August 2021 Insider

Well-Defined Business Strategy Spurs Growth at Atria Senior Living: A Conversation with CEO John Moore

John Moore is a strategic thinker. As Chairman and CEO of Atria Senior Living, Moore has thoughtfully grown the company to become a highly regarded seniors housing operator. Since taking the helm in 2003, he helped to expand Atria to more than 200 communities throughout the United States and Canada. Revenue has doubled since 2011 to $1.3 billion. And most recently, in a blockbuster deal, Atria purchased Holiday Retirement. The newly combined entity will manage 447 communities across 45 states and seven Canadian provinces, making it the second largest seniors housing operator in the country.

NIC Chief Economist Beth Mace recently talked with Moore about his strategy. It’s not growth for growth’s sake. He has a plan. Moore also weighed in on lessons learned from the pandemic, as well as the short and long-term outlook for the industry. What follows is a recap of their conversation.

Mace: As a premiere, vertically-integrated, multi-brand seniors housing operator, Atria’s brands include Atria Senior Living, Atria Retirement, Atria Signature, Gladwell, and Glennis Solutions. Can you tell our readership what’s next and how you are positioning Atria for growth in the 2020s, in what you have dubbed the so-called “Seniors Decade”?

Moore: The next thing for Atria will be the introduction of our new brand, a joint venture with Related Companies. The brand will fill the unmet need for very high-end communities with custom services and amenities in highly desirable locations. We plan to open a community next April in San Francisco’s Cathedral Hill neighborhood. Our new community in New York’s Hudson Yards opens in the fall of 2022. In Boston, we’re working on a project on Tremont Street, the current site of the Franklin Institute which is moving. It’s a great spot between the Back Bay and South End, near restaurants and arts centers. The building will be taller than anything around with great rooftop views of all Boston. We’re also looking for more locations in the San Francisco Bay Area, West L.A., and other upscale spots. The apartments in these developments have high-end finishes, kitchens, and washers and dryers. The Atria model is to license the entire building for assisted living. But 50% of our residents don’t buy assisted living services, except for medication management. We’re using technology to create a better care and lifestyle experience. Our memory care units will be highly staffed.

At the other end of the spectrum is Holiday Retirement and Atria Retirement, which we think represent a good opportunity since these brands have a very approachable, or reasonable price points. The smart way to do business on the approachable side is through scale and repeatability. Bill Colson, who founded Holiday, was brilliant and created a usable building, and repeated that successful model.

Mace: Holiday had live-in couples who managed the property. Are you still using that model?

Moore: We unwound the couple management structure first in Canada when we took over that portfolio in 2014 to 2015. Holiday has also since unwound the couple management structure as well. Putting professional management in place has helped to create efficiencies, and we’re planning better use of technology. Maybe even turning to wearables that can track residents in a community. Sign-ins, meal attendance, and status checks, to some extent, can be automated. Technology efficiencies allow us to put more dollars into staffing to support lifestyle and hospitality offerings. For example, meal service at one seating in the common areas allows us to spend more money on food quality while having a congregate setting where staff can help residents. The approachable end of the market is about standardization and using scale to create a quality advantage.

Mace: Can you explain your strategy to target the high-end and approachable segments of the market?

Moore: We think the middle of the senior housing sector is crowded. These are typically the average, higher-quality developments in low barrier-to-entry markets. We’re interested in the very top and the approachable ends of market. Both models have a high barrier to entry. It’s hard to find good locations in affluent areas for the high-end model, which also is hard to execute from a service standpoint. The approachable model is hard to execute because you need scale to drive value.

Mace: NIC did a study on the need for housing for middle income seniors, such as teachers and government employees. Would the Holiday model serve that market?

Moore: Defined benefit pension plans in the private sector went away in the 1980s and 1990s but exploded in the public sector. There is a generation of workers about to retire with a solid fixed income. They represent a good opportunity if we give them a good product and if they know what they can expect.

Mace: Our readership includes operators, developers, and capital providers—both debt and equity. You have more than one capital partnership. What do you look for in a good capital partnership?

Moore: We want financially-sound partners that care about the business and bring value to the table. The other reality is that different capital partners have access to different opportunities at different times. You have to be smart about partnerships. If you want to control your vision and your program, you need different capital partners. One capital partner may not be interested in what makes the most sense for your business at any point in time.

