Hundreds of investors, owners, operators, analysts, and other industry stakeholders attended the latest in NIC’s new series of Leadership Huddle events Wednesday. In the webinar portion of the event, which was sponsored by National Health Investors (NHI), they were treated to a virtual smorgasbord of insights and expert discussion around financing markets in seniors housing and care. Attendees who had opted to participate in the Zoom discussion breakout session that followed, continued the discussion, adding their own thoughts and experiences in small groups.

Seniors housing financing markets have evolved over the course of the COVID-19 pandemic—as lenders and owners both adapted in real-time—to unprecedented asset-level revenue declines exacerbated by operating expense increases. In a “fact or fiction” Q&A-based format, an expert panel, including both lenders and borrowers, explored what really occurred during 2020 from a lending perspective, how transactions are being quoted currently, and what the near- and long-term future will hold for seniors housing debt. Co-facilitators Joel Mendes, Senior Director, JLL Capital Markets, Seniors Housing, and James Thompson, Senior Vice President, Director of Senior Housing Investments, BOK Financial, came prepared with a variety of “fact or fiction” questions, designed to elicit honest, insightful responses on how lenders, owners, and others in the industry are thinking and behaving during this extraordinary time. Panelists Robb Chapin, Chief Executive Officer, Bridge Seniors Housing Fund Manager, LLC, and Steven Schmidt, National Director, Seniors Housing Group, Freddie Mac, fielded the questions.

On whether COVID-19 has reduced investor interest in seniors housing funds, Chapin responded, “that’s a hard fact, for sure.” He said that his group shelved those funds in the first six months of the year, focusing instead on the operational challenges brought on by the pandemic. For the rest of the year, he saw “10% to 15%” of normal flows of investment.

Mendes, responding to a question on non-recourse acquisition financing in 2020, suggested that the most-used term within the industry last year was “hit the pause button.” Permanent lenders such as Fannie Mae and Freddie Mac underwrote fewer loans as in-place cash flows, which they require to support their loans, declined throughout the year. Further, the non-recourse bridge debt market, according to Mendes, “did not fully materialize until later in 2020.”

Asked whether Freddie Mac’s senior housing portfolio has fared well, Schmidt responded, “relative to what we’ve heard from other lenders, that is predominantly true.” However, he said that the pandemic caused more stress in the seniors housing sector than did the global financial crisis. Freddie Mac instituted a three-month forbearance program, which he said was taken up by twice as many in seniors housing than in multifamily. The good news, according to Schmidt, is that most of those borrowers are now current. “We feel the program provided the necessary relief during the worst part of the pandemic, and we feel very good about that.”

Another line of questioning concerned the impact of regulators throughout the pandemic. Generally, panelists were positive, lauding the CARES Act, the Federal Reserve, who took action to temporarily ease balance sheet requirements, and PPP loans, all of which helped stabilize the sector throughout 2020.

Other questions focused on the present situation. The first of these concerned whether debt markets are a hindrance to the desire to buy and build new assets. Chapin labeled this one as a fiction, indicating that his organization was generally pleased with the response from lending relationships. He said, “we anticipate that we will continue to have very good outcomes with our lenders as it relates to refinancings and new acquisitions in 2021.” He continued, saying, “What we’re generally seeing is more conservative underwriting on debt service coverage ratios, lower LTVs, increased underwriting expenses for PPE, labor, insurance, and all the typical things that we’re all experiencing right now that have to be factored in.” He said that, although his company isn’t planning any new ground-up development projects for 2021, they expect to have shovel-ready projects in 2022.

Another “fiction,” according to Mendes, is that “new development financing terms are so conservative as to render them non-existent.” On the contrary, he said, “we closed new development debt financings all through 2020 and continue to do so today.” He said, “If I could pick one financing term that has changed the most since March 2020, I’d say it’s ‘recourse.’ Lenders are requiring more of it. Non-recourse debt financing, particularly that starts with a six on the loan-to-cost, is pretty hard to come by.” He continued, “If you’ve got a solid project it can get financed today, no doubt about it.”

