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LaShuan Bethea

Discussion with LaShuan Bethea, Executive Director of the National Center for Assisted Living (NCAL)

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The number one thing we're doing is educating people; making people aware that while assisted living is primarily private pay, there is a growing number of seniors that will need to access a more affordable option.


LaShuan Bethea, Executive Director of the National Center for Assisted Living (NCAL), joins Scott Tittle on VERSED to discuss current topics in assisted living, including the Senate Aging Committee's hearings in early 2024 that focused on the committee members’ concerns over transparency, resident safety, and rising prices.

Hi, welcome to VERSED podcast powered by VIUM Capital. Where you'll be hearing from leaders all across the long-term care sector who are shaping the future of our profession. Through these discussions, it's our hope that you'll be even more well-versed as you tackle your day in seniors' housing and healthcare. I'm your host, Scott Tittle, and this is VERSED. 

Scott 00:25

Hey I’d like to welcome to this episode of our VIUM Versed podcast LaShuan Bethea who's the Executive Director of the National Center for Assisted Living. Hey, LaShuan, welcome to the podcast.

LaShuan 00:32

Thank you so much for having me here.

Scott 00:34

For our listeners, this is going to be really fun for both of us because, what most everyone doesn't know is, I served as executive director of NCAL from 2015 to 2021, and then you came in to succeed me, and you brought NCAL to all kinds of new levels. So this is gonna be really fun for me on a personal and professional level. So thanks for your time today. I really look forward to the conversation.

LaShuan 00:55

Absolutely excited to be here.

Scott 00:57

Well, again, we have a lot to talk about. You've got an incredibly fascinating background. You've got about 30 years of experience in long term care, lots of different roles and responsibilities, both as a nurse background as a lawyer and a reimbursement specialist. And we don't have time to go through all of those roles you've played in the past, but maybe say a little about what was the moment when you knew you wanted to get into long term care and be part of this mission driven industry? And then maybe, other than the role you're in right now,what was a role from the past that you really look back fondly on and just know that was a really special opportunity?

LaShuan 01:29

Sure. So, before I get into that, I just want to say, when you said 30 years, I had to catch my breath for a minute because it has been almost 30 years and it's just been an amazing journey. So when did I know that I wanted to work in long term care? I will tell you that my first experience in long term care was when I was in high school. I had the most amazing opportunity, and I didn't quite know how amazing it was when I was in high school. But we had a licensed practical nursing program in my high school, and I had the opportunity to, not work in long term care, but get practical experience as a licensed practical nursing student in a long term care setting. And I was a little afraid at that moment, but then when I saw that people really were being impacted by the care that I was providing even as a student, it resonated with me in a significant way. And so when I graduated, I took my first job working in a nursing home as a licensed practical nurse. And from that, it really touched my heart. I was able to talk with the residents and learn about their history, which was also very amazing to me to learn about how things changed, about what was important to them. And so it was at that moment that I knew that this was an industry that I really wanted to work in. And while I tried many other sectors, I worked in the emergency room, I worked in psychiatric behavioral health, I worked in home care, and obviously I worked in assisted living. So every time I crossed over into another area, I always end up coming back to long term care because there was something about it that just kept pulling me back, and I really knew that it was the place for me.

Scott 03:24

What a great story. And I love asking all of our guests about the moment that they thought about getting in long term care and knew it was for them. One of the things I think we both love about this industry, the sector really is it's such mission driven focus. There's a lot of faith component to as well, but there's a really strong mission there because there's a person there that everyone ultimately is trying to help get better. And so I love those early calls for our vocations and to know that your high school had that option, it's just really special. That's a great story. And thanks for sharing that.

So you started NCAL in late 2021, and the country was still kind of very much dealing with COVID. Say a little bit about what your memories were from those early couple weeks and, managing the membership through COVID and then kind of where we are today in terms of how assisted living operators are still battling COVID, where they are in terms of numbers and the like.

