Building A Parkinson’s Care Team

Background – Parkinson’s is a progressive, degenerative condition that requires a comprehensive approach to care. But the fragmented U.S. system of health care reimbursement, multiple managed care networks and referrals is not designed to guide patients toward an integrated, top quality care team to meet your individualized needs.    A Parkinson’s patient must take on this responsibility, with help from family, friends, other patients and support organizations.

In building a Parkinson’s care team, it is important to remember that medications prescribed for Parkinson’s care generally do a good job controlling symptoms (stooped posture, temporary freezing of limbs, shuffling gate, tremors, back pain, etc.) but do not slow the progression of the disease. Research studies going back to the 1980s have shown exercise may improve Parkinson’s symptoms. More recent studies, focus on the concept of intense “forced” exercise suggest that certain kinds of exercise may be neuro-protective, i.e., actually slowing disease progression.  So it is important your personal Parkinson’s care plan include both medical and non-medical components.

I am a great proponent of an intense exercise program, specifically Rock Steady Boxing, as an integral part of your care plan. When I retired from a career in equity research and investment banking in 2017, I weighed 212 pounds, wore a size 44 waist pants and a 46 or 48 suit or sport coat. After 3.5 years of being diagnosed with Parkinson’s and adopting the exercise routine outlined below, I weigh 174 pounds (38 pounds less), wear a 38 waist slim pants and a 44 suit or sport coat.

My personal Parkinson’s exercise program includes Rock Steady Boxing (4x per week online during the pandemic) now 2x per week in the gym and 2x per week online, 1x per week yoga class still online, walking 1 to 2 miles 2x to 3x per week and golf 2x per week – 18 to 27 holes. Rock Steady Boxing provides my most intense exercise, usually leaving me dripping with sweat and a bit sore after an hour. But, with the weather improving, I will shift my routine more toward golf and walking and do less Rock Steady Boxing on line. When the weather turns cold, I will rotate back to more Rock Steady sessions per week.

Building Your Team – I was fortunate when I started building a care team in that I had the advice of two old friends, one a clinical psychologist and and one a psychiatrist specializing in geriatric care who first diagnosed my Parkinson’s (see prior post), from my daughter-in-law who had recently completed her master’s degree in Speech Pathology, from a business associate who developed the disease at a young age, and from the wife and principal caregiver of another friend who was a long-term Parkinson’s patient, now confined to a wheel chair and whose speech is very difficult to understand.

To assemble my care team, I researched Parkinson’s and Parkinson’s care. But actual patients and caregiver’s were the most helpful.  I was also fortunate to live in a major metropolitan area, Baltimore, with some of the best medical institutions in the world. So I had a choice of multiple motor disorder’s specialist physicians and numerous options for all types of Parkinson’s care and therapy.

Resources – Sources of information on Parkinson’s that we consulted include:

Parkinson’s Disease – A Complete Guide for Patients and Families, Third Edition, William J. Weiner, M.D., Lisa M. Shulman, M.D., Anthony E Lang, M.D., F.R.C.P., Johns Hopkins University Press, 2013). This is the best patient/layman’s guide to Parkinson’s I have found and Lisa Shulman now directs the motor disorders center at the University of Maryland Medical Center.

The Michael J. Fox Foundation for Parkinson’s Research https://www.michaeljfox.org

The American Parkinson Disease Association https://www.apdaparkinson.org

The Maryland Association for Parkinson Support, Inc. which fully funds Rock Steady Boxing and other programs for Parkinson’s patients

https://www.google.com/search?gs_ssp=eJwNx0ESQCAUANCxNeMObWxs_E9SjuAWX2EaVFOZ4fa83Surdm8R9Zi7k8sLiqmGRyotERc-rIQcDE7wiM0o4KIbaBWj6XFuLorvSc4wSslrS9l6xzYfWaB4WJf-pTsEH_MHcoAfXg&q=maryland+association+for+parkinson+support&rlz=1C5CHFA_enUS820US820&oq=maryland+assocation+for+par&aqs=chrome.1.69i57j46i13i175i199j0i390l3.9399j1j7&sourceid=chrome&ie=UTF-8https://www.apdaparkinson.org/resources-support/living-with-parkinsons-disease/?gclid=Cj0KCQjwn8_mBRCLARIsAKxi0GIyyoaSICbiiZtFzsB33dJzK-O01qslQ7-56ym6xi314UFMP-t4Ll8aArfNEALw_wcB

