4A (Expenses $ 13517965 including grants of $ 0) (Revenue $ 12346312)
MARGARETVILLE MEMORIAL HOSPITAL IS A CRITICAL ACCESS HOSPITAL THAT PROVIDES ACUTE HEALTH CARE SERVICES TO RESIDENTS AND VISITORS TO THE COMMUNITES SERVICED. MARGARETVILLE MEMORIAL HOSPITAL RECORDED 1,280 PATIENT DAYS. 3,331 EMERGENCY ROOM VISITS, 126 OUTPATIENT SURGERIES, 160 DISCHARGES AND 195 INFUSION THERAPIES IN 2021.

Part V, Section B, Line 3E:
"THROUGH THE COLLABORATION AND PARTNERSHIP WITH DELAWARE COUNTY PUBLIC HEALTH DEPARTMENT, MARGARETVILLE HOSPITAL, IN ACCORDANCE WITH NEW YORK STATE PREVENTION AGENDA MANDATE, HAS CHOSEN TO ALIGN WITH OUR COMMUNITY PARTNERS IN FOCUSING ON TWO PRIORITY AREAS: A. PREVENT CHRONIC DISEASES B. PROMOTE HEALTHY WOMEN, INFANTS, AND CHILDREN MARGARETVILLE HOSPITAL INVOLVED KEY MEMBERS OF THE HOSPITAL TEAM IN THE ASSESSMENT AND SELECTION OF ITS HEALTH PRIORITIES. AFTER IDENTIFICATION OF THE CRITERIA FOR PRIORITY SELECTION, A WORK GROUP WAS CONVENED BY THE DELAWARE COUNTY PUBLIC HEALTH DEPARTMENT WHICH INCLUDED MARGARETVILLE HOSPITAL AFFILIATED WITH HEALTH ALLIANCE OF THE HUDSON VALLEY AND WESTCHESTER MEDICAL CENTER HEALTH, DELAWARE VALLEY HOSPITAL AFFILIATED WITH UNITED HEALTH SERVICES, BASSETT HEALTHCARE NETWORK O'CONNOR HOSPITAL, AS WELL AS THE SOUTHERN TIER POPULATION HEALTH IMPROVEMENT PROGRAM (""PHIP""). THROUGH THIS WORK GROUP, THE DATA FROM THE COMMUNITY ENGAGEMENT SESSIONS, AS WELL AS THE HOSPITAL AND COUNTY HEALTH DEPARTMENT COMMUNITY HEALTH ASSESSMENTS, WERE ALIGNED WITH THE PRIORITIES OUTLINED BY THE NYS 2019-2024 PREVENTION AGENDA. ADDITIONALLY, THE RATIONALE FOR CHOICE OF PRIORITIES WAS BASED ON AVAILABLE RESOURCES AND CAPACITY TO ADDRESS THE PRIORITY. OPPORTUNITY FOR DEVELOPMENT OF COLLABORATIVE INTERVENTIONS BY MARGARETVILLE HOSPITAL, THE DELAWARE COUNTY PUBLIC HEALTH DEPARTMENT AND OTHER COMMUNITY PARTNERS, WAS ALSO CONSIDERED. THROUGH THE COLLABORATION DESCRIBED ABOVE WITH COUNTY PUBLIC HEALTH AND COMMUNITY-BASED ORGANIZATIONS, MARGARETVILLE HOSPITAL ALIGNED TOGETHER TO SELECT TWO PREVENTION AGENDA PRIORITIES: A. PREVENT CHRONIC DISEASES B. PROMOTE WELL-BEING AND PREVENT MENTAL AND SUBSTANCE USE DISORDERS BOTH OF THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) 2019 PRIORITIES ARE FROM THE NYS PREVENTION AGENDA 2019-2024. MARGARETVILLE HOSPITAL PARTICIPATED IN A WORKGROUP CONSISTING OF THE THREE LOCAL HEALTH SYSTEMS AND THE COUNTY PUBLIC HEALTH DEPARTMENT TO IDENTIFY FOCUS AREAS, AND OBJECTIVES FOR EACH OF THE AGENDA PRIORITIES JOINTLY IDENTIFIED BY THE HOSPITAL AND COLLABORATORS: THE NEW YORK STATE PREVENTION AGENDA OUTLINES THREE OTHER PRIORITY AREAS THAT WERE NOT SELECTED AS PRIORITIES FOR THE MARGARETVILLE HOSPITAL 2019-2021 COMMUNITY SERVICE PLAN: PROMOTE A HEALTHY AND SAFE ENVIRONMENT, PROMOTE HEALTHY WOMEN, INFANTS AND CHILDREN, AND PREVENT COMMUNICABLE DISEASES. ALTHOUGH ALL OF THESE MERIT FOCUS FOR IMPROVING POPULATION HEALTH, THEY WERE NOT SELECTED DUE TO THE LIMITED AMOUNT OF RESOURCES AVAILABLE TO ADDRESS THESE ISSUES AND THE RELATIVE SEVERITY OF NEED DEMONSTRATED FOR THE PRIORITY AREAS THAT WERE CHOSEN."

