Senior housing providers branch into at-home care models

Market research has shown that fewer Americans plan to move to continuing care retirement communities (CCRCs), assisted living centers, and nursing homes. Factors contributing to this shift include increasing costs and moderating income for seniors, technology that enables people to receive care and maintain social relationships at home and public policy efforts to support older adults at home.

To address changing consumer demands and industry trends, senior living providers are refining their business models to offer more services and stay competitive. Many senior living providers are extending services off-campus to reach those people who plan to stay in their homes for as long as possible as they age.

The 2012 LeadingAge Ziegler 100 Fact Sheet, a study of the largest 100 nonprofit senior living organizations in the United States, notes the number of at-home programs offered by the listed organizations increased by 32 percent between 2010 and 2011. Franchise Business Review has identified private-duty home care franchises as among the fastest-growing businesses with solid financial returns.

The Patient Protection and Affordable Care Act included demonstration projects for providing home- and community-based services as alternatives to higher levels of care, and also reduced the financial qualifications for consumers to receive these services.


While some organizations are offering traditional home care models that include home health, hospice and private-duty care, others are developing innovative programs that duplicate the breadth of services typically provided on a continuing care campus. Along with serving more older adults, senior living providers are diversifying off-campus in order to:

  • develop new and diverse revenue streams,
  • prepare for bundled payments under healthcare reform,
  • spread administrative expenses over additional product lines,
  • drive referrals to other service lines in private homes and facilities,
  • increase brand awareness and
  • retain senior managers by offering programmatic challenges. 

While innovative at-home programs across the country include a variety of fee structures, staffing models and service packages, most share a common model: a continuum of services that allows seniors to easily access the services they need as they age. Home-based services ranging from personal care to home maintenance and transportation are provided by employees of the sponsor or through partnerships with local vendors. Assisted living and home nursing care is provided by the sponsor or through a network. Any service a client needs can be obtained by making one phone call.

Care coordination is an integral component of this new approach. Care coordinators assess and monitor the medical status of their clients, coordinate necessary services, solve problems, facilitate communication among family and friends, and advocate for clients with healthcare and service providers. Care coordinators are the heart of at-home programs and are essential to consumer satisfaction and successful aging.

Most innovative home-based programs—which target a private pay market ranging from people with incomes just above the poverty line to the very wealthy—also offer educational opportunities, wellness programs, social and spiritual experiences. The goal is to provide comprehensive services that enhance quality of life, not just physical health.

Following are examples of several different innovative home-based program models.


These at-home membership programs are similar to Type A CCRC services. In return for payment of an entrance fee and a monthly fee, the member or participant can access a comprehensive package of LTC services that supports independence even as care needs increase. An initial screening of applicants is required, and only those who are not in need of services and have no degenerative diagnoses, such as Alzheimer’s or Parkinson’s, are accepted. A deficit in at least one of five Activities of Daily Living (ADL) is required to access services.

The pricing structure for continuing care at home is a life-care model that offers a member a lifetime guarantee of care for a one-time entry or membership fee paid when he or she joins the program, and monthly fees that begin the first month of membership. Entry fees vary depending upon the age of the member; fees are higher with age.

Monthly fees increase annually to reflect the overall operating expense and cost of living, but typically do not increase as a member needs care, thus protecting the member’s assets. Pricing is actuarially based and entry fees can be used by the provider to support the initial start-up, keeping the investment capital needed to a minimum. Excess cash goes into a reserve account that funds future services.

Life-care-at-home programs appeal to healthy older adults who are planners and want the security of knowing where to turn for future care and services.


These programs offer a continuum of services on a fee-for-service or as-needed basis. The provider must employ many of the service workers and charge prevailing rates, so the margins from the sale of services can be used to support the administrative infrastructure. Typically, services sold by the provider fall into the general category of home care or private-duty services, and also may include simple home maintenance, housekeeping and transportation. Referrals to outside vendors are provided for service requests not offered by the provider.

Fee-for-service programs typically appeal to seniors who have a deficit in one or more ADL or IADL (instrumental activities of daily living), and who choose to purchase services to support long-term independence in private homes.


The first virtual village was founded in Boston in 2001 by a group of neighborhood residents who wanted to stay in their homes as they aged, but also wanted a supportive local network of services and activities. Today, there are 89 active villages and 123 villages in development across the country, most started by older consumer activists. 

Villages are distinguished by their grass-roots, volunteer nature. Most are run by a combination of volunteers and a small paid staff. The programs are designed to coordinate access to affordable services including transportation, health and wellness programs, home repair, social and educational activities, and trips provided by vetted, discounted providers.

The biggest challenge for village members are the membership fees, which average $50 to $60 a month. While these fees may appear to be affordable, they can be a barrier when it comes time for a consumer to make the decision to join. As a result, membership numbers are often too low to provide the operating revenue needed to break even. Many villages raise funds and solicit in-kind support to make up for operating losses.

Villages offer a unique opportunity for senior living providers that have services to offer. In return, village members may need assisted living or nursing home services from the provider in the future.


The concept of free membership allows organizations to capture a larger percentage of the market. The value of memberships to consumers might be access to social events, publications and local discounts. The goal for the provider is to nurture an affinity among members, which can result in the purchase of services. This approach is new to senior living but has been used by hospitals for years.


One goal of healthcare reform is to reduce costs by decreasing readmissions to hospitals. In April 2009, the New England Journal of Medicine reported that more than 19 percent of Medicare beneficiaries were readmitted within a 30-day period and 34 percent within a 90-day period. Readmissions within 30 days alone accounted for more than $15 billion in Medicare spending.

Innovative home-based programs serve as models for care management and service coordination that can reduce hospital readmissions. Some life care at home program managers have tracked the number of readmissions among their members and found the numbers to be lower than expected.

Joan Krueger, director of Longwood at Home, the continuing care at home program affiliated with Presbyterian SeniorCare in Pittsburgh, said her organization experienced significantly lower readmissions as a result of her program’s coordination of services. In 2011, 38 Longwood members were hospitalized for a total of 46 acute admissions, Krueger says. Only two members were readmitted within 30 days.

“I believe our experience is attributable to the quality of our care coordination,” Krueger says. “The Longwood at Home care coordinators are actively involved in discharge planning, which includes referrals for Medicare-certified home care, private-duty care, short-term skilled admissions and other services as needed. We get to know our members over time and can develop a more effective discharge plan based on our understanding of their support systems, level of independence prior to their hospitalization, family involvement and home situation.”

According to Lynne Giacobbe, executive director of Kendal at Home in Westlake, Ohio, of the 140 hospitalizations of Kendal at Home members since 2004, only 11 percent were readmitted within a 30-day period, and less than 6 percent were readmitted within a six-month period.

“It is the involvement of the care manager and the supportive services our members can access that enable us to impact readmission,” Giacobbe explains. “It is typically more than just calling if they need help. We most often are arranging for discharge and providing care in order to help the member recuperate fully and regain whatever level of independence is possible. So often, older adults go home after a hospitalization with little or no support in place—ultimately resulting in readmission.”


There is no single type of at-home service that represents one solution or opportunity to serve an increasing number of older Americans. Innovative home-based programs are one way entrepreneurial providers are shaping the future. Providers who implement these programs build on their strengths as they recognize the key differences between their core businesses and the demands of a new and distinct service line.

Sarah L. Spellman, LNHA is a Health Care Director at CliftonLarsonAllen LLP (CLA). She has extensive experience with providers that are expanding their service models. Before joining CLA, she developed and operated one of the first continuing care at home programs in the country. She can be reached at

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