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FINANCIAL ASSISTANCE AND CERTAIN OTHER COMMUNITY BENEFITS
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COMMUNITY HEALTH IMPROVEMENT SERVICES AND CASH AND IN-KIND CONTRIBUTIONS TO COMMUNITY GROUPSWINCHESTER HOSPITAL AFFILIATIONBETH ISRAEL LAHEY HEALTH (BILH) IS THE SOLE MEMBER OF WINCHESTER HOSPITAL. THE BILH NETWORK OF AFFILIATES IS AN INTEGRATED HEALTH CARE SYSTEM COMMITTED TO EXPANDING ACCESS TO EXTRAORDINARY PATIENT CARE ACROSS EASTERN MASSACHUSETTS AND ADVANCING THE SCIENCE AND PRACTICE OF MEDICINE THROUGH GROUNDBREAKING RESEARCH AND EDUCATION. THE BILH SYSTEM IS COMPRISED OF ACADEMIC AND TEACHING HOSPITALS, A PREMIER ORTHOPEDICS HOSPITAL, PRIMARY CARE AND SPECIALTY CARE PROVIDERS, AMBULATORY SURGERY CENTERS, URGENT CARE CENTERS, COMMUNITY HOSPITALS, HOMECARE SERVICES, OUTPATIENT BEHAVIORAL HEALTH CENTERS, ADDICTION TREATMENT PROGRAMS. THE BILH'S COMMUNITY OF CLINICIANS, CAREGIVERS AND STAFF INCLUDES APPROXIMATELY 4,000 PHYSICIANS AND 35,000 EMPLOYEES. AT THE HEART OF BILH IS THE BELIEF THAT EVERYONE DESERVES HIGH-QUALITY, AFFORDABLE HEALTH CARE AND THIS BELIEF IS WHAT DRIVES EACH AFFILIATE TO WORK WITH COMMUNITY PARTNERS ACROSS THE REGION TO PROMOTE HEALTH, EXPAND ACCESS AND DELIVER THE BEST CARE IN THE COMMUNITIES BILH SERVES. BILH'S COMMUNITY BENEFITS STAFF IS COMMITTED TO WORKING COLLABORATIVELY WITH BILH'S COMMUNITIES TO ADDRESS THE LEADING HEALTH ISSUES AND CREATE A HEALTHY FUTURE FOR INDIVIDUALS, FAMILIES, AND COMMUNITIES.WINCHESTER HOSPITAL COMMUNITY BENEFITS MISSION STATEMENT WINCHESTER HOSPITAL'S MISSION IS TO TREAT PATIENTS COMPASSIONATELY AND EFFECTIVELY, AND TO CREATE A HEALTHY FUTURE FOR THEM AND THEIR FAMILIES. THIS MISSION IS SUPPORTED BY THE HOSPITAL'S COMMITMENT TO PERSONALIZED, EXCELLENT CARE FOR PATIENTS; A WORKFORCE COMMITTED TO INDIVIDUAL ACCOUNTABILITY, MUTUAL RESPECT, AND COLLABORATION; AND A COMMITMENT TO MAINTAINING FINANCIAL HEALTH. WINCHESTER HOSPITAL IS ALSO COMMITTED TO BEING ACTIVE IN THE COMMUNITY. SERVICE TO COMMUNITY IS AT THE CORE OF WINCHESTER HOSPITAL'S MISSION. THE WINCHESTER HOSPITAL FOUNDERS MADE A COVENANT TO CARE FOR THE UNDERSERVED IN THE HOSPITAL'S SERVICE AREA, ATTEND TO UNMET NEEDS, AND ADDRESS DISPARITIES IN ACCESS TO CARE AND HEALTH OUTCOMES. WINCHESTER HOSPITAL'S COMMITMENT TO THIS COVENANT AND THE PEOPLE IT SERVES REMAINS STEADFAST TODAY. IN 2013, WINCHESTER HOSPITAL'S COMMUNITY BENEFITS ADVISORY COMMITTEE AND BOARD OF TRUSTEES AGREED UPON OUR MISSION: WINCHESTER HOSPITAL IS COMMITTED TO BENEFIT ALL OF THE COMMUNITIES WE SERVE BY COLLABORATING WITH COMMUNITY PARTNERS TO IDENTIFY HEALTH NEEDS, IMPROVE THE HEALTH STATUS OF COMMUNITY RESIDENTS, ADDRESS HEALTH DISPARITIES, AND EDUCATE COMMUNITY MEMBERS ABOUT PREVENTION AND SELF-CARE.WINCHESTER HOSPITAL'S COMMUNITY BENEFITS MISSION IS FULFILLED BY: INVOLVING WINCHESTER HOSPITAL'S STAFF, INCLUDING ITS LEADERSHIP AND DOZENS OF COMMUNITY PARTNERS IN THE COMMUNITY HEALTH ASSESSMENT PROCESS AS WELL AS IN THE DEVELOPMENT, IMPLEMENTATION, AND OVERSIGHT OF THE HOSPITAL'S THREE-YEAR IMPLEMENTATION STRATEGY (IS). ENGAGING AND LEARNING FROM RESIDENTS THROUGHOUT WINCHESTER HOSPITAL'S SERVICE AREA IN ALL ASPECTS OF THE COMMUNITY BENEFITS PROCESS, INCLUDING ASSESSMENT, PLANNING, IMPLEMENTATION, AND EVALUATION. THE HOSPITAL PAYS SPECIAL ATTENTION TO ENGAGING THOSE COMMUNITY MEMBERS WHO ARE NOT PATIENTS OF WINCHESTER HOSPITAL AND THOSE WHO ARE OFTEN LEFT OUT OF ASSESSMENT, PLANNING, AND PROGRAM IMPLEMENTATION PROCESSES. ASSESSING UNMET COMMUNITY NEED BY COLLECTING PRIMARY AND SECONDARY DATA (BOTH QUANTITATIVE AND QUALITATIVE) IN ORDER TO CHARACTERIZE THOSE IN THE COMMUNITY WHO ARE MOST VULNERABLE AND FACE DISPARITIES IN ACCESS AND OUTCOMES. IMPLEMENTING COMMUNITY HEALTH PROGRAMS AND SERVICES IN WINCHESTER HOSPITAL'S CBSA THAT ARE GEARED TOWARD IMPROVING THE CURRENT AND FUTURE HEALTH STATUS OF INDIVIDUALS, FAMILIES, AND COMMUNITIES BY REMOVING BARRIERS TO CARE, ADDRESSING SOCIAL DETERMINANTS OF HEALTH, STRENGTHENING THE HEALTH CARE SYSTEM, AND WORKING TO DECREASE THE BURDEN OF LEADING HEALTH ISSUES; PROMOTING HEALTH EQUITY BY ADDRESSING SOCIAL AND INSTITUTIONAL INEQUITIES, RACISM, AND BIGOTRY AND ENSURING THAT ALL PATIENTS ARE WELCOMED AND RECEIVED WITH RESPECT AND HAVE ACCESS TO CULTURALLY RESPONSIVE CARE; AND FACILITATING COLLABORATION AND PARTNERSHIP WITHIN AND ACROSS SECTORS (E.G., PUBLIC HEALTH, HEALTH CARE, SOCIAL SERVICES, BUSINESS, ACADEMIC, AND COMMUNITY HEALTH) TO ADVOCATE FOR, SUPPORT, AND IMPLEMENT EFFECTIVE HEALTH POLICIES, COMMUNITY PROGRAMS, AND SERVICES.COMMUNITY BENEFITS FINANCIAL SUMMARY DURING THE FISCAL YEAR COVERED BY THIS FILING, WINCHESTER HOSPITAL PROVIDED COMMUNITY HEALTH IMPROVEMENT SERVICES, COMMUNITY BENEFITS OPERATIONS AND CASH AND IN-KIND CONTRIBUTIONS TO COMMUNITY GROUPS OF $2,222,005 AS REPORTED ON THIS SCHEDULE H, PART I, LINES 7E AND 7I. COMMUNITY BENEFITS LEADERSHIP/TEAMTHE MEMBERSHIP OF WINCHESTER HOSPITAL'S CBAC ASPIRES TO BE REPRESENTATIVE OF THE CONSTITUENCIES AND PRIORITY POPULATIONS SERVED BY WINCHESTER HOSPITAL'S PROGRAMMATIC ENDEAVORS, INCLUDING THOSE FROM DIVERSE RACIAL AND ETHNIC BACKGROUNDS AND OF DIVERSE AGE, GENDER, SEXUAL ORIENTATION, AND GENDER IDENTITY, AS WELL AS THOSE FROM CORPORATE AND NONPROFIT COMMUNITY ORGANIZATIONS. SENIOR MANAGEMENT IS ACTIVELY ENGAGED IN THE DEVELOPMENT AND IMPLEMENTATION OF THE COMMUNITY BENEFITS PLAN, ENSURING THAT HOSPITAL POLICIES AND RESOURCES ARE ALLOCATED TO SUPPORT PLANNED ACTIVITIES. WINCHESTER HOSPITAL FY20 CBAC MEMBERS: RICHARD WEINER, PRESIDENT, WINCHESTER HOSPITAL JANE WALSH, WINCHESTER BOARD OF TRUSTEES CHAIR, MEMBER OF BILH BOARD AND COMMUNITY BENEFITS COMMITTEE PAUL ANDREWS, WINCHESTER HOSPITAL BOARD OF TRUSTEES MICHAEL BALDASARRE, ASSISTANT SUPERINTENDENT, WOBURN PUBLIC SCHOOLS CARLA BEAUDOIN, DIRECTOR OF DEVELOPMENT, METRO HOUSING BOSTON DOT BUTLER, WINCHESTER SAFER COALITION DENISE FLYNN, VICE PRESIDENT OF PHILANTHROPY, WINCHESTER HOSPITAL MARYLOU HARDY, REGIONAL MANAGER, COMMUNITY BENEFITS AND COMMUNITY RELATIONS, WINCHESTER HOSPITAL CHRISTINE HEALEY, DIRECTOR OF COMMUNITY BENEFITS/COMMUNITY RELATIONS, BILH KAREN KEANEY, ASSOCIATE CHIEF NURSING OFFICER, EMERGENCY DEPARTMENT, AND CASE MANAGEMENT DEB MCDONOUGH, WINCHESTER HOSPITAL BOARD OF TRUSTEES JENNIFER MURPHY, DIRECTOR OF HEALTH, WINCHESTER HEALTH DEPARTMENT LAUREN REID, DIRECTOR OF COMMUNITY PROGRAMS, MYSTIC VALLEY ELDER SERVICES ADAM ROGERS, EXECUTIVE DIRECTOR, BOYS & GIRLS CLUB OF STONEHAM & WAKEFIELD KATHY SCHULER, CHIEF OPERATING OFFICER, CHIEF NURSING OFFICER, WINCHESTER HOSPITAL DEAN SOLOMON, EXECUTIVE DIRECTOR, COUNCIL OF SOCIAL CONCERN, WOBURN JOSEPH TARBY, WINCHESTER HOSPITAL BOARD OF TRUSTEES MATTHEW WOODS, VICE PRESIDENT OF FINANCE, WINCHESTER HOSPITAL SUE POWERS, ASSOCIATE DIRECTOR OF THE WINCHESTER HOSPITAL CENTER FOR HEALTHY LIVING AND NURSING STAFF DEVELOPMENTIT IS NOT ONLY THE BOARD MEMBERS AND SENIOR LEADERSHIP WHO ARE HELD ACCOUNTABLE FOR FULFILLING WINCHESTER HOSPITAL'S COMMUNITY BENEFITS MISSION. AMONG WINCHESTER HOSPITAL'S CORE VALUES IS THE RECOGNITION THAT THE MOST SUCCESSFUL COMMUNITY BENEFITS PROGRAMS ARE IMPLEMENTED ORGANIZATION WIDE AND INTEGRATED INTO THE VERY FABRIC OF THE HOSPITAL'S CULTURE, POLICIES, AND PROCEDURES. A COMMITMENT TO COMMUNITY BENEFITS IS A FOCUS AND VALUE MANIFESTED THROUGHOUT WINCHESTER HOSPITAL'S STRUCTURE AND REFLECTED IN HOW IT PROVIDES CARE AT THE HOSPITAL AND IN AFFILIATED PRACTICES.WINCHESTER HOSPITAL IS A MEMBER OF BILH. WHILE WINCHESTER HOSPITAL OVERSEES LOCAL COMMUNITY BENEFITS PROGRAMMING AND COMMUNITY ENGAGEMENT EFFORTS, COMMUNITY BENEFITS IS UNDER THE PURVIEW OF THE BILH CHIEF STRATEGY OFFICER. THIS STRUCTURE ENSURES THAT COMMUNITY BENEFITS EFFORTS, PRIORITIZATION, PLANNING, AND STRATEGY ALIGN AND ARE INTEGRATED WITH LOCAL AND SYSTEM STRATEGIC AND REGULATORY PRIORITIES. THE WINCHESTER HOSPITAL COMMUNITY BENEFITS PROGRAM IS SPEARHEADED BY THE BILH COMMUNITY BENEFITS/COMMUNITY RELATIONS REGIONAL MANAGER. THE REGIONAL MANAGER HAS DIRECT ACCESS AND IS ACCOUNTABLE TO THE WINCHESTER HOSPITAL PRESIDENT AND THE BILH VICE PRESIDENT OF COMMUNITY BENEFITS AND COMMUNITY RELATIONS, THE LATTER OF WHOM REPORTS DIRECTLY TO THE BILH CHIEF STRATEGY OFFICER. IT IS THE RESPONSIBILITY OF THESE LEADERS TO ENSURE THAT COMMUNITY BENEFITS IS ADDRESSED BY THE ENTIRE ORGANIZATION AND THAT THE NEEDS OF UNDERSERVED POPULATIONS ARE CONSIDERED EVERY DAY IN DISCUSSIONS ON RESOURCE ALLOCATION, POLICIES, AND PROGRAM DEVELOPMENT. THIS IS THE STRUCTURE AND METHODOLOGY EMPLOYED TO ENSURE THAT COMMUNITY BENEFITS IS NOT THE PURVIEW OF ONE OFFICE ALONE AND TO MAXIMIZE EFFORTS ACROSS THE ORGANIZATION TO FULFILL THE MISSION AND GOALS OF COMMUNITY BENEFITS.
