As COVID-19 continues to threaten millions of frail elders, the seniors housing and care communities in which many of them live face immense challenges. Despite shortages of PPE, testing, and support, operators have had to find ways to care for residents, many of whom require intimate personal contact to assist in activities of daily living, while fending off a highly contagious, invisible, lethal disease that can be spread by asymptomatic or presymptomatic carriers.  

A national spotlight is on the sector. As policy makers plan to reopen society, and frontline care workers continue the fight to protect vulnerable residents, it is time for industry leaders to address what may become a significant additional challenge to come out of this crisis: a narrative based on a lack of context, lack of understanding, and lack of comparable data.  

While many news reports are balanced, and report facts as well as they can, some lack clear, consistent definitions and complete and accurate data, simply because it is not available. While the difference between independent living, assisted living, memory care, and skilled nursing is apparent to those who work in the industry, the general population lumps these different care settings and their different populations into one category.   

Additionally, data, where it is available, varies from state to state, and even from county to county. States vary on how they count COVID-19 infections and deaths. Some have mandated available data be made public; others have not. Coverage often focuses on the “numerator” – the total number of COVID-19 positive cases and deaths – but rarely is the “denominator” – the total number of residents in the care setting – included in the story.  Furthermore, reports often do not take into account the fact that the very reason residents of high acuity settings are there is because they are frail with multiple comorbidities, a known risk factor for COVID-19 mortality, and many need help with ADLs. Context requires understanding how populations of similar acuity and need for help with ADLs in traditional private housing fared during the pandemic. 

Of course, owners, operators, and capital providers understand that different property types serve very different acuity levels, but the media – and the public – often do not. According to the recently released “Seniors Housing Data Book” from ATI Advisory, in skilled nursing settings, the average resident is 83.5 years of age, requires assistance with 5.1 activities of daily living (ADL), such as feeding, bathing, and toileting, suffers from multiple comorbidities, and has a 76% likelihood of cognitive impairment.  In Independent Living, however, the average resident is 82.2 years of age, requires help with 0.3 ADLs, and has a 21% likelihood of cognitive impairment.  Without COVID-19–relevant data that distinguishes between these populations, how can we expect the media to provide context? And how can we expect anxious families, both now and in the future, to understand how a single data point from a headline – such as their state’s “long term care facilities” COVID-19 mortality rate, is relevant to their particular situation?   

NIC was founded nearly 30 years ago to help improve transparency to capital providers for an industry that was, at the time, deeply opaque, compared to other types of commercial real estate. Small and large operators then, as now, were understandably resistant to the idea of sharing some of their most sensitive data, particularly given potential short-term risks. But over time the effort has proven highly effective at improving liquidity, lowering the costs of capital, and making it possible to improve the options available to America’s seniors.   

The industry now has an unprecedented opportunity to improve trust in the public eye, while simultaneously helping efforts to control the spread of this deadly virus. Accurate, consistent, and timely data with broad reach can help families, policymakers, health officials, and senior living operators understand and combat the virus – and be better prepared in the future. With the nation looking on, it is time to demonstrate a willingness to be transparent, and to share data that will help track and combat COVID-19 across each property type and care segment. 

NIC has launched a number of data initiatives in response to the COVID-19 pandemic. They rely on the continued participation of owners and operators, many of whom are overwhelmed and beset with other pressing issues. Yet, we encourage participation as an essential means to help shed light and provide context across an industry that can only benefit from greater transparency and clarity.   

As evidenced over several decades of improved access to capital by seniors housing and care, increased transparency leads to increased trust. NIC is a trusted, respected third party source of industry data with national scope across all sector property types. We understand what defines each property, and why these differences matter, and we can be relied upon to educate those outside the industry as we provide the industry data to them.   

We encourage operators to take a few minutes each week to share data with NIC, which will help to improve transparency, and build trust, while the spotlight is shining. During a time of intense national scrutiny, this is a rare opportunity to build a foundation of understanding and greater clarity, which may yield dividends for many years to come. 