Mace: Now, let’s switch to operations and the pandemic. How are you turning the page on COVID-19? What lessons have been learned, and what will you carry forward into future day-to-day operations?

Moore: It’s been a crash course in relearning what we do. Execution is everything. We quickly secured personal protective equipment. We did more than 300,000 COVID-19 tests, conducting three test clinics a week in every community at the heights of the pandemic. We partnered with Mayo Clinic Laboratories who gave us results in two-and-a-half days so we could take action. Leadership is about communication: telling people what you are going to do, doing it, telling them you’ve done it, and then telling them what’s going to happen next. We worked hard on communications during the pandemic, and I think it served us well with staff, residents, and family members. I still record a weekly video to update the staff or talk about company events. We also took steps early on to keep the staff safe. For example, in the first weeks of the pandemic, we sent our New York City staff home every night in new KN-95 masks and gave them packets of masks to take home for their families. It’s both the right thing to do and good business. You need to show people you’re paying attention to what they need.

Mace: What is the “Atria Cares” campaign?

Moore: It’s a 501(c)(3) charity that awards grants to front-line staff for emergency needs. We came up with the idea after the hurricanes of 2004 when the frontline staff had uninsured situations such as a tree falling on a house. We’ve made all kinds of grants. We donated $500,000 for Atria staff displaced by the devasting fire in Paradise, California. We replaced a stolen computer for a worker’s son. We have another program to give scholarships to the children of frontline workers. We’ve given out more than $600,000 in scholarships.

Mace: You have a near-100% COVID-19 vaccine participation rate for your U.S. employees. What was your approach? Did you mandate the vaccine?

Moore: The biggest lesson from the pandemic is the importance of leadership. People want those in a position of authority to take control. Yes, we mandated the vaccine, and a couple things led up to that decision. First, the state of Massachusetts in 2020 required flu shots for everyone working in licensed communities. We had an information campaign about the new law. We told employees there was nothing we could do about it and, if they didn’t take the flu shot, they would lose their job. That was an ah-ha moment. People needed to be told what to do. We mandated the COVID-19 vaccine on January 11 and built a positive campaign with lots of communication about vaccination. The immediate reaction from executive directors when we mandated the vaccine was a palpable relief and thank you. The surprise was how much everyone jumped on board.

The way we talked about it with the staff was that our residents deserve to be in a vaccinated environment, and you deserve to work in a vaccinated environment. We are in an industry that got priority access to the vaccine, and we have just lived through a period where we have seen what COVID-19 does. The sooner the vaccine gets into people’s arms, the sooner the pandemic is going to go away. And if we are given priority access, we have an obligation not to waste it.

We met with workers who were hesitant and talked to them. The most resistant group were mostly younger people. I think they don’t have memories of horrible disease outbreaks like that of polio. At the end of the day, almost all of them took the vaccine. The number of people we let go was less than 2%.

Mace: Has mandating the vaccine turned into a competitive advantage for you, helping lead generation and move ins?

Moore: We think so. Our occupancy recovery has far outpaced expectations. We saw things turn around in February, and momentum has been strong. Our website is setting records for visits. When someone is making a decision about moving, we feel like we are more likely to win.

Mace: Staffing is top of mind for our entire industry. What programs/policies/strategies do you have in place that have helped Atria to recruit workers before and during the pandemic?

Moore: It’s an issue everywhere, and there is more pressure on wages. But we’re not in crisis from a staffing point of view because we build loyalty.

Mace: How do you build loyalty in your staff?

Moore: There’s no magic. It’s about delivering on what you communicate about, whether its vaccinations, scholarships for the children of frontline staff, or supplying masks for the staff to take home to their families. The business needs to be about putting people in the community in a position to succeed. That gets back to our strategy of targeting the high-end and approachable end of the senior living spectrum. We think it will be easier to succeed in those situations, instead of in the middle of the market which is highly competitive.

Mace: And now one last topic. You have served on the NIC Board and most recently as its Chair from 2014 to 2016. On behalf of NIC and myself, thank you for all the time, insights, humor, stimulating conversation, and leadership that you provided. Now you serve on the Argentum Board of Directors. What are some observations you’ve made about being in leadership roles such as these?

