Leadership in Home Health: Elevating Everyone s Role to Stay Afloat

Leadership in Home Health: Elevating Everyone s Role to Stay Afloat CPAs & ADVISORS experience clarity // 2014 MAHC Annual Conference Mark P. Sharp, CPA Objectives Identify how to drive accountability and incentives for financial and clinical success throughout the organization Recognize how to optimize engagement of employees by aligning financial and clinical operations metrics Identify best practices for managing the numbers to reduce costs, improve care quality and improve patient capacity 2 // 2014 MAHC Annual Conference 2014 MAHC Annual Conference 1

Medicare Home Health Where Have We Been Year Change in Medicare Base Rate Market Basket (Inflation in Costs) Loss in Rate Compared to Market Basket 2008 0.25% 3.00% -2.75% 2009 0.15% 2.90% -2.75% 2010 1.75% 2.00% -0.25% 2011-5.19% 2.10% -7.29% 2012-2.39% 2.40% -4.79% 2013-2.00% 2.30% -4.30% 3 // 2014 MAHC Annual Conference Freestanding Medicare Margins Wide 2008 2009 2010 2011 2012 15.2% 15.3% 15.8% 12.2% 12.0% 4 // 2014 MAHC Annual Conference 2014 MAHC Annual Conference 2

Hospital-Based Medicare Margins Wide 2008 2009 2010 2011 2012-5.3% -5.8% -5.2% -12.1% -14.9% 5 // 2014 MAHC Annual Conference Freestanding Overall Margins Wide 2008 2009 2010 2011 2012 4.0% 5.3% 4.8% 2.8% 2.7% 6 // 2014 MAHC Annual Conference 2014 MAHC Annual Conference 3

Medicare Home Health Where Are We Going Year Forecasted Change in Medicare Base Rate Forecasted Market Basket (Inflation in Costs) Forecasted Loss in Rate Compared to Market Basket 2014-1.00% 2.40% -3.40% 2015-2.00% 2.50% -4.50% 2016-2.00% 2.50% -4.50% 2017-2.00% 2.50% -4.50% 2018 1.50% 2.50% -1.00% 7 // 2014 MAHC Annual Conference Elevating Everyone s Role Watching the Bottom Line 8 // 2014 MAHC Annual Conference 2014 MAHC Annual Conference 4

Bottom Line Translated to Behaviors Margin Revenue Expenses Episode Payment Volume Indirect Costs Direct Costs Case mix weight Episode adjustment Episode per patient Admin hours per visit Visits per episode Direct costs per visit 9 // 2014 MAHC Annual Conference Changing the Bottom Line Benchmark At an agency level Drill Down To a staff level Target Performance Changing the numbers Monitor Performance Accountability 10 // 2014 MAHC Annual Conference 2014 MAHC Annual Conference 5

Overall Profitability 8.9% 1.2% 2.7% 16.3% 6.4% 10.1% Consists of Revenues (payments) Expenses (costs) Payer mix Program mix 11 // 2014 MAHC Annual Conference Medicare Profitability 21.7% 2.8% 9.9% 30.1% 19.7% 22.7% Consists of 12 // 2014 MAHC Annual Conference 2014 MAHC Annual Conference 6

13 // 2014 MAHC Annual Conference Medicare Payment Per Episode $2,709 $2,316 $2,630 $2,997 $2,618 $3,042 Consists of 14 // 2014 MAHC Annual Conference 2014 MAHC Annual Conference 7

Average Case Mix Weight 1.3933 1.3487 1.3390 1.5211 1.5055 1.5068 15 // 2014 MAHC Annual Conference Managing Case Mix Weight OASIS accuracy Painting the right picture of the patient & the POC Clinician Training initial & ongoing 16 // 2014 MAHC Annual Conference 2014 MAHC Annual Conference 8

LUPA Episode Adjustments 8.9% 10.6% 6.3% 5.8% 7.2% 2.9% 17 // 2014 MAHC Annual Conference Managing LUPA Episode Adjustment Thorough clinical assessment Clinical oversight of POC Proper discharge planning Fewer LUPAS 18 // 2014 MAHC Annual Conference 2014 MAHC Annual Conference 9