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COMMUNITY HEALTH NEEDS ASSESSMENT AND IMPLEMENTATION STRATEGY
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MOST RECENT COMMUNITY HEALTH NEEDS ASSESSMENT- INTERNAL REVENUE CODE SECTION 501(R)INTERNAL REVENUE CODE SECTION 501(R), ENACTED AS PART OF THE PATIENT PROTECTION AND AFFORDABLE CARE ACT, REQUIRES EACH HOSPITAL TO COMPLETE A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) AND TO FORMALLY ADOPT AN IMPLEMENTATION STRATEGY PURSUANT TO FEDERAL GUIDELINES, IN ORDER TO MAINTAIN ITS TAX EXEMPT STATUS AS A HOSPITAL UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (IRC) OF 1986, AS AMENDED. WINCHESTER HOSPITAL COMPLETED ITS MOST RECENT NEEDS ASSESSMENT IN FY19. THAT CHNA WAS APPROVED BY THE WINCHESTER HOSPITAL BOARD OF TRUSTEES ON SEPTEMBER 18, 2019. THE ACCOMPANYING IMPLEMENTATION STRATEGY FOR THE MOST RECENT CHNA WAS ALSO APPROVED BY THE BOARD ON SEPTEMBER 18, 2019, WHICH IS WITHIN THE TIMELINE REQUIRED BY THE TREASURY REGULATIONS UNDER 501(R). THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) AND THE ASSOCIATED IMPLEMENTATION STRATEGY (IS) REPRESENT THE CULMINATION OF A YEAR OF WORK AND WERE BORNE LARGELY OF WINCHESTER HOSPITAL COMMITMENT TO BETTER UNDERSTAND AND ADDRESS THE HEALTH-RELATED NEEDS OF THOSE LIVING IN ITS COMMUNITY BENEFITS SERVICE AREA WITH AN EMPHASIS ON THOSE WHO ARE MOST DISADVANTAGED. THE PROJECT ALSO FULFILLS THE COMMONWEALTH ATTORNEY GENERAL'S OFFICE AND FEDERAL INTERNAL REVENUE SERVICE (IRS) REGULATIONS THAT REQUIRE THAT WINCHESTER HOSPITAL ASSESS COMMUNITY HEALTH NEEDS, ENGAGE THE COMMUNITY, IDENTIFY PRIORITY HEALTH ISSUES AND CREATE A COMMUNITY HEALTH STRATEGY THAT DESCRIBES HOW WINCHESTER HOSPITAL, IN COLLABORATION WITH THE COMMUNITY AND LOCAL HEALTH DEPARTMENT(S), WILL ADDRESS THE NEEDS AND THE PRIORITIES IDENTIFIED BY THE CHNA.2019 COMMUNITY HEALTH NEEDS ASSESSMENT- TARGETED GEOGRAPHY AND POPULATIONAS NOTED ABOVE, WINCHESTER HOSPITAL COMPLETED ITS LAST ASSESSMENT IN SEPTEMBER 2019. THE GEOGRAPHICAL FOCUS OF WINCHESTER HOSPITAL'S MOST RECENTLY COMPLETED COMMUNITY HEALTH NEEDS ASSESSMENT ENCOMPASSES MEDFORD, NORTH READING, READING, STONEHAM, TEWKSBURY, WAKEFIELD, WILMINGTON, WINCHESTER, AND WOBURN. TARGET POPULATIONS FOR WINCHESTER HOSPITAL'S COMMUNITY BENEFITS INITIATIVES ARE IDENTIFIED THROUGH A COMMUNITY INPUT AND PLANNING PROCESS, COLLABORATIVE EFFORTS AND A CHNA THAT IS CONDUCTED EVERY THREE YEARS IN ACCORDANCE WITH THE REQUIREMENTS UNDER IRC SECTION 501(R). WINCHESTER HOSPITAL'S TARGET POPULATIONS FOCUS ON MEDICALLY UNDERSERVED AND VULNERABLE GROUPS OF ALL AGES IN THE WINCHESTER HOSPITAL COMMUNITY BENEFITS CBSA, AS FOLLOWS: OLDER ADULTS YOUTH AND ADOLESCENTS LOW-RESOURCE INDIVIDUALS AND FAMILIES INDIVIDUALS WITH CHRONIC/COMPLEX CONDITIONS2019 COMMUNITY HEALTH NEEDS ASSESSMENT- SUMMARY OF APPROACH AND METHODSWINCHESTER HOSPITAL CONDUCTED THEIR CHNAS IN THREE PHASES, WHICH ALLOWED THEM TO: COMPILE AN EXTENSIVE AMOUNT OF QUANTITATIVE AND QUALITATIVE DATA. ENGAGE AND INVOLVE KEY STAKEHOLDERS, WINCHESTER HOSPITAL CLINICAL AND ADMINISTRATIVE STAFF AND THE COMMUNITY AT-LARGE. DEVELOP A REPORT AND DETAILED STRATEGIC PLAN; AND COMPLY WITH ALL COMMONWEALTH ATTORNEY GENERAL AND FEDERAL IRS COMMUNITY BENEFITS REQUIREMENTSTHE CHNA USED A PARTICIPATORY, COLLABORATIVE APPROACH TO LOOK AT HEALTH IN ITS BROADEST CONTEXT. THE COLLABORATIVE PROCESS INCLUDED SYNTHESIZING EXISTING REGIONAL DATA ON SOCIAL, ECONOMIC AND HEALTH INDICATORS AS WELL AS INFORMATION FROM KEY INFORMANT INTERVIEWS, COMMUNITY SURVEYS, FOCUS GROUPS AND COMMUNITY MEETINGS CONDUCTED WITH INDIVIDUALS FROM THE NINE CITIES AND TOWNS IN WINCHESTER HOSPITAL'S CBSA, AND WITH A RANGE OF PEOPLE REPRESENTING DIFFERENT AUDIENCES, INCLUDING LEADERS IN EMERGENCY RESPONSE, EDUCATION, HEALTH CARE AND SOCIAL SERVICE ORGANIZATIONS FOCUSING ON VULNERABLE POPULATIONS (E.G., OLDER ADULTS) (SCHEDULE H, PART V, SECTION B, QUESTIONS 3 AND 5). ULTIMATELY, THE QUALITATIVE RESEARCH ENGAGED APPROXIMATELY 1,061 PEOPLE.- KEY INFORMANT INTERVIEWS WITH WINCHESTER HOSPITAL/BILH STAFF - 28- KEY INFORMANT INTERVIEWS WITH COMMUNITY PARTNERS 20- FOCUS GROUPS (4) - 95 ATTENDEES- COMMUNITY LISTENING SESSIONS (2) - 100 ATTENDEES - COMMUNITY SURVEYS 806 RESPONDENTS- CBAB MEETINGS (2) - 35 ATTENDEES TOTAL - PAC MEETINGS 25 ATTENDEES2019 COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS- DETAIL OF APPROACH AND METHODSTHE ASSESSMENT BEGAN IN DECEMBER 2018 AND WAS CONDUCTED IN THREE PHASES, ALLOWING FOR THE COLLECTION OF AN EXTENSIVE AMOUNT OF QUANTITATIVE AND QUALITATIVE DATA:PHASE 1 PRELIMINARY ASSESSMENT AND ENGAGEMENTPHASE 2 TARGETED ENGAGEMENTPHASE 3 STRATEGIC PLANNING AND REPORTINGHUNDREDS OF INDIVIDUALS FROM ACROSS WINCHESTER HOSPITAL'S SERVICE AREA WERE ENGAGED IN THE ASSESSMENT AND PLANNING PROCESS, INCLUDING HEALTH AND SOCIAL SERVICES PROVIDERS, PUBLIC HEALTH OFFICIALS, ELECTED OFFICIALS, PUBLIC SCHOOL NURSES AND ADMINISTRATORS, FIRST RESPONDERS, LEADERS OF FAITH-BASED ORGANIZATIONS, BILH SENIOR LEADERSHIP, STAFF, AND BOARD MEMBERS, AND COMMUNITY RESIDENTS. QUANTITATIVE DATA SOURCES: AN EXTENSIVE AMOUNT OF DEMOGRAPHIC AND SOCIOECONOMIC DATA, HEALTH STATUS, UTILIZATION RATES, AND RISK SURVEY DATA WAS COLLECTED FROM A BROAD RANGE OF SOURCES AND ANALYZED TO MEASURE HEALTH AND UNDERSTAND HEALTH ISSUES. EXAMPLES OF DATA SOURCES WINCHESTER HOSPITAL LEVERAGED INCLUDED: U.S. CENSUS BUREAU, AMERICAN COMMUNITY SURVEY 5-YEAR ESTIMATES (2013-2017) MASSACHUSETTS DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION: SCHOOL AND DISTRICT PROFILES FBI UNIFORM CRIME REPORTS (2017) MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH, REGISTRY OF VITAL RECORDS AND STATISTICS (2015) MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH, BUREAU OF SUBSTANCE ABUSE SERVICES (2017) MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH, ANNUAL REPORTS ON BIRTHS (2016) MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH, OPIOID RELATED EMS INCIDENTS (2018) MASSACHUSETTS BUREAU OF INFECTIOUS DISEASE AND LABORATORY SCIENCES (2017) MASSACHUSETTS CENTER FOR HEALTH INFORMATION ANALYSIS (CHIA) HOSPITAL PROFILES (FY 2013-2017) MASSACHUSETTS CENTER FOR HEALTH INFORMATION ANALYSIS (CHIA) HOSPITAL DISCHARGES (2017) MASSACHUSETTS HEALTHY AGING COLLABORATIVE, COMMUNITY PROFILES (2018) MIDDLESEX LEAGUE YOUTH RISK BEHAVIOR SURVEY (2019) CHANGING FACES OF GREATER BOSTON, BOSTON FOUNDATION (2019)
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PART V, SECTION B, LINE 5: 2019 COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS
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KEY INFORMANT INTERVIEWS WITH INTERNAL AND EXTERNAL STAKEHOLDERSTO OBTAIN TARGETED DATA AND UNDERSTAND THE CURRENT ISSUES FACING THE COMMUNITY, QUALITATIVE DATA WAS COLLECTED THROUGH A VARIETY OF SOURCES INCLUDING 48 KEY INFORMANT INTERVIEWS THAT ENGAGED INSTITUTIONAL, ORGANIZATIONAL AND COMMUNITY LEADERS AND FRONT-LINE STAFF ACROSS SECTORS. DISCUSSIONS EXPLORED INTERVIEWEES' EXPERIENCES OF ADDRESSING COMMUNITY NEEDS AND OPPORTUNITIES FOR FUTURE ALIGNMENT, COORDINATION AND EXPANSION OF SERVICES, INITIATIVES, AND POLICIES. A LIST OF KEY INFORMANTS IS INCLUDED IN APPENDIX H OF THE CHNA REPORT THAT IS POSTED ON WINCHESTER HOSPITAL'S WEBSITE. THESE INDIVIDUALS WERE CHOSEN TO AMASS A REPRESENTATIVE GROUP OF PEOPLE WHO HAD THE EXPERIENCE NECESSARY TO PROVIDE INSIGHT ON THE HEALTH OF COMMUNITIES IN WINCHESTER HOSPITAL'S CBSA. INTERVIEWS WERE CONDUCTED IN PERSON AND ON THE PHONE USING A STANDARD INTERVIEW GUIDE. INTERVIEWS FOCUSED ON IDENTIFYING MAJOR HEALTH ISSUES, INCLUDING POSSIBLE STRATEGIES TO ADDRESS THOSE CONCERNS, AND TARGET POPULATIONS. WHILE IT WAS NOT POSSIBLE FOR THE CHNA TO INVOLVE ALL COMMUNITY STAKEHOLDERS, EVERY EFFORT WAS MADE TO BE AS INCLUSIVE AS POSSIBLE AND PROVIDE A BROAD RANGE OF OPPORTUNITIES FOR PARTICIPATION. 2019 COMMUNITY HEALTH NEEDS ASSESSMENT PROCESSFOCUS GROUPS AND COMMUNITY FORUMS (SCHEDULE H, PART V, SECTION B, LINE 5)FOCUS GROUPS: WINCHESTER HOSPITAL CONDUCTED COMMUNITY FOCUS GROUPS IN WINCHESTER HOSPITAL'S CBSA, TO GATHER CRITICAL COMMUNITY INPUT FROM COMMUNITY RESIDENTS AND STAKEHOLDERS. THE FOCUS GROUPS WERE CONDUCTED FOR THREE DIFFERENT VULNERABLE SEGMENTS OF THE POPULATION, ALONG WITH A SESSION FOR THOSE WHO SPECIALIZE IN SUBSTANCE MISUSE PREVENTION AND WERE ORGANIZED IN COLLABORATION WITH COMMUNITY PARTNERS REPRESENTING THESE POPULATIONS. THE FOCUS GROUP SESSIONS INCLUDED:YOUTH/ADOLESCENTS BOYS & GIRLS CLUB OF STONEHAM AND WAKEFIELDSUBSTANCE USE DISORDER WINCHESTER SAFER COALITIONINDIVIDUALS WITH HOUSING/ECONOMIC INSECURITY WINCHESTER HOUSING AUTHORITYOLDER ADULTS LOCAL COASFOCUS GROUPS WERE HELD AT LOCATIONS THAT WERE CONSIDERED SAFE SPACES AND ACCESSIBLE TO PARTICIPANTS FROM ACROSS THE CBSA. JSI FACILITATED ALL THE FOCUS GROUPS EXCEPT THOSE FOCUSED-ON YOUTH, WHICH WERE CONDUCTED BY THE BOYS & GIRLS CLUB OF STONEHAM & WAKEFIELD, WHO SHARED THEIR FINDINGS WITH JSI. FOCUS GROUPS ALLOWED FOR THE COLLECTION OF INFORMATION TO AUGMENT FINDINGS FROM SECONDARY DATA AND KEY INFORMANT INTERVIEWS, AND FOR THE EXPLORATION OF STRATEGIC AND PROGRAMMATIC OPTIONS TO ADDRESS IDENTIFIED HEALTH ISSUES, SERVICE GAPS, AND/OR BARRIERS TO CARE. PARTICIPANTS WERE RECRUITED BY WINCHESTER HOSPITAL, WORKING IN COLLABORATION WITH COMMUNITY PARTNERS.COMMUNITY FORUMS: WINCHESTER HOSPITAL FACILITATED TWO COMMUNITY LISTENING SESSIONS, ONE OF WHICH WAS CONDUCTED JOINTLY WITH MELROSE-WAKEFIELD HOSPITAL SINCE THERE IS OVERLAP BETWEEN WINCHESTER HOSPITAL'S AND MELROSE-WAKEFIELD HOSPITAL'S COMMUNITY BENEFITS SERVICE AREAS. THE LISTENING SESSIONS WERE PUBLICIZED AND OPEN TO THE PUBLIC. AT THE LISTENING SESSIONS, A SUMMARY OF KEY QUANTITATIVE AND QUALITATIVE DATA FINDINGS TO DATE WERE PRESENTED, AND FEEDBACK AND INPUT FROM COMMUNITY MEMBERS ON PRIORITY POPULATIONS AND HEALTH NEEDS WAS SOLICITED. THE SESSIONS WERE ALSO USED TO SHARE INFORMATION AND SOLICITED. THE SESSIONS ALLOWED FOR THE CAPTURE OF INFORMATION DIRECTLY FROM COMMUNITY RESIDENTS, REPRESENTATIVES FROM LOCAL COMMUNITY ORGANIZATIONS, AND LOCAL SERVICE PROVIDERS. TWO LOCATIONS WITH COMFORTABLE AND ACCESSIBLE SPACE WITH AMPLE PUBLIC PARKING WERE SELECTED IN WINCHESTER AND STONEHAM. COMMUNITY SURVEYS: WINCHESTER HOSPITAL HAS BEEN INTENTIONAL IN ENSURING THAT VARIED EXPERIENCES AND PERSPECTIVES, REFLECTIVE OF WINCHESTER HOSPITAL'S CBSA AND THE COMMUNITY AT LARGE, WERE SHARED THROUGHOUT THE CHNA AND IS PROCESS. TO REACH A BROAD RANGE OF COMMUNITY MEMBERS, ALL COMMUNITY SURVEYS, FOCUS GROUPS AND KEY INFORMANT INTERVIEWS WERE CONDUCTED WITH A FOCUS ON COMMUNITY REPRESENTATIVENESS. FOR EXAMPLE, THE COMMUNITY SURVEY WAS DISTRIBUTED THROUGH COMMUNITY PARTNERS AND WAS ADMINISTERED ONLINE AND VIA HARD