LaShuan 04:11

You're right. It was late August, early September that I started with NCAL, and one of the first things that I really wanted to do was to: 1) make sure that I had a solid relationship with the board and with the state affiliates, but also with the provider members. And so I took a lot of time during that last quarter of 2021 to really reach out to providers, to state affiliates, and really having a solid understanding. And what I remember is a lot of providers talking about the resident experiences and how it has changed, how we were in an environment where we couldn't have visitors in our communities, and the impact that that was having on the residents. And I think that we look back at that period of time and we know how devastating it was to all of a sudden have to shut down our communities because we were doing what we believed was the best thing to do to keep our residents safe, but it definitely had a significant impact.

I would say for assisted living providers at the time that I joined NCAL, it was when they were really starting to see some impact on occupancy and census and staffing shortages. And so it was almost a year after the pandemic had started. And again, it depends on the part of the country that you were in, because there were clearly providers that were experiencing things on the same trend, that the nursing homes were experiencing. But by and large, providers in the assisted living setting and it's probably primarily because there are a lot of private rooms. And so that helped to decrease the spread of COVID. But, again, there were other factors that were at play. And so about about the time that I started at NCAL was when providers started to see, oh, we're having some challenges with occupancy, we're having some challenges with staffing. About that time is when they hit their lowest occupancy and their most significant staffing challenges. And it was about maybe a two quarter period where they went from pre-pandemic, we were about 84, 85% average occupancy. And they dropped over those two quarters to about low 70% occupancy. And so it was significant for many providers across the country.

At that point then, we had the vaccine and there was a progressive increase in occupancy, a progressive return for staffing slow. It was a trickle, but you could see it improve quarter over quarter and the same was true with occupancy. And so we went from an average of 73% occupancy in assisted living to where we sit right now. At the end of the first quarter at around 84% occupancy. So about a percentage or percentage and a half below where we were pre-pandemic. And so a nice recovery in terms of workforce, we've seen recovery there as well.

What I would say in terms of workforce that I think is really important is that the demand or need to have more staff is even greater than it was pre-pandemic. And so while you may see numbers that show that we are higher than we were or at where we were pre-pandemic, you need more workers now than you did then. And so those numbers aren't really equivalent to what we would need right now.

Scott 07:27

And I know AHCA/NCAL has put forth a number of initiatives to the membership, on helping improve the labor markets and workforce. Say a little bit about what the association is doing to work with members and state affiliate chapters.

LaShuan 07:39

Absolutely. And so I think a couple of things that we're trying to do as it relates to workforce. One is we know that there's a lot of correlation between workforce and leadership programs. And so we do have a building trust program that is out there that is offered free to provider members. Again, to build their leadership, because we know that that's a key component. We're also engaged in apprenticeship programs. We know, I had the opportunity to participate in a licensed practical nursing program as a high school student, and it definitely made an impact into where I am today. And so we know that apprenticeship programs play a significant role in being able to get people early in their decision making around what career opportunities do they want to have. And so we've been able to partner with Equus Workforce Solutions, who has approved apprenticeship programs through the Department of Labor, in a variety of fields that impact our sector. So whether it be licensed or unlicensed caregivers, so certified nursing assistants that are both licensed or unlicensed, licensed practical nurses, food and nutrition, environmental services, all of those areas which are critical to us being able to provide quality care in our setting, they have approved apprenticeship programs in all of those areas. And so we've been educating our state affiliates, educating our providers, because those programs, providers can also engage in those same apprenticeship programs and bring them right to their community. And we've had success with that. In fact, we did a webinar about a year ago where we had some providers that were participating in those apprenticeship programs and said they went from having no applications to having applications because of them offering those apprenticeship programs. And so those are a couple of the things that we are doing as it relates to workforce. And again, we continue to advocate on the legislative side to again have bills that allow us to use, unused visas, because we know that a significant part of our workforce comes from individuals that are coming in from out of the country. And so if there is a way for us to increase the number of individuals that we bring in that can work in our sector, that will have a significant impact on our ability to be able to increase access to not only assisted living, but nursing homes as well. And so we're working on the legislative side as well.

