The use of social media among those aged 65 or more years has more than tripled since 2010, according to a new analysis from the Pew Research Center. Now, 35% of those in this age group report using social media compared with 2% in 2005 when Pew began tracking usage.

Fifty-one percent of adults aged 50 to 64 now use social media, compared with 5% in 2005 and 33% in 2010.

Among adults in general, 65% now use social networking sites, a nearly tenfold jump since 2005, according to the report. Adults aged 18 to 29 years are the most likely to use social media—with 90% of those in this age group reportedly using it—although their usage began to level off as early as 2010.

The report authors analyzed data from 27 national surveys of Americans, about 47,000 interviews of adult Internet users and about 62,000 interviews among all adults conducted by the Pew Research Center from March 2005 to July 2015. The report also includes differences based on other demographic characteristics, such as socioeconomic status, education level, gender, rural/suburban/urban dwellers and race and ethnicity.

In reality, getting operators — of all sorts — on the same page with healthcare IT has been something of a mixed bag. The relatively new world of HIT has been a strange one for providers, many of whom are reluctant to embrace change. For the first few years, software programs were also relatively siloed, focusing on one aspect of care or compliance. 

But as the years go on, the full scope of possibilities is starting to come into focus, and providers are more comfortable using HIT to improve communication, increase compliance and predict patient outcomes — all with an eye toward reducing rehospitalization. 

Catching the carrot

With the passage of the Protecting Access to Medicare Act of 2014 in April, preventing readmission to hospitals has become an even more pressing concern for senior living providers. As part of the law, CMS will implement a new reimbursement plan starting in 2018, explains Doc DeVore, director of clinical informatics & industry relations with Answers On Demand (AOD) Software.

“A reserve of 2 percent of total payments will be set aside and the top 30 percent of long-term care providers with the lowest re-hospitalization rates will receive a reimbursement from the reserve pool,” he says.

But the government’s stick-and-carrot plan may prove to be redundant. That’s because low readmission rates are already vital to ensure ongoing hospital referrals and to keep communities financially stable.

“If a hospital looks at its data and says, ‘my readmission rate from operator A is much lower than it is from operator B,’ guess where they’re going to refer their patients?” asks Kim Ross, senior director of marketing with MatrixCare.

To benefit from these higher referral rates — and, ultimately, increase revenue — providers need to have a way to track their progress when it comes to rehospitalization and share that data with accountable care organizations and other stakeholders. Statistics regarding length of stay, even patient satisfaction surveys are important metrics ACOs consider, and HIT solutions are more capable of collecting and packaging that information than ever.

“In order to stay ahead of the curve, providers need to look at healthcare information technology solutions that are flexible, scalable and interoperable,” says Dave Wessinger, chief technology officer at PointClickCare.

Preventing readmissions also relies on a rapid transfer of accurate health information, says Keith Speights, the president at RosieConnect. 

“If you can’t make a change quickly enough, that patient will go back to the hospital. If you can intervene, the resident can be taken care of in the facility,” he says. “It’s about getting the key clinical information into the hands of the right person.”

Attitude adjustment

While many industry insiders correctly point to financial constraints as a barrier to adoption — “It’s not like [providers] are making a ton of money, and government reimbursements aren’t setting the world on fire, either,” quips Ross — there are other blockades that may be less obvious but a hindrance, nonetheless.

First and foremost, says Jeremiah Johnson, vice president of business development with VorroHealth, is a lack of strategy. IT needs to support a company’s overall goals, not just the specific needs of senior care. 

“As a popular saying goes, ‘Begin with the end in mind,’” he says. “An IT strategy that is well thought out, documented and communicable creates an environment in which barriers can be broken and implementation can survive when the headwinds arise.”

Hesitancy and skepticism on the part of staff is another major drag on HIT implementation in senior living. Older physicians and nurses might be reluctant to change their way of working. Administrators may worry over security fears and the potential for medical records to be hacked. Many have taken an attitude of, “if it ain’t broke, don’t fix it” — but just because something isn’t broken doesn’t mean it’s working well.

Overcoming reluctance from staff can be difficult, but there’s a way around it, according to Wessinger. “Organizations need to involve everyone in the selection process, determine what will work within the organization’s capabilities and train staff accordingly,” he says.

For all these stumbling points, however, it still comes down to money for most providers. But LeRoy Boan, senior sales representative at NTT DATA Long-Term Care Solutions, advises providers to look well beyond the first year, when the costs outweigh the benefits, in order to really see their return on investment.

“Adding [HIT solutions] may not show savings immediately,” he says, “but they will as soon as nurses eliminate things like medication notebooks and monthly recaps from their routines. The nursing hours saved on this alone would pay for the software.”

