The Latest In Memory Science + How Loren Shook Built The Legendary Silverado Memory Care Group
Jeremy Clerc: So I have the pleasure of sitting here today with co-founder and CEO of Silverado, and author of The Silverado Story, New Possibilities in Memory Care, one of the most influential people in senior living and a key innovator in memory care. Loren Shook, thank you so much for taking the time to be with us today.
Loren Shook: Good. Well, thank you for having me.
Jeremy Clerc: We’re very excited to have Silverado as one of our new partners and to discuss a few key topics here today. So the first question that I have for you, Loren, is what do you believe has been the key to sustaining your organization’s growth while maintaining a reputation for high quality, dedicated care for nearly three decades?
Loren Shook: Well, thank you, Jeremy. I appreciate the question. I think that having clarity about the vision of Silverado to give a quality of life to our residents, our families and each other, and also to our patients in the hospice and palliative care programs, in addition to the families and each other as well. is, is very important.
So clarity of that vision, clarity of our purpose, and our purpose is to change the world in the way memory care services are delivered. So those coupled with our culture of love greater than fear sets the basis. for which we work going forward into the future and how we train staff, how we seek to continually innovate and find new paths to treat people in a better way that honors their dignity and improves their cognition.
And always thinking that we can improve people’s cognition, we can build off their strengths, we can develop them further than where they come to us with a lot of needs. So we don’t focus on what they can’t do. We focus on what they can do, but having those three key foundation stones for the company, the purpose, the vision, and the culture, uh, enables us to have clarity to our staff that this is the big picture we’re looking for.
There’s the change of the world. The big picture is to give a quality of life to the families that they haven’t seen before, certainly the residents and a quality of life that they think that they have probably lost forever. And the reality is they can have a better quality of life than they’re having when they come to us.
And the quality of life can really exceed any of their expectations. But they don’t know it, and others would not think it’s possible either. But we’ve proven tens of thousands of times to be able to achieve that. And then to really improve the quality of life for our associates. We work with them every day.
So there are ways in which we manage the company that can be designed to meet the needs of the resident or the patients in hospice but don’t meet the needs of the associate. Or we can take the extra step and work hard with regard to if we did this. And we could also improve the lives of our associates.
And the foundational culture of love greater than fear is one of those examples where we teach people how to deal with challenges that come up in the workplace, coming from more of the love side of the human emotion spectrum than the fear side. And that same technique, those same tools you can take into your home and you can have a better quality of life with your, with your wife, with your adolescent daughter, or or a son, uh, with your husband, with your partner, it helps all the way around.
Jeremy Clerc: In your book, you mention that you have found new types of therapies that actually create significant changes in the optimism of the person’s life. Some of them have been like music, others have been pet therapy. Can you just give us a little bit more examples on those? It’s it’s very interesting and I think you were probably one of the first ones to do that
Loren Shook: Well, sure, there’s a lot of different tools and you’re talking about, you know, pets and bringing in children. We invite the staff to bring their children to work.
So we have intergenerational programming in the community. But those are kind of holistic methods of improving people’s quality of life, which are relatively new to the medical world and the western culture today, but they’re age old. The Romans had them, the Greeks had them. You go back in antiquities, and they were very present, just like gardening was.
So, we’re just resurfacing those, and I learned that while working at my aunt and uncle’s psychiatric hospital when I was growing up, and they had pets. They had children. My brother and I and a lot of other family members and they had the gardening and they had purpose. So one of the therapies, if you will, is purpose.
Giving people purpose and meaning in life and giving them an avenue of normalization. So Dr. Wolfensberger is a pretty renowned researcher and professor that my co-founder Steve Winter studied under at the University of Maryland. And he learned a very hard lesson as a child. In Germany during World War II, he had a loving Dad who came home and played with him and was just a wonderful person.
