Seniors Housing and Government Can Work Together for a Bright Future. 

One of the attractions of any NIC Conference is the caliber of thought leadership and insight provided in main stage keynote sessions. Typical keynotes, held in large ballrooms, hardly feel intimate. In contrast, much of the 2020 NIC Fall Conference, hosted on a virtual platform that put every speaker and attendee on a face-to-face basis, felt close, personal, and disarmingly genuine. This dynamic was on display for one of the most anticipated keynote discussions of the nation’s most important seniors housing and care event.

Award-winning journalist Soledad O’Brien adeptly moderated a discussion with Mark Parkinson, president and CEO, American Health Care Association (AHCA) and National Center for Assisted Living (NCAL), and Andy Slavitt, senior advisor for The Bipartisan Policy Center and former Acting Administrator of the Centers for Medicare & Medicaid Services (CMS). Both leaders were frank and forthcoming regarding the impact of COVID-19 on seniors housing and care. Despite coming from the often opposing viewpoints of industry leader and policymaker, the discussion demonstrated that, for seniors housing and care, the pandemic promises to teach industry leaders a great deal – and has created opportunities to work with government to craft a bright future, while delivering better outcomes for America’s frail elders.

Trump and COVID

O’Brien’s first question was for reactions to the news which had just broken, that President Trump and the first lady had tested positive for COVID-19. Parkinson took the opportunity to express his hope that, “As bad as the news is, maybe it will be a wakeup call some people needed, that you’ve got to take this stuff seriously. You have got to wear a mask because anybody, under any circumstance, can get this virus.”

Slavitt pointed out that, in addition to the President, “43,000 other people were diagnosed with COVID yesterday.” He agreed that while we shouldn’t be politicizing the President’s health, the country might learn two lessons from the news, “One is, a thin piece of cloth would have prevented this from happening…the second lesson is simple consideration. Trump and his staff and his family entered a room, sat around Chris Wallace, were feet away from Joe Biden. None of us know whether we have COVID-19 or not…that’s why we wear masks.” He hoped that, like (UK Prime Minister) Boris Johnson, who fell seriously ill with the virus, Trump would take this more seriously, wear a mask, and encourage others to do so.

The Second Wave

Asked whether the seniors housing and care industry is prepared for a second wave, Parkinson was optimistic. “We are. We were completely unprepared for the first wave.” He explained that the virus’ ability to spread via asymptomatic carriers wasn’t understood at first. That, and the lack of masks and appropriate PPE, “really caused it to spread like wildfire in nursing homes and assisted living facilities across the country…the other thing we needed was testing, and we didn’t have that either.” He pointed to “horrendous policy mistakes made at multiple levels, that created the challenges we had.”

Parkinson continued, “For phase two we’re in better shape. The policymakers have not done great, but the scientists have. The testing we now have…as well as a little better position on PPE, I think we’re in a much better position. Clinically, we also know a heck of a lot more about how to take care of people, so the mortality rate is down.” Nevertheless, he echoed Slavitt’s frustration with America’s failure to enact simple preventive measures. He said, “We don’t have to have a second wave. What’s so damned frustrating about this is that if everyone would just wear a mask, just that simple, considerate thing, if we would just make a decision as a country that everywhere we go we wear a mask and socially distance, we wouldn’t eliminate this in two weeks – but we would grind it to very low numbers.”

Slavitt raised community spread as another key factor impacting nursing homes. He said, “It is very, very difficult, once there is community spread, to prevent that spread from getting into the nooks and crannies where everybody lives.” While agreeing that the industry today is better prepared to protect frail elders, he appealed to everyone, politics aside, to be considerate of others and help to contain the spread of the virus.

“A Business Disaster”

The discussion turned to the state of the industry, which has seen a fall in occupancy rates and a simultaneous rise in costs associated with fighting the pandemic. Parkinson said that, “My overriding message to the folks who are watching this, who are primarily investors in long term care, is that we’re going to get through this, and this is going to continue to be a good space to invest in and that’s not just hollow cheerleading. I believe there’s good data and good reason to believe that.” He went on, however, to outline how the pandemic has caused a “clinical nightmare and a business disaster.”

Parkinson offered a litany of dismal facts, including over 50,000 deaths in nursing homes, and tens of thousands in assisted living facilities. He pointed to census data that dropped from 85% to 75% in just a “month or two,” and half that in assisted living. He pointed to major increases in expenses, as operators scrambled to acquire PPE, often at “ten times the normal rate” on the black market, while paying ‘hero pay’ to staff and incurring other related expenses.

