Interconnecting Trends Reshape Assisted Living Communities work to incorporate the latest  technology into their increasingly medical model, as REITs direct more attention to the sector.  JULY 2014  Kathleen Lourde The increasing medical needs of assisted living residents, the growing pressure to incorporate technology into operations brought to bear by more tracking of quality data, the expanding investor interest in assisted living projects—these are some of the dominant trends affecting assisted living directors, administrators, operators, staff, and others involved in the profession, and one overlaps the others. More medical care is generating greater interest from accountable care organizations (ACOs) and regulators, who rely on technology to provide them with the data they need. Families want to be kept in the loop as assisted living staff struggle to navigate a resident’s treatment through the continually larger circle of providers and other parties involved in that care. Investors, including real estate investment trusts (REITs) with their escalating activity, are drawn to assisted living communities and portfolios smiled upon by the powers that be. Provider offers a look at three of today’s biggest assisted living trends: care, technology, and the world of the REITs. Care, Therapy Offerings Expanding These days, assisted living is increasingly about providing quality care beyond the traditional safer living environment it’s offered since its inception, say providers. Physician and Administrator Tim Giancarlo is president and chief executive officer (CEO) of a company founded by his physician father almost 50 years ago: The Allendale Community for Senior Living. The privately owned Allendale Community offers skilled nursing, post-acute care with an extensive rehab program, assisted and independent living, dementia care, and day care spread across 12 acres. The community features waterfalls and fountains in the suburban Allendale, N.J., community 25 minutes away from New York City. Giancarlo was literally raised to become who he is today. Many of his earliest memories are of The Allendale Community; his parents began bringing him there to be part of the community’s life from the time he was a baby. Meeting Multiple Needs Assisted living providers are increasingly called upon to provide higher and more complex levels of medical care, says Giancarlo, and providers are responding with an astonishing array of care and therapy offerings. “Caregiving is going in all kinds of directions in assisted living,” says Giancarlo. “There’s assisted living for people who are still somewhat independent, and assisted living for people suffering from dementia, and everything in between. “There’s respite care for people in assisted living. We’re dealing with more complex care these days, such as congestive heart failure, diabetes, and all kinds of conditions.” The Allendale Community’s assisted living residence, like many assisted living providers, has turned to hiring staff with higher levels of clinical training. “We’re bringing in more trained personnel,” he says. “We’re going with an all-LPN [licensed practical nurse] staff in our assisted living [residence],” and he says other assisted living providers are making similar decisions. Just managing the greater complexity of residents’ medication regimens makes the change necessary. In fact, underneath the glamorous environment, private rooms, and astonishing array of activities and social opportunities at the assisted living residence, “we are pretty much running it like a nursing home” of years past, he says. Along with physical, occupational, and speech therapy, many of Allendale’s activities serve a therapeutic purpose: the Zumba, tai chi, and karate classes, for example, or aroma and music therapies, along with a host of other wellness activities. “With the increase in [the national population’s] age, you’re seeing a rise in elderly people with cognitive issues,” says Giancarlo. “Dementia’s becoming a big sector in this industry. People are living from 90 to 100 years and are walking around healthy from the neck down, but cognitively [compromised].” Because of this, The Allendale Community provides cognitive therapies, such as its recently implemented Brain HQ program, which has been recognized by the state’s Department of Health. Activities List A Mile Long “We’re putting a lot of focus on assisted living,” says Giancarlo. “It’s all about community, so even though we’re running the assisted living facility very medically, we try to run it from an activity standpoint.” And activities are numerous. Because assisted living residents “are getting hipper,” says Giancarlo, the residence features an Internet café, game room with free video games and WiFi, 24-hour theater, 24-hour diner with free coffee and snacks, putting green, bridge room, and miniature golf, as well as a daily 5 p.m. “happy hour” with live entertainment, followed by the cocktail “hour” that runs from 6 p.m. to 8:30. Oh, and of course, a library, billiards room, and, naturally, shuffleboard. Cultural offerings include concerts featuring classical music or show tunes (as well as the live music the community offers daily), poetry readings, plays, and day-long celebrations of Shakespeare or opera. Educational opportunities are offered not only for residents but the surrounding community, such as the forums on such topics as elder law, finance, or health-related issues, as well as lectures on a wide array of subjects. Good old family-inclusive events abound, such as the annual strawberry festival and the heritage-based festivals like the community’s Filipino Festival. Time-honored activities are also abundant, such as the quilting circle, gala events such as the recent Evening in Paris, no-holds-barred birthday