A NIC report developed to provide timely insights from owners and C-suite operators on the pulse of seniors housing and skilled nursing sectors.

This report marks the second installment of findings from NIC’s weekly Executive Survey of operators in seniors housing and skilled nursing. The report highlights the findings from responses collected at the beginning of the pandemic to now as operators experience changing market conditions due to the COVID-19 threat to residents, staff and business operations; effects of social distancing mandates from state and local governments and seniors housing and care organizations themselves; and the economic effects of shuttered non-essential businesses on local economies.

Summary of Insights and Findings

• The share of organizations reporting lower occupancy rates from the prior month increased in Wave 2. This directional decline in occupancy rates from the prior month occurred across care segments and are supported by anecdotal reports from operators, with some expecting to see greater impact in the coming weeks.
• The segment with the largest share of operators reporting a decrease in occupancy from the prior month was nursing care, with 70% of respondents noting downward directional trends in occupancy rates in Wave 2. The nursing care segment also saw the largest deceleration of move-ins in the past 30-days, likely driven by fewer hospitals discharging patients to post-acute care settings for rehabilitative therapy as hospitals defer elective surgeries due to the pandemic.
• While the majority of organizations continued to report no change in the pace of move-outs by segment, a larger share of respondents reported an increase in move-outs across the board compared to Wave 1. Additionally, the pace of move-ins has decelerated across all segment types compared to Wave 1, except for memory care. Two-thirds attribute the deceleration in move-ins to a slowdown in leads conversion/sales due to a moratorium on in-person tours to keep residents and staff protected from outside contagion. Additionally, about half have an organization-imposed ban on settling new residents into their communities.
• Workforce shortages and staffing challenges are putting financial stress on some organizations. Most are back-filling staffing shortages by increasing overtime hours, and they are supporting the health and wellbeing of property staff by providing flexible work hours and remote work; some are also offering additional paid sick leave and food and meals support for staff and their families.
• Slightly more respondents in Wave 2 expect no change or a decrease in their development pipeline going forward than in Wave 1. While several respondents have new development and/or expansion plans currently underway, uncertainty is a primary concern going forward in the coming weeks and months, despite the prevailing sentiment that demand for seniors housing will continue to grow. This may continue the recent trend seen in NIC MAP data showing a decline in new construction relative to existing supply. 

 Wave 2 Survey Demographics

• Responses were collected April 1-12, 2020 from owners and C-suite executives of 146 seniors housing and skilled nursing operators from across the nation.
• 59% of respondents were exclusively for-profit providers, 31% were exclusively nonprofit providers, and 10% operate both for-profit and nonprofit seniors housing and care organizations.
• Owner/operators with 1 to 10 properties comprise 61% of the sample. Operators with 11 to 25 properties make up 21% while operators with 26 properties or more make up 18% of the sample.
• Many respondents in the sample report operating combinations of property types. Across their entire portfolios of properties, 75% of the organizations operate seniors housing properties (IL, AL, MC), 34% operate CCRCs (Life Plan Communities), and 32% operate nursing care properties.

Key Survey Results

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)”

• Approximately one-third to one half of organizations reporting on their independent living, assisted living and memory care units in Wave 2—across their respective portfolios of properties—saw a decrease in occupancy from the prior month. Roughly one fourth saw a decrease compared with the prior week. There were more survey respondents reporting a decrease in occupancy in Wave 2 results than in Wave 1 results.
• Conversely, roughly half to two-thirds of organizations reporting on their independent living, assisted living and memory care units in Wave 2 saw no change or an increase in occupancy rates from the time they responded April 1-April 12, 2020 to one month prior; down from roughly two-thirds to three-quarters in Wave 1.
• Organizations with nursing care beds reported the largest directional declines in occupancy among the four segment types and more respondents reported declines in Wave 2 than in Wave 1. Nearly three-quarters to half of organizations with nursing care beds and assisted living units reported occupancy declines in Wave 2.
• Compared to one week prior, most organizations report little change in occupancy by care segment, except nearly two-thirds of organizations saw occupancy declines in nursing care beds from a week ago, and a quarter saw occupancy increases in memory care units.
  