COPY IN ENGLISH AS WELL AS SEVEN ADDITIONAL LANGUAGES INCLUDING TRADITIONAL CHINESE, HAITIAN CREOLE, HINDI, ITALIAN, KHMER, PORTUGUESE, AND SPANISH. FURTHERMORE, EXTENSIVE OUTREACH WAS CONDUCTED VIA SOCIAL MEDIA, INSTITUTIONAL NEWSLETTERS, EMAILS TO LARGE NETWORKS, WAITING ROOMS, LOCAL LIBRARIES, COMMUNITY EVENTS AND LARGE APARTMENT BUILDINGS TO HELP ENSURE DIVERSE REPRESENTATION IN THE CHNA.019 COMMUNITY HEALTH NEEDS ASSESSMENT PROCESSREVIEWING RESULTS AND COMPILING THE COMMUNITY HEALTH NEEDS ASSESSMENT AND IMPLEMENTATION STRATEGY DOCUMENTSAS NOTED ABOVE, THE CHNA PROCESS WAS DIVIDED INTO THREE PHASES. THE FINAL PHASE, PHASE III, INCLUDED THE FOLLOWING STEPS: REVIEW OF THE ASSESSMENT'S MAJOR FINDINGS. IDENTIFY WINCHESTER HOSPITAL'S COMMUNITY BENEFITS PRIORITY POPULATIONS, GEOGRAPHIC FOCUS, AND COMMUNITY HEALTH PRIORITIES.ANALYZE WINCHESTER HOSPITAL'S EXISTING COMMUNITY BENEFITS ACTIVITIES WHICH WERE INFORMED BY THE 2016 CHNA AND SUBSEQUENT IMPLEMENTATION STRATEGY THAT WERE COMPLETED BY WINCHESTER HOSPITAL DURING THE FISCAL PERIOD ENDED SEPTEMBER 30, 2016 (TAX YEAR 2015). DETERMINE IF THE RANGE OF COMMUNITY BENEFITS ACTIVITIES ESTABLISHED DURING THE PREVIOUS CHNA AND IMPLEMENTATION STRATEGY PROCESS NEEDED TO BE AUGMENTED OR CHANGED TO RESPOND TO THE ASSESSMENT COMPLETED DURING THE FISCAL YEAR ENDED SEPTEMBER 30, 2019 (TAX YEAR 2018).2019 COMMUNITY HEALTH NEEDS ASSESSMENT PROCESS-KEY FINDINGSBELOW IS A HIGH-LEVEL SUMMARY OF HEALTH-RELATED FINDINGS THAT WERE IDENTIFIED AFTER A COMPREHENSIVE REVIEW OF ALL THE QUANTITATIVE AND QUALITATIVE INFORMATION COLLECTED: SOCIAL DETERMINANTS OF HEALTH (E.G., ECONOMIC STABILITY, TRANSPORTATION, ACCESS TO CARE, HOUSING FOOD INSECURITY) IMPACT MANY SEGMENTS OF THE POPULATION. A KEY THEME FROM THE ASSESSMENT'S KEY INFORMANT INTERVIEWS, FOCUS GROUPS, LISTENING SESSIONS, AND COMMUNITY HEALTH SURVEY WAS THE CONTINUED IMPACT THAT THE SOCIAL DETERMINANTS OF HEALTH HAVE ON RESIDENTS OF WH'S SERVICE AREA, ESPECIALLY THOSE WHO ARE LOW TO MODERATE INCOME, ARE FRAIL OR HOMEBOUND, HAVE MENTAL HEALTH OR SUBSTANCE USE ISSUES, OR LACK A CLOSE SUPPORT SYSTEM. THE INCREASING COST OF HOUSING IN AREAS OUTSIDE BOSTON WAS ALSO NOTED AS CONTRIBUTING TO HOUSING/FINANCIAL INSTABILITY.CERTAIN POPULATIONS ARE MORE VULNERABLE TO HEALTH CARE DISPARITIES AND BARRIERS TO CARE. DESPITE THE FACTS THAT MASSACHUSETTS HAS ONE OF THE HIGHEST RATES OF HEALTH INSURANCE ENROLLMENT AND THE COMMUNITIES THAT MAKE UP WH'S CBSA ARE GENERALLY INSURED AND EMPLOYED, THERE WAS CONCERN THAT FAMILIES FACE FINANCIAL STRESS BECAUSE OF HIGH OUT-OF-POCKET COSTS FOR HEALTH CARE SERVICES AND NOT BEING ELIGIBLE FOR PUBLIC BENEFITS, OR, IF THEY ARE ELIGIBLE, THEY ARE NOT ENROLLING BECAUSE OF THE STIGMA OF ACCEPTING PUBLIC ASSISTANCE. IN ADDITION, THERE ARE GROUPS THAT FACE LANGUAGE AND CULTURAL BARRIERS TO ACCESSING SERVICES.MENTAL HEALTH ISSUES (E.G., DEPRESSION, ANXIETY/STRESS, ACCESS TO TREATMENT, STIGMA) UNDERLIE MANY HEALTH AND SOCIAL CONCERNS. NEARLY EVERY KEY INFORMANT INTERVIEW, FOCUS GROUP, AND LISTENING SESSION INCLUDED DISCUSSIONS ON THE IMPACT OF MENTAL HEALTH ISSUES. FROM A REVIEW OF THE QUANTITATIVE AND QUALITATIVE INFORMATION, DEPRESSION, ANXIETY/STRESS, AND SOCIAL ISOLATION WERE THE LEADING CONCERNS. THERE WERE PARTICULAR CONCERNS ABOUT THE IMPACT OF DEPRESSION, ANXIETY, AND E-CIGARETTES/VAPING ON YOUTH AND OF SOCIAL ISOLATION AMONG OLDER ADULTS. ACCESS TO MENTAL HEALTH SERVICES WAS LIMITED BY THE GENERAL LACK OF PROVIDERS AND THE LOW NUMBER ACCEPTING EVEN PRIVATE HEALTH INSURANCE.SUBSTANCE DEPENDENCY CONTINUES TO IMPACT INDIVIDUALS, FAMILIES, AND COMMUNITIES. THE OPIOID EPIDEMIC CONTINUES TO BE AN AREA OF FOCUS. BEYOND OPIOIDS, KEY INFORMANTS WERE ALSO CONCERNED WITH WINCHESTER HOSPITAL COMMUNITY HEALTH NEEDS ASSESSMENT 2019 ALCOHOL MISUSE, CHANGING COMMUNITY NORMS IN LIGHT OF THE LEGALIZATION OF RECREATIONAL MARIJUANA USE, AND E-CIGARETTES/VAPING AMONG ADOLESCENTS.CHRONIC DISEASES (E.G., CARDIOVASCULAR DISEASE, CANCER, DIABETES, ASTHMA) REQUIRE MORE EDUCATION, SCREENING/EARLY INTERVENTION, AND MANAGEMENT AND A FOCUS ON RISK FACTORS. ALTHOUGH THERE WAS MAJOR EMPHASIS ON BEHAVIORAL HEALTH ISSUES, MANY KEY INFORMANTS, FOCUS GROUP PARTICIPANTS, AND LISTENING SESSION PARTICIPANTS IDENTIFIED A NEED TO ADDRESS THE MANY RISK FACTORS ASSOCIATED WITH CHRONIC AND COMPLEX HEALTH CONDITIONS. PHYSICAL INACTIVITY AND POOR NUTRITION/LIFESTYLE WERE DISCUSSED BY MANY, WITH SOME OF THESE ISSUES BEING ASSOCIATED WITH AGE (MOBILITY ISSUES AMONG OLDER ADULTS), EDUCATION/HEALTH LITERACY (LACK OF UNDERSTANDING ABOUT HEALTHY EATING), AND EASE OF ACCESS TO HIGH CALORIE /UNHEALTHY FOOD CHOICES, AND A LACK OF WALKABLE STREETS IN NEIGHBORHOODS. ADDRESSING THE LEADING RISK FACTORS IS AT THE ROOT OF MANY CHRONIC DISEASE PREVENTION AND MANAGEMENT
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PART V, SECTION B, LINE 5
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STRATEGIES.AN INTEGRATED ANALYSIS OF ALL ASSESSMENT ACTIVITIES FRAMED THE LEADING COMMUNITY HEALTH ISSUES INTO THE FOLLOWING PRIORITY AREAS AND TARGET POPULATIONS:PRIORITY AREAS: MENTAL HEALTH & SUBSTANCE USE DISORDERS: CHRONIC COMPLEX CONDITIONS: SOCIAL DETERMINANTS OF HEALTH & ACCESS TO CARE: TARGET POPULATIONS: YOUTH AND ADOLESCENTS OLDER ADULTS LOW-RESOURCE INDIVIDUALS AND FAMILIES INDIVIDUALS WITH CHRONIC/COMPLEX CONDITIONSTHE CHNA THAT WAS COMPLETED DURING THE FISCAL YEAR ENDED SEPTEMBER 30, 2019, AND THE ASSOCIATED IMPLEMENTATION STRATEGY ADOPTED FROM THIS PROCESS WERE DESIGNED TO INFORM WINCHESTER HOSPITAL'S COMMUNITY BENEFITS INITIATIVES DURING THE FISCAL YEARS ENDED SEPTEMBER 30, 2020; SEPTEMBER 30, 2021; AND SEPTEMBER 30, 2022. INTERIM CHANGES AND UPDATES TO IMPLEMENTATION STRATEGY BASED ON NEWLY IDENTIFIED COMMUNITY NEEDS COVID PANDEMICAS PREVIOUSLY NOTED IN THIS FILING, IRC SECTION 501(R)(3) AND THE PROMULGATED REGULATIONS REQUIRE THAT A TAX-EXEMPT HOSPITAL CONDUCT A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) AND ADOPT AN IMPLEMENTATION STRATEGY ADDRESSING COMMUNITY HEALTH NEEDS IDENTIFIED THROUGH THE CHNA AT LEAST ONCE EVERY THREE YEARS. THE PREAMBLE TO THE REGULATIONS PROMULGATED UNDER IRC SECTION 501(R)(3) NOTES THAT THE TREASURY AND THE IRS INTENDED FOR THE CHNA AND IMPLEMENTATION STRATEGY REQUIREMENT TO ESTABLISH CONTINUAL FEEDBACK ON CHNA REPORTS AND A HOSPITAL IS REQUIRED TO CONSIDER COMMENTS RECEIVED RELATED TO THE EXISTING CHNA AND IMPLEMENTATION STRATEGY WHEN ENGAGING IN THE NEXT CHNA PROCESS NOT MORE THAN THREE YEARS AFTER ADOPTION. IN ADDITION, FINAL REGULATIONS DO NOT PROHIBIT IMPLEMENTATION STRATEGIES FROM DISCUSSING HEALTH NEEDS IDENTIFIED THROUGH MEANS OTHER THAN A CHNA, PROVIDED THAT THE SIGNIFICANT HEALTH NEEDS IDENTIFIED IN THE CHNA ARE ALSO DISCUSSED. FINALLY, THERE IS NOTHING IN THE REGULATIONS THAT PROHIBITS A HOSPITAL FROM UPDATING ITS IMPLEMENTATION STRATEGY BASED ON AN OFF-CYCLE CHANGE TO THE COMMUNITY HEALTH NEEDS THAT ARISE. DURING THE PERIOD COVERED BY THIS FILING, OCTOBER 1, 2019 TO SEPTEMBER 30, 2020, THE HEALTH NEEDS OF THE COMMUNITIES SERVED BY WINCHESTER HOSPITAL WERE IMPACTED BY AN UNEXPECTED GLOBAL PANDEMIC. ON JANUARY 9, 2020, THE WORLD HEALTH ORGANIZATION (WHO) ANNOUNCED THE IDENTIFICATION OF A NEW AND NOVEL CORONAVIRUS-RELATED PNEUMONIA IN WUHAN, CHINA. ON JANUARY 21, 2020 THE UNITED STATES CENTER FOR DISEASE CONTROL CONFIRMED THE FIRST CASE OF THIS NEW CORONA VIRUS IN THE UNITED STATES. ON JANUARY 31, 2020, THE WHO ISSUED A GLOBAL HEALTH EMERGENCY AND ON FEBRUARY 3 THE UNITED STATES DECLARED A PUBLIC HEALTH EMERGENCY BECAUSE OF THE COVID-19 VIRUS. ON MARCH 11, 2020, THE WHO DECLARED COVID-19 A PANDEMIC AND TWO DAYS LATER, THE PRESIDENT OF THE UNITED STATES DECLARED COVID-19 A NATIONAL EMERGENCY.THE HEALTH OF THE COMMUNITIES SERVED BY WINCHESTER HOSPITAL WAS IMPACTED BY THIS UNFORESEEN HEALTH CRISIS AND IN THE ABSENCE OF REGULATORY GUIDANCE TO THE CONTRARY. WINCHESTER HOSPITAL NEEDED TO QUICKLY REASSESS AND PIVOT TO MEET THE NEW AND PREVIOUSLY UNEXPECTED COMMUNITY NEEDS. IN RESPONSE TO THE COVID-19 CRISIS WINCHESTER HOSPITAL'S COMMUNITY BENEFITS STAFF ALONG WITH THE HOSPITAL'S COMMUNITY BENEFITS ADVISORY COMMITTEE (CBAC) EXPANDED GOALS RELATED TO ACCESS TO CARE AND SOCIAL DETERMINANTS OF HEALTH TARGETED PRIMARILY AT LOW INCOME AND MINORITY POPULATIONS WHO HAVE BEEN DISPROPORTIONATELY IMPACTED BY COVID-19. THE ADDITIONAL AND NEWLY URGENT HEALTH NEEDS IN RESPONSE TO COVID-19 INCLUDED: INCREASED DEMAND FOR FOOD ACCESS INCREASED DEMAND/NEED FOR MENTAL HEALTH SERVICES ACCESS TO PREVENTIVE MEASURES, TESTING, SCREENING AND TREATMENT FOR THOSE AT-RISK OR EXPOSED TO COVID-19 SDOH IMPACTS DUE TO THE PANDEMIC (FINANCIALS, HOUSING, MENTAL HEALTH, ETC.). THE ACTIONS TAKEN TOWARD ADDRESSING THESE NEEDS ARE INCLUDED FURTHER IN THIS NARRATIVE SUPPORT ALONG WITH WINCHESTER HOSPITAL'S DETAILED DESCRIPTION OF ACTIVITIES UNDERTAKEN TO MEET THE COMMUNITY NEEDS. COMMUNITY HEALTH NEEDS ASSESSMENTMAKING THE CHNA AND IMPLEMENTATION STRATEGY WIDELY AVAILABLE WINCHESTER HOSPITAL STRIVES TO ADDRESS THE PRIORITY AREAS IN ITS CHNA AND IMPLEMENTATION STRATEGY.BETH ISRAEL LAHEY HEALTH ("BILH") QUICKLY AND EFFECTIVELY MARSHALLED ITS RESOURCES TO MOUNT A COMPREHENSIVE RESPONSE TO THE COVID-19 PANDEMIC. PLEASE REFER TO THE PROGRAM SERVICE ACCOMPLISHMENTS IN PART III FOR FURTHER DETAILS REGARDING BILH'S COVID-19 RESPONSE IN FY20.AS NOTED ABOVE, WINCHESTER HOSPITAL COMPLETED ITS MOST RECENT CHNA DURING ITS FISCAL YEAR ENDED SEPTEMBER 30, 2019 (TAX YEAR 2018). THAT CHNA IS AVAILABLE ON THE WINCHESTER HOSPITAL WEBSITE AT: HTTPS://WWW.WINCHESTERHOSPITAL.ORG/FILE%20LIBRARY/UNASSIGNED/WH-2019-CHNA-091319.PDFIN ADDITION TO THE CHNA, WINCHESTER HOSPITAL COMPLETED ITS MOST RECENT IMPLEMENTATION STRATEGY DURING ITS FISCAL YEAR ENDED SEPTEMBER 30, 2019 (TAX YEAR 2018). THE IMPLEMENTATION STRATEGY IS AVAILABLE ON THE WINCHESTER HOSPITAL WEBSITE AT:HTTPS://WWW.WINCHESTERHOSPITAL.ORG/OUR-PROMISE/SUPPORTING-OUR-COMMUNITYIN ADDITION, AS NOTED ABOVE, WINCHESTER HOSPITAL COMPLETED ITS PREVIOUS CHNA DURING ITS FISCAL YEAR ENDED SEPTEMBER 30, 2016 (TAX YEAR 2015). THAT CHNA IS AVAILABLE ON THE WINCHESTER HOSPITAL WEBSITE AT:HTTPS://WWW.WINCHESTERHOSPITAL.ORG/FILE%20LIBRARY/WINCHESTER%20HOSPITAL/OUR%20PROMISE/WINCHESTER-HOSPITAL-2016-COMMUNITY-HEALTH-ASSESSMENT.PDFFINALLY, THE IMPLEMENTATION STRATEGY ASSOCIATED WITH THE CHNA COMPLETED DURING WINCHESTER HOSPITAL'S FISCAL YEAR ENDED SEPTEMBER 30, 2016 (TAX YEAR 2015) IS AVAILABLE ON THE WINCHESTER HOSPITAL WEBSITE AT:HTTPS://WWW.WINCHESTERHOSPITAL.ORG/FILE%20LIBRARY/WINCHESTER%20HOSPITAL/OUR%20PROMISE/WINCHESTER-HOSPITAL-2016-COMMUNITY-HEALTH-ASSESSMENT.PDFEACH OF THESE DOCUMENTS IS ALSO AVAILABLE ON REQUEST (SCHEDULE H, PART V, SECTION B, LINE 7A).
