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Preparing for the Future:Trends in Continuing CareRetirement CommunitiesSusan B. Brecht; Sandra Fein; Linda Hollinger-Smith, PhD, RN, FAANAbstractThis article presents exploratory research conducted independently by two organizations, Brecht Associates, Inc. and Mather LifeWays, to learn what senior livingproviders look forward to in serving the next generations of older adults. Resultsdemonstrated that senior living organizations, particularly continuing care retirement communities (CCRCs), are addressing and plan to continue addressing needsand interests of their current and future residents that will allow older adults to agein place. Plans include expanding health care services, growing wellness and lifelonglearning initiatives, addressing technology needs, delivering services to homeboundolder adults “beyond the CCRC walls,” adding affordable housing options, andpartnering with organizations, including universities and active adult communities. Overall, consumer choice will continue to be a central focus in planning futurefacilities and services.Seniors Housing & Care Journal47
Susan B. Brecht; Sandra Fein; Linda Hollinger-Smith, PhD, RN, FAANIntroductionContinuing care retirement communities (CCRCs)are defined as featuring “a combination of independent living units and skilled nursing beds, aswell as properties that include independent livingunits, assisted living beds, and skilled nursing beds”(American Seniors Housing Association (ASHA),et al., 2008). These types of communities are frequently structured financially to include the paymentof both an entrance fee and a monthly fee (althoughsome are structured as either straight rental or on anequity basis) and may offer varying levels of healthcare services depending on the type of contract1.CCRCs have been a mainstay of the seniors housingindustry for decades, and today, it is estimated thatapproximately 1,850 are in operation throughout theU.S.CCRCs flourished while serving the GI Generation(those born between 1901 and 1924) and continuingto serve the Silent Generation (1925 to 1942), whoform the base of those who select this type of seniorshousing today (Howe & Strauss, 1992). As the market has shifted from one generation to the next, theCCRC product itself has grown and shifted as wellto meet the changing demands and preferences ofconsumers by offering such features as larger residences and greater contract choices. Although theSilents will continue to supply residents for 30 yearsto come, their preferences, as well as those of babyboomers, will influence the shape of CCRCs of thefuture.In the latter part of 2008, Brecht Associates, Inc.(BAI) conducted selective interviews with variousindustry professionals regarding their vision of thefuture for CCRCs, focusing on what they believeresidents will want and expect of this product. Theinterviewed industry professionals included chiefexecutive officers and senior marketing representatives of multifacility seniors housing organizationslocated across the U.S.; nationally recognized architects and planners; and respected consultants withnational practices focused on gerontology, ancil482009 Volume 16 Number 1lary services, and marketing targeting the seniorshousing and services industry. The results of theseinterviews were published in The Shape of the CCRCof the Future, avaliable on BAI’s Web site. Whereappropriate, pertinent quotes from some of theseprofessionals are included in the text of this article.BAI’s consultants drew upon their industry knowledge, gained during more than 20 years in servingthe seniors housing industry.During the last quarter of 2008, Mather LifeWaysInstitute on Aging (MLIA) conducted a Web-basedsurvey of senior living organizations to learn whatproviders look forward to in serving the next generation of older adults. Both BAI and MLIA addressedtrends in programs, services, amenities, and environments in this work. While the two organizations didnot collaborate until preparing this article, the resultsof these independent efforts were similar and formthe basis of this article. The limit of the researchdone by each organization is that it did not includesenior consumers. Furthermore, it did not addressspecifically the 2008-2009 economic downturn’simpact on the U.S. housing market. The subprimemortgage debacle contributed to the over-valuationof many homes and the massive collapse of creditmarkets. These issues affect consumers across arange of age groups, including mature households.For many mature adults, their home is the biggestasset they can draw upon to support their retirement.The economic slump depressed home values and leftlocal real estate markets flooded with excess inventory. Additionally, a 2008 survey by the Universityof Michigan and sponsored by the National Instituteon Aging found that among the wealthiest 40% ofthe population age 75 and older, more than half hadat least one-third of their accumulated savings instocks.2 As we know, the equity markets also havecontinued to fluctuate wildly.One might ask, “How do these factors affectretirement communities?” Seniors who have seentheir investment portfolios decline by 30% to 60%are reluctant to dip into the funds that remain and