On current lending, both Chapin and Thompson indicated optimism, particularly as vaccinations continue to reach millions of residents within seniors housing. Thompson said, “Lenders are learning what to ask when it comes to underwriting and due diligence. I see more lenders willing to dig in and do the due diligence than earlier in the pandemic. It’s early in the year so, from a practical standpoint, lending groups have loan-growth goals that they have to deal with.”

Some questions probed into the near future. Mendes, explaining his optimism, said, “a theme in the senior housing capital markets in 2020 and through to today is that in-place performance at the asset level is usually declining month-over-month. You engage a deal in September and, come December, the numbers look worse, which has caused ongoing stress in the transaction process. I believe what we’ll see later this year is just the opposite. The numbers are going to start looking better as the transaction process progresses. This trend, in my opinion, will be accelerated by the decline in construction starts, and also combined with the growth in the 80-plus demographic.” He pointed out that growth in that demographic from 2021 to 2023, “is projected to be twice what it was from 2017 to 2019.”

Mendes continued, saying, “from an equity perspective, dry powder in the United States for real estate in December 2020 was over $200 billion, that’s uninvested private equity, which is close to a record high.” He explained that, with so much liquidity in the market, “lenders can expect high quality sponsors, like Bridge for instance, with the ability to invest meaningful equity into transactions.”

Looking ahead, the panelists generally foresee a gradual return to pre-pandemic business practices and performance. They discussed the impact of numerous factors throughout 2021, including the regulatory impact on banks, the potential for improved occupancy, and the attractiveness of the sector to investors. On that point, Schmidt pointed out that big pre-COVID challenges, such as labor shortages and oversupply of new properties have eased. He said, “Operators will have to recognize, and I think we are, the new normal and not revert back to the old normal and continue to evolve. That creates the real opportunity. The owners and operators that do that really well will attract a lot of investment capital going forward.” The webinar portion of this NIC Leadership Huddle event is available, in its entirety, on NIC.org. Registration is now open for the upcoming February 24 Leadership Huddle, titled, “Is There an Investment Case for Skilled Nursing in the Intra-and Post-Pandemic World?” Spaces for the follow-up discussion group are limited, and are offered on a first-come, first-served basis

“Significant headway is being made to vaccinate residents and staff in seniors housing and care communities. According to 84 small, medium, and large seniors housing and skilled nursing operators from across the country—ranging in size from single-building operators to operators with hundreds of buildings across their portfolios of properties—considering all care segments, approximately 80% of residents and 50% of staff have received their first dose of the COVID-19 vaccine on average, and about 60% of residents and 45% of staff have received their second dose. While educating and motivating staff to be vaccinated continues to be cited as a challenge, the majority of organizations have not made the vaccine mandatory. Although one-quarter of respondents noted an increase in prospect interest specifically related to the availability of the vaccine, the survey data has yet to show an upward trend in occupancy. It will be interesting to see when the trend begins to reverse with greater penetration of the COVID-19 vaccine in the coming weeks and months.”

                                                                                                                                                                –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 as market conditions continue to change. This Wave 21 survey includes responses collected from January 25 to February 7, 2021, from owners and executives of 84 small, medium, and large seniors housing and skilled nursing operators from across the nation, representing hundreds of buildings and thousands of units across respondents’ portfolios of properties.

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 21 Summary of Insights and Findings

• Most organizations that responded to the Wave 21 survey, which ended on February 7, had already finished their first COVID-19 vaccine clinics, and many, but not all, have started their second clinics. Nine out of ten have had their first clinic (94%), while two out of three (62%) have had their second clinic. Among those organizations that have received the second dose and have more than three properties in their portfolios, over half (57%) have received it in up to 25% of their properties, and one-third (32%) have received the second dose in 50% to 75% of their properties.

