4A (Expenses $ 236646068 including grants of $ 143303) (Revenue $ 275814810)
See Schedule O

Part V, Section B
Facility Reporting Group A

Facility Reporting Group A consists of:
- Facility 1: St. Helena Hospital, - Facility 2: Adventist Health Vallejo

Facility Reporting Group - A Part V, Section B, line 5:
The 2019 CHNA data collection process can be summarized as follows: 1. Review of prior CHNA reporting efforts; 2. Collection of most recently available demographic, socioeconomic and health indicator data;3. Data gathering from community members. Data gathering was accomplished by engaging with community focus groups and conducting key stakeholder interviews. Focus group participants were end-users of programs and services provided by AHSH. Populations represented by focus group members included Promotoras, seniors, low-income, homeless/at-risk and representatives from the education sector. The majority of focus group participants live in Napa County, specifically in Santa Rosa, Yountville, St. Helena, and Calistoga. Key informant interviews consisted of key leaders in our community from an array of agencies, including those that serve children, homeless populations, seniors and community at large populations. Additionally, key informant interviews were conducted with representatives from the non-profit, educational, homeless, law enforcement, and faith-based sectors. The majority of the people interviewed serve residents in Napa County, specifically in in Santa Rosa, Yountville, St. Helena, and Calistoga. Additional localities identified for the service areas were Rutherford, Ronald Park, Deer Park and Hope Valley. Most key informants hold titles such as Executive Directors or Presidents, Superintendent, Mayor, and Head Pastor.A significant portion of secondary data for this assessment was collected through reports generated through CARES Engagement Network CHNA(https://engagementnetwork.org/assessment/). Other sources include California Department of Public Health, County Health Rankings & Road maps, and California Environmental Protection Agency's Office of Environmental Health Hazard Assessment. When feasible, health metrics have been further compared to estimates for the state or national benchmarks, such as the Healthy People 2020 objectives.

Facility Reporting Group - A Part V, Section B, line 6b:
St. Helena Hospital partnered with Abode Services, Napa Valley Unified School District-St. Helena School District, Rianda House and Up Valley Center to prepare the 2019 Community Health Needs Assessment.

