Calls for systemic overhauls of long-term care and senior living are nothing new. From operators to government payers to resident advocates, a variety of voices has challenged the status quo with support for new reimbursement systems, creative partnerships, and the substantial redesign of care models over the last decade — with varying results.
But with COVID-19 striking the senior housing and care industry harder than any other, one leader believes that — powered by clear data — providers have an opportunity to effect real change in the wake of a deadly pandemic.
“Crisis is really this burning platform to figure out how to innovate in this space, and we’re certainly heading even more so in that direction from a value-based care perspective,” Brian Jurutka, CEO of the National Investment Center for Seniors Housing & Care (NIC), told SNN in a recent interview.
SNN caught up with Jurutka in early June to discuss the kinds of data that operators, regulators, and the media should be analyzing as they attempt to unpack the full scope of the coronavirus pandemic — as well as what he believes will be the lasting legacy of COVID-19 in senior housing and care.
How do you see the role of data changing for nursing homes — both in the near and long term?
As you’ve alluded to in, I think, a pretty powerful piece that you wrote, seniors housing and skilled nursing is in the spotlight right now. It’s certainly a harsh spotlight. I think with that, though, also comes — the right word here probably is not opportunity, but it is the ability to also tell the story that goes with seniors housing and skilled nursing.
We see, through our executive survey insight data, that there is not a mass exodus from seniors housing and skilled nursing, particularly on the move-out side. It’s not like a whole bunch of folks said: “Oh my gosh, I need to bring my parents home,” because in many instances, people are in seniors housing and skilled nursing … because they need help with activities of daily living in addition to medication management, and so on and so forth.
So they play, I think, a really important role in the broader health care continuum, and care for America’s elders. There’s a need here to tell the story of the role that these important communities play in the broader ecosystem. And there’s an education opportunity as well, to say: Here’s what we do. Particularly as it pertains to this pandemic, here’s the story that we have to tell relative to … normal operations.
What seniors housing and skilled nursing does on a regular basis is practice things like infection control, practice things like taking care of our most frail and vulnerable population. But this pandemic has highlighted something, which was: We were unable to identify those that were carrying the virus for the longest time. I think in the very early days, there was really very little discussion around asymptomatic transmission of the virus.
Then as that became more readily available, the challenge was: There was no testing to figure out whether or not [residents] had the virus, and even if there were testing available, the challenge was with PPE itself. Yet the folks that live within assisted living and skilled nursing still need help with some of the most intimate activities on a daily basis — whether it’s bathing, toileting, getting dressed, feeding. By definition, you now need to come in regular, close contact with caregivers who go out in the broader community.
This is a virus that is transmitted through people, and so the education piece that I think is really important is to tell the story of — and I think, be very transparent about it — here’s the impact that COVID has had by setting.
I think the other important piece here would be to tell it by setting, relative to the general population, for a population that has similar care needs — a population that is similar in frailty, and comorbidities.
What is the story among seniors housing and skilled nursing? And let’s put it in context of what we knew at the time. It’s an opportunity, by telling that story, to build credibility — and by building credibility, you also have the opportunity of building trust with a broader population, as well as, of course, for investors and operators to understand really what’s been occurring within the space.
What types of data will be most important going forward? We’ve obviously seen the federal government weigh in with new reporting requirements for COVID-19 cases and deaths.
I think it’s important to be able to, whenever possible, explain data in an apples-to-apples context. One of the things that I find challenging right now, by looking at what I would say is in the broader general media, is lack of context associated with the stories on seniors housing and skilled nursing.
There are a whole bunch of what I would call numerator stories. And so numerator stories would be, within a particular community, here are the total number of infections and here are the total number of deaths. So they identify, obviously, those communities that have a high number of infections and/or deaths. There are very few discussions around the broader communities that have very few infections and/or deaths, or none at all.
Of course, any incremental life lost as a result of COVID-19 is a bad thing. But let’s put it into the context as to the broader community that’s being served — and ideally, let’s see if we can put it in the context amongst the broader population that both lives within seniors housing and skilled nursing and outside. I think that’s an important piece.
So what is, I think, an important piece of data to collect — in addition to the number of residents that are infected, the number of deaths — is also just to collect the total number of residents, and then also to get a sense as to the total number that has been tested within that population as well. So when you start looking at statistics and say, “Gosh, of those that have either tested positive or have died as a result of COVID, a lot of that is going to have to do with what percentage of that population has been tested.”
And you’ve already seen some of that in the general population. There’s relatively low testing, but many states now have mandated that testing be required within skilled nursing. Almost by definition, if you have 100% of that population being tested, even those that are asymptomatic are going to be identified as being positive with COVID.
Let’s at least allow for some apples-to-apples comparison amongst those populations, and even across settings. Right now, we see a lot of information on skilled nursing; we see quite a bit of information on assisted living, because at the state level, that information is being collected. But it’s hard to get any information on independent living, or even to be able to break out memory care from assisted living, by way of example.
If you look at stories in the broader general media, you’ll see stories that say: Here’s the statistic with long-term care, but it actually rarely differentiates between the care setting. Now, one might argue that for the general population, that’s a distinction not [worth] noting. However, I think it’s an opportunity for us to educate the broader public on: There are different care settings, everything from independent living through skilled nursing.
That’s important, because as you move through that continuum of care, you will have a population that tends to be older, with more comorbidities, that is more frail. One would expect — because of this virus itself, because it targets those with multiple comorbidities, and those that are older — a higher rate of mortality amongst those populations.