• Four out of five organizations in Waves 20 and 21 indicated that educating and motivating staff to take the vaccine was a challenge (the Wave 20 survey report detailed strategies by operators to encourage and improve vaccine acceptance; Wave 21 measures those strategies for change). The majority of organizations have not made the COVID-19 vaccine mandatory for residents and/or staff (87%). Whether or not the vaccine remains voluntary for most organizations will continue to be monitored in Wave 22 of the survey as anecdotal comments by some operators suggest that unless staff vaccination rates improve, mandatory vaccination may be considered.

• According to Wave 21 survey respondents, approximately 80% of residents and 50% of staff of seniors housing and care properties—considering all care segments across their portfolios of properties—have received their first dose of the COVID-19 vaccine on average, and about 60% of residents and 45% of staff have received their second dose. This CDC report offers comparison data regarding vaccine coverage among more than 11,000 skilled nursing facilities in their first clinic conducted during the first month of the CDC Pharmacy Partnership for Long-Term Care Program.
• The chart below shows the average of survey respondents’ residents and staff that have taken the first dose of the COVID-19 vaccine, by region. The East North Central and Mid-Atlantic regions were the lowest for residents—averaging 76% and 69%, respectively. The Southeast and Mid-Atlantic regions were the lowest for staff—averaging 45% and 40%, respectively. It is important to note that vaccine distribution rates depend on a variety of factors including but not limited to supply and demand, acceptance, and vaccination administration logistics.

• Vaccination administration logistics was a challenge for roughly 40% of organizations in Waves 20 and 21. Many operators indicated that their organizations have experienced varying levels of disorganization, confusion, and delays in terms of the pharmacy program in vaccinating residents. Some organizations mentioned that they are working to provide resources and information for their independent living residents on where they can get the vaccine on their own in some states, including Florida and California.

• Many operators have been eagerly anticipating a boost in occupancy due to the COVID-19 vaccine availability. Although about one-quarter of organizations responding to the Wave 21 survey note an increase in prospect interest specifically related to the vaccine, most (67%) do not, suggesting other influential factors. For example, the share of organizations citing increased resident demand (86%) as a reason for acceleration in the pace of move-ins in the past 30-days is at the highest level since the Wave 12 survey. Additionally, respondents citing resident or family member concerns as a reason for acceleration in move-outs continues to trend at its lowest level (20%) due in part to operator innovations in infection mitigation and creative visitation protocols which have gained acceptance from many residents and families, quelling move-outs due to the virus. (Some organizations have branded programs to the marketplace highlighting their commitment to safety and health protocols).
• In Wave 21, the shares of organizations reporting acceleration in the pace of move-ins is higher than the portion of organizations reporting deceleration for each of the care segments. Furthermore, organizations reporting deceleration in the pace of move-ins has shrunk across each of the care segments over the past three waves of the survey.
• While the independent living care segment saw the least change in the pace of move-ins, with 62% of organizations noting no change, more organizations with memory care units reported acceleration in the past 30 days (40%) than in eight prior waves of the survey (reflecting operators’ experiences in mid to late August).

• Substantially fewer respondents in Wave 21 noted that their organizations had a backlog of residents waiting to move in (15%)—lower than at any time since the question was first asked in late July, and down from approximately one-third of respondents in the prior survey. Possible reasons may include typical seasonality experienced during the winter months and fewer organizations offering rent concessions to support sales. In the Wave 21 survey, the fewest respondents reported offering rent concessions to attract new residents (45%) since mid to late August. Another possible reason may include less turnover of inventory. The pace of move-outs slowed in the Wave 21 survey. Between 75% and 82% of organizations noted no change or deceleration in the pace of move-outs in the past 30-days for each of the care segments.

