ziegler -the undisputed leader in · u.s. bancorp piper jaffray salomon smith barney ubs...

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B.C. Ziegler and Company | Member SIPC & FINRA

2019 STATE OF SENIOR LIVING

PRESENTED BY

Tommy BrewerManaging DirectorZiegler Investment [email protected]

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ABOUT ZIEGLER

ZIEGLER is a privately held, national boutique investment bank, capital markets and proprietary investments firm. Specializing in the healthcare, senior living and education sectors, as well as general municipal and structured finance, enables us to generate a positive impact on the communities we serve.

PROPRIETARYINVESTMENTS & FUND MNGT

INVESTMENT BANKING CAPITAL

INVESTMENT BANKING

ADVISORY

CAPITAL MARKETS +

INVESTMENT BANKING

CAPITALMARKETS

PROPRIETARY INVESTMENTS & FUND MNGT

Strategic advisory, financing and capital planning solutions in healthcare, senior living and educational sectors as well as general municipal and structured finance

Active participant in municipal sales and trading including public, tax-exempt, taxable, private placement and preferred trading markets

Providing opportunities for investors in senior living, healthcare services & technology solutions

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Dougherty & Company

Cain Brothers

Legg Mason

U.S. Bancorp Piper Jaffray

Salomon Smith Barney

UBS PaineWebber

First Union National Bank


ZIEGLER

Millions

ZIEGLER - THE UNDISPUTED LEADER INSENIOR LIVING FINANCINGS

Top Lead Managing Underwriters 2000-2009

Top Lead Managing Underwriters 1990-1999

Top Lead Managing Underwriters 2010 - 2017

Top Lead Managing Underwriters 2018

Based on full credit given to senior manager of lead-managed underwriting principal volume for senior living transactions completed nationally. Rankings and amounts through Refinitiv data as of 12/31/18

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ZIEGLER’S SENIOR LIVING RESEARCH, EDUCATION & THOUGHT LEADERSHIP

• Education

• 2019 will host a total of 13 Conferences/ Symposiums

• Annual Ziegler Senior Living Finance + Strategy Conference

• LeadingAge Ziegler National CFO Workshop

• Ziegler National Senior Living Investor Workshop SeriesSM

• External research

• LeadingAge Ziegler 200

• CARF Financial Ratios and Trends Publication (Baker Tilly, CARF)

• Statewide CCRC Reports (MD, VA, TX) (My LifeSite)

• Industry communication

• Z-News

• White papers

• Ziegler CFO HotlineSM

• Internal information and research

– Ziegler CCRC National Listing & Profile

– Client-requested research

– Client education sessions

• Secondary Market Investor Research

– Surveillance updates on current credits

– Supports active secondary trading

• Investor Market Research

– ZieglerResearch.com

• Databases

– Industry Trends (e.g. CCaH, Rental CCRCs)

– All Senior Living Financings

– All New Communities (CCRCs) since 1990

– Senior Living Rated Organizations

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1: Understanding the Growth of the Sector

2: Disruptors & Catalysts in Senior Living

3: The Changing Role of the NFP Senior Living Board

QUESTIONS & ANSWERS

AGENDA

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5

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3

UNDERSTANDING THE GROWTH OF THE SECTOR

Item 1

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U.S. OLDER ADULT POPULATION- DRIVING CHANGE

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000

2010 2015 2020 2025 2030 2035 2040 2045 2050 2055 2060

Po

pu

latio

n (

In th

ou

san

ds)

65 Years & Over 75 Years & Over 85 Years & Over 100 Years & Over

Source: U.S. Census Bureau National Population Projections based on 2010 Data. 2016 Base Population; Projections updated in 2017 (released March 13, 2018)*AV Powell & Associates, 2017

Avg. Age of Entry into Independent Living*: 80

(range= 78-82)2019

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A CHANGING CONSUMER

• Delivering both quality of life and care (longevity vs quality of life)

