HCR ManorCare Quality Report 2012

Quality RepoRt 2012

Nearly 90 percent of our rehabilitation patients are discharged home, with the majority of the others deciding that they need the 24/7 care of long-term skilled nursing services.

We Are HCR ManorCare 4

Getting Patients Back to Their Lives 5

Our Outcomes Hasten Patients’ Return Home 8

Reducing Hospital Readmissions 10

Hospice and Home Care 18

Dementia Services 23

Quality Care from a Quality Workforce 26

Page

What’s Inside

2

After my total knee replacement, I was anxious about my recovery and had a lot of questions about the process. Thankfully, the team at Heartland of Oregon was able to reassure me and provide the information, care and therapy I needed to quickly get back home where I wanted to be. As a former nurse’s aide, I know how challenging working in a skilled center can be, and the Heartland of Oregon team was very impressive. My call lights were answered timely, and the therapy team was supportive and pushed me to reach my goals. I would certainly recommend Heartland of Oregon to anyone after a hospital stay or surgery, and I would come back if I needed to.

Lynne

2

3

1

10 4

4

242

3

9

2

2

6

1

1

2

79

617

4

18

6

2

232

5

1

6

7

12

3

4

316

7

8

2

2

2

2

1

1

1

3

3

78

3652

4

55

39

16

9323

HOMe HeALTH CARe AnD HOSPICe AGenCIeS

SkILLeD nuRSInG AnD ASSISTeD LIvInG CenTeRS

4

We Are HCR ManorCare• Quality caring provided by nearly 60,000 employees through more than

500 locations in 32 states

• The largest provider of post-acute skilled nursing and rehabilitation through more than 280 centers, most of which provide care under the respected names of Heartland and ManorCare Health Services

• With rehabilitation outcomes for Medicare patients comparable to and often exceeding those of independent rehabilitation facilities

• The third largest u.S. provider of hospice care in over 100 markets under the Heartland name

• A leading u.S. provider of home care under the Heartland name

• A leading provider of Alzheimer’s/dementia care through 54 Arden Courts memory care communities and in many of our skilled nursing centers

• Rehabilitation also provided through nearly 60 outpatient therapy clinics, primarily under the Heartland name

5

Getting Patients Back to Their LivesA vISIT MORe THAn A STAyHome is still where the heart is and helps explain why for most of our patients, time at one of our skilled nursing and rehabilitation centers is considered a visit, not a stay. Nearly 90 percent have come directly from the hospital, and all have come because they are not quite ready to get on with their lives. They have experienced a disabling illness, surgery or injury, and the hospital has treated and stabilized the condition, and now they are visiting us to receive the rehabilitation and other services they need to complete their recovery and return home.

These patients are predominantly ones that a few years ago would have completed their care in the acute care hospital because their condition remained clinically complex and functionally limiting. But with changes in reimbursement, time in the hospital has decreased dramatically. This has increased the need for lower-cost alternatives that can meet the care needs of patients with “hospital-level” acuity and offer them a combination of clinical excellence and rehabilitation sophistication that can help them reach their goal of getting home.

HCR ManorCare has embraced this new role through considerable investment in an increased number and higher skill level of professional staff, enhanced rehabilitation space and equipment, and adjustments to a younger patient population that has different needs than a nursing center’s traditional long-term residents. We have employed new technologies and modalities to improve the probability of a successful outcome and increase the percentage of patients returning home with an equal or higher level of functioning. today, that means 89 percent of our rehab patients are discharged home, with the majority of the others deciding that they no longer could function well on their own and need the 24/7 services offered through long-term care. The average length of stay for our post-acute patients is 34 days, and over 65 percent are discharged in less than 40 days.

the average length of stay for our post-acute patients is 34 days, and over 65 percent are discharged in less than 40 days.

6

Average Daily Percent of Patients Receiving Chemotherapy

0.4

0.30.4

0.4

0

0.20.3

0.1

0.40.50.60.7

1.0Pe

rcen

t

0.80.9

2007 2008 2009 2010 2011

0.4

0.5

0.5

0.5

0.4

0.4

HCRMC Nation

on any given day in 2011, the average percent of HCR ManorCare rehabilitation patients was about 50 percent higher than the percent average of skilled nursing centers nationwide.

Average Daily Percent of Rehabilitation Patients

39.4

22.3

0

10

20

30

50

Perc

ent

40 37.7

2007 2008 2009 2010 2011

21

39.4

40.8

38.5

23.8

24.7

25.3

HCRMC Nation

patients at our skilled nursing and rehabilitation centers generally require a higher level of clinical care. the average percentage of our patients receiving I.V. therapy, dialysis and chemotherapy, for example, was significantly higher in 2011 than the national average.

