Long-Term Care Market Analysis

LONGTERMCAREMARKETANALYSIS

PlatteCountyHospitalDistrict

November2010

CommunityBuilders,Inc. www.consultCBI.com873EsterbrookRoad [email protected],WY82633 (307)3591640

PlatteCountyLongTermCareMarketAnalysis Page2of51

TableofContentsExecutiveSummary..............................................................................................................................3Introduction............................................................................................................................................4CommunityProfile................................................................................................................................5PublicParticipationPlan....................................................................................................................6ReviewofLongTermCareIndustry...............................................................................................8

NursingHomesU.S.............................................................................................................................11NursingHomesWyoming................................................................................................................12AssistedLivingFacilitiesU.S..........................................................................................................14AssistedLivingFacilitiesWyoming.............................................................................................15MemoryCareU.S.................................................................................................................................21MemoryCareWyoming....................................................................................................................22

DescriptionofMarketArea.............................................................................................................23Demographics...........................................................................................................................................24Income.........................................................................................................................................................28Housing.......................................................................................................................................................29

TargetMarketAnalysis.....................................................................................................................30Demographics...........................................................................................................................................31LimitationswithADLsandIADLs....................................................................................................33IncomeandHousing..............................................................................................................................38CompetitionandSupportServices..................................................................................................43TheUnmetNeed......................................................................................................................................45SeniorIndependentLivingHousingDemand.............................................................................48

Conclusion.............................................................................................................................................50APPENDIX...............................................................................................................................................51


ExecutiveSummaryPlatte CountyHospital District has retained Community Builders, Inc. (CBI) to study thelongtermcaremarket in theWheatland,Wyomingregion. CBIhasexaminedpopulationandotherdemographic trends inPlatteCountyand,moregenerally,SoutheastWyoming.CBI has also analyzed existing and planned development of longterm care facilities intheseareas.Followingthisexaminationandanalysis,CBIidentifiedtheregionsneedsfornursinghomefacilities,assistedlivingfacilities,andmemorycareunits.Thosefindingsaresummarizedinthetablebelow:

MarketGrowthForecast,byMarketAreaandYearDEMANDFORNURSINGHOMEUNITS

MarketArea PRIMARY SECONDARY TERTIARY ALLAREASYear PlatteCounty SEWyoming StateofWyoming UnitedStates TOTAL2010 7 4 9 2 92011 7 3 7 2 52012 8 2 5 1 12013 8 1 4 1 32014 9 0 2 1 72015 10 2 0 0 11

DEMANDFORASSISTEDLIVINGFACILITYUNITSMarketArea PRIMARY SECONDARY TERTIARY ALLAREAS

Year PlatteCounty SEWyoming StateofWyoming UnitedStates TOTAL2010 20 6 1 1 272011 20 7 1 1 292012 21 7 1 1 312013 21 8 1 2 322014 22 9 2 2 342015 22 10 2 2 36

DEMANDFORMEMORYCAREUNITSMarketArea PRIMARY SECONDARY TERTIARY ALLAREAS

Year PlatteCounty SEWyoming StateofWyoming UnitedStates TOTAL2010 2 2 3 0 32011 2 2 3 0 32012 2 2 3 0 42013 2 1 3 0 42014 2 1 3 0 42015 2 1 3 0 5

Basedonthesefindings, itappearsthatconstructionofadditionalnursingfacilityunitsisneededtomeetcurrentdemandinthePrimaryMarketarea(PlatteCounty).Additionally,construction of a new assisted living facility will be needed to meet current and futuredemand.Considerationshouldbegiventooptionsforaccommodatingthismarketdemandwhen reviewing the costs and opportunities of remodeling the existing nursing home.However,givenconsumerpreferencesandconstructionefficiencies,thecommunityshouldalsoconsiderdevelopmentofanentirelynewlongtermcarecampus,wherebothtypesofresidentialfacilitieswouldbebuilt,andanticipatetheneedforexpandingallservicesforthenext4050years.


IntroductionAmericaisanagingcountry.Americansarelivinglonger,andunprecedentednumbersofolder citizens are choosing to live in longterm care facilities. The largest generation ofAmericanstheBabyBoomgenerationisnowreachingretirementage. TheBoomergenerationiswealthierthanpreviousgenerations,andsotodayselderlycitizenscanaffordto demand higher levels of privacy, safety and quality from service providers.Consequently,marketdemandisstrongfornewlongtermcarefacilitiesthatofferprivaterooms,highqualityservices,andspecialamenities.PreviousgenerationsofAmericansstruggledwiththeconceptof longtermcare. Forthemostpart,theelderlylivedwiththeirchildrenduringtheirlateryears.Thelast50yearshavebeenmarkedby just one type of longterm care facility: nursinghomes, or skillednursing facilities. Most of these facilities have operated with an institutional mindset,focusedentirelyonthehealthneedsandnotonthesocialorpersonalrelationshipneedsofresidents.Todays elderly have many longterm care choices. In fact, most communities offer acontinuumofcare includingsupportservices(e.g., transportationormeals),homehealthcare, independent living,boardinghomes,assisted living facilities, skillednursinghomes,andhospicefacilities.Wyoming's agingpopulation is similar to thenations. In fact, the state is actually agingfasterthannationalaverages.However,perhapsbecauseofitsruralnature,Wyominghasnotyetdevelopeda fullrangeof longtermcareoptions inmostof itscommunities. ThelevelsofcareandalternativestotraditionalnursinghomefacilitieshavenotyetbeenfullydevelopedinWyoming,astheyhaveelsewhere.Accordingly,someWyomingcommunitiesarecurrentlyevaluatingtheirlongtermcareneedsandidentifyingnewopportunitiesforprovidingservicestotheirregionselderlycitizens.This study reviews national and regional longterm care trends, and compares thosefindingstomarketareaunderconsideration.Populationdemographics,disabilitystatistics,housing,andincomedataareevaluatedtodeterminemarketdemand.Wyominglicensedlongtermcarefacilitiesarereviewedtodeterminecompetitivesupplyinthemarketarea.Finally, calculations aremade to estimate the net, unmet need for longterm care in themarketarea.


CommunityProfilePlatteCountyislocatedinsoutheasternWyoming.ElevationsinPlatteCountyrangefromahighofabout7,000feetinthesouthwesttoalowof4,300feet,intheextremeeasternpartofthecounty.PlatteCounty,roughly60milesfromnorthtosouthand30milesfromeasttowest,covers2,111squaremiles.The county includes five incorporated municipalities Chugwater, Glendo, Guernsey,Hartville,andWheatland.

Wheatland, the county seat and largest town in Platte County with an estimatedpopulationof3548,issetamidirrigatedfarmsandranchesandisafamilycenteredcommunity. Primarilyanagriculturalcommunity,Wheatlandboastsa large,cleanindustrialpowerplant.

PicturesqueHartville (population 76), isoneof theoldest incorporatedtowns inWyomingestablished in1884. It is located inEurekaCanyonasmallcommunitysixmilesnorthofGuernseyonhighway270.

ThetownofGuernsey(population1147),liesdirectlyontheoldOregonTrail.Thetownwasincorporatedin1902andisaccessedalongU.S.Highway26.

Chugwater is a small community of 244 located adjacent to Interstate 25 at thesouthernedgeofPlatteCounty.

GlendoisthenorthernmostcommunityinPlatteCountyandislocatedonI25nearGlendoReservoirandStatePark.Glendo'spopulationis229.

TransportationRail,AirandRoadServicePlatteCountyisservedbyseveralmajorhighways,includingInterstate25,Wyoming'sonlynorthsouthinterstateandU.S.Highway26,amajoreastwestartery.Inaddition,WyomingStateHighway34runsfromcentralPlatteCountytoU.S.Highway30,justnorthofLaramie,and Wyoming State Highway 270 connects Guernsey and Hartville with U.S. Highway18/20,anothermajoreastwesthighway.Distances fromWheatland tomajorpopulationcentersinWyomingandneighboringstatesinclude:

Laramie85miles Denver:177miles Cheyenne70miles RapidCity,SouthDakota275miles

ThefivecommunitiesareroughlythreehoursfromDenverInternationalairport,oneofthenation'sbusiestcommercialairports,andsmaller regionalairports inCheyenne,LaramieandCasperareroughlyanhourbyautomobile.The Burlington Northern Santa Fe Railroad provides freight, coal and other commercialservicethroughPlatteCounty.ElectricityThe vast majority of Platte Countys 8,300 residents receive their power from theWheatland Rural Electric Association (Wheatland R.E.A.).Established in 1936, the


Wheatland R.E.A. has expanded dramatically over the years to provide even the mostremote parts of Platte County, and several neighboring counties as well, with reliable,reasonably priced electricity.Today the R.E.A. provides electric power for agriculturalpurposes such as irrigation wells and pivot sprinklers, domestic use, and business andindustriesthattendtobelocatedinmoreruralareas.WaterTheTownofWheatlandalsosupplieswaterfordomestic,business,andindustrialuses,aswellassewerandsanitationpickupforitsresidents.NaturalGasResidents,businessesand industry in andnear theCityofWheatland canaccessnaturalgas,providedandmaintainedlocallybySourceGasofWyoming.TelecommunicationsQWEST is the provider of landline telephone service in Wheatland and much of PlatteCounty. Cell phone service is presently provided by Verizon, Alltel and UnionWireless.WirelessInternetserviceisprovidedlocallybyWyomingWireless.