Episodes per Patient 1.4 1.4 1.6 1.6 1.7 2.3 19 // 2014 MAHC Annual Conference Managing Episodes POC oversight Team collaboration Good discharge planning Care Managment Managed Episodes Optimum clinical outcomes 20 // 2014 MAHC Annual Conference 2014 MAHC Annual Conference 10

21 // 2014 MAHC Annual Conference Direct Cost Per Episode $1,224 $1,269 $1,223 $1,047 $1,043 $988 Consists of 22 // 2014 MAHC Annual Conference 2014 MAHC Annual Conference 11

Visits per Episode 14.9 15.1 16.6 13.3 13.1 14.0 23 // 2014 MAHC Annual Conference Episode Management POC oversight Care Management Team collaboration Good clinical & financial outcomes 24 // 2014 MAHC Annual Conference 2014 MAHC Annual Conference 12

Episode Management Care Management Patient involvement Care managed by episode, not by visit Outcome: self management POC Oversight Cultivate clinical reasoning Every cost must add value to the outcomes Team Collaboration Best skill mix for the POC Frontload CARE to reduce ACH Optimize between visit progress 25 // 2014 MAHC Annual Conference Direct Cost per Visit - Nursing $75.16 $84.46 $67.84 $62.42 $65.64 $49.73 Consists of Direct labor wages, benefits and contract Direct travel 26 // 2014 MAHC Annual Conference 2014 MAHC Annual Conference 13

Direct Labor as a % of Revenue 45.0% 51.6% 45.1% 41.8% 40.9% 34.5% Consists of Wage rates Employee productivity Benefits package Contract rates 27 // 2014 MAHC Annual Conference Per Visit Pay Rates - Nursing $43.00 Region $40.00 $39.00 $40.50 $39.00 $34.00 Salary, hourly or per-visit Market appropriate Experience mix 28 // 2014 MAHC Annual Conference 2014 MAHC Annual Conference 14

Compensation Models Advantages Challenges Non-exempt hourly Allows flex time pay Paying by employee s report of hours worked Reinforces poor performer Wage & hour laws Requires much managing Exempt salary Per event pay Consistent pay amount Exempt from overtime pay Paying only for productive time, defined by agency No productivity standard Productivity not managed Requires much managing for productivity Incentivizes making visits Requires firm structure for episode management, oversight for POC 29 // 2014 MAHC Annual Conference Nursing Hours per Nursing Visit 2.1 2.5 1.9 1.6 1.9 1.2 Productivity standards Visits per day/week Caseload Accountability Incentivize 30 // 2014 MAHC Annual Conference 2014 MAHC Annual Conference 15

Productivity Align incentive Encourage increased caseload Visit standard counterproductive Support efficiency Decrease need to be in office Optimize technology Enforce accountability Make accountabilities objective Establish, enforce consequences 31 // 2014 MAHC Annual Conference Benefits as a % of Salaries 17.0% 17.5% 15.0% 13.5% 13.6% 11.0% Market appropriate Shop packages Full time vs. part time Use of contract services 32 // 2014 MAHC Annual Conference 2014 MAHC Annual Conference 16

Transportation as a % of Revenue 2.6% 3.3% 1.5% 1.6% 1.7% 0.0% Mileage, zone payment or fleet GPS technology Market appropriate 33 // 2014 MAHC Annual Conference Medical Supply Cost Per Episode $24 $18 $11 $10 $0 $0 Supply management Secure storage 34 // 2014 MAHC Annual Conference 2014 MAHC Annual Conference 17

Indirect Cost per Episode $757 $751 $1,054 $571 $519 $750 Consists Administrative costs Capital costs 35 // 2014 MAHC Annual Conference Administrative Costs as a % of Revenue 33.1% 37.6% 39.8% 26.1% 27.7% 29.7% Consists of Indirect labor wages, benefits and contract Employee productivity Back office management 36 // 2014 MAHC Annual Conference 2014 MAHC Annual Conference 18

Administrative Hours per Visit 0.9 1.0 1.3 0.7 0.8 0.9 Productivity standards Accountability Incentivize 37 // 2014 MAHC Annual Conference Capital Costs as a % of Revenue 2.4% 3.8% 3.1% 1.9% 2.1% 1.9% Appropriate space Proper equipment/technology utilization 38 // 2014 MAHC Annual Conference 2014 MAHC Annual Conference 19

