Facilities with a higher ambulatory resident population have less to worry about, as those residents can bathe themselves privately in their rooms or apartments and staff typically doesn’t have to be involved. But as assisted living continues to take in higher acuity residents from the skilled nursing sector, the bathing issue assumes greater importance. 

In fact, facility operators should be thinking about their demographics and occupancy levels over the next decade in order to determine future bath safety procedures, says David Anderson, national sales manager for Apollo Bath.

“If there is a centralized bathing area, it is important to not only consider the make-up of your current resident mix, but what you expect the profile to be five to ten years from now,” he says. “It does little good to purchase a bathing system for your current resident mix without considering the acuity levels of that population in the next decade.”

Consideration also should be given to the acuity levels of those residents who bathe themselves on their own right now, and how they would manage after a debilitating stroke or after undergoing an invasive medical procedure, Anderson says. 

“If they can no longer bathe themselves, a centralized system that meets their needs should be made available,” he says.

Fran Spidare, product development manager for safe patient handling at Invacare, says safety and comfort are not mutually exclusive in bathing.

“Many centers understand the importance of creating a relaxing bathing environment, balancing the time required for true hygiene with the time for relaxing in the physical and emotional warmth of the total environment,” she says. “Safety is a mindset and the consistent actions that go with it, including well-defined procedures for safe transfers, training for staff, preparations to making the area safe and assurance that the bathing area is a clean and inviting atmosphere.”

Safe transfers

The greatest risks involved with bathing focus on ensuring the safety of the resident transfer as well as slip, fall and burn prevention and keeping on top of infection control.

For transfers, the process of lifting and moving can cause stress, strain and injury for residents and staff members alike, Spidare says.

“Safe handling of residents involves a thorough assessment of the resident,” she says. “Lifting equipment must be used so that both the caregiver and resident remain safe during the transfer process. The more familiar caregivers are with the equipment and its proper use, the more at ease they can make the resident.”

Indeed, staff must operate transfer equipment according to manufacturer specifications, Anderson says. For heavier residents, bariatric equipment and special protocols should be followed. 

The key to transfers, whether from bed to wheelchair or wheelchair to bath, is leverage, adds Lee Penner, president of Penner Patient Care.

“If it’s a weight-bearing transfer and the resident shifts during the move, the caregiver’s body mechanics will fail if there is not proper leverage,” he says. “Employees get hurt more often than residents because of bad body mechanics and lack of leverage.”

A low entry point to the bath is another advantage, as is an in-spa transfer device, Penner says.

Arden Olson, president of Accessible Systems, says the best way to minimize risk in transfers is to avoid transfers whenever possible.

“Our adjustable sink allows most non-ambulatory residents to remain in their wheelchairs for a shampoo service,” he says. “When the number of transfers is reduced, the opportunities for accidents and injuries is reduced.”

Danger areas

Slips and falls are more likely on wet surfaces, so keeping the floor as dry as possible is critical to a safe bathing environment, Spidare says.

“This relates to the design of the room — the floor should be slightly sloped to allow for good drainage,” she says. “Rubber mats should be used to provide traction and some slip resistance.”

Placing a non-slip rug in front of the tub is another effective slip prevention tactic, Anderson adds.

Burns are another concern and bathing suppliers recommend equipping each tub with an anti-scald mixing valve. These valves automatically control the flow of hot and cold water so the temperature does not fluctuate, which virtually eliminates the chances of residents being scalded by hot water, Anderson says.  

Given their potential for cross-contamination and germ fertility, bathing areas should always be on high alert for infection control, specialists say.

“Cross-contamination is always an issue,” says Anderson. “A bathing system equipped with a means to flush the lines with cleaner and disinfectant is needed and a means of purifying the water during the bath minimizes self-infection as well.”

To be sure, the bathing tub and its jet must be properly cleaned and disinfected every time between bathing cycles, Spidare says. 

“For tubs with pipes and tubing that circulate water from the tub, this is a difficult task,” she says. “Pipeless jet systems allow for much easier cleaning and disinfecting.”

Penner’s spas have a dual disinfecting system that uses a sporicide that kills even the most stubborn pathogens, like clostridium difficile, Methicillin-resistant Staphylococcus aureus and Vancomycin-resistant enterococci.

“When the need arises, the sporicide is available in our system,” he says. “But in 95 percent of the cross-contamination cases, the problem is with a lack of diligence in cleaning the equipment according to the manufacturer’s specifications.”

Bathing technology

Bathing manufacturers are constantly listening to their assisted living customers about the challenges with resident bathing and are incorporating that feedback into their technology. Regarding resident transfers, Apollo has developed the Level Glide Transfer System to eliminate hydraulic lifts.

“These lifts would hoist the resident high in the air so that the chair could swing around and over the tub so the resident could be lowered into the water — it is a means of transferring that is undignified for residents and unsafe for both residents and staff,” Anderson says.

Apollo also developed the Remedy Ultraviolet Water Purification System to address the “often ignored but very real issue of self-infection,” Anderson says. “Regardless of how well a bathing system was cleaned and disinfected between baths, the number of harmful bacteria skyrocket during a bath because the pathogens wash off the bather’s body. Instead of bathing in whatever washes off one’s body, the UV system continuously kills those bacteria. This results in lowered rates of infection; in fact, the system was clinically proven to reduce UTIs by 50 percent and respiratory infections by 35 percent.”