I think the reach of testing is an important piece — and ideally, to get some sense by setting what that looks like, and understanding the denominator piece, is an important component as well.
As someone whose inbox is perpetually full of news alerts about the long-term care crisis, I’ve seen that lack of clarity around differences in care settings firsthand — and I’ve also seen that some senior living leaders have taken umbrage with being “lumped in” with nursing homes. How do you think this crisis will affect the branding of different care settings going forward? Obviously a lot of work went into differentiating assisted living and independent living from “nursing homes.”
It goes back to: Here’s an opportunity while the spotlight is on seniors housing and skilled nursing. If we were able to provide the transparency through data that says, “here are different outcomes based on these types of care settings,” that’s an opportunity to educate. That’s an opportunity to provide information, not just for the trade groups, if you will, and those within the industry, but to the broader media that says: “Wait a second. It is important that there exists this group of owners and operators in a broader industry that cares for our most vulnerable, but within that there’s some important distinctions — and so here’s one example of those distinctions.”
It’s not to say whether or not it’s good or bad, or right or wrong; it’s just [that] a lot of this is also based on characteristics of the population that resides within these different care settings. So it starts off with independent living, with those that are still fairly mobile and don’t need, necessarily, help with activities of daily living — all the way to skilled nursing, that need help with, on average, something like 5.1 activities of daily living per day.
As you look at this virus, you would expect certain mortality rates because of the residents themselves. I think in general, the media would love to be able to also provide some of that differentiation, because it’s important data and statistics — but generally, it’s just not available.
One of the things that we’ve really been looking to do is help provide some of that information to the broader markets — and, ideally, to get it at scale, so that we can help educate and inform the broader market, as well as of course investors and operators, to benchmark what some of the key metrics might look like.
What are some of the other big changes that you think the industry should start to embrace?
I do think transparency is a key component.
Imagine what mortality looks like within these communities relative to the general population. If one were to have a baseline, one would also be able to compare what [future] pandemics would look like as well; I think the incremental piece here is an important component — to provide that type of information, to have that information available for comparison purposes when you do have these types of pandemics, may be an interesting thought.
I would suspect some of the lessons learned coming out of this — it goes back to transparency — [are] more of the communication piece. Communication with either potential residents, or current residents and their families, seems to be one of the pieces that has been incredibly important in terms of response from operators to the broader pandemic.
Embracing the ability to have those communications on a regular basis; keep families and residents informed, and be fairly upfront about what is going on and what actions you’re taking. That’s how you help alleviate — I should say not alleviate, but minimize the rumor mill if you will, and the concerns associated with no information — is being able to help provide information and clarity into some of the actions that are being taken on a regular basis.
It’s been interesting to see nursing homes in particular have to adopt communication plans that include things like social media and other tech that in the past was just seen as unnecessary, particularly given the tight budgets on which most of them operate.
I can’t imagine being thrust into this need to be able to communicate at scale on a near-daily basis. You hear these stories of: “Hey, I called to see how my mother and father and so on and so forth is doing.” And to have 100 people doing that on a regular basis, I can only imagine the challenges that come with that.
But the opportunity that I think it illuminates is the ability to communicate one to many — whether it’s a daily update, or some regular communication around, hey, here’s the status, here’s what’s going on, I think is incredibly helpful.
But you’re right; the challenge with that as well is just how does one identify a source of funding to implement [it]? In many instances, it might be a technological solution, or to think about it in terms of: How do we modify our existing processes to incorporate that into our regular day-to-day? Crisis breeds innovation, right?
That funding piece will be key; I think we’re currently reaping the harvest of a system that for many years allowed the long-term care model to deteriorate. There’s a lot of innovation around care design, but few people want to invest what it would take to build a new Medicaid-heavy nursing facility given the payment risks. Moving forward, how do you think the government and the industry can create an environment where investing in new long-term care inventory “pencils out”?
One of the things that I think this pandemic has particularly highlighted is that senior housing and skilled nursing, in particular, but assisted living as well — it is part of the broader health care continuum. Take a look at the move from fee-for-service to value-based care, and the fact that we’ve just taken on trillions of additional dollars of debt as a country to have various stimulus packages to get the country moving forward.
Take a look at unemployment. Take a look at the fact that many people’s financial wherewithal, in many instances, is really being tested at this time — I think is almost a doubling-down on the move from fee-for-service to value-based care. And part of that mechanism is to say, well, the population that resides within skilled nursing, assisted living — those particular needs-based communities — is a key piece on how we figure out providing same or better outcomes at lower cost across the broader health care continuum.
I think this highlights the necessity of that continued move, and I think there are opportunities to help integrate — whether it is, and this may sound crazy in this world, taking on more risk at this time to allow you the flexibility to provide care for your residents. Or if you take on your own health care plan, your beneficiaries at that point provide you with the flexibility to go ahead and provide care for that population and to innovate as appropriate.
I’m amazed to have seen the speed at which CMS moved to allow reimbursement for telemedicine, the elimination of the three-day hospital stay. I think those innovations, if they’re not here to stay, some portion thereof will be here, and there will be the data to support what that looks like.
So then the question is, if you look at that, are there opportunities to better integrate? And to some extent it is figuring out how to use that together to [provide] better care for America’s elders — whether it’s through some combination of health care, and the broader continuum, I think there are opportunities here.
Crisis is really this burning platform to figure out how to innovate in this space, and we’re certainly heading even more so in that direction from a value-based care perspective.
This interview has been condensed and edited for clarity.