Robert Kramer - Tech and Retail Giants' Senior Care | Proposed Solutions to Nursing Homes | Senior Living Market Segmentation

We're problem-solving futurists and innovators in the aging sector.

The Baby Boomer cohort is aging, and the number of seniors is growing rapidly. Aging in place is an essential concept for older adults to age at home longer and healthier.  Technology/ Smart hubs have made it easier for people of all ages to live independently at home, so they delay going into long-term care.

Nursing homes are dealing with a lot of problems and challenges. These issues have resulted in lower-quality care, higher staff turnover rates, and declining occupancy rates that translate into financial pressure for nursing home operators.

There is no one-size-fits-all solution for seniors. Seniors are not a homogenous group; they have different needs and preferences, which means that the housing products should reflect this diversity. Senior living market segmentation allows marketers to develop housing that better serves the unique needs of each senior demographic. This approach makes it possible to create personalized care plans based on the individual’s age, health conditions, financial situation, and lifestyle choices.

Timestamps:

[04:34]
I'm eager to talk to him about three topics. The first one is tech and retail giant senior care products impact on senior living. And the second is Bob's proposed solutions for the problems facing long-term in today's nursing homes. And the third topic is the segmentation he believes will arise in the senior living industry.

[05:03]
The rise of the aging population is leading to a need for more senior care in corporate giants. Like Amazon, Best Buy, Walmart is disrupting this with their products. So, technology is changing the way people live and age in America, older adults are now able to maintain their independence with convenient products from, Amazon, Best Buy, and Walmart, which makes it easier for them to take care of themselves at home. So, do you see smart hubs as a future of elder care?

[32:35]
So, this brings us to the next topic, which, your thoughts on the problems with nursing homes and some possible solutions. So, you recently wrote an article in health affairs regarding this, problems with nursing homes, and some solutions. So, can you get us up to speed on some of the most vital issues in the skilled nursing setting today?

[43:30]
You've talked about how product segmentation into new living space is in its infancy, in what you call Boomerville segments will emerge. So, can you explain why you believe this?
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Bio:
Bob Kramer
Founder and Fellow of Nexus Insights, a thought leadership platform dedicated to the dissemination of ideas and models that challenge the status quo and contribute to the transformation of housing and aging services for older adults. Mr. Kramer is also Co-founder, former CEO, and now Strategic Advisor at the National Investment Center for Seniors Housing & Care (NIC).

He is broadly recognized as one of senior living’s most influential and high-profile thought leaders and connectors. With over 35 years of industry leadership, he has earned the reputation of “agent provocateur” in the seniors housing and care industry. He has been described as an “ice-cutter” and scout in identifying industries and trends that will disrupt the future of seniors housing, aging services, and aging more broadly.

In April 2020, Mr. Kramer launched Nexus Insights to “rethink aging from every angle.” The organization engages a network of leading thinkers and thought leaders to provide provocative insights and actionable models to catalyze the next generation of housing and aging services.

You can find Mr. Kramer at: https://www.linkedin.com/in/robert-kramer-15238b15/

Transcript

Robert: 0:00

The very phrase senior living will become an anachronism. In the decade of the 2020s, why? Because it represents to boomers, their parents notion of retirement and of retirement living and of aging. And so boomers won't be called seniors and they won't move on and move into senior living. I don't know what the new phrase will be. I called it Boom Orville only because it was specific to boomers and how different they are and their values and expectations. Some marketing genius will make a lot of money coming up with whatever phrase. I don't know what that phrase will be, but I will say the first thing about senior living of the future that will serve boomers is it won't be called senior living that I promise you. And that ties to we'll also be challenged with our vocabulary because even those of us in the sector, many of the way we use terms, age aging, retirement, health, housing, Senior living. There's a lot of aged ageist terminology without our realizing. And so getting away from a dependency, helplessness, lack of independency agency perspective how we think about look at the very phrase, Silver Tsunami.

Hanh: 1:18

I don't like that word.

Robert: 1:19

And if you think about it has, does anything good come out of a tsunami? A tsunami is an unmitigated disaster. And what that's saying is the increased longevity in our society is a disaster, which implicitly is the most age of statement you could make.

Hanh: 1:35

It is so insulting. I don't like that word, and I'm so glad you brought it up. You know what? Aging is beautiful. It is a gift. How can you associate that with a tsunami, which is a disaster, So I am, I'm so glad you brought that up. And I think everyone should stop using it.

Robert: 1:51

That, that, we've got to get rid of the ageist terminology within our own field. And my goal and my belief 10 years from now the type of greeting cards for me, people's 40th, 50th, 60th, 70th, 80th 90th birthday, which today all make jokes based upon the idea that it's a bummer to get old, that we all want to be young, and that we've lost vital things about our identity and our humanity, because we've gotten old and there is nowhere that displays the ages bias of our society. Then the greeting cards for birthdays after you pass 40. So, I hope we'll see a great change in that. I think we will. I'm hopeful.

Hanh: 3:23

How are you today?

Robert: 3:25

Good. Thank you. It's a gorgeous day. I was on a call earlier. I was saying I was out walking early this morning and it's one of those here. I'm in Annapolis, Maryland. It's one of those gorgeous spring warnings where it's as if someone painted the colors to be bright, but they're naturally bright because it's springtime and it's just, you know, we had some recent rain and it's just, it's uh, the vividness of the colors outside. I think we long for that after all we've endured over the last 15, 16 months. It's a delightful start to a new week. I'll put

Hanh: 3:58

Absolutely. Yeah, I'm in Michigan.

Robert: 4:00

You're in Michigan. Oh, okay. Very good.

