Luanne S. Rogers Interview Transcript

The following is a transcript of my interview with Luanne Rogers. To find links to the audio files and more information about the interview, please click here.

These transcripts are made possible by a gift from the NNEAHE.

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Mark: Welcome to The Forge, Luanne.

Luanne: Thanks for having me.

Mark: You went to Loyola University in Chicago and you earned a BS in Psychology. Why did you choose Loyola and why psychology?

Luanne: It's sort of a long answer to this one.

Mark: Okay, I'm listening.

Luanne: I'm the oldest of 6 children in Chicago, being the oldest and a girl, very traditional Catholic family. If I was going to go to college, I've had to figure out how to do that. Loyola was a place I could go as a day student essentially, riding the bus anyhow. I could also, for the tuition, being an Illinois State scholar and having worked as a nurse's aide and saving money, I could afford to go Loyola. That's how I got to Loyola ...

Mark: You put yourself through school?

Luanne: Yeah, yeah.

Mark: Okay, wonderful.

Luanne: I always thought it was interesting because my brothers went to Purdue, I don't think they put themselves in school and I'm probably, of the 4 girls, there are 2 boys and 4 girls, I'm the only one who went to 4-year college. That's how I got to Loyola.

Mark: Why psychology?

Luanne: I liked it. I mean, I went to ... when I went to Loyola, I really didn't know what I wanted to do. I was good in Math and Sciences, I like those, but then I took some psychology courses. I was actually, started as a nursing student so I took all the anatomy and physiology, the organic chemistry, the physics. I figured, I did all the hard stuff first which is a lot of fun but then, since I was paying for it, I was also trying to figure out how I could graduate in less than 4 years.

Mark: Okay.

Luanne: The psychology degree allowed me to do that and ...

Mark: Okay, and you were working as an ...

Luanne: A nurse's aide through ...

Mark: Nurse's aide at the same time.

Luanne: Yeah.

Mark: Did you kind of know right away, even while you were in school that you might want to work in health care?

Luanne: I knew I liked health care, before I worked at ... worked on as a nurse's aide, it was at geriatric floor.

Mark: Okay.

Luanne: Just kind of interesting and ...

Mark: Foreshadowing.

Luanne: Yeah. Never ... when I was sent up, sometimes you floated and you would go up to different floors and I liked my geriatric floor a whole lot.

Mark: Okay.

Luanne: That was ...

Mark: What was it about it that appealed to you even back then?

Luanne: I think you could talk to your patients in a way that they had history, they had ... I got my first department through one of my patients, I believe, you know. Things like that and she could make those personal connections and that was nice.

Mark: Okay, so after you graduated, you came to Exeter Healthcare in Exeter, New Hampshire and worked as a certified nursing assistant. What brought you from Chicago to Exeter?

Luanne: I got married.

Mark: Okay.

Luanne: My husband had a job at Phillips Exeter Academy.

Mark: Okay.

Luanne: We moved into a dormitory with AB boys, 4th floor, apartment with AB boys. I wanted to get a job and, as a social worker somewhere. I went to Exeter Healthcare, when they had an opening but I had no experience so they didn't hire me for that. I said, well, I've been a nurse's aide. I can do that and figured I could work my way up as they got to know me, I could learn more about long term care in New Hampshire.

Mark: You kind of knew you wanted to do long term care?

Luanne: Yeah.

Mark: Exeter Healthcare was that ...

Luanne: That was a long term care center that the hospital operated.

Mark: I see.

Luanne: Since ... They've since close their long term care beds but ... and then I always lucky enough to work with the director of nurses at that center who said, even if you can't grow here, I happen to know the people down at Goodwin's of Exeter and she knew they were a company that was growing and said maybe that's a place you should ...

Mark: That was in fact your next stop.

Luanne: That was my next stop. Yeah.

Mark: You stayed at Exeter for a fairly short period of time and then you were hired as the director of social services and activities at Goodwin's of Exeter, which I think now is SunBridge Goodwin ...

Luanne: It's now Genesis at Exeter.

Mark: Okay. You said a second ago, you had kind of already decided, you want to do some long term care work.

Luanne: I just really liked working with the residents and the families. It just clicked for me and I think either you have a good feeling about working with the elderly or you don't. I firmly believe, it's not like McDonald's.

Mark: Right, right.

Luanne: Everybody can flip a burger probably but not everybody can work in long term care because you're caring for people and you have to have some connection.

Mark: You felt that.

Luanne: Yeah.

Mark: Tell me a little bit about the director of social services. What was that role?

Luanne: I sort of, back in the day, nursing homes, 30 years ago, where ... are significantly different than they are today but that was the role that did all the admission work so you met all the families when they first came in. You were then responsible for quarterly notes and working with families through everything from financial applications for Medicaid or understanding the differences between Medicare and Medicaid. I also oversaw the activities department that put on events and had the activities for the residents so I had a few staff members who would work and I would oversee them and do their notes for them, for their documentation.

Mark: Okay, so how many people were you supervising at that time?

Luanne: Probably 2 or 3 at that time.

Mark: Okay, so small team but a supervisor right away pretty much?

Luanne: Yeah.

Mark: Okay, so you were the director of social services and activities for about 4 years and in your 4th year, you began to do administrator-in-training. What does administrator-in-training referred to and why is it important in the nursing home community?

Luanne: Well, first of all, to be an administrator in the state of New Hampshire, in most states, it's a licensing activity and part of that licensing is an AIT in almost every state, in New Hampshire, it's a one year process. The reason the New Hampshire Board requires a one year process is they want someone to go through a full year cycle of events in a nursing home, whether it's budgeting, your survey, how cash flows, how admissions flow, as well as to get to know every department that you're going to be ultimately overseeing. That's what an AIT is, some states, Massachusetts I believe is a 6-month AIT but almost every state wants you to have that hands on experience, that gives you that exposure.

Mark: It's kind of an on the job training?

Luanne: Yeah and you have to do it under an administrator who's been an administrator for at least 5 years in a facility, I believe it's more than 50 beds here in New Hampshire. You're then paired with a mentor almost right off.

Mark: Someone at Goodwin's must have looked at you and said, Luanne's got potential to be a leader, to do this?

Luanne: Well, part of it, I think was also that Goodwin's was the first of the facilities that the Clipper Homes grew from. It was a family owned single facility and that owner partnered with another man to develop the Clipper Homes. They were a growing company, when I was hired, they were building the Clipper Home of Portsmouth so they were already growing. They needed to grow their own people so they could, for example, the woman that I worked with moved to the new building and that's how I became the administrator of the building.

Mark: I see, so as you just said, you became the administrator in 1984, what does the role of the administrator encompass?

