Carolyn Seaton had been looking for a way to stretch the savings of her nonagenarian parents and still get them the full-time care they needed. When the school nurse found a condo opening in a long-term care facility near her home outside Philadelphia in early March, she felt fortunate and put down a $1,000 deposit.
Then the facility told her she could lose the room to an emergency admission, so Seaton agreed to pay $200 a day to reserve the spot until her parents could move in. She says the facility made no mention of Covid-19 quarantines or other coronavirus-related restrictions, though the Centers for Medicare and Medicaid Services by that point had issued warnings.
As the outbreak spread and deaths mounted, Seaton and her family decided a move was untenable and tried to cancel their reservation. “Nobody in their right mind would move their parents in such a situation,” Seaton says. While she’s wary about senior-living facilities after the experience, she’s also worried about the costs and possible dangers of her parents staying put in their New Jersey home, where they already have full-time care with an aide.
Fraught in good times, long-term care decisions have become even more agonizing in the pandemic era. Covid-19 preys on older people, and congregate-care settings like nursing homes and assisted-living facilities are an ideal environment for a highly contagious virus to spread quickly. Nursing homes and other senior-living facilities have been hit hard. National statistics are difficult to get, but the nonprofit Foundation for Research on Equal Opportunity estimates 40% of Covid-19 deaths occurred in nursing homes and assisted-living facilities.
The senior-living industry was already in a state of flux—adjusting to longer life spans, more-active retirements, a labor shortage, and changing desires for care—before the coronavirus outbreak. The crisis is sure to accelerate the upheaval—and what emerges will look different from today.
“When it comes to the senior-housing industry and care, there will be a time we see this in the rearview mirror but not a time when we will return to the old normal,” says Robert Kramer, who founded the nonprofit National Investment Center for Seniors Housing & Care, or NIC, and now heads aging advisory Nexus Insights. “That is critical for this industry and investors to understand.”
The pandemic has led many families to think about pulling a relative from a congregate-living situation—an emotional, personal decision based on the individual’s needs, family situation, and alternatives. For those who try to place their loved ones elsewhere, even temporarily, there may not be a spot to return to.
Long-term care experts also caution that people often move into assisted living because care at home isn’t feasible. It can be difficult to find an apartment for an older person who may be bed-bound and require in-home care—which itself can be difficult to find—as well as fighting the isolation of being home alone without pre-crisis activities or visits. And while assisted-living facilities have strict protocols to prevent the spread of coronavirus, it may be harder to replicate that in a family home with children and others going in and out of the community.
Yet to understand what the future could look like, it’s important first to understand that not all senior-living facilities are the same. Different types of facilities are lumped together under the broad senior-living umbrella, which in turn is often confused with nursing homes that provide skilled care for the most frail patients. Outside of nursing homes, senior living takes different forms, with some built around a hospitality or real estate model and others, like assisted living, more care-oriented.
Nor are all senior-living facilities regulated the same. While nursing homes are federally regulated, the broader range of options from assisted-living and memory-care facilities to independent senior-living communities are largely paid for privately by residents and regulated to different extents by states. That means coronavirus infection and fatality data for these properties are hard to find on a national level, leaving the roughly two million older Americans who live in these communities largely off the radar.
The pandemic’s challenges
This divergence in oversight has led to an acute health crisis during the pandemic. While the government in recent weeks has taken steps to get more personal protective equipment, or PPE, and testing into nursing homes, some models of senior living haven’t received the same priority. Assisted-living facilities; continuing-care retirement communities, or CCRCs; and home health-care agencies that tend to millions of seniors aging in place remain largely undersupplied.
“The most consistent and frightening trend is the lack of prioritization of these facilities,” says Lori Smetanka, executive director of nonprofit National Consumer Voice for Quality Long-Term Care. This is especially troubling, she adds, because these communities may not have the same amount of staffing to help—both with medical needs or in connecting quarantined residents with their families—as nursing homes.
