By Dean Solden
This is a two-part article adapted from works by Dean Solden, Founder and President of Creative Senior Solutions (creativeseniorsolutions.com).
Hello everyone. My name is Dean Solden and I have been involved with senior living for over thirty years as an Executive Director, Regional Director, Owner/Operator of a regional chain of assisted living and memory care communities, and as a nursing home administrator. Over that time, I have seen the good, the bad, and the ugly of the industry. And that was before the pandemic, which has been the most difficult time in most of our careers.
As we are starting to fill our buildings back up, and start a new chapter in our industry, I thought it would be a good time to take a step back and re-evaluate the past years, value our successes, and see where we as an industry could have done better. The goal is to help our older citizens lead even more fulfilling lives in the coming decades, help our staff and managers become more successful and professionally satisfied, and create strong and vibrant businesses and an industry we can all be proud of.
Whenever there is a break in an industry cycle, this is a chance for a new start. There are many senior companies out there who were struggling even before the pandemic hit. Now, for some, it is even worse, and although our buildings are beginning to fill up again, census still has not reached pre-pandemic levels. Maybe, as the years have gone on, your buildings are a bit tired and worn; maybe you haven’t focused on your “philosophy” in quite a few years. Or maybe you’ve been thinking about your mission and vision.
Wherever you are in your business cycle, one thing we can count on: things will be changing in the next few years and changing fast.
Change is Coming
I believe there are three significant elements impacting Senior Living right now and will even more so in the near future. They are:
- The COVID-19 pandemic and its ramifications
- A fresh wave of senior-specific technology
- Boomers starting to enter the senior living marketplace
I believe these three elements will radically change the industry, and those who don’t pay attention to them may not stay relevant and may not be able to compete in the years ahead. In other words, I believe it is time to Re-imagine Senior Living.
In a series of articles, I hope to provide you with information and inspiration which will:
- Help newcomers in the industry understand our history a little better
- Identify some structural deficiencies in the industry many of us have seen over the years
- Offer some potential solutions for companies, owners, and managers to, not only overcome these deficiencies, but to create newer systems and models so they can be better prepared for the changing needs of our existing and new customers
First, however, I would like to say that I truly love the senior care industry. There are so many caring and compassionate people in this field! And so many showed up big time during the pandemic. Our care staff has been phenomenal, especially those who stayed through the storm. They are true American heroes. Our managers have also been terrific – working sixteen-hour days and taking shifts on the floor when they were short-staffed. Owners and operators came through with money for supplies and “hero pay”. And many kept the doors open even when the cash flow wasn’t there. (Thank you, US Government for the PPP money. That truly helped.)
Despite these wonderful people, from inception, there have been systemic flaws in both the nursing home and assisted living industry. And I think now is a good time to address them. I think it is important that before we re-open a chapter in the industry, we at least talk about them, address them, and see if we can learn from those challenges to make things better for everyone.
So here goes . . .
Part 1: The Old Frontier – The Early Days . . . Nursing Homes
The idea of congregating hundreds of seniors together started approximately in the late 1950s and early 1960s. It was necessary at the time, as for the first time in our country, we had one million senior citizens needing some sort of care outside of the home. This was a direct result of two societal milestones:
- People were living longer due to the rapid advance of medical technology throughout the twentieth century, (i.e., x-rays, surgeries, and advancements in medications), and
- Women were joining the workforce, both for gender equality as well as financial reasons.
This brings up what I call, Problem Number One. What model did we use to care for these people? Unfortunately, in my opinion, the government and industry used the hospital as the model of choice. While this seemed the most efficient model at the time, it also created problems we are still dealing with today sixty years later.
While good nursing homes provided reasonably good quality of care, the model and the buildings themselves hindered people from helping create a high quality of life for residents. They just weren’t built for that. This turned out to be a big mistake. This is why nursing homes always have had a poor reputation as far as the public is concerned, despite the amazing people who have worked in them over the years.
In addition to the model being imperfect, some of the problems were created by the state surveying process, which emphasized the “safety” of each person over their quality of life, rather than the quality of care being equal to the quality of life.
As far as payment, nursing homes were, and are, paid for mostly by the government in the form of Medicare and Medicaid. Medicare, as many of you know, pays for and continues to pay for up to 100 days of “rehab” for everyone over the age of 65, as “rehab” is one of a person’s Medicare benefits. Medicaid was originally set up to pay for and guarantee the long-term care of those poorer citizens in the country. But this has evolved to be a middle-class program, as almost everyone who isn’t wealthy runs out of private funds not long after entering a nursing home. Unfortunately, the government has not yet expanded that right in most states to pay for assisted living.
I cannot see most boomers wanting to go into forty, fifty, and sixty-year-old nursing homes that have not had a major renovation. We will need new and updated rehab communities for them.
Assisted Living 1.0
In the 1990s I watched with delight and excitement and was honored to be a part of the creation of the revolutionary assisted living industry, which I like to call Assisted Living 1.0. With its residential living and social model in place of an institutional medical model and its goal of providing more dignity and respect to its “residents,” things improved for one-half of the now three million people needing some form of care in America. However, assisted living did not cure all the systemic issues of the industry.
