COVID-19 Vaccine Could Boost Seniors Housing Occupancy in 2021

This week we received preliminary very positive news that the Pfizer/BioNTech COVID-19 vaccine is 90% effective and that Pfizer could apply for emergency use approval by the end of the year.

On October 22, 2020, the Department of Health and Human Services (HHS) announced HHS’ partnership with CVS and Walgreens to provide the COVID-19 vaccine to residents in long-term care settings will include residents in independent living settings, including standalone independent living residences, IL/AL communities, and life plan or continuing care retirement communities (CCRCs).

Having a vaccine available in limited quantities that will be made available to seniors housing staff and residents on a priority basis could be a boon to seniors housing occupancy in 2021. Senior housing operators will be able to market that residing in senior housing residence will get you priority access to a vaccine, while staying in your might mean waiting 6 – 12 month or longer until a vaccine can be made available in large quantities.

We believe the impact of having access to a vaccine on a priority basis could most dramatic improve occupancy in IL and CCRC properties, where the move into a seniors housing community are most discretionary.

Seniors housing occupancy should also benefit from a track record demonstrating an ability to limiting the spread of COVID-19. For example, Ventas’ 3Q20 investor presentation indicates that its senior housing properties have not experienced a significant increase in new COVID-19 case since April 2020, while in the general community across American infections and death continue to increase.

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At the Life Care Centers skill nursing facility in Kirkland Washington two thirds of the residents and staff were infected with the Coronavirus and 37 people connected to the facility have died. In Brooklyn, the Cobble Hill skilled nursing facility had 55 Covid-19 deaths and was stacking up bodies in a makeshift morgue. In my own State of Maryland, just released statistics show nursing homes accounting for about half of all Covid-19 deaths statewide.

The drumbeat of news about widespread infection of patients and staff at senior housing and care facilities (mostly skilled nursing facilities) and large numbers of Covid-19 deaths is damaging the reputation of the entire seniors housing and care industry. While it seems clear that patients in skilled nursing facilities, who are self-selected to be frail, usually more than 80 years and who often have multiple pre-existing conditions have been hard hit by the Coronavirus and Covid-19, it is far from clear to me that the seniors housing and care industry as a whole has performed as badly as the news reports would indicate.

Most articles on Coronavirus and Covid-19 deaths in long term care lump all seniors housing and care facilities together including: skilled nursing facilities, assisted living facilities, independent living communities and continuing care retirement communities that combine two or more levels of care within a single community. Even though each of these facilities serves residents with overlapping but often very different, age, income and health profiles, press reports dramatize conditions at a relatively small number of skilled nursing facilities and generalize the skilled nursing to all types of seniors housing and care.

To do a fair comparison of how the seniors housing and care industry has performed during the Coronavirus pandemic, a number of variables need to be considered.

First, you need an accurate baseline of Coronavirus infections and deaths in the community. Because of insufficient testing it is likely impossible to get accurate Coronavirus infection rates for the community at large. It has also been widely reported that the number of community-wide Coronavirus deaths has been undercounted because the overall number of deaths in the community in 2020 has been much higher than the increased number of Coronavirus linked-deaths reported. Early deaths were not attributed to the pandemic, many early victims were misdiagnosed and were never tested for Coronavirus and little retesting of corpses has been done. Even today, many of those dying at home and even some of those dying in hospitals may not be tested and deaths may be attributed to other conditions complicated by the virus. However, Coronavirus may not account for the entire increase in death rates in 2020, as some physicians believe patients with other emergency conditions, such as heart attack and stroke, may be avoiding hospital care in an attempt to avoid the virus and, as a result, deaths from some other conditions may be up as well.

So the first step is to calculate the overall increase in deaths on a statewide or metropolitan in 2020 for the period from January 1 2020 through the most recent date for which deaths are available with the average number of deaths say over the last three years. Then to refine these numbers by looking at trends for major diseases, such as heart attacks and strokes and developing a reasonable community-wide estimate of Coronavirus/Covid-19 deaths. Ideally death statistics would be available by age and race since both are believed to increase the risk of dying from Covid-19.

The second step in a fair analysis of the performance of seniors housing and care facilities during the Coronavirus pandemic would be to control for the age, race and health status of those in facilities and in the community. Provisional death counts for the Coronavirus (Covid-19) and pneumonia and influenza reported by the CDC for the period from February 1, 2020 through April 25, 2020 show that 56% of all deaths were among those 75 years of age and above. Deaths of residents in seniors housing and care facilities contributed to these totals but were seniors in these facilities simply more at risk because of their age or did senior housing and care facilities have higher overall rates of infection and death than similarly aged seniors in the community? It has also been reported that people of color have died at higher rates from Covid-19 and whites. Ideally, we would also compare both the racial composition of seniors housing and care facility residents with those dying community-wide in order to understands if the racial composition of seniors housing and care facility resident can explain potentially higher death rates.

Finally, why did some seniors housing and care facilities perform better than others. Seasonal flu and other contagious conditions are a risk at all seniors housing and care facilities and typically result in higher death rates during the winter months when flu is most common. Senior housing and care facilities, particularly skill nursing facilities, have well-established protocols for infection control that often include segregating sick patients, shutting down new admissions, limiting visitors, use of protective equipment and enhanced cleaning regimens. Did some facilities implement infection control measures sooner than others and was implementation of infection control measures delayed because of asymptomatic staff, visitors and patients and the inability to get patients and staff tested? What role did government regulations such as mandatory social isolation play, if any, in infection and death levels in seniors housing and care facilities?

As part of this final stage of analysis, it is important for the industry to evaluate how seniors housing and care facilities of various types performed. Did skilled nursing facilities housing the oldest and most frail seniors have higher infection and death rates? Did access to testing and protective equipment make a difference? Did continuing care retirement communities, which typically have younger, more affluent, better educated senior population perform better than other types of communities and better than living in the community.

I believe it is important for the seniors housing and care industry to undertake the study outlined above in order to provide a more accurate assessment of how residents of seniors housing and care facilities faired from the Coronavirus pandemic. This should be done to provide seniors and their families with an objective basis upon which to select seniors housing and care choices. It can also provide operators, property owners and investors with useful information on how to limit future risks from a Corona virus return.

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I have written twice before on this blog about the opportunity to convert small college campuses in senior housing communities. The first time was February 2, 2019 in response to an opinion piece in the Wall Street Journal about the challenges facing small, private colleges and how many of these would need to close or radically change their operations to survive. I reissued my original post with some updated commentary in September 2019 after Welltower REIT announced it acquisition of a college campus in the Boston area for conversion to a seniors housing community.

Today’s Wall Street Journal has an article entitled “Coronavirus Pushes Colleges to the Breaking Point, Forcing ‘Hard Choices’ about Education. The Journal article leads with the announced closing of MacMurray College in central Illinois after 174 years. The article goes on to indicate 50% of college enrollment managers are very worried about meeting fall targets for enrollment and tuition.

