4A (Expenses $ 212577997 including grants of $ 162329) (Revenue $ 321296303)
Sonora Community Hospital (AHSR) 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 to Sonora Community Hospital, the organization recognizes that not all individuals possess the ability to pay for essential medical services.Adventist Healths vision is to enhance the health of the communities where we live and serve, by engaging our communities 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 Sonora Community Hospital provide low cost care to individuals covered by government-programs and those unable to afford healthcare, it also helps patients find and access private and governmental resources for healthcare benefits.AHSR recognizes below-cost reimbursement as charity and uncompensated care in meeting its mission to the entire community. The unreimbursed cost of providing care to these patients in 2021 was $401,447.The following Inpatient services that were provided to all our patients. These services included:520 Babies delivered848 Surgeries performed34,809 Patient days The following Outpatient services that were provided to all our patients. These services included:32,794 Emergency department visits2,996 Outpatient Surgeries performed146,927 Outpatient visits 203,946 Clinic visitsAHSR 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. The total unreimbursed cost of these community benefits in 2021 was $2,338,374.Adventist Healths mission statement of Living Gods love by inspiring health, wholeness and hope is coupled with a vision to transform the health experience of our communities through collaborative programs, community investments and community outreach. We are inspired by the healing ministry as represented by the life of Jesus Christ and believe we are called to live out our mission intentionally in the communities we serve. In the small towns, suburbs and inner cities we serve, we continue our journey to provide quality healthcare until every person made in Gods image has experienced the best health today, hope for tomorrow, and Gods love that endures forever.The following story provides an illustration of how our team at Adventist Health Sonora connects with our community:When John Kirby, of Greeley Hill, was diagnosed with lymphoma in April 2019, he was certain that hed be traveling far from home to get quality care. Despite his intention to go elsewhere, Johns best friend convinced him to go to a consultation with Shane Tipton FNP, PA-C, MS at the Diana J. White Cancer Institute.One meeting was all it took to change Johns plans.From that first meeting with Shane, he was so cheerful and kind, John said. I could tell all of the staff really cared about me and that this was a special place.John ended up going through three rounds of chemotherapy and twenty days of radiation with the support of his care team at Adventist Health Sonora, friends and family.I consider myself a strong person, but I was really, really sick. It was the hardest thing Ive ever done in my life, John remembered. Shane called me every day during treatment. Some days I was too sick to pick up the phone, but hed leave me a voicemail to check up on me. I never expected to get this level of care here, and it made such a difference.John finished his last round of radiation just before Christmas in 2019. It took a while, he said, but hes finally feeling like himself again. Now, hes passionate about helping other patients facing a cancer diagnosis.Dealing with cancer is really scary, and the financial part just adds to it, John explained. The bills add up to hundreds of thousands of dollars, even if you have good insurance. That means homes lost, retirement savings gone. That's why the Cancer Patient Support Fund is so important.Teaming up with Andee Houser, Director of Philanthropy, John is making fundraising plans to ensure all local cancer patients have what they need.This is just one example of how our team of professionals care for our patients and our community. Feel free to connect with us at any time.Website for our community benefit information: https://www.adventisthealth.org/about-us/community-benefit/

Facility: - 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. From March 1, 2019 to May 11, 2019, focus groups, key informant interviews and surveys were administered. Approximately 163 people were surveyed to obtain input from the community in the form of 3 focus groups (with a total of 33 focus group participants), 12 key informant interviews and 118 people responded to the online survey. Community Survey: Survey participants lived in areas similar to that of focus group participants and key informants. Over 93 percent of the survey respondents live in Tuolumne County. Sonora was selected almost 7 times more than any other city, including Jamestown, Groveland, Twain Harte, and Columbia for survey responses.Focus group: Focus group participants were end-users of programs and services provided by AHSR or members of the community. Populations represented by focus group members included seniors, low-income, homeless/at risk and a group of stakeholders from an array of agencies who serve families, low-income, domestic abuse woman and other sectors. The majority of focus group participants live in Sonora, Jamestown, and Twain Harte. Additionally, multiple unsuccessful attempts were made to convene a group representative of the Mi Wuk and Black Oak Mi Wuk Tribe. Future reporting cycles will seek to establish and strengthen partnerships to ensure this population is adequately represented.Key informant interview: Key informant interviews consisted of key leaders in our community from an array of agencies, including those that represent youth services, including schools and education, elderly services, mental and behavioral health, and human services. Public safety, non-profit community, business retention, law, and charities were also represented. Most key informants hold titles such as physician, director positions.Secondary data sources include publicly available state and nationally recognized data sources. A significant portion of the data for this assessment was collected through a custom report generated through CARES Engagement Network CHNA (https://engagementnetwork.org/assessment/). Other sources include California Department of Public Health, County Health Rankings & Roadmaps, and California Environmental Protection Agencys Office of Environmental Health Hazard Assessment. When feasible, health metrics have been further compared to estimates for the state or national benchmarks, such as Healthy People 2020 objectives.

