2025-05-13T16:14:45-05:00 2024-06-30 470617373 COMMONSPIRIT HEALTH 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 990 2023-07-01 470757164 ALEGENT CREIGHTON HEALTH ALEG 4023434323 12809 WEST DODGE ROAD OMAHA NE 68154 NICK O'TOOL MARKET CFO 4023434323 2025-05-13 1 1 HEATHER ADKINS P01725376 3032989100 2023 2025-03-06 01:10:19Z TIM BRICKER 12809 WEST DODGE ROAD OMAHA NE 68154 488064662 0 X WWW.CHIHEALTH.COM X 1992 NE THE MISSION OF THE CORPORATION IS TO NURTURE THE HEALING MINISTRY OF THE CHURCH, SUPPORTED BY EDUCATION AND RESEARCH. 15 10 3023 173 13820235 73337 12407337 6507737 335332787 367070555 6807904 10542350 156195023 96232694 510743051 480353336 161311 1479673 0 0 182282702 153608378 0 0 0 317838299 315839231 500282312 470927282 10460739 9426054 962759089 839014664 437691322 279341800 525067767 559672864 X AS AN AFFILIATE OF COMMONSPIRIT HEALTH, WE MAKE THE HEALING PRESENCE OF GOD KNOWN IN OUR WORLD BY IMPROVING THE HEALTH OF THE PEOPLE WE SERVE, ESPECIALLY THOSE WHO ARE VULNERABLE, WHILE WE ADVANCE SOCIAL JUSTICE FOR ALL. 0 0 54766733 440061 105272418 ALEGENT CREIGHTON HEALTH STAFF ARE FOCUSED ON RESTORING PATIENTS' HEALTH BY USING PERSONALIZED CARE AND STATE-OF-THE-ART TECHNOLOGY. THE DIAGNOSTIC CENTER AT THE HOSPITALS ARE EQUIPPED WITH THE LATEST DIGITAL IMAGING TECHNOLOGY. HEALTHCARE PROVIDERS HAVE MEDICAL INFORMATION AT THEIR FINGER TIPS, SO DIAGNOSIS IS QUICKER AND TREATMENT CAN BE STARTED SOONER. EACH DIAGNOSTIC CENTER OFFERS A FULL RANGE OF DIAGNOSTIC IMAGING SERVICES INCLUDING BUT NOT LIMITED TO THE FOLLOWING: MRI, CT SCANNING, PET/CT SCAN, ULTRASOUND, MAMMOGRAMS, NUCLEAR MEDICINE, CLINICAL LABORATORY, X-RAY IMAGING, PULMONARY SERVICES, OUTPATIENT LABORATORY TESTING, ANGIOGRAPHY AND RADIOGRAPHY. 42998396 335470 80251875 AT ALEGENT CREIGHTON HEALTH, OUR TEAM OF BOARD-CERTIFIED SURGEONS PROVIDES A FULL RANGE OF SURGICAL SOLUTIONS. OUR SURGEONS ARE EXCEPTIONALLY SKILLED AND HAVE MANY YEARS OF EXPERIENCE, WHICH ENSURES EVERY PATIENT WILL RECEIVE THE EXPERTISE THEY NEED AND THE COMPASSIONATE CARE THEY DESERVE. WE TAKE PRIDE IN MAKING SURE YOUR EXPERIENCE IS AS CONVENIENT AND COMFORTABLE AS POSSIBLE. EACH PATIENT CAN COUNT ON US FOR AN UNPARALLELED LEVEL OF CARE AND QUALITY SURGICAL OUTCOMES. 17596761 126480 30256711 ALEGENT CREIGHTON HEALTH OFFERS A WIDE RANGE OF COMPREHENSIVE CARDIOVASCULAR SERVICES IN THE REGION, USING A TEAM APPROACH TO ADDRESS THE TOTAL NEEDS OF THE CARDIOVASCULAR PATIENT. CARDIAC SERVICES INCLUDE BUT ARE NOT LIMITED TO: HI-TECH DIAGNOSIS AND INTERVENTION, CARDIAC CATHETERIZATION LAB, ECHOCARDIOGRAPHY, VASCULAR ULTRASOUND, HEART SCANS AND HEART CHECKS, ANGIOPLASTY AND DRUG-ELUTING STENTS. 336467135 577662 138189527 ALEGENT CREIGHTON HEALTH GIVES BACK TO OUR COMMUNITY THROUGH A VARIETY OF MEDICAL SERVICES AND PARTNERSHIPS. ALEGENT HEALTH QUICK CARE PROVIDES URGENT MEDICAL TREATMENTS, SCREENINGS AND ADULT IMMUNIZATIONS FOR PATIENTS 18 MONTHS AND OLDER. THROUGH OUR COLLABORATION WITH OTHER LOCAL COMMUNITY ORGANIZATIONS SUCH AS BOYS TOWN, CREIGHTON UNIVERSITY, OUR HEALTHY COMMUNITY PARTNERSHIP AND ONE WORLD COMMUNITY HEALTH CENTER, ALEGENT CREIGHTON HEALTH IS HELPING TO IDENTIFY AND ADDRESS COMMUNITY HEALTH NEEDS. IN ADDITION, ALEGENT CREIGHTON HEALTH ALSO PROVIDES THE FOLLOWING SERVICES: MATERNITY CARE SERVICES, MENTAL AND BEHAVIORAL HEALTH CARE, ONCOLOGY, PROCEDURE CENTER AND INPATIENT FACILITIES INCLUDING INTENSIVE CARE. 336467135 577662 138189527 451829025 1 1 0 1 0 0 0 0 0 1 1 1 0 1 1 1 0 1 0 1 1 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 1 0 0 1 X 36 0 1 3023 1 1 1 0 0 0 0 0 0 0 0 0 1 0 X 15 10 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 1 1 0 X NICK O'TOOL 4023434323 12809 WEST DODGE ROAD OMAHA NE 68154 JOHN PETERSDORF BOARD MEMBER 1.00 45.00 X 0 2089747 992820 EVERT KUIPER FORMER PRESIDENT, CHI HEALTH 0.00 0.00 X 0 2787233 48534 TIM BRICKER EX-OFFICIO BM/ PRESIDENT & CEO CENTRAL REGION 5.00 45.00 X X 0 2499192 116526 JEANETTE WOJTALEWICZ FORMER CFO, CHI HEALTH 0.00 0.00 X 1344835 0 12367 DEREK VANCE PRESIDENT ST. ELIZABETH 0.00 0.00 X 1032975 0 25180 JULIE GOEBEL DIV SVP COO 10.00 40.00 X 964934 0 55466 CARY WARD MD MARKET PRESIDENT 10.00 40.00 X 824779 0 48784 KEVIN MILLER PRESIDENT - LKS & MDL HOSPITAL 50.00 0.00 X 669205 0 49688 EDWARD HANNON PRESIDENT - ST. 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CREIGHTON HEALTH. PART X, LINE 2: ALEGENT CREIGHTON HEALTH'S FINANCIAL INFORMATION IS INCLUDED IN COMMONSPIRIT HEALTH'S CONSOLIDATED AUDITED FINANCIAL STATEMENTS, WHICH INCLUDES THE FOLLOWING DISCLOSURE: COMMONSPIRIT REVIEWS ITS TAX POSITIONS QUARTERLY AND HAS DETERMINED THAT THERE ARE NO MATERIAL UNCERTAIN TAX POSITIONS THAT REQUIRE RECOGNITION IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. SUB-SAHARAN AFRICA 1 1 PROGRAM SERVICES SCHOOL OF NURSING 194580 1 1 0 0 1 1 194580 0 194580 0 0 0 0 0 0 PART I, LINE 3: SUB-SAHARAN AFRICA: ACCRUAL ALEGENT CREIGHTON HEALTH HAS ONE DESIGNATED EMPLOYEE WHO IS THE LIAISON FOR THE HOSPITAL LOCATED IN TANZANIA. THE EMPLOYEE ASSISTS WITH THE PROGRAMS, SERVICES, AND ACTIVITIES FOR THE HOUSES FOR HEALTH AND SCHOOL OF NURSING DEPARTMENTS. 1 1 X 1 X 1 X 1 1 0 1 1 3483 3059402 0 3059402 0.00650 13268 24801161 16925763 7875398 0.01670 0 0 0 16751 27860563 16925763 10934800 0.02320 23 1804 338469 2615 335854 0.00070 5 557 511047 0 511047 0.00110 3 0 894095 493561 400534 0.00090 2 0 4 0 4 0.00000 18 3 195585 0 195585 0.00040 51 2364 1939200 496176 1443024 0.00310 51 19115 29799763 17421939 12377824 0.02630 1 0 355 0 355 0.00000 1 0 1164 0 1164 0.00000 2 1519 1519 0.00000 1 16149263 0 43148798 61083794 -17934996 X 1 1 1 LAKESIDE AMBULATORY SURGICAL CENTER LLC AMBULATORY SURGICAL CENTER 0.60510 0.00000 0.39490 2 LAKESIDE ENDOSCOPY CENTER LLC AMBULATORY SURGICAL CENTER 0.51020 0.00000 0.48980 3 NEBRASKA SPINE LLC SPINE HOSPITAL 0.51000 0.00000 0.44000 4 BERGAN MERCY SURGICAL CENTER LLC AMBULATORY SURGICAL CENTER 0.63660 0.00000 0.36340 3 1 CHI HEALTH LAKESIDE 16901 LAKESIDE HILLS CT OMAHA NE 68130 WWW.CHIHEALTH.COM H000106 X X X A 2 CHI HEALTH MIDLANDS 11111 S 84TH ST PAPILLION NE 68046 WWW.CHIHEALTH.COM 680001 X X X A 3 CHI HEALTH PLAINVIEW 704 N 3RD ST PLAINVIEW NE 68769 WWW.CHIHEALTH.COM 620002 X X X B FACILITY REPORTING GROUP - A 0 0 1 X X X X X X X X X 21 1 1 1 1 X WWW.CHIHEALTH.COM/CHNA X X 1 22 1 WWW.CHIHEALTH.COM/CHNA 0 1 X 200.000000000000 400.000000000000 X X X X X X 1 1 X X X 1 X HTTPS://WWW.CHIHEALTH.COM/EN/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE.HTML X HTTPS://WWW.CHIHEALTH.COM/EN/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE.HTML X HTTPS://WWW.CHIHEALTH.COM/EN/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE.HTML X X X X X X 1 X 0 X X X X 1 X 0 0 FACILITY REPORTING GROUP - B 0 0 1 X X X X X X X X X 21 1 1 1 1 X WWW.CHIHEALTH.COM/CHNA X X 1 22 1 WWW.CHIHEALTH.COM/CHNA 0 1 X 200.000000000000 400.000000000000 X X X X X X 1 1 X X X 1 X HTTPS://WWW.CHIHEALTH.COM/EN/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE.HTML X HTTPS://WWW.CHIHEALTH.COM/EN/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE.HTML X HTTPS://WWW.CHIHEALTH.COM/EN/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE.HTML X X X X X X 1 X 0 X X X X 1 X 0 0 FACILITY REPORTING GROUP A, PART V, SECTION B, LINE 3E: THE SIGNIFICANT HEALTH NEEDS ARE A PRIORITIZED DESCRIPTION OF THE SIGNIFICANT HEALTH NEEDS OF THE COMMUNITY AS IDENTIFIED THROUGH THE CHNA. FACILITY REPORTING GROUP B, PART V, SECTION B, LINE 3E: THE SIGNIFICANT HEALTH NEEDS ARE A PRIORITIZED DESCRIPTION OF THE SIGNIFICANT HEALTH NEEDS OF THE COMMUNITY AS IDENTIFIED THROUGH THE CHNA. PART V, SECTION B FACILITY REPORTING GROUP A FACILITY REPORTING GROUP A CONSISTS OF: - FACILITY 2: CHI HEALTH MIDLANDS, - FACILITY 1: CHI HEALTH LAKESIDE FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 5: IN CONDUCTING ITS MOST RECENT CHNA, THE CHI HEALTH LAKESIDE AND CHI HEALTH MIDLANDS HOSPITALS TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITY SERVED BY THE HOSPITAL FACILITY, INCLUDING THOSE WITH SPECIAL KNOWLEDGE OF OR EXPERTISE IN PUBLIC HEALTH. IN THIS CYCLE OF CHNA PROCESS, PROFESSIONAL RESEARCH CONSULTANTS (PRC), A THIRD-PARTY NATIONAL HEALTHCARE RESEARCH FIRM, CONTRACTED BY LOCAL HEALTH SYSTEMS (INCLUDING CHI HEALTH) AND HEALTH DEPARTMENTS. THE ASSESSMENT CONDUCTED ENCOMPASSED A FOUR-COUNTY AREA, INCLUDING POTTAWATTAMIE COUNTY, IOWA AND DOUGLAS, SARPY, AND CASS COUNTIES, NEBRASKA. THE ASSESSMENT WAS COMPOSED OF A SECONDARY DATA ANALYSIS, COMMUNITY HEALTH SURVEY, ONLINE KEY INFORMANT, AND COMMUNITY PRESENTATION. BASED LARGELY ON THE CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) BEHAVIORAL RISK FACTOR SURVEILLANCE SYSTEM (BRFSS), ALONG WITH OTHER PUBLIC HEALTH SURVEYS, AND CUSTOMIZED TO ADDRESS GAPS IN INDICATOR DATA RELATIVE TO HEALTH PROMOTION, DISEASE PREVENTION OBJECTIVES AND OTHER RECOGNIZED HEALTH ISSUES, THE PRC COMMUNITY HEALTH SURVEY WAS DEVELOPED BY THE SPONSORING ORGANIZATIONS AND PRC. THE SURVEY WAS KEPT SIMILAR TO A PREVIOUS SURVEY USED IN THE REGION IN 2011, 2015, AND 2018 TO ALLOW FOR TREND ANALYSIS. THE PRC COMMUNITY HEALTH SURVEY WAS COMPLETED BY 2,527 RESIDENTS VIA MIXED MODE METHODOLOGY, INCLUDING A TELEPHONE SURVEY WHICH INCORPORATED BOTH LANDLINE AND CELL PHONE INTERVIEWS, AS WELL AS THROUGH ONLINE QUESTIONNAIRES, AND UTILIZED A STRATIFIED RANDOM SAMPLE OF INDIVIDUALS AGE 18 AND OVER ACROSS THE METRO AREA. THE HIGHER DOUGLAS COUNTY SAMPLE REFLECTS A TARGET OF 50 SURVEYS PER ZIP CODE WITHIN THE COUNTY (ALTHOUGH SOME LESSER-POPULATED ZIP CODES DID NOT REACH THIS THRESHOLD). ONCE THE INTERVIEWS WERE COMPLETED, THESE WERE WEIGHTED IN PROPORTION TO THE ACTUAL POPULATION DISTRIBUTION SO AS TO APPROPRIATELY REPRESENT THE METRO AREA AS A WHOLE. PARTICIPANTS IN THE KEY INFORMANT SURVEY WERE INDIVIDUALS WHO HAVE A BROAD INTEREST IN THE HEALTH OF THE COMMUNITY AND WERE IDENTIFIED THROUGH THE SPONSORING ORGANIZATIONS. THE LIST INCLUDED PHYSICIANS, PUBLIC HEALTH REPRESENTATIVES, OTHER HEALTH PROFESSIONALS, SOCIAL SERVICE PROVIDERS, AND A VARIETY OF OTHER COMMUNITY LEADERS WHO THE SPONSORS FELT WERE ABLE TO IDENTIFY PRIMARY CONCERNS WITHIN THE POPULATIONS THEY SERVE, AS WELL AS THE COMMUNITY AS A WHOLE. KEY INFORMANTS WERE CONTACTED VIA EMAIL TO INTRODUCE THE PURPOSE OF THE SURVEY AND WERE PROVIDED A LINK TO COMPLETE THE SURVEY ONLINE. A TOTAL OF 150 KEY INFORMANTS COMPLETED THE SURVEY. DATA PRESENTATION AND DISCUSSION WAS IMPLEMENTED AT THE WELLBEING PARTNERS XCHANGE SUMMIT. COMMUNITY INPUT WAS COLLECTED AT THE XCHANGE SUMMIT ON OCT 6, 2021, CO-SPONSORED BY THE LOCAL AREA HOSPITAL SYSTEMS- CHI HEALTH, METHODIST HEALTH SYSTEM, CHILDREN'S HOSPITAL & MEDICAL CENTER AND NEBRASKA MEDICINE- ALONG WITH SEVERAL OTHER NON-GOVERNMENTAL HEALTH AND SOCIAL SERVICE ORGANIZATIONS. OVER 94 INDIVIDUALS REPRESENTING HEALTHCARE, PUBLIC HEALTH, SOCIAL SERVICES AND OTHERS ENGAGED IN A COMMUNITY CONVERSATION TO DIVE DEEPER INTO RESOURCES AND GAPS IN OUR REGIONAL APPROACH TO MENTAL HEALTH. FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 6A: CHI HEALTH (CHI HEALTH CREIGHTON UNIVERSITY MEDICAL CENTER BERGAN MERCY; CHI HEALTH IMMANUEL; CHI HEALTH MERCY COUNCIL BLUFFS; CHI HEALTH MIDLANDS; LASTING HOPE RECOVERY CENTER; NEBRASKA SPINE HOSPITAL)NEBRASKA MEDICINE (BELLEVUE MEDICAL CENTER AND NEBRASKA MEDICAL CENTER)METHODIST HEALTH SYSTEM (METHODIST HOSPITAL, METHODIST JENNIE EDMUNDSON HOSPITAL, AND METHODIST WOMEN'S HOSPITAL) FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 6B: DOUGLAS COUNTY HEALTH DEPARTMENTPOTTAWATTAMIE COUNTY PUBLIC HEALTHSARPY/CASS HEALTH DEPARTMENTOMAHA COMMUNITY FOUNDATIONCHARLES DREW HEALTH CENTER, INC.ONE WORLD COMMUNITY HEALTH CENTERS, INC.THE WELLBEING PARTNERS FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 7D: THIS CHNA WAS COMPLETED IN PARTNERSHIP WITH THE HEALTH DEPARTMENT AND HEALTH SYSTEMS, IN ADDITION PRESENTATIONS WERE MADE TO REGIONAL HEALTH COUNCIL ON APRIL 12TH, 2022, CHI CUMC BERGAN MERCY COMMUNITY BOARD ON MAY 12TH, 2022, CHI IMMANUEL COMMUNITY BOARD ON MAY 19TH ,2022, CHI LAKESIDE COMMUNITY BOARD ON JUNE 2ND, 2022, AND CHI MIDLANDS COMMUNITY BOARD ON JUNE 7TH, 2022. FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 11: THE MOST RECENT CHNA WAS COMPLETED IN THE TAX REPORTING YEAR 2021 AND THE CORRESPONDING IMPLEMENTATION PLAN WAS APPROVED IN THE TAX REPORTING YEAR 2022. THE FOLLOWING OUTLINES THE CURRENT IMPLEMENTATION PLAN PRIORITIES AND STRATEGIES. THIS PLAN WAS POSTED PUBLICLY ON WWW.CHIHEALTH.COM/CHNA. THE COMMUNITY IDENTIFIED THE FOLLOWING PRIORITIES AS TOP HEALTH NEEDS THROUGH PRIMARY AND SECONDARY DATA REVIEW INCLUDING A COMMUNITY SURVEY, AND KEY INFORMANT INTERVIEWS.TOP HEALTH NEEDS (FROM 2022 CHNA): 1. MENTAL HEALTH2. NUTRITION, PHYSICAL ACTIVITY & WEIGHT3. SUBSTANCE ABUSE4. DIABETES5. SEXUAL HEALTH6. INJURY & VIOLENCE7. HEART DISEASE & STROKE8. TOBACCO USE9. INFANT HEALTH & FAMILY PLANNING10. POTENTIALLY DISABLING CONDITIONS11. ORAL HEALTH12. ACCESS TO HEALTH CARE SERVICES13. RESPIRATORY DISEASE14. CANCERFOR THIS PLAN THE HOSPITALS PRIORITIZED THE FOLLOWING HEALTH NEEDS:PRIORITY HEALTH NEED #1: BEHAVIORAL HEALTH (MENTAL HEALTH/SUBSTANCE MISUSE)TO ADDRESS THIS NEED THE HOSPITAL WILL IMPLEMENT THE FOLLOWING STRATEGIES IN FISCAL YEARS 2023- 2025:1.1 EXPAND ACCESS TO MENTAL HEALTH SERVICES FOR YOUTH* OPERATE AN INTEGRATED SCHOOL-BASED MENTAL HEALTH PROGRAMFY24 ACTIONS AND IMPACT: - MAINTAINED AND INTEGRATED SCHOOL-BASED MENTAL HEALTH PROGRAM IN THE DC WEST SCHOOL SYSTEM IN VALLEY, NE. THE PROGRAM SERVES STUDENTS AND THEIR FAMILIES IN GRADES K-12.MEASURES: - STUDENTS SERVED (NOT UNDUPLICATED): 41- AVERAGE NUMBER OF STUDENTS SERVED IN SCHOOL-BASED AND VIRTUAL PROGRAMS: 26- NEW STUDENT REFERRALS: 26- BILLABLE OFFICE VISITS: 5331.2 EXPAND ACCESS TO RESOURCES FOR INDIVIDUALS LIVING WITH ALZHEIMERS AND DEMENTIA- RELATED DISEASES (ADRD)* PROVIDE SUPPORT FOR INDIVIDUALS WITH ALZHEIMER'S/ DEMENTIA AND THEIR CAREGIVERSFY24 ACTIONS AND IMPACT: NOT AVAILABLE AT TIME OF REPORTING. MEASURES: NO MEASURES TO REPORT. 