Before the pandemic, Robert Zemsky, a professor at the University of Pennsylvania graduate school of education in his book The College Stress Test indicated that 100 of the nation’s 1,000 private, liberal arts colleges were likely to close over the next five years. He now says 200 of these colleges could close in the next year, according to the Journal. Potential cancellation of on-campus classes this fall, growing impediments to overseas students and the increased appeal of lower cost, closer to home college alternatives all contribute to the growing financial distress of American colleges.

While the seniors housing and care is facing some challenges of its own, including: lower occupancy, some overbuilding, restricted admissions to due Coronavirus self-isolation and high levels of infection and death at some skilled nursing facilities, the number of seniors 75+, when many begin considering seniors housing and care options, is expect to grow about 40% between 2020 and 2030.

Strong population growth in the 75+ senior population, together with the fact that many seniors are looking for more dynamic living environments that include life-long learning, make us optimistic about redeveloping exiting college campuses in whole or in part to seniors housing.

Earlier in my career, before I began to focus on seniors housing and care and health care real estate as a stock analyst and investment banker, I spent more than five years as a real estate market and feasibility consultant doing a lot of work for colleges and universities including: University of Maryland at its flagship College Park campus, its Baltimore professional schools and UMBC in Baltimore County, Johns Hopkins, and Penn State Hershey Medical Center.

Please contact me at jdoc@robustretirement.com if you wish to discuss specific college to senior housing projects.

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Adjusting To Retirement

I will turn 70 next month. I have been semi-retired for five years and fully retired from my last full-time employer for three years. I find a number of my close friends, who elected to keep working after age 65, are now shifting to full or partial retirement at age 70 and I thought I would share with readers of this blog some of the advice I have been informally providing to friends.

For high achieving Baby Boomers with well established careers, it is scary to think of giving up a career in which you are still investing more than 40 hours per week, which provides status and professional recognition, and which is the nexus for many of your social relationships. A number of my friends are very concerned about how they will fill their time post-retirement.

I was fortunate in being able to cut back with my full-time employer, from working 50+ hours per week as a stock analyst covering seniors housing and care stocks and healthcare REITs to working 20 hours per week in investment banking focusing on business development and providing input on industry trends and corporate strategy for M&A transactions and capital raises. This step-down in time, together with a shift in my responsibilities, kept me productively engaged while allowing me to ease into retirement. I believe employers today are more open to these types of arrangements but, based on feedback from friends, this seems to work less well for law firms and other employers that bill by the hour.

When I ceased working as an investment banker part-time for my long-time employer – Stifel Nicolaus, it was my choice to end the relationship. I was spurred to retire by my older brother’s death, which increased my desire to enjoy more of life while I was still healthy. However, I still wanted to remain professionally engaged post-retirement, so I set up Robust Retirement, LLC as a vehicle though which I could provide consulting services with a liability shield and set up this blog to allow me a platform from which to comment on industry issues. Setting up and maintaining an LLC and a web blog is not very difficult. In the years since I fully retired, I have done a number of consulting assignments through my LLC and served on the Board of Directors at the publicly traded healthcare REIT – Quality Care Properties.

My advice to pending retirees or those contemplating retirement.

  • Don’t do too much pre-planning of your time in retirement or make a lot of commitments.
  • Take some time to clear your head and reflect on what’s really important to you.
  • Observe and talk with friends and neighbors about how they transitioned to retirement and what they like and dislike.
  • Dabble – take some courses, try some organizations and see what you like before you commit.
  • Avoid getting over committed to too many volunteer organizations or projects. It’s okay to say no – my own rule is no more than one board or major volunteer assignment at a time.
  • Free, unstructured time is okay.
  • Commit to an exercise regime. Vigorous exercise is one of the few things that can extend your good health. My current program includes boxing/intensive cardio twice a week, yoga and tai chi each once a week, weight training once or twice a week and golf once or twice a week now that the weather is turning warm.
  • Consider a move to a condo before or shortly after you retire unless you really enjoy yard work. My wife and I moved to a high rise condo with a doorman and valet parking. One story living with someone to help with deliveries will allow us to stay in our current home for many more years and, if you are looking for more than two bedrooms in a well-located condo, these can be relatively hard to find.
  • Stay connected with professional colleagues – I belong to one professional association with a local chapter that keeps me connected and make a point of connecting to former colleagues for lunch or drinks from time to time.

Notice some things not included in the above list – buying a second home, relocating to a warming climate or lower tax state. These reflect my personal preferences. I don’t want the added work of maintaining two homes and prefer to remain in a location where we are closer to family and long-time friends.

We do travel a lot but that is not for everyone. This past winter, we traveled a week a month to someplace warm (Hilton Head, SC and the Caribbean) and over the last several years have traveled to Scandinavia, Israel, Northern Italy, Costa Rica, the Galapagos and more. A planned Spring trip to Japan was just cancelled by our tour operator but eventually the virus will pass and we will be on the road again.

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Scandinavia Trip Mixed Cities & Scenic Fjords

My wife and I traveled to Scandinavia in late August 2019. The trip combined visits to Copenhagen, Oslo, Bergen and Norwegian fjords. We flew direct from Washington, Dulles to Copenhagen, where we spend five days. We took an overnight ferry from Copenhagen to Oslo, where we spent four days. We used trains and ferries to visit Sognefjord and Naeroyfjord, spending one night in Flam and one night in Balestrand. We then took a ferry from Balestrand to Bergen, where we spent one day and two nights before connecting with a flight in Copenhagen back to DC.

We were very impressed with Scandinavia. Clean, well planned cities with less income stratification and homelessness than you find in the U.S. The fjords are very picturesque and easy to visit with the Norway in a Nutshell route. Temperatures ranged from the mid-50s to low 70s, with very little rain, less than typical for late summer. It was already past the solstice but it was still light until after 9 pm in late August.

Like a number of our recent trips, we had our travel agent work with a local tour company to plan a trip just for us, with tour guides and outings scheduled throughout the trip but also free time for us to do as we liked on our own schedule. We stayed at very good hotels and enjoyed some excellent meals.

Copenhagen

Copenhagen is a city of 600,000, where a third of the residents reportedly bike to work. Flat terrain, abundant dedicated bike lanes and bikes everywhere make that figure believable. The city is located on a body of water connecting the North and Baltic Seas, covers several islands and has a number of canals. It is connected to Sweden by a bridge/tunnel and, together with Malmo, Sweden across the bridge, is part of the largest metropolitan region in Scandinavia – the Oresund.

We arrived in Copenhagen on Monday morning, August 19, 2019 and had a boat tour of the city on our first day, which is an easy and pleasant way to get an overview of the City. A number of castles and important institutions, such as the opera house and national theatre, are located on the water.

Opera House from tourboat
Amalienborg Palace
Modern Apartment in Christianshavn

On our first full day in Copenhagen we took a guided walking tour that brought us to a number of historic sites. Our hotel, the Skt Petri (Saint Peter) was centrally located in the historic core of Copenhagen, convenient to pedestrian shopping streets, a transit hub and many historic sites.

Pedestrian Street
Rosenborg Castle and King’s Garden
Our Copenhagen Guide in front of National Museum

On our second full day in Denmark we met a guide/driver to take us to the Fredensborg Castle, the largest Renaissance residence in Scandinavia when it was built, and the Louisiana Art Museum, which are both located north of Copenhagen. Fredensborg is impressive, despite having been sacked on at least one occasion, and has very attractive grounds. The private Louisiana Museum has a great setting overlooking the straight to Sweden and a large permanent collection and interesting temporary exhibits of modern art.

