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.

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.

A large national trade group advocating for senior living and other long-term care providers is urging its members to “carefully evaluate their existing classifications” of workers following the Tuesday announcement of a new federal rule pertaining to independent contractors.

“The Department of Labor has put a strong emphasis on ensuring proper classification, and we can expect those efforts to continue,” LeadingAge Vice President of Legal Affairs Jonathan Lips told McKnight’s Senior Living on Tuesday. “Now that the final rule is released, we are carefully reviewing the content and its implications for providers and urge our members to carefully evaluate their existing classifications based on the new regulations.”

The rule comes as senior living providers continue to face workforce shortages and sometimes turn to staffing agencies for help.

Another association, Argentum, said that the rule “unfortunately” will result in many workers being unfairly classified as employees and “depriving them of their choice of the manner in which they wish to work.”

“The senior living industry lost hundreds of thousands of jobs during the pandemic, and while the situation is gradually improving, many communities are still struggling to recruit, hire and retain employees,” Argentum Senior Vice President of Public Policy Maggie Elehwany told McKnight’s Senior Living. “We are concerned that the rule, coupled with other proposed federal regulations, will only serve to exacerbate the workforce shortage and wipe out some of the recent modest gains communities have made in recruiting individuals to help care for our seniors.”

Additional experts are concerned that providers will face greater legal and financial burdens under the rule.

The US Department of Labor announced the final rule Tuesday morning, clarifying its interpretation of the Fair Labor Standards Act’s classification of workers as independent contractors. The final rule largely mirror’s the rule it proposed in October 2022, retaining the framework it laid out for determining independent contractor status versus employee status. 

The new rule restores the multifactor analysis to determine independent contractor status, including any opportunity for profit or loss a worker might have; the financial nature of any resources a worker invested in the work; the degree of permanence of the work relationship; the degree of control and employer has over someone’s work; whether the work done is essential to the employer’s business; and a worker’s skill and initiative.

That “control” piece is something senior living and care providers will be reviewing carefully. 

The DOL said that the new rule will provide “a consistent approach for businesses that engage with individuals who are in business for themselves” and ensure that “employers that comply with the law are not placed at a competitive disadvantage when competing against employers that misclassify employees.”

The US Chamber of Commerce, a national business advocacy organization, called the new regulation “harmful” and “clearly biased” toward labeling most independent contractors as employees, a move it said will “decrease flexibility and opportunity and result in lost earning opportunities for millions of Americans.”

“It threatens the flexibility of individuals to work when and how they want and could have significant negative impacts on our economy,” Chamber Vice President of Workplace Policy Marc Freedman said in a statement. “Making matters worse, the rule is completely unnecessary, as the department continues to report success in cracking down on bad actors that are misclassifying workers.”

Indeed, the Department of Labor frequently reports on employers who pay the price for misclassifying workers as independent contractors rather than employees. In September, for instance, the department reported that a Pittsburgh-based healthcare services provider for people living with dementia or disabilities misclassified two workers as independent contractors, resulting in a recovery of $98,620 in back wages by the federal government. And in 2022, an investigation into a Lansing, MI, adult foster care company’s practice of treating its residential healthcare workers as independent contractors cost it $94,000 in back wages.

In a blog post, law firm Fisher Phillips noted that the DOL’s test applies only to the FLSA and that many states apply their own tests to state-level wage and hour claims. Although some state laws protect the independent contractor relationships if certain criteria are met, other state laws make it more difficult to establish such relationships, the firm said.

Fisher Phillips added that under the new rule, “the risk of misclassification will skyrocket,” with more employers facing potential liability for not paying minimum wage and overtime premiums to their workers.

“The ramifications can be staggering — class-action lawsuits, large settlement demands, backpay, liquidated damages, interst, penalties and attorneys’ fees can all quickly add up,” the authors wrote.

Fisher Phillips suggested that businesses using independent contractors conduct internal audits to assess their risk level for misclassification, update policies and procedures, train managers and work with counsel to evaluate programs and minimize risks.

The new rule rescinds one issued during the final days of the Trump administration in January 2021. The Labor Department under the Biden administration had sought to delay the rule, and then withdrew it in May 2021, believing that it was inconsistent with the FLSA’s text and purpose. A district court, however, in March 2022 determined that the rule had taken effect on its original effective date and remained in effect.

In June 2022, the DOL announced plans to hold public forums to gather feedback on writing a new rule. A proposed rule was issued in October of that year, and the department said it received more than 55,000 comments on the proposal during the comment period and listening sessions. 