Moore: The industry is great in terms of how collaborative everyone wants to be. I hope that now is the time we drop the competitiveness. During my Board chairmanship, I have one regret that the industry couldn’t develop one voice. The industry has grown through several organizations, such as ASHA, Argentum, and NIC. There’s crossover, of course. But the industry needs to realize the benefits of unity and the differences that will make. The industry was almost an afterthought for pandemic relief funds. This is a time when we should think about finding ways to work together.

Mace: Lastly, is there anything else you would like our readership to know?

Moore: I’d like to know how the recovery will play out. The industry has benefitted the last few months from pent-up demand. But what’s next? We’ll see what happens throughout the summer. But if the recovery stalls, some operators might not be able to catch up on occupancy and could have capital structure pressures. I think the recovery could take 2-3 years to play out.

But I’m optimistic. The over-age-80 demographic is growing at a 75% greater rate this year than it did in 2019. You have real demographic juice this year for the first time, and it will continue. Demand growth will double by mid-decade. There will be fewer caregivers, and congregate settings will make a lot of sense. The math is on our side.

Paul Krugman and Lawrence H. Summers to Discuss the Economic Outlook at the 2021 NIC Fall Conference

In keeping with a long tradition of featuring nationally prominent experts at the NIC Fall Conference, NIC recently announced that two preeminent economists would discuss the macroeconomic and capital market trends that will impact the seniors housing and care sector over the coming months and years.

Lawrence H. Summers, former Secretary of the U.S. Treasury, and Paul Krugman, 2008 Nobel Prize for Economics recipient and New York Times columnist, will engage in a moderated discussion focused on the economic outlook during the 2021 NIC Fall Conference on November 2 in Houston. The potential for rising inflation, the direction with interest rates, cost of capital, the direction of fiscal and monetary policy, rising deficits, and labor markets will be included in the spectrum of macroeconomic and capital market trends addressed. The discussion will be moderated by Angela Mago, president, Commercial Bank & Real Estate Capital, KeyCorp.

Recognized as one of the world’s most influential thinkers by Time, Foreign Policy, Prospect, and The Economist magazines, Lawrence H. Summers continues to move forward the debate on national and global economic policy in his speeches, regular newspaper columns in The Washington Post, and as a contributor to Bloomberg’s Wall Street. Having played a crucial role in tackling every major financial crisis for the last two decades, Summers will bring an exclusive perspective on the continuing impact of COVID-19 on the economy.

As one of the world’s most acclaimed economists, Paul Krugman frequently speaks on leading issues of the day affecting the world economy. His twice-weekly Op-Ed pieces for the New York Times highlight his depth of insight and outspoken style. Krugman has extensively researched consumer’s desires for variety and choice and the impact on economies of scale leading to groundbreaking work on international trade and the new economic geography.

“Paul Krugman’s and Lawrence H. Summer’s vast understanding of the macroeconomic factors and trends that impact the economic and capital market environments – both now and into the future – will provide key insights to executive leaders in seniors housing and care who are addressing market challenges compounded by the pandemic.” said Brian Jurutka, NIC president and CEO.

As conference attendees are already aware, the evolving economy will have a significant impact on their businesses. Access to capital, cost of finance, availability and cost of workforce, consumer buying power, and many other economic factors are likely to influence how business leaders plan for the future. Many are expected to listen closely to the discussion during this featured session as they consider their strategies moving forward.

For those that wish to get a primer on the economy ahead of the conference, NIC Chief Economist Beth Mace is presenting “The NIC Bluebook: Market Conditions and the Senior Housing Sector.” The unique webinar, scheduled just ahead of the conference, will be made available to Early Bird registrants only. Those attendees who register by Monday, August 16th will be rewarded with the latest economic data and analysis relevant to the seniors housing and care sector, better preparing them to get the most out of conference discussions, whether listening to the acclaimed economists – or discussing face-to-face with peers and prospects on the conference floor in Houston.

In addition to access to the economic primer, early registration offers significant savings and thoughtful perks, including NIC lapel pins for pre- and post-conference networking, PPE kits, and the advance delivery of conference credentials. All registrations can be cancelled for free, up to 30 days prior to the event.

To learn more about the 2021 NIC Fall Conference, and to register, Click Here.
The Early Bird discounted registration ends on August 16th.