PublicParticipationPlanIn compliance with the Wyoming Business Council's requirement to community andeconomic development recipients to "inform and educate the public and businesscommunity to the greatest extent possible about the proposed economic developmentproject utilizing a variety of techniques and media," the Platte County LongTerm CarePublic Participation Action Plan was developed and is attached to this document asAppendixA.Asthelongtermcareplanunfoldsinthecommunity,thepublicengagementprocesswillprovide the greatest possibility of successful implementation of project goals. Specialeffortsarebeingmadetohearthethoughtsandopinionsofseniorcitizenswhocurrentlyormayinthefuturereceivelongtermcareresidentialservices.

CommunitySurveysAcommunitysurveywasdevelopedandcirculated throughout thecommunity toget thepublic's inputon longtermcareneeds. Thesurveywasnot intendedtobeastatisticallyvalid instrument; rather itwas intended togauge thepulseof the interestedcommunity.Surveysweremadeavailableatvariouscommunitycentersfrequentedbyseniorcitizens;aSurvey Monkey Internet link was created and advertised in the newspaper; and lettersencouraging survey completion were sent to advisory committee members for theirconstituents. A separate survey for advisory committee members was also conducted.SamplesurveysandcompleteresultsofthosesurveysareattachedasAppendixB.


AdvisoryCommitteeSurveySummaryIn general, most Advisory Committee respondents reported knowing someonewho hadmovedawayfromthecommunitytoreceivelongtermcareservices.Mostoftheseformerresidentsmoved to nursing homes orAlzheimer (memory care) units. Overwhelmingly,the reason given for leaving the community for these longterm care services was thatserviceswerenotavailableinPlatteCounty.When asked if there is a need for additional longterm care services in the community,most advisory committee respondents listed memory care, skilled nursing facility, orassisted living facilityasneeds. Clearly, theopinionexists that thecurrentPlatteCountyMemorial Nursing Home does not adequately meet the needs of the community for avarietyofreasons,mostnotablytheneedformoreroomsandmoreprivacy,handicappedaccessiblebathrooms,andmemorycare.CommunitySurveyTheAdvisoryCommitteeresponsesweremirroredby theCommunitySurveyresults. Ofthe60 respondents, 23%ormore reported receivingnursinghome care, transportation,publichealthservicesand/oradultdaycareservices. By far, themost importantreasongivenwhenseekingout longtermcarehousing isqualityofcare, followedbyadesiretostayinthearea,andthenprivacy.HalfoftherespondentsreportedknowingsomeonewhohadmovedoutofthecommunitytoanAlzheimerormemorycarefacility.Aclosesecond(28respondents)knowsomeonewhomovedtoanursinghome.Themajorreasonthesepeoplemoveawaywasbecausetheserviceis(orwas)notavailableinPlatteCounty.Nearly all (90%) of the community survey respondents indicated a need for additionallongtermcareservicesinthecommunitycommonresponseswereaneedforanAssistedLiving Facility, Alzheimer or Memory Care and Skilled Nursing Care in a larger facility.Desired improvements include more and larger rooms, modern updates, larger privatebathroomsandimprovedkitchenservices.TheoverwhelmingmajorityofthosecommunitymemberswhoreturnedsurveysindicatedthattheywouldusetheNursingHomeifitcouldberemodeledtomeettheirneeds.Ahighpercentage(86%)ofrespondentsalsosaidtheywouldbelikelytouseanAssistedLivingFacilityifitwereconstructed.Accordingtotherespondents,thebestwaytogatherinputfromthecommunitymemberswhoneedorwillneed longtermcarecenteroncommunitybasedmethods: facetofacecontact, informational meetings, newspaper or radio announcements and variouscommunitygrouppresentations.


ReviewofLongTermCareIndustryAsweage,manypeople losesomeof theirabilities tocarefor themselves. Manyelderlycitizens develop difficulties in completing activities of daily living (ADLs). ADLs are thethingswenormallydoinlife,includinganydailyactivityweperformforselfcare(suchasfeeding ourselves, bathing, dressing, grooming), work, homemaking, and leisure. Theability or inability to perform ADLs can be used as a very practical measure ofability/disabilityinmanydisorders.Similarly,somecitizensstrugglewithinstrumentalactivitiesofdailyliving(IADLs),whicharetheactivitiesoftenperformedbyapersonwhoislivingindependentlyinacommunitysetting.IADLswouldincludeactivitiessuchasmanagingmoney,shopping,telephoneuse,travel,housekeeping,preparingmeals,andtakingmedicationscorrectly.LimitationsinperformingADLsandIADLsmayresultintheneedforlongtermcare.Thevastmajorityofpeopleneedinglongtermcarereceiveitfromtheirownfamilymembersand/or friends. Only a small portion of the population needing longterm care actuallyreceiveitfrompaidcaregivers,andanevensmallerpercentage(about6%)oftheelderlypopulation receiveneeded services at a longterm care facility. Yet, this segment of ourpopulation is very large, growing exponentially, and increasingly needs longterm careservices.Typically,elderlypersonswiththehighest levelsofneedaretheoneswhoseekcareinalongtermcarefacility.Theconceptof longtermcare(LTC) intheUnitedStateshastraditionallymeantsendingelderly citizens to institutionalized nursing homes. Those institutions, called SkilledNursingFacilitiesorSNFs,currentlyhouseabout1.6millionelderlyAmericans.Yet,muchhas changed in the last20years! Today, there is awide rangeofLTCoptions available,including:

CommunitybasedServicesManycommunitiesprovideservicesandprogramstohelpseniorsandpeoplewithdisabilitieswithavarietyofpersonalactivities.Theseservices include MealsonWheels, transportation services, personal care, choreservices,adultdaycare,andavarietyofactivitiesinseniorcenters.Theseservicesareusuallyfreeoratlowcosttoindividualswhoqualify.Localorganizations,calledAreaAgenciesonAging,coordinatetheseservicestopromotetheindependenceanddignityofolderadults.

HomeHealthCareSomeeldersreceivecareintheirownhome.Suchservicescan

includeskillednursingcare,homemaker/healthaides,personalcareaides, respitecare,medicalequipment,homerepairandmodification,andhospice.

SeniorIndependentLivingTypically,aclusterofmultifamilyunits(duplexes)orcondominiumunitsthataredesignedforseniorswhopayforsomeservices(suchashousekeeping, transportation,ormeals)aspartofamonthlyfee,andwhorequirelittle,ifany,assistancewithActivitiesofDailyLiving. Independentlivingunitsare


notnormally licensedforhealthcare,althoughresidentsmayreceivehomehealthcareservicesintheirownunit.

Inlaw Apartments An inlaw apartment is a separate housing arrangement

within a singlefamily home or lot. It may also be referred to as a second unit,accessoryapartment,oraccessorydwellingunit.Aninlawapartmentisacompleteliving space and includes a private kitchen and bath. An inlaw apartment mayprovidelivingspaceforacaretakerormayberentedtoprovideadditionalincome.

Subsidized Senior Housing The federal government and most states have

programsthathelppayforhousingforolderpeoplewithlowormoderateincomes(lessthan$46,000ifsingleor$53,000ifmarried).Someofthesehousingprogramsalso offer help with meals and other activities like housekeeping, shopping, anddoingthelaundry.Residentstypicallyliveintheirownapartmentsinthecomplex.Usually a Federal or State agency will review monthly income and expenses foreligibility for this type of housing. Rent payments are usually a percentage ofincome.

BoardingHomesThisgroup livingarrangementprovideshelpwithactivitiesof

dailylivingsuchaseating,bathing,andusingthebathroomforpeoplewhocannotlive on their own but do not need nursing home services. These are sometimescalled "grouphomes". In some cases, private longterm care insuranceandothertypes of assistance programs may help pay for this type of living arrangement.Manyof thesehomesdonot receivepayment fromMedicareorMedicaidandarenotstrictlymonitored.Themonthlychargeisusuallyapercentageofincome.

Assisted Living Facilities (ALFs) This group living arrangement provides help

withactivitiesofdailylivingsuchaseating,bathing,andusingthebathroom,takingmedicine,andgettingtoappointmentsasneeded.Residentsoftenliveintheirownroomorapartmentwithinabuildingorgroupofbuildingsandhavesomeoralloftheirmealstogether.Socialandrecreationalactivitiesareusuallyprovided.Someassisted living facilities have health services on site. Costs for assisted livingfacilitiescanvarywidelydependingonthesizeofthelivingareas,servicesprovided,type of help needed, and where the building is located. Residents usually pay amonthlyrentandthenpayadditionalfeesfortheservicesthattheyget.

