As Covid spread through the nation’s nursing homes last summer, Thomas fixated on one idea: We have to push deinstitutionalization further.

The vision for the new project he’s working on with Signature HealthCare — currently called “Canopy” — starts with a cluster of small ADA-accessible houses built close together, with communal greenspace and an intention that residents get to know their neighbors. The idea is that residents have much more autonomy than in a congregate setting, living in their own homes with access to the outdoors. And the goal is to enable them to tap into a tight web of services — from help eating and bathing, to physical therapy and nursing care.

The specifics are still in the works, says Nick Jacoby, the chief development officer of Signature HealthCare, a long-term care provider. But he says the first community will likely be built in a small town in rural Tennessee, on the grounds of one of the company’s existing nursing home campuses. It may include anywhere from eight to 16 homes, roughly 400 to 600 square feet each. That’s roughly the size of so-called small houses, or “granny flats,” except instead of being built in a backyard, the first homes will likely be built on the grounds of one of the company’s full-service nursing homes.

They’re still hammering out what exactly the first homes will look like, both inside and outside, thinking through questions like: “Where is the world going in terms of preference and technology and care delivery — and how do we create the home for that?” Jacoby said.

But the idea is that if residents need nursing care and help with daily living, they’ll rely on getting those services inside their home, which they’ll rent. Thomas and his partners are betting that in coming years, state and federal governments will turn their attention and money more toward what’s known as home and community-based services, transforming how the country pays for aging and ending the current regulatory emphasis on traditional nursing homes.

That shift is already underway. In the last few years, the Trump administration opened the door to let private Medicare plans begin paying for nonmedical services, such as meal delivery or a ride to the grocery store.

States have also started to shift away from paying only for institutional care in nursing homes. Instead, they’re devoting more of their Medicaid dollars toward home-and-community based services, which can consist of everything from home health aides to assistance prepping meals.

“The pendulum’s swinging to home and community-based services,” said Thomas. “And in order to make those services really work, we need better homes and better communities — and that’s what Canopy is designed to provide.”

President Joe Biden’s sweeping infrastructure plan includes a massive, $400 billion investment in covering in-home care under Medicaid — which Thomas called the “biggest rebalancing” of payments ever for long-term care. And Biden’s massive coronavirus relief package passed in March provided the first federal funding boost to home and community-based services since Obamacare’s passage. But the increase is just for a year, and advocates are already working to push for ways to permanently redirect more money toward the benefit.

“The larger public has been making clear forever that people who are aging would really rather stay in their own home,” said Anne Montgomery, the director of eldercare improvement at the nonprofit research and consulting group, Altarum, and a former senior staffer on the Senate’s aging committee.

Yet, waitlists are still long in many states, and finding care inside the home can still be a frustrating process for many Americans.

“It will be a challenge,” said Montgomery, who first learned of Thomas’ and Signature Healthcare’s project when contacted by a POLITICO reporter. “I’m pretty sure that somebody like Bill Thomas would be thinking hard about that — where he’s building or hoping to build the small houses, and what kind of services are available in that area, and how do you help organize those services into something that is accessible for the residents of that community.”



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