Senior Housing and Assisted Living

By Doug Fullaway, President & COO, Vigilan

In a previous article, we explored the staffing in assisted living based on ratios versus staffing based on acuity. Ratios are the most commonly used, but it is also clear there is a tendency to overstaff and in all cases, ratios ignore the actual changes in acuity for an individual resident. Staffing based on acuity is preferred, but not widely used as it seems to be too difficult to implement. Let’s look at one method that can be used to develop an easy-to-use acuity staffing tool.

The first step is to build a spreadsheet with a column for each service you are offering and a row for each resident. For bathing you could look at your own assessment document and you might add the following columns: Independent, Provide Reminders Only, Partial Assistance, Full Assistance.

Enter a row just above all of the resident’s names that says, “Standard Time.” In that row enter a standard time. But where do you get that time? Start with an estimate. You know a great deal already and these times can be revised as you learn over time. And be consistent in the way you set the times. For example, hours per week or hours per month is a reasonably simple way to think about the services. Full bathing assistance might be 30 minutes per bath and delivered twice each week so one hour per week could be a good place to start with a standard time for bathing.

Now fill in the cells for each service that a resident receives services. Your spreadsheet is filled out and ready for some simple analysis.

Add totals at the end of each row and each column. You will see the acuity as measured in hours for each resident. Does this comparison across the residents seem reasonable? Does it seem correct that Martha takes twice the time as most other residents? Is John really only taking three hours a week for all of the services you provide? If not, perhaps you need to start adjusting the time for that resident. If the standard time for full bathing assistance is one hour per week and you know John is just difficult and requires more time, then perhaps the cell for his bathing needs to say 1.5 hours.

Now look at the totals for each column. You will likely see the amount of time for medication management for each resident is about six hours per month and is the largest single time for any service. If this is not the case, then perhaps you are doing some work that does not show up on the assessment. For example, does the nurse provide a monthly review of the medications? And does it take about 20 minutes for each resident? Time to add a column to reflect the time the nurse is actually putting into the work for that review.

Build a summary for each job skill of the total time for the period. Caregivers deliver the care for many of the columns.

You will probably end up with something that looks like this.

As residents move in, add a row. As they move out, remove a row. As you update an assessment for a resident, update the cells for that resident. You can gather the caregivers who take care of Mary Albright and have a discussion to see that all services being delivered are documented. You can also ask how long it takes to do the job for each service for Mary.

You can also make the standard times more accurate by actually measuring how long it’s taking for that service for about 30 observations and then take an average time. Adjust the time upward by 20% to allow for lunch breaks, taking time to talk with residents, filling out reports, etc.

You should see several benefits from your use of an acuity-based staffing approach. You will better understand where your staff time really goes. You will adjust your staffing based on changes in census AND based on the change in care you are delivering to each resident. (Ratios just don’t do this!) And our analysis shows you will have enough staff, but not too much, which should save you money.

About the Author:

Doug Fullaway is president and COO of Vigilan, a provider of software for senior living management, and has over 30 years of management experience. In 2002, Doug entered the senior market by joining the executive staff of Vigilan and is the proud owner of several senior communities.  Prior to Vigilan, Doug held positions in distribution, manufacturing, customer support, sales, and general management in the U.S., Europe and Asia.  Doug earned his undergraduate degree in industrial engineering from Oregon State University, served as an infantry officer in the US Marine Corps and graduated from the Harvard Business School.  In his spare time he loves to snow ski, fly a Cessna and go fly-fishing. He can be reached at dougf@vigilan.com.

Five Star Quality Care, Inc. (NYSE Amex: FVE) last week announced its financial results for the quarter ended March 31, 2010 that showed revenues for the first quarter of 2010 increased 5.6% to $310.3 million from $293.8 million for the same period last year.  FVE’s net income from continuing operations for the first quarter of 2010 was $4.3 million compared to $25.1 million for the same period last year. Net income for Q1 2010 was down compared to 2009 due to extraordinary items that included a $25.1 million gain on extinguishment of debt and other gains during Q1 2009.

