4A (Expenses $ 1933408844 including grants of $ 174531) (Revenue $ 2452058601)
"Fairview Health Services is an industry-leading, award-winning, nonprofit, integrated health system providing exceptional health care across the full spectrum of health care services. Founded in 1906, Fairview serves the twelve-county Minneapolis/St. Paul Metro Area, as well as communities throughout greater Minnesota and portions of Northern Iowa and Western Wisconsin and is one of the most comprehensive and geographically accessible systems in Minnesota. Fairview, the University of Minnesota and the University of Minnesota Physicians approved an agreement which became effective in late 2018 (the ""M Health Fairview Agreement""). While the parties maintain their separate governance, the M Health Fairview Agreement further integrated operations across the clinical delivery system and enhances research and education by creating a joint clinical enterprise among the parties. The M Health Fairview Agreement brings together not only UMMC and its related service lines, but also Fairview's other hospitals, primary care clinics, and other services. All are part of a shared care delivery system that is led by a single structure that includes academic physician leadership. The goal of the joint clinical enterprise is to create a nationally-renowned academic health system. This care system was united under a single brand, M Health Fairview, which is inclusive of the Fairview Hospitals and Clinics In March 2020, the World Health Organization declared the COVID-19 outbreak a pandemic. The pandemic has had a significant negative effect on the healthcare industry. Fairview continues to follow guidance from the Center for Disease Control and Prevention and the Minnesota Department of Health and is coordinating its activities with state and local governments as well as other health systems in the state and region. First and foremost, Fairview's focus is on caring for its patients during this ongoing pandemic. Fairview continues to provide COVID-19 vaccines to all individuals ages 5 and older. Fairview is committed to educating the community and distributing vaccines. Fairview has administered the most vaccines in the State of Minnesota. As of December 31, 2021, Fairview has administered more than 540,000 doses to patients in the system. A remarkable program called the Minnesota Immunization Network Initiative (MINI), a collaboration led by Fairview and supported by over 120 community partners, works to reduce barriers to influenza vaccinations for communities experiencing disparities. MINI provides flu immunizations free of charge to community members six months and older. Since inception, more than 100,000 immunizations have been given to prevent influenza. MINI clinics are hosted at non-traditional locations such as churches, mosques, temples, schools, community centers, libraries, food pantries, and homeless shelters. The clinics are hosted by a local partner who provides the space, promotion, and serves as a trusted messenger for community members. Fairview provides the vaccine and clinical team, including interpreters, support staff and information about other local community resources. Influenza vaccinations are provided at no charge to participants, six months and older. MINI clinics have expanded their reach to include other vaccinations such as Hepatitis A, blood pressure screening and cardiovascular health education, free dental varnish treatments and oral health education. These services are often provided in conjunction with MINI flu shots clinics or on their own. During the COVID-19 pandemic, the MINI program leveraged over 15 years of experience providing mobile clinical services in diverse settings to respond to the urgent public health crisis. MINI launched a large scale, low barrier testing initiative in partnership with Saint Paul Ramsey County Public Health and the Minnesota Department of Health. This collaboration enabled thousands of community members to receive a free COVID-19 test in convenient, trusted community spaces. In total, MINI supported 47 testing events and administered almost 20,000 tests. To date, MINI has provided 800 community based COVID vaccination clinics and given over 49,800 vaccinations. MINI continued to provide influenza vaccinations throughout the pandemic and administered over 4,000 free flu shots in 2021. The Fairview system consists of 11 hospitals, it controls and operates University of Minnesota Medical Center, the adult and pediatric teaching hospital of the University of Minnesota Medical School, has 10 community based general acute care hospitals and 1 long-term acute care hospital; over 80 primary and specialty care clinics; offers over 100 specialty care services; urgent care clinics; occupational health clinics; 36 retail and specialty pharmacies; pharmacy benefit management services; rehabilitation centers; counseling; hospice services; 90+ owned and managed senior care facilities and long-term care housing facilities (through Ebenezer Society, a Fairview subsidiary); and emergency medical transportation. Fairview's 34,000+ employees and network of 5,000+ system providers embrace innovation and new thinking to drive a healthier future through healing, discovery and education. The health care and medical services which Fairview provides to the community include, but are not limited to: primary, specialty, tertiary, and quaternary care; hospital and physician services; senior services; assisted living; long-term care; urgent care and emergency services; pharmacy; care of mothers and children; physical therapy/sports medicine; rehabilitation services; and inpatient and outpatient behavioral health care and chemical dependency services. Fairview provides specialized care for the treatment of cancer, heart disease, diabetes, wound care, chronic conditions, solid organ transplant, blood and marrow transplant, and many other specialties. Fairview also offers social work services, health education and support groups and services for various health issues. Fairview Health Services provides care at the following: University of Minnesota Medical Center and University of Minnesota Masonic Children's Hospital (UMMC) are the adult and pediatric teaching hospitals of the University of Minnesota. The medical center is located on both the East and West banks of the University of Minnesota campus. With 1,700 licensed beds, UMMC is committed to providing exceptional, innovative health care, pairing groundbreaking technology and treatments with patient-centered care. Our partnership with the University of Minnesota Medical School and University of Minnesota Physicians provides the platform to specialize in breakthrough treatments, surgical techniques, and lifesaving therapies, and to train tomorrow's physicians. Clinical trials advance our clinical services, bringing the newest research and ideas to patient care. We also provide an important training environment for residents, fellows, and many other health care learners. Key services include maternity, heart care, general surgery, cancer care, solid organ transplants, blood marrow transplants, and pediatric specialties. Fairview, in partnership with University of Minnesota Physicians, provides exceptional care in more than 100 specialty areas. Other services offered through related entities include Pharmacy, Rehabilitation Services, Fairview Achievement Center, Fairview Partners, Fairview Counseling Services, care management and coordination, Medical Transportation, and subsidized health services. Fairview Southdale Hospital opened in Edina in 1965. With 390 licensed beds, the hospital is known for its award-winning heart, stroke, and cancer care. Fairview Southdale offers convenient access to more than 40 specialty services including cardiology, orthopedics, oncology, obstetrics, primary care, neurosciences, critical care, vascular and emergency services. Key services include labor and delivery, heart care, cancer care, a breast center, orthopedic surgery, general surgery, spine & brain, a stroke center, and sleep services. Fairview Ridges Hospital opened in Burnsville in 1985. It provides comprehensive, specialized care to the southern Twin Cities community with its 150 licensed beds. Fairview Ridges Hospital provides care for the entire family, including pediatric emergency care and neonatal intensive care. The hospital offers onsite access to specialists in everything from heart and cancer care to midwifery and sports medicine. In December 2021, U.S. News & World Report released its first-ever ""Best Hospitals for Maternity"" list, recognizing M Health Fairview Ridges Hospital, as among 237 ""high performing"" hospitals nationwide. Key services include labor and delivery, heart care, cancer care, breast center, orthopedic surgery, general surgery, spine & brain, pediatric inpatient, and sleep services."

4B (Expenses $ 1013647951 including grants of $ 0) (Revenue $ 1193547875)
Cost of participating in government programs: Fairview is committed to serving the health care needs of members of its community. To support full access to services, Fairview participates in the following public health care programs: Medicare, Medicaid, and Minnesota Care. Reimbursement from these programs for services rendered, generally falls below the cost of providing the care. To compensate for the under funding by government programs, Fairview makes a significant financial investment to offset these losses. In 2021, Fairview incurred $57,646,309 of taxes and surcharge costs in health care services that exceeded the reimbursement received by public programs, surcharge, taxes and fees related to these programs and not including Medicare. The following is a breakdown on costs related to the cost of participating in government programs: Costs exceed Medicaid Reimbursement: Fairview is serving thousands of low income individuals covered by Medical Assistance and Minnesota Care. Reimbursement from these programs is less than Fairview's cost of providing care to these patients. Total Medicaid surtax costs related to hospitals, pharmacies, and surgical centers was $26,200,664. Minnesota Care tax: The state of Minnesota levies a 2 percent tax on certain health care provider revenues. Money generated from this tax helps to defray the costs incurred from Minnesota Care and other programs/services for uninsured individuals. In 2021, Fairview paid $30,821,605 in Minnesota Care taxes. Taxes and fees: Fairview does pay some property tax to local and state government. This helps to fund civil and educational services in the community. The real estate costs for 2021 totaled $2,557,166 and the sales and income taxes totaled $7,494,530. Costs exceeding Medicare Reimbursement: Fairview cares for thousands of individuals ages 65 and older who are covered by Medicare. Fairview incurred $155,956,878 of Medicare reimbursement shortfalls. Reimbursement from Medicare is less than Fairview's cost of providing care to the patient. The total cost of providing these benefits was $953,444,476.

4C (Expenses $ 113370993 including grants of $ 0) (Revenue $ 15324156)
The primary purpose of our educational and research programs is to benefit patients and the community at large by educating health professionals both within Fairview and in the broader community, and by fostering advances in knowledge and evidence-based improvements to clinical treatments and approaches to health care delivery. In partnership with the University of Minnesota Academic Health Center and University of Minnesota Physicians, Fairview has a strong and abiding commitment to research and education. Together, we view research as an integral and critical component in providing exceptional care to patients and the community. We seek to be a national leader in clinical research and a regional center for clinical research activities. Fairview continues its focus and support of research and education. This commitment included providing the resources of time, money, and talent while ensuring the facilities, supporting infrastructures, and processes were available to facilitate and encourage the creation of new knowledge. Fairview had more than 1,100 active clinical research studies underway across the health care system. Research ranges from deep brain stimulation to ultrasound treatment of rheumatoid arthritis, stem cell transplants for multiple sclerosis to recurrent hypoglycemia and many other topics. Fairview offers numerous sponsorships and training programs, internships, and scholarships to employees and their dependents - as well as to students in our communities. Fairview partners with more than 160 schools, 255 faith communities, and 50 community groups. Fairview has educational partnerships with the University of Minnesota and St. Catherine University and affiliations with many other institutions. Fairview also offers its own specialized training program in perioperative nursing. More than 5,500 college and graduate students prepared for careers in a wide range of medical fields through clinical training, internships, and job shadowing at Fairview hospitals and clinics. Through Fairview's close partnership with the University of Minnesota, more than 1,140 medical students, residents, and fellows took courses and completed rotations of various lengths at Fairview settings, including M Health Fairview University of Minnesota Medical Center, M Health Fairview University of Minnesota Masonic Children's Hospital, and Fairview's primary care clinics. Fairview also provides numerous continuing education opportunities to its employees to enable them to ensure they are knowledgeable about the latest innovations in health care delivery.

Schedule H, Part V, Section B, Line 3E
Fairview is committed to transparency and accountability in all we do, including our efforts to assess - and respond to - our community's most pressing health needs. The community benefit work that we do across Fairview must reflect our community's actual needs, not our assumptions about what those needs might or should be. Because we understand that change cannot happen when we work in silos, and it cannot happen in a single year, we grounded our 2021 CHNA process in alignment with our 2018 CHNA needs, existing data, and the voices of community members and community partners. Once we had collected, analyzed, and synthesized the information we received from both primary and secondary data sources, we established a prioritization process through which we could identify the community health needs that, if effectively addressed, would have the greatest positive impact on our communities and particularly on our priority populations. Having a consistent, defined process helps reduce the skewing effect of conscious and unconscious biases and enables us to define priority need areas that reflect our community's top health needs rather than our perception of those needs. We evaluated areas of need based on four broad criteria: -Has this need been voiced by the community? Has this need been vetted by the community? -Does this need align with Fairview's strategies and priorities? -Does this need align with existing public health strategies and community health assessments? -Does this need build upon Fairview's 2018 CHNA priority needs? Our process resulted in the identification of three priority need areas. They are: -Navigating and accessing care and resources -Healing, connectedness, and mental health -Addressing structural racism and barriers to achieving health equity.

Schedule H, Part V, Section B, Line 5 Facility , 1
Facility , 1 - University of Minnesota Medical Center. The assessment process and data collection methods we used during this CHNA cycle were different than ever before due to the COVID-19 pandemic. COVID- 19 caused delays in data collection among local, state, and national organizations. As a result of these delays, the U.S. Census Bureau had not yet released finalized data from the 2020 U.S. Census by the time we began the CHNA process. As a result, we used 2015-2019 American Community Survey data. Local public health agencies also were not able to provide updated data as they have in the past. We acknowledge that, due to these setbacks, the data we used is less recent than desired. Additionally, COVID-19 required us to add new safety precautions to our method of gathering community voice data. For example, all conversations and interviews, which had previously been in-person meetings, took place in a virtual format instead. We collected additional community voice data by convening a broad array of stakeholders, with special focus on the priority populations. The process included discussions with community benefit and assessment committees, our community advisory council, the HOPE Commission listening and learning sessions, and key stakeholder interviews. Throughout this process, community members, local business leaders, government representatives, nonprofit and community organizations, and content experts shared their voices and perspectives about their community's health needs. Each hospital within Fairview has a community benefit and assessment committee that is involved in the CHNA process throughout the three-year cycle. Each committee is comprised of local community and organizational leaders and staffed by the Fairview Community Advancement department. Community benefit and assessment committees met four times between April and October in 2021, three of which were individual committee meetings and one of which was a system-wide Community Impact Summit that brought all the committees together. Each committee meeting consisted of facilitated discussions through which our team gathered input about top community needs. The Fairview Community Advisory Council, composed of key community leaders and staffed by Community Advancement, reviews the CHNA report and written implementation strategy and recommends it to the Patient Care and Experience Committee of the Fairview Board of Directors for review and adoption. Each member represents the member's respective community, and members represent a broad range of sectors, among them community organizations serving cultural communities, higher education organizations, banks, and a nonprofit electric company. The Community Advisory Council met from May through November 2021 to participate in the CHNA process, give feedback, and ultimately recommend the CHNA and implementation strategy for adoption. The HOPE Commission is a multi-year transformational change effort of M Health Fairview to drive more equitable outcomes and inclusive environments and experiences for our patients, employees, and communities. The Commission conducted a series of listening and learning sessions in 2020 and 2021. The objective was to hold a mirror to Fairview to assess where we are now and how we can make lasting change. Part of being an anti-racist health system is developing a candid understanding of our shortcomings. We particularly sought to hear perspectives and ideas from the most impacted populations: BIPOC employees and patients, front-line workers who care for underserved and marginalized patients, and those patients themselves. A survey was also made available each year to gather insights and suggestions from employees and patients who could not directly participate in a listening and learning session. In 2020, the commission convened 32 virtual listening and learning sessions and two town halls involving more than 1,500 participants across Fairview sites. The sessions focused on employees but included patients and community members as well. In September 2021, the HOPE Commission continued the listening and learning sessions following the same model. In this iteration, however, the focus was primarily on gathering input from patients (and employees as patients). In both 2020 and 2021's listening and learning sessions, the facilitators and note takers reflected the community represented by the session's group to the greatest degree possible. In August and September 2021, Fairview's Community Advancement team conducted a series of interviews with staff members who work with communities. Each conversation followed a consistent interview protocol developed for this purpose, and each interview was captured by means of detailed notes. The goal of these interviews was to draw on staff expertise to gain a deeper understanding of our priority needs and to determine whether there are any emerging needs that we should be considering. Between Aug. 31 and Sept.17, 2021, we conducted 17 interviews. In August 2021, we held two focus groups in partnership with other organizations. We convened the first focus group in partnership with HealthPartners and Allina Health, and the participants were faith community nurses. We convened the second focus group in partnership with the organizations that are a part of the East Side Health and Well-being Collaborative. This meeting's focus was on accessing care and resources for different cultural communities. Fairview also participated in two large surveys. KRC Research conducted a survey around health and health care needs in St. Paul between June 8 and July 7, 2021, and administered it to community members, Fairview employees, patients, and community partners. Responses were received from 294 residents, more than 1,000 employees, 221 patients, and 20 partners. The survey was offered online and by phone and in five languages: English, Spanish, Hmong, Somali, and Karen. Fairview also supported and was a partner organization in Bridge to Health, a survey that assesses the health needs of northern Minnesota residents. The Bridge to Health survey was administered between Aug.28 and Oct. 23, 2020. The geographic areas that were sampled included Aitkin, Carlton, Cook, Itasca, Koochiching, Lake, St. Louis, and Pine counties in Minnesota, as well as Douglas County in Wisconsin. As a foundational part of program planning and evaluation, Community Advancement staff are continuously soliciting feedback from community partners and program participants. We capture this information on an ongoing basis and use it to provide valuable context and drive insights into the needs of the communities we serve. Fairview staff developed standardized tools, processes, instructions, and facilitator, interviewer, and note-taker protocols and training. All primary data was compiled, cleaned, and analyzed. Community conversations lasted various lengths from 30-120 minutes. All community input was captured by a note-taker. The Fairview team contracted with the following groups to support our assessment process: -Loren Blinde, PhD of Writing Power, a copywriter and content strategist, on the writing of the report. -Kristi Fordyce, an independent contractor, for analysis support. -Weber Shandwick, for data collection and analysis of focus groups and stakeholder interviews focused on St. Paul. -KRC Research for the administration and analysis of the St. Paul Community Survey

Schedule H, Part V, Section B, Line 7 Facility , 1
Facility , 1 - University of Minnesota Medical Center. The Community Health Needs Assessment Report for University of Minnesota Medical Center are located at: https://stcr-prd-cd.fairview.org/-/media/Files/Local-Health-Needs/Read-full-reports/2021-CHNA-Report-UMMC-and-Masonic-Childrens-Hospital2125.pdf?_ga=2.XXX-XX-XXXX.1916792193.1654267916-XXX-XX-XXXX.1594916074 The Community Health Needs Assessment and Implementation Strategy for University of Minnesota Medical Center are located at: https://stcr-prd-cd.fairview.org/-/media/Files/Local-Health-Needs/CHNA-Implementation-Strategy-Report-20222024-UMMCUMMCH.pdf?_ga=2.XXX-XX-XXXX.1916792193.1654267916-XXX-XX-XXXX.1594916074

Schedule H, Part V, Section B, Line 11 Facility , 1
"Facility , 1 - University of Minnesota Medical Center. Over the course of 2021, Fairview's hospitals and medical centers, including the University of Minnesota Medical Center and Masonic Children's Hospital, conducted our Community Health Needs Assessment (CHNA) process to determine our priority needs and our response. As part of this process, we listened and learned much about our community's most pressing needs. Through those conversations, and supported by community data, we prioritized the following needs: Navigating and accessing care and resources; Healing, connectedness; and mental health, and Addressing structural racism and barriers to achieving health equity. The CHNA Implementation Strategy Report outlines the major strategies and actions we will deploy throughout the 2022-2024 assessment cycle. The current generation will be the first generation in American history to experience shorter life expectancy than their parents did.1 Over the past decade, rates of poverty, food insecurity, isolation, mental illness, addiction, and other determinants of poor health have continued to rise and these do not impact everyone equally - Minnesota has some of the nation's largest racial, ethnic, and geographic health inequities. To impact these devastating trends, we must respond in ways that align with the factors that research has shown to have a significant effect on an individual's health and wellbeing. Studies estimate that eighty percent of a person's health outcomes are influenced by factors outside a healthcare setting,2 and a person's zip code matters more than their genetic code when it comes to long-term health.3 Given these realities, our response must reach outside the health system's walls and must focus on those experiencing health inequities to be most effective. Since the 2010 passage of the Affordable Care Act, our health system has engaged in four CHNA cycles. During each cycle, we have found the same or similar needs have existed for our communities. This means that our communities have largely faced the same challenges for more than a decade - and that despite our efforts to address these issues, these problems are not relenting. In fact, in many cases, these conditions have worsened over the past decade. Over the past 10 years of responding to our communities' biggest needs we have learned important lessons which have guided us in the development of our Fairview Health Services 2022-2024 implementation strategies. An essential part of the 2018 CHNA process was the identification of priority needs in the local community. The hospitals and/or medical centers identified the following priority needs for University of Minnesota Medical Center and University of Minnesota Masonic Children's Hospital: Mental health and well-being, Healthy lifestyles, Access to care and services. Each hospital and/or medical center developed a hospital specific implementation plan around its priority health issues along with a system focus on policy, system, and environmental (PSE) change to address their identified priority needs. Each program is evaluated on an annual basis against program specific anticipated impacts. As part of the evaluation process each program indicator is assigned a value of ""green"", ""yellow"" or ""red"" based upon the criteria that follows. A rating of ""green"" means that the program (a) met, or exceeded, 2020 hospital goal/s as written in hospital implementation plan (b) it has count data tied to both goal/s and anticipated impact/s (c) there is an evaluation tool with measure tied to anticipated impact/s. A rating of ""yellow"" means that the program (a) had partial completion of 2020 hospital goal/s as written in hospital implementation plan (b) it has count data tied to either goal/s or anticipated impact/s but not both (c) there is an evaluation tool without measure tied to anticipated impact/s. A rating of ""red"" means that the program (a) did not complete the 2020 hospital goal/s written in hospital implementation plan (b) there was no count data (c) there was no evaluation tool/s. Policy, System, and Environmental (PSE) change initiatives often take multiple years to plan and implement. Using a CDC evaluation framework each PSE initiative is monitored and evaluated annually against anticipated activities and milestones linked to the six connected PSE evaluation steps. The six connected steps of PSE change we tracked for monitoring and evaluation purposes are (1) engage stakeholders, (2) describe the program, (3) focus the evaluation design, (4) gather credible evidence, (5) justify conclusions, and (6) ensure use and share lessons learned. Priority: Mental health and wellbeing: The University of Minnesota Medical Center offered the evidence-based Mental Health First Aid program. The program introduces risk factors and warning signs of common mental health and substance use disorders, builds understanding of their impact, and reviews support options. The interactive course teaches participants how to offer initial help to an individual who may be experiencing a mental health concern or crisis and connect them to the appropriate resources. Youth Mental Health First Aid is the second core program which focuses on mental health concerns among youth ages 12-18. The anticipated impact for the Mental Health First Aid programs was an increase in participants' ability to recognize and correct misconceptions about mental health and mental illness. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: Outcome: 30% increase from pre-survey (70%) to post-survey (100%) in response to the following: I strongly agree or agree that I can recognize and correct misconceptions about mental health, substance use and mental illness as I encounter them. Evaluation of survey results was done on a program level. The University of Minnesota Medical Center offered the evidence-based Stress Reduction Suite which included two programs (1) Flourish a restorative four-week series, that lets participants experience a variety of mind-body practices designed to promote a sense of calm, joy, connection, and inner strength. A few of the practices explored are moving meditation, journaling, guided imagery, and mindfulness. (2) Resiliency and Stress Management Training Series a restorative six-week series, based on Center Mind Body Medicine, 90-minute sessions. Participants experience a variety of mind-body practices designed to promote a sense of calm, joy, connection, and inner strength. A few of the practices explored by participants include moving meditation, journaling, guided imagery, and mindfulness. This mind body Series is a proven method to reduce stress, increase self-esteem, and improve a person's overall quality of life. The 2020 anticipated impact for the Stress Reduction Suite was a decrease in participants' perceived stress. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: .20 points decrease from pre-program-survey to post-program-survey in response to the following metric: participants' perceived stress. Average change (decrease) in participants' perceived stress on a 10 point scale - the higher the score, the more the perceived stress. Evaluation of survey results was done on a program level."