Motor Disorder’s Specialist – The first step in assembling a Parkinson Disease care team is to find a neurologist who specializes in motor disorders.   This person can best diagnose if you have Parkinson’s or some other condition, get you started on a medication regimen that works for you and help you understand your illness and how it is likely to progress.   The Parkinson’s patients and care givers we consulted, as well of my primary care doctor and a general neurologist, all recommended the same motor disorders specialist – Dr. Stephen Reich, MD at the University of Maryland Medical System. https://www.umms.org/find-a-doctor/profiles/dr-stephen-reich-md-1023125507

University of Maryland Medical Center is located in downtown Baltimore, with a number of affiliated hospitals throughout the state. It has a large ambulatory neurological center, with considerable expertise and active research underway on Parkinson’s. It took several months to get an appointment with Dr. Reich, which I believe is typical for well-regarded motor disease specialists. So I first saw a general neurologist for an initial assessment and a basic and relatively low dose set of Parkinson’s medication.

Other components of my Parkinson’s care team:

Physical therapist – I chose Patty Wessel, who is a physical therapist with Mind Body Physical Therapy & Wellness Center and a Parkinson’s specialist. Patty is LSVT certified and also runs Rock Steady Boxing Charm City, one of a number of Rock Steady Boxing programs in the Baltimore area designed specifically for Parkinson’s patients. Like Dr. Reich, Patty was recommended by multiple sources and has been great to work with.

LSVT (Lee Silverman Voice Treatment) Programs for individuals with PD have been developed and researched over the past 20 years beginning with a focus on the speech motor system (LSVT LOUD) and more recently have been extended to address limb motor systems (LSVT BIG). Both the LSVT LOUD exercises for voice and LSVT BIG exercises for movement have been clinically tested and are widely used for Parkinson’s patients. Therapists are specifically trained and certified to use the LSVT programs.

https://www.lsvtglobal.com/Patients_Family

Rock Steady Boxing is the first gym in the country dedicated to the fight against Parkinson’s. In the Rock Steady Boxing program exercises are largely adapted from boxing drills. Boxers condition for optimal agility, speed, muscular endurance, accuracy, hand-eye coordination, footwork and overall strength to defend against and overcome opponents. At RSB, Parkinson’s disease is the opponent. Exercises vary in purpose and form but share one common trait: they are rigorous and intended to extend the perceived capabilities of the participant.

https://www.rocksteadyboxing.org/about/

Speech therapist – I used the Outpatient Rehabilitation Institute at St. Joseph’s University of Maryland Medical Center for speech therapy. St, Joseph’s is close to my home, LSVT LOUD certified and one of my Boxing class members recommended them. The speech therapist I work work with is Angela Ferrara, MS, CCC/SLP, LEAD. After working for several months with a therapist, you go home with speech exercises design to spur Parkinson’s patents to speak loudly and clearly. The disease causes patients, without realizing it, to speak very quietly and slur their words, making them difficult to understand. To add some fun to the exercises, my therapist included Shel Silverstein poems. Ideally, a Parkinson’s patient will do these exercises once or twice day, every day. There is an Iphone app called Voice Analyst that allows you to measure your pitch and volume, just as a therapist would. I am seldom diligent enough to do my speech exercises every day, but quickly notice the difference in my speech if I don’t keep up my practice. I schedule periodic tune-ups with my therapist to check on my progress and due for one of these.

Psychiatrist or psychologist able to do neurological/psychological testing – This is not part of every Parkinson’s patient’s initial care team, but my friend Mitch Clionsky encouraged me to get a comprehensive baseline cognitive evaluation soon after my diagnosis, so my care team could better assess how my cognitive abilities change overtime. Mitch recommended Jason Brandt, Ph.D., ABPP(CN) Professor and Director at the Johns Hopkins Cortical Function Laboratory & Medical Psychology Clinic. I could have had this same type of testing done elsewhere but decided to follow Mitch’s suggestion. My motor disorders physician previously worked at Hopkins and was very comfortable with having Dr. Brandt do baseline testing.