Invacare has introduced the SANIJET Pipeless technology to its tub line, Spidare says.

“Pipeless jet technology really improves the bathing experience because it allows clients to use whatever soap, shampoo or bath oil they like; it moves the water to relax the muscles, and it provides a truly clean bath because everything may be properly disinfected since there are no pipes in which dirty water can sit,” she says. 

Some have overstepped the intent of the regulations. Others still think they’re not included under the rules, which were designed, ultimately, to guide the flow of health information, secure an increasingly digitized healthcare system and protect patients’ and residents’ privacy.

For those who aren’t paying enough attention to the details, ethical and legal violations are a real possibility.

“A lot of healthcare organizations have done a great job of scratching the surface, but they’re not looking closely enough at the parts that can bite you,” says Candace LaRochelle, HIPAA privacy officer for eHealth Data Solutions, which provides clinical assessment, risk management and billing services to clients.

Although HIPAA’s components are clear about making protections, they leave the details of implementation to covered entities such as nursing homes and continuing care communities. That wiggle room, experts say, creates problems for facilities without the resources or knowledge to make technical decisions.

With the regulation’s latest revisions focusing on protecting information shared with business associates, new vulnerabilities have been revealed. 

“Privacy officers with skills and knowledge know to be checking up on vendors or have input into contracts,” says Michelle Dougherty, senior director of research and development for the American Health Information Management Association Foundation. “The concern is when we move to the organizations that don’t have that infrastructure.”

Kitty Williams, research and development director for The Compliance Store, says small, independent communities are more prone to making mistakes because they lack IT support, are crunched for time and might not understand HIPAA’s nuances.

It’s one thing to appoint a privacy official; it’s another to make sure that employee gets routine education and has the power to invest in technology and practices that provide security suited to a particular community’s physical location, as well as its use of business partners, electronic devices, wireless technology and off-site servers.

“Nothing ever ceases to amaze me, the things we still get questions on,” says Angela Rose, director, health information management practice excellence at AHIMA. “We have to continue to teach and educate and develop programs that continuously engage and energize employees.”

Bad practices

The good news is that the rollout of additional regulations — HIPAA debuted in 1996, got an update in 2009, and most recently expanded under the 2013 HITECH Omnibus rule — has created an entire industry designed to build good safety nets.

John DiMaggio, CEO of BlueOrange Compliance, has been working on privacy and security in pharmacies, skilled nursing settings and continuing care communities since 2012.

As part of a HIPAA review, his representatives conduct site visits and penetration testing to get a full picture of written, security-related policies and procedures; the technical working environment; the location and security of workstations and access to secure areas; and organizational information such as vendor agreements and documentation management.

“We’ve seen it all,” says DiMaggio. “Shared username and passwords. Simple, non-expiring passwords. No firewall.”

He adds that providers often have policies or training that is too limited in scope, fail to update antivirus software or don’t appoint a HIPAA security officer as mandated. Lack of encryption is a significant problem in this era of BYOD (Bring Your Own Device).

LaRochelle is a fan of third-party risk assessments because they provide non-biased information that creates targets for improvements. If leadership can’t be sold on annual reviews, she suggests at least building a checklist to standardize contracts with vendors so that everyone is working together to protect identifiable information.

A checklist approved by a lawyer is a start; a better bet is to check with someone with up-to-date and thorough knowledge of healthcare IT who speaks the right language. For example, Cheryl Field, MSN, RN, points to the concept of remote data storage. Having an RN/privacy officer with limited technical training review a contract with a business associate providing cloud-based storage for electronic medical records could be problematic.

“How does he know that it’s encrypted, encrypted at rest?” asks Field, vice president of healthcare and privacy officer for PointRight analytics. “He can’t see info in the cloud. They’re sort of at the mercy of the person doing the marketing.”

LaRochelle says small companies can get “taken advantage of because of the fear” associated with compliance or breach penalties.

In fact, many made drastic assumptions about the regulations when they were first passed in 1996. But HIPAA doesn’t require senior living settings to do away with sign-in logs at spas, stop calling patients by name in communal areas or remove their names from doorways.

Such incidental disclosures are specifically provided for within the regulations — provided they are limited in nature. Besides, placing over-the-top limits on privacy dampens the home-like environment providers are working so hard to cultivate.

“We’ve seen gun-shy caregivers unnecessarily withhold information for fear they would violate HIPAA, which could be solved with good training,” says DiMaggio.

Questions about HIPAA’s reach can often be answered by health care IT groups; AHIMA, for example, offers extensive HIPAA guidance on its website at www.ahima.org/topics/psc and at its annual conference.

And many companies offer online and group workshops tailored for IT staff, practitioners, even housekeeping.

“Everyone in the organization should be trained,” says Debbie Newsholme, senior director of content operations at HCCS. “Everyone has the potential to cause a breach or to access information they don’t need.”

Unwittingly wrong

Maria D. Moen, vice president of care innovation for VorroHealth, says she’s had well-meaning customers ask for generic log-ins, to allow archiving on personal devices, or to permit non-designated family members to access records. Once she explains that those actions undermine HIPAA standards, operators usually find alternative solutions.

