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September 2019

Symphony Post Acute Expands into Michigan with Caretel Acquisitions; County SNF Hits Market for $19M

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Symphony Post Acute Network expanded its footprint into the Michigan market this week with the acquisition of Caretel Inns of Brighton and Caretel Inns of Lakeland, a pair of skilled nursing and assisted living facilities.

Located in Brighton and St. Joseph, Mich., respectively, the facilities blend high-end post-acute care with assisted living units, according to an announcement from the Chicagoland-based Symphony.

The move marks the first step in Symphony’s gradual takeover of Caretel Inns of America; Symphony concurrently announced plans to take over Caretel’s remaining properties in Linden, Bay City, and Woodhaven, Mich. pending approval from the Department of Housing and Urban Development.

“I am very excited for Caretel to become part of the Symphony family,” Stephanie Hildebrant, vice president of innovation and operations at Caretel Inns of America, said in a statement. “The history, philosophies, and values of the two organizations are parallel, allowing the Caretel Concept to not only continue but to grow.”

Symphony does not plan to rebrand the Caretel facilities in the near term, partially as a nod to the “Caretel Concept” brand initially developed by company founder Horace D’Angelo, Jr.

Evans Senior Investments Pulls Off Pair of Deals

Evans Senior Investments announced a pair of long-term care transactions this week, with the first covering two senior living and skilled nursing facilities in Michigan. Sold on behalf of a regional owner/operator, the properties boasted a 100% private-pay census on the senior living side, and a favorable Medicare Part A mix within its skilled nursing population.

“This transaction presented an exciting opportunity for a new entrant to establish a portfolio in the state with one transaction and the potential for a regional operator to solidify their economies of scale with an infusion of beds to their regional portfolio,” Jason Stroiman, president and founder of the Chicago-based Evans Senior Investments, said in a statement announcing the deal.

The second transaction involved the $11.5 million sale of the Ellenburg Nursing Center in Greenville, S.C. The property features 181 beds and was 90% full when it first hit the market, though the previous owners struggled with less than ideal economies of scale and a lack of partnership opportunities; the Ellenburg property, which took in about $12 million in annaual revenue, was the group’s only skilled nursing community.

Evans Senior Investments represented the former owners, eventually locating a regional owner-operator group to buy the facility.

“Ellenburg is well-positioned with strong demographic growth and limited competition,” Stroiman said in a separate statement. “This value-add sale presented a great opportunity for the new ownership group with operational expertise and synergies in the skilled nursing market to significantly improve the profitability at the facility.”

County to Sell Troubled Skilled Nursing Facility for $19M

Local officials in Rock Island County, Ill. approved plans to put the Hope Creek Care Center on the market for $19 million — a figure that falls just below its current $19.5 million debt load, according to a report in the Quad-City Times.

Marcus & Millichap has signed on to help broker the sale of the property, located in East Moline, Ill.

Built in 2007, the facility has 245 licensed beds on 12.5 acres of land, according to the Times; the property currently takes in about $10.6 million in revenue against $13.2 million in expenses.

Marcus & Millichap senior marketing director Ray Giannini told the publication that the brokerage firm expects multiple bids on the property, calling the local landscape “a seller’s market.”

“It’s a beautiful facility. Nothing else out there is 2007 construction,” Giannini said, per the Times. “I walked through the facility. The sun was shining; it’s got a two-story dining room. Most nursing facilities were built in the ’60s and ’70s with an addition. But this is new, state-of-the-art, sexy stuff. If a facility can be sexy, this is sexy.”

However, Giannini also told officials that the $19 million asking price likely represents the ceiling for the nursing home — which he predicted would sell for no less than $12 million, the publication reported.


AuthorAlex Spanko

Symphony Post Acute expands network to Michigan

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The Illinois-based Symphony Post Acute Network has acquired Caretel Inns of Brighton and Caretel Inns of Lakeland, with plans to acquire three more affiliated facilities.

Caretel’s holdings cross Michigan; facilities offering post-acute rehab, assisted living and memory care were designed to mimic residential hotels. Symphony said it is working to purchase Caretel Inns of Linden, Caretel Inns of the Tri-Cities and Applewood Nursing Center but is awaiting approval from the Department of Housing and Urban and Development.

The Caretel sites are expected to retain their existing names.

Symphony Post Acute Network operates facilities in Illinois, Indiana and Wisconsin with medical resort amenities, from putting greens to day spas. Symphony will add to its Caretel sites an array of pulmonary, cardiac and memory care programming in a major rebranding effort.


Balancing Risks, Rewards of Targeting Higher-Acuity Residents in Skilled Nursing

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Over recent years, as length of stay and reimbursement have declined in the skilled nursing space, one trend has risen steadily: the acuity of the patient population.

It’s a trend that multiple executives in the skilled nursing field have observed, particularly as the industry prepares to pivot toward the new Patient-Driven Payment Model.

But it’s also a trend that hospitals have been watching closely, Angie Roberson, the president of the American Case Management Association (ACMA), told Skilled Nursing News.