And then, but Loving Dad actually worked in a concentration camp, was a Nazi, a concentration camp. A staff member who, uh, when he learned what Dad did in the concentration camps, he couldn’t, Make the connection. How could that be? And you know in the bottom line is if you don’t treat a human as a human Then you wind up being able to do whatever you want to them And the Nazis did not treat the Jewish people as humans, and they thought they were less than human And enable them to get over doing the horrible things that we all know they did.
So, if you give people who have memory impairing diseases a normalization of life, it results in also giving them dignity. And then you see them as a more normal individual with an impediment for sure. With some, um, challenges. But you can overcome that. So, it goes to avoiding abuse. Uh, that can happen, and there’s a risk of it happening in well meaning people who are professionals in the field for many, many years, and, and those individuals, having treated the same person, having served the same person who has, you know, all these sets of needs, and the person, you know, is with them for maybe a few years and passes away, they also begin to put up a barrier to protect themselves against the loss.
They can wind up seeing people as not normal. Just because of all the years of doing that when they’re really fine people. So we actually have a program at Silverado that Steve Innovated called the past review. Then it reviews about 800 different elements in our communities with a team of peers and goes in and evaluates What are we doing that’s not treating this person as a normal person or with dignity?
And, you know, one would be finding Christmas decorations in July still up in the room. Another would be having a sign at the closet of the person that says change, you know, Fred’s depends, you know, three times a day or worse yet changing his diapers, you know, three times a day. And, and so every time he walks by that, he sees that he’s a person with deficiencies.
And it hurts his psyche. It also tells everyone else you have to change his, change his diapers.
Jeremy Clerc: Yeah.
Loren Shook: So all that erodes the confidence he has in himself. All of it erodes people’s image of him. Uh, and they’re really little things, but they add up.
Jeremy Clerc: So, you had an original vision for Silverado. And that vision, I’m assuming, has evolved as you’ve been doing this for three decades now.
Can you tell us a little bit more about how it’s evolved? And I think the purpose of this question is really to try and understand what were like the non obvious things that you kind of figured out along the way.
Loren Shook: Well, we learned some things that we didn’t set out to actually innovate our buildings to, our properties.
They, uh, they just happened. So there were unintended consequences that were good things. So we put in on the outside of the courtyards and we fence every available piece of land we have. So that the resident, uh, has access to have freedom to move around. But outside we’ll put in a decomposed granite, a wandering path, along with concrete over here, patio, and, and grass.
So you give people different textures to walk on. But what we didn’t realize, we saw our residents one day, a couple of ladies, you know, sort of eyeing the decomposed granite wandering path, and their conversation was, this was a challenge for them, to walk that distance on that surface. And so they were up for the challenge, they were, you know, encouraging each other along.
And when they got to the end of it, they were really very happy with their accomplishment. So what we put in to provide people with a different texture and more interest and a feeling they’re going further, they actually found as, as a balancing tool, as a, as a challenge. So, so who, who would know, we invited the staff to bring their children to work.
To provide intergenerational programming for the residents and also to help our staff with children after school and that sort of thing. Which both work tremendously well. But then we went back and interviewed the kids later on as they became adults and some of them have gone into medicine. Some of them have actually joined us and some of them have gone on to, you know, science or finance or business or any other area.
professions. And what they have all told us is that they learned that people with memory impairing diseases or disabilities aren’t scary. You know, so they learned that they’re, they’re humans. They have needs, they want to love and be loved. And you know, they, they all took that away and they all saw it as a big plus.
And the kids want to come to Silverado. They want to spend the time there. Moms will tell me as I’m talking to them in our town hall meetings, they’ll tell me that, you know, they give. Their daughter or their son has the opportunity to come to Silverado or go to preschool and inevitably choose Silverado.
They also use it as a little disciplinary thing. You know, if you don’t clean up your room, Sally, you’re not going to be able to go to Silverado. And, uh, and there’s a lot of, uh, angst if that child hasn’t cleaned up their room and can’t go, you know, so the kids really look forward to coming and the residents look forward to seeing them, but we, the residents, really took to their.
