‘Start with the Why’ by Ryan Frederick

If you’re developing real estate housing projects for baby boomers, there are many critical dimensions to think about. These will include making the financing case, addressing the customer value proposition, and more. But the best way to approach them all is to think more deeply about the reason you are doing what you do. The article below, “Start with the Why” by Ryan Frederick, originally appeared in the 2021 MFE Concept Community Report.

Simon Sinek became a YouTube sensation with his 2010 TEDx Talk, “Start with Why.” The video has been watched more than 55 million times, and his book with the same title is a New York Times best seller. The message is simple but powerful: The most successful companies provide a compelling reason for why they do what they do. This compelling reason drives customer loyalty, increases employee retention and builds an inspiring brand. Apple, one of the world’s most valuable companies with a market capitalization of more than $2 trillion, is an example of a company that has excelled with this philosophy at scale.

As real estate developers and investors consider creating communities and offering services for baby boomers, a cohort 78 million strong with ages ranging from 57 to 75, it is critical to start with the question, why? There are at least three dimensions to consider:

Start with Why: The Financial Decision—With such a large cohort, there will be plenty of people looking for housing options as they age. Demand is not in question. But there’s more. Older adults tend to move less than younger people such as millennial and Gen Z consumers. The benefit for apartment owners is that there is less annual turnover of residents. It is not uncommon for renters over 50 to stay five years or longer. In addition, older adults that elect to move into apartments out of choice— “renters by choice”—tend to spend more for living environments they desire. Some apartment buildings that target older adults through design and programming have shown to receive a rent premium over equivalent conventional multifamily peers. This premium can range from 15% to 30% or more in some cases. All in all, the financial opportunity represented by the boomers is an attractive one.

Start with Why: The Customer Value Proposition—While the outlook for demand is attractive, older consumers can be fickle. Prospective residents, especially those living in single family homes, need a compelling reason to move. Considerations can be bracketed into two categories: pull and push. Pull factors draw people to a residence, whereas push factors drive people out of their current residence. Examples of pull dimensions include attractive unit design that incorporates universal design principles, ample common spaces for activities and socialization, a friendly and lively cohort of residents and hospitality-oriented staff. Examples of push elements include an existing residence that is expensive and difficult to maintain, is difficult to navigate with stairs, is geographically distant from desirable amenities and risks social isolation and loneliness.

Older consumers are generally not on an urgent timetable to move, unlike young people who need a place to live when graduating from school or relocating for a new job and can’t afford to purchase a home. Those that do have an urgent need to move may have health risks driving a change, and apartment living may not be the best option for them. As a result, apartment buildings targeting older adults tend to take longer to absorb than conventional apartments even when the value proposition is clearly understood by prospective residents and their families. However, if the value proposition is not compelling and a project is age-restricted, thereby limiting the market size, lease-up risk can increase significantly.

Start with Why: Helping People Live Longer, Healthier and More Purposeful Lives. Following Simon Sinek’s core message, the most successful developers and investors appeal to a deeper purpose. Successful aging is driven primarily by wise lifestyle choices; only about 30% of longevity is linked to DNA. Purpose in daily life, social connectedness, physical activity and financial security are all linked to longer, healthier lives. Real estate developers and investors have an opportunity to create an environment that helps boomers thrive as they age. Such a mission not only appeals to prospective residents but can also draw and retain a passionate workforce and engage partners, such as architects and third-party service providers, in a deeper way. It can be noble work that helps people take advantage of longer lives and fill an important housing need between single family homes and senior living.

I have firsthand experience applying this framework. I created The Stories at Congressional Plaza, an age-friendly apartment community in Rockville, Maryland, in partnership with Federal Realty Investment Trust, a public retail REIT. From the beginning, we framed our project using the question of why. It influenced our brand, location, design, operating model and key hires. Not coincidentally, the effort was both financially successful and impactful for residents. In fact, one baby boomer described the decision to move into The Stories as one of the best decisions of her life.

