At press time, a federal court granted the American Health Care Association’s motion to stop the ban from beginning in late November. Attorneys for the 13,000-member provider organization argued the reprieve was “appropriate and necessary” to protect senior living operators while the court hashed out related legal issues.

Judge Michael P. Mills of the U.S. District Court for the Northern District of Mississippi said the case puts the court in an “undesirable position,” since it believes the ban is “based upon sound public policy.” But ultimately, Mills said, the case provokes in-depth legal questions about the Centers for Medicare & Medicaid Services’ authority. This needs to be addressed before the rule can take effect, he wrote.

“As sympathetic as this court may be to the public policy considerations which motivated the rule, it is unwilling to play a role in countenancing the incremental ‘creep’ of federal agency authority beyond that envisioned by the U.S. Constitution,” Mills wrote.

AHCA/NCAL President and CEO Mark Parkinson said the association is “pleased with the outcome” of its motion, as actual implementation could have caused “real harm to providers as well as to our residents.”

But the victory may be short-lived. The court’s decision notes that CMS could show that it had the authority to ban the agreements, something it has failed to do so far. It is not known how much the agency might benefit from the court’s decision, which expressed sympathy with the public policy considerations, such as the potentially stressful nature of nursing home admissions, which partially motivated the ban.

“The court has actually said that they agree wholeheartedly with the principle behind [a ban on pre-dispute arbitration],” Mario C. Giannettino, a partner at law firm Kaufman Borgeest & Ryan LLP, told McKnight’s. Giannettino specializes in the defense of long-term care providers.

Pro-consumer groups lashed out against the decision. Sen. Al Franken (D-MN) said that he was “disappointed” by the judge’s ruling but that he remains “hopeful that we can get this rule implemented.”

Franken was one of 34 Democrats who called for an outright ban on arbitration agreements

A: You are dealing with a very significant financial challenge.

First, the facts: 1) seniors will get a Social Security increase of only 0.3% in 2017; 2) short-term CDs and money market funds have returns of less than 0.3%; 3) inflation as reported by the September Consumer Price Index for all items, currently is 1.5%. This does not appropriately track the real world of a senior’s typical costs incurred in senior living communities.

The two areas of highest cost for sponsors and owner/ operators are dietary, representing approximately 20% of total operating expenses, and direct care, typically representing more than 40%.

In 2016, the annual increase in employee wages represented approximately 2.5% to 3.0%. Similar increases are planned for 2017.

In attempting to make these numbers work, consider at least the following: 1) occupancy enhancement; 2) responsible expense reduction and 3) optimized unit pricing. Enhanced financial performance represents both a pressing need and a huge opportunity frequently overlooked by many owner/operators. In 2017 and beyond, it will become a significant imperative.

Jim Moore runs a national senior housing and healthcare consulting firm based in Fort Worth, TX. He has written several books about assisted living and senior housing, including “Assisted Living Strategies for Changing Markets.”

LCCA offers skilled care, assisted living and independent living services at more than 200 locations.

As part of the deal, the firm admits to no wrongdoing.

The company said it has “strongly disagreed with the allegations and believes that it was entitled to payment for services rendered.”

“We deny in the strongest possible terms that Life Care engaged in any illegal or improper conduct,” CEO Forrest Preston said in a statement. “We are, however, pleased to finally put this matter behind us, without any admission of wrongdoing.”

The community features sections called Soulful Environments, designed to appeal to different aspects of memory care. For instance, the Nature Immersion Room provides residents with a multi-sensory nature-based experience that helps reinforce a daily sense of routine and circadian rhythm, which plays a key role in memory function.

“The most complicated aspect of dementia is keeping residents in the natural rhythm of the day,” said Robyn Johnson, director of brand and strategic initiatives who created the concept.

“So we use light, sound and smell to convey a sensory experience associated with different parts of the day — morning is the sound of gulls, midday is busy birds and end of the day is crickets and frogs. And the stars come out at night,” Johnson explained. Another Soulful Environment is Arabella’s Garden, a therapeutic landscape focusing critical attention on the design and creation of a landscape to promote health and wellbeing, emphasizing the importance of evidence-based design to meet the needs of residents with dementia, as well as those of visitors and staff.