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…”

• Generally, more organizations in the recent Wave 2 survey than in Wave 1 report that the pace of move-in rates decelerated over the past 30-days. Approximately two-thirds to three-quarters report a deceleration in move-ins. Only one-third of organizations reporting on their memory care units noted a deceleration.
• The majority of respondents noted no change in move-outs, with generally slight declines from Wave 1 to Wave 2.Nursing care beds had a higher pace of accelerated move-outs compared to other care segments in Wave 2.
  
• About two-thirds to one half of respondents attributed the deceleration in move-ins to a slowdown in leads conversion/sales, an organization-imposed ban and/or resident or family member concerns. At this point in the pandemic, fewer than a quarter of organizations attribute a deceleration in move-ins to a mandatory government ban.
  

Mitigation Strategies for Labor Shortages

Respondents were asked: “My organization is back-filling property staffing shortages by utilizing… (Choose all that apply)”

• Consistent with Wave 1, organizations in Wave 2 are:
  • increasing overtime hours (89%)
  • hiring agency or temp staff (43%)
  • hiring professionals from other industries (29%)
  • using volunteers (14%)

Supporting Property Staff

Respondents were asked: “My organization is supporting property staff who may be experiencing challenges by providing… (Choose all that apply)”

• Most respondents in Wave 2 and Wave 1 report offering flexible work hours and remote work. Others provide additional paid sick leave and to-go meals for families; some are addressing challenges by providing staff childcare.

Development Pipeline Considerations

Respondents were asked: “My organization’s projected development pipeline going forward is expected to… (Choose all that apply)”

• There are generally minimal differences in expectations about organizations’ development pipelines between Wave 2 and Wave 1, however slightly more respondents expect no change (46% vs. 42%) or a decrease (35% vs 25%).
• Uncertainty (95% vs. 88%), and lack of construction labor (13% vs. 3%) between Wave 2 and Wave 1 appear to be growing concerns. Like Wave 1, about 20% in Wave 2 cite supply chain disruptions.

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 rapidly changing. Your support helps provide both capital providers and capital seekers with data as to how COVID-19 is impacting the space, helping leaders make informed decisions. 

If you are an owner or C-suite executive of seniors housing and care properties and have not received an email initiation but would like to participate in the current Executive Survey, please click here for the online questionnaire.

More seniors will need an affordable alternative for housing and care as the consequences of the pandemic unfold.

As seniors housing owners and operators grapple with the day-to-day challenges of the COVID-19 pandemic, the longer-term ripple effects of the crisis are just now coming into focus.

A growing number of middle-income elders will likely be unable to afford today’s seniors housing and care offerings as the economic fallout of the pandemic plays out. Middle-income seniors had already been identified last year as a vulnerable population in the NIC-sponsored project, “The Forgotten Middle:  Middle Market Seniors Housing Study.”

“Given the COVID-19 pandemic, the need for housing and care for the ‘Forgotten Middle’ is only going to get bigger,” said NIC Chief Economist Beth Mace.

A townhall-style session at the NIC Spring Conference addressed how best to provide housing and care for the growing number of middle-income seniors, a situation even more urgent in the wake of the disease outbreak. Session participants offered a number of creative ideas: providing services through Medicare Advantage plans; adaptive re-use of commercial properties; and the increased use of technology such as telehealth.

The “Forgotten Middle” study showed that 54% of seniors cannot afford today’s senior housing product, based on a monthly cost of $4,500, and do not qualify for assistance under the Medicaid program. By 2029, 14 million seniors will fall into that category.

Mace now expects that number to grow. While it’s hard to predict the depth of the economic upshot of the pandemic, several scenarios seem likely.