Average Daily Percent of Patients Receiving I.v. Therapy

1.8

3.9

1.9

0

1

2

3

5

Perc

ent

4 3.5

2007 2008 2009 2010 2011

1.8

4.6

4.5

4.3

2.0 2.1

HCRMC Nation

Average Daily Percent of Patients Receiving Dialysis

2.5

1.9

2.5

1.7

0

1

2

3

5

Perc

ent

4

2007 2008 2009 2010 2011

1.6

2.7 3.

0 3.1

1.7 1.8

HCRMC Nation

Recovering from my knee surgery at Heartland of Marion has been a wonderful experience. My therapists and nurses have motivated me daily so that I can recover as quickly as possible. I can’t wait to be home so that I can walk my puppy again! I highly recommend Heartland of Marion to anyone having joint replacement surgery because of their excellent rehabilitation and nursing care.

Janet

7

OuR PROfeSSIOnAL STAffThe heart and soul of our skilled nursing and rehabilitation centers is our interdisciplinary team of professionals who interact with our patients the most on a day-to-day basis. The team of nurses, therapists, therapy assistants, dietitians, social workers and recreation staff collaborate with the patient to design a patient-centered plan of care to achieve the highest practicable level of functioning. The high-quality care and services given to an increasingly clinically complex patient population necessitate employing a greater number of specialized professionals to efficiently guide progress, manage discharge planning and reduce the probability of the patient going back to acute care after discharge home.

Each of our skilled nursing and rehabilitation centers is staffed by an administrative medical director who typically is affiliated with a local acute care hospital. The medical director’s primary responsibilities include oversight of all attending and consulting physicians, implementation and management of clinical protocols, and collaboration with center staff on program development. in our highest acuity centers, staffing may also include a post-acute care hospitalist, nurse practitioner and a consulting physiatrist or other specialty physician.

Employing center-based nurse practitioners in each of our highest acuity centers has been a particularly key enhancement. Nurse practitioners have advanced our centers’ medical knowledge and clinical skills. They assist with providing a comprehensive initial medical assessment for all new admissions within the first 48 hours, which has been critical in decreasing rehospitalizations that often occur in the first three to seven days of a patient’s admission.

excellent presentations and information. This was very clear and concise, and even though it was directed to HCR ManorCare, I thought it much more useful than the six-day, 80-hour, core curriculum [provided by a national organization] or Medical Direction.

A physician attending HCR ManorCare’s Medical Director trainingI was a three-time patient

in need of care at Heartland of Zephyrhills in the years 2010 and 2011. I can say this was the best place I could have chosen for the care and rehab I needed to get me back to my old self after a fall resulting in open-heart surgery. I found the staff to be caring and concerned about my every need. The occupational and physical therapists were genuinely concerned with my progress and encouraged me to do my best. I was impressed that everyone knew my name and remembered my name as I returned for the second and third visits.

Glenn

8

Our Outcomes Hasten Patients’ Return HomeHCR ManorCare’s mission continues to expand to meet the needs of patients who are discharged from hospitals and need rehabilitation to go home and resume their lives. We are raising the bar for aggressive, short-term, expert and outcomes-focused rehabilitation – with an impressive track record of success in achieving necessary results for our patients and their families. We believe to assure effective medical care and rehabilitation – and continuously improve – providers must measure and compare outcomes to benchmarks and targets. Further, we believe it is vital for patients and their families, as well as those who refer patients, to examine evidence of a post-acute care provider’s success before deciding whom to trust.

We measure the outcomes patients need, not only to provide objective evidence of our success, but also to drive our ongoing commitment to improve clinical effectiveness.

HCR ManorCare’s companywide average shows progress in rehabilitation Self-Care skills that is significantly greater than results from U.S. inpatient rehabilitation facilities (IRFs).

1.87

1.64

1.56

1.31

1.59

1.39

1.67

1.51

0

0.5

1.0

1.5

2.5

Inde

xed

Scor

e

2.0

Orthopedic Cardiac Pulmonary Stroke

HCRMC IRF

Improvement in Self-Care from Admission to Discharge for Medicare Patients (2011)

From admission to discharge, HCR ManorCare’s companywide average shows our rehabilitation patients make a dramatic improvement in their ability to walk.

3125

5

5730

2

5226

4

4827

4

0

50

100

150

350

Feet

250

300

200

HipFracture

HipReplacement

KneeReplacement

MultipleFractures

Admission Discharge

Average Walking Distance Improvement of Medicare Orthopedic Patients (2011)

9

HCR ManorCare’s companywide average shows progress in rehabilitation Mobility skills that is significantly greater than results from U.S. inpatient rehabilitation facilities (IRFs).