Fredensborg Castle
Calder sculpture at Louisiana Museum with Sweden in backgound

For our remaining time in Copenhagen we were on our own, equipped by our tour company with the Copenhagen Card that provides free train and transit travel and free admission to most attractions. Over our remaining three days we visited the Great Synagogue, the Jewish Museum designed by Daniel Lebeskind, took a day trip to Roskilde to see the Viking Ship Museum and Roskilde Cathedral, and explored the city, its parks and museums.

Ark – Great Synagogue
Jewish Museum
Viking Ship Museum
Tivoli Garden Carousel

We enjoyed both the upscale and everyday food scene in Copenhagen with some of our favorites being Restaurant Barr by the famous Noma operators, Kodbyens Fiskebar in the now trendy meatpacking district and the modest Cafe Halvvejen located near our hotel.

Halibut from Kodbyens Fiskebar
Cafe Halvvejen

Oslo

We were unable to book one of the large staterooms on the overnight DFDS ferry from Copenhagen to Oslo but our cabin had two lower berths with a window and we managed to fit in us and our luggage. Our Oslo city tour guide met us at the pier, helped us get a cab to our hotel and waited while we checked in and freshened up before beginning our tour. Because we arrived in Oslo Sunday morning, the city was quiet and some attractions were closed. Rather than take us to some of the major museums and tourist sites, our guide showed us parts of the city we might not have seen on our own including the increasingly trendy Gruner Lokka neighborhood. She also showed us a nice sweater shop, one of the few stores open Sunday.

Aker Brygge waterfront with new modern art museum, apartments, offices and hotels

Our hotel in Oslo was the Continental, was very nice and in a great location near City Hall, the National Theatre, Royal Palace, a major transit up and Aker Brygge, a portion of the harbor with many restaurants and tour boat docks. The tour company provided us with an Oslo pass providing free transit access and admission to many museums and tourist sites. We also discovered that the Apple Maps App connects to the City’s transit system and provides information on which bus, tram and metro routes to take to reach specific locations including arrival times for metro trains and trams. This makes using the transit system in Oslo a breeze.

We planned our touring in Oslo around museum schedules, since some are closed on Monday. We visited the Holocaust Center and Norwegian Folk Museum, Munch Museum, Botanical Garden and City Hall, Vigeland Park and Museum and explored parts of downtown and the waterfront. Oslo is hillier than Copenhagen so using transit is easier than walking or biking.

The Scream – Munch Museum
Church – Norwegian Folk Museum
City Hall

Out tour guide directed us to some traditional Norwegian restaurants in Oslo. The Stortorvets Gjaestgiveri near the Catholic Cathedral had good food and is in an historic building with an interior courtyard.

Mussels at Trortorvets Gjaestgiveri

The Fjords

Norway in Nutshell is a group of rail and ferry connections that allow visits to Sognefjord and other fjords ranging from a day trip to multi-day stays out of Bergen or Oslo. We opted for a train from Oslo to Myrdal for a connection to the Flamsbana train that descends steeply into the Sognefjord at Flam, a private boat tour of Sognefjord and Naeroyfjord out of Flam, a ferry from Flam to Balestrand and a ferry from Balestrand to Bergen. We stayed one night in Flam at the Fretheim Hotel and one night in Balestrand at the Kviknes Hotel. This allowed us time for a more extensive exploration of the fjords via our boat tour and multiple ferry trips and a chance to explore both Flam and Balestrand to get a feel for village life on the fjords. The Fretheim and Kviknes are both interesting old hotels but truthfully there is little to see or do in Flam and Balestrand other than look at the fjord.

Kjosfossen Waterfall on Flambana train route
Sognefjord from Balestand
Sognefjord from Kviknes Hotel, Balestrand
Farm in Balestrand

Bergen

Bergen has less than half the population of Copenhagen and Oslo and is located on steep slopes on a North Sea fjord with water on three sides. It has been an important trading center since the 15th century when it was part of the Germanic Hanseatic League and has some remaining buildings dating from this period. Due to its location near the north sea and the surrounding mountains it gets the most rain of any city we visited on we experienced everything from heavy showers to bright sunshine during our one full day in the city.

In Bergen we stayed at the Opus XVI hotel, which is in an attractive former bank building close to the harbor. The hotel was redeveloped by the family of composer Edvard Greig.

Bergen From Top of Funicular
Hanseatic Warehouses Converted To Shops & Restaurants, Bergen
Bergen Residential Street
Traditional Norwegian Costumes
Skin Fried Mountain Trout at Bryggeloftet & Stuene
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Trip To Israel Was Great Family Experience

In June 2019 my wife, son, daughter-in-law and I vacationed for 10 days in Israel. My wife, son and I had last been to Israel 20 years ago and my daughter-in-law had never previously visited. We flew from Washington’s Dulles airport to Israel via Frankfurt and had a direct return flight from Israel to Washington.

As we have done with a number of our recent trips, we used an experienced U.S. based travel agent working with an in-country tour operator, in this case Mabat Platinum Touring Services, Ltd., to develop a customized tour for us. The tour company arranged for our own guide/driver and minivan, arranged hotels, admissions to most sites we visited, some guided tours, and some meals. They provided us with restaurant and touring suggestions for days and times when we were on out own. The tour company also arranged for two people to meet us at our gate on arrival to accompany us through immigration and customs and to get us through check-in to our gate on our departure. This significantly shortened the time and anxiety typically associated with arrivals and departments in foreign countries and is something I would recommend to anyone traveling to Israel.

Our itinerary started in Tel Aviv where we stayed three nights. We arrived in the early evening. We toured the beach near our hotel and had dinner before going to bed early. Our first full day in Israel was on our own, which allowed us to get over jet lag at our own pace. We visited the Nahalet Benjamin Art and Craft Fair and spent the afternoon at our hotel pool and on the beach. On our second full day we were met by our guide to tour Jaffe, the original Neve Zedak neighborhood of Tel Aviv, eat some falafel for lunch and visit the Tel Aviv Museum of Art, which has a very good modern art wing and interesting collection of Israeli art. That evening we dined at a very nice restaurant in the Old Port area of Tel Aviv called the Kitchen Market. Our hotel in Tel Aviv was the Carlton, which is right on the beach, offered large rooms with balconies and very good service. Our room included a large breakfast buffet served at the hotel’s beach club overlooking the water.

Beach in Tel Aviv Looking South Toward Jaffa

On day four we checked out of our hotel in Tel Aviv and went up the coast, visiting the Roman/King Herod era Caesarea, Haifa, Crusader developed Akko and Nazareth before arriving at our hotel in the Galilee, the Pastoral in Kfar Blum Kibbutz. Caesarea has a well-preserved Roman aqueduct, theatre, arena and temples along with the ruins of King Herod’s palace by the sea. It also contains a mosque and remains of later Crusader defensive walls and shops and restaurants serving the tourists.

