LeadingAge Magazine · May/June 2014 • Volume 04 • Number 03

Communicating Change to Consumers

May 14, 2014 | by Gene Mitchell

Many providers are making big changes in their business models and service mixes to meet consumer needs. But how well are they changing the image they project?

Change, driven by the demands of consumers and emerging demographic realities, is a major focus of LeadingAge member organizations. Some providers, built on a foundation of residential care, are reducing and in some cases ending those services. The strong movement toward promoting wellness is fundamentally altering the missions of organizations once devoted mainly to a medical model of care. Providers once limited to housing seniors are adopting an expanded mission that includes services to keep residents independent longer. And many LeadingAge members are reaching beyond their walls to offer services of all kinds to seniors in the surrounding areas.

But the old adage about doing good, and being seen doing good, must be part of the puzzle. As aging services providers respond to consumer needs and wants, how can they communicate the changes they’ve made to a public that knows little about the work they do? And to what degree do they—or can they—change the image of long-term care and other services for seniors?

LeadingAge looked at how three providers changed their business models, and the challenges they face as they fitfully try to help consumers understand those changes.

The Benjamin Rose Institute on Aging, Cleveland, OH, found itself in a dilemma in the early years of this century. Though proud of its new nursing home, which had opened in 1997 and had won a design award, the Benjamin Rose leadership realized that the home’s continued operation was financially unsustainable and threatened the future financial health of the organization’s other functions, including its 50-year-old Margaret Blenkner Research Institute and its large community service and mental health service operations.

CEO Richard Browdie, who notes that the new building was “one of the most expensive nursing homes, per bed, built in Ohio,” cites three issues the organization had to face.

“First, the building [Kethley House] was located on a lovely site but in a part of the city where the mix of residents likely was going to skew toward low income,” he says. “Second, the census … on Day One was 95% Medicaid. [Benjamin Rose’s] financial assumptions when it was built required a more traditional mix, with Medicaid at 50-60% and the remainder private pay and Medicare. Third, the Benjamin Rose Institute on Aging has significant resources, but most of the assets are in a permanent trust that can’t be used to back or eliminate debt, and not enough donated capital was raised to bring the costs of debt down to a sustainable level with a very high Medicaid census.”

Despite decades of experience in skilled nursing, Benjamin Rose finally concluded that it would need to sell or close Kethley House. While the decision to close the home was difficult, the potential impact on residents was mitigated by the number of options available for residents, and good planning.

“We were confident that we would not have too much trouble finding homes for residents,” Browdie says. “Cuyahoga County at the time had almost 10,000 licensed beds, and has a substantially larger proportion of not-for-profit nursing home beds than the rest of the state. Virtually all of them are LeadingAge members. So there were a lot of high-quality beds available to people.”

Within three weeks, all residents had moved out, and it wasn’t long before all the displaced Benjamin Rose employees found new jobs (and a few retired). “We had a well-earned reputation for having very high-quality staff that provided great care. Our staff turned out to be in high demand.”

Kethley House was leased to Kindred Health Care as a long-term acute care hospital, and Benjamin Rose retained enough space for offices on the 3rd floor. After five years Kindred exercised its option to purchase the building. “We negotiated a price that gave us more than enough to eliminate the debt,” Browdie says. “We had a nice nest-egg to build a new headquarters, and we’ve confirmed our historic commitment to Cleveland by building a beautiful office building and conference center with a view of downtown Cleveland.”

Benjamin Rose now offers independent living in its Margaret Wagner Apartments (in the building that once housed its original nursing home, built in 1960), and Browdie says it would consider expanding its low-income housing in the right circumstances, but the organization’s work today is much less residential and much more oriented toward education, advocacy and research. Part of the Margaret Wagner building is also rented to a PACE, along with two Benjamin Rose therapeutic group programs and an adult day program.

“We have a primary commitment to poor older people,” he says, “and we are looking for ways to broaden what we do. Our mission, in addition to community-based services, is now more concentrated in research and development of evidence-based practices, and becoming more active in turning research and service activity into information that can be shared with providers of services and to older people themselves. A newly expanded, complementary activity is training. We had always been in training in an incidental way, but now we are developing a new year-round training program.”

Benjamin Rose is in the process of establishing a center on evidence-based practices (with which it has long experience), and developing information systems to guide and evaluate those practices. It has just partnered with the state to implement two evidence-based practices in all the Ohio Alzheimer’s Associations.

When the organization closed its nursing home, says Browdie, “Our messaging had to be that in order for us to continue to do the other things we are known and valued for, we had to make a choice. The decision surprised some people, but with others we gained credibility. When we said that rather than compete with our friends by, for example, shrinking our other services and acquiring additional nursing homes to spread our costs and move into higher paying markets, we’ll use our time and talents to do something different and complementary, it was seen as a positive.”