Improvement in Mobility from Admission to Discharge for Medicare Patients (2011)

2.27

2.09

1.85

1.65 1.

771.

58

1.93

1.87

0

0.5

1.0

1.5

2.5

Inde

xed

Scor

e

2.0

Orthopedic Cardiac Pulmonary Stroke

HCRMC IRF

Nearly 90 percent of our rehabilitation patients discharged to the community report they are prepared to manage their care at home – compared to less than 3 percent who are prepared when they’re first admitted from the hospital.

0

20

40

60

10090

70

50

30

10

Perc

ent

80

2.9

Upon Admission

Upon Discharge

87.4

Percentage of Patients Able to Manage Their Care needs (2011)

I came to ManorCare Health Services–northbrook from evanston Hospital after I broke three vertebrae. ManorCare was the only facility that would admit me over the weekend with my insurance. Since I have been here, I feel that I have improved dramatically, and I feel confident that I will be successful at home. It worked out very nicely, and I would definitely recommend ManorCare to my family and friends.

Ted

In 2011, an average of about 5,400 physical, occupational and speech full- and part-time therapists provided rehab to our patients.

9

10

Reducing Hospital ReadmissionsSuccessful transition of CareBecause discharged patients are leaving the hospital much sooner than in the past, they are more likely to be readmitted to the hospital due to lingering or new medical complications. The cost of these readmissions is prohibitive to the health care system and a target of government agencies to remove cost from the system. Just as important, once patients are released from the hospital, they don’t want to go back. HCR ManorCare is working closely with its hospital referral sources to help ensure there is a smooth transition from hospital to our centers so that when patients leave the hospital, they do not return.

Post-hospital patients who are referred to our skilled nursing and rehabilitation centers can expect focus on a successful and safe outcome. This begins with a comprehensive assessment and development of a patient-specific plan of care. Education and counseling target individual and family concerns. Frequent meetings that include the patient, family and staff help ensure we are meeting patient needs, addressing any concerns and working toward patient goals. Challenges of home and community life after discharge are also addressed and includes follow-up to ensure the patients’ well-being.

11

exTenSIve COMMunICATIOn IS eSSenTIALCommunication on every level – hospital to post-hospital care provider, nursing assistant to nurse, nurse to doctor, and all caregivers to the patient and his or her family – is critical to a smooth transition of care and decreasing rehospitalizations within the first 30 days of a patient’s stay in the post-hospital care setting. HCR ManorCare’s transition of Care form helps improve communication between the hospital and the post-hospital center when a patient is discharged. Evidence-based medicine indicates that the communication of specific and focused patient information can reduce those “bounce-backs” which occur in the first 24 to 48 hours.

additionally, we have implemented a series of educational programs to train nurses and nursing assistants in the early warning signs for care conditions that have been identified as unnecessary reasons for rehospitalizations. This educational initiative is designed for everyday use and instructs the clinical teams in providing appropriate interventions for these specific care conditions. Missed communications are a primary cause of rehospitalizations that occur between day 8 and day 30 after discharge. Our educational initiatives have reduced rehospitalizations in this time period by as much as 40 percent.

eLeCTROnIC InnOvATIOn AnD InTeGRATIOnEarly identification, evaluation, documentation and communication of patients who have a change in status are reducing rehospitalizations and the associated emotional and physical complications. Nursing assistants at our centers access conveniently located electronic kiosks to record changes in patient conditions such as mental status, communication skills, participation in activities, ability to perform activities of daily living, fatigue and changes in skin color or condition. This information sends an alert to licensed staff, enabling our clinical team to identify issues early and prevent sending the patient back to the hospital.

This is just one example of our focus on bringing electronic systems innovation to our clinical delivery. Other enhancements include:

• Physicianaccesstoelectronichealthrecords.

• Nursepractitionerelectronicnotepads.

• PointClickCareelectronicmedicalrecordsystem.

•Therapyhandhelddevices.

JOInT TRAnSITIOn Of CARe COMMITTeeHCR ManorCare has created Joint transition of Care Committees with key hospital systems. The committees comprise operational, medical, clinical and business development leaders from HCR ManorCare and the participating hospital system. The joint initiative provides an important point of accountability for ensuring both quality of care and quality of life throughout the transitions of care. The objectives of the committee are to:

• Improvethequalityofpatienttransitionsacrossthecontinuum of care.

• Reducethepreventableandunnecessaryrehospitalizationof patients.

• Enhancepatientsatisfaction.

At an average of 18 percent, our skilled nursing and rehabilitation centers’ rehospitalization rate is lower than the national average, with many of our centers achieving rates lower than 10 percent.

