The COVID-19 pandemic is far from over, and still threatens older adults. Operators are implementing new protocols to keep residents safe, but the future is still very unclear, particularly regarding the duration of the pandemic. As a result, operators are shifting their approach from a sprint, dealing with immediate, life-threatening emergencies, to a marathon without a known finish line. In NIC’s tenth “Leadership Huddle” webinar, operators, joined by an executive coach, discussed how they are shifting to this new paradigm, and how this longer-term vision of the pandemic will impact psychology, overall costs, and the bottom line.

NIC Chief Economist, and moderator, Beth Burnham Mace, began the discussion by acknowledging that, “Many of the challenges that were evident in the early days of the pandemic remain, unfortunately.” She mentioned the continued need for adequate PPE and pointed to the need for timely testing: “In recent weeks we have seen that the turnaround time for test results is inadequate. If tests are meant to be helpful and an effective surveillance tool, we need to act further on this.” She also encouraged operators to continue to improve transparency and trust, by providing data to NIC as part of the effort to track and understand the impact of COVID. “As the COVID-19 pandemic has developed, it has become increasingly clear that the availability of data on seniors housing and skilled nursing communities is vitally important,” she said.

From Sprint to Marathon

The panelists started off by reminding attendees of the scale of the sprint so far. Lynne Katzmann, Founder & CEO, Juniper Communities, by way of introduction, shared some numbers illustrating the effort her organization has put in during the pandemic: “1,500 or more days that associates sheltered in place, the 2,000 separate, different, communications to families that I authored, 5,100 status reports, 6,400 personal calls, and more than 2,500 virtual programs that we put together.”

Katzmann outlined how her organization was moving from that initial sprint to a longer-term challenge, saying, “how we look at the world has shifted.” She outlined a three-phase approach to the pandemic: “phase one is crisis management, phase two is what we’re calling the path forward, and phase three is something that will be a new normal.” Now in the second phase, her organization’s goals are, “to restore profitability while keeping our residents and our associates healthy, safe, and engaged.”

“What’s most noticeable about the paradigm shift is how we look at the world, and I think this is true not just at Juniper but for all of us. I think we can simply say that the new certainty is uncertainty.”

A key to Katzmann’s strategy at this stage is to jump-start move-ins through a variety of adjustments, including doubling the sales team, doubling her digital spend, and changing the way the organization communicates and “packages” its offering to consumers. Underlying the new approach is a new vision, “What’s most noticeable about the paradigm shift is how we look at the world, and I think this is true not just at Juniper but for all of us. I think we can simply say that the new certainty is uncertainty.”

Lori Alford, Co-Founder & COO, Avanti Senior Living, agreed that the sprint has become a marathon, adding, “Now we’ve embraced it being a journey. COVID is here, it’s not going away, there’s not a finish line that we can see anytime soon.” Her company has begun to focus on shifting mindsets. She explained, for example, how sales staff have had to adapt to the loss of the opportunity to walk prospects through their properties: “that’s been taken away from us.” Adapting to such challenges, by employing virtual tours, in this case, needs to be viewed as a new normal, which, she said, “is not wrong, it’s just different.”

Mental Health Impacts

Asked about mental health impacts of the pandemic on staff, Dan Brown, Executive Coach, Arden Coaching, pointed out that the impacts can be severe, particularly on frontline care givers. He discussed the high rate of suicides among doctors, which is double that of the overall population. “This isn’t something that’s abstract or theoretical. It’s actually happening.” In response to high stress levels, operators, administrators, even investors, according to Brown, should be attuned to the signs of high stress amongst frontline workers. He said he listens for maladaptive thoughts, or feelings, and whether they are persistent. “One of the feelings that you really want to listen to, when you’re working with people on the front line, is a feeling of guilt, that ‘I can’t do enough.’”

Another thing to look for is an “incongruence,” such as smiling or laughing upon the loss of a patient or resident. “There could be emotional numbness…that, too, is a worrying sign that something may need to be addressed; that they’ve lost touch with their own emotion, their own humanity.” He suggested gently observing and checking in with staff showing these types of signs of stress. He recommends that his clients, most of whom are administrators, have the national suicide hotline number on hand at all times, for immediate intervention in such cases. He also suggested using wearables to monitor their own stress levels, and techniques such as meditation to help control the impact of stress.

Alford has begun to focus on mental wellness in her company. She said, “families are tired, residents are tired, our teams are extraordinarily tired, not just mentally from all of the changes, but the physical draining of being up late to take calls because families are in panic, or keeping the staff calm…they have a mental fatigue and they have a physical fatigue…COVID fatigue is very, very real.” She has found that traditional team motivations, such as, “high-fiving people, passing out candy bars, passing out kudos, sending flowers and adult beverages to their homes” which were effective pre-COVID, are no longer sufficient.

Taking a different approach to deal with the stresses of COVID, Alford’s home office and executive team are engaging in a six-week coaching program, focusing on individual needs and shifting to a more positive approach to dealing with the new normal. “We’re all learning together and it’s OK. Shifting into this more positive mind-set has been incredible; you can see the team standing taller…they bring that home to their families and so if we can get our key folks in the communities to not only lead their team and residents and families, but can send them home and be that great leader at home too, its just a well-rounded approach and makes a difference.” With the positive results of the program, Alford said the organization plans to extend the program to department heads, and eventually to line staff and nurses. She said, “We’re a lost industry. We’re invisible. Because we don’t work in a hospital or a skilled (nursing community), we often times forget our folks on the frontline. They’re facing it every single day, probably a little bit more than even some of the other healthcare workers, and they need just as much support.”

