Shirley Weinstock, 91, lives in a studio suite at Jewish Home Family at Rockleigh, a senior residence in New Jersey, not far from Manhattan. On a recent weekday morning, I had the pleasure of meeting her in a Zoom call.
Since mid-March, when most US states entered Covid-19 lockdowns, retirement homes have banned all visitors, though most now permit outdoor, social-distanced visits. Group recreation programs were cancelled, or at least postponed indefinitely. Weinstock, like people in care homes around the world, also had to adjust to eating meals alone in her room for a spell, rather than in the dining room with friends from the building.
How does she feel about these changes? She shrugs. “I know that whatever they’re doing, they’re doing it for our safety, our health,” she tells me. “They had us confined to our apartments, they brought us our meals.”
“I read, I did my crossword puzzles, I watched television,” she recalls of the first month or so of isolation. Her three adult daughters phoned regularly to chat.
Weinstock explains that she lost a leg when she was hit by a car, so she uses a wheelchair. The caregiving staff at the home, where she has lived for five years, are “wonderful,” she says, beaming at someone off-screen.
“Is there anything you’d like to see change?” I ask.
Suddenly energized, she points at the white roots encroaching on her chestnut-brown locks and declares, “I’d like to get my hair done.”
Leaning forward toward the camera, she adds with frustration, “Why can they have the salons open all over New Jersey and not here in our home?”
That Weinstock doesn’t mention how the coronavirus infiltrated her residence this spring may be a sign of how successfully the home has managed to protect some normalcy for its residents despite its traumatic spring.
In total, 76 cases developed in seniors and staff out of 527 total number of people. Tragically, 28 residents died, 22 in the skilled nursing rooms, and six in assisted living. (Weinstock lives in the assisted living section, whose residents don’t require regular medical care.)
Carol Silver Elliott, CEO of Jewish Home Family, says that she wishes she knew in March what she has learned since. “We have our testing resources. We know who those people are. We’re keeping those relationships close. We’re sharing best practices with our colleagues. I think we’re in a very different place than we were several months ago,” she says.
When the coronavirus arrived—first brought in by an asymptomatic family visitor, she believes—Silver Elliott had to figure out how to procure personal protection equipment for her staff and masks for the residents, all without help from the government. There was no official guidance regarding how to manage or watch for symptoms. Staff found themselves doing things they never imagined, like suiting up in full protective gear to enter the room of a sick resident with an iPhone or iPad, so that a family member could connect with a loved one virtually. People who joined the company to lead bingo games or dancercise classes were instead witnessing what was sometimes the last conversation between family members.
“The staff have been through a lot,” says Silver Elliot. “They’ve watched people they love die from this. They’ve been in situations they never thought they would be in, in their careers.” The whole experience has been devastating, she says, and it still weighs heavily on everyone.
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The complicated reality of senior housing during Covid
The statistics about deaths in nursing homes are so overwhelming that it can be hard to grasp the amount of pain and grief that they describe. In the US, nursing home residents and other seniors in residential settings make up about one percent of the population. Yet they account for 10% of total Covid-19 cases and a staggering 40% of fatalities to date, according to a New York Times analysis.
An even higher percentage of Covid-19 deaths in Canada were linked to long-term care homes: more than 80%. That ratio is skewed partly because community transmission was more successfully contained in Canada than in the US, but some Canadians also blame their provincial governments for not acting quickly enough to protect the elderly. Many countries in Europe reported that half or more of their Covid-19 mortalities also occurred among seniors in care homes. In Spain, the figure was 66%. In France, it was 48%.
Readers may notice, however, that the picture both Weinstock and Silver Elliott paint of their experiences do not totally align with other media accounts of senior homes dealing with Covid-19. Their battle sounds nothing like the nightmare at a rehabilitation center in Andover, New Jersey, where 17 bodies were found stacked in a shed in April, or the nursing home in Riverside, California, where all of the residents had to be evacuated because too many staffers did not show up for work.
Some of these catastrophic cases involved criminal neglect, reckless management, and blatant attempts to hide illnesses from family. But many other facilities did all they could, with staffers putting their own health at risk, all without the public support they required. “We did a really good job,” says Silver Elliott, “and I resent being lumped into the same bucket as those who didn’t.”