Purpose some of them that connected with their purpose. They were teachers before something else. So they’re actually helping the kids with their homework. You know, so it creates a normalcy of the environment. That’s that’s very effective
Jeremy Clerc: Yeah, that’s amazing And I think that goes back to your anchor being purpose number one and a sub component of that making sure that they are still Treated completely normally right as like functioning members Of society which they can still be in in different ways You did a very good job.
I think in the book like illustrating some examples where the potential residents Had the opportunity to actually visit their parents more Or their grandparents more once they truly believed that they could still find some type of connection with them And the assumption sometimes was that there was no connection anymore and bringing that connection back Actually gave more purpose to the residents themselves.
Loren Shook: That’s right. Jeremy and also addressing the fear the children have with the loss of their grandparents faculties And one of the examples in the book that you you’re talking about is we do You Um, essentially a group with the children and we talked to them about how things are going and with children you start with play and then you have some lunch and you talk about how’s it going and in, in that particular scenario, it’s not unusual that child was otherwise happy and go, go lucky was a little sad.
So what came out of the conversation is her grandmother mistook her for her mother and she tried to correct her. No, no, I’m. I’m Sally, I’m not Maria, and, um, Grandmother, of course, has dementia and wasn’t going there, so it was a back and forth, and she felt, um, she felt really sad that the grandmother didn’t recognize her.
So our staff were able to reposition her thinking that her grandmother loved her mother, and in her grandmother’s loss of her memory, as a result of the dementia, uh, You know, she is seeing the older memories come up, you know, sees the grandchild as her daughter. And if she can frame that in her own head as a great thing, and a loving thing, then she can recognize that the grandmother means that she loves her, what she does means well, and that she’s no lesser than as a result of this mistaken identity, and feel good about it again.
In this case, that worked. And the team did a much better job of managing that and describing it to her than I’m doing right now. But it’s a skill set that the team has. Kids have, you know, problems, you know, with their, their, their loved one’s loss of memory. So if you don’t deal with it, then it can be a barrier for them to visit, and it can be something that hangs in their mind years later.
Jeremy Clerc: Absolutely. So I saw at Nick that you discussed moving past the current system for Medicaid, where only licensed facilities are applicable to a model where instead Medicaid funds are given back to the communities in the form of vouchers. And naturally, as a referral service, this would directly benefit us.
But I believe and understand this could open up opportunities for individuals and families. To have access to higher quality care. Is this something you could see genuinely happening in the near future? And what would the industry need to do to support this reform?
Loren Shook: Well, I think it’s a really important element Jeremy to help solving the problem for people in the middle income level And lower income levels not being able to afford Silverado or another, you know top brand and have choices as to You where they can take their loved ones.
Otherwise, they’re pretty much stuck in a Medicaid or Medi Cal funding source, and whatever the state licensing allows uh, and lines up with Medicaid or Medi Cal is where they can go. And, and that’s too bad because it limits them from choosing the right care. Operator the right provider. We do not take Medicaid.
We do not take Medi Cal At Silverado because none of the state programs that we’re in and we’re in ten states pay enough to deliver the level of care we deliver, you know, so we can’t do that. Many other operators don’t participate in those programs either in the state of California. Very few assisted living will qualify for Medi Cal in the first place.
Otherwise, it’s skilled nursing only. So to allow this, you know, voucher program to be in place, it puts the power in the family’s hands as to finding the right source. And if you couple it and it needs to be coupled with the family or any other source can supplement the money that the family gets through the voucher.
Now they can afford Silverado. They can afford to name it the top brand in the nation. Just like somebody who’s got a home. And, and maybe has a million, two million, uh, plus in the bank. It puts them in the same league as that. And the delta isn’t that much. So, you can have a lot of, uh, you know, number of family members, they all chip in something.
And they get there. And it just is a game changer. It also would improve the quality of care across the spectrum. So if there’s a, you know, let’s say there’s a long term care operator that’s not delivering very good care, which we’ve seen somewhat, sometimes in the industry, what happens? Licensing comes and cites them in this.
