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This is a two-part article adapted from works by Dean Solden, Founder and President of Creative Senior Solutions (creativeseniorsolutions.com).

Hello everyone. My name is Dean Solden and I have been involved with senior living for over thirty years as an Executive Director, Regional Director and Owner/Operator of a regional chain of assisted living and memory care communities, and as a nursing home administrator. Over that time, I had seen the good, the bad and the ugly of the industry. And that was before the pandemic, which has been the most difficult time in most of our careers.

As we are starting to fill our buildings back up, and start a new chapter in our industry, I thought it would be a good time to take a step back and re-evaluate the past years, value our successes, and see where we as an industry could have done better, so we can help our older citizens lead even more fulfilling lives in the coming decades, help our staff and managers become more successful and professionally satisfied, and create strong and vibrant businesses and an industry we can all be proud of.

As whenever there is a break in an industry cycle, this is a chance for a new start. There are many senior companies out there who were struggling even before the pandemic hit. Now, for some, it is even worse, as although our buildings are beginning to fill up again, census still has not reach pre-pandemic levels. Maybe, as the years have gone on, your buildings are a bit tired and worn; maybe you haven’t’ focused on your “philosophy” in quite a few years. Maybe you’ve been thinking about your mission and vision.

Wherever you are at in your business cycle, one thing we can count on; things will be changing in the next few years and changing fast.

I believe there are three significant elements impacting Senior Living right now and will even more so in the near future. They are:

The Covid – 19 Pandemic and its ramificationsA fresh wave of senior specific technologyBoomers starting to enter the senior living marketplace.

I believe these three elements will radically change the industry, and those who don’t pay attention to them may not stay relevant and may not be able to compete in the years ahead. In other words, I believe it is time to Re-imagine Senior Living.

In a series of articles, I hope to provide your with information and inspiration which will a) help newcomers in the industry understand our history a little better; b) identify some structural deficiencies in the industry many of us have seen over the years; and c) offer some potential solutions for companies, owners and managers to not only overcome these deficiencies, but to create newer systems and models so they can be better prepared for our existing and new customers and their changing needs.

First, however, I would like to say that I truly love the senior care industry. There are so many caring and compassionate people in this field! And so many showed up big time during the pandemic. Our care staff has been phenomenal, especially those who stayed through the storm. They are true American heroes. Our managers have also been terrific, working sixteen-hour days and taking shifts on the floor when they were short. Owners and Operators came through with money for supplies and “hero pay” and many kept the doors open even when the cash flow wasn’t there. (Thank you, US Government for the PPP money. That truly helped.)

Despite these wonderful people, from their inception, there have been systemic flaws in both the nursing home and assisted living industry that I think now is a good time to address. I think it is important that before we re-open a chapter in the industry, we at least talk about them, address them, and see if we can learn from those challenges to make things better for everyone.

So here goes….

Part 1: The Old Frontier The early days…. Nursing Homes

The idea of congregating hundreds of seniors together started in approximately the late 1950’s and early 1960’s. It was necessary at the time, as for the first time in our country, we had one million senior citizens who needing some sort of care outside of the home. This was a direct result of two societal milestones: a) people were living longer due to the rapid advance of medical technology throughout the twentieth century, (i.e., x-rays, surgeries, and advancement in medications) and b) women joining the workforce, both for gender equality as well as financial reasons.

This brings up what I call, Problem Number One. What model did we use to care for these people? Unfortunately, in my opinion, the Government and industry used the hospital as the model of choice. While this seemed the most efficient model at the time, it also created problems we are still dealing with today, sixty years later.

While good nursing homes provided reasonably good quality of care, the model and the buildings themselves hindered people from helping create a high quality of life for residents. They just weren’t built for that. This turned out to be a big mistake. This is why nursing homes always have had a poor reputation as far as the public is concerned, despite the amazing people who have worked in them over the years.

Besides the model being imperfect, some of the problems were also created by the state surveying process, which emphasized the “safety” of each person over their quality of life, rather than quality of care being equal to quality of life.

As far as payment, nursing homes were and are paid for mostly by the government in the form of Medicare and Medicaid. Medicare, as many of you know, pays for and continues to pay for up to 100 days of “rehab” for everyone over the age of 65, as “rehab” is one of a person’s Medicare benefits. Medicaid was originally set up to pay for and guarantee the long- term care of those poorer citizens in the country, but has evolved to be a middle-class program, as almost everyone who isn’t wealthy runs out of private funds not long after entering a nursing home. Unfortunately, the government has not yet expanded that right in most states to pay for assisted living.

Observation:

I cannot see most boomers wanting to go into forty, fifty and sixty year-old nursing homes that have not had a major renovation. We will need new and updated Rehab communities for them.

