2012-05-08T11:39:23-05:00 2011-09-30 WILLIAM STEELE & ASSOCIATES PC 40 STARK STREET MANCHESTER NH 03101 990 2010-10-01 020354549 THE CHESHIRE MEDICAL CENTER CHES 580 COURT STREET KEENE NH 03431 JILL BATTY 2012-04-30 1 MICHAEL A BARBARITA CPA 6036228881 2010 2016-02-24 21:20:13Z ARTHUR NICHOLS 580 COURT STREET KEENE NH 03431 153728162 0 X WWW.CHESHIRE-MED.COM X 1980 NH THE PRIMARY PURPOSE OF THE CHESHIRE MEDICAL CENTER IS TO ENSURE ACCESS TO QUALITY HEALTH CARE SERVICES TO ALL RESIDENTS OF THE MONADNOCK REGION. THE ORGANIZATION'S CHARITABLE MISSION IS ENHANCED THROUGH THE OPERATION OF A JOINT OPERATING PARTNERSHIP AGREEMENT WITH THE HITCHCOCK CLINIC. THE PURPOSE OF THE JOINT OPERATING PARTNERSHIP AGREEMENT IS TO PROVIDE A MORE EXTENSIVE AND EFFECTIVE HEALTH CARE DELIVERY SYSTEM TO THE COMMUNITIES IN THE MONADNOCK REGION BY ESTABLISHING JOINT PLANNING AND DECISION MAKING PROCESSES, INTERGRATING HEALTH CARE SERVICES AND ESTABLISHING MECHANISMS FOR THE REINVESTMENT OF RESOURCES TO IMPROVE COMMUNITY HEALTH. THE FINANCIAL RESULTS OF THE JOINT OPERATING PARTNERSHIP ARE REPORTED ANNUALLY ON FORM 1065, US PARTNERSHIP RETURN OF INCOME. 16 14 1133 235 191588 -262212 784279 733247 153761651 148687291 432176 1029747 3041232 3277877 158019338 153728162 0 0 0 0 58039730 62719447 0 0 0 99301760 91101239 157341490 153820686 677848 -92524 124631712 127769556 71976783 80428389 52654929 47341167 X THE PRIMARY PURPOSE OF THE CHESHIRE MEDICAL CENTER IS TO ENSURE ACCESS TO QUALITY HEALTH CARE SERVICES TO ALL RESIDENTS OF THE MONADNOCK REGION. THE ORGANIZATION'S CHARITABLE MISSION IS ENHANCED THROUGH THE OPERATION OF A JOINT OPERATING PARTNERSHIP AGREEMENT WITH THE HITCHCOCK CLINIC. THE PURPOSE OF THE JOINT OPERATING PARTNERSHIP AGREEMENT IS TO PROVIDE A MORE EXTENSIVE AND EFFECTIVE HEALTH CARE DELIVERY SYSTEM TO THE COMMUNITIES IN THE MONADNOCK REGION BY ESTABLISHING JOINT PLANNING AND DECISION MAKING PROCESSES, INTERGRATING HEALTH CARE SERVICES AND ESTABLISHING MECHANISMS FOR THE REINVESTMENT OF RESOURCES TO IMPROVE COMMUNITY HEALTH. THE FINANCIAL RESULTS OF THE JOINT OPERATING PARTNERSHIP ARE REPORTED ANNUALLY ON FORM 1065, US PARTNERSHIP RETURN OF INCOME. 0 0 138483679 148959345 THE CHESHIRE MEDICAL CENTER IS A COMMUNITY HEALTH CARE ORGANIZATION SERVING AS A REGIONAL REFERRAL CENTER FOR KEENE AND THE SURROUNDING SERVICE AREA. IT IS FULLY COMMITTED TO MEETING THE HEALTH CARE NEEDS OF THESE COMMUNITIES AND PROVIDING ACCESS TO QUALITY HEALTH CARE SERVICES AND PROGRAMS. AS A NON-PROFIT CORPORATION, THE CHESHIRE MEDICAL CENTER ACKNOWLEDGES ITS COMMITMENT TO PROVIDE SERVICES TO THE COMMUNITY. THESE SERVICES ARISE PRIMARILY FROM THE FOUR FOLLOWING GENERAL SERVICE CATEGORIES. 1) SUBSIDIZATION OF GOVERNMENT-SPONSORED HEALTHCARE PROGRAMS - PRINCIPALLY MEDICARE AND MEDICAID. 2) SPONSORSHIP AND/OR SUBSIDIZATION OF HEALTH-RELATED COMMUNITY SERVICES AND EDUCATIONAL PROGRAMS. 3) PROVISION OF HEALTHCARE AT NO CHARGE OR REDUCED CHARGE, ACCORDING TO FINANCIAL NEED. 4) PROVISION OF 24-HOUR EMERGENCY ROOM SERVICES, WITHOUT REGARD FOR ABILITY TO PAY. THE CHESHIRE MEDICAL CENTER, AS A MATTER OF POLICY AND PRACTICE HAS PROVIDED, AND WILL CONTINUE TO PROVIDE, A SIGNIFICANT CONTRIBUTION TO THE COMMUNITIES IT SERVES. 