Understanding the "Mechanics" of our Kirkhaven Operation.

Last week we took an in depth look at the mechanics of our Valley Manor operation, so this week let's do the same with Kirkhaven.

We currently have 144 skilled nursing beds in operation at Kirkhaven that include a special care unit for residents with Alzheimer's or other related dementia and a short-term rehabilitation and transitional care unit.

The annual expense budget is 11.5 million dollars broken down as follows:

• Nursing services- 4.3 million
• Other professional services- 1.3 million (therapies, medical, pharmacy, etc)
• General services-2.2 million (dietary, environmental services, utilities, etc)
• Administrative services-1.0 million (administration, fiscal, HR, PR, etc)
• Employee Benefits- 1.7 million
• Property costs- 1.0 million

The revenue we earn to pay for these costs come from many sources as listed below:

• Private pay resident fees
• NYS Medicaid Assistance program
• Medicare & HMO insurance programs
• Donations
• Investment Income

Let's take a look at each to better understand our revenue sources.

Private pay residents are those who don't qualify for other insurance coverage and thus pay for their own care at our regular established per-diem rate. Our current rate is $320/day plus $15/day for a private room. This rate is revised annually in conjunction with our annual cost increases. We also monitor our rates against the market to ensure that they are reasonable and competitive. Approximately 20% of our residents are private pay.

Medicaid residents are those who meet specific resource and income limitations established by the state and thus can't afford to pay privately for their nursing home care needs. Upon application and approval for Medicaid Assistance, the resident's care is paid by the state at a facility specific Medicaid rate. Our current Medicaid rate averages about $164/day. Approximately 68% of our residents are on Medicaid Assistance.

Medicare/HMO residents are those who meet specific clinical guidelines with respect to their care and thus qualify for some limited coverage under Medicare or private HMO insurance policies. Coverage under these insurance programs is limited to high acuity skilled care needs only and often for a maximum of 100 days only within any one spell-of-illness. Short-term rehab and transitional care are generally what is covered by Medicare and HMO insurance. Medicare pays different rates for different residents depending on what rate category their acuity needs and care fall into. On average, our Medicare/HMO rates are about $420/day. Approximately 12% of our residents are on Medicare or HMO insurance.

So you can see that occupancy and payer class are key components to our nursing home revenue. We average about 95% occupancy and thus our average cost per day computes to about $225/day. With a Medicaid rate that averages $61/day below our costs, a private pay rate that averages $100 over cost and a Medicare/HMO rate that averages $195 over cost, payer class mix is a critical challenge that must be managed well.

Donations and investment income help to subsidize our program costs over time, but due to the volatility of the cash flow of this non-operating revenue, can't be counted on for on-going regular operating costs. Often, this income provides for capital improvements or venture capital for special programs.

As a not-for-profit organization, our goal is to create a modest operating margin of 1-2% to meet our cash flow needs. 100% of all revenue goes toward the cost of our services. We continually monitor customer satisfaction and we are subject to on-going regulatory compliance surveys by both the Medicare and Medicaid programs.

Our challenges are many, but primarily include the following:

• Occupancy and payer mix utilization
• Maximization of third-party insurance rates
• Decreasing Medicare and Medicaid program reimbursements
• Increasing care acuity of our residents
• Decreasing private pay resident market
• Aging and antiquated building
• Culture Change movement from the medical model of long term care
• Shortage of nurses and therapists

Despite these challenges, our work is a labor of love and we have very caring and dedicated staff that really make the difference. The mission of what we do is uncompromising, despite the many challenges.

And now you know a little more about the mechanics of our nursing home operation and how we make it work. Thanks for visiting my Blog this week!

Understanding the "mechanics" of our Valley Manor Operation

I thought I would dedicate the next couple of Blogs to communicating more about how our communites operate from a business strategy perspective. As you read on, I hope to answer the following questions:

1. What type of expenses do we incur?


2. How are our rates set?


3. What are the opportunities and risks?


4. How do we monitor results?


5. What do we do next?

Let's look at our Valley Manor community first.


