Nurse robots. For years, researchers have been experimenting on ways to make robots that act like nurse aides. Among the potential benefits: safe resident lifting, medication assistance, fewer workplace injuries and improved resident satisfaction. Several prototypes are being tested this year.

Self-driving cars. Few adults want to have “the talk” with their parents about giving up car keys. Thanks to advances in self-driving cars by Google and others, that conversation might not be necessary in years to come.

Edema socks. Based on technology developed by the Danish firm Ohmatex, these stockings are able to notify wearers if they have swollen feet, caused by excess fluid trapped in the body’s tissues. This swelling often is the sign of a larger underlying medical condition.

Stockings that detect diabetes. University of Arizona researchers are testing SmartSox. These stockings detect excessive pressure, heat and misplaced joint angles that could cause foot ulcers. Early detection can lead to more aggressive treatment and prevent limb amputation.

Fall-prevention shoes. Equipped with vibrating shoe insoles, this footwear can aid balance and stability, which makes a fall far less likely. An earlier study found the product could be useful in the marketplace.

CPR from your shirt? Investigators at the Massachusetts Institute of Technology are attempting to create a shirt that can sense a heart attack and administer cardio-pulmonary resuscitation. 

Making homes smarter. Technology for homes that takes advantage of sensors, apps and personal computers exists, but has only been adopted on a small scale so far. 

Few of these issues are more confounding than medication management. Although these operators’ residents are generally less acutely ill and have fewer chronic conditions than those in nursing homes, the challenges that drug awareness pose are nearly as complex, and in some respects, even riskier. 

When people enter nursing homes, they usually surrender the large bag of drugs they came with over to nurses charged with monitoring and dispensing them. But when people check into assisted living, many continue visiting multiple doctors and pharmacies, even managing their own dispensing. That level of independence and loose monitoring can pose keen challenges for caregivers.

Medication errors

As if prescribing and dosing issues aren’t enough, the problem of polypharmacy can compound medication errors tenfold, experts say.

As Leading Age points out in its 2015 report, “Medication Management Technologies for Long-Term and Post-Acute Care,” the higher the number of medications a patient takes, the higher the risk of medication errors, drug interactions and adverse reactions. 

The issue of polypharmacy is even more acute in assisted living settings, according to Steve Piepenbrink, president of Guardian Pharmacy of Indiana. Although more and more nursing home residents tend to use one doctor the longer their stay, the transient nature of assisted living often means many residents are swirling in multiple scripts from multiple places. 

“An assisted living facility may use four or five different pharmacies, so there can be a lot of duplication and overlap,” prompting some communities to adopt a preferred pharmacy provider, he notes.

Reimbursement issues can be especially frustrating for assisted living residents when it comes to third-party insurance prior authorizations for non-covered drugs. 

“Insurance companies may require test results, clinical information or additional rationale/documentation from prescribers for certain drugs prior to approving them for payment,” says Jennifer L. Hardesty, PharmD, chief clinical officer and corporate compliance officer for Remedi SeniorCare. “This becomes an operational, administrative, and financial burden to prescribers, pharmacies, facilities and patients of assisted living facilities.”

Consider even those medications assisted living residents buy off the shelves of their local store or corner pharmacy. It’s not uncommon for them to expire under the radar or cause potentially dangerous interactions with prescription meds. 

“Mismedication occurs even with OTC drugs,” says Laya Klein, quality control director of Geri-Care Pharmaceuticals. “Nursing staff are even more harried as Medicaid cost cutting results in a greater patient-to-staff ratio than ever before. Nurses complain that the labels and packaging of their OTCs are inconsistent since the supplier will send them whatever drug is cheapest. Pressed for time, nurses have difficulty choosing the correct OTC pain killer from their crowded OTC supply drawer.” 

Many long-term care pharmacists pointed to poorly managed transitions as a leading culprit in medication errors and adverse reactions.

As seniors move from home to hospital to nursing home to other settings like assisted living, a lot of information can and does fall through the cracks. 

“Seniors living in the community with multiple doctors will go to the hospital, go to rehab or move to a nursing home or assisted living facility, take their drugs with them and no one knows about all the medications they’ve taken,” says Patricia Howell, RN, a member of McKesson’s Clinical Resource Team. 

Now that the problem of ADEs has reached critical mass in the industry’s psyche, solutions abound. Most prominent among them are data aggregators. In its recent report, LeadingAge identifies several “upstream technologies” like the electronic health record, e-Prescribing, computerized physician order entry and clinical decision support systems, and “downstream technologies” like electronic medication administration records, bar-coded point-of-care systems and remote pharmacy systems. 