So there’s a regulatory, you know, hammer to make them behave right. So this adds to that. The competitive hammer with regard to, if you’re not delivering services that are as good as ours, then they can walk out and come to our community or another operator that is a top tier operator and get that. So, uh, just the power of making successful business operations work would motivate the operator to improve.
Uh, whereas otherwise they’re going to have a contained market. A trapped market, if you will. So it gives those tools and the industry is, is, um, really a driver for making this, um, possible. And I have, uh, pitched this to the president of the Senate, the speaker of the house, when I was president of the Alzheimer’s association, Orange County to the Alzheimer’s association chapter here.
And at the national level, I’ve spoken, uh, in front of the president of AARP and the entire entire group. There, and it wasn’t the right time, there wasn’t enough pain of not being able to serve people who didn’t have enough money at the time, maybe, and this is my speculation, to move the needle, to make it happen, but it’s a different look on how we use monies that are already available and how we allocate them so it doesn’t cost any more money, you know, from CMS or, you know, The state, uh, matching the Medicaid, you know, and Medi Cal programs doesn’t cost any more.
They’re already spending it, and now they can spend it with a company that, you know, we have less than 3 percent emergency room visitation rate. We have less than 4 percent 30 day re hospitalization rates compared to north of 20 percent or north of, you know, 10, 12 percent in the nursing homes. 90 percent of our people plus will pass away on hospice care compared to 60%, which is a huge quality measure.
It’s a huge satisfaction to families and is a major. Driver of reducing end of life costs because when they’re on hospice, they’re not going to the ER because of things that aren’t going to be treated. And the, the spend will just keep churning and costing the government money, costing the, the, the resident pain and suffering.
And, none of us family members want to go to an er.
Jeremy Clerc: Yeah, that’s a very good point. It seems like incentives are misaligned right now.
Loren Shook: Yes. Incentives. Uh, are misaligned given the resources we have today in senior housing that weren’t available when Medicaid and Medi Cal were first started, you know, so it’s, it’s updating the payment systems due relative to what’s new in, in resources available to take care of people.
Jeremy Clerc: So, what’s the next step, you think, given that, you know, you’ve already talked to people in the government about this, AARP, et cetera?
Loren Shook: I think it’s, uh, time for the industry to get behind it, uh, at the national level, at the state level, like California Assisted Living Association, Texas Assisted Living Association, and, you know, align with other organizations that care about people getting quality of care.
Yeah. So there are other national organizations that can get behind this, American Senior Housing Association, along with Argentum, along with just a host of others. The Alzheimer’s Association should be a hundred percent behind it because that’s their mission. Right. Is to really advance the quality of life for people with memory impairing diseases.
And there’s a lot of university researchers, uh, Uh, types that would see this as very important. Uh, so, I’m sure there’s other aligned groups.
Jeremy Clerc: Yeah.
Loren Shook: That would find this beneficial. So.
Jeremy Clerc: In dementia research. Space specifically. What do you find there to be most exciting looking ahead?
Loren Shook: There’s a lot happening and earlier Stage diagnosis is happening now with a simple blood test You can determine if a person has beta amyloid plaque or tau in their systems Which are indicators of certainly Alzheimer’s disease.
You can actually see if there are substances that would be indicative of Parkinson’s disease or Lewy body’s disease. Yeah You And this is available to people today, you know, pre symptom. And that’s really powerful for families and for residents. And so they can take action ahead of decline and other functions that go along with Alzheimer’s disease, and judgment and those kinds of things.
So, Our NEXUS program is proven to improve cognition by 60%, and that’s 730 cases that we gave to University of California, San Diego, Geriatrics and Psychiatry Department, and in analyzing that, those with a 20 mini mental state exam and above, and that’s a 0 to 30 scale, with 20 to 30, 30 being perfect cognition, and 20 being very high functioning.
So this is an early stage case. Of that group, there was a 60 percent improvement in cognition, which is overwhelming. And we also know from that research and other research that the principles within the Nexus program help to slow up the progression of the disease. So if you’ve got beta amyloid plaque in your system or tau or these other substances, it’s indicative that you are at a risk for getting beta amyloid.