Part V, Section B, Line 5:
Margaretville Memorial Hospital (Margaretville Hospital), an affiliate of HealthAlliance of the Hudson Valley, a member of the Westchester Medical Center Health Network (WMCHealth) was an active member of a comprehensive Delaware County Community Health Assessment which includes 3 hospitals and the Delaware County Public Health Department. Margaretville Hospital staff was heavily involved in the collaborative and contributed immensely towards the creation of the assessment. The primary proactive means for receiving community input was through the Regional Assessment conducted by the Southern Tier Population Health Improvement Program (PHIP). In the Southern Tier, PHIP covers five counties including Delaware County. In order to inform the direction of the Southern Tier PHIP, also known as Health Action Priorities Network (HAPN), the team conducted a regional health assessment utilizing stakeholder interviews and consumer focus groups. The information/data from the Delaware County assessment was utilized to direct the selection of the public health priorities for Margaretville Hospital. From June 2018 through January 2019, structured interviews in Delaware County were conducted with professionals working in diverse fields such as health care, education, transportation, economic development, mental health, law enforcement and elected officials, among others. The interview focused on 10 key questions and five secondary questions centered on health disparities, key barriers to addressing them, and gaps in service provision. Consumers' input was sought through focus groups which were conducted from January through March of 2019. Population Health Coordinators met with pre-existing groups including support groups, service clubs, parent groups and senior meals. HAPN/PHIP Southern Tier conducted focus groups in Delaware County. The group attendants were asked about their experiences with health and health care delivery. Responses from the focus groups were collected by note-takers and summarized qualitatively by the Population Health Coordinators. In addition, Margaretville Hospital is an active participant in Delaware County's Community Health Improvement Plan process. This process included input and suggestions from Delaware County Public Health, Delaware Valley Hospital, Margaretville Hospital, O'Connor Hospital, and the Southern Tier PHIP. In May of 2019, the PHIP Population Health Coordinators worked with the Delaware County committee to hold a community roundtable event at SUNY Delhi, located in Delhi NY, Delaware County. All Health and Human Services providers that received the survey were invited, as well as the community residents who provided their names and contact information electronically via the survey. The event was also promoted via email and social media communications. Hospital and Public Health representatives shared the invitation with their Boards of Directors. The roundtable event was attended by 40 people, and included a presentation on the survey data by the PHIP Coordinators. In addition, Delaware County's Director of Public Health and the Director of Operational Support from O'Connor Hospital (located in Delhi and affiliated with the Bassett Healthcare system) presented on the NY State and Federal requirements for completion of the Community Health Assessment, Community Health Improvement Plan, and the hospitals' Community Service Plans.

PART V, SECTION B, LINE 6A:
The CHNA was conducted with Delaware Valley Hospital (DVH), an affiliate of United Health Services (UHS) system; Margaretville Hospital (MH), which is a part of the Health Alliance of the Hudson Valley and a member of the Westchester Medical Center Health Network; and O'Connor Hospital (OCH), of the Bassett Healthcare Network.

PART V, SECTION B, LINE 6B:
Margaretville Hospital worked very closely with Delaware County Public Health and the Southern Tier Population Health Improvement Program (PHIP), known as the Health Action Priorities Network, which covers five counties including Delaware County.

PART V, SECTION B, LINE 7:
The CHNA has been widely available to the public through the website at HTTPS://WWW.HAHV.ORG/COMMUNITY-HEALTH-NEEDS-ASSESSMENTS AND PAPER COPIES ARE AVAILABLE FOR PUBLIC INSPECTION WITHOUT CHARGE AT MARGARETVILLE HOSPITAL.

PART V, SECTION B, LINE 10:
Margaretville Hospital has adopted an implementation strategy that will address the significant community health needs outlined in the hospital's CHNA which can be found on our website at https://www.hahv.org/community-health-needs-assessments under 'Delaware County' - Margaretville Hospital/Delaware County Community Service Plan and Implementation Plan, both for 2019-2021.

