4A (Expenses $ 92482540 including grants of $ 15380) (Revenue $ 91253069)
See Schedule O

Facility: A 1,2 - Part V, Section B, Line 3j
Facility/Group A includes the following hospital campuses:Greeneville Community Hospital-East and Greeneville Community Hospital-WestDuring FY20, Takoma Regional Hospital, Inc. d/b/a Greeneville Community Hospital operated under the FY19 Community Health Needs Assessment (CHNA) approved by its board of directors at the end of FY19. Priorities established for our CHNA were determined by the most significant health needs of the community. For the FY19 CHNA, Ballad Health and its hospitals and entities agreed to focus on an index of 25 active population health index measures (plus an additional 31 measures for monitoring). The population health index itself is based on the focus areas outlined in the previous FY15 CHNA and align with national health improvement efforts, such as Healthy People 2020. Wellmont Health System and its hospitals, Mountain States Health Alliance and its hospitals, focused on the same population health index measures determined by Ballad Health, our health system's parent, when completing their individual FY19 CHNA's.To understand each communitys individual needs, Ballad Health conducted a community health needs assessment (CHNA) for each Ballad hospital to profile the health of the residents within its service area. Throughout the CHNA process, high priority was given to determining the health disparities and available resources within each community. Community members from each county met with Ballad representatives to discuss current health priorities and identify potential solutions.The CHNA community members for each facility evaluated measures that make up Ballad Healths population health index and a few additional measures related to access to health screenings. The groups members completed a survey relative to what health priorities should be a focus for their specific community over the next three years. After all the details and data collection was complete and interviews with various focus groups were complete, representatives identified four top focus areas:- Smoking- Physical activity/obesity - Substance abuse/mental health- Maternal/infant health

Facility: A 1,2 - Part V, Section B, Line 5
Information for the CHNA assessment was gathered from a variety of sources, including:- Physician needs assessment- Community health facility assessment- Mental health needs assessment- Publicly available population and demographic information- Publicly available population health information, including America's Health Rankings and the County Health Rankings- State and regional health department data- The Southwest Virginia Health Authority's Blueprint for Health Enabled Prosperity- The ETSU, Wellmont, Mountain States Community Work Group Project- Other studiesSignificant information was gleaned from a process conducted by the ETSU College of Public Health and supported by both Wellmont Health System and Mountain States Health Alliance. Community workgroups were formed, involving a cross section of subject matter experts to assess regional health needs, including those of underserved people, families, children and those suffering from mental health and substance abuse challenges. Regional meetings were also held which included representatives of the community at large, patients and minorities or agencies serving them.Findings from this work were taken into account in both the assessment and implementation plan. The information was then collated and assessed to determine the greatest unmet health needs facing our region. Strategies to address these needs were then developed, utilizing internal resources and partnerships with other health care organizations and physicians.

Facility: A 1,2 - Part V, Section B, Line 6a
The community health needs assessment conducted by Greeneville Community Hospital (GCH) was based upon the hospital's involvement and enrichment of those who live within Greene County, Tennessee. The primary service area is shared by GCH-East (Laughlin Memorial Hospital) and GCH-West (Takoma Regional Hospital, Inc.) and thus the community health needs assessment was completed in cooperation with both hospitals.

Facility: A 1,2 - Part V, Section B, Line 11
Key findings noted during the FY19 CHNA were the low rankings of the counties we serve in several categories related to health and wellness, including prevalence of chronic disease management, tobacco use, diet and exercise, as well as a need for expanded and enhanced mental health services. They also emphasized the vulnerability of our underinsured and uninsured populations, and that if our communities are to thrive, we must focus on encouraging healthy children and families.Greeneville Community Hospital operates a diabetes treatment center. The center offers diabetes services and free educational programs. Dietitians, nurses and certified diabetes educators teach about topics such as preparing nutritious meals, tracking blood sugar, reducing diabetes' long-term effects, and other diabetes related topics.Many additional community needs exist in our region. It is fiscally impossible for a hospital to address every health need in a community, which is why the CHNA process is used to identify and prioritize areas of focus. A thoughtful CHNA evaluates overall community health needs to determine which ones the hospital can best influence in a positive way. Consideration is given to other organizations in the hospital's geographic area that already offer services addressing specific health needs. In some cases, it is best to simply support an identified health need through a financial donation to another nonprofit organization skilled in certain areas: teen pregnancy, dental health, fighting homelessness, etc. Hospitals also lend support to other nonprofit organizations by serving on their boards, committees, and assisting with fundraising efforts.To help meet these needs, Greeneville Community Hospital will continue to strengthen our partnerships and continuum of care opportunities with area health departments, Federally Qualified Health Centers, and Frontier Health, the region's leading provider of behavioral health services.