Roman Aqueduct in Caesarea

In Haifa we stopped briefly to see the spectacular Bahai Shrine and Gardens and take in panoramic views of the city from Mt. Carmel.

Bahai Shrine and Garden

In Akko we visited the Crusader fortress and tour Arab markets in the city. The Fortress was used as a prison during the British Mandate and was the site of a dramatic jailbreak by the Irgun. Today it serves as a museum and event venue. We had an excellent seafood lunch at El Marsa in Akko, which the Wall Street Journal had recommended.

Barramundi at El Marsa

We combined touring both Jewish and Christian religious site on our trip, visiting the Basilica of the Annunciation in Nazareth. It is a church located over Mary’s home in Nazareth that has been built, destroyed and rebuilt many times. Today’s Basilica is a modern building featuring large murals and art contributed from Christian communities around the world. It has an opening in the where you can descend to see the remains of Mary’s house and pray in front of it. There is reportedly some actual archeological evidence that it is the house where Mary lived.

Basilica of the Annunciation

The Hotel Pastoral in Kfar Blum is a modest hotel with rooms in pods spread across a fairly large property with a central restaurant and reception area. The property is located in northern Israel, close to the Lebanese border and the Golan Heights. Meals served buffet style was plentiful and kosher but nothing to write home about.

Tel Dan Israel Gate

The next day we toured the Dan Nature Preserve, which includes the one of the headwaters of the Jordan River and Tel Dan, an extensive and important archeological site once settled by the Jewish tribe of Dan. Much of the Preserve is green and fed from active underground springs with the historical site located on higher, dryer ground with views into Syria. The most important find at the site is the only archeological reference to King David and the House of David. The site also has a temple built by the King of the Northern Kingdom that featured a golden calf and was intended as an alternative to the Temple in Jerusalem.

The following day we toured the Golan Heights, visiting a memorial to defenders who resisted the attacked of nearly 1,500 Syrian tanks long enough for reinforcements to arrive and Mt. Bental Volcano where you can see old fortifications and look into Syria. We also visited the Assaf Family Estate Winery and Kibbutz Ortal where we stopped for lunch. What turned out to be one of the highlights of our trip was dinner in the home of a Druze family in the Golan Heights village of Majdal Shamss. We had an excellent meat and learned about the Druze religion and culture, which is a offshoot of Islam.

Druze Dinner

On Tuesday, June, 11, 2019 we visit Tzfat or Safed, the center of Jewish mysticism and a community filled with synagogues and yeshivahs along with galleries and artist studios. In Tzfat, like in Jerusalem, you can feel the religious spirit of the place.

Lane in Tzfat

Continuing south from Tzfat with had lunch at a Arab schwarma restaurant on the shore of Lake Kinneret (the Sea of Galilee) and visited a historic synagogue in Beit Alfa with a 5th century mosaic floor. In the evening we entered Jerusalem where we stayed at the Mamilla Hotel, which adjoins a large shopping mall of the same name and is close to the Jaffa gate into the Old City. We had dinner at Eucalyptus, which was highly rated but where we found the food so so and the service dreadful.

On out first full day in Jerusalem, we received an overview of the Old City from an overlooked on the Mt. of Olives and toured on foot. It was a long, exhausting but rewarding day. We saw the reported site of the last supper, yeshivahs and synagogues, walked through the Jewish quarter where the old Roman road, the Cardo has been excavated, visit the Western Wall and Western Wall tunnels and walked the Via Dolorosa and toured the Church of the Holy Sepulchre. In the evening we dined a Satya, an excellent restaurant.

Praying at the Western Wall
Church of the Holy Sepulchre

The next day we toured new Jerusalem with a docent led tour of the Yad Vashem museum, a visit to the Mehane Yehuda market and the Kennesset. We were impressed by the Moshe Safdie designed museum at Yad Vashem. That evening and a light supper in the Mall, we saw a light and sound show in the King David town in the old city, which was technically impressive but which lacked much of a storyline.

On Friday June 14th we visited Masada and the Dead Sea. Masada, the castle and fortress complex built by King Herod on top of a stone monolith is where 960 Jewish zealots who revolted against the Romans chose to commit suicide rather than be captured after a long siege. The remains of Masada and of the fortifications and siege lines built by the Romans are still visible today.

Masada from cable car station

The Dead Sea, where we covered ourselves with mud the cleanse our skin and floated in the salt-thickened waters on a private beach was fund for all.

Floating on the Dead Sea

On Friday evening we returned to our hotel and said goodbye to our guide, Avi Cohen, who did a great job explaining what we saw and putting it in a historical and geographic context. We dined at Chakra, another excellent restaurant.

We were on our own in our final day in Jerusalem and spent much of it at the Jewish Museum, where we toured the archeological and Jewish collections, had lunch, saw the Dead Sea scrolls and a large model of Jerusalem. We had a light supper at the rooftop lounge in out hotel watching the sun set over the Old City of Jerusalem before heading to the airport for our 12:20 am flight.

Old City from Mamilla Hotel

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On September 18, 2019, news sources reported the sale of the Newbury College Campus in Brookline, Massachusetts to the health care REIT Welltower for redevelopment into a senior housing community. Welltower reportedly acquired the nearly eight acre site containing 8 buildings with approximately 142,000 sq. ft. for $34 million. Welltower’s purchase confirm my view, expressed in a February post, that small college campus have the potential to be successfully converted to seniors housing (see below).

There was an opinion piece in The Wall Street Journal on Friday, February 22 entitled “America’s Disappearing Private Colleges”, written by Allen C. Guelzo, a professor of history at Gettysburg College. The piece documents the closing of Concordia College, a small historically black school in Selma, Alabama. It goes on to assert “The post-Great Recession baby bust will soon mean not enough students to keep small schools alive.”

In the early 1990s I spent more than five years advising colleges and universities on real estate issues. My clients included the University of Maryland, Johns Hopkins and the Hershey Medical Center of Penn State. Even then, future weakness was evident in demand for higher education once the Echo Boomers (children of the baby boomers) passed through their college years. As Mr. Guelzo documents, the decline in the number of future potential college students has worsened since that time because of the Great Recession.

“Birthrates plunged by almost 13% from 2007 to 2012 and the CDC believes fertility could fall further”. The birth dearth means 450,000 fewer college applicants in the 2020s according to economist Nathan Grawe in Demographics and the Demand for Higher Education.  Hardest hit will be New York, Pennsylvania, New England and around the Great Lakes, areas most populated by private colleges.

Harvard and other well regarded and well-endowed universities will continue to see high demand and have the resources to make their institutions more affordable and more attractive to U.S and international student. Rice University, my son’s alma mater, for example just announced a 30% increase in applications after the University put in place a more generous and more predictable aid formula and my alma mater, Johns Hopkins University, recently announced a major gift from alum Michael Bloomberg to provide more generous aid for undergraduates.

While the best regarded and best-endowed colleges and universities will continue to do well, Mr. Guelzo documents a number of small colleges closing, “17 in Massachusetts alone in the past six years”, and cites estimates that up to half of all U.S. colleges will close or go bankrupt within the next decade. Moody’s estimates that 15 private colleges will close per year. My experience as a real estate advisor to colleges and universities, and as a student of demographics, lead me to believe these dire predictions.

