Annual Quality Report 2013...patient experience, and bending the cost curve through Signature CareConnect. There are always opportunities for health care organizations to improve quality

Annual Quality Report 2013

avamerecom

Since 1995 the Avamere Family of Companies has promoted our mission to enhance the life of every person we serve Through our mission we continually drive the innovation necessary to redefine quality care and stay ahead of the ever-changing national health care landscape From expanded training for our staff significant reinvestments in our buildings and substantial improvements in our technology infrastructure Avamere has time and again demonstrated that we are committed to quality that is obvious

Of course our successes over the years would not be possible without the dedication of our support staff and clinicians living out our mission every day in the communities we serve Every member of the Avamere Family ndash from caregivers and nurses to therapists and administrators and everyone in-between ndash play an integral role in helping our patients reach their goals our residents maintain their independence and ensuring effective communication to the families of those we serve

With the recent advent of the Affordable Care Act (ACA) we are experiencing tremendous change in our country surrounding health care With approximately 10000 new 65-year-olds every day the population we serve continues to grow rapidly To provide the level of quality services these active aging adults demand the Avamere Family of Companies continues to innovate upon our existing care models and lead the way for a more individually-focused and satisfying post-acute experience

For us quality is not a destination but a journey We began breaking down the walls between our lines of services nearly five years ago in order to improve communication amongst our post-acute providers streamline patient transitions prevent unnecessary re-hospitalizations and return patients to the residence of their choice Through our efforts the Avamere Family of Companies introduced Signature CareConnect

Signature CareConnect is a successful network of affiliated healthcare professionals united by the common goal of providing seamless care and support across the post-acute continuum The development and rollout of Signature CareConnect was a monumental task It effectively changed our approach to how post-acute care is delivered and reconfigured the standard model of long-term and skilled care that had been nationally accepted for decades The major components of national care initiatives and our own care pathways put patient satisfaction and quality outcomes at the center

Through our passion for the quality of peoplersquos lives continued innovation a culture of trust and respect and placing integrity above all else the Avamere Family of Companies will build on our many successes of 2013 and continue to insure a quality experience for every person we serve

John W Morgan CEOAvamere Family of Companies

2 Avamere A Family of Companies

The mission of the Avamere Family of Companies is to enhance the life of every person we serve It is through our Core Values that each member of our Family lives our mission By putting integrity above all else our passion for the quality of peoplesrsquo lives shows in our evidenced-based approaches to achieving the best possible outcomes We strive for quality that is obvious the type of quality that is won through hard work and innovation Our culture of trust and respect is recognized during the first meeting between the families patients residents and our caring staff As a leader of post-acute care services the Avamere Family of Companies continually reaches to learn grow and embrace change Ultimately it all comes down to teamwork camaraderie and fun

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1 Avamere Family of Companies p6 Providing Quality Care during Changing Times

2 Signature CareConnect p6 Risk Stratification Process

Results

3 Avamere Skilled Nursing Long-Term Care Transitional Care p9 CMS Five-Star Registered Nurse Staffing Reducing Incidences of Re-hospitalization Shorter Stays for Faster Recovery

4 Avamere Assisted and Independent Living p14

5 Signature Hospice Home Health Home Care p15 Quality Outcomes Improvement Improving our Care Management Model Home Health Hospice

6 Infinity Rehab p19 Employee and Customer Satisfaction

Telehealth Therapy Solutions

7 Investing in Our Future and the Future of Others p22

8 Expanding the Avamere Footprint p22

9 Our Commitment to 2014 p22

Your Life Our Commitment

MissionTo enhance the life of every person we serve

Core ValuesIntegrity above all else

Passion for the quality of peoplersquos livesQuality that is obvious

Innovation not emulationA culture of trust and respect

Reaching to learn grow and embrace changeTeamwork camaraderie and fun

In order to deliver a quality patient experience we place the needs and desires of the patient at the center of every decision made Every person presents a wholly unique health care situationmdashfrom lifestyle choices and age to current health status and a host of other factorsmdashour person-centered attitude shapes and informs our comprehensive approach to quality care Simply everything we do we do with those we serve at the center

T A B L E O FC O N T E N T S

1

2

3

4

5

6

7

8

9


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A S S I ST E D

L I V I N G

M E MO RY

C A R E

H O S P I C ES K I L L E D N U R S I N G

LO N G -T E R M A N D

T R A N S I T I O N A L R E H A B

I N D E P E N D E N T

L I V I N G

H OM E H E A LT HCOM M U N I T Y B A S E D

C A R E

I N V E ST E D I N N EW B U I L D I N G S A N D U P DAT E S TO C U R R E N T FAC I L I T I E S

AVA M E R E AT A G L A N C EThrough each line of service we offer the Avamere Family of Companies continue to receive national and local recognition for our innovative care models quality outcomes and customer satisfaction It is our mission to enhance the life of every person we serve

I N V E ST E D I N I M P ROV I N G T EC H N O LO GY A N D EQ U I P M E N T

R E H A B I L I TAT I O N

H OM E C A R E

T H E AVA M E R E FA M I LY O F COM PA N I E S

S E RV I C E S P ROV I D E D

AWA R D S a n d R ECO G N I T I O N S

O U R I N V E ST M E N TS

$408M $9M

reg

SILVER BRONZE


Accountable care organizations bundled payment programs pay-for-performance avoidable re-hospitalization penalties the Affordable Care Act (ACA) and Medicare shared savings programs all continue to be the new language for healthcare The result and reality of these new laws regulations and marketplace convergence is stronger alliances among providers The full effect of the ACA passed in 2010 is still unknown Many of the primary requirements that were intended to begin in 2014 are delayed or postponed creating uncertainty as well as opportunities

The US health care system is the most costly in the world accounting for 17 percent of the gross domestic product with estimates that percentage will grow to nearly 20 percent by 20201 An aging population and increased longevity coupled with chronic health problems have become a global challenge putting new demands on medical and social services In response to this the Institute for Healthcare Improvement (IHI) initiated the Triple Aim (Fig 1)mdasha framework for optimizing health system performance

