CCRCs, ALFs, and Private Equity: John Burton, Bill Applegate, & Melissa Aldridge

Eric 00:13

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:18

This is Alex Smith.

Eric 00:19

And Alex, who do we have with us today?

Alex 00:21

We have an honored list of guests today. I’m going to start with Bill Applegate, who’s a geriatrician and a palliative care doctor, former editor in chief of the Journal of the American Geriatric Society, or JAGS, and in that capacity recruited both Eric and me to the Journal, and is a retired faculty at Wake Forest. Bill, welcome to the GeriPal Podcast.

Bill 00:46

Thank you.

Alex 00:47

We’re also delighted to welcome John Burton, who’s a geriatrician and formerly director of the Division of Geriatric Medicine at Johns Hopkins for 35 years. John, welcome to GeriPal.

John 01:00

Thank you. It’s an honor.

Alex 01:02

And we’re delighted to welcome back Melissa Aldridge, who is a former banker turned health services researcher and is vice chair of Research at Mount Sinai School of Medicine in the Department of Geriatrics and Palliative Medicine, and is also one of the ascent, which is this national research network, multiple principal investigators. So, Melissa, welcome back to GeriPal.

Melissa 01:25

Thanks for having me.

Eric 01:26

So we have an exciting podcast. This is a little bit different. We’re going to be talking about transitions a lot in geriatrics and palliative care. We think about transitions from home to different living environments. We’re going to be talking about that today in this podcast to CCRCs or continuing care retirement communities, assisted living facilities, and also hopefully get some idea of kind of who. And that’s why we have Melissa on this podcast who and how these are being financed, including in these other transitions, like to hospice. But before we do all of that, which is a lot, I just realized, I think we have a song request. Melissa, do you have the song request for Alex?

Melissa 02:07

I do. I’d like to request Live Like You Were Dying by Tim McGraw.

Eric 02:12

Why did you pick this song?

Melissa 02:14

It sounds pessimistic, although the lyrics are not. And it’s just about living life to your fullest, or at least trying to, wherever you are.

Eric 02:23

Wonderful,

Alex 02:37

(singing)

Eric 03:43

Wonderful song. Thank you, Melissa.

Alex 03:46

Great choice, Melissa. I think that’s the second time we’ve done it, but I do like we’ve done over 400 so that’s a song that you’ve done. I know, but we’ve done over 400 so I think occasionally it’s okay to return to songs. And we do get this request has the word dying in the title. Any song with the word dying is likely to be requested multiple times in the J PAL podcast. Thank you, Melissa.

Eric 04:09

So again, this podcast is a lot about transitions. I’m going to start off with you, John. You wrote a manuscript for JAGS titled Waiting for the Other Shoe to Drop, talking about your transition into a CCRC or continuing care retirement community. Can you tell me why you decided to write this article?

John 04:31

Well, it was in my mind and I thought it would be a good thing to share with people. Recall it was written during COVID so a very different time in the history of transitioning into to retirement communities. Unusual because everything was isolated and you couldn’t suddenly become a real member of a large community. But once you get through that, there are very many, many, many advantages as you get older. It takes a whole lot of burden off your kids from worrying about you. My wife, for example, fell and fractured her pelvis about three or four years ago and simply can’t get around without a rollator and can’t use stairs effectively. So.

Eric 05:24

And you were living in a big Victorian, is that right?

John 05:29

Yes. Yeah. Yeah. So it goes around, comes around a little bit. But CCRCs are communities of people who realize they’re aging and realize that they want to take potential burdens away from kids and have access to all things in healthcare without having to drive across the town or across the Hank County.

Eric 05:51

And John, can you describe what a CCRC my understanding and I think this is great to have somebody who’s actually living in it is it’s kind of the full spectrum from independent living to all the way to assisted living or nursing home level care that you kind of buy into, correct?

John 06:09

Yes. So it’s continuing care retirement community. You can live in the community and in a cottage, which is what we do, or in a high rise apartment, which is available on this campus. And it’s just like you are living that in a regular community, except all your neighbors are older. And you end up suddenly realizing you go to more funerals than you do anything else because only old people are coming in. So you miss that connection with youth. But most people have families in the neighborhood, families are coming to visit.

