1. Ohio Presbyterian Retirement Services Presented by: Richard M. Boyson, Senior Independence President EXPERIENCE ● STRENGTH ● MISSION

2. Manages & Operates 12 Retirement Communities Serving 6,000+ Residents Apartments & Villas Assisted Living Memory Care Skilled Nursing Rehabilitation Raises & Manages Funds to Provide Charitable Support for the People, Projects, and Programs of OPRS Over $200 million raised since 1986! Provides Home and Community Based Services to 67,000+ Older Adults in 41 Ohio Counties and To 6 iPartners in 6 States Home Health Care Hospice Adult Day Care Centers Senior Centers My Independence / iVillages Overview EXPERIENCE ● STRENGTH ● MISSION

3. Locations

4. Service Areas MICHIGAN JOINT VENTURE

5. iPartner Service Areas EXPERIENCE ● STRENGTH ● MISSION

6. Our Service Offerings & Volumes Certified Home Health – Daily census of about 1,350 clients Certified Hospice – Daily census of about 285 Private Duty – about 15,000 – 16,000 hours of service a month Adult Day Centers – operate 7 throughout the state of Ohio We employee about 560 team members

7. EXPERIENCE ● STRENGTH ● MISSION Partnerships and Collaborative Relationships

8. Home and Community Based Services changes quickly like the hare, but at times, it feels like we are moving in slow motion – like the tortoise!

9. Anybody remember this one? “With Managed Care coming down the pike, it will change healthcare!” I remember hearing this in 1996, thinking, oh boy here it comes – CHANGE! Not much seemed to change, at least in the Ohio markets for years after that. But now…

10. Looking at it now… Pioneer ACO’s CMS MSSP Hospital systems getting in and out of HCBS Medicare regulatory and pricing changes Readmission penalties Value based payments BPCI

11. Some National Industry Trends Leading Age / Ziegler * – 61% of LZ top 100 offer HCBS – Not just the large systems, although weighted to the larger systems. (70% of top 10, but 74% of the top 50) – From 2012 – 2013 34% Expanded HCBS 37% Reduced 29% Stayed the same * Data from Ziegler Leading Age National Senior Living CFO Workshop

12. Why invest in these services? Short Term Goals: – Offer additional services on your campus – Control the quality of services – Bring another revenue stream into your organization

13. Why invest in these services? Long Term Goals: – Strengthening of your organization – marketing and clinical – Attract better talent, more opportunity – Perhaps as an entrance point to bundled payment, staying in front of healthcare reform

14. Options for Starting Develop – Timely, somewhat expensive – Need to hire on talent to operate Buy – Talent may come with the deal – Some census levels Joint Venture – Develop with another partner that has the expertise

15. Operational Considerations – Home Health Market to pursue – campus and/or beyond? Operational expertise Volume goals – Critical Mass Reimbursement – declining Regs very different than SNF world Mobile workforce Back office – billing, scheduling Software Strong Marketing

16. Home Health Success Factors Minimum number of episodes per month Strong Administrator Quality Nursing and Nurse Aide providers Therapy staff Coding and Billing expertise SNF referral sources may have these services – need to balance

17. Operational Considerations - Hospice Market Share – on campus only? Capitated payment system – some risk with a small population Census of 13-15 is probably a breakeven point Many disciplines needed, despite size of the agency – Nursing – Social Worker – Volunteer Coordinator – Spiritual Care – Aides – Therapists – Medical Director

18. HCBS within a larger organization Can really compliment your bricks and mortar portion of the business Our Private duty services, much on our own campuses, help to maintain census Diversification of revenue streams (hospice, home health) and product offerings Our communities provide about 20% of our business annually.

19. Expectations / Risk of HCBS Very sales driven business. If you grow outside of your campuses, be prepared to invest in a solid sales force Mobile work force – need to leverage technology to stay in touch with staff Billing and medical records data collection is complex No real control over revenue rate increases

20. Economics… Hospice can be the most profitable, assuming there is sufficient volume – CMS is looking at payment reform… Home Health can be profitable – Similar to the SNF, Medicare is the best payer, many commercial insurances pay a fraction of Medicare Private Duty and Adult Day – Low margins, but can feed referrals to your community or to other home and community based services.

21. Home Health Where to market to find the bigger referral sources?

22. ACO agreement with Northwest Ohio ACO (Toledo market) Began August 2013 11,400 covered beneficiaries 300+ physicians in a Shared Savings ACO Senior Independence is the Primary Care Coordination Partner At Risk Model, Value Proposition to the ACO Using our Core Competencies – Large Market Share – Technology – Good Clinical Pathways – Strong Clinical Quality Outcomes – Development of a Free Care Model: Home to Stay Partnering with Senior Independence EXPERIENCE ● STRENGTH ● MISSION

23. Service Areas MICHIGAN JOINT VENTURE

24. Began August 29, 2013 Started with 1 Toledo-area hospital, now visit 8 ACO Beneficiary Admissions 3,930 from 08/29/2013 to 11/30/2014 Senior Independence Visits 2,672 ACO Beneficiaries Home to Stay (HTS) Program 1,099 beneficiaries agreed to participate while still in the hospital. Following discharge, 524 of those beneficiaries continued with the program. Of those 524 episodes that were opened under HTS, only 18 were re- admitted to the hospital. This reflects a readmission rate of 3.4%! The regional readmission rate for the Toledo area is 14.5%. These visits also resulted in 75 conversions to home health and 2 conversions to hospice. Outcomes EXPERIENCE ● STRENGTH ● MISSION

25. 3.4% Return to Hospital Rate Home to Stay Opens vs. Return to Hospital Outcomes EXPERIENCE ● STRENGTH ● MISSION

26. Allowed us to begin to study and trial some different care delivery models and population management protocols. Our Foundation raised over $60,000 to fund our Home to Stay model from one healthcare provider and Verizon Healthcare March 2014 – Partnered with a large Acute based system in the Toledo market and began to managed their home care services May 2014 - Became a part of the acute system’s Accountable Care Organization in the Toledo market September 2014 – Formed a Joint Venture with Evangelical Homes of Michigan for a 3 county footprint in the southern most counties of Michigan, where many referrals were traveling once leaving the Toledo hospitals. April 2015 – Bundled Payment for Care Improvement 2015 – 2016 – Continue to look for statewide partners As a direct result…. EXPERIENCE ● STRENGTH ● MISSION

27. Closing thoughts… Need to be committed to it before starting, typically losses in the first year Need to determine strategically why HCBS make sense Roll with the changes in Healthcare, be prepared to change your care delivery model Determine marketshare will support this endeavor

28. Questions? Richard M Boyson Jr President, Senior Independence