2016-11-15T12:50:09-07:00 2015-12-31 202707086 JWT and Associates 1111 E Herndon Ave Fresno CA 93720 990 2015-01-01 860732836 Cobre Valley Regional Medical Center COBR 9284253261 5880 S Hospital Drive Globe AZ 85501 Allan Scroggins Interim CFO 9284253261 2016-10-18 1 Jeremy Ware P00642659 5594317708 2016-10-13 2015 2017-02-10 21:41:12Z CVRMC 5880 S Hospital Drive Globe AZ 85501 44067010 0 X www.cvrmc.org X 1988 AZ The Organization will provide medical services which will be competitive with those charged for similar services by comparable facilities. The Organization will also allow a portion of its services and facilities to be used for charity patients. 9 9 381 0 0 0 89759 19355 40090188 43501631 291374 252975 322074 293049 40793395 44067010 0 0 0 0 20100401 21832577 0 0 0 18870735 19801680 38971136 41634257 1822259 2432753 71078316 73614645 38304829 38690465 32773487 34924180 X The Mission of our Hospital is to develop and maintain a local health care delivery system that serves the region with quality, efficiency and compassion. Our mission is your health. 0 0 34140966 0 43501631 Along with providing acute health care services to the community as a non-profit entity, CVRMC is committed to the many communities we serve. Several members of our administration, directors, managers, and staff serve on various community associations including: Chambers of Commerce, Rotary, Work Force Development, Economic Development, Cancer Awareness Committees, Diabetes Education, Grief Support Teams, Scholarship Committees, and Youth Athletic Programs, to name just a few. CVRMC has its finger on the pulse of the community, provides charitable care with purpose, and offers educational services and programs for the good of our public. From September 2015 through February 2016, stakeholders across Gila County and the CVRMC service region engaged in a community-driven process to identify the most pressing health issues facing our residents through the Community Health Needs Assessment and Implementation Plan (CHNA and CHIP) process. Lead by the Gila County Division of Health and Emergency Management (GCDHEM) and CVRMC, community members and organizations came together to provide valuable insights on experiences of health and sickness, as well as realistic ways to affect change. The process of the Community Health Needs Assessment took place from September 2015 through December of 2015. The Community Health Improvement Plan was produced from the data collected from the needs of our population and GCDHEM and CVRMC are currently working with community organizations to formulate concrete actions to address the four health priorities identified in the CHIP: Obesity, Substance Abuse, Access to Quality Healthcare - Including Mental Health Services, and Sexual Health. The first CHNA and CHIP was completed by CVRMC in 2013 with many action plans driving the success of our identified community health issues. Together, with the collaboration of GCDHEM and many health care organizations and professionals of our service area, we will respond to the identified needs of all our diverse communities with this next CHIP. The Expansion Project of CVRMC began in February of 2015 and is expected to complete in August of 2016. The new construction includes all new, family-centered, single-patient rooms - Med/Surg, ICU, and Family Birth Center - which will bring comfort to the patients and their families we serve. The expansion also included new pharmacy, cath lab, wound center, infusion center, café and kitchen, gift shop, and conference rooms. The 11,000 square feet of new physician offices and exam rooms will provide for growth and will centralize services for the convenience of our patients. CVRMC sponsors an annual health fair, working with other local and state social and charitable agencies to distribute and disseminate health, wellness, safety and other valuable information. Without any charge to our communities, CVRMC sponsors diabetic workshops, birthing and new baby care classes, customer service training, and grief support meetings. Many community organizations have taken advantage of the conference rooms CVRMC has to offer free of charge for meetings and educational training. Some examples of these groups are Teenage Outreach for Pregnancy Services, Rotary Club, Little League, EMS Training, Gila Community College and many more. Meeting places are difficult to find in our rural community and CVRMC is pleased to accommodate our neighboring associations. CVRMC is continually upgrading and improving equipment. Much of the equipment that is replaced is still viable and is passed on to education facilities, fire departments, or other local agencies that will continue to get useful years for their programs and services. Supplies are also donated regularly to EMS, schools, senior citizen groups, and other organizations in need of medical and or other types of supplies. The PACT Committee, comprised of CVRMC staff, dedicates its efforts to making a difference in employee and community relations. The PACT Committee is instrumental in the activities of many hospital activities, promoting employee engagement and satisfaction. The PACT Committee also helps CVRMC employees through the HOPE (Helping Our People in Emergencies) Fund. Donations made to the HOPE fund are used in times of emergency for employees. The PACT Committee also ensures the hospital's presence in community events to build public support and trust. As we celebrate 103 years of service to the Globe-Miami and surrounding communities, CVRMC continues to evolve with the changing needs of our population base. Healthcare is ever moving and advancing and CVRMC is progressing with the demands of our target markets. The continued accomplishments we have made are a direct result of a dedicated and compassionate workforce, a steadfast Board of Directors, and strong supporting management which is focused on one mission - the mission of health with quality, efficiency, and compassion. With the development of our next 3-year strategic plan, we are focused on these areas: The Patient Experience (Quality and Customer Service) People Growth Community (including the CHNA and CHIP) Today, the healthcare arena is facing some monumental changes and challenges. This strategic plan encompasses our accountability and compassion to patients and families; our respect and collaboration to all who surround us; our earnest responsibility to grow with the needs of our population; and our social and public responsibility as healthcare leaders of our communities. Yesterday, today, and tomorrow, CVRMC is committed to our communities with an unwavering dedicated spirit. 0 0 0 34140966 1 0 0 0 0 0 0 0 0 0 1 0 0 1 1 0 1 0 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 276 0 1 381 1 0 0 0 0 0 0 X 9 9 0 1 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 AZ X Virginia Kilmer 9284021123 5880 S Hospital Drive Globe AZ 85501 Byron Belew Chairperson 1 0 X 0 0 0 Ed Carpenter Secretary 1 0 X 0 0 0 Fernando Shipley Treasurer 1 0 X 0 0 0 Jim Rasmussen Vice Chairman 1 0 X 0 0 0 Janice Cook Director 1 0 X 0 0 0 Jendean Sartain Director 1 0 X 0 0 0 Gary Gustason Director 1 0 X 0 0 0 Brad Werrell Director 1 0 X 0 0 0 Alan Osumi Director 1 0 X 0 0 0 Eddie Koury Director 1 0 X 0 0 0 Robert Hollis Director 1 0 X 0 0 0 Joseph Ring Director 1 0 X 0 0 0 Thomas Hansen Physician 40 0 X 434412 0 0 Dana Miller Physician 40 0 X 357354 0 0 Anthony Daniels Physician 40 0 X 406006 0 0 Binoy Chandra Physician 40 0 X 322409 0 0 1520181 0 0 9 0 1 0 Cobre Valley Heart Institute 2055 Highway 60 Globe AZ 85501 Cardiologist 309447 ARUP Laboratories PO Box 27964 Salt Lake City UT 84127 Lab Testing 286050 Globe Medical Properties PO Box 257 Emerson NJ 07630 Rent and associated services 264989 Robert Half Technology PO Box 743295 Los Angeles CA 90074 Staffing 217399 Corthall Laundry Service PO Box 742268 Atlanta GA 30374 Laundry 169438 12 0 0 0 0 0 19355 0 19355 Net Patient Service Revenue 622000 43501631 43501631 0 0 0 0 0 0 43501631 252975 0 0 252975 0 0 0 0 0 0 0 0 67485 0 0 0 67485 0 67485 0 0 67485 0 0 0 225564 225564 0 0 225564 44067010 43727195 0 320460 X 17555073 14044058 3511015 4277504 3422003 855501 6477797 5182238 1295559 1135712 908570 227142 339605 271684 67921 2320338 1856270 464068 563034 450427 112607 Supplies 6661336 5932336 729000 0 Equipment Rental 1152392 921914 230478 0 1151466 1151466 41634257 34140966 7493291 0 4324087 4026681 13790474 13760606 5079527 6493388 1321717 2224931 1352028 1408183 395247 467240 58063547 32293357 16086095 25770190 28729141 19463426 71078316 73614645 3866718 4447988 33000000 32851225 1102111 522330 336000 868922 38304829 38690465 X 32231839 34382309 541648 541871 0 0 32773487 34924180 71078316 73614645 2432753 -282060 0 0 0 0 X 0 1 X 1 0 