Whether you are an experienced operator opening your 100th retirement residence or a novice opening your first, you’ll be faced with thousands of decisions — big and small — along the way. Falling distinctly into the “big decision” category is your choice of care model.

If you intend to operate a residence that caters to both a relatively independent clientele, and those who require more extensive care, you need to consider your options before the shovel hits the earth. As life expectancies lengthen, this decision becomes even more acute. Changing the care delivery model within an existing building can be difficult and expensive.

There are two basic approaches for delivery of care services: Providing a dedicated assisted living area or providing care within a resident’s current suite. The resident either moves to care or care moves to the resident. In the first case, most clients first move into the “independent” area of the building, knowing a second move may be required if their health dictates. In the second case, a resident moves into a suite, receiving a basic service package. When care is required, the package is changed to include care services, but no move is required.

Industry opinion is mixed on the benefits of each model. Many operators provide one model at some locations and the other model at other locations.

“There’s not a right or wrong way,” says Debbie Doherty, Chief Operations Officer and Vice President of Operations with Specialty Living, the retirement division of Specialty Care, which offers both care models, depending on the location. “It depends on your market and the capabilities of your building.”

Operationally, most agree that the dedicated assisted living area is preferable. “When designing a new build, I recognize the operational advantages to a dedicated assisted living area,” says Doherty. “There’s greater efficiency. Your care staffing is more efficient when they’re not running all over the building. Your service is also more efficient, as is resident supervision.”

Susan Gerard, Vice-President of Marketing and Communications for Amica Mature Lifestyles Inc., agrees. The company, well-known for its “wellness and vitality” theme, has included a dedicated assisted living area in its recent and upcoming developments.

“Operationally and financially, it’s of greater benefit to have everyone in one area,” says Gerard. “It’s really the efficiency of having everything in one place — and that includes staffing. Offering more care or specialized care is easier if every amenity that goes into offering it is accessible in one area.”

Successful dedicated assisted living areas strive to have the same “look” as the rest of the building, say both Doherty and Gerard.

“The care services shouldn’t be staring you in the face,” Doherty says. “The clinical services have to be made to look less obvious. The decor should have the same look and feel as the rest of the building but have practical features built in.”

Gerard agrees. “You shouldn’t be able to tell the difference between a regular floor and a Vitalis floor,” she says, referring to the name of Amica’s assisted living areas. “There has to be a desk of sorts but it doesn’t need to look like a nursing station.”

Dedicated assisted living areas will generally have a dining room, recreation area and lounges. Often the nursing office and medication room are housed in this area, as is a spa area that may include a therapeutic tub. While there are more studios in most assisted living areas than throughout the rest of building, there is growing recognition that “care” residents want the same features, including as much space, as their healthier counterparts.

“Though the majority of suites are studios, there’s a trend to building more one-bedrooms in our Vitalis areas,” says Gerard. “The suite sizes are comparable between the areas. Most features are the same throughout the building. All suites have a kitchenette and walk-in shower, for example.”

A move from an independent area to an assisted living area generally involves a change in hospitality services, as well as care services. Most independent areas offer a basic service package that includes weekly housekeeping, laundry of linens only and no care services, although some operators allow residents to buy assistance with bathing and/or medication. When a resident moves to the assisted living area, daily tidying and personal laundry are added to the basic service package.

Some operators recoup additional costs through a premium on the suite rate, along with a care fee. Others combine the cost of the hospitality and first level of care services and charge it in addition to the suite rate. Still others combine all elements — suite rate, additional hospitality services and care fee — into one fee. Included in a suite premium may be for a charge for general nursing supervision as well as indirect care items such as charting or proximity to the nursing station.

Systems for measuring and charging care fees range from an all-in-one set price to an à la carte menu of services or incremental charges based on time or points used. Several software companies, including Canadian-based Retirement Homes Software Inc. (www.RHOSI.com), and U.S.-based Move’N (www.move-n.com) and Vigilan (www.vigilan.com), now offer industry-specific programs for measuring and tracking care charges, among other features.

From a marketing perspective, which care model do customers prefer? “It depends on the individual, the building and the market,” says Sheldon Gould, Vice-President of Development and Operations at Delmanor Seniors Communities Inc. He prefers a system of providing service right to the resident’s suite. “It’s the right system if you don’t want to move. You know you can stay in your own home (suite) and receive services.”

It is clear that for prospective residents, perception is vital. While a prospect who already requires care may be comfortable with either model, an independent prospect will likely favour a separate assisted living area.

“Both systems have to be carefully marketed,” explains Doherty. “If you tell a resident he has to move, it can be off-putting and sound cold. On the other hand, if you operate a separate assisted living area, it’s much easier to continue to attract the truly independent senior and couples because of the programming, dining and general appearance of the common areas. If you have residents requiring care in the general areas, you may find them sleeping in the lounges and have issues in the dining room. Nobody wants to see themselves as frail before they actually get there. It’s a turn-off to your independent prospects.”

“There is no definitive answer,” says Gerard. “From one perspective, (as a resident) I may not want to move again. From another, I may not want to see where I’m going to be in a few years.”

Both systems have one important factor in common: The need for clear, distinct and well-documented guidelines as to the definition of care. “Having a good health assessment process and knowing who goes where is vital to making a care unit work,” says Gerard. “We work very hard at our levels of appropriateness. We try to say ‘are we appropriate for the client?’ The final say is that of the director of care with the doctor’s assessment.”

“You have to be clear about your criteria,” says Doherty. “And you have to do very good assessments up front as well as regular assessments once the resident is living with you.”

Any staff person dedicated to the marketing function must be in sync with the director of care, according to Linda Potrykus, Provincial Long Term Care’s Director of Operations, Retirement and Facility Marketing. “The directors of marketing and care have to have an explicit understanding of the client profile,”Potrykus says. “They need to work as a team so the director of marketing is bringing forward clients, whether for an independent or an assisted living area, that both she and the director of care agree are appropriate.

“The director of marketing has to be able to understand and communicate to clients exactly what the expectations for each area are. The director of care then has to ensure those expectations are the reality. This is important both when a client is first moving in, as well as when he or she begins showing signs that additional care may be required. Everyone has to be using the same yardstick.”

Whether a resident is moving to another area to receive care or is simply changing his or her service package in order to receive care in the suite, all those interviewed agreed on one thing — communicate expectations with the resident and his or her family early and often.

“The earlier we have the talk to our client, the less resistance we get,” says Gerard. “When you phone regularly to check in with families and ask if they have any concerns, they’re more open to a discussion when a change is necessary. It’s really just keeping in touch.”

“You have to give people lots of lead time,” says Doherty, “so it’s not a sudden unpleasant surprise.”

If you are planning a separate assisted living unit, Doherty, Gerard and Gould say a ratio of 75 to 80 per cent independent suites to 20 to 25 per cent assisted living units is advisable. Gould feels retirement homes should have no less than 80 suites. Doherty recommends a minimum of 22 assisted living units in order to cover the associated overhead costs, such as the need for at least one registered nurse or practical nurse.

Even among the experts, there is no right answer as to whether a new building should have a separate assisted living unit. “Establish the needs of your clientele in your specific market and know what your competition is offering,” says Gould.

“Think of it like a hotel,” advises Doherty. “One hotel type doesn’t suit everyone. Some people like Holiday Inns, some want the Marriott and others want to check into the King Eddie. It usually comes down to cost and comfort. What can they afford and what do they consider comfortable? Do some research, know your market and understand your location in relation to others.”