4A (Expenses $ 32202078 including grants of $ 37930) (Revenue $ 47852641)
See Schedule O

4B (Expenses $ 7180558 including grants of $ 0) (Revenue $ 6351165)
See Schedule O

Smyth County Community Hospital
Part V, Section B, Line 3j: To understand each community's 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. Priorities established for our CHNA were determined by the most significant health needs of the community. Ballad Health hospitals, including, Smyth County Community Hospital, conducted their fifth CHNA last year with board approval and publication occurring at the end of FY21.For FY21 CHNAs, Ballad Health utilized a mixed-methods approach for primary and secondary data collection to gather regional information to inform the 2021 community health needs assessments. The secondary data collection entailed the compilation of secondary data pertaining to agreed-upon metrics and indicators from an array of verified sources. The primary data collection component involved both a key stakeholder survey and key stakeholder focus groups. Findings from both research methods were used to prioritize the needs of the community served by each Ballad Health facility and determine priority focus areas for future improvement efforts. Analysis of secondary data for Smyth County, findings from the key stakeholder survey, and the perspectives of diverse key stakeholders led to the prioritization of community issues for Smyth County. For Smyth County Community Hospital, the three priority areas for future improvement efforts that were selected by key stakeholders in Smyth County are substance abuse, mental health, and Adverse Childhood Experiences (ACEs).

Smyth County Community Hospital
Part V, Section B, Line 5: The community health needs assessment process was guided by the Mobilizing for Action Through Planning and Partnerships (MAPP) model, with an understanding that aspects of the model may have to be adapted due to the purpose of the assessment for Ballad Health and constraints related to the COVID-19 pandemic. In coordination with the MAPP model, concepts from both Community-Based Participatory Research (CBPR) and the Arkansas Center for Health Improvement (ACHI) Community Health Assessment Toolkit were also utilized for the assessments. Following guidance from the MAPP model, a Key Stakeholder Survey was designed with the primary aim of identifying the most-pressing community issues. In aligning with principles of CBPR, the key stakeholder survey was designed to allow key stakeholders to frame community issues in their own words through the use of open-ended questions. In addition to the identification of community issues, the key stakeholder survey was also designed to discern why survey respondents believed the community issues they selected had the greatest effect on the overall health and wellbeing of their community. Questions related to ideas and suggestions for improvement efforts, gauging the success of efforts after the previous community health needs assessments, and community struggles related to the COVID-19 pandemic were also included in the survey. Independent focus groups were conducted for each Ballad Health facility in order to provide specific and unique information for each community being served. The MAPP model and questions from the key stakeholder survey were used to guide the development and construction of the focus groups. Because the key stakeholder survey primarily dealt with the identification of community issues, the focus groups were primarily designed to prioritize community issues identified through the key stakeholder survey and discuss actionable items around how to best address these community issues. Questions related to root causes of community issues, the current state of resources to address community issues, needed resources to initiate improvement efforts and be successful, and community struggles related to the COVID-19 pandemic were also included in the focus group facilitation guide. The key stakeholder focus groups were conducted virtually via WebEx and were one hour and thirty minutes in length.For Smyth County Community Hospital there were eight focus group participants. Similar to the key stakeholder survey representation, focus group participants represented an array of different sectors in Smyth County, VA which included: the school system, businesses, government, the health care system, health departments, faith-based organizations, and a diverse group of community-based organizations. For stakeholders who were not able to attend the focus group in real-time, blank facilitation guide templates with questions concerning the three priority areas identified by the focus group participants were sent to them immediately after the conclusion of the focus group. This allowed key stakeholders who were not able to attend the focus group in real-time to still provide input and the hospital to ensure the involvement of diverse stakeholders. Activities associated with the June 2021 assessments took place from summer of 2020 through the spring of 2021. The assessment activity including focus groups & surveys were used to develop the hospital implementation plans that were completed fall 2021.