• Opportunity for niche communities

– College/University affiliations

• Increased focus on urban influx

– 4% of Boomers moving into “urban core”; translates into 400 a day among 65+

• Branding and image are incredibly important

– Name changes

• Future generations have more information at their fingertips

– Transparency; Pricing

• Choice = Control

• Growing need for housing options among seniors with limited income

Source: Ziegler Investment Banking

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8

9

4

10

DEMOGRAPHICS ARE DRIVING GROWTH

• Significant new development among for-profit owners and operators– Significant Shift to Independent Living development

• Not-for-profits largely growing through expansions and affiliation activity

• Continued growth in HCBS and home-based models

• A number of joint ventures and partnerships are developing

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• Allows for greater promotion of mission

• Diversification in services insures long-term financial stability

• Additional programs and services enhance current customer experience

• Greater ability to generate economies of scale

• Attract better talent & leadership

• Defensive move against competition

• Increased ability to borrow capital

• Greater ability to expand into underserved markets

WHY GROW? WHY CHANGE?

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REPOSITIONING & GROWTHBUSINESS MODEL INNOVATION OPPORTUNITY

Stages of Product Life Cycle1 2 3 4 5

Mar

ket

Posi

tion

Innovation

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11

12

5

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THE POTENTIAL FUTURE NOT-FOR-PROFIT COMPREHENSIVE SENIOR LIVING & SERVICES MODELCONCENTRATION IN PRIMARY & ADJACENT MARKETS

Market Rate IL – hospitality focus(Primarily Entry EF; Rental)

Moderate Independent Living(Moderate EF & Rental)

Assisted Living

Memory Care

Skilled Nursing-private pay-post-acute-Medicaid

Government Subsidized-HUD 202-tax credit

Continuing Care at Home

Home Health

Home Care

Hospice

Concierge

Adult Day

PACE

Home Services


Maximization of partnerships in the region

IncomeServices

OFFERINGS

AgeResidential

CONSUMER

14Sources: Ziegler National CCRC Listing & Profile (Jan. ‘19), LeadingAge, NIC MAP® Data and Analysis Service (Q4 2017), The National Center for Health Statistics, Centers for Medicare and Medicaid Services (2015), Ziegler population estimates

TODAY’S RETIREMENT OPTIONSA LOOK AT SENIORS HOUSING & SERVICES SUPPLY

• 1,950 communities 600,000 unitsLife Plan Communities

• 4,800 centers avg. 39 participants/dayAdult Day

• 12,000 communities 1 million residentsAffordable Housing

• 4,000 agencies 1.34 mill discharged/yr.Hospice

• 15,600 homes 1,400,000 units Nursing Homes

• 1,400 communities 73,000 unitsFreestanding Memory Care

• 7,200 communities 595,000 unitsAssisted Living

• 12,600 agencies 4 million served/yr.Home Health

• 2,800 properties 427,000 unitsPrimarily IL Housing 3%

15%

17%

22%

24%

26%

33%

51%

77%

% NFP

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LZ 200 PUBLICATION: BACKGROUND AND METHODOLOGY

• Size not quality

• Not-for-profit multi-site senior living organizations primary focus

• Descriptive information on eachsystem– state, size (by type of unit),

classification of system, rating, accreditation, addition of 2nd

community.

• Statistics related to affiliation, employees, residents and more

• Excludes affordable units when computing size; excludes primarily acute/post-acute/health care systems

• Comparable to other listings of largest organizations (i.e. Fortune 500)

Source: 2018 LeadingAge Ziegler 200 Publication (data as of 12/31/17)

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16Source: 2018 LeadingAge Ziegler 200 Publication (data as of 12/31/17)