Asked how he can be optimistic in the wake of such grim realities, Parkinson said, “The good news is the government recognizes that we are an essential service, and thank god for the CARES Act funds, that have now provided nursing homes a combined, probably, almost 20 billion dollars.” He also pointed to long-term demographic advantages, saying, “people need our services. We have a growing demographic, really exploding in the age group that we take care of, and as reluctant as people will be for a while to move into our buildings, which I completely understand, people don’t move into our buildings because they want to, they move into our buildings because they have to. They just can’t be taken care of safely at home anymore. It will be bumpy, and it will take some time, but the demographics are compelling. We will win the public’s confidence back, and I think this will be a good space to be in, eventually.”

The Opportunity to Improve

In agreement with Parkinson, Slavitt said, “industries through time emerge stronger from crises, often, if they do some self-examination, like Mark’s talking about, if they really, genuinely look at what they’re doing and say, ‘here are four or five things that can help us.’” He added, “This is an industry that everybody cares about, every Congress person, every senator, every presidential candidate needs this community to be successful. It’s not too big to fail, it’s too important to fail.” He said, “I love the fact that the industry is opening dialogue, that the industry is talking to the White House and HHS every day, that we’re figuring this out together.”

Parkinson warned industry decision makers not to miss this opportunity to improve. “The knee-jerk reaction for some might be, ‘Hey, let’s just get this behind us and try to move on with business as usual.’ That would be a huge mistake. You cannot ignore the fact that close to 100,000 people have died in long term care facilities. If we don’t use that as a moment of reflection, to not just look at what caused this, outside of our control, but look in the mirror and figure out those things that were within our control that could have slowed some of this down, and what could we do to be better in the future, then we’re missing an enormous opportunity.”

Regulatory Reform

Both panelists agreed in other areas, as well. On the burden of regulations, Parkinson pointed out that skilled nursing is more heavily regulated than “virtually all other healthcare providers,” and stated the “amazing statistic” that “80% of the enforcement budget at CMS is spent on nursing facilities.” He suggested that CMS focus regulations on “things that really matter,” such as infection control, person-centered planning and activities, and other areas where nursing homes can improve care for their residents.

“Mark’s right. You can’t regulate culture,” Slavitt responded, then advocated for “what works best,” which he described as an industry that recognizes what it needs to improve and asks for investment from the taxpayer to get there, as well as the accompanying regulations, which, “would make everybody comfortable, and provide assurances.” He added, “If the industry is able to move itself to that point, I think the industry will find a very ready and willing partner in the government, no matter which government…”

Workforce

On workforce issues, Parkinson said, “We don’t pay our healthcare workers enough, particularly the frontline workers in long term care.” He asked the question, “What do we do to make sure that we not only have enough people to work in our facilities, but that they can do so and take care of their own lives?” He linked the answer to the need for funding, as well as immigration reform. In response, Slavitt again offered some agreement, saying, “Right now, people who spend their day caring for the rest of us, if they somehow don’t have enough money to make ends meet, that is a litmus test that we should address…there’s plenty of resources in this country to do that.”

On immigration, Parkinson advocated for resolving the “dreamer problem,” as well as reviving programs that bring nurses in from foreign countries. “The challenge that economies will face in the 21^st century, is where they will get the workers that are needed. The demographics of a declining workforce are very bad across all of the developed world.”

Addressing the politics of immigration, and acknowledging the need for workers, Slavitt said that “there actually is a center point of agreement on a number of these topics.” He explained that while they may not make everyone happy, they offer solutions to “add fairness” and move the country forward. “Sometimes it takes an event, sometimes it takes a new Congress, sometimes it takes a new way of looking at things, but one day, hopefully soon, we can resolve some of these issues.”

Medicare and Medicaid

Another issue that both experts addressed was Medicare and Medicaid. On Medicare, Parkinson acknowledged that the new payment plan, PDPM, initiated under Slavitt’s administration and recently put in place, is working well. He views Medicaid, on the other hand, as a politicized program that is now underfunding care in many states. “We’re going to have to figure out what our priorities are. Instead of just talking about these workers, these heroes, and the greatest generation, are we really willing to put some resources behind that, to give them the kind of care, and the kind of jobs, that they deserve.”