First of all, it was, and still is to a great degree, a private-pay business. Only about 40 percent of the population can afford assisted living, as Medicaid only pays for a small percentage of assisted living care in the country. And, despite the buildings having changed for the better, many “facilities” were and are still using the nursing home organizational model. This means the focus is still primarily on the quality of care, with quality of life being important but secondary.
In all fairness, like the nursing homes, much of this was and still is due to state surveying processes. Despite the surveying issues, many of us have seen beautiful and elaborate assisted living and independent living communities where some people are still often bored, lonely, and depressed. In the first decade of assisted living communities, operators were still providing “custodial” care, without, I believe, enough emphasis on quality of life.
Assisted Living 2.0
In the 2000s through the 2010s, I watched the further evolution of Independent Living (IL), Assisted Living (AL), and Memory Care (MC) communities. Individual rooms and apartments became larger, and more amenities like movie theaters, swimming pools, and gourmet dining became more common (for those who could afford it). There became more emphasis on stimulating activities, meaningful relationships, and a better quality of life for the residents. All good stuff.
However, there was little evolution in the development of our front-line staff, and how they were trained, treated, and respected.
Today – 2021
So here we are, 2021. We are still living with remnants of the Great Pandemic of 2020, going into our second year of this new normal. Now, with most of our residents and many of our staff having been vaccinated, we are seeing some light at the end of the tunnel. Many of us have lost census. And while people are slowly coming back to senior living communities, we are not fully back yet. In many places, we still do not have normal visitation, normal activities, and sometimes even normal dining.
So where do we go from here? We all know as the boomers hit AL and MC in the coming years, they are not going to want much of what we are now offering. Boomers are more independent (even when dependent), want to lead meaningful lives where they can make a difference (and have fun), and will want meaningful relationships. They are going to want to do what they want to do and will not want to fit in to a simplistic formula.
Here are a few items all senior communities should look at and think hard about in changing the culture of their communities as we enter the age of what I call Senior Living 3.0.
Remove “Senior Living” from the Community
We should think about not being senior living communities and focus on just being communities where there are seniors living. Despite all our advances in the industry with hospitality, there is still an “us and them” perception of senior living in the outside world. We need to stop being seen as them – (even beautiful) senior homes on the hill where someone goes to die or live out their final years, separate from the rest of society. I suggest moving toward being fully integrated into the community — socially, physically, financially, and emotionally. Boomers do not want to be separated from society.
In fact, we are a community — we have people who live here, people who work here, and both groups have families that are very involved. (You may notice I like to use those terms when possible instead of the words “resident” and “staff.” We are all just “people.”) I believe there has been an over-focus on “the resident,” and an under-focus on the “staff,” with both groups having families sometimes overlooked. If we focus on being communities where seniors live, people work, and families are interacting with each other, everyone will live a more fulfilling life, especially our seniors.
I have an idea for this kind of community focus. As some are starting to do, our dining rooms could be more like coffee shop/bistros with comfortable couches and counters where families, outside community members, grandkids, and students can come and just hang out, buy lunch or coffee, and sit with their grandparents and their laptops. Like urban cities now providing retail on the first floors of almost all buildings, we, too, could provide retail in our communities, with small shops and stores or kiosks. So our residents, their families, and the outside community can stop by and purchase the items they need. (Senior) Communities can be “dynamic,” not “static.” We can be a part of society, not an island away from it.
Focus on Quality of Life
Quality of life should be considered by companies (and the state) as just as important as quality of care (Assisted Living 2.0). State surveyors need to integrate quality of life into their survey process. Many providers have quality of life in their mission and do try and live up to that. But I have seen many who struggle with this, as so much time and energy is allocated to providing the basic care people need. I have seen some inexperienced operators still think that providing just custodial care (Assisted Living 1.0) is enough to draw in residents. I think that is a mistake. But all is not lost! There are ways to turn things around. It starts at the top, with a great mission and vision, then motivation, training, and finally a commitment toward culture change.
Ditch Old Names (and Old Sentiments)
Can we once and for all agree on some new names in our industry? Can we please retire the word, facility, as in assisted living facility, as well as nursing home, and convalescent home? These names add to the “we versus them” mentality. No one wants to live in a facility. Or should. Thank you for indulging me. It’s my pet peeve.
A New Focus for a New Generation of Seniors
I firmly believe that boomers are not going to be satisfied with bingo and mediocre food, even in nicely appointed communities. (I know many people still like bingo, but you know what I mean.) Most will not even want studio apartments. Many AL’s are going to have to up their game, have larger apartments, serve much better food (farm to table is the current trend), and have more robust activity departments. Individual “life plans,” will be a norm, just as we have individualized care plans.
I believe we could use more focus on monitoring people’s emotional and mental health as we do their physical health. At least part-time social workers could be the norm. There is now also good software out there that can help with this as well.
This new generation of seniors is going to want to do what they want to do, not just what we offer them. And with the soon-to-be-unlimited quantity of virtual activities at their fingertips and on their TV/computer monitors, they will be able to. Having a full-time IT person is starting to be a must in moderate to larger senior communities to maximize both communications with family and friends and entertainment.
However, much of this is old news, already. Many of you have been doing these things for years.
Is this really all there is? Is this what the new frontier will look like? I don’t think so. In Part two of this series, I will “Re-Imagine” what senior living could look like in the not far distant future.