138483679 1 1 0 1 0 0 0 0 1 1 1 0 0 1 0 1 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 1 136 0 1 1133 1 1 1 0 0 0 0 0 0 0 0 0 X 16 14 0 0 0 0 1 1 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NH X MARY SHERWIN CONTROLLER 6033545400 CHESHIRE MEDICAL CENTER 580 COURT KEENE NH 03431 KATHI SNOW 2.00 X 0 0 0 LARRY JAEGER MD 2.00 X 0 0 0 JAMES PUTNAM 2.00 X X 0 0 0 WALTER ROHR 1.00 X 0 0 0 JAY KAHN 3.00 X X 0 0 0 MICHAEL NEWBOLD 2.00 X 0 0 0 JANE BEAUCHAMP 2.00 X 0 0 0 JOSEPH BERGMAN MD 2.00 X 194388 0 0 SYLVIA MCBETH 2.00 X X 0 0 0 MATTHEW GUILTINAN MD 2.00 X 0 0 0 JUDY KALICH 2.00 X 0 0 0 RICK CHURCH 1.00 X 0 0 0 ROBERT MUCHA 2.00 X 0 0 0 LESLIE PITTS MD 2.00 X X 0 0 0 ARTHUR NICHOLS 53.00 X X 496516 0 52509 ED BERGERON 1.00 X 0 0 0 JOSEPH HALLIDAY 1.00 X 0 0 0 STEVE HORTON 2.00 X 0 0 0 MARY LOUISE CAFFREY 2.00 X 0 0 0 JOHN SCHLEGELMILCH 3.00 X 0 0 0 KATHLEEN CRONIN 26.00 X 206689 0 47798 JILL BATTY 52.00 X 247597 0 48609 CINDI COUGHLIN 52.00 X 127629 0 28794 JULIE GREEN 51.00 X 161980 0 41976 PAUL PEZONE 51.00 X 144991 0 32742 ERLI CHEN 50.00 X 210894 0 37752 LARRY MILLER 50.00 X 187678 0 41242 KRISTIN ROSSI 50.00 X 160704 0 35237 2139066 0 366659 28 0 1 0 HUTTER CONSTRUCTION 130 SPIT BROOK ROAD NASHUA NH 03062 CONSTRUCTION MANAGERS 1216760 QUEST DIAGNOSTICS 5763 COLLECTION CENTER DRIVE CHICAGO IL 60693 LAB DIAGNOSTIC SERVICES 886820 NEW ENGLAND MEDICAL TRANSCRIPTION PO BOX 430 WOOLWICH ME 04579 TRANSCRIPTION 624106 MARY HITCHCOCK MEMORIAL ONE MEDICAL CENTER DR LEBANON NH 03755 LAB DIAGNOSTIC SERVICES 477123 HEALTHSOUTH OF CONCORD 254 PLEASANT ST NASHUA NH 03301 REHAB PROGRAM MGT SVCS 390380 23 268467 464780 733247 PATIENT SERVICE REVENU 621300 148639799 148639799 CONTRACT REVENUE 621300 47492 47492 148687291 624673 624673 405074 405074 405074 405074 PHARMACY & DRUGS 621300 1196036 1196036 FOOD SERVICE 621300 933924 933924 CHILD CARE CENTER 624410 591649 191588 400061 556268 272054 284214 3277877 153728162 148959345 191588 3843982 1272819 1081896 190923 40964125 34737578 6226547 4709335 3993516 715819 12505262 10604462 1900800 3267906 2771184 496722 102862 102862 131460 131460 630951 535046 95905 322427 322427 362157 307109 55048 6482116 5496834 985282 188089 188089 1237450 1049358 188092 7830568 6640322 1190246 1203491 1020560 182931 DRUGS, CHEMICALS, SUPPL 14931843 14931843 CONTRACT LABOR 11011623 11011623 BAD DEBTS 8757199 8757199 MEDICAL & SURG. SUPPLIE 7239083 7239083 OTHER PURCHASED SERVICE 6884762 5838278 1046484 23785158 21957272 1827886 153820686 138483679 15337007 0 14984165 22641220 18778536 15478992 2251617 2207852 1603607 1916756 164200786 95034275 69036247 69166511 11988185 12425042 5989355 3933183 124631712 127769556 11798315 14175684 38831 12291042 11884485 14959855 15497187 32888740 38871033 71976783 80428389 X 50209368 44706598 2445561 2634569 52654929 47341167 124631712 127769556 X -92524 -5221238 X 0 1 1 X 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 27458 27458 0 EXPLANATION OF OTHER LOBBYING ACTIVITIES: PART II-B, LINE 1I: A PORTION OF AHA & NHHA DUES ARE ALLOCATED TO LOBBYING EXPENSE 2445561 168756 299947 279695 2634569 1479480 164317 1124611 322848 2445561 1408853 88740 18113 1479480 1.00000 0 0 4058474 4058474 74593240 36728683 37864557 85549072 58305592 27243480 69166511 POOLED INVESTMENTS 11480195 F FUNDED DEPR ACCOUNT 944847 F 12425042 PENSION LIABILITY 33904316 AMOUNTS PAYABLE TO THIRD PARTY 712384 MISCELLANEOUS OTHER LIABILITIES 548138 DUE TO AFFILIATES 3706195 38871033 153728162 153820686 -92524 -596500 -4624738 -5221238 -5313762 152586689 0 152586689 1141473 1141473 153728162 152679213 0 152679213 1141473 1141473 153820686 DESCRIPTION OF INTENDED USE OF ENDOWMENT FUNDS: PART V, LINE 4: INCOME FROM THE ENDOWMENTS ARE USED TO SUPPORT THE ORGANIZATION'S PROGRAMS. PART XI, LINE 8 - OTHER ADJUSTMENTS: PENSION LIABILITY ADJUSTMENT -4,624,738. PART XII, LINE 4B - OTHER ADJUSTMENTS: RECLASS FROM REVENUE TO EXPENSE 1,141,473. PART XIII, LINE 4B - OTHER ADJUSTMENTS: RECLASS FROM REVENUE TO EXPENSE 1,141,473. 