If there is one major transitional development amid the acuity shift within eldercare, a strong case could be made for the growth of rehabilitation within the senior living sector.
Over the past decade, assisted living residents have entered communities with more complex healthcare needs – especially with regard to physical, occupational and cognitive rehab. And based on the observations of rehab specialists, this trend has continued to grow.
“I can say very tangibly that assisted living was 10% of our business five years ago and now represents 25% to 40%,” says Paul Riccio, vice president of finance and development for Vertis Therapy. “That’s a huge uptick. It’s like a lightbulb turned on for senior living communities, that if they could offer the same rehab services, those residents wouldn’t have to go to a nursing home.”
In Riccio’s view, the trend toward rehab in senior living stems from a mindset change about optimal square foot usage. In the past, a senior living provider might have opted for a maximum number of residential units, whereas now rehab is seen as the key to higher occupancy rates.
“A rehab area may generate fewer dollars per square foot, but if they can keep 10 residents a year at the community, it pays off tenfold,” he says. “It has become a matter of maximizing the health and stability of the resident rather than looking at revenue generated per square foot.”
Matthew Mesibov, clinical physical therapy specialist for Centrex Rehab, says the trend accounts for a senior living environment that is designed for effective aging in place.
“Senior living communities recognize that quality and necessary therapy services help residents to function much better,” he says. “As a result, longevity of the residents remaining in the community can improve. In the current environment where aging in place is highly valued, providing rehabilitation services in a senior living community is consistent with this value.”
Overall, senior living communities are positioning themselves to offer all necessary services to their residents to help them regain function and live independently as possible, says Kathleen Weissberg, director of education at Select Rehabilitation. One reason why rehab hasn’t made inroads into senior living before now, she reasons, could be due to communities wanting to avoid the perception of being more “healthcare” than “hospitality” oriented.
“For many residents, there is a negative stigma associated with the ‘health center,’” she says. “For this reason, therapy services are available in the home, apartment or outpatient clinic.”
To be sure, senior living communities avoid the “healthcare” connotation, and that includes the rehab segment. “Wellness” is a term that seems to be much more palatable for all concerned, says Erik Painter, national director of community rehab services for RehabCare.
“Many communities have wonderful wellness centers, but the missing piece with these wellness spaces is that there are no structured programs for the residents, and often the residents don’t understand how the equipment works,” he says. “When the community has a strong rehab program, wellness is something that can be incorporated in their goals. Having the ability to address residents’ needs in their own environment is a huge benefit. You don’t need to have a full-fledged gym in order to address those functional goals.”
Rehabilitation is a multi-dimensional discipline designed for each individual’s unique situation. The skilled nursing sector has thrived on furnishing short-term post-surgical rehab, typically covered by Medicare or private insurance.
As senior living invites more rehab services into its fold for a higher-acuity resident base, is short-term post-surgical recovery part of their service offering? Based on rehab specialists’ observations, there is no definitive answer, but it’s a situation that can be assessed on a case-by-case basis.
Pam Brooks, clinical occupational therapy specialist for Centrex, says regulations and reimbursement play a differentiating role in how rehab is provided in both skilled nursing and senior living sectors.
“As providers of therapy services in senior living, skilled nursing and home health, we find that rehab in senior living and home health allow patients to progress functionally in their own environment and is a good progression for patients who initially require more intense therapy and nursing services in a skilled nursing community,” she says.
Multi-sector rehab providers are equipped to handle whatever red tape is necessary for therapies, no matter the physical site. So for senior living communities to bring in the post-surgical rehab population, they can rely on a contractor like Vertis to meet all the requirements. Even so, there are financial considerations senior living providers need to make to determine whether the effort is worthwhile, Riccio says.
“All the appropriate equipment and staff can transfer over from one sector to another,” he says. “We have the expertise to do that, and they can lease to any provider that is the best service fit. But the double-edged sword is that the only revenue they get is fair market value from renting square footage, and we assume the financial and regulatory burden. That can be a scary proposition.”
Ultimately, though, Riccio says “we don’t look at the license on the wall. We look at that the elder in the room. The best tools aren’t focused on high-end knees and hips, but those focused on engagement.”
Christopher Krause, director of rehab for It’s Never 2 Late, also has seen the trend of senior living communities receiving more clients that “historically fit those normally seen in skilled nursing facilities.” Rehab therapies, he says, “are pretty much the same,” with the difference being “how the therapies are deployed.”
For example, he says that in senior living, rehab is used more as part of an outpatient benefit.
“An assisted living environment often lends itself to wellness programs and general health activities, where in skilled nursing environments, rehab is more clinically based due to the acute nature of the clientele,” he says.
As more patients and residents are receiving services through bundled payment arrangements and accountable care organizations, the emphasis is on providing the right amount of care in the right setting, Weissberg says.
“Providers are following sometimes detailed and complex algorithms to help them determine the best and most cost-effective setting to complete the patient’s rehab,” she says. “There are times when the patient’s complexity does not warrant a lengthy skilled stay, and these patients do go back to assisted or independent living and receive services through a home care agency or outpatient services.”
Boosting memory care
With senior living communities, most notably assisted living, bolstering cognitive rehab services comes as a natural extension of focusing on Alzheimer’s and dementia residents and adding memory support wings.
“There is a relationship between the growth of memory care in senior housing and rehab in this sector,” Brooks says. “Therapy services help maintain functional levels for those with cognitive impairments.”
Weissberg adds that although memory care has grown as a market niche for senior living, therapy services need to grow to keep pace.
“In settings such as assisted living communities dedicated to memory care that provide a specialized, safe and secure care environment for those living with cognitive impairments, they are often void of comprehensive rehabilitative services,” she says. “When rehabilitative services are available, they are often ‘as needed,’ not full time, and sometimes not on-site.”
As it relates to senior living, memory care has become “inextricably connected” to the sector, Krause says, citing a Centers for Disease Control & Prevention statistic that more than 16 million U.S. residents currently live with some kind of cognitive impairment. Alzheimer’s incidence is expected to rise to more than 13 million by 2050, when there will be more than 88 million Americans over the age of 65.
“The costs of caring for these individuals is already incredibly high and is only going to get more challenging as time goes by,” Krause says. “This, more than anything, is why memory care cannot be viewed in isolation anymore. Rehab is driving the intervention.”