PART V, SECTION B, LINE 11:
Through the collaboration and partnership with Delaware County Public Health Department, Margaretville Hospital, in accordance with New York State Prevention Agenda mandate, has chosen to align with our community partners in focusing on two priority areas: a. Prevent Chronic Diseases b. Promote Healthy Women, Infants, and Children Margaretville Hospital involved key members of the Hospital Team in the assessment and selection of its health priorities. After identification of the criteria for priority selection, a work group was convened by the Delaware County Public Health Department which included Margaretville Hospital affiliated with Health Alliance of the Hudson Valley and Westchester Medical Center Health, Delaware Valley Hospital affiliated with United Health Services, Bassett Healthcare Network O'Connor Hospital, as well as the Southern Tier PHIP. Through this work group, the data from the community engagement sessions, as well as the hospital and county health department community health assessments, were aligned with the priorities outlined by the NYS 2019-2024 Prevention Agenda. Additionally, the rationale for choice of priorities was based on available resources and capacity to address the priority. Opportunity for development of collaborative interventions by Margaretville Hospital, the Delaware County Public Health Department and other community partners, was also considered. Through the collaboration described above with county public health and community-based organizations, Margaretville Hospital aligned together to select two Prevention Agenda Priorities: a. Prevent Chronic Diseases b. Promote Well-Being and Prevent Mental and Substance Use Disorders Both of the Community Health Needs Assessment (CHNA) 2019 priorities are from the NYS Prevention Agenda 2019-2024. Margaretville Hospital participated in a workgroup consisting of the three local health systems and the county Public Health department to identify focus areas, and objectives for each of the Agenda Priorities jointly identified by the hospital and collaborators: The New York State Prevention Agenda outlines three other priority areas that were not selected as priorities for the Margaretville hospital 2019-2021 Community Service Plan: Promote a Healthy and Safe Environment, Promote Healthy Women, Infants and Children, and Prevent Communicable Diseases. Although all of these merit focus for improving population health, they were not selected due to the limited amount of resources available to address these issues and the relative severity of need demonstrated for the priority areas that were chosen. AREAS OF FOCUS: Margaretville decided to address the county's health needs through the following implementation plan in guidance of NYS Prevention Agenda. Priority 1: Prevent Chronic Disease Focus Area 1: Healthy eating and food security Goal 1.3: Increase food security Objective 1.13: Increase the % of adults with perceived food security. Community Based Strategy and Commitment of Resources: The dietary department at Margaretville Hospital/MRCC will design and implement a food program designed to address food insecurity for inpatients (acute, observation and swing bed). The goal is for the dietitians, upon interview and screening, to identify patients with limited food access or possible food insecurity. They will establish a patient referral process to public health nutrition program such as WIC, SNAP or local food emergency services or food pantry prior to patients discharge. Focus Area 3: Tobacco Prevention Goal 3.2: Promote tobacco use cessation Objective: 3.2.2 Use health communications and media opportunities to promote the treatment of tobacco dependence by targeting smokers with emotional evocative and graphic messaging to encourage evidence-based quit attempts and increase awareness of available cessation benefits. Community Based Strategy and Commitment of Resources: Margaretville Hospital will partner with the HealthAlliance Marketing Department and Tobacco-Free Action Coalition to develop annual campaigns targeting current tobacco users in the community and our own facilities on the harm of smoking. In addition, we provide information through various messaging channels to include email, social media, earned media, and message boards. Focus Area 4: Preventive Care and management. Goal 4.4: In the community setting, improve self-management skills for individuals with chronic diseases, including asthma, arthritis, cardiovascular disease, diabetes and pre-diabetes and obesity. Objective 4.4.1: Increase the % of adults with chronic conditions who have taken a course or class to learn how to manage their condition. Community Based Strategy and Commitment of Resources: Margaretville Hospital will provide COPD education classes including a focus on self-management. Margaretville Hospital will also promote and support the Chronic Disease Self-Management Program (CDSMP) classes taking place in Delaware County. Priority 2: Promote Well-Being and Prevent Mental Health and Substance Use Disorders Focus Area 1: Mental and Substance Use Disorders Prevention Goal 2.2: Prevent opioid and other substance misuse and deaths. Objective 2.2.4: Reduce all E.D. visits (including outpatient and admitted patients) involving one opioid overdose. Community Based Strategy and Commitment of Resources: Margaretville Hospital will actively participate in the Catskills Addiction Coalition as the fiduciary member and recipient of the Rural Communities Opioid Response Planning grant for 2019 to 2020. In addition, the hospital will participate in the Delaware County Opioid Task Force and openly share OCH data with the Delaware County Public Health Department on number of patients reporting to E.D. with substance abuse issues for collaboration and appropriate access to services among community partners. Additionally, work towards receiving a three-year HRSA implementation grant to implement programs of the Catskills Addiction Coalition. Devote resources and attention of staff and leadership to collaborating with other community organizations on creative solutions. Focus Area 2: Mental and Substance Use Disorders Prevention Goal 2.3: Prevent and address adverse childhood experiences (ACES) Objective 2.3.3: Increase communities reached by opportunities to build resilience by at least 10 percent Community Based Strategy and Commitment of Resources: Margaretville Hospital will partner with HealthAlliance's Youth Mental Health First Aid Program to deliver the training to a variety of organizations and overall public through a variety of outreach and network building. In addition, the ultimate goal is to help drive referrals of youth needing additional support from clinicians. Focus Area 3: Promote Well-Being and Prevent Substance Use Disorders Goal 2.5: Prevent Suicides Objective 2.5.4: Build support systems to care for opioid users or at risk of an overdose Community Based strategy and Commitment of Resources: Margaretville Hospital will host QPR training at least once annually for Margaretville Hospital staff and four times annually throughout Delaware County in conjunction with the Delaware County Suicide Prevention. We will assess and identify the appropriate community organizations and internal staff for preventative steps to be taken.

