Q: How did you first become interested in the area of long-term care?

A: Probably similar to a lot of other folks, it was a little accidental. My background and training is actually in clinical psychology, but I had always been involved in research and initially aspired to be a professor in academia. Instead, I went into clinical work for a few years, and I still had a hand in the research side of things. But after several years of doing that, I joined Holleran, a research consulting firm in the industry. That’s really what opened up the doors to me to this whole world that I did not even know existed. I loved it from day one.

Q: What appeals to you about working in the industry? Why do you stay?

A: Hands down, it’s just the work that’s being done, and that’s across the spectrum. I’ve always appreciated the work that is being done and the trust that people put in you. It’s good work; it’s fulfilling work, and I like to feel that the work I’ve done the past 23 years with information and data and insights really just helps organizations and individuals to do all of that better.

Q: What are some of the ways that you’ve seen the industry change over time?

A: When I look back, even just in the past five to 10 years, things have definitely changed. You can look back and see where, first of all, there’s more choices for older adults these days and, frankly, even living in your home. We’ve seen a lot more technology support that has enabled some of the aging in place. And whether they need some support services or not, that variety of support is available in more settings. Some of that has had to do with the changing consumer, too.

The other thing that we’ve seen a greater focus on is this focus on living your best life and wellness — the prevention type of activities. We have shifted to, this is the place where you maybe go to retire, maybe slow down a little bit, to where you can come here and live your best life, and how can we enable that?

That’s part of what I’ve seen as the value proposition — what can we provide in this housing setting? The senior living setting is going to be much better than what you can have in your own home prior to moving in. Those are things that I think about.

On the hospitality side of things, the bar has been raised a good bit there, with a number of different things — dining options, housing options and settings.

Obviously, we think about labor and those dynamics that have changed in recent years. We’ve always had committed, wonderful people, but I think the focus on them and the importance of the staff as an equal customer to the older adult has really advanced a good bit in recent years. Those are things I look back on, and think we’re in a better place.

There are more choices for individuals as they age. I think their ability to do it in a way that’s self-directed by them is greater. And I’m proud of the sector for advancing in that regard. We’ve still got a ways to go, but I think that we’re more on top of some of the consumer preferences and wants and using some of the technologies and advancements to do all of that better.

Q: How have you seen the consumer change over time, and is senior living rising quickly enough to answer those needs?

A: If you think back to 23 years ago and all of the web-based review systems and information at your fingertips to inform the customer, whether it’s the older adult or whether it’s their family, you can see more reviews. You also can see more employee reviews of what is this place like to work here. I think that sort of transparency, whether it’s provided by you or your constituents, puts us in a place to all be doing a better job and continuing with quality improvements.

We know that the active adult segment continues to grow, so I do think that the industry is responding and trying to give more choices and options depending on where people are.

But at the end of the day, we know the majority of people still want to age in their own home. So where do we find that balance? 

The one area that has been very big and where we still have a lot of work to do is with the group in the middle. I think we could all argue here that having more low-income housing is as well. I feel like we’ve made progress. We have more today than we did even five years ago, but that cohort is so big. We’ve got to crack that nut as a sector, but it’s not easy. It’s tied to the economic conditions, and it’s tied to construction costs and a lot of different financing mechanisms.

Q: Talk about your new role as head of research and analytics at NIC. How does that compare with what you were doing at Holleran and Ziegler?

A: When I sit back and I think about it, it’s actually a blend of my 13 years.

When I was at Holleran, it was very heavily focused on a lot of resident satisfaction, family member satisfaction, staff engagement.

At Ziegler, I really covered a lot of the macro industry trends — how was the industry behaving and growing, and everything from technology to labor to consumer types of areas to home- and community-based services, but also with capital. 

At NIC, it’s really the gamut of all of that, which I appreciate. I also feel it’s a significantly large platform in terms of audience. NIC is an organization that is very well respected, and we have the ability to really impact the sector in some pretty meaningful ways. 

We’re also doing what we call sponsored research, and I’m really excited about these in particular. We had a recent announcement of a $3 million grant to the Milken Institute for the Center for the Future of Aging Innovation Collaborative. It’s exciting that a group is going to demonstrate leadership and do some consumer research. There is a lot to come out of that group.

