4A (Expenses $ 380750609 including grants of $ 261404) (Revenue $ 465919748)
See Schedule O.

Schedule H, Part V, Section B, Line 3E
The significant health needs are a prioritized description of the significant health needs of the community and identified through the CHNA.

Schedule H, Part V, Section B, Line 5 Facility A, 1
Facility A, 1 - BALTIMORE WASHINGTON MEDICAL CENTER, INC.. The CHNA used quantitative and qualitative methods and was designed to be as comprehensive as possible. No written comments on the previous CHNA were received to be incorporated into this CHNA. A community meeting sponsored by the Healthy Anne Arundel Coalition to discuss and prioritize the CHNA findings was attended by approximately 60 community members. Including county residents, business leaders, and community organizations. UM BWMC remains committed to assessing ongoing community trends and uses additional data compiled and available from public sources including but not limited to, United States Census Bureau, Maryland State Health Improvement Plan, Maryland Vital Statistics data, CDC Wonder database, Anne Arundel County Department of Health Report Card, and Anne Arundel County Public School System data. UM BWMC uses our Community Health Needs Assessment (CHNA) and internal data to continually assess ongoing trends and occurring locally, and address those needs on an ongoing basis. The Anne Arundel County Department of Health assisted with secondary data analysis, with the quantitative portion of the CHNA consisting of a data from local, state and federal data sources. This data also includes information from hard to reach portions of the population, such as domestic violence victims and homeless individuals. While much of the data on these subpopulations primarily came from police reports, Emergency Department (ED) data, and the public school system, focus groups and key informant interviews were used to solicit the thoughts and opinions of diverse Anne Arundel County residents including homeless youth, victims of violence, health care providers, social service providers and community leaders. Focus groups and key informant interviews were used to solicit the thoughts and opinions of diverse Anne Arundel County residents, health care providers, social service providers and community leaders. A total of eleven focus groups were conducted. The groups included representation from: UM BWMC and Luminis Health Anne Arundel Medical Center Emergency Department, Anne Arundel County Emergency Response personnel, low-income youth from public housing, behavioral health providers, domestic violence and sexual assault victims, senior citizens, Hispanic community members, human services providers and advocates, early childhood advocates, community health providers, aging and disabilities providers, Anne Arundel County Public Schools Pupil Personnel workers, Anne Arundel County Health Department senior staff, and criminal justice system representatives. The twenty-six informants that provided qualitative data for the report include: CEO, Luminis Health Anne Arundel Medical Center; CEO, University of Maryland Baltimore Washington Medical Center; Executive Director, Anne Arundel County Mental Health Agency; Director, Anne Arundel County Crisis Response; Clinical Director, Anne Arundel County Mental Health Agency; Domestic Violence Coordinator, Luminis Health Anne Arundel Medical Center; Director, Department of Social Services; Director, Anne Arundel County Department of Aging and Disabilities; Anne Arundel County Chief of Police; Executive Director, Community Health Agency; Executive Director, YWCA of Annapolis and Anne Arundel County; Executive Director, Alternate Education - Anne Arundel County Public Schools; Director, Anne Arundel County Transportation; Anne Arundel County Executive; Superintendent, Anne Arundel County Public Schools; Anne Arundel County Administrative Officer; County legislative leader; middle school ambassador; three domestic violence victims; Hispanic community leader; faith leader; public housing residents; formally homeless youth The joint Anne Arundel County CHNA that was conducted with other county organizations, provided a detailed profile of Anne Arundel County and illustrated the social determinants of health that impact residents. This report contains detailed narratives, tables, graphs and maps. Where possible, comparisons were made to state and national data, and data was extracted by age, gender, race, ethnicity, and zip code. UM BWMC then used the joint Anne Arundel County CHNA to develop a detailed hospital CHNA with additional commentary and analysis specific to UM BWMC and the community we serve. When using the CHNA data to determine the hospital's community benefit priorities, UM BWMC consulted with the medical center's administrative and clinical leadership, state and local health and social service officials, other health care providers and community members. UM BWMC's community health improvement priorities align with the Maryland State Health Improvement Process and the priorities of our local health improvement coalition, the Healthy Anne Arundel Coalition.

Schedule H, Part V, Section B, Line 6a Facility A, 1
Facility A, 1 - BALTIMORE WASHINGTON MEDICAL CENTER, INC.. THE OTHER HOSPITAL FACILITY WITH WHICH THE REPORTING HOSPITAL FACILITY CONDUCTED ITS CHNA IS: - Luminis Health Anne Arundel Medical Center

Schedule H, Part V, Section B, Line 6b Facility A, 1
Facility A, 1 - BALTIMORE WASHINGTON MEDICAL CENTER, INC.. Anne Arundel County Department of Health Anne Arundel County Mental Health Agency, Inc. Anne Arundel County Partnership for Children, Youth and Families Community Foundation of Anne Arundel County Healthy Anne Arundel Coalition YWCA of Annapolis and Anne Arundel County

Schedule H, Part V, Section B, Line 7 Facility A, 1
Facility A, 1 - BALTIMORE WASHINGTON MEDICAL CENTER, INC.. UM BWMC's CHNA report is made widely available to the public. The CHNA is posted on the hospital's web site at www.umbwmc.org/community/assessment-plan. This link allows the viewer to download the UM BWMC Community Health Needs Assessment report that summarizes the Anne Arundel County Community Health Needs Assessment and prioritizes the identified community health needs. The Anne Arundel County Community Health Needs Assessment is also available for download. Paper copies of CHNA documents are available upon request. The Healthy Anne Arundel Coalition helped to make the Anne Arundel County CHNA report widely available to the public. The Healthy Anne Arundel Coalition hosted a meeting in February 2019 to present and discuss the countywide CHNA findings. Approximately sixty area professionals and community members attended. A website was developed to share the county-wide CHNA results (www.aahealth.org/chna) and it was promoted on the Coalition Facebook page. Other Coalition members also used their websites and social media to promote the release of the CHNA and key findings. Additionally, a press release was issued and generated several news stories.

