Staffing shortages continue to be a serious concern and a contributing factor driving the high number of cases and fatalities across the four regions.

The Centers for Medicare & Medicaid Services (CMS) provides up-to-date information on the incidence of COVID-19 cases among nursing facilities as well as fatality statistics associated with COVID-19. The NIC Skilled Nursing COVID-19 Tracker (Tracker) was recently updated to include fatality counts. This is the fourth sorting metric available in the Tracker. The other sorting options include same-store occupancy (CMS data), new COVID-19 confirmed cases as a share of residents, and new COVID-19 confirmed cases per same store facilities.

Data for November 29 showed that Midwest properties continued to report high numbers of new COVID cases: 6,574 among staff/personnel and 6,663 new residents’ cases within 4,104 facilities. This accounted for over 40% of overall new cases and was equivalent to 2.65% rate of newly confirmed cases among residents. This was the highest rate recorded across all four U.S. regions since CMS began reporting nursing homes COVID-19 data in late May. The South reported the second highest rate at 1.53%, followed by the Northeast (1.22%), and West (1.01%).

*Exhibit 1 – Source: NIC Skilled Nursing COVID-19 Tracker

Exhibit 1 shows that the share of properties reporting new confirmed cases on a weekly basis has increased dramatically in the Midwest from 9.4% on May 31 to 32.2% on November 29. The South and West regions experienced an increase of 11.2 percentage points to 22.3% and 4.5 percentage points to 14.1%, respectively. The Northeast rate saw a slight uptick from its highest peak of 25.2% recorded in late May to 26.1%.

Although the number of new COVID-19 confirmed cases has reached new records since the pandemic began, the number of fatalities in the Northeast and West regions remains below the high points seen earlier in the pandemic. The West reported the lowest rate of fatalities as a share of residents at 0.14%, followed by the Northeast (0.17%), down from 0.46% on May 31. However, the Tracker shows that COVID-19 fatalities reached unprecedented levels in the Midwest as new cases rose to the highest levels since the month of October. There, new fatalities among residents reached 0.49% on November 29, double the rate recorded on May 31 (0.24%).

*Exhibit 2 – Source: NIC Skilled Nursing COVID-19 Tracker

CMS data depicted in Exhibit 3 show that properties in the Midwest also experienced high shortages of aides, clinical staff, nursing staff and other staff in general. About one-third (32.1%) of properties reported shortages of aides and nearly 29% were critically short on nursing staff for the week ending November 22. Notably, shortages of aides and staff in the Northeast were relatively few. This suggests that staffing shortages continue to be a serious concern and a contributing factor driving the high number of cases and fatalities across the U.S. four regions, particularly, in the Midwest and South.

*Exhibit 3 – Source: NIC Skilled Nursing COVID-19 Supplemental Data

In terms of CMS-reported occupancy rates, the Midwest had the lowest rate of 67.5% on November 29. The South’s occupancy rate fell to 68.1%, down 3.7 percentage points from May 31 levels.
Skilled nursing properties in the Northeast maintained their weekly occupancy levels above 73% over the past six months and rank highest among the four regions. In fact, occupancy increased by 0.3 percentage points on November 29 from May 31 levels. The West reported the second highest rate of 71.4%.

For the first time since the pandemic began, all U.S. states showed a decrease in occupancy on a week-over-week basis between November 22 and November 29.

*Exhibit 4 – Source: NIC Skilled Nursing COVID-19 Tracker

The FDA approved Pfizer’s COVID-19 vaccine for distribution on December 11 and is moving to authorize the vaccine made by Moderna. Health care workers and nursing home residents are a top priority for COVID-19 vaccines. While this is promising, it remains ever important to stay vigilant for the next few months until a vaccine is widely distributed.

To gain in-depth insights and track the week-over-week change rate for new resident cases of COVID-19 within skilled nursing properties at the state and county levels, visit NIC’s Skilled Nursing COVID-19 Tracker. Access to the Skilled Nursing COVID-19 Tracker as well as a rich trove of analysis and insights can also be found on the NIC COVID-19 Resource Center.