Smyth County Community Hospital
Part V, Section B, Line 6a: Each hospital within Ballad Health completed a CHNA. SCCH's CHNA was conducted with all Ballad Health hospitals at that time to include: Bristol Regional Medical Center, Hancock County Hospital, Hawkins County Memorial Hospital, Greeneville Community Hospital, Holston Valley Medical Center, Johnson City Medical Center (includes Niswonger Children's Hospital and Woodridge Hospital), Franklin Woods Community Hospital, Indian Path Community Hospital, Lonesome Pine Hospital (including Mountain View campus), Johnson County Community Hospital, Johnston Memorial Hospital, Norton Community Hospital, Dickenson Community Hospital, Russell County Hospital, Smyth County Community Hospital, Sycamore Shoals Hospital, and Unicoi County Hospital.

Smyth County Community Hospital
Part V, Section B, Line 11: During the year, Smyth County Community Hospital focused on its CHNA priorities as identified in its FY21 CHNA report. SCCH's primary areas of focus included: substance abuse, mental health, and Adverse Childhood Experiences (ACEs). 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. Ballad Health made financial contributions to other nonprofit organizations providing community services that support the hospital's CHNA. SCCH continued its practice of providing medications and supplies to area rescue squads this year

Smyth County Community Hospital
Part V, Section B, Line 13h: Ballad Health's 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:
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 Health's qualifications for financial assistance is based on federal poverty guidelines, asset values may also be used to determine financial assistance eligibility. Unique circumstances may be assessed on 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 hospital's charity write-offs exceed the hospital's charity budget.All Ballad Health hospitals provide an uninsured discount. The current uninsured discount for Critical Access Hospitals (CAH's) is 77% and for all other hospitals or physician practices it 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 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, Ballad Health offers 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:
"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. 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 local schools and universities, allowing their health profession students to get hands-on training in a hospital setting. Another source of health professions education reported on line 7f is our Medicare-approved CNA, ""Certified Nursing Assistant"", program. The CNA program cost and reimbursement information comes from our filed Medicare cost report, adhering to IRS 990 instructions. For line 7g subsidized health care services, we use our cost accounting system because we have established, standard costing reports for these services. We are careful to ensure no double counting of cost. Although we have other service lines within our hospital that lose money, we do not report services that hospitals are required by state licensure to provide, routine services or ancillary services. Line 7h research represents SCCH's expense allocation from Ballad Health for research. Line 7i cash and in-kind contributions include cash disbursements and in-kind donations of medications to local nonprofit rescue squads and fire departments. In-kind donations of medications are based on our actual cost for these items."

Part II, Community Building Activities:
SCCH 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 SCCH 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.SCCH, in collaboration with area health agencies and providers, may offer assistance with coordination, advocacy, or contribute supplies to support groups for their program activities that serve to assist special populations within our area. Most of these organizations work to improve the lives of community members that have limited, or no, financial resources.In FY22 SCCH provided sponsorship for the Town of Marion Veterans Memorial Park.

Part III, Line 2:
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 Health's system-wide self-pay policy, any patient who has no insurance and is ineligible for any government assistance program received 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 that we need to deem them eligible or upon determination of presumptive charity eligibility.After the normal collection process has indicated an account is uncollectible, SCCH 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:
Ballad Health's audited financial statements include a footnote on page 14 that describes bad debt. SCCH is included in the June 30, 2022 audited financial statements of Ballad Health (attached).

Part VI, Line 7, Reports Filed With States
VA,TN

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 and the two states to allow Mountain States Health Alliance and Wellmont Health System to merge.

Part III, Line 3:
Our primary external collection agency historically estimated that approximately 37% of SCCH's bad debt would have qualified for financial assistance if patients had provided our hospital with a financial assistance application and required documentation. Pursuant to the merger, SCCH 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. There are many instances of patients with account balances and no health insurance coverage that SCCH believes would qualify for financial assistance. Although patients are encouraged to apply for assistance, many will not do so. SCCH would prefer for patients to submit completed financial assistance applications given that historical data clearly indicates that most uninsured patients and many underinsured patients will qualify for financial assistance under SCCH's program. Without a completed application, these are recorded as bad debt instead of charity care.

