​

The world is aging. In 2017, there were an estimated 962 million people aged 60 or over in the world, comprising 13 percent of the global population, according to the United Nations.

Population aging is poised to become one of the most significant social transformations of the 21st century. All branches of society, from transportation to financial markets to housing, face implications.

What can be learned from other countries that care for the aging? For U.S.-based long term and post-acute care (LT/PAC) providers operating in Canada, Wales, China, and England, one of the most remarkable lessons learned is that there are more similarities than differences.

“They are seniors, and they have many of the same care needs that we would see in the U.S.,” says Sue Coppola, chief clinical officer at Sunrise Senior Living. In addition to its LT/PAC centers in the United States, Sunrise operates centers in Canada, Wales, and England.

Wellness and well-being for the whole person is universal. “I don’t see that that really varies,” says Coppola. “What does vary is what each country allows us to do within their regulatory framework. So we try to be very nimble in providing the highest level of care and service that we can within that.”

In the United Kingdom, Sunrise provides personal care, nursing care, accommodation, and independent living. In a similar way, Sunrise’s Canada centers provide assisted and independent living.

How much Sunrise can do in these areas depends on what the province allows in its regulatory framework. In addition to medication management, Sunrise provides services to residents with Alzheimer’s or other forms of memory loss in every country in which it operates.

Another similarity is trends. “Broadly, there are trends that are evolving in the U.S. that are evolving in Canada 10 years later,” says Tim Lukenda, president and chief executive officer of Extendicare. “The main area where this is the case is in the level of acuity of the residents and the nature of the services that are provided in skilled nursing in the U.S. compared to what’s called long term care [LTC] in Canada,” he says.

Based in Markham, Ontario, Extendicare started with centers in Canada and grew in the United States over a 30-year period. It was one of the largest providers in the United States, with 185 skilled nursing centers in operation. In 2015, Extendicare exited the United States and refocused its attention on its Canadian locations.

Today, Extendicare is the largest provider of LTC and home care in Canada. Next year, Extendicare celebrates its 50th year.

An example of evolution can be observed in the Canadian regulatory system, says Lukenda. “I lived through the regulatory environment in the U.S. over the last 20 years and saw the increase in the regulatory focus, often in a negative way in terms of the constraints they put on providers,” he says, “being somewhat of a punitive system from my perspective.” The Canadian system historically has been more collaborative and collegial in terms of performance improvement and clinical standards, he says.

“But I have to say that the Canadian system is evolving a little bit more like the U.S. system,” he adds. Recently, some measures have been introduced in Ontario, the largest province, that are more like the U.S. survey system in terms of imposing the potential for fines and penalties for repeat citations.

Another similar trend is individuals leaving the hospital sooner and sicker, Lukenda says, but the LTC beds are generally full, and there’s a waiting list in most places in Canada. “That’s very different than the U.S.,” he says. The result is a bottleneck in the system where more people are receiving services in the hospital, such as rehabilitation, that could be covered in LTC if there were rooms available.

The problem may be that in Canada, LTC has been more oriented to chronic disease and dementia than to the short-stay rehab kind of care, he says.

With increased acuity often comes increased frailty. “Memory care seems to be a very large demand, and along with that, it’s also the frailty,” says Coppola. To answer the need, Sunrise coordinates nursing and other support services.

Sunrise also coordinates nursing services with local government support. “For example, in Quebec, they have an organization called CLSC [local community service centers], which provides home health, therapy, respiratory care, and palliative care,” says Coppola.

“It’s a publicly funded service, so we coordinate a lot of those community health services.” It’s a similar situation in England, she says. The only difference is in the name, and Sunrise works a lot with the national health system in England as well as in Wales.

Keeping their residents’ well-being front and center, Sunrise looks at their overall needs, what Sunrise could provide, and what other services could be offered by organizations like CLSC. Services are married to help residents have a holistic experience.

“And we’re utilizing their health benefits,” says Coppola, “So that way we’re able to really coordinate so that they are able to optimize their health insurance benefits. It’s not costing them privately for care that the government would reimburse.”

No matter the country, Coppola says, Sunrise is focused on quality improvement, resident choice, and individualized resident assessment. “Following that guidance and layering what we can and can’t do based on the regulations, then it makes for a very successful performance within the regulatory framework.”