0

5,000

10,000

15,000

20,000

25,000

30,000

35,000

40,000

45,000

50,000

1980

1981

1982

1983

1984

1985

1986

1987

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

Un

its

Year

ILU ALU NCB All Units

2018 LeadingAge Ziegler 200Growth: Growth of Largest 10 Systems, Combined Unit MixFROM 1980 (Excludes Evangelical Lutheran Good Samaritan Society, Trinity Health Senior Communities, Ascension Senior Living, Benedictine Health System)

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PRIMARY NOT-FOR-PROFIT SENIOR LIVING GROWTH IN RECENT YEARS

Community Expansions

Affiliations & Mergers

Acquisitions

New Campus Development


18

GROWTH PLANS OVER THE NEXT TWO YEARS

Source: 2015–2018 LeadingAge Ziegler 200 Publications

Plantation Estates

16

17

18

7

19

COMMUNITY EXPANSION & REPOSITIONINGS: TRENDS 2014-2017

Source: Ziegler Investment Banking (deals as of 7/31/17)

• Repositioning dated units• Conversion to private units*does not include those who downsized SN

• Carving out specialized memory care units

• Largely in Assisted Living

• Adding IL units• Expanding amenities;

investing in common areas• Repositioning dated ILUs

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910 10

14

10 1011

13

54

7

34

1

7

4

23 3

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

• An average of 4 new LPC locations financed annually since 2009, versus 10 new campuses per year from 2000-2008

Source: Ziegler Investment Banking (as of 12/31/18)

POST-RECESSION NEW ENTRANCE FEE LPCS

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DRIVERS FOR NFP SENIOR LIVING CONSOLIDATIONComplexities of Healthcare

1990 2000 2010

Influ

ence

Leadership Turnover

Technology Demands

Diversify Service Lines

Hospital Consolidation

Attracting & Retaining

TalentComplexities of Healthcare

Leadership Turnover

Technology Demands

Diversify Service Lines


Ability to Attract Talent

Technology Demands


Ability to Attract Talent

Financial Pressure

Financial Pressure

Access to Capital

Access to Capital

Access to Capital

Financial Pressure

Leadership Turnover

Complexities of Healthcare

Access to Capital

Reinvestment Requirements

Reinvestment Requirements

Competition

Competition

Competition

TODAY

Growth Capital

Complexities of Healthcare

• Occupancy pressures

• Competition• Higher pt. acuity• Negative revenue

impact

Leadership Turnover

• As Boomer CEOs retire, can serve as catalyst to explore affiliation

• CEO recruitment challenge for smaller organizations

Board Strength


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NOT-FOR-PROFIT SPONSORSHIP TRANSITIONSCUMULATIVE DATA

29 41 6397

149204

264320

385

36 5175

111

174

254

345

405

568

0

100

200

300

400

500

600

2010 2011 2012 2013 2014 2015 2016 2017 2018

Cumulative Totals (2010-YE 2018) by # of Transactions & # of Communities

Transactions Market-Rate Communities

Note: Includes market-rate communities; excludes government subsidizedSource: Ziegler Investment Banking 12/31/2018

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SPONSORSHIP TRANSITION TRENDS

• Of the nearly 600 not-for-profit communities that have changed owner/sponsor since 2010, roughly 54% have been dispositions to the for-profit sector

– Waiting too long

– Lack of board strength

– Heavy skilled nursing exposure

• We are seeing an increase in system affiliations/mergers

• “Merger of equals” trend is on the rise

Source: Ziegler Investment Banking; public sources

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HOME & COMMUNITY-BASED SERVICES DEFINED


Home Care

Home Health

Hospice

Adult Day

PACE

Continuing Care at Home

Concierge Services

Alternative Models

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HOME & COMMUNITY-BASED SERVICES REVENUELARGEST PROVIDERS OF HCBSTHOSE WITH REVENUE >$10MILLION

2018 Rank

System Name StateHCBS Annual

Revenue

6 Trinity Health Senior Communities MI >$50 million40 ArchCare NY >$50 million2 The Evangelical Lutheran Good Samaritan Society SD >$50 million

