4A (Expenses $ 365240440 including grants of $ 503311) (Revenue $ 501317544)
San Joaquin Community Hospital (AHBD) 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 San Joaquin 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 San Joaquin 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.AHBD 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 $14,077,965.The following Inpatient services that were provided to all our patients. These services included:2,101 Babies delivered3,288 Surgeries performed74,833 Patient days The following Outpatient services that were provided to all our patients. These services included:61,557 Emergency department visits5,565 Outpatient Surgeries performed155,994 Outpatient visits 74,833 Clinic visitsAHBD 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 $4,216,162.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.Adventist Health Bakersfield cares for patients facing health crisis (serving over 225,000 patients each year) through a whole-person approach, meeting people where they are often serving people who are economically vulnerable.Our world class health care is complimented by the work of social workers, case managers, care coordinators, and patient navigators work with patients in tandem with physician care. Access to care, healthy food, and a healthy environment aid in a patients healing. The implications that a health crisis can have on a household is significant. Mr. B (name changed) is an example of this. He began the battle for his life when he was diagnosed with prostate cancer and needed 40 radiation treatment sessions. He lived alone in a rural community 45 miles from Adventist Health Bakersfield, with a monthly income below $900. Mr. B faced the health crisis of his life, financial toxicity, and no money for transportation to and from treatment. Like so many others, he also faced hunger having to choose between groceries or medication. Without the help of care coordination staff Mr. B would not have been able to access treatment nor have the support he needed for fuel costs and groceries. Today, Mr. B is well on the road to recovery. Over 1,800 support services were provided in the past year including transportation, clothing, and food. Another example is a patient who was discharged from the hospital after undergoing a major surgery. Mrs. Ms case manager (name changed) contacted her following her operation. Like many people, especially the elderly, she was hesitant to disclose her need. Mrs. M finally disclosed that she had no groceries, no transportation to the store, and not enough physical strength to go grocery shopping or prepare her own meals. The team immediately provided a food basket and connected Mrs. M to longer term meal support services. Today Mrs. M has recovered and participates in ongoing wellness programs.Together with physicians, care coordination staff live our mission. Adventist Health Bakersfield is dedicated to inspiring health, wholeness and hope.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 was accomplished by using a widely-distributed community survey, engaging with community focus groups and conducting key stakeholder interviews.Community Survey: The Kern County Community Benefit Collaborative hospital representatives developed a plan for distribution of a survey to engage community residents. The survey was available in an electronic format through a Survey Monkey link, and in a paper copy format. The electronic and paper surveys were available in English and Spanish. The surveys were available from November 2018 to January 2019 and during this time, 1,114 usable surveys were collected. The hospitals distributed the surveys to their clients, in hospital waiting rooms and service sites, and through social media, including posting the survey link on hospital Facebook pages. The survey was also distributed to community partners who made them available to their clients. A written introduction to the survey questions explained the purpose of the survey and assured participants the survey was voluntary, and that they would remain anonymous. For community members who were illiterate, an agency staff member read the survey introduction and questions to the client in his/her preferred language and marked his/her responses on the survey. The survey included the following: demographics, biggest health issues in the community, greatest needs facing children and families, where residents and their families receive routine health care services, problems faced accessing health care, mental health care, dental care or supportive services, what would make it easier to obtain care, types of support or services needed in the community, and safety concerns in the community.Targeted Interviews: Interviews were used to gather information and opinions, by phone, from persons who represent the community served by the hospital. Interview participants were asked to share their perspectives on a number of topics related to the identified preliminary health needs in the community area. Given shared community areas, the Kern County Community Benefit Adventist Health Bakersfield 14 Collaborative hospitals worked together to conduct the interviews. Forty-one (41) interviews were completed from October 2018 through March 2019. Secondary data were collected from a variety of local, county and state sources to present a community profile, social determinants of health, health care access, birth indicators, leading causes of death, acute and chronic disease, health behaviors, mental health, substance use and misuse, and preventive practices. When available, data sets are presented in the context of Kern County and California to help frame the scope of an issue, as it relates to the broader community. Sources of data include: the U.S. Census American Community Survey, California Department of Public Health, California Health Interview Survey, Kern County Public Health Department, Healthy Kern County, County Health Rankings, California Department of Education, California Office of Statewide Health Planning and Development and California Department of Justice, among others.