X 0 904177 904177 0 21472805 12917343 8555462 0 0 0 0 0 21935752 19376014 2559738 0 13750813 0 13750813 25770190 Assets limited as to use 19266843 Bond Issuance Costs 196583 19463426 Third Party Settlements 868922 868922 44067010 0 0 0 0 0 44067010 0 0 0 44067010 41634257 0 0 0 0 0 41634257 0 0 0 41634257 1 1 X 1 X 1 X 1 1 0 1 1 2504851 13153095 0 0 15657946 0 0 0 0 0 0 0 0 0 0 0 15657946 0 0 0 1 2453229 2453229 12756378 11942089 814289 X 1 1 1 1 Cobre Valley Regional Medical Center 5880 South Hospital Drive Globe AZ 85501 www.cvrmc.org X X X X Cobre Valley Regional Medical Center 1 0 0 1 X X X X X X X X 15 1 0 0 1 X cvrmc.org 1 15 1 cvrmc.org 0 0 1 1 1 1 1 0 X X X X 1 X 0 0 Schedule H, Part V, Section B, Line 5-Cobre Valley Regional Medical Center The recent movement to transform public health and health systems stresses that where we live, work, play, pray and learn determines our health and well being. It helps to shift our focus from treating disease and sickness towards prevention and collaboration in order to improve the quality of life for all citizens. Social, economic, political, environmental and individual factors all have a role to play in our health problems, and most importantly, in the solutions. Conducting a Community Health Needs Assessment and Community Health Improvement Plan are the most important first steps in transforming health and wellness. From September 2015 through February 2016, stakeholders across Gila County and the CVRMC service region engaged in a community driven process to identify the most pressing health issues facing residents. Lead by the Gila County Division of Health and Emergency Management and CVRMC, community members and organizations came together to provide valuable insights on experiences of health and sickness, as well as realistic ways to affect change. The CHNA and CHIP documents, found on our website www.CVRMC.org, outline that process and the plan of action to improve health for all residents across Gila County and the CVRMC service region. The Community Health Needs Assessment describes the health of residents across Gila County and the CVRMC service region. No single agency or organization can make measurable improvements in public health alone; therefore, to achieve a greater impact in improving the health of residents, GCDHEM collaborated with CVRMC to strengthen their collective impact with shared resources and expertise to complete the 2015 CHNA. This collaborative effort provides shared ownership for improving community health. To identify those health outcomes with the greatest potential for improvement, the CHNA collaboration explored the countys population demographics and social and economic realities while capturing community and partner input. The end result is a comprehensive summary of leading health issues affecting Arizonans across Gila County and the CVRMC service region. The GCDHEM and CVRMC used the Mobilizing for Action through Planning and Partnerships methodology to conduct the 2015 CHNA. MAPP emphasizes a community driven approach and builds on previous experiences and lessons learned from the 2012 GCDHEM CHA and the 2013 CVRMC CHNA. To ensure a comprehensive approach, the 2015 CHNA relies on the collection and analysis of secondary, quantitative, morbidity, and mortality data from thirty six priority health indicators, in alignment with the CDC Community Health Status Indicators , as well as primary, qualitative data collected from community stakeholders, key informants, and community members at large through 637 surveys and community engagement through six focus groups and fourteen key informant interviews. Where available, health status indicators are compared with other peer counties across the U.S. based on the variables. While the CHNA illustrates disease rates and individual health behaviors, the selected measures provide a broader analysis of factors that affect peoples health. This includes capturing environmental conditions that contribute to health, such as access to healthy foods. The CHA highlights disparities related to health status and community conditions through a data driven analysis. The 2015 CHNA for Gila County and the CVRMC service region set out to gain a more comprehensive picture of health issues facing Gila County residents and the CVRMC region. Through a systematic analysis of secondary data, primary quantitative and qualitative research through community engagement, specific key findings were identified across all or most sources of data. These findings are specifically outlined in the CHNA document found on the CVRMC website, www.CVRMC.org. The effort to assess and address the health needs was a joint effort led by the GCDHEM and CVRMC in cooperation with multiple community organizations that made up the CHIP Advisory Committee. All of the members in the CHIP Advisory Committee expressed their commitment to being part of the solution, developing new partnerships, and understand health in the most holistic way possible. They also agreed that they wanted an actionable, comprehensive, and useful plan that not only reflects the needs and the diversity of community, but also represents what the community wants. The committee met once every week for the course of two months and utilized the Mobilizing Action for Planning and Partnerships framework to review the results from the CHA, pinpoint the key criteria used to prioritize community health needs, and develop detailed goals, objectives, and strategies to guide them in taking action to create change over the next five years. Using the criteria of size, seriousness, feasibility, potential for collective impact, and influence, a structured process designed to ensure input from all participants, the Advisory Committee identified 12 health issues from the CHA to be considered for prioritization. After thoughtful dialogue around these 12 health issues the committee came to consensus on four health priorities to address in the CHIP. 1. Obesity 2. Substance Abuse 3. Access to Quality Healthcare, including Mental Health Services 4. Sexual Health The CHIP Advisory Committee identified long-term and short term goals for "Obesity", "Substance Abuse", and "Sexual Health" using an Asset based Analysis Approach in order to educate each other on current efforts, opportunities to collaborate, and potential gaps to fill. Next, the committee brainstormed strategies and tactics to support the goals. With the help of facilitators and subject matter experts, key evidence-based strategies were highlighted within the list of ideas. For "Access to Quality Healthcare, including Mental Health Services", a SWOT Analysis was used to explore existing strengths and brainstorm opportunities while faced with known weaknesses and threats. GCDHEM, in collaboration with CVRMC, will be responsible for maintaining ongoing community engagement in the implementation of the CHIP. Gila County will continue quarterly meetings with the CHIP Advisory Committee to periodically review the plan, track and evaluate progress made in implementing strategies, and propose changes when greater impact can be achieved by modifying approaches. CVRMC has incorporated the CHNA and CHIP in their strategic action plans under the strategic goal of "Community." When needed, and as recommended by the Advisory Committee, workgroups focusing on particular goals will be established to ensure successful implementation. GCDHEM and CVRMC acknowledge that health improvements cannot be achieved alone. While participating in the development of the CHIP, partners demonstrated enthusiasm for ensuring that the plan is utilized to improve the health of Gila County and the CVRMC service region. This enthusiasm relates not only to the important priorities outlined in the CHIP, but also in the spirit of partnership that is required to work together across organizations to achieve the CHIP goals. Currently, CVRMC utilizes several methods of assessing community healthcare needs. Evaluating the health needs of the CVRMC service area leads to identifying physicians needed in the area as well as recognizing those services that are required to address illnesses which can be targeted for community education and intervention. Community Feedback CVRMC utilizes many methods of community feedback for needs determination. Our patients, their families, and the greater community enlighten our organization through patient surveys and direct comments. CVRMC strives to give the very best care, and in order to accomplish that goal, it is vital that patient and community comments and concerns are addressed. Professional Research Consultants conducts outpatient surveys for the Outpatient Surgery, Physical Therapy, Registration, Med Surg ICU, Obstetrics, Respiratory Therapy, Emergency, Laboratory, Clinics, and