Many of the private-pay senior-living communities also aren’t linked to their cities’ essential services, like hospitals or nursing homes. These communities have also struggled to get much-needed weapons to fight the virus, such as widespread testing, which is crucial as resident-to-resident transmission has been higher in assisted living than nursing homes, where people tend to be bed-bound and doors are closed, says Morgan Katz, director of antimicrobial stewardship at Johns Hopkins Bayview Medical Center and an assistant professor of infectious disease at Johns Hopkins University School of Medicine.
“We are very behind in responding to assisted-living facilities,” Katz says. In testing assisted-living and skilled-nursing facilities in Maryland, Katz and her Hopkins team found swift transmission of the virus. If widespread testing was performed soon after one symptomatic resident tested positive, about 15% of the residents and staff were positive when universal testing was done; if universal testing was performed later, when five to seven symptomatic residents had already tested positive, about half of the facility was infected. Katz says the situation in assisted-living alone was worse.
And though most communities have ended communal dining and canceled group activities, residents are still getting infected—in part as asymptomatic staff or other workers are unknowingly spreading the virus. In Katz’s tests at facilities, 60% to 70% of those who came back as positive were asymptomatic at the time of testing.
“We are on the front lines of the battle, but assisted living has largely been left out of priority for key components of personal protective equipment, testing, and funding,” says Scott Tittle, executive director of the National Center for Assisted Living, which represents 30,000 operators and roughly 800,000 residents.
The group has called on governors to make long-term care facilities a priority for PPE and testing and letting nurses and other medical professionals cross state lines to assist with staffing shortages. About 75% of operators of independent living, assisted living, memory care, and CCRCs surveyed in April by McKnight’s Senior Living reported shortages of PPE.
Some operators have taken things into their own hands. For example, Atlanta-based Thrive Senior Living, which operates 16 communities in the South and Middle Atlantic regions, located tests, labs, and doctors that could prescribe tests, and joined a co-op with 41 other senior-living communities to source gear from China and find new distributors. “We just blew up the phone,” says Les Strech, president of Thrive Senior Living. The co-op vetted multiple factories in China—including doing testing on-site to assess quality— and then found space on a privately chartered plane and hired a truck to transport the gear to Atlanta.
James Balda, chief executive of Argentum, the largest senior-living group in the U.S., says that operators’ supply costs have doubled and that labor costs could rise 20% on average. The industry may need to hire 200,000 to 300,000 more people to help with the additional needs from the pandemic. As a result, the industry could face an economic cost of $40 billion to $57 billion over the next year.
Operators’ finances are also taking a hit from a fall in occupancy rates as move-ins slow, sometimes due to family concerns but at other times because of state and local lockdown restrictions and guidance for long-term care facilities. Before the crisis, roughly a fifth of senior-living communities had occupancy rates below 80%—a level that could make it harder for them to weather the slowdown, especially as costs increase and cash flow takes a hit.
Occupancy rates at assisted living and memory care should recover, since the coronavirus won’t eliminate the need for a certain portion of the population to require higher levels of care, says Beth Mace, chief economist at NIC. But the fallout from the economy and people’s confidence about the industry could slow demand for independent senior living, especially among those who were planning to sell their homes or use savings to fund their retirement homes.
The upshot is that families are faced with decisions on what to do next, while thousands of senior-living communities are left to fend for themselves to protect residents and staff, recalibrate for a post-Covid world, and grapple with soaring costs.
Rethinking where to live
The daily news of tragedies at nursing homes and stories of families unable to visit loved ones because of quarantines are going to leave a mark on the industry. “There’s a great danger that the boomers will view senior living as equating to senior dying,” Nexus Insights’ Kramer says.
Even before the crisis, however, many seniors were leery of moving into a senior-living community. Surveys routinely find 9 out of 10 people say they would like to stay in their homes, says Bob Stephen, vice president of caregiving and health at AARP.