Performance Incentive Sample (Attachment) 39 // 2014 MAHC Annual Conference Summary Managing financial performance critical in current environment Everyone plays a critical role in performance management Study current state of your revenues and expenses Help establish performance targets Monitor ongoing performance Hold staff accountable for achieving the targets 40 // 2014 MAHC Annual Conference 2014 MAHC Annual Conference 20

Thank you Mark P. Sharp, CPA // Partner msharp@bkd.com // 417.865.8701 2014 MAHC Annual Conference 21

Attachment A Best Practice Home Health Benchmarks

3/24/2014 Medicare Home Health Operations Dashboard Report Peer Group Data 1 State Data 1 al Data 1 All All United States SHP Benchmark Leaders Medicare Certified Medicare Certified Measure Agencies Agencies Lower Upper Lower Upper Lower Upper Quartile Quartile Quartile Quartile Quartile Quartile Number of Agencies Total agencies in peer group data: 94 Total agencies in state data: 160 Total agencies in national data: 9,864 Service Delivery Dashboards Total home health visits 13,561 22,782 46,196 2,735 6,755 14,256 4,020 8,673 19,101 Total visits for other services 4 - - - - - - - - - Total net patient revenue 4 $ 2,494,426 $ 5,320,904 $ 10,175,002 $ 827,128 $ 1,381,141 $ 2,899,602 $ 659,562 $ 1,386,704 $ 3,134,283 Total Medicare episodes 584 1,038 1,915 142 305 658 171 355 754 Total Medicare home health revenue $ 1,625,427 $ 2,500,462 $ 5,014,547 $ 299,782 $ 791,493 $ 1,684,150 $ 424,573 $ 903,979 $ 1,925,385 Total home health unduplicated patients 4 479 1,100 2,172 116 272 772 103 252 648 Total unduplicated patients for other services 4 - - - - - - - - - Payer mix, measured on total visits Medicare 51.2% 68.1% 86.3% 64.2% 75.7% 84.2% 61.5% 84.2% 99.8% Other 13.7% 31.9% 48.8% 15.8% 24.3% 35.8% 0.2% 15.8% 38.5% Payer mix, measured on unduplicated patients Medicare 51.6% 66.4% 86.2% 62.2% 73.5% 88.0% 58.3% 81.9% 100.0% Other 13.8% 33.6% 48.4% 12.0% 26.5% 37.8% 0.0% 18.1% 41.7% Visits per Medicare episode (all episodes) Skilled nursing 6.3 7.5 8.4 6.3 7.5 8.7 7.0 8.5 10.4 Physical therapy 3.6 4.4 5.8 3.6 4.4 5.9 2.8 4.2 6.0 Occupational therapy 0.6 1.1 1.5 0.3 0.9 1.6 0.2 0.6 1.3 Speech therapy 0.1 0.2 0.3 0.0 0.1 0.2-0.1 0.2 Medical social services 0.1 0.1 0.2-0.0 0.1-0.1 0.1 Home health aide 0.7 1.2 2.3 0.6 1.3 2.6 0.7 1.7 3.5 Total visits per episode 13.3 14.9 17.1 13.1 15.1 17.7 14.0 16.6 19.7 Total therapy visits per episode 4.6 6.0 7.3 4.3 5.8 7.4 3.4 5.2 7.5 Visits per Medicare full episode (including outliers) Skilled nursing 6.9 8.1 9.2 6.8 8.3 9.4 7.6 9.0 11.0 Physical therapy 4.0 4.9 6.2 4.0 5.1 6.3 3.1 4.6 6.5 Occupational therapy 0.6 1.2 1.7 0.3 1.0 1.8 0.2 0.7 1.5 Speech therapy 0.1 0.2 0.3 0.0 0.1 0.3-0.1 0.2 Medical social services 0.1 0.1 0.2-0.0 0.1-0.1 0.2 Home health aide 0.8 1.3 2.6 0.7 1.5 2.8 0.8 1.9 3.9 Total visits per episode 14.9 16.4 18.6 14.6 16.9 19.3 15.2 17.8 21.1 Total therapy visits per episode 5.3 6.5 8.2 4.9 6.5 8.1 3.7 5.8 8.2 Visits per Medicare LUPA episode 2.6 2.7 2.8 2.6 2.8 3.0 2.5 2.7 2.9 Health Care Group www.bkd.com Questions? Contact Mark Sharp at msharp@bkd.com. 1 of 7