Assisted Living 1.0

In the 1990’s I watched with delight and excitement and was honored to be a part of the creation of the revolutionary assisted living industry, which I like to call Assisted Living 1.0. With its residential living and social model in place of an institutional model and its goal of providing more dignity and respect to its “residents,” thingsimproved for one half of the now three million people needing some form of care in America in the form of Assisted Living. However, this did not cure all the systemic issues of the industry. First of all, it was, and still is to a great degree, a private pay business. Only about 40 percent of the population can afford assisted living, as Medicaid only pays for a small percentage of assisted living in the country. And, despite the buildings having changed for the better, many “facilities” were and are still using the nursing home organizational model – where the focus is still primarily on the quality of care, with quality of life being important, but secondary. In all fairness, like the nursing homes, much of this was and still is due to state surveying processes. But even besides the surveying issues, many of us have seen beautiful and elaborate assisted living and Independent Living communities where some people are still often bored, lonely, and depressed, despite the nicer buildings. In the first decade of assisted living communities were still providing “custodial” care, without, I believe, enough emphasis on quality of life.

Assisted Living 2.0

In the 2000’s through the 2010’s, I watched the further evolution of Independent Living (IL), Assisted Living (AL) and Memory Care (MC) communities. Individual rooms and apartments became larger, and more amenities like movie theaters, swimming pools, and gourmet dining became more common (for those who could afford it). There became more emphasis on stimulating activities, meaningful relationships, and a better quality of life for the residents. All good stuff.

However, there was little evolution in the development of our front-line staff, and how they were trained, treated, and respected.

Today – 2021

So here we are, 2021; we are still living with remnants of the Great Pandemic of 2020, going into our second year of this new normal. Now, with most of our residents and many of our staff having been vaccinated, we are seeing some light at the end of the tunnel. Many of us have lost census, and while people are slowly coming back to senior living communities, we are not fully back yet. In many places, we still do not have normal visitation, normal activities, and sometimes even normal dining.

Fresh Eyes

So where do we go from here? We all know as the boomers hit AL and MC in the coming years, they are not going to want much of what we are now offering. Boomers are more independent (even when dependent), want to lead meaningful lives where they can make a difference, (and have fun) and will want meaningful relationships. They are going to want to do what they want to do and will not want to fit in to a simplistic formula.

Here are a few items all senior communities should look at and think hard about in changing the culture of their communities as we enter the age of what I call Senior Living 3.0:

We should think about not being senior living communities and focus on just being communities where there are seniors living. Despite all our advances in the industry with hospitality, there is still an “us and them” mentality perception of senior living in the outside world. We need to stop being seen as them, (even beautiful) senior homes on the hill where someone goes to die or live out their final years, separate from the rest of society. I suggest moving toward being fully integrated into the community, socially, physically, financially, and emotionally. Boomers do not want to be separate from society.If fact, we are a community – we have people who live there, people who work there, and both groups have families that are very involved (you may notice I like to use those terms, when possible, instead of the words “resident” and “staff.” We are all just “people.”) I believe there has been an over-focus on “the resident,” and an under-focus on the “staff,” with both groups of families sometimes overlooked. If we focus on being communities where seniors live, people work, and families are interacting with each other, everyone will live a more fulfilling life, especially our seniors.

Suggestion: As some are starting to do, our dining rooms could be more like coffee shop/bistro’s with comfortable couches and counters where families, outside community members, grandkids and students can come and just hang out, buy lunch or coffee, and sit with their grandparents and their laptops. Like urban cities now providing retail on first floors of almost all buildings, we, too, could provide retail in our communities, with small shops and stores or kiosks, so our residents, their families and the outside community can stop by and purchase the items they need. (Senior) Communities can be “dynamic,” not “static.” We can be a part of society, not an island away from it.