bashes, spiritual activities, and field trips to nearby cultural sites like the aviation museum. “There’s always something going on,” says Giancarlo. “As long as you keep [residents] youthful, I think you will keep them living longer,” while leading more fulfilling lives. Quality Focus The Allendale Community’s assisted living residence is an “Advanced Standing” facility, which means that it has been singled out by the state’s Department of Health as providing outstanding care. Achieving that status wasn’t cheap, says Giancarlo, but it was an important goal to him and his staff. “We had to increase resident satisfaction,” he says, “so we had resident and family council meetings frequently.” Although turnover is a big issue for many assisted living facilities, The Allendale Community was ahead of the game on that one. “We don’t have a lot of turnover,” he says. “We try to keep the staff happy; happy staff members provide higher-quality care.” Keeping turnover low is also important to Giancarlo because he wants residents and families to see familiar faces providing their care.   Quality indicators also get a lot of attention, he says. “We’re very active in data tracking, such as indicators like rehospitalizations.” Tracking quality data will be more and more important to assisted living providers, says Giancarlo, as ACOs turn their gaze toward assisted living. “ACOs track all that,” Giancarlo says. “ACOs are approaching us and want to make sure we have all that documentation available.” Technology More And More Important To Assisted Living For Todd Stivland, MD, owner and CEO of Bluestone Solutions and provider of onsite medical care for assisted living facility (ALF) residents, technology has become pretty much a way of life. A family physician for 19 years, Stivland oversaw clinical tool development and implementation of a Duluth clinic’s electronic health records, directed the creation of custom software for onsite care models, and serves on Minnesota state policy committees. In 2012, Stivland founded Bluestone, now the largest provider of onsite coordinated care and advanced care coordination for complex patients in Minnesota. “From what we’re seeing, the biggest trend [in assisted living] is ALFs are becoming much more of a medical model than they used to be,” says Stivland. “They’re caring for some of the sickest people in the community. There’s not much difference between assisted living and skilled nursing anymore in their complexity. That’s forced assisted living to be more aggressive about their medical model. There’s really been a big push to make the medical model more balanced.” That’s true of health care in general, and in keeping with the whole health care sector, assisted living is seeing “a boom in technology,” Stivland says. Of course, not all ALFs have embraced this trend yet, he says. “We have customers who don’t even have Internet in the building, and others who’ve installed very advanced systems.” Necessity Again Proves The Mother Of Invention One of the biggest issues in health care—one that technology has the power to solve—is the difficulty in coordinating care, Stivland says. “We have multiple organizations providing care on different [computer] systems, so getting people able to communicate with each other is a big issue.” It was such a problem, in fact, that Stivland created technology that reconciles all of these different data sources on its varying computer systems and streamlines the process of providing the data to all the parties involved. “All of the faxes and phone calls were killing us—they’re so inefficient and time consuming,” he says. “We’ve created a system where anybody involved in the care system can communicate with each other.” The system handles everything from patient monitoring to getting prescriptions filled and follow-up arranged. “For instance, say the nurse at the ALF goes to see a resident and finds he has a bladder infection,” says Stivland. “She would send the information to us—the symptoms and that she wants a urine test.” The Bluestone doctor receives the information on a smart phone that’s kept near at all times; reviews the information; and, if a test is warranted, sends an electronic order to the lab. “The lab goes out to draw blood for the test. The results come back to us, and we send them to the nurse. We then order the antibiotic.” If the family chose to be informed of health-related activities, Bluestone sends a note to the family saying the loved one has a bladder infection, specifies the manner in which it’s being treated, and asks if they have any questions. If they do, the doctors at Bluestone answer them. The system, Stivland says, “keeps everybody in the loop and allows us to treat people very quickly. We turn orders around a lot of times within minutes; always within two hours.” Bluestone now provides easily accessed physician services to 4,000 patients, 180 ALFs, and more than 100 home care agencies. Even without any marketing, Bluestone has sold the system to four other local practices, and others are considering a purchase. The system was developed over eight years in close consultation with technology companies that make assisted living-specific software. The effort required a $2 million investment. “We were just doctors who couldn’t keep up with the phone calls [and developed the system] out of necessity,” Stivland says. “We never intended to sell it, but other people saw it and wanted it.” The needs of the elderly are inspiring more than just Stivland.  