Radiology Departments on patient satisfaction. PRC also conducts the inpatient, Hospital Consumers Assessment of Healthcare Providers and Systems survey which measures patient satisfaction in multiple areas including promptness and efficiency of the admission and registration process, length of time waiting, nursing care, physician care, teamwork, discharge instructions, safety, cleanliness of the facility, food service, overall quality of care, and the likelihood of recommending the hospital to relatives and friends. Statistics regarding patient feedback are calculated on a weekly basis and distributed to all department directors with a hard copy, graphs are posted, and emails are dispersed to ensure all staff is informed of results. Management is then able to make necessary assessments of weak areas and strategically plan for improvements. Schedule H, Part V, Section B, Line 11-Cobre Valley Regional Medical Center See other disclosures for Schedule H. 4 Cobre Valley Surgical Services 5860 South Hospital Drive Globe AZ 85501 Surgical Clinic. Schedule H, Part I, Line 2 The recent movement to transform public health and health systems stresses that where we live, work, play, pray and learn determines our health and well being. It helps to shift our focus from treating disease and sickness towards prevention and collaboration in order to improve the quality of life for all citizens. Social, economic, political, environmental and individual factors all have a role to play in our health problems, and most importantly, in the solutions. Conducting a Community Health Needs Assessment and Community Health Improvement Plan are the most important first steps in transforming health and wellness. From September 2015 through February 2016, stakeholders across Gila County and the CVRMC service region engaged in a community driven process to identify the most pressing health issues facing residents. Lead by the Gila County Division of Health and Emergency Management and CVRMC, community members and organizations came together to provide valuable insights on experiences of health and sickness, as well as realistic ways to affect change. The CHNA and CHIP documents, found on our website www.CVRMC.org, outline that process and the plan of action to improve health for all residents across Gila County and the CVRMC service region. The Community Health Needs Assessment describes the health of residents across Gila County and the CVRMC service region. No single agency or organization can make measurable improvements in public health alone; therefore, to achieve a greater impact in improving the health of residents, GCDHEM collaborated with CVRMC to strengthen their collective impact with shared resources and expertise to complete the 2015 CHNA. This collaborative effort provides shared ownership for improving community health. To identify those health outcomes with the greatest potential for improvement, the CHNA collaboration explored the countys population demographics and social and economic realities while capturing community and partner input. The end result is a comprehensive summary of leading health issues affecting Arizonans across Gila County and the CVRMC service region. The GCDHEM and CVRMC used the Mobilizing for Action through Planning and Partnerships methodology to conduct the 2015 CHNA. MAPP emphasizes a community driven approach and builds on previous experiences and lessons learned from the 2012 GCDHEM CHA and the 2013 CVRMC CHNA. To ensure a comprehensive approach, the 2015 CHNA relies on the collection and analysis of secondary, quantitative, morbidity, and mortality data from thirty six priority health indicators, in alignment with the CDC Community Health Status Indicators , as well as primary, qualitative data collected from community stakeholders, key informants, and community members at large through 637 surveys and community engagement through six focus groups and fourteen key informant interviews. Where available, health status indicators are compared with other peer counties across the U.S. based on the variables. While the CHNA illustrates disease rates and individual health behaviors, the selected measures provide a broader analysis of factors that affect peoples health. This includes capturing environmental conditions that contribute to health, such as access to healthy foods. The CHA highlights disparities related to health status and community conditions through a data driven analysis. The 2015 CHNA for Gila County and the CVRMC service region set out to gain a more comprehensive picture of health issues facing Gila County residents and the CVRMC region. Through a systematic analysis of secondary data, primary quantitative and qualitative research through community engagement, specific key findings were identified across all or most sources of data. These findings are specifically outlined in the CHNA document found on the CVRMC website, www.CVRMC.org. The effort to assess and address the health needs was a joint effort led by the GCDHEM and CVRMC in cooperation with multiple community organizations that made up the CHIP Advisory Committee. All of the members in the CHIP Advisory Committee expressed their commitment to being part of the solution, developing new partnerships, and understand health in the most holistic way possible. They also agreed that they wanted an actionable, comprehensive, and useful plan that not only reflects the needs and the diversity of community, but also represents what the community wants. The committee met once every week for the course of two months and utilized the Mobilizing Action for Planning and Partnerships framework to review the results from the CHA, pinpoint the key criteria used to prioritize community health needs, and develop detailed goals, objectives, and strategies to guide them in taking action to create change over the next five years. Using the criteria of size, seriousness, feasibility, potential for collective impact, and influence, a structured process designed to ensure input from all participants, the Advisory Committee identified 12 health issues from the CHA to be considered for prioritization. After thoughtful dialogue around these 12 health issues the committee came to consensus on four health priorities to address in the CHIP. 1. Obesity 2. Substance Abuse 3. Access to Quality Healthcare, including Mental Health Services 4. Sexual Health The CHIP Advisory Committee identified long-term and short term goals for "Obesity", "Substance Abuse", and "Sexual Health" using an Asset based Analysis Approach in order to educate each other on current efforts, opportunities to collaborate, and potential gaps to fill. Next, the committee brainstormed strategies and tactics to support the goals. With the help of facilitators and subject matter experts, key evidence-based strategies were highlighted within the list of ideas. For "Access to Quality Healthcare, including Mental Health Services", a SWOT Analysis was used to explore existing strengths and brainstorm opportunities while faced with known weaknesses and threats. GCDHEM, in collaboration with CVRMC, will be responsible for maintaining ongoing community engagement in the implementation of the CHIP. Gila County will continue quarterly meetings with the CHIP Advisory Committee to periodically review the plan, track and evaluate progress made in implementing strategies, and propose changes when greater impact can be achieved by modifying approaches. CVRMC has incorporated the CHNA and CHIP in their strategic action plans under the strategic goal of "Community." When needed, and as recommended by the Advisory Committee, workgroups focusing on particular goals will be established to ensure successful implementation. GCDHEM and CVRMC acknowledge that health improvements cannot be achieved alone. While participating in the development of the CHIP, partners demonstrated enthusiasm for ensuring that the plan is utilized to improve the health of Gila County and the CVRMC service region. This enthusiasm relates not only to the important priorities outlined in the CHIP, but also in the spirit of partnership that is required to work together across organizations to achieve the CHIP goals. Currently, CVRMC utilizes several methods of assessing community healthcare needs. Evaluating the health needs of the CVRMC service area leads to identifying physicians needed in the area as well as recognizing those services that are required to address illnesses which can be targeted for community education and intervention. Community Feedback CVRMC utilizes many methods of community feedback for needs determination. Our patients, their families, and the greater community enlighten our organization through patient surveys and direct comments. CVRMC