Facility: - 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 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: Access to Health Care, Mental and Behavioral Health, Housing and Homelessness, and Chronic Disease. Priority Need 1- Access to Care- The goal is to increase access to local health care through an increased number of providers and removing barriers to medical care. Strategy 1- Increase the number of access points to medical services and social services. Activity 1.1- Physician Recruiting (Program to be retired in 2021)- Throughout 2021, 11 providers were onboarded. NEW: Activity 1.2- Community Information Center- A project of the County of Tuolumne is currently in the planning stages. Our primary focus is partnering with First 5 Tuolumne County on launching Unite Us as a No wrong door of entry and data dashboard for all existing social services in the county. NEW: Activity 1.3- COVID Clinics- As a community wide effort, we participated and help support and administer 9,700 COVID vaccines. NEW: Activity 1.4- Project HOPE- Is a charitable fund administered by Adventist Health Sonoras Community Well-Being Department. Due to the pandemic, Project HOPEs outreach component has grown to assist community members facing financial hardship. Project HOPE has provided applicants with payment of medical bills, purchases of medical equipment, transportation and lodging. This project is expected to continue into 2022. Priority Need 2- Mental and Behavioral Health- The goal is to increase access to classes and care pertaining to mental and behavioral health. Strategy 1- Raise awareness of substance misuse and increase efforts in mental health screening creating more opportunities for healthful choices. Activity 1.1- Opioid Safety Coalition (Program to be retired in 2021). In FY 2021, this program launched the Red Feather Opioid Coalition in collaboration with the Mathiesen Memorial Health Clinic. Activity 1.2- Drug Store Project- An anti-substance abuse program aimed at eighth graders is currently on hold due to COVID-19 and gathering restrictions and distancing requirements but will be reinstated in the future. Activity 1.3- ACEs Pilot Program- this grant covered program hopes to improve access to mental and behavioral health, by providing screenings by checking children for Adverse Childhood Experiences (ACEs). Additional activities include Prescription Drug Take-back days are ongoing. Adventist Health Sonora continues to sponsor TeenWorks Mentoring, a program that provides faith-based mentoring to at-risk youth, and Spiritual Roads, a faith-based recovery program. Priority Need 3- Housing and Homelessness- The goal is to increase access to shelters, tiny homes, and affordable housing through strategic partnerships. Strategy 1- Partner with county and local programs to have a greater impact on creating access to shelter and housing. Activities include the following: Resiliency Village Project and Camp Hope Project. The County of Tuolumne has taken the lead in providing initiatives, services and resources in addressing this community need; therefore, AHS is no longer planning to address this directly but will continue to provide support and resources as appropriate such as sponsorship opportunities. In 2021 Resiliency Village provided housing and case management to 49 medically vulnerable unsheltered people. Adventist Health Sonora supported COVID-19 efforts such as testing and vaccination opportunities. Priority Need 4- Chronic Disease- The goal is to reduce incidences of chronic disease through education. Strategy 1- Increase support for local education addressing smoking, diabetes, asthma and cancer. Activities included: Freedom from Smoking Classes, Better Breathers Club and Ladies Night Out. Chronic disease related activities such as Freedom of Smoking classes, Better Breathers Club, Ladies Night Out and Heart Walk are currently on hold and plan to reactivate in 2022.