Luanne: Lots of stuff. That's probably the ... I think it's probably the most interesting and challenging job there is because no day is the same. It's not boring. If an administrator tells me, they're bored, I kind of wonder what the hell they're doing because you do everything from HR to, you need to be smart clinically and be able to oversee your nursing department and know all of your residents, you have to collect the cash. You have to make sure your buildings is done correctly, you have to make sure your folks get paid and all of the HR kind of components of managing a team hits you everyday and you don't know which one of them will be the most important that day.

It's ... you're a part of the marketing team out in the community so you're involved in events outside of your facility. You are accountable for your survey results so your state and local rules and regulations have to be monitored so that you're not surprised that, to be found that you're not compliant.

Mark: How many people were you responsible for? How big was your team ...

Luanne: Probably about 100 people. Yeah.

Mark: You went from supervising a team of 2 or 3 to now being responsible for the entire operation with 100 people and so it's a new job.

Luanne: It didn't feel like it because you got to ... because I was already working in the facility. I think that was one of the pluses, I got to know everybody as a social worker first so it didn't feel as awesome of a job as it is, were but I think it was, it's all about relationships that you build in the building and so it didn't feel as intimidating perhaps.

Mark: Okay, you had some nursing experience and you had experience in services and activities that we talked about a second ago, but now you were responsible for the entire operation as we're talking about, all the different functions. What was the ... what was maybe the most challenging part of making that adjustment?

Luanne: I would probably have to say the HR or the managing of people because it's one thing to be responsible for yourself and what you do but when you are interacting with up to 100 people or more, you have to change how you do that. You have to figure out what makes that person good at their job and how to keep them motivated and on task and doing what you've decided as a team, your goals are. That was probably, just trying to figure out how that fit and it's probably an ongoing thing that every manager continually learns as they move along as, everybody is different. You can't treat everybody all the same and if you want them to be on your team, you have to figure out how to make that work for both of you.

Mark: At what point did you decide you were really committed to long term care?

Luanne: Pretty early on, I would say.

Mark: Yeah, it sounds like.

Luanne: Yeah, I think and probably, I knew both of my grand parents when I was a kid so and they were always over for dinner and my Austrian grandmother made some of the best meals and we copy ... I still have a party every Christmas with my team, my administrators and my administrative team at my house and I make my grandmother's Hungarian Chicken Paprikash. It's really a good soup and once I tried to change what I was serving for lunch and there was a revolt.

Mark: You don't want to let your people down.

Luanne: Yeah.

Mark: Goodwin's as you said was kind of the core ...

Luanne: It was the first. It was actually named after the man's grandmother, the owner's grandmother.

Mark: It's the first of the Clipper ...

Luanne: Affiliates.

Mark: Affiliates, and that's relevant because as you said, they were building the Clipper Home of Portsmouth and you actually went from Goodwin's to the Clipper Home of Portsmouth and this is ... was a significantly larger facility it sounds like.

Luanne: Yeah, as he developed the company, he thought besides the nursing home, assisted living and independent living, would make some sense so the Clipper Home of Portsmouth which is now, the Clipper Home of Portsmouth. I think it still has that name, but it's a Genesis facility.

Mark: Genesis is ... since we're going to, we'll talk about that, it's ...

Luanne: Yes, Genesis is the big dog in New Hampshire, they're the largest owner of ... and manager of facilities now in New Hampshire.

Mark: Okay, and they're a national organization.

Luanne: They're a national. They are everywhere, yeah.

Mark: Okay, all right, we'll talk a little more about consolidation in a minute.

Luanne: Yeah.

Mark: What I saw was, it was a 92 bed facility so previously you had Goodwin's, was 81 beds, this is a 92 bed nursing facility, 32 bed assisted living facility and then a 26 apartment, retirement community. What was that like making the jump again from just managing a single facility to managing 3 different kind of levels of care? Were they kind of different buildings as well?

Luanne: They were all ... You could walk from one building to the next. They were set up in a ...

Mark: Okay, so they're pretty close.

Luanne: Yeah, but they were separately licensed or at least the assisted living was but, and we named the independent living, Langdon Place. That, as an independent facility, it had studio apartments and it had one and 2 bedroom apartments and it was independent living but a congregate independent living so that folks would come to meals in a congregate dining room. There were activities for people to participate in but not ... it was at their discretion. They had their own mailbox, as they lived independently, we just added some congregate support as it were.

Mark: What does congregate mean in the United States?

Luanne: They were all ... they lived together in an apartment but in an apartment building essentially that offered dining and activities which would be different than just out in your community.

Mark: How does that differ from assisted living?

Luanne: Assisted living, there are 2 levels of assisted living in the State of New Hampshire with roles, 804s and 805s. They are a step ... care is provided in both levels but the 805s allows more care to be provided by caregivers so often, say, 804s are a more of a social level of care where people again, living in congregate, maybe not apartments but more rooms with congregate space where they gather together for meals. In 805s, medication can be passed, more care can be provided.

Mark: The regulations that govern those are different?

Luanne: Right.

Mark: The 804, 805, so 805 was the higher level of care?

Luanne: Right.

Mark: It requires different staffing, what is it, that's different about the requirements?

Luanne: You have to have enough staff to meet the needs of your residents.

Mark: Okay.

Luanne: At least a kind of wide open and it's up to you as a manager of the facility to figure out what that staffing level is but it usually means for, for us at Courville, we have a nurse around the clock and nurse's aide to staff the building.

Mark: Okay

Luanne: We're 805s.

Mark: Okay, that's the assisted living.

Luanne: Yeah.

Mark: You stayed 2 years at Clipper Home and then you moved to Clipper Affiliates which is the corporate level offices where you are the vice president for operations and then 4 years after that, you took the president role. What was the scope at that time, of Clipper Affiliates?

Luanne: Back at that time, in New Hampshire, there were ... most of the facilities were privately owned, family owned facilities. They were the McCurley's who sort of had all the buildings up to 93 Corridor. Dwight Sowerby was another owner and he sort of had 93 West, 101 Keene, Peterborough, that direction. It was interesting how the state divided up, Dick Courville had the Manchester, Nashua area. Ray Lamir had some Manchester facilities and the Clipper Affiliates and Bill Gilmore sort of had the 16 Corridor. The Clipper Affiliates at that time was the organization that grew the facilities. We went from 2 facilities to the 10 facilities.

Mark: Were you there during that whole period?

Luanne: Yes, so, what I did that was different is, not only did I oversee each of the facilities and the managers of those facilities but I managed the administrators essentially, not the teams and the buildings but I helped them, all the strategic planning, the CON process. The ...

Mark: What's CON?

Luanne: Certificate of Need it's just ... is the way a state controls, the number of beds in the state of New Hampshire.