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SCHEDULE H, PART V, SECTION B, LINE 11-COMMUNITY HEALTH NEEDS ASSESSMENT
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ADDRESSING COMMUNITY HEALTH NEEDSAS NOTED ABOVE, WINCHESTER HOSPITAL'S MOST RECENT CHNA AND IMPLEMENTATION STRATEGY WERE CONDUCTED AND APPROVED BY THE BOARD DURING THE FISCAL YEAR ENDED SEPTEMBER 30, 2019. THAT CHNA AND IMPLEMENTATION STRATEGY INFORMED THE COMMUNITY BENEFITS MISSION AND ACTIVITIES OF WINCHESTER HOSPITAL FOR THE FISCAL YEAR ENDED SEPTEMBER 30, 2020 AND WILL CONTINUE TO INFORM THE HOSPITAL'S COMMUNITY BENEFITS MISSION AND ACTIVITIES FOR THE FISCAL YEARS ENDING SEPTEMBER 30, 2021 AND SEPTEMBER 30, 2022. A SUMMARY OF WINCHESTER HOSPITAL'S COMMUNITY BENEFITS ACTIVITIES THAT ADDRESS THE NEEDS IDENTIFIED IN THE CHNA COMPLETED DURING THE FISCAL YEAR ENDED SEPTEMBER 30, 2019 AND PRIORITIZED IN THE RELATED IMPLEMENTATION STRATEGY ARE PROVIDED HERE ALONG WITH THE ENTITIES THAT THE HOSPITAL PARTNERS WITH ON THESE EFFORTS. GIVEN THE COMPLEX HEALTH ISSUES IN THE COMMUNITY, WINCHESTER HOSPITAL HAS BEEN STRATEGIC IN IDENTIFYING ITS PRIORITY AREAS IN ORDER TO MAXIMIZE THE IMPACT OF ITS COMMUNITY BENEFITS PROGRAM AND WORK TO IMPROVE THE OVERALL HEALTH AND WELLNESS OF RESIDENTS IN ITS CBSA. THE PRIORITY AREAS AND GOALS ARE LISTED BELOW:PRIORITY AREA 1: MENTAL HEALTH AND SUBSTANCE USE DISORDERGOAL: ADDRESS THE PREVALENCE AND IMPACT, STIGMA, RISK/PROTECTIVE FACTORS, AND ACCESS ISSUES ASSOCIATED WITH MENTAL HEALTH AND SUBSTANCE USE DISORDER. PRIORITY AREA 2: CHRONIC COMPLEX CONDITIONS AND RISK FACTORSGOAL: PREVENT, DETECT, AND MANAGE CHRONIC DISEASE AND COMPLEX CONDITIONS AND ENHANCE ACCESS TO TREATMENT AND SUPPORT ACTIVITIES. PRIORITY AREA 3: SOCIAL DETERMINANTS OF HEALTH AND ACCESS TO CAREGOAL: ADDRESS SOCIAL DETERMINANTS OF HEALTH AND BARRIERS TO CARE.COMMUNITY HEALTH NEEDS ASSESSMENT- APPROACH TO ADDRESSING HEALTH NEEDS (SCHEDULE H, PART V, SECTION B, LINE 11) THE FY19 COMMUNITY HEALTH NEEDS ASSESSMENT ALONG WITH THE ASSOCIATED FY20-22 IMPLEMENTATION STRATEGY WAS DEVELOPED OVER A 10-MONTH PERIOD FROM OCTOBER 2018 TO AUGUST 2019. THESE COMMUNITY HEALTH ASSESSMENT, PLANNING, AND IMPLEMENTATION EFFORTS FULFILL THE COMMONWEALTH OF MASSACHUSETTS ATTORNEY GENERAL'S OFFICE AND FEDERAL INTERNAL REVENUE SERVICE (IRS) REQUIREMENTS. MORE SPECIFICALLY, THESE ACTIVITIES FULFILL WINCHESTER HOSPITAL'S NEED TO CONDUCT A COMMUNITY HEALTH NEEDS ASSESSMENT, ENGAGE THE COMMUNITY, IDENTIFY PRIORITY HEALTH ISSUES, INVENTORY COMMUNITY ASSETS, ASSESS IMPACT, AND DEVELOP AN IMPLEMENTATION STRATEGY. HOWEVER, THESE ACTIVITIES ARE DRIVEN PRIMARILY BY WINCHESTER HOSPITAL'S DEDICATION TO ITS MISSION, ITS COVENANT TO CARE FOR THE UNDERSERVED, AND ITS COMMITMENT TO COMMUNITY HEALTH IMPROVEMENT. BELOW IS A SUMMARY DESCRIPTION OF THE FY19 CHNA APPROACH, METHODS, AND KEY FINDINGS. APPROACH AND METHODS:THE ASSESSMENT BEGAN IN DECEMBER 2018 AND WAS CONDUCTED IN THREE PHASES, ALLOWING FOR THE COLLECTION OF AN EXTENSIVE AMOUNT OF QUANTITATIVE AND QUALITATIVE DATA:PHASE 1 PRELIMINARY ASSESSMENT AND ENGAGEMENTPHASE 2 TARGETED ENGAGEMENTPHASE 3 STRATEGIC PLANNING AND REPORTINGHUNDREDS OF INDIVIDUALS FROM ACROSS WINCHESTER HOSPITAL'S SERVICE AREA WERE ENGAGED IN THE ASSESSMENT AND PLANNING PROCESS, INCLUDING HEALTH AND SOCIAL SERVICES PROVIDERS, PUBLIC HEALTH OFFICIALS, ELECTED OFFICIALS, PUBLIC SCHOOL NURSES AND ADMINISTRATORS, FIRST RESPONDERS, LEADERS OF FAITH-BASED ORGANIZATIONS, BILH SENIOR LEADERSHIP, STAFF, AND BOARD MEMBERS, AND COMMUNITY RESIDENTS. QUANTITATIVE DATA SOURCES: AN EXTENSIVE AMOUNT OF DEMOGRAPHIC AND SOCIOECONOMIC DATA, HEALTH STATUS, UTILIZATION RATES, AND RISK SURVEY DATA WAS COLLECTED FROM A BROAD RANGE OF SOURCES AND ANALYZED TO MEASURE HEALTH AND UNDERSTAND HEALTH ISSUES: U.S. CENSUS BUREAU, AMERICAN COMMUNITY SURVEY 5-YEAR ESTIMATES (2013-2017) MASSACHUSETTS DEPARTMENT OF ELEMENTARY AND SECONDARY EDUCATION: SCHOOL AND DISTRICT PROFILES FBI UNIFORM CRIME REPORTS (2017) MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH, REGISTRY OF VITAL RECORDS AND STATISTICS (2015) MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH, BUREAU OF SUBSTANCE ABUSE SERVICES (2017) MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH, ANNUAL REPORTS ON BIRTHS (2016) MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH, OPIOID RELATED EMS INCIDENTS (2018) MASSACHUSETTS BUREAU OF INFECTIOUS DISEASE AND LABORATORY SCIENCES (2017) MASSACHUSETTS CENTER FOR HEALTH INFORMATION ANALYSIS (CHIA) HOSPITAL PROFILES (FY 2013-2017) MASSACHUSETTS CENTER FOR HEALTH INFORMATION ANALYSIS (CHIA) HOSPITAL DISCHARGES (2017) MASSACHUSETTS HEALTHY AGING COLLABORATIVE, COMMUNITY PROFILES (2018) MIDDLESEX LEAGUE YOUTH RISK BEHAVIOR SURVEY (2019) CHANGING FACES OF GREATER BOSTON, BOSTON FOUNDATION (2019)QUALITATIVE DATA SOURCES: TO OBTAIN TARGETED DATA AND UNDERSTAND THE CURRENT ISSUES FACING THE COMMUNITY, THE FOLLOWING WAS DONE: 28 INTERNAL STAKEHOLDER INTERVIEWS (BOARD MEMBERS, SENIOR LEADERS, AND SERVICE LINE LEADERS) 20 EXTERNAL STAKEHOLDER INTERVIEWS 1,022 HOUSEHOLD SURVEYS TWO COMMUNITY LISTENING SESSIONS (100 ATTENDEES)INDIVIDUALS PROVIDED INPUT THROUGH INTERVIEWS, FOCUS GROUPS, COMMUNITY LISTENING SESSIONS, AND A WIDELY DISTRIBUTED COMMUNITY HEALTH SURVEY. WHILE IT WAS NOT POSSIBLE FOR THE CHNA TO INVOLVE ALL COMMUNITY STAKEHOLDERS, EVERY EFFORT WAS MADE TO BE AS INCLUSIVE AS POSSIBLE AND PROVIDE A BROAD RANGE OF OPPORTUNITIES FOR PARTICIPATION. WINCHESTER HOSPITAL'S COMMUNITY BENEFITS PROGRAM IS BUILT ON PARTNERSHIP AND DIALOGUE WITH OUR MANY COMMUNITIES. OUR UNDERSTANDING OF THESE COMMUNITIES' NEEDS IS DERIVED FROM DISCUSSIONS WITH AND OBSERVATIONS BY HEALTH CARE AND HEALTH-RELATED WORKERS IN THE NEIGHBORHOODS AS WELL AS FROM MORE FORMAL ASSESSMENTS OF PUBLIC HEALTH DATA AND THROUGH FOCUS GROUPS, SURVEYS, ETC. THIS DATA WAS THEN AUGMENTED BY DEMOGRAPHIC AND HEALTH STATUS INFORMATION FROM A VARIETY OF SOURCES INCLUDING THE MASSACHUSETTS DEPARTMENT OF PUBLIC HEALTH, FEDERAL RESOURCES SUCH AS THE INSTITUTE OF MEDICINE AND THE CENTERS FOR DISEASE CONTROL AND PREVENTION, AND REVIEW OF LITERATURE RELEVANT TO A PARTICULAR COMMUNITY'S NEEDS. AN ARTICULATION OF EACH SPECIFIC COMMUNITY'S NEEDS (CRAFTED JOINTLY BY WINCHESTER HOSPITAL AND COMMUNITY PARTNERS) INFORMS WINCHESTER HOSPITAL'S DECISION-MAKING ABOUT PRIORITIES FOR COMMUNITY BENEFITS EFFORTS. WE WORK IN CONCERT WITH COMMUNITY RESIDENTS AND LEADERS TO DESIGN SPECIFIC ACTIONS TO BE UNDERTAKEN EACH YEAR. EACH COMPONENT OF THE PLAN IS WOVEN INTO THE GOALS AND AGENDA FOR WINCHESTER HOSPITAL'S COMMUNITY BENEFITS IMPLEMENTATION STRATEGY, ADOPTED BY THE BOARD OF TRUSTEES.
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FY20 SCHEDULE HIMPLEMENTATION STRATEGY UPDATE
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WINCHESTER HOSPITAL'S FY20-22 IMPLEMENTATION STRATEGY FOCUSES ON THE FOLLOWING THREE PRIORITY AREAS IDENTIFIED IN THE CHNA THAT ADDRESS THE BROAD RANGE OF HEALTH AND SOCIAL ISSUES FACING RESIDENTS WHO HAVE THE GREATEST HEALTH DISPARITIES:BASELINE-2019, YEAR 1-2020, YEAR 2-2021, YEAR 3 - 2022PRIORITY AREA #1 - MENTAL HEALTH AND SUBSTANCE USE DISORDERSMENTAL HEALTH ISSUES (E.G., DEPRESSION, ANXIETY, STRESS, STIGMA, AND ACCESS TO TREATMENT) UNDERLIE MANY HEALTH AND SOCIAL CONCERNS. CONCERNS INCLUDE DEPRESSION, ANXIETY/STRESS, SOCIAL ISOLATION AMONG OLDER ADULTS, SUBSTANCE DEPENDENCY (PARTICULARLY USE OF E-CIGARETTES/VAPING AND ALCOHOL BY YOUTH), AND THE OPIOID EPIDEMIC, WHICH CONTINUES TO IMPACT INDIVIDUALS, FAMILIES, AND COMMUNITIES.GOAL: ADDRESS THE PREVALENCE AND IMPACT, STIGMA, RISK/PROTECTIVE FACTORS, AND ACCESS ISSUES ASSOCIATED WITH MENTAL HEALTH AND SUBSTANCE USE DISORDER. TARGET POPULATION: CHILDREN, YOUTH, ADULTS, OLDER ADULTS1.1 PROGRAMMATIC OBJECTIVE: REDUCE ISOLATION AND DEPRESSION:1.2 PROGRAMMATIC OBJECTIVE: REDUCE ENVIRONMENTAL RISK FACTORS ASSOCIATED WITH DEVELOPING MENTAL HEALTH ISSUES1.3 PROGRAMMATIC OBJECTIVE: PROMOTE COLLABORATION, SHARE KNOWLEDGE, AND COORDINATE ACTIVITIES WITH INTERNAL AND EXTERNAL PARTNERS1.4 PROGRAMMATIC OBJECTIVE: INCREASE AWARENESS OF THE IMPACTS AND RISK FACTORS FOR DEVELOPING SUBSTANCE USE DISORDERS1.5 PROGRAMMATIC OBJECTIVE: INCREASE AWARENESS OF THE SIGNS, SYMPTOMS, RISKS, AND STIGMA OF DEVELOPING MENTAL HEALTH ISSUES AND PROMOTE ACCESS TO TREATMENT1.6 INCREASE ACCESS TO APPROPRIATE MENTAL HEALTH AND SUBSTANCE USE TREATMENT AND SUPPORT SERVICES:COMMUNITY ACTIVITIES/STRATEGIES: ORGANIZE AND/OR SUPPORT INITIATIVES THAT INCREASE OPPORTUNITIES FOR SOCIAL ENGAGEMENT ORGANIZE AND/OR SUPPORT COMMUNITY-BASED INITIATIVES THAT INCREASE AWARENESS, PREVENT, AND/OR IDENTIFY INDIVIDUALS AT RISK FOR DEVELOPING SUBSTANCE USE DISORDERS, INCLUDING VAPING. (E.G. BOYS & GIRLS CLUB SBIRT) ORGANIZE AND/OR SUPPORT INITIATIVES THAT REDUCE ENVIRONMENTAL RISK FACTORS ASSOCIATED WITH DEVELOPING MENTAL HEALTH ISSUES SUCH AS HOARDING, ETC. (E.G. SAFE HOME INITIATIVE) SUPPORT AND/OR PARTICIPATE IN TASK FORCES AND COMMUNITY COLLABORATIVES THAT DISCUSS STRATEGIES TO ADDRESS MENTAL HEALTH/SUBSTANCE USE ISSUES ENHANCE ACCESS TO INTEGRATED BEHAVIORAL HEALTH SERVICES PROVIDE SUPPORT/REFERRALS TO INDIVIDUALS WITH MENTAL HEALTH AND/OR SUBSTANCE USE ISSUES WITHIN THE EMERGENCY DEPARTMENTMETRICS/STATUS UPDATE: THE SAFE HOME INITIATIVE IMPLEMENTED FY19 IN COLLABORATION WITH THE WOBURN COUNCIL ON AGING WAS PUT ON HOLD IN FY20 DUE TO COVID RESTRICTIONS. MORE THAN 100 HOURS OF STAFF TIME WAS DEDICATED TO PARTICIPATION IN LOCAL AND REGIONAL SUBSTANCE USE TASK FORCES AND COALITIONS IN FY20. WINCHESTER HOSPITAL PROVIDED A GRANT TO THE BOYS & GIRLS CLUB OF STONEHAM & WAKEFIELD TO CONTINUE PROVIDING THE SBIRT PROGRAM ONSITE AT THE CLUB.IN FY20, 220 YOUTH WERE SCREENED. IN ADDITION, 8 NEW STAFF MEMBERS RECEIVED TRAINING IN EARLY RECOGNITION, BASIC TREATMENT, AND SBIRT METHODOLOGY, SCREENING TECHNIQUES, MOTIVATIONAL