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 4th 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.”