Operating Highlights Include:

• Senior living occupancy for the first quarter of 2010 was 86.2% compared to 86.7% for the same period last year.
• Senior living average daily rate for the first quarter of 2010 increased by 2.8% to $149.09 from $145.07 in the same period last year and increased by 3.1% from $144.64 in the fourth quarter of 2009.
• The percentage of senior living revenue derived from private and other resources for the first quarter of 2010 increased to 70.0% from 69.4% for the same period last year.

FVE Q1 2010 8-K

Watercrest at Mansfield, Mansfield, Texas’s first and only active adult community, recently announced that the facility has officially opened their doors to residents.  Watercrest at Mansfield offers resort-style living on 12 park-like acres. The campus features 11 villas and 200 independent living apartments for lease with features that include a heated saltwater pool, hair/nail salon, media library and learning center with Posit Science classes, fitness center, arts and crafts classroom center, and massage therapy salon.  The 13,000 square foot club house is the center of the gated community offering an array of recreational and social activities.

“We are thrilled that the doors of Watercrest at Mansfield are now open,” said Rick Simmons, president and CEO, Integrated Real Estate Group, developer of Watercrest at Mansfield. “The first residents are already taking advantage of the wide array of services and amenities offered by the community.”

Last week, 2,725 retirees celebrated the 10^th Anniversary of Riderwood in Silver Spring, MD,  in all five of the campus’ neighborhoods.  Riderwood, which is managed by Maryland-based Erickson Retirement Communities, is located on 120 acres across two counties in Maryland, Montgomery County and Prince George’s County.  Riderwood employs 1,400 full-time and part-time staff and the campus has 1,950 independent living units, 230 assisted living units and 132 skilled nursing units.  As part of its community, Riderwood has prided itself upon its connections to the local community and the impact its residents have made on the area.  Some of these achievements include:

• Riderwood is the only retirement community in the world that has the Corporate Lands for Learning Certification. It is also the only  retirement community in the United States that has earned Wildlife Habitat  Council Certification.
• Riderwood Friends of Habitat for Humanity support Habitats in Montgomery County, Prince George’s County and Washington, D.C.,  by attending Build Days, making quilts for the families, making kitchen cabinets and bathroom vanities.
• Riderwood has an average of 650 residents attending classes each semester in a partnership with the Community College of Prince George’s County.  There is an average of 60 sessions on 40 topics.
• Forty-three students currently attending twelve high schools in Montgomery County and Prince George’s County this past year earned collegiate scholarships in the amount of $6,000 each for their four-year academic careers.  They did so through Riderwood’s Student Scholarship Program in which residents voluntarily contribute money to help student workers at the campus attend college. Riderwood has awarded over $1.35 million in scholarships to 325 students in the Student Scholarship Program since 2002.

“It has been inspiring over the years to watch residents  share their interests and talents,” said Resident Life Senior Manager  Claudia Farr,  “The volunteer leaders across the campus are the backbone of Riderwood and its community. Individual residents have a passion for the community spirit. Our groups and activities reflect our vibrant community and the unique people who live here. Truly, this activity level and volunteerism has enhanced the lives of all of us in some way.”

Construction is underway on the $20.4 million, 89,000 project for Senior Living at Cambridge Heights facility in St. Louis, Missouri. Cambridge Heights will feature 117 one- and two-bedroom apartments designed for older adults and be comprised of apartments ranging in size from 504-618 square feet for a one-bedroom apartment and 837 square feet for a two-bedroom apartment.  The development will contain 75 public housing apartments, 36 apartments to receive project-based Section 8 assistance (nine of those are also Missouri Housing Finance Agency Home Investment Partnership Act apartments and eight are also Affordable Housing Assistance Payment apartments) and six Low Income Housing Tax Credit-only apartments. The facility also includes a common outdoor green space and approximately 51 private parking spaces.

