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Bridging Business & Emotional Intelligence

Bridging Business & Emotional Intelligence

If you have personal experience with Horses and the evolving field of Equine-Assisted Learning (EAL), you are aware of a powerful truism: animals, nature and the non-verbal skills they represent breed an accelerated path toward gaining confidence, patience & knowledge in caregiving.

When our education is tied to verbal language (as it nearly always is), our potential to share and absorb information is limited.  Having completed the Master’s Program of the Erickson School’s Management of Aging Services, I can attest to the intellectual and experiential capacities of Dean Judah Ronch and his Faculty, but even the best of academia would agree that the pinnacle of teaching – when hearts and minds are transformed by information sharing – can’t be planned for – sometimes it happens in spite of our best efforts. Interestingly, it did happen recently at the 3rd Annual Memory Care Summit and can be relayed best by highlighting the book ends of an experience that was shared by all at the South Seas Island Resort in Captiva, FL. We may have traveled to a Summit  titled, “Breaking Away from the Pack,” but the outcome of our time together triggered an alternative thought – What would it mean for our Senior Living Industry if we became a Herd instead of a Pack?

Power Outage – the First Book End

If it is true that “words matter”, then Blind Pass on Captiva Island is living up to its name. Over 700 vacationers and residents were without power for almost 12 hours after an alleged intoxicated driver struck a utility pole on Captiva Drive. The South Seas Island Resort was darkened and without power until 7AM on Tuesday – an hour before the Conference was to begin.  It’s pretty common to get a Maslow reference at a conference event no matter what industry is represented. The “hierarchy of needs” is timeless for obvious reasons – and the survival state that a power outage conjures reminds us that our collective consciousness shifts 180 degrees when our environment dramatically changes.


As I settled in with my morning coffee, I began the Conference ritual of scanning the room for friends and colleagues as they meandered into to the lobby. When I heard attendee Bob Oriol (CEO of Oriol Healthcare) say something to his neighbor about “self-awareness”, a calm fell over me. I accepted that this might not be a typical “business” conference with empty keywords or hashtags.  Bob caught my attention again mid-morning when he asked an important question: “How do we (or should we) differentiate between Dementia problems vs. Thinking problems?” The answer to this admittedly quasi-rhetorical question is much less important than the spirit of the inquiry. If there was a single theme that was about to emerge from the Conference, it was simply that we all need reserves of patience and education in order to prevent and treat what we might want to call a memory spectrum. While the 10 Early Signs and Symptoms of Alzheimer’s provide important cues for a diagnosis, there is a silver-ling on the preventative side of the equation – Active Aging and the dimensions of wellness that it proffers hold the key(s) to better health for old and young alike irrespective of a clinical code or label.

In a healthcare system that has been dominated historically by “specialization”, we are reminded that a disease like Alzheimer’s is becoming so pervasive that it will require us to work together not only across multiple disciplines but also more deeply – at a universal (human) level. It is easy to be complacent about some of the other top ten leading causes of death either because we feel more empowered to prevent them or because the emotional impact of the symptoms and caregiving requirements are perceived as having a different scale and quality. According to the Alzheimer’s Association, friends and family of people with Alzheimer’s and other dementias provided an estimated 17.9 billion hours of unpaid care in 2014 and an estimated 5.3 million Americans of all ages have Alzheimer’s disease as of 2015.

When John Erickson, industry pioneer and founder of the Erickson Companies, took the podium for introductory remarks, I was further comforted to hear him proclaim that “aging-in-place” is not a good solution for what ails us. This is of course the challenge that we have charged ourselves with. On the one-hand, we know that we are building properties (need-driven) having limited lifestyle appeal (whether they have memory programs or not) and on the other hand we recognize that the home and community-based setting is poorly suited for aging services “in-place”.

Memory Care Landscape

As CEO of the National Investment Center, Bob Kramer is in a unique position for sharing data metrics as well as his anecdotal personal insights in witnessing the evolution of the Seniors Housing & Care Industry – and notably its cycles surrounding arguably “payer driven” products and services. After sharing some of the emerging trends pertinent to Memory Care as a property-type, Bob stepped away from the NICMAP data to offer his personal observations and to suggest there are three general provider characteristics differentiating new entrants to the emerging Memory Care sector.