Aging baby boomers represent a golden opportunity for real estate developers. But without the right approach, it is more likely to turn into a failed or missed opportunity. Be sure to start with why.

Ryan Frederick is the CEO of SmartLiving 360, a strategic consulting and development firm focused on age-friendly communities. He is the author of the book “Right Place, Right Time: The Ultimate Guide To Choosing a Home in the Second Half of Life,” published by Johns Hopkins University Press. More information is available at www.smartliving360.com.

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A New Wrinkle on Aging – Jill Vitale-Aussem

In a recent blog post, Jill Vitale-Aussem, President & CEO of Christian Living Communities, describes how many women feel about aging–and it’s not good. Most times we focus on the negatives: the wrinkles, the aches and pains, the doctor appointments and so on. Fortunately, she has a more positive message to share, asking “what’s awesome about aging?” 

It turns out that while there are challenges that come with aging, there are also many upsides. Most older people agree that their lived experience makes them wiser than they used to be. There’s some evidence that older people are better able to see things from different perspectives than their younger counterparts and better able to find compromises. Studies also show that in our later years we are often just plain happier and have better well-being than when we were younger. 

Finally Vitale-Aussem reminds us that maintaining an attitude of gratitude is key. After all, she points out, “aging is just another word for living.” And living will be much more rewarding if we can focus on the positive aspects of life. 

Read the full article: https://www.christianlivingcommunities.org/blog/a-new-wrinkle-on-aging/ 

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Frazzled? Caregivers Turn To Nature

According to an AARP article published last month, many family caregivers have been turning to nature and outdoor activities for comfort and stress relief during the pandemic. Doing so can decrease worry and depression. The article cites Nexus Fellow Dr. Bill Thomas who, back in the early 90s, recommended keeping parakeets inside senior living communities to lift spirits.

The article points out that when going to baseball games, weddings, or even the grocery store seems too risky, simply getting outside can do wonders. The regular rhythms of nature can be reassuring in a time when so many other things seem uncertain. Here are a few guidelines to make the most out of your natural retreat time: 

  1. Put down your phone and walk away from your computer. They have their place, especially when we can use them to connect with others virtually via Facebook or Zoom. But they are no substitute for the rejuvenation of being outdoors.
  2. Pay close attention to the natural world. The way the plants grow, the changing color of the leaves. Even local wildlife like birds and squirrels can be utterly fascinating–if you take the time to look closely. 
  3. Go with others! Just because there’s a pandemic doesn’t mean you can’t take a walk with a friend. Experiencing nature together can really enhance the experience. 
  4. Recognize that you are a part of it all. From the stars in the sky to the cardinal at your birdfeeder, we’re all in one big cycle of life, giving meaning to everything we do–including and especially our caregiving work. 

Read the full article here

Read more about Nexus Fellow Dr. Bill Thomas here


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people holding hands

Medicare Advantage Hospice Carve-in Will Bring Challenges

According to Anne Tumlinson, Nexus Fellow and CEO of ATI Advisory, moving hospice benefits to more value-based payment models comes with some challenges and some growth opportunities for providers. Her remarks appear in a Hospice News article titled MA Hospice Carve-In Doubles in Size for 2022

Beginning in 2021, a number of Medicare Advantage plans began participating in a CMS experiment to provide hospice benefits to their members who elected to receive them. Typically, a MA member who elects to receive hospice benefits does so through traditional Medicare, not through their MA plan. Now in 2022 the number of MA plans participating in the program will double, going from 53 plans to 115. The experiment to allow MA payers to provide hospice benefits is slated to run for four years. Participation is voluntary for both payers and providers.

“In the short term, this growth represents primarily an opportunity for hospice providers in the markets where these plans are operating. The plans must pay Medicare rates and accept any hospice provider for a limited time,” Tumlinson told Hospice News. “The key opportunity/potential longer term threat is that the plans may move forward and establish special ‘value-based’ arrangements with a subset of the hospice market.”