1.3 EXPAND ACCESS TO BEHAVIORAL HEALTH SERVICES FOR ADULTS IN CRISIS* CONTINUE TO PROVIDE ACCESS TO OUTPATIENT BEHAVIORAL HEALTH SERVICES AND REDUCE BEHAVIORAL HEALTH READMISSIONS THROUGH LASTING HOPE RECOVERY CENTER OUTPATIENT CLINICFY24 ACTIONS AND IMPACT: EXPANDED SERVICES OFFERED AT LASTING HOPE, INCLUDING AN INTENSIVE OUTPATIENT PROGRAM.MEASURES: LASTING HOPE OUTPATIENT CLINIC VISITS: 7,644* INVEST IN NONPROFITS ADDRESSING OUR PRIORITY HEALTH NEED OF BEHAVIORAL HEALTH FY24 ACTIONS AND IMPACT: - FUNDED FOUR NONPROFITS THROUGH COMMUNITY HEALTH IMPROVEMENT GRANTS (CHIG): IMMIGRANT LEGAL CENTER + REFUGEE EMPOWERMENT CENTER, LATINO CENTER OF THE MIDLANDS, COMUNIDAD MAYA PIXAN IXIM, RISE ACADEMY.MEASURES: CHIG FUNDS AWARDED (1/1/24-12/31/24): $190,000* DEVELOP AND PILOT AN INTEGRATED PEER SUPPORT SPECIALIST (PSS) PROGRAM ACROSS ALL AREAS OF BEHAVIORAL HEALTH SERVICES FY24 ACTIONS AND IMPACT:- THE HEALTHY COMMUNITIES TEAM SUPPORTED THIS STRATEGY THROUGH A FY24-25 MISSION AND MINISTRY COMMUNITY HEALTH & WELLBEING PROJECT GRANT. THROUGHOUT FY24:* HIRED AND TRAINED AN FTE FOR AN OUTPATIENT POSITION, A 0.6 FTE FOR PARTIAL CARE, AND A 0.4 FTE FOR YOUTH RESIDENTIAL. THESE STAFF RECEIVED TRAINING IN THE SUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION'S (SAMHSA) TAKING ACTION FOR WHOLE HEALTH AND WELLBEING PROGRAM IN JUNE 2024. * AN ADVISORY COUNCIL FIRST MET ON DECEMBER 18, 2023. THE COUNCIL CREATED A WORK GROUP TO IDENTIFY EXISTING RELEVANT QUALITY MEASURES FOR PERFORMANCE MANAGEMENT. *EACH DEPARTMENT TO WHICH A PSS IS ASSIGNED WILL TAKE ON THE COST OF THE PSS. FUTURE WORK WILL EXPLORE HOW TO STRUCTURE SERVICE DELIVERY AND/OR ADVOCATE FOR MEDICAID/MEDICARE REIMBURSEMENT OF EXISTING SERVICE DELIVERY.* THE PEER SUPPORT PROGRAM MANAGER VISITED LAKESIDE AND CUMC-BERGAN MERCY TO SHARE ABOUT THE PROGRAM. MEASURES:- 82% OF PATIENTS REPORTED THROUGH THEIR SATISFACTION SURVEYS THAT PEER SUPPORT MADE A SIGNIFICANT OR DEFINITE IMPACT ON THEIR RECOVERY.1.4 ADVOCATE FOR POLICY CHANGE* LEAD POLICY AND ADVOCACY EFFORTS THAT EXPAND ACCESS TO BEHAVIORAL HEALTH SERVICES FY24 ACTIONS AND IMPACT:- THROUGH THE NEBRASKA HOSPITAL ASSOCIATION, CHI HEALTH SUPPORTED ADVOCACY EFFORTS THAT CULMINATED IN THE PASSAGE OF SEVERAL LAWS THAT PRESERVE ACCESS AND SUSTAINABILITY OF BEHAVIORAL HEALTH SERVICES, SUCH AS:* LBB896- CHANGE PROVISIONS RELATING TO TELEHEALTH CONSULTATIONS INCLUDED IN HEALTH AND HUMAN SERVICES COMMITTEE PRIORITY LEGISLATION ELIMINATES THE REQUIREMENT TO COLLECT A SIGNED CONSENT STATEMENT FOR A TELEHEALTH CONSULTATION IF VERBAL CONSENT HAS ALREADY BEEN GIVEN. THE BILL REMOVES THE FOLLOWING LANGUAGE: "THE SIGNED STATEMENT MAY BE COLLECTED BY PAPER OR ELECTRONIC SIGNATURE AND SHALL BECOME A PART OF THE PATIENT'S MEDICAL RECORD. IF THE PATIENT GIVES VERBAL CONSENT DURING THE INITIAL TELEHEALTH CONSULTATION, THE SIGNED STATEMENT SHALL BE COLLECTED WITHIN TEN DAYS AFTER SUCH TELEHEALTH CONSULTATION."* LB62 COVERAGE OF TRANSLATION AND INTERPRETATION SERVICES UNDER MEDICAID REQUIRES THE STATE TO PROVIDE COVERAGE FOR ALL NECESSARY TRANSLATION AND INTERPRETATION SERVICES FOR INDIVIDUALS WHO RECEIVE MEDICAID. IT REQUIRES THE DEPARTMENT OF HEALTH AND HUMAN SERVICES TO PROVIDE THE COVERAGE, AS WELL AS REIMBURSEMENT FOR PROVIDERS, AND TO "TAKE ALL ACTIONS NECESSARY" TO MAXIMIZE FEDERAL FUNDING TO DO SO. * LB857 CREATES THE NEBRASKA PRENATAL PLUS PROGRAM, PROVIDE FOR USE OF THE MEDICAID MANAGED CARE EXCESS PROFIT FUND, AND CHANGE PROVISIONS RELATING TO COVERAGE OF GLUCOSE MONITORS UNDER THE MEDICAL ASSISTANCE ACT. LB857 CREATES THE NEBRASKA PRENATAL PLUS PROGRAM AT DHHS FOR WOMEN ELIGIBLE FOR MEDICAID OR THE CHILDREN'S HEALTH INSURANCE PROGRAM TO REDUCE THE INCIDENCE OF LOW BIRTH WEIGHT, PRE-TERM BIRTH, AND ADVERSE BIRTH OUTCOMES WHILE ALSO ADDRESSING OTHER LIFESTYLE, BEHAVIORAL, AND NONMEDICAL ASPECTS OF AN AT-RISK MOTHER'S LIFE THAT MAY AFFECT THE HEALTH AND WELL-BEING OF THE MOTHER OR THE CHILD. SERVICES ELIGIBLE FOR REIMBURSEMENT FOR AT-RISK MOTHERS INCLUDE NUTRITION COUNSELING, PSYCHOSOCIAL COUNSELING AND SUPPORT, GENERAL CLIENT EDUCATION AND HEALTH PROMOTION, BREASTFEEDING SUPPORT, AND TARGETED CASE MANAGEMENT. LB857 LIMITS ELIGIBILITY FOR AT-RISK MOTHERS OTHERWISE ELIGIBLE FOR MEDICAID WHILE PREGNANT, REMOVES CHIP ELIGIBILITY AND POSTPARTUM COVERAGE. IT ALSO LIMITS NUTRITION COUNSELING TO 6 OR FEWER SESSIONS.* LB905 REQUIRE THE DEPARTMENT OF HEALTH AND HUMAN SERVICES TO SUBMIT A MEDICAID WAIVER OR STATE PLAN AMENDMENT FOR MEDICAL RESPITE CARE, CHANGE THE DEFINITION OF RESPITE CARE, AND CHANGE PROVISIONS RELATING TO THE MEDICAID MANAGED CARE EXCESS PROFIT FUND. LB905 REQUIRES DHHS TO SUBMIT A MEDICAID WAIVER OR STATE PLAN AMENDMENT TO DESIGNATE TWO MEDICAL RESPITE FACILITIES TO REIMBURSE FOR SERVICES PROVIDED TO AN INDIVIDUAL WHO IS HOMELESS AND AN ADULT IN THE EXPANSION POPULATION NO LATER THAN JAN. 1, 2025. * LB1355 PROVIDE FOR RELEASE OF CERTAIN PATIENT DATA BY AN EMERGENCY MEDICAL SERVICE, CHANGE PROVISIONS OF THE OPIOID PREVENTION AND TREATMENT ACT, AND PROVIDE FOR STATE AID, RESEARCH, FIRST RESPONDER TRAINING, AND OVERDOSE FATALITY REVIEW. LB1355 REQUIRES THE DEPARTMENT OF HEALTH AND HUMAN SERVICES TO PROVIDE GRANTS TO LOCAL PUBLIC HEALTH DEPARTMENTS, LAW ENFORCEMENT AGENCIES, AND HEALTH CARE FACILITIES, TO AID PROGRAMS TO FACILITATE OPIOID OVERDOSE PREVENTION EFFORTS, EDUCATION AND TRAINING, RECOVERY, PROBLEM-SOLVING COURTS, AND DATA TRACKING. THE BILL INCLUDES THE INTENT OF THE LEGISLATURE TO APPROPRIATE $4,000,000 ANNUALLY FROM THE NEBRASKA OPIOID RECOVERY FUND BEGINNING IN FY2024-25 FOR GRANTS UNDER THE OPIOID PREVENTION AND TREATMENT ACT. WOULD PROVIDE $500,000 EACH TO A LOCAL PUBLIC HEALTH DEPARTMENT, A LAW ENFORCEMENT AGENCY APPLICANT, AND TO A HEALTH CARE FACILITY APPLICANT. LB1355 ALLOWS PHARMACISTS TO SELL, AND PUBLIC HEALTH DEPARTMENTS TO DISTRIBUTE, FENTANYL TEST STRIPS.MEASURES:- BEHAVIORAL HEALTH BILLS APPROVED (OF THOSE SUPPORTED BY NHA AND/OR CHI HEALTH): 5* SUPPORT SARPY/CASS TOBACCO COALITION FY24 ACTIONS AND IMPACT:- TOBACCO EDUCATION & ADVOCACY OF THE MIDLANDS (TEAM) CONTINUED TO WORK WITH BUSINESSES, SCHOOL DISTRICTS, PUBLIC HOUSING PROGRAMS AND CITY PARKS TO IMPLEMENT SMOKE-FREE/ VAPE-FREE/ TOBACCO- FREE POLICIES. CONTINUED WORKING ON NEW INITIATIVES TO DECREASE THE NUMBER OF TOBACCO RETAILERS AND INCREASE THE NUMBER OF CESSATION ASSESSMENT AND REFERRAL SYSTEM POLICIES WITHIN HEALTH CARE, SOCIAL SERVICE, AND EDUCATION AGENCIES.MEASURES:- TEAM COALITIONMEMBERS: 116NEW MEMBERS: 9- MULTI-FAMILY BUILDINGS THAT ADOPTED 100% SMOKE-FREE/VAPE-FREE/TOBACCO-FREE POLICIES WITHIN SARPY/CASS COUNTY: 142- JURISDICTIONS THAT DESIGNATE OUTDOOR RECREATIONAL AREAS AS SMOKE-FREE/VAPE-FREE OR TOBACCO-FREE IN SARPY/CASS COUNTY: 10- CESSATION ASSESSMENT AND REFERRAL SYSTEM POLICIES WITHIN HEALTH CARE, SOCIAL SERVICE, AND EDUCATION AGENCIES IN SARPY/CASS COUNTY: 8SCH H, PART V, LINE 11 (CONTINUED) FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 13H: THE PATIENT MUST HAVE A MINIMUM ACCOUNT BALANCE OF TEN DOLLARS ($10.00) WITH THE COMMONSPIRIT HOSPITAL ORGANIZATION. MULTIPLE ACCOUNT BALANCES MAY BE COMBINED TO REACH THIS AMOUNT. PATIENTS/GUARANTORS WITH BALANCES BELOW TEN DOLLARS ($10.00) MAY CONTACT A FINANCIAL COUNSELOR TO MAKE MONTHLY INSTALLMENT PAYMENT ARRANGEMENTS. THE PATIENT MUST SUBMIT A COMPLETED FINANCIAL ASSISTANCE APPLICATION. PATIENT COOPERATION STANDARDS - A PATIENT MUST COOPERATE WITH THE HOSPITAL FACILITY IN PROVIDING THE INFORMATION AND DOCUMENTATION NECESSARY TO DETERMINE ELIGIBILITY. SUCH COOPERATION INCLUDES COMPLETING ANY REQUIRED APPLICATIONS OR FORMS. THE PATIENT IS RESPONSIBLE FOR NOTIFYING THE HOSPITAL FACILITY OF ANY CHANGE IN FINANCIAL SITUATION THAT WOULD IMPACT THE ASSESSMENT OF ELIGIBILITY. A PATIENT MUST EXHAUST ALL OTHER PAYMENT OPTIONS, INCLUDING PRIVATE COVERAGE, FEDERAL, STATE AND LOCAL MEDICAL ASSISTANCE PROGRAMS, AND OTHER FORMS OF ASSISTANCE PROVIDED BY THIRD PARTIES PRIOR TO BEING APPROVED. AN APPLICANT FOR FINANCIAL ASSISTANCE IS RESPONSIBLE FOR APPLYING TO PUBLIC PROGRAMS FOR AVAILABLE COVERAGE. HE OR SHE IS ALSO EXPECTED TO PURSUE PUBLIC OR PRIVATE HEALTH INSURANCE PAYMENT OPTIONS FOR CARE PROVIDED BY A COMMONSPIRIT HOSPITAL ORGANIZATION WITHIN A HOSPITAL FACILITY. A PATIENT'S AND, IF APPLICABLE, ANY GUARANTOR'S COOPERATION IN APPLYING FOR APPLICABLE PROGRAMS AND IDENTIFIABLE FUNDING SOURCES, INCLUDING COBRA COVERAGE (A FEDERAL LAW ALLOWING FOR A TIME-LIMITED EXTENSION OF EMPLOYEE HEALTHCARE BENEFITS), SHALL BE REQUIRED. IF A HOSPITAL FACILITY DETERMINES THAT COBRA COVERAGE IS POTENTIALLY AVAILABLE, AND THAT A PATIENT IS NOT A MEDICARE OR MEDICAID BENEFICIARY, THE PATIENT OR GUARANTOR SHALL PROVIDE THE HOSPITAL FACILITY WITH INFORMATION NECESSARY TO DETERMINE THE MONTHLY COBRA PREMIUM FOR SUCH PATIENT, AND SHALL COOPERATE WITH HOSPITAL FACILITY STAFF TO DETERMINE WHETHER HE OR SHE QUALIFIES FOR HOSPITAL FACILITY COBRA PREMIUM ASSISTANCE, WHICH MAY BE OFFERED FOR A LIMITED TIME TO ASSIST IN SECURING INSURANCE COVERAGE. A HOSPITAL FACILITY SHALL MAKE AFFIRMATIVE EFFORTS TO HELP A PATIENT OR PATIENT'S GUARANTOR APPLY FOR PUBLIC AND PRIVATE PROGRAMS. PART V, SECTION B FACILITY REPORTING GROUP B FACILITY REPORTING GROUP B CONSISTS OF: - FACILITY 3: CHI HEALTH PLAINVIEW FACILITY REPORTING GROUP - B PART V, SECTION B, LINE 5: IN CONDUCTING ITS MOST RECENT CHNA, CHI HEALTH PLAINVIEW TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITY SERVED BY THE HOSPITAL FACILITY, INCLUDING THOSE WITH SPECIAL KNOWLEDGE OF OR EXPERTISE IN PUBLIC HEALTH. THE NORTH CENTRAL DISTRICT HEALTH DEPARTMENT EMPLOYED THE MAPP FRAMEWORK TO IDENTIFY PRIORITIES AND STRATEGIES TO ADDRESS COMMUNITY HEALTH ISSUES. MAPP IS AN ESTABLISHED FRAMEWORK DEVELOPED BY THE NATIONAL ASSOCIATION OF COUNTY AND CITY HEALTH OFFICIALS, AND HAS BEEN USED BY NUMEROUS COMMUNITIES SINCE ITS INCEPTION IN 2001. FOUNDATIONALLY, THE MAPP APPROACH ENGAGES COMMUNITY MEMBERS, STAKEHOLDERS, AND HEALTHCARE PROFESSIONALS IN ASSESSING THE OVERALL HEALTH STATUS OF THE COMMUNITY, PRIORITIZING HEALTH CONCERNS, AND IDENTIFYING STRENGTHS AND GAPS SALIENT TO COMMUNITY HEALTH. COMMUNITY INPUT WAS GATHERED THROUGH THE MAPP ASSESSMENTS AND DATA VALIDATION AND HEALTH NEED PRIORITIZATION. SPECIFIC POPULATIONS AT HIGHER HEALTH RISK OR THAT HAVE POORER HEALTH OUTCOMES WERE IDENTIFIED IN THE NORTH CENTRAL DISTRICT COMMUNITY AS: - LOW-INCOME POPULATION - RACIAL AND ETHNIC MINORITY POPULATION, PARTICULARLY HISPANIC AND NATIVE AMERICAN INDIVIDUALS - INDIVIDUALS 65 YEARS AND OLDER - LOW EDUCATION POPULATION IN ADDITION TO USING EXISTING RELATIONSHIPS WITH ORGANIZATIONS IN THE NORTH CENTRAL DISTRICT WHO WORK WITH THESE POPULATIONS TO DISTRIBUTE TARGETED COMMUNITY SURVEYS, REPRESENTATIVES FROM THESE ORGANIZATIONS ALSO PARTICIPATED IN COMMUNITY MEETINGS THROUGHOUT THE ASSESSMENT PROCESS. THE FOLLOWING ORGANIZATIONS PARTICIPATED IN THE PROCESS: - NORTH CENTRAL DISTRICT HEALTH DEPARTMENT (NCDHD)- NIOBRARA VALLEY HOSPITAL - NCDHD BOARD OF HEALTH - OSMOND GENERAL HOSPITAL - ANTELOPE MEMORIAL HOSPITAL - ROCK COUNTY HOSPITAL - AVERA CREIGHTON HOSPITAL - WEST HOLT MEMORIAL HOSPITAL - AVERA ST. ANTHONY'S HOSPITAL - INDIAN HEALTH SERVICES - BROWN COUNTY HOSPITAL - THE EVERGREEN ASSISTED LIVING FACILITY- CHERRY COUNTY HOSPITAL - COTTONWOOD VILLA ASSISTED LIVING FACILITY - GOOD SAMARITAN SOCIETY ATKINSON PREGNANCY RESOURCE CENTER COUNSELING & ENRICHMENT CENTER - BROWN-ROCK-KEYA PAHA COUNTY - BUILDING BLOCKS - O'NEILL PUBLIC SCHOOL BOARD - REGION 4 BEHAVIORAL HEALTH SYSTEM - O'NEILL MINISTERIAL ASSOCIATION - CENTRAL NEBRASKA COMMUNITY ACTION PARTNERSHIP - WEST HOLT HEALTH MINISTRIES- NORTHEAST NEBRASKA COMMUNITY ACTION PARTNERSHIP - NORTHWEST NEBRASKA COMMUNITY ACTION PARTNERSHIP - O'NEILL ROTARY CLUB - O'NEILL LIONS CLUB - NORTHSTAR SERVICES- SANTEE SIOUX NATION - NORTH CENTRAL COMMUNITY CARE PARTNERSHIP- BROWN-ROCK-KEYA PAHA COUNTY AREA SUBSTANCE ABUSE PREVENTION COALITION - O'NEILL PUBLIC SCHOOL BOARD - O'NEILL CHAMBER OF COMMERCE - O'NEILL MINISTERIAL ASSOCIATION - CENTRAL NEBRASKA ECONOMIC DEVELOPMENT - HOLT COUNTY ECONOMIC DEVELOPMENT - KNOX COUNTY ECONOMIC DEVELOPMENT - NELIGH ECONOMIC DEVELOPMENT - PIERCE COUNTY ECONOMIC DEVELOPMENT - UNIVERSITY OF NEBRASKA LINCOLN EXTENSION OFFICE FACILITY REPORTING GROUP - B PART V, SECTION B, LINE 6A: NIOBRARA VALLEY HOSPITAL; OSMOND GENERAL HOSPITAL; ANTELOPE MEMORIAL HOSPITAL; ROCK COUNTY HOSPITAL; AVERA CREIGHTON HOSPITAL; WEST HOLT MEMORIAL HOSPITAL; AVERA ST. ANTHONY'S HOSPITAL; BROWN COUNTY HOSPITAL; CHERRY COUNTY HOSPITAL FACILITY REPORTING GROUP - B PART V, SECTION B, LINE 6B: NCDHD BOARD OF HEALTHTHE EVERGREEN ASSISTED LIVING FACILITYINDIAN HEALTH SERVICESNORTH CENTRAL DISTRICT HEALTH DEPARTMENT (NCDHD)UNL PUBLIC POLICY CENTERGOOD SAMARITAN SOCIETY ATKINSON PREGNANCY RESOURCE CENTER COUNSELING & ENRICHMENT CENTER BROWN-ROCK-KEYA PAHA COUNTY BUILDING BLOCKS O'NEILL PUBLIC SCHOOL BOARD REGION 4 BEHAVIORAL HEALTH SYSTEM O'NEILL MINISTERIAL ASSOCIATION CENTRAL NEBRASKA COMMUNITY ACTION PARTNERSHIP WEST HOLT HEALTH MINISTRIESNORTHEAST NEBRASKA COMMUNITY ACTION PARTNERSHIP NORTHWEST NEBRASKA COMMUNITY ACTION PARTNERSHIP O'NEILL ROTARY CLUB O'NEILL LIONS CLUB NORTHSTAR SERVICESSANTEE SIOUX NATION NORTH CENTRAL COMMUNITY CARE PARTNERSHIPBROWN-ROCK-KEYA PAHA COUNTY AREA SUBSTANCE ABUSE PREVENTION COALITION O'NEILL PUBLIC SCHOOL BOARD O'NEILL CHAMBER OF COMMERCE O'NEILL MINISTERIAL