Katzmann shared that the pandemic, particularly early on, was very hard on her own emotional wellbeing. “I learned that I couldn’t work hard enough, and nothing that I did could control some of the outcomes. The sadness and the feelings of guilt…were really difficult, and I think it’s important for each of us to acknowledge that we have feelings and that this has impacted us at every level. That vulnerability in myself enabled me to accept that vulnerability in others.” She pointed to the “great source of support and strength and solutions,” provided by her peers in the industry, which she said has been very supportive. “You know the hashtag at the beginning of all this was, ‘we’re all in this together’…regardless of what side of the industry you play with every day, we are all in this together. At the end of the day we all benefit when we all do well at the end, so we need to support one another through this.”

The Importance of Testing

Shifting gears, Mace asked the panel, and in particular Katzmann, who she described as “one of the leading experts on how to go about (testing) as an operator,” to share “what you’ve learned about testing, where we are today, and where it needs to get to.” Katzmann described reading about how Asian nations, which experienced COVID-19 ahead of the U.S., instituted mass testing early on, and how effective that proved to be. Speaking of the successful South Korean strategy, she said, “Their strategy is simple: test early and universally, regardless of symptoms.” She explained how that approach identifies who is carrying the virus, which then allows for effective contact tracing and isolation. “If you do it early enough, everyone doesn’t have to be isolated.” Katzmann said that Juniper made the decision in late March to test everyone, and that, at the time, “We thought we would do it once.”

“No one was actively symptomatic in our communities and guess what we found? Roughly 50% of our residents and staff were positive.”

Using a private lab, they tested all their residents and associates in hot spot areas. Katzmann relayed how their first test went: “No one was actively symptomatic in our communities and guess what we found? Roughly 50% of our residents and staff were positive.” Of those, according to Katzmann, “94% of our staff and 72% of our residents were not showing any symptoms, no matter how mild. The vast majority of those never showed symptoms. This was April 4^th when we’re getting this information. All of a sudden, we knew that this disease was not being transmitted the way everyone was being told. This disease is transmitted by asymptomatic and presymptomatic individuals.”

With their testing data, Katzmann’s team was able to put together a “battleplan,” which involved creating “bubbles,” and sheltering in place. “We thought we could keep it out and within three weeks COVID would not be an issue,” said Katzmann. Of course, when they realized that wasn’t the case, Juniper, in addition to infection prevention strategies, cleaning, disinfecting, and PPE, realized they would have to test regularly to prevent the spread of disease within their communities. Since then, the company has been testing all associates who have not tested positive in the past, and a number of residents, based on state and level of care. “The thought is that the disease is being transmitted from the outside in, and that if we can catch it early enough, before it spreads within the community, and use proper PPE, we do universal masking, we’re still cohorting, although not at the same level we were earlier, we’ve been able to keep the disease at bay.”

Additional Costs

“we did spend $100,000 a week on testing. So, if you have 1,000 employees and the test is a hundred bucks, you do the math.”

Asked about cost, Katzmann said, “we did spend $100,000 a week on testing. So, if you have 1,000 employees and the test is a hundred bucks, you do the math.” She went on to say, “until there is a vaccine, and not just a vaccine but a vaccine that’s proven, that’s taken by enough people to develop herd immunity, effectively, we must find a way to mitigate the spread of this disease, and I believe rapid, accurate, cost-effective testing is the only way to do that.” She described a number of initiatives designed to streamline the testing process, some of which will also help reduce costs, and suggested new testing technologies will likely drop costs while improving ease-of-use. A new cheek-swab test may soon drop costs to $50-$60 per test. “We’ll be doing it for a long time and eventually it will look like a pregnancy test,” Katzmann summarized, adding, “it’ll be much cheaper and much easier to administer.”

Alford also addressed the impact of COVID costs, likening the new normal of dealing with COVID to the additional preparation, regulatory requirements, and processes in place where hurricanes are a risk. She discussed the likelihood of regulatory requirements which would mandate such things as PPE supplies, testing, cleaning and chemical supplies, all of which would likely impact the cost of doing business.

Questions on the New Normal

NIC Senior Principal, Healthcare, Ryan Brooks posed some attendee questions to the panelists. The first was on hero- or hazard-pay, and how big a role it plays in beating fatigue, and whether it’s cost-prohibitive to offer long-term. In response, Alford said that while her organization used hero pay early on, they have since done away with it. “In order to do that you just have to have a really good culture and programs in place.” Katzmann had a similar position, adding that communication around the issue is critical.

Responding to a question on facility design and architecture, Katzmann discussed the use of ‘neighborhoods’ as a means to cohort and isolate small groups of residents and staff, while providing a degree of socialization. “I think you’re going to see more neighborhood, small house design in the future.”