Part III, Line 8:
Excluding Medicare losses reported in Part I subsidized health, the Part III Medicare allowable costs are reported using SCCH's filed Medicare cost report (C/R). The C/R uses a cost to charge ratio based on a step-down allocation methodology.Ballad Health believes 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:
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 patient's 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.The Ballad Health collection policy clearly states that all patients are treated equally - with dignity and respect. Ballad Health ensures that outside collection agencies used by our hospitals adhere to Ballad Health billing and collection guidelines. The collection program includes communicating expected financial responsibility prior to service. Ballad Health 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, Ballad Health bills 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. Ballad Health 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- the hospital 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 Ballad Health hospitals- 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:
Focusing on population health improvement and associated priority metrics 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 expands 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. Because our hospitals are located in a region with many chronic disease challenges and high levels of health-related social risks, Ballad Health's goal is to target population health issues to make lasting improvements. Ballad conducts ongoing interviews, focus groups and meetings with external groups, including the regional health departments, United Way agencies, chambers of commerce, schools and community organizations, the regional accountable care community leadership council, as well as internal groups such as our population health and community benefit committee of the Ballad Health board of directors, the Ballad Health population health clinical committee, social needs council, grant advisory committees and our hospital community boards in the creation and on-going implementation of its population health plan.

Part VI, Line 3:
Consistent with the Ballad Health financial assistance policy, SCCH 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 SCCH 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. SCCH's financial assistance policy and documents are available in our Emergency Department and admitting areas. SCCH is also happy to mail all documents to patients and offers a plain language summary. All 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:
Smyth County Community Hospital, located in Marion, Virginia, primarily serves Smyth and Wythe Counties in Southwest Virginia. Smyth County has a population of 29,893. The population projections for Smyth County over the next five years show that the county will likely experience a slight decline in population overall. However, the age 65+ population for Smyth County is projected to experience the most population change over the next five years, as it moves from 23.3% of the total population in 2021 to 25.8% of the population in 2026. The aging population of the county presents opportunities for earlier identification and better management of health conditions that oftentimes affect elderly populations in rural areas.Additionally, the median household income for Smyth County is $41,000 which ranks well below the average for the state of Virginia at $72,600. Other demographic factors influencing health status in the county also includes education levels. A large portion of Smyth County residents do not have an education past high school (54.7%). The remaining portion of the population reports having some college/associates degree (31.3%) or a bachelor's degree or greater (14.0%). Additionally, a large portion of Smyth County (13.0%) adult residents do not have health insurance, which is higher than the Virginia state average (12.0%).According to the 2021 County Health Rankings, Smyth County, where SCCH is located, is ranked among the least healthy counties in Virginia. Smyth County is ranked 112th in Virginia for health outcomes and 102nd for health factors out of 133 counties/cities. Smyth County also ranked 108th in health behaviors, due to higher than desired rates of adult obesity, physical inactivity, adult smoking, and alcohol-impaired driving deaths. As for social and economic factors, Smyth County ranks 105th due to high rates of children in poverty and higher unemployment rates.

Part VI, Line 5:
SCCH is dedicated to operating efficiently so that waste is minimized. SCCH's 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. SCCH serves as a training site for many types of health professions: nursing, pharmacy, psychology, lab, respiratory therapy, EMT, public health, etc. Students from several colleges receive training and hands-on experience in our hospital. We devote resources to health conferences for local health professionals and offer other programs focused on improving the health of our residents. We provide free drugs and medical supplies to local nonprofit emergency response organizations. While we operate in a predominantly low-income, rural area, we continue to offer services that operate at a loss because Smyth County residents would otherwise need to leave their hometown or county to receive needed care.Physicians that request privileges who are qualified and credentialed are extended privileges by SCCH.

Part VI, Line 6:
Smyth County Community Hospital is a member of Ballad Health. The merger of Mountain States Health Alliance and Wellmont Health System in 2018 to form Ballad Health opened up many opportunities not previously available to two competing health systems. Collaboration started post-merger and Ballad Health continues to see progress towards improving efficiencies within our health system, activities consistent with Ballad Health's population health initiative, sharing best practice quality improvements, and other benefits related to operating as one rather than operating in a competitive environment. A clinical council was formed immediately following the merger. The council includes physicians nominated from the leadership of all Ballad hospitals. A Community Benefit and Population Health Committee of the board was established, and various other infrastructures have been established since the merger. Across Ballad's hospitals, there were many projects, programs and collaborative efforts that took place during the year.