Continuing Care Retirement Community (CCRC) These housing communities

havedifferentlevelsofcarebasedonresidentsneeds.Whereonelivesdependsonthelevelofcareneeded.Inthesamecommunity,theremaybeindividualhomesorapartments for residentswho still live on their own, an assisted living facility forpeople who need some help with daily care, and a nursing home for those whorequire higher levels of care. Residents move from one level of care to anotherbasedontheirneedsbutstillstayintheCCRC.


NursingHomesThesefacilitiesprovidecaretopeoplewhocannotbecaredforathomeor inthecommunity. Nursinghomesprovideawiderangeofpersonalcareand health services. Formost people, this care generally is to assist peoplewithsupportservicessuchasdressing,bathing,andusingthebathroom,forpeoplewhocannottakecareofthemselvesduetophysical,emotional,ormentalproblems.

Memory Care These are secure units designed for people with significantcognitive impairment as a result of having Alzheimers disease or some otherdementia. InWyoming, there are additional licensure requirements for MemoryCarebeds.

Source:AdaptedfromU.S.DepartmentofHealthandHumanServices/Medicare.ReviewedontheInternetonFebruary20,2010,at:http://www.medicare.gov/LongTermCare/Static/TypesOverview.asp.

Platte CountyHospital District has retained Community Builders, Inc. (CBI) to study thelongtermcaremarket inthePlatteCounty,Wyomingregion. Acompleteexaminationofthefullcontinuumofall longtermcareoptionswouldgobeyondthescopeofthisstudy.Instead, this studywill focusonmarketdemand for threeprimary types longtermcare:NursingHomes,AssistedLivingFacilities,andsecureMemoryCareunits.


NursingHomesU.S.Nursing homes provide the most intense longterm care services in the United States.Servicesatanursinghomemeetawiderangeofmedical,personal,rehabilitativeandlongtermneeds for residents. Themostdistinguishing characteristic of these facilities is theskilled nursing care that is available to nursing home residents 24hours a day. Thus,unlike many other types of longterm care facilities, governmentfunded programs(MedicareandMedicaid)typicallypaythecostfornursinghomecare.According to the U.S. Department of Health and Human Services, there were 1,412,540residents living in 15,730 certified nursing facilities during 2008 (most recent dataavailable).Thosesamefacilitiescontained1,703,846licensedbeds,resultinginanoveralloccupancy rate of 82.9%. Source: Health, United States, 2009, prepared by the U.S.Department ofHealth andHuman Services, downloaded from the Internet onOctober 28,2010 at http://www.cdc.gov/nchs/hus/older.htm. At that time (2008), the U.S. CensusBureau estimated that there were 38,869,716 residents aged 65 or older living in theUnitedStates.Thus,in2008,3.63%ofallpersonsaged65orolderwerelivingincertifiednursing facilities in the United States. Source: U.S.CensusBureau,downloaded from theInternet on October 28, 2010 at http://www.census.gov/popest/national/asrh/NCEST2009/NCEST200902.xls.WhilethecostofresidingatanursinghomeistypicallypaidbyMedicareorMedicaid,mostnursinghomesareprivatelyownedandoperated.Oneothersourceofpaymentisderivedfromlongtermcareinsurance,andsolongtermcarecostsareannuallytrackedbymajorinsurancecompaniesthatprovidesuchcoverage.AccordingtoGenworthFinancials2010CostofCareSurvey,thenationalmediandailyratefornursinghomeswas$185forasemiprivate room, or $206 for a private room. Those daily rates translate into $5,627 and$6,266,respectively,permonth,and$67,525and$75,190,respectively,peryear.Inordertobuildanewnursinghomeorexpandanexistingfacility,manystatesrequirethedeveloper toobtainaCertificateofNeed(CON). The justification forCONprogramsis tocontrolhealthcarefacilitycostsandallowcoordinatedplanningofnewfacilities.Theideais thatneworexpandedfacilitiesshouldbeapprovedonlywhenthere isagenuineneed.Statutorycriteriahelplicensingagenciesdecidewhatisnecessaryforagivenlocation.Byreviewing occupancy levels of existing facilities, theagencies make judgments aboutwhether there is a need for additional beds. Once that need is established, the licensingagencywillgrantthedeveloperpermissiontobeginaproject.


NursingHomesWyomingAccording to the U.S. Department of Health and Human Services, there were 2,431residents living in 39 certified nursing facilities inWyoming during 2008. Those samefacilities contained 2,993 licensed beds, resulting in an overall occupancy rate of 81.2%.Source: Health,UnitedStates,2009,preparedbytheU.S.DepartmentofHealthandHumanServices, downloaded from the Internet on October 28, 2010 athttp://www.cdc.gov/nchs/hus/older.htm.TheWyomingDepartmentofHealth,OfficeofHealthcareLicensingandSurveysconductsannual surveys of every nursing home in the state. According to data on their website(http://wdh.state.wy.us/ohls/index.html), there are currently 2,958 licensed beds in 38nursing facilities inWyoming. The census of residents taken during the annual surveys(thetimingofwhichisdifferentforeachfacility)is2,416people,resultinginastatewideoccupancyof81.7%.Because the federal government measures data from facilities that maintain federalMedicareandMedicaidcertificates(notthesameasastatelicense),andbecauseoftimingdifferences for state licensing annual surveys, data from the two sources is slightlydifferent.According to Genworth Financials 2010 Cost of Care Survey cited above, Wyomingsmedian daily rate for nursing homes was $188 for a semiprivate room, or $200 for aprivateroom.Thosedailyratestranslateinto$5,718and$6,083,respectively,permonth,and$68,620and$72,818,respectively,peryear.WyomingisnotaCONstate.However,beforetheStatewillawardalicensetoadeveloperfor a new or expanded nursing home, the Office of Healthcare Licensing and Surveysconsiders occupancy levels (from its most recent surveys) for the construction area.Wyoming Statute 352901(a)(v) defines the construction area to include all nursinghomeswithina30miledrivefromtheproposedsite.Bylaw,nursinghomeoccupanciesintheconstructionareamustexceed85%inordertosecurealicensetobuildmorenursinghome beds (Wyoming Statute 352906(b)). However, that same statute allows existingnursinghomestoincreasetheirlicensedbedcapacitybytenpercent(10%),uptotenbeds,inanytwoyearperiod.CurrentlylicensednursinghomefacilitiesintheStateofWyomingareidentifiedbelowinTable1,alongwiththeiroccupancystatus.


Table1:WyomingLicensedNursingHomeFacilitiesNursingHomeFacility #ofLicensedBeds

#Occupied

Occupancy% City

StarValleyCareCenter 24 22 91% AftonBonnieBluejacketMemorialNursingHome 37 31 85% BasinWyomingRetirementCenter 90 55 61% BasinAmieHoltCareCenter 50 45 90% BuffaloLifeCareCenterofCasper 120 113 94% CasperShepherdoftheValleyCareCenter 192 182 95% CasperSSCCasperOperatingCompanyLLC 120 110 92% CasperWyomingMedicalCenterTransitionalCareUnit 15 12 78% CasperLifeCareCenterofCheyenne 160 150 94% CheyenneMemorialHospitalofLaramieCo 16 10 63% CheyenneMountainTowersHealthcare&RehabilitationCenter 146 130 89% CheyenneSSCCheyenneOperatingCoLLC 105 93 89% CheyenneWestParkLongTermCareCenter 128 74 58% CodyDouglasCareCenterLLC 60 41 68% DouglasRockyMountainCareEvanston 60 43 71% EvanstonMorningStarCareCenter 45 40 89% FtWashakiePioneerManorNursingHome 150 123 82% GilletteCastleRockConvalescentCenter 59 56 95% GreenRiverStJohn'sNursingHome 60 41 69% JacksonSouthLincolnNursingCenter 24 24 98% KemmererWestwardHeightsCareCenter 60 56 94% LanderAlbanyCoHospitalDistrict 10 7 72% LaramieLaramieCareCenter 105 75 71% LaramieNewHorizonsCareCenter 85 69 81% LovellWestonCountyHealthServices 54 52 97% NewcastleSubletteCenter 50 30 60% PinedalePowellValleyCareCenter 100 94 94% PowellSouthCentralWyomingHealthcare&RehabilitationCenter 62 29 47% RawlinsWindRiverHealthcare&RehabilitationCenter 88 77 87% RivertonSageViewCareCenter 82 52 63% RockSprgsValleyViewCare&RehabilitationCenter 46 34 74% SaratogaSSCSheridanOperatingCompanyLLC 128 95 74% SheridanWestviewHealthCareCenter 102 83 81% SheridanCrookCoMedicalServiceDistrictLongTermCare 32 30 94% SundanceThermopolisRehabilitation&CareCenter 60 47 78% ThermopolisGoshenCareCenter 103 101 98% TorringtonPlatteCountyMemorialNursingHome 43 26 60% WheatlandWorlandHealthcare&RehabilitationCenter 87 64 74% WorlandTOTAL 2,958 2,416 81.7%

Source: Wyoming Department of Health/Office of Healthcare Licensing and Surveys,Healthcare Facility Directory, downloaded from the Internet on October 28, 2010 athttp://www.health.wyo.gov/ohls/facilitiesdirectory.html.


