Seniors Housing And The Age Of Irrational Exuberance…

Are we looking at senior housing bubble? (Photo courtesy the fine folks at Wikimedia Commons.)

Are seniors housing investors in for a real shock? (Photo courtesy of the fine folks at Wikimedia Commons.)

Bill Myers

Good morning, ProviderNation. Irving Stackpole is a man who is hard to impress. Stackpole, a veteran long term and post-acute care analyst who runs his own consulting firm in Boston, has already played Eeyore on providers’ chances in a bundled payment world, but earlier this week, he rang a fire bell in the night for the whole seniors housing sector.

This time playing Cassandra to the chorus, Stackpole comes right out and says, “Investors should be worried about oversupply” (emphasis, italics—and underline—all his).

“What’s amazing is the lack of caution,” Stackpole marvels, “despite the overall signs in the markets, and the devil-may-care attitude of some investors and developers. This may seem a troublesome detail, but occupancies are declining in most marketplace areas. The decline in occupancy isn’t because sales and marketing have collectively fallen asleep across the USA, it’s because the market for age-qualified individuals is declining.”

Demography As Destiny

For Stackpole, demography is destiny.

“From 1925 to 1945, birth rates in this country, and many parts of the world, plummeted due in large measure to the Great Depression and war,” he says. “These are the lowest birth rate years on record in the United States.”

That’s the very cohort, Stackpole says, that’s hitting America’s assisted living centers right now.

Now, Paul A. Samuelson famously disposed of stock viziers by pointing out that the market had correctly predicted “nine of the last five recessions.”

Irrational Exuberance

But those of us who’ve grown up in what might someday be called The Age of Irrational Exuberance have no right to ignore Stackpole’s warnings. That’s partly because he’s not the only one worried about oversupply.

But that’s also because “seniors housing,” as a sector of the economy, is only in its birth stages. (In 2009, for instance, not one of the nation’s largest real estate investment trusts bothered with seniors housing; today, three out of the top five do.)

Additionally, boosters have been arguing for at least a couple of years that seniors housing stock is undervalued. Yet the stocks remain stable, or even “disappointing,” and, in some cases, companies are under increasing pressure to sell.

The Danes Are Coming

Another reason to heed Stackpole is that he—like so many charming, sophisticated, and otherwise awesome observers—has his eye on the international dimensions of long term and post-acute care.

So it’s worth noting that the Danish invasion has begun.

On Tuesday, Ry, Denmark-based Pressalit Care announced that its height-adjustable toilet had won cUPC approval for the U.S. and Canada. cUPC is the Universal Plumbing Code. The announcement comes barely a week after a delegation of intrepid Americans traveled to Denmark to tour its long term and post-acute care sector; they returned with tales more wondrous than the Arabian Nights.

Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter, @ProviderMyers.

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The Illinois Insectarium…

Illinois providers are surviving an unusually harsh political winter because they've minded their Aesop. (Painting compliments the fine folks at Wikimedia Commons.)

Illinois providers are surviving an unusually harsh political winter because they’ve minded their Aesop. (Painting compliments of the fine folks at Wikimedia Commons.)


Springfield, Ill.—Good morning, ProviderNation. Illinois’ official state insect is the monarch butterfly. But, hanging with the fine folks of the Illinois Health Care Association last month for their inaugural future leaders program, I was struck not by their fluttering, regal beauty (although Illinois Health Care Association board President John Vrba is the very picture of one who hums on gossamer wings) but by their ant-ness.

You’ll recall from your Aesop that the sturdy ants had the last laugh when the frivolous grasshopper—who had mocked the ants for working hard during the summer—found his own frigid nose pressed to the glass as the bleak winter descended.

Illinois’ winters are no fun for anyone, and this year’s version hasn’t been made any better by the political permafrost that has left the state without a budget and teetering on the brink of something like collapse. But providers here, apparently, have accustomed themselves to the long, hungry winters.

‘Tighten Your Belt Up’

“You live within your means,” says Josh Matthis, assistant administrator at Evergreen Nursing and Rehabilitation in Effingham. “You tighten your belt up, and you give the care. We really haven’t had to do without. If we need it for the resident, we will get it.”