11

CARInG fOR LOnGeR-STAy ReSIDenTSWhile short-stay patients in need of intensive rehabilitation are an increasing percentage of those we care for, we also continue to care for a medically complex, functionally limited and/or cognitively impaired longer-stay population. Many enter a nursing center only as their care needs go beyond their ability to stay in their homes. Others enter because their frailty and need for around-the-clock, comprehensive care can best be met in a professional care setting. Community-based services are enabling people to stay longer in their homes or assisted living residences, and this means by the time they do come to our skilled nursing centers, they are in need of more intensive care than this population required 10 to 15 years ago. Nearly half are taking nine or more medications.

These residents come from the hospital, home and other community residences and need assistance in performing activities of daily living (aDls), such as walking, eating and bathing. like short-term patients, they receive physical, occupational and speech therapies to keep their functional level at as high a level as possible. They may also require pain management, medication management, wound care, and counseling and social services. Some short-term patients may become long-term residents. after receiving the rehabilitation and other care required, it’s often determined that the patient is not going to progress to the point where he or she can return to the community. He or she needs a level of care that cannot be safely provided at home.

12

over the past three years, we invested nearly $350 million in new construction, renovation and expansion of existing facilities, new equipment and information technology. three new skilled nursing and rehabilitation centers were opened, 39 expansions were completed to add short-term stay beds and enhance rehab therapy areas, and more than 1,000 renovations, each at a cost of more than $30,000, were completed.

Dining ServicesWhether one is a short-term patient or long-term

resident, dining services are an important part of the stay. HCR ManorCare has introduced enhanced dining

service standards that value patient choice and control in food and dining along with exceptional, engaging service.

Promptly visiting each newly admitted patient to review food and meal services available in the center has a significant impact on customer satisfaction and the quality for both the short-term and long-term patient’s stay.

Our standards include updated china, glass and service ware; new uniforms identifying hospitality workers; and restaurant-style menu items. A variety of training, education and tools has been developed and introduced to assist our food service operators in providing the best meal service experience for patients. The food, nutrition and dining experience at HCR ManorCare is about respecting a patient’s choices so we can increase contentment, nutritional status and success in meeting rehabilitation goals.

13

14

Mary is 58 years old and was diagnosed with advanced head and neck cancer. She has been receiving curative

treatments including surgical resection, chemotherapy and radiation therapy. Recently, her physician informed her

that the cancer had progressed to her lung. Mary’s physician prescribed intermittent morphine to relieve a sense of breathlessness she had begun to experience, but Mary has been hesitant to take it due to her fears of addiction. At this point, her physician made a referral to Heartland Advanced Disease Management, requesting a nurse Practitioner to assist in educating and supporting Mary and her family regarding misconceptions about morphine use. Based on the nurse Practitioner’s observations, Mary’s plan of care was adjusted to increase psychosocial support, and she and her family were educated on treatment strategies, drug choices and therapeutic ranges of doses specific to this type of cancer and its potential progression.

ADvAnCeD DISeASe MAnAGeMenTHeartland Care Partners is a provider of short- and long-term health care with a particular emphasis on effectively treating medically complex patients. Oftentimes, patients with progressive illnesses and persistent symptoms can benefit from a higher level of consultation, management and involvement than they are receiving in their current setting. Heartland advanced Disease Management is a pilot program under the direction of Heartland Care Partners to provide patients with advanced disease and pain management when they are chronically ill but not quite ready or appropriate for hospice or dedicated end-of-life services. The pilot began in November 2011 by working with HCR ManorCare skilled nursing and rehabilitation centers and Heartland Home Health Care and Hospice agencies in parts of Pennsylvania. The initiative has also involved developing relationships with non-company home care/hospice agencies and Pennsylvania hospital systems.

Referrals primarily come from patients’ attending physicians, oncologists and hospitalists. Heartland Care Partners staff processes the referrals and matches patients with Nurse Practitioners. They, in turn, provide consultation services to patients, physicians and families regarding recommendations for pain/symptom management and complex health care needs related to diseases such as cancer, heart disease, pulmonary disease, alzheimer’s disease and disease combinations.

The Heartland advanced Disease Management care team involves the patient, family, Nurse Practitioner and collaborating physicians, with the Nurse Practitioner also working closely with the nursing center, assisted living center, home care agency or hospice agency team throughout the process. in the skilled nursing center, recommendations become part of the patient chart. in the home setting, Nurse Practitioner recommendations are sent to the attending physician’s office.

This program fills a critical gap in the health care continuum and helps to improve transitions of care by addressing chronic disease processes, uncontrolled pain and end-of-life decision making for the frailest of the frail.