So you see young people all the time. But the advantage is one campus. All care needs to walk to the dining room. It’s a little bit like being a freshman in college. You go and eat with folks and share issues, share histories. And I’ve enjoyed it because I met a lot of people who are not physicians. All of my friends before that time pretty much were physicians and local neighbors. But here I’ve met philosophers, engineers, aircraft designers, and it’s just a fascinating daily encounter with people who are trying to age effectively.

Eric 07:34

What surprised you the most as a geriatrician about this transition from living in your Victorian house to this ccrc?

John 07:43

It’s a bigger shock than I thought because suddenly, almost like throwing an electric switch, you are in a totally different environment. Nobody’s doing any cooking anymore. You go up for meals, you walk to the swimming pool, you walk to the gym, you walk in the neighborhood. You participate in many of the various activities. For example, I’m involved in the wood shop here, which has, I may be 15 or 17 members doing all kinds of repairs for people’s chairs and doing other things like that. So it’s an engaging, enriching environment from that point of view.

Lots of new friends talked this morning for about an hour with a person who taught history in high school, and we discussed how he would be teaching about current activity, current history, as it’s unfolding. So it’s just fascinating, engaging, intellectually challenged, more to do than you can possibly go to. There’s a special lecture almost every day, really, and musical groups come in. So it’s been very interesting and exciting.

Eric 09:03

Did you ever have that regret moment of like, oh, my God, what did I get myself into before, like, feeling like, oh, this is actually quite nice?

John 09:11

Well, again, the COVID issue spoils the answer to that question a little bit, because you were isolated and you had to stay in your room and they brought food to you, so. But once that was over, the joy is really being in a neighborhood of people who are interested in education, interested in all kinds of activities, and meeting them on a fundamentally a daily basis. It’s like going to a small college on a little island in Chesapeake Bay, and everybody Kind of understands the issues, but everybody has a different history.

Alex 09:51

If I could reflect, there’s a somewhat disconnect between the title and content of your Jags piece, Waiting for the Other Shoe to Drop, which talks about the sort of homogeneity of people at the facility in terms of class and educational background, in terms of the sense that people were seeing each other grow ill, get sicker, die, and that. That the tone of your piece was much more. I don’t know if despairing is quite the level, but ruminative. And it’s sort of more negative connotation than the. What you’re describing now in the podcast.

John 10:30

Any thoughts on that? That’s true. And again, I think it was related to the time and the problem of the pandemic that we were in and the isolation and the absence of people coming to visit you. So you kind of felt isolated. That’s all gone away. And now we’re connected with the community living north of Baltimore. We’re involved with a local high school.

Eric 11:00

So you actually see some younger folks there?

John 11:03

Yeah. Oh yeah, yeah, yeah. I’m an advisor to a couple of freshmen in high school at one of the local schools. They come here and chat. What is it like to be old? That kind of thing. And then you. We go to the school and they make presentations and we talk. So that kind of thing is very engaging. There’s a very active group in environmental issues.

Eric 11:30

And can I ask, John, how in general is CCRC paid for? So I’m guessing you give a lump sum and then you have a monthly fee. And then if you need more help, do you have to pay extra help? Do you know how that works? Like if you need more of these systems?

John 11:46

Yeah, yeah. The CCRCs were pretty much invented in the 70s, late 60s, and Broadmead where I live was the first in Maryland in the late mid to late 80s. And at that time it was all pay up front. Nowadays you pay a major entrance fee and then you have a monthly fee. Nowadays more than half the people have long term care insurance, which changes the dynamic. So if you have long term care insurance, you don’t need to be having the organization be the insurance company for you for all levels of care.

So in my case, long term care insurance for a number of years, you pay a much smaller entrance fee and a much smaller monthly fee, but you have to pay for long term care if it goes there or things such as that. Fortunately we’ve not had to use that. So Medicare covers certain things. For example, rehabilitation, which if you go you have a fractured hip and you come back, then you go to the rehab unit that’s covered by Medicare. But in my case, if I had to go to a long term care, couldn’t care for myself anymore or something like that, then my insurance would start covering after I think it’s 30 days, something like that.

Eric 13:24

And if you didn’t have insurance, you would just be paying for that out of pocket.

John 13:28

Well, you’d pay it. The two forms of payment are the all inclusive big entrance thing and a big monthly fee. Then it’s covered by the institution. In this case broadmeat or in mine it’s kind of an a la carte, smaller entrance fee, smaller monthly fee. But if you need additional care, you’re paying it out of your own insurance or out of your own pocket. Okay, so that’s the change that’s happened in recent years with the movement in long term care insurance.