  1. New Business Opportunities – entrants principally driven by recognition of the market demand absent specialized programming (the “danger zone”);
  2. Comfort/Safety/Cleanliness – entrants equally alert to the market opportunity and promoting basic services yet absent specialized care capabilities (the “comfort zone”)  –  and
  3. Ongoing Intense Commitment – entrants representing the genuine attributes of customized quality care, progressive program development and customized environments (the “real deal”).

If there was a single soundbite to use as an umbrella takeaway for the 2016 Summit it would be to charge ahead as group three by focusing on

  1. Education and Training of Staff;
  2. Attention to the Physical Environment;
  3. Investment in Changing Ideas/Culture, and
  4. Engaging residents, families and caregivers in a personal way.

Interestingly, when Ryan Novaczyk and Bill Holman shared their own provider experiences with entering the Memory Care market (representing New Perspective Senior Living and Sagepoint Senior Living, respectively) both relayed how the four point process referenced above has expanded beyond the walls of their planned neighborhoods. In summary, the attributes of great care are universal to all populations.  Both Ryan and Bill represent genuine passion driven providers to learn from and to be emulated – the “real-deal”.

Living with ALZ – the Second Book End

Linda MacCallum and her boyfriend Paul Larson joined Dr. Peter Rabins as guests for our final session.  Linda had suffered multiple concussions throughout her life and began to experience severe memory loss in her late forties.  She was subsequently diagnosed with early onset Alzheimer’s Disease before she was fifty years old. As we listened to her heart wrenching story and she relayed her experiences and emotions, the air became magnetic. After three days of sitting in a confined venue with over fifty other heads, the feeling of a single heart emerged. As I listened to Linda and Paul, my mind’s eye traveled back to comments and questions that I might have made in prior sessions: they all seemed so inconsequential when juxtaposed with her real life story. The survival state that our power outage had conjured may have passed quickly but the human narrative that Linda shared reminded us why were on the island to begin with. I wondered how we would prioritize our daily actions if the spell of these moments lingered. More importantly, what did Linda relay that is actionable for each of us? She needs to have patience, purpose and peace of mind so that she is not a burden to family and friends. She does not want to be reminded of her symptoms and she increasingly wants decisions to be made for her. Perhaps most dramatically, she views the products we provide as being worse than a death sentence.  We need products and solutions that are valued and embraced by individuals like Linda – rather than feared.

Pack vs Herd

Hearing Linda’s emotional story reinforced thinking about why we are in the business we are in and who we really serve.  It ignited the key points presented by Scott Townsley (Industry Professional and Faculty Member) surrounding new Business Models and strategic business directions.  It is clearly a new day for the Senior Living Industry where the traditional product and services approach is being dramatically redefined and redirected by a changing landscape – where who we serve rather than who pays for it drives such change.  We are now well engulfed in the era of the operator who defines our future while the payer influences become subordinate to recognizing and rewarding success.  As we confront these new directions, the “real-deal” providers alert to new ideas, innovation and progressive business development will prevail.  Only by avoiding the “danger zone” and reaching beyond the “comfort zone” will we collectively attain the genuine branding of quality services and compassionate care we strive for.  In coming together, collaboration must displace competition among the “real-deal” constituents to our world.

If collaboration is the driver for marshaling and managing our change landscape, then new technologies and innovation are undoubtedly the fuel sources to fire the engine.  Breaking away from the Pack breeds isolation while cultivating like-minded Herds fosters collaboration and expectedly acceleration.

The most obvious literal distinction between Pack and Herd dynamics is understood by emphasizing the non-predatory and cooperative nature of grazing animals. Of course, the simple contrast of hunting and grazing should be enough to complete the metaphor! When you consider the depth of expertise represented by a Conference like this and couple it with the prescriptive nature of the clear take-away, it becomes evident that we need better distribution channels for knowledge. Summits like this and programs offered by the Erickson School provide an important next step.

Post-Acute Program Development

Post-Acute Program Development

CCA serves in a financial advisory capacity to the Board of Directors of a community based not-for-profit skilled nursing provider in the Greater Boston market area.

