White Paper

Senior living's new healthcare focus: pre-acute care


John M. Robinson MD, PhD - CEO, Wellzesta, Inc.

David A. Pearson, MD, MA, MBA - CMO, Wellzesta Health Research Institute

Life Plan Communities, formerly called Continuing Care Retirement Communities, initially set out to provide healthcare to medium-acuity and high-acuity seniors. Life Plan Communities conceived of themselves as providers of long-term post-acute (LTPAC) care.1 Here, we show that the scope of healthcare has expanded to include care coordination and care delivery to low-acuity seniors. Common concerns among low-acuity and medium-acuity seniors motivate grouping them into a new population called pre-acute. This article summarizes the task and challenges of delivering pre-acute care to seniors. 

Problem #1

Senior adults are entering Life Plan Communities later in life.2 Residents often cite some precipitating event (usually medical) that catalyzed the mental/emotional switch from “I’m not ready” to “I’m ready” to move.  A practical consequence of delayed entry is that residents enter the community with more chronic health conditions to manage. Life Plan Communities are being asked to, directly or indirectly, help low-acuity residents manage their chronic health conditions.

Problem #2

Residents who are not able to perform all instrumental activities of daily living (IADL) are increasingly choosing to remain in independent living (age in place) rather than move to assisted living (3).Residents’ main concern is “I paid $___ to move into my apartment/cottage. Why would I want to move from my apartment/cottage/home, a 4-star amenity, to a 1-star assisting living unit?” 

Both top-line and bottom-line risk are pushing Life Plan Communities to offer pre-acute care. Simply put, the product being purchased is “continuum of care.” In the mind of the buyer (prospective residents and sometimes their children), care means care management (coordination) as well as care delivery. Buyer expectations, irrespective of the fine print within the lifecare contract, are what matter. Communities that fail to align with consumer expectations for personalized in-home pre-acute care are subject to product-market mismatch, declining occupancy, and declining revenue. We call this “top-line risk.”

Life Plan Communities face “bottom-line risk” from their pre-acute residents. The report "2019 Insurance Marketplace Realities" predicts that commercial liability insurance rates for senior living and long-term care facilities will increase as much as 30% or more in 2019 (5). Rising insurance rates reflect an increase in claims. Resident falls account for around 40% of those claims, of which about half result in a resident’s death (6). Moving forward, more insurance carriers will focus on community efforts like the management of falls, memory care, and prescription drugs (5). Often, adult children of residents are stakeholders in their parent/s health. Most adult children of residents believe the community is a provider, and therefore accountable, for the health and well-being of their parent/s.

Communities must be able to detect health decline of residents early. More importantly, communities should be able to anticipate (predict) health decline and act proactively. Delivering pre-acute care means engaging in preventative health. Adult children of residents and insurance companies expect this level of care.

Communities should offer pre-acute care around an outpatient healthcare model. For residents in independent living, or at-home care for non-residents, many communities already offer the following “care”-type services:

- Arrange transportation for off-site doctor’s appointments

- Provide, recommend, or support home care services

- Advise about annual Medicare enrollment

- Offer meal take-out & delivery

- Provide medication reminders

- Offer companionship

- Triage health-related (medical) emergencies

- Be first-line emergency/crisis responders

- Perform wellness assessments

- Diagnose/predict early disease onset, deterioration, or improvement in health conditions

- Measure/monitor/improve behavioral health (emotional wellness) and risk of social isolation (social wellness)

These so-called “care” services are typically offered by semi-skilled workers. In contrast, “delivery”-type services are offered by skilled medical professionals. Health “delivery”-type services include:

- Flu shots

- Laboratory testing

- Annual health screenings

- Primary medical care

By offering these services, communities are delivering pre-acute care, which encompasses both care-type and delivery-type services, in a new healthcare delivery model built around outpatient care. By delivering pre-acute care, communities are engaged in preventative health and care coordination for the management of chronic disease.


Traditionally, communities felt that they were meeting the needs of independent living residents by providing activities, amenities, housing, and hospitality. This set of services has now expanded to include the delivery of pre-acute healthcare. As the task of caring for independent living residents has ballooned from keeping residents “busy” to the delivery of pre-acute care, administrative control has been transferred from events coordinator (director of activities), to director of wellness, then to the director of healthcare. The director of healthcare then has to oversee two very different healthcare delivery models: inpatient healthcare and outpatient healthcare.


Life Plan Communities formerly delivered only institutional post-acute healthcare. They must now deliver in-home pre-acute healthcare. Demand for in-home pre-acute healthcare is predicted to increase.

To learn more about how Wellzesta helps partner communities provide pre-acute healthcare through personal health records, integrations with wearables, and preventative health monitoring with the Wellzesta Health platform, click here. 


Home care, a form of long-term care, is non-clinical healthcare provided by caregivers, usually called home care aides, who assist seniors in their daily activities. Home health, a form of care delivery, is clinical healthcare provided by a skilled medical professional. Home health is often prescribed as part of a care plan following a hospitalization. Whether care is being delivered to on-campus residents in independent living or assisted living or to off-campus residents through a home care program, Life Plan Communities are now in the business of providing pre-acute care. Table S1 summarizes the differences between home care and home health.

Table S1. Staff skill level, services, and payment models for home care vs. home health.



Medium-acuity patients require long-term services and supports (LTSS), also called long-term care (1). Long-term care involves non- clinical healthcare services provided by caregivers who assist seniors in their daily activities. High-acuity persons require clinical healthcare. Often, these are patients will be recovering from an acute medical episode (e.g., pneumonia, broken hip), hence the term post-acute care.

Residents typically enter a Life Plan Community in their mid-80s, although new communities can sometimes attract a younger demographic (2).

Many new communities are not building assisted living facilities because of weak demand for it.


  1. Tripp A (2017) A New Vision for Long-Term Services and Supports (Leading Age).
  2. What Will Be The Baby Boomer Entry Age Into Senior Living? Aging With Freedom. Available at: https://agingwithfreedom.com/2016/09/29/ boomer-entry-age/ [Accessed February 4, 2019].
  3. Estate of Blanche W. Bell vs. Bishop Gadsden Retirement Community (2016) Mutual settlement agreement and release. Ragged Edge. Available at: http://www.raggededgemagazine.com/belldocs/ Consent%20Order%20of%20Dismissal%20Exhibit%20A.pdf [Accessed February 4, 2019].
  4. Domains of Well-Being (Eden Alternative).
  5. Insurance Marketplace Realities (2019) Willis Towers Watson. Available at: https://www.willistowerswatson.com/en-US/insights/2018/11/ insurance-marketplace-realities-overview [Accessed February 3, 2019].
  6. Resources to manage and reduce insurance risk CNA. Available at: https://www.cna.com/web/guest/cna/managerisklevels/ [Accessed February 4, 2019].


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