Slavitt responded, “In some point of time, whether it’s before or after the election, we’re going to have to do that [fund Medicaid], or many people who are on Medicaid today are going to face challenges, and payments are going to get even lower.” He pointed to a recent actuarial report that indicated, “Over the last year, Medicare lost two years of the life of its trust fund, and is now projected to turn insolvent in 2024.” What worries him, he said, is that during the next presidential term, the program will become underfunded. He explained that the next President may be in a position either to fund the program or cut benefits and payments under the program.

Towards the close of the discussion, addressing national priorities, Slavitt said, ”What we need is some radical introspection, as a country, into what kind of country we want to be. Part and parcel of this is the question of how we take care of people who need our help; they’re no longer at the stage where they can care for themselves, whether it’s because they have a disability, whether it’s because they’re aged, whether it’s because they’re low income, whether it’s because they’re sick. I think that is an enormous part of our national debate.”

For the past two weeks, over a thousand seniors housing and care leaders from across the U.S. have logged on, often from their own home offices, to participate in their industry’s most important event. Of course, ‘the NIC’, in response to the COVID-19 pandemic, is now a virtual experience. But industry professionals have embraced what it has to offer. Many have discovered that ‘the NIC’ is as rich in thought-leadership and opportunities to connect with other decision-makers as ever – and that in some ways, the ‘essential virtual’ experience offers surprising advantages over traditional events.

In the runup to the conference, NIC Founder & Strategic Advisor, Bob Kramer, pointed out that the new platform offers real value for attendees. He said, “The 2020 NIC Fall Conference is not only a uniquely affordable educational opportunity, it also provides an unprecedented new dealmaking platform, the NIC Community Connector™.” The vast majority of attendees are now registered on the NIC Community Connector, ensuring that there are, indeed, plenty of opportunities to connect directly with people in a position to make a deal.

In practice, attending companies were able to extend opportunities to connect and learn to more of their staff than they would otherwise send in person. “We are taking advantage of the virtual format by including more of our team to build on essential relationships and gain invaluable insights from the educational sessions,” said Marilynn Duker, CEO of Brightview Senior Living. Without the cost, both in dollars and time, of travel and booking accommodations, and with a lower price for registration, the conference attracted numerous attendees who might otherwise not have made the trip.

By Popular Demand

In many ways, the conference adhered to traditional educational and thought-leadership programming. In total, more than 50 sessions offered insights, opportunities to participate in substantive discussions, presented the latest data and analysis, and featured some of the nation’s foremost experts and industry leaders. As in any in-person NIC conference, keynote general sessions featured panels of experts who needed no introductions.

Award-winning journalist Soledad O’Brien moderated a discussion with Mark Parkinson, President & CEO, American Health Care Association (AHCA) and National Center for Assisted Living (NCAL), and Andy Slavitt, senior advisor for The Bipartisan Policy Center and former Acting Administrator of the Centers for Medicare & Medicaid Services. Both leaders were frank and forthcoming regarding the impact of COVID-19 on seniors housing and care.

Parkinson, on whether the seniors housing and care industry is prepared for a second wave, said, “We don’t have to have a second wave. What’s so damned frustrating about this is that if everyone would just wear a mask, just that simple, considerate thing, if we would just make a decision as a country that everywhere we go we wear a mask and socially distance, we wouldn’t eliminate this in two weeks – but we would grind it to very low numbers.”

On funding Medicaid, Slavitt said, “In some point of time, whether it’s before or after the election, we’re going to have to do that [fund Medicaid], or many people who are on Medicaid today are going to face challenges, and payments are going to get even lower.” Towards the close of the discussion, Slavitt had this to say about national priorities, ”What we need is some radical introspection, as a country, into what kind of country we want to be. Part and parcel of this is the question of how we take care of people who need our help, they’re no longer at the stage where they can care for themselves, whether it’s because they have a disability, whether it’s because they’re aged, whether it’s because they’re low income, whether it’s because they’re sick. I think that is an enormous part of our national debate.”

Another highly anticipated general session featured an O’Brien-moderated discussion with seasoned political commentators, David Brooks and David Gergen. It felt like an honest, forthright assessment of the impact of the coming election on the sector. David Brooks offered a mea culpa on his 2016 predictions of a Clinton victory, and described his efforts since then to reconnect with the segments of the American populace with whom he’d grown out of touch. Both men offered their insights and predictions for the election – as well as their assessment on the impact it will have on American life and business interests.

