A: Baby boomers have become a highly studied demographic over the past few years, and it is clear that their preferences are different than those of previous generations.

Baby boomers — those born between 1946 and 1964 — are characterized as being focused on health and wellness, living an active lifestyle and maintaining social connections that will allow them to stay independent and to live with a sense of purpose. They are self-sufficient, living longer and choosing a higher quality of life. Many are still working and some are continuing to work into their retirement years.

Active adult housing, or age-restricted/targeted housing, is a product that has been developed and designed to appeal to this demographic group. So far, it appears that baby boomers are embracing this active adult lifestyle, and at a younger age than traditional independent living.

If they are to make the move to an age-restricted community, boomers have indicated that their living units should feel like home and have features similar to the home they have moved from, including open floor plans, full-function kitchens, washer/dryers, large closets/extra storage and a patio. They also want options and choices with respect to indoor and outdoor amenities that facilitate and encourage social interaction and shared activities. Security and maintenance-free living are important factors in this move decision, but they do not need or want services such as meals, laundry, transportation, assistance with activities of daily living, etc.

Of course, cost always is an issue, and boomers may be more discriminating about value and concerned about their ability to pay over the long term. To address different levels of affordability and value perceptions, many operators now are offering upper income/luxury, middle income and low income/affordable active adult product offerings and brands within their portfolios. Although it still is a work in progress, emerging active adult products are becoming more diverse, and designs and amenities are constantly evolving to address the preferences of this important target market. It is anticipated that segmentation will continue and that this product type will evolve as more experience is gained with this segment of the older adult population.

Lynne Moore is president of MDS Research Company Inc., a national senior living and healthcare consulting firm based in Fort Worth, TX, that has been serving clients for more than 50 years. MDS is a two-generation company — she is following in Jim Moore’s footsteps. Lynne Moore is responsible for all MDS market research-related projects involving all aspects of senior housing and healthcare. She can be reached at (817) 731-4266 or lynnemoore@m-d-s.com.

A version of this column appeared as “You’ve Got Questions, We’ve Got Answers” in the August 2023 print issue of McKnight’s Senior Living.

The opinions expressed in each McKnight’s Senior Living guest column are those of the author and are not necessarily those of McKnight’s Senior Living.

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A proposal that the Centers for Medicare & Medicaid Services says is meant to “support and stabilize the direct care workforce” in home- and community-based settings, if it becomes final, ultimately could lead to fewer jobs, stagnant pay for caregivers and a reduction in older adult access to home- and community-based services — the exact opposite of what the government intends, according to several senior living industry advocacy groups.

Also, quality measures that are part of the proposed rule have the potential to burden assisted living providers financially and administratively, some of the groups said in comments to the federal agency.

The American Seniors Housing Association, Argentum, LeadingAge and the National Center for Assisted Living were among the more than 2,000 groups and individuals submitting comments to CMS on a rule it had proposed in April titled “Medicaid Program; Ensuring Access to Medicaid Services.” July 3 was the deadline for comment submissions.

The proposed rule — with an overall goal of increasing access to HCBS — in part would require that providers spend at least 80% of Medicaid payments for personal care, homemaker and home health aide services on compensation for direct care workers as opposed to administrative overhead or profit.

United in disagreement

Although the advocacy groups said they generally support the intentions behind the proposed rule and its provisions, as well as a living wage for direct care workers, a common theme among their comments was disagreement with the spending-related requirement.

“The math does not work” without additional federal funding, LeadingAge Director of Medicaid Policy Georgia Goodman said in her July 3 submission.

“While we are supportive of the intent, this threshold is not tenable for LeadingAge members, and we fear unintended consequences including erosion of service quality, inadequate clinical support for direct care staff causing unnecessary stress on front line staff, and access issues — the antithesis of the goal of the Access Rule,” she said, saying that LeadingAge was “very concerned” about the provision.

Rather than increase pay to comply with the rule, Goodman said, providers most likely would “cut back on other administrative functions that support quality.”

“If this provision is enacted as proposed, we will see more people go without care and not see the growth in wages that CMS is seeking,” she added. “CMS needs to go back to the drawing board.”

NCAL, in comments dated June 28, said it was “highly concerned” that the spending-related provision, as written, only applies to payments made for personal care, homemaker and home health aide services.