FOCUS ON MEMORY CARE

John Goodman, the late founder of Chaska, MN-based The Goodman Group, was driven to continually innovate with healthcare design, and Villa at Terracina Grand underscores his desire for a community dedicated to the various stages of dementia and Alzheimer’s, said Burt Elmer, director of architecture for JBG Design & Development, a division of The Goodman Group.

BROADER APPROACH

“Memory care has become more of an issue because people are living longer,” he said. “So we’ve looked at opportunities for innovation. John wanted a stand-alone memory care unit that treats all stages, from early to late. From an architectural standpoint, the basis was to broaden what we offer and expand it into a refined piece as we study memory impairment. Evidence-based design was John’s dream and this community provides that.”

Opened on April 28, 2015, the community took 13 to 14 months of construction to complete.

Kim Campbell, wife of country singer Glen Campbell (who has Alzheimer’s) attended the opening and said she fully supports the community’s objective.

Following John Goodman’s lead, Villa at Terracina Grand provides “an atmosphere of freedom,” where residents can travel in a loop that “always brings them back to the center,” Elmer said.

The layout adheres to the Goodman principle of “dignified freedom,” so residents are able to navigate the building safely while experiencing indoor and outdoor areas.

Between the Nature Immersion room, courtyard garden and natural light through ample windows, residents have a natural rhythm for the time of day, which fosters peace and tranquility, he said.

And even as the American economic recovery sputters along at a snail’s pace, senior living operators are finding ways to ensure their facilities and environments are as relevant as the services and amenities they provide. Facelifts are being fueled by any number of things — from a need to replace aging infrastructure and improve safety to opening new wings or services, rebranding and increased competition.

Restoring and renewing may be as brisk as new construction right now, but either way, a lot of freshening up is going on. One observer calls it “post-recession gusto.” Surprising to some, renovation financing activity is frenetic.

“This is a good time for operators with a long time horizon to try and borrow capital to spend on all kinds of projects that may be necessary for a property in the long run,” said Imran Javaid, managing director for BMO Harris Healthcare Real Estate Finance. “Rates are low and debt capital is still plentiful. With rates as low as they are currently, it is a good time to evaluate how you can add or preserve value for your facility.”

That optimism was echoed by Pat Copps, director of capital sales at Direct Supply. “Don’t underestimate the power of a fresh look and the impact it can have on your occupancy rates,” Copps said. “Many of today’s prospective family members who are looking for a place for their loved one to stay judge more by the overall look and feel of the building than they do the level of care provided. It’s critically important to stay up-to-date within your market.”

That doesn’t mean lenders are passing loans out like candy. There are many hurdles to cross, and operators need to have their house in order before seeking construction loans.

SNOWBALL EFFECT

It’s no surprise lenders attribute the frenetic activity to the changing tastes of aging boomers.

“We’re seeing a move from semiprivate to private rooms, updated rehab spaces — sometimes with a private entrance for outpatient work — common areas that create a ‘wow’ factor and memory care wings and additions,” said Heather Bushie, capital sales manager at Direct Supply. “Rehab helps diversify the revenue stream.” There’s almost a snowball effect going on in the industry.

“As the amount of new seniors housing construction has increased significantly in the past several years, we have seen existing operators have to adjust under the pressure of increased supply and the allure of new construction,” observed Jennifer Lawley, senior vice president for the Senior Care Lending Group at United Community Bank. “Operators of existing buildings are not only borrowing for aesthetic upgrades and updates to the physical plant but are also looking at expansion opportunities to allow their existing residents the ability to age in place by adding additional units and/or levels of care. The spectrum runs from something as simple as adding units by re-configuring the existing building’s footprint to a more complex expansion with a newly constructed addition to the facility.”

Many lenders said that “value add” projects are becoming popular lending opportunities. “Those are buildings that need substantial renovation because the physical plant is dated, or projects where the market demand is lopsided with the existing supply in the building, necessitating the addition of memory care units, semi-private or private units, or some other product that can meet demand,” said Eric Mendelsohn, CEO of National Health Investors Inc. Of course, a new competitor almost always spurs activity. “If you know a new building will be coming online in your market, you need to address that by updating your own physical plant or amenities to remain competitive. There is also a building life cycle that needs to be respected. Buildings built in the 1990s are now ready for a major refresh,” he added.