Tech Innovations Fostered The first Aging 2.0 Global Innovation Summit was held in San Francisco in mid-May and brought a select group of technology innovators together with investors and seniors housing providers. The Aging 2.0 summit was organized by Generator Ventures, founded by Katy Fike, a 35-year-old gerontologist and former investment banker, and Stephen Johnston, a 2002 Harvard Business School graduate. Generator Ventures’ other program, called Aging 2.0 Generator, takes a few hand-picked technology innovators and works with them for six months to help them develop their ideas into companies with marketable products. The six-month effort is housed in a senior center—the Bay Area nonprofit Institute on Aging, which provides services for thousands of seniors every year. That gives innovators unique research opportunities as they develop their products. The Generator program also provides customized curriculum designed and delivered by industry leaders and facilitates the innovators connecting with investors, distributors, senior care providers, and press. The program culminated with the Aging 2.0 summit, which was also attended by 30 new innovators hoping to get into the next Generator program. The Aging 2.0 Innovators Among those 11 select companies and products developed through Generator and featured at the summit were: ■ Pixie Scientific. Pixie is developing patches that can be put on the outside of a senior’s diaper. When the diaper is soiled and removed, the caregiver can scan the patch and upload information about the senior’s health condition, such as indicators that a urinary tract infection is developing or the senior is dehydrated.  ■ Life2. This company is developing a database and program based on predictive analytics that aim to predict which residents are likely to develop specific health issues, such as pulmonary problems. The information would alert staff to keep an eye out for a list of early warning signs and tell them why the resident is at heightened risk. The program would also provide information on what can be done to mitigate the risk. ■ Jibo. This company hired a Massachusetts Institute of Technology professor to help develop “emotional robotics.” The goal is to develop a robot that a senior can interact with and that will appear to respond with human-like emotions to the senior. The robot would act both as a companion (assisting with crossword puzzles, for example, or helping the senior use the Internet to connect with family members) as well as an entity that provides services like medication reminders and diet and exercise monitoring. The idea is to provide this technology for about the cost of a laptop computer. ■ Lift Hero. This is a service that allows seniors to request a ride via the Internet or phone. Drivers, who are prescreened, off-duty EMTs and other medical professionals, pick up the seniors, drive them to their locations, assist them inside, and then return them to their homes and help them get situated there again. Rides can be ordered when needed or be pre-booked. Standing arrangements may also be made. ■ Lively. This is a system of activity sensors that wirelessly transmit information about a senior’s activities to a Web-based app that a family member can check regularly to make sure the senior is up and about and engaging in his or her routine activities. Other Brilliant Tech Ideas Stanford University, in collaboration with Aging 2.0, issued a design challenge from its Stanford Center on Longevity last year with the goal of identifying students around the world with great technology-based ideas useful to seniors, and to help students refine those ideas. Among the finalists was Ritika Mathur from the Copenhagen Institute of Design. Mathur’s idea, called Memory Maps, would combine a device with a radio frequency identification reader with a map of the senior’s neighborhood and global positioning satellite technology. The device would be used by someone with early-stage dementia or other cognitive problems. It would allow the senior and his or her family to actually record memories associated with the map and “pin” them to map locations. Another finalist was Huabin Kok from Singapore National University whose idea is called Taste+. This is a spoon with electrical stimulation that would be used by someone whose taste sensations have been diminished (common with dementia). By tapping a button on the spoon, the device provides a simulated salty or sour flavor when the user puts the spoon (and the food on it) into his or her mouth. Investment In Seniors Housing Surging REITs have been significantly expanding their portfolios this year, investing considerable money in assisted living, say industry watchers. REITs can offer seniors housing providers a cost-effective monetization option, making capital available to help them take advantage of growth opportunities or build a hedge against risk. And although in the past REITs were reluctant to be involved in new construction or turnarounds, their greater access to capital has made them more flexible in this regard, especially when it comes to seniors housing companies they’ve partnered with successfully in the past. The fragmented, $2 trillion health care real estate market is benefiting from competitive capital costs and demographic trends, among other factors. Investor interest will continue to grow, extending the seniors housing recovery into next year, according to Beth Mace, chief economist at the National Investment Center for the Seniors Housing and Care Industry, Annapolis, Md. There are several reasons for her optimism, including improvements in the volume and prices of home sales, stock market performance, and consumer confidence and income. And as the number of people over age 80 grows through the next decades, the number of middle-aged family caregivers will shrink, according to a recent AARP study. Today, the ratio of caregivers aged 45 to 64 to people over age 80 is 7:1, the study showed. That ratio will drop to 4:1 in 2030 and to less than 3:1 in 2050, the study found—a decrease due not only to the aging of the