Leading Age 2015 Presentation Repositioning ROI Synergy in Design, Care, and Finance

Repositioning ROI: Synergy in Design, Care and Finance

LeadingAge Annual MeetingNovember 1st, 2015

3:15 – 4:45 PMPresenters:Rebecca Donato, Chief Operating Officer, North HillAdam Goldman, Director of Operations, Marquis Health ServicesMark Moeller, AIA LEED AP, Principal, JSA ArchitectsChristine Rancourt, Project Manager, JSA Architects

Provider Number: G318Course # 119040A

Credit(s) earned on completion of this course will be reported to AIA CES for AIA members. Certificates of Completion for both AIA members and non-AIA

members are available upon request.

This course is registered with AIA CES for continuing professional education. As such, it does not include content that may be deemed or construed to be an approval or endorsement by the AIA of any material of construction or any

method or manner ofhandling, using, distributing, or

dealing in any material or product.

Questions related to specific materials, methods, and services will be addressed at the conclusion of this presentation.

This presentation is protected by US and International Copyright laws. Reproduction, distribution, display and use of the presentation without written

permission of the speaker is prohibited.

© JSA and North Hill 2015

Copyright Materials

True North is the latest chapter in the story of North Hill, the leader in Massachusetts continuing care retirement communities and a major initiative that has transformed their campus into a vibrant community. A few years ago North Hill’s outlook was not so bright. Occupancy was at an all-time low, and the need to change and evolve was evident. They embarked on a new repositioning journey that would transform their campus visually, culturally, and financially.

From a design standpoint, they will discuss how the design team partnered with North Hill to help them improve campus amenities, transition to a “Small House” model of care, and reestablish themselves in the Senior Living community. Operationally, speakers will present the challenges of culture change for both the residents and the staff at North Hill. This will be explored from the initial stages through post occupancy. Speakers will discuss their evolution from a traditional standard of care to the “small house” model. Finally, speakers will look at the return on investment holistically– from a design, care, and financial standpoint. The session will conclude with a presentation on the overall impact of this initiative. How did the repositioning project fulfill its original goal of revitalizing this community? What was learned during the process? Presenters will explore and analyze the data from the project as a whole.

CourseDescription

LearningObjectives

1. Hear about a repositioning initiative that transformed a tired campus into a revitalized community.

2. Discuss the multiple phases of design and construction to improve campus amenities and transition to a small house model of care.

3. Explore the return on investment to the organization from a design, care and financial standpoint.

4. Realize how embracing innovation resulted in better meeting resident need, as well as aligning with the preferences of new consumers in the marketplace.

At the end of the this course, participants will be able to:

Project Background

North Hill Overview• Single site CCRC 12 miles West of Boston• Roots of Innovation

– Babson College Connection– Creation of the 90% refund

• Extraordinary success 20+ years– 2nd CCRC in Massachusetts– Decades with 100+ wait list– In 2006, largest single site portfolio

2006 Scenario

• Solid occupancy, but board knew change needed• New CEO recruited• Conducted Strategic Planning Retreat• Outcome: Recognized that existing campus /

product in dire need of change

Marketing & Product Challenges• Physical plant – no changes since 1984• 65 units < 600SF• Undesirable and limited common areas• No assisted living or memory care• Semi-private SNF• Very frail population in IL• Home health services given away

• Increasing competition• Weakened economy / housing market• Inadequate marketing program/investment• Tarnished brand

–“the nursing home for rich people”• FY 2010 - 44 deaths (14% of IL) and 7 sales

Marketing & Product Challenges

Mission Challenges

• Frail Residents becoming isolated• Residents dreaded semi-private rooms,

postponed SNF moves until very sick• Healthy residents disturbed by increasing frailty• Memory impaired residents req’d other facilities• Home Health used by some, subsidized by all• Embraced holistic wellness but few amenities• Dark, depressing environment