I also continue to see my personal physician who monitors my overall health and have recently encountered some dental issues, which may be exacerbated by Parkinson’s – specifically grinding my teeth and clenching my draw. As Parkinson’s progresses, it can impact your cognitive abilities and sometimes prompt impulsive and compulsive behaviours, possibly as a result of Parkinson’s medications. While this has not been a significant issue for me so far, I would like to add a therapist to my care team to explore these issues if they arise.

Out of the Closet on Parkinson’s

I was first diagnosed with Parkinson’s disease in October 2018. My family and close friends have long known of my condition. But I have been reluctant to discuss Parkinson’s on my blog. I was concerned that potential consulting clients and board recruiters might be less willing to use my services if they knew I had a condition that could limit my mobility and potentially impair my cognitive abilities.

Parkinson’s disease is a progressive nervous system disorder that affects movement. Symptoms start gradually, sometimes starting with a barely noticeable tremor in just one hand. Tremors are common, but the disorder also commonly causes stiffness or slowing of movement.

Mayo Clinic

As Parkinson’s disease progresses patients may experience impaired posture and balance, their speech may become slurred and it may impact their cognitive abilities. There is no cure for Parkinson’s. Medication can control symptoms but are not able to slow the progression of the disease. Exercise to improve flexibility, balance, strength and speech appear to slow disease progression.

In Parkinson’s disease, certain nerve cells (neurons) in the brain gradually break down or die. Many of the symptoms are due to a loss of neurons that produce a chemical messenger in your brain called dopamine. When dopamine levels decrease, it causes abnormal brain activity, leading to impaired movement and other symptoms of Parkinson’s disease.

Mayo Clinic

Parkinson’s disease is very difficult to diagnose because symptoms develop slowly and are different for different individuals. For example, I have been formally diagnosed for about three and a half years but have never developed a tremor in a limb, which is widely seen as a key characteristic of Parkinson’s. For more than two-years before my Parkinson’s was diagnosed I was assessed and treated for back pain by my primary care doctor, an excellent Hopkins’ trained physician, an orthopedic surgeon and a chiropractor for stiffness in my back. None of these professionals recognized that I had Parkinson’s, even though the orthopedist and chiropractor specialize in back and muscle treatment and my primary care doctor has observe me for more than 10 years.

My first Parkinson’s diagnosis came at my 50th high school reunion when a former classmate, Mitchell Clionsky, PhD and his wife Dr. Emily Clionsky immediately saw my posture and gate as telltale signs of Parkinson’s. http://www.cns-neuro.com/DrClionsky.html. Emily wanted to write me a script for carbidopa/ levodopa on the spot so I could better enjoy my highschool reunion weekend. But I elected to wait and see my personal physician when I returned home. He found the diagnosis credible, referred me to a general neurologist who confirmed the diagnosis, provided a basic initial drug regimen and referred me to a motor disease specialist.

In the three and a half years since my Parkinson’s diagnosis my motor disease specialist (Dr. Stephen Reich) has prescribed and adapted a medication regimen that keeps my symptoms well under control most of the time, using four different medications at present. I have used a physical therapist and a speech therapist, both with lots of experience with Parkinson’s patients, and I have joined the Rock Steady Boxing Program. Rock Steady is specifically designed for Parkinson’s patients and offered without charge in Maryland by the Maryland Alliance for Parkinson’s Support (MAPS). I also took a battery of cognitions tests shortly after my formal diagnosis, at Mitch’s recommendation, so my care givers and I would have a base line from wish to measure changes in cognition as my disease progresses.

