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Getting Too Much of a Good Thing

18 Jul

Stanford Business Center for Innovation recently published an article on how to avoid “Social Good Fatigue” and to be honest it rang a bell with me. While my work still motivates me more than anything else I do in my life, I still feel sometimes I must try something else.

The article argues that social entrepreneurs live in a state of permanent emotional drain produced by dealing with people and problems all the time, selling hope and mobilizing others to create change. Creating change is never a straightforward event, we deal with complex issues requiring complex solutions. People prefer to stick with simple resolutions. The social entrepreneur is always dealing with urgent issues. In our case, we often deal with life and death issues, knowing that if we slow down some people are going to go without assistance that they often need to stay alive. This means that the rest of our lives get a back seat. My husband constantly argues that I do not have time for him or for the family. He is right. Because we concentrate so much on one issue, we often stop learning and growing, stop taking side roads, smelling flowers, enjoying the family, reading a good book. We are in a constant state of flux, that success often contains the seeds of failure. When I look at my journey, I see this so clearly, every success I have had has been followed by failure. I cannot forget that every single innovation has been met with failure to begin with. We get used to this, but it is consuming.

The article spells out several remedies to this “burn-out” syndrome. Most of them I have followed during my 17 years of being a social entrepreneur. Particularly during the past four years I have made time to reach out to friends, particularly childhood friends. Our conversations have nothing in common and perhaps that is the beauty of it all. We talk about things of no consequence. I engage in a lot of physical activity. I get up at 4:00 a.m., do a half hour of yoga, and then put my scull on the water and row for two hours. I have been doing this for 10 years, and I find that rowing in the dark allows me to meditate, calm my mind, and re-arrange things. I hope I am never forced to give this up. I am also planning my trip to Nepal, something I have been trying to do for many years. I know that if I wait longer, I may not be able to physically do it. Whatever I want to do, I do today.

I have told my daughter that I would like to retire in two years because I have a new idea that I want to develop before I leave this world. It is when you let go of things that you are truly creative and it is in this process of creation that I feel best. After all, like the article says, “You never conquer the mountain, you can only conquer yourself.”

Conchy Bretos gives testimony to the Senate Committee on Aging and Entrepreneurship

14 Feb

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On February 12th I was invited to testify to the US Senate Aging and Entrepreneurship committees to provide information about the challenges that “late-in-life” entrepreneurs like myself face in starting their businesses. The purpose was for the Committees to gather recommendations on how to facilitate these initiatives. At the meeting were senior senators and chair of committees, Senators Bill Nelson, Susan Collins and Tim Scott. There was consensus among those providing testimony that older entrepreneurs constitute the largest group of small business owners today and is growing. Today over 9 million seniors are establishing businesses with 30 million more coming over the next decade. It is a matter of great interest to the Senate and a matter they want to prepare for and facilitate. These businesses are also the largest source of new jobs to young employees.

A main challenge that these older entrepreneurs encounter is access to capital to start and remain in business. Access to government, federal agencies and investors is also a barrier. Discrimination toward seniors is real and alive. Accessing capital from lenders always raises the question of how long the business will be operating given the age of the owner. Succession planning then becomes more necessary than ever. The myth that older individuals cannot learn new skills or new technology; that they take rather than give was shattered with the testimony and research presented at the hearing.

The Senators asked for ideas of what would make life easier including introducing legislation. Several workable ideas were submitted that include allowing the use of unemployment benefits for startups, new regulations to make it easier to obtain a Small Business loan, coordination at the federal level so entrepreneurs can communicate with federal agencies, and more.

The hearing was the first to address this issue We believe that it provided clear understanding of the role that older entrepreneurs are playing today and in the future and the obstacles that they face that could be facilitated by the Senators. More on this.

Conchy Bretos and Senator Bill Nelson after the hearing:
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Conchy Bretos’ testimony to the committee:

For the past seventeen years our firm has worked with public and private entities in 23 states. Later this spring we will be opening and managing an affordable assisted living facility for the District of Columbia Housing Authority. Our projects have proven to reduce Medicaid and Medicare spending by keeping our residents healthy, away from costly institutions, while generating thousands of new jobs and healthy operating margins. For the past two years we have partnered with low income housing tax credit developers, owners of affordable housing and private owners/investors to scale our model. This has required a major restructuring of our firm and our business model.
In 1995 I created Mia Senior Living Solutions as a for profit company understanding that if our firm was to grow rapidly it had to be fueled by profits. As Florida Secretary for Aging under the Lawton Chiles governorship, I got a good understanding of aging issues and developed a strong relationship with the aging network. I had lived long enough to learn from failures, how to deal with detours and the inevitable ups and downs. Changing the way we care for low income seniors and disabled adults was not a new idea but no one had created a successful model to do it. We created a model within an exponentially growing market with little competition.
Starting my own business was as much due to life circumstances as it was a career change. An empty nest, the end of a marriage, the loss of a job, I reached midlife with an urgency to leave a legacy, to contribute, to make money and live to the fullest those bonus years that longevity gives us. Wanting to leave an impact on the world grows stronger as we age. I asked myself if not now, when? If not me, who? For a long time I had dreamed of creating something lasting that would connect me with future generations. I did not want to defer this dream any longer. Not having health insurance kept me awake at night. I took some time to reflect and assess what I wanted to do, what skills I possessed and then tested the idea in the real world.
When my term ended as Florida Secretary for Aging, I came home to Miami with some savings from my job and an idea; to convert a public housing building into assisted living and allow for true aging in place. The Miami-Dade Housing Agency Director wanted to dispose of the highly deteriorated Helen Sawyer building in downtown Miami. I told him I had an idea I wanted to test in the building. He said yes but he had two requirements: One was that I had to prove my idea quickly and two, I had to find the funds to do it. That day I formed my company, invested some money in stationery and worked on a feasibility report with the help of some friends. At the same time I approached the State Legislature and was able to get a $1.2 million allocation of Medicaid waivers. I was awarded a five year contract by the Board of County Commissioners to start the conversion of Helen Sawyer Plaza with a promise that it would be self-sustainable by the end of the first year. We developed detailed budgets, worked on the policies and procedures needed, hired the staff needed, secured vendors. I worked very hard until what seemed like the impossible, happened. We opened the doors of Helen Sawyer and in six months the place was full with a good waiting list. I knew that this first project had to be successful if we were to move forward. This innovative project was featured several times in the media, won four national awards and became the model for the nation. It became a show place with constant visitors from the entire nation, senators, governors, secretaries and a multitude of housing directors who wanted to have one just like the one I had created. I was able to negotiate new contracts with housing authorities as far away as West Virginia. I was invited to speak at several industry conferences and build a community and a larger network. Although we did a lot of free work in the beginning, we moved away from the pro-bono and created a successful business. It was hard to keep up with demand with only myself so in 2001 I asked my daughter, a management consultant in New York, to join the firm. To my amazement she accepted. Mother/daughter teams weave together business and family life, school schedules, time with the grandchildren. All are important parts of the day-to-day routine. Succession planning is a prominent topic of discussion. Although letting go is not an easy process for me.
Receiving the first Purpose Prize award in 2006 and becoming an Ashoka Fellow in 2010 have certainly been turning points in our business life. These awards have provided validation for what we do and a network of professionals that are interested in our scaling our business. We have received expert and legal advice, mentoring and support. We have learned how to present ourselves, how to raise money, structure ventures, re-engineer our firm. I know now more about databases, LinkedIn, Facebook, electronic health records and blogging than I ever wanted. I do not have one boss anymore but many of them, our advisors, board members, funders, clients and investors.
However, most of my fellow entrepreneurs are not so lucky. Lack of capital, connections and mentoring remain major obstacles for us aging entrepreneurs. Relying on grants to sustain your work has become an impossible proposition. In order to survive, the initiative must generate its own source of revenues by selling products produced by the company and that can be replicated over and over again.
Most of our work involves partnering with government to change policies that represent obstacles. Today, more than ever, government needs individuals like us with the public interest in mind, talented and driven. Approaching government usually ends in rejection at least that was my case. Two years ago we made a major decision to team up with private entities to better grow our business. But this too has its own challenges like the distrust by investors of the reliability of government subsidies like the Medicaid waiver or the disconnection between the regulations of the Low Income Tax Credit program and assisted living. For these investors financial rewards come first and social impact is gravy. Maintaining that balance has been a major challenge for us. But we know consumers are demanding more socially responsible behavior from businesses. Businesses need to catch up with this trend. Profits are not everything.
America is a young country; our models do not include old people. The most common image of an innovator is that of a youth creating a great idea in a garage, a dormitory, or a makeshift office. In reality these are the exceptions. Research tells us that it usually takes 20 years for the birth of an idea to become fully implemented. It is around the age of 40 or 50 years that individuals are at the peak of their work. It has been proven that a 55 year old and even a 65 year old have significantly more innovation potential than a 25 year old. It is fair to say that less gray hair sharply reduces the innovation potential in an organization. Yet, stereotypes like old people cannot learn new skills, master new technology, that they take rather than give abound. Shattering these stereotypes must be a major priority for all. This hearing goes a long way to doing that.

