Future of Aging

If You Hated 2020, You’re Going to Despise Old Age: A Nexus Op-Ed

It’s safe to say that none of us want to experience life as it was lived in 2020 ever again.

We missed our friends and family during the era of “social distancing.” In the short term, most of us could handle the loneliness. But as the pandemic wore on, we found that Zoom meetings and virtual happy hours, at first novel and fun, were a very poor substitute for authentic human connection and became tiresome and annoying. We grew frustrated with the monotony of a limited life. Netflix binges, family game nights and jigsaw puzzles eventually lost their appeal.

Most of us are tired of rehashing what life was like during pandemic lockdowns, but there are important lessons to be learned. Sadly, not everyone has the option for a life filled with purpose, autonomy, and variety. What we experienced during 2020 is the life many older adults living alone in their homes or institutional care settings experience every day – both before and after the pandemic. COVID lockdowns gave younger Americans an unpleasant taste of the “medicine” that millions of elders swallow every day.

We learned lessons during the height of COVID that we can — and should — apply to older Americans. The time is now!

What would it take to have older people live where they wish without becoming socially isolated? What would it take for older people to be viewed as valuable members of a society that desperately needs their lived experiences and knowledge? What would it take for those receiving care in congregate settings to have lives filled with purpose, meaningful relationships, and, dare we say it, joy?

Read the full article, If You Hated 2020, You’re Going to Despise Old Age, authored by Nexus Insights’ Fellows Jill Vitale-Aussem, Caroline Pearson, and Dr. Bill Thomas, on LinkedIn, and join the #NexusVoices conversation.

What do you think we have learned? How can we improve the future of aging in America?

About the Authors

Jill Vitale-Aussem, President & CEO of Christian Living Communities, and Nexus Fellow, has over two decades of boots-on-the-ground senior living leadership experience, transforming organizations by creating age-positive, ability-inclusive community cultures of growth, belonging and purpose.

Caroline Pearson’s deep understanding of public and private health insurance informs new financing models that leverage healthcare dollars to fund non-medical support for older adults. Caroline is the Executive Director of The Peterson Center on Healthcare, and a Nexus Fellow.

Dr. Bill Thomas, Nexus Fellow, founder of The Eden Alternative, The Green House Project and Minka is a serial creator of scalable models and an innovator in the field of housing and services for older people. He brings to Nexus his belief that people, properly equipped and prepared, can solve the most difficult problems of living.

Related:

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Impact of COVID In Nursing Homes

Problems We’ve Ignored for Too Long: A Hearing on the Impact of COVID In Nursing Homes

“COVID completely devastated nursing homes in the U.S.”

Dr. David Grabowski, a professor of health care policy at Harvard Medical School, and a Nexus Fellow, made this statement before a House subcommittee hearing on the impact of the coronavirus in our nation’s nursing homes.

Among the staggering statistics Grabowski shared with the subcommittee:

  • There were more than 1.2 million cases of COVID among nursing home residents, which led to roughly 172,000 COVID-related fatalities.
  • More than 2,600 nursing home staff members died from COVID, “making nursing home workers the most dangerous job in America.”
  • In the aftermath, both resident census levels and staff employment levels were down by more than 10% from pre-pandemic levels.

Drawing on his research, as well as his work on a commission with the National Academies of Sciences, Engineering, and Medicine, Grabowski made recommendations for reform to improve the situation for caregivers and residents going forward.

Grabowski urged policymakers to take a system-level approach to policy reforms to protect residents and caregivers. He emphasized that it is not too late. “We have an incredible opportunity right now to address problems that we have ignored for far too long.”

He proposed recommendations for short-run policies in two areas:

  1. Increase vaccination levels
    1. Extend the federal vaccine mandate for nursing home staff to include booster doses. Currently, only about half of all staff are fully vaccinated.
    2. Provide federally supported vaccination clinics for facilities with lower booster vaccine rates for staff and residents, to ensure that residents and staff have access to a vaccine clinic.
  2. Improve staffing
    1. Introduce a federal minimum staffing standard
    2. Increase staff pay and benefits
    3. Provide opportunities for career advancement
    4. Create a better work environment

“The way the U.S. finances and regulates care in nursing home settings is ineffective, inefficient, fragmented and unsustainable.” – David Grabowski

As a move towards a federal long-term care benefit, Grabowski suggested an approach for locally testing and creating benefit implementation with established criteria to evaluate success. He also emphasized the importance of accurate financial information to ensure payments are adequate to cover comprehensive nursing home care. In addition, value-based nursing home payment models should be created to reward facilities for providing better quality.