KAI Design & Build is the architect, general contractor and mechanical/electrical/plumbing engineer for the project and expects the project to be completed in January 2011.  Financing for the three-story building was secured through the Missouri Housing Development Commission, St. Louis Housing Authority, Enterprise Bank & Trust and Business Bank of St. Louis, and the U.S. Department of Housing and Urban Development. St. Louis-based McCormack Baron Salazar is the project’s developer.

“This capstone to the redevelopment of the former Cochran Gardens public housing site will meet an important need in the community to provide affordable, quality senior living and will serve to replace an obsolete and isolating tower building with a sustainable, universally-designed, low-rise facility,” said Vince Bennett, Executive Vice-President of McCormack Baron Salazar. “This development will also further the dramatic transformation of this community started with the Cochran Gardens HOPE VI and will support the revitalization efforts in the Columbus Square neighborhood.”

Foster Pointe Senior Homes, a 61-unit three story affordable senior development located in the Brooklyn Centre neighborhood on Cleveland’s west side, announced that it will be ready for occupancy mid-summer 2010.  Brooklyn Centre is a walkable neighborhood with a number of parks including the renowned Cleveland Metroparks Zoo and the Ohio and Erie Canal Towpath Trail. The community’s units boast one and two-bedroom efficient floor plans that connect kitchen and living room areas to create a large, open living space, with all floor plans providing a breakfast bar.  Foster Pointe includes numerous environmentally friendly development features, including upgraded insulation, energy efficient windows, Energy Star appliances and an advanced light package.  Foster Pointe exceeds the Enterprise Green Community Program Standards, a national standard for green and environmentally healthy affordable housing.

“We’ve been incorporating green components for several years and that includes Energy Star certification for many of NRP properties. We are attempting to improve the quality of people’s lives and not charge them extra for it,” says Aaron Pechota, Vice President Development, The NRP Group.

Sunrise Senior Living, Inc. (NYSE: SRZ) announced that, in an oral ruling, the United States District Court for the Eastern District of Virginia granted summary judgment for Sunrise, dismissing all claims in the litigation filed against the Company by HCP, Inc. with respect to management agreements under which Sunrise manages four assisted living communities owned by HCP.  Sunrise expects a formal written order in the coming weeks.

"We are very pleased that the Court has thrown out the baseless case brought against Sunrise by HCP," said Mark Ordan, Sunrise’s chief executive officer. "The Court’s ruling confirms that Sunrise has fulfilled its obligations under the management contracts with HCP. We are grateful for the support of our team members, shareholders, residents and their families throughout this process. The greatest strength of our Company has always been the outstanding service we provide to all of our seniors and we look forward to continuing to serve these communities."

Earlier this year, Del Webb released a “preview” of its 2010 Baby Boomer Housing Survey that showed that interest in age-restricted housing appears to peak after age 50 and those that are planning to move again, almost 10 to 1 indicated a preference for an age restriction in their next choice for housing.  The full survey fills in all the details and finds that changing attitudes are leading to changes in latitudes when it comes to decisions on retirement housing. According to the survey, Boomer movement is defined by what they do with their life and mind that makes a difference in how they live, work and play and portrays a highly mobile demographic.  Some of the highlights include:

Trends on Moving in Retirement:

• About 1/3 of Baby Boomers plan to move to a new home during retirement.
• The desire to move during retirement is on the rise as 42% of today’s 50-year-olds plan to do so as compared to 36% among the 1996 50-year-olds.
• Approximately 50% of both age groups who plan to move during retirement plan to move to a different state while about 25% of them plan to move to a different city within the same state.
• The Carolinas are the New Florida among both the younger and older Baby Boomers. Florida, Tennessee and Arizona remain Top 5 contenders.
• “Cost of living” and “healthcare” were the MOST important considerations in selecting a location for both age groups; trumping a “favorable climate,” which was the most important factor in 1996.
• Interest in age-restricted appears to peak after age 50.  Of those Del Webbers who are planning to move again, fully 10 to 1 indicate a preference for age restriction.