Preparing for the Future: Trends in Continuing Care Retirement Communitiescommit them to pay CCRC entrance and monthlyservice fees. Those experiencing delays in sellingexisting homes also are deferring plans to move toCCRCs. Some who have already made deposits foradmission to a CCRC have requested that they bemoved to the end of priority waiting lists. Othersare withholding deposits until the housing marketimproves. Increasingly, retirement communities areoffering financial incentives to encourage prospectsto move to their independent living (IL) units during the current economic downturn. To counterthe slow down in move-ins, retirement communities are employing creative strategies and tactics,which include deferring entrance fees until prospects’homes are sold; offering bridge loans to cover all ora portion of an entrance fee; providing assistance inmarketing an existing home, including “home staging”; and reducing or freezing monthly fees for aspecific period of time. As the overall economy stabilizes, we anticipate that CCRCs may no longer needto offer these financial and marketing incentives toattract residents.Description of Methodologies andResponse ProfileBAI conducted interviews with 12 representativesof organizations that operate and develop CCRCs,as well as architects and financial, marketing, andservice professionals. A formal discussion guide wasprepared and used for these interviews. Referencesare made throughout this article to those 12 interviewees.MLIA worked with two organizations, Life ServicesNetwork (the Illinois affiliate of the AmericanAssociation of Homes and Services for the Aging(AAHSA)), and Caring Communities SharedService Group, which is a liability insurance providerthat represents nonprofit senior living organizationsacross the country, to identify the sample, trend categories, and topic areas for the CCRC Web survey.Given the exploratory nature of the Web survey, allCCRCs that are members of Life Services Networkand Caring Communities were invited to partici-pate. The targeted sample consisted of 266 seniorliving organization members representing CCRCsin 20 states. A total of 107 organizations volunteeredto participate in the Web survey (40% participationrate) representing 348 CCRCs (nearly 30,000 units).Senior living organizations were asked to report oneach of their CCRCs if they had multiple sites, sothe sample size for the CCRC Web survey is basedon responses from 348 CCRCs. Approximately96% of these CCRCs are in Midwestern states:Illinois, Missouri, Indiana, Ohio, Iowa, Michigan,and Wisconsin. Thus, results of this survey are mostrepresentative of markets in Midwest regions. Size ofCCRCs was used as a differentiator for analyses. Ofthe survey sample, 35% of CCRCs (n 122) have atotal of 300 or more units, and 65% (n 226) haveless than 300 units. This distribution by number ofunits is representative of the targeted sample.The CCRC trends Web survey consisted of bothclose- and open-ended items targeting key trendareas. For close-ended items, respondents were askedif their CCRC currently offers, may offer in the nextfive years, or do not plan to offer particular programs, services, amenities, or environmental designs.Additionally, respondents were asked to describetheir current and potential partnering relationshipswith various groups, such as colleges/universities,health care systems, active adult communities, andother senior living providers. Finally, open-endedquestions targeted emerging trends in aging servicesfrom the respondents’ perspectives.The results of the work conducted by BAI andMLIA address the following topics: existing physical plant: buildings and grounds programs and services focus on the resident connections technology other models (addressed only by MLIA)Each topic is covered in this article, as are conclusions drawn from the results of the research.Existing Physical Plant or BuildingsSeniors Housing & Care Journal49
Susan B. Brecht; Sandra Fein; Linda Hollinger-Smith, PhD, RN, FAANand Groundsand experiences based on residents’ preferences.Change tends to happen slowly within CCRCsdue to the lengthy development time cycle andmultilayered decision-making processes involvingmanagement, trustees, and residents. As reported bythe interviewees, many current CCRCs are workingon strategic and master plans for the next five-yearperiod. In order to remain competitive, CCRCsneed to refresh or, in some cases, make substantialchanges to their existing offerings.Common Amenities. Changes have been underwayfor years to increase the size and improve the amenities (kitchens and baths particularly) of individualliving spaces offered to residents in both independent and assisted living units. Emerging trends insenior living include focusing on broader varietiesof amenities and activities, including