• Reflecting operators experiences at the end of 2020, the Wave 21 survey data has yet to show an upward trend in occupancy. For each of the care segments, the shares of organizations reporting occupancy declines in the past 30-days (across their portfolios of properties) continued to outpace those reporting higher occupancy. It will be interesting to see if the data that has been trending this way since the Fall surge of the coronavirus begins to reverse with greater penetration of the COVID-19 vaccine in the coming weeks and months.

• The chart above shows that in Wave 21, 41% of organizations with nursing care beds reported increasing occupancy rates. The chart below describes the degree of those occupancy rate changes and illustrates that more organizations with nursing care beds in Wave 21 reported stronger increases than in the prior three waves of the survey. (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 21 survey, about one-third of respondents with nursing care beds (31%) reported occupancy increases of three percentage points or more. However, in the Wave 20 survey, fewer than one-fifth had reported the same (16%).
• Similar to past surveys, differences in week-over-week occupancy rates typically result in little change. However, the assisted living and nursing care segments show higher shares of respondents reporting occupancy rate increases from one week prior in Wave 21 compared to Wave 20 (23% vs 13% and 40% vs. 28%, respectively).

Wave 21 Survey Demographics

• Responses were collected between January 25 and February 7, 2021 from owners and executives of 84 seniors housing and skilled nursing operators from across the nation. 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 (26%), while operators with 26 properties or more make up 15% of the sample.
• About one-half of respondents are exclusively for-profit providers (47%), two out of five (41%) are nonprofit providers, and 12% operate both for-profit and nonprofit seniors housing and care organizations.
• Many respondents in the sample report operating combinations of property types. Across their entire portfolios of properties, 68% of the organizations operate seniors housing properties (IL, AL, MC), 36% operate nursing care properties, and 45% operate CCRCs (aka Life Plan Communities).

Owners and C-suite executives of seniors housing and care properties, we’re asking for your input! By demonstrating transparency, you can help build trust. The survey results and analysis are frequently referenced in media reports on the sector including in McKnight’s publications, Mortgage Professional America Magazine, Senior Housing News, Multi-Housing News, and other industry-watching media outlets. The surveys’ findings have also been mentioned in stories by Kaiser Health News, CNN, the Wall Street Journal, and other major news outlets across the U.S.

The Wave 22 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.

Medicaid Revenue Per Patient Day Up But Cost of Care Still a Concern.

NIC MAP^® Data Service released its latest Skilled Nursing Monthly Report on February 4, 2021, which includes key monthly data points from January 2012 through November 2020.

Here are some key takeaways from the report:

Occupancy

Occupancy continues to be challenged for skilled nursing properties, with the November 2020 occupancy rate falling to a new low of 74.2%. It was down 69 basis points from October (74.9%) and 11.2 percentage points from pre-pandemic levels in February 2020 (85.4%) and 10.7 percentage points from year-earlier levels. Since February 2020, COVID-19 has significantly impacted skilled nursing operations across the country due to high acuity levels of residents, pandemic-related deaths as well as fewer elective surgeries at hospitals which have resulted in less need for rehab services often provided by nursing care properties. As the country and the skilled nursing sector navigate through the Winter months and vaccine distributions, it is likely that occupancy will continue to face pressure.

Nursing homes have disproportionately suffered during the COVID-19 pandemic, housing some of those most vulnerable to the virus. Over the past year, the rate of new COVID-19 cases among skilled nursing residents moved nearly in tandem with the rate of new cases within the nation as a whole. However, the distribution and administration of vaccines looks to be having an impact on this susceptible population.

Within a few weeks of the launch of the Long Term Care (LTC) vaccination program administered through the Pharmacy Partnership Program, with the Pfizer-BioNTech vaccine on December 21, 2020 and the Moderna vaccine on December 28, new COVID-19 cases within skilled nursing properties have been sharply lower than the U.S overall new cases at any previous point. Various reports show that residents overwhelming opt in to receiving vaccinations, whereas during a similar time less than 10% of the U.S. population had received at least one vaccine shot. These initial results are promising and provide another potential data point on the effectiveness of vaccinations in preventing new COVID-19 cases.

