As many nursing homes have been forced to close due to economic hardship, a greater degree of specialization in back-office function and front-office work is proving to be necessary to maintain longevity, especially for small operators.

This is according to Adam Berman, President and CEO of Legacy Lifecare, which provides back-end management services to seven non-profit providers across New England.

Berman worked with the very first urban Green House through Legacy’s founding organization – Chelsea Jewish Lifecare. Based on a model designed by the Green House Project, which is dedicated to creating alternative living environments to traditional nursing home care facilities, Chelsea Jewish has condominium-style Green Houses and caters to populations typically underserved by traditional skilled nursing facilities, such as individuals with ALS, multiple sclerosis, and those requiring ventilator-dependent care. Additionally, Chelsea Jewish has multiple campuses offering skilled nursing, assisted living, and various other community-based services.

In creating Legacy Lifecare and working with partners to provide back-office support for nonprofit affiliates, Berman has learned that such support can make all the difference in keeping smaller operations afloat.

“Larger organizations, primarily for-profit but also some nonprofit ones, have been able to leverage their managerial infrastructure, providing them with advantages in areas such as IT systems, marketing, and relationship building with referral networks and hospital systems,” Berman told Skilled Nursing News. “They are more agile and can move faster, which puts nonprofits at a disadvantage.”

Berman said that to an extent, the closure of nursing homes represents a societal shift toward home care, independent living, and assisted living, which he believes should be celebrated. And yet, he worries that without the specific services nursing homes provide, there won’t be enough beds for patients who need them.

“I am just very passionate about what we’re doing and really want to make sure that both nonprofits and any value-driven for-profits are supported,” he said. “There are many value-driven and family-owned smaller organizations, small regional chains, that really do the right thing. We want to support those organizations and nonprofits to ensure that this industry has a very bright future.”

This interview has been edited for length and clarity.

Skilled Nursing News: So, could you give me the backstory behind Legacy Lifecare – when were you founded, who do you serve?

Adam Berman: Legacy was founded in 2018 by Chelsea Jewish Lifecare, which has the first urban model Green House skilled nursing facility in the nation.

Chelsea Jewish identified a greater need in the nonprofit market where many organizations were experiencing difficulties for the first time in their long histories, some dating back 100 to 150 years. Despite our larger size compared to some of these organizations, we too felt the same pressures.

Recognizing these challenges, we at Chelsea Jewish saw an opportunity to create a model for nonprofits that preserves their unique community-focused approach. We partnered with JGS Lifecare in Long Meadow to establish Legacy Lifecare, providing back-office support to our nonprofit affiliates. This support enables us to benefit from shared managerial infrastructure and specialized services, operating more efficiently without compromising frontline care. We strive for the best of both worlds, maintaining our mission, identity, branding, and community relationships while accessing resources typically available only to larger organizations. We believe this balance is crucial in retaining what makes nonprofits unique and impactful within their communities.

SNN: How many affiliates does Legacy work with in what regions are they based?

Berman: We currently have seven affiliates. This includes what we call full member affiliates, which have shared governance, and managed affiliates, and which operate on a management contract basis. However, we manage them similarly from a managerial perspective, and they benefit from many of the same services. Currently, we are in Massachusetts, with one affiliate in Connecticut, spanning both Western and Eastern Massachusetts. We see more opportunities in other New England states in the future.

SNN: What are your thoughts on the staffing mandate?

Berman: All of our homes already operate at ratios that are equal to or greater than the minimum required. The main reason why we might still face an indirect impact is if we ever compete for staff from other local nursing homes that fall below this mandate. If suddenly they have to increase their hiring but can’t match it with a growth in their workforce, it could affect us. However, as the vice chair of the Massachusetts Senior Care Association, which is affiliated with the American Health Care Association, and with our chief operating officer serving as a board member of LeadingAge Massachusetts, we closely collaborate with our trade associations. They are doing tremendous work to increase the overall supply of staff members for the industry. So, while the staffing mandate shouldn’t directly affect us financially since we won’t need to increase our staffing levels, it could indirectly impact us if there’s a surge in labor demand without a corresponding increase in supply. I’m confident that the efforts of our trade associations will lead to sufficient growth in the workforce to meet this increased demand.

SNN: Can you talk about some of the advantages and disadvantages of specialized communities?

Berman: One of the things that we’re very passionate about at Legacy Lifecare is the future of all senior care but of nonprofit nursing home care specifically. We find that because it is so difficult to be a single site … that so many nonprofits have divested or have sold or have been acquired or have had to close.

I don’t think of ethnic identity or even the religious identity of some of our organizations necessarily as being a big specialization. It is to the people that need it, which is why I think it’s so important that these homes exist. But for example, in our Jewish-affiliated organizations or organizations with strong Jewish roots, still, in many parts of those organizations, you’ll find homes that are predominantly non-Jewish. That being said, whether it be an observant Jewish person or a cultural Jewish person, they may seek us out specifically. In general, we’re just serving our local communities and whatever that population may be.

Memory care is a big component of most of the different affiliates. That’s been a growing need. We do provide that specialized care as I shared at the beginning at Chelsea Jewish Lifecare for people with ALS, multiple sclerosis, and have a very large ventilator-dependent chronic ventilator support population.

There are those [operators] who have focused on specific areas but with a strong sense of purpose rather than just profit-driven opportunities. [Legacy] recognized a significant need and saw how these organizations were evolving. We work with them, often through Legacy’s support and strategic planning, to envision their future.

What sets Legacy apart is our ability to guide boards to look beyond daily operations, which we handle efficiently, and instead focus on long-term goals. As we look ahead, topics like residential care, independent living, and assisted living are central. Many affiliates are already involved in Independent Living to some extent, but we’re also considering home care and whether that’s a feasible next step for them.

Legacy also does have our own home health and hospice services, which some affiliates also do work with. But some may want their own agencies, and that’s certainly something that we support as well. So we have the expertise in those areas to allow the affiliates to really make informed decisions about what the future of their organizations might look like.

SNN: Why is it part of Legacy’s mission to support nonprofits and smaller operators? 

Berman: There have obviously been many nursing home closures throughout the country. And in Massachusetts, the state with which I am most familiar, we’ve gone from 520 nursing homes in less than two decades ago to around 370 now. We also expect another 10 to 20 closures in Massachusetts alone this year. Some of that, you know, reflects the increased supply of everything from home care to independent living to assisted living. So, as a society, we can celebrate that to a point. But I am very, very nervous that as we look to the next 10, 20, 30 years, there will still always be a need for the services that nursing homes specifically provide. If we are not careful as a society, two things are going to happen. One is we won’t have enough beds overall. But also, we’re finding that the proportion of nonprofits that have closed relative to for-profits is quite high, and I am very concerned about what the industry may look like, from a quality perspective, in the future.