Featured Guest: Rebecca Adelman

What she does:  Rebecca is the founder of Adelman Law Firm in Tennessee.  Her practice is concentrated in healthcare and insurance defense and business litigation, and includes representation of insurance companies and long-term care providers and their insurers - both regionally and nationally. The firm also provides claims management services to senior living insurance companies.  Rebecca is involved in state and national legislative matters on behalf of the healthcare industry and serves as Legal Advisor for the American Assisted Living Nurses Association and the National Association of Health Care Assistants.  She founded the National Long-Term Care Defense Summit, co-founded the Adelman-Mettle Palliative Care Alliance, and is a member of Claims and Litigation Management Alliance.  In addition, Rebecca is a published author and national speaker and contributor.

On risk:  "Risk in senior living is multifaceted, there are so many aspects of senior living … How we define, view, and think about risk, really depends on that we all agree there are varying types of risks in senior living. There's obvious risks of injury, or just an incident and an outcome, a negative outcome, but then there are a lot of other risks, emerging risks, and some smoldering risks, all sorts of risks embedded in all of these little subparts of the ecosystem … There's so much at stake where risk is concerned in senior living that the importance of considering it cannot be overemphasized. We need to really appreciate how risk is managed in organizations because risk management is everyone's business, it's everyone's responsibility … From my vantage point along the whole risk spectrum, I'm showing up at the 9s and the 10s and moving down the risk spectrum into the 6s and 7s. The real place for everyone to begin in its least complex form, with all types of risk management, to mitigate risks, to hopefully eliminate risk, certainly to identify it so it doesn't come up, is really when it's in the 1s and the 2s. Proactivity would be the word of the day … Here's the ticket, the real small key that opens up the big door is implementation. You've got to implement across your organization."

Transcript

Scott Nelson  0:01  
Welcome to The Risky Health Care Business Podcast, where we help you prepare for the future by sharing stories, insights, and skills from expert voices in and around the United States health care world with a mission to inform, educate, and help health care organizations and individuals, ranging from one doctor practices to large integrated systems and organizations throughout the dental, medical, and veterinary health care industry with risk, while hopefully having some fun along the way. I'm your host, Scott Nelson, a guy that grew up in Ohio and has been working all over the United States during my 20 plus year and counting career in the health care industry, with a commitment to accelerating health care performance through creativity, not just productivity. Let's dive in.

According to the American Health Care Association and the National Center for Assisted Living, there are approximately 30,600 assisted living communities with nearly 1.2 million licensed beds in the United States today.  56% are chain-affiliated (chain-affiliated means an organization with two or more communities) and 42% are independently-owned.  

As of the 2020 census, one in six Americans is over the age of 65.  Seniorliving.org notes that due to the rising population and growing number of retirement-age Americans, investment in the senior living industry is expected to increase in the years to come. According to research conducted by IBISWorld, there are more than 19,000 retirement community businesses in the United States as of 2023. That represents a 1.2% increase since 2018, and the number of senior living businesses is projected to continue growing to meet the evolving needs of an aging population. The market size of the senior living industry is expected to grow by just over 4% each year, potentially exceeding $805 billion by 2030.  According to Genworth estimates, the cost of assistive care and housing for seniors could rise by more than 30% by 2030.

There are many stakeholders in and around senior and assisted living health care: providers and organizations, owners, insurance companies, government, families, and the most important group, whatever the label, patients, clients, customers, the people receiving care and services.  This segment of health care has many internal and external risk factors.  With senior living in the top grouping of health care businesses to file for bankruptcy protections in 2023, along with workforce challenges and other legal issues, patient falls is not the only current and future risk for senior and assisted living health care.

Today I'm speaking with Rebecca Adelman about risk in senior and assisted living health care.  Rebecca is the founder of Adelman Law Firm in Tennessee.  Her practice is in health care and insurance defense and business litigation, and includes representation of insurance companies and long-term care providers and their insurers - both regionally and nationally. The firm also provides claims management services to senior living insurance companies.  Rebecca is involved in state and national legislative matters on behalf of the health care industry and serves as Legal Advisor for the American Assisted Living Nurses Association and the National Association of Health Care Assistants.  She founded the National Long-Term Care Defense Summit, co-founded the Adelman-Mettle Palliative Care Alliance, and is a member of Claims and Litigation Management Alliance.  In addition, Rebecca is a published author and national speaker and contributor.  