Goals of Triple Aimbull Improve the patient experience of care (including

quality and satisfaction)bull Improve the health of populationsbull Reduce the per-capita cost of health care

The IHI has proclaimed that ldquoin most health care settings today no one is accountable for all three dimensions of the IHI Triple Aim2rdquo The Avamere Family of Companies agrees with the overall principles of Triple Aim but we believe through our successful innovative care models we can be responsible for all three We continue to experience success in achieving quality outcomes improving the patient experience and bending the cost curve through Signature CareConnect

There are always opportunities for health care organizations to improve quality of care In fact through penalties and incentives The Centers for Medicare and Medicaid Services (CMS) structured reimbursements to reward improved quality Hospital readmissions have become the central national focus for improving patient outcomes lowering healthcare costs and creating better transitions between care settings To implement effective change it takes planning innovating managing and executing improved care models

As early as 2009 the Avamere Family of Companies anticipated the emerging realities of the national health care landscape and began developing a new care model that would eventually become Signature CareConnect Signature CareConnect is a successful network of affiliated

AVA M E R E FA M I LY O F COM PA N I E SP ROV I D I N G Q UA L I T Y C A R E D U R I N G C H A N G I N G

T I M E S

S I G N AT U R E C A R ECO N N EC TI N T EG R AT E D C A R E F O R B E T T E R L I V I N G

1

2

Figure 1 The Institute for Healthcare Improvementrsquos Triple

Aim framework

Popu

lation

Hea

lth

Experience of Care

Per Capita Cost

1 The Office of the Actuary Centers for Medicare amp Medicaid Services National Health Expenditure Projections 2010-2020 (accessed April 12 2014) available from httpswwwcmsgovResearch-Statistics-Data-and-SystemsStatistics-Trends-and-ReportsNationalHealthExpendDataDownloadsproj2010pdf2 ldquoThe IHI Triple Aimrdquo Institute for Healthcare Improvement np nd Web (accessed April 28 2014) available from httpwwwihiorgEngageInitiativesTripleAimPagesdefaultaspx

avamerecom

healthcare professionals united by the common goal of providing seamless care and support

Signature CareConnect integrates our current lines of care services improves communication and efficiencies among the independent health care organizations under the Avamere Family of Companies umbrella and teams with regional health care partners for greater continuity of care Through these methods we achieve the objectives of Signature CareConnect which are to reduce re-hospitalization strengthen communication between provider and patient and position our businesses as market leaders We have since adopted the Triple Aim health care improvement standards because its core principles align with our ongoing endeavors

The development and rollout of Signature CareConnect was a monumental task It effectively changed our approach to how post-acute care was delivered and upended the standard model of long-term and skilled care that had been nationally accepted for decades Combining the major components of national care initiatives with our own patient satisfaction and quality outcomes moved to the center Signature CareConnect reaffirms our commitment to quality

We strongly believe in providing the right kind of care at the right time and in the right setting This person-centered approach upholds our conviction that convenience timeliness customization and continuity of care are the driving factors toward improved customer satisfaction The Signature CareConnect network is accessible to seniors through all the twists and turns that may come along in lifersquos journey Our network of professionals provides both the road map to navigating a complex health care system as well as assistance along the way

Our networks ndash which include skilled nursing transitional rehabilitation home health home care hospice memory

care independent living and assisted living providers ndash work to ensure that the continuum of care is left unbroken for seniors At the same time our innovative care system addresses clinical and financial concerns at all levels

A patient enters anywhere into the Signature CareConnect system and we manage the patient throughout our network (Fig 2) This increases our ability to coordinate the care of the patient in a consistent efficient and quality manner for up to 90 days after discharge from the hospital We utilize Clinical Liaisons in partner hospitals and Care Management Registered Nurses (RNs) to guide patients throughout our continuum In 2014 we will incorporate nurse practitioners in the skilled nursing and assisted living settings into this care model through NP2U

NP2U is a new member of the Avamere Family of Companies that is managed by nurse practitioners and focuses on health assessments and quality coordination of care The goals of NP2U are

bull Collaborate with attending physiciansbull Address resident health issues on a weekly basisbull Promote early identification and treatment of resident health concernsbull Improve health education and counselingbull Avoid unnecessary doctor office trips hospitalizations and emergency department usebull Increase collaboration among the Avamere clinical team attending physician residents and family

2 0 1 3Q U A L I T Y R E P O R T

Figure 2 The Signature CareConnect network


To better allocate resources for high-risk and at-risk patients of re-hospitalizations the Avamere Family of Companies created PLACES ndash a stratification tool to assess risk of re-hospitalization for all patients at the time of intake When designing PLACES there were several considerations that directed our efforts The tool had to be easy to implement and use by clinical staff while facilitating a greater focus on limited resources And ultimately achieve better outcomes for patients based on the guidance of the risk assessment tool

Signature CareConnect Risk Stratification Process (Fig 3)1 PLACES readmission risk assessment performed for

every patient referred to our network2 All patients are educated on identifying and managing

disease-specific red flags3 Clinicians organized into pods to promote better

communication and care planning4 Clinician pods conduct care coordination calls for

real-time risk management5 My Health Diary and patient follow-up calls are

designed to engage patients in their health and recovery process and enhance satisfaction

Signature CareConnect ResultsDuring a three-month period toward the end of 2013 we examined patient satisfaction data re-hospitalization

rates and 90-day episode impact from a single network skilled nursing center to determine the effectiveness of Signature CareConnect The results are very promising Overall patient satisfaction improved across five key categories (Fig 4) and re-hospitalization rates were down over 30 percent (Fig 5)

According to a report by the Healthcare Cost and Utilization Project the average cost of a hospital re-admission is $10K Based on that estimate approximately $240K was saved in episode costs through 24 avoided readmissions (Fig 6)3

Figure 3 Signature CareConnect Risk Stratification Process

Figure 4 Overall Patient Satisfaction

Figure 5 SNF Re-Hospitalization Rate

Our Mission To enhance the life of every person we serve

3 httpswwwhcup-usahrqgovreportsstatbriefssb142pdf

avamerecom

AVA M E R E S K I L L E D N U R S I N G LO N G -T E R M C A R E T R A N S I T I O N A L C A R EYO U R L I F E O U R COM M I T M E N T