During a typical week I do three or four hour-long boxing/intense cardio workouts, an hour of yoga, and walk 1 -2 miles or play 9 holes of golf one or two times per week, weather permitting. Since beginning my exercise regimen I have lost 0ver 30 pounds, dropped six inches from my waist and am much stronger and more fit than I have been in many years. The boxing program, in particular, and associated Parkinson’s targeted exercise has improved my posture and my balance and is important for keeping my Parkinson’s symptoms under control. We continued boxing on line during COVID and course are now split two days per week in the gym and two on line. We are in temporary gym space now but hope to have improve long term gym space later this year.

My symptoms are largely unchanged since I have been diagnosed. But, as anyone with Parkinson’s knows, can occasionally flare up between medication dosages or if you eat something (usually protein) that interferes with your medication being absorbed or experience some stress that may aggravate your symptoms. After living with your illness and working with your motor disease specialist, you can develop tools to manage these situations.

Next – Building A Parkinson’s Care Team

New FNMA/FHLMC Requirements Set National Standard For Condominium Maintenance

The Federal National Mortgage Association, commonly known as Fannie Mae (FNMA), and The Federal Home Loan Mortgage Corporation, commonly known as Freddie Mac (FHLMC), are publicly traded, government-sponsored entities (GSEs) that purchase mortgage loans from banks and mortgage banking companies. GSEs package these loans into mortgage back securities that are sold to investors. This process results in lower interest rates for homebuyers and allows these two entities to set standards for the mortgages they purchase and securitize.

As of January 1, 2022, condominium properties for which banks or mortgage bankers are seeking to sell loans to purchase individual units to GSEs must meet the following requirements:

Properties with significant deferred maintenance items or that have received a repair directive from a regulatory or inspection agency must provide proof that needed repairs have been completed.

• At least 10% of the community’s annual budget must go to a reserve account to fund capital improvements needed to maintain the property.

• If a special assessment related to safety, soundness, structural integrity, or habitability has been proposed or approved, all related repairs must be fully completed.

Cooperator News New York

Prospective buyers of units in condominium properties with structural deficiencies or deferred maintenance that are unable to quality for FNMA/FHLMC financing are likely to have pay higher interest rates for their mortgage financing and will be able to finance a smaller portion of the purchase price, if they can get financing at all. The value of units in such buildings could significantly decline if they become more expensive and more difficult to finance.

Even if a condominium property has committed to make needed improvements and has a way to finance the work, GSEs will not purchase and securities mortgage to purchase units in a property with structural issues or deferred maintenance until all needed improvements are completed. For condominium properties needing major improvements, this could depress property values or prevent the sale of units for a year or more.

To collect information from condominium projects, FNMA and FHLMC or financial intermediaries wishing to sell mortgages for condominium unit will require condominium associations to complete form FNMA 1076A/FHLMC 476A shown below.

Benefits For Condominium Buyers – The amount of information available to purchasers of condominium units has varied by state and, in some cases, has required prospective purchases to dig through voluminous reserve studies and other documents to determine if any structural or deferred maintenance exist. It has also been difficult in some states for a prospective purchaser to determine if a condominium property has sufficient reserves to fund needed capital projects or may require a special assessment soon after a unit is purchased.

Since the collapse of Champlain Towers South (CTS), many have called for more stringent government requirements on condominiums, such as requiring more frequent independent studies to assess the adequacy of reserves and structural integrity and mandating minimum reserve levels. However, condominium developers and condominium associations generally oppose such mandates and it is not clear whether increased government regulation of condominiums will occur, despite the collapse of CTS. The adoption by FNMA and FHLMC reduces the need for governmental action by establishing a de facto national standard for condominium maintenance, reserves and structural integrity and a clear, straightforward way for a prospective purchaser to evaluate a property before purchase.

I would encourage anyone considering the purchase of a unit in a condominium, whether it be a multi-story property or community of single family homes, to obtain a copy of form FNMA 1076A/FHLMC 476A (shown above) before submitting a bid for a condominium unit, or making any purchase offer contingent upon your review of this form. Prospective buyers should also ask the seller to certify that the building qualifies for FNMA/FHLMC financing.

Making a purchase offer contingent on review of the FNMA/FHLMC form and having the seller certify the property qualifies for FNMA/FHLMC financing:

Assures the buyer that financing will be available at competitive rates.

Provides a quick and easy way to determine if structural deficiencies or deferred maintenance is a problem at the property.

