2. Repositioning Your Continuum of Care to Improve Operating Results 106-G Wednesday November 4, 2015 12-1:30 2

3. Today’s Objectives The overall goal of this meeting is to learn how the home health and hospice programs changed WC Bay’s ‘system’ of caring for residents and overall operational performance: 1.Learn how one organization improved resident satisfaction, quality outcomes and financial results through more effective continuum and care management. 2.Consider ways to align your organization’s care management goals with your therapy provider. 3.Understand how adding specialized assisted living, respite, home health and hospice services provides stronger positioning for post-acute care

4. Operational Improvements at Westminster Canterbury on Chesapeake Bay Dan Nimon President Senior Options Vice President Health Services, Westminster Canterbury on Chesapeake Bay Dan.Nimon@wcbay.com

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6. 6 Home Health and Hospice in the Virginia Beach Area Advisory Services to Non-Profit Senior Living Organizations Life Care Community in Virginia Beach, VA Our Brand Family

7. To provide home health & hospice services to residents of Westminster-Canterbury on Chesapeake Bay To provide home health & hospice services to residents of the Greater Hampton Roads area To assist Faith-Based Non-Profit Organizations with development and on-going operations of independently owned home health & hospice services: Advisory Services 7 Big Picture Strategy

8. Quality of Care: Need to control quality of care and assure positive clinical outcomes A new day: ensuring and proving quality. Value Based Purchasing. Opportunities to grow and diversify revenue stream without bricks & mortar Serve our own residents: patients already here on campus – 15 -20 outside/community patients in short stay at NH & saw opportunity to start home health with immediate volume. Preserving and enhancing our mission, values and culture. Why did WCCB decide to start home health, homecare and hospice? 8

9. The market was demanding more choices and care coordination MCO’s - ACO’s –Bundled Payment –Value Based Payment Patients – shorter length of stays or NO length of stay – by- passing SNF altogether and going straight home with home health services Desire of health services division to continue to assist CCRC with bottom line margin

10. ILALMCNFRehab Home Health Hospice Hospice and Home Health Enhance Your Continuum of Care

11. The 5 R’s in Nursing Care – Right Person – Right Med – Right Dose – Right Time – Right Route The 5 R’s in Continuum Management – Right Person – Right Location – Right Services – Right Staff – Right Frequency Providing the right care in the right location in the continuum

12. 20112015 Average Rehab Census823 Average RUG Rate$410$460 Average Rehab LOS2921 Hospital Re-admission Rate % National Average Not Tracked9% 21% Hoy Center Medicare Revenue$2.2M$4.2M Hoy Center Bottom Line (Without Overhead Allocation) $1.8M$3.1M Changes in Our Skilled Nursing

13. Already licensed to provide private pay home care services to residents on the campus. $400K annual operating loss from home care services provided to ILU residents, much of it without charge – ALF Operating at 89% occupancy – Medication Management (47 ILU residents) – NO CHARGE – 3 day Automatic follow-up for all hospital and post acute discharges – NO CHARGE – ADL Care – Most at No Char ge 13 Our Story

14. Medicare Home Health in 2012 – $400K losses converted to $150K positive income in first full year. – Residents happier to recover in their independent living apartment. – More bed space for outside community patients for rehab. – Can offer community patients the chance to be followed by our WC @ Home team. – Readmission rates LOW: 13% vs. 17% national average. Hospice in December 2013 14

15. What Do our Residents Think?

16. Therapy in the New Continuum Leigh Ann Frick, PT, MBA Chief Clinical Officer Heritage Healthcare/ HealthPRO® Rehabilitation lfrick@heritage-healthcare.com

17. Heritage Healthcare/HealthPRO® Founded 1999/1997 respectively; has grown to one of the largest independently owned therapy companies; Experienced management team with rehab, long term care, CCRC, out-patient and home health operations background Proven expertise: – Therapy delivered by 7,400+ therapists in ~550 sites across 27 states – 30% CCRC’s – 50% Not-for Profit Unique, flexible models offering innovative partnership approach

