While many providers offer a continuum of care for older adults, Trilogy Health Services CEO Leigh Ann Barney describes the company as something of a “unicorn” in its commitment to offering a full continuum — including skilled nursing — at scale.

Indeed, the commitment to skilled nursing as part of a larger continuum is part of the company’s DNA. When Trilogy was founded nearly 30 years ago, the name was chosen to represent skilled nursing, assisted living and adult day services, Barney pointed out during a fireside chat at the recent Senior Housing News (RE)BUILD conference in Chicago.

Today, Trilogy has expanded to offer various other service lines across a large portfolio. The Louisville, Kentucky-based company is the eighth-largest U.S. nursing home provider, according to Centers for Medicare & Medicaid Services (CMS) data, and ranked as the 26th-largest private-pay senior living provider on the 2024 Argentum list.

Trilogy is also somewhat unique in that it is now owned by a real estate investment trust, American Healthcare REIT (NYSE: AHR).

Looking ahead, Barney believes that the incoming baby boomer generation will prioritize having many choices at their fingertips and the security of living in one community that has many different services that they may eventually need.

“Our whole continuum gives them the comfort that they only have to go to one place,” Barney said. “The boomers are going to want more choices … and they’re going to want to stay in place longer.”

It’s no secret to many operators that offering higher-acuity senior living services is more complicated than the lower end of the acuity ladder. Operators offering higher-acuity services must grapple with new and complicated payment sources and clinical complexity, and that is not an exercise for the faint of heart.

But Barney said that it is Trilogy’s specialty, and that it positions the company well for the years to come as baby boomers move into senior living communities that can offer what they are looking for.

“It doesn’t scare us,” she said. “We’ve actually always looked at our senior housing as a more clinical model.”

Inside Trilogy’s ‘fourth generation’ model

Trilogy has tinkered with its model over the years, and the company is now on its “fourth generation” of senior living communities, Barney said.

Trilogy builds communities with a “big village concept” in mind, and locates units around common services and amenities. Typical Trilogy communities have both large community rooms and smaller more intimate spaces, like libraries.

Not long ago, senior living operators thought that senior living residents receiving different services would want separate spaces, but Trilogy has found that is not true with today’s residents.

“People mix a lot more than we originally anticipated,” Barney said.

From a building design perspective, she believes that the company’s skilled nursing designs differentiate Trilogy in the market even more than its senior housing designs, where a hospitality-forward approach is more commonplace.

“Our skilled side is what I think looks different, in that we try to focus on the hospitality service, making it not that old cinder block skilled nursing facility that people think of in their mind, [but] truly a place where there’s a large dining area, there’s vibrant activities, upscale finishes,” she said.

Trilogy in the past year has opened several new communities under its newest model, and the operator has also undertaken adding patio homes to existing communities in a few cases in that time. Looking ahead, the company has another campus under construction in Portage, Michigan, and projects to add or expand villa homes at five properties.

“The patio home concept … we like them,” Barney said. “They’re quicker to build, so we can get them done in under a year, and usually with a lower capital investment. And then they sell very well. It seems to be a great entry point to getting into our continuum.”

Like other senior living operators, Trilogy is building out its services and communities in service of attracting members of the incoming baby boomer generation. Barney believes that boomers will want to pick one community in which to live and age in place, and that they will want many of the lifestyle amenities they enjoyed in live when they do.

Incoming older adults will desire telemedicine and medication delivery in addition to familiar dining and entertainment options. And they will want maximum flexibility in their daily activities, she said.

“We’re going to have to rethink our activity calendars,” Barney said. “Self-scheduling makes a lot of sense. [They want to] go on apps and choose what they want for dinner or choose when they go to the beauty shop, those types of things.”

To meet those demands, Trilogy has its own pharmacy to deliver medications onsite. The company also is piloting software that would log incoming residents’ wants and needs and compile them into a database that helps group them by their preferences. That way, for example, the company could more easily identify affinity groups to plan better connections among residents.

“When construction does start, you don’t want to go out and just think that you know everything and rush out to do something,” Barney said. “We’ve taken this time where we aren’t building as much to look at our new design, and we’re going to be very consumer-focused, trying to not think that we know all the answers.”

Affordability is another major consideration as the boomer generation ages, and this is a pain point in particular for residents with more healthcare needs.

“Somehow, we’re going to have to figure out how we can pay for some of these services in senior housing, because it is a lower cost, and we have people that are in our skilled nursing setting that can’t afford to be in a private pay setting, but they don’t need the full skilled services, so the government is paying for them to be in a higher level of care than what they need,” Barney said. “And how we figure all this out, I’m not sure, because with government pay comes government regulation, and that’s what most people don’t want to get into the skilled nursing business for, is the risk and the regulation.”

Trilogy’s next steps

Looking ahead, Barney sees a runway for slow and steady senior living growth. The company will for now focus on expanding its foothold in the U.S. Midwest, both by expanding services at existing communities and building new ones.

The company’s owner, American Healthcare REIT, has in the past noted that it sees Trilogy as a springboard for further expansion.

“We believe that at Trilogy, we will have consistent external growth opportunities every year,” American Healthcare REIT CEO Danny Prosky said last month. “We expect to be able to increase our pipeline of growth opportunities.”

In general, Barney said she is looking forward to the new year in 2025, and she does believe that the federal nursing home staffing will “get modified somewhat,” while noting that if the mandate takes effect, “it’s going to trickle down into senior housing.”

“Having a set staffing mandate for 15,000 nursing facilities across the country, to say they should all be staffed the same, doesn’t make sense to me,” she said. “But should there be a focus on quality care and the right staffing? I think that is a good thing.”

She is generally optimistic about what lies ahead, especially given the demand upside ahead in the form of the baby boomers.

“I think we are seeing relief in interest rates, construction costs, even staffing has been … much better across the industry than it was coming out of Covid,” she said. “So, I’m very positive on it, but I would like to see more growth coming and to have that inventory there for the need that’s coming.”

One wildcard in Barney’s mind for 2025 is the incoming president’s mass deportation plans and how it could affect the workforce. Senior living operators have long called for more comprehensive immigration reform that would allow more people to become citizens and permanent residents.

“I think there does need to be a path for folks to become citizens, or to get work visas,” she said. “The reality is that there aren’t enough workers to take care of a lot of the jobs in this country.”

In general, she believes that staffing will continue to be a thorn in many operators’ sides, and believes that is a good reason to make future community designs “as efficient as possible.”

“We’ve had a bad four years as an industry, both on the skilled and the senior housing side,” she said. “I think it is time to be positive and optimistic about what we’re doing but do it in a thoughtful way.”