The final rule will be published today in the Federal Register (see a PDF here) and will take effect March 11. 

The Labor Department has published answers to frequently asked questions on its website.

For more coverage of the rule, see McKnight’s Long-Term Care News and McKnight’s Home Care.

Increasing COVID-19, influenza and respiratory syncytial virus vaccination rates in older adults is going to require a village to battle vaccine reluctance in the form of misinformation, hesitancy and fatigue, according to senior living experts.

The Centers for Disease Control and Prevention recently released two reports on vaccination coverage and treatment for respiratory viruses. The agency found that vaccine fatigue, inaccurate health information and vaccine hesitancy contributed to lower vaccination rates in older adults. 

A significant challenge is that many people now tend to equate COVID-19 with catching a cold, Argentum Vice President of Government Relations Paul Williams told McKnight’s Senior Living. 

“We need to continue to emphasize how serious these respiratory viruses can be for our residents, who tend to have multiple comorbidities and chronic conditions, putting them at greater risk for serious complications, and even death,” Williams said. “At this point, so many people have made up their minds on vaccination, and trying to get folks to reconsider is an uphill task.”

Many people are “done with COVID” and any discussion of vaccines, he added.

“Vaccine fatigue is real, even though it remains a threat to the older adults we serve,” Williams said.

Raising vaccination rates

According to the CDC, uptake of the updated COVID-19 vaccine is approximately 37% in adults aged 75 or more years, compared with the national average of 19% among all adults. The statistics aren’t much better for the flu and RSV vaccines — only 34% of adults aged 65 or more years had received the flu vaccine as of Oct. 28 and only 17% of adults aged 60 or more years reported receiving an RSV vaccine as of Dec. 23.

Nursing homes have national reporting requirements for resident and staff member vaccination rates, making statistics more readily available than in assisted living, which does not have such requirements. And not all states are mandating or tracking vaccination in senior living community staff members for COVID, RSV or flu.

Williams said that Argentum is hearing that communities with strong leadership often have higher vaccination rates, and that staff members who trust and respect community leaders are more receptive to calls for vaccination and the importance of helping to protect residents and colleagues in the community.

“Communities that involve trusted nurses and clinicians to educate residents and answer questions on the risk and benefits of vaccines have higher rates,” he added. “The use of toolkits and talking points have proven to be helpful but the main barrier to increasing compliance remains ‘vaccine fatigue.’”

Challenges of vaccine reluctance

The challenge in battling vaccine reluctance is not unique to senior living or nursing home providers; it is systemic among the US population at large, according to the American Health Care Association / National Center for Assisted Living.

“As a country, we face significant challenges with vaccine reluctance that require a collective endeavor by public health officials, other healthcare providers and the public,” an AHCA/NCAL spokeswoman told McKnight’s Senior Living. “Assisted living providers remain persistent in talking to family members and residents about their vaccine concerns and appreciate the partnerships of the larger healthcare system to help reinforce the importance of the vaccines.”

Last week, US Department of Health and Human Services Secretary Xavier Becerra met virtually with representatives from LeadingAge and AHCA/NCAL to express concerns about low vaccination rates among residents of nursing homes, which are supported by federal dollars through the Medicare and Medicaid programs. LeadingAge said in a statement after that meeting that it had urged HHS to help ease logistical issues that have slowed vaccination rates and to encourage hospitals to offer vaccines on discharge. 

David Gifford, MD, MPH, chief medical officer of AHCA/NCAL, writing in a column in McKnight’s Senior Living sister publication McKnight’s Long-Term Care News last week, discussed the need for the nation to collectively combat vaccine reluctance. He opined that strides in the right direction since the pandemic have been taken with vaccines, especially in the long-term care industry, but much collective work remains to be done by the healthcare profession to combat widespread hesitancy.

Vaccine fatigue and hesitancy, Gifford said, are “rampant,’ but especially so when it comes to COVID-19 and RSV vaccines. And although vaccine uptake in skilled nursing facilities is higher than in the general community (a number easier to know for nursing homes due to federal reporting requirements), he called for a doubling down on efforts to increase those numbers.

Gifford called for the ready availability of vaccines for residents through on-site vaccine clinics, provider reimbursements and consistent public health messaging. He said many new admissions arrive at an assisted living community or nursing home without being offered or having received the vaccine during visits with physicians in other healthcare settings.

AHCA/NCAL created a #GetVaccinated website last year with resources for providers to secure and administer vaccines on site, as well as resources to help encourage residents and staff members to receive vaccines.

