February 2012

Vol. 18 No. 2

T h e S o u r c e f o r A s s i s t e d L i v i n g M a n a g e m e n t , N e w s , a n d P o l i c y I n f o r m a t i o n

Outbreaks of noroviruses, a group of viruses that cause stomach flu, can happen

in an instant and spread quickly in a setting such as an assisted living community. These illnesses are espe-cially common in the cold weather when people spend more time inside.

Norovirus outbreaks can cause sig-nificant op-erational and financial bur-dens in terms of infection management, staff sick leave and overtime, and additional health care and cleaning sup-plies and costs. Fortunately, you don’t have to just bite the bullet and accept noroviruses as inevitable. There is much an assisted living facility can do to minimize the impact of a norovirus outbreak and protect its residents and staff.

Daniel Haimowitz, MD, CMD, a long term care physician in Pennsyl-vania, says, “Philadelphia Depart-ment of Public Health guidelines suggest that the best way to reduce the risk or impact of an outbreak is

for facilities to establish pre-season prepara-tion measures and have a standardized and widely communicated rapid response plan in place.”

This plan should address risk factors that increase the possibility of a norovirus out-break, the best ways to identify an outbreak at its onset, and interventions that are most likely to prevent

or contain outbreaks. Staff, as well as residents, should

know the signs of noroviruses so that they can notify management when they see or experience signs of the

An Unwanted Winter Guest: How To Keep Norovirus Visit Short

in this issue

3. Marketing: Solving The Motivation Mystery

5. Finance: New Construction Possible

>> pg 6

Casting A Vote For Facility Election Coverage

Prior to the Republican primary in New Hampshire, at least one facility was part of the hoopla

and excitement. Kendal at Hanover hosted presidential candidate Jon Huntsman for a visit.

“He was well received,” says Diana Cox, the facility’s director of resident health care services. She adds, “The residents enjoyed the opportunity to talk to the candidate about key issues such as health care.”

Interestingly, Cox says, “Coming so closely on the heels of the Iowa primary, there wasn’t a lot of interest in or activity surrounding the pri-mary.” However, she adds, residents want information about the candidates and the issues. They take the right to choose their candidates seriously.

As Cox explains, “Most of our residents are women. When they were younger—in the 1940s and ’50s, they were expected to vote for the same candidates their husbands did. Now they make their own decisions and choices.”

The elections are discussed at com-munity coffees and resident council meetings. “Additionally, the activities department does some historical pro-grams about the election process and plays memory games around political issues. We also coordinate with our social worker to coordinate absentee

>> pg 4

‘Staff, as well as residents, should know the signs of

noroviruses so that they can notify management when

they see signs of the illness.’

nCAL FOCus February 2012 ncal.org

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Demonstrate Quality; Complete Two Online Surveys

NCAL encourages members to spend a few min-utes to complete two online surveys as part of its third annual Performance Measurement

Initiative. The two online surveys are the Performance Measures Survey and the Employee Vacancy, Retention, and Turnover (VRT) Survey. NCAL’s goal is to produce reports that convey to consumers and policymakers the assisted living profession’s commitment to delivering quality care to residents.

The Performance Measures Survey was established in 2010 to help the profession assess and improve the quality of care and quality of life for residents in as-sisted living. It includes questions about how providers evaluate their quality of care and services in nine areas of operation. This year, NCAL’s Quality Committee added nine questions about workforce. Most of the

questions require “yes” or “no” responses and should take participants about 15-20 minutes to complete.

The VRT Survey focuses on one performance mea-sure—staff retention. The VRT requires providers to insert numbers related to staff vacancies, retention, and turnover.

Data collection for these two surveys will close on Monday, April 2. NCAL will analyze the data and produce reports to provide benchmarks for residents, family members, state and federal policymakers, and providers alike. Individual provider data submitted are confidential. The data will be used in aggregate form only, without any identifying information.

Access these surveys on NCAL’s website, NCAL.org, under the “Be Heard” section. If you have any ques-tions, contact Shelley Sabo at ssabo@ncal.org.

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February 2012 nCAL FOCusncal.org

Solving The Motivation Mystery For Sales

Finding, keeping, and moti-vating sales staff that can fill assisted living communities

and keep them filled is an art and a science. When you get the right people on the job, it enhances the facility’s profitability and reputa-tion. When someone is a bad fit, the cost to replace him or her is high.

According to Russ Watson, EdD, president of Illinois-based Target Consultants, a bad hire can cost

from $150,000 to $450,000 in busi-ness revenue, or two to six times wages and benefits.

The key is to use proven means of assessing applicants and determining their motivations before they come on board. This can help employers identify those individuals who are most likely to succeed in this sales setting.

