2022-05-13T14:04:45-05:00 2021-06-30 350921680 CROWE LLP 9600 Brownsboro Road Suite 400 Louisville KY 402413902 990 2020-07-01 020354549 Cheshire Medical Center CHES 6033545400 580 - 590 Court Street Keene NH 034315400 Daniel J Gross CFO 2022-05-13 true Daniel J Gross 999009999 Kim Scifres P01316095 5023263996 2020 2022-09-23 18:48:47Z DON CARUSO 580 - 590 Court Street Keene NH 034315400 247401480 false X https://www.cheshiremed.org X 1980 NH TO LEAD OUR COMMUNITY TO OPTIMAL HEALTH AND WELLNESS THROUGH OUR CLINICAL AND SERVICE EXCELLENCE, COLLABORATION, AND COMPASSION FOR EVERY PATIENT, EVERY TIME. 18 10 1252 119 294820 0 2188452 12479448 206527892 232080526 1397005 264042 15546202 2574788 225659551 247398804 929014 389532 0 0 106856163 98907039 0 0 586999 131943559 141498493 239728736 240795064 -14069185 6603740 185465067 168346405 126986570 87920426 58478497 80425979 THE MISSION OF CHESHIRE MEDICAL CENTER IS TO LEAD OUR COMMUNITY TO OPTIMAL HEALTH AND WELLNESS THROUGH OUR CLINICAL AND SERVICE EXCELLENCE, COLLABORATION, AND COMPASSION FOR EVERY PATIENT, EVERY TIME. false false 223307898 389532 232898552 THE CHESHIRE MEDICAL CENTER (CMC) IS A COMMUNITY HOSPITAL LOCATED IN KEENE, NEW HAMPSHIRE. CMC IS A NOT-FOR-PROFIT ORGANIZATION, AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE (THE CODE) AND IS EXEMPT FROM FEDERAL INCOME TAXES ON RELATED INCOME PURSUANT TO SECTION 501(A) OF THE CODE. THE HOSPITAL IS AFFILIATED WITH DARTMOUTH-HITCHCOCK HEALTH ("D-HH"), A NOT-FOR-PROFIT TAX-EXEMPT CORPORATION WITH A PRINCIPAL PLACE OF BUSINESS AT ONE MEDICAL CENTER DRIVE, LEBANON, NEW HAMPSHIRE. CONSISTENT WITH THE D-HH VISION AND STRATEGY TO CREATE A SUSTAINABLE HEALTH SYSTEM, CMC AND D-HH SHARE A COMMON COMMITMENT TO IMPROVING POPULATION HEALTH, VALUE-BASED CARE, AND CREATING NEW PAYMENT MODELS FOR THE BENEFIT OF THE CITIZENS OF NEW HAMPSHIRE AND VERMONT. CMC PROVIDES A BROAD RANGE OF PATIENT SERVICES AND HEALTH-RELATED COMMUNITY SERVICES, CONSISTENT WITH ITS ROLE AS A COMMUNITY HOSPITAL. THESE INCLUDE A FULL RANGE OF SERVICES IN BOTH ACUTE AND CRITICAL MEDICINE, SURGERY, AND REHABILITATION. DURING FY21, CMC PROVIDED 227,803 PROVIDER VISITS AND HAD 4,115 HOSPITAL ADMISSIONS AND DISCHARGES, WHILE THE EMERGENCY DEPARTMENT WAS OPEN TO THE PUBLIC 24 HOURS PER DAY, 7 DAYS PER WEEK AND HAD 19,869 ER PATIENT VISITS. THERE ARE A TOTAL OF 207 PROVIDERS CONSISTING OF 130 PHYSICIANS AND 77 ASSOCIATE PROVIDERS. EACH YEAR CHESHIRE MEDICAL CENTER FILES AN ANNUAL COMMUNITY BENEFIT REPORT WITH THE STATE OF NEW HAMPSHIRE WHICH OUTLINES THE COMMUNITY AND CHARITABLE BENEFITS CMC PROVIDES. THE MOST RECENT COMMUNITY BENEFIT REPORTS ARE AVAILABLE UPON REQUEST OR CAN BE FOUND ON CMC'S WEBSITE (https://www.cheshiremed.org/about/reports-community). THE COMMUNITY HEALTH ACTIVITIES INCLUDE THE COST OR VALUE OF SEVERAL DIFFERENT TYPES OF PROGRAMS INCLUDING THE COST OF COMMUNITY-BASED EDUCATION PROGRAMS INVOLVING A VARIETY OF CHRONIC DISEASE AND WELLNESS TOPICS SUCH AS STRESS MANAGEMENT AND RESILIENCY, NUTRITION, PHYSICAL EDUCATION AND EXERCISE, HIGH BLOOD PRESSURE PREVENTION AND MONITORING, DIABETES PREVENTION AND MONITORING, ADVANCED DIRECTIVE PLANNING, AND OTHERS. IN TOTAL, CMC PROVIDED ALMOST $18 MILLION IN COMMUNITY BENEFITS INCLUDING UNREIMBURSED CHARITY CARE, HEALTH SERVICES, HEALTH PROFESSION EDUCATION, SUBSIDIZED HEALTH SERVICES, AND COMMUNITY-BUILDING ACTIVITIES. THESE CONTRIBUTIONS ARE IN ADDITION TO THE OVER $16.6 MILLION DOLLARS IN UNREIMBURSED MEDICARE COSTS ABSORBED BY CMC. 223307898 true true false true false false false false false true false false true true false false true false false false false false false false false true true true true true true false false false false false false false false true false false false false false false true true true false false true 230 0 true 1252 true true true false false false false true true false false false false false false X 18 10 false false false false true true true true true false false true true true true true true false true false NH X Daniel J Gross 6033545400 580-590 COURT STREET KEENE NH 034315400 CLAIRE FABIAN MD Trustee/ Medical Staff President (eff. 11/1/20) 0.5 41.0 X X 0 335077 53467 DON CARUSO MD TRUSTEE/CEO/PRESIDENT - CMC 1.0 41.0 X X 0 529046 59431 KATHERINE SNOW TRUSTEE/SECRETARY (thru 12/31/20) 1.0 1.0 X X 0 0 0 MARK GAVIN TRUSTEE/TREASURER 1.0 1.0 X X 0 0 0 Michael Ormont MD TRUSTEE/EX-OFFICIO/Medical Staff Pres-CMC(thru 10/31/20) 0.5 40.5 X X 0 416175 55889 NATHALIE HOUDER TRUSTEE/CHAIR 1.0 0.5 X X 0 0 0 ROBERT MITCHELL TRUSTEE / Secretary (eff. 1/1/21) 0.5 0.5 X X 0 0 0 SUSAN ABERT TRUSTEE/VICE CHAIR 1.0 0.5 X X 0 0 0 ANDREW TREMBLAY MD TRUSTEE 1.0 40.0 X 0 324797 56841 ASHOK BAHL TRUSTEE 0.5 0 X 0 0 0 Barbara Duckett Trustee (Eff. 1/1/21) 0.5 0 X 0 0 0 BETSY COTTER Trustee (Eff. 1/1/21) 0.5 0.5 X 0 0 0 Cherie Holmes MD Trustee / Physician 1.0 40.0 X 0 526558 45791 GEOF MOLINA TRUSTEE (thru 12/31/20) 1.0 0 X 0 0 0 GREGG TEWKSBURY CPA TRUSTEE (thru 12/31/20) 1.0 0 X 0 0 0 H ROGER HANSEN TRUSTEE 1.0 0.5 X 0 0 0 Maria Padin MD TRUSTEE 1.0 41.0 X 0 552590 70033 Mark Bodin Trustee (Eff. 1/1/21) 0.5 0 X 0 0 0 MICHAEL KAPILOFF TRUSTEE 1.0 0 X 0 0 0 Michael Waters Trustee (Eff. 7/1/20) / Treasurer 0.5 40.0 X 0 258147 20319 RACHEL LOVINS MD TRUSTEE 0.5 40.0 X 0 405279 47003 Stephen Leblanc Trustee (eff. 7/1/20) 0.5 42.5 X 0 786125 60997 AMY MATTHEWS CHIEF NURSING OFFICER 40.0 0 X 222665 0 21034 Christine Schon MPA COO (thru 12/31/20) 20.0 20.5 X 0 373374 53981 Daniel Gross CFO (Hired 5/2021) 40.0 1.0 X 0 0 0 KATHRYN WILLBARGER COO (Eff. 1/2021) / Sr. VP-Finance (thru 12/2020) 40.0 1.0 X 410411 0 24259 David Quigley VP Clinical Operations - CMC 20.0 20.0 X 0 255901 27975 ERLI CHEN PHYSICiST 40.0 0 X 258799 0 33217 LATASHA HEAPE CHIEF CRNA 40.0 0 X 215867 0 24219 MICHAEL W FRANK