Workforce recruiting and retention efforts in the seniors housing and care sector are particularly challenging today. During a panel discussion at the 2019 NIC Fall Conference, representatives from leading operating companies shared their strategies for attracting and retaining top talent.

Moderating the discussion, Jacquelyn Kung, CEO, Activated Insights, noted that “Better workplaces lead to better performance.” She opened with examples of companies in other industries that have succeeded financially by focusing on workplace culture, including Southwest Airlines and Hilton Hotels. Hilton tops the Forbes 100 best companies list currently—a list compiled by the Great Place to Work® Institute—and has seen tremendous growth in stock price over the past five years.

Great Place to Work began an initiative in the senior care industry two years ago, and this year surveyed almost a quarter million employees at more than 3,000 locations. Kung highlighted survey findings showing lower employee turnover in companies with higher trust index scores. She noted the data showed higher occupancy rates and higher charge rates in those companies as well.

The panelists shared moments of inspiration from their careers and how those experiences impact their work with their own employees. Common among the stories was the timing; all had experienced moments of inspiration very early in their careers. Kung noted that almost half of workers in senior care are very young adults and the importance of creating moments of impact to inspire the young workers to remain in the industry.

Audience members then submitted questions around staffing challenges for insights from the three panelists: Tom Grape, founder, chairman & CEO at Benchmark Senior Living, Manny Ocasio, chief human resources and compliance officer at Asbury Communities, and Ahkira McPherson, RN, staff development manager at Vi Lakeside Village.

When asked whether the industry’s biggest issue is recruiting, retention, or engagement, panelists all agreed that the three are equally important and intertwined. From Ocasio’s perspective, engagement allows you to attract more staff, “If you focus on engaging, you’ll get results on both retention and recruitment.”

Next, the panelists shared ideas on how to show return on investment (ROI) for workforce strategies. Tom Grape from Benchmark noted that culture can be an amorphous concept, and the ongoing pressure on wages and benefits in today’s hiring environment is tricky. But, data like that collected by Great Place to Work offer a compelling place to start. Ocasio added that some initiatives at Asbury have demonstrated measurable reductions in turnover, and that can directly affect the bottom line: “It costs about 1.1 times the salary per year of every nurse that you turn over.”

The discussion then turned to staff training. McPherson shared that Vi places a priority on management and staff development programs, and support from the top down. “From our corporate office, we have ongoing support down to our managers. And then we filter that down to the other stakeholders within the company and to the other employees.” The three panelists shared that training in their companies is primarily handled internally, with managers coaching staff directly. “Every manager has been trained in both being receptive to feedback and in being able to provide feedback that’s meaningful,” noted Ocasio.

When asked about hiring practices, Grape shared Benchmark’s success in reducing staff turnover through use of a predictive analytics tool, Arena, during the application process. He also noted the enthusiasm generated by the 3-day onboarding orientation program in Benchmark headquarters for new department heads and above. Ocasio talked about the use of behavioral interviewing in Asbury’s hiring process and the in-house culture program that helps tie behaviors to the organization’s values. McPherson noted that Vi recruits students and veterans, and offers apprenticeship and mentorship programs, “We are adamant about developing our own employees and promoting from within through leadership programs.”

Having advanced through the leadership programs at Vi herself, McPherson understands the importance of communication and connecting with staff at all levels, “Every day I’m encouraging someone.” Ocasio noted Asbury’s results in developing an app to improve communications with staff, and the nearly doubled message open rates versus email, “It’s really changed the way we communicate.”

Kung then asked the panelists about what she called “the elephant in the room:” workforce pay. Ocasio described Asbury’s living wage strategy, “Nobody makes less than what in their particular jurisdiction would be a living wage.” Grape noted Benchmark’s competitive market studies, recognizing that they are competing for workers with not just other senior living providers but with other local employers. Kung highlighted the importance of drilling down market studies to the local level, “The metro area is really important.”

“I would say you can pay better wages and have lower costs of labor,” said Ocasio, noting that higher wages reduce turnover.