1 1 1 X 225.000000000000 1 X 1 1 1 0 1 1 1945 2734383 2734383 0.01780 16343984 7239010 9104974 0.05920 1945 19078367 7239010 11839357 0.07700 16272 2466971 75741 2391230 0.01550 1221 228386 100 228286 0.00150 335 242529 9915 232614 0.00150 50 153597 153597 0.00100 5254 301141 301141 0.00200 23132 3392624 85756 3306868 0.02150 25077 22470991 7324766 15146225 0.09850 20702 235821 235821 0.00150 4420 122093 54656 67437 0.00040 94428 94428 0.00060 25122 452342 54656 397686 0.00250 1 3896954 974238 44635486 47785907 -3150421 X 1 1 1 KEENE HEALTH ALLIANCE INTEGRATING HEALTH CARE SERVICES TO PROVIDE EFFECTIVE DELIVERY SYSTEM 0.50000 0.00000 0.00000 3 NEW ENGLAND LIFE CARE INC A NOT-FOR-PROFIT HOME INFUSION THERAPY COOPERATIVE. 0.02000 0.00000 0.00000 4 NH LITHOTRIPSY LITHOTRIPCY SERVICES 0.03750 0.00000 0.00000 5 NH IMAGING IMAGING SERVICES 0.08330 0.00000 0.00000 1 1 CHESHIRE MEDICAL CENTER

580 COURT STREET KEENE NH 03431

X X X NOT REQUIRED 1 PART II: THE MEDICAL CENTER HAS BEEN ACTIVELY ENGAGED SINCE THE SPRING OF 2006 IN VISION 2020: TO MAKE KEENE AND THE SURROUNDING REGION THE HEALTHIEST IN THE NATION BY THE YEAR 2020. OVER THE PAST THREE YEARS THE ORGANIZATION HAS FOCUSED ON STREAMLINING AND IMPROVING INTERNAL OPERATIONS TO CREATE THE STRENGTH NECESSARY TO LEAD AND FACILITATE THIS INITIATIVE WITHIN THE BROADER COMMUNITY. MANAGEMENT HAS CREATED COMMUNITY-BASED WORKGROUPS TO DEFINE THE OBJECTIVES, TASKS, AND CHANGES NECESSARY TO ACHIEVE VISION 2020. THE CAMPUS HAS BUILT ON ITS EXISTING STRONG RELATIONSHIPS WITH OTHER REGIONAL PROVIDERS, AGENCIES, AND BUSINESSES TO SUPPORT THE PLAN AND HAS STARTED IMPLEMENTING A VARIETY OF PILOT PROGRAMS RELATED TO POPULATION HEALTH MANAGEMENT AND EMPLOYEE WELLNESS. THE ORGANIZATION IS A FOUNDING MEMBER OF THE COUNCIL FOR HEALTH COMMUNITIES WHICH HAS BEEN IN EXISTENCE FOR MORE THAN 10 YEARS AND HAS DEVELOPED A VARIETY OF PREVENTION, TRANSPORTATION, REFERRAL, AND HEALTH PROMOTION PROGRAMS. PART III, LINE 4: CHESHIRE MEDICAL CENTER MANAGEMENT ESTIMATES THAT APPROXIMATELY 25% OF BAD DEBT EXPENSE (APPROXIMATELY 5 TIMES THE REGION'S POVERTY RATE) IS AN APPROPRIATE ESIMATION OF PATIENTS WHO WOULD HAVE BEEN ELIGIBLE FOR THE ORGANIZATION'S FINANCIAL ASSISTANCE PROGRAM BUT DID NOT APPLY. THIS ESTIMATION IS BASED ON THE RECOGNITION THAT THE FINANCIAL ASSISTANCE PROGRAM IS AVAILABLE TO RESIDENTS WITH INCOMES OF UP TO THREE TIMES THE FEDERALLY DEFINED POVERTY INCOME LEVELS AND THE ASSUMPTION THAT PATIENTS WHO CHOOSE NOT TO PAY THEIR BILLS ARE MORE LIKELY TO FALL WITHIN THE LOWER INCOME LEVELS. FOR 2011, THE ESTIMATED AMOUNT OF BAD DEBT EXPENSE (AT COST) ATTRIBUTABLE TO PATIENTS WHO WOULD HAVE BEEN ELIGIBLE FOR FINANCIAL ASSISTANCE IS $974,238. PART III, LINE 8: THIS SHORTFALL SHOULD BE CONSIDERED COMMUNITY BENEFIT BECAUSE WE ARE THE ONLY HOSPITAL/MEDICAL CENTER IN CHESHIRE COUNTY, NEW HAMPSHIRE AND WE ARE DESIGNATED BY CMS AS A MEDICARE DEPENDENT HOSPITAL (MDH) DUE TO GREATER THAN 60% 