4A (Expenses $ 69452348 including grants of $ 175607) (Revenue $ 93326126)
See Schedule O

Willits Hospital, Inc. dba Adventist Health Howard
Part V, Section B, Line 5: The 2019 CHNA data collection process can be summarized as follows: 1. Review of prior CHNA reporting efforts;2. Collection of most recently available demographic, socioeconomic and health indicator data; and3. Data gathering accomplished by using a widely-distributed community health survey and conducting key informant interviews and written surveys. Community Health Survey: Community Health Survey was provided to Mendocino County residents online as well as in hardcopy format. A total of 1,324 residents completed the Community Health Survey; 1,276 were completed in English and 48 in Spanish; 94 were completed by Native Americans, mostly from the Round Valley area.Key Informant Interviews and written surveys: 34 key stakeholders in the community, including representatives of county and city government, private businesses, health and human services, hospitals and clinics, community-based organizations and nonprofits, law enforcement, children and youth services, education, media, geography, and racial/ethnic groups, among others. Interviews were conducted in person or by phone. Some questions were also provided in hardcopy format for written response. While an effort was made to have diverse representation, the opinions provided by the key informants are not necessarily representative of the county as a whole. Key Leader Survey of 56 formal and informal leaders in the community that was provided online. Together with the Key Informant Interviews, a total of 90 key informants/leaders in Mendocino County participated.These key stakeholders were selected by the workgroup because they would provide a unique perspective on the health of the community, health care delivery systems in place and overall conditions that influence health behaviors.Secondary data sources included publicly available state and nationally recognized data sources. Data on key health indicators, morbidity, mortality, and various social determinants of health were collected from the US Government Accountability office, California Department of Social Services, California Department of Public Health, US Department of Health and Human Services, HealthyPeople2020, Centers for Disease Control and Prevention, and the American Heart Association.

Willits Hospital, Inc. dba Adventist Health Howard
Part V, Section B, Line 6a: Adventist Health Howard Memorial partnered with Adventist Health Ukiah Valley to produce the 2019 CHNA.

Willits Hospital, Inc. dba Adventist Health Howard
Part V, Section B, Line 6b: Adventist Health Howard Memorial collaborated with the Mendocino County Health and Human Services Agency Public Health Branch, Healthy Mendocino, Redwood Community Services, Mendocino Coast Clinics, Mendocino Community Health Clinics, Alliance for Rural Community Health and North Coast Opportunities to prepare the 2019 Community Health Needs Assessment.

Willits Hospital, Inc. dba Adventist Health Howard
Part V, Section B, Line 11: The COVID-19 global pandemic has caused extraordinary challenges for Adventist Health hospitals and health care systems across the world including keeping front line workers safe, shortages of protective equipment, limited ICU bed space and developing testing protocols. They have also focused on helping patients and families deal with the isolation needed to stop the spread of the virus, and more recently vaccine roll out efforts. Adventist Health, like other health care systems, had to pivot its focus to meet the most urgent healthcare needs of its community during the pandemic, as well as reassess the ability to continue with some community health strategies due to public health guidelines for social distancing. Adjustments have been made to continue community health improvement efforts as possible, while ensuring the health and safety of those participating. Our 2019 CHNA identified three areas of significant need: Mental Health, Substance Abuse, and Workforce Development. Priority Need 1 - Mental Health - The goal is to build community partnerships to address critical mental health needs. Strategy - Collaborate with partners to build the system of care for mental health. Activity 1 - Build the Mendocino County Trauma Informed Network of Care - Adventist Health Howard Memorial worked with partners on the development of a proposal to build a Trauma Informed Network of Care. This work was merged with the Childhood Trauma Action Team, which was later changed to the Adverse Childhood Experiences (ACEs) Community Resilience Team. During 2021, the group joined PACEs Connection Cooperative of Communities. Additionally, Adventist Health Howard Memorial serves on the Mendocino County's Mental Health Treatment Act Citizens' Oversight Committee. During 2021, this working group surveyed and mapped existing trauma informed organizations across Mendocino County. Priority Need 2 - Substance Abuse - The goal is to provide support in a community with high substance abuse. Strategy - Participating in county collaborative for substance use treatment and expanding SUD case management. Activity 1 - Participate in monthly Safe Rx Mendocino Coalition meetings to design a plan to reduce substance abuse in Mendocino County - Adventist Health Howard Memorial is an active member of the Safe Rx Mendocino Coalition. Although not reflected in our community benefit financials, additional state funding was received to continue the Substance Use Navigator (SUN) Program. During a patient's stay, SUN supports early intervention and advocates for the patient's substance use treatment need with inpatient providers. Additionally, through this work, Naloxone was successfully administered in 2021 and resulted in 156 overdose reversals within the county. In 2021, there were 37 overdose diagnosis within the hospital emergency department (ED).Priority Need 3 - Workforce Development - The goal is to create educational pathways for entry into health care environments. Strategy 1 - Work with Mendocino College to create a Physical Therapy Assistant Program. Activity 1.1 - Participate in the advisory council for Mendocino College to create Physical Therapy Assistant Program (PTAP) - A total of 16 PTAP students graduated from the program. Additionally, a total of two students were provided externships and one student was hired from the inaugural cohort. Currently three Adventist Health associates teach at Mendocino College. Additional activities include Adventist Health Howard Memorial support of the Mendocino College RN program by funding one instructor and providing preceptorships at Adventist Health facilities. In 2021, 24 nursing students graduated, five preceptorships were hosted, and five students hired by Adventist Health Howard Memorial. Priority needs not addressed:No hospital can address all the health needs identified in its community. Adventist Health Howard Memorial is committed to serving the community by adhering to its mission, and using its skills, expertise and resources to provide a range of community benefit programs. Areas of significant health needs that will not be directly addressed at this time include domestic abuse due to insufficient funding and staff time to address the need, and housing & homelessness as this need will be addressed by other community organizations.