Facility: - Part V, Section B, Line 6a
The Kern County Community Benefit Collaborative convened area hospitals and included these partners:Adventist Health Bakersfield and Adventist Health Tehachapi Valley Hospitals, Delano Regional Medical Center, Dignity Health Bakersfield, Mercy and Memorial Hospitals, Kaiser Permanente Kern County, Kern Medical, and Valley Childrens Healthcare.

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 six areas of significant need: Housing and Homelessness, Economic Insecurity, Chronic Diseases, Food Insecurity, Preventative Practices, Overweight and Obesity. Priority Need 1- Housing and Homelessness- The goal is to work hand-in-hand with community partners to deliver a metric-driven strategy to reduce chronic homelessness across the county. Strategy- Partner with existing organizations in Kern County to support accurate homeless counts, data sharing, and grant funding opportunities. Activity 1.1- Adventist Health to provide financial and volunteer support for the annual Point-in-Time count. During the Point-in-Time count, it was determined that 2,150 unduplicated persons are currently sleeping in shelters (569) and/or are unsheltered (1,581). Currently eight homeless shelters provide services in Kern County. Activity 1.2- County of Kern Emergency Solutions Homeless Care Coordination Grant- During 2020 this grant was retained from the County of Kern. Program implementation started in the Fall of 2021. The program screened patients, aligned patients with rapid re-housing and hotel stays to vulnerable patients. The program offers case management services to assist in the process of finding permeant housing solutions along with emergent housing. Community benefit expenses includes the time and effort of our Community Well-Being lead to secure, process, and coordinate program requirements. Priority Need 2- Economic Insecurity- The goal is to improve the economic security of the county, improve the social and physical well-being of its residents by decreasing barriers to employment. Strategy 1- Partner in the community to address employment barriers for homeless and those recently released from incarceration. Activity 1.1- Deploy a Homeless Workforce Development Initiative in partnership with Bakersfield College, Bakersfield Homeless Center and the Mission at Kern County and employ graduates at the hospital. Due to COVID this program was inactive for FY 2021, Adventist Health Bakersfield has plans to re-engage in 2022. Activity 1.2- Provide administrative and volunteer staff for a medical tattoo removal program with Garden Pathways to reduce barriers to employment for those recently released from incarceration- Over 150 were seen in the tattoo removal program to remove employment barriers and sigmatisms around tattoos. Priority Need 3- Chronic Diseases- The goal is to reduce the impact of chronic diseases, increase prevention and awareness. Strategy- Target education and screening activities to high-risk zip codes. Strategy 1.1- Provide screening for cholesterol, blood glucose, BMI, blood pressure at various health fairs, including the American Heart Association Community Block Party. Strategy 1.2- Provide cancer-related screenings and preventative practice information at a variety of health fairs and community events. Activity 1.1- Provide screening for cholesterol, blood glucose, BMI, blood pressure at various health fairs, including the American Heart Association Community Block Party- Diabetes and heart disease education was provided to over 15,000 people through virtual events. Activity 1.2- Provide cancer-related screenings and preventative practice information at a variety of health fairs and community events- Through cancer-related screenings, preventative practice education was provided to over 5,000 people. Activity 1.3- Equity and Diversity- A focused event was held providing breast cancer screening for Punjabi women; the outcome included a small handful of women diagnosed with lumps and who would have not sought out care outside their community. Additionally, colon cancer screenings were held to identify early stages of colon cancer. Priority Need 4- Food Insecurity- The goal is to reduce surplus food waste and improve distribution to those in need. Strategy- Partner with Waste Hunger Not Food program to take edible, surplus food to distribute to those in need. Activity 1.1- Partner with Kern Public Health Waste Hunger Not Food to recover leftover hospital caf food and transport/redirect to local churches for distribution- From donated food from the hospital caf, over 3,000 people were served. Activity 1.2- Community Garden in partnership with edible schoolyard Kern County and CSUB- Adventist Health Bakersfield financially supported the creation of the editable school community garden at California State University Bakersfield. This garden provides food to students on campus to reduce the hunger burden of food insecurity. In FY 2021, the garden produced 3,000 pounds of fresh