INTERVIEWING, TREATMENT OF SUBSTANCE USE DISORDERS, AND SUICIDE PREVENTION. WINCHESTER HOSPITAL PROVIDED SUPPORT TO MYSTIC VALLEY ELDER SERVICES (MVES) TO CONTINUE THE MOBILE MENTAL HEALTH PROGRAM, WHICH PROVIDES HOME-BASED MENTAL HEALTH SERVICES TO OLDER ADULTS IN MEDFORD, NORTH READING, READING, STONEHAM, AND WAKEFIELD. DESPITE THE PANDEMIC, THE MOBILE MENTAL HEALTH PROGRAM PROVIDED SERVICES TO A TOTAL OF 329 COMMUNITY MEMBERS IN FY20, 34% (114) IN THE WINCHESTER HOSPITAL CBSA: MEDFORD (46), STONEHAM (25), NORTH READING (6), READING (20), AND WAKEFIELD (17). WINCHESTER HOSPITAL PROVIDED A GRANT TO THE WINCHESTER HEALTH DEPARTMENT AND THE SAFER COALITION TO SUPPORT THE INTERFACE MENTAL HEALTH REFERRAL SERVICE, LAUNCHED IN JANUARY 2020. IN FY20, 85 RESIDENTS RECEIVED ASSISTANCE. OF THE 82 RESIDENTS SERVED IN FY20, THE LEADING ISSUES WERE ANXIETY, DEPRESSION, AND COVID RELATED ISSUES. MORE THAN 50% WERE FEMALE, AND THE MAJORITY REQUESTING ASSISTANCE WAS BETWEEN THE AGES OF 6-17 LAHEY HEALTH PRIMARY CARE ADOPTED THE COLLABORATIVE CARE MODEL (COCM) AND INTEGRATED BEHAVIORAL HEALTH SERVICES INTO PRIMARY CARE OFFICES IN WINCHESTER HOSPITAL'S CBSA. BEHAVIORAL HEALTH SERVICES WERE PROVIDED TO 624 PATIENTS IN THREE PRIMARY CARE OFFICES LOCATED IN STONEHAM, TEWKSBURY, AND WINCHESTER.COMMUNITY PARTNERS: BOYS & GIRLS CLUB OF STONEHAM/WAKEFIELD, STONEHAM COALITION FOR A HEALTH COMMUNITY, MYSTIC VALLEY ELDER SERVICES, WINCHESTER HEALTH DEPARTMENT, WINCHESTER SAFER COALITIONPRIORITY AREA #2 - CHRONIC/COMPLEX CONDITIONS AND RISK FACTORSTHE CHNA FINDINGS REVEALED A NEED TO ADDRESS THE MANY RISK FACTORS ASSOCIATED WITH CHRONIC AND COMPLEX HEALTH CONDITIONS, INCLUDING PHYSICAL INACTIVITY AND POOR NUTRITION/LIFESTYLE, PARTICULARLY FOR OLDER ADULTS, PEOPLE WITH LOWER LEVELS OF EDUCATION/HEALTH LITERACY, AND THOSE WITH ACCESS ISSUES. ADDRESSING THE LEADING RISK FACTORS IS THE KEY TO MANY CHRONIC DISEASE PREVENTION AND MANAGEMENT STRATEGIES.GOAL: PREVENT, DETECT AND MANAGE CHRONIC DISEASE AND COMPLEX CONDITIONS AND ENHANCE ACCESS TO TREATMENT AND SUPPORT SERVICESTARGET POPULATION: OLDER ADULTS, INDIVIDUALS WITH CHRONIC/COMPLEX CONDITIONS, LOW-RESOURCE INDIVIDUALS AND FAMILIES, YOUTH AND ADOLESCENTS2.1 PROGRAMMATIC OBJECTIVE: CREATE AWARENESS OF/EDUCATE COMMUNITY MEMBERS ABOUT THE PREVENTABLE RISK FACTORS ASSOCIATED WITH CHRONIC AND COMPLEX HEALTH CONDITIONS.2.2 PROGRAMMATIC OBJECTIVE: HELP COMMUNITY MEMBERS DETECT CHRONIC DISEASE ANDPROVIDE LINKAGES TO SERVICES2.3 PROGRAMMATIC OBJECTIVE: ENGAGE INDIVIDUALS IN EVIDENCE-BASED/EVIDENCE-INFORMEDPROGRAMS THAT HELP THEM BETTER MANAGE THEIR CHRONIC DISEASE2.4 PROGRAMMATIC OBJECTIVE: EDUCATE INDIVIDUALS ABOUT ACHIEVING A HEALTHY DIET2.5 PROGRAMMATIC OBJECTIVE: INCREASE ACCESS TO SUPPORTIVE SERVICES THAT REDUCE THE STRESS AND ANXIETY ASSOCIATED WITH CHRONIC ILLNESS:COMMUNITY ACTIVITIES/STRATEGIES: ORGANIZE AND/OR SUPPORT PROGRAMS AND ACTIVITIES IN CLINICAL OR COMMUNITY-BASED SETTINGS TO PROVIDE EDUCATION (E.G. BREAST CANCER EDUCATION & OUTREACH, STROKE AWARENESS, BACK TO SCHOOL EVENT). ORGANIZE AND/OR SUPPORT HEALTH SCREENINGS IN CLINICAL OR NON-CLINICAL SETTINGS TO DETECT CHRONIC/COMPLEX CONDITIONS AND REFER TO AND/OR COORDINATE CARE (E.G. BREAST CANCER RISK ASSESSMENT, HOME BLOOD DRAW PROGRAM) ORGANIZE AND/OR SUPPORT PROGRAMS AND ACTIVITIES THAT REFER, EDUCATE AND SUPPORT INDIVIDUALS IN BETTER MANAGING THEIR CHRONIC/COMPLEX CONDITIONS (E.G. CHRONIC DISEASE MANAGEMENT PROGRAM, CHAMP PEDIATRIC ASTHMA PROGRAM, FIGHTING FATIGUE, ETC.) ORGANIZE AND/OR SUPPORT PROGRAMS IN CLINICAL AND NON-CLINICAL SETTINGS THAT EDUCATE ON HOW TO CHOOSE AND/OR PREPARE HEALTHY FOODS PROVIDE OR SUPPORT PROGRAMS AND SERVICES THAT HELP INDIVIDUALS AND FAMILY MEMBERS ALLEVIATE THE BURDEN(S) ASSOCIATED WITH CHRONIC/COMPLEX CONDITIONSMETRICS/STATUS UPDATE: IN FY20, WINCHESTER HOSPITAL CONDUCTED 3,342 FREE BREAST CANCER RISK ASSESSMENTS. IN FY20, 72 ADULTS WITH CHRONIC DISEASES PARTICIPATED IN WINCHESTER HOSPITAL'S CHRONIC DISEASE MANAGEMENT PROGRAM DUE TO COVID-19, CHAMP WAS PUT ON HOLD FROM MARCH TO SEPTEMBER 2020. HOWEVER, 85 CHILDREN ENROLLED. TRAINING SESSIONS WERE PROVIDED TO 37 NURSES AT FOUR DIFFERENT SCHOOLS. 56 HOME VISITS AND 163 ASTHMA ACTION PLANS WERE COMPLETED. PHYSICAL THERAPISTS FROM WINCHESTER HOSPITAL DEVELOPED AND LAUNCHED THE FIGHTING FATIGUE PROGRAM. IN FY20, A TOTAL OF 94 CLASSES WERE HELD, WITH 13 PARTICIPANTS COMPLETING THE 12-WEEK PROGRAM. IN FY20 AN AVERAGE OF 85 COMMUNITY MEMBERS PER MONTH PARTICIPATED IN WINCHESTER HOSPITAL'S HMR WEIGHT MANAGEMENT PROGRAM. IN FY20, WINCHESTER HOSPITAL PROVIDED 584 FREE INTEGRATIVE THERAPY SESSIONS TO MORE THAN 500 PATIENTS UNDERGOING CANCER TREATMENT. IN ADDITION, 13 YOGA CLASSES WERE OFFERED TO CANCER PATIENTS IN TREATMENT OR RECOVERY, REACHING APPROXIMATELY 50 PARTICIPANTS. COMMUNITY PARTNERS: AMERICAN CANCER SOCIETY
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PRIORITY AREA # 3: SOCIAL DETERMINANTS OF HEALTH AND ACCESS TO CARE:
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A DOMINANT THEME FROM THE ASSESSMENT WAS THE TREMENDOUS IMPACT THAT THE SOCIAL DETERMINANTS OF HEALTH, PARTICULARLY FINANCIAL INSECURITY, ADEQUATE HEALTH INSURANCE COVERAGE, HOUSING, TRANSPORTATION, AND ACCESS TO HEALTHY FOODS HAVE ON RESIDENTS WITHIN WH'S CBSA. THE SOCIAL DETERMINANTS OF HEALTH ARE OFTEN THE DRIVERS OR UNDERLYING FACTORS THAT CREATE OR EXACERBATE MENTAL HEALTH ISSUES, SUBSTANCE MISUSE, AND CHRONIC/COMPLEX CONDITIONS. THESE SOCIAL DETERMINANTS OF HEALTH, PARTICULAR FINANCIAL INSECURITY, ALSO UNDERLIE MANY OF THE ACCESS TO CARE ISSUES THAT WERE PRIORITIZED IN THE ASSESSMENT: NAVIGATING THE HEALTH SYSTEM (INCLUDING HEALTH INSURANCE), CHRONIC DISEASE MANAGEMENT, AND AFFORDING CARE. A KEY FINDING WAS THE CONTINUED IMPACT THAT THE SOCIAL DETERMINANTS OF HEALTH (E.G., ECONOMIC STABILITY, TRANSPORTATION, ACCESS TO CARE, HOUSING, FOOD SECURITY) HAVE ON RESIDENTS OF WINCHESTER HOSPITAL'S SERVICE AREA, ESPECIALLY THOSE WITH LOW TO MODERATE INCOME AND THOSE WHO ARE FRAIL OR HOMEBOUND, HAVE MENTAL HEALTH OR SUBSTANCE USE ISSUES, OR LACK A CLOSE SUPPORT SYSTEM. DESPITE THE FACT THAT PEOPLE IN WINCHESTER HOSPITAL'S SERVICE AREA ARE GENERALLY INSURED AND EMPLOYED, THE CHNA INDICATED CONCERN THAT FAMILIES FACE FINANCIAL STRESS BECAUSE OF HIGH OUT-OF-POCKET COSTS FOR HEALTH CARE SERVICES AND INELIGIBILITY FOR PUBLIC BENEFITS. IF ELIGIBLE, FAMILIES IN NEED OFTEN DON'T ENROLL BECAUSE OF THE STIGMA OF ACCEPTING PUBLIC ASSISTANCE. IN ADDITION, SOME GROUPS FACE LANGUAGE AND CULTURAL BARRIERS TO SERVICES.GOAL: ADDRESS SOCIAL DETERMINANTS OF HEALTH AND BARRIERS TO CARETARGET POPULATION: OLDER ADULTS, INDIVIDUALS WITH CHRONIC/COMPLEX CONDITIONS, LOW-RESOURCE INDIVIDUALS AND FAMILIES, YOUTH AND ADOLESCENTS3.1 PROGRAMMATIC OBJECTIVE: INCREASE ACCESS TO AFFORDABLE AND SAFE TRANSPORTATION OPTIONS3.2 PROGRAMMATIC OBJECTIVE: EDUCATE PROVIDERS AND COMMUNITY MEMBERS ABOUT HOSPITAL AND/OR PUBLIC ASSISTANCE PROGRAMS THAT CAN HELP THEM IDENTIFY AND ENROLL IN APPROPRIATE HEALTH INSURANCE PLANS AND/OR REDUCE THEIR FINANCIAL BURDEN3.3 PROGRAMMATIC OBJECTIVE: ENHANCE AWARENESS ABOUT HOSPITAL/COMMUNITY RESOURCES THAT ADDRESS HEALTH ISSUES AND SOCIAL DETERMINANTS OF HEALTH3.4 PROGRAMMATIC OBJECTIVE: EXPLORE WAYS TO REDUCE/ADDRESS HOUSING INSTABILITY3.5 PROGRAMMATIC OBJECTIVE: INCREASE ACCESS TO CLINICAL SERVICES FOR HOMEBOUND PATIENTS3.6 PROGRAMMATIC OBJECTIVE: INCREASE ACCESS TO AFFORDABLE AND NUTRITIOUS FOODS AND AFFORDABLE PHYSICAL ACTIVITY3.7 PROGRAMMATIC OBJECTIVE: INCREASE AWARENESS ABOUT HOW TO CREATE A HEALTHY AND SAFE ENVIRONMENT FOR BABIES AND FAMILIES, AND PROMOTE HEALTHY CHILD DEVELOPMENT:3.8 PROGRAMMATIC OBJECTIVE: ENSURE ACCESS TO PREVENTIVE MEASURES, TESTING, SCREENING AND TREATMENT FOR THOSE AT-RISK OR EXPOSED TO COVID-19 AND MITIGATE THE IMPACTS OF THE PANDEMIC ON THE SOCIAL DETERMINANTS OF HEALTH3.9 PROGRAMMATIC OBJECTIVE: PROMOTE EQUITABLE CARE AND SUPPORT FOR THOSE WHO FACE CULTURAL AND LINGUISTIC BARRIERSCOMMUNITY ACTIVITIES/STRATEGIES: PROVIDE SUPPORT FOR PROGRAMS/INITIATIVES THAT ADDRESS ISSUES ASSOCIATED WITH TRANSPORTATION PROVIDE COUNSELING, SUPPORT, AND REFERRAL SERVICES TO COMMUNITY MEMBERS TO ENROLL AND REMAIN IN APPROPRIATE DISTRIBUTE INFORMATION AT COMMUNITY EVENTS AND TO PHYSICIANS, CLINICAL STAFF, AND COMMUNITY PARTNERS. DEVELOP RELATIONSHIPS WITH COMMUNITY PARTNERS AND ORGANIZATIONS THAT ADDRESS ISSUES ASSOCIATED WITH HOUSING INSTABILITY PROVIDE OR SUPPORT PROGRAMS/INITIATIVES THAT ENHANCE ACCESS TO CLINICAL SERVICES ORGANIZE AND/OR SUPPORT PROGRAMS THAT PROVIDE ACCESS TO FREE OR LOW-COST HEALTHY FOODS AND PHYSICAL ORGANIZE AND/OR SUPPORT PROGRAMS THAT PROMOTE A HEALTHY AND SAFE ENVIRONMENT AND/OR FOSTER HEALTHY GROWTH AND DEVELOPMENT FOR INFANTS AND BABIES ORGANIZE AND/OR SUPPORT PROGRAMS/INITIATIVES THAT HELP PREVENT THE SPREAD OF COVID AND/OR INCREASE ACCESS TO SCREENING AND TREATMENT. PROVIDE LINGUISTICALLY AND CULTURALLY APPROPRIATE HEALTH EDUCATION AND CARE MANAGEMENT SUPPORT COMMUNITY-BASED INITIATIVES THAT ADDRESS LANGUAGE BARRIERSMETRICS/STATUS UPDATE WINCHESTER HOSPITAL COLLABORATED WITH CHECKER CAB OF WOBURN TO PROVIDE FREE RIDES TO MEDICAL APPOINTMENTS FOR MORE THAN 90 PATIENTS. THROUGH A GRANT WINCHESTER HOSPITAL PROVIDED TO METRO HOUSING BOSTON, THE CO-LOCATION PROGRAM PROVIDED FREE COUNSELING TO 107 LOW- TO MODERATE-INCOME INDIVIDUALS AND FAMILIES TO HELP PREVENT THEM FROM BEING EVICTED AND INCREASE HOUSING STABILITY. IN FY20, WINCHESTER HOSPITAL LAB SERVICES PROVIDED 10,293 FREE IN-HOME BLOOD DRAWS. PROVIDED MORE THAN $40,000 IN SUPPORT TO HELP LOCAL FOOD PANTRIES, SENIOR CENTERS, AND VARIOUS COMMUNITY ORGANIZATIONS REDUCE FOOD INSECURITY FOR OVER 20,000 COMMUNITY MEMBERS AND FAMILIES THE MEDFORD SNAP GAP PROGRAM ENROLLED 10 LOW-INCOME FAMILIES WITH YOUNG CHILDREN FACING FOOD INSECURITY INTO THE SNAP. 1,498 MEDFORD PUBLIC SCHOOL STUDENTS RECEIVED PANDEMIC ELECTRONIC BENEFITS TRANSFER (P-EBT) CARDS. IN FY20, INTERPRETERS ASSISTED 1,063 PATIENTS BY PROVIDING FREE INTERPRETER SERVICES SESSIONS, TOTALING 494 IN-PERSON AND 1007 REMOTE VIDEO SESSIONS. COMMUNITY PARTNERS: METRO HOUSING BOSTON, MINUTEMAN SENIOR SERVICES, NEW ENTRY SUSTAINABLE FARMING INITIATIVE, WINCHESTER HOUSING AUTHORITY