Lisa McCracken, the new head of research and analytics for the National Investment Center for Seniors Housing & Care, talked during Wednesday’s LeadingAge policy update call about what she is seeing in her crystal ball as the industry enters the new year. 

“The pandemic was an accelerant across a lot of different levels. A lot of things unfolded much quicker,” she said.

The industry, McCracken said, is in the earlier stages regarding much technology, especially as relates to adoption. That reality, she added, brings questions about how to pay for it, who will pay for it and what providers can cover from an investment standpoint if technology helps improve outcomes and efficiencies.

Artificial intelligence also presents opportunities in terms of predicting when a resident’s health might start to decline or when a resident might be prone to falling, and to identify signs of employees who may be more likely to leave their jobs, McCracken said. 

“There is a lot of predictive data out there,” she said. Generative AI, McCracken added, processes data in different ways and helps with the human touch aspect of care and service provision by allowing staff members “to do the more important things.”

“I’m a big fan of a lot of the workforce tech that helps from an efficiency standpoint to reallocate staff time,” she said.

NIC, she added, is working with NORC at the University of Chicago to quantify the value that senior living brings to individuals from the standpoint of quality of life, longevity and health outcomes — and how that value can translate to the reimbursement side for some operators. Organizations, McCracken added, must adopt a business intelligence and analytics mindset to better quantify the sector’s story.

“How can you prove your own worth?” she asked. “We know it, we feel it, we see it — but we live in a world that demands the evidence. We need to do better at that.”

The integration of wellness into offerings, as well as risk partnerships with payers, are other innovative happenings that McCracken said she is seeing, “recognizing we can’t do this alone, and maybe we don’t need to be the end all, be all, but a convener to make bold moves.”

Partnerships, she added, are helping NIC propel some initiatives forward. McCracken mentioned a partnership with the Milken Institute that will yield a report next week regarding middle market solutions for senior housing and care. This report follows the November announcement of a $3 million grant that NIC provided to the institute’s Center for the Future of Aging to “develop bold new models” for senior housing and care. As part of that effort, Nexus Insights, a think tank founded almost four years ago by NIC founder Bob Kramer, is merging with the new Aging Innovation Collaborative within the center.

“We recognize that NIC has a powerful voice within the senior housing and care space, but others are looking at the population of older adults and saying what we need to know, how to partner, how to think innovatively,” McCracken said.

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.”

Assisted living operators that provide home- and community-based services to residents who are Medicaid beneficiaries could be affected as states continue to come into compliance with the provisions of the HCBS settings final rule, suggests the results of a KFF survey of state Medicaid HCBS programs.

One expert said that even providers that don’t provide HCBS would benefit from becoming familiar with its provisions.

The HCBS settings final rule in part is meant to protect beneficiaries’ autonomy in making choices and controlling decisions that affect their lives. Senior living industry advocates, however, had warned that the regulation could lead assisted living communities to stop accepting Medicaid as a payment source, causing some residents to need to move to nursing homes or other settings.

In 2023, 47 states provided HCBS through a combination of 1915(c) waivers — used by assisted living operators to provide such services — and 1115 waivers. Currently, 18% of assisted living residents rely on Medicaid to pay for daily services, and 61% of all assisted living communities are Medicaid-certified, according to the National Center for Assisted Living.

In their analysis, the KFF researchers included challenges for states and anticipated effects on those served, and they referenced a white paper released by LeadingAge that was issued this summer and recommended a two-year enforcement moratorium on the rule.

Alice Burns, associate director of the KFF Program on Medicaid and the Uninsured, told McKnight’s Senior Living that the assisted living communities that would be helped the most by the KFF report are those located in states that have not finished implementing the Medicaid HCBS settings final rule.

But even settings that aren’t affected by the final rule might want to become familiar with its provisions, as they could be a preview of what might be coming with an update to Section 504 of the Rehabilitation Act, which Burns calls a “what to watch” rule.

That update could have implications for assisted living providers, she said, because it addresses discrimination and would apply to any provider that takes federal money. So even providers that aren’t paid through a Medicaid waiver could be affected if they provide home health or personal care services. 

The comment period on Section 504 is now closed, but Burns said that the Section 504 rule is so broad that it could affect most assisted living communities. 

“It’s one of those things that if facilities are already in compliance with the HCBS settings rule, the 504 rule probably is not going to add a whole lot more challenges,” Burns said. “But for those who don’t take money from a waiver, or they’re in a state that is not yet in compliance, this rehabilitation rule could be a bigger deal.”