At the end of his opinion piece, Mr Guelzo identifies four options for leadership of small private colleges (1. Get serious about mergers, 2. Focus recruitment strategies westward where the decline in birthrates was lower, 3. Craft a niche for a particular student, and 4. Establish partnerships with local two-year colleges. ) I doubt any of these options alone will be very effective in combatting the “birth dearth” but see another option that small colleges should definitely consider – converting in whole or in part to seniors housing communities.

I make the connections between private colleges and seniors housing because, after working as a real estate advisor to colleges and universities, I spent 15 as a stock analyst covering senior’s housing and care companies and REITs owning seniors housing and heath care real estate. While the demographics driving potential demand for colleges and universities are dreadful in the 2020s, the demographics driving demand for seniors housing and care are very strong. The first Baby Boomers turn 75 in 2021 and turn 80 in 2026.

Senior housing operators and REITs owning senior housing real estate are currently struggling with some overcapacity pressuring rents and occupancy and higher labor cost pressuring margins. I believe the seniors housing industry was too optimistic about the age at which seniors would move to seniors housing, found capital too easy to get, which prompted some overbuilding, and has been less than fully successful in providing living environments to which seniors want to move. Lower levels of seniors housing construction and the continued aging of the population should gradual and significantly improve demand prospects for seniors housing in the 2020s. I believe converting small colleges in whole or in part to seniors housing has the potential to allow small colleges to survive or provide a softer landing for faculty and staff at colleges that need to close; and can also provide a more desirable housing option for seniors and potentially help with labor costs.

Some of the most successful and most attractive senior housing communities i have observed offer campus-like settings with a wide range of social, cultural, educational and recreational amenities. Erickson Living and Senior Living Communities and a number of large not-for-profit continuing care communities (CCRCs) provide attractive campuses with a high level or amenities. (See links below to ericksonliving.com and senior-living-communities.com). Erickson’s first senior housing community was developed on the site of a former convent with some of the same qualities as a small college campus.

https://www.ericksonliving.com

https://senior-living-communities.com/

The challenge of developing large CCRCs is that they require very large upfront investments of money and time to be created on a greenfield basis. Small colleges, which have campuses, dormitories, cultural, educational and recreational amenities in place, could potentially be converted to seniors housing campuses at a lower cost than greenfield development while offering name recognition and character from the outset. One other feature seldom seen in senior housing communities, but which appears to significantly increase a community’s appeal to seniors, is a mixed age environment rather than a senior citizen ghetto. My favorite example remains Merrill Gardens at the University (see link below).

https://www.merrillgardens.com/senior-living/wa/

Merrill Garden at the University is a community near the University of Washington in Seattle that combines a senior housing community, non-age-restricted apartments and retail on a single site with the apartment building and senior housing community sharing an interior courtyard and the senior housing community’s bars and restaurant open to the public allowing apartment and senior housing residents to mix. Senior housing communities developed on or near other university campuses also have been attractive to seniors and appeal to alumni but I believe there is an opportunity to more fully integrate seniors housing into a college or university campus and create more interaction between seniors, traditional college-age students, faculty and staff than has been done to date. It is this type of integrated seniors housing / college setting development that I see as an attractive 5th option to those Mr. Guezlo identifies to save some of America’s small colleges.

Integrating senior housing into an existing college campus or fully converting a small college campus to seniors housing may also offer labor force benefits because students, existing college staff and potentially even faculty could be employed to providing programming, patient care and building maintenance for seniors housing as well as university buildings and might form a base labor force from which senior housing could draw even if the college is closing. Seniors may also be able to help fill college classes, particularly in the humanities or even serve as adjunct faculty.

The most feasible strategy for a college to evaluate and execute a partial or full conversion to seniors housing is to engaged qualified real estate and financial advisors to evaluate the option and help run a process to select a for-profit or not-for-profit senior housing partner. For some religious-affiliated colleges, the same denomination may also develop and operate seniors housing, which might ease some of the anxiety of teaming with a senior housing partner.

I welcome inquiries from colleges and universities wishing to consider a college to senior housing conversion and may be able to help evaluate such options at a strategic level and assemble a team to help a college or university execute such a conversion. For some insights into the process see the link to an article I co-authored in 1996 entitled “Privatizing University Properties” in the Journal Planning for Higher Education.

https://www.scup.org/page/phe/read/article?data_id=31113&view=article

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Customized Tour of Northern Italy Was Great Experience

My wife and I spent nearly three weeks touring northern Italy in September and early October 2018.   As was the case with several of our recent vacations, we used a travel agent working with a in-country tour operator to design a customized tour for the two of us rather than joining a group.  The Italian tour operator we worked with was Olive Tree Escapes, which has an office in Chicago.

This was our third trip to Italy and was designed to allow us to see parts of the county we had not visited before, see great art and have some time to relax and immerse ourselves in Italian culture.   We visited Venice, Bologna which we used as a base for a number of day trips, Lake Como and Milan.  Our day trips from Bologna included Ravenna, Florence, Ferrara and the Emilia Romagna countryside.

Logistics

We flew direct from Philadelphia to Venice on American Airlines and returned from Venice to Philadelphia on another direct flight.   If we had returned from Milan, we would have had to take a connecting flight to reach Philadelphia.   For travel between major cities in Italy we used the excellent high speed rail service, the Frecciarossa, that travels up to 185 miles per hour with a much smoother ride than Acela service in the U.S.    For shorter day-trips out of Bologna we used slower but still comfortable and efficient regional train service.   It is possible to reserve trains and get tickets from the U.S. over the Internet.  We used the national rail service, Trenitalia.  A private rail company, .Italio, now offers competitive and sometimes lower priced service on some routes and it may be worth checking on this option.    Our tour company arranged for transfers to and from the airport and the major inter-city train stations in cities we visited.

Venice

There are no cars, buses or taxis in the central parts of Venice. Getting from Venice’s Marco Polo airport to the old city included a car service from the airport terminal to a water taxi and porter, a water taxi ride up the Grand Canal to a dock near our hotel and a walk from the dock to our hotel with our porter.  We stayed at the Londra Palace located on the waterfront promenade facing the Canale di San Marco, a few blocks from Piazza San Marco, the center of Venice.  This is an ideal location, close to the main tourist sites with canal views and vaparetto (Venice’s water bus) docks located just across from the front of the hotel.   Even though we booked well in advance we were unable to get a deluxe room with a canal view but our room was comfortable, big enough for two and well appointed.   Our room came with complementary breakfast served on the first floor with the option of eating outside facing the canal. Service at the Londra Palace was excellent and we would definitely recommend the hotel.

Grand Canal

On the day we arrived in Venice we walked through Piazza San Marco and explored parts of central Venice on foot, visiting Santa Maria Gloriosa dei Frari Church, which feature altarpieces and artwork by Titian, Bellini and Tiziano.   Our first full day in the city we toured the Basilica San Marco and the Doge’s Palace, for which a guide that can help you avoid the long lines is a worthwhile investment.  Other highlights of our visit to Venice included a guided tour of the Peggy Guggenheim Collection of modern art, touring the Academia museum, a visit to the Jewish ghetto where we toured several synagogues and visiting a European Crafts Fair at San Giorgio Maggiore.  Our tour company arranged a gondola ride for us one evening in Venice, which was very short and a bit of a disappointment.  If I was doing it again, I would find and negotiate my own gondola ride.  We ate well in Venice but favored small, local restaurants recommended by our guides or hotel.  We did splurge on aperitifs at the Caffe Florian on Piazza San Marco.