NURSE ANESTHETIST CRNA 40.0 0 X 277127 0 27355 Richard Crowe Jr Pharmacy Manager 40.0 0 X 172187 0 28747 Shawn V Lafrance VP Population Health 40.0 0 X 200266 0 33799 JENNIFER DINUBILA DO Former President of Medical Staff 0.0 40.5 X 0 408835 58316 1757322 5171904 802673 73 true true false CONIFER REVENUE CYCLE SOLUTIONS PO BOX 655025 DALLAS TX 752655025 Revenue Management 6630451 Mary Hitchcock Memorial Hospital ONE MEDICAL CENTER DRIVE LEBANON NH 03756 Healthcare Services 5889478 Dartmouth-Hitchcock Clinic ONE MEDICAL CENTER DRIVE Lebanon NH 03756 Healthcare Services 2405561 Cerner Health Services Inc 51 Valley Stream Parkway Malvern PA 19355 Healthcare Services 1005346 Comprehensive Pharmacy Services 6409 No Quail Hollow Road Memphis TN 38120 Pharmacy Management 989723 22 9337428 2549883 592137 12479448 NET PATIENT SERVICE REVENUE 622110 230273436 230273436 PHARMACY REVENUE 446110 1619770 1512270 107500 Laboratory Services 621500 187320 187320 0 0 0 0 232080526 259869 259869 19161 19161 0 19161 19161 2691 4158 2676 0 15 4158 4173 4173 FOOD SERVICES 722514 863240 863240 Childcare Income 624410 579541 579541 REBATES AND DISCOUNTS 622110 707401 707401 405445 405445 0 0 2555627 247398804 232898552 294820 1725984 X 334531 334531 55001 55001 0 0 0 0 709742 10095 699647 0 137183 137183 0 0 68919871 62158210 6383141 378520 3252568 2936653 298230 17685 21805312 19672777 2013155 119380 4082363 3685852 374314 22197 0 0 0 0 35888 8874 27014 0 0 0 0 0 8250 8250 0 0 0 0 0 0 0 0 63615410 62942896 665950 6564 212032 175960 35245 827 1213732 928562 282783 2387 1752607 1751947 0 660 0 0 0 0 5565956 4250164 1315792 0 58137 46919 10578 640 0 0 0 0 0 0 0 0 935882 935882 0 0 0 0 0 0 8498730 6489909 2008821 0 1621076 1381301 239775 0 MEDICAL SUPPLIES 42129005 42129005 0 0 MEDICAID ENHANCEMENT & PILOT TAXES 8315940 8315940 0 0 FOOD AND CAFETERIA EXPENSES 831177 831177 0 0 EQUIPMENT RENTAL AND MAINTENANCE 5047657 3098830 1942216 6611 1657014 1021980 603506 31528 240795064 223307898 16900167 586999 43939812 35146503 11329829 13325989 0 0 0 0 3557684 3330484 1155183 961554 244057405 179955681 64803490 64101724 0 4296339 1774315 56382730 49705836 185465067 168346405 16784196 22589586 31846840 412505 24483074 23617565 0 0 53872460 41300770 126986570 87920426 X 52234015 65213770 6244482 15212209 58478497 80425979 185465067 168346405 X 6603740 19514123 -4170381 X X false true X true true true X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED false false false false false false false false true 32586 32586 false Schedule C, Part II-B, Line 1 DETAILED DESCRIPTION OF THE LOBBYING ACTIVITY CHESHIRE MEDICAL CENTER PAYS DUES TO VARIOUS ORGANIZATIONS RELATED TO ITS EXEMPT MISSION AND A THIRD PARTY REPRESENTING THE RURAL HOSPITAL COALITION. THE AMOUNT REPORTED UNDER OTHER ACTIVITIES ON LINE 1i REFERS TO THE AMOUNT OF LOBBYING ACTIVITIES IDENTIFIED IN DUES TO OUTSIDE ORGANIZATIONS ALONG WITH THE THIRD PARTY REPRESENTATIVE. 231151 231151 77828930 55609284 22219646 27429792 10177107 17252685 138567532 114169290 24398242 64101724 Due from Affiliate 46043401 Deferred 457(b) Plan Assets 1060582 Other Assets 2601853 49705836 PENSION LIABILITY 5285868 DUE TO RELATED PARTY 4788537 RESERVES FOR ESTIMATED 3RD PARTY SETTLEMENTS 31226365 41300770 true true X true X 225 true X true true false true true 1796260 0 1796260 0.0075 29264737 17679140 11585597 0.0481 0 0.0 0 0 31060997 17679140 13381857 0.0556 2025859 0 2025859 0.0084 1489725 0 1489725 0.0062 1427627 811960 615667 0.0026 15963 0 15963 0.0001 512323 73300 439023 0.0018 0 0 5471497 885260 4586237 0.0190 0 0 36532494 18564400 17968094 0.0746 0 0.0 0 0.0 327501 255063 72438 0.0003 0 0.0 0 0.0 1528924 0 1528924 0.0063 0 0.0 0 0.0 0 0.0 0 0 1856425 255063 1601362 0.0067 true 0 0 98506247 115083259 -16577012 X true true 1 1 CHESHIRE MEDICAL CENTER 580 COURT STREET KEENE NH 03431 https://www.cheshiremed.org 00014 X X X IN-PATIENT REHAB CHESHIRE MEDICAL CENTER 1 false false true X X X X X X X X X 18 true true true true X https://www.cheshiremed.org/about/reports-community X X true 19 true https://www.cheshiremed.org/about/reports-community false true X 225.0 300.0 X X X X X X X true true X X X true X https://www.cheshiremed.org/patients-visitors/billing-charges X https://www.cheshiremed.org/patients-visitors/billing-charges X https://www.cheshiremed.org/patients-visitors/billing-charges X X X X X X X true X false X X X X true X false false Schedule H, Part V, Section B, Line 3E THE SIGNIFICANT HEALTH NEEDS ARE A PRIORITIZED DESCRIPTION OF THE SIGNIFICANT HEALTH NEEDS OF THE COMMUNITY WHICH ARE IDENTIFIED THROUGH CHNA. Schedule H, Part V, Section B, Line 5 Facility , 1 Facility , 1 - CHESHIRE MEDICAL CENTER. The hospital took into account a cross-section of community members through an RDD telephone survey conducted by the UNH Survey Center that was analyzed by age, education, income, etc. The Council for a Healthier Community is a group, established in 1995, that includes community leaders representing local and county government, business, education sector, social service agencies, health care and public health organizations, faith-based groups and non-profit organizations providing childcare, mental health and substance abuse prevention. The hospital worked with the Council for a Healthier Community to determine the priorities from our community health needs assessment. Key people involved include: Tim Murphy (Southwest Regional Planning Commission); Ellen Avery (Community Volunteer Transportation Co.); Chris Coates (Greater Monadnock Public Health Advisory Council); Phil Wyzik (Monadnock Family Services); Phil Suter (Greater Keene Chamber of Commerce); NH State Senator Jay Kahn; George Tremblay (Antioch University); Liz LaRose (Monadnock United Way); and others. Schedule H, Part V, Section B, Line 6a Facility , 1 Facility , 1 - CHESHIRE MEDICAL CENTER. THE CHESHIRE MEDICAL CENTER COLLABORATED WITH MONADNOCK COMMUNITY HOSPITAL ALLOWING US TO COMPARE COMMUNITY NEEDS AGAINST A MULTI-HOSPITAL REGION. Schedule H, Part V, Section B, Line 6b Facility , 1 Facility , 1 - CHESHIRE MEDICAL CENTER. THE CHESHIRE MEDICAL CENTER COLLABORATED WITH THE NEW HAMPSHIRE DEPARTMENT OF HEALTH AND HUMAN SERVICES; GREATER MONADNOCK PUBLIC HEALTH NETWORK; THE NEW HAMPSHIRE HOSPITAL ASSOCIATION; FOUNDATION FOR HEALTHY COMMUNITIES; ANTIOCH UNIVERSITY NEW ENGLAND; AND SOUTHWESTERN REGIONAL PLANNING COMMISSION. THESE ORGANIZATIONS HELPED TO DISSEMINATE SURVEYS, SERVE AS KEY INFORMANTS, AND TO PROVIDE OVERALL ANALYSIS, REVIEW, AND FEEDBACK. Schedule H, Part V, Section B, Line 7 Facility , 1 Facility , 1 - CHESHIRE MEDICAL CENTER. THE NEEDS ASSESSMENT WAS DISTRIBUTED TO NON-PROFIT ORGANIZATIONS THROUGHOUT THE REGION. IT IS ALSO AVAILABLE FROM THE ORGANIZATION UPON REQUEST AND IS POSTED ON THE CMC WEBSITE. Schedule H, Part V, Section B, Line 11 Facility , 1 Facility , 1 - CHESHIRE MEDICAL CENTER. THE CHESHIRE MEDICAL CENTER IS INCREASING BOTH COMMUNITY BENEFITS SPENDING AND PARTNERSHIPS TO ADDRESS IDENTIFIED COMMUNITY NEEDS BASED ON THE MOST RECENT CHNA. THESE NEEDS ARE IN THE AREAS OF BEHAVIORAL HEALTH, SUBSTANCE AND ALCOHOL MISUSE, TOBACCO USE, OBESITY, AND EMERGENCY PREPAREDNESS. WITH THE ONSET OF COVID-19 IN FEBRUARY-MARCH 2020, MHMH HAS ADDED AND PRIORITIZED COVID-19 DRIVEN COMMUNITY NEEDS TO OUR OTHER CHNA PRIORITIES. THIS HAS INCLUDED PROVIDING SIGNIFICANT FUNDING AND STAFF SUPPORT TO HELP COMMUNITY FOOD SUPPORT PROGRAMS, BEHAVIORAL HEALTH PROVIDERS, NURSING HOMES, AND OTHER COMMUNITY ORGANIZATIONS ADAPT TO AND MAINTAIN BASIC SOCIAL SERVICES SAFELY DURING THE PANDEMIC. IN FY 2019, THE HOSPITAL'S COMMUNITY HEALTH IMPROVEMENT STRATEGIES WERE CONSISTENT WITH THE INTENTIONS IDENTIFIED IN THE FY2019 COMMUNITY HEALTH IMPROVEMENT PLANS. AREAS WERE ANALYZED AND THE HOSPITAL RESPONDED BY INCREASING INVESTMENTS, MAINTAINING SIMILAR LEVELS OF INVESTMENTS FOR SERVICES AND INITIATIVES, OR LIMITING INVESTMENT IN AREAS WHERE OTHER COMMUNITY ORGANIZATIONS ALREADY PROVIDE LEADERSHIP AND SERVICES TO ADDRESS THE NEED, AND/OR WHERE THE IDENTIFIED NEED IS SIGNIFICANTLY OUTSIDE THE HOSPITAL'S MISSION/SERVICES/SCOPE. COLLABORATION WITH COMMUNITY GROUPS HAS ALLOWED SERVICES TO EXPAND INTO NEW AREAS AND BRING FORTH ADDITIONAL RESOURCES TO THE COMMUNITY AND REMOVE BARRIERS TO HEALTHCARE. IN ADDITION, THE HOSPITAL'S AFFILIATION WITH DARTHMOUTH-HITCHCOCK HEALTH HAS ALSO PROVIDED SUPPORT FOR THE IDENTIFIED COMMUNITY-BASED NEEDS. THE CHESHIRE MEDICAL CENTER'S COMMUNITY HEALTH IMPROVEMENT PLAN IS A 3-YEAR DOCUMENT IDENTIFYING ANTICIPATED INVESTMENTS AND ACTIVITIES THAT IT WILL TAKE TO ADDRESS NEEDS IDENTIFIED IN THE MOST RECENT CENTRAL NEW HAMPSHIRE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA). Schedule H, Part V, Section B, Line 13 Facility , 1 Facility , 1 - Cheshire Medical Center. PATIENTS WHOSE FAMILY INCOME EXCEEDS 300% OF THE FPL MAY BE ELIGIBLE TO RECEIVE DISCOUNTED RATES ON A CASE-BY-CASE BASIS BASED ON THEIR SPECIFIC CIRCUMSTANCES, SUCH AS CATASTROPHIC ILLNESS OR MEDICAL INDIGENCE, AT THE DISCRETION OF CMC. Schedule H, Part V, Section B, Line 13 Facility , 1 Facility , 1 - Cheshire Medical Center. CMC HAS A SEPARATE UNINSURED DISCOUNT POLICY THAT OUTLINES HOW THE DISCOUNT IS CALCULATED ANNUALLY AND IS APPLIED PRIOR TO BILLING ANY UNINSURED PATIENT. THIS ASSURES A PATIENT IS NOT BILLED AT AN AMOUNT GREATER THAN THE AMOUNT GENERALLY BILLED TO PATIENTS WITH INSURANCE. THIS POLICY IS REFERENCED IN THE FINANCIAL ASSISTANCE POLICY. Schedule H, Part V, Section B, Line 16 Facility , 1 Facility , 1 - Cheshire Medical Center. THE FINANCIAL ASSISTANCE POLICY IS POSTED ON CMC'S WEBSITE, INCLUDING THE VERBATIM POLICY AND A SHORTER, MORE PATIENT-FRIENDLY PLAIN-LANGUAGE SUMMARY. CMC PROVIDES THE PLAIN-LANGUAGE SUMMARY BROCHURE TO ALL INPATIENTS, EMERGENCY DEPARTMENT INTAKES, UNINSURED, AND SELF-PAY INDIVIDUALS. CMC CONTINUES TO NOTIFY PATIENTS ON THE BACK OF THE BILLING STATEMENT ABOUT FINANCIAL ASSISTANCE AVAILABLE TO THEM. ADDITIONALLY, CMC POSTS INFORMATION ABOUT THE POLICY IN PUBLIC AREAS THROUGHOUT THE FACILITIES INCLUDING ADMISSION OFFICES, PUBLIC AREA BOARDS THROUGHOUT THE FACILITIES, THE EMERGENCY ROOMS, AND FINANCIAL ASSISTANCE POLICY BROCHURES IN PATIENT AREAS. CMC SCREENS 100% OF UNINSURED INPATIENT AND SAME-DAY PATIENTS PRIOR TO ADMISSION. AS PART OF THIS PROCESS, CMC CHECKS ALL STATE AND FEDERAL PROGRAMS TO SEE IF INDIVIDUALS ARE ELIGIBLE FOR ASSISTANCE. PATIENTS ARE ALSO SCREENED TO DETERMINE QUALIFICATION FOR FINANCIAL ASSISTANCE AND THE APPLICATION IS PROVIDED AND/OR COMPLETED AT THIS TIME. 1 CHESHIRE MEDICAL CENTER COLLECTING STATION 580-590 COURT STREET KEENE NH 03431 COLLECTING STATION Schedule H, Part V, Section B, Line 22 MAX CHARGES TO FAP ELIGIBLE INDIVIDUALS THE STATE OF NEW HAMPSHIRE MANDATES A DISCOUNT FOR ALL UNINSURED PATIENTS. THIS DISCOUNT IS EQUAL TO THE AVERAGE DISCOUNT NEGOTIATED BY THE LARGEST (BY DOLLAR) THREE COMMERCIAL INSURERS. THE CHESHIRE MEDICAL CENTER HAS ALWAYS BEEN IN FULL COMPLIANCE WITH THE LAWS OF THE STATE NEW HAMPSHIRE, AND A COMMITTEE IS IN PLACE TO ENSURE THE HOSPITAL IS IN FULL COMPLIANCE WITH FINAL 501(R) REGULATIONS IN AREAS WHERE FEDERAL REGULATIONS DIFFER FROM OR ARE MORE STRINGENT THAN THOSE ISSUED BY THE STATE. Schedule H, Part V, Section C MEASURES TO PUBLICIZE FINANCIAL ASSISTANCE POLICY THE FINANCIAL ASSISTANCE POLICY, APPLICATION, AND PLAIN LANGUAGE SUMMARY CAN BE FOUND AT: https://www.cheshiremed.org/patients-visitors/billing-charges. CMC HAS PLAIN LANGUAGE SUMMARY BROCHURES AVAILABLE AT ALL ADMISSION SITES AS WELL AS PLAIN LANGUAGE SUMMARY POSTERS AT ALL PHYSICAL LOCATIONS. Schedule H, Part I, Line 7g Subsidized