PART V, SECTION B, LINE 16A, B AND C:
The hospital's financial assistance policy and application are available at the following link: https://www.hahv.org/financial-assistance

PART I, LINE 7:
Margaretville Memorial Hospital's costing methodology was based upon worksheet S-10 of the Medicare cost report. The cost-to-charge ratio was used for the various sub-line items of line # 7. PART I, LINE 7G: The costs on line 7g do not include any costs attributable to physician clinics.

Part III, Line 2: Methodology Used to Estimate Amount of Bad Debt Expense
The amount reported on line 2 is equal to the provision for bad debt expense per the Audited Financial Statements. The explanation of the methodology used to estimate this amount can be found in footnote #2 on pages 19-22 of the attached Audited Financial Statements.

Part III, Line 4: Description of Bad Debt Expense
The text of the footnote that describes bad debt expense can be found on pages 19-22 of the attached Audited Financial Statements.

Part III, Line 8: Costing Methodology
Since Margaretville Memorial Hospital is a critical access hospital, the hospital receives 101% of its cost for most of its services; therefore, Margaretville should always have a surplus from Medicare. The amount reported on Line 6 was derived by using the Medicare allowable costs as reported on the Medicare cost report and the applicable adjustments from Worksheet A. For 2021, Margaretville Memorial Hospital does not have a loss from Medicare therefore it is not considered a community benefit.

PART III LINE 9B: Collection Practices
The credit and collection policy for self-pay balances provides that, in some cases, non-insured patients that do not qualify for Medicaid qualify for charity care. In those instances, the credit and collection department will follow the guidelines as set forth in the charity care policy. The charity care policy provides that the financial counselor evaluates the information provided in patients' charity care applications in conjunction with federal income poverty guidelines to determine the write-off percentage. If the patient/guarantor qualifies for charity care based on the sliding scale, the patient will be required to pay the outstanding amount. A payment plan is established not to exceed 10% of the guarantor's gross monthly income.

PART VI, LINE 2: NEEDS ASSESSMENT
Process to maintain engagement, track progress, and make mid-course corrections For the community-based strategies, Margaretville hospital will continue to actively participate in a work group consisting of the public health department and three other local hospitals for the purposes of maintaining engagement with local partners over the next three-year period. Initially, meetings will be held on a quarterly basis; however, frequency will be revisited throughout the timeframe to ensure that the meetings are meeting the needs of all partners. Progress will be tracked by the work group Margaretville hospital is actively participating in. Annually hospital leadership presents an update to the hospital's board of trustees noting specific achievements and barriers to implementation. Anecdotal feedback will be in work group meetings, meetings involving health and wellness groups such as the suicide prevention network of Delaware County, and from patients and individuals participating in interventions, allowing continual review of the community service plan tasks and mid-course corrections when required. Periodic public notices will be posted on the hospital website. Finally, as available, local, state and national health status indicators will be reviewed.