Additional panel members of the expert witnesses testifying before the House subcommittee included: Alice Bonner PhD, RN, FAAN; Adelina Ramos, Certified Nursing Assistant and 1199NE member, from Greenville, RI; and Jasmine Travers, AGPCNP-BC CCRN PhD RN, Assistant Professor of Nursing, NYU Rory Meyers College of Nursing.

See a video of the full hearing:

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Nursing Home Staff Vaccination and Covid-19 Outcomes

The emergence of the delta variant of the covid-19 virus has raised new concerns about nursing home staff as a vector of infection among residents. This is especially true in facilities with low staff vaccination rates, but the actual relationship between staff vaccination rates and resident infection is not well studied. That is why a group of researchers used CMS data on more than 12,000 nursing homes to get some answers. That group of researchers included David Grabowski, Nexus Fellow and professor of public health at Harvard Medical School.

What they found is that in locations with high community transmission of the virus, low staff vaccination rates were associated with a 132% increase in resident cases, a 58% increase in staff cases, and a 195% increase in resident deaths. The relationships were not as strong in areas with low community transmission.

These findings were published in a letter to the editor in the December 2021 issue of the New England Journal of Medicine.

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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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unvaccinated caregivers in long-term care

COVID on the Rise in Nursing Homes Again: Unvaccinated Caregivers is the Reason.

Here we go again. Despite the successful efforts nationwide to vaccinate nursing home residents, infections and deaths are increasing again in senior facilities. The reason? “Lagging vaccination rates among nursing home staff,” according to an Associated Press story in the Star Tribune.

Although nearly 80% nursing home residents are vaccinated, nursing home staff vaccination rates are much lower, about 59% nationwide, according to the story. This more closely matches the rate of vaccinated adults nationwide. The rates vary by state, however, with some states having vaccination rates as low as 40%.

The problem? This poses a danger to the unvaccinated staffers, and it poses a danger to the residents, even those who are vaccinated. Vaccinated older adults may be more vulnerable than younger people, particularly against aggressive COVID variants, such as delta. This raises concerns that “successes in protecting vulnerable elders with vaccines could be in peril,” the story reports.

“Vaccinating workers in nursing homes is a national emergency because the delta variant is a threat even to those already vaccinated,” according to Dr. Joshua Sharfstein, vice dean for public health practice at Johns Hopkins Bloomberg School of Public Health. “Older adults may not respond fully to the vaccine and there’s enormous risk of someone coming in with the virus.”

“Vaccinating workers in nursing homes is a national emergency because the delta variant is a threat even to those already vaccinated.”

David Grabowski, Professor of Health Care Policy at Harvard University, and a Nexus Insights Fellow, said “trust is the core question” among the unvaccinated, especially among low-wage workers who may not have confidence in recommendations from their management. “I think some of this mirrors what we see in the overall population, but among health care workers it is really disconcerting,” Grabowski said.

Read the full story.

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Patient and physician trust in U.S. Health Care

Trust in the U.S. Health Care System: New Findings

Caroline Pearson, Senior VP of Health Care Strategy at NORC at the University of Chicago and a Nexus Insights Fellow, announced the release of new research from NORC that examines physician and patient trust in the U.S. health care system. The research was conducted as part of the ABIM Foundation Building Trust initiative.

The study, which surveyed 2069 adults from the general public and 600 physicians, found that while 78% of patients report high levels of trust in their doctors, trust is lower among Black, Hispanic, lower-income, and younger patients.

Other key findings from the study:

  • Both physicians and patients trust clinicians more than they trust the healthcare system as a whole.
  • While most physicians trust community health services to support patients’ health and well-being, physicians report lower levels of trust in long-term care and home healthcare providers, who are essential during discharges and care transitions.
  • Physicians overestimate their patients’ ability to adhere to their treatment recommendations.
  • Although physicians understand the importance of building trust with patients, they do not always perform trust-building behaviors.
  • The majority of the public reported favorable or no change in how much they trust their doctor due to the pandemic, however roughly 30% of physicians experienced a decrease in their level of trust in the healthcare system and healthcare organization leadership during the pandemic. Rebuilding trust is needed.

The nonpartisan and objective research organization NORC at the University of Chicago was founded in 1941 as the National Opinion Research Center.  It’s purpose is to help governments, nonprofits, and businesses make better decisions through data and analysis.

See the findings.