Gondoliers
St. Mark’s Square

Bologna

We picked Bologna, which is much less of a tourist destination than Venice, Florence or Milan more for its location as a base from which to explore Ravenna and Florence than for any other reason. But we found Bologna to be a delightful city featuring great food, the oldest university in Europe, attractive streets with covered arcades and good shopping options.   We stayed for a week in an apartment in Bologna located mid-way between the train station and the main square just off Via dell’ Indipendenza.    We took a walking food tour in Bologna with stops at a chocolate shop, charcuterie, pasta restaurant, bakery and gelateria, which were all great.    We also did a food tour of the Emiglia Romagna countryside to see Parmigiano Reggiano, Balsamic Vinegar and Parma Ham being made, with a stop for lunch at a vineyard restaurant.  When planning the trip we thought two food tours were excessive but we very much enjoyed them both.  We also explored the center of Bologna including historic buildings of the University of Bologna, founded in 1088.

Deli Shop Window
Making Parmigiano Reggiano
Library University of Bologna

 One of the nice things about staying in an apartment versus a hotel, in addition to having a washer and dryer, is the ability to have meals on your own.   The owner of the apartment we rented directed us to groceries and salumerias.  We ate simple breakfasts of yogurt and coffee and had two dinners in, one of fresh pasta with pesto and salad and one of cheese, charcuterie and bread with olive oil and balsamic vinegar.

Restaurant near our apartment in Bologna

Florence

We took a day trip from Bologna to Florence, only 35 minutes by train, to visit the Uffizi Gallery, the Bargello and Pitti Palace. We had spent time in Florence on a previous trip to Italy, so it was an easy choice for us to focus on the art rather than exploring the City. It is essential to make reservations in advance to tour the Uffizi and the Pitti Palace and at the Uffizi you will still wait in a long line to enter near when your timed-ticket indicates. The Uffizi is one of the world’s great museums and it is well worth putting up with the large crowds to see its collection. In Florence, we had cappuccino and breakfast at an outdoor cafe, a nice lunch in wine bar overlooking the Arno River but ended up having dinner in the train station because our train back to Bologna was 90 minutes late. Due to a problem with the tracks north of Rome, all of the trains running south to north were delayed.

Ponte Vecchio from Uffizi window

Ravenna

Ravenna dates to the 2nd century BC, when the Romans colonized the Po River Valley. It served as a major port and naval station for Caesar Augustus, was the capital of the western Roman empire and the capital for barbarian kings Odoacer and Theodoric. The magnificent mosaics found in Ravenna today combine Byzantine, Arian and Roman Christian influences.

Ravenna is a flat, compact and very walkable city and we toured the city and a number of its churches with a private guide. It was a highlight of our trip and a place you could spend more than a day. Ravenna was a high priority for my wife, who is an art museum docent, but both of us really enjoyed the mosaics and the city.

Mosaics in Basilica di San Vitale

Ferrara

Ferrara is only 20 – 30 minutes from Bologna by trains and was recommended to us as a pleasant city with a strong Jewish heritage. The city seemed pleasant enough and has a very interesting castle but all of the Jewish sites were closed for renovation when we visited and we we were a bit disappointed. We did not have a guide in Ferrara, which may have also caused us to miss some things.

Lake Como

Lake Como is simply gorgeous. We stayed in Varenna on the eastern shore of the lake, which is only a little more than an hour’s very scenic drive from Milan’s central station. We chose Varenna because Rick Steves recommends it as a base and were very pleased with our choice. We stayed at the delightful Villa Cipressi hotel, which is right on the lake, features it own botanical gardens and is only a short walk to the main square.

While on Lake Como, we took our own private boat tour of the Lake that included stops at Bellagio and Villa del Balbianello and cruising past a number of towns and villa’s including George Clooney’s. We also spent a day exploring Varenna and one day lounging on the grounds of our hotel and the Villa Monastero, which is right next door. We had meals at restaurants overlook the main square with its historic churches or overlooking the lake.

Our hotel Villa Cipressi
Sunset over Lake Como from our hotel window

Milan

We really had only one reason to visit Milan – to see Leonardo da Vinci’s Last Supper. This requires advance booking and usually booking with a guided group. Seeing the Last Supper was a great experience but it is a highly regimented and short visit. At your appointed time, your guide gives you background while you wait on the plaza outside the refectory of the Santa Maria della Grazie Church, where the painting is located. You then enter an anteroom where the humidity is adjusted before you enter the room housing the painting. Each group only gets 15 minutes to view the painting and for this year preparatory sketches for the Last Supper from the collection of the British Royal Family. While the Last Supper began deteriorating from almost the moment it was completed because of the technique da Vinci chose to use, has suffered through bad and good restoration and has very muted colors today, it is still a painting of immense power and a masterful work of art.

While our focus in Milan was the Last Supper, we spent a day and a half and two nights in the City. Our hotel, the Sina Hotel de la Ville, was nondescript but pleasant and well-located. While in Milan we visited the La Scala opera house and museum on our own and did some shopping in and around the Galleria Vittorio Emanuele II shopping arcade, a 19th century high-end mall that remind us of GUM in Moscow. We also took a guided tour of Milan’s Duomo, which is a grand while lace-like Italian Gothic Cathedral.

Milan Duomo
Duomo Dome
Galleria Vittorio Emanuele II

We also ate two very good meals in Milan, one in the restaurant hotel and one in a restaurant called Restaurante Da Bruno, which is located in a brutalist Fascist-era building a couple of blocks off the main Piazza del Duomo. The waiter did not speak English so he brought out a large basket of freshly harvested porcini mushrooms to convey his recommendation and the pasta with mushrooms were great.

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Background

Like most issues about which I post, the topic of “Finding A Good Death” arose from a personal connection. In this case when a neighbor consulted me about his sister who was being referred to hospice care after battling cancer.  While not an expert in hospice care, I have long studied seniors housing and care and, for a time, I followed the publicly traded hospice companies as a stock analyst.  I also have some personal experience with hospice care.  My older brother (only four years my senior) utilized hospice care before his death in late 2014 from a degenerative neurological condition. To supplement my own knowledge for this blog post, I interviewed a friend and neighbor who is a long-time bereavement counselor volunteer at a large not-for-profit hospice in Baltimore and researched the topic on line.

John McCain’s death, which appeared to come quickly surrounded by friends and family after the Senator elected hospice care, also makes the subject of Finding A Good Death very relevant.

Even though we all die eventually, talking about death and planning for death, beyond making funeral arrangements, are taboo subjects for most Americans. We are culturally geared to want to live as long as possible and most physicians and patients have a strong bias toward utilizing the most expensive, invasive and technologically advanced medical procedures to prolong life, viewing death as failure rather than an inevitable part of the life cycle.

