“A compelling departure from recent surveys, significantly fewer respondents in the Wave 20 survey cited resident or family member concerns as a reason for slower pace of move-ins and/or faster pace of move-outs the past 30-days—and notably fewer survey respondents cited a slowdown in leads conversions/sales. The CDC reports that more than 2.7 million doses of the COVID-19 vaccine had been administered as of January 26 to residents in nursing care, assisted living communities, and other senior living settings. According to Wave 20 survey respondents, four out of five organizations have had their first clinic. Of those organizations, on average, two-thirds of residents (66%) and nearly one-half of staff (47%) have received the first dose of the vaccine, and nine out of ten respondents anticipate that all residents willing to take the vaccine will be vaccinated within two months. More consumers having access to the vaccine in an environment where infection mitigation is the highest priority may encourage prospective residents to move in and improve future occupancy rates.”

                                           –Lana Peck, Senior Principal, NIC

NIC’s Executive Survey of operators in seniors housing and skilled nursing is designed to deliver transparency into market fundamentals in the seniors housing and care space at a time when market conditions continue to change. This Wave 20 survey includes responses collected January 11 to January 24, 2021 from owners and executives of 92 seniors housing and skilled nursing operators from across the nation. Detailed reports for each “wave” of the survey and a PDF of the report charts can be found on the NIC COVID-19 Resource Center webpage under Executive Survey Insights.

Additionally, the full range of time series data for each wave of the survey by care segment for move-ins, move-outs and occupancy rate changes can be found  HERE.

Wave 20 Summary of Insights and Findings

• Long-anticipated as a game-changer with regard to improving occupancy, seniors housing and care operators are currently holding vaccination clinics for their residents and staff. In December, the CDC prioritized skilled nursing and assisted living residents and staff members in phase 1a of the COVID-19 vaccine distribution. According to Wave 20 survey respondents, four out of five organizations have had their first clinic. On average, two-thirds of residents (66%) and nearly one-half of staff (47%) have received the first dose of the vaccine, and nine out of ten respondents anticipate that all residents willing to take the vaccine will be vaccinated within two months.

• A few survey respondents shared caveats regarding vaccine availability and percentage of residents and staff who received their first dose of the vaccine. Due to varied local vaccine allocations on phases 1a and 1b, or only being able to vaccinate nursing care residents while independent living residents were still waiting for vaccination dates, some said their responses were skewed lower compared to total population.
• Four out of five respondents indicated that educating and motivating staff to take the vaccine was a challenge in distributing the vaccine. To mitigate these challenges, operators are implementing a variety of strategies to encourage and improve vaccine acceptance.

• Mentioned most frequently, early and continued education and robust communication campaigns including print, digital and social media to residents, staff and families about the benefits and risks of the vaccine were strategies noted by all respondents. Other approaches included one-on-one, open-door discussions with community and corporate leadership to answer questions and allay concerns, hosting webinars and holding virtual and town hall discussions with local health authorities and pharmacy partners, management leading by example by taking the vaccine publicly, financial incentives and non-cash prizes for special recognition, utilizing testimonials from resident and staff “champions” of the benefits (and lack of side effects) of the vaccine, and paring up vaccination “buddies” to encourage clinic participation. [Detail on measures some communities are taking to encourage vaccine acceptance among staff can be found in the NIC Notes Blog.]
• In the Wave 20 survey, there was some improvement in the pace of move-ins for each of the care segments except the nursing care segment. The shares of organizations reporting an acceleration in the pace of move-ins in the past 30-days is higher than the portion of organizations reporting decelerations for independent living and assisted living (an improvement for these two care segments since the Wave 14 and 15 surveys conducted in October, reflecting operator experiences in early Fall), but equal for memory care. More organizations with nursing care beds have reported decelerations than accelerations in move-ins for the past seven waves of the survey. The full range of time-series data can be viewed here.

• The share of organizations citing increased resident demand as a reason for acceleration in the pace of move-ins remained high (77%) in the Wave 20 survey but down from a recent high of 86% in the Wave 16 survey, conducted in mid-November. Presumably for various reasons including anecdotal reports of more hospital discharges of patients to home health, and elective surgeries on hold in some locales hard hit by the coronavirus, hospital placement cited as a reason for acceleration in the pace of move-ins (26%) continued to lag the survey time series high of 41% reached in Wave 10, conducted in late July. Other reasons for faster pace of move-ins mentioned by respondents included admissions restrictions being lifted and COVID-19 vaccination clinics having been started.