strives to give the very best care, and in order to accomplish that goal, it is vital that patient and community comments and concerns are addressed. Professional Research Consultants conducts outpatient surveys for the Outpatient Surgery, Physical Therapy, Registration, Med Surg ICU, Obstetrics, Respiratory Therapy, Emergency, Laboratory, Clinics, and Radiology Departments on patient satisfaction. PRC also conducts the inpatient, Hospital Consumers Assessment of Healthcare Providers and Systems survey which measures patient satisfaction in multiple areas including promptness and efficiency of the admission and registration process, length of time waiting, nursing care, physician care, teamwork, discharge instructions, safety, cleanliness of the facility, food service, overall quality of care, and the likelihood of recommending the hospital to relatives and friends. Statistics regarding patient feedback are calculated on a weekly basis and distributed to all department directors with a hard copy, graphs are posted, and emails are dispersed to ensure all staff is informed of results. Management is then able to make necessary assessments of weak areas and strategically plan for improvements. Schedule H, Part I, Line 7 Cost to Charge Ratio Schedule H, Part III, Section A, Line 4 PATIENT ACCOUNTS RECEIVABLE CONSIST OF AMOUNTS OWED BY VARIOUS GOVERNMENTAL AGENCIES, INSURANCE COMPANIES AND PRIVATE PATIENTS. THE HOSPITAL MANAGES ITS RECEIVABLES BY REGULARLY REVIEWING THE ACCOUNTS, INQUIRING WITH RESPECTIVE PAYORS AS TO COLLECTABILITY AND PROVIDING FOR ALLOWANCES ON THEIR ACCOUNTING RECORDS FOR ESTIMATED CONTRACTUAL ADJUSTMENTS AND NONCOLLECTABLE ACCOUNTS. Schedule H, Part III, Section B, Line 8 The costing methodology is Cost to Charge, as calculated by the annual Medicare cost report. Schedule H, Part III, Section C, Line 9b CVRMC MANAGEMENT SHALL DEVELOP POLICIES AND PROCEDURES FOR INTERNAL AND EXTERNAL COLLECTION PRACTICES THAT TAKE INTO ACCOUNT THE EXTENT TO WHICH THE PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE, A PATIENT'S GOOD FAITH EFFORT TO APPLY FOR A GOVERNMENTAL PROGRAM OR FOR FINANCIAL ASSISTANCE FROM CVRMC, AND A PATIENTS GOOD FAITH EFFORT TO COMPLY WITH HIS OR HER PAYMENT AGREEMENTS WITH CVRMC. Schedule H, Part VI, Line 2 Audio of the actual phone surveys are also available to all management. Many changes within CVRMC have been made as a direct result of the feedback obtained in these surveys. Hospital Consumers Assessment of Healthcare Providers and Systems is a standardized survey method conducted nationally and is publicly reported regarding the patients opinions and observations regarding their hospital care. This survey is helpful in determining how CVRMC measures against other hospitals across the nation. These objective and meaningful comparisons of hospitals on topics that are important to the consumer and the public reporting aspect of HCAHPS serves as a transparency tool which drives accountability and improves quality of care. Direct feedback from patients and family members is also a tool utilized for needs assessment. One of the many advantages of a rural hospital is the personal relationships the staff and patients are able to build. Direct phone calls, emails, or letters received from patients after their care has been provided is a valuable source of information for determining need. Legislative Actions Legislative decisions will have a dramatic effect on the direction CVRMC will move regarding community benefit as well as how healthcare for the region will be financed and delivered. As healthcare reform moves forth, CVRMC will continue to offer community benefit programs within its budgetary means in response to the needs of the region served. CVRMC will continue to strive for growth, bringing new services and structures to the hospital while focusing on wellness and prevention. The Payer Mix By identifying "customers," CVRMC is able to determine to whom services are provided. This information is invaluable for the strategic planning and management of the hospital in regards to new services and/or the addition of new providers. The payer mix also provides valuable information regarding the mix of services needed, education programs, new outreach programs, and future demands. The payer mix is also a very good indicator of the social economic structure of the community, allowing CVRMC to tailor programs to better meet the communities needs. Medical Staff Development Plan The approach used to project physician need for Cobre Valley Regional Medical Centers service area included the following: Defining the CVRMC service area and market share by service area and service line Projecting the service areas population growth and characteristics for the next five years Taking into account competition and other local circumstances such as, in migration, outmigration Developing a profile of the current medical staff including number, FTE, specialty, age, activity Identifying an appropriate demand model from among the available physician need estimation tools Utilizing the above information, estimates are developed projecting the number of physicians by specialty required to serve the CVRMC service region. Methods used to project physician need include: Demographics Population The source for the population is the Claritas Update Demographics product. Estimates are data prepared for the current year and projections are prepared for dates five years in the future. The CUD is brought up to date each year for many geographic levels including national, state, county, city town, census tract and block group. Data is also available for commonly used areas as metropolitan areas, ZIP Codes, and other media areas. Because it is produced for small areas, the update can be easily aggregated to custom geographic areas specified by the user. Provider Supply Provider supply is provided by CVRMC management. Much of the physician information is obtained by medical staff rosters and the survey responses. The information gathered for the provider supply is the provider name, specialty, town in which they practice, office days and times, birth date, and any information about their practice. Provider Demand The two models used to determine provider demand and community need are the: 1. Population Based Model which is obtained by multiplying Thomson Reuters physician to population ratios by the population of the service area. 2. Productivity Based Model provides data on current and projected physician resources required within a defined market. Service Area Definition A service area definition takes into consideration multiple factors including patient origin, market share, population and geography. The service area is defined as the geographic area from which a healthcare facility draws at least 75 percent of its patients and in which it maintains a considerable share of the healthcare market. The first step in defining CVRMCs service area is identification of the communities from which the hospital draws 75 percent of patients, and to assess the hospital's market share in each of these communities. The service area was then divided into two service areas: Primary and Secondary. Three ZIP Codes have been identified as CVRMCs primary service area and five Zip Codes comprise the secondary service area. Out Migration Data CVRMC is located 85 miles southeast of the largest metropolitan area in Arizona. The cities of Phoenix, Mesa, and Tempe are the out migration areas patients of the CVRMC service area sometimes choose for healthcare services. Out migration data is provided by the HealthTech Strategic Planning department in the Environmental Assessment and Market Share Report. Two data sources are used. Service areas are determined by analyzing the ZIP Codes from several perspectives including patient origin, market share, population, and geographic location of the ZIP Code. This information along with payer mix information can determine the inpatient market share by service area, discharges, inpatients market share by payer mix in the primary service area, inpatients market share by payer mix in the secondary service area, service line market share of primary service area, service line market share of the secondary service area, market share of emergency visits in the primary service area, market share of emergency visits in the secondary service area, and Medicare outpatient volume, and market share by competing hospitals in the metropolitan areas. Population trends are another determination for needs assessment. Population trends by ZIP Code are provided for the primary and secondary service areas of CVRMC as well as population trends by age. As the population trends increase or decrease, and healthcare needs change with age, it is definitely something