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FORM 990 SCHEDULE H PART VI SUPPLEMENTAL INFORMATION
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THE PURPOSE OF THIS FORM 990 SCHEDULE H NARRATIVE DISCLOSURE IS TO HELP THE READER UNDERSTAND IN MORE DETAIL HOW WINCHESTER HOSPITAL CARES FOR ITS COMMUNITY BY PROVIDING FINANCIAL ASSISTANCE AND CERTAIN OTHER COMMUNITY BENEFITS. AS DEMONSTRATED IN THIS SCHEDULE H, 8.33% OF WINCHESTER HOSPITAL'S TOTAL EXPENSES AS REPORTED ON FORM 990 PART IX, LINE 24, ARE INCURRED IN PROVIDING FINANCIAL ASSISTANCE AND CERTAIN OTHER COMMUNITY BENEFITS AT COST. COMMUNITY BENEFITSANNUAL COMMUNITY BENEFITS REPORTAS PREVIOUSLY NOTED IN THIS FILING, BIDMC'S MOST RECENT COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) AND IMPLEMENTATION STRATEGY WERE COMPLETED AND APPROVED BY THE COMMUNITY BENEFITS ADVISORY COMMITTEE AND BOARD OF TRUSTEES DURING THE FISCAL YEAR ENDED SEPTEMBER 30, 2019, AS REQUIRED PURSUANT TO THE REGULATIONS UNDER INTERNAL REVENUE CODE SECTION 501(R). IN ADDITION, AS NOTED IN THIS FORM 990 SCHEDULE H, PART I, LINES 6A AND 6B, THE HOSPITAL PREPARES AN ANNUAL COMMUNITY BENEFITS REPORT THAT IS SUBMITTED TO THE MASSACHUSETTS ATTORNEY GENERAL (SCHEDULE H, PART VI, LINE 7). THAT FILING IS AVAILABLE FOR PUBLIC INSPECTION AT THE ATTORNEY GENERAL'S OFFICE, ON THE ATTORNEY GENERAL'S WEBSITE AND ON THE HOSPITAL WEBSITE AT:HTTPS://WWW.WINCHESTERHOSPITAL.ORG/OUR-PROMISE/SUPPORTING-OUR-COMMUNITY.THERE ARE SOME DIFFERENCES BETWEEN THE MASSACHUSETTS ATTORNEY GENERAL DEFINITION OF CHARITY CARE AND COMMUNITY BENEFITS AND THE INTERNAL REVENUE SERVICE DEFINITION OF FINANCIAL ASSISTANCE AND COMMUNITY BENEFITS. AS SUCH, THERE ARE VARIANCES BETWEEN THIS SCHEDULE H DISCLOSURE AND THE REPORT WINCHESTER HOSPITAL FILED WITH THE ATTORNEY GENERAL'S OFFICE. EMERGENCY CARE ACCESSIN ADDITION, AS NOTED IN THIS FORM 990, SCHEDULE H, PART V, SECTION A, WINCHESTER HOSPITAL IS A GENERAL MEDICAL AND SURGICAL HOSPITAL, PROVIDING 24-HOUR EMERGENCY MEDICAL CARE TO ALL PATIENTS WITHOUT REGARD TO ABILITY TO PAY. FINANCIAL ASSISTANCE AND CERTAIN OTHER COMMUNITY BENEFITSCHARITY CARE AND MEANS TESTED GOVERNMENT PROGRAMSFINANCIAL ASSISTANCEWINCHESTER HOSPITAL'S NET COST OF CHARITY CARE, INCLUDING CARE FOR EMERGENT SERVICES PROVIDED TO NON-PAYING PATIENTS AND INCLUDING PAYMENTS TO THE HEALTH SAFETY NET TRUST, WAS $2,889,641 FOR THE FISCAL YEAR ENDED SEPTEMBER 30, 2020 AND HAS BEEN REPORTED ON THIS SCHEDULE H, PART I, LINE 7A.AS PREVIOUSLY NOTED IN THIS FORM 990, WINCHESTER HOSPITAL IS ONE OF TEN HOSPITALS WITHIN THE BETH ISRAEL LAHEY HEALTH NETWORK. COMBINED THESE HOSPITALS' NET COST OF CHARITY CARE, INCLUDING CARE FOR EMERGENT SERVICES PROVIDED TO NON-PAYING PATIENTS AND INCLUDING PAYMENTS TO THE HEALTH SAFETY NET TRUST, WAS $44M FOR THE FISCAL YEAR ENDED SEPTEMBER 30, 2020. DURING THE FISCAL YEAR COVERED BY THIS FILING, WINCHESTER HOSPITAL ADOPTED AN AMENDED WRITTEN FINANCIAL ASSISTANCE POLICY. AS REPORTED IN SCHEDULE H PART I LINE 3 AND AGAIN IN SCHEDULE H PART V SECTION B LINE 13, UNDER THAT POLICY, ELIGIBILITY FOR FREE CARE TO LOW-INCOME INDIVIDUALS IS DETERMINED USING FEDERAL POVERTY GUIDELINES OF 400% FOR FULL FREE CARE AND 400% FOR PARTIAL FREE CARE. ELIGIBILITY FOR DISCOUNTED CARE IS DETERMINED BY REVIEWING THE INDIVIDUAL'S EMPLOYMENT STATUS, FAMILY SIZE AND MONTHLY EXPENSES, INCLUDING MEDICAL HARDSHIP REVIEW.OTHER UNCOMPENSATED CHARITY CAREMEDICAID AND MEDICAREIN ADDITION TO THE CHARITY CARE REPORTED ABOVE, WINCHESTER HOSPITAL ALSO PROVIDES CARE TO PATIENTS WHO PARTICIPATE IN OTHER PROGRAMS DESIGNED TO SUPPORT LOW-INCOME FAMILIES, INCLUDING PARTICULARLY THE MEDICAID PROGRAM, WHICH IS JOINTLY FUNDED BY FEDERAL AND STATE GOVERNMENTS. THE MASSACHUSETTS HEALTH REFORM LAW PROVIDED AN INITIATIVE FOR EXPANSION OF MEDICAID COVERAGE TO GREATER POPULATIONS AND FOR ENROLLMENT OF UNINSURED PATIENTS IN OTHER INSURANCE PROGRAMS. PAYMENTS FROM MEDICAID AND OTHER PROGRAMS THAT INSURE LOW-INCOME POPULATIONS DO NOT COVER THE COST OF SERVICES PROVIDED. DURING THE FISCAL PERIOD COVERED BY THIS FILING, WINCHESTER HOSPITAL GENERATED $15,644,823 RELATED TO TREATING MEDICAID PATIENTS WHICH WAS LESS THAN THE COST OF CARE PROVIDED BY WINCHESTER HOSPITAL FOR SUCH SERVICES BY $9,117,365 AS REPORTED ON THIS SCHEDULE H, PART I LINE 7B. MEDICARE IS THE FEDERALLY SPONSORED HEALTH INSURANCE PROGRAM FOR ELDERLY OR DISABLED PATIENTS, AND WINCHESTER HOSPITAL PROVIDES CARE TO PATIENTS WHO PARTICIPATE IN THE MEDICARE PROGRAM. DURING THE FISCAL PERIOD COVERED BY THIS FILING, WINCHESTER HOSPITAL GENERATED $91,039,384 RELATED TO TREATING MEDICARE PATIENTS. THE COSTS OF PROVIDING CARE TO MEDICARE PATIENTS EXCEEDED REVENUE BY $36,405,802. OF THESE AMOUNTS, REVENUE OF $ $ 19,121,617 IS RELATED TO THE PROVISION OF CARDIOLOGY, GYNECOLOGY, HEMATOLOGY & ONCOLOGY, AND RHEUMATOLOGY AND IS INCLUDED ON THIS SCHEDULE H, PART I, LINE 7G, AS PART OF SUBSIDIZED HEALTH SERVICES BECAUSE THE COST OF THOSE SERVICES EXCEEDED REVENUES BY $8,998,333. IN RESPONSE TO THE FORM 990, SCHEDULE H, PART III, LINE 8, ALTHOUGH WINCHESTER HOSPITAL CONSIDERS THE PROVISION OF CLINICAL CARE TO ALL MEDICARE PATIENTS AS PART OF ITS COMMUNITY BENEFIT, THE REMAINING CARE TO MEDICARE PATIENTS IS NOT QUANTIFIED ON PAGE 1 OF THE SCHEDULE H. INSTEAD, PER THE IRS INSTRUCTIONS TO SCHEDULE H, WINCHESTER HOSPITAL HAS SEPARATELY REPORTED THIS AMOUNT IN SCHEDULE H, PART III, LINE 7, AS REQUIRED. HOWEVER, IF THE MEDICARE SHORTFALL WERE INCLUDED IN THE SCHEDULE H PART I LINE 7 CALCULATION, IT WOULD INCREASE TO 17.37%.
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BAD DEBTS
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IN ADDITION TO CHARITY CARE AND SHORTFALLS IN PROVIDING SERVICES TO PATIENTS INSURED UNDER STATE AND FEDERAL PROGRAMS, WINCHESTER HOSPITAL ALSO INCURS LOSSES RELATED TO SELF-PAY PATIENTS WHO FAIL TO MAKE PAYMENTS FOR SERVICES OR INSURED PATIENTS WHO FAIL TO PAY COINSURANCE OR DEDUCTIBLES FOR WHICH THEY ARE RESPONSIBLE UNDER INSURANCE CONTRACTS. BAD DEBT EXPENSE IS INCLUDED IN UNCOMPENSATED CARE EXPENSE IN THE CONSOLIDATED FINANCIAL STATEMENTS AND INCLUDES THE PROVISION FOR ACCOUNTS ANTICIPATED TO BE UNCOLLECTIBLE. CHARGES FOR THOSE SERVICES DURING THE FISCAL PERIOD COVERED BY THIS FILING OF $7,699,268AND ARE REPORTED AS BAD DEBT ON FORM 990, SCHEDULE H, PART III, LINE 2. AS REQUIRED BY THE INSTRUCTIONS TO THIS FORM 990 SCHEDULE H, LOSSES RELATED TO BAD DEBTS HAVE NOT BEEN INCLUDED IN THE CALCULATION OF FINANCIAL ASSISTANCE AND CERTAIN OTHER COMMUNITY BENEFITS IN SCHEDULE H PART I LINE 7. RATHER IT HAS BEEN SEPARATELY REPORTED IN SCHEDULE H PART III AS REQUIRED. THE PERCENTAGES CALCULATED IN PART I, LINE 7, COLUMN F WERE BASED ON EACH ITEM OF FINANCIAL ASSISTANCE AND COMMUNITY BENEFIT AS A PERCENTAGE OF TOTAL EXPENSES REPORTED IN PART IX OF THIS FORM 990. THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS OF THE BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES FOR THE FISCAL YEAR ENDED SEPTEMBER 30, 2020 INCLUDE THE ACCOUNTS OF: BETH ISRAEL DEACONESS MEDICAL CENTER, INC. (BIDMC), MOUNT AUBURN HOSPITAL (MAH), NEW ENGLAND BAPTIST HOSPITAL (NEBH), BETH ISRAEL DEACONESS HOSPITAL MILTON, INC. (MILTON), BETH ISRAEL DEACONESS HOSPITAL NEEDHAM, INC. (NEEDHAM), BETH ISRAEL DEACONESS HOSPITAL PLYMOUTH, INC. (PLYMOUTH), LAHEY CLINIC FOUNDATION (LCF) , LAHEY CLINIC (LCI), LAHEY CLINIC HOSPITAL D/B/A LAHEY HOSPITAL AND MEDICAL CENTER (LHMC), WINCHESTER HOSPITAL (WINCHESTER), NORTHEAST HOSPITAL CORPORATION (NORTHEAST), ANNA JAQUES HOSPITAL (AJH) AND AFFILIATES. THE FINANCIAL STATEMENTS OF THE SYSTEM ALSO INCLUDE A CONTROLLED AFFILIATE, HARVARD MEDICAL FACULTY PHYSICIANS AT BETH ISRAEL DEACONESS MEDICAL CENTER, INC. (HMFP).FINANCIAL STATEMENT FOOTNOTESTHE CONSOLIDATED AUDITED FINANCIAL STATEMENTS OF THE BETH ISRAEL LAHEY HEALTH, INC. AND AFFILIATES FOR THE FOR FISCAL PERIOD ENDED SEPTEMBER 30, 2020 INCLUDE THE ACCOUNTS OF: BETH ISRAEL LAHEY HEALTH, INC. (BILH), AND THE ENTITIES FOR WHICH BETH ISRAEL LAHEY HEALTH, INC. (BILH) SERVED AS SOLE MEMBER DURING THE FISCAL PERIOD COVERED BY THIS FILING, (BETH ISRAEL DEACONESS MEDICAL CENTER (BIDMC), MOUNT AUBURN HOSPITAL (MAH), NEW ENGLAND BAPTIST HOSPITAL (NEBH), BETH ISRAEL DEACONESS HOSPITAL MILTON, INC. (MILTON), BETH ISRAEL DEACONESS HOSPITAL NEEDHAM, INC. (NEEDHAM), BETH ISRAEL DEACONESS HOSPITAL PLYMOUTH, INC. (PLYMOUTH), LAHEY CLINIC FOUNDATION, LAHEY HEALTH SHARED SERVICES, WINCHESTER HOSPITAL (WINCHESTER), NORTHEAST HOSPITAL CORPORATION (NHC), NORTHEAST BEHAVIORAL HEALTH CORPORATION (NBHC) AND ANNA JAQUES HOSPITAL). EACH OF THESE AFFILIATES MAY IN TURN SERVE AS MEMBER OF ADDITIONAL ENTITIES WITHIN THE NETWORK OF AFFILIATES, AND WHOSE ACCOUNTS ARE INCLUDED IN THE BILH AUDITED FINANCIAL STATEMENTS. THE FINANCIAL STATEMENTS ALSO INCLUDE THE ACCOUNTS OF HARVARD MEDICAL FACULTY PHYSICIANS AT BETH ISRAEL DEACONESS MEDICAL CENTER, INC. (HMFP), THE DEDICATED PHYSICIAN PRACTICE OF BETH ISRAEL DEACONESS MEDICAL CENTER AND AN ENTITY INTEGRALLY RELATED TO HELPING BIDMC AND OTHER AFFILIATES IN THE BILH NETWORK ACCOMPLISH THEIR CHARITABLE PURPOSES.THE BETH ISRAEL LAHEY HEALTH INC. CONSOLIDATED FINANCIAL STATEMENTS DO NOT INCLUDE A FOOTNOTE REGARDING BAD DEBT EXPENSE.EMERGENCY CARE ACCESSWINCHESTER HOSPITAL'S DEPARTMENT OF EMERGENCY MEDICINE PROVIDES MEDICALLY NECESSARY CARE FOR ALL PEOPLE REGARDLESS OF THEIR ABILITY TO PAY. THE HOSPITAL OFFERS THIS CARE FOR ALL PATIENTS THAT COME TO THIS FACILITY 24 HOURS A DAY, 7 DAYS A WEEK, AND 365 DAYS A YEAR.