Schedule H, Part V, Section B, Line 11 Facility A, 1
"Facility A, 1 - BALTIMORE WASHINGTON MEDICAL CENTER, INC.. UM BWMC remains committed to assessing ongoing community trends and uses data compiled and available from public sources including but limited to, United States Census Bureau, Maryland State Health Improvement Plan, Maryland Vital Statistics data, CDC Wonder database, Anne Arundel County Department of Health Report Card, and Anne Arundel County Public School System data. In addition to current UM BWMC hospital data. While conducting this CHNA, UM BWMC took a multi-pronged approach to reviewing data with hospital faculty allowing for prioritization of our local community health needs, and development of a comprehensive Community Benefit Implementation Plan with strategies to address the significant needs identified in the CHNA. This approach helped to assure that our Community Benefit Implementation Plan addresses the most significant needs identified in the CHNA, while also being aligned with UMMS community health improvement initiatives, and national, state and local public health priorities. The plan was also developed to be responsive to Maryland's health system transformation, included the increase focus on population health and community partnerships. This approach also helped to assure that we had the necessary infrastructure and resources to successfully implement our Implementation Plan. Our planning process resulted in the following community benefit strategic priorities being identified for UM BWMC's FY2020-2022 Community Benefit Implementation Plan. These priorities include: Chronic Health Conditions (Cancer, Cardiovascular Disease, Diabetes, Obesity/Overweight, and Chronic Lower Respiratory Diseases); Behavioral Health; Maternal and Child Health; Health Care Access and Utilization; and Healthy and Safe Social Environments. An overarching theme in this CHNA is the reduction of health disparities among vulnerable populations. UM BWMC's FY2020-2022 Community Benefit Implementation Plan can be downloaded from www.umbwmc.org/community/assessment-plan. It provides an overview of community benefit at UM BWMC, a summary of the CHNA, the process used to prioritize community health needs, and a description of the goals, strategies, key partners, and intended outcomes for each of our identified community benefit priorities. UM BWMC focuses the majority of our community benefit resources on our identified implementation strategies, as these areas are important to the health of the community, and UM BWMC has the expertise and resources to support these priorities directly through existing infrastructure. Below are some of the highlights of UM BWMC's FY22 initiatives that support these priorities: Stork's Nest: Stork's Nest is a prenatal education program that offers several sessions a year in English and Spanish. Any pregnant Anne Arundel County resident is eligible to participate; however, the program targets pregnant women at the greatest risk for having poor pregnancy outcomes, specifically African American women, teenagers, women of low socioeconomic status, and women with previous poor pregnancy outcomes. Participants earn points by attending classes, going to prenatal care appointments and adopting health behaviors. Participants continue to earn points until their baby turns one year old by attending well-baby checkups. Points can be used to ""purchase"" pregnancy and infant care items at the Stork's Nest Store until their baby turns 18-months old. In FY22, 53 Anne Arundel County women participated in the Stork's Nest program, with each receiving a pack and play and safe sleep kit (crib sheets, sleep sack, and education materials) to give babies a safe sleep environment in the attempt to reduce sleep related infant deaths in Anne Arundel County. Due to the ongoing COVID-19 pandemic, all classes from July 2021-March 2022 were held virtually, with curbside shopping available for participants to receive needed baby items. Flu Education and Prevention: UM BWMC provide free community flu vaccinations to 400 county residents in FY22. Education and outreach regarding the importance of receiving a influenza vaccine, prevention of disease transmission/self-care, and hand hygiene education was also provided. Mobile COVID-19 Vaccination Program: In FY22, UM BWMC continued to respond to the pandemic by helping to increase access to COVID-19 vaccinations throughout the county. Partnering with different local churches, organizations, community centers, schools, and businesses, UM BWMC provided 1,213 doses of the vaccine through its mobile vaccination program, meeting community members where they are. Community Wellness Day: In April 2022, UM BWMC hosted its first community wellness days. The event welcomed 265 community members to receive free health education, screenings, COVID-19 vaccinations, free fresh produce boxes and free healthy lunches. Free Screening Programs: In FY22, UM BWMC provided a number of free screening opportunities to our most vulnerable residents to provide broader access to health care services. Vascular screenings, which included screenings for carotid artery, peripheral artery disease, and abdominal aortic aneurysm, were provided to 185 community members over the age of 55. A breast cancer screening, that included both a clinical exam and mammograms were provided to 20 women. Physician Subsidies: Subsidies for behavioral health - including addiction medicine and inpatient psychiatric care, primary and senior care, diabetes care, women's health services, cardiology, pulmonary, Transitional Care Center, and emergency services of emergency department care in urology, general surgery, orthopedic surgery, neuro surgery, as well as services for victims of crimes in our emergency department, are all subsidized services to ensure access to care in our community. The need for these services is documented in our CHNA report. UM BWMC is committed to support the advancement of community health initiatives identified through the CHNA, and while many priorities are beyond the scope of what UM BWMC can provide, we will provide resources in the following areas as feasible. Affordable dental services: While UM BWMC does not have a dental clinic or routine dental care at this time, we do refer patients to low-cost clinics for care. We subsidized oral surgery on-call services and have oral surgeons on our medical staff. UM BWMC partners with the Anne Arundel County Health Department to divert dental patients presenting in the ED to providers in the community. Care coordination will be provided to prevent repeat ED visits. Environmental health concerns: Environmental health concerns are being addressed by the Anne Arundel County Health Department's Bureau of Environmental Health Services and other local environmental advocacy organizations. Public Transportation: While public transportation and bus line access is not in the scope of services that UM BWMC can provide, it is being addressed by County and State officials. UM BWMC does provide some transportation assistance to patients and participants of classes. Lyft, Uber, bus tokens, and taxi fees are covered for some patients in need through our Care Management Program. This program also helps to cover the cost of transportation assistance to rehabilitation and care facilities. We also provide transportation to participants in our Stork's Nest pre-natal education program. Other needs identified in the CHNA include affordable housing, homelessness, and gun violence. UM BWMC will support these priorities through participation in economic development initiatives and community building activities, and health profession training designed to help improve the socioeconomic climate and overall wellbeing of individuals and the local community. Through the initiatives mentioned above as well as those outlined in the CHNA Implementation Plan, UM BWMC is addressing each of the prioritized needs identified in its most recent CHNA."