PART VI, LINE 5: Promotion of Community Health
Please see narrative for Schedule H, Part V, Section B, line 11 for a complete description of how the organization's hospital facilities work to further its exempt purposes by promoting the health of the community. In addition, 2021 and the ongoing COVID-19 pandemic created a greater need and focus on community health care. Margaretville Hospital and HealthAlliance of the Hudson Valley and the WMCHealth Network took a leading role in the Hudson Valley on the dissemination of information surrounding COVID-19, educating the community and providing community testing. In all of our efforts we focused on the hardest to reach individuals and communities. We coordinated closely on all of our COVID-19 messaging, outreach, and direct care with New York State Department of Health, Delaware County Department of Health, and Ulster County Department of Health. We provided detailed and ongoing information and messaging for community organizations, employers, and municipal governments. We participated at all levels of governments and with numerous community organizations on COVID-19 planning, preparedness, and response efforts.

PART VI, LINE 6: Affiliated Health Care System
Health Alliance is the parent company to affiliate members HA Mary's Avenue campus, Broadway campus, Margaretville Memorial Hospital, a rural critical access hospital; Mountainside Residential Care Center, a skilled nursing facility. This integrated healthcare system is committed to providing quality and compassionate medical care for our patients, their families and our community. In addition to service consolidation between the two Kingston hospitals, HAHV also committed to streamlining operations and improving care at the other affiliate locations.

PART VI, LINE 7: STATE FILING OF COMMUNITY BENEFIT REPORT
NEW YORK

PART VI, LINE 3:
The hospital informs the patient of the availability of charity care several ways: 1. notice is on every patient bill with an application on the back of the bill 2. on the hospital website 3. all members of the patient accounting department are trained to screen patients for charity care when discussing bills and concerns regarding inability to pay 4. fliers are posted in registration areas of the hospital 5. registration clerks will identify patients without a pay source and refer the patient to a financial counselor and hand the patient a financial assistance form 6. financial counselors assist patients in securing Medicaid and screen for charity care 7. the collection agencies that HAHV engages with are aware of the charity care policy and assist patients in applying up to 180 days post-placement with them HealthAlliance is committed to: - Providing access to quality healthcare services with compassion, dignity and respect for those we serve, particularly the poor and the underserved in our communities. - Caring for all persons, regardless of their ability to pay for services. - Assisting patients who cannot pay for part or all of the care they receive. - Balancing needed financial assistance for some patients with broader fiscal responsibilities in order to sustain viability and provide the quality and quantity of services for all who may need care in a community. In accordance with AHA recommendations, HealthAlliance adopted the following guiding principles when handling the billing, collection and financial support functions for our patients: - provide effective communications with patients regarding hospital bills - make affirmative efforts to help patients apply for public and private financial support programs - offer financial support to patients with limited means - implement policies for assisting low-income patients in a consistent manner - implement fair and consistent billing and collection practices for all patients with patient payment obligations HealthAlliance effectively communicates with patients regarding patient payment obligations. Financial counseling is provided to patients about their payment obligation and hospital bills. Information on hospital-based financial support policies and external programs that provide coverage for services are made available to patients during the pre-registration and registration processes and in response to patients seeking financial assistance. Information regarding the financial assistance is also provided by the onsite financial counseling staff in both inpatient and outpatient areas. Patient accounting also supports the financial counseling program by providing patients with information and applications while handling customer service calls. Financial counselors and county Medicaid workers also provide guidance regarding the financial assistance program when necessary. Financial assistance is available on the back of every hospital bill as well as the hospital website at www.hahv.org. Financial counselors make affirmative efforts to help patients apply for public and private programs for which they may qualify and that may help them obtain and pay for healthcare services. The patient does not need to have an account with the hospital; they just have to be in a situation where they are in need of insurance coverage. Every effort is made to determine a patient's eligibility prior to or at the time of admission or service. However, determination for financial support can be made during any stage of the patient's stay after stabilization or collection cycle. HealthAlliance offers financial support to patients with limited means. This support is available to uninsured and underinsured patients who do not qualify for public programs or other assistance. Notification about financial assistance, including contact information, is available through the hospital website, hospital posters and flyers, financial assistance applications and hospital statements. The financial assistance policy (FAP) and application are available on our website at http://www.hahv.org/hahv/financial-assistance.aspx and are supplied in both English and Spanish as well as plain language summary format. If additional assistance is needed, HealthAlliance offers translation services for patients. HealthAlliance has an established written policy for the billing, collection and support for patients with payment obligations. The organization makes every effort to adhere to the policy and is committed to implementing and applying the policy for assisting patients with limited means in a professional, consistent manner. Educated staff members work closely with patients (including those working in patient registration and admitting, financial assistance, customer service, billing and collections) about these policies with an emphasis on treating all patients with dignity and respect regardless of their insurance status or their ability to pay for services. All patient registration staff receive in-service training regarding the financial assistance program. Patient accounting also receives information about the program and how to handle patients seeking financial assistance. Financial counselors receive in depth training to handle financial assistance requests, process applications, and manage outcomes. HealthAlliance provides several options for patients who either do not have insurance coverage or who have inadequate insurance coverage. Our many programs have been very successful and many have taken advantage of our offerings. Financial counseling offers a patient the opportunity to speak to a financial counselor to determine what assistance can be accessible based on family income. Patients often shop around for the most economical healthcare and we offer price quotes. This allows the patient to know their financial obligation up front and understand the competitive pricing being offered. Despite millions of dollars of charity care distributed to needy patients every year, a consistent challenge is patients not utilizing the programs we offer. Often, they don't want to provide the necessary financial information to initiate the financial aid process. Continual outreach and education is ongoing to minimize confusion and improve utilization. HealthAlliance is committed to providing the best possible healthcare and is very sensitive to low income patients' ability to pay. The call center offers the convenience of calling one telephone number for all billing inquiries regardless of which hospital the patient is calling about.