We are continuing our work and released information around frailty of individuals living on their own in the greater community versus within a seniors housing community. We’ve got some really exciting research coming out around longevity that is being led by researchers from NORC at the University of Chicago, and continuing work on the middle market with four potential models of how to finance and scale those middle-market seniors housing and care projects. And then there’s a great research study coming out from the Harvard Joint Center for Housing Studies focusing on affordability. 

So I feel like what I’m doing right now is the next step in my career and really a blend of the past 23 years, both with Ziegler and Holleran.

Q: With your depth of experience, where do you think the senior living field is headed into the future? What trends are you seeing?

A: I think there will be a focus on wellness and prevention. Some of those technologies, like AI, and where you can start to predict everything from workforce-related things — where is this person at, and are they at risk of leaving, or who’s going to be the right fit for a new hire, to predicting potential falls.

I think about greater integration. I still think we can function in our silos a little bit — whether it’s the tech companies or the operators or the hospitals and health systems — I think we are seeing more of some of these value-based care partnerships and initiatives. How do we provide housing and support services where it’s needed for the whole person and not just manage certain aspects? I think we need to be more innovative when we think about what we offer. At the end of the day, for people who reside in our communities, we have a unique opportunity to make a pretty significant impact above and beyond just the day-to-day services that we’re providing, and keep them healthier for longer.

What we all intuitively have known for many years is that these settings can really make a difference in terms of some longevity, frailty and potential outcomes. So we’re excited to see some of that research unfold in 2024. And what does that mean for other sectors as it relates to payers like Medicare Advantage plans and CMS? Does that put a different perspective on how they view the industry and the benefits from a quality-of-life and longevity and outcomes standpoint?

A lot is underway. One of the things that attracted me to NIC and to take this position was, in the past year, the board and leadership put out a new strategic plan with five focus areas. I think they are really forward-thinking — age tech, the ongoing commitment to the middle market, partnering for health and innovative whole-person models, value-based care, active adult. I feel like we’re having some really great conversations and movement forward with that. To move forward — the strategic plan and how our team supports that from a research analytics and thought leadership standpoint — that’s what excites me when I look at the year ahead.

“You cannot be successful today offering plain vanilla assisted living. In order for operators to be successful, they’re going to have to supply more and more diversity of product.”

Those words of wisdom were shared by Robert G. Kramer in the very first issue of the print magazine of the media brand known today as McKnight’s Senior Living, in October 2003. A cartoon image of Kramer appeared on the cover, showing him tossing a vanilla ice cream cone while looking at other ice cream flavor options.

Many things have changed in the past 20 years.

In 2003, McKnight’s Senior Living was known as McKnight’s Assisted Living.

At the time, Kramer was president of an organization he founded named the National Investment Center for Seniors Housing and Care Industries. Today, he is a strategic adviser to the organization, now known by a slightly shorter moniker, the National Investment Center for Seniors Housing & Care. Kramer also is the founder of think tank Nexus Insights, which soon will merge with the new Aging Innovation Collaborative of the Milken Institute’s Center for the Future of Aging thanks to $3 million in funding from NIC.

Yes, things have changed. But Kramer still has many words of wisdom to share.

In 2023, he said, “I would say it’s diversity of product, and it’s also customization and personalization of product” that senior living operators now need to be successful.

A focus on living, not just care

That customization and personalization is warranted not only in price points, amenities, care plans and proactive management of chronic conditions, “but also in how we are customizing and personalizing engagement, which is actually key to healthy longevity,” Kramer said. “What I mean by that is not just having a care focus, but having a living focus.”

The product segmentation within the industry that was starting to be evident in 2003 in the relatively new stand-alone memory care communities operated by Silverado is now further manifesting in several ways — for instance, in high-end urban communities, intergenerational/multigenerational communities, active adult communities and offerings to appeal to middle-income individuals. Another change over the years, Kramer said, is that many continuing care retirement/life plan communities, which traditionally focused primarily on independent living and skilled nursing, have added assisted living and memory care, and “many are getting rid of skilled nursing, at least on campus,” due to staffing and regulatory costs and concerns.