“From the hospital perspective, we see very ill patients being discharged much sooner, and we do feel like we are sending patients with higher complexities to skilled nursing partners in the community,” Roberson, who also serves as the director of case management for the Spartanburg Regional Healthcare System in South Carolina, said.

There are some specific populations that pose challenges for hospitals, Roberson said, citing conversations with its members from around the country. Patients on long-term ventilation who also require hemodialysis are hard to place in the facilities, simply because of the equipment and care requirements. Other challenging populations include patients with behavioral needs and complex wounds, mainly because of the cost of the antibiotics involved.

“The cost of some of this care is so expensive that oftentimes the reimbursement for the SNF doesn’t cover the cost,” she told SNN. “You end up with a person who’s in a gap, if there’s nobody to provide their care and treatment for them in a home setting.”

Conversations and partnerships

Patient demographics vary considerably depending on geographic location, Tim Fields, the co-founder and CEO of Ignite Medical Resorts of Niles, Ill., told SNN. The company, which specializes in higher-end facilities for post-acute residents, currently operates in the greater Kansas City and Chicago markets, and when it comes to where patients go after a hospital stay, those regions differ greatly.

“A new tracheostomy patient would never go to a [long-term acute care hospital] or an acute rehab facility in Chicago,” he said. “But in Kansas City, they would go there almost all the time.”

Donna Sroczynski, the president of operations at Symphony Post Acute Network — which operates in Illinois, Wisconsin, Indiana and most recently, Michigan — also emphasized this point.

“We find hospitals are very different, markets are very different, and physician practice patterns differ from geographic area to geographic area,” she told SNN.

The landscape has shifted considerably over the past decade, Roberson said, and many SNFs are trying to increase their clinicians’ skill levels to deal with the changing population.

In fact, she’s seen SNFs partner with hospitals to bolster staff competencies, sending employees to the acute setting in order to work on simulations, mannequins, and other training devices. Hospital respiratory therapists will go to SNFs to offer in-services and education, Roberson said.

One of the results has been that new tracheostomy patients, who used to be particularly challenging to place in a SNF, have a much easier path to the post-acute setting, she told SNN.

“Just at my organization, we approached some of the facilities who were forward-thinking and asked: Would you be wiling to learn some new skills, and would you be willing to have equipment in place so you could meet the needs of the patients?” Roberson explained. “We saw that. Now some SNFs employ respiratory therapists and so discharging patients with trachs is not as complex as it once was.”

Sroczynski confirmed this trajectory for patients with new trachs. Symphony has also worked with major systems such as UChicago Medicine to build out pulmonary or cardiac programs to care for higher-acuity patients.

“The key component in that was the competency and qualifications of the nursing staff that worked on those units, and making sure they were adequately trained and prepared to take care of those patients,” she said.

Those training partnerships with hospitals were vital to getting the programs off the ground, she said, and the collaboration has gone both ways: On occasion, Symphony has approached hospitals with Medicare claims data to show where their programs could help with patient needs, while other times hospitals have approached Symphony to ask for help placing difficult patients.

The challenges

But operators considering making additions to their service lineups need to consider some of the challenges. One issue Roberson has seen relates to reimbursement, particularly around antibiotics.

“Oftentimes the reimbursement for the SNF doesn’t even cover the cost of the special bed and the high-dollar antibiotics that some of these folks need,” she said. “So you end up with a person who’s in a gap; if there’s nobody to provide their care and treatment for them in a home setting, they really need to be in a skilled environment. It’s a gap that exists.”

SNFs also need to make sure, when they’re approaching payers and referral sources, that they know the decision-makers at their partner hospitals and managed care organizations (MCOs), Fields said.

“I’d sit down with multiple levels, so you’ve got to find sometimes the right people to talk to,” he told SNN. “So maybe sometimes it’s the director of case management. Sometimes it’s the chief nursing officer. Sometimes it’s the CEO … and usually with the MCOs, it’s not the person in charge of contracts. There’s usually a chief medical officer of the plan, or a vice president that’s over the plan.”

Another issue, both for SNFs and the hospitals with patients ready for the SNF setting, is the fact that patients who are particularly complex — whether through difficult behaviors or acute medical conditions — tend to draw attention from regulators, she said. Though Roberson stressed that her experience comes from the hospital side of the continuum, she said she’s heard that surveyors tend to focus on medically complex, high-acuity patients within a given building.

Roberson also noted that families, when given a choice, won’t always choose four- or five-star facilities, but rather the ones where they know the staff and are familiar with the care — intangibles that aren’t always captured in the federal star rating system on the Centers for Medicare & Medicaid Services’ (CMS) consumer-facing Nursing Home Compare website. Though Roberson emphasized that the rankings have validity, experience with families makes her think those ratings don’t tell the whole story, especially when it comes to complex patients.

“I do think there is some truth to the [idea] that facilities that take your more complex patients, when they’re surveyed under the SNF regulations, I think they struggle with some of the regulations,” Roberson said. “I don’t think it always means they’re providing a low quality of care.”


AuthorMaggie Flyn