According to Brooks, many questions centered on the counseling program offered by Avanti Senior Living. “We’ve been fire-hosed with negativity,” responded Alford. “It doesn’t matter what the topic is; it seems every time we turn around the news is just filled with negativity. It’s been really, really hard. So, the focus is really mind-shifting from old habits…how do you shift your mind in a positive way, so that you can reflect inward first, believe in yourself, believe in your company, and then strategize, which then leads to results.” She said, “what we were doing in January doesn’t work anymore,” and suggested that this kind of counseling can benefit entire organizations, saying, “any leader deserves access to that, and it does make a difference, and so we’re looking at actually crafting a program that can be ongoing for our teams.”

Another question addressed the impact of COVID on consumer demand. Katzmann said that Juniper, in the last several weeks, “has seen leads skyrocket to levels that are about 30%-40% above the same period last year,” and suggested the rise is due to immediate need. “How that will translate into the type of demand that we experienced before, a mixture of immediate and longer-term need, will be difficult to know at this point in time.”

Katzmann also mentioned a recent Pro Matura study, which looked at what adult children, particularly eldest daughters, wanted when looking at options for their parents. “They wanted a clean and disinfected environment. They wanted to know that there was regular testing, and they wanted to know that there was access to primary care onsite.” While surprised at the finding, Katzmann sees it as evidence that demand is there. She ended her comments on the subject by asserting that, while it may take time, the industry will be able to restore their bottom line performance, but, Katzmann warned, “We’ll have to be creative, we’ll have to be continuously resilient, we’ll have to adapt, but most importantly…people have to have the cash wherewithal to ride the storm. We are still in the storm and it’s very important to be able to get through it successfully. We can get through it, but people need the support during that process.”

Contact tracing has emerged as a first-line defense at senior living communities in the fight against the pandemic. Knowing who has tested positive for COVID-19 and being able to identify their contacts has helped to keep community outbreaks in check.

While many providers rely on manual systems to conduct contact tracing, new technologies show promise to assist in the process to ensure resident and staff safety.

Take, for example, Kisco Senior Living. The Carlsbad, California-based company installed Accushield touchscreen kiosks at its 20 properties. Everyone entering the buildings—employees, outside providers, and visitors—are screened at the kiosks daily.

Individuals sign in at the kiosk which records the time, date, and, if applicable, who they’re seeing. The individual answers a series of screening questions about their current health condition. The questions can be customized to better identify those who might be at high risk for exposure to the virus. An immediate alert is generated if the individual has tested positive in the last 30 days.

Temperatures are checked manually at the kiosk, though an automated infrared temperature scanner is now being rolled out to expedite the process. Individuals who pass the screening receive a photo badge to wear while on site, an assurance for residents that the individual is authorized to be in the building. Individuals sign out at the kiosk when they leave the building.

Executive directors can log on to a dashboard to monitor data collected at the kiosk. If a home health agency, for example, calls to say an employee of theirs tested positive, Kisco can quickly access the records to determine which residents might have been exposed.

Of course, successful contact tracing relies on the ability to test those at risk. Kisco conducts surveillance testing depending on local mandates and whether the positivity rate in the county is 5% or higher. “We are data driven,” said Ed Ward, vice president of operations at Kisco.

Twenty-five percent of employees and outside providers are tested every two weeks. Residents are tested free of charge if they ask for a test. If a positive test is found, 100% of employees are tested every two weeks until two testing cycles show no positive cases.

“The Accushield system has proved to be exceptionally helpful with contact tracing,” said Ward. “Families and residents have a higher level of security and peace of mind.” He added that the company has initiated a campaign—Kisco Confidence—focused on the wellbeing, safety and security of all residents and associates.

Screening Advances

For years, senior living providers have mostly relied on manual sign-in logs to monitor who is in a building. But using these logs to conduct contact tracing can prove difficult, building operators say. Hand-written logs can be hard to read or may be incomplete. Interviews with staff and residents to recall their contacts may not produce an accurate report.

CarePredict launched an automated contact tracing product March 31 called PinPoint. It is an add on to the company’s monitoring solution that uses wearables and beacon technology to chart resident activity.

The PinPoint product allows facility staff to quickly identify all residents, staff, and visitors exposed to a suspected virus carrier. A report provides a breakdown of contacts, location and duration of contact.

“It’s a tool to break the chain of spread,” said Jerry Wilmink, chief business officer of CarePredict, which has offices in Fort Lauderdale, Florida, and Menlo Park, California.  

Contacts are classified by risk, so the staff can test and isolate those who pose the most significant threat. Another advantage, according to Wilmink, is that the Pinpoint solution reveals which individuals have not been exposed so they don’t have to be isolated. “They can get their life back,” he said.

CarePredict is being used at more than 20 communities, said Wilmink. Inquiries from Arizona, Texas and Florida have increased recently because of the uptick in COVID-19 cases there.

Costs of automated visitor management and contact tracing systems typically include installation and monthly subscription fees.

Many operators use a combination of approaches to trace cases. Montgomery Place, a life plan community in Chicago, has an automated check-in system for employees, visitors and outside service providers. The check-in system was enhanced in the wake of the pandemic with health questions and temperature screens.

COVID-19 cases are tracked manually. But the information is entered into the community data base system to generate email and cell phone alerts for the staff, residents and family members. “We know automated tracing technology is out there,” said Deborah Hart, executive director at Montgomery Place. “But I’m not going ‘Big Brother’ and putting chips on people. I’m not there yet.”  