• Significantly fewer respondents in the Wave 20 survey cited resident or family member concerns than in the Wave 19 survey (38% vs. 74%), and notably fewer cited a slowdown in leads conversions/sales (64% vs. 79%) as reasons for deceleration in move-ins in the past 30-days.

• Approximately one-third of respondents (31%) noted that their organizations had a backlog of residents waiting to move-in. This is just below the high point (34%) reached in the Wave 16 survey conducted in mid-November, and higher than Waves 17 and 19 conducted in December and early January (26%).
• Between 50% to 60% of survey respondents have consistently reported offering rent concessions to attract new residents since the Wave 13 survey conducted in late-September to early-October. Among organizations with multiple properties that were offering rent concessions in the Wave 20 survey, one in three (32%) were offering rent concessions in more than one-half of their properties, and one in four (26%) were offering rent concessions in all of their properties.

• As shown in the chart below, more organizations with assisted living and/or memory care units in the Wave 20 survey than at any other time in the survey time series reported accelerations in the pace of move-outs in the past 30-days. That said, fewer organizations with nursing care beds noted acceleration in the pace of move-outs than in the past five waves of the survey dating back to Wave 15 conducted late-October to early November. Presumably in part due to operator innovations in infection mitigation and creative visitation protocols which have gained acceptance from many residents and families, respondents citing resident or family member concerns as a reason for acceleration in move-outs is at the lowest level in the survey time series (23%). The full range of time-series data can be viewed here.

• For each of the care segments, the shares of organizations reporting occupancy declines continued to outpace those reporting higher occupancy. Considering recent survey data, this trend began in the Wave 16 survey conducted in mid-November (reflecting experiences that occurred during the beginning of the Fall surge in coronavirus cases in October). Essentially unchanged from the Wave 19 survey, between 46% and 57% of organizations with assisted living units, memory care units and/or nursing care beds, and 36% with independent living units, reported declines in occupancy in the past 30-days. The full range of time-series data can be viewed here.

• The chart above shows that in Waves 19 and 20, an equal proportion of operators with nursing care beds (57%) reported declines in occupancy rates. The chart below describes the degree of those occupancy rate changes and illustrates that more organizations with nursing care beds in Wave 20 reported deeper declines than in Wave 19. (The blue and orange-hued stacked bars correspond to the solid bars in the chart above indicating the degree of change by the saturation of color.) In the Wave 19 survey, more than one-third of respondents (38%) reported occupancy decreases of between three and ten percentage points. However, in the Wave 20 survey, nearly one-half had reported the same (48%).

• Similar to past surveys, differences in week-over-week occupancy rates typically result in little change. However, the memory care and nursing care segments show higher shares of respondents reporting occupancy rate increases from one week prior in Wave 20 compared to Wave 19 (17% vs. 7% and 28% vs. 22%, respectively).

Wave 20 Survey Demographics

• Responses were collected between January 11 and January 24, 2021 from owners and executives of 92 seniors housing and skilled nursing operators from across the nation. Just over half of respondents are exclusively for-profit providers (56%), one-third are nonprofit providers (32%), and 12% operate both for-profit and nonprofit seniors housing and care organizations.
• Owner/operators with 1 to 10 properties comprise just over half of the sample (58%). Operators with 11 to 25 properties make up about one-quarter of the sample (22%), while operators with 26 properties or more make up 20% of the sample.
• Many respondents in the sample report operating combinations of property types. Across their entire portfolios of properties, 65% of the organizations operate seniors housing properties (IL, AL, MC), 31% operate nursing care properties, and 36% operate CCRCs (aka Life Plan Communities).

Owners and C-suite executives of seniors housing and care properties, we’re asking for your input! By providing real-time insights to the longest running pulse of the industry survey you can help ensure the narrative on the seniors housing and care sector is accurate. By demonstrating transparency, you can help build trust.