• Antiquated systems• Silo mentality• Service creep• Cultural barriers

–Superiority–Complacency–Resistance to change

Operational Challenges

Master Planning Process

Strategic Objectives

Secure long-term sustainability of North HillRebrand / reposition in the marketplace Defend our marketIncrease the value of our Lifecare PromiseRestructure the business modelRe-infuse spirit of innovation

14

Master Planning Process• Evaluate market perceptions• Understand future market desires• Understand current resident desires• Assess marketing priorities • Estimate the investment needed• Determine the optimal sequence• Develop financial model

15

Primary Market Area Map

Competitive environment

changed dramatically

between 1984 and 2007

Still attractive room to grow

Conduct Market Analysis

16

Resident Input

17

• Focus Groups with all residents–27 page report

• Identified top 5 priorities• Significant resistance• First change in 22 years of history• Board Member served as “Ombudsman”

Resident Priorities

• Add assisted living and memory care• Modernize skilled nursing• Ensure physical connectivity to Health Care • Sustain service during construction• Minimize disruption• Provide open communication channels

18

Conduct Competitor Study & Customer Surveys

19

Guideposts for Our Journey

20

Creating platforms and being partners to residents in the fulfillment and ongoing

discovery of their passions

Guideposts for Our Journey

21

Team Selection Process

Extensive design “charrette” and team

selection process

Board and management engaged a team of senior living and

development experts

22

23

The Project True North initiative is designed to evolve North Hill’s living accommodations, common spaces and programs so that the

community more closely resembles what would be

standard if North Hill were being built today.

24

Design & ConstructionPhase One

North Hill 2006

Project Changes - Campus Occupancy• 1984

• Original IL 341• Skilled Nursing 72*

*12 beds added in 1992

Phase One Design Priorities

Create an arrival experienceImprove wayfindingMake the entrance visible Redesign landscaping

Make room on campus for expansionRelocate maintenance buildingRedesign loading dockRedesign traffic flow and parking plan

28

Enhance existing buildingExpand lifestyle amenitiesModernize common area interiorsCreate “social gathering” spaces


29

Bring IL apt finish levels to market standardsModernize the 1984 finishes

Adjust unit mix to be competitiveCombine small aptsRebuild the mix by constructing new large apts

30


Phase One Design Themes• Support multi-dimensional wellness• Provide central spaces that elicit socialization• Generate engagement through spaces • Increase visual connectivity

Phase One Design Themes• Allow for more natural light• Incorporate more elements from nature• Create more expansive interiors • Add grandeur • Create a contemporary feel

Phase One Design Themes

BEFORE

34

PHASE One - 2011 & 2012New Arrival – Town Green

Site RedesignNew Maintenance Bldg

Amenities Additions/Redesign (25)Apt Redesign (285)

Window Replacement (978)

Greatest Resident Resistance • Adding staircases• Relocating the library• Building a new lobby• Contemporary interior finishes• Cost

Project Changes - Campus Occupancy• 1984

• Original IL 341• Skilled Nursing 72*

*12 beds added in 1992

• 2016• IL Existing (full renovation) 285• IL Under Construction (new) 45• EIL /MC Addition 45

• Skilled Nursing (replace) 72

375

2011 And Construction Begins!

Commons Construction

39


40


41

• 14 Residents Relocated to Create Space for Common Amenities


Town Green

BEFORE

New Main Lobby

Boutique

Galleria

Screening Room

47

Intermission Lounge

48

Public Art Gallery

49

New Fitness Center

New Fitness Center

Newly Re-designed Pool & Spa

Creative Arts Center

53

Art Studio

Tech Lab

Greenhouse

Conference Suite

The Commons

Day Spa & Salon

Bridge Room

60

Outdoor Dining

Casual Fare

Casual Small Plates

Fine Dining

Alice Rose

Kevin Burke

Linda RileyEric Moore

New Apartment Interiors

BEFORE

Alice Rose

Kevin Burke

Robert Snyder



Alice Rose

Kevin Burke

Robert Snyder



Alice Rose

Kevin Burke

Robert Snyder



Design & Construction Phase Two

Phase Two Priorities

Complete continuum of health care servicesAdd enhanced living and memory care

Rebuild health center to be fully privateCreate appropriate rehabilitation spaceSeparate long-term and short-term needs

