The sixth edition of the NIC Investment Guide: Investing in Seniors Housing & Care is scheduled to publish in fall 2020. We invite your organization to submit photos of seniors housing and nursing care properties to be featured within this publication.

The NIC Investment Guide is a primer for understanding the seniors housing and care sector. It provides the most reliable industry data for investors to help them evaluate risks and returns, and to fine-tune their individual investment strategies.

What We’re Looking For:

• Images of property interiors or exteriors (new and older properties).
• Images of property amenities.
• Images may include non-posed shots of residents.

Visit NIC.org to easily upload one or more photographs, along with captions. Images must be high resolution and use a common file format: JPG, JPEG, or PNG. Photos must be received by Friday, May 15, 2020, to be featured in the NIC Investment Guide.

The Department of Labor reported that 6,606,000 Americans filed for unemployment insurance benefits in the week ending April 4, 2020 as the COVID-19 pandemic caused businesses to reduce or furlough their workforces. This was a very slight decline of 261,000 from the previous week’s upwardly revised record high level of 6,868,000. The speed and scale of the job losses is unprecedented. In the past three weeks, more than 16 million people have filed claims. At its worse during the Great Recession, there were 665,000 first-time claims filed in the week ended March 28, 2009. That was second only to the week ended October 2, 1982, when 695,000 first-time claims were filed.

Continuing claims for regular benefits, which are reported with an extra week’s lag, rose 4.4 million to 7.5 million.

The largest increases in initial claims for the week ending March 28 were in California, New York, Michigan, Florida, Georgia Texas and New Jersey.

This week’s increase in unemployment claims marks the third consecutive week of surging jobless claims and provides a window into the magnitude of the economic downturn into which we are solidly moving. Economists from a Wall Street Journal survey now project a spike in the jobless rate to 13% by June from its 50 year low of 3.5% as recently as February. In March, the rate had already increased to 4.4%. This same group of economists predict that real GDP will contract at an annual rate of 25% in the second quarter. In March, the expectation had been a decline of merely 0.1%. For the full year of 2020, GDP is projected to decline by 4.9%. In 2019 it grew by 2.3%.

In response to the expected sharp slowdown in the economy, the President signed into law a $2 trillion economic stimulus rescue package that broadly expands unemployment benefits. Independent contractors and self-employed individuals are now eligible, at least in some cases. More fiscal stimulus packages are expected to be enacted in the coming months to further blunt the economic fallout of the COVID-19 pandemic.

The Centers for Medicare and Medicaid Services (CMS) have taken numerous actions in response to the coronavirus pandemic. This blog is intended to capture the latest announcements from CMS. For prior CMS summaries please click here.

The following are the latest summaries and links to CMS for further details.

Expansion of CMS Accelerated and Advance Payment Program

The Centers for Medicare & Medicaid Services (CMS) has announced an expansion of its accelerated and advance payment program for Medicare participating health care providers and suppliers, to ensure they have the resources needed to combat COVID-19. Accelerated and advance Medicare payments provide emergency funding and addresses cash flow issues based on historical payments when there is disruption in claims submission and/or claims processing. CMS is expanding the program for all Medicare providers throughout the country during the public health emergency related to COVID-19. The payments can be requested by hospitals, doctors, durable medical equipment suppliers and other Medicare Part A and Part B providers and suppliers.

https://www.cms.gov/files/document/Accelerated-and-Advanced-Payments-Fact-Sheet.pdf

CMS Facility without Walls (Temporary Expansion Sites)

In an effort to ensure that local hospitals and health systems have the capacity to handle a potential surge of COVID-19 patients, CMS took action to allow temporary expansion sites (also known as CMS Hospital Without Walls). This means that a long-term care (LTC) facility can temporarily transfer its COVID-19 positive resident(s) to another facility. The facility that is transferring a resident does not have to issue a formal discharge in this situation because it will still be considered the provider and will bill Medicare. The facility transferring will then be responsible for reimbursing the other provider that accepted its resident(s) during the emergency period. This will help residents with COVID-19 by placing them into facilities that are prepared to care for them, which is consistent with recent CDC guidance. In addition, it will help residents without COVID-19 by placing them in facilities without other COVID-19 residents, which will mitigate the risk of spreading the virus.