As of February, over 30 million people have been inoculated in the U.S. and the vaccines appear to be safe and effective. According to the latest NIC Executive Survey Insights (Wave 20), which collected survey results from January 11 – 24, 2021, “two-thirds of residents (66%) and nearly one-half of staff (47%) have had their first dose.” Increasingly, there is support for the idea that as the number of people who are vaccinated increases, the number of hospitalizations should potentially decrease, as was indicated in a study of trends in Israel and its high vaccination rates.

Since CMS began reporting data in late May, newly confirmed cases within skilled nursing properties have followed the same pattern as the U.S. overall new cases, as reported by the CDC. For the week ending December 20, both overall new cases in the U.S. and within skilled nursing properties reached new peaks before slipping back in late December. In fact, U.S. new virus cases reached a seven-day moving average of about 220,000 on December 20, while the per-resident rate of new COVID-19 infections set a record at 3.03% at the same time, according to data compiled by NIC’s Skilled Nursing COVID Tracker.

However, in recent weeks, there has been a noticeable divergence in these trends as the vaccines have been administered and distributed to skilled nursing properties. NIC’s Skilled Nursing COVID Tracker featuring the latest CMS data update as of January 24, 2021 shows that case counts of COVID-19 and fatalities at skilled nursing properties have started to decline. Although, new cases in the U.S. (7-day moving average) reached levels higher than the prior December peaks by January 10 (244,702), newly confirmed cases within skilled nursing properties continued falling steadily and remained far below the previous peak seen on December 20, with a one percentage point decline recorded over four weeks from 3.03% on December 20 to 1.96% on January 17.

Similarly, new coronavirus fatalities among skilled nursing residents have flattened and slightly decreased from December 20 levels, while U.S new fatalities (7-day moving average) continued to climb at a faster pace. For the week ending December 20, fatalities in skilled nursing properties accounted for approximately 31% of overall new fatalities in the U.S. By January 17, the skilled nursing new fatalities as a share of total fatalities in the U.S. dropped to 21%.

“It’s only through having access to representative data that we can begin to understand the impact of policies and actions. The transparency provided by the CMS data set is helpful in understanding the impact prioritizing skilled nursing has had since it provides for a longitudinal view of the impact COVID-19 has had relative to the broader U.S. The decrease in new cases and fatalities in skilled nursing properties relative to trends in the total U.S. is encouraging, particularly given the timing relative to widespread distribution of the vaccine to long term care properties,” said NIC president and CEO, Brian Jurutka.

As background, NIC has been publishing a regular updated weekly surveillance report since June 2020 on the incidence of COVID-19 cases and fatalities among residents in the nation’s nursing care properties. Using data collected and reported by the Centers for Medicare & Medicaid Services (CMS), NIC’s Skilled Nursing COVID-19 Tracker (Tracker) reports CMS nursing home data and provides insights into the rate of virus spread within skilled nursing properties.

The Tracker shows where cases are spreading, slowing, or remaining flat. In addition, the Tracker depicts the incremental week-over-week change rate in four important metrics on a same-store basis, i.e. the same nursing properties are tracked each week across regions, sub-regions, states, and counties. The metrics include: (1) new COVID-19 confirmed cases per same store properties, (2) new COVID-19 confirmed cases as a share of residents, (3) new COVID-19 fatalities as a share of residents, and (4) occupancy rates (based on CMS Data). Importantly, the Tracker allows users to drill down to a smaller market or a specific property and access the underlying data.

To gain in-depth insights and track the week-over-week change rate for new resident cases and fatalities of COVID-19 within skilled nursing properties at the state and county levels, visit NIC.org. You can also access the Skilled Nursing COVID-19 Tracker along with a rich trove of analysis and insight on the NIC COVID-19 Resource Center.