18. Therapy Challenges Assess knowledge of Home Health – Regulations/compliance – Clinical strategies – Billing/Part A vs. Part B; what’s best for the patient Assess staff’s ability to meet the needs of HH patients Pay structure for HH therapists

19. Therapy Changes Hired a full-time manager for HH Delineated dedicated therapy teams for different parts of the continuum – One team meets the needs of the CCRC resident – One team meets the needs of the home health patients

20. Therapy Education Educating therapists on moving the patient through the continuum; next level of care Not focused on LOS in one setting, but effective transitions across settings Optimized independence, autonomy and caregiver involvement

21. Therapy Focus Safe transitions – Discharge planning BEFORE admission – Home assessments on the front end of the stay to better structure plan of care and therapy interventions – Medication management – Health Literacy: Patient education on the disease process – Caregiver education and training – Systems for success; communication with interdisciplinary team, caregiver education, emphasis on next level of care

22. Prehab SNF Part AHome Health Part A Out Patient Part B You have to prepare the staff through education and training to provide services across the continuum; emphasis on next level of care. This means that clinicians need to know and understand the flow and dynamics of each setting in order to best navigate the patient through emphasizing efficacy, efficiency and function! Therapy Continuum

23. Prehab Research shows implementing a therapy program prior to surgery or invasive treatments often results in better outcomes. It gives the patient an understanding of what to expect; lessens anxiety Establishes relationship/rapport between patient and therapist(s).

24. The Impact of Home Health and Hospice Across our Continuum Amy Powell Director of Continuum Management and Special Assistant to the President, Westminster Canterbury on Chesapeake Bay Amy.Powell@wcbay.com

25. Nurse Practitioners Treating in clinic AL and IL Resident Services Those in Crisis Assisted Living Those in Crisis Previous IDT Team

26. Health Care Resident Life Resident Services HH/ Hospice Therapy Hospice Health Care- Therapy Chaplain Clinic Home Health Assisted Living Social Work New Continuum of Care/IDT Team Resident and Family

27. New Continuum of Care New Purpose: Optimize functioning in resident’s current environment utilizing all services available to them: Home Health, Therapy, Home Care, Hospice, Clinic New Policy Changes: required to give guidance to team members-responsibilities, expectations at each care level Additional Programs and Synergies: Hospice Bridge, Furnished AL Respite/Transition Rooms, Wellness Connection, Strength and Balance Classes/Fall-Proof

28. New Levels of Care: Home health and Hospice are treated in continuum meetings as their own levels of care Not just as a service, or an ancillary service, but a department of care. Home Health Hospice

29. ALF residents are able to benefit from therapies within their apartment and areas in which they're most comfortable, not a foreign area such as a rehabilitation gym; better success rates when a resident is in a familiar setting HH checks-in with residents upon a return from a hospital stay reassures the resident that we're here to help and assist in any way necessary, while the resident remains at home Home health enables us to have a higher acuity in Assisted Living Supplements Assisted Living staff Home Health in Assisted Living

30. Hospice in an ALF provides residents with the comfort and care that they need most at the end of life Working with a Hospice Team within the community, allows for smoother communication for the ALF, resident, family and Hospice Team; most comforting for the resident because the staff are already familiar with the resident and their needs Hospice in AL

31. Example of Continuum Discussion: 1.Review of assessments and current services being provided, 2.Current living discussions discuss reasons for resident being on agenda, 3.Review of needs not being met and how we can meet those needs within their living environment, and 4.If we cannot meet their needs at their current setting, we begin transition discussions. New Continuum

32. Create process of communication, how and when to communicate with residents and families Utilizing concept of consultation instead of decision Brochure/flyer to discuss types of care and services Educate staff in all departments on talking points with families and residents about the continuum Educate families and residents prior to crisis on the continuum Stick with the process for each discussion Always keep the discussions Resident Centered and be flexible to processes on communication Communication

33. Bottom Line: We need to manage across the continuum! By successfully managing the transitions between levels of care and services and providing seniors with outstanding post acute care, senior living organizations can take the lead in bundled payments and value based purchasing.

34. Questions for the Panel Nancy King, DM Vice President Operations Senior Options and Westminster Canterbury at Home Nancy.King@wcbay.com