Storage issues

The very nature of how medications are stored in so many long-term care facilities has led to chronic waste. 

Not realized by many, these costly medications quickly go bad if they aren’t kept in tightly controlled, consistent and narrow temperature ranges, says Cynthia Fitton, product marketing manager, Follett Corp., which has long supplied medical grade refrigeration to the healthcare industry and recently began marketing to the long-term care community.

“A lot of providers don’t have the same kind of awareness that a hospital pharmacy would for the tight temperature tolerance for some of these medications,” Fitton tells McKnight’s Senior Living. “Everyone wants to do the right thing, but it’s a cost issue,” says Bent Gay, R.Ph., chief executive officer of Gayco Healthcare, a long-term care pharmacy, whose hospice and assisted living customers have asked him to pick up and destroy meds. Large retail pharmacies may tout their “free” drug takeback programs, but the task is costly and burdensome for so many independents, he adds.

Some legislative efforts have actually caused patients to be denied badly needed pain medications. “Medicare Part D beneficiaries are able to get multiple scripts for the same drug, and so there’s a congressional effort afoot to give Part D plans the ability to determine certain beneficiaries are at risk for substance abuse and to limit them to one prescribing physician for all of their medications and to one pharmacy to pick up their meds,” Pharmacy Operator’s Association leader Alan Rosenbloom explains. The problem is when a beneficiary goes to the hospital on a Part A stay, gets transferred to a nursing home and starts on a Part A stay that only applies to Part D, then transfers off the Part A stay and now his or her drugs are being paid for by Part D. All of a sudden, both the pharmacy that’s contracted with the facility and the one that the plan has designated as a retail pharmacy can’t provide the drug legally. Now you have a patient who can’t get any drugs.” 

Indeed, senior living operators are rapidly becoming reliant on information technology and are being transformed in the process.

As Argentum points out in its state-of-the-industry report, “Getting to 2025: A roadmap for the senior living industry,” operators must create more efficient operating environments through technology and innovation. 

“Technology empowers operators to know more about patients/residents, and more strategic personal health information about these residents, than ever before,” says Russ Hertzberg, vice president of technology solutions for Prime Care Technologies. “This enhanced resident data profile can eliminate ineffective care, reduce stay length and increase quality of care.”

Adds his colleague, Rand Johnson: “Data is the new currency of long-term care. With technology as the catalyst, efficiencies and savings can fuel the further development of affordable and accessible senior living and care services.” 

Consider how far the senior living industry already has come with information tech:

• Mobility — IHS Technology predicts that sensors in wearable electronic devices will rise by a factor of seven through 2019. Companies like MatrixCare are finding ways of mining the data from those devices to populate other databases with critical health information.

• Connectivity — Tablets, medical apps and mobile phones are exponentially increasing the numbers and complexity of connections between residents, caregivers and business staff. 

Even MatrixCare, a company that etched its imprint as a leading electronic health record provider, and Yardi, a property management software giant, have their own integrated platforms that allow residents two-way communication and sharing over myriad channels. At press time, Yardi released RentCafe Senior Living, a portal that allows families and residents to view their loved one’s health record as well as schedule activity participation and pay bills online, according to Fil Southerland, director of healthcare solutions for the
company.

• EHR systems — Argentum recently reported that 20% of residential care communities currently use electronic health records, and most are using them for purposes other than billing or accounting. Dave Wessinger, co-founder and chief technology officer of PointClickCare, says he believes the EHR is at the very core of providers’ insatiable quest “to build a highly valued, sustainable business.”

• Monitoring and security — There seems to be no end to innovation around resident monitoring and security, says Mike MacLeod, founder and lead strategist of Status Solutions, a high-tech situational awareness solutions provider. 

“Being able to know where staff and residents are at any one time gives you the ability to potentially manage and plan and fix,” says Ari Naim, CEO of CenTrak, a real-time location services (RTLS) provider. “These are efficiencies you need in order to provide excellent care and services to those residents at your facility.” 

Naim believes one of the greatest benefits of RTLS is the ability to associate all the elements, whether it’s people or equipment. 

More and more, senior living operators “are relying on solutions that leverage data throughout the employee lifecycle so they can make better decisions while driving cost efficiencies,” says Mark Woodka, CEO of OnShift, which provides cloud-based software and proactive services to solve everyday workforce challenges. 

Challenges abound

Adds Keith Speights, president and CEO of Constant Care Technology, LLC, “The real challenge for providers in staying up to date on important technology developments is avoiding information overload. I wouldn’t overlook using your technology vendors as resources for information.”