“By not including all provider types, we are concerned that the workforce will resign from one provider type and move to another provider type because they are paid higher wages related to the 80% proposal,” wrote Pamela Truscott, director of quality improvement, and Jill Schewe, director of policy and regulatory affairs for the organization. “If this shift in workforce occurs, it would have devastating results on resident care and services provided,” they added.

Clarification sought

Argentum President and CEO James Balda said that the spending requirement “is not the right approach” to address workforce shortages or increase Medicaid beneficiary access to services. But clarification is needed for assisted living providers to be certain that the proposal would apply to them, he added.

Between 18% and 20% of all assisted living residents receive Medicaid services under state HCBS programs and waivers, Balda said, but “CMS’ proposal is ambiguous, making it unclear whether and to what extent this policy would apply to assisted living or similar residential facilities providing HCBS under state Medicaid programs.”

For instance, he said, CMS “states that it is proposing to require a minimum percentage requirement for homemaker, home health aide, and personal care services because these services ‘would most commonly be conducted in individuals’ homes and generally community settings’ but then separately states that it is soliciting comment on ‘facility-based residential services and other facility-based round-the-clock services….’ ”

CMS should provide clarification and define personal care, homemaker and home health aide services, Balda recommended, noting that state definitions can vary.

But even if the proposal applies to assisted living, he said, without increased reimbursement, if providers are able to use only 20% of payments “to address all other expenses” except caregiver pay, then they will “either reduce HCBS services they are currently providing or cease participation in the Medicaid program altogether, which ultimately would have a negative impact on direct care workforce participation and Medicaid beneficiary access to care.”

And with fewer options in assisted living, Balda said, older adults might be forced to live in skilled nursing facilities, which would be “substantially more” expensive for state and federal governments as well as more restrictive for residents.

Provision has unintended consequences

ASHA President and CEO David Schless pointed out in his letter that “[a]ssisted living is an important part of the HCBS settings continuum but often unrecognized as such.” Demand for the setting “is growing, the benefits are many, and the average national costs are among the lowest of Long-Term Care Services (LTSS) options and therefore beneficial to taxpayers,” he said, noting recreation and socialization opportunities for assisted living residents. 

The spending provision of the rule, however, may create “unintended consequences that may result in fewer providers able to participate in the program, especially in rural or tertiary markets,” Schless said.

Also, he said, “the timing of such a policy change presents even greater challenges” due to the fact that providers still are emerging from the effects of the pandemic. “Imposing policy changes now without an accompanying payment increase for providers may result in driving providers out of the program, leaving fewer affordable options for older adults in need of this care,” Schless said.

Overall, however, ASHA members “support taking steps to encourage more participation by assisted living providers” to increase overall access for Medicaid beneficiaries, he said. “The community living environment in assisted living combats prolonged social isolation, lack of engagement and loneliness that can contribute to functional and cognitive decline, as well as depression and anxiety in older adults. These benefits should factor heavily as efforts to improve access and choice are considered. This setting meets the intended purpose of HCBS by offering person centered care, a homelike environment, and quality care.”

More data needed

The associations said that more data are needed before the rule is implemented and called on CMS to withdraw the proposed rule and work with the industry to accomplish its goals.

“There is not sufficient data to tell us what this type of proposal could look like without substantially more data collection, particularly on rates, rate setting, and provider infrastructure,” LeadingAge’s Goodman said. “CMS presents no data to show why a threshold of 80% was chosen for this proposal.”

“We ask that CMS suspend consideration of this proposal, and instead work with stakeholders to identify other approaches to remedying this issue, particularly by addressing the inadequacy of state Medicaid reimbursement rates for assisted living and similar residential communities participating in HCBS programs,” Argentum’s Balda said.

“NCAL recommends a study to collect data to ensure that there are no unintended consequences from initiating an 80% proposed rule,” Truscott and Schewe said. “More specifically, NCAL recommends data collection and analyses across all provider types including the impact on the operations and resident access to services occur before determining the percentage of the rate that should be applied to support wage adequacy.”

Funding requested for quality measures

Argentum and NCAL made a case for additional funding to implement the quality measures that are part of the proposed rule while also lobbying to keep as much related oversight as possible at the state level.

“Argentum understands the need for a uniform quality measure set for HCBS services. However, we ask that CMS work with states to ensure that this new requirement does not excessively burden HCBS providers, who are already experiencing financial difficulties due to low reimbursement rates and workforce shortage issues,” Balda said. Additional reporting requirements, he added, “will only serve to exacerbate the issue.”