ASSOCIATION CENTRAL NEBRASKA ECONOMIC DEVELOPMENT HOLT COUNTY ECONOMIC DEVELOPMENT KNOX COUNTY ECONOMIC DEVELOPMENT NELIGH ECONOMIC DEVELOPMENT SANTEE SIOUX NATION PIERCE COUNTY ECONOMIC DEVELOPMENT UNIVERSITY OF NEBRASKA LINCOLN EXTENSION OFFICE FACILITY REPORTING GROUP - B PART V, SECTION B, LINE 7D: AN OVERVIEW OF THE MOST RECENT CHNA WAS SHARED WITH THE CHI HEALTH PLAINVIEW COMMUNITY BOARD ON JUNE 2, 2022. FACILITY REPORTING GROUP - B PART V, SECTION B, LINE 11: THE FOLLOWING OUTLINES THE CURRENT IMPLEMENTATION PLAN PRIORITIES AND STRATEGIES. THIS PLAN WAS POSTED PUBLICLY ON WWW.CHIHEALTH.COM/CHNA. THE COMMUNITY IDENTIFIED THE FOLLOWING PRIORITIES AS TOP HEALTH NEEDS THROUGH PRIMARY DATA REVIEW AND SECONDARY DATA COLLECTION AND VALIDATION.TOP HEALTH NEEDS (FROM 2022 CHNA): 1. BEHAVIORAL HEALTH2. CANCER3. CHRONIC DISEASE4. SOCIAL DETERMINANTS OF HEALTH (INCLUDING ACCESS TO CARE)FOR THIS PLAN THE HOSPITAL PRIORITIZED THE FOLLOWING HEALTH NEEDS:PRIORITY HEALTH NEED #1: BEHAVIORAL HEALTHTO ADDRESS THIS NEED THE HOSPITAL WILL IMPLEMENT THE FOLLOWING STRATEGIES IN FISCAL YEARS 2023- 2025:1.1 SUPPORT INTERNAL AND EXTERNAL EFFORTS TO PROMOTE MENTAL HEALTH SERVICES AND REDUCE SUBSTANCE ABUSE THROUGH EARLY INTERVENTION AND EDUCATION.1.1.1 CONVENE A BEHAVIORAL HEALTH COALITION THAT MEETS MONTHLY TO ADDRESS BEHAVIORAL HEALTH ISSUES, CONNECT SERVICE PROVIDERS AND MAINTAIN ACTIVE PARTICIPATION IN LOCAL AREA SUBSTANCE USE PREVENTION COALITIONS. COALITION MAY WORK ON THE FOLLOWING ACTIVITIES AND ADOPT OTHER STRATEGIES AS APPROPRIATE: * SUPPORT AND PROMOTE SCHOOL- BASED MENTAL HEALTH PROGRAMMING FOCUSED ON PREVENTION OF SUBSTANCE ABUSE AND SUICIDE* IDENTIFY EMERGING ISSUES THROUGH THE BEHAVIORAL HEALTH COALITION AND CREATE A TRAINING PLAN TO INCREASE COMMUNITY AWARENESS FY24 ACTIONS AND IMPACT:- CONTINUED TO CONVENE THE BEHAVIORAL HEALTH COALITION (HEALTHY CHOICES FOR PIERCE COUNTY) AND EXPLORE EMERGING NEEDS AROUND BEHAVIORAL HEALTH. THE COALITION WORKED TO RAISE AWARENESS AND TO EDUCATE THE COMMUNITY ABOUT SUBSTANCE ABUSE AND MENTAL HEALTH FIRST AID. - DISSEMINATED SUICIDE PREVENTION FLYERS DURING AN OUTREACH EVENT AT PLAINVEW HIGH SCHOOL. MEASURES:- HEALTH CHOICES FOR PIERCE COUNTYMEETINGS: 10AVERAGE NUMBER OF STAFF WHO ATTENDED: 8- STAFF WHO ATTENDED THE HIGH SCHOOL OUTREACH EVENT: 41.1.2 EXPAND USE OF TELEHEALTH AND OTHER HEALTH CARE SYSTEM STRATEGIES FOR BEHAVIORAL HEALTH SERVICESFY24 ACTIONS AND IMPACT:- COLLABORATED WITH PLAINVIEW PUBLIC SCHOOL TO HIRE A LICENSED MENTAL HEALTH PRACTITIONER (LIMHP).MEASURES: NO MEASURES TO REPORT. 1.1.3 SUPPORT AND PARTICIPATE IN THE NCDHD CHIP EFFORTS TO: * INCREASE MENTAL HEALTH FIRST AID TRAINING (MHFA) PROVIDERS IN NCDHD DISTRICT * PROVIDE MHFA TRAININGS IN EACH COUNTY * BRING ONE BCBA (BOARD CERTIFIED BEHAVIOR ANALYST) TO THE DISTRICT * PROVIDE PEER TO PEER MENTAL HEALTH TRAINING TO LOCAL SCHOOLS (QPR, TEEN MHFA) * UTILIZE MEDIA OUTLETS TO INCREASE THE AWARENESS OF MENTAL HEALTH AND SUICIDE (RESOURCE LINE/ TEXT 741741/ PHONE 988)FY24 ACTIONS AND IMPACT:- STAFF PARTICIPATED IN A BIMONTHLY CHIP WORKGROUP, IN NORTH CENTRAL COMMUNITY CARE PARTNERS (NCCC), AND IN AREA SUBSTANCE ABUSE PREVENTION (ASAP) MEETINGS.- STAFF SERVED ON NCDHD'S AND NCCC'S BOARD OF DIRECTORS.MEASURES:- CHIP MEETINGS: 6- NCCC/ASAP MEETINGS: 61.1.4 EXPLORE STRATEGIES AROUND VIOLENCE PREVENTION AND INCORPORATE HEALTH SYSTEM STRATEGIES TO PROVIDE TRAUMA INFORMED PATIENT CARE AND MITIGATE FURTHER VIOLENCEFY24 ACTIONS AND IMPACT:- THE ANTI-TRAFFICKING COORDINATOR CONTINUED TO SHARE RESOURCES WITH CRITICAL ACCESS HOSPITALS.- THE VICE PRESIDENT OF PATIENT CARE SERVICES PARTICIPATED IN NATIONAL HUMAN TRAFFICKING INFORMATIONAL CALLS.- THE HEALTHY COMMUNITIES TEAM SUPPORTED THIS STRATEGY THROUGH A FY22-24 MISSION AND MINISTRY UNITED AGAINST VIOLENCE GRANT. THROUGHOUT FY24:THE FORENSIC NURSE EXAMINER (FNE) PROGRAM MARKET MANAGER PROVIDED ONGOING EDUCATION ON INTIMATE PARTNER VIOLENCE (IPV), SEXUAL ASSAULT (SA), AND HUMAN TRAFFICKING (HT) IDENTIFICATION TO EMERGENCY DEPARTMENTS. HOSTED, IN COLLABORATION WITH CREIGHTON UNIVERSITY'S OFFICE OF CONTINUING EDUCATION AND 11 COMMUNITY/STATE ORGANIZATIONS, INCLUDING WILLOW RISING, CATHOLIC CHARITIES, OMAHA POLICE DEPARTMENT, AND THE DOUGLAS COUNTY SHERIFF'S DEPARTMENT, THE SECOND ANNUAL MIDWEST REGIONAL ANTI-HUMAN TRAFFICKING CONFERENCE ON NOVEMBER 8, 2023 IN OMAHA, NE. CONFERENCE ATTENDEES RECEIVED ALL RESOURCES SUCH AS POWERPOINTS AND HANDOUTS VIA THE VIRTUAL EVENT APP. CONTINUED TO OFFER THE HUMAN TRAFFICKING AWARENESS WEBINAR SERIES. THE WEBINARS WERE FREE, ONE-HOUR, AND OFFERED ONLINE FOR HEALTHCARE, LAW ENFORCEMENT AND SOCIAL SERVICE PROFESSIONALS. VARIOUS COMMUNITY ORGANIZATIONS AND SERVICE PROVIDERS ACROSS NEBRASKA AND SOUTHWEST IOWA SERVED AS PRESENTERS.REQUIRED HUMAN TRAFFICKING 101, PEARR (TRAUMA-INFORMED APPROACH TO VICTIM ASSISTANCE IN HEALTH CARE SETTINGS), AND TRAUMA INFORMED CARE STAFF TRAINING VIA PATHWAYS. THE DIVISION RELEASES THESE TRAININGS ANNUALLY ON OCTOBER 1ST AND REQUIRES THEIR COMPLETION BY DECEMBER 31ST.MEASURES:- MIDWEST REGIONAL ANTI-HUMAN TRAFFICKING CONFERENCE REGISTRANTS: 377LIVE ATTENDEES: 161 VIRTUAL AND 77 IN-PERSON FROM 22 DIFFERENT STATESCEUS: 786.5 CLAIMED BY 143 ELIGIBLE PROFESSIONALS- STAFF PATHWAYS TRAININGS (NEBRASKA AND IOWA COMPLETION RATES AS OF JANUARY 2024)HUMAN TRAFFICKING 101: 85% (11,194/13,128)PEARR TOOL: 90% (6893/7686**ASSIGNED TO DEFINED CLINICAL STAFF ONLY.TRAUMA-INFORMED CARE: 90% (7089/7854)PRIORITY HEALTH NEED #2: CARDIOVASCULAR HEALTHTO ADDRESS THIS NEED THE HOSPITAL WILL IMPLEMENT THE FOLLOWING STRATEGIES IN FISCAL YEARS 2023- 2025:2.1 EXPAND ACCESS TO HEALTHY FOODS AND RECREATIONAL OPPORTUNITIES AND INCREASE AWARENESS OF RISK FACTORS FOR CHRONIC DISEASE BY ALIGNING HOSPITAL EFFORTS AND FINANCIAL SUPPORT WITH PIERCE COUNTY COMMUNITY PARTNERS.2.1.1 PARTICIPATE IN THE NCDHD COMMUNITY HEALTH IMPROVEMENT PLAN AND IDENTIFY OPPORTUNITIES TO SUPPORT COMMUNITY PARTNERS' CHRONIC DISEASE DETECTION AND MANAGEMENT EFFORTS SUCH AS: * INCREASE AMOUNT OF CPR CERTIFIED (INSTRUCTOR AND TRAINEES) * PROMOTE AND PROVIDE BLOOD PRESSURE SCREENINGS, WITH APPROPRIATE REFERRALS * PROMOTE AWARENESS OF THE RISKS OF ABNORMAL BLOOD PRESSURE VALUES * EXPLORE AVENUES FOR PHYSICAL ACTIVITY IN EACH COUNTY * INCREASE MEDICAID AWARENESS AND ENROLLMENTFY24 ACTIONS AND IMPACT:- CONTINUED TO IDENTIFY OPPORTUNITIES TO PLACE BLOOD PRESSURE MACHINES IN COMMUNITY SETTINGS SUCH AS THE SENIOR CENTER AND LIBRARY. - A STAFF MEMBER MAINTAINS CPR INSTRUCTOR CERTIFICATION AND WORKS WITH THE AREA FIRE DEPARTMENT TO FACILITATE TRAININGS. - ANOTHER STAFF MEMBER FACILITATED AUTOMATED EXTERNAL DEFIBRILLATOR (AED) TRAININGS. - STAFF CONTINUED TO SUPPORT LOCAL EMT WITH VOLUNTEER/ON CALL HOURS. MEASURES:- AED TRAININGS: 2TOTAL NUMBER OF ATTENDEES: 30- EMT TRAINING ATTENDEES: 7- STAFF WHO COVERED FOR LOCAL EMTS AT LEAST ONCE: 92.1.2 EXPLORE OPPORTUNITIES TO SUPPORT HEALTHY FOOD CONSUMPTION AND BEHAVIORS SUCH AS: * SPONSORING A COOKING CLASS IN PLAINVIEW * INSTALL/ MAINTAIN COMMUNITY GARDEN AT CHI HEALTH PLAINVIEWFY24 ACTIONS AND IMPACT: NO UPDATES TO REPORT. MEASURES: NO MEASURES TO REPORT.2.1.3 HOST AN ANNUAL LAB FAIR OFFERING NO AND LOW COST SKIN CANCER SCREENING, BLOOD PRESSURE CHECKS AND GLUCOSE TESTING TO SUPPORT EARLY DETECTION OF RISK FACTORS FOR CHRONIC DISEASEFY24 ACTIONS AND IMPACT:- HOSTED A LAB FAIR IN APRIL 2024 AND OFFERED THE FOLLOWING SERVICES: COMPREHENSIVE METABOLIC PANELS, COMPLETE BLOOD COUNTS, LIPID PANELS, THYROID CHECKS, HBA1C, PROSTHETIC SPECIFIC ANTIGEN, BLOOD PRESSURE CHECKS, AND SKIN CHECKS.MEASURES:- APRIL LAB FAIRATTENDEES: 240ATTENDEES WHO RECEIVED A SERVICE: 141ATTENDEES WHO RECEIVED BLOOD PRESSURE CHECKS: 50ATTENDEES WHO RECEIVED SKIN CHECKS: 20ATTENDEES WHO PARTICIPATED IN FOLLOW UP APPOINTMENTS AS A RESULT OF THE SKIN CHECK: 112.1.4 WORK WITH CHI HEALTH CLINICS TO SUPPORT BLOOD PRESSURE SCREENING, DIABETES A1C TESTING AND MANAGEMENT, AND OTHER METRICS DETERMINED BY THE CLINICSFY24 ACTIONS AND IMPACT:- CONTINUED TO WORK WITH CLINICS TO MONITOR PROGRESS.MEASURES:- HYPERTENSION CONTROL: 78%; GOAL: >78%- HGB A1C MEASURE: <20%; GOAL: <20%2.1.5 INVEST IN COMMUNITY ORGANIZATIONS FOCUSED ON CARDIOVASCULAR HEALTH THROUGH THE IMPLEMENTATION OF THE COMMUNITY HEALTH IMPROVEMENT GRANT (CHIG) PROGRAM.FY24 ACTIONS AND IMPACT:- AWARDED A CHIG TO THE PLAINVIEW SOCIAL CENTER. THE PLAINVIEW SOCIAL CENTER IS A LOCAL NONPROFIT THAT SUPPORTS HEALTHY AGING AND AGING AT HOME. THROUGH CHIG, THE PLAINVIEW SOCIAL CENTER PROVIDED NUTRITION EDUCATION COURSES, EXERCISE CLASSES, AND SOCIAL ACTIVITIES FOR OLDER ADULTS.MEASURES:- CHIG FUNDS AWARDED (1/1/24-12/31/24): $4,500SCH H, PART V, LINE 11 (CONTINUED) FACILITY REPORTING GROUP - B PART V, SECTION B, LINE 13H: THE PATIENT MUST HAVE A MINIMUM ACCOUNT BALANCE OF TEN DOLLARS ($10.00) WITH THE COMMONSPIRIT HOSPITAL ORGANIZATION. MULTIPLE ACCOUNT BALANCES MAY BE COMBINED TO REACH THIS AMOUNT. PATIENTS/GUARANTORS WITH BALANCES BELOW TEN DOLLARS ($10.00) MAY CONTACT A FINANCIAL COUNSELOR TO MAKE MONTHLY INSTALLMENT PAYMENT ARRANGEMENTS. THE PATIENT MUST SUBMIT A COMPLETED FINANCIAL ASSISTANCE APPLICATION. PATIENT COOPERATION STANDARDS - A PATIENT MUST COOPERATE WITH THE HOSPITAL FACILITY IN PROVIDING THE INFORMATION AND DOCUMENTATION NECESSARY TO DETERMINE ELIGIBILITY. SUCH COOPERATION INCLUDES COMPLETING ANY REQUIRED APPLICATIONS OR FORMS. THE PATIENT IS RESPONSIBLE FOR NOTIFYING THE HOSPITAL FACILITY OF ANY CHANGE IN FINANCIAL SITUATION THAT WOULD IMPACT THE ASSESSMENT OF ELIGIBILITY. A PATIENT MUST EXHAUST ALL OTHER PAYMENT OPTIONS, INCLUDING PRIVATE COVERAGE, FEDERAL, STATE AND LOCAL MEDICAL ASSISTANCE PROGRAMS, AND OTHER FORMS OF ASSISTANCE PROVIDED BY THIRD PARTIES PRIOR TO BEING APPROVED. AN APPLICANT FOR FINANCIAL ASSISTANCE IS RESPONSIBLE FOR APPLYING TO PUBLIC PROGRAMS FOR AVAILABLE COVERAGE. HE OR SHE IS ALSO EXPECTED TO PURSUE PUBLIC OR PRIVATE HEALTH INSURANCE PAYMENT OPTIONS FOR CARE PROVIDED BY A COMMONSPIRIT HOSPITAL ORGANIZATION WITHIN A HOSPITAL FACILITY. A PATIENT'S AND, IF APPLICABLE, ANY GUARANTOR'S COOPERATION IN APPLYING FOR APPLICABLE PROGRAMS AND IDENTIFIABLE FUNDING SOURCES, INCLUDING COBRA COVERAGE (A FEDERAL LAW ALLOWING FOR A TIME-LIMITED EXTENSION OF EMPLOYEE HEALTHCARE BENEFITS), SHALL BE REQUIRED. IF A HOSPITAL FACILITY DETERMINES THAT COBRA COVERAGE IS POTENTIALLY AVAILABLE, AND THAT A PATIENT IS NOT A MEDICARE OR MEDICAID BENEFICIARY, THE PATIENT OR GUARANTOR SHALL PROVIDE THE HOSPITAL FACILITY WITH INFORMATION NECESSARY TO DETERMINE THE MONTHLY COBRA PREMIUM FOR SUCH PATIENT, AND SHALL COOPERATE WITH HOSPITAL FACILITY STAFF TO DETERMINE WHETHER HE OR SHE QUALIFIES FOR HOSPITAL FACILITY COBRA PREMIUM ASSISTANCE, WHICH MAY BE OFFERED FOR A LIMITED TIME TO ASSIST IN SECURING INSURANCE COVERAGE. A HOSPITAL FACILITY SHALL MAKE AFFIRMATIVE EFFORTS TO HELP A PATIENT OR PATIENT'S GUARANTOR APPLY FOR PUBLIC AND PRIVATE PROGRAMS. FACILITY REPORTING GROUP A, PART V, SECTION B, LINE 11 (CONTINUED 1): 1.5 DECREASE BEHAVIORAL HEALTH WORKFORCE SHORTAGE THROUGH EDUCATIONAL PARTNERSHIPS* DEVELOP, IMPLEMENT AND EVALUATE BEHAVIORAL HEALTH WORKFORCE RECRUITMENT AND RETENTION STRATEGIESFY24 ACTIONS AND IMPACT:- CONTINUED TO IMPLEMENT RETENTION STRATEGIES. UTILIZED FUNDING FOR QUARTERLY RECOGNITION OF PRECEPTORS, SUPERVISORS, AND MENTORS AND FOR SPONSORING CONFERENCES AND CONTINUING EDUCATION. - RELOCATED THE CREIGHTON PSYCHIATRIC RESIDENCY PROGRAM TO IMMANUEL TO ACCOMMODATE ADDITIONAL THERAPISTS AT LASTING HOPE.- ADDED A NEW INTENSIVE OUTPATIENT PROGRAM FOR CHEMICAL DEPENDENCY AT LASTING HOPE. MEASURES:- HIRED:PSYCHIATRISTS: 4PSYCHIATRIC NURSE PRACTITIONERS: 6CHEMICAL DEPENDENCY PROGRAMTHERAPISTS: 2NURSE: 1ADDICTION PSYCHIATRIST: 1- VACANCY RATES AS OF JULY 2024 IMMANUEL: 18.98% (23.67% IN JUNE 2024)LASTING HOPE: 30.34% (39.33% IN JUNE 2024)1.6 REDUCE MENTAL HEALTH STIGMA* SUPPORT INTERNAL/ COMMUNITY MENTAL HEALTH STIGMA REDUCTION CAMPAIGNSFY24 ACTIONS AND IMPACT: - IMPLEMENTED THE AMERICAN HOSPITAL ASSOCIATION'S PEOPLE MATTER WORDS MATTER CAMPAIGN BY DISTRIBUTING MONTHLY POSTERS AND COMMUNICATIONS AND ENSURING THAT ALL ORGANIZATION LEADERS KNEW HOW TO ORDER PROMOTIONAL MATERIALS.MEASURES: NO MEASURES TO REPORT.1.7 EARLY DETECTION OF DEPRESSION AND CONNECTION TO MENTAL HEALTH SERVICES AMONG PREGNANT PEOPLE* CONDUCT PERINATAL DEPRESSION SCREENING DURING PRENATAL VISIT, WHILE INPATIENT FOR DELIVERY AND AT POSTPARTUM VISITFY24 ACTIONS AND IMPACT:- CONTINUED TO IMPLEMENT INPATIENT DEPRESSION SCREENING.MEASURES:- CUMC - BERGAN MERCY: 30,000- IMMANUEL: 504- LAKESIDE: 9231.8 PREVENT SUICIDE* EXPLORE LOCAL SCHOOL NEEDS REGARDING SUICIDE PREVENTION SUICIDE AND PROVIDE TRAINING AND FINANCIAL RESOURCES (E.G. QUESTION. PERSUADE. RESPOND (QPR), MENTAL HEALTH FIRST AID, ETC.)FY24 ACTIONS AND IMPACT: NO ACTIONS TO REPORT. MEASURES: NO MEASURES TO REPORT.PRIORITY HEALTH NEED #2: HEALTH-RELATED SOCIAL NEEDSTO ADDRESS THIS NEED THE HOSPITAL WILL IMPLEMENT THE FOLLOWING STRATEGIES IN FISCAL YEARS 2023- 2025:2.1 HEALTHY FOOD ACCESS* IMPLEMENT AND EVALUATE A FOOD PRESCRIPTION PROGRAM PILOTFY24 ACTIONS AND IMPACT: CONTINUED TO SUPPORT THE CURA PROJECT.MEASURES:- # OF PARTICIPANTS: 105- PARTICIPANT A1C: AVERAGE BASELINE A1C: 8.1% BASELINE A1C <7%: 32.4% (N = 34)BASELINE A1C 7-8.9%: 32.4% (N = 34)BASELINE A1C>9%: 35.2% (N = 37)- OVERALL RETENTION RATE FOR THE 18-MONTH PROGRAM: 72.7% * PROVIDE FINANCIAL SUPPORT AND PROMOTION OF DOUBLE UP FOOD BUCKS, A SNAP INCENTIVE PROGRAMFY24 ACTIONS AND IMPACT:- CONTINUED TO SUPPORT THE DOUBLE UP FOOD BUCKS (DUFB) PROGRAM STATEWIDE. PARTICIPANTS ENGAGED WITH DUFB AT PARTICIPATING RETAIL SITES [GROCERY STORES, FARMERS MARKETS, AND COMMUNITY SUPPORTED AGRICULTURE (CSAS)] THROUGH FOOD DEMONSTRATIONS, PROGRAM USE, AND PROGRAM PROMOTION/OUTREACH.MEASURES:- VALUE OF QUALIFYING SNAP PURCHASES OF FRESH FRUITS AND VEGETABLES: $351,715.72- DOUBLE UP FOOD BUCKS REDEEMED: >$192,800- DOUBLE UP FOOD BUCKS PURCHASES: $16,321 * PROVIDE FINANCIAL SUPPORT TO ORGANIZATIONS ADDRESSING FOOD SECURITY, SUCH AS SAVING GRACEFY24 ACTIONS AND IMPACT: DONATED FUNDS TO SAVING GRACE PERISHABLE FOOD RESCUE.MEASURES: FUNDS DONATED: $1,000* SUPPORT A SENIOR AND WIC FARMERS MARKET VOUCHER REDEMPTION PROGRAM AND POP UP FARMSTANDSFY24 ACTIONS AND IMPACT:- CONTINUED TO PARTNER WITH BIG GARDENS AND WHISPERING ROOTS TO OFFER POP-UP FARM STANDS AT FIVE WOMEN, INFANT AND CHILDREN (WIC) CLINICS AND TWO SENIOR CENTERS IN DOUGLAS AND SARPY COUNTY. THESE SITES WERE SELECTED TO ACCOMMODATE INDIVIDUALS PARTICIPATING IN THE WIC AND SENIOR FARMER'S MARKET VOUCHER PROGRAM IN A SAFER, SMALLER MARKET ENVIRONMENT AND TO IMPROVE ACCESS (TRANSPORTATION WAS CITED AS A BARRIER CONTRIBUTING TO HISTORICALLY LOW REDEMPTION RATES IN THE WIC FARMER'S MARKET VOUCHER PROGRAM IN NE).