Consumer needs, wants have changed

But at the heart of everything, from an operator standpoint, is an industry seeking to anticipate and respond to the needs and wants of an aging population, and those needs and wants have changed over the years. Kramer pointed out the shifting acuity levels in various settings that see some people who used to receive care in hospital units now cared for in SNFs, residents in assisted living today resembling the skilled nursing residents of a decade or two ago, and the independent living population of the present looking like the assisted living population of the past.

The new kids on the block, active adult communities, in many cases are becoming the independent living communities of yesteryear, enabling operators to “capture people sooner” and “creating enormous interest from investors and also from consumers who are not looking for care-driven settings and want a lifestyle type of setting,” he said.

In fact, in addition to addressing residents’ health-related needs, Kramer said, operators’ focus should be on “helping people discover and connect with their life’s purpose,” which will “make us a more aspirational setting rather than what we’re in danger of becoming with the public, a setting to avoid” due to a perception that senior living and care is a “continuum of decline.”

Providers have a six- to seven-year window before the oldest members of what Kramer referred to as the “Boom X” generation — which includes the baby boomers but also the older members of Gen X — start thinking in earnest about their next living arrangements. But the industry already knows that they don’t want what their parents wanted, Kramer said.

“They’re going to radically change our industry, which I think is exciting,” he said.

“This new generation is not looking for end-stage living,” he added. “They want something much more, and if you haven’t made the investments in technology and thought through how you’re going to deliver healthcare on-site but also provide that customized, personalized lifestyle that people are looking for, you’re going to find that the market is not anywhere near as big as you thought it was.”

Room for many flavors

In 2023, just as in 2003, room exists for many flavors of serving the needs of older adults, Kramer said, including not just next-generation residential senior living and care settings but also home care for people who want to remain in their homes, roommate-matching services for people who want to live “Golden Girls” style, and more.

“The demands and needs are going to be so great that we need to have all of the options,” he said. “It’s not either/or. It’s not this against that. The demands that are going to be there for affordable lifestyle options and for care are going to overwhelm the senior housing and care sector.”

As for federal regulation of assisted living? It was a topic of discussion in the 2003 pages of McKnight’s Assisted Living, but 20 years later, 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.

“I do believe that we will deliver more and more healthcare where people live, which means in our communities, and much of that healthcare will be paid for by federal dollars — Medicare and, in some instances, Medicaid,” he said. “That’s going to mean more regulation, without question, but do I see an entire federal apparatus to regulate assisted living? I don’t see it in the near term because of the cost.”

But Kramer predicts increased state action.

“The things we see at the federal level now for skilled nursing, we’re going to see at the state level for assisted living and memory care,” he said. “The reality is that there are good operators and not-so-good operators. 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.”

“One is the ‘frenemy’ status with home care. It’s going to be interesting to see to what extent home care and senior living work together versus compete against each other,” he said.

A second big issue for the industry, O’Connor said, is finding a way to serve middle-income individuals, those whose incomes aren’t high enough to afford to live in most existing senior living communities but are too high to qualify for Medicaid. “Solving that is going to remain challenging for economic reasons and some others as well,” he said.

A third big challenge, O’Connor said, is “something I predicted 20 years ago that still hasn’t happened” — the prospect of federal regulation.

“Back then,” he continued, “I said it was inevitable that assisted living was going to become a federally regulated business, and my rationale then as now was, you have a very large customer base of older adults with various health conditions who are trusting an option in the market to help them get through their final years in as much comfort and dignity is possible. To me, it’s mind-blowing that for as many things as our government regulates, it doesn’t regulate that kind of activity.”

“We saw there was a need in the marketplace,” said John O’Connor, editorial director, vice president and associate publisher of all of the McKnight’s brands. “The thing that I really am happy about is that we’re helping our readers — our customers — do their jobs better, understand what’s going on better, make better choices, serve their residents better and, hopefully, at the end of the day, do well as they’re doing good.”

The magazine has been published every other month since February 2004. The brand was expanded in 2015 to include a website, the Daily Briefing e-newsletter and social media. Lois Bowers was brought on board at that time to help lead the digital expansion. That year also saw the brand’s name change to McKnight’s Senior Living.

Today, the brand also offers the annual McKnight’s Senior Living Online Expo as well as numerous e-newsletters, webinars, podcasts, awards, and online and live events, some in collaboration with its sister brands, McKnight’s Long-Term Care News (covering skilled nursing and having celebrated its 40th anniversary in 2020) and McKnight’s Home Care, launched in 2020. 