15

HCR MAnORCARe InDePenDenT ADvISORy COMMITTee On QuALITyHCR ManorCare has created an independent advisory Committee on Quality to provide advice and recommendations to the company’s Board of Directors on ways to measure, maintain and improve quality of care for HCR ManorCare patients and residents. The distinguished three-person panel is composed of Vincent Mor, Ph.D., Professor of Medical Science in the Department of Health Services, Policy & Practice at the Warren alpert Medical School, Brown university; Robyn Stone, Dr.P.H., Executive Director of the institute for the Future of aging Services and Senior Vice President of Research for leadingage; and Gail Wilensky, Ph.D., Economist and Senior Fellow at Project HOPE.

in 2011, the independent advisory Committee on Quality met three times, visiting a half dozen skilled nursing and rehabilitation centers during the year. While there, they met with our staff, observed care conferences, discussed training initiatives and made recommendations. The continuing focus of the committee has been on clinical and administrative practices being planned and implemented to prevent rehospitalization of new post-hospital admissions, exploring the factors influencing regulatory performance, and quality improvement and staff training initiatives designed to implement new programs.

I came to ManorCare Health Services–kenosha with many complex medical issues, which left me extremely weak and unable to walk. I could barely sit up and was getting nutrition through a feeding tube. everything changed for the better in just a few short months. The therapy staff got me better, stronger and healthy enough to go home. The day I left the center, I was strong enough to walk to my son’s car and was looking forward to having lunch at my favorite restaurant. I would recommend that anyone come to ManorCare–kenosha for rehabilitation.

Lester

the vast majority of our skilled nursing and rehabilitation center patients came to us from the hospital in 2011.

Residence Prior to Admission to HCR ManorCare

Acute Care Hospital 86.2% Nursing Home 6.1% Home 3.2% Other 4.5%

15

16

91% of patients rated the quality of the rehabilitation therapy they received as “excellent” or “Good.”

92% of patients rated the respect shown them by therapists and nurses as “excellent” or “Good.”

91% of patients reported being satisfied with the encouragement their therapist provided to help them meet their individual rehabilitation goals.

on average in 2011, the Medicare and managed care patients in our skilled nursing and rehabilitation centers returned to the community in less than 40 days.

Insu

ranc

e/M

anag

ed C

are

26

Med

icar

e

38

Vete

rans

Adm

inis

trat

ion

92

Hosp

ice

70

Priv

ate

Pay

99

Med

icai

d

270

0

50

100

150

200

300

Day

s

250

Average Length of Stay in Days

Almost all of our skilled nursing and rehabilitation center Medicare patients received at least one form of rehabilitation therapy in 2011.

Percent of Medicare Patients Receiving Therapy

0

20

40

60

80

100

Perc

ent Any

TherapyPhysicalTherapy

OccupationalTherapy

SpeechTherapy

98 96 95

35

17

QuALITy CARe RefLeCTeD In SATISfACTIOn SuRveySCollecting and using patient satisfaction survey data is an important part of our process for ensuring that patients feel that they have received the care they expected. as a member of the alliance for Quality Nursing Home Care, HCR ManorCare participates in a regular independent customer satisfaction survey. We are proud to report that results from these surveys show high levels of satisfaction. in 2011, over 25,000 discharged patients from our skilled nursing and rehabilitation centers returned surveys, which has helped us create a good gauge of patient satisfaction.

achieving high levels of customer satisfaction begins with training our employees. We have developed a training program called “Patient-Focused Customer Service.” This program helps employees understand how service is perceived by patients and family members. The program focuses on improving professionalism in three areas -- appearance, attitude and action. New employees complete “Patient-Focused Customer Service” during general orientation. in addition, the program is taught annually to all current employees to reinforce the importance of providing excellent customer service each day. also important in achieving customer satisfaction is educating our patients and families about the normal aging process. We use a wide variety of communication materials to enhance their understanding of this process.

18

We believe that our mission is to enrich lives. That begins with every life we encounter – our employees, our patients and those who

love and care for them, the communities in which we operate, our stakeholders and those who are yet to become our customers.

H e a r t l a n d

Mission

Hospice and Home Care

19

fulfilling and keeping our promises to our hospice and home care patients is a commitment of all Heartland Home Health Care and Hospice employees.

We promise to care for the mind, body and spirit in a way that is comforting and compassionate.

We provide care that not only addresses physical concerns but also the psychosocial and spiritual needs of patients. The goal is to provide care in a way that offers a blanket of comforting and compassionate support for the whole person and his or her family,

no matter what the issue.

We promise to be the difference in our customers’ day, working to make every connection a personal one, and creating memorable moments that

define their Heartland experience.