Several lenders agreed about one overarching renovation trend right now called “repositioning.”

“We’re seeing a great deal of repositioning where operators are converting an allotment of beds to a different type of care,” Copps said. “What seems to be most common is converting from long-term care beds to short-term rehab. Others are converting from long-term care to assisted living so they can offer multiple levels of care to prospective patients.” Copps added that he’s also seeing the addition of large therapy/ rehab gyms, “which offer a tremendous competitive advantage in the marketplace.”

“Repositioning of a therapy wing remains the number one renovation project,” said Bill Wilson, senior vice president-regional manager, Central States for Lancaster Pollard. “With competition increasing, providers believe they need separate entrances and hotel-like amenities to continue attracting the Medicare residents.”

Michael Hass, founding partner of Drive Development Partners, referred to such projects his design firm is involved with as “reinventions.” “These are fairly major and they are driven by a need to entirely change either the environment or the care mix [for instance, adding memory care where there was previously none or little],” he said. “I think competition is always a concern, but I see the strong demand for memory care and the consumer’s desire for rental options as being the primary drivers.”

Hass called his firm’s “dabbling in narrow affinity targets” in certain areas “incredibly interesting. If you take a typical assisted living community that competes on ‘care’ and ‘lifestyle,’ it can seem pretty generic to the prospective resident,” he added. “But if you hyper-focus on branding your community as ‘for foodies,’ ‘foreign travelers,’ or ‘fitness enthusiasts,’ you can really stand out.”

Consider one Maryland continuing care retirement community that recently converted its traditional nurses station into a luxurious, amenity-rich residential lounge, or a Wisconsin facility that transformed itself from a staid 60-bed institution to a contemporary pod-like configuration of long-term, rehab and memory care “households.”

RED Mortgage Capital, the mortgage banking arm of RED Capital Group LLC, recently closed a $3.5 million FHA 232/241(a) loan for Woodlands at Hampton Woods, a skilled nursing and assisted living facility in Poland, OH. The project, called The Rehabilitation Center at Hampton Woods, will include 26 private beds designed for short-term rehabilitation care and a 5,000-square-foot therapy gym.

“For assisted living facilities, the number of renovation projects that we have seen is a very small fraction of the new development activity,” said Lee Delaveris, director at RED Mortgage Capital LLC. “However, in the past few years, some of our clients have been successful in repositioning a lagging assisted living facility.”

Delaveris said the level of work necessary to reposition could be as simple as a basic refresh (remodeling of common areas and rebranding) or as complex as a building expansion or reconfiguration. Delaveris said many clients have repositioned skilled nursing communities through capital projects to better market themselves to hospital referral sources and adult children.

FINANCING TIPS

Three words — location, location, location — are invariably a plus for any senior living project. Mendelsohn said his firm recently acquired a cluster of larger assisted living units in “great in-fill markets with barriers to entry and fantastic demographics the Northeast” and leased them back to the client who sourced the deal. It didn’t hurt that the buildings, although falling behind in upkeep, “had great bones.” Mendelsohn said the buyer worked with his firm to provide acquisition funding and a renovation budget to bring the buildings “back to their former glory.”

Financing is plentiful whether borrowers come hat in hand for “defensive” capital spending plans, spurred mostly by competition, or offensive plans, in which they are trying to increase their bottom line and capitalize on an amenity or, most often, a need that is being unmet in the primary market area of the facility, according to Javaid. Both are common, but “most financial institutions” find the latter easier to support.

“Sometimes these [defensive] requests are also in conjunction with an acquisition in which the operator who is being bought out had not kept up with the changing competitive landscape and is currently underperforming, he added. One example BMO worked on was a facility in an upscale area that “had not kept up with the times. We financed a renovation that included upgrading rooms as they turned over, and also a complete redo of the common areas and lobby,” he says. “Ultimately, the renovation worked out better than anticipated, and the facility did see some pricing power, which it had been losing.”

One example of an offensive-type loan involved an independent living facility that had excess land but had not built out the assisted living/ memory care portion of its master plan. “We financed the acquisition and construction, and the facility saw improvement in its bottom line, in part because it was able to attract more couples who had varying needs,” Javaid adds.