Hanh: 4:04

Yeah. Yeah. Thank you so much for your time in shedding insight on some of the topics that we're going to cover. So, I'll get started. Today's guest, Bob Kramer is the co-founder former CEO and now strategic advisor at the National Investment Center for Seniors, Housing and Care. Also known as NIC with over 35 years of industry leadership. He's recognized as one of the senior living industry's most influential thought leaders today. I'm eager to talk to him about three topics. The first one is tech and retail giant senior care products impact on senior living. And the second is Bob's proposed solutions for the problems facing longterm today's nursing homes. And the third topic is the segmentation he believes will arise in the senior living industry. So Bob, welcome to Boomer Living.

Robert: 4:57

Thanks so much, Hanh it's, I'm delighted to be with you and looking forward to our conversation.

Hanh: 5:02

Yeah. Great. So, the rise of aging population is leading to a need for more senior care in corporate giants. Like Amazon, Best Buy, Walmart are disrupting this with their products. So, technology is changing the way people live in age in America, older adults are now able to maintain their independence with convenient products from Amazon, Best Buy and Walmart, which makes it easier for them to take care of themselves at home. So, do you see smart hubs as a future of elder care?

Robert: 5:32

Let me say yes, but yes, in the sense that smart, I think smart hubs are going to be an essential sort of table stakes for senior care in the future. So, that's the yes, absolutely. I think smart hubs, whether you're living in an assisted living community, living in a life plan or CCRC or living at home alone. I think the smart hubs are going to be critical. They respond to the consumer demand for digital, which has only been intensified or sped up because of COVID consumers. Now realize how many things they can get delivered to them in their home and that they don't have to go out. And that includes health and healthcare. And so I think these sorts of smart hubs will become integral to senior care in the future that said they are not going to replace the need for people and the role of people. In other words, this is a classic example of technology, enabling people to do what they do better rather than replacing people. And I think that's an important distinction. If we rely on these data hubs what's called connected health connected living. You'll usually see connected in key phrases that any technology group inter or company entering the area of health care is and senior care. But ultimately those connections as COVID has shown with all the restrictions and not being able to go out, not being able to gather in a congregate setting at whatever age, which it's great that we can do it, but we desperately long for the real thing. And the real thing is human contact. The real thing is hugging somebody. The real thing is being with somebody and having a glass of wine or sharing a meal. And quite frankly, Zoom and FaceTime is it can give comfort. It can give a sense of assurance to a loved one, that they can see you but they still want to be with you. And so I think that kind of distinction it'll become table stakes for delivering healthcare period because of the consumer demand feature. That's beginning to become influential in healthcare, and it will become I think essential in senior care, but it will not replace the desire for what is the most important thing that people look for at any age, but especially as they're in their later years and that's human contact, a sense of belonging and a sense of purpose.

Hanh: 8:07

The future assisted living could be changing it devices become more widely available that can help people age at home. So, will more people stay out of assisted living communities longer with the help of these devices?

Robert: 8:20

Bear in mind, assisted living is home. You move to it as a new home because often times not only you may need to have support, need support for services, but you also want community you're single or single again, you're alone. Your children live far away. The folks in your social group have either passed away or they're no longer, you're no longer able to travel to see each other. I think again, like a couple things to bear in mind if providers of senior living. Only market care, then they will lose out because if all I offer in my community is care when you absolutely can't live without it, technology is going to mean I can live at home, especially if I have money a lot longer without it, without making the move. So again, it underlines my point that if all we're selling is care, then yes, it's an enormous threat Han for the reasons you said, because now people discovered that with technology and I would add with money, I can stay home a lot longer and still have some degree of safety. So if all we're marketing is care, we're going to be in trouble as a sector. We've got to offer an aspirational life setting. We've got to offer something that gives people a sense again, of belonging. The Japanese have that great expression, which my pronunciation will ruin, but Icky Guy, a reason literally translates a reason to get up for breakfast. We have to be places that give people reasons to get up for breakfast. If all we provide is care, then you're right. Then the whole move to home, moving health home the connected hubs the, all of these things. Then they do become a threat. I hope and think that the sector, senior housing and care senior living is smart enough to realize that ultimately they've got to offer an attractive setting, not a place you try and avoid as people think of nursing homes that you want to do everything you can, because you don't want to end up there.

Hanh: 10:27

Now, that takes me to the next question. Are these devices at some point yet where they can replace some of the services assisted living can offer?