Health Services The organization did not include as subsidize health services any costs attributable to a physician clinic on line 7g. Schedule H, Part I, Line 7 Bad Debt Expense excluded from financial assistance calculation 0 Schedule H, Part I, Line 7 Costing Methodology used to calculate financial assistance The costing methodology used to calculate the amounts reported was a cost-to-charge ratio derived from worksheet 2, ratio of patient care to cost-to-charges. Schedule H, Part II Community Building Activities CHESHIRE MEDICAL CENTER IS PARTNERING WITH THE GREATER MONADNOCK PUBLIC HEALTH NETWORK (GMPHN), A COMMUNITY HEALTH AND SAFETY COLLABORATIVE, WHICH WORKS TO ENHANCE AND IMPROVE PUBLIC HEALTH-RELATED SERVICES. THE GMPHN IS ONE OF 13 PUBLIC HEALTH NETWORKS IN THE STATE OF NEW HAMPSHIRE. THE GMPHN IS HOUSED BY CMC AND, IN COLLABORATION WITH CHESHIRE COUNTY, IS FINANCED WITH FUNDS PROVIDED BY THE US CENTERS FOR DISEASE CONTROL AND PREVENTION, UNDER AN AGREEMENT WITH THE STATE OF NH DEPARTMENT OF HEALTH AND HUMAN SERVICES/DIVISION OF PUBLIC HEALTH SERVICES AND A MIX OF STATE FUNDING VIA THE GENERAL FUNDS. THE GMPHN SERVES ALL OF CHESHIRE COUNTY AND THE 10 WESTERN-MOST TOWNS IN HILLSBOROUGH COUNTY. THE GMPHN STRIVES TO INCREASE COLLABORATION AND PLANNING ACROSS MUNICIPAL BOUNDARIES AND THE HEALTH AND SAFETY SECTORS BY THE DEVELOPMENT OF A PUBLIC HEALTH ADVISORY COUNCIL, ADDRESSING EMERGENCY PREPAREDNESS, AND THROUGH A REGIONAL NETWORK, SUBSTANCE MISUSE PREVENTION, REDUCING SUBSTANCE ABUSE IN THE REGION. AS OF JUNE 2020 THERE ARE 80 INDIVIDUALS AND/OR ORGANIZATIONS ENGAGED IN ACTIVITIES RELATED TO THE PUBLIC HEALTH ADVISORY COUNCIL, 122 MEMBER INDIVIDUALS/ORGANIZATIONS ADDRESSING EMERGENCY PREPAREDNESS AND OVER 300 INDIVIDUALS SUPPORTING REGIONAL SUBSTANCE MISUSE PREVENTION AND RECOVERY EFFORTS. INCLUDED WITHIN THE GMPHN IS THE GREATER MONADNOCK MEDICAL RESERVE CORPS. DEVELOPED INITIALLY TO BUILD LOCAL CAPACITY TO ADDRESS PUBLIC HEALTH EMERGENCY RESPONSE NEEDS, THE GMMRC ALSO SUPPORTS LOCAL INITIATIVES TO ADDRESS PRESSING PUBLIC HEALTH ACTIVITIES. THESE ACTIVITIES INCLUDE ANYTIME CPR CLINICS, RECRUITING AND PLANNING HEPATITIS A CLINICS, AND EDUCATING THE PUBLIC ON PREPAREDNESS RESOURCES. MEMBERSHIP INCLUDES DOCTORS, NURSES, EMT/PARAMEDICS, PHARMACISTS, VETERINARIANS, OTHER PUBLIC HEALTH PROFESSIONALS, AND NONMEDICAL/PUBLIC HEALTH MEMBERS. The GMPHN has been pivotal to the COVID-19 response efforts in the region, working in concert with Cheshire Medical Center and other agencies to disseminate information and supplies. Further, the GMPHN stood up an Alternate Care Site at Keene State College, as well as secured a fixed COVID-19 community testing location. Schedule H, Part III, Line 2 Bad debt expense - methodology used to estimate amount AS A RESULT OF NEW ACCOUNTING GUIDANCE (STATEMENT 15 AND ASC 606), BAD DEBT IS NO LONGER AN EXPENSE, BUT IS INCLUDED AS A REDUCTION IN NET PATIENT REVENUE. Schedule H, Part III, Line 3 Bad Debt Expense Methodology Bad Debt is no longer treated as an expense due to accounting guidance (Statement 15 and ASC 606). As a result, an amount attributable to patients eligible under the organization's financial assistance policy is unable to be reasonably estimated. Schedule H, Part III, Line 4 Bad debt expense - financial statement footnote THE CHESHIRE MEDICAL CENTER IS INCLUDED IN THE DARTMOUTH-HITCHCOCK HEALTH AND SUBSIDIARIES CONSOLIDATED FINANCIAL STATEMENTS. AS A RESULT OF ACCOUNTING CHANGES (ASC 606), BAD DEBT IS NO LONGER AN EXPENSE, BUT IS INCLUDED AS A REDUCTION IN NET PATIENT REVENUE. THEREFORE, THERE IS NO SEPARATE FOOTNOTE IN THE AUDITED FINANCIAL STATEMENTS THAT DESCRIBES BAD DEBT. Schedule H, Part III, Line 8 Community benefit & methodology for determining medicare costs THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS REPORTED AS MEDICARE SHORTFALLS WAS DERIVED FROM THE INTERNAL REVENUE SERVICE'S WORKSHEET B AS PROVIDED FOR PART III CALCULATIONS. THE SHORTFALL SHOULD BE CONSIDERED COMMUNITY BENEFIT BECAUSE THE CHESHIRE MEDICAL CENTER IS THE ONLY HOSPITAL/MEDICAL CENTER IN CHESHIRE COUNTY, NEW HAMPSHIRE AND IS DESIGNATED BY CMS AS A MEDICARE DEPENDENT HOSPITAL (MDH) DUE TO GREATER THAN HALF OF OUR AVERAGE DAILY CENSUS BEING COMPRISED OF MEDICARE PATIENTS. OUR PRESENCE IN THE COMMUNITY ALLOWS THE RESIDENTS OF CHESHIRE COUNTY, ESPECIALLY THE ELDERLY POPULATION, TO RECEIVE COMPREHENSIVE HOSPITAL AND MEDICAL SERVICES CLOSE TO HOME. Schedule H, Part III, Line 9b Collection practices for patients eligible for financial assistance CHESHIRE MEDICAL CENTER HAS A CREDIT AND COLLECTION POLICY THAT ADDRESSES THE PROCEDURES FOR PATIENTS WHO QUALIFY FOR REDUCED-COST CARE. THE POLICY PROHIBITS USING EXTRAORDINARY COLLECTION PRACTICES OR PLACING AMOUNTS WITH COLLECTION AGENCIES. IF A FINANCIAL-ASSISTANCE-POLICY-ELIGIBLE PATIENT HAS A BALANCE FOR WHICH THEY ARE RESPONSIBLE AFTER A FINANCIAL ASSISTANCE DISCOUNT IS APPLIED, THE STANDARD PRACTICES ARE FOLLOWED AS OUTLINED IN THE CREDIT AND COLLECTIONS POLICY. Schedule H, Part V, Section B, Line 16a FAP website - CHESHIRE MEDICAL CENTER: Line 16a URL: https://www.cheshiremed.org/patients-visitors/billing-charges; Schedule H, Part V, Section B, Line 16b FAP Application website - CHESHIRE MEDICAL CENTER: Line 16b URL: https://www.cheshiremed.org/patients-visitors/billing-charges; Schedule H, Part V, Section B, Line 16c FAP plain language summary website - CHESHIRE MEDICAL CENTER: Line 16c URL: https://www.cheshiremed.org/patients-visitors/billing-charges; Schedule H, Part VI, Line 2 Needs assessment IN ADDITON TO THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA), THE HOSPITAL USES REGULAR FEEDBACK FROM THE COMMUNITY, PROVIDED THROUGHOUT THE YEAR, TO ASSESS ITS HEALTH NEEDS. THE HEALTH STAFF PARTICPATES IN OR LEADS MULTIPLE COMMUNITY