Alzheimer’s disease, Parkinson’s, Lewy bodies, you name it. And if you implement these activities, and none of them have anything to do with drugs, if you implement those, before you get the symptoms, you’re effectively slowing it up. And, and it’s, it’s My speculation based on the fact that in science, we know it slows it up after you have it.
So it makes sense to me that if you’re implementing these before you have it, that you can see, because you actually have it. It’s just not at the level you can see. We all know Alzheimer’s disease probably is going on in our bodies ten years before anyone sees it. You know, so if you can slow it up then, likely you can slow it up enough that normal aging would be the end of your life as opposed to aging with dementia.
Jeremy Clerc: Wow, so you can get it to the point where you never actually have to face the symptoms of dementia.
Loren Shook: I think for a lot of people that would be the case and in other people it would come later and it would be less. There’s some other things that help people. Reduce the risk of having these kinds of situations.
Turmeric is proven in some research to, to reduce inflammation. And anytime you’re reducing inflammation, you’re doing great things, you know, for your brain as well as the rest of your body. And, you know, so things that are proven, and I’m not talking about a bucket full of expensive different natural substances proven in research to be beneficial.
So there’s those kinds of things. And then there’s olfactory system stimulation, which is relatively new research. A researcher, Dr. Leon. Michael Leon at the University of California, Irvine, has done a lot of work on this and actually started a company with some other people called Memory Air, developing the olfactory system which is proven when you improve people’s smelling abilities, because that’s what we’re doing, just smelling different scents during the day, you’re actually building the hippocampus.
So through looking at different screens, it’s proven that the hippocampus is growing. You know, so that science is crystal clear, but there is improvement in people’s memory that has been shown. It also improves behaviors in autistic kids, which is pretty cool too. That research was like a 300 percent improvement.
When he used it for people who had memory intact, they weren’t dementia residents, there was a 288 percent improvement. in their recall, in their memory, and they had normal memory. So it’s also been studied in South Korea. The imaging also shows the growth in the hippocampus, but it, um, but their memory improved substantially, and those are people with dementia.
So we’re going to be implementing that in our company when the equipment comes out. When you go back and look at people with memory loss, there’s olfactory loss. When you look at people who have psychiatric problems, you know, there’s also olfactory loss. It’s a simple thing to implement, but it’s powerful.
And it’s, it’s here.
Jeremy Clerc: Are enough people talking about this? Is this known to most?
Loren Shook: No. I talked to people about it. I brought it up at Nick. Most people don’t know anything about it.
Jeremy Clerc: What triggers the need or the ideal time to start figuring out, you know, start doing those tests to figure out if we are prone to Alzheimer’s.
Loren Shook: Well, you can do 23andMe or some other genetic tests and see if you have the APOE 4 allele from mom and dad today. Some people don’t want to know, but if you do, then you have a much higher risk of having dementia. And it’s very rare that you would have it. Uh, researchers tell me it’s very rare that you would have it from mom and dad.
Yeah. But if you do, then you have a much higher risk. Right. There are different markers you can check today. Having the blood test, which is a pretty new blood test, by the way.
Jeremy Clerc: Yeah. But
Loren Shook: having that done would be really wise in just a physical exam.
Jeremy Clerc: Yeah.
Loren Shook: And I would be asking, uh, to have that done as well.
Right. Now that it’s, it’s available.
Jeremy Clerc: Yeah.
Loren Shook: And it’s inexpensive. Uh, so, there were scans you could do before that would show beta amyloid plaque in the brain and tau, but those are very expensive to do. And you could do spinal taps, but that’s pretty invasive. People didn’t want to, didn’t want to do that.
Understandably so. And understandably so. And more expensive. Yeah. But, now it’s become very simple. Yeah. Yeah.
Jeremy Clerc: So given the fact that we started a referral slash placement service, what would be your advice in order to build the best possible program for seniors looking for senior care, but also for the communities who are looking to fill their occupancy needs?