Schedule H, Part V, Section B, Line 13 Facility A, 1
Facility A, 1 - BALTIMORE WASHINGTON MEDICAL CENTER, INC.. THE FINANCIAL ASSISTANCE POLICY EXPLAINS SEVERAL ELIGIBILITY CRITERIA, INCLUDING PARTICIPATION IN MEDICAID/MEDICARE PROGRAMS AS WELL AS ELIGIBILITY UNDER VARIOUS STATE REGULATIONS. IN ADDITION TO FPG, THE INCOME LEVELS DEFINED BY THE MARYLAND STATE DEPARTMENT OF HEALTH AND MENTAL HYGIENE (MD DHMH) ARE USED TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE. THE MD DHMH INCOME LEVELS ARE MORE GENEROUS THAN THE FPG INCOME LEVELS.

Schedule H, Part I, Line 3c CRITERIA FOR FREE OR DISCOUNTED CARE
BWMC IS COMMITTED TO PROVIDING FINANCIAL ASSISTANCE TO PERSONS 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. IN ADDITION TO FPG, THE INCOME LEVELS DEFINED BY THE MARYLAND STATE DEPARTMENT OF HEALTH AND MENTAL HYGIENE (MD DHMH) ARE USED TO DETERMINE ELIGIBILITY FOR FINANCIAL ASSISTANCE. THE MD DHMH INCOME LEVELS ARE MORE GENEROUS THAT THE FPG INCOME LEVELS. THE FAP ALSO USES A FINANCIAL HARDSHIP THRESHOLD WHEN DETERMINING ELIGIBILITY. A PATIENT WITH MEDICAL DEBT EXCEEDING 25% OF FAMILY ANNUAL HOUSEHOLD INCOME MAY BE ELIGIBLE FOR FINANCIAL ASSISTANCE.

Schedule H, Part I, Line 6b RELATED ORGANIZATION REPORT
THE ORGANIZATION ANNUALLY FILES A COMMUNITY BENEFIT REPORT AS REQUIRED BY THE MARYLAND HSCRC. THE REPORT CAN BE FOUND AT HTTPS://HSCRC.STATE.MD.US/PAGES/INIT_CB.ASPX.

Schedule H, Part VI, Line 4 Community Information
The following is a summary description of the community that UM BWMC serves as described in our Community Health Needs Assessment and Community Benefit Implementation Plan. A more detailed description, including maps and data tables, can be found in our full CHNA report available at www.umbwmc.org/community/assessment-plan. UM BWMC considers our Community Benefit Service Area (CBSA) to be the Anne Arundel County portions of our primary and secondary service area as defined by our Global Budget Revenue Agreement with the Maryland Health Services Cost Review Commission. These zip codes include: 21060- Glen Burnie, 21061- Glen Burnie, 21122- Pasadena, 21144- Severn, 21225- Brooklyn Park, 21054- Gambrills, 21076- Hanover, 21090- Linthicum Heights, 21108- Millersville, 21113- Odenton, 21146- Severna Park. The primary service area surrounding UM BWMC where most of our discharges originate has some of the most vulnerable, high-risk residents in Anne Arundel County based on socioeconomic and health data. We make concerted efforts to reach vulnerable, at-risk populations, including uninsured, racial/ethnic minorities, persons with risky health behaviors (e.g. smoking), and people with chronic health conditions (e.g. diabetes, cancer). Zip codes in our secondary service area have more localized pockets of community health needs. According to 2016 census estimates, the Anne Arundel County population is 537,656. The Hispanic population in Anne Arundel County is growing more significantly than all races/ethnicities, increase 205% from 2000-2016. Currently, 13.4% of Anne Arundel's population is age 65 and older. This portion of the population is expected to increase until 2030. As such, seniors will have an increasing impact on county services, supports, resource allocation, and health care use. The number of Medicare beneficiaries is rising in the county as a result of the growing senior population. The county has severed about 3,000 new beneficiaries in the last three years. The number who are eligible for Medicaid, dur to low income, rose from 10.9 percent to 11.3 percent in three years. The income gap between rich and poor in the county has widened since 2010. Anne Arundel County's median household income is $99,652, which is 19% higher than Maryland and 65% more than the nation. Poverty is concentrated in the northern (near UM BWMC) and southern portions of the county. The highest percentage of poverty is in the zip code that contains Brooklyn Park, 21225, at a staggering 27.3 percent, followed by Curtis Bay. Both are areas that border Baltimore City. Social determinants of health can impact individuals and community health. Social determinants of health include race and ethnicity, employment status and income level, education, housing quality, neighborhood safety, family and social supports, and sense of community and belonging. Many demographic and health indicators associated with poorer health status and outcomes are found in the northern (near UM BWMC) and southern portions of the county, and parts of Annapolis. When patterns of hospitalizations and emergency department visits are examined by zip code, they generally reflect the social determinants illustrated above. Zip code 21225, which contains Brooklyn Park, has the highest hospitalization and emergency department visits in the county. There are a variety of needs concerning social determinants of health. There is a lack of public transportation throughout Anne Arundel County, and the operating bus routes have limited hours. This is especially an issue for the county's low-income and elderly residents. Limited transportation affects residents' ability to access health care services and their educational and employment options. Thirteen percent of county residents live in areas considered food deserts and don't have access to healthy eating options which contributes to higher levels of obesity and associated chronic health conditions such as diabetes. Affordable, quality child care is in scarce supply. There is limited affordable housing in the county, and homelessness has been increasing. The amount of money spent on housing limits the funds available for meeting other personal needs, including health care, health food, and opportunities for physical activity and recreational activities that could reduce weight and stress. Anne Arundel County is served by two major hospitals: University of Maryland Baltimore Washington Medical Center (UM BWMC) and Luminis Health Anne Arundel Medical Center (AAMC) in Annapolis. MedStar Harbor Hospital, which is located just north of the county line in Baltimore City, also serves county residents. However, the medical-surgical services available at Harbor Hospital have been declining over recent years, although an inpatient Behavioral Health service was added. Additionally, there are four Federally Qualified Health Centers (FQHCs) that service county residents: Chase Brexton Health Care (Glen Burnie), Total Health Care (Odenton), Family Health Centers of Baltimore (Brooklyn), and Bay Community Health (West River area in South County). Chase Brexton Health Care is located across the street from UM BWMC and we have a formal partnership agreement with them. We also collaborate with Total Health Care. The Anne Arundel County Department of Health offers a range of physical and behavioral health services at multiple clinic sites throughout the county. The Anne Arundel County Mental Health Agency, Inc. provides a wide range of mental health services to Medicaid recipients and other low-income and uninsured county residents who meet certain criteria. Other health care services available in the county include primary care practices, outpatient specialty care, community clinics, urgent care facilities and retail store-based health clinics. Many providers of health care offer financial assistance. All hospitals in Maryland have financial assistance policies that provide medically necessary services to all people regardless of their ability to pay. Depending on their circumstances, patients can receive coverage for up to 100% of their medically necessary care. Payment plans are also available. FQHCs, community clinics and governmental providers offer services on a sliding scale or free basis. Assistance with enrolling in publicly funded entitlement programs and health insurance plans through the state health benefit exchange are available from the hospitals, county health departments, social service agencies and the Maryland Health Connection. However, it is important to note that note all health care providers, particularly behavioral health providers, accept all insurance plans or self-pay patients. In Maryland, under the Affordable Care Act (ACA), persons whose income is up to 138% of the poverty level are eligible for Medicaid. The number of Medicaid enrollments increased from 84,616 in 2014 to 93,425 in May 2018, a 10 percent increase. However, there are still many primary care providers who do not accept Medicare/Medicaid. In addition, a small percentage of county residents such as undocumented people and those not enrolled in Medicaid despite being eligible, will remain uninsured. Access to primary care physicians, dentists, and mental health services are demonstrated needs within the county. Having a primary care provided reduces nonfinancial barriers to obtaining care, facilitates access to services, and increases the frequency of contacts with health care providers. Without a primary care provider, people have more difficulty obtaining prescriptions and attending necessary appointments. In 2016, 9.6 percent of emergency department visits were by uninsured residents. Although not all visits to the emergency department are avoidable, care in lower level settings for some conditions, such as diabetes and hypertension, can potentially reduce the number of visits, thereby reducing costs and increasing the quality of care. In 2017, there were 59,277 hospital stays in Anne Arundel County; a rate of 104.3 stays per thousand population. The hospitalization rate increased with age from 68.7 hospitalizations per 1,000 population among 0-18 year old's, to 262.5 hospitalizations per 1,000 population among those aged 65 years and over. It should be noted that this data only includes Anne Arundel County residents admitted to hospitals in Maryland. The rate changes depending on zip code. The zip code containing Brooklyn Park, 21225, has the highest rate of hospitalization at 163.9 per 1,000 residents. The Glen Burnie rates are also notable when population density is considered. These three zip codes are in UM BWMC's primary service area. Lack of access to primary care, multiple health issues presenting at the same time, poverty, unhealthy food and lack of medication management were reasons given for the high rates.