Eric 13:59

And do you know who owns your ccrc? Do you know anything about the ownership structure?

John 14:05

Oh, yeah, yeah. It is a not for profit organization formed by a group of Quakers, really from Pennsylvania. I’m not a Quaker and maybe only 20 or 30% of the people here are Quakers, but not for profit organizations have formed these. There’s a lot of for profit organizations have gotten in this business too, but a lot of.

Eric 14:32

We’ll talk about that.

John 14:34

Okay. A lot of them are not for profit and they can’t lose money. So it is a business and the fees are high. But. But in my experience, the fees are less than what it costs to live independently in Baltimore. If you talk about maintenance of the house and insurance of the house and stuff like that, it turns out to be a little less much to my surprise and my dower paper, the other shoe to falling was really had to do with the isolation that was necessary at the time. And I think I changed that tone a little bit now. People come in now and they don’t seem to have that what have I done kind of thing that happened during the isolation and isolation was serious business. They brought your food in a paper bag every night. Yeah.

Alex 15:35

I’m glad to hear that things have improved so much, John. Thank you.

John 15:38

Yeah.

Eric 15:38

Well, I wonder if we can hear Bill your story. So you wrote another paper in Jags and this one was my Journey Through Assisted Living Facilities. Can you tell me why you decided to write this article? We’ll have links to both of these articles in our show notes.

Bill 15:54

Well, a lot of the things that John has said would apply to me, but I will say that assistive living is a much more. More depressing and sort of a place where you don’t want to be if there’s any way you can get out of it. So fundamentally, when I went to assisted living, I’d had a bad fall, I’d had a brain bleed, I had broken hip and a broken shoulder and I was delirious. And for really, for better part of a year or so, I was delirious.

I required either a rollator or other sort of assistance device to get around. I really required a wheelchair. I couldn’t really get around independently. And so what John said about them bringing food into the room rather than going to a situation where people would eat together and share some social activities. In the sister living facilities I was in, I only got food brought in and there were no social activities for me. And the other, what I would call us all inmates.

Eric 17:19

Was this in Covid era, is this kind of post Covid?

Bill 17:23

This was definitely post Covid.

Eric 17:25

Post Covid.

Bill 17:26

In general, when you think about it, efficiency care living facilities are at least half of all long term care facilities or institutions in the country. That’s what the data are, at least half. Okay. Now in these facilities they’re very much like how we always have thought of nursing homes in the past in terms of the services they provide and the quality of the staff. Generally what I found in assisted living is that there are no regulations that require, for instance, a chief nurse or a medical director.

Some assisted living facilities do not necessarily care for people as debilitated as I was. So there’s great variability in the quality of and what you can say about assisted living facilities. But more and more assisted living facilities are going to be like think of the nursing homes of old. The doctors are often not present. Yeah, often not a head nurse. And the nursing staff and other aides are, shall we say, spotty.

Eric 18:44

And can I ask Bill, how, how was the decision made, do you know for you from to go from the hospital to either a nursing home or assisted living facility?

Bill 18:54

Very simply, you know, with my fall fracture and other things, I was very debilitated. And recall I said that I was delirious. Now I had have normal pressure hydrocephalus. And so I was pretty much cognitively debilitated very. For over a year.

John 19:18

Yeah.

Bill 19:18

And you know, you would view, anyone would view me as sort of demented or pre dementia. My ability to care for myself was very limited. So my ability to get out and do things. My wife came to my room at the assistant living facility almost every day and was involved in my Feeding. She actually hired some people to come in and help me with mobility.

Eric 19:47

But do you know. Do you know how they chose to send you to assisted living facility versus a nursing home? Like when that is.

Bill 19:54

Yes, I do. Here’s the interesting thing. And I dealt with some of this as a clinician when I went through the fall and delirium, et cetera. If you look at the assisted living facilities that I was in, they look very much like nursing homes. They look very much like federally evaluated and mandated sort of quality nursing homes. But there is a big difference in that assisted living facilities are only beholden to state level regulation, whereas standard nursing homes are beholden to federal regulation. I promise both as a clinician, but major as a patient.

The lack of federal oversight of assisted living facilities allows them to have less staff, less able staff, less medical input. And really the patient outcomes. There’s never been a study of this. The patient outcomes are not so great.