Schedule H, Part V, Section B, Line 11 Facility , 2
"Facility , 2 - University of Minnesota Medical Center-Continued. The University of Minnesota Medical Center offered services at Health Commons - Cedar Riverside, a health and wellness drop-in center located in the Cedar Riverside neighborhood of Minneapolis. Health Commons is open five days a week for two to three hours and provides the following services: health consultations, nutrition and physical activity classes, massage and healing touch services, and resources and referrals. The anticipated impact for Health Commons - Cedar Riverside was an increase in participants' self-reported social connectedness. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: 100% of participants that responded to the convenience sample survey indicated that they strongly agree or agree that Health commons has made them feel more connected to others. The University of Minnesota Medical Center offered services at Health Commons - The Living Room, a health and wellness drop-in center located in North Minneapolis. Health Commons is open two days a week for three to four hours and provides the following services: health consultations, blood pressure checks, health education classes, massage and healing touch services, and resources and referrals. The anticipated impact for Health Commons - The Living Room was an increase in participants' self- reported social connectedness. The anticipated impact was assigned a value of ""green"". 2021 Impact: Given COVID and social distancing in 2021, survey was unable to be completed. The University of Minnesota Medical Center offered the Trauma Informed Congregations program, the implementation of the Risking Connection in Faith Communities curriculum across Faith Communities. Risking Connection helps clergy understand the nature of trauma, its impact on people and how faith leaders can support and bring healing to trauma survivors. The anticipated impact for the Trauma Informed Congregations program was an increase in clergy/leader understanding of the impact of trauma on trauma survivors. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: 100% of participants reported they understand the impact trauma can have on their clients. Evaluation of survey results was done on a program level. The University of Minnesota Medical Center offered Youth Grief Services sessions and camps. Youth Grief Services (YGS) provides a safe and nurturing place where families can turn for help after a loved one dies. YGS assists in the healing process through a network of programs and services that support, educate, and connect grieving families. The anticipated impact for Youth Grief Services was an increase in youth participants' knowledge of healthy coping strategies in response to grief. The anticipated impact was assigned a value of ""red"". 2021 Outcome: Ownership of Youth Grief Services transferred from Fairview Health Services to Brighter Days Grief Center in December 2020, providing a seamless transition of the program for participants. The University of Minnesota Medical Center collaborated in policy, systems and environmental (PSE) change around responding to trauma in settings such as schools and faith communities. This initiative includes activities and milestones linked to PSE evaluation steps (1) engage stakeholders, (2) describe the program, and (3) focus the evaluation design. 2021 Impact: Green - Opened Minnesota's first EmPATH unit- or Emergency Psychiatric Assessment, Treatment, and Healing- a pioneering approach to emergency mental health that offers rapid, comprehensive care in a calming environment at Fairview Southdale Hospital. Planning underway for opening a second unit at University of Minnesota Medical Center. Conducted HOPE Listening and Learning sessions and a survey, to assess the experiential needs of patients and caregivers when accessing care in our system. Planning for Virtual Health Hubs that will break down barriers and allow people to access mental health care despite physical location. Member partner of both the Mental Well Being Task Force for the Hennepin County Community Health Improvement Partnership (CHIP) and Ramsey County Mental Health and Wellness Action Team (MHWAT). In partnership with Ebenezer Senior Living, developed a new quarterly speaking series called HOPE, that address topics such as Adverse Childhood Experiences (ACEs), trauma, and pandemic fatigue. In the development/planning stage for a Wellness Hub that will include providing comprehensive mental health care in a calming, relaxing space. Priority: Healthy lifestyles: The M Health Fairview University of Minnesota Medical Center offered the evidence-based Falls Prevention Suite which included two programs (1) Matter of Balance a program designed to reduce the fear of falling and increase activity levels among older adults. It includes 8 sessions for a small group of 8-12 participants led by two trained facilitators. Participants learn to view falls and fear of falling as controllable, set realistic goals to increase activity, change their environment to reduce fall risk factors, and exercise to increase strength and balance. (2) Tai Ji Quan a research-based 12-week program that is designed to keep older adults mobile and independent. The program meets twice a week for one hour. The classes will help participants improve balance, strengthen muscles, and reduce the risk of falling. The anticipated impact for the Falls Prevention Suite was an increase in participants' comfort talking to their health care provider about medications and other possible risks of falling. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: 14% decrease from pre-survey (86%) to post-survey (73%) in participants that responded with a little, somewhat, or a lot to the following: How fearful are you of falling? Evaluation of survey results was done on a program level. The University of Minnesota Medical Center offered the evidence-based Living Well Suite which included three programs that were developed by Stanford University's Patient Education Research Center. (1) Chronic Disease Self-Management is a workshop given 2.5 hours once a week, for six weeks offered to individuals and their caregivers who are living with chronic conditions. Subjects addressed include medication use, communication with doctors and caregivers, nutrition, and fitness- with practical exercises and advice designed to meet participants' needs. (2) Chronic Pain Self-Management is a workshop given 2 hours once a week, for six weeks, in community settings. The workshop helps participants, and their support person, deal with the ongoing issues associated with chronic pain. (3) Diabetes Self-Management is a 6 week once a week program developed to helps those living with diabetes or pre-diabetes to improve their general health. The anticipated impact for the Living Well Suite was an increase participants' perception of positive lifestyle changes. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: 89% of participants that responded to the post program survey indicated that they strongly agree or agree with the following statement: The program has helped them manage chronic condition(s). Evaluation of survey results was done on a program level."

Schedule H, Part V, Section B, Line 11 Facility , 3
"Facility , 3 - University of Minnesota Medical Center-Continued. The University of Minnesota Medical Center offered services at Health Commons - Cedar Riverside, a health and wellness drop-in center located in the Cedar Riverside neighborhood of Minneapolis. Health Commons is open five days a week for two to three hours and provides the following services: health consultations, nutrition and physical activity classes, massage and healing touch services, and resources and referrals. The anticipated impact for Health Commons - Cedar Riverside was an increase in participants' perception of positive lifestyle changes. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: 100% of participants that responded to the convenience sample survey indicated that because of Health Commons, they are making positives changes toward a healthier lifestyle. The University of Minnesota Medical Center offered services at Health Commons - The Living Room, a health and wellness drop-in center located in North Minneapolis. Health Commons is open two days a week for three to four hours and provides the following services: health consultations, blood pressure checks, health education classes, massage and healing touch services, and resources and referrals. The anticipated impact for Health Commons - The Living Room was an increase in participants' self- reported social connectedness. The anticipated impact was assigned a value of ""green"". 2021 Outcome: Given COVID and social distancing in 2021, survey was unable to be completed. The University of Minnesota Medical Center offered Veggie Rx a program intended to decrease food insecurity by distributing vegetables to populations of color and those experiencing poverty who are food insecure, have diet related chronic disease and would benefit from increased access to nutritious food. The Hmong American Farmers Association (HAFA) provides CSA (community shared agriculture) shares for this program. The anticipated impact for Veggie Rx was an increase vegetable consumption in food insecure patients. 2021 Impact: Yellow - Outcome: 3% decrease from pre-survey (42%) to post-survey (39%) in response to the following question: I consume three or more servings of vegetable per day. The University of Minnesota Medical Center collaborated in policy, systems and environmental (PSE) change around healthy food transformation addressing issues such as food insecurity, food access, and changes to cafeteria menus. This initiative includes activities and milestones linked to PSE evaluation steps (1) engage stakeholders, (2) describe the program, and (3) focus the evaluation design. 2021 Impact: Green - Outcome: Strengthened partnerships with local food organizations such as Second Harvest Heartland and Sanneh Foundation. Includes planning for a Wellness Hub that will be a new distribution site for food and provide workforce development opportunities for youth in the food sector. Continue to serve as a backbone partner in the Food Justice Network. Expanded Community Supported Agriculture (CSA) program to new CSA farms to meet the differing needs of clinic participants and support new farmer partners. Planning to offer, in partnership with Keystone Community Services, a mobile food pantry at clinics. Signed contact for Now Pow which will screen patients for social determinants such as food security and provide resources and referrals. Priority: Access to care and resources: The University of Minnesota Medical Center conducted Minnesota Immunization Network Initiative (MINI) Clinics. MINI is a multi-sector, community collaboration providing free flu shots to uninsured, underserved, and minority populations. The MINI clinics bring flu vaccine, educational materials, and volunteers to community locations such as churches or community centers and with its partners, ensure a culturally and linguistically appropriate experience in a safe and trusted environment. The anticipated impact for the MINI clinics was an increase in the number of clinics with culturally and/or linguistically appropriate materials around accessing care and resources. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: 31% of new partner clinic sites had culturally and/or linguistically appropriate materials around accessing care and resources. The University of Minnesota Medical Center offered the evidence-based Falls Prevention Suite which included two programs (1) Matter of Balance a program designed to reduce the fear of falling and increase activity levels among older adults. It includes 8 sessions for a small group of 8-12 participants led by two trained facilitators. Participants learn to view falls and fear of falling as controllable, set realistic goals to increase activity, change their environment to reduce fall risk factors, and exercise to increase strength and balance. (2) Tai Ji Quan a research-based 12-week program that is designed to keep older adults mobile and independent. The program meets twice a week for one hour. The classes will help participants improve balance, strengthen muscles, and reduce the risk of falling. The anticipated impact for the Falls Prevention Suite was an increase in participants' comfort talking to their health care provider about medications and other possible risks of falling. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - * Outcome: 67% of participants that responded to the post program survey indicated that they strongly agree or agree with the following statement: I feel more comfortable talking to my health care provider about my medications and other possible risks for falling. Evaluation of survey results was done on a program level. The University of Minnesota Medical Center offered the evidence-based Living Well Suite which included three programs that were developed by Stanford University's Patient Education Research Center. (1) Chronic Disease Self-Management is a workshop given 2.5 hours once a week, for six weeks offered to individuals and their caregivers who are living with chronic conditions. Subjects addressed include medication use, communication with doctors and caregivers, nutrition, and fitness- with practical exercises and advice designed to meet participants' needs. (2) Chronic Pain Self-Management is a workshop given 2 hours once a week, for six weeks, in community settings. The workshop helps participants, and their support person, deal with the ongoing issues associated with chronic pain. (3) Diabetes Self-Management is a 6 week once a week program developed to helps those living with diabetes or pre-diabetes to improve their general health. The anticipated impact for the Living Well Suite was an increase in participants who agree that the program helps them work with their health care providers. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - * Outcome: 86% of participants that responded to the post program survey indicated that they strongly agree or agree with the following statement: The program has helped them work with healthcare professionals. Evaluation of survey results was done on a program level. The University of Minnesota Medical Center offered the evidence-based Mental Health First Aid program. The program introduces risk factors and warning signs of common mental health and substance use disorders, builds understanding of their impact, and reviews support options. The interactive course teaches participants how to offer initial help to an individual who may be experiencing a mental health concern or crisis and connect them to the appropriate resources. Youth Mental Health First Aid is the second core program which focuses on mental health concerns among youth ages 12-18. The anticipated impact for the Mental Health First Aid programs was increase participants' confidence in assisting someone to connect with professional resources. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: 31% increase from pre-survey (67%) to post-survey (98%) in response to the following: I strongly agree or agree that I can assist someone who may be dealing with a mental health problem, substance use challenge or crisis in seeking professional help. Evaluation of survey results was done on a program level."

Schedule H, Part V, Section B, Line 11 Facility , 4
"Facility , 4 - University of Minnesota Medical Center-Continued. The University of Minnesota Medical Center offered services at Health Commons - Cedar Riverside, a health and wellness drop-in center located in the Cedar Riverside neighborhood of Minneapolis. Health Commons is open five days a week for two to three hours and provides the following services: health consultations, nutrition and physical activity classes, massage and healing touch services, and resources and referrals. The anticipated impact for Health Commons - Cedar Riverside was an increase in participants' access to community resources. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: 100% of participants that responded to the convenience sample survey indicated that they strongly agree or agree that they have gained more access to community resources because of Health Commons. The University of Minnesota Medical Center offered services at Health Commons - The Living Room, a health and wellness drop-in center located in North Minneapolis. Health Commons is open two days a week for three to four hours and provides the following services: health consultations, blood pressure checks, health education classes, massage and healing touch services, and resources and referrals. The anticipated impact for Health Commons - The Living Room was an increase in participants' access to community resources. The anticipated impact was assigned a value of ""green"". 2021 Outcome: Given COVID and social distancing in 2021, survey was unable to be completed. The University of Minnesota Medical Center offered Veggie Rx a program intended to decrease food insecurity by distributing vegetables to populations of color and those experiencing poverty who are food insecure, have diet related chronic disease and would benefit from increased access to nutritious food. The Hmong American Farmers Association (HAFA) provides CSA (community shared agriculture) shares for this program. The 2020 anticipated impact for Veggie Rx was an Increase participants' knowledge about where to buy locally grown produce. 2021 Impact: Green - Outcome: 79% of participants reported they strongly agree or agree to the following: Where to buy locally grown produce in your area. Needs identified but not addressed: Although the following health needs were not selected as priority needs, M Health Fairview will continue to support work aligned with addressing these needs as appropriate particularly when doing so would address the social determinants of health and/or the leading causes of premature death. Childcare: This issue is beyond what M Health Fairview resources can support at this time. Chronic lower respiratory disease: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Clinic hours: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Cost associated with care: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Health literacy: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Safe neighborhoods: This issue is beyond what M Health Fairview resources can support at this time. Stroke: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Health literacy: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Safe neighborhoods: This issue is beyond what M Health Fairview resources can support at this time. Stroke: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Transportation: This issue is beyond what M Health Fairview resources can support at this time."

Schedule H, Part V, Section B, Line 13 Facility , 1
Facility , 1 - University of Minnesota Medical Center. The Minnesota Attorney General agreement was used in the determination of the eligibility for financial assistance.

Schedule H, Part V, Section B, Line 16 Facility , 1
Facility , 1 - University of Minnesota Medical Center. The organization attaches a summary of the policy to billing invoices and also communicates to patients during admission, financial counseling and collection calls that there is a financial assistance program and that an application can be provided to them. A summary of the Financial Assistance Policy is posted in various locations in the hospital.

Schedule H, Part V, Section B, Line 3E
Fairview is committed to transparency and accountability in all we do, including our efforts to assess - and respond to - our community's most pressing health needs. The community benefit work that we do across Fairview must reflect our community's actual needs, not our assumptions about what those needs might or should be. Because we understand that change cannot happen when we work in silos, and it cannot happen in a single year, we grounded our 2021 CHNA process in alignment with our 2018 CHNA needs, existing data, and the voices of community members and community partners. Once we had collected, analyzed, and synthesized the information we received from both primary and secondary data sources, we established a prioritization process through which we could identify the community health needs that, if effectively addressed, would have the greatest positive impact on our communities and particularly on our priority populations. Having a consistent, defined process helps reduce the skewing effect of conscious and unconscious biases and enables us to define priority need areas that reflect our community's top health needs rather than our perception of those needs. We evaluated areas of need based on four broad criteria: -Has this need been voiced by the community? Has this need been vetted by the community? -Does this need align with Fairview's strategies and priorities? -Does this need align with existing public health strategies and community health assessments? -Does this need build upon Fairview's 2018 CHNA priority needs? Our process resulted in the identification of three priority need areas. They are: -Navigating and accessing care and resources -Healing, connectedness, and mental health -Addressing structural racism and barriers to achieving health equity.

