Month: July 2015

Repositioning Older Assisted Living Properties

Background

With NIC-MAP data starting to report an upturn in senior housing development activity, many older senior housing properties are or can soon be expected to face a more competitive market for new residents.    Senior housing, and particularly purpose built assisted living and memory care, are relatively young industries and most early assisted living properties were developed in the mid-1990s.    Nevertheless, early assisted living properties, particularly those that did not receive substantial capital infusions during the recession, are becoming dated in comparison to newly constructed buildings.   As a result, repositioning of older assisted living and memory care properties is likely to become increasingly important for the senior housing industry as more new units are constructed and competition increases.

Because many, but certainly not all, early assisted living and memory care properties are located in very attractive, hard-to-duplicate infill locations, repositioning good 1990s vintage properties may prove a very attractive investment alternative if such properties decline in value because of occupancy declines in a more competitive environment.   In this blog, I focus on repositioning opportunities for the classic Sunrise Mansion property as a proxy for all older assisted living and memory care properties.   I focus on Sunrise properties not because I believe the company has underinvested in their assets relative to other operators but because the Sunrise Mansion is the prototype for almost all of the mid- to late-1990s assisted living and memory care buildings.  As I write this, it has been 3 – 4 years since I toured a Sunrise mansion. So some of my observations may be dated.   However, over the course of my consulting, equity research and investment banking careers I easily toured dozens of Sunrise Mansions and similar vintage properties operated by national companies, regional and local operators.   I had the opportunity over the years to meet with several generations of Sunrise senior and operational management as well as senior and operational management of many other national and regional senior housing operators.   I also have had many informal discussions advising family and friends about senior housing options and getting feedback on their senior housing experiences and was actively engaged with the placement and experiences of my own parents in both assisted living and skilled nursing care.

Sunrise Mansion Pros and Cons

Before providing my thoughts on repositioning Sunrise Mansions and properties of similar vintage, I wanted to list the pros and cons I see for these Sunrise Mansions as a proxy for well located, good quality 1990s vintage assisted living properties:
 

Sunrise chart

Suggestions For Repositioning Sunrise Mansions and Properties Of Similar Vintage

Location – Most locations are very good.  However, some may have become less viable because of changing neighborhood conditions, because some site locations were forced at height of late-1990s development push or because newer competition has come on the market.  You can’t move the buildings but in most cases existing locations work and some existing sites may offer redevelopment or new construction options.

Design – Property sizes range from 75+/- resident capacity to 120+ resident capacity.   While I conceptually agree that residents should be out interacting with other residents and staff, not in their units, some Sunrise and other early assisted living units may be too small for current affluent senior preferences, which I summarize as independent living size apartments with assisted living + level services.   I continue to like pricing flexibility that flexible single/dual occupancy units provide but some may need to be reconfigured into more interesting larger units given demand.

Since, in most cases, buildings are on in-fill sites and cannot be enlarged, the practicality of combining some existing units to increase average room size, reduce total unit count and add some common space elements should be explored.   Given building size, an opportunity may exist to differentiate a Sunrise Mansion type property as the boutique/exclusive/personalized sized provider with somewhat smaller buildings than competitors if the economics will work.  I do not know the economic impact of reducing residents/increasing unit size but believe these options need to be explored and believe that there may be pricing flexibility for more exclusive, more personalized services in smaller buildings.

I believe the basic building design in Sunrise Mansion type properties is excellent but I would add room for a personal trainer and possibly some weight equipment, and perhaps more dedicated space for classes like yoga/palates, more space for a spa (facials/pedicures/massage, etc.) rather than just a beauty shop and perhaps space for a rehab therapy provider, which might be combined with personal trainer space.   If rooms are being enlarged and number of residents reduced, I believe it should be possible to convert a few smaller rooms to the uses noted above.   I believe these changes should appeal to affluent consumers and their children and can be used to offer more personalized care options than three levels of care that have traditionally been used by Sunrise and many other operators.   Personal trainer, yoga classes, extra beauty treatments could all be offered on fee for service or club membership plan.   I believe personalized services like those described above could all be offered in relatively small spaces and still make Sunrise type buildings much more competitive with larger AL and IL properties with services.