Eric 21:03

Do you regret going to an assisted living facility versus a nursing home?

Bill 21:08

I do, but regret is a good word in a way. I was so delirious.

Eric 21:14

Yeah.

Bill 21:15

And I don’t think, you know, some of the doctors who decided to send me to these places really understood the difference between assisted living facilities and skilled nursing facilities. I tell you, there should be a major national study. This is a great study waiting to be done. And that is the level of care. The outcomes clinically of patients in assisted living are worse than the ones in either regular symptoms. And very little has been written about this. It’s astonishingly horrible.

Eric 21:55

You know, go ahead, John.

John 21:58

I was just going to mention that assisted living is a form of long term care. And I think it’s a little different in each state how it’s funded.

Bill 22:07

You’re right.

John 22:08

And the requirements. But I think Bill’s absolutely right. As a group of facilities, they generally are understaffed compared to a nursing home. At Broadmead, for example, there are all levels of care. I’m in independent living, which is living in an apartment like a community. But on our campus we have an assisted living facility that certain requirements to get there and certain staffing.

I think it’s probably higher than in the community. And we have subacute care and we have rehabilitation care and we have memory care for people whose care problem is primarily memory. So. So that’s a little variation of the theme. All different kinds of care that I think are more or less state specific. And assisted living is pretty dominantly a Medicaid program in Maryland.

Eric 23:11

Assisted living or nursing home?

John 23:15

Assisted living. Nursing home is Much more Medicare because the rehabilitation stuff.

Eric 23:22

Oh, okay. So for short stay rehab, we’re looking. Medicare paying for. Medicare doesn’t pay for long term care, so they don’t pay for any of this. Like in California, I know for, for if you have Medicaid, it’s largely snf, so skilled nursing facility, nursing home, and a lot of our assisted living facility is private pay. So it’s kind of the, the wealthier people go to assisted living facilities, but it’s this largely unregulated institution, poorly regulated,

John 23:48

and unless it’s incorporated into an all inclusive institution like a continuing care retirement community. But assisted living isolated. I’ve been in assisted livings that had three patients in somebody’s home. I’ve been in assisted livings that had 40 patients. But generally they’re small, they’re under regulated, and mostly you pay out of pocket. So people very quickly go from self pay to Medicaid.

Bill 24:24

That is correct.

John 24:25

Thank you, Bill.

Eric 24:28

Melissa, were you going to say something?

Melissa 24:30

Yeah, I was just going to say I think one of the things that’s interesting about hearing your experiences with this is it demonstrates some of the areas that we talk about more theoretically of where we have to be careful around ownership and where we have to be careful about quality. Because you both mentioned that in this transition period, first of all, it can be chaotic. Like you said, Bill, you weren’t even able to kind of be part of this decision about where you went.

Bill 24:59

Right.

Melissa 24:59

And it’s not only that, but you don’t really know what to expect. Right. And so you’re paying for something. You kind of think you know what it’s going to be like, but you don’t really have a way to judge once you’re there whether you’re getting the services that you were supposed to be receiving or the care or whatever it is. So it’s one of those areas similar to hospice, which I’ve studied, which has some of these unique characteristics about the transition that you think about.

That’s very different from getting like an outpatient visit or hospital service where you do it multiple times, you know what to expect, you know, and there’s some guardrails around the quality. So these personal experiences are really. Interesting comment.

Bill 25:42

What you just said is absolutely correct. I want to say again that our field of geriatric medicine and in general healthcare and medicine in general do not understand the limitations of assisted living and how assisted living facilities are often thought of in the same breath as nursing homes. And neither are great. In assisted living, the oversight, the supervision sort of where the money comes from and the type of care that’s provided.

There’s not been a sufficient enough study on a national level. And also the other thing a study could look at is that these facilities, I’ve looked at this, they have a way of presenting themselves, ads and other things as if they’re a high quality. I’d say nursing home. And they really mislead the public and older people with a lot of disability. And this is my way of thinking, something that really needs to be further

John 26:51

evaluated and needs to be figured out, how to finance it properly. Right now it’s kind of a loose element that doesn’t fit into anybody’s category. So it’s not rehabilitation, it’s not Medicare. You gotta either self pay or you become poor enough to cut Medicaid.

Eric 27:13

And that’s if you’re in a state where Medicaid pays for assisted living, which again, I think you have to get a specific waiver. It’s like, it’s really, really complicated.