Additionally, “adequate funding is needed for these efforts,” NCAL’s Truscott and Schewe wrote in their comments.

CMS released its first-ever quality measure set for HCBS in July 2022, saying at the time that although the measures were voluntary, they were expected to become mandatory in the future. At the time, the agency “strongly” encouraged states to use the standards to assess and improve quality and outcomes in their HCBS programs.

The introduction of the voluntary measures, assisted living provider groups told McKnight’s Senior Living then, came amid “longstanding, chronic underfunding” of HCBS that led to provider workforce shortages. The financial issue needed to be addressed, the groups said, noting, however, that they supported the quality improvement effort in general.

Duplicative of state requirements?

Some of the quality measures would become mandatory under the rule proposed in April, and the rule contains several other changes related to HCBS as well. “It is critical to ensure that the proposals made are not duplicative of state requirements,” Truscott and Schewe said.

NCAL said that it supports part of the proposed rule that would require states to report every other year on the HCBS quality measure set for their HCBS programs. “Additionally, we support giving states flexibility in identifying measures that are most appropriate for their population given the variations within each state,” Truscott and Schewe said. CMS said that the measure set would be updated “at least every other year” in consultation with states and other interested parties.

As part of the reporting requirements announced in April, states would be required to establish performance targets for each of the mandatory measures. NCAL said it supports this requirement but that “[i]f established, national performance targets should consider applicability and feasibility across the country.”

Also, Truscott and Schewe told CMS, “It is important to consider that the more data that is asked of providers increases the burden on providers, necessitating the need for adequate funding to support increased data reporting.”

NCAL recommended that CMS not set national performance targets, however, “as this deters from allowing states the flexibility to make informed determinations about the targets.”

Phased-in approach supported

CMS is proposing that the requirements be effective three years after the effective date of the final rule, although reporting for certain mandatory measures and reporting for certain populations of beneficiaries could be phased in over time due to the complexity required for state reporting. “Further, the requirements for states to report stratified data would be phased in over a seven-year period after the effective date of the final rule,” the federal agency said.

Truscott and Schewe said that NCAL supports a phased-in approach to quality measure stratification since the voluntary use of the quality measure set released in July 2022 is relatively new.

“However, measures that require the submission of electronic health records or paper records to be faxed or mailed add either additional administrative burdens or additional cost for assisted living providers,” they said. “Not all assisted living providers use an electronic health record, and implementing one would be costly. NCAL asks CMS to consider funding to support implementation of this proposal.”

As for quality measure reviewing and updating, NCAL said that it supports such efforts “provided that there is an adequate public comment period that includes the opportunity for stakeholders, including stakeholders from the long-term care community, to provide comments. However, it is also important to note that a one-size-fits-all approach is not what is best for individual states.

“State agencies have the primary role of oversight of assisted living. State agencies are in the most appropriate position to determine state-specific quality metrics,” they continued.

The final rule publication date is not known yet.

Demand for clinical care efficiencies and effectiveness will propel significant product innovation over the next five to 10 years, driven largely by the unavoidable collision of staffing challenges and the tidal wave of aging baby boomers.

That’s according to long-term care tech experts including Daniel Zhu, vice president of product management of data, analytics and AI/ML at MatrixCare.

“This is going to push for the adoption and regulation of machine-assisted clinical decision-making, robotic surveillance and monitoring, as well as intelligence-informed optimization of processes,” he said. “Imagine a voice-activated assistant (such as Alexa and Siri) at the bedside of every patient, helping to automatically chart and record patient vitals, quickly and accurately answer questions regarding patient medications, clinical history, and more.”

Travis Palmquist, senior vice president and general manager of senior care at PointClickCare, envisions a more prominent role for technologists soon.

“When we look at the next generation of products and applications, there’s an opportunity for technologists to take a more active role in keeping people healthier, stronger and safer (for longer),” he said. “All of these tech trailblazers play an important role in providing preventative care and wellness solutions to an aging population.”

Palmquist calls attention to his company’s collaboration with DBSync, a leading SaaS integration platform that recently expanded its data integration suite into the healthcare market by launching Microsoft Dynamics 365 Cloud Workflow for Senior Living within the PointClickCare marketplace. Providers, he said, “now have a 360-degree perspective of their residents across their cloud and on-site applications, which simplifies the admission process and resident move-in.”