Recent initiatives have included the introduction of a distinct short-stay unit of operations to accommodate increasing post-acute and rehabilitative service programing. This initiative was undertaken by reducing licensed bed capacity to accommodate the conversion of an existing long-term care unit to establish 20 private room accommodations; introduction of common area amenities; and reconfiguration of more customized resident support areas. The unit renovation and conversion was funded through extended capital provided by existing lenders interests.

The strategic business plan ideally introduces more distinct and customized post-acute programming responsive to market trends and demands of emerging ACO providers as well as other primary referral sources.


A Case for Convergence

A Case for Convergence

The future of what we now call the Senior Living Industry needs to be forged by a more collective voice. We are all familiar with Miles’ Law which states that “where you stand depends upon where you sit.” If you apply this thinking to our own Industry, an important question emerges. Does this future of aging rely upon attributes that are unique to any single age cohort? The clear answer is no. There are a myriad of consumer personas characterized by the tidal wave of baby boomers alone. The Senior Living Industry should represent what constitutes quality housing, care and connectivity for everyone. This requires us to learn from and incorporate what is happening in adjacent spaces. If we learn to rise above the market silos we have created, we will better honor our shared journey as a community. Aging begins at birth and the future belongs to all of us.

Senior Living

Progressive Senior Living providers are now focused on battling ageism and promoting more community connectivity. They recognize that lifestyle and personal preferences beyond supportive services alone must be sourced and delivered. To compete with an expressed preferences to “age in place” at home, it is necessary to offer an equivalent alternative – with broader programming. The unspoken issue is that freestanding homes do not offer an ideal setting for any age group either – they are only superior to the loss of independence that senior housing options conjure in our psyche. Even the allure of suburbia is fading because of a preference for quality over quantity in life and we are starting to question our role (and responsibility) in creating the built environments we share.

​When we leverage technology and economies of scale we get more value out of products and services. Increased consumer education reflects a market force that is not unique to seniors or boomers alone. Information access is the common thread disrupting all of our business models and worldviews. We want more, better, faster and we know now that it is possible.

Urban living / Coworking

Coliving and Coworking environments are being created in revitalized urban settings with growing prevalence. The same principles apply – exhibiting trends of community connection catering to lifestyle preferences. There is a coworking space in Syracuse, NY. that recently published a post titled, The Case for Micro-units. The author John Talaric relays that, “Coworking spaces supply these independents with a rich working environment where they can meet, make business connections, and be more productive than outside of home offices and cafes.” Is this not analogous to challenges confronting the Senior Living Industry? Community spaces supply isolated people and organizations with a rich environment where they can meet, make social connections, and be more productive than they can be from inside of their independent homes.

Common Threads

The example above is obvious and trite, but the argument for more integrated community development is simple – our world is changing and we need more customized property development that responds to evolving needs and preferences. The future of aging is not about our elders alone. It is a future that we need to imagine for everyone. We need better Cities and Towns cultivating connectivity rather than fostering fragmentation.

Knowledge Notes #002

Knowledge Notes #002

CCA’s “Knowledge Notes” covers varied perspectives on trends and best practices in the Senior Living Industry together with news about our practice, clients and associates. We want to help create a better future for aging by supporting professionals whose main capital is knowledge.

Read and Share:

July 28, 2015

Knowledge Notes #001

Knowledge Notes #001

CCA’s “Knowledge Notes” covers varied perspectives on trends and best practices in the Senior Living Industry together with news about our practice, clients and associates. We want to help create a better future for aging by supporting professionals whose main capital is knowledge.

Read and Share Issue #001:

July 27, 2015

Come together for Medicaid dependent elders

Come together for Medicaid dependent elders

A recent article in Newsweek entitled “You Don’t Want to Be Old in These States” amplifies a longstanding dilemma confronting long-term care providers in rural settings across America. The Medicaid program is broken – where inadequate funding is a breeding ground for unfortunate incidents like this. The negativity fueled by such circumstances should be a call to action rather than a blemish on the industry and its majority of compassionate providers of care to our Medicaid dependent elderly.

The emerging landscape of the collective Senior Living Industry is leaving the chronic care resident behind – particularly the resident dependent upon Medicaid funding. The industry remains highly fragmented where providers remain payer driven – more focused on payer sources to subsidize if not abandon the losing proposition of Medicaid funding. It’s time for the industry to come together to leverage the proven “low-cost” alternative of the nursing home setting – and drive legislative change rather than being policed in a reactive fashion by escalating regulations.