Facility Reporting Group - A Part V, Section B, line 11:
The COVID-19 global pandemic has caused extraordinary challenges for Adventist Health hospitals and health care systems across the world including keeping front line workers safe, shortages of protective equipment, limited ICU bed space and developing testing protocols. They have also focused on helping patients and families deal with the isolation needed to stop the spread of the virus, and more recently vaccine roll out efforts. Adventist Health, like other health care systems, had to pivot its focus to meet the most urgent healthcare needs of its community during the pandemic, as well as reassess the ability to continue with some community health strategies due to public health guidelines for social distancing. Adjustments have been made to continue community health improvement efforts as possible, while ensuring the health and safety of those participating. Our 2019 CHNA identified four areas of significant need: Mental and Behavioral Health, Access to Health Care, Chronic Diseases, and Housing. Priority Need 1 - Mental and Behavioral Health - The goal is to reduce stigma of mental health for youth and seniors through education and engagement in the communities served by Adventist Health St. Helena & Vallejo. Strategy 1 - Stigma reduction through increased education and awareness. Strategy 1.2 - Advance existing peer and professional counseling to struggling youth.Strategy 1.3 - Increase awareness and resources for seniors to live safely in home. Activity 1.1 - Teens Connect - This Wellness Cafe is open to all and is considered a safe space for teens to discuss struggles as well as tools for managing stress and anxiety.Activity 1.2 - Aldea Children & Family Services at Boys and Girls Clubs - This program provides mental health, child welfare and support services for individuals who have barriers in receiving treatment. Activity 1.3 - Healthy Minds Healthy Aging - This program provides screening for cognitive, behavioral and psychosocial health issues. Due to the impact of COVID-19, our Teens Connect, Aldea Children & Family Services, and our Healthy Minds Healthy Aging programs have been placed on hold for the duration of 2021. Our hope is to revisit these programs in 2022. Priority Need 2 - Access to Health Care and Health - The goal is to increase access to quality, culturally competent health care and health to underinsured, uninsured and vulnerable in the community served by St. Helena and Vallejo. Strategy 1 - Identify and screen vulnerable community members providing education and resources for referrals to ongoing health management. Strategy 1.2 - Maintain and/or increase referrals for necessary diagnostic and surgical procedures for under or uninsured population. Activity 1.1 - Mobile Health Program - Our Mobile Health grant funded program was actively engaged within our community throughout 2021. As we seek to improve the health and well-being of our communities, bringing healthcare to the consumer and meeting people where they are is crucial. Due to the pandemic our focus included providing flu and COVID-19 vaccination clinics throughout Napa County. During 2021, our Mobile Health program provided more than 43,000 COVID-19 vaccine doses and targeted our seniors, farmworkers, teachers and essential workers including employees and patients from other hospitals, clinics and health plans. We look forward to continuing our mobile health program in 2022 and hope to increase our impact on those who need it most. Activity 1.2 - Operation Access - Due to the impacts of COVID-19 and high surges in early 2021, the Operation Access program was not able to serve patients in 2021. It is our hope that we will continue outreach and collaboration in 2022, to get much needed services to those who need them. Additional activities include our Blue Zones Project work. With Blue Zones coming into our community, we have been able to start the foundation of bringing awareness to access to healthcare and health through the following activities: We have set the goal of creating an environment in the Upper Napa Valley where healthy foods and beverages are embraced, universally accessible, and locally produced, with emphasis on food and nutrition insecure households. Our specific targets are for each city/town to adopt four policy/systems/environmental changes, complete three capacity building initiatives, and implement one marquee project. Another objective is to increase healthy food and beverage access with an emphasis on underserved community members. Our strategies to accomplish this are to: establish comprehensive adoption and use of food benefit programs at Calistoga farmers market, including universal SNAP/WIC acceptance, pilot produce Rx and market match; ensure timing of the farmers market works for the community, and that the community feels comfortable attending the market; (Calistoga) create a pilot Produce Rx program at St. Helena Farmers Market; ensure timing of the Farmer's Market events works for the community, and that the community feels comfortable attending the event; (St. Helena) establish food insecurity screening and referral through relevant healthcare providers and community-based programs; (Regional) establish accessible transportation to existing hunger relief sites, including free food pantries and churches, and/or expand mobile market access/delivery; and explore the expansion of public growing space such as vineyards and community gardens. (Calistoga, Regional) We've also included the objective of reducing the availability of and access to tobacco products, focusing on flavors. We plan to advocate for the implementation of a Tobacco Retail Licensing program, including prohibiting the retail sale of tobacco within a specified distance from youth areas and prohibiting the retail sale of flavored tobacco products. (Calistoga, St. Helena, Yountville) Additionally, we will also advocate for zoning reform to prohibit the retail sale of tobacco within a specified distance from youth areas (Calistoga, St. Helena, Yountville), as well as advocate for the passage of a flavor ban (Calistoga, St. Helena, Yountville).Priority Need 3 - Chronic Diseases - Heart Disease, Obesity/Diabetes, Cancer - The goal is to increase community's knowledge and ability to self-manage their disease. Strategy 1 - Local education and screening capacity addressing heart disease, obesity/diabetes and cancer through mobile screening program, local events, and disease specific screening opportunities. Strategy 1.2 - Educate community on prevention of chronic diseases. Activity 1.1 - Dare to C.A.R.E - Due to the COVID-19 pandemic, Dare to CARE was put on hold back in early 2020 and currently remains on hold throughout 2021. Activity 1.2 - 4-Weel Diabetes Education Course - With COVID-19 still actively present in 2021, there were limited number of community outreach and education classes. Total number of persons served in 2021 were nine. Activity 1.3 - AHEAD Hereditary Cancer Screening - Due to COVID-19 activities had to pivot direction. Number of participants screened: 1,455 with 171 directly affected and a total of 411 classified as being high risk and eligible for genetic testing. A total of 354 individuals agreed to testing and are currently pending results. Additional activities include our Blue Zones Project work. With Blue Zones coming into our community, we have been able to start the foundation to bring awareness around chronic disease - heart disease, obesity/diabetes and cancer priority through the following activities: working to decrease childhood obesity (Baseline, BMI) by increasing access to healthy fruits and vegetables, increasing walkability and physical activity opportunities in the community. This will effectively decrease the rates of all the above diseases. One of the key points of Blue Zones is that they have lower rates of chronic diseases and a higher quality of life, but this is due to the collective intervention and is difficult to attribute to just one thing. Optimizing food, tobacco, and built-environment policy is a high-impact, cost- effective strategy to reduce chronic disease and improve well-being.