3

As the Avamere Family of Companies moves forward with Signature CareConnect we will continue to monitor outcomes and share the results with the public and our partners This comprehensive evidence-based approach to person-centered post-acute care could very well be the answer to each principle of the Triple Aim

The Avamere Family of Companies operates or manages 32 care centers in four states ndash Oregon Washington Idaho and Colorado These centers offer a range of services designed to promote independence and provide comfort while producing quality outcomes Each care center is guided by the same mission and core values but is wholly special and unique to the community it serves

In addition to the feedback we receive directly from the people we serve and their families the Avamere Family of Companies utilizes multiple metrics to evaluate our quality of services these include federal and state regulatory surveys third-party data collection companies and our own internal reporting systems The information gathered from these sources is used to further evolve our care models and help to ensure we continue to stay

O U RL O C A T I O N S

Figure 6 90-day Episode Impact

Avamere at BethanyAvamere at HillsboroAvamere at NewbergAvamere at SandyAvamere at SherwoodAvamere at St HelensAvamere at Three FountainsWaterfordAvamere Bellingham Health Care amp Rehab ServicesAvamere Court at KeizerAvamere Crestview of PortlandAvamere Georgian House of LakewoodAvamere Heritage Rehab of TacomaAvamere Living at Berry ParkAvamere Olympic Rehabilitation of SequimAvamere Rehabilitation of BeavertonAvamere Rehabilitation of ClackamasAvamere Rehabilitation of Coos BayAvamere Rehabilitation of EugeneAvamere Rehabilitation of HillsboroAvamere Rehabilitation of Junction CityAvamere Rehabilitation of King CityAvamere Rehabilitation of LebanonAvamere Rehabilitation of NewportAvamere Rehabilitation of Oregon CityAvamere Rehabilitation of Rogue ValleyAvamere Rehabilitation of SalemAvamere Riverpark of EugeneAvamere Skilled Nursing of TacomaAvamere Transitional Care amp Rehabilitation- BoiseAvamere Transitional Care amp Rehabilitation- BrightonAvamere Transitional Care amp Rehabilitation- MalleyAvamere Transitional Care amp Rehabilitation- Queen AnneAvamere Twin Oaks of Sweet HomeBend Transitional CareLaurelhurst VillageRichmond Beach RehabilitationSt Francis of BellinghamSuzanne Elise Assisted Living CommunityThe Pearl at Kruse WayThe Stafford

Approximately 200 Therapy Contracts

Six Hospice Home Health Home Care Locations


ahead of national trends Continual innovation through feedback is imperative for us to remain a regional leader of post-acute care services

CMS Five-StarA comprehensive way for patients families and caregivers to choose the right nursing home for their needs is through the Centers for Medicare amp Medicaid Services (CMS) Five-Star Quality Rating System which is publicly available through the Nursing Home Compare website Each skilled nursing home in the nation is assigned a rating between one and five stars The rating is a composite of individual star ratings calculated in three separate categories

1 Health inspections2 Quality measures3 Staffing levels

The distribution of star ratings across the nation is fixed with the top 10 percent receiving five stars the bottom 20 percent receiving one star and the remaining 70 percent evenly distributed

Avamere nursing home Five-Star Quality Ratings have steadily increased over the past several years Figure 7 shows the overall average of Five-Star Ratings for Avamere nursing homes is 32 stars The important takeaways are the strategies we implemented to bring our average rating from 28 to 32 in just three years

As with any health care organization clear communication across operational divisions can be a challenge We embraced the opportunity to standardize our policies and procedures thus successfully reducing internal communication inefficiencies These efforts allowed us to implement our Facility Risk Stratification in 2013 This is a comprehensive review of systems with the goal of achieving optimal allocation of resources

In 2012 and 2013 the Avamere Family of Companies invested over $8M to convert our clinical recording and reporting systems to electronic health records (EHR) This initiative provides seamless access to patient health data at all care levels EHR also allows for improved physician and pharmacy integration into patient care planning In addition EHR helped us drive standardization and remote review of facility systems during 2013

Care staff received over 1000 hours of MDS training through the implementation of Assessment Intelligence Systems (online training) with the goal of increased accuracy of Quality Metrics

The comprehensive wound management programs implemented in 2012 continued to return positive outcomes for patients as we grew partnerships with onsite advanced practitioners in our skilled nursing centers

Another method leveraged to achieve increased Five-Star success is the utilization of Providigmrsquos abaqisreg quality management system This CMS-sanctioned suite of tools is used to conduct mock quality surveys measure customer satisfaction track and trend hospital readmissions and provide a solid base for Quality Assurance and Performance Improvement (QAPI) Based around the principles of QAPI we initiated the Champions of Quality program that focused on comprehensive leadership training on regulatory compliance and the use of systematic analysis for systemic action Figure 7 Avamere Five-Star Overall Rating

Integrity above all else

avamerecom

We are proud to be a part of the first international group of QAPI accredited nursing homes and recipients of Providigmrsquos 2013 Embracing Quality Awards Our select skilled nursing and transitional care communities were recognized in the areas of customer satisfaction prevention of hospital re-admissions and deficiency-free surveys

Registered Nurse StaffingAn important category examined under the CMS Five-Star ratings is the number of registered nurses (RN) on staff compared to the patient population Within this category the number of hours and days each RN actively works is also taken into account According to national data we outpace our peers in this category (Fig 8)

We are successful in this category primarily because Avamere skilled nursing and transitional care centers have placed an emphasis on maintaining 247 RN coverage when applicable We also re-engineered our interdisciplinary teams to include more RN team members for greater oversight of medical needs Standardization of the RN orientation and on-boarding process and the introduction of a Director of Nursing Services training program have established a foundation for providing quality care Our strategic use of RN case managers and

Q U A L I T Y A W A R D

W I N N E R S

Providigm 2013 Embracing Quality Award Recipients

Customer Satisfactionbull Avamere Rehabilitation of Oregon City

Prevention of Hospital Readmissionsbull Avamere Rehabilitation of Eugenebull Avamere Rehabilitation of Junction Citybull Avamere Rehabilitation of Salem