Schedule H, Part V, Section B, Line 5 Facility , 1
Facility , 1 - Fairview Southdale Hospital. The assessment process and data collection methods we used during this CHNA cycle were different than ever before due to the COVID-19 pandemic. COVID- 19 caused delays in data collection among local, state, and national organizations. As a result of these delays, the U.S. Census Bureau had not yet released finalized data from the 2020 U.S. Census by the time we began the CHNA process. As a result, we used 2015-2019 American Community Survey data. Local public health agencies also were not able to provide updated data as they have in the past. We acknowledge that, due to these setbacks, the data we used is less recent than desired. Additionally, COVID-19 required us to add new safety precautions to our method of gathering community voice data. For example, all conversations and interviews, which had previously been in-person meetings, took place in a virtual format instead. We collected additional community voice data by convening a broad array of stakeholders, with special focus on the priority populations. The process included discussions with community benefit and assessment committees, our community advisory council, the HOPE Commission listening and learning sessions, and key stakeholder interviews. Throughout this process, community members, local business leaders, government representatives, nonprofit and community organizations, and content experts shared their voices and perspectives about their community's health needs. Each hospital within Fairview has a community benefit and assessment committee that is involved in the CHNA process throughout the three-year cycle. Each committee is comprised of local community and organizational leaders and staffed by the Fairview Community Advancement department. Community benefit and assessment committees met four times between April and October in 2021, three of which were individual committee meetings and one of which was a system-wide Community Impact Summit that brought all the committees together. Each committee meeting consisted of facilitated discussions through which our team gathered input about top community needs. The Fairview Community Advisory Council, composed of key community leaders and staffed by Community Advancement, reviews the CHNA report and written implementation strategy and recommends it to the Patient Care and Experience Committee of the Fairview Board of Directors for review and adoption. Each member represents the member's respective community, and members represent a broad range of sectors, among them community organizations serving cultural communities, higher education organizations, banks, and a nonprofit electric company. The Community Advisory Council met from May through November 2021 to participate in the CHNA process, give feedback, and ultimately recommend the CHNA and implementation strategy for adoption. The HOPE Commission is a multi-year transformational change effort of M Health Fairview to drive more equitable outcomes and inclusive environments and experiences for our patients, employees, and communities. The Commission conducted a series of listening and learning sessions in 2020 and 2021. The objective was to hold a mirror to Fairview to assess where we are now and how we can make lasting change. Part of being an anti-racist health system is developing a candid understanding of our shortcomings. We particularly sought to hear perspectives and ideas from the most impacted populations: BIPOC employees and patients, front-line workers who care for underserved and marginalized patients, and those patients themselves. A survey was also made available each year to gather insights and suggestions from employees and patients who could not directly participate in a listening and learning session. In 2020, the commission convened 32 virtual listening and learning sessions and two town halls involving more than 1,500 participants across Fairview sites. The sessions focused on employees but included patients and community members as well. In September 2021, the HOPE Commission continued the listening and learning sessions following the same model. In this iteration, however, the focus was primarily on gathering input from patients (and employees as patients). In both 2020 and 2021's listening and learning sessions, the facilitators and note takers reflected the community represented by the session's group to the greatest degree possible. In August and September 2021, Fairview's Community Advancement team conducted a series of interviews with staff members who work with communities. Each conversation followed a consistent interview protocol developed for this purpose, and each interview was captured by means of detailed notes. The goal of these interviews was to draw on staff expertise to gain a deeper understanding of our priority needs and to determine whether there are any emerging needs that we should be considering. Between Aug. 31 and Sept.17, 2021, we conducted 17 interviews. In August 2021, we held two focus groups in partnership with other organizations. We convened the first focus group in partnership with HealthPartners and Allina Health, and the participants were faith community nurses. We convened the second focus group in partnership with the organizations that are a part of the East Side Health and Well-being Collaborative. This meeting's focus was on accessing care and resources for different cultural communities. Fairview also participated in two large surveys. KRC Research conducted a survey around health and health care needs in St. Paul between June 8 and July 7, 2021, and administered it to community members, Fairview employees, patients, and community partners. Responses were received from 294 residents, more than 1,000 employees, 221 patients, and 20 partners. The survey was offered online and by phone and in five languages: English, Spanish, Hmong, Somali, and Karen. Fairview also supported and was a partner organization in Bridge to Health, a survey that assesses the health needs of northern Minnesota residents. The Bridge to Health survey was administered between Aug.28 and Oct. 23, 2020. The geographic areas that were sampled included Aitkin, Carlton, Cook, Itasca, Koochiching, Lake, St. Louis, and Pine counties in Minnesota, as well as Douglas County in Wisconsin. As a foundational part of program planning and evaluation, Community Advancement staff are continuously soliciting feedback from community partners and program participants. We capture this information on an ongoing basis and use it to provide valuable context and drive insights into the needs of the communities we serve. Fairview staff developed standardized tools, processes, instructions, and facilitator, interviewer, and note-taker protocols and training. All primary data was compiled, cleaned, and analyzed. Community conversations lasted various lengths from 30-120 minutes. All community input was captured by a note-taker. The Fairview team contracted with the following groups to support our assessment process: -Loren Blinde, PhD of Writing Power, a copywriter and content strategist, on the writing of the report. -Kristi Fordyce, an independent contractor, for analysis support. -Weber Shandwick, for data collection and analysis of focus groups and stakeholder interviews focused on St. Paul. -KRC Research for the administration and analysis of the St. Paul Community Survey

Schedule H, Part V, Section B, Line 7 Facility , 1
Facility , 1 - Fairview Southdale Hospital. The Community Health Needs Assessment Report for Fairview Southdale Hospital are located at: https://stcr-prd-cd.fairview.org/-/media/Files/Local-Health-Needs/Read-full-reports/2021-CHNA-Report-Southdale-Hospital2125.pdf?_ga=2.XXX-XX-XXXX.1916792193.1654267916-XXX-XX-XXXX.1594916074 The Community Health Needs Assessment and Implementation Strategy for Fairview Southdale Hospital are located at: https://stcr-prd-cd.fairview.org/-/media/Files/Local-Health-Needs/CHNA-Implementation-Strategy-Report-20222024-Southdale.pdf?_ga=2.XXX-XX-XXXX.1916792193.1654267916-XXX-XX-XXXX.1594916074

Schedule H, Part V, Section B, Line 11 Facility , 1
Facility , 1 - Fairview Southdale Hospital. Over the course of 2021, Fairview's hospitals and medical centers, including the Southdale Hospital, conducted our Community Health Needs Assessment (CHNA) process to determine our priority needs and our response. As part of this process, we listened and learned much about our community's most pressing needs. Through those conversations, and supported by community data, we prioritized the following needs: Navigating and accessing care and resources; Healing, connectedness, and mental health; and Addressing structural racism and barriers to achieving health equity.

Schedule H, Part V, Section B, Line 11 Facility , 2
"Facility , 2 - Fairview Southdale Hospital - continued. The CHNA Implementation Strategy Report outlines the major strategies and actions we will deploy throughout the 2022-2024 assessment cycle. The current generation will be the first generation in American history to experience shorter life expectancy than their parents did.1 Over the past decade, rates of poverty, food insecurity, isolation, mental illness, addiction, and other determinants of poor health have continued to rise and these do not impact everyone equally - Minnesota has some of the nation's largest racial, ethnic, and geographic health inequities. To impact these devastating trends, we must respond in ways that align with the factors that research has shown to have a significant effect on an individual's health and wellbeing. Studies estimate that eighty percent of a person's health outcomes are influenced by factors outside a healthcare setting,2 and a person's zip code matters more than their genetic code when it comes to long-term health.3 Given these realities, our response must reach outside the health system's walls and must focus on those experiencing health inequities to be most effective. Since the 2010 passage of the Affordable Care Act, our health system has engaged in four CHNA cycles. During each cycle, we have found the same or similar needs have existed for our communities. This means that our communities have largely faced the same challenges for more than a decade - and that despite our efforts to address these issues, these problems are not relenting. In fact, in many cases, these conditions have worsened over the past decade. Over the past 10 years of responding to our communities' biggest needs we have learned important lessons which have guided us in the development of our Fairview Health Services 2022-2024 implementation strategies. An essential part of the 2018 CHNA process was the identification of priority needs in the local community. The hospitals and/or medical centers identified the following priority needs for Fairview Southdale Hospital: Mental health and well-being, Healthy lifestyles, Access to care and services. Each hospital and/or medical center developed a hospital specific implementation plan around its priority health issues along with a system focus on policy, system, and environmental (PSE) change to address their identified priority needs. Each program is evaluated on an annual basis against program specific anticipated impacts. As part of the evaluation process each program indicator is assigned a value of ""green"", ""yellow"" or ""red"" based upon the criteria that follows. A rating of ""green"" means that the program (a) met, or exceeded, 2021 hospital goal/s as written in hospital implementation plan (b) it has count data tied to both goal/s and anticipated impact/s (c) there is an evaluation tool with measure tied to anticipated impact/s. A rating of ""yellow"" means that the program (a) had partial completion of 2021 hospital goal/s as written in hospital implementation plan (b) it has count data tied to either goal/s or anticipated impact/s but not both (c)there is an evaluation tool without measure tied to anticipated impact/s. A rating of ""red"" means that the program (a) did not complete the 2021 hospital goal/s written in hospital implementation plan (b) there was no count data (c) there was no evaluation tool/s. Policy, System, and Environmental (PSE) change initiatives often take multiple years to plan and implement. Using a CDC evaluation framework each PSE initiative is monitored and evaluated annually against anticipated activities and milestones linked to the six connected PSE evaluation steps. The six connected steps of PSE change we tracked for monitoring and evaluation purposes are (1) engage stakeholders, (2) describe the program, (3) focus the evaluation design, (4) gather credible evidence, (5) justify conclusions, and (6) ensure use and share lessons learned. Our 2021 evaluation of the PSE initiatives note the specific PSE step/s for that initiatives based on the activities. In 2021 we are identifying PSE initiative specific metrics related to each step to deepen our evaluation of outcomes in future years. Any programmatic anticipated impact that received a rating of ""yellow"" or ""red"" has a corresponding brief explanation and 2021 action plan. In 2021 we will continue refining the rating system and corresponding programmatic and PSE evaluation as part of our commitment to continuous process improvement. Detailed results and action plans on program and PSE initiatives are available upon request. An essential part of the 2018 CHNA process was the identification of priority needs in the local community. The hospitals and/or medical centers identified the following priority needs for Fairview Southdale Hospital: Mental health and well-being, Healthy lifestyles, Access to care and services. Each hospital and/or medical center developed a hospital specific implementation plan around its priority health issues along with a system focus on policy, system, and environmental (PSE) change to address their identified priority needs. Each program is evaluated on an annual basis against program specific anticipated impacts. As part of the evaluation process each program indicator is assigned a value of ""green"", ""yellow"" or ""red"" based upon the criteria that follows. A rating of ""green"" means that the program (a) met, or exceeded, 2021 hospital goal/s as written in hospital implementation plan (b) it has count data tied to both goal/s and anticipated impact/s (c) there is an evaluation tool with measure tied to anticipated impact/s. A rating of ""yellow"" means that the program (a) had partial completion of 2021 hospital goal/s as written in hospital implementation plan (b) it has count data tied to either goal/s or anticipated impact/s but not both (c)there is an evaluation tool without measure tied to anticipated impact/s. A rating of ""red"" means that the program (a) did not complete the 2021 hospital goal/s written in hospital implementation plan (b) there was no count data (c) there was no evaluation tool/s. Policy, System, and Environmental (PSE) change initiatives often take multiple years to plan and implement. Using a CDC evaluation framework each PSE initiative is monitored and evaluated annually against anticipated activities and milestones linked to the six connected PSE evaluation steps. The six connected steps of PSE change we tracked for monitoring and evaluation purposes are (1) engage stakeholders, (2) describe the program, (3) focus the evaluation design, (4) gather credible evidence, (5) justify conclusions, and (6) ensure use and share lessons learned. Our 2021 evaluation of the PSE initiatives note the specific PSE step/s for that initiatives based on the activities. In 2021 we are identifying PSE initiative specific metrics related to each step to deepen our evaluation of outcomes in future years. Any programmatic anticipated impact that received a rating of ""yellow"" or ""red"" has a corresponding brief explanation and 2021 action plan. In 2021 we will continue refining the rating system and corresponding programmatic and PSE evaluation as part of our commitment to continuous process improvement. Detailed results and action plans on program and PSE initiatives are available upon request. Priority: Mental health and wellbeing M Health Fairview Southdale Hospital offered the evidence-based Mental Health First Aid program. The program introduces risk factors and warning signs of common mental health and substance use disorders, builds understanding of their impact, and reviews support options. The interactive course teaches participants how to offer initial help to an individual who may be experiencing a mental health concern or crisis and connect them to the appropriate resources. Youth Mental Health First Aid is the second core program which focuses on mental health concerns among youth ages 12-18. The 2021 anticipated impact for the Mental Health First Aid programs was an increase in participants' ability to recognize and correct misconceptions about mental health and mental illness. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: Outcome: 30% increase from pre-survey (70%) to post-survey (100%) in response to the following: I strongly agree or agree that I can recognize and correct misconceptions about mental health, substance use and mental illness as I encounter them. Evaluation of survey results was done on a program level."

Schedule H, Part V, Section B, Line 11 Facility , 3
"Facility , 3 - Fairview Southdale Hospital - continued. M Health Fairview Southdale Hospital offered the evidence-based Stress Reduction Suite which included two programs (1) Flourish a restorative four-week series, that lets participants experience a variety of mind-body practices designed to promote a sense of calm, joy, connection, and inner strength. A few of the practices explored are moving meditation, journaling, guided imagery, and mindfulness. (2) Resiliency and Stress Management Training Series a restorative six-week series, based on Center Mind Body Medicine, 90-minute sessions. Participants experience a variety of mind-body practices designed to promote a sense of calm, joy, connection, and inner strength. A few of the practices explored by participants include moving meditation, journaling, guided imagery, and mindfulness. This mind body Series is a proven method to reduce stress, increase self-esteem, and improve a person's overall quality of life. The 2021 anticipated impact for the Stress Reduction Suite was a decrease in participants' perceived stress. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: .20 points decrease from pre-program-survey to post-program-survey in response to the following metric: participants' perceived stress. Average change (decrease) in participants' perceived stress on a 10 point scale - the higher the score, the more the perceived stress. Evaluation of survey results was done on a program level. M Health Fairview Southdale Hospital offered the Trauma Informed Congregations program, the implementation of the Risking Connection in Faith Communities curriculum across Faith Communities. Risking Connection helps clergy understand the nature of trauma, its impact on people and how faith leaders can support and bring healing to trauma survivors. The 2021 anticipated impact for the Trauma Informed Congregations program was an increase in clergy/leader understanding of the impact of trauma on trauma survivors. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: 100% of participants reported they understand the impact trauma can have on their clients. Evaluation of survey results was done on a program level. M Health Fairview Southdale Hospital offered Youth Grief Services sessions and camps. Youth Grief Services (YGS) provides a safe and nurturing place where families can turn for help after a loved one dies. YGS assists in the healing process through a network of programs and services that support, educate, and connect grieving families. The 2021 anticipated impact for Youth Grief Services was an increase in youth participants' knowledge of healthy coping strategies in response to grief. The anticipated impact was assigned a value of ""red"". 2021 Outcome: Ownership of Youth Grief Services transferred from Fairview Health Services to Brighter Days Grief Center in December 2020, providing a seamless transition of the program for participants. M Health Fairview Southdale Hospital collaborated in policy, systems and environmental (PSE) change around responding to trauma in settings such as schools and faith communities. This initiative includes activities and milestones linked to PSE evaluation steps (1) engage stakeholders, (2) describe the program, and (3) focus the evaluation design. 2021 Impact: Green - Opened Minnesota's first EmPATH unit- or Emergency Psychiatric Assessment, Treatment, and Healing- a pioneering approach to emergency mental health that offers rapid, comprehensive care in a calming environment at Fairview Southdale Hospital. Planning underway for opening a second unit at University of Minnesota Medical Center. Conducted HOPE Listening and Learning sessions and a survey, to assess the experiential needs of patients and caregivers when accessing care in our system. Planning for Virtual Health Hubs that will break down barriers and allow people to access mental health care despite physical location. Member partner of both the Mental Well Being Task Force for the Hennepin County Community Health Improvement Partnership (CHIP) and Ramsey County Mental Health and Wellness Action Team (MHWAT). In partnership with Ebenezer Senior Living, developed a new quarterly speaking series called HOPE, that address topics such as Adverse Childhood Experiences (ACEs), trauma, and pandemic fatigue. In the development/planning stage for a Wellness Hub that will include providing comprehensive mental health care in a calming, relaxing space. Priority: Healthy lifestyles: M Health Fairview Southdale Hospital offered the evidence-based Falls Prevention Suite which included two programs (1) Matter of Balance a program designed to reduce the fear of falling and increase activity levels among older adults. It includes 8 sessions for a small group of 8-12 participants led by two trained facilitators. Participants learn to view falls and fear of falling as controllable, set realistic goals to increase activity, change their environment to reduce fall risk factors, and exercise to increase strength and balance. (2) Tai Ji Quan a research-based 12-week program that is designed to keep older adults mobile and independent. The program meets twice a week for one hour. The classes will help participants improve balance, strengthen muscles, and reduce the risk of falling. The 2021 anticipated impact for the Falls Prevention Suite was a decrease participants' fear of falling. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: 14% decrease from pre-survey (86%) to post-survey (73%) in participants that responded with a little, somewhat, or a lot to the following: How fearful are you of falling? Evaluation of survey results was done on a program level. M Health Fairview Southdale Hospital offered the evidence-based Living Well Suite which included three programs that were developed by Stanford University's Patient Education Research Center. (1) Chronic Disease Self- Management is a workshop given 2.5 hours once a week, for six weeks offered to individuals and their caregivers who are living with chronic conditions. Subjects addressed include medication use, communication with doctors and caregivers, nutrition, and fitness- with practical exercises and advice designed to meet participants' needs. (2) Chronic Pain Self-Management is a workshop given 2 hours once a week, for six weeks, in community settings. The workshop helps participants, and their support person, deal with the ongoing issues associated with chronic pain. (3) Diabetes Self-Management is a 6 week once a week program developed to helps those living with diabetes or pre-diabetes to improve their general health. The 2021 anticipated impact for the Living Well Suite was an increase participants' perception of positive lifestyle changes. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: 89% of participants that responded to the post program survey indicated that they strongly agree or agree with the following statement: The program has helped them manage chronic condition(s). Evaluation of survey results was done on a program level. M Health Fairview Southdale Hospital collaborated in policy, systems and environmental (PSE) change around healthy food transformation addressing issues such as food insecurity, food access, and changes to cafeteria menus. This initiative includes activities and milestones linked to PSE evaluation steps (1) engage stakeholders, (2) describe the program, and (3) focus the evaluation design. 2021 Impact: Green - Outcome: Strengthened partnerships with local food organizations such as Second Harvest Heartland and Sanneh Foundation. Includes planning for a Wellness Hub that will be a new distribution site for food and provide workforce development opportunities for youth in the food sector. Continue to serve as a backbone partner in the Food Justice Network. Expanded Community Supported Agriculture (CSA) program to new CSA farms to meet the differing needs of clinic participants and support new farmer partners. Planning to offer, in partnership with Keystone Community Services, a mobile food pantry at clinics. Signed contact for Now Pow which will screen patients for social determinants such as food security and provide resources and referrals."

Schedule H, Part V, Section B, Line 11 Facility , 4
"Facility , 4 - Fairview Southdale Hospital - continued. Priority: Access to care and resources: M Health Fairview Southdale Hospital conducted Minnesota Immunization Network Initiative (MINI) Clinics. MINI is a multi-sector, community collaboration providing free flu shots to uninsured, underserved, and minority populations. The MINI clinics bring flu vaccine, educational materials, and volunteers to community locations such as churches or community centers and with its partners, ensure a culturally and linguistically appropriate experience in a safe and trusted environment. The 2021 anticipated impact for the MINI clinics was an increase in the number of clinics with culturally and/or linguistically appropriate materials around accessing care and resources. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: 31% of new partner clinic sites had culturally and/or linguistically appropriate materials around accessing care and resources. M Health Fairview Southdale Hospital offered the evidence-based Falls Prevention Suite which included two programs (1) Matter of Balance a program designed to reduce the fear of falling and increase activity levels among older adults. It includes 8 sessions for a small group of 8-12 participants led by two trained facilitators. Participants learn to view falls and fear of falling as controllable, set realistic goals to increase activity, change their environment to reduce fall risk factors, and exercise to increase strength and balance. (2) Tai Ji Quan a research-based 12-week program that is designed to keep older adults mobile and independent. The program meets twice a week for one hour. The classes will help participants improve balance, strengthen muscles, and reduce the risk of falling. The 2021 anticipated impact for the Falls Prevention Suite was an increase in participants' comfort talking to their health care provider about medications and other possible risks of falling. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - * Outcome: 67% of participants that responded to the post program survey indicated that they strongly agree or agree with the following statement: I feel more comfortable talking to my health care provider about my medications and other possible risks for falling. Evaluation of survey results was done on a program level. M Health Fairview Southdale Hospital offered the evidence-based Living Well Suite which included three programs that were developed by Stanford University's Patient Education Research Center. (1) Chronic Disease Self- Management is a workshop given 2.5 hours once a week, for six weeks offered to individuals and their caregivers who are living with chronic conditions. Subjects addressed include medication use, communication with doctors and caregivers, nutrition, and fitness- with practical exercises and advice designed to meet participants' needs. (2) Chronic Pain Self-Management is a workshop given 2 hours once a week, for six weeks, in community settings. The workshop helps participants, and their support person, deal with the ongoing issues associated with chronic pain. (3) Diabetes Self-Management is a 6 week once a week program developed to helps those living with diabetes or pre-diabetes to improve their general health. The 2021 anticipated impact for the Living Well Suite was an increase in participants who agree that the program helps them work with their health care providers. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - * Outcome: 86% of participants that responded to the post program survey indicated that they strongly agree or agree with the following statement: The program has helped them work with healthcare professionals. Evaluation of survey results was done on a program level. M Health Fairview Southdale Hospital offered the evidence-based Mental Health First Aid program. The program introduces risk factors and warning signs of common mental health and substance use disorders, builds understanding of their impact, and reviews support options. The interactive course teaches participants how to offer initial help to an individual who may be experiencing a mental health concern or crisis and connect them to the appropriate resources. Youth Mental Health First Aid is the second core program which focuses on mental health concerns among youth ages 12-18. The 2021 anticipated impact for the Mental Health First Aid programs was increase participants' confidence in assisting someone to connect with professional resources. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: 31% increase from pre-survey (67%) to post-survey (98%) in response to the following: I strongly agree or agree that I can assist someone who may be dealing with a mental health problem, substance use challenge or crisis in seeking professional help. Evaluation of survey results was done on a program level. Needs identified but not addressed: Although the following health needs were not selected as priority needs, M Health Fairview will continue to support work aligned with addressing these needs as appropriate particularly when doing so would address the social determinants of health and/or the leading causes of premature death. Childcare: This issue is beyond what M Health Fairview resources can support at this time. Chronic lower respiratory disease: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Clinic hours: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Cost associated with care: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Health literacy: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Safe neighborhoods: This issue is beyond what M Health Fairview resources can support at this time. Stroke: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Health literacy: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Safe neighborhoods: This issue is beyond what M Health Fairview resources can support at this time. Stroke: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Transportation: This issue is beyond what M Health Fairview resources can support at this time."