We work to help create special moments for our customers that they will always remember, moments that make them feel warm, cherished and valued.

We promise to discover what is important to our customers, respect their choices and customize our service specifically to their needs.

We work to provide our patients with the support they need wherever they are in their health care journey. We ask them questions to find out exactly what they want and need

and then help them get it. it is our patients’ choices that matter most, not ours.

We promise to be leaders in care delivery, corporate responsibility and community action.

First, we want to be leaders in care delivery. Our goal is for every employee to model behavior that is committed to quality care and service. No matter what the employee’s

job, it is critical to the services we provide.Second, each employee needs to do his or her part to keep our company healthy so that we have the tools and systems necessary to do the important work that we do for our

patients and families.Third, we strive to be part of the fabric of the communities in which we operate and

serve. We will help by providing education and information, partnering with community resources and taking actions in the community that benefit more than our patients.

ProMisesH e a r t l a n d

19

20

I would recommend Heartland Home Care to anyone who needs home nursing care. If it wasn’t for your caring and knowledgeable staff, I do not think my husband would have made such a great recovery. I was scared when he came home from the hospital. I felt overwhelmed. But once Heartland came into our home to evaluate his needs, I felt I had someone that I could count on. Someone who was only a phone call away if I needed them. The nurses showed true compassion for both of us and always took the time to listen to our concerns. The physical therapist has to be one of the best in the area. I was so happy to have your agency helping us. I cannot thank you enough for all the help you gave us.

Wife of a Heartland Home Care patient in Pennsylvania

20

21

HOSPICe SeRvICeSOur hospice services integrate holistic principles with palliative disease management, expert pain and symptom control, family education and psychospiritual support for end-of-life care. Hospice also provides the education, counseling and other resources that can help with emotional needs. Care is culturally sensitive, respecting the traditions and heritage that are important to patients and their family members. These services can be provided within a skilled nursing center or the individual’s home.

HOMe CARe SeRvICeSOur home care services help patients experiencing an illness, hospitalization or surgery requiring recovery and healing, or a new health diagnosis requiring a change in daily lifestyle. Our goal is to provide the same specialized treatment a patient would receive in the hospital or doctor’s office, but to do it in familiar surroundings where patients have the love, support and understanding of family and friends.

We coordinate comprehensive assessments, medical treatments, symptom control and medication management. Physical rehabilitation services help restore patients’ functions that have been impaired by illness or surgery, helping the patient to continue to live independently. We also care for patients with a wide variety of medical conditions requiring i.V. care. i.V. patients are supported, monitored and educated by professional staff members trained to guide them through complex medical issues.

Heartland has developed a library of comprehensive medical and rehabilitation management programs to serve our patients better. among these are care programs for patients living with chronic heart disease or recovering from a cardiac event, patients living with pulmonary disease and total joint replacement patients. The goal is treatment management that enables patients to increase positive outcomes, maintain quality of life and remain at home. Care services are provided based on risk, and patients are educated to promote self-management of care to the extent possible.

When I was looking for hospice care for my mother, I literally took out the yellow Pages and thought I would call all agencies from A to Z. I got in contact with Heartland’s receptionist, and immediately felt at ease with her. I was also impressed with the social worker’s infinite caring, compassion and kindness toward my mother. She was hands-on and instantly made suggestions for making my mom more comfortable. She took the time to explain everything to me, but mainly just took the time to listen. At one point a Heartland employee actually reached out and held my hand to comfort me and reassure me that I was making the right decision. I couldn’t get over all of the offers of prayers, hugs and kisses from every Heartland employee. Thank you.

Daughter of a Heartland Hospice patient in Wisconsin

22

When we called the pharmacy to find out if Sadie needed more of her prescription, everyone was kind to us. One of the pharmacists answered all of my questions. She called back about three minutes later and sang Happy Birthday to Sadie. That made her day! She could not stop talking about it, saying, “It was so kind of her to remember.” We want to say a big thank you to her and everyone else who helped every time I called. They answered all of my questions. I would recommend your company to anyone that needs your help.”

Caregiver of a Heartland I.v. Care patient in Michigan

A high percentage of our hospice patients would recommend our care to others.

Percent of Patients and families Who Would Recommend Heartland Hospice Services to Others

80

82

84

86

88

90

Perc

ent Heartland

HospiceIndustry Average

89.588.5

our percent of home health care rehospitalizations in 2011 was well below the national average.

Percent of Home Health Care Patients Who Returned to the Hospital

0

10

20

30

Perc

ent Heartland Industry

Average

25

15

5

20

27

23

Dementia ServicesWe know. We understand. We can help.HCR ManorCare offers specialized services to advance the care of those with memory loss from alzheimer’s disease or other types of dementias. Our arden Courts memory care communities tailor care specific to the unique characteristics of the individual with dementia and provide approaches that preserve remaining abilities. Five years of research was spent in creating an arden Courts design environment that is safe, supportive and home-like.