One interesting aspect of outsiders’ reactions to change is that an organization that offers a variety of services is “known” in different ways by different groups. Browdie says, “People in the aging services field had always known us primarily for the way we touched their lives.” For instance, some other providers knew Benjamin Rose for its mental health and social work services, but knew little about its nursing home. Others interacted mostly with the nursing home but had little knowledge of the Margaret Blenkner Research Institute. “Our research is known nationally and internationally, but those audiences know nothing of our local service activities,” he says.

The Kethley House closing passed without much public notice, he adds. Since then, Browdie says, Benjamin Rose’s local reputation for research, advocacy and training has gone up to match its national reputation.

Changing the organization’s own self-perception might have been more of a hurdle than making a case to the public.

“We asked ourselves,” says Browdie, “was this a cataclysm for old people in Cleveland, or just for us? We were running 184 beds in a county with 10,000 beds. Were we a drop in the ocean or the center of universe? This is pivotal: Our understanding was that despite the fact that we ran an excellent nursing home, there were other excellent ones, so we knew our residents would find good care. Accepting that from a mission point of view was harder than you might think.”

How about media attention? “The local media doesn’t really understand us,” says Browdie. He cites the frequent turnover within the media as a factor in public understanding of aging services: There are few local media members that cover the “aging beat” long enough to gain a strong understanding of it.

Otterbein Senior Lifestyle Choices, based in Lebanon, Ohio, traces its history to 1912, when it was founded as a home for orphaned children, missionaries, United Methodist ministers and others less fortunate. By the 1960s, Otterbein had evolved into a large single-site CCRC. According to Vice President of Marketing & Communications Gary Horning, over the next 30 years Otterbein developed and assumed responsibility for four more continuing care retirement communities and was, he says, “a traditional multisite CCRC.”

Change began in earnest in 2007, when Otterbein debuted its first “small houses” for skilled nursing and rehabilitative care. There are now five Otterbein skilled nursing & rehab neighborhoods, each supporting 50 elders, and four more are under development. Entrance into the community and home services market came in 2009 with the launch of Otterbein Home Health, and again in 2013 with the start of Otterbein Hospice. Both operate in communities throughout southwestern Ohio. In 2010 Otterbein opened its first “Life Enrichment Center,” a multi-use wellness, fitness and social center. Subsequently Otterbein opened Life Enrichment Centers in four of the five CCRCs.

In 2011 the organization changed its name from Otterbein Homes to Otterbein Senior Lifestyle Choices, recognizing that it represents five distinctive ministries: senior lifestyle communities, skilled nursing & rehab neighborhoods, wellness senior services, home health and hospice. Otterbein seems to have mastered the business model for small houses, each devoted to both long-term care and post-acute rehabilitation. A new five-year plan is in place to “revamp long-term and post-acute/rehabilitative care at all of our Senior Lifestyle Community (CCRC) campuses … more to a small-house concept with self-directed work teams and person-centered care,” says Horning.

Otterbein’s wellness centers make the organization something of a “fitness provider” as well.

“The last three [Life Enrichment Centers] have much larger fitness centers, warm water therapy pools, and spas,” says Horning. “One has a library, and one has an indoor walking track. They are used by residents and employees, predominantly, but most are operated in conjunction with a local YMCA; the Y people run a variety of fitness programs, and we sell memberships to local community folks that are 55 and older.”

One problem with “products” that most consumers don’t really know much about in the first place is that dramatic innovations for the better fly under the radar. This can be frustrating for a provider like Otterbein, which has changed its approach to long-term care in a big way with its small-house model, yet remains what Horning calls “a well-kept secret.” He says that consumers familiar with traditional long-term care understand the difference. “But we still have a wide array of old myths to overcome about this field, yes. There are still a lot of people who drive past our small houses that have no clue they are nursing homes and advanced rehabilitation centers.”

For Otterbein, great attention has been paid to branding in the last three years. One source of confusion was that the small houses were once branded as a separate entity, “Avalon.”

“The name Otterbein was not leveraged. We went through an aggressive outbound branding campaign, with new logos for each distinctive ministry,” says Horning. “We put the Otterbein name right up front on all ministries. The outbound work was local advertising, direct mail, lots of sponsorships, and revamping our web and social media presence. We were really aggressive for 18 months or so in outbound promotion of the brand.” Lately Otterbein has cut back on that, focusing more attention on geographically-focused advertising, direct mail, social media focused on specific communities and/or neighborhoods within each ministry .

