Dr Bill Thomas 2002 PBS interview

Human Growth and Nursing Homes – a 2002 Interview with Dr. Bill Thomas

What can the United States do to make senior housing and the lives of older adults better? This is a particularly hot topic throughout the nation, especially in the aftermath of COVID-19.

A recent report with seven bold, actionable and important recommendations was recently released by the National Academies of Sciences, Engineering, and Medicine. These recommendations, when implemented, will transform nursing home care, to make it person-centered, transparent, affordable, and create living situations that are good for residents, families, and staff.

Where did these revolutionary ideas come from? Let’s turn our calendar back a few decades and spotlight Dr. Bill Thomas, a physician specializing in geriatrics and a visionary ahead of his time. Thomas founded The Eden Alternative, The Green House Project, Minka and is currently the Chief Independence Officer for Lifespark as well as a Nexus Fellow. He has long been a driving force behind the vision that is transforming care for seniors. And he has been putting his vision into practice, piloting his ideas to demonstrate that nursing homes can be places for elders to thrive. We are delighted to have him on-board as a Fellow for Nexus Insights.

In a PBS interview that aired 20 years ago, Thomas said, “There has to be a commitment to ongoing growth…Even the frailest, most demented, most feeble elder can grow…And those words, human growth, nursing home, they’ve never gone together before.”

Thomas explained the inspiration for his ideas. “In the early 1990’s I took a job as a physician at a nursing home…and I fell in love with the work. And I fell in love with the people. And I came to detest the environment in which that care was being provided. The nursing home takes good loving, caring people and plugs them into an institutional factory-like arrangement. And it’s no good. I believe that, when we make a place that’s worthy of our elders, we make a place that enriches all of our lives, caregiver, family member and elder alike.”

“He was right and ahead of his time 20 years ago. He’s still right today. Unfortunately, the tragedy of COVID has revealed how much we devalue the lives of our older adults,” said Bob Kramer, Founder and Fellow at Nexus Insights.

“We need to be concrete about it. If we want to improve life for everybody in our society, one of the very best places to begin is changing how we think about, care for and honor our elders,” said Thomas.

Read the full interview.
See a clip from the PBS 2002 broadcast.


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Grabowski at covid nursing home hearing

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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7 Recommendations for Nursing Home Reform

Swinging for the Fences: 7 Recommendations for Nursing Home Reform

“Our whole policy infrastructure for nursing homes is broken in many respects: how we pay for them, how we regulate them and how they deliver services,” said Dr. David Grabowski, Professor of Health Care Policy at Harvard Medical School and a Fellow for Nexus Insights.

Dr. Grabowski was selected to participate in a National Academies of Sciences, Engineering, and Medicine commission tasked in reforming nursing home care. The 19-member committee worked for 18 months to create a report (published April 2022) with seven actionable recommendations to improve every aspect of nursing home care in the United States.

“The recommendations are bold. Nobody has accused us of trying to hit a single. We tried to swing for the fences in each of the areas of the report,” said Grabowski on a recent “Elevate Elder Care” podcast hosted by Susan Ryan of The Green House Project. “They can’t just be nibbling around the edges. They have to be transformative.”

The commission identifies seven key aspects in need of reform:

  1. Deliver comprehensive, person-centered, equitable care: “The system is broken because it’s not about the people receiving the services or the people providing the care,” said Grabowski.
  2. Prepare, empower and better compensate staff: “Everybody knows we have too few staff, training is not always up to par, we don’t pay them a competitive wage and benefits. This goal is around minimum staffing, ensuring that working conditions for staff are better, and improving the way staff are valued, paid and empowered.”
  3. Increase transparency & financial accountability: “This is an issue that predates the pandemic. Ownership is so much more complex, and it’s more necessary than ever that we get accountability and transparency, to make sure money is being spent on what it should be.”
  4. Create a more rational and robust financing system: “We propose a federal long-term care benefit. In other areas we have comprehensive federal benefits, but we piece it together for long-term care,” Grabowski said. “We should be paying a rate commensurate with a high level of quality. We have to figure out how to pay for it.”
  5. Reimagine quality assurance and regulation: “There is very little consistency among states. More data is needed about which quality assurance activities work, how we make sure the regulation is serving the residents well, and how we ensure that we’re improving performance.”
  6. Expand and enhance quality measurement and improvement: “A lot of our quality measures don’t work well. We have to reimagine quality measures, to make sure they reflect what residents and their families want in a long-term care experience.”
  7. Adopt health information technology: “Nursing homes lag behind other parts of the healthcare system, and they aren’t well connected to other parts of the system. It’s so important for care coordination. But they haven’t had the dollars or the incentives to do it.”

Grabowski is hopeful that the time is right for meaningful reform.

“The problems and the solutions have been around for 35 years, but COVID shone a light on it. It’s amazing the attention nursing homes have received. There’s tremendous interest now. Americans are waking up and saying, ‘Hey, this system isn’t working.’ There are long-standing issues that have gone unaddressed for decades. COVID galvanized Americans to look at this issue differently than they had previously.”