3/24/2014 Medicare Home Health Operations Dashboard Report Peer Group Data 1 State Data 1 al Data 1 All All United States SHP Benchmark Leaders Medicare Certified Medicare Certified Measure Agencies Agencies Lower Upper Lower Upper Lower Upper Quartile Quartile Quartile Quartile Quartile Quartile Service Delivery Dashboards (Continued) Number of episodes per Medicare patient 1.2 1.4 1.6 1.2 1.4 1.7 1.3 1.6 2.3 Estimated number of hours per visit Direct nursing service (based on SN visits) 1.6 2.1 2.8 1.9 2.5 3.4 1.2 1.9 2.8 Home health aide service (based on HHA visits) 1.3 1.8 2.5 1.4 2.0 2.6 1.0 1.6 2.3 Administrative staff 0.7 0.9 1.3 0.8 1.0 1.6 0.9 1.3 1.9 Total staff 2.3 2.8 3.4 2.9 3.7 5.1 2.5 3.3 4.4 Estimated number of visits per day per FTE 5 Direct nursing service 3.2 4.1 5.3 2.5 3.5 4.7 3.2 4.6 7.1 Physical therapy service 4.3 5.2 6.7 3.8 4.9 6.6 4.4 6.1 8.8 Occupational therapy service 3.9 4.8 7.5 3.6 4.6 7.0 4.0 5.7 8.3 Speech therapy service 3.4 5.5 8.4 3.7 5.3 6.8 3.5 5.2 7.8 Medical social services 0.9 2.1 4.7-0.1 1.9-0.7 3.5 Home health aide service 3.5 5.0 6.8 3.4 4.5 6.1 3.8 5.5 8.3 Operating Dashboards Cost Per Visit Skilled nursing Salaries $ 52.25 $ 60.38 $ 76.34 $ 51.74 $ 64.95 $ 91.20 $ 37.19 $ 54.21 $ 73.36 Employee benefits 5.98 8.98 12.28-7.91 16.86-5.79 10.37 Contract services - - 0.47 - - - - - 0.92 Total labor 58.23 69.57 92.32 60.50 77.69 103.97 47.78 64.76 86.92 Transportation 0.51 3.94 5.43-5.43 8.27 - - 4.66 Other direct costs - - 0.13 - - - - - - Total direct care costs 62.42 75.16 94.00 65.64 84.46 109.26 49.73 67.84 91.50 Indirect agency costs 40.48 49.70 63.12 40.28 53.16 72.06 43.89 62.59 91.84 Total agency cost per visit 108.84 128.70 149.94 113.90 141.87 180.52 107.05 135.97 173.79 Provider-based overhead costs 3 23.05 26.88 56.85 31.92 61.17 77.31 33.52 47.93 67.60 Total cost per visit $ 112.31 $ 129.89 $ 155.85 $ 117.67 $ 156.74 $ 215.01 $ 108.35 $ 139.54 $ 180.87 Health Care Group www.bkd.com Questions? Contact Mark Sharp at msharp@bkd.com. 2 of 7