In addition, staff work hard to have good relationships with regulators, with a focus on quality assurance and compliance along with performance improvement. “And that we have transparency when something doesn’t go right goes a long way in every country,” she says.

Sunrise takes a population health management approach to quality improvement. “When we’re looking at what can we improve for our residents who are living within a community, we’re really looking to say—how do we individually assist the resident to their optimal function and promote quality of life?”

For example, if a resident has a challenge with falling, staff will ask how they can help the resident to mitigate the number of falls and injuries from the fall.

Then the next approach focuses on the broader elderly population, identifying the most impactful areas that help to promote wellness.

“And with that, in a similar way to the U.S., we’re looking at antipsychotics, medication management, we’re looking at the use of antibiotics and the length of time that residents are on them,” says Coppola.

In England, regulators are focused on the “Mum” test—as in, would a person’s Mum want to live in the community, based on factors such as availability of choice; individuality; safe environment; and whether there appear to be happy residents, families, and team members.

“We maintain a focus on quality and continuous improvement,” says Coppola. “It is always good when the government comes six months later and says, ‘here are some of the things we’re looking at in senior care settings,’ and we’ve said, ‘great we’re ahead of that.’”

Cascade Healthcare Senior Communities is an American-owned company with three of its centers in China. While the company opened its first building in January 2013, the process for searching for land started earlier, in 2012.

It was a little slow to start, says Nate McLemore, managing director at Columbia Pacific Management and spokesperson for Cascade Healthcare. It took the company two years to break even, which is longer than it typically takes in the United States, he says. Today, all of Cascade’s centers in China have an above 90 percent occupancy.

“This is for two reasons,” he says. “One, we’ve figured out how best to reach the Chinese consumer. And two, the market is catching up quickly in terms of its understanding of what senior living is and how it works and what it means to be a high-quality provider.”

Currently, Cascade operates three centers in Shanghai and Beijing, two of the largest cities in China. The rationale for choosing these locations is that many families here have had international experience and exposure, either having lived abroad or maybe their children lived abroad. “So our belief was that their acceptance of senior living would be higher,” says McLemore.

Similar to home care in the United States, many Chinese elders may receive paid help at home, he says. It’s relatively inexpensive to get a domestic helper in China, so a lot of families hire one if needed. The helper will check on the elder and assist with the basic house cleaning and food preparation.

But if an elder starts crossing the threshold of needing a little more medical care, that’s where Cascade can help. The public health care system can be hard to access in China, McLemore says, and real estate is very expensive. “It’s not very easy to zip down and go see your doctor, and it can be very expensive to afford an apartment with multi-generations living there,” he says.

Combining these two things—a health care system that is not easy to access and rising real estate costs—

creates an opportunity for an LTC provider to offer a compelling solution to elders and their families, he says.

Most of Cascade’s residents in the three locations are receiving assisted living or skilled nursing care. “There aren’t really those [same] licensing categories in China, so if you kind of look at the services and the population, we’d be bridging between assisted living and skilled nursing,” says McLemore.

Cascade accepts government reimbursement in the area of rehabilitation, which is similar to Medicare Part B. If elders are enrolled in the facility, and they’re getting ongoing rehab treatment, they’re typically paying out of pocket for their living and care, but any rehab treatments are covered by China’s social insurance, called Yibao.

While demand for services has not changed since Cascade’s inception, the acceptance and understanding of senior living has, McLemore says. “The market has changed, and it’s really taking off. During our first year, we were sitting in a building in Shanghai with 70 beds and wondering what it was going to take to fill it,” he says. “That’s certainly not where we are today.”

And as more and more Chinese elders get comfortable with the concept of senior living, says McLemore, “they come to Cascade to be part of the community and gravitate toward those social aspects of community living, as opposed to the isolation of really being alone.”

Being owned by a U.S. company has given Cascade a competitive boost, he says. “About 20 percent of our residents have children who are living overseas, so they have worked really hard to get their kids educated, perhaps in the West,” he says. Many times, those kids have grown up and decided to work in the United States or Europe and are looking for a community that can take care of their parents. They like that Cascade is owned by a U.S. investor with operating experience. “I think that gives them a higher level of trust and comfort,” he says. “And when they return to visit them, they see them in our facilities.”