Communicate better

Interoperability is the ability for an organization’s systems to share critical information with other providers across the senior care continuum, Wessinger explains — and it’s the name of the game for many in the healthcare IT field.

“Interoperability with health systems and other acute care settings is at a crucial level for long-term and post-acute care providers,” says Chris Dollar, chief operating officer at HealthMEDX. “We are reaching a tipping point where providers will not be able to successfully run their businesses without the benefits that the right electronic medical record can provide.”

Providers don’t need to look to the future to see these trends; they’re starting to take shape now.

“[Acute care providers are] under pressure to shorten length of stay,” notes Jim Hoey, president and CEO of Prime Care Technologies. “[Senior living] centers are being transferred increasingly fragile patients with complex medical needs. Patients are arriving quicker and sicker than ever.”

The receiving facility needs instant access to all sorts of patient information, from medications and physician orders to diagnoses, potential complications and allergies. 

“All care settings need to receive accurate and pertinent information in a timely fashion to ensure a good transition,” according to Maria Arellano, RN, MS, clinical product manager at American HealthTech. 

“We have to share what we’ve learned about the patient with their next caregiver. Otherwise they have to start all over again, which takes time and resources. A vulnerable patient doesn’t have the time for the new setting to figure it out all over again.”  

Care for the future

In the face of rising demand for healthcare and senior care services from an aging population, providers are searching for ways to sustain and improve the level of care they provide. Fortunately, says Johnson, technology firms are starting to address this growing need.

“We will start to see IT solutions that will not only allow providers a look upstream using predictive analytics, modeling and trending of information,” he says, “but also the interactive ability to immediately alert providers and intervene to create more appropriate care paths.” 

Traditional charting methods, where nurses and physicians hand-write their notes on paper, are inefficient when it comes to pulling out patient data and looking for trends that could affect care decisions, according to Debi Damas, RN, senior care product manager with Relias Learning.

“IT allows providers to track better,” she says. “When you’re doing the documentation, you can see problems coming before you actually have a problem.” 

By finding problems early, patients often can be treated in the facility, without requiring a return trip to the hospital. 

Predictive analytics also can help reduce costs and improve care by identifying when an individual is approaching the end of life. 

“At least 30 percent of all Medicare expenditures are attributed to the 5 percent of beneficiaries that die each year, with one-third of that cost occurring in the last month of life,” according to Janine Savage, RN, national account manager at PointRight. 

“Several reputable studies have shown that when life expectancy is limited, hospitalization and aggressive medical treatment may not only be futile and costly, but quality of life is often sacrificed and patients experience a ‘worse’ dying process,” she says.

Social safety net

Clinical data mining and communication between providers are unquestionably vital when it comes to reducing rehospitalization. 

But according to Richard Juknavorian, senior director of product management at PointRight, socioeconomic and psychosocial factors will prove more important in preventing return trips to the hospital, and it’s something that HIT will start to incorporate more over the coming years.

It’s a point that has more assisted living operators taking notice and consciously striving to boost their security offerings, and also their competitive advantage. This is especially important as today’s assisted living communities serve residents with widely varying care needs and acuity levels.

Independent living, assisted living and memory care under one roof is now quite common, explains Steve Elder, senior marketing manager at STANLEY Healthcare. “Given this, resident safety technology is essential and I’m sure virtually all executive directors and directors of nursing would readily acknowledge [that].” He adds that communities also see resident security technology as an integral part of their identity in the marketplace. “It’s a visible sign of their commitment to keeping residents safe.”

Still, experts agree that the secret to success lies in flexible, customizable and easily integrated solutions that let operators stay resident-centric and proactive, while also keeping existing technologies in play.

Beyond that, “any effective solution must be simple to use and maintain, and extremely reliable,” says Will Kaigler, president and CEO of NewCare Solutions LLC.

An ever-growing array of resident security solutions meets each of those critical needs — and more. Whether it’s emergency call systems, fall management technologies, wander and elopement solutions, sleep and behavior monitoring, facility security systems, and beyond, caregivers have access to more innovative, intuitive and integrative resident safety offerings than ever. 

Easy does it

Operators will find new-and-improved features and capabilities on many of today’s security solutions, not the least of which includes the ability to more readily communicate with residents and capture key resident data to promote more prompt, proactive response. 

Two-way voice communication is just one example. As Jim Kelley, vice president of sales and marketing for Digital Care Systems, explains, such communication capabilities on E-call systems assure residents that their call was received and that help is on the way. “It also allows the responder to know what the issue is, so they can rally other resources, if necessary, [when] they are on the way to help the resident.”