35 Concordia Lutheran Ministries PA >$50 million51 Masonicare CT >$50 million58 Holland Home MI >$50 million8 Ascension Senior Living MO >$50 million

17 Presence Life Connections IL >$50 million67 Presbyterian Villages of Michigan MI $25-$50 million18 Ohio Living OH $25-$50 million

109 The New Jewish Home NY $25-$50 million66 SpiriTrust Lutheran PA $25-$50 million44 National Church Residences OH $25-$50 million5 Covenant Retirement Communities IL $10-$24 million4 Presbyterian Homes and Services MN $10-$24 million

89 United Church Homes and Services NC $10-$24 million74 Lutheran SeniorLife PA $10-$24 million27 Ecumen MN $10-$24 million75 Lutheran homes of South Carolina, Inc. SC $10-$24 million57 WesleyLife IA $10-$24 million

154 Chelsea Jewish Lifecare, Inc. MA $10-$24 million3 Acts Retirement-Services, Inc. PA $10-$24 million

120 Lutheran Social Ministries of New Jersey, Inc. NJ $10-$24 million41 Providence Life Services IL $10-$24 million46 Hebrew SeniorLife, Inc. MA $10-$24 million

198 Knute Nelson MN $10-$24 million38 Transforming Age WA $10-$24 million

Source: 2018 LeadingAge Ziegler 200 Publication

• Can be very market-specific

• Competition and state reimbursement framework plays role in growth

• 70% of providers have HCBS revenue less than $10million

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• NFP senior living organizations are increasingly creating strategy and business development positions to drive growth and innovation initiatives

Source: Ziegler Investment Banking; 2018 LeadingAge Ziegler 200 Publication

Estimated that roughly

20% of LZ 200 organizations

have allocated a full or half FTE to this

role

Corporate Positions Added in Past YearNumber of LZ 200

adding the position

Chief Clinical/Health Officer 18

Business Development/Strategy Officer 12

Chief Information/Technology Officer 9

Marketing & Sales Officer 8

Regional Leadership Positions 6

Chief Financial Officer 4

Chief Operating Officer 4

Chief Talent/Human Resources Officer 4

Chief Compliance Officer 3

Philanthropy/Foundation Director 3

ADVANCING THE COMMITMENT TO GROWTH

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PROVIDER EXAMPLES – COMPREHENSIVE SENIOR LIVING & SERVICES MODEL (HOUSING, SERVICES, AGE, INCOME)

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26

27

10

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NFP PROVIDER CASE STUDIES: GROWTH

Provider Type of Growth

Growth Examples

Acts Retirement Communities (PA)

Horizontal Type-A, CCRC Organization; growth through affiliations, expansions, new campus development; eastern U.S.

Holland Home (MI) Vertical & Horizontal

Significant expansion into HCBS (PACE, home care, hospice, Tandem 365, joint ventures); campus expansions

BHI Senior Living (IN) Horizontal Primarily a CCRC organization; growth through affiliations and acquisitions; new development (satellite campuses)

Concordia Lutheran Ministries (PA)

Vertical & Horizontal

Significant growth through acquisitions (both communities & home health, hospice agencies)

The RiverWoods Group (NH)

Horizontal Growth through development of satellite campuses and new CCRCs; affiliation activity as well

Ohio Living (OH) Vertical & Horizontal

Affiliation activity, expansions; significantHCBS platform; developing I-SNP plan


DISRUPTORS & CATALYSTS IN SENIOR LIVING

Section 2

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CATALYSTS & DISRUPTORS

• Older adults have more choices than ever

– Multiple residential housing options

– Ability to “age in place” in own home

• Workforce recruitment and retention pressures continue

• Healthcare payment reform is moving fast

– Pressures on post-acute providers

– Skilled nursing occupancies are at record lows

– Vertical integration of healthcare providers may be a game changer

• Technology as a solution and stimulator of change


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VIEWING YOUR STAFF AS YOUR CUSTOMER

