4A (Expenses $ 106352935 including grants of $ 456231) (Revenue $ 160733224)
See Schedule O

Adventist Health Clearlake Hospital
Part V, Section B, Line 5: The 2019 CHNA data collection process can be summarized as follows:1. Review of prior CHNA reporting efforts2. Collection of most recently available demographic, socioeconomic and health indicator data3. Data gathering from community membersData from a community engagement process that facilitated participation by a broad representation of local professionals, Lake County residents, and other stakeholders. Data gathering was accomplished by using a widely-distributed community survey, engaging with community focus groups and conducting key informant interviews.Community Survey: Provided to Lake County residents in English and Spanish that solicited people's opinions about most important health needs, behaviors that have the greatest impact on overall community health, in addition to personal health and demographic questions. Distributed online through SurveyMonkey. Paper surveys were also made available and answers to the paper survey were entered into the SurveyMonkey tool. A total of 708 responses were collected.Community Focus Groups: Five focus groups, including 31 participants, took place between March 5th and March 21st, 2019. The groups were organized and facilitated by the Health Programs Coordinator of the Lake County Health Department. Participants were recruited from zip codes with a high burden according to Conduent HCI's SocioNeeds Index using multiple modes: direct recruitment by partner community-based organizations, email invitations, flyers, and social media postings. Each focus group was recorded, and the audio recordings were transcribed to capture the verbatim conversation. Key Informant Interviews: Key informant interviews were conducted by telephone, each ranging from 30-60 minutes in length with stakeholders from a range of sectors such as government, healthcare, Tribal Health, law enforcement and community service organizations. Interviewees who were asked to participate were recognized as having expertise in public health, special knowledge of community health needs and/or represented the broad interest of the community served by the Hospital, and/or could speak to the needs of medically underserved or vulnerable populations. Community leaders with specific experience working with priority populations, such as women, children, tribal communities, the disabled, and more were interviewed. Secondary data used for this assessment were collected and analyzed from Conduent HCI's community indicator database. This database, maintained by researchers and analysts at Conduent HCI, includes over 204 community indicators from at least 21 state and national data sources. Conduent HCI carefully evaluates sources based on the following three criteria: the source has a validated methodology for data collection and analysis; the source has scheduled, regular publication of findings; and the source has data values for small geographic areas or populations. Data sources include but are not limited to the American Cancer Society, California Department of Health, County Health Rankings & Roadmaps, WHO, United States Department of Housing and Development, US Census Bureau, and Centers for Disease Control and Prevention.

Adventist Health Clearlake Hospital
Part V, Section B, Line 6a: Adventist Health Clearlake Hospital collaborated with Sutter Lakeside Hospital.

Adventist Health Clearlake Hospital
Part V, Section B, Line 6b: Adventist Health Clearlake Hospital collaborated with the County of Lake Board of Supervisors, Lake County Health Department, Lake County Office of Education, Lakeview Health Center, North Coast Opportunities, Redwood Community Services, The Way to Wellville, County of Lake Behavioral Health, Department of Social Services, Mendocino County Health Clinic, Partnership Health Plan of California, and Woodland Community College to prepare the 2019 Lake County Community Health Needs Assessment.

