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Episode #20: Senior Housing and the Future of Community with Sharon Wilson-Geno

Volunteers of America National Services owns and operates more than 30 senior living and care communities throughout the United States, as well as several hundred affordable senior, multi-family and special needs housing, and other real estate projects. 

In this episode, Millionacres Editor, Deidre Woollard, interviews Sharon Wilson-Geno, who is responsible for the overall strategy and operations of Volunteers of America National Services.

Transcript

Deidre Woollard: Hello, I'm Deidre Woollard an Editor at Millionacres. Thank you so much for tuning into The Millionacres podcast. There's no denying that this has been one of the toughest years, the toughest times this country has ever faced. Death toll from COVID-19 has been devastating, especially, among the elder population. Right now, hope is on the horizon, we're watching people get vaccinated, but it's still going to be a long road ahead, and so many people are wondering what we can do to help. So today, I'm talking with Sharon Wilson Geno, who's responsible for the overall strategy and operations of Volunteers of American National Services. National Services owns and operates more than 30 senior living and care communities throughout the United States, as well as several 100 affordable senior, multi-family and special needs housing and other real estate projects. Sharon, thank you for joining me today. Let's start by explaining what Volunteers of America actually is.

Sharon Wilson Geno: I'm very happy to be here today. Volunteers of America is going to be 125 years old next year. We're one of the oldest and largest social service organizations in the country that was founded with a mission to serve America's most vulnerable people. We serve now in 46 different states in Puerto Rico and the District of Columbia. Organizations really broken up into two parts. One is we have 30 local affiliates that are based in communities across the country, and each of those local Volunteers of America affiliates serves in a different way. We provide a whole myriad of social services, everything from behavioral health, to substance abuse, recovery programs, to charter schools, to foster care, and a million other things in between. The other part of the organization, which is the part of the organization which I'm responsible is Volunteers of American National Services, and National Services operates coast-to-coast, but we only do two things. One, we run the largest non-profit affordable housing developers in the country. We have over 17,000 units in 40 states in Puerto Rico. The second thing we do is senior healthcare. So we run over 46 senior healthcare programs in seven states, and we do everything from eight different lines of business. So we run skilled nursing, we run assisted living, we run adult day, we run a nursing home [inaudible 00:05:08] program called the Program for All-Inclusive Care for the Elderly or PACE. We run a geriatric site hospital, so a variety of other smaller programs. So through the COVID experience, we've had eyes on a lot of the work that we do on the housing and the senior care side. It's been an interesting time.

Deidre Woollard: I'm sure. Let's talk a little bit about that. Certainly, I know that COVID has disproportionately affected the elderly. I know of some people who've lost parents and lost grandparents, and I know that this has changed how people view eldercare and nursing homes. Do you feel like that's a temporary shift that's going to change after we get a vaccine or is there a different feeling that you're noticing?

Sharon Wilson Geno: I think that's a really good question, and I think there's been a lot said about, are these goods and safe places to be? I think a lot of facts are missing from that conversation, which are, who are the people that are traditionally in senior care facilities? They are our most vulnerable, and we've sadly lost a number of people in various facilities that we have, but many of them were already on hospice care. Many of them have these preexisting conditions for which this really dreaded virus goes right to. I think there's some public perception that somehow it was the care facility that didn't do enough. But when you have a collection of people for whom this disease is completely targeted, those numbers are going to be very different from what you're going to see in the general population, so I think there's some skewing of what that is. But more to your question, is that concern going to be temporary? Frankly, I think so. Our senior care facilities are going to be first-in-line here for the vaccine, as well as our staff. So if people are concerned about their loved ones, and they want to be sure they get vaccinated, being in a skilled or other kinds of senior care facility is one place where they can maybe have that opportunity sooner and be surrounded by staff who also had that opportunity as well. But I think as we talk more, there's going to be a whole variety of kinds of ways that seniors are served in the future, this is just one of them.

Deidre Woollard: Interesting. So as far as those vaccine like that rollout, what is that looking like already? Have you been in touch with different providers?

