The LCS Foundation has announced a partnership with the Granger Cobb Institute for Senior Living to provide an annual scholarship to add more professionals to the senior living industry.

The institute was announced for Washington State University in 2017 and dedicated in 2019 to focus on building the future senior living workforce through academic programs, industry partnerships and research. It is named for the senior living industry executive who helped build the Washington State University senior living curriculum and taught a course in senior housing administration before he died in 2015. The senior living management program, launched in 2020, offers industry-driven courses, immersive learning, community operations expertise and industry-expert connections before graduation. 

In December, the program celebrated its first graduate, who earned the degree through the institute’s global campus. Six students have completed the senior living minor, which began in fall 2021, and 25 students are in the pipeline working on a senior living major or minor, according to GCISL founding director Nancy Swanger, PhD. Since offering an elective class in senior living management in 2010, almost 800 students have taken the course, with many now working in the industry. 

“Our program is quite unique in that it is housed in a hospitality school within an accredited college of business. The industry loves the business acumen and relationship-building foci in our curriculum,” Swanger told McKnight’s Senior Living. “The program at Washington State University is relatively new, and having such generous support for our students from LCS lends tremendous validity and credibility to what we are trying to build.”

Swanger added that many industry providers have given their “time, talent and treasure to help the program grow,” and that the LCS scholarship is one of three specifically for students studying senior living.

Swanger is on the board of trustees of the Vision Centre, which is supported by several industry associations — including the American Health Care Association / National Center for Assisted Living, the American Seniors Housing Association, Argentum, LeadingAge and the National Investment Center for Seniors Housing & Care — and working to create university and college programs and facilitate internships to prepare future generations of aging services leaders.

Since 2017, the LCS Foundation has awarded more than $450,000 in scholarships and professional development programs. The foundation also has collegiate partnerships with the University of Northern Iowa, Northwood University and the University of Wisconsin-Eau Claire. Those partnerships have placed senior living experts on advisory boards, developed curricula and helped provide students with interactions to advance their learning.

Other senior living-focused academic programs include an assisted living/senior housing administration concentration at George Mason University, a Master of Arts degree in senior living hospitality at the University of Southern California Leonard Davis School of Gerontology, an undergraduate degree in senior living management in University of Central Florida’s Rose College of Hospitality Management, and Boston University’s concentration in senior living in the Masters of Management in Hospitality degree program.

A significant number of senior living companies have implemented diversity, equity, inclusion and belonging programs in the past year, indicating that more owners and operators are “leaning in” to those initiatives to meet strategic goals, according to new industry research.

But the authors of the report about the results of the 2023 Senior Living DEIB Survey, which was released Wednesday, say it’s time for operators to focus on actions aimed at improving retention in addition to recruiting.

“Organizations should establish a holistic vision for what they are trying to achieve through their DEIB efforts,” they wrote. “It is time to move beyond the focus of just recruiting diverse talent. Companies must foster inclusive work environments that provide a sense of belonging, so that they can retain the talent that they work hard to attract.”

The survey, which continued to track the industry’s progression addressing DEIB initiatives, was conducted by Ferguson Partners and sponsored by the Senior Living DEIB Coalition, a two-year-old partnership among Argentum, the American Seniors Housing Association and the National Investment Center for Seniors Housing & Care.

Although more work lies ahead, Argentum President and CEO James Balda said that it is important to acknowledge the progress to date.

“It is exciting to note that this year’s survey showed an increase in the percentage of companies with formal DEIB programs, from 27% to 40%, which indicates a growing recognition within the industry of the importance and positive impact of promoting diversity, equity, inclusion and belonging among employees and residents,” Balda said in a statement. “A formal DEIB program is an important step to foster a culture of diversity, equity, including and belonging, which also bolsters employee engagement.”

Recommendations

The survey, however, also revealed that well more than 80% of executive positions are held by white employees, presenting a “huge opportunity” for racial/ethnic parity at the executive level with employees of color. More work also is needed at the mid-management level, with women of color leaving at twice the rate of their promotion, according to the report. 

“Senior living is about creating communities where everyone feels welcome and valued,” NIC President and CEO Ray Braun said. “The results of this survey provide us with a roadmap for furthering our DEIB initiatives and creating an industry that is truly inclusive for all.”

DEIB trends

The results also provide a market overview of how the senior living industry is addressing DEIB, according to ASHA President and CEO David Schless. 

“The data collected provides valuable insights into current industry trends, best practices and areas of improvement for those looking to further their DEIB efforts,” he said.

Survey participation increased 36% — from 44 to 60 companies — from 2022. 

According to the results, 40% of respondents have a formal DEIB program in place — up from 27% in 2022 — and 37% have implemented some DEIB initiatives or policies. In addition, 93% of respondents said they are taking steps to recruit potential employees from underrepresented groups, and 95% said they are taking steps to increase retention and promotion rates of members of underrepresented groups.

Other findings:

• The majority of organizations focus on gender (91%), race/ethnicity (98%), sexual orientation (89%) and age (83%) as dimensions of diversity.
• 73% of senior living professionals are women.
• 50% of employees are white, and 46% are people of color.
• 14% of executive management is people of color, and women make up 50% of executives.

In most cases (57%), DEIB initiatives originate in the C-suite (57%), although some initiatives are developed by the human resources department (17%) or by a dedicated DEIB committee (13%).

An executive summary of the survey results is available on Argentum’s website.

The US Senate Special Committee on Aging is launching a review of the assisted living industry following recent articles in the Washington Post, which reported on the deaths of residents who wandered from communities, as well as the New York Times and KFF, which scrutinized an industry pricing structure that adds fees on top of basic charges to cover additional services, as well as rate increases and the for-profit status of most providers.

Committee Chairman Sen. Bob Casey (D-PA), who has scheduled a hearing for Jan. 25, sent letters dated Monday to the leaders of Brookdale Senior Living, Atria Senior Living and Sunrise Senior Living, asking them to address his “significant concerns” about costs, staffing levels and resident safety.

“Despite these high costs, residents in assisted living facilities have been put in harm’s way, leading to avoidable injuries and death,” Casey wrote in his letter to the large providers, detailing points made in the November Times/KFF articles and December Post articles. 

