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Session M13: the Senior Living Universe: Not-For-Profit & for Profit

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Session M13: the Senior Living Universe: Not-For-Profit & for Profit SESSION M13: THE SENIOR LIVING UNIVERSE: NOT-FOR-PROFIT & FOR PROFIT May 22, 2017 PRESENTED BY Tom Meyers Managing Director Ziegler B.C. Ziegler and Company | Member of SIPC & FINRA DISCLOSURE LANGUAGE 1. The information contained herein is intended to be general, factual, and educational in nature, and does not reflect any assumptions, opinions, or views of B.C. Ziegler and Company (“Ziegler”) with respect to the recipient municipal entity’s or obligated person’s particular situation. Further, a) Ziegler is not recommending an action to the municipal entity or obligated person; b) Ziegler is not acting as an advisor to the municipal entity or obligated person and does not owe a fiduciary duty pursuant to Section 15B of the Exchange Act to the municipal entity or obligated person with respect to the information and material contained in this communication; c) Ziegler is acting for its own interests; and d) The municipal entity or obligated person should discuss any information and material contained in this communication with any and all internal or external advisors and experts that the municipal entity or obligated person deems appropriate before acting on this information or material. 2. B.C. Ziegler and Company (“Ziegler”) seeks to serve as an underwriter on a future transaction and not as a financial advisor or municipal advisor. The information provided is for discussion purposes only in anticipation of being engaged to serve as underwriter. AGENDA TOPIC 1 • SELECT SENIOR LIVING TRENDS FOR 2017 TOPIC 2 • NOT-FOR-PROFIT SENIOR LIVING GROWTH TRENDS AND SCOPE TOPIC 3 • FOR-PROFIT COMPETITION, GROWTH TRENDS AND SCOPE TOPIC 4 • SENIOR LIVING CAPITAL MARKETS 3 TOPIC 1: SELECT SENIOR LIVING TRENDS FOR 2017 2016-2017 DRIVERS FOR NFP SENIOR LIVING Complexities of CONSOLIDATION Healthcare Leadership Turnover Competition Ability to Attract Talent/Wrkforce Mgmt. Technology Demands Reinvestment Requirements Hospital Consolidation Pressure Financial Pressure Diversify Service Lines Growth Capital Needs Source: Ziegler Investment Banking 5 DEMOGRAPHICS DEFINE THE MARKET LOOKING TO THE FUTURE 100,000 We Are 90,000 Here 80,000 70,000 60,000 50,000 40,000 (In Thousands) 30,000 20,000 10,000 0 2010 2015 2020 2025 2030 2035 2040 2045 2050 65 Years & Over 75 Years & Over 85 Years & Over 100 Years & Over Source: U.S. Census Bureau National Population Projections (released 2008, based on Census 2000) 6 COMPLEXITIES OF HEALTHCARE Sophistication • Do you have the scale needed to compete in the local healthcare marketplace? •What expertise do you have regarding the ACA and payment reform (bundles, etc.)? • Are you technologically advanced with data analytics, outcome-based reporting, etc.? Partnerships • Are you able to compete and be a player in the new models of care emerging as a result of the ACA? • Are you engaged in any joint ventures, post-acute networks or bundled-payment agreements? 