According to data from the Social Security Administration:

  • A man age 65 today can expect to live, on average, until age 84.3.
  • A woman age 65 today can expect to live, on average, until age 86.7.

About one out of every four 65-year-olds today will live past age 90, one out of 10 will live past age 95; and longevity estimates for 65 year olds continue to rise.   Also, these statistics are averages for the entire population, so healthy non-smokers and those with better health plans and medical care should expect to live longer. Once you reach 65, I would argue you already have a very good chance of living a long life and you and your family should be more concerned with the quality rather than quantity of the remaining life you lead, and with the quality of your death, the focus of this post.

A good death is generally understood to be one that comes quickly and peacefully and with minimal pain and suffering, ideally at home and with an opportunity for loved ones to say their goodbyes.

Understanding Hospice

English physician Dame Cicely Saunders first applied the term “hospice” to specialized care for dying patients in the UK in 1948. Hospice care was introduced to the U.S, in the mid-60s and did not become a Medicare eligible benefit until 1982. History of hospice care

As defined by Medicare, hospice is a program of care and support for people who are terminally ill (with a life expectancy of 6 months or less if the illness runs its normal course) and their families. Hospice helps people who are terminally ill live comfortably.

  • The focus is on comfort (palliative care), not on curing an illness.
  • A specially trained team of professionals and caregivers provide care for the “whole person,” including physical, emotional, social, and spiritual needs.
  • Services typically include physical care, counseling, medications for relief of pain and suffering, medical equipment, and supplies for the terminal illness and related conditions. Things like diapers are not covered by Medicare although catheters are.  Patients and their families should not expect 24/7 physical care from hospice unless the patient is receiving inpatient care.  Home health aides can be provided for bathing, etc. but cannot provide total care.
  • Care is generally given in the home.
  • Family caregivers can get support.

In order to qualify for Medicare’s hospice benefit, you must participate in Medicare Part A and

  • Your hospice doctor and your regular doctor (if you have one) certify that you’re terminally ill (you’re expected to live 6 months or less).
  • You accept palliative care (for comfort) instead of care to cure your illness.
  • You sign a statement choosing hospice care instead of other Medicare-covered treatments for your terminal illness and related conditions.

Medicare will cover the cost of a one-time hospice consultation even if you decide not to elect hospice care.   Once you elect hospice care, the first step in the process is development of an individualized care plan. Original Medicare will cover everything you need related to your terminal illness, but the care you get must be from a Medicare-approved hospice provider.

Hospice care is usually given in your home, but it also may be covered in a senior housing community, a nursing home or a specialized hospice inpatient facility. Depending on your terminal illness and related conditions, the plan of care your hospice team creates can include any or all of these services:

  • Doctor services
  • Nursing care
  • Medical equipment (like wheelchairs or walkers)
  • Medical supplies (like bandages and catheters)
  • Prescription drugs
  • Hospice aide and limited homemaker services. At Gilchrist, a large not-for-profit Baltimore area hospice, a volunteer may do light housekeeping but that is all
  • Physical and occupational therapy
  • Speech-language pathology services
  • Social worker services
  • Dietary counseling
  • Grief and loss counseling for you and your family
  • Short-term inpatient care (for pain and symptom management)
  • Short-term respite care
  • Any other Medicare-covered services needed to manage your terminal illness and related conditions, as recommended by your hospice team.

Note that the above list does not include the cost of room and board in a seniors housing or skilled nursing facility, so the patient or their family may have to cover this cost if routine hospice care cannot be provided at home.

If your usual caregiver (a family member or other caregiver) needs rest, a hospice patient can get inpatient respite care in a Medicare-approved facility (such as a hospice inpatient facility, hospital, or nursing home). Your hospice provider will arrange this for you. You can stay up to 5 days each time you get respite care. You can get respite care more than once, but only on an occasional basis.

Medicare pays the hospice provider for your hospice care.  There’s no deductible. You’ll pay:

  • Your monthly Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance) premiums.
  • A copayment of up to $5 per prescription for outpatient prescription drugs for pain and symptom management.
  • 5% of the Medicare-approved amount for inpatient respite care if used.

Medicare won’t cover any of these once your hospice benefit starts:

  • Treatment intended to cure your terminal illness and/or related conditions. Talk with your doctor if you’re thinking about getting treatment to cure your illness. You always have the right to stop hospice care at any time.
  • Prescription drugs (except for symptom control or pain relief).
  • Care from any provider that wasn’t set up by the hospice medical team. You must get hospice care from the hospice provider you chose. All care that you get for your terminal illness and related conditions must be given by or arranged by the hospice team. You can’t get the same type of hospice care from a different hospice, unless you change your hospice provider. However, you can still see your regular doctor or nurse practitioner if you’ve chosen him or her to be the attending medical professional who helps supervise your hospice care.
  • Room and board. Medicare doesn’t cover room and board. However, if the hospice team determines that you need short-term inpatient or respite care services that they arrange, Medicare will cover your stay in the facility. You may have to pay a small copayment for the respite stay.
  • Care you get as a hospital outpatient (such as in an emergency room), care you get as a hospital inpatient, or ambulance transportation, unless it’s either arranged by your hospice team or is unrelated to your terminal illness and related condition.

The Medicare hospice benefit is paid by original fee-for-service Medicare.   To understand how the hospice benefit relates to Medicare Advantage plan, Part B or D coverage speak with Medicare or your hospice provider and you might consult the publication Medicare Hospice Benefits – Medicare Hospice Benefits

A Popular Benefit

Hospice care enjoys wide support from patients and patient advocates who are supportive of patients dying with dignity and having control over the final chapter of their lives.  It is supported by policy makers who believe hospice can save Medicare funds by having terminally ill patients avoid expensive procedures at the end of life that often provide little lasting benefit.  Mean medical spending during the last 12 months of life is reaching $80,000 in the U.S., with 44.2% spending for hospital care (57.6% is hospital spending during the final three months of life).   To the extent hospice care can reduce expensive end of life hospital care it has the potential to reduce growth in Medicare spending. Hospice Impact On Medical Spending

Hospice care is also viewed favorably by investors and for-profit healthcare companies who see it offering stable reimbursement, attractive margins and very attractive growth prospects as Baby Boomers age.   Because hospice reimbursement is designed to adequately fund small not-for-profit hospice providers, not-for-profit and for-profit operators with scale can generate an excess revenue/profits from spreading their overhead costs over a large number of patients, thereby generating reasonable margins from hospice reimbursement.

Electing Hospice Care

The key issue for patients and their families in electing hospice care is that doing so requires you to forgo additional curative treatment for the condition that is expected to lead to your death in order to receive funding for palliative care designed to give you a dignified death with minimal pain and suffering. As noted above, In order to qualify for hospice care a physician, typically your primary care doctor or a hospice doctor, certifies that you are expected to live no more than six months if your disease follows its typical progression.  With this physician’s certification and your election to shift from curative to hospice/palliative care you will qualify for Medicare hospice benefits or hospice benefits from a private insurer.  If you live more than six months in hospice care, the hospice benefit can be extended but Medicare manages this by penalizing operators that have average length of stays in hospice care.