“Senior living communities tend to be particularly sensitive to privacy and security issues with the aging population they care for,” says Moen.

Still, employees can cross lines unwittingly, whether it’s a medication aide sharing resident information in front of housekeeping staff, an activity director posting images on social media or an executive director opting for wireless Internet that offers only consumer-grade protections.

That last one is a major concern for Ginna Baik, business development executive with CDW Healthcare.

“There are unsecured networks within these 63,000 communities (across the country), and we don’t even know what’s getting hacked — no one’s tracking it,” says Baik. “We don’t know what we don’t know.”

If a visiting doctor logs on to a guest network, are his notes adequately protected? How sure are you that your 85-year-old residents won’t have their information stolen while using your system to shop Amazon?

Though senior living care has, as an industry, generally managed to avoid major HIPAA-related breaches so far, security experts predict the time is coming.

“It’s not ‘if.’ It’s ‘when,’” says HCCS’s Newsholme.

The fifth annual study by the Medical Identity Fraud Alliance found the number of patients affected by medical identity theft increased nearly 22% in the last year. It noted that 65% of victims surveyed paid more than $13,000 in resolution costs.

Sadik Al-Abdulla, director of security solutions for CDW, agrees with that assessment. He calls an attack on a senior living network “inevitable.”

“You have these cyber criminals going after bigger targets with larger piles of information. But as those places become more secure, they’re going to look for new targets,” he says. 

Nobody immune

And nearly everyone is at risk.

Al-Abdulla’s teams perform several types of security testing. Though none is designed to test HIPAA compliance specifically, they reveal privacy and security weaknesses.

During penetration tests, his IT professionals “always” gain access to protected systems. And he says data-loss prevention assessments reveal information in places his clients say it shouldn’t be 100% of the time (for instance, on an unencrypted spreadsheet). In about 80% of reviews intended to unearth existing breaches, CDW has found malware of other hostile programs that were operating unbeknownst to clients.

When the big breach finally hits long-term care, the best defense against huge penalties from the Office of Civil Rights might be proof of due diligence. 

If the facility were to be brought into the modern age, those dimensions definitely had to change.

The space rearrangements, decorative additions and functional improvements took only four months to complete, resulting in what is essentially a new community inside the shell of the old one, says Ryan Harrington, CEO of Trinity Healthcare, owner of the newly christened Fort Stockton (TX) Living & Rehabilitation.

“The bones were OK, but finishes and flooring looked very dated,” he says. Trinity purchased the building in January 2014. “We were committed to modernizing the building and got the work done relatively quickly.”

The 120-bed property is a one-story campus spread into four wings, with two dedicated to skilled nursing care, one for memory care and the other for post-operative rehabilitation and Medicare.

Aside from painting over the archaic “mauves and teals” on the walls and adding appealing aesthetic touches, general contractor Darrell Smith says a greatly oversized nursing station at the entrance — emblematic of its era — stuck out like a sore thumb. Its dismantling took top priority.  

“The first thing visitors saw was a medical feel and look, not a home-like atmosphere. Our goal was to take that in-your-face nursing station and turn it into a welcome station,” says Smith, president of Oakbrook Builders, which handled the construction.

Expanding the rehabilitation area consisted of basically repurposing some unused space, Harrington says. “They were doing virtually no rehab, so we switched the area they had dedicated to therapy with a generic room to create a larger rehab space,” he says. 

The much-roomier area allows the facility to now provide full-time physical, speech and occupational therapy. The renovation also added an occupational and restorative therapy room.

Technology upgrades also were a major part of the remodeling, as Trinity added modern computers, a new electronic medical records system, upgraded electrical wiring, network cables, an advanced phone system and touch-screen technology on the walls.

Fort Stockton is a town of about 10,000 in West Texas and Fort Stockton Living & Rehabilitation is the only skilled nursing facility in the county,  Harrington explains.

“There were only 70 residents in the facility at the time, so we thought the renovation could create a better environment for the residents and employees, while increasing occupancy 20%,” he says.

Creative use of earth tones, stone, tile and wood convey the local landscape, while wall murals painted by a San Antonio artist depict a historical narrative. Sun rooms with stacked windows present plentiful views of the surrounding mountains, bringing the area’s landscape directly into play. 

The first proverbial shot over the bow was fired in 2011. That’s when the NLRB voted 3-1 to let just nursing assistants organize at Specialty Healthcare, in Mobile, AL. Earlier this week, the labor board’s Chicago arm gave a similar option to selected employees at the Rush University Medical Center.

Industry groups — including senior living operators — are concerned that such drilling down could create havoc. At the very least, it will apparently force providers and others to bargain with multiple unions at the same location.

Jim Plunkett, director of labor law policy at the U.S. Chamber of Commerce, says that by allowing micro unions, the NLRB is letting unions gerrymander elections.

“Unions are allowed to cherry pick the employees in the workplace that they know will be supportive,” he said.

The introduction of micro unions also would appear to raise the issue of what options will remain in play for other employees. It would seem they could opt to form their own separate union, or not join a union at all. Or perhaps even join more than one. Regardless, collective bargaining as we’ve known it is likely to change.

For their part, labor unions insist micro unions can help make working conditions fairer for workers.

“In most workplaces, business owners have figured out ways to hijack the collective bargaining process,” said Keith Wrightson, a spokesman for Public Citizen. 