Read full article


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housing for solo agers

What senior living providers need to know about Solo Agers

Adult children do many things for their aging parents, including helping them find a senior community. But what about “Solo Agers”? This term was coined by author and solo aging expert Dr. Sara Zeff Geber to describe those seniors who find themselves aging alone. Dr. Geber wrote the 2018 book, Essential Retirement Planning for Solo Agers.

According to Geber, “A significant number of Boomers will not have adult children to help them with care or relocation if living independently becomes difficult or impossible.” She cites geriatric specialist Maria Carney, MD, and colleagues, who determined in 2016 that “approximately 22% of older Americans had no one to turn to in a crisis.” 

In a recent article in the International Council on Active Aging’s The Journal on Active Aging, Geber points out that, while the COVID pandemic has brought into national focus the devastating isolation of those aging alone, it also made clear that there are opportunities for senior housing communities and the aging services industry to provide for the needs of solo agers. The important first step is to understand this cohort, and their unique needs.

“I noticed many of my contemporaries were starting to spend huge chunks of time and energy helping to care for their aging parents,” said Geber. “They were chauffeuring their parents to appointments, shopping for their groceries and other essentials, monitoring their medications, arranging for home repairs, and spending considerably more time on the phone and in person with them than they had in the past.” That got Geber wondering. “Who is going to do all the above for those of us without children? More questions arose. How many of us are there? What are our options? And how should we prepare?”

Among the differences she noticed that set Solo Agers apart:

  • Solo Agers (women and men) tend to be more highly educated and to have made a good living over their lives, making them excellent candidates for higher-end senior living. 
  • Congregate living offers the advantage of built-in community, to help Solo Agers make social connections, and avoid isolation and loneliness.
  • Choosing independent living that is connected to communities that also provide options for higher levels of care can provide peace of mind to Solo Agers, who want to prepare for greater care needs in the future.
  • Many seniors find comfort in moving closer to adult children or grandchildren. Solo Agers may likewise choose proximity to loved ones, who may be extended family or friends.
  • Solo Agers have typically been living independently, as “masters of their universe” their whole lives, and will want choices for how they live that allow them to continue to learn, develop, and pursue healthy lifestyles.

What are the challenges for senior living communities? According to Geber, “the first hurdle will be selling the concept.” This involves knowing how to sell directly to seniors who may approach the community alone, and make their decisions without the assistance, encouragement or “cajoling” of adult children.

The second hurdle is to develop models of housing that appeal to Solo Agers. One good example, Geber suggests, is to build residences, such as Garden Spot Village’s Cooperative Living House, that house a small number of unrelated roommates. The home provides private bedrooms and baths for the residents and shared communal space. Roommates in these residences maintain some privacy and independence, but they also have the opportunity to develop friendships and even family-like connections, and to provide one another with mutual support, much like what happened in ”The Golden Girls” TV show from the 80s).

Another example is cohousing. Geber describes it as “generally a grassroots effort by individuals who want to create a way to live together in an intentional community.” According to Geber, “Senior cohousing is one of the fastest-growing segments of the cohousing movement.” It’s also “extremely attractive to Solo Agers.”

According to Geber, the window of opportunity has arrived. Boomers have already begun to retire, and the number of Boomers who are also Solo Agers is large and growing. “Many of these individuals will have no real need to continue ‘aging in place’ in their single-family homes,” she said. “They will remain there, however, unless senior living communities demonstrate a viable and attractive alternative—one that meets Solo Agers’ needs to maintain their social networks and participate actively in their communities.”

Download the full article here.

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Innovation for Senior Living

Are We Being Bold Enough? Bob Kramer Keynotes SLIF 2021

Nexus founder and Fellow Bob Kramer set the tone of this year’s Senior Living Innovation Forum by kicking off the first day of the conference with a provocative keynote speech. “Are we being bold enough?” asked Kramer. “No. The industry demands a significant shakeup.”

