes can take advantage of a 20 percent business income tax deduction under the tax reform bill that passed last year. Next year, we’re anticipating a revised overtime rule from the Department of Labor.

Q: Are there any particular issues at the state level that NCAL is closely monitoring?

A: Our state affiliates do a great job advocating for commonsense state regulations and reimbursement for assisted living providers. NCAL monitors high-level changes through our annual State Regulatory Review. What’s interesting about our latest findings is the sheer number of states updating their regulations in some form or fashion. More than half – 29 – states did so this past year, and on a wide number of areas.

It just goes to show that the state-based regulatory model is a really robust one.

We’re also encouraged to see more innovative and collaborative regulatory models like you see in Oregon, New Jersey and Wisconsin.

Here’s where state regulators, providers, consumers and other stakeholders came together to establish quality metrics and reporting requirements, combined with a focus on improvement rather than punishment. We believe this could be the future of oversight, because it truly encourages high-quality care and creates a better relationship between providers and regulators. 

Q: Heading into 2019, what do you believe are the biggest issues facing senior living operators?

A: Assisted living providers must step forward to tell their story. As the assisted living profession grows, we should continue to anticipate scrutiny from the public, press and policymakers. We need to clearly demonstrate how we are a low-cost, high-quality long-term care option.

We’re going to have approximately 80 new members of Congress in the 116th, many of whom have never held political office before. Whether they know much about assisted living will remain to be seen, but it’s on us to help educate them about the care we provide and the policies that could impact us.

“When thinking of ‘technology,’ there are really two distinctive kinds — one referred to as ‘medical’ and the other simply as ‘technology,’” he says. “In fact, investors often classify their investments as one or the other, although some invest in both, but from different teams.”

With regard to medical technologies, Moody says there has always been great interest from acute-care providers to invest in medical devices, information technology and pharmaceutical systems for their patients. Conversely, he says, investment for technology directed at older adults as consumers has lagged far behind, which is surprising given the vast size of the demographic market. 

“That lack of investment and interest has led to technology presently having very little influence on the long-term care and senior living industries outside medically oriented investments,” Moody says. “While this has not really changed that much in terms of actual spending in recent years, there is no doubt that interest levels are increasing rapidly and thus, I believe it is fair to say that this interest is slowly turning into increased investment, implementations and influence.”

Jerry Wilmink, Ph.D., chief business officer for CarePredict, agrees that signs are pointing upward for increased technology adoption.

“Technology has a major influence on the senior living industry, largely because we are in the midst of the Fourth Industrial Revolution,” he says. “This is the fourth major industrial era since the initial Industrial Revolution of the 18th century. The 4IR is characterized by a ‘big bang’ and fusion of technologies that is blurring the lines between the physical and digital spaces.”

This fourth revolution, Wilmink says, is marked by the ubiquitous nature of wireless connectivity, miniaturization of sensors that collect big data, the internet of things and artificial intelligence — specifically machine learning and deep learning. Of those developments, he says artificial intelligence has the most influence.

“Fueled by connected devices, wearables and the data that they generate, AI is in full swing and is both powering and impacting our everyday lives,” Wilmink says. “Whether you are using Google maps to find the shortest commute to work or scheduling a hair appointment for your mother by voice command, the use of AI has disrupted nearly every industry and it is now set to modernize the senior living industry.”

Advancement of AI

AI is progressing rapidly in the field of medicine, and a newly developed offshoot called artificial emotional intelligence is now taking root, which has potentially profound application for healthcare and, specifically, long-term care.

BPU Holdings, a technology company dedicated to developing AEI in healthcare, is working with the National Science Foundation and University of Arizona in a collaboration currently called SeVA to create a digital nurse assistant, designed to track patients’ emotions. Proponents see the future of AI and healthcare as being able to use AEI to engage patients and track their daily patterns and medication and assess physical symptoms outside the doctor’s office.

Should emergencies occur, the application of this AI technology would be that the digital assistant may alert hospitals and physicians within minutes based on the recorded data from the patient’s emotional state.

For the long-term care and senior living environments, this digital device — known as aiMei — will be used to recognize early signs of dementia and inform the medical team, says geriatric physician Nimit Agarwal, M.D., an integral member of the SeVA research team.

With nurses and care teams unable to provide continued direct observation of the patient population, windows of “unsupervised care” get created, where the patient is not being directly observed, Agarwal says.

“This window leads to adverse events like falls, further cognitive impairment and increased risk of depression and dementia due to poor cognitive stimulation,” he says. “In addition, for patients requiring direct observation care, it also adds a burden on the patient’s family from a social, economic and physical perspective.”

