4A (Expenses $ 228752579 including grants of $ 70710) (Revenue $ 317415999)
Hanford Community Hospital provides quality medical health care regardless of race, creed, sex, national origin, handicap, age, or ability to pay. Although reimbursement for services rendered is critical to the operation and stability of Hanford Community Hospital, the organization recognizes that not all individuals possess the ability to pay for essential medical services. Adventist Health's vision is to enhance the health of the communities where we live and serve, by engaging our community and our patients in a new definition of and partnership for personal community health. In keeping with this commitment to serve all members of the community, the following will be considered when individuals who need health care cannot pay:providing free care and/or subsidized careproviding care to persons covered by governmental programs at below costproviding health/wellness activities and community education programsNot only does Hanford Community Hospital provide low-cost care to individuals covered by government programs and those unable to afford health care, but it also helps patients find and access private and governmental resources for health care benefits. Hanford Community Hospital recognizes below-cost reimbursement as charity and uncompensated care in meeting its mission to the entire community. The unreimbursed value of providing care to these patients in 2016 was $23,872,385.Inpatient services in 2016 were provided to 46,419 patients. These services included: Babies delivered - 2,377 Surgeries performed - 3,894 Cardiac catheterizations and other procedures - 866Outpatient services in 2016 were provided to 167,558 patients. These services included: Emergency room visits - 124,068 Outpatient surgeries performed - 5,617 Radiology procedures performed - 67,391 Laboratory tests performed - 425,806Hanford Community Hospital recognizes it has an obligation to provide human services above and beyond its role as a healing facility. The following community benefits demonstrate the tangible ways in which the organization is fulfilling its mission: Free Health education and screening at weekly farmer's market Provided clothing, food, toys, and gifts to needy families Provided Christmas gifts for Kings County foster children Partnered with Kings United Way for day of caring and project homeless connect Worked with Kings County Commission on Aging to provide meals for home bound seniors Performed physicals, immunizations, dental screenings and healthy family enrollments at back-to-school health fairs Educated individuals at diabetes support group meetings Taught children and parents about healthy living

Part V, Line 5 - Account Input from Persons Who Represent the Community
The 2016 CHNA data collection process can be summarized as follows: Review of prior CHNA reporting efforts Review of CHNA data set available for this report Interview with Benefits Work Group on expectations for CHNA Agreement on survey, focus group and interview questions Gather additional data from communities Summarize findings Prioritize needs Identify target prioritizationFocus Groups: A total of 15 focus groups were conducted ranging in size from 4 to 24 participants. They were attended by hospital and facility staff, community leaders from nonprofit and faith-based organization and elected officials and residents. These sessions were conducted primarily in English. Focus groups comprised of primarily residents, including mothers and youth were conducted in English and Spanish. Key Stakeholder Interviews: The workgroup identified approximately 95 individuals considered to be key stakeholders in the region that would be important to interview. Consultants contacted each stakeholder offering to conduct phone or in-person interviews. Thirty-five stakeholder interviews were conducted between July 20 and September 10. The format for these was identical to the focus group process. Participants in this effort included the following stakeholders in all four counties: County Public Health Directors, hospital executives and nonprofit leaders who serve the community with social, health, or educational support services. These key stakeholders were selected by the workgroup because they would provide a unique perspective on the health of the community, health care delivery systems in place and overall conditions that influence health behaviors. In addition, as perIRS guidelines the CHNA community outreach also involved the Tule River Nation Elders and Tribal Council Members in Tulare County. The qualitative data that was generated from the focus groups, surveys and interviews provides additional context and increased the importance of this information.

Part V, Line 6a - List Other Hospital Facilities that Jointly Conducted Needs Assessment
This report is the result of a unique collaboration among the hospitals committed to serve the nearly 1.7 million diverse residents in the Central California counties of Fresno, Kings, Madera and Tulare. Since 2011, this is the third shared needs assessment process to identify the health needs of the region and reflect a strong desire and commitment to align strategies and resources in order to achieve quality care and health equity for the communities served. With coordinating support from the Hospital Council of Northern and Central California, a total of 15 medical centers and hospitals have worked together on this Community Health Needs Assessment (CHNA) covering four counties. The Hospital Council works with hospitals to advance quality health care delivery and supports the CHNA process with a committee comprised of key executives representing the major hospitals in each county. This Hospital Council Community Benefit Workgroup (workgroup) invested significant time and resources to work on the design of the overall CHNA strategy and the coordination of primary and secondary data collection with Leap Solutions, LLC, an independent consulting firm. The 2016 report represents the collective hospital communitys third health needs assessment. These hospitals are:1. Adventist Medical Center - Reedley2. Central Valley General Hospital3. Clovis Community Medical Center4. Coalinga Regional Medical Center5. Corcoran District Hospital6. Community Regional Medical Center (includes Community Behavioral Health Center)7. Children's Hospital Central California8. Fresno Heart & Surgical Hospital9. Kaiser Permanente Fresno Medical Center10. Kaweah Delta Health Care District11. Madera Community Hospital12. San Joaquin Valley Rehabilitation Hospital13. Sierra View District Hospital14. Saint Agnes Medical Center15. Tulare Regional Medical Center

Part I, Line 7 - Explanation of Costing Methodology
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 audited combined financial statements. The formula used for computation equals financial statement data labeled as follows:Total expenses - (Provision for bad debts + Other revenue + Interest income) divided by Gross patient charges

Part III, Line 2 - Methodology Used To Estimate Bad Debt Expense
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 as reported in the system-wide audited combined financial statements. The resulting figure has been reported as bad debts at cost on Part III, Line 2.