AssistedLivingFacilitiesU.S.Traditionally,longtermcareintheUnitedStateshasbeenresistedbytheelderlybecauseofastigmaattachedtonursinghomesasaplaceforoldfolksoraplacetodie.Today,however,many elders are choosing tomove to anoninstitutionalized alternative, calledassistedliving.TheseAssistedLivingFacilities(ALFs)havefocusedonprovidingnecessaryservicesinahometypeenvironment.ALFshavebeenthefastinggrowingsegmentofthelongtermcaremarketintheUnitedStatesduringthelast20years.In 2007 (the year with the most recent estimates), the U.S. Department of Health andHumanServicesreportedthattherewere38,373licensedALFsintheUnitedStates,with974,585 units/beds. Source: Residential Care and Assisted Living Compendium: 2007.DownloadedfromtheInternetathttp://aspe.hhs.gov/daltcp/reports/2007/07alcom.htm. Atthat time, anestimated37,887,958 residents in theUnitedStateswereaged65yearsorolder. Source:PopulationDivision,U.S.CensusBureau;Table1:EstimatesofthePopulationbySelectedAgeGroupsforJuly1,2007. ReleaseDate: May1,2008. DownloadedfromtheInternet on February 13, 2010 at http://www.census.gov/popest/states/asrh/tables/SCEST200701.xls. Accordingly, in 2007, approximately 2.572% of the entire nationspopulationofpeopleaged65orolderwerelivinginALFs(974,585/37,887,958=2.57%).According to those same sources, in 2004, there were 935,634 residents living in ALFsnationwide,when the total population of people aged 65 or olderwas estimated by theCensusBureau tobe36,301,469,meaning that therewas then2.576%of thatagegroupliving in ALFs. Similarly, according to the same federal sources, there were 908,488residentsinALFsin2002,atwhichtimetherewasapopulationof35,591,009peopleaged65orolderintheUnitedStates;thus2.553%ofthatselectagegroupchosetoliveinALFs.The data for each of these years (2002, 2004, and 2007) are remarkably consistent;demonstratingthatthepercentageofpersonsaged65andolderwholiveinALFshasbeenrelativelyconstantforthepastfiveyears.Accordingtothe2009OverviewofAssistedLiving,themediancost(i.e.,thecostpointatwhichthebaseratesfor50%ofallunitsishigher,and50%islower)forasingleoccupancyassisted living unit is $2,864 permonth, and themean average is $3,022 permonth. Amore recent study, The State of Seniors Housing 2010 cited above, reported that themedian total cost (i.e., includes costs that are charged in addition to the base rate) forassistedlivingresidencesunitsis$3,352permonth.


AssistedLivingFacilitiesWyomingGiven the relative constancyof thepercentageofAmericanswho choose to live inALFs,andconsideringthatthenationalstatisticsabovetakeintoaccounteverystatelargeandsmallandeverykindofcommunityruralandurbanthisstudymakestheassumptionthat the same percentage (2.57%) of Wyoming residents, including the Primary andSecondaryMarketArearesidents,willmakethesamedecisiontoliveinanALF.Onemightargue that theaboveassumption isovergeneralized. Forexample,onecouldtheorizethatmanyretireesmovetothesouth,toawarmerclimateandmorecomfortablelifestyle.Yet,onapercentagebasis,theassumptionholdstrue.Consider,forexample,thetoptenstateswiththehighestpercentagesofelderly(aged65orolder)livinginALFs,aspresentedinTable2below.

Table2:TopTenStateswithHighestPercentageofALFresidents(2007)NatlRank State

TotalPopulation(1)

65yearsandover(1)

65yearsandover% Units/Beds(2)

Units/Bedsperperson65yearsandover(%)

1 Oregon 3,747,455 488,936 13.05% 22,130 4.53%2 Maine 1,317,207 194,986 14.80% 8,703 4.46%3 Wisconsin 5,601,640 736,301 13.14% 31,782 4.32%4 Nebraska 1,774,571 236,648 13.34% 10,063 4.25%5 California 36,553,215 4,003,593 10.95% 161,586 4.04%6 Alaska 683,478 47,935 7.01% 1,912 3.99%7 Idaho 1,499,402 174,946 11.67% 6,819 3.90%8 Pennsylvania 12,432,792 1,889,660 15.20% 71,831 3.80%9 NorthCarolina 9,061,032 1,103,413 12.18% 41,642 3.77%10 NorthDakota 639,715 93,285 14.58% 3,472 3.72% Top10States 73,310,507 8,969,703 12.24% 359,940 4.01%

Source(1):PopulationDivision,U.S.CensusBureau;Table1:EstimatesofthePopulationbySelectedAgeGroupsforJuly1,2007. ReleaseDate: May1,2008. DownloadedonFebruary13, 2010 at http://www.census.gov/popest/states/asrh/tables/SCEST200701.xls. Source(2):U.S.Department ofHealth andHuman Services. Residential Care andAssisted LivingCompendium:2007.Downloadedathttp://aspe.hhs.gov/daltcp/reports/2007/07alcom.htm.WiththeexceptionsofCaliforniaandNorthCarolina,thesetopstatesarealllocatedinthenorthernpartofthenation.Thereare,ofcourse,averylargenumberofretireeslivinginsouthern states such as Florida but, on a percentage basis, those states tend to drag thenationalaveragedownward,notupward.Similarly,onemaysuggestthatWyomingspercentageofelderly livinginALFsshouldbelessthanthenationalaverage,giventhestatesrural,westernculturewherefamiliestakecareoftheirownandareproudlyindependent.However,ananalysisofthesixstatesthatareimmediatelyadjacenttoWyomingsuggestsjusttheopposite,asseeninTable3below.


Table3:ALFPercentagesforStatesAdjacenttoWyoming(2007)

NatlRank State

TotalPopulation(1)

65yearsandover(1)

65yearsandover% Units/Beds(2)


19 Colorado 4,861,515 492,685 10.13% 14,237 2.89%7 Idaho 1,499,402 174,946 11.67% 6,819 3.90%15 Montana 957,861 133,578 13.95% 4,351 3.26%4 Nebraska 1,774,571 236,648 13.34% 10,063 4.25%16 SouthDakota 796,214 113,555 14.26% 3,578 3.15%30 Utah 2,645,330 233,982 8.85% 5,256 2.25% AdjacentStates 12,534,893 1,385,394 11.05% 44,304 3.20%

Source(1):PopulationDivision,U.S.CensusBureau;Table1:EstimatesofthePopulationbySelectedAgeGroupsforJuly1,2007. ReleaseDate: May1,2008. DownloadedonFebruary13, 2010 at http://www.census.gov/popest/states/asrh/tables/SCEST200701.xls. Source(2):U.S.Department ofHealth andHuman Services. Residential Care andAssisted LivingCompendium:2007.Downloadedathttp://aspe.hhs.gov/daltcp/reports/2007/07alcom.htm.As Table 3 above demonstrates, the states adjacent toWyoming actually have a higherpercentage(3.2%)ofelderlypersonsaged65orolderlivinginALFsthandoesthenationasawhole(2.57%).Wyomingspopulationofelderlyaged65ormorein2007was63,901people.IfWyomingprovidedthesamerateofALFbedsto itscitizensas thenation(2.57%)oras theregioncomprisedof adjoining states (3.2%), thenWyomingneeds tohave a supply of 1,642or2,045ALFunits,respectively.However,asof2007,Wyominghadjust1,436ALFbeds,asseeninTable4below.Table4:ComparisonofALFPercentagesforUnitedStates,WyominganditsAdjacentStates(2007)

NatlRank State

TotalPopulation(1)

65yearsandover(1)

65yearsand

over%Units/Beds(2)