Currently, no AEI devices are geared to the geriatric population and people with dementia, but Agarwal says they are on the horizon for the senior living industry.

“With SeVA functionality, we can cater to this growing patient population through the whole spectrum of healthcare, including acute, post-acute and long-term care facilities,” he says. “The possibilities for SeVA in this regard are limitless, and we are just starting to know what it is capable of to change the healthcare structure for senior living.”

‘Non-care’ tools

Because senior living is such a competitive marketplace, operators may find an edge with certain technologies — specifically those that deal with the non-care aspects of the business, says Josh Malbogat, director of senior living for Dude Solutions.

“Care is becoming more and more of a standard expectation, with resident service-related elements becoming essential to operators looking to differentiate themselves from competitors,” he says. “Residents are now demanding access to the same technologies they had while living and working independently, and operators are being pushed to adapt.”

A prime example of this is the simple act of getting maintenance to fix something in a resident unit, Malbogat says.

“It used to be acceptable to simply stop by the front desk, write out a form and check back in a few days,” he says. “Now, residents expect a self-sufficient process in which they submit a request and check the status themselves — all in real time. The same is true for family members — they want online access with the ability to self-service. The great thing about this is that it not only delivers great resident service, it actually increases the productivity of the staff by offloading the process of manually checking for status updates.”

Although technologic innovations have been established and growing for some time, the long-term care and senior living sectors have been challenged about how to select, adopt and deploy systems in a way that will benefit their residents.

Travis Palmquist, vice-president and general manager of senior living for PointClickCare, acknowledges that senior living providers are receptive to concepts but that “execution has sometimes been difficult due to a lack of resources.”

For example, having a chief information officer or team of systems analysts in a senior living community is still in an embryonic stage, he says.

Today, resident security tech is giving a new generation of seniors an unprecedented level of independence and safety — two concepts that until recently rarely worked well together.

Consider:

• Personal alert systems that allow people to live their lives with confidence while having the peace of mind to summon medical help at the push of a button.

• Wearable personal monitors that not only promote wellness and physical activity but trigger alarms when irregular heartbeats are detected.

• High-tech sensors and other devices, concealed in clothing or inside walls, that reliably can predict everything from falls to urinary tract infections.

• Elopement warning devices that allow seniors to move freely about a property while giving caregivers the ability to intervene at a moment’s notice.

• Social engagement devices and apps that enable seniors to live independently while connected with loved ones at the push of a button, something mounting evidence is proving can promote wellness and reduce the risk of depression, and even stave off dementia.

This tech revolution has given newfound freedom and security to older adults both aging in place and inside independent and assisted living communities.

“Moving to a senior living community can be a highly vulnerable time in seniors’ lives,” says Syed Ahmed, senior living segment leader for Philips Aging & Caregiving. “During this time, seniors may feel that joining this new setting decreases their level of independence, and the change can lower their confidence and self-esteem. By leveraging the right types of integrated technology, senior living community leaders can help residents maintain and build their independence and feel more confident.”

Adds Majd Alwan, Ph.D., senior vice president of technology for LeadingAge and executive director of the Center for Aging Services Technologies: “These technologies all contribute to the older adult’s sense of safety and the peace of mind of their caregivers and loved ones. This is especially true for older adults at heightened risk of falling or wandering, like older adults with dementia, particularly. Obviously, safety technologies support independence, too.” Alwan and his team at LeadingAge recently released an online portfolio of tools to help providers understand, plan for and select safety technologies that meet their requirements and needs.

A closer look

Looking deeper into new and emerging resident security tech reveals just how engineers have exploited the capabilities of IoT and in some cases, applications borne out of military research.

• Global positioning and real-time location services.

GPS is being applied to myriad devices in senior living. Almost a decade ago, engineers found a way to embed chips inside sneaker soles to find memory-addled residents who wandered into the night. Today, GPS can be found in everything from wristband wearables to emergency call pendants.

Several companies have merged various types of resident security tech into a single solution.
Stanley Healthcare’s Arial and WanderGuard Blue “give administrators and caregivers accurate, timely location information so they can respond quickly and appropriately,” according to Mike Webster, director of senior living products.

Philips Aging & Caregiving’s restraint-free wander management system uses GPS, fall detection technology and two-way voice communication to alert others via mobile tech. Ahmed says the company’s resident safety system features geo-fencing, which allows staff to control residents’ physical access across the community for wander management and other safety concerns.

With the help of vector technology and GPS, “resident wandering and emergency call technology can pinpoint a room level or even chair level status and send notifications to staff,” says Laura Wasson, director of healthcare and owner of Tech Electronics. 

• Artificial intelligence.