All constituents to the industry have ownership in the circumstances we confront. As we migrate away from fee for service to more outcomes oriented payment systems, antiquated government payer programs focused on cost reductions require reengineering to foster more integration and alignment of all providers.

It is essential that payment reform reaches across the “continuum of care” – providing reasonable incentive for all providers in the most cost effective and efficient care setting. Perhaps a solution could stem from thoughtful integration and redistribution of public funding – aligning interests rather than fueling a divide. It is no surprise that the aging inventory of nursing homes in rural America where there is inadequate public funding to support reasonable costs of care or for reinvestment in property interests is breeding “horror stories” like this. They will remain unavoidable until we catch up with the times.

Lead or Exit: Strategic Business Planning for Senior Living

Lead or Exit: Strategic Business Planning for Senior Living

Health Care Reform has essentially mandated that the Health Services realm imagine a New Future for Aging. This requires cooperation with the full complement of sub-acute care providers coupled with a renewed focus on technology gains and partnership with multiple stakeholders. Strategic Business planning that is responsive to emerging trends and dynamic changes in this sector must be equally informed by broader social and economic influences. Absent clear markers of Leadership and Vision, the advisable direction for current Operators is an exit strategy or plans for succession.

With all of the complexities emerging from healthcare reform, it is clear that the prevalence of “silos” threaten our survival. Now more than ever before, health care providers must conceive and execute strategic business plans to safeguard their asset interests and promote sustainability of continuing operations. This is particularly relevant to the Senior Housing & Care Industry – and most notably to freestanding operators of Skilled Nursing Facilities. The stable of inter-related issues and opportunities that confront us are financial, legislative, clinical, architectural, social and environmental. We would clearly advantage from an integrative perspective that acknowledges Aging as a universal process where preventative and human-centered measures apply equally across all age cohorts and business specialties.

The Skilled Nursing Sector is being dramatically redefined – where the traditional model of long-term chronic care is antiquated and trending to extinction. The new model is defined as the sub-acute provider – represented by progressive operating, clinical and rehabilitative service capabilities that are fully aligned and integrated into the “continuum of care” – strategically positioned and qualified to partner with acute care providers in particular. The greatest opportunity represented by the Skilled Nursing provider is a proven history of being the most cost effective post-acute care setting. The greatest threat is meeting and sustaining the qualifications to seize this opportunity.

Progressive operating capabilities and demonstrated care outcomes are essential. The key drivers for meeting the challenges of this new landscape will be strategic initiatives that promote active collaboration; foster provider integration; and leverage technology to evidence best practices and demonstrated outcomes. Strategic business thinking must extend to product, program and practice delivery – fully integrated and optimally aligned in the healthcare provider community. The status quo is clearly not viable – and undoubtedly operators not responsive to change will be casualties. Providers absent the willingness and resource capacity to conceive and implement Strategic Business Planning should take the next exit.

Not-For-Profit ALF Development

Not-For-Profit ALF Development

CCA recently completed a project development and financing transaction for a community not-for-profit skilled nursing and assisted living provider located in the Seacoast market of New Hampshire.  The transaction involved securing $16MM in development financing from a commercial healthcare lender.

The project contemplates an expansion of existing operations to accommodate 52 added units of assisted living and memory care programming for the provider.  Serving as business and financial advisors, CCA provided full scope services to originate, plan and close the project transaction.   The strategic business plan ideally leverages existing operations while revitalizing and expanding existing asset interests to strengthen and broaden continuing operations.

Rating the Five Star Ratings

Rating the Five Star Ratings

The Kaiser Foundation published an issue brief in May that presents an analysis of the February 2015 update of the Nursing Home Compare database: Reading the Stars: Nursing Home Quality Star Ratings, Nationally and by State.