UnitedStates 301,621,157 37,887,958 12.56% 974,585 2.57% AdjacentStates 12,534,893 1,385,394 11.05% 44,304 3.20%29 Wyoming 522,830 63,901 12.22% 1,436 2.25%Source(1):PopulationDivision,U.S.CensusBureau;Table1:EstimatesofthePopulationbySelectedAgeGroupsforJuly1,2007. ReleaseDate: May1,2008. DownloadedonFebruary13, 2010 at http://www.census.gov/popest/states/asrh/tables/SCEST200701.xls. Source(2):U.S.Department ofHealth andHuman Services. Residential Care andAssisted LivingCompendium: 2007. Downloaded from the Internet on February 13, 2010 athttp://aspe.hhs.gov/daltcp/reports/2007/07alcom.htm.Given the number ofWyoming residentswho are 65 years or older, and the number oflicensedALFs,thereisashortfallofALFbedsnomatterwhichaverageisused.Ifoneuses


thenationalaverage(2.57%)ofelderlypeople(65orolder)whoare living inALFs, thenWyominghadashortfallin2007of206beds;andifoneusestheregionalaverage(3.2%)thenWyominghadashortfall in2007of609beds. Forthesakeofargumentandtoriskerringonlyontheconservativeside, thisstudywillusethe lower,nationalpercentageofelderlylivinginALFs(2.57%)fortherestofthisstudy.The shortfall of ALF beds actually has worsened in Wyoming since 2007. As of 2010,Wyomings elderly population (age 65 and older) has grown to 69,485 residents,generatingevenmoredemandforALFs.Source:ESRIBusinessAnalystOnline,basedonU.S.Bureau of theCensus,2000Census ofPopulationandHousing,andESRI. Downloaded onOctober1,2010athttp://www.esri.com/bao. Atthesametime,thenumberofALFbedsinWyoming has not grown to accommodate the rising demand. As of September 2010,Wyominghadjust1,234licensedbeds,whichwouldincreasetheshortfallbyanother202beds.In2010,then,ifthenationalaverageof2.57%ofWyomingselderlywereresidinginALFs,thenWyomingwouldneed1,786ALFbeds.However,accordingtolicensingdatafromtheWyoming Department of Health (see Table 5 below), there currently are 20 privatelylicensedALFsinWyoming(oneofwhichisanewstartupinearly2010thatisnotyetfullyoperational), plus two governmentoperated ALFs. Theoretically, if Wyomings targetpopulation were to abandon their values for privacy and quality of services, then theexistingALFsinthestatecouldpossiblymeet69%ofthemarketdemand(i.e.,1,234bedsarecurrentlyavailable,leavinganunmetneedofatleast552beds).However,WyomingsALFoperatorsclaimthatWyomingsseniorsplaceahighvalueonprivacyandqualityofALF services. Accordingly,mostWyomingALFoperatorsareable to sell services to justoneoccupantperunit,regardlessofthenumberofbedslicensedforthatroom.Thetypicalexceptiontothisruleandtheonlytimethatunitsactuallyhousetworesidentsiswhenmarriedcouples/partnersorsiblingsdesiretolivetogether.OnemustbeclearaboutthedifferencebetweenALFlicensedunitsandbeds.Unitsareroomsinwhichresidentsmaylive;bedsarethenumberofresidentsthatarelicensedtobeplaced in all rooms. The design and construction of the ALF determines the number ofunits(rooms)intheALF.Incontrast,theWyomingDepartmentofHealthdeterminesandlicensesthenumberofbedsthatcouldbeplacedintheALF,basedonthesquarefootageof each room at the time of initial facility licensing. However, according to the 2009OverviewofAssistedLiving,manyother reports cited in this study, andCBIs telephoneinterviewswithWyomingALFs,mostALFresidentswillnotsharearoomunlessitiswiththeirspouse.PrivacyisoneofthemostcommondecisionmakingcriteriaidentifiedbyALFresidents when choosing where they will live (quality of services is the other majorcriteria), according to the 2009 Overview of Assisted Living. Accordingly, whenconsidering the occupancy level of any ALF, it is most appropriate to consider thepercentageofunits that are occupied, not thenumber of beds. Source:2009OverviewofAssistedLiving,a collaborative researchprojectof theAmericanAssociationofHomesandServices for the Aging (AAHSA), the American Seniors Housing Association (ASHA), theAssistedLivingFederationofAmerica(ALFA),theNationalCenterforAssistedLiving(NCAL),andtheNationalInvestmentCenterfortheSeniorsHousing&CareIndustry(NIC).Published


byStrattonPublishing&Marketing,Inc.(August2009).[Note: Thenational organizationsthat collaborate in this reports preparation consider it to be the singlemost importanteffort to provide core national metrics about the assisted living customer and aninvaluable statistical resource for senior housing providers, policymakers, regulators,consumers,consumeradvocates,andhealthcareprofessionals.]

Accordingly,ifoneassumes(asdoesthisstudy)thatthemostappropriatemeasureofALFusageisthenumberofunits,thenWyominghasamuchlargershortfall.IftheactualneedinWyoming is for 1,786units (not beds), then there is a current need for 817newALFunits (i.e.,differencebetweencurrentdemand for1,786unitsandcurrent supplyof969units).ThisstatewideshortageisevenmoreacuteatsomelocalitieswithinWyoming,andisalikelyreasonthatelderlyresidentsareleavingcommunitieslikeWheatlandandPlatteCounty.For comparison purposes, this study will primarily examine other private pay ALFs,excludingthegovernmentownedfacilities.Also,becausetheAgapeManorALFinBuffalo,Wyoming,hasbeenopenlessthanoneyear,ithasnotyetreachedfulloperationalcapacity,and so that facilitys occupancy is not a good comparison. The 19 remainingWyomingALFsallprivatepayfacilitiesthathavebeenoperationalformorethanoneyear,contain768 units. CBI phone surveys of those private pay assisted living facilities establish anaveragemonthlybasecostof$3,011.Currently,thereare655residentsinthosefacilities,resultinginastatewideprivateALFoccupancylevelof85%,asseeninTable5below.


Table5:WyomingLicensedAssistedLivingFacilities

AssistedLivingFacility#of

LicensedBeds

#Units #ResidentsOccupancy

% CITY

AgapeManorAssistedLiving 26 24 BuffaloGardenSquareofCasper 50 48 43 90% CasperMeadowWindAssistedLivingCommunity 75 53 48 91% CasperParkPlaceAssistedLivingCommunity 116 61 56 91% CasperPrimroseRetirementCommunityofCasper 42 32 31 74% CasperAspenWindAssistedLivingCommunity 100 77 72 94% CheyennePointeFrontierRetirementCommunity 50 45 41 92% CheyenneSierraHillsAssistedLivingCommunity 100 80 63 79% CheyenneAbsarokaAssistedLivingCommunity 51 46 44 95% CodyBeeHiveHomesofEvanston 16 12 8 69% EvanstonTenderHeartAssistedLivingFacility 16 14 11 77% EvanstonRiverRockLodgeAssistedLivingCommunity 65 57 38 66% JacksonShowboatRetirementCenter 50 32 27 84% LanderSpringWindAssistedLivingCommunity 75 53 37 69% LaramieNewHorizonsAssistedLivingFacility 9 7 5 75% LovellTheHeartland 24 24 23 95% PowellHomesteadAssistedLiving 48 45 32 71% RivertonSugarlandRidgeSeniorAssistedLivingCommunity 65 55 52 94% SheridanSundanceAssistedCare 15 14 13 95% SundanceLegacyHomesAssistedLiving 16 13 11 81% ThayneAverageoccupancynonstatefacilities 1009 792 655 83%PRIVATEALFs,LESSBUFFALO 983 768 655 85%

Veterans'HomeofWyoming 117 117 91 78% BuffaloWyomingPioneerHome 108 60 30 50% ThermopolisTOTALPRIVATEANDPUBLICLYOPERATEDALFs 1,234 969 776 80%

Source: Wyoming Department of Health/Office of Healthcare Licensing and Surveys,Directory ofWyomingAssistedLivingFacilities,downloaded from the Internet onMay22,2010athttp://www.health.wyo.gov/ohls/facilitiesdirectory.html. Dataupdated byCBI viaemailsandphonecallstofacilities.AsidentifiedinTable5above,WyomingsprivateALFsarecurrentlyoperatingat85%oftheirunitcapacity.Thisnumberhasdecreasedfrom90%occupancyduringthecourseofthelast12months. Facilityadministratorscitedtheeconomicdownturnasakeyreasonfor higher than normal vacancy rates. By comparison, median occupancy for ALFsnationwide is 90.5%. Source: The State of Seniors Housing 2010, a joint publicationproduced by the American Association of Homes and Services for the Aging (AAHSA),AmericanSeniorsHousingAssociation(ASHA),AssistedLivingFederationofAmerica(ALFA),


National Investment Center for the Seniors Housing & Care Industry (NIC), and NationalCenterforAssistedLiving(NCAL).Accordingtothe2009OverviewofAssistedLivingcitedabove, thereareseveralreasonsthatsomeALFsdonotoperateatfulloccupancy.SomeALFsfaceoperationallimitations,such as limitedworkforce, older structures, and local competition. However, the largestfactoronoccupancyisconsumerchoice,primarilyledbytwodecisionpoints:Privacyandquality. According to this study, the elderlymarketwill avoid ALF units that have onlysemiprivate rooms (i.e., units shared by two residents). Additionally, todays elderlyconsumer seeks to avoid ALFs that appear to be institutionalized or that lack quality ofservices.Accordingly,manyofWyomingscurrentALFsdonotmeetwiththeexpectationsanddemandsoftodaysconsumer.The findings of the 2009 Overview of Assisted Living study seem particularly on pointwhenoneconsiderstheALFslocatedinWyomingslargermarkets,CheyenneandCasper.There,withineachmarket,onecanfindanALFthatmeetsorexceedsthatnationalmedianoccupancyrate.Yet,inthatsamemarket,onefindsotherALFswhoseoccupancyisfarless.Suchdiscrepanciescannotbeexplainedbythesizeofmarket,marketdemand,oranythingotherthanconsumerchoice.Finally, itshouldbenotedthatunlikenursinghomestheStatedoesnotrequireproofthat construction of an ALF is warranted by high occupancy rates in the area. Instead,recognizing that ALFs are primarily funded by privatepay residents, the governmentallows development of new or expanded ALFs to be determined by market demands.Therefore,thisstudywillparticularlyexplorethemarketareaslevelofdemandandsupplyofALFs.