Covid-19 deaths in nursing homes and assisted living centers were not inevitable. One nursing home in Baltimore has so far seen zero cases of Covid-19. Its director, Derrek DeWitt, was so alarmed by President Donald Trump’s comments in late February claiming the 15 cases in the US at the time would be resolved within a week that he locked down his residence immediately, the Atlantic reported. His reading of the international news told him to ban guests, monitor staff closely, and buy masks and gowns right away; now it appears that early action was in fact a key defense against a viral outbreak.
“Being in an underserved part of Baltimore City, we’ve kinda gotten used to the fact that if help is going to come, it’s probably going to come too late, so we need to take care of ourselves,” DeWitt told PBS. As it happens, Silver Elliott, whose nursing home is in a solidly middle-class suburb, says she learned that same lesson during the pandemic. For her, the realization was new.
To be sure, assisted living and nursing homes are doing their best to counter the narrative of nursing home carnage and caretaker apathy that has tainted the industry, and there’s a public relations war happening between the homes and elected leaders. In some states, including New York, seniors homes’ administrators, residents and their families believe that orders from state governors to take in patients who were discharged from the hospital before recovering led to many deaths for which the state should take responsibility. Meanwhile, nursing homes chains are seeking immunity from lawsuits expected to be filed by angry and grieving families, and many states are granting some legal protections.
Nevertheless, although Jewish Home selected Weinstock for a press interview, I also trust that she was not being censored or coached. Why? Because my mother, who lives in a memory care unit of a retirement home in Canada, has said all of the same things about her life in lockdown—right down to the complaint about her unruly hair.
I share all of this by way of an introduction to our series on the future of senior living, because it’s helpful to establish that the present state of senior housing is more complicated than what has surfaced in the news.
In fact, given the tens of thousands of deaths in care homes globally, it would be understandable to question whether senior housing—an industry worth hundreds of billions in the US alone—will survive Covid-19 at all. It may seem logical to think that, seeing how quickly a virus can spread in multi-unit residences with shared common spaces, more families will choose to become unpaid caregivers for their elderly relatives, or that more people will work harder to arrange aging-in-place services so they can remain in their own homes as their needs escalate.
That slice of the senior care market is in fact expected to grow exponentially, continuing pre-pandemic trends. Mortgage lender Freddie Mac just released data showing a steady and significant increase in sales of so-called in-law suites, granny pods, or coach houses—officially known as accessory dwelling units, or ADUs—between 2009 and 2018. Although Freddie Mac’s report doesn’t include demographic information, it seems safe to assume that the pandemic will further fuel interest in ADUs for aging parents.
But for people who need greater levels of care, especially 24-hour care because of a physical or cognitive disability, living with family or aging in place may not be feasible. Besides, the astoundingly low death rates in well-prepared nursing homes in Singapore and Hong Kong suggest that communal senior housing—which is designed to protect seniors from the well-documented health hazards of social isolation and save families money through economies of scale—can survive pandemics like this one relatively unharmed.
Demographics are also squarely on the industry’s side. With 10,000 boomers turning 65 every day in the US, and advanced economies facing aging populations and dropping birth rates, retirement residences and nursing homes appear unlikely to shut down or go out of business because of the Covid-19 pandemic.
That said, the lessons learned from this battle, and the universal anguish and outrage over how the disaster unfolded, may mean that senior housing could become much safer, more enriching, more equitable, and better understood.
It will almost certainly permanently alter the way nursing homes are designed and operated, and could pave the way for entirely new models of integrated communities—a new cultural consensus, as geriatrician and innovator Bill Thomas puts it, that gives seniors of all income levels a choice about how to live into old age.
If we’re fortunate, a true reckoning with the grim events that led to so many deaths may also push people around the world to examine the deep biases we hold against the aged and aging. “We upended every other system—suburbia, education, child-rearing, college campuses—but not long-term care,” Dan Reingold, CEO of RiverSpring Health in New York told New York Magazine. “Now the pandemic is forcing us to take care of the design and delivery of long-term care just as the baby boomers are about to overwhelm the system.”
The inequities in senior care make everyone less safe
In January, long before Covid-19 was deemed a serious threat to North America, I wrote a series of stories about the cost of aging comfortably, and the differences between assisted living homes, nursing homes, memory care, and other housing and care models. I talked to people developing new housing systems, like a Soho House-style co-living club that would appeal to those who loved travel and the arts, multigenerational apartment complexes, and dementia villages.
The experts who spoke to me then were aware of deficiencies in the system, namely, that caregiver jobs were not valued enough, despite labor shortages in every world market, and that senior housing solutions have so far been out of reach for lower-income Americans, particularly those without a home to sell. In the US, rents in assisted living can average $4,000 to $5,000 per month and rise to $10,000 and beyond in luxury properties.
