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The potential downside of a core plus real estate investment is that the cash flow is less predictable than a core investment, and these properties require active participation by ownership. A 15-year-old apartment building that is well-occupied but in need of light upgrades is an example of a core plus investment opportunity. The property will produce ample cash flow but some of the cash will be used for future deferred maintenance such as roofs and parking lot repairs.

Core plus investors tend to use between 40% and 60% leverage and expect to achieve returns between 9% and 13% annually.

‘Value Add’ is synonymous with ‘growth’ in the stock market and is associated with moderate to high risk. Value add properties often have little to no cash flow at acquisition but have the potential to produce a tremendous amount of cash flow once the value has been added . These building often times have occupancy issues, management problems, deferred maintenance or a combination of all three. These investments require a deep knowledge of real estate, strategic planning, and daily oversight by their owners.

Value add investors tend to use between 60% and 75% leverage to generate annual returns between 13% and 18%.

Opportunistic is the riskiest of all real estate investment strategies. It is also synonymous with ‘growth’ in the stock market, like ‘value add,’ but it is even riskier. Opportunistic investors take on the most complicated projects and may not see a return on their investment for three or more years. These investment strategies require years of experience and a team of people to be successful. Ground up developments, acquiring an empty building, land development and repositioning a building from one use to another are examples of opportunistic investments.

Opportunistic properties often have little to no cash flow at acquisition but have the potential to produce a tremendous amount of cash flow once the value has been added. Opportunistic investors tend to use leverage of 70% or more, but the amount of leverage can vary based on the ability to obtain debt. For land development, banks simply won’t lend more than 50%. Opportunistic investors expect to generate annual returns in excess of 20%.

It’s important for investors to know the difference of each strategy because the actual risk of an investment and the advertised risk may be very different. A conservative investor focused on income generation should be investing in higher-quality properties with low leverage or in a debt fund that lends money. Those with a bigger appetite for risk and a longer time horizon should consider value add or even opportunistic strategies. Dialing leverage up or down will reduce or increase the financial risk and the risk profile. There is a private real estate investment strategy for virtually every individual investor and finding the investments that suit their personal risk/return profile is essential.

This article was abridged from “Why Every Investment Portfolio Needs Private Real Estate,” our comprehensive guide for accredited investors. Click here to download your copy .

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Emergency Department Utilization in Children <36 Months Is Not an Independent Risk Factor for Maltreatment

Corresponding Author

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Carolinas Healthcare SystemCharlotte, NC

Address for correspondence and reprints: Emily C. MacNeill, MD; e‐mail: E-mail address: Multistrap Bikini Bottom SEAFOLLY Black Block Party Seafolly Clearance Official Best Sale Online 2BHz1eF
.
Address for correspondence and reprints: Emily C. MacNeill, MD; e‐mail: E-mail address: Emily.macneill@carolinas.org .

Carolinas Healthcare SystemCharlotte, NC

Philadelphia Veterans Administration Medical CenterPhiladelphia, PA

Robert Wood Johnson Clinical Scholars Program, The University of PennsylvaniaPhiladelphia, PA

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Carolinas Healthcare SystemCharlotte, NC

Indiana University School of MedicineIndianapolis, IN

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First published: 22 September 2016
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The authors have no relevant financial information or potential conflicts to disclose.

The views presented in this article are those of the authors and do not reflect official positions of the above‐named institutions.

Dr. MacNeill conceptualized and helped with design of the study, assisted with data collection and analysis, wrote the manuscript, and approved the final manuscript for submission. Dr. Cabey aided with conceptualization and design of the study, performed the majority of medical record data acquisition, and contributed greatly to the editing and review of the manuscript. Mr. Kluge aided with study design for feasibility and did data acquisition for the outcomes of this paper; he has approved the final manuscript as submitted. Dr. Norton aided with study design as it relates to statistical analysis, reviewed the statistical design, and ultimately reviewed the final data; he has approved the final manuscript as submitted. Dr. Mitchell aided with conceptualization of the study and created the statistical design of the study; she performed all statistical analysis and interpretation. Additionally, she aided with the writing of the manuscript and has approved the final manuscript as submitted.

Background and Objectives

Early childhood high‐frequency use (HFU) of the emergency department (ED) has been endorsed as a marker for increased risk of child maltreatment. In a prior analysis of pediatric ED (PED) visits by 16,664 children, 0–36months old, we defined early childhood HFU (the 90th percentile) as five or more visits. The purpose of this study was to follow HFU patients to determine if they had a higher likelihood of reported maltreatment.

Methods

This is a single‐center, cross‐sectional, observational study of the association between PED use in early life and subsequent intervention by child protective services (CPS). CPS data were obtained from a Department of Social Services database for subjects meeting criteria for PED HFU as well as sex, race, and ethnicity‐matched controls. Multivariable analyses were performed to assess if HFU was independently associated with child maltreatment.

Results

While CPS involvement was more highly represented in the group with PED HFU, so were many confounding variables such as African American race, history of hospital admissions, and social work consultations in the PED for any reason. HFU, by itself, is not a risk factor for a major intervention by CPS.

Conclusions

In efforts to identify children at risk for maltreatment, objective assessments such as PED utilization are potential markers to utilize to aid in recognition. Unfortunately, there are many risk factors for increased PED utilization that act as confounders for this marker. Future work is necessary to identify children at risk for maltreatment in the ED.

Volume 23 , Issue 11

November 2016

Pages 1228-1234

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