The brief extends to identifying correlations between nursing homes and reported ratings – factoring not-for-profit vs. for profit status; number of licensed nursing home beds; and state locations. The brief effectively amplifies the complexities and select shortcomings of the Five Star Rating System – as well as the inference that there remains a high degree of subjectivity in the system. However, the analysis excludes two fundamental criteria that undoubtedly breed material variability in ratings. Namely, the attributes of financial performance and property features that are essential considerations in proving correlations among providers.
A conclusive correlation between not-for-profit and for-profit providers cannot be made absent a financial analysis of differentiations. This extends to elements of financial performance as well as capital structure. Factors associated with revenue realization, expense management, profitability and capital resources are highly variable and influential to the rating criteria. Financial metrics introduced in a transparent and uniform manner would prove insightful in validating or otherwise interpreting correlations.

As to property features, similar variability exists among providers beyond bed size alone. Chief among these are the age, condition and functional design of the operating environment. Operating efficiencies, and by extension financial performance, drive outcomes and prove influential as to impacting rating criteria. These are important disparities to consider. Prevailing initiatives to reposition, revitalize or re-invent new models of nursing home care are clearly responsive to the predominately aged inventory of nursing homes. This trend amplifies growing recognition that the traditional “geriatric” nursing home model is not sustainable – while new models the likes of The Green House Project and Small Homes emerge. These new models are clearly conceived to support and promote resident and staff satisfaction above all. This in turn advances all facets of performance outcomes – the fundamental drivers for any rating system.

As we consider the three domains of the existing Five Star Rating System (Staffing Measures; State Health Inspections; and Quality Measures), advancing efforts to develop a more reliable and equitable process – and to draw valid correlations from reported ratings – the playing field needs to be leveled. Truly reliable ratings are predicated on differentiating between the drivers of the measurement criteria – financial and operational factors alike.

SWOT – Highlights

SWOT – Highlights


  • SNF Providers enjoy a distinct competitive advantage in the emerging environment driven by longstanding market insight and experience qualifications
  • SNF Providers are threatened by not adapting to changing Product, Program & Practice
  • SNF Providers are uniquely positioned to leverage new identity and strategic re-direction
  • The status quo is not sustainable in the new and emerging Senior Living landscape

SWOT – Strengths

swot-strengthsMarket Considerations

SNF settings are proven as the low cost providers in the post-acute environment. SNF Providers are advantaged by:

  • Growing demographic demand for skilled services – both post-acute and long-term care
  • The need-driven attribute of its business
  • Being most competitive in providing service value at low cost

SNF providers are competitively entrenched in the local healthcare and community market

Regulatory Influences

  • The franchise nature of the SNF Sector remains competitively advantageous
  • SNF Providers are most adept at managing regulatory intervention and influences
  • SNF Providers are proficient in the management of third party payer reimbursement
SWOT – Weakness

SWOT – Weakness

Product Attributes

  • The traditional “geriatric” model nursing center is not sustainable
  • The SNF Sector represents a low margin business
  • The SNF Sector is increasingly competing with assisted living product and other home and community based service providers
  • The SNF Sector is replete with aging property interests requiring capital reinvestment

Practice Attributes

  • The SNF Sector has historically been misdirected by adopting payer driven business strategies
  • The SNF Sector exhibits limited progressiveness in leveraging technology
  • More formalized and intensive marketing efforts are required to sustain and improve census and promote quality mix of residents.
  • Managed care associations require more aggressive and targeted collaboration coupled with demonstrating performance expectations
  • Limited proficiencies among direct caregivers are prevalent with respect to combining clinical and financial management capabilities
  • There exists inadequate financial and clinical management systems integration in promoting combined skill sets
  • Emerging technologies are proving essential to promoting progressive practice delivery

Market Considerations

  • Freestanding Community Providers are threatened by the economies and progressiveness represented by emerging competition.
  • The SNF Sector has been obstructed by prevalent fragmentation and competition within the industry
  • Industry data is scarce and disparate as available to providers for benchmarking and lenders/investors for underwriting and credit monitoring
  • SNF Providers experience heightened risk factors associated with resident claims and other contingent liabilities stemming from resident care activities

Regulatory Influence

  • Government programs offer no incentive and inadequate capital reimbursement for reinvesting in asset interests as well as advanced operating systems
  • There exists high disparity and growing complexities in principles of reimbursement in the SNF Sector where providers experience economic dependency on inadequate Government programs – principally Medicaid
  • Government payer programs are actively migrating away from the fee-for-service model where revenue realization is increasingly driven by demonstrated cost efficiencies and outcomes achieved