3/24/2014 Medicare Home Health Operations Dashboard Report Peer Group Data 1 State Data 1 al Data 1 All All United States SHP Benchmark Leaders Medicare Certified Medicare Certified Measure Agencies Agencies Lower Upper Lower Upper Lower Upper Quartile Quartile Quartile Quartile Quartile Quartile Operating Dashboards (Continued) Cost Per Visit (Continued ) Physical therapy Salaries $ 17.21 $ 59.01 $ 69.26 $ - $ 46.15 $ 69.75 $ - $ 10.33 $ 61.90 Employee benefits - 7.36 10.90 - - 9.34 - - 7.64 Contract services 0.07 6.61 46.95-3.83 66.60 0.54 46.73 80.03 Total labor 69.97 79.18 88.27 65.58 77.73 90.96 68.74 81.65 95.79 Transportation - 2.13 3.89-1.39 6.36 - - 2.51 Other direct costs - - - - - - - - - Total direct care costs 71.86 81.90 91.75 67.17 81.42 98.10 70.00 83.77 98.15 Indirect agency costs 43.02 54.56 79.48 33.88 52.69 70.66 48.23 73.05 117.24 Total agency cost per visit 121.25 138.62 161.23 106.45 140.37 168.70 127.78 160.27 207.44 Provider-based overhead costs 3 23.02 31.08 41.62 26.47 40.78 64.00 26.59 38.62 56.17 Total cost per visit $ 123.39 $ 142.69 $ 170.33 $ 111.96 $ 149.17 $ 191.25 $ 131.78 $ 164.44 $ 212.48 Occupational therapy Salaries $ - $ 60.63 $ 77.73 $ - $ 44.64 $ 66.79 $ - $ - $ 63.66 Employee benefits - 6.87 12.99 - - 9.18 - - 7.71 Contract services - 1.09 51.91-4.33 64.00-39.64 79.55 Total labor 69.26 83.06 99.77 60.01 73.90 97.42 62.64 79.81 94.85 Transportation - 1.70 4.24 - - 6.30 - - 2.16 Other direct costs - - - - - - - - - Total direct care costs 72.35 85.47 103.07 64.95 76.69 99.89 64.41 81.16 96.88 Indirect agency costs 43.60 60.12 84.94 35.37 50.81 78.35 48.38 74.56 118.90 Total agency cost per visit 120.59 151.92 177.29 104.88 132.59 177.61 124.86 159.67 207.32 Provider-based overhead costs 3 27.30 31.56 45.48 30.60 42.33 61.93 27.68 39.30 57.17 Total cost per visit $ 127.33 $ 157.77 $ 179.27 $ 111.02 $ 149.65 $ 190.50 $ 128.91 $ 163.41 $ 211.52 Health Care Group www.bkd.com Questions? Contact Mark Sharp at msharp@bkd.com. 3 of 7

3/24/2014 Medicare Home Health Operations Dashboard Report Peer Group Data 1 State Data 1 al Data 1 All All United States SHP Benchmark Leaders Medicare Certified Medicare Certified Measure Agencies Agencies Lower Upper Lower Upper Lower Upper Quartile Quartile Quartile Quartile Quartile Quartile Operating Dashboards (Continued) Cost Per Visit (Continued ) Speech therapy Salaries $ - $ 57.56 $ 77.26 $ - $ 0.09 $ 60.96 $ - $ - $ 66.55 Employee benefits - 4.08 11.68 - - 9.58 - - 7.42 Contract services - 3.42 62.18-21.23 78.57-43.22 82.13 Total labor 70.39 81.97 104.42 56.61 78.34 100.08 63.50 81.89 100.78 Transportation - - 4.83 - - 6.60 - - 2.53 Other direct costs - - - - - - - - - Total direct care costs 70.89 86.40 106.34 65.47 86.22 106.29 65.45 84.91 104.35 Indirect agency costs 45.05 67.85 88.65 32.17 55.73 88.75 48.59 74.74 116.33 Total agency cost per visit 120.77 152.28 188.16 101.17 141.06 193.86 125.21 163.00 214.16 Provider-based overhead costs 3 28.58 37.51 51.65 25.88 34.91 65.93 26.88 40.75 59.01 Total cost per visit $ 123.48 $ 152.64 $ 191.35 $ 116.81 $ 153.05 $ 207.33 $ 129.50 $ 166.47 $ 219.67 Medical social services Salaries $ 49.26 $ 66.64 $ 98.54 $ 45.78 $ 86.06 $ 143.11 $ - $ 46.94 $ 89.22 Employee benefits 0.65 8.59 15.63-9.51 20.72 - - 11.83 Contract services - - 1.21 - - - - - 75.71 Total labor 65.43 84.54 114.00 68.86 104.55 163.41 67.97 87.58 122.33 Transportation - 3.45 7.87-3.82 10.04 - - 4.84 Other direct costs - - - - - - - - - Total direct care costs 70.66 92.52 121.93 77.22 112.78 175.97 70.33 90.00 128.19 Indirect agency costs 45.29 68.45 104.60 46.91 87.82 125.29 58.81 94.62 158.38 Total agency cost per visit 123.06 167.96 219.13 141.56 206.78 295.14 141.03 194.08 277.45 Provider-based overhead costs 3 27.87 40.36 56.98 30.00 74.40 135.93 38.18 62.63 107.28 Total cost per visit $ 127.54 $ 170.79 $ 226.84 $ 142.40 $ 224.12 $ 321.54 $ 143.35 $ 197.71 $ 285.33 Health Care Group www.bkd.com Questions? Contact Mark Sharp at msharp@bkd.com. 4 of 7