Quality of Life should be considered by companies (and the state) as important as quality of care (Assisted Living 2.0). State surveyors need to integrate quality of life in their survey process. Many providers have quality of life in their mission and do try and live up to that. But I have seen many who struggle with this, as so much time and energy are allocated providing the basic care people need. I have seen some inexperienced operators still think that providing just custodial care (Assisted Living 1.0) is enough to draw in residents. I think that is a mistake. But all is not lost! There are ways to turn things around. It starts at the top, with a great mission and vision, then motivation, training, and finally a commitment toward culture change. Names. Can we once and for all agree on some new names in our industry? Can we please retire the word, facility, as in assisted living facility, as well as nursing home, and convalescent home? These names add to the “we versus them” mentality. No one wants to live in a facility. Or should. Thank you for indulging me. It’s my pet peeve. Assisted Living. I firmly believe that Boomers are going to be satisfied with bingo and mediocre food, even in nicely appointed communities. (I know many people still like bingo. You know what I mean.) Most will not even want studio apartments. Many AL’s are going to have to up their game, have larger apartments, serve much better food (farm to table is the current trend), and have more robust activity departments. Individual “life plans,” will be a norm, just as we have individualized care plans.Mental Health. I believe we could use more focus on monitoring people’s emotional and mental health as we do their physical health. At least part-time social workers could be a norm. There is now also good software out there that can help with this as well.Activity wise, people are going to want to do what they want to do, not what we offer for them. And with soon to be unlimited quantity of virtual activities at their fingertips and on their TV’s/compute monitors, they will be able to. Having a full-time IT person is starting to be a must in moderate to larger senior communities to maximize both communication with family and friends and entertainment.

However, much of this is old news, already. Many of you have been doing these things for years.

Is this really all there is? Is this what the new frontier will look like? I don’t think so. In Part two of this series, I will “Re-Imagine” what senior living could look like in the not far distant future.

Dean Solden has been a senior care speaker, writer, consultant, and owner/operator for the past thirty years and has a passion for helping people and companies reach their potential and realize their vision. You can reach him and his company at CreativeSeniorSolutions.com and info@creativeseniorsolutions.com. (734) 260-3600.

Re-Imagining Senior Living, Part Two.

In Part 1 Dean set the stage for what the new frontier looks like. You can read it here.

Part 2: The New Frontier – Assisted Living 3.0

In Part One of this article, I described how the nursing home of the 1960’s evolved into the AL revolution of the 1990’s (Assisted Living 1.0) with a social and residential model while still providing mostly custodial care. In the 2000’s and 2010’s, the industry evolved into having a better quality of life for its residents, with more vibrant activity programs and more social interactions (Assisted Living 2.0). Now, almost post-pandemic, I believe we are entering into what I call Assisted living 3.0.

Despite the progress we have made, we still have challenges in our industry, staffing the most notable and apparent right now. As we re-tool from the Pandemic, trying to get our census back to normal or better, it is a good time to re-evaluate what the future of senior living may look like, in other words, to Re-Imagine Senior Living.

As I mentioned in the first segment of this article, there are three significant elements impacting Senior Living right now and will even more so in the near future. They are:

The Covid-19 Pandemic and its ramificationsA fresh wave of senior specific technologyBoomers starting to enter the senior living marketplace.

These elements, especially the boomers entering the marketplace, with completely different attitudes and expectations about life and how they want to live out their later decades, will transform the industry. I believe those who don’t adapt to these new realities will have a challenging time surviving.

Below are a few of what I believe to be the basic tenants of the industry we need to seriously explore, in order to re-imagine the senior living industry.

Segregation. This is the nasty little secret that no one likes to think or talk about. But we need to be honest with ourselves and realize that there is one thing inherently – should I say “odd” – with our entire industry. We segregate people by age. There is just something a little bit wrong about this. Maybe this is the element which makes many lay people cringe a little every time they enter a nursing home, assisted living, or even a beautiful independent retirement community. It is hard to believe we were put on this earth to live a long and good life and then end up living in a small room with only other eighty- and ninety-year-old people. While it would be ideal if every family could live and care for their older senior, we know that is not possible, and there are good reasons to be in a senior community, from twenty-four hour supervision and care, to socialization. However, the model of having older seniors all living together in one building, with just each other, is not ideal either.As one who has always focused on people’s quality of life in our communities, I realized that it has been challenging to offer and create a great quality of life for people when they are only living with older people. So, what even the best senior communities have done is to spend an enormous amount of time and energy compensating for the segregation and lack of intergenerational living we have placed on people.In other words, by solving one problem, (helping care for people who need twenty-four hour supervision), we have created another problem (segregating people, which is a negative factor in creating quality of life).

Be clear, I am NOT advocating to get rid of our industry! I believe we just need to be more creative in figuring out how to have more intergenerational experiences for our seniors. Here are some examples of what we could do:

We could consider going back to having some caregivers live in the building with the seniors. We could consider having some families live in our buildings.We could consider having some units in AL and MC buildings for more independent people, even a few units for younger people.We could consider starting to look at “two-generation” buildings, as there are going to be two generations of seniors in one family.We could consider looking at models where caregivers and families at least live close by, so they can come by more often. We could seriously consider having childcare, which would help our staffing issue and create intergenerational relationships.

The bottom line is, the more children, teenagers, adults, staff, families, and the outside community, live in closer proximity to our communities, the more we become real communities and less senior communities, which ultimately will provide everyone, especially our seniors, a higher quality of life.