Deficiency-Free Surveybull Avamere Rehabilitation of Junction Citybull Avamere Rehabilitation of Oregon Citybull Bend Transitional Care

Figure 8 Registered Nurse Staffing Five-Star Ratings


care transition nurses through the Signature CareConnect networks has also contributed to our overall high RN staffing numbers

Reducing Incidences of Re-hospitalizationA major transformation is underway in managing 30-day hospital readmissions According to CMS health care costs accounted for nearly $28 trillion of the nationrsquos GDP in 2012 Of that hospital care was responsible for $8823 billion of national health expenditures ndash the single most costly category4 To break it down even further 30-Day hospital readmissions are estimated to cost $17 billion annually in Medicare spending5 According to the Institute for Healthcare Improvement approximately five million re-hospitalizations occur each year 76 percent of which are preventable6

The Avamere Family of Companies views reducing re-hospitalizations as a major priority as evidence through our ongoing investment in Signature CareConnect development of risk stratification tools and forming stronger partnerships with acute-care organizations However no single initiative holds the answer for effectively reducing re-hospitalization rates In fact we have found that a combined effort of multiple measures is necessary to successfully address this issue

Here are just a few of the tools we use to reduce a patientrsquos risk of readmitting to an acute setting

bull Risk stratification of all new admissions using PLACES tool

bull INTERACTreg tools

bull abaqisreg data tracking and system quality improvement based on root cause

bull Development of care pathwaysbull Advanced clinical skills program bull Refine diagnostic support through use of

technology including facility based PTINR testing use of bladder scans

bull Re-engineered discharge planning bull Signature CareConnect transition nursebull Palliative care consult program and advanced care

planning toolsbull Standardized processes including daily team

review of high risk patientsbull Comprehensive physician strategy

Over the previous year re-hospitalization rates within Avamere skilled nursing communities transitional care centers and assisted living campuses declined by 10 percent (Fig 9)

Shorter Stays for Faster RecoveryThe number one goal of everything we do throughout the post-acute environment is to improve the well-being and physical abilities of each patient so that he or she may enjoy the highest quality of life possible Through a combination of rehabilitative therapies and skilled nursing our clinicians work with the patient and his or her primary care physician on a custom care plan designed with the

Figure 9 Re-hospitalization Rate Trends

Passion for the quality of peoplersquos lives

4 The National Health Expenditure Accounts Centers for Medicare amp Medicaid Services National Health Expenditures 2012 Highlights (accessed April 12 2014) available from httpwwwcmsgovResearch-Statistics-Data-and-SystemsStatistics-Trends-and-ReportsNationalHealthExpendDataDownloadshighlightspdf5 Robert Wood Johnson Foundation The Revolving Door A Report on US Hospital Readmissions (February 2013) available at httpwwwrwjforgcontentdamfarmreportsreports2013rwjf4041786 ldquoCombating Preventable Rehospitalizations No Easy Taskrdquo Institute for Healthcare Improvement np nd Web (accessed April 28 2014) available from httpwwwihiorgaboutnewsPagesCombatingPreventableRehospitalizationsNoEasyTaskaspx

avamerecom

intent to return the patient to their preferred choice of residence

Through patient-specific clinically appropriate therapy utilization intelligent patient risk stratification post-discharge follow-up and leveraging care transition nurses our rate of discharging patients back to their communities far outpaces that of our national peers (Fig 10) Avamerersquos overall average for returning patients back to their preferred living choice is just under 70 percent with a number of our facilities returning patients to the community at 90 percent within 30-days

Providing shorter stays for faster recovery is an integral piece to our approach to post-acute care services In fact in 2012 we welcomed Bend Transitional Care to the Family The newly built short-stay facility is designed to rehabilitate patients quickly which has resulted in quality outcomes and increased patient satisfaction Upon opening its doors to the public the transitional care facility reached capacity within 45-days Bend Transitional Care has exceeded all our expectations In late 2014 Salem Transitional Care will open its doors to the public (see ldquoExpanding the Avamere Footprintrdquo section for more information) Both short-stay centers are located close to hospitals for greater continuity of care and smoother patient transfers

Figure 10 30-day Discharge Comparison


W I N N E R S

SILVER

BRONZE

Silver ndash Achievement in QualityAvamere Rehabilitation of Hillsboro - 2013Avamere at Bethany - 2013The Pearl at Kruse Way - 2013Avamere at Sherwood - 2013Avamere Rehabilitation of Junction City - 2010 Richmond Beach Rehab - 2008St Francis of Bellingham - 2008

Bronze ndash Commitment to QualityAvamere Rehabilitation of Oregon City- 2013Avamere Rehabilitation of King City - 2012The Stafford Boutique Retirement Community - 2012 Avamere Crestview of Portland - 2012Avamere Rehabilitation of Beaverton - 2012 Avamere at Sandy - 2011Avamere at Hillsboro - 2011Avamere at Newberg - 2011Avamere at Waterford - 2011Avamere at Three Fountains - 2011Bend Transitional Care (Harmony House of Bend) - 2011Avamere Twin Oaks of Sweet Home - 2010 Avamere Rehabilitation of Lebanon - 2010Suzanne Elise Assisted Living Community - 2010 Avamere Rehabilitation of Eugene - 2009 Avamere Court at Keizer - 2009Avamere at Three Fountains - 2009Avamere Rehabilitation of Newport - 2009 Avamere Riverpark of Eugene - 2009Avamere at St Helens - 2009Avamere Rehabilitation of Coos Bay - 2009 Avamere Olympic Rehabilitation of Sequim - 2008 Avamere Rehabilitation of Clackamas - 2008


The Avamere Family of Companies offers living and care options for every stage of life Independent living is defined by freedom choice amenities and convenient assistance for a range of needs We apply that same definition to our Community Based Care campuses Residents enjoy a community lifestyle that promotes independence and respects the privacy of the individual as well as their personality and character From onsite restaurant-style dining to a full calendar of physical and social activities there is something for everyone at our Independent and Community Based Care campuses