Combining data from multiple technologies further enhances resident care. If a resident has dementia and is prone to wandering, for example, it’s relatively simple to create an immediate alert system with a door monitor, which can then contact a designated caregiver each time the door opens. However, taking this a step further, there are other technologies that can help with more upstream care, notes Bryan Fuhr, co-founder and VP of sales and marketing for Healthsense. 

Monitoring activities that are precursors for risk behaviors — such as elopement — provide the opportunity to deliver proactive care intervention and can help provide better staff efficiencies, Fuhr adds. “If a resident has a sleep monitor that measures time out of bed during key nighttime wandering hours, for example, caregivers can be notified earlier of elopement risk and can manage more proactively, versus reactively.”

Information-based technology also is gaining momentum in the marketplace, allowing senior living communities to more easily engage in passive, remote monitoring — without the need for a resident-worn device. Passive monitoring also requires no education on the senior’s behalf, notes Fuhr. 

Critical health information is at the heart of the Healthsense eNeighbor System. Analytics are used to evaluate sensor data to provide relevant, timely health and safety information to caregivers regarding residents’ activities of daily living (ADL). The key, according to Fuhr, is providing “relevant analysis when it’s needed, through real-time observation and the prioritization of care needs.”

Sleep monitoring is one area, in particular, that’s proving effective in catching potential health issues earlier, rather than later. NewCare Solutions’ SilentAlert Sleep Monitor System is designed for monitoring sleep patterns in residents living in memory care and assisted living. Kaigler says customers evaluating sleep behavior have successfully caught urinary tract infections, medication issues and more, and have prevented falls, transitions to higher levels of care and potential hospital admissions. 

“Caregivers can see what’s happening during the period of the day that has some of the highest rates of incidents and the lowest staffing levels,” he notes. 

Solutions that provide “situational awareness” — that is, allow owner-operators to read, hear and see what’s happening around their enterprise, so they can respond promptly and effectively — are becoming more commonplace and increasingly vital as operators strive to best manage their available resources to improve resident care and response. 

“From the mundane blown fuse to a life-and-death scenario, situation awareness helps prevent operational disruptions and speed emergency response,” says Status Solutions President Mike McLeod. “Real-time and historical reports then let you analyze response times and protocols to identify problem areas.”

Blended benefits

System integration enhances data-gathering capabilities of today’s solutions even more. E-call systems, for example, now can be extended to cover wander and fall management, so facilities needn’t invest in three separate systems, according to Elder. “This will also give facilities one system to manage and train staff on.”

Another example is the increasing ability to integrate a fire alarm panel into a resident security solution. As Elder explains, this allows staff to be notified of the alarm location via their pagers, phones, portable devices, and other communication sources. What’s more, integrated alarm management and automated mass notification lets facilities unify disparate alarm and communication systems, ensuring that critical data is collected, processed, analyzed and delivered to the right people, so they can address an unfolding situation right away, adds McLeod.

“Inefficient, standalone alarms are converted into real-time, detailed alerts delivered to key individuals, select groups and response teams, or larger populations via the designated communication end-points — from smart phones to PA systems and virtually any device in-between,” he notes. Additionally, predefined modes and actions set alerting/mass notification in motion when a triggering event occurs, according to the facility’s protocols and escalation paths. 

“With computer-telephony integration, existing networks, devices and other software systems can work together, without silos,” he said.

On the move

Because reliability reigns supreme on any resident security technology, more systems have self-monitoring capabilities that can pinpoint failures, keep tabs on battery life, and more. Wireless monitoring capabilities are another way to improve technologies’ reach and usability, and allow for simpler expansion. Fuhr says the use of wireless technologies is rapidly becoming a differentiator among provider organizations.

Digital Care Systems recently stepped into the Wi-Fi segment with its LISA Wi-Fi System, which allows emergency calls to be sent directly over the community’s Wi-Fi system. “Many assisted living operators have or are in the process of installing Wi-Fi throughout their communities, and are looking for more ways to utilize these networks,” Kelley confirms.

Status Solutions, too, has recently introduced a mobile dashboard. Its SARA eMessenger Mobile is voice-, Wi-Fi- and cellular-enabled, which turns mobile devices into command and control centers, according to McLeod. The mobile dashboard also works on smart devices, such as iPhones and iPads, for greater staff mobility. Video paging is another feature that enhances staff mobilization and response time. With the help of integrated security cameras, live video can be pushed to desktops and mobile devices when a triggering event occurs, says McLeod. Aside from streaming live video, “pre-recorded videos, photos and maps may also be included in video-enhanced alerts or video pages,” he points out. 