Real Life. I am also an advocate for providing more “real life” in our senior communities, even with segregation. As Jill Vitale-Aussem talks about in her outstanding book, Disruption the Status Quo of Senior Living, we have taken the concept of integrating the hospitality culture coming into our communities to an extreme, and many times we provide one hundred percent of everything for people.This, again, on a common-sense level, does not seem natural. I personally think most people would rather be having more participation in their own lives, as they did for their entire life when they lived in their own home. We all do better when we all (residents, staff, families) contribute our talents as best as we can to as many as we can. In other words….We need to try and create cultures of interdependency, rather than cultures of complete independence or complete dependence. More family interaction. Another way to increase interdependency and inter-generationality is to create cultures where families are more a part of our existing communities. While many people do this already, we could develop different cultures where families – especially where there are two generations of seniors in the family – are a part of daily activity, mealtimes and be more a part of the overall culture. Many of our family members are now retired or semi-retired and have the time and resources to use their individual talents and energies to help all the members of the community, not just their loved ones. I would also like to see more interaction between our staff and our families. They could contribute so much to each other. The communities of the future could be a true extension of a family’s home, not a separate entity.Changing the culture for “the people who work in our communities.” (in other words, our staff). This, I believe, is not just our greatest challenge, but, honestly, has been one of our biggest failures as an industry. The concept of caregiving has not evolved nearly as much as other disciplines over the past sixty years of our industry.

It is understandable. It is hard work to care for people twenty-four hours a day, seven days a week – for management as well as staff. It is also understandable why many people would not want to be a “nurse’s aide.” It is hard physical work, difficult emotional work, and sometimes without the respect or emotional support they deserve. Maybe as an industry we have not had enough empathy – and subsequent strategies – for how people are living and what they are going through. Many of our staff are single moms and dads, many people are working two jobs, some people are working and going to school, and some amazing people are raising a family, working, and going to school – all at the same time!

I believe we need a full-blown re-imagining of staffing in our industry. Here are some concepts and ideas we have worked with and developed over the years, and I believe are worth exploring more fully:

Para-professionals. We could talk about caregivers as being “para-professionals and talk to them, treat them, train them, and provide benefits to them as the professionals they are. Better pay. The pay most communities pay Caregivers is just too low. I know many of our business models are based on such lower wages. To get the dysfunction out of our business, we need to pay more and figure it out. Period.Stepping- Stone positions. We could strive to make a good percentage of the resident assistant position a “steppingstone” position for further health-care careers, especially nursing. Think of it as a best first job, rather than a last, “worst” job. We all know that being a CareFriend, (what we call caregivers) is a fantastic job for people who are entering the health care field as a career. It is also a great job for students. It is tremendous training for future nurses, physicians, management, and any job in the healthcare arena. There are ways of creating a culture where people want to come and work for you. Career-ladders. For those who want to make a career of caring for people, career ladders within organizations are excellent ways to recruit and retain people and give people hope for advancement. Having a care positions, med techs, team leaders and then mentor/trainers are excellent ways for people to grow in the organization, earn more money, and become leaders.Partnering with learning institutions. Partnering with high schools, community colleges and local universities with coordinated work-study programs are an excellent way to recruit and retain staff. It is very difficult for an individual to schedule work and school at the same time. Something always has to give, which is usually their shift in your building. Co-ordinated programs between employers and educators makes sense.Child-Care. We need to re-thing our attitudes about child-care. It may be time that childcare in our communities should be the norm, not the outlier. And that would help create more intergenerational relationships as well.

Ultimately, we need to re-imagine the senior care industry. Even before the Boomers dominate our buildings in the coming years, there are things we can do now to not only improve the quality of life in our buildings for the people who live and work in our communities, but to create more census and revenue to owners. We can provide better and healthier food, more robust activities, and better individual IT experiences for each person both in communications and entertainment. We could have more family interaction and change the way we think about staffing, creating steppingstone, work-study programs, and child-care in our communities. We could be thinking in terms of interdependency, not just dependency. We could use more real life in our communities, with a greater focus on quality of life, not just quality of care. We could think about being communities and not just senior communities.

Finally, in just a few short years there will be many more models than just the IL, AL, and MC we know of today. People will be staying home, living with their families with four generations living and working together. People will be living with their friends, and sharing care, and not just in our communities. We need to seriously think about if segregating seniors into one living environment is the best solution for providing excellent quality of life for seniors in one’s later years. As Boomers always have done in every phase of their lives, they live life to the fullest. They changed the world in the sixties, and they are going to change the world again, in their senior years.

The question is this: Are you ready for them?