Like many hammer-and-tong disputes, this one may have a courtroom decision in its future. Recently, Sen. Johnny Isakson  (R-GA) again introduced his Representation Fairness Restoration Act, which would outlaw micro unions.

“When the National Labor Relations Board decided to allow micro unions, they tipped the scales dramatically in favor of unions and neglected 77 years’ worth of precedent in collective bargaining,” Isakson said.

It remains to be seen what micro unions will ultimately do to companies and workers. What we can say with full certainty, however, is that they will surely be a boon for labor lawyers.

Today’s residents are more ambulatory and facility cleaning protocols more stringent than they were just 10 years ago — meaning even the best furniture can expect to take a beating routinely.

The right knowledge, however, can leave residents sitting on a good investment. The trick is striking the right balance between function, fashion and financial return.

“Return on investment is important,” says Jane Rohde, principal with JSR Associates, a senior-design specialist. “Furniture’s going to impact safety, marketing, resident satisfaction — even employee satisfaction.”

Rohde says a 7- to 10-year cycle for furniture replacement is common in senior living settings. So if your facility is ready for a facelift, but the budget’s not, what’s the best approach?

• Put the most money into pieces that will be used the most often.
• Look for multi-purpose pieces.
• Consider rethinking materials that cost too much just a few years ago.
• Encourage residents to bring their own furnishings when space allows.
• Choose quality over quantity (unless you can get quantity pricing on quality pieces). 

That’s the advice of pros in the furniture market’s burgeoning healthcare sector.

“Don’t skimp on quality,” says Bethany Luhrs, an interior designer with Atlanta-based THW Interiors. “A good piece of furniture will last you a long time — sometimes as long as the design and interiors are still viable…. It is far better to have less furniture with higher quality than quantity.”

Jack Armstrong, executive vice president of  Cooltree, estimates 95 percent of furniture in assisted living communities came from residential or commercial furniture vendors until about five years ago.

Suddenly, the industry has taken note of senior living’s need for more durable products in a variety of price points. They’re paying attention to things like stain resistance and seating depth and adding more selection.

“We’re designing all of our furniture, whether casegoods or seating, for healthcare,” says Armstrong, whose company is a three-year-old offshoot of Artone. “We understand the environment.”

Damage control

While designers are busy creating hospitality-inspired interiors, on-site staff members must deal with the damage an aging population can do to furniture that only looks suitable for senior living.

“The typical wooden chairs and tables are simply not holding up,” says Michael Zusman, CEO of Kwalu. “When the furniture is beautiful and can stand up to the repeated punishment of knocks from carts, walkers and wheelchairs, as well as the constant cleanings of a senior living environment, then communities can say goodbye to beat up and worn-looking tables and chairs.”

Wood is still the preferred frame in senior living, but Armstrong says the tide is starting to turn toward non-wood options like all-steel frames. Designers have resisted their use, especially in formal dining rooms. 

That’s where Armstrong says they can be most beneficial, since dining chairs are the type that get the most use. While a facility might get by with a nice-looking seating arrangement in a quiet common area, dining chairs are pushed, pulled and leaned on for support daily. 

Rohde appreciates the functional advantages of stronger steel frames but acknowledges they’ve been a hard sell to clients, who say they’re “too cold.”

Seeing the price differential, purchasing teams often have been happy to stick with wood chairs and sofas. But Armstrong expects more selection will soon lead to price drops in steel or aluminum alternatives, making the choice more appealing.

And investing in steel frame pieces could offer critical paybacks. The typical wood-framed pieces aren’t designed to meet the demands of constant transfers and can be prone to breaking down — or even tipping.

Pieces that are inexpensive but too low or made without strong arms could create a potential safety hazard.

“I’ve been in facilities where I’ve seen residents pushing and pulling each other because they’re stuck in their seats,” says Rohde, who has designed communities from the East Coast to China.

Luhrs agrees that factors such as size, seat depth and height, and dense seat foam are critical for today’s more ambulatory assisted living communities.

“Though most facilities aim to achieve a homelike environment, it is important to select materials that are resistant to moisture, stains and frequent cleaning,” she says.

Maintenance and care can help protect an investment without adding significant up-front dollars, says Lynn Vogeltanz, studio lead for the selections studio at Direct Supply Aptura.

Fabric selection

Vogeltanz likes Crypton fabrics, which provide stain resistance and a moisture barrier to keep fabric “looking great.” An extractor should be used on ground-in stains, along with the least abrasive cleaning solution possible — always used in line with manufacturer’s cleaning instructions and warranty details. 

Buyers also should consider drop-through seating with removable cushions and an open seat deck that allows crumbs and bodily fluids to fall to the floor instead of compromising the piece.

Rohde hopes to see more assisted living communities choose companies that make furniture that’s easily de-constructed when it is damaged. If the base of a couch takes one too many hits from a walker, it can be replaced. The same holds for chair arms and other components.

“Then you don’t have to replace the entire piece,” Rohde says.

In assisted living communities, where facilities might include wellness centers, libraries, theaters and business centers in addition to residents’ units, a full renovation can require a large variety of pieces.

“Senior living room boundary lines are being blurred as multi-purpose spaces emerge,” says Kwalu’s Zusman. “An integrated look is crucial when it comes to furnishing all areas of a very open floor plan.”