Illustrating the Value Proposition of the Physician in Senior Living

In the last of the latest series of NIC Leadership Huddles, titled “Illustrating the Value Proposition of the Physician in Senior Living,” a panel of experts looked at the ongoing shift in the industry towards models that incorporate healthcare as well as hospitality. The discussion, moderated by William Shatraw, MHA, DPT, vice president, client success leader, Signify Health, centered on the role of the primary care physician in senior living today, and on understanding, from a business perspective, the viability of the physicians’ onsite presence.

For many, the COVID-19 pandemic has underlined the importance of keeping frail elders out of emergency departments and physician’s offices, but for industry veteran Charles Trefzger, president and CEO, ALG Senior, the trend goes back much further. “It’s the natural progression of our industry, that we have seen since the mid-90s,” he said. Trefzger explained that the industry has long experienced a ‘dichotomy’ between hospitality and care, but that today, although hospitality is still extremely important, his company must respond to increased demand for healthcare. “But what we’ve had to do, because of increasing acuity of our residents, because of advancements in medicine, because of advancements in technology, and the expectations of our residents and their families, is to embrace more of a medical posture than we have ever had to do in the past.”

Beyond housing and hospitality, the industry, as expressed by Trefzger, is now increasingly expected to manage resident health and wellness. Jennifer Rucci, chief medical officer, Eventus WholeHealth, agreed that operators are shifting towards care coordination and the provision of medical services. She noted that acuity levels are changing, “The skilled nursing home patients look more like hospital patients, the assisted living patients look more like the old days of skilled nursing patients, and so on.” But, operators, according to Rucci, don’t have to choose between hospitality and care. “You can still provide a very hospitable, warm, welcoming home to your residents in assisted living communities, but also embrace the role…as care coordinator to the medical service lines.”

Michael Kwame Poku, MD, MBA, senior medical director, Oak Street Health, emphasized that demand is driving the shift to provide care. Speaking of today’s senior living residents, he said, “They just want to be healthy. They want to be out of the hospital, out of the emergency department.” Poku sees residents asking questions of operators around their care coordination and beginning to expect good answers.

The panel discussed the central role that primary care physicians must play within a community. As value-based care continues to focus the healthcare system more on wellness and better outcomes at lower cost, senior living providers can align themselves with the key components of achieving those goals. Speaking of primary care providers and specialists working in senior living communities, Poku said, “In order to achieve that next level of value, we need to bring other stakeholders in and really lock arms.”

Referring to the primary care physician as the ‘quarterback’ of a patient’s medical care, Rucci described a patient-centered system built around the various needs of the population. Her company provides both primary care and specialty care, such as behavioral health, cardiology, and orthopedics. “Isn’t it nice, if the resident were to have a small fracture, for instance, and not have to send them to the emergency room to be casted; to be able to bring that specialty to that resident is amazing,” she said. “The outcomes just become better. You wind up with proven better outcomes for the patient, clinically, and you wind up with better systems for the operators, as well.”

Trefzger explained that this approach is different from the traditional medical director model. “It’s a very interactive, collaborative method that if we don’t start doing we’re going to see increasingly our lengths of stay diminish. The easiest resident to obtain, in our marketing world, is the one we already have. We need to focus on those folks in our communities and keep them there.” He emphasized that the hospital is not necessarily a safe place for his residents, before saying, “We have to be a collaborative member of this team sport that is now being created.”

Asked by Shatraw who should own the responsibility for aligning the various providers, Trefzger pointed to the community operator. “Right now, your community has a network, whether you know it or not, whether you’re managing it or not, it exists. Why not get in front of running that network and lead the parade instead of following?” He also suggested operators should narrow their networks to improve quality, outcomes, and compliance with regulations. He said, “Our strategic analysis is you own it, ‘Mr. Provider’.”

The panel agreed that value-based care is here to stay – and that the need for senior living to align with care providers is pressing. Payors and regulators are pushing operators to change, both through regulatory action and payment models. “It’s coming, and the faster and the better we can work together to provide those clinical outcomes for the residents, that’s in everyone’s interest: residents, medical operators, and facility operators,” Rucci said.