Willits Hospital, Inc. dba Adventist Health Howard
Part V, Section B, Line 13h: Patients who do not meet the income criteria, may be eligible for financial assistance based on essential living expenses and resources. The following two (2) qualifications must both apply:1. Essential living expenses: Exceed fifty percent (50%) of the household income; and2. Resources: The patient's excess medical expenses (the amount that allowable medical expenses are greater than 50% of annual household income) must be greater than available qualifying assets.

Part I, Line 7:
The costs were determined by using a cost-to-charge ratio. The cost-to-charge computation is based on hospital specific data included in the system-wide combined audited financial statements. The formula used for computation equals financial statement data as follows:Total expenses - (Provision for bad debts + Other revenue + Interest income)/Gross patient chargesThe Hospital is located in a medically underserved area and participates in a quality assurance fee program with the State of California to fund certain Medi-Cal coverage expansions. The state redistributes funds to hospitals that provide patient care to a higher proportion of indigent and medically underprivileged patients, who otherwise would most likely not have access to physicians and other medical services. The community benefit analysis includes receipts from this redistribution that are used to assist in partially offsetting the significant costs associated with providing patient care to this population group. The program may or may not continue in the future based on the State of California's regulations and policies and the approval of the federal government.

Part II, Community Building Activities:
The Hospital is involved in numerous community building activities which promote the health of the community. Overwhelmingly, we see diseases of despair including suicide, substance abuse, mental health and chronic illnesses plaguing the communities in which we have a significant presence in. These community concerns are addressed through health improvement, education, poverty, workforce development and access to care. This is why we have focused our work around addressing behavior and the systems keeping the most vulnerable people in cycles of poverty and high utilization. In an effort to heal these communities, we have strategically invested in our communities by partnering with national leaders in community well-being. We believe the power of community transformation lies in the hands of the community. Our solution for transformation is to create a sustainable model of well-being that measurably impacts the well-being of people, well-being of place and equity. In 2020, Adventist Health acquired Blue Zones as the first step toward reaching our solution. By partnering with Blue Zones, we will be able to gain ground in shifting the balance from healthcare - treating people once they are ill - to transformative well-being - changing the way communities live, work and play. In 2021, Adventist Health committed to launching six Blue Zone Projects within our community footprint, and as we enter 2022 these projects are active. Blue Zones widens our impact from only reaching our hospitals' communities in four states to a global mission practice. We also encourage our employees to serve on community collaboration boards, health advocacy programs, and physical improvement projects to promote the health of the communities we serve. In addition, we work with neighborhood programs, including schools, work sites and safety net providers to promote health and wellness and prevent disease. These activities are not included elsewhere on Schedule H.