MemoryCareU.S.

In addition to limitations in physical abilities, many Americans have additional needsrelated to theirmental abilities. For example, an estimated 5.3millionAmericans of allageshaveAlzheimersdisease. Thisfigureincludes5.1millionpeopleaged65andolder.Aboutoneineightpeopleaged65andolder(12.6%)haveAlzheimersdisease.Estimatesfromvarious studies indicated that4567percentof residentsofassisted living facilitieshaveAlzheimersdiseaseorsomeotherformofdementia. Yet,only5%ofassistedlivingbedsare inAlzheimers special careunits (asof June2009,according to themost recentdata available). Thus, it is clear that the greatmajority of nursing home residentswithAlzheimers and other dementias are not in Alzheimers special care units. Source:AlzheimersAssociation,AlzheimersDiseaseFactsandFigures,2010.Accordingtothe2009OverviewofAssistedLiving,themediancost(i.e.,thecostpointatwhich the base rates for 50% of all units is higher, and 50% is lower) for dedicatedAlzheimersunit is$4,200permonth,and themeanaverage is$4,504permonth. Morerecentdata,reportedinTheStateofSeniorsHousing2010citedabove,indicatesthatthemedian total cost (i.e., includes costs that are charged in addition to the base rate) forassistedlivingresidenceswithAlzheimersunitsis$4,900permonth.


MemoryCareWyomingThe lack of memory care is profound in Wyoming. The state has about 7,600 elderlyresidentswithAlzheimersdiseaseorsomeotherdementia,butdoesnothaveanylicensedLevelII(MemoryCare)assistedlivingunits.Untilrecently,fewWyominglicensednursingfacilities had secure memory care units. TheWyoming Department of Health does nottrackdesignatedmemorycareunitswithin skillednursing facilities in thestate. GoshenCare Center in Torrington opened a 28bed SecureMemory CareUnit in the summer of2010, and Douglas Care Center in Douglas will open its 20bed Memory Care Unit inDecember2010.Based on a review of literature and interviews with existing ALF operators, there areseveral reasons for this lackofcare: Cumbersomeregulations;relativecostofproviding24hourLPNorRNcare(versusCNAcoverage);highdemandforexistingALFservices;andthehighcostofproviding(andpayingfor)dementiacareservices.SincetherearenoestablishedlicensedassistedlivingmemorycareunitsinWyoming(andthus no reliable data), the national median base cost will be used for this study. Thisassumptionisreasonable,giventhatWyomingaveragecostsforlongtermcareingeneralisquitesimilartonationalcosts.


DescriptionofMarketAreaTypically, feasibility studies will define markets as that area enclosed within a certainradiusofaproposedsite(forexample,a50mileradius).However,inWyoming,giventheuniquegeographyandlongdistancesseparatingruralcommunities,itismoreappropriatetoconsidermarketsastheyareactuallyestablishedbycommunityshopping,workingandlivingpatterns.Accordingly,forthisstudy,PlatteCountywillbetheprimarymarketareatobestudied.Inthemapbelow,thisareaisenclosedbythebluemarkings.WhiletheWheatlandareaisrelativelyrural,thisareaisakeypartofamuchlargerregion.Infact,mostpeoplefromtheareaidentifythemselvesasbeingfromSoutheastWyoming,or, more broadly, Wyoming. Many residents of Wheatland shop and/or work inCheyenne,andsoitisnotunusualforarearesidentstofrequentlycommutemorethananhourtoandfromCheyenne. Giventhispattern, theareathat iscommonlyreferredtoasSoutheastWyoming(i.e.,theareaenclosedbyDouglasandLusktothenorth,TorringtonandPineBluffstotheeast,DouglasandLaramietothewest,andWyoming/Coloradostatelinetothesouth)willbeconsideredastheSecondaryMarketforpurposesofthisfeasibilitystudy.Thatmarketareaisshowninredonthemapbelow.

Finally,becausemostexistinglongtermcarefacilitiesdrawalimitednumberofresidentsfromextendedstateandnationalmarkets, thisstudywill consider theStateofWyomingandtheentireUnitedStatesasatertiarymarketarea.

Map:PrimaryandSecondaryMarketAreas


DemographicsWheatlandisthecountyseatofPlatteCounty,locatedinsoutheasternWyoming.In2000,PlatteCountycontained8,807residents.Sincethen,itisestimatedtohaveshrunktoabout8,494people.Itisforecasttocontinuelosingpopulationthrough2015,whenitisforecastto have 8,256 residents. The Secondary Market area (Southeast Wyoming) contained142,105residentsin2000,hasgrownto152,847peopletoday,andisexpectedtogrowto158,672 residents by 2015. The population of the Secondary Market area is heavilyinfluencedbytheCityofCheyenne,whichis70milessouthofWheatland.TheresidentsinthePrimaryMarketareaaremucholder(41.1yearsoldin2000)thaninotherpartsofWyomingandtheUnitedStates.TheSecondaryMarketresidentsareslightlyyounger(34.2in2000)thanWyoming(36.1in2000)andtheUnitedStates(35.3in2000).Moreover,PrimaryMarketarearesidentsareagingmorequicklythantheotherareas,asseenGraph1below.

Source: ESRIBusinessAnalystOnline, based onU.S.Bureau of the Census, 2000 Census ofPopulation and Housing, and ESRI forecasts for 2010 and 2015. Downloaded from theInternetonOctober1,2010athttp://www.esri.com/bao.Whilealltheareasidentifiedaboveareaging,thePrimaryMarketareaisagingsignificantlyfaster than the others. A series of population comparisons of the market areas clearly

0

5

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2000 2010 2015

Graph1:MedianAge,byAreaandYear


demonstratesthepreponderanceofolderresidentslivinginthisregion,asseeninTable6below.

Table6:MedianAge,byMarketAreaandYearMarketArea 2000 2010 2015PlatteCounty 41.1 44.5 45.1SEWyoming 34.2 35.9 36.5StateofWyoming 36.1 38.0 38.4UnitedStates 35.3 37.0 37.3

Further,asrevealedbyGraph2below,thepercentageofthepopulationineveryagegroup55 or older in 2000 in the PrimaryMarket area was greater than the state or country.Consequently,thePrimaryMarketareawillcontinuetohavearelativelyhighpercentageofelderlyresidentsforthenext4050years.

Source: ESRIBusinessAnalystOnline, based onU.S.Bureau of the Census, 2000 Census ofPopulation and Housing, and ESRI forecasts for 2010 and 2015. Downloaded from theInternetonOctober1,2010athttp://www.esri.com/bao.

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Graph2:2000PopulationbyAgeGroupandArea

PlatteCounty SEWyoming StateofWyoming UnitedStates


Through2010,therelativelylargepercentageofresidentsaged55ormoreinthePrimaryMarketarearemainssignificantlygreaterthanthestateorthecountry,asseeninGraph3below.


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Thisagingtrendisabouttobecomeevenmoreacute.Thebabyboomgenerationthatisjustnowreachingretirementage(i.e.,thatgroupofpeoplewhowillbe55to74yearsoldin2015)isforecasttobecomeamuchlargerpercentageofthetotalpopulation,asseeninGraph4below.Infact,by2015,37.3%oftheresidentsinthePrimaryMarketareawillbe55orolder.Bycomparison,just26.8%ofthenationspopulationwillbethatold.

Source: ESRIBusinessAnalystOnline, based onU.S.Bureau of the Census, 2000 Census ofPopulation and Housing, and ESRI forecasts for 2010 and 2015. Downloaded from theInternetonOctober1,2010athttp://www.esri.com/bao.ThepopulationdemographicanalysisabovesupportsthedirectionthatcommunityleadersinPlatteCountyarenowgoingtodevelopappropriateseniorhousingforlocalresidents.

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IncomeAstheresidentsofthePrimaryMarketareahaveaged,theirincomeandtheirhomevalueshavegrown.Yet,growthratesforMedianHouseholdIncome,AverageHouseholdIncome,and Per Capita Income in the PrimaryMarket have been slower than state and nationalgrowth rates. In particular, the local areas Median Household Income has risen muchslowerthanthestateornation,assuggestedinGraph5below.


$0

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2000 2010 2015

Graph5:MedianHouseholdIncome



HousingMedianHomeValuesinthePrimaryMarketareahaveincreasedalso,butnotasquicklyastheotherareas.Asof2010,theMedianHomeValueinthePrimaryMarketwas$132,929.The State of Wyoming as a whole driven by an energy development boom hasexperiencedmuch faster growth than the local region or the nation, as seen in Graph 6below.