COALITIONS AND PROJECTS COLLABORATING AND CONNECTING WITH A WIDE ARRAY OF COMMUNITY-BASED HEALTH, MUNICIPAL, SCHOOL, SERVICE ORGANIZATION, REGIONAL PLANNING AND STATE PUBLIC HEALTH STAKEHOLDERS. WE REGULARLY REVIEW EMERGING NH & VT STATE HEALTH DATA; QUANTITATIVE AND QUALITATIVE DATA FROM LOCAL SOURCES (NEWSPAPERS, REGIONAL PLANNING OFFICES, COMMUNITY FORUMS), AND CONVERSATIONS WITH COMMUNITY PARTNERS TO IDENTIFY CONCERNS THAT ARE EMERGING, INTENSIFYING, OR ARE THE SOURCE OF LOCAL ATTENTION SINCE THE LAST CHNA WAS CONDUCTED. Schedule H, Part VI, Line 3 Patient education of eligibility for assistance THE CHESHIRE MEDICAL CENTER IS COMMITTED TO PROVIDING MEDICALLY NECESSARY CARE TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY FOR SERVICES. ALL UNINSURED INPATIENTS, SAME DAY SURGERY, OBSERVATION, AND EMERGENCY DEPARTMENT PATIENTS ARE PRO-ACTIVELY SCREENED USING PAPER AND/OR AN AUTOMATED TOOL TO IDENTIFY POTENTIAL QUALIFICATION FOR OTHER FEDERAL, STATE, AND LOCAL PROGRAMS. IN ADDITION, SPECIFIC OUTPATIENT ACTIVITIES DEEMED TO HAVE A HIGHER RATE OF NEED ARE SCREENED AS PART OF REGULAR PROTOCOL. IF A PATIENT APPEARS TO BE ELIGIBLE, ON-SITE FINANCIAL COUNSELORS ASSIST THE PATIENT IN COMPLETING THE APPROPRIATE PAPERWORK/APPLICATIONS AND PROVIDE INSTRUCTION REGARDING HOW TO COMPLETE THE QUALIFICATION PROCESS. IN SOME CASES A FINANCIAL COUNSELOR WILL ACT ON BEHALF OF THE PATIENT, AT THEIR SIGNED CONSENT, IN ORDER TO COMPLETE THE APPLICATION PROCESS (FOR EXAMPLE, IN NEW HAMPSHIRE A PATIENT MUST BE PHYSICALLY PRESENT AT THE DISTRICT OFFICE). IF A PATIENT DOESN'T QUALIFY FOR SPECIFIC PROGRAMS, THEY ARE ALSO CONSIDERED FOR FINANCIAL ASSISTANCE AS PART OF THEIR SCREENING. FOR OUTPATIENT SERVICES THAT ARE NOT ROUTINELY SCREENED, STAFF INTERACTING WITH PATIENTS ARE INSTRUCTED TO PROVIDE EITHER A FINANCIAL ASSISTANCE APPLICATION OR CONTACT INFORMATION FOR A FINANCIAL COUNSELOR WHEN A PATIENT EXPRESSES THEIR INABILITY TO MAKE PAYMENT. EVERY APPLICATION IS SCREENED FOR COMPLETED INCOME AND ASSET DOCUMENTATION. APPLICATIONS ARE ALSO SCREENED TO ASSURE THERE ARE NO OTHER POTENTIAL OPTIONS OF FEDERAL, STATE, OR LOCAL PROGRAMS. THE WEBSITE, PATIENT STATEMENTS, AND FINANCIAL BROCHURES ALL INCLUDE INFORMATION ABOUT FINANCIAL ASSISTANCE AND HOW TO APPLY. Schedule H, Part VI, Line 4 Community information THE MEDICAL CENTER IS THE ONLY HOSPITAL IN ITS PRIMARY SERVICE AREA ("PSA"). MANAGEMENT DEFINES ITS PSA AS THE CITY OF KEENE AND 19 GEOGRAPHICALLY PROXIMATE COMMUNITIES. TOWNS AND CITIES INCLUDED IN THE PSA INCLUDE ALSTEAD, CHESTERFIELD, FITZWILLIAM, GILSUM, HARRISVILLE/CHESHAM, KEENE, MARLBOROUGH, MARLOW, MUNSON/MUNSONVILLE, RICHMOND, ROXBURY, STODDARD, SULLIVAN, SURRY, SWANZEY, TROY, WALPOLE, WESTMORELAND AND WINCHESTER, ALL LOCATED IN CHESHIRE COUNTY. BASED ON THE US CENSUS BUREAU'S POPULATION ESTIMATES FROM 2012 TO 2016: MEDICAL CENTER'S PSA REPRESENTED APPROXIMATELY 4.52% OF NEW HAMPSHIRE'S POPULATION. THE PSA'S TOTAL POPULATION IS 59,612 WITH 23,409 RESIDING IN KEENE, THE LARGEST COMMUNITY IN THE SERVICE AREA. CHESHIRE COUNTY POPULATION IS 75,950 . THE MEDIAN AGE OF RESIDENTS IN CHESHIRE COUNTY IS 42.2 WITH: - 14,886 OR 19.6% LESS THAN 18 YEARS OF AGE, - 49,899 OR 65.7% BETWEEN THE AGES OF 18-64, AND - 11,164 OR 14.7% OVER THE AGE OF 64, IN 2020 THE POVERTY RATE FOR CHESHIRE COUNTY WAS 10.2%. THE MEDIAN HOUSEHOLD INCOME IS $64,751. ACCORDING TO THE JUNE 2021 NEW HAMPSHIRE EMPLOYMENT SECURITY, ECONOMIC & LABOR MARKET INFORMATION BUREAU REPORT, THE STATE AND CHESHIRE COUNTY HAD AN UNEMPLOYMENT RATES OF 3.1% AND 3.6%, RESPECTIVELY (NOT SEASONALLY-ADJUSTED). Schedule H, Part VI, Line 5 Promotion of community health CHESHIRE MEDICAL CENTER (CMC) PLAYS AN ACTIVE ROLE IN PROMOTING COMMUNITY HEALTH AND OFFERS EDUCATIONAL PROGRAMS INCLUDING CLASSES AND WORKSHOPS. CMC (IN PARTNERSHIP WITH DARTMOUTH-HITCHCOCK HEALTH (D-HH)) OFFERS A VARIETY OF HEALTH PROMOTION, EDUCATION PROGRAMS, AND DIRECT SERVICES FOR THE COMMUNITY SPANNING A BROAD SPECTRUM OF HEALTH AND WELLNESS TOPICS. OUR CLINICAL STAFF WORKS CLOSELY WITH THE STAFF OF THE CENTER FOR POPULATION HEALTH TO DEVELOP PROGRAMS THAT COVER EMERGING HEALTH CONCERNS AND ARE DELIVERED AT THE RIGHT LITERACY LEVEL FOR OUR COMMUNITY. THE PROGRAMS OFFERED INCLUDE A VARIETY OF CHRONIC DISEASE AND WELLNESS TOPICS SUCH AS: STRESS MANAGEMENT AND RESILIENCY, NUTRITION, PHYSICAL EDUCATION AND EXERCISE, HIGH BLOOD PRESSURE PREVENTION AND MONITORING, DIABETES PREVENTION AND MONITORING, ADVANCED DIRECTIVE PLANNING, MEMORY LOSS, TOBACCO CESSATION AND WRITING AS A TOOL TO MANAGE STRESS. ALL PROGRAMS ARE OFFERED FREE OF CHARGE. IN ADDITION, CMC OFFERS SEVERAL COMMUNITY PROGRAMS INCLUDING CHESHIRE SMILES, A SCHOOL-BASED DENTAL HEALTH PROGRAM FOR CHILDREN IN GRADES K-3, WHICH PROVIDES SCREENING, PREVENTION AND RESTORATIVE DENTAL CARE FOR CHILDREN IN CHESHIRE COUNTY SCHOOLS. CHESHIRE MEDICAL CENTER ALSO WORKS IN PARTNERSHIP WITH OTHER COMMUNITY HEALTH AND HUMAN SERVICE ORGANIZATIONS TO MEET THE DENTAL HEALTH NEEDS OF UNDERSERVED POPULATIONS SUCH AS THE CHRONICALLY MENTALLY ILL, PREGNANT WOMEN WHO CANNOT AFFORD DENTAL CARE, CHILDREN IDENTIFIED THROUGH THE SCHOOL-BASED CHESHIRE SMILES PROGRAM, AND OTHERS. OTHER INITIATIVES INCLUDE HOSTING OR LEADING COMMUNITY PARTNERSHIPS TO ADDRESS SUBSTANCE MISUSE AND TREATMENT AND TO IMPROVE PUBLIC HEALTH; AND PARTICIPATION OF OUR STAFF IN OTHER PARTNERSHIPS SUCH AS THE FOUNDATION FOR HEALTHY COMMUNITIES AND THE CHESHIRE COALITON FOR TOBACCO-FREE COMMUNITIES. IN ADDITION, THE HOSPITAL OPERATES HEALTH EDUCATION AND OTHER SUPPORT SERVICES SUCH AS ADVANCE CARE PLANNNG, SENIOR PASSPORT, AND VARIOUS HEALTH AND WELLNESS PROGRAMS. CASH CONTRIBUTIONS, CONTRACTED SERVICES, AND IN-KIND CONTRIBUTIONS OF STAFF TIME AND EXPERTISE ARE USED TO SUPPORT THESE STRATEGIES WHICH IMPROVE THE HEALTH OF THE