Although the original COVID-19 drama appears to have waned, infectious disease and medication management experts were guarded heading into this fall’s flu season.

“Something new this year is that two new vaccines were recently approved by the FDA to protect against pneumonia due to respiratory syncytial virus in adults age 60 and over,” said Erica Johnson, chair of the Infectious Disease Board of the American Board of Internal Medicine. 

“While there has been a fair amount of media attention surrounding the new vaccine [for seniors], it may prove to be a bit more challenging to incorporate into the core group of routine vaccines we are accustomed to,” warns Erin Marriott, RPh, director of clinical and regulatory support at Guardian Pharmacy Services.

Erin Donatelli, PharmD, vice president of clinical and consulting services for Remedi SeniorCare, stresses that treatment options and outbreak procedures for COVID-19 and the flu should follow a tight timeline after symptoms or a positive test.

Pharmacists and others expressed confidence in the preparation and efficacy of new COVID boosters and vaccines. Still, work remains to be done.

“As a country, we are still dealing with misinformation, mandates and some poor communications from government leaders,” says Chad Worz, PharmD, chief executive of the American Society of Consultant Pharmacists. “It will take a huge effort by doctors, nurses and pharmacists to rebuild confidence in vaccines.”

Meanwhile, experts are mixed about a repeat of drug shortages. Andrew Agan, a spokesperson for Guardian Pharmacy Services, said that drug shortages remain a major issue. “From atropine to lidocaine, there’s a large list of drugs currently in shortage,” he says.

As for parting advice, experts have plenty.

“Get ahead of potential outbreaks,” Worz says. Residents should be vaccinated and evaluated in anticipation of needed antiviral treatments that could involve possible interactions with other medications, he adds.

And finally, “work collaboratively with your pharmacy partner on securing access to any of the needed vaccines,” Marriott says. 

Millions of adults in the United States are not taking their medications as prescribed because of the costs, according to a new report from the Centers for Disease Control and Prevention.

Most adults aged 18 to 64 took at least one prescription medication in 2021, noted a recent CNN report. But more than 8% of them — about 9.2 million people — said that they tried to save money by skipping doses, taking less than prescribed or delaying a prescription fill, according to the CDC data.

Although average drug costs did not increase in 2021, the number of prescriptions did, and that increased spending, CNN reported.

Many adults aged more than 65 years who have chronic conditions, however, may be taking too many medications and could benefit from a medication review with their primary care physician. Patients also may assume that their health providers check for drug interactions or assess whether a medication no longer is needed, even if that is not actually happening, according to a recent report from WebMD.

If given the option, up to 80% of older adults aged 50 to 80 would be open to stopping one or more of their prescribed medications, according to a 2023 poll by researchers at the University of Michigan. 

» Older Americans have access to more vaccines than ever, but increasing numbers cause concern for some individuals

From pneumonia and shingles to COVID boosters to the new respiratory syncytial virus vaccines and a broader range of flu shots for seniors, older Americans are facing an ever-growing array of vaccines to be mindful about every autumn, as one USA Today article posits.

And although most older adults understand and agree with the importance of prevention, the sheer numbers of shots are giving some of them pause.  “They are tired of getting shots, and their hesitation often comes from confusion about what they need and when,” one expert told the national newspaper. “Educating them about their risks and administering several shots at the same time can help,” she said.

“We have the opportunity as we never have before to prevent much more disease,” said an infectious disease specialist at Vanderbilt University School of Medicine.

Artificial intelligence is everywhere.

AI promises to create untold efficiencies and, in turn, solutions to so many thorny issues of workforce, care and operations. 

Still, caution with this emerging tool is advised, experts say.

“AI is not new,” says Majd Alwan, PhD, chief strategy and growth officer for ThriveWell Tech. “Alan Turing, a computer scientist who is considered the ‘godfather’ of AI, devised what is known as the Turing Test in 1950, which asks, ‘Can a computer convince a human they’re communicating with another human?’”

Recent examples of innovation at work:

• Certainty-based location visibility, which Deric Blattenberger, general manager of senior care for CenTrak, describes as “enterprise visibility with location certainty,” supported by real-time location systems through wearable pendants.