Solutions that allow staff members to capture resident data at the point of care are also proving invaluable, for both the facility and the residents. As Rebecca Single, director of healthcare operations for Honeywell — Vocollect Solutions, explains, staff should be able to chart issues as they’re occurring, thereby allowing the staff member to observe if there’s a time of day or night when wandering is an issue and then determine whether there’s a set pattern or if it occurs at all times. 

More in store

In the not so distant future, operators will have even more advanced features at their fingertips. Elder predicts data and business intelligence will become even more critical, as will enhanced integration that will facilitate data exchange between a real-time locating system, like E-call or wander and an electronic medical record system.

Moving forward, operators will also find more technologies that integrate with electronic health record systems. It’s an area that some vendors are already engaging, and customers are reporting benefits from the efficiencies and improved data capture. 

“Having [Status Solutions’]
SARA integrated with HealthMEDX makes it possible for us to improve our data collection, processing and analysis, which ultimately improves our level of resident service and care,” says Nadim Abi-Antoun, VP of information technology for Presbyterian Homes. 

According to McLeod, situation awareness is not just about making customer data more valuable for the purpose of emergency alerting, but also for business improvements: “A medical record is data-rich, so we’re committed to helping our healthcare customers extract more meaning from their databases to improve care and overall business operations.” 

“We’re looking at wound care management and risk assessment solutions to prevent skin breakdown, close wounds faster, and lower that risk of infection,” says AJ Ford, product manager for advanced wound care and biologics at Medline. “It’s a new way for us to approach efficiencies in patient care and improve health economics.”

It’s also indicative of a wider trend in infection control that will likely mean more surveillance, better communication and more integration of some acute-care techniques in skilled nursing.

No ignored mistakes

While long-standing hand-washing and needle protocols are known to work, momentary lapses still put thousands of patients at risk every year. Infection control experts say both philosophical and technical changes will help make the fight against superbugs less vulnerable to human error.

The disinfectant, sanitary, medical waste management and wound care markets continue to evolve, with one eye on today’s biggest problems (C. Diff, MRSA, CRE) and the other on emerging threats (such as Ebola).

J. Hudson Garrett, Ph.D., vice president of clinical affairs for PDI, is excited about programs that challenge the culture. He’s working with communities in Georgia and Tennessee to implement TeamStepps, a healthcare management approach created by the Department of Defense and the Agency for Healthcare Research and Quality.

Garrett says the system encourages compliance by creating an atmosphere where infection control and other mistakes aren’t ignored. A secretary who sees a nurse placing a catheter without gloves could report that to a third party and effect change without fear of retribution. It can also get more staff members involved in infection control, whether they’re C-suite professionals, wound care specialists or on-site pharmacists.

“We have to take what we know and make people accountable,” Garrett says. “It’s about championing change all the way to the bedside component.”

That includes tracking residents’ exposure to infectious diseases. Upon an outbreak of a contagious infection — whether it’s the flu or something more exotic, like Ebola — it is critical to identify who might have been in contact with the contagion and which equipment might require disinfection.

Using an RTLS (real-time location system) such as the NoWander from PointRF greatly expands tracking capabilities. RTLS is relatively new to senior living settings.

Staff can pull customized reports for individuals, revealing their historic location data and whom they’ve had contact with. Authorization to enter certain areas also can be regulated. 

“You can identify those who have a high risk of contracting the infection and monitor their location as well,” says Ahuva Goldshmidt, PointRF’s marketing coordinator. “It’s very effective and, at the same time, not intrusive. It could be a life saver.”

Future indicators

Controlling future infections depends on what happens today.

The Obama administration this fall launched a multi-year plan to develop the next generation of tests, antibiotics and vaccines for infectious diseases. A related report from the president’s science and technology advisers also called for improved surveillance of antibiotic-resistant bacteria, increasing the effectiveness of existing antibiotics, and developing new ones.

Antibiotic resistance is especially troubling in the presence of medical devices.

“Once you start to put residents on antibiotics or central lines and put a hole in their body, that’s when those residents get into trouble,” says Garrett.

In a hospital, a unit nurse might be specifically assigned to check patient health progress and recommend removal of devices like Foley catheters when no longer needed. But with lower staffing ratios, senior care facilities might overlook that risk factor, or others like it. 

They can instead put technology to use with automatic alerts that work with electronic medical records to remind doctors to order device removal, says Silvia Munoz-Price, M.D., Ph.D., an enterprise epidemiologist studying infection control for the Froedtert & Medical College of Wisconsin. Another alternative is to institute policies that allow certain nurses to remove the devices based on published guidelines.