Mark: You would have to get permission?

Luanne: You would have to apply to a board who ... and it was often competing so you wouldn't necessarily be the only ... you have to start with, the state would decide that there was a need for bed. They put a request for proposals and then, people would come out to compete for it and that process could be month long. It depends on how many people were involved in it and then ultimately someone is awarded the Certificate of Need, that would contain the building cost, because you had to project what your building cost were. Part of the process was to ... for the state to control the number of beds and the reimbursement of how many beds the state would be responsible for.

Mark: Okay, that process, is that, that no longer exist in New Hampshire, does it?

Luanne: It just ... since this year, but before it sunsetted, many of the restrictions on controlling the number of beds, moved to another agency so still same level of control over the number of beds, that's the way the state controls or can contain its budget commitments.

Mark: Okay, so you were the president for 5 years, what was that like? You said, you were now managing the administrators, rather than the people. How did your leadership have to change when you took on that level of responsibility?

Luanne: I guess it just ... the people changed and the people I had to deal within ... well, previously, it was all just the people in a facility, now, it was multiple facilities but also, external bankers, state agencies and you just have to figure out how to relate with them to get what your company's goals are and what you needed from them.

Mark: As the administrator, as an administrator of the individual facility, that was part of Clipper Affiliates, you were able to stay focused internally for the most part?

Luanne: Right.

Mark: You said you did some marketing and this and that but as the president now, you're dealing with a lot of more external stakeholders.

Luanne: Absolutely.

Mark: Okay.

Luanne: It was kind of fun to meet new people.

Mark: Yeah, so after serving as president for 5 years, Clipper was acquired by SunBridge Healthcare Corporation and you served another 13 years as the regional vice president for operations. How was the decision arrived at, to sell the system to SunBridge?

Luanne: The owner said he was done. When the Clipper Homes were sold to Sun, we were not in the Medicare business. We just had private pay ... we pretty much been a private pay with Medicaid facilities and I was convinced that we wouldn't survive without adding a Medicare component to the business and he did not want to get into another government program. He said, it's my time to step out and that's what he did.

Mark: You had made the analysis, in order for us to survive in this new environment, we've got to engage Medicare than ...

Luanne: Right.

Mark: He saw that and said, that's something that wasn't interesting.

Luanne: Yes.

Mark: Okay.

Luanne: He just didn't want ... he thought Medicaid was nasty enough to deal with. He don't want anything else and he doesn't know how good we have it back then neither.

Mark: Okay, so part of the factors were the owner was just not interested in kind of making the next ... that next step.

Luanne: Yeah, and it was time for him ... it was also the time that many as I said, of those other families were selling, McCurley sold first to Genesis. Dwight Sowerby sold to Harborside, which you'll see.

Mark: Okay.

Luanne: It all comes together but ...

Mark: Was this the point where ...

Luanne: A lot of the families just decided it was time to leave the business.

Mark: Is that because the business was changing, because of things like Medicare become necessary?

Luanne: Yeah, and they were ...

Mark: What was kind of driving this acquisition process?

Luanne: I think there were more ... there were big companies who wanted to grow as well so they were making good offers to those folks so it met, the needs met.

Mark: Okay. What was your role in the acquisition process? This is you, the president at the time that it went through right?

Luanne: Yes, so we were working with a financial company to setup all of the documents that you need but I was the point person to answer any operational questions. I did all the tours and I went on tours to meet people.

Mark: Okay. We often ... you often hear when an organization is acquired, senior leaders are kind of showing the door but you stayed on, you were asked to stay on, not only that, you could have became the regional director.

Luanne: I was told that my ... in my first year that it wasn't likely I would survive and I thought that was just kind of ... after the first year that it was rare that I had survived and I was kind of surprised by that, because I didn't ... it was different than working for an independent family owned, one person you'd go to and if you needed an answer or you made the decision yourself to having many people telling you what to do. There were a lot more resources as well.

Mark: Okay.

Luanne: I think at the time, Sun was growing, they couldn't afford to throw people out. They ... I mean, I met with the leadership that I worked for before the company was sold and was offered a job so that, I think I interviewed for the job essentially and I didn't find it a hard fit, they ... there were more resources for us to use.

Mark: Can you give an example of what kind of resources came available to you as a result of being part of a larger corporate structure?

Luanne: There was someone to call, if you had a legal issue. There was someone to call if you had an HR issue. There was someone who process your payroll. I mean, we were doing payroll ourselves. I mean, it was, there were just more people ... in some ways, it freed up your time so you could focus more if you were building on patient care. That was ...

Mark: Okay, so there is some economies, to scale the work were available and maybe that partly justifies the ongoing consolidation.

Luanne: Right, I think that's what it's all about. It's ... the more you can spread those resources out over more facilities, it just becomes more economical. I didn't find it .. I found the people that I worked with, it's on, we went bankrupt for God's sake in '11. I forgot that.

Mark: Okay, I didn't know that.

Luanne: We did, we did.

Mark: Okay.

Luanne: We came out much better and all the senior leadership changed inside, but I was blessed with a group of 10 facilities that I had nurtured and grown, I knew all of my managers. We were one of the best regions, the company had. We always met our targets, we volunteered for every kind of new initiative to try it out first because we knew we could break it the best and figure out how to make it better and it just ... it worked.

Mark: SunBridge later acquired Harborside Healthcare Centers and those facilities came under your control as well, is that right?

Luanne: Yes.

Mark: You said, Harborside, where was Harborside by?

Luanne: Sowerby. Sowerby, sold to Harborside. Harborside was a smaller regional company, it wasn't a national company.

Mark: Okay, and those were the units out in the west so Keene, in that area.

Luanne: Yeah, they ... we had one in Keene but now I had more in Keene.

Mark: Okay.

Luanne: Peter Burrell, and Milford and Bedford.

Mark: Okay, so now, you're physically spreading out because ...

Luanne: North Conway to Keene.

Mark: All kind of the eastern, north eastern and then all the way, for the listeners who don't really know ...

Luanne: From 101, 101 West. That was 101 West.

Mark: Basically, all of Southern New Hampshire?

Luanne: Yeah.

Mark: Okay.

Luanne: Now, we are more mixed with some of it, or some of the Genesis facilities we're in.

Mark: You stayed with SunBridge for 13 years until 2010 when you left and became the tri-state District director of operations for Kindred Healthcare. What is Kindred Healthcare and where is that headquartered?

Luanne: It's another national chain. It is a company that would have been comparable to Sun at the time. It since ... it's gotten out of the long term care side of business. It's doing more sub-acute and hospital based markets, as well.

Mark: What does sub-acute refer to? For the listeners out there.

