Debbie Stadtler: Since its inception in the 1980s, assisted living has used innovation to redesign aging. Hear more about the evolution of assisted living, how quality has matured, and why the next 25 years may be the best yet.

Hi, I'm Debbie Stadtler, editor-in-chief of Provider magazine, the flagship publication of the American Health Care Association and the National Center for Assisted Living. I'd like to welcome you to this episode of Perspectives in Long Term Care, a monthly podcast produced by AHCA and NCAL. Each month, we'll talk with long term care and assisted living professionals about the opportunities and challenges impacting the long term and post-acute care profession.

My guests today are Jim Carlson and Nicolette Reilly. Jim is a senior reimbursement advisor at AHCA/NCAL, and he spent 30 years with the Oregon Health care Association, including 23 years as the CEO. Nicolette is the senior vice president of quality at the Oregon Health care Association. Welcome, Jim and Nicolette.

Thanks for being with us.

Jim Carlson: Good afternoon. 

Debbie Stadtler: Well, let's start at the beginning. Tell us about your career journey. What led you to get started in assisted living and long term care? Jim, do you want to kick us off there?

Jim Carlson: Sure. I'd say probably my first interest really in health policy and all the issues related to Medicaid and Medicare and the economics and aging demographics was, I worked for an economics professor of mine in college when he ran for Congress.

And we spent hours upon hours driving around the Fourth Congressional District in Oregon, and he had a particular interest in health care and health care economics. And since he was running for Congress, he had a particular interest in federal level issues, dealing with Medicaid and Medicare and health care economics.

And so it piqued my interest. He ended up losing that race, but I ended up, after graduation, going to work for another member of Congress, and being low man on the totem pole on the staff, Medicaid and Medicare came into my portfolio. And so I really, from just a very young age, got very interested in federal health care finance and reimbursement programs and the economics, and I always had a real keen interest about demographics and the impact that had on the economy and society.

Debbie Stadtler: Nicolette, how did you get started? 

Nicolette Reilly: My path was very different from Jim's. When I graduated with my undergraduate degree, I had a business minor, and right out of college, I started working as a finance and business office manager for a new assisted living in Fort Collins, Colorado. And as a very young, new into the profession, I never envisioned that my career would be in long term care.

It just happened to be this door that opened up to me from a business perspective. So in 1995, I started out as a business office manager in an assisted living, and just over the years went from a business office manager to an assistant administrator to an administrator, and then to a regional ops person, and then a vice president of operations.

Even did a stint as an owner/operator of an assisted living company a while back. And then about four or five years ago, really wanted to find a way to take my passion of working with seniors and take my passion around driving quality in long term care, and try and find different ways that I could engage and influence the quality that was happening in long term care and how to drive that.

And so I had a great opportunity to come over to the Oregon Health Care Association, where now I've been able to see long term care from a completely different perspective, more from the legislative perspective and the regulatory perspective and what goes into that, and the wonderful opportunity to advocate on behalf of providers in both of those areas.

Debbie Stadtler: That's interesting. So both of you come at assisted living from a different perspective than normal. Usually I hear about people have a family member that inspired them, or they start as a caregiver, a CNA, and things like that. But you guys really come from, like, the business economics perspectives, and yet you've developed a similar passion and desire to serve in this industry.

So it's really interesting the variety of ways people start these careers. Knowing that assisted living started in Oregon, I want to focus on assisted living. You both are from Oregon. What was the profession like when you started, and how has it changed to where we are now? Jim, do you want to start us off?

Jim Carlson: Sure. So I joined Oregon Health Care Association in 1994, and came over to run their government relations program, and for the previous seven years, I'd been working on acute care and representing the Oregon Medical Association and doing a variety of health policy issues there. But I closely followed what was going on in long term care, really starting in the, the mid-'80s when I was working for a member of Congress from Oregon.

And Oregon was the first state in the country to get a home- and community-based care Medicaid waiver from the federal government, and that happened in 1980. And after the state got that waiver, really it kind of took them until the mid to late '80s till they really started making a lot of serious programmatic changes.

But one of those policy initiatives, if you will, was to kind of nurture this new growing model of care that a couple of the early pioneers who were based in Oregon had developed, called assisted living. And so you had people like Wendell White, who'd come from a long family history and background growing up in his mother's nursing home, and developed one of the very first assisted living facilities anywhere in the country.