$0

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2000 2010 2015

Graph6:MedianHomeValue



TargetMarketAnalysis

ThepreviousSectionof this studyconductedademographicanalysisof thePrimaryandSecondary Market Areas, the State of Wyoming, and the United States, and made thefollowingkeyobservations:

1. Thetargetpopulationofseniorsaged65andolderisgrowing;2. ThePrimaryMarketAreatargetpopulationisagingmorequicklythantheother

areas;3. As of 2010, Wyomings elderly population (age 65 and older) has grown to

69,485residents, includingabout7,600residentswithsomeformofdementia;and

4. By2015,Wyomings elderlypopulation (age65andolder)willhavegrown to84,509residentsorapproximately14.5%oftheentirestatepopulation.

Likewise, thefirstsectionofthisStudyreviewedthe longtermindustry inWyomingandtheUnitedStates,anddiscoveredimportantfacts:

1. Of thenations population of seniors aged 65 and older, approximately 3.63%

resideinanursinghome;2.57%resideinanassistedlivingfacility;and0.21%liveinamemorycareunit;

2. Nationaloccupanciesoflongtermcarefacilitiesarehigh:NursingHomesareat82.9% occupancy, and ALFs are currently operating at 90.5% occupancy; noaccurateoccupancydataexistformemorycareunits;

3. Nationalandlocalsurveysdemonstratethatseniorswillprimarilyseekprivacy(i.e., singleoccupancyrooms)andqualityofserviceswhenchoosing longtermcare(theexception:dementiacareunits);

4. Wyoming has 38 nursing homes licensed for 2,958 beds, operating at 81.7%occupancy.

5. Wyominghas22ALFs(publicandprivate)licensedfor1,234bedslocatedwith969units,whicharecurrentlyoperatingat80%unitoccupancy;

6. Wyomings established private pay ALFs (i.e., nongovernment ownedALFs inoperationmorethanoneyear)arecurrentlyoperatingat85%occupancy;and

7. Wyoming has (orwill soon have) 48 newmemory care units associatedwithnursinghomefacilities,arelativelysmallnumberofexistingmemorycarebedslocatedwithinexistingskillednursing facilities, andno licensedassisted livingfacilitiesthathavedementiacareunits.


DemographicsThe consideration of longterm care facilities statewide is an important premise of thisstudy. WyomingGovernorMike Sullivan once said, Wyoming is like a small townwithvery long streets. Many people have subsequently used that phrase to explain severalrealitiesoflifeinWyoming:

Everyoneseemstoknoweveryone Wyoming residents share common values, in spite of the vast distances between

communities The needs of Wyoming residents are just like the needs of residents in more

populatedareas,andsoresourcesareneededtomeetthoseneeds Wyomingresidentsareaccustomedtotravelingmuchgreaterdistancestogetwhat

theywantthandoresidentsinotherpartsofthecountryyetthesesameWyomingresidentsfeelthattheyareshopping/traveling/visitinglocally

GovernorSullivansinsightfulobservationwaspointon.Accordingly,thisstudyrecognizesthat Wyomings elderly population regardless of where senior citizens may live collectively needs more longterm care living opportunities. Small municipalities inWyoming(suchasWheatlandorPlatteCounty)maynotbeabletojustifyconstructionofanew longterm care facility based only on local market demand contained withinarbitrary linesonamapthatdefinemunicipalorcountyboundaries. Rather,Wyomingselderlycitizenscollectivelydefineanddrivethestatewidemarketforlongtermcare.Asexplainedabove,thereareculturalandrelationshipbasedboundariesthatdefinehowWyoming residents live. In order to secure dependable data, and to identify readilyrecognized and competitivemarkets, this study has defined the Primary and SecondaryMarketAreasaslocalresidentswoulddoso:PlatteCountyistheareawheretheyreside,paytaxes,andshop;SoutheastWyomingistheextendedareathattheycallhome.Further,consistentwith thediscussionabove, thisstudyhas foundthat there isastatewide longtermcaremarket,andsotheStateofWyomingwillbetreatedasaTertiaryMarketArea.Finally,basedontheresourcescitedabove,andareviewofWyomingscurrentlongtermcare facility residents, this study concludes that a very small number of elderly personsfrom outofstate have moved and will continue to move to Wyoming longterm carefacilities. Of course, as the respectivemarket areas get bigger, this study assumes thatsmallerpercentagesofeachsuccessivelylargerareastargetpopulationwillactuallymovetothearea.A brief comparison of key 2010 demographics for each of the relevantMarket Areas iscontainedinTable7below.


Table7:ComparisonofMarketAreas(2010)

DataPrimaryMarket

SecondaryMarket TertiaryMarket

PlatteCounty

SEWyoming

StateofWyoming

UnitedStates

TotalPopulation 8,494 152,847 548,154 311,212,863Aged65andolder 1,551 18,797 69,485 40,471,364Aged85andolder 230 2,720 9,383 6,070,110PerCapitaIncome $21,538 $23,627 $24,080 $26,739MedianHomeValue $132,929 $164,631 $171,316 $157,913

Source: ESRIBusinessAnalystOnline, based onU.S.Bureau of the Census, 2000 Census ofPopulation andHousing, andESRI. Downloaded from the Internet onOctober 1, 2010 athttp://www.esri.com/bao.Inadditiontothedemographicsabove,twootherfactorsarerelevanttoananalysisoftheassistedlivingfacilitymarket:

1. Thenumberofelderlywhoareconsideredfrailorotherwiseinneedofservices;and

2. Thenumberofelderlywhohavesufficientincomeand/orassetstobeabletoaffordtheprivatepayonlycostsoftheALF.

Analysisofthosetwoitemsfollowsinthenextsection.


LimitationswithADLsandIADLsAs discussed above, frail elderly can be identified by evaluating abilities to performcertainfunctions,commonlycalledactivitiesofdailyliving(ADLs). ADLsarethethingsnormallydone in life, includinganydailyactivityperformed forselfcare(suchaseating,bathing,dressing,orgrooming),work,homemaking,andleisure.TheabilityorinabilitytoperformADLs is a verypracticalmeasure of ability/disability inmanydisorders. Thoseelderly citizens who have one or more limitations in performing ADLs are consideredprimecandidatesforassistedliving.Similarly, some elderly citizens struggle with socalled instrumental activities of dailyliving(IADLs),whicharetheactivitiesoftenperformedbyapersonwhohasbeenlivingindependently in a community setting. IADLswould includeactivities suchasmanagingmoney, shopping, telephone use, travel, housekeeping, preparing meals, and takingmedicationscorrectly.Surveys of persons with limitations in ADLs and IADLs have been conducted for manyyearsbytheCentersforDiseaseControlandPrevention(CDC).AccordingtotheCDC,themost recent data (20032007) from the National Health Interview Surveys reveal theselimitations,byagegroup,asseeninTable8below.

Table8:PersonswithLimitationswithADLsandIADLs,byAgeGroup(20032007)AgeGroup Limitationwith:

1ormoreADL 1ormoreIADLAlladults(age18+) 1.57% 3.63%

6574years 2.94% 6.23%7584years 6.11% 13.76%85+years 17.80% 35.29%

Source:CentersforDiseaseControlandPrevention,"LimitationsinActivitiesofDailyLivingandInstrumentalActivitiesofDailyLiving,20032007,"downloadedonFebruary17,2010athttp://www.cdc.gov/nchs/health_policy/ADL_tables.htm. [Note: the population of personswith limitations inADLsmay overlapwith the population of personswith limitations inIADLs.Inotherwords,thetwopopulationsarenotnecessarilymutuallyexclusive.]According to the CDC, their surveys, taken over a period of five years, draw from largeenough samples as to produce reliable estimates of the percentages of people withlimitations in ADLs and IADLs, by age group. This study assumes that the 20032007distribution (percentages) of persons with limitations in performing ADLs and IADLsremainsthesamefor2010.Withthatassumption,applicationoftheCDCsfindingstotherelevantagegrouppopulationin2010foreachMarketAreaappearsinTable9below.