Schedule H, Part V, Section B, Line 13 Facility , 1
Facility , 1 - Fairview Southdale Hospital. The Minnesota Attorney General agreement was used in the determination of the eligibility for financial assistance.

Schedule H, Part V, Section B, Line 16 Facility , 1
Facility , 1 - Fairview Southdale Hospital. A summary of the Financial Assistance Policy is posted in various locations in the hospital.

Schedule H, Part V, Section B, Line 3E
Fairview is committed to transparency and accountability in all we do, including our efforts to assess - and respond to - our community's most pressing health needs. The community benefit work that we do across Fairview must reflect our community's actual needs, not our assumptions about what those needs might or should be. Because we understand that change cannot happen when we work in silos, and it cannot happen in a single year, we grounded our 2021 CHNA process in alignment with our 2018 CHNA needs, existing data, and the voices of community members and community partners. Once we had collected, analyzed, and synthesized the information we received from both primary and secondary data sources, we established a prioritization process through which we could identify the community health needs that, if effectively addressed, would have the greatest positive impact on our communities and particularly on our priority populations. Having a consistent, defined process helps reduce the skewing effect of conscious and unconscious biases and enables us to define priority need areas that reflect our community's top health needs rather than our perception of those needs. We evaluated areas of need based on four broad criteria: -Has this need been voiced by the community? Has this need been vetted by the community? -Does this need align with Fairview's strategies and priorities? -Does this need align with existing public health strategies and community health assessments? -Does this need build upon Fairview's 2018 CHNA priority needs? Our process resulted in the identification of three priority need areas. They are: -Navigating and accessing care and resources -Healing, connectedness, and mental health -Addressing structural racism and barriers to achieving health equity.

Schedule H, Part V, Section B, Line 5 Facility , 1
Facility , 1 - Fairview Ridges Hospital. The assessment process and data collection methods we used during this CHNA cycle were different than ever before due to the COVID-19 pandemic. COVID- 19 caused delays in data collection among local, state, and national organizations. As a result of these delays, the U.S. Census Bureau had not yet released finalized data from the 2020 U.S. Census by the time we began the CHNA process. As a result, we used 2015-2019 American Community Survey data. Local public health agencies also were not able to provide updated data as they have in the past. We acknowledge that, due to these setbacks, the data we used is less recent than desired. Additionally, COVID-19 required us to add new safety precautions to our method of gathering community voice data. For example, all conversations and interviews, which had previously been in-person meetings, took place in a virtual format instead. We collected additional community voice data by convening a broad array of stakeholders, with special focus on the priority populations. The process included discussions with community benefit and assessment committees, our community advisory council, the HOPE Commission listening and learning sessions, and key stakeholder interviews. Throughout this process, community members, local business leaders, government representatives, nonprofit and community organizations, and content experts shared their voices and perspectives about their community's health needs. Each hospital within Fairview has a community benefit and assessment committee that is involved in the CHNA process throughout the three-year cycle. Each committee is comprised of local community and organizational leaders and staffed by the Fairview Community Advancement department. Community benefit and assessment committees met four times between April and October in 2021, three of which were individual committee meetings and one of which was a system-wide Community Impact Summit that brought all the committees together. Each committee meeting consisted of facilitated discussions through which our team gathered input about top community needs. The Fairview Community Advisory Council, composed of key community leaders and staffed by Community Advancement, reviews the CHNA report and written implementation strategy and recommends it to the Patient Care and Experience Committee of the Fairview Board of Directors for review and adoption. Each member represents the member's respective community, and members represent a broad range of sectors, among them community organizations serving cultural communities, higher education organizations, banks, and a nonprofit electric company. The Community Advisory Council met from May through November 2021 to participate in the CHNA process, give feedback, and ultimately recommend the CHNA and implementation strategy for adoption. The HOPE Commission is a multi-year transformational change effort of M Health Fairview to drive more equitable outcomes and inclusive environments and experiences for our patients, employees, and communities. The Commission conducted a series of listening and learning sessions in 2020 and 2021. The objective was to hold a mirror to Fairview to assess where we are now and how we can make lasting change. Part of being an anti-racist health system is developing a candid understanding of our shortcomings. We particularly sought to hear perspectives and ideas from the most impacted populations: BIPOC employees and patients, front-line workers who care for underserved and marginalized patients, and those patients themselves. A survey was also made available each year to gather insights and suggestions from employees and patients who could not directly participate in a listening and learning session. In 2020, the commission convened 32 virtual listening and learning sessions and two town halls involving more than 1,500 participants across Fairview sites. The sessions focused on employees but included patients and community members as well. In September 2021, the HOPE Commission continued the listening and learning sessions following the same model. In this iteration, however, the focus was primarily on gathering input from patients (and employees as patients). In both 2020 and 2021's listening and learning sessions, the facilitators and note takers reflected the community represented by the session's group to the greatest degree possible. In August and September 2021, Fairview's Community Advancement team conducted a series of interviews with staff members who work with communities. Each conversation followed a consistent interview protocol developed for this purpose, and each interview was captured by means of detailed notes. The goal of these interviews was to draw on staff expertise to gain a deeper understanding of our priority needs and to determine whether there are any emerging needs that we should be considering. Between Aug. 31 and Sept.17, 2021, we conducted 17 interviews. In August 2021, we held two focus groups in partnership with other organizations. We convened the first focus group in partnership with HealthPartners and Allina Health, and the participants were faith community nurses. We convened the second focus group in partnership with the organizations that are a part of the East Side Health and Well-being Collaborative. This meeting's focus was on accessing care and resources for different cultural communities. Fairview also participated in two large surveys. KRC Research conducted a survey around health and health care needs in St. Paul between June 8 and July 7, 2021, and administered it to community members, Fairview employees, patients, and community partners. Responses were received from 294 residents, more than 1,000 employees, 221 patients, and 20 partners. The survey was offered online and by phone and in five languages: English, Spanish, Hmong, Somali, and Karen. Fairview also supported and was a partner organization in Bridge to Health, a survey that assesses the health needs of northern Minnesota residents. The Bridge to Health survey was administered between Aug.28 and Oct. 23, 2020. The geographic areas that were sampled included Aitkin, Carlton, Cook, Itasca, Koochiching, Lake, St. Louis, and Pine counties in Minnesota, as well as Douglas County in Wisconsin. As a foundational part of program planning and evaluation, Community Advancement staff are continuously soliciting feedback from community partners and program participants. We capture this information on an ongoing basis and use it to provide valuable context and drive insights into the needs of the communities we serve. Fairview staff developed standardized tools, processes, instructions, and facilitator, interviewer, and note-taker protocols and training. All primary data was compiled, cleaned, and analyzed. Community conversations lasted various lengths from 30-120 minutes. All community input was captured by a note-taker. The Fairview team contracted with the following groups to support our assessment process: -Loren Blinde, PhD of Writing Power, a copywriter and content strategist, on the writing of the report. -Kristi Fordyce, an independent contractor, for analysis support. -Weber Shandwick, for data collection and analysis of focus groups and stakeholder interviews focused on St. Paul. -KRC Research for the administration and analysis of the St. Paul Community Survey

Schedule H, Part V, Section B, Line 7 Facility , 1
Facility , 1 - Fairview Ridges Hospital. The Community Health Needs Assessment Report for Fairview Ridges Hospital are located at: https://stcr-prd-cd.fairview.org/-/media/Files/Local-Health-Needs/Read-full-reports/2021-CHNA-Report-Ridges-Hospital2125.pdf?_ga=2.80614103.1916792193.1654267916-XXX-XX-XXXX.1594916074 The Community Health Needs Assessment and Implementation Strategy for Fairview Ridges Hospital are located at: https://stcr-prd-cd.fairview.org/-/media/Files/Local-Health-Needs/CHNA-Implementation-Strategy-Report-20222024-Ridges.pdf?_ga=2.80614103.1916792193.1654267916-XXX-XX-XXXX.1594916074

Schedule H, Part V, Section B, Line 11 Facility , 1
Facility , 1 - Fairview Ridges Hospital. Over the course of 2021, Fairview's hospitals and medical centers, including the Fairview Ridges Hospital, conducted our Community Health Needs Assessment (CHNA) process to determine our priority needs and our response. As part of this process, we listened and learned much about our community's most pressing needs. Through those conversations, and supported by community data, we prioritized the following needs: Navigating and accessing care and resources; Healing, connectedness, and mental health; and Addressing structural racism and barriers to achieving health equity. The CHNA Implementation Strategy Report outlines the major strategies and actions we will deploy throughout the 2022-2024 assessment cycle. The current generation will be the first generation in American history to experience shorter life expectancy than their parents did.1 Over the past decade, rates of poverty, food insecurity, isolation, mental illness, addiction, and other determinants of poor health have continued to rise and these do not impact everyone equally - Minnesota has some of the nation's largest racial, ethnic, and geographic health inequities. To impact these devastating trends, we must respond in ways that align with the factors that research has shown to have a significant effect on an individual's health and wellbeing. Studies estimate that eighty percent of a person's health outcomes are influenced by factors outside a healthcare setting,2 and a person's zip code matters more than their genetic code when it comes to long-term health.3 Given these realities, our response must reach outside the health system's walls and must focus on those experiencing health inequities to be most effective. Since the 2010 passage of the Affordable Care Act, our health system has engaged in four CHNA cycles. During each cycle, we have found the same or similar needs have existed for our communities. This means that our communities have largely faced the same challenges for more than a decade - and that despite our efforts to address these issues, these problems are not relenting. In fact, in many cases, these conditions have worsened over the past decade. Over the past 10 years of responding to our communities' biggest needs we have learned important lessons which have guided us in the development of our Fairview Health Services 2022-2024 implementation strategies.

Schedule H, Part V, Section B, Line 11 Facility , 2
"Facility , 2 - Fairview Ridges Hospital - continued. An essential part of the 2018 CHNA process was the identification of priority needs in the local community. The hospitals and/or medical centers identified the following priority needs for Fairview Ridges Hospital: Mental health and well-being, Healthy lifestyles, Access to care and services. Each hospital and/or medical center developed a hospital specific implementation plan around its priority health issues along with a system focus on policy, system, and environmental (PSE) change to address their identified priority needs. Each program is evaluated on an annual basis against program specific anticipated impacts. As part of the evaluation process each program indicator is assigned a value of ""green"", ""yellow"" or ""red"" based upon the criteria that follows. A rating of ""green"" means that the program (a) met, or exceeded, 2021 hospital goal/s as written in hospital implementation plan (b) it has count data tied to both goal/s and anticipated impact/s (c) there is an evaluation tool with measure tied to anticipated impact/s. A rating of ""yellow"" means that the program (a) had partial completion of 2021 hospital goal/s as written in hospital implementation plan (b) it has count data tied to either goal/s or anticipated impact/s but not both (c)there is an evaluation tool without measure tied to anticipated impact/s. A rating of ""red"" means that the program (a) did not complete the 2021 hospital goal/s written in hospital implementation plan (b) there was no count data (c) there was no evaluation tool/s. Policy, System, and Environmental (PSE) change initiatives often take multiple years to plan and implement. Using a CDC evaluation framework each PSE initiative is monitored and evaluated annually against anticipated activities and milestones linked to the six connected PSE evaluation steps. The six connected steps of PSE change we tracked for monitoring and evaluation purposes are (1) engage stakeholders, (2) describe the program, (3) focus the evaluation design, (4) gather credible evidence, (5) justify conclusions, and (6) ensure use and share lessons learned. Our 2021 evaluation of the PSE initiatives note the specific PSE step/s for that initiatives based on the activities. In 2021 we are identifying PSE initiative specific metrics related to each step to deepen our evaluation of outcomes in future years. Any programmatic anticipated impact that received a rating of ""yellow"" or ""red"" has a corresponding brief explanation and 2021 action plan. In 2021 we will continue refining the rating system and corresponding programmatic and PSE evaluation as part of our commitment to continuous process improvement. Detailed results and action plans on program and PSE initiatives are available upon request. Priority: Mental health and wellbeing M Health Fairview Ridges Hospital offered the evidence-based Mental Health First Aid program. The program introduces risk factors and warning signs of common mental health and substance use disorders, builds understanding of their impact, and reviews support options. The interactive course teaches participants how to offer initial help to an individual who may be experiencing a mental health concern or crisis and connect them to the appropriate resources. Youth Mental Health First Aid is the second core program which focuses on mental health concerns among youth ages 12-18. The 2021 anticipated impact for the Mental Health First Aid programs was an increase in participants' ability to recognize and correct misconceptions about mental health and mental illness. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: Outcome: 30% increase from pre-survey (70%) to post-survey (100%) in response to the following: I strongly agree or agree that I can recognize and correct misconceptions about mental health, substance use and mental illness as I encounter them. Evaluation of survey results was done on a program level. M Health Fairview Ridges Hospital offered the Trauma Informed Congregations program, the implementation of the Risking Connection in Faith Communities curriculum across Faith Communities. Risking Connection helps clergy understand the nature of trauma, its impact on people and how faith leaders can support and bring healing to trauma survivors. The 2021 anticipated impact for the Trauma Informed Congregations program was an increase in clergy/leader understanding of the impact of trauma on trauma survivors. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: 100% of participants reported they understand the impact trauma can have on their clients. Evaluation of survey results was done on a program level. M Health Fairview Ridges Hospital offered Youth Grief Services sessions and camps. Youth Grief Services (YGS) provides a safe and nurturing place where families can turn for help after a loved one dies. YGS assists in the healing process through a network of programs and services that support, educate, and connect grieving families. The 2021 anticipated impact for Youth Grief Services was an increase in youth participants' knowledge of healthy coping strategies in response to grief. The anticipated impact was assigned a value of ""red"". 2021 Outcome: Ownership of Youth Grief Services transferred from Fairview Health Services to Brighter Days Grief Center in December 2020, providing a seamless transition of the program for participants. M Health Fairview Ridges Hospital offered the Mobile Substance Use Disorder Support Program, serving adult residents (18+) in Ramsey, Dakota, and Washington Counties who have substance use issues through Mobile SUDs team who are professional peer recovery specialists and clinical staff who collaborate to develop individual recovery plans. The 2021 anticipated impact for the Mobile Substance Use Disorder Support Program was an increase in the number of active participants in the recovery program. The anticipated impact was assigned a value of ""red"". 2021 Impact: Red - The program was discontinued in 2021. A similar program will be developed within the Mental Health & Addiction Transition Clinic for short-term treatment of patients after an emergency room visit. M Health Fairview Rdges Hospital collaborated in policy, systems and environmental (PSE) change around responding to trauma in settings such as schools and faith communities. This initiative includes activities and milestones linked to PSE evaluation steps (1) engage stakeholders, (2) describe the program, and (3) focus the evaluation design. 2021 Impact: Green - Opened Minnesota's first EmPATH unit- or Emergency Psychiatric Assessment, Treatment, and Healing- a pioneering approach to emergency mental health that offers rapid, comprehensive care in a calming environment at Fairview Southdale Hospital. Planning underway for opening a second unit at University of Minnesota Medical Center. Conducted HOPE Listening and Learning sessions and a survey, to assess the experiential needs of patients and caregivers when accessing care in our system. Planning for Virtual Health Hubs that will break down barriers and allow people to access mental health care despite physical location. Member partner of both the Mental Well Being Task Force for the Hennepin County Community Health Improvement Partnership (CHIP) and Ramsey County Mental Health and Wellness Action Team (MHWAT). In partnership with Ebenezer Senior Living, developed a new quarterly speaking series called HOPE, that address topics such as Adverse Childhood Experiences (ACEs), trauma, and pandemic fatigue. In the development/planning stage for a Wellness Hub that will include providing comprehensive mental health care in a calming, relaxing space."

Schedule H, Part V, Section B, Line 11 Facility , 3
"Facility , 3 - Fairview Ridges Hospital - continued. Priority: Healthy lifestyles M Health Fairview Ridges Hospital offered the evidence-based Falls Prevention Suite which included two programs (1) Matter of Balance a program designed to reduce the fear of falling and increase activity levels among older adults. It includes 8 sessions for a small group of 8-12 participants led by two trained facilitators. Participants learn to view falls and fear of falling as controllable, set realistic goals to increase activity, change their environment to reduce fall risk factors, and exercise to increase strength and balance. (2) Tai Ji Quan a research-based 12-week program that is designed to keep older adults mobile and independent. The program meets twice a week for one hour. The classes will help participants improve balance, strengthen muscles, and reduce the risk of falling. The 2021 anticipated impact for the Falls Prevention Suite was a decrease participants' fear of falling. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: 14% decrease from pre-survey (86%) to post-survey (73%) in participants that responded with a little, somewhat, or a lot to the following: How fearful are you of falling? Evaluation of survey results was done on a program level. M Health Fairview Ridges Hospital offered the evidence-based Living Well Suite which included three programs that were developed by Stanford University's Patient Education Research Center. (1) Chronic Disease Self- Management is a workshop given 2.5 hours once a week, for six weeks offered to individuals and their caregivers who are living with chronic conditions. Subjects addressed include medication use, communication with doctors and caregivers, nutrition, and fitness- with practical exercises and advice designed to meet participants' needs. (2) Chronic Pain Self-Management is a workshop given 2 hours once a week, for six weeks, in community settings. The workshop helps participants, and their support person, deal with the ongoing issues associated with chronic pain. (3) Diabetes Self-Management is a 6 week once a week program developed to helps those living with diabetes or pre-diabetes to improve their general health. The 2021 anticipated impact for the Living Well Suite was an increase participants' perception of positive lifestyle changes. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: 89% of participants that responded to the post program survey indicated that they strongly agree or agree with the following statement: The program has helped them manage chronic condition(s). Evaluation of survey results was done on a program level. M Health Fairview Ridges Hospital collaborated in policy, systems and environmental (PSE) change around healthy food transformation addressing issues such as food insecurity, food access, and changes to cafeteria menus. This initiative includes activities and milestones linked to PSE evaluation steps (1) engage stakeholders, (2) describe the program, and (3) focus the evaluation design. 2021 Impact: Green - Outcome: Strengthened partnerships with local food organizations such as Second Harvest Heartland and Sanneh Foundation. Includes planning for a Wellness Hub that will be a new distribution site for food and provide workforce development opportunities for youth in the food sector. Continue to serve as a backbone partner in the Food Justice Network. Expanded Community Supported Agriculture (CSA) program to new CSA farms to meet the differing needs of clinic participants and support new farmer partners. Planning to offer, in partnership with Keystone Community Services, a mobile food pantry at clinics. Signed contact for Now Pow which will screen patients for social determinants such as food security and provide resources and referrals. Priority: Access to care and resources M Health Fairview Ridges Hospital conducted Minnesota Immunization Network Initiative (MINI) Clinics. MINI is a multi-sector, community collaboration providing free flu shots to uninsured, underserved, and minority populations. The MINI clinics bring flu vaccine, educational materials, and volunteers to community locations such as churches or community centers and with its partners, ensure a culturally and linguistically appropriate experience in a safe and trusted environment. The 2021 anticipated impact for the MINI clinics was an increase in the number of clinics with culturally and/or linguistically appropriate materials around accessing care and resources. 2021 Impact: Red - Outcome: No new clinics were added. M Health Fairview Ridges Hospital offered the evidence-based Falls Prevention Suite which included two programs (1) Matter of Balance a program designed to reduce the fear of falling and increase activity levels among older adults. It includes 8 sessions for a small group of 8-12 participants led by two trained facilitators. Participants learn to view falls and fear of falling as controllable, set realistic goals to increase activity, change their environment to reduce fall risk factors, and exercise to increase strength and balance. (2) Tai Ji Quan a research-based 12-week program that is designed to keep older adults mobile and independent. The program meets twice a week for one hour. The classes will help participants improve balance, strengthen muscles, and reduce the risk of falling. The 2021 anticipated impact for the Falls Prevention Suite was an increase in participants' comfort talking to their health care provider about medications and other possible risks of falling. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - * Outcome: 67% of participants that responded to the post program survey indicated that they strongly agree or agree with the following statement: I feel more comfortable talking to my health care provider about my medications and other possible risks for falling. Evaluation of survey results was done on a program level. M Health Fairview Ridges Hospital offered the evidence-based Living Well Suite which included three programs that were developed by Stanford University's Patient Education Research Center. (1) Chronic Disease Self- Management is a workshop given 2.5 hours once a week, for six weeks offered to individuals and their caregivers who are living with chronic conditions. Subjects addressed include medication use, communication with doctors and caregivers, nutrition, and fitness- with practical exercises and advice designed to meet participants' needs. (2) Chronic Pain Self-Management is a workshop given 2 hours once a week, for six weeks, in community settings. The workshop helps participants, and their support person, deal with the ongoing issues associated with chronic pain. (3) Diabetes Self-Management is a 6 week once a week program developed to helps those living with diabetes or pre-diabetes to improve their general health. The 2021 anticipated impact for the Living Well Suite was an increase in participants who agree that the program helps them work with their health care providers. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - * Outcome: 86% of participants that responded to the post program survey indicated that they strongly agree or agree with the following statement: The program has helped them work with healthcare professionals. Evaluation of survey results was done on a program level.M Health Fairview Ridges Hospital offered the evidence-based Mental Health First Aid program. The program introduces risk factors and warning signs of common mental health and substance use disorders, builds understanding of their impact, and reviews support options. The interactive course teaches participants how to offer initial help to an individual who may be experiencing a mental health concern or crisis and connect them to the appropriate resources. Youth Mental Health First Aid is the second core program which focuses on mental health concerns among youth ages 12-18. The 2021 anticipated impact for the Mental Health First Aid programs was increase participants' confidence in assisting someone to connect with professional resources. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: 31% increase from pre-survey (67%) to post-survey (98%) in response to the following: I strongly agree or agree that I can assist someone who may be dealing with a mental health problem, substance use challenge or crisis in seeking professional help. Evaluation of survey results was done on a program level."