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. PART III, LINE 9B: SYSTEMS ARE IN PLACE TO CAPTURE FINANCIAL ASSISTANCE ACCOUNTS PRIOR TO A BILL GOING TO THE PATIENT PART VI, LINE 2: THE COMMUNITY NEEDS ASSESSMENT WAS COORDINATED WITH THE ASSISTANCE OF THE BROAD-BASED COMMUNITY HEALTH COALITION, THE COUNCIL FOR A HEALTHIER COMMUNITY. IN PROMOTING THE HEALTHIEST COMMUNITY INITIATIVE, KNOWN LOCALLY AS VISION 2020, THE COUNCIL IDENTIFIED COMMUNITY NEEDS TOWARD A GOAL OF BECOMING THE HEALTHIEST COMMUNITY IN THE NATION BY THE YEAR 2020. THE COUNCIL FORMED FIVE WORKGROUPS AROUND STRATEGIC THEMES INCLUDING: HEALTH STATUS, HEALTHCARE ACCESS; HEALTH LITERACY, WELLNESS, AND SOCIAL CAPITAL. THE WORKGROUPS MET FROM JANUARY 2008 - OCTOBER 2009 TO IDENTIFY KEY GOALS, KEY MEASURES, AND LOCAL COMMUNITY ASSETS. THIS WORK IS SUMMARIZED IN THE COMMUNITY NEEDS ASSESSMENT FOUND AT THE WEB SITE HEALTHIESTCOMMUNITY.ORG. WE HOSTED A PLANNING SUMMIT IN MAY OF 2010 TO IDENTIFY CONTRIBUTING FACTORS FOR EACH INDICATOR IN THE COMMUNITY ASSESSMENT. THE 215 ATTENDEES ALSO IDENTIFIED POSSIBLE PROGRAMS AND POLICIES TO ADDRESS EACH NEED. SUMMIT INFORMATION WILL BE USED TO DEVELOP ACTION PLANS DURING THE FALL AND WINTER OF 2010. CHESHIRE MEDICAL CENTER PROVIDES STAFF FOR THE VISION 2020 INITIATIVE AND FUNDED THE COMMUNITY ASSESSMENT PROCESS THROUGH AN EVALUATION PARTNERSHIP CONTRACT WITH ANTIOCH NEW ENGLAND UNIVERSITY. THE COMMUNITY ADVISORY COMMITTEE, SERVING IN AN ADVISORY CAPACITY FOR BOTH HOME HEALTHCARE, HOSPICE AND COMMUNITY SERVICES, AND CHESHIRE MEDICAL CENTER/DARTMOUTH HITCHCOCK KEENE, REVIEWED AND COMMENTED ON THE COMMUNITY BENEFIT PLAN. THE REPORT IS AVAILABLE TO THE PUBLIC ON THE CHESHIRE MEDICAL CENTER WEBSITE: CHESHIREMED.ORG PART VI, LINE 3: CMC IS COMMITTED TO PROVIDING MEDICALLY NECESSARY CARE TO PATIENTS REGARDLESS OF THEIR ABILITY TO PAY FOR SERVICES. NON-EMERGENCY PATIENTS SIGN A FINANCIAL RESPONSIBILITY STATEMENT UPON ADMISSION TO CERTIFY RECOGNITION OF THEIR RESPONSIBILITY FOR PAYMENT OF THEIR BILLS. HOWEVER, THERE WILL BE INSTANCES WHERE THE PATIENT, DUE TO THE LACK OF FUNDS OR THIRD PARTY COVERAGE, WILL NOT BE ABLE TO MEET THIS OBLIGATION. CMC NOTIFIES PATIENTS OF THEIR POTENTIAL TO OBTAIN ASSISTANCE THROUGH THE REGISTRATION AND BILLING PROCESSES. UPON REGISTRATION, PATIENTS WITHOUT INSURANCE ARE OFFERED THE OPPORTUNITY TO APPLY FOR FINANCIAL ASSISTANCE. IN ADDITION, RECEPTIONISTS AND CLINICIANS IN ALL AREAS ARE EDUCATED TO REFER PATIENTS TO THE FINANCIAL ASSISTANCE PROCESS IN THE EVENT PATIENTS EXPRESS CONCERNS WITH THEIR ABILITY TO PAY FOR SERVICES. THE APPLICATION INFORMATION IS POSTED ON THE INTRANET AND BROCHURES DESCRIBING THE PROGRAM ARE READILY AVAILABLE TO PATIENTS. PATIENTS ARE INFORMED OF THE PROGRAM AVAILABILITY ON ANY INVOICES THEY RECEIVE AND INDIVIDUALS WHO ATTEMPT TO COLLECT PATIENT BALANCES ARE ALSO TRAINED TO REFER PATIENTS TO THE FINANCIAL ASSISTANCE PROCESS. THE FINANCIAL ASSISTANCE APPLICATION PROCESS IS COMPREHENSIVE AND EVALUATES A PATIENTS ELIGIBILITY FOR A VARIETY OF FEDERAL, STATE, AND LOCAL GOVERNMENT PROGRAMS IN ADDITION TO CMC'S INTERNALLY FUNDED FINANCIAL ASSISTANCE PROGRAM. PART VI, LINE 4: 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, NELSON/MUNSONVILLE, RICHMOND, ROXBURY, STODDARD, SULLIVAN, SURRY, SWANZEY, TROY, WALPOLE, WESTMORELAND AND WINCHESTER, ALL LOCATED IN CHESHIRE COUNTY. ACCORDING TO THE 2010 CENSUS, THE MEDICAL CENTER'S PSA REPRESENTED