Should alert the buyer to the potential for a special assessment soon after purchase.

Senior Housing Options

What we mean by a seniors housing community?   The industry defines seniors housing as communities that offer a place to live and varying levels of supportive services.   Such housing is grouped into four categories: (1) independent living, (2) assisted living, (3) memory care and (4) continuing care retirement communities that combine multiple levels of care on a single campus and may include skilled nursing care in addition or in lieu of distinct assisted living and memory care units.

Not included in this list are “board and care homes”, which are private residences in which usually less than ten seniors may be cared for.   Such facilities may offer a more homelike setting for seniors with limited needs for care but many such facilities are targeted to seniors that qualify for Medicaid rather than for private pay clients that are the focus of this post. Also not included in the definition of seniors housing are age restricted/senior apartments or condominiums that do not provide meals or supportive services and skilled nursing facilities that are considered healthcare facilities rather than supportive seniors housing.   While skilled nursing facilities historically provided long-term supportive care for seniors they are increasingly providers of either short-stay post-acute care following a hospital visit or long-term care for very frail seniors that need high levels of medical care or are indigent and covered by Medicaid.

It is helpful for consumers to understand the categories of seniors housing available. However, in reality, there is considerable overlap between the categories of seniors housing noted above and it is important to assess how well a particular community will meet your needs or the needs of a family member regardless of how a community is categorized. Increasingly IL communities offer assistance with the activities of daily living (ADL) services through affiliated or third party homecare providers, further blurring the distinctions noted below.

Independent Living Community

Capital Senior Living IL Community
Capital Senior Living IL Community

Snapshot

  • $1,800 TO $4,000+ per month
  • Meals, transportation, housekeeping
  • Emergency call buttons, 24-hour staffing, sprinkler systems in some

The typical IL community is located in a suburban setting, has been open eight years, and contains approximately 137 units. It offers full-size apartments with kitchen facilities as well as a central dining room and common areas for services that may include exercise classes, lectures, concerts, bingo, Wii sports, etc. We have seen properties with well-equipped gyms and pools, and more communities are adding space for rehabilitation and medical care. However, some older IL communities offer small units with limited space for services and face a risk of functional obsolescence.[1]

Approximately 92% of the IL communities surveyed by the American Seniors Housing Association (ASHA) in 2010 were owned by for-profit companies, with about 25% owned by publicly traded companies and 8% owned by not-for-profit organizations. About 94% of the IL communities surveyed by ASHA in 2010 were rental, and 6% had an entrance fee of more than $20,000.[2]

ASHA’s survey of IL community residents[3] indicates the average age of a resident moving to IL is 81.7 years. In IL communities, 54% of residents were widowed, 35% married, and 6% divorced or never married, and more graduated from college (45%) than in the general population of the same age. While the majority of residents in CCRCs (see Exhibit 16) live in IL units, CCRC residents are generally younger, have more education, and more are married than is the case in free-standing IL communities. Approximately 73% of IL residents had one or more cars at the community, and over 90% of those with cars drove within the last week. About 10% of new IL residents receive home health services in their residences, and the growing availability of home health services in freestanding rental IL communities is beginning to blur the line between IL and AL service offerings. Surprising to us, 37% of IL residents say they have long term care insurance. According to the ASHA’s IL survey, 61% of new IL residents were moving from a single-family detached home and 85% owned their former residence. About 20% of new IL residents moved from an age-restricted active adult community to IL. A majority of residents moving to IL communities (53%) had been hospitalized within a year before moving. The median income of all IL residents was approximately $46,500. About two-thirds of the residents moving to IL sold their homes when they moved, and the median sales price was approximately $243,000.