Valley Manor Apartments is a retirement community for active seniors. It is an independent living facility by New York State definition, which means we can not and do not provide any resident care and thus are not regulated by the State. Independent living facilities provide residents a life-style which includes living accomodations, meal options,housekeeping, security, scheduled transportation and recreation programs. Residents who require personal care services, to help maintain their independence, are permitted to contract with an outside home care agency to provide this service in their apartment home. The home care agency is regulated by the State and is solely responsible for the care plan they establish with the resident.


Valley Manor incurs several costs associated with providing residents a unique style of living within the classification of independent living. The majority of these costs are fixed or fixed/variable, meaning we incur them regardless of any moderate variance in occupancy. These costs include the following:

• Staff Wages and Benefits


• Food


• Supplies


• Repairs & Maintenance


• Utilities & Services


• Mortgage


• Real Estate Taxes


• Insurance


• Marketing & Advertising


• Administration & General Support

To ensure that we have adequate resources to pay for these annual expenses, we establish prices for our apartments and services based on our costs. Since we are a not-for-profit organization, we do not need to produce profit distributions for owners or stock-holders. Our objective is to create only a modest surplus that allows for us to pay our costs, meet our cash flow needs and establish a reasonable reserve for capital reinvestment in the building.



We establish our prices using both a cost-based and market-based methodology. First, we compile our actual costs into the following categories:

• Property (Mortgage,Taxes,Insurance,Capital Improvement Reserves)


• Food Service (Kitchen, Dining Room, Deli, Food)


• Environmental (Maintenance,Utilities,Housekeeping,Laundry,Security)


• Resident Services (Activities,Health & Fitness,Transportation)


• A & G (Administration,Marketing,Sales,Corporate Support)

Then, we allocate the total costs in the Property category to each of our various apartment styles based on square footage. Valley Manor currently has 11 different apartment styles ranging from 1 to 2 bedrooms and square footage from 450 sqft to 1,430 sqft. The larger the apartment, the larger the pro-rata property related costs allocated to it.


At Valley Manor we currently have 137 apartments (11 different styles) that collectively represent 103,330 rentable square feet. Our annual property costs are approximatly 1 million dollars, which thus computes to a cost per rentable square foot of $10.


We recover our property related costs by collecting an upfront Entrance Fee from residents upon initial move in. The Entrance Fee for each apartment style is calculated on the $10/sqft annual cost multiplied by the average length of stay of 7 years and grossed up to account for less than 100% occupancy. An apartment preparation fee is added to the Entrance Fee to recover the average cost associated with preparing an apartment for reoccupancy (painting, carpeting, upgrading, etc.). Entrance Fees range from $45,000 to $133,000.


We recover our other costs by charging residents a monthly maintenance fee. To calculate the appropriate monthly fee for each apartment style, we first deduct from our costs any incremental income received from other services (garage & parking fees, guest room fees, building usage fees, health & fitness fees, laundry fees, outside food functions, guest meals, cafeteria & deli income, transportation fees, etc.).


Then, we allocate the net cost to each apartment style by category. The net Environmental cost is allocated based on square feet, thus the larger the apartment the larger the pro-rata share of environmental costs. Our net annual Environmental costs are approximately 1.3 million dollars or $12.50 sqft. The net Resident Services and A & G costs are allocated evenly to all apartments based on the number of total apartments, as these costs are not driven by square feet. Our net annual cost for both is approximatley 1 million dollars or $7300/apartment.


The monthly maintenance fee (excluding meal plan) is calculated on the sum of the allocated annual costs for each apartment style grossed up to account for less than 100% occupancy and divided by 12 months. An incremental fee is added to the monthly maintenance fee if more than one person resides in the apartment. Monthly Maintenance Fees (excluding meal plan) can run from $1200 to $2150.