“The pace of move-ins continued to be sluggish in Wave 17 with more survey respondents reporting declines in occupancy rates than increases in occupancy for each of the four care segments. Fewer organizations cited stronger resident demand as a factor influencing the pace of move-ins. Comments by survey respondents added color to the key survey findings: several leaders of their organizations cited rising COVID-19 cases among residents and staff in some properties resulting in stress in containing outbreaks and maintaining staffing levels amid wage growth and hazard pay challenges. While some operators were eagerly anticipating the arrival of the vaccine, others expressed frustration with new slowdowns in the turnaround times for receiving COVID-19 lab test results.”

                                                                                                                                                                –Lana Peck, Senior Principal, NIC

NIC’s Executive Survey of operators in seniors housing and skilled nursing is designed to deliver transparency into market fundamentals in the seniors housing and care space at a time when market conditions continue to change. This Wave 17 survey includes responses collected November 30-December 13, 2020 from owners and executives of 80 seniors housing and skilled nursing operators from across the nation. Detailed reports for each “wave” of the survey and a PDF of the report charts can be found on the NIC COVID-19 Resource Center webpage under Executive Survey Insights.

Wave 17 Summary of Insights and Findings

• In Wave 17, reports of decelerations in the pace of move-ins slightly outpaced accelerations in independent living, assisted living and memory care, and continued to significantly outpace accelerations in move-ins in the nursing care segment since Wave 14 surveyed in mid-October. The shares of organizations reporting an acceleration in the pace of move-ins in the past 30-days for the independent living, assisted living and memory care segments remained at or around their lowest levels since Wave 8 (surveyed late-May to early-June).

• The shares of organizations citing increased resident demand as a reason for acceleration in the pace of move-ins (59%) was at the lowest level in the survey time series, falling from a recent high of 84% in Wave 16. Hospital placement cited as a reason for acceleration in the pace of move-ins (24%) continued to lag the survey time series high of 41% reached in Wave 10, surveyed in late July. The percentage of respondents citing “another reason” for acceleration in the pace of move-ins has risen to 38%. Comments from respondents included reasons such as rent concessions and incentives, residents transferring from different levels of care, more needs-based admissions, and residents and families becoming comfortable with COVID-19 infection mitigation and visitation protocols.

• NOI is continuing to be pressured as more organizations in the Wave 17 survey sample were offering rent concessions, paying staff overtime hours, and using agency or temp staff to backfill staffing shortages. Organizations offering rent concessions (63%) is up from 51% in Wave 16, and nine out of ten organizations (87%) were paying overtime wages. Staffing is a growing challenge. One respondent noted that with the surge of recent COVID-19 cases and the resulting second wave of infections, their organization is experiencing distress in finding labor at “double-time wages.” Others addressed the issue of financial tension in the context of occupancy challenges indicating that fewer move-ins coupled with attrition and transfers to higher levels of care is putting pressure on business operations.

• About two-thirds of organizations (65%) noted they are experiencing challenges obtaining PPE due to high demand/competition (36%) and/or restrictions on allocation (29%). One-third (33%) reported budgetary constraints in paying for PPE.

• Higher levels of care segments (assisted living, memory care and nursing care) reported increases in PPE budgets commensurate with growing levels of care. Additionally, organizations with the largest portfolios of properties were more likely to report significantly higher PPE budget increases than single-site operators.

• Despite surging COVID-19 cases across the country, only about one in five organizations (21%) reported a self-imposed ban as a reason for deceleration in the pace of move-ins in Wave 17. At this point in the pandemic, two-thirds of organizations were neither increasing nor easing move-in restrictions in some or all geographies. The share of organizations increasing move-in restrictions in Wave 17 (22%) rose slightly since Wave 15 surveyed in late October (19%).
• Slowdown in leads conversions/sales and/or resident or family member concerns cited as reasons for decelerations in the pace of in move-ins in the past 30-days were either up or down slightly from Wave 16 (67% and 59%, respectively).

