4A (Expenses $ 40711463 including grants of $ 0) (Revenue $ 42375804)
MT SAN RAFAEL HOSPITAL PROVIDES GENERAL MEDICAL AND SURGICAL CARE FOR INPATIENT, OUTPATIENT, AND EMERGENCY ROOM PATIENTS, AND PARTICIPATES IN THE MEDICARE AND MEDICAID PROGRAMS. MT SAN RAFAEL IS A 25 BED CRITICAL ACCESS FACILITY SERVICING THE MEDICAL AND SURGICAL NEEDS OF TRINIDAD RESIDENTS AND THE SURROUNDING AREAS. DURING 2021, PATIENT DAYS TOTALED 1,894, ER VISITS 8,508, SURGERIES 1,093, OP VISITS 41,458.

PART V, LINE 5
Completion of the MSRH Community Health Needs Assessment (CHNA) followed a modified outline designed by the Center for Rural Health at the University of North Dakota for the North Dakota Critical Access Hospitals. The sections of this CHNA generally follow their suggested methodology, but were only slightly modified to meet the needs of MSRH. A first meeting was held in person during the month of June 2021. This meeting was a general review of health information on a county level. The participants were asked to review the survey that would go out to the public to make sure we were able to get information to help the hospital address the health needs of the community. The survey was further revised by Cycle of Business and Mt. San Rafael Hospital to ensure the questions asked would help the Senior Leadership Team and Board decide on the best course of action for the hospital. Before the survey was distributed to the community, special care was taken to ensure the verbiage was inclusive and members of that committee volunteered to make sure it was delivered to the Native American and Latin communities. Once the community had been given time to fill out the survey, COB collected the data and reviewed the findings with community members from various departments within the hospital. This meeting allowed the group to review the information collected in the survey and prioritize the most important health issues that could and should be addressed, given the resources of Mt. San Rafael Hospital. Key findings from the survey were reviewed to see what needed to be addressed by the hospital and what needed to be given priority. As the survey was reviewed by the staff from the hospital, areas of focus and clarification were outlined. The Senior Leadership Team wanted to ensure the CHNA was not only dealing with the opinions of the community, they wanted to make sure they had the data to make appropriate decisions. Employees from MSRH decided on the several goals to work on over the next few years that would allow them to better serve the community. These goals were then compiled into a Community Health Implementation Plan (CHIP) for them to track progress. That plan was started in Action Strategy, an online tool to track and monitor progress on the CHIP. Action Strategy also made the plan accessible in Word and Excel formats in case MSRH decided not to use the electronic format. Finally, a revised CHNA was prepared and taken to the Board of Directors for their input and approval.

PART V, LINE 6B
The CHNA was conducted with one or more organizations other than MSRH as seen in the Appendix of the CHNA: Las Animas County Health Department Las Animas County Trinidad City Council Dental Practice Trinidad School District Number 1 Trinidad State College Hospice Health Solutions Senior Advocates Salud Family Health Center Advocates Against Domestic Assault INNOVA Medical Associates Griego Insurance