Three of our Community Based Care campuses applied for the American Health Care Association and National Center for Assisted Living (AHCANCAL) Quality Award The program encourages continuous learning and development of integrated quality systems to achieve performance excellence Campuses that move through the three levels of the program are expected to gain insight into their organizationsrsquo strengths and opportunities for improvement as well as receive customized feedback to help improve overall organizational effectiveness and capabilities

Nursing hours in each of our assisted living communities were increased to a range of 12 to 40 Licensed Practical Nurse hours as well as 247 RN support This has allowed our communities to implement new tools effectivelymdashsuch as PLACESmdashand to focus on decreasing patient risk of unnecessary re-hospitalizations We are proud to report that through this increased focus on clinical care at the assisted level re-hospitalization rates declined by over 10 percent from 225 percent to 12 percent (Fig 11)

We rely on the feedback of our residents to gauge how well we are meeting their needs In a recent survey 95 percent of respondents rated their overall satisfaction with Avamere as positive (Fig 12) In addition 93 percent of respondents said they would likely refer our services to a friend The majority of respondents had lived at one of our Community Based Care campuses between one and three years Such positive feedback from those we serve just reinforces that our mission to enhance the life of every person we serve happens at every level of senior care

Figure 11 Decline in 30-day Rehospitalization Rate

Figure 12 Customer Positive Response to Overall Satisfaction

AVA M E R E A S S I ST E D A N D I N D E P E N D E N T L I V I N GC H O I C E S F O R A N AC T I V E AG I N G P O P U L AT I O N

4

Quality that is obvious

avamerecom

The healthcare world and market dynamics continue to change with dizzying speed For the home health arena the most significant changes revolve around regulatory and reimbursement changes as well as consolidation of provider relationships Signature which is an independent member of the Avamere Family of Companies and offers hospice home health and home care services is poised to thrive during these trying times through efficient and cost effective care continual focus on quality outcomes and an increased ability to serve more patients

In 2011 and 2012 the home health industry experienced a combined 115 percent cut in Medicare reimbursement In 2013 all Medicare providers (including home health and hospice) had an additional two percent cut due to government sequestration This cut will continue for the foreseeable future The home health industry also faces a re-basing of rates from 2014 through 2017 The Visiting Nurse Associations of America ndash a nonprofit home health hospice and palliative care advocacy group ndash estimates that agencies will see cuts of up to 35 percent each year from 2014 through 20177 Many agencies will not be able to survive those cuts

Hospices will be required to carry a greater cost burden for medications These medications may not be related to a patientrsquos hospice diagnosis but will be the responsibility of the hospice Some industry estimates point to a 30 percent to 40 percent increase in medication costs if the new requirement is not effectively managed

With a rapidly changing health care environment providers are actively seeking the best strategy for the

O H C AV O L U N T E E R

O F T H E Y E A R

Avamere at Sherwood Volunteer Receives 2013 OHCA Volunteer of the Year Award

This is a story about what it means to give back in the most selfless way possible Evelyn Rogers 87-years-young has volunteered with Avamere at Sherwood for over 10 years and recently received the ldquoVolunteer of the Yearrdquo award from the Or-egon Health Care Association Nicolette Merino Regional Director of Operations attributes Evelynrsquos up-beat outgoing attitude to her success as a vol-unteer ldquoEvelyn always contributes to the positive well-being of the residents and the morale around our campus She brings a special kind of vibrancy and excitement that the residents and staff abso-lutely cherishrdquo says Merino

Evelyn has visited the assisted living community every day for more than a decade which is one of the many reasons she deserves this recognition ldquoEvelyn does everything She comes in around 11 AM to help with activities and stays until well after her expected shift is overrdquo says Sabrina Thompson Activities Director ldquoShersquoll go grocery shopping host activities when Irsquom not here and is a constant source of kindness enjoyment and warmth for our staff and residentsrdquo

During the awards ceremony OHCA representa-tives highlighted Evelynrsquos drive to perform above and beyond the call of duty and provide comfort to residents family members and enhance the culture of Avamere at Sherwood

S I G N AT U R E H O S P I C E H OM E H E A LT H H OM E C A R EPA S S I O N AT E A B O U T P E O P L E

5

7 rdquoState by State Medicare Rebasing Access amp Jobsrdquo Visiting Nurse Associations of America np nd Web (accessed April 28 2014) available from httpvnaaorgFilesPublicPolicyRegulationshome-health-4-americaImpact20Overview20-20Projected20201720Home20Health20Medicare20Marginspdf


new ndash and sometimes uncertain ndash health care frontier We experienced some difficult challenges in 2013 but also encountered significant opportunities Signature continued to show improvement in growth quality and culture benchmarks Employee satisfaction scores and quality metrics also improved With 650 staff associates in 12 branch offices the Signature companies provided over 250000 care visits to more than 9000 patients and clients in 2013 (Fig 13)

Quality Outcomes ImprovementIncreasingly our sector of health care is scrutinized by external agencies for improvements in quality and patient satisfaction Although this places a larger operational burden on us we welcome the scrutiny because it gives us more incentive to optimize our care models for quality outcomes

Our vision is to exceed national benchmarks in 80 percent of our quality outcomes over the next several years Signature created a regional Quality and Compliance team comprised of Regional Quality Directors to oversee and actively track outcomes This team interprets the data to continually fine-tune our approach to patient care for increased patient satisfaction

Improving our Care Management Model This initiative began in 2013 with the inclusion of Signature CareConnectrsquos risk stratification tool ndash PLACES ndash and the development of a cost efficient and effective care management model for high-risk patients Our goal is to decrease re-hospitalizations and improve the care of patients and clients All of our agenciesrsquo personnel are trained in this model and we look forward to sharing the results after full implementation in 2014

Based on our 2013 Employee Satisfaction survey Signature is in a position to mobilize our employees for care transformation initiatives

bull 95 percent of employees would recommend Signature as good place to work (Fig 14)

bull More than 92 percent of employees believe Signature and its agencies are heading in a positive direction

bull Close to 90 percent of staff agree that our leaders are leading effectively

Home HealthSignature Home Health has improved patient outcomes Six of seven publicly reported outcome meausures show an average year-over-year increase of 437 percent Four of these outcomes have a greater than five percent improvement in the past 12 months Outcomes related