Assisted Living Community

Sunrise Assisted Living Community
Sunrise Assisted Living Community

Snapshot

  • $2,400 TO $6,000+ per month
  • Hospitality services – meals, transportation, housekeeping
  • Safety – emergency call buttons, 24-hour security, most offer sprinkler systems
  • ADL care – bathing, dressing, transferring, eating, toilet use
  • IADL care – financial oversight, phone use, shopping, money management
  • Medical Care – Medications management, in some cases dementia care, possibly registered nursing on site full or part time

The typical AL community is located in a suburban setting, has been open for nine years, and has an average of about 62 assisted living units and 20 dementia care (ALZ) units, with a resident capacity between 90 and 100. Assisted living units are more akin to efficiency apartments with private baths, but with minimal or no kitchen facilities. Common areas include a central dining room and space for hospitality services, but on a smaller scale than in an independent living (IL) community. In most surveys, freestanding Alzheimer (ALZ) communities are considered a specialized type of AL community. The typical ALZ community is smaller and slightly newer than the average AL community and has higher staffing ratios. An ALZ community is usually a one story secure community with about 40 units or 60-resident capacity. ALZ care is also often provided in dedicated units within an AL community (on the third floor of the community in Exhibit 16 for example) or in a dedicated unit within a skilled nursing facility.

Approximately 98% of the AL communities surveyed by ASHA in 2011 were owned by for-profit companies, with about 47% of the total owned by publicly traded companies and 2% owned by not-for-profit organizations. All of the AL communities surveyed were rental communities.[4]

According to the 2009 Overview of Assisted Living (published by a coalition of industry groups)[5], the average entry age for an AL community is 84.6 years. Female residents outnumber males by about three to one. Most are widowed, and only 12% are still married or have a significant other. Average length of stay in combination AL/ALZ communities is 26.6 months. The decision to move in was either entirely (22%) or partially (40.9%) the responsibility of the resident, and about 70% of residents moved from a private home or apartment. About 80% of residents live within 25 miles of a relative. The median single occupancy rate at combination AL/ALZ communities is $3,700 per month, with median resident income of about $19,000 per year and net assets of approximately $205,000 including home equity. About 66% of residents are self-paying, 10.6% receive assistance from their families, and the remainder pays with various combinations of Medicaid, VA, etc. However, the pure private-pay percentage is typically higher at communities operated by publicly-traded companies.

Memory Care

Arden Courts memory care community by HCR Manor Care
Arden Courts memory care community by HCR Manor Care

[6]

Snapshot

  • $3,500 TO $10,000+ per month
  • Hospitality services – meals, transportation, housekeeping
  • Safety – emergency call buttons, 24-hour security, most offer sprinkler systems
  • ADL care – bathing, dressing, transferring, eating, toilet use
  • IADL care – financial oversight, phone use, shopping, money management
  • Medical Care – Medications management, dementia care, possibly registered nursing on site full or part time

The typical MC community is located in a suburban setting and is generally somewhat newer than the average assisted living facility because the development of standalone memory care communities is a relatively new phenomenon.   In memory care communities, services are generally considered more important than design and layouts do vary, but a purpose built memory care community generally averages about 40 units and 60 person capacity or smaller.   Purpose built properties are generally one story with outdoor space that is secured to prevent dementia patients from wondering off the site.   Service offerings are similar to those for assisted living and many assisted living communities also include a dedicated memory care unit but a memory care community will generally have higher staffing levels, with more staff per resident and more staff with medical training such as registered nurses or nurse practitioners because medications management can be more extensive in such communities.

Independent statistics on ownership of memory care communities is not readily available because such communities are often grouped together with assisted living but the ownership characteristics for memory care and assisted living should be similar with most owned by private companies and run by for-profit operators.

Average entry age for many memory care communities is similar overall to assisted living and the incidence of dementia increases with age but may include younger residents suffering from early onset Alzheimer’s.

Continuing Care Retirement Community (CCRC)

CCRC by Brookdale Living Communities
CCRC by Brookdale Living Communities

Snapshot

  • $1,800 to $10,000+ per month and may include entrance fee options
  • Typically offers IL, AL and may offer MC care, all on a single campus and may, in addition also offer skilled nursing care providing for post-operative rehabilitation and long term care for very frail patients.

The typical CCRC is located in a suburban location, has been open for 15 years, and contains approximately 300 units, with over 60% of these being independent living accommodations. According to the American Seniors Housing Association (ASHA), about 13% of the units are assisted living and 23% skilled nursing. The large size of a typical CCRC allows these projects to offer a greater range of dining and hospitality options than are available in stand-alone IL or AL properties.

