4A (Expenses $ 1459719545 including grants of $ 8525209) (Revenue $ 1609488352)
SEE SCHEDULE O.

Schedule H, Part V, Section B, Line 3E
The publicly available community health needs assessment report details the prioritization process for the community's significant health needs as identified through the CHNA. The Community Health Assessment Team (CHAT), made up of community stakeholders, reviews all data and completes a prioritization survey. Through the survey, each CHAT member selects and ranks the most pertinent community needs. The data are combined and priorities are selected based on the highest weighted score of each need. Through this process, CHAT members prioritize needs according to the need's perceived burden, scope, severity or urgency; the importance the community places on addressing the need through survey responses and other interactions; and each member's unique perspective on community health.

Schedule H, Part V, Section B, Line 5 Facility A, 1
Facility A, 1 - GROUP A. Carilion Clinic's Community Health Needs Assessments (CHNAs) are community-driven projects. Their success is highly dependent on engaging citizens, health and human service agencies, businesses and community leaders. Stakeholder collaborations known as Community Health Assessment Teams (CHATs) lead the CHNAs. The CHATs are a dynamic group that includes health and human service agency leaders, people with exceptional knowledge of, or expertise in, public health, and local health department officials. The CHATs obtain input from leaders, representatives or members of medically underserved populations who report low-income, are minorities and suffer from chronic diseases. The following organizations served on the CHAT for the 2021 Roanoke Valley Community Health Needs Assessment (RVCHNA): Carilion Clinic, Carilion Medical Center, American National Bank, Blue Blaze Consulting, Blue Ridge Behavioral Healthcare, Botetourt County Libraries, Children's Trust, CHIP of Roanoke Valley, City of Roanoke - Department of Social Services, City of Roanoke's Financial Empowerment Center, Council of Community Services, Craig County Health Center, Family Service of Roanoke Valley, Feeding Southwest Virginia, Freedom First Credit Union, Goodwill Industries of the Valleys, Leffel Consulting Group, LLC, New Horizons Healthcare, Radford University Carilion, Rescue Mission Ministries, Inc., Restoration Housing, Roanoke City Alleghany Health Districts, Roanoke City Public Schools, Roanoke County Department of Social Services, Roanoke Valley Alleghany Regional Commission, Sisters of Change, United Way of Roanoke Valley, Virginia Blue Ridge Works (Western VA Workforce Development Board), and Virginia Western Community College. To obtain input from the community, the RVCHNA conducted a focus group among CHAT stakeholders and administered a 40-question community health survey broadly across the service area. This occurred from October 1, 2020, through January 31, 2021. The survey was developed (in English and Spanish) with questions about socioeconomic factors; access to medical, dental and mental health care; health behaviors; physical environment; health outcomes; and demographics. The survey included commonly used questions and metrics from previously validated community surveys conducted by organizations such as the National Association of County and City Health Officials and Centers for Disease Control and Prevention. During the CHNA process, community stakeholders, leaders and providers were encouraged to complete a stakeholder survey electronically to provide additional perspectives about our community's health needs and barriers. A focus group was held with the CHAT stakeholders to further discuss the data collected through the stakeholder survey. The CHAT assisted with survey distribution in an effort to reach particular target populations. The survey focused on Roanoke Valley residents 18 years of age and older in the following service area: Bedford, Botetourt, Craig and Roanoke counties, Roanoke City, and Salem City. Special efforts were made to include underserved/vulnerable populations disproportionately impacted by social determinants of health such as income, race/ethnicity, education and insurance status. Specific populations served by CHAT representatives include the un- or underinsured, the homeless, the food insecure, small business owners, and low-income individuals and families with young children. The survey was also made available to all residents living in the Roanoke Valley. Due to the COVID-19 pandemic, most responses were collected electronically, though the survey was also available by phone and on paper.

Schedule H, Part V, Section B, Line 6a Facility A, 1
Facility A, 1 - Group A. Carilion Roanoke Memorial Hospital and Carilion Roanoke Community Hospital, both owned by Carilion Medical Center and serving the same area, jointly conducted their Community Health Needs Assessment. The Salem Veteran Affairs Medical Center also participated on the Community Health Assessment Team.