to consider when strategically planning for future needs. Demographic snapshots are also provided by the report for each of the service areas that reflect various characteristics, including the education, household income, and ethnicity. These are important factors to consider when establishing marketing and public relations messages. Those in CVRMCs primary and secondary service areas are primarily White and Hispanic; have a lower percentage than the U.S. with a high school degree, and a higher percentage than the U.S. with lower incomes. Diagnosis Related Groups Groups of patients tend to have common demographic, diagnostic, and therapeutic attributes that determine their healthcare needs. Diagnosis Related Groups form a manageable, clinically coherent set of patient classes relating CVRMCs case mix to the resource demands and the associated costs experienced by the hospital. Database of Admissions Queries of the CVRMC Admissions database are a quick analytical source for determining the major health issues of the region. From this information education, prevention, and intervention can be determined and implemented in community benefit programs or released to other regional health organizations for tracking and trending the impact of their programs within the region. Case Management, Discharge Planning, and Social Work Through case management, discharge planning, and social work provided by CVRMC, data is generated by specific diagnosis related groups. This diagnosis data by group could be used to identify key risks for change, i.e. tobacco cessation or weight management programs. Many of these groups move on to long term care facilities, hospice services, or home care needs. CVRMC Board of Directors The CVRMC Board of Directors is strategically designed to encompass a variety of professions from the region. Mining, county government, ranching, banking, insurance, business, and medical professionals make up the members of the board which bring a diversity of ideas and information regarding healthcare needs within the service region. Other Data from the National Health Association and the Arizona Health Association gives CVRMC comparisons to national and state averages for specific health issues. Connectivity to organizations such as the County Health Department, regional school districts, and other health, safety, and regional associations provides information regarding health issues and needs. Schedule H, Part VI, Line 3 In public waiting areas of Cobre Valley Regional Medical Center, multi lingual posters explain to patients in common language that CVRMC is a Medicare/AHCCCS participating facility. In addition, posters and signs in these areas explain to the patient what financial obligations may occur and if additional billing will be submitted by providers. If, at the time of admission or visit, the patient does not have third party insurance coverage, the patient is offered an AHCCCS application for health-care coverage through public programs. In addition, staff members in the ER are trained to run searches to determine if a patient has existing coverage. Below is a description of the Patient Education Policy followed by a copy of the Patient Financial Assistance and Discount Program. When neither existing insurance coverage nor AHCCCS eligibility is available, the Patient Account Services department talks to the patient about the Cobre Valley Regional Medical Centers Charity Care program. The patient is offered an AHCCCS application, and a financial contract. The patient is advised they must complete the AHCCCS application, appointment, etc. If the patient is denied by AHCCCS, they are to present the denial to the Patient Accounting Department. When the patient is offered the financial assistance application, demonstrable proof of income, living expenses, size of household and proof of AHCCCS denial are required for completion of the application. Included in the income computation are earnings from employment and other income such as child support, alimony, social security and from any other sources. When requesting proof of living expenses, patients are asked to provide documentation of expenses associated with housing, utilities, transportation, insurance, food, other medical bills, and all other living expenses. After all information is obtained and reviewed, the Federal Poverty Income Guidelines and Discount Table is now being used to calculate the total discount that can be offered to the patient. Once this is compiled, Patient Account Services signs off on the Financial Assistance Form which is forwarded to the Director, CFO, and CEO for approval, as appropriate. POLICY OVERVIEW Cobre Valley Regional Medical Center is committed to providing financial assistance to persons who have health care needs and are uninsured. Consistent with its mission to deliver quality healthcare in a safe, respectful, and efficient manner, CVRMC strives to ensure that the financial capacity of people who need health care services does not prevent them from seeking or receiving care. PURPOSE This Policy provides a fair and comprehensive system of distributing free or discounted medical care to uninsured patients within the available resources of Cobre Valley Regional Medical Center. The Policy addresses: Eligibility criteria for financial assistance; The extent to which financial assistance includes free or discounted care; The basis for calculating amounts charged to individuals who are eligible for assistance under this policy; The method for applying for assistance; Measures to widely publicize the Policy RESPONSIBILITY It is the responsibility of the Hospital Board of Directors to ensure that this Policy is being administered and carried out in a consistent manner and within the guidelines set forth in controlling laws and regulations. SCOPE This Policy applies to all emergency and medically necessary inpatient and outpatient hospital services provided to Uninsured individuals who qualify for assistance in accordance with the terms and conditions herein. It also applies to CVRMC employed physician services, clinic services, or other services that may be offered by the Hospital. Any services deemed non-medically necessary or cosmetic in nature are not eligible for financial assistance. DEFINITIONS The following definitions shall apply to this Policy: "AGB discount percentage" is determined by dividing the sum of all claims Medically Necessary services provided at Cobre Valley Regional Medical Center paid during the Relevant Period by Medicare fee-for-service and all private health insurers as primary payors, together with any associated portions of these claims paid by Medicare beneficiaries or insured individuals in the form of co-pays, co insurance or deductibles. "Application Period": The period during which the Hospital must accept and process an application for assistance under this Policy in order to have made "reasonable efforts" to determine whether the patient is an individual who is eligible for assistance under this Policy. The Application Period ends on the 240th day the Hospital provides the individual with the first statement for care provided. "Extraordinary Collection Action" or "ECA": Actions taken by the Hospital against a patient or any other individual who has accepted or is required to accept responsibility for the patients bills that involve (i) a legal or judicial process; (ii) selling an individuals debt to a third party; or (iii) reporting adverse information about the individual to a consumer credit agency or credit bureau. charges all patients before applying any contractual allowances, discounts, or deductions. "Household Income": Means the total income of all members living in the individuals household. "Individuals who are eligible for assistance under this Policy": An individual who is uninsured and is eligible for financial assistance under this Policy. "Individuals who qualify for financial assistance": Individuals who are eligible for assistance under this Policy and who have submitted a completed financial assistance application within required time periods as set forth herein and have been approved for financial assistance according to the processes set forth herein. "Medically Indigent": Individuals who do not have health insurance and who are not eligible for other health care coverage, such as Medicare, Medicaid, or private health insurance. "Notification Period": Begins on the first date care is provided and ends on the 120th day after the Hospital provides the individual with the first bill for care. "Uninsured": A patient has no insurance or medical coverage under governmental programs and is not eligible for any other third party payment. ELIGIBILITY FOR FINANCIAL ASSISTANCE 1 Uninsured Status to be verified through state websites or other third party eligibility systems 2 Citizenship Individuals must be U.S. citizens a. Patients who are not legal U.S. citizens are not eligible for Financial Assistance. However, they are encouraged to inquire about emergency health care services through the Federal Emergency Services Program provided by AHCCCS. Patients who do not meet the qualifications of this program will be able to receive the Self Pay discount. 