Even as headlines announce White House and CMS plans to reopen nursing homes, many operators are already planning for a new normal. The COVID-19 pandemic is far from over, and still threatens older adults, but operators will have to find ways to protect residents and staff, facilitate social connection, and restart move-ins, likely while the virus remains at large. Some forward-looking decision-makers are planning to reinvent how they operate their properties. Some are going forward with existing plans to launch new properties, with similar operational modifications, on schedules that were determined months and years before the pandemic became our new reality.

But what will life look like in the seniors housing and care communities of the very near future? What will it take to protect residents and staff? And, how will it impact operating and capital budgets? Operators across the sector have already put many operational changes in place, as part of a massive effort to protect highly vulnerable residents. Most operators have announced what they’re doing to combat the virus, which in almost every case involves new protocols around testing, PPE, quarantining infected residents, and supporting frontline care workers and their families.

Brookdale Senior Living CEO Cindy Baier, in an online video message, states, “It’s been nothing short of extraordinary what our Brookdale associates have done to protect as much as possible tens of thousands of lives during this COVID-19 crisis.” Baier indicated that the company is planning for more normalized post-COVID-19 operations, even as they continue to fight to protect residents at the height of this pandemic: “We are all focusing on where we are right now, even as we start thinking about where we’re going.”

Many need-based seniors housing and care settings are purpose-built to protect this disproportionately high-risk population from viruses, such as the flu, while delivering the care and services residents often cannot access elsewhere. But COVID-19 is far more virulent than the flu, and has a disproportionately high mortality rate for seniors, particularly those with preexisting conditions, millions of whom call these communities home. Protecting residents and staff is further complicated by the fact that COVID-19 can be spread by asymptomatic carriers – often for weeks at a time.

Testing, therefore, has been an essential component of combating the virus, and for many operators, it will likely continue to be of paramount importance. In a recent NIC “Leadership Huddle,” on May 7, Atria Senior Living Chairman and CEO, John Moore, described how his organization was able to obtain testing in partnership with Mayo Clinic. In addition to obtaining sufficient PPE, their own source of hand-sanitizer, and new technologies for remote care and connectivity, testing has allowed Atria to detect the virus and combat its spread. Moore is not alone is his prioritization of testing. NIC, in coordination with industry groups, has issued a joint statement which lists access to testing as an essential component of the fight against COVID-19.

But there are many other details to consider. NIC spoke with Jonathan Cook, President/CEO of LifeSpire Living, an operator of four continuing care retirement communities (CCRC) in Virginia. Cook has already been planning for the lifting of travel restrictions and inevitable reopening of his properties to visitors and new residents. His target date is June 10, and he’s determined to be prepared when the time comes. He outlined his team’s “general work plan,” which he describes as a “brain dump of ideas,” which he hopes will evolve as his teams learn and adapt.

Planning includes a careful review of financial models, which have had to be modified to support the new operational plans. Although move-ins are down, Cook says they expect to pick up a backlog of deferred move-ins in the next few quarters. Medicare part A revenue is currently reduced, as hospitals have cut back on elective surgeries. Budgets, although different, aren’t expected to grow. “We’re going to redeploy our capital budget, so I don’t know that we’re going to have a huge impact there,” said Cook, “I don’t think we’re going to have large capital investments that we can’t absorb in the current budgets.

“Operationally, we’re doing things like the ‘hero pay’ and things like that…those are certainly going to have an impact on our operations.” But, at the same time, Cook said, “your dining rooms have been closed, so where you used to have 25 servers, you now only have 15, because they’re running food, so there have actually been some savings on that side…we have not seen these huge swings up or down in our payroll levels. We’ve been able to maintain and redeploy resources in ways that have really created a balance.”

