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Published on March 26, 2017

Table of Experts: The Business of Health Care and Senior Living

Senior Americans comprise about 13 percent of the population and are projected to account for about 20 percent of the population by 2060. As baby boomers age and care for their parents, the issues surrounding senior care touch nearly every family. The Boston Business Journal’s Table of Experts program highlights the business opportunities, challenges, and changes in technology in health care and senior living.

Here’s an edited transcription from the program discussion, which included Tom Grape, Benchmark CEO; Andrea Cohen, HouseWorks CEO; Erik Anderson, PROCON Vice President of Architecture; Greg Martin, Brookdale’s Vice President, Divisional Field Sales & Marketing, Sales – Northeast; Denise McQuaide, Mt. Auburn’s Vice President of Post-Acute Care and President of CareGroup Parmenter Home Care & Hospice. Carolyn Jones, BBJ Market President, moderated the program.

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Carolyn Jones: Let’s start with an overview of senior living, private home care, the building industry and how that connects.

Andrea Cohen: We are focused on helping people remain at home for as long as they can with as much independence as they can. The private home care industry has skyrocketed and the demand is really high right now. The latest estimate that I’ve heard from various sources is that it’s a $30 billion industry. With private home care, the care is delivered in the home but supplemental care is also delivered in senior housing. So, we do a lot of work in senior housing and also in skilled nursing facilities. I would say the majority of what we do is really helping transition people from one setting to another. The kinds of services that we provide range from personal care services to companion. I would say that about 50 percent of our service now is 24-hour care in some way, shape or form.

Tom Grape: Senior housing covers a broad range of different options and I think for both Brookdale and Benchmark and our peer companies we provide a range including independent living, assisted living, memory care communities and continuing care retirement communities. Independent living really serves people who are still – as the name implies – still independent. Assisted living serves folks who are physically frail and who are starting to need help with the activities of daily living and need more in the way of three meals a day and some help with medications or other supports because of their physical frailty. Memory care assisted living is for folks who may not be physically frail but who either have Alzheimer’s or another form of dementia but who do not yet need more intensive medical care. And assisted living is a great setting for those folks. Continuing care retirement communities are those that are for folks that are independent but want access to higher levels of care if the need arises. And of course, skilled nursing as the name implies, the traditional nursing homes that we all have seen in our communities for many years.

Jones: Denise, talk a little bit about Mt. Auburn because you provide the before and the after, so maybe see how that connects to what everyone else does.

Denise McQuaide: The Mt. Auburn network is actually made up of three components. One is the hospital with its inpatient, outpatient clinics. But it’s also a large physician practice, and the home health care and hospice agency. We work very closely together as a network in senior housing with the operators. Just as my colleagues here have talked about how important it is to keep people at home, we as a network really believe that, too. So, we actually send physicians and nurse practitioners into senior housing on a very regular basis.

Jones: Erik, talk a little bit about what PROCON does, which is obviously providing and building the facilities. What are some of the priorities you see?

Erik Anderson: As a design builder, we serve senior living developers. And as they change and adapt we change and adapt with them in adopting new technology. One of the trends that we are seeing, specifically in Boston and other urban areas is open flat sites are getting very, very hard to come by. So, the sites are generally getting more challenging. We’re seeing more urban and downtown projects that inherently have smaller, more complex sites. For example, a memory care unit that would typically be on one floor for purposes of staffing and shared amenities might increase to two floors as the building gets taller and narrower.

Jones: What are the things that are happening in all your areas that need to change how you do things or create new things, build new facilities? What are some of the key trends?

Grape: Over the last 15 or 20 years we’ve seen an increase in the age and acuity or frailty of the residents that are served in all senior housing settings. So, they’re coming in older and frailer or choosing to stay at home longer before they move to a senior housing setting. We’re seeing a more demanding customer. The generation we’re now serving are folks who are no longer the Depression generation. These folks and the adult children who are participating in the decision-making process with them are folks who have higher expectations and want things when they want them and how they want them and at the time they want them and so on. And that’s only going to increase. We’re seeing increases in technology obviously playing an increasing role. We’re seeing changes in the health care system. We’re seeing people wanting a greater variety of what the communities look like and where they’re located and how they’re constructed, which Erik can speak to.

