Nursing Home Business Plan

Bright House

Executive Summary

Opportunity

Problem

There is a lack of full-time assisted living facilities available that offer skilled and respectful care to residents. In addition, there are not enough medically skilled short-term care facilities for patients in CT.

Solution

Bright House aims to be that home for 14 lucky full-time assisted living residents, offering medically-skilled care in a respectful, self-sustaining community, and offering skilled nursing care for short-term residents. On our beautiful, newly remodeled 6 acre property (the former Wayfield Bed and Breakfast) in the small college town of Middletown, CT, Bright House brings together decades of experience and innovative, alternative visions of the potential in our elderly family members’ latest years.

Market

The aging of the Baby Boomers is a well-known and much discussed fact of our times. More and more of this population, many of whom were instrumental in creating the counter-culture of the 1960’s and 70’s, are unhappily surprised about the options available to them as they age. Fortunately, just as AARP (formerly known as the American Association of Retired Persons) has become a major representative of this non-traditional group, elder-care alternatives along the Eden Care model are being founded.

Residents’/Patients’ Needs

Our own experience, based on years of caring for elderly patients, is that people seeking assisted living care and skilled nursing care have many of the same needs:

• To be treated with respect and dignity
• To be actively engaged in a community of some kind
• To be involved in his/her own treatment and living plan
• To be cared for by skilled, medically-knowledgeable clinicians and caregivers, working as a team

You may notice that our list of "needs" seems to go in the opposite order to that of most hospital-model nursing homes; this is not an accident. Unfortunately, most of our elderly population who need care are treated with the billing system’s needs, and not their own, in mind. 

Families’ Needs

Similarly, the families of people seeking caring environments have their own set of needs they are seeking to fulfill:

• Peace of mind about their loved-ones’ physical and mental state
• Relief from the time-consuming job of caring for their family members themselves
• Relief from the feelings of guilt which often overcome them when they find they do not have the physical, emotional, or intellectual resources to personally provide appropriate care for those they love

The big, unstated elephant-in-the-room for families seeking care is the feeling of being a bad daughter or son or spouse, who is not willing or able to put her life on hold to take care of a much-loved family member. At Bright House, we do not seek to dismiss this feeling, but to reassure families in everything we do that the choice to let us take care of their family member is a loving, kind, and generous act.

Competition

There are a number of different options for families seeking nursing home care, from in-hospital recovery centers, to for-profit chains, to specialized care for people with Alzheimer’s, AIDS, diabetes, and so on. The specialized care facilities, which are usually nonprofit, and offer individualized nursing care, come closest to our care model, but are usually reserved for people with a particular ailment in need of intensive medical assistance.

Why Us?

At Bright House, we promote the dignity and self-worth of all of our residents, and strive to give them excellent quality of life, as defined by the residents, individually and as a group. To that end, we encourage resident group decision-making through the House Councils, access to all areas of their homes here at Bright House, and self-determination in activities, socialization, and food preferences. Bright House is not just a caregiving facility—it is their home, and their community.​​​​​​

Expectations

Financial Highlights by Year

Opportunity

Problem & Solution

Problem Worth Solving

There is a lack of full-time assisted living facilities available that offer skilled and respectful care to residents. In addition, there are not enough medically skilled short-term care facilities for patients in CT.

Our solution

Bright House aims to be that home for 14 lucky full-time assisted living residents, offering medically-skilled care in a respectful, self-sustaining community, and offering skilled nursing care for short-term residents. On our beautiful, newly remodeled 6 acre property (the former Wayfield Bed and Breakfast) in the small college town of Middletown, CT, Bright House brings together decades of experience and innovative, alternative visions of the potential in our elderly family members’ latest years.

Target Market

Market Size & Segments

We are basing our Market Analysis on data from Middlesex and Hartford counties, affluent portions of which, such as Glastonbury, are within a short drive of our facility.

Base Numbers for private residents:

The current total population of residents 65 and older, according to the 2000 U.S. Census, is 155,071 in Middlesex County, and 857,183 for the same group in nearby Hartford County. (The percentage of elderly in both counties is slightly higher than the 12.4% of the overall Connecticut population.) Our projections reduce that number by 70% to account for those healthy enough to care for themselves, or with family members able to care for them, leaving us with a total potential market of 303,676. We then reduce that number again by half to get the total potential customers living within a 35 minute drive of Middletown (these are small counties, and we are situated at their juncture), leaving us with 151,838. Of these, we estimate roughly 8.5% will have the means ($150,000 or more family income) to pay for full-time private care at our facility (based on the 2000 census data about Connecticut income).