Scott 09:58

And by the way, thanks for walking through that, because I want to make sure our listeners know what's happening in Washington, DC and through state affiliated chapters to help improve the workforce environment. Say a little bit about immigration, because for a lot of people it seems like, well, that's the answer. Just allow more people to come in and work. But that’s a really complicated pathway, isn't there? But what are the barriers, do you think, to having a really robust, viable, immigration program for long term care workers?

LaShuan 10:24

I think you hit the nail on the head. Immigration, I think that everyone recognizes that there is a solution, by bringing more workers here that want to work in our industry. Unfortunately, immigration is one of those topics that can be very political. And it is one of those topics where people have concerns about security, about safety. We have a visa program right now that currently looks at all of those factors. And so I think that if we look at our current visa program and figure out is there a way to leverage that, that allows us to bring more workers in, I think that's the key. The challenge is getting over the political obstacles that allow us to be able to do that. My advice to anyone that is listening is to talk to your member of Congress, talk to them about the need for workers, talk to them about the fact that there is a worker shortage and that we believe that there is a solution through immigration, and they are the ones to bring that solution to fruition.

Scott 11:26

And I know we were talking offline just before the podcast started. I'm going to be joining you all in Washington, DC in about two weeks with the annual AHCA/NCAL Fly-In. I know the record attendance numbers are already out there, but I encourage our listeners to also think about if you can't get to DC through any of the national trade association and or fly-ins to host a tour of your facilities with local officials, state officials, district staff, so they can really see what happens inside the four walls of buildings and really see the need for good, high quality labor in the operations side. So just a little plug for facility tours.

Let's talk a little bit about the really hot topic, which is, President Biden's, minimum staffing ratio, because a lot of people don't recognize that that has a lot of potential consequences for assisted living and other parts of the healthcare continuum, home health and hospital as well. Say a little about the focus that NCAL has added to that advocacy effort, and why it's so concerning for assisted living operators.

LaShuan 12:19

Absolutely. I'm so glad that you asked this question. Since the minimum staffing mandate has been released, I've talked to assisted living providers across the country, some of whom have recovered. They do have adequate staffing, but they are also significantly concerned, equally as concerned as those who have not recovered because they recognize that we have a limited workforce. And so while this mandate puts requirements on nursing facilities, it's the entire continuum that will be impacted because we have a limited number of workers. And so you may have an assisted living community that is right down the street from a hospital that's right down the street from a nursing home. And now there will be significant competition for those workers, and they will potentially be pulled from those other sectors to meet the staffing needs of the nursing home.

And the bottom line is that the staffing mandate does use a one size fits all approach to providing staffing needs. And I will tell you, I'm a nurse. I've worked in all of these settings. The staffing ratios, the staffing needs that you need in a nursing home are very different than what you need in a memory care unit that are very different from what you need in an emergency room. I worked in emergency room; you don't staff an emergency room like you staff in nursing home like you staff a memory care and they're not looking at what are the individual needs of the resident populations that are being cared for in these settings. It is not the same. If you go into one assisted living community, you've been in one assisted living community. They are catering to a particular population and it is not the same. And the same is true for the nursing home side. And so again, they are really using a one size fits all approach. And in a time where we are going to have increased demand for our services along the entire post-acute continuum, now is not the time to kind of say, okay, everybody gets the same thing, because guess what? The type of care that is delivered in all of those settings is not the same.

Scott 14:18

I imagine that's true market to market as well. Different settings, different markets as well. So I think that's the concern also that some of these advocacy efforts can trickle down into the states and also that there are state level staffing ratio requirements both for skilled and AL. And I think I want to make one thing clear for our listeners that I think I heard you and Mark Parkinson say, too, is that the sector overall is not against staffing requirements. They just have to be reasonable, achievable and quite honestly, fully funded. I mean, that's the significant concern to me. And that's assuming that the people are there to even meet the requirements. Right?