Schedule H, Part VI, Line 4 Community Information Cont
"In 2016, there were 4,380 deaths in Anne Arundel County, and life expectancy was 79.6 years. Accidental (unintentional injury) deaths rose to the fourth leading cause of death, driven by increases in opioid overdose deaths. Cancer was the leading cause of death, although this number has seen a 1 percent decrease since 2013. Overweight and obesity continue to drive poor health outcomes from the county, including secondary issues such as diabetes. Diabetes was the sixth leading cause of death. Heart disease accounts for 22 percent or 974 of all county deaths as of 2016. That number has risen almost 10 percent since 2013. Age-adjusted rates for coronary heart disease decreased for African American/Black and White residents between 2013 and 2016. While the Black population still has the highest death rates in the county per 100,000 residents, that number decreased by 18 percent in just three years. The decrease for White residents was only 8 percent. Several chronic somatic health conditions were identified in the CHNA as community health needs including cardiovascular disease, cancer, diabetes, and respiratory disease. Overweight and obesity are risk factors for many chronic health conditions, and was also identified as a community health problem. Overweight and obesity are determined using weight and height to determine BWI or ""body mass index"" measure. Between 2012 and 2016, the percent of overweight adults aged 18 and over with a body mass index of 25 to 29.9, rose slightly from 36.7 to 37.2 percent, while the state average fell. The percent of county residents who are classified as obese and have a body mass index of 30 and over, also rose from 27 to 31 percent, as did the state average. Many factors play a role in weight including being of a lower income, lifestyle, surrounding environment, access to health foods, genetics, and certain diseases. Obesity is prevalent in low income families in the county for a variety of reasons: their neighborhoods often lack full-service grocery stores and farmer's markets, healthy food can be more expensive, there is a lack of transportation to get to a grocery store, there is a greater availability of fast food restaurants that are selling cheap and filling food, and there are fewer recreational facilities for exercise. Many of the streets in these neighborhoods also tend to be unsafe and have little for children to do. Smoking is associated with an increased risk of heart disease, stroke, lung and other types of cancers, and chronic lung disease (Centers for Disease Control, 2018). The rate of adult tobacco use has continued to drop in the country and now is equal to the state and less than the nation. According to the 2016 Middle School Risk Behavior Survey, cigarette smoking by Anne Arundel Middle School students is trending significantly downwards. However, many participants commented on the increased use of e-cigarettes and vaping, in and outside of the school gates. UM BWMC clinical staff have identified cardiovascular disease, cancer, diabetes, and respiratory disease as a particular concern to the UM BWMC service area. This diagnosis has a significant contribution to emergency department utilization, hospital admissions, and hospital readmissions. Co-morbid chronic conditions are common in the hospital's patient population. The rise in behavioral health issues for every age group, and the lack of appropriate services and service providers (e.g. psychiatrists, crisis beds, residential services), were the major concern for all participants in the CHNA. These issues are exacerbated by providers who don't accept Medicaid and Medicare, and patients with inadequate health insurance, or no insurance at all. Participants in the CHNA focus groups shared many opinions as to why mental health issues are increasing including, poverty, isolation, social media, increasing societal violence, the fast pace of technology and the reduction of stigma around mental health services. The county's hospital emergency departments are often the receiving facilities for behavioral health issues. In 2017, there were 12,446 behavioral health encounters; mood disorders accounted for 26.3 percent of encounters, and over 38 percent were alcohol or substance abuse related. Increased behavioral issues in the birth to five early childhood population are causing widespread concern in every system. Behavioral problems in children as young as two years old are disrupting child care facilities including Early Head Start and Head Start. Professionals are divided as to the cause of this increase but they all agree that this is a new phenomenon unrelated to income. Many suggested the use of social media by parents and young children is leading to huge deficits in social and emotional skills. Some serious mental health issues are surfacing earlier; often co-occurring with developmental issues such as autism. The number of crisis interventions in the public school system for social and emotional issues has doubled since 2013, reaching close to 5,000 during the 2016-2017 school year. As of 2016, the Anne Arundel County youth suicide rate was 7.8 per 100,000, an increase compared to the rate of 5.3 per 100,000 in 2012. The Centers for Disease Control and Prevention (CDC) estimates that for each youth suicide, there are 25 suicide attempts. Between 2012 and 2016, there were 1,306 emergency department encounters in Maryland hospitals for suicide attempts by Anne Arundel County youth aged 0-24 years, and average of 261 per year. It was noted in the CHNA focus groups that the constant access to electronic information, devices, and social apps like Instagram and Snap Chat, is impacting every age group and demographic with increases in bullying, suicide, and suicide ideation for youth. Prescription opioid addiction is now a major public health crisis. Although Anne Arundel County is the fifth largest county in the state in terms of population, it has the third highest rate of prescription opioid related deaths as of 2017. In 2017, Anne Arundel County police reported almost 1,100 opioid-related overdoses occurring, a 171 percent increase since 2014. The rate of fatal overdoses continues to increase, driven by the introduction of fentanyl into the community. Fentanyl-related deaths in the county have increase significantly since 2013 and surpassed heroin related deaths through 2017. As with many other county issues, geography plays a part with the majority of overdoses occurring in the northern portion of the county and Annapolis. The infant mortality rate in Anne Arundel County between 2010 and 2014 was 5.5 deaths per 1,000 live births, which is lower than both the United States and Maryland rates during the same period. Although the overall infant mortality rate is lower for the county than the state average, disparities exist when stratifying the data by race and ethnicity. Black infants have the highest infant mortality rate in the county (11.2 deaths per 1,000 live births) compared to 5.3 deaths and 4.0 deaths per 1,000 births for Hispanic and White infants respectively. Low birth weight (LBW), defined as less than 2,500 grams) is the single most important factor affection neonatal mortality (newborn infants up to 28 days old) and a significant determinants of post neonatal mortality (infant between 28 and 364 days old). Infants who are born at a LBW run the risk of developing health issues ranging from respiratory disorders to neurodevelopmental disabilities. In Anne Arundel County, the percentage of LBW babies is dropping slowly and is less than the sate average at 8.7%. However, there are several zip codes concentrated in the northern part of the county where the percentages of LWB infants is much higher than the overall county average of 7.9%, especially in Brooklyn, Severn, Laurel, Glen Burnie (West), Hanover, Millersville, and Jessup. Five of these zip codes are within the UM BWMC primary service area. Anne Arundel County Police Department tracks domestic violence statistics. The data shows an upward trend although there was a dip in numbers for the 2015-2016 year. In the first six months of 2018, there were just over 1,000 assaults, which confirms the police, schools, and hospital personnel who identified a notable increase in domestic violence over the same period. The CHNA also identified a rise in youth gang activity, particularly in the Annapolis area and the western part of the county."