• Approximately one-quarter of respondents (26%) indicated that their organizations had a backlog of residents waiting to move in. This is down from a high of 34% reached in Wave 16 and similar to levels last observed in Waves 12 through 15 surveyed mid-September to late-October/early November.
• A growing share of those organizations that responded to the Wave 17 Survey reported an acceleration in the pace of move-outs for each of the care segments except nursing care—which remains at levels last seen in the surveys from the month of April (Waves 2-5). Notably, the shares of organizations with assisted living and/or memory care units reporting acceleration in the pace of move-outs in the past 30-days is at the highest levels reported in the survey time series (32%, respectively).

• As shown in the chart below, resident deaths (unspecified reason) continued to be cited most frequently as a reason for acceleration in the pace of move-outs in the last 30-days (84%). This is up from 61% in Wave 13 and similar to the peak of 85% reached in Wave 6 surveyed in early-May. Comments by respondents citing “another reason,” included COVID-19 (unspecified), COVID-19 deaths, and residents transferring to other levels of care.
• Presumably as a result of better and safer visitation protocols and more acceptance, resident or family member concerns cited as a reason for acceleration in the pace of move-outs (28%) was down from 40% in Wave 16 and is at the lowest level in the survey time series.

• For each of the care segments, the shares of organizations reporting downward changes in occupancy in the past 30 days outpaced those reporting upward changes. One survey respondent mentioned that November was the first month in which their organization saw a net occupancy increase since February—but the last week of November and the first week of December also had the highest positive COVID-19 tests in their communities among residents and associates. Compared to Wave 16, the percentage of organizations reporting month-over-month declines in occupancy rates remained at similar levels. Between 40% and 51% of organizations with assisted living units, memory care units and/or nursing care beds reported downward changes in occupancy in the past 30-days.

• The chart above illustrates that In Wave 17, 51% of operators with assisted living units noted declines in occupancy rates. The chart below describes the degree of those occupancy rate changes. The blue and orange-hued stacked bars correspond to the solid bars in the chart above indicating the degree of change by the saturation of color. For the assisted living care segment, one in four organizations (27%) reported occupancy drops of more than three percentage points, while another one in four (24%) reported occupancy declines between 0.1 and three percentage points.
• The independent living segment saw the least occupancy rate change: just under one-third (29%) reported a decline in occupancy of less than three percentage points, and one-quarter (24%) reported an increase of no more than three percentage points.
• The nursing care segment saw the largest changes (downward and upward) in occupancy rates—ten percentage points or more, respectively. One half (49%) reported a decline in occupancy in Wave 17.

• Consistent with the findings of the Wave 16 survey, organizations with nursing care and/or memory care segments reported more week-over-week occupancy declines than those organization with other care segments (31% and 29%, respectively). However, nursing care also saw the highest week-over-week increase in occupancy rates in recent waves of the survey (28%). 
• In Wave 17, one-half of respondents received their COVID-19 test results within 2 days, however it is taking 3 or more days to receive test results for the other half of respondents (48%). Although frustration with turnaround times was expressed in the survey comments with some fearing the impact of delays could result in difficulty mitigating infection control before effective isolation can be accomplished, given the swell in coronavirus cases across the country, these findings were relatively unchanged since Wave 14 surveyed mid-October.
• Nearly nine out of ten respondents (87%) indicated their organizations have increased the use of telehealth/virtual appointments since the beginning of the pandemic.

Wave 17 Survey Demographics

• Responses were collected November 30 – December 13, 2020 from owners and executives of 80 seniors housing and skilled nursing operators from across the nation. Just under half of respondents are exclusively for-profit or nonprofit providers (46% and 44%, respectively), and 10% operate both for-profit and nonprofit seniors housing and care organizations.
• Owner/operators with 1 to 10 properties comprise 64% of the sample. Operators with 11 to 25 properties make up 20% of the sample, while operators with 26 properties or more make up 16% of the sample.
• Many respondents in the sample report operating combinations of property types. Across their entire portfolios of properties, 78% of the organizations operate seniors housing properties (IL, AL, MC), 35% operate nursing care properties, and 38% operate CCRCs (aka Life Plan Communities).