Professional program staff designs programs for residents utilizing information taken from career choices, habits of a lifetime and current hobbies. Programming is then presented linking abilities and honoring preferences so residents maintain self-esteem and experience meaningful moments of joy.

With nearly 20 years of caring exclusively for individuals presenting all levels of dementia, our arden Courts communities know the emotional commitment and critical decisions that families must manage as dementia progresses and greater loss occurs. Making an informed care decision includes understanding changes, safety risks and determining the right time to choose a protected and safe environment. Waiting until a crisis such as leaving on a stove, wandering away from home, a car accident, setting the microwave on too long and an inability to dial 911 can result in heartbreak and misfortune for the individual with memory loss and for family members seeking to allow independence when what’s needed is a protected environment. We partner with our families, individuals presenting in all stages of dementia and professionally trained staff to strive for the goal with our dementia services to provide a safe, supportive and home-like environment that nurtures the individuality of memory-impaired people and gives their families peace of mind.

24

98% of the families of Arden Courts residents rated the respect shown them by staff as “excellent” or “Good.”

95% of the families of residents rated their overall

satisfaction with Arden Courts centers as “excellent” or “Good.”

94% of the families of residents rated the home-like environment of our Arden Courts centers as “excellent” or “Good.”

94% of the families of residents rated the safety of our Arden Courts centers as “excellent” or “Good.”

95% of the families of residents rated the caring of our Arden Courts

staff as “excellent” or “Good.”

95% of the families of Arden Courts residents would tell others that our services rate “excellent” or “Good.”

25

“In memory of my mom, I wanted to take this opportunity to thank you all from the bottom of my heart. you helped make her last years so much more enjoyable than I could have imagined. you treated her with respect, kindness and a gentleness, which she so deserved. It takes someone special to do the work you do. you have that special quality, which is truly a gift. I consider each one of you a blessing in both my mom’s life and in mine. May God bless you all as you continue to do his work, and never forget that you do make a difference.” Arden Courts center in Pennsylvania

“We feel very positive about the atmosphere at Arden Courts. When we take Mom out for a family gathering, or to get her hair done, she is ready to go back ‘home,’ eager to see where everyone is and hoping that she hasn’t missed out on something fun. Mom is a people person and a nurturer, and we knew that she would be happier if she were around other people. We can see how her life has been enriched by living at Arden Courts and how important the interaction with others has been for her. We thank everyone at Arden Courts for opening up opportunities for Mom to be her best and happiest self by living in your community. She is precious to our family, and it helps us to know that she is happy and treated with respect and kindness.” Arden Courts center in Virginia

SAyInGwHAt FAMIly MeMbeRS ARe

“It doesn’t seem that long ago that I was sitting in the lobby of Arden Courts reading testimonials from families, and now I am writing one of my own. My Dad was diagnosed with Alzheimer’s disease, and we visited Arden Courts. We were very impressed with the facility but were not ready or able to separate my parents. eventually, the assisted living home my father was in asked us to make other arrangements for my father. His last months at the assisted living were awful to say the least. Then we moved my Dad to Arden Courts. I can’t really find the words to express the relief we felt. My Dad was welcomed with open arms. He could sing, and people enjoyed it. He could tell jokes and be accepted for who he was. I left knowing my Dad was in the right place. When Alzheimer’s began to take its toll on my Dad, you were all there, too. you made an awful situation so much more tolerable. you should all be proud of the job you do.” Arden Courts center in Ohio

26

Quality Care from a Quality Workforce

27

SOMe SHInInG exAMPLeS InCLuDe:

Assisted Living DivisionKarolee Vandrush, the Executive Director at arden Courts of Northbrook, illinois, started with us as a frontline caregiver, then advanced to become Program Services Coordinator, Marketing Director and now Executive Director.

Skilled nursing – Midwest DivisionKathy Karr, who is Regional Director of Operations (RDO) with responsibility for centers in indiana and iowa, joined HCR ManorCare as a Registered Nurse with Heartland Home Care. She advanced to administrative Director of Nursing Services, and then administrator in training, administrator, Senior administrator and today RDO with responsibility for 11 centers.

Skilled nursing – West DivisionGurprit Dhaliwal is the administrator at ManorCare Health Services in Hemet, California. She started with us as a Nursing assistant, progressed to Nurse Supervisor, was promoted to Resident assessment Coordinator, assistant Director of Nursing and administrative Director of Nursing Services before being named administrator of the Hemet center.