Of course, no gaze into the crystal ball is complete without artificial intelligence.

“From utilizing computer vision technology … to measure, monitor, and assess wounds using a simple mobile phone camera [and] to voice-to-text dictation functionalities to help with various charting needs, AI has already influenced the future and success of the market,” Zhu said.

Telehealth has been steadily gaining traction in the United States since the pandemic began, reports MarketWatch. 

A recent National Center for Health Statistics report found more than one in three adults in 2021 reported using telemedicine in 2020, and use was more prevalent among older adults, women and those in urban areas. Women were much more likely than men to use telemedicine, whereas 43% of adults aged 65 or more years leveraged telemedicine versus 29% of those aged 18 to 29. Older adults — namely, older women — might gain the most benefit from telehealth, although previous research has found that older adults often have the least access to technology due to poor engagement, age discrimination and noninclusion in product design. 

The use of telehealth by older women counters the ageist stereotype that older adults are not receptive to technology. Yet the pandemic-induced migration to telemedicine has led to an even more profound disparity in health outcomes for groups such as older adults, those with chronic conditions and members of ethnic minorities. 

PointClickCare holds top ranking as long-term care software provider

PointClickCare Technologies recently announced that it was recognized by KLAS Research as the Best in KLAS long-term care software segment winner for 2023 for the fourth consecutive year.

KLAS is a research and insights firm focused on improving healthcare by amplifying payer and provider voices.

The firm’s 2023 “Best in KLAS: Software & Services Report” recognizes software and services companies that excel in helping healthcare professionals improve care.

All rankings are a direct result of the feedback of thousands of providers over the past year and signify to the healthcare IT industry the commitment and partnership that the top vendors should provide.

“We are honored to be recognized as the leader in long-term care software and will continue to connect care across the continuum to enhance care collaboration, strengthen provider productivity, improve care outcomes and help to reduce costs,” PointClickCare Chief Strategy Officer Kari Hall said.

With all the pressing matters facing senior living and care providers, it’s unclear how high green energy initiatives are on their list of priorities with on-premise laundry operations. For the association representing commercial laundry suppliers and processors, however, it’s very significant.

Sustainability, carbon footprint reduction and environmentally friendly chemistry are prime for continued innovation, said Ken Koepper, director, member and industry relations for TRSA.

“Proper wash chemistry plays a critical role in ensuring linen services become more effective and meet hygiene standards,” Koepper said. “Chemical formulas … contribute mightily to reducing costs and improving productivity in ensuring cleanliness.”

Koepper stressed that water consumption per laundry pound has declined steadily, due in part to large tunnel washers that move multiple loads through a line of batches containing a combination of water and/or chemicals that can be used repeatedly.

“Every wash cycle for every type of linen or garment has a formula: a customized balance of chemistry, run time, water temperature and mechanical action,” Koepper said. “Formulas are optimized to balance productivity, chemical levels, water requirements and energy use with overall quality. 

Other environmental innovations in laundry chemistry include the use of fewer phosphates and near-elimination of nonylphenol ethoxylate surfactants. Finding ways to activate chemicals at lower temperatures also conserves energy, whereas oxygen bleaching is being used instead of chlorine.

Laundry equipment and chemistry makers also have been engineering better methods to mitigate the spread of multidrug-resistant pathogens. A former principal scientist and products researcher with Procter & Gamble Professional told McKnight’s that whatever chemicals are used, it’s critical to understand the distinction between disinfection and cleaning and the order in which the steps are performed.

“The future of commercial laundry looks promising, as continuous advancements promise further enhancements in cost reduction, productivity, sustainability and hygiene,” Koepper said.

Alliance Laundry Systems, a large commercial laundry equipment seller, recently acquired the distribution assets of California-based commercial laundry Taylor Houseman. 

“This acquisition further solidifies our capacity to provide exceptional services in the significant California market,” said Craig Dakauskas, senior vice president, Americas Commercial, Alliance Laundry Systems. 

Alliance reports that it also recently reorganized its North America sales team into three regions: Northeast, Central and West Coast, the latter of which will include Latin America.

JVK adds to LAVATEC lineup

Commercial laundry operator JVK has invested in additional LAVATEC equipment to expand capacity and speed up processing. The company, which serves five long-term care facilities in addition to other commercial clients, said it processed 36 million pounds of laundry last year and hopes to boost that by eight million more this year. 