Sharon Wilson Geno: We have a date to start, at least, in some of our facilities, December 28, and that was news today. It is and we've been back and forth with our consulting team today, our clinical team, about how that's going to work. The CDC has really given us a nice protocol of how you prioritize, who gets the vaccine, and how that works out. There is going to be some timing issues with the different national providers that we're working with, so we have to figure that out. There are concerns with staff about people having side effects from the vaccine, about being out for work for a couple of days because of that, and being sure we are staffed sufficiently and we're staggering how that vaccine rolls out, both to be sure that residents who potentially could have side effects are cared for properly when that happens. Two, to be sure we have sufficient staff to cover those possibilities as well. So it's a very complicated process, but we're excited to get started.

Deidre Woollard: Yeah. I'm sure. So that brings up my next question which is about the healthcare and housing and the ways that they're connected. I know that's a passionate point for you, and I think it's interesting this year that the federal eviction moratorium came from the CDC because they were talking about it being the homelessness has become a health risk. Do you think we're going to see more interventions like that, and specifically around senior care?

Sharon Wilson Geno: It's already happening. The research, finally, after years and years of talking about this is it's clear, housing is healthcare and healthcare is the base, and housing forms the basis for good healthcare as well. Healthcare is housing, so we have a really good basis to work from. Of all the really awfully and difficult things that happened during this pandemic. I do have to say that spotlight on the growing need for better senior care and housing to help support that senior care in a cost-effective way has been something of the positive side effect from this pandemic.

Deidre Woollard: I would say another positive side effective there if it can be said is community. I know that people in your units had to shelter in place for a lot of the year and that isolation was hard on people. But I think we're also seeing community gather around people, we're seeing food banks and a lot of donations happening. What do you think we've learned this year about community in general?

Sharon Wilson Geno: We are all in this together, and our seniors are an important part of our communities. I think our history of doing senior care has often been to isolate seniors, to have them in specific locations, a little bit out of sight, out of mind. We haven't always integrated the talents and skills that many of our seniors have with our communities as a whole. To see people step-up and realize that those seniors needed help and have helped in so many different ways in our communities across the country. I can't explain to you, and even our own staff, our staff whose chosen careers in senior care have been asked to do new and different things that they were never asked to do before. We learned how to play hallway bingo, we've learned how to do yoga classes from a courtyard down below, where people stand at their windows. We have learned just to listen. A lot of that listening has happened one on one via telephone calls via socially distanced ways, so it's really nice to see that people have finally, because they're so vulnerable have seen the value in supporting our seniors in new and different ways.

Deidre Woollard: Are you seeing a rise in senior homelessness? Is that something that you're also concerned about?

Sharon Wilson Geno: This is a growing tsunami of seniors as many people know that the growth in the senior population is enormous, and there's a significant growth between 2010 and 2030 when the baby boom generation all turned 65. We're in 2020 right now, so we're in the middle of that accelerated growth piece, and then there's even more growth on top of that. What's happening with that, it's not just that there are more seniors by population, but because of medical advances, they are living longer. They are living with more chronic health conditions because we can now treat them, and they are living longer in poverty. Sadly, because many of them had never expected to live as long as they have and their savings and the actuarial tables on their pensions to the extent they have them, did not anticipate lives into the 80s or 90s. Poverty and just making the bills are one of the increasing issues that we're going to be facing, there will be more and more low-income seniors in our communities. We're going to be living with chronic health conditions and we think sometimes that people just going into retirement and traveling and spending time, they're not going to have those kinds of luxuries available because the two things driving their costs are increased medical costs care and two is housing.

Deidre Woollard: Yeah. I think that's an important point, and I know building affordable senior housing is challenging. Certainly, there have been concerns about funding and financing that are probably changing. There's been a bit of a senior housing glut I know from an investor perspective, but what are you and your team exploring as solutions in terms of funding and financing?