Assisted living communities primarily are regulated at the state level, but the committee frequently has used its authority to “examine private companies when concerns arise about potential health and safety, as well as financial risks posted to older adults,” the senator said.

“The Senate Special Committee on Aging has jurisdiction over the problems older adults face, including matters of maintaining older adults’ health, their ability to secure proper housing, and their ability to obtain care or assistance when needed,” Casey wrote. “As chairman, I have an interest in ensuring that older adults and people with disabilities are receiving high quality care, have access to proper housing and receive good value for their hard-earned dollars.”

Specifically, Casey asked the companies to provide information and documents no later than Feb. 5 detailing how they communicate the cost of services to residents and their families, rates they charge in each state, and their schedules of services and costs. Additionally, he asked them to provide information on average revenue per occupied unit for the past seven years, figures on the number of residents who have eloped or sustained injuries due to being left unattended, information about the accessibility of information about complaints and citations received by their communities, their policies and procedures for informing residents and families about accidents, applicable staffing requirements, and job titles and associated pay rates at their companies. 

“We look forward to reviewing and responding to Sen. Casey’s letter on the assisted living industry with candor and transparency,” Sunrise Senior Manager of External Communications Heather Hunter told McKnight’s Senior Living. 

Atria Senior Living provided a similar response.

“Our top priority is our residents’ well-being and safety,” an Atria spokesperson told McKnight’s Senior Living. “We look forward to providing information in response to Sen. Casey’s letter.”

Brookdale said it is aware of the letter from Casey.

“Brookdale values the relationships we have created with our hundreds of thousands of residents at communities across the country over the last decade, and we are committed to providing high quality care,” a spokesperson said. “We take seriously our mission of enriching the lives of those we serve with compassion, respect, excellence and integrity.”

Atria, Brookdale and Sunrise are some of the largest senior living operators in the country. On the 2023 ASHA 50 list issued by the American Seniors Housing Association, Brookdale topped the list of operators, and Atria came in at No. 2. Sunrise was No. 3. On Argentum’s 2023 list of largest providers, Brookdale was No. 1, Atria was No. 2 and Sunrise was No. 5.

This isn’t the first time that senators have called for an investigation related to assisted living. In one of the most recent actions, a bipartisan group of US senators, all members of the Aging Committee, in 2015 asked the Government Accountability Office to report on Medicaid oversight and quality of care in assisted living communities. Their request resulted in a 2018 GAO report.

That report contained a to-do list for the Centers for Medicare & Medicaid Services related to state reporting of deficiencies in care and services provided to Medicaid beneficiaries in assisted living communities. Some federal lawmakers and consumer advocates, however, said that they would push for changes in assisted living because of the report’s findings.

‘Isolated incidents’

Senior living industry groups have called the number of deaths reported in The Post’s story a small fraction of the total number of assisted living and memory care residents, most of whom report high satisfaction with their communities.

“The Washington Post’s reporting featured isolated incidents that assisted living communities take very seriously,” Argentum President and CEO James Balda told McKnight’s Senior Living, adding that the elopement-related fatalities highlighted in the Washington Post stories are “exceedingly rare,” occurring with 0.0015% of more than 6.2 million residents served during the timeframe of the reports.

“Our communities look forward to demonstrating to the committee that as the nation grapples to care for our aging population, assisted living provides independence and dignity for seniors,” he said.

Argentum, Balda added, “strongly supports” state regulations already in place to investigate incidents and punish any wrongdoing, and he said that any fatality is “devastating for our staff, our residents and their families.”

Calling elopements rare while acknowledging that any resident injury is “truly tragic,” National Center for Assisted Living Executive Director LaShuan Bethea said she welcomes the opportunity to engage with the committee to “further their understanding of the assisted living profession, its oversight and our deep commitment to providing quality care.”

“The assisted living profession is committed to continuing to learn all that we can about dementia and the disease process to meet the ever-changing needs of our residents,” Bethea told McKnight’s Senior Living. “Policymakers, providers and other stakeholders should come together to find ways to advance memory care while honoring why seniors and their families love assisted living — by supporting their independence and autonomy in a home-like environment.”

Assisted living will continue to evolve with the nation’s changing needs, and regulations, staffing and training requirements must evolve with them, LeadingAge President and CEO Katie Smith Sloan told McKnight’s Senior Living.

“Our elected officials and other stakeholders must prioritize policies to support older adults and the professionals working in aging services to ensure equitable access to high-quality care in assisted living, as well as other care settings,” she said.

In a response to the original package of Washington Post stories, American Seniors Housing Association President and CEO David Schless said the stories “inaccurately” suggest that elopements in assisted living or memory care settings would not occur if there were federal oversight of the setting. He also said that the articles failed to recognize the contributions of the vast majority of frontline caregivers and other senior living professionals.

Schless called assisted living “highly regulated” by states that impose strict requirements, including licensure, and cover a broad range of provisions such as those Casey asked about in his letter to providers. Schless added that states are actively involved in updating and modifying regulations and statutes on an ongoing basis.

“The states are far more responsive than the federal government in addressing the needs of residents and their families to ensure innovative services and programs are available to meet their needs and those of a rapidly aging population, including those with Alzheimer’s and related dementias,” Schless said. 

ASHA, he said, also plans to respond to the committee with a rebuttal of the Post’s “misrepresentation” of the industry, providing information he said was overlooked in the reporting as well as information about the benefits and value of senior living.

Association leaders previously submitted letters to the editor to the New York Times and the Washington Post in response to their articles. Although The Post has not published letters from the associations, it did post a letter from Andrew Carle, lead instructor in senior living administration at Georgetown University. He said that the more than 6 million Americans affected by dementia and prone to wandering would be “exponentially safer” in assisted living communities than at homes in the greater community.

Industry quality initiatives

The industry has launched several initiatives focused on building consensus around assisted living quality measures, as well as infection prevention and control efforts. NCAL last week released its 2023 regulatory review report, which highlighted regulatory requirements across all 50 states. 