Cook’s team conducted a complete assessment of their capital budgets, to understand where resources were being dedicated, and where they could be reassigned. They then created action plans for every discipline, such as housekeeping, and laundry. They sent out requests for proposals for professional housekeeping companies, to provide daily cleaning, and to meet additional cleaning standards, throughout each day. As Cook said, “cleaning your lobby in the morning and afternoon will likely no longer be sufficient.” Prior to reopening, the team plans to deep-clean every apartment in buildings that have had a case of COVID-19.

During COVID-19 lockdown, the community has limited engineering, transportation, and security services, to help reduce the risk of infection. A lot of routine work orders will therefore be backed up. Cook’s team reached out to construction partners, in order to get handy men on staff for 4-5 weeks to help catch up.

Every vehicle in the LifeSpire fleet has been equipped with sanitation kits, so they will be ready to safely transport residents. The company is also looking at redeploying existing staff, and using corporate cars, to accommodate the transportation needs caused by a backlog of deferred doctor’s visits. The company put a hold on the planned purchase of several busses this year, as they wait to see whether vehicles will need to be special-ordered or customized to accommodate residents post-COVID.

Another concern relating to transportation is handling EMS staff responding to emergencies on the property. Due to their heightened exposure to COVID-19, new procedures provide for a hand-off of the resident to EMS, who receive them at the building entrance and place them on their gurney there. “It’s not how we like to do things, but it’s what we’re trying to do to maintain a COVID-free environment for our residents,” said Cook.

Fitness classes are now available on residents’ TV’s and an exercise app. This change is already in effect, and has resulted in some residents participating more than before. Cook reported that his mother-in-law, a resident, had been self-conscious and avoided attending in-person sessions – but has now lost 14 pounds attending from her apartment. Post-COVID classes will be smaller, and more frequent, in order to accommodate residents who prefer to exercise in classes, and on equipment not available in their apartments. This will require more staff hours.

Another COVID-related adaptation is to move more activities outdoors, to help further reduce chances of transmission. Cook is looking into increasing patio dining, heated tents, and expanded use of outdoor areas as a means to maintain social distancing.

Beauticians, tested and screened daily, and equipped with full PPE, will visit residents in their homes. Visitors to the beauty shop will skip the waiting room and come when they receive a call, during which time the space will be sanitized.

Gift shops will no longer accept cash, cutting out another potential infection point. Resident outings will still be on offer, but mainly only to outdoor venues, such as baseball parks, outdoor concert spaces, and parks. Indoor activities, such as card games, will remain, but on a smaller scale, to accommodate social distancing protocols. A new lottery program will limit numbers of residents attending onsite performances, with spaced seating installed. Others will be able to watch on the in-house TV system.

According to Cook, the biggest impact, both on the resident community and the budget, will be the revamped dining program. Details such as grab-and-go packaging, separate entrances and exits, expansions of dining rooms into outdoor spaces and heated patio tents, will change how everyone approaches meal times. In addition to offering room tray service, like a hotel, and mobile and web ordering, previously public vending and snack options will be offered as individually wrapped options. Employee break rooms will receive similar consideration, and will also gain outdoor dining options.

New budgets also accommodate new gatehouses, designed to control access, and continued screening of all visitors. For residents who don’t already have smart devices, the budget provisions tablets for running Facetime, Teams, and other technologies that enable connecting with others remotely.

As move-ins are approved, the company will offer new residents incentives, such as paying for movers. Cook’s team is looking  to negotiate with one corporate moving vendor who will be contractually obligated to learn and follow the correct procedures, properly sanitize equipment and maintain corporate standards. He sees having one vendor that is well-versed in operations as another means to reduce the risk of infection, while offering value and service to residents.

