2023-11-15T21:58:14-06:00 2022-12-31 873231666 PKF O'CONNOR DAVIES ADVISORY LLC 500 MAMARONECK AVENUE SUITE 301 HARRISON NY 105281633 990 2022-01-01 134111638 WESTCHESTER-ELLENVILLE HOSPITAL INC WEST 8456476400 10 HEALTHY WAY ELLENVILLE NY 12428 BOB RUE CFO 8456476400 2023-11-15 1 BOB RUE XXX-XX-XXXX 1 GARRETT M HIGGINS P00543209 9143818900 2023-11-15 3 AAL1 IAL1 2022 2023-04-26 12:10:37Z ELLENVILLE REGIONAL HOSPITAL STEVEN KELLEY 10 HEALTHY WAY ELLENVILLE NY 12428 31551766 0 X WWW.ERHNY.ORG X 2000 NY TO PROVIDE EXCEPTIONAL HEALTH CARE SERVICES TO ALL PEOPLE WHO LIVE IN, WORK IN AND VISIT OUR SURROUNDING COMMUNITIES. 12 11 291 26 1000 0 6992336 4720686 25610543 26459157 673142 292875 74550 50020 33350571 31522738 0 0 0 0 14061301 16000673 0 0 0 11533784 11204043 25595085 27204716 7755486 4318022 45889582 41883049 15018166 9003086 30871416 32879963 X ELLENVILLE REGIONAL HOSPITAL PROVIDES EXCEPTIONAL HEALTH CARE SERVICES TO ALL PEOPLE WHO LIVE IN, WORK IN AND VISIT OUR SURROUNDING COMMUNITIES. THIS HEALTH CARE IS DELIVERED WITH COMPASSION AND RESPECT BASED ON OUR COMMITMENT TO IMPROVING OUR COMMUNITY HEALTH THROUGH EXCELLENCE, INNOVATION AND STATE-OF-THE-ART TECHNOLOGIES. 0 0 20713350 0 26459157 IN-PATIENT DEPARTMENTS (MED/SURG AND SWING REHAB): IN 2022, THE HOSPITAL AND THE FOUNDATION SUPPORTED OUR STAFF WITH TUITION ASSISTANCE AND REIMBURSEMENT FOR EDUCATION RELATED TO HEALTH CARE SERVICES. THIS GENEROUS ASSISTANCE MADE IT POSSIBLE FOR NINE OF OUR STAFF MEMBERS TO PURSUE HIGHER DEGREES IN HEALTH CARE RELATED FIELDS. ERH TAKES PRIDE IN SERVING AS A TEACHING HOSPITAL AND HOSTING NURSING, PHARMACY AND PA STUDENTS FROM MANY SCHOOLS. IN 2022, ERH HOSTED STUDENTS FROM SUNY SULLIVAN, SUNY ULSTER, ORANGE, BOCES NEW VISIONS PROGRAM, LE MOYNE COLLEGE, CLARKSON UNIVERSITY, PACE UNIVERSITY, LONG ISLAND UNIVERSITY, AND MARIST COLLEGE. ERH COLLABORATED WITH THESE SCHOOLS TO PROVIDE ESSENTIAL AND MUCH NEEDED CLINICAL EXPERIENCE ROTATIONS. THE STUDENTS BENEFITED FROM WORKING SIDE BY SIDE WITH OUR SKILLED AND COMPASSIONATE CLINICAL TEAM. THEY OBSERVED FIRSTHAND THE DELIVERY OF EXCEPTIONAL CARE IN OUR INPATIENT, EMERGENCY DEPARTMENT, OPERATING ROOM, AND SPECIALTY SERVICES AS PART OF THEIR CLINICAL ROTATION. AS IN PAST YEARS, ERH PROVIDED THESE SERVICES WITHOUT REQUIRING ANY MONETARY COMPENSATION. PATIENT SATISFACTION AND POSITIVE OUTCOMES REMAIN SIGNIFICANT QUALITY INDICATORS WITH PATIENT SATISFACTION SCORES REACHING 99.3% FOR THE INPATIENT SERVICES AND 96.1% FOR EMERGENCY DEPARTMENT. DUE TO THE LINGERING IMPACT OF THE COVID, THE SUB-ACUTE UNIT SAW A SIGNIFICANT INCREASE IN ACUITY AND NUMBER OF COMPLEX CASES. ERH'S LONG TERM CARE PLACEMENT RATE WAS 7.5% WHILE THE PATIENTS DISCHARGE TO HOME RATE WAS AT A STELLAR 80.3%. THESE STELLAR RESULTS ARE THE PRODUCT OF A MULTIDISCIPLINARY COLLABORATIVE EFFORT AMONG NURSING, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH-LANGUAGE PATHOLOGY, RESPIRATORY