The Center for Excellence in Assisted Living, known as CEAL@UNC for the past year, itself was launched in 2003 as a result of a recommendation in the landmark Assisted Living Workgroup Report, delivered to the Senate Special Committee on Aging. 

In a recent podcast interview with McKnight’s Senior Living, Sheryl Zimmerman, MSW, PhD, the center’s executive director, called on all assisted living stakeholders “to be more mindful in a pragmatic, feasible way” across all of assisted living to address resident care needs.

“Most everyone involved in assisted living is aware there are opportunities for improvement,” Zimmerman told McKnight’s Senior Living. “The Senate Aging Committee delved into assisted living 20 years ago with the Assisted Living Workgroup Report, which led to the national Center for Excellence in Assisted Living, and as the executive director, I welcome the opportunity this brings to coordinate efforts to work towards excellence while providing person-centered care and quality jobs.”

LeadingAge, Argentum, NCAL and ASHA in June announced that they had joined with the National Association for Regulatory Administration to develop guidance for the industry and resources for operators, regulators, policymakers and other stakeholders. The groups, working together as the Quality in Assisted Living Collaborative, first turned their attention to the area of infection prevention and control, an issue brought to the forefront during the COVID-19 pandemic, with plans to address other issues.

NCAL also has its own National Quality Award program, based on the Baldrige Performance Excellence Framework. It recognizes assisted living providers that meet certain goals. The organization’s voluntary quality initiative for assisted living communities also has goals related to staff stability, customer satisfaction, hospital readmissions and the off-label use of antipsychotic medications.

The Joint Commission is planning to revise its infection prevention and control requirements for assisted living community accreditation as infection prevention and control regulations for the setting become more common at the state level.

The commission’s proposal focuses on the structures deemed essential to supporting quality and safety and outlines a framework for infection prevention and control programs. The suggested changes also more closely align with the the Centers for Disease Control and Prevention’s core infection prevention and control practices for safe healthcare delivery in all settings, according to the commission. 

A Joint Commission spokeswoman told McKnight’s Senior Living that the proposed revisions are a continuation of the wider infection prevention and control chapter rewrite initiative that spans all areas of accreditation.

“Broadly speaking, the goal of the IC [infection prevention and control] chapter rewrite is to align the IC standards and elements of performance more closely with law and regulation, eliminate the requirements that do not add value to surveys, and streamline the chapter,” the spokeswoman said. “The proposed revisions are currently in field review. Once approved, the revised IC chapter will replace current IC chapter requirements.”

Once the new requirements are implemented, commission-accredited assisted living communities will receive access to a new assessment tool that will outline the specific actions and processes they will need to take to meet them.

The Joint Commission is accepting comments on the proposal until Feb. 21 through an online survey.

The changes

Specifically, the changes cover assigning management responsibilities for infection prevention and control, including developing policies and procedures, coordinating competency-based training and risk management. They also require organizations to have written policies and procedures guiding infection prevention and control, including reporting duties to local and state public health authorities.

The Joint Commission also is deleting an existing performance improvement component of the accreditation program requiring assisted living organizations to provide incidence data to key stakeholders — leaders, licensed practitioners, nursing and staff members — about multidrug-resistant organisms, because it was determined to be out of scope.

The Joint Commission launched its assisted living community accreditation program in 2022 to bring “national, consensus-based standards” to the industry. Its standards address the environment, staffing, emergency management, dementia care, medication management, the provision of care and services, process improvement and more. The program also requires organizations to track and report on five standardized performance measures: off-label antipsychotic drug use, resident falls, resident preferences and goals of care, advanced care plans/surrogate decision-makers, and staff stability.

The Joint Commission also launched an assisted living community memory care certification program last year in collaboration with the Alzheimer’s Association, to promote consistent, high-quality dementia care in assisted living. 

Industry efforts

Indicative of the growing importance of infection control in assisted living, regulatory requirements related to infection control and emergency preparedness were an addition to the National Center for Assisted Living’s 2023 regulatory review report, released last week. The report noted that such regulations now are in place in a majority of states.

Industry groups devised their own guidance for infection control and prevention in 2023.

NCAL, Argentum, the American Seniors Housing Association and LeadingAge in June announced that they had joined with the National Association for Regulatory Administration to develop guidance for the industry and resources for operators, regulators, policymakers and other stakeholders. Infection prevention and control was the initial focus of the effort, called the Quality in Assisted Living Collaborative.

Other existing infection control efforts available to providers include the CDC’s Project Firstline training program for infection control and prevention, a certification for infection prevention and control professionals via the Certification Board of Infection Control and Epidemiology, and an infection prevention and control document produced by Argentum during the pandemic. Other than the Argentum document, however, most of those efforts are not focused on assisted living, and they are not strictly guidance.

And assisted living was an area where such focus was needed, according to a study published in December 2022 in JAMDA – The Journal of Post-Acute and Long-Term Care Medicine. That research found that infection control and preparedness in assisted living during the pandemic was hampered in part by limited clinical expertise and medical oversight of staff members and conflicting regulations and guidance for federal, state and local health agencies.

And in memory care settings, according to a study published in the June 2022 edition of the Journal of the American Geriatrics Society, a need existed “to bolster infection prevention capacity when caring for this especially vulnerable population.” 

Regarding overall quality, NCAL has its own National Quality Award Program, based on the Baldrige Performance Excellence Framework, that recognizes assisted living providers that meet certain goals.

NCAL also has a voluntary quality initiative for assisted living communities, with goals related to staff stability, customer satisfaction, hospital readmissions and the off-label use of antipsychotic medications.

Senior living operators will continue to face inflationary pressures and capital market challenges in 2024, but some effects may lessen before the year is out, according to industry experts. Expect the workforce-related issues that have dogged providers for years to persist, however, they said.

“The elevated interest rates driven by the Federal Reserve efforts to bring down inflationary pressures had a profound impact on the sector in 2023,” National Investment Center for Seniors Housing & Care President and CEO Ray Braun told McKnight’s Senior Living.