3/24/2014 Medicare Home Health Operations Dashboard Report Peer Group Data 1 State Data 1 al Data 1 All All United States SHP Benchmark Leaders Medicare Certified Medicare Certified Measure Agencies Agencies Lower Upper Lower Upper Lower Upper Quartile Quartile Quartile Quartile Quartile Quartile Operating Dashboards (Continued) Cost Per Visit (Continued ) Home health aide Salaries $ 16.22 $ 23.51 $ 32.15 $ 18.53 $ 24.85 $ 35.53 $ 13.50 $ 20.09 $ 28.41 Employee benefits 1.89 3.60 5.99-3.09 5.89-2.17 4.08 Contract services - - - - - - - - - Total labor 20.84 27.93 37.40 21.13 28.22 42.26 17.54 24.67 34.51 Transportation - 3.00 5.14-3.14 6.44 - - 4.34 Other direct costs - - - - - - - - - Total direct care costs 25.48 31.99 41.68 23.75 31.98 48.09 19.83 27.09 37.78 Indirect agency costs 15.39 20.57 32.14 14.59 22.16 34.30 16.52 25.66 40.77 Total agency cost per visit 40.25 51.68 74.72 39.49 57.88 81.48 40.43 54.93 76.66 Provider-based overhead costs 3 8.58 11.87 30.25 10.36 20.55 30.62 11.23 17.44 26.97 Total cost per visit $ 41.31 $ 52.36 $ 76.57 $ 42.95 $ 65.89 $ 92.12 $ 41.26 $ 56.48 $ 79.73 Overall agency cost per visit (all disciplines) $ 109.41 $ 133.49 $ 149.30 $ 119.93 $ 146.37 $ 181.86 $ 109.36 $ 138.31 $ 175.48 Medical Supplies Non-routine medical supplies $ 1.30 $ 2.62 $ 3.91 $ 1.85 $ 3.20 $ 5.66 $ 1.04 $ 2.40 $ 4.45 Medicare Episode Payments Estimated average case-mix weight 2 1.2863 1.3933 1.5211 1.2582 1.3487 1.5055 1.1967 1.3390 1.5068 Recalibrated average case-mix weight 2 0.9554 1.0348 1.1298 0.9345 1.0017 1.1181 0.8888 0.9945 1.1191 Average payment ratio 2 1.1520 1.2650 1.3879 1.0980 1.1994 1.3297 1.1121 1.2442 1.4101 Medicare episode mix by payment type Unadjusted episodes 84.0% 87.3% 90.7% 82.1% 86.0% 90.5% 83.7% 88.6% 93.1% LUPA episodes 5.8% 8.9% 11.3% 7.2% 10.6% 13.3% 2.9% 6.3% 10.8% PEP episodes 1.4% 2.4% 3.1% 1.3% 2.1% 3.0% 0.9% 1.8% 3.0% Outlier episodes 0.2% 0.5% 1.3% 0.0% 0.5% 1.3% 0.0% 0.8% 3.1% Average payment per episode by payment type Unadjusted episodes $ 2,682.25 $ 2,971.09 $ 3,247.38 $ 2,380.52 $ 2,582.75 $ 2,864.26 $ 2,465.57 $ 2,845.98 $ 3,229.86 LUPA episodes 307.90 342.54 385.85 299.91 326.97 352.83 295.00 331.32 373.62 PEP episodes 1,008.28 1,146.64 1,352.42 737.51 991.76 1,207.00 954.27 1,198.00 1,494.02 Outlier episodes - - - - - - - - - Health Care Group www.bkd.com Questions? Contact Mark Sharp at msharp@bkd.com. 5 of 7