This leaves us with roughly 12,906 nearby upper-income residents of Hartford and Middlesex County who are 65 or older, and in need of medical or other daily assistance in their living situation. To project into the future, we again looked to the 2000 Census. The Census’ Projected Population of Connecticut is as follows:

While the overall population of Connecticut is projected to decline over the next five years, before rising again, we know that the proportion of the overall population age 75 and older (our target market age) is slowly rising. We therefore include a modest projected increase in potential customers of 1% over the next five years.

Medicare residents and short stays:

A study published recently in the journal Health Affairs by Morrissey, Sloan, and Valvona found that the proportion of Medicare patients transferred to post-hospital care has doubled since the Prospective Payment System (PPS) was introduced. Rather than staying in the hospital until recuperated, the current system preferentially delegates recovery care to private non-hospital facilities, leaving room in hospitals for urgent or crisis care. We base our projections for Medicare residents on the same figures listed above, but looking at the percentage of elderly with family incomes between $30,000 and $75,000 dollars,* rather than just the highest bracket, we get 40% of the population, or 60,735. We apply the same conservative 1% growth rate, below.

This income range was chosen because it correlates with the kind of higher education levels that most families choosing non-hospital model skilled nursing care report. Although residents with lower incomes may have a need for our service, they are traditionally less likely to seek out alternative care.

Market Segmentation

Although we have broken our target population into two groups based on income, our marketing strategies rely on another level of breakdown—marketing to potential residents, and marketing to the families of potential residents, who may or may not have similar needs.

Target Market Segment Strategy

The overall populations we wish to serve are older people (65 and older), in need of daily assistance, who value community and the contributions of their peers. Since Bright House will become their home, we especially are seeking residents willing to make this house a home, and learn from and teach each other.

We also recognize that we must meet the somewhat different needs of our residents’ families, who will help them make the decision to live with us, or recuperate here, and who will almost certainly be contributing to the monthly payments necessary to provide for their care.

Competition

Current alternatives

 Alternatives and Usage Patterns

Families choose one elder care facility over another for a variety of reasons. The most common issues involved in their decision are distance from their home(s), affordability, quality of staff and facilities, and particular medical specialties necessary for their family member. Families will usually choose the highest level of care affordable within 45 minutes to one hour of their homes, in order to make visiting their family member easier.

Main Alternatives

The following three organizations are representative of the types described above:

Fox Hill Center, Rockville

• For-profit, part of a chain
• 3.37 nursing staff hours/resident day
• 150 beds (not 150 rooms)
• 11 deficiencies in Medicare inspection

Fox Hill Center is typical of the hospital-model nursing home. It is large (150 beds), for-profit, and has a fairly low rate of nursing hours per resident day. Its size makes it able to care for many patients, but often at the expense of individual attention.

Sister Anne Virginie Grimes Health Center, New Haven

• Nonprofit, religious based, located in a hospital
• 4.16 nh/rd
• 125 beds
• 3 deficiencies

The Grimes Health Center, like many religious care centers, is nonprofit, and has a slightly higher rate of nursing hours per resident day than the for-profit centers, despite its large size. Quality of care, however, is noticeably higher (3 deficiencies in inspection, compared to 11 at Fox Hill).

Leeway, Inc., New Haven

• Nonprofit
• 5.04 nh/rd
• 40 beds
• 4 deficiencies

Leeway is a typical specialized private (not in a hospital) nonprofit care facility. It is much smaller than the other two described, has the highest rate of nursing care per resident day, and high quality marks in inspection. Its small size and nonprofit status allow it to focus on providing individual attention. Leeway is Connecticut’s first and only skilled nursing home dedicated solely to the treatment of people living with AIDS.

Our advantages

Although the hospital model of care practiced in most nursing homes provides good results for Medicaid and Medicare billing purposes—that is, easily quantifiable lists of procedures and medicines administered, test results, and billable nursing hours—it does not provide good quality of life for residents (or "patients," as they are referred to in the hospital model).

At Bright House, we see a different way of assisting our elderly members through a new stage in their lives. Acknowledging that where they live is their home, and belongs to them, not to the medical staff, we have established a facility that not only meets their medical and physical needs, but one that also nourishes their social connections, individual dignity, and personal preferences. Each resident has a private room with bath, opening onto a central shared common area containing the kitchen, living room, and dining room, where all meals are shared communally at our 15 foot farm-style dining table.

Far more devastating than physical illness to our elders, is lack of purpose. Studies have shown over and over that seniors who are engaged in activities they find meaningful are far more likely to retain mental acuity, physical health, and emotional well-being. Although the hospital model tries to provide such stimulation, its "activities" are usually organized by staff, with little or no input from "patients," and become just one more set of required tasks for all involved. At Bright House, we have already begun working with prospective residents to identify areas of interest and methods of community involvement that will appeal to them.