Noting the “significant demographic wave on the horizon,” he said that the past year also saw record absorption of new senior housing inventory as it hit the market. “At the same time, we experienced a marked decline in new construction as well as transaction activity in 2023,” Braun said. “The lending environment and overall cost of capital has been prohibitive and has been a definite headwind.”

Capital still will be constrained early this year, he said, “but we are also hopeful that as the year progresses, we will start to see some improvement on this front.”

National Center for Assisted Living Executive Director LaShuan Bethea singled out inflation as the top issue faced by the industry over the past year.

“Inflation has caused soaring labor costs, in addition to other expenses, and made it difficult for assisted living providers to compete for caregivers,” she told McKnight’s Senior Living. “As a result, assisted living communities have been forced to use more contract nurses and staffing agencies, many of which are charging two or three times more than they charged prior to the pandemic.”

As 2024 dawns, Bethea said, the financial challenges will continue.

“Inflation makes all other expenses in assisted living more expensive, from food to cleaning supplies,” she said. “Additionally, the entire industry is still facing the ongoing ripple effects of skyrocketing costs from the pandemic.”

Assisted living providers, Bethea said, managed their COVID-19 response with little support from the government. According to some estimates, assisted living communities collectively received approximately $1 billion in relief funds, compared with the $12.5 billion received by nursing homes, despite the fact that assisted living providers serve about the same number of older adults and incurred more than $30 billion in pandemic losses and expenses.

“Federal and state policymakers provided little support to these communities in terms of personal protective equipment, testing and staff support,” she said. “Those COVID-related expenses continue today.”

Senior living providers, American Seniors Housing Association President and CEO David Schless said, continue to be confronted by “inflationary pressures across several key expense categories and a significant and rapid increase in interest rates.”

“Ultimately, the top challenge in 2023 was related to the capital markets and liquidity challenges,” he told McKnight’s Senior Living, adding that he expected those issues to continue this year.

“While inflationary pressures appear to be moderating somewhat, the interest rate environment and overall capital market environment for all real estate-based assets will likely remain challenging,” Schless said. “And we know there are many owners facing debt maturities in the upcoming year, which may prove to be extremely challenging with an ongoing liquidity crisis.”

NIC believes that the industry will reach an inflection point this year and that a “reset” will occur, Braun said.

“There will be some distressed inventory and underwater loans that the market is going to have to work through,” Braun said. “We think this reset is going to force a narrowing of the bid-ask spread and some reconciliation around equity contributions to stabilize outstanding debt.”

A ‘patchwork’ system

From a broader perspective, LeadingAge President and CEO Katie Smith Sloan told McKnight’s Senior Living, operators are challenged by “the shortcomings of our current patchwork system of delivering and financing long-term care.”

The association for nonprofit providers across the continuum of aging services is “doing all we can to raise up and urge policymakers and other stakeholders” to address the issue, she said.

“America is experiencing a massive demographic shift with implications for every aspect of society,” Sloan said. “Accessing quality long-term care is very often challenging, for many reasons. There is little political will to address these issues systemically, but policymakers are quick to criticize. Too often, aging services and providers are the scapegoat.”

Policymakers and members of the public must be educated about the industry as a whole as well as the differences between provider types, Sloan said.

“Ensuring that the public understands how long-term care is delivered and paid for — in a patchwork, inefficient system — and that the public appreciates the support that is needed, is critical,” she said. “And then advocating for long overdue change. We’re committed to doing everything we can to achieve that goal.”

Issues related to access and affordability also are on NIC’s radar screen, said Braun, who called them “an ongoing challenge for the sector.”

“NIC has been committed to defining and finding solutions for the middle-market consumer segment, and this work is more important than ever,” he said. “We need to be creative in finding solutions and models that are scalable and will bring forth greater access and options for the wave of baby boomers ahead.”

NIC funded a 2019 study by NORC at the University of Chicago that found that 54% of the 14.4 million middle-income older adults in 2029 in the United States will lack the financial resources to pay for senior housing and care, and a combination of public and private efforts will be needed to address the looming crisis.

More recently, Braun noted, NIC provided funding for the Housing for America’s Older Adults 2023 report, prepared by the Joint Center for Housing Studies of Harvard University. According to findings shared in that report, only 13% of adults aged 75 or more years who are living alone across 97 US metro areas can afford to move into an assisted living community without starting to cash in their assets.

NIC also has partnered with CVS Health to support a soon-to-be released report from the Milken Institute, “Innovative Financing and Care Models to Scale Affordable Housing Solutions for Middle Income Older Adults,” Braun added.

Intertwined with staffing issues

Access and affordability issues are intertwined with senior living’s perennial challenges related to staffing, Braun indicated.

“​​Staffing-related expenses continue to pressure margins, and there is sensitivity to how much of this expense can be passed along to the consumer,” he said, noting that in the first quarter of 2023, the percentage of assisted living rent increases surpassed the percentage of wage escalation.

“We went several years where wage increases consistently exceeded rent increases,” Braun said. “This is an ongoing challenge for operators, who need to ‘read the tea leaves’ and determine how far they can go in rent increases to cover some of these expenses without pricing themselves out of the market.”

Sloan cited labor issues — specifically, recruiting and retaining workers — as the top challenge that has faced senior living owners and operators over the past year. And those issues affect access, she said.

“These challenges are particularly acute in senior living communities that provide skilled nursing and home healthcare,” such as continuing care retirement / life plan communities or assisted living communities where home- and community-based services are provided, she said. “Insufficient reimbursement rates, coupled with a highly competitive labor market, make for a very tough operating environment. Members are having to make hard choices — which service lines to continue, what to reduce — in order to maintain operations. That prospect of limiting older adults and families’ access to much-needed care is really antithetical to our members’ mission. Yet without staff, there is no care.”

NCAL’s Bethea noted that assisted living providers and those they could serve are feeling the pain as well.

“While the assisted living workforce has recovered in many areas, workforce shortages still remain a top challenge, especially in rural areas,” she said. “ Rural areas do not have as many people in general, let alone the qualified caregivers needed to support the communities’ seniors. As a result, assisted living providers are having to compete with other healthcare sectors for new hires or make the tough decision to limit admissions.”

