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Cottage Senior Living The leadership of Cottage Senior Living (CSL) assembled at a strategic planning retreat away from their headquarters in Huntsville, Alabama to prepare a plan to move the business “to the next level.” For the president of the company, Cliff White, the goal of reaching the next level involved growth that focused on identifying locations for acquisition and development. In addition to White, attending the retreat were: Sandy Brackin Vice President of Operations, Cheryl Westlake, Director of Operations; Alan Hangartner, Vice President of Marketing and Sales; Greg Dykes, Regional Managing Director – South; Selena Jackson, Regional Managing Director – North; and Holly Mitchell, Senior Accountant. To begin the retreat, White articulated Cottage Senior Living’s vision as the “development of housing and service offerings that attract empty nesters who choose to live an active, vibrant, and engaged lifestyle.” He further explained, “Our product is differentiated from the traditional markets for independent living (IL), assisted living (AL), memory care (MC), and skilled nursing facility (SNF) by focusing on non-subsidized, private-pay customers in tertiary markets.” White continued, “Moving toward the goals of the retreat, our task today is to answer three questions: 1) How to grow? 2) Where to grow? and 3) Do we have the organizational capacity to grow? Answering the ‘how to grow’ question involves assessing additions to existing capacity, offering services we presently do not, and expanding our same product into other geographic markets (horizontal integration). The ‘where to grow’ question involves the consideration of new cities and perhaps new states. And both questions, how to grow and where to grow, require us to examine our organizational capacity to grow.” The Cottage Story Cottage Senior Living, also known as “the Cottages,” was headquartered in Huntsville, Alabama. The founders of Cottage Senior Living, Peg Thompson and Wade White, met in Doylestown, Pennsylvania in 1980 while consulting as turn- around specialists focused on continuing care retirement communities (CCRCs) and more specifically, the Pine Run Community, a for-profit CCRC. The Pine Run Community opened in 1976, and was one of the first retirement communities to be developed and the only one at that time with a full service, 200-bed regional health center devoted to senior care.1 Thompson and White married and spent the remainder of the 1980s creating the assisted living service model, something that did not exist prior to 1980. Thompson and White sought distressed retirement communities, especially religiously-affiliated CCRCs and spent the mid-1980s 1 through the mid-1990s making deals. Their first venture was a management contract to operate the “Regency” Community in Huntsville, Alabama. The Regency Community became the company’s headquarters. During the 1990s, Cottage Senior Living developed CCRCs in Florence, Alabama; Russellville, Alabama; Corinth, Mississippi; Lawrenceburg, Tennessee; Mountain Brook, Alabama; and acquired CCRCs in Hoover, Alabama; Decatur, Alabama; Hartselle, Alabama; and Huntsville, Alabama (see Exhibit 1 for Cottage Senior Living’s market area). Exhibit 1. Cottage Senior Living Service Area Cliff White, Wade and Peg’s eldest child, returned to the family business in 2009 after completing an MBA at the American University in Washington, DC. Beginning in 2011, White served as president of Cottage Senior Living, LLC. Among Cliff White’s accomplishments was the development of The Commons, a 54-unit active adult community in Huntsville, Alabama where he implemented several information technology (IT) projects to improve operational efficiency and management reporting. White focused much attention on innovating assisted living. He was a member of the Urban Land Institute Senior Housing Council and the American Seniors Housing Association and was a Certified Public Accountant. The Industry The long-term care industry was composed of health-service, social service, and residential service organizations that provided rehabilitative, restorative, and ongoing skilled nursing care to disabled and elderly patients who required assistance with daily living.2 The assisted living industry was comprised of a variety of senior care services; generally divided into two major subcategories: (1) 2 continuing care retirement communities and (2) homes for the elderly. The primary difference between the two subcategories was the presence of nursing care. Continuing care retirement communities provided on-site nursing facilities whereas homes for the elderly did not. Future growth of the industry would be spurred by 77 million Baby Boomers and the increasing life expectancy of the elderly population. Approximately 1 million Americans lived in senior care facilities and the number was expected to double by 2030. Competition in the assisted living industry was intense. The four largest providers in the industry (Brookdale Senior Living, Sunrise Senior Living, Emeritus Corporation, and Atria Senior Living Group) controlled only about 13 percent of the market share. The remaining 87 percent was comprised of a variety of not-for-profit and for-profit enterprises. The largest source of revenue for providers came from private payers representing almost two-thirds of total revenue. Medicaid provided about 10.5 percent, Medicare about 6.2 percent, and private insurance about 3 percent. The remaining 14 percent came from a variety of sources including other government programs and assigned Social Security. Great variety occurred in the demographic make-up of retirement communities. Approximately 69 percent of residents were female and 31 percent were male. The typical resident of a senior living community was an 85-year-old female. Individuals over the age of 85 made up the largest percentage of residents in senior living facilities.3 More specifically, the industry was comprised of a variety of facilities differentiated by the intensity of care provided as summarized in Exhibit 2. Exhibit 2. Senior Living Communities in Order of Increasing Intensity of Care2 Type of Community Age Range or Average Age of Residents Regulation Transportation Activities Services Senior Apartments 55 plus Not regulated Occasional Daily, but not required A la carte Independent Living 82 average Not regulated Scheduled Daily, but not required Housekeeping (included*), nursing call system3,4 Assisted Living Facilities 85 plus and need driven Regulated by state government Scheduled and required by regulation Scheduled 6 times per day; (schedule required by regulation) Housekeeping (included); nursing call system; food service (3 times/day, scheduled); medication assistance – all required by regulation Memory Care – a 85 plus and need Regulated by state Scheduled and required by Scheduled 6 times per Housekeeping (included), nursing 3 Specialty Care Assisted Living Facility (SCALF) driven government regulation day; (schedule required by regulation) call system, food service (3 times/day, scheduled), nurse administered medication, monthly RN assessments- all required by regulation Skilled Nursing Facility (SNF) Adolescent and older Regulated by state and federal governments Scheduled and required by regulation Scheduled, 6 times per day; (schedule required by regulation) Housekeeping (included); nurse calling system; food service (3 times/day, scheduled); nurse administered medication; monthly RN assessments – all required by regulation *Included means incorporated into the residential fee-for-service structure Independent living settings were adult communities that usually imposed age restrictions, offered social activities, provided security, offered access to transportation services, but did not provide medical services. Although no uniformly accepted definition of assisted living facilities (ALFs) existed, ALFs were considered “multi-family properties with personalized support services for seniors.”4 A relatively new development in the long-term care industry was the Continuing Care Residential Community or CCRC. CCRCs attracted private-pay residents5 “of high socioeconomic status, who were independent upon entering the CCRC.”6 CCRCs offered a variety of services providing a progression of care from independent living to nursing facilities in a single campus setting focusing on wellness activities and amenities.7,8,9 The progression of services offered by CCRCs acknowledged the inevitable decline of independent older adults during the last few years of life, making CCRCs the “final station” of an older adult’s life.10 A skilled nursing facility (SNF) was defined by the Social Security Act as an institution (or a distinct part of an institution) that was primarily engaged in providing skilled nursing care and related services for residents who required medical or nursing care, or rehab services for the rehabilitation of injured, disabled, or sick persons, and was not primarily for the care and treatment of mental diseases; and had in effect, a transfer agreement with one or more hospitals. Nursing facilities offered the most intense level of long term care and were for individuals requiring around the clock care.11 Memory care facilities catered to the needs of individuals with Alzheimer’s disease or a related disorder (ADRD)12 and was an emerging development within CCRCs.13 Memory care and skilled nursing facilities were categorized as Specialty Care Assisted Living Facilities or SCALFs. From an industry perspective, Medicaid was the primary payer of long term care services inasmuch as more than 60 percent of the patients in nursing homes 4 were Medicaid recipients and that Medicaid patients comprised almost 20 percent of residents in assisted living facilities.14 The Cottages did not market to or admit Medicaid recipients. The CSL Regulatory Environment The Cottages operated three types of facilities – Assisted Living, Memory Care, and Active Adult as “group” facilities or “congregate” facilities. The word congregate used as an adjective to describe long-term-care facilities is a synonym of the word group and thus appeared to refer to the same thing;15 however, state regulations distinguish between the terms as they applied to health care facilities. Because the Cottages operated facilities in three states, agencies in each state regulated the facilities; however, the majority of the Cottages’ facilities were located in Alabama and as a result the company was profoundly affected by regulations of the Alabama Department of Public Health (ADPH). ADPH regulations differentiated between group assisted living and congregate assisted living facilities. Group assisted living facilities were authorized to care for three to sixteen adults. Congregate assisted living facilities were authorized to care for 17 or more adults. Regulations addressed staffing requirements and the qualification of key members of the staff. The key regulatory parameters, shown in Exhibit 3, indicate that in general, ALFs had fewer staffing requirements than SCALFs and both ALFs and SCALFs had similar building requirements. 5 Exhibit 3. Key Regulation Parameters within the Cottages Footprint15 ALF SCALF Staffing General requirement: sufficient staff on duty to provide the care needs of all residents twenty-four hours per day, seven-days per week. General requirement: sufficient staff on duty to provide the care needs of all residents twenty-four hours per day, seven-days per week. Staff requirement: based on resident population and time of day; no set, specific requirement. Staff requirement: based on resident population and time of day: Staff Residents by Time Period 7am-3pm 3pm-11pm 11pm-7am 2 1-16 1-16 1-16 3 17-24 17-36 17-48 4 25-32 37-48 49-64 5 33-40 49-60 65-80 6 41-48 61-72 81-96 7 49-56 73-84 97-112 8 57-64 85-96 113-128 9 65-72 97-108 129-144 10 73-80 109-120 145-160 11 81-88 120-132 161-176 +1 per 8 12 16 Specific professional licensed staff: Administrator Dietician – could be full-time, part-time, or consultant Specific professional licensed staff: Administrator Medical Director – licensed physician Registered Professional Nurse Coordinator – an administrator who was an RN Dietician – could be full-time, part-time, or consultant Building Requirements Dining separate from kitchen Dining separate from kitchen Separate rooms for administrative and office purposes Separate rooms for administrative and office purposes Centrally located staff station with call for assistance and fire alarm communication system Centrally located staff station with call for assistance and fire alarm communication system Grab bars conforming to current building code Grab bars conforming to current building code Commercial exhaust food system Commercial exhaust food system Institutional grade range with double oven Institutional grade range with double oven Bedrooms individually and consecutively numbered Institutional grade refrigerator Hand washing lavatory in kitchen with soap dispenser, supply of soap, disposable towels, and hot and cold running water running through a mixing valve or combination faucet Hand washing lavatory in kitchen with soap dispenser, supply of soap, disposable towels, and hot and cold running water running through a mixing valve or combination faucet Commercial grade dishwashing equipment with a booster water heater Three-compartment sink with a booster heater or chemical sanitizing system Laundry rooms shall not open directly into resident rooms or food service areas Doors of resident bathrooms swing into the bedroom 6 ALF SCALF Utility rooms on