https://www.cms.gov/files/document/covid-long-term-care-facilities.pdf

CMS Issues Critical Recommendations

The Centers for Medicare & Medicaid Services (CMS) and the Centers for Disease Control and Prevention (CDC) issued new recommendations to state and local governments and long-term care facilities to help mitigate the spread of COVID-19. CMS issued new guidance while highlighting that long-term care facilities are a critical component of America’s healthcare system and they are unique, as they serve as both healthcare providers and as full-time homes for some of the most vulnerable Americans. To address this spread, CMS is working with CDC to provide nursing homes with clear guidance on how they can keep their residents safe. The recommendations include the following:

• Nursing homes should immediately ensure that they are complying with all CMS and CDC guidance related to infection control.
• CMS urges state and local leaders to consider the needs of long-term care facilities with respect to supplies of PPE and COVID-19 tests.
• Nursing homes should immediately implement symptom screening for all staff, residents, and visitors – including temperature checks.
• Nursing homes should ensure all staff are using appropriate PPE when they are interacting with patients and residents, to the extent PPE is available and per CDC guidance on conservation of PPE.
• To avoid transmission within nursing homes, facilities should use separate staffing teams for residents to the best of their ability, and the administration urges nursing homes to work with state and local leaders to designate separate facilities or units within a facility to separate COVID-19 negative residents from COVID-19 positive residents and individuals with unknown COVID-19 status.

https://www.cms.gov/files/document/4220-covid-19-long-term-care-facility-guidance.pdf

Last week, the United States claimed the top spot in known coronavirus cases. States across the country are issuing guidelines to stay at home; an increasing number are mandating a social distancing strategy with shelter in place orders. Seniors housing operators are cancelling all non-essential group activities and events. Essential activities like meals are being staggered to minimize contact with multiple staff members and other residents.

The consensus is COVID-19 is most dangerous for older adults – particularly those with underlying health conditions, who are at the greatest risk of succumbing to the illness that the virus causes. For many of the frailest in our nation’s skilled nursing properties, human touch, familiar faces, and family are critical to their well-being and serve as an antidote to loneliness and depression.

Maintaining the health of this population means taking extra precautions to keep their distance from others and closely heeding the advice of medical professionals to simply stay home. As for visitors, who are usually considered a health benefit by seniors housing and care properties, the safest policy unfortunately must now be a no-visitation policy. While the new restrictions can be difficult for both residents and their families, they are necessary to ensure the health and safety of communities and the frontline staff who serve them.

How do we ensure that at this critical time, the very important act of social distancing doesn’t result in adverse mental health effects? The key is realizing that physical separation does not unequivocally translate to loneliness. Being alone and being lonely are two very different things.  Fortunately, there are a lot of creative ideas being put into practice. Every day I read of innovative solutions, as operators, staff, vendors, and activity directors find creative new approaches to enabling social interaction even at a time when physical distancing is required. There are plenty of examples of socialization being maintained while safe distancing practices are being observed.

Despite aggressive infection control procedures curtailing group activities and social meals, there are still a great number of opportunities for seniors to connect with family, friends, and loved ones during these turbulent times. For some operators, this highly infectious coronavirus has highlighted an opportunity to use technology in seniors housing and care communities to maintain and expand the sense of connections that people have. Others focused on the number of seemingly solitary activities that can provide a sense of purpose, improve mental health, and maintain a sense of connectedness. Here are a few examples of what some communities and the vendors who support them are doing to maintain physical isolation while avoiding the feeling of being socially isolated.

Maintaining a Digital Connection

For families looking to stay updated on their loved ones’ care, software maker SafeKeeping has begun providing its Family Communicator platform to all senior care facilities in the U.S. and Canada – free of charge. Providers who manage resident records with PointClickCare can now give never-before-seen insights to residents’ families. Families can access patient care records, exchange messages with staff, and be notified of major events through secure SMS text and email.