Part V, Section B, Line 11, continuation:
Priority Need 4 - Housing and Homelessness - The goal is to have community collaboration to provide goods to individuals experiencing housing insecurity. Strategy 1 - Community Building Initiatives (CBI). Activity 1 - Inspire Hope/World Vision - This community-based initiative is designed to respond to the growing financial, housing and economic needs within our community. Throughout 2021, our local Inspire Hope Program met people where they are at and provided support through the following outlets: community members who have experienced big life changes due to the pandemic, have been impacted/displaced by local wildfires, and those who are unhoused and need basic essentials to survive. Some of the smallest donations are making a huge impact to those we are serving. Over 2021, we had an average of at least 25 active partners that worked collectively to get resources out to our community members. Additional activities include Blue Zones Projects. Additionally with Blue Zones coming into our community, we have been able to start the foundation of bringing awareness to housing and homeless priorities through the following activities: engaging in strategic conversations with the State around Veterans Home Workforce Housing Development and ADA/multimodal accessibility, and adopting policies or plans that will further the development of affordable and accessible housing to service Upper Napa Valley community needs by updating the housing elements of general plans as required for each community, while addressing the regional housing need projections for each and utilizing innovative housing solutions that best suit respective communities. We will also develop policies to require affordable and missing-middle housing, with a focus on workforce housing. We plan to activate the old fairgrounds to accommodate the community's need for additional green space, a community center, further parks programming, open multimodal connectivity, and access, and offer developable land for housing solutions. One way we will measure success is by the number of planned or contracted affordable and missing middle housing units (at x% AMI to align with city housing elements).Priorities not addressed: No hospital can address all the health needs identified in its community. Adventist Health St. Helena and Vallejo are committed to serving the community by adhering to its mission, and using its skills, expertise and resources to provide a range of community benefit programs. Significant needs that will not be directly addressed include 'Access to Health Foods' & 'Sexually Transmitted Diseases'. These needs will be addressed by other community organizations within the community.

Part V, Section B, Line 13h:
Patients who do not meet the income criteria, may be eligible for financial assistance based on essential living expenses and resources. The following two (2) qualifications must both apply:1. Essential living expenses: Exceed fifty percent (50%) of the household income; and2. Resources: The patient's excess medical expenses (the amount that allowable medical expenses are greater than 50% of annual household income) must be greater than available qualifying assets.

Part I, Line 7:
The costs were determined by using a cost-to-charge ratio. The cost-to-charge computation is based on Hospital specific data included in the system-wide combined audited financial statements. The formula used for computation equals financial statement data as follows:Total expenses - (Provision for bad debts + Other revenue + Interest income)/Gross patient chargesThe Hospital is located in a medically underserved area and participates in a quality assurance fee program with the State of California to fund certain Medi-Cal coverage expansions. The state redistributes funds to hospitals that provide patient care to a higher proportion of indigent and medically underprivileged patients, who otherwise would most likely not have access to physicians and other medical services. The community benefit analysis includes receipts from this redistribution that are used to assist in partially offsetting the significant costs associated with providing patient care to this population group. The program may or may not continue in the future based on the State of California's regulations and policies and the approval of the federal government.