American nursing homes are partially funded by Medicaid, but cost an average of $7,500 per month for those who don’t qualify. Thus, because of systemic racism in the US and elsewhere, elders who live in senior care are overwhelmingly white, while those who provide care are often women of color earning minimum wage or less, often without stable full-time positions or benefits. They eke out a precarious living.
In the US, nursing home regulations—governing issues like staffing ratios and infection control training—have been relaxed under the Trump administration. There’s only a patchwork of state laws, some of which are far more lax than others, that pertain to assisted living companies.
Assisted living operators argue that less regulation allows them to create a less institutionalized atmosphere. Industry giants like Brookdale, Sunrise, and Amica emphasize their hotel-like offerings, and a promise to grant residents as much independence as possible. (Many allow pets and all permit residents to furnish their suites as they see fit, both of which are not possible in most nursing homes.) It’s this model which has been exported around the world, in some cases allowing gross profit margins of more than 40%.
But consumer groups say that assisted living facilities should be subject to federal oversight and far stricter regulations, especially because people are living longer and are increasingly frail when they move into these properties. They also say that regulations that do exist in any care category have not always been enforced, allowing bad players to continue operating despite fines and repeated inspection failures, often with fatal consequences.
Not shutting down those players who have violated regulations long before the pandemic appears to have been a driver of Covid-19 deaths in Canada, too, whereas a history of showing zero-tolerance for noncompliance may have contributed to Australia’s relative success in protecting the elderly there. (As of mid-July, there have been 40 deaths in nursing homes in that country, although case counts were spiking in Victoria state.)
All of these topics are again top of mind for experts after Covid-19. “One of the things that I really think is important for people to understand is we need to pay attention to this population, the people who are being served as well as the people who are giving the care,” says Robyn Stone, co-director of the LeadingAge LTSS Center @UMass Boston, a research group focused on aging population issues, “because they’re both at risk.”
Over the past few months, frontline caregivers have been heralded as heroes of the pandemic, alongside ER doctors or nurses, particularly by family members who saw them as a lifeline to loved ones. But they’ve also been unjustly made to look complicit in Covid-19 deaths, for showing up to work when they had become virus carriers or working at more than one residence. Caregivers often do not earn enough to make a living in one job and instead cobble together a few jobs to survive, which is stressful for those who wouldn’t choose that lifestyle and is shown to lead to poorer outcomes and inconsistent care for seniors, says Stone.
If staffers caused more spread of Covid-19 by traveling between their workplaces, that is not on them, but on a system enabled by income inequality and discriminatory ageism.
Before Covid-19, the injustices in senior care had not “caught the imagination of the public,” says Stone. “I’m not even sure that you can put the blame on any one entity. I think it has been a societal failure,” she tells me. But, she says, the search for a truly sustainable and equitable model is now urgently sought around the globe—whether in the United Kingdom or in Sweden— “and that gives me some hope as well.”
What’s already changing
The most immediate and obvious impact of Covid-19 in homes for seniors has shown up in preparedness plans. Silver Elliott says she now has PPE supplies under lock and key, and she’ll never work anywhere that doesn’t have a 100-day supply at the ready.
Many senior care homes are now upgrading their ventilation filters and air exchange systems to reduce the possible spread of Covid-19 through aerosols, says Tim Mullaney, editor of Senior Housing News. Some were sourcing antimicrobial surface materials before the World Health Organization this month said contracting the disease from surfaces was less likely than feared. Jewish Home Family may buy portable ventilation equipment that could be used to create negative pressure rooms, which are typically used in hospitals to isolate patients with contagious diseases and prevent potentially contaminated air from escaping.
Beth Mace, chief economist at the National Investment Center for Seniors Housing & Care (NIC), says the new infection control protocols in senior housing are likely to stay in place, and that more residences are likely to adopt some of the robotic technology now deployed in some hotels to constantly clean high-traffic areas and handrails.
Where pub nights and farm-to-table cuisine were the key talking points for sales people at senior homes before the pandemic, the focus has shifted squarely to health and safety. For better or worse, assisted living and nursing homes are now seen as part of the healthcare continuum, Bob Kramer, NIC founder, told the Senior Living Innovation Forum this spring.