Robert: 10:36

Good question. What I would say is this as with any technology and any use of data, it enables a better use of humans. It doesn't replace them, but for, let me give you an example in Japan, it's not widely available here. They have smart diapers. And I'm going to a very practical, not a discussion most people want to have, but they have smart diapers that tell you when a person is wet or soiled, but also do an instant analysis and tell you if the person's dehydrated and at risk of UTI, one of the most common reasons for hospitalizations for folks and as they get older, particularly older women. And so what does this mean? Take my mother-in-law who passed away a few years ago, who had dementia. She hated it. When on a routine basis she was incontinent and she hated it. And she didn't understand the reason for it when every hour they would come to check on her to see if she needed to be changed. Think of the staff time and doing that, thinking of her frustration and anger of this invasion of her personal intimate space and how much more efficient, if they only went to check on her, when truly she needed to be changed, it's a more efficient use of staff. It's better for the resident is a better quality of life. And particularly for someone with dementia, there's less times when the interactions are frustrating and the interactions are upsetting. And so now you've gotta be in damage control mode because this person doesn't understand why you're doing this thing, that she senses is wrong, that you're doing this to her. So again, I come back to my thesis these will it can it enable more efficient staff use? Absolutely. Can it because of using artificial intelligence and predictive analytics, we can intervene when a person's at risk of a fall and prevent that fall. We can intervene when a person is getting dehydrated and at risk of a UTI that would then require a hospitalization. We can do all those things. So, I think it's exciting to see the promise of this, but it helps us solve our biggest problem. Our biggest problem is labor, the cost of it and the availability of it. So, I think as a sector, we should embrace this. This is a wonderful thing, and we need it. And yes, it will enable people to, if safety is the issue to stay at home longer, but that's a good thing with the ballooning number of older adults and the declining number of family, what we used to call informal. We now rightly call unpaid caregivers and that percentage of those family caregivers to older adults over 80 is shrinking dramatically. And what that means is we're going to have more need for paid care. And so the longer we can enable people to live safely at home, the better, I don't see that as a threat. If we're going to meet the challenges of the future, I think it's let a thousand flowers that we're allowed a thousand options bloom. We need to enable people to who want to live safely longer at home while also realizing all ultimately. And the pandemic, particularly the second half of our experience with it on has shown loneliness and social isolation kills. If you want to basically degrade a person's physical and mental health, isolate them. And then on top of that, with, for those with dementia, I would add, restrict them, put them in a closed space and tell them they can't come out. And those are the things that destroy the human spirit, not just the physical body. And so again, I think that means there's going to be enormous demand for the right type of senior living communities in the future. And at the same time, we're not going to be able a we're not going to be able to build them fast enough. And B some people would just prefer to stay home. There they're much more independent. They don't feel the need to be around other people or great. We need to enable them to do that safely and to do it more safely longer. What we don't want is for them to be home, but not taking good care of their chronic conditions. So by the time they then spend down to qualify for Medicaid, they're very disabled and need, need of enormous amount of care and care that can only efficiently be provided in an institutional setting. We need to avoid those what I'd call premature of institutionalizations, whether it's in a hospital or in a nursing home. And this technology has enormous problem promise. The tech companies that you mentioned, whether it's an Amazon and Apple alphabet, Google Microsoft and then what we see in retail giants with best buy what we see with Walmart and then Walgreens and CVS, there they're really jump-starting healthcare and senior care consumer demand for digital they're enabling connectivity and data exchange that healthcare has been in the stone ages on, and they're assisting with healthcare workforce burnout, which includes senior living workforce burnout. And lastly they're pushing new models of care delivery. We need them in all the settings. So I see it as a plus. I see it as a threat only if we say we're going to keep doing things the way we've done them before. If we do that, it's definitely a threat. Then yes, technology is going to enable me to stay home and I won't need to go to that senior living place. But I think the big tech companies, and especially, I think the most fascinating company to watch is best buy because basically all the others Amazon, Microsoft, Apple, so forth, they all see and CVS and Walgreens and Walmart, they all see enormous opportunities in there and using their strengths to, to come into the healthcare field. But only one of all those players has really targeted from the get go seniors and that's best buy. And you look at their pattern of acquisitions, critical signal technologies, a company that specializes in pop health and using predictive analytics to manage chronic conditions. They bought great call, which had already purchased a jitterbug. They unveiled an assured living, which was an aging in place platform for aging in place at home. They bought MD live and they're building a powerhouse of a whole continuum of services. Again all of these companies, eventually the opportunity is partnering with those who help hold the healthcare dollar risk. And no one is more expensive than that older senior who has multiple chronic conditions. But I think best buy is already partnering. They're already serving about 20,000 assisted living residents around a hundred thousand independent living residents today through partnerships with existing providers. But again, you either address and find a way to partner to address the things they're addressing, or yes, they will steal your customer, but shame on you do, because quite honestly, you deserve to have the customer stolen because you're not giving the customer what the customer wants and knows out there and is available today.

Hanh: 18:20

Absolutely. Yeah. So, we should embrace these tech giants and retail giants and together in partnership with them because they have the horsepower, the means to add value to the senior sector.

Robert: 18:33

And I had one of the things that they bring. They not only bring out of box thinking, which is foreign to healthcare for the most part, which is very staid and set in its ways. But if you look at healthcare generally and specifically senior care right now, after what we've been through throughout 2020, and now in this first third of 2021, what's true. What's true. Is our workforce at all levels is exhausted. People have just been literally for their own physical and mental health for their business models, they've just been trying to survive to get to the other side. And the second thing that's true is that particularly in senior living many are resource constrained, like never before meaning they don't have the capital, they need to invest in technology and in people. And so both on an energy point of view and an a resource people and money point of view, many in our industry right now are really challenged. That's a time where you're ripe to be disrupted from the outside and along comes big tech. What do they have? Tons of money, very innovative thinking and business models used to seeing a problem and going at it and putting a lot of resources, people, ideas, new business models, money. So, I think we're ripe for disruption. But I think that, for those senior living providers who, who realize that COVID has only as my friend, Joe Kauflin, who runs the MIT Age Lab, says "It has propelled us into our future faster." These trends were already happening pre-COVID, but they've just been intensified and sped up. So again, as you can see, hopefully here in the tone of my I'm incredibly optimistic about how we'll respond as a sector, but for those that don't, they will become dinosaurs and they will be out of business because they won't stay up with the consumer and what the consumer demands and now knows is available.

Hanh: 20:37

Sure. Yeah. I echo that. It's very true, if you only focus on care, that means there's all their services that can be more efficient. Cost-effective than you. But I think folks, 60 seventies or eighties, whatever age you're looking for, that socialization belonging purpose. So, all of those key components, if you're not up to providing that, then like you said. They will be a threat. So, that's great. Now, do you see a downside to these hubs? Do you think some providers will rely on them too much at the expense of in-person interaction?