Schedule H, Part V, Section B, Line 6b Facility A, 1
Facility A, 1 - GROUP A. The 2021 Roanoke Valley CHNA was conducted with: American National Bank, Blue Blaze Consulting, Blue Ridge Behavioral Healthcare, Botetourt County Libraries, Children's Trust, CHIP of Roanoke Valley, City of Roanoke - Department of Social Services, City of Roanoke's Financial Empowerment Center, Council of Community Services, Craig County Health Center, Family Service of Roanoke Valley, Feeding Southwest Virginia, Freedom First Credit Union, Goodwill Industries of the Valleys, Leffel Consulting Group, LLC, New Horizons Healthcare, Radford University Carilion, Rescue Mission Ministries, Inc., Restoration Housing, Roanoke City Alleghany Health Districts, Roanoke City Public Schools, Roanoke County Department of Social Services, Roanoke Valley Alleghany Regional Commission, Sisters of Change, United Way of Roanoke Valley, Virginia Blue Ridge Works (Western VA Workforce Development Board), and Virginia Western Community College.

Schedule H, Part V, Section B, Line 7 Facility A, 1
Facility A, 1 - Group A. The Community Health Assessment Team shared the 2021 Roanoke Valley Community Health Needs Assessment (RVCHNA) on partner websites and social media. The RVCHNA was also shared through community presentations to groups including Radford University Carilion students and staff, the local chapter of the American College of Health Executives, Virginia Tech Carilion School of Medicine students, and other internal and external audiences.

Schedule H, Part V, Section B, Line 11 Facility A, 1
Facility A, 1 - Group A. The following information describes the implementation strategy used by Carilion Medical Center (CMC)-comprised of Carilion Roanoke Memorial Hospital (CRMH) and Carilion Roanoke Community Hospital (CRCH)-to address the community health needs identified in the 2021 Roanoke Valley Community Health Needs Assessment (RVCHNA). The complete implementation strategy is available online at https://www.carilionclinic.org/sites/default/files/2022-02/2021%20CMC%20Implementation%20Strategy_FINAL%20APPROVED.pdf . Per Regulation Section 1.501(r)-3(c)(5) the implementation strategy must be adopted before 4.5 months after the end of the taxable year in which the CHNA is completed. The implementation strategy was adopted on January 18, 2022 and applies for the 2020 tax year (fiscal year 9/30/2021). The top prioritized needs for the 2021 RVCHNA were grouped into four overarching categories: mental health, socioeconomic factors, access to care, and COVID-19. We plan to address prioritized needs with the following strategies and a commitment of financial resources, staff time and leadership. Strategies to address mental health include developing a community-wide mental health collaborative; supporting ongoing work of Roanoke Valley Collective Response in addressing recovery and transitional housing needs; providing community grants to mental health safety net providers such as Bradley Free Clinic, Children's Advocacy Programs of the Blue Ridge, and Family Service of Roanoke Valley; increasing CMC's internal capacity to address substance use by hiring a community-based workforce manager to oversee and expand the peer support program; continuing an addiction task force; developing capacity to provide mental health services at Fallon Park Elementary School; and providing grant funding to the Virginia Harm Reduction Coalition in efforts to expand comprehensive harm reduction services in Roanoke. Strategies to address socioeconomic factors include working with the Blue Ridge Partnership for Health Science Careers to increase enrollment in health sciences education; continuing to support the Healthy Homes initiative to provide health-related home repair for low-income residents; investing in local housing-focused organizations; assisting in the creation of Neighborhoods of Opportunity, a community leadership development program; and working with United Way and the Virginia Department of Health to assess engagement and interest from key community organizations in the utilization of Unite Us, a social resource referral platform that will be integrated with medical records for clinical utilization. Strategies to address access to care include enhancing virtual visit accessibility by launching Carilion Now; developing a plan to grow community health center presence; and opening the LIFT health center at Fallon Park Elementary School to provide pediatric medical, dental and mental health services to students. Strategies to address COVID-19 include providing quality care and treatment for COVID patients, disease prevention, and aiding in the community's economic recovery. Although we will not be addressing the priority need of transportation/transit system during this implementation strategy period, we are working to bring prevention services to neighborhoods and other easily accessible locations to overcome some transportation barriers and improve access to care. CMC has limited ability and expertise to impact the large-scale transit system infrastructure. Instead, we will allow other organizations such as the Roanoke Valley Regional Commission to continue addressing these needs. Additional strategies to more broadly address a culture of community health and its ties to each of the priority needs include developing a system-wide community health investment plan; further developing community health infrastructure; engaging employees in supporting community partnerships; leveraging internal data to assess health disparities; and continuing to provide health education and community outreach events such as health fairs, immunizations and health screenings. Progress made in 2022 in our additional strategies category was closely aligned with increasing infrastructure and strategic impact. Increased staffing infrastructure in the Planning and Community Development division has opened opportunities to evaluate and update current processes to better communicate initiative rationale, program outcomes, and expected community impact. Community Health and Outreach's community health worker (CHW) and peer support specialist programs have been integrated into the electronic medical record system-increasing provider capacity for referrals to community health services and streamlining CHW and peer case management, tracking, and reporting. Continuing our commitment to care, the Planning and Community Development division is working closely with the Quality team and the office of Diversity, Equity, and Inclusion to identify and leverage internal data to identify any disparities in the communities we serve.