3 Federal Poverty Level - The applicant's household income must be at or below 400% of the Federal Poverty Guidelines 4 Homeless Individuals without a payment source may be classified as eligible for Financial Assistance if it is determined that they do not have a job, mailing address, residence, or insurance. Consideration must also be given to classifying emergency room patients who do not provide adequate information as to their financial status. In many instances, these patients are homeless and have few resources to cover the cost of their care. 5 Bankruptcy Individuals who are in bankruptcy or recently completed bankruptcy may be eligible for Financial Assistance. 6 Special circumstances In rare occasions, a patient's individual circumstances may be such that while they do not meet the regular Financial Assistance criteria in this policy, they do not have the ability to pay their Hospital bill. In these situations, with the approval of the CVRMC CEO/CFO, part or all of their cost of care may be written off. There must be complete documentation of why the decision was made to do so and why the patient did not meet the regular criteria. 7 Deceased patients without an estate or third party coverage will be eligible for financial assistance. Schedule H, Part VI, Line 4 Cobre Valley Regional Medical Center is located in Globe, Arizona and serves a population of 45,000 within a radius of 65 miles in a full-service acute care facility. This population includes both the primary and secondary service areas. CVRMC is located in the heart of the copper belt of Arizona and serves many rural copper communities within the region including its neighboring towns of Miami, Superior to the west, Kearny, Hayden, and Winkelman to the south. The Apache San Carlos Nation borders Globe to the east and Roosevelt, Pleasant Valley Young are located to the north. CVRMC serves as an acute medical surgical, obstetric, orthopedic, pediatric, and family practice provider for all the residents of these communities. The CVRMC primary and secondary service area communities are located in two counties, Gila and Pinal. Based on the 2010 U. S. Census, approximately 23 percent of the total population in Gila County was over the age of 65 while in neighboring Pinal County it was 15 percent, compared to 14 percent for Arizona and 13 percent for the United States. The five leading causes of death among adults age 65 and older in Gila and Pinal Counties are heart disease, cancer, chronic lower respiratory diseases, cerebrovascular disease, and diabetes. Total reported number of people with disabilities within Gila County is 22,453 and 63,082 for Pinal County. Globe and Miami, Arizona - Primary Service Area 62.7 percent Inpatient Patient Origin Globe, Miami and the unincorporated areas nearby are commonly called Globe Miami. The towns are located on the northeastern slope of the Pinal Mountains, and are surrounded by the Tonto National Forest. Globe Miami is located on U.S. Routes 60 and 70, and is served industrially by the Arizona Eastern Railway Globe Miami are located in Gila County with a total population of 18,134. Globes economy remains heavily dependent on the mining industry, but as the county seat, county as well as city government employment are the highest numbers of jobs within the city. Tourism and retirees are also important in Globe's economy. Miami borders Globe to the west and copper mining accounts for the largest number of jobs in Miami according to the 2014 annual report of the Arizona State Mine Inspector. Freeport McMoRan currently employs approximately 900 employees at its Miami operations; KGBM employs approximately 85 at its Carlota facility as it continues into a 5-year, shut down phase; Capstone Pinto Valley Mine employs approximately 300, while BHP Billiton employs 30 employees at the Miami Unit Operation. As of 2012, Miami was home to one of the last 4 copper smelters in the United States. Below is the housing status and demographic information for the population of Globe Miami and the unincorporated areas: Available upon request. Housing Status for Globe Miami, U.S. Census 2010 Total 9,090 Occupied 7,253 Owner-occupied 5,324 Population in owner-occupied( number of individuals ) 12,727 Renter-occupied 1,929 Population in renter-occupied( number of individuals ) 4,827 Households with individuals under 18 2,099 Vacant 1,837 Vacant: for rent 319 Vacant: for sale 142 Male 9,102 Female 9,032 Under 18 4,195 18 & over 13,939 20 - 24 989 25 - 34 1,787 35 - 49 3,146 50 - 64 4,104 65 over 3,486 Population by Ethnicity Hispanic or Latino 6,175 Non Hispanic or Latino 11,959 Population by Race White 14,862 African American 130 Asian 129 American Indian and Alaska Native 692 Native Hawaiian and Pacific Islander 15 Other 1,784 Identified by two or more 522 Roosevelt, Arizona - Primary Service Area 2.5 percent Inpatient Patient Origin Roosevelt is located 20 miles north of CVRMC and is a major center for fishing, boating, camping, water skiing, and other recreational water sports. The community of Roosevelt was developed after the construction of a masonry dam on the Salt River in 1911, making it the oldest artificial reservoir in Arizona and the largest within the boundaries of the state. The population of Roosevelt is estimated at 220 with many visitors moving in and out of the area depending on the season. San Carlos Apache Nation San Carlos, Ft. Apache, and Peridot, Arizona - Secondary Service Area 20.8 percen Inpatient Patient Origin The San Carlos Apache Indian Reservation is located 4 miles east of Globe and is located in Gila, Graham, and Pinal Counties. The San Carlos Reservation is home to a number of Apache tribes relocated from traditional Apache homelands from Arizona and New Mexico in 1871. The San Carlos Reservation is one of the poorest Native American communities in the United States, with the median annual household income being approximately 13,000. About 60 percent of the people live under the poverty level, and one-fourth of the active labor force is unemployed. The population of the San Carlos Reservation is just over 10,000 residents with its largest communities being San Carlos, Ft. Thomas, and Peridot, Arizona. The Apache Gold Casino employs 300 people while hunting, fishing, boating, camping, and gaming are attractions to tourists visiting the area. AZ - San Carlos CCD, Gila County, US Census 2010 Population Total Population 4,780 Housing Status ( in housing units unless noted ) Total 1,171 Occupied 1,059 Owner-occupied 769 Population in owner-occupied ( number of individuals ) 3,295 Renter-occupied 290 Population in renter-occupied ( number of individuals ) 1,474 Households with individuals under 18 706 Vacant 112 Vacant: for rent 13 Vacant: for sale 0 Population by Sex/Age Male 2,296 Female 2,484 Under 18 1,889 18 & over 2,891 20 - 24 454 25 - 34 617 35 - 49 732 50 - 64 610 65 & over 237 Population by Ethnicity Hispanic or Latino 152 Non Hispanic or Latino 4,628 Population by Race White 28 African American 1 Asian 0 American Indian and Alaska Native 4,727 Native Hawaiian and Pacific Islander 1 Other 2 Identified by two or more 21 AZ - San Carlos CCD, Graham County, US Census 2010 Population Total Population 5,288 Housing Status ( in housing units unless noted ) Total 1,455 Occupied 1,261 Owner-occupied 950 Population in owner-occupied 3,992 ( number of individuals ) Renter-occupied 311 Population in renter-occupied 1,296 ( number of individuals ) Households with individuals under 18 758 Vacant 194 Vacant: for rent 12 Vacant: for sale 1 Population by Sex/Age Male 2,607 Female 2,681 Under 18 1,965 18 & over 3,323 20 - 24 450 35 - 49 918 50 - 64 748 65 & over 353 Population by Ethnicity Hispanic or Latino 205 Non Hispanic or Latino 5,083 Population by Race White 112 African American 5 Asian 1 American Indian and Alaska Native 5,108 Native Hawaiian and Pacific Islander 0 Other 14 Identified by two or more 48 Pleasant Valley-Young, Arizona - Secondary Service Area Surrounded by the Tonto National Forest, Pleasant Valley-Young is a community in Gila County situated in the beautiful pines of the mountains. There are two main dirt roads in and out of Young, one from the north and one from the south, but no fully paved road to a connecting highway. Globe is 65 miles to the south of Young. According to the 2010 