In part, that’s because Matthis—like many of the Illinois providers I talked to—have learned to adjust their business practices. Nationally, most providers rely on Medicaid for nearly two-thirds of their income. That just doesn’t seem to be true here in Illinois. Providers I talked with averaged between a quarter and one-third Medicaid for their census.

Never mind the current budget apocalypse: from an Illinoisan’s point of view, the state’s Medicaid payments—and timeliness—didn’t have to go too far before they hit rock bottom.

True Grit

“They are behind, and you’ve just gotten used to trying to operate within that,” Matthis says. “Because that’s become the norm.”

That kind of grit is essential—and inspiring—says Dave Voepel, executive director of the Illinois Health Care Association.

“I continue to be amazed at the quality of services and the fortitude our members have in the wake of this budget crisis and in a state that has such a low reimbursement rate,” he says. “We continue to impress upon those in state government that long term care must have more dollars to continue to provide quality care.”

Indeed, it’s a source of pride to many Illinoisans here that they offer top-quality care even when a resident’s money runs out (or the state’s money runs late).



‘Does The Resident Need It?’

“I don’t make our department heads strain under budgets,” says Molly Carpenter, the administrator of Imboden Creek Living Center in Decatur. “The question is, does the resident need it? Okay, then, how do we meet that need while still being good stewards of our resources?”

That doesn’t mean that providers are in grasshopper mode, though. Carpenter, for instance, spends most of her days scrubbing every single data point in her building, making sure that “we’re capturing everything we’re doing from a care perspective” so that they can maximize their resources.

Perhaps it’s ironic, but the famine years here in Illinois have given many providers a kind of perverse expertise in minimizing cost while not sacrificing value.

A Delicate Balance

Love Dave, the administrator and owner of Elmhurst Extended Care in a tony, western suburb of Chicago, has created his own to-do list on the topic: Everything from hiring a full-time purchaser (“the cost of the salary pays for itself, almost immediately”) to buying the more expensive gloves (“when we have cheap gloves, you automatically lose a certain amount in a box. We, essentially, save money because our use is going down.”)

“There’s got to be a balance between making money and offering good care,” he says.

The key, Dave says, is to be mindful always of the coming winter. Things that may seem expensive now aren’t nearly so dear as when you find out you really, really need them, he says. For instance:

“Taxes in Illinois are incredibly high. So if you make a profit, your taxes are high,” he says. “Quarterly, we look at where our taxes are going to be, and we try to put it back in the building. I’d rather spend money on the building than give it to the government. Putting money into building repairs is not only great for the residents, it’ll essentially save you money.”




Dave and Elmhurst Extended have also thrived by bringing it all home, he says.

“We internalize all of our services,” he says. “A lot of places contract out for therapy or kitchen, and they actually share their revenue with the contractors. It takes a lot of work to get it going, but once you have someone in place, it works a lot better for the residents because they have the same therapist, they have consistently good food.”

Take, for example, the (initially, very expensive) chemo/dialysis services Elmhurst Extended offers its residents.

“It’s really nice for our residents because it improves the quality of their life,” he says. “If we don’t have it, they have to go in and out of the building three times a week. They miss meals, they miss activities, and it’s just disruptive. We don’t have to turn beds over as quickly. They’re actually getting healthier, quicker, because they’re not missing their meals, they’re not missing their therapy, they’re not missing their meds.”

That, in turn, pays its own dividends, Dave says.

“That’s one of the best things about an internalized model. You can drive quality and show people that they’re welcome to come back,” he says. “They don’t mind staying long-term, because they trust us.”

Ole Aesop couldn’t have said it better himself.

Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter, @ProviderMyers.





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Telemedicine’s ‘Time Has Clearly Come,’ JAMDA Op-Ed Says…

JAMDA's own John Morley challenges providers to adopt telemedicine in a new editorial. (Photo courtesy the good people of WikiMedia Commons.)

JAMDA’s own John Morley challenges providers to adopt telemedicine in a new editorial. (Photo courtesy the good people of WikiMedia Commons.)

Bill Myers

Merry New Year, ProviderNation. Whatever else you’re getting under the tree, John Morley hopes that it’s a hearty doze of 21st century telecommunications technology. Telemedicine, he tells us in the latest issue of JAMDA, is an “idea whose time has clearly come!”