Sometimes, working with one vendor can produce that integration, as well as cost savings.

Volume discount

If you have the capital but can’t weather a significant drop in census, Rohde recommends buying in bulk and warehousing pieces. She’s worked with several clients that earned a manufacturer’s discount and saved money on freight by buying enough pieces for a complete renovation, even if working on only two to four rooms at a time.

Also consider buying items that can serve more than one purpose, or those that can be moved easily from room to room as needs change. A theater chair with a tablet arm and an ottoman, suggests Zusman, works equally well in a media room, library or lounge. 

Stocking a few shared pieces also can work in combination with policies that encourage residents to bring as much of their own furniture to personal rooms as possible. 

Luhrs says the opportunity to furnish a room allows residents and family to personalize the space, maintaining a sense of independence and familiarity. 

For those who are outfitting bedrooms, custom casegoods aren’t necessarily out of reach.

Cooltree debuted its Metropolitan casegoods collection at the 2014 Leading Age Idea House, for example, and it’s been popular. Armstrong says that’s because the line’s mix of traditional floor furniture and wall-mounted space-saver units deliver versatility which, he says, the market had been demanding.

“Our philosophy of care is built around providing the best resident-centered care that we can, centered around respect and dignity, and we really wanted our space to reflect that commitment to creating a healing environment,” Loop says.

The project, which was unveiled at the end of March, involved the conversion of the facility’s traditional nurses’ station into a contemporary residential lounge for residents to relax, read, watch TV and visit with family and friends. The renovations also included the creation of a spacious spa treatment area with a state-of-the-art immersion tub, renovated semi-private, private and deluxe private rooms for transitional care and a multi-functional bistro providing round-the-clock access to healthy snacks and refreshments.

It was a massive project that required ongoing communication to residents and staff, weekly progress update meetings, support from donors and a lot of give-and-take, Loop says. Finding that middle ground can be a delicate — but necessary — step in any remodeling project, explains Bonnie Cauthorn, principal/manager of DesignSource Inc., a firm specializing in senior living space.

“Renovation is so much about compromise,” Cauthorn says. As more long-term care facilities look to remodel, here’s some real-world advice from those who have done it — or who help design long-term care renovations all the time.

Take a step back

One of the first stages of a successful remodeling project is making sure you know why you’re renovating in the first place, points out Chris Morgan, renovations national account manager for healthcare at HD Supply. 

“Revenue-enhancing projects will help ensure your long-term success, so weave in your company initiatives and include corporate goals in your planning process,” Morgan says. He recommends considering survey requirements, local competition, current and future care needs, safety, marketability, employee retention and efficiencies in labor or energy when thinking through renovation plans. 

Approach a renovation with an overall master plan, and then break it down over a two- to five-year period, advises Dean Maddalena, president and architect of Texas firm studioSIX5.

“This will assure that when the renovation is complete it is cohesive,” he says. “Resident rooms can be upgraded as they turn over, which minimizes disruption. Commons areas have to be carefully strategized with operations and the contractor to develop the most economical plan with the fewest inconveniences. Before work starts, it is imperative that all building materials and furnishings are in a local warehouse and readily available, so as not to cause delays.” 

Jane Rohde, principal and founder of JSR Associates Inc., a senior living and healthcare consulting firm, also says the most successful renovations she’s been involved in have been those where providers focus first on developing a strategic plan for their remodeling project. 

“Having a master plan discussing all the different things they’d like to do, even if they’re big things like eventually buying the property next door, helps providers be more strategic about how they do their renovation, and in how to target their money,” Rohde says. 

Listen to many

As part of the strategic planning process, it’s imperative to get input from all of your stakeholders, Rohde says. That includes holding focus groups with staff, residents and their families, even if it’s just to get their basic ideas or to let them air their concerns. Loop agrees, noting that Asbury realized early on that incorporating residents into the renovation project would help ensure a smoother process for all involved. 

“Any renovation causes disruptions, but we were able to get so much more buy-in by keeping our resident council group involved in the project,” Loop says. “They served as a mouthpiece throughout the remodel, communicating about the changes that people could expect and where things stood, which was incredibly valuable for us.”

Staff also can provide indispensable insights into important renovation needs, because they’re the most familiar with the day-to-day operations, says Lee Penner, owner of Penner Manufacturing. 

“One of the most important people to have on your committee is your maintenance engineer,” Penner says. 

It’s also a good idea to hire an interior designer that has experience in the area of senior living, says Lynn Vogeltanz, studio lead for Direct Supply Selections Studio.

“They can come in with fresh eyes to discuss ideas on how to best use your budget,” Vogeltanz notes. Listen to what they suggest for the facility, and use them and your corporate suppliers as resources for compiling supporting documents such as case studies, energy audits and solution-based design concepts, adds Morgan. 

In the end, it has to be a partnership between the facility and the design firm to talk through the various options and determine how to best move forward. 

Share your vision 

Money attracts money, Rohde notes, so letting potential donor and local partners know about your facility’s renovation plans, and the money you already have committed to the project, can help draw in additional funds. 

“If you already have a commitment of $2 million, it’s a lot easier to go to a foundation and say, ‘I have this much already, but if we had another $1 million, this is what we could finish out and have available for residents in the community,’” she says. 