Let's talk with Rebecca about risk in senior and assisted living health care.

Rebecca, welcome to the show.

Rebecca Adelman  3:21  
It's so nice to be here with you, Scott, thank you so much for having me as a guest.

Scott Nelson  3:26  
Before we begin our conversation about risk in health care, I'd like to take a moment to talk about your background and work as an attorney in health care and specifically senior and assisted living health care. What is your work and what do you do in and with senior and assisted living?

Rebecca Adelman  3:39  
Yeah, my my experience spans gosh, now I'm into my 30, almost my 35th year I think in senior living, and in by way of kind of the early years, I'm a I tell people I'm a I'm an entrepreneur with a with a law degree, but my my law practice really started in health care 35 years ago, and there I was introduced to senior living, assisted living, skilled nursing homes that was in the 90s when there were so just a an escalation of lawsuits against senior living. And then over the course of time that practice started to grow. And you know, I started to develop some thought leadership around senior living, risk management, claims management, all in the senior living sort of ecosystem. And yeah, and then developed some claims management platforms, as well as some risk management and risk mitigation platforms and some products and services that are all related to address, solve to, have conversations like this, Scott, about senior senior living risks and solutions to problems that are in senior living. So that said, I'm I'm a lawyer by trade, I think I would say.

Scott Nelson  4:56  
Getting into risk, how do you view and think about risk in senior living and health care?

Rebecca Adelman  5:01  
Yeah, so risk in senior living is, is multifaceted. In answering the question, I think it's good to frame it in the sense of, you know, what really is senior living, right? What is senior living health care? And there are so many aspects of senior living, you know, there's, there's the operations of providing care and senior living, right. So that's the senior living care providers and all the people who are associated with giving amazing care to residents and to their families, along the whole continuum of care. And then there's the, you know, then there's the it could be managers, it could be the property owners, it can be the regulator's, professional liability insurance providers. So in with each of those stakeholders in senior living health care, Scott, there's risk associated with it, sort of how we define risk, or how we view and think about risk, really depends from a perspective, that we can all agree that there are varying types of risks in senior living. There's your obvious risks of an injury, or just an incident and an outcome a negative outcome but then there are a lot of and I know, we're going to spend some time talking about them today. So but there's some other risks, emerging risks, and some smoldering risks, and, you know, all sorts of risks embedded in in all of these little sub parts of the ecosystem.

Scott Nelson  6:27  
When you mentioned perspective, and all the types, why is it important to think about risk?

Rebecca Adelman  6:32  
Well, you know, I think, course thinking about risk allows you to understand the operations of your organization, regardless of what perspective your your viewpoint is, you know, you you have to really understand what kind of risks your organization is facing, right, from an operational standpoint. And so because the importance of that is thinking about risk in senior living health care is because we've got to those risks have consequences to them, right? There are losses we can suffer, financial losses, capital losses, there are reputational losses, there's so much at stake where risk is concerned in senior living that the importance of considering it cannot be overemphasized. So, yeah, I mean, that's that's sort of the key to solving to risk is really understanding and thinking about risk and how it impacts where your organization is in the senior living ecosystem.

Scott Nelson  7:29  
You touched on injuries as a type of risk. Where are risks in senior living? What are the areas that are or should be of concern to professionals and health care organizations?

Rebecca Adelman  7:39  
Yeah, I mean, maybe we just look at it in a couple of perspectives. So from the actual care provider, from the operators perspective, you know, the areas I think that should be or that are and should be of concern to professionals, and the organizations are just the delivery of quality care, and the risks that are associated with, you know, challenges we have with staffing, challenges that we have with budgets, or you know, the financial components of our operations, that then translate into incidences, right, they could translate into an injury, they could translate into multiple injuries. So I think that's probably from the perspective of the operator, what we're looking for is the consequences of not delivering care within the acceptable standards of practice. I think the risks we look at from the maybe from the, you know, the ownership perspective is, you know, is really thinking about like leadership, and how we're structured, the risks of our structure, our corporate structures, how enterprise risk management is being implemented in our organization. So from a much higher level, enterprise level, I think, looking at all the different risks in the domains of enterprise risk management, are really key for leadership. And then, you know, there are a lot of risks in the insurance marketplace. So insuring and underwriting, to management, to ownership, to private equity, to historic losses in senior living. So I think that's where risk really lies. And, you know, I think from from the standpoint of how we're seeing it manifest, Scott, I mean, what you're seeing at the very end game, when we talk about sort of a risk spectrum, you know, in the end game, when risks are at the nines and the 10s, you know, when they come to me and my law firm, you know, that's when you start seeing these crazy verdicts, these nuclear verdicts, and you see large jury awards or arbitration awards. So I think that's how we ultimately see people see the reaction that people have to the risk that's in senior living.