Part II, Community Building Activities:
The Hospital is involved in numerous community building activities which promote the health of the community. Overwhelmingly, we see diseases of despair including suicide, substance abuse, mental health and chronic illnesses plaguing the communities that we have a significant presence in. These community concerns are addressed through health improvement, education, poverty, workforce development and access to care. This is why we have focused our work around addressing behavior and the systems keeping the most vulnerable people in cycles of poverty and high utilization. In an effort to heal these communities, we have strategically invested in our communities by partnering with national leaders in community well-being. We believe the power of community transformation lies in the hands of the community. Our solution for transformation is to create a sustainable model of well-being that measurably impacts the well-being of people, well-being of place and equity. In 2020, Adventist Health acquired Blue Zones as the first step toward reaching our solution. By partnering with Blue Zones, we will be able to gain ground in shifting the balance from healthcare - treating people once they are ill - to transformative well-being - changing the way communities live, work and play. In 2021, Adventist Health committed to launching six Blue Zone Projects within our community footprint, and as we enter 2022 these projects are active. Blue Zones widens our impact from only reaching our hospitals' communities in four states to a global mission practice. We also encourage our employees to serve on community collaboration boards, health advocacy programs, and physical improvement projects to promote the health of the communities we serve. In addition, we work with neighborhood programs, including schools, work sites and safety net providers to promote health and wellness and prevent disease. These activities are not included elsewhere on Schedule H.

Part III, Line 2:
Uncollected patient accounts are analyzed using written patient financial services policies that apply standard procedures for all patient accounts. The result of the analysis is what is recognized as bad debt expense. For example, all self-pay patients receive a discount. If the discounted account is unpaid after collection efforts, the unpaid balance is classified as bad debt. The cost-to-charge ratio described for Part I, Line 7 is multiplied times the Hospital's bad debt expense. The resulting figure has been reported as bad debts at cost on Part III, Line 2.

Part III, Line 3:
The portion of the bad debts attributed to charity care as reported on Part III, Line 3 was calculated by an independent third-party consulting firm. This is an estimate of additional charity care that would have been granted if patients had cooperated by furnishing family financial information. A statistically valid sampling of patient accounts written-off was evaluated. The evaluation used various factors to determine which patients would have been eligible for charity care. Had the Hospital obtained sufficient information from all patients who qualified for financial assistance, these additional accounts would have been recorded as charity care instead of bad debt.

Part III, Line 4:
The system-wide audited combined financial statements do not contain a footnote describing bad debt expense.

Part III, Line 8:
"The Medicare Cost Report apportions the Hospital's costs on the basis of inpatient days and ancillary and outpatient charges to establish the costing methodology. Healthcare delivery by hospitals is a complex, highly regulated business in the United States. Healthcare unit cost inflation is driven by compliance with ever expanding regulatory requirements, shortages of highly skilled labor and involving medical and information technology. The health care ""market basket"" is unrelated to that of the average individual consumer. Medicare annual payment updates have fallen behind actual healthcare cost inflation to the point that Medicare payments to many U.S. hospitals are well below the cost of providing care. These unreimbursed costs are a community benefit for seniors and others in the community as these individuals are continuing to receive care without which many would become dependent on other governmental resources such as Medicaid. The benefit to the community for healthier Medicare recipients is no different than those benefits the community realizes for uninsured and underinsured patients who are eligible for partial and full charity care. Medicare is a safety net for seniors and others. Without Medicare coverage, many individuals would undoubtedly qualify for charity care. In addition to the mismatch between Medicare payment increases and healthcare cost inflation, the highly complex Medicare payment systems and formulas produce disparate payment levels from one hospital to another for the same service. These disparate payment levels create disparate results within groups of hospitals. For further information, please refer to Schedule H, Part III, Section B."