The last component of the maintenance fee is the meal plan (if chosen). Our net annual food service costs are calculated to a cost per meal and then meal plan option prices are established depending on the number of meals each resident selects with their meal plan (1 meal/day, 2 meals/day, 3 meals/day, 20 meals/month, 15 meals/month).


Cost-based rates are designed to generate necessary income to recover your costs, but if our costs are not competitive, neither will our cost-based rates. We therefore also conduct a competitive market rate analysis to ensure that our rates are in line with comparable products and competition in our market. We have also recently implemented a "premium pricing" policy, which adjusts apartment pricing to take into account demand for certain apartment locations.


There are boths risks and opportunities associated with this rate methodology.


First, there is the occupancy factor we use in setting our rates. We are currently using 88% in our rate formula. If we experience less occupancy we run the risk of falling short of recovering our costs. Alternatively, if we experience an increase in occupancy we have the opportunity to create additional capital to invest in the facility or to reduce future rates.


Second, there is the cost factor we use in our rates. To the extent that our costs run over or under projections, we experience risk or opportunity to our bottom-line.


Third, there is the length of stay factor used in the Entrance Fee calculation. We base our 7 year factor on a rolling 3-year actual history. While stability in occupancy has an obvious upside, we need a certain turnover rate to re-generate new Entrance Fees of 1 to 1.2 million per year. We offer residents a maintenance-only option on our smaller apartments (no Entrance Fee), but gross up the monthly fee to capture what we would have collected on an Entrance Fee amortized over 7 years on a present value basis. We also offer a much higher 90% refundable Entrance Fee option which is calculated on a 7 year present value basis. Each plan returns the same income over a 7 year period, but there is risk and opportunity associated with the actual length in stay and the interest rate assumptions.


Fourth, there is the utilization factor assumed in the calculation of the meal plan prices, revenue and other ancillary service income projections.


At Valley Manor we also provide Assisted Living and a Social Model Adult Day Program. We compile the direct incremental costs associated with each of these programs and compute the rates for these services such that the Program revenue adequately recovers the Program cost.


We monitor our results using monthly budget variance reports, occupancy statistical reports and financial statements. We also benchmark our results against industry trends where feasible. We conduct resident satisfaction surveys annually to measure customer satisfaction and to learn where risks and opportunities exist from a service perspective.


Based on these monitoring results, we initiate goals and strategies to improve our performance as necessary. We develop a new operating budget annually, that includes expense and revenue projections related to our service goals and strategies. We adjust our rates accordingly, based on both cost and market trends. Our Board of Directors oversees these processes by reviewing, approving or modifying our goals and strategies.

I hope this tutorial Blog helped to shed some light on the "inside mechanics" of the Valley Manor financial operation. Be sure to visit my Blog next week, when I'll talk about the nursing home side of our business. See you then...............

3 Shots for a Quarter!

As I look back at the end of the first quarter of 2009, there are 3 primary initiatives that pretty much define the first 3 months of our 2009 operation at Seniorsfirst. Lets take a look at each and see how we fared.

First shot........ our state leaders finalized and approved a state budget that goes into effect April 1, 2009-March 31, 2010. As anticipated, it wasn't very kind to nursing homes as the Medicaid portion of the expense budget was slashed considerably to help offset a growing state deficit. The final budget did fulfill a previous promise to update the antiquated Medicaid rate-setting formula for nursing homes, and in doing so resulted in a significant increase in Kirkhaven's (and most other homes) Medicaid revenue.

However, at the same time they were putting money into our "right pocket", they were taking even more money out of our "left pocket". In short, they tweaked other elements of the Medicaid rate-setting formula that conveniently resulted in exactly the desired net savings the State established as their target objective for state-wide Medicaid cost reductions.