APPROXIMATELY 5.01% OF NEW HAMPSHIRES POPULATION. THE PSA'S TOTAL POPULATION WAS 66,017 WITH 23,409 RESIDING IN KEENE, THE LARGEST COMMUNITY IN THE SERVICE AREA. AS OF 2010, 8,350 OR 12.65% OF THE MEDICAL CENTER'S PSA RESIDENTS WERE 65 YEARS OF AGE OR OLDER. APPROXIMATELY 2,744 RESIDENTS, OR 4.1% OF THE TOTAL PSA POPULATION, WERE 80 YEARS OF AGE OR OLDER. AS OF 2010, APPROXIMATELY 42% OF THE POPULATION OF THE MEDICAL CENTERS PSA WAS 45 YEARS OF AGE OR OLDER. APPROXIMATELY 40% OF THE POPULATION OF THE MEDICAL CENTERS PSA WAS BETWEEN 15 AND 44, THE AS OF FEBRUARY 2010, THE STATE UNEMPLOYMENT RATE WAS 5.2% AND THE UNEMPLOYMENT RATE FOR CHESHIRE COUNTY WAS 5.5%. ACCORDING TO THE 2010 CENSUS, THE POVERTY RATE FOR CHESHIRE COUNTY WAS 10% AS COMPARED TO 7.8% FOR THE STATE OF NEW HAMPSHIRE. PART VI, LINE 6: A COMPLETE COPY OF THE ORGANIZATION'S COMMUNITY BENEFIT REPORT CAN BE FOUND AT:HTTP://WWW.CHESHIRE-MED.COM/IMAGES/STORIES/COMMHEALTH/COMMUNITY_BENEFITS_2011.PDFTHE MEDICAL CENTER PLAYS AN ACTIVE ROLE IN PROMOTING COMMUNITY HEALTH AND OFFERS EDUCATIONAL PROGRAMS INCLUDING CLASSES AND WORKSHOPS IN DIABETES AND ASTHMA, STRESS MANAGEMENT, NUTRITIONAL COUNSELING, SMOKING CESSATION, HEALTHY BACK, WEIGHT CONTROL, TIME MANAGEMENT AND BREAST SELF-EXAMINATION. IN ADDITION, THE MEDICAL CENTER WORKS WITH THE COUNCIL FOR A HEALTHIER COMMUNITY, COMPRISED OF COMMUNITY LEADERS, TO OFFER SEVERAL COMMUNITY PROGRAMS INCLUDING: CHESHIRE SMILES, A SCHOOL-BASED DENTAL HEALTH PROGRAM FOR CHILDREN IN GRADES K-3, PROVIDES SCREENING, PREVENTION AND RESTORATIVE DENTAL CARE FOR CHILDREN IN CHESHIRE COUNTY SCHOOLS. A PUBLIC HEALTH HYGIENIST HIRED BY THE MEDICAL CENTER IS ASSISTED BY AREA DENTISTS. CHESHIRE MEDICAL CENTER /DARTMOUTH-HITCHCOCK KEENE 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. THE MEDICAL CENTER SPONSORS PATIENT VISITS AT DENTAL HEALTH WORKS, A PUBLIC/PRIVATE PROGRAM SERVING UNDERSERVED RESIDENTS OF CHESHIRE COUNTY. CHESHIRE COALITION FOR TOBACCO-FREE YOUTH IS COMMITTED TO REDUCING THE NUMBER OF YOUNG PEOPLE IN THE COMMUNITY WHO USE TOBACCO PRODUCTS. WORKING WITH LOCAL SCHOOLS, POLICE AND HEALTH PROVIDERS, THE COALITION HAS IMPLEMENTED VENDOR COMPLIANCE PROGRAMS, HAS PROVIDED A TOBACCO AVOIDANCE CURRICULUM FOR USE IN AREA SCHOOLS AND HAS PRODUCED ITS OWN TELEVISION AND RADIO PUBLIC SERVICE ANNOUNCEMENTS ADDRESSING TOBACCO USE. MEDICATION ASSISTANCE PROGRAM ADDRESSES THE CRITICAL NEED FOR PROGRAMS TO HELP LOW INCOME PEOPLE AFFORD MEDICATIONS. THE MEDICATION ASSISTANCE PROGRAM AT THE MEDICAL CENTER WAS INITIATED IN MARCH, 1999. IT WAS THE FIRST HOSPITAL-BASED PROGRAM OF ITS KIND IN THE STATE OF NEW HAMPSHIRE AND WAS THE FIRST RECIPIENT OF THE NEW HAMPSHIRE MEDICATION BRIDGE AWARD. ADVOCATES FOR HEALTHY YOUTH (AFHY) IS A COMMUNITY COALITION SUPPORTED BY THE MEDICAL CENTER WHICH HAS BEEN WORKING CLOSELY WITH COMMUNITY HEALTH PROVIDERS, KEENE STATE COLLEGE, ANTIOCH UNIVERSITY NEW ENGLAND, KEENE PARKS AND RECREATION CENTER, AND AREA SCHOOLS TO ADDRESS THE EPIDEMIC OF CHILDHOOD OBESITY. IN 2005, AFHY COMPLETED IMPLEMENTATION OF A PILOT PROGRAM IN TWO AREA SCHOOLS. IN 2006 THE PROGRAM EXPANDED EFFORTS BY OFFERING SMALL GRANTS TO SCHOOLS AND AFTER SCHOOL PROGRAMS TO SUPPORT COSTS OF PHYSICAL ACTIVITY AND NUTRITION PROGRAMS. GRANT PROJECTS INCORPORATED THE KEY LESSONS LEARNED DURING THE PILOT PROJECT. IN 2007, AFHY BEGAN TAKING STEPS TO IMPLEMENT THE 5-2-1-0 COMMUNITY