Schedule H, Part V, Section B, Line 13 Facility A, 1
Facility A, 1 - Group A. Policy changed for February 1, 2021, Individuals with out of network insurance are eligible for financial assistance. Previously, these individuals were not eligible unless their plan did not meet the Patient Protection and Affordable Care Act (PPACA) minimum essential coverage.

Schedule H, Part I, Line 3c Financial Assistance Eligibility Criteria
Financial assistance policy in effect for February 1, 2021: Families with family income equal or below 300% of the FPG and assets equal or below $25,000 receive 100% adjustment under FAP. Families with family income greater than 300% of the FPG but less than or equal to 500% of the FPG or assets above $25,000 and less than or equal to $100,000 receive a partial adjustment under FAP. The partial adjustment matches the highest AGB percentage determined.

Schedule H, Part I, Line 6a Community Benefit Report
Information on community benefit is reported annually through a consolidated report prepared by Carilion Clinic (EIN 54-1190771). Printed copies of this report are distributed throughout communities served by hospitals affiliated with Carilion Clinic. Additionally, the community benefit report is available on Carilion Clinic's website: https://www.carilionclinic.org/cho-community-health-assessments#community-benefit-reports

Schedule H, Part I, Line 7 Bad Debt Expense excluded from financial assistance calculation
71146123

Schedule H, Part I, Line 7 Costing Methodology used to calculate financial assistance
Line 7a and 7b: For activities reported on the Medicaid cost report, a cost-to-charge ratio as determined from the Medicaid cost report was used. For all other activities, a cost to charge ratio derived from Worksheet 2 of the 990 instructions was used. Lines 7e and 7f are reported at actual cost. Line 7g: A combination of cost accounting and actual costs per service line financial statement was used. Lines 7h and 7i are reported at actual cost.