“We have been servicing healthcare institutions almost since the first day,” said Vinny Samuel, president and co-owner. “Today it accounts for 50% of our business, and the other half is hospitality-driven.”

The company dates to 2004 and services customers in Connecticut, New Jersey, New York and Pennsylvania. Recent upgrades include six 330-pound capacity dryers that now are helping operations run more efficiently. 

TRSA launches new laundry website

TRSA, the association for linen, uniform and facility services providers, has launched LaundryServices.org to connect healthcare institutions and other consumer-oriented businesses with commercial laundry providers. The website educates users about the benefits of commercial laundries, including practices that support environmental and supply chain sustainability.

A directory enables businesses to locate nearby providers, whereas videos explain how commercial laundry works and highlights the requirements of Clean Green and Hygienically Clean certifications. The certification programs demonstrate commercial laundries’ commitment to environmental sustainability and hygiene.  

Companies dedicated to skin care have a long track record of innovating, but few things have ignited a greater sense of urgency than the staffing shortages plaguing so many long-term care providers.

A growing number of skin health and wound care firms are devoting considerable resources to provide short-staffed caregivers greater ease and confidence in addressing skin issues common in older adults.

“Our customers are really forced to do so much more with less. We know in the industry that preventative skin care has a major impact on skin care conditions,” said
Cristina Alvarez of Medline’s post-acute care skin health program. “However, in the past, there was never a specific standard as far as the right products to use, how often to use them, and how much product to use. As a result, many organizations today don’t have a comprehensive preventative skin care program.”

Training challenges are a major culprit.

“Research shows that many caregivers feel they don’t have the tools or training they need to provide proper skin and wound care,” Alvarez said, noting that customers are now open to tools that make it easier to assess, treat and monitor wounds.

Medline says that its new advanced wound assessment and classification technology, called “NE1,” can help care for pressure injuries by providing simple written descriptors that guide caregivers to properly stage a pressure injury. Alvarez noted Medline recently revamped its decades-old Remedy Skin Care line as part of the company’s commitment to making skin care more intuitive for clinicians.

Meanwhile, skin care in older adults continues attracting worldwide attention, according to Tony Forsberg, RN, BSBA, WCC, CSPHA, national clinical director for Essity HMS North America. The recently developed Skin Tear Risk Reduction Program Checklist covers actions to be taken for various categories of risk factors. A skin tear is a traumatic wound caused by mechanical forces, including removal of adhesives. 

“Medical adhesives are a frequent source of skin trauma,” Forsberg said. “Therefore, a recommendation to use silicone fixation or cohesive bandages is made.”

Wound-related costs and number of cell tissue product applications were significantly lower for cryopreserved human skin when compared with bilayered living cell construct and dermal skin substitutes, researchers concluded in a study published in the May issue of Advances in Skin & Wound Care.

The study authors analyzed commercial insurance claims data from 2010 to 2018. They concluded that a statistically significant reduction occurred in the cost of treating diabetic foot ulcers and venous leg ulcers with cryopreserved skin. 

Swift touts outcomes  

With Swift Medical’s artificial intelligence-powered wound care platform deployed across almost 4,000 healthcare facilities in North America, the technology has been shown to speed up wound healing by 37% and reduce wound prevalence by 35%, according to statistics published by the company in June.

The platform also was linked to a 62% reduction in hospital length of stay. Long-term care length of stay was not addressed.

“These outcomes demonstrate the impact of having the most powerful wound image dataset in the world and its ability to deliver high quality wound care with reduced costs,” CEO Brian Litten said.

The Swift Skin & Wound mobile application enables any mobile device to be equipped with AI-powered imaging capabilities to capture high-precision 3-D images, measurements and other clinical data. The imaging enables real-time patient monitoring and decision-making.

Medline optimizes Remedy Skin Care line

Medline recently announced a repackaging initiative for its Remedy Skin Care line as part of what the company says is its commitment to making skin care more intuitive for clinicians. The firm unveiled the changes for attendees at this year’s WOCNext conference in June.

In addition to a unique color coding system meant to enhance efficiency, other advances include packaging and labeling designed to be more useful, as well as education for nurses.

Enhanced color coding on both ends of the product packaging also aligns with the new Coalition for At-Risk Skin’s 21 consensus statements.