When an unflappable chap such as Morley reaches for his exclamation points, perhaps it’s time to give a listen. An “obvious starting” point for providers to take advantage of telecom is by connecting remotely with specialists.

“For many residents with disabilities in nursing homes, transport to see a specialist represents a major barrier,” Morley says. “For patients with Parkinson disease and multiple sclerosis, there is evidence that these consultations can be performed by telemedicine. Teledermatology is already an accepted approach to care for skin disorders in the nursing homes.”

Morley also canvases the possibilities of remote psychiatry, counseling and even Cognitive Stimulation Therapy or Reminiscence Therapy for those suffering from dementia.

“Given the shortage of geriatricians, telemedicine would be an excellent modality to reduce polypharmacy, explore treatable causes of weight loss, and approaches to reversing frailty and sarcopenia,” he says.

Looking at previous work on the impact of telemedicine, Morley says it will likely be a huge help in reducing needless hospitalizations. “The time to introduce geriatric telemedince is clearly upon us,” he concludes.

Loyal readers of this space (and thank you, both of you), of course, will know that telemedicine is before Congress as we speak. The fine folks at Good Samaritan—who’ve already pioneered remote treatment—have lobbied for more than a decade to obtain federal funding for high-speed broadband in the nation’s skilled nursing centers.

What’s fascinating in Morley’s piece is just how ancient telemedicine really is. “In 1905,” Morley tells us, “the Dutch physician, Willem Enthoven, transferred electrocardiograms by telephone. In the 1930s, two-way radio communications were introduced to provide medical care for sick persons in the outback of Australia.”

Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter, @ProviderMyers.  



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Another Merry Festivus For Provider Advocates…

AHCA/NCAL's Clif Porter: The harder he and his team work, the luckier they seem to get...

AHCA/NCAL’s Clif Porter: The harder he and his team work, the luckier they seem to get…

Bill Myers

Washington, DC—Good morning, ProviderNation. Hope your Festivus shopping is going well. Speaking of feats of strength, though, how about them provider advocates who—despite last months’ mad, budget scramble on Capitol Hill—have once again kept their sector safe from harm.

“The tensest moments in our shop come in those last-minute, political melees,” AHCA/NCAL gunslinger Clif Porter tells me. “It can feel like being a fireman whose own station is on fire.”

It may feel that way, but it certainly doesn’t look that way from the outside. (What was the mark of a Balliol College, Oxford gent? Effortless superiority?) After all, this year, provider advocates have been able to:

For Porter and the gang, it’s a simple matter of fortes fortunas adiuvat.

“Look,” he says, “we’ve worked hard to develop the kind of constructive relationships with Congress and their staffs so that people on the Hill understand that we can be their first phone call, and not their last.”

So gather round the Festivus pole, ProviderNation, but leave Lobbyist-American types off your disappointment list.

Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter, @ProviderMyers.


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Good Samaritan, The Tech Boulder, And Making It All Meaningful…

The fine folks at Good Samaritan think providers are due for a tech upgrade... (Photo courtesy WikiMedia Commons.)

The fine folks at Good Samaritan think providers are due for a tech upgrade… (Photo courtesy WikiMedia Commons.)

Bill Myers

Washington, DC—Good Morning, ProviderNation. The House has taken up a bill that would set aside tens of millions of dollars to help skilled nursing centers plug into high-speed broadband. Sponsored by U.S. Rep. Leonard Lance, R-N.J., it’s basically the mirror version of a Senate bill championed by Sen. John Thune, R-S.D.

If the bill passes, providers will owe a huge thanks to Good Samaritan and its top lobbyist, Dan Holdhusen. He has been working on this issue for more than a decade.

“We’ve tried to be very advanced in using technology to move the data. It gets pretty expensive in those frontier areas to support and pay for broadband,” he says.

Rolling The Boulder

With broadband, Good Samaritan is able to use apps like Skype to connect their residents with doctors and therapists hundreds, even thousands, of miles away. But it’s not cheap. “It would’ve been useful if we’d been able to access these universal service funds say 15, 20 years ago,” Holdhusen tells me.

Holdhusen is coming to D.C. this week to work Congress, again, and to underline the importance of the bill. The bill doesn’t seem to have any in-principle enemies. Then again, it never has had such enemies, and yet Holdhusen has been rolling this boulder up a hill for a long, long time.

