On January 9, 17 and 23, 2023, Beth Am synagogue sponsored a 3-session webinar on senior housing and care options and selecting a Life-Plan Community in Baltimore. I led the webinar and was assisted in its preparation and presentation by Becky Bees, Marketing Director of Roland Park Place (RPP), the only Life-Plan Community in the City of Baltimore.
RPP is located within walking distance of the Arts and Science (Homewood) campus of Johns Hopkins University, and about 2.5 miles from Beth Am synagogue. RPP has 10 -12 Beth Am members among its residents, and additional Jewish residents to are not members of our synagogue, but most of its residents are not Jewish. Because of its location near the Homewood Campus of Johns Hopkins, RPP attracts a lot of retired professors and physicians. Its residents are known as being intellectually curious with interests across a broad range of topics.
While Becky Bees and I both have ties to RPP, and used pricing and other details from RPP to explain Life-Plan Community pricing and entrance fee options. the webinar provides information to help seniors and their families make an informed choice about the type of senior housing and care that best meets their needs and information on all Life-Plan communities in the Baltimore metropolitan area. The 3rd session features Beth Am members living in four different Life-Plan Communities explaining their own selection process, their satisfaction with their chosen community and their advice to those considering such a move.
We welcome your questions, comments and suggestions. If you are considering senior housing and care options for yourself or a member of your family, you may also find other posts on this blog of interest. A Life-Plan Community, previously referred to as Continuing Care Retirement Community (CCRC), charges a significant entrance fee, offers a broad range of care for its residents (independent living, assisted living, memory care and skilled nursing) and offers assurance that a senior, or a senior and her or his spouse, will get any type care the need as they age at a predictable cost.
Whether you are interested in a Life-Plan Community, another type of senior housing community, or care at home, we encourage you and your family to consider your options sooner than you believe is necessary, so you are not force by an unexpected health condition to make a decision about your care in a couple of days with very little time to assess your options.
Becky Bees and I appreciate the support we received from the clergy and staff at Beth Am to offer this webinar and make it available via the synagogues web site.
On June 24, 2021 the 12-story, 136 unit, Champlain Towers South condominium in the Miami, FL suburb of Surfside collapsed. The collapse took only 12 seconds, killed nearly 100 people, and was among the worst structural failures in US history.
Factors being investigated as causes for the collapse: long-term degradation of reinforced concretestructural support in the basement-level parking garage under the pool deck, due to water penetration and corrosion of the reinforcing steel. The problems had been reported in 2018 and noted as “much worse” in April 2021. A $15 million program of remedial works had been approved before the collapse, but the main structural work had not started. Other possible factors include land subsidence, insufficient reinforcing steel, and corruption during construction.
Highfield House Condominiums is one of only two buildings in Baltimore designed by the world renowned modern architect Ludwig Mies van der Rohe. The building was completed in 1964 and is listed on the National Register of Historic Places. It opened as a rental apartment project and was converted to condominiums in 1979.
In 2020, Highfield House owners approve a special assessment of nearly $4.3 million to repair and restore the large plaza that also serves as the roof of the building’s parking garage. The critical items addressed in Highfield House’s plaza repair and restoration project are the same as those identified as postential causes of the Champlain Tower collapse – water leaking into the parking garage leading to deterioration of concrete and steel support for the building. Plaza repair and restoration work at Highfield House was substantially completed in 2020. We believe Highfield Houses’ ability to obtain approval for, finance and complete major structural repairs provides an important case study for other condominium owners, particularly following the Champlain Towers South collapse.
At the LAI Balitimore Chapter meeting on Wednesday April 19, 2023 Highfield House owners and officers who worked for six year to obtain approval for and complete the plaza repair and restoration project will review:
The effort and challenges to obtain 2/3rd approval for a $4 million + condo special assessment -Stephen Cleghorn – past president HH Condominium
The scope of work and the surprises and challenges encountered – Tom Liebel, – Moseley Architects, led the design team for the HH plaza repair and restoration project.
Challenges facing Maryland condominiums as a result of significant changes made in the 2022 session of the General Assembly – David Fishman – Highfield House board member and real estate attorney.
Condominium development and redevelopment opportunities expected to appear in 2024 – Jerry Doctrow – former HH board member, and board president who oversaw financing for the plaza repair and restoration project.
An article from Common Ground magazine is attached below for LAI members to review in advance of our meeting followed by a the changes to MD condo law approved in 2022 and links to a few press articles on Champlain Towers South and the impact of changes in FL condo regulations. We encourage LAI members attending on April 19 read the item below before the meeting.