Through its history of more than 130 years, Stonehill Franciscan Services, Dubuque, IA, has been seen as what it has been: a faith-based, not-for-profit organization caring for the aged. While well-known and respected in its community, that traditional identity is now supplemented by recognition for a complementary new face: fitness club.

The story of this new image goes back to 2007, when Eric Thomas, president/CEO, started at Stonehill.

“We were certified for Medicare rehab [services], but didn’t do any,” says Thomas. “So we knocked out a couple of rooms and called it a therapy gym. That was the start, and it was not much, but as corny as it sounds, it was something.”

Within a couple of years that modest beginning was not enough, so Stonehill built what Thomas calls “Therapy Center 2.0,” by converting half of the first floor of the care center, about 1,500 square feet, into a dedicated rehab wing.

“The rooms were private with bathrooms,” Thomas says. “The idea was, move in, have a successful rehab and then go home. Even after that our caseload was growing and that got me thinking, gosh, this won’t be the end of this.”

The answer to more growing pains was construction of a new therapy and wellness center on the Stonehill campus. Half of the building is dedicated to rehab, the other to a wellness center with a “fitness club” look and vibe.

While running a capital campaign to raise funds for the therapy/wellness center and four attached households, Stonehill decided to open the wellness center to people from the surrounding community. Later it went that idea one better by offering free one-year memberships to anyone 65 or older.

Thomas says, “That’s when the buzz started to hum really loudly! On several of the sign-up days, we had lines of people going out our driveway and our maintenance guys had to haul up truckloads of chairs because we couldn’t process the members quickly enough. We ultimately signed up more than 3,000 members in the first six months and had to order more [gym] equipment at least twice.”

A year later, the price of a one-year membership has gone up to a modest $10 for anyone 65 or older, but remains free for any current or past rehab clients. Use of the center is also free for employees and their families.

“These are people who never had thought about spending money on a fitness membership,” says Thomas. “But I’ve heard people say at least 100 times, ‘I didn’t know you did therapy here.’ In the first six months, we tracked people who first became wellness members and who then went through outpatient therapy.” That group, says Thomas, was responsible for more than $400,000 in revenue over that time.

The wellness/fitness center features a variety of state-of-the-art equipment. Technogym fitness machines have LED screens attached to every piece of strength and cardio equipment so users can use their “smart keys” to track their workouts. Because the rehab center treats so many people under weight-bearing restrictions, a therapy pool by Hydroworx, which facilitates “water walking,” was installed. It handles up to four people at once and is routinely booked two weeks in advance. “When we opened we even had a team marathon relay event covered by the radio [station] wherein people of all ages did a leg or two in the pool. Some were local celebrities or All-American runners and some were 90-year-old residents,” Thomas says.

Based on his experience at a “boot camp” at another gym, Thomas added MoveStrong training equipment for staff and team members. Stonehill sent a restorative aide through massage therapy school, and now she provides a free one-hour massage each week to rehab patients.

“We’re admitting close to 40 people a month for rehab,” says Thomas. “Then they go home, we provide transportation for outpatient therapy, and when they’re done, we give them a free wellness membership to stay connected to us. We’re trying to reinvent what it means to be a retirement community. We’re trying to keep people out of here, not bring them in.”

At Stonehill, getting the word out about the new wellness and rehab services has been mostly a matter of word-of-mouth.

Physicians are a built-in referral source. “They suggest that clients can go to Stonehill Wellness Center for rehab, and get a free membership,” Thomas says. In our outpatient therapy center, we’ve been averaging 300 people per day from the community coming to our campus—people who don’t live on our campus.”

Stonehill very consciously seeks to change people’s impressions of the organization: “For 100 years we were long-term care,” says Thomas. “On this wellness center, we put giant windows, and it’s situated between our two main driveways. I want people to drive in here to do wellness and see this as a destination. We rebranded ourselves. There’s no question that the people using it now have a favorable, cool image of what’s happening.

“One of the inspiring parts of the story is a real intergenerational thing going on,” he adds. “The skilled nursing people might come over to use a stair-stepper and they see younger people working out here. The younger people working out inspire older ones. One day I took a picture of a guy on a Technogym in his coveralls … he looked like Jerry Garcia. People feel accepted, [they] don’t have to be in their yuppie [workout] clothes.”

With its juice bar and soup and sandwich services, the wellness center builds its own momentum by becoming a socialization center. “We’re in the north end of town, [which is] kind of forgotten because it’s an older part of town,” says Thomas. “Another thing you hear is that ‘this is the best thing that’s happened in 30 years on the north end.’”