The current Universal Service Fund was reworked in the 1996 Telecommunications Act. The Federal Communications Commission did another major overhaul in 2010, turning the fund—which was designed to help lower the costs of telephone services for remote or desperately poor areas by charging all phone users a small fee—into a broadband for America fund. Tens of millions were set aside for health care centers, but FCC insisted that skilled nursing centers weren’t included in the list.

‘It’s A Mystery’

“It’s a mystery to us,” Holdhusen says of FCC’s stance.

Nonetheless, Holdhusen and his colleagues had their hopes raised in fiscal 2014, when the commission agreed to set aside $50 million in universal service cash for pilot programs for skilled nursing.

“It kind of fell by the wayside,” Holdhusen says. “I don’t think anyone was against it, it just wasn’t part of their priorities.”

Tired of working the commission, Holdhusen turned to Congress for help.

“It doesn’t feel any good just to beat your head against the wall,” he says.

‘It Will Mean A Great Deal’

As Congress deliberates on the legislation, Holdhusen finds himself once again cautiously optimistic. He doubts that the bill will pass before year’s end, but he’s hoping “we can hit the ground running” early next year.

“It will mean a great deal to us,” he says.

Meanwhile, though, providers ought not to wait for Congress—or anyone else—to start plugging their residents into the 21st century and closing the elder care app gap, says Jack York, my personal tech god and founder of It’s Never 2 Late, a tech company that serves long term care residents.




Make It Meaningful

“There are dozens and dozens of off-the-shelf tools and adaptive devices available to address virtually any disability out there,” York says. “Our experience, however, is that it’s an equally important issue to make the technology meaningful for older adults.  The physical issues matter, but they can sometimes be perceived as the only issues that matter.”

York has long argued that providers have to stop thinking about technology merely in operational terms. E-health records are awesome, but not exclusive, and providers who don’t find ways to connect their residents with modern tech are doing the residents—and themselves—a disservice, York says.

“Some of the off-the-shelf tools are game-changers for almost everyone, and are a great place to start,” he says. “Through Google Earth, you can show a 92-year-old woman the satellite image of where she went to high school. Have Skype or Facetime be part of the fabric of your nursing home. Do a virtual tour of the Louvre and hear the stories come to life of a trip to Paris 50-plus years ago. You’ll be amazed by what you see.”

“The thing is,” York continues, “these experiences, and opportunities, are not novel anymore. Get off your keister and make technology available for your residents, but go through the process on their terms, not yours.  You’ll be amazed at what you can learn about the person you serve every day.”

Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter, @ProviderMyers.


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Elder Abuse: The Enemy Within…

The greatest threat to residents in long-term care is ... other residents, a new review points out. That means staff will have to be well-trained to look for the insidious signs of elder abuse. (Picture courtesy the fine folks at Wiki Media Commons.)

The greatest threat to residents in long term care is … other residents, a new review points out.  (Picture courtesy the fine folks at Wiki Media Commons.)

Bill Myers

Good morning, ProviderNation. Elder abuse may be more common than previously thought—or more common than is really tolerable—but those who guard against abuse in care centers ought to be looking for an enemy within, a new piece in the New England Journal of Medicine argues.

Arguing that around 10 percent of elders are physically, emotionally or financially abused every year—a “major public health problem”—researchers from the Cornell’s medical school say that “abuse of older residents by other residents in long term care facilities is now recognized as a problem that is more common than physical abuse by staff.”

“Physicians,” lead researcher Mark S. Lachs writes for his colleagues, “should be alert to this possibility when examining and treating nursing home residents, because clinically significant injuries have been found to result from resident-to-resident aggression.”

Context Matters

(Context is precious here: By the numbers, long term care residents are much less likely to be abused, for instance, than poor sixty-something women who live in large households, Lachs points out. Still, there’s no level of abuse that’s really tolerable, and dementia is another risk factor for victimhood.)

Among the difficulties, of course, is that elder abuse is particularly insidious, Lachs notes.

“First, victims may conceal their circumstances or be unable to articulate them owing to cognitive impairment. Second, the high burden of chronic illness in older people creates both false negative findings … and false positive findings,” Lachs says.