PART V, LINE 11
"IMPLEMENTATION PLAN Currently, hospitals are being asked to have a Community Health Implementation Plan to outline what they are doing to address the needs of the community. Through these implementation plans, the IRS is able to see hospitals are doing their best to address the needs of the community. It also helps hospitals justify why they should be given 501(c)(3) status. While evaluating the results of the survey, MSRH leadership began to see how addressing certain issues could help improve the overall access to local healthcare. By increasing public access to mental health services, improving transportation to health services expanding general surgery, and educating the community on better health, Mt. San Rafael Hospital hopes to encourage residents in the area to take advantage of local quality healthcare rather than traveling outside the area for treatment. Mt. San Rafael Hospital's CHIP reflects the decisions of the staff, with input from the community, on what needs to happen at the hospital to help MSRH meet the needs of the community. The five following areas will assist MSRH in better meeting the community's healthcare needs. 1. IMPROVE CAPACITY IN GENERAL SURGERY Prior to the Community Health Needs process, Mt. San Rafael Hospital saw a need to increase the number of surgeons to better care for the community. At the time of the survey, MSRH had already hired two new surgeons. Once the survey results were in, MSRH could see their decision was supported by the responses in the survey. Now that the surgeons have been hired, MSRH will need to make sure they maximize these surgeons and the services they offer. First, MSRH has decided to implement an awareness campaign and begin to market the surgeons to the community. By creating awareness around their existence MSRH hopes to reduce the number of surgeries that could have been done locally, but were actually performed at a hospital outside the community. Second, MSRH hopes to create a referral system from Primary Care Providers in the clinic as well as other providers in the area. This referral system will be designed to inform prospective surgical patients of the increased local capabilities and capacities. MSRH hopes to ensure patients are receiving surgeries locally whenever possible. Finally, MSRH feels they could help support these two surgeons by partnering with Spanish Peaks Regional Health System and Miner's Colfax Medical Center to provide surgical coverage when these facilities do not have the coverage they need in-house. This would give the surgeons more hours and reduce the financial burden on MSRH. 2. NAVIGATE TO OUTSIDE SPECIALISTS Ensuring patients are getting the proper care for their individual circumstances can be one of the most challenging things a rural hospital can do. Resources and personnel can be limited. However, when a hospital is able to help the patient get the best care, locally or outside of the area, the patient will be better served and will be happier with the hospital. Knowing the hospital is caring for you throughout your health challenges goes a long way toward patient satisfaction and local support of the hospital. In order to better serve patients MSRH felt they should hire and train staff to provide care coordination for patients. This Care Coordinator, would help the patient connect with the appropriate specialist for services the patient needs. They would assist the patient with obtaining pre-authorizations and would also ensure the patient was going to the correct specialist whether they worked at the hospital or were outside of MSRH. In addition, similar to what MSRH is doing to help other hospitals by sharing their surgeons, this Care Coordinator would work with other hospitals to see if MSRH could bring specialists to offer services at Mt. San Rafael Hospital. This sharing of specialists would help other hospitals cover the costs of the specialist and to ensure patients can get needed specialties close to home. 3. MENTAL HEALTH/SUBSTANCE ABUSE Throughout the survey the topic of Mental Health and Substance Abuse showed up as a concern for the community. MSRH saw this in the answers to the survey questions as well as in the comments. MSRH realized mental health is something that effects all generations. Whether it takes the form of counselors for youth facing bullying in school or social media, the elderly dealing with the challenges of aging, or adults working through relationships, there is a need for mental health and a lack of awareness of available resources in the community. There are many aspects of mental health that are currently covered by organizations in the community. While working with the focus group who helped analyze the survey, MSRH realized the mental health resources in the community were being underutilized. It was decided that rather than bring on resources to address the differing aspects of mental health, it might be wiser to help assist people in need through existing local resources. MSRH decided to expand the role of their Discharge Planner to help facilitate getting the people needing Mental Health and Substance Abuse treatments to the organizations that already exist in the community. This role would have two focus areas. One, to help facilitate the transition of patients that need Mental Health or Substance Abuse treatment to the appropriate resources. Two, this position would help communicate to the community how they can access these resources for themselves or a loved one. 4. HEALTH EDUCATION As part of the Affordable Care Act, hospitals were encouraged to move to a wellness model. Rather than treating the illness once it was discovered, hospitals were asked to help patients proactively work on their health so they would not become sick in the future. As a result many hospitals are now looking at ways they can help their communities realize the importance of diet and exercise in staying healthy and preventing illness. MSRH would like to hire a Registered Dietitian to provide one-on-one nutrition counseling to patients and help them reduce the risk of developing serious illness in the future. In addition, they would like to conduct annual Health Fairs to give community members resources for preventing illnesses and dealing with current illnesses they may have. The hospital also is looking to host ""Lunch and Learn"" health education sessions that will be hosted monthly on various health topics. This will allow people who are dealing with certain illnesses to get familiar with providers and resources available at the hospital. Information about national resources and or support groups will be given to families struggling with uncommon health issues to help them deal with the illness now and in the future. 5. TRANSPORTATION Transportation has become a challenge within the community particularly with the elderly. Finding safe and inexpensive ways to get them from their homes to their appointments can be challenging. There are transportation companies that may be able to assist with this challenge; however, Mt. San Rafael Hospital does not have a current arrangement with any company. MSRH will reach out to the companies in the area to see if there is a way to better address these transportation needs. The goal would be to find a safe and effective way to help patients get from home to the hospital or to a specialist in a neighboring community. These five areas of focus will be addressed over the next three years. In doing so, MSRH expects the community will see improved health and community support for the hospital and other healthcare organizations in the area."