Publicly traded companies owned 16% of the CCRC communities surveyed by ASHA, another 31.2% were owned by private for-profit companies, and 62.8% were owned by not-for-profit organizations.[7] Of the CCRC communities surveyed, 77% were rental and 23% charged an entrance fee of more than $20,000.25

The majority of residents in CCRC communities are independent living residents with characteristics similar to those described above for IL communities. However, residents of entrance fee CCRC communities (see payment options below) are younger and significantly more likely to have a college degree, have higher household income, receive $300,000 or more from the sale of their home and have a net worth of $1 million or more.[8] We believe CCRCs, particularly entrance fee CCRCs, target more affluent seniors and those who are more likely to plan ahead for future care needs.

Payment Options

Most senior housing is operated as a rental on a monthly basis. The monthly fee covers room and board with an additional sliding fee based on the level of assistance the resident requires. In some settings, the community may bill only for room, board, and basic hospitality services, while a separate home-health agency may provide and bill patients directly for assistance with the activities of daily living, medications management, and other potential healthcare services.

Some private senior housing operators, notably Brookdale Senior Living and  Vi, and many non-profit providers operate entry fee CCRCs exclusively or in addition to operating communities charging only a monthly rental and service fee.  ASHA notes three types of entry fee contracts. These include:

  • Life Care Contract, in which the resident pays an upfront fee and an ongoing monthly fee in exchange for lifetime occupancy at whatever service level (independent living, assisted living, Alzheimer’s, or skilled nursing) the resident may need, with the monthly fee staying the same regardless of the service level provided;
  • Modified Life Care Contract, in which the resident pays an upfront fee plus a monthly service fee for independent living services with the community obligated to provide assisted living or skilled nursing care when required, but only for a specified period of time at a specified rate that may or may not be tied to the independent living rate; and
  • Fee for Service Contract, in which the resident pays an entrance fee essentially to pay for the real estate and a monthly fee that varies according to the services provided, with the community offering priority admission to its assisted living, Alzheimer’s, and skilled nursing units, but no guarantee of all services being available.

[1] American Seniors Housing Association, The State of Seniors Housing 2011.

[2] Ibid, the 94% assumes All or Virtually All Rental (60.8%) plus No Response (33.2%).

[3] American Seniors Housing Association, The Independent Living Report, 2009

[4] American Seniors Housing Association, The State of Seniors Housing 2011.

[5] American Association of Homes and Services for the Aged (AAHSA), American Seniors Housing Association (ASHA), Assisted Living Federation of American (ALFA), National Center for Assisted Living (NCAL) and National Investment Center for the Seniors Housing and Care Industry (NIC), 2009 Overview of Assisted Living, 2009

[6] Layout is of an Arden Courts community operated by HCR Manor Care and features four self contained neighborhoods to make the property easier for dementia patients to negotiate.

[7] American Seniors Housing Association, The State of Seniors Housing 2011.

[8] American Seniors Housing Association, The Independent Living Report, 2009

Benefits of Retirement Center Living

I thought a letter to the editor published in the Wall Street Journal on November 11, 2021 from Jane Shaw Stroup contained a number of good insights on retirement center living from someone whose husband had recently died after the couple spent five years in a community. Jane Shaw Stroup is a retired nonprofit executive and her husband, Richard L. Stroup, was an economist. The couple moved into a retirement community in Raleigh, N.C. in 2017.

Key points in Mrs. Stroup’s letter include:

Experience was mixed but generally a good one.

Your friends are close by, with was important during the depths of COVID pandemic. A small group of us met once week for wine and snacks during the pandemic.

A retirement center has some resemblance to a college dorm, but that a good thing. You are able to meet people at meals, exercise classes, lectures and clubs.

Having gym and a restaurant downstairs makes life easier.

Retirement centers are full of people who have experienced long, interesting lives – lots of opportunities for good conversation.

Emptying the contents of one’s home and selling it are poignant experience but leaving the process to one’s children may not be the right approach.