U. S. Census, Pleasant Valley-Young had a population of 376 people, 320 households, and 132 families living in the Pleasant Valley-Young area. The racial makeup was 100% White. The 320 households are comprised of 15.3% with children under the age of 18 living with them, 50.9% were married couples living together, 4.7% had a female householder with no husband present, and 39.7% were non-families. Individuals made up 33.4% of all households and 10.3% had someone living alone who was 65 years of age or older. The average household size was 2.08 and the average family size was 2.65. The median age was 51.5. Several small businesses exist in Pleasant Valley-Young. A gas station, convenience store, auto parts store, motel, thrift shore, library, and refuse service are among the businesses. Cobre Valley Regional Medical Center services the primary medical needs of the area with a medical clinic. The median income for a household in the Pleasant Valley-Young area is $26,250, and the median income for a family was $24,886. Males had a median income of $21,000 versus $26,458 for females. The per capita income for the area was $16,943. Schedule H, Part VI, Line 5 Cobre Valley Regional Medical Center has a health commitment to our employees, physicians, health and wellness organizations, our board of directors, benefactors, volunteers, and most importantly to our patients and families of the region we serve. CVRMC is striving to be more inclusive, collaborative, and effective regarding community building activities and donations. The mission of CVRMC is: "To develop and maintain a local health care delivery system that serves the region with quality, efficiency, and compassion. Our mission is your health." This is a living statement within each of our employees who work to provide direct or indirect patient care and is the driving force when setting goals, purchasing equipment, hiring employees, and planning activities throughout the region. The CVRMC Standards of Performance are the required code of conduct which will ensure the mission of CVRMC is carried forth. These standards include personal behaviors regarding privacy, attitude, communication, teamwork, courtesy, accountability, appearance, responsiveness, and safety. Through our community benefit and building activities, utilizing the standards of performance as the driving force, CVRMC is demonstrating accountability, gaining community trust, and fulfilling our mission to all our constituents of our service region. CVRMC receives expert operational support services through HealthTech Management Services. These areas of expertise include quality patient care, finance, revenue cycle, materials management, and strategic planning. The resources HealthTech Management Services provide are invaluable in assisting the CVRMC Board of Directors, administration, physicians, directors, and clinical and non-clinical staff in fulfilling the hospital's mission of Quality, Efficiency, and Compassion. Every three years, CVRMC has a strategic planning meeting with HealthTech Management Services. The meeting held on August 7 and 8, 2015, consisted of the CVRMC Board of Directors, Administration Team, and key advisors from HealthTech, who facilitated the meeting. The result of the meeting is the Strategic Plan which will guide and direct the leaders of CVRMC into the next three years. Through our strategic planning process, CVRMC identified The Patient Experience, People, Growth, and Community as our key strategic goals for the next three years. These goals are not independent of each other, but rather interdependent, connected and overlapping, each individual function thriving on the success of the others. The Patient Experience is defined as the combination of customer service and the quality provided to patients and families receiving services at CVRMC and its surrounding clinics. CVRMC will foster an environment where the quality of care and customer service provided to our patients, physicians and employees is relentlessly pursued with a philosophy of continuous improvement in delivery and outcome. People make the difference in the delivery of care and in the lives of our patients, physicians, fellow workers, and associates. CVRMC is committed to cultivate a workforce and medical provider community that are highly engaged, accountable, collaborative and committed to fulfilling the mission of maintaining a local healthcare delivery system that serves the region with quality, efficiency, and compassion. Growth, in both services and facilities, will provide for the needs of all the communities that depend on the healthcare provided by CVRMC. It is a strategy of CVRMC to aggressively pursue an increased share of the market and reduce out-migration by improving, expanding, adding and promoting services and physical structures that meet service area needs and are clinically and financially feasible. Community is the heart of our healthcare mission. Focused on promoting healthy living and prevention of chronic diseases, CVRMC realizes healthier communities are safer, have a stronger environment, are socially connected, and have people who truly care for one another. CVRMC has a commitment to care for its communities and the overall health of the people who make these communities great. Through strategic planning, relationship building, and collaboration, CVRMC will be able to address community health needs and move our population to a healthier state. Community Health Needs Assessment/Implementation with the Gila County Health Department From September 2015 through February 2016, stakeholders across Gila County and the CVRMC service region engaged in a community-driven process to identify the most pressing health issues facing residents. Lead by the Gila County Division of Health and Emergency Management and CVRMC, community members and organizations came together to provide valuable insights on experiences of health and sickness, as well as realistic ways to affect change. Through the process of the Community Health Needs Assessment, the following characteristics surfaced regarding Gila County and the CVRMC service region: Available upon request. The CHNA generated the data through community surveys, focus groups, and key informant interviews. The Community Health Implementation Plan will guide GCDHEM, CVRMC, and our partners to collaborate and respond to key factors that may be limiting our communities' ability to lead full, happy and healthy lives. Both the Community Health Needs Assessment and Implementation Plan are found on the CVRMC website. Community Benefit o "One Call" is a new service implemented by CVRMC in late 2015. The phone service is to help reduce the number of calls a customer needs to make in order to obtain information on health needs and/or social service agencies within the service region. "One Call" is a free service open to the general public and is staffed by a registered nurse who can also act as a liaison between medical staff, medical health facilities, and social services on behalf of the user. o "Healthy Living from the Inside Out" is a region-wide radio program which promotes health and wellness. Different topics are addressed each month with a health professional from CVRMC speaking to the listening audience and answering any phone questions. Topics have included educational information on diabetes, heart disease, nutrition, healthy pregnancy, exercise and wellness, to name a few. o The CVRMC Health Fair, over the past 7 years, saw a rapid increase in participation of health and wellness organizations as well as public attendance. In 2010, an estimated 500 members of our communities attended the health fair with 42 organizations providing health and wellness information. Public attendance has remained steady at about 1,000 for the past four years with participation of health o Donations to Community Organizations CVRMC recognizes the need to contribute to local organizations to help support their causes in regards to awareness, fundraising, promoting health/exercise/wellness, education, or finding a cure for cancer. The March of Dimes, Relay for Life, and Little League programs are examples. The State of Arizona has made drastic educational funding reductions the past several years and many schools in our service region have cut physical and health education programs in order to provide the basic requirements of English, Math, Science, and Social Studies. Cobre Valley Regional Medical Center chose to sponsor Copper Cities Youth Sports, Little League teams, Ray Elementary, Superior athletics, Miami Soccer, Globe High Cheer, to name just a few. Many youth programs are entirely dependent on the contributions of the major organizations of the area mining organizations, city and county governments, trucking