Watson gathered data from participants at a recent sales and marketing summit for seniors housing sales staff from numerous organizations to conduct a statisti-cal study of the top and lowest performers. “We looked at where they were common, where they

were different, and how we can move the lower performers more toward the middle of the curve,” says Watson.

“The first thing we found was that top performers were slightly more decisive than lower perform-ers, and this was accompanied by a higher sense of urgency,” Watson says.

For example, when a pros-pect says that he wants to wait and see how his illness progresses,

the sales person helps the prospect imagine how impor-tant it is to make a decision while he is able to take the time and effort to examine all options.

The sales person also makes the pros-pect envision how waiting until a move is necessary can re-sult in an impulsive

decision that he may regret later.Conversely, Watson says, when

prospects say they want to wait, a lower performer is more likely to say, “Okay, I’ll talk to you again in six months.”

Knowing how top performers think and function can help you improve the results of low per-formers. However, Watson says, “you don’t turn low performers into top performers, but you can bring them closer to the middle.” To do this, he suggests a number of useful exercises and activities.

For example, “Ask lower per-formers to make two more calls

Another type of assessment Watson used identifies a person’s drives and

motivators. It addresses six types of values: theoretical (drive for knowledge), utilitarian/economic (drive for money and materials), aesthetic (drive for harmony and form), social/altruistic (drive to help others), individual/political (drive for uniqueness and influence), and traditional/regulatory (drive for order and routine).

Watson used this assessment with the same study group, and “some things emerged in a robust way,” he says. “There was a huge difference in theoretical drive between high and low performers. Top perform-ers were much better at learning about the industry, properties, and customers. They were naturally in-quisitive.” Economic drive also was stronger in top performers. Interest-ingly, while they were more driven by money than lower performers, the difference between the two wasn’t extreme, and top perform-ers’ drive for the dollar was “appro-priate and not extreme.”

Top performers were much less driven by aesthetics. Watson says that this generally translates into more personalized and effective facility tours. Top performers are more likely to encourage prospects to explore the grounds and features that are of greatest interest to them. Low performers, on the other hand, give tours based on what they think are the property’s strongest, best

How Head, Heart, And Money Drive Sales

>> pg 4>> pg 4

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nCAL FOCus February 2012 ncal.org

every day for two weeks. These can be prospect calls or follow-ups to a visit or question. This might make a difference in getting a prospect into their pipeline.”

Role playing exercises can help sharpen their decisiveness, says Watson. For example, pair up low and high performers. Ask the low performers to throw out a role objection they’ve encountered at the high performer. Then discuss the possible answers. “I always encourage sales people to role play with others when they are stumped or have a problem. This can be done informally, and it helps them envision solutions they hadn’t seen before,” he says.

By partnering strong sales people

with weaker ones, low perform-ers can learn to be less dependent on structure. “Low performers often use structure—processes and paperwork—as a safety blanket to avoid asking for money. They may be a little afraid to close a deal or ask for a contract,” he says. “Lower performers can be encouraged to let go a little bit by learning how to manage structure without being consumed by it,” he says.

Another way to help low per-formers is have the two top sales people in the organization stand in front of the sales team, and have people call out actual objections they have heard in the past month. The top people then say how they would overcome these objections.

features. Lower performers are more altruistically aimed. While this may seem like a positive, it often means that they are overly, inappropriately involved with prospects and may get too involved with them or dig too deeply into their problems and concerns. “The top performers are a nonanxious, reassuring presence,” says Watson.

“This study surprised me, and I’ve been doing research for 30 years,” says Watson. There was only a six-point spread between the top three motivators for leading performers.

“What drives top performers is a combination of business, heart, and head.”

Sales continued from page 3

Motivation Mystery continued from page 3

ballots and get residents who are able out to the polls,” says Cox.

As few facilities are com-pletely homogenous, it is important to invite candidates from both parties. These invitations can be extended through local Democrat and Republican headquarters, congressional representa-tives’ local offices, and organizations such as the League of Women Voters.

Alec Pruchnicki, MD, medical director of Robert Lott As-sisted Living Facility in New York City, adds that his facility’s recre-ational therapist invites speakers and arranges political programs. He says, “We are Medicaid-supported, so we have to be attuned to policy

changes and legislative issues. We try to keep in close touch with politicians. We often invite them

to come in and speak with staff and residents.” Political infight-ing could cause problems in the assisted living community. Fortunately, this doesn’t seem to be an

issue. Cox and Pruch-nicki agree that their residents are respectful of each other’s political viewpoints and opinions. “People with minority views are respected. Debates or arguments have never risen to the level where we needed to address this,” says Cox.