As staffing needs ramp up, new procedures for recruiting and onboarding will be in place, using facetime for interviews, and screening for COVID-19 as part of routine measures. Cook expects new staff will be needed soon. Using modeling to project his team’s planning, he sees a backlog of deferred move-ins, a return to some elective procedures, and a balanced reallocation of resources that will help his communities adjust to a new normal and still be able to keep residents safe, healthy, and happy. He said, “We think this is certainly going to represent some expenses, but its not anything we’re not going to be able to recover from.”

The COVID-19 pandemic has ushered in an era of unprecedented change in the world’s healthcare landscape.  Some of these changes may be temporary – lasting only until a vaccine or widespread testing is available – but others will have secured their place with consumers and will become permanently woven into the fabric of the healthcare system. There is an increased sense of uneasiness in visiting medical office buildings, urgent care sites, and hospitals, especially for routine checkups and minor ailments. Despite this apprehension, the level of care needed to support the United States’ population has not subsided.

It is a real concern that people may be deferring or delaying preventive care and physician visits out of a fear of getting infected, potentially allowing problems to remain undetected and untreated. In lieu of face-to-face health visits, telehealth has stepped in to bridge the gap, as individuals can now increasingly use interactive apps with audio and video capabilities to visit with their clinician for a broad array of services.

CMS Regulatory Changes Encourage Telehealth Adoption

CMS (Centers for Medicare and Medicaid Services) is taking aggressive regulatory action to allow for the rapid implementation and expansion of telehealth programs. Among these actions is a series of waivers intended to break down barriers so that patients can access these services and to ensure that providers are reimbursed for them. These actions are currently intended to remain in effect only during the coronavirus public health emergency. One can easily imagine that a tipping point may be reached during the pandemic, where telehealth is proven to be a viable solution to health needs and is ultimately embraced as fully in a post-COVID world as it is being embraced currently.

Prior to these waivers, health care professionals could only bill Medicare fee-for-service for patient care delivered by telehealth if the established-relationship rule was met, meaning the patient had been to an in-person, face-to-face visit with the provider at least once in the prior three years. CMS has clarified that the established-relationship rule will not be enforced during the state of public emergency.  Medicare’s originating site rule has also been waived, meaning that instead of providers needing to be in a medical office, community clinic, hospital, stroke unit, dialysis center, or other more traditional healthcare delivery site, providers can virtually treat patients from anywhere – including their home.

CMS is also temporarily breaking down state boundaries to allow providers to practice across state lines, giving patients in rural areas improved access to telemedicine while simultaneously preserving the nation’s frontline medical staff. Such measures are encouraging the utilization and adoption of telemedicine and preventing the spread of coronavirus.

What’s been made clear with the changes in the telemedicine regulatory environment is that CMS believes this practice is a viable channel for delivering care, if a patient’s condition doesn’t require more intensive hospital care. For routine physicals, prescription refills, and other minor ailments, telemedicine is a preferred conduit for obtaining care. What was intended to be a temporary measure during a public health emergency may have cemented a role in the future of our nation’s healthcare.

Benefits of Telemedicine Implementation

The COVID-19 pandemic has resulted in an extraordinary adoption in telemedicine by providers and patients alike and there’s no doubt that there are general benefits to expanded telehealth programs. Certainly, there is a convenience factor for patients who no longer experience long waits in a physician’s office waiting room. For frail elders and residents of seniors housing properties, however, the benefits are even greater. Those with a high risk of falling no longer need to hesitate when making appointments for fear of navigating parking structures and medical offices. Patients can rest easier knowing they can avoid potential exposure as telemedicine can connect them to specialized medical expertise to determine if they really require that trip to the hospital.

Residents of seniors housing and care properties that have established telemedicine programs are also able to rely on the expertise of on-site staff to use the remote equipment appropriately. For routine physicals and checkups, having an audio/visual connection will often suffice. But for more complex health problems, on-site staff are available to properly use the cameras, otoscopes, and stethoscopes that are making telemedicine technologies so robust. Having the staff onsite to assist with these remote office visits is delivering improved care to residents. Without this assistance, providers would not have access to the real-time vital signs and patient images that allow them to deliver high-quality care.

