With a call into the senior living industry, Loren Shook, Chief Executive Officer and Chairman of the Board at Silverado, discusses his journey from behavioral health to seniors housing and why he’s passionate about dementia and memory care.

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This episode was recorded at the ASHA Mid-Year Meeting. 

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Produced by Solinity Marketing.

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Loren Shook

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

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Intro

0:12

Welcome to season seven of Bridge The Gap, a podcast dedicated to informing, educating, and influencing the future of housing and services for seniors. Powered by sponsors Accushield, Aline, NIC MAP Vision, ProCare HR, Sage, Hamilton CapTel, Service Master, The Bridge Group Construction and Solinity. And produced by Solinity Marketing.

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0:39

Lucas McCurdy

Welcome to Bridge the Gap Podcast the Senior Living Podcast with Josh and Lucas. This is an exciting episode here at the ASHA Membership in the Summer of 2024 here at Dana Point. And we have a really special guest on today, Loren Shook, CEO and chairman of Silverado. Welcome to the program.

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0:55

Loren Shook

It's a pleasure to be here.

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0:57

Lucas McCurdy

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 Shook 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.

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1:23

Loren Shook

Well, you know, when we go back into my career, I actually grew up on the grounds of my aunts and uncles psychiatric hospital in Kirkland, Washington, and they had a 28 bed dementia unit, 133 bed acute psychiatric hospital. You know. So, yeah, that's where I first learned about dementia care and saw it in place. So I decided to become a hospital administrator, focused on behavioral health when I was a junior in high school and pursue that career after graduating from high school I 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 Center, in, in, on the San Francisco Peninsula, Belmont Hills

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Interestingly enough, that is now Silverado Senior Living, Belmont Hills. So we converted it from a psychiatric hospital that I started at at age 22 to the Silverado today. But nonetheless, I did 20, I spent 20 years with CPC, and became president. We were on the New York Stock Exchange and moved from six hospitals to 50 throughout the U.S, Puerto Rico and England. Second largest dialysis operator in the country, about 130, which is now DaVita, and another, ten subacute med-surge hospitals.

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So, I 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, you know, where should I be spending my time? And, I really felt a call 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 than 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.

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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 ten states, coast to coast. And we also deliver palliative care.

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4:13

Josh Crisp

Wow. So what a rich history. You know, when we say pioneer, that kind of defines it. And an 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, 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 adults. And you've got obviously your purpose and intentionally built memory care communities and facilities. Where do you see our industry gravitating towards and how do you provide- how are we going to be able to meet the, seems like, growing demand of care? How's our industry, how should we attack that?

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5:12

Loren Shook

I think that the first realization is the people who have dementia at 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 a question  I'm not sure the answer, but the drivers for people to move into assisted living a lot of times are compounded by an 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, you know, 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, and, and actually, improve cognition. So this, 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 overall, we take all stages, you know, from the end of life to the earliest stages of people that you wouldn't recognize, I wouldn't recognize, have dementia unless they had done the test and shown the results.

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So, 20 to 30 on a mini mental state exam is a very high functioning individual. And that individual, you know, can be anywhere driving, can be anywhere in the USA, and no one would know they have dementia unless you see them under pressure perhaps, or something like that. The Nexus programs’ devoted to that population and interrupting the decline, that is, that is inevitable, slowing it up.

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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 mental state exam score- and 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, on our website, the clinical, the clinical outcomes of what we were doing for the world to see. About a year and a half later, Doctor Mette Andresen, head of dementia for Denmark, called me and said, you know, look, I've been looking at this. I think it's real. Can I come to California and see what you're doing? Oh, 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 Bostrom or a senior VP of clinical services and co-presents at that conference that she's going to try and duplicate Silverados results in Denmark.

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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 Lolland, Denmark, where one of the now eight nursing homes has duplicated that results. And met with the residents, met with the staff and just incredibly, affirming, to see people's quality life so much improved.

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So we then went from there to Krakow, 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 Sofia of Spain was also there and the Princess from Jordan. So, you know, people that you've traveled with a lot, I don't. But it was pretty fun to see, and hear what's going on around the world in the focus of dementia. Research, focused training from countries with a lot of money, like the US, UK and other countries to countries with very little money like Kenya and other countries. So, there's a thinker study, which I finished studying, which is very, well known, you know, kind of looks at and approaches many of the fundamentals of our Nexus program.

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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 it affects slow up this disease progression in a way that can make an incredible difference in the quality of people's lives.

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So when I started in this industry, I met with Doctor Leon Thal, chair of neurology at UCSD. We partner with all teaching research centers where we're at. UCSD, UCLA, USC, Stanford, UCSF, Baylor College of Medicine and Northwestern and so on. Doctor Thal is the top neurologist in the world and got the top award in any way. 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. And if we can do that, then 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. If you can do that with a medication, then, probably people will die of natural causes because of age, will catch up with them, and you won't have to deal with the institutionalization in 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.