Schedule H, Part II Community Building Activities
Line 1 - Physical improvements and housing: Carilion acknowledges the impact of housing on health and is becoming increasingly more involved with housing-focused activities. Carilion has worked with various community partners to discuss collaborations around housing, including Community Housing Partners, and serves a key role in supporting Healthy Homes Roanoke, a collaboration that will help identify and remediate health hazards within Roanoke City homes. Line 2 - Economic development: As the largest employer in Southwest Virginia, Carilion impacts economic development by investing in jobs, increased wages for employees and various capital building projects. In addition, Carilion had direct economic development expenses from support of the Go Virginia Foundation and the Virginia Economic Development Partnership. Carilion is active in many local economic development endeavors, including supporting the Valleys Innovation Council, investing in research and technology, communicating with local businesses about the region's current business climate and prospective companies, and the Roanoke Region Chamber of Commerce. All of these initiatives promote the community's health by improving economic vitality and making the region a vibrant place to live, work and play. Line 3 - Community support: Research demonstrates the strong connection between social determinants of health-such as transportation, housing and education-and communities' overall health and well-being. Carilion supports nonprofit organizations addressing barriers to good health arising from these social determinants in various ways. Carilion also collaborates with local partners, such as the Boys and Girls Club of SWVA, the West End Center for Youth, and the Roanoke County Public Schools Education Foundation, to support better education and opportunities for children and families and improved housing, better nutrition and additional resources for our neighbors in need. These efforts help to remove a range of obstacles to good health for our region's residents. Carilion worked with the Rescue Mission homeless shelter to support the Back-to-School Blast, which equips around 1,000 area students with new backpacks containing school supplies at the start of the school year. Carilion physicians provided physicals and immunizations at the event. Through monetary donations and organizational support, Carilion promotes mental health through local arts and culture, reduces inequity, promotes youth development, and supports events for organizations like the Humble Hustle Company, Junior Achievement, Mill Mountain Theatre, the Roanoke Cultural Endowment, the Harrison Museum of African American Culture, and the Southwest Virginia Ballet. Line 4 - Environmental improvements: Carilion recognizes the impact of the physical environment on health both locally and globally. Studies on the heat island effect show Roanoke City, the heart of CMC's service area, to be at higher risk of heat-related illnesses that could be mitigated by environmental improvement strategies. As such, a team of Carilion staff are involved in a heat resiliency project in partnership with the City of Roanoke and Virginia Tech. Line 6 - Coalition building: Carilion believes in the power of collaboration and understands that we must address our most significant health issues in concert with the community. To ensure lasting impact from the health assessment and community health improvement process, Carilion participates in coalitions that address health, safety and social determinant needs in the Roanoke Valley. These coalition-building activities include participation with the Child Health Investment Partnership of the Roanoke Valley, the United Way and Healthy Roanoke Valley, Children's Trust of Roanoke Valley, DePaul Community Resources, and the Virginia Rural Health Association. Line 7 - Community health improvement advocacy: Carilion's mission of community health improvement focuses not only on what the organization does directly but also on supporting the advocacy efforts of other organizations. Carilion supported the Medical Society of Virginia Foundation, the Virginia Health Care Foundation and the American Hospital Association. Carilion was also involved in building awareness and advocacy around domestic violence, sexual assault, sun safety and autism. All of these efforts promote better health by advocating for specific causes under the larger umbrella of health, safety, and the social determinants of health. Line 8 - Workforce development: With the understanding that employment is directly linked to health and wellness, Carilion partners to provide workforce development and training for community members. These efforts also develop a pipeline of future health care workers. Carilion again partnered to offer Project SEARCH, a one-year high school transition program providing employment and educational opportunities for individuals with significant disabilities. This collaborative program includes Goodwill Industries of the Valleys, the Virginia Department of Aging and Rehabilitative Services, and local school systems. Carilion continues to convene the Blue Ridge Partnership for Health Science Careers, a program that will increase awareness of health science careers in elementary, middle and high school children and create pipelines for students to enter specific health science higher education programs. Carilion is involved in the Virginia Business Higher Education Council, promoting reform and reinvestment in the higher education system, and supports the Virginia Foundation for Community College Education.

Schedule H, Part III, Line 2 Bad debt expense - methodology used to estimate amount
Carilion Medical Center estimates bad debt expense by reserving a percentage of all self-pay patient accounts receivable by aging category, based on collection history, adjusted for expected recoveries and, if present, anticipated changes in trends.

Schedule H, Part III, Line 4 Bad debt expense - financial statement footnote
Accounts receivable are stated at net realizable amounts due from patients, third-party payors, and other insurers for which Carilion Medical Center expects to be entitled in exchange for providing patient care. In accordance with Accounting Standards Update (ASU) No. 2014-09, Revenue from Contracts with Customers (Topic 606) (ASU 2014-09), the estimated uncollectible amounts are generally considered implicit price concessions that are a direct reduction to patient accounts receivable.

Schedule H, Part III, Line 8 Community benefit methodology for determining medicare costs
Medicare allowable costs are determined from the Medicare cost report using the cost-to-charge ratio. The Hospital believes our Medicare shortfall is a cost we incur as a benefit to the community. IRS Rev. Rul. 69-545 provides that one of the factors demonstrating community benefit is caring for patients who pay their bills through public programs such as Medicare. In order to operate for the benefit of the broad community that we serve we must include our significant Medicare population, even if we are required to subsidize care to our Medicare patients due to being reimbursed at less than cost by Medicare's nonnegotiable rates.

Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance
When accounts receivable efforts are exhausted, the account may be placed with a collection agency and extraodinary collection actions (ECAs) may be considered. Accounts will not be placed with a collection agency prior to 120 days from the date the first post-discharge billing statement is provided except when mailings are returned with no forwarding address and combining multiple accounts of varying age with those already transferred or for legal verification regarding other liabilities. Reasonable efforts will be made to identify appropriate forwarding addresses. When a Financial Assistance Application (FAA) is received during the application period (within 240 days after the date the first post-discharge billing statement is provided), but after initiation of ECAs, all ECAs will be suspended. Best efforts will be made to process completed applications within 30 days of receipt of the application; financial assistance eligibility will be determined and communicated to the individual. Incomplete applications must be completed within 30 days of the initial notification of additional items required; otherwise, the application will be deemed incomplete and closed. If an individual is eligible for financial assistance, ECAs, other than the sale of debt, will be reversed and any payments related to eligible care refunded to the extent no longer owed. ECAs will be reinstated if the individual is not eligible for financial assistance or does not complete the FAA by the deadline. At least 30 days before initiating an ECA, Carilion will send the patient written notice of intended ECA(s), a plain language summary explaining financial assistance available and the process for determining eligibility, and the deadline for applying for assistance. Carilion will also attempt to call individuals at least 30 days before initiating an ECA to make them aware of the financial assistance available and how to obtain assistance with the application process. Carilion shall enter into a written contract with any collection agency to which it refers bad debt. The contract will obligate the collection agency to observe and comply with Carilion's obligations under this Policy and the Financial Assistance Policy. A collection agency to which bad debt is referred for collection may not engage in any ECAs without the prior written consent of Carilion. After making reasonable efforts to determine if a patient qualifies for Financial Assistance and the patient either does not qualify for Financial Assistance or fails to submit an application as requested, within 240 days from the date the first post-discharge billing statement is provided, Carilion may engage in one or more of the following ECAs: 1. Place a lien on an individual's property; 2. Attach or seize an individual's bank account or any other personal property; 3. Commence a civil action against an individual; 4. Garnish an individual's wages; 5. Sell an individual's debt to another party; or 6. Report the account to credit agencies. Individual account balances greater than $5,000 are not sent to a collection agency. These are handled through the Debt Recovery Department (DRD) for verification of Financial Assistance status before further collection activity occurs. DRD will also investigate any accounts that require special handling. For example, in cases of a deceased patient, auto accident, or any other unique circumstances requiring special handling, the accounts are placed with the DRD. When all collection efforts have been exhausted, all hospital accounts will be returned and closed as uncollectible. No further collection activity is taken at that time. Accounts with satisfactory payment arrangements, legal activity or accounts with pending payment will be considered active and are not returned.

Schedule H, Part V, Section B, Line 16a FAP website
A - CARILION MEDICAL CENTER -DBA CRMH: Line 16a URL: https://www.carilionclinic.org/billing/financial-assistance;

Schedule H, Part V, Section B, Line 16b FAP Application website
A - CARILION MEDICAL CENTER -DBA CRMH: Line 16b URL: https://www.carilionclinic.org/billing/financial-assistance;

Schedule H, Part V, Section B, Line 16c FAP plain language summary website
A - CARILION MEDICAL CENTER -DBA CRMH: Line 16c URL: https://www.carilionclinic.org/billing/financial-assistance;

Schedule H, Part VI, Line 2 Needs assessment
"In addition to conducting regular Community Health Needs Assessments (CHNAs), Carilion Clinic closely monitors community health indicators and responds to needs as they arise. Each year, Carilion updates scorecards with refreshed County Health Rankings indicators provided by the Robert Wood Johnson Foundation. Carilion is also responsive to needs identified through clinical data and internal departments. Carilion's call center, Carilion Direct, is available for community members to ask questions and connect with community resources. Community health workers (CHWs) are also utilized to help address needs, and data is reviewed periodically to identify trends in health care needs of patients served by CHWs. Needs are also identified through current collaborative relationships and community partnerships. Ongoing collaboration with stakeholders allows for regular communication of needs and gives our partners opportunities to respond cohesively. Carilion has adapted its community health improvement process from Associates in Process Improvement's Model for Improvement and the Plan-Do-Study-Act cycle developed by Walter Shewhart. It consists of five steps: (1) conducting the CHNA, (2) strategic planning, (3) creating the implementation strategy, (4) program implementation and (5) evaluation. This cycle is repeated every three years. Carilion fosters community development in its CHNA and community health improvement processes through the Strive Collective Impact Model for the Community Health Assessment Team. This evidence-based model focuses on ""the commitment of a group of important players from different sectors to a common agenda for solving a specific social problem(s) and has been proven to lead to large-scale changes. It focuses on relationship-building between organizations and the progress toward shared strategies."

