Photos of Life Plan Communities in Baltimore

In my November 9, 2023 webcast for the Maryland Association for Parkinson’s Support (MAPS) I discuss Life Plan Communities (LPCs) as a housing option for Parkinson’s patients. LPCs were preciously called continuing care retirement communities (CCRCs). The industry changed the terminology used to describe these communities to emphasize the lifestyle they offer, rather than their ability to provide different levels of care over time as residents age.

There are 17 LPCs in the Baltimore metro area, with two additional communities under development or seeking pre-sales. We focused on Broadmead, Charlestown, Edenwald, Roland Park Place and Vantage Point in Columbia to understand pricing, contract options, etc. and to determine if the community offers PD care on site or in close proximity to the community. The photos below provide additional a feel for our focus communities.

LPCs offer a full range of senior housing options on a single campus. These communities are typically 300 to 500 units in size, offer very attractive common areas, programs and a wide variety of activities and programs. Two Baltimore area LPCs, developed by Erickson, have 1,850 units and I call them mega LPCs. LPCs typically charge an entrance fee and a month service fee. We believe these communities are well-designed to accommodate a PD patient and a healthy spouse because of the broad range of activities they offer, and a number of Baltimore LPCs now provide PD support groups and exercise programs on campus.

LINK TO WEBINAR ON UNDERSTANDING SENIOR HOUSING & CARE OPTIONS – SELECTING A LIFE-PLAN COMMUNITY IN BALTIMORE

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.

https://bethambaltimore.org/selecting-a-life-plan-community-in-baltimore-webinar-series/

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.

Finding Happiness In A Senior Housing Community

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.​

ASHA Feel At Home Graph

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.

Convert Colleges to Senior Hsg. Enrollment Declines Create New Opportunities

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, The Wall 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.

Are Baby Boomers Now Ready for Seniors Housing?

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.

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.

Converting Private Colleges To Senior Housing – Just Announced Welltower Transaction Shows Opportunity is Real

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

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

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

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

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

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

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

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

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

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

https://www.ericksonliving.com

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

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

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

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

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

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

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

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

Finding A Good Death – Understanding and Shopping For Hospice Care

Background

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

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

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

According to data from the Social Security Administration:

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

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

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

Understanding Hospice

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A Popular Benefit

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

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

Electing Hospice Care

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

Selecting A Hospice Provider

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

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

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

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

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

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

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

 

 

Reusing Suburban Corporate Headquarters As CCRCs

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

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

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

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

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

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

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

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