THERAPY, PHARMACY, CASE MANAGEMENT AND REGISTERED DIETITIAN SERVICES. ERH CONTINUED TO HOLD STEADFAST COLLABORATING WITH COMMUNITY-BASED AGENCIES AND PROVIDING QUALITY, COMPASSIONATE CARE AND GENERATING POSITIVE OUTCOMES. BY COMBINING EVIDENCE-BASED RESEARCH, EXCELLENT NURSING SKILLS, AND EXPANDING OUR CLINICAL EDUCATION PROGRAMS, THE INPATIENT UNIT AT ELLENVILLE REGIONAL HOSPITAL MADE IT THEIR GOAL TO IMPROVE PATIENT OUTCOMES ACROSS THE CARE SPECTRUM. SOME OF THE MITIGATION STRATEGIES IMPLEMENTED DURING THE ONSET OF THE PANDEMIC COMBINED WITH THE COVID-19 WAIVER ALLOWED OUR FACILITY TO OFFER A MUCH-NEEDED SERVICE. ERH WAS A GREAT RESOURCE FOR TERTIARY FACILITIES DESPERATELY SEEKING TO BALANCE THEIR PATIENT LOADS. WE SERVED PATIENTS WHO WERE READY TO LEAVE THE ACUTE CARE SETTING; HOWEVER, THEIR POSITIVE COVID-19 STATUS DID NOT ALLOW THEM TO RETURN TO LONG TERM CARE FACILITIES (LTC) FOR REHABILITATION. ERH PROVIDED THE CARE THEY NEEDED, HELPED THEM REGAIN THE STAMINA THEY HAD LOST AND ULTIMATELY, AFTER TESTING NEGATIVE FOR COVID-19, THESE PATIENTS MADE IT BACK TO LTC FACILITIES. PATIENT SAFETY CONTINUED TO BE PARAMOUNT IN OUR FACILITY. WE TRACKED AND REPORTED COMPLIANCE WITH MEDICATION SCANNING, A PRACTICE THAT ENHANCES SAFE MEDICATION ADMINISTRATION BY HELPING VERIFY PATIENT IDENTIFICATION AND CORRECT MEDICATION AND SUBSEQUENTLY ENSURING CORRECT MEDICATION ADMINISTRATION AND MITIGATING POTENTIAL ERRORS. OUR SCANNING AVERAGE OF 80.6% REMAINED WELL ABOVE THE NATIONAL AVERAGE. ERH'S SAFE PATIENT HANDLING COMMITTEE REVIEWED AND MAINTAINED SUCCESSFUL PRACTICES THAT MAXIMIZED A SAFE ENVIRONMENT FOR OUR PATIENTS AND STAFF. THE FOCUS OF THIS INITIATIVE IS TO ENSURE THAT OUR STAFF ARE INJURY FREE. THE COMMITTEE HAS MADE A TREMENDOUS EFFORT TO DELIVER GUIDANCE AND TRAINING STAFF ON TRANSFERS, BODY MECHANICS, AND THE USE OF ASSISTIVE DEVICES. THEY HAVE DONE THIS VERY EFFECTIVELY BY INCORPORATING EVIDENCE-BASED PRACTICES IN OUR EVERYDAY TASKS AND ROUTINES LIKE THE BMAT MODEL (BED SIDE MOBILITY ASSESSMENT TOOL). THE SAFE PATIENT HANDLING COMMITTEE CONTINUES TO MEET REGULARLY TO DISCUSS EDUCATIONAL NEEDS AND PROVIDE HANDS-ON TRAINING TO ALL CLINICAL STAFF. ADDITIONALLY, OUR BEDS ARE NOW EQUIPPED WITH ALARMS AND SPECIALTY MATTRESSES TO ASSURE SAFETY AND MAINTAIN SKIN INTEGRITY. WE ALSO CONTINUE TO USE THE VIDEO MONITORING SYSTEM TO HELP INCREASE SAFETY MEASURES FOR OUR PATIENTS IN ISOLATION. STAFF EDUCATION IS ALSO AN ESSENTIAL ELEMENT IN MAINTAINING AND PROMOTING CLINICAL COMPETENCY. ONE HUNDRED PERCENT OF OUR REGISTERED NURSES MAINTAINS CERTIFICATION IN BASIC AND ADVANCED LIFE SUPPORT THROUGH THE AMERICAN HEART ASSOCIATION AND TELEMETRY. OUR NURSE EDUCATOR PROVIDES EDUCATION OPPORTUNITIES VIA IN-SERVICES, WEBINARS, LECTURES, AND SCHOLARLY ARTICLES. THE HANDS-ON TRAINING AND ACADEMIC OFFERINGS ENSURE OUR CLINICAL STAFF IS KNOWLEDGEABLE OF CURRENT TRENDS AND STANDARDS OF CARE. WE LINK ALL NEW HIRES WITH