I believe space for Internet café within building and a broader look at use of technology for patient interaction with families, staff monitoring, etc. is important.   See my blog on “Technology In Seniors Housing” for a more extensive discussion of how technology can be used to increase resident and family engagement, interaction, mobility and evaluation.   But FaceTime or Skype interaction between residents and families, regular email or video reports to families on the condition of loved ones, computerized links to physicians and other care providers, computerized tools for patient monitoring and stimulation and things like Uber for more flexible transportation services are all things that might reasonably be incorporated into existing senior housing communities.   Some of these require dedicated space and all require trained or specialized staff.

Overall decor, which in early Sunrise properties I remember as being a bit fussy “Laurel Ashley-like” may need to be updated.

The levels of cap ex spending by operator varied, particularly during the recession but I expect basic-cap ex and infrastructure investment will be needed for mid-90s vintage properties to remain competitive as new properties are introduced to the market.

After a fire last year in senior housing facility in Canada, the importance of life safety standards, which I believe is high at Sunrise Mansion properties but not all 1990s vintage properties, should be emphasized.

Services – Service has and will continue to be more important than space for high quality senior care.   Sunrise was a trendsetter in quality and personalized care compared to traditional skilled nursing properties and I believe continues to have a strong commitment to resident independence, dignity and quality care. However, patient wellness and treatment standards for memory care have evolved since the core Sunrise care concepts were developed in the 1990s and I believe a complete review of Sunrise’s memory care service offerings and those of many other AL/memory care operators with an eye to setting a new standard for quality and personal attention is likely needed. Key elements in a revision to services that I see include:

  • A wellness program that provides individualized and integrated exercise, nutrition and mental health services for each resident.   This would incorporate a personal trainer rather than the group exercise programs now seen at Sunrise Mansion and other facilities, even more personalized meal planning and both computer assisted and staff provided mental agility and health services screening and stimulation.   This assumes additional staff on contract or employed with specialized training not now found in Sunrise facilities to the best of my knowledge.
  • More active review of medication management, particularly for memory care residents.   This may require a more active link between Sunrise facilities and healthcare or mental healthcare providers.  I am no expert in this area but believe that some dedicated memory care providers, such as Silverado, are more active in reviewing medications and medication management than most AL operators, are more likely to recommend changes in medication regimens and have more active involvement by attending physicians in reviewing their resident’s medications.  I believe over medication and adverse medication interaction remains a bit issue for seniors and this is an area with AL operators may be able to distinguish their service offerings.
  • A review of the memory care program. My sense is that providers like Silverado, with links to leading healthcare researchers at many of its facilities, have developed more comprehensive memory care treatment protocols than Sunrise any other operators who have been in the business for a while and Sunrise and other national AL operators should again set the standard.
  • I believe respite care is offered at many Sunrise communities but not certain if this is considered an integral part of the service offering that could be coordinated with a more robust therapy offering to position Sunrise as a post-acute or recovery option in a more integrated healthcare system. My recollection is that respite care is just used where units are vacant as a marketing and supplemental revenue generation tool.   I am not certain that Sunrise or other assisted living providers should be in the post-acute or respite business but these options should be evaluated and a business decision made.   Focusing some buildings on respite/post-acute care may make sense and it may be possible to combine on site respite care with rehab therapy to offer a more attractive and lower cost post-acute care alternative for some seniors and insurance providers.
  • Other ancillary services, in addition to rehab therapy and medications management noted above, such as hospice and home healthcare care have been at times offered by Sunrise and other operators both in and outside their properties with company staff.  I believe home healthcare and hospice care continue to be offered by third parties at some Sunrise properties.   I believe Sunrise’s commitment to let residents age and ultimately die in place is an important part of the Sunrise culture and a differentiated element of the Sunrise brand and is also an important part of some other operators culture.   However, there are a range of ancillary care options for assisted living operators ranging from: avoiding supplemental ancillary services to make their buildings more appealing to healthier seniors, to allowing residents to purchase services from third parties, to having approved partners, to directly providing ancillary services. My sense is that directly providing of ancillary services would be a significant distraction for many assisted living operators but a clear policy about the use of ancillary services in all of a company’s properties should be made if this has not already been done and using different levels of ancillary care at different buildings may be a way to differentiate a particularly property within a market.
  • Medicare managed care for residents is another option that Sunrise and other operators may wish to consider, likely teamed with a partner.   The only senior housing operator to operate its own Medicare Advantage plan, to the best of my knowledge, is Erickson Retirement and only at some of its communities.   Sunrise, Brookdale and some regional operators may have the resident density in some markets to either operate a MA plan themselves or team with a managed care or healthcare provider partner to operate one.   This could be an important differentiator if it helps ease the burden of coordinating healthcare services for residents and their families and is seen an providing quality care.  It might also be a more effective way of providing other ancillary services rather that teaming with various hospice, healthcare or therapy providers. In some markets it may be possible for multiple operators with links to a single healthcare REIT to join in a Medicare Advantage or other type of ACO plan to gain sufficient scale to be effective.
  • Transportation – Mobility is an important factor for many seniors.   A review of transportation options with multiple vehicles and multiple drivers available in lieu of the single bus should be considered. I envision each repositioned property having or having access to two or more of the new small SUV cab-type vehicles increasingly seen in major cities, and becoming standard in New York, that can readily accommodate a wheel chair and perhaps up to four passenger in total.  In addition, I envision each facility having something more akin to Uber to schedule cars and pick ups as needed, giving residents much more flexible mobility.   It may even be possible to use an outside Uber or Lyft like service specially tailored to seniors for this. The traditional facility bus might or might not still be needed for group outings.

