4A (Expenses $ 211104275 including grants of $ 368268) (Revenue $ 263179998)
See Schedule O

Part V, Section B
Facility Reporting Group A

Facility Reporting Group A consists of:
- Facility 1: Lodi Memorial Hospital Association, Inc. dba A, - Facility 2: Lodi Memorial Hospital - West dba AHLM

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; and3. Data gathering from community members. Community input was provided by a broad range of community members using key informant interviews, focus groups, and surveys. Individuals with the knowledge, information, and expertise relevant to the health needs of the community were consulted. These individuals included representatives from local governmental and public health agencies as well as leaders, representatives, or members of underserved, low-income, and minority populations. Additionally, where applicable, other individuals with expertise of local health needs were consulted. Thirteen key informant interviews individuals representing diverse sectors in San Joaquin County including: public health, health care, community-based organizations, social services, education and government. Thirty-one community resident focus groups were conducted in geographic areas within San Joaquin County, including Stockton, Lodi, Tracy and Manteca. Nineteen groups were conducted in English, ten were conducted in Spanish, one was conducted in Tagalog and one was conducted in Cambodian. Participants were teens, adults, and older adults, who represented underserved, low-income, and varied ethnic communities.Secondary data sources include collected data on key health indicators, morbidity, mortality, and various social determinants of health from the Kaiser Permanente CHNA Data Platform, Health Places Index, American Community Survey and various other state and federal databases.

Facility Reporting Group - A Part V, Section B, line 6a:
Hospitals that participated in the 2019 CHNA process included Dameron Hospital, Kaiser Permanente, Sutter Health and Dignity Health St. Joseph's Medical Center.

Facility Reporting Group - A Part V, Section B, line 6b:
Other non-hospital facilities that participated in the 2019 CHNA process included Community Medical Centers, First 5 San Joaquin, Health Net, Health Plan of San Joaquin, San Joaquin County Public Health Services.

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 three areas of significant need: Mental Health, Economic Security, and Obesity/Healthy Eating Active Living (HEAL)/Diabetes. Priority Need 1 - Mental Health - The goal is to improve trauma informed care by creating awareness of trauma and providing or connecting our patients with the proper resources to address trauma. Strategy 1.1 - Hire a substance use navigator in our emergency department. Activity 1.1 - Substance Use Navigator (SUN). AHLM applied for funds under the Behavioral Health Pilot Program (BHPP) to support a substance use navigator (SUN) in our emergency department (ED). In 2021, the SUN provided services to 186 patients in ED inpatient care between April December. A total of 102 patients accepted referrals to Medicated Assisted Treatment (MAT) treatment, substance use treatment and behavioral health with scheduled appointments as the patients were discharged from the ER (Emergency Room) or inpatient hospital setting. Out of the 102 patients that accepted referral 65 patients were MAT referrals for opiates and alcohol. Out of 65 patients, 30 patients attended their MAT program schedule appointments. For the year of 2021, a total of 63 doses of buprenorphine was administered or written in the ER/inpatient setting. A total of 223 Patients were given an overdose diagnosis. Also, 339 patients were diagnosed with opiate use.Other work around mental health continuing as a funding partner of the ""Unite Us"" platform to participate in the San Joaquin County's Connected Community Network (CCN). Priority Need 2 - Economic Security - The goal is to improve economic security in our county by improving career opportunities for our residents, increasing the supply of qualified workers to meet the needs of the healthcare industry, and improve the overall health of our local businesses. Strategy 1.1 - AHLM has partnered with Health Force Partners to improve career pathway opportunities for community residents and to increase the supply of skilled workers to meet the needs of dynamic healthcare industry in the Northern San Joaquin Valley. Strategy 1.2 - AHLM is also collaborating with the American Heart Association and the Lodi Chamber of Commerce's Health Value Action Team to provide our local businesses with a nationally successful program, the Workplace Health Solutions. The program will offer local businesses a suite of science-based, evidence-informed tools and services to help build a workplace culture of health. Activity 1.1 - Participation in the HOPE pilot program & Activity 1.2 - Health Careers Academy - coincide. In 2021, the Board of Registered Nursing approved 40 fast track (18-month ADN) positions annually at San Joaquin Delta College (indefinitely). Half of the positions have been dedicated to the HOPE RN program. This enables partners to have a direct talent pool of nursing candidates to be employed at partnered employers. The current cohort (Cohort #2) has 22 incumbent workers. In 2021, Cohort #1 graduated with 24 out of 25 students passing their licensing and examination process. Activity 1.3 - Partnership with American Health Association - AHLM's successful collaboration with the Lodi Chamber of Commerce's Healthy Lodi initiative and the American Heart Association allows continued work to address economic security. Together we worked with local HR Directors, Workplace Wellness Champions and other organizational leaders to help their employees learn more about working towards cardiovascular health. The American Heart Association's Workplace Health Solutions is a ""science-based, evidence-informed package of tools and services to help build and maximize an effective workplace culture of health."" Building a healthy work environment and promoting a healthy workforce can lead to improved efficiency, reduced absenteeism, and cost savings for both workers and employers.In 2021, eight new organizations were recruited, for a total of 16 participating organizations. Over 12,850 employees were covered in the Workplace Wellness Program. Two quarterly learning cohorts for employer groups were facilitated for mutual sharing of workplace health practices and challenges they might have experienced. Priority Need 3 - Obesity/Healthy Eating Active Living (HEAL)/Diabetes - the goal is to increase physical activity for all ages and establish programs in high-risk neighborhoods. Strategy 1 - Engage businesses and community organizations to improve facilities and offer programs for physical activity. Activity 1.1 - Convene a Community Faith Summit in 2020 to encourage cross-sector collaboration and improve parks and neighborhoods, & Activity 1.2 - Diabetes Among Friends - Due to COVID-19 Adventist Health Lodi Memorial had lower participation but continued participating in community events, health fairs and sponsorships related to health priorities. The Diabetes Among Friends classes were halted due to COVID-19 restrictions and are expected to reactive in 2022."