• CarePredict has developed a continuous activity and behavior observation platform that uses AI to learn correlations between particular changes in activity and behaviors and labeled health events, says Satish Movva, the company’s CEO and founder.

Alwan asserts that the “deep learning” promises of AI in senior living and other long-term care settings seem endless — everything from falls detection and medication management to early detection of pressure ulcers.

“AI can play a significant role in early identification of risk,” notes TK King, vice president of healthcare strategy for Accushield. “Its ability to scan data, search for keywords and evaluate trends means it can pinpoint staffing needs and resident risks.”

Still, healthcare experts agree, many issues surrounding risk need to be tested.

Movva urges early adopters to be mindful of privacy and security concerns. And Blattenberger warns of a risky upcoming phase that introduces virtual caregivers and “approximate” outcomes.

Alwan describes current efforts as a significantly acceleration and competitive “race” and warns adopters to protect data from corruption or premature release.

He’s also adamant about ensuring that humans remain in charge of testing and evaluation.

Researchers have demonstrated the ability to use artificial intelligence as a tool for detecting diabetes early in older adults.

The new artificial intelligence model finds that X-ray images collected during routine medical care can provide warning signs for diabetes, even in people who don’t meet the guidelines for elevated risk, as reported recently by Emory University.

In some cases, the chest X-ray warned of high diabetes risk as early as three years before the patient eventually received a diagnosis. The model’s output also provides a numerical risk score that potentially could help clinicians customize the treatment approach for patients.

The multi-institutional team reported that the model could help physicians detect the disease earlier and prevent complications. The findings were published in Nature Communications.

» Robots, virtual reality increasingly enhance senior living experiences

Robots are in force at many senior living communities across the country, providing everything from meals to locating help.

Some American Senior Communities properties in Indiana have added a robot named “Robbie” to help provide limited services.

Robbie delivers and serves food, allowing members of the dining staff to give more attention to residents. The robot features trays, safety sensors and music, and it has been assigned the task of transporting food between the kitchen and dining rooms alongside culinary staff members.

“Our goal in using robots is to allow our dining staff to spend more time in the dining room with residents, ensuring that their needs are met,” said Karen Powell, vice president of nutrition and culinary services at American Senior Communities.

At The Falls at Cordingly Dam, a Benchmark Senior Living assisterd living and memory care community in Newton, MA, it is virtual reality experiences from Rendever that are enhancing daily life. The platform includes videos and 360-degree images that let viewers explore places from their past or sites they have never seen. 

This embrace of some types of technology, however, comes with express hesitancy about other forms of technology, including the use of artificial intelligence in primary care and various types of therapy.

Real estate investment trusts with portfolios heavy in senior living and care assets are being called the “unsung heroes” among investors by the author of one online post.

As the baby boom generation continues to age, “the proportion of older adults in the US population is projected to increase, leading to a higher number of seniors in need of healthcare services, assisted living and retirement communities, and other age-related solutions,” wrote Kate Stalter, a Series 65-licensed asset manager, in a late September “MarketBeat” article. That, combined with their income potential, means such REITs could be lucrative investments for the long haul, she said.

The article described Irvine, CA-based Sabra Health Care REIT; Hunt Valley, MD-based Omega Healthcare Investors; and Westlake Village, CA-based LTC Properties as high-yield investments, with yields of 8.74%, 8.14% and 7.42%, respectively.

“REITs have built-in tax benefits, as they are required to distribute at least 90% of their taxable income to shareholders,” Stalter added. “That means REIT investors receive a consistent stream of dividends derived from rental income or property sales.”

» Aging boomers pressure key systems

The US population is rapidly aging, presenting profound implications for economic development, national security, Social Security, Medicare and Medicaid, a recent Census report found.

According to the US Census Bureau, the median age in the United States hit a record 38.9 in 2022. That number is going up rapidly. In 2000, the median age was 35; in 1980, it was 30.

» Think tank argues case for AI for seniors

In a new Brookings Institution study, researchers said that addressing the older adult population’s financial challenges requires exploring innovative strategies and tapping technology to fundamentally transform healthcare delivery. One crucial application of artificial intelligence, the study noted, is its ability help manage the overall well-being of older adults. For example, AI can assist with routine financial tasks such as automatic bill payments, expense management and personalized recommendations, which might greatly benefit older adults.