wellness programs. Results of the Web survey demonstrated thatCCRCs are focused particularly on wellness amenities, including health spas, therapy pools, aquaticcenters, and dance/aerobic studios. Redefining common amenities appears to be the wave of the future.Dining. The dining experience is at the core of lifein a CCRC. At one time, many CCRCs not onlyoffered but required residents to take all three dailymeals as part of the program paid for through themonthly fee. The inclusion of fewer meals has beenone of the significant changes that have taken placeover the last decade. Now, the focus is the diningenvironment and the ability to enjoy a meal in settings beyond the traditional formal dining room, likein a bistro, café, or casual dining room.Residents also expect not only choice of diningvenues, but also a variety of options ranging fromthe selection of menu items to the ability to take outprepared or partially prepared entrees. These preferences signal a profound shift from institutional mealpreparation and dining to restaurant-style diningwith cooked-to-order selections and open kitchens.According to the Web survey, more than 83% ofCCRCs provide their own dining services ratherthan outsource, in order to individualize selectionsDaniel Look, founder of Dining ManagementResources, comments that residents will “expect anengaging experience rather than just a meal.” Furtherexploring this trend, Daniel Cinelli, managing partner at Perkins Eastman, stated that CCRC diningvenues would be “more like retail establishments,with a sports bar, food to go shop, and even a chainrestaurant.” Some of these changes will be achievedby partnering with other organizations or commercial entities.Spa, Wellness Center, and Related Spaces. First-classhealth and wellness facilities will continue to bean important feature for both current and futureresidents. Today and tomorrow’s older adult iswell acquainted with spas and alternative relaxationmodalities, and they will desire the ability to conveniently access these services. While some CCRCshave developed or upgraded these facilities, manyof those interviewed by BAI reported that for manyconsumers, the onsite spas and salons do not yethave the same ambiance and consumer comforts ofpremier establishments in the external community.Wellness centers have moved from simply beinga suite of physician offices, where residents can gettheir blood pressure checked and receive their annualflu shots, to full-scale fitness centers that includeswimming pools, Jacuzzis, well-equipped exerciserooms with personal trainers, massage therapy tables,and locker rooms.The Web survey supported these predictions.Exhibit 1 presents the top five trends in wellnessservices and amenities in order of projected growthrates (highest to lowest) from 2008-2013, comparingCCRCs with 300 units to those with fewer than300 units. Chi-square analyses examined differences between larger and smaller CCRCs. Althoughcurrently offered by 44% of all respondents, a significantly greater percentage of CCRCs with 300 units (92%) plan to offer wellness/healing gardensin 2013 compared to CCRCs with fewer than 300units (71%) (χ2 6.459, p 0.03). Currently offered502009 Volume 16 Number 1
Preparing for the Future: Trends in Continuing Care Retirement Communitiesby 25% of all respondents, a significantly greaterpercentage of CCRCs with 300 units (62%) willoffer health spas in 2013 compared to 46% of smallerCCRCs (χ2 6.123, p 0.04). Twenty-three percent of all respondents currently provide therapypools. By 2013, a significantly greater percentage ofCCRCs with 300 units (62%) will provide therapypools compared to 31% of smaller CCRCs (χ2 16.369, p 0.001). Currently, 20% of all respondentsprovide indoor aquatic centers and putting greens forresidents. By 2013, a significantly greater percentage of CCRCs with 300 units will provide indooraquatic centers (69%) and putting greens (69%)compared to smaller CCRCs (33%, χ2 11.108, p 0.004 and 26%, χ2 16.369, p 0.001, respectively).Theaters/Entertainment Venues. An increasing number of CCRCs, particularly the larger ones, are nowoffering substantial entertainment venues. WillowValley, a CCRC of more than 1,800 units locatedin Lancaster, PA, includes an 80,000-square-footcultural center. On the lower level, there are stateof-the-art fitness and aquatics centers, a full-serviceday spa, dance/aerobic studio, a rehabilitation center,and the Vitality Café to nurture the body. On theupper level is a 500-seat performing arts theater, aballroom for dances and catered events, an education room, broadcast studio, art gallery, and artstudio. Other larger CCRCs such as those developedby Erickson Retirement Communities also offerextensive amenities that include theaters and othersuch cultural venues, but even some smaller CCRCsare starting to create more modestly sized theaters,where both resident groups and outside entertainment can be featured.Family/Intergenerational Entertainment Space.Exhibit 1. Top Five Trends in Wellness Services and Amenities: Projected GrowthFrom 2008 to 2013 by Size of CCRC.Seniors Housing & Care Journal51