Munoz-Price advocates for better coordination of efforts between hospitals and the senior living centers, noting that knowing where infections start can help to battle them communitywide. She’s spent much of the past few years studying carbapenem-resistant Enterobacteriaceae transmission and found that senior care facilities often miss — and fail to segregate — carriers.

“As we expand our surveillance to senior living, we’re going to realize all these areas for improvement,” she says. “But we know there are not as many resources or as much fancy equipment to decrease infections rates.”

For communities with ongoing outbreaks, Munoz-Price suggests using chlorhexidine baths. The long-acting antiseptic is applied daily to ICU patients to reduce the presence of bacteria on their skin. Though it shouldn’t be used on all patients, Munoz-Price said it could be a good strategic tool for facilities with continuing MRSA or VRE problems. It has been proven to decrease transmission of CRE, and central-line and bloodstream infections.

The Centers for Disease Control and Prevention’s CRE toolkit suggests chlorhexidine for residents who are dependent on healthcare personnel for activities of daily living, who are incontinent, who have wounds with hard-to-control drainage, and for those on ventilators.

A community using a bulk liquid form needs to have a plan for mixing and applying, and train staff and families to understand that the product should not bubble. The addition of sudsing agents undermines chlorhexidine’s efficacy. A wipe form with emollients is available but costs more. 

Sharps strategies

Jan Harris, director of environmental health and safety for SHARPS Compliance Inc., says resident buy-in is also critical to stopping accidental needle pricks. 

Senior care settings with residents who administer their own daily injections for diabetes or other chronic conditions traditionally have not provided an in-room option for safe disposal.

“The housekeepers are the ones who are getting needle sticks now,” says Harris. “It puts the employees at risk, and it puts the organizations at risk of lawsuits.”

Small containers that can be provided to residents as a service and mailed back by a wellness director make it easy for patients to comply with sharps guidelines and provide a new layer of safety.

A one-use spill kit also is gaining traction among Sharps’ customers, Harris says. In the rare case of falls, staff in some facilities sometimes grab any old mop to wipe up blood or other fluids and then fail to dispose of messes properly, Harris adds.

SHARPS’ kit includes a mop, personal protection equipment and a second-generation quaternary solution. After clean-up, the whole package can be stuffed into the bucket and mailed away for medical waste disposal.

Quicker death

When it comes to surface disinfection, the quest for faster kill times is unending, according to Steven McNabb, vice president of marketing for Medline’s environmental services and interiors division.

Many current formulations are highly effective against airborne and surface agents. But if a product’s kill time is five minutes and it dries faster than that, it won’t deliver promised results. Few communities have the resources to allow cleaning crews to watch disinfectants dry and reapply if needed. 

Earlier this year, Medline introduced MicroKill One, an alcohol-based quaternary that kills gram-positive, gram-negative and multi-drug-resistant bacteria and non-enveloped organisms like norovirus in one minute.

McNabb says he’s seeing a move away from spray-based applications, which might trigger respiratory reactions, in favor of flip-top bottles or wipes. In the future, he predicts wipe-on products also will create a coating that kills germs even when dry.

Yes, honey

McNabb says peracetic acid is comparable to bleach but offers less surface damage. Some companies are experimenting with iodine-based solutions to see if its efficacy on skin translates to hard surfaces. Metal ion solutions are becoming popular due to their good health rating, and they can be used on food prep surfaces.

Metals and natural ingredients are also increasingly popular.

Molnlycke expanded its silver dressing line to develop Mepitel Film IV AM, a new silicone product impregnated with silver and chlorhexidine acetate and designed for fragile skin.

In November, Medline planned to roll out a manuka honey dressing that releases into the skin for seven days to absorb drainage. At 4-by-4 inches, it’s ideal for pressure and diabetic ulcers or skin tears common in senior care, McNabb says.

In Garrett’s eyes, new products and electronic surveillance will not matter if staff isn’t educated on the basics of infection control or doesn’t have time to follow guidelines. As facilities develop the ability to record data with the help of devices, he wants Medicare and Medicaid to “step up” and fund more data monitoring for numbers-driven interventions.

Until that happens, he says the best bet is still to focus on core practices. 

“If you do the right things every time, you won’t have these outbreaks,” he notes.

That meant simultaneously opening assisted living, post-acute rehabilitation, nursing care and memory care services upon the completion of a new 120,000-square-foot, four-story continuing care building.

The full-speed-ahead implementation might seem intimidating. But it was just a part of the plan, according to Amy Grossman, director of Continuing Care at the Ashburn, VA, facility.

“You have some advantage to opening multiple levels of care,” Grossman says. With “the fixed cost of the leadership here and the staffing, you’re able to share those resources. And having all of the levels open is advantageous to the marketplace we’re serving.”