The popular NIC Talks series, now a highly anticipated staple of the traditional event, returned —featuring another group of uniquely qualified, passionate thought-leaders, including JoAnn Jenkins, CEO of AARP, addressing the question, “How will COVID-19 impact the future of aging and aging services?” In the style of “TED-Talks,” these often emotionally powerful presentations added some punch to the analysis and data on offer in week one. A week two peer-to-peer discussion offered an opportunity to further discuss the NIC Talks presentations, with moderator Bob Kramer and NIC Talks presenter, Dan Cinelli.

In addition to one of the richest educational programs ever offered at a NIC conference, the event extended a variety of means for attendees to build and grow their business and social networks. Echoing in-person events, the virtual platform reveals to its users who else is in the lobby, or in a breakout session, and allows them to message one another, either in text or via video chat. Anyone who misses running into old friends in hallways should be heartened by this means to interact in such an organic, impromptu manner.

New Ways to Network

The unique, new NIC Community Connector launched in parallel to the event, and is currently only available to its attendees, who may continue to use it free of charge through the end of 2020. The innovative online platform provides a means to search for potential new contacts, and to communicate directly with the deal-makers they need to meet with. NIC is continuing to develop the platform, with new features scheduled to launch this year.

Attendees were also able to set up ‘braindates’ with each other, either one-on-one or in small groups. These intimate, focused exchanges provided not only a means to share thinking, but to connect with fellow attendees, and potentially to begin to build and grow new relationships with peers, based on those interactions. Through braindate™, attendees set up their own focused discussion groups, joined groups set up by fellow attendees, or arranged one-on-one meetings of their own.

In week two, called ‘connections week,’ NIC hosted numerous peer-to-peer discussions, on carefully curated topics of immediate relevance in today’s world. These moderated events offered participants expert thought-leadership, as well as frank discussion, and often eye-opening insights and ideas, offered up by attendees sharing their own real-world experiences and perspectives in more intimate small group breakout discussions.

Beyond educational sessions, the event offered attendees a variety of opportunities to spend time with each other, network, engage in self-care, and even share some cocktails or world-class entertainment together.

A series of ‘Brand, Brain, and Being’ sessions offered attendees a chance to focus on themselves and gain expert tips on improving personal brand, productivity, creativity, and overall wellness. Just as in traditional events, there was a LinkedIn expert on hand to help improve social profiles.

Meanwhile, for NIC MAP® Data Service power users and novices alike, there were opportunities to learn from NIC MAP experts, discuss how they use the NIC MAP Data Service platform, and meet (virtually, of course) with NIC MAP staff to discuss how the industry’s leading data service might benefit their businesses. Discussion groups for NIC MAP users delved into how they use the platform to analyze market feasibility, inform underwriting, and effectively target markets.

As with traditional NIC events, the attendee experience also included world-class entertainment. As week one drew to a close, the Young@Heart chorus, introduced by an impressive collection of A-list celebrity admirers, charmed and entertained with their talented, and infectiously fun, performances. Perhaps the most anticipated session of week two was a behind-the-scenes experience with Broadway and film cast members from “Hamilton!”, who also delighted fans of Broadway’s most popular show with exclusive performances that were simply not to be missed.

Although the conference has ended, attendees will retain access to a library of its many educational sessions and will also be able to use the powerful NIC Community Connector through the end of 2020. As expressed by NIC CEO Brian Jurutka in a press briefing, “I believe this conference – and the NIC Community Connector – will be valuable to thousands of leaders and their businesses, as they begin to craft a new normal and build towards a successful future, both for their businesses and for the millions of America’s elders seeking access and choice in seniors housing and care.”

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—providing both capital providers and capital seekers with data as to how COVID-19 is impacting the sector.

This Wave 13 survey sample includes responses collected from September 28-October 11, 2020 from owners and executives of 73 seniors housing and skilled nursing operators from across the nation. Detailed reports for each “wave” of the survey can be found on the NIC COVID-19 Resource Center webpage under Executive Survey Insights.