MORE ADVICE

• Document the need. Detailed plans, as well as a “good” market study, zoning checks, a vetted contractor/architect, bids and a solid business plan with pro forma analysis are a must, Mendelsohn said. Objective evidence is key, says Ross Holland, vice president of Lancaster Pollard. “For any major project, providers must ensure that the value proposition has been thoroughly vetted and substantiated, ideally through third-party studies and/or analyses,” he added. Jason Smeck, managing director at RED Mortgage Capital, LLC, said his company’s focus when evaluating a renovation or conversion project “is on the owner’s business plan and their operating capability to execute the plan.” 

• Revenue generation a plus. Projects involving new services are attractive because they generate revenue, says Copps. “Secondarily, partner with a finance/leasing company who can offer you the cash up front and allow you to pay off the capital expenditure in monthly installments.” Hass, meanwhile, had some advice for lenders.

“The industry as a whole is really starting to innovate and think differently about locations, partnerships, styles, et cetera,” he said. “One thing that frustrates me a little bit is that lenders in particular tend to want to compartmentalize projects.”

The pressures couldn’t be greater. Though hospitals have been heavily scrutinized and penalized since 2012 for 30-day readmissions under the Affordable Care Act, 2017 promises to see thousands of others join the fray as the Centers for Medicare & Medicaid Services adds more and more reasons to reduce payments. Even as you’re reading this, many continue pouring over the mountain of changes the agency has in store.

Many, if not most, of those readmissions are coming from the long-term care side.

“Hospitals, clinics and accountable care organizations all over the nation are really putting pressure on facilities out there to have good rehospitalization rates, shooting for 10% or less,” said Dan Billings, vice president of business development at Pathway Health. “The readmissions piece is an indicator of so many different things — good nursing and clinic practice and recognizing disease states early.”

By 2018, CMS hopes to have met its ambitious goal of having at least half of all Medicare payments tendered through alternative models such as accountable care organizations. And by 2019, CMS will launch its much ballyhooed value based purchasing program, which will reimburse providers based on the quality, not quantity, of care pay.

For decades, senior living providers have been looked on as the final stop in the human journey from health and wellness to end of life. But no more. In the coming years, providers and operators will be held as accountable as doctors and hospitals for improving outcomes. Data will be at the heart of their survival.

But as experts observed, despite all of their investments in information technology, senior living providers are woefully behind the curve in mastering data to compete in the emerging world of performance-based care. As one leading consultant observes, winners will be those who are looking as much at their windshield as their rearview mirrors.

Of course, the morphing inflicted by ACA should ring familiar with healthcare executives who were around two decades ago. “When it went from cost-plus to prospective payment, the industry just imploded,” said Steve Scott, CEO of PointRight. “They couldn’t unwind quickly enough. They didn’t know how to manage their costs.”

“You get the same feeling when you talk to executives today — they remember that time very well,” he added. “They want to know how to get ahead of that curve now.”

To many, including Scott, operators are again fighting an uphill battle. “We are at a point in the industry of being behind the power curve,” he said. Unlike the retail sector, which quickly embraced new models, the internet and IT technology, healthcare is still connecting the wires. “Before, we were a brick-and-mortar business. We put heads in the beds and focused purely on taking care of people,” he added. “Now it’s become way more sophisticated.”

Looming changes are fueling more questions than answers. “Value-based purchasing is scaring a lot of people. And it’s scaring not only the operators, but those who financially support them,” Scott added. “If you have Medicare receivables, they’ll loan you based on 95% of it because it’s almost a guaranteed payment. All of a sudden that’s all changed. It’s no longer a guaranteed payment because you have to prove you created value.”

DEALING WITH ‘DIRTY DATA’

Even though more and more operators are investing in sophisticated IT systems and electronic health record platforms, the old ‘garbage in, garbage out’ cliché still has relevance. And Scott has seen his share of “dirty data.”

“EHRs can standardize all of this information, but if people are still filling out the elements in that EHR incorrectly, then your results are going to be skewed,” he said. Filling in the gaps can be an exhaustive endeavor. “We’ve seen within the MDS where a patient was bed-bound but in another section is described as ambulatory,” he adds. “These kinds of conflicts can throw off their quality measures, and present [an operator] as not performing correctly.”