COMMUNITY. CMC EXTENDS PROFESSIONAL STAFF PRIVILEGES TO QUALIFIED AND APPROPRIATE PHYSICIANS WHO ARE EMPLOYEES OF DARTMOUTH HITCHCOCK CLINIC, MARY HITCHCOCK MEMORIAL HOSPITAL, AND DARTMOUTH COLLEGE, WHO ALSO HOLD A FACULTY APPOINTMENT AT GEISEL SCHOOL OF MEDICINE. OF THE 18 VOTING MEMBERS OF THE CHESHIRE MEDICAL CENTER BOARD OF TRUSTEES AT THE END OF THE FISCAL YEAR, 10 ARE NEITHER CONTRACTORS NOR EMPLOYEES OF THE HOSPITAL OR ITS AFFILIATES. The majority of Cheshire Medical Center's volunteer Board of Trustees, the governing body of the organization, represents a broad range of interests which exist in the communities it serves. In particular the trustees, who are neither employees nor independent contractors (nor family members thereof) of the Cheshire Medical Center, are representative of the consumer interests of the various neighborhoods and localities which are serviced by the hospital. Schedule H, Part VI, Line 6 Affiliated health care system CHESHIRE MEDICAL CENTER IS OWNED BY DARTMOUTH-HICHCOCK HEALTH. THIS RELATIONSHIP ALLOWS THE STREAMLINING OF PATIENT CARE BETWEEN THE TWO HEALTHCARE SYSTEMS AND STRENGTHENS THE CENTER AS A REGIONAL RESOURCE FOR SOUTHWESTERN NEW HAMPSHIRE AND SOUTHEASTERN VERMONT. THE AFFILIATION ALLOWS MORE PATIENTS TO RECEIVE CARE CLOSER TO HOME, FREES UP BED CAPACITY FOR TERTIARY CARE PATIENTS AT DARTMOUTH-HITCHCOCK MEDICAL CENTER IN LEBANON, AND ALLOWS THE CHESHIRE MEDICAL CENTER TO CONTINUE ITS LEADERSHIP ROLE IN POPULATION HEALTH AND THE HEALTHY MONADNOCK 2020 INITIATIVE. CHESHIRE MEDICAL HAS A MULTI-SPECIALTY GROUP PRACTICE THAT COMPRISES THE MAJORITY OF CHESHIRE MEDICAL CENTER'S MEDICAL STAFF AND WITH THE AFFILIATION, IT ENABLES BOTH ORGANIZATIONS TO MORE EFFECTIVELY PURSUE A COMMON VISION OF THE FUTURE OF HEALTH CARE THAT IS BASED ON CREATING A SUSTAINABLE HEALTH SYSTEM, FOCUSING ON POPULATION HEALTH, DELIVERING VALUE-BASED CARE, AND EMBRACING THE OPPORTUNITIES PROVIDED BY NEW PAYMENT MODELS. IN ADDITION TO THE CHESHIRE MEDICAL CENTER AND THE DARTMOUTH-HITCHCOCK HEALTH, THE AFFILIATED HEALTH CARE SYSTEM INCLUDES MARY HITCHCOCK MEMORIAL HOSPITAL, DARTMOUTH-HITCHCOCK CLINIC, THE NEW LONDON HOSPITAL ASSOCIATION, WINDSOR HOSPITAL CORPORATION, ALICE PECK DAY MEMORIAL HOSPITAL, VISITING NURSE ASSOCIATION AND HOSPICE OF NEW HAMPSHIRE AND VERMONT, AND A NUMBER OF OTHER RELATED ORGANIZATIONS WHOSE PRIMARY MISSION IS HEALTH CARE IN THE REGION. THE CHESHIRE MEDICAL CENTER AND OTHER MEMBERS OF THE AFFILIATED HEALTH CARE SYSTEM OPERATE JOINTLY THROUGH INTERLOCKING DIRECTORATES, STRATEGIC PLANNING, MANAGEMENT, AND SHARE IDENTICAL MISSIONS. Schedule H, Part VI, Line 7 State filing of community benefit report NH true FOUNDATION FOR HEALTHY COMMUNITIES 125 AIRPORT ROAD Concord NH 03301 020275078 501(c)(3) 330784 FMV Program Support MONADNOCK FAMILY SERVICES 17 93RD ST kEENE NH 03431 026012230 501(C)(3) 204711 FMV PROGRAM SUPPORT SOUTHWEST REGION PLANNING COMMISSION STATE OF NH 37 ASHUELOT STREET KEENE NH 03431 020359624 GOVERNMENT 55250 FMV PROGRAM SUPPORT KEENE STATE COLLEGE 229 MAIN STREET KEENE NH 03431 026000937 GOVERNMENT 10815 FMV PROGRAM SUPPORT DENTAL HEALTH WORKS 69V ISLAND STREET KEENE NH 03431 300275867 501(C)(3) 10000 FMV PROGRAM SUPPORT 5 0 NURSING & HEALTHCARE SCHOLARSIHPS 27 55001 FMV Schedule I, Part I, Line 2 Procedures for monitoring use of grant funds. ALL GRANTS AND ASSISTANCE ARE PAID TO 501(C)(3) ORGANIZATIONS OR GOVERNMENTAL ENTITIES. X true true false true false false false false false false false JENNIFER DINUBILA DO Former President of Medical Staff 0 383055 0 0 0 25780 0 21615 0 36701 0 467151 0 0 DON CARUSO MD TRUSTEE/CEO/PRESIDENT - CMC 0 457446 0 37420 0 34180 0 27315 0 32116 0 588477 0 0 CLAIRE FABIAN MD Trustee/ Medical Staff President (eff. 11/1/20) 0 330063 0 0 0 5014 0 27315 0 26152 0 388544 0 0 Michael Ormont MD TRUSTEE/EX-OFFICIO/Medical Staff Pres-CMC(thru 10/31/20) 0 381411 0 13687 0 21077 0 27315 0 28574 0 472064 0 0 Cherie Holmes MD Trustee / Physician 0 482870 0 0 0 43688 0 27315 0 18476 0 572349 0 0 Stephen Leblanc Trustee (eff. 7/1/20) 0 683250 0 0 0 102875 0 27315 0 33682 0 847122 0 0 Maria Padin MD TRUSTEE 0 467964 0 45000 0 39626 0 27315 0 42718 0 622623 0 0 ANDREW TREMBLAY MD TRUSTEE 0 321716 0 0 0 3081 0 21615 0 35226 0 381638 0 0 RACHEL LOVINS MD TRUSTEE 0 392810 0 0 0 12469 0 11400 0 35603 0 452282 0 0 Michael Waters Trustee (Eff. 7/1/20) / Treasurer 0 257597 0 0 0 550 0 18875 0 1444 0 278466 0 0 Christine Schon MPA COO (thru 12/31/20) 0 341947 0 0 0 31427 0 27315 0 26666 0 427355 0 0 KATHRYN WILLBARGER COO (Eff. 1/2021) / Sr. VP-Finance (thru 12/2020) 358894 0 0 0 51517 0 21615 0 2644 0 434670 0 0 0 AMY MATTHEWS CHIEF NURSING OFFICER 221892 0 0 0 773 0 19742 0 1292 0 243699 0 0 0 David Quigley VP Clinical Operations - CMC 0 253372 0 0 0 2529 0 23844 0 4131 0 283876 0 0 ERLI CHEN PHYSICiST 239807 0 0 0 18992 0 24779 0 8438 0 292016 0 0 0 LATASHA HEAPE CHIEF CRNA 215867 0 0 0 0 0 9116 0 15103 0 240086 0 0 0 MICHAEL W FRANK NURSE ANESTHETIST CRNA 268575 0 0 0 8552 0 25706 0 1649 0 304482 0 0 0 Shawn V Lafrance VP Population Health 197977 0 0 0 2289 0 18337 0 15462 0 234065 0 0 0 Richard Crowe Jr Pharmacy Manager 160721 0 0 0 11466 0 14842 0 13905 0 200934 0 0 0 Schedule J, Part I, Line 1a Tax indemnification and gross-up payments Kathryn Willbarger received a gross-up payment that was treated as taxable compensation. Schedule J, Part I, Line 3 Arrangement used to establish the top management official's compensation THE CEO IS PAID BY DARTMOUTH-HITCHCOCK CLINIC, A RELATED ORGANIZATION, WHICH USES A COMPENSATION COMMITTEE, AN INDEPENDENT CONSULTANT, FORM 990 OF OTHER ORGANIZATIONS, A COMPENSATION SURVEY OR STUDY, AND APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE TO ESTABLISH THE CEO'S COMPENSATION. Schedule J, Part I, Line 4b Supplemental