- THE STATE OF NEBRASKA ELIMINATED WIC VOUCHERS IN 2022, SO WHISPERING ROOTS, RATHER THAN ACCEPTING AND MATCHING THE VOUCHERS, BEGAN DISTRIBUTING MONTHLY TOKENS TO WIC AND OTHER LOW-INCOME FAMILIES TO SPEND ON FRESH PRODUCE. MEASURES:- PARTICIPATING SITES: 7- FARM STAND CUSTOMERS SERVED: 616- VALUE OF FREE PRODUCE DISTRIBUTED TO WIC AND OTHER LOW-INCOME FAMILIES: $52,566- VALUE OF SENIOR FARMER'S MARKET VOUCHERS REDEEMED: $4,371 (1,457 VOUCHERS)- VALUE OF SENIOR PRODUCE MATCH PROVIDED TO VOUCHERS RECIPIENTS TO 'DOUBLE UP': $5,754- TOTAL OF ALL PURCHASES OF FRESH, LOCAL PRODUCE: $63,8802.2 FINANCIAL LITERACY* PROVIDE FINANCIAL SUPPORT AND PROMOTION OF THE BRIDGES OUT OF POVERTY FINANCIAL LITERACY PROGRAMFY24 ACTIONS AND IMPACT:- AWARDED A COMMUNITY HEALTH IMPROVEMENT GRANT (CHIG) TO BRIDGES OUT OF POVERTY.MEASURES:- CHIG FUNDS AWARDED (1/1/24-12/31/24): $50,000- GETTING AHEAD PROGRAMGRADUATION RATE: 91% (416/441)PARTICIPANT DEMOGRAPHICS:AFRICAN-AMERICAN: 25.34%ASIAN: 2.45%CAUCASIAN: 25.61%HISPANIC: 40.33%MIDDLE EASTERN: 0.27%NATIVE AMERICAN: 2.45%OTHER: 3.54%3 MONTHS POST GRADUATION ASSESSMENT:AVERAGE MONTHLY INCOME INCREASE: $1,500AVERAGE MONTHLY BILL REDUCTION: $580AVERAGE INCREASE IN ASSETS: $7,500AVERAGE REDUCTION IN MONTHLY PUBLIC BENEFITS USAGE: $124AVERAGE DECREASE IN DEBT TO INCOME RATIO: 50%2.3 SUPPORT EFFORTS TO ADDRESS HOUSING STABILITY* IMPLEMENT AND SUSTAIN A MEDICAL RESPITE PROGRAM FY24 ACTIONS AND IMPACT:- MEDICAL RESPITE GUESTS RECEIVE CASE MANAGEMENT, ACCESS TO MEDICAL CARE, DAILY MEALS, AND CLOTHING. COMMUNITY PARTNERS, SUCH AS UNITED HEALTHCARE, AND NEBRASKA TOTAL CARE, COMMUNITY ALLIANCE (PEER SUPPORT AND SOAR), HOUSING NAVIGATION AND DIVERSION ARE ALSO AVAILABLE AT THE SHELTER FOR GUESTS.MEASURES:- PATIENTS DISCHARGED INTO MEDICAL RESPITE CARE: 28- GENDERMALE: 22FEMALE: 6- AGE35-44: 645-54: 655-64: 11 65+: 5- RACE/ETHNICITY: BLACK OR AFRICAN AMERICAN: 9WHITE: 17MULTIPLE RACES: 1HISPANIC/LATINO: 1- PATIENTS CONNECTED TO ADDITIONAL WRAPAROUND SERVICES IN MEDICAL RESPITE: 100%- PATIENTS IN MEDICAL RESPITE REFERRED TO A PRIMARY CARE PROVIDER: 100%- PATIENTS SCREENED FOR BEHAVIORAL HEALTH CARE AND SUBSTANCE USE NEEDS: 100%- PATIENTS CONNECTED TO PERMANENT HOUSING: 2* SUPPORT A HEALTH AND HOUSING COALITION FY24 ACTIONS AND IMPACT:- THE HEALTH & HOUSING COALITION CONTINUES TO MEET AND DISCUSS: THE PURPOSE OF THE COALITION AND THE ROLE OF PARTICIPANTS, THE INTERSECTION OF CLINICAL CARE AND HOUSING NEEDS, IMPLEMENTATION OF THE MEDICAL RESPITE PILOT, UPDATES FROM THRESHOLD CONTINUUM OF CARE (FORMERLY METRO AREA CONTINUUM OF CARE), NEWS FROM THE CITY OF OMAHA'S HOMELESS SERVICES COORDINATOR, HEALTH SYSTEM IMPLEMENTATION OF SOCIAL NEEDS SCREENGINGS, AND HOUSING LEGISLATION.- THE MEDICAL RESPITE STEERING COMMITTEE CONTINUED TO MEET (BIWEEKLY). THE HIGH UTILIZERS OF EMERGENCY SERVICES COMMITTEE TRANSITIONED TO A FREQUENT USERS SYSTEMS ENGAGEMENT (FUSE) COMMITTEE. MEASURES:- COALITION MEETING ATTENDANCE:AUGUST 29, 2023: 43 PEOPLE REPRESENTING 27 ORGANIZATIONS SEPTEMBER 14, 2023: 15 PEOPLE REPRESENTING 21 ORGANIZATIONSNOVEMBER 14, 2023: 42 PEOPLE REPRESENTING 25 ORGANIZATIONSJANUARY 30, 2024: 39 PEOPLE REPRESENTING 26 ORGANIZATIONSAPRIL 30, 2024: 40 PEOPLE REPRESENTING 27 ORGANIZATIONS* EVALUATE AND SUSTAIN AN INPATIENT HOUSING CASE MANAGEMENT PROGRAM FY24 ACTIONS AND IMPACT:- CONTINUED TO IMPROVE THE PROCESS OF IDENTIFYING AND REFERRING PATIENTS WITH HOUSING INSTABILITY ADMITTED TO CUMC-BERGAN MERCY TO TOGETHER FOR ONSITE HOUSING PROBLEM SOLVING AND CASE MANAGEMENT.MEASURES:- REFERRALS MADE TO TOGETHER FOR HOUSING CASE MANAGEMENT: 67INTERVENTIONS:PREVENTION: 44DIVERSION: 13GENERAL INFORMATION: 2UTILITIES: 1FINANCIAL INTERVENTIONS TO PREVENT HOMELESSNESS OR ACHIEVE STABLE HOUSING: $87,382.472.4 ADDRESS TRANSPORTATION BARRIERS TO ACCESSING HEALTHCARE SERVICES* CONVENE AN INTERNAL WORKING GROUP TO EXPLORE OPPORTUNITIES TO MEET PATIENT TRANSPORTATION NEEDSFY24 ACTIONS AND IMPACT: NO UPDATES TO REPORT. MEASURES: NO MEASURES TO REPORT. FACILITY REPORTING GROUP A, PART V, SECTION B, LINE 11 (CONTINUED 2): 2.5 SOCIAL NEEDS INTEGRATION* DEVELOP AND TEST REFERRAL PROCESSES FOR SOCIAL NEEDS THROUGH UNITE US FY24 ACTIONS AND IMPACT:- INTEGRATED UNITE US WITHIN THE ELECTRONIC HEALTH RECORD SYSTEM, EPIC, IN MAY 2024. - LAUNCHED UNIVERSAL HEALTH-RELATED SOCIAL NEEDS SCREENING OF ALL ADULT INPATIENT ADMISSIONS IN APRIL 2024.MEASURES:- CHI HEALTH CUMC - BERGAN MERCYPATIENTS IMPACTED BY UNITE US REFERRALS: 20REFERRALS: 37- CHI HEALTH IMMANUELPATIENTS IMPACTED BY UNITE US REFERRALS: 20REFERRALS: 50NOTE: COUNTS MAY BE SKEWED. REFERRAL TRACKING WAS BROKEN OUT BY HOSPITAL BEGINNING IN MAY 2024. PREVIOUSLY, ALL TRACKING WAS CENTRALIZED UNDER ONE HOSPITAL/CLINIC REPORTING ORGANIZATION.* LEVERAGE COMMUNITY HEALTH WORKERS TO IMPROVE PATIENT OUTCOMES AND REDUCE HEALTH DISPARITIES FY24 ACTIONS AND IMPACT:- COMMUNITY LINK MAINTAINED COMMUNITY HEALTH WORKERS (CHWS) IN FOUR AMBULATORY CLINICS, BUT RECEIVED SOCIAL WORK REFERRALS FROM A TOTAL OF 28 OMAHA METRO CHI HEALTH CLINICS. - FOUR COMMUNITY LINK CHWS COMPLETED HRSA-FUNDED COMMUNITY HEALTH WORKER TRAINING PROGRAMS DURING WHICH THEY COMPLETED APPRENTICESHIPS IN THEIR CURRENT ROLES. - SEVERAL COMMUNITY LINK CHWS SHARED THEIR TIME AND EXPERTISE WITH THE NEBRASKA CHW CONSULTANT-TRAINER CADRE TO SUPPORT CHW WORKFORCE DEVELOPMENT. - COMMUNITY LINK SERVED AS A CONSULTANT TO THE NEBRASKA ASSOCIATION OF LOCAL HEALTH DIRECTORS (NALHD) AS THEY DEVELOPED CHW TRAINING MODULES. - CHI INTEGRATED THE UNITE US RESOURCE AND REFERRAL PLATFORM INTO THE ELECTRONIC HEALTH RECORD SYSTEM. COMMUNITY LINK CONTINUED TO USE UNITE US TO SEND REFERRALS THAT DID NOT REQUIRE IMMEDIATE RESPONSE.- COMMUNITY LINK CONTINUED TO COLLABORATE ON A MIDWEST CHW COMMUNITY OF PRACTICE CALL THAT INCLUDES ALL THE CHW TEAMS FROM THE UPPER AND LOWER CENTRAL REGION (INCLUDING NE/IA/ND/MN).MEASURES:- REFERRALS RECEIVED: 3,627- BARRIERS IDENTIFIED: 4,895 (TOP 5 INCLUDE FINANCIAL, INSURANCE, TRANSPORTATION, FOOD, AND HOUSING)- BARRIERS ADDRESSED: 7,657- INTERVENTIONS PROVIDED: 9,337RESOURCES: 2,600COORDINATED CALLS: 1,138APPLICATION ASSISTANCE: 870INTERNAL REFERRALS: 653EDUCATION AND INFORMATION: 4,013OTHER: 63REFERRALS MADE THROUGH UNITE US: 223* SUPPORT THE IMPLEMENTATION OF PATHWAYS COMMUNITY HUB TO SUSTAIN A COMMUNITY HEALTH WORKER (CHW) WORKFORCE IN THE OMAHA METRO AND REDUCE DISPARATE MATERNAL AND INFANT HEALTH OUTCOMES FY24 ACTIONS AND IMPACT:- AWARDED A COMMUNITY HEALTH IMPROVEMENT GRANT (CHIG) TO OMAHA PATHWAYS COMMUNITY HUB TO SERVE PREGNANT PEOPLE AT RISK FOR POOR BIRTH OUTCOMES DUE TO SOCIAL, MEDICAL AND BEHAVIORAL RESOURCES WITH 1) A FOCUS ON SERVING INDIVIDUALS EAST OF 72ND ST. IN DOUGLAS AND SARPY COUNTIES IN NEBRASKA AND 2) A PRIORITY TO SERVE BLACK PREGNANT INDIVIDUALS.MEASURES:- CHIG FUNDS AWARDED (1/1/24-12/31/24): $50,000- PATHWAYS COMMUNITY HUB METRICS (MARCH 1, 2024-JUNE 30, 2024):PREGNANT PEOPLE SERVED (MEANING AT LEAST ONE NEED SUCCESSFULLY ADDRESSED): 38REFERRED INDIVIDUALS ENROLLED IN THE PROGRAM: 70% (47/63)PATHWAYS CLOSED: 98; ACROSS 12 NEED AREASSOCIAL SERVICE REFERRAL: 58PREGNANCY: 13FOOD SECURITY: 5FAMILY PLANNING: 4POSTPARTUM: 4EMPLOYMENT: 3HEALTHCARE COVERAGE: 3MEDICAL REFERRAL: 3ORAL HEALTH: 2TRANSPORTATION: 1MEDICAL HOME: 1HOUSING: 1HEALTH EDUCATION MODULES DELIVERED: 77* INVEST IN NONPROFITS ADDRESSING OUR PRIORITY HEALTH NEED OF HEALTH RELATED SOCIAL NEEDS (ALL HOSPITALS)FY24 ACTIONS AND IMPACT:- FUNDED FIVE NONPROFITS THROUGH COMMUNITY HEALTH IMPROVEMENT GRANTS (CHIG): OMAHA COMMUNITY FOUNDATION, NO MORE EMPTY POTS, OMAHA BRIDGES OUT OF POVERTY, INCOMMON COMMUNITY, TOGETHER.MEASURES:- CHIG FUNDS AWARDED (1/1/24-12/31/24): $247,0862.6 INCREASE THE NUMBER AND DIVERSITY OF YOUTH INTERESTED IN HEALTH CARE CAREERS* CREATE A HEALTH CARE CAREER PIPELINE FOR STUDENTSFY24 ACTIONS AND IMPACT: HOSTED A MEDICAL ACADEMY FOR HIGH SCHOOL STUDENTS INTERESTED IN A HEALTH CARE CAREER. MEASURES: NO MEASURES TO REPORT. * SUPPORT SIEMBRA SALUD, HEALTH CAREER LADDER PROGRAMFY24 ACTIONS AND IMPACT:- CONTINUED TO SUPPORT THE SIEMBRA SALUD INTERNSHIP PROGRAM. INTERNS SPLIT THEIR TIME BETWEEN URBAN AGRICULTURE OR PROFESSIONAL DEVELOPMENT LEARNING AND CAREER EXPLORATION ACTIVITIES. THEY COMPLETED MENTAL HEALTH FIRST AID, (MHFA); CPR; QUESTION, PERSUADE, REFER (QPR); AND STOP THE BLEED TRAININGS. - THE CNA TRAINING AND LICENSURE PROGRAM RECRUITED STUDENTS FROM TWO HUBSTHE LATINO CENTER OF THE MIDLANDS AND BRYAN HIGH SCHOOL. STUDENTS RECEIVED THEIR TRAINING AT METROPOLITAN COMMUNITY COLLEGE OR FULTON HOMES. PARTNERED WITH MCC TO SUPPORT STUDENTS AND PILOT AN INSTRUCTIONAL RESTRUCTURING. MEASURES:- SIEMBRA SALUDAPPLICATIONS RECEIVED: 37APPLICATIONS ACCEPTED: 12INTERNS: 14HEALTH CAREER EXPERIENCES: 5HOSPITAL: 2CLINIC: 1CAREER PANEL PRESENTATIONS: 2TRAININGS AND CERTIFICATIONS: 15FAMILIES REACHED THROUGH HOME GARDENING PROGRAM: 50 - CNA LICENSURE AND TRAINING PROGRAMAPPLICATIONS RECEIVED: 49ENROLLEES: 5GRADUATES: 4HIRED BY CHI: 22.7 HEALTH EQUITY TRANSFORMATION ASSESSMENT (HETA)* COLLECT RACE, ETHNICITY AND LANGUAGE DATA FOR PATIENTS AND STAFF. ASSESS DATA AND IDENTIFY STRATEGIES TO RECRUIT/ RETAIN A HEALTHCARE WORKFORCE REFLECTIVE OF THE RACIAL, ETHNIC AND LINGUISTIC DIVERSITY OF OUR PATIENTS AND COMMUNITY.FY24 ACTIONS AND IMPACT:- COMPLETED THE AMERICAN HOSPITAL ASSOCIATION'S HEALTH EQUITY TRANSFORMATION ASSESSMENT. CREATED A HEALTH EQUITY ACTION PLAN AND FORMED A COMMITTEE TO ADVANCE THE WORK. WILL FOCUS ON UNDERSTANDING DRIVERS OF PREVENTABLE READMISSIONS (INCLUDING UNMET SOCIAL NEEDS) IN FY25.MEASURES: NO MEASURES TO REPORT. FACILITY REPORTING GROUP A, PART V, SECTION B, LINE 11 (CONTINUED 3): PRIORITY HEALTH NEED #3: VIOLENCE PREVENTION & INTERVENTIONTO ADDRESS THIS NEED THE HOSPITAL WILL IMPLEMENT THE FOLLOWING STRATEGIES IN FISCAL YEARS 2023- 2025:3.1 PROVIDE RESOURCES AND SUPPORT TO VICTIMS OF VIOLENCE* SUPPORT AND EXPAND THE FORENSIC NURSE EXAMINER PROGRAM FY24 ACTIONS AND IMPACT: - THE FORENSIC NURSE EXAMINER (FNE) PROGRAM MARKET MANAGER PROVIDED ONGOING EDUCATION ON INTIMATE PARTNER VIOLENCE (IPV), SEXUAL ASSAULT (SA), AND HUMAN TRAFFICKING (HT) IDENTIFICATION TO EMERGENCY DEPARTMENTS.MEASURES:- FNES: 18- IDENTIFIED IPV, SA, AND/OR HT CASES FOR WHICH FNES WERE CALLED TO PROVIDE SUPPORT (AS OF NOVEMBER 13, 2024): 434- # OF SURVIVORS OF DOMESTIC VIOLENCE, SEXUAL ASSAULT AND HUMAN TRAFFICKING SERVED THROUGH THE FORENSIC NURSE EXAMINER PROGRAM: 547* SUPPORT TRAUMA RESPONSE, INCLUDING INPATIENT CASE MANAGEMENT AND COMMUNITY-BASED VIOLENCE INTERVENTION EFFORTS SUPPORT TRAUMA RESPONSE, INCLUDING INPATIENT CASE MANAGEMENT AND COMMUNITY-BASED VIOLENCE INTERVENTION EFFORTSFY24 ACTIONS AND IMPACT: - CONTINUED TO PARTNER WITH YOUTURN. MEASURES:- HOSPITAL TRAUMA RESPONSES: 0 (IN-PERSON RESPONSE PAUSED DUE TO COVID-19) CURRENTLY PLANNING TO REINSTATE TRAUMA RESPONSE FOR FY25- FACILITATED ENCOUNTERS WITH HIGH SCHOOL STUDENTS: 4,428- TRAINING PROVIDED TO HIGHEST RISK YOUTH: 78- DIRECT CONTACT WITH HIGHEST RISK YOUTH HOUSED AT DOUGLAS COUNTY YOUTH CENTER: 745- CASE MANAGEMENT FOR ADOLESCENT AND YOUNG ADULTS: 137- COMMUNITY-BASED REFERRALS: 875- PUBLIC EDUCATION MATERIALS DISTRIBUTED: 3,852- COMMUNITY MEMBERS REACHED THROUGH VIOLENCE PREVENTION EVENTS: 10,253 3.2 PREVENT VIOLENCE AND INTERVENE WHEN IT IS SUSPECTED* INCREASE HEALTH SYSTEM AND COMMUNITY CAPACITY TO IDENTIFY VICTIMS OF HUMAN TRAFFICKING AND RESPOND APPROPRIATELYFY24 ACTIONS AND IMPACT:- THE HEALTHY COMMUNITIES TEAM SUPPORTED THIS STRATEGY THROUGH A FY22-24 MISSION AND MINISTRY UNITED AGAINST VIOLENCE GRANT. THROUGHOUT FY24:- THE FORENSIC NURSE EXAMINER (FNE) PROGRAM MARKET MANAGER PROVIDED ONGOING EDUCATION ON INTIMATE PARTNER VIOLENCE (IPV), SEXUAL ASSAULT (SA), AND HUMAN TRAFFICKING (HT) IDENTIFICATION TO EMERGENCY DEPARTMENTS.- CHI HEALTH AWARDED HUMAN TRAFFICKING AND VIOLENCE PREVENTION MINI-GRANTS TO SUPPORT COMMUNITY ORGANIZATIONS SERVING VICTIMS AND SURVIVORS IN THE OMAHA METRO AREA; AWARDEES: RESTORED WINGS (FY23 + FY24), HEARTLAND FAMILY SERVICE (FY23 + FY24), AND MEN AGAINST DOMESTIC VIOLENCE ACTION COALITION (FY24).- SUPPORTED COMMUNITY TRAINING/EDUCATION FACILITATED BY THE WOMEN'S CENTER FOR ADVANCEMENT (WCA), AN ADVOCACY ORGANIZATION PROVIDING DIRECT SUPPORT TO VICTIMS/SURVIVORS OF VIOLENCE.