Nursing homes and assisted living companies are also making physical changes that do not require costly renovations, says Mullaney. A few weeks into shelter-in-place orders, several senior homes designed makeshift “clean rooms” in which plexiglass partitions separate residents and their guests. He believes such safe spaces will become permanent fixtures.
But the more dramatic architectural changes prompted by Covid-19 are still to come. Many industry experts foresee a rise in properties made up of smaller households, or pocket neighborhoods, whether as a collection of homes on one property, or as clusters and pods within a large building. The thinking is that such a design would not allow an undetected virus to travel quite as freely. In the case of an outbreak, pods could be isolated more easily, and seniors might still be able to socialize within their units.
The concept was first introduced to senior housing through the work of the aforementioned geriatrician Bill Thomas, who invented the Green House model—or movement—two decades ago. He wasn’t thinking specifically about pandemics, but instead designing for more humane daily-living in skilled nursing homes. Rather than ask older people with complicated medical needs to live in sprawling and disorienting institutions that house hundreds of people in hospital-like rooms, he envisioned a home-like setting where seniors would see the same faces every day. Green House properties are divided into households of about 10 to 12 people, who share an actual living room and communal table for meals, next to a recognizable kitchen, not a commercial cafeteria. Care workers are encouraged to get to know the community members—”elders” in Green House parlance—as people, not patients.
More than 260 Green House properties now exist across the US and many more are in development. Independent studies have found that on the whole, they do enable better outcomes for seniors and cost savings for Medicare. Significantly, Green House properties have so far fared better through Covid-19, seeing fewer infections than traditional skilled nursing homes. Thomas, who is no longer affiliated with the Green House project, predicts the idea will take off “like a shoot” because of Covid-19, and others agree, even if future developments take inspiration from the Green House footprint without embracing all of its philosophical tenets.
Future projects may also incorporate spaces for things like telemedicine visits, says Mullaney, and purpose-built mailrooms for packages and deliveries from family. Mace says many providers have already built outdoor living rooms for residents to socialize safely, with space for social distancing, and meet family and guests. That emphasis on outdoor space, particularly private patios and gardens, is expected to continue long past the pandemic.
Finally, Covid-19 could rearrange the way staff work in care buildings. During the pandemic, some operators set up grocery stores for employees inside their homes, or sent employees home with food, to minimize the amount of mingling staff would need to do with people outside their own households. Some large, national providers and small regional players went further, inviting staff to move into buildings, or trailers parked on the property, so they could shelter-in-place alongside the senior residents, as Quartz reporter Katherine Foley discovered.
It’s not an entirely reactive measure: Live-in managers, usually married couples, used to be a distinguishing feature at the independent living chain Holiday Retirement, Mullaney explains. “That was very popular, but it became more difficult for various reasons,” he adds, “including that it is a big ask for people to do that and it takes a particular kind of person.” Covid-19 may make this approach popular again, despite the extra costs.
The rise of senior tech
Before Covid-19, elder tech was already a growing category. Alexis Ohanian’s Catalyst venture fund had already invested in autonomous taxis for the senior community. Wearables, like a wristlet and fob that allows homes to track seniors’ whereabouts and to protect those with dementia from wandering, were slowly gaining traction. Amazon, Best Buy, Walmart and Apple made products or completed acquisitions that pointed to—or at least hinted at—a move into the senior care and home health market.
Now, says Stephen Golant, a gerontologist, author, and professor emeritus at University of Florida, the pandemic has led to“ the elevation of technology as much more of routine, as opposed to exceptional, response to old age.”
As has been true everywhere, telehealth has surged inside long-term care buildings, says Golant, and will likely stick around as a convenient and safe option. Wearables are likely to gain steam, too, he says, both for seniors at home and inside congregate settings. They could detect falls or track metrics like rising pulse rates, a possible sign that the body is preparing to fight an infection.
Providers were already experimenting with voice-activated, senior-friendly technology before this spring, but now they realize that these apps could provide useful data during or before a crisis. So, too, could infrared cameras that quietly track a person’s movement inside their rooms, says Mace. “Let’s say that this infrared camera is watching you, and it knows that typically, at two o’clock in the morning, you get up to go to the bathroom, and all of a sudden that computer system now tracks that you’re getting up three times a night,” she says. The system could alert a nurse or caregiver to the change, because chances are there’s something going on, she adds, like an infection or a gastrointestinal illness.