Susan B. Brecht; Sandra Fein; Linda Hollinger-Smith, PhD, RN, FAANFocus group research conducted by marketing professionals and architects interviewed for this articlealso has identified consumers’ desires that seniorcommunities be more family-friendly to accommodate visiting grandchildren.3 This also will affectaccessibility and the way that swimming pools andlocker rooms will need to be designed with privacyand dignity in mind. Instead of small single-purposegame rooms, residents with visiting families willwant a more general entertainment room with alarger club-like feel—a place where some can watchthe large-screen TV and others can play billiards orother table games and be in touch with each other.Future residents also are likely to continue to wanta variety of dining venues that can accommodatefamilies and private celebrations. Results of the Websurvey indicated that larger CCRCs are leading theway in identifying the need for such spaces. Eightyfive percent of CCRCs with 300 units currentlyoffer or plan to offer intergenerational activitiescompared to 76% of CCRCs with fewer than 300units. Additionally, CCRCs that are planning tooffer additional wellness programs for residents andstaff over the next first years are more likely to offeror plan to offer intergenerational activities (r 0.382,p 0.001).Taking this a significant step further, some industryprofessionals see a movement toward planned communities with an intergenerational focus, includingmixed-use developments with retail and housingcombinations, and a trend toward returning to urbanenvironments. In this vision, a senior apartmentbuilding might be located next to non-age-restrictedmultifamily housing within a planned development.Amenities like fitness centers and theaters wouldbe open to all residents of the planned community,regardless of age.Office/Business Spaces. Older adults are increasingly remaining in the workforce, a trend that maycontinue out of necessity rather than choice due tothe deteriorated conditions dominating the U.S. andworld economy. According to the U.S. Bureau ofLabor Statistics (2007), the number of workers age522009 Volume 16 Number 155 and older is projected to grow by nearly 47%,nearly 5.5 times the 9% growth projected for thelabor force overall. Whether one needs or desiresto work into later life, some older adults are alreadylooking for business centers (faxes, photocopiers,mail assembly, etc.) and support services in theirCCRC. According to the Web survey, the majorityof larger CCRCs (73% with 300 units comparedto 35% with fewer than 300 units) currently have acomputer center with capacity to address businessoperations. Within the next five years, a significantly greater percentage of larger CCRCs (90%)compared to 67% of smaller CCRCs plan to offer acomputer/business center (χ2 53.486, p 0.001).Additionally, CCRCs that currently offer or plan tooffer wellness programs also are more likely to offeror plan to offer computer training for both residentsand staff (r 0.338, p 0.003).Health Care DesignThe movement away from the highly institutionalized model of health care design characterized bydouble-loaded corridors and large, fixed nursingstations and the associated assembly-line operating philosophy is an area where some of the mostsignificant change is taking place. Comments like“traditional nursing facilities are going away” and“I hope nursing facilities will not look anythinglike the traditional model” were common amongseniors housing professionals interviewed by BAIand, indeed, reflect general industry thinking today.Green House or Other Residential Concepts. In recentyears, the Green House model has captured theimagination of those in long-term care. Accordingto the Green House Web site, “Green House homesare residences for six to 10 elders who require skillednursing care and want to live a rich life. They area radical departure from traditional skilled nursinghomes and assisted living facilities, altering size,design, and organization to create a warm community. Their innovative architecture and servicesoffer privacy, autonomy, support, enjoyment and aplace to call home. Green House homes are devel-
Preparing for the Future: Trends in Continuing Care Retirement Communitiesoped and operated by long-term care organizationsin partnership with The Green House Project andNCB Capital Impact” (NCB Capital Impact, 2009).According to the Web survey of senior living providers, the projected growth in Green House modelsover the next five years will be significant. Currently,fewer than 8% of CCRCs with 300 units haveimplemented this model, whereas participants in theCCRC Web survey predict that 50% of CCRCs willimplement the model within the next five years.Variations of this model also are emerging interms of design. Examples include the award-winning one-story residential design of the GwynneddHouse nursing home at the CCRC Foulkeways atGwynnedd, in Gwynnedd, PA. Each