Luanne: Yes, sub-acute would sort of be, between the step, being hospitalized in an acute care, higher intensity care, sub-acute then, long term care or rehab care.

Mark: More nursing, more PT.

Luanne: More physicians are on site kind of, but anyways ...

Mark: At the time.

Luanne: Kindred had ... it's a national company, it's still is a national company. It's just ... and when I moved to the tri-state, it's because my husband became the headmaster of a school in Connecticut.

Mark: Okay, so it's a geographic decision.

Luanne: Yes and I thought for a short time that I could ... we kept our house here in New Hampshire and I could just go back and forth. That's only 3 hours away. That was insanity if it is, and at the height, it's insanity.

Mark: What were your responsibilities? What was your scope and responsibility as the tri-state district director?

Luanne: Tri-state was a misnomer when I had the tri-state because it was only Connecticut and Massachusetts facility. I think there might have been Vermont at some point but not one, I got the tri-state and then, so I had facilities in Connecticut and Massachusetts.

Mark: Okay, and then you were promoted to be the vice president of operations for Northern New England. How did that change your scope and responsibilities?

Luanne: Well, then, after we moved back to New Hampshire and my husband retired, lucky him, sort of retired I should say, and then the Northern New England had facilities in Maine, New Hampshire, Vermont and Massachusetts. I had 25 facilities between Bangor, Maine, Burlington, Vermont and the Berkshires of Massachusetts.

Mark: That's a huge region.

Luanne: Truly.

Mark: I mean, that's a ... I mean, how did you drive that in a day?

Luanne: You can't drive in a day.

Mark: Yeah.

Luanne: That was ... Kindred was trying to become more efficient and traditionally, regions were about 10 or 12, maybe 15 buildings to go to 25, makes your life just a little crazier. Just to keep track of 25 buildings and monitor everything from their senses to their quality indicators to financials. I found, I became less connected to the buildings with 25, even though I drove to all 25 of those buildings but not as connected to the buildings as I was when, at a smaller region. I did more communication and I think that, that puts more distance between you and the people and it's harder to manage when you're on the phone and you can't see what ... how they're looking at you.

Mark: Right, right, so your folks is much more on metrics.

Luanne: Yes and not ...

Mark: A management by metrics.

Luanne: Yes, and I tend to be a more people person so that made me a little more challenged.

Mark: Okay. You were there for 3 years, let me back up a second. We're there any differences between working for SunBridge and working for Kindred? Did you ...

Luanne: I can't say.

Mark: No.

Luanne: There were ... I would probably, I think there are little differences between the big companies.

Mark: Yeah.

Luanne: I can't say it.

Mark: Mostly operate the same.

Luanne: They do.

Mark: Okay.

Luanne: Maybe your financials look different. Maybe your dashboard of information that you get looks different ...

Mark: The expectations as a manager are about the same.

Luanne: Yeah, pretty much.

Mark: Okay.

Luanne: It's a pretty simple business in some ways.

Mark: You left Kindred in 2013 and came to the Courville Communities to be the President and CEO which is where we are today?

Luanne: Yes.

Mark: What led you to leave Kindred and come to Courville?

Luanne: The man who had my job before me, Henri LeBlanc, had been the president of this company for about 15, 18 years, something like that. He came to the company at a point where he put many more systems, management systems into the company but he was ill. Henri knew me from his first days, here at Courville because his expertise was more business and not healthcare. He would just call me. He just called me and asked me the question of who do I call for this or I'm thinking of hiring so and so, do you know them? What can you tell me about them? I would just answer his questions. It seems like a nice thing to do. I mean, that's the nice thing about New Hampshire, if you ask me, it's ... I think, even though it's the competition as it were, we all just want to do what's right for the patient so if you can help, help.

Henri and I had a relationship early on and when he became ill and knew he needed to step down from the role, he picked up the phone and called me and said, would you be interested and I have to be honest at that point. I was kind of dumb with the big companies and also, a region that had 25 buildings and I also saw that Kindred was starting to downsize and I kind of wondered if I'd have a job in the next couple of years with them and it just seem like the right fit at the right time.

Mark: What kind of corporation is Courville? Is it a nonprofit? Is it ...

Luanne: It's for profit, family owned, great little company.

Mark: It's private, it's not publicly traded company?

Luanne: No.

Mark: Okay.

Luanne: One owner, been in this ... almost through our 50th anniversary. His father built the first, the first family nursing home. It's the Fairview down in Hudson and then he had 2 boys. One boy got the Fairview and his father helped him build the Courville at Nashua and Dick grew the business from the Courville, Nashua. He built the to assisted livings in Courville. The CON process, he got the beds to build, the Courville of Manchester.

Mark: I see.

Luanne: That's how he grew his business.

Mark: Okay, so when you interviewed for the position, you interviewed with the owner, I assume?

Luanne: Yes. Yeah, yup and Henri.

Mark: Okay, but Henri knew you from a long time so ...

Luanne: Yeah, and I knew Dick as well through the healthcare association through some CON competitions, things like that.

Mark: Sometimes it's you, who's in competition was you.

Luanne: You're right. Yeah.

Mark: Okay, okay.

Luanne: I always believe, you never burn a bridge. You just can't. You can't burn a bridge.

Mark: Okay, so before we talk about your role as President and CEO, can you tell me a little bit about the Courville Communities and we've talked about the fact that there are in fact family owned so they're for profit, family owned. How many facilities are we talking about, number of residents so forth?

Luanne: We have 4 facilities. If you count the villas, we'd say 5 but there is only 2 villas, it's 2 apartments so, I don't know, I'll try to call it a whole facility. There is the Courville Nashua which is 100 bed and it's a straight nursing skilled long term care facility. We have other nursing homes, the Courville of Manchester. It is 70 nursing home facility beds and 12 assisted living beds on the first floor. It does short term rehab and long term care and we have 2 assisted livings, that kind of our whole place in Bedford, in Aynsley Place which you would, in Nashua, just almost, you'd say it's on the campus of the Nashua facilities that you can ... the parking lots connect. They're both 46 bed, assisted living facilities.

Mark: Okay. When we talk about skilled nursing, what does that mean?

Luanne: It's ... we take care of sick people.

Mark: Okay.

Luanne: I would ... one of the differences that I've seen in long term care is, that nursing homes used to be the long term aging centers. Now, a huge component of every nursing home is skilled care and that means, that you have a nurse around the clock and there is an RN around the clock. You have many nurses on your staff, depending on the size of your facilities. You take sick people right from the hospital, who need everything from therapy, physical therapy, speech therapy or occupational therapy but also the complicated medical conditions. Older people don't usually have one thing wrong with them.

Mark: Sure.