More than 740 individuals reside in independent living at the 132-acre campus in northern Virginia. That number grew with the addition of a new building in summer and another will be added in early 2015.  

The March rollout for the new building took a measured approach. 

“We slowly had folks move in so we could focus on operation,” says Grossman, who is part of the management team that began about a year ago. “It wasn’t a quick barrage of residents. We put together a move-in schedule based on the folks who had reserved apartments.”

As of mid-July, the facility housed 34 of its 144-resident capacity. It offers rehabilitation (first floor, 44 residents), assisted living (second and third floors, 64 possible residents) and memory care (fourth floor, 36 residents).

The total cost was $19 million, according to Jeremy Keimig, project manager.

Erickson Living’s philosophy toward care — staff members learn residents’ interests and engage in one-on-one activities — also manifests itself in the living arrangements.

Residents are encouraged to make their apartments feel more like home with their own color schemes and furniture, wall hangings and other  personal items.

“When we design those spaces, we model them after rooms in a house,” says Dennis Boggio, president of Lantz-Boggio Architects, P.C., of Englewood, CO. 

“If we look at living rooms and kitchen areas in a house, we all expect them to be of a certain dimension. We look at the single-family home industry, the homes that the people are likely to come from, and see it we can relate, if not imitate, that size and scale.” 

The centerpiece of each neighborhood in the facility is a great room meant to be a gathering place for residents and families.  

An additional emphasis is the ability to get outside. Those options include a roof-top patio for memory care residents.

“Those outdoor spaces are very important, especially in memory care,” says Boggio. “When you can present familiar things to memory-impaired people, that is very satisfying and improves their overall lifestyle … and gives them access to nature and the sky.” ν

“I have a loved one at home that I can no longer care for, now what?”…“My loved one has Alzheimer’s disease, and I can’t afford to place him in a secured community, now what?”… “Our family argues about the care for mom and her finances, now what?” 

Not knowing where to go or what to do can be challenging for caregivers and can leave them asking, “Now what?” on a daily basis.

In Hillcrest Health Services’ ongoing effort to provide answers and education for caregivers and the communities serving those with dementia, we partnered with the Consortium of Dementia Alternatives and Nebraska’s public television station, NET-TV, to produce a series of programs called “Now What?” 

With eight episodes under our belt, we’ve established a solid foundation of resources to share with caregivers, family members and professionals to help guide their care. 

We discuss the role of the caregiver and offer advice on what to expect and how to manage stress in this role. Our experts provide guidance on tackling financial and estate issues as well as understanding Medicare and Medicaid.  

We are fortunate to feature leading experts in geriatric neurology and dementia presenting the latest research and treatments along with leading clinical and administrative professionals offering their perspectives.

The “Now What?” series can be viewed on-demand at http://netnebraska.org/basic-page/television/now-what and descriptions of each episode listed below are available online. 

• Living with Dementia
• The Dementia Journey
• A Holistic Approach to Care
• The Caregiver
• Dementia Types and Diagnosis
• Rural Health in Aging Populations
• Eldercare and Dementia
• Approaches in Elder and Dementia Care

Produced by NET-TV, the series was recognized by the Nebraska Broadcaster’s Association with bronze and silver “Service to the Community” awards in 2012 and 2014.

If you are interested in learning more about the “Now What?” series or if you would like to explore developing this type of an initiative in your area, I would be happy to visit with you about it and share my insight and resources. You can reach me at afisher@hillcresthealth.com.

Except this time, the monster is no figment of our imagination. And instead of mingling with the dust bunnies, it’s spreading across West Africa — where it has already been tied to nearly 5,000 deaths.

And now it appears ready to pounce on us. To give senior living operators some tools, the Centers for Disease Control and Prevention has set up some helpful links.

These are all well and good. And to the extent that these and other resources can help prevent the spread of Ebola, let’s use them.

But here’s the thing: If you were to count all the people in this country who have Ebola, you could complete the exercise with just two hands. That’s because as this is being written, only eight Ebola cases have been documented.

Does that mean we shouldn’t be doing everything possible to limit the spread of this deadly virus? Of course not.

But if we are going to get hysterical over Ebola cases in the single digits, why are we not similarly hyperventilating over numbers that document death and destruction on a far larger scale?

Consider: There are more than 600 accidental shooting deaths in this nation every year. Worse, people are 51 times more likely to die from an accidental poisoning death than an accidental shooting, according to the Centers for Disease Control and Prevention. Even more people — roughly 30,000 — will be killed in auto accidents by the time New Year’s Eve rolls around.