Wave 13 Summary of Insights and Findings

The shares of organizations with assisted living units and/or nursing care beds reporting an acceleration in the pace of move-ins in the past 30-days rose to the highest levels since the survey began in March (43% and 46%, respectively). Coupled with fewer organizations reporting an acceleration in the pace of move-outs, more organizations reported upward changes in occupancy for these care segments. Acceleration in move-ins was most frequently attributed to increased resident demand, with one-quarter of respondents indicating that their organizations had a backlog of residents to move into their communities. Organizations citing resident or family member concerns as a reason for deceleration in move-ins (presumably due to the uncertainty of the prevalence of COVID-19 in the fall months and potential for restrictions on visitation) declined from three-quarters to two-thirds but remains higher than in prior surveys. While accurate and timely testing (within 48-hours) is crucial to operators’ ability to settle new residents into communities and keep them safe from outside contagion which could be brought in by visitors or staff, nearly two-thirds of respondents were waiting three days or more for test results, and still only about one-half of respondents find it easy to obtain PPE and COVID-19 test kits.

• • In Wave 13, approximately 40% of organizations with independent living, assisted living, and/or memory care segments and nearly one-half of organizations with nursing care beds (46%) reported that the pace of move-ins had accelerated in the past 30 days.
  • The share of organizations citing increased resident demand as a reason for the acceleration in move-ins in Wave 13 remained high (85%). Some respondents noted greater urgency among new residents regarding move-ins in geographies where restrictions have been lifted; others cited new buildings leasing up, and resident transfers to higher levels of care.
  • Regarding reasons for a deceleration in move-ins, more organizations in Wave 13 than in Wave 12 cited a slowdown in leads conversions/sales (82% vs. 55%). Resident or family member concerns also remained high in Wave 13 (68%) but declined slightly since Waves 12 and 11 (73% and 74%, respectively).
  • In Wave 13, organizations with nursing care beds reported both the highest proportion of month-over-month occupancy increases (44%) and decreases (44%). Greater shares of organizations across all care segments in Wave 13 reported upward changes in occupancy than in Wave 12 (to varying degrees). However, more organizations with assisted living and independent living report occupancy decreases than occupancy increases.
  • Looking forward, between 21% and 26% of organizations with independent living, assisted living, and/or memory care units, and 28% of organizations with nursing care beds reported an increase in week-over-week occupancy. Organizations with nursing care beds and/or independent living units reported the highest shares of week-over-week occupancy increases. However, the majority of respondents cited no changes in occupancy from the prior week.
  • The strain on operating costs persist as three-quarters of organizations continued to provide staff overtime hours, and one-half continued to offer rent concessions to attract new residents—up from one-third in Wave 10. Of the organizations that operate any independent living units (including a combination of other seniors housing and care segments), two-thirds (65%) were currently offering rent concessions, followed by roughly one-half of organizations with any memory care and/or assisted living units (58% and 55%, respectively). About two in five organizations with any nursing care beds (41%) reported offering rent concessions.

Wave 13 Survey Demographics

• • Responses were collected from September 28-October 11, 2020 from owners and executives of 73 seniors housing and skilled nursing operators from across the nation. More than half of respondents are exclusively for-profit providers (61%), about one-third (31%) are exclusively nonprofit providers, and 8% operate both for-profit and nonprofit seniors housing and care organizations.
  • Owner/operators with 1 to 10 properties comprise 63% of the sample. Operators with 11 to 25 properties make up 18% of the sample, while operators with 26 properties or more make up 19% of the sample.
  • Many respondents in the sample report operating combinations of property types. Across their entire portfolios of properties, 79% of the organizations operate seniors housing properties (IL, AL, MC), 21% operate nursing care properties, and 34% operate CCRCs (aka Life Plan Communities).

Key Survey Results

Pace of Move-Ins and Move-Outs

Respondents were asked: “Considering my organization’s entire portfolio of properties, overall, the pace of move-ins and move-outs by care segment in the past 30-days has…”

• • The shares of organizations with assisted living units and/or nursing care beds that reported an acceleration in move-ins in the past 30-days increased in Wave 13 to the highest levels since the survey began in March (43% and 46%, respectively). For both of these care segments, the shares of organizations reporting deceleration in the pace of move-ins were the lowest in the time series (23% and 20%, respectively).

• • In Wave 13, approximately 40% of organizations with independent living, assisted living, and/or memory care segments compared to nearly half (46%) of organizations with nursing care beds reported that the pace of move-ins had accelerated in the past 30-days.
  • The shares of organizations experiencing an acceleration of move-ins in independent living in Waves 12 and 13 were higher than in previous waves of the survey, and near the time series peak reached in Wave 9 surveyed at the end of June.