“…a closely watched Covid-19-related weekly survey of…operators
conducted by the National Investment Center for Seniors Housing & Care…”
The Wall Street Journal | June 30, 2020

The Wave 21 survey is available and takes 5-10 minutes to complete. If you are an owner or C-suite executive of seniors housing and care and have not received an email invitation to take the survey, please click this link or send a message to insight@nic.org to be added to the email distribution list.

NIC wishes to thank survey respondents for their valuable input and continuing support for this effort to bring clarity and transparency into market fundamentals in the seniors housing and care space at a time where trends are continuing to change.

In December, the CDC prioritized skilled nursing and assisted living residents and staff members in phase 1a of vaccine rollouts. Now, across the nation, long-term care operators are hosting vaccination clinics for their residents and staff. There are two COVID-19 vaccines currently approved for use in the U.S., with multiple others showing promise in Phase 3 clinical trials. All of this comes as good news. Despite it, Ruth Katz, senior vice president of policy at LeadingAge, warns that as of January 3, 2021, about 50% of nursing home workers were declining to be vaccinated against COVID-19.

In response, operators are implementing a variety of strategies to encourage and improve vaccine acceptance. It should be noted that vaccination clinics continue to ramp up and the CDC reports, as of January 19, that more than 1.7 million doses have been administered across long-term care, representing over 56 percent of the 3 million seniors in skilled nursing facilities, assisted living communities, and other congregate settings.

Leading by Example
To alleviate fears of vaccine side effects, leaders in the long-term care segment are publicizing their own vaccinations. Cindy Baier, President and CEO of Brentwood, Tennessee based Brookdale Senior Living, was among the first in the nation to receive the vaccine. Alongside residents and associates, Baier was one of the first to demonstrate her leadership through example. Similarly, John Moore, Chairman and CEO of Louisville, Kentucky based Atria Senior Living spearheaded what he called the ‘Sleeve Up Atria’ campaign, which urges all staff and residents to get the vaccine as soon as it’s available. By making public their own vaccinations, Cindy Baier, John Moore, and others led through example.

Disseminating Educational Resources
Vigorous education campaigns have also been among the tools used by different types of long-term care operators to increase staff participation in receiving the COVID-19 vaccine. Operators are posting ‘Myth vs. Reality’ posters throughout communities. Educating staff about the safety and benefits of the vaccine and giving them the opportunity to ask questions can alleviate staff concerns. These educational opportunities often have a snowball effect as well and can help persuade others to get vaccinated and add peer pressure to those who are anxious.

Incentives Encourage Immunization
Birmingham, Alabama based Atlas Senior Living is incentivizing staff with up to five paid days off for getting vaccinated. Atlas’ approach focuses on the ‘carrot’ rather than a ‘stick.’ Scott Goldberg, Atlas co-chief executive, said Atlas sought to “avoid villainizing people that didn’t want to take it,” opting instead to focus on education and the reward of paid time off.
Riverdale, New York based Riverspring Health is focusing on small incentives in addition to education and peer encouragement. All staff who receive their vaccine receive a lottery ticket and an entry to win a $50 gift card. Susan Whery, Chief of Geriatrics at the University of New England College of Osteopathic Medicine, suggests that these small “thank you” gifts can be as effective as large bonuses. But the real key to success she says is to “make it the norm to take the vaccine.”

Mandating Compliance
Bloomfield, New Jersey based Juniper Communities has also been engaged in a staff educational campaign showing that the COVID-19 vaccine is both safe and effective. More recently, they have implemented a policy of mandatory vaccinations for all staff, just as is with the case with the seasonal flu shot. CEO Lynne Katzmann says “Our job is to protect people so they can be as healthy as possible…and vaccines are the ultimate form of protection.” In addition to Juniper Communities, Atria Senior Living has also announced that its workers must get both doses of the COVID-19 vaccine by May 1, 2021.

Labor challenges – staffing shortages, turnover, and high staff stress – already challenge the long-term care sector. Some fear that mandating vaccine compliance could worsen employee relations that are already under strain. Katzmann indicates that implementing their peer support program and educational campaigns before imposing the vaccine requirement, has kept staff resignations to a minimum.

Convincing staff to take the vaccine has proven to be challenging, but for the health and well-being of America’s elders, these long-term care operators must persist. As Kim Elliott, senior vice president of Clinical Services, Brookdale Senior Living says, long-term care operators need to “create a culture of vaccine acceptance.”