Larger senior living chains have their own unique issues as well. “They may have bought 20 facilities from six different owners and are wrestling with different EHRs as well as paper and are trying to find a true operating picture of their portfolio, both clinically and from a business performance perspective,” he said. Data integrity issues can doom any efforts when it comes to root cause and predictive analytics. “You have to have a method to ensure the data you captured is accurate, or clean,” he added.

SUCCESS FACTORS

As McKnight’s Senior Living reported earlier this year, assisted living professionals seem to be answering the call to action. In its 2015 performance measures survey of them, the National Center for Assisted Living found that nearly 97% had established mission statements for quality improvement, and almost 83% had quality assurance or improvement committees in place. It’s a start. Here are some key success factors.

• Perform data discovery. “If you look across the spectrum, gathering data is a challenge, because it could reside in a paper chart, an electronic record, your pharmacy, your lab or the info that comes back from CMS, so it’s in these disparate silos,” says Scott. “And so data discovery is a meaningful exploration of data.”

• Know how to harness your EHR system. “Having an EHR to track care and quality outcomes will be table stakes,” said Mark Woodka, CEO of OnShift. “The more data that a senior living provider can offer to prove quality will not only be beneficial, but it will also become an imperative.” Jason Principe, segment marketing manager, Senior Living for PointClickCare, said he believes it is at the core of providers’ future success meeting performance benchmarks. “An EHR is fundamental when it comes to telling the resident story,” he said. “When the right people have access to the right information at the right time — and can act on it without delay — they can make better care decisions and promise safer transitions of care.” Pathway Health’s Dan Billings agreed. “Operators really have to be at the top of their game in terms of nursing and have the systems in place in order to recognize and catch things early,” he said. “Because most EHRs integrate rehospitalization practices, those processes can assist with decision support. In terms of quality assurance and performance improvement [QAPI], they can dive into that ocean of data and pull out value and see what their trends are, spot problems early, and react much quicker.”

• Have a plan. “Companies that successfully use their data are the ones that have a vision and purpose of what they want to drive with data,” Scott said. “They usually have some type of data governance. The key will be predictive analytics and data-driven decision support because value-based purchasing is changing that revenue stream.”

• Ensure adequate resources. “Staffing must not be overlooked when determining key performance indicators and demonstrating measurable value to network partners,” Woodka said. “Those organizations that can prove that they staff consistently and drive high retention will have a competitive edge while delivering quality care and service.”

• Understand your partners’ expectations. “One thing senior living operators need to do when partnering with a hospital or ACO is knowing what data they are interested in,” Billings said. “Because for now, they have the power in the relationship. Successful providers go to the table and listen to the hospitals and ACOs on the quality indicators and data items that they are requiring.”

• Know what to look for. In her recent column for sister publication McKnight’s Long-Term Care News, Cheryl Field, chief product officer for Prime Care Technologies, urges providers to “find value in your data. The Five Star pressure still lingers — with three or more stars required for marketability across managed care organizations, ACOs and acute providers beholden to bundling.” Billings said community health data are a key place to start. “Certain specific quality indicators are just beginning to engage,” he said. “There’s community health data that allows you see which diagnoses are flowing out of the hospitals and you can see from that data where people are going. If you can sift through the data as an operator, then you will know where you fit in.”

• Change your mindset. Robert Choi, chief strategy officer for Collain Healthcare LLC, a LG CNS company, urged senior living operators to begin thinking like their partners. “They need to have a data strategy that aligns with their care delivery strategy,” he said.

Statistics are grim for those with dementia who venture off unsupervised. More than half who elope die if not located within 24 hours, statistics show. Death and serious injury can occur within minutes, however, as one Indiana assisted living facility discovered last year after an elderly resident with dementia was fatally struck by a car just moments after wandering offsite.

Unsafe wandering and elopement can be avoided if senior housing operators take steps to proactively manage the risks. (See related story.) Experts agree that ongoing staff training and carefully developed policies and procedures — along with the adoption of resident security technologies that promote dignity and freedom while maintaining safety — is the most effective approach.

“Most communities approach wandering as a facet of a resident’s dementia, which requires a number of interventions,” said Steve Elder, senior marketing manager at STANLEY Healthcare.