Seniors who draw down their savings will join the middle-income ranks of those who can’t afford the housing they need. At the same time, more of today’s middle- income seniors could fall into the low-income category of seniors dependent on Medicaid, putting more strain on an already overstretched program. 

The slowed economy will impact consumer confidence, said Mace. “Confidence is a big factor in people’s decisions to move into seniors housing because it often involves choice.”

Consumers regard the stock market as a metric of wealth. Job losses grab headlines.

“Everyone gets skittish when a lot of people aren’t working,” said Mace. Also housing sales could slow to a trickle. That could impact the seniors housing market, at least in the near term.

Multi-Faceted Solutions

Amid this growing need for middle-market housing, the ideas presented at the NIC Spring Conference are even more relevant, noted Mace. The session was titled, “Planning for the Care Needs of the Forgotten Middle.”

The challenge is to create a housing and care model that is affordable. New approaches will be needed to finance projects and deliver care at a low cost.  

“The middle market is where health and housing intersect,” said study co-author and session participant Caroline Pearson, senior vice president, at NORC at the University of Chicago, which conducted the original research.

Medicare Advantage plans, which cover a growing number of senior living residents, could provide a way to pay for the extra services needed by middle-income seniors, session participants agreed.  Insurers are beginning to recognize the importance of the social determinants of health, such as safe housing, good nutrition and access to healthcare.

Expanded benefits for residents under Medicare Advantage plans could include payments for meals and the activities of daily living, according to Jan Eyer, regional president at Optum, a division of United HeathGroup. Optum consults with seniors housing providers on Medicare Advantage plans.

Different types of partnerships between senior living companies and insurers are emerging. Some operators are forming their own Medicare Advantage plans, while others are aligning with healthcare providers.

The big healthcare REIT Welltower formed a partnership with CareMore Health, a division of Anthem insurance. CareMore enrolls residents in Medicare Advantage plans and then offers healthcare on site at several Welltower-owned buildings. The arrangement helps offset costs, according to James Lydiard, general manager of CareMore’s Touch program for senior living communities.

Integrated healthcare models can reduce costs, said Kevin O’Neil, chief medical officer at Affinity Living Group. Many residents have chronic conditions and functional limitations best addressed in the senior living environment rather than in the more expensive hospital system. “Senior living should be the convener of healthcare,” he said.

Working with local health systems is a priority, session participants emphasized.

Presbyterian Senior Living offers middle market housing. Most of its projects are in Pennsylvania. A hospital system opened a clinic in one of the group’s buildings to help reduce hospital admissions.

“It took a long time of sitting together to figure out how to solve this problem,” noted Diane Burfeindt, vice president of population health, Presbyterian Senior Living. Managed care organizations will only partner with senior living providers that can track outcomes, she noted. “Data is huge.”  

Serving middle-income seniors calls for multi-faceted solutions. Food costs could be reduced through programs such as Meals on Wheels. A small middle market property operated by Presbyterian Senior Living, for example, developed a relationship with a local restaurant to serve meals at the community.

Capital costs represent a big challenge. “Who will finance these projects?” asked Mace.

Unused properties, such as vacant schools might be converted into seniors housing. The low-cost basis of the property would help keep rents in check.

Government programs such as low-income housing tax credits could be expanded to provide an affordable financing vehicle to lower rents. Ground floor space could be rented to retailers to help subsidize costs. “It will take a multi-industry mindset,” said Lydiard.  

Technology will play a big role to lower costs. Senior living providers are already adopting telehealth solutions in the wake of the pandemic. Remote visits by health care providers will help keep middle-income seniors healthier and avoid the costs associated with emergency room visits.

“Telehealth is the way to go to reduce the cost curve for the middle market,” Mace concluded.

The second of NIC’s “Leadership Huddle” webinar series featured a frank discussion amongst capital provider and operator leaders currently navigating their businesses on the frontlines of the COVID-19 pandemic.