4%

8%

23%

26%

26%

27%

28%

29%

31%

36%

46%

47%

75%

79%

0% 50% 100%

Emergency Preparedness

Succession Planning

IL Occupancy

Changing Consumer

Competition

Technology Costs & Adoption

Regulatory Changes

Affordability ofproduct/services

Capital Needs

Declining Reimbursement

Financial Performance

Skilled Nursing/Post-AcutePressures

Labor Costs (wages, benefits)

Staff Recruitment & Retention

Top 5 Areas of Concern for 2018

Source: Ziegler CFO HotlineSM, January 2018

• Sheer numbers … Boomers exiting the workforce; aging population

• Minimum wage pressures

• Image problems with the sector

• Immigration policy

• Growth among for-profit providers and agencies

• Workforce shortages impacting construction market

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0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

1980 1985 1990 1995 2000 2005 2010 2015 2020

To

tal

nu

mb

er o

f p

rop

erti

es

Total Inventory of Market-Rate CommunitiesExcludes Freestanding Nursing Homes

For-Profit/Private Sector Not-for-Profit Sector

Source: Ziegler Investment Banking Estimates & Projections (August, 2018); based on sources from Ziegler as well as ASHA, CMS, LeadingAge NIC, ASHA Note: As of 2017, there were approximately 15,600 nursing homes in the U.S.

OVERALL SENIORS HOUSING INVENTORY

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FOR-PROFIT DEVELOPMENT SLOWING, BUT LEVELS REMAIN SIGNIFICANT

Source: NIC MAP® Data Service | www.nic.org/nic-map

* Excludes CCRCs

0%

2%

4%

6%

8%

10%

12%

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Construction vs. Inventory; MAP31Seniors Housing | 4Q05 – 1Q19

For-Profit Independent Living*

For-Profit Assisted Living*

Not-for-Profits

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12

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• Occupancies at all-time lows nationally– Dramatically varies by state and market

• Shortages of caregivers impacting operations– Ability to staff to census

– Some providers shutting down units

– Rural areas significantly impacted (telehealth solution)

• Payment reform squeezing providers– Discharges to the home

– Growing Managed Medicare

• Consumer preference to ‘age in place’


SKILLED NURSING & POST-ACUTE DISRUPTION

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UNRAVELING THE SKILLED NURSING MARKETPLACE


Long-term SN

Resident

Post-acute/Short

Stay

Skilled Nursing Overall

• Changing preferences among consumers to stay in AL or IL with services

• Future of private pay?

• “Skip the SNF” trend• Decreasing LOS• Referral networks

narrowing• FP up-scale development

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SKILLED NURSING

• Some NFP communities exiting skilled nursing entirely, largely western U.S.– Replace with high acuity assisted living

– Replace with home care and home health

– Refer off-site


CCRC Providers Who Have Eliminated SNF

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SENIOR LIVING & POST-ACUTE’S EMERGING MANAGED CARE ROLE

Senior living operators increasingly empowered to take a lead role in US healthcare industry

Aging PopulationPressure on

Broader Senior Living Industry

Managed Medicare & Medicaid Expansion

Senior Living Operators & Risk

Relationships

Momentum re: Senior Living and

Managed Care

Share of Medicare Beneficiaries In

Medicare Managed Care Plans

Source: Kaiser Family Foundation

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PARTNERSHIP-PERENNIAL CONSORTIUM

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TECHNOLOGY – CATALYST & DISRUPTOR