Schedule H, Part VI, Line 4 Community Information Cont
"In 2018, the county's Child Advocacy Center investigated 326 sexual abuse cases, of which seven were for sexual assault. The 50-mile radius surrounding BWI airport is becoming known as the third-most-lucrative area in the nation for trafficking in people (Maryland Human Trafficking Taskforce, 2018). Anne Arundel County Police Department tracks the number of sex trafficking incidents in the county. While the numbers were stable between 2015 and 2017, data for the first 6 months of 2018 are showing an almost 100 percent increase in cases with 18 cases during that timeframe. UM BWMC has identified and treated sex trafficking victims in its emergency department. In the 2016 State of the Bay Report from the Chesapeake Bay Foundation, it showed that each of the three indicator categories - pollution, habitat, and fisheries have improved since 2014. However, despite many efforts by federal, state, and local governments and other interested parties, pollution in the Bay does not meet existing water quality standards. All of the county's waterways are considered ""impaired"" because of excessive levels of major contaminants, which are largely a result of untreated storm water runoff. Air quality is another issue for the county. Anne Arundel was given an F by the American Lung Association in 2018 for an average of 13 high ozone days, a reduction from the 2013 rate of 23 days. High ozone causes respiratory harm (e.g. worsened asthma, worsened COPD, inflammation) and can cause cardiovascular harm (e.g. heart attacks, strokes, heart disease, congestive heart failure) and may cause hard to the central nervous system."

Schedule H, Part I, Line 7 Bad Debt Expense excluded from financial assistance calculation
19384996

Schedule H, Part I, Line 7 Costing Methodology used to calculate financial assistance
Maryland's regulatory system creates a unique process for hospital payment that differs from the rest of the nation. The Health Services Cost Review Commission, (HSCRC) determines payment through a rate setting process and all payors, including governmental payors, pay the same amount for the same services delivered at the same hospital. Maryland's unique all payor system includes a method for referencing Uncompensated Care in each payors' rates, which does not enable Maryland hospitals to breakout any offsetting revenue related to Uncompensated Care. Community benefit expenses are equal to Medicaid revenues in Maryland, as such, the net effect is zero. Additionally, net revenues for Medicaid should reflect the full impact on the hospital of its share of the Medicaid assessment.

