We don't realize how many things we're doing that actually cause negative behaviors. It's not the dementia at all. It's the preventing a person from leading their life. - Welcome to season seven of "Bridged the Gap," a podcast dedicated to informing, educating, and influencing the future of housing and services for seniors. Powered by sponsors, AccuShilt, Align, NickMappVision, ProCare HR, Sage, Hamilton Captel, ServiceMaster, the Bridge Group Construction, and Felinity, and produced by Felinity Marketing. - Welcome to "Bridged the Gap" podcast, the senior living podcast with Josh and Lucas. This is an exciting episode here at the AASHA membership in the summer of 2024 here at Dana Point, and we have a really special guest on today, Lauren Schook, CEO and Chairman of Silverado. Welcome to the program. It's a pleasure to be here. - Absolutely. Very, very happy to have this conversation because one of the big things about our podcast here at the summer meeting is getting to talk to industry pioneers. And of course, everyone knows, Lauren Schook is an industry pioneer. Take us back to the early days of your career and how you started to get even knowledge and influence of the senior housing world. Let's start there. - When we go back into my career, I actually grew up on the grounds of my Antonuckles Psychiatric Hospital in Kirkland, Washington, and they had a 28-bed dementia unit, 133-bed acute psychiatric hospital. So that's where I first learned about dementia care and saw it in place. So I had decided to become a hospital administrator focused on behavioral health when I was a junior in high school, and pursued that career after graduating high school, became a hospital administrator of a psychiatric hospital that they operated in when I was 22. And moved up from being the administrator of that hospital, which was called Community Psychiatric Centers on the San Francisco Peninsula of Belmont Hills. Interestingly enough, that is now Silverado Senior Living Belmont Hills. So we converted it from a psychiatric hospital that I started at age 22 to a Silverado today. But nonetheless, I spent 20 years with CPC and became a president COO. We were on the New York Stock Exchange and moved from six hospitals to 50 throughout the U.S. Puerto Rico and England, a second largest dialysis operator in the country, about 130, which is now Devita, and another 10 subacute and that search hospitals. So left there and decided that I had a calling to do that for 17 of the 20 years and the last three not so much. So then I looked and where should I be spending my time? And really felt called to step into the senior housing industry and start a specialty dementia care operation because I didn't think that the services being delivered throughout the country met the needs of the people that had dementia. I felt like they could have a much higher quality of life and they were getting, I felt like they could do a lot more than people expected that they could do. And I felt like that's where a lot of my skills that I had developed over the years could be put into play. So started Silverado in October '96 and two weeks after opening our first community in Escondido, California, our nurses said we need our own hospice and we said, great idea. You know, let's put that in the parking lot. Let's get the company going first and 2004. We started our first Silverado hospice and now have eight locations there, 27 memory care locations in 10 states, coast to coast. And we also deliver palliative care. - Wow, so what a rich history. You know, when we say pioneer, that kind of defines it. And exciting history, so many changes. Interesting, or I would be interested to know and I know our listeners would be to, you know, you've got this wealth of knowledge on where things have come from, but I would love to know where you see it going with the prevalence of dementia in our society and now so many different types of housing type. From, you know, the home, all the way through independent livings and now we're hearing so much about active adult and you've got obviously your purpose and intentional built memory care communities and facilities. Where do you see our industry gravitating towards and how you provide, how are we going to be able to meet, this seems like growing demand of care, how's our industry, how should we attack that? - I think that the first realization is the people who have dementia, one level or another, are the majority of our population today in assisted living, certainly memory care, but in assisted living as well. And how much of that population is being drawn into independent living is the question I'm not sure, the answer, but the drivers for people to move into assisted living a lot of times are confounded by the underlying dementia at a very early stage where they may be the only one knowing that they have a problem and they're hiding it. So that's a big cause for people to move into our services. And I think there are things we can do early on that can slow up the progression and actually improve cognition. So we're innovators at Silverado and we commit ourselves to innovating in dementia care in all ways. And one of them was the Nexus program that we started about seven years ago. And that program is dedicated to early stage people. So at Silverado we take all stages, from end of life to the earliest stages of people that you wouldn't recognize, I wouldn't recognize have dementia unless they had done a test and shown the results. So 20 to 30 on a mini metal state exam is a very high functioning individual. And that individual can be anywhere driving, can be anywhere USA and no one would know they have dementia unless you see them under pressure perhaps or something like that. But the Nexus programs devoted to that population and interrupting the decline that is inevitable. Slowing it up, but it also is