Luanne: They usually have many comorbidities so you might have a stroke with ... who has a congestive heart failure, so the complicated care so our nurses are there 24 hours to ... and we, those short term rehab people do go home. I think that's one of the things people don't really understand about what we do these days is, it is rare that one of those short term admissions stays with us. If we can help them get the supports to go back to their prior living, that's our goal, was to get them back home.

Mark: You've got several categories of patients that come to you, one of which is short term rehab. How does one come to you as a short term rehab patient?

Luanne: You come from the hospital because the Medicare will say, Medicare stay in our facilities only approved after 3 nights in the hospital.

Mark: A Medicare stay in Courville is only approved if they've got 3 days in the hospital?

Luanne: To have Medicare pay for your stay, in a nursing home, you have to been in the hospital for 3 nights. That's just in the ... not on observation. You have to have been in admission, for 3 nights.

Mark: Okay. What's the incentive for the hospital not to just hang on to the patient, do the rehab in the hospital?

Luanne: It's not cost effective for them and we usually ... and I would say, our short term rehab patients are with us between 2 weeks and a month, usually not any longer than that, it depends on ...

Mark: Can you give an example of what kind of illness or injury would result in, ultimately or procedure would ultimately result in a short term rehab state that then would lead to a discharge?

Luanne: I would say, any kind of broken issue. Hip, sometimes even knees, if your knees are done, replaced. Less of that, because now, that surgery and that healing process has been, because of the techniques in the hospital and the surgical, lots of those people go home.

Mark: Straight from the hospital.

Luanne: Straight from the hospital.

Mark: You got a knee replacement or a hip replacement, you're just supposed to ...

Luanne: Yeah, you're not going to come to us too much anymore. It's only when you have other things wrong with you.

Mark: The comorbidities is what we're talking about.

Luanne: Yes. Whether it's diabetes or stroke or congestive heart failure and infection. Wounds that aren't healing. There are just a lot of different things that don't make you a good candidate to go right home but we could take care of you for a couple of weeks and get you to a better place to get there.

Mark: You mentioned the kinds of care that are given in the rehab, PT, speech therapy, things like that. Are those people ... are those providers on staff? Are they independent and they ...

Luanne: For us, we contract with an outside agency. It's actually Genesis Rehab who provides our services. Some facilities bring ... do hire them and have them on staff.

Mark: Okay.

Luanne: It depends on what works best for your facility.

Mark: Is there a global reimbursement arrangements so when someone is admitted to Courville for a short term rehab, is it ...

Luanne: It's a federal program. We get paid, based on the care that we give you so there is an assessment form called an MDS, a medical data set that we have to complete their strict guidelines of ... for 7 days, 14 days and that score based on your MDS, puts you in a category that determines what we get reimbursed but if you're with us as Medicare patient, that money that we get for you pays for everything, your room and board, your therapy, your medications, it's an all inclusive right that we get. We have to manage your care, efficiently when you come to us as well.

Mark: You get a single payment that is dictated by the evaluation ...

Luanne: It's resident specific but it's ...

Mark: If you spend more on PT, that comes out of that.

Luanne: That comes out of that and so you have to ... it's a more complicated patient to manage because you have to be aware of what the meds cost, how much therapy is being given and do the right thing for the patient, to get them to their discharge goals.

Mark: How is that different than someone that you admit for long term care?

Luanne: Payment is either one of 2 things for long term care. It's either private pay or it's Medicaid.

Mark: Why not Medicare?

Luanne: Medicare doesn't pay for long term care.

Mark: Okay.

Luanne: It does not. It does not. That's one of the ... I think it's one of the misnomers that most people don't understand about. When they're older, they think Medicare pays for everything and specially if someone tells them Medicare pays for 100 days of care, it's rare, I've ever seen anyone who's 100 days of Medicare in one stay. It is usually a much more episodic kind of system but it does, it pays for nothing, for long term care.

Mark: Okay, so you were saying, payers for long term care are either private payer or Medicaid. What about long term care insurance? Do you see that influencing the industry?

Luanne: A little bit, a little bit but not ... I mean most of our patients are 85 to 105.

Mark: That are long term care.

Luanne: That are long term care and I don't think that age group was really, buying long term care insurance or knew much about it or I'm not sure how available it was and most long term care insurance, as I have seen some of the policies, they pay a daily rate. You're insured for a daily rate, that may or may not pay what I charge you.

Mark: Okay.

Luanne: It's probably a supplement so that you don't, you're not paying the full ranges that were, I think that's how I've seen it most of the time, people who have it have a policy that will pay $100 a day or $150 a day towards your private pay rate.

Mark: Okay, what is the ratio of, if it's okay for me to ask. What's the ratio between Medicaid and private pay?

Luanne: I have to write it down. I always looked at it as my quality mix and if you're a private pay or a Medicare or managed care patient, I get fairly reimbursed, that's how I would describe it. I would say most ... my 2 nursing homes run between 30, 32 percent, medicare managed care, combined, private is between, around 30 percent and then the rest is Medicaid so 40 ...

Mark: Forty percent Medicaid.

Luanne: Yeah.

Mark: Now, thew Medicaid is going to be primarily the long term care patients or residence and then Medicare would be only short term stay people and so then the private would be some combination of the 2.

Luanne: Most of your private or your Medicaid patients will ... can be, have Medicare reimbursement if they go off to the hospital and come back, so they can have access to that benefit as well.

Mark: Okay.

Luanne: I think one of the ... our goals as a private family owned independent company, is we have to manage the mix in our buildings.

Mark: How do you go about doing that?

Luanne: It's honored missions work and we also commit to the folks who live in our assisted living facilities and if you paid privately with us for 2 years and you run out of money, we'll take care of you, in one of nursing homes, on Medicaid or whatever is appropriate. Most of our Medicaid patients are self-grown. It's the private pays who have spent down. We rarely admit a straight Medicaid from the community because we can't afford it. We can't afford to do that.

Mark: Where do patients with straight Medicaid wind up going in Manchester or Nashua? Are there state facilities?

Luanne: There is the county homes. They stay pretty full too and they've also figured out, they have to have, run some Medicare business to stay afloat. I would say, one of the benefits of having a large company like a Genesis is they can absorb more of that Medicaid population in their centers because of their ... how they spread their resources out. I think one of my frustrations when I work for a big company is it seem that payer source didn't matter when you did an admission. Sometimes they didn't have a payer source which kind of made me a little crazy, because their view often was a head in the bed, was better than an empty bed and I think ...

Mark: Even if it was a risk of not getting paid at all.

Luanne: Well, I think it often came down to, we'll view as an administrator to figure out how you're going to get paid for it. If it's a homeless person, I don't think I'm going to get paid, this is where I would always come from.

Mark: Okay.