And then he and Karen Brown Wilson, who was another early pioneer... There's a lot of disagreement, or you could get a little argument on who, who had the first assisted living facility. Most of that conversation focuses around Karen and Wendell and some other folks who were early pioneers. Oregon had a Medicaid director at the time, a fellow by the name of Dick Ladd, and he wanted to kind of nurture this little care setting.

And so using that waiver that Oregon had received from the federal government, he worked with some of these early developers of what we now call assisted living to come up with a Medicaid payment stream to essentially reimburse them for services in this model. And that led to what was the country's first licensed assisted living setting anywhere in the country.

And so really from all that early pioneering work that was done in the '80s, you really saw it take off in the '90s. And as I was coming and transitioning away from an acute care focus into long term care and joined the Oregon Health Care Association in '94, assisted living was becoming a big focus, and the association and our leadership recognized that at the time and really made a heavy investment into trying to support and help guide that development and that growth of assisted living.

Debbie Stadtler: Oregon has been a pioneer, and the growth of assisted living has really been impressive, even now, still on a big growth trend as well. Nicolette, how was it when you started, and what changes have you noticed over time? 

Nicolette Reilly: I think I come... I look at this from a very different perspective.

Jim is the all-knowing legislative, how these things started from a legislative perspective. But for me, coming from the operational side, when assisted living was first emerging, it was this exciting, new model that hadn't existed before. And so the goal was to move away from that traditional institutional model of care to create this place where older adults could actually receive support, but still maintain their independence, and their choice, and their kind of control over their individual lives.

I think in the early days of assisted living, it was a lot about just knowing the person. It was a relationship-based care. It was focused on that home-like environment where residents were surrounded by people who knew their stories, and their preferences, and what really mattered most to them. But I also, because it was so new, there was a really strong entrepreneurial spirit too.

Communities were, like, figuring out what worked, and they were learning each other, and they were building that foundation for what this kind of dream of what assisted living could be for the consumer. And so you had this great kind of fun, competitiveness, entrepreneurial spirit around who could build the better building, who could provide the best care, who could fill their buildings, and those types of things.

And I think there was this great spirit of this new concept, really focusing on what the resident wanted and what the resident needed, and trying to create it all in this fun, social, home-like environment. 

Debbie Stadtler: I love that. The entrepreneurial spirit really is so true, and everybody's finding their way and seeing what works and doesn't work.

So I love that depiction of the environment where everybody's trying something new. Well, Nicolette, you work a lot with quality in assisted living. How has the definition of quality evolved since the profession's inception? 

Nicolette Reilly: It's what I was saying before, when... I think when assisted living... quality in assisted living very first started out, it was really, was measured by the environment.

Was the community beautiful? Was it safe? Was it welcoming? Were the staff nice? Those types of things. And then those things obviously still matter, but our kind of understanding of what quality is in assisted living has... it's expanded significantly. It's more about the resident experience. It's about whether someone feels known or valued or respected.

Again, ability to live the life that they want to live and that emotional kind of wellbeing and engagement with others. I also think that kind of over time we've seen this quality evolve from simply responding to problems when they actually occur, to really embracing this culture of continuous quality improvement, this high-performing example, like where organizations recognize that quality's not just about fixing an issue after something goes wrong, but it's more about intentionally examining our systems and our processes and our policies, and really identifying opportunities for improvement before the challenges arise.

And so I think that's this vision of quality that has evolved as we've continued to grow in the health care system really. 

Debbie Stadtler: Yeah, I like that you mentioned the proactive nature of quality now, like you said, more at the process level of making sure those are all functioning as well as they can in assisted living to deliver that quality experience.
Jim, what have you seen about quality as things have evolved? 

Jim Carlson: Couple points. So first off- One of the things I love about assisted living and senior living is that innovation and that spirit and culture that Nicolette's touched on. And the model was designed to be more that social model, to be more that resident-centered model, and to allow them to live as independently as they're able to, but get the services and supports they need.

And I've seen this with my own grandmother, my own family members, friends, others, when people are reluctant to make that transition and move and leave their home and maybe move into an assisted living community. And I've seen when people do that, I've seen them just blossom in terms of the social interactions, the better nutrition, the wide range of activities, and the fascinating and just fascinating, interesting people you meet in, in senior living communities and assisted living communities.

