Community Benefit Insight - Tax-exempt hospital

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Avera Holy Family

Avera Holy Family Health

826 N 8th Street
Estherville, IA 51334

Bed count	25	Medicare provider number	161351	Member of the Council of Teaching Hospitals	NO	Children's hospital	NO

EIN: 420680370

Display data for year:

Community Benefit Spending- 2021
(as % of functional expenses, which all tax-exempt organizations report on Form 990 Schedule H)

15.79%

Spending by Community Benefit Category- 2021
(as % of total functional expenses)

* = CBI denoted preventative categories

Community Benefit Spending Compared to Functional Expenses, 2010-2021

Additional data

Community Benefit Expenditures: 2021

All tax-exempt organizations file a Form 990 with the IRS for every tax year. If the tax-exempt organization operates one or more hospital facilities during the tax year, the organization must attach a Schedule H to Form 990. On Part I of Schedule H, the organization records the expenditures it made during the tax year for various types of community benefits; 9 types are shown on this web tool. By default, this web tool presents community benefit expenditures as a percentage of the organization’s functional expenses, which it reports on Form 990, Part IX, Line 25, Column A. (The more commonly heard term, ‘total operating expenses’, which organizations report to CMS, is generally about 90% of the ‘functional expenses’). The user may change the default to see the dollar expenditures.
Amount spent in the following IRS community benefit categories:

Financial Assistance at cost as % of operating expenses	$ 121,620 0.45 %
Medicaid as % of operating expenses	$ 375,836 1.38 %
Costs of other means-tested government programs as % of operating expenses	$ 0 0 %
Health professions education as % of operating expenses	$ 26,404 0.10 %
Subsidized health services as % of operating expenses	$ 3,638,481 13.41 %
Research as % of operating expenses	$ 0 0 %
Community health improvement services and community benefit operations* as % of operating expenses Note: these two community benefit categories are reported together on the Schedule H, part I, line 7e.	$ 14,051 0.05 %
Cash and in-kind contributions for community benefit* as % of operating expenses	$ 108,282 0.40 %
Community building* as % of operating expenses	$ 4,943 0.02 %

* = CBI denoted preventative categories

Community building activities details:

Did tax-exempt hospital report community building activities?	YES
Number of activities or programs (optional)	0
Physical improvements and housing	0
Economic development	0
Community support	0
Environmental improvements	0
Leadership development and training for community members	0
Coalition building	0
Community health improvement advocacy	0
Workforce development	0
Other	0
Persons served (optional)	0
Physical improvements and housing	0
Economic development	0
Community support	0
Environmental improvements	0
Leadership development and training for community members	0
Coalition building	0
Community health improvement advocacy	0
Workforce development	0
Other	0
Community building expense as % of operating expenses	$ 4,943 0.02 %
Physical improvements and housing as % of community building expenses	$ 0 0 %
Economic development as % of community building expenses	$ 4,943 100 %
Community support as % of community building expenses	$ 0 0 %
Environmental improvements as % of community building expenses	$ 0 0 %
Leadership development and training for community members as % of community building expenses	$ 0 0 %
Coalition building as % of community building expenses	$ 0 0 %
Community health improvement advocacy as % of community building expenses	$ 0 0 %
Workforce development as % of community building expenses	$ 0 0 %
Other as % of community building expenses	$ 0 0 %
Direct offsetting revenue	$ 0
Physical improvements and housing	$ 0
Economic development	$ 0
Community support	$ 0
Environmental improvements	$ 0
Leadership development and training for community members	$ 0
Coalition building	$ 0
Community health improvement advocacy	$ 0
Workforce development	$ 0
Other	$ 0

Other Useful Tax-exempt Hospital Information: 2021

In addition to community benefit and community building expenditures, the Schedule H worksheet includes sections on what percentage of bad debt can be attributable to patients eligible for financial assistance, and questions on the tax-exempt hospital's debt collection policy. When searching a specific tax-exempt hospital in this web tool, Section II provides information about bad debt and the financial assistance policy, and whether the state in which the tax-exempt hospital resides has expanded Medicaid coverage under the federal ACA.