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 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 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 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 - 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 combined audited 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. 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. For further information please refer to schedule H part III section B.

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 incomeX 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 2 - Needs Assessment
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 Community Benefit : Roseville, California : Adventist Health. The two most recent Community Health Needs Assessment, two most recent Implementation Strategy reports and the most recent Community Health Plan Update are also available on the Adventist Health Corporate website at Community Benefit : Roseville, California : Adventist Health. 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 7 - States Filing of Community Benefit Report
CA

Part VI, Line 3 - Patient Education of Eligibility for Assistance
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 - Community Information
Adventist Health Sonora (AHSR) is located in the city of Sonora in Tuolumne County. Tuolumne County is located in the beautiful Sierra Nevada foothills and is located at the gateway to Gold Country. Bay Area natives move to Tuolumne County to retire and get away from the hustle and bustle of the city. The majority of our market is made up of retired and midscale mature adults with no kids. Tourism is a large part of Tuolumne County, as tourists escape from the heat of the summer in the Central Valley to go to one of many reservoirs for boating or swimming or visit Yosemite National Park. Winter tourists enjoy skiing, snowboarding and snowmobiling. The main industries for employment are government, logging, gaming industry (casino), health care and tourism. AHSRs primary and secondary service areas span parts of four counties Mariposa, Tuolumne, Calaveras and Stanislaus. The primary service area includes 15 zip codes and a population of 131,982. In Calaveras County, the population is 45,602, median household income is $52,814, and the median age is 55.4. Tuolumne County has a population of 55,961, a median household income of $50,446 and a median age of 50. Across the two-county region, for every 10,000 children, Calaveras County has a higher rate of Head Start Facilities at 35.1 than Tuolumne County at 21.5. Comparatively, for the state of California the rate was 5.9 per 10,000. Rates for those aged 25 and older without a high school diploma in Calaveras (9.9%) and Tuolumne (9.3%) Counties, is lower than the state estimate at 17.5%. Attainment of a bachelors degree or higher, one finds that across the two county region, Calaveras (19.3%) and Tuolumne (20.6%) Counties are lower than the state estimate of 32.6%.Calaveras and Tuolumne County have a lower percentage of total population and children under age 18 living under the 100% federal poverty level, compared to the state estimate at 15.1% and 20.8%, respectively. In Tuolumne County, 36.2% of households exceed 30% of total household income and 41.9% have substandard housing conditions. These figures are better than Calaveras County at 39.8% and 38.5%, respectively. In the two-county region, these percentages are lower than the state estimates at 41.9% and 44.8%, respectively. Within the homeless population, Tuolumne County has 291 households of homeless population and 116 for Calaveras County.

Part VI, Line 4 - 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 in which 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 VI, Line 5 - Promotion of Community Health
Our hospitals mission is, Living Gods 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 todays state of health, where cost and heartache is 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 healthyeven 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.

Part VI, Line 6 - Affilated Health Care System
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 - Additional Information
Identified Needs from CHNA, Not Addressed and Why (Based on 2020 (FY 2019) CHP Update) - No hospital can address all the health needs identified in its community. Adventist Health Sonora is committed to serving the community be adhering to its mission, and using its skills, expertise and resources to provide a range of community-benefit programs. Poverty: Adventist Health Sonora will not be addressing poverty directly as many aspects of poverty will be addressed in our current CHNA priorities. Other Items:In FY 2021, Adventist Health Sonora continued the following actions in response to the needs created or exacerbated by COVID-19: Continued offering virtual healthcare visits to keep community members safe and healthy; continued their online symptom tracker; participated in a communitywide effort to vaccinate eligible community members. Additionally, Adventist Health Sonora provided outpatient monoclonal antibody treatments for COVID-positive patients at our infusion center and established processes for testing inpatients, surgery patients and symptomatic community members. Primary website address: See Form 990, Pg. 1, Item JNeeds Assessment website: See Sch H Part VI - Needs AssessmentFAP website: See Sch H Part VI-Patient Education