Scott Nelson  9:54  
In September of 2023, the Department of Health and Human Services, through the Centers for Medicare and Medicaid Services, issued a proposed rule that seeks to establish comprehensive staffing requirements for nursing homes, including for the first time national minimum nurse staffing standards. How can that help address risk?

Rebecca Adelman  10:11  
Well, that's a great question. You know, it truly depends on who you ask. You know, we would like to believe that, you know, the more staff we have, the better care that's gonna get delivered, right? The more people the better care. I, you know, there's a lot, this is really kind of a loaded question, right? Because the cost of these minimum staffing requirements to the senior living industry is very, very, very high. You know, how do we, how do we shoulder the burden associated with minimum staffing requirements? And is that burden, the financial burden and the time and the human capital needed, is that burden really being expressed in like improved quality of care, because you know, those minimum staffing requirements are sort of our government's response or policies response to a crisis in senior living and trying to address the imperative of improving quality of care, and all of that, all those issues, it might be short sighted to think, well, if we just have more staff than we're going to be, we're going to deliver better care, right? And I think that it's a very, very complex conversation, but certainly a complex system, where it really isn't about necessarily more, it's about better. So better trained, more training, more education, more financial support, more conversations, and a rewriting of the narrative around the importance of empowering caregivers and those who employ caregivers. So I think it's, you know, when we talk about in silos, like a silo of just a separate, independent conversation, you know, our minimum staffing requirements, you know, what do we think about those and how are they going to address quality of care, and in the United States, it's yet to be seen, honestly. And it's kind of not necessarily addressing the underlying long standing issues that have been there in senior living that were, of course, highlighted, really amplified, during COVID, and the challenges that our senior living world was facing during the pandemic. And I think that we've never in this country really elevated a conversation around the importance of living and dying and the importance of providing really quality care and accessible care to our seniors. So now, the policy is, you know, moving ahead in that direction. And so I'm not sure that there's a lot of clarity around what the key issues are. So again, that's, that's just my, that's my take on it. So it's really yet to be seen, we'll see how impactful it's going to be to enforce minimum staffing requirements. We'll see what happens. Of course, there's a lot of a lot of perspectives on that one, Scott.

Scott Nelson  13:06  
Who are the stakeholders and actors that are typically involved and how do or can they address risk? When you mention providers and organizations, and there's ownership and there's insurance, there's also when you look at the providers in the organizations, you know, there's the staff that's involved and we've touched on, each of those has a significant role, I would imagine to play into risk. Are there anybody else that you know, should be involved? I always think about risk is that an individual or a team or a group all has a potential role that they can play in solving risk or in addressing a mitigating risk. What are your thoughts on that?

Rebecca Adelman  13:40  
Yeah, that's really great, I mean, those are, such a great question and you could devote a whole podcast to that. I think that one of the things to really understand when we start talking about the different stakeholders, and what impact they can have, what role they have in the overall team, right? I think you have to really understand that what one does, what one stakeholder, does directly impacts someone else, right, someone else in the system. And so I think one of the most important points to make that we could talk about is that everyone really needs to have a high level of understanding about what everyone else is doing. Because if professional liability organization, you know, insurance companies are sort of pricing in a vacuum, or underwriting in a vacuum, and not really understanding what's going on from an operator standpoint. And then the operators aren't really understanding what's going on from the regulator standpoint. The regulators might be completely detached from the challenges that are being faced by the senior living providers and managers and staff, and there's all sorts of ways that there are just knowledge gaps between stakeholders I think are what create a lot of risk and really a lot of dysfunction in the system. So in addition to the ones, you identify that we've talked about, I think the regulatory framework of it all, we're a highly regulated industry on the skilled side, from a federal level. And then, you know, for assisted living, we're pretty regulated on a state level, I expect, particularly listening to recent discussions on the Hill about assisted living, regulatory oversight, what should we do, what's the future of senior living, right, what are we going to, how innovative can we get, what new care models are out there? All those questions that we have been recently been discussing, I think that understanding where the regulatory oversight comes in and how to partner with the, you know, our regulatory bodies and get them to truly understand the limitations we have, the needs that on the frontline, you know, our operators have, and how we can work together, you know, it just, it's always felt to me, like, keep in mind, you know, I'm a, been trying cases and been a litigator in this space for three decades, so there's always, you know, one side of the V and the other side of the V, there's always a conflict. But I think that to really address how we can look at risk, evaluate risk, make our way into senior living into the future, and do some risk mitigation, we really have to work together. That's what I think I think there's a lot of built in dysfunction that creates its own risk. And I think with higher levels of understanding, particularly with the regulatory framework, we do ourselves really well to address risk together, as opposed to separate. That's really how I think about that.

