Transforming Wellness-First Senior Communities Through AI and Social Determinants

Q: Hi Mike. Good to have you on the podcast today. Mike. I’m Rohit Mahajan, Managing Partner and CEO at BigRio and Damo Consulting. I’m very fortunate to carry on The Big Unlock podcast, which is the legacy of Paddy Padmanabhan, who was the founder of Damo Consulting. We are, I think, getting well over 170 podcasts at this point. I’m super excited to have you here today.

Mike: Hey, Rohit, great to be on. Thanks for inviting me. I am currently the Chief Transformation and Innovation Officer at United Church Homes. We are a nonprofit provider of senior living, with over a hundred different properties in 15 states and on two tribal nations. That includes about 75 affordable housing properties—owned and managed.

And then in the state of Ohio, where we’re headquartered, we have 10 owned and managed skilled nursing communities. We have life plan communities, and we also have independent living communities focused on the middle market.

We’ve definitely been growing—a very innovative organization that I’m proud to be part of. That includes growth into more services. We’re starting to do programs with CMS, like the GUIDE program. We also have a joint venture with a managed care payer called CareSource.

I really think that’s the future for many senior living providers—growing from being just housing providers to becoming health and wellness providers, with housing at the core.

Q: That’s amazing. So Mike, would you like to share with us your journey in healthcare? What got you started, how did you get to where you are, and what are some of the things you’re seeing for the future? 

Mike: Well, thanks for asking the question. When I started my career, I came down to the U.S. from Canada right out of grad school. I got into advertising, and with my first degree in economics, I became very compelled by the age wave.

I think there’s nothing more predictive—outside of maybe climate change—of future demand than the current age wave. It’s what I call the anomaly of the baby boom generation. This huge baby boom spike—we’re sitting here on July 14, 2025, and in 2027, we’re going to have the most people turning 80 in any year ever. Why? Because of what happened in 1947.

We know people needing healthcare services today are just a small fraction of what we’ll see in the future. So why not get in and plan for it?

Being a very naive Canadian at the time, I thought, “Maybe I should just get into the healthcare space—because that’s easy in the U.S., right?” Very straightforward! But it’s been compelling.

I started at AARP. They were a client of mine when I worked in advertising, and they’re the largest association for older people in the country. Then I moved into health IT with a role at Surescripts, the nation’s e-prescribing network, and later returned to AARP. So I got a taste of interoperability, health tech, and how we could apply that to aging.

With labor shortages and so many constraints, I started asking: how can technology fill the gap and support people at scale?

Through further experience, I realized clinical care isn’t the most important factor in the health and wellness of older people. It’s the non-clinical care and functional support that matter more.

So I’ve built expertise in social determinants of health—risk modeling and strategies to support aging at home. And importantly, that doesn’t just mean care and safety. I think it’s far more effective to support someone’s needs when there’s real meaning behind it.

One of my favorite sayings is: “Nobody takes their pills because they like how they taste.”

I’m a big fan of more relational care models, where we work hand in hand with people—focusing on their personal goals and motivations. And I hope that at United Church Homes, and in the future, that’s the kind of model I can help advance.

Q: That’s an amazing journey, Mike. Given your deep immersion and expertise in this area, would you like to talk about some growth strategies for senior living care?

Mike: I’ve had the privilege of working with United Church Homes for almost four years, and it’s helped me really get to know the nonprofit senior living industry. I’ve been incredibly impressed. As I like to say—we do the most with the least.

Especially in affordable housing. For about 30 years, United Church Homes and others in our space have been participating in a program that HUD (Housing and Urban Development) started called Service Coordination in Multifamily Housing. They provide funding for staff to be at those properties and conduct social determinant assessments on residents.

We help reduce risks by connecting residents to local community resources they may not know about. We also help qualify people for Medicaid and Medicare waivers. More importantly, we talk people down off a cliff.

What I mean is, when someone is going through a health or aging challenge for the first or second time—we’ve been through it hundreds of times. So we can tell people what’s normal, what’s not, and what might happen next.

That program has been amazingly effective in keeping people out of the hospital and skilled nursing. We have about 3,800 people in affordable housing—3,200 of them are on service coordination contracts. In the last 15 months, only 50 transitioned into skilled nursing, and 110 had an unplanned hospitalization. These are very low numbers—and they’re similar to others in our space.

So when I think about growth in senior living, I think about unbundling this service skillset and offering it as a standalone solution. It’s a plug-in for managed care, employer programs, and long-term care insurance. I think the future of senior living is transitioning from housing providers to health and wellness providers—with housing at the core.

I also think the industry needs to shift from centralized service delivery to a more decentralized model—because there’s an opportunity to support people in housing who could never afford or don’t want to move into a community. A hub-and-spoke model—I think we’ll see more of that in senior living.

Q: That’s very interesting, Mike. Just curious—typically at what age do people come into these kinds of facilities? What have you seen, and is that changing? 

Mike: Yeah, I mean, average age is going up—we’re getting them older and sicker. The lifetime value is going down. So the business strategy has to diversify toward more community-based models—serving people where they are.