Establishing Telemedicine Programs in Seniors Housing and Care

Seniors housing and care providers had begun to experiment with telemedicine even before the coronavirus and COVID-19 pandemic became our reality. But in the new world we are living in, the pace at which properties are adopting and accepting this new form of care delivery is rapidly increasing.

Winter Park, Florida’s Holiday Retirement, the largest independent senior living provider in the U.S. announced in March that it has provided telehealth access and services to the residents of its 250+ senior living communities for urgent care situations and other conditions from the safety and comfort of their home. Senior leadership with Holiday indicated that partnering with MeMD’s national network of healthcare providers was in part a way to provide convenient care to residents, but also a larger strategy to reduce the stress on the United States’ healthcare delivery system. In the recently released Q1 2020 earnings report, Sabra Health Care REIT CEO Rick Matros commented that Holiday Retirement had done an effective job keeping infections low in their independent living buildings, in part due to the valuable rollout of their telemedicine program.Hh

Glendale, California-based senior living provider Front Porch Retirement Communities is working to expand the telehealth programs within the variety of senior living options they offer. As Kari Olson, chief innovation and technology officer indicates, “Any expansion of telehealth services is a very good thing, especially during this time when we need folks to stay home, and in particular, to safeguard people over 65 as well as other high-risk individuals.” Front Porch has been a proponent of telehealth for years, believing that telemedicine reduces barriers to accessing care, such as travel time and transportation risks.

Whether seniors housing and care providers are entering the world of telemedicine as a result of our new reality or they are expanding an already established telemedicine program, one thing is clear: telemedicine is proving itself to be a valuable aspect of care delivery in this country.

And the beat goes on as the new normal of living in a world of COVID-19 becomes our reality. However, the beat is not like any rhythm we have ever known. The pandemic has changed the pace of virtually every aspect of our lives and for those of us involved in caring for America’s elders who reside in seniors housing and skilled nursing properties, the challenge has been formidable, although not insurmountable. Despite impaired supply chains and a lack of federal coordination, operators are increasingly acquiring the personal protective equipment (PPE) that is needed to keep their staff and residents better protected from this invasive virus. While heroic stories of frontline care workers seldom make frontpage headlines, stories of carefully implemented safety protocols that limit the spread of the virus within properties abound. 

Images of well-planned opportunities for staff and residents to interact, socialize, exercise, and be engaged are common, yet little publicized. When we look back on this time, we will be proud of what the industry has collectively achieved in protecting our seniors in this difficult period. But we will also look back and be frustrated that circumstances were such that many people in the public at large as well as in congregate settings did become ill and, in some cases, die from this perilous virus.To prevent further spread of the COVID-19 virus, we continue to seek PPE. And of critical importance, the industry seeks extensive and reliable testing protocols, again for the general public, as well as for the staff working in and the vulnerable and often frail residents living in congregate settings. 

Against this background is the economy and the anguish it is unleashing on millions of workers. In just eight weeks, a staggeringly 36 million Americans have filed initial claims to collect unemployment insurance through the period ending May 9th, 2020. That is more than all the jobs created in the national economy since the time the economy began to recover from the 2008/09 recession and it potentially shrinks the job base to 116 million from 152 million at its peak, a level not seen since November 1994.  Moreover, the figure does not consider the millions of workers who have not yet or will not file claims. We can only expect more of these record-setting events in the months ahead. Separately in a different report, the BLS reported that the unemployment rate surged to 14.7% in April from a 50-year low of 3.5% as recently as February 2020.

The outlook is difficult to project because we still do not know when the pandemic will retreat and if it will return in the future. Its only once we discover a vaccine and it becomes easily replicated and people become immunized that we will really be able to put the pandemic behind us. Until then, we will gradually try to re-open parts of the economy, but the opening will be sputtered, and large groups of businesses may never re-open leaving workers on their own to seek new positions.