There are ways to make aging in place easier. The village model, a grass-roots movement of older Americans who form their own microcommunities that are run by volunteers and paid staff, could become more popular postcrisis, according to Stephen. Members typically pay a small annual fee to be part of the community, partake in group activities, and tap volunteers to run errands or help with other services. Members also get a list of vetted service providers such as maintenance and household help.
Beacon Hill Village in Boston was a pioneer, and during the pandemic its members mobilized quickly. The village had its dedicated drivers become grocery shoppers, taking lists via text, email, or paper, and organized a phone tree of volunteers to check in on one another.
The pandemic also pushed members to re-examine their ideas on how things should be done, including an acceleration in technology use such as telemedicine for routine doctor visits or Zoom for chatting with friends and family. The village’s regular speaker series, tea parties, and cocktail hours moved online—and enrollment in online exercise classes even outpaced the old classes, says Steve Roop, chairman of the village. “We held our own very well, thank you, because we cooperated and understood there was a value of hanging together versus hanging separate,” Roop adds.
But the village model hasn’t tackled the one big challenge to aging in place: dealing with care needs once they become more intense. And that’s one of the reasons that some families are still thinking about senior-living options. If the social part of the equation is in place, it’s the care component that typically drives people to senior care like assisted living or CCRCs that offer both independent living and various levels of care.
Michael and Simone Onder for years have been debating moving into a CCRC that has independent living and then, if needed, various levels of care available, and were getting closer to making a purchase before Covid-19 struck. The Virginia couple is still leaning toward the CCRC. “It’s about being realistic,” Simone Onder says. “If something happens to either of us, we have to have a safety net.”
But Covid-19 has changed the type of unit they want to buy: “We were looking for a top unit with a view of the woods and a balcony, but are now thinking it would be better to have a first-floor unit with a patio so we can escape without going through the building,” Michael Onder says.
Senior-living operators are also rethinking design and layouts. “Physical distancing is the key that keeps us safe, but we saw residents physically and cognitively declining from two to three weeks of social distancing,” Thrive’s Strech says.
Thrive looked for alternatives, including moving Covid-19 isolation units from upper floors of facilities where there was no access to the outdoors for fresh air and sunshine to the ground floor where patients could get outside safely. Thrive also created clear panels in doorways so residents could see and talk safely with visitors—and is trying to do that for dining options, as well.
Also under consideration across the industry: smaller groups of units in a building rather than several dozen units down a long hallway, designating areas that can be used for isolation and incorporating much more outside space, and rethinking the heating and air-conditioning system to circulate air over smaller areas.
Johns Hopkins’ Katz says that group activities and communal dining will need to be reinvented and done in smaller groups, and buffets probably will be a thing of the past. Telemedicine and technology will be much more integrated into communities.
Pressure to reinvent senior living more broadly is also intensifying. Part of the industry has used a hospitality or real-estate model and not accounted for the public-health ramifications of older people living in close proximity.
That model is the “worst of all worlds,” says Anne Tumlinson, who runs aging consultancy ATI Advisory. She has long advocated that assisted-living properties have a doctor on-site—an arrangement already in place at some places that has sped up things like testing during the crisis. Some new models that are taking a multidisciplinary approach—such as bringing in mini-health and wellness clinics to senior living—could be a path to the future.
And to woo baby boomers after the crisis, senior-living communities will also have to rethink what they are offering. “The model of aging services is built on this condescending dependency model,” Kramer says. “People don’t want to turn 75 and be entertained until they die as if they don’t have anything to give.”
The successful operators will be those offering opportunities for enrichment, volunteering, and multigenerational activities—possibly by partnering with liberal-arts colleges, he adds.
And while the industry had been focused on small condos in major urban centers for empty-nesters, Kramer sees an end, or reversal, of that trend, with a preference instead toward less-dense cities and college towns with access to top hospitals and culture.
“The idea [that] retirees will buy a tiny one-bedroom with little private space and then hang out in congregate areas, this is where we aren’t going back to the old,” Kramer says.
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