Part III, Line 2:
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 described for Part I, Line 7 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:
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:
The system-wide audited combined financial statements do not contain a footnote describing bad debt expense.

Part III, Line 8:
"The Medicare Cost Report apportions the Hospital's costs on the basis of inpatient days and ancillary and outpatient charges to establish the costing methodology. Healthcare delivery by hospitals is a complex, highly regulated business in the United States. Healthcare unit cost inflation is driven by compliance with ever expanding regulatory requirements, shortages of highly skilled labor and involving medical and information technology. The health care ""market basket"" is unrelated to that of the average individual consumer. Medicare annual payment updates have fallen behind actual healthcare cost inflation to the point that Medicare payments to many U.S. hospitals are well below the cost of providing care. These unreimbursed costs are a community benefit for seniors and others in the community as these individuals are continuing to receive care without which many would become dependent on other governmental resources such as Medicaid. The benefit to the community for healthier Medicare recipients is no different than those benefits the community realizes for uninsured and underinsured patients who are eligible for partial and full charity care. Medicare is a safety net for seniors and others. Without Medicare coverage, many individuals would undoubtedly qualify for charity care. In addition to the mismatch between Medicare payment increases and healthcare cost inflation, the highly complex Medicare payment systems and formulas produce disparate payment levels from one hospital to another for the same service. These disparate payment levels create disparate results within groups of hospitals. For further information, please refer to Schedule H, Part III, Section B."

Part III, Line 9b:
"When a patient has requested screening for charity care, the Hospital must immediately cease collection activity and place the account in a charity pending status. If 100% charity is approved, the entire account balance is written off to charity care. If the patient has a sliding scale liability based on the federal poverty guidelines, they are billed only for that liability. If the patient fails to pay their after-charity liability, they are assigned to a collection agency with an identifier that indicates to the agency that the patient is ""low income and the following criteria must be followed by the agency:1. They may not report the patient to a credit bureau2. They may not file a lawsuit to recover the outstanding liability3. They may not charge interest"

Part VI, Line 7, Reports Filed With States
CA

Part VI: Other Information:
In 2021, Adventist Health Howard Memorial continued to offer the following actions in response to the needs created or exacerbated by COVID-19: continued virtual healthcare visits to keep community members safe and healthy; continued their online symptom tracker; participated in a communitywide effort to vaccinate eligible community members. Additionally, Adventist Health Howard Memorial continued to support the COVID-19 work group which provided health equity advocacy for the Latino population in Mendocino County. In 2021, the group launched a county-wide Community Health Worker Coalition. The coalition was tasked with formulating a plan for a county-wide Community Health Worker program and securing funding.

Part VI, Line 2:
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:https://www.adventisthealth.org/about-us/community-benefit/The most recent Community Health Needs Assessment, two most recent Implementation Strategy reports and the most recent Community Health Plan Updates are also available on the Adventist Health Corporate website at:https://www.adventisthealth.org/about-us/community-benefit/The Community Health Needs Assessment (CHNA) includes both the activity and product of identifying and prioritizing a community's health needs, accomplished through the collection and development of a community health plan. The second component of the CHNA, the community health plan, includes strategies and plans to address prioritized needs, with the goal of contributing to improvements in the community's health. Qualitative and quantitative data sources were used in conducting the CHNA. To accomplish the many important systemic goals that are underway in our community, our hospital support local partners to augment our own efforts, and to promote a healthier community. Partnership is not used as a legal term, but a description of the relationships of connectivity that are necessary to collectively improve the health of the regions we serve. One of our objectives is to partner with other nonprofit and faith-based organizations that share our values and priorities to improve the health status and quality of life of the community we serve. This is an intentional effort to avoid duplication and leverage the successful work already in existence in the community.