Limiting move-ins, Bethea said, “leaves vulnerable residents displaced from their long-standing communities, as well as reduces their options for quality care. …Families are left scrambling to find new care options and often must travel farther to visit their loved one.”

NCAL, she added, is working with its state affiliates and individual providers to try to find solutions to address workforce challenges so that older adults’ access to assisted living is protected.

Mandate effects outside of nursing homes

Both Sloan and Bethea cited the federal government’s proposed minimum staffing mandate for nursing homes as a potential challenge for other types of providers along the long-term care continuum.

“There’s a bit of irony here. I’ve spent my career in this sector and finally — a true first in a long time — the federal government is focused on aging services and older adults’ access to quality care,” Sloan said. “But the Biden administration is not making the right choices.”

At LeadingAge’s annual meeting in November, Sloan said that even though the staffing mandate proposed by the Centers for Medicare & Medicaid Services directly would apply only to nursing homes, senior living and other providers would be affected because they are “fishing from the same pool” of workers and “there are just not enough people to hire.”

In December, she told McKnight’s Senior Living that “decisions are being made that will have far-reaching impact and potentially negative unintended consequences.”

Bethea predicted that the proposed mandate will be senior living’s top challenge this year.

“With the impending Biden administration’s staffing mandate for nursing homes, assisted living communities are at risk of losing staff,” she said. “No matter where an assisted living community sits on this continuum, a federal minimum staffing mandate threatens to take away the essential staff on which these communities depend to provide high-quality care for millions of residents.”

And because labor shortages can lead operators to curtail admissions, Bethea said, another top challenge for the industry will be to rebuild the capacity to accept new residents.

“As [the] workforce slowly recovers, assisted living providers must do everything they can to effectively communicate that they are willing and able to accept new residents,” she said. 

ASHA continues to pursue a variety of legislative solutions to workforce challenges, including immigration reform, Schless said. “Of course, the politics of immigration reform are extremely challenging,” he added, noting that, with 2024 being an election year, “getting any significant legislation enacted is unlikely,” although “ASHA will continue to look for any opportunities that may add new foreign workers to the workforce.”

Although the situation has improved from the previous two to three years, Braun said, labor issues continue to be a “pressure point” for operators.

“We have seen year-over-year wage increases come down from record highs, and a number of operators are reporting reduced agency dependency, but the challenges have not gone away,” he said.

Operators, Braun said, “need to be better about reducing turnover and ultimately improving the experience of our workforce, which in the end will pay dividends.”

Workforce issues also are a primary concern for affordable senior housing providers, Sloan said.

“Congressionally appropriated funds are critical to both meet rising demand for homes and support the programs for service coordinators, whose work helps residents to age in place,” she said. “Research — and the experience of our nonprofit members who provide federally assisted homes to seniors with low-incomes — show that residents are better able to age in community with improved health and overall well-being thanks to service coordinators’ work, yet for the past  decade, these programs hadn’t received support, until only recently.”

In December, the US Department of Housing and Urban Development released $40 million in new funding for service coordination programs in affordable senior housing. LeadingAge said it was the first service coordinator funding opportunity in 10 years.

A 2015 study by LeadingAge and the Lewin Group found that the availability of an on-site service coordinator, such as a social worker, at federally subsidized seniors housing reduced hospital admissions among residents by 18%. More recent studies found that service coordinators improved affordable senior housing resident resilience during the COVID-19 pandemic.

But “even with recent support, there are still significant unmet needs,” Sloan said.

Looking to the future

Looking toward the future, Braun said that the industry is “going to have to refine the owner-operator relationship in some cases.”

“We remain a fragmented space with many different owners and operators, and those relationships can be complicated depending on experience in the sector and generally a limited set of industry standards for measuring and defining quality,” he continued. “NIC is working with some others on this very topic. We think it will be critical to advance the sector in this regard as we prepare for the wave of new development that will come once the capital starts to free up.”

Look for the topics to be covered in educational sessions, forums and networking opportunities at the 2024 NIC Spring Conference, Braun said.

Meanwhile, Sloan said that LeadingAge members “are laser-focused on reimagining themselves for the future.”

“We know that the majority of Americans want to age in community, in their homes. That’s an opportunity for providers across the spectrum,” she said. “The big question for our members is determining the path that is consistent with their mission and sets them up to be successful well into the future. It’s really about making the smart and strategic choices and executing on them while at the same time navigating workforce shortages and other pressing issues.”

To educate potential residents and their families about senior living options, Schless said, ASHA will be re-launching a “completely overhauled” version of its consumer website, Where You Live Matters, this year.

Bethea said that quality will remain a top focus for NCAL and its members in 2024.

“Assisted living continues to deliver high-quality care in a safe, homelike setting that offers the ability to meet residents’ needs,” she added. “The only thing the current labor shortage has impacted is access to care, not quality. The caregivers in our assisted living communities are dedicated individuals who are committed to continuous quality improvement.”

A coalition of senior living, healthcare and veterans organizations collectively provided their continued support in a letter sent Thursday to House and Senate leadership for an assisted living pilot program geared toward serving veterans.

The American Seniors Housing Association, Argentum, LeadingAge and the National Center for Assisted Living signed a letter advocating for the Expanding Veterans’ Options for Long Term Care Act. The bill would establish a three-year pilot enabling some veterans to have their care needs met in an assisted living community rather than a Veterans Affairs home.

The associations previously voiced their support for the bill, which was reintroduced earlier this year after going nowhere last year. The House Committee on Veterans’ Affairs Subcommittee on Health held a hearing this summer on the bill, which received the support of the US Department of Veterans Affairs — with conditions. 

The VA indicated that having the authority to provide assisted living services would help the agency find a place veterans who need such services but don’t qualify for nursing home care. But a VA representative testified that the agency would need more time and resources to implement the program. 

In its letter to House and Senate leadership as well as Veternas’s Affairs Committee leaders, the coalition called the proposed pilot program an “economically sound and sensible approach to demonstrate the benefits” of assisted living, and that the bill gives the VA the authority to offer additional options in its long-term care programs.