Incorporate same feel as ILPhysically connect all levels of care

71

Phase Two Priorities

Small House / Home /Non InstitutionalMinimize Move Anxiety / Smooth TransitionsMinimize Stigma / Encourage Moving

72

Health Care Design• Evaluated extensively

– Small House concept• Extended same Design Priorities as IL

Health Care Design• Land constraints req’d vertical house stacking • Small House model embraced for all services

– Enhanced Living – Memory Care– Skilled Nursing

Phase Two - 2013/2014• Enhanced Living Households

• Memory Care Household• New Health Center

(For Short-Term Rehabilitation and Long-Term Care Services)

Private Residences & Suites

75

Small House Features• Close proximity to amenities • Fireplaces• Dens• Patios• No call bells

• Enhanced Living - 4 Houses on 2 Levels– 3 Traditional Houses

• Variety of Studios - 2-Beds – 1 Memory Care House

• All Studios• Goal: More like IL than SNF

Health Care Design

Enhanced Independent Living Household

Health Care Design• Nursing Care – 7 Houses over 4 Levels

– Grand Entrance – Winter Garden and Mezzanine– 6 Long Term Care Houses

• All rooms private bed and shower (10/house)– 1 Rehab House

• All rooms private bed and shower (12/house)

Skilled Nursing Household

Communicating with DPH• Massachusetts DPH process

– Challenge to comply with Skilled Nursing requirements while still maintaining a residential Small House community

• JSA Relationship/Strategy

Communicating with DPH• Operational Plan• Waivers -Required space vs. Functional space

– 19 Waivers requested and approved including:• Central Resident Toilet Rooms (105 CMR 151.370)• Bedroom Door Width (105 CMR 151.630A)• Drinking Fountain (105CMR 151.310)• Shower stall size (105 CMR 151.370B)• Public Telephone (105 CMR 151.860)• Bathing Facilities – Freestanding tub requirement (105 CMR 151.370A)• Medication Storage (105 CMR 151.008D)• Nurse Station location (105 CMR 151.340A)• Linen Closet (105 CMR 151.370C)• Medicine Room (105 CMR 151.350)• Main Entrance/Lobby (105 CMR 153.030A)• Soiled Utility Room (105 CMR 151.390C)• Exam/treatment room (105 CMR 151.520)• Dietician’s Office (105 CMR 151.560)• Access to central dishwashing area (105 CMR 151.560F)• Freestanding tub location (105 CMR 151.370A)• Consultant’s Office (105 CMR 151.530B)• Consolidating service and clinical sinks in soiled utility (105 CMR 151.390)

Construction

•Mock ups•Collaboration of all stakeholders

85

86

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Small HousePreparing for Operations

Key Transformations

• Resident Centered Care Vs Task Oriented• Universal Worker –

Dining/Engagement/Housekeeping• The Dining Experience• Electronic Medical Record• Polypharmacy Reduction• Team Member Commitment / Job Descriptions /

Job Titles

Preparing the Team• Began 18 Months Prior to

Opening• Commitment to Change• Frequent Meetings• Team Member

Input/Feedback• Resident Engagement• Dining / ServSafe Training• Schedule/Hours Changes

Staffing Up• Traditional Economies of Scale Vs Small House

Teams

7-3 3-11 11-7 Hrs/DayTotal

Hrs/Day

Old SNF UMs/Nurses 6 5 3 112Aides 10 8 4 165 277

New Small House Nurses 4 5 5 112

CarePartners 14 14 7 262.5 374.5

Challenges

• Training / Philosophy of Care Change• Team Member Envisioning of Space• Operational Plan Development• Hiring New Team Members• Construction Schedule/DPH Engagement/Move