Sharon Wilson Geno: When we talked about senior care, I think people will traditionally gravitate toward the nursing home, the assisted living, the senior healthcare side of it. You're right, there has been a glut of that kind of investment. I think primarily for optimistic investors who saw the growth in the population and said, "Yeah, that's exactly where I want to be." But what's changed fundamentally is what seniors want. The baby boom generation is not the generation of World War II, many of whom are serving and are now serving a more baby boom generation. Those people were very focused on security and service, so moving into a senior care type facility, where they could get that service and know that they were being taken care of was a really important aspect for them. The baby boom generation, they really want to be relevant, and they really want to be integrated within communities. What we're doing is we're always going to continue to provide that senior care piece because there's going to be a percentage of that population that's still going to need that kind of high level of healthcare service. While people used to come to our nursing homes, our assisted livings, and live there for 10 years, they're now living there for 10 months. They're staying in their homes much longer in part due to economics, but in part due to their strong desire to be relevant in the community. We're providing more and more home and community-based service care, so that's really the shift in the pivot that's going to be I think happening in the senior care space over time. Much of that, is going to be provided in independent senior housing. Much of that also will be provided for the reasons I indicated earlier, independent senior housing that has a subsidy so it can support folks of a lower income bracket.

Deidre Woollard: Interesting. In other countries, I know they've paired college students with seniors and things like that to try to help seniors not feel like that. Do you feel like seniors really want more integrated communities?

Sharon Wilson Geno: Yeah. They do. Again, the pandemic has really brought that out where we've had seniors in some of our buildings have been very independent, and during the pandemic, they have come down and they were not doing social events in the community rooms. We're not doing that kind of group activity. It's been interesting to see even some of the most independent of them, how much they've missed that, and how they've really been clamoring to get back into those kinds of events. At Volunteers of American National Services and our independent senior buildings, many of which are for folks of modest means, we don't just provide housing, we provide housing with services, so there are social workers in some cases preventive health nurses and some cases community health workers who work with that population on an ongoing basis to help leverage services that they need in the communities, help facilitate, what's going on with them and navigate the healthcare system. This is really the growth area for our services, where we've modeled a new paradigm called Aging with Options, where we're ensuring we have social workers, community health workers, in some cases a wellness nurse, and technology is part of our independent affordable buildings. They have access to all these different means and all these different ways to stay off connected with community, but also connected with the healthcare system.

You mentioned earlier that your communities are going to go through a vaccine protocol, so let's talk a little bit about post-vaccine world. How fast do you think that things can get back to some semblance of normal in your communities?

Sharon Wilson Geno: I think we're all going to be experiencing one of the buzzwords of 2020, the new normal. Are we going to be able to go back? I think even as a society, are we really going to go back? I don't think so. We're going to take some of the learnings from this and move forward. What point in time we'll be able to open, particularly, our senior care facilities and make them available for people. I think here in the next 3-4 months, we're going to have an opportunity to do that. I think there's truly pent-up demand in the market for folks that have not gone into a senior care facility and whose parents have now experienced difficulty in accessing food, accessing medicine because they needed higher level of care, and we're staying at home because they didn't want to be in a more counter get setting. I think we're going to see pretty quick blip of those folks going into those kinds of senior care facilities. But then I think there's also the group of people that are going to stay in independent housing type models like we also have on the affordable side. Well, we'll start maybe in the next six months doing more community events in our spaces, being able to bring people together, which is so very important. I think one thing that we have also learned from the first six months, we have already in lock down and we were very, very rigid about that, and as deadly as COVID is so is social isolation, and so is loneliness. We really had to balance those two things and think through. We should stop talking about everything we can't do and let's start talking about what we can do. How can we engage people in a safe way? How can we do something with socially distanced where they can see people when you throw a screen, but they aren't exposing themselves to the virus. We've really had to double-down on balancing those two things. That will be, I think some of our new normal because we're going to continue to serve people that have underlying health conditions and vulnerabilities. We're going to have to continue to be cautious, but hopefully, open things up a little bit more so we can ensure that we're engaging people socially because it's so important to overall health.

Deidre Woollard: Absolutely. Loneliness I know was a problem before the pandemic for seniors, and it's certainly only gotten worse. Well, I think all of us this year maybe have a greater empathy for what seniors are going through because we've all been isolated to some extent.

Sharon Wilson Geno: Across the board when we survey our residents, when we do screenings on mental health, it continues to just above and beyond any other health condition via the condition that most people are self lifted.

Deidre Woollard: That makes sense. I want to talk a little bit more about affordable housing. I think you and I both share an interest in this idea of public sector and private sector working together to solve problems. Let's talk about that. How do you see that playing out in the future?