7 ZIEGLER CFO HOTLINE: POST-ACUTE ACTIVITIES Is your organization experiencing any of the following regarding your healthcare setting? (% Yes Responses) Patients with a higher level of acuity 86.5% than in years' past Decreased length of stays in skilled 84.6% care Narrowing of networks from area 51.9% hospitals, physician groups Increase in consumers w/ treatment 44.2% plans that skip skilled care altogether 0% 20% 40% 60% 80% 100% Source: Ziegler CFO Hotline, August 2016 8 SN REVENUE & PATIENT MIX Source: National Investment Center for the Seniors Housing & Care Industry | Skilled Nursing Data Report; data through June 2016 9 INTERLUDE RESTORATIVE SUITES MINNESOTA • Three hospital/senior living partners • Interlude™ Restorative Suites is a new, holistic model of transitional care - upscale, soothing environment with superior, clinically-integrated care, in-patient rehabilitation, and guest-focused hospitality for the body and mind alike 10 THE CHANGING FACE OF FOR-PROFIT POST-ACUTE • SNF market is bifurcating into newer physical plants w/ ST Medicare rehab focus vs. older SNFs focusing on long- term Medicaid patients 11 PRESSURES IMPACTING SKILLED NURSING OCCUPANCY FIVE-YEAR LOW IN Q4 2016 81.8% Source: National Investment Center for the Seniors Housing & Care Industry | Skilled Nursing Data Report; data through December 31, 2016 12 STAFFING: A COMPLEX ISSUE Will need to • Many factors contributing to challenges: recruit 1.2 –An aging population; retirements million – Increase in minimum wages direct care staff by 2025 – Department of labor overtime ruling – Pressure on immigration rules – Growth among for-profits • Many providers are working together, partnering with schools and universities • Efforts to better understand work preferences, traits of the Millennials • Not just your workforce…workforce of your partners (e.g. impact on construction costs) Source: Ziegler Investment Banking; Argentum 13 WORKFORCE: A STRATEGIC IMPERATIVE Has your organization had to… Work w/ temp agencies to fill direct 53.0% care staff vacancies Limit admissions b/c of staffing 15.6% shortages 0% 10% 20% 30% 40% 50% 60% Limit admissions b/c of staffing shortages Work w/ temp agencies to fill direct care staff vacancies Source: Ziegler CFO Hotline, June 2016 14 DISRUPTORS & CATALYSTS DEMAND GREATER SCALE AND SOPHISTICATION • Largest multi-sites are adding corporate-level positions in response – Pushing some added costs down to affiliates • Corporate areas of specialty being added by the LeadingAge Ziegler 150 in 2015 (in order of mentions) 1. Chief Clinical/Health Officer 2. Chief Information/Technology Officer 3. Chief Talent/HR Officer 4. Business Development/Strategy Officer 5. Chief Compliance Officer 6. Philanthropy/Foundation Director Source: 2016 LeadingAge Ziegler 150 (Preliminary data) 15 UNIT GROWTH NOT JUST FROM BUILDING NEW UNITS, BUT ALSO FROM SYSTEM GROWTH • Currently the primary mode of growth for residential Affiliations settings among not-for- profit senior living providers – Systems coming together Acquisitions – Two smaller organizations joining to form larger Transitions Sponsorship Dispositions – Single-sites joining a system 16 NOT-FOR-PROFIT CHANGE OF OWNER/SPONSOR AFFILIATIONS, DISPOSITIONS, ACQUISITIONS, CLOSURES Total by # of Transactions & # of Communities 100 91 80 80 63 60 40 36 36 24 60 15 52 55 20 34 29 22 12 0 2010 2011 2012 2013 2014 2015 2016 Transactions Market-Rate Communities Note: Includes market-rate communities; excludes government subsidized Source: Ziegler Investment Banking 12/31/16 17 NOT-FOR-PROFIT CHANGE OF OWNER/SPONSOR AFFILIATIONS, DISPOSITIONS, ACQUISITIONS, CLOSURES