Parker Jewish Institute for Health Care and Rehabilitation has been making personal calls to family members to share information on the status of residents. Recently, the Family Call Center was implemented to simplify the process.  Employees from Parker’s Admissions Department and Social Adult Day Health Program were rerouted to staff the new resource, which is assisting with both non-emergent matters and connecting family members through virtual technology.

Staff members of seniors housing and care properties are now increasingly walking family members through the process of accessing technology so they can visit virtually with friends and loved ones. Platforms like Zoom, Discord, and Houseparty provide video-enabled social networking, allowing residents to spend time with people that they care about, bringing them together despite their physical distancing. In many cases, these communication tools are being used between residents and staff as well, as communication that doesn’t require staff to be physically present in the room is safest for all parties involved. While nothing replaces the touch of a loved one, being able to see a smile, blow a kiss, or read a story together can go a long way to ensure that feelings of loneliness are kept to a minimum.

Improved In-Room Interactive Programming

Visitor restrictions for seniors housing and skilled nursing communities are now approaching their fourth week, and if the growth in U.S. confirmed cases is any indication, are not likely to be lifted anytime in the near future. Activity directors – or purpose matchmakers as I like to call them – have been finding ways to bring interactive programming directly to the rooms of residents. Activities once meant to physically bring residents together are now being offered through the residents’ TV sets with Entertain 360’s MessageNOW software. Instead of cancelling religious services and interactive games, these are now being broadcast directly to residents’ rooms over a dedicated channel.  Residents must continue engaging in activities and conversations that enable them to feel connected rather than isolated.

For family members looking to keep residents up to date on their activities, how tall the grandson is getting, or how they are managing their own homebound time, web-connected, digital photo frames are an easy solution. Nixplay picture frames allow for a cloud-based photo to be sent directly to the frame without the need for publication to a wider audience, as is often the case on Facebook or Instagram. These digital picture frames offer one more way to help maintain a sense of mental well-being during this challenging time.

Eversound has been improving well-being in assisted living and memory care communities by enhancing their ability to focus and engage in group events and one-on-one interactions. Their live-streamed interactive programming gives residents the power to connect, discover, and learn from the comfort of their own couch.  Eversound recently opened the archives of past live-streamed events and is providing them at no cost through the end of April. Included in the archives being made available are art classes, concert series, food and cocktail hours, history lessons, and science classes.

These examples are just a few of the many tools that are now available to help improve in-room programming. Many of these vendors are joining the likes of Never Too Late and being viewed truly as partners to providers, communities, and their residents. In collaboration with operators, they are addressing real needs, and overcoming concerns of social isolation by helping to keep residents engaged in this crisis.

Upholding Mind and Body Health

Residents at The Landings of Mills River have been brushing up on their art skills, having decided to create stained-glass style art on the windows throughout their community for those driving by. They have also been encouraging photo shoots with staff and residents alike. According to Executive Director Joy Elliot, this new program is producing by far the most photos ever taken at the Landings. Perhaps one silver lining is that staff have discovered a program well worth continuing long after the crisis has passed.

Understanding that it is vital for residents to stay active and engaged, many seniors housing operators are also encouraging gardening for their residents. Gardening has been linked with better recovery following surgery, lower rates of anxiety and depression, as well as better stress management. In addition to the rewards of witnessing a cultivation grow, the practice can prove to be beneficial for residents’ physical and mental health. If the thought of starting a garden seems daunting, with safety restrictions in place, consider something as simple as having a few potted plants or herbs on a table or windowsill. These can give a sense of purpose to the resident while practicing safe distancing. Their growth can result in a sense of pride, accomplishment, and responsibility.