Scott Nelson  16:58  
You've mentioned senior living, and then assisted living, and nursing homes. Are there differences, technical differences, legal differences, between each one of those? I think that, you know, some people, including myself included, may sometimes use those interchangeably. Are there differences in the eyes of the government, you're talking about in the federal and state?

Rebecca Adelman  17:17  
Oh yeah, definitely, and from the standpoint of skilled nursing services, right, I mean, historically, you would, I guess, you know, call them nursing homes, right, that's, that's what we've before, there was a very, very important culture change around how we language and how we narrate the story of our elders think nursing home, I guess, and in order to be a licensed provider of skilled nursing services, you've got to comply with a lot of rules and regulations from the federal government in order to get Medicare funding. That's the federal oversight. There's a big regulatory framework around communities that need Medicare funding. And then when you're talking about assisted living, or private pay, or you know, private insurance, you don't have the same regulatory oversight from the federal government, because you're not getting federal funding, right, so there's no real compliance issue, except on the state level. So each state now has created their own regulatory scheme around the operations of assisted living, the operations of memory care. And in order to obtain a license in those states to operate assisted living, you have to comply with those state requirements. And they differ from state to state. They're all different models and levels of care. And there's some similarities, but then there are a lot of differences. So depending on what state you're in, you, you know, you've got to be very, of course, ever mindful of, of the regulations and complying with the regulations, but they differ from state to state, so much more autonomy at the state level, than there is at the federal level, many more challenges that you can just open the newspaper, and you'll see it. And so yeah, a lot of differences. And then, between those spectrums, there's a lot you know, there are continuing care communities, there are group homes, there are behavioral health, there's, there's all sorts of other ways and models for delivering senior care, senior living care, or care for those who are in their, you know, who are elders, so, again, really different. And working together, I think is really the key as opposed to being in conflict and having it be us against them. I mean, I really think reaching that level of cooperation and collaboration is so critically important, because ultimately, we're all moving in the same direction, which is to deliver high quality care, good environments for our loved ones in this country.

Scott Nelson  19:58  
The Washington Post published an article in December of '23 with the headline "Dozens of Assisted-Living Residents Died After Wandering Away Unnoticed." That article noted, according to The Post's research of inspection results, since 2018, more than 2,000 people have wandered away, which is called an elopement, from assisted living and dementia care units, or been left unattended outside, incident reports and media accounts nationwide.  Nearly 100 of those people died, though the exact numbers unknowable because nobody's counting. My question is what should health care professionals and groups be doing? What actions should be taken to strengthen and manage risk and decrease vulnerabilities? When you talk about the various stakeholders, and there are knowledge gaps within those stakeholders, and then you layer in potentially at some point, the regulatory framework, there's a lot of moving pieces and parts here to consider.