A retirement community can only succeed if it has caring staff who tolerate the foibles of older people. We were never reprimanded or chided by the staff even though we did some stupid things, like forgetting to push the button each morning to let staff know you are okay.

A retirement center is a place where you don’t have to be smarter or younger than you are. And a place where many friends can ease the loss of a spouse.

Recommended Home Accessibility Provider In Baltimore

After working for more than 15 years as a stock analyst covering senior housing and care and healthcare real estate companies, I try to apply what I learned professionally to my own lifestyle and care as I age. I am now 71 years old and was diagnosed with Parkinson’s Disease in September 2018. My Parkinson symptoms are well controlled with medication. I participate in Rock Steady boxing classes two or three days a week, have a once a week yoga class and, while the weather is good, I am playing one or two rounds of golf weekly (usually 9 holes). I also have speech therapy practice sessions for the LSVT Loud Program that I try to do several times a week.

My wife and I see ourselves as forward-thinking and well prepared for lifestyle changes as we age. Fifteen years ago we moved to a one-level condominium in an elevator-served 15 story building and our unit has wide door openings and no internal thresholds, which can be a fall risk. While our condo is well-designed for our current lifestyle and care needs, I recently decided to add a couple of grab bars in our walk-in shower in the master bath. Grab bars are not essential for my current condition. I can use the shower without them. But the grab bars should reduce the risk of a fall in the shower and you don’t want to prove you need grab bars by falling first. My movement disorders physician also recently adjusted my Parkinson’s medication, adding a time-released Carbidopa/Levodopa pill at bedtime to make my movement more fluid when I use the bathroom during the night.

After receiving their brochure from a Parkinson’s organization, we engaged a local firm, Home Safe Home (www.homesafehomemd.com – info@homesafehomemd.com – 410 394-8955) to perform an accessibility / safely audit of our condo. Home Safe Home recommended removing a number of small rugs and installing two grab bars in the showed in our master bath, which has about a 12 inch step to get in and out. Home Safe Home showed us samples of grab bars, ordered the bars we liked that matched the other chrome hardware in our shower and installed the bars though glass tile that we have in all of our bathrooms. The entire process required only one phone call from us and a few email exchanges. It took less that 30 days from our first phone call to installation, which took less than an hour, and the total cost for two grab bars and the home assessment was less than $500. If you are considering installing accessibility measures in your home for yourself or a loved one in the Baltimore area, I recommend Home Safe Home.

Pandemic, Lockdowns, Election Denial Getting You Down – Try Fondue

My wife and I actually have two fondue pots. I thought they were both presents from our 1977 wedding, but my wife says one if from my first marriage in 1972 and the other from my mother when she downsized in the 90s. Regardless of their lineage, we have not used either fondue pot for at least 10 years while they sat on top of one of our kitchen cabinets, retrievable only with a step ladder.

Like all Americans we have been primarily dining at home since the Coronavirus first appeared in March and are getting tired of staying in. The end of daylight’s saving time and the arrival of early evening darkness and colder weather, limiting outdoor dining, have further circumscribed our daily activity.

While shopping last week, I came across a prepackaged fondue cheese mix and, on a whim, thought I would try it. Remarkably, we still had Sterno, which apparently lasts forever if sealed, to power one of the fondue pots and were able to find our fondue skews.

Last night, on a cold, windy and snowy evening in Baltimore we tried fondue, dipping bread, vegetables and fruit into our prepackaged fondue cheese accompanied by a pinot noir. It was a cozy, warm, tasty dinner and a nice diversion from our routine. Based on a recent news report that red wine and cheese are good for you, you can even try to convince yourself its healthy. We are likely to do fondue again. Next time we plan to make our own fondue cheese mix from scratch. The constant in most recipes is gruyere with cheddar, fontina and other cheeses, plus white wine and some seasoning.

So if the pandemic and lockdowns and rigged election claims are depressing you, be happy and make some fondue. I even have an extra fondue pot I can let you have.

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.

Industry Response Needed On Coronavirus Impact On Seniors Housing and Care

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.

Converting Colleges To Seniors Housing – Pandemic Creating New Opportunities

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.