Then there’s the misery we annually witness as a result of health-related problems. According to the National Center for Health Statistics, here’s the death tally for 2011, the most recent year for which full numbers are available: heart disease 596,577; cancer 576,691; chronic lower respiratory diseases 142,943; stroke (cerebrovascular diseases) 128,932; Alzheimer’s disease 84,974; diabetes 73,831; and influenza and pneumonia 53,826. You’ll need more than two hands to tally those figures, as they exceed 1.6 million. 

But as far as I can tell, none of them have moved the president of the United States to cancel travel plans so he could keep a closer eye on them. Nor have they unleashed public outrage over whether the federal government is capable of dealing with serious health-related challenges. Yet we saw both happen recently, thanks to the Ebola scare.

I’m not trying to suggest that we don’t give this deadly virus all the attention it deserves. But perhaps we should also get more serious about dealing with the real bullies.

Six years later, the lending environment is a stark contrast to the stagnant atmosphere that brought senior housing investment to a standstill as interest in the market is intensifying from various sectors. While increased activity is generally a positive trend, the seniors housing market has been wracked by overbuilding and irrational exuberance in the past and industry veterans like Dan Biron are on guard against the same mistakes being made.

“The last thing this industry needs is overbuilding,” says Biron, senior vice president at Berkadia. “What worries us is the number of development deals for construction financing. At the [National Investment Center for the Seniors Housing & Care Industry] National Conference there were 500 first-time attendees and 160 of them were developers. We cringe when we see that.”

Interest from investors outside of healthcare and seniors housing typically raises skepticism among those who specialize in the field and are acutely aware of its parameters. Yet because the demographics are so compelling, it is attracting money from investors unfamiliar with the market, Biron says.

“It is usually one of two examples,” he says. “One is a guy wakes up one morning and decides to pursue seniors housing and the other is a guy who decides his condo development isn’t working so he wants to convert to senior living. They are desperate to throw money at something and, unfortunately, we can’t control it.”

Jeff Binder, principal and managing director of Senior Living Investment Brokerage, agrees that market overheating is a legitimate worry.

“The greatest area of concern revolves around development and if certain markets are ‘too hot’ right now, or if virgin developers in the space are savvy enough to successfully quantify markets, build appropriately, and operate efficiently,” he says.

Even so, the market currently appears to have a strong inventory balance and smart money has been the prevailing source of funds to date, Biron says. 

AL sector favored

Although all facets of seniors housing — independent living, assisted living and continuing care retirement communities — are drawing investor interest, the lion’s share of funds is going to the assisted living with memory care model, financial specialists say.

“Since assisted living is driven primarily by private pay residents, most lenders that finance in the healthcare space would rather lend to that type of payer class than the Medicare and Medicaid risks in the skilled nursing world,” says Kathryn Burton Gray, senior managing director of seniors housing and healthcare for Red Capital Group.

The focus for Red Capital this year has been on providing balance sheet development loans, specifically for new construction and re-positioning, Gray says. 

“The demand for new assisted living and specialty stand-alone memory care has resulted in our focus on accommodating these requests,” she says. “Our strong balance sheet has allowed us the flexibility to better serve our clients in their construction and rehab projects.”

Concurrently, the continued growth of Alzheimer’s and dementia residents will present opportunities for assisted living operators, she says, because “the statistics are staggering in terms of anticipated Americans to need some form of memory care in the next 25 years.” 

Gray also expresses concerns about the stability of the marketplace, however, noting that “we are witnessing a trend where this segment is attracting interest from a variety of developers to include a large number of ‘multifamily-specific’ developers that may not fully appreciate that this is an operating business model with a needs base, so partnering with the right operator is crucial to the success of each project.”

The lending mosaic

Not so long ago, seniors housing operators had limited options when it came to financing — HUD, Fannie Mae or Freddie Mac were the only game in town. Those agencies have underwritten the bulk of industry loans in the years following the economic meltdown and continue to handle a large portion today.

Michael Vaughn, senior vice president of FHA Finance for Walker & Dunlop, says his firm regularly works through the HUD Lean program as well as with Fannie and Freddie. 

“HUD insured $1.4 billion in long term fixed rate loans on assisted living and board and care facilities in their fiscal year ending Sept. 30,” he says. “Fannie and Freddie had lower volume, but are very active.”

Over the past two years, a variety of financiers have entered the marketplace, including banks, private equity firms, commercial backed mortgage securities, life insurance companies and bridge lenders. 

Most of the mergers and acquisitions have been handled by real estate investment trusts, which were one of the first players to return to seniors housing.