Schedule H, Part II Community Building Activities
Through a variety of community building activities, UM BWMC promotes health and wellness in the community that it serves. These activities include community support, coalition building, and community health improvement advocacy. UM BWMC provides leadership to many community collations and collaborative partnerships to improve community health and health care access. UM BWMC is an active participant in the Healthy Anne Arundel Coalition. This coalition is a partnership of public sector agencies, health care providers and payers, community-based partners, the business community and academic institutions, as well as community members that are advocating for better health. Other community coalitions that UM BWMC plays and active role in include: Conquer Cancer Coalition, Fetal and Infant Mortality Review Team, Fort Meade Alliance, Community of Hope Brooklyn Park, YWCA, Anne Arundel County Multi-D for Substance Exposed Newborns, Anne Arundel County Guardianship Review Board, Judy Center Steering Committee, and Glen Burnie Revitalization Task Force. All of these committees and coalitions are collaborative efforts to address health issues and advocate for policies and programs that improve the health in the communities that we serve. In FY22, UM BWMC continued its response to the COVID-19 pandemic with helping to increase access to vaccinations in the county. Partnering with different community organizations, community centers, local churches, schools, and businesses, UM BWMC provided 1,213 doses of vaccine through its mobile vaccination program. Meeting community members where they were and reducing the barrier of transportation. UM BWMC also able to disburse 400 doses of flu vaccine into the community at free vaccination clinics held throughout Anne Arundel County. Through work with community partners such as Advanced Radiology, UM BWMC was able to provide 20 free clinical breast exams and mammograms to women in Anne Arundel County that were under or uninsured, and provide appropriate follow up care at low or no cost for women that needed additional testing. Throughout FY22, UM BWMC supported the ongoing needs of the community by working with the University of Maryland Medical System and the Let's Talk About Health Series, to offer monthly education sessions that ranged in topic fall's prevention and healthy aging, to long-COVID and pharmacy and medication management. All presentations are an effort to increase access to reliable and accurate health information, and to increase health literacy and communication with individuals health care providers using the Ask Me 3 program - what is my main problem, what do I need to do, what is it important for me to do this.

Schedule H, Part III, Line 3 Bad Debt Expense Methodology
BECAUSE OF THE UNIQUE PAYMENT SYSTEM DESCRIBED ON LINE 2 (ABOVE), THE HOSPITAL IS UNABLE TO ESTIMATE HOW MUCH OF THE AMOUNT REPORTED IN LINE 2 IS ATTRIBUTED TO PATIENTS WHO WOULD APPLY UNDER THE FAP.

Schedule H, Part III, Line 8 Community benefit & methodology for determining medicare costs
THE ORGANIZATION FILES ANNUALLY A COMMUNITY BENEFIT REPORT WITH THE STATE OF MARYLAND'S HEALTH SERVICES COST REVIEW COMMISSION (HSCRC). THE HSCRC, WHICH OPERATES UNDER A MEDICARE WAIVER, DOES NOT CONSIDER MEDICARE SHORTFALL AS COMMUNITY BENEFIT. THE COSTING METHODOLOGY USED BY THE ORGANIZATION IS A COST-TO-CHARGE RATIO.

Schedule H, Part III, Line 2 Bad debt expense - methodology used to estimate amount
THE HEALTH SERVICES COST REVIEW COMMISSION (HSCRC) STARTED SETTING HOSPITAL RATES IN 1974. AT THAT TIME, THE HSCRC APPROVED RATES APPLIED ONLY TO COMMERCIAL INSURERS. IN 1977, THE HSCRC NEGOTIATED A WAIVER FROM MEDICARE HOSPITAL PAYMENT RULES FOR MARYLAND HOSPITALS TO BRING THE FEDERAL MEDICARE PAYMENTS UNDER HSCRC CONTROL. IN 2014, MARYLAND'S WAIVER WITH MEDICARE WAS RENEGOTIATED AND UPDATED TO REFLECT THE CURRENT HEALTHCARE ENVIRONMENT. UNDER THIS NEW WAIVER, SEVERAL CRITERIA WERE ESTABLISHED TO MONITOR THE SUCCESS OF THE SYSTEM IN CONTROLLING HEALTHCARE COSTS AND THE CONTINUANCE OF THE WAIVER ITSELF: 1. REVENUE GROWTH PER CAPITA 2. MEDICARE HOSPITAL REVENUE PER BENEFICIARY 3. MEDICARE ALL PROVIDER REVENUE GROWTH PER BENEFICIARY 4. MEDICARE READMISSION RATES 5. HOSPITAL ACQUIRED CONDITION RATE

Schedule H, Part III, Line 4 Bad debt expense - financial statement footnote
THE CORPORATION RECORDS REVENUES AND ACCOUNTS RECEIVABLE FROM PATIENTS AND THIRD-PARTY PAYORS AT THEIR ESTIMATED NET REALIZABLE VALUE. REVENUE IS REDUCED FOR ANTICIPATED DISCOUNTS UNDER CONTRACTUAL ARRANGEMENTS AND FOR CHARITY CARE. AN ESTIMATED PROVISION FOR BAD DEBTS IS RECORDED IN THE PERIOD THE RELATED SERVICES ARE PROVIDED BASED UPON ANTICIPATED UNCOMPENSATED CARE, AND IS ADJUSTED AS ADDITIONAL INFORMATION BECOMES AVAILABLE. THE PROVISION FOR BAD DEBTS IS BASED UPON MANAGEMENT'S ASSESSMENT OF HISTORICAL AND EXPECTED NET COLLECTIONS CONSIDERING HISTORICAL BUSINESS AND ECONOMIC CONDITIONS, TRENDS IN HEALTHCARE COVERAGE, AND OTHER COLLECTION INDICATORS. PERIODICALLY THROUGHOUT THE YEAR, MANAGEMENT ASSESSES THE ADEQUACY OF THE ALLOWANCE FOR UNCOLLECTIBLE ACCOUNTS BASED UPON HISTORICAL WRITE-OFF EXPERIENCE BY PAYOR CATEGORY. THE RESULTS OF THIS REVIEW ARE THEN USED TO MAKE MODIFICATIONS TO THE PROVISION FOR BAD EBTS AND TO ESTABLISH AN ALLOWANCE FOR UNCOLLECTIBLE RECEIVABLES. AFTER COLLECTION OF AMOUNTS DUE FROM INSURERS, THE CORPORATION FOLLOWS INTERNAL GUIDELINES FOR PLACING CERTAIN PAST DUE BALANCES WITH COLLECTION AGENCIES. FOR RECEIVABLES ASSOCIATED WITH SERVICES PROVIDED TO PATIENTS WHO HAVE THIRD-PARTY COVERAGE, THE CORPORATION ANALYZES CONTRACTUALLY DUE AMOUNTS AND PROVIDES AN ALLOWANCE FOR BAD DEBTS, ALLOWANCE FOR CONTRACTUAL ADJUSTMENTS, PROVISION FOR BAD DEBTS, AND CONTRACTUAL ADJUSTMENTS ON ACCOUNTS FOR WHICH THE THIRD-PARTY PAYOR HAS NOT YET PAID OR FOR PAYORS WHO ARE KNOWN TO BE HAVING FINANCIAL DIFFICULTIES THAT MAKE THE REALIZATION OF AMOUNTS DUE UNLIKELY. FOR RECEIVABLES ASSOCIATED WITH SELF-PAY PATIENTS OR WITH BALANCES REMAINING AFTER THE THIRD-PARTY COVERAGE HAD ALREADY PAID, THE CORPORATION RECORDS A SIGNIFICANT PROVISION FOR BAD DEBTS IN THE PERIOD OF SERVICE ON THE BASIS OF ITS HISTOICAL COLLECTIONS, WHICH INDICATES THAT MANY PATIENTS ULTIMATELY DO NOT PAY THE PORTION OF THEIR BILL FOR WHICH THEY ARE FINANCIALLY RESPONSIBLE. THE DIFFERENCE BETWEEN THE DISCOUNTED RATES AND THE AMOUNTS COLLECTED AFTER ALL REASONABLE COLLECTION EFFORTS HAVE BEEN EXHAUSTED IS CHARGED AGAINST THE ALLOWANCE FOR DOUBTFUL ACCOUNTS.

Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance
THE ORGANIZATION EXPECTS PAYMENT AT THE TIME THE SERVICE IS PROVIDED. OUR POLICY IS TO COMPLY WITH ALL STATE AND FEDERAL LAW AND THIRD PARTY REGULATIONS AND TO PERFORM ALL CREDIT AND COLLECTION FUNCTIONS IN A DIGNIFIED AND RESPECTFUL MANNER. EMERGENCY SERVICES WILL BE PROVIDED TO ALL PATIENTS REGARDLESS OF ABILITY TO PAY. FINANCIAL ASSISTANCE IS AVAILABLE FOR PATIENTS BASED ON FINANCIAL NEED AS DEFINED IN THE FINANCIAL ASSISTANCE POLICY. THE ORGANIZATION DOES NOT DISCRIMINATE ON THE BASIS OF AGE, RACE, CREED, SEX OR ABILITY TO PAY. PATIENTS WHO ARE UNABLE TO PAY MAY REQUEST A FINANCIAL ASSISTANCE APPLICATION AT ANY TIME PRIOR TO SERVICE OR DURING THE BILLING AND COLLECTION PROCESS, EVEN IN EXCESS OF 240 DAYS FOLLOWING THE FIRST POST-DISCHARGE BILLING STATEMENT. THE ORGANIZATION MAY REQUEST THE PATIENT TO APPLY FOR MEDICAL ASSISTANCE PRIOR TO APPLYING FOR FINANCIAL ASSISTANCE. THE ACCOUNT WILL NOT BE FORWARDED FOR COLLECTION DURING THE MEDICAL ASSISTANCE APPLICATION PROCESS OR THE FINANCIAL ASSISTANCE APPLICATION PROCESS. NO EXTRAORDINARY COLLECTION ACTIONS (ECAS) WILL OCCUR EARLIER THAN 120 DAYS FROM SUBMISSION OF FIRST BILL TO THE PATIENT AND WILL BE PRECEDED BY NOTICE 30 DAYS PRIOR TO COMMENCEMENT OF THE ACTION. AVAILABILITY OF FINANCIAL ASSISTANCE WILL BE COMMUNICATED TO THE PATIENT AND A PRESUMPTIVE ELIGIBILITY REVIEW WILL OCCUR PRIOR TO ANY ACTION BEING TAKEN. IF A PATIENT IS DETERMINED TO BE ELIGIBLE FOR FINANCIAL ASSISTANCE AFTER AN ECA IS INITIATED, THE ORGANIZATION WILL TAKE REASONABLE MEASURES TO REVERSE THE ECAS AGAINST THE PATIENT ACCOUNT.

Schedule H, Part V, Section B, Line 16a FAP website
A - BALTIMORE WASHINGTON MEDICAL CENTER: Line 16a URL: https://www.umms.org/bwmc/patients-visitors/for-patients/financial-assistance;

Schedule H, Part V, Section B, Line 16b FAP Application website
A - BALTIMORE WASHINGTON MEDICAL CENTER: Line 16b URL: https://www.umms.org/bwmc/patients-visitors/for-patients/financial-assistance;

Schedule H, Part V, Section B, Line 16c FAP plain language summary website
A - BALTIMORE WASHINGTON MEDICAL CENTER: Line 16c URL: https://www.umms.org/bwmc/patients-visitors/for-patients/financial-assistance;

Schedule H, Part VI, Line 7 State filing of community benefit report
MD

Schedule H, Part VI, Line 2 Needs assessment
UM BWMC continuously assesses the health needs of the communities it serves. In addition, the CHNA that is conducted every three years, UM BWMC regularly analyzes inpatient, observation and Emergency Department utilization data, and data from affiliated outpatient physician practices. UM BWMC also reviews Anne Arundel County, Maryland and national health data and trends, and receives feedback from the Patient and Family Advisory Council on input to community needs. Additionally, UM BWMC receives feedback into community needs through participation in community coalitions and committees. Some of these coalitions and committees are described in the narrative for Part II. UM BWMC's process for conduction its most recent CHNA is described in detail in Part IV, Section C.