proven to improve cognition by 60%. So that's not me saying that. That's UCSD, University of California, San Diego, Geriatrics Department and Psychiatry Department analyzing 730 cases of Silverado residents at a 20 MMSE mini metal state exam score in above. And they concluded that of that population there's a 60% improvement in cognition. Now we're not curing anything, but we are improving cognition for a while and then we're slowing up the progression and that's proven. Now that's also been third party duplicated in Denmark. So we presented this program at the International Alzheimer's Disease Conference in Budapest many years ago. And we put up on our website, the clinical outcomes of what we were doing for the world to see. About a year and a half later, Dr. Mette and Driessen the head of dementia or Denmark called me and said, "Look, I've been looking at this, I think it's real. "Can I come to California and see what you're doing?" Sure. So she does and then she concludes at the ADI Alzheimer's Disease International Conference in Chicago the next year. She meets with our team, Kim Butrom, our Senior VP of Clinical Services and co-presence at that conference. That she's going to try and duplicate several of those results in Denmark. So she did that at three 200 bed nursing homes, principally for people with dementia. And so in May this year, Kim and I were in Denmark and we went to law land Denmark where one of the now eight nursing homes that has duplicated that results. And met with the residents, met with the staff, just incredibly affirming to see people's quality life so much improved. So we then went from there to crack out Poland where the Alzheimer's Disease International Conference was this year. And in that conference, there's about 700 attendees. You've got 160 or so leaders of different countries represented and mostly government and mostly universities. Queen Sophia of Spain was also there and the Princess from Jordan. So people that you've traveled with a lot, I don't. - Not at all. - But it was pretty fun to see and hear what's going on around the world in the focus of dementia. Research, focus, training. From countries with a lot of money, like the US, UK and other countries with very little money like Kenya and other countries. So there's a finger study, which is a Finnish study, which is very well known. Kind of looks at and approaches many of the fundamentals of our Nexus program. And that is a focus around the world that all the countries are really pursuing. So those same fundamentals are proven to be effective. So getting back to your point about our industry, those kinds of techniques, Silverado Nexus technique, can go into assisted living, independent living where people have a concern. And I think in effect, slow up this disease progression in a way that can make an incredible difference in the quality of people's lives. So when I started in this industry, I met with Dr. Leon Thal, Chair of Neurology at UCSD. We've partnered with all teaching research centers where we're at UCSD, UCLA, USC, Stanford, UCSF, Baylor College of Medicine in Northwestern and so on. Dr. Thal is the top neurologist in the world, got the top award in the anyway. And what he said when I was educating myself in '95, he said, "Look, our goal is to really "interrupt the progression of dementia by five years. "If we can do that, and he is going to do that "with a medication, which has never been found yet, "but the goal is to do that with a medication. "And if you can do that with a medication, "then probably people will die of natural causes "because of age we'll catch up with them. "And you won't have to deal with the institutionalization "and the later stages of dementia we know today." That's not happened. But what has happened is the Nexus program is there, it's in place, it slows up the progression. I think that's where the biggest hope is. Right now, short of a miracle cure coming up, which in the form of a drug, but that hasn't happened yet. We've cured mice, that was done a long time ago. We've got Alzheimer's disease mice cured of Alzheimer's. And right here where we are in Orange County, the Alzheimer's disease mice was created at UCI, University of California Irvine. They innovated the Alzheimer's disease mice. And that's used all over the world for research. But that mouse gets cured. When you roll it into human trials, there's typically an autoimmune reaction that blows it up. Billions of dollars have been spent chasing that. And it just unfortunately hasn't happened yet. But we have in our power the program like Nexus, which are programs that are engagement based. I say the side effect of Nexus is fun. That's the side effect. And it's free. And it does require staff, it requires structure, it requires implementation, which is not free. That has to be done effectively. I think that can be leveraged beyond what we're doing today. - Well, and so I got another question. And this kind of gets maybe not so forward looking as the last question, but more of kind of where we are right now. And so many communities are struggling with the topic of labor, getting talent into the communities and quality caregivers. And with the turnover rate that a lot of community operators struggle with, as we have more specialized care needs, for example, the dementia population, what are some of the advice and tactics that you could give to our listeners who may be out in a community and they're trying to maintain this quality of care model, this specialized care model, but they feel like maybe, I just feel like I'm always in the process of training caregivers because the turnover rate. So what are some of the tactics you would say that have been successful for your teams to maintain quality of care for such a specialized level of care? - We certainly don't have all the answers of which I did, but what is working for us is hiring people who have a heart for what we are doing. And really working with them to see is that is this what you want to do, working with this population? 