3/24/2014 Medicare Home Health Operations Dashboard Report Peer Group Data 1 State Data 1 al Data 1 All All United States SHP Benchmark Leaders Medicare Certified Medicare Certified Measure Agencies Agencies Lower Upper Lower Upper Lower Upper Quartile Quartile Quartile Quartile Quartile Quartile Operating Dashboards (Continued) Medicare Episode Profitability Average payment per episode $ 2,378 $ 2,709 $ 2,997 $ 2,105 $ 2,316 $ 2,618 $ 2,283 $ 2,630 $ 3,042 Direct costs per episode Salaries 642 824 1,038 673 849 1,082 525 764 1,031 Employee benefits 74 112 173-100 207 21 87 161 Contract services 6 71 225-29 342 25 189 443 Total labor 924 1,103 1,308 920 1,124 1,367 881 1,120 1,396 Transportation 18 54 72 9 69 110-10 70 Other direct costs - - 2 - - - - - - Nonroutine supplies 10 24 43-18 46-11 34 Total direct care costs per episode 1,047 1,224 1,410 1,043 1,269 1,607 988 1,223 1,512 Direct profit (loss) per episode 1,211 1,401 1,630 734 1,023 1,351 1,055 1,380 1,718 Direct profit (loss) margin per episode 48.2% 54.9% 60.6% 33.6% 45.4% 55.1% 43.8% 54.0% 62.0% Indirect agency costs per episode 571 757 981 519 751 1,077 750 1,054 1,575 Total agency cost per episode 1,749 2,005 2,326 1,662 2,049 2,498 1,901 2,318 2,860 Profit (loss) per episode based on total agency costs 470 622 922 (41) 279 559 (28) 319 644 Profit (loss) margin per episode based on total agency costs 17.6% 25.0% 33.0% -1.4% 11.6% 25.2% -1.1% 12.4% 24.4% Provider-based overhead costs per episode 3 - - - - - 142 - - - Total costs per episode 1,794 2,068 2,344 1,953 2,286 2,923 1,963 2,383 2,965 Overall profit (loss) per episode 408 550 849 (408) 65 450 (142) 258 608 Profit (loss) margin per episode 15.4% 21.7% 30.1% -17.6% 2.8% 19.7% -5.6% 9.9% 22.7% Health Care Group www.bkd.com Questions? Contact Mark Sharp at msharp@bkd.com. 6 of 7

3/24/2014 Medicare Home Health Operations Dashboard Report Peer Group Data 1 State Data 1 al Data 1 All All United States SHP Benchmark Leaders Medicare Certified Medicare Certified Measure Agencies Agencies Lower Upper Lower Upper Lower Upper Quartile Quartile Quartile Quartile Quartile Quartile Operating Dashboards (Continued) Gross profit (loss) margin 4 39.0% 48.0% 55.0% 29.0% 41.0% 52.0% 38.0% 50.0% 61.0% Agency profit (loss) margin 4 6.2% 8.9% 16.3% -5.5% 1.2% 6.4% -3.5% 2.7% 10.1% Salaries as a % of total costs 4 52.3% 60.7% 67.5% 50.6% 57.3% 64.5% 47.1% 57.3% 65.2% Salaries as a % of total revenue 4 46.7% 53.1% 60.6% 49.6% 57.7% 65.4% 44.4% 55.0% 65.0% Employee benefits as a % of total salaries 4 13.5% 17.0% 22.1% 13.6% 17.5% 24.3% 11.0% 15.0% 19.6% Total salaries & employee benefits as a % of total costs 4 62.8% 71.9% 78.9% 62.4% 68.6% 77.2% 49.9% 64.7% 74.4% Total salaries & employee benefits as a % of total revenue 4 53.5% 63.0% 71.2% 61.5% 68.4% 82.0% 46.5% 61.6% 73.4% Purchased services as a % of total costs 4 2.7% 5.8% 13.8% 0.8% 4.5% 11.8% 3.3% 10.0% 21.4% Purchased services as a % of total revenue 4 1.9% 5.3% 11.5% 0.9% 4.1% 12.1% 3.2% 10.2% 21.2% Total labor as a % of total costs 74.0% 82.2% 85.5% 73.6% 81.7% 86.6% 72.1% 79.7% 85.5% Total labor as a % of total revenue 4 62.2% 69.6% 75.4% 68.1% 77.5% 87.0% 65.1% 75.0% 84.5% Direct labor as a % of total costs 4 48.3% 53.9% 60.7% 43.4% 51.5% 60.4% 36.6% 47.3% 58.2% Direct labor as a % of total revenue 4 41.8% 45.0% 54.6% 40.9% 51.6% 63.5% 34.5% 45.1% 56.1% Indirect labor as a % of total costs 4 20.2% 24.4% 30.8% 17.9% 22.9% 31.0% 19.1% 27.6% 39.2% Indirect labor as a % of total revenue 4 17.0% 20.9% 26.8% 17.8% 23.0% 33.0% 17.7% 27.3% 39.7% Transportation as a % of total costs 2.0% 3.2% 4.1% 2.0% 4.0% 5.4% 0.0% 1.9% 3.8% Transportation as a % of total revenue 4 1.6% 2.6% 3.5% 1.7% 3.3% 4.9% 0.0% 1.5% 3.5% Other costs as a % of total costs 11.0% 14.4% 22.8% 8.5% 14.1% 22.9% 12.1% 18.2% 25.9% Other costs as a % of total revenue 4 10.0% 13.7% 21.3% 13.3% 19.8% 26.0% 13.0% 18.9% 27.0% Administrative & general costs as a % of total cost 28.9% 35.8% 44.3% 25.4% 32.1% 41.5% 30.4% 39.6% 48.9% Administrative & general costs as a % of total revenue 4 26.1% 33.1% 40.4% 27.7% 37.6% 45.0% 29.7% 39.8% 49.6% Capital & plant costs as a % of total cost 4 2.4% 2.9% 3.9% 2.1% 3.9% 5.9% 2.1% 3.3% 4.8% Capital & plant costs as a % of total revenue 4 1.9% 2.4% 3.4% 2.1% 3.8% 6.4% 1.9% 3.1% 4.9% Days in accounts receivable 4 41.0 50.3 67.4 46.6 55.4 73.2 37.4 53.9 79.4 Current ratio 4 1.3 2.2 4.7 1.0 2.0 7.4 0.9 1.8 4.7 Quick ratio 4 1.2 1.9 3.5 0.9 1.6 3.7 0.8 1.5 3.7 Return on equity 4 7.5% 18.9% 55.5% 0.1% 7.4% 35.4% -6.6% 13.2% 77.0% Return on assets 4 8.6% 16.5% 50.1% -7.6% 1.7% 24.0% -9.5% 8.2% 51.9% 1 Data compiled using all Medicare cost reports available from CMS with fiscal years ending in 2012. 2 Estimated based on payment rates effective for the location of the agency rather than service area. 3 Dashboard indicator only applies to hospital-based agencies, and accounts for costs allocated to the agency from the provider. 4 Dashboard indicator only includes freestanding agencies as hospital-based agency data is not available from CMS data sets. 5 Estimated based on 230 work days per year. Health Care Group www.bkd.com Questions? Contact Mark Sharp at msharp@bkd.com. 7 of 7