Owners and C-suite executives of seniors housing and care properties, we’re asking for your input! By providing real-time insights to the longest running pulse of the industry survey you can help ensure the narrative on the seniors housing and care sector is accurate. By demonstrating transparency, you can help build trust.

“…a closely watched Covid-19-related weekly survey of…operators
conducted by the National Investment Center for Seniors Housing & Care…”
The Wall Street Journal | June 30, 2020

The Wave 18 survey is available and takes just 5 minutes to complete. If you are an owner or C-suite executive of seniors housing and care and have not received an email invitation to take the survey, please click this link or send a message to insight@nic.org to be added to the email distribution list.

NIC wishes to thank survey respondents for their valuable input and continuing support for this effort to bring clarity and transparency into market fundamentals in the seniors housing and care space at a time where trends are continuing to change.

Two educational sessions at NIC Fall Conference address the sales challenge.

As an effective vaccine for COVID-19 rolls out, seniors housing operators and owners are hopeful that sales will get a big boost in early 2021. But until then, they still face a challenging marketing landscape as the virus continues to spread amid renewed lockdowns and restrictions. 

“We have to win back consumer confidence,” said Traci Bild, CEO at Bild & Co., a Tampa-based sales and marketing firm.  “We have to be proactive.’ 

Bild participated in two sessions at NIC’s Fall Conference on the sales and marketing challenges presented by the COVID-19 era. Other panelists included operators and providers.  

The sessions were led by Bre Grubbs, senior vice president at Leisure Care, a Seattle-based operator with 52 communities nationwide. She asked the participants how their marketing plans have changed over the course of the pandemic.  

Sales took a back seat when the pandemic first hit. Operators were focused on saving lives and securing personal protective equipment. They also faced a changing array of rules as regulators struggled to find the best approaches to mitigate the spread of the virus. “It was a crisis,” said panelist Joe Kiernan, chief strategy officer and senior vice president at Ocean Healthcare, a New Jersey-based post-acute provider.  

As the first wave of the pandemic eased in the Northeast, Ocean Healthcare was able to admit new patients with strict precautions in place. COVID and isolation units were created. As testing ramped up, more patients were admitted. “We have learned so much,” said Kiernan. 

Transparency saved the hospital referral pipeline. Ocean Healthcare had direct conversations with all its stakeholders including resident families. Data was shared on the number and outcome of cases. A plan was developed to handle a resurgence of the virus. “We are ready to support our hospital partners,” said Kiernan. 

Salespeople Get Creative 

Flexibility has been key, according to session participants. Marketing strategies have evolved over time as the virus spread across the country as new hot spots emerged and cases surged in the fall nationwide.  

Sales efforts are being tailored to local market conditions. Contributing factors include the disease positivity rate in the wider community, and state and county regulations.  

Operators knew the pandemic would hurt move-ins, so early on they turned their attention to prevent move-outs. “One of the things we could control was our back door,” said Summer Blizzard. At the time of the panel discussion, she was vice president of sales at Independent Healthcare Properties. She now works for another provider.   

Blizzard said that the sales team quickly pivoted to working with families to deepen relationships with them. The goal was to keep current resident safe, happy and engaged. “We had to get creative,” she said. The sales team had to be educated about the virus and take a new approach.  

The session panelists said that sales representatives have faced two big objections from potential residents and their families: safety and isolation. They want to know how the threat from the virus is being handled by the community; and how the community is dealing with the isolation of residents because of the need for infection control.  

The panelists emphasized the importance for salespeople to be transparent and authentic. Sales leads must be nurtured. A soft approach works best. An occasional check in with those who have shown interest in the property has been found to be valuable.  

With restrictions on in-person meetings and tours, virtual tours and zoom conferences have helped sales teams stay in touch with referral sources and prospects.  

