Despite staffing challenges and affordability concerns, Nevada’s senior and assisted living communities pour their heart and soul into providing the best care for this growing population. Recently, a group of senior and assisted living executives met at the Las Vegas offices of City National Bank to discuss the trends and challenges facing their industry.
Connie Brennan, publisher and CEO of Nevada Business Magazine, served as moderator for the event. These monthly roundtables are designed to bring together leaders to discuss issues relevant to their industries. Following is a condensed version of the roundtable discussion.
Is staffing an issue?
Denise Gray: One of our biggest needs is staffing, and quality staffing.
Ron Stewart: It’s not just about finding the people out there, but it’s retaining those folks and make sure they continue to remember what we train them on. We’re talking about transient labor because we’re paying them at that kind of wage. It’s difficult for us to motivate and keep them motivated to do what we request them to do.
Linn Thome: No question about it, you have to have it in your heart. If you don’t have that love for seniors, you won’t make it. We’ve got people who’ve been with us since our building opened. Typically our greatest area of need is in dining services; that’s where we see the greatest turnover. We see a lot of competition from the hotels, and certainly they can pay more. Folks come to us and they have great backgrounds. We hire them and pay for their training, pay for their background checks and so forth, then one or two months later they’ve taken a job elsewhere that has a higher salary or tips.
Dennis Gradillas: The team members who have been there for a long time aren’t where the turnover is. They have the heart and the passion; it’s what they want to do. Where we see the turnover is in the other 20 percent where we’re constantly turning the door around. With Certified Nursing Assistants (CNAs), there’s high turnover and that’s just competition in the marketplace.
What types of standards are there for assisted living communities?
Ramon Perez: After looking into it for my 94-year old grandmother, I find that there are no real national standards for both training and evaluating some of these companies. When I was figuring out how to get some help for my grandmother, I found it very difficult. Without any of the guidelines put into place, it’s hard to make a decision.
Thome: Assisted living started out about 20 years ago as a social model with a health services component. Over the past 10 years, I’ve seen significant change where now we have a much larger health services component. Most assisted living companies in the past didn’t have nurses, now all the large providers do because of the higher acuity levels. Nevada is really great because we’re one of the few states that actually had regulations, and we’re surveyed annually by Nevada’s Bureau of Health Care Quality and Compliance (HCQC).
Is assisted living a target for Fradulent Lawsuits?
Gradillas: Litigation scares the heck out of me. There’s no real protection when it comes to the care we provide in assisted living or skilled nursing. The sky is the limit for fraudulent cases.
Stewart: Skilled nursing was targeted horribly for years. They’re trying to find the next target and I think that’s assisted living. The billboards used to say, “Has your mom been hurt in skilled nursing? Has she fallen?” and now you’re seeing, “Has your mom been hurt in skilled nursing and assisted living?” It’s an attorney that sees an opportunity.
Gray: We are addressing your loved ones and we are doing what we can to provide care. I’m losing sleep over it. Families are suing for no reason because we have eager attorneys.
Dana Daunter: Which will drive up healthcare costs.
Stewart: We’re a human company with human jobs. Humans make mistakes.
Gradillas: Things also happen for no reason at all. People can just be walking and fall out of nowhere. There’s nothing wrong with that, but then suddenly you’re faced with litigation.
What advice can you give for those looking at assisted living?
Thome: It’s very important that families look around and visit the various properties. By doing that, they get a chance to see if it’s clean, if the residents look happy, if the staff looks happy and if the residents are engaged and active. Those are the things families want to look at.
Perez: I made a list of questions because no one was helping to educate me. There are pretty lawns and great landscaping, but what really are the levels of care? It took a while for someone to finally educate me that they’re just helping and assisting residents. There’s not necessarily nurses because it’s not required. They may have that as a part of the sales pitch, but the state doesn’t require it. They may require someone to be on site, but they may not even have to be awake. Those are some of the things I found that were interesting.
Stewart: We decided to rip apart our website. We had pictures but we were doing an injustice to families because we weren’t telling them what we were. We’re trying to move away from being a pretty picture to providing actual information. When families come in, their eyes are wide open like deer in headlights because they’re still thinking it’s a skilled nursing facility. It’s not. We don’t do a good enough job of educating people on what we do.
Gray: Nevada provides a lot more. We do have regulations and we do have some ratios with staffing. We don’t hide a lot of things and that’s nice. Our consumers can look online on several sites.