As the above examples have shown, physically isolated seniors do not have to feel as though they have become socially isolated.  Providers, vendors, staff, and residents are finding creative ways to ensure that physical separation does not translate to social isolation and feelings of loneliness.  Vendors implementing solutions to improve social connection in these difficult times are positioning themselves truly as partners to the seniors housing and care communities, because being alone does not unequivocally mean being lonely. 

In closing, I would like to encourage everyone to reach for their phones and connect with a loved one.

With the recent change in policy around Medicare reimbursement for telehealth services, and the escalating pace of the spread of the coronavirus, seniors housing operators can use support for telehealth as a way to keep residents healthy to maintain census, and also as a sales tool for future move-ins. As a follow-on to the NIC Spring Conference panel discussion on telehealth, experts shared their thoughts on specific steps seniors housing communities can take both during the COVID-19 emergency and also on an ongoing basis.

Right Now: Support Physicians with Videoconferencing

In most seniors housing communities, residents can see any physician they choose. Since there are no standards for telehealth technology, according to Mei Kwong, executive director of the national Center for Connected Health Policy, this means operators must be ready to support whatever conferencing and monitoring technology their residents’ health providers have selected.

Yet Kwong said many health systems have recently started offering straightforward video visits as an emergency measure to keep patients away from offices and clinics where they might be exposed to the novel coronavirus, and in most states, there is no requirement that a person assisting a patient with telehealth technology hold medical credentials. This means any tech-savvy staff member with a camera- and microphone-equipped laptop could easily move from room to room to help residents connect with their doctors via videoconference during the current emergency – taking appropriate precautions such as wearing a mask and gloves and disinfecting the laptop after each visit, of course.

This is only possible if the seniors housing community has broadband throughout the community, Kwong pointed out. She also cautioned that while CMS has announced the policy change to allow for telehealth reimbursement, the companies that actually process claims “sometimes haven’t caught up yet,” so residents taking advantage of video doctor visits should watch their insurance statements carefully.

Medium Term: Support Specialists with Telemonitoring

Beyond virtual doctor visits, telehealth also encompasses various remote health monitoring technology, according to Kwong. While CMS’s current policy to reimburse for telehealth services is envisioned as an emergency measure, Kwong believes that many of its elements will become permanent. She suggests that once the pandemic ebbs and it is safe for residents to move freely throughout communities, operators might consider setting up a special room where they would host the various telehealth peripherals required by their local health systems, such as smart scales, internet-connected stethoscopes and blood pressure cuffs, or even higher-resolution imaging technology to allow specialists like dermatologists to examine patients remotely. Residents’ physicians could schedule consults or request regular monitoring of vital signs, and trained staff in the community could accompany residents to the special room where they could assist with any technology hurdles.

Long Term: Integrate Telehealth into the Community

For operators who want to equip their on-site nursing staff with specialist access, or who want to deliver more medical services within their communities, a tighter integration with a specialist telehealth service provider is an option, according to Michael Kurliand, director of telehealth and process improvement at West Health. West Health offers a free guide for seniors housing companies considering a move like this.

Joshua Hofmeyer, senior care officer at Avera E-Care, one such specialist provider, has a call center staffed by geriatricians and RNs with geriatric training. Client staff can call any time, day or night, and get immediate medical advice from specialists. Avera equips its seniors housing clients with mobile carts which hold all necessary peripherals to monitor health vitals or provide videoconferencing, and nursing staff can bring the carts to residents, either to deal with an emergency or on a regular basis to monitor chronic conditions. Avera does not aim to replace residents’ doctors, but rather, to work collaboratively with primary care providers and seniors housing staff, said Hofmeyer.

Even without Medicare reimbursement for these services, Hofmeyer calculates that his service is priced to offer positive ROI to any partner through census stabilization by avoiding unnecessary hospitalizations, as well as reduced turnover due to staff burnout. For skilled nursing operators who participate in risk-sharing networks, Avera clients see a reduction in both care costs and hospital readmissions, Hofmeyer adds.

Implementing services such as Avera E-Care typically requires support from IT staff, as well as specialist training for nurses and CNAs, and takes about 3-4 weeks, said Hofmeyer.