John 27:20

Yeah, but that’s the reason, the, precisely the reason that continuing retirement communities are taking off. Because now as part of our payment, we have assisted living, we have memory care. Medicare jumps in if we need rehab. So the continuing care retirement community business, which is growing rapidly, much of it is not for profit, but there are some profits that kind of are doing all of the care and orchestrating it to try to get control of it.

Alex 27:56

This is a perfect segue. Melissa was at ucsf, gave a grand rounds about the rise of private equity and really described the uptake of, I don’t know what, the growth of rapid growth of private equity across many fields, the financing and when you think, you know, we, we had Melissa on previously in a podcast with Lauren Hunt and I think Claren Kuda about private equity gobbling up hospice. And what I loved about the grand rounds you gave here at UCSF was it described the bigger landscape of like how, what, what are the motivations of private equity?

What are they doing here in terms of acquiring companies, breaking them up? How do they make a profit? How do they finance these acquisitions? What’s going on with the mergers? Vertical and a horizontal. We don’t have time for 40, 50 minute grand rounds. But we’d love for you to give our listeners some sense of what’s behind this growth. Because it’s not just in hospices, it’s happening in assisted livings, it’s happening in nursing homes as well.

Melissa 28:55

Yeah. Thank you. Thank you. Yes. So I think private equity, of course, is not new and its entrance into health care is also not new. However, it has transitioned over time in some interesting ways. I mean, the first investments of private equity in health care were in areas that were very removed from patient care, Things like labs or imaging centers and things like that. Around the 2000s, it moved into hospital care and some specialty care, Kind of getting closer to direct patient care investments. And what we’ve seen over the past, say eight to 10 years or so, but more like eight years is really investments in hands on patient care companies like hospice, like home health, like behavioral health, where you’re really looking at very vulnerable patient populations.

And so I think that that’s a big transition and it’s something that people need to be aware of. We’ve studied a lot about the differences between for profit and nonprofit healthcare providers. John mentioned he was at a nonprofit. More than half of assisted living facilities are for profit. And we see very different patterns of care, different access to care, different quality of care. And private equity is kind of an extension of that. There’s a lot of work now to try to understand its impact on patients and families. But it differs kind of from a regular for profit investment in two ways. It’s first, a short term investment. A company comes in and invests in something like an assisted living facility and wants to sell it fairly quickly, say within five years, and in that time generate a return.

How do you do that? A lot of it can be around staffing, and we were talking about that before. How much staffing can vary, not only the number of staff, but their training, their qualifications. You can change staff salary. So reducing salary, that can impact turnover. We know in the nursing home, staff turnover can be a big deal. Right? And even if you’re in assisted living, maybe you have like a home health aide or something like that. When that person turns over, it’s very, very difficult to kind of train and get used to somebody else. So those are some big impacts on patients and families. And the second thing is the private equity’s use of debt.

And so when you invest in a company, when private equity invests in, say a hospice or an assisted living facility, they do it by debt, by taking out a loan for maybe 80% of the cost of this investment. And so not only are you taking a company and trying to generate a return with the existing revenue and costs, but you’ve added this huge interest cost. So you really have to push the revenue even harder to get that return over a short time frame. And so that’s kind of the gist of how they work. And I think that we are concerned about it in areas like hospice and areas like assisted living.

Because as you both described, there’s very different regulations. It might be at the state level, it might be at the federal level. There’s a lot of opaque information in terms of who is the owner, who’s not the owner. And we don’t really have great quality metrics in a lot of these settings. So how do we even know that people are getting what they need, what they expect, or what they paid for? So there’s really a great interest in kind of understanding this emerging structure that’s in these new areas of healthcare.

Bill 32:30

Great points. Great. We need work. We need to understand. Thank you.

Eric 32:37

Bill, do you know who owned your assisted living? You lived in two different assisted living facilities, correct?

Bill 32:43

I did.

Eric 32:43

Do you know the ownership structure or was that completely opaque to you?

Bill 32:47

It was completely opaque to me. It was, you know, private sort of equity investment. But I don’t know who, I don’t know exactly how it was structured. I know it was sort of for profit investment corporations. And by the way, my physicians who referred me to these places, who I love, they’re my partners, really didn’t have as good an understanding of the difference between assisted living, regular nursing homes and other things. They really, our field needs to understand this better.