Of the tax-exempt hospital’s overall operating expenses, amount reported as bad debt as % of operating expenses	$ 829,070 3.05 %
Is the tax-exempt hospital considered a "sole community hospital" under the Medicare program?	NO

Information about the tax-exempt hospital's Financial Assistance Policy and Debt Collection Policy
The Financial Assistance Policy section of Schedule H has changed over the years. The questions listed below reflect the questions on the 2009-2011 Schedule H forms and the answers tax-exempt hospitals provided for those years. The Financial Assistance Policy requirements were changed under the ACA. In the future, as the Community Benefit Insight web site is populated with 2021 data and subsequent years, the web tool will also be updated to reflect the new wording and requirements. In the meantime, if you have any questions about this section, we encourage you to contact your tax-exempt hospital directly.

Does the organization have a written financial assistance (charity care) policy?	YES
Did the tax-exempt hospital rely upon Federal Poverty Guidelines (FPG) to determine when to provide free or discounted care for patients?	YES
Amount of the tax-exempt hospital’s bad debt (at cost) attributed to patients eligible under the organization’s financial assistance (charity care) policy as % of operating expenses	$ 0 0 %

Did the tax-exempt hospital, or an authorized third party, take any of the following collection activities before determining whether the patient was eligible for financial assistance:
Under the ACA, states have the choice to expand Medicaid eligibility for their residents up to 138% of the federal poverty guidelines. The Medicaid expansion provision of the ACA did not go into effect until January 2014, so data in this web tool will not reflect each state's current Medicaid eligibility threshold. For up to date information, please visit the Terms and Glossary under the Resources tab.
The federal poverty guidelines (FPG) are set by the government and used to determine eligibility for many federal financial assistance programs. Tax-exempt hospitals often use FPG guidelines in their Financial Assistance policies to determine which patients will qualify for free or discounted care.
In addition to the federal requirements, some states have laws stipulating community benefit requirements as a result of tax-exemption. The laws vary from state to state and may require the tax-exempt hospitals to submit community benefit reports. Data on this web tool captures whether or not a state had a mandatory community benefit reporting law as of 2011. For more information, please see Community Benefit State Law Profiles Comparison at The Hilltop Institute.

Community Health Needs Assessment Activities: 2021

The ACA requires all 501(c)(3) tax-exempt hospitals to conduct a Community Health Needs Assessment (CHNA) every three years, starting with the hospital's tax year beginning after March 23, 2012. The 2011 Schedule H included an optional section of questions on the CHNA process. This web tool includes responses for those hospitals voluntary reporting this information. The web tool will be updated to reflect changes in these questions on the 2012 and subsequent Schedule H forms.

Did the tax-exempt hospital report that they had conducted a CHNA?	YES
Did the CHNA define the community served by the tax-exempt hospital?	YES
Did the CHNA consider input from individuals that represent the broad interests of the community served by the tax-exempt hospital?	YES
Did the tax-exempt hospital make the CHNA widely available (i.e. post online)?	YES
Did the tax-exempt hospital adopt an implementation strategy to address the community needs identified by the CHNA?	YES

Supplemental Information: 2021

This section presents qualitative information submitted by the hospital, verbatim from the 990H record.

Statement of Program Service Accomplishments
Description of the organization's program service accomplishments for each of its three largest program services, as measured by expenses. Section 501(c)(3) and 501(c)(4) organizations are required to report the amount of grants and allocations to others, the total expenses, and revenue, if any, for each program service reported.

4A (Expenses $ 25269727 including grants of $ 21134) (Revenue $ 29661432)
Avera Holy Family's mission is to provide healthcare services to Estherville, Iowa residents and residents of the surrounding area. Avera Holy Family is a 501(c)(3) organization affiliated with Avera Health. Avera Holy Family consists of a 22-bed critical access hospital and a clinic in Estherville, Iowa. The program services offered include primary care, general surgery, cardiac rehab, nuclear medicine, ICU, emergency, ultrasound, speech therapy, physical therapy and occupational therapy. Avera Holy Family provides acute care and long-term healthcare services. Following is a breakdown of these statistics by facility:Avera Holy Family Hospital338 Acute inpatient discharges134 Swing-bed patient discharges24,793 Outpatient visits907 Swing-bed patient days17,249 Clinic visitsAvera Holy Family maintains records to identify and monitor the level of charity care it provides. These records include the amount of charges forgone for services and supplies furnished under its charity care policy and equivalent service statistics. The amount of charges foregone, based on established rates, were $192,925.Avera Holy Family also provides community benefit health activities at less than or at no cost to support those in the area serviced, see Schedule H. As a member of the Avera Health Network, Avera Holy Family upholds the vision of the Presentation and Benedictine Sisters to work through collaboration to provide quality, effective health ministry and to improve the healthcare of individuals and our communities through a regionally integrated network of persons and institutions. Avera Holy Family engages in activities designed to improve the health of individuals and communities in response to a calling to heal the sick, the elderly, and the oppressed.