Part V, Section B, Line 11:
Priority needs not addressed:No hospital can address all the health needs identified in its community. Adventist Health Lodi Memorial is 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. 1. Violence/Injury Prevention: Need is being addressed by others. 2. Access to Care: Need is being addressed by others. 3. Substance Abuse/Tobacco: Need is currently being addressed by others, however, if we are awarded the Behavioral Health Pilot Project grant, we will be able to address this need through hiring a Substance Use Navigator. 4. Asthma: AHLM does not have the resources necessary at this time to address this need. 5. Oral Health: Need is being addressed by others. 6. Climate and Health: AHLM does not have the expertise to effectively address this need.

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:
Specific Ratios of Costs to charges are utilized for each department. Where applicable the source of these ratios are the Medicare Cost Report.

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 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 III, Line 3:
"The Hospital provided care to all who presented themselves in our emergency room, without asking for proof of insurance. The Hospital's uninsured population continues to increase. Uninsured patients are screened for Medicaid linkage, given assistance in applying for Medicaid and if ineligible for Medicaid are given information regarding the Hospital's Charity Care Policy and encouraged to apply for charity care. Often the information gathered in the Medicaid application will make this determination ""automatic"". If additional information is required, the Hospital attempts to contact the patient. Those that do not respond will be sent to a collection agency after 120 days and four statements. The Hospital estimates 21% of bad debt expense (calculated at cost) should be considered charity care. The Hospital's bad debt accounts are analyzed by a third party to determine this amount."