Layman’s Guide To Post Acute Care

I had a conversation with a friend today who has a relative that is comatose after a surgical procedure.   The patient has recently been shifted from a feeding tube though the nose to one connected to the stomach and is about to be transitioned from oxygen through a breathing tube to a ventilator connected directly to the throat via a tracheotomy.   This progression is typical for someone who is unable to eat or breath on their own because temporary breathing and feeding tubes over time begin irritate the throat and must be replaced with more direct connections.     Once these more permanent breathing and feeding connections are completed, the patient will likely be transitioned from an ICU to a transitional care unit within the hospital and then the hospital and Medicare or a private insurer will likely soon want the patient relocated to from the hospital, which is designed to provide short-term acute care.

While hospital discharge planners or social workers and the patient’s health insurance provider may all have suggestions or recommendations or preferences about where the patient’s post-acute care should be provided, under Medicare and some types of private health insurance the family will have a choice about where post-acute care is provided.    This short guide summarizes the options to help you achieve the best result for a loved-one at a stressful time for all concerned.

Types of Facilities – There are four types of post-acute care options, which are typically stand-alone facilities but can also be co-located within a general acute care hospital in some cases.   The four types of post-acute care facilities are:

  1. Rehab Hospital, also called an IRF- Inpatient Rehabilitation Facility
  2. Long Term Acute Care Hospital, LTAC, sometimes LTACH
  3. Nursing Home, also called a SNF – Skilled Nursing Facility or in some cases a Transitional Care Facility, which is essentially a SNF located within a hospital
  4. Hospice, which can be provided in a specialized hospice facility, within a SNF or other medical facility or in someone’s home.

A Rehab Hospital or IRF is designed to provide post-acute care for patients who require and are physically able to participate in a minimum of three hours a day of physical therapy (PT), occupational therapy (OT), and/or speech therapy at least five days per week.   Requirements for IRFs call for registered nurse (RN) oversight and availability 24 hours a day and between five and seven and a half nursing hours per patient per day, while the standard for nursing homes is usually between two and a half and four nursing hours per patient per day.   IRFs are also going to have regular physician visits and supervision and extensive rehabilitation gyms and specialized rehab equipment and staff.     So IRFs generally offer a higher level of care than nursing homes but only those patients who are able to handle at least three hours of therapy per day are able to transition to a IRF.   Medicare and most private insurers will pay for IRF care for patient who needs and can tolerate relatively intense therapy following an episode of care in a general acute care hospital.

A Long Term Acute Care Hospital (LTAC) is licensed as a acute care hospital but is designed to care for patients with a 25 – 30 day average length of stay versus less than 5 days in a general acute-care hospital.   Typical LTAC patients have multiple co-morbidities, multi organ system failure, and significant loss of independence, most following a traditional hospital stay.   LTACs are designed to care for critically ill patients who require specialized, aggressive, goal-directed care over an extended recovery period.   So patients on feeding tubes, with tracheotomies and complex, difficult to treat medical conditions are well-suited for care in an LTAC provided there are expectations that the patient’s condition can improve or that their condition needs to be stabilized before stepping down to another setting offer less intense care, such as a SNF or home healthcare.  Medicare and most private insurers will pay for LTAC care for medically complex patients who need ICU level care for an extended period following an episode of care in a general acute care hospital and have some prospect for recovery or being stabilized so they can ultimately be cared for at home or in a SNF.