Gradillas: All the surveys are accessible so you can see the fines and penalties within the state. It’s also posted within each building. If you’re looking for suggestions and you want to get beyond the superficial landscaping, have a meal or two with other residents. You’ll get a sense of what the food quality is. You’ll get a sense of what the table talk is, which will give you a sense of the temperature of that community. Also, if you ask questions, you will get an honest answer.
Daunter: As a director, it’s important that you really know your business and really know what you can and can’t do for an individual. It’s not if they’re appropriate for our community, it’s if our community is appropriate for them. I’d like to say that my staff knows they need to function with integrity. You have to learn and earn trust.
Is there a disconnect between consumer expectations and reality?
Daunter: Here in Las Vegas, there’s not a lot of family involvement – if there is, it’s over-the-phone – because there are not a lot of families. It’s such a transient community. The kids are abroad or somewhere across the nation so there are not as many family members who could be invested in the decision making.
Gray: They see the pretty pictures on the website and the virtual tours, and they don’t get to sit down for a meal to see how it truly is. A lot of our consumers still think of assisted living as sterile nursing.
Stewart: There is also difficulty distinguishing between what is dementia and what is behavior. There’s no where for people with behavior issues to go so they’re put under the umbrella of dementia, and that’s not the right answer. They could be anywhere from 35 to 83-years old.
How are reimbursements handled in the assisted living industry?
Gradillas: Within assisted living there are no reimbursements. You either privately pay or you have long-term care insurance. You have to have the money. For us, it’s about $5,000 a month for assisted living so you have to look at that as out-of-pocket costs just for room-and-board. Looking at skilled nursing, if some of the changes in Medicare take place and reimbursements are lowered, what kind of impact is that going to have? That may push families into an inappropriate setting for care. Medicare is going to pay for that stay if you’re in skilled nursing, but not in assisted living.There’s going to be a trickle effect on the way care is provided if Medicare is cut.
Thome: Through the VA, there’s also a program called Aid-in-Attendance. It pays for close to $2,000 a month for veterans, and the surviving spouse receives $1,100 a month, if they meet some criteria. The caveat is that the resident would have to be getting at least two activities of daily living in order to qualify for this benefit, but it’s a nice benefit.
What is long-term care insurance?
Gradillas: Long-term care insurance is for those who can afford it. There are probably less than more who can afford it. It’s a great solution. Benefits are starting to shrink drastically, the policies are evolving quite a bit. The premiums are going up, the benefits are decreasing. My father-in-law just wrote a $80,000 check to prepay his long-term care insurance and it’s for five years if he ever needs that benefit. If he never needs it and doesn’t access the benefit, he gets it back.
Daunter: You should get it when you’re around 53 years old. By the time you’re 55 years old you should really have it in place.
Is this industry competitive?
Thome: It is to some extent, but most of us offer a different model. We focus on a higher-functioning senior, whereas you have some of the other communities who need more or are frailer. There’s a niche for all of us. As we see this increase of seniors coming in, it’s going to be a challenge just to find the housing for them.
Gray: We’re all in it because of our heart; we care. If I know my residents are more likely to stay at home and I see someone come in that’s more active, I am going to refer them to another community. I want what’s best for the resident and so whatever community that is, I want to share that.
Stewart: There’s a level of competition, but that’s just inherent in business. It’s friendly competition. If we can’t take care of someone, it’s our job to help them find a resource that can.
Gradillas: Our philosophy is very simple. It is what is the best solution for the family. If anything the competition helps us get better. If there’s competition, we get better as a group.
Thome: There are certain endorsements that an assisted living community can get. For example, you can get an Alzheimer’s endorsement, mental health endorsements or chronic illness endorsements. They require additional training for your staff in those areas. The majority of assisted living facilities provide really good care. Every once in a while someone makes a mistake, but by and large it’s very good and loving care. We become the families whose son or daughter are on the east coast. Having said that, there are the occasional ones that aren’t good and they’re quickly identified by the state. The state is proactive in terms of monitoring this.
Stewart: The last thing anyone here wants to have happen is for a facility to go bad.
Gradillas: It hurts everybody.
How will the baby boomers affect the assisted living industry?
Daunter: There are approximately 70 million boomers.
Thome: It’s going to impact not only the state, but the country as well. Trying to accommodate these people, particularly the ones who don’t have the financial resources to pay for it, unless we make some changes, there’s going to be a real challenge.
Stewart: The average age in assisted living is about 83 years old in our buildings. We still have some time to figure some things out [before the baby boomers need our services]. We’re not so far behind the eight ball that we can’t do it.
Gray: And then staff it.