Brain Fitness Consumer Engagement

Chronic Disease Management

EMR Platforms Remote Monitoring Smart Home Technologies

Telehealth Solutions Voice Activation/AI Workforce Solutions

Infrastructure Wellness/Prevention


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ZIEGLER LINK•AGE FUNDS

HEALTH SYSTEMS INDUSTRY PROFESSIONALSSENIOR LIVING PROVIDERS

HEALTHCARE IT

• Population Analytics

• Clinical Decision Support

• Care Management Software

• Regulatory Reporting

• Medication Management and Adherence

• Remote Monitoring

• Telehealth Platforms

HEALTHCARESERVICES

• Homecare 2.0

• Palliative and Hospice Care

• Capitated Physician Models

• Concierge Medicine

• Behavioral Change Management

• Emerging Managed Care Models

OTHER POST-ACUTE OR AGING RELATED

• Post-Acute Care Diagnostics and Therapeutics

• Medicare Advantage / Dual Eligible Plans

• Chronic Disease Management

• Institutional Pharmacy

GENERATING RETURNS, both financial and strategic, for organizations across the healthcare and aging services landscape that have a significant interest in finding innovative solutions to improve the independence, quality and cost of care, and overall lives of the aging population.

Source: Ziegler Investment Banking; Ziegler Link•Age Funds

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SCANNING THE TECH-ENABLED & SENIOR SERVICES ECOSYSTEM

Sourcing of Companies

Initial Engagement

Assessment & Vetting

Curating the Relationship

Investment23

companies

1,200 companies


42

A key goal of our Funds is to foster collaboration between our limited partners and our portfolio companies, and introduce limited partners to new technologies and services. Since launching our first fund, Ziegler Link•Age Longevity Fund, the Investment Managers have…

• Sponsored >80 demonstrations of new technologies and services for senior care providers

• Helped arrange >30 pilot programs/customer relationships between our limited partners and portfolio companies or companies conducting demonstrations

ZIEGLER LINK•AGE FUNDSDEMO THURSDAY PROGRAMS | ZLF INVESTMENTS

Source: Ziegler Investment Banking; Ziegler Link•Age Funds

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41

42

15

THE CHANGING ROLE OF THE NFP SENIOR LIVING BOARD

Item 3

44

EXAMPLES OF NFP SENIOR LIVING ORGANIZATIONS WHO HAVE EVOLVED GOVERNING BOARDS

45

SENIOR LIVING GOVERNANCE TRENDS

Smaller boards

Fewer standing committees

Fewer meetings

More adaptable structures/procedures

Greater delegation to management

Vigilant monitoring of key performance indicators

Source: Rick Stiffney, Mennonite Health Alliance, 2017

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44

45

16

46

SENIOR LIVING GOVERNANCE TRENDS (CONTINUED)

Monitoring of progress on strategic priorities/

Greater engagement in strategic/generative work

More rigorous board-driven evaluation and growth

Greater diversification on boards

Source: Rick Stiffney, Mennonite Health Alliance, 2017

ADDITIONAL DISCUSSION / Q&A

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• Ziegler is a privately-held investment bank, capital markets and proprietary investments firm

• A registered broker dealer with SIPC & FINRA

• Ziegler provides its clients with capital raising, strategic advisory services, equity & fixed-income trading and research

• Founded in 1902, Ziegler specializes in the healthcare, senior living and educational sectors as well as general municipal finance

ABOUT ZIEGLER

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Investment banking, capital markets and proprietary investment services offered through B.C. Ziegler and Company. FHA mortgage banking services are provided through Ziegler Financing Corporation which is not a registered broker/dealer. Ziegler Financing Corporation and B.C. Ziegler and Company are affiliated and referral fees may be paid by either entity for services provided.

This presentation was prepared based upon information provided by Management and contains certain financial information, including audited and unaudited information, certain statistical information and explanations of such information in narrative form (the “Information”). Management believes this information to be correct as of the date or dates contained herein. However, the financial affairs change constantly, and such changes may be material. Today’s discussion may contain forward-looking statements, which may or may not come to fruition depending on certain circumstances, including those outside the control of management. Please be advised that management has not undertaken, assumed no duty and are not obligated to update the Information. In addition, please be advised that past financial results do not predict futurefinancial performance.

DISCLAIMERS

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