Someone has to pay

7 Aug

As states begin to provide more home and assisted living services to seniors the number of nursing home beds begins to decline. A study done by Harvard Medical School found that a 10% increase in assisted living capacity led to a 1.4% decline in private pay nursing home occupancy. Most nursing home residents pay privately for nursing home care thus don’t affect the occupancy in Medicaid beds. In order to decrease the number of nursing home Medicaid beds, states must make an effort to increase funding for Medicaid clients living in nursing homes that want to receive services at home or in a Medicaid funded community care (assisted living) facility. To this day, the private assisted living industry takes Medicaid eligible residents only if they have an occupancy problem. They prefer not to deal with the complexities of billing the government and the excess of monitoring and reporting that goes with having a Medicaid resident. However, state Medicaid agencies are hard pressed to reduce the number of individuals in nursing homes paid by Medicaid if they are going to see reductions in their Medicaid long-term care budgets.

Although this move benefits clients who wish to remain at home, it drastically impacts the financial viability of nursing homes across the U.S. With less private paying clients nursing homes will start cutting back essential services to an ever growing number of very frail clients. What is more, some states like Pennsylvania are billing family members for the cost of nursing homes. The Pennsylvania law stipulates that family members of nursing home clients are ultimately responsible for the cost. Some families have been billed some $96,000 for the care provided to a family member residing in a nursing home.

At the end someone has to pay, either a family member or us, the taxpayers. What the story tells us is that long-term care in the U.S. is broken and needs to be reformed soon. One answer will be for states to continue to rebalance their long-term care program, provide more community care and make it easier for providers to want to work with the government.

Changing Lifestyles is our Business

1 Aug

At the beginning we just wanted to provide a dignified life to our low-income seniors. We had seen what isolation and neglect was doing to seniors living in public housing. Most of them had given up on life and were just waiting for the day that they would leave their sorrowful living conditions. Our first impulse was to provide them with a clean, comfortable apartment and the services that would allow them to keep living with decency. After we experienced how their lives changed by having good meals, a little help in getting out of bed and bathing, the opportunity to be with others and having the right medication at the right time, we realized that there was much more we could do. What about if we improve their life expectancy, help them avoid hospitalization, prevent them from falling down, make them more alert so they can enjoy this stage of life.

At first most were reluctant to engage in any kind of physical activity. After all, most had never done much exercise in the past and exercising was not an acceptable behavior from elderly individuals. Changing their mind-set was sometimes a struggle, a change of routine from one of complete inertia to one where they have to exert themselves. So we started with a very small group of “willing victims” that were willing to perform stretching exercises. We used music and dancing to entice them. Some were embarrassed at the beginning but later it became their morning routine. Little by little others, watching from afar, joined the group. After all, it seemed that those willing to go along were having fun and socializing with those next to them. The group grew from a handful to over fifty and from that moment they were not willing to live without the exercises. We became more innovative with our program, offering dancing classes, yoga, music classes, fitness programs, personal trainers, aquatic courses and gardening.

The clients were having fun but that was not all. Those who regularly engaged in these activities saw great improvements in cognitive and physical health, fewer trips to the emergency room, less need for medication, 50% less daily bathroom trips, a decrease in back and muscle pain and dramatic decrease in nursing home care. They also experienced less anxiety and agitation, using their energy in a positive way. Another side effect was an increase in socialization with the staff and the residents.

The beneficial results of exercising have been well-recognized, not only for aging individuals but for people of all ages. Recent reports on wellness programs collaborate what we found happening among our clients, improved health, less hospitalization, increased alertness and feeling of wellness and increased socialization among clients.

The moral of the story: if you give seniors a chance to change their lifestyles, after some reluctance they will experience, on their own, a sense of wellness and optimism. But this is not all, by changing lifestyles and improving health, everyone wins. Healthcare costs go down, costs to families are reduced and turnover at the facility goes down.

Despite funding, moving from a nursing home back to the community is difficult

1 Aug

The Deficit Reduction Act of 2005 was created to reduce barriers that allowed people to move from nursing homes back to the community. The biggest allocation of funds by Medicaid in 2007, The Money Follows the Person program, allocated $1.7 billion to 30 states with the goal of transitioning 38,000 individuals away from nursing homes. As of June 30, 2011 only 15,818 individuals had actually moved to community care despite the fact that the funding was increased to $4 billion in 2010 and 13 additional states were included in the program. With this additional funding, participating states have until 2019 to meet their targets and until 2020 to spend the funds. Florida was among the 13 states that were approved under the program but failed to secure the needed administrative funds for implementation of the program. In fact, states are given great flexibility by the federal government to use these funds to reduce waiting lists, conduct research and other activities that help rebalance their long-term program. Rebalancing means increasing the funding for community care and decreasing the amount spent on nursing home care.