Facility: A 1,2 - Part V, Section B, Line 13h
The Ballad Health financial assistance policy allows for some exceptions to strictly adhering to federal poverty guidelines when awarding financial assistance. Unique circumstances may be weighed and assessed for financial assistance consideration on a case-by-case basis. Also, there are some services where financial assistance may be provided outside of federal poverty guidelines. These are noted in Ballad Health's financial assistance policy.

Part I, Line 3c - Charity Care Eligibility Criteria (FPG Is Not Used)
Financial assistance approval can apply to an assortment of patients such as those who have exhausted their Medicaid/TennCare benefits, those who qualified for Medicaid/TennCare after the date of service, deceased patients with no estate or assets, uninsured patients,and underinsured patients. While Ballad Healths qualifications for financial assistance is based on federal poverty guidelines, asset values may also be used to determine eligibility. Unique circumstances may be assessed on a case-by-case basis. Charity approval covers current or active patient balances when they are approved and there is no limitation or cap on the amount of charity that a patient may receive. Ballad Health hospitals do not stop approving financial assistance for patient accounts if a hospitals charity write-offs exceed the hospitals charity budget.All Ballad Health hospitals provide an uninsured discount; the current uninsured discount is 85%. In addition to the uninsured discount, many patients will further qualify for additional financial assistance. All patients seeking financial assistance must submit an application for financial assistance and submit documents in support of the information on the application, unless specifically excluded according to our policy guidelines. Medicaid eligible patients will qualify for 100% financial assistance and not be required to complete the required documentation when: a) Medicaid eligibility requirements are met after the service is provided, b) non-covered charges occur on a Medicaid eligible encounter, or c) benefits have been exhausted. Deceased patients with no estate also qualify for 100% financial assistance.Financial assistance determinations may be retroactive for all outstanding balances. In addition, we have a number of programs with special discounts such as lactation consultation services, oncology treatment regimens, enrollment in various community programs, and prescription drugs filled post-discharge.

Part I, Line 7 - Explanation of Costing Methodology
"The cost to charge ratio (worksheet 2 ""ratio of patient care cost to charges"") was used to calculate line 7a financial assistance (charity care) cost and line 7b TennCare and Medicaid losses. Line 7e community health improvement includes costs that are taken directly from departmental operating reports or expenses specific to a community health event, with no additional overhead included in the cost. Line 7f health professions education is comprised of internships (primarily nursing, pharmacy, and therapy students) with schools and universities, allowing their health profession students to get hands-on training in a hospital setting. The Ballad Health Organizational Development Department (OD) maintains records for the non-Medicare programs. OD keeps records of the number of students receiving training at our hospitals and the amount of hours the students spend at our hospitals. Hours may differ based on the school and the type of program (RN, radiology, lab, etc.). The number of team members that provide training to students will also vary based on where the student is training. For example, an RN trainer on a medical floor may have 3 or 4 students under his/her direction, while an RN trainer in a specialty area such as ICU or the ER may be training one-on-one with a single student. We only include labor costs for our hospital team members that provide training (i.e. no overhead is applied) and we only attribute a percentage of our team members time to actual training. Line 7h research represents GCH's expense allocation from Ballad Health for research. Line 7i cash and in-kind contributions include cash disbursements and an in-kind donation of land to local nonprofit organizations."

Part III, Line 2 - Methodology Used To Estimate Bad Debt Expense
Self-pay balances include accounts after payments and contractual adjustments (discounts) have been applied from all third-party payers such as Medicare, Medicaid, commercial insurers, and others - generally leaving the patient responsible for any remaining deductible and/or co-payment. Other self-pay accounts are from patients with no insurance or other third-party coverage. Under Ballad Healths system-wide self-pay policy, any patient who has no insurance and is ineligible for any government assistance program receives an 85% discount. Many self-pay patients will further qualify for financial assistance (sometimes referred to as charity care) if they provide the financial information we need to deem them eligible.After the normal collection process has indicated an account is uncollectible, GCH writes the account off to bad debt. The hospital's overall self-pay accounts receivable balance is evaluated on an ongoing basis to evaluate the age of accounts receivable, historical write-offs and recoveries and any unusual instances (such as local, regional or national economic conditions) which affect the collectability of receivables.