Titled, “The Intersection of Operators and the Financial Community in a COVID-19 Environment,” the April 9 event focused on how the industry is managing the crisis, both from the perspective of operators on the frontlines of the pandemic, and the capital providers who are grappling with shifting economic realities. Attendees gained insights from an Oregon-based operator, whose properties have been fighting to protect their residents since late February, as well as capital providers who are working every day to provide support to their portfolios of operators, while planning for the future during a time of monumental change.

Moderated by NIC Chief Economist, Beth Burnham Mace, the webinar began with data from the newly launched NIC Executive Survey Insights. The initial “Wave 1” of the survey of 180 seniors housing and skilled nursing operators, released last week, provides a baseline on occupancy, move-in, and move-out rates across the sector, as the pandemic begins to have an impact. NIC has announced it will release new survey results on a weekly basis. While there is some loss in occupancy rates, mostly in skilled nursing, many operators reported little change in these key metrics towards the end of March. Lower occupancy, however, may loom on the near horizon.

Operator Fee Stubblefield, Founder & CEO, The Springs Living, said that his properties began to enact protocols on February 29^th, spurred by the early appearance of COVID-19 in neighboring Washington state. In addition to enabling his Executive Directors to keep staff at home if they showed symptoms, Stubblefield said, “We immediately shut down dining, moved to staff delivering meals in rooms, and began screening visitors. We limited all outside visits to essential-only in the first week.” He also acknowledged the helpfulness of regulatory action from the state of Oregon.

As a joint-venture-structured capital partner, Kathryn Sweeney, Co-Founder and Managing Partner, Blue Moon Capital Partners LP, shared how her organization is supporting their operator partners, “This is really hard. Discussions, truthfully, lean to the empathetic rather than the financial side of the scale. We want to make sure our operators are not worried about spending money on PPE and test kits.” She pointed out that, although many operators have protocols in place, “Nobody has experience with this. We’re all running to catch up.”

Wendy Simpson, Chairman, President & CEO, LTC Properties, offered the perspective of a triple-net capital partner. Her approach has been to bring her operators together to share vital information, such as where to find supplies of PPE, and to ensure channels of communication remain open – without overburdening her partners with too many requests. She noted that, compared to assisted living, her skilled nursing facilities are more prepared to fight the pandemic, “They are prepared for infections; they always have a flu season, and already have stringent protocols in place…They have been able to respond faster than assisted living and memory care…more of their employees are trained for this type of thing. They did have challenges with PPE at the beginning. They are experiencing COVID, but they are more experienced in handling communicable diseases.”

Fee described how, after the initial few days, his organization also found itself seeking out additional supplies, and taking additional steps to keep COVID-19 away, saying, “We spent days building a moat around all of our communities. This has been about the physical protection of our existing residents.” He described “burning through” PPE, even enlisting residents and families with sewing machines, who made thousands of home-made masks. “COVID rides our breath; droplet suppression is critical. Six foot separation is not enough in our opinion. Everybody needs a face mask.”

Despite these protocols, which Fee says have been effective across The Springs Living’s 17 communities, a resident tested positive for COVID-19, just a day prior to the webinar. He said, “Emotionally…it was hard to take when we learned we had it…after we were past that we were able to react very quickly, with industrial cleaning and sanitation…we deployed tests. We did 30 tests on employees. As of this morning, nine results have come back so far, all negative.” With the resident recovering in a local hospital, the staff is holding to protocols and continuing to fight. “We’re ready for this. We’re fighting this thing and…we’re going to minimize the impact.”

From the capital-provider standpoint, Sweeney said how heartened she is by how many operators, many of whom are fierce competitors, are now cooperating with each other.  “Now, we’re all facing a common enemy…operators are joining forces, collaborating with each other…facing challenges on PPE…sharing suppliers…sharing strategies and tactics on labor. We’re in this together.” Asked about preventative costs, she pointed out that keeping COVID-19 out has a cost-benefit, “Once COVID hits a building it could be a million dollar hit to the economics of that building…keeping it out costs a fraction of that.”