fruit and vegetables. Additionally, the Bakersfield City College community garden, also sponsored by Adventist Health Bakersfield also produced enough produce to prepare 2,500 meals. Priority Need 5- Preventative Practices- The goal is to reduce the rate of unvaccinated and under vaccinated kids ages 0-5 and decrease the risk for outbreaks of vaccine-preventable diseases. Strategy 1- Utilize grant funding to provide free flu and childhood immunizations to Kern County residents through a specialty equipped mobile unit. Activity 1.1- Mobile Immunization Van- Over 2,300 children immunizations were provided free of charge to the community. Activity 1.2- Mobile Immunization Van- COVID Adults- The mobile COVID vaccine van in conjunction with the Kern County Public Health Department provided over 10,000 vaccines throughout the community, targeting areas with ethnic disparities and those who lack access to healthcare. Priority Need 6- Overweight and Obesity- The goal is to use the mobile kitchen concept to address diabetes and adolescent obesity by transferring preventative knowledge and providing farm-to-table experiences that will increase student familiarity, recognition, and tasting of fruits and vegetables. Strategy 1- Utilize the mobile kitchen unit to provide a unique hands-on experience to 800 students at eight locations during the first year, with opportunities in year two to expand outreach to other Boys and Girls Club sites. Activity 1.1- Mobile Kitchen- In conjunction with our food insecurity priority, Adventist Health Bakersfield continues to build collaborations and opportunities to address our overweight and obesity priority areas. Due to COVID-19, activities were limited and reduced. It is our hope that program opportunities will reactive and increase in 2022.

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
The hospital is one of the largest healthcare systems in the area serving Kern County and surrounding areas. The service area includes a small city and surrounding suburbs, small towns and rural agricultural areas. The diverse population includes Caucasian (31.5%) and a large minority populationHispanic (56.2%), Asian (4.9%), and African-American (5.0%). Of the area population, 50.8% are male and 49.2% are female. Children and youth, ages 0-17, make up 30.5% of the population, 60.6% are adults, ages 18-64, and 8.9% of the population are seniors, 65 and over. The service area has a higher percentage of children, ages 0-17, and adults, ages 18-44, than the county. Seniors living alone may be isolated and lack adequate support systems. In the service area, rates of seniors living alone range from 8.8% in Bakersfield 93314, to 31.7% in Bakersfield 93301. Among county residents, 5.2% are veterans. About 48.2% of residents in Kern County speak a non-English language, and 21.9% of the population is foreign-born. Of the foreign-born, 67.4% are not citizens.For 2016 (the most recent Adventist Health Bakersfield year that the American Community Survey poverty data were available when this report was prepared), the federal poverty level (FPL) was set at an annual income of $11,880 for one person and $24,300 for a family of four. Among residents in the service area, 23.7% are at or below 100% of the federal poverty level (FPL) and 48.8% are low-income (200% of FPL or below). Of these residents, 32.6% of children under 18 years of age are living in poverty. In Bakersfield 93305, more than half (58.6%) of children are living in poverty.The U.S. Department of Agriculture (USDA) defines food insecurity as limited or uncertain availability of nutritionally adequate foods or uncertain ability to acquire these foods in socially-acceptable ways. Among the population in Kern County, 13.6% experienced food insecurity during the past year. Among children in Kern County, 25% lived in households that experienced food insecurity at some point in the year. The rate of food insecurity is higher in Kern County than in the state.

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 are 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 Bakersfield 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. Significant health needs that will not be directly addressed but fulfilled by other community organizations include mental health access to health care, sexually transmitted infections, dental car/oral health, and Alzheimers disease. The hospital does not have the expertise or resources to effectively address the following needs: substance use and misuse, environmental pollution, violence and injury, birth indicators, and unintentional injuries. Other Items:In FY2021, Adventist Health Bakersfield, took the additional following actions to support COVID-19 efforts: provided COVID vaccines for employee families and children; provided mobile vaccine efforts in rural areas with no access to healthcare; partnered with large employer groups to bring vaccines to their workforce. 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