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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 have cured mice. That was done a long time ago. You know, we got Alzheimer's disease, the mice cured of Alzheimer's. And right here where we are in Orange County, the Alzheimer's disease mice was created at UCI, the University of California, Irvine. They innovated 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 out. Billions of dollars have been spent chasing that, and it just unfortunately hasn't happened yet. But we have in our power, the, you know, programs like Nexus, which are, are programs that, you know, are engagement based. I say the side effect of Nexus is fun. That's a 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

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13:02

Josh Crisp

Well, and so I got another question. and this kind of gets, maybe not so, so forward looking as the last question, but more of, kind of where we are right now and so many communities are struggling with, you know, 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,

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You know, as we have more specialized aged care needs, for example, this 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, I just feel like I'm always in the process of training caregivers because of 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?

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14:01

Loren Shook

So I certainly don't have all the answers I wished I did, but, what is working for us is, is hiring people who have a heart for what we are doing. And really working with them to see is, is this what you want to do, working with this population? Because it can be, tremendously rewarding. But it also can be challenging, 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, all kinds of people with all types of dementia.

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We're the number one referral party of choice for the NFL, for the behavioral health hospitals that can't place people anywhere else. 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 those who say we take the easy ones, too. So we have this system set up that we got the top award in the nation for behavior management without relying on medications as a go-to. Use medications for the benefits of what they can provide. 

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And as I said, we were also innovators. So we were the first to embrace THC and, those other tools of which is a very effective tool, used in the right way. It's a very effective tool. We had a medical we have medical directors in our communities or one of our medical directors conferences. We brought in experts on the use of marijuana and THC and, and, you know, how to best use it. And this is an aside, but there's a whole cannabinoid system in our bodies. And it's part of medical science that used to be taught before, the days of reefer madness, and 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 were 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. 

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To your caregiver question, you 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 and in our training systems, our clinical training systems and people focused on just training our leaders, our nurses. And then, you know, we've upped the game relative to training our director of health services, which is the registered nurse, and 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 license an LPN before we give them the keys to the med cart and, you know, and go. And then we have caregiver mentors that are, helping those new caregivers especially. And we have longtime people who are really good, you know, so we have layers of training for those people. And then we have, of course, it’s a whole team. So our motto is everybody is there to take care of the resident first. The second job is, oh, I mop the floors or I vacuum or I do the laundry. 

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And, you know, so everybody's, given our background training and in dementia, which is accredited by the Alzheimer's Disease International, by the way. So we're one of five accredited programs in the world. So there are, 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, the administrator and the director of health services on making sure they understand what frontotemporal lobe dementia is, making sure they understand. And, you know, what Pick's disease is, what Alzheimer's disease is , what Parkinson's disease is and how they relate. And how Parkinson's disease is oftentimes masked in symptoms if the person has Alzheimer's disease, you know, 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, and, how you approach someone differently so you don't trigger, things to happen. And we have lots of different systems that it 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 has never seen before. People laughing, talking, engaging, walking. So then the family gives them the credit of, of doing a miracle, which is not a miracle, but it's, they deserve all the credit. Yeah. You know, so those are things of value they get. 

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They can also bring their children to work. So we encourage them to bring their children to work. That's where we get intergenerational programming, where we have pets, so we use all the different holistic medicine tools in addition to what science and nursing has to offer.

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19:39

Josh Crisp

Wow, what an insightful, look into behind the scenes of what you guys have been doing in process development for years.

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19:48

Lucas McCurdy

Well, you know, you mentioned, holistic. You also mentioned bringing children to work. Which leads me to kind of questioning around design, building design. You know, you have been innovators even in how you have developed your communities. I recall, you know, the playground outside, it was 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?

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20:17

Loren Shook

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 in, in, did his master's thesis in dementia architecture, you know, so that's the kind of people we like to work with, somebody who's passionate, somebody who's really focused on it.

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So, you know, we co-design with people like that that are real experts in what they do and in 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 in there. But everywhere else, pretty, pretty much open, including the administrator's office, the DHS, all the team. So if they want to go in and lodge a complaint or fire the CEO Loren, you know they can do it, you know, 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 leading their life in a normal, normalized way, you know? So when you remove those doors, for example, you give them access. You give them access to a bistro with a, you know, refrigerator with ice cream and food and various things like that. 