Facility Information

Schedule H (Form 990) Section C. Supplemental Information for Part V, Section B.

Avera Holy Family
Part V, Section B, Line 5: Avera Holy Family Hospital initiated community discussion groups and community health needs survey. Community input was gathered through community partners and service groups that represented the broad interests of the community. The process involved determining the participant's opinions on our community's strengths, weaknesses, resources, and improvements. All of those providing community input represent the interests of medically underserved populations and provided helpful information related to the needs of the community. The following organizations were represented in the process: * Emmet County Public Health* Avera Holy Family Medical Staff* Emmet County Wellness Coalition* Nursing Home Leaders* Fire, Law Enforcement, Ambulance and Support Services (FLEAS)

Avera Holy Family
"Part V, Section B, Line 11: Avera Holy Family conducted a community health needs assessment during FY2022. The assessment included a survey using the Survey Monkey tool. Approximately 282 community members completed the survey and respondent ages ranged from 19 to 80 plus years of age. The majority of the survey responses were in the 40-49 years age group. After review and analysis of the data and input from the community, many healthcare needs were identified. Information from community health data sets and input from community leaders was used to prioritize the community health needs identified. The priority areas to be addressed by Avera Holy Family include: Covid mitigation, access to mental health care, access to urgent/convenient healthcare, cardiovascular disease/hypertension, early detection of cancer and obesity.The following actions will be taken in future years to address the identified and prioritized community health needs:COVID MITIGATION*Continue to educate and inform patients and community members on latest COVID information*Collaborate and educate medical staff, employees, patients, and community members on new variants and need to get vaccines*Continue to work with people to show the continued concerns and health issues COVID presentsACCESS TO MENTAL HEALTH SERVICES*Promote awareness of mental health issues*Identify resources to address mental health concerns*Determine gaps in programs/services that address mental illnessACCESS TO URGENT/CONVENIENT HEALTH CARE SERVICES*Increase effort to recruit physicians and mid-level providers*Collaborate with medical staff to identify options for expanding services to allow more flexible and convenient hours of service to the community*Utilize locum providers to fill gapsCARDIOVASCULAR DISEASE/HYPERTENSION*Raise awareness of the factors that contribute to heart disease and measures to prevent disease*Ensure people at risk have access to diagnosis and appropriate treatment*Promote healthy eating and physical activity*Encourage smoking cessationEARLY DETECTION OF CANCER*Promote awareness of contributing factors and signs and symptoms of cancer*Encourage screening for early detectionOBESITY*Raise awareness of the impact of poor eating habits on health and wellness*Collaborate with Emmet County Public Health, Emmet County Wellness Coalition and other community partners to promote healthier eating habitsThe following needs were identified but will not be addressed for a variety of reasons:Low immunization rates- Competing priorities and projectsLack of access to dental care- Lack of professional resources and competing priorities and projectsLack of parenting skills- Better addressed by another community partnerAlcohol and drug abuse- Lack of professional resources, competing priorities and projectsAvera Holy Family continued to address the community health needs identified in the community health needs assessment completed in 2018. The following community health priority areas were identified and the following actions were taken during FY22.ACCESS TO MENTAL HEALTH CARE* Promote public awareness of mental health issuesFY2022 Update: Senior Life Solutions continued to work with organizations to promote mental health in elderly people. Senior Life Solutions also worked with promoting suicide awareness in the community and amongst hospital employees. * Identify resources to address mental health concerns FY2022 Update: Joined the Sioux Rivers Regional Mental Health area led by Beth Will.* Determine gaps in programs/services that address mental illnessFY2022 Update: Avera marketing joined the ""Just Ask the Question"" campaign to target suicide prevention.ACCESS TO URGENT/CONVENIENT HEALTHCARE* Collaborate with medical staff to determine options for expanding services to allow more flexible and convenient hours of service to the communityFY2022 Update: Continued Virtual Clinics for part of the year, added Locum providers to improve accessibility at Avera Medical Group EsthervilleCARDIOVASCULAR DISEASE/HYPERTENSION* Raise awareness of the factors that contribute to heart disease and measures to prevent diseaseFY2022: Continue to promote Planet Heart screenings. Started the Better Choices Better Health classes. Continued with Diabetic Education classes including virtual classes.* Ensure people at risk have access to diagnosis and appropriate treatment* Promote healthy eating and physical activity * Encourage smoking cessationFY2022 Update: Continued Diabetic Education as well as starting a Better Choices Better Health class to promote healthy eating. EARLY DETECTION OF CANCER* Promote awareness of contributing factors and signs and symptoms of cancerFY2022 Update: Focused on Breast Cancer Awareness month at the hospital with a ""Pink out"" theme which raised money to help patients that can't afford mammograms to get them done.* Encourage screening for early detection of cancer. OBESITY* Raise awareness regarding the impact obesity has on quality of life, incidence of disease and medical complications, and healthcare costs* Collaborate with Emmet County Public Health, Emmet County Wellness Coalition, and other community partners to promote physical activity and wellness * Raise awareness regarding the impact that poor eating habits have on health and wellness. * Collaborate with Emmet County Public Health, Emmett County Wellness Coalition and other community partners to promote healthier eating habits.Many of these activities are continuations of activities the hospital has been conducting related to the prior community health needs assessment."