For Kirkhaven, we project that the net impact of the state budget will result in an estimated loss revenue of $134,000 from what we had originally budgeted for in 2009. To put that in perspective, Kirkhaven's total annual revenue is about 10 million dollars and we historically aim for an average margin of 1-2% ($100-200,00 net surplus a year). The state's action in affect, eliminated what little margin we attempt to operate on.

On a more positive note, Kirkhaven appears to have fared better than most. We were conservative in our Medicaid rate projections for 2009 and we also were positioned better than most to mitigate the negative implications of many of the Medicaid rate-setting revisions. Still, the reduction in Medicaid revenue represents a deficit for Kirkhaven that needs to be addressed.

Second shot........Kirkhaven has been actively pursuing a third-party reimbursement maximization initiative for over a year now. Our objective is to improve on our ability to legitimately maximize Medicare and Medicaid revenue through enhanced understanding and strategies within the reimbursement regulations. In short, the regulations are specific but there is a vast "area of opportunity" that can be taken advantage of if understood and used both wisely and appropriately.

For example, Medicare pays nursing homes different rates for different residents depending on the specific care acuity of and services provided for the resident. How this care acuity and service provided are documented and reported can result in significant differences in the Medicare rate you receive. This is no easy task though. It takes a lot of effort and coordination between the nursing and clinical staff who are the primary care givers of the services and requires extensive planning and documentation. Medicaid rates also have a component of the rate that is based on resident acuity and thus these maximization initiatives have a similar revenue enhancement potential with our Medicaid covered residents.

For the first quarter of 2009, our Medicare Maximization program has resulted in both an increase in Medicare covered days and an increase in our average Medicare rate. Additionally, our occupancy has soared to 98% of late. Further, our Medicaid resident acuity has increased significantly and appears to position us well for maximizing our share of the limited remaining "Medicaid pie". We project that the estimated positive impact of these results is approaching $100,000 on an annualized basis and we're not done yet.

In short, because of the efforts of our staff with the third-party reimbursement maximization program results, Kirkhaven is not in immediate jeopardy of requiring any layoffs or budget cuts as a result of the 2009 state budget and Medicaid program revisions. I don't believe this will be the case with all nursing homes across the State, so kudos to Kirkhaven for a job well done!

Third shot........at Valley Manor we have been pursuing an Occupancy Enhancement program aimed at increasing our occupancy to at least 90% (our 2009 budget is set to work at 88%). The Winter season is not historically a very active time for seniors to be moving into retirement communities and the recent challenging economy has slowed this process down even further. All the more reason for us to invest even more resources towards this initiative, which is the "life blood" of our Valley Manor operation.

The first quarter 2009 results are very promising. We had a net gain of 5 new apartment leases, moving our current occupancy to 86.8%. Additionally, we have 6 more committed apartment sales that are scheduled to move in by May and only 2 projected known move-outs, which will result in a 89.9% occupancy in the near future. We're only getting started, and with the onset of Spring and the continuation of our Occupancy Enhancement program, there is still a lot more upside to pursue. Great job Valley Manor!

A Parting shot........one quarter does not a success make. This is a volatile industry and we can't rest on our laurels or ever think that we have arrived at our destination. This is a continuing journey we're on and the risk of failure and the next big challenge is always just around the corner. The economy is healing, but still hurting. The 2010 State budget is already threatening to be devastating. Cash flow and expense budget controls will continue to be difficult.

But lets just take a moment to take a big collective sigh, catch our breath and maybe even celebrate all we have already accomplished amidst the vast challenges of our work.

Congratulations Seniorsfirst on an awesome first quarter and keep up the great work! Our efforts will eventually show up on the financial statements in the long run, but in the short run give yourself and the person working next to you a congratulatory pat on the back.

Thanks for all you do and for visiting my Blog. See you next week.........................

Business and Politics?

With so much attention lately centered around the business of politics and what is happening on both the local scene with the Governor and the State budget process and the national scene with new President Obama and his challenges, I got to thinking................