Adventist Health Clearlake Hospital
"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 four health priorities: address drug abuse/substance use within the community, increase housing stability and target homelessness, community outreach and education for all high need and/or disenfranchised communities and access to health services, and increase opportunity for cancer prevention and screenings. Priority Need 1 - Address Drug Abuse/Substance Use Within the Community - the goal is to improve healthy behaviors by reducing drug dependency. Strategy 1 - Fill gaps in drug addiction recovery services continuum to improve recovery, access and outcomes.Activity 1.1 - ED Bridge and Substance Use Navigator (SUN) Program - Adventist Health Clearlake Hospital applied for and received grant funding to provide the Medically Assisted Treatment (MAT) program to help address California's opioid epidemic in 2020. Although most costs were covered by the grant, a small portion of community benefit expenses were associated with this program. During 2021 there were 778 encounters, 489 interventions, and 189 individuals who accepted treatment. Activity 1.2 - X-Wavier Training & Certification - Since starting the SUN program, lives have been impacted and 11 new providers in 2021 have received training specific for supporting patients who are ready for immediate medical assistance to begin navigating the road to recovery. Additional activities were placed on hold due to COVID-19. Priority Need 2 - Increase Housing Stability and Target Homelessness - The goal is to connect high utilizers of health care to housing. Strategy 1 - Grow capacity for existing programs and reduce time to secure supportive housing for program participants. Activity 1.1 - Restoration House - Project Restoration focuses on: high utilizer identification, readmission prevention, streamlined access to services for vulnerable populations, homelessness alternatives, intensive case management (through Live Well's Intensive Program), mental health options and substance abuse support. Due to the ongoing pandemic, many of our programs were impacted throughout 2021. Due to staffing shortages and transitions, many of our programs were unable to capture the necessary data and/or placed on hold. Activity 1.2 - Hope Center and Activity 1.3 - Elijah House Collaboration are currently placed on hold due to COVID-19. Activity 1.4 - Healthy Homes - This program is currently placed on hold due to COVID-19. It is our hope to reactivate programs in 2022. Priority Need 3 - Community outreach and engagement for all high need and/or disenfranchised communities, and access to health services - The goal is to increase healthy behaviors in the community. Strategy 1 - Providing services into the community and adding access points to health and social services. Activity 1.1 - Shower Trailer - The Shower Trailer serves the homeless, poorly shelters and others up to three days a week among different communities within Lake County. We have seen a substantial increase in the number of guests served each week. In addition, we have had two health outreach events offering COVID vaccines/testing, wound care, Narcan training and kit giveaway, dental screenings, social services, and more. Our hope is to expand services in 2022 by adding more service hours and additional locations in surrounding communities. Activity 1.2 - Safe Sleeping for Baby & New Mothers (English & Spanish) - Baby Sleep Safe is part of the Comprehensive Perinatal Services Program (CPSP) that guides a mother through pregnancy and the postpartum journey. The program follows three assessments: health education, nutrition, and psychosocial. Due to COVID-19 and staff shortages this program was reduced and there are plans to reactivate in early 2022. Priority Need 4 - Increase opportunity for cancer prevention and screenings - The goal is to reduce cancer mortality rates in Lake County. Strategy 1 - Increase screening opportunities by expanding early detection programming. Activity 1.1 - ""AHEAD"" Hereditary Cancer Screening - This program is currently on hold due to COVID-19 and staff shortages. Activity 1.2 - 3D Mammography - In 2021, a total of 1,873 screenings were provided with 50% of participants being referred to a PCP. Activity 1.3 - Colorectal Screening (Scope) - A total of 3,004 screenings were provided with 60% being referred to a PCP. Activity 1.4 - Prostate Cancer Screenings - This program is currently on hold due to COVID-19 and staff shortages. Additional activities - Although cancer screenings were reduced to clinic closures, Adventist Health Clearlake Hospital has begun ramping up services and screening protocols within rural health clinics. Although not an activity callout, an additional 3,807 cervical cancer screenings were provided with 50% of patients receiving referrals to specialty care.Priority needs not addressed:No hospital can address all the health needs identified in its community. Adventist Health Clearlake Hospital 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. Adventist Health Clearlake Hospital strives to address all significant health needs in our community. Adventist Health Clearlake Hospital is operating and expanding programs aimed at addressing community health needs in all identified four priority areas."

Adventist Health Clearlake Hospital
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 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 completed the acquisition of Blue Zones as the first step toward reaching this goal. By partnering with Blue Zones, we are 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. 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, those accounts would have been reclassified from bad debt expense to charity care.

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 Clearlake Hospital continued to offer virtual health care visits to keep community members safe and healthy, continued their online symptom tracker and was part of communitywide efforts with local health systems to vaccinate the community.

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 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 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.pdfThese 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:
Located in north central California, Lake County has a land area of 1,256.46 square miles, about 100 miles long by 50 miles wide, which encompasses two cities and 13 census-designated places. Lake County has a population of 64,562 persons. The county is predominantly rural and includes Clearlake. The county economy is based largely on tourism and recreation. Lake County is mostly agricultural, with tourist facilities and some light industry. Major crops include pears, walnuts and wine grapes. Dotted with vineyards and wineries, orchards and farm stands, and small towns, the county is also home to Mt. Konocti. Many roads are unpaved, unmarked, and unlit, even within blocks of main streets and schools in Clearlake and Lakeport. In addition, few markets and stores are available, which makes transportation a necessity for this population (California Department of Public Health, 2017-2018).In 2018, Lake County's population had a median age of 45.8 years and a median household income of $40,446 (United States Census Bureau, 2019). In Lake County, 50.2% of the population are female, 5.7% are below 5 years of age, 20.7% are below 18 years and 22.4% are 65 years and above. Among county residents, 10.7% have veteran status. About 15.3% of the people in Lake County speak a non-English language, and 8.7% are foreign born. The median value of owner-occupied houses in Lake County is $182,000 and the homeownership rate is 65.9%. The percent of households with a computer is 81.3% and with a broadband internet subscription is 70.6% (United States Census Bureau, 2019). According to data from the National Vital Statistics System (NVSS), the life expectancy in Lake County is 74.5 years on an average, 74.2 for White and 80.2 for Hispanic residents (County Health Rankings and Roadmaps, 2015-2017).Lake County has a higher rate of poverty compared to the state and national poverty rates. Lake County has a poverty rate of 22.8%, while state and national rates of poverty are 15.1% and 14.6% respectively. According to the American Community Survey, in 2013-2017, 31.6% of children below 18 years in Lake County were living below the 100% federal poverty level. This is higher than the proportion of children living below poverty level in California (20.8%) and the US (20.3%). Examining this by race, American Indian or Alaska Native children and other race/ethnicity had the highest disparity, with 63.1% of American Indian or Alaska Native children living under poverty and 45.1% of children from other race/ethnicities living below poverty.Per the 2013-2017 American Community Survey 5-Year Estimates, 11.4% or 3,007 of all households in Lake County and 53.6% or 5,529 households with children less than 18 years receive food stamps or SNAP benefits. Of the households receiving SNAP benefits, 47.9% had one worker in the 12 months; 73% of these households is White alone, 17.2% are Hispanic or Latino, 4.4% are American Indian and Alaska Native alone, and 3.4% are Black or African American alone.

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."

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.