​​NCAL Roundtable

Provider magazine sat down with four leaders in assisted living to discuss the workforce crisis, quality improvement, affordable assisted living, and the future of assisted living.


  • Todd Dockerty, CEO, Dockerty Health Care Services
  • Rod Burkett, CEO, Gardant Management Solutions
  • LaShuan Bethea, executive director of the National Center for Assisted Living (NCAL)
  • Sarah Silva, president of Arete Living

Provider magazine: We know that assisted living companies are struggling to find long term care workers. What are your thoughts on the shortage, and what are some ways that you're addressing this?

Sarah SilvaSarah Silva: It's the key issue at hand, and no other initiatives that we try are going to be successful until we understand workforce. Those of us who will be successful are going to be those who are willing to be innovative and flexible. We need to understand what it is that our team members are looking for and to be able to solve those problems. We've done so much work related to wages that it's easy to forget that wages may not be the top priority for people right now.

LaShuan Bethea: Flexibility means tuning into who is our workforce and what they need. Benefits, such as health care, vacation, sick time, and more, are important but do they match the priorities for the people that are in our workforce right now?

If you have a husband and wife and one is your employee, maybe that individual gets benefits through their spouse and doesn't need health care. Could they take those dollars that would have provided health care and use it for tuition reimbursement? Or if you have a parent, they might need childcare most. Similar to the way that we care plan for our residents, we need to care plan for our employees and provide individualized benefits packages.

Rod Burkett: There's no one single magic pill. We are all trying lots of things like wage increases, flexible scheduling, more vacation, tuition reimbursement, and more. One of the things that we're trying to improve is creating a career path. We're not waiting for them to come up with a career path but helping to plant that seed so they can picture having a longer tenure with us.

Todd Dockerty: We've also realized that creating that career path within our current buildings is what's going to help us grow. We've always said that our growth will be driven by the people that are working for us. It's about creating that path within our company to make that true.

Provider: Assisted living providers are continuously working to improve quality and provide the highest quality care for residents. What are things that you have focused on to ensure the quality improvement process in your communities? What are the areas that you're having success with quality improvement?

Dockerty: When COVID-19 hit, we struggled with the number of people that were leaving the industry and leaving our buildings. We have had this influx of new people over the last two and a half years, and we struggled with quality. Now, we are focused on offering more education for our staff on a continual basis. Ongoing education for our staff on the why we're doing what we're doing has helped engage staff too.

Silva: It's been back to basics. What were we doing that worked well before COVID-19? What lessons have we learned during the pandemic to expand and have an even higher level of quality? Our organization is actively involved in the Baldrige quality process. One of the things we love is that you get a third-party evaluation of your system. It's not just that we believe we're doing a great job. As we reset and refocus, the ability to benchmark ourselves and learn best practices is what we're invested in doing.

Rod Burkett

Burkett: At Gardant, we use AHCA/NCAL's Baldrige Award criteria as a guide. We've had 85 percent of our portfolio receive the bronze, and we won silver this year. Even during the pandemic, we tried to create that mindset in our communities that this was not something extra. The Baldrige criteria became a guide during the pandemic to have everyone rowing in the same direction. Nobody wants to be the one that is not achieving bronze status and missing out on the excitement of trying to get silver.

We are also providing primary care and psychiatric behavioral services. If we are not coordinating the primary care, we're always reacting. To create better health outcomes, better quality of life standards for our residents, we've picked up our game in offering those services on site through third parties.

Bethea: We have had tunnel vision for infection control over the last couple of years. With the turnover and that focus on infection control, we must push the reset button to bring our staff back to the things that encompass quality and great outcomes. The Quality Awards Baldrige Program focuses on the ability to develop systems that will sustain quality outcomes long term. We want the residents that are in assisted living to have a sustainable quality future no matter what community they're in.

Provider: A higher need for affordable assisted living is on the horizon. Demographics are changing, baby boomers are aging, there are differences in family structures. How do we address this affordable assisted living need?

Burkett: Increasing accessibility and affordability was the purpose of why we created our company. We've worked to educate and influence state and federal decision-makers that using the Medicaid dollar spend at the assisted living level is not more Medicaid—it's smarter Medicaid. It's critical to have those decision-makers realize they're going to spend more dollars if the frail or elderly end up in the emergency room, become hospitalized, or move into more institutional care earlier than they need.

LaShuan Bethea

Bethea: At NCAL, we see there is a growing number of elderly who are going to be financially insecure. They make too much to qualify for Medicaid in the traditional format, but they also aren't appropriate for the skilled nursing setting. They don't make enough money to be able to afford some of the options for assisted living. What we need to do is partner with government at the federal and state level to work on solving this problem.

We see in the data that there is the highest number of unpaid caregivers now. Unpaid caregivers are family and/or friends that help take care of elderly individuals who need assistance. Without that, they would need to live in a different setting because they wouldn't be able to do it on their own. As we see the growing number of elderly who are childless or who will not have that family member or friend to assist them at home, they will need some other type of assistance.

Dockerty: In Michigan, we have Michigan MI Choice waiver program that addresses a small number of people in the state, but it is not accessible to a significant amount of people. There's a huge need. I have seen people who have no pension, no social security, all they have is savings.

We need to figure out how to address it differently, and education is a huge piece. In Michigan legislators have term limits so finding the right person to receive the right information is a challenge. It's not going to happen overnight; it's going to take time.

Silva: Oregon has a comprehensive Medicaid program, which has been beneficial. I agree that we must get in front of the right people and explain the necessity for our Medicaid waiver programs. There is an incredible population of people, my own parents included, who will need these services.

It is critical that we have the data to tell the story of the coordination of care. When we can coordinate care and bring in additional services, we can reduce the health care spend to free up dollars to invest in the Medicaid waiver programs within our states to allow for more people to participate. When someone can utilize the Medicaid waiver programs that are in place and move into an assisted living community, it is a significant savings on the part of both the state and the federal programs.

Provider: What other things do you see in the future for assisted living? Where will we be in 15 to 20 years?

Burkett: There is no question that as we shift from serving the silent generation to the boomer generation, we are going to have a more educated and demanding customer. We're hearing from the early boomers that apartment-style living is fine, but they want to be involved in all decision-making about the parameters of their life.  

Todd DockertyDockerty: Future residents are going to demand something very different than what we're currently providing. Expectations have increased about the technology that's available within the building, meal services, activities, even the outings that are provided. The individualization of what each resident wants is going to become much more important.

Bethea: What is being offered in different communities will be focused on the individualized needs of the residents. They don't want a cookie-cutter community, they don't want every community to be the same. That's why they look around to see what community best meets their needs. The generations to come will demand the highest level of independence they can have for the longest time they can have it.

Silva: One of the reasons assisted living is such a fascinating industry is because we diversify what we offer. It used to be that you could walk into a community and you had seen all of them, but that's so not the case any longer. I love the consumer's ability to find something perfect for them.