The average time between knowing you need to move into a community and actually doing it can be 9 to 18 months. What happens in between? That’s where we need technology to help. Technology that tells us when someone may need assistance—and also helps capture that data.

Q: Right, of course. And you talked about social determinants of health—that caught my attention. How does that play into your transformation and innovation efforts? And what are some things you’re doing with machine learning or GenAI in this space? 

Mike: Social determinants impact about 70% of health outcomes. Clinical care is about 10%, genetics about 20%. But social determinants cover everything from food, transportation, and shelter to how people engage with their health—adherence to care plans and motivation.

That’s why the service coordination model is so important. It builds trust first. Then it designs care plans around personal motivations—like wanting to keep a dog, visit a garden every day, or attend a museum show. These are real examples.

We need to understand what impacts those motivations. I like to call it “micro social determinants.” The macro ones are where you live, education, resource access, etc. But the micro ones are things like: do you have a primary care doctor? Can you get to appointments? Do you have a reconciled med list? Can you follow your meds? What’s your functional status?

Because if you have three or more chronic conditions, you cost about 50% more. Add one functional limitation—and that jumps to 330%. That’s about 5% of patients consuming 25% of healthcare spending. They trip, fall, and go to the most expensive sites of care.

So home safety—clutter, lighting, cords—all matter. Caregiver presence and quality matters. Your own goals and motivations matter. These are social determinants.

Another big insight from my career—when I was at AARP, we did a study on health literacy. The doctor sees me, puts on a blood pressure cuff, and says “119 over 70-something.” I ask, “Is that good?” He says “Yeah,” but it means nothing to me.

People over 65 are the least health literate—but when they are literate, they’re the most adherent to care plans. So again, that supports a social determinants and relational care model—to reduce spending on the highest-cost patients.

That’s what I get excited about in data analytics. I don’t think we’ll ever get to a point where we have social determinant care pathways like clinical ones—like in cancer, where you try drug A, then chemo B.

Nonclinical care has so many variables—social, financial, environmental, motivational—but maybe we can get close.

Q: So in your journey, what have you been experimenting with or piloting in terms of new technologies like GenAI or AI in this space, or Internet of Things—devices to keep this patient population safe and risk-free?

Mike: Appreciate that. Yeah—so first, machine learning is my top priority for innovation right now. Just like I said before: how can we take all the data we’re collecting on social determinants, the referrals we make to local community programs, and the efficacy of those programs?

We often know the best home health providers in the area. Just last month, a woman had bedbugs, and we knew Catholic Charities has a furniture bank that helps with new furniture. So how can we take both the referral and the result information, the social determinant data, and model it into efficacy?

Because that’s going to be our pathway into managed care programs. The biggest challenge for our industry is that we can’t take risks within managed care yet—our data game isn’t strong enough. When we combine clinical care and nonclinical care, it’s like baking a cake and trying to take the eggs back out. What part was the doctor and what part was us? It’s mostly us—but we need data to prove it.

So that’s the first piece. And to get that data, we’ve tried using chatbots and other engagement tools. So far, we’ve learned that where humans struggle to get other humans to communicate with them, AI chatbots tend to do worse. So we’ve gone back to using simple text message reminders: “Is there anything you need to tell us this week?”—things like that.

As for in-home technology, I’ve gone on a bit of a journey. We tested things like Alexa, sensors, and other tools. That helped us narrow down the data we really need to know if someone’s well or not. I think it’s about identifying when someone is active when they usually wouldn’t be, or when their activity looks different than normal.

I used to think about multiple sensor systems. But recently, I saw a very elegant solution that uses an AI chatbot avatar interface paired with RFID tags in shoes—50 cents apiece. Versus more complex sensor systems, can I get 60% of the data that gives me 80% of the information I need, for 10% of the cost? That’s the goal. There’s just too much data out there.

Fall prevention versus fall detection—that’s key. Anything that motivates people around exercise or engagement, that’s where we want to stay ahead. You can see it in healthcare spending: when someone falls, they start a downward spiral. That’s when all the spending happens. So anything that helps with preventative wellness is huge.

Q: That’s very cool. And you’ve mentioned broadening clinical care, Mike—you were talking about social prescribing. Can you tell us what that means to you?

Mike: Yeah, I just heard that term today, which I think is neat. In Canada, where I’m from, doctors will prescribe National Park passes. In England, they even have a Minister of Loneliness.

The joke I always tell—and maybe one listener will get this—is: “Minister of Loneliness is not the name of the new Morrissey album.” That’s my 1980s joke.

But seriously, I think social prescribing is taking off. I heard a great story on NPR today—Kaiser is supporting an initiative around this. The model is really about understanding your motivations. Why do you want to stay healthy? Why do you want to stay engaged?

What’s really important for people in their 70s, 80s, 90s is to have a strong sense of purpose. Why do you want to stay well? Maybe to see your grandkids grow up. Or to stay in your home. Maybe you want to maintain your garden. The number one reason people move from their home into another home is home maintenance—cooking, cleaning, that sort of thing.