I could tell stories all day long about just amazing people and amazing stories that I've heard from different residents. I think a concern I've got is that as the model has grown and matured and spread throughout the United States and become such a big sector of post-acute long term care services and supports, from a regulatory standpoint, I see regulators trying to come in and regulate assisted living in the same manner they did, let's say, skilled nursing or hospitals and others.

And really what I think has always been at the core of assisted living has been that resident satisfaction, that family member satisfaction component, and I really think that needs to stay at the center of this, and that you don't want to come in and get prescriptive models overlaid. You want to allow for innovation.

You want to allow for culture and community. And sometimes people to try to maintain their independence, yeah, there's some risk, and there's some, there, there's some things where you're not going to be living in a hermetically sealed bubble to keep you safe 24/7, but you've got the ability... None of us when we're out living our daily lives, we all understand when you're out in a part of the world, there's always some risk.

And I think people in assisted living communities are still active and want to live and thrive. And so get concerned when regulators are trying to come in and get overly prescriptive, and I think that really will stifle innovation and chip away at a lot of the strengths of what makes assisted living and senior living so special.

Debbie Stadtler: I think that's a great point.

Yeah, the innovation, the entrepreneurial spirit, that, that sense of thriving is really so important to assisted living. 
Jim Carlson: Yeah, and I've just seen it time and time again with, like I said, people I know in my family and friends when individuals go out into assisted living. And I've got a friend of mine, a gentleman in his late 80s, and he moved into a senior living community that has assisted and Alzheimer's and independent.

And I was talking with him and asking him how he enjoyed the move, and he was telling me one of our former governors lives in the community that he's in. He says, "It's fascinating. At breakfast this morning, I was discussing a recent Supreme Court decision with a former governor." And so it's incredible because you can live and thrive, you know, in these communities.

And I don't want to see regulators really get so prescriptive where people just don't have the freedom to, to get out in the community and do things. 

Debbie Stadtler: Yes. Yes. Speaking of celebrating assisted living and that spark that it has, the profession celebrates National Assisted Living Week each year. This year it's September 13th through 19th, and the theme is Shining Through the Years.

What does that mean to you as an assisted living professional? Nicolette, you want to start us? 

Nicolette Reilly: Yeah, sure. When I think about- Shining through the years, I think about really our seniors and the incredible stories, the resilience, the contributions that those seniors have made throughout their lifetime, and the impact that has on what they bring to our communities and driving that vibrancy in the communities.

But I also think, too, we're getting to the point, as Jim and I have talked about this morning, about just the emergence of assisted living, and it's now been around- Yes ... to the point that now we have these great team members that have been in the profession for 30, 40, 50 years. So now we're starting to see this fun blend of our seniors and their incredible stories and their decades of experience and wisdom and accomplishments, but now it's starting to mesh with these great team members that have built amazing careers from a very young age in community-based care and assisted living.

And just seeing those kind of stories all mesh together kind of just represents that dedication of the professionals that have cared for the generation of these older adults. And I just think that's really profound, that impact of both our team members and our residents, and the stories and the joy and the connection that they have brought to the profession.

I just think that kind of just wraps it up with that shining through the years, is looking at all of the things our residents have done, but really looking at all the things our team members have done, too, as this concept of assisted living has continued to grow across the country over the years. 

Debbie Stadtler: It's a great reminder.

National Assisted Living Week is not only about the residents, but also about the staff and caregivers and even other parties like the families and the providers and all of that. So that's a great reminder that there's a great blend in this idea of shining through the years. Yeah. Jim, what does shining through the years mean to you?

Jim Carlson: I really like what you just said about celebrating the caregivers and the professionals in the field. I can tell you through the years when you're out advocating on behalf of folks, and sometimes you'd get really frustrated dealing with elected officials or regulators or unfair media coverage and things like that.

And whenever I would get a chance to engage directly with professionals and frontline caregivers, I would get such energy, and it would be a touchstone on really what the mission is, right? And the importance of that mission and how it touches all of us, everybody, in terms of our family and our friends and our communities, and how important that all is.

And so I think celebrating that important role and that important mission, right? And what I love about the energy that I would get from that, right, is it, it makes me feel good too about all of us as we're on our own path and our own journey and what the future holds and all the, all the options and opportunities people have to live out their life and the way they want to.