Rebecca Adelman  20:52  
Yeah, I mean, right on, and that article was very alarming, you know, all the media that we see around senior living is always very alarming. Because you know, we're highlighted in difficult traumatic events that happen. But I do want to remind you that there are providers around this country that are putting 1,000s and 1,000s and 1,000s and 1,000s of people to sleep at night, and they are getting amazing care, like the most amazing caregivers, and the people who are drawn to this industry to really make a difference, who care, who sacrificed it all in order to deliver care to our elders in the in the United States. And so, I do want to bring that up, because I think it's important to really understand that perspective. So when we see these articles, I'm not deminimizing the importance of highlighting these challenges that we've got, and particularly in assisted living it is, it's alarming, but I will say that, I guess to your question is what what can they what can we all do? You know, what can what can we do? I think number one, what we can do is is to create the strongest leadership we possibly can. So within our own organizations, in our governments, our policymakers, leaders, who really are trustworthy leaders who really do are super competent, and understand this industry. So that's, that's number one is leadership. And I mean, I don't know that there's a 1, 2, 3, 4, so I'll just say that is an important aspect of all of it is to be developing and cultivating and supporting leaders in senior living, I think it's key, advocates, for example. And I think that also, you know, we need to really appreciate how risk is managed in organizations, most, traditionally, you know, there's a risk manager, and then we've got lots of policies and procedures, and everyone's supposed to follow those. And there's some level of education about those. And but really, there's a, there's this lack of enterprise approach to risk management, where all the different silos where risk lives in an organization are talking to each other. Because, and I've said this, and I'm on the record saying it over the course of my career, is risk management is everyone's business, it's everyone's responsibility. And so empowering our caregivers with good education and good training to understand risks, to see where it lives to have tools in order to respond, right? I think that's key. Education, training, innovation in communities, support, all of that, I think is really key. Making sure we don't leave out the most important component of risk management, which is the people we serve, right? I mean, we serve families, and we serve residents, and we serve people who are living with us. That's their home, regardless of if it's a skilled nursing home, or if it's a assisted living home, it's their home, they live there. They live, congregate together. And so really involving families and residents in partnering with the delivery of care, partnering so we really understand what their needs are, what resident directed care really looks like. I think those are those are really to me, the keys, the keys of the kingdom right there. That's what that's what I think.

Scott Nelson  20:54  
Going back to that HHS announcement, there were some other announcements they made at that time, too, with some things about helping out the assisted living nursing home facilities by putting in some guidelines about around audits and inspections and things like that. When you talk about how risk is managed and involving all the individuals, a lot of times that can be just overwhelming and people think about risk management. With your experience and your approaches, what can individuals and groups do to simplify and either portion out or address it in a way that doesn't, makes it less overwhelming when they're starting to have these new things that are coming in, they haven't had before, that they can then say, proactively and say, okay, this, we can do this, we can manage this, and we can, we can begin to move forward.

Rebecca Adelman  25:16  
Yeah, from my vantage point along the whole risk spectrum, I'm showing up at, you know, the 9s and the 10s and you're there and then, you know, kind of moving down the risk spectrum, you know, into the 6s and 7s. The real place, I think, for everyone to begin, in it's least complex form, with all types of risk management, to mitigate risks, to hopefully eliminate risk, certainly to identify it so it doesn't come up is really when it's in the 1s and the 2s. Proactivity would be the word of the day if I were going to pick a word to respond to your question, which is, you know, you've got to be proactive. Yes, there's a lot coming at us, there's a lot of expectations around what's going to happen in the future for senior living, what's going to happen in the future for staff, and all the gosh all the parts of the pieces of the puzzle. But if you can start at the beginning, you know, if you can start with the basics of like, who we serve, why we serve, that we serve each other, where does risk live there? Typically, it's in you know, where needs and needs and expectations meet their unmet, they're unrealistic, there's a lack of knowledge about transitions of care and people coming to your community, which then develop into certainly develop into like, grievances. So if we can begin in its simplest way to look at risk management proactively, right? Don't wait till something happens. Don't wait to learn about it later. Don't put your head in the sand. Don't hope it's not gonna happen to you. Don't cross your fingers, knock on wood, you know what, don't jinx yourself. All that stuff. Like, that's just, that's risky business, my friend, is to ignore the fact that risk lives in all these different transitions. And so if we are willing to through our great leadership and some good tools and resources, to be proactive, to surround ourselves with people like you, Scott, consultants, you know, people who know where risk lives and who can help us identify it when it's like zero and one and two. And then, here's the ticket, the real small key that opens up the big door is implementation. You've got to implement these across your organization. A one-off in-service isn't going to solve the problem. It's how do you really transform your organization to have them be thinking proactively about what's going on along all the domains of risk. That's what I teach. That's what I share. That's what I create, you know, you can see the type of programming, my thought leadership, it's all around that. That's, to me, the real place to begin. I think there's, we can reduce complexities at that point. Also think things get much more complex the higher up the risk scale, you get, you know.