Part III, Line 4 - Bad Debt Expense
Ballad Healths audited financial statements include a footnote on page 13 that describes bad debt. GCH is included in the June 30, 2020 audited financial statements of Ballad Health (attached).

Part VI, Line 4 - Community Building Activities
GCH leaders support and encourage all team members to volunteer time, money and skills to community service projects and charitable organizations. Senior leaders and board members set a positive example for GCH team members, serving voluntarily on committees and boards of local service and nonprofit organizations. Some also serve as members and consultants on professional committees and task forces that affect regional development in healthcare and education. We do not capture costs associated with team members that serve on other nonprofit boards or provide services to other nonprofits.

Part VI, Line 7 - States Filing of Community Benefit Report
TN VA

Part VI - Additional Information
Ballad Health is required to report community benefit estimates on a quarterly basis with the states of Tennessee and Virginia. The reporting includes all of Ballad's hospital organizations and is reported using IRS Form 990, Schedule H instructions for reporting community benefit. Ballad operates under a Cooperative Agreement (CA) in Virginia and a Certificate of Public Advantage (COPA) in Tennessee as obligated by agreements between Ballad Health and the two states to allow Wellmont Health System and Mountain States Health Alliance to merge.

Part III, Line 3 - Methodology of Estimated Amount & Rationale for Including in Community Benefit
Our primary external collection agency historically estimated that approximately 37% of TRH's bad debt would have qualified for financial assistance if patients had provided our hospitals with a financial assistance application and required documentation. Pursuant to the merger, TRH has begun to score accounts using a presumptive eligibility tool. This tool utilizes various data points for a proprietary algorithm operated by an outside vendor to provide an individual's score. We have instances of patients with account balances and no health insurance coverage that we believe would qualify for financial assistance. Although patients are encouraged to apply for assistance, many will not do so. TRH would prefer for patients to submit completed financial assistance applications given that historical data clearly indicates that most uninsured patients and many underinsured will qualify for financial assistance under our program. Without a completed application, we have no choice other than to record an unpaid account as bad debt instead of charity care.

Part III, Line 8 - Explanation Of Shortfall As Community Benefit
Excluding Medicare losses reported in Part I subsidized health, the Part III Medicare loss is reported using GCH's filed Medicare cost report (C/R). The C/R uses a cost to charge ratio based on a step-down allocation methodology. We believe Medicare losses should be allowed as a reportable community benefit, similar to governmental programs such as Medicaid. As a participating provider in the Medicare program, hospitals are required to provide the full regimen of care for the Medicare population. There are a number of care regimens that are compensated by the Medicare program at levels below cost. Therefore, it is only logical to allow hospitals to report these uncompensated services as a community benefit. By making this change, nonprofit providers will be encouraged to continue important care delivery models for our aging population in spite of the fact it may be economically injurious.

Part III, Line 9b - Provisions On Collection Practices For Qualified Patients
Requests for financial assistance are evaluated using established guidelines, while allowing for unique financial circumstances - for example, medically indigent patients with catastrophic medical costs that would threaten the patients household financial viability. When a patient requests financial assistance or when an application has been received, the patient's account is placed in a hold status to prevent further collection activities until financial assistance eligibility is determined. All Ballad Health hospitals comply with IRS 501(r) regulatory guidelines.Our collection policy clearly states that all patients are treated equally - with dignity and respect. We ensure that outside collection agencies used by our hospitals adhere to our billing and collection guidelines. Our collection program includes communicating expected financial responsibility prior to service. Our hospitals provide assistance to help underinsured and uninsured patients determine sources of payment for medical bills and to help patients determine eligibility for programs such as Medicaid or TennCare.After insurance benefit verification, our hospitals bill insurance carriers. If the insurance carrier denies payment of the service/procedure as non-covered or the patient has exceeded their maximum benefits, the service/procedure will qualify for the uninsured discount.Financial counselors are available to discuss financial assistance with patients and their families. Our hospitals provide a number of payment options:- a pre-service discount may be offered- a discount in excess of established discounting rates may be granted for catastrophic high dollar accounts- GCH accepts all non-contracted and out-of-network payers and will make attempts to work with these payers regarding appropriate reimbursement and billing to their members- as part of Ballad Health's commitments to the State of Tennessee and Commonwealth of Virginia to form Ballad Health, not-in-network discounts are applied per policies in place for GCH- payment arrangements are available so long as the account is not with a collection agencyReasonable efforts are made to determine if a patient is eligible for financial assistance - see Schedule H, Part VI, line 3 for information on how patients are informed about our financial assistance policy.