Most Depressing Sentence Ever

“Thus,” Lachs and his colleagues say in what may well be the most depressing sentence ever published in a peer-reviewed journal, “a busy physician caring for older adults will encounter a victim of such abuse on a frequent basis, regardless of whether the physician recognizes the abuse.”

Doctors, the researchers conclude, have “an important role” to play in preventing elder abuse, but not the only one. Docs’ efforts “must include connecting with specialists in other disciplines, including social work, law enforcement, and protective services, ideally in the context of an interprofessional-team approach,” Lachs says.

Enter the Great Dayne DuVall, chief operating officer of the National Certification Board for Alzheimer Care. Reading Lachs’ study, he says that, if care centers are serious about stopping abuse, they’ll start with careful training for front-line staff.

“You have situations in our homes and centers where residents have trouble communicating, and staff is expected to interpret their wants and needs,” he tells me. “As a profession, though, the data shows we don’t even do a good job interpreting pain in that population. If you can’t figure out that someone is in pain, how can we expect staff to take the next, great leap, and understand that the pain is being caused by another resident?”

Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter, @ProviderMyers.

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Fun With The Interweb…

A new bill would help skilled nursing centers get connected to the Interweb revolution. (Photo courtesy the good people of WikiMedia Commons.)

A new bill would help skilled nursing centers get connected to the Interweb. (Photo courtesy the good people of WikiMedia Commons.)

Bill Myers

Happy Thanksgiving, ProviderNation. “Life,” as the late, great Kingsley Amis has it,

          … is mainly toil and labor

          Two things see you through:

          Chortling when it hits your neighbor,

          Whinging when it’s you.

So mad props to the fine folks at, who’ve decided to have a little chortle at the new ICD-10 codes. Whatever our differences as a nation, I think we can all agree that this is the kind of thing that the Interweb was invented for.

The Broadband Bill You Should Know About

Speaking of the Interweb, there has been a fascinating—and underreported—development from your Nation’s Capital. Last week, a bill entitled the “Rural Healthcare Connectivity Act of 2015” cleared the Senate Commerce committee without amendment.

In Washingtonese, the bill amends the 1934 Communications Act to allow skilled nursing centers to request, under the Universal Service Fund, “necessary telecommunications and information services to serve persons who reside in rural areas at rates that are reasonably comparable to rates charged for similar services in urban areas.”

In plain language, the bill offers tens of millions of dollars in subsidies so that care centers can get hooked up to high-speed broadband.

 Skilled Nursing Left Out

Here’s the background: If you look at your phone bill, you’ll see that the FCC docks you for what it calls the Universal Service Fund. In days of yore, the fund was used as a way to help pay for phone service in poor and rural neighborhoods that couldn’t otherwise make a business case for Ma Bell. But about five years ago, the FCC did a soup-to-nuts overhaul of the fund and it became a broadband-for-America fund.

As part of that overhaul, the FCC set aside a special Healthcare Connect Fund, with the idea of connecting health providers to high-speed Internet. The commission even promised a $50 million pilot program specifically for nonprofit skilled nursing centers. But in fiscal 2014, when the skilled nursing pilot was supposed to take off, the commission redirected the cash, saying it didn’t have the legal authority for the program, after all.

Enter Sen. John Thune, R-S.D., the champion of rural connectivity, who is shepherding the current bill through Washington.

Anchors Away?

The heavy lifting here has been done by the fine folks at Good Samaritan, who’ve generally been ahead of the tech curve. If their efforts are successful, though, all providers will owe them a big thanks.

And not just by way of helping residents stay atop of Game of Thrones, either. There are two further Universal Service implications for providers.

The first is that elders face what we might call an App Gap.  If new technology is going to serve elders, many are arguing, it must needs be designed by elders, not just for them. Low-cost, high-speed broadband is one of the best labs for that kind of innovation: Think of what some tech-savvy CNA, for instance, might be able to do in her down time, as she wonders how she can help one of her residents enjoy Angry Birds (say) the same way the kids do.

The second is that, in many rural areas, the only high-speed broadband available is through what tech types call “anchor institutions”—schools, libraries, hospitals, &c. Think of the good will that rural providers could engender by being the place where kids go to finish their homework online, or moms and dads look for jobs.

Bill Myers is Provider’s senior editor. Email him at Follow him on Twitter, @ProviderMyers.

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