With so many seniors currently living in nursing homes and wishing to go back to the community it’s a wonder why so little progress has been made. The numbers of transitions vary sharply by state. Some like Texas and Ohio have transitioned thousands back home or to assisted living facilities. Others like North Carolina, Missouri and Kentucky have moved fewer than 500. Our firm has worked in North Carolina and Kentucky and these states have very strong nursing home lobby’s preventing the increase in community care. Some states have found it hard to move the elderly with only 1/3 of transitioning individuals being 65 years and older. 900,000 individuals living in nursing homes are in fact eligible to be transferred. Barriers to transfers reported by the states are the lack of state funds (federal funds must be matched by state funds) and the absence of affordable housing and community care providers.

Our experience, having worked with the program, is that other barriers exist which include very strict requirements by the federal government as to eligibility of both the individuals and the place they are transitioning to. For example, in order for an assisted living facility to be eligible to take clients they must offer full apartments with kitchens, a separate bedroom and dining space. The client must have lived in the nursing home for 90 days. But more importantly is the reluctance of some states to stop relying on nursing home care for the growing number of seniors; a reason that is more political than financial.

Elders Do Better at Home

19 Jun

 What accounts for reducing healthcare costs, faster recovery of seriously ill clients and improved physical and cognitive heatlh? You will never guess – bringing services to where these clients live.

The private assisted living industry is now fully engaged in servicing elderly clients in their homes. Most major assisted living chains are now caring for clients by dispatching caregivers to their homes at a cost of $240/day. Most have seen a growth of 20% in this line of service. The impetus to engage in this line of service may have come as a result of the stagnation that private facilities have been experiencing for the last five years; or, perhaps it may have been the result of several studies revealing that 89% of elders wish to remain at home as long as possible. Hospitals are finding out that seriously ill elders do better when medical services are provided in their homes.

John Hopkins University School of Medicine began the home-hospital movement back in 1996 as a pilot program. Research has proven that elders with potentially deadly diseases like congestive heart failure and cellulites can be safely treated at home with astonishing results. Not only was the care as safe and as satisfactory as hospital care, but recovery was faster and the cost much lower, 60% less.

There is no doubt that the trend in the future will be to provide as many services as possible to elders in their homes. A great idea!

The Challenges of Global Aging

23 May

America is a relatively young country as far as the percentage of individuals 65 years and older in the U.S. today. About 12% of the population in the U.S. is 65 years and older. However, that percentage is projected to increase to 20% within the next decade. Compare those numbers with that of other countries like Japan with the highest percentage of seniors currently at 21.5% of the population. Global aging affects all aspects of our society: work, health care, retirement, services and housing, among others. One of the major challenges is what we call the dependency ratio which means that for every person age 65 years and older there will be fewer than two persons in the workforce and available to care for the older generation. Exceptions are those countries with high birth rates (Mexico, Iceland and Turkey) or in countries like Australia, Canada and New Zealand with high immigration. However, in most countries the dependency ratio will sharply increase from 2020 to 2050. It is becoming more important that we create new ways to care for this aging population that is cost effective and dignified. The U.S. has the highest per capita health care expenditure in the world with a per capita cost per individual of $6,714. Japan, on the other hand, has the lowest health expenditure with a per capita expenditure of $2,581, half of that of the U.S. Most of the expenditure in Japan is paid by the government.

During the Ashoka Summit held this month we were able to discuss with other Fellows challenges facing their countries. Masue Katayama, a Fellow from Japan, has worked for the past twenty years in providing services to the older population in Japan. She came to learn how our firm has been able to change how we care for this older population. We believe that the global financial crisis is pushing us to make due with less and to learn how to use government funding more efficiently. Our firm has a proven track record of being able to service three times as many seniors with the funding the government spends on one. Japan, along with many European countries, has older people and lower health care spending than the U.S. They do this by fixing prices and manipulating prices to keep costs down. Every two years the price of each treatment, test and medication is examined to see if excess profits are leading to overuse and if so the price is cut. This is not done in the U.S. because those who profit from high prices are so powerful. This rationing and price cutting impacts the ability to control chronic illnesses at an early stage. Instead of rationing, Japan should look at ways to improve people’s lives by systematically changing lifestyles through better diets, exercise, medication management and supervision. This is something that Japan and other European countries can learn from the U.S.

Masue and I sat down to establish a collaborative effort that will enable us to learn from each other. She visited one of our affordable assisted living facilities and was impressed with the home atmosphere and the improvement in the physical and cognitive health of our residents. We agreed to formalize this collaboration by her sending a group of her operators to the U.S. for a month to live and learn at one of our facilities. Mia will do the same as we know that there are lessons to be learned from Japan as they tackle the common challenges of global aging.