AN EXPERIENCED PRECEPTOR AND ADJUST THE ORIENTATION PROCESS TO MEET THE NEEDS OF EACH INDIVIDUAL. IN OUR FACILITY, EDUCATION DELIVERY INVOLVES EVERYONE. THE NURSE EDUCATOR COLLABORATES WITH THE NURSING TEAM, PHARMACY, REHABILITATION SERVICES, CLINICAL IT APPLICATIONS SPECIALIST, AND RESPIRATORY SERVICES TO OFFER COMPREHENSIVE ANNUAL EDUCATION FOR ALL NURSING STAFF. EMERGENCY DEPARTMENT:LIMITED ACCESS TO PUBLIC TRANSPORT AND SCANT EMERGENCY MEDICAL SERVICE COVERAGE ARE MONUMENTAL CHALLENGES IN ALL RURAL SETTINGS. IN 2022, OUR NEWLY RENOVATED AND EXPANDED EMERGENCY DEPARTMENT PROVIDED HIGH-QUALITY EMERGENCY CARE TO OUR RURAL RESIDENTS AND SEASONAL VISITORS. BY COMBINING QUALITY CARE, EVIDENCE-BASED RESEARCH, EXCELLENT NURSING SKILLS, AND EXPANDING OUR CLINICAL EDUCATION PROGRAMS, THE EMERGENCY DEPARTMENT AT ERH FOCUSED ON IMPROVING PATIENT OUTCOMES ACROSS THE CARE SPECTRUM. THE EMERGENCY DEPARTMENT TREATED 14,530 AT ELLENVILLE REGIONAL HOSPITAL. WE CONTINUED TO PROVIDE EXCELLENT CARE IN A MORE EXPEDIENT MANNER THAN OTHER EMERGENCY DEPARTMENTS ACROSS THE COUNTRY. OUR 2022 AVERAGE FOR ARRIVAL TO TRIAGE WAS A STELLAR 15.5 MINUTES. ADDITIONALLY, THE AVERAGE LENGTH OF STAY WAS 113.9 MINUTES. THESE REMARKABLE TURNAROUND TIMES DERIVE FROM THE DEDICATION OF OUR MULTIDISCIPLINARY TEAM COMPRISED OF ED PROVIDERS, NURSES, PATIENT CARE TECHNICIANS, REGISTRATION, LAB, AND RADIOLOGY. THE TEAM'S PRIMARY FOCUS IS OPTIMAL PATIENT CARE. OUR PATIENTS' NEEDS AND OUR COMMUNITY ALWAYS REMAIN TOP PRIORITY. IMPROVING PATIENT OUTCOMES IS THE PRIMARY DRIVER IN OUR EVERYDAY OPERATIONS. WHILE MANAGING THE LASTING EFFECTS OF THE COVID PANDEMIC, ERH CONTINUED TO FOCUS ON THE RELENTLESS OPIOID CRISIS. OUR EMERGENCY DEPARTMENT'S RESCUE INITIATIVE REMAINS IN EFFECT AND CONTINUES TO GENERATE POSITIVE OUTCOMES. THE ED PROVIDERS ARE CERTIFIED TO PROVIDE MAT (MEDICATION ASSISTED TREATMENT). THIS HAS GREATLY FACILITATED TREATMENT OF PATIENTS PRESENTING TO THE ED AFTER AN OVERDOSE. WE HAVE CONTINUED OUR COLLABORATION EFFORTS WITH THE ULSTER COUNTY SHERIFF'S DEPARTMENT'S IN THE ORACLE PROGRAM AND UTILIZE THE SERVICES OF OUR IN-HOUSE SUBSTANCE USE DISORDER (SUD) PROGRAM. OUR COLLABORATIVE EFFORTS HAVE HELPED WITH INDUCTION OF MAT AND SECURING INPATIENT AND OUTPATIENT REHABILITATION SERVICES FOR THOSE WHO ARE IN NEED. OUR ED AND POPULATION HEALTH TEAMS CONTINUE COLLABORATING, PROVIDING SAFE KITS UPON DISCHARGE TO PATIENTS WHO EXPERIENCED AN OVERDOSE EVENT, AND EDUCATING PATIENTS AND FAMILY MEMBERS ON NALOXONE ADMINISTRATION. THE FOCUS REMAINED ON HARM-REDUCTION, EDUCATION, AND PREVENTION. WE ALSO CONTINUED TO WORK CLOSELY WITH OUR LOCAL EMS AGENCIES. RADIOLOGY:IN 2022, THE RADIOLOGY & CARDIOLOGY DEPARTMENTS AT ERH STARTED THE YEAR WITH OUTPATIENT MODALITIES HOVERING OR EXCEEDING VOLUME FOR ALL MODALITIES FROM THE PAST SEVERAL YEARS. EVEN WITH THE SPIKES IN COVID AND EXTREME FLUCTUATION, THE VOLUME REMAINED CONSISTENT. WITH MANY