Luanne: Then, you have to be creative in discharging and figure out how do you get that person because one of the rules we live by is if they're your ... once they're your patient, you have to make sure if you're going to discharge and you put them, take, send them to somewhere safe for them so you have to have a safe discharge plan.

Mark: How has health reform and in particular the Affordable Care Act affected the long term care industry and the Courville Community specifically?

Luanne: I don't think it's affected long term care yet like it potentially will. It's not ... we're not like Massachusetts thankfully, where I think more ... there is more influence down in Massachusetts but New Hampshire has stayed out of it because as, managed Medicaid has come into the state for example, it's for the at home population, it's for ... it has not yet stepped into long term care. I think at the hospital level. Hospitals are working to do more discharges directly home and then to community based care. Right now, where the people ... the aged group that we care for, that was 85 is slightly depressing.

Their cohort is slightly depressing before we climb that huge mountain of baby boomers that will be eventually needing care, though I don't think they're going to need as much care as a current because people are healthier. They're living healthier lifestyles and I think people are planning perhaps more for themselves. I think the day as the families taking care of grandma and grandpa are long gone because most families need to have 2 incomes to survive and who stays home then. I don't think we figured out as a state or necessarily as a society of how we're going to care for all of those older people, when they're ... because the number of caregivers is not growing as fast as the number of people who need care.

Mark: You think people are aware of this fact that are making arrangements in advanced?

Luanne: I'm hoping that someone people are. I don't ... I think in the state of New Hampshire, there is a cap on the number of nursing home beds. The state has some control. They don't pay us, what it cost us to deliver care because ...

Mark: When you say the state you mean Medicaid.

Luanne: The state, Medicaid but it's 50% state, the rest is the counties and the feds. It's the state side of the budget, they always heard us. What happens is, every facility submits the cost report of what the cost to deliver care, to the state and they don't pay for some things like your marketing and stuff like that. Even though there are real cost that you have, they don't even recognize those as real cost. They decide and based on that, they know how much it cost to deliver care but the state only has certain amount of money in its budget and what they allocate for long term care is a dollar amount so they simply do what they call budget neutrality and cut 30% to 40% off of your daily rate and that's what they pay you. It's exciting.

Mark: Yeah.

Luanne: You should know how much that percentage is going to be. If your senses can take, if your mix is so highly Medicaid and your rate drops, $5 a day per patient, that's huge and it can swing that much, twice a year.

Mark: What is the Medicaid rate per day right now? It does vary by acuity ...

Luanne: It does vary by ... it varies ... there is an acuity factor that's part of that rate sending, it's not the big influencer. Budget neutrality is more of an influencer where the acuity portion when they came into our rate setting, was to make sure that we were only caring for people who really needed care because you would be disincentivized if they were light care people and on Medicaid. Well, we're way passed that. We have sick people in our facilities because everybody who needs lesser care is in assisted living. The options are there but it's budget neutrality that hurts us as the most. You have to understand that that's a very volatile piece of our rate.

Mark: What's the dollar amount roughly?

Luanne: A hundred and fifty dollars a day maybe.

Mark: Okay, so you have to run your whole facility, pay your nursing staff, pay for their food, pay for ...

Luanne: We are an employee based business and our biggest cost is labor. You need housekeepers, you need dietary aides. You needs cooks, you need nurses, you need nurse's aides, you need activity staff, you need your management staff. It's a people business.

Mark: Yeah. Does Medicaid pay for assisted living?

Luanne: Yeah but ...

Mark: Even less?

Luanne: Forty six dollars a day.

Mark: Okay.

Luanne: There aren't many Medicaid providers in the state because of that.

Mark: In the assisted living business?

Luanne: Yeah. Yeah.

Mark: What kind of living arrangement does Medicaid pay for in assisted living, so was it like private rule or ...

Luanne: Any provider could accept Medicaid patient, Medicaid reimbursement and I think most often, it's a private or a semi-private room. I'm going to guess ...

Mark: What is semi private room?

Luanne: Two people sharing a room and a bathroom.

Mark: Okay.

Luanne: There are fewer and fewer facilities that can afford to do it for ... there are some wonderful small providers who do it and bless them, I don't know how they do ... the administrator is the owner who lives in the house and somehow makes it work and I don't ... they're angels. It's all I can say.

Mark: Okay. You've spent 30 years in the long term care industry. What makes a good nursing home or long term care facility, in your experience, in your observation. I mean,  you've seen dozens of different homes and worked with them.

Luanne: I would say, it's the people who work in the facilities so, and lots of times, you can tell it's a good building when there is longevity of staff in the building because that means the management is taking good care of their people. That consistency of staff delivers good outcomes for your patients. Relationships develop and good care is given. Running a facility is about, I would say, if you take care of your employees, they'll take good care of your patients. If those 2 things happen, your building will stay full, because you'll have a good reputation and then you'll stay financially solvent. It doesn't always work that simply.

I think it's a pretty good formula and that ... there are scorecards, there are metrics that consumers can look at from the Centers for Medicare Services, CMS. They have a scorecard that consumers and it's five stars that can tell you and the stars are based on staffing and surveys and quality indicators. You get stars from all state and that can ... I would always say to someone, you could start there but go to the building, because if you don't go and meet the staff, you have no idea. It's a feeling where you're comfortable. It's a gut thing in some ways because you have to see if the residents are smiling. You have to see if the employees will great you. There is some gut things you can check.

Mark: Hard to measure.

Luanne: Yeah.

Mark: Intangible also.

Luanne: Yeah, and we, as a company, tried to do satisfaction surveys because I think customer service is truly what it's about. Again, taking good care of your residence but it's not just our residence we take care of. We take care of their families as well. Sometimes you have the sweetest resident, then you could have the family somehow.

Mark: Okay.

Luanne: You have to manage both of them.

Mark: I see. Speaking of managing, so this is a family owned facility. You have a single owner, how do you and the owner interact? How much is he involved in the day to day operations?

Luanne: I wouldn't say he is so involved in the day to day operations. He's usually here everyday. His office is right over there.

Mark: Okay.

Luanne: We talk everyday. He watches the census and our mix as I do, because we know what that means for our business. Any big things, I tell him about it if I think it's something that any big decision.

Mark: What's a big decision? Capital expenditures or something like that?

Luanne: No, I get ... If we're going to rehab the entire facility. He has ... if you sell one of our facilities, they're nice. They look nice and he takes great pride in providing a hotel kind of look so he would want to have some input on the furnishings for example of the facility. He would let me narrow it down kind of ... we're just refinanced the company so that I don't have to refinance it again ever in my life because it's for 40 years but he kind of let us take care of that because now, he doesn't ... and it's, no recourse on him, which means nobody could ever after go after him for any money but he can't transfer to a new owner. It's HUD financing so it took care of his needs and I have a good interest rate for the next 40 years.