John 33:24

Yeah.

Alex 33:25

Melissa, I remember in your grand rounds, you gave an example of private equity, how they started before health care. I don’t remember what that example was, but it was like their success story of we did this and we broke up this company and we made a profit profitable in this way. And then they came to healthcare and it seems to be somewhat different, although they’re trying to replicate those experiences. Does that ring a bell to you?

Melissa 33:46

Is that stay a little more.

Alex 33:49

No. Okay, maybe not. But I worry about. What I worry about is a challenge of what worked for Bain and Co. Or whatever, some private equity firm breaking up a merchandise chain and selling off smaller parts and making them profitable, consolidating, laying off staff. We should not apply that same model to healthcare, which has a different relationship with people based on like maintaining quality of life and good health. Right. Rather than the profit motive. And what we’re seeing is in this space is like that private equity sees opportunity in these spaces with less federal oversight and regulation. And so they’re seeing opportunity in say, hospice industry. Seeing opportunity in assisted living facilities. Yeah, exactly.

Melissa 34:40

Yeah. Thank you. And I think the, the example and what you worry about also is the, the financial health of these companies after they’re purchased. And you kind of add on to them and add on to them, but you squeeze their balance sheet so much, there’s a big risk of bankruptcy. About 20% of companies, once they go through private equity investment and sale, go bankrupt, versus about 2% of other companies. And so if you think of an area where you live and you’re moving into say an assisted living facility or something, that’s part of a roll up when that company goes bankrupt, what other options do you have?

It’s different from something like a toy company or some type of other commercial product where you can just get another product or maybe it’s something you don’t absolutely need. I mean, we’re talking about where people need to live as they age. And then if an entire market, you know, if your decisions were not only moving into these spaces, but moving maybe three hours away into the space, that that’s kind of a different decision. And so it’s another type of risk in terms of the, the financial health of these types of investments.

Alex 35:50

And they’re making a bet, right? Because as you say, they take on enormous debt and they have to, they have to show returns that are greater than the interest rate that they’re paying on the debt. So their incentive is to create tremendous profits rapidly in a very short time period. And that, I think creates fundamental issues with healthcare as it’s delivered. The staffing, for example, as Bill saw. John, I think you had a comment. Go ahead.

John 36:17

I agree with all that’s been said here. It just seems to me that there’s a lot of opportunity to get this right if you get the right people into it. And how do you get the right people into it? In my view, it’s a great opportunity for major large local healthcare insurers to get into that business or even continuing care retirement communities to not just keep themselves on a campus, but begin to offer their services for people still living in the community. You got probably a lot of pushback on that, but to me it’s just an expansion of resources and just connecting a lot more with the community.

Eric 37:07

It feels like the two stories I’m hearing. Again, you don’t want to make generalizations out of two stories. But John, you’re working in a nonprofit Quaker institution, very different. Doing woodworking and going to area high

Alex 37:20

schools, mentoring high schoolers.

John 37:23

I think very different.

Eric 37:25

And it’s been around for what, 50 years, how long?

John 37:29

I could be an assisted living, but

Eric 37:32

it’s still in this nonprofit system, Right?

Alex 37:35

Right.

Eric 37:35

Versus Bill’s is in this for profit, probably equity, a private equity owned or

John 37:40

recently sold in an Isolated company. Yes.

Eric 37:45

The difference between the two stories is shocking. It’s also honestly like, the difference that we’re seeing, like hospice care, is that we’re seeing these places that have been around for 50 years. I would say both the longstanding nonprofits and some of the longstanding for profits, and then these fly by night, small for profit entities that private equity is gobbling up where we’re seeing tremendous variation in care.

Bill 38:14

Good point.

Alex 38:15

And towards the end of our podcast, we like to get towards, like, what can we do about this? Right? We gotta leave people with something positive. What can they do about it? As a clinician, and it sounds like I’ve already heard they need to learn more about the differences between assisted living and nursing home facilities. We’ve already heard we need studies of the outcomes of people who go to assisted living facilities versus nursing homes.

I think we heard from Melissa that we need more research about what’s happening with private equity owned assisted living facilities, hospices, nursing homes, and particularly longitudinal data. What happens over time to these sorts of facilities? What else can we learn about? Can the individual. Most of our listeners are clinicians. So, like, what can the individual clinician do? We could start there and then also what can we do more in terms of research and policy?