Part III, Line 4:
Costing methodology:Utilizing the previous costing methodology as outlined in response to Part I, Line 7, all patients are assigned a payor class (i.e. charity, self pay, Medicare, Medi-Cal, managed care). The cost by payor is a summation of all patients in the assigned payor class. The amounts written off as bad debt (assigned to a collection agency) are net of any applicable payments or discounts. Any payments received after an account is assigned to a collection agency reduce the bad debt expense in the period received.Uncompensated care and community benefit costs:Our policy is to provide service to all who require it, regardless of their ability to pay. As such, the Hospital provides substantial amounts of uncompensated care. When this care is provided to patients who lack financial resources and therefore are deemed medically indigent, it is classified as charity care. When it is provided to patients who have the means to pay, but decline to do so, it is classified as provision for uncollectible accounts. Some undetermined portion of the provision for uncollectible accounts represents care to indigent patients who the Hospital has been unable to identity as charity. Charity care charges are not reflected in net patient service revenues. In addition, we provide services to poor and underserved persons who cannot afford health care because of inadequate resources and/or are uninsured or underinsured, including patients insured under certain government-reimbursed public aid programs. Such programs pay providers amounts that are less than established charges for the services provided to the recipients and frequently the payments are less than the costs of rendering the services.Patient accounts receivable:Patient accounts receivable for services provided to patients covered under the Medicare and Medicaid (Medi-cal in California) programs, privately sponsored managed care programs for which payment is made based on terms defined under formal contracts, and other payors (including self-pay) are recorded at their estimated realizable value based on contractual billing rates or our standard billing rates for our non-contracted payors. The Hospital regularly reviews accounts and contracts and provide appropriate estimates of contractual allowances that are then netted against patient accounts receivable. The Hospital also provides an estimated allowance for uncollectible accounts based on the Hospital's evaluation of the aging of our patient accounts receivable, the Hospital's historical collection experience for each type of payor and other relevant factors.The Hospital's primary concentration of credit risk is patient accounts receivable, which consists of amounts owed by various governmental agencies, insurance companies and private patients. The Hospital grants credit without collateral to the Hospital's patients and third party payors.

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 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 VI, Line 2:
The Hospital's 2019 CHNA, the 2021 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.pdfThese 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:
Adventist Health Lodi Memorial considers San Joaquin County its primary service area as well as the city of Galt. San Joaquin County contains both rural and urban areas. Communities and cities maintain their unique geographic identities, separated by agriculture and open space lands. The county includes seven incorporated cities: Stockton, Tracy, Manteca, Lodi, Lathrop, Ripon and Escalon as well as many small well-established rural communities in the unincorporated areas.The demographic profile of San Joaquin county indicates a total population of 745,424 with 17.8% living in poverty and 24.9% of children living in poverty. Unemployment is 11.7% and the uninsured population is 11.7% as well. Of the population, 41.6% identify as Hispanic/Latino, 31.8% identify as White, 16.7% identify as Asian, 8.2% identify as Black, 5.3% identify as multiple races and 2.0% identify as Native American/Alaska Native.

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 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 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."

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 can 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 - Other Information:
In 2021, Adventist Health Lodi Memorial (AHLM) continued the following actions in response to the needs created or exacerbated by COVID-19: Continued 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, AHLM made big strides in community outreach in 2021 by allocating resources to COVID-19 vaccination efforts to ensure the safety and wellness of the community. COVID-19 cases remained high during 2021 in San Joaquin County, and it was of utmost importance to AHLM that vaccines were made available and accessible to the community it is serving. Upon CDC's guidelines in late 2020 that healthcare workers be offered the vaccine, the AHLM team did not hesitate to offer the vaccines to the staff of surrounding skilled nursing facilities. The vaccination operation was soon moved to AHLM Urgent Care in January, 2021 and made the appointments available to other healthcare workers in the community. Over 9,700 vaccines were given at the AHLM Urgent Care from January, 2021 to April, 2021. In April, 2021, AHLM was part of two mass vaccination efforts in the San Joaquin County. Hutchins Street Square Vaccine Clinic was opened in collaboration with the City of Lodi, and the Stockton Arena Mass Vaccination Site was in partnership with Kaiser Permanente and Dignity Health. AHLM hired a bigger team utilizing contract nurses and pharmacists, retired nurses, and volunteers to provide the much-needed vaccination services. Both clinics had the capacity to provide over 7,000 vaccines per day. AHLM also conducted popup clinics at Heritage High School, and McNair High School in June/July, 2021 providing over 280 doses to students who were eligible to receive the vaccine.