Keys to Success

Keys to Success

We have identified four keys to success for Bright House:

• We offer more resident-oriented, small-scale, home-model care than our competitors;
• Our innovative use of Elder Assistants lowers the cost of providing this care considerably;
• Our fair wages and team structure lower dissatisfaction, and thus turnover rates among our staff;
• Our on-site Skilled Nursing Facility ensures continuity of care when our residents need more intensive assistance.

Execution

Marketing & Sales

Marketing Plan

The main means of marketing for Bright House is through word of mouth. Due to our respectful and medically skilled staff we trust our business to speak for itself. Therefore, we don’t need much marketing. In addition to word of mouth, we will offer tours Monday-Friday. These tours will allow us to show off our beautiful facilities, and will hopefully draw in more potential residents. Lastly we will have a website that we will use to promote our tours and will serve as marketing to our more tech-oriented customers.

Sales Plan

Our sales will mostly come from tours, but some will come from our website as well. Our space is limited, especially for full-time residents, so potential customers will need to go through an application process. People are able to fill out an application in person at our main office, or can submit an application online. If the application is approved, we can talk to the family about the specific needs of the resident and when they can move in!

Operations

Locations & Facilities

We have now nearly completed the five-month renovation of the former Wayfield Bed and Breakfast into our two main facilities. The main building will house our privately insured, assisted-living residents. The skilled nursing facility across the courtyard offers more intensive care for post-operative and recovering temporary residents, as well as providing a setting for increased care for our residents as needed.

Each resident in our assisted living retreat will have a private bedroom and bath, opening onto a central social area containing the living room, dining room, and kitchen. We have two larger rooms that can accommodate married couples who move in at the same time, for a total of 12 rooms, holding up to 14 residents. Each room is wheelchair accessible, and can accommodate maintenance machines such as oxygen.

The skilled nursing facility to the left of the main building can house up to eleven adults, and is the only area of the facilities which will house residents receiving Medicare or Medicaid payments. This part of Bright House has two purposes: as a short-term rehabilitation center for community members recovering from surgery or medical emergencies; and as a full-service nursing facility for residents who can no longer take care of their own needs sufficiently in the main building. The continuity of location, social contact, and quality of care ensures that our residents will remain in the best possible surroundings when their needs are greatest.

Middletown, where we are situated, is centrally located 25 minutes from Hartford, and 30 minutes from New Haven. Middletown is a small college town, with an ethnically and economically-varied population.

Technology

In addition to our advanced medical equipment, the main use of technology at Bright House will be the installation and use of our computerized medical record system. The benefits of this system (described in the Start-up Summary, above) are numerous. The system will also allow residents to access their own individual records with a password at will, to ensure that they understand as much as they can about their own situation, and how to maintain their health.

We are working carefully with DigInfoMedTel to ensure that all of our technology meets Health Insurance Portability and Accountability Act (HIPAA) standards before implementation. We will hold a series of HIPAA trainings with the software in mid-December to ensure that our staff is fully-knowledgeable in this area.

Milestones & Metrics

Milestones Table

Key metrics

Key Metrics 

• cost effective housing and prcing 
• pharmacy inventory 
• twitter reviews and retweets 
• radio advertisements 

Company

Overview

Ownership & Structure

Bright House is chartered as a nonprofit 501(C)(3) corporation in Middletown, CT, with the goal of providing holistic and respectful assisted living and skilled nursing home care to a small group of elderly residents. Our primary location is the old Wayfield Bed and Breakfast, on Farmer’s Road, which we have spent the last five months converting into a two building nursing home facility in line with Eden Alternatives "Greenhouse" model for enlightened elder living. (See architectural drawing, attached.)

Team

Management team

Caregiving Management

Bright House offers a different management structure from that of the typical hospital-model nursing home. Our primary caregivers, the 6 Elder Assistants, work as a self-managed team, meeting with the Medical Director and the nurse on-call every morning to coordinate care for the coming day.

Although the Medical Director has the ultimate responsibility for the health and well-being of all residents and visitors, the nursing and caregiving staff, with their different kinds of knowledge about the residents’ physical, social, and mental well-being, are expected to note, discuss, and recommend courses of action for all residents who, in their combined estimation, need help.

A 2001 study by the Robert Wood Johnson Foundation found that the small percentage of Chief Nursing Officers reporting no nursing shortages in their facilities at the time of the study cited formalized programs focused on the needs of, and professional recognition for, their nursing staffs as the reason for their adequate staffing. Our compensation packages, management structure, and caregiving requirements are designed to continually remind our LPNs and Elder Assistants how very valuable they are. 