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FINANCIAL ASSISTANCE POLICYINTERNAL REVENUE CODE SECTION 501(R)(4)
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FINANCIAL ASSISTANCE POLICY PURPOSE WINCHESTER HOSPITAL IS DEDICATED TO PROVIDING FINANCIAL ASSISTANCE TO PATIENTS WHO HAVE HEALTH CARE NEEDS AND ARE UNINSURED, UNDERINSURED, INELIGIBLE FOR A GOVERNMENT PROGRAM OR OTHERWISE UNABLE TO PAY FOR MEDICALLY NECESSARY CARE BASED ON THEIR INDIVIDUAL FINANCIAL SITUATION. THE WH FINANCIAL ASSISTANCE POLICY (FAP) IS INTENDED TO BE IN COMPLIANCE WITH APPLICABLE FEDERAL AND STATE LAWS FOR OUR SERVICE AREA. PATIENTS ELIGIBLE FOR FINANCIAL ASSISTANCE WILL RECEIVE FREE AND/OR DISCOUNTED CARE FROM WINCHESTER HOSPITAL AS WELL AS PROVIDERS WHO FOLLOW WINCHESTER HOSPITAL'S FINANCIAL ASSISTANCE POLICY. A LIST OF ALL PROVIDERS WHO PROVIDE CARE WITHIN WINCHESTER HOSPITAL AS WELL AS INFORMATION INDICATING IF THE LISTED PROVIDERS FOLLOW WINCHESTER HOSPITAL'S FINANCIAL ASSISTANCE POLICY IS INCLUDED IN APPENDIX 5 TO THE FINANCIAL ASSISTANCE POLICY. WINCHESTER HOSPITAL DOES NOT DISCRIMINATE BASED ON THE PATIENT'S AGE, GENDER, RACE, CREED, RELIGION, DISABILITY, SEXUAL ORIENTATION, GENDER IDENTITY, NATIONAL ORIGIN OR IMMIGRATION STATUS WHEN DETERMINING ELIGIBILITY.FINANCIAL ASSISTANCE POLICY, CREDIT AND COLLECTION POLICY AND EMERGENCY CARE POLICYAS REQUIRED BY IRC SECTION 501(R)(4) AND THE REGULATIONS PROMULGATED THEREUNDER, THE HOSPITAL MAINTAINS A WRITTEN FINANCIAL ASSISTANCE POLICY (FAP) THAT APPLIES TO ALL EMERGENCY AND OTHER MEDICALLY NECESSARY CARE PROVIDED BY THE HOSPITAL FACILITY. (SCHEDULE H PART I QUESTIONS 1A AND 1B). DETAIL RELATED TO EMERGENCY AND OTHER MEDICALLY NECESSARY CARE COVERED BY THE POLICY IS INCLUDED WITHIN THE POLICY AND THE DEFINITION OF EMERGENCY CARE MEETS THE DEFINITION OF THE EMERGENCY MEDICAL TREATMENT AND LABOR ACT (EMTALA), SECTION 1867 OF THE SOCIAL SECURITY ACT (42 USC 1395DD). (SCHEDULE H PART V SECTION B QUESTION 21). THE FAP INCLUDES A LIST OF PROVIDERS OTHER THAN THE HOSPITAL ITSELF, WHICH ARE COVERED BY THE FAP AND SPECIFIES ELIGIBILITY CRITERIA FOR BOTH FREE AND DISCOUNTED CARE. THE FAP ALSO INCLUDES THE BASIS FOR CALCULATING AMOUNTS CHARGED TO PATIENTS. THE PROVIDER LIST IS UPDATED NOT LESS THAN QUARTERLY AND THE AMOUNTS GENERALLY BILLED (AGB) CALCULATION IS UPDATED NOT LESS THAN ANNUALLY. THE HOSPITAL MAINTAINS A SEPARATE CREDIT AND COLLECTION POLICY AS PERMITTED UNDER THE TREASURY REGULATIONS AND THIS CREDIT AND COLLECTION POLICY IS REFERENCED WITHIN THE FAP AS REQUIRED, ALONG WITH INFORMATION ON HOW TO OBTAIN A FREE COPY OF THE CREDIT AND COLLECTION POLICY. (SCHEDULE H PART III SECTION C QUESTIONS 9A AND 9B AND PART V SECTION B QUESTION 17). THE HOSPITAL'S FAP AND CREDIT & COLLECTION POLICY, REVISED AUGUST 2020, WERE ADOPTED BY THE HOSPITAL'S BOARD PRIOR TO SEPTEMBER 30, 2017 AND THESE DOCUMENTS WERE ALL EFFECTIVE AS OF OCTOBER 1, 2017, THE FIRST DAY OF THE HOSPITAL'S FISCAL YEAR IN WHICH THE HOSPITAL WAS REQUIRED TO BE IN COMPLIANCE WITH THE REGULATIONS PROMULGATED BY THE TREASURY AND RELATED TO IRC SECTION 501(R). FINANCIAL ASSISTANCE POLICYAPPLYING FOR ASSISTANCE THE HOSPITAL'S FAP INCLUDES INFORMATION ON THE METHOD FOR APPLYING FOR FINANCIAL ASSISTANCE UNDER THE FAP. THIS INFORMATION IS ALSO INCLUDED IN THE PLAIN LANGUAGE SUMMARY (PLS). IN ADDITION, THE HOSPITAL'S FINANCIAL ASSISTANCE APPLICATION INCLUDES A LIST OF INFORMATION/DOCUMENTATION REQUIRED AS PART OF A PATIENT'S APPLICATION FOR FINANCIAL ASSISTANCE. (SCHEDULE H PART V SECTION B QUESTION 15)FINANCIAL ASSISTANCE POLICYELIGIBILITY GUIDELINES THE HOSPITAL'S FAP USES THE FEDERAL POVERTY GUIDELINES IN DETERMINING ELIGIBILITY FOR FREE AND DISCOUNTED CARE. (SCHEDULE H PART I QUESTION 3A AND 3B AND PART V SECTION B QUESTION 13). IN ADDITION, THE HOSPITAL'S FAP PROVIDES FOR FINANCIAL ASSISTANCE BASED ON MEDICAL HARDSHIP AND ASSET LEVEL (SCHEDULE H PART I QUESTIONS 3C AND 4, PART V SECTION B QUESTION 13 AND PART VI QUESTION 3). FINALLY, THE HOSPITAL UNDERSTANDS THAT NOT ALL PATIENTS ARE ABLE TO COMPLETE A FINANCIAL ASSISTANCE APPLICATION OR COMPLY WITH REQUESTS FOR DOCUMENTATION. THERE MAY BE INSTANCES UNDER WHICH A PATIENT/GUARANTOR'S QUALIFICATION FOR FINANCIAL ASSISTANCE IS ESTABLISHED WITHOUT COMPLETING THE APPLICATION FORM. OTHER INFORMATION MAY BE USED BY THE HOSPITAL TO DETERMINE WHETHER A PATIENT/GUARANTOR'S ACCOUNT IS UNCOLLECTIBLE, AND THIS INFORMATION WILL BE USED TO DETERMINE PRESUMPTIVE ELIGIBILITY AS OUTLINED IN THE HOSPITAL'S FAP. (SCHEDULE H PART I QUESTIONS 3C).FINANCIAL ASSISTANCEPUBLIC ASSISTANCE PROGRAMS (SCHEDULE H PART I QUESTION 3C)IN ADDITION TO FINANCIAL ASSISTANCE ELIGIBILITY UNDER THE HOSPITAL'S FAP, FOR THOSE INDIVIDUALS WHO ARE UNINSURED OR UNDERINSURED, THE HOSPITAL WILL WORK WITH PATIENTS TO ASSIST THEM IN APPLYING FOR PUBLIC ASSISTANCE AND/OR HOSPITAL FINANCIAL ASSISTANCE PROGRAMS THAT MAY COVER SOME OR ALL OF THEIR UNPAID HOSPITAL BILLS. IN ORDER TO HELP UNINSURED AND UNDERINSURED INDIVIDUALS FIND AVAILABLE AND APPROPRIATE OPTIONS, THE HOSPITAL WILL PROVIDE ALL INDIVIDUALS WITH A GENERAL NOTICE OF THE AVAILABILITY OF PUBLIC ASSISTANCE AND FINANCIAL ASSISTANCE PROGRAMS DURING THE PATIENT'S INITIAL IN-PERSON REGISTRATION AT A HOSPITAL LOCATION FOR A SERVICE, IN ALL BILLING INVOICES THAT ARE SENT TO A PATIENT OR GUARANTOR, AND WHEN THE PROVIDER IS NOTIFIED OR THROUGH ITS OWN DUE DILIGENCE BECOMES AWARE OF A CHANGE IN THE PATIENT'S ELIGIBILITY STATUS FOR PUBLIC OR PRIVATE INSURANCE COVERAGE.HOSPITAL PATIENTS MAY BE ELIGIBLE FOR FREE OR REDUCED COST OF HEALTH CARE SERVICES THROUGH VARIOUS STATE PUBLIC ASSISTANCE PROGRAMS AS WELL AS THE HOSPITAL FINANCIAL ASSISTANCE PROGRAMS (INCLUDING BUT NOT LIMITED TO MASSHEALTH, THE PREMIUM ASSISTANCE PAYMENT PROGRAM OPERATED BY THE HEALTH CONNECTOR, THE CHILDREN'S MEDICAL SECURITY PROGRAM, THE HEALTH SAFETY NET, AND MEDICAL HARDSHIP). SUCH PROGRAMS ARE INTENDED TO ASSIST LOW-INCOME PATIENTS TAKING INTO ACCOUNT EACH INDIVIDUAL'S ABILITY TO CONTRIBUTE TO THE COST OF HIS OR HER CARE. FOR THOSE INDIVIDUALS THAT ARE UNINSURED OR UNDERINSURED, THE HOSPITAL WILL, WHEN REQUESTED, HELP THEM WITH APPLYING FOR EITHER COVERAGE THROUGH PUBLIC ASSISTANCE PROGRAMS OR HOSPITAL FINANCIAL ASSISTANCE PROGRAMS THAT MAY COVER ALL OR SOME OF THEIR UNPAID HOSPITAL BILLS.THE HOSPITAL IS AVAILABLE TO ASSIST PATIENTS IN ENROLLING INTO STATE HEALTH COVERAGE PROGRAMS. THESE INCLUDE MASSHEALTH, THE PREMIUM ASSISTANCE PAYMENT PROGRAM OPERATED BY THE STATE'S HEALTH CONNECTOR, AND THE CHILDREN'S MEDICAL SECURITY PLAN. FOR THESE PROGRAMS, APPLICANTS CAN SUBMIT AN APPLICATION THROUGH AN ONLINE WEBSITE (WHICH IS CENTRALLY LOCATED ON THE STATE'S HEALTH CONNECTOR WEBSITE), A PAPER APPLICATION, OR OVER THE PHONE WITH A CUSTOMER SERVICE REPRESENTATIVE LOCATED AT EITHER MASSHEALTH OR THE CONNECTOR. INDIVIDUALS MAY ALSO ASK FOR ASSISTANCE FROM HOSPITAL FINANCIAL COUNSELORS (ALSO CALLED CERTIFIED APPLICATION COUNSELORS) WITH SUBMITTING THE APPLICATION EITHER ON THE WEBSITE OR THROUGH A PAPER APPLICATION.FINANCIAL ASSISTANCE POLICYTRANSLATIONS THE HOSPITAL'S FAP, CREDIT AND COLLECTION POLICY AND PLAIN LANGUAGE SUMMARY, APPLICATION FOR FINANCIAL ASSISTANCE AND HARDSHIP APPLICATION (SEE DETAIL BELOW) HAVE ALL BEEN TRANSLATED INTO THE LANGUAGES SPOKEN BY THOSE IN THE HOSPITAL'S COMMUNITY WHO MAY COMMUNICATE IN A LANGUAGE OTHER THAN ENGLISH. THE HOSPITAL HAS TRANSLATED THESE DOCUMENTS INTO THE LANGUAGES OF LIMITED ENGLISH PROFICIENCY (LEP) OF ITS PATIENTS, 5% OF THE POPULATION OR 1000 PERSONS, WHICHEVER IS LESS, IN ACCORDANCE WITH THE REGULATIONS PROMULGATED UNDER IRC SECTION 501(R). BASED ON THE HOSPITAL'S REVIEW OF THIS SAFE HARBOR, THE HOSPITAL HAS TRANSLATED THESE DOCUMENTS INTO THE FOLLOWING LANGUAGES: ENGLISH, ARABIC, ARMENIAN, CAMBODIAN, FRENCH, GREEK, HAITIAN-CREOLE, HINDI, ITALIAN, JAPANESE, KOREAN, MON-KHINER, PORTUGUESE, PANJABI, RUSSIAN, SPANISH, VIETNAMESE, SIMPLIFIED AND TRADITIONAL CHINESE. (SCHEDULE H PART V SECTION B QUESTION 16I)
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FINANCIAL ASSISTANCE POLICYWIDELY PUBLICIZING AND AVAILABILITY
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COPIES OF THE FAP, CREDIT AND COLLECTION POLICY, FAP SUMMARY AND APPLICATION FOR FINANCIAL ASSISTANCE ARE ALL AVAILABLE IN BOTH ENGLISH AND ALL LEP LANGUAGES AT THE HOSPITAL, BY MAIL FREE OF CHARGE AND/OR ON THE HOSPITAL'S WEBSITE: (SCHEDULE H PART V SECTION B QUESTIONS 16A, 16B, 16C, 16D, 16E, 16H) AT HTTPS://WWW.WINCHESTERHOSPITAL.ORG/FILE%20LIBRARY/UNASSIGNED/WH---ENGLISH-FAP--JAN.-2021_FINAL-.PDFIN ADDITION, THE FAP, CREDIT AND COLLECTION POLICY, FAP SUMMARY AND APPLICATION FOR FINANCIAL ASSISTANCE ARE ALL AVAILABLE IN THE HOSPITAL'S EMERGENCY DEPARTMENT AND FINANCIAL COUNSELING OFFICE. (SCHEDULE H PART V SECTION B QUESTION 16F AND SCHEDULE H PART VI QUESTION 3).THE HOSPITAL MAINTAINS SIGNAGE AND CONSPICUOUS PUBLIC DISPLAYS ABOUT FINANCIAL ASSISTANCE AND THE FAP DESIGNED TO ATTRACT THE ATTENTION OF PATIENTS AND VISITORS, INCLUDING BOTH THE EMERGENCY DEPARTMENT AND ADMISSIONS. SUCH SIGNAGE IS POSTED BOTH IN ENGLISH AND THE LEP LANGUAGES NOTED ABOVE. IN ADDITION, FINANCIAL COUNSELING PERSONNEL ROUTINELY VISIT LOCATIONS DESIGNATED FOR SIGNAGE TO ENSURE THAT SUCH SIGNAGE REMAINS VISIBLE TO PATIENTS AND VISITORS AS ATTENDED. THE HOSPITAL PROVIDES INFORMATION ABOUT THE FAP TO PATIENTS BEFORE DISCHARGE AND CONSPICUOUSLY WITHIN BILLING STATEMENTS. INFORMATION PROVIDED TO PATIENTS IN THESE COMMUNICATIONS INCLUDES CONTACT INFORMATION FOR THOSE THAT CAN HELP PROVIDE ADDITIONAL INFORMATION ABOUT THE FAP, INFORMATION ON THE APPLICATION PROCESS AND THE WEBSITE WHERE THE FAP CAN BE OBTAINED. ADDITIONALLY, A PLAIN LANGUAGE SUMMARY OF THE FAP IS PROVIDED TO PATIENTS AS PART OF THE INTAKE AND/OR DISCHARGE PROCESS. (SCHEDULE H PART V SECTION B QUESTION 16G). FINANCIAL ASSISTANCE POLICYPLAIN LANGUAGE SUMMARYAS NOTED IN THIS NARRATIVE SUPPORT TO THE FORM 990 SCHEDULE H, THE HOSPITAL HAS A PLAIN LANGUAGE SUMMARY OF ITS FAP. THIS IS A WRITTEN STATEMENT DESIGNED TO NOTIFY PATIENTS AND VISITORS THAT THE HOSPITAL HAS A WRITTEN FAP AND PROVIDES FINANCIAL ASSISTANCE. THIS PLAIN LANGUAGE SUMMARY INCLUDES INFORMATION ON FREE AND DISCOUNTED CARE, HOW TO OBTAIN A COPY OF THE FAP POLICY AND APPLICATION, INCLUDING THE WEBSITE ADDRESS, THE LOCATION AND PHONE NUMBER OF THE FINANCIAL COUNSELING OFFICE. THE PLAIN LANGUAGE SUMMARY ALSO INCLUDES THE LIST OF LANGUAGES INTO WHICH THE FAP AND SUMMARY HAVE BEEN TRANSLATED AS WELL AS HOW TO ACCESS INFORMATION ON PROVIDERS NOT COVERED BY THE FAP AND TO WHICH OTHER RELATED HOSPITALS APPROVAL UNDER THE FAP WILL APPLY. LINKS TO FINANCIAL ASSISTANCE POLICY AND RELATED DOCUMENTSTHE FOLLOWING FINANCIAL ASSISTANCE POLICY (FAP) DOCUMENTS: CREDIT AND COLLECTION POLICY APPLICATION FOR FINANCIAL ASSISTANCE MEDICAL HARDSHIP APPLICATION FINANCIAL ASSISTANCE POLICY PLAIN LANGUAGE SUMMARY AS WELL AS ADDITIONAL INFORMATION ON PATIENT FINANCIAL ASSISTANCE AND BILLING, ALL IN [ENGLISH, ARABIC, ARMENIAN, CAMBODIAN, FRENCH, GREEK, HAITIAN-CREOLE, HINDI, ITALIAN, JAPANESE, KOREAN, MON-KHINER, PORTUGUESE, PANJABI, RUSSIAN, SPANISH, VIETNAMESE, SIMPLIFIED AND TRADITIONAL CHINESE, CAN BE FOUND ON THE WINCHESTER HOSPITAL WEBSITE ATHTTPS://WWW.WINCHESTERHOSPITAL.ORG/FILE%20LIBRARY/UNASSIGNED/WH---ENGLISH-FAP--JAN.-2021_FINAL-.PDFLIMITATION ON CHARGESINTERNAL REVENUE CODE SECTION 501(R)(5)LIMITATION ON CHARGESAS REQUIRED BY IRC SECTION 501(R)(5) AND THE REGULATIONS PROMULGATED THEREUNDER, THE HOSPITAL LIMITS THE AMOUNTS CHARGED FOR ANY EMERGENCY OR OTHER MEDICALLY NECESSARY CARE IT PROVIDES TO A FINANCIAL ASSISTANCE-ELIGIBLE PATIENT, TO NOT MORE THAN AMOUNTS GENERALLY BILLED (AGB) AND LIMITS THE AMOUNTS CHARGED TO ANY FINANCIAL ASSISTANCE ELIGIBLE PATIENT FOR ALL OTHER MEDICAL CARE TO LESS THAN GROSS CHARGES. AMOUNTS GENERALLY BILLEDLOOK BACK METHODTHE HOSPITAL CALCULATES ITS AGB, USING THE LOOK BACK METHOD, DIVIDING THE TOTAL PAYMENTS RECEIVED FROM ALL COMMERCIAL PLANS AND MEDICARE BY THE TOTAL CHARGES SENT TO THOSE SAME PAYERS FOR THE PREVIOUS FISCAL YEAR. CALCULATED AGB IS INCLUDED IN THE HOSPITAL'S FAP AS REQUIRED UNDER THE REGULATIONS DETAILING THE REQUIREMENTS UNDER IRC SECTION 501(R)(5). (SCHEDULE H PART V SECTION B QUESTION 22). PATIENT REFUNDS FOR CHARGES IN EXCESS OF AMOUNTS GENERALLY BILLEDTHE HOSPITAL REGULARLY MONITORS THE FINANCIAL ACCOUNTS OF FINANCIAL ASSISTANCE ELIGIBLE PATIENTS. WHERE A PATIENT SUBMITS A COMPLETED APPLICATION FOR FINANCIAL ASSISTANCE AND IS DETERMINED TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE, THE HOSPITAL REFUNDS ANY AMOUNTS PREVIOUSLY PAID FOR CARE THAN EXCEEDS THE AMOUNT THAT THE PATIENT IS PERSONALLY RESPONSIBLE FOR PAYING WHERE SUCH AMOUNTS ARE EQUAL TO OR EXCEED $5.00.