Figure 13 Home Health Episodes of Care

Figure 14 Percent of Employees Recommended Signature as a Good Place to Work

Innovation not emulation

avamerecom

to reducing hospital readmissions show the biggest gains (increased dyspnea improvement by over nine percent and improved ability to manage medications by more than six percent) (Fig 15)

Signature Home Healthrsquos low re-hospitalization rate consistently beats the national average Our re-hospitalization rate is 36 percent below national peers In addition our re-hospitalization rate is lower for key high-risk medical conditions such as chronic heart failure chronic obtrusive pulmonary disease cerebrovascular accidents hypertension diabetes and mental disorders

Signature Home Health continues to put the right processes in place Nine of 13 publicly reported process measures improved in the past 12 months Our tracking measures already indicate that we will have patient satisfaction over 96 percent with a goal of 98 percent by the end of 2014 (Fig 16)

T O P - R A N K I N GH O M E

H E A L T H

Signature Home Health Medford Office Receives High Marks for Quality Measures

The Medford OR Signature Home Health office is nationally recognized through healthinsightorg as the second highest-ranking agency in the State of Oregon for quality measures for 2013 In fact all of Signaturersquos Oregon offices were ranked in the top 10

This ranking is based on the Home Health Compare Data Set as compiled by CMS and empowers Americans with quality of care information to help them make informed decisions about their health care

Bob Thomas PT President of Signature Home Health attributes the success of the Medford division to adhering to a simple mission ldquoWe strive to enhance the life of every person we serverdquo says Thomas ldquoAnd through that we work to continually improve the patient experience while producing quality outcomes that are in line with the patientrsquos plan of carerdquo

The CMS data set results placed the office in the 95th percentile nationally for quality measures

Figure 15 Publicly Reported Patient Outcomes

Figure 16 Home Health Patient Satisfaction


HospiceSignature Hospice strives to create a pleasant experience for families and patients during what can be a difficult journey With a devoted support team our services focus on comfort companionship relief peace and resolution For any journey preparation and evaluation are essential Before going on vacation we make lists research our destination check the weather and find a trusted person to care for our home That is what Signature Hospice does so well We prepare families for an anticipated journey through compassionate thoughtful evaluation

In 2013 126 hospice volunteers provided 3810 hours of comfort to patients in the Portland Salem and Eugene Oregon communities It is through the compassion and dedication of these volunteers that our hospice program is so successful Our volunteers provide direct patient and family companionship and supportndashwriting letters reading books aloud playing board and card games playing a musical instrument sharing a good conversation grocery shopping sitting quietly together watching a movie together and so much more

Our holistic approach to senior care and hospice services involves a team dedicated to the quality of life The patientrsquos primary care physician maintains one-on-one care while a medical director oversees the entire plan of care Signature registered nurses home health aides medical social workers spiritual counselors and volunteers all play a role in providing comfort and care during this time of transition

Signature Hospice is strongly focused on improving quality of life for every individual we serve To this end over 99 percent of patients received appropriate symptom assessment and 94 percent of patients reported satisfaction with the comfort we provided In both Symptom Assessment and Symptom Control Signature

Hospice far out performed national patient satisfaction levels in every reported category (Figs 17 amp 18)

Home CareSignaturersquos holistic approach to post-hospital care takes in to account that assistance with basic home care tasks such as shopping and cleaning to direct care services including medication assistance and case management - may be required during the recovery process and beyond It is through our mission to enhance the life of every person we serve that we assess the specific situation of the individual and tailor our services to meet their needs

Figure 17 Hospice Patient Symptom Assessment

Figure 18 Percent of Satisfied Patients

A culture of trust and respect

avamerecom

Since 1999 customers have chosen Infinity Rehabrsquos unique brand of high intensity clinical care services for our ability to achieve quality outcomes and manage rehab programs that provide better business results As an independent member of the Avamere Family of Companies Infinity Rehab is well-suited for the rapidly changing marketplace because of our proven track record of seizing opportunities for growth during times of industry contraction and using our combined experience to develop tailored rehab programs that achieve operational and financial efficiency compliance and clinical programming outcomes

As reimbursement rates change from volume based to outcomes based Infinity Rehab has already taken the next step in redefining how we deliver care by placing the patient squarely at the center of all we do (Fig 19) Our newly established Quality and Outcomes department is hard at work overhauling therapy delivery models Through the creation of a Professional Development department existing talent within Infinity Rehab is being cultivated and supplied with the tools and training to be best-in-class clinicians

I N F I N I T Y R E H A BR E AC H F U RT H E R N EV E R S E T T L E 6

Figure 19 Focus on Person-Centered Care

Pinnacle Customer Experience Awards

A senior healthcare advocate for over 15 years Pinnacle Quality Insight established the Customer Experience Awardtrade to recognize organizations that achieve exceptional resident and patient assistance Pinnacle conducts thousands of monthly surveys that are included in a comprehensive review of an organizationrsquos dedication to quality and service

Infinity Rehab utilizes the feedback from Pinnacle surveys to better understand the needs and desires of the people we serve and to assess how our individual rehabilitation programs are performing

Over the course of 2012 nearly 80 of Infinity Rehabrsquos contract therapy programs achieved best-in-class customer satisfaction standards based on customer and family feedback Pinnacle Customer Experience Awardstrade were attained in the following categories

bull Overall Satisfactionbull Overall Customer Experiencebull Response to Concernsbull Atmosphere Therapy Areabull Knowledge Skills of Therapistsbull Equipment Qualitybull Dignity and Respectbull Results Achievedbull Recommend to Othersbull Understood Proceduresbull Pace of Progressbull Involvement Goals

reg

C U S T O M E R E X P E R I E N C E

A W A R D S


Infinity Rehab physical occupational and speech therapists across all settings of post-acute care provided over 15 million patient visits in 2013 Our therapeutic touch is felt through our more than 2000 full-time part-time and on-call employees We maintained a strong presence throughout the states in which we operate ndash OR WA ID CO UT NE IL AK and AZ ndash with significant growth in the Colorado outpatient market