Dr. Mildred Johnson is our Medical Director. Dr. Johnson has served as the head of Gerontology for six years at The Connecticut Hospital, and oversaw the creation, last year, of their Elder Assistant training program, which provides certification for Certified Nursing Assistants (CNA) to provide in-home hospice and respite care. Dr. Johnson has 20 years of experience working with elderly patients in this area, and has been integral in designing the physical layout, management structure, and priorities of Bright House.

The rest of our already-hired caregiving staff brings a whopping collective 75 years of professional experience in caring for elderly patients.

Financial Management:

Madeleine Morgan has been overseeing financial management of nonprofit organizations in Connecticut for 27 years. She became involved in our project when her mother developed a long-term care plan with Dr. Johnson which included home-based hospice care. "I wish everyone could have the same love and attention Dr. Johnson showed to my mother," Madeleine said. Ms. Morgan will be in charge of all financial operations at Bright House, overseeing billing, personnel payment and benefits, and development efforts.

Advertising and Marketing:

We are fortunate to have a skilled public relations officer in our group. Janice Ruthers is a retired ad executive living in Middletown with her husband (a professor at the university). She will be working 20 hours per week in our offices as a volunteer for the first two years of our plan, helping us design advertisements and brochures, and to plan events like our Open House in December to let the public see the results of our efforts.

5.1 Management Team Gaps

We still need to hire one swing-shift LPN, and one Elder Assistant. We are currently recruiting through Dr. Johnson’s connections at The Connecticut Hospital, and expect to complete our team by mid-December, at the latest.

Financial Plan

Forecast

Key assumptions

A "full" elder care facility is generally 90% to 95% full. Our non-standard model allows us to forecast for full occupancy in the main building, since turnover rates for assisted living residents are expected to be quite low (1-2 per year, at most). The skilled nursing facility, on the other hand, requires a certain number of empty beds to offer the flexibility needed to accommodate shorter stays. We therefore are projecting reaching "capacity" of our eleven-bed facility at 10 full beds.

Our resident monthly prices are based on the current Medicare nursing-hours-per-resident-day rates for our kind of services. Medicare patients are billed at roughly $135/day for nursing care, not including the cost of any medication to be administered by our staff. Our private patients are billed at a slightly higher rate to account for the low Medicare reimbursement rate, but also to pay for the extra benefits they receive as part of living at Bright House. Our rates are roughly 2/3 of our nearest competitors, the difference being made up for in donations, and savings gained through staff retention and the use of highly trained, flexible, Elder Assistants.

The small size of our facility allows us a cost savings on maintenance and grounds.

One other important assumption concerns payables: We have assumed collection days of 60, which averages our private residents’ monthly up-front payment, and the typical 60-90 day reimbursement rate from Medicare.

Revenue by Month

Expenses by Month

Net Profit (or Loss) by Year

Financing

Use of funds

Start-up Expenses

One of the largest items in our Start-up budget is a computerized medical records system. Preliminary designs of this system have already been constructed by DigInfoMedTel. In addition to the obvious benefit of allowing multiple care-team members to easily exchange information as they change shifts, this system will allow our residents and staff to keep track of chronic conditions, monitor gradual but serious changes in condition which might be overlooked in day-to-day interactions, and corroborate quantifiable medical data for our Medicare patients in the skilled nursing facility.

Start-up Assets

Current (Short-term) Assets include $6,000 of start-up inventory (bedding, cleaning and disposable medical supplies) and non-expensed, smaller medical equipment that will depreciate quickly, and will need to be replaced in year four or five.

Long-term assets include our existing location, the former Wayfield Bed and Breakfast, currently assessed at $400,000 including renovations. The location was willed to us by Evelyn and Jack Bright last February, with the condition that we include a small Medicare facility as part of the overall plan. This category includes new Long-term Assets needed as follows: $200,000 for (long-term, resalable) medical equipment, and $150,000 for initial furnishings, after the renovation.

Medical Equipment:

• 1 Fully-loaded Crash Cart
• Standard monitoring equipment (blood pressure, sugar, etc.)
• Call-button system

Furnishings:

For the common areas of both buildings, we will need couches, self-lifting recliners, tables, and chairs suitable to our residents’ needs. We have allocated $35,000 for furnishing the four common rooms.

Each private room will need a hospital-capable bed, linens, a dresser, and a phone, at the minimum. With the remaining funding, that leaves just over $6,000 per room. This budget will allow us to provide attractive, functional, and comfortable surroundings to our residents in their new homes. Each bedroom in the main building will have enough remaining space that residents can bring plenty of familiar furniture with them (up to two side tables and wingback/reclining chairs, and a second dressing table or its equivalent).

Sources of Funds

We will get a low interest loan for $210,000. We have collected donations and pledges of $291,000 Our founders will provide $407,000 

Statements

Projected Profit and Loss

Projected Balance Sheet

Projected Cash Flow Statement