NAVIGATING TECHNOLOGY

Some operators may be intimidated by resident monitoring solutions and reluctant to adopt them because of noise concerns, training requirements, installation challenges or the fear that technology will create an intrusive, institutional feel. Fortunately, today’s solutions are more discreet, cost-effective and easy to use than ever.

Many of today’s wander management solutions are silencing loud alarms and instead sending inaudible alerts to nurse stations, smartphones and mobile pagers. These silent notifications incorporate accountability and safety features that ensure caregivers respond to incidents promptly and accurately.

“We are hearing that [operators] are wanting to get away from alarms, but it’s not practical to eliminate them altogether,” said Jared Pitney, vice president of RF Technologies’ Senior Living Division. Silent alarms make it possible to eliminate alarm fatigue and reduce excessive noise that can agitate residents, visitors and employees, while still alerting caregivers in real time of potentially dangerous wandering, falls, elopement incidents and more, he said.

Because it often is difficult to know with certainty whether a resident is an elopement risk, communities should consider comprehensive security solutions that can help monitor the perimeter of the building and residents with or without tags, reasoned Bob Vinditti, engineering manager for Philips Lifeline. Many modern solutions are making institutional door lockdowns a thing of the past while incorporating components that blend with residential-inspired aesthetics. Systems may feature lowprofile door controllers with discreet keypads, for example, that seamlessly blend with the residential setting, and unobtrusive resident-worn bracelets, pendants and tags that can be tailored to each resident’s unique and changing needs. Some wall-mounted transmitters even can be camouflaged with custom-printed graphics or images that match a resident’s memory box outside his or her room, or otherwise mirror a resident’s interests or the community’s design aesthetic. “Many operators don’t want to brand a resident, and this helps take the stigma away,” Pitney said.

Resident identification is another key feature of today’s wander management solutions, although it is still not widely adopted, according to Vinditti. “It’s important for operators to feel confident they are looking for and securing the right resident who has wandered.”

The shift away from stand-alone technologies continues to trend as operators look to integrate their resident security solutions and pool data to enhance response times and decision-making capabilities.

“We’re seeing a consolidation of alerting systems in the healthcare industry,” said Chris Konicek, sales and marketing director for Accutech Security. “Communities aren’t interested in three different computers for three different systems.” Accutech is working to provide reliable, scalable, cost-effective solutions that integrate with as many existing systems as possible, he said, adding that Accutech’s LS 2400 system directly integrates with most major nurse call providers.

Many wandering incidents happen at night, so knowing when the resident is about to leave or already has left the bed can help staff quickly and safely redirect the resident, while also reducing the risk for falls. Bed exit solutions that allow the information to reach the caregiver in a timely fashion, without bothering or scaring the residents, are key, stressed Maayan Wenderow, director of marketing for EarlySense. The company’s new InSight solution sends all information to a central display and caregivers’ handheld devices or tablets. “The information is actionable and allows immediate intervention by staff, if needed.”

Automatic fall detection is a critical feature for wander-prone residents because many residents may not have the instinct to call for help themselves, Vinditti added. Philips Lifeline’s CarePoint 5.0 solution goes beyond standard help buttons to include the AutoAlert fall-detection technology.

As with any technology, practical application lies at the heart of these solutions’ long-term success. The more data points systems can offer caregivers and the better their reporting capabilities, the better equipped caregivers will be to deliver effective, resident-focused care decisions and response, Pitney explained. RF Technologies’ Sensatec fall management alarm solution integrates with the company’s Code Alert nurse call system to silently alert caregivers at a central computing station or via a mobile device and allow staff to respond to incidents faster. With the nurse call system, caregivers must physically go to the resident’s bed to reset the alarm and appropriately clear the pendant.

“It’s important to make sure staff understands [alert] escalation and how to clear the alarm, and also how to utilize the reports fully,” Pitney added. RF Technologies is developing training modules to provide staff with remote access education to simplify use and make the most of the technology.

DATA DRIVES RESULTS

As beneficial as technology is, experts stress the most important thing is understanding the resident and using technology as a complementary component to comprehensive and ongoing resident assessments. “Technology should never be a substitute for human involvement,” said Todd Stanley, senior product manager for Inovonics.