Scott Nelson  28:18  
That's interesting when you mentioned, like the one-off seminars and some of these other things. I'm really interested in your perspective on methodologies and approaches and resources that you use and utilize that can be helpful. We've talked about staffing, and just in general in health care overall staffing seems to be an issue, and people are trying to address that. This may or may not be an area where staffing helps or hurts, and it may not be some, it may be something where staffing isn't actually it, it's it's more of a culture situation. And you need to teach and train and you talk about how is that risk managed. What have you found to be successful within your work as resources, as a platform, or as the methodologies that you've used?

Rebecca Adelman  28:57  
Well, one, of course, the resources I've created, right, so just taking all my years of experience, and I was sharing that we have a risk management expectations management program that I have created a certification program that covers a lot of these topics that we've talked about. So that's one way is to expose your organization to a lot of really good education, about the areas where risk lives beyond, you know, the falls risks or the elopement risks or, but where the risks drivers really live, right, what's driving claims, what's driving complaints? And I think by focusing there, I mean, you would show up in places like making sure your teams are trained in the areas of nonviolent communication and empathic leadership and areas where the broader vision the more proactive vision around risk management and those kinds of resources, and their gosh, just a multitude of organizations out there that helps support that culture change in senior living, including ours, including Guide Path. But there are many organizations out there. And my recommendation would be to invest in those, you know, go there for the resources. And then gosh, we forget that our organizations are just like gold mines of resources, our own organizations and our own people. It's like I tell my son, he's just always got to bet on yourself. And you've got to bet on the people who are in your organization, and look to your right and look to your left, and just lift them up and see what they have to contribute and what to offer. And you will be amazed that the resources you may need are already right there. The education, the training, somebody who has a specialty in something that your organization needs, you know, sometimes you don't have to look very far for solutions. So maybe starting, starting at home, starting where you are meeting the people that are in your organization where they are, help identify your great leaders and the people who you can trust who have been there the longest, who have lots of experience, and let them show you what they think they need. Like doing, I call it in my world a vulnerabilities assessment, where are you vulnerable? That's the first start, right? Where are your organizations vulnerable? Is it staffing? Is it, who knows what well, you know, could be a host of different things, maybe it's your policies and procedures? Maybe it's your leadership? Maybe it's your, who knows, I mean, it's different for every organization, but we do, my firm does a vulnerability assessment for our clients. What's your historic survey? What's the history of your survey look like? What kinds of penalties have you had? What, who are your people? What's your turnover rate? All sorts of different aspects that, that help us to solve to those vulnerabilities. But I think the first start is like know who you are, know who your people are, right? Really self assess. I think sometimes we our own best resources.

Scott Nelson  32:03  
Yeah, I think even just thinking about this from if you are, no matter what size of organization you are, if you are a small one that's always considering resources and financial investments into these areas, starting internally and going with the resources you have, starting with your staff and your people, that is the commitment there of time and money is a great way to start, you can mine that data and that information, like you said, and not have to factor in some large financial investment that a lot of people potentially, that they always think about, which is a lot of times seems to be the obstacle to get them off the starting block, exactly.

Rebecca Adelman  32:41  
It's a real barrier, you know, the financial barriers are very high. And the resistance to change is very high. If you are working within your organization, the sense of like, ooh, a lot of change or another thing we have to do or you know, whatever it might be, we're just out there trying to give good care, you know what I mean?

Scott Nelson  33:03  
Looking back through recent history, from a risk standpoint, what was expected versus unexpected in senior and assisted living health care and what could have potentially been done differently to have different results?