In a sector with a wide range of stakeholders—at times with differing agendas—a bright spot of the pandemic is how the industry has come together to find common solutions and advocate for help.

The industry’s cooperation and unified messaging has proved beneficial throughout the crisis. Organized efforts early on helped to increase the availability of personal protective equipment (PPE) and testing. A concerted industry approach has also helped to provide additional government assistance to operators and heighten awareness of the role of seniors housing and care in the healthcare continuum.

“The crisis caused the industry to focus and clarify that we’re working toward common goals,” said Brian Jurutka, president and CEO at NIC. He led a discussion with top executives at NIC’s Fall Conference during a session titled, “Working Together to Support Older American: A Conversation with Industry Leaders.”

Jurutka was joined on the panel by James Balda, president and CEO, Argentum; David Schless, president, American Seniors Housing Association; Katie Sloan, president and CEO, LeadingAge; and Scott Tittle, executive director, NCAL.

“We’ve seen an unprecedented level of cooperation among industry groups,” said Jurutka. He added that the industry has continued through the winter to work together to guide government policy, secure additional financial support, and prioritize vaccinations for the staff and residents of seniors housing and care communities. 

“It’s more important than ever that the industry has a united message,” said Argentum’s Balda. “Collaboration has moved the needle on several fronts.”

When the pandemic hit, NIC’s Jurutka pulled industry leaders together for a weekly call. They addressed the sector’s priorities to present a unified message and share best practices on how to mitigate the spread of the virus.

Early industry goals not only focused on securing adequate supplies of PPE and testing, but also on financial help.

After several months of industry effort, licensed senior living settings qualified for access to funds from the CARES Act Provider Relief Fund. “It was a significant step for the industry,” said ASHA’s Schless.

Ongoing Efforts

In late December, Congress passed legislation adding another $3 billion to the Provider Relief Fund. Industry leaders agree that it helps, but the amount won’t be enough to cover rising expenses and occupancy challenges.

Also, many providers are still waiting for the government to distribute previously promised relief funds. Argentum’s Balda said in a follow-up email that all payments should be distributed as quickly as possible, and future funding should apply to third and fourth quarter losses.

Separately, the Department of Health and Human Services announced in January that providers who received more than $10,000 in Provider Relief Fund payments will now have a longer grace period to report to the federal government how the aid was used.

Left unaddressed by the December legislation was the question of reasonable liability protections, which continues to be an industry focus. “We are not asking to not be responsible,” said NCAL’s Tittle during the panel discussion. “But where there is a good faith effort, we need time-limited liability protection.”

Tittle added that the insurance market was already in a difficult place prior to the pandemic. Now carriers, the ones still even offering policies, have raised rates 60%-100% and exclude claims for COVID-19. “The challenge will be significant,” he said.

About half of the states have taken steps to provide liability protections, though a federal approach is preferred by industry leaders.

Consumer outreach and reputation repair is a priority. “We have work to do,” said Katie Smith Sloan, president and CEO at LeadingAge, the association of nonprofit providers.

That work started last spring. Stories and videos of how senior living communities and their residents have adapted to the pandemic are posted on Facebook and ASHA’s consumer website, Where You Live Matters.

More testimonials are being rolled out during the second phase of the campaign. “Consumer sentiment has improved,” said Schless. The other leaders agreed that more consumer education is needed to restore trust in the sector.

Throughout the crisis, NIC has provided data to put the crisis in context. For example, NIC’s Skilled Nursing COVID-19 Tracker shows the week-over-week change rate for new resident cases of COVID-19 within skilled nursing facilities on a per-facility basis, by geography.

The data is displayed in an easy-to-use interactive dashboard that can be sorted down to the county level. NIC is also working on a study of the impact of the pandemic on older Americans by care setting.

The panel discussion wrapped up with a lightning round of predictions. The leaders agreed that the fundamentals of the sector are still strong, but challenges remain.

The industry is focused on securing more federal relief from the Biden Administration; educating consumers and lawmakers about the sector; and adapting to new realities including the prospect of more government regulation. “There is no more important time to be involved in a trade association,” said Tittle. “We encourage everyone to reach out.”