How would things be different at Seniorsfirst if I was elected to the office of President/CEO by all the people of Rochester? The staff, the residents, families of residents, vendors, consultants, future prospective customers, competitors, peers, friends, enemies, etc. What if every 4 years an election was held and all these people decided by their vote if I was the best person for the job?

Would it change the way I perform my job? Would I alter my objectives, my priorities, my style of leadership.? I would think I would have to, or accept the fact that I wouldn't have my job very long. But would the change be beneficial for the overall organization over the long term? Or would it be aimed at meeting the needs of the most vocal, most powerful, most influential?

I like to think that my role as CEO is to balance the conflicting needs of different parties and to serve in a leadership capacity that attempts to unite the organization in a common vision and mission, despite the often conflicting and competing goods. While I always utilize the collective wisdom and perspective of those around me and my ultimate authority is controlled and accountable by a Board of Governors, I make the final decisions that set the course for Seniorsfirst.

How convenient (not to mention effective and efficient) it is that I also am able to choose my support team and create a cohesive group with a common vision and set of goals. From the board on down, everyone pulls in the same direction, and as a result, things get done!

I can't imagine how our political system can ever be efficient or effective the way it is structured. First, the CEO must run for office. Excessive amount of time and money must be spent to "spin" idealistic messages to influence support and gain votes. People who might not really understand your skills or capabilities will determine your fate based on how they think you will measure up to their individual needs and desires.

If you are elected by the masses, you then have to run your office working through groups of other elected people formed to create various eclectic teams, all of whom have different visions and objectives they desire to accomplish. We call these groups the Senate, House of Representatives and the Assembly.

Additionally, everybody has only 1 term (or 4 years) to make a positive difference and thus hopefully get re-elected. Therefore, decisions are made for short-term advantages and immediate gratification rather than the long-term benefit. If by chance you are actually able to succeed in this crazy system, you are eventually thrown out anyway by term limits.

This system has rarely worked and the proof here in New York has either been a history of late budgets or hastily created on-time budgets that are developed behind closed doors by a chosen few and then passed off on by others in the interest of political party support or sheer peer pressure. Every budget passed has been short-sighted and lacks any sense of sustainable long-term vision or goals.

So, with my apologies to our forefathers who may have developed a good system for their times, here is how I would propose we change it for the better today.

First, the people would only elect representatives to serve on a Board of Governors. These Representatives would have to adhere to strict campaign limitations and the majority of the campaign materials and process would be conducted by a Board of Elections that would provide necessary information on candidates to enable people to make informed decisions. The Board of Governors would serve in a capacity much like boards of not-for-profit organizations. They would only help establish broad-based policy, vision and goals but would not play a role in making or approving operational decisions, laws or how policies are carried out. The Board would be charged with hiring the CEO (Governor of the State or President of the Country).

In hiring this CEO, the Board and the CEO would be aligned and work collaboratively. Board Representatives would serve on various cabinet committees and work with the CEO's chosen team of staff to help support and oversee the work of the administration. Monthly Board meeting would be held to ensure that the work and performance led by the CEO was in sync with the vision, mission and goals established by the Board. The Board of Governors would serve staggered terms and would have term limits subject to re-election by the voters. The CEO would serve without limits subject to the will of the majority of the Board.

Maybe I'm just being a skeptic, but the current system doesn't appear to work very well and needs to be changed. And I don't mean we need someone new in charge. It's like trying to cut down a redwood tree with a toothbrush. It doesn't really matter who you have holding on to the handle or what strategies they employ, until you get a new tool you're not going to fall that tree.

Anyway, that's my opinion from a CEO perspective. Probably never will happen, but it makes for fun blogging. In the meantime, I'm just happy that I get to work in an environment where we all sing from the same hymnal, pull in the same direction and aim at the same targets, despite our unique perspectives, ideas and styles.

Thanks for visiting my Blog. Check back next week when we may have a final State budget passed and I will share my insights.