Mark: It's a long time.

Luanne: Otherwise you ... most companies refinance every 10 years. To refinance is a lot of work.

Mark: Right, because we're not talking about small numbers.

Luanne: No.

Mark: Right. As the president and CEO, what keeps you up at night, so you're laying in bed staring at the ceiling, what are you worried about?

Luanne: I think right now, I have great managers in my buildings so the day to day management of them, we have good communication so I have a great trust to them but as a company our biggest challenge right now is we're so labor intensive and the workforce needs for every provider in the state are huge. I think we've taken nursing programs, to be in our end, now you have to do 4 year BSN. Years ago, there were the easier entries into an RN program, 2 and 3 year programs so we have fewer RNs. We have fewer programs because the board of nursing has made it pretty stringent requirements for instructors. We don't have enough instructors so we cannot produce the nurses that we need. Nurses just move from job to job as best that I can tell.

Then, aides, yes, we can keep growing those aides but if I can't pay an aide because of, I'm still dependent on my Medicaid rate. More than McDonald's or another, the grocery store, how do I get them to stay with me. I mean, right now, I work to make sure, I have great benefits but for ... but they live paycheck to paycheck.

Mark: The aides do.

Luanne: The aides do in particular and it's a struggle to keep, and I'm a company that has a rate longevity. I threw a part for all of my employees, who've been with me for 5 years or more, for 160 people. I mean, I don't ... I'm not the worse off but that's a long term problem ... they're, we're working with the legislature to try to figure out some solutions to that but it's a people issue. Where do you find the people to come into our industry, our profession? It's ... and it's hard work. It's hard to be a nurse's aide. It's hard to be a nurse. I think to be a nurse in long term care, the skilled unit, you need more, skill and knowledge and assessment than if you work in a hospital because you're not backed up by a doctor staying at your elbow.

You are the eyes and ears for those doctors, that you're going to be calling. You have lot of autonomy and a lot of skills and skill needs to work in one of our facilities and that's hard. It's just a hard job. You make the call.

Mark: When you first took on the role of being president and CEO and you've done this a couple of times now, what surprise you most about that role?

Luanne: The best part is how quick you can make a decision and it just ... you can just do it.

Mark: Okay, right.

Luanne: If you work for a big company, there is nothing that simple, nothing that simple. For example, when I came to the company, we still had beds that you would crank so we just bought all new beds. I mean, that was a great thing for our residents and our staff and I can make that decision, that could happen quickly. The part that was more challenging was sort of the finance side of things and working through refinancing was not my favorite thing to do but now it's done. It's out of that immediacy of being able to do the right thing for the patients. My administrators can usually just call me and say, this is going on. This is what I'd like to do, what do you think and we can say, yes, or if there is a problem, we can solve the problem easily, quickly, it's fun that way.

Mark: Let's transition and talk a little bit about leadership. What would you say as your leadership philosophy?

Luanne: Well, that one, I have already put a lot of thought into, because when you're meeting new people, they want to get to know you and what's important to you as their leader but I believe I'm a coach first.

Mark: Okay.

Luanne: I'm only as good as my team. If they fail, I fail so my job is to make sure I give them all the tools they need, I coach them, I mentor them to be successful. At the same time, I know stuff happens and what I want from any manager or leader is they learn from it because if they learn from it, I'm not going get rid of them because now, they're stronger, they're better. They've grown from the experience and stuff happens in our business. When you're managing other people, you can't always be sure what those other people are going to do. Those stuff can happen. I think it's important that I build good trust and communication. I tell everyone, I don't want to hear about it. It's the last person, okay.

It's really nice for our facilities, because it's a phone call away. I don't even need a conference call. They're a phone call away so building that trust and that good communication, one thing that we're trying to strengthen with our facilities right now is consistency of policies. They had been allowed sort of before independently operating facilities and now I'm trying to bring them to more consistency and best practices. They like that idea that they don't have to figure it out all for themselves. I think that's another thing I bring that I want that consistency of ...

Mark: That's something you learned working for the chains.

Luanne: Yeah. Well, I think part ... I think the part of it, but I don't want to take it so far because sometimes, you could feel like the chains just weren't robots to implement their policies and health care is more an art than that and how do they personalize it. How do they train their staff to make it part of their ... what they do everyday. I tried to make sure that we all know what our goals are, what we're aiming for and then we communicated regularly on how we're doing to our goals, whether it's our senses, our mix, our survey results, our ... this is our business plan for this year, that our surveys have fewer deficiencies than our competitors.

Deficiency for these are all I want to go. One of our clinical focus is on hospital readmission so we want to be better in our competition that we don't bounce people back to the hospital and we want to see our customer satisfaction on our customer satisfaction surveys. We're trying to keep our turnover targets good so that we have low turnover. We'd eliminated agency, that seems to be creeping back in because ...

Mark: Agencies, short term ...

Luanne: Staff, yeah.

Mark: Staffing, okay.

Luanne: We work hard on our employee satisfaction scores, trying to find out what benefits they want. We've created a culture club to work with our staff then managing our revenue in our mix and meeting our budget, pretty simple. We talk about it every month. How's your building doing? How are we doing as a company? They get to see that because one is not an island anymore. They get a, one can support. If one is down, the other one can help them, you know.

Mark: Okay.

Luanne: Kind of thing.

Mark: There is some transparency within the corporation.

Luanne: There has to be, otherwise, how do you get the buy in and, that's not for us so how do you get leaders to buy in if they don't know what you're aiming for and that they're not kept apprised of how you're doing. They should help you set the goals.

Mark: On that same line of thought, how do you, what do you look for when you're hiring leaders and evaluating leaders?

Luanne: If I'm hiring administrator, I want to know, your care giving background. I want to know what you've done that's cared for people, because I've always ... I can't teach you that. I can't teach you the care but if you can talk to me about your passion for care giving, you want to be a nurse's aide, you don't have to, but tell me what you've done that shows that compassion for people, because at night, I don't want ... I want to be able to go to sleep and know that you're going to make the right decision for that patient, because you care about the patient. I can teach you the financial side. I can teach you the HR side. If I could learn it, I can teach it, right? I can't teach you the care and that's the first thing I need to know.

Mark: What are the characteristics and behaviors of a good leader and how do you aspire those yourself?

Luanne: I think it's always about relationships and how as a leader, I help other people be better people. Better in their roles, better people in their roles and I think, that's something I'm always trying ... how could I be a better leader by being a better person in terms of those relationships and how I nurture them in making sure, I stay ... I'm looking for how they can be helped, not waiting for them to ask. I think for my leaders, I need them to be that too. That were, they're comfortable working together and not wanting to be that isolated entity. I think that's one of the things that we've struggled as a company, to do because they were used to being 4 independent people who did their thing, like, "That may have worked."