With different tools available, communities are sorting through the options. “We are debating automated contact tracing,” said Nancy Kao, executive director at The Forum at Rancho San Antonio, Cupertino, California. LCS is the management company. Contact tracing is currently done manually.

The life plan community is undergoing a $100 million repositioning that incorporates a lot of technology. The new memory care building, for example, includes a GPS tracking system for residents.

Kao chairs the Innovation Council at LCS, which manages about 140 senior living properties. The Council evaluates different products and recommends best practices.

“Communities are reaching out for more guidance on technology because of COVID-19,” said Kao. “Every community is in a different place on the adoption of technology.”

The Labor Department reported that nonfarm payrolls rose by 1.8 million in July and that the unemployment rate fell to 10.2%. This suggests that the employment recovery from the unprecedented COVID-related drop in March and April continues to reverse course, although the pace of recovery appears to be slowing. The 1.8 million job gain in July was less than the increases of 4.8 million in June and 2.7 million in May. Combined, 9.3 million jobs were generated in May, June and July, recouping some of the 22.2 million jobs lost in March and April. Nevertheless, the July level of employment was lower than its February level by 12.9 million positions or by 8.4%.

While the July improvement is welcome news, the labor market continues to be strained and the recent spike in the virus across many states could hamper further gains. Indeed, some states are backtracking plans to reopen as coronavirus infections are rising again.

The largest July job increases occurred in the leisure and hospitality sectors, which added 592,000 jobs. This accounted for about one-third of the job gains. Health care added 126,000 jobs in July but is still down by 797,000 jobs since February. July job gains in health care occurred in offices of dentists and physicians, hospitals, and home health care services. Job losses continued in nursing and residential care facilities (-28,000).  

The July unemployment rate of 10.2% was down 0.9 percentage point from June but is still quite elevated by historic standards and significantly higher than the 50-year low of 3.5% in February. The number of unemployed persons fell by 1.4 million to 16.3 million. Despite this decline, total unemployed persons are still 10.6 million more than in February.

Among major worker groups, the unemployment rate fell in July for adult men to 9.4%, adult women to 10.5% and teenagers to 19.3%. Among the unemployed, those who were jobless less than 5 weeks increased by 364,000 to 3.2 million in July and the number of persons jobless 15 to 26 weeks rose by 4.6 million to 6.5 million.

The underemployment rate or the U-6 jobless rate fell to 16.5% in July from 18.0% in June. This figure includes those who have quit looking for a job because they are discouraged about their prospects and people working part-time but desiring a full work week. In the previous 2008/2009 recession, this rate peaked at 17.2%.  

The change in total nonfarm payroll employment for May was revised up by 26,000 from a gain of 2.699 million to 2.725 million and the change for June was revised own by 9,000 from 4.800 million to 4.791 million. Combined, 17,000 jobs were added to the original estimates. Monthly revisions result from additional reports received from businesses and government agencies since the last published estimates and from the recalculation of seasonal factors. Market expectations had been for a gain of 1.480 million.

Average hourly earnings for all employees on private nonfarm payrolls rose by $0.07 in July to $29.39, a gain of 4.8% from a year earlier.  

The labor force participation rate, which is a measure of the share of working age people who are employed or looking for work was little changed in July from June at 61.4%.  

Separately, the Department of Labor reported yesterday that the number of new applications for jobless benefits fell to the lowest level since March, though remained historically high at 1.2 million new applications.

A NIC report developed to provide timely insights from owners and C-suite operators and executives on the pulse of seniors housing and skilled nursing sectors

NIC’s Executive Survey of operators in seniors housing and skilled nursing is designed to deliver transparency into market fundamentals in the seniors housing and care space at a time when market conditions are rapidly changing—providing both capital providers and capital seekers with data as to how COVID-19 is impacting the space, helping leaders make informed decisions.

This Wave 10 survey sample includes responses collected July 20-August 2, 2020 from owners and executives of 73 seniors housing and skilled nursing operators from across the nation. Detailed reports for each “wave” of the survey can be found on the NIC COVID-19 Resource Center webpage under Executive Survey Insights.

Wave 10 Summary of Insights and Findings

The Wave 10 survey revealed a slight deterioration in the pace of move-ins, specifically in the independent living and memory care segments, resulting in downward changes in occupancy rates month-over-month and week-over-week for these care segments—likely because of an increase in COVID-19 cases in certain areas of the country. However, the assisted living and nursing care segments continued to improve in Wave 10 in terms of the market fundamentals, with both segments seeing the highest shares of organizations reporting an acceleration in move-ins and upward movement in occupancy rate changes since the survey began. The Wave 9 survey results (June 22-July 5, 2020) showed that larger shares of organizations reported month-over-month and week-over-week improvements in occupancy rates than in all prior waves of the survey. This was likely due to pent-up demand from resident/family members and the easing of COVID-19 related move-in restrictions.