This post updates one I originally published in 2015 that uses data from a study of nearly 6,900 seniors mostly living in independent living community or an IL unit within a larger, multi-level Life Plan Community. While the study was designed to guide senior housing developers and operators, I use the study results to guide seniors and the families on factors to evaluate and ease the transfer of a senior to community.
What’s Most Important For Happiness?
How frequently and how strongly a senior housing resident feels at home accounted for nearly half of the overall satisfaction of senior housing residents in a 2012 ASHA study. The 2014 study explored what caused independent living residents to “Feel at Home”. ASHA’s “Feel at Home” study was based on a survey of 6,858 predominantly rental independent living residents in 11 metropolitan areas who completed a 55 question survey.
ProMatura Group, a well-respected survey research firm based in Oxford, MS that specializes in senior housing and care research, conducted the survey, evaluated the survey results and authored the ASHA study. I want to thank Margaret Wylde Ph.D., CEO of ProMatura Group and her staff since for this blog I have borrowed liberally from the ASHA study, which was the product of their work.
Key factors contributing to “Feel at Home” identified in the 2014 ASHA study include satisfaction with private residence (32%), camaraderie with others (31%), sense of control (14%) and staff know them well (5%). Other items contributing less that 5% of “Feel at Home” included:
Number of friends in the community
Decorated residence the way they like
Know the things they need to know about the community
Quality of daily activities and programs
Dining program
Dining schedules
Frequency of seeing friends outside the community
Transportation provided by the community
What To Look For When You Visit?
ASHA’s “Feel at Home” study and this blog focus on satisfaction of independent living residents. Someone moving to independent living is about 85 years old, is moving from their a private residence they have occupied for an average of 19 years, usually a single family home, and is healthy enough to live with minimum outside help with the activities of daily living. The prospective resident is typically active in making the decision about whether and where to move.
Private Residence – Most senior housing communities are designed to wow you with their façade, grounds and the common areas you see just inside the front door, what marketers call “curb appeal”. While the ASHA study indicates the quality of common areas contributes to resident satisfaction, the study indicates attributes of the private residence are more important to residents feeling at home and being very satisfied. Key factors in making a private residence satisfying include:
Unit size – Just like with Goldilocks, the most satisfying independent living residence was not too big or too small, with 841 sq. ft. on average being “just the right size”.
Decor and Storage Space – Being surrounded by familiar things, having a décor that you liked and the ability to store possessions where you can access them were important for overall satisfaction with one’s private residence.
Natural Light – In the ASHA surveys more than half of the “I’m Home” customers strongly agreed with the amount of natural light in their residence, so looking for multiple windows that allow for plenty of natural light is a feature prospective residents and their families should consider.
View from the Windows in Private Residence – Along with natural light, “I’m Home” customers were likely to have a nice view from the windows in their private residence. More than half (54%) of “I’m Home” customers strongly agreed they enjoy the view from the windows of their residence. A view doesn’t have to include beaches, mountains, parks or rivers; a nice view can be as simple as a tree, a small garden area, a fountain, or a bird feeder.
Camaraderie With Others – Camaraderie with others was nearly tied with “satisfaction with private residence” as the most important factor making senior housing residents feel at home and very satisfied. Other factors, such as having close friends and the number of friends also contributed to residents’ satisfaction. Gauging how well you or a loved one will fit in at a senior living residence can be difficult to do during a visit. Things you can ask about or do during a visit for how welcoming a community will be include:
Warmth of Greetings – Make it a point to notice if you are greeted warmly by staff and other residents.
Cliques – Ask staff specifically about the presence of cliques in the building and the specific measures staff takes to address cliques and the off-putting behavior that may be associated with them.
Steps To Help New Residents Fit In – A senior housing community cannot impose friendships on new or existing customers, but staff can and should facilitate that eventuality. According to the ASHA study, staff from the very beginning of association with a new customer need to learn who they are, what they like, identify and help them form links with other customers. Items noted in the ASHA study that might help include staff sponsoring house warming coffees for a small group of residents in a new resident’s unit after they settle in and having a mentor from among the existing residents help acclimate newcomers. You should ask what specific steps each community takes to help new residents fit in.
Cultural Fit – Try to assess how you or your love one’s economic and social background compares with that of other residents and how the future resident’s age and physical and mental capacity match up. New residents that are on the slightly younger side, more mentally alert and better dressed may find it easier to fit in according to the New York Times article.
Interests – What are your interests and are there any others at the facility that have similar interests or some other connection that might make it easier for you to make one or two friends.