Part VI, Line 3:
The plain language summary of the Financial Assistance Policy (FAP) is posted along with the complete FAP policy and FAP Application on the Hospital's website at:https://www.adventisthealth.org/documents/financial-assistance/ENG_PFS-112_Financial-Assistance-Policy.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:
Adventist Health Howard Memorial is located in the city of Willits, Mendocino County which has a population of approximately 5,100 within the city limits and over 28,000 in the Hospital's service area. Adventist Health Howard Memorial primarily serves the people of northern Mendocino County.According to 2018 data from the U.S. Census Bureau, Mendocino County has an estimated population of 87,580, slightly lower than the 87,869 reported in the 2014 U.S. Census data. More than one-half (55%) of the population live in urban areas, while 45% live in rural communities, on farms or ranches. The proportion of residents who are ages 65 years and over make up 21.7% of the county population, higher than the proportion in the state with 14.5%.In 2018, the county's population was 76% White, 22% Hispanic, 4% Native American, 1% Asian, 0.7% African American, 0.6% Pacific Islander, and 15.4% Two or More Races. Between 2010 and 2060, the Hispanic/Latino population is expected to increase from 19,802 to 37,293 or to 37% of the county population, while Whites will decrease from 60,449 to 48,450 (to 48% of the county population).In the most recent data, nearly one-quarter of adults in Mendocino County ages 25 and older (22%) had a bachelor's degree or higher, and 7% had less than a high school diploma (compared to 31% and 10%, respectively, for California as a whole). Also in 2017, the median household income in Mendocino County, at $47,656, was 36% lower than that of the state ($74,605), compared to 2014 when the median household income in Mendocino County was 29% lower than the state.The 2019 County Health Rankings estimate that about 27% of the county population lives in substandard housing, i.e., without a kitchen or adequate plumbing, or lives in crowded conditions. In addition to substandard or crowded housing, over one-half of Mendocino County residents who rent (52%) pay more than a third (35%) of their total income for rent.

Part VI, Line 6:
The Hospital is a member of Adventist Health, a health care system which provides healthcare services in diverse markets within the Western United States. A member hospital may share some services with other member hospitals in its geographic area, such as clinical, management and support services. Using today's technology, hospitals outside the geographic area 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, Line 5:
"Our Hospital's mission is, ""Living God's love by inspiring health, wholeness and hope."" Our community benefit work is rooted deep within our mission and merely an extension of our mission and service. We have also incorporated our community benefit work to be an integral component of improving the ""triple aim."" The ""Triple Aim"" concept broadly known and accepted within health care includes:1. Improve the experience of care for our residents.2. Improve the health of populations.3. Reduce the per capita costs of health care.Our strategic investments in our community are focused on a more planned, proactive approach to community health. The basic issue of good stewardship is making optimal use of limited charitable funds. Defaulting to charity care in our emergency rooms for the most vulnerable is not consistent with our mission. An upstream and more proactive and strategic allocation of resources enables us to help low income populations avoid preventable pain and suffering; in turn allowing the reallocation of funds to serve an increasing number of people experiencing health disparities.Hospitals and health systems are facing continuous challenges during this historic shift in our health system. Given today's state of health, where cost and heartache is soaring, now more than ever, we believe we can do something to change this. These challenges include a paradigm shift in how hospitals and health systems are positioning themselves and their strategies for success in a new payment environment. This will impact everyone in a community and will require shared responsibility among all stakeholders. As hospitals move toward population health management, community health interventions are a key element in achieving the overall goals of reducing the overall cost of health care, improving the health of the population, and improving access to affordable health services for the community both in outpatient and community settings. The key factor in improving quality and efficiency of the care hospitals provide is to include the larger community they serve as a part of their overall strategy. Population health is not just the overall health of a population, but also includes the distribution of health. Overall health could be quite high if the majority of the population is relatively healthy even though a minority of the population is much less healthy. Ideally such differences would be eliminated or at least substantially reduced.Community health can serve as a strategic platform to improve the health outcomes of a defined group of people, concentrating on three correlated stages:1. The distribution of specific health statuses and outcomes within a population.2. Factors that cause the present outcomes distribution; and 3. Interventions that may modify the factors to improve health outcomes.Improving population health requires effective initiatives to: 1. Increase the prevalence of evidence-based preventive health services and preventive health behaviors, 2. Improve care quality and patient safety, and 3. Advance care coordination across the health care continuum. We will work together with our community to ensure the community health improvements are identified and then targeted for programs to influence behaviors to obtain improved health within the whole community."