Employee Satisfaction There is growing national awareness of and research to support the importance of high-intensity therapy interventions for patient recovery It is therefore critical that our clinicians stay up-to-date on the latest therapy practices Clinical training and continued education are cornerstones to the quality outcomes our therapists produce annually

A recent AHCA survey showed that higher employee satisfaction translates to higher quality of care In 2013 982 percent of Infinity employees said they would recommend Infinity Rehab to a friend (Fig 20)

Infinity Rehab University is our continuing education forum for employees and professional therapists in the communities we serve Each year Infinity Rehab University hosts several Continuing Education Symposiums Year after year attendance grows at each event The Pacific

Northwest Symposium (held in Portland Oregon) has become one of the largest continuing education events for therapists in the region Just this past year nearly 700 physical occupational and speech therapists attended to earn up to 12 continuing education credits

Infinity Rehab is only as strong as the people we employ We believe it is important to develop our managers and clinicians to be the best at every level of service This produces opportunities and results including

bull A front-line clinical staff that excels at efficient evidence-based care

bull High levels of career and job satisfaction for our health care professionals and support staff

bull Regional and national exposure for our professionals and for Infinity Rehab to maximize the influence we have in the health care industry

bull A solid retention strategy and a reflection of our companyrsquos commitment to our patients and our customers

We believe our high employee satisfaction translates to high customer satisfaction with 945 percent of customers reporting they would recommend our services to others (Fig 21) The skilled nursing acute-care organizations and assisted living campuses we serve continue to report outstanding satisfaction year-over-year with the services Infinity Rehab provides and patient outcomes our therapists achieve

Figure 20 Percent of Employees would Recommend Infinity

Figure 21 Customer Satisfaction

Reaching to learn grow and embrace change

avamerecom

Telehealth The Future of Access to Affordable Care On November 15 2013 the Washington State Board of Hearing and Speech voted unanimously in support of a proposal to allow telehealth supervision of Speech Language Pathologists (SLPs) during their Clinical Fellowship Year Angie Quesnell SLP and Regional Mentor for Infinity Rehab submitted and championed the proposal through the process

Telehealth is the use of videoconferencing advance technology and telecommunications to support long-distance clinical care for patients or in this case other therapists Once a SLP graduates from school they spend a year as a Clinical Fellow (CF) working to develop their skills under supervision of an experienced clinician Angie currently supervises 4 to 5 CFs in a rural area of Washington and travels extensively to be onsite to meet with her supervisees She seized the opportunity and succeeded in improving the current methods to the benefit of patients and therapists

Angiersquos drive to change legislation is right in line with Infinity Rehabrsquos on-going initiatives to expand this important service to as many communities as possible In 2005 Infinity Rehab approached the Washington State Board of Physical Therapy with a modest goal allow physical therapy supervisory visits and rechecks to be conducted via telehealth

After receiving approval for a pilot program we arranged secure two-way webcams for two centers and a web-based electronic medical record that could be reviewed and charted remotely With these critical mechanisms in place Infinity Rehab began conducting 5th visits patients teleconferenced with a physical therapist while in the presence of a physical therapist assistant The result ndash decreased delays in treatment improved accessibility affordability and coordination of care

In June 2012 the National Association of Rehabilitation Providers and Agencies (NARA) honored Infinity Rehab with the coveted NARA Award for Innovation for our pioneering use of telehealth in physical therapy This award recognizes the talents of a NARA member organization who demonstrates excellence in the creation of an innovation that has made a demonstrable difference in their rehab business

Though Infinity Rehab utilizes telehealth for a very small amount of the care we provide the value of these legislative victories and national recognition will lead to positive change over the coming years as health care providers everywhere grapple with offering more care and services with less reimbursement and personnel

Therapy Solutions Reaching to Learn Grow and Embrace ChangeIn 2013 Therapy Solutions ndash the therapist staffing agency of Infinity Rehab ndash achieved renewal of the Gold Seal of Approval from the Joint Commission for Health Care Staffing Services To receive the award Therapy Solutions underwent an extensive on-site review of its compliance using national standards to determine the qualifications and competency of staff the methodology for staff placement and the systems for monitoring staff performance

Therapy Solutions renewed its Gold Seal of Approval after successfully passing the annual review process which ensures the organization has maintained and improved upon the standards and policies that have been enacted

ldquoHealth care organizations that contract with Therapy Solutions can look to Joint Commission certification as an assurance that Therapy Solutions demonstrates a commitment to providing and continuously improving quality servicesrdquo says Michele Sacco MS executive director Health Care Staffing Services Certification of The Joint Commission

I N N O V A T I V ER E H A B

S E R V I C E S


The Avamere Family of Companies purchased nearly $1M in advance rehabilitation technology for use in its skilled nursing and transitional care centers by Infinity Rehab ndash the Avamere Family of Companiesrsquo contract therapy organization In addition to the significant monetary investment we devoted approximately 750 hours of clinician training across all therapy disciplines Both initiatives will help patients recovering from illness or injury regain independence faster and return to their homes

ldquoOur goal is to always deliver quality patient outcomes through intensive and responsive clinical programsrdquo says Mike Billings PT MS CEEAA Infinity Rehab President ldquoThis substantial investment from Avamere mirrors our mission to enhance the life of every person we serverdquo

The advance rehabilitation technology includes shortwave diathermy and electrotherapy implements motorized parallel bars LiteGaittrade body-weight supported treadmill training Shuttle Balancetrade systems training stairs and an array of other devices and tools designed to promote quality therapy results

ldquoWith these capital improvements Infinity Rehab is continuing its long-held position as an industry leader in post-acute rehab servicesrdquo says Gary Wart Avamere Family of Companies President ldquoShort stays in transitional care centers are increasingly looked upon as the most cost effective form of treatment What wersquore doing is providing an enhanced positive experience for those under our care while reducing the cost to Medicare and other payers through faster resultsrdquo