• In Wave 10 of the survey, 43% of organizations with nursing care beds and 39% of organizations with assisted living units noted a continuing upward trend in move-ins in the past 30-days—the highest shares achieved by these segments in the survey time series. However, fewer organizations with independent living and memory care units reported an acceleration in move-ins than in Wave 9 of the survey.
• In each of the past four waves of the survey, roughly two-thirds to three-quarters of organizations cited increased resident demand (many due to pre-COVID-19 planned move-ins resuming) as a reason for acceleration in move-ins. Additionally, organizations with any nursing care beds cited hospital placement more frequently than in the prior three waves of the survey. Other reasons cited for an acceleration in move-ins included properties being re-opened for tours, current and new residents feeling more comfortable about moving-in, and seniors in the lead pipelines ready to move-in.
• Regarding reasons for a deceleration in move-ins, most organizations continued to cite a slowdown in leads conversions/sales, while considerably more in Wave 10 than in Wave 9 cited resident or family member concerns (60% in Wave 10 vs. 38% in Wave 9), presumably due to the increase of COVID-19 cases in many areas of the country since June and July.
• At this point in the pandemic, most organizations are easing move-in restrictions, but others are increasing move-in restrictions. About half of organizations with more than one property in Wave 10 of the survey are easing move in restrictions in some or all geographies (53%), while about one in five are increasing move-in restrictions in some or all geographies (21%). Among single-site organizations, most (42%) are easing move-in restrictions, while about a quarter (26%) are increasing move-in restrictions at this time.
• In Wave 10 of the survey, roughly two-thirds of organizations (62% to 67%) note no change in the pace of move-outs in the past 30-days across all four care segments, while about one quarter (23% to 27%) report an acceleration in move-outs. Primary reasons for move-outs included deaths and residents moving to higher levels of care. Compared to the Wave 9 survey, the shares of organizations reporting an acceleration in the pace of move-outs for the independent living and memory care segments increased in Wave 10 survey, while the assisted living and nursing care segments remained relatively unchanged.
• The nursing care segment continued to have the largest shares of organizations with increasing occupancy rates. In Wave 10, approximately half (53%) reported an upward change in month-over-month occupancy—the highest in the survey time series for the nursing care segment—likely a result of more hospitals around the country resuming greater amounts of elective surgeries that require post-acute care rehabilitation, and/or seniors housing residents moving to higher levels of care.
• As a result of the slight pullback in move-in rates for the independent living and memory care segments, the Wave 10 survey shows a slight decline in the shares of organizations reporting increasing occupancy from a week prior. Slightly more organizations with assisted living units report an increase in week-over-week occupancy, while slightly more organizations with nursing care report a decrease.
• As of Wave 10, about two-thirds of organizations report they are not currently offering rent concessions to attract new residents. Similarly, 70% indicate they do not have a backlog of new residents waiting to move in.
• Regarding the availability of PPE and COVID-19 testing kits, and the time it takes to receive test results back, more than one-quarter of organizations (29%) report that it is still very difficult to obtain enough COVID-19 testing kits in most markets, and 17% report difficulty accessing PPE—up from Wave 9 but similar to Wave 8.
• Two-thirds of organizations reported that COVID-19 test results for staff, residents or prospective residents are typically available in 3-5 days (66%). However, one in five say it is taking 7 or more days to receive results (21%).
• More respondents in the Wave 10 survey (July 20-August 2, 2020) compared to the Wave 3 survey (April 13-19, 2020) expect an increase in their development pipelines going forward (30% vs. 15%).
• Many respondents in Wave 10 offered comments about how their organizations are supporting staff as the pandemic emergency continues for employees and their families, with most citing pay incentives. Additionally, more are supporting staff with flexible work hours, but fewer are currently offering additional paid sick leave. Organizations offering overtime hours to mitigate labor shortages has remained steady at 85% and 84% from Wave 10 compared to Wave 3. However, slightly more report tapping agency or temp staff (42% vs. 36%) to fill staffing vacancies.

Wave 10 Survey Demographics

• Responses were collected July 20-August 2, 2020 from owners and executives of 73 seniors housing and skilled nursing operators from across the nation.
• Roughly half of respondents are exclusively for-profit providers (52%), more than one-third (39%) are exclusively nonprofit providers, and 9% operate both for-profit and nonprofit seniors housing and care organizations.
• Owner/operators with 1 to 10 properties comprise 77% of the sample. Operators with 11 to 25 properties make up 10% while operators with 26 properties or more make up 13% of the sample.
• Many respondents in the sample report operating combinations of property types. Across their entire portfolios of properties, 73% of the organizations operate seniors housing properties (IL, AL, MC), 39% operate nursing care properties, and 34% operate CCRCs (aka Life Plan Communities).

Key Survey Results

Pace of Move-Ins and Move-Outs

Respondents were asked: “Considering my organization’s entire portfolio of properties, overall, the pace of move-ins and move-outs by care segment in the past 30-days has…”

• • The shares of organizations reporting deceleration in move-ins—across each of the care segments—ticked up slightly between Wave 9 and Wave 10 of the survey. In Wave 10 of the survey, between 21% and 30% of organizations with independent living, assisted living and/or memory care segments, and 38% of organizations with nursing care beds indicated that the pace of move-ins decelerated in the past 30-days. Comparatively in Wave 9, between 16% and 26% of organizations with independent living, assisted living and memory care segments and 33% of organizations with nursing care beds reported a deceleration in move-ins.
  • Conversely in Wave 10, between 31% and 43% of organizations reporting on their independent living, assisted living, memory care, and nursing care segments indicated that the pace of move-ins accelerated in the past 30-days, compared to between 36% and 42% respectively in Wave 9.
  • While the shares of organizations with independent living units reporting an acceleration in move-ins in the past 30-days retreated slightly, the assisted living and nursing care segments continued to increase shares to their highest levels in the survey time series (39% and 43%, respectively).