of four neighborhoods contains 10 bedrooms designed with aconnected living room, dining room, and countrykitchen. Earning national awards for design andprogramming, Splendido, a CCRC in Tucson, AZ,representing a joint venture of Plaza Companies andMather LifeWays, created Sonora at Splendido.Sonora offers assisted living, skilled nursing, andmemory support in intimate “neighborhoods of care”that contribute to feelings of security and comfort.Each neighborhood includes a living room, activity area, and restaurant-style dining room or bistro.Special attention was given to color palettes, tactileart, customized window treatments, and to memoryboxes that feature special family treasures.Skilled Rehab and Other Specialty Care. Virtually allinterviewees noted that residents of CCRCs as wellas older adults in the external community insist onremaining in what they consider to be home (thiscould be an independent living or assisted livingunits in a CCRC as well as a traditional home in thegeneral community). As a result, specialized nursingand even assisted living settings are becoming both anecessity as well as a choice. National studies (Zinn& Mor, 1994) indicate that among the nation’s nursing homes, nearly 80% report that they offer one ormore specialty programs or distinct units, where thefacility has specially trained personnel dedicated tothe program.4 In rank order, the most frequentlyoffered programs are in restorative care or “rehab”(69%), followed by dementia care (32%), and thenhospice or palliative care (19%). Nursing facilities arecreating dedicated rehab wings or floors designed toserve short-term residents who are looking for private rooms, attractive décor, restaurant-style dining,and a more spa-like environment.Specialized dementia or memory support care alsois an important area of growth in both the assistedliving and nursing home setting. Faced by an agingpopulation, rates of dementia are expected to doubleevery 20 years for the next several decades, with anestimated worldwide number of cases reaching 81million by 2040 (Ferri, et al, 2005). According tothe Web survey, 85% of CCRCs with 300 unitsand 50% of those with fewer than 300 units currentlyhave memory support care programs. In the nextfive years, 92% of larger CCRCs and 80% of smallerCCRCs anticipate having these programs in place.Rightsizing. One of the key questions that CCRCsare addressing is what is the right ratio betweenindependent living units and health care accommodations, including both assisted living and nursing?Given the increasing propensity for residents toremain in apartments and cottages and receive services there, the old statistical models are definitelychanging. Earlier models that preceded the emergence of assisted living as part of the continuumassumed that the proper ratio of independent livingunits to nursing home beds was approximately fourto one. Numerous states created mechanisms forapproval of a CCRC’s nursing home beds in accordance with this ratio.One of the top five emerging trends identified byWeb survey respondents was the increased emphasison serving a growing number of independent andassisted residents as the number of nursing homeresidents continues to decrease. The proportion ofnursing home beds is declining, as evidenced by theongoing report (AAHSA, Herbert J. Sims & Co.,2004). According to the report, CCRCs built in theprevious four years (2000 to 2003) did, in fact, average 25% of all units in their nursing wings. By 2004,Seniors Housing & Care Journal53
Susan B. Brecht; Sandra Fein; Linda Hollinger-Smith, PhD, RN, FAANthose CCRCs built during the previous four yearsaveraged 23%. We expect that the report due out inlate 2009 will show a greater drop in this ratio.LEED-Certified Communities. As new CCRCs areconstructed, a number of them are looking at waysto be more energy efficient while promoting “green”living for both residents and staff. Recognition of rigorous, environmentally sensitive designs throughoutthe building process is awarded through Leadershipin Energy & Environmental Design (LEED) certification. Web survey results indicated that 35% ofrespondents plan to integrate eco-friendly designinto new construction or renovation and apply forLEED certification. Additionally, with the focus on“eco-friendly” living, some CCRCs are focusing on“eco-retirement” living to market to the next generations of older adults.Programs and ServicesPrograms. Activities and programming are changing as well, particularly in the areas of wellness andlifelong learning, according to the Web survey. Theshift is from the more sedentary to the more vibrantand active, and from those designed or created bystaff who “know what the residents want” to thoseinitiated by residents. Exhibit 2 presents top trendsin CCRCs in order of projected growth rates (highest to lowest) from 2008-2013, comparing CCRCsof 300 units to those with fewer than 300 units.Currently offered by 22% of all respondents, thegreatest growth rate is projected for resident Webbased education programs. By 2013, 73% of CCRCswith 300 units and 67% of smaller CCRCs are planning to offer Web-based education for residents (χ2 6.559, p 0.038). In 2008, 47% of all respondentsoffered wellness programs for residents. By 2013,92% of CCRCS with 300 units and 91% of smallerCCRCs will focus on resident wellness programsExhibit 2. Top Five Trends in CCRC Programs: Projected Growth From 2008 to 2013 bySize of CCRC.542009 Volume 16 Number 1