Successful sales reps have learned to quickly convert a phone call into a walking tour. “Virtual tours are fun,” noted Bild. “No one will move in without seeing the community.” She added that in some respects a virtual live tour makes it easier for prospects to ask questions.  

Though sales have slowed, marketing executives say that the new residents who have moved in are frailer than those of previous years. Healthier seniors are staying put. The ones who are moving can’t manage at home anymore. However, Grubbs noted an uptick of interest in recent months from seniors looking for independent living units.  

Marketing executives are revamping advertising campaigns. Video testimonials are finding some success. Property websites should be refreshed, the panelists said. Direct mail is getting another look since more people are at home. Fewer folks are out driving by properties, which can be a big source in inquiries.  

Much of the marketing focus has shifted to social media outlets such as Facebook. People at home are spending a lot of time online. A thoughtfully designed Facebook page can show a vibrant lifestyle in action despite the restrictions, according to Grubbs. Residents can be seen meeting with family outside or engaging in a fun activity.  

Marketing consultant Bild noted that the pandemic has heightened the realization that senior living is still an emotional sale. What drives a new move-in is the connection that the sales team makes with the adult child or resident. “It’s not about the building,” she said.  

Grubbs emphasized the importance of getting back to marketing basics. The goal is to stay in touch with prospects, show genuine concern and follow up on leads.   

Bild agreed. She advised operators to stay on top of leads. “The pandemic has hurt traffic,” she said. “But the traffic that is coming in is legitimate.” She expects demand to resume with the introduction of the vaccine, advising operators to redouble their sales efforts. “Prepare now,” she said.  

Senior living providers eagerly await FDA approval of a COVID-19 vaccine and are preparing the logistical plans needed to ensure a fast and efficient process to vaccinate residents. In the meantime, robust testing remains the most effective strategy for protecting residents and staff from widespread infection. To better understand current testing strategies and how they have adapted over time, I spoke with Ed Ward, Vice President of Operations, Kisco Senior Living to learn more about their innovative testing program.

Kisco Senior Living, a Carlsbad, California-based provider, has embarked on a strategy of pool testing. Pool testing, also known as batch testing, combines saliva samples from a large group and tests the combined sample for evidence of the coronavirus all at one time. This process can be cost effective and easier to implement than repeated, individual testing. It can also instill confidence among staff, residents, and their families. Further, pool testing cuts down on both time and supplies required and, as discussed in a NIC Leadership Huddle, is a strategy that is being utilized by other high-profile organizations, such as the National Basketball Association. If a sampled pool generates positive test results, then everyone in that group receives an individual PCR test as follow-up. Contact tracing to identify other residents or staff who may have been exposed can then begin as well.

In our conversation, Ward described reluctance by some residents to undergo the sometimes uncomfortable nasopharyngeal PCR testing process, and as a result, he said that a portion of residents were foregoing routine medical appointments to avoid having to isolate themselves for the subsequent two weeks. Ward said, “We thought it was unacceptable to do invasive testing if we were going to do regular and routine testing of our residents.” Kisco implemented rapid, antigen testing residents for a time, but found that for asymptomatic individuals, the rapid test wasn’t as accurate as they needed it to be. “We wanted something as accurate for asymptomatic individuals as it was for those who are symptomatic.”

Residents are grouped into pools based on their risk profile. All residents are tested at least once per week. Any resident who leaves the community, to go to a medical appointment for example, is considered at higher-risk, and tested twice per week. Associates are also tested twice per week.

At Kisco, two pool sample sizes are utilized, depending on factors such as building census and location of where people work or reside. For smaller properties, a pool of up to 50 residents is typically used. For larger properties, a pool size of up to 100 can be tested. It is more expensive to test the larger pool size, but on a per-resident basis, the cost is less than the smaller pool size. The program’s cost amounted to approximately $100,000 per month, and Kisco has included testing expenses in their 2021 budget.

Ward told me that he is in regular contact with the labs that process their pooled samples to understand their turnaround times. Samples are overnighted and are turned around within at least 24 hours, often only taking 12 hours. Because Kisco can identify COVID-19 positive cases so early, “This has allowed us to open up dining and activities and have a lot more confidence about our operation,” Ward explained.