Reasons for Acceleration/Deceleration in Move-Ins

Respondents were asked: “The acceleration/deceleration in move-ins is due to…”

• • In Wave 10 of the survey—hospital placement was cited most frequently as a reason for an acceleration in move-ins in the past 30-days (41%) among organizations with any nursing care beds—significantly higher than in the prior three waves of the survey.
  • In each of the past four waves of the survey, roughly two-thirds to three-quarters of organizations cited increased resident demand (many due to pre-COVID-19 planned move-ins resuming) as a reason for the acceleration in move-ins.

• • • Regarding reasons for a deceleration in move-ins, most organizations continued to cite a slowdown in leads conversions/sales, while considerably more in Wave 10 than in Wave 9 cited resident or family member concerns (60% vs. 38%), presumably due to new spikes of COVID-19 cases in many areas of the country.

Organizations Easing or Increasing Move-In Restrictions

Respondents were asked: “At this point in the pandemic, my organization is…”

• • Given the resurgence of COVID-19 cases across the country in June and July, organizations with more than one-property were asked to describe whether they were easing or increasing move-in restrictions in some or all geographies. In Wave 10 of the survey, while roughly half (53%) were easing move in restrictions in some or all geographies, about one in five organizations (21%) were increasing move-in restrictions in some or all geographies.
  • Among single-site organizations, most (42%) are easing move-in restrictions at this time, while about a quarter (26%) are increasing move-in restrictions.

Organizations Currently Offering Rent Concessions to Attract New Residents and Organizations Experiencing a Backlog of Residents Waiting to Move-In

Respondents were asked: “My organization is currently offering rent concessions to attract new residents,” and “My organization is experiencing a backlog of residents waiting to move-in”

• • As of Wave 10, about one-third of organizations report they are currently offering rent concessions to attract new residents and/or have a waitlist of new residents waiting to move-in.

Move-Outs

• • • Roughly two-thirds of organizations (62% to 67%) in Wave 10 of the survey note no change in the pace of move-outs in the past 30-days across all four care segments, while about one quarter (23% to 27%) report an acceleration in move-outs.
    • Compared to the Wave 9 survey, the shares of organizations reporting an acceleration in the pace of move-outs for the independent living and memory care segments increased in the Wave 10 survey, while the assisted living and nursing care segments remained relatively unchanged.
• 

Change in Occupancy by Care Segment

Respondents were asked: “Considering the entire portfolio of properties, overall, my organization’s occupancy rates by care segment are… (Most Recent Occupancy, Occupancy One Month Ago, Occupancy One Week Ago, Percent 0-100)”

• • In Wave 9, the largest shares of survey respondents reported occupancy improvement across all care segments since the survey began. However, in Wave 10, more organizations with independent living and memory care units note a month-over-month decline in occupancy, while organizations with assisted living report a month-over-month increase in occupancy—the highest in the survey time series (March 24 to August 2, 2020).
  • The nursing care segment continued to have the largest shares of organizations with increasing month-over-month occupancy. In Wave 10, approximately half (53%) reported an upward change in occupancy from the month prior (also the highest in the survey time series for the nursing care segment).

• • • Regarding the change in occupancy from one week ago—while each of the care segments in the Wave 9 survey showed the smallest shares of organizations reporting occupancy declines since the survey began—the Wave 10 survey shows a slight decline in the shares of organizations reporting increasing occupancy from a week prior for the independent living, memory care, and nursing care segments. Slightly more organizations with assisted living units report an increase in week-over-week occupancy.

Improvement in Access to PPE and COVID-19 Testing Kits

Respondents were asked: “Considering access to PPE (personal protective equipment) and COVID-19 testing kits, my organization has experienced that access has improved… Very little, it is still difficult to obtain enough PPE/testing kits in most markets/Somewhat, in some markets it is easier to obtain PPE/testing kits than in others/Considerably, we typically have no difficulty obtaining PPE/testing kits, regardless of market”

• • In the Wave 10 survey (late July to early August), similar to Wave 8 (late May to early June), more than one-quarter of organizations (29%) report that it is still very difficult to obtain enough COVID-19 testing kits in most markets, and 17% report difficulty accessing PPE.

Time Frames for Receiving Back COVID-19 Test Results

Respondents were asked: “Regarding COVID-19 test results (either for staff, residents or prospective residents) results typically come back within…”

• • • Two-thirds of organizations reported that COVID-19 test results for staff, residents or prospective residents are typically available in 3-5 days. However, one in five say it is taking 7 or more days to receive results.

Supporting Property Staff

Respondents were asked: “My organization is supporting property staff who may be experiencing challenges by providing… (Choose all that apply)” Note: this question has not been asked since Wave 3.

• • More organizations in Wave 10 (July 20-August 2) than earlier in the pandemic in Wave 3 (April 13-April 19) report offering staff flexible work hours, while fewer report offering additional paid sick leave.

• • • With regard to mitigating labor shortages, the proportion of organizations offering overtime hours has remained steady at 85% and 84% (Wave 10 compared to Wave 3, respectively). However, slightly more report tapping agency or temp staff to fill staffing vacancies (42% vs. 36%). Many are supporting staff with pay incentives.