Part III, Line 3 - Methodology of Estimated Amount & Rationale for Including in Community Benefit
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 - Bad Debt Expense
The system-wide audited combined financial statements do not contain a footnote describing bad debt expense.

Part III, Line 8 - Explanation Of Shortfall As Community Benefit
The Medicare cost report apportions the hospitals 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 evolving medical and information technology. The health care market basket is unrelated to that of the average individual consumer. Since the 1997 Balanced Budget Act, Medicare annual payment updates have fallen behind actual healthcare cost inflation to the point that Medicare payments too 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.Reconciliation of Medicare Revenue from the hospital's Medicare Cost Report to GL*Medicare Cost Report Revenue $60,605,798Prior Year Settlements 750,286Cost Report Reimbursable Bad Debts 1,060,271Estimates and Accrual Variances (1,715,128)Other (1,818,738)Subtotal - Amount reported in Pt. III, line 5 $58,882,489Amounts included in Part 1, lines g and f -Total Medicare Revenue $58,882,489*Note: The Medicare Cost Report revenue does not include the bad debt reimbursement. The Cost Report revenue does include the patient co-pay and deductible amounts. Adding the bad debt reimbursement would have duplicated the revenue already accounted for in the co-pay and deductible amounts.

Part III, Line 9b - Provisions On Collection Practices For Qualified Patients
"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 - Community Building Activities
The hospital is involved in numerous community building activities that promote the health of the communities it serves. Numerous community concerns are addressed, including health improvement, education, poverty, workforce development and access to care. 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. And, 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 VI - States Where Community Benefit Report Filed
CA

Part VI - Needs Assessment
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. Quantitative data was gathered through Kaiser Permanentes CHNA Data Platform and local county and national data. We also look at the needs of our patients by looking at trends in our admissions rates. For our CHNA, a total of 14 focus groups were conducted. In addition, eight facility CEOs or senior executives were interviewed by phone or in person as were all four county public health directors. An online survey was also developed from the focus group questions. Copies of the hospital's 2016 CHNA study and the 2015 Community Health Implementation Plan Update are posted on the hospital's website, https://www.adventisthealth.org/central-valley/pages/about-us/our-publications.aspx, as well as on the Adventist Health Corporate website, https://www.adventisthealth.org/Pages/About-Us/Community-Health-Needs-Assessments.aspx

Part VI - Patient Education of Eligibility for Assistance
When someone is uninsured, we automatically discount their costs to Medi-Cal level and invite them to apply for charity care at admission. We also inform all patients with signs and on their statements about our patient financial assistance policy and have a brochure available for those who would like to apply prior or get more information about the process. Facilities are required to post signs in the business office, the admitting and registration areas and the emergency department that inform patients about the facility's financial assistance policies and the availability of charity discounts. Additionally, patient statements must include standard language informing patients that they may request financial screening to determine eligibility for charity discounts and how that request may be made.The Financial Assistance Policy is posted, summarized and the Financial Assistance Program Application is made widely available on the hospital's website at: https://www.adventisthealth.org/central-valley/pages/patients-and-visitors/financial-services.aspx

Part VI - Community Information
The Adventist Health Central Valley Network operates more than 60 sites in Kings, Tulare, Kern, Madera and southern Fresno counties. It includes some of the poorest congressional districts with some of the worst health disparities in California. Many of the communities served are rural and do not have the infrastructure that supports active lifestyles. The area largely depends on agriculture, government employment, hospitals and educational institutions for jobs.The population we serve is largely made up of Hispanic/Latino and White, non-Hispanic residents representing almost 90% of the entire population. The next largest ethnic group is Asian, estimated at 5%, African-Americans followed with 4%, American Indian, multiracial population and Pacific Islander complete the other 2%. Depending on the community the percentage ranges between the make up of racial groups, but in our rural communities the Hispanic/Latino population often is more than 70% of the population many of whom are Spanish language speakers.

Part VI - Explanation Of How Organization Furthers Its Exempt Purpose
As hospitals move toward population health management, community health interventions are a key element in achieving the overall goals of improving the health of the population, improving access to affordable health services for the community both in outpatient and community settings, and reducing the overall cost of health care. 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.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; and3) 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, and3) 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.

Part VI - Affilated Health Care System Roles and Promotion
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.