Sharon Wilson Geno: There are a number of different ways. On the affordable housing side, we've had the Low- Income Housing Tax Credits since 1986, more got off to a slow start. That is a public private partnership where government subsidy does leverage private investment to build more housing. But it is only as good as, number 1, the economic value to private investors for coming into that space, and that goes up and down depending on the economic conditions. It's not a consistent, reliable source like a federal appropriation, for example, or other kinds of housing subsidy which you can rely on. It fluctuates, but it is a way that we brought a lot of private money into the affordable housing space during that time. I think the bigger question really lies in the service area. Medicare and Medicaid are huge parts of our federal budget. With the growing aging population, they are the drivers and social security, which is also something that supports seniors. Those are the things that are driving our national debt. If we don't find ways to bring those costs in line to provide different ways of serving people as cost effectively and really focusing on preventative care for seniors, we are going to continue to dig national deficit hole that could create a national security issue because so much of our deficit is supported in lending. Unless we can find a way ourselves to bring those costs down and stop continuing to provide a more rigid programs for senior care, we're going to struggle to get that part of our economy under control. Already though, I think there has been some changes in that area. Many states with Medicaid expansion with Medicare advantage or looking at cost containment programs and managed care programs, those are all partnered with private sector players, insurance companies, and others who have more of a focus on cost containment, and we're really playing very heavily with a lot of payers right now. For those private sector players see the value in housing, they seeing the value and what we bring to the table on the senior care side as well, and we're all looking for ways to work together to make those investments in affordable housing so they can help reduce the reliance on payments from Medicare and Medicaid, and thereby reducing the government expenditures in that area.

Deidre Woollard: Interesting. Also, I want to talk a little bit about private companies contributing to try to help affordable housing, for example, I know Facebook, Google, a lot of those companies have started putting money towards affordable housings. It's solving frankly some of the problems they have create in certain cities. But are you seeing a lot of interest from private companies wanting to work with you, wanting to donate or contribute and help solve some of the problems that your company and that your organization is facing?

Sharon Wilson Geno: Yeah. We've had some really good relationships with the private sector banks and investors, and for the housing side for many years. We have started a fund which will launch in January, a Housing and Healthcare Adjusted Fund. It really used to help focus private investment around the intersection of housing and healthcare, which is exactly where we're going and exactly where our organization is. We're one of just a handful of national organizations. It does both affordable housing and senior care, so we're well-positioned to pull these two things together as I was discussing before, and really being sure we're focusing those investments, particularly in the affordable housing, all of which is going to have some health care component to it moving forward in underserved communities, being racially underserved because they're in a rural area, are being underserved because of economic disparity. We're looking at targeting those funds and partnering with the private sector to help deploy those funds in a way that will have some really strong results and can show data-driven solutions to how the intersection of housing, healthcare, particularly for seniors, can reduce costs and provide better quality outcomes.

Deidre Woollard: Is the expiring of eviction moratoriums something that impacts your work at all?

Sharon Wilson Geno: It does a little bit, but I'll give you a hidden one which is another area we are looking for help from the private sector for as well. Most of our portfolio is senior, in most senior portfolio about 75 percent of it is subsidized with government subsidies. We're serving folks in that portfolio, can make $13,000 a year. They make a social security check, sometimes disability, that's about it. Without that government subsidy and if government subsidy pays the rent, we would be seeing much higher numbers. About 28 percent of our portfolio is family, and those families are working in relying on wages, granted, they're getting their subsidy as well. However, that's where we're seeing a little bit of an uptick, not as much as one would expect because they are the lucky ones. They are the one in four families who need housing subsidy in this country that actually get it. The other three out of four that are living in unsubsidized housing that are in the private market, those are the ones that are probably most vulnerable. But I'll give you another hidden one that affects us more than people with thinking, and it is really an issue that we're working to solve here. It's our healthcare workforce. The people that are caring for seniors are low aid workers. Many of them working our dietary or laundry. They are a certified nursing assistants, they're LPNs. Many of them work two jobs to make ends meet. Many of them now with children trying to struggle with virtual school. Because we've had illnesses and then people out, we've been short staffed, like all other skilled nursing and other senior care spaces, so we've been relying on them to pick-up extra shifts. Those are the folks that I am really most worried about from eviction moratorium standpoint. If they've gotten COVID and had to be out of work for a period of time, we've been doing our best to cover and help them. Really working with healthcare systems in other ways with a couple of initiatives going on right now that are very [inaudible 00:30:16] to develop workforce housing for healthcare workers. It's a really growing need, and unfortunately, because of the way Medicare and Medicaid works, the wage scales for those workers have not been able to keep pace with the rising cost of living in particularly the cost of housing in certain communities. That's a problem we're really looking for private partnership to solve.