PART VI, LINE 4: Community Description
Margaretville Memorial Hospital (Margaretville Hospital), a member of HealthAlliance of the Hudson Valley and the Westchester Medical Center Health Network (WMCHealth) is a rural Critical Access Hospital whose mission is to provide immediate access to high quality medical care and diagnostic testing services to medically underserved areas in the Catskill Mountains. Margaretville Hospital provides linkages to high tech and specialty medical care through an active relationship with HealthAlliance and WMCHealth. Margaretville Hospital is the Delaware County affiliate of HealthAlliance of the Hudson Valley (HealthAlliance), a multi-campus health care system consisting of HealthAlliance Hospital's Mary's Ave. and Broadway campuses in Kingston, NY, and Margaretville Hospital, which is co-located on a single campus in Margaretville, NY (Delaware County), with the Mountainside Residential Care Center, a skilled nursing facility. HealthAlliance defines its primary service area by a federal definition that consists of the top 75% of hospital discharges from the lowest number of contiguous zip codes. Margaretville hospital serves the communities of Margaretville, Arkville, Andes, Fleischmanns, Roxbury, Halcott Center, Halcottsville, and New Kingston. Due to the geographical location of acute care hospitals affiliated with HealthAlliance, there are two distinct primary services areas within Ulster and Delaware Counties, though not encompassing all of each county. For operational and community needs development, HealthAlliance regards these two service areas as a single primary service area with the predominant population in Ulster County. However, for the purposes of this document, which will align with the Delaware County Community Health Assessment and the Community Health Improvement Plan, we will present the information pertaining to the Margaretville Hospital service area, located in Delaware County and described in the beginning of this section. Other community health services and resources available in Delaware County include 23 ambulance services, mostly consisting of volunteer membership. In addition to Margaretville Hospital, there are three other hospitals, operated by two other healthcare systems: Delaware Valley Hospital affiliated with United Health Services, as well as O'Connor Hospital affiliated with the Bassett Healthcare Network. Additionally, there are three nursing homes in the county, 15 primary care offices including health centers and private physician offices, 15 locations and 9 full-time equivalent dentists, and two mental health clinics with multiple locations within the county. Delaware County covers 1,442 square miles in upstate New York, belonging to both the Southern Tier region and the Catskill Mountain range. Delaware County is the fourth largest county in New York by area and is the sixth most rural with a population density of 31 persons per square mile. The county includes the Catskill/Delaware Watershed, which is the largest unfiltered drinking water supply in the United States. The watershed region encompasses the central and eastern sections of Delaware County and includes roughly 65% of the county's land area and 11 of its 19 townships. Approximately 55% of Delaware County's population lies within the Watershed. Based on the 2020 Census, the population of Delaware County is 44,676, and is split evenly at 50% male and 50%% female. This represents a 6.6% decrease in population from the 2010 census which had the population at 47,840. At the time of the 2020 Census the age of the population was found to b:, 20% of the people were less than 18, 80% were 18 and over and 41% were 65 and over, with a median average age of 48.3.