Planning• Family Anxiety/Concerns

Design – Phase Three

PHASE Three2015 - 2016

Independent Living Expansion

95

The Avery Expansion

Results

Impact on Independent Living

• Market responded quickly to Phase One • Refueled Sales!• Design was right on target

–Apt combinations–Apt finishes/redesigns–25 new or renovated amenities– Improved arrival experience

5,000+ Leads Generated

481

1223

1436

1015882

0

200

400

600

800

1000

1200

1400

1600

FY11 FY12 FY13 FY14 FY15

98

> 50% of all IL Inventory Resold Since Project Launch

99

7

22

32

3934

28

20

0

5

10

15

20

25

30

35

40

45

FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 FY 2016 (6 mo)

IL Closings

Phas

e 1

Laun

ch

Phas

e 1

Com

plet

ePh

ase

2 La

unch

Phas

e 2

Com

plet

e

New IL Sales

100

In Fiscal Year 2015, in addition to 28 IL closings,

our sales team took 44 of 45 potential deposits

on Phase 3 construction of new luxury IL units

IN 6 WEEKS.

Year End Occupancy

76% 81%87% 92% 88%

0%

20%

40%

60%

80%

100%

FY11 FY12 FY13 FY14 FY15

101

The reason for FY 2015 dip = 18 IL Residents moved to new Enhanced Living last 5 months

• Added value to Lifecare contracts• More engagement of compromised residents• Met dire need for memory support• Added private pay revenue pool• Expanded EF pool

Impact of Adding Enhanced Living

• Created a more dignified living experience–Home environment, not hospital like–Peacefulness - no call bells, alarms–Privacy–Access to outdoors–Long term and short term residents separated

Impact of New Skilled Nursing

• Improved Occupancy and Private Pay revenue• Expanded referral network into SNF• Increased referrals to Home Health agency

Impact of New Skilled Nursing

FY 2013 - 2015 Average

FY 2016 to Date (April - Sept 2015)

Private Pay % 19% 24%SNF Occupancy 90% 95%

Impact Since Opening of New SNF January 2015

• Historically, annual operational losses were funded by investment portfolio

• Restructured model = self-funding ops• Potential EF pool increased by 30%• Eliminate ($1.5M) yearly loss of in-home support• Productivity initiative to reduce expenses $1M

• Projected breakeven end of FY2017

Projected Long TermFinancial Impact of Project

Other Project True North Fun Facts• Renovated or constructed 475,000SF• Existing apartments reno’d to date 170• New apt constructed (45 IL+45 EIL+72 SNF) 162 • Sliders and windows replaced 978• Courses & Events attendees since Nov 2011 3860• National awards won 10

106

Overall Results

Enhanced resident quality of lifeIncreased value of Lifecare contractSuccessfully repositioned in market Secured future of community

107

Learning Lessons & Biggest Successes

What Would We Do Differently?

• Not wait for competitive crisis to change• Better supplement ops team bandwidth• From day 1

– Hire an Owner’s Rep– Manage Apartment Renovations internally

• Select a CM with senior living experience

What Would We Do Differently?

• Before Design Development –Engage the small house ops consultant–Build entire small house ops plan

• Dining and low voltage systems–Don’t assume another models work for you

What Were the Biggest Successes?

• “True North” marketing strategy• Impact of experiential marketing on rebranding• Design priorities hit the mark!• Immediacy of demand returning after apt renos

began and Commons project was complete

• Smoothness of SNF relocation• Final DPH architectural and clinical approvals• Increased engagement of SNF residents in

household model• Eagerness of residents to move to EIL• Preservation of a “one-community” feel

What Were the Biggest Successes?

Other Successes…

Creating Something New

114

Learning to Embrace Change

Collaboration

116

Teamwork

117

Commitment

118

Surprise!

119

Fun!

120

Celebration

Learning Together

122

Deeper Fulfillment of our Mission

124

Questions & Comments

Leading Age 2015 Presentation Repositioning ROI Synergy in Design, Care, and Finance

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