Part III, Line 9b:
"When a patient has requested screening for charity care, the hospital must immediately cease collection activity and place the account in a charity pending status. If 100% charity is approved, the entire account balance is written off to charity care. If the patient has a sliding scale liability based on the federal poverty guidelines, they are billed only for that liability. If the patient fails to pay their after-charity liability, they are assigned to a collection agency with an identifier that indicates to the agency that the patient is ""low income and the following criteria must be followed by the agency:1. They may not report the patient to a credit bureau2. They may not file a lawsuit to recover the outstanding liability3. They may not charge interest"

Part VI, Line 7, Reports Filed With States
CA

Part VI: Other Information:
In 2021, Adventist Health St. Helena continued the following actions in response to the needs created or exacerbated by COVID-19: Continued offering virtual healthcare visits; continued their online symptom tracker; and participated in a communitywide effort to vaccinate eligible community members. Additionally, the Hospital supported the county's public health department mobile health program in launching a testing initiative to reach agricultural workers and vineyard/winery support staff on a bi-weekly basis to meet them where they are. This allowed us to develop relationships, build trust and provide education on safety precautions to keep themselves and their families safe.

Part VI, Line 2:
The Hospital's 2019 CHNA, the 2022 Community Health Plan (CHP) Update for fiscal year 2021, and the 2020 Implementation Strategy adopted in 2020 are posted on the Hospital's website at:https://www.adventisthealth.org/about-us/community-benefit/The most recent Community Health Needs Assessment, two most recent Implementation Strategy reports and the most recent Community Health Plan Updates are also available on the Adventist Health Corporate website at:https://www.adventisthealth.org/about-us/community-benefit/The Community Health Needs Assessment (CHNA) includes both the activity and product of identifying and prioritizing a community's health needs, accomplished through the collection and development of a community health plan. The second component of the CHNA, the community health plan, includes strategies and plans to address prioritized needs, with the goal of contributing to improvements in the community's health. Qualitative and quantitative data sources were used in conducting the CHNA. To accomplish the many important systemic goals that are underway in our community, our hospitals support local partners to augment our own efforts, and to promote a healthier community. Partnership is not used as a legal term, but a description of the relationships of connectivity that are necessary to collectively improve the health of the regions we serve. One of our objectives is to partner with other nonprofit and faith-based organizations that share our values and priorities to improve the health status and quality of life of the community we serve. This is an intentional effort to avoid duplication and leverage the successful work already in existence in the community.

Part VI, Line 3:
The plain language summary of the Financial Assistance Policy (FAP) is posted along with the complete FAP policy and FAP Application on the hospital's website at:https://www.adventisthealth.org/documents/financial-assistance/ENG_PFS-112_Financial-Assistance-Policy.pdf These documents are available in multiple languages.At the time of registration, patients who are uninsured and underinsured are provided information about government healthcare programs. Patients are also orally informed of their right to request charity assistance. Signs are displayed in the patient business office, patient registration areas and the emergency room in multiple languages informing patients of this right as well. The Hospital also provides a brochure during the registration process that explains the hospital billing and collection procedures, and how to request financial assistance. In addition, every billing statement sent to patients contains information on how to request financial assistance.