Machine learning and AI already are embedded tech in a limited number of resident security devices. Its potential is nearly limitless.

CarePredict describes itself as an AI- driven digital health company that has developed a deep learning platform to provide insights into seniors’ health by collecting data points using a smart wearable and smart remote sensors. To Jerry Wilmink, Ph.D., chief business officer, current technology that relies on a “finite number of data points a human can both observe and remember” limits the ability to have continuous visibility so crucial to detecting changes in activity and behavior patterns in a timely fashion.

• Data analytics.

Some say aggregating data is at the heart of the current healthcare revolution and its drive toward resident-centered care. Personalizing resident security is providing a direct data pipeline from people to powerful computers.

“Across the board, these solutions, like wander management and personal alerts, are giving senior living administrators access to a wealth of data that they can review and analyze,” Webster says. 

Wilmink said CarePredict is using data culled from AI to predict the occurrence of a urinary tract infection 3.7 days, on average, before it is diagnosed, and is also expanding predictive analytics to more issues such as depression, malnutrition risk and others.

Ahmed said with Philips’ recent acquisition of the Blue Willow advanced data analytics platform, “senior living communities can offer residents an even greater sense of independence than ever before.” The company’s wrist-worn devices automatically can detect falls and can be used to call for help at any time.

Top priority

Ask relatively healthy seniors and they will say “independence.” Ask the frail elderly and “safety” usually trumps.

“My sense is that independence ranks higher than safety for seniors, even if they’re more frail,” says Todd Stanley, senior product manager for Inovonics. “However, once an adverse event happens, safety will become more important as the risk becomes real to them.”

“In senior living communities, the word independence can have layers of meaning, whether it’s residents recovering from surgery or [who are] unstable for other reasons,” adds Lila Corwin, senior vice president, marketing communications, for Biodex Medical Systems, who adds that her company’s products provide equal measures of both safety and mobility, which translates to independence for so many.

Others in the resident security space, meanwhile, have equally fascinating perspectives.

For example, SecureCare, which regards itself as a wander management pioneer in senior living, considered both when it entered the market 40 years ago. “Being able to add a layer of safety and security while maintaining a resident’s independence, dignity and freedom of movement was key,” says Michele York, the product marketing manager for Secure Care.

In some cases, utility considerations often govern the level of freedom they provide, says Danielle Myers, general manager of Status Solutions. “In most cases, safety solutions promote mobility and therefore support independence,” she says.

This particular beach house, located in Wesley Chapel, FL, is a 96,000-square-foot community that features 100 assisted living and memory care residences. Sixty-seven units are designated for assisted living, and 33 are for memory care.  The community was developed by a collaboration of The Douglas Co., Architectural Concepts, LCS, Prevarian Senior Living and StudioSIX5.

Established in 1942 by the James H. Porter family, Wiregrass Ranch is a 5,000-acre property now managed by JD and Quinn Porter and has been developed as a family community that includes residential neighborhoods, schools, retail shopping, entertainment and healthcare. It has been the centerpiece of a new construction trend that is revitalizing the North Tampa area.

“We could not be in a better location,” says Linda Mena, executive director of Beach House. “We’re not really close to the water, but the whole beach house concept is to create and new and relive old memories for residents. Many of our residents are people who spent their summers at the beach. We’ve only been open for six months, but we’re already 50% full.”

StudioSIX5 created the nautical flair of the community’s design theme, going beyond the typical pastel shades to bolder accents of red, navy and yellow against the neutral sand tone. Texture also is part of the ambience, as light-colored wood-look tiles recall boardwalks and driftwood. Casework for the reception desk and dining room hostess stand features river pebble accents.

“We did a lot of research on Wesley Chapel and found things that were local to the community,” says Emily Young, design coordinator. “We also wanted to incorporate vibrant colors and interior finishes that capture the character of the local area.”

That includes nautical upholstery and artwork featuring boats. Black-and-white photos of various watercraft are framed and presented in gallery spaces. Modern sculpture, such as a mesh-on-metal jellyfish piece, hangs on the wall above one of the lounges.

A wall mural depicts a sandy pathway to the ocean surrounded by soft seagrasses, enhancing the mailroom space as it opens to a multipurpose area in the wellness center. The community also features a billiards room and a tiki tavern called The Sand Bar to further the beach house theme.

“We market ourselves as ‘resort style living’ and Wiregrass Ranch is an inherent sales hook,” Mena says. “The décor is uplifting, and the environment is beautiful. But while the aesthetics are great, what really matters is the culture, the programs and our person-centered approach that considers each resident as an individual. We are committed to meeting each resident’s clinical and personal needs, giving them a purpose for each day.” n