What does innovation mean for the next generation of senior living customers? Will they be our customers? Is increased longevity a blessing or a curse? Will the boomers be a vast resource that is both unwilling and unwanted as contributors to our society and economy? What does senior living have to do with it? And what about those who have been left behind in the longevity revolution?

According to Kramer, the upcoming generation of senior living customers “wants nothing to do with senior living” because the image that comes into their minds when they think about senior living is a negative one. It is our job, he said, to reimagine and redefine what senior living can mean for the next generation.  

His keynote set off some lively conversations and debates, with several following speakers referencing and adding further insight to Kramer’s remarks.

Other highlights of the event include a talk from Nexus Fellow and SmartLiving 360 CEO Ryan Frederick about his book, “Right Place, Right Time: The Ultimate Guide to Choosing a Home for the Second Half of Life” and Fellow Sarah Thomas’ interactive session on experience design.


Watch Bob Kramer’s entire speech:


Photo courtesy of Influence Group.


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Alzheimer's prevention

How Can We Reduce Alzheimer’s? Start by Reducing Our Age Bias

When Americans think about getting older, Alzheimer’s disease is one of our greatest fears. But while we’ve long believed that there is nothing to be done to prevent it, a study by Becca Levy at Yale University suggests that the opposite is true. Ashton Applewhite explores the surprising and interesting finding that the negative messages our ageist culture has barraged us with from childhood on could actually make us more vulnerable to the very things about aging that we fear.

What affliction do Americans fear most? Alzheimer’s disease. I’m one of them, unless so many bones give out that I have to be carried around in a shovel. But facts comfort me. Abundant new data shows that our fears are way out of proportion to the threat—and that those fears themselves put us at risk.

Fact #1: Dementia rates are falling.  As I reported last April, the likelihood of you or me developing dementia has dropped—significantly—and people are getting diagnosed at later ages. That’s despite a surge in diabetes among older Americans, which significantly increases the risk. Numbers remain high—an estimated four million to five million Americans currently have dementia—but that number pales in comparison to all the people who are worried about getting it, and about aging in general. Why is that important?

Fact #2: Worrying about dementia—and about getting older—is itself a health risk. We’ve known for some time that attitudes towards aging affect how the mind and body function at the cellular level. New research published on February 7th in the prestigious Public Library of Science journal confirms that finding, reporting that people who associate old age with becoming useless or incompetent are more likely to develop dementia than people with a more positive outlook.

Scientists consider a gene called ApoE to be the primary genetic risk factor in late-onset Alzheimer’s disease, yet many who carry it never develop dementia. How come? Could environmental—and therefore modifiable—factors play a role?  The new study, led by Yale’s Becca Levy, worked with a group of 4,765 people over age 60 who were dementia-free at the start, more than a quarter of whom carried the gene. Levy and her team interviewed them regularly over the course of four years, asking them to rank their feelings to prompts such as, “The older I get the more useful I feel.” They found that people with more negative attitudes were twice as likely to develop dementia. In other words, positive age beliefs confer protection against cognitive decline—even among people who are genetically predisposed to the disease.

Both experimental and longitudinal research show that stress, which links to dementia, may be the mechanism. Levy’s team found that positive attitudes about aging can reduce stress and help us cope with ageist messages that bombard us from the media and popular culture. People assimilate cultural beliefs from early childhood on, and as these stereotypes become more relevant over time, we tend to act as though they were accurate, creating self-fulfilling prophecies. (More here about Levy’s theory of stereotype embodiment.) Positive beliefs (e.g. late life is inherently valuable, old age is a time of growth and development, olders contribute to society) help keep us healthy by buffering stress and prejudice: the effects of ageism. Negative beliefs (e.g. it’s sad to be old, old people are ugly, aging means becoming a burden) make us vulnerable to disease and decline.

It’s time for an anti-ageism public health campaign.