But I just think the celebration of, of the people in the profession and how far we've come on the professionalization of the setting and the phenomenal options that are available to people across this country. And so there's just so much to celebrate, and the mission is so important 

Debbie Stadtler: Speaking of mission, the National Center for Assisted Living is dedicated to the profession of assisted living.

NCAL is celebrating 25 years this year. So what does NCAL's work mean for the people who work and live in assisted living communities? Jim, tell us your thoughts. 

Jim Carlson: I'm a big believer in people coming together around common goals and objectives and missions, and the power of that. And NCAL really is that guide star.

And for the 23 years I was running a state association and representing hundreds and hundreds of different providers who are all out doing what they do in their organizations on a daily basis, we were out there, and I think to advocate on their behalf, advocate on behalf of the, the residents and the families.

But also, I think we always tried to be thought leaders, and we tried to always help educate the elected officials, regulators, but also other operators and providers to be their best, right? And I think the role that NCAL plays, American Health Care Association plays, our state affiliates play, is really to be that convener, to bring together leaders from throughout the country, throughout the profession, and to advocate, to educate, and to lead really, and be that kind of guide star for folks.

And I can tell you, when I ran one state, I would go and when I would talk to... I met Nicolette first when Nicolette was a board member for NCAL on her way to become the NCAL chair. And so at that point in time, she was working clear across the country, but we struck up a relationship that's continued to this day.

And so the opportunity to meet and engage with people and to learn from them on what's happening throughout the country, and from other innovative operators and models throughout the profession, really NCAL helps make that possible and helps convene all that and curate all that, if you will. And I just can't imagine what it would be like if NCAL did not exist, right?

Because there's just such a tremendous wealth of resources and value in all the work that's done 

Debbie Stadtler: Absolutely. Nicolette, what does NCAL's work mean for you in your role? 

Nicolette Reilly: When I think of NCAL, I've been involved with NCAL really since its inception and grew up in the career with NCAL as a really close partner for everything that I did.

And when I think about celebrating 25 years, I really think about just NCAL and the power of, as Jim said, bringing assisted living professionals together, giving our profession a unified voice, and it's elevated the importance of assisted living on a national perspective too. Obviously advocating for our residents and our staff and our, and the organizations that are working really hard every day to provide these services for our seniors.

But I also think that NCAL does an amazing job of kind of shaping those conversations with the appropriate parties around quality and workforce and leadership, not only from the organizations all coming together and collaborating together and learning together, but also advocating for us with the federal government and with federal agencies and with consumer groups and those types of things to help them understand the provider perspective that sometimes gets missed when we're doing these huge policies and advocating for seniors.

There are all these great ideas, but actually implementing these ideas is always not the easiest of tasks. And so having NCAL there to really advocate for professionals across the country and creating this safe space to share those ideas, to learn from each other. But I also think that what NCAL does really is they remind us as providers on a continuous basis that it's not just about the building.

It's not just about the regulations. It's not just about a service. It is truly this amazing profession where individuals are, are working in these communities every single day trying to make a meaningful difference in the lives of our older adults, and there's that passion there. And NCAL understands that passion and does an amazing job sharing that passion with all of those different groups there and helps them understand what we're all about 

Debbie Stadtler: Passion, it's at the heart of what NCAL does, and definitely the professionals in assisted living.
I love that reminder. Pull out your crystal balls. What are you most excited about for the next 25 years in assisted living? Nicolette, give us your thoughts. 

Nicolette Reilly: I think if I had to think about what I was excited the most about with assisted living, I think I'm really excited about this continued evolution of assisted living and the opportunity to redefine what aging looks like.

I think we're going to see a lot of innovation, new technology, stronger workforce development programs, and even more kind of personalized approaches to care. As Jim mentioned earlier on, I am just really hopeful that we continue to move toward models that are flexible and creative and centered around the individual resident, not just focusing on the needs that they have, but really the person that they are, and not over-regulating this sector so much to the point that we forget that this is a service industry providing services for real people and caring for real people. 

I'm also excited about this kind of next generation of leaders that are entering the profession, where the workforce is really tight right now. We're seeing some amazing youth, this next generation of leaders entering the profession, and the future of the, of assisted living as a whole really depends on these individuals, depends on them to have that same passion and belief in the mission of what assisted living is.