nonqualified retirement plan Dartmouth Hitchcock Clinic (DHC) sponsors a split dollar life plan for certain long-term employees. The original objectives for offering these plans were to better enable DHC to attract and retain quality executive personnel, improve the physicians' post-retirement life insurance benefits, and to replace an increasingly costly retiree life insurance program. The plan was frozen to new participants in 1998. THE FOLLOWING INDIVIDUAL HAS A SPLIT DOLLAR LIFE PLAN ARRANGEMENT AND RESPECTIVE EMPLOYER PREMIUM: STEPHEN LEBLANC $61,630 A NH HEALTH AND ED FACILITIES AUTHORITY 020279866 644614V48 2012-11-15 30360529 REFUND OF EXISTING DEBT; ACQUISITION false false false A 6180000 30360529 379754 554125 4777102 24649548 2013 true false true true A false true false false 0.0 0.0126 0.0126 false false true A false false true false false false false false true A true ASHLEY COPELAND FAMILY MEMBER of TRUSTEE H. ROGER HANSON 79067 Employment Compensation false ELIZABETH LEHR FAMILY MEMBER OF TRUSTEE H. ROGER HANSON 58116 Employment Compensation false Schedule L, Part III Tuition Assistance A related organization remitted $15,144 to an educational institution for the tuition of Kathryn Willbarger. Form 990, Part VI, Line 15a PROCESS TO ESTABLISH CEO COMPENSATION THE CEO IS PAID BY A RELATED ORGANIZATION. TO ASSIST WITH COMPENSATION DECISIONS, THE ORGANIZATION RETAINED YAFFE & COMPANY, INC. TO PROVIDE CONSULTATION TO THE EXECUTIVE COMMITTEE OF THE CMC BOARD OF TRUSTEES REGARDING EXECUTIVE COMPENSATION, BENEFITS, AND PREREQUISITES. THE EXECUTIVE COMMITTEE HAS A COMPENSATION REVIEW PROCESS TO PROVIDE AN ORDERLY STRUCTURE FOR EXECUTIVE COMPENSATION DECISIONS. ANNUALLY, THE COMMITTEE USES A MULTI-TIERED APPROACH THAT INCLUDES INDEPENDENT COMPARABILITY DATA TO GAUGE APPROPRIATE COMPARATIVE MARKET LEVELS OF COMPENSATION AND BENEFITS. AN ANNUAL PERFORMANCE EVALUATION IS BASED ON SUBJECTIVE AND OBJECTIVE CRITERIA WHICH FLOWS FROM THE ORGANIZATION'S STRATEGIC PLAN. BY WAY OF QUESTIONNAIRE, BOARD MEMBERS PARTICIPATE IN THE PERFORMANCE REVIEW PROCESS AND A SUMMARY REPORT IS SHARED WITH THE CEO. VARIABLE PAY IS AWARDED BASED ON ACHIEVEMENT OF SPECIFIC QUALITATIVE AND QUANTITATIVE GOALS. IN CONJUNCTION WITH THE EXECUTIVE COMMITTEE, CHALLENGING AND MEASURABLE GOALS ARE ESTABLISHED, WHICH PROVIDE ALIGNMENT BETWEEN EXECUTIVE COMPENSATION AND ACHIEVEMENT OF THE HOSPITAL'S STRATEGIC INITIATIVES. Form 990, Part VI, Line 1a Delegate broad authority to a committee As described in the organization's bylaws, the Executive Committee shall consist of the officers of the Board of Trustees of the Corporation and an additional trustee recommended by the Chairperson of the Board and approved by the Board. The Chairperson of the Board of Trustees shall be the Chairperson of the Executive Committee, which shall work at the direction of (and report to) the Board of Trustees, undertaking specific activities assigned to it by the full Board. The Executive Committee shall serve as a resource in the following areas: policy formulation, preparation of background material and analysis for Board deliberations, evaluation of the CEO's performance and recommendations on compensation, and other areas in which the Board requires the deliberation of the officers. The Executive Committee shall have the power to transact all regular business of the Corporation between meetings of the Board. The Executive Committee shall also perform functions of the "Executive Compensation Committee." Form 990, Part VI, Line 6 Classes of members or stockholders DARTMOUTH-HITCHCOCK HEALTH, A NEW HAMPSHIRE VOLUNTARY CORPORATION, IS THE SOLE CORPORATE MEMBER OF THE CHESHIRE MEDICAL CENTER. Form 990, Part VI, Line 7a Members or stockholders electing members of governing body DARTMOUTH-HITCHCOCK HEALTH, A NEW HAMPSHIRE VOLUNTARY CORPORATION, IS THE SOLE CORPORATE MEMBER OF THE CHESHIRE MEDICAL CENTER. D-HH HAS THE POWER TO APPOINT 1/3 OF THE MEMBERS OF THE CHESHIRE MEDICAL CENTER'S BOARD OF TRUSTEES. Form 990, Part VI, Line 7b Decisions requiring approval by members or stockholders THE SOLE MEMBER HAS THE RIGHT TO RATIFY THE CHESHIRE MEDICAL CENTER'S NOMINATION OF 2/3 OF THE MEMBERS OF THE BOARD OF TRUSTEES; REMOVE TRUSTEES AFTER CONSULTATION WITH THE CHAIRPERSON OF THE BOARD, APPROVE THE DISSOLUTION OR LIQUIDATION OF THE CHESHIRE MEDICAL CENTER; APPOINT, EVALUATE, TERMINATE, AND APPROVE THE COMPENSATION OF THE PRESIDENT AND CEO; AND OTHER GOVERNANCE DECISIONS. Form 990, Part VI, Line 11b Review of form 990 by governing body THE FORM 990 IS REVIEWED BY EXTERNAL TAX ADVISORS AND THE CFO BEFORE THE FILING OF THE RETURN. ONCE THE RETURN HAS BEEN FULLY PREPARED, A FINAL 990 IS SENT TO EACH BOARD MEMBER AND TIME IS ALLOCATED FOR COMMENTS AND RESPONSES PRIOR TO THE OFFICIAL FILING OF OF THE FORMS. Form 990, Part VI, Line 12c Conflict of interest policy CHESHIRE MEDICAL CENTER'S BOARD OF TRUSTEES APPROVED A POLICY CONCERNING A VOLUNTARY SELF-DISCLOSURE OF ANY POTENTIAL CONFLICT OF INTEREST. THE DARTMOUTH-HITCHCOCK COMPLIANCE AND AUDIT SERVICES DEPARTMENT CONDUCTS AN ANNUAL SURVEY OF ALL OFFICERS AND TRUSTEES AND PERFORMS OTHER PROCEDURES AS CONSIDERED NECESSARY TO REPORT ON COMPLIANCE WITH THE CONFLICT OF INTEREST POLICY. THE DEPARTMENT THEN REPORTS TO EACH BOARD ANY POTENTIAL CONFLICTS FOR THEIR REVIEW. PER THE POLICY, ANY CONFLICTS OR OTHERWISE PERCEIVED CONFLICTS ARE REQUIRED TO BE ADDRESSED BY THE BOARD OF TRUSTEEES ON AN ONGOING BASIS. IN THE EVENT A CONFLICT ARISES, THE INDIVIDUAL MAY BE REMOVED FROM PARTICIPATING IN ANY DECISION MAKING REGARDING THE IDENTIFIED CONFLICT AND/OR ITS CORRESPONDING TRANSACTIONS. IF THE BOARD OR COMMITTEE HAS REASONABLE CAUSE TO BELIEVE THAT AN INTERESTED PERSON HAS FAILED TO DISCLOSE ACTUAL OR POSSIBLE CONFLICTS OF INTEREST, IT SHALL INFORM SUCH PERSON