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Ageism and Ableism

The Pandemic is Exposing Ageism and Ableism — and that’s a good thing

The COVID-19 pandemic has disproportionately affected the nation’s older population. In the process, it has also brought ageism and ableism — discrimination on the basis of physical and cognitive function — into the spotlight. Writer and activist Ashton Applewhite, the author of This Chair Rocks: A Manifesto Against Ageism, argues that this presents us with a unique opportunity to educate people about these two intertwined forms of bias, and to mobilize against them. 

Media coverage of anything aging-related has long been characterized by alarmist hand-wringing, the most egregious example being the gray tsunami metaphor. Coverage of the pandemic is no exception, given that some three quarters of COVID19-related deaths are of people over age 65, many occurring in nursing homes where the virus has run largely unchecked. Typical headlines read, “Ageism on the rise” and “Pandemic making ageism worse!” Don’t make the same mistake.

The pandemic isn’t generating more prejudice, it’s glaringly exposing the ageism and ableism that have been all around us all along. Because ageism is so unexamined, the pandemic is bringing it to many people’s attention for the first time. It’s not ageist and ableist attitudes and behaviors that are on the rise, it’s public awareness and outrage about this type of stigma and discrimination. That’s what’s new and here’s what makes it so exciting: we have a historic opportunity to build on that awareness.

Yes, there’s been awfulness, but there’s also been swift, fierce pushback: against the Telegraph journalist who suggested the virus could benefit the economy by “culling” older Britons; against the Boomer Remover nickname, the handiwork of clueless trolls; against the Texas Lieutenant Governor’s grotesque proposal that grandparents sacrifice themselves for the good of the economy. Supporting this kind of grassroots activism means framing the pandemic, in all its terror and uncertainty, as an unprecedented opportunity to join forces across age, race, and class and create a more equitable post-pandemic society.

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 Ashton’s This Chair Rocks blog. 

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long-term care

The Future of Long-Term Care Depends on Trust, Transparency, Liability Relief – Bob Kramer

In a recent op-ed with Morning Consult, Bob Kramer, Nexus Insights founder and Fellow, argues for the importance of transparency in nursing homes. But the situation isn’t a simple one, as he points out. With transparency comes the need for liability protections, and policy makers must look to history to understand the unique risks and requirements of the skilled nursing industry. 

The following originally appeared in Morning Consult. Reposted with permission.

No one is arguing that America should be satisfied with our current nursing home system. But we can expect to hear a cacophony of arguments on how to fix it over the coming months and perhaps year.

Nursing home operators will rightly point to chronic underfunding and the failure to address the real costs of long-term care for poor, frail seniors on Medicaid. Their critics will demand more regulation and enforcement, higher staffing requirements and better wages. Some will argue that any additional funding for long-term care should go to home and community-based services. If unfunded increases in requirements for nursing homes lead to increased rates of bankruptcy — and closures — across the sector, so be it.

It would be careless and unrealistic to argue that the skilled nursing industry is without value. Harvard’s David C. Grabowski, among other experts, has argued that it is necessary, and requires increased investment. Studies show that Americans are growing older and more frail; many have no family or are beyond the capabilities of those that they have, increasing numbers are homeless and millions will require 24/7 care, often in specially equipped and staffed facilities. Furthermore, as highlighted in the landmark “Forgotten Middle” study conducted by NORC at the University of Chicago, a giant influx of middle-class seniors is coming. Neither qualifying for Medicaid nor being able to afford private-pay seniors housing, many will “spend down” their resources and rely on Medicaid. That is simply not a tenable solution.

Twenty years ago, another industry crisis precipitated a dramatic decrease in the availability of skilled nursing facilities. Lawsuits had become so damaging that nursing home operators began to flee certain states in which plaintiffs’ attorneys, seeking insurance-mandated settlement payoffs, triggered a feeding frenzy. Insurance for operators became either unaffordable or unobtainable. As a result, many families who found themselves unable to care for an elder at home were left without appropriate options, unable to secure care for their loved one at any price.

In response, nursing home owners and operators began to develop limited liability partnerships in increasingly complex — and opaque — business relationships, all designed to shield assets from trial lawyers. That system exists today in many places, particularly with respect to larger, multi-facility operators. It enables these businesses to exist — but it also raises questions as to where the money is going.

This is why I have been advocating for even greater transparency throughout the long-term care industry. To be entrusted with a greater investment from government, owners and operators of care facilities must open up their books and allow regulators and policymakers to see that their investment is going to increased staffing, pay and benefits for those on the front lines, as well as toward improvements in technology, and enhanced infection prevention and control. In short, they need to build trust in order to gain dollars.