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Eco friendly housing for seniors

Two Challenges. One Solution. Age-Friendly and Climate-Friendly Housing.

Our growing population of older adults is facing housing challenges. Creative solutions are beginning to find a foothold. Ryan Frederick, an expert on housing and the role of place in healthy aging, looks at how those solutions could be used to simultaneously address issues of climate change in a Generations Journal article, published by the American Society on Aging.

“As a real estate developer and advisor to real estate developers, I see a valuable opportunity to rise to this challenge by developing communities that appeal to the needs and desires of older adults and incorporate design that is eco-friendly and climate change resilient,” said Frederick, CEO of SmartLiving 360 and a Nexus Insights Fellow. “As a concerned citizen, I know this challenge is urgent.”

Where people live has a big impact on their well-being, according to Frederick. “The best place elevates purpose, social connection, physical well-being, and financial well-being. Place can be designed to support our needs as we age and help insulate us from the perils of climate change.”

But he pointed to a variety of issues that make it difficult for people to age in place, including:

  • Housing that is designed for younger people without mobility issues. The statistics are striking. According to Frederick, “Only about 4% of all housing stock in the United States is suitable for people with moderate mobility difficulties.”
  • Single-use neighborhoods without convenient access to needed services and amenities. “Too much housing requires transportation to get to services and a lack of density makes it inefficient for services to come to the home.”
  • Social disconnectedness. “About half of older adults don’t know any of their neighbors,” he said.

In the article, Frederick offered actionable ideas to help communities address these issues, including:

  • Incentives for incorporating universal design principles in all new housing, which both emphasize the use of eco-friendly materials, and reduce the need for retrofitting as residents in the home age.
  • Housing developments that work for people of all ages, to help foster intergenerational connections, and reduce loneliness across all ages. Frederick pointed out the cost incentive for landlords: vacancies are reduced when older adults can remain in their housing even as their physical needs change.
  • Housing design that reflects the role of the home as a place where people increasingly receive their health care.
  • Choosing locations for housing that are less prone to disasters such as flooding and wildfires and therefore are more resilient to climate change.
  • Designing neighborhoods for walkability. Reducing the need for car travel is both age-friendly and eco-friendly.

“Ultimately, as a society and as individuals, we will be defined by our legacy,” Frederick observed. “How did we positively impact the generations following us?”

Read the full article in Generations by the American Society on Aging.


Ryan Frederick, MBA, is the CEO of SmartLiving 360, an Austin, Texas–based strategy consulting and real estate development firm focused on the intersection of successful aging and the built environment. He is the author of Right Place, Right Time: The Ultimate Guide to Choosing a Home for the Second Half of Life. He is an Encore Public Voices Fellow, a Nexus Insights Fellow and National Advisory Board Member for Johns Hopkins University School of Nursing.


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The Challenge of Senior Communities

The Challenge of Senior Communities Staying Affordable in a Time of Rising Prices

Nexus Fellow and CEO of Christian Living Communities, Jill Vitale-Aussem, discussed the challenges senior communities are having in remaining affordable amidst rising costs and staffing shortages on the Senior Housing News’ Transform Podcast with Tim Regan.

Inflation in everything from food to utility costs, combined with continued wage escalation can drive increases in monthly service fees and rent. Vitale-Aussem is concerned that this will lead to shrinking the already limited population of older adults who can afford senior living. Her organization is focused on evaluating opportunities for greater efficiencies, especially in the areas of construction, amenities and staffing.

Staffing continues to be a challenge for her communities, but she’s seeing bright spots. “One of our communities that was having staffing challenges is now fully staffed,” she said. “We now celebrate that the way we used to celebrate 100% occupancy rates.” She said they’ve achieved success by getting more creative in recruiting and casting a wider net. She offered several suggestions, including the importance of explaining the story of why working in senior living is so rewarding. “It’s a pretty amazing work opportunity for people, but they don’t know.”

Watch the full video at Senior Housing News.


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Bringing together different perspectives with a common passon

Bringing Together Different Perspectives with a Common Passion

Nexus Insights is a think tank comprised of a diverse group of thought leaders and stakeholders in aging and health care (Nexus Fellows) with a shared vision to advance the well-being of older adults through innovative models of housing, community and health care. The goal of Nexus Insights is to affect change by sharing innovation across traditional silos, convening leaders from different perspectives in our Nexus Voices salons, and bringing positive, life-affirming ideas into the public domain.

What makes Nexus Insights truly unique is the diversity of our Fellows. We bring together different perspectives and different backgrounds, leaders with expertise in academic research, government policy, private sector startups, and successful businesses serving older adults. It’s the diversity of perspectives, together with the common passion, that drive the disruptive thinking within Nexus.

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. Learn more about Bob Kramer at Nexus Insights.