Part VI, Line 4:
St. Helena Hospital Napa Valley service area is comprised primarily of communities in Napa and Solano counties. The major communities are the upper valley cities of St. Helena and Calistoga. The demographics of the communities we serve are wide scope, including urban, suburban, and rural, and from all income levels. Although we primarily serve those in the Napa and Solano counties, our destination services also bring us patients from larger and further demographics including Lake County. Napa County has a population of 140,314 with a median household income of $88,457. At the end of the 2017 school year, testing for fourth graders found that far more students scored Not proficient or worse on standardized reading testing, than 'Proficient or better in Lake County (76.4%), this average was higher than AHSH PSA (72.6%) and Napa County (59.1%).Across the two-county region, Napa County has a lower percentage of populations receiving Public Assistance Income at 1.7% and SNAP benefits at 5.1% as compared to Lake County and the state estimate of 3.6% and 11.2%, respectively. Napa County demonstrated a higher proportion of woman receiving prenatal care and adequate care at 79.7% in comparison to Lake County at 68.5%. Notably, Napa County estimates meet the Healthy People 2020 performance target of 77.9% and 77.6%, respectively. AHSH PSA Medicare population has the lowest rates of depression (16.4%) and heart disease (24.4%) as compared to Lake County (16.6% and 25.8%, respectively). AHSH PSA had higher rates of diabetes as compared to Lake and Napa County (21.6% and 22.2%, respectively). Food insecurity averages in Lake County for the overall population (15.6%) and children (23.2%) are higher than reported averages for the state (11% and 18.1%, respectively). These averages are higher than Napa County.

Part VI, Line 6:
The Hospital is a member of Adventist Health, a health care system which provides healthcare services in diverse markets within the Western United States. A member hospital may share some services with other member hospitals in its geographic area, such as clinical, management and support services. Using today's technology, hospitals outside the geographic area are able to provide support through remote services such as telepharmacy and robotics surgery. The Corporate Office provides important shared administrative support for member hospitals' rural health clinics and home care agencies, quality of care, other clinical needs, financing and risk management, and shared clinical and financial information technology. As many experienced and new physicians search for alternatives to independent practice, there is also corporate administrative support for hospital affiliated medical groups that engage physicians through employment or other contracts. This provides stability and growth of qualified physicians across many specialties, which is very important to make healthcare services available and to maintain and improve health within the communities served by all member hospitals.

Part VI, Line 5:
"Our Hospital's mission is, ""Living God's love by inspiring health, wholeness and hope."" Our community benefit work is rooted deep within our mission and merely an extension of our mission and service. We have also incorporated our community benefit work to be an integral component of improving the ""triple aim."" The ""Triple Aim"" concept broadly known and accepted within health care includes:1. Improve the experience of care for our residents.2. Improve the health of populations.3. Reduce the per capita costs of health care.Our strategic investments in our community are focused on a more planned, proactive approach to community health. The basic issue of good stewardship is making optimal use of limited charitable funds. Defaulting to charity care in our emergency rooms for the most vulnerable is not consistent with our mission. An upstream and more proactive and strategic allocation of resources enables us to help low income populations avoid preventable pain and suffering; in turn allowing the reallocation of funds to serve an increasing number of people experiencing health disparities. Hospitals and health systems are facing continuous challenges during this historic shift in our health system. Given today's state of health, where cost and heartache are soaring, now more than ever, we believe we can do something to change this. These challenges include a paradigm shift in how hospitals and health systems are positioning themselves and their strategies for success in a new payment environment. This will impact everyone in a community and will require shared responsibility among all stakeholders. As hospitals move toward population health management, community health interventions are a key element in achieving the overall goals of reducing the overall cost of health care, improving the health of the population, and improving access to affordable health services for the community both in outpatient and community settings. The key factor in improving quality and efficiency of the care hospitals provide is to include the larger community they serve as a part of their overall strategy. Population health is not just the overall health of a population, but also includes the distribution of health. Overall health could be quite high if the majority of the population is relatively healthy even though a minority of the population is much less healthy. Ideally such differences would be eliminated or at least substantially reduced.Community health can serve as a strategic platform to improve the health outcomes of a defined group of people, concentrating on three correlated stages:1. The distribution of specific health statuses and outcomes within a population; 2. Factors that cause the present outcomes distribution; and 3. Interventions that may modify the factors to improve health outcomes.Improving population health requires effective initiatives to: 1. Increase the prevalence of evidence-based preventive health services and preventive health behaviors, 2. Improve care quality and patient safety, and 3. Advance care coordination across the health care continuum. We will work together with our community to ensure the community health improvements are identified and then targeted for programs to influence behaviors to obtain improved health within the whole community."