The panel also discussed the importance of data. “No data, no trust,” said Trefzger. He explained that all the providers in his network must provide data, which is then reconciled with his organization’s data. “We’re tracking, for instance, all the medication orders, and the type of medication orders, and then we’re mining that data to try to find out who is the outlier. We are…looking at who is creating a fall risk because of the type of medications they are prescribing.” He said he’d had a resident on 32 medications and had to “go after that physicians’ group to get it down to an appropriate level.” Trefzger’s group also looks at incident reports, watching for falls, congestive heart issues and their possible causes, such as discontinued medications, and much more. He said, “I cannot emphasize more the need for all my industry partners and peers to begin undertaking collaboration and creation of data points.”

About NIC Leadership Huddles

The discussion closed out the second season of the popular live webinar series, the first of which NIC initially launched as part of its response to the COVID-19 pandemic last year. This eleven-event series was launched on January 27, 2021, with a very timely focus on policy, just a week after the swearing in of President Biden. The series, which has offered a complimentary new Leadership Huddle twice each month, was designed to retain the same level of relevance, and quality of discussion, which drew thousands of industry decision-makers to the first season.

NIC Leadership Huddles bring together subject matter experts from senior housing, skilled nursing, and healthcare to share -and discuss- timely perspectives and thought-leadership on topics spanning investment, operations, and policy.

Both seasons of NIC Leadership Huddles are posted for complimentary public access on NIC’s website. Visitors to NIC’s COVID-19 Resource Center will find a video recording of each webinar discussion, plus a corresponding recap article. The second season of NIC Leadership Huddles includes the following titles:

• Policy Outlook: A New Administration & A New Congress | January 27, 2021
• Fact or Fiction: Lending Markets During a Pandemic, and Beyond | February 10, 2021
• Is There an Investment Case for Skilled Nursing in the Intra-and Post-Pandemic World? | February 24, 2021
• Deal Structures and Alignment of Interests During a Pandemic: A Case Study with an Operator, Lender and Equity Provider | March 10, 2021
• Value-Based Care: What’s in It for Me? | March 24, 2021
• Skilled Nursing Integration Will COVID be the Catalyst for Tighter Hospital Partnerships | April 14, 2021
• Seniors Housing Equity Players Talk Investment Strategy | May 12, 2021
• Trends That Will Shape Senior Living Post-Pandemic | May 26, 2021
•  Pandemic 2020 Changing How Debt and Equity Partners Look at Financial Performance | June 16, 2021
• Illustrating the Value Proposition of the Physician in Senior Living | July 14

COVID-19 Research Study: Phase 2 Summary

In June 2021, NIC released the results of a Study conducted by NORC at the University of Chicago, with a grant provided by NIC, on the impact of the COVID-19 pandemic on mortality rates in seniors housing and care. The analysis examined mortality rates by level of care – independent living, assisted living, memory care, and skilled nursing – as well as providing a comparison to seniors aged 75+ living in non-congregate settings (single-family homes and apartments).

The analysis showed that the COVID-related mortality rates of seniors housing during 2020 were significantly less than for skilled nursing. Specifically, 67% of independent living properties had no COVID-19 deaths in 2020, while 64% of assisted living and 61% of memory care properties had no deaths. This compares with 39% for skilled nursing. Further, the analysis found COVID-19 deaths across senior housing properties rose in tandem with the acuity, or severity of the illness of the average resident, and the complexity of caregiving needed. The highest mortality by percentage occurred in memory care and skilled nursing facilities. In contrast, the average mortality rate for adults in independent living properties was statistically the same as the mortality rate of the age 75 and over population in corresponding counties, suggesting residents in this type of group setting were not at higher risk of death from COVID-19 than those living in private homes.

With a subsequent and additional grant from NIC, NORC will expand on the initial research findings by using Medicare fee-for-service claims data and Medicare Current Beneficiary Survey (MCBS) data to risk-adjust the death rates for those individuals living in seniors housing as well as non-congregate settings. This risk-adjustment will account for baseline demographics such as age, race, gender, health status, and degree of frailty at the individual level. This manner of risk-adjustment allows for a rigorous assessment of differences in outcomes across seniors with comparable health statuses living within the same market areas. The intent of this phase in the study is to understand how overall health status and underlying health conditions impacted COVID-19 death rates of seniors living in different settings within the same geographic areas.

These data findings will be critical to improving the public’s understanding of the safety levels within the various seniors housing care segments. Phase 2 of the COVID-19 research Study is expected to be completed by March 31, 2022. To view the Study’s Phase 1 complete findings and conclusions, please see the Final Report and detailed Technical Report by visiting NIC’s COVID-19 Study landing page.

