Administrators: transitioning from nursing homes to assisted living.

It's different, it's rewarding - IT'S NOT EASIER

Today, more than ever before, seniors have a variety of health care options - and those options translate into exciting opportunities for the career-minded nursing home administrator.

But nursing home administrators who are considering a change because they perceive assisted living to be "easier" are in for a surprise. Those who have made the change to assisted living emphatically caution their peers: Though the work is extremely rewarding, be ready for new challenges.

Steven M. Still, Regional Director of Operations for Karrington Health, Inc., who had 12 years of experience as a nursing home administrator before joining the assisted living industry last year, says, "The assisted living environment is a lot of fun, but it certainly isn't any easier."

Obviously, the biggest difference between the two settings is the degree of regulation. While state and Federal agencies heavily regulate the skilled nursing environment, the assisted living setting currently enjoys more freedom and fewer official parameters. Assisted living administrators don't have to jump through Medicaid and Medicare hoops, for example. The assisted living environment has a nearly 100% private paying market. However, those customers bring a whole set of expectations that can be at least as demanding, if not more so, than those of state and Federal customers. The assisted living administrator must have the skills to provide what this marketplace demands.

"I used to spend a lot of time thinking about how to keep my nursing home out of the regulatory firing line," notes Still. "Now I spend a lot more time thinking about the private paying customer's needs and how to meet them."

For one thing, administrators who are going to make the transition will definitely want to polish their communications skills. "I think I had pretty good communication skills in the skilled nursing setting," says Still, "but I had to bring those skills to a new level in assisted living. Families and residents are paying from their own pockets and, therefore, have heightened expectations. I think that knowing every resident and their family members personally is essential. You have to know them well in order to personalize each interaction that you have."

Still adds that being available to residents and family members on a regular and consistent basis is extremely important. "Of course, I would tell a nursing home administrator the same thing. But this is where another difference between the two settings is apparent - in the assisted living setting, there are fewer staff members to be available for residents and families. Therefore, the administrator is typically the one who has to have his or her door open all the time." Staff hierarchy in the assisted living facility is practically non-existent, Still adds. "Every staff member is close to the customer."

Ann Schiff has been Executive Director of Springhouse Assisted Living in Bethesda, MD for three years. She came to assisted living with 15 years' experience as a skilled nursing administrator. Schiff concurs with Steve Still: "AL residents are definitely more active and more vocal. They can tell you exactly what they want.

"I find that, because there are fewer parameters in this less regulated environment, families have higher expectations of what we will do for a resident. We take residents shopping for special events. We accompany them to appointments with trust officers and attorneys. We walk their dogs and change the cat litter. And," she adds, "keep in mind, we're doing all of this with fewer staff. In fact, sometimes we have to know where to draw the line. I like to remind family members that it benefits them, as well as the resident, to stay involved in the resident's care."

Schiff says that, although the work is different, a skilled nursing administrator should be prepared to do the same amount of work with fewer resources. "I spend a lot more of my time problem-solving with residents and family members. When I was in the nursing home setting, I typically had a social worker on my staff who handled many of these issues."

She also believes that it is important for a nursing home administrator to be up-to-date on human resources issues such as fair hiring practices, labor relations and benefits. "Often, a nursing home will have a human resources manager or some equivalent, and perhaps doesn't need an in-depth knowledge of personnel issues. Although I am fortunate in that my assisted living organization now has a part-time human resources manager, before that I needed to be up-to-speed on interviewing and hiring issues, as well as legal issues that relate to. staffing."

Steve Still agrees that the assisted living administrator has to be able to manage staff differently than he or she did in the skilled nursing facility. "The 'universal employee' concept is more prevalent in assisted living. If there's a spill on the floor, a staff person doesn't wait for housekeeping to clean it up. They do it themselves. In essence, everyone's a front-line worker."

The professionals who have made the switch to assisted living agree that hiring and training currently is more challenging in assisted living. "When I was a nursing home administrator, I could generally count on a generous supply of reasonably experienced people from which to recruit for open positions," Schiff recalls. "Now, I focus my hiring efforts on people who have the right personality and who will fit in with the current residents and staff members. Currently it's difficult to find people who have assisted living experience, although that will change as the industry matures."

And how do assisted living administrators train their staffs? "Most assisted living facilities don't have the inservice directors that you often find in nursing homes," notes Schiff. "So the responsibility for orientation and training generally falls directly on the shoulders of the administrator and other staff." It is true that assisted living homes operated by large chains often have the benefit of corporate training departments that can lend some assistance in writing and implementing training programs. However, because the industry is still fairly young, training continues to be a challenge for administration.

In order to fill the gap in training resources, the Assisted Living Federation of America (ALFA) offers the industry a complete Assisted Living Training System (ALTS). Karen Wayne, President of ALFA, explains that one of the greatest benefits of providing standardized training through ALTS is that it creates a common vocabulary for the industry.

"As more and more staff are trained in this field, it will become easier for assisted living administrators to recruit experienced staff. Until our industry becomes more mature, though, we will be recruiting scores of staff who are brand new to assisted living, and possibly even to the larger health care industry. Thus, with the input of dozens of assisted living experts, we have created a training system that models the nation's best practices." It is a system, Wayne suggests, that would prove to be an excellent resource for skilled nursing home administrators who are transitioning into the field.

Assisted living administrators are no different from nursing home administrators when it comes to keeping an eye on census. "That's one thing that doesn't change," Schiff laughs, but then adds that there is a difference in the sales and networking process for assisted living. "We find that the sales cycle is longer in assisted living because this is usually not a crisis-driven decision. On average, families spend about four months making the assisted living decision. Usually they information-gather, and then wait until their parent can no longer manage alone at home. Sometimes it can take longer than a year before the resident moves in." The assisted living facility therefore needs to develop a large lead base and focus on developing long-term relationships with prospective customers.

Schiff maintains that an assisted living facility has to work hard to develop a broad base of referral sources. It can't rely on hospitals the way a skilled nursing facility can, and a broad referral base may even include skilled nursing facilities.

"In assisted living," says Schiff, "we use our sales and networking interactions to educate prospective customers and referral sources. We have to, because people are not as versed in assisted living as they are in skilled nursing. Furthermore, with lack of regulation, the product varies from one provider to the next."

Schiff and Still agree that the assisted living setting, which is entirely resident- and family-focused, is very rewarding. Most nursing home administrators get into the nursing home business because they are seeking the same reward - to work directly with and care for the elderly. Often, however, they find that in this regulated environment, they are several layers removed from the customer. In the assisted living environment, as it exists today, it is still all about the resident and family.

David Peete is President of the Assisted Living University, which provides education and training for assisted living management and conducts, for ALFA, the Assisted Living Training System. For further information, 800-ALU-7030.