But should skilled nursing providers provide real transparency into their financials, without liability reform or relief from lawsuits? It would only benefit the same attorneys who benefitted from transparency in the 1990s. It would quickly become impossible or prohibitively expensive to get insurance again — and again, operators would seek to protect themselves. And again, dollars intended to go to the care and housing of our low-income seniors would go instead to ever more expensive legal actions or insurance premiums.

This is where policymakers must step up. Without liability protections, increased transparency will lead only to increasing costs, as opposed to improving the wages and benefits for front-line workers. The real losers will be the millions of poor, frail, complex-care residents who need 24-hour care, and the staff to care for them. Operators will have to agree to greater transparency and accountability. Advocates will have to understand that targeted liability relief is essential. Policymakers hold the keys to both sides working together.

Bob Kramer 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 and aging services field. 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.

Bob is founder and Fellow at Nexus Insights. He co-founded the National Investment Center for Seniors Housing & Care (NIC), where he now serves as strategic advisor. Nexus Insights is a think tank that brings together a diverse group of researchers, policy experts, entrepreneurs, and executives, each of whom are distinguished and well-established thought leaders on aging and aging services.

Read the op ed

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future of senior living

Let’s Quit Talking to Ourselves: Sarah Thomas and Bob Kramer on the Future of Senior Living

“They’re coming for our space,” said Sarah Thomas, CEO of Delight by Design, and a Nexus Insights Fellow. Thomas is an accomplished leader of innovation and a global aging expert, advising startups, large corporations and investors. “Those of us in senior living and senior care need to lift our heads to see what’s coming. We need to see how we can be part of creating what’s ahead of us.”

Thomas recently joined Bob Kramer, Founder & Fellow at Nexus Insights and Co-founder and Strategic Advisor for NIC, for a conversation on Senior Living Foresight TV, entitled “Let’s Quit Talking to Ourselves: Moving the Conversation Outside Senior Living.”

The two discussed the increasing presence of investors and large corporations in the aging industry. Kramer and Thomas agreed that outside companies can be perceived as threats. But a wiser approach, they advise, is to see opportunities for productive partnerships.

“We must elevate our voice to be heard beyond our own walls,” said Thomas. “If we don’t want to partner with them, we may be replaced. So we need to look at what is not our domain expertise, and to identify gaps and consumer expectations that we’re not meeting.” Kramer agreed, observing that larger companies have greater logistical support, and greater expertise in certain domains. The key is to look for partners who can help close those gaps.

“We must elevate our voice to be heard beyond our own walls.” – Sarah Thomas

Thomas and Kramer discussed the importance of ageism, which is everywhere, and impacts everyone, and not just the older demographic. Thomas’s consulting work includes helping investors understand the marketplace, and to see the true needs and not the perceived needs “that are often misperceived,” and based on ageist ideas and stigmas. The two agreed that communities need to know their own value proposition, and to know how to communicate it, if they want to have a bigger seat at the table.

The discussion also touched on the value of universal design. “If we’re designing for all instead of designing for old, then we have beautiful designs that are also functional,” Thomas explained. Her experience includes work with the integration of robotics and fashion. The lesson for the aging industry, she suggested, is that beautiful designs help accelerate the adoption of new ideas, a philosophy that should be applied to senior living and senior care.

The two also talked out the potentially lasting impact of the pandemic on the industry. “The pandemic reinforced the idea that senior living is all about care,” Kramer said. “Ultimately we have to offer an experience that is aspirational, that is about a sense of belonging, about the joy of being alive, and not just making it through the day.”

See the whole conversation:

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Bob Kramer and John Cochrane

How COVID-19 Has Impacted the Senior Living Industry: Lessons for the Future

“Out of the tragedy of COVID, there are a lot of silver linings, a lot of good things we’re learning,” said Bob Kramer, Founder & Fellow at Nexus Insights and Co-founder & Strategic Advisor at NIC.

Kramer was featured in a session entitled, “How COVID-19 Has Impacted Our Industry, a Conversation with Bob Kramer” as part of The Big Connect 2021, presented by HumanGood. Kramer spoke with John Cochrane, President & CEO of HumanGood, California’s largest nonprofit provider of senior housing and one of the 10 largest nonprofit senior living organizations in the nation.

“The worst may be yet to come in terms of public perception,” Kramer observed. “We’re just now starting to rev up for countless investigations, task forces, hearings, research studies, and so on that will ask one question: What went wrong and how do we prevent it in the future?”

The Big Connect is an annual event that brings together HumanGood’s leadership team, board members and strategic partners to showcase how they are designing experiences that inspire their residents, team members and prospective customers to live their best lives possible.

Click to view the entire conversation.

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