Table9:PersonswithLimitationsinADLsandIADLs,byMarketAreaandbyAgeGroup(2010)MarketArea PercentageandNumberofPersonsforeachMarketArea,byAgeGroup

All20+ 6574 7584 85+ Total65+

PRIMARY

PlatteCounty(1) 76.5% 9.9% 5.7% 2.7% 18.3%#inagegroup 6,499 841 480 230 1,551LimitationinADL%(2) 1.57% 2.94% 6.11% 17.80% 6.13%LimitationinADL# 102 25 29 41 95LimitationinIADL%(2) 3.63% 6.23% 13.76% 35.29% 12.87%LimitationinIADL# 236 52 66 81 200

SECONDARY

SEWyoming(1) 74.3% 6.3% 3.9% 1.7% 11.9%#inagegroup[netofMarketabove] 107,245 9,112 5,644 2,490 17,246LimitationinADL%(2) 1.57% 2.94% 6.11% 17.80% 6.13%LimitationinADL# 1,680 268 345 443 1,057LimitationinIADL%(2) 3.63% 6.23% 13.76% 35.29% 12.89%LimitationinIADL# 3,892 567 777 879 2,223

TERTIARY

StateofWyoming%ofpopulation(1) 75.5% 7.3% 4.1% 1.7% 13.1%#inagegroup[netofMarketsabove] 291,996 28,239 15,786 6,663 50,688LimitationinADL%(2) 1.57% 2.94% 6.11% 17.80% 5.88%LimitationinADL# 4,574 831 965 1,186 2,982LimitationinIADL%(2) 3.63% 6.23% 13.76% 35.29% 12.39%LimitationinIADL# 10,598 1,758 2,172 2,351 6,281UnitedStates%ofpopulation(1) 72.9% 6.8% 4.3% 2.0% 13.0%#inagegroup[netofMarketsabove] 226,424,143 21,076,583 13,264,569 6,060,727 40,401,879LimitationinADL%(2) 1.57% 2.94% 6.11% 17.80% 6.21%LimitationinADL# 3,546,727 620,532 811,109 1,078,604 2,510,245LimitationinIADL%(2) 3.63% 6.23% 13.76% 35.29% 13.06%LimitationinIADL# 8,217,847 1,312,403 1,824,995 2,138,531 5,275,928

Total[allAreas] 226,829,883 21,114,775 13,286,479 6,070,110 40,471,364Source(1):ESRIBusinessAnalystOnline,basedonU.S.BureauoftheCensus,2000CensusofPopulation andHousing, andESRI. Downloaded from the Internet onOctober 1, 2010 athttp://www.esri.com/bao. Source (2): Centers for Disease Control and Prevention,"Limitations inActivities ofDaily Living and InstrumentalActivities ofDaily Living, 20032007," downloaded from the Internet on February 17, 2010 athttp://www.cdc.gov/nchs/health_policy/ADL_tables.htm.Using thisanalysis, thePrimaryMarketAreacontains1,551personswhoareaged65orolder. Of those 1,551 residents, 95 have limitationswith at least one ADL and 200 arelimited in IADLs. Similarly, theSecondaryMarketAreacontainsanother17,246personswhoareaged65orolder. Of those17,246residents,1,057are limitedwithat leastoneADLand2,223arelimitedwithIADLs.EachsuccessiveMarketArea inTable9fullycontainstheMarketArea(s)aboveit,sothenumbers of persons in eachMarket Area excludes the population of theMarket Area(s)aboveit(i.e.,nopersoniscountedmorethanonceinanyparticulargroup). Accordingly,onewould add the totalnumbersofpersons in eachMarketArea todetermine the total


targetpopulation. Forexample, todetermine the total targetpopulation for thePrimaryandSecondaryMarketAreasaged65orolder,onewouldaddthemtogetherandfindthatthereare18,797persons inthosetwocombinedareas,with1,152residents limitedwithADLsand2,422limitedwithIADLs.Additionally,theentirepopulationofadults(i.e.,allpersonsaged20andolder)isincludedasthefirstagegroupinTable9.Allsuchadultsshouldbeconsideredapartofthetargetmarket,sinceassistedlivingfacilitiesarelicensedandcapableofmeetingtheneedsofanyadultwhohas limitations inADLs,not just thosewhoareaged65andolder. It is clear,though,thattheoverwhelmingmajorityofpersonswithlimitationsarethosewhoare65andolder.TheinformationcontainedinTable9aboveiscurrentasof2010.However,itisimportanttoconsiderwhetherfuturedemographictrendsjustifythedevelopmentofnewlongtermcare facilities. Usingpopulationprojections for 2015, alongwith the samemethodologyfollowedabove,therelevantagegrouppopulationsin2015foreachMarketAreawouldbeasfollows,inTable10.


Table10:PersonswithLimitationsinADLsandIADLs,byMarketAreaandbyAgeGroup(2015)

MarketArea PercentageandNumberofPersonsforeachMarketArea,byAgeGroupAll20+ 6574 7584 85+ Total65+

PRIMARY

PlatteCounty(1) 77.3% 12.2% 5.9% 2.6% 20.7%#inagegroup 6,382 1,010 484 218 1,712LimitationinADL%(2) 1.57% 2.94% 6.11% 17.80% 5.73%LimitationinADL# 100 30 30 39 98LimitationinIADL%(2) 3.63% 6.23% 13.76% 35.29% 12.06%LimitationinIADL# 232 63 67 77 206

SECONDARY

SEWyoming(1) 74.8% 7.9% 3.9% 1.7% 13.5%#inagegroup[netofMarketabove] 112,437 11,845 5,878 2,544 20,267LimitationinADL%(2) 1.57% 2.94% 6.11% 17.80% 5.73%LimitationinADL# 1,761 349 359 453 1,161LimitationinIADL%(2) 3.63% 6.23% 13.76% 35.29% 12.06%LimitationinIADL# 4,081 738 809 898 2,444

TERTIARY

StateofWyoming%ofpopulation(1) 75.7% 9.2% 4.1% 1.7% 15.0%#inagegroup[netofMarketsabove] 314,623 38,294 17,078 7,158 62,530LimitationinADL%(2) 1.57% 2.94% 6.11% 17.80% 5.51%LimitationinADL# 4,928 1,127 1,044 1,274 3,446LimitationinIADL%(2) 3.63% 6.23% 13.76% 35.29% 11.61%LimitationinIADL# 11,419 2,385 2,350 2,526 7,260UnitedStates%ofpopulation(1) 73.4% 8.3% 4.2% 1.9% 14.4%#inagegroup[netofMarketsabove] 236,622,035 26,776,215 13,523,675 6,274,315 46,574,205LimitationinADL%(2) 1.57% 2.94% 6.11% 17.80% 5.87%LimitationinADL# 3,706,467 788,340 826,953 1,116,615 2,731,908LimitationinIADL%(2) 3.63% 6.23% 13.76% 35.29% 12.33%LimitationinIADL# 8,587,970 1,667,310 1,860,643 2,213,895 5,741,848

Total[allAreas] 237,055,477 26,827,364 13,547,115 6,284,235 46,658,714Source(1):ESRIBusinessAnalystOnline,basedonU.S.BureauoftheCensus,2000CensusofPopulation andHousing, andESRI. Downloaded from the Internet onOctober 1, 2010 athttp://www.esri.com/bao. Source (2): Centers for Disease Control and Prevention,"Limitations inActivities ofDaily Living and InstrumentalActivities ofDaily Living, 20032007," downloaded from the Internet on February 17, 2010 athttp://www.cdc.gov/nchs/health_policy/ADL_tables.htm.Usingthesameanalysisbutwiththeprojectedpopulationgrowthfor2015thePrimaryMarketAreaisprojectedtocontain1,712personswhoareaged65orolder.Ofthose1,712residents,theprojectionisthattherewillbe98residentslimitedwithatleastoneADLand206 limited in IADLs. Similarly, the SecondaryMarketArea is projected to have 20,267additionalpersonswhoareaged65orolder. Of those20,267projectedresidents,1,161willbelimitedwithatleastoneADLand2,444willbelimitedwithIADLs.Inotherwords,thetargetpopulationoffrailelderlycitizensisprojectedtogrowsignificantlyby2015.Infact, all the Market Areas will see significant, doubledigit growth of elderly residents


between2010and2015,eventhoughtheentirenationalpopulationisexpectedtogrowbylessthan4%duringthatsametime!


IncomeandHousingAccordingtothesourcescitedabove,theaveragecostofnursinghomecareinWyomingis$5,627forsemiprivateroomsand$6,266forprivaterooms.ThemediancostforassistedlivingfacilitiesisentrylevelALFroomsinWyomingis$3,011permonth.SincetherearenoestablishedmemorycareunitsinWyoming,thisstudywillusethenationalmedianbasecostof$4,200permonth.Recognizing that payment of those longterm costs comes from a variety of sources(privatepay,longtermcareinsurance,Medicaid,andMedicare,etc.),prospectiveresidentsmusthaveappropriate levelsof incometopay thesecosts. Ofcourse,whenmoving intoany formof longtermcare facility,manyelderlypeoplewillsell theirhomeand/orhaveotherpersonal assets topay the costsof their care. Still otherswill be assistedby theirfamilyorhaveprivatelongtermhealthcareinsurance.Given the average costs and sources of payment noted above, this study assumes thatfuturenursinghomeresidentswill likelyneedtohave incomeofat least$15,000; futureassistedlivingfacilityresidentswillneedincomeofatleast$35,000;andfutureresidentsof memory care units will need annual income of at least $50,000. To complete thatanalysis,onemustexamineHouseholdIncomelevelsbyAgeGroup,ascompiledinTables11A,11B,and11Cbelow.[Note:EachtablerepresentsadifferentMarketArea.]

Table11A:HouseholdIncomeLevels,PrimaryMarketAreabyAgeGroup(2010)MARKETAREA/IncomeLevel 6574 7584 85+ Total65+ %65+

PRIMARYM

ARKET

PlatteCounty 540 338 145 1,023 100.0%

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Long-Term Care Market Analysis