Reasons for Acceleration/Deceleration in Move-Ins

Respondents were asked: “The acceleration/deceleration in move-ins is due to…”

• • The share of organizations citing increased resident demand as a reason for the acceleration in move-ins in Wave 13 remained high (85%) after peaking in Wave 12 (88%). Organizations citing hospital placement in Wave 13 (30%) is lower since the peak reached in Wave 10 surveyed in the latter half of July (41%).
  • Regarding reasons for a deceleration in move-ins, more organizations in Wave 13 than in Wave 12 cited a slowdown in leads conversions/sales (82% vs. 55%). Resident or family member concerns also remained high (68%) but declined slightly since Waves 12 and 11 (73% and 74%, respectively). Very few organizations cited a moratorium on move-ins as a reason for deceleration in the pace of move-ins (5%). This is down from 61% at its peak in Wave 4 surveyed in the latter half of April.

Organizations Currently Offering Rent Concessions to Attract New Residents and Organizations Experiencing a Backlog of Residents Waiting to Move-In

Respondents were asked: “My organization is currently offering rent concessions to attract new residents,” and “My organization is experiencing a backlog of residents waiting to move-in”

• • Half of the organizations in both Waves 12 and 13 were offering rent concessions to attract new residents (51% and 53%, respectively)—up from one-third in Wave 10 (34%).
  • Of the organizations that operate any independent living units (including a combination of other seniors housing and care segments), two-thirds (65%) indicated they were currently offering rent concessions, followed by roughly one-half of organizations with any memory care and/or assisted living units (58% and 55%, respectively). About two in five organizations with any nursing care beds (41%) reported offering rent concessions.
    • Digging deeper, organizations with CCRCs in their portfolios were less likely to be currently offering rent concessions than organizations without CCRCs (48% vs. 56%). Additionally, the majority of organizations with declining occupancy in assisted living and/or memory care were currently offering discounts.
  • Approximately one-quarter of respondents in Waves 12 and 13 indicate that their organizations have a backlog of residents waiting to move in (25% and 26%, respectively).

Move-Outs

• • The shares of organizations reporting an acceleration in the pace of move-outs decreased in Wave 13 for the assisted living and nursing care segments. The majority of organizations in Wave 13 continue to note no change in the pace of move-outs in the past 30 days. This has been consistent since the survey began in late March.

Change in Occupancy by Care Segment

Respondents were asked: “Considering the entire portfolio of properties, overall, my organization’s occupancy rates by care segment are… (Most Recent Occupancy, Occupancy One Month Ago, Occupancy One Week Ago, Percent 0-100)”

• • In Wave 13, organizations with nursing care beds reported both the highest proportion of month-over-month occupancy increases and decreases (44%). The share of organizations reporting nursing care occupancy decreases is the highest since Wave 8 surveyed in late May to early June.

• • Greater shares of organizations across all care segments in Wave 13 than in Wave 12 reported increasing occupancy. However, more organizations with assisted living and independent living report occupancy decreases than occupancy increases.

• • Regarding the change in occupancy from one week ago, between 21% and 26% of organizations with independent living, assisted living, and/or memory care units and 28% of organizations with memory care beds reported an increase in week-over-week occupancy. The majority of respondents cited no changes in occupancy from the prior week. Organizations with nursing care beds and/or independent living units reported the highest shares of week-over-week occupancy increases.

Improvement in Access to PPE and COVID-19 Testing Kits

Respondents were asked: “Considering access to PPE (personal protective equipment) and COVID-19 testing kits, my organization has experienced that access has improved… Very little, it is still difficult to obtain enough PPE/testing kits in most markets/Somewhat, in some markets it is easier to obtain PPE/testing kits than in others/Considerably, we typically have no difficulty obtaining PPE/testing kits, regardless of market”

• • While there’s been some improvement in recent waves of the survey, still only about half of the respondents find it easy to obtain PPE and COVID-19 test kits. Slightly fewer respondents reported no difficulty getting PPE in Wave 13 than in Wave 12 (51% vs. 59%), however, slightly more in Wave 13 noted no difficulty getting COVID-19 test kits (52% vs. 45%).

Time Frames for Receiving Back COVID-19 Test Results

Respondents were asked: “Regarding COVID-19 test results (either for staff, residents or prospective residents) results typically come back within…”

• • The time frames for receiving back COVID-19 test results did not continue to trend as positively in Wave 13 as Wave 12. Just over one-third of respondents (38%) received their COVID-19 test results within 2 days, down from 43%.
  • Importantly, the majority (62%) note that it still takes more than 3 days to receive test results—however, this is down from 87% in Wave 10.