Patrick O’Toole, director of development for the Asbury Foundation, also notes that those who have had a personal experience with the facility, including former residents and their families, are often generous supporters.

“Many former short-term rehab residents are back on their feet now and looking for a way to show their thanks for the care they received,” O’Toole says.

As the Wilson Health Care Center renovations began, O’Toole says they brought donors and community members in to see the progress, discuss naming opportunities and explain how their donations would help.

Rohde also suggests bringing in local partners to provide volunteer services or community-based resources where it makes sense.

“If you wanted to do a new garden or landscape area, talk to the local garden club and see if they might be willing to make that into their mission project, or ask the rotary club to come in and complete a portion of the renovation as part of a service project,” she says. “These can often be really good relationship builders and they don’t cost anything.” 

Prioritize choices

There are many items that come up as wish list items, but everything may not be able to occur at once, Vogeltanz says. Take time to determine wants versus needs, and whether they fit into your strategic plan, and then break it into phases.

When you’re prioritizing, it’s important to choose quality and function over look, Penner says.

“Be sure you don’t buy something because it looks ‘cute,’” he warns. 

That goes for everything from bathing equipment to the ovens you purchase for a kitchen renovation to the type of carpet you choose, says Marc Ahrens, vice president, commercial at Invista Surfaces.

“The right carpet fiber, backing and pile height can dramatically improve performance against stains, odors, resident mobility and ease of maintenance compared to a facility that does not specify carpet correctly,” he says.

 Of course, you’re never going to be able to do everything you would like, Loop says. At Wilson Health Care Center, replacing every single piece of furniture during their renovation just was not an option, so they took time to incorporate older furniture that was still in good shape into the new design. 

One way to cut costs is by purchasing dining room chairs that are non-wood, says Jack Armstrong, executive vice president of Cooltree. These chairs, whether steel, plastic or aluminum, have a longer lifespan than wood and can be reupholstered rather than replaced, saving significant dollars during a dining room refresh. 

“The money saved can go toward other products needed for the dining room renovation or refresh,” he says.

Resident safety and comfort are also key factors to consider when prioritizing your renovation wish list, adds David Daughtrey, J+J Flooring Group director of business development for healthcare. For example, finishes that reduce ambient background noise should be chosen to provide improved acoustics and a better atmosphere for hearing. Floor products that provide greater roller mobility and slip resistance will reduce the potential for trip, slip and fall injuries, he says. Renovations should reflect a positive environment.

“The interior environment should appear less institutional and create the appearance and feel of home,” Daughtrey says.

Invest in residents

Taking the time to focus on providing residents with a home-like environment can pay off, says Troy Rabbett, commercial marketing specialist at Flexsteel Commercial Furniture.

“Resident rooms can sometimes be overlooked in renovations, but taking the time to select a really comfortable and attractive resident room chair can show your residents and their families how much you care about the well-being and comfort of your residents.”

Finally, never underestimate the ability of small, inexpensive refreshes to transform a space and make a facility more marketable, Rabbett notes. 

“A fresh coat of paint and attractive new furniture can help make a great first impression in entry lobbies and other smaller public spaces such as hallways off the entryway,” he says. “You can even add in some new window treatments and accessories to fully update the space.”

Assisted living is a booming industry that currently enjoys a premium payer mix with a relatively light regulatory overhang. Look for the construction cranes in any major market in the country and it is more likely than a coin toss that underneath will be some form of senior living development. The leading edge of the baby boomer tsunami is coming ashore and the first stop in long-term care is senior living. They are more educated than ever, have some level of personal assets intact and have high expectations for their experiences in long-term care.

While the AL market continues to roll, what is the determining factor with respect to the operational model employed in a given organization or community? A very prominent factor is clearly the structure of the value chain or the partnering model employed by the AL operator. In other words, where do all of those residents come from? Many AL operators simply market directly or indirectly to families and seniors to identify suitable prospects to drive occupancy. They are able to target and qualify prospects who meet their desired acuity levels and payer mix. This allows the operator to proactively determine its operating model focus (either real estate or medical services) and then fill the units accordingly. 

However, an increasing number of operators are becoming part of larger diversified long-term care organizations or are entering into ACOs and other federated care models where they contract to accept a certain population and provide living and care services accordingly for a set fee and set terms. In these cases, the operating model focus is driven by the population management needs of the upstream entity and the resulting terms of the contracts or business relationships. So today, the degree of autonomy of the provider and the availability of a mix of acuity levels and payer types gives the operator some ability to choose whether it will operate a real estate-focused model or a medical services-focused model — at least in the short term.

Future factors

Will the ability of the AL operator to choose its operating model persist going forward? We need to look where the autonomy, acuity and payer factors are headed to answer that question. With respect to autonomy, we can look at the evolution of the acute and ambulatory care markets into fully integrated delivery networks. Just as there are virtually no “standalone” hospitals anymore, we will continue to see the pure-play operators in long-term care becoming directly or indirectly affiliated with diversified operators who can manage a population across the full spectrum of long-term care. Operational autonomy will continue to decline. 

With respect to acuity, we have a senior population with increased life expectancies and multiple chronic conditions and co-morbidities. These seniors increasingly flow into the AL care setting from skilled nursing and home care due to cost, personal preference, and other factors. Acuity levels in AL will continue to rise. 