As you age, small frictions become big obstacles. I woke up today and my back hurt—it sucks, but I got through it. For older adults, those frictions increase. Supportive services can reduce the friction, take burdens off their shoulders, and help them return to their baseline.

But you can’t do that without knowing the person and what drives them. Taking your pills every day—it’s not about liking how they taste. It’s about what motivates you.

If we start there and build a partnership, speak to someone in a language they understand—then we can make a difference. I can’t pretend to be a doctor—I don’t know the medical language, no matter how many episodes of ER I’ve watched. But we need to meet people where they are.

All healthcare is local. All social work is local. I think today’s technologies have great promise in expanding these highly successful, local, relational models. That’s what I’m excited to see.

Q: That’s amazing. So as we come to the close of the podcast, Mike—when you look ahead, based on all the innovation and transformation happening in this space—what do you see coming our way? 

Mike: Wow. Well, it’s funny with AI right now, isn’t it? Every 8 months, it seems like there’s a new revolution in capability. I used to be very cynical about it. I’m a marketing professional—my background is in direct marketing.

Then came customer relationship marketing—because consultants needed something new to sell. So I looked at AI and thought, this is just machine learning, right? It’s been around forever.

But when I started thinking about AI as pattern recognition, I began to see the bigger picture. Where else do we find patterns? We find them in nature—in fractals, in repeating structures. AI taps into that same concept of pattern recognition. It’s fundamental.

I don’t think it will ever become sentient—that’s carnival barkery. But I think it has promise. Agent AI is interesting. I haven’t seen it work properly yet—but if we can automate prescription renewals, appointment scheduling, or even coordinating a ride to the doctor—that’s big.

If we can reduce the frictions that prevent people from getting back to baseline—that’s where it’ll be most successful. And most importantly, AI should maximize human time—what we’re doing right now: having a conversation. That’s where the value in healthcare will be—freeing up more time for this.

Q: Absolutely. You know, I think the more help we can get from tools like AI coding, the better. We’re even seeing our clients ask, when we start a project, “Do your people use AI coding tools?” We’re now selecting people who are good at using those tools because some say it can make them up to 100% more productive. 

Mike: And I think there’s a democratization happening with AI. A lot of what I’m seeing is like everyone inventing the same thing at the same time, everywhere. It’s like how the light bulb and the steam engine were invented around the same time in different places—because innovation opened adjacent doors all over. That’s what’s happening now.

But unless you co-create with the people you aim to serve, you have no load around your system. So just a call to action to anyone developing solutions in our space: co-create with the patients. Co-create with the customers. The UX will be simpler, the data will be simpler, and you’ll be far more effective in selling it through.

Q: Mike, on that point, please talk to us about imparting—about your concept of entrepreneur-in-residence. I’ve talked with you about that, and it’s a very successful program. Please share.

Mike: Thank you for bringing that up. I didn’t have it written down, but yeah. In my position, I get a lot of calls from people asking for advice in the aging, longevity, or age-tech space. And by the way, I think we should get rid of the term “age-tech.” I haven’t found a better word yet, but just because you’re of a certain age doesn’t mean you need special tech.

One of the biggest challenges we face is change management. We’re largely a reactionary workforce. We don’t know what we’re walking into every day. If you want to create solutions for our space, you really need to fall in love with our problems before coming up with a solution. That’s part of human-centered design—having deep, embedded experience with those you aim to serve.

So we have a program at our Glenwood community in Marietta, Ohio—a very historic community. We have cottages, independent living, assisted living, and 15 minutes away we have Harmar Place, which is skilled nursing with memory care.

We offer a two-week program where you can come live with us. Week one, you formally shadow different job roles. Week two is kind of a “choose your own adventure.” We give you a persona—like you’re a new resident in independent living. Your persona has specific traits. Walk into the dining room, sit down, feel nervous because no one’s sitting with you.

Our residents are wonderful—they’ll sit with you and talk with you. Make friends. Get to know them. See who they are. If you make enough friends, maybe you can test your prototype or do user group testing. But it’s not going to work unless you can embody the experience and make friends. You’ll learn why people don’t have time—and what conditions make change possible.

Q: Yeah. You immerse yourself in the setting, then pick a problem to solve, and co-create. 

Mike:   Exactly. And we’ve had a lot of fun with it. We’ve been running it for over a year. A lot of the people come from places like New York City. I think half of it is because they like the idea of living in a two-bedroom, two-bath apartment in a peaceful setting for two weeks. But now they’re starting to collaborate and use the experience as a foundation. I love seeing that happen.

I encourage any senior living provider to start a program like this. And any developer—look for these opportunities.

Q: That’s amazing, Mike. Thank you so much. This was a very exciting discussion. Wishing you all the best and hoping to stay in touch.

Mike: I invite everyone to check out unitedchurchhomes.org. For our entrepreneur-in-residence program, the email is eir@uclinc.org. We also have our own podcast series—abundantagingpodcast.com—and our Center for Abundant Aging, which champions ending ageism, spiritual wellness (which we didn’t talk about today), and rediscovering purpose. That’s at abundantaging.org.

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Disclaimer: This Q&A has been derived from the podcast transcript and has been edited for readability and clarity.