“It provides VA the critical flexibility to address the needs of a rapidly growing population of aging or disabled veterans who are not able to live at home, and future cost savings will help more veterans receive the assistance they need,” the letter read. “The timing is right for such action given what we know about aging and the increasing demand for supportive services.”

Pointing to statistics from a 2020 VA report, the authors noted that the number of veterans eligible for nursing home care will increase 535% over the next 20 years. The letter also noted that costs to the VA for nursing home care alone are not sustainable and that assisted living offers “significant cost savings” for those who don’t require a high level of medical care.

Additional signers of the letter were the AARP, the Alzheimer’s Association and the Alzheimer’s Impact Movement, DAV, Iraq and Afghanistan Veterans of America, the National Association of State Veterans Homes, the National Rural Health Association and Paralyzed Veterans of America.

Determining assisted living’s value is part of a “significant and unavoidable issue” that thrust the sector under a hot national spotlight recently, thanks to a KFF Health News / New York Times series examining the struggles of the middle class to access and pay for long-term care.

The “Dying Broke” series, published in November, was the focus of a panel discussion Tuesday that included a policy expert, and reporters and families involved in the series. Collectively, the panelists provided potential policy solutions to address the long-term care industry challenges highlighted in the series.

Meanwhile, letters from senior living leaders to the New York Times made it clear that they think assisted living is part of the answer, not the cause of a problem.

Part one of the series examined America’s high long-term care costs, including how they compare with those of other countries. Part two looked at the high costs and profits of assisted living communities. Part three pondered the shortcomings of long-term care insurance.

In a letter to the editor submitted Nov. 21 by Argentum to the New York Times, president and CEO James Balda applauded the outlet for recognizing that assisted living is more cost-effective than nursing homes and in-home care. But he said the series failed to recognize that “senior residents and their families overwhelmingly love assisted living.”

“Our communities promote independence and dignity through care and socialization — encouraging pets, physical and mental activity, social excursions and purpose, all within the secure environment of their home,” Balda wrote, pointing to a recent J.D. Power 2023 Senior Living Satisfaction Study resident and family satisfaction survey. “More seniors should have access to the quality care our communities provide.”

Balda called on state and federal policymakers to create more options for seniors, such as expanding Medicaid, modernizing tax savings programs to include long-term care, and increasing availability of long-term care insurance.

The American Seniors Housing Association similarly submitted a letter to the editor on Nov. 21, acknowledging that although many Americans have sufficient savings and home equity to pay for long-term care at home or in assisted living, many underestimate the consequences of longer life spans. 

“Our society does not have an adequate answer in place to help those whose savings are insufficient or who do not qualify for Medicaid assisted living, which is limited and not an option in all states,” ASHA President and CEO David Schless wrote, adding that Congress, agencies and states need to work together on finding solutions. “Policymakers need to think broadly for ways to incentivize retirement savings, reactivate the market for long-term care insurance, expand Medicare benefits and much more.”

Addressing challenges through collaboration

Rani Snyder, vice president of program for the John A. Hartford Foundation, introduced the panel and said the scale of change needed to address the industry’s shortfalls is going to be “hugely challenging” and includes long-term care insurance, assisted living regulations, and transparency. 

Reed Abelson, the New York Times healthcare reporter on the series along with KFF Health News correspondent Jordan Rau, said that through her reporting she found that the struggle to figure out long-term care is a “universal experience.”

“I’m amazed at how people were able to find solutions. They really worked hard and they were creative and really self-sacrificing,” Abelson said. “People were incredibly committed to trying to make life better for someone.”

Anne Tumlinson, founder and CEO of ATI Advisory and founder of the online family caregiver support community Daughterhood, said that the data show that the vast majority of older adults with high levels of need are living in the community, not in assisted living or in nursing homes, due to the high costs of care and the lack of a financing system in this country to pay for it. 

‘Very dire situation’

Of those living in the community, only one-third are receiving financial support from Medicaid to pay for home- and community-based services, she said. Of the remaining two-thirds, half live under 200% of the poverty level and are paying out of pocket or relying exclusively on family caregivers, Tumlinson added.

“A lot of older adults living in the community today without any kind of Medicaid assistance, who cannot afford home care or assisted living, and do not have long-term care insurance policies,” she said. “”Those people are 100% relying on family caregivers, if they even have them. If they don’t, it’s a very dire situation.”

She called the long-term care system underfunded and one in which every single family is developing its own solutions one family, one household at a time. But she said that the issue is not something the private market can solve alone, and she called on the federal government to come up with a solution by pooling risk through taxes or premiums.

“It’s politically difficult, but as a matter of policy, it’s pretty simple,” Tumlinson said. We know what to do; we just haven’t had the political will.”

That lack of political interest, she said, is compounded by people looking at the situation as an individual problem, when it really is a “collective problem that requires a collective solution.” 

“When we are in community together, that creates the opportunity for us to elevate our voices as a community,” Tumlinson said. “We have to elevate that fire, and we can do it as a community. And these lived experiences are critically important for policymakers to hear because it informs everything.”

Financial support from the federal government and private lenders would be required to lower assisted living rates, National Center for Assisted Living Executive Director LaShuan Bethea told the New York Times and KFF for an article posted Monday on the KFF Health news website.

The piece in which Bethea was quoted, titled “Extra Fees Drive Assisted Living Profits,” is part of a KFF-Times project entitled “Dying Broke.” In part, the article scrutinized an industry pricing structure that adds fees on top of basic charges, to cover additional services such as help with activities of daily living, insulin injections and blood pressure checks.

“Assisted living providers are ready and willing to provide more affordable options, especially for a growing elderly population,” Bethea told the media outlets. “But we need the support of policymakers and other industries.” Offering affordable assisted living, she added, “requires an entirely different business model.”

The article also referenced a 2022 survey by KFF, published Nov. 14, that found that 83% of adults said it would be “impossible” (37%) or “very difficult” (46%) to pay $60,000 a year to live in an assisted living community or get help with ADLs at home (14% said it would be “not very difficult,” and 3% said it would be “not a problem at all”).

The article also cited the growth of rate increases, the for-profit status of most providers, and the operating margins they see. Several provider organizations and real estate investment trusts were named.