Loren Shook: So seniors looking for memory impairing diseases, they have a lot of very unique needs. Incomplex needs and a knowledgeable party who’s the referral party of geriatric care manager will work with people who might be marriage, family, child counselors, they might be social workers, they might be just experts have really trained themselves in this area, but they understand the psychodynamics, if you will, that the family’s going through with this.
Horrendous death and loss and dying process that the family is going through and has already well down that path by the time they get to us. And I say they’re well down that path because they’ve lost. This loved one’s, uh, ability to behave like the loved one would normally behave. Memory, um, confusion, executive functioning, behaviors.
There’s a host of things that may be going on already in that family that then bring them to our door. So, you’ve got to deal with that when they come to us. Plus, you’ve got the family, oftentimes, feeling like they have, uh, Let their loved one down. Feeling guilty that they shouldn’t be searching for someone else to take care of them.
They should be able to do this themselves. But of course they can’t. No one can. So there’s a lot of processing that the family needs to do. But start with the degree of complexity of the problem. So temporal lobe dementia, For example, that’s a very complex dementia. And that is, uh, prone to people maybe having no inhibitions.
Uh, what they say or do and striking out and having some behaviors go with it and saying some things that we would say are incredibly rude because they have no inhibitions.
Jeremy Clerc: All right.
Loren Shook: So those are the kinds of things that it takes a very strong, uh, informed, knowledgeable operator and their staff to be able to manage and create a normalcy and have those behaviors under control without reverting to.
Drugs that aren’t going to make any, any sense for that person’s health. So the referral party needs to know the skillset of the operator. And then there’s a classic Alzheimer’s case of a person who is very mild mannered and easy to get along with. can be handled in a lot of different settings. There’s a person who is the, you know, the man who has been in the outdoor sort of life and hunting and fishing and that sort of thing that likes to go inside, go outside and move around.
So you want to find a location that has space to move around as opposed to a very small confined unit or a small house, right? Because when they’re confined, now you’re going to have behaviors. So a host of scenarios that, um, The referral party is going to know talking to the family, and then when they go and they tour the community to have the trusting relationship with the community staff to work with that referral party as to what did the family see?
You know, what did they say? What did you see? What do you think’s going on? And then for them to, you know, partner and relay that information to the community experts. And then. You know, connect the dots with the family. Some families will have questions they’re not raising with us as operators because they may feel ashamed.
They feel guilty. Maybe there’s uh, several family members and one says to the other one, uh, don’t you dare talk about that problem with mom to, to a perfect stranger because they will see us as a stranger because they’re embarrassed. Now, those of us in the field, there isn’t anything we haven’t seen.
We’ve already been there, done that probably hundreds of times, but to them, it’s only their mom that did that. No one else in the world is doing that. You know, it’s my mom and I’m embarrassed by it. And so, they don’t talk about it. And so then we can’t talk about it and can’t talk about how we could address it and relieve them of those concerns.
So it’s really a partnership. And, and without that partnership. That family may decide to go to the wrong place, may decide to go nowhere, and then now they’re not getting the care. So, you can have the best professional referral party, but without the partnership of the knowledgeable community, they’re only working with half a deck.
And it’s the other way around, too. And the family’s not getting well served.
Jeremy Clerc: Definitely. It seems like that relationship between the referral partner and the Operator is just essential and lacking in the industry for sure.
Loren Shook: It is essential. It is present for a number of very solid geriatric care managers today that we work with But there’s an opportunity to expand it Tremendously,
Jeremy Clerc: right?
Loren Shook: And there’s just a huge gain for everybody if they can implement this and have the relationship between the referral party and the operator Has that trust to do it?
Jeremy Clerc: Yeah Well, Loren, thank you so much for your time today. Thank you for going over all of the questions that we have for you and for giving so much clarity and depth on some topics that weren’t obvious at all.
Loren Shook: My pleasure, Jeremy. Great to spend time with you. All right. Thank you very much.
Jeremy Clerc: Take care, Loren. Thank you.