Attachment B Sample Staff Incentive Approach

Sample Home Health Agency Home Health Outcome Based Performance Incentive Results Performance as of March 31, 2013 Employee Identification Employee Name Position Hire Date Branch Location Nancy Nurse Clinical personnel 1/1/2007 Performance Incentive Maximum incentive compensation $ 200 Performance Data Formula (A) (B) (C) (D) (E) (F) (G) (H) (A) - (B) = (D) (A) - (C) = (E) (E) (D) = (F) Incentive x (F) x (G) = (H) Expected Percent of Minimum Optimal Actual Maximum Actual Optimal Maximum Performance Performance Performance Performance Success Success Goals Incentive Incentive Performance Measures Measures Goals Results Measures Measure Achieved Weight Compensation Case Conference Participation 95.0% 97.0% 96.0% 2.0% 1.0% 50.0% 15.0% $ 15 Lupa rate 8.0% 6.0% 7.0% 2.0% 1.0% 50.0% 15.0% $ 15 Improved medication management 35.0% 40.0% 33.0% 5.0% -2.0% -40.0% 15.0% $ (12) Caseload 22 25 23 3 1 33.3% 25.0% $ 17 SOC OASIS completed within five days Other OASIS completed within two days 90.0% 95.0% 92.0% 5.0% 2.0% 40.0% 10.0% $ 8 85.0% 92.0% 100.0% 7.0% 15.0% 100.0% 10.0% $ 20 Documentation compliance 87.0% 94.0% 99.0% 7.0% 12.0% 100.0% 10.0% $ 20 Performance Summary Performance incentive results 41.3% 100.0% $ 83 @ Base compensation $ 65,000 Performance incentive compensation$ 83 @ Total fiscal year compensation $ 65,083 For more information about managing performance incentives contact M. Aaron Little with BKD, LLP at: mlittle@bkd.com