The federal government and the Federal Reserve have worked hard to mitigate the damage. Congress and the Administration have now allocated approximately $3 trillion on programs (equivalent to roughly 14% of U.S. GDP) within the CARES Act, the Small Business Administration Paycheck Protection Program (PPP) and other programs. Meanwhile the Fed has worked hard to keep the economy functioning and the credit markets liquid. It pushed the federal funds rate down by 150 basis points in mid-March to effectively zero, lowered the cost of discount window lending, introduced multiple facilities to support the flow of credit and launched the Main Street Lending Program to purchase new or expanded loans to small and mid-sized businesses including seniors housing. Fannie Mae and Freddie Mac have also announced assistance to borrowers, including seniors housing operators, by providing mortgage forbearance for 12 months and waiving related late fees.

Only in time will we know the success of these programs, but what we do know at this time is that much of the economy remains open, the credit system is still functioning, and relief is being provided to millions of jobless workers. Nevertheless, real GDP is still projected to drop by up to 40% at an annualized rate in the second quarter of this year.

The great uncertainty wrought by the pandemic and the economy has virtually shut down commercial real estate transactions markets, including seniors housing, with few deals getting done. Price discovery between buyers and sellers is opaque, at best, and capital is sitting on the sidelines waiting to see how these circumstances unfold.

All eyes are on operations. Move-ins have virtually stopped as operators strive to prevent contagion in their properties from the virus. And occupancy rates continue to decline as the weekly NIC Executive Survey results show. In the week ending May 10, 2020, approximately two-thirds to three-quarters of organizations reporting on their independent living, assisted living, memory care and nursing care units saw a decrease in occupancy from the prior month.  The Survey results also show that move-in rates continue to slow, with two-thirds to three-quarters of organizations reporting on their independent living, assisted living and memory care segments reporting a deceleration in move-ins.

Where it will end is hard to say, with the virus once again largely dictating the extent of business impact and disruption. In the meanwhile, operators remain fully diligent in their efforts to prevent further contagion, with strict protocols to prevent and limit the spread of the illness across properties. Extra cleaning and contact prevention protocols, limitations on visits, restrictions on group activities, travel restrictions and other rules have been implemented. And for staff, safety protocols, flexible schedules, and accommodations to the new reality of social distancing rules with school closures are all in place.

So, how do you operate in this environment? Contingency planning, scenario analysis, best case-worse case plans all need to be implemented to address the myriad paths that may unfold. From an investor’s point of view, property valuations may be pressured lower, but how much lower? What is the impact on investment returns? From a borrower’s point of view, banks will be looking for lower loan-to-values, stricter covenant agreements, and higher interest reserve requirements, but how much higher? From a broker’s point of view, fewer deals will be coming across desks at least for now, until distressed properties that require capital infusions and recapitalizations emerge, but when? From an operator’s point of view, occupancy rates will be pushed lowered, but by how much? If you are among the half of all properties that had an occupancy rate of 90% or greater as of the first quarter of 2020 by NIC MAP® metrics, the challenge may be large but not impossible. If you are among the 22% of properties with occupancy rates below 80% and in a market with generally low stabilized occupancy rates, the challenges may be greater.

In this time of unprecedented uncertainty and to be best prepared, one step forward would be for all businesses—capital providers and capital seekers–to create a worse case scenario and then ease up on the assumptions to identify the impact on the bottom line. Once there, better informed decisions can be thoughtfully considered.

In the meanwhile, on behalf of NIC, we continue to laud the industry’s frontline workers and those behind the scenes in management and decision-making roles. Cooperation has never been stronger between capital providers and operators, demonstrating that together, we can fight and overcome this pandemic.

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

NIC’s weekly 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 where market conditions are rapidly changing—providing both capital providers and capital seekers with data as to how COVID-19 is impacting the space, helping leaders make informed decisions.