Greg Martin: Tom brings up a really good point. You have (to) work with architects to change your product line so (that) what was once an independent living community now might offer assisted living or memory care as well within that community. We look at our assets and we determine what do we need to change within the community to meet the market needs.

Andrea Cohen: I spend a lot of time visualizing what it’s going to look like in our industry because we think about that all the time. One of the things that I think is important because we do a lot of work with residents that live in senior housing is this whole culture shift of what’s really happening that all of us collectively have to be thinking progressively that we put the client first and wrap services around the client.

Jones: Erik, do you want to talk a little bit about trends and what you’re seeing on the construction side?

Anderson: To Tom’s point, we just have to be as adaptable as our clients are. And, as changes in senior living occur very quickly we need to be conscious of those changes when we design each new community. For example, we may be designing an independent living wing but the owner may want the potential to convert that and license it as assisted living in the future. That can have a huge impact on the structure of the building and how we design the building which has major code implications. Adaptability is key in our designs.

McQuaide: When I think of senior housing and health care, I think of the most successful businesses – the buildings have a wellness center where we can actually put a physician or nurse practitioner. Patients or families can meet with that provider or physician. Home health care can be there to be able to collaborate with the staff that actually work there. Probably one of the biggest trends that we’re seeing is really about value-based purchasing and risk. This is an area where Mt Auburn’s network is at risk financially. It is critical we deliver the best care in the lowest cost setting to prevent rehospitalizations. Home health care really enters that market being patient-centered, wrapping services around that patient, as Andrea said, which becomes essential.

Jones: Let’s talk about technology for a moment. Everybody has mentioned that in some way. Talk about the role that technology plays in your overall strategy.

Martin: It’s enormous. It’s huge, whether it’s customer facing to our resident families, or whether it’s our community teams reaching out to referral sources and being able to stream live continuing education series over an Apple TV or an iPad. We’ve had some great stories where someone couldn’t get out from a rehab facility to see our community and we can Skype virtual tours. We walk the community.

McQuaide: Technology is key to the delivery of health care. It starts with the patient centered electronic medical record where all providers and the patient can communicate. Telemedicine in the home is significantly improving communication and monitoring to keep patients well. Data is essential in delivering care and managing risk.

Grape: There’s technology that helps us run buildings more efficiently. There’s technology that helps with things like the healthcare integration side that Denise referred to. There are things Greg was speaking to that help customer interaction and communication. I worry right now that we’re sort of gadget heavy. There’s a million gadgets out there right now that I think don’t add a lot of value. There are some that do or some that have the potential to. And I think we’ve found that it’s easy to get distracted with a lot of gadgets. Ultimately, there certainly will be some things that will add value and be helpful. But I worry that technology hasn’t quite matured yet. There’s a lot of people, a lot of the entrepreneurs that we’ve come across are techie’s who have an idea but they haven’t started with what the need or problem is that they’re trying to solve.

Cohen: What’s happening in my industry is there’s been home care disruptors across the country that investors have funded. I believe this year, the count is $300 to $400 million invested in tech enabled home care. The big debate in the industry for private home care is how much technology do you need. I think about these super charged homecare workers. Technology is going to help us engage our direct care staff and our administrative staff to do their jobs better. And it’s going to get them psyched up to remain in the field and create career ladders which is huge because there’s a national shortage of direct care workers. And to Tom’s point, I totally agree that part of our plan is to have a technology solution that we help families use and gets everybody on the same page. But if we just start doing technology in a silo it’s just not going to work. Technology is about engaging our staff in a way that’s going to make them want to work for us.