Part VI, Line 2 - Needs Assessment
Focusing on 25 active population health index measures allows Ballad Health to further engage the efforts of its hospitals in partnership with communities in our service areas. It has helped Ballad to better identify health disparities that appear across the individual communities and has helped Ballad to prioritize issues that are most important in each hospital's community. Engaging local community organizations will expand partnerships so that organizations work together more to address community health needs.Ballad Health uses a comprehensive process to gather input for and continues to evolve its population health plan. The executive steering team, aided by national experts with experience in large-scale population health improvement, help guide the evolution. Because our hospitals are located in a region with many chronic disease challenges, Ballad Health's goal is to target population health issues to make lasting improvements. Ballad conducted approximately 150 interviews and held 40 meetings with external groups, including the regional health departments, United Way agencies, chambers of commerce, schools and community organizations, the regional accountable care community steering committee, as well as internal groups such as our population health and social responsibility committee of the Ballad Health board of directors, the Ballad Health population health clinical committee, and our hospital community boards in the creation and ongoing implementation of its population health plan.

Part VI, Line 3 - Patient Education of Eligibility for Assistance
Consistent with the Ballad Health financial assistance policy, GCH communicates with and provides education to our patients through various avenues regarding governmental assistance programs and hospital financial assistance. Various educational and application documents related to obtaining financial assistance are widely available at GCH and all documents are available on the Ballad Health website. Printed financial assistance educational materials are part of each registration packet and posters are displayed in highly visible areas of the hospital. Our financial assistance policy and documents are available in our emergency departments and admitting areas. We are also happy to mail all documents to patients. We offer a plain language summary and all of our documents are available in English and Spanish. Financial assistance information is available during pre-registration, registration and/or during financial counseling. We offer governmental program eligibility representatives to assist patients in securing eligibility for Medicaid or TennCare, federal disability and other governmental assistance programs. Additionally, if a patient or community resident expresses an interest in the ACA healthcare exchange, our representatives have the qualifications and experience to assist them through the entire process. Our financial counselors offer financial assistance applications to patients who do not qualify for governmental assistance programs and are unable to pay for some or all of their healthcare.All patient billing statements have verbiage discussing financial assistance along with contact information. Our last letter to the patient displays the plain language summary. In all oral correspondences with a patient, if it is identified the patient cannot meet payment requirements on their account, financial assistance is discussed as an option. Applicants are notified of financial assistance determination in writing.