A Nursing Home or Skilled Nursing Facility (SNF) in most cases offers two types of care.    One is true post-acute care that includes therapy services similar to what is provided in an IRF and some may accommodate complex patients including patients with tracheotomies similar to what may be provided in an LTAC.   Some nursing homes have extensive rehab gyms and therapy staff and will have 24/7 RN care and attending physicians.  But not all nursing homes provide post-acute care services or take medically complex patients and requirements for nursing hours and physician supervision are typically lower in a SNF than an IRF or LTAC.    Nursing homes also offer longer-term nursing care, sometimes call custodial care, for patients who have health conditions that require enough nursing care to make care at home infeasible or who do not have a home or family situation that will allow care at home.    Custodial patients may staff for years and there is little expectation that they will recover and return home.    Medicare and private insurers will generally pay for a limited period of post-acute care in a SNF following an episode of care in an acute care hospital.  But the amount of time for which Medicare will fully cover SNF care is 20 days, after which a co-pay kicks in, and Medicare will not cover long-term custodial care for a patient who is not making progress toward recovery.   For patients without long term care insurance the only option for paying for long-term custodial care in a SNF is Medicaid, which generally will only cover payments after all of a patient’s own funds are exhausted.

Home Healthcare is non-facility based option that provides post-acute care for some patients.   It can deliver wound care, PT, OT and speech therapy and other types of skilled care but will not provide 24/7 patient monitoring and generally requires support from family members in order for this to be a viable option immediately following a general acute care hospital treatment.   Home healthcare often comes into the picture is to provide followup therapy or nursing care after a patient transitions from an IRF, LTAC or SNF to home but is only relatively healthy patients with supportive living situations and families are typically able to get all of their post-acute care from home healthcare.   Medicare and private insurances will pay for home healthcare but only for specific skill nursing and therapy services.

Hospice Care provided in a specialized facility, within a senior housing, nursing home or other health facility, or in one’s own home, is intended for patients who are expected to live for six months are less.    The care is design to keep the patient comfortable and free from pain and to help family member cope with a loved-ones impending death.   While most healthcare providers are reluctant to conclude that additional medical treatment will not allow a patient to get better, hospice care is a very good option once the family and their healthcare providers reach this conclusion.  Medicare and most private insurers will pay for hospice care in a variety of settings.

Deciding Where a Love-One Should Receive Post-Acute Care – Important factors to consider include: the type and level of care the patient needs, the quality and location of the facility.     The type of care that each facility offers is summarized above and you can discuss the appropriate placement with the care team at the hospital including your physicians, nurses, discharge planners and social workers who usually take primary responsibility for transitioning a patient to post-acute care.    There is a tendency to favor facilities offering the highest level of care, such as an LTAC or rehab facility over a nursing home.   However, if the patient will does not need or will not be able to tolerate the level of therapy these facilities can provide it may be better to to directly to a nursing home rather than spend a few days or a week in another type of facility and have to move the patient a second time.    Many patients will prefer home healthcare to facility-based care but it is important to be realistic about whether the physical conditions of the home and the amount of support family members can provide make this the best first post-acute care option.    Location matters because it is important for family members to visit during what may be a multiple week or month period of post-acute care and family members are more likely to visit if a facility is conveniently located.     Finally, quality can be assessed by visiting a facility, speaking with discharge planners and social workers, checking online (The Centers for Medicare and Medicaid Services (CMS) has a 5-star quality rating system that isn’t perfect but can help – https://www.medicare.gov/nursinghomecompare) and in the case of skilled nursing, check with the state Office of Aging ombudsman about any prior complaints.