STAFF CONTRACTING COVID PERSONALLY MADE IT CHALLENGING TO OPERATE, HOWEVER ERH STAFF ARE RESILIENT AND HELD STRONG KEEPING UP WITH OUR PATIENT DEMAND AND CONTINUED TO PROVIDE SERVICES WITHOUT INTERRUPTION OR DELAY.MAMMOGRAPHY HAD ITS ANNUAL MQSA INSPECTION COMPLETED WITH NO CITATIONS. WE CONTINUED OUR REDUCED X-RAY REPEAT/REJECT RATE, WHICH AVERAGED ABOUT 3% OVER THE YEAR. THIS CONTINUED REDUCTION IN REPEATED EXAMS ALLOWED US TO PROVIDE THE HIGHEST LEVEL OF CARE TO OUR PATIENTS. ERH ACQUIRED 5 NEW EKG MACHINES TO MONITOR PATIENT'S HEARTBEATS WITH MORE CLARITY AND IMPROVED DIAGNOSTIC ABILITIES. THE PURCHASE OF THESE MACHINES ELEVATED OUR OUTPATIENT OFFERINGS TO A HIGHER STANDARD. ADDITIONALLY, ERH ACQUIRED SERVICE CONTRACTS AND APPLICATIONS SUPPORT ON ALL OF THE EQUIPMENT. THIS ALLOWED FOR IMMEDIATE SERVICE ACCESS IF THERE WAS AN INTERRUPTION AND INCLUDED GUIDANCE ON NEW PROTOCOLS AND USING SPECIAL FEATURES ON THE MACHINES. 20713350 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 45 0 291 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 12 11 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X X BOB RUE CFO 8456476400 10 HEALTHY WAY ELLENVILLE NY 12428 STEVEN KELLEY PRESIDENT & CEO 36.00 5.00 X X 506729 0 161750 REVEREND JULIUS A COLLINS JR CHAIRPERSON 4.00 0.00 X X 0 0 0 MYRNA JARGOWSKY VICE CHAIRPERSON 2.00 5.00 X X 0 0 0 WILLIAM D BROWN TREASURER 3.00 8.00 X X 0 0 0 JOHN B GILLETTE SECRETARY 3.00 0.00 X X 0 0 0 RICHARD BRADFORD TRUSTEE 2.00 5.00 X 0 0 0 DR NEIL CALMAN MD TRUSTEE 2.00 0.00 X 0 0 0 PHILIP COOMBE III TRUSTEE 2.00 6.00 X 0 0 0 DAVID EIKSZTA TRUSTEE 2.00 5.00 X 0 0 0 JULIE C LONSTEIN TRUSTEE 2.00 0.00 X 0 0 0 CRAIG LOPEZ TRUSTEE 2.00 6.00 X 0 0 0 KRISTINA URSITTI DO TRUSTEE 2.00 0.00 X 0 0 0 BOB RUE CFO 36.00 5.00 X 225071 0 47408 ASHIMA BUTLER COO 36.00 0.00 X 236191 0 13466 MARIE BROWN REGISTERED NURSE 40.00 0.00 X 169708 0 36102 MARIA GONZALEZ CHIEF NURSING OFFICER 40.00 0.00 X 142290 0 41210 KERRY BYTHEWOOD-SAVERINO DIRECTOR OF PHARMACY 40.00 0.00 X 136567 0 0 THERESA AVERSANO DIRECTOR PHYSICAL MEDICINE & REHAB 40.00 0.00 X 134902 0 36573 CLARE FARRELL MANAGER OF LABORATORY SERVICES 36.00 0.00 X 136800 0 2183 1688258 0 338692 20 0 1 0 LAB CORP OF AMERICA HOLDINGS PO BOX 12140 BURLINGTON NC 27216 LAB SERVICES 541375 ADAPTIVE WORKFORCE SOLUTIONS LLC 111 E RIVULON BOULEVARD SUITE 107 GILBERT AZ 85297 STAFFING SERVICES 396361 THE INSTITUTE FOR FAMILY HEALTH INC 2006 MADISON AVENUE NEW YORK NY 10035 MEDICAL SERVICES 396269 CONSTABLE CUSTODIAL SERVICES INC PO BOX 1115 LIBERTY NY 12754 CLEANING SERVICES 384150 ATHENAHEALTH INC PO BOX 415615 BOSTON MA 02241 SOFTWARE SERVICES 250923 10 4443603 277083 4720686 PATIENT SERVICE REVENUE 621990 25838485 25838485 NY INDIGENT CARE POOL REVENUE 621990 620672 620672 26459157 260213 260213 34098 29028 5070 5070 5070 32662 0 32662 32662 32662 MISCELLANEOUS INCOME 900099 12398 12398 CAFETERIA INCOME 900099 10698 10698 