Development Pipeline Considerations

Respondents were asked: “My organization’s projected development pipeline going forward is expected to… (Choose all that apply)” Note: this question has not been asked since Wave 3.

• • More respondents in the Wave 10 survey (July 20-August 2, 2020) compared to the Wave 3 survey (April 13-19, 2020) expect an increase in their development pipelines going forward (30% vs. 15%).

NIC wishes to thank survey respondents for their valuable input and continuing support for this effort to bring clarity and transparency into market fundamentals in the seniors housing and care space at a time where trends are rapidly changing. NIC also thanks both ASHA and Argentum for their support in encouraging participation in the Executive Survey Insights: COVID-19 survey. The results of our joint efforts to provide timely and informative data to the market in this challenging time have been significant and noteworthy. The Executive Survey Insights: COVID-19 survey is now open. To respond to the survey, please click here.

If you are an owner or C-suite executive of seniors housing and care properties and have not received an email invitation but would like to participate in the upcoming Executive Survey: Market Fundamentals (which will start again on Monday, August 17), please send a message to insight@nic.org to be added to the email distribution list.

Just two days ahead of the NBA season’s restart in Orlando, Florida, NIC hosted it’s ninth “Leadership Huddle” webinar to discuss the professional sports league’s efforts to contain the virus, and gain insight on the latest developments in testing, wearables, and protocols. Titled “From Pro Sports to Senior Care: Innovations in Testing, Tech, and Protection,” the event was intended to share lessons and experiences earned fighting COVID-19 in other industries with seniors housing and care providers and investors.

While very different in terms of scope, demographics, access to resources, and scale, the NBA has been faced with some of the same challenges that senior living operators face today. Working with experts across the country, including Testing for America, a “nonprofit established by leading scientists, academics, and entrepreneurs,” the NBA is showing significant improvements in curtailing the spread of the virus amongst its players and staff, despite putting them in close proximity to train and play together in a ‘bubble’ located in Orlando, Florida.

As NIC CEO Brian Jurutka explained in his opening remarks, “We are now approaching the fifth month since the coronavirus was declared a pandemic. The country has moved from the crisis response phase, where we pulled back from business as usual, to trying to resume activities that were shut down as we await developments in vaccines and treatments for the virus.” As different sectors approach reopening, there is the potential to share critical lessons, innovations, and experiences across industries.

Sri Kosaraju, Governing Council, Testing for America, expressed the importance of testing, saying, “all of you are obviously dealing with this every single day, and it’s critically important to what you do, and the intent of this, from our perspective, is for it to be a resource, and to be helpful to you in this hour.” Testing for America is a nonprofit “established by leading academics, engineers, and entrepreneurs to solve the COVID-19 testing crisis.” Their volunteer members include leading experts and industry leaders in the science of testing.

The bubble

Kosaraju, who stepped down as president of global healthcare company Penumbra (NYSE: PEN) to focus his efforts on Testing for America, has been working closely with fellow panelist Robby Sikka and the NBA for months. Robby Sikka, an anesthesiologist by training, is the founder and CEO of Sports Medicine Analytics Research Team (SMART), an organization that has assisted numerous NBA, NFL, MLB and NHL clubs with injury data, return to play planning, and player evaluation and development. He is VP of Basketball Performance for The Minnesota Timberwolves, and has been working more broadly with the NBA to develop protocols to protect players and staff from infection as they plan to reopen their season. He described what he calls the NBA’s “bubble and mini-bubble” approach to preventing the spread of COVID-19, which he said could be used within seniors housing and care communities.

The NBA’s approach is to have each team separated into its own mini-bubble within a larger bubble, so that they can train and play together, whilst retaining distancing and protocols designed both to protect from outside, and from bubble to bubble. Sikka said it has been well-documented that the league “went from a 10% positivity rate in the first week amongst players to 0% in the last two weeks. And the reason is, they had mini-bubbles.”

Sikka described a number of approaches that have helped achieve that result. Between June 23 and July 7 the NBA tested every other day. “Your testing cadence really matters because you may not have testing every day. You may also have delays.” When test results are delayed, he assumes there are positives and acts accordingly. “We’re seeing anecdotally its not just the games that are putting players at risk, but group activities. We’re seeing it in baseball and soccer… there are too many things where sharing air in small, confined spaces are leading to outbreaks.” He discussed travel on aircraft and busses, and other instances of close confinement causing outbreaks.

The NBA’s system is a phased approach to allowing players to interact, beginning with social distancing protocols, then increasing levels of testing as teams allowed individual workouts, whittling down the pool of uninfected players until there was a high assurance that it was safe to practice and play in groups. With a COVID-free group, the NBA added rapid testing to their protocol. Today, as the teams prepare to play each other, each team’s mini-bubble practices strict protocols, minimizing exposure, and decreasing the chance of spread. Sikka pointed out that in this system, it is not necessary to test all staff, while observing the bubble system protocols, which strictly limits potential exposure and keeps teams isolated.