Schedule H, Part V, Section B, Line 11 Facility , 4
Facility , 4 - Fairview Ridges Hospital - continued. Needs identified but not addressed: Although the following health needs were not selected as priority needs, M Health Fairview will continue to support work aligned with addressing these needs as appropriate particularly when doing so would address the social determinants of health and/or the leading causes of premature death. Childcare: This issue is beyond what M Health Fairview resources can support at this time. Chronic lower respiratory disease: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Clinic hours: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Cost associated with care: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Health literacy: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Safe neighborhoods: This issue is beyond what M Health Fairview resources can support at this time.

Schedule H, Part V, Section B, Line 13 Facility , 1
Facility , 1 - Fairview Ridges Hospital. The Minnesota Attorney General agreement was used in the determination of the eligibility for financial assistance.

Schedule H, Part V, Section B, Line 16 Facility , 1
Facility , 1 - Fairview Ridges Hospital. A summary of the Financial Assistance Policy is posted in various locations in the hospital.

Schedule H, Part V, Section B, Line 3E
Fairview is committed to transparency and accountability in all we do, including our efforts to assess - and respond to - our community's most pressing health needs. The community benefit work that we do across Fairview must reflect our community's actual needs, not our assumptions about what those needs might or should be. Because we understand that change cannot happen when we work in silos, and it cannot happen in a single year, we grounded our 2021 CHNA process in alignment with our 2018 CHNA needs, existing data, and the voices of community members and community partners. Once we had collected, analyzed, and synthesized the information we received from both primary and secondary data sources, we established a prioritization process through which we could identify the community health needs that, if effectively addressed, would have the greatest positive impact on our communities and particularly on our priority populations. Having a consistent, defined process helps reduce the skewing effect of conscious and unconscious biases and enables us to define priority need areas that reflect our community's top health needs rather than our perception of those needs. We evaluated areas of need based on four broad criteria: -Has this need been voiced by the community? Has this need been vetted by the community? -Does this need align with Fairview's strategies and priorities? -Does this need align with existing public health strategies and community health assessments? -Does this need build upon Fairview's 2018 CHNA priority needs? Our process resulted in the identification of three priority need areas. They are: -Navigating and accessing care and resources -Healing, connectedness, and mental health -Addressing structural racism and barriers to achieving health equity.

Schedule H, Part V, Section B, Line 5 Facility , 1
Facility , 1 - Fairview Lakes Regional Medical Ctr. The assessment process and data collection methods we used during this CHNA cycle were different than ever before due to the COVID-19 pandemic. COVID- 19 caused delays in data collection among local, state, and national organizations. As a result of these delays, the U.S. Census Bureau had not yet released finalized data from the 2020 U.S. Census by the time we began the CHNA process. As a result, we used 2015-2019 American Community Survey data. Local public health agencies also were not able to provide updated data as they have in the past. We acknowledge that, due to these setbacks, the data we used is less recent than desired. Additionally, COVID-19 required us to add new safety precautions to our method of gathering community voice data. For example, all conversations and interviews, which had previously been in-person meetings, took place in a virtual format instead. We collected additional community voice data by convening a broad array of stakeholders, with special focus on the priority populations. The process included discussions with community benefit and assessment committees, our community advisory council, the HOPE Commission listening and learning sessions, and key stakeholder interviews. Throughout this process, community members, local business leaders, government representatives, nonprofit and community organizations, and content experts shared their voices and perspectives about their community's health needs. Each hospital within Fairview has a community benefit and assessment committee that is involved in the CHNA process throughout the three-year cycle. Each committee is comprised of local community and organizational leaders and staffed by the Fairview Community Advancement department. Community benefit and assessment committees met four times between April and October in 2021, three of which were individual committee meetings and one of which was a system-wide Community Impact Summit that brought all the committees together. Each committee meeting consisted of facilitated discussions through which our team gathered input about top community needs. The Fairview Community Advisory Council, composed of key community leaders and staffed by Community Advancement, reviews the CHNA report and written implementation strategy and recommends it to the Patient Care and Experience Committee of the Fairview Board of Directors for review and adoption. Each member represents the member's respective community, and members represent a broad range of sectors, among them community organizations serving cultural communities, higher education organizations, banks, and a nonprofit electric company. The Community Advisory Council met from May through November 2021 to participate in the CHNA process, give feedback, and ultimately recommend the CHNA and implementation strategy for adoption. The HOPE Commission is a multi-year transformational change effort of M Health Fairview to drive more equitable outcomes and inclusive environments and experiences for our patients, employees, and communities. The Commission conducted a series of listening and learning sessions in 2020 and 2021. The objective was to hold a mirror to Fairview to assess where we are now and how we can make lasting change. Part of being an anti-racist health system is developing a candid understanding of our shortcomings. We particularly sought to hear perspectives and ideas from the most impacted populations: BIPOC employees and patients, front-line workers who care for underserved and marginalized patients, and those patients themselves. A survey was also made available each year to gather insights and suggestions from employees and patients who could not directly participate in a listening and learning session. In 2020, the commission convened 32 virtual listening and learning sessions and two town halls involving more than 1,500 participants across Fairview sites. The sessions focused on employees but included patients and community members as well. In September 2021, the HOPE Commission continued the listening and learning sessions following the same model. In this iteration, however, the focus was primarily on gathering input from patients (and employees as patients). In both 2020 and 2021's listening and learning sessions, the facilitators and note takers reflected the community represented by the session's group to the greatest degree possible. In August and September 2021, Fairview's Community Advancement team conducted a series of interviews with staff members who work with communities. Each conversation followed a consistent interview protocol developed for this purpose, and each interview was captured by means of detailed notes. The goal of these interviews was to draw on staff expertise to gain a deeper understanding of our priority needs and to determine whether there are any emerging needs that we should be considering. Between Aug. 31 and Sept.17, 2021, we conducted 17 interviews. In August 2021, we held two focus groups in partnership with other organizations. We convened the first focus group in partnership with HealthPartners and Allina Health, and the participants were faith community nurses. We convened the second focus group in partnership with the organizations that are a part of the East Side Health and Well-being Collaborative. This meeting's focus was on accessing care and resources for different cultural communities. Fairview also participated in two large surveys. KRC Research conducted a survey around health and health care needs in St. Paul between June 8 and July 7, 2021, and administered it to community members, Fairview employees, patients, and community partners. Responses were received from 294 residents, more than 1,000 employees, 221 patients, and 20 partners. The survey was offered online and by phone and in five languages: English, Spanish, Hmong, Somali, and Karen. Fairview also supported and was a partner organization in Bridge to Health, a survey that assesses the health needs of northern Minnesota residents. The Bridge to Health survey was administered between Aug.28 and Oct. 23, 2020. The geographic areas that were sampled included Aitkin, Carlton, Cook, Itasca, Koochiching, Lake, St. Louis, and Pine counties in Minnesota, as well as Douglas County in Wisconsin. As a foundational part of program planning and evaluation, Community Advancement staff are continuously soliciting feedback from community partners and program participants. We capture this information on an ongoing basis and use it to provide valuable context and drive insights into the needs of the communities we serve. Fairview staff developed standardized tools, processes, instructions, and facilitator, interviewer, and note-taker protocols and training. All primary data was compiled, cleaned, and analyzed. Community conversations lasted various lengths from 30-120 minutes. All community input was captured by a note-taker. The Fairview team contracted with the following groups to support our assessment process: -Loren Blinde, PhD of Writing Power, a copywriter and content strategist, on the writing of the report. -Kristi Fordyce, an independent contractor, for analysis support. -Weber Shandwick, for data collection and analysis of focus groups and stakeholder interviews focused on St. Paul. -KRC Research for the administration and analysis of the St. Paul Community Survey

Schedule H, Part V, Section B, Line 7 Facility , 1
Facility , 1 - Fairview Lakes Regional Medical Ctr. The Community Health Needs Assessment Report for Fairview Lakes Medical Center are located at: https://stcr-prd-cd.fairview.org/-/media/Files/Local-Health-Needs/Read-full-reports/2021-CHNA-Report-Lakes-Medical-Center2125.pdf?_ga=2.XXX-XX-XXXX.1916792193.1654267916-XXX-XX-XXXX.1594916074 The Community Health Needs Assessment and Implementation Strategy for Fairview Lakes Medical Center are located at: https://stcr-prd-cd.fairview.org/-/media/Files/Local-Health-Needs/CHNA-Implementation-Strategy-Report-20222024-Lakes.pdf?_ga=2.XXX-XX-XXXX.1916792193.1654267916-XXX-XX-XXXX.1594916074

Schedule H, Part V, Section B, Line 11 Facility , 1
Facility , 1 - Fairview Lakes Regional Medical Ctr. Over the course of 2021, Fairview's hospitals and medical centers, including the Fairview Lakes Reginal Medical Center, conducted our Community Health Needs Assessment (CHNA) process to determine our priority needs and our response. As part of this process, we listened and learned much about our community's most pressing needs. Through those conversations, and supported by community data, we prioritized the following needs: Navigating and accessing care and resources; Healing, connectedness, and mental health; and Addressing structural racism and barriers to achieving health equity. The CHNA Implementation Strategy Report outlines the major strategies and actions we will deploy throughout the 2022-2024 assessment cycle. The current generation will be the first generation in American history to experience shorter life expectancy than their parents did.1 Over the past decade, rates of poverty, food insecurity, isolation, mental illness, addiction, and other determinants of poor health have continued to rise and these do not impact everyone equally - Minnesota has some of the nation's largest racial, ethnic, and geographic health inequities. To impact these devastating trends, we must respond in ways that align with the factors that research has shown to have a significant effect on an individual's health and wellbeing. Studies estimate that eighty percent of a person's health outcomes are influenced by factors outside a healthcare setting,2 and a person's zip code matters more than their genetic code when it comes to long-term health.3 Given these realities, our response must reach outside the health system's walls and must focus on those experiencing health inequities to be most effective. Since the 2010 passage of the Affordable Care Act, our health system has engaged in four CHNA cycles. During each cycle, we have found the same or similar needs have existed for our communities. This means that our communities have largely faced the same challenges for more than a decade - and that despite our efforts to address these issues, these problems are not relenting. In fact, in many cases, these conditions have worsened over the past decade. Over the past 10 years of responding to our communities' biggest needs we have learned important lessons which have guided us in the development of our Fairview Health Services 2022-2024 implementation strategies.

Schedule H, Part V, Section B, Line 11 Facility , 2
"Facility , 2 - Fairview Lakes Regional Medical Ctr - continued. An essential part of the 2018 CHNA process was the identification of priority needs in the local community. The hospitals and/or medical centers identified the following priority needs for Fairview Lakes Medical Center: Mental health and well-being, Healthy lifestyles, Access to care and services. Each hospital and/or medical center developed a hospital specific implementation plan around its priority health issues along with a system focus on policy, system, and environmental (PSE) change to address their identified priority needs. Each program is evaluated on an annual basis against program specific anticipated impacts. As part of the evaluation process each program indicator is assigned a value of ""green"", ""yellow"" or ""red"" based upon the criteria that follows. A rating of ""green"" means that the program (a) met, or exceeded, 2021 hospital goal/s as written in hospital implementation plan (b) it has count data tied to both goal/s and anticipated impact/s (c) there is an evaluation tool with measure tied to anticipated impact/s. A rating of ""yellow"" means that the program (a) had partial completion of 2021 hospital goal/s as written in hospital implementation plan (b) it has count data tied to either goal/s or anticipated impact/s but not both (c)there is an evaluation tool without measure tied to anticipated impact/s. A rating of ""red"" means that the program (a) did not complete the 2021 hospital goal/s written in hospital implementation plan (b) there was no count data (c) there was no evaluation tool/s. Policy, System, and Environmental (PSE) change initiatives often take multiple years to plan and implement. Using a CDC evaluation framework each PSE initiative is monitored and evaluated annually against anticipated activities and milestones linked to the six connected PSE evaluation steps. The six connected steps of PSE change we tracked for monitoring and evaluation purposes are (1) engage stakeholders, (2) describe the program, (3) focus the evaluation design, (4) gather credible evidence, (5) justify conclusions, and (6) ensure use and share lessons learned. Our 2021 evaluation of the PSE initiatives note the specific PSE step/s for that initiatives based on the activities. In 2021 we are identifying PSE initiative specific metrics related to each step to deepen our evaluation of outcomes in future years. Any programmatic anticipated impact that received a rating of ""yellow"" or ""red"" has a corresponding brief explanation and 2021 action plan. In 2021 we will continue refining the rating system and corresponding programmatic and PSE evaluation as part of our commitment to continuous process improvement. Detailed results and action plans on program and PSE initiatives are available upon request. Priority: Mental health and wellbeing M Health Fairview Lakes Medical Center offered the evidence-based Mental Health First Aid program. The program introduces risk factors and warning signs of common mental health and substance use disorders, builds understanding of their impact, and reviews support options. The interactive course teaches participants how to offer initial help to an individual who may be experiencing a mental health concern or crisis and connect them to the appropriate resources. Youth Mental Health First Aid is the second core program which focuses on mental health concerns among youth ages 12-18. The 2021 anticipated impact for the Mental Health First Aid programs was an increase in participants' ability to recognize and correct misconceptions about mental health and mental illness. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: Outcome: 30% increase from pre-survey (70%) to post-survey (100%) in response to the following: I strongly agree or agree that I can recognize and correct misconceptions about mental health, substance use and mental illness as I encounter them. Evaluation of survey results was done on a program level. M Health Fairview Lakes Medical Center the Trauma Informed Congregations program, the implementation of the Risking Connection in Faith Communities curriculum across Faith Communities. Risking Connection helps clergy understand the nature of trauma, its impact on people and how faith leaders can support and bring healing to trauma survivors. The 2021 anticipated impact for the Trauma Informed Congregations program was an increase in clergy/leader understanding of the impact of trauma on trauma survivors. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: 100% of participants reported they understand the impact trauma can have on their clients. Evaluation of survey results was done on a program level. M Health Fairview Lakes Medical Center offered Youth Grief Services sessions and camps. Youth Grief Services (YGS) provides a safe and nurturing place where families can turn for help after a loved one dies. YGS assists in the healing process through a network of programs and services that support, educate, and connect grieving families. The 2021 anticipated impact for Youth Grief Services was an increase in youth participants' knowledge of healthy coping strategies in response to grief.. 2021 Outcome: Ownership of Youth Grief Services transferred from Fairview Health Services to Brighter Days Grief Center in December 2020, providing a seamless transition of the program for participants.M Health Fairview Lakes Medical Center collaborated in policy, systems and environmental (PSE) change around responding to trauma in settings such as schools and faith communities. This initiative includes activities and milestones linked to PSE evaluation steps (1) engage stakeholders, (2) describe the program, and (3) focus the evaluation design. 2021 Impact: Green - Opened Minnesota's first EmPATH unit- or Emergency Psychiatric Assessment, Treatment, and Healing- a pioneering approach to emergency mental health that offers rapid, comprehensive care in a calming environment at Fairview Southdale Hospital. Planning underway for opening a second unit at University of Minnesota Medical Center. Conducted HOPE Listening and Learning sessions and a survey, to assess the experiential needs of patients and caregivers when accessing care in our system. Planning for Virtual Health Hubs that will break down barriers and allow people to access mental health care despite physical location. Member partner of both the Mental Well Being Task Force for the Hennepin County Community Health Improvement Partnership (CHIP) and Ramsey County Mental Health and Wellness Action Team (MHWAT). In partnership with Ebenezer Senior Living, developed a new quarterly speaking series called HOPE, that address topics such as Adverse Childhood Experiences (ACEs), trauma, and pandemic fatigue. In the development/planning stage for a Wellness Hub that will include providing comprehensive mental health care in a calming, relaxing space."

Schedule H, Part V, Section B, Line 11 Facility , 3
"Facility , 3 - Fairview Lakes Regional Medical Ctr- continued. Priority: Healthy lifestyles M Health Fairview Lakes Medical Center offered the evidence-based Falls Prevention Suite which included two programs (1) Matter of Balance a program designed to reduce the fear of falling and increase activity levels among older adults. It includes 8 sessions for a small group of 8-12 participants led by two trained facilitators. Participants learn to view falls and fear of falling as controllable, set realistic goals to increase activity, change their environment to reduce fall risk factors, and exercise to increase strength and balance. (2) Tai Ji Quan a research-based 12-week program that is designed to keep older adults mobile and independent. The program meets twice a week for one hour. The classes will help participants improve balance, strengthen muscles, and reduce the risk of falling. The 2021 participants' fear of falling. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: 14% decrease from pre-survey (86%) to post-survey (73%) in participants that responded with a little, somewhat, or a lot to the following: How fearful are you of falling? Evaluation of survey results was done on a program level. M Health Fairview Lakes Medical Center offered the evidence-based Living Well Suite which included three programs that were developed by Stanford University's Patient Education Research Center. (1) Chronic Disease Self- Management is a workshop given 2.5 hours once a week, for six weeks offered to individuals and their caregivers who are living with chronic conditions. Subjects addressed include medication use, communication with doctors and caregivers, nutrition, and fitness- with practical exercises and advice designed to meet participants' needs. (2) Chronic Pain Self-Management is a workshop given 2 hours once a week, for six weeks, in community settings. The workshop helps participants, and their support person, deal with the ongoing issues associated with chronic pain. (3) Diabetes Self-Management is a 6 week once a week program developed to helps those living with diabetes or pre-diabetes to improve their general health. The 2021 anticipated impact for the Living Well Suite was an increase participants' perception of positive lifestyle changes. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: 89% of participants that responded to the post program survey indicated that they strongly agree or agree with the following statement: The program has helped them manage chronic condition(s). Evaluation of survey results was done on a program level. M Health Fairview Lakes Medical Center collaborated in policy, systems and environmental (PSE) change around healthy food transformation addressing issues such as food insecurity, food access, and changes to cafeteria menus. This initiative includes activities and milestones linked to PSE evaluation steps (1) engage stakeholders, (2) describe the program, and (3) focus the evaluation design. 2021 Impact: Green - Outcome: Strengthened partnerships with local food organizations such as Second Harvest Heartland and Sanneh Foundation. Includes planning for a Wellness Hub that will be a new distribution site for food and provide workforce development opportunities for youth in the food sector. Continue to serve as a backbone partner in the Food Justice Network. Expanded Community Supported Agriculture (CSA) program to new CSA farms to meet the differing needs of clinic participants and support new farmer partners. Planning to offer, in partnership with Keystone Community Services, a mobile food pantry at clinics. Signed contact for Now Pow which will screen patients for social determinants such as food security and provide resources and referrals. Priority: Access to care and resources M Health Fairview Lakes Medical Center conducted Minnesota Immunization Network Initiative (MINI) Clinics. MINI is a multi-sector, community collaboration providing free flu shots to uninsured, underserved, and minority populations. The MINI clinics bring flu vaccine, educational materials, and volunteers to community locations such as churches or community centers and with its partners, ensure a culturally and linguistically appropriate experience in a safe and trusted environment. The 2021 anticipated impact for the MINI clinics was an increase in the number of clinics with culturally and/or linguistically appropriate materials around accessing care and resources. 2021 Impact: No new clinics were offered. M Health Fairview Lakes Medical Center offered the evidence-based Falls Prevention Suite which included two programs (1) Matter of Balance a program designed to reduce the fear of falling and increase activity levels among older adults. It includes 8 sessions for a small group of 8-12 participants led by two trained facilitators. Participants learn to view falls and fear of falling as controllable, set realistic goals to increase activity, change their environment to reduce fall risk factors, and exercise to increase strength and balance. (2) Tai Ji Quan a research-based 12-week program that is designed to keep older adults mobile and independent. The program meets twice a week for one hour. The classes will help participants improve balance, strengthen muscles, and reduce the risk of falling. The 2021 anticipated impact for the Falls Prevention Suite was an increase in participants' comfort talking to their health care provider about medications and other possible risks of falling. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - * Outcome: 67% of participants that responded to the post program survey indicated that they strongly agree or agree with the following statement: I feel more comfortable talking to my health care provider about my medications and other possible risks for falling. Evaluation of survey results was done on a program level."