“Senior living residents typically are cared for by a team of people, including healthcare professionals who are not staff members of the senior living community,” says Joe Weber, MatrixCare’s chief technical officer. “Technology can help save time and improve the quality of care by ensuring that all members of the care team have access to current and accurate resident information.”

At the end of the proverbial day, it’s all about taking the plunge, and not just dipping your toe, into the IT waters, experts say.

“A few big misconceptions about IT inside senior living communities are that it is optional, that it is too cumbersome or that it is too expensive,” says PointClickCare’s Wessinger. “However, health IT systems can be a bridge to creating greater care efficiencies, but only for the forward-thinking senior care providers who get on board now, before it’s too late and the ‘silver tsunami’ of aging baby boomers outpaces the ability of the next generation’s capacity to take care of them.” 

“We love it when our borrowers reach out to us. We’re customer-oriented, not transaction-oriented, so whatever we can do to help, we want that opportunity,” says Jeffrey Stein, the executive managing director at Capital Finance LLC, a subsidiary of Capital Funding Group/CFG Community Bank. “We succeed when our customers succeed.”

Market masters

Depending on the lending shop, a lender may have strong capital market connections and keen knowledge of what’s going on with deals. “If you want to know where rates are trading or how the market’s looking, in general, we’re able to share that information,” notes Latoria Thompson, a managing director at Housing & Healthcare Finance LLC. “We also live and breathe the HUD market and are happy to give an update on what’s going on there.”

A lender with a finger on the market’s pulse can go a long way toward helping senior housing operators determine their best growth and business strategy. According to Craig Jones, the president of Lancaster Pollard Fund Manager who also manages Lancaster Pollard’s Prospero Seniors Housing Equity Fund and the Lancaster Pollard Finance Co. LLC, his firm has a good grasp on the market climate in various states across the country. 

“If an organization is pursuing a particular business, we often will know some of the challenges they may face,” Jones says. 

The company also may help clients find areas that allow a certain type of structure to be built within a particular community. 

Because many lenders are doing business with operators and developers across the country, those borrowers’ experiences, trials and tribulations can help pave the way for success for others. “We want to know if a client has an interest in growing. We see so much going on in different regions of the country, so if someone is looking to expand into California, for example, we may know some opportunities and information we can pass along,” notes Jim Dwyer, the president of Capital Purchasing Group PPC, a subsidiary of Capital Funding Group/CFG Community Bank.

Those information-sharing opportunities can run even deeper. As Jones explains, broad client experiences and discussions can even make it possible to pass along word to another client on which questions the planning commission will likely ask. “We can also help someone who got out of the business years ago and is now wanting to get back in to better navigate the market changes,” Dwyer explains. 

Tim King, the managing director of the healthcare division for EverBank Business Credit, says the value of collaborative information-sharing across the client base is an advantage that can’t be overestimated. “We view our existing clients as our best referral source for our business. We work in collaboration with them, with both sides providing market intelligence to each other.” Clients may contact him about his experience in a complementary business line they are contemplating, for example, or they may ask about reimbursement trends in a neighboring state where they plan to enter.

The information sharing goes both ways. As King stresses, he may ask a client what they’re seeing in the marketplace or ask a client to help explain a deal that another client brought to the lender that King may not fully understand. 

“Clearly, we build these relationships over time,” he says.

Making connections

Another notable offering borrowers should be tapping is their lenders’ ability to proactively pinpoint potential business offerings and growth potential. 

“Because we have a broad client base all across the country and really work to understand our clients’ immediate and long-term needs and goals, we can connect one of our borrowers who is looking to sell a property with one who is looking to buy,” Thompson explains. “We may also know from experience working with an operator that they like to buy properties and turn them around. Who knows? That may be just the deal we’re working on today, and we can pass it along to that prospective buyer. I don’t think a lot of borrowers are fully aware that those types of opportunities exist with their lenders.” 

Having that connection especially pays big dividends in the healthcare segment, where reimbursement and regulatory changes happen regularly. 

“If we’ve heard one of our clients on the West Coast has had experience with a recovery audit contractor review, we can connect them with someone on the East Coast or another region to gain their perspective,” King says. “We’re all in this boat together. If someone is going the managed care Medicaid route and is a late adopter, for example, we can try and connect them with an early adopter to help them gain that invaluable experience. The great news is many of our borrowers aren’t direct competitors, so that information can be shared pretty freely.”  

Added leverage

Some lenders have subsidiary businesses aimed at analyzing a client’s operations to improve the bottom line and positively affect real estate value. Capital Purchasing Group LLC, for example, helps clients that are seeking financing, but falling short on valuations. 