Labor and Staffing

Respondents were asked: “My organization is backfilling property staffing shortages by utilizing … (Choose all that apply).” Note: this question was asked in Wave 3, and then again in Waves 10-13.

• • Three-quarters of organizations (76%) are continuing to offer staff overtime hours in Waves 12 and 13 (down from 85% in Wave 3), and roughly half are still using agency or temp staff to fill staffing vacancies—up from 36% in Wave 3.

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 14 survey is available until Sunday, October 25, 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.

Educational session at 2020 NIC Fall Conference highlights onsite service.

Key Takeaways 

• Seniors housing is emerging as a key part of the healthcare continuum. 
• Keeping residents out of the hospital is a major objective. 
• Seniors housing providers are managing healthcare risk onsite for their residents—both for infection and for social isolation/loneliness. 
• Health and healthcare must become an essential focus for seniors housing providers—but they don’t have to be the provider of the healthcare.  

The COVID-19 outbreak has accelerated emerging trends. Consumers are making more purchases online. Virtual meetings are now routine. Telehealth has gone mainstream in a matter of months.   

Likewise, the pandemic is fast-tracking the link between seniors housing and healthcare. Residents not only want a hospitality-type experience but also expect to be protected from infection. Many want access to onsite care, no matter the setting.   

Different approaches are emerging.  

One example of how to partner with a healthcare provider was presented during  Education Week at the 2020 NIC Fall Conference during a session  titled: “What Does Senior Living Look Like in the COVID Era: The New Role of Health and Healthcare Onsite.”    

Separately, a peer-to-peer discussion on the topic was held during the conference Connections Week. Participants shared their experiences with onsite healthcare. 

The educational session was led by Bob Kramer, NIC founder and strategic advisor, and president at Nexus Insights. Participants included Michael Grust, founder and CEO at San Diego-based senior living provider SRG; and Jim Lydiard, staff vice president at CareMore Health, a division of insurer Anthem.    

SRG collaborates with CareMore to offer onsite healthcare services, a partnership that has deepened during the COVID-19 crisis.  

Kramer provided context, noting that older adults have become more fearful about visits to traditional healthcare settings, such as doctors’ offices and clinics. At the same time, new models of care are emerging, including the use of telemedicine. 

“We are at a nexus point as an industry,” said Grust. He explained that the ability to protect the health of residents while creating environments where they can thrive will make a big difference in their decision to leave their homes and move into senior living communities. “We are focused on quality of life,” said Grust. 

CareMore’s insurance program—called Touch—provides a full range of medical services to residents who enroll. Many of the CareMore visits by healthcare providers are proactive, which helps contribute to the overall health of residents and improve their quality of life.  

The program is meant to compliment the work of SRG’s hospitality and wellness teams. CareMore does not offer dining services or help with the activities of daily living.  

Kramer noted the distinction between health and healthcare services. Health is related to prevention and wellness. SRG’s ZEST program, for example, keeps residents healthy and engaged. CareMore provides the actual medical services. “Health and healthcare have to be an essential focus, but you don’t have to do it all yourself,” said Kramer. “Partnerships can deliver benefits.” 

Teamwork Succeeds 

CareMore works together with the wellness team onsite. They can communicate with CareMore via text, video and phone. “Residents can get help right way,” said Lydiard, which helps keep them out of the hospital.  

Residents voluntarily sign up for the CareMore program. Enrollees receive a health assessment and a customized care plan. Regular visits from healthcare practitioners are provided as well as telehealth sessions. Mini clinics, operating three to five days a week, are created on campuses with a sizable number of enrollees.  

SRG does not pay a fee to CareMore. The patient’s insurance pays for the service under Medicare, Medicare Advantage or Medicaid. “This does not cost the operator more money,” said Lydiard. He added that the arrangement can help reduce the operator’s costs by eliminating unnecessary healthcare expenses that the operator might incur. Also, residents who enroll in the CareMore  Medicare Advantage plan may save as much as $200-$300 a month.  

Another plus: The partnership aligns the interests of the insurer and the operator. SRG keeps its residents healthier, often resulting in a longer length of stay. CareMore is motivated to keep residents healthy because it is paid through a capitation contract or risk-sharing model.   