Try It Out – You should definitely try the dining and do it in the residents’ dining room not in a private dining room while meeting with the marketing staff. This will give you an ideal of the quality of the food and how it is served as well as how receptive existing residents are to newcomers. Many senior housing communities also allow for short-term respite stays or give prospects a chance to try out the community. This may offer a better way to assess your compatibility with a community than a visit or two of a hour or so. You may also want to visit in the evening to see what staffing and the activity level is like after prime viewing hours.
Sense of Control – Sense of control was about half as important to resident satisfaction and feeling at home than a resident’s unit and camaraderie with other residents but did matter. Factors affecting a sense of control included:
Information – Knowing where things are, how things work and what is going on can be important for residents to feel in control. The orientation and communication process between the building and its staff with residents is worth asking about. Sales counselors should explore the social preferences of prospects and ensure they understand the communal nature of the community. They should discuss group activities, dining, and the many interactions with others that occur during a typical day.
Scheduling Flexibility – New residents moving from a private home where they may have few visitors to a senior housing community with scheduled meals and activities and its own daily routine can experience a loss of control Flexibility on meal times, when to get up and go to bed and options for transportation and activities can contribute to a resident maintaining a sense of control.
Options – Not Requirements – Residents should be encouraged to be out of their residences and participating in activities but should feel that have the option to pass on activities that aren’t of interest.
Staff Knowing Residents – How well the staff knows a resident accounted for about 5% of residents feeling at home and being very satisfied. You should get a sense of staff interaction with residents during a visit and should explicitly ask existing residents if they believe the staff know them well.
Strategies For A Successful Transition and Finding Happiness
To ease the transition and find happiness in a move to a senior housing community, the studies suggest the following:
Recognize The Move Will Be Stressful – It is important for a senior moving into a community and their family to recognize that such a move is a major transition and will be challenging and somewhat stressful under the best of circumstances.
It Will Take Time To Adjust – Very satisfied residents who “Feel at Home” have an average tenure of four years, versus three years for those that sometimes feel at home and two years for those who don’t feel at home. So the longer a resident lives in a senior housing community, the more likely they are to “Feel at Home”. Give yourself some time to adjust and stop missing your former home.
Identify Some Positives – Despite the magnitude of the change, there are usually real advantages for a senior previously living on their own. These include: greater social interaction, better nutrition, more physical activity and potential greater freedom of action if you take advantage of community provided transportation and support services.
Incorporate Familiar Items – A resident’s own furniture and other familiar and personal items can help make the new residence “Feel At Home”.
Visit Often – The quality of visits by family members is important to overall satisfaction and can help ease the transition and the feelings some new residents may have of being isolated in their new surroundings.
Get Out and About – Opportunities to visit places and friends outside the community is also an important factor differentiating very satisfied residents. Excursions with family members or friends, using transportation offered by the community, or Uber or taxi may all be beneficial in easing a transition to a new senior housing community.
I have written three times before on this blog about augmenting college finances and declining enrollment by introducing senior housing on campus or by fully converting small college campuses into 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. The author said many of these institutions will need to close or radically change their operations to survive.
I republished my second blog post, with some updated commentary, in September 2019 after Welltower (WELL), the largest publicly traded Healthcare REIT, announced it acquired for$34 million Newbury College’s 7.8-acre campus in the Boston suburb of Brookline to convert the campus into a seniors housing community. Newbury had an enrollment of 600 mostly disadvantaged students, to which it was providing substantial financial aid, and was reportedly operated at a loss for several years before closing. The campus included 142,000 sq. ft of built space. The sales price was sufficient to repay all of the college’s debt, provide severance for staff and provide funds to assist some disadvantaged students obtain a college education elsewhere according to press reports.
Newbury College Campus, Brookline, MA
On April 30, 2020, TheWall Street Journal published 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, which prompted my third blog post.
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. Cancellation of on-campus classes during the pandemic, growing impediments to overseas students wishing to study in the U.S., and the increased appeal of lower cost, closer to home college alternatives all contribute to the growing financial distress of small, private American colleges.
Another news item last week prompted me to again revise, update and publish a new blog post on converting small colleges to senior housing conversion. On September 12, 2022, The Trustees of the College of Notre Dame of Maryland announced this Catholic women’s college, founded in 1895 with an undergraduate enrollment of about 660, would go Coed. The college already has about 1,750 coed graduate students, most part-time evening or weekends. I am friends with a number of Notre Dame of Maryland graduates, some dating back to my undergraduate days at Johns Hopkins. I live less than a mile from campus and my wife was an adjunct professor of management at the College in the 1980s. It has many great attributes. But it is hard for me to see how going coed will meaningfully improve its competitive or financial position.