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Senior Living and Hospitality Industry

Senior Living – a Huge Opportunity for the Hospitality Industry

There is a newly emerging market for new models of lifestyle-driven senior living, and it’s a “mammoth market that nobody owns,” according to Bob Kramer, Founder of Nexus Insights, and Co-founder, Strategic Advisor of NIC – the National Investment Center for Seniors Housing & Care.

With over 35 years of experience in the seniors housing and care industry, Kramer has long been recognized as one of the most influential and high-profile thought leaders in the field. In a recent article in the Boston Hospitality Review, he shared his thoughts on the changing market and the opportunities for the hospitality industry.

The market for senior living is growing rapidly, but the demand is for something different than traditional care-driven products. Kramer observed that baby boomers are the first generation to make housing and care decisions for their parents, due to lengthening lifespans. “And they didn’t like what they saw.” Rather than traditional assisted living solutions and nursing homes, boomers are looking for living situations that “appeal to their desire to remain engaged and fulfilled in their lives.”

“From 2020 to 2050, new models will be driven by a new type of customer, and a new way of thinking about retirement and aging,” Kramer said. “This generation of senior living products will attract younger seniors with products that deliver engagement, connection, and fulfillment, and will draw residents who still have decades to live. The business potential of such a market is significant.” Heavyweights as well as new entrants in the hospitality field, such as Disney and Latitudes Margaritaville, are already recognizing the business potential, and introducing novel housing developments aimed at seniors.

The opportunities are not without challenges, and Kramer identified several, including affordability for the growing middle-income market, sometimes called “the forgotten middle.” In order to be successful in this new market, it will also be important to address both lifestyle and care needs for senior residents. Kramer’s recommendation is “to leverage industry expertise to deliver what seniors want in terms of lifestyle choices, and what they need in terms of care.”

According to Kramer, the challenge for those entering the market, ”is to deliver personalized experiences that are metaphors for being alive rather than signals that meaningful life is over. The demand will be huge, but this product is yet to be delivered.”Read the full piece in the Boston Hospitality Review.


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The Green House Project and Pioneer Network Partner to Improve the Lives of Older Adults

A new partnership between the Green House Project, a not-for-profit dedicated to creating alternative living environments for seniors, and Pioneer Network, a not-for-profit advocating person-directed care, is being cultivated to improve the lives of residents in nursing home communities. According to Skilled Nursing News, “the joint entity will serve as a full-continuum consulting, advisory, and education partner for eldercare organizations.”

Industry visionary, Geriatrician and Nexus Fellow, Dr. Bill Thomas, has a long history of improving the quality of life and purpose for older adults. In the 1990s, he co-founded the Eden Alternative, the Pioneer Network and in 2003 he founded the Green House Project.

“For years, the Green House Project and Pioneer have collaborated on a variety of eldercare reform initiatives, driven by our shared history and mission to improve the lives of nursing home residents today and in the future,” said Pioneer Network President & CEO, Penny Cook. “Together, we will go farther than we could as parallel travelers on the same path.”

Read more at Skilled Nursing News.


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Special Focus Facility program

CMS ‘Retooled’ Special Focus Facility Program Pushes for Faster Upgrades to Troubled Nursing Homes

CMS is going to put troubled nursing homes on a fast-track to improve with a ‘retooled’ Special Focus Facility program as reported by Bloomberg Law. Those who don’t make it will have their certifications revoked. This effort is designed to bring problem providers into compliance more quickly. But according to David Grabowski, Nexus Fellow and Harvard Medical School professor, there could be a downside to consider.

This new approach could be “taking dollars and access away from beneficiaries who don’t have anywhere else to turn,” says Grabowski, adding that “there’s not always operators lining up to enter into those markets.”

There are approximately 15,500 Medicare and Medicaid certified nursing homes in the United States. Approximately 2,500 of them have one star ratings.

Read more at Bloomberg Law.

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Cohousing for Seniors

Cohousing for Seniors – An Instructional Model for the Senior Living Industry?

Cohousing for seniors. It’s an intriguing alternative to aging-in-place, especially for those willing to make a housing change before they are forced to and who want a setting that reinforces the values and activities that are important (or meaningful) to them. Cohousing could also be a key model for the senior living industry as it seeks to attract the boomer generation.

“Professionals in the senior living industry are dragging their feet about making the changes necessary to attract boomers.” While they are remodeling old units with new kitchens, adding fresh paint, hiring top chefs, and even involving residents in policy decisions, “it doesn’t address the devotion many boomers have to their work, their communities, their causes and projects, and their families – the exact kind of interests of people in cohousing,” said Nexus Fellow Sara Zeff Geber in her recent post in Forbes.

Most people don’t know about cohousing communities, but there are over 200 of them in the US right now with more in the works. They are intentional communities built around a set of shared values. They are also places where people can live independently and can request services as they need them. This could be a better alternative to staying at home for too long and realizing too late that some changes should have been made years ago.

Read the full story at Forbes.


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