Schedule H, Part V, Section B, Line 11 Facility , 4
"Facility , 4 - Fairview Lakes Regional Medical Ctr - continued. M Health Fairview Lakes Medical Center offered the evidence-based Living Well Suite which included three programs that were developed by Stanford University's Patient Education Research Center. (1) Chronic Disease Self- Management is a workshop given 2.5 hours once a week, for six weeks offered to individuals and their caregivers who are living with chronic conditions. Subjects addressed include medication use, communication with doctors and caregivers, nutrition, and fitness- with practical exercises and advice designed to meet participants' needs. (2) Chronic Pain Self-Management is a workshop given 2 hours once a week, for six weeks, in community settings. The workshop helps participants, and their support person, deal with the ongoing issues associated with chronic pain. (3) Diabetes Self-Management is a 6 week once a week program developed to helps those living with diabetes or pre-diabetes to improve their general health. The 2021 anticipated impact for the Living Well Suite was an increase in participants who agree that the program helps them work with their health care providers. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - * Outcome: 86% of participants that responded to the post program survey indicated that they strongly agree or agree with the following statement: The program has helped them work with healthcare professionals. Evaluation of survey results was done on a program level. M Health Fairview Lakes Medical Center offered the evidence-based Mental Health First Aid program. The program introduces risk factors and warning signs of common mental health and substance use disorders, builds understanding of their impact, and reviews support options. The interactive course teaches participants how to offer initial help to an individual who may be experiencing a mental health concern or crisis and connect them to the appropriate resources. Youth Mental Health First Aid is the second core program which focuses on mental health concerns among youth ages 12-18. The 2021 anticipated impact for the Mental Health First Aid programs was increase participants' confidence in assisting someone to connect with professional resources. The anticipated impact was assigned a value of ""green"". 2021 Impact: Green - Outcome: 31% increase from pre-survey (67%) to post-survey (98%) in response to the following: I strongly agree or agree that I can assist someone who may be dealing with a mental health problem, substance use challenge or crisis in seeking professional help. Evaluation of survey results was done on a program level."

Schedule H, Part V, Section B, Line 11 Facility , 5
Facility , 5 - Fairview Lakes Regional Medical Ctr - continued. Needs identified but not addressed: Although the following health needs were not selected as priority needs, M Health Fairview will continue to support work aligned with addressing these needs as appropriate particularly when doing so would address the social determinants of health and/or the leading causes of premature death. Childcare: This issue is beyond what M Health Fairview resources can support at this time. Chronic lower respiratory disease: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Clinic hours: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Cost associated with care: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Health literacy: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Safe neighborhoods: This issue is beyond what M Health Fairview resources can support at this time. Stroke: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Health literacy: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Safe neighborhoods: This issue is beyond what M Health Fairview resources can support at this time. Stroke: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Transportation: This issue is beyond what M Health Fairview resources can support at this time.

Schedule H, Part V, Section B, Line 13 Facility , 1
Facility , 1 - Fairview Lakes Regional Medical Ctr. The Minnesota Attorney General agreement was used in the determination of the eligibility for financial assistance.

Schedule H, Part V, Section B, Line 16 Facility , 1
Facility , 1 - Fairview Lakes Regional Medical Ctr. A summary of the Financial Assistance Policy is posted in various locations in the hospital.

Schedule H, Part V, Section B, Line 3E
Fairview is committed to transparency and accountability in all we do, including our efforts to assess - and respond to - our community's most pressing health needs. The community benefit work that we do across Fairview must reflect our community's actual needs, not our assumptions about what those needs might or should be. Because we understand that change cannot happen when we work in silos, and it cannot happen in a single year, we grounded our 2021 CHNA process in alignment with our 2018 CHNA needs, existing data, and the voices of community members and community partners. Once we had collected, analyzed, and synthesized the information we received from both primary and secondary data sources, we established a prioritization process through which we could identify the community health needs that, if effectively addressed, would have the greatest positive impact on our communities and particularly on our priority populations. Having a consistent, defined process helps reduce the skewing effect of conscious and unconscious biases and enables us to define priority need areas that reflect our community's top health needs rather than our perception of those needs. We evaluated areas of need based on four broad criteria: -Has this need been voiced by the community? Has this need been vetted by the community? -Does this need align with Fairview's strategies and priorities? -Does this need align with existing public health strategies and community health assessments? -Does this need build upon Fairview's 2018 CHNA priority needs? Our process resulted in the identification of three priority need areas. They are: -Navigating and accessing care and resources -Healing, connectedness, and mental health -Addressing structural racism and barriers to achieving health equity.

Schedule H, Part V, Section B, Line 5 Facility , 1
Facility , 1 - Fairview Northland Regional Hosp. The assessment process and data collection methods we used during this CHNA cycle were different than ever before due to the COVID-19 pandemic. COVID- 19 caused delays in data collection among local, state, and national organizations. As a result of these delays, the U.S. Census Bureau had not yet released finalized data from the 2020 U.S. Census by the time we began the CHNA process. As a result, we used 2015-2019 American Community Survey data. Local public health agencies also were not able to provide updated data as they have in the past. We acknowledge that, due to these setbacks, the data we used is less recent than desired. Additionally, COVID-19 required us to add new safety precautions to our method of gathering community voice data. For example, all conversations and interviews, which had previously been in-person meetings, took place in a virtual format instead. We collected additional community voice data by convening a broad array of stakeholders, with special focus on the priority populations. The process included discussions with community benefit and assessment committees, our community advisory council, the HOPE Commission listening and learning sessions, and key stakeholder interviews. Throughout this process, community members, local business leaders, government representatives, nonprofit and community organizations, and content experts shared their voices and perspectives about their community's health needs. Each hospital within Fairview has a community benefit and assessment committee that is involved in the CHNA process throughout the three-year cycle. Each committee is comprised of local community and organizational leaders and staffed by the Fairview Community Advancement department. Community benefit and assessment committees met four times between April and October in 2021, three of which were individual committee meetings and one of which was a system-wide Community Impact Summit that brought all the committees together. Each committee meeting consisted of facilitated discussions through which our team gathered input about top community needs. The Fairview Community Advisory Council, composed of key community leaders and staffed by Community Advancement, reviews the CHNA report and written implementation strategy and recommends it to the Patient Care and Experience Committee of the Fairview Board of Directors for review and adoption. Each member represents the member's respective community, and members represent a broad range of sectors, among them community organizations serving cultural communities, higher education organizations, banks, and a nonprofit electric company. The Community Advisory Council met from May through November 2021 to participate in the CHNA process, give feedback, and ultimately recommend the CHNA and implementation strategy for adoption. The HOPE Commission is a multi-year transformational change effort of M Health Fairview to drive more equitable outcomes and inclusive environments and experiences for our patients, employees, and communities. The Commission conducted a series of listening and learning sessions in 2020 and 2021. The objective was to hold a mirror to Fairview to assess where we are now and how we can make lasting change. Part of being an anti-racist health system is developing a candid understanding of our shortcomings. We particularly sought to hear perspectives and ideas from the most impacted populations: BIPOC employees and patients, front-line workers who care for underserved and marginalized patients, and those patients themselves. A survey was also made available each year to gather insights and suggestions from employees and patients who could not directly participate in a listening and learning session. In 2020, the commission convened 32 virtual listening and learning sessions and two town halls involving more than 1,500 participants across Fairview sites. The sessions focused on employees but included patients and community members as well. In September 2021, the HOPE Commission continued the listening and learning sessions following the same model. In this iteration, however, the focus was primarily on gathering input from patients (and employees as patients). In both 2020 and 2021's listening and learning sessions, the facilitators and note takers reflected the community represented by the session's group to the greatest degree possible. In August and September 2021, Fairview's Community Advancement team conducted a series of interviews with staff members who work with communities. Each conversation followed a consistent interview protocol developed for this purpose, and each interview was captured by means of detailed notes. The goal of these interviews was to draw on staff expertise to gain a deeper understanding of our priority needs and to determine whether there are any emerging needs that we should be considering. Between Aug. 31 and Sept.17, 2021, we conducted 17 interviews. In August 2021, we held two focus groups in partnership with other organizations. We convened the first focus group in partnership with HealthPartners and Allina Health, and the participants were faith community nurses. We convened the second focus group in partnership with the organizations that are a part of the East Side Health and Well-being Collaborative. This meeting's focus was on accessing care and resources for different cultural communities. Fairview also participated in two large surveys. KRC Research conducted a survey around health and health care needs in St. Paul between June 8 and July 7, 2021, and administered it to community members, Fairview employees, patients, and community partners. Responses were received from 294 residents, more than 1,000 employees, 221 patients, and 20 partners. The survey was offered online and by phone and in five languages: English, Spanish, Hmong, Somali, and Karen. Fairview also supported and was a partner organization in Bridge to Health, a survey that assesses the health needs of northern Minnesota residents. The Bridge to Health survey was administered between Aug.28 and Oct. 23, 2020. The geographic areas that were sampled included Aitkin, Carlton, Cook, Itasca, Koochiching, Lake, St. Louis, and Pine counties in Minnesota, as well as Douglas County in Wisconsin. As a foundational part of program planning and evaluation, Community Advancement staff are continuously soliciting feedback from community partners and program participants. We capture this information on an ongoing basis and use it to provide valuable context and drive insights into the needs of the communities we serve. Fairview staff developed standardized tools, processes, instructions, and facilitator, interviewer, and note-taker protocols and training. All primary data was compiled, cleaned, and analyzed. Community conversations lasted various lengths from 30-120 minutes. All community input was captured by a note-taker. The Fairview team contracted with the following groups to support our assessment process: -Loren Blinde, PhD of Writing Power, a copywriter and content strategist, on the writing of the report. -Kristi Fordyce, an independent contractor, for analysis support. -Weber Shandwick, for data collection and analysis of focus groups and stakeholder interviews focused on St. Paul. -KRC Research for the administration and analysis of the St. Paul Community Survey.

Schedule H, Part V, Section B, Line 7 Facility , 1
Facility , 1 - Fairview Northland Regional Hosp. The Community Health Needs Assessment Report for Fairview Northland Regional Hospital are located at: https://stcr-prd-cd.fairview.org/-/media/Files/Local-Health-Needs/Read-full-reports/2021-CHNA-Report-Northland-Medical-Center2125.pdf?_ga=2.81139543.1916792193.1654267916-XXX-XX-XXXX.1594916074 The Community Health Needs Assessment Implementation Strategy for Fairview Northland Regional Hospital are located at: https://stcr-prd-cd.fairview.org/-/media/Files/Local-Health-Needs/CHNA-Implementation-Strategy-Report-20222024-Northland.pdf?_ga=2.XXX-XX-XXXX.1916792193.1654267916-XXX-XX-XXXX.1594916074

Schedule H, Part V, Section B, Line 11 Facility , 1
Facility , 1 - Fairview Northland Regional Hospital. Over the course of 2021, Fairview's hospitals and medical centers, including the Fairview Northland Regional Hospital, conducted our Community Health Needs Assessment (CHNA) process to determine our priority needs and our response. As part of this process, we listened and learned much about our community's most pressing needs. Through those conversations, and supported by community data, we prioritized the following needs: Navigating and accessing care and resources; Healing, connectedness, and mental health; and Addressing structural racism and barriers to achieving health equity. The CHNA Implementation Strategy Report outlines the major strategies and actions we will deploy throughout the 2022-2024 assessment cycle. The current generation will be the first generation in American history to experience shorter life expectancy than their parents did.1 Over the past decade, rates of poverty, food insecurity, isolation, mental illness, addiction, and other determinants of poor health have continued to rise and these do not impact everyone equally - Minnesota has some of the nation's largest racial, ethnic, and geographic health inequities. To impact these devastating trends, we must respond in ways that align with the factors that research has shown to have a significant effect on an individual's health and wellbeing. Studies estimate that eighty percent of a person's health outcomes are influenced by factors outside a healthcare setting,2 and a person's zip code matters more than their genetic code when it comes to long-term health.3 Given these realities, our response must reach outside the health system's walls and must focus on those experiencing health inequities to be most effective. Since the 2010 passage of the Affordable Care Act, our health system has engaged in four CHNA cycles. During each cycle, we have found the same or similar needs have existed for our communities. This means that our communities have largely faced the same challenges for more than a decade - and that despite our efforts to address these issues, these problems are not relenting. In fact, in many cases, these conditions have worsened over the past decade. Over the past 10 years of responding to our communities' biggest needs we have learned important lessons which have guided us in the development of our Fairview Health Services 2022-2024 implementation strategies.

Schedule H, Part V, Section B, Line 11 Facility , 2
"Facility , 2 - Fairview Northland Regional Hosp - continued. AN ESSENTIAL PART OF THE 2018 CHNA PROCESS WAS THE IDENTIFICATION OF PRIORITY NEEDS IN THE LOCAL COMMUNITY. THE HOSPITALS AND/OR MEDICAL CENTERS IDENTIFIED THE FOLLOWING PRIORITY NEEDS FOR FAIRVIEW NORTHLAND MEDICAL CENTER: MENTAL HEALTH AND WELL-BEING, HEALTHY LIFESTYLES, ACCESS TO CARE AND SERVICES. EACH HOSPITAL AND/OR MEDICAL CENTER DEVELOPED A HOSPITAL SPECIFIC IMPLEMENTATION PLAN AROUND ITS PRIORITY HEALTH ISSUES ALONG WITH A SYSTEM FOCUS ON POLICY, SYSTEM, AND ENVIRONMENTAL (PSE) CHANGE TO ADDRESS THEIR IDENTIFIED PRIORITY NEEDS. EACH PROGRAM IS EVALUATED ON AN ANNUAL BASIS AGAINST PROGRAM SPECIFIC ANTICIPATED IMPACTS. AS PART OF THE EVALUATION PROCESS EACH PROGRAM INDICATOR IS ASSIGNED A VALUE OF ""GREEN"", ""YELLOW"" OR ""RED"" BASED UPON THE CRITERIA THAT FOLLOWS. A RATING OF ""GREEN"" MEANS THAT THE PROGRAM (A) MET, OR EXCEEDED, 2021 HOSPITAL GOAL/S AS WRITTEN IN HOSPITAL IMPLEMENTATION PLAN (B) IT HAS COUNT DATA TIED TO BOTH GOAL/S AND ANTICIPATED IMPACT/S (C) THERE IS AN EVALUATION TOOL WITH MEASURE TIED TO ANTICIPATED IMPACT/S. A RATING OF ""YELLOW"" MEANS THAT THE PROGRAM (A) HAD PARTIAL COMPLETION OF 2021 HOSPITAL GOAL/S AS WRITTEN IN HOSPITAL IMPLEMENTATION PLAN (B) IT HAS COUNT DATA TIED TO EITHER GOAL/S OR ANTICIPATED IMPACT/S BUT NOT BOTH (C)THERE IS AN EVALUATION TOOL WITHOUT MEASURE TIED TO ANTICIPATED IMPACT/S. A RATING OF ""RED"" MEANS THAT THE PROGRAM (A) DID NOT COMPLETE THE 2019 HOSPITAL GOAL/S WRITTEN IN HOSPITAL IMPLEMENTATION PLAN (B) THERE WAS NO COUNT DATA (C) THERE WAS NO EVALUATION TOOL/S. POLICY, SYSTEM, AND ENVIRONMENTAL (PSE) CHANGE INITIATIVES OFTEN TAKE MULTIPLE YEARS TO PLAN AND IMPLEMENT. USING A CDC EVALUATION FRAMEWORK EACH PSE INITIATIVE IS MONITORED AND EVALUATED ANNUALLY AGAINST ANTICIPATED ACTIVITIES AND MILESTONES LINKED TO THE SIX CONNECTED PSE EVALUATION STEPS. THE SIX CONNECTED STEPS OF PSE CHANGE WE TRACKED FOR MONITORING AND EVALUATION PURPOSES ARE (1) ENGAGE STAKEHOLDERS, (2) DESCRIBE THE PROGRAM, (3) FOCUS THE EVALUATION DESIGN, (4) GATHER CREDIBLE EVIDENCE, (5) JUSTIFY CONCLUSIONS, AND (6) ENSURE USE AND SHARE LESSONS LEARNED. OUR 2021 EVALUATION OF THE PSE INITIATIVES NOTE THE SPECIFIC PSE STEP/S FOR THAT INITIATIVES BASED ON THE ACTIVITIES. IN 2021 WE ARE IDENTIFYING PSE INITIATIVE SPECIFIC METRICS RELATED TO EACH STEP TO DEEPEN OUR EVALUATION OF OUTCOMES IN FUTURE YEARS. ANY PROGRAMMATIC ANTICIPATED IMPACT THAT RECEIVED A RATING OF ""YELLOW"" OR ""RED"" HAS A CORRESPONDING BRIEF EXPLANATION AND 2021 ACTION PLAN. IN 2021 WE WILL CONTINUE REFINING THE RATING SYSTEM AND CORRESPONDING PROGRAMMATIC AND PSE EVALUATION AS PART OF OUR COMMITMENT TO CONTINUOUS PROCESS IMPROVEMENT. DETAILED RESULTS AND ACTION PLANS ON PROGRAM AND PSE INITIATIVES ARE AVAILABLE UPON REQUEST. PRIORITY: MENTAL HEALTH AND WELLBEING M HEALTH FAIRVIEW NORTHLAND MEDICAL CENTER OFFERED THE EVIDENCE-BASED MENTAL HEALTH FIRST AID PROGRAM. THE PROGRAM INTRODUCES RISK FACTORS AND WARNING SIGNS OF COMMON MENTAL HEALTH AND SUBSTANCE USE DISORDERS, BUILDS UNDERSTANDING OF THEIR IMPACT, AND REVIEWS SUPPORT OPTIONS. THE INTERACTIVE COURSE TEACHES PARTICIPANTS HOW TO OFFER INITIAL HELP TO AN INDIVIDUAL WHO MAY BE EXPERIENCING A MENTAL HEALTH CONCERN OR CRISIS AND CONNECT THEM TO THE APPROPRIATE RESOURCES. YOUTH MENTAL HEALTH FIRST AID IS THE SECOND CORE PROGRAM WHICH FOCUSES ON MENTAL HEALTH CONCERNS AMONG YOUTH AGES 12-18. THE 2021 ANTICIPATED IMPACT FOR THE MENTAL HEALTH FIRST AID PROGRAMS WAS AN INCREASE IN PARTICIPANTS' ABILITY TO RECOGNIZE AND CORRECT MISCONCEPTIONS ABOUT MENTAL HEALTH AND MENTAL ILLNESS. THE ANTICIPATED IMPACT WAS ASSIGNED A VALUE OF ""GREEN"". 2021 IMPACT: GREEN - OUTCOME: OUTCOME: 30% INCREASE FROM PRE-SURVEY (70%) TO POST-SURVEY (100%) IN RESPONSE TO THE FOLLOWING: I STRONGLY AGREE OR AGREE THAT I CAN RECOGNIZE AND CORRECT MISCONCEPTIONS ABOUT MENTAL HEALTH, SUBSTANCE USE AND MENTAL ILLNESS AS I ENCOUNTER THEM. EVALUATION OF SURVEY RESULTS WAS DONE ON A PROGRAM LEVEL. M HEALTH FAIRVIEW NORTHLAND MEDICAL CENTER OFFERED THE TRAUMA INFORMED CONGREGATIONS PROGRAM, THE IMPLEMENTATION OF THE RISKING CONNECTION IN FAITH COMMUNITIES CURRICULUM ACROSS FAITH COMMUNITIES. RISKING CONNECTION HELPS CLERGY UNDERSTAND THE NATURE OF TRAUMA, ITS IMPACT ON PEOPLE AND HOW FAITH LEADERS CAN SUPPORT AND BRING HEALING TO TRAUMA SURVIVORS. THE 2021 ANTICIPATED IMPACT FOR THE TRAUMA INFORMED CONGREGATIONS PROGRAM WAS AN INCREASE IN CLERGY/LEADER UNDERSTANDING OF THE IMPACT OF TRAUMA ON TRAUMA SURVIVORS. THE ANTICIPATED IMPACT WAS ASSIGNED A VALUE OF ""GREEN"". 2021 IMPACT: GREEN - OUTCOME: 100% OF PARTICIPANTS REPORTED THEY UNDERSTAND THE IMPACT TRAUMA CAN HAVE ON THEIR CLIENTS. EVALUATION OF SURVEY RESULTS WAS DONE ON A PROGRAM LEVEL. M HEALTH FAIRVIEW NORTHLAND MEDICAL CENTER OFFERED YOUTH GRIEF SERVICES SESSIONS AND CAMPS. YOUTH GRIEF SERVICES (YGS) PROVIDES A SAFE AND NURTURING PLACE WHERE FAMILIES CAN TURN FOR HELP AFTER A LOVED ONE DIES. YGS ASSISTS IN THE HEALING PROCESS THROUGH A NETWORK OF PROGRAMS AND SERVICES THAT SUPPORT, EDUCATE, AND CONNECT GRIEVING FAMILIES. THE 2021 ANTICIPATED IMPACT FOR YOUTH GRIEF SERVICES WAS AN INCREASE IN YOUTH PARTICIPANTS' KNOWLEDGE OF HEALTHY COPING STRATEGIES IN RESPONSE TO GRIEF. 2021 OUTCOME: OWNERSHIP OF YOUTH GRIEF SERVICES TRANSFERRED FROM FAIRVIEW HEALTH SERVICES TO BRIGHTER DAYS GRIEF CENTER IN DECEMBER 2020, PROVIDING A SEAMLESS TRANSITION OF THE PROGRAM FOR PARTICIPANTS. M HEALTH FAIRVIEW NORTHLAND MEDICAL CENTER COLLABORATED IN POLICY, SYSTEMS AND ENVIRONMENTAL (PSE) CHANGE AROUND RESPONDING TO TRAUMA IN SETTINGS SUCH AS SCHOOLS AND FAITH COMMUNITIES. THIS INITIATIVE INCLUDES ACTIVITIES AND MILESTONES LINKED TO PSE EVALUATION STEPS (1) ENGAGE STAKEHOLDERS, (2) DESCRIBE THE PROGRAM, AND (3) FOCUS THE EVALUATION DESIGN. 2021 IMPACT: GREEN - OPENED MINNESOTA'S FIRST EMPATH UNIT- OR EMERGENCY PSYCHIATRIC ASSESSMENT, TREATMENT, AND HEALING- A PIONEERING APPROACH TO EMERGENCY MENTAL HEALTH THAT OFFERS RAPID, COMPREHENSIVE CARE IN A CALMING ENVIRONMENT AT FAIRVIEW SOUTHDALE HOSPITAL. PLANNING UNDERWAY FOR OPENING A SECOND UNIT AT UNIVERSITY OF MINNESOTA MEDICAL CENTER. CONDUCTED HOPE LISTENING AND LEARNING SESSIONS AND A SURVEY, TO ASSESS THE EXPERIENTIAL NEEDS OF PATIENTS AND CAREGIVERS WHEN ACCESSING CARE IN OUR SYSTEM. PLANNING FOR VIRTUAL HEALTH HUBS THAT WILL BREAK DOWN BARRIERS AND ALLOW PEOPLE TO ACCESS MENTAL HEALTH CARE DESPITE PHYSICAL LOCATION. MEMBER PARTNER OF BOTH THE MENTAL WELL BEING TASK FORCE FOR THE HENNEPIN COUNTY COMMUNITY HEALTH IMPROVEMENT PARTNERSHIP (CHIP) AND RAMSEY COUNTY MENTAL HEALTH AND WELLNESS ACTION TEAM (MHWAT). IN PARTNERSHIP WITH EBENEZER SENIOR LIVING, DEVELOPED A NEW QUARTERLY SPEAKING SERIES CALLED HOPE, THAT ADDRESS TOPICS SUCH AS ADVERSE CHILDHOOD EXPERIENCES (ACES), TRAUMA, AND PANDEMIC FATIGUE. IN THE DEVELOPMENT/PLANNING STAGE FOR A WELLNESS HUB THAT WILL INCLUDE PROVIDING COMPREHENSIVE MENTAL HEALTH CARE IN A CALMING, RELAXING SPACE. PRIORITY: HEALTHY LIFESTYLES M HEALTH FAIRVIEW NORTHLAND MEDICAL CENTER OFFERED THE EVIDENCE-BASED FALLS PREVENTION SUITE WHICH INCLUDED TWO PROGRAMS (1) MATTER OF BALANCE A PROGRAM DESIGNED TO REDUCE THE FEAR OF FALLING AND INCREASE ACTIVITY LEVELS AMONG OLDER ADULTS. IT INCLUDES 8 SESSIONS FOR A SMALL GROUP OF 8-12 PARTICIPANTS LED BY TWO TRAINED FACILITATORS. PARTICIPANTS LEARN TO VIEW FALLS AND FEAR OF FALLING AS CONTROLLABLE, SET REALISTIC GOALS TO INCREASE ACTIVITY, CHANGE THEIR ENVIRONMENT TO REDUCE FALL RISK FACTORS, AND EXERCISE TO INCREASE STRENGTH AND BALANCE. (2) TAI JI QUAN A RESEARCH-BASED 12-WEEK PROGRAM THAT IS DESIGNED TO KEEP OLDER ADULTS MOBILE AND INDEPENDENT. THE PROGRAM MEETS TWICE A WEEK FOR ONE HOUR. THE CLASSES WILL HELP PARTICIPANTS IMPROVE BALANCE, STRENGTHEN MUSCLES, AND REDUCE THE RISK OF FALLING. THE 2021 ANTICIPATED IMPACT FOR THE FALLS PREVENTION SUITE WAS A DECREASE PARTICIPANTS' FEAR OF FALLING. THE ANTICIPATED IMPACT WAS ASSIGNED A VALUE OF ""GREEN"". 2021 IMPACT: GREEN - OUTCOME: 14% DECREASE FROM PRE-SURVEY (86%) TO POST-SURVEY (73%) IN PARTICIPANTS THAT RESPONDED WITH A LITTLE, SOMEWHAT, OR A LOT TO THE FOLLOWING: HOW FEARFUL ARE YOU OF FALLING? EVALUATION OF SURVEY RESULTS WAS DONE ON A PROGRAM LEVEL."