Robert: 21:10

I think there's always that danger. We tend to keep something at arms length when we finally decide to embrace it, we may be all in and we may think it does things it doesn't really do. So is there, is that danger present? Absolutely. And it's the danger with data generally? We, at times, don't want to use data, then all of a sudden, when we decide to use data, we overuse it or use it for the wrong reasons. And what do I mean by that? What I mean is, first of all, just having lots of data actually usually makes a company inefficient. What you need is actionable data. You need the ability to discern between what's important and what's not. And then ultimately, do you use data to address what matters most in this case to the resident or to the consumer? Or do you use data to check boxes to say, "Gee I'm delivering, but you're not really doing what matters most to the resident or to the consumer." And that has to do with, for instance, do you use data to do a checklist for quality of care? Rather than use data to enhance quality of life for the individual, they want to know about quality of life. And yes, there's a there's as always a danger to overuse the data over, rely on it, or I would say use it for the wrong reasons. Ultimately, we talked so much about person centered person directed, resident centered residant directed care, and resident directed living. There's a danger with data that if you use it wrongly, it's the antithesis of resident centered or resident directed care. And it actually doesn't does dress the things that matter most to the person who's the recipient. And I would argue, and again, I, it's not, I understand I've started off. I think there's enormous potential from these data hubs. And this connected living connected health, but there's also a danger that we'll use this to falsely think that we're doing consumer a failure, a favor when in react reality, we're actually reducing the consumer two data points. And what do we mean by that? What it mean is, yeah, it's good to know your chronic conditions and how well we're managing and how many ADL needs for service you have and how many prescription drugs you take. But I don't know a person in the world that wants their identity defined by those things. When you only get data on those things, you start defining the person by those things. That's not what matters to the person that person has a desire to belong and have a sense of purpose, no matter what their age or frailty level. And Lisa Marsh Ryerson the President of the AARP foundation, and one of our NIC talks, she challenged the industry to rethink our activities, directors that they needed instead to be purpose matchmakers. And when she said that, I told her Lisa, I'm going to quote you incessantly. And I have gone on to do that because I thought it was brilliant. What we need to do is ultimately to use data, to connect our residents, which what gives them a sense of purpose and meaning and belonging. And that's going to be different for different people, but they don't want to be defined. If you define people by their deficits and their limitations, you enforce a sense of dependency and helplessness. That basically I'm just, I'm an, I'm no longer an independent agent and I'm here to be entertained and cared for until I die. That's depressing. To most people, I'm sorry, and it's not attractive. And if we offer that as an industry, they ought to leave us in droves. What we need to offer again, is that sense of, we connect you with that sense of that purpose, that passion and whether it's, yeah, it's, it is a lifestyle ultimately, and it's a lifestyle that centers around, what are your life? I think in senior living, we ask a lot of important questions. We often don't ask the most important questions. What's next for you? Where would you like to grow? How would you like to contribute? How do you think you can contribute to this community as you move in here? What have been your moments of greatest life joys and greatest pride? How do you see those moments continuing now that you're moving into our community? How can we help you towards that? I think those are the kinds of questions that suddenly wake people up to. Gee, they're not thinking of me. It's totally dependent and helpless. And they're not going to just reinforce that helplessness. No, they see me as a participant. They may see me as somebody, a value. They still have something to give and they want to work with me to, to in a sense, make sure that's engaged in whatever that means. So those

Hanh: 26:12

And to do that, And to do that you really have to touch in to their emotional needs and understands their temperament when they come to the community and also, them in trusting you enough to share their goals and aspirations. So, I think it's so important.

Robert: 26:29

It's a whole different way of thinking about the role of the individual or individuals that do intake, because we tend to, again, we have a checklist. And it's about ADL needs. It's about chronic conditions. It's about over the counter medications for scription medications. It's about ability to pay all important questions, not key to the individual.

Hanh: 26:50

Gotta dig in deeper.

Robert: 26:52

Yeah, and also I think another thing COVID is brought out that we knew before, and that is physical health is one thing. Mental health is just as important. And just as we've seen across the society, a lot of people's mental health, emotional health, spiritual health, has taken it's been tough. And so we have to be sensitive to that. And we have to realize that part of providing an aspirational setting is addressing the whole person, not just addressing their physical ailments and their chronic conditions.

Hanh: 27:25

So, now what's your thought on, do you worry about the privacy concerns could less trustworthy people abuse the data coming off of these devices? I know you worked as a state lawmaker in Maryland before starting NIC. Are there protections the government could use or could put in place to protect against abuses?