Upon admission and on a routine basis, residents should undergo a comprehensive risk assessment for resident wandering, notes Melinda Laupert, RN, of the McKesson Medical-Surgical Clinical Resource Team. She recommended developing and implementing a variety of resident-specific approaches that address wandering and elopement risks.

“Begin with keeping a daily log to identify changes in resident behaviors and mood,” she said. “Make notes [about] behavior patterns, such as pacing, anxiety and anger, that may lead to wandering.”

Among other steps, Laupert advocates interviewing family and friends regarding a resident’s prior hobbies, interests, routines and profession, so they can be integrated into the resident’s daily schedule.

Silverado communities use information gleaned during initial resident assessments to redirect the individual in community clubs and workshops based on their interests. “When a resident wishes to leave the community, we ask them why. We listen to them. Sometimes, validating their feelings is all they wanted,” said Kathy Greene, MSW, senior vice president of program and services integration at Silverado. She further pointed out that pacing is one way a memory-impaired person might communicate pain. One Silverado resident in Austin, TX, repeatedly tried to elope and chronic pain was determined to be the culprit. “Since being treated for [the pain], she has not attempted to leave. She now engages in social programs with other residents.” 

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Q: How did you first decide to volunteer with older adults who had Alzheimer’s?

A: I’ve been a fiction writer for a long time, and when I turned to playwriting, I wrote older characters. That was when I started having resistance. There was no audience for a play about four women in their 90s in a nursing home, nor were there actors. So I wrote. My dissertation on the social performance of aging, looking at senior theater groups all over the country, and later turned it into a book. I found that performance could change the way we think about aging by enabling people to take new roles in late life, but almost all the representations I had looked at were healthy older adults. I wanted to see if that premise held water when you were working with profound disabilities. 

Q: How did TimeSlips Creative Storytelling, which offers online and in-person training programs in improvisational storytelling for senior care facilities and caregivers, get started?

A: Most of the techniques at the time were oriented toward repairing memory via reminiscence theory and enabling people to remember by having residents retell the story of who they are. I found that just did not work in the nursing home where I was volunteering. I shifted toward, “Let’s make it up.” Inevitably, who we are comes out in those moments. Memories come out. Residents can experiment with language — whatever sounds or movements they have can contribute to it. It’s really a place where people can open up their communication again after sort of self-editing or being shamed into silence. The Penelope Project is a great example. We worked with an entire continuing care retirement community — residents, family members, staff and volunteers — and partnered with a professional theater company. We used “The Odyssey” as a prompt, and we broke it into workshops — poetry, story-writing, dance, visual art, weaving, absolutely everything. It culminated in a professionally produced and performed play that was specifically staged for an outside, paying audience. You’re creating the care community as a cultural center rather than a stigmatized medical center.

Q: Do you know what you plan to do with the MacArthur stipend yet?

A: It’ll support mostly my time. With so many potential initiatives, even ones we’ve already piloted but now can go to scale, having time to spend on them will be amazing. We’re also renovating our website a little bit as well, so I can imagine working on that, too. I’ll keep teaching because I think it’s really important to engage students in this work. It’ll be a valuable skill set for them to have and also will help change the field. We’re educating the students, but we’re also educating the field of aging care to say, “You should hire therapists, but you should also hire artists to come in and do these community-building projects. It can completely change the way your community sees itself.”

Q: What’s next for you?

A: TimeSlips has a contract from the state of Wisconsin to do 15 nursing home trainings. We made a 60-page prompt guide specially for those care communities. We received a National Endowment for the Arts grant to gather up all their creative output and then we’ll partner with Wisconsin Public Radio to create radio pieces to let people hear the creative strength of people in nursing homes across the state.

We’re in the recruitment phase. We’ll send folks out through the state to model it, and most of the rest will be done online at the convenience of the staffing, whose time is very precious.

One of the big projects that I’m super-excited about is a collaboration with Signature HealthCare in eastern Tennessee and eastern Kentucky. We’re framing out a 60-care-home art project similar to the Penelope Project. Ideally, it is going to position the homes as cultural centers in their communities. The art-marking is inspired loosely by the story of Peter Pan, so it’s going to be an intergenerational look into the meaning and value of childhood. I’m almost unable to sleep at night because I’m so excited. We’re writing grants. It’s in the planning stages.