Schedule H, Part V, Section B, Line 11 Facility , 3
"Facility , 3 - Fairview Northland Regional Hosp - continued. M HEALTH FAIRVIEW NORTHLAND MEDICAL CENTER OFFERED THE EVIDENCE-BASED LIVING WELL SUITE WHICH INCLUDED THREE PROGRAMS THAT WERE DEVELOPED BY STANFORD UNIVERSITY'S PATIENT EDUCATION RESEARCH CENTER. (1) CHRONIC DISEASE SELF-MANAGEMENT IS A WORKSHOP GIVEN 2.5 HOURS ONCE A WEEK, FOR SIX WEEKS OFFERED TO INDIVIDUALS AND THEIR CAREGIVERS WHO ARE LIVING WITH CHRONIC CONDITIONS. SUBJECTS ADDRESSED INCLUDE MEDICATION USE, COMMUNICATION WITH DOCTORS AND CAREGIVERS, NUTRITION, AND FITNESS- WITH PRACTICAL EXERCISES AND ADVICE DESIGNED TO MEET PARTICIPANTS' NEEDS. (2) CHRONIC PAIN SELF-MANAGEMENT IS A WORKSHOP GIVEN 2 HOURS ONCE A WEEK, FOR SIX WEEKS, IN COMMUNITY SETTINGS. THE WORKSHOP HELPS PARTICIPANTS, AND THEIR SUPPORT PERSON, DEAL WITH THE ONGOING ISSUES ASSOCIATED WITH CHRONIC PAIN. (3) DIABETES SELF-MANAGEMENT IS A 6 WEEK ONCE A WEEK PROGRAM DEVELOPED TO HELPS THOSE LIVING WITH DIABETES OR PRE-DIABETES TO IMPROVE THEIR GENERAL HEALTH. THE 2021 ANTICIPATED IMPACT FOR THE LIVING WELL SUITE WAS AN INCREASE PARTICIPANTS' PERCEPTION OF POSITIVE LIFESTYLE CHANGES. THE ANTICIPATED IMPACT WAS ASSIGNED A VALUE OF ""GREEN"". 2021 IMPACT: GREEN - OUTCOME: 89% OF PARTICIPANTS THAT RESPONDED TO THE POST PROGRAM SURVEY INDICATED THAT THEY STRONGLY AGREE OR AGREE WITH THE FOLLOWING STATEMENT: THE PROGRAM HAS HELPED THEM MANAGE CHRONIC CONDITION(S). EVALUATION OF SURVEY RESULTS WAS DONE ON A PROGRAM LEVEL. M HEALTH FAIRVIEW NORTHLAND MEDICAL CENTER COLLABORATED IN POLICY, SYSTEMS AND ENVIRONMENTAL (PSE) CHANGE AROUND HEALTHY FOOD TRANSFORMATION ADDRESSING ISSUES SUCH AS FOOD INSECURITY, FOOD ACCESS, AND CHANGES TO CAFETERIA MENUS. THIS INITIATIVE INCLUDES ACTIVITIES AND MILESTONES LINKED TO PSE EVALUATION STEPS (1) ENGAGE STAKEHOLDERS, (2) DESCRIBE THE PROGRAM, AND (3) FOCUS THE EVALUATION DESIGN. 2021 IMPACT: GREEN - OUTCOME: STRENGTHENED PARTNERSHIPS WITH LOCAL FOOD ORGANIZATIONS SUCH AS SECOND HARVEST HEARTLAND AND SANNEH FOUNDATION. INCLUDES PLANNING FOR A WELLNESS HUB THAT WILL BE A NEW DISTRIBUTION SITE FOR FOOD AND PROVIDE WORKFORCE DEVELOPMENT OPPORTUNITIES FOR YOUTH IN THE FOOD SECTOR. CONTINUE TO SERVE AS A BACKBONE PARTNER IN THE FOOD JUSTICE NETWORK. EXPANDED COMMUNITY SUPPORTED AGRICULTURE (CSA) PROGRAM TO NEW CSA FARMS TO MEET THE DIFFERING NEEDS OF CLINIC PARTICIPANTS AND SUPPORT NEW FARMER PARTNERS. PLANNING TO OFFER, IN PARTNERSHIP WITH KEYSTONE COMMUNITY SERVICES, A MOBILE FOOD PANTRY AT CLINICS. SIGNED CONTACT FOR NOW POW WHICH WILL SCREEN PATIENTS FOR SOCIAL DETERMINANTS SUCH AS FOOD SECURITY AND PROVIDE RESOURCES AND REFERRALS. PRIORITY: ACCESS TO CARE AND RESOURCES M HEALTH FAIRVIEW NORTHLAND MEDICAL CENTER CONDUCTED MINNESOTA IMMUNIZATION NETWORK INITIATIVE (MINI) CLINICS. MINI IS A MULTI-SECTOR, COMMUNITY COLLABORATION PROVIDING FREE FLU SHOTS TO UNINSURED, UNDERSERVED, AND MINORITY POPULATIONS. THE MINI CLINICS BRING FLU VACCINE, EDUCATIONAL MATERIALS, AND VOLUNTEERS TO COMMUNITY LOCATIONS SUCH AS CHURCHES OR COMMUNITY CENTERS AND WITH ITS PARTNERS, ENSURE A CULTURALLY AND LINGUISTICALLY APPROPRIATE EXPERIENCE IN A SAFE AND TRUSTED ENVIRONMENT. THE 2021 ANTICIPATED IMPACT FOR THE MINI CLINICS WAS AN INCREASE IN THE NUMBER OF CLINICS WITH CULTURALLY AND/OR LINGUISTICALLY APPROPRIATE MATERIALS AROUND ACCESSING CARE AND RESOURCES. THE ANTICIPATED IMPACT WAS ASSIGNED A VALUE OF ""GREEN"". 2021 IMPACT: GREEN -33% OF NEW PARTNER CLINIC SITES HAD CULTURALLY AND/OR LINGUISTICALLY APPROPRIATE MATERIALS AROUND ACCESSING CARE AND RESOURCES. M HEALTH FAIRVIEW NORTHLAND MEDICAL CENTER OFFERED THE EVIDENCE-BASED FALLS PREVENTION SUITE WHICH INCLUDED TWO PROGRAMS (1) MATTER OF BALANCE A PROGRAM DESIGNED TO REDUCE THE FEAR OF FALLING AND INCREASE ACTIVITY LEVELS AMONG OLDER ADULTS. IT INCLUDES 8 SESSIONS FOR A SMALL GROUP OF 8-12 PARTICIPANTS LED BY TWO TRAINED FACILITATORS. PARTICIPANTS LEARN TO VIEW FALLS AND FEAR OF FALLING AS CONTROLLABLE, SET REALISTIC GOALS TO INCREASE ACTIVITY, CHANGE THEIR ENVIRONMENT TO REDUCE FALL RISK FACTORS, AND EXERCISE TO INCREASE STRENGTH AND BALANCE. (2) TAI JI QUAN A RESEARCH-BASED 12-WEEK PROGRAM THAT IS DESIGNED TO KEEP OLDER ADULTS MOBILE AND INDEPENDENT. THE PROGRAM MEETS TWICE A WEEK FOR ONE HOUR. THE CLASSES WILL HELP PARTICIPANTS IMPROVE BALANCE, STRENGTHEN MUSCLES, AND REDUCE THE RISK OF FALLING. THE 2021 ANTICIPATED IMPACT FOR THE FALLS PREVENTION SUITE WAS AN INCREASE IN PARTICIPANTS' COMFORT TALKING TO THEIR HEALTH CARE PROVIDER ABOUT MEDICATIONS AND OTHER POSSIBLE RISKS OF FALLING. THE ANTICIPATED IMPACT WAS ASSIGNED A VALUE OF ""GREEN"". 2021 IMPACT: GREEN - * OUTCOME: 67% OF PARTICIPANTS THAT RESPONDED TO THE POST PROGRAM SURVEY INDICATED THAT THEY STRONGLY AGREE OR AGREE WITH THE FOLLOWING STATEMENT: I FEEL MORE COMFORTABLE TALKING TO MY HEALTH CARE PROVIDER ABOUT MY MEDICATIONS AND OTHER POSSIBLE RISKS FOR FALLING. EVALUATION OF SURVEY RESULTS WAS DONE ON A PROGRAM LEVEL. M HEALTH FAIRVIEW NORTHLAND MEDICAL CENTER OFFERED THE EVIDENCE-BASED LIVING WELL SUITE WHICH INCLUDED THREE PROGRAMS THAT WERE DEVELOPED BY STANFORD UNIVERSITY'S PATIENT EDUCATION RESEARCH CENTER. (1) CHRONIC DISEASE SELF-MANAGEMENT IS A WORKSHOP GIVEN 2.5 HOURS ONCE A WEEK, FOR SIX WEEKS OFFERED TO INDIVIDUALS AND THEIR CAREGIVERS WHO ARE LIVING WITH CHRONIC CONDITIONS. SUBJECTS ADDRESSED INCLUDE MEDICATION USE, COMMUNICATION WITH DOCTORS AND CAREGIVERS, NUTRITION, AND FITNESS- WITH PRACTICAL EXERCISES AND ADVICE DESIGNED TO MEET PARTICIPANTS' NEEDS. (2) CHRONIC PAIN SELF-MANAGEMENT IS A WORKSHOP GIVEN 2 HOURS ONCE A WEEK, FOR SIX WEEKS, IN COMMUNITY SETTINGS. THE WORKSHOP HELPS PARTICIPANTS, AND THEIR SUPPORT PERSON, DEAL WITH THE ONGOING ISSUES ASSOCIATED WITH CHRONIC PAIN. (3) DIABETES SELF-MANAGEMENT IS A 6 WEEK ONCE A WEEK PROGRAM DEVELOPED TO HELPS THOSE LIVING WITH DIABETES OR PRE-DIABETES TO IMPROVE THEIR GENERAL HEALTH. THE 2019 ANTICIPATED IMPACT FOR THE LIVING WELL SUITE WAS AN INCREASE IN PARTICIPANTS WHO AGREE THAT THE PROGRAM HELPS THEM WORK WITH THEIR HEALTH CARE PROVIDERS. THE ANTICIPATED IMPACT WAS ASSIGNED A VALUE OF ""GREEN"". 2021 IMPACT: GREEN - * OUTCOME: 86% OF PARTICIPANTS THAT RESPONDED TO THE POST PROGRAM SURVEY INDICATED THAT THEY STRONGLY AGREE OR AGREE WITH THE FOLLOWING STATEMENT: THE PROGRAM HAS HELPED THEM WORK WITH HEALTHCARE PROFESSIONALS. EVALUATION OF SURVEY RESULTS WAS DONE ON A PROGRAM LEVEL."

Schedule H, Part V, Section B, Line 11 Facility , 4
"Facility , 4 - Fairview Northland Regional Hosp - continued. M HEALTH FAIRVIEW NORTHLAND MEDICAL CENTER OFFERED THE EVIDENCE-BASED MENTAL HEALTH FIRST AID PROGRAM. THE PROGRAM INTRODUCES RISK FACTORS AND WARNING SIGNS OF COMMON MENTAL HEALTH AND SUBSTANCE USE DISORDERS, BUILDS UNDERSTANDING OF THEIR IMPACT, AND REVIEWS SUPPORT OPTIONS. THE INTERACTIVE COURSE TEACHES PARTICIPANTS HOW TO OFFER INITIAL HELP TO AN INDIVIDUAL WHO MAY BE EXPERIENCING A MENTAL HEALTH CONCERN OR CRISIS AND CONNECT THEM TO THE APPROPRIATE RESOURCES. YOUTH MENTAL HEALTH FIRST AID IS THE SECOND CORE PROGRAM WHICH FOCUSES ON MENTAL HEALTH CONCERNS AMONG YOUTH AGES 12-18. THE 2021 ANTICIPATED IMPACT FOR THE MENTAL HEALTH FIRST AID PROGRAMS WAS INCREASE PARTICIPANTS' CONFIDENCE IN ASSISTING SOMEONE TO CONNECT WITH PROFESSIONAL RESOURCES. THE ANTICIPATED IMPACT WAS ASSIGNED A VALUE OF ""GREEN"". 2021 IMPACT: GREEN - OUTCOME: 31% INCREASE FROM PRE-SURVEY (67%) TO POST-SURVEY (98%) IN RESPONSE TO THE FOLLOWING: I STRONGLY AGREE OR AGREE THAT I CAN ASSIST SOMEONE WHO MAY BE DEALING WITH A MENTAL HEALTH PROBLEM, SUBSTANCE USE CHALLENGE OR CRISIS IN SEEKING PROFESSIONAL HELP. EVALUATION OF SURVEY RESULTS WAS DONE ON A PROGRAM LEVEL."

Schedule H, Part V, Section B, Line 11 Facility , 5
Facility , 5 - Fairview Northland Regional Hosp - continued. Needs identified but not addressed: Although the following health needs were not selected as priority needs, M Health Fairview will continue to support work aligned with addressing these needs as appropriate particularly when doing so would address the social determinants of health and/or the leading causes of premature death. Childcare: This issue is beyond what M Health Fairview resources can support at this time. Chronic lower respiratory disease: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Clinic hours: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Cost associated with care: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Health literacy: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Safe neighborhoods: This issue is beyond what M Health Fairview resources can support at this time. Stroke: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Health literacy: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Safe neighborhoods: This issue is beyond what M Health Fairview resources can support at this time. Stroke: This issue will be addressed as part of patient care but falls outside the scope of the community-based CHNA Implementation Strategy. Transportation: This issue is beyond what M Health Fairview resources can support at this time.

Schedule H, Part V, Section B, Line 13 Facility , 1
Facility , 1 - Fairview Northland Regional Hosp. The Minnesota Attorney General agreement was used in the determination of the eligibility for financial assistance.

Schedule H, Part V, Section B, Line 16 Facility , 1
Facility , 1 - Fairview Northland Regional Hosp. A summary of the Financial Assistance Policy is posted in various locations in the hospital.