An audio recording of the entire panel discussion is available to conference attendees on the conference recap page on NIC.org.

The Labor Department reported that there were 136,000 jobs added in September, below the consensus estimate of 145,000. For the nine months through September, the average monthly increase in total employment has been 161,000, below the average monthly gain of 223,000 in 2018 (note that this will likely be revised down based on the recent preliminary benchmark revision estimate). Health care added 39,000 jobs, in line with its average monthly gain over the past 12 months.

Revisions added 45,000 to the prior two months. The change in total nonfarm payroll employment for July was revised up by 7,000 from 159,000 to 166,000 and the change for August was revised up by 38,000 from 130,000 to 168,000. Monthly revisions result from additional reports received from businesses and government agencies since the last published estimates and from the recalculation of seasonal factors.

The September jobs report is important to the Federal Reserve and analysts because it is the first major piece of data for the fourth quarter. While not entirely consistent, data through the third quarter suggest that both the global and national economies are slowing. Indeed, the U.S. manufacturing sector is weakening as evidenced by a contraction for the second consecutive month in September in U.S. factory activity to its lowest level since June 2009. Expectations for GDP growth in the fourth quarter have also slipped to less than 2%. Global trade is slowing, and business investment is weakening due to mounting concerns about trade-related weakness associated with rising tariffs and geopolitical strife around the world. In fact, the Fed lowered interest rates on July 31st for the first time since 2008 and then again at its September 18th FOMC meeting as it reacted preemptively to concerns of a potential economic slowdown. The fed funds rate is now targeted at a range of 1.75% to 2.00%, down 25 basis points from its prior target range. Until July and since late 2015, the Federal Reserve had been gradually raising rates following six years of virtually 0% interest rates (2009 through 2015).

The August unemployment rate fell 0.2 percentage points to 3.5%. The last time the rate was this low was 50 years ago in December 1969. A broader measure of unemployment, which includes those who are working part time but would prefer full-time jobs and those that they have given up searching—the U-6 unemployment rate—fell to 6.9% from 7.2%.

Average hourly earnings for all employees on private nonfarm payrolls fell in September by one cent to $28.09. Over the past 12 months, average hourly earnings have increased by 2.9%, but this marked a 14-month low. For 2018, the year over year pace was 3.0% and in 2017 it was 2.6%.

The labor force participation rate, which is a measure of the share of working age people who are employed or looking for work was unchanged at 63.2% in September, very low but up from its cyclical low of 62.3% in 2015. The low rate at least partially reflecting the effects of an aging population.

Life expectancy rates over the past century have nearly doubled. And as Terry Fulmer, president of The John A. Hartford Foundation, sees it, increased longevity is the greatest success story of the 20th century.  

Speaking to an audience of seniors housing and care leaders gathered for NIC Talks at the 2019 NIC Fall Conference last month, she said “Here’s your moment, your inflection point, your opportunity to think about how we celebrate this wonderful success and take a look at how we can maximize these additional years in life.”  

Fulmer believes with this extended lifespan comes a call for age-friendly health systems that adapt to the needs of the older population. Age-friendly health systems celebrate and maximize longevity, provide the best care, offer greater customer satisfaction, and at a more reasonable cost, she noted.  

The World Health Organization (WHO) launched an “age friendly cities” initiative in 2006 to, among other things, bring focus to ways cities could become more accommodating to older adults and their families. AARP then brought focus to age friendly communities, described as those that are inclusive and considerate of the perspectives of all residents, of all ages and all persuasions.  

Without age friendly health care systems in those communities, Fulmer noted, older adults may not be fully served. “You’re not an age friendly community if you can’t get someone the care they need, the way they want it, in the time that it should be delivered,” said Dr. Fulmer.  

She then presented the 4Ms framework health care providers can use to inform their work with older patients.  

Developed in partnership with the Institute for Healthcare Improvement (IHI), the 4Ms framework was based on research into “the 70+ care models that we know, based on science, improved care for older adults,” said Fulmer.  