Robert: 27:42

There, there certainly are. Obviously we have HIPAA to begin with, which is comprehensive and the health and information privates, privacy act. But the bottom line, as we've learned, unfortunately, is that there are, if you, if your entire waking life is devoted to trying to hack in to security systems, there are very few systems that can't be hacked into. And it's just, it's a sad reality of modern life that these very things that, that show so much promise at the same time can be used by people with ill intent either to hold hostage a hospital or or to go sell information on the black market, so on and so forth. We're going to be challenged with that. It's going to be an ongoing issue for years to come on the one hand trying to regulate it. But on the other hand, trying to not regular way that squashes the opportunity to make, to eat, to have this data serve a positive function, but at the same time does try and protect folks. I think one of the areas that the tech companies are getting better at and better than the traditional vendors into senior living, and that is. Making the very items that collect the data and the way the data is collected no longer seen as both intrusive. And in a sense, marking you as old and frail, what do the classic late night TV ad with the woman, with the pendant around her neck and she's fallen and she's saying "Help, I've fallen.", and what, and so you have these pendants, which are, they stick out as, okay. I'm old, I'm frail. And either because I'm afraid or because my daughter's afraid I wear this pendant. Now you con, you, you contrast that to the lively Aging In Place app of Best Buy that's now in a partnership with Apple, is now on the Apple Watch. So instead of being this pendant that screams out, why grandma you have that because you're afraid of falling instead, grandma, that's a cool watch. Wow. It does that too. And just that we used to make all, whether it was clothes, canes, walkers, they were all made functional and the, we didn't care if they were ugly. If they screamed you're old and frail what's happening now is that folks are getting into designing clothes and all of these remote monitoring devices(in a way that a) isn't as intrusive.(Isn't as demeaning and b), where the individual themselves feels they're more in control. And that will be key. Again, as we're going to serve boomers, boomer, women spent a career fighting for their rights and part of that rights to their privacy, rights to be in the workforce and they are not going to just trade those in for a sense of "Gee, this will enable us to more efficiently care for you. And we're going to return you to the infant toddler stage, forget it.", they said. That's a gen, this is a generation that said, "Hell no, in the sixties, we won't go." In the nineties they said, "Hell no, we're not going to put mom in a nursing home." And that was boomer women. Why? Assisted living took off in the nineties because boomer women who are now in the workforce and what traditionally were expected to be providing this care. I said, no, I don't want to leave my job, but I couldn't live with myself. If I put mom in that old style nursing home, and all of a sudden assisted living came along, gorgeous atriums, curved, stair, staircases, that you did never want the resident to use. Queen Anne furniture, carpeting, glorias chandelier. It wasn't designed for mom. It was designed for the adult daughter to address her guilt she said "Now, this is a place I can be. I can keep my job and feel comfortable that I've moved mom into this gorgeous place where she's going to get the care she needs." So again, boomer women in the 2020s are, I think, going to say, "We're not going to accept hell no, we're not going to accept your notion of retirement and of aging." And it's the antithesis right now of the late night TV ads, where the person is helpless dependent. And our device will suddenly enable you to not have to be afraid any longer. That's not the image boomers want. And it's fascinating to me. We are marketing to the greatest generation. We're going to be serving the boomers and there's a complete contrast in values and priorities there.

Hanh: 32:25

I'm a young baby boomer. I am that daughter. I'm in my mid fifties. And I went through that journey to find a good fit for my mom. So, I'm with you, two hundred percent. So, this brings us to the next topic, which your thoughts on the problems with nursing homes and some possible solutions. So, you recently wrote an article in health affairs regarding this, problems with nursing homes and some solutions. So, can you get us up to speed on some of the most vital issues in skilled nursing setting today?

Robert: 32:55

Sure. This was a lengthy blog. I wrote that appeared in health affairs called fixing nursing homes, a fleeting opportunity. I said it was a fleeting opportunity because for the first time in my entire life nursing homes and long-term care are public conversation. They're center stage because of COVID unfortunately the tragedies of COVID, which has put a center stage and shined a spotlight into our nation's whole long-term care system and into nursing homes. So it's, and it's a painful spotlight. But that said, and so I think it's a fleeting opportunity. Cause I think that spotlight will only last another six or eight months and then public policy folks, politicians will be on to midterms and other issues, but we have an opportunity here. I think, what this spotlight is revealed is that we have a totally broken system. And and that in essence, we didn't care up till now as a nation, we chronically underfunded long-term care. And if you had money, you did everything you could to stay out of a nursing home setting, if for long stay. I understand there are two populations, there's a short stay rehab population where the stay is usually less than 30 days. And then there's folks most, all of them on Medicaid who have spent down to officially qualify as in poverty. And they're there as this is the only place where government will pay their room and board, as well as giving them the long-term care services and supports they need. And basically the systems perverse because it encourages forces operators to get enough Medicare days short stay days to offset what they lose on Medicaid, the long stay residents. So it's a perverse incentive, and that needs to be changed. The simplistic solutions, what I said was we've got to acknowledge the real problems. And part of it is that as a country, we've been content to abandon elders, particularly poor or newly poor elders, and just know we abandoned them to conditions we wouldn't want our put our mom in. So when we get upset, when our mom's forced to move there, but other than that there's no move to, to to address it. And, and so that tends to be not only lower income individuals and then middle income individuals who will finally spend all their resources to qualify for care.

Hanh: 35:28

So, in the article you talked about how we need to stay away from quick fixes that only put a bandaid on the problem. So, can you share with us some of those quick fixes and why do you think they're ineffective?