Schedule H, Part VI, Line 3 Patient education of eligibility for assistance
UM BWMC provides emergency, inpatient, and other care regardless of someone's ability to pay. UM BWMC's financial assistance policy (FAP) was established to assist patients in obtaining financial aid when the services rendered are beyond a patient's ability to pay. A patient's inability to obtain financial assistance does not in any way preclude the patient's right to receive and have access to medical treatment at UM BWMC. UM BWMC's FAP complies with Maryland regulations. UM BWMC's financial assistance policy provides assistance ranging up to 100% of the total cost of hospital services. Physician charges for non-hospital employees, which are billed separately, are excluded from UM BWMC's FAP. Patients are encouraged to contact their physician's directly for financial assistance related to physician charges. UM BWMC's financial assistance application packet is available in English, Spanish, and Korean, consistent with federal regulations for translating documents for Limited-English Proficient (LEP) populations. This packet includes the information and forms needed to apply for financial assistance. For emergency services, applications to the financial assistance program are completed and evaluated after treatment is commenced and the process will not delay patients from receiving necessary emergency and inpatient care. Application materials and additional information about financial assistance program are available at www.umms.org/bwmc/patients-visitors/for-patients/financial-assistance. UM BWMC informs patients and persons who would otherwise be billed for services about their eligibility for assistance under federal, state or local government programs or under the hospital's financial assistance policy in the following manner: 1. UM BWMC prepares its financial assistance information in a culturally sensitive manner, at a reading level appropriate for the service area's population and in English, Spanish, and Korean, the languages prevalent in the UM BWMC's community benefit service area. 2. UM BWMC publishes annual notices informing the public that the financial assistance is available at UM BWMC. The notices are published in the Baltimore Sun, Maryland Gazette and The Capital, the three main newspapers distributed in the UM BWMC's community benefit service area. 3. UM BWMC provides information about its FAP, including downloadable application forms and financial assistance contact information on its website in English, Spanish, and Korean. The website address is www.umms.org/bwmc/patients-visitors/for-patients/financial-assistance. 4. UM BWMC posts information about its FAP and financial assistance contact information in the business office, all admission areas, the emergency department, and other outpatient areas throughout the facility. 5. UM BWMC provides individualized notices regarding the hospital's FAP at the time of preadmission or admission to each person who seeks services at the hospital. 6. UM BWMC provides each patients a patient handbook upon admission that contains information about its FAP and answers to common billing questions. 7. UM BWMC provides information about its FAP and financial assistance contact information in patient bills. 8. UM BWMC contracts with the medical assistance eligibility firm DECO to assist patients with applying for its financial assistance program and other financial assistance programs that may be available to patients for health care services. UM BWMC discusses with patients or their families the availability of various government benefits such as Medicaid and other federal, state, and local programs.

Schedule H, Part VI, Line 6 Affiliated health care system
The University of Maryland Medical System Corporation (UMMS) is a private, not-for-profit corporation providing comprehensive healthcare services through an integrated regional network of hospitals and related clinical enterprises. UMMS was created in 1984 when its founding hospital was privatized by the State of Maryland. Over its 30-year history, UMMS evolved into a multi-hospital system with academic, community and specialty service mission reaching primarily across Maryland. UM BWMC is part of the University of Maryland Medical System (UMMS). We collaborate with other UMMS hospitals to develop and implement activities, programs and initiatives to help Marylanders live healthier lives and to identify the most impactful ways we can give back to communities throughout Maryland. UMMS convenes a bi-monthly Community Health Improvement Committee meeting that includes leaders for community health improvement across the system. There is a roundtable at each meeting to discuss best practices and strategies, program evaluation methodologies, community benefit reporting and other concerns or topics of interest. The Community Health Improvement Committee selects community health concerns that impact all system hospitals and devotes collaborative resources and expertise to addressing those concerns.

Schedule H, Part VI, Line 5 Promotion of community health
UM BWMC's mission is to provide the highest quality health care services to the communities that we serve. We extend our services beyond the hospital walls and outside of our campus through partnerships with organizations throughout our community. We are always engaging in new and collaborative ways, enhancing existing partnerships and establishing new ones to meet the needs of the community. We place particular emphasis on reaching vulnerable populations and addressing the health improvement priorities identified through our CHNA. Our community benefit program includes community outreach and health education services to provide people with the education and tools to lead healthier lives, screenings so that people can be diagnosed with diseases early, when they are most treatable, support groups for patients and their families, financial assistance to those who could not otherwise afford health care services, subsidies to increase access to care, health care workforce development, partnership development and other community building activities. As part of our commitment to provide the highest quality of health care services to the communities we serve, UM BWMC is working to ensure patients can receive the right care, at the right place and at the right time. UM BWMC is helping connect community members with medical and social resources to help them be healthier. Our annual operating plan, which is derived from our strategic plan, included a focus on population health and reducing potentially avoidable utilization, specifically related to readmissions. UM BWMC collaborates with numerous external partners for the promotion of community health. UM BWMC works with many county government agencies including the Anne Arundel County Department of Health, Aging and Disabilities, Recreation and Parks, and Social Services, the Office of Community and Constituent Services, and Anne Arundel County Public Schools. We Collaborate with Luminis Health Anne Arundel Medical Center, MedStar Harbor Hospital, Chase Brexton and Total Health Care - Federally Qualified Health Centers, and primary care, behavioral health, specialty and post-acute care providers. Most importantly, we partner with local community and faith-based organizations such as March of Dimes, Maryland Chapter, Safe Sitter, Inc, American Red Cross, American Cancer Society, Judy Center and Belle Grove Elementary, Glen Burnie Improvement Association, Severna Park Community Center, several local businesses and Chambers of Commerce, and numerous churches. In FY22, key health promotion initiatives included: free community flu vaccinations; mobile COVID-19 vaccinations; Stork's Nest prenatal education program for at-risk women; Community Wellness Day; preventing diabetes classes; Red Cross blood drives; support group for cancer patients; therapeutic yoga and exercise classes; Safe Sitter and Safe at Home classes; childbirth education classes; food distributions; and vascular and breast cancer screenings. In addition to the community outreach activities described above, UM BWMC provides support to our community in numerous other ways. We allow community groups to utilize our conference facilities free of charge, as space availability allows. We also make donations to community organizations that have similar missions and goals to UM BWMC, such as the American Foundation for Suicide Prevention, Burgers and Bands, and the Caring Cupboard. We also participate in emergency preparedness planning to assure appropriate health services are available during emergency situations. UM BWMC extends medical staff privileges to qualifying physicians in the community. UM BWMC operates under a unique regulatory system that caps hospital revenues and provides adjustments to allow for population health improvement investments. Under Maryland's global revenue model, UM BWMC reports on a regular basis how it is investing in efforts to improve population health.