Skilled nursing – eastern DivisionDiane Johnson started as a part-time activities assistant, advanced to Social Services Director, then administrator in training before serving in a series of assistant administrator and administrator positions. today, she is Regional Director of Operations for 12 centers in eastern Pennsylvania.

Skilled nursing – Central Divisionlucy Muklewicz started with us as a Nursing assistant, and then advanced to licensed Practical Nurse and Registered Nurse, and today is a Senior Case Mix Specialist in Ohio.

Skilled nursing – Great Lakes Divisiontracy Peterson, administrator at Heartland Health Care Center in Jackson, Michigan, started with us as a payroll clerk/receptionist and worked her way up to the administrator position.

Skilled nursing – Atlantic Coastal DivisionJoylin Nation joined the company as RN Nurse Supervisor, and then became the assistant Director of Nursing at Heartland of tamarac, Florida. She became the administrative Director of Nursing Services later that same year and then was promoted to Clinical Services Consultant. She returned to operations as an administrator, progressed to Senior administrator and then was promoted to Regional Director of Operations with responsibility for 12 centers.

Heartland Home Health Care and HospiceMercedes Wirdzek started with us as a field nurse making home visits and then became Patient Care Coordinator and Director of Professional Services before being named a Clinical Services Consultant in Ohio and indiana.

Corporate StaffGreg Seiple began his career as a Nursing assistant in lebanon, Pennsylvania. He became a Registered Nurse, progressed to administrative Director of Nursing Services and then moved into the corporate Clinical Services department. There he has advanced through several leadership roles and is now assistant Vice President, Clinical information Systems.

GROWInG OuR LeADeRSHIP fROM WITHInHCR ManorCare has a long-standing tradition of growing talent and preparing people for leadership roles. This leads to long-tenured and seasoned leaders with a proven track record of success.

all of our General Managers with responsibility for our operations have been promoted from within the company, and only one has less than 10 years of service. all the others have over 15 years of continuous service, and together have leadership experience totaling nearly 200 years.

There are many examples in each division of people who have been promoted through the ranks into increasingly larger leadership roles, and several are highlighted in the column to the right.

in addition, the tenure of all staff is a big part of our consistent successful performance:

• 8,875employeeshave10yearsormoreofservice.

• Nearly2,300have20yearsormoreofservice.

• About475have30yearsormoreofservice.

• Almost30remarkablyhave40years or more of service.

27

28

HCR ManorCare Gives is our company’s commitment to our patients, employees and communities, demonstrated through our many philanthropic programs. Here are highlights of two of our most supportive programs:

The Hug fund, also a non-profit charity, is a partnership of HCR ManorCare employees helping their fellow employees who have experienced a catastrophic event causing financial hardship. Whether it’s an employee whose home has been destroyed by fire, an employee who has been diagnosed with a terminal illness, an employee whose child has died or an employee who lost his or her possessions to a tornado, the Hug Fund is there to help. The fund provides financial assistance to employees who are unable to meet their urgent need.

Many Hug Fund grant applicants are experiencing catastrophic financial distress as a result of a medical crisis. time off from work, decreased income, caregiver and medical expenses can cause utility disconnection and even homelessness. These employees are in need of a financial bridge to regain financial stability. The Hug Fund can help these families to get through a very difficult time by providing that bridge. Through the financial support of HCR ManorCare employees, the Hug Fund is able to offer hope and peace of mind for their fellow employees across the nation.

The Heartland Hospice Memorial fund, a non-profit charity, operates under the belief that people who are at the end of their lives should be able to focus on enjoying time with their family and friends, cherishing their last days and making lasting memories. But financial stressors due to a terminal diagnosis often complicate the end-of-life journey, leaving little time for families and friends to focus on this important time with the patient. The fund can relieve the financial pressures experienced by patients and their families coping with terminal illness and its aftermath by providing financial assistance with household expenses, last wishes and funeral expenses, thereby helping to remove the burdens and stressors associated with financial distress directly related to illness.

Many grants from the Heartland Hospice Memorial Fund are awarded to fulfill a patient’s dying wishes to bring faraway family members to visit, to purchase one-way tickets for the patient to “go home” or spend one last vacation together as a family. Grants are also awarded to assist caregivers as they transition with household financial challenges after the patient’s death. But the majority of grant awards are to simply help patients and their families stay together in the comfort of their homes. The Heartland Hospice Memorial Fund also provides community education and bereavement resources for those suffering the loss of a loved one.

29

© 2012 HCR Healthcare, llC HCR-MC-0058D

HCR ManorCare333 N. Summit Streettoledo, ohio 43604

419-252-5500www.hcr-manorcare.com