The traditional “geriatric” model nursing center is not sustainable
The SNF Sector represents a low margin business
The SNF Sector is increasingly competing with assisted living product and other home and community based service providers
The SNF Sector is replete with aging property interests requiring capital reinvestment
Practice Attributes
The SNF Sector has historically been misdirected by adopting payer driven business strategies
The SNF Sector exhibits limited progressiveness in leveraging technology
More formalized and intensive marketing efforts are required to sustain and improve census and promote quality mix of residents.
Managed care associations require more aggressive and targeted collaboration coupled with demonstrating performance expectations
Limited proficiencies among direct caregivers are prevalent with respect to combining clinical and financial management capabilities
There exists inadequate financial and clinical management systems integration in promoting combined skill sets
Emerging technologies are proving essential to promoting progressive practice delivery
Market Considerations
Freestanding Community Providers are threatened by the economies and progressiveness represented by emerging competition.
The SNF Sector has been obstructed by prevalent fragmentation and competition within the industry
Industry data is scarce and disparate as available to providers for benchmarking and lenders/investors for underwriting and credit monitoring
SNF Providers experience heightened risk factors associated with resident claims and other contingent liabilities stemming from resident care activities
Regulatory Influence
Government programs offer no incentive and inadequate capital reimbursement for reinvesting in asset interests as well as advanced operating systems
There exists high disparity and growing complexities in principles of reimbursement in the SNF Sector where providers experience economic dependency on inadequate Government programs – principally Medicaid
Government payer programs are actively migrating away from the fee-for-service model where revenue realization is increasingly driven by demonstrated cost efficiencies and outcomes achieved
The growing integration of the healthcare industry generally is being fostered by various elements of health care reform legislation. New payment mechanisms have been conceived to provide incentives for providers that demonstrate cost effective operations and favorable patient or resident care outcomes. The emergence of Accountable Care Organizations (“ACO’s”) and other “bundled payment” arrangements will mandate the greater collaboration of health care providers in the realm of post-acute delivery of health care services. Health care providers who fail to advance progressive management practices as well as information technology capabilities to effectively compete and collaborate in this new environment will be threatened for business survival.
The loss or deterioration of valued referral relations in this new provider setting could prove devastating.
Growing competitive influences in Product, Program & Practice
Aging and deterioration of asset interests
Growing consumer expectations for goods & services
Sustained exposure to risk management factors
Demands of growing specialized resource needs of continuing operations
Capital demands of emerging technologies & systems development
Implications of current and future economic conditions
Viability of freestanding single purpose providers
Practice Attributes
Progressive management capabilities exhibited by “best practices” in leveraging technology and strategic collaboration will constitute the formulary for success and sustainability in the new healthcare business environment.
The effectiveness of management leadership in advancing organizational development in this manner will be essential.
Ignoring the demands of Human Resources and associated management challenges of recruitment and retention
Regulatory Influences
Diminishing government funding
Escalating regulatory intervention
Exposure to risk factors stemming from management and operating deficiencies
Failure to meet mandated practice standards imposed by regulatory compliance and health care reform legislation
CCA has served in business and financial services capacity to a community not-for-profit senior campus provider of skilled nursing and assisted living operations located in Cambridge, MA.
Recent initiatives have included the completion of $20MM in combined recapitalization transactions with a single regional commercial healthcare lender. Proceeds of the transactions were utilized to refinance and retire existing debt obligations through a private placement revenue bond issue and term debt credit facility; early redemption of a prior revenue bond issue; discounted settlement and retirement of multiple subordinated debt obligations; purchase redemption of interests associated with terminating a tax credit partnership; and funding of new endowment and operating reserve accounts for continuing operations.
The resultant transactions materially improve the capital structure of the company through realization of liquid collateral associated with prior debt obligations as well as a material increase in unrestricted net assets represented by the discounted settlement and elimination of subordinated debt. The renewed and strengthened capital structure ideally supports new programming initiatives as well as prospects for emerging fund raising activities for continuing operations.
CENTRAL MASSACHUSETTS – CCA served in a business and financial advisory capacity to a regional multi-facility skilled nursing provider in Central Massachusetts. Recent initiatives have included the introduction of a senior living campus development surrounding its primary skilled nursing property.
To date, CCA has secured $30MM from a regional commercial healthcare lender to fund the initial phases of the campus development. Proceeds of the financing transactions have been dedicated to refinance existing asset interests while completing a major renovation and 40,000 square foot expansion of the skilled nursing property. The full scope renovation extended to reconfiguring all existing units; establishment of substantially all private room accommodations; expanded therapy service areas; replacement kitchen; and improved customization of resident care and common areas. The expanded property allowed for the planned merger of an existing respiratory long-term care program unit operating in a leased property.
Concurrent with the renovation and expansion project, funding was utilized to develop an adjacent new Medical Office Building representing 36,000 square feet of new program space. The MOB is currently occupied by an anchor tenant that provides a wide array of both physician specialty offerings and extensive ancillary services. Continuing initiatives are planned to introduce added senior living product and program presence for the campus.
Market Considerations
Strategic Action Initiatives
Market Considerations
CCA has served in business and financial services capacity to a community not-for-profit senior campus provider of skilled nursing and assisted living operations located in Cambridge, MA. 
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