“For residents, the median annual price of assisted living has increased 31% faster than inflation, nearly doubling from 2004 to 2021, to $54,000, according to surveys by the insurance firm Genworth,” wrote the article’s authors, who also noted that 80% of the 31,000 assisted living communities nationwide are operated by for-profit organizations.

American Seniors Housing Association President and CEO David Schless told the media outlets that the median operating margin for assisted living communities in 2021 was 23% for communities offering memory care and 20% for communities not offering it.

Providers and shareholders aren’t necessarily just pocketing profits, Bethea said.

Operators can invest returns back into communities’ services, technology and updates to buildings, she pointed out, adding that their doing so contributes to the industry’s “high customer satisfaction rates.”

Beth Burnham Mace, special adviser to the National Investment Center for Seniors Housing & Care, also made the point that a la carte pricing promotes choice and allows residents to pay for what they “actually desire and need.”

Issues beyond provider charges also are in play, the article shared.

The market for long-term care insurance, which individuals could purchase to help them pay to live in assisted living, “has virtually collapsed,” the authors noted, and most assisted living residents pay using private funds. Eighteen percent of residential care facilities do accept Medicaid payments, they said, citing data from the Centers for Disease Control and Prevention’s National Center for Health Statistics, although “a resident must be frail enough to qualify for a nursing home before Medicaid will cover the health care costs in an assisted living facility,” and 37 states have waiting lists.

Read the full article here. Read the survey results here. As part of the project, the media outlets also published a Q&A about assisted living for consumers.

A new overtime rule proposed by the federal government would worsen workforce issues for senior living providers and create unintended consequences for workers and residents, according to industry advocacy groups.

Most salaried workers earning less than $1,059 per week, or about $55,000 per year, would be eligible for overtime pay under the proposed rule. The Department of Labor estimates that 3.6 million more salaried workers would be newly eligible for overtime under the changed thresholds, and approximately 600,000 of them work in healthcare.

The rule would increase the standard salary level for eligibility to the 35th percentile of weekly earnings of full-time salaried workers in the lowest-wage census region (which was the South at the time of the rule’s proposal). Currently, employees earning up to $684 per week, or $35,568 per year, are eligible for overtime pay. The rule would

The Labor Department also is proposing to automatically update all of the earnings thresholds beginning three years after the overtime rule’s effective date and every three years thereafter, to reflect current earnings data. The proposed salary threshold represents an increase of almost 55% since 2019.

The rule also would restore overtime protections in US territories, where the overtime threshold applied from 2004 until 2019.

33,000+ comments received

The DOL’s Wage and Hour Division said it received more than 33,000 comments and as of Wednesday had posted almost 24,000 of them online. The deadline for commenting was Tuesday.

In a joint comment letter, Argentum President and CEO James Balda and American Seniors Housing Association President and CEO David Schless called the proposed rule “flawed” and urged the agency to withdraw it.

“The proposed rule constitutes bad policy at a time when employers and employees are adapting new and innovative approaches in staffing to meet these needs,” they wrote.

Specifically, their comments focused on the “unnecessary and harmful” layering of complexity on a workforce and workplace that already has imposed new demands on employers to offer new flexibility, higher wages and other accommodations. Balda and Schless also addressed what they described as the “flawed” methodology for determining the standard salary level for eligibility, urged removal of bonus caps to meet exempt status and include safe harbors of unintentional errors, and called for keeping the current salary threshold for “highly compensated” employees and for the withdraw the automatic indexing of the salary level test every three years.

“If enacted, these proposed rules would exacerbate the workforce crisis in senior living, increase costs and likely reduce access to assisted living at the same time that the population is aging at the fastest rate in more than a century,” Argentum Senior Vice President of Public Affairs Maggie Elehwany and ASHA Vice President of Government Affairs Jeanne McGlynn Delgado said in a joint statement. “We urge the Department of Labor to withdraw this proposed rule and work with stakeholders to develop solutions for overtime pay that more closely reflect current economic conditions, while also ensuring that senior living providers can continue to provide high-quality care to their residents.”

Argentum and ASHA said that during the pandemic, senior living operators faced substantial operating losses and increased care expenses exceeding $30 billion with minimal government relief. Providers also increased wages “significantly” for nonexempt employees and hired thousands of additional employees to meet residents’ needs, Balda and Schless said.

“The proposed rules would have a disproportionate and potentially devastating impact on the long-term care industry, which will need to attract more than 20 million workers by 2040 to keep pace with our rapidly aging population,” they said. Argentum previously calculated that of those 20 million workers, 3 million would be needed for senior living.

LeadingAge also submitted comments about the proposed rule, calling it “challenging to absorb” for providers.

“We are concerned that the impact of the Department of Labor’s proposed rule, if enacted unchanged, will add to the financial burdens of providers who are already navigating a lot of operational challenges, from inadequate reimbursements to cover the cost of care; a highly competitive labor market that drives up wages; and inflation-fueled rising prices for necessary goods,” LeadingAge Vice President of Legal Affairs Jon Lips told McKnight’s Senior Living. 

In submitted comments, Lips told the federal government that the proposed increases would  have significant effects on long-term care operators, especially those that heavily depend on reimbursements from public healthcare programs, which he said are insufficient. 

“Providers that are not able to absorb the full increased labor costs of the proposed rule will be required to make challenging decisions,” Lips wrote. “In some cases, a provider may have to reduce non-essential services and programming in some form, affecting the quality of life for those they serve, or, alternatively, choose to serve fewer individuals.”

Other unintended outcomes of the proposed rule, he said, could include increased costs for residents and added work burdens on exempt employees as employers reclassify some workers to hourly status.

In its comments, the American Health Care Association / National Center for Assisted Living asked that a final rule consider the challenges that providers face and to allow flexibilities.

AHCA/NCAL Associate Vice President of Constituency Services and Workforce Dana Ritchie raised concerns about the effects on operations at a time when long-term care is “being squeezed by inflation, wage increases rising interest rates” and, for skilled nursing facilities, the Centers for Medicare & Medicaid Services’ minimum staffing proposal. 