Avera Holy Family
Part V, Section B, Line 13h: Presumptive charity care may be applied in situations where all other avenues of financial assistance have been exhausted. The facility has the discretion to weigh extenuating circumstances when determining eligibility for and the amount of charity care to provide.

Avera Holy Family
Part V, Section B, Line 16j: A summary of the financial assistance policy is posted in the Hospital facility's emergency rooms, waiting rooms, and admissions office and included in the billing statement. In addition, the financial assistance policy is discussed with the patient upon admission to the facility.

Avera Holy Family
Part V, Section B, Line 20e: If a patient is self-pay and has a large balance, an Avera patient advocate will help them apply for other forms of assistance. If they are not eligible for any other coverage, the patient is given a financial assistance application to complete and return to the facility.

Avera Holy Family
Part V, Section B, Line 24: The hospital financial assistance policy does not cover elective procedures. The hospital may have charged FAP eligible patients gross charges for services that are not covered under the financial assistance policy.

Schedule H, Part V, Section B, Line 7a, 7b and 10a:
avera.org/about/community-health-needs-assessments/#holy

Schedule H, Part V, Section A organization's website:
avera.org/locations/profile/avera-holy-family-hospital/

Schedule H, Part V, Section B, Lines 16a, 16b, and 16c:
avera.org/patients-visitors/charity-patient-assistance-programs/

Supplemental Information

Schedule H (Form 990) Part VI

Part I, Line 3c:
The methodology used to determine eligibility for financial assistance takes into consideration income, net assets, family size and resources available to pay for care. In addition, presumptive charity care may be applied in situations where all other avenues have been exhausted.

Part I, Line 7:
Charity care was converted to cost using an overall cost-to-charge ratio addressing all patient segments. Unreimbursed Medicaid was calculated using the costing methods to prepare the cost report. Subsidized health services were calculated based on a combination of the Medicare cost report and an overall cost-to-charge ratio for certain expenses. Community health improvement services, health professions education, and cash and in-kind contributions are reported based on actual expenses recorded to the general ledger.

Part I, Line 7g:
Provider based clinic costs are included in subsidized health services. Revenues of $2,183,701 and costs of $4,823,423 were included for a net community benefit of $2,684,722.

Part II, Community Building Activities:
The organization supports and donates to various community organizations focusing on issues impacting the community's health and safety.

Part III, Line 2:
The amount on line 2 represents implicit price concessions. The Organization determines its estimate of implicit price concessions based on its historical collection experience with the respective class of patients and residents.

Part III, Line 4:
The footnote to the Organization's financial statements that describes implicit price concession is located in the audited financial statement report on pages 19 and 20.