industries, etc., and CVRMC, the regional medical provider. Many CVRMC employees donate time and expertise to speak at career fairs for the regional high schools, provide job shadowing experiences for the 7 regional high schools, and many tours for civic organizations and elementary/junior high students. The Globe Active Adult Center was given an electric wheel chair which was donated to CVRMC from a local family. Building networks of support has become part of the culture of CVRMC. Scholarship money was given to several organizations supporting the advancement in health education. As CVRMC, along with Gila County, moves forward to promote health and wellness within our service communities, our response to the needs of special populations will be essential for the reporting standards for "Community Health Needs." Together, with the assistance of health care organizations and professionals of our area, a well constructed Community Health Needs Assessment and Implementation Plan has been established and is responding to the identified needs of all our diverse communities, providing charitable care with purpose, and offers educational services and programs for the good of our public. Schedule H, Part VI, Line 7 State of Arizona. X 0 0 0 0 0 0 0 0 0 Thomas Hansen Physician 434412 0 0 0 0 0 0 0 0 0 434412 0 0 0 Anthony Daniels Physician 406006 0 0 0 0 0 0 0 0 0 406006 0 0 0 Dana Miller Physician 357354 0 0 0 0 0 0 0 0 0 357354 0 0 0 Binoy Chandra Physician 322409 0 0 0 0 0 0 0 0 0 322409 0 0 0 Form 990, Part III, Line 3 From Schedule H Part VI, Line 3DETERMINATION OF FINANCIAL ASSISTANCE ELIGIBILITY Financial assistance will be determined through an individual assessment of financial need, including an application process in which the patient or the patient's guarantor is required to cooperate and submit all documentation necessary to make the determination of financial need; a reasonable effort by the CVRMC to explore and assist patients in applying for appropriate alternative sources of payment and coverage from public and private payment programs; and will take into account the patient's assets and other financial resources. It is preferred but not required that a request for financial assistance and a determination of financial need occur prior to rendering of medically necessary services. The need for financial assistance shall be re-evaluated at each subsequent rendering of medically necessary services, if the last financial evaluation was completed more than one hundred eighty days prior, and at any time additional information relevant to the eligibility of the patient for financial assistance becomes known. The granting of financial assistance shall be based on an individualized determination of financial need, and shall not take into account age, gender, race, socio-economic, sexual orientation or religious affiliation. In determining whether each individual qualifies for Financial Assistance, only those patient billings not covered by other county or governmental assistance programs should also be considered. Many applicants are not aware that they may be eligible for assistance such as AHCCCS or other government or private funded programs. Persons eligible for programs such as AHCCCS but whose eligibility status is not established for the period during which the medical services were rendered may be granted Financial Assistance for those services. CVRMC may make the granting of Financial Assistance contingent upon applying for governmental program assistance. This may be prudent, especially if the patient requires ongoing services. EXCLUSIONS 1. This policy and the Financial Assistance Program do not apply to the portion of charges an insured patient is personally responsible for, i.e., co pays, co insurance, and deductibles, and does not apply to elective procedures except as may be determined in the sole discretion of CVRMC on a case-by-case basis. METHOD FOR APPLYING FOR FINANCIAL ASSISTANCE 1. A copy of this Policy and Financial Assistance applications will be made available at the Hospital or by contacting Patient Accounts/Billing Office at 928 425 3261. 2. Individuals, who feel that they qualify for financial assistance under this Policy, or have requested that financial assistance be provided, are required to submit an application on the Hospital provided form during the Application Period. It is the applicant's responsibility to provide proof of household income and/or any other information provided on the application as requested by the Hospital. 3. The applicant is required to submit all information required on the financial assistance application form, including, but not limited to, the following information: Copy of AHCCCS denial letter May be waived on a case by case basis Copies of pay stubs for the last 2 pay periods Number of dependents claimed on tax return Copies of bills showing expenses 4. Failure to provide this information will result in an incomplete application, which may result in the individual being denied assistance under this Policy. 5. Completed applications shall be returned to the Patient Accounts/Billing Department within the Application Period. All eligible applications will be processed within 30 calendar days. PUBLICATION OF POLICY 1 This Policy, an application, a plain language summary of the Policy, and any notices or publications regarding the Policy will be made available on the Hospital's website in pdf form. 2 The Policy, applications, and plain language summaries shall be available upon request, without charge at the Patient Accounts/Billing Department and by mail. 3 A plain language summary shall be conspicuously displayed in Hospital patient waiting areas and in the Patient Accounts/Billing Department in a manner that is reasonably calculated to attract visitors' attention. 4 A plain language summary of this Policy and a copy of the financial assistance application will be provided to all patients upon admission or registration at the Hospital or Clinics. ACTIONS THAT MAY BE TAKEN IN EVENT OF NONPAYMENT OR INSUFFICIENT PAYMENT 1. Accounts for hospital services for patients who are able, but unwilling, to pay are considered uncollectible bad debts and will be referred to outside agencies for collections. REGULATORY REQUIREMENTS 1. In implementing this policy, CVRMC management and CVRMC facilities shall comply with all federal, state and local laws, rules and regulations that may apply to activities conducted pursuant to this policy. ACCOUNTING FOR FINANCIAL ASSISTANCE 1. CVRMC will track and monitor Financial Assistance care being granted and will account for the write- offs as a separate Deduction from the Revenue general ledger account. RECORDKEEPING 1. Records relating to potential Financial Assistance applicants must be readily available. CVRMC will maintain a spreadsheet of all applicants and final disposition. the patient's account. APPLICATION OF POLICY 1. This policy does not create an obligation to discount for any charges or services not included in the Hospital bill at the time of service. This policy does not apply to services provided within the Hospital by physicians or other medical providers including Emergency Physicians, Anesthesiologists, Radiologists, Pathologist, etc. RELATED WEBSITES: Available upon request. Form 990, Part VI, Section A, Line 3 The CEO and CFO duties are carried out by employees of HealthTech Management Services, Inc. an unrelated management company. Compensation is included in the management fee paid to HealthTech Management Services. Form 990, Part VI, Section B, Line 11b A CPA firm prepares and reviews the Form 990 from data gathered and provided by CVRMC. The return is then provided to the CFO for review and approval. Any questions or concerns the CFO has are addressed and any corrections or clarifications are made. The final form 990, with all required schedules, is made available to the full board prior to filing with the IRS. Form 990, Part VI, Section B, Line 12c Board members and officers are covered by the organization's conflict of interest policy and are required to annually complete a questionnaire disclosing any and all possible conflicts of interest. Form 990, Part VI, Section B, Line 15 The Officer's compensation is determined by a review conducted by Healthtech management services, Inc. using data provided by a nationally recognized management consulting firm, along with Form 990 data from comparable organizations and other hospitals managed by Healthtech. Once this information has been compiled and reviewed, a meeting is held with the board and a decision is made on the Officers' compensation. Form 990, Part VI, Section C, Line 19 Available upon request. Form 990, Part IX, Line 11g Contract labor, Physician fees and Purchased Services.