“While providers certainly understand what DOL is trying to accomplish here — and fully support appropriate overtime pay — there is concern on how many additional requirements the long-term care industry will be able to bear,” Ritchie wrote, adding that keeping up with the every-three-year update of the salary threshold would present additional challenges.

All of the association commenters said that if a final rule is adopted, there should be a transition period to enable employers to conduct analyses and make operational adjustments.

Cost? $664 million+ over 10 years

The Fair Labor Standards Act requires covered employers to pay minimum wage, and for employees who work more than 40 hours a week, overtime pay of at least 1.5 times the regular rate. Certain executive, administrative and professional employees are exempt, however.

Annualized direct employer costs over the first 10 years of the rule would total $664 million, according to a Labor Department estimate. But the proposed rule also gives employees higher earnings in the form of transfers of income from employers to employees, and the department estimates that those annualized transfers would total $1.3 billion.

In total, the Labor Department estimates that 3.4 million people earning $55,068 or less annually, and 248,999 “highly compensated” employees, would be eligible for overtime pay under the changes in the first year after implementation.

CHICAGO — Even though the staffing mandate proposed by the Centers for Medicare & Medicaid Services directly would apply only to nursing homes, senior living providers as well as providers across the rest of the aging services continuum would be affected because they are “fishing from the same pool” of workers, LeadingAge President and CEO Katie Smith Sloan said Monday.

The bottom line, she said, speaking at the opening session of the LeadingAge Annual Meeting, is that the proposal simply is not viable. “There are just not enough people to hire,” Sloan said.

The CEO said that the proposed standard for nursing homes, as written, would require 90,000 additional nurses and nurse aides at a cost of approximately $7.1 billion annually.

“We know the impact of such mandates have a ripple effect across the whole entire aging services sectors,” she said, adding that “assisted living residents in need of a higher level of care may have to do without, and older adults in independent living seeking intermittent care will not get that support.”

“Shuffling workers among different settings will not work,” Sloan said. “Getting it wrong will undercut equity, access and care across the spectrum of aging services.”

With almost 42,000 comments received and posted from providers and consumers as of Monday morning, including 450 people who submitted comments from the LeadingAge meeting on Sunday — the deadline for comments was midnight Monday — Sloan said in a meeting with McKnight’s Senior Living, McKnight’s Long-Term Care News and McKnight’s Home Care that she never had seen providers so engaged in an issue as this one.

“What this issue is doing is sort of galvanizing our senior living, nursing home community, I think, in a really important way, and really thinking about, ‘What is quality? What does it take to get to quality?” she said.

“In a sense, we’re all fishing from the same pool [for workers]. We’re all looking for employees,” Sloan said. “Every part of the continuum is facing staffing shortages. Sometimes those are personal care aides, nurse aides, nurses, for sure. …For assisted living, you need nursing assistants and personal care aides. So as we tighten the pool and drive more staff to nursing homes to meet whatever the standard may be, you’ve got to get these folks from someplace, unless we figure out a way to broaden the pipeline through immigration or other channels.”

It’ll take CMS “a heck of a long time” to go through all of the comments, she predicted. “They have to read all of them, and that’s going to take months and months and months” and will involve reconciling “very, very, very divergent opinions,” Sloan said, predicting that it will be more than a year before CMS issues a final rule and noting, however, that proposed rules don’t have to be finalized.

Mandate ‘potentially devastating’

Argentum joined a coalition of senior living industry stakeholders — including AMDA–The Society for Post-Acute and Long-Term Care Medicine, the American Seniors Housing Association, the National Center for Assisted Living, LeadingAge, the American Assisted Living Nurses Association, the Association of Jewish Aging Services and Lutheran Services in America — to submit public comments on how the proposed rule would have “potentially devastating impact” on the long-term care industry.

“The vast majority of senior living providers continue to deal with labor shortages and have not returned to pre-pandemic workforce levels,” Argentum Senior Vice President of Public Affairs Maggie Elehwany said in response to the campaign. “Regardless of an assisted living community’s workforce situation, a federal minimum staffing mandate for nursing homes threatens to reduce the available pool of essential caregivers that assisted living and other senior living communities also depend on to serve more than 1 million residents.”

An Argentum report published earlier this year found that the senior living industry will need to attract more than 3 million workers by 2040 to keep pace with a rapidly aging population.

“A federal minimum staffing standard will not create more caregivers. It will simply further exacerbate the current shortage,” Elehwany said, adding that the coalition encouraged CMS to instead focus on efforts to strengthen the long-term care workforce through policies to address training, recruitment and retention. 

NCAL Executive Director LaShuan Bethea echoed comments from American Health Care Association/NCAL President and CEO Mark Parkinson that the staffing mandate won’t create more caregivers.

“It just creates a situation where long-term care facilities, assisted living and other healthcare providers are all competing for a limited pool of caregivers,” Bethea wrote to CMS, adding that senior living communities are at risk of losing staff. “No matter an assisted living community’s workforce situation, a federal minimum staffing mandate for nursing homes threatens to take away essential caregivers on which assisted living communities depend to serve hundreds of thousands of residents.”

The proposal would create a rural struggle for senior living providers for which the main competitor for staffing is nursing homes, she said. In urban areas, long-term care providers are pitted against healthcare providers, competing with each other for the same pool of nurse and direct care staff members, Bethea added.

“Long-term care providers need supportive policies that will strengthen their workforce, not a blanke mandate that doesn’t account for individualized resident needs,” Bethea wrote. This only results in inefficient use of nurses and other caregivers, and threatens access to care for hundreds of thousands of seniors across the care continuum.”

Roberto Muniz, LeadingAge board chair-elect and president and CEO of New Jersey-based Parker Health Group, told the McKnight’s group that aging service organizations provide a diverse number of services and that all will be affected in some way by the mandate. Although his organization promotes aging in place at home “because that’s what people want to do,” eventually those individuals may need to move into a senior living community, and they need qualified people there to be able to care for older adults.

The sooner CMS comes out with a decision, the better, he said.

“As a provider, we’re in limbo,” Muniz said. “We want to know what’s going on, what we should do and what we should be planning to do. It’s a critical issue for us.”