Deidre Woollard: Yeah. That's a huge problem workforce housing is, I think, one of the most important issues that we're facing right now, because there's simply isn't enough of it, and we have seen real estate rent rising all over the country, and it's rising faster than wages in many cases.

Sharon Wilson Geno: Exactly. We had little bit of economic downturn due to COVID. Rents have not been dropping, [laughs] at least, not residential rents at this stage of the game. That issue just persists.

Deidre Woollard: In terms of building communities, are you building them out? Are you doing any adaptive reuse or anything like that?

Sharon Wilson Geno: A couple of things that we're involved in. One is we recapitalize our own senior portfolio as it ages, and some of it was built in the '70s and '80s and needs to be recapitalized. We are coming in at recapitalizing as we're doing big recapitalization project in Miami right now. Those buildings were built in the '80s, they need updates to serve the more frail population that we're serving today. When we built those buildings, those people were in their 50s and 60s, and relatively able bodied, and stay there until they went to a nursing home for the next 10 years. We now have people in those buildings are living to be 100 plus. So we have to be sure that they have grab bars, lighted hallways. We're doing the technology upgrades to allow for the opportunity for home and training based services to come in and transmit medical data to make that work during the social isolation pieces, and adding where appropriate healthcare space, where we could have clinical space in those buildings, where we could have opportunities for social workers or other groups to come in and do a little clinic on blood pressure, do commercial kitchens where appropriate, where we could provide a meal service if necessary. We're doing a lot of recapitalization on one hand. On the other hand, all of our new builds are all being built with an eye toward integrating housing and health. That's a big focus of what we're doing right now. We're doing no senior buildings right now that don't have some healthcare intersection depending on what the community needs. All those buildings moving forward in terms of our new construction will be that. We start increasingly to do more and more acquisition of buildings that would otherwise be lost before warehousing space when their different requirements expire. Investors can take those to the private market in some circumstances. We've been stepping in and trying to acquire some of those properties and preserve them, reposition them because most of them are at least 15, 20 years old, and again, with the healthcare component too.

Deidre Woollard: That's interesting. I talked to someone who develops modular healthcare and he was saying that large hospitals are going to become less popular, and that we're going to see more small hospitals and more medical that's more spread out and accessible to people. It sounds like that's part of that trend as well.

Sharon Wilson Geno: It is. We're actually doing a really interesting project right now with veterans. It's a targeted program. Many of whom are also senior or folks with physical or mental disabilities that will be not a [inaudible 00:34:02] building, but will be small, kind of bungalow style units that could be accessory dwelling units in somebody's backyard or an extra lot, where cities are really seeing this as an opportunity to put more affordable housing in cities that are increasingly becoming overbuilt with high-rise housing. That's one interesting thing that we're working on right now. Also, there's demand for that in the senior space as well. Again, getting back to the earlier conversation, there's a feel among seniors of this generation that they like that idea of having that front porch, and being in a community where they could be supported, but maybe not in a high rise or other kind of [inaudible 00:34:51] settings. There's some of that going on in senior space as well.

Deidre Woollard: Interesting. I've seen a couple of stories about hotels that are being converted into senior living. I'm watching the hotels statistics right now, and we're going to see some hotel foreclosures. It's going to be a rough year for hotels. Do you think that's another aspect that's going to become more interesting next year?