Part VI, Line 4 - Community Information
Greeneville Community Hospital campuses are located in Greeneville, Tennessee (Greene County) on the eastern border of the state. The county is primarily rural, and the population is estimated by the U.S. Census Bureau to be 69,069. The latest census bureau data estimates the median age of residents of Greene County is 45 which is older than the median age of 39 in Tennessee. 21.1% of Greene County residents are 65 or older compared to 16.7% for the state. The population projections for Greene County over the next five years indicate that the county will likely experience little to no population growth overall. However, the age 65+ population for Greene county is projected to experience the most population change over the next five years. The aging population of the county presents opportunities for earlier identification and better management of health conditions that oftentimes affect elderly populations.The bureau estimates Greene County median household income at $44,400 ($37,121) for the town of Greeneville) compared to the State of Tennessee's median income of $52,400. 24.3% of Greene County's children live in poverty compared to 19.4% statewide.Greene County is 65.2% rural compared with the statewide rural rate of 33.6%. This is a significant contributing factor in influencing health outcomes in a population. Many rural residents must travel a greater distance to access different points of the health care delivery system; however, due to geographic distance, sometimes extreme weather conditions, lack of public transportation and challenging roads, rural residents may be limited, and in some instances, even prohibited from accessing health care services. While our area has generally unfavorable health statistics, there are far fewer primary care physicians per resident in our county than the state's average. Our county's ratio of population to primary care physicians is 1,760:1 compared to the state's average of 1,400:1. In other words, we have 26% more residents per physician than the overall state rate. Our county's ratio of population of mental health providers is 1,080:1 compared to the state's average of 660:1. This is over 64% more residents per mental health provider than the overall state rate. Recruiting physicians to rural areas is often challenging due to a myriad of factors, such as geography, economics, culture and education. Geographically, rural communities are often far removed from suburban and urban centers that provide access to education, cultural and economic opportunities. These limitations influence the relocation decision of the physician candidate and his/her spouse/children to locate to a rural area.A number of factors contribute to a unique and challenging environment that influence overall health standing in our county. According to the Robert Wood Johnson Foundation's county health rankings, 38% of the adults in Greene County are obese. Obesity increases the risk for many health conditions such as coronary heart disease, type 2 diabetes, hypertension, stroke, cancer, sleep apnea and respiratory problems, and osteoarthritis. Evidence indicates physical activity, independent of its effect on weight, has substantial benefits for health. Our county's inactivity rate of 35% is 30% higher than the statewide rate and resident's access to exercise opportunities is 36% less than the state. Approximately 19.05% of our patients are Medicaid recipients, and 5.60% are uninsured and Greene County is designated as a medically underserved area.

Part VI, Line 5 - Promotion of Community Health
GCH is dedicated to operating efficiently so that waste is minimized. GCHs leadership remains mindful of managing limited resources so that adequate facilities and equipment are available for the care of our patients. Surplus funds are invested into improving treatment options for our patients through new technologies, recruiting physicians and trained staff in shortage areas, and improving our facilities. Various checks and balances are established to ensure that expenditures for operating expenses and capital costs are reasonable and necessary.GCH campuses have Medicare-approved health profession education programs. In addition, GCH campuses serve as training sites for many types of health professions: nursing, pharmacy, psychology, lab, respiratory therapy, EMT, public health, etc. Students from several colleges, universities, and programs receive training and hands-on experience in our hospitals. We devote resources to health conferences for local health professionals and offer other programs focused on improving the health of our residents. While we operate in a predominantly low-income, rural area, we continue to offer services that operate at a loss to GCH because residents would otherwise need to leave their home town or county to receive needed care.Physicians that request privileges who are qualified and credentialed are extended privileges by GCH.

Part VI, Line 6 - Affilated Health Care System
Greeneville Community Hospital is a two campus hospital in Greeneville, Tennessee which includes Greeneville Community Hospital-East and Greeneville Community Hospital-West and one of the hospitals within the Ballad Health system. Ballad Health (BH) operates a family of 21 hospitals, including three tertiary care facilities, a dedicated children's hospital, community hospitals, three critical access hospitals, a behavioral health hospital, an addiction treatment facility, long-term care facilities, home care and hospice services, retail pharmacies, outpatient services and a comprehensive medical management corporation.Patients benefit from GCH's affiliation with a healthcare system where they can be efficiently moved along an integrated, comprehensive continuum of care as their health status dictates. If needed, patients can be moved to one of Ballad Health's tertiary care facilities providing advanced treatment options.Wellmont Health Systems merger with Mountain States Health Alliance opened up many opportunities not previously available to two competing health systems. Collaboration started post-merger and we continue to see progress towards improving efficiencies within our health system, activities consistent with Ballad Healths population health initiative, sharing best practice quality improvements, and other benefits related to operating as one rather than operating in a competitive environment. A new clinical council was formed immediately following the merger. The council includes physician nominated from the leadership of all Ballad hospitals. A new Community Benefit and Population Health Committee of the board was established and various other infrastructures have been established since the merger.Across GCH campuses, there were many projects, programs and collaborative efforts that took place during the year. Some examples include:- A plan was approved to adopt an integrated technology platform bringing all of our hospitals and points of service together as an integrated system- Opioid prescribing reduction across all BH hospitals- BH hospitals shared successful achievements from value optimization team projectsSince our system is both horizontally and vertically integrated, patients can be efficiently moved along an integrated, comprehensive continuum of care as their health dictates. If needed, patients can be moved to one of Ballad Health's tertiary care facilities providing advanced treatment options.Hospitals in the Ballad Health system work closely with one another to share expertise and resources.