“The continuing demand for affordable assisted living and memory care is a positive trend for those owners who are able to meet it,” Vaughn says. “Some markets for higher rate facilities may be becoming saturated and lenders are aware of the need to exercise caution where those conditions are starting to occur. Any significant decline in housing prices would have a negative effect, but the gradual recovery of the economy has allowed more families to afford assisted living and memory care options for their elders.” 

“We believed for almost 100 years that [amyloid-beta] plaques are the main culprit in Alzheimer’s disease,” study senior investigator Charbel E-H Moussa said. “This study shows it’s another protein — a very, very important one, called tau, that is basically the main guilty one.”

Neuronal death happens when tau, found inside neurons, fails to function. Tau’s role is to provide a structure — like a train track — inside brain neurons that allows the cells to clear accumulation of unwanted and toxic proteins.

He says his study suggests the remaining Abeta inside the neuron (that isn’t pushed out) destroys the cells, not the plaques that build up outside. “When tau does not function, the cell cannot remove the garbage, which at that point includes Abeta as well as tangles of nonfunctioning tau, and the cell dies. The Abeta released from the dead neuron then sticks to the plaque that had been forming.”

Moussa’s experiments in animal models also show less plaques accumulates outside the cell when tau is functioning; when tau was reintroduced into neurons that did not have it, plaques did not grow.

Full findings appear in the journal Molecular Neurodegeneration.

Malfunctioning tau can occur due to errant genes or through aging. As individuals grow older, some tau can malfunction while enough normal tau remains to help clear the garbage. In these cases, the neurons don’t die, he says. “That explains the confusing clinical observations of older people who have plaque build-up, but no dementia,” Moussa says.

The researcher has long sought a way to force neurons to clean up their garbage. In this study, he shows that nilotinib, a drug approved to treat cancer, can aid in that process. Nilotinib helps the neuron clear garbage, but requires some functional tau, he says.

“The common culprit is tau, so a drug that helps tau do its job may help protect against progression of these diseases,” Moussa added. n

The benefit increase is determined by the change in prices for “urban wage earners and clerical workers,” known as the CPI – W. Unfortunately, this COLA criteria does not realistically relate to a senior’s true cost of living, especially those considering or living in retirement communities. There are two dramatic differences: 1) most seniors in either assisted living or independent living communities do not work, and 2) the specific index excludes food and energy costs.

Coverage Gap

While cost-of-living adjustments may reflect inflation of individual commodities, they do not track the real world of a typical senior’s cost in senior living communities. The senior living industry attempts to hold year-over-year annual operating expense inflation to 3% or less while maintaining annual increases in monthly service fees to approximately 4%. This positive 1.0% “spread” is a typical financial planning objective. 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 over 40% of operating expenses. In 2014, the annual increase in employee wages represented approximately 2.5% to 3%. Similar increases are planned for 2015.

Many seniors’ monthly cash flow income is frequently stretched as they try to meet their mandatory and discretionary budget needs. That’s because short-term certificates of deposit and money market accounts have current annual yields of less than 0.5%. Many have to access their savings accounts and net worth, which results in a form of spend-down.  In the private pay senior living industry, we focus on the higher “market rate” income group — those seniors with typical household incomes in excess of $55,000 per year. The arithmetic is simple. Determining a senior’s pre-tax qualifying income requirement is a four-step process. Here is an example:

1. Assume an ultimate need to cover at least $3,200 for monthly service fees, or $38,400 per year.

2. Many seniors also have a desired discretionary spending objective of approximately 20%, adding another $9,600 for a total after-tax annual need of approximately $48,000.

3. If the resident has a modest/marginal income tax rate of 12%, that involves approximately $6,545 for income taxes.

4. Therefore, the gross pre-tax qualifying annual income need totals approximately $54,545 or $4,545 per month before any spend-down.

Four very important industry issues must be addressed in 2015 and beyond: 1) What is the real inflation impact being experienced by seniors? 2) How will some seniors access real cash flow to pay their monthly service fees while avoiding serious spend-down? 3) Will resident accounts receivable resulting from unpaid fees increase? and 4) What action do sponsors and owner/operators need to take?

The industry has two major consumer target groups to address regarding affordability: 1) existing senior living residents and 2) new potential prospects for senior living.

Bottom-line concerns

Affordability for some seniors will be a continuing issue. It is especially a tough one to address for the private pay, market rate sector.  There are at least five practical strategies that should be considered: 1) occupancy enhancement for income-qualified seniors, 2) responsible expense reduction, 3) optimized unit pricing, 4) deploying alternative sources of revenue, such as charitable content as part of a not-for-profit mission, and 5) practical and compassionate implementation of accounts receivable policies.

Enhanced performance within existing senior living communities represents a huge opportunity frequently overlooked by many owner/operators. But in 2015 and beyond, it will become a significant imperative.