In addition to testing staff and residents, Kisco includes anyone coming into their property – whether for hospice, home health, or salon services – in their higher-risk pools. “Agencies might have their own testing protocols, but by controlling it ourselves and including them in our pools in order to provide services in our buildings, this gives us another degree of confidence,” Ward said.

Kisco is also working with their lab partners to facilitate safer and more confident visitation of residents. This includes a program – now available in all Kisco communities – where visitors can consent to providing PCR test results directly from the lab to Kisco. Upon a negative test, visitors are cleared to visit the community within a 24-hour period. Moving forward, Ward explains, “If vaccines, therapeutics, or other advances to control this virus emerge, we will monitor the science and data and make adjustments based on the facts at the time.”

It seems clear that pool testing may in fact be one of the most appropriate ways to test residents in a large, congregate setting, and in this case, has increased the likelihood of residents keeping up with their routine medical appointments, allowed for safer and more confident visitation of residents, and a return to more ‘normal’ conditions for Kisco residents.

2020 has been a challenging year. The seniors housing and care sector was thrust into an adrenaline-fueled, 24/7 pitched battle to protect millions of America’s most vulnerable citizens from the deadly COVID-19 global pandemic. Leaders across the sector have been challenged by regulatory inconsistencies, sweeping changes in public policy, an intense media spotlight, evolving consumer attitudes, changes in healthcare delivery, the implementation of new technology, mental and physical health concerns of staff and residents, and uncertainty in capital markets – just to name a few.

NIC has responded to these challenges by doing what we do best: provide data, analysis, and a platform for connections. Since mid-March, we have launched a number of initiatives designed to improve our understanding of the impact of the pandemic on the seniors housing and care industry. Much of this information can be found on the COVID-19 Resource Center on NIC.org.

As the situation evolves, it is essential that industry leaders be able to share lessons learned, discuss strategies, hear the latest insights and continue to connect with one another, even as travel restrictions and risk of infection continues to make in-person gatherings and networking nearly impossible. NIC is therefore temporarily shifting from its traditional emphasis on a major in-person spring conference event.

For the first half of 2021, NIC is pivoting to provide a program of online opportunities for seniors housing and care leaders both to stay informed and connected across the industry.

To that end, NIC is extending the extremely popular “Leadership Huddle” webinar series and enhancing it with the addition of post-webinar ‘peer-to-peer’ breakout sessions designed to facilitate further discussion, moderated by webinar hosts and experts. Made possible by our generous partners and sponsors, the entire series of Leadership Huddle webinars will be complimentary and open to attendees across the industry.

The series of enhanced Leadership Huddle webinars will kick off on Wednesday, January 27, and then will continue, with additional events to be held on the 2nd and 4th weeks of each month, through the first half of 2021. Attendees of NIC conferences can expect the same high level of expertise, analysis, insight, and thought-leadership typically found in our conference programming. The program will enable NIC to be able to provide the most relevant, timely, and impactful subject-matter, keeping pace with change as it occurs.

2021 will likely bring further change, hopefully bringing America, and the seniors housing and care industry, beyond this crisis and into a new normal, in which in-person events are again possible. Until then, NIC will continue to take a nimble, adaptive approach, in order to continue to offer industry leaders and stakeholders the most efficient, effective means to stay informed, share information, and connect with one another.

Partners and sponsors, who typically enjoy opportunities for recognition and visibility at the NIC Spring Conference, can, instead, now choose to gain visibility and associate their brands with NIC’s via Leadership Huddle webinar presentations, as well as a variety of other opportunities, some of which are unique this coming year. Interested parties can sign up to receive up-to-date information on all upcoming sponsorship opportunities here.

In the absence of large, in-person events, NIC’s pivot to develop the industry’s premier digital properties, with the support of partners and sponsors, is a major opportunity to gain visibility and recognition with industry leaders, where they will safely and efficiently convene online, throughout the entire year.