baby boomer generation but also to younger women having had fewer children. Big Health Care REITs Getting Bigger Ventas, a Chicago-based REIT, is already one of the largest health care REITs in the country, and it will soon be easily the biggest if its plan to acquire competitor American Realty Capital Healthcare Trust (ARCHT) is approved by ARCHT shareholders. The offer was announced in early June. In fact, Debra Cafaro, Ventas chairman and CEO, said in a video interview at a New York City investor forum that the move will make Ventas “the leading senior housing franchise globally.” Ventas has now purchased at least three health care REITs, according to The Seniorcare Investor, published by Levin Associates, based in Norwalk, Conn., and the publication’s editors expect Ventas won’t stop there. The unsolicited $2.6 billion deal has been approved by both boards of directors and is expected to close in the fourth quarter. The announcement caused ARCHT’s stock price to rise by 11.1 percent, while Ventas’ dropped by 2.2 percent. Ventas also plans to acquire 29 Canadian independent living communities from Holiday Retirement in a $900 million transaction expected to close in the third quarter. The properties will be managed by its portfolio company, Atria Senior Living. Ventas is recording notable gains in its funds from operations, Cafaro said at the investor forum, arising from productive assets, refinancing at lower interest rates, and the company’s development and redevelopment efforts. Another Company Expands Into Market Another of the largest health care REITs, Health Care REIT (HCR) based in Toledo, Ohio, also made a significant move in June, completing a $1 billion public offering. HCR plans to use some of the money to increase its investment in seniors housing and other health care properties. During the previous month, the REIT sold 14 million shares at $62.35 per share and announced that it has signed preliminary agreements to acquire $414 million of seniors housing and medical office properties during the second quarter. HCR also announced in May the purchase of a 46.8 percent interest in a 10-property Senior Resource Group package. Those properties are in California, Arizona, and Oregon. In April, Irvine, Calif.-based HCP announced a $1.2 billion entry-fee continuing care retirement community (CCRC) joint venture with Brookdale Senior Living. The 49 percent ownership would give HCP the largest CCRC package of any health care REIT in the country. Mid-Range REITs Active Griffin-American Healthcare REIT, a public, nonlisted company that claims 73 acquisitions comprising 286 buildings, has an approach President and Chief Operating Officer Dan Prosky describes as “rifle shot”—as opposed to the larger REITs’ “shotgun”—approach to acquisitions.  Last year, Griffin-American completed $1.5 billion in small acquisitions. Nontraded REITs like Griffin-American have been very successful with raising capital and, therefore, are aggressive purchasers of property, according to analysts. For example, Griffin-American has raised almost $3 billion in the past four years, and its investments haven’t stayed solely in the United States. Griffin-American acquired a $472 million seniors housing portfolio from London-based Caring Homes Health Care Group last year. Prosky doesn’t anticipate as much activity this year, but cites the company’s lack of debt and high percentage of mortgage-free properties as conducive to further acquisitions and development. Industry watchers were anticipating the acquisition of Griffin-American itself. A Wall Street Journal story in May listed four companies vying for Griffin-American and predicted a price tag in the $3.7 billion range. Some analysts saw ARCHT as the front-runner, with Ventas close behind. But now that Ventas has announced its plan to purchase ARCHT, guessing is the name of the game again. Nontraded REITs aren’t the only active players in the mid-range, though. Chicago-based Aviv REIT, which is public, has announced a new $600 million credit facility that can be expanded to $800 million. Analysts are predicting the company will use the money for acquisitions. Small REITs Move Up—At Their Own Pace The smaller health care REITs are also quite active, although less likely to purchase whole portfolios of properties.  ■ Sabra Health Care REIT, Irvine, Calif. Sabra sold 7 million shares at $28.35 per share earlier this year. The company plans to invest between $350 million and $450 million this year, according to Chairman and CEO Rick Matros. ■ CNL Health Care Properties, Orlando, Fla. CNL’s credit facility, increased in May from $120 million to $275 million, will likely result in portfolio growth, especially since the line of credit has the option of being expanded to $325 million. “The initial line of credit has helped us substantially grow our senior living and health care portfolio over the last several months,” says Stephen Mauldin, CNL’s president and CEO. “The expanded facility will further assist us in taking advantage of compelling investment opportunities as we continue to broaden and diversify our portfolio.” ■ National Health Investors, Murfreesboro, Tenn. NHI acquired an assisted living community for $11.5 million in April, but its long-range goals don’t include growing itself into a large REIT, according to President and CEO Justin Hutchens; rather, NHI takes pride in its attention to prized, quality customers. ■ CareTrust REIT, Mission Viejo, Calif. As of June 2, a new health care REIT has entered the field: CareTrust REIT. CareTrust is a spin-off of The Ensign Group and owns substantially all of Ensign’s properties. CareTrust is now trading on the NASDAQ. Global Select Market. The Ensign Group is now the operating company.  Kathleen Lourde is a freelance writer based in Dacoma, Okla.