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BILLING AND COLLECTIONS501(R)(6)
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EXTRAORDINARY COLLECTION ACTIVITIESTHE HOSPITAL DOES NOT ENGAGE IN ANY EXTRAORDINARY COLLECTION ACTIVITIES (ECAS) FOR FINANCIAL ASSISTANCE ELIGIBLE PATIENTS. SPECIFICALLY, THE HOSPITAL DOES NOT REPORT TO CREDIT AGENCIES, ENGAGE IN LEGAL OR JUDICIAL PROCESSES OR SELL A PATIENT'S OUTSTANDING AMOUNTS OWED FOR PATIENT CARE. IN ADDITION, THIS EXTENDS TO ANY THIRD PARTY CONTRACTED WITH THE HOSPITAL RELATED TO BILLING AND COLLECTIONS. (SCHEDULE H PART V SECTION B QUESTIONS 18 AND 19).APPLICATION PERIOD PATIENTS MAY APPLY FOR FINANCIAL ASSISTANCE AT ANY TIME UP TO TWO HUNDRED FORTY (240) DAYS AFTER THE FIRST POST-DISCHARGE BILLING STATEMENT IS AVAILABLE. BIDMCADDITIONAL INFORMATION REGARDING PROMOTING THE HEALTH OF THE COMMUNITY (SCHEDULE H, PART VI, QUESTIONS 5 AND 6)COMMUNITY BOARDAS NOTED IN THIS FORM 990 PARTS I AND VI, THE MAJORITY OF BOARD MEMBERS ARE INDEPENDENT COMMUNITY MEMBERS. AFFILIATED HEALTH CARE SYSTEMAS NOTED IN VARIOUS NARRATIVE DISCLOSURES THAT SUPPORT THIS FORM 990 AND RELATED SCHEDULES FOR THE PERIOD COVERED BY THIS FILING, BILH IS A MASSACHUSETTS NON-PROFIT CORPORATION EXEMPT FROM INCOME TAX UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE OF 1986, AS AMENDED. BILH IS AN INTEGRATED HEALTH CARE SYSTEM COMMITTED TO EXPANDING ACCESS TO EXTRAORDINARY PATIENT CARE ACROSS EASTERN MASSACHUSETTS AND ADVANCING THE SCIENCE AND PRACTICE OF MEDICINE THROUGH GROUNDBREAKING RESEARCH AND EDUCATION. THE BILH SYSTEM IS COMPRISED OF ACADEMIC AND TEACHING HOSPITALS, A PREMIER ORTHOPEDICS HOSPITAL, PRIMARY CARE AND SPECIALTY CARE PROVIDERS, AMBULATORY SURGERY CENTERS, URGENT CARE CENTERS, COMMUNITY HOSPITALS, HOMECARE SERVICES, OUTPATIENT BEHAVIORAL HEALTH CENTERS, ADDICTION TREATMENT PROGRAMS. BILH'S COMMUNITY OF CLINICIANS, CAREGIVERS AND STAFF INCLUDES APPROXIMATELY 4,000 PHYSICIANS AND 35,000 EMPLOYEES. BILH SERVES AS SOLE MEMBER OF BETH ISRAEL DEACONESS MEDICAL CENTER (BIDMC), MOUNT AUBURN HOSPITAL (MAH), NEW ENGLAND BAPTIST HOSPITAL (NEBH), BETH ISRAEL DEACONESS HOSPITAL MILTON, INC. (MILTON), BETH ISRAEL DEACONESS HOSPITAL NEEDHAM, INC. (NEEDHAM), BETH ISRAEL DEACONESS HOSPITAL PLYMOUTH, INC. (PLYMOUTH), LAHEY CLINIC FOUNDATION, LAHEY HEALTH SHARED SERVICES, WINCHESTER HOSPITAL (WINCHESTER), NORTHEAST HOSPITAL CORPORATION (NHC), NORTHEAST BEHAVIORAL HEALTH CORPORATION (NBHC) AND ANNA JAQUES HOSPITAL). LAHEY CLINIC FOUNDATION SERVES AS THE SOLE MEMBER OF LAHEY CLINIC, INC. AND LAHEY CLINIC HOSPITAL D/B/A LAHEY HOSPITAL AND MEDICAL CENTER. EACH OF THESE AFFILIATES MAY IN TURN SERVE AS MEMBER OF ADDITIONAL ENTITIES WITHIN THE NETWORK OF AFFILIATES.FOR THE FISCAL YEAR 2020 THE BILH HOSPITALS NOTED ABOVE PROVIDED CARE TO MEDICAID PATIENTS AT COSTS WHICH EXCEEDED REVENUES BY OVER $86 MILLION AND PROVIDED CARE TO MEDICARE PATIENTS AT COSTS WHICH EXCEEDED REVENUES BY $117 MILLION. IN ADDITION, THE BILH HOSPITALS PROVIDED TOTAL COMMUNITY BENEFITS IN THE NATURE OF DIRECT SERVICES TO THE COMMUNITIES SERVED BY THE BILH NETWORK AS WELL AS FUNDS PROVIDED TO COMMUNITY PARTNERS IN THE AMOUNT OF $93 MILLION BILH HOSPITALS ALSO INCURRED NET COSTS FOR SUBSIDIZED HEALTH SERVICES TO ENSURE THAT CARE WAS AVAILABLE WITHIN THE COMMUNITIES SERVED ACROSS BILH IN THE AMOUNT OF $32 MILLION. FINALLY, BILH HOSPITALS ARE COMMITTED TO PROVIDING RESEARCH TO FURTHER ADVANCE CARE TO BILH PATIENTS AND TO THE GENERAL ADVANCEMENT TO HEALTHCARE TREATMENT BEYOND THE COMMUNITIES IMMEDIATELY SERVED BY BILH AND TO PROVIDING CUTTING EDGE TRAINING TO FUTURE HEALTHCARE PROVIDERS. BILH HOSPITALS INVESTED NET COSTS OF $183 MILLION TOWARD THESE MISSIONS DURING THE FISCAL YEAR COVERED BY THIS FILING.
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IRC 501(R) REPORTING UNDER REVENUE PROCEDURE 2015-21:
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DURING A REVIEW OF WINCHESTER HOSPITAL, INC.'S SECTION 501(R) COMPLIANCE IN THE HOSPITAL'S FISCAL YEAR ENDED SEPTEMBER 30, 2019, IT WAS DETERMINED THAT CERTAIN INFORMATION IN THE HOSPITAL'S FINANCIAL ASSISTANCE POLICY (FAP), PLAIN LANGUAGE SUMMARY (PLS) AND CREDIT AND COLLECTIONS POLICY (CCP) AS THEN IN EFFECT REQUIRED CLARIFICATION OR CORRECTION. ALL CORRECTIONS AND CLARIFICATIONS WERE MADE AS REQUIRED PRIOR TO THE HOSPITAL'S FILING OF THE FORM 990 FOR THAT SAME FISCAL PERIOD. BECAUSE THE CORRECTIONS AND CLARIFICATIONS WERE MADE DURING THE FISCAL YEAR COVERED BY THE CURRENT FILING, THIS DISCLOSURE IS INCLUDED AGAIN IN THE FORM 990. IN ACCORDANCE WITH THE PROCEDURES SET FORTH IN REVENUE PROCEDURE 2015-21, EACH OF THE IDENTIFIED ITEMS IS LISTED ALONG WITH THE METHOD OF CORRECTION. CORRECTION OCCURRED BY ADOPTION OF A REVISED FAP, PLS AND CCP BY THE HOSPITAL'S AUTHORIZED BODY PRIOR TO FILING THE RETURN FOR FISCAL YEAR 2019, WHICH WAS FILED DURING THE HOSPITAL'S FISCAL YEAR 2020. (1) WHILE THE FAP SPECIFIED THE PERCENTAGE OF DISCOUNTS AVAILABLE, IT DID NOT SPECIFICALLY REFER TO WHAT CHARGES THOSE DISCOUNTS WOULD BE APPLIED. THE FAP HAS BEEN REVISED TO CLARIFY THAT THE DISCOUNTS ARE APPLIED TO PATIENT GROSS CHARGES. (2) THE FAP DID NOT SPECIFY THE AMOUNTS GENERALLY BILLED (AGB) BY THE HOSPITAL OR SPECIFY THE METHODOLOGY FOR CALCULATING THE AGB. THIS INFORMATION WAS POSTED ON THE HOSPITAL'S WEBSITE BUT WAS NOT SPECIFICALLY INCLUDED IN THE FAP. THE FAP HAS BEEN REVISED TO INCLUDE THIS INFORMATION. (3) THE FAP DID NOT CLEARLY DESCRIBE INFORMATION OBTAINED FROM SOURCES OTHER THAN THE INDIVIDUAL SEEKING FINANCIAL ASSISTANCE TO PRESUMPTIVELY DETERMINE THAT THE INDIVIDUAL IS FAP-ELIGIBLE. THE FAP HAS BEEN REVISED TO CLARIFY SUCH INFORMATION. (4) THE LIST OF PROVIDERS OF EMERGENCY AND MEDICALLY NECESSARY CARE AT THE HOSPITAL DID NOT INCLUDE ALL PROVIDERS. THE LIST HAS BEEN UPDATED AND NOW REFLECTS ALL PROVIDERS. (5) THE PLS DID NOT INCLUDE INSTRUCTIONS ON HOW AN INDIVIDUAL CAN OBTAIN A FREE COPY OF THE FAP AND FAP INSTRUCTIONS BY MAIL AND DID NOT INCLUDE THE CONTACT INFORMATION, INCLUDING TELEPHONE NUMBER AND PHYSICAL LOCATION OF THE HOSPITAL'S OFFICE OR DEPARTMENT THAT CAN PROVIDE ASSISTANCE WITH THE FAP APPLICATION PROCESS. THE PLS HAS BEEN REVISED TO INCLUDE THIS INFORMATION. (6) THE HOSPITAL HAD NOT YET MADE EFFORTS TO INFORM MEMBERS OF THE COMMUNITY SERVED BY THE HOSPITAL ABOUT THE FAP IN A MANNER REASONABLY CALCULATED TO REACH THOSE MEMBERS WHO ARE MOST LIKELY TO REQUIRE FINANCIAL ASSISTANCE. THE HOSPITAL HAS SINCE MADE SUCH EFFORTS, INCLUDING BY DISTRIBUTING COPIES OF ITS FAP AND FAP APPLICATION TO REFERRING STAFF PHYSICIANS AND TO COMMUNITY HEALTH CENTERS SERVING THE HOSPITAL'S COMMUNITY. (7) THE HOSPITAL HAD NOT BEEN OFFERING A PAPER COPY OF ITS PLS TO PATIENTS AS PART OF THE INTAKE OR DISCHARGE PROCESS. THE HOSPITAL HAS NOW ENSURED THAT IT IS DOING SO. (8) WHILE THE HOSPITAL HAD NOT BEEN ENGAGING IN ANY EXTRAORDINARY COLLECTION ACTIONS (ECAS), ITS CCP DID NOT INCLUDE A DESCRIPTION OF THE OFFICE, DEPARTMENT OR COMMITTEE WITH FINAL AUTHORITY FOR DETERMINING THAT REASONABLE EFFORTS HAD BEEN MADE TO DETERMINE FAP ELIGIBILITY BEFORE ENGAGING IN ANY ECAS. THE CCP HAS BEEN REVISED TO [EXPLICITLY PROHIBIT THE HOSPITAL FROM ENGAGING IN ECAS / INCLUDE SUCH A DESCRIPTION].FINALLY, THE HOSPITAL HAS ADOPTED PROCEDURES THAT REQUIRE THE HOSPITAL TO REVIEW, ON A REGULAR BASIS, THE HOSPITAL'S POLICIES AND PROCEDURE TO ENSURE COMPLIANCE WITH THE REQUIREMENTS OF SECTION 501(R) AND THE REGULATIONS ISSUED THEREUNDER. THOSE PROCEDURES INCLUDE REVIEWING A SECTION 501(R) COMPLIANCE CHECKLIST.
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Attach to Form 990 or Form 990-EZ. 
Attach to Form 990 or 990-EZ.