This week’s sample (Wave 6) includes responses collected May 4 – May 10, 2020 from owners and executives of 100 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 under “Executive Survey Insights.”

This report also features two weeks of COVID-19 seniors housing and care incidence data collected April 27 – May 10 (Waves 5 and 6 combined) as reported by a subset of survey-takers.

Summary of Insights and Findings

While more data is needed to observe definitive turning points in occupancy rate trend data there are signs of potential improvements in occupancy patterns in the survey’s week-over-week data. In Wave 6, 21% of the respondents reporting on nursing care indicated that occupancy rates had started to increase, the most since the survey started. That said, 36% of respondents do continue to report declines in occupancy for skilled nursing from the prior week, although that is down from 67% in Wave 5. Respondents with independent living and memory care segment units also report slightly higher shares of improving occupancy rates from a week prior.

Other potentially positive signals include a slightly lower percentage of operators reporting decelerations of move-ins in Wave 6 relative to Wave 5—although the majority of organizations across all care segments did still report that move-ins decelerated in the past 30-days. Additionally, the percentage of respondents citing an organization-imposed ban on move-ins decreased from 59% in Wave 5 to 46% in Wave 6, and fewer respondents cited resident or family member concerns about moving residents in or out of communities.

• Regarding the change in occupancy from one week ago, the independent living and nursing care segments reported the most improvement from prior waves of the survey. The nursing care segment had the largest increase in the share of organizations reporting higher occupancy rates from the prior week (21%).
• The share of organizations reporting a deceleration in move-ins with regard to their nursing care segments in Wave 6 of the survey is lower compared to Wave 5 and Wave 3. Of note, 19% of organizations with nursing care beds report a deceleration in move-outs in the past 30-days in Wave 6, compared to 7% in Wave 5. Furthermore, under a quarter note an acceleration in move-outs, compared to around one-third in the prior three waves of the survey.
• The share of organizations reporting an acceleration in the pace of move-outs for the assisted living and memory care segments remain comparable to Wave 5 (around one-quarter), but higher than earlier waves of the survey. While the assisted living care segment saw a slight increase in the share of organizations experiencing a deceleration of move-outs compared to Wave 5, the memory care segment reported a slightly lower share.
• For the data collected between April 27 and May 10, 2020 (Waves 5 and 6 of the survey combined), a subset of seniors housing and care executives, answering on behalf of their organizations, provided the number of residents that were tested for COVID-19 and the number of residents tested positive by care segment.
• The operator average for the percentage of residents tested for COVID-19 by care segment rose with acuity level and ranged from 4.2% for independent living, 11.6% for assisted living, 14.1% for memory care and 21.0% for nursing care. The operator average of all residents with a lab-confirmed positive test for COVID-19 ranged from 0.3% for independent living, 1.3% for assisted living, 2.2% for memory care and 5.3% for nursing care. More detail can be found in the Key Survey Results section of this report.

Wave 6 Survey Demographics

• Responses were collected May 4 – May 10, 2020 from owners and executives of 100 seniors housing and skilled nursing operators from across the nation.
• Nearly two-thirds of respondents were exclusively for-profit providers (60%), about one-third (31%) were exclusively nonprofit providers, and 9% operate both for-profit and nonprofit seniors housing and care organizations.
• Owner/operators with 1 to 10 properties comprise 56% of the sample. Operators with 11 to 25 properties make up 26% 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, 84% of the organizations operate seniors housing properties (IL, AL, MC), 26% operate nursing care properties, and 31% 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…”

• In Wave 6 of the survey, between 66% and 70% of organizations reporting on their independent living, assisted living and memory care segments indicated that the pace of move-ins decelerated. However, between 26% and 28% report no change in the pace of move-ins for these care segments.
• Most of the organizations reporting on their nursing care segments in Wave 6 of the survey note a deceleration in move-ins (79%); however, the share is lower compared to Wave 5 (84%) and Wave 3 (87%).