“We have just under 300 facilities now, so we have that leverage and experience to draw from,” says Dwyer. 

The company sold 21.4 million connected health and fitness devices in 2015, with 8.2 million  sold in the fourth quarter alone. But despite such growth, there has been scant research on how accurate they actually are. Researchers from the Charles Perkins Centre at the University of Sydney concluded that they are pretty close.

For the study, investigators examined four dozen patients and family members participating in community-based exercise programs. Participants wore the device over four days to monitor daily step counts and minutes of moderate to vigorous physical activity. The researchers discovered that:“Fitbit-Flex is a valid, reliable and inexpensive alternative device for activity monitoring specific to predicted attainment of physical activity guideline recommendations,” authors wrote.

These devices can give activity directors “real world assessments of their patients’ daily activity
patterns,” the authors said in the European Journal of Preventive
Cardiology.

The Fitbit was introduced in 2008 in San Francisco by co-founders Eric Friedman and James Park. It’s essentially a 21st-century pedometer.

Throughout the day, Fitbit logs a range of data about the user’s activities, including the number of steps taken, distance covered and calories burned. n

The idea of patterning an assisted living facility in West Newton, MA, after long established traditions in Denmark, Norway and Sweden has finally reached the point that designer Joe Carella envisioned when he started the venture.

“I knew Scandinavia was good at eldercare, so I got a grant and researched how they did things over there,” he says. “What struck me was how connected they were to the community.”

The name could just as well be It Takes a Village. Though not a radical idea by any stretch, the 40-unit property operated by the Scandinavian Charitable Society of Greater Boston struck a chord with residents — one of wanting to belong to the community at large instead of being segregated from it. What that means is opening the facility up to the outside world, with office spaces for several local businesses, a performing arts center with a variety of events and a gym and walking track open to the public. It also means inviting 20 or 30 civic groups to hold events on site. In all, more than 20,000 people a year visit the facility for a wide variety of purposes, says Carella, who serves as executive director.

“I wanted to have groups coming in for events that take place naturally as they would in the community,” he says. “That is the connection that is necessary. That is where the magic happens. When you connect, the elderly share their ideas and wisdom.”

It has taken time for the neighborhood Carella to evolve into his vision — not because the residents weren’t on board with it, but because getting community members to change their perceptions of how an eldercare facility should operate has been a slow process. Overcoming conventions has been the main challenge, which Carella addresses at every opportunity.

“When I hired a cultural director, I told her to focus on programs that would attract the community, not the residents,” he says. “I didn’t want to limit her thinking on what programs to have.”

Carella admits that the neighbors were unsure about getting involved with the center “because of their institutional perceptions” about eldercare. Gradually, though, they have broken through those barriers. By opening up the gym to the public, a mother came in with her teenage boy for physical therapy and from that encounter, he has made progress.

“That is when we realized that we had something special — something powerful,” Carella says.

While the campus is welcoming and open, Carella insists that it does not come at the expense of resident safety. The key, he says, is for everyone to look out for each other.

“We have security here, but let’s face it — you and I aren’t safe in our own neighborhoods,” he says. “It’s about not isolating a population segment. They are ‘elders,’ not ‘seniors.’ 

“When you connect elders with the younger generation, you recreate the most important part of the neighborhood. Community-centered living is a difficult concept — it needs to be connected to the neighbors and you have to interact.” 

A: Your organization is likely to be affected. If the minimum wage of $7.25 per hour is increased, you will likely feel pressure to raise hourly wages for other lower paid entry-level employees. These employees typically like to earn about $1.00 to $1.50 per hour more. There could be a heavy concentration of them in your community. 

I analyzed the typical impact for a 110-unit community that increased entry level wages by $1.50 per hour. Total expenses obviously increased, net income and cash flow decreased significantly, and operating profit margin decreased. You need to run your own numbers. 

The minimum wage issue poses both an ethical and a real world business challenge. There is a win-win solution to this financial dilemma, however. You can address the unavoidable potential minimum wage financial impact by improving your community’s long-run financial performance. 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.

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. 

Hospital admissions among assisted living residents in 46 Brookdale Senior Living communities decreased 17% in a three-year pilot program funded by a $7.3 million Centers for Medicare & Medicaid Services Health Innovations Challenge grant.

To modify the program for assisted living, project organizers chose the INTERACT components most relevant for those residents. Key elements were the STOP and WATCH and SBAR (Situation, Background, Assessment, Recommendations) communication tools, as well as advance care planning resources. 

