An emerging trend in the long-term care narrative is the renewed emphasis on home and community-based services (HCBS). Social determinants of health and non-clinical measures are emerging as key performance indicators (KPIs) among the elderly with chronic conditions. A recent Google search for “home and community-based services” generated about 4,070,000,000 results, whereas “nursing home” generated about 103,000,000 results; 39 times more for HCBS than for nursing homes. At this time, because nursing homes were seen as the breeding ground for COVID-19, there are widespread calls for more HCBS and less nursing homes.
Those of us in the long-term care sector, whether we represent home and community-based or congregate care providers (or both), need to counterbalance popular narrative with facts, data, and good professional judgment. We also need to look around the corner and anticipate the transition and implications from the service economy to the care economy.
Nursing Homes Are Essential
Despite pleas from various “advocacy” groups and special interests to the contrary, the need for congregate, long-term, medically, and behaviorally focused care endures.
It is true that demand for, and utilization of SNFs have been declining.
Utilization decreased still further as a result of the pandemic shock, but there is an underlying base of disease burden which cannot be served given the available domestic housing infrastructure, family fragmentation, and limited supply of paid in or nonpaid caregivers.
The US will need most of the existing SNF beds (15,269) for dementia-related care through 2050. General estimates suggest that as much as two-thirds of current SNF utilization is due to dementia-related demand.
A possible potential mitigating variable that could have a substantial impact on future demand are potential new treatments for Alzheimer’s and related dementias.
Nursing homes are not going away, but they do need to change. While we all recognize that drastic changes are desperately needed in the built environments, program environments, and staffing, these factors will dictate and determine how the demand is fulfilled. The need for congregate, long-term care centers staffed with trained professional nurses & caregivers will not disappear.
Assisted Living Will Be Democratized
To date, the assisted living sector has selectively targeted high-income population segments and has resisted medicalization. Both of these will change.
Democratization of assisted living will occur. The availability, affordability and accessibility challenge for the assisted living category was described very well in a recent Health Affairs article.[i] As “old & alone” becomes more endemic, society (and the long term care sector) should / will advocate for financial supplements and support to enable more of the aged population to relocate to assisted living. Currently penetration of the age-qualified markets is ~11% nationwide. Even if this increases to 20% (which the existing supply of assisted living residences would easily absorb) 80% of the age-qualified population would be resident in other locations: for example, ~2.5% in SNFs, 2.5% in CCRCs, 2.5% in Board & Care and 72.5% in their own homes. Some of these “homes” will be apartments and town homes in age-restricted housing, or so-called “active-adult” residences. This brings us to loneliness as the new epidemic.
The medicalization of assisted living is occurring before our very eyes, as more and more middle-income residents access care through Medicare Part C (Medicare Advantage). While representative provider groups and membership organizations might overtly protest, assisted living residences of today and tomorrow look like the private duty nursing homes of yesterday. Wheelchairs, oxygen, and other assistive devices will be commonplace.
Old & Alone
Most of the elderly want to and will stay where they are. Opportunities abound to connect them to what they need, and connect with them in an eco-system of supports that can be branded, as well as act as the primary sales funnel for the future survival of the sector. Social determinants of health (SDoH) should be the new key performance indicators (KPIs) for the long term care sector. An example is the Linn Health Navigator we recently developed with a client in Rhode Island. Funded in part by a Cares Act Grant, the Linn Health Navigator acts as a source of information and referral agent in the local marketplace area, identifying needs and solutions before the consumer’s condition deteriorates. Long term care providers need to get out in front of this endemic loneliness by reaching out to and engaging with the age-qualified population in their marketplace areas.
As early as 2002, loneliness among the elderly was recognized as a serious public health problem; the pandemic made this worse, and trends in housing are piling on.
Relocation among the aged, despite a short-term effect of the pandemic, has been declining and is now perhaps as low as 5% nationwide[ii]. Certainly, destinations like the Carolinas Pennsylvania, Florida, California, and Arizona will see net inward migration rates higher than this, but this is the nature of averages! In enormous proportion (and therefore numbers) the elderly will remain in their primary residences. One author noted[iii]:
“Between 2020 and 2030 , the number of households is set to rise by around 2m to 30.7m , but 35 per cent of the increase will comprise older households and , of these , 61 per cent will be one – person . The outlook is similar for 2030 to 2040 , with further growth of 1.6m in the number of households to 32.3m , with 38 per cent of the additions forecast to be older households , of which 67 per cent will be one – person . Without any change , this spells a very inefficient use of the housing stock , not to mention the health and social care implications of so many older , often frail , people living alone.”
The health and social implications of so many elderly living alone will create news-cycle narratives which simply cannot not be ignored. There will be more and more elderly seeking paid work outside the home, and other forms of community and social engagement. The “reserve army of the retired” will become the warriors of the care economy. One glaring shortcoming is that most urban and suburban environments are certainly not “age friendly”. Furthermore, the current age and means-targeted transportation infrastructure is woefully inadequate.
There’s an enormous amount of work to be done, and we must not waste time deflecting frivolous or self-dealing calls for eliminating nursing homes or preposterous suggestions that home care is the answer to everything. Please join me and others who are trying to develop serious and responsible dialogue. Contact me today and we will learn together what can be done in your neighborhood!
Irving Stackpole is the President of Stackpole & Associates, Inc. a consulting firm founded in 1991. Irving can be reached at +1 617 719 9530, and at email@example.com
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[i] The Forgotten Middle: Many Middle-Income Seniors Will Have Insufficient Resources For Housing And Health Care. Caroline F. Pearson, Charlene C. Quinn, Sai Loganathan, A. Rupa Datta, Beth Burnham Mace, and David C. Grabowski. Health Affairs 2019 38:5
[ii] A prior study in 2009 at UNC reported the level of age-qualified migration at 9%
[iii] Goodheart, C. and Pradhan, M. The Great Demographic Reversal: Ageing Societies, Waning Inequality, and an Inflation Revival. 1st ed. 2020. Palgrave MacMillan