But keeping COVID-19 out does come at a cost. Fee described a number of investments, including providing “hero meals” to staff, who often work long shifts and have little time to prepare their meals. Providing food at no cost to employees, and allowing staff to take meals home to their families, not only provides needed support, but keeps them from going into their own communities, to get takeout or visit grocery stores, for example, exposing them to additional points of potential contact with the virus. But the cost is significant. According to Stubblefield, “We have 1,824 units. We spent $300,000 already, including paid time off, and meals, and PPE is by far the largest part of that. We are at $164 per unit right now. Our forecast on spend is in a range from $500 to $700 per unit.”

Throughout the Leadership Huddle, audience questions were posed to panelists by NIC COO, Chuck Harry. The first of these was on operators’ ability to test their residents for the virus. Sweeny’s response revealed frustration, “It’s really hard. Unfortunately, the seniors housing industry, excluding skilled nursing, is not prioritized in terms of accessing PPE and tests. We’re fighting this battle with rudimentary and limited tools…We have had inconsistent access to tests in our portfolio.” She observed that those operators with ties to healthcare professionals were better able to access tests, and that all tests are not the same. Referring to Abbott Labs’ 5 to 13 minute “quick test,” she said, “That’s what every senior living community in the country needs…how do you fight an enemy without knowing where it is?”

Stubblefield, in response to the same question, said he had access to some tests developed locally and expected more to come, but stressed that not all tests have proven their accuracy. Access to the swabs required by the most accurate lab testing remains a problem. He agreed that seniors housing and care is on the front lines of this battle, and should be prioritized for testing availability, in order to prevent overrunning emergency rooms and hospitals. He said, “One of the ways that the hospitals and public health can stop this virus from impacting our healthcare systems is to recognize that seniors housing and care is on the frontline and if we get the PPE and testing we can help diminish the impact on the healthcare system.”

The discussion also addressed how the pandemic is affecting budgets. Both capital providers agreed that it is too early to be able to calculate the full impact on their financials, which will be reflected partially in March financials, and more fully in April’s. According to Simpson, rents received in May will provide better insight into the impact on her operators. Her company is running analysis, and, along with industry groups, such as NAREIT, is looking to Congress for some relief on rules, particularly on rent deferrals or forgiveness, that impact their ability to support operators. While some short-term impacts are expected, Simpson sees little impact financially over the long-term. There will be other impacts, however. “It will be a long-term change in healthcare providing,” she said.

Looking ahead, all the panelists saw a silver lining, particularly in labor and new supply. Mace pointed out that 16 million people have just filed for unemployment insurance, a fact which panelists agreed will ease labor shortages. Sweeney suggested operators that support their staff today, by supplying PPE, offering meals, and other investments in their well-being during this crisis, will likely attract staff. “Post-COVID puts us in a very good place on the labor front,” she said.

Simpson is seeing a sharp drop in development, and expects some sources of capital to back away, stating that, “We are thinking private equity may not think this is an industry for investment. There will be less competition when this crisis is over.”

Fee, also looking ahead, said of the future that, “We will come out of this stronger. Our sector will show not only the sustainability to survive this, but that older adults are the safest they can be in our facilities.” He pointed out that national projections of fatalities from COVID-19 are declining every week, “We went from 150,000 projected deaths on one site…to 80,000, and this morning, 60,000. If we can hold the line, and our capital providers continue to give support…we’ll emerge showing we’re relevant and that senior living is the very safest place for older adults to be.”

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Additional Capital for Small and Mid-Sized Businesses.

The Fed can purchase up to $600 billion in loans through the Main Street Lending Program.

NIC continues to provide updates on the many aspects of the COVID-19 pandemic effecting the seniors housing and care industry. In keeping with NIC’s mission of providing information and transparency to operators and other stakeholders, it is important to understand the latest announcements from the government and other influencing sources that may affect the sector in this difficult time.