The research resulted in identification of four elements of senior health they labeled the 4Ms: What Matters, Mobility, Mentation, and Medication. According to Fulmer, these four elements need to be working, and in balance, for the older adult’s health to be working, “Any one of those off kilter will set the others into a cascade of problems.”  

What Matters 

“Healthcare providers should be asking ‘What matters to you?’ instead of ‘What’s the matter with you?’,” said Fulmer. This, she said, will fundamentally change the clinical encounter. It allows care providers to focus on patients as individuals, thinking about their wants and needs, for more personal care. 

Medication  

Older adults typically take several medications, often prescribed by different doctors with inconsistent monitoring across the health care system. According to Fulmer, “about 80% of people in a given year have some sort of adverse drug effect, and that’s a problem.” Age friendly health care requires a better way to monitor a patient’s medications, both what is prescribed and what is taken. 

Mentation 

Despite common misperception, depression is not a normal part of aging, noted Fulmer. When evaluating older patients’ mental acuity, care providers should consider other causes that could contribute to an apparent decline in cognition. Is the patient’s medication causing cognitive changes, for example, or perhaps he isn’t wearing his hearing aids consistently? 

Mobility 

“Mobility is one of the things people want most in their life, and is so essential to our sense of wellbeing,” said Fulmer. Beyond preventing falls, age friendly health systems should work to enhance mobility. 

Fulmer and her team have partnered with the American Hospital Association (AHA) and the Catholic Health Association of the United States (CHA) to implement the 4M model. Their goal is to hit 20% of health systems by 2020.  

“But,” said Fulmer, “do not think of this as just a hospital problem. This is all of us— continuity of care across settings.” She challenged the audience to consider what they will do differently in their age friendly work tomorrow.  

To watch a replay of Dr. Fulmer’s 2019 NIC Talk, visit NIC.org.   

1. Occupancy decreased from first quarter, up from year-earlier levels.

2. Medicaid revenue mix over 50%, Managed Medicare revenue mix down from first quarter.

NIC released its second quarter 2019 Skilled Nursing Data Report two weeks ago, which includes key monthly data points from January 2012 through June 2019.

Here are some key takeaways from the report:

• Skilled nursing occupancy decreased 52 basis points to 83.3% in the second quarter of 2019 from the first quarter. However, occupancy was up 48 basis points from year-earlier levels, reflecting the stabilization pattern that has been evident over the past year. Since March 2018, occupancy has fluctuated about one percentage point. A quarterly decline is not unexpected as occupancy usually decreases from March to June due to seasonality. The decrease could be related to flu season coming to an end in the second quarter. The second quarter drop in occupancy was not evident in all geographic areas as occupancy increased slightly in rural areas, while urban areas experienced a decline.

• Quality mix decreased 66 basis points to a near seven-year low of 33.5% in the second quarter and was down 57 basis points from year-earlier levels. Quality mix fell due to declines in both private pay patient day mix and Medicare patient day mix. However, the main driver of the decrease in quality mix has been the decline in Medicare patient day mix, which fell 72 basis points quarter-over-quarter and now stands at a time-series low of 11.5%. Medicare patient day mix has fallen 525 basis points since January 2012. The quality mix trends vary when comparing geographic areas as rural areas saw an increase in the second quarter 2019, while urban areas decreased.
• Medicaid revenue per patient day (RPPD) increased from the first quarter to end the second quarter of 2019 at $215. It was up $6, or 2.7%, compared to a year ago when the RPPD was $209. Medicaid continues to be the fastest growing payor in terms of RPPD on a year-over-year basis, but the concern continues to be that Medicaid RPPD may not cover the cost of care for residents in some states. The growth in Medicaid RPPD is evident in both urban and rural areas as it increased on both a quarterly and yearly basis in both geographies. It ended the second quarter 2019 at $219 in urban areas and $198 in rural areas. Meanwhile, Medicaid revenue mix ended the second quarter 2019 at 50.4% which underscores the importance of following the Medicaid RPPD trend.