Eric 39:08

We’ll start off with Melissa.

Melissa 39:10

I think two things. I think as an individual, whether you’re a clinician or not, I think understanding more about what’s going on and being informed and understanding who kind of locally, politically, if or what they’re doing about this. Because most of the regulatory initiatives, at least the things states are trying, are state level and some states are more engaged than this than others, and some political figures are more engaged than others. So I think if you become informed and understand where people stand on that issue issue, and then vote accordingly, I think is one thing that all people can do and I think the other aspect. So you, you mentioned the types of studies that I think would be amazing to do.

And I also like what both John and Bill have done, which is people who have experience. Maybe a clinician’s been at a healthcare provider that’s been invested in by private equity and then kind of bought and sold to kind of tell their experience, write about it so people can hear about it not as like a whistleblower, but just as kind of like, what were the positives, what were the negatives? Was there a change in culture? Like, what did you experience going through this? And I think those types of stories, you know, qualitative research, as we would say, or just stories can be really telling and really helpful.

Eric 40:29

Great. I also find it really interesting, like you can go on Medicare compare and you could pull up like nursing homes, but it’s not Medicare paid. So there’s no assisted living facility star rating out there.

Bill 40:41

Right.

John 40:42

But that’s why continuing care retirement communities could expand their services beyond a campus and into the community. I don’t know anybody that’s doing that. But let’s serve a broader community than just a campus community because the resources, the insight, the knowledge of how you do this healthcare has to be coordinated. The older you are, the more that’s true. And then we’ve got to back up and get the hospitals engaged. They have no clue what a continuing tear retirement community is. Or an assisted living community. Yeah, they just, they don’t know. Oh, oh, they have a bed. Okay, great.

Eric 41:26

Oh, discharge, length of stay.

Bill 41:28

Right.

Alex 41:29

Yeah.

John 41:30

And I, in my experience as a clinician, I’ve had some patients do that and have gone to visit these places and said, oh my, this isn’t exactly what we thought we were getting at. So I, I think there’s enormous opportunity for growth and development and we need to get it accelerated because the population’s aging and we need to make continuing care retirement communities more affordable for people without long term care insurance. And again, I think if they expand in the community, you can begin to control costs.

Eric 42:05

Wonderful.

John 42:06

So come back in 10 years and we’ll see where we are.

Eric 42:09

Bill, what’s yours? Two things or one thing? We should focus on kind of the concrete next steps.

Bill 42:15

Well, I think Melissa and John have both made very important comments. Fundamentally, the American public needs to understand these issues better, but frankly, our own geriatricians need to really look at these things more objectively and really push more for better reorganization of long term care. So that’s all I have to say.

Alex 42:44

One other piece I took from your essay, Bill, in JAGS was that there was a disconnect that you and your wife did not feel like goals of care were adequately assessed and that goals were presumed to be purely palliative in nature. Whereas you and your wife, your goals for you were organized primarily around improving function.

Bill 43:08

I don’t, I won’t be careful about who I make mad by comments, but let me just say that even my physicians thought I needed palliative care and was going to die. That was true of many of the people in the skilled nursing facility. The overall result was that these people are going to die of need and they did do some pretty good stuff with palliative medicine. So bottom line is we, the leadership of this geriatrics, we need to look at this and redefine the perspective so that our members can be appropriate, understanding advocates for better care in these facilities.

Eric 43:55

I love that we’ll end with that.

Speaker 6 43:57

Alex he said I was finally the husband that most of the time I wasn’t. And I became a friend a friend would like to have. And all the sudden going fishing was in such an imposition. And I went three times that year. I lost my dad. Well, I finally read the good Book and I took a good long, hard look at what I’d do if I could do it all again. And then I went skydiving. I went rocky mountain climbing, I went 2.7 seconds on a bull named Fu Manchu. And I love deeper. And I spoke sweeter and I gave forgiveness I’ve been denying. Said someday I hope you get the chance to live like you had done.

Eric 45:05

Bill John, thanks for joining us on this podcast and also just big thank you for sharing your own experiences with these transitions. And Melissa, always great to have you on.

Melissa 45:15

Thank you very much.

Eric 45:16

And to all of us, thank you to all of our listeners, thank you for your continued support.

Bill 45:21

You guys are great. Thank you.

This episode is not CME eligible.

For more info on the CME credit, go to https://geripal.org/cme/