'Cause it can be tremendously rewarding, but it also can be challenging. And so getting the right selection in the first place and then training them and giving them the resources and the tools to succeed. So we take all kinds of people with all types of dementia. We're the number one referral party of choice for the NFL, for the behavioral health hospitals that can't place people anywhere else. We're for our colleagues in the industry that are having a challenge and can't succeed with who they have, they come to us. In addition to all of us who say we take the easy ones too. So we have the system set up that we got the top award in the nation for behavior management without relying on medications as a go to. - Sure. So medications for the benefits of what they can provide. And as I said, we are also innovators. So we were the first to embrace THC and those other tools of which is a very effective tool done used in the right way. It's a very effective tool. We have medical, we have medical directors in our communities. One of our medical directors conferences we brought in experts on the use of marijuana and THC. And how to best use it, and this is an aside, but there's a whole cabinoid system in our bodies. And it's part of medical science used to be taught before the days of reefer madness and THC became persona non grata. But now it's back being taught in medical schools. So it's a real tool, it actually works. We're one of the first to use it in Texas. And of course we've been using it in California and some other states for quite a while. To your caregiver question, you've got to give them the tools to succeed. So we've seen that we're using, we have a lot of talent that's coming to us that hasn't been in this industry before. We have licensed nurses 24/7 in our model. We have a master social worker as well as medical directors. So the nurses we're hiring are oftentimes now fairly new and they don't have the experience. So we have upped our game in our training systems, our clinical training systems and people focused on just training our leaders, our nurses. And then we've upped the game relative to training our director health services, which is the registered nurse in leading the rest of the nurses. So you can't really expect a caregiver to be successful if you don't have the leaders over them knowing what they're supposed to do, how to do it. So you go to training them. So EHS, for example, we don't put in a place of doing anything before they have a month of training with us. That's a big investment for us, but it's essential that they know what to do, how to do it. And then we give several weeks of training to a licensed and LVN before we give them the keys to the med card and go. And then we have caregiver mentors that are helping those new caregivers especially. We have long time people who are really good. So we have a layers of training of those people. And then we have, of course, it's a whole team. So our model is everybody is there to take care of the resident first. The second job is, oh, I'm off the floors or I vacuum or I do the laundry. And so everybody's given our background training in dementia, which is accredited by the Alzheimer's Disease International, by the way. So we're the one of five accredited programs in the world. So the other four are universities like China. We fundamentally have that in-house training we built. It's 20 hours testing in and out of. And we will train people, the dishwasher, to the administrator and the director of health services on making sure they understand what frontal temporal lobe dementia is, making sure they understand what fixed disease is, what Alzheimer's disease, what Parkinson's disease is, and how they relate to how Parkinson's disease is oftentimes masked in symptoms if the person has Alzheimer's disease. So we treat them all like they're experts and we try to give them the expertise to discern the difference in behaviors that are going to happen when you have different diagnoses and how you approach someone differently so you don't trigger things to happen. And we have lots of different systems that can support helping people with their behaviors. So those are also tools that serve the caregiver to be successful. And they get people doing things that the family's never seen before, people laughing, talking, engaging, walking. So then the family gives them the credit of doing a miracle, which is not a miracle, but it's, it deserves all the credit. - Yeah. - And so those are things of value they get. They also can bring their children to work. So we encourage them to bring their children to work. That's where we get intergenerational programming and we have pets. So we use all the different holistic medicine tools in addition to what science and nursing has to offer. - Wow, what an insightful look into behind the scenes of what you guys have been doing in process development for years. - Well, you know, you mentioned holistic, you also mentioned bringing children to work, which leads me to kind of questioning about around design, building design. You have been innovators even in how you have developed your communities. I recall, you know, the playground outside. Really unique. I'd love to get your thoughts on how you innovated on design and are there new innovations that you would like to see implemented in your next round of developments? - You know, great question and it's fun. Designing is fun. And, you know, when we go to an architect like Doug Pancake, for example, and here in Orange County who did his dementia thesis and I did his master's thesis in dementia architecture. You know, so that's kind of people we like to work with. Somebody's