We’re stuck with our genes, but not with our behaviors or attitudes. Interventions work. Last year New York Times science reporter Gina Kolata described the decline in dementia rates as “what seems to be a long-term trend, despite researchers’ failure to find any effective way for individuals to protect themselves from Alzheimer’s, the most common form of dementia.” That is no longer the case.

Reputable researchers are careful not to overstate their findings, but the scientists behind this new study note that their findings have far-reaching social implications. In personalized medicine, for example, education could bolster positive attitudes in people at higher risk of developing dementia. On a broader scale, as Levy points out, the research “lays a foundation for creating a public health campaign to beat back against ageism and negative beliefs about aging.” I’ve been making this case for years.

No matter how you feel about the longevity boom, or just about hitting that next big birthday, everyone wants olders to stay as healthy as possible for as long as possible. Imagine the benefits to health and human potential of replacing negative stereotypes about age and aging with more nuanced, positive, and accurate portrayals. The 65+ population of the US is expected to double by the year 2030. Let’s get cracking!

The author of This Chair Rocks: A Manifesto Against Ageism, Ashton Applewhite is a leading spokesperson for the emerging movement to raise awareness of ageism and to dismantle it. Ashton has been recognized by the New York Times, the New Yorker, National Public Radio, and the American Society on Aging as an expert on ageism. She blogs at This Chair Rocks and is the voice of Yo, Is This Ageist? Ashton speaks widely at venues that have ranged from the United Nations to the TED mainstage, has written for Harper’s, the Guardian, and the New York Times, and is a co-founder of the Old School Anti-Ageism Clearinghouse.

This post first appeared on Applewhite’s blog.

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Improving the Availability of Long-Term Care

The Forgotten Middle: Improving the Availability of Long-Term Care

Don’t overlook the “forgotten middle” when creating policy, said Nexus Fellow Caroline Pearson, Senior Vice President at NORC at the University of Chicago. Pearson recently took part in an interesting and in-depth panel discussion on a report from the Bipartisan Policy Center (BPC) that provides policy recommendations for increasing access to long-term services and supports (LTSS).

The forgotten middle are those seniors who are “unlikely to qualify for Medicaid, and unlikely to be able to afford many of the private seniors housing options they may need as their health, mobility and cognitive status decline,” Pearson explained. 

She cautioned that while “we have tried before and failed to do major, audacious, long-term care reforms” there is reason to hope for something more significant now. “The magnitude of the problem before us has paralyzed us for a long time. But it doesn’t have to be a purely public sector solution,” she said. “There are private resources available, if we were more creative and organized about how we helped people find those and how we delivered them to people.” She cautioned that reform may turn out to be an incremental process. 

Pearson addressed the issue of helping people remain in their homes longer, which many seniors prefer. “When you look at the cost of care as people age, housing is a huge component. If we can safely and effectively keep people in their homes, that really lowers the annual cost of care.” In fact, now is a good time for advances in this area. As she pointed out, “In a year in which I’ve had basically everything delivered to my house, and all services come to me, it’s a good time for this sort of innovation.”

When asked which policy for expanding or improving long-term care would top her priority list, Pearson gave a nod to an idea raised by her fellow Nexus Fellows, Anne Tumlinson and David Grabowski. “Funding and program coverage is important, but the landscape is confusing. For people trying to help themselves or their loved ones, it’s difficult to know where to begin,” Pearson said. “Funding a navigation service, a place to begin, to connect you to the private and public resources available to you, would be a huge step in the right direction.”

Pearson was joined on the panel by Leena Sharma, Project Manager and Senior Policy Analyst at Community Catalyst, Henry Claypool, Policy Director of the Community Living Policy Center at UCSF, and Hemi Tewarson, Executive Director of The National Academy for State Health Policy. The panel was hosted by Marilyn Serafani, Director of the Health Project at BPC.

Listen to the full discussion.

Read the BPC Report.