Congress has moved at breakneck speed in an attempt to provide relief for businesses and individuals. Thus far, Congress has approved three coronavirus relief and economic stimulus bills, while regulators continue to make adjustments to rules to provide additional relief as quickly as they can. Information is changing rapidly, which is adding to a very dynamic situation. In addition, the Federal Reserve has made history by implementing extraordinary measures to provide stimulus and ensure credit continues to flow to businesses.

The latest move from the Federal Reserve is to provide up to $2.3 trillion in liquidity commitments to support the economy. This policy is aimed to help households, small and medium-sized businesses, and support state and local governments to issue debt in order to provide critical services during the pandemic. This latest liquidity commitment suggests the Fed will do whatever it takes to support the economy during this economic recession. As part of this commitment, and relevant to the seniors housing and care sector within this historical development, is the Main Street Lending Program that will permit small and medium-size businesses to obtain bridge financing through eligible lenders.

Through this lending program, the Fed will ensure credit flows to small and mid-sized businesses with the purchase of up to $600 billion in loans. The Department of the Treasury, using funding from the Coronavirus Aid, Relief, and Economic Security Act (CARES Act) will provide $75 billion in equity to the lending facility. Businesses that were in good financial standing before the crisis could be offered 4-year loans to companies employing up to 10,000 workers or with revenues of less than $2.5 billion. Payments, including principal and interest payments, will be deferred for one year and eligible banks may originate new Main Street loans or use Main Street loans to increase the size of existing loans to businesses. In addition, firms seeking Main Street loans must commit to make reasonable efforts to maintain payroll and retain workers. Businesses that do not qualify for the Paychecks Protection Program (PPP) may welcome this new lending facility to help through the crisis. For clarification, businesses that have also taken advantage of the PPP may also take out Main Street loans. Potential borrowers are encouraged to discuss the details with their trusted banking relationships.

Currently there are two Main Street Lending Facilities which are 1) Main Street New Loan Facility and 2) Main Street Expanded Loan Facility. The Federal Reserve did state that as the program is being finalized, it will continue to seek input from lenders, borrowers, and other stakeholders to make sure the program supports the economy as effectively and efficiently as possible while also safeguarding taxpayer funds. Comments may be sent until April 16. 

NIC will continue to communicate as necessary to the seniors housing and care sector as more information becomes available. The links below can be useful for information from the Federal Reserve regarding the Main Street Lending Program, which includes two Loan Facilities:

Main Street New Loan Facility:

https://www.federalreserve.gov/newsevents/pressreleases/files/monetary20200409a7.pdf

Main Street Expanded Loan Facility:

https://www.federalreserve.gov/newsevents/pressreleases/files/monetary20200409a4.pdf

The Centers for Medicare and Medicaid Services (CMS) have taken numerous critical steps to ensure U.S. health care facilities are prepared to respond to the threat of disease caused by the 2019 Novel Coronavirus. These actions include deadline extensions, policy waivers, benefit expansions, and a reprioritization of certain surveys to grant flexibilities to skilled nursing operators and allow them to take the necessary steps to provide uninterrupted care to their communities.

The federal response has centered around temporarily removing regulatory barriers while the public health emergency and national emergency remain in effect. CMS’ announcements have come continuously throughout the rise of the COVID-19 pandemic and affect myriad aspects of the seniors housing and care industry, including facility infection control, resident safety, reimbursement, workforce training, and certification requirements. As the COVID-19 crisis endures, CMS will continue to provide additional recommendations and guidance to safeguard residents of these communities.

To keep seniors housing and care operators and investors up to date on the latest policy changes, National Investment Center for Seniors Housing and Care (NIC) is consolidating relevant announcements in a single place with the COVID-19: CMS Regulatory Review. The policy summaries will be available in the NIC COVID-19 Resources Center, along with other complimentary initiatives designed to inform the industry, even at today’s rapid pace of change.