PUBLIC MESSAGING CAMPAIGN TO EDUCATE FAMILIES ABOUT CHILDHOOD OBESITY AND TO ADVOCATE HEALTH PROMOTION OPTIONS TO PREVENT OR REDUCE OBESITY. THE PROGRAM IS NOW WORKING WITH LOCAL SCHOOLS AND AFTERSCHOOL PROGRAMS TO IMPLEMENT THE COORDINATED APPROACH TO CHILD HEALTH (CATCH) PROGRAM. THE CHESHIRE HEALTHY EATING ACTIVE LIVING (HEAL) INITIATIVE CREATED THE TURN A NEW LEAF MENU LABELING PROGRAM IN LOCAL RESTAURANTS. THIS INITIATIVE IS ALSO AVAILABLE IN THE LOCAL COMMUNITY KITCHEN TO BRING HEALTHY EATING OPTIONS TO OUR MOST VULNERABLE POPULATION. SENIOR PASSPORT PROGRAM IS DESIGNED TO SERVE THE MEDICAL CENTER'S COMMUNITIES' ELDERS. PASSPORT MEMBERSHIP, WHICH IS OFFERED AT NO COST TO THOSE SIXTY YEARS AND OLDER, ENTITLES HOLDERS TO ENJOY LOW COST, HEART HEALTHY MEALS IN THE MEDICAL CENTER CAFETERIA, AND ATTEND WORKSHOPS AND HEALTH LECTURES WITH A SENIOR FOCUS. A NEWSLETTER IS SENT QUARTERLY TO PASSPORT HOLDERS. AS A PROGRAM OF THE VISION 2020 INITIATIVE, THE HEALTHY COMMUNITY CHAMPIONS PROGRAM HAS ENROLLED 1000 MEMBERS THAT HAVE MADE A COMMITMENT TO ACTIVELY ENGAGE IN IMPROVING THEIR HEALTH AND THE HEALTH OF OTHERS WHERE THEY LIVE, LEARN, WORK AND PLAY. THE TOTAL EXPENDITURES ASSOCIATED WITH THESE AND OTHER PROGRAMS FOR PERIOD ENDING 9/30/11 IS $6,438,937. REPORTS FILED WITH STATES PART VI, LINE 7 NH X 1 1 X X X X X 0 0 0 0 0 0 0 1 0 JOSEPH BERGMAN MD 194388 0 0 0 0 0 0 0 0 0 194388 0 0 0 ARTHUR NICHOLS 348825 0 103053 0 44638 0 31410 0 21099 0 549025 0 0 0 KATHLEEN CRONIN 158487 0 0 0 48202 0 30350 0 17448 0 254487 0 0 0 JILL BATTY 222697 0 0 0 24900 0 26510 0 22099 0 296206 0 0 0 CINDI COUGHLIN 115667 0 0 0 11962 0 14597 0 14197 0 156423 0 0 0 JULIE GREEN 124589 0 0 0 37391 0 23476 0 18500 0 203956 0 0 0 PAUL PEZONE 124991 0 0 0 20000 0 14461 0 18281 0 177733 0 0 0 ERLI CHEN 180886 0 0 0 30008 0 22243 0 15509 0 248646 0 0 0 LARRY MILLER 165682 0 0 0 21996 0 23375 0 17867 0 228920 0 0 0 KRISTIN ROSSI 138704 0 0 0 22000 0 16435 0 18802 0 195941 0 0 0 PART I, LINE 1A CHESHIRE MEDICAL CENTER DOES NOT REIMBURSE EXPENSES FOR FIRST CLASS TRAVEL, HOUSING ALLOWANCE, HEALTH OR SOCIAL CLUB DUES, PERSONAL SERVICES, BUSINESS USE OF PERSONAL RESIDENCE, DISCRETIONARY SPENDING ACCOUNTS, OR PROVIDE TAX INDEMNIFICATION OR GROSS UP PAYMENTS. CHESIRE MEDICAL CENTER DOES REIMBURSE BOARD MEMBERS FOR COMPANION TRAVEL TO BUSINESS RELATED MEETING UNDER SPECIFIC CIRCUMSTANCES. ALL REIMBURSEMENTS ARE REPORTED ON FORM 1099 ISSUED TO THE BOARD MEMBER. ONE REIMBURSEMENT WAS MADE IN CALENDAR YEAR 2010. PART I, LINE 7 SENIOR MANAGEMENT IS ELIGIBLE FOR AN INCENTIVE COMP PAYMENT AT THE DISCRETION OF THE BOARD BASED ON, BUT NOT DIRECTLY RELATED TO, OVERALL ORGANIZATIONAL FINANCIAL PERFORMANCE AND OTHER DISCRETIONARY MEASURES. NH HEALTH & EDUCATION FACILITIES AUTHORITY 020279866 2009-08-27 15000000 REFUND COMMERCIAL DEBT, AQUISITION OF EQUIPMENT, RENOVATIONS 0 0 0 15000000 5667081 244244 578012 8510663 2009 0 0 1 1 0 0 0 0 0 0.00000 0.00000 0.00000 1 1 1 1 TD BANK NA 7.000000000000 0 0 0 0 0 FORM 990, PART VI, SECTION A, LINE 6 THE SOLE MEMBER OF THE CHESHIRE MEDICAL CENTER IS THE CHESHIRE HEALTH FOUNDATION FORM 990, PART VI, SECTION A, LINE 7A THE BOARD OF TRUSTEES CONSISTS OF NO FEWER THAN 15 VOTING MEMBERS WHICH INCLUDES THE PRESIDENT/CEO AND PRESIDENT OF THE MEDICAL STAFF. OTHER MEMBERS ARE NOMINATED BY THE CHESHIRE HEALTH FOUNDATION GOVERNANCE COMMITTEE AND ELECTED BY THE FOUNDATION