With respect to payer mix, AL may be in the “roaring 20s” today, with a premium payer mix dominated by private pay. But the great depression is sure to follow. The average savings rate for seniors headed into retirement has been negative since the 2008 crisis. Many have depleted their nest eggs simply to avoid bankruptcy. While there will always be the affluent who can pay any price necessary for premium care, the average senior is not entering the long-term care system with sufficient assets to cover the cost of their care through their full life expectancy. 

Hence, the role of the government as the payer of last resort will continue to grow in all of long-term care, including AL. The payer mix will continue to become increasingly challenging. These factors combined indicate that AL will increasingly employ a medical services model.

When will the majority of ALs transition to a medical services model? Recent data from the 2013 NCAL Performance Measure Survey gives us a strong clue:

• 94.9% of AL facilities have a nurse available 24 hours a day

• 68% have a nurse available onsite 24 hours a day

• Over 54% of direct caregiver staff hold a CNA, LPN, RN or other nursing designation

It is clear that the transition has already largely occurred and very few ALFs continue to operate in the traditional real estate model. This data seems to support the common statement today that “ALFs have become the SNFs of five years ago.”

Added concerns

This transition to the medical services model has many implications for AL operators. There are new legal implications, as the liability associated with providing even basic care services such as medication administration is considerably higher than that associated with simple living services. There are new regulatory implications that, while they may continue to be relatively light compared to a skilled nursing setting, also may vary widely from state to state and add significant complexity. 

There are obvious operational implications, not the least of which is staffing profiles. In addition, EHR and care coordination technologies to document care and provide robust audit trails to manage regulatory and legal risks will have to integrate with primary care physicians, laboratories, pharmacies, family members, and others involved in the care extended team.

While the real estate model may largely be in the rearview mirror for AL operators, the great news is that this historical model has positioned operators well to succeed in a medical services model under the increasing use of capitated or shared risk reimbursement models. The strong focus on cost controls and operational metrics and the solid understanding of break-even points gives them a leg up on other care providers who have traditionally focused most of their energies on just the reimbursement part of the equation.

It is clear that the dominant operating model for AL will be a medical services model from here on out. The operators who will thrive have accepted this change and have begun to aggressively employ the necessary people, processes, and technology required for success in this new environment. 

“The move to memory care is a major step on a number of levels, and certainly has security implications,” says Steve Elder, senior marketing manager for Stanley Healthcare. “There are a variety of security risks that AL communities need to manage.”

Elopement of dementia and Alzheimer’s residents is certainly of paramount concern, as are the risks that come with the natural process of aging, such as falls, seizures and other medical emergencies, Elder says. And while rare, the potential for resident-on-resident and resident-on-staff attacks also must be recognized and prevented. Overall, assisted living centers must manage general security with appropriate visitor management policies and systems for access control, intrusion detection and fire prevention, among others.

Because a certain percentage of dementia residents is prone to restlessness and wandering, assisted living communities must be ready to address this behavior from multiple angles. Wander gardens have become staples at assisted living facilities and these areas have demonstrated great therapeutic value. But “in terms of security, at some point residents who are wander-prone will need the protection of a secure unit,” Elder says.

Predicting incidents

In assessing the functionality and effectiveness of a secure dementia unit, facility operators should consider how comfortable residents are with living there, says Sam Youngwirth, owner of Ciscor.

“If you enter a dementia care area and you notice the emergency call system — whether it’s audio, with buzzers or alarms, or visual, with flashing lights, the system is outdated,” he says. “The system should blend into the environment and should not induce stress to the residents.”

The mindset is changing within the security industry from a reactive approach in responding to incidents to a proactive one of trying to get out in front of an incident using predictive technologies, Youngwirth says.

“We know that when residents deviate from their ‘norm,’ the probability of an incident can increase,” he says. “Our system helps caregivers learn individual resident patterns and sends an alert when a resident deviates from the ‘norm,’ giving caregivers an opportunity to intercede before an incident happens.”

Utilizing technology

Technological advancements have created “an exciting time in resident safety and security,” Elder says. Information systems for wander management and emergency call now capture a wealth of data that can be used to improve care plans for better and more personalized care, he explains.

“This business intelligence also helps raise efficiency by revealing things like staff workflow patterns and staff-to-resident contact time,” he says. “Another growing trend is system interoperability; for example, exchanging data between a real-time location system and an electronic medical records system to extend the functionality of both.”

Balancing processes

Wander monitoring systems are becoming more advanced, so Wes Columbia, technology studio lead for Direct Supply Aptura, advises facility operators to create a plan that includes a thorough evaluation of the community’s processes.

“When evaluating systems and processes, make sure to involve stakeholders from clinical, maintenance and IT,” he says. “These three perspectives all provide a unique point of view that help the community make sure that what they design meets the best interest of everyone.” 

Columbia favors a “digital signature”-based verification for wander monitoring because the technology prevents false alarms and helps staff “feel comfortable that they are responding to a real alarm and not just interference.”

Alert buttons and medallions have been on the market for several years, but this type of wearable technology also has drawbacks, says Jack Zhang, CEO of Vitall, which offers a wrist-worn monitor that automatically sends out a distress call.