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Healthcare at Home Options for Seniors

More Healthcare at Home Options for Seniors with the Choose Home Care Act

Big news on the horizon for seniors and the aging services industry. A bill introduced last month in the United States Senate would allow for in-home care alternatives to skilled nursing facilities for rehab and post-acute services. The Choose Home Care Act, which was sponsored by Senator Debbie Stabenow (D-Mich.) and Senator Todd Young (R-Ind.), has bi-partisan support.

In a recent article in Senior Housing News, Anne Tumlinson, CEO of ATI Advisory, Founder of Daughterhood, and a Nexus Fellow, weighed in on the winners and losers, should this bill become law.

It would be a big win for seniors, allowing eligible Medicare patients to receive extended post-acute care services at home, rather than in a nursing home, “without placing undue burden on families to care for them.” According to Tumlinson, “The benefits are long overdue.”

Qualified home care agencies would also benefit, according to Tumlinson, with an additional avenue for billable services. “This legislation would essentially allow home health agencies to compete with skilled nursing facilities,” she said.

According to Tumlinson, the flexibility to consumers means more overlap in the post-acute services that skilled nursing facilities and home health care agencies could offer. Skilled nursing facilities may view the Choose Home Care Act as a threat. In fact, the American Health Care Association has expressed concerns that “it would supplant existing benefits and increase out-of-pocket costs.” If the bill passes, it may provide opportunities for private pay senior living providers, Tumlinson explained. “They can entertain partnerships with qualified home health agencies. For instance, they might team up with a Medicare-certified home health provider that will receive the expanded Medicare payments to care for residents that are recently discharged from the hospital, while the senior living provider would be able to collect the private-pay rent.”

In addition to bi-partisan political support, the legislation has broad support, including AARP, home care advocacy groups, and senior housing organizations such as LeadingAge. The bill was introduced in the Senate in late summer, and has been referred to the Senate Finance Committee.

Read the full story at Senior Housing News.

Follow status of the bill.

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Vaccination in Long-Term Care

They Don’t Trust it. David Grabowski Weighs in on Low Vaccination in Long-Term Care

Why aren’t nursing home caregivers getting vaccinated? David Grabowski, Ph.D., Professor of Health Care Policy at Harvard Medical School and a Nexus Fellow, discussed the issue recently with Arthur Caplan, Ph.D., Head of the Division of Medical Ethics at NYU Grossman School of Medicine, and Judy Stone, M.D., an infectious disease expert. 

The biggest concern: The lowest vaccination rates are among those who have the most contact with residents. “I have encountered quite a bit of hesitancy among nursing home staff. Unfortunately, the vaccination rates are lower among the nurse aides, those with the most direct contact with the resident,” Grabowski said. “And that’s been the greatest policy challenge.”

The cause? Grabowski believes it’s often an issue with trust. “Nurse aides are making close to minimum wage. Oftentimes, they don’t trust management or leadership,” he said. “They’re very resistant to authority and being told what to do. There’s just not a strong relationship between labor and management in this setting. This is a for-profit nursing home where this workforce hasn’t been treated very well historically and hasn’t been treated well during this pandemic. Remember that direct caregivers in nursing homes had the highest death rate among any profession in the U.S. during the pandemic. More so than commercial fishermen, and more so than logging workers.”

“Remember that direct caregivers in nursing homes had the highest death rate among any profession in the U.S. during the pandemic.” – David Grabowski

Another issue? “They don’t trust the vaccine,” Grabowski said. “I’ve heard some concerns about side effects. Hopefully, some of that has receded. Hopefully, they’ve seen their colleagues getting vaccinated and have seen few side effects. But there’s a lot of concern about long-term side effects and the overall safety of the vaccine.”

Stone agreed. What’s more, she suggested that incentives can actually increase distrust. “Why do you have to give me a gift card to take this? Is there something wrong with it? It sows suspicion.” In addition, she said that vaccine mandates may lead workers to believe that, rather than making them safer, it will instead lead to them working in a riskier setting.

See the full discussion.

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