“The drag on occupancy rates continued to be observed in the Wave 19 survey results. This likely reflects a combination of challenges in backfilling COVID-related vacancies as well as the effects of typical seasonality during the holidays and winter months. Despite reports of record-high COVID-19 cases across the country occurring daily, roughly two-thirds of respondent organizations were not increasing move-in restrictions presumably in part due to operator innovations in infection mitigation and creative visitation protocols which have gained acceptance from many residents and families. Long-anticipated as a game-changer with regard to improving occupancy, many operators are now starting to receive the COVID-19 vaccine. The Wave 20 survey is currently collecting data on the distribution of the vaccine to provide new insights for decision-makers.”

                                                                                                                                                                –Lana Peck, Senior Principal, NIC

NIC’s Executive Survey of operators in seniors housing and skilled nursing is designed to deliver transparency into market fundamentals in the seniors housing and care space at a time when market conditions continue to change. This Wave 19 survey includes responses collected from December 28, 2020, to January 10, 2021, from owners and executives of 86 seniors housing and skilled nursing operators from across the nation. Detailed reports for each “wave” of the survey and a PDF of the report charts can be found on the NIC COVID-19 Resource Center webpage under Executive Survey Insights.

Additionally, the full range of time series data for each wave of the survey by care segment for move-ins, move-outs and occupancy rate changes can be found HERE.

Wave 19 Summary of Insights and Findings

• In the Wave 19 survey, more respondents reported decelerations in the pace of move-ins than accelerations in move-ins for the independent living, memory care and nursing care segments. Apart from earlier in the pandemic, this has been the case for the past three surveys for independent living and memory care, and the past six surveys for nursing care. For the assisted living care segment, one third of survey respondents reported accelerations, one-third decelerations and one-third reported no change in the pace of move-ins. The shares of organizations reporting an acceleration in the pace of move-ins in the past 30 days for the independent living segment remained at or around its lowest level since Wave 8 (surveyed late-May to early-June). The full range of time-series data can be viewed here.

• Roughly three-quarters of organizations cited a slowdown in leads conversions/sales and/or resident or family member concerns as reasons for decelerations in the pace of in move-ins in the past 30-days (79% and 76%, respectively), up from about two-thirds in the Wave 18 survey. The approximately one-third of organizations that cited self-imposed or government-imposed moratoriums as a reason for the slowdown in settling new residents into their communities remained unchanged from the prior survey conducted at year-end 2020.

• One-quarter of respondents (26%) indicated that their organizations had a backlog of residents waiting to move in. This is down from a high of 34% reached in the Wave 16 survey and similar to levels last observed in Waves 12 through 15 conducted between mid-September to late October and early November.
• As in prior surveys, the majority of the organizations that responded to the Wave 19 Survey reported no change in the pace of move-outs for each of the care segments. However, the share of organizations that reported an acceleration in the pace of move-outs in the memory care segment increased from about one-quarter in the Wave 18 survey (23%) to one-third (33%) in the Wave 19 survey. The full range of time-series data can be viewed here.

• Shown in the chart below, resident deaths (unspecified reason) continued to be the most frequently cited reason for the acceleration in the pace of move-outs in the last 30-days (79%). This is up from 61% in Wave 13 and below the peak of 85% reached in the Wave 6 survey conducted in early-May. One-half of survey respondents cited residents moving to higher levels of care since the Wave 16 survey conducted in mid-November. Resident or family member concerns cited as a reason for move-outs (34%) was up from 24% in the prior survey.

• Three-quarters of organizations (78%) cited increased resident demand as a reason for acceleration in the pace of move-ins (down from a recent high of 84% in Wave 16). Presumably for various reasons including anecdotal reports of more hospital discharges of patients to home health, hospital placement cited as a reason for acceleration in the pace of move-ins (28%) continued to lag the survey time series high of 41% reached in Wave 10, conducted in late July.
• Between 45% and 57% of organizations with assisted living units, memory care units and/or nursing care beds, and 38% with independent living units, reported declines in occupancy in the past 30 days. For each of the care segments, the shares of organizations reporting occupancy declines continued to outpace those reporting higher occupancy. Considering recent survey data, this trend began in the Wave 16 survey conducted in early November (reflecting experiences that occurred during the beginning of the Fall surge in coronavirus cases in October).
• Compared to Wave 18, the percentage of organizations with independent living and nursing care segments reporting month-over-month declines in occupancy rates was higher in the Wave 19 survey results. While notably fewer organizations with assisted living units reported declines in occupancy since the prior survey, notably more organizations with nursing care beds reported declining occupancy. The full range of time-series data can be viewed here.