It's been a change for some of those, of the 4 buildings, only one facilities changed leadership in that time and that one leader went to Maryland to go to ... to get a PHD, what can I say.

Mark: Not because they were dissatisfied.

Luanne: No, and I think that's another thing that as a leader, if you're not performing to my standards, you're not going to know that the day I fire you or we decided to ... it's because we've had a lot of communication and I've tried to help you and you know where you stand with me all along that process and I've never separated from someone that's worked for me and we both didn't understand it was the right thing and a good thing for both of us. It just, if you're fair with people that way, forget about burning those bridges because you're never going to know who you're bumping to again.

Mark: What is organizational culture and why is it important?

Luanne: I think the culture of a company is what binds it together, what everyone shares as what motivates them. We just went through a process of defining our mission statement. What do we do everyday? What do we want to make sure happens everyday and that in itself was I think great to bring the team, the leadership team to and now we're spreading that out in the buildings with lanyards and keychains. What everyone agreed, our mission is just to enhance the lives of everyone we touch and it just seem so simple once we just seen all the awards we came up with before that but that process in itself, I think is creating and enhancing the culture of why people work for the Courville company and the personal touch part of it ...

Mark: The process of coming up with that mission was helpful in terms of making people understand.

Luanne: It took ... we had to do little, we'd come up with something, we go back to the buildings and have a little group and say, what are you thinking? Man, I didn't like that. This was one that everyone believed they did every single day and could get behind and wear a lanyard and set it to them. I think, but that also motivates the creation of the culture club that ... somebody had a song in their mind, I'm sure of it when we came up with that name but it's doing things in each of the centers with ... for the employees for example, back to school, the culture club came up with the idea of ... everyone should clean their closets and bring gently used clothing, shoes, lunchboxes, anything for a back to school, for other employees to go shopping for their kids.

I mean, just ... it's employees helping other employees with something that can be a costly and time consuming event. I mean, but I'm also wanting to empower the employees to come up with those ideas, that's it's not my idea all the time because I tell them, I just steal good ideas from other people. I'd like them to come up with some.

Mark: Did you have a mentor or mentors early in your career that helped steer you toward this ... to where you are?

Luanne: I think almost every boss that I've had is sort have been a mentor and I think what mentors can do is teach you some skills, also help you form your own idea of what kind of leader you want to be because like sometimes they have bad ... they do things you don't think you would want to do or you wouldn't want to do it that way, let's just say that and I ... yes, so almost everybody and I had ... it's Sun, the 13 years I was with Sun, I think I had 9 bosses. Most of them didn't last 2 years obviously. That was kind of juggling. They had a couple of really good ones. I'm thankful for those and they've stayed friends and ... but you do learn from mentors or bosses, a lot of things about how do you want to form your own approach.

Mark: Are you a mentor to any other administrators or other nursing home leaders?

Luanne: I've done AIT programs with other, for ... over the years. I belong to the New Hampshire Healthcare Association. Somehow, I got to treasure this year and I don't even know how that happened but I had been present many years ago. I'm part ... I'm the president of the Long Term Care Foundation but I think both of ... specially, the Healthcare Association, is a great organization that helps mentor leaders through education programs, through activities of the association. It gives administrators a voice beyond just their facilities I think. Whether there is some legislative action that we need people to show up and speak at or they have legislators come in to your facilities.

I think a lot of administrators are a little timid about ... they're not timid in their buildings but public speaking or talking about their business, and what they do, it's a profession that we're in, that we should be proud of so helping new leaders understand the value of their profession and how to present themselves in a positive way because most people don't think highly of nursing homes even to this day. Yet, if you work in one, you see the impact you've had on people that's made their lives better.

Mark: You mentioned the ... I'm sorry, you've mentioned the name, New Hampshire Healthcare Association. That's a professional organization.

Luanne: It's our trade organization. Yeah.

Mark: Okay, is that the local chapter of a national?

Luanne: It's part of the American Healthcare Association, which is a national association and one of the things, the national association does for us, if you remember the New Hampshire Association, you're a member of American Healthcare. They help collect a lot of those metrics and data points through their long term care tracker system. Even as a private independent provider, I can see how my facilities compare to other facilities in my state and lots of metrics, nationally, for profit, not for profit. They have all sorts of ways for you to manipulate your data so you can do those comparisons, because it becomes more and more apparent that if you are going to negotiate with a hospital or negotiate with another, you need to know what your statistics are.

Mark: For a young person thinking about a career in health, why should they look at long term care?

Luanne: It's not boring, and it's exciting. It is the one job that you do everything. You do everything as a manager of a facility. You run a business, you run all parts of the business and that makes your days interesting exciting, a little crazy sometimes. I'll admit to some of those crazy days but it's the most exciting job I can think of because it's never the same and you have to be able to figure out all the pieces to make it work and they're lots of pieces.

Mark: If you had to pick one book that an early nurse should read, who is aspiring to senior leadership, what would it be?

Luanne: I thought about this one. What came to my mind first was, Oh, The Places You'll Go by Doctor Seuss, because I think, what I like about that book is it's such a positive inspiring but fun book and some days are just hard.

Mark: Yeah.

Luanne: To be able to pull off something that could say, it's not as serious as I think it is. Today, we'll pass and tomorrow is a new day. I think that's a fun one. Not the one, it's not so much about leadership but I thought was a book that talks about long term care and how seniors sort of navigate through that process is, Knocking On Heaven's Door. It's by Katie, I had to look up the author's name, Katie Butler and it's a story of her father's process through all this comorbidities and dementia and end of life experience. I think it's, if you're going to work with the elderly, it's a good lesson.

Mark: Last question, what kind of training in education should someone pursue, if they're thinking about getting into a long term care field?

Luanne: I think you can come into the long term care field from almost any bachelors degree program. If you have in that process, understanding of some of the health care system, that's ... when you get licensed, there is a core of knowledge checklist. Care giving is part of, some understanding of care giving is in there. Accounting is helpful. I have to take accounting. That's what I learned that it's not a science. It's a religion. That was my take on accounting but you can pick up all the pieces if you think you have the passion to be a caregiver. I wouldn't limit it to having taken a program for it and I would tell you that probably most administrators today didn't necessarily do health studies program.

They went back to school. I took 2 courses in UNH to get my license but you can pick up those pieces if you figure it out that that's what you want to do and my only recommendation is to find a job and doing something to find out if it is where your passion is, because you'll see that it's a pretty exciting dynamic place to work.

Mark: Thank you so much for your time today, I appreciate it.

Luanne: Thank you.