While the facility can help make sure residents have access to infor-mation about issues and candidates, they have to be careful to remain neutral. Nonetheless, making sure residents have accurate information is important. As Pruchnicki says, “Sometimes residents will complain about government programs, and I gently tell them that they’re in the facility because of one. If I hear someone say something factually incorrect, I try to give them the facts as objectively as possible.”

Why should facilities make the effort to put politics on the front burner? According to Cox, “For people in their 70s, 80s, and 90s, voting was one of their first oppor-tunities to speak their mind. It is a hallmark of their values. It is very important to people.”

Casting A Vote, continued from page 1

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New Construction: More Possible Than You Might Think

In this fragile economy when budget cutting is the norm and banks are tightening their purse strings, new assisted living construction or expansion may

seem like a pipedream. However, some innovative owner/operators have found creative ways to make their dreams come true.

Gerald Hamilton, partner in Beehive Homes of Albu-querque, N.M., opened two small (15-bed) facilities in 2006 and 2008. Even then, financing was a challenge. “I started with a Small Business Associa-tion [SBA] loan for the first building. I was able to convert to a commercial bank loan in a couple of years.”

Establishing a track record made a difference when he went back for funding to open a third building in April. “I found that it works well to use a bank where I have an estab-lished relationship with people,” Hamilton says. Bank personnel who have witnessed a business’ success and seen the fruits of the owner’s labor can be strong allies.

In contrast, Hamilton is working on a project in another state where he lacks such relationships, and he says, “It’s been slow going—with lots of paperwork and meetings.”

When dealing with strangers, research and preparation can make a huge difference. As Hamilton says, “When you’re dealing with people who don’t know you, they want to know you’ve done a good needs analysis. They want to know precisely what kind of money you’ll be putting in, what you need, and when cash flow will start. They want to see your marketing plan and where your customers will be coming from.”

He adds, “There’s an old saying: ‘Banks don’t lend you money unless you can prove you don’t need it.’ There is some truth to that. Banks want to see a track record and a proven product.”

Financing isn’t the only challenge, says Hamilton. He had to learn to be a diplomat, educator, and student. He explains, “The people we deal with for permits, inspec-tions, and so on know their business, but they don’t

know assisted living. They don’t know the kind of building we’re constructing. We have to educate them in a diplomatic way.” As these individuals hold the key to zoning and approval processes, assisted living facil-ity owners can’t afford to offend them.

Especially if you’re a one-person operation, you can’t always get what you want when dealing with inspec-tors and other officials. “I don’t have a lot of time and money to sit around and wait for approvals. Sometimes

it’s easier to compromise and do what they want me to do,” Hamilton says.

For example, contrary to his own wishes, he put a commercial lid over the range in one home. “It cost money and took away from the residential look and feel of the place. But it enabled us to get the construction done in a reasonable time frame,” he says.

Rosalene Black, owner of Midland Meadows Senior Living in West Virginia, avoided some of the challenges Hamilton faced by going the prefab route. “When I had an opportunity to be an owner, I went with a prefab building because that’s all I’ve known. The quality is good, set up is fast, and cold weather doesn’t delay

>> pg 8

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nCAL FOCus February 2012 ncal.orgncal.org

illness. Norovirus symptoms include nausea, diarrhea, and stomach cramps. Additionally, some people experi-ence a low-grade fever, chills, headache, muscle aches, and fatigue. Symptoms can appear as soon as 12 hours or up to 48 hours after infection.

Identifying incidences of norovirus early is impor-tant, because prevention is difficult and treatments are limited. There is no vaccine to prevent infections. There are no antiviral medications that work for noroviruses, and the illness cannot be treated with antibiotics.

Treatment includes keeping people well-hydrated with fluids containing electrolytes. Over-the-counter antidiarrheal medications may be helpful, except for

patients with severe abdominal pain or fever.

For most people, the illness lasts for a day or two. However, the elderly, es-pecially those with impaired immune systems, are more likely to experience a longer duration of diarrhea and vomiting and complications such as dehydration, electrolyte disturbances, aspiration, and even death.

To limit the spread of the norovirus, says Haimowitz, “it is important to restrict symptomatic and recovering patients from leaving the residence other than for care or treatment.”

This can be challenging in an assisted living community where residents are

used to being active and moving freely throughout the grounds.

“This is one reason education is so important. When residents and their families understand how staying in their units can prevent the spread of the illness, they are more likely to comply,” says Haimowitz.

Norovirus Visit Short continued from page 1

“Norovirus is easily transmitted and hard to remove from the environ-ment,” says Haimowitz. It can

survive temperatures from freezing to 60 degrees Centigrade. “Some outbreaks have been traced to contaminated computer keyboards and sinks where food service workers first washed their hands and then rinsed vegetables,” he says. Sur-faces soiled with vomit or contaminated hands can “sustain an uncontrolled epidemic,” he says. In fact, contaminated fingers could transfer noro-virus to up to seven con-secutive clean surfaces.