Preparing for the Future: Trends in Continuing Care Retirement Communities(χ2 1.405, p 0.05, not significant). Currentlyoffered by 32% of all respondents, a significantlygreater percentage of CCRCs with 300 units (92%)will offer lifelong learning programs for residentscompared to smaller CCRCs (65%) (χ2 9.546, p 0.01). Currently offered by 50% of all respondents,by 2013, 88% of all respondents will offer wellnessprograms for staff (χ2 15,750, p 0.001). In 2008,67% of all respondents offered computer trainingfor residents. By 2013, 100% of CCRCS with 300 units and 94% of smaller CCRCs will offer computertraining for residents (χ2 6.546, p 0.03).Lifelong learning programs and connections tocolleges and universities also is a growing trend.According to the Web survey, more than one-quarter of CCRCs indicated they currently partner withcolleges and universities. Another one-third have a“strong interest” and one-third have “some interest” in establishing such partnerships. Currently,there are approximately 31 retirement communitiesassociated with institutions of higher learning thatare either in operation or the development planningstage (Best Guide Retirement Communities, 2009).One of the greatest examples of such a community isLasell Village, a CCRC sponsored by Lasell Collegein Newton, MA. Lasell Village is the first CCRC tofeature a formal, individualized, and required continuing education program for residents, embodyingits philosophy that learning “is not a chore or task,or even a specified activity. Rather, it is a way ofbeing—an approach to life in which we pursueinterests and new experiences that enrich our lives”(Lasell Village, 2009).Over the past 10 years, the field of senior living move management has grown from a smallhandful of individuals who developed expertise inhelping older adults transition from their homes tosenior living communities to a national associationnumbering more than 400 members. CCRCs arepartnering with move managers or starting their ownservices in some cases. According to the Web survey,about one-third of respondents currently offer olderadult relocation assistance. Another 23% of CCRCsmore than 300 units and 17% of those with fewerthan 300 units plan to offer these services within thenext five years.Aging in Place/Home Health Care Services. As suggested earlier, residents are reluctant to move againwithin the CCRC once they have made the initialmove. In response, many CCRCs now provide additional support services for a fee to enable residents toage in place. This trend is expected to continue andgrow in the future. In fact, some believe that stratification of residential units by level of care will becomea thing of the past. Some seniors housing professionals predict that CCRCs will offer a package of basicservices and a variety of optional services stratifiedby price. There is an attitudinal change in the Silentand baby boomer generations. Residents will expectto receive services in their independent living unitsand age in place. The challenge will be to make theCCRC experience more affordable or expand homeand community-based services.Exhibit 3 presents the top trends in senior livingservices related to aging in place in order of projectedgrowth rates (highest to lowest) from 2008-2013,comparing CCRCs of 300 units to those with fewerthan 300 units. The greatest growth over the nextfive years is projected in the areas of home healthcare, followed by adult day care services, deliveringservices to homebound elders, geriatric assessmentservices, and home care services. By 2013, a significantly greater percentage of CCRCs with 300 unitsplan to offer home health care (χ2 6.412, p 0.04)and home care services (χ2 9.262, p 0.01) compared to smaller CCRCs.CCRCs that currently offer or plan to offer wellness programs for residents also are more likely tooffer or plan to offer home care services (r 0.283, p 0.023), demonstrating their commitment to fosteraging in place. Along with offering these services toresidents, a number of CCRCs are looking towardoffering these and other services to non-residents, asdiscussed in the next section.Services Made Available to Non-Residents. In numerous instances, CCRCs are offering services to thoseSeniors Housing & Care Journal55
Susan B
Seniors Housing & Care Journal 47 . to learn what senior living providers look forward to in serving the next generations of older adults. Results demonstrated that senior living organizations, particularly continuing care retire- . (American Seniors Housing Association (ASHA), et al., 2008). These types of communities are fre-