Reasons for Deceleration in Move-Ins

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

• The most common reason cited for deceleration in move-ins continues to be slowdowns in leads conversions/sales due to moratoriums of moving residents into communities to mitigate COVID-19 contagion among residents and the staff members who care for them.
• Fewer respondents in Wave 6 cited an organization-imposed ban on settling new residents into their communities (46%) compared to the prior two waves (59% and 61%, respectively). Additionally, fewer organizations in Wave 6 cited resident or family member concerns (45%) than in the prior three waves of the survey.

Move-Outs

• Between 58% and 74% of organizations reporting on their independent living, assisted living and memory care units saw no change in move-outs in the past 30-days. The share of organizations with independent living units reporting no change in move-outs has remained between 76% and 71% since Wave 4.
• The share of organizations reporting an acceleration in move-outs in the past 30-days for the assisted living and memory care segments remained comparable to Wave 5 (28% and 24%), but higher than Waves 4 and 3. The assisted living care segment, however, saw a slight increase in the share of organizations experiencing a deceleration of move-outs (14%) compared to Wave 5 (11%), while a slightly greater share with memory care units saw a slight decrease (from 14% to 11%).
• Until Wave 6, the pace of move-outs reported for the nursing care segment had been consistent across waves of the survey with around one-third of organizations with nursing care beds reporting an acceleration in move-outs. However, the pace of move-outs in Wave 6 slowed with under a quarter of survey respondents experiencing an acceleration in move-outs. Further, 19% of organizations with nursing care beds report a deceleration in move-outs in Wave 6 compared to 7% in Wave 5.

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 similar proportions to Wave 5, approximately one-half to more than two-thirds (54% to 71%) of organizations reporting on their independent living and assisted living segment units, and 79% of organizations reporting on their nursing care beds in Wave 6 of the survey—across their respective portfolios of properties—experienced a decrease in occupancy from the prior month.
• The share of organizations with memory care units reporting a decline in occupancy rates fell from 70% in Wave 5 to 63% in Wave 6, and more than one third (36%) noted either no change or an increase in occupancy from the prior month.

• The independent living segment saw the highest share of organizations reporting an increase in occupancy from one month prior (13%).
• The percent of organizations reporting nursing care segment occupancy declines in Wave 6 was equal to Wave 5 (79%) and down slightly from 84% in Wave 3.
• Regarding the change in occupancy from one week ago, the independent living and nursing care segments reported the most improvement from prior waves of the survey. In Wave 6, 84% of organizations with independent living units and 63% of organizations with nursing care beds saw no change or an increase in occupancy rates.
• The nursing care segment had the largest increase in share of organizations reporting higher occupancy rates from the prior week (21%). More organizations with assisted living units note no change in occupancy rates from the prior week than in previous waves of the study (63%).

Incidence of COVID-19 Among Survey Respondents

For the data collected between April 27 and May 10, 2020 (Waves 5 and 6 combined), seniors housing and care executives, answering on behalf of their organizations, provided the number of residents that were tested for COVID-19 and the number of residents that tested positive by care segment. 

• The COVID-19 incidence data is a self-reported, non-validated sampling of seniors housing and care owners and operator executives for the two-week timeframe. It is important to note that this sample is not a statistical representation of COVID-19 incidence in seniors housing and care, in general.

• As shown in the table, in this sample of survey respondents, the percentage of residents that were tested for COVID-19 by care segment rose with acuity level and the operator average percent of residents tested ranged from 4.2% for independent living, 11.6% for assisted living, 14.1% for memory care and 21.0% for nursing care. The operator average percent of all residents that had a lab-confirmed positive test for COVID-19 ranged from 0.3% for independent living, 1.3% for assisted living, 2.2% for memory care and 5.3% for nursing care.

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 invitation but would like to participate in the current Executive Survey, please click here for the current online questionnaire.