Schedule H, Part VI, Line 3 Patient education of eligibility for assistance
Information on Financial Assistance is provided to the patient at hospital admission and ambulatory areas in the form of signage, a plain language summary which includes contact information, financial assistance application and documentation in the inpatient handbook. Patient Access staff, Hospital social workers and customer service representatives verbally inform patients on availability of assistance. Each patient statement and patient financial responsibility letter includes information on the Financial Assistance policy including who to contact for additional information and location of in-person assisters. The Application, the Policy, and the plain language summary are available free of charge to the patient. They are available by mail and on the web site if the patient did not receive written information at the time of service. Financial Assistance policy and application are also distributed to community partners through electronic mailing groups. Carilion Clinic employs an Eligibility staff that counsel patients on federal and state programs. The staff completes applications for Medicaid and provides information on Social Security, Social Security Disability and Medicare. The staff provides support services ensuring the applications are processed correctly based on federal and state policy. In addition, Eligibility staff are trained as Certified Application Counselors and will assist patients in enrollment in the Marketplace. Eligibility staff will also complete Carilion's financial assistance application and counsel patients on the requirements for financial assistance.

Schedule H, Part VI, Line 5 Promotion of community health
Carilion Medical Center is part of the non-profit Carilion Clinic integrated health care system located among the Blue Ridge Mountains. Carilion provides quality care for nearly one million individuals through a comprehensive network of hospitals, primary and specialty physician practices, wellness centers, and other complementary services. Carilion's roots go back more than a century when a group of dedicated citizens came together and built a hospital to meet the community's health care needs. Today, Carilion is a vital anchor institution focused on health care and dedicated to our mission of improving the health of the communities we serve. With an enduring commitment to our region's health, care is advanced through clinical services, medical education, research and community health investments. Carilion believes in service, collaboration and caring for all. Carilion invests in discovering and responding to local and regional health needs, understanding that we must involve additional stakeholders to address community health issues and create change effectively. Carilion recognizes the impact the environment has on the health of our communities. Efforts continue to make our hospitals and other facilities more energy-efficient, increase recycling and use of recyclable or bio-degradable materials, reduce waste materials and serve local, sustainable foods to patients and in our cafeterias. Carilion Medical Center (CMC) includes Carilion's flagship facility, Carilion Roanoke Memorial Hospital (CRMH). CRMH includes a Level 1 Trauma Center, a Neonatal Intensive Care Unit, Carilion Children's Hospital and 718 patient beds. Offering a wide range of inpatient and outpatient care, specialty care, medical education, and fellowships, CRMH has gained recognition as one of Virginia's top hospitals by U.S. News and World Report. CRMH provides access to the region's most experienced providers and specialty services while teaching and developing tomorrow's medical leaders through residencies and fellowships sponsored by the Virginia Tech Carilion School of Medicine. Additionally, Carilion Roanoke Community Hospital houses a highly skilled inpatient rehabilitation unit. CMC serves patients regardless of their ability to pay. The hospital's governing board members are elected annually and reside in the region. The majority of members are neither hospital employees nor contractors. Medical staff privileges are extended to qualified providers. Surplus funds are reinvested in new technology, clinical initiatives, education and charitable efforts. Reinvestments include providing free, discounted and subsidized care and critical medical services not otherwise offered in our region.