LaShuan 14:49

100%, I think that that is something sometimes a message that gets lost in this push back on the minimum staffing. What we would love to be able to see is let's increase the number of workers first. Let's put the horse before the cart. Let's increase the number of workers. Let's look at some of the current obstacles around education. Again we talked a little bit about immigration. I mean those are things that we need to address to bring more workers into our sector. Then we can talk about what is the appropriate amount of workers that need to be in each sector based on the type of care that is provided. 

So again, as a nurse, my perspective is that the one size fits all approach is never the right approach.

We need to look at the level of care that's being provided and then make a determination on how many nurses do you need, how many CNAs do you need, and are there other ancillary workers that help complement that that could potentially change what those ratios look like? A one size fits all approach

is the check the box approach to how we should do staffing. But that's not the way that health care is provided. That's not the way that care is provided. And services are delivered in assisted living or any of these other settings. We are here to meet the unique needs of the residents that are in our communities. So it's important that we make sure that we are very deliberate about the way that we do that.

Scott 16:13

Thanks for sharing that. And again, I think one thing that needs to be stressed is that there's still some time here to advocate against this really concerning regulation. We have a couple election cycles to go in between when the rule becomes effective in two years. But again, really strongly encourage everyone to outreach to their members of Congress and get to DC and do facility tours so they can really understand what the workforce needs are inside the buildings and what could be workable going forward.

I want to transition to something I know that's really important at NCAL which is there's always been this concern about federal regulation or more federal scrutiny of assisted living. And, earlier this year, kind of at the end of last year and carry into this year, there was a little bit more attention in DC, both with some national investigative reports with the Boston Herald and also with, I think, The Washington Post, had some investigative pieces on the cost of assisted living and also the care concerns of certain assisted living operators and some cases of elopement in the past. Say a little about what those stories were all about. And then, of course, that led up in into the Senate Aging Committee hearing on assisted living and kind of where we are today.

LaShuan 17:19

You're absolutely correct. There were a series of articles, one focused on elopement, and some that ended in fatality. The other articles focused on transparency, fees, cost of care. And I'd like to start by saying that to assisted living providers across the country to NCAL there is nothing that is more important than resident safety. Providers across the country are dedicated to providing quality care to the residents that they serve. And, any case of fatality, no matter where it happened, is tragic. And it's devastating to all those that are involved. And you're absolutely right that the Senate Aging Committee reviewed those articles not only on elopement, reviewed those articles related to transparency and fees, and had a hearing that was focused on that, where they talked to, not only, individuals who had family members that resided in assisted living communities or memory care communities, they talked to providers who were providing those services and educators as well. I will tell you that what came out of the committees were a couple of things. Or out of those hearings were a couple of things: a clear understanding of what assisted living is and the services that we provide. Assisted living providers do provide life affirming care to almost a million individuals every single day are in our communities. And the satisfaction rates of those residents and those family members that are in those communities are significantly high, and they're high because of the quality care that is being provided in those communities. I think the other significant thing that came out of those hearings is the cost of care in assisted living. I think it's important to recognize what is assisted living and what does it cover. It is housing and it is services. And so when you are combining the cost of housing and food and services, it is costly. And I think it's important to understand that it's not just the housing, it's not just the services. It's a combination of all of those things.

And so when someone comes into assisted living, the price that they are paying, again, it's not just for housing, it's not just for services. It's a combination of both of those things.

The other thing that did come out of the Senate Aging Committee hearing is a request for the Government Accountability Office to take a look at assisted living to better understand its construct, particularly around Medicaid. And so I think this is a great opportunity to educate people who may not understand that assisted living is primarily private pay. And while there is some Medicaid funding, it does not cover room and board. It just covers the services component. In many cases, it does not adequately cover the services component or the cost of the care that is provided in the assisted living setting. And so we welcome that GAO request because I think it will shed some light on what the request was for them to look at the Medicaid reimbursement rates across the state.