PART V LINE 22D and 24
ALL PATIENTS ARE CHARGED THE SAME REGARDLESS OF FINANCIAL CLASS.

PART I, LINE 7
The Hospital uses the cost to charge ratio as computed in the Medicare cost report. Bad debts excluded from column f calculations equal $2,935,649 PART III, LINE 4 The Hospital provides an allowance for doubtful accounts based upon a review of outstanding receivables, historical collection information and existing economic conditions for its major payor groups. Accounts are considered delinquent and subsequently written off based on individual credit evaluation and specific circumstances of the patient or third-party payer. For receivables associated with services provided to patients who have third-party coverage, the Hospital analyzes contractually due amounts and provides an allowance for doubtful accounts and a provision for bad debts, if necessary (for example, for expected uncollectible deductibles and copayments on accounts for which the third-party payer has not yet paid, or for payers who are known to be having financial difficulties that make the realization of amounts due unlikely). For receivables associated with self-pay patients (which includes both patients without insurance and patients with deductible and copayment balances due for which third-party coverage exists for part of the bill), the Hospital records a significant provision for bad debts in the period of service on the basis of its past experience, which indicates that many patients are unable or unwilling to pay the portion of their bill for which they are financially responsible. The difference between the standard rates (or the discounted rates if negotiated) and the amounts actually collected after all reasonable collection efforts have been exhausted is charged off against the allowance for doubtful accounts. Rationale for including bad debt as community benefit: A number of patients are truly unable to pay their out-of-pocket liability, but do not complete the process required to apply for financial assistance under the hospital's charity care policy. These patients would qualify for charity care if they completed the paperwork, so the bad debt expense associated with treating them should be treated as community benefit. Part III, line 8 The Medicare allowable costs of care a pulled from the Medicare cost and reimbursement summary of the medicare cost report. IRS revenue ruling 69 545, which established the community benefit standard for nonprofit hospitals, states that if a hospital serves patients with government health benefits, including medicare, then this is an indication that the hospital operates to promote the health of the community. This implies that treating medicare patients is a community benefit.

Part III, Line 9B
THE HOSPITAL HAS A SLIDING SCALE CHARITY CARE POLICY.

Part VI line 2.
The Hospital utilitizes the survey and data from the Community Health Needs assessment to assess the health needs of the community.

Part VI line 3.
The organization informs and educates patients and persons regarding their eligibility for assistance through printed material, financial counselors and via the website. When an un-insured patient presents themselves for an appointment at the hospital, RHC or Emergency Room visit, the Patient Access Representative will register the patient and present them with a business card that has the hospitals financial counselors name and phone number and request that they get an appointment to apply for aid. The hospital financial counselor will review their case and will offer a plan that qualifies for financial assistance. If patient does not qualify for Medicaid or CICP they will be screened to see if they qualify for the hospitals sliding fee schedule, Charity Care. The patient will be required to pay any co-pay due for the qualifying plan.

Part VI line 4.
Community Information: Mount San Rafael Hospital is located in Trinidad, Colorado. Trinidad is approximately 200 miles south of Denver, Colorado. MSRH principally serves the residents of Las Animas County with a population of approximately 14,500 persons. MSRH is the only hospital in the County. See the Community Health Needs assessment page 2 for detailed description of the residents and demographics.

Part VI line 5
The Hospital's Board of Directors is comprised of persons inside the primary service area and are concerned with the health of the community as a whole.

Part VI line 6
Trinidad Area Health Association, DBA Mt San Rafael Hospital is not part of an affiliated health care system.

Part VI line 7
Community Benefit report is filed with Colorado.