• Managed Medicare revenue mix decreased 218 basis points from the first quarter to the second quarter 2019 ending at 10.3%. It was relatively flat from year ago levels. The decrease in overall occupancy along with only a small decrease in managed Medicare patient day mix in the second quarter suggests that the decrease in revenue mix is likely due to RPPD pressure and patient admissions. Managed Medicare RPPD decreased on a quarterly and yearly basis to end the quarter at $432. Managed Medicare RPPD is down $78 since January 2012. The revenue mix trend differed between geographic areas as urban areas drove the overall quarterly trend, declining 231 basis points to end the second quarter 2019 at 12.1%. Rural area revenue mix was flat at 5.2% for managed Medicare.

To get more trends from the latest data you can download the NIC Skilled Nursing Data Report here. There is no charge for this report.

The report provides aggregate data at the national level from a sampling of skilled nursing operators with multiple properties in the United States. NIC continues to grow its database of participating operators in order to provide data at localized levels in the future. Operators who are interested in participating can complete a participation form here. NIC maintains strict confidentiality of all data it receives.

Dr. Yulun Wang, chairman, founder & chief innovation officer of InTouch Health believes that senior living should be an extension of the healthcare system, with telehealth capabilities allowing senior living to care for chronic conditions and keep people healthier than hospitals can.

In his NIC Talk, The Future of Telemedicine, at the 2019 NIC Fall Conference, he opens with: “I’m here to tell you about why, and how, the healthcare delivery system that we have today is going to be virtualized. This is important to you because if you have a virtualized healthcare delivery system you can actually bring healthcare to the seniors as opposed to the seniors having to travel into the healthcare delivery system to get their care.”

As Dr. Wang points out, over the last 150 years, life expectancy has risen about a year for every four to five calendar years, but at a cost: increased complexity within the system. He pointed to the number of medical subspecialties, which has increased from 20 in 1970 to 150 today. Meanwhile, the number of doctors per patient is decreasing, from 7.3 per 100,000 people in 1980, to 5.0 today. With the significant rise of healthcare costs, which Dr. Wang describes as unsustainable, the challenge of providing quality care to everyone, without negatively impacting our economy, is a major one.

Dr. Wang characterizes the rise of digital technology as our fourth industrial revolution, shaking up markets and industries, and believes that healthcare, while not the first industry to be disrupted, will nevertheless feel the impact of today’s new technologies – and must embrace them in order to become better and more cost-effective.

Telehealth will allow the healthcare system to leverage new technologies to solve its greatest challenges. In today’s system, the expertise of our 150 subspecialties is scattered across the vast network of hospitals, doctor’s offices, and all sorts of brick and mortar locations. Virtual technology allows those experts to be distributed far more efficiently, while keeping frail elders out of the hospital. Dr. Wang shares a vision of the near future, in which we will have a virtual care delivery layer on top of the traditional brick and mortar layer, enabling clinicians to deliver care far beyond their geographic boundaries. “Beaming in” a clinician through the internet is possible with today’s technology – and is becoming more commonplace already.

Dr. Wang points out that a major barrier slowing the adoption of telehealth is a restrictive regulatory and reimbursement environment. But we are at an inflection point right now. Just in the past year, 40 congressional bills were introduced, and have either been passed or are in the process of being passed, that enable telehealth to be used in a wide range of applications, ranging from behavioral health to COPD, congestive heart failure, and more.

The RUSH Act, which stands for “Reducing Unnecessary Senior Hospitalizations” is close to passing this year, he said. It will allow CMS reimbursements to skilled nursing and senior living for technology, in recognition of the fact that, according to CMS, 45% of transfers from SNFs to hospitals can be avoided. Other regulatory changes, which are either already in place or on the near horizon, expand payment policies and increase payments for telemedicine.

Dr. Wang said that the use of telehealth is far from hypothetical. “Now is the time to link your senior living facilities with healthcare systems in partnership, with financial business models that work.”

This and all of the 2019 NIC Talks can now be viewed on NIC.org.