passionate, somebody's really focused on it. So, you know, we co-design with people like that that are real experts in what they do. And then our own, of course, our own teams. And so one of the things we do is reduce barriers for people with dementia. So we don't have a lobby. And if we assume an operation from someone else, they typically have a lobby. So we open those doors and we make them that space accessible to our residents. So the fewer locked doors, the better. The one going outside, yes, commercial kitchen. Don't want you there. But everywhere else, pretty much open, including the administrator's office, the DHS, all the teams. So if they want to go in and lodge a complaint or fire the CEO, Lauren, you know, they can do it. So it is one of those avenues where you reduce the insults to the person with dementia, you will reduce negative behaviors. And in this industry, we don't know, we don't realize how many things we're doing that actually cause negative behaviors. It's not the dementia at all. It's the preventing a person from leading their life in a normalized way. So when you remove those doors, for example, you give them access. You give them access to a bistro with a refrigerator with ice cream and food and various things like that. You give them opportunities to have a purpose in life. So we try to connect people in different ways to their purpose. And we try to find out what it is. And our engagement programs are designed just for that, is we have different clubs, you know, travel, cooking, horticulture, various things like that. We take people on outings, we engage them. So you take away the barriers for a person to have a quality of life in your design and the building. And so one of the things we did long ago is put in memory boxes, right? And when you're looking back 28 years, there was a big theory in the industry that you did memory boxes didn't work. They do work and they help people find their room. If you can help a person have independence and control, then you're going to reduce anxiety, fear, and that reduces negative behaviors. So, you know, those are the kinds of things I'm talking about. Not of course, snowing people on medications, if they have behaviors, redirecting them, having to train staff. So, but in the building design, it's, you know, you use light that simulates the sun, give them a plenty of opportunities to get outside. We did a study with Dr. Annacola, Israel at UCSD, probably 18 years ago now, or maybe even longer. And it shows that two hours of outdoor light in the morning significantly reduces sundowning behavior in the afternoon. And if you have somebody up all night, you know, you get these residents with dementia, they're sleep cycles upside down. And, you know, they come in and they're, you know, kind of sleeping during the day and then they're up all night. And that's no good, we're not, we're not for that program. So, if you take them outside at later on in the afternoon with the light, that will help them to sleep at night without the use of medications. And why it works, nobody knows, who cares, right? We just go with what works. So, give them plenty of access to the outdoors. Give them plenty of access to go do things that they might want to do like, like garden, or watch the kids on the playground or. We have swimming pools in some of our communities 'cause they are converted to behavioral health hospitals for my prior life. So, we're kind of, a lot of people architects have told us we're the only ones that don't fill in the swimming pool. We actually use them. So, we use them for residents to swim in. We raise them to three and a half foot if they were deeper. But we also engage the residents of the staff's children. And of course, the grandchildren of the residents can use them too. So, you'll see playground next to one of the pools. I have a new nurse joined us and she said, this is really cool. I'm looking out the window and there's a five year old going down the slide of the playground and there's a 95 year old going down right behind her. So, it's those kinds of things that we have. So, we have cats, dogs, birds, those kinds of different cats and we actually have in one community two miniature horses. We've had kangaroos. We've had all kinds of different cats. We've actually had someone bring in a quarter horse through our community. A lot of it is, and we go to stables, but a lot of it is to create interests and to create fun. So, get a design a building that can accommodate those things and the building needs to look respectful. We put the same crown moldings from the beginning as a lobby through the end where people are on sensory care in the life hospice. So, it doesn't make any difference where you're at. There's no marketing lobby. It's all the same. And the culinary services are designed to please people with plates and silverware and not use any disposables unless we're into some crisis of a water supply in Houston or something. - You know what I'm hearing in this is really elevating dignity, right? Treating people how you would want to be treated. Treating them like family. And that's really, I can tell that's a core value of yours that you have injected into the culture of Silverado. - Try, you're exactly right. And it's really, you know, really big into behavior management without going to medications. Another thing I just want to make a point of is one of the big things unrecognized in the industry by and large, and we have to teach our own staff and teach our own physicians who come and work with us that undiagnosed pain drives behaviors. It's so simple, you know, Josh and Lucas. It's so simple, but it is hard to get through to the medical world because an ibuprofen pill and solve all the problems you don't need to go to heavy duty psychotropics because the behavior isn't from the Alzheimer's disease or the other. It's