In 2013 the Avamere Family of Companies leased an additional six transitional care facilities in Oregon Washington Idaho and Colorado The transaction expanded the Avamere Family of Companies physical plant footprint into two new territories ndash Idaho and Colorado

bull Avamere Transitional Care and Rehabilitation-Malley (Northglenn CO)

bull Avamere Transitional Care and Rehabilitation-Brighton (Brighton CO)

bull Avamere Transitional Care and Rehabilitation-Boise (Boise ID)

bull Avamere Health Services of Rogue Valley (Medford OR)

bull Avamere Bellingham Health Care and Rehabilitation Services (Bellingham WA)

bull Avamere Transitional Care and Rehabilitation-Queen Anne (Seattle WA)

The added transitional care centers continue to reinforce Avamerersquos desire for growth in existing markets and the expansion of our evidence-based senior services into new territories We are committed to giving our patients the most comprehensive course of treatment to return home As a regional operator we are in a position to provide the resources necessary for the new facilities to be financially responsible while providing quality patient outcomes

In addition to this substantial expansion the Avamere Family of Companies assumed managing daily operations of the historic Laurelhurst Village Laurelhurst Village established over 100 years ago by the Sisters of Mercy has served as a hallmark for senior care services for Southeast Portland OR and surrounding communities

I N V E ST I N G I N O U R F U T U R E A N D T H E F U T U R E O F OT H E R S

7

Teamwork camaraderie and fun

E X PA N D I N G T H E AVA M E R E F O OT P R I N T8

avamerecom

The Avamere Family of Companiesrsquo management services are recognized for reinvigorating assisted living communities and skilled nursing buildings transforming them into market leaders while residents and patients receive the benefits of Signature CareConnect Our unique brand of health care management services work toward higher operational efficiencies while focusing on greater clinical outcomes in the skilled setting

On November 12 2013 two monumental ground-breaking events took place one ceremony for a brand new memory care center on the Avamere Court at Keizer campus and another for Salem Transitional Care Both represent the Avamere Family of Companies drive to provide modern care options for the communities we serve

The memory care project will create 48 private memory care units designed to provide a compassionate environment for seniors with Alzheimerrsquos dementia or other mental illnesses Avamere Court at Keizer currently offers 69 skilled nursing beds 50 residential care apartments and 96 independent living apartments The memory care expansion will give residents of Marion County a comprehensive choice for skilled nursing rehabilitation assisted living and independent living options for aging adults

Salem Transitional Care will provide patients recovering from illness or injury with intensive short-stay skilled nursing and rehabilitation services Salem Transitional Care will have 79 skilled nursing beds with 72 private rooms This is the second transitional care facility the Avamere Family of Companies has built from the ground up Taking this approach allows us the freedom to implement modern amenities and rehabilitation equipment necessary for a successful short-stay transitional environment

The Avamere Family of Companies recognizes that to continue our successes of 2013 we must further integrate Signature CareConnect into our existing markets and continue to increase customer satisfaction across our entire line of post-acute services

Our drive to provide integrated care keeps us focused on improving the patient experience through smoother transitions between settings faster and easier access to patient health data and enhanced clinical services that exceed national quality benchmarks

Through our mission to enhance the life of every person we serve the Avamere Family of Companies remains a regional leader of post-acute services And as such we are well-positioned to continue our positive impact on the national health care landscape

Through intelligent coordinated care we will continue to reduce costs for payers and providers and continue to be a leader by basing the quality of our services on value rather than volume

We look forward to the challenges and achievements that lie ahead in 2014 and beyond

T H E F U T U R E O F

A V A M E R E

O U R COM M I T M E N T TO 2 0149


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2 5 1 1 5 S W P A R K W A Y S U I T E B W I L S O N V I L L E O R 9 7 0 7 0 5 0 3 5 7 0 3 4 0 5

avamerecom

Since 1995 the Avamere Family of Companies has promoted our mission to enhance the life of every person we serve Through our mission we continually drive the innovation necessary to redefine quality care and stay ahead of the ever-changing national health care landscape From expanded training for our staff significant reinvestments in our buildings and substantial improvements in our technology infrastructure Avamere has time and again demonstrated that we are committed to quality that is obvious

Of course our successes over the years would not be possible without the dedication of our support staff and clinicians living out our mission every day in the communities we serve Every member of the Avamere Family ndash from caregivers and nurses to therapists and administrators and everyone in-between ndash play an integral role in helping our patients reach their goals our residents maintain their independence and ensuring effective communication to the families of those we serve

With the recent advent of the Affordable Care Act (ACA) we are experiencing tremendous change in our country surrounding health care With approximately 10000 new 65-year-olds every day the population we serve continues to grow rapidly To provide the level of quality services these active aging adults demand the Avamere Family of Companies continues to innovate upon our existing care models and lead the way for a more individually-focused and satisfying post-acute experience

For us quality is not a destination but a journey We began breaking down the walls between our lines of services nearly five years ago in order to improve communication amongst our post-acute providers streamline patient transitions prevent unnecessary re-hospitalizations and return patients to the residence of their choice Through our efforts the Avamere Family of Companies introduced Signature CareConnect

Signature CareConnect is a successful network of affiliated healthcare professionals united by the common goal of providing seamless care and support across the post-acute continuum The development and rollout of Signature CareConnect was a monumental task It effectively changed our approach to how post-acute care is delivered and reconfigured the standard model of long-term and skilled care that had been nationally accepted for decades The major components of national care initiatives and our own care pathways put patient satisfaction and quality outcomes at the center

Through our passion for the quality of peoplersquos lives continued innovation a culture of trust and respect and placing integrity above all else the Avamere Family of Companies will build on our many successes of 2013 and continue to insure a quality experience for every person we serve

John W Morgan CEOAvamere Family of Companies



avamerecom



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A V A M E R E




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7



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A V A M E R E




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avamerecom











A V A M E R E




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5 0 3 5 7 0 3 4 0 5 a v a m e r e c o m










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Documents

Annual Quality Report 2013...patient experience, and bending the cost curve through Signature CareConnect. There are always opportunities for health care organizations to improve quality