- THE INTERNAL EDUCATION AND AWARENESS INITIATIVES BECAME SELF-SUSTAINED/AUTONOMOUS AND NO LONGER REQUIRED THE OVERSIGHT OF THE HOSPITAL-BASED OMAHA METRO HUMAN TRAFFICKING/VIOLENCE PREVENTION TASK FORCE, SO THE TASK FORCE TRANSITIONED TO A BI-MONTHLY "ADVISORY COUNCIL." THE ADVISORY COUNCIL REGULARLY ATTENDED THE NEBRASKA HUMAN TRAFFICKING TASK FORCE MEETINGS LED BY THE NEBRASKA ATTORNEY GENERAL'S OFFICE, AND REGULARLY CONNECTED WITH VARIOUS MULTIDISCIPLINARY TASK FORCES/RESPONSE GROUPS IN THE OMAHA METRO COMMUNITIES. - HOSTED, IN COLLABORATION WITH CREIGHTON UNIVERSITY'S OFFICE OF CONTINUING EDUCATION AND 11 COMMUNITY/STATE ORGANIZATIONS, INCLUDING WILLOW RISING, CATHOLIC CHARITIES, OMAHA POLICE DEPARTMENT, AND THE DOUGLAS COUNTY SHERIFF'S DEPARTMENT, THE SECOND ANNUAL MIDWEST REGIONAL ANTI-HUMAN TRAFFICKING CONFERENCE ON NOVEMBER 8, 2023 IN OMAHA, NE. CONFERENCE ATTENDEES RECEIVED ALL RESOURCES SUCH AS POWERPOINTS AND HANDOUTS VIA THE VIRTUAL EVENT APP. - REQUIRED HUMAN TRAFFICKING 101, PEARR (TRAUMA-INFORMED APPROACH TO VICTIM ASSISTANCE IN HEALTH CARE SETTINGS), AND TRAUMA INFORMED CARE STAFF TRAINING VIA PATHWAYS. THE DIVISION RELEASES THESE TRAININGS ANNUALLY ON OCTOBER 1ST AND REQUIRES THEIR COMPLETION BY DECEMBER 31ST.MEASURES:- FNES: 18- IDENTIFIED IPV, SA, AND/OR HT CASES FOR WHICH FNES WERE CALLED TO PROVIDE SUPPORT (AS OF NOVEMBER 13, 2024): 434- FY24 VIOLENCE PREVENTION/TRAUMA RESPONSE MINI-GRANTS: $21,500- ESTHETICIANS AND TATTOO ARTISTS TRAINED ON IDENTIFYING IPV/ HUMAN TRAFFICKING: 100- MIDWEST REGIONAL ANTI-HUMAN TRAFFICKING CONFERENCE REGISTRANTS: 377LIVE ATTENDEES: 161 VIRTUAL AND 77 IN-PERSON FROM 22 DIFFERENT STATESCEUS: 786.5 CLAIMED BY 143 ELIGIBLE PROFESSIONALS- STAFF PATHWAYS TRAININGS (NEBRASKA AND IOWA COMPLETION RATES AS OF JANUARY 2024)HUMAN TRAFFICKING 101: 85% (11,194/13,128)PEARR TOOL: 90% (6893/7686)**ASSIGNED TO DEFINED CLINICAL STAFF ONLY.TRAUMA-INFORMED CARE: 90% (7089/7854)* INVEST IN COMMUNITY ORGANIZATION ADDRESSING OUR PRIORITY HEALTH NEED OF VIOLENCE PREVENTION & INTERVENTIONFY24 ACTIONS AND IMPACT:- FUNDED ONE NONPROFIT THROUGH COMMUNITY HEALTH IMPROVEMENT GRANTS (CHIG): RISE ACADEMY.- FUNDED THREE NONPROFITS THROUGH HUMAN TRAFFICKING AND VIOLENCE PREVENTION MISSION AND MINISTRY FUND (MMF) MINI GRANTS: HEARTLAND FAMILY SERVICE, RESTORED WINGS, AND MEN AGAINST DOMESTIC VIOLENCE ACTION COALITION (MADVAC).- NEBRASKA SPINE DONATED TO THE OMAHA POLICE AND FIRE DEPARTMENTS TO SUPPORT THEIR COMMUNITY OUTREACH EVENTS AND EDUCATION.MEASURES:- CHIG FUNDS AWARDED (1/1/24-12/31/24): $40,000- HUMAN TRAFFICKING AND VIOLENCE PREVENTION MMF MINI GRANT FUNDS AWARDED: $21,500- FUNDS DONATED TO THE OMAHA POLICE AND FIRE DEPARTMENTS: $2,0003.3 PROVIDE TRAUMA- INFORMED CARE FOR PATIENTS* EXPLORE ONGOING OPPORTUNITIES TO PROMOTE TRAUMA INFORMED CARE PRACTICES WITHIN THE BEHAVIORAL HEALTH SERVICE LINEFY24 ACTIONS AND IMPACT: ALL STAFF RECEIVE ANNUAL TRAUMA INFORMED CARE TRAINING.MEASURES: NO MEASURES TO REPORT. 3.4 SUPPORT SCHOOL-BASED PROGRAMMING TO INCREASE PROTECTIVE FACTORS AND REDUCE RISK FACTORS FOR VIOLENCE* PROVIDE FUNDING TO COMMUNITY- BASED ORGANIZATIONS DELIVERING EDUCATION AND TRAINING TO LOCAL SCHOOLSF24 ACTIONS AND IMPACT: NO UPDATES TO REPORT. MEASURES: NO MEASURES TO REPORT. FACILITY REPORTING GROUP A, PART V, SECTION B, LINE 11 (CONTINUED 4): THE HOSPITAL WILL NOT ADDRESS THE FOLLOWING HEALTH NEEDS FOR THE FOLLOWING REASONS: ACCESS TO HEALTHCARE SERVICES- ACCESS TO CARE IS A FUNDAMENTAL COMPONENT OF CHI HEALTH'S MISSION AND STRATEGY. THIS ISSUE WAS NOT ELEVATED TO A PRIORITY FOR THIS PARTICULAR PLAN BECAUSE THE INTENT WAS TO IDENTIFY ADDITIONAL STRATEGIES AND INITIATIVES THAT REACH ABOVE AND BEYOND CHI HEALTH'S TYPICAL BUSINESS. FOR EXAMPLE, CHI HEALTH CONTINUES TO OFFER A WIDE ARRAY OF PRIMARY CARE ACCESS POINTS INCLUDING: EXTENDED CLINIC HOURS, PRIORITY CARE SERVICES (WALK-IN CARE), QUICK CARE AND VIRTUAL CARE. ADDITIONAL PROGRAMS LIKE MD SAVE, WHICH ALLOWS PATIENTS TO PRE-PURCHASE CERTAIN SERVICES AT A DISCOUNTED PRICE, AND THE MEDICATION ACCESS PROGRAM (A PRESCRIPTION MEDICATION FINANCIAL ASSISTANCE PROGRAM), ARE WORKING TO LOWER THE COST OF CARE TO THE CONSUMER. IN ADDITION TO PROVIDING THE MAJORITY OF CARE TO THE UNINSURED AND UNDERINSURED IN THE OMAHA METRO AREA, CHI HEALTH WILL CONTINUE TO ADDRESS ACCESS TO HEALTHCARE SERVICES THROUGH FINANCIAL SUPPORT PROVIDED TO THE MAGIS CLINIC, HOPE MEDICAL, FEDERALLY QUALIFIED HEALTH CENTERS- CHARLES DREW AND ONE WORLD COMMUNITY HEALTH CENTER- AND THROUGH FREE HEALTH SCREENINGS AND IMMUNIZATION CLINICS IN THE COMMUNITY.CANCER- CHI HEALTH DID NOT PRIORITIZE CANCER AS A TOP HEALTH NEED BASED ON THE CONSIDERATIONS ABOVE AND IN ORDER TO FOCUS AND MEANINGFULLY IMPACT OTHER AREAS OF NEED. CHI HEALTH WILL CONTINUE TO PERFORM EXISTING CANCER OUTREACH THROUGHOUT THE COMMUNITY AND FINANCIALLY SUPPORT COMMUNITY PARTNERS SUCH AS THE AMERICAN CANCER SOCIETY, THE NEBRASKA CANCER COALITION AND PROJECT PINK'D. CHI HEALTH PARTICIPATES IN THE EVERY WOMAN MATTERS AND NEBRASKA COLON CANCER SCREENING PROGRAMS TO PROVIDE TESTING AND DIAGNOSTIC SERVICES FOR THE MEDICALLY UNDERSERVED IN NEBRASKA. ADDITIONALLY, CHI HEALTH CLINICS ARE WORKING TO INCREASE UTILIZATION OF HPV VACCINATION TO PREVENT CERVICAL CANCER.DIABETES- CHI HEALTH DID NOT PRIORITIZE DIABETES BASED ON THE CONSIDERATIONS ABOVE AND IN ORDER TO FOCUS AND MEANINGFULLY IMPACT OTHER AREAS OF NEED. CHI HEALTH WILL CONTINUE PERFORMING DIABETES OUTREACH AND EDUCATION ACROSS THE OMAHA METRO AREA, INCLUDING THROUGH THE INTEGRATION OF CERTIFIED DIABETES EDUCATORS INTO PRIMARY CARE CLINICS. SEE ALSO HEALTH RELATED SOCIAL NEEDS FOR RELATED ACTIVITIES, SUCH AS THE CURA PROJECT/ PRODUCE PRESCRIPTION PROGRAM FOR LOW- INCOME, DIABETIC PATIENTS.HEART DISEASE AND STROKE- WHILE THIS NEED WAS NOT PRIORITIZED SPECIFICALLY, THE FOCUS ON SUBSTANCE ABUSE THROUGH THE BEHAVIORAL HEALTH PRIORITY WILL HAVE AN IMPACT ON BEHAVIORAL RISK FACTORS FOR HEART DISEASE AND STROKE, SUCH AS ALCOHOL AND SUBSTANCE ABUSE. ADDITIONALLY, CHI HEALTH OFFERS PROGRAMMING DESIGNED TO MITIGATE RISK FACTORS FOR HEART DISEASE AND STROKE THROUGH CHI HEALTH HEART CARE CLASSES INCLUDING HEALTHY COOKING CLASSES. CHI HEALTH IS A FINANCIAL SUPPORTER OF THE AMERICAN HEART ASSOCIATION.INFANT HEALTH & FAMILY PLANNING - WHILE THIS NEED WAS NOT PRIORITIZED SPECIFICALLY, IT IS ANTICIPATED THAT THE PRIORITY FOCUS AREAS WILL HAVE AN IMPACT ON INFANT HEALTH & FAMILY PLANNING, PARTICULARLY THROUGH THE PATHWAYS COMMUNITY HUB PROGRAM, PERINATAL DEPRESSION SCREENING, BLACK, INDIGENOUS, PEOPLE OF COLOR (BIPOC) DOULA PROGRAM AND CENTERING PREGNANCY. REPRESENTATIVES FROM CHI HEALTH PARTICIPATE IN THE DOUGLAS COUNTY HEALTH DEPARTMENT- LED BABY BLOSSOMS COLLABORATIVE. IN ADDITION, CHI SUPPORTS ORGANIZATIONS FOCUSED ON IMPROVING CHILD AND MATERNAL HEALTH OUTCOMES AND REDUCING RACIAL/ ETHNIC DISPARITIES, SUCH AS I BE BLACK GIRL AND MARCH OF DIMES.NUTRITION, PHYSICAL ACTIVITY AND WEIGHT- THIS NEED WILL BE ADDRESSED IN PART THROUGH THE FOOD ACCESS STRATEGIES UNDER THE HEALTH RELATED SOCIAL NEEDS PRIORITY, INCLUDING PROVIDING FINANCIAL SUPPORT FOR DOUBLE UP FOOD BUCKS AND THE WOMEN, INFANT & CHILDREN (WIC)/ SENIOR FARMER'S MARKET VOUCHER PROGRAM. THERE IS SIGNIFICANT EXISTING WORK WITHIN CHI HEALTH AND THE COMMUNITY TO ADDRESS NUTRITION, PHYSICAL ACTIVITY AND WEIGHT STATUS, SUCH AS THE HEALTHY FAMILIES PROGRAM, AND 5-4-3-2-1 GO! CAMPAIGN. ADDITIONALLY, CHI HEALTH PROVIDES FINANCIAL SUPPORT AND IN-KIND CONTRIBUTIONS TO ORGANIZATIONS COMMITTED TO THIS WORK, SUCH AS: CITY SPROUTS, BIG GARDEN/ "GATHER" MOBILE KITCHEN CLASSROOM, SAVING GRACE AND WHISPERING ROOTS.RESPIRATORY DISEASES- CHI HEALTH DID NOT PRIORITIZE RESPIRATORY DISEASES BASED ON THE CONSIDERATIONS ABOVE AND IN ORDER TO FOCUS AND MEANINGFULLY IMPACT OTHER AREAS OF NEED. CHI HEALTH WILL CONTINUE TO PROVIDE FISCAL SPONSORSHIP, PROVIDE IN- KIND SUPPORT OF TOBACCO EDUCATION AND ADVOCACY OF THE MIDLANDS (TEAM). ORAL HEALTH- CHI HEALTH DID NOT PRIORITIZE RESPIRATORY DISEASES BASED ON THE CONSIDERATIONS ABOVE AND IN ORDER TO FOCUS AND MEANINGFULLY IMPACT OTHER AREAS OF NEED. OTHER COMMUNITY PARTNERS ARE ADDRESSING THIS NEED SUCH AS CHARLES DREW HEALTH CENTER DENTAL CLINIC, ONE WORLD COMMUNITY HEALTH CENTER AND FAMILY INC.POTENTIALLY DISABLING CONDITIONS- THIS NEED WILL BE MET IN PART THROUGH THE BEHAVIORAL HEALTH PRIORITY, WHICH IDENTIFIES, "PROVIDING SUPPORT FOR INDIVIDUALS WITH ALZHEIMER'S/ DEMENTIA AND THEIR CAREGIVERS" AS A KEY ACTIVITY. IN ADDITION, CHI HEALTH IMMANUEL OPERATES AN INPATIENT AND OUTPATIENT GERIATRIC PSYCHIATRY PROGRAM AND RECENTLY OPENED A NEUROLOGICAL INSTITUTE. CHI HEALTH PROVIDES FINANCIAL SUPPORT TO THE NEBRASKA ALZHEIMER'S ASSOCIATION FOR FREE CARE CONSULTATION FOR FAMILIES WITH A LOVED ONE WHO HAS RECENTLY RECEIVED A DEMENTIA/ ALZHEIMER'S DIAGNOSIS.SEXUAL HEALTH- THERE IS EXTENSIVE EXISTING WORK CURRENTLY TAKING PLACE AROUND SEXUALLY TRANSMITTED DISEASES ACROSS THE OMAHA METRO AREA LED BY COMMUNITY PARTNERS, SUCH AS THE DOUGLAS COUNTY HEALTH DEPARTMENT, WOMEN'S FUND AND THE FEDERALLY QUALIFIED HEALTH CENTERS. THEREFORE, THIS IS NOT AN AREA THAT CHI HEALTH PRIORITIZED. HOWEVER, AS MENTIONED IN THE CANCER SECTION ABOVE, CHI HEALTH CLINICS ARE FOCUSING ON HPV VACCINATION FOR THE PREVENTION OF CERVICAL CANCER. FACILITY REPORTING GROUP B, PART V, SECTION B, LINE 11 (CONTINUED): THE HOSPITAL WILL NOT ADDRESS THE FOLLOWING HEALTH NEEDS FOR THE FOLLOWING REASONS: IN ACKNOWLEDGING THE RANGE OF PRIORITY HEALTH ISSUES THAT EMERGED FROM THE CHNA PROCESS, CHI HEALTH PLAINVIEW PRIORITIZED THE HEALTH ISSUES ABOVE IN ORDER TO MOST EFFECTIVELY FOCUS RESOURCES AND MEANINGFULLY IMPACT THE SELECTED HEALTH ISSUES. AS DESCRIBED IN THE PROCESS ABOVE, THE HOSPITAL TOOK INTO CONSIDERATION EXISTING PARTNERSHIPS, AVAILABLE RESOURCES, THE HOSPITAL'S LEVEL OF EXPERTISE, EXISTING INITIATIVES (OR LACK THEREOF), POTENTIAL FOR IMPACT, AND THE COMMUNITY'S INTEREST IN THE HOSPITAL ENGAGING IN THAT AREA IN ORDER TO SELECT THE PRIORITIES. CHI HEALTH PLAINVIEW SELECTED THE SAME TOP HEALTH NEEDS AS IDENTIFIED BY THE COMMUNITY AND WILL ADDRESS EACH OF THOSE NEEDS AS DESCRIBED IN THE SECTION BELOW. CANCER AND CHRONIC DISEASE - IN ORDER TO MEANINGFULLY ADDRESS THE SELECT PRIORITY HEALTH NEEDS ABOVE AND MAXIMIZE IMPACT, CHI HEALTH PLAINVIEW DID NOT PRIORITIZE CANCER AND CHRONIC DISEASE FOR WORK ON THIS ISP. HOWEVER, THE HOSPITALS HAVE PRIORITIZED CARDIOVASCULAR DISEASE AND THESE EFFORTS MAY INDIRECTLY IMPROVE THE ABILITY OF HEALTHCARE SERVICES AND COMMUNITY PARTNERS TO ADDRESS CHRONIC DISEASE ON AN INDIVIDUAL BASIS. SOCIAL DETERMINANTS OF HEALTH - IN ORDER TO MEANINGFULLY ADDRESS THE SELECTED PRIORITY HEALTH NEEDS ABOVE AND MAXIMIZE IMPACT, CHI HEALTH PLAINVIEW DID NOT PRIORITIZE SOCIAL DETERMINANTS OF HEALTH FOR WORK ON THIS ISP. CHI HEALTH PLAINVIEW PRIORITIZED THE HEALTH NEEDS IDENTIFIED AS THE PRIMARY FOCUS OF THE HEALTH DEPARTMENT'S COMMUNITY HEALTH IMPROVEMENT PLAN (CHIP) WORKGROUP IN ORDER TO LEVERAGE RESOURCES AND SHARED IMPACT. THROUGH THE EFFORTS OUTLINED IN THE CHIP AND ISP, THE SOCIAL DETERMINANTS OF HEALTH WILL BE CONSIDERED AND MAY BE IMPACTED BY THE OUTLINED ACTIVITIES. 11 1 - ACH-PLAINVIEW RURAL HEALTH CLINIC 704 N 3RD ST PLAINVIEW NE 68769 RURAL HEALTH CLINIC 2 - LAKESIDE ENDOSCOPY CENTER LLC 17001 LAKESIDE HILLS PLAZA OMAHA NE 68130 ENDOSCOPY CENTER 3 - LAKESIDE AMBULATORY SURGICAL CENTER LLC 17031 LAKESIDE HILLS DR OMAHA NE 68130 AMBULATORY SURGICAL CENTER 4 - BERGAN MERCY SURGERY CENTER LLC 7710 MERCY RD OMAHA NE 68124 AMBULATORY SURGICAL CENTER 5 - NEBRASKA SPINE HOSPITAL LLC 6901 N 72ND ST OMAHA NE 68122 SPINE HOSPITAL 6 - CHI HEALTH QUICK CARE LLC 12809 W DODGE RD OMAHA NE 68154 QUICK CARE 7 - CHI HEALTH AMBULATORY SURGERY CTR - MDLS 11111 84TH ST PAPILLION NE 68046 AMBULATORY SURGICAL CENTER 8 - CHI HEALTH CLINIC PLAINVIEW 704 N 3RD ST PLAINVIEW NE 68769 RURAL HEALTH CLINIC 9 - CHI HEALTH LAKESIDE IMAGING CENTER 17201 LAKESIDE HILLS PL STE 107 OMAHA NE 68130 DIAGNOSTIC IMAGING CENTER 10 - CHI HEALTH NURSING HOME NETWORK 12809 W DODGE RD OMAHA NE 68154 HOME CARE AND HOSPICE 11 - CHI HEALTH WEST OMAHA IMAGING CENTER 17201 WRIGHT ST STE 100 OMAHA NE 68130 DIAGNOSTIC IMAGING CENTER PART I, LINE 3C: UNLESS ELIGIBLE FOR PRESUMPTIVE FINANCIAL ASSISTANCE, THE FOLLOWING ELIGIBILITY CRITERIA MUST BE MET IN ORDER FOR A PATIENT TO QUALIFY FOR FINANCIAL ASSISTANCE: * THE PATIENT MUST HAVE A MINIMUM ACCOUNT BALANCE OF TEN DOLLARS ($10.00) WITH THE COMMONSPIRIT HOSPITAL ORGANIZATION. MULTIPLE ACCOUNT BALANCES MAY BE COMBINED TO REACH THIS AMOUNT. PATIENTS/GUARANTORS WITH BALANCES BELOW TEN DOLLARS ($10) MAY CONTACT A FINANCIAL COUNSELOR TO MAKE MONTHLY INSTALLMENT PAYMENT ARRANGEMENTS. * THE PATIENT MUST COMPLY WITH PATIENT COOPERATION STANDARDS AS DESCRIBED [IN THE FAP]. * THE PATIENT MUST SUBMIT A COMPLETED FINANCIAL ASSISTANCE APPLICATION. FOR PATIENTS AND GUARANTORS WHO ARE UNABLE TO PROVIDE REQUIRED DOCUMENTATION, A HOSPITAL FACILITY MAY GRANT PRESUMPTIVE FINANCIAL ASSISTANCE BASED ON INFORMATION OBTAINED FROM OTHER RESOURCES. IN PARTICULAR, PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED ON THE BASIS OF INDIVIDUAL LIFE CIRCUMSTANCES THAT MAY INCLUDE: * RECIPIENT OF STATE-FUNDED PRESCRIPTION PROGRAMS; * HOMELESS OR ONE WHO RECEIVED CARE FROM A HOMELESS CLINIC; * PARTICIPATION IN WOMEN, INFANTS AND CHILDREN PROGRAMS (WIC); * FOOD STAMP ELIGIBILITY; * ELIGIBILITY OR REFERRALS FOR OTHER STATE OR LOCAL ASSISTANCE PROGRAMS (E.G., MEDICAID); * LOW INCOME/SUBSIDIZED HOUSING IS PROVIDED AS A VALID ADDRESS; OR * PATIENT IS DECEASED WITH NO KNOWN ESTATE. PART I, LINE 6A: THE CHI HEALTH SYSTEM PRODUCES AN ANNUAL PUBLIC COMMUNITY BENEFIT REPORT THAT IS MAILED TO A CORE CONSTITUENCY, PLACED IN KEY PLACES THROUGHOUT THE ORGANIZATION AND DISTRIBUTED IN COMMUNITY MEETINGS. IT IS ALSO AVAILABLE ON THE COMPANY'S INTRANET SITE, AND ON ITS PUBLIC WEBSITE AT HTTPS://WWW.CHIHEALTH.COM/ABOUT-US/MISSION-VALUES/COMMUNITY-BENEFIT. PART I, LINE 7: COMMONSPIRIT HEALTH HOSPITALS USE A COST ACCOUNTING SYSTEM OR AN ADJUSTED