because when the caregiver tries to put a shirt on Lauren, he's got arthritis in his arm and it hurts like the Dickens. And I can't express, I can't tell you it hurts. So you keep doing it and the pain is too much, so, you know, I'm sorry about that, you know. - Thought you were about to take me out right there. - That happens, you know, I'll just check in your reflexes. - Yeah, thankfully I'm still good. He's been punched in the face plenty of times. - But that happens, and then the person gets sent to behavioral health all downhill from there. You know, that never goes well. - Sure, Lucas actually just gave you some ibuprofen right before this, to calm you down a little bit. - Yeah, I know, I was whining. (laughing) - Well, we can get to the gummy bears, you know. - Absolutely. - The little later, the little later in the innocent THC for you. - Yeah, absolutely, I'm down for that, absolutely. - Does he like a tincture of the 18s? (laughing) - Well, I don't know, what are you into? - This sounds like after behind the scenes content that we're getting into right now. - Well, actually, you know, this is our everyday. - This is cool, well what, I tell you, this is such an insightful conversation. We need to have more of these conversations and thank you for leading the effort and the charge in this conversation and something that our industry needs and we're gonna just continue to need this more until we kill this terrible disease out and solve this problem. But thank you for leading the charge there at Silverado and all that you've done for all the years as a pioneer in our industry. - That was too much fun. So we have a great team and it's, I do nothing but stay out of the way. - All right, final word of encouragement. Lauren, you've seen the industry change so much over the decades. We've got a lot of new leaders, young and old, new people coming into this industry. And while bridge the gaps listeners are largely industry professionals, we do have a contingency of university students that come across our podcasts that are interested in either gerontology or, you know, elder care, health care, and they utilize our program to gain access to information about senior housing. And so maybe give a word of encouragement to the people that may be looking at this industry as a potential career choice. - Well, I can't tell you what a great career choice this industry is. This is an industry where you get to do great things for people, you get to have a great income for yourself and you get to make a difference that has legacy lasts for forever. And, you know, what industry can you go to that you can do all three things? And it's, I'm on the board of the USC Davis School of Gerontology for many years and work with Douglass and the Division Center and work with the different universities across the nation in helping to develop educational programs to develop leaders. At the Davis School of Gerontology, it's the number one gerontology school in the world, others say, and I think it is. The other side of it is they've partnered with Cornell University and we've hired two of their graduates just recently who are now administrators of Silverado, young young guys doing a fantastic job. And we look at these other university graduates too because they've got the science of aging and they've got the business of humans. So if you, like myself, had a business degree, then educate yourself on the science of aging because you need to learn what your customer needs. And, you know, so you don't have to come through a gerontology program, but you can educate yourself on the basics of what you need to know. And if you're lucky enough to be a young individual, you're really looking at career development and look at one of these programs that can do both, that is absolutely a golden ticket. And it positions you well to start as an administrator, ED, whatever the term you want to say is the leader of the senior housing community, but then move up to the C-suite in any level. And this industry is just beginning. And it's certainly a multi-billion dollar, probably trillion dollar industry in the US. US is leading the way, US is leading the world. Other countries want to duplicate what we're doing. We've been toured by 60 different countries, the leaders of dementia in more than 60 different countries. And, for example, China is hammering on our door, you know, come there, come to even the UK, come to different African countries in South American and so on, the world needs the leaders. So you have an international market that is untapped. So where do you get to go that is a brand new market and has an open field to create? So unlike healthcare, I'm a recovering hospital administrators that has closed earlier, but there you kind of locked into a whole lot of things you have to do. For licensing, for joint commission, for this, you know, Medicare, CMS, that, in this industry, you get to create your path. How cool is that? So you get to really see what the need is, put the team together and deliver it. And that changes lives and that is just too much fun. - What an amazing vision to cast, you know? And leave it to Lauren. I know you're incredible visionary and a pioneer and a great leader. And we really appreciate your time today on the podcast. - Well, thank you, you're both too kind, but thank you. - Thank you. And so for our listeners, I know that you've enjoyed this conversation, we'd love to hear your comments about it. Check us out on LinkedIn, where this is posted. Like and comment, join the conversation and go to btgvoiced.com. Check out this content and so much more. And thanks for listening to another great episode of Bridge the Gap. - Thanks for listening to Bridge the Gap podcast with Josh and Lucas. Connect with the BTG Network team and use your voice to influence the industry by connecting with us at btgvoiced.com.