NFP to NFP Sponsorship Transitions Only 40 35 36 30 25 20 18 15 12 11 10 7 19 5 4 14 5 11 77 5 4 0 2010 2011 2012 2013 2014 2015 2016 Transactions Market-Rate Communities Note: Includes market-rate communities; excludes government subsidized Source: Ziegler Investment Banking 12/31/16 18 SELECT NFP LPC SPONSORSHIP TRANSITIONS: 2016/17 Year Organization New Sponsor FP/NFP State 2017 Cadbury at Lewes Springpoint Senior Living NFP to NFP DE 2016 Franciscan Oaks Springpoint Senior Living FP to NFP NJ 2016 Rockhill Community & Lutheran Community at Telford NFP to NFP PA 2016 Bishop Spencer Place St. Luke’s Hospital NFP to NFP MO 2016 Westchester Meadows Bethel Methodist Home NFP to NFP NY 2016 LutheranCare Presbyterian Homes & Services NFP to NFP NY 2016 Episcopal Church Home Episcopal Retirement Services NFP to NFP KY 2016 Wesley Manor BHI Senior Living NFP to NFP IN 2016 Glacier Hills Trinity Senior Communities NFP to NFP MI 2016 Asbury Place Asbury Communities NFP to NFP TN 2016 Shenango Presbyterian Presbyterian SeniorCare NFP to NFP PA 2016 Birch Hill Terrace RiverWoods NFP to NFP NH 2016 Sacred Heart Village Nazareth Home NFP to NFP KY 2016 ABHOW & be.group Human Good NFP to NFP CA Source: Ziegler Investment Banking 19 TOPIC 2: NOT-FOR-PROFIT SENIOR LIVING GROWTH TRENDS AND SCOPE TODAY’S RETIREMENT OPTIONS A LOOK AT SENIORS HOUSING SUPPLY % NFP Life Plan Communities • 1,961 communities 600,000 units 80% Adult Day Programs • 4,800 programs 289,400 participants/day 51% Hospice • 4,000 agencies 1.34 mill discharged/yr. 26% Nursing Homes • 15,600 homes 1,663,000 units 24% Freestanding Memory • 1,100 communities 53,000 units 22% Care Assisted Living/ • 30,200 communities 1million residents 17% Residential Care Home Health • 12,400 agencies 4.9 mill discharged/yr. 15% IL Housing • 1,100 properties 184,000 units 3% Sources: Ziegler National CCRC Listing & Profile, LeadingAge, NIC MAP® Data and Analysis Service, The National Center for Health Statistics, Centers for Medicare and Medicaid Services 21 TYPICAL LIFE PLAN COMMUNITY PROFILE NFP: 80% FP: 20% # Affiliated w/a Single-sites: 38.1% Health System: LPCs 108 Multi-Sites: 61.9% Avg # of Units: 283 Source: Ziegler National CCRC Database 22 2016 LEADINGAGE ZIEGLER 150 • Represents the Largest 150 Not-for-Profit Sr Living Multi-site Providers • Range from 18,527 market-rate units (National Senior Campuses) to 588 units (St. John’s Lutheran Ministries) • Represents a total of 1,253 market-rate Accessible via Ziegler & LeadingAge websites communities Source: 2016 LeadingAge Ziegler 150 23 2016 LZ 150 ANALYSIS OF THE DATA: SYSTEM HEADQUARTERS HEADQUARTERS’ LOCATIONS BY SIZE (TOTAL UNITS) TopTopTop 502510015010 3,250+ Units (Top 10) 1,350+ Units (Top 50) 780+ Units (Top 100) 1,970+ Units (Top 25) 588+ Units (Top 150) Source: 2016 LeadingAge Ziegler 150 Publication (data as of 12/31/15) 24 2016 LEADINGAGE ZIEGLER 150 THE NATION'S LARGEST NOT-FOR-PROFIT MULTI-SITE SENIOR LIVING ORGANIZATIONS RANKED BY TOTAL SENIOR LIVING UNITS Units Communities (as of 12/31/15) (as of 12/31/15) 2016 Rank 2015 Rank System Name State Total ILU ALU NCB Total LPC IL AL NH 1 1 National Senior Campuses MD 18,527 15,873 1,370 1,284 15 15 0 0 0 2 2 The Evangelical Lutheran Good Samaritan Society SD 17,822 5,013 2,286 10,523 168 69 8 8 83 3 3 ACTS Retirement Services, Inc.
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