So we welcome the GAO report. We think it's an opportunity for them to look at a couple of things that we think will help educate the public, as well as the committee. And so a couple of things that the report requested was for them to look at Medicaid reimbursement rates across the country, for them to look at, participation requirements. In other words, are there certain things that providers need to do or comply with in order to participate in the Medicaid waiver programs that allow Medicaid dollars to be used to pay for services in assisted living, but also to look at utilization. So how many individuals that are in assisted living, how many people use Medicaid to pay for the services portion of assisted living? And so we think that it will shed some light. It will help educate not only the public, but it will educate members of the committee around the use of Medicaid dollars in assisted living. Again, just to reiterate, the majority of assisted living is private pay, and while most states do have some Medicaid dollars, it does not cover the room and board portion. And in many cases, it doesn't even fully cover the services portion.

Scott 21:33

Well, thanks for going through all that. It sounds like nothing imminent right now in DC in terms of federal regulation of assisted living but sounds like a little bit more attention, which is welcomed and maybe a great opportunity to open a door and have a great conversation to educate members of the Senate Aging Committee and Capitol Hill more at large about what assisted living is and what it's not. Is that right?

LaShuan 21:51

Absolutely. I couldn't agree with that more.

Scott 21:53

We just have 1 or 2 more questions for you, LaShuan, because I know you're in a really unique spot right now. You are in San Antonio at the AHCA/NCAL Quality Summit and Population Health Management Summit, so a lot to talk about there. We've covered kind of value based care on this podcast before and I know there's a lot of opportunities. But say a little about what the Quality Summit means to assisted living operators and what NCAL is doing to help promote quality insights membership.

LaShuan 22:16

100%. So you're absolutely correct. And I was so excited to attend the assisted living focused, quality,

sessions. And the room was packed, which warmed my heart because again, it reiterates what I already know from going around the country that assisted living providers continue to be focused on ways to move the needle forward to meet the needs of the residents in their communities. And so, one of the sessions that I attended focused on how to again, it combined a population health component or a networks component with quality and how to use what we're doing in the positive outcomes as it relates to participating in a network or participating in a population health initiative. How to use some of those gains in applying for the quality award program. And so you had individuals that have actually done it talk about the improvements that they have gained, but not just what they did, but how they did it and how they used that to apply for the Quality Awards program.

And so, I will tell you that another area that we've continued to focus on is the importance of data. And I would say that data is more important now than ever before because we know anecdotally and even more than anecdotally, because a year ago, NCAL partnered with Brown University to take a look at assisted living providers who have participated in the Quality Awards program to look at what are their outcomes in a couple of different areas. And through that evaluation, we were able to determine that individuals who had a silver or gold quality award had better outcomes in the areas of hospitalizations, re-hospitalizations, and I believe long term care transfers from assisted living into another setting than people who were not quality award recipients. And again, something that we anecdotally knew, but now we have hard data that actually demonstrates that there are improved outcomes. And so the data really just helps us to validate much of what we already know about quality and assisted living and those outcomes. And so we're really encouraging providers to participate in Trend Tracker because it's a way for them to look at data metrics, but also make improvements in their own quality improvement programs that they have in their communities.

Scott 24:23

And for our listeners who may not be familiar with the AHCA/NCAL Quality Awards program, it is the largest Baldrige Quality Awards program in the country. And it's an incredible opportunity to not only demonstrate the quality efforts and gains that you've made inside your facility, but also where you can

hope to achieve. I remember talking to a member many years ago who did not get the bronze level award, but they said that the application process was so valuable to them that they knew their operations were better just for going through the application process. So again, for any AHCA/NCAL members out there listening, I really encourage you to think about going down this quality journey path because you'll be better for it. So really exciting news coming hot off the press from San Antonio there at the Quality Awards Summit, LaShuan.

Hey, just one last question. Kind of back to the topic of affordability of assisted living. I know this is a topic that's really near and dear to your heart, which is this push towards trying to find an affordable assisted living concept inside of our sector, so that we can serve residents in the future better. Tell us a little bit about what AHCA/NCAL is doing to support affordable assisted living efforts.