Lessons from COVID-19 to Benefit All Seniors, Including Middle Market Prospects

By Matthew G. Derrick, Senior Development Director, Confluent Senior Living, NIC Future Leaders Council, Class of 2023

The world is beginning to emerge from the historically challenging COVID-19 pandemic. No industry was immune to its effects, and the seniors housing industry was significantly impacted as many of our residents are in a high-risk category. It was no surprise to those in the senior living world that the industry faced these challenges with heroism and grit. Most crises and emergency events tend to expose weaknesses and areas ripe for improvement, however, and COVID-19 was no different. During this time, developers and operators were challenged to take a step back and reflect to determine what lessons could be learned from the pandemic and how we could take these lessons and use them to elevate our communities to become even better and safer on the tail end of COVID-19.

Senior living post-pandemic will likely look different, and we as an industry can take this opportunity to reimagine the senior living experience for not just the affluent, but all seniors housing residents. Developers, owners, and operators strive to strike a healthy and delicate balance between improving building designs with the latest in holistic technology, while also adhering to increased regulation around health and safety protocols across the senior housing industry. It is important that we remain focused on hospitality, community, wellness, safety, and the overall joy of our residents and associates.

Many developers and operators have answered the call and adopted new standards for health, safety, and wellness. Thought leaders in the industry have integrated technologies such as sanitation stations, touchless fixtures and light switches, bipolar ionization, or UV treatments through the HVAC systems, as well as electrostatic sprayers that neutralize infectious diseases. In addition to new technologies, many developers and operators are enhancing their designs to encourage more active outdoor activities and lifestyles. Balconies and outdoor spaces such as open-air dining areas, pools, and community parks and gardens are just a few of the design changes that should be implemented to help promote enjoyable outdoor activities.

While these changes might seem like obvious improvements for the industry and for the future of our residents, they all come with a cost. At a time of inflated construction costs, labor challenges, and material shortages, it may be difficult for some to justify additional costs, especially in a post-pandemic world as life seems to be returning to a pre-pandemic “normal.” Many residents in more affluent communities may come to demand these new design features and technologies, and they can afford the premium that comes with these added costs.

Much has been discussed about the middle market gap between low-income seniors housing and the higher-end, private pay communities that dominate the construction and pipeline reports. The innovative lessons learned from the pandemic should not be reserved for only the most affluent of the senior population who can afford to live in communities that have the means to install the most recent, and expensive, safety and wellness technology. The question remains, how do we ensure that the middle market residents are afforded a comparable caliber of health, safety, and wellness technologies?

The world appears to be entering a new era of heightened focus on inclusion and equity where governments, organizations, and individuals are focused on doing the right thing even as it has an impact on their bottom line. There has been an increase in investment funds that are focused on investing in companies that have a record of measuring and improving workplace diversity and equal pay for equal work. There are eco-friendly funds focused on investments in companies that benefit the planet and the well-being of its inhabitants. These funds may perform well for their investors, but the return on investment is not the only goal. Return on investment while simultaneously improving the world are the goals, and one without the other results in failure.

The seniors housing industry has an opportunity to capitalize on that sentiment and appeal to capital sources that are willing to invest in low income and middle market communities that benefit the “Forgotten Middle” market. This might potentially mean those investors would realize compressed returns, which may be a small price to pay for the greater good of this segment of the population. While the returns might be somewhat less than a traditional seniors housing investment, the middle market provides access to a much larger segment of the population who can afford the product that a middle market opportunity would offer. Buying older, existing product below replacement cost would reduce much of the development risk. À la carte services would reduce the operational expenses, and shared units would reduce the building space needed for our residents. Those changes, coupled with investors focused on returns AND equity for all seniors will help guide us to a larger middle market offering.

While the senior housings industry is not new, we are in fact entering a new era. With the emerging baby boomer wave right around the corner, and the COVID-19 pandemic hopefully in our rearview (or soon to be), it is an opportune time for us to improve our product with a focus on safety, wellness, hospitality, and equity. It would not reflect well on the industry if those improvements were only afforded to the most affluent. We can and must do better for our seniors, and it is in our best interest to lean in and focus on the greater good for all.