For more reading on the effects of COVID-19 in skilled nursing properties, see the following report:
https://www.nic.org/wp-content/uploads/pdf/SNCT-Insights-Report-Special-Issue.pdf

NIC is committed to provide timely data, analyses and insights that increase transparency and understanding of the sector, especially in this difficult time of COVID-19. We strongly support all actions and efforts that prioritize distribution of COVID-19 vaccines, testing, and availability of PPE to protect frontline workers and residents.

NIC Leadership Huddles are back. The popular live webinar series, which NIC initially launched as part of its response to the COVID-19 pandemic last year, launched anew on January 27, with a very timely focus on policy, just a week after the swearing in of President Biden. The new series, which offers a complimentary new Leadership Huddle twice each month into July, seeks to retain the same level of relevance, and quality of discussion, which drew thousands of industry decision-makers to the Leadership Huddles in 2020.

The new series comes with a few tweaks. Upon registration, attendees can sign up not only for the webinar, held via GoToWebinar, but can opt to attend a facilitated peer-to-peer group discussion within Zoom, immediately afterwards. Attendees are also encouraged to pose a question or two during registration for prospective discussion during the webinar sessions. Access to the peer-to-peer group discussions is offered on a first-come, first-served basis, to ensure an appropriate number of participants for the collective discussions.

While COVID-19 will likely feature prominently in many Leadership Huddle Webinars and associated discussions, the series will cast a broader net, to include all of the major issues impacting the sector today. Titled, “Policy Outlook: A New Administration & A New Congress,” this series-first Leadership Huddle focused, appropriately, on the key policy issues impacting the seniors housing and skilled nursing sectors; what actions the new Administration and new Congress are likely to take; and the funding decisions that are critical for advancing integrated care and services for America’s seniors.

The fast-paced webinar covered a great deal of ground concerning policy impacts on the industry, leaving attendees hungry to delve into more detail in the peer-to-peer discussion session, which was moderated by Juniper Communities Founder and CEO, Lynne Katzmann. But first, NIC Co-Founder and Strategic Advisor, and President, Nexus Insights, Bob Kramer, moderated the webinar. He kicked it off by observing that the new administration and new Congress have hit the ground running, saying, “It seems like every few hours there’s a release, a report, an announcement, dealing with the topics we want to talk about today.”

Expert panelists Dan Mendelson, Founder and former CEO of Avalere Health, and Anne Tumlinson, Founder, ATI Advisory, offered insights on a broad range of policy-related topics, many of which can be expected to have a significant impact on the seniors housing and care industry, both in the long- and short-term.

The discussion kicked off with assessments on the vaccination goals of the Biden administration. Mendelson said investors and operators in the space should “should strap on their seatbelts because there’s going to be a lot of activity coming out.” Pressed by Kramer on whether we’ll meet the administration’s 100-day goal on vaccinations, Mendelson said, “I think we’ll exceed it, if the people on this call get into gear and really facilitate the change. This is not something that’s just going to happen because someone else does it.”

Another major policy movement is Biden’s proposed $1.9 Trillion stimulus package, designed to revive the economy, protect businesses, and combat the pandemic. Both panelists agreed that, unlike previous packages, this one is designed to put money directly into the hands of individuals. Nevertheless, the package, which is quickly going through Congress, is likely to flow resources into the sector as a means to combat the pandemic.

Panelists also tackled the expansion of Medicaid and Medicare coverage, minimum wage increases, and a variety of “lightning round” questions on the public health emergency, the three-day hospital stay rule, telehealth, and scrutiny on assisted living. An in-depth recap of the full discussion is available in this month’s NIC Insider.

You can register to attend upcoming NIC Leadership Huddles, including both the live webinars as well as the optional, first come, first served participation in peer-to-peer discussions, within the Events tab on www.nic.org. Registrants are provided with a recording of the event, compliments of NIC, and our generous sponsors and partners.