Scale matters, however. The ability of CareMore to greatly impact resident outcomes depends on enrolling a critical mass of residents in the program. Membership grows virally after about 20 percent of residents sign up as CareMore’s presence on campus increases and residents see the value of onsite care. “We have to build membership,” said Lydiard.  

CareMore handles the marketing of the plan. But the staff at the community is educated on the benefits. 

 A hurdle to enrollment has been the reluctance by residents to switch insurance plans. They want to keep their primary care doctors, specialists and healthcare networks. 

But a big change will make it easier for residents to sign up. CMS is expanding its value-based care model to allow groups like CareMore to enroll residents with a traditional Medicare plan. They can keep their providers and still get the wraparound services provided onsite by CareMore. “This is a game changer,” said Grust.  

 The panelists agreed that senior living is now a part of the healthcare continuum. “We need to raise our game,” said Grust, noting “We are not post-COVID.” Senior living providers must continue to protect residents while providing an environment where people can thrive. “We have always been focused on the quality of life,” said Grust. “That is our unique selling proposition.”

Marking the sixth consecutive year, NIC once again partnered with National Real Estate Investor (NREI) on an annual investor sentiment survey in late summer 2020. Conducted from August 5 to August 11, 167 surveys were completed answering questions on topics ranging from attitudes on seniors housing market fundamentals to investment attitudes. The points below highlight some of the key survey findings.

Additionally, NREI hosted a webinar with NIC on September 17 which presented further commentary and analysis on the results of the 2020 survey, as well as a broader discussion on the opportunities and challenges facing seniors housing,

• Most survey respondents indicated that the COVID-19 virus was the biggest factor impacting occupancy rates at seniors housing properties over the past six months. Roughly four of every five respondents said the pandemic has had a very significant impact, while a little more than half of the respondents also reported that the state of the economy is having a significant impact. The state of the economy had not been as large an influencing factor since 2016. Further, more than half of the respondents believe that seniors housing sector itself is in recession or at a trough.
  
  
• About 45% of respondents expect occupancy rates to increase, the fewest since the survey began in 2014 and down from 72% in 2019. On the flip side, 42% expect occupancy rates to decline, the most of any survey ever conducted.
• Partly because of the pandemic and the effect it has had on the seniors housing sector, survey respondents had a less favorable view of seniors housing as an investment property than in any of the past seven surveys. Indeed, for the five-year period from 2015-2019, respondents had ranked seniors housing as the most attractive property type for investment out of six property types (apartments, industrial, office, hotel, and retail). When asked to rate the attractiveness of different property types for investment on a scale of 1 to 10, industrial and apartments rated the highest at 7.4 and 7.1, respectively. All other property types showed a decline in sentiment compared to results from the past five years with seniors housing dropping to 6.3 from 7.2 in 2019 and 2018.

  

  • The coronavirus is taking a toll on net operating incomes. The vast majority of respondents (90%) believe there has been at least some increase in expenses due to the virus between March 1 and August 1, with an estimated mean increase of 9.2%. Operators have seen costs rise for bonuses paid to staff, testing for staff and residents, increases related to PPE and additional cleaning. While not asked in the survey, it’s likely that operators could see additional upward pressure on expenses due to potentially higher property taxes and higher insurance costs.
  • Although uncertainty related to the path of the virus is affecting near-term investment decisions, investors seem to be more positive on their long-term plans to increase investment in the sector. Nearly half of respondents expect no change in seniors housing investment in either the near (47%) or long term (52%). However, views are split on whether investment will increase or decrease in the near term versus long term. Roughly 36% of investors said they plan to invest less in the near term compared to 18% who plan to invest more. Those percentages flip when asked about long-term strategies with 34% who expect to invest more in the long-term and 15% who think they will invest less.
  • A large number of respondents believe both equity and debt will be more difficult to get over the next 12 months and more than half anticipate that it will take longer to close a transaction. Roughly 80% of respondents expect underwriting standards to become tighter.
  • Nearly two of three respondents think seniors housing construction starts will decrease over the next 12 months, while one in five percent believe they will remain the same. That is a notable shift compared to survey results over the past five years where nearly half, if not more, respondents consistently anticipated an increase in starts in what had been a robust construction cycle.

  All in all, the 2020 Investor Sentiment Survey results paint a picture of a more cautious view on the sector. This makes perfect sense given the current state of the economy and the capital markets as we all collectively continue to make our way through the crisis of the COVID-19 global pandemic.