Rebecca Adelman  33:15  
Gosh, these are not softballs my friend you're throwing me. This is, this is like, you know, this is Dodgers stuff here. What can we do differently? I will say that reacting, responding, counter-punching our way through a national crisis around an aging population, okay. We somehow woke up during COVID and realized what now that there's just going to be a lot of people who need care, and they're going to be elderly, like when, so we have not, in the past 25, 30, 35 years prioritized this as a national platform, as a national conversation, as a policy imperative, is caring for our elderly. We have not been a nation that has had a strategy and a plan. And, you know, all we did was create a bunch of regulations back in 1987, that no one really even knew about the Omnibus Budget Reconciliation Act. I mean, even when I say that to you, you're like, what is that, you know, and all of a sudden, you know, out of nowhere long term care communities, senior living, starts to become regulated. And we're like, what in the heck is going on here? What are these regulations? And even then, you know, there was never really a conversation about where we're headed. Where are we headed? We can see 20 years out, we can see 30 years out, we can see 40 years out. What are we going to do about this crisis of eldercare in our world and in our country? So I think the first thing is, is we never really have cared enough about our aging population, and the people and our elders who need us, we've never prioritized them. So now instead of making it a national priority, it's like a national imperative to like improve something that has been broken for decades. Okay, this isn't new, okay. And so that's something we could have done, is prioritized the older people in our country more, right, and seen what's on the horizon. I think we also could have been wiser about how the regulatory framework around senior living was created and what it rewarded, you know, when you've got regulations like we have here in the United States, for decades and decades and decades and decades, the regulations, meaning, you know, how are you going to get paid from the federal government, you know, you've got compliance, you got to comply with things in order to get your Medicare in order to get money to run your organization. So I think there was a grand dysfunction in who our clients became. So instead of like delivering care, we were delivering care to the government so that we could make sure we properly coded and we could properly respond, you know, with lots of rehabilitation, and it was rewarding the regulations, early in their inception, just were rewarding this much unnecessary, not resident directed care at all. And so I think the the sort of the genesis of the regulatory framework was just so so ill-conceived, where they left out the most important component of the entire framework, which was the resident. And then, you know, not until recently, honestly, Scott, not till recently, did we start talking about resident directed care and care planning and assessments, and oh, my goodness, it should be all about the needs and the desires and the rights of the people who we're caring for. Where did that go wrong? Like, how did we not start there? And I'm sure there are a lot of other things, I mean, not anticipating these plaintiffs attorneys who are just going to come and just create an entire playbook around our regulations, which is what they did. That's what the 90s were. That's what 90s nursing home litigation was, was a playbook designed around the ill conceived regulations, and our inability to comply with the regulations which left us out there hanging for millions and millions and millions and millions and millions of dollars. That put most of these larger nursing homes that were caring for our loved ones, like under, in bankruptcy. So then, you know, we had more crises and more health care crises, and then insurance crises, and you name it. And now we have a staffing crises. Like how can we put a person on the moon and we couldn't see that coming? That, that would be my, my perspective on that, what could we have done different.

Scott Nelson  38:27  
Well now taking that and looking forward during this year, maybe even beyond, what do you see as potential issues in senior and assisted living health care? And how can individuals and organizations anticipate those and be prepared, thinking about what you just said, if we have this history and things that we've been able to do in the past, how can we take this and learn learn from these lessons and move that forward?

Rebecca Adelman  38:48  
A lot of people who are considering that question, you know, what's the future of senior living? You know, how are we going to care for our, how are we going to care for our elderly, right, what are we going to do, are real doomsday about it, you know, and I feel the other way, I feel like there's just endless, infinite opportunities for us to create models, to collaborate, to understand where we went wrong and the dysfunctions of a just a really an ill-conceived regulatory framework and start to focus on the innovative leaders, new care models, and hear from the people who we're caring for, and are going to care for, they need to be a key part of the conversation, right? What do they want? What do they anticipate? How can we partner with the people who we're going to give care to? So again, it, to me, is more like a real culture change movement, moving forward into the future. Innovation is going to be key, different health care models is going to be key, making sure that, you know, we keep a check on private investment into senior living, where there might be a knowledge gap about operations. Just making sure that all systems are communicating with each other properly, with the right intentions, which in the end, there's only really one intention, you know, are the people that we're serving, living their best life. I think that's how we can really capitalize on opportunities into the future, for me, for you, for the people we love and that we care for.

Scott Nelson  40:37  
That's a great point to conclude our conversation. I knew that this would be a great conversation. We've, we've talked about this before and we joked about it, I'm from Ohio and an Ohio State fan, you're from Michigan and a Michigan alum. I knew we would be able to do this and it would be phenomenal. So Rebecca, thank you very much for your time and sharing your thoughts and experiences today. I really appreciate it.

Rebecca Adelman  40:57  
Oh, it was just such a pleasure. And we are making the difference just by having this conversation and you're making the difference just by having this risky business podcast where people can learn. Really appreciate you.

Scott Nelson  41:11  
Thanks so much, Rebecca. 

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