The Notre Dame of Maryland is located on a hilly, wooded 60-acre campus in a very attractive wealthy residential part of Baltimore. The campus adjoins and connects with the campus of the coed Loyola College of Maryland, with which it shares a library. Loyola University Maryland is a Jesuit, Catholic University with nearly 4,000 undergraduate and 1,300 graduate students. Land constrained Loyola has long been interested in acquiring the smaller woman’s college to accommodate future growth, something which Notre Dame has long resisted.
College of Notre Dame of Maryland
The seniors housing and care industry has faced its own admissions and operating challenges during the pandemic, including lower occupancy, some overbuilding, restricted admissions to due Coronavirus self-isolation and high levels of COVID infections and deaths at some skilled nursing facilities. But the number of seniors 75+, when many begin seriously considering seniors housing and care options, is expected to grow about 40% between 2020 and 2030, while no growth is expected during that time in the undergraduate U.S. college population, age 18 -24. The lack of growth in the undergraduate age population in U.S., increasing administrative burdens and geopolitical tension, and the high costs of a four-year college education are continuing to reduce college enrollment, particularly for small, private colleges.
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. At a college like Notre Dame of Maryland, the College could joint venture with a for profit or nonprofit senior housing developer to add a senior housing community on campus, generate some immediate cash, leverage its existing dining and maintenance staff, providing on-campus work-study experience for students in nursing and allied health programs and providing opportunities for the College of Notre Dame of Maryland to expand it’s curriculum to include seniors housing management.
Notre Dame of Maryland should also consider selling its entire campus and fully converting it to a senior housing community because it is one of the few uses (other than an educational institution) that its neighbors and City officials are likely to support on the site. Conventional, higher density housing or commercial development is likely to be opposed by owners of large single- family homes nearby because of increased traffic and congestion. A seniors housing community will generate little if any additional traffic and should generate a substantial number of jobs for city residents. It might be able to accommodate retired nuns at a preferential rate, as well as provide an endowment that could continue the mission of educating woman. If I were the university’s real estate advisor, I would see seniors housing as one of the few real competitors to Loyola to purchase the site.
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. Other clients included Johns Hopkins Health System, Penn State Hershey Medical Center and Arizona State University.
Please contact me at jdoc@robustretirement.com with comments and questions.
I am 72. I graduated college 50 years ago and am a quintessential baby boomer. I studied seniors housing and care as a real estate market and stock analyst for more than 20 years. I spent several years raising capital and advising companies in the seniors housing and care space and served on the board of Quality Care Properties, a health care REIT.
The holy grail of seniors housing and care throughout the last 20 to 25 years has been the arrival of baby boomers as senior housing residents. Despite a series of ups and downs driven by overbuilding, varying economic conditions, and a pandemic, the arrival of the baby boomers at the front door of seniors housing properties nationwide continues to be seen as spurring huge investment upside for the seniors housing and care industry.
The problem with this thinking is boomers have not moved in mass to seniors housing in their 60s or so far in their 70s. There is a rethink going on among some in seniors housing considering if boomers may abandon traditional seniors housing offerings altogether and, instead, seek out active adult communities, both large ones like the Villages and Del Webb and smaller scale active adult options. In these scenarios, boomers use home health care to avoid traditional independent, assisted living, memory care and CCRC properties altogether.
A funny thing happened this past week. Two baby boomer couples we have known for many years, who are our age or just a few years older, independently started touring CCRC communities around Baltimore, where I live. These same boomers, until very recently, could not picture themselves ever living in a CCRC. It is too soon to call this a trend, much less a wave of baby boomer demand, but it appears to me that after three years of pandemic, on and off masking, and much reduced social interaction more boomers are ready to consider communities that offer a wide range of education, entertainment and social activities, even if these properties are full of “old people”. Another couple we know is selling their condo near the water in a hip Baltimore neighborhood to rent in a 55 plus community in the suburbs with pickleball courts, educational and social programs.
I am curious if other senior housing industry professionals and other baby boomers are seeing evidence that boomer attitudes toward at least CCRCs are beginning to change and the holy grail of increased boomer demand for seniors housing may yet remake the industry. Please respond with your comments on this post.
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.
What do we mean when we use the term “seniors housing community”? The industry defines seniors housing communities as properties offer a place to live and varying levels of supportive services. Discussions of seniors housing generally focus on professionally managed, market-rate properties with capacity for at least 25 seniors. 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, CCRCs may include units providing skilled nursing care in addition or in lieu of assisted living and memory care units.
Board and care homes 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
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.
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 Memory Care (MC) community is smaller and slightly newer than the average AL community and has higher staffing ratios. An MC community is usually a one story secure community with about 40 units or 60-resident capacity. Memory care is also often provided in dedicated units within an AL community (on the third floor of the community shown above 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/MC 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/MR 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
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
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
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.
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.
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.