The newness of senior living in China brings with it a nascent regulatory environment. McLemore says that Cascade’s challenge had to do with getting the right license and getting people to license the company.
“When we started, it was not like they have a senior living licensing department in each jurisdiction,” he says.

Cascade worked to help the local authorities understand what the goal was and secured the right license.
“The government has been super helpful, but if you’re going in and saying this is what I want to do, in some jurisdictions they’ve never issued a license before,” he says. “But that’s changing.”

One of the biggest challenges for Cascade was finding available real estate. With extremely high land prices in most of the large cities, there is also a high appreciation on property. The search for affordable real estate in places where people want to live is a feat in itself. “We spent a lot of time sourcing the right sites,” says McLemore. “Because if the land is expensive, you can’t deliver the service at a rate that people can afford.”

The second challenge was to show the market what senior living is. “When we came on the scene there weren’t many products like ours,” he says. “There were very large public facilities that maybe had 16 bedded rooms, not many amenities, and a very high resident-to-staff ratio.” Delivering more of an international standard product is more expensive, he says. And so the task became to help the market understand that good clinical quality and a high service level come at a higher cost.

The last task was training staff and getting qualified staff to work in facilities. The challenge, says McLemore, is that traditional nurse training in China is often geared to large public hospitals, where a nurse might see 30 patients in an hour.

“The volume in those hospitals is so great that they’re all about executing orders, moving very quickly, rather than having the bedside manner that’s really important in senior care,” he says. Honing critical thinking skills is critical. Nurses must be trained to watch a patient over time, diagnose, and think about how to best adjust or modify a treatment plan specifically for that patient.

Ideally, Cascade is looking for nurses who can adapt to the different way of caring for seniors in a senior living facility. This means taking more time with residents and developing a compassionate bedside manner, but also learning to think critically—observing factors with a patient over a period of days or weeks and adapting the care plan if needed.

“We invest a lot in training nurses to take them from the academic training they have to being the kind of nurses we need to deliver the kind of quality we want to deliver in our senior care facilities,” McLemore says.

A steady supply of health care workers is a big challenge in Canada, says Lukenda. “We call our certified nurse assistants PSWs—personal support workers,” he says. “I think the first crisis that is hitting certain areas in Canada is a shortage of PSWs in home health care and long term care. We also have pockets of nursing shortages.”

Lukenda says that Extendicare is seeing a new energy and focus by the Canadian government and by the profession in coming up with more creative solutions to try to create career paths for individuals to select senior care as a career option. Why?

“I think too often in the past, it’s been transitional, temporary work,” says Lukenda. “We want to make sure we’re providing solid career paths for individuals to progress through different roles and stay in senior care.
That’s coming in the form of higher wages, more training, and more progression opportunities. But it is clearly a challenge that’s on our horizon as well.”

For most providers, the future looks promising for growth.

While Extendicare plans to grow the private-pay retirement and memory care space, home care is also in its future.

“We think that home health care is becoming an increasingly important part of the senior care continuum,” says Lukenda.

“Home health care will never replace long term care or skilled nursing, in my opinion, but it plays an important role in the transitions of people from the hospital and back into the community.” Over the next five years, he anticipates significant growth in home care volumes across Canada.

Another looming change in Canada is a push to redevelop older centers into newer, more modern designs.
Government-supported programs and actual funding give companies incentives to redevelop their 30-plus-year-old buildings into more modern centers that are much more hospitality-oriented and less clinical in design.

Overall, the Canadian market is an opportunity to grow and expand services in different areas. “There are some very established providers but we’re starting to see new entrants, particularly on the retirement home side, assisted living, and memory care,” says Lukenda. “And we’re starting to see some capital flowing in from the U.S. in the form of some of the real estate investment trusts. And I think that trend will continue over time.”

In China, Cascade plans to open three new centers in the next six to nine months. It hopes to more than double its number of beds by this time next year. Continuing to grow out at a measured pace will be determined by how well Cascade can secure available real estate and qualified staff that can be trained.

“We think the market demand is enormous and continues to grow,” says McLemore. “It’s the largest population of seniors in the world.”