• The chart above illustrates that in Wave 19, 57% of operators with nursing care beds noted declines in occupancy rates. The chart below describes the degree of those occupancy rate changes. The blue and orange-hued stacked bars correspond to the solid bars in the chart above indicating the degree of change by the saturation of color. For the nursing care segment, more than one-third (38%) reported occupancy decreases of between three and ten percentage points. The independent living segment saw the least occupancy rate change, with more than one-third (38%) reporting no change.

• Regarding the change in occupancy from one week ago, between two-thirds and three-quarters (65% to 79%) of organizations reporting on their seniors housing units, and 46% of organizations with nursing care beds noted no change. That said, all care segments saw more organizations reporting week-over-week occupancy declines than increases.
• More than one-half of respondents in the Wave 19 survey (56%) were offering rent concessions to attract new residents. Organizations offering rent concessions has been above 50% in the survey since mid-September. One survey respondent noted that newer, cleaner, or better maintained buildings appear to be better positioned for supporting rents due to steady demand.

• In addition to rent concessions putting pressure on many organizations’ NOI, operating costs are continuing to be strained as nine out of ten of the organizations in the Wave 19 survey were paying staff overtime hours and two-thirds were using agency or temp staff to backfill staffing shortages (92% and 65%, respectively). Some respondents cited additional staffing shortages due to infection and overwhelmed local hospitals reducing the pool of nursing agency staff available in the market.
• Budget increases due to increased need for PPE were a challenge for about one-third of respondents to the Wave 19 survey. However, fewer respondents reported challenges obtaining PPE due to restrictions on allocation (15%, down from 29% in the Wave 17 survey) or obtaining product due to high demand/competition (23%, down from 36% in the Wave 17 survey).
• Over the past three waves of the survey, the higher levels of care segments (assisted living, memory care and nursing care) reported increases in PPE budgets commensurate with growing levels of care. Additionally, organizations with the largest portfolios of properties were more likely to report significantly higher PPE budget increases than single-site operators.
• In Waves 17, 18 and 19 of the survey, one-half of respondents received their COVID-19 test results within 2 days (52%). Despite the swell in coronavirus cases across the country beginning in the Fall months, these findings were relatively unchanged since the Wave 14 survey in mid-October.

Wave 19 Survey Demographics

• Responses were collected between December 28, 2020 and January 10, 2021 from owners and executives of 86 seniors housing and skilled nursing operators from across the nation. Approximately half of respondents are exclusively for-profit providers (52%), one-third are nonprofit providers (34%), and 14% operate both for-profit and nonprofit seniors housing and care organizations.
• Owner/operators with 1 to 10 properties comprise just over half of the sample (66%). Operators with 11 to 25 properties make up about one-quarter of the sample (14%), while operators with 26 properties or more make up 20% of the sample.
• Many respondents in the sample report operating combinations of property types. Across their entire portfolios of properties, 69% of the organizations operate seniors housing properties (IL, AL, MC), 32% operate nursing care properties, and 35% operate CCRCs (aka Life Plan Communities).

Owners and C-suite executives of seniors housing and care properties, we’re asking for your input! By providing real-time insights to the longest running pulse of the industry survey you can help ensure the narrative on the seniors housing and care sector is accurate. By demonstrating transparency, you can help build trust.

“…a closely watched Covid-19-related weekly survey of…operators
conducted by the National Investment Center for Seniors Housing & Care…”
The Wall Street Journal | June 30, 2020

The Wave 20 survey is available and takes just 5 minutes to complete. If you are an owner or C-suite executive of seniors housing and care and have not received an email invitation to take the survey, please click this link or send a message to insight@nic.org to be added to the email distribution list.

NIC wishes to thank survey respondents for their valuable input and continuing support for this effort to bring clarity and transparency into market fundamentals in the seniors housing and care space at a time where trends are continuing to change.