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You give them opportunities to have a purpose in life, you know? So we try to connect people in different ways to their purpose, and we try to find out what it is that, and our engagement programs are designed just for that, and we have different clubs, you know, travel, cooking, horticulture, various things like that. We take people on outings, we engage them. So, so you, you take away the barriers, for a person to have a quality of life in your design, in the building. And so one of the things we did long ago was put in memory boxes, right. And we are 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 a trained staff. 

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So, but in the building design, it's, you know, use light that simulates the sun. Give them plenty of opportunities to get outside. We did a study with Doctor Anna Cola 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, their 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, later on in the afternoon with a 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 garden or watch the kids on the playground. Or, we have swimming pools in some of our communities because they are converted behavioral health hospitals from my prior life.

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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 3.5ft 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, you know, so you'll see, playground next to one of the pools. A new nurse joined us, and she said, this is really cool. I'm looking out the window, there's a, you know, five year old going down the slide of the playground, and there's a 95 year old going down right behind her, you know. So it's those kinds of things, you know, that we have. So we have, you know, cats, dogs, birds, you know, those kinds of different pets and, and we actually have, in one community, two miniature horses. We've had kangaroos, we've had all kinds of different pets. 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 interest and to create fun. So, you got to design a building that can accommodate those things. And, you know, 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 end-of-life. 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, you know, know, plates and silverware and not, not use any, disposables unless, we're into some crisis of a water supply in Houston or something.

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26:03

Lucas McCurdy

You know, what I'm hearing in this is really, elevating dignity, right? You know, treating people how you would want to be treated, treating them like, 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.

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26:22

Loren Shook

That's right? Yeah. You're exactly right. Yeah. And, it's really, you know, I'm 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. This is 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 can 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, Loren, 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, so, you know.

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27:33

Josh Crisp

Thought you were about to take me out right there.

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27:34

Loren Shook

It happens. You know I’m just checking your reflexes.

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27:37

Josh Crisp

Yeah, thankfully, I'm still good.

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27:39

Lucas McCurdy

He's been punched in the face plenty of times.

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27:45

Loren Shook

But that happens. And then the person gets sent to behavioral health. All downhill from there. yeah. You know, that never goes well.

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27:49

Lucas McCurdy

Sure.

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27:50

Josh Crisp

Lucas, I actually just gave you some ibuprofen right before this that's calmed you down a little bit.

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27:53

Lucas McCurdy

Yeah, I know, I was whining.

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27:56

Loren Shook

Well, we can get to the gummy bears, you know?

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27:58

Josh Crisp

Absolutely. Later, a little later in the afternoon.

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28:00

Lucas McCurdy

Some THC for you.

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28:01

Josh Crisp

Yeah, absolutely. I'm down for that. Absolutely.

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28:04

Loren Shook

Does he like a tincture of THC?

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28:07

Lucas McCurdy

Well, I don't know. What are you into?

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28:09

Josh Crisp

This sounds like, after the behind the scenes content that we're getting into right now.

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28:14

Loren Shook

Actually, you know, this is our, our every day.

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28:17

Josh Crisp

This is cool. Well, it's like 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 going to just continue to need this more, until we kill this terrible disease out and, 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 to our industry.

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28:43

Loren Shook

Well, it's too much fun. So we have a great team. And as I do nothing but stay out of the way. Yeah.

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28:48

Lucas McCurdy

Yeah. All right. Final word of encouragement. Loren, 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 podcast 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.

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29:33

Loren Shook

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 legacy lasts 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 Doug Olson and the Vision Center. They work with the different universities across the nation, in helping to develop educational programs to develop leaders. At the Davis School of Gerontology, this 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 acumen. 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, you know, so you don't have to come through a gerontology program, but you can educate yourself on on the basics of what you need to know.

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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 or 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, any level. And it, this industry is just beginning, and it's a, certainly a multi-billion dollar, probably trillion dollar industry in the US. The US is leading the way. The U.S. is leading the world. Other countries want to duplicate what we're doing. We've toured by 60 different countries. The leaders of dementia in more than 60 different countries. And, you know, for example, China is, you know, hammering on our door, you know, come there, come, come to, even the UK come, come to, you know, different African countries and South America 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. 

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So unlike health care, I'm a recovering hospital administrator as I disclosed earlier, but there you’re 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, and deliver it. And that changes lives. And that is just too much fun.

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32:51

Lucas McCurdy

What an amazing vision to cast, you know, and leave it to Loren. And I know, you're an incredible visionary and a pioneer and a great leader. And we really appreciate your time today on the podcast.

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33:03

Loren Shook

Well, thank you. You're both too kind, but thank you.

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33:05

Josh Crisp

Thank you.

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33:07

Lucas McCurdy

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. Go to BTGvoice.com to check out this content and so much more. And thanks for listening to another great episode of Bridge the Gap. 

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3:25

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 BTG voice.com.

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