LaShuan 25:23

So I think the number one thing we're doing is educating people; making people aware that while assisted living is primarily private pay, there is a growing number of seniors that will need to access a more affordable option. And we do have providers that are participating in this more affordable option like Garden Management Solutions is one They are located in Illinois, Indiana and a couple of other states, but they have an affordable assisted living model. But it requires intention to engage in that model. And so you need things like HUD loans; you need to make sure that when you are going into this more affordable model that do everything to keep your overhead low so that the cost of accessing those properties is also lower as well. And so it requires some education, but we also want to make sure that states know that waiver programs is another way to kind of supplement. You pay for the services portion of it, but we need to make sure that Medicaid reimbursement is significant enough that it does cover the cost of that.

So about a year and a half ago, we partnered with Plante Moran, and they did an analysis for us that not only looked at Medicaid waiver rates and access and affordable housing or affordable assisted living across the country, they also looked at some of the key components that determine when or if someone will need those services, like home ownership, which is a key component of how many people are able to afford assisted living from a private pay perspective. They also looked at the ratio of unpaid caregivers. Again, will people have someone in their home to be able to take care of them and something that's significant about the unpaid caregiver ratio is that we right now have about 5.2 unpaid caregivers per individual that's over the age of 65. Again, those are people that are available to take care of seniors outside of an assisted living community, meaning in their homes. That number over the next ten years is expected to be cut in half. So from about 5.2 to about three and a half, and that's going to have a significant increase on the number of people that will need some services outside of the home, because they won't have someone to help them in the home. And so we partnered with Plante Moran. They did a state by state report. And again, it really is putting states on notice that we do need to go at this from a partnership perspective. We need a public/private partnership to figure out how are we going to make assisted living more affordable or providing a more affordable option?

There is a white paper that is available on the NCAL website, and I encourage people to read it to understand more about the dynamics.

Scott 27:59

Well, thanks for all you're doing in that area, LaShuan because it’s incredibly important, and I really appreciate your leadership at the national level.

LaShuan, this has been awesome. It's been so fun to catch up with you and talk about all these really important topics that are impacting assisted living operators and really can't thank you enough for your leadership in Washington, DC and all you're doing up and through NCAL.

Hey just one last question I ask all of our guests: what's on your nightstand? I'm always curious to kind of understand what people like to read. What do you recommend to people? What do you hand off to people? But kind of say a little about what you're reading right now and you might recommend to somebody.

LaShuan 28:28

I'm so glad you asked this question, because even without being asked the question, I'm talking about this book that I have on my nightstand right now, which it's called The End of Alzheimer's. And the nurse in me and understanding more about the resident population that we're treating, but not just the residents, really just people in general. And so this book really talks about how to prevent and even reverse cognitive decline by making lifestyle changes. And so making changes in the food that you eat, making sure that you get adequate sleep, doing things that stimulate your cognition, like dancing; learning different types of dancing because, again, it requires you to use your brain in a different way that you haven't used it. And so the book is really amazing to me, and I've learned a lot from reading the book. In fact, I'm going through the book a second time right now and highlighting all the things that we do when we really want to commit something to memory. And so I encourage you to read it. It's probably a different book. Normally I would give you a leadership book that I'm reading, but this is really the book that is on my nightstand as we speak.

Scott 29:31

And I think for a lot of our listeners that Alzheimer's is unfortunately a disease that impacts so many people throughout the country. And so I think what an incredible opportunity for people to kind of pick up this book that you're recommending and see how they can help, maybe in their own personal lives, too.

So I'll just share one book for you. I just picked up a book, called The Obstacle Is the Way by Ryan Holiday. And Ryan Holiday is kind of a modern stoic philosopher. And the book really talks about how we need to really focus on things that we can control in this life, in order so we can be better in those moments where we need to engage in all directions for ourselves and our families and really see setbacks not as obstacles or things that happen to us, but I think he phrases it as things that are suited to our purpose. What are we supposed to learn by obstacles and suffering, and how are we going to move forward and learn from it? So anyway, The End of Alzheimer's, I'll be picking that up next LaShuan.

Thanks so much for this time. I can't wait to see you in DC in a few weeks. And for our listeners, thanks for tuning in. This is VERSED.

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