Even players’ families must abide by the system. They must test every other day for seven days prior to entering the NBA bubble in Orlando. Once in the bubble, they must quarantine for another seven days, before being able to stay with their loved one. Staff are not allowed visits from family. The organization also enforces a test protocol for anyone reentering the bubble after traveling beyond it, requiring negative results on at least two tests over a 72 hour period prior to gaining entry. “We’ve saved a ton of money because we haven’t spent a single penny on cleaning our building at all,” Sikka said, explaining that with the protocols and testing, they only need standard cleaning. According to Sikka, the protocols are preventing infiltration of the virus, despite rising infection rates within the community outside, and even some positive tests amongst family members.

Sikka also emphasized the critical importance of mask compliance to the program’s success. It is strictly adhered to, particularly to keep mini-bubbles from potentially contaminating each other within the larger bubble. “You don’t need to have a perfect test if you have good communication and compliance with masks,” he said.

Saliva testing

The NBA is funding a study with Yale University, which has developed a $1, reagent agnostic saliva test that can be pooled. According to Sikka, the test may be about two weeks away from gaining FDA “Early Use Authorization” approval, which will allow labs to begin using the test more widely. He envisions labs across the country soon being able to provide saliva tests at scale, and suggested, while not every resident may be able to produce saliva, the test could be used for all staff and visitors, and many residents. “This is a cheap, asymptomatic screening test that can be run rapidly,” he said. Without the need for swabs and for more time-consuming lab work, the test would be quick, comfortable, and lower-risk to administer. He claimed the test is “90% sensitive compared to nasal pharyngeal swabs.”

NIC Leadership Huddle 
Coping with the Pandemic: Shifting from a Sprint to a Marathon

Aug 13, 2020, 11:00 AM EDT

REGISTER NOW

Wearables and contact tracing

Another innovation in use by the NBA involves wearable devices, such as the Apple watch, Oura ring, and Fitbit – all devices that the NBA has selected to work with. Already hugely popular, millions of Americans are wearing such devices already, and have smart phones that can enhance the devices’ capabilities. The NBA is using wearables as proximity trackers as well as a means to perform contact tracing. Wearables are promising to be able to detect subtle temperature changes, and to thereby detect a COVID-19 infection up to three days prior to other symptoms appearing. Data from these devices can be used to track and screen groups of people, and to identify higher-risk individuals over larger populations. Proximity tracking can warn a wearer that they are too close to other individuals for an extended period of time.

Other considerations that Sikka commented on ranged from activity and social gathering protocols, to having the “guts” as an organization to make tough decisions. The NBA is ensuring disposal of playing cards after they are used, and prohibiting doubles play in ping pong, among other steps to ensure safety while allowing limited social interactions. While the organization is less focused on facility cleaning, they believe ventilation “is probably not appreciated enough,” according to Sikka. He also emphasized the importance of early quarantines and early testing, saying, “I will not let someone in my building if they are not tested.”

Contact tracing, according to Sikka, is also essential. “We have 100% compliance on contact tracing and 100% compliance on wearables, and this is because we’ve forced our folks to really understand, hey, this isn’t just about you. This is about everybody else. It’s not about us trying to control your behavior but it is about you participating in a group that really needs every person to step up. We cannot have weak links” he said.

The importance of testing

Kosaraju provided an overview of where we stand on the development of testing for COVID-19, referring to three phases of development. The initial “shutdown” phase saw development of the first tests, such as PCR (polymerase chain reaction) and Isothermal nucleic acid amplification, which require a significant amount of lab work. As we enter a gradual reopening phase, according to Kosaraju, “Not only do we need more testing, its our view that we need to make smarter decisions about testing.” He described using testing as a screening tool, and incorporating testing into the environment, not only for the sick, but to detect potentially asymptomatic carriers. That will require testing more people, and therefore a development of technological capabilities. Once vaccines are “available and effective,” testing will enter a new phase, in which they will help monitor and protect against future outbreaks.

Today we need more testing, and to get tests to the right people, according to Kosaraju. Challenges include mixed messages on the need for testing, and a lack of a centrally coordinated plan that addresses COVID-19 and potential future pandemics. He underlined the importance of providing “accurate, affordable, and rapid” testing, saying, “waiting 7 days for a turnaround time defeats the purpose, if not making it worse.” He then outlined the advantages and disadvantages of today’s testing technologies, as well as new approaches that are being investigated and may soon become more widely available, such as the saliva test in development at Yale. “We’ve come a long way in testing…testing technology is improving. We are making improvements to make it faster, more scalable, rapid, and more cost-effective, ultimately. We are heading down the right path.”

Jurutka posed a few questions submitted by the webinar audience. The first centered on whether and when the saliva test in development at Yale would become approved, and widely available. In response, Sikka pointed out that the protocol for the test is open-source, and publicly available. The test is awaiting the FDA’s Early Use Authorization, which will enable labs to begin using the test, but Sikka expressed hope that a “clear verification” step can be waived. “We’ve seen a negative predictive value that’s equivalent to swabs…we’ve also seen, in a hospitalized population set, 94% sensitivity…so for a screening test its really a perfect test.” While the test will cost $1-2, he suggested a commercial lab will likely mark that up.

Automation, pooling, and more test runs per day will also help scale up testing capacity, on a test that is “much, much more tolerable, and safer” than swab testing. He said, “we’re not going to be swabbing for the rest of the year, we’re going to have alternative tests, and we’re going to have a lot of different tests available by December. But really to get us out of this and to help us get back to whatever the new sense of normalcy is, we’re going to have to have alternatives to swabs.”