BOARD FORM 990, PART VI, SECTION B, LINE 11 COPY OF 990 IS AVAILABLE FOR ANY BOARD MEMBER TO REVIEW PRIOR TO FILING. THE BOARD HAS FORMALLY DELEGATED REVIEW OF THE 990 TO THE FINANCE AND AUDIT COMMITTEE. COMMITTEE MEMBERS RECEIVE COPIES OF THE 990 AND IT IS REVIEWED IN A MEETING PRIOR TO FILING. FORM 990, PART VI, SECTION B, LINE 12C OFFICER, BOARD MEMBERS AND KEY EMPLOYEES ANNUALLY DISCLOSE POTENTIAL CONFLICTS OF INTEREST AND ARE REQUIRED TO RECUSE THEMSELVES FROM ALL BOARD ACTIVITY RELATED TO ALL CONFLICTS. FORM 990, PART VI, SECTION B, LINE 15 CHESHIRE MEDICAL CENTER/DARTMOUTH HITCHCOCK KEENE HAS RETAINED YAFFE & COMPANY, INC. TO PROVIDE CONSULTATION TO THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES REGARDING EXECUTIVE COMPENSATION, BENEFITS, AND PERQUISITES. YAFFE & COMPANY, INC. IS A INDEPENDENT CONSULTING FIRM WITH 35 YEARS OF SERVICE AND PROVIDES SERVICES TO NOT-FOR-PROFIT HOSPITALS AND HEALTH SYSTEMS. FURTHER YAFFE & COMPANY, INC. HAS BEEN ENGAGED DIRECTLY BY THE BOARD OF TRUSTEES OF CHESHIRE MEDICAL CENTER THROUGH ITS EXECUTIVE COMMITTEE TO ONLY PROVIDE SERVICES TO THE BOARD. AN EXECUTIVE COMMITTEE D/B/A COMPENSATION COMMITTEE CHARTER AND COMPENSATION PHILOSOPHY (APPROVED BY THE BOARD) DOCUMENTS THE COMPENSATION REVIEW PROCESS AND GUIDELINES SO AS TO PROVIDE AN ORDERLY STRUCTURE FOR EXECUTIVE TOTAL COMPENSATION DECISIONS. ANNUALLY, A MULTI-TIERED APPROACH USING INDEPENDENT COMPARABILITY DATA IS UTILIZED TO GAUGE APPROPRIATE COMPARATIVE MARKET LEVELS OF COMPENSATION AND BENEFITS. AN ANNUAL PERFORMANCE EVALUATION IS BASED ON SUBJECTIVE AND OBJECTIVE CRITERIA WHICH FLOW FROM THE 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 FOR THE OFFICE OF THE PRESIDENT WHICH PROVIDES AN ALIGNMENT BETWEEN EXECUTIVE COMPENSATION AND ACHIEVEMENT OF THE HOSPITAL'S STRATEGIC GOALS." FORM 990, PART VI, SECTION C, LINE 19 CMC MAKES GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND FINANCIAL STATEMENTS AVAILABLE TO MEMBERS OF THE PUBLIC UPON REQUEST, THROUGH ITS ANNUAL REPORT, AND THROUGH STATE AND FEDERAL FILINGS. ALL OTHER FUNCTIONAL EXPENSES FORM 990, PART X, LINE 24F MEDICAID ENHANCEMENT TAX : PROGRAM SERVICE EXPENSES 5,312,400. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 5,312,400. PHYSICIAN FEES : PROGRAM SERVICE EXPENSES 4,012,512. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 4,012,512. JOA GAINSHARE : PROGRAM SERVICE EXPENSES 2,907,792. MANAGEMENT AND GENERAL EXPENSES 521,208. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 3,429,000. MAINTENANCE CONTRACTS : PROGRAM SERVICE EXPENSES 2,025,397. MANAGEMENT AND GENERAL EXPENSES 363,043. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,388,440. DATA PROCESSING FEES : PROGRAM SERVICE EXPENSES 1,847,976. MANAGEMENT AND GENERAL EXPENSES 331,241. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,179,217. FOOD & FOOD SUPPLIES : PROGRAM SERVICE EXPENSES 978,418. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 978,418. CHILDCARE CENTER EXPENSE : PROGRAM SERVICE EXPENSES 962,163. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 962,163. MAINTENANCE & REPAIR : PROGRAM SERVICE EXPENSES 678,063. MANAGEMENT AND GENERAL EXPENSES 121,540. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 799,603. RENTAL AND LEASE EXPENSE : PROGRAM SERVICE EXPENSES 672,853. MANAGEMENT AND GENERAL EXPENSES 120,606. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 793,459. DUES & SUBSCRIPTIONS : PROGRAM SERVICE EXPENSES 435,163. MANAGEMENT AND GENERAL EXPENSES 78,001. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 513,164. MISCELLANEOUS EXPENSE : PROGRAM SERVICE EXPENSES 393,010. MANAGEMENT AND GENERAL EXPENSES 70,445. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 463,455. INSTRUMENTS & MINOR EQUIPMENT : PROGRAM SERVICE EXPENSES 349,162. MANAGEMENT AND GENERAL EXPENSES 62,586. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 411,748. POSTAGE : PROGRAM SERVICE EXPENSES 326,739. MANAGEMENT AND GENERAL EXPENSES 58,567. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 385,306. COLLECTION EXPENSE : PROGRAM SERVICE EXPENSES 362,161. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 362,161. LICENSES & TAXES : PROGRAM SERVICE EXPENSES 202,183. MANAGEMENT AND GENERAL EXPENSES 36,240. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 238,423. AFFILIATION EXPENSES : PROGRAM SERVICE EXPENSES 134,854. MANAGEMENT AND GENERAL EXPENSES 24,172. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 159,026. LINENS & APPAREL : PROGRAM SERVICE EXPENSES 130,177. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 130,177. BANK FEES : PROGRAM SERVICE EXPENSES 61,431. MANAGEMENT AND GENERAL EXPENSES 11,011. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 72,442. QUALITY CONTROL : PROGRAM SERVICE EXPENSES 59,355. MANAGEMENT AND GENERAL EXPENSES 10,639. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 69,994. RECRUITMENT : PROGRAM SERVICE EXPENSES 42,096. MANAGEMENT AND GENERAL EXPENSES 7,546. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 49,642. COURIER FEES : PROGRAM SERVICE EXPENSES 37,657. MANAGEMENT AND GENERAL EXPENSES 6,750. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 44,407. MANGEMENT SERVICES : PROGRAM SERVICE EXPENSES 14,303. MANAGEMENT AND GENERAL EXPENSES 2,564. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 16,867. BOND FEES : PROGRAM SERVICE EXPENSES 7,352. MANAGEMENT AND GENERAL EXPENSES 1,318. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 8,670. TRUSTEE DEVELOPMENT : PROGRAM SERVICE EXPENSES 2,282. MANAGEMENT AND GENERAL EXPENSES 409. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 2,691. PATIENT VALUABLES : PROGRAM SERVICE EXPENSES 1,773. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,773. CHANGES IN NET ASSETS OR FUND BALANCES: FORM 990, PART XI, LINE 5: NET UNREALIZED LOSSES ON INVESTMENTS: -596,500. PENSION LIABILITY ADJUSTMENT -4,624,738. TOTAL TO FORM 990, PART XI, LINE 5: -5,221,238. CHESHIRE HEALTH FOUNDATION 580 COURT STREET KEENE NH 03431 020202220 MANAGEMENT OF ENDOWMENT FUNDS NH 501(C)(3) LINE 11B, II 0 KEENE HEALTH ALLIANCE 580 COURT STREET KEENE NH 03431 300179297 HEALTHCARE NH MEDICAL CARE 1341000 0 1 0.50000 KEENE HEALTH SERVICES 580 COURT STREET KEENE NH 03431 020374997 INVESTMENTS REAL ESTATE NH CHESHIRE HEALTH FOUNDATION C -18278 -4199176 1.00000 KEENE HEALTH REALTY 580 COURT STREET KEENE NH 03431 020374998 INVESTMENTS REAL ESTATE NH KEENE HEALTH SERVICES C -58029 -762261 1.00000 KEENE HEALTH ENTERPRISES 580 COURT STREET KEENE NH 03431 020374999 INVESTMENTS REAL ESTATE NH KEENE HEALTH SERVICES C 1.00000 0 0 1 1 0 0 0 0 0 1 0 0 1 1 0 0 1 0 CHESHIRE HEALTH FOUNDATION C 235647 CASH CHESHIRE HEALTH FOUNDATION D 538134 CASH CHESHIRE HEALTH FOUNDATION J 72000 CASH CHESHIRE HEALTH FOUNDATION M 1082126 CASH CHESHIRE HEALTH FOUNDATION R 5000000 CASH