And we're also seeing this generation of people that are Asking the question of how can we do this better? How can we improve upon this? I feel very fortunate in my two older children, whom I never thought would follow in my path by any means, are both now working in the profession as an administrator and as a med tech.

And it's really fun to get those mom calls where my kids are like, "Mom, this is what happened today, and how does this work with the regulations, and how would you handle this?" And it's just been fun to see this next group of leaders.

I have been so fortunate to be involved in the OHCA and Quality Award program, and just doing fun pilot programs with them and bringing these young, new leaders into the program as not only applicants, but as examiners, and just seeing the fresh passion that they have for quality in our profession just makes me really optimistic and really hopeful.

I think NCAL has done this great job of building this foundation, and I think the next chapter of assisted living just has great opportunities to be really impactful, not only for our seniors, but for our team members in the profession. 

Debbie Stadtler: That's a great point. Sometimes folks can get a little skeptical of the coming generations and that they'll be able to step up when the time comes, but it sounds like the next generation is really developing that passion, like you mentioned, and that desire to kind of take assisted living to the next level.

So I think that's such a great point Jim, what are you most excited about for the next 25 years of assisted living? 

Jim Carlson: I just think it's an amazing time to be alive because I think we're witnessing how we're redesigning aging and what that looks like. And I love Nicolette talked about the evolution, but this kind of confluence of technology and innovative design, the talent that we're attracting into the profession because they see this as an area with tremendous opportunity.

In the marketplace, we're attracting capital from capital partners, allowing owners and operators and developers to create amazing places to live and to enjoy life. And so I just think it's an opportunity to redesign what aging looks like, and it's a very exciting time. There's innovative operators all across the country.

I get super excited when I go out and I meet with people from the Springs Living or Oakmont or Human Good in the not-for-profit sectors, and you start talking with these folks about what it is that they're doing and the innovation and what they're looking at on trying to essentially envision what the future is going to look like and the innovation that they're trying to bring.

And I think it's a wonderful time for folks because they're going to have these choices and these options that I think it’s really going to allow people to live a fabulous life along their journey. And so it's all coming together now, and for a lot of years everybody was waiting for that kind of demographic wave to hit and everything.

We're here right now. We're on the cusp of that for the next 30 years. And so I think it's just a tremendously exciting time, and it's fascinating to watch folks kind of painting their own masterpieces out there in the innovations. And I'm sure for Nicolette, when she gets out and she tours communities and she gets a chance to experience firsthand the programming, the services, how they're doing that, how they're harnessing technology, and then some of the design elements on just these beautiful communities and places to live.

And it's hard to imagine going back into the '80s and going into the '90s and then looking at the options that are available for people today. So I think it's a wonderful thing for people, for families, and communities 
Nicolette Reilly: I think our consumers changed too. Yeah. Our consumer... Now that assisted living has developed, as Jim's saying, you have these developers that are just getting very creative around the physical plant.

Yeah. But I also think our consumers have changed. What our consumers want in a community are very different now. They're not just the beauty shop that can do their hair, but they want manicures and pedicures and massages and facials and all of these different things. And they want the coffee shop in the building where they can go down and sit in kind of this fun coffee shop environment, and they like the multiple dining rooms, restaurants, activities, and the community space in and of itself, the rooftop gardens and real fun.

Yeah. It's amazing to me. Nice ... that this fun development. 

Jim Carlson: Yeah. I'm going out and visiting communities, and it's... This is way cooler than where I live. You know? So I want to hang out with these guys and join their scotch tasting club or, you know, play cards with these guys on, on Wednesday nights. So there's a lot of really cool things happening all across the country, and it's really exciting just to be able to see it and experience it.

Debbie Stadtler: It's a great summation really. Everyone wants to live a fabulous life, and assisted living has grown so much, and it's only going to grow more, and there's so many exciting things on the horizon that it's really an area we should all be optimistic and looking forward to. So thank you for joining us today, Jim and Nicolette.

This has been a really great conversation, and I am excited about the future of assisted living. Visit ncal.org, that's N-C-A-L.org, to learn more about assisted living, and visit N-A-L-W.org for more about National Assisted Living Week, September 13th through the 19th of this year. Thanks to everyone for listening to this episode of Perspectives in Long Term Care.

Join us each month as we discuss issues that impact the long term and post-acute care profession. And be sure to subscribe to this podcast wherever you listen to your favorite podcasts. Take care.