The senior living market faces a new reality. The economic fallout of the pandemic has put pressure on the affordability of many communities. Elders who previously had the resources to move into a community may no longer be able to do so, expanding the already large group of seniors with modest incomes in need of housing. At the same time, more middle-income seniors are drifting into the low-cost end of the market.

Alternative housing models for middle-income seniors were explored at the 2020 NIC Fall Conference. The session, “Senior Housing’s New Reality: Impacts and Ideas for the Forgotten Middle,” was led by Torey Riso, an investor and independent consultant. He was joined by John Cochrane, CEO, HumanGood; James Lydiard, staff vice president, CareMore Health; and Bill Pettit, president, R.D. Merrill Company.

Riso kicked off the discussion noting that a NIC-funded study in 2019 highlighted the need for middle-market housing. The study showed that 54% of seniors could not afford much of the seniors housing product on the market. “The pandemic focused attention on the already challenging reality to serve this middle market,” said Riso. He added that there is an opportunity to change the rules and reconsider all elements of the seniors housing model: the building, financing, services, staffing and payment sources.

The panelists discussed three different approaches to help reduce the cost of housing for middle-income seniors.

Create a Mixed-Use Community

HumanGood operates life plan communities and affordable housing for low-income seniors. The challenge is to meet the needs of the 80% of seniors who fall between those two extremes, noted Cochrane. “We have a unique opportunity to bridge the gap.”

Cochrane pointed to the successful example of Plaza Roberto Maestas, a transit-oriented community in Seattle’s Beacon Hill neighborhood, financed with public and private funding sources. The development is more than housing, creating a true community. Elements include affordable apartments for seniors and families, along with retail and commercial space, an early childhood facility and a community center. The project is situated around a central plaza, allowing all age groups to interact. “The project connects to the larger community,” said Cochrane.

Middle market communities will increasingly rely on complex financing structures, such as those used at Plaza Roberto. “That is the future,” said Cochrane. “No one size fits all.” He added that the size and stability of the affordable seniors housing market will attract investors that will enjoy reliable returns over a long period as well as a social benefit.

Rethink the Full-Service Model

Owner /operator Merrill Gardens primarily serves seniors in the upper 25% income category. But management felt the company was losing touch with its traditional middle-income base. So, Merrill Gardens partnered with ReNew REIT and purchased a portfolio of older seniors housing properties. The cost of the properties was lower than that of new developments which could help lower rents for residents.

The properties will be rolled out as a new brand for middle-income seniors. But despite the lower cost basis of the properties, Pettit noted that much of the rent is still driven by operations. “We need to think about how to deliver a valuable product for middle-income seniors,” he said.

The new brand will not be a full-service model. Instead, it will be designed around what typical seniors might do for themselves living at home. “We think middle-income seniors are more open to participating in their own needs,” said Pettit. For example, instead of a restaurant-style dining program with multiple menu items, the new model might offer food options more like those available at an extended stay hotel. The new model also will take a close look at alternative service delivery models to cut personnel expenses. “Take off your full-service hat,” Pettit advised.

Merrill is exploring partnerships with local providers, such as home health services. The family will also be a key partner to provide some care needs.

Pettit believes that through partnerships on the care side, and dining changes, that the buildings can operate at rents of $1,000 to $2,000 less a month than at higher-end properties. That provides a lower profit margin than that of the expensive projects. But when the real estate is acquired at a 40-45% discount to new development, the yield on cost is superior, according to Pettit.

Reduce Healthcare Costs

The pandemic has shown that housing and healthcare are intrinsically linked. Making healthcare accessible and affordable helps reduce care costs and increase the residents’ length of stay. CareMore offers a Medicare Advantage plan for seniors housing properties that can help offset care costs. When enough residents sign up for the plan, CareMore can provide medical personnel on-site. Also, working with one health plan can save the community staff time spent coordinating care among different providers. “Government funded dollars should be part of the equation,” said Lydiard. He added that the Medicare program is seeking novel approaches to reduce costs. Seniors housing, where care can be delivered efficiently to a growing number of elders, will be part of the solution.

The panelists agreed that more than one solution will emerge to meet the challenge to house middle and lower-income seniors. “This is a huge market, and its needs are varied,” said Cochrane. “There will be different models and we will need every one of them.”