Schedule H, Part I, Line 3c Other Income Based Criteria for Free or Discounted Care
PATIENTS THAT ARE ELIGIBLE FOR THE FAIRVIEW COMMUNITY CARE PROGRAM OR OTHER CHARITY CARE PLANS MAY RECEIVE A REDUCTION ON AMOUNTS OWED OR UP TO 100% OF TOTAL CHARGES. FAIRVIEW INFORMS PATIENTS ABOUT THE COMMUNITY CARE PROGRAM PRIOR TO DELIVERY OF SERVICES IF FEASIBLE AND AS APPROPRIATE AND DURING THE BILLING PROCESS. PATIENTS WITH HOUSEHOLD INCOME UP TO 200% OF THE FEDERAL POVERTY LEVEL QUALIFY FOR A 100% DISCOUNT OF TOTAL CHARGES. PATIENTS WITH A HOUSEHOLD INCOME OF 201%-300% OF THE FEDERAL POVERTY LEVEL QUALIFY FOR A PARTIAL DISCOUNT OF TOTAL CHARGES BASED ON THE AMOUNT GENERALLY BILLED OR EQUAL TO THE RATE FROM FAIRVIEW'S HIGHEST VOLUME PRIVATE PAYOR CONTRACT, WHICHEVER IS HIGHER. UNINSURED PATIENTS WHO ARE RESIDENTS OF MINNESOTA OR WISCONSIN AND WITH A HOUSEHOLD INCOME GREATER THAN 300% OF THE FEDERAL POVERTY LEVEL AND RECEIVE MEDICALLY NECESSARY HOSPITAL OR HOSPITAL BASED SERVICES ARE CHARGED A DISCOUNT RATE EQUAL TO THE RATE FROM FAIRVIEW'S HIGHEST VOLUME PRIVATE PAYOR CONTRACT.

Schedule H, Part I, Line 7f Exclusions from Percent of Total Expense
"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. There is no bad debt expense included in Form 990 Part IX as an expense. Due to the adoption of new GAAP reporting, the bad debt expense has been included with ""discounts"" netted against patient service revenue on Part VIII of Form 990."

Schedule H, Part I, Line 7g Subsidized Health Services
There are no costs associated with physician clinics included in line 7g.

Schedule H, Part I, Line 7 Costing Methodology used to calculate financial assistance
The amounts reported on Form 990, Schedule H, Part I, Line 7a through 7c were determined using the cost to charge ratio derived from Worksheet 2 in the Schedule H, Form 990 Instructions. Form 990, Schedule H, Part I, Lines 7e through 7j are reported at charges as recorded by the organization.

Schedule H, Part III, Line 2 Bad debt expense - methodology used to estimate amount
"THE BAD DEBT EXPENSE REPORTED ON PART III, LINE 2 IS REPORTED AT CHARGES AS RECORDED BY THE ORGANIZATION. THERE IS NO BAD DEBT EXPENSE INCLUDED IN FORM 990 PART IX AS AN EXPENSE. DUE TO THE ADOPTION OF NEW GAAP REPORTING, THE BAD DEBT EXPENSE HAS BEEN INCLUDED WITH ""DISCOUNTS"" NETTED AGAINST PATIENT SERVICE REVENUE ON PART VIII OF FORM 990. 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."

Schedule H, Part III, Line 3 Bad Debt Expense Methodology
The bad debt expense attributable to patients that may be eligible for financial assistance 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.

Schedule H, Part III, Line 4 Bad debt expense - financial statement footnote
Subsequent changes that are determined to be the result of an adverse change in the patient's ability to pay (determined on a portfolio basis when applicable) are recorded as bad debt expense. Bad expense for the years ended December 31, 2021 and 2020, was not significant. See page 23 of the audited financial statements for additional information.

Schedule H, Part III, Line 8 Community benefit & methodology for determining medicare costs
It is part of Fairview's mission that community benefit activity is carried out by staff/leadership at each facility based on the health care needs in that service area. The Medicare cost to charge ratio reporting is calculated service line by service line. Other expenses are calculated using the overall cost to charge ratio. Uncompensated costs resulting from Medicare, Medicaid and state and local indigent care programs are considered a community benefit because of the significant differences between actual costs and reimbursement.

Schedule H, Part V, Section B, Line 16a FAP website
- University of Minnesota Medical Center: Line 16a URL: https://www.fairview.org/billing/financial-assistance; - Fairview Southdale Hospital: Line 16a URL: https://www.fairview.org/billing/financial-assistance; - Fairview Ridges Hospital: Line 16a URL: https://www.fairview.org/billing/financial-assistance; - Fairview Lakes Regional Medical Ctr: Line 16a URL: https://www.fairview.org/billing/financial-assistance; - Fairview Northland Regional Hosp: Line 16a URL: https://www.fairview.org/billing/financial-assistance;

Schedule H, Part V, Section B, Line 16b FAP Application website
- University of Minnesota Medical Center: Line 16b URL: http://www.fvfiles.com/2266.pdf; - Fairview Southdale Hospital: Line 16b URL: ttp://www.fvfiles.com/2266.pdf; - Fairview Ridges Hospital: Line 16b URL: http://www.fvfiles.com/2266.pdf; - Fairview Lakes Regional Medical Ctr: Line 16b URL: http://www.fvfiles.com/2266.pdf; - Fairview Northland Regional Hosp: Line 16b URL: http://www.fvfiles.com/2266.pdf;

Schedule H, Part V, Section B, Line 16c FAP plain language summary website
- University of Minnesota Medical Center: Line 16c URL: https://www.fairview.org/billing/financial-assistance; - Fairview Southdale Hospital: Line 16c URL: https://www.fairview.org/billing/financial-assistance; - Fairview Ridges Hospital: Line 16c URL: https://www.fairview.org/billing/financial-assistance; - Fairview Lakes Regional Medical Ctr: Line 16c URL: https://www.fairview.org/billing/financial-assistance; - Fairview Northland Regional Hosp: Line 16c URL: https://www.fairview.org/billing/financial-assistance;

Schedule H, Part VI, Line 6 Affiliated health care system
Fairview Health Services is an integrated health care system headquartered in Minneapolis, Minnesota. It operates five community hospitals, one academic medical center and one ambulatory medical center. Community benefit activity is carried out by staff/leadership at each facility based on the health care needs in that service area. Fairview's Corporate Community Health Department supports these local efforts by sharing best practices, finding efficiencies among hospital community health leaders as appropriate, coordinating the community health needs assessments and more.

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

Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance
After our patients have received services, it is the policy of Fairview Health Services to bill patients and their applicable payors on a timely and accurate basis. During this billing and collection process, Fairview staff is committed to providing quality customer service and timely follow up on all outstanding accounts. Billing: It is the goal of Fairview to bill all claims accurately and on a timely basis. Although dependent on information and communications from patients and payors, Fairview will provide sufficient follow up service to ensure that patients receive accurate account and billing information and have the opportunity to make payment and/or apply for community care. Fairview has agreed to certain billing and collection practices by an agreement with the Minnesota Attorney General's office. There are financial counselors at every entity Monday through Friday who interact with the patients in person and over the phone to inform of programs available to them as well as assist them in applying for the programs. The information about needing assistance with paying the bill is posted on signs in the hospitals and materials are distributed to self-pay patients by registration staff. The statements sent out after the visit provide this information as well. If a patient/family member calls the Central Business Office customer service staff to ask for assistance with paying their bill, they are informed about options at that time. Fairview provides an interpreter service that interprets conversations over the phone. This service can be used either as a three way phone call or the Financial Counselor, in a room with the patient or family can place the call together to the interpreter phone service. The interpreter services line accommodates close to 200 languages. The billing process will be assisted by the following guidelines: 1) For all insured patients, Fairview will bill all third party payor information (as provided by or verified by the patient) on a timely and accurate basis. 2) For all uninsured patients with Minnesota residency receiving hospital based services deemed medically necessary, Fairview will apply an uninsured discount equal to the discount provider to our largest contracted non-government payor, any remaining balance will be billed to the patient in a timely and manner. 3) All billed patients have the opportunity to contact Fairview regarding financial assistance for their accounts. Financial assistance may include Community Care, payment arrangements, medical assistance or other applicable programs. 4) If a patient contacts Fairview regarding Community Care before the account is referred to a collection agency or attorney, an application and required documentation is requested (income verification etc.), the account will then be processed based on the outcome of the Community Care determination. 5) Fairview takes reasonable measures to avoid referring an account to collection unless there are no responses from the patient. If a patient contacts Fairview regarding Community Care after their account has been referred to a collection agency or attorney, Fairview will send an application to the patient provided the account meets the Community Care requirements. If the completed application along with required documentation (income verification, etc.) is submitted, all collection action will be suspended until the patient is notified of Fairview's determination.

Schedule H, Part VI, Line 3 Patient education of eligibility for assistance
Fairview makes information about its charity care programs available on its Website (www.fairview.org). At the time of registration for services and through written materials in lobbies and waiting rooms. For patients identified as self-pay (whether that occurs before services are delivered or during the billing cycle), Fairview utilizes a standard process to assist patients learn about and access assistance from government programs or Fairview's Charity Care Program. For uninsured patients seen in a Fairview hospital, Fairview partners with an external vendor who meets with self-pay patients to assist them determine eligibility for government programs of Fairview's Charity Care Program. The vendor will also assist patients with completing the necessary paperwork to access these resources. Staff in Fairview's central business office have a self-pay team, which directs patients to the appropriate resources. There is also a community care coordinator who assists in getting patients connected to additional resources for which they may qualify.

Schedule H, Part VI, Line 5 Promotion of community health
As a nonprofit health system, Fairview reinvests any excess revenues into the core operations of the organization. Research and education are at the very heart of the mission. In partnership with the University of Minnesota, Fairview invests millions of dollars each year into ground-breaking research and education of our next generation of healthcare workforce. Fairview also partners with a myriad of higher educational institutions to provide clinical hands-on training for future nurses, pharmacists, laboratory professionals and more. Fairview serves as a training site for residents in various specialties and is the core teaching site for the University of Minnesota residents. Senior residents and fellows provide Fairview some degree of clinical service that we would otherwise not receive.

Schedule H, Part VI, Line 2 Needs assessment
"Our triennial community health needs assessment process provides an important opportunity to engage with and understand our community, analyze what has changed-for better or worse-since the last assessment, and prioritize together with the community the issues we must urgently address in order to improve wellbeing and resilience. Fairview's 2021 Community Health Needs Assessment (CHNA) builds upon previous assessments and was developed in partnership with community members and organizations, local public health agencies, and other hospitals and health systems. It serves as a tool for guiding policy, advocacy, and program planning. It also fulfills Internal Revenue Service (IRS) requirements for CHNA pursuant to the Affordable Care Act of 2010, which requires 501(c)(3) nonprofit hospitals to conduct an assessment at least every three years and provide an annual evaluation of the previous implementation strategy's impact. Through this process, we aim to: -Intentionally engage with community members and organizations, public health agencies, and other hospitals and health systems to identify and understand significant health needs in the community. -Understand the needs of the community it serves by analyzing current demographics and social determinants of health indicators, as well as by collecting direct input from community members and organizations. -Inform the CHNA implementation strategy and action plan development. As part of the 2021 CHNA process, we reexamined and built upon the extensive community insights shared during our 2018 CHNA, while also surveying the community for current and emerging needs. We have identified three system-wide priority need areas, and we will collaborate with our hospitals and shared services to address these priorities. Our specific response will vary by hospital based on the ways in which the priority needs manifest across a given community as well as the partnerships, both ongoing and new, that we have developed to address those needs. Our community commitment - creating a healthier future and Improving the health and wellbeing of our communities. The healthcare people receive in a hospital or clinic is only a small part of a person's overall health. That's why our commitment to advancing health equity goes beyond the walls of our facilities and reaches out into the community. We collaborate with community partners to improve health and wellbeing and advance health equity. Our priorities include: * Bringing clinical services into neighborhoods to expand access * Advancing our anchor mission initiatives - local hiring, local purchasing, local investing, and leading and serving locally * Addressing social risk factors through food access and housing programs and community education and outreach. Why is this a priority for our healthcare system? Nearly 80 percent of health is influenced by factors outside of clinical care. These factors, called the social determinants of health, are our health behaviors and the economic and social conditions in which we live. To help address the social determinants of health, we are creating a health and wellness hub in downtown St. Paul that will focus on health, housing, and supportive services for the community. All this work is closely tied to our HOPE Commission's health equity and anti-racism efforts. It's designed to be culturally appropriate and to meet the specific needs of the community. We seek to do ""with"" and not ""to"" the communities we belong to and are proud to contribute to our community in so many ways. Fairview Health Services is committed to the health and wellbeing of our communities. For generations we have served the people of Minnesota, cared for our patients, and invested in the people and partnerships that make us stronger, together. As a nonprofit health system and an anchor institution-an organization rooted in our communities-we have a commitment to intentionally apply our long-term, place-based economic power and human capital in partnership with community to mutually benefit the long-term wellbeing of both. We recognize that this commitment begins in and with our communities. This work cannot be done alone, we must collaborate with community-based organizations, local public health departments, and other health systems. Our efforts, resources, and commitments are investments in the health and wellbeing of our communities where we live, work, learn, play, and worship. Our community benefit programs and activities focus on our mission to heal, discover, and educate for longer, healthier lives and must meet at least one of these objectives: * Improve access to health care services. * Enhance the health of the community. * Advance medical or health care knowledge. * Relieve the burden of government to improve health. Fairview Health Services, is committed to providing exceptional care, delivering breakthrough research and innovation to healthcare, improving health and wellbeing, and promoting health equity. As anchor institutions rooted in the hearts of the communities we serve, this commitment goes beyond our walls and into the community. THERE ARE DIFFERENT WAYS OUR HEALTH SYSTEM FULFILLS THIS PROMISE INCLUDING: * Allocating resources to benefit the community. The process is guided by our community health needs assessments, developed collaboratively with the communities we serve, and implemented in partnership with local organizations and leaders. - The priority needs identified in our 2021 assessment are: healing, connectedness, and mental health; addressing structural racism and barriers to achieving health equity; and navigating and accessing care and resources. Our efforts will center on people experiencing poverty as well as racial or ethnic populations experiencing health disparities. * Bringing clinical services into neighborhoods to expand access. These free healthcare services are offered in diverse and/or under-resourced neighborhoods. * Addressing social risk factors, known as the social determinants of health, through food access and housing programs, and community education and outreach. The goal is to improve community health and wellbeing. * Advancing our HOPE (Healing, Opportunity, People, and Equity) Commission's - health equity and anti-racism efforts to drive more equitable outcomes and inclusive environments and experiences for our patients, employees, and communities. Success stories include: improving patient sociodemographic data to better understand the populations we serve and more accurately assess for disparities, and increasing the representation of diverse populations in clinical trials."

Schedule H, Part VI, Line 4 Community information
Fairview Health Services is a Minneapolis-based nonprofit health system driven to heal, discover, and educate for longer, healthier lives. Founded in 1906, Fairview provides exceptional care to patients and communities as one of the most comprehensive and geographically accessible systems in Minnesota. Fairview has enjoyed a long partnership with the University of Minnesota and University of Minnesota Physicians, now represented in the M Health Fairview brand. Together, we offer access to breakthrough medical research and specialty expertise as part of a continuum of care that reaches all ages and health needs. Fairview Health Services is an integrated health system headquartered in Minneapolis, Minnesota. Fairview Health Services includes five hospitals: 1) Fairview Lakes Medical Center in Wyoming, MN, 2) Fairview Northland Medical Center in Princeton, MN, 3) Fairview Ridges Hospital in Burnsville, MN, 4) Fairview Southdale Hospital in Edina, MN, 5) University of Minnesota Medical Center, Minneapolis, MN Fairview also has a full continuum of health care services. See Part III Page 2 , Lines 4a, 4b and 4c. 1) Fairview Lakes Medical Center is located in Chisago county and has a primary service area of individuals residing in Anoka, Chisago, Isanti, Pine and Washington counties in Minnesota. For the purposes of the CHNA, Lakes Medical Center community includes 18 zip codes. The total population of this geographic community is180,629 people, and it covers 1,100 square miles. Lakes Medical Center is located between Interstate 35 and Highway 61. The City of Wyoming is proud of its 18 parks and 15 miles of walking and hiking trails. The city's commercial base is primarily industrial, with limited retail. The Lakes Medical Center community has a larger percentage of its population who are between 45 and 64 years old (29 percent) than the state's percentage (25 percent). The Lakes Medical Center community has a much larger percentage of people who identify as white (93.0 percent) than in the state as a whole (81.0 percent). This also means that the medical center community has a smaller percentage of people who identify as Black/African American, American Indian/Alaska Native, Asian, Native Hawaiian/Pacific Islander, two or more races, some other race, as well as Hispanic/Latino than the statewide percentage. There is projected to be very little change in racial or ethnic diversity in the Lakes Medical Center community between 2021 and 2026. Fairview Lakes provides a full continuum of services, from primary care services at the clinic to home care services to long-term care. 2) Fairview Northland Medical Center has a primary service area of individuals residing in Sherburne, Benton, Kanabec, Mille Lacs and Isanti counties in Minnesota. The hospital is uniquely located on the border of Mille Lacs and Sherburne Counties. For the purposes of the CHNA, Northland Medical Center community includes 11 zip codes. The total population of this geographic community is 126,669 people, and it covers 918 square miles. The Northland Medical Center community is younger than Minnesota at large, with a median age of 37.6 years as compared to a statewide median age of 39.7 years. Additionally, the community has a smaller percentage of its population aged 65+ (13 percent) than the state's percentage (17 percent). The Northland Medical Center community has a much larger percentage of people who identify as white (93.9 percent) than the statewide percentage (81.0 percent). This means that the medical center community has a smaller percentage of people who identify as Black/African American (1.72 percent), American Indian/Alaska Native (0.52 percent), Asian (1.03 percent), Native Hawaiian/Pacific Islander (0.04 percent), two or more races (2.17 percent), or some other race (0.65 percent) than the state percentages. The Northland Medical Center community also has a smaller percentage of those who identify as Hispanic/Latino than the statewide percentage. There is projected to be very little change in the racial or ethnic diversity in the Northland Medical Center community between 2021 and 2026. Fairview Northland provides a full continuum of services, from primary care services to home care. 3) Fairview Ridges Hospital in Burnsville, MN has a primary service area in Scott and Dakota counties. The hospital is Located in the southern part of the greater Minneapolis-St. Paul metropolitan area in Dakota county. For the purposes of the CHNA, Ridges Hospital includes 14 zip codes. The total population of this geographic community is 428,073 people, and it covers 444 square miles. About eight percent of the state's entire population live within this geographic area. The percentage of the Ridges Hospital community who are within the age range of 0-17 is slightly higher than the statewide average, and the percentage of the hospital community in the 65+ age range is slightly lower than the statewide percentage. In the Ridges Hospital community a slightly higher percent identify as Black/African American (7.9 percent) than the state (7.0 percent), Asian (6.8 percent) than the state (5.3 percent), some other race (2.7 percent) than the state (2.4 percent), two or more races (3.5 percent) than the state (3.0 percent) and Hispanic/Latino (6.5 percent) than the state (5.9 percent). In the next five years in the Ridges Hospital community there will be an increase from 7.9 percent in 2021 to 9.3 percent in 2026 in those who identify as Black/African American and an increase in those that identify as Hispanic/Latino from 6.5 percent in 2021 to 7.3 percent in 2026. Fairview Ridges Hospital is a multi-specialty medical center. 4) Fairview Southdale Hospital in Edina, MN has a primary service area of individuals residing in Hennepin and Carver counties. For the purposes of the CHNA, Southdale Hospital's community includes 28 zip codes. The total population of this geographic community is 560,916, which makes up about 10 percent of the state's population. It covers 278 square miles. The Southdale Hospital community has a median age of 41.8 years, which is slightly higher than the state's median age of 39.7 years. The age profile is very similar to that of the state, with 21 percent of the population being ages 0-17, 34 percent ages 18-44, 26 percent ages 45-64 and 18 percent ages 65 and older. In the Southdale Hospital community, 80 percent identify as white. However, the younger population is much more diverse. Among those ages 0-17, 33 percent of residents identify as Black/African American, Hispanic/Latino, Asian, American Indian/Alaska Native, Native Hawaiian/Pacific Islander, two or more races, or another race not listed. 5) University of Minnesota Medical Center and Masonic Children's Hospital, our flagship hospital, are located in the Cedar Riverside neighborhood. For the purposes of the CHNA, University of Minnesota Medical Center and Masonic Children's Hospital's community includes 57 zip codes. The total population of this geographic community is 1,270,209 people, and it covers 468 square miles. Nearly one-quarter (22 percent) of the state's entire population live within this geographic area. The community is younger than Minnesota at large, with a median age of 37.5 years as compared to a statewide median age of 39.7 years. People ages 18 to 44 make up nearly 40 percent of the population in this area. The UMMC and children's hospital community's population is comprised of 31.7 percent Black/African American, Asian, American Indian/Alaskan Native, Native Hawaiian/Pacific Islander, two or more races, and other races, significantly higher than the statewide percentage (19.0 percent). Of those, 15.1 percent are Black/African American, a percentage more than twice as high as in Minnesota at large. Additionally, 7.8 percent of the community's residents are Hispanic or Latino, exceeding Minnesota's statewide average of 5.9 percent. The University of Minnesota Medical Center, Fairview is the only medical center in the Cedar-Riverside neighborhood.