Sharon Wilson Geno: We actually are working with the city of Los Angeles on that opportunity in Los Angeles actually for two hotels. The thing that I think we have not even begun to scratch the surface on, but it's coming to an office building near you is adaptive reuse of office space. As we are all going to sort out here in the next year, who is going to go virtual, who's not, how permanent that is, and a lot of organizations looking to really shrink their footprint. I think we're going to be looking at opportunities to do interesting adaptive reuse of office, and I'm excited about that. There hasn't been a ton of that done, and obviously, there are some structural things that make that somewhat more challenging. But I think in certain cities where it's been very difficult to get real estate at a cost that's effective for senior housing, this might be a real opportunity to bring people into communities and make them feel more relevant rather than communities that are on the outskirts of town with pretty lakes and greenery around them, but sometimes can be isolating for certain seniors.

Deidre Woollard: Yeah, I think that's really interesting too and that's something that I'm excited about. Let's close up on a positive note. What are you most optimistic about next year and in the next five years as the need for senior housing continues to grow?

Sharon Wilson Geno: I got to tell you, I am really excited, I feel like it's happening. First of all, just to focus on seniors. I mean, the fact that this has been a quiet population that people have taken for granted. Now, folks are really targeted, are understanding better the demographics of the senior population, the growing population, and the needs of that population. Just focus around that I think is a really important piece. The second one is to focus on our healthcare workers; first responders, essential workers, heroes. We're finally recognizing the contributions that these people make every single day, and we have started here. But they have been sadly underpaid by the systems and allowed that to happen. We've made a commitment here to the end of bringing all of our workers up to a living wage in all of our geographies across the country. It's going to take a commitment on our part over multiple years to make that happen simply because the revenue streams from Medicare, and Medicaid, and other programs don't support it. But we're making a commitment to do that regardless. That I think is a really important issue, and that we need to value those people for the strongest as they provide and how important that is. The final one is really this focus on technology and what role will technology play in serving seniors moving forward. One of the initiatives we have right now is just to get all of our buildings wired in a way where people can use personal devices. Many of them were built a number of years ago where that really wasn't necessary. But we're going back and doing that now. We had a couple of demonstrations going on where we're using Alexa and Google Dot in certain buildings for social isolation purposes and communication purposes and those are going well. But really being sure that they are wired sufficiently to allow healthcare workers and home-health aids to come in and out and transmit medical information from the home. There are all sorts of the system devices right now that can measure your heart rate, your blood pressure, your blood sugar. I saw one that was generated by radar that didn't even need Wi-Fi, that I thought was pretty cool. There's all sorts of noise going around this technology space, and I think as we've come to recognize that the cost and just the workforce to support seniors one-on-one is not going to be there in the future given the growth of the population, particularly for low-income seniors frankly, we're going to have to shift to more cost effective ways that are going to be driven in part by technology. That's a really exciting part of what's going on. There's a lot of noise going on.

Deidre Woollard: Yeah. I think telemedicine has proven this year that it's actually very viable and very useful.

Sharon Wilson Geno: It's really taking all these different devices and technology things and figuring out exactly where they fit. Telemedicine is a tool in the toolbox, but I think we've also learned that the COVID is not a panacea. It has a role, but where does that role fit and where could other technologies play a role, and where do actual humans have to come in? We're all learning what that continuum is. The other thing that's exciting about it too is that even before COVID, to their enormous credit, the centers for Medicare and Medicaid had been looking at ways to use the Medicare and Medicaid payments to start paying for these kinds of alternatives, preventative devices, and other things including broadband, including preventive health, including exercise opportunity, including all these other things because they're recognizing that if they don't pay for those kinds of things upfront, the costs when someone with a chronic illness goes emergency room is significantly higher. The flexibility that they are now showing under their labor programs to support a number of different solutions and create a very large smorgasbord from which different populations and different individuals can select at different points of their life too, because it's not static. You might be looking at certain kinds of interventions at one point in your life, another kind of intervention later, and you might go back to the other intervention because something else has happened. Just creating all those different opportunities and figuring out how those pieces fit for each individual is really going to be our future I think.

Deidre Woollard: That makes lot of sense. Well, Sharon, thank you for your time today, and just a reminder for our listeners, you can find out more about Volunteers of America at voa.org, and we named VOA one of our top places to donate this year on Millionacres because they serve a growing need, so I hope you will check them out.