Part III, Line 8:
Avera Holy Family provides services to patients under the Medicare program knowing they may not recover all the costs associated with providing these services. Providing these services is essential to these patients and the community and increases their access to healthcare services. Therefore, in years the costs associated with services provided under the Medicare program are not completely covered, the Medicare shortfall is considered a community benefit. Medicare allowable costs of care are based on the Medicare cost report. The Medicare cost report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services.

Part III, Line 9b:
If the patient qualifies for the organization's financial assistance policy for low-income, uninsured patients and is cooperating with the organization with regard to efforts to settle an outstanding bill within current self-pay collection policy guidelines and timeframes, the organization or its agent shall not send, nor intimate that it will send, the unpaid bill to any outside collection agency. Avera organizations will allow all individuals 120 days from the first post discharge statement to apply for financial assistance before sending the uncollected account to an outside collection agency. Avera will provide the patient with a statement or final notice that contains a listing of the specific collection action(s) it intends to initiate, and a deadline after which they may be initiated no earlier than 30 days before action is initiated. If the patient qualifies for 100% charity care, no further bills will be sent. A letter will be sent instead indicating that the patient's bill has been completely forgiven.

Part VI, Line 2:
The hospital utilizes the Press Ganey patient Experience Survey to gather information about patients' perceptions of their care experiences. The survey helps us know how to improve care and services to better meet the needs of our community.The Professional Activities Committee of the Medical Staff meets eight times a year to discuss patient needs, evaluate care and services and identify opportunities to enhance care and services. The Medical Staff meets quarterly to discuss these same topics. The other duty of both of these parties is to ensure all providers who are considered for the Medical Staff have the proper credentials and training that are needed before voting to accept them as part of the organizations Medical Staff.The Critical Access CAH Committee meets quarterly to provide bi-annual policy review of all patient care policies. The CAH committee also approves new patient care and service policies and procedures while also evaluating care and services of patients.

Part VI, Line 3:
Uninsured patients who hold an inpatient status are counseled by a Patient Advocate to screen them for coverage eligibility and to assist in payer source enrollment. Those that are not eligible are provided a charity care application along with instructions on how to fill out the application. All patients receive statements that indicate who to contact should they need financial assistance. In addition, all patients receive a summary of financial assistance upon registration, as well as in their final statement. Should a patient contact Patient Financial Services and indicate inability to pay, they are transferred to a financial counselor to assist them with the financial assistance application process. Also, inpatient and same day surgery patients receive a brochure in their admissions packet. Pre-collection letters also include information regarding the financial assistance and uninsured programs.

Part VI, Line 4:
Avera Holy Family is a 22-bed critical access hospital in Estherville, Iowa. The primary service area is defined as Emmet County, Iowa, including the communities of Armstrong, Dolliver, Estherville, Gruver, Ringsted and Wallingford. Estherville is the county seat. According to the U.S. Census Bureau Quick Facts 2021 data, the estimated population of Emmet County as of July 1, 2021 is 9,321 and is predominately white at 94.0%. It is estimated that 22.2% of the population is 65 years and over. The median household income is $56,708 with a 10.2% poverty rate. Uninsured individuals under age 65 is estimated at 7.6%.

Part VI, Line 5:
The Organization's governing body is comprised of volunteer members who reside in the community. Medical staff privileges are extended to all qualified physicians in the community and are given final approval by the governing body. Surplus funds are reinvested in facilities to improve patient care. The Organization supports the free clinic in the community; conducts public health screenings; participates in community health fairs; provides health education to community and schools; conducts a lifestyle challenge for the community; donates to various community organizations and health care scholarships; provides tours for school children; utilizes telecare; provides preceptorships for students; and provides Meals on Wheels.

Part VI, Line 6:
Avera is a sponsored ministry of the Benedictine and Presentation Sisters. The communities in which Avera operates all have unique health and community benefit needs. In keeping with the Catholic Healthcare Association guidelines, each hospital strives to meet its community's identified needs. The corporate staff of Avera Health advocates for all members regarding community benefit related matters of state, regional and national importance.

Operating expenses	$ 27,141,163
Total amount spent on community benefits as % of operating expenses	$ 4,284,674 15.79 %