Grape: One of the real implications of technology is the ability to allow people to stay at home longer. And there’s a lot of people spending a lot of time and effort and money on technologies that allow people to live at home longer. I think that will have a lot of implications for us – good and bad. I think that’s obviously a field that’s getting a lot of attention with us right now.

Jones: Erik, can you speak to that a little bit from the construction side?

Anderson: We effectively provide the backbone and the infrastructure for the developers to successfully accomplish their goals. Part of our challenge is adopting all the technology while still making the community feel like home and feel very residential to its residents. For example, advances in mechanical systems can make the building spaces quieter and more comfortable. We’ve found ways to make even the largest dining rooms quieter so the residents, who typically have some degree of hearing loss, have an easier time hearing each other. Those are the kinds of design tweaks that we make behind the scenes to make the community feel more like home, which is always our goal.

Jones: How do you find talent? What do you do for retention?

Grape: It’s sort of job No. 1 for, I suspect, all of us. This is a high touch service business and when we do it right, when we get letters complimenting us when we’ve really served a family well it’s never about how beautiful our building is or how good our food is or how great the activities were. It’s always about the connection people have felt with our staff and the way we’ve made them feel loved and cared for beyond what the family might have expected initially.

Anderson: One of the things I do about a year after we finish a senior living community and it’s occupied, is go back and talk with the residents to find out what they like about the building itself. The number one comment I get is always about the staff, so in my experience, the staff is absolutely critical.

Jones: So, is there anything you look at when you’re designing a facility that is for the worker?

Anderson: We look at staff amenities and common areas, such as is the staff breakroom landlocked space where there are no windows, or is it an area that has access to natural light? We typically find that the staff are always around the residents. Therefore, the things we do that are beneficial to the residents also benefit the staff. Thermal control is a huge one so that people are comfortable. Also, access to natural light and views, fresh air, and noise control are all very important to both the staff and residents.

Jones: Andrea, how do you do that especially when your folks are out on the road every day?

Cohen: It’s hard. Waking up every day and night, thinking about how to do this right is what we do as a company now. And when we first started the company there was not a shortage of direct care workers. We did some analysis. We’re most at risk of losing people between the first 30 and 60 days so why is that? We make phone calls after the first shift. We call them after they get their clients. We spend a lot of time in that first 30 or 60 days giving them a tremendous amount of support. We have someone on call 24/7. We have case managers that go visit them in the field. Success for us is when we feel when we go out there and we talk to our caregivers and they say to us we really want to work for HouseWorks. And that happens a fair amount.

Martin: So, there’s no doubt when someone wakes up in the morning they typically don’t say “I want to look for assisted living today”. This is a pretty stressful part of their life. Making good decisions on hiring and selecting talent (is important). What does the team look like? Are they making eye contact? Are they shaking your hand? Do they have an out-going personality? I have associates with us that have started as care assistants that have moved towards an operational care path of becoming an executive director. And this is important, sharing the bigger picture with our community teams on how important they are. (We need to) make sure we have a good culture of recognition at the community level.

Jones: I just want to talk a little bit about the Affordable Care Act. The cost of health care has a huge and significant impact and health care reform continues to evolve daily.

McQuaide: What the Affordable Care Act really has done is it’s forced every element of the health care world to focus on quality and on cost and on patient experience. And when you put those three things together they really do form a nice basis for what you’re going to deliver. The least costly setting is always going to be in the home. For the frail, senior housing is the perfect home because you get support systems but you’re still independent or as independent as you can be.

Martin: About 70 percent of our communities fall within one of our networks. And our networks really are derived from where we see that customer travel time or our professional referral source. One of our initiatives is to strengthen our network and that is a continuum of care and a differential in price point. In a network you may have assisted living, memory care, skilled nursing, independent living. But it’s this customer centric journey. It’s finding the right level of care for that customer. And then having them only talk to one person. They’re calling multiple providers. There’s a lot of confusion on price, on what services are included. A lot of emotion behind it. We know typically a traumatic experience has happened. We want to limit it to one individual that can guide them through a process.