Robert: 35:39

So, simplistic solutions that I in this article said, we gotta be aware of and beware of, is solutions that in themselves sound good. But if they're not part of an integrated package of solutions, they actually will compound the problem, not solve it. Not because they're wrong. Let me give you a few examples. We have should have more money, better funding. We, well yes, we should. But taking and pouring more money into a broken system isn't going to give you better the results. We should have more staff. Absolutely, we need more staff. We should pay them better. Absolutely, we should. But we've got to look at the whole funding structure and why we have these problems. We should have a regulatory enforcement system that gets rid of bad actors who perennially are folks that have poor quality in their nursing homes. Absolutely, we should. But simply having tougher regs and more enforcement has never been shown to actually improve quality. So, these are all examples of simplistic solutions. Some of the solutions then I recommend the first and foremost thing is I said, we need to do things together. It needs to be an integrated package. So, for instance, we need more money, in a nursing home for those long stay residents. We need, in other words, higher Medicaid funding for those folks that need to be there. But we need to couple that with a couple of things, one insisting that the money actually goes to be able to go for staffing. For more staff for better wages for staff for more training for staff. Because right now there's not public confidence in policymaker confidence that because of some of the Byzantine ownership structures of nursing homes, that the money's not getting siphoned off and going into some execs pocket rather than into improving care. So, there needs to be more transparency I said, and more accountability in ownership structures and where the dollars go. But then a third thing is I said, "Okay, but you also then are going to need some liability relief. Why? Because those business seen structures exist because if you have any size as an operator, then plaintiff's attorneys want to go after those dollars that represent your size." And so, this Byzantine structure was set up after the liability crisis in the early two thousands. And we've got to address that. On the one hand, we got to demand total transparency and accountability of owners of nursing homes. At the same time, we can't just open up then a field day for plaintiff's attorneys to sue for defense attorneys to make money defending. And then for insurance companies to make money as they order settlements, because they are afraid to go to a jury trial because then they could really have to pay out big time. So, who wins and all this attorneys on both sides and the insurance companies. And, but the money that's going into the system is now going to pay all of that, not to improving care, improving staff salaries and proving training, so forth. We need to move our long-term care infrastructure in nursing homes is old. Half of the homes, half, more than half the homes were built over 40 years ago. Three quarters were built over 30 years ago. They were designed for a different resident. They were designed in the old rest home type of resident, not for the Medicaid complex, multiple chronic condition individual of today. Many times who has severe either mobility or cognitive issues. We know that the design of the, all those nursing homes is horrific for infection, prevention, and control. So, we need to move to private rooms with private baths. We need to move to neighborhood models, which means where you have assigned staff that just work in that neighborhood. We've seen in evidence from studies like the Greenhouse model that when you do this, for instance, in terms of COVID, they had far greater success and keeping it out of their buildings, and even when it came in at dealing with it. So, that you have pods or neighborhoods and staff just work in that pod. Is better for the residents. They get to know that staff rather than seeing different people constantly. So, those are a few examples. Lastly, and most importantly though, I said, we have to seize this moment as an opportunity. That means all the sort of interest groups, operators, their investors, labor, organized labor, the consumer advocacy groups, regulators. Everyone's got to come to the table and figure out, "Okay. I'm not going to get everything I want, but how can we together come up with a package of things that we can then get policy makers to act on?" If we don't do that, if we define success as making sure that investor or that consumer advocacy group doesn't get what they want, we will miss this moment. It will be a fleeting opportunity because the nation will then move on from long-term care, because they can only stay on that topic for a short period of time. So, we're going to seize this moment. We're going to have to work together. We're going to have to come up with a package of things that won't represent everything that any one of those constituency groups wants, but represents something they can agree on that will genuinely seize this moment for real reform.

Hanh: 41:21

The fact that, the senior care is in the media, capitalize the window of opportunity into something positive and that work in a silo, but also working together across all sectors and come up with a comprehensive solution, as opposed to separate entities, individual sectors. So, that's great.

Robert: 41:39

Absolutely. And that, just to close on that, I would say we do need to. Those that don't need 24 hour nursing care who are there as long stay residents, we should get them out into the community. We should provide home and community based services and not have them in a skilled nursing setting. And we do need to have better funding for home and community based services. But again, simplistic solution. Gee, we can just shut down nursing homes, not deal with the problems there and put everything in the Home community-based services, cause everyone wants to stay at home. Yes, but the reality is as people live longer and live longer with multiple chronic conditions, not to mention long haul COVID folks. You know, there are people that are going to need the type of care that can only be provided in a skilled nursing setting and can also be provided most efficiently and effectively because if you need more than five or six hours of supportive care at home, or if you need care when you need it, as opposed to being able to schedule it in increments of time for a person to come, it gets very expensive very fast. So, we're still going to need nursing homes. We don't need the 45 year old nursing home built for three and four people in a bedroom, in a room which doesn't have private baths. That is something, yes. The more we can retire those the better. But we're still going to need nursing homes. We need to improve in them. We need to invest them in them. At the same time, we need to provide options out in the community for people that don't need to be in skilled nursing. And we need to not be forcing people into poverty as the only way they can get long-term services and support.

Hanh: 43:25

Thank you. Thank you so much for your passion. Okay, so I'm going to go into the next, the third topic. I know you've talked about how product segmentation into new living space is in its infancy, in what you call Boomerville segments will emerge. So, can you explain why you believe this?