Selecting A Hospice Provider

According to the National Hospice and Palliative Care Organization (NHPCO) Medicare paid about 4,200 different hospice providers for services in 2015. About 60% of these hospice providers were profit-making companies and 40% are not-for-profit (Long-Term Care Providers and Services Users in the United States: Data From the National Study of Long-Term Care Providers, 2013–2014 Department of Health and Human Services, Centers for Disease Control, Center for Health Statistics, February 2016 – CDC Report On Hospice Services

Hospice providers served approximately 1.3 million patients in 2013 with an average length of stay of 23 days – indicating an average daily census of about 14 patients per hospice.

The statistics above suggest two criteria for selecting a hospice provider 1) for-profit vs. not-for-profit and size.  Many hospice providers are small not- for-profit operations.   For-profit companies tend to be larger in size, as are some well established not-for-profit organizations, such as Gilchrist Hospice in Baltimore.    Smaller operations may offer more personalized care options but larger operations may have their own specially designed dedicated inpatient hospice units and greater resources to Invest in family grief counseling, for example.

Your physician or a social worker/discharge planner at a hospital should be able to recommend or refer you to one or more hospice providers.  A simple online search on “finding a hospice provider” results in links to larger for-profit and not-for-profit providers in your area (Heartland, Amedysis and Gilchrist in Baltimore) and links to referral services, such as A Place for Mom, an Internet focused senior housing and care referral company, and the National Hospice and Palliative Care Organization (NHPCO). Keep in mind that referral services will only refer you to organizations that are members of that organization or agree to pay a referral fee.

The Medicare.gov/hospice compare website provides ratings for hospice providers with percentage scores for a number of objective and subjective measures including results from user surveys.  The site allows you to search for specific providers and provides near particular zip codes. See Medicare Hospice Compare.   Some of this data is likely self-reported but still appears useful for comparing providers.

Before committing to a particular hospice provider a prospective patient and their family should ideally meet with the provider to assess the staff who will oversee and deliver care to your loved one, share information about your family’s situation and discuss options for delivering hospice care in a way that best meets your families needs.   Care will most likely be delivered at home with family members engaged in the hospice care delivery process.  It can also be provided in a seniors housing or skilled nursing facility but this may require the family to pay for the coast of board. If required, typically right at the end of life when 24/7 oversight is needed, the location of care may be shifted to an inpatient hospice care facility and you should understand when and how such a facility might be used.   You may wish to check on the location and quality of the inpatient option.

I welcome comments and questions on this blog and hope it aids you finding a good death for you and your loved ones.

 

 

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Reusing Suburban Corporate Headquarters As CCRCs

I had lunch yesterday with Robert Kramer, Founder and Strategic Advisor of the National Investment Center for the Seniors Housing and Care Industry (NIC).    In the course of our conversation, Bob mentioned that National Development and Epoch Senior Living were proposing to develop 130 units of upscale senior housing on the former headquarters of GE Capital Corporation in Stamford, Connecticut.  http://www.courant.com/business/hc-br-plans-former-ge-building-developed-into-senior-living-home-20180815-story.html.     This led me to re-post my blog from February 2016 on the opportunity to reuse suburban office locations for seniors housing – see below.

The Wall Street Journal on Tuesday, February 9, 2016 featured an article entitled “Office Glut Strains Suburbs – Landlords, officials at odds over revamping vacant campuses as firms leave for cities”.    The article highlights a growing trend of major corporations abandoning leafy suburban headquarter’s campuses for urban locations where transportation options are better and it is easier to attract tech-savvy Millennials.    The article focuses on the relocation of Pearson Education from its Upper Saddle River, N.J. site to locations in Manhattan and Hoboken, N.J.

The site Pearson is leaving is a 47 acre site in a wealthy town of about 8,000 people located about 30 miles northwest of Manhattan.   It features a “bunkerlike” structure of grey concrete built in 1973 for Western Union with 470,000 sq. ft. of space and few prospects.   The suburban couplex is owned by publicly traded Mack-Cali Realty Corp. (CLI).   The building previously generated annual revenue of $8.6M but after testing the market, Mack-Cali found no office takers.    The company is proposing to replace the former Pearson Education headquarters with 240 apartments, which some in the town oppose because it would change the character of the community and generate expenses for public services while bringing in less taxes than a corporate office property.   Other locations noted in the WSJ article with similar former headquarters locations include:   the former Bell Labs headquarters in Holmdel, NJ; BASF’s former North American headquarters in Mount Olive, NJ and the former home of Merck & Co. in Readington, NJ.

None of the real estate owners or developers cited by the WSJ were mentioned to be considering a continuing care retirement community (CCRC) as a primary reuse for these corporate office sites or as a principal use in a larger mixed-use complex that might combine office and retail and non-age restricted housing together with a CCRC.   Yet, a CCRC would appear to offer a number of benefits.    Principally, a CCRC would:

  • Target the existing older, affluent residents of the wealthy suburbs where these former headquarters are located.
  • Likely generate more in tax revenue than would be required to service the CCRC because CCRC residents would not have children in public schools.
  • Generate less in the way of traffic congestion than conventional apartment or condominium development and less than a former corporate headquarters.
  • Generate spending in the community for existing or to-be-built retail space.
  • Generate demand for additional healthcare and other services that might be found in the community or incorporated on the site.
  • Generate greater demand for employment on the site and potentially taxes than would a conventional housing development.

CCRCs typical range in size from about 250 units including a mix of independent living, assisted living, memory care and skilled nursing or healthcare units/beds to as many as 2,000 units/beds in large complexes that have principally been developed by Erickson Living.    While there is an emerging trend among seniors housing developers, like office developers, to consider higher density, mixed use urban locations, I believe there is still significant demand for suburban CCRCs, particularly in wealthy, aging, hard to develop locations, like northern New Jersey, where the corporate headquarters sites noted above are located.

CCRC’s are typically developed in either an entrance-fee or rental format.   In an entrance-fee format, residents pay an upfront fee that may be partially or fully refundable.   This fee is used to repay construction debt and the non-refundable portion is amortized over time to reduce the monthly cost of housing and care.   In a rental format, there is no entrance fee, more long-term financing is used and monthly rent must cover the full cost of housing and services.    The largest CCRC campuses typically incorporate multiple casual and formal dining venues, pools, gyms, lecture halls, entertainment and recreational amenities and may include full physician practices and their own health plans as well as health centers that provide therapy space.

In 2014, while I was still working in investment banking, I pitched seniors housing as a reuse for some undeveloped or partially developed suburban office locations to a publicly traded suburban office REIT.   However, the sites this company had available at the time were not as large or as well located as the corporate headquarters’ sites noted above and were not well suited to CCRC developments of scale.    While CCRCs are well outside the comfort zone of most office owners/developers, outright sale of large suburban headquarters sites for this purpose or joint venture development with existing owners of suburban headquarters sites and CCRC developers or healthcare REITs would appear to be a very viable option for such locations, particularly in cases where a CCRC would be an element in a larger mixed use campus that might include some conventional apartments (potentially for staff), retail and office/healthcare uses.

 

 

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