Anderson: Quality, cost and the resident experience (are important) and becomes readily apparent in the building if you’re lacking in any of those things. Our goal in working with our clients is making sure that their quality is high and the resident experience is a positive one.

Cohen: I think it’s really important to remember that sometimes small, small supports actually make a huge difference when it comes to either being readmitted to the hospital or being able to stay home. Helping someone program their cellphone so they can call the doctor to make a follow up appointment (is valuable). What I think is really interesting about private home care now is that technology will help us prove our value. We have always been of the mind that slight changes can make enormous leaps in reducing readmissions or emergency room visits—being able to prove that will be huge.

Grape: I would just build on something that Denise said. Innovation here is the awareness and the collaboration. Because a lot of doctors are actually pretty uninformed about what senior living is, who senior living serves and what level of care we’re able to provide. A lot of hospitals and health networks are uninformed and don’t really know how we might be able to help them. I think Mt. Auburn deserves a lot of credit for being on the leading edge in New England and having that kind of collaboration and awareness.

Jones: I’d like to give each of you a final chance to talk a little bit about your organization. Give us a recap about who you are, what you do and what you see for the future in senior living from your particular point of view.

Anderson: As an 83-year-old design build firm that works throughout the Northeast, our team works closely with clients to deliver a high quality building. We help our clients provide the superior care they’re seeking to provide for their residents. That’s our approach. And for me personally, and I know my colleagues on the construction side feel the same way that these are very meaningful projects for us. We build office buildings. We build retail centers, but it’s very rewarding for us building a home and especially for people who have worked hard their entire lives and deserve and want the opportunity to enjoy the fruits of their labor. Especially when we go back later and hear good things from residents about the building, the design, and that they’re happy there. It’s very rewarding for us.

Jones: It’s interesting how the quality of the staff and the quality of the facility all connect.

Martin: We have a lot of challenges and a lot of opportunity. We’re in about 47 states. Our biggest opportunity is offering a differentiated experience for our customer that comes through our doors. (We are) making sure that we’re helping that customer go through their journey from that initial interest phase, getting into education and then getting along the lines where they can make a decision. And that decision may not be us but we want to be able to provide that wide scope of options even if it’s not one of our communities.

McQuaide: Mt. Auburn is positioned as one of the very few systems that has everything. It has the hospital. It has a large owned physician practice as well as a larger network. It also has home care and hospice and some wonderful partnerships with other hospitals and systems. But as a system we do try to be cutting edge. And what’s been exciting for me is looking at senior living as a way of life that used to be the exception and not the rule. And I think that we as a health care system look at senior housing as where frail seniors could live to keep them at "home," quite frankly. They want to live in their own homes but resources to be able to maintain in the home become inefficient.

Cohen: The challenge for HouseWorks and the whole senior care industry is getting everybody on the same page. A lot of the doctors and families still don’t know the difference between private home care and certified home care and no one talks about what they don’t know. There’s been some good changes. Medicare is paying for a 10-minute conversation about end of life and some case coordination. Everybody is beginning to recognize that we’ve got to get the conversation started sooner. People our age are sitting around talking about how we want to die. And you know, I bring that up with my kids. They’re just like we don’t want to talk about it. How do we shift the paradigm? Everybody’s going to be a caregiver in their life. HouseWorks’ goal is to ensure choice and control to our clients and their families.

Grape: At Benchmark, we’re the largest provider of senior living in New England and pleased about that. We are proud to be celebrating our 20th anniversary this year. Our focus is about what we call elevating human connections between our associates, our residents and our families. And so, we’re all about creating an environment in our company that does that, for our residents, families and our associates. That’s our purpose and our mission and what we’re trying to do every day.

The BBJ will have more Table of Experts programs on other topics and if you are interested in participating, please contact the BBJ advertising department at 617-316-3212.

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