Robert: 43:43

Sure. Well, first of all, when I talk about market segmentation, the oldest boomer is 75. We have. Thousands, hundreds of thousands soon to be millions of folks living past a hundred. So, to assume that the same product you're going to develop and market to somebody in their early seventies and to somebody well into their nineties, it's absurd. And yet we do that. So, one market segmentation is to realize those that they want a lifestyle that will keep them vital and healthy. And they're not really interested in care. They're more interested in a lifestyle that's going to keep them healthy and vital. I would argue that many boomers are not excited by extra longevity, if with it doesn't come vitality. And they want a lifestyle, that's going to keep them vital. The idea of "I'm going to be incapacitated for 30 years, but I'm going to be alive.", is not necessarily attractive to them. And so, they want to know what can I do in my sixties and seventies and even eighties, eighties, such that my health span is likely to match as closely as possible, my age span or lifespan. And so, that's part of market segmentation. People that are chasing the boomers or riding the boomer rave again, they're addressing people in there from there it's an 18 year cohort. So, they're addressing people 57 to 75, and that's a completely different market than the market we serve in assisted living communities now, for instance, where the average age of moving is 85 and residents are basically in their late eighties and nineties, and many believe boomers won't move into things like assisted living until at least their late eighties. So, if you're going to serve the boomer market, if you think the boomers have come, which I've been hearing, the boomers are coming for 40 years. If you think the boomers are come, you're not going to serve them with an assisted living product today, you're gonna, you're gonna misfire, totally. So, that's part of it just segmenting, the boomer cohort from the cohort both the greatest generation to find the experience of the war and the boomer generation to find the experience going to college, two very different groups. And within that, you have the between that you have the silent generation. The first half of that generation age wise, more like the greatest generation. The second half, much more like the boomers. This sort of lifestyle dynamic that I see going on, there'll be several features of it. One, it will be customized and personalized to give the boomer the sense they're in control. What does that mean? It means not bundling things because boomers are going to be suspicious. They're paying for something they don't need. It will also not be one size fits all. And all the marketing will be stressing that personalization, that customization, so that basically you can have the lifestyle that fits you rather than here's the lifestyle everybody wants. But I have defined a few themes within that. Now, some people have misunderstood this, these themes aren't mutually exclusive. In fact, most communities will mesh together a number of these themes. Some will emphasize some more than others. One theme of Boomerville. I've talked about is Wellnessville, where the whole focus is on health and wellness and vitality. And so, in that group it's almost like an extension of the Canyon Ranch and out of the Spa type and where diet and exercise and doing all the things to maximize vitality. The next area I talked about is Margaritaville. So, if one's about being healthy, this is about having fun. And obviously there is a Margaritaville, and there's a waiting list for it. And that's an example I'd say of, this is a community where the one theme here, they really stress, some would say to the exclusion of the others I'm talking about. So, Margaritaville the healthy me Margaritaville the fun me, then there's Changeville. The activist, me that's the boomers. We're going to change society. And they did it in the sixties, as I said earlier, but now in the 2020s, it's about global warming. It's about inclusivity. It's about diversity. It's it's about a number of issues, sustainability. If the sourcing of your food. What's your carbon footprint? These aren't trivial issues to the boomers and these are issues they're going to care about. So, the activist, me and other words, where the focus is on creating a new and better society. And That now in my older years, I now have the expertise and the experience. I know how to get things done and dog gone it we're going to change this." The next is Serviceville, the better me. This is about volunteering. This is about mentoring. This is about teaching. This is about caregiving. This is about raising money. But it's all about this is the better me. This is about uh, 70 year olds, boomers caring for people in their nineties. This is about mentoring, volunteering. This is about, as we saw during COVID, this is about residents of life plan communities, volunteering to mentor the children of the CNA age, working in their buildings. Because when they talked to the staff about the biggest concern of the staff, it was "My kids who are at home and they're not really getting an education and they're falling far behind. And it just really worries me." So, you have communities like Engleside, a life plan community here in DC, where they said, "Gee, we can help address that. We've got a number of masters and PhDs here." And so, they started partnering and they started mentoring in a sense, and volunteering to tutor the children of their staff. So, I think, and we've seen, there are other examples of programs like that all around the country. And then lastly, Collegeville, that's what I'd call the New Me. And as I said, greatest generation defining experience was the war, "Three hots and a cot.", as my father-in-law used to always say. For the boomers defining experience was college. And that was not about three hots and a cot. That was a little different focus. But, the new me is, it's about going back to college. It's about continuous, lifelong learning, or as Chip Conley, likes to say "Long life learning.", meaning learning so that you can have a long life. And so, this is about pursuing my passions, pursuing interests. It's about boomers now saying, "Gee, I'd love to go back and take a Great Books course because in college I just read the Cliff Notes cause I was afraid it was going to hurt my GPA for grad school. Now I'd like to go back and actually read those Russian novelists that wrote those a thousand page novels and then have a discussion. But I don't want to have the discussion at 2:00 AM in the morning, over a keg. I'd rather have it at two in the afternoon or at four over some good wine." And so, this is about the fact that boomers are going to be one of the most exciting new audiences for universities in the future, to take courses, to be residents on campus. And to also be doing, and there'll be issues of this in terms of union and tenure. But here you got folks that don't need healthcare benefits, aren't looking for tenure, but have tons of experience and could be great teachers.

Hanh: 51:25

Great. Great.

Robert: 51:26

You know, all of these WellnessVille, Margaritaville Changeville, Serviceville, Collegeville, they're not mutally exclusive. But different communities will be known for social change and activism. Others will be known for their volunteering. I see communities in the future that are going to attract boomers. Advertising, "90% of our residents are involved in volunteer organizations. Here's a list of the 30 organizations in Phoenix that our, that our residents volunteer in. ", or, " Here are four social issues that our community is known for its advocacy and the work we're doing on this." And I also see communities of the future that will say "60% of our residents are working. 25% of our residents have started new businesses in the last three years or since moving in." This, you wouldn't have conceived of this in terms of the old product that served the greatest generation.

Hanh: 52:27

Right. So, so you see more of a crossover as opposed to communities fitting into one of these buckets. Is that right?

Robert: 52:34

Yes, but I do think like with Margaritaville in Florida, some will be defined very much by one theme, but the themes aren't mutually exclusive. Most boomers are gonna care about wellness. And I think the aspect of continuing learning, it's going to be part of a lot of communities. It doesn't mean though that all these communities will be built next door to a college campus. As though we will see a number who are really going to put them Kendall Communities. Kendall has a number of communities built, Cornell, Dartmouth, Oberlin, Washington, and Lee. They've got all of these communities built basically next door to a college campus. So again, I think there's going to be exploding, uh, diversity here, but again, the values for the greatest generation were safety and security and comfort. Those are assumed, but the values for the boomers are, are sense of belonging and connection and purpose. And you're going to have to address that. Safety and security? Sure. Prevention, disease prevention control? Yes. Gotta do all those things. But you got to be about, I would say the old model, Hanh was a separated from model. The new model is an integrated with, in other words, you're not separated from the rest of the society, you're integrated with it. But it may not, it may be age restricted, but only for a it's only age restricted from nine o'clock at night until seven in the morning. In other words the days of saying, "How do you have, how do you foster engagement for your residents and pointing to a multi-purpose activity room?", and saying "That's how we do it." And then how do you keep them connected with the outside community?"Oh, see our van there with our name on it. We take trips out." That, cOVID has shown those two answers to be woefully inadequate. You flunk the test of being a senior living provider, if that's your response. So, connected, engaged in differing ways with the broader community.