Schedule H, Part VI, Line 4 Community information
The Roanoke metropolitan statistical area (MSA), home to Carilion Clinic's flagship hospital CRMH, is commonly known as the Roanoke Valley. It is composed of the independent cities of Roanoke and Salem and the counties of Botetourt, Craig, Franklin and Roanoke. The Valley is mostly rural, nestled among the Blue Ridge Mountains with the urban city of Roanoke at its heart. Roanoke is a destination place, rich in cultural diversity, the arts, shopping, recreational opportunities, natural beauty and services not available in more rural areas of the region. The Roanoke Valley is comprised of distinct communities with significant disparities in size, population and social determinants of health. The 2017-2021 American Community Survey (ACS) found the Roanoke MSA's total population to be 313,501. The cities of Roanoke and Salem had 99,578 residents and 25,335 people, respectively. The counties of Botetourt, Craig, Franklin and Roanoke had 33,542, 4,914, 54,829 and 96,303 residents, respectively. The median household income ranges from a low of $48,476 in Roanoke City to a high of $72,941 in Botetourt County. Across the Roanoke Valley localities, 11.59% of the population has a household income below the federal poverty guideline. (US Census Bureau, ACS. 2017-2021.) Similarly, 16.0% of the population are receiving Medicaid, and 6.65% have no health insurance at all. (US Census Bureau, ACS. 2017-2021.) The highest rates of Medicaid patients are in Roanoke City (27.04%). Specific to CMC inpatients and outpatients in fiscal year 2022, 21.9% received Medicaid while 2.9% were self-pay. (Strata internal data) The median age in the MSA localities ranges from 38.0 in the city of Roanoke to 48.65 in Craig and Franklin counties, all above the state median of 38.5. The ACS finds that for most of the Roanoke MSA, a more significant percentage of the population is White than in the Commonwealth of Virginia as a whole, with rates ranging up to 96.2% in Craig County. (US Census Bureau. ACS. 2017-2021.) The Weldon Cooper Center for Public Service predicts positive population change by 2040 for all communities except Craig County, which may have very slight population loss. The city of Roanoke, Roanoke Valley's urban hub, is more racially and ethnically diverse than the rest of the MSA. Roanoke's population is 60.01% White, 29.3% Black and 3.2% Asian, with 6.0% representing more than one race. The remainder represents small minorities of American Indian/Alaskan Native, Native Hawaiian/Pacific Islander or some other race. Of the population, 6.65% are Hispanic or Latino. (US Census Bureau, ACS. 2017-2021.) Roanoke City is divided into quadrants (Northwest, Northeast, Southwest and Southeast) separated geographically by railroad tracks, the Roanoke River and Interstate 581. These quadrants vary significantly in the demographic and economic make-up of their residents. Specifically, two of the quadrants-Northwest and Southeast-have federal designations as Medically Underserved Areas (MUAs). These areas are home to a large proportion of the low-income individuals and families in the city who may be uninsured, underinsured or are Medicaid recipients facing additional barriers due to cultural differences. MUAs are also present in Bedford County, Botetourt County, Craig County and Franklin County. (https://data.hrsa.gov/tools/shortage-area) In addition to Carilion, two other hospitals serve the MSA: the Salem Veterans Administration Medical Center and LewisGale Medical Center. Key safety net providers in the region include the Veteran Affairs Medical Center, a federally qualified health center, free clinics, local offices of the Virginia Department of Health and other service organizations.

Schedule H, Part VI, Line 6 Affiliated health care system
"Carilion Medical Center is wholly owned by Carilion Clinic, a not-for-profit health care organization based in Roanoke, Virginia. Carilion Clinic includes a comprehensive network of hospitals, primary and specialty physician practices, and complementary services consisting of six hospital entities, over 75 specialties and 282 practice sites across Southwest Virginia. All of these are centered on a common mission and shared values. In the mid-2000s, Carilion made the strategic decision to transform from a collection of hospitals to a physician-led, integrated health care system. Advances include developing a multi-specialty physician group, transforming our primary care practices into patient-centered medical homes, Implementing electronic health records system-wide, and creating a robust partnership with Virginia Tech, including developing the Virginia Tech Carilion (VTC) School of Medicine and the Fralin Biomedical Research Institute at VTC. Each decision and adaptation have fundamentally changed the way Carilion collaborates and provides care (https://www.carilionclinic.org/about-carilion-clinic). Carilion's community and population health infrastructure is the health system's engine for providing collaborative opportunities to improve and promote the community's health. Carilion's Community Health Assessment process helps identify the strengths and barriers impacting health. Our community-based programs reflect the Robert Wood Johnson Foundation's framework of four main influences of health: health behaviors, social and economic factors, clinical care access and quality, and physical environment. Our many partnerships with cross-sector organizations create a collaborative culture of health and wellness. Carilion has a long history of working with Radford University and Jefferson College to advance health professionals' education. Founded in 1914 as the Jefferson Hospital School of Nursing, what became known as the Jefferson College of Health Sciences merged with Radford University in early 2018 to form Radford University Carilion (RUC). Located on the campus of Carilion Roanoke Community Hospital, this higher education institution ""prepares, within a scholarly environment, ethical, knowledgeable, competent and caring healthcare professionals."" Today, RUC provides more than 1,100 students with opportunities to become part of the health care profession, serving communities ranging from Southwest Virginia to the Shenandoah Valley and beyond. The school's graduates are building healthier tomorrows in our region and across the country every day."