It will be much easier to evaluate and find space in a facility of your choice if you start looking before your loved-one is about to be discharged.    However, if you need more time it is possible to appeal a hospital discharge and generally buy yourself one-three days if you need more time to evaluate and decide upon your best option for post-acute care (see appeals on the Medicare.gov website).
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Relationships Key to Happiness In Retirement & Seniors Housing

I spent a recent weekend on the Rhode Island shore with a eight friends I have known for over 40 years and several of their spouses/significant others.     We try to get together every two or three years and it is amazing how quickly we are able to reconnect and how reminiscences we have all been over many times before are still a pleasure to hear.

This weekend experience reminded me of the importance of relationships – with a spouse or significant other, with your children and family and with friends and neighbors – for happiness.     I believe the importance of relationships in making us happy is too often overlooked when seniors contemplate a move from work to retirement, in relocating to a new location for all or part of the year, and in thinking about and executing a move to a seniors housing community.

Relationships In Retirement – One important aspect of moving from full time work to full time retirement is that many of our friends and social relationship revolve around our work.   We all have business colleagues inside or outside our organizations that we interact with socially as well as professionally for lunches, dinners, conferences and meetings, charity events, golf and other activities.   These relationships are hard to maintain when you no longer see these colleagues on a regular basis.   If you want to maintain these relationships you, as the retiree, will have to work hard to maintain active contact with former colleagues.

Even if you make the effort to keep connected with former colleagues, many of these work-connected relationships will slip away when you retire because you simply won’t be moving in the same circles as former colleagues.   To supplement these relationships, you need a plan of action to build alternative social relationships, particularly some that are intellectually stimulating.

Once you do retire, some of the most significant challenges you encounter in your social relationships may involve your spouse, significant other, children and other family members.   The relationship with your spouse, if you are married, may be the most important post-retirement relationship you have.   But the nature of your relationship with you spouse may change dramatically as one or both of you has more time at home and you negotiate new responsibilities on household chores, financial management, planning vacations and social activities.     It is important to anticipate and discuss these changes in advance and to maintain an active dialogue as you settle in to your post-retirement lifestyle.

Relationships with children are another important aspect of happiness for retirees but can also create challenges.   Children may live far away, may want more of your time for childcare than you want to give or may not want your advice or help now that you have more time to offer it. For many of us baby boomers our retirement may coincide with our children marrying, getting traction in their careers, establishing families and generally feeling more independent from parents and less in need of parental advice. It is important for the parent/retiree to be sensitive to these changes in roles and to adapt to changing conditions.   It is also important to let your children know if you believe they are claiming more of your time for childcare or other responsibilities than you want to give.

Relationships As We Age – Another aspect of relationships that I believe is very important for happiness and underappreciated as we age is the loss of connectivity to others as your mobility and that of friends is reduced, you or friends relocate to new locations or a spouse or other close friends die.     Many seniors face a gradual narrowing of social relationships and human interaction for the reasons just noted.     Most of the literature that discusses a senior moving to senior housing, including a July 10, 2015 New York Times article entitled “Team Effort In Making Decisions on Elder Housing” focus on a senior’s cognitive and physical abilities, as well as financial considerations, in determining when a move from a home to seniors housing is appropriate.   I believe an equal or more important reason to consider seniors housing, and one that I believe is a good predictor of future health, is a senior’s social network and level of social interaction.   If a senior has lost a spouse, has a shrinking network of social relationships and has very little interaction with peers, family or friends when living at their home or apartment, I believe a move to seniors housing should be actively considered as a way of putting a senior in a position to re-establish meaningful social relationships and interactions.  It may be appropriate to adopt for seniors the same rule I recently saw advocated for children – if they are spending more than two hours a day in front of a screen, be it TV, PC, videogame or tablet it may be time to examine their level of social interaction consider intervention.

I believe there are also practical advantages to discussing a senior’s potential need for seniors housing in terms of social interaction, rather than cognitive or physical limitations.   In the discussion of social interaction, there is a presumption and a focus on a senior being alert, active and in need of human interaction rather than a focus on declining mental and physical abilities.   A move to a senior housing community to make new friends and increase social interaction is a much more positive discussion than a move to prevent falls or keep a senior from harming themselves through mental lapses.   It is also a discussion that can and should happen sooner in a senior’s life when they will gain much more out of a move to a seniors housing facility and before a life incident forces consideration of a move under crisis conditions.

In a future blog, I will discuss the challenges to fitting in and establishing positive social interaction after a move to seniors housing based on some recent industry research.