“The truth is that residents may fall and not be able to press a button for help,” he says. “They could be unconscious, confused or scared. By implementing a solution that offers a fall detection algorithm, a distress alert will go out as soon as the device detects that someone has gone from standing to lying down. There is no need for anyone to press a button — help will already be on the way.”

Staff training

While automated security systems have improved tremendously, no amount of technology can substitute for a well-trained and attentive staff, Columbia says.

“Accountability is key — your staff must know that they’re responsible for the care of the residents all the time,” he says. “Thorough semi-annual training of all the care staff should be done for any of the resident monitoring and wander management systems. What’s more, key codes and other credentials should be changed monthly so that the system is kept up to date, and to prevent residents from learning the codes.”

Elder advises facility operators to provide a comprehensive overall policy and detailed individual care plan for staff to review regularly.

“In this context, solutions that give caregivers actionable information at the point of care help them respond more quickly to a resident in need of assistance, while eliminating sound alarms and other alert mechanisms that can detract from quality of life for all residents,” he says. n

Researchers from Chicago’s Rush University Medical Center seem to think the answer is yes. They are arguing that people who follow a “MIND diet they have developed are less likely to become afflicted.

Much like the Mediterranean diet and the anti-hypertension DASH diet, this one encourages people to consume green leafy vegetables, whole grains, nuts, berries (particularly blueberries), fish, poultry, olive oil and wine. Foods that should be limited include red meat, butter, cheese, fried foods and sweets. 

In a study involving more than 900 Chicago residents, people on the MIND diet lowered their risk for Alzheimer’s by 35% to 53%, depending on whether they followed it moderately well or rigorously.

Experts caution that this is just one more step to understanding and preventing Alzheimer’s, not a cure-all.

“There is no silver bullet right now,” says Richard King, M.D., Ph.D., an Alzheimer’s specialist at University of Utah Health Care.

“What I think a lot of these things do is adjust your risk,” King says. “We know Alzheimer’s is complicated in its origin and in its development.” He notes that both genetic and environmental factors likely play a role. 

King says the genetic component makes it difficult to say whether specific foods endorsed or eschewed by the MIND diet make that much of an impact. 

But that doesn’t mean you shouldn’t pay attention to what you eat. King says people who are concerned about developing Alzheimer’s should heed some general rules of thumb.

“Foods that are good for your heart are good for your brain,” he says. “I think a lot of foods in that diet are just reasonable choices: less of the red meat, a lot more fish, vegetables and fruit.”

Alzheimer’s is a fatal brain disease. Initial symptoms include memory and thinking challenges. Sufferers eventually lose their ability to carry out the simplest tasks of daily living. Symptoms usually appear after age 65. 

Flawed Mindset 

I’ve conducted more than 900 focus groups. One thing I’ve repeatedly noticed is that many seniors have a flawed financial mindset. For example, many seniors and their families have not considered how they can put the pent-up equity value of their currently owned home to work for them prudently in the later phases of life. 

Seniors certainly recognize the value of this passive fixed asset, but they fail to consider how it can significantly augment the affordability of future senior living options. Sales and marketing teams should show seniors the advantages of liquidating their home equity and prudently putting the new cash to work today.

Another serious mindset flaw is how seniors view their true current cost of living. Seniors consistently cannot accurately estimate their current monthly cost of living. They frequently forget non-recurring expenses such as real estate taxes, homeowner’s insurance and home repairs. This serious misconception frequently leads to sticker shock when discussing the cost of senior living.

There is a practical solution to put this serious financial dilemma into proper perspective. Address and customize each senior’s unique financial situation to show that senior living may, in fact, be affordable. 

The Planning Scenario

The setting should be a private sales and marketing office or conference room. The sales professional takes an age- and income-qualified senior, their family members and sometimes a trust officer/financial planner through a simple, but effective, financial sensitivity analysis. Create a customized computer template. Use a screen large enough for all the participants to view. Include the following: 

1. Tabulate the senior’s available financial resources. This includes Social Security, monthly income derived from his or her current investment portfolio, and any other sources of income, along with an estimate of the senior’s typical tax rate. A discretionary spending income reserve — usually about 35% of after-tax income for independent living and approximately 20% for assisted living — should then be subtracted.  

2. Estimate the cost of your senior living community. This input should reflect the base monthly service fee for several living options being considered. Include any tiered pricing in assisted living that might be necessary based on the resident’s acuity level. 

3. Summarize overall affordability (gap or surplus). Compare the senior’s total after-tax income with the community’s monthly service fee which shows either a surplus or deficit. The analysis also should show the expected equity value of the senior’s current home based on an assumed re-sale. 

4. Analyze the consumer’s affordability. The analysis should consider the following information: 

• The annual interest earned on the newly liquidated home equity (invested in a safe fixed income account).

• Social Security income, existing investment portfolio proceeds and other income. 

The end result would be the net after-tax cash available for the senior living monthly service fee showing either a surplus or annual spend down/shortfall requirement.

If the analysis reflects a surplus, the senior can clearly afford to live at your community. Conversely, the analysis might show the need for modest spend-down of the savings portfolio at a relatively slow pace with the asset lasting longer than the senior’s expected life or residency at your community. 

The ultimate expected outcome would be to show the senior and family members the relative affordability of your senior living community — both now and in future years. We have an opportunity — and an obligation — to help seniors and their families properly plan for the future.