That central message repeatedly has emerged during the 2016 NIC Spring Investment Forum, which ends Friday.

“You need to have a conscious strategy for how you are positioning [your organization],” said Robert G. Kramer, CEO of the National Investment Center for Seniors Housing & Care.  

Finding that best approach, however, will be challenged as various payment sources continue to favor top-shelf services at discount prices.

That’s one reason why operators increasingly will need to rely on analytics to define and defend their advantages, said Dan Mendeslon, CEO of Avalere Health, a keynote speaker at Thursday’s opening session.

Mendelson sees the Medicare Advantage model increasingly determining how various players — including insurers, acute care hospitals, post-acute facilities and assisted living communities — find their sweet spots.

Despite the many uncertainties ahead, Mendelson sees a viable role for assisted living operators. He noted that such communities are well-positioned to manage patients/residents with memory care needs and other challenges that can complicate treatment plans.

“The beauty of assisted living is that, while it is relatively unregulated, it’s well-positioned to deliver value,” he noted.

Still, a real concern exists among many smaller operators that many of the things that have historically made assisted living attractive — such as preserving resident choice and autonomy — might be compromised. Some also are speculating that the assisted living model might bifurcate into two general channels: one focused on healthcare, the other emphasizing housing and hospitality services.

Among the advice doled out to assisted living operators: take an active leadership role, have well-functioning electronic health records, network with hospitals and other possible population-based plan partners, commit to upgraded staff training and employ evidence-based care transitions interventions.

Christopher Kazantis, director of AEW Capital Management, noted that many properties built 15 or 20 years ago don’t meet the desires of those looking for seniors housing today. To be competitive, properties now need to have larger common areas, multiple dining areas, and individual units that are bigger and have more storage space. Some owners can’t or don’t want to update their communities.

“I think a lot of this older product … is going to turn into the affordable product, because the only way they’re going to be able to compete is on price,” he said.

Standing out in the market

Lori Alford, chief operating officer of Avanti Senior Living, said her company tries to differentiate itself by building communities that are unlike other properties in the markets it serves. “If you’re going to go out and build a brand new building, and it’s just going to be the same design as 10 years ago, that shiny, new penny is not going to get you very far,” she said, especially if the competitor has a good reputation.

Avanti communities feature dining areas that function more as restaurants rather than dining rooms, art rooms that are not simply converted former residents’ rooms, mind/body/strength areas that offer massage and other spa-type services, and fitness areas that offer yoga, barre and strength classes. And the communities don’t have activity rooms.

“You don’t have to design a lot of spaces. It’s really about the programming,” she said. For example, faculty from a local community college teach art and other classes.

The properties, Alford added, have a boutique feel, with blown glass decorations and executive team members wearing all black. It may seem expensive, but the communities do not have the highest rates in the market, she said.

Residents are very pleased with the changes, Alford said — and so are their adult children. During focus groups, she added, adult children have said: “I would live here, I’m proud that my mom lives here, and, more importantly, we love coming here.”

“We just started with a clean slate and said, ‘Who do we want to sell to, who do we want to serve and who do we want to employ?’ Let’s create a building that’s built for them, that’s designed for them and that appeals to them,” Alford said. “It’s served us well, and we have captured market share because of it.” In fact, she added, more than 50% of move-ins and deposits are from existing competition.

New models, new funding

William Shine, senior director at Synovus Bank, said a future trend will be a hybrid model of senior housing and care that combines assisted living and skilled nursing. Such a model will be easier to implement in states such as Texas and Florida, which have no certificate of need requirements, he added.

Kazantis predicted that every major core fund will have a senior living component within 10 years. “A lot of these huge core funds that have only invested in the traditional asset classes — office, multifamily, retail, industrial — they, like the lenders and everyone else, are really looking for yield, and they’re looking for assets that can throw off cash,” he said. “Stabilized senior housing hit both of those in spades. …So you’re going to start to see a lot of these big core funds start to come into the sector and replace the real estate investment trusts and start buying that asset class.”

Kazantis also cautioned potential senior living investors and operators to be sure their motives are pure. “Anyone who is out there and thinking of getting into the industry, make sure you’re getting into the industry because you really have a mission and you really care about taking care of seniors and seniors’ families,” he said. “If that’s what your ultimate goal is, then you have to run it like a business — dollars and cents and bottom line — but if that’s your goal, you’ll probably be successful.” Those who enter the market just looking to make money probably will not be successful in the long run, he said.

Most of the pioneers of the industry started in the business because they didn’t like what they saw when they were looking for living arrangements for their aging parents, Kazantis said.

The NIC event runs through Friday in Dallas.