COST TO CHARGE RATIO CALCULATED IN A MANNER CONSISTENT WITH WORKSHEET 2 FOR EACH REPORTING FACILITY, TO DERIVE THE REPORTED COSTS OF FINANCIAL ASSISTANCE, MEDICAID AND OTHER MEANS-TESTED PROGRAMS. WORKSHEET 3 OR THE EQUIVALENT IN THE COMMUNITY BENEFIT INVENTORY FOR SOCIAL ACCOUNTABILITY ("CBISA") SOFTWARE ARE USED TO CALCULATE EXPENSE AND REVENUE, INCLUDING WHERE APPLICABLE MEDICAID PROVIDER FEES AND PAYMENTS FROM UNCOMPENSATED CARE PROGRAMS. ACTUAL OR ESTIMATED COST AND ANY DIRECT OFFSETTING REVENUE IS REPORTED, AND SCHEDULE H WORKSHEETS OR THEIR EQUIVALENTS ARE USED, FOR OTHER COMMUNITY BENEFIT ACTIVITIES SUCH AS COMMUNITY HEALTH IMPROVEMENT SERVICES, COMMUNITY BENEFIT OPERATIONS, HEALTH PROFESSIONS EDUCATION, SUBSIDIZED HEALTH SERVICES, RESEARCH, AND CASH AND IN-KIND DONATIONS. PART II, COMMUNITY BUILDING ACTIVITIES: CHI HEALTH HAS A HISTORY OF CENTRALIZED COMMUNITY BENEFIT INVESTMENTS, AS WELL AS HOSPITAL SPECIFIC INVESTMENTS THAT ADDRESS COMMUNITY HEALTH NEEDS WHICH INCLUDE SUPPORT OF LOCAL HEALTH COALITIONS, INVESTMENTS IN PARTNERSHIPS AND PROGRAMS THAT ADDRESS TOP COMMUNITY HEALTH NEEDS, PARTICIPATION IN LOCAL COMMITTEES AND BOARDS TIED TO TOP HEALTH NEEDS, AND INVESTMENTS IN MANY OTHER WAYS AS DESCRIBED IN OTHER AREAS OF THE SCHEDULE H NARRATIVE. PART III, LINE 2: THE AMOUNT OF THE ORGANIZATION'S BAD DEBT AT COST IS DETERMINED BY APPLYING THE COST TO CHARGE RATIO TO PATIENT CHARGES THAT ARE DEEMED TO BE UNCOLLECTIBLE. THIS AMOUNT REPRESENTS THE COST OF SERVICES PROVIDED TO PATIENTS WHO ARE UNABLE OR REFUSE TO PAY THEIR BILLS AND DO NOT QUALIFY FOR FREE OR ADDITIONAL DISCOUNTED CARE, GOVERNMENT SPONSORED PROGRAMS OR OTHER PAYMENT ASSISTANCE, AND ARE OTHERWISE UNINSURED.THE FILING ORGANIZATION PROVIDES FREE CARE TO ANY PATIENT WHOSE FAMILY INCOME IS AT OR BELOW 200% OF THE FEDERAL POVERTY LEVEL, OR DISCOUNTED CARE TO UNINSURED OR UNDER-INSURED INDIVIDUALS WHOSE FAMILY INCOME IS ABOVE 201% BUT LOWER THAN 400% OF THE FEDERAL POVERTY LEVEL. THE FILING ORGANIZATION ALSO PROVIDES OPTIONS FOR INTEREST-FREE EXTENDED PAYMENT PLANS FOR PATIENTS WHO HAVE DEMONSTRATED GOOD FAITH AND ARE COOPERATING IN RESOLVING THEIR HOSPITAL BILLS. ALL ACCOUNTS FOR ELIGIBLE UNINSURED PATIENTS AT ALL FACILITIES RECEIVE AN AUTOMATIC UNINSURED DISCOUNT. THE EXPECTED PATIENT PAYMENT AMOUNT ON THE PATIENT'S BILL REFLECTS THIS DISCOUNT. DISCOUNTS ARE ACCOUNTED FOR AS DEDUCTIONS FROM REVENUE, NOT AS BAD DEBT EXPENSE. PART III, LINE 3: ALEGENT CREIGHTON HEALTH MAKES EVERY EFFORT TO DETERMINE IF A PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE UPON ADMISSION. ALEGENT CREIGHTON HEALTH'S FINANCIAL ASSISTANCE POLICY IS COMMUNICATED TO PATIENTS UPON ADMISSION AND IS AVAILABLE IN THE LANGUAGES PRIMARILY SPOKEN IN THE COMMUNITY. IT IS ALSO POSTED IN VARIOUS COMMON AREAS OF THE HOSPITAL, SUCH AS EMERGENCY ROOMS, URGENT CARE CENTERS, ADMITTING AND REGISTRATION DEPARTMENTS, HOSPITAL BUSINESS OFFICES LOCATED ON FACILITY CAMPUSES, AND OTHER PUBLIC PLACES, AND IS PROVIDED UPON BILLING IF ELIGIBILITY IS NOT PREVIOUSLY DETERMINED. ELIGIBILITY IS REEVALUATED AS NEEDED AND AMOUNTS ARE CLASSIFIED AS CHARITY AS SOON AS ELIGIBILITY IS KNOWN. ALEGENT CREIGHTON HEALTH ALSO UTILIZES A WAYSTAR SCORING SYSTEM TO ASSIST IN DETERMINING IF A PATIENT MAY QUALIFY FOR PAYMENT ASSISTANCE EVEN THOUGH THEY HAVE NOT APPLIED FOR IT. WAYSTAR USES A METHODOLOGY THAT APPLIES CONSISTENT SCREENING AND APPLICATION STANDARDS TO ALL PATIENTS UTILIZING HISTORICAL DATA TO DEVELOP A PREDICTIVE MODEL FOR HEALTHCARE PAYMENT ASSISTANCE. IN ITS DEVELOPMENT, SPECIAL ATTENTION WAS PAID TO THOSE SOCIOECONOMIC FACTORS THAT MIGHT ADVERSELY AFFECT THOSE PATIENTS DESERVING THE MOST ATTENTION. OTHER CRITERIA ARE ALSO UTILIZED TO ENSURE THAT SERVICES THAT HAVE QUALIFIED AS FINANCIAL ASSISTANCE ARE NOT REPORTED AS BAD DEBT. AS SUCH, ALEGENT CREIGHTON HEALTH DOES NOT BELIEVE THAT ANY AMOUNTS INCLUDED IN PART III, LINE 2, ARE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S PAYMENT ASSISTANCE POLICY, AND THEREFORE, NO PORTION OF BAD DEBT EXPENSE IS INCLUDED AS COMMUNITY BENEFIT EXPENSE. PART III, LINE 4: ALEGENT CREIGHTON HEALTH DOES NOT ISSUE SEPARATE COMPANY AUDITED FINANCIAL STATEMENTS. HOWEVER, THE ORGANIZATION IS INCLUDED IN THE CONSOLIDATED FINANCIAL STATEMENTS OF COMMONSPIRIT HEALTH. THE FOLLOWING IS AN EXCERPT FROM COMMONSPIRIT'S CONSOLIDATED ANNUAL AUDITED FINANCIAL STATEMENTS FOR THE YEAR ENDED JUNE 30, 2024, RELATED TO PATIENT ACCOUNTS RECEIVABLE AND NET PATIENT REVENUE. THE ENTIRE FOOTNOTE CAN BE VIEWED IN THE ATTACHED COMMONSPIRIT CONSOLIDATED FINANCIAL STATEMENTS ON PAGES 11-12."PATIENT SERVICE REVENUE IS REPORTED AT THE AMOUNTS THAT REFLECT THE CONSIDERATION COMMONSPIRIT EXPECTS TO BE PAID IN EXCHANGE FOR PROVIDING PATIENT CARE. THESE AMOUNTS ARE DUE FROM PATIENTS, THIRD-PARTY PAYORS (INCLUDING HEALTH INSURERS AND GOVERNMENT PROGRAMS), AND OTHERS, AND INCLUDE CONSIDERATION FOR RETROACTIVE REVENUE ADJUSTMENTS DUE TO SETTLEMENT OF AUDITS AND REVIEWS. GENERALLY, PERFORMANCE OBLIGATIONS FOR PATIENTS RECEIVING INPATIENT ACUTE CARE SERVICES AND OUTPATIENT SERVICES ARE RECOGNIZED OVER TIME AS SERVICES ARE PROVIDED. NET PATIENT REVENUE IS PRIMARILY COMPRISED OF HOSPITAL AND PHYSICIAN SERVICES." PART III, LINE 8: COMMONSPIRIT HEALTH HOSPITALS PREPARE MEDICARE COST REPORTS IN A MANNER THAT COMPORTS WITH PROVIDER REIMBURSEMENT MANUAL (PRM) 15-1 AND PRM 15-2 CHAPTER 40 (TRANSMITTAL 13). AS SUCH, THE FOLLOWING LANGUAGE PER PRM 15-1 DESCRIBES THE COMPUTATION OF COSTS PER THE MEDICARE COST REPORT: TOTAL ALLOWABLE COSTS OF A PROVIDER ARE APPORTIONED BETWEEN PROGRAM BENEFICIARIES AND OTHER PATIENTS SO THAT THE SHARE BORNE BY THE PROGRAM IS BASED UPON ACTUAL SERVICES RECEIVED BY PROGRAM BENEFICIARIES. THE RATIO OF COVERED BENEFICIARY CHARGES TO TOTAL PATIENT CHARGES FOR THE SERVICES OF EACH ANCILLARY DEPARTMENT IS APPLIED TO THE COST OF THE DEPARTMENT. ADDED TO THIS AMOUNT IS THE COST OF ROUTINE SERVICES FOR PROGRAM BENEFICIARIES, DETERMINED ON THE BASIS OF A SEPARATE AVERAGE COST PER DIEM FOR ALL PATIENTS FOR GENERAL ROUTINE PATIENT CARE AREAS. ANOTHER FACTOR CONSIDERED IS A SEPARATE AVERAGE COST PER DIEM FOR EACH INTENSIVE CARE UNIT, CORONARY CARE UNIT, AND OTHER SPECIAL CARE INPATIENT HOSPITAL UNITS. COMMONSPIRIT HEALTH AND ITS SUBORDINATE CORPORATIONS BELIEVE THAT THE ENTIRE MEDICARE SHORTFALL FOR THE CONSOLIDATED ENTITIES CONSTITUTES COMMUNITY BENEFIT. THE IRS COMMUNITY BENEFIT STANDARD INCLUDES THE PROVISION OF CARE TO THE ELDERLY AND MEDICARE PATIENTS. MEDICARE SHORTFALLS MUST BE ABSORBED BY COMMONSPIRIT HEALTH HOSPITALS IN ORDER TO CONTINUE TREATING THE ELDERLY IN OUR COMMUNITIES. THE HOSPITALS PROVIDE CARE REGARDLESS OF THIS SHORTFALL AND THEREBY RELIEVE THE FEDERAL GOVERNMENT OF THE BURDEN OF PAYING THE FULL COST FOR MEDICARE BENEFICIARIES. ALEGENT CREIGHTON HEALTH'S SHORTFALL, AS REPORTED ON PART III, SECTION B, LINE 7, OF $17,934,996 REPRESENTS THE FILING ORGANIZATION'S MEDICARE COST REPORTS. PART III, LINE 9B: COMMONSPIRIT HEALTH ENSURES THAT PATIENT ACCOUNTS ARE PROCESSED FAIRLY AND CONSISTENTLY. COMMONSPIRIT HEALTH'S BILLING AND COLLECTION POLICY CONTAINS PROVISIONS THAT PROHIBIT THE COLLECTION OF AMOUNTS DUE FROM PATIENTS WHO THE ORGANIZATION KNOWS QUALIFY FOR FINANCIAL ASSISTANCE. ACCOUNTS WITH INCORRECT OR INCOMPLETE DEMOGRAPHIC INFORMATION ARE ASSIGNED TO A COLLECTION AGENCY IF THE COMMONSPIRIT HEALTH FACILITY, OR BILLING COMPANY RETAINED BY COMMONSPIRIT HEALTH, IS UNABLE TO OBTAIN AN UPDATED ADDRESS THROUGH SKIP TRACING OR OTHER MEANS. FOR PATIENTS WHO HAVE AN APPLICATION PENDING FOR EITHER GOVERNMENT-SPONSORED ASSISTANCE OR FOR ASSISTANCE UNDER COMMONSPIRIT HEALTH'S FINANCIAL ASSISTANCE POLICY, OR WHERE THE PATIENT IS ATTEMPTING IN GOOD FAITH TO SETTLE AN OUTSTANDING BILL WITH THE FACILITY VIA PAYMENT PLANS, COMMONSPIRIT HEALTH WILL NOT KNOWINGLY SEND THAT PATIENT'S BILL TO AN OUTSIDE COLLECTION AGENCY. ON SELF-PAY ACCOUNTS THAT DO NOT MEET THE CRITERIA NOTED ABOVE, THE INITIAL DETERMINATION OF ASSIGNMENT TO A COLLECTION AGENCY WILL VARY DEPENDING ON THE NATURE OF THE ACCOUNT WITH THE FINAL DECISION BEING AT THE DISCRETION OF THE BILLING COMPANY RETAINED BY COMMONSPIRIT HEALTH. UPON ASSIGNMENT OF SUCH A PATIENT ACCOUNT TO A COLLECTION AGENCY, COMMONSPIRIT HEALTH REQUIRES THE AGENCY TO COMPLY WITH THE FAIR DEBT COLLECTION PRACTICES ACT. PART VI, LINE 3: INFORMATION ABOUT COMMONSPIRIT HEALTH'S FINANCIAL ASSISTANCE PROGRAM AND A CONTACT NUMBER ARE MADE AVAILABLE TO PATIENTS AND THE PUBLIC. PATIENTS ARE INFORMED OF COMMONSPIRIT HEALTH'S FINANCIAL ASSISTANCE PROGRAM VIA SIGNAGE IN ALL ADMITTING AREAS AND IN VARIOUS COMMON AREAS OF THE HOSPITAL. FINANCIAL ASSISTANCE PROGRAM INFORMATION NOTICES ARE POSTED IN THE EMERGENCY AND ADMITTING DEPARTMENTS AND AT OTHER PUBLIC PLACES AS EACH FACILITY MAY ELECT. SUCH INFORMATION IS PROVIDED IN THE PRIMARY LANGUAGES SPOKEN IN THE COMMUNITIES COMMONSPIRIT HEALTH SERVES. THE SIGNAGE INCLUDES NOTIFICATION THAT FURTHER DISCOUNTS MAY BE PROVIDED UPON THE COMPLETION AND SUBMISSION OF A FINANCIAL ASSISTANCE APPLICATION AND HOW TO REACH STAFF THAT CAN ASSIST WITH ANSWERING QUESTIONS AND GUIDE PATIENTS THROUGH THE APPLICATION PROCESS. INFORMATION CAN ALSO BE FOUND ON THE FACILITY WEBSITES. IF FINANCIAL ASSISTANCE ELIGIBILITY IS NOT DETERMINED PRIOR TO BILLING, INITIAL BILLING STATEMENTS TO PATIENTS INCLUDE A REQUEST TO THE PATIENT TO PROVIDE ANY INSURANCE INFORMATION THAT WAS VALID FOR THE DATES OF SERVICE BILLED AND A STATEMENT INFORMING PATIENTS HOW TO CONTACT US REGARDING FINANCIAL ASSISTANCE. ADDITIONALLY, CONTRACT TERMS WITH COLLECTION VENDORS WORKING ON BEHALF OF COMMONSPIRIT HEALTH REQUIRE THEY FOLLOW COMMONSPIRIT HEALTH FINANCIAL ASSISTANCE POLICY. ALSO, REFERRAL OF PATIENTS FOR FINANCIAL ASSISTANCE MAY BE MADE BY ANY MEMBER OF THE COMMONSPIRIT HOSPITAL ORGANIZATION NON-MEDICAL OR MEDICAL STAFF, INCLUDING PHYSICIANS, NURSES, FINANCIAL COUNSELORS, SOCIAL WORKERS, CASE MANAGERS, CHAPLAINS, AND RELIGIOUS SPONSORS. A REQUEST FOR ASSISTANCE MAY BE MADE BY THE PATIENT OR A FAMILY MEMBER, CLOSE FRIEND OR ASSOCIATE OF THE PATIENT, SUBJECT TO APPLICABLE PRIVACY LAWS. PART VI, LINE 4: CHI HEALTH LAKESIDE AND CHI HEALTH MIDLANDS ARE LOCATED IN OMAHA, NE AND LARGELY SERVE THE OMAHA METRO AREA THAT CONSISTS OF DOUGLAS, SARPY, AND CASS COUNTIES IN NEBRASKA AND POTTAWATTAMIE COUNTY IN IOWA. THESE FOUR COUNTIES WERE IDENTIFIED AS THE COMMUNITY FOR THIS CHNA, AS THEY ENCOMPASS THE PRIMARY SERVICE FOR CHI HEALTH HOSPITALS LOCATED IN THE OMAHA METRO AREA, THUS COVERING BETWEEN 75% AND 90% OF PATIENTS SERVED. THESE COUNTIES ARE CONSIDERED TO BE AND REFERRED TO AS THE "OMAHA METRO AREA." FOR THE PURPOSES OF THE CHNA DOUGLAS, SARPY, AND CASS COUNTIES IN NEBRASKA AND POTTAWATTAMIE COUNTY IN IOWA WERE IDENTIFIED AS THE COMMUNITY FOR THIS CHNA. WITH A TOTAL POPULATION OF OVER 800,000 IN THE FOUR COUNTY AREA, THE DATA SHOW A LARGELY NON-HISPANIC WHITE POPULATION ACROSS THE FOUR COUNTIES WITH GREATER DIVERSITY OBSERVED IN DOUGLAS COUNTY AND TO A LESSER EXTENT, SARPY COUNTY, BOTH OF WHICH ARE THE MOST URBAN COUNTIES IN THE OMAHA METRO AREA. WHILE DOUGLAS COUNTY IS THE MOST DIVERSE OF THE FOUR COUNTIES, WITH 11.5% OF THE POPULATION IDENTIFYING AS BLACK OR AFRICAN AMERICAN AND 12.9% IDENTIFYING AS HISPANIC, IT IS LESS DIVERSE THAN THE UNITED STATES OVERALL (13.4% BLACK OR AFRICAN AMERICAN, 18.5% HISPANIC). CASS COUNTY HAS THE LARGEST PERCENTAGE OF THE POPULATION OVER THE AGE OF 65 YEARS (16%), INDICATING UNIQUE HEALTH NEEDS SPECIFIC TO THE AGING POPULATION. DOUGLAS COUNTY HAS THE HIGHEST PERCENTAGE OF UNINSURED RESIDENTS OVERALL AND UNINSURED CHILDREN (UNDER THE AGE OF 19). THE AVERAGE INCOME FOR THE FOUR COUNTY AREA IS AS FOLLOWS DOUGLAS ($66,600), SARPY ($83,051), CASS ($73,683) AND POTTAWATTAMIE ($60,065). SARPY COUNTY HAS THE HIGHEST MEDIAN INCOME IN THE FOUR COUNTY AREA (DOUGLAS: $66,600, SARPY $83,051, CASS: $73,683, POTTAWATTAMIE: $60,065). DOUGLAS COUNTY HAS THE HIGHEST PERCENTAGE OF PEOPLE LIVING IN POVERTY IN THE FOUR COUNTY AREA (DOUGLAS: 9.8%, SARPY:4.9%, CASS 5.9%, POTTAWATTAMIE: 9.2%). THE PERCENTAGE OF PERSONS WITHOUT HEALTH INSURANCE UNDER 65 IS 10.3% IN DOUGLAS COUNTY, 5.7% IN SARPY COUNTY, 6.6% IN CASS COUNTY, AND 6% IN POTTAWATTAMIE COUNTY. THE FOUR COUNTY SERVICE AREA HAS 26 DESIGNATED HEALTH PROFESSIONAL SHORTAGE AREAS (HPSA) INCLUDING PRIMARY CARE, DENTAL HEALTH, MENTAL HEALTH DISCIPLINES. THE 26 DESIGNATED HPSA HAVE SCORES THAT RANGE FROM NINE TO 25 WHERE THE SCORE RANGE IS ZERO TO 26 (HIGHER SCORES INDICATE AN INCREASINGLY GREATER HEALTH PROFESSIONAL SHORTAGE). THE FOUR COUNTY SERVICE AREA HAS EIGHT DESIGNATED MEDICALLY UNDERSERVED AREAS (MUA) INCLUDING PRIMARY CARE. THE EIGHT DESIGNATED MUA'S HAVE SCORES THAT RANGE FROM 44.9 - 64.3 IN WHICH THE LOWEST SCORE (HIGHEST NEED) IS ZERO; THE HIGHEST SCORE (LOWEST NEED) IS 100. THE FOLLOWING ORGANIZATIONS REPRESENT HOSPITALS AND OTHER HEALTHCARE SYSTEMS DELIVERING HEALTHCARE SERVICES IN THE OMAHA COUNCIL BLUFFS METROPOLITAN AREA:FEDERALLY QUALIFIED HEALTH CENTERS- ALL CARE HEALTH CENTER- CHARLES DREW HEALTH CENTER- ONE WORLD COMMUNITY HEALTH CENTERS, INC.