John Means, a McKinsey real estate consultant, also tells Quartz that providers are looking at wearables as potential early warning systems, but that McKinsey’s surveys found that the technology is of more interest to those who manage the residents, and the families of elders, than to the residents themselves. When his firm—which has developed smart home systems for multi-family housing—surveyed seniors, it found they were more interested in having people on site, particularly in the case of an emergency. If they’re interested in new technology, it’s not to make their lives more efficient, says Means. “They’re looking for more ways to fill their time. They’re asking, ‘How can I find events within my community that are going to fill my passion?’” he says. What they really want is “the electronic replacement of the community calendar on the refrigerator,” says Means.
More immediately, the pandemic’s lockdown orders quickened the adoption of video technology to help friends and families outside the home connect with people inside, or to connect people inside residential homes, without having residents meet in one room.
Some providers were ahead of this trend, building small in-house production companies and green-screen production studios, says Mullaney. “Now they’re relying on those capabilities to be able to put together messaging and programs and to do virtual versions of their usual programming,” he says, “whether it’s for fitness, or for church services,” or something else. They’re also seeing the same faces they’ve always seen—not strangers on YouTube, which can be tricky for the computer-illiterate.
Here comes the neighborhood
Retirement homes are sometimes seen as sad islands for the elderly, but top providers have been working for years to build better connections with their surrounding communities. As Quartz reported in January, intergenerational concepts and mixed-use developments, some on college campuses, are the latest architectural approaches meant to pave over any separation between the community at large and the cloistered seniors.
Part of their motivation, “just to put it in crass commercial terms” says Mullaney, “comes from seeing the big boomer generation coming and wanting to start building those close relationships early.”
But designers and planners are also recognizing the value of creating long-term care homes that are fully integrated into a city. Before the pandemic, a Danish architectural firm began construction on a nursing home that shares clinics, shopping areas, walkways, and other public spaces, with the local, working class Copenhagen neighbourhood. Protecting seniors during a public health crisis in such a space would come down to the conduct of the staff, the chief architect told New York Magazine.
With public awareness brought to the plight of seniors stuck inside their residences because the world had become too unsafe for them, and heightened empathy for what it feels like to have limited social contact, many communities have organically started to build more ties with local seniors homes. “We’re seeing things like bands coming and performing in parking lots or church services happening in parking lots, or drive-by parades, or different kinds of programming that happens just online with big sort of celebrity names coming in,” says Mullaney.
Some of the entertainment programming developed during the pandemic pushed the sophistication factor up a notch. For instance, the Seniorly podcast produced a variety show that connected seniors with Broadway singers performing live from their living rooms. The comedian Nick Kroll headlined one episode.
Of all the people I spoke to about this topic last winter, Stephen Golant was the most wary of making predictions and most open to a wide range of possible futures. He had thoughts on where the industry was heading, but he also cautioned that some unforeseen event could upend all predictions and take the industry in a new direction.
Here it is, just a few months later, and the world has changed. A public health crisis has taken the lives of tens of thousands of seniors living in congregate care around the world, and it appears that many of those deaths could have been prevented.
The pandemic has also triggered an economic crisis that put millions of people out of work. Now the need to find an affordable model for seniors who need daily support will be even more pressing.
In the short-term, it already appears that private senior living companies will rebound financially, to a degree, from the pandemic, says Mace. After significant drop-offs in April, June’s data showed that occupancy rates are still trending downward in all categories of senior residences, but more slowly, according to a NIC survey.
Golant reports that some providers even saw a small surge in demand at the start of the pandemic, when people realized that self-isolating older family members would be cut off from their usual support systems and would be safer, physically and emotionally, in the company of others. Counterintuitively, it’s possible that more families will actually see the value in retirement homes because of Covid-19, he says.
Anecdotally, says Mace, she has heard from many housing operators that the lockdowns that also banned new move-ins have created pent-up demand. Her thesis is that once the world has an effective vaccine, occupancy rates in senior housing will return to pre-pandemic levels or better, because new construction has slowed down and supply has dwindled. She’s also betting that more companies will continue to pay workers, particularly caregiving staff, the higher wages that many instituted as “pandemic pay.”
But it would be folly to suggest that we can guess where senior housing goes in the longer term. Ideally, Covid-19 will instill a sense of productive shame about the way governments, culture, and the acceptance of highly profit-motivated businesses in this sector has left so many seniors vulnerable, despite the best efforts of caregivers and families in most cases.
Aging is inevitable for all of us. If we’re fortunate, we might now feel pressed to make the project of rebuilding the entire system everyone’s business.