According to Haimow-itz, among the common ways noroviruses are transmitted in an assisted living facility are through:

■ Eating food prepared by contaminated hands of food handlers who are sick;

■ Eating shellfish or water contaminated by raw sewage;

■ Oral contact after exposure to contaminated body fluids or skin or contaminated environmental surfaces; and

■ Oral exposure to droplets of vomit. Although preventing person-to-person trans-

mission can be difficult, the Centers for Disease Control and Prevention (CDC) recommends the following measures:

■ Frequent hand washing with soap and water;■ Wearing masks (for people who clean areas

substantially contaminated by feces or vomitus);■ Minimal handling of soiled linens and

clothes. Laundering these with detergent at the maximum available cycle length and then ma-chine dried; and

■ Clean soiled surfaces with an appropriate ger-micidal product (for example, 10 percent solution of household bleach).

Limiting The Spread Of Norovirus

In March 2011, CDC released its “Updated Norovi-rus Outbreak Management and Disease Prevention Guideline.” The guideline includes recommendations regarding infection and control, updates on diag-nostic methods, information about transmission and outbreaks, and guidance on reporting and assistance. For more information, visit www.cdc.gov/mmwr/pre-view/mmwrhtml/rr6003a1.htm.

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February 2012 nCAL FOCusncal.orgncal.org

Home Visits: A View Of The Present Shapes The Future

Imagine this scenario. Mrs. Jones, a prospect for your community,

has come for visits twice. She seems to like what she’s seen, and her adult children are encouraging the move. How can you find out what is holding her back? Con-sider a visit to her home. It can speak volumes about issues or concerns she can’t or won’t express.

“The main benefit is to be able to see them in their comfortable environment. You can get a clear picture of their living conditions and how they function,” says Jill Sproul, vice president of operations, Harmony Senior Services, Roanoke, Va. She adds, “You can look around and see pictures. You find out about their families and how much interaction they have with them and what—if any—support they get.” You get a sense of how dependent they are on others and who is influential in their lives. By observing, asking questions, and listen-ing, you can “see things you couldn’t see if they come to your community.”

The visit can help determine what services the prospective resident needs and if assisted living is the best setting for this individual. “A lot of times people come to use and say that their mom needs assisted living, but we see that independent living would be more appropriate. If you find that the person is a good fit for your facility, you’ll be better able to sell it,” says Sproul. Conversely,

Some keys to ensure a successful home visit include:

■ Bring a little gift that you know the prospective resident will like. For ex-ample, if they love gardening, bring a little plant. “The gift says, ‘Thank you for letting us into your home.’ It also shows that you cared enough to get to know something about them,” says Sproul.

■ Take someone else with you on the visit. Also, tell the prospect to invite a family member to join you. This is a risk issue. For example, if a prospect with mild dementia got upset and confused and later made an unfounded accusation against the facility representative, it is important to have a witness.

■ Gently ask questions to give you insight into the person’s living situation. What challenges do they face by living alone? Do they cook their own meals? What would make their life easier? How do they get around (to the store, for example)? Who helps them?

■ Observe details in the environment. Is the home clean? Is there evidence of hoarding? Are there pets? Are there signs of the person’s hobbies or interests?

if you find out that it isn’t a good fit or that the person absolutely can’t afford the community, don’t waste their time or yours. You can give him or her other options,” she adds.

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NCAL is the assisted living voice of the American Health Care Association. NCAL Focus (ISSN: 1095-5585) is published monthly by the American Health Care Association (AHCA), 1201 L Street, NW, Washington, DC 20005. Copyright © 2012 by AHCA. Reproduction

in whole or in part is prohibited without written authorization from the copyright holder. NCAL or AHCA members’ subscription fees are included in membership dues. AHCA is the nation’s largest federation of assisted

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construction,” she says. While prefab has advantages, Black says, it doesn’t affect financing. However, Black hasn’t had trouble with financing, mainly because of her diligence and passion.

“We have a wonderful relationship with the local branch of our bank. The bank president knows us personally and believes in our project.”

Black also has the advantage of a good track record she established several years ago. She explains, “We’ve been able to show that we pay our bills on time, we’ve been successful, and we have 45 people on a waiting list.”

In planning her buildings today, Black considers features and expenses that would have seemed foolish 10 or 15 years ago. “I wouldn’t have dreamed about installing exercise rooms and equipment or wireless Internet access. Today, residents expect that,” she says.

One thing that hasn’t changed is the desire to make residents happy. “You can have the best building in the world, but you won’t keep or attract residents if you don’t provide a home and life that make them happy.”

New Construction continued from page 5