Profile of LTSS users

Another KFF report Burns said would be of interest to both assisted living communities and nursing homes looked at the age distribution of people using long-term services and supports. According to KFF, 6 million people receive Medicaid LTSS.

People aged fewer than 65 years tend not to live in assisted living and are served in their homes or in the greater community. But for adults aged more than 65 years — the assisted living target population — healthcare care plays a much bigger role in long-term care needs fulfillment, Burns said. 

The researchers found that 56% of Medicaid LTSS users are aged fewer than 65 years and are using HCBS, whereas most older adults who use LTSS services are in institutional settings such as nursing homes. Most (62%) of Medicaid enrollees who use LTSS also are enrolled in the Medicare program or are dually eligible for both Medicare and Medicaid. The data, the authors concluded, suggest a consistent unmet need for services, contributing to the risk of unnecessary institutionalization for people with disabilities.

“It points to the fact that one of the barriers to moving more older people into HCBS is that it’s harder to have Medicaid coverage when you’re in assisted living,” Burns said. “You talk about demographics and this interesting age pattern emerges.”

According to the Post’s research, more than 2,000 residents wandered away from or were “left unattended for hours outside” of senior living communities from 2018 to 2023, and 98 of them died. (Read this article to learn more about the response of industry advocates.)

It isn’t the first time the industry has been scrutinized by the national lay press, of course, and it won’t be the last.

In fact, the Post articles follow the November publication of a package of articles by the New York Times and KFF. That report, titled “Dying Broke,” 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. It also cited the growth of rate increases, the for-profit status of most providers, and the operating margins they see.

Other examples of somewhat recent unflattering coverage of the industry include a 2017 report by CNN that counted more than 16,000 cases of sexual abuse in assisted living communities and nursing homes since 2000 and, on a more local level, articles about the senior living industry in the Minneapolis Star Tribune and Atlanta Journal Constitution in 2017 and 2019, respectively.

Although such attention can lead to efforts to try to increase state regulation of operators, in a recent interview I conducted with Nexus Insights and National Investment Center for Seniors Housing & Care founder Bob Kramer (not about these media investigations), Kramer said he believes that the government’s “desire to invest the money to set up a federal regulatory apparatus is still going to be lacking,” although “there will be a lot of noise” about it.

A 2018 report by the Government Accountability Office certainly generated some “noise” when some federal lawmakers and consumer advocates said they would push for changes in assisted living because of the report’s findings. But the report’s to-do list primarily was for the Centers for Medicare & Medicaid Services and state Medicaid agencies related to state reporting of deficiencies in care and services provided to some assisted living residents.

Still, at a time when demographics mean that a larger number of older adults will be in the market for senior living in the coming years, operators can expect the scrutiny to continue.

As Kramer told me: “The reality is that there are good operators and not-so-good operators.” Even well-intentioned providers may find themselves challenged by staffing shortages, although many have limited move-ins in an effort to better align staffing and resident needs.

“The more the industry can articulate and, in a sense, hold itself accountable for higher standards of care, the better off the industry will be, because we don’t want to go the direction of skilled nursing,” Kramer said as I interviewed him on the occasion of McKnight’s Senior Living’s 20th anniversary. (If you haven’t seen the cartoon of him on the first-ever cover of our print magazine in 2003, you can see it here.)

And therein lies the opportunity.

Possible solutions are suggested in the Post coverage, among them training, increased vigilance and more accurate risk assessments. Industry advocates also point to their efforts to attain and maintain quality among providers.

“Our association has participated in multiple efforts to build sector consensus on assisted living quality measures and other topics,” LeadingAge President and CEO Katie Smith Sloan said Sunday in response to the Post’s coverage.

For instance, LeadingAge, Argentum, the National Center for Assisted Living and the American Seniors Housing Association 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. The work “will help the sector collaboratively address the most urgent issues,” Sloan predicted at the time.

On top of that effort, NCAL offers its National Quality Award program, and Argentum offers several certificate and certification programs, just to name a few quality-focused initiatives. And providers can pursue efforts outside of those offered by industry membership associations, such as assisted living accreditation and memory care certification through The Joint Commission.

Keep it up. The Post is. The media outlet promises to continue to report on the assisted living industry and is soliciting information from readers about their “experiences with elder care, assisted living and dementia care.”

Lois A. Bowers is the editor of McKnight’s Senior Living. Read her other columns here.