- COUNCIL BLUFFS COMMUNITY HEALTH CENTER- FRED LEROY HEALTH & WELLNESS CENTERHEALTH DEPARTMENTS- DOUGLAS COUNTY HEALTH DEPARTMENT- POTTAWATTAMIE COUNTY PUBLIC HEALTH DEPARTMENT- SARPY CASS DEPARTMENT OF HEALTH & WELLNESSHEALTH SYSTEMS (HOSPITALS/ CLINICS): - CHI HEALTH CLINICS- CHILDREN'S HOSPITAL & MEDICAL CENTER- METHODIST HEALTH SYSTEM- NEBRASKA MEDICINE- VA NEBRASKA-WESTERN IOWA HEALTH CARE SYSTEMPLAINVIEW, NE IS LOCATED 141 MILES FROM OMAHA, NE AND 101 MILES FROM SIOUX CITY, IA. ACCORDING TO THE MOST RECENT CENSUS, PIERCE COUNTY IS 100% RURAL, ENCOMPASSES 573 SQUARE MILES, AND HAS 7,317 RESIDENTS. THE POPULATION DENSITY OF PIERCE COUNTY IS ESTIMATED AT 12.7 PERSONS PER SQUARE MILE, MAKING IT ABOUT HALF AS DENSELY POPULATED AS THE STATE OF NEBRASKA, WHICH IS 73% RURAL, AND HAS A POPULATION DENSITY OF 23.8 PERSONS PER SQUARE MILE. THE MAJORITY OF THE RESIDENTS IN PIERCE COUNTY (95.6%) ARE WHITE, NOT HISPANIC OR LATINO, 2.3% IDENTIFY AS HISPANIC OR LATINO, 0.6% ARE BLACK, AND 0.5% ARE AMERICAN INDIAN OR ALASKA NATIVE. COMPARED TO THE STATE OF NEBRASKA, PIERCE COUNTY HAS A SLIGHTLY HIGHER MEDIAN HOUSEHOLD INCOME, LOWER RATES OF PERSONS AND CHILDREN IN POVERTY, LOWER UNEMPLOYMENT RATE, HIGHER HIGH-SCHOOL GRADUATION RATE, AND A LOWER PERCENTAGE OF THE POPULATION THAT IS UNINSURED. WITHIN PIERCE COUNTY, THE PERCENTAGE OF UNINSURED POPULATION IS 8.4%, WHICH IS LESS THAN THE STATE AVERAGE (9.8%). POVERTY PRESENTS A BARRIER TO MANY FACTORS IMPACTING HEALTH, INCLUDING: ACCESS TO CARE, NUTRITION, EDUCATION, SAFE HOUSING, ETC. IN PIERCE COUNTY 8.2% ARE LIVING BELOW THE POVERTY LINE. PIERCE COUNTY IS DESIGNATED A HEALTH PROFESSIONAL SHORTAGE AREA IN PRIMARY CARE (7), DENTAL CARE (7), AND MENTAL HEALTH (17). THE SCORE RANGES FROM 0-26 WHERE THE HIGHER THE SCORE, THE GREATER THE PRIORITY. PIERCE COUNTY IS CONSIDERED A MEDICALLY UNDERSERVED AREA (MUA) IN PRIMARY CARE WITH AN INDEX OF MEDICAL UNSERVED SCORE OF 60.7 (TO QUALIFY FOR THIS DESIGNATION, THE SCORE MUST BE BELOW OR EQUAL TO N/A ON A SCALE OF 0 -100 WITH 100 BEING THE LOWEST NEED).OSMOND GENERAL HOSPITAL, LOCATED IN OSMOND, NE, IS 10 MILES FROM PLAINVIEW AND IS A 20-BED CRITICAL ACCESS HOSPITAL. SERVICES PROVIDED INCLUDE EMERGENCY SERVICES, RADIOLOGY, CT SCAN, ULTRASOUND, MRI, LABORATORY SERVICES, CARDIAC REHAB, PHYSICAL, OCCUPATIONAL AND SPEECH THERAPY, AND SENIOR LIFE SOLUTIONS. OUTREACH CLINICS INCLUDE: GENERAL SURGERY, CARDIOLOGY, PODIATRY, PULMONOLOGY, MOBILE MAMMOGRAPHY, AND SLEEP STUDIES. OUTPATIENT CLINICS ALSO SERVE THE COMMUNITIES OF OSMOND, RANDOLPH, AND WAUSA. PART VI, LINE 5: FINANCIAL ASSISTANCE: IT IS THE POLICY OF COMMONSPIRIT HEALTH TO PROVIDE, WITHOUT DISCRIMINATION, EMERGENCY MEDICAL CARE AND MEDICALLY NECESSARY CARE IN COMMONSPIRIT HOSPITAL FACILITIES TO ALL PATIENTS, WITHOUT REGARD TO A PATIENT'S FINANCIAL ABILITY TO PAY. THIS HOSPITAL HAS A FINANCIAL ASSISTANCE POLICY THAT DESCRIBES THE ASSISTANCE PROVIDED TO PATIENTS FOR WHOM IT WOULD BE A FINANCIAL HARDSHIP TO FULLY PAY THE EXPECTED OUT-OF-POCKET EXPENSES FOR SUCH CARE, AND WHO MEET THE ELIGIBILITY CRITERIA FOR SUCH ASSISTANCE. THE FINANCIAL ASSISTANCE POLICY, A PLAIN LANGUAGE SUMMARY AND RELATED MATERIALS ARE AVAILABLE IN MULTIPLE LANGUAGES ON THE HOSPITAL'S WEBSITE.USE OF SURPLUS FUNDS: AS A NOT-FOR-PROFIT HOSPITAL ORGANIZATION DEDICATED TO IMPROVING THE QUALITY OF LIFE, THE HOSPITAL REINVESTS ALL OF ITS SURPLUS FUNDS FROM OPERATING AND INVESTMENT ACTIVITIES TO IMPROVE THE QUALITY OF PATIENT CARE, EXPAND AND REPLACE EXISTING FACILITIES AND EQUIPMENT, INVEST IN TECHNOLOGICAL ADVANCEMENTS, SUPPORT COMMUNITY HEALTH PROGRAMS, AND ADVANCE MEDICAL TRAINING, EDUCATION, AND RESEARCH. THIS ACTIVE REINVESTMENT OF FUNDS MAKES IT POSSIBLE FOR THE HOSPITAL TO DELIVER ON ITS MISSION, INCLUDING HELPING TO ENSURE THAT EVERYONE IN THE COMMUNITIES SERVED HAS ACCESS TO HEALTH CARE.OPEN MEDICAL STAFF: MEDICAL STAFF PRIVILEGES ARE OPEN TO PHYSICIANS WHOSE EXPERIENCE AND TRAINING ARE VERIFIED THROUGH A CREDENTIALING PROCESS. THE PROCESS INCLUDES GATHERING AND VERIFYING CREDENTIALS, ALLOWING THE MEDICAL STAFF TO EVALUATE AN APPLICANT'S QUALIFICATIONS, PREVIOUS EXPERIENCE, AND COMPETENCE, AND ULTIMATELY MAKING A DECISION TO GRANT OR DENY MEDICAL STAFF MEMBERSHIP AND CLINICAL PRIVILEGES ON THE BASIS OF AUTHENTIC AND VALID CREDENTIALS.ROLE OF THE BOARD: THE COMMONSPIRIT HEALTH BOARD AND SPECIFIC COMMITTEES HAVE ORGANIZATIONAL, POLICY-BASED ROLES TO OVERSEE COMMUNITY BENEFIT AND COMMUNITY HEALTH PROGRAMS, AND THEY RECEIVE REGULAR REPORTS ON ACTIVITIES AND PERFORMANCE. HOSPITAL COMMUNITY BOARDS (OR THEIR DESIGNATED COMMUNITY HEALTH OR COMMUNITY BENEFIT COMMITTEES) ARE RESPONSIBLE FOR ENSURING THAT THE HOSPITALS CONDUCT AND ADOPT COMMUNITY HEALTH NEEDS ASSESSMENTS AND IMPLEMENTATION STRATEGIES, TAKE ACTIONS TO HELP ADDRESS IDENTIFIED SIGNIFICANT HEALTH NEEDS WITH AN EMPHASIS ON POOR AND VULNERABLE POPULATIONS AND HEALTH EQUITY, AND MONITORING ACTIONS AND PROGRESS TOWARD IDENTIFIED GOALS. PART VI, LINE 6: THE ORGANIZATION IS AFFILIATED WITH COMMONSPIRIT HEALTH. COMMONSPIRIT HEALTH WAS CREATED BY THE ALIGNMENT OF CATHOLIC HEALTH INITIATIVES AND DIGNITY HEALTH IN EARLY 2019. COMMONSPIRIT HEALTH, A NONPROFIT, FAITH-BASED HEALTH SYSTEM IS COMMITTED TO BUILDING HEALTHIER COMMUNITIES, ADVOCATING FOR THOSE WHO ARE POOR AND VULNERABLE, AND INNOVATING HOW AND WHERE HEALING CAN HAPPEN BOTH INSIDE ITS HOSPITALS AND OUT IN THE COMMUNITY. COMMONSPIRIT HEALTH OWNS AND OPERATES HEALTH CARE FACILITIES IN 24 STATES AND IS THE SOLE CORPORATE MEMBER (PARENT CORPORATION) OF OTHER PRIMARILY NONPROFIT CORPORATIONS. COMMONSPIRIT HEALTH AND SUBSTANTIALLY ALL OF ITS DIRECT AFFILIATES AND SUBSIDIARIES HAVE BEEN GRANTED EXEMPTIONS FROM FEDERAL INCOME TAX AS CHARITABLE ORGANIZATIONS UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. AS OF SEPTEMBER 25, 2024, COMMONSPIRIT HEALTH IS COMPRISED OF APPROXIMATELY 2,300 CARE SITES, CONSISTING OF 137 HOSPITALS, INCLUDING ACADEMIC HEALTH CENTERS, MAJOR TEACHING HOSPITALS, AND CRITICAL ACCESS FACILITIES, COMMUNITY HEALTH SERVICES ORGANIZATIONS, ACCREDITED NURSING COLLEGES, HOME HEALTH AGENCIES, LIVING COMMUNITIES, A MEDICAL FOUNDATION AND OTHER AFFILIATED MEDICAL GROUPS, AND OTHER FACILITIES AND SERVICES THAT SPAN THE INPATIENT AND OUTPATIENT CONTINUUM OF CARE. AN ADDITIONAL 21 HOSPITALS ARE OPERATED THROUGH UNCONSOLIDATED JOINT VENTURES. IN FISCAL YEAR 2024, COMMONSPIRIT HEALTH PROVIDED MORE THAN $2.574 BILLION IN FINANCIAL ASSISTANCE AND COMMUNITY BENEFIT FOR PROGRAMS AND SERVICES FOR THE POOR, FREE CLINICS, EDUCATION AND RESEARCH. FINANCIAL ASSISTANCE AND COMMUNITY BENEFIT TOTALED MORE THAN $4.22 BILLION WITH THE INCLUSION OF THE UNPAID COSTS OF MEDICARE. THE HEALTH SYSTEM, WHICH GENERATED OPERATING REVENUES OF $37.5 BILLION IN FISCAL YEAR 2024, HAS TOTAL ASSETS OF APPROXIMATELY $54.73 BILLION.COMMONSPIRIT HEALTH PROVIDES STRATEGIC PLANNING AND MANAGEMENT SERVICES AS WELL AS CENTRALIZED SERVICES FOR ITS DIVISIONS. THE PROVISION OF CENTRALIZED MANAGEMENT AND SHARED SERVICES INCLUDING AREAS SUCH AS ACCOUNTING, HUMAN RESOURCES, PAYROLL AND SUPPLY CHAIN PROVIDES ECONOMIES OF SCALE AND PURCHASING POWER TO THE DIVISIONS. THE COST SAVINGS ACHIEVED THROUGH COMMONSPIRIT HEALTH'S CENTRALIZATION ENABLE DIVISIONS TO DEDICATE ADDITIONAL RESOURCES TO HIGH-QUALITY HEALTH CARE AND COMMUNITY OUTREACH SERVICES TO THE MOST VULNERABLE MEMBERS OF OUR SOCIETY. 1 COMUNIDAD MAYA PIXAN IXIM 4913 S 25TH ST SUITE 1 OMAHA NE 68107 455539560 501(C)(3) 50000 0 GENERAL SUPPORT CHI HEALTH FOUNDATION 12809 W DODGE RD OMAHA NE 68154 470648586 501(C)(3) 1260240 0 GENERAL SUPPORT ARCHDIOCESE OF OMAHA 2222 N 111TH ST OMAHA NE 68164 470614394 501(C)(3) 50000 0 GENERAL SUPPORT AFRICAN AMERICAN EMPOWERMENT NETWORK 2401 LAKE STREET 110 OMAHA NE 68111 264296811 501(C)(3) 15000 0 GENERAL SUPPORT MOSAIC COMMUNITY DEVELOPMENT PO BOX 3451 OMAHA NE 68103 470842143 501(C)(3) 44185 0 GENERAL SUPPORT UNITED WAY OF THE MIDLANDS 2201 FARNAM ST SUITE 200 OMAHA NE 68102 470376605 501(C)(3) 12500 0 GENERAL SUPPORT 6 0 WOW/CARE SUPPORT 18 270 BOOK PROVIDING NECESSITIES FOR INPATIENTS SCHOLARSHIPS 5 9000 PART I, LINE 2: MOST DISBURSEMENTS IN FURTHERANCE OF THE ORGANIZATION'S EXEMPT PROGRAMS ARE MADE DIRECTLY IN THE ACTIVE CONDUCT OF THE ACTIVITIES CONSTITUTING THE EXEMPT PURPOSE OR FUNCTION OF THE ORGANIZATION. OTHERWISE, DISTRIBUTIONS IN FURTHERANCE OF THE INSTITUTION'S EXEMPT PROGRAMS ARE MADE IN ACCORDANCE WITH PROCEDURES OR SUBJECT TO CONDITIONS ESTABLISHED BY THE INSTITUTION'S GOVERNING BOARD OR MANAGEMENT DESIGNED TO ENSURE THAT RECIPIENTS OF SUCH DISBURSEMENTS FROM THE ORGANIZATION ARE ADEQUATELY INVESTIGATED AND GRANTED TO QUALIFIED RECIPIENTS. ALEGENT CREIGHTON HEALTH ONLY DISTRIBUTES FUNDS TO OTHER 501(C)(3) ORGANIZATIONS WITH THE SAME MISSION AND PURPOSE AS THE ALEGENT CREIGHTON HEALTH SYSTEM. THESE DISTRIBUTIONS ARE MONITORED TO ENSURE THEY ARE BEING USED AS SPECIFIED BY THE ORGANIZATION. PART III: LAKESIDE AND MIDLANDS PROVIDED 5 SCHOLARSHIPS DURING FISCAL YEAR 2024 TO STUDENTS INTERESTED IN THE HEALTHCARE INDUSTRY. 1 1 0 0 0 0 0 0 0 JOHN PETERSDORF BOARD MEMBER 0 645040 0 716812 0 727895 0 923913 0 68907 0 3082567 0 713173 EVERT KUIPER FORMER PRESIDENT, CHI HEALTH 0 749566 0 0 0 2037667 0 20045 0 28489 0 2835767 0 0 TIM BRICKER EX-OFFICIO BM/ PRESIDENT & CEO CENTR 0 876719 0 1582430 0 40043 0 82634 0 33892 0 2615718 0 0 JEANETTE WOJTALEWICZ FORMER CFO, CHI HEALTH 128679 0 132479 0 1083677 0 9698 0 2669 0 1357202 0 0 0 DEREK VANCE PRESIDENT ST. ELIZABETH 172974 0 155062 0 704939 0 11388 0 13792 0 1058155 0 39486 0 JULIE GOEBEL DIV SVP COO 515562 0 448209 0 1163 0 19175 0 36291 0 1020400 0 0 0 CARY WARD MD MARKET PRESIDENT 582241 0 237420 0 5118 0 19350 0 29434 0 873563 0 0 0 KEVIN MILLER PRESIDENT - LKS & MDL HOSPITAL 407568 0 216896 0 44741 0 18862 0 30826 0 718893 0 20206 0 EDWARD HANNON PRESIDENT - ST. FRANCIS 373906 0 202249 0 91338 0 14694 0 28934 0 711121 0 55138 0 THOMAS FREDERICKSON FORMER HCE 0 462687 0 181341 0 5994 0 19175 0 25314 0 694511 0 0 SEAN HANSEN MD HOSPITALIST 352197 283324 0 0 0 1260 0 19000 6674 22575 358871 326159 0 0 DENNIS EDWARDS VP MEDICAL OPERATIONS 164710 0 72836 0 409422 0 12503 0 10529 0 670000 0 0 0 ARMAN PAJNIGAR FORMER HCE 0 573170 0 0 0 2007 0 19350 0 34543 0 629070 0 0 STEVE HOUSTON SVP STRATEGY & BUSINESS DEVELOPMENT 391427 0 161650 0 5118 0 18625 0 29809 0 606629 0 0 0 KLAUS THALER VP MEDICAL OPERATIONS 423121 0 108021 0 4904 0 18277 0 29743 0 584066 0 0 0 AARON AUSTIN REGION CHRO 375791 0 152439 0 4904 0 19259 0 23508 0 575901 0 0 0 GREGORY BECKMANN FORMER PRESIDENT - PLAINVIEW HOSPITA 70411 0 64332 0 313028 0 6723 0 8952 0 463446 0 15380 0 NICK OTOOL MARKET CFO 252554 0 96047 0 419 0 16660 0 34289 0 399969 0 0 0 KIRTIBALA GUPTA MD BOARD MEMBER/PHYSICIAN 0 342890 0 0 0 3612 0 18825 0 28699 0 394026 0 0 HEATHER MORGAN MD BOARD MEMBER/PHYSICIAN 0 319514 0 0 0 911 0 18500 0 39877 0 378802 0 0 CONNIE PETERS PRESIDENT - PLAINVIEW HOSPITAL 0 197374 0 102615 0 11813 0 15936 0 12397 0 340135 0 0 PART I, LINE 3 DURING THE CALENDAR YEAR 2023, COMPENSATION FOR THE TOP MANAGEMENT OFFICIAL WAS ESTABLISHED BY COMMONSPIRIT HEALTH, A RELATED ORGANIZATION. COMMONSPIRIT HEALTH USED ONE OR MORE OF THE METHODS DESCRIBED IN SCHEDULE J, PART I, LINE 3 TO ESTABLISH THE TOP MANAGEMENT OFFICIAL'S COMPENSATION: (1) COMPENSATION COMMITTEE; (2) INDEPENDENT COMPENSATION CONSULTANT; (3) COMPENSATION SURVEY OR STUDY; (4) APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE. SEE SCHEDULE O DISCLOSURE FOR FORM 990, PART VI, SECTION B, LINE 15 FOR ADDITIONAL INFORMATION. PART I, LINE 4A: CERTAIN REPORTABLE INDIVIDUALS ARE COVERED BY AN EXECUTIVE SEVERANCE POLICY THAT PROVIDES MARKET-STANDARD COMPENSATION, RANGING FROM PAYMENTS OF 9 MONTHS TO 2 YEARS OF BASE COMPENSATION, DEPENDING ON THE EXECUTIVE'S POSITION, IN THE EVENT OF A POSITION ELIMINATION OR OTHER INVOLUNTARY TERMINATION, IN ACCORDANCE WITH THE GUIDELINES OF THE POLICY. CERTAIN REPORTABLE INDIVIDUALS ARE COVERED BY A NON-EXECUTIVE SEVERANCE POLICY THAT PROVIDES MARKET-STANDARD COMPENSATION, RANGING FROM PAYMENTS OF 2 WEEKS TO 52 WEEKS OF BASE COMPENSATION, DEPENDING ON THE EMPLOYEE'S POSITION AND TENURE, IN THE EVENT OF A POSITION ELIMINATION OR OTHER INVOLUNTARY TERMINATION, IN ACCORDANCE WITH THE GUIDELINES OF THE POLICY. THE FOLLOWING REPORTABLE INDIVIDUAL RECEIVED SEVERANCE PAYMENTS DURING THE 2023 CALENDAR YEAR, AND THESE SEVERANCE PAYMENTS WERE INCLUDED IN THE INDIVIDUAL'S W-2 INCOME AND REPORTABLE COMPENSATION ON PART VII AND SCHEDULE J, PART II, COLUMN (B)(III): GREGORY BECKMANN, $289,030; DENNIS EDWARDS, $407,259; EVERT KUIPER, $2,025,542; DEREK VANCE, $658,888; JEANETTE WOJTALEWICZ, $1,083,464. IN ACCORDANCE WITH AN EXECUTIVE SEVERANCE POLICY, DIGNITY HEALTH'S LISTED PERSONS ARE PROVIDED WITH MARKET-STANDARD COMPENSATION RANGING FROM PAYMENTS OF 9-24 MONTHS OF BASE COMPENSATION, DEPENDING ON THE EXECUTIVE'S POSITION, IN THE EVENT OF A POSITION ELIMINATION OR OTHER INVOLUNTARY TERMINATION. PART I, LINE 4B: DURING THE 2023 CALENDAR YEAR, COMMONSPIRIT HEALTH ("COMMONSPIRIT") MAINTAINED A SUPPLEMENTAL NON-QUALIFIED DEFERRED COMPENSATION PLAN FOR DIVISION CEOS/PRESIDENTS AND OTHER DESIGNATED COMMONSPIRIT EXECUTIVES AT THE LEVEL OF SENIOR VICE PRESIDENT AND ABOVE. DURING 2023 THE FOLLOWING DISTRIBUTIONS WERE MADE BY COMMONSPIRIT FROM THE DEFERRED COMPENSATION PLAN: GREGORY BECKMANN, $21,752; EDWARD HANNON, $61,375; KEVIN MILLER, $16,987; DEREK VANCE, $40,496. DUE TO THE "SUPER" VESTING RULES UNDER COMMONSPIRIT'S DEFERRED COMPENSATION PLAN, PARTICIPANTS WHO HAVE MET CERTAIN REQUIREMENTS SUCH AS INVOLUNTARY TERMINATION WITHOUT CAUSE, AGE, AGE AND YEARS OF SERVICE, OR MORE THAN 5 YEARS OF PLAN PARTICIPATION ARE ELIGIBLE TO RECEIVE THEIR 2023 CONTRIBUTIONS IN CASH. THESE CASH PAYOUTS ARE INCLUDED IN THE PARTICIPANT'S REPORTABLE COMPENSATION IN COLUMN (III) OTHER REPORTABLE COMPENSATION ON SCHEDULE J PART II. DURING 2023, THE FOLLOWING PAYMENTS WERE MADE PURSUANT TO THE SUPER VESTING RULES: GREGORY BECKMANN, $2,164; EDWARD HANNON, $20,116; KEVIN MILLER, $22,637; CONNIE PETERS, $9,404; DEREK VANCE, $5,215. CERTAIN LISTED PERSONS EMPLOYED BY DIGNITY HEALTH PARTICIPATE IN THE DIGNITY HEALTH EXCESS BENEFIT PLAN, A NONQUALIFIED SUPPLEMENTAL BENEFIT PLAN LIMITED TO PARTICIPANTS IN THE DIGNITY HEALTH RETIREMENT