ON THE BASIS FOR SUCH BELIEF AND AFFORD HIM/HER AN OPPORTUNITY TO EXPLAIN THE ALLEGED FAILURE TO DISCLOSE. IF, AFTER HEARING THE RESPONSE OF THE INTERESTED PERSON AND MAKING SUCH FURTHER INVESTIGATION AS MAY BE WARRANTED IN THE CURCUMSTANCES, THE BOARD OR COMMITTEE DETERMINES THAT SUCH PERSON HAS IN FACT FAILED TO DISCLOSE AN ACTUAL OR POSSIBLE CONFLICT OF INTEREST, IT SHALL TAKE APPROPRIATE DISCIPLINARY AND CORRECTIVE ACTION. Form 990, Part VI, Line 15b Process to establish compensation of other employees TO ASSIST WITH COMPENSATION DECISIONS, THE ORGANIZATION RETAINED YAFFE & COMPANY, INC. TO PROVIDE CONSULTATION TO THE EXECUTIVE COMMITTEE OF THE CMC BOARD OF TRUSTEES REGARDING EXECUTIVE COMPENSATION, BENEFITS, AND PREREQUISITES. THE EXECUTIVE COMMITTEE HAS A COMPENSATION REVIEW PROCESS TO PROVIDE AN ORDERLY STRUCTURE FOR EXECUTIVE COMPENSATION DECISIONS. ANNUALLY, THE COMMITTEE USES A MULTI-TIERED APPROACH THAT INCLUDES INDEPENDENT COMPARABILITY DATA TO GAUGE APPROPRIATE COMPARATIVE MARKET LEVELS OF COMPENSATION AND BENEFITS. AN ANNUAL PERFORMANCE EVALUATION IS BASED ON SUBJECTIVE AND OBJECTIVE CRITERIA WHICH FLOWS FROM THE ORGANIZATION'S STRATEGIC PLAN. BY WAY OF QUESTIONNAIRE, BOARD MEMBERS PARTICIPATE IN THE PERFORMANCE REVIEW PROCESS AND A SUMMARY REPORT IS SHARED WITH THE CEO. VARIABLE PAY IS AWARDED BASED ON ACHIEVEMENT OF SPECIFIC QUALITATIVE AND QUANTITATIVE GOALS. IN CONJUNCTION WITH THE EXECUTIVE COMMITTEE, CHALLENGING AND MEASURABLE GOALS ARE ESTABLISHED, WHICH PROVIDE ALIGNMENT BETWEEN EXECUTIVE COMPENSATION AND ACHIEVEMENT OF THE HOSPITAL'S STRATEGIC INITIATIVES. DURING FY21, COMPENSATION FOR THE FOLLOWING POSITIONS WERE REVIEWED: CHIEF NURSING OFFICER, CHIEF OPERATING OFFICER, AND THE CHIEF FINANCIAL OFFICER. THE PRESIDENT OF THE MEDICAL STAFF IS PAID BY A RELATED PARTY WHO CONDUCTED A SIMILAR REVIEW. Form 990, Part VI, Line 19 Required documents available to the public THE CHESHIRE MEDICAL CENTER MAKES ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY, AND FINANCIAL STATEMENTS AVAILABLE TO MEMBERS OF THE PUBLIC UPON REQUEST. Form 990, Part VIII, Line 11d Other Miscellaneous Revenue Other Income - Total Revenue: 405445, Related or Exempt Function Revenue: 405445, Unrelated Business Revenue: , Revenue Excluded from Tax Under Sections 512, 513, or 514: ; Form 990, Part IX, Line 11g Other Fees Contracted Healthcare Services - Total Expense: 48595885, Program Service Expense: 48595885, Management and General Expenses: , Fundraising Expenses: ; Lab and Radiology Services - Total Expense: 2346072, Program Service Expense: 2346072, Management and General Expenses: , Fundraising Expenses: ; Consulting and Other Services - Total Expense: 12217386, Program Service Expense: 11544872, Management and General Expenses: 665950, Fundraising Expenses: 6564; Pharmacy Management Services - Total Expense: 456067, Program Service Expense: 456067, Management and General Expenses: , Fundraising Expenses: ; Form 990, Part XI, Line 9 Other changes in net assets or fund balances NET ASSET TRANSFERS - 680017; Transfer to related organization - -4850398; Form 990, Part XII, Line 3a FINANCIAL STATEMENTS AND REPORTING THE MEDICAL CENTER WAS INCLUDED IN THE CONSOLIDATED AUDITED FINANCIAL STATEMENTS OF THE DARTMOUTH-HITCHCOCK HEALTH SYSTEM. DURING FISCAL YEAR 2021, MARY HITCHCOCK MEMORIAL HOSPITAL EXPENDED FEDERAL FUNDING WHICH MET THE MINIMUM THRESHOLD SET FORTH IN THE SINGLE AUDIT ACT AND OMB CIRCULAR A-133 . DUE TO THE NATURE OF THE CONSOLIDATED FINANCIAL STATEMENTS, THE AUDIT WAS PERFORMED ON THE FINANCIAL INFORMATION OF ALL ORGANIZATIONS, INCLUDING CHESHIRE MEDICAL CENTER. Form 990, Part XII, Line 2c Change of oversight process or selection process CHESHIRE MEDICAL CENTER DELEGATES OVERSIGHT OF THE AUDIT TO THE FINANCE & AUDIT SUBCOMMITTEE. THE FULL BOARD REVIEWS AND APPROVES THE AUDITED FINANCIAL STATEMENTS. THE ORGANIZATION IS ALSO INCLUDED IN THE AUDIT AND CONSOLIDATED FINANCIAL STATEMENTS OF ITS PARENT ORGANIZATION, DARTMOUTH-HITCHCOCK HEALTH. CHESHIRE HEALTH FOUNDATION 580 COURT STREET KEENE NH 03431 020202220 SUPPORTING ORGANIZATION NH 501(c)(3) Type I CMC true CHESHIRE HEALTH SERVICES 580-590 COURT STREET KEENE NH 03431 473379283 HEALTHCARE NH 501(c)(3) 3 CMC true DARTMOUTH-HITCHCOCK CLINIC ONE MEDICAL CENTER DRIVE LEBANON NH 03756 222519596 PHYSICIAN SERVICES NH 501(c)(3) 10 D-HH false DARTMOUTH-HITCHCOCK HEALTH ONE MEDICAL CENTER DRIVE LEBANON NH 03756 264812335 PARENT ORGANIZATION NH 501(c)(3) 7 NA false MARY HITCHCOCK MEMORIAL HOSPITAL ONE MEDICAL CENTER DRIVE LEBANON NH 03756 020222140 HOSPITAL NH 501(c)(3) 3 D-HH false THE NEW LONDON HOSPITAL ASSOCIATION INC 273 COUNTY ROAD NEW LONDON NH 03257 020222171 HOSPITAL NH 501(c)(3) 3 D-HH false WINDSOR HOSPITAL CORPORATION 289 COUNTY ROAD WINDSOR VT 05089 030183721 HOSPITAL VT 501(c)(3) 3 D-HH false ALICE PECK DAY MEMORIAL HOSPITAL 10 ALICE PECK DAY DRIVE LEBANON NH 03766 020222791 HOSPITAL NH 501(c)(3) 3 D-HH false VISITING NURSE ASSOCIATON AND HOSPICE OF VERMONT AND NEW HAMPSHIRE INC 88 Prospect Street White River Junction VT 05001 036006494 HOSPICE VT 501(c)(3) 10 D-HH false KEENE HEALTH ENTERPRISES 580 COURT STREET KEENE NH 03431 020374999 REAL ESTATE HOLDING NH CMC C Corporation 0 0 1 true KEENE HEALTH REALTY 580 COURT STREET KEENE NH 03431 020374998 REAL ESTATE HOLDING NH CMC C Corporation -45911 505810 1 true KEENE HEALTH SERVICES 580 COURT STREET KEENE NH 03431 020374997 REAL ESTATE HOLDING NH CMC C Corporation 19352 1306192 1 true false false true true true false false false false true true true true true true true true true true Cheshire Health Foundation C 8623795 FMV Cheshire Health Foundation Q 176960 FMV Cheshire Health Foundation K 72000 FMV Cheshire Health Services Q 165887 FMV Cheshire Health Services O 1443134 FMV Cheshire Health Services R 4850398 FMV