Rising acuity of residents has prompted operators to build in more support across unit types, sometimes by blurring lines among them.
To adapt to changing resident needs, providers have redesigned communities to create more shared spaces and introduced programs that ease transitions among levels of care. By blending acuity levels and offering certain kinds of cognitive care and other higher-acuity services, operators are helping residents stay in their current care level.
Small-home senior living operator Sage Oak in the last year has launched a personalized resident placement program to group residents together based on their needs.This is all possible through Sage Oak’s high caregiver-to-resident ratio and its smaller properties ranging between 8 and 16 units.
“Blended environments are not like a carte blanche pass to just throw everyone in together that says yes and wants to move in, because that’ll be a recipe for disaster,” Hornbuckle told SHN. “Personalization means that you’re either going to see a highly curated group of people or you’re going to be received by very thoughtful, blended environments designed to meet those needs.”
Other operators, including Merrill Gardens, Pegasus Senior Living and AgeWell Solvere Living, are each working to craft blended environments for senior living residents as the lines of the continuum blur due to rising resident acuity.
Operators must ‘curate early’ to find balance
Dallas, Texas-based Sage Oak operates communities across the Southeast and since 2024, the senior living provider has taken a new approach to resident assessments and personalization of where residents are placed. The operator is grouping residents with specific care needs, like those who are recovering from a procedure or medical incident, in assisted living with residents in early-stage memory care.
In order for these blended communities to thrive, Hornbuckle said, operators must “curate early” in resident assessments to find the right fit among dietary preferences and social, cultural and religious backgrounds.
“Dementia care and high-acuity assisted living pair really well, but I don’t think that independent and assisted living residents pairs well with much of anything else,” Hornbuckle added, noting how some new senior living residents bristle at the idea of seeing medical equipment or assistive equipment like walkers or wheelchairs.
Sage Oak operates five communities across three states.
Seattle, Washington-based Merrill Gardens is aiming to offer independent living residents in-unit care, where possible, to help them age in place without having to move to another unit. Typically, Merrill Gardens communities have between 120 and 150 apartment units mixed across independent living, assisted living and memory care.
“When you need services down the road, you can stay in your apartment and we bring those services to you,” said Merrill Gardens COO Jason Childers. “We try to do this as discreetly as possible so there’s a feeling that everyone is a resident of the community and isn’t separated by their care needs.”
As residents need help with cognitive decline, safety and accessibility to care become a greater focus, Childers and other operators told SHN.
Dining spaces are also an area where residents across acuity levels can interact, along with participating in shared programming and events, Childers added.
For example, Merrill Gardens recently opened a new community in Hillsboro, Oregon, that is licensed for assisted living and memory care. This has become a strong marketing tool to show prospects the ability to age in place as their acuity levels change.
“Residents don’t really know where someone else may be in the care continuum,” Childers said. “That’s by design.”
Merrill Gardens also has a program for assisted living residents in need of memory care services, and the company is “looking at growing” its bridge program among acuity levels, Childers said.
“What we’re trying to do is find those residents that are in need of a little more support but not to a level where they need to be in a secured environment,” Childers said. “What the bridges program does is it finds a group of eight to 10 residents and we provide additional support and engagement to this group of residents.”
This has helped “ease the transition” of independent living residents into assisted living and assisted living residents into memory care, Childers added.
In recent years, senior living operators have taken steps to rethink community layouts geared for connectivity and social engagement.
North Palm Beach, Florida-based AgeWell Solvere Living designs its assisted living and memory care communities to feel “open and inviting” while still providing needed security in memory care to ensure resident safety, according to Chief Strategy Officer Rich Gordon.
“These areas are often located near assisted living spaces, with transitional zones that allow for supervised interaction when appropriate,” Gordon said. “We also use discreet sensor technology to monitor wellness while respecting privacy and to support independence without compromising safety or emotional comfort.”
Dallas, Texas-based Pegasus Senior Living has blended assisted living and memory care communities since its inception as an operator, according to CEO Chris Hollister. The operator places memory care units on the first floor of a community while designing other spaces in clusters to make sure residents aren’t walking too far to the dining room or activity areas.
It’s critical for senior living operators to create memory care spaces that have access to “natural and spontaneous” access to outside amenities, with secured courtyards nearby to let residents go outside and enjoy pleasant weather, Hollister said.
“We prefer one-story buildings that are easier for staff to manage and we create wings with shorter walking distances and replace carpeted hallways with plank flooring so it’s easier for residents using walkers to navigate,” Hollister said.
Spaces must balance autonomy of assisted living residents with the security and safety of memory care residents, and units must be easy to navigate, Hollister added.
Merrill Gardens groups certain common areas together for ease of access and designs communities so residents of all acuity levels can share dining spaces. For example, at the operator’s new community in Hillsboro, residents have access to dining on the first floor along with access to fitness and activity spaces like a movie theater.
“Nothing should be designed towards one group or another and we see a lot of interaction in the dining room and in our activity spaces,” Childers said.
While independent is always going to be a “better social model” and a lower cost, Sage Oak has specifically targeted residents in need of assisted living and memory care by constructing small-home communities that have “ample floor space.”
“The physical plant element that goes into this acuity conversation and nobody is talking about that,” Hornbuckle said. “There’s a connection between physical plant and acuity level.”
For example, Hornbuckle said smaller units and rooms don’t lend well to high-acuity assisted living and memory care and these blended environments can’t succeed if they have large amenity spaces that aren’t easily accessible to residents at higher acuity.
“You get the opportunity to buy buildings that fit your acuity profile,” Hornbuckle added.
Spurring transitions across care levels
Senior living providers have bulked up care levels and care coordination efforts in order to ensure smooth transitions of residents from independent living to assisted living and assisted living to memory care. But another element of these transitions lies in communication with families to demonstrate clinical data to show just how their loved one is progressing across care types.
This must be approached with “empathy and a proactive approach,” Gordon said, combined with frequent assessments to identify changes in care needs. AgeWell uses “flexible care plans,” and care staff and operations employees are trained in identifying early signs of cognitive change to work in conjunction with families to demonstrate a resident’s rising acuity.
“Blended models allow for more flexible pricing tiers and care level allocations,” Gordon said. “We’ve aligned our pricing and revenue strategies with our [regulatory] standards and broader market trends. This approach supports financial sustainability while offering value to residents.”
Looking ahead, Gordon sees a “promising future” for blended environments in senior living, bringing together “continuity, efficiency and higher satisfaction for residents.”
“Our focus remains on creating communities that feel like home while evolving to meet the expectations of the next generation of residents and families,” Gordon said.
The “best model” for blended communities will continue to remain 80 assisted living units and 24 memory care units, surrounded by cottages which allow for independent living units, Hollister said. But many questions remain to be answered in solving this puzzle of rising resident acuity and crafting blended spaces across the continuum.
“When you think about managing transitions, especially in this evolving clinical space where heavy assisted living overlaps with light memory care, how are you approaching those shifts? Specifically, when an assisted living resident begins progressing and really needs memory care-level support, how do you handle that?” Hollister said.
For Hornbuckle, he sees the future of senior living blended environments and emphasis on personalization that is “just getting started.”
“Personalization and thematic housing are going to continue to explode as we see generational shifts unfold in senior living,” Hornbuckle said.