PLAN WHOSE BENEFITS ARE AFFECTED BY THE LIMITATIONS IMPOSED BY SECTIONS 401(A)(17) AND 415 OF THE INTERNAL REVENUE CODE. BENEFIT SERVICE UNDER THIS PLAN WAS FROZEN AS OF JANUARY 1, 2008. CERTAIN LISTED PERSONS EMPLOYED BY DIGNITY HEALTH ARE ELIGIBLE TO PARTICIPATE IN NON-QUALIFIED 457(F) PLANS THAT ARE SUBJECT TO SUBSTANTIAL RISK OF FORFEITURE, AS REQUIRED BY THE IRS. THE 2007 EXECUTIVE DEFERRED COMPENSATION PLAN IS FOR EXECUTIVES HIRED PRIOR TO JUNE 30, 2006. THE BENEFIT IS INTENDED TO BRIDGE THE DIFFERENCE, IF ANY, BETWEEN THE BENEFIT PROVIDED UNDER THE DIGNITY HEALTH EXCESS BENEFIT PLAN HAD BENEFIT SERVICE NOT BEEN FROZEN AT JANUARY 1, 2008, AND THE BENEFITS PROVIDED FROM ALL OTHER QUALIFIED AND NON-QUALIFIED PLANS. BENEFITS VEST UNDER THIS 457(F) PLAN AT THE LATER OF THE DATE THE PARTICIPANT ATTAINS AGE 62 OR IS CREDITED WITH 15 YEARS OF SERVICE. THE 2010 EXECUTIVE DEFERRED COMPENSATION PLAN IS FOR CERTAIN OFFICERS AND KEY EMPLOYEES, PRIMARILY THOSE WHO ARE NOT ELIGIBLE TO PARTICIPATE IN THE DIGNITY HEALTH EXCESS BENEFIT PLAN OR THE 2007 EXECUTIVE DEFERRED COMPENSATION PLAN DESCRIBED ABOVE. THIS BENEFIT PROVIDES AN ANNUAL ACCRUAL OF 10% OF TOTAL COMPENSATION AND IS PAYABLE ANNUALLY ON JULY 1 ONCE VESTED, WHICH IS AGE 62 WITH 5 YEARS OF SERVICE. THE PLAN ALSO ALLOWS FOR SPECIAL AWARDS. PAYMENTS PURSUANT TO THE PLAN ARRANGEMENTS FOR CERTAIN EMPLOYEES OCCURRED DURING 2023 AND INCLUDE J. PETERSDORF, $713,173. CERTAIN LISTED PERSONS EMPLOYED BY DIGNITY HEALTH PARTICIPATE IN THE DIGNITY HEALTH SUPPLEMENTAL EXECUTIVE RETENTION/RETIREMENT PLAN, A NONQUALIFIED SUPPLEMENTAL BENEFIT PLAN WHICH IN 2002 WAS OFFERED TO MEMBERS OF THE EXECUTIVE MANAGEMENT TEAM BY THE DIGNITY HEALTH BOARD OF DIRECTORS AND WOULD BE PAID ONLY IF THE EXECUTIVES STAYED WITH THE ORGANIZATION FOR A SPECIFIED NUMBER OF YEARS AS THE PRIMARY PURPOSE OF THIS PLAN IS TO PROVIDE FOR THE RETENTION AND RETIREMENT OF THE PARTICIPANTS. THE EXECUTIVE MANAGEMENT TEAM IS RECRUITED FROM STABLE CAREERS IN ORGANIZATIONS FROM ACROSS THE COUNTRY AND FROM VARIOUS INDUSTRIES. DUTIES ARE BOTH EXTENSIVE AND COMPLEX AND REQUIRE SUBSTANTIAL AND DIVERSE EXPERIENCE AND SKILL SETS TO EXECUTE THEIR ROLES SUCCESSFULLY. THE CALCULATION FOR THE PAYMENTS TO EACH EXECUTIVE ARE BASED ON THE VALUE OF A FINAL AVERAGE PAY ANNUITY BENEFIT BASED ON RETIREMENT AGE AND SERVICE YEARS TO THE ORGANIZATION. DISTRIBUTION OCCURS EACH JULY 1 IF THE PLAN FORMULA WARRANTS A PAYMENT. NO PAYMENTS PURSUANT TO THE PLAN ARRANGEMENT OCCURRED DURING 2023. PART II: ALEGENT CREIGHTON HEALTH FOLLOWS COMMONSPIRIT'S EXECUTIVE COMPENSATION PHILOSOPHY. COMMONSPIRIT'S EXECUTIVE COMPENSATION PHILOSOPHY IS DESIGNED TO ASSIST COMMONSPIRIT IN ATTRACTING AND RETAINING THE CALIBER OF EXECUTIVES REQUIRED TO ENABLE COMMONSPIRIT TO FULFILL ITS MISSION OF PROVIDING HIGH QUALITY HEALTHCARE FOR ALL PERSONS REGARDLESS OF THEIR ABILITY TO PAY FOR SERVICES, IMPROVING THE QUALITY OF LIFE IN THE COMMUNITIES COMMONSPIRIT SERVES, PROMOTING PATIENT AND EMPLOYEE SATISFACTION, AND ENSURING FINANCIAL STABILITY. A SUBSTANTIAL PORTION OF EXECUTIVE COMPENSATION IS PERFORMANCE BASED AND IS LINKED TO ORGANIZATIONAL GOALS APPROVED IN ADVANCE BY THE HUMAN RESOURCES AND COMPENSATION COMMITTEE. THESE GOALS INCLUDE ATTAINMENT OF ANNUAL AND LONG-TERM FINANCIAL PERFORMANCE, CERTAIN HEALTHCARE QUALITY STANDARDS AND COMMONSPIRIT'S COMMITMENT TO SERVING THE POOR AND DISENFRANCHISED IN THE COMMUNITIES IT SERVES. TOTAL COMPENSATION, WHICH INCLUDES BASE SALARY, ANNUAL, AND LONG-TERM INCENTIVE COMPENSATION, IS ESTABLISHED TO APPROXIMATE THE PREVAILING MARKET CONDITIONS FOR EXECUTIVES OF COMPANIES OF SIMILAR SIZE, REVENUES AND COMPLEXITY. PAYMENTS PURSUANT TO A LONG-TERM FINANCIAL PERFORMANCE GOAL WERE PAID IN CALENDAR YEAR 2023. FORM 990, PART V, LINE 1C: PAYMENTS TO VENDORS PAYMENTS TO VENDORS FOR ENTITIES THAT ARE PART OF COMMONSPIRIT HEALTH (CSH) ARE MADE BY CSH. CSH FILES THE FORM 1099S AND COMPLIES WITH THE BACKUP WITHHOLDING RULES FOR REPORTABLE PAYMENTS TO VENDORS AND GAMING WINNINGS. THE 1099S ISSUED BY CSH ON BEHALF OF ALEGENT CREIGHTON HEALTH ARE REPORTED TO THE IRS. FORM 990, PART VI, SECTION A, LINE 2 MARDELL WILSON AND KEVIN FITZGERALD: BUSINESS RELATIONSHIP FORM 990, PART VI, SECTION A, LINE 6 CHI NEBRASKA IS THE SOLE MEMBER OF ALEGENT CREIGHTON HEALTH. FORM 990, PART VI, SECTION A, LINE 7A ACCORDING TO THE ORGANIZATION'S BYLAWS, DIRECTORS SHALL BE APPOINTED OR REFUSED BY THE CORPORATE MEMBER. THE CORPORATE MEMBER MAY APPOINT ONE OR MORE INDIVIDUALS TO THE BOARD OF DIRECTORS, AND MAY AT ANY TIME REMOVE, WITH OR WITHOUT CAUSE, ANY MEMBER OF THE BOARD OF DIRECTORS. ACCORDING TO THE ORGANIZATION'S BYLAWS, DIRECTORS OF THE CORPORATION SHALL BE APPOINTED BY THE CORPORATE MEMBER NO LATER THAN JUNE 30 OF EACH YEAR. THE NAMES AND QUALIFICATIONS OF EACH INDIVIDUAL ACCEPTED BY THE BOARD OF DIRECTORS SHALL BE SUBMITTED TO THE CORPORATE MEMBER, WHO SHALL APPOINT OR REFUSE EACH NOMINEE IN ACCORDANCE WITH THE CORPORATE MEMBER'S BYLAWS AND WITH ENDORSEMENT OF THE SENIOR VICE PRESIDENT OF OPERATIONS. THE CORPORATE MEMBER MAY UNILATERALLY APPOINT ONE OR MORE INDIVIDUALS TO THE BOARD OF DIRECTORS SHOULD THE BOARD FAIL TO FURNISH THE CORPORATE MEMBER WITH A LIST OF INDIVIDUALS QUALIFIED TO SERVE ON THE BOARD OF DIRECTORS OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7B THE ORGANIZATION'S CORPORATE MEMBER IS CHI NEBRASKA. PURSUANT TO SECTION 5.4.1 OF THE ORGANIZATION'S BYLAWS, BOTH CHI NEBRASKA AND COMMONSPIRIT HEALTH HAVE RESERVED POWERS AS OUTLINED IN THE COMMONSPIRIT HEALTH GOVERNANCE MATRIX. PURSUANT TO THE GOVERNANCE MATRIX THE FOLLOWING RIGHTS ARE HELD BY THE CHI NEBRASKA'S BOARD: * APPROVE MEMBERS OF THE ALEGENT CREIGHTON HEALTH BOARD. * AMENDMENT OF THE CORPORATE DOCUMENTS OF ALEGENT CREIGHTON HEALTH. * APPROVE REMOVAL OF A MEMBER OF THE GOVERNING BODY OF ALEGENT CREIGHTON HEALTH. * ADOPTION OF LONG RANGE AND STRATEGIC PLANS FOR ALEGENT CREIGHTON HEALTH. THE FOLLOWING RIGHTS ARE RESERVED TO THE COMMONSPIRIT HEALTH BOARD DIRECTLY OR THROUGH POWERS DELEGATED TO THE COMMONSPIRIT HEALTH CHIEF EXECUTIVE OFFICER: * SUBSTANTIAL CHANGE IN THE MISSION OR PHILOSOPHY OF ALEGENT CREIGHTON HEALTH. * REMOVAL OF A MEMBER OF THE GOVERNING BODY OF ALEGENT CREIGHTON HEALTH. * APPROVAL OF ISSUANCE OF DEBT BY ALEGENT CREIGHTON HEALTH. * APPROVAL OF PARTICIPATION OF ALEGENT CREIGHTON HEALTH IN A JOINT VENTURE. * APPROVAL OF FORMATION OF A NEW CORPORATION BY ALEGENT CREIGHTON HEALTH. * APPROVAL OF A MERGER INVOLVING ALEGENT CREIGHTON HEALTH. * APPROVAL OF THE SALE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF ALEGENT CREIGHTON HEALTH. * TO REQUIRE THE TRANSFER OF ASSETS BY ALEGENT CREIGHTON HEALTH TO COMMONSPIRIT HEALTH TO ACCOMPLISH COMMONSPIRIT HEALTH'S GOALS AND OBJECTIVES, AND TO SATISFY COMMONSPIRIT HEALTH DEBTS. PURSUANT TO SECTION 5.5.2 OF THE ORGANIZATION'S BYLAWS, CHI NEBRASKA OR COMMONSPIRIT HEALTH MAY, IN EXERCISE OF THEIR APPROVAL POWERS, GRANT OR WITHHOLD APPROVAL IN WHOLE OR IN PART, OR MAY, IN ITS COMPLETE DISCRETION, AFTER CONSULTATION WITH THE BOARD AND ITS PRESIDENT AND THE CHIEF EXECUTIVE OFFICER OF THE ORGANIZATION, RECOMMEND SUCH OTHER OR DIFFERENT ACTIONS AS IT DEEMS APPROPRIATE. FORM 990, PART VI, SECTION B, LINE 11B FOLLOWING THE PREPARATION OF THE FORM 990 BY TAX ANALYSTS OF COMMONSPIRIT HEALTH (CSH), A RELATED ORGANIZATION, THE RETURN IS REVIEWED BY THE CSH TAX DIRECTOR AND THE LOCAL CHIEF FINANCIAL OFFICER. ADDITIONALLY, THE BOARD OF DIRECTORS ARE PROVIDED THE FINAL FORM 990 AND RELATED SCHEDULES TO REVIEW AND ARE ABLE TO ASK THE CHIEF FINANCIAL OFFICER AND TAX DIRECTOR QUESTIONS PRIOR TO FILING WITH THE IRS. UPON CHIEF FINANCIAL OFFICER APPROVAL AND SIGNATURE, THE TAX ANALYST FILES THE FINAL FORM 990 AS PRESENTED TO THE BOARD AND FINANCE COMMITTEE, MAKING ANY NON-SUBSTANTIVE CHANGES NECESSARY IN ORDER TO EFFECT E-FILING. ANY SUCH CHANGES ARE NOT RE-SUBMITTED TO THE BOARD. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A CONFLICTS OF INTEREST ("COI") POLICY (THE "POLICY") IN PLACE TO PROTECT THE INTERESTS OF COMMONSPIRIT HEALTH ("COMMONSPIRIT") IN CIRCUMSTANCES THAT MAY RESULT IN A CONFLICT BETWEEN PERSONAL INTERESTS OF A PERSON AND THE INTERESTS OF THE ORGANIZATION AND THOSE IT SERVES. COMMONSPIRIT'S COI POLICY APPLIES TO COMMONSPIRIT, ITS DIRECT AFFILIATES AND SUBSIDIARIES AND ANY RELATED ENTITY THE GOVERNING DOCUMENTS OF WHICH REQUIRE THE ENTITY TO COMPLY WITH COMMONSPIRIT POLICY (COLLECTIVELY THE "SYSTEM ENTITIES"). THE FOLLOWING PERSONS ARE REQUIRED TO DISCLOSE ACTUAL OR POTENTIAL CONFLICTS OF INTEREST AT LEAST ANNUALLY (VIA A FORMAL SYSTEM-ADMINISTERED SURVEY) IF THE PERSON'S AFFILIATION WITH COMMONSPIRIT CONTINUES: - MEMBERS OF CORPORATE AND COMMUNITY BOARDS OF SYSTEM ENTITIES - MEMBERS OF COMMITTEES OF CORPORATE AND COMMUNITY BOARDS OF SYSTEM ENTITIES - MEMBERS OF THE EXECUTIVE LEADERSHIP TEAM ("ELT") OF COMMONSPIRIT - CORPORATE OFFICERS OF SYSTEM ENTITIES - EMPLOYED PHYSICIANS AND ADVANCED PRACTICE PROVIDERS - KEY EMPLOYEES AND HIGHEST COMPENSATED EMPLOYEES AS SPECIFIED BY THE INTERNAL REVENUE SERVICE FOR FORM 990 PURPOSES WHO ARE NOT OTHERWISE INCLUDED IN THE CATEGORIES ABOVE - EMPLOYEES OF SYSTEM ENTITIES AT THE VICE PRESIDENT LEVEL AND ABOVE - ALL INDIVIDUALS ENGAGED IN RESEARCH AT INSTITUTIONS OWNED OR OPERATED BY A SYSTEM ENTITY - SELECT EMPLOYEES AS DETERMINED FROM TIME TO TIME BY LEADERSHIP DISCLOSURE, REVIEW, AND MANAGEMENT OF PERCEIVED, POTENTIAL, OR ACTUAL CONFLICTS OF INTEREST ARE ACCOMPLISHED THROUGH A DEFINED COI DISCLOSURE REVIEW PROCESS. EACH PERSON IS REQUIRED TO PROMPTLY AND FULLY DISCLOSE ANY SITUATION OR CIRCUMSTANCE THAT MAY CREATE A CONFLICT OF INTEREST AS SOON AS SHE/HE BECOMES AWARE OF IT. IN ADDITION, AT THE INCEPTION OF AN INDIVIDUAL'S RELATIONSHIP WITH COMMONSPIRIT (E.G. HIRING, BOARD APPOINTMENT), AND FOR CERTAIN POSITIONS, ANNUALLY THEREAFTER, WRITTEN CONFLICT OF INTEREST DISCLOSURE FORMS MUST BE COMPLETED. A FAILURE TO DISCLOSE MAY RESULT IN DISCIPLINARY OR CORRECTIVE ACTIONS. REPORTED POTENTIAL OR ACTUAL CONFLICTS OF INTEREST ARE INITIALLY REVIEWED BY LEGAL, CORPORATE RESPONSIBILITY OR RESEARCH INTEGRITY STAFF. IF NECESSARY, A CONFLICT OF INTEREST MANAGEMENT PLAN IS DEVELOPED, WHICH PLAN SHALL BE SUBJECT TO ACCEPTANCE BY THE APPROPRIATE DIRECT MANAGER, SUPERVISOR, MEDICAL STAFF OFFICE, BOARD OR BOARD COMMITTEE (FOR BOARD, BOARD COMMITTEE, ELT OR CORPORATE OFFICER CONFLICTS), OR OTHER APPROPRIATE INDIVIDUAL OR BODY. ONCE ACCEPTED, THE CONFLICT OF INTEREST MANAGEMENT PLAN IS COMMUNICATED TO THE PERSON WITH THE ACTUAL OR POTENTIAL CONFLICT AND THE INDIVIDUAL MUST CONDUCT THEMSELVES IN CONFORMITY WITH THE PLAN. IN THE EVENT THAT A TRANSACTIONAL CONFLICT INTEREST ARISES IN CONNECTION WITH A SYSTEM ENTITY BOARD MEETING, THE CONFLICTED INDIVIDUAL MUST DISCLOSE THAT CONFLICT PRIOR TO OR AT THE BEGINNING OF THE MEETING IN WHICH THE MATTER IS TO BE CONSIDERED. THE CONFLICTED INDIVIDUAL IS EXCLUDED FROM VOTING ON THE TRANSACTION AND IS PROHIBITED FROM USING PERSONAL INFLUENCE WITH RESPECT TO THE MATTER, BUT IS NOT PROHIBITED FROM PROVIDING INPUT IF REQUESTED TO DO SO. FORM 990, PART VI, SECTION B, LINE 15B COMMONSPIRIT'S BOARD OF STEWARDSHIP TRUSTEES APPOINTS A HUMAN RESOURCES AND COMPENSATION COMMITTEE, COMPRISED EXCLUSIVELY OF INDEPENDENT DIRECTORS, WHO ARE ACCOUNTABLE FOR SETTING REASONABLE COMPENSATION PRACTICES FOR CERTAIN EXECUTIVES WITHIN ORGANIZATION. THE HUMAN RESOURCES AND COMPENSATION COMMITTEE APPROVES, CONSISTENT WITH THE ORGANIZATION'S PHILOSOPHY AND PRINCIPLES, THE ANNUAL PERFORMANCE GOALS AND CRITERIA TO BE IN DETERMINING VARIABLE COMPENSATION. THE HUMAN RESOURCES AND COMPENSATION COMMITTEE ALSO ENGAGES AN INDEPENDENT CONSULTANT AND FINANCIAL LEGAL COUNSEL TO VALIDATE THE ORGANIZATION'S BENCHMARKING APPROACH AND REASONABLENESS OF THE TOTAL COMPENSATION AND BENEFITS PACKAGES FOR CERTAIN EXECUTIVES. APPROPRIATE COMPARABLE DATA IS OBTAINED BY THE COMMONSPIRIT HEALTH COMPENSATION DEPARTMENT FROM INDEPENDENT THIRD-PARTY SALARY SURVEYS, (E.G., TOTAL ECONOMIC BENEFITS PAID BY SIMILARLY SITUATED ORGANIZATIONS, BOTH TAXABLE AND TAX-EXEMPT, FOR SIMILAR JOB RESPONSIBILITIES) FOR ALL OTHER STAFF AND LEADERSHIP ROLES. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST FROM THE ADMINISTRATION DEPARTMENT. IN ADDITION, THE ARTICLES OF INCORPORATION ARE AVAILABLE FROM THE NEBRASKA SECRETARY OF STATE WEBSITE AT WWW.SOS.NE.GOV/BUSINESS. THE ORGANIZATION'S FINANCIAL STATEMENTS ARE INCLUDED IN COMMONSPIRIT HEALTH'S CONSOLIDATED AUDITED FINANCIAL STATEMENTS THAT ARE AVAILABLE AT WWW.COMMONSPIRIT.ORG. FORM 990, PART VI, SECTION B, LINE 16B: ALEGENT CREIGHTON HEALTH HAS NOT FORMALLY ADOPTED A WRITTEN POLICY OR WRITTEN PROCEDURE REGARDING JOINT VENTURES. HOWEVER COMMONSPIRIT HEALTH'S SYSTEM-WIDE JOINT VENTURE MODEL OPERATING AGREEMENT INCORPORATES CONTROLS OVER THE VENTURE SUFFICIENT TO ENSURE THAT (1) THE EXEMPT ORGANIZATION AT ALL TIMES RETAINS CONTROL OVER THE VENTURE SUFFICIENT TO ENSURE THAT THE PARTNERSHIP FURTHERS THE EXEMPT PURPOSE OF THE ORGANIZATION; (2) IN ANY PARTNERSHIP IN WHICH THE EXEMPT ORGANIZATION IS A PARTNER, ACHIEVEMENT OF EXEMPT PURPOSES IS PRIORITIZED OVER MAXIMIZATION OF PROFITS FOR THE PARTNERS; (3) THE PARTNERSHIP DOES NOT ENGAGE IN ANY ACTIVITIES THAT WOULD JEOPARDIZE THE EXEMPT ORGANIZATION'S EXEMPTION; AND (4) RETURNS OF CAPITAL, ALLOCATIONS, AND DISTRIBUTIONS MUST BE MADE IN PROPORTION TO THE PARTNERS' RESPECTIVE OWNERSHIP INTERESTS. ANY JOINT VENTURE AGREEMENTS THAT DO NOT CONFORM TO THE MODEL AGREEMENT ARE GENERALLY REVIEWED BY COUNSEL. FORM 990, PART XI, LINE 9: BENEFIT PLAN ACCRUAL ADJUSTMENT 3,137,478. EQUITY CHANGES IN UNCONSOLIDATED ORGS. 17,477,584. 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