Hanh: 54:43

How can existing senior living communities leverage this insight around Boomerville segment to stand out among the crowd? Is that something they can do right now? What would your advice be to those folks?

Robert: 54:55

I think it depends on the type of community they are. I think CCRCs, also known as the lifespan communities. They have a leg up on this because they've tended to much of the assisted living and memory care. And even to a great extent, rental independent living has in a sense follow the increasing acuity levels and older ages of their residents to, to market more and more care and less lifestyle CCRCs, particularly entrance fee CCRCs have most consistently continued to market lifestyle, and therefore it's not as much of a pivot for them, all right. But I guess the other point I'm making is that I think there's an enormous opportunity to capture boomers in their sixties and seventies with these types of models. But if you want to capture boomers in your assisted living product and in your memory care product, and in your independent living product, you better have a plan B for the next 10 years because they're not going to be ready to come into your community. And because the boomers aren't coming into today's assisted living. Let me close with this. If I were to take a step back and look at the big picture of senior living, particularly the private pay senior living that has grown so much since the 1990s, I would say that the first generation of product of senior living, which was designed to serve the greatest generation was 1990 to 2020, first generation product. It served the greatest generation. The second generation product I always saw as 2030 to 2060, serving again, the boomers, Defining experience college. I saw 20, 20 to 2030 as a decade of transition, but then what happened? COVID the first year of that decade of transition. And what COVID did again, was propelled us into our future faster. Trends about digital, trends about transfer digital hubs and connected health platforms, trends of bringing health and vitality and health care into where people live rather than shipping out for their healthcare. All of those trends got sped up overnight. And so, that's exciting. It's also challenging. But so, I think for existing providers as they look to pivot, if your assisted living independent living. Don't so much think of it as serving boomers, as your residents. Think about boomers and gen X-ers shopping for their parents and the questions they're going to be asking. And again, if your answer to the question of how are you going to address my mom's healthcare needs is to say, "See our van. We will take mom to the doctor's office and Oh yes. At night we have a great relationship with our local paramedics at the fire station.", you just flunked the test of providing healthcare. You're now going to have to show how in mom's apartment, in your building, how are you bringing healthcare services to her? How are you enabling her to be able to manage her chronic conditions so she avoids having to go out to the doctor's office and especially so that she avoids the hospital? That's and then are you keeping good data on that? Can you demonstrate your effectiveness? And can you use that then data, whether it's with a Best Buy or with whoever is holding the healthcare dollar risk for that senior, particularly that Medicare Advantage plan or that group of physicians, they farmed out that risk too. Can you demonstrate that your data, how you are keeping that person healthier longer in your setting so, they don't have to go to the hospital as much? That's relevant today, but that's not for the boomer resident. That's to the boomer or the Gen-Xr asking questions for their parents. And that's about basically integrating health and health care into your setting and showing that you know how to manage chronic conditions in a way that extends vitality. That extends, the end, and that keeps people out of the hospital and the doctor's office. So, to me again, great opportunity there. You're not going to be serving the boomers as your residents, but learn the lessons from COVID. If we think we're going to go back to business as usual pre-COVID, you're going to go out of business. The only question is how fast? But you have a great opportunity where we started our conversation, these digital tech hubs, these connected health platforms, enormous opportunity for today's senior living provider to partner or to themselves develop those platforms and to work with both healthcare providers, healthcare insurers and ultimately to have something really attractive to the consumer.

Hanh: 59:46

Great. Great. I echo that. I'm the daughter that was seeking for senior care for my mom in the comments that you made in the level of depth and questions that, you raise are the same level of questions that I asked for the different communities. Because you know what, I'm impressing them, whether it's, the interior decor and so forth. And that's wonderful, but I think folks like myself, we're going to go deeper in researching the communities. So, I echo you. So, thank you. Thank you so much. Do you have anything else that you would like to add?

Robert: 1:00:19

No, it's been a delight. Thank you for a wide ranging conversation. We covered a lot of topics. I appreciate that. And thanks for your great questions Hanh. And thank you for having me and hope we can do some follow-up on some of these observations and see what happened to them? When everyone talks about the future, you won't be a hundred percent right, guaranteed. And, but for all of us that like to study and look at trends and big picture movements, we gotta learn from what didn't go the way we thought it would go. What's different? So, that's always fun, and to see what we can learn from that. So, again, thanks, for the time. Thanks for this opportunity Hanh, I really enjoyed our conversation.

Hanh: 1:00:59

Absolutely. And I thank you for your time. Do you have anything else that you would like to add?

Robert: 1:01:04

Encourage People to go to Nexislnsights.net and to sign up for our newsletter. It isn't me, there are 13 of us. We're all we're all entrepreneurs in challenging the status quo. We're united in a passion about the field and a conviction we can and must do better by older adults. I would love to see people check us out at Nexuslnsights.net and sign up for our newsletter.

Hanh: 1:01:28

Great. Great. Thank you. You have a great day.

Robert: 1:01:31

You too.