Working in retirement:

• The vast majority of both those planning for retirement and those living retirement are planning to include working as part of their lives. 
• Among young boomers, 72% plan to work.  For older Boomers not yet retired, 74% plan to work.  In the 1996 survey, 68% of the 50-year-olds surveyed said they planned to work
• Today’s 50-year-old Boomer anticipates retiring four years later.
  • Compared to 50-year-olds in 1996, today’s 50-year-olds plan to retire a median of four years later – Age 67 vs Age 63.
  • Of those turning 50, 54% anticipate retiring from their primary career after age 65; 0f those turning 64 and still working, 8% plan to retire over the next few years, and 74% after the age of 65.
  • 14% of 50-year-olds and 18% of 64-year-olds who are still working never anticipate retiring.
• Among current retirees, just under 40% report actually working since retiring.
• Finances- Fulfillment & Fun – While finances are a common reason for why many will continue to work, other top reasons include:
  • “Warding off boredom/keeping busy”
  • “Self satisfaction”
  • “Simple enjoyment” 

“Baby Boomers have a much different mindset toward growing older than earlier generations,” said Deborah Blake, Del Webb creative director. “Feeling older is just a state of mind for many of them – one that most have no interest in. Many consider themselves healthy and active, primed for the next part of their lives with no plans to slow down anytime soon. They want to do it all as they enter this next phase, from working longer to trying Zumba and acting classes to volunteering their time.”

Del Webb has conducted these surveys since 1996.

2010 Del Webb Baby Boomer Survey

Tired of that musty, stale smell in senior housing facilities?  Apparently Aegis was too.  Aegis recently announced that it has selected Prolitec Inc.to introduce aromatherapy to public areas in all 35 of its senior living facilities in Washington, California and Nevada.   Aegis selected Prolitec to roll out the systems to the remainder of its communities over the course of 2010 after an initial installation at its Aegis of Bellevue community. The systems from Milwaukee-based Prolitec will condition the air in lobbies and hallways with tiny amounts of a scent created especially for Aegis.  Aegis’ scent, called ‘Serene,’ is a blend of chamomile, aromatic lavender and other complementary and proprietary ingredients. Chamomile reduces stress and anxiety and is used to treat insomnia, while lavender relaxes the body. According to a Duke University study, the scent of lavender relaxed participants as much as a massage.

Depending on the community’s mechanical system, Aegis’ proprietary scent will be dispersed in the designated common areas through a variety of HVAC or wall-mounted delivery systems from Prolitec. As the program evolves, residents will also be given the opportunity to have aromatherapy in their individual units through Prolitec’s Air/Q Whole Room system for an additional monthly charge.

"Already known as one of the premier operators of retirement and assisting living communities, Aegis is taking another step forward in raising the standards for better senior living with the introduction of aromatherapy," said Richard Weening, CEO of Prolitec. "The scent that we developed for them will make residents feel better and they don’t have to do anything, just breathe in the air."

"Prolitec is the technology leader in the safe and sensible use of scent in public spaces," added Jerry Meyer, COO of Aegis. "We chose Prolitec because they have a customer-focused, high-standards culture like Aegis and they understand the special requirements of senior communities."

As the mainstream press drones on and on about for foreclosures, a well written article in the New York Times talks about foreclosures of senior living projects, entitled “Elder-Care Home Foreclosures, Without Warning”.  The article highlights the need for financial due diligence that should be done on senior housing/living providers prior to moving into those facilities for consumers.  One of the more interesting tidbits are the comments about the “dirty side” of the business associated with the sale of distressed senior housing that the author wrote about as adjunct piece to the article in her blog.  The blog states that:

“The commercial real estate website loopnet.com advertises a six-bed board and care facility for elderly in “the heart of San Francisco,” whose owner “needs to sell.” The ad calls the asking price of $155,000 “a steal,” citing a $14,000 monthly income from its six residents and a five-year term of “interest-only payments.” However, the ad warns, “Do Not Approach Care Home as Staff are unaware of the sale.”

Both the story and blog entries are worth a read.