PURCHASING REBATES 900099 7749 7749 14105 1000 13105 44950 31522738 26459157 1000 341895 1190615 438666 751949 12196115 9587594 2608521 16449 12337 4112 1499051 1138075 360976 1098443 823832 274611 1626 1219 407 129045 96784 32261 4265 4265 297286 222964 74322 117413 88060 29353 492195 371927 120268 300 225 75 390937 291322 99615 108986 81739 27247 1226765 918419 308346 451903 338927 112976 CONTRACT/PURCHASED SVCS 3364385 2520756 843629 MEDICAL SUPPLIES 1300954 975715 325239 BAD DEBT EXPENSE 1268281 1268281 PRESCRIPTION DRUGS 1011903 758927 252976 1037799 777581 260218 27204716 20713350 6491366 0 2268579 2411329 10251526 7289841 397046 245646 2875194 3755747 156864 225245 550566 623238 22930884 10250541 13103927 12680343 13568908 12509158 2716972 2142502 45889582 41883049 2904602 2634006 3215302 1181870 8898262 5187210 15018166 9003086 X 22282794 31455424 8588622 1424539 30871416 32879963 45889582 41883049 X 4318022 -2281472 -28003 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 4265 4265 1 PART II-B, LINE 1: AMOUNT REPORTED ON LINE 1I REPRESENTS THE PORTION OF MEMBERSHIP DUES PAID BY THE ORGANIZATION TO PROFESSIONAL ASSOCIATIONS AND SIMILAR ORGANIZATIONS ATTRIBUTABLE TO LOBBYING ACTIVITIES. 13645789 4399986 9245803 9174986 5850555 3324431 110109 110109 12680343 INTEREST IN NET ASSETS OF ELLENVILLE REGIONAL HOSPITAL FOUNDATION 1399407 INVESTMENT IN ELLENVILLE REGIONAL FAMILY HEALTH PROPERTIES 99966 INSURANCE RECOVERY RECEIVABLE 643129 2142502 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS 4544081 INSURANCE CLAIM LIABILITY 643129 5187210 X 28003162 -2281472 39329 -2242143 30245305 1277433 1277433 31522738 26003767 67332 67332 25936435 1268281 1268281 27204716 PART X, LINE 2: THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY WHEN THEY ARE MORE LIKELY THAN NOT TO BE SUSTAINED. MANAGEMENT HAS DETERMINED THAT THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS THAT WOULD REQUIRE FINANCIAL STATEMENT RECOGNITION AND/OR DISCLOSURE. THE HOSPITAL IS NO LONGER SUBJECT TO EXAMINATION BY APPLICABLE TAXING JURISDICTIONS FOR YEARS PRIOR TO 2019. PART XI, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES REPORTED ON PART VIII, LINE 6B 29,028. CHANGE IN INTEREST IN NET ASSETS OF ELLENVILLE REGIONAL HOSPITAL FOUNDATION 1,149. ELIMINATIONS 9,152. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 1,268,281. CHANGE IN EQUITY INVESTMENT IN ELLENVILLE REGIONAL FAMILY HEALTH PROPERTIES 9,152. PART XII, LINE 2D - OTHER ADJUSTMENTS: RENTAL EXPENSES REPORTED ON PART VIII, LINE 6B 29,028. EXPENSES ATTRIBUTED TO CONSOLIDATED ENTITIES 18,304. HOSPITAL RESTRICTED NET ASSETS RELEASED TO RELATED FOUNDATION 20,000. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE 1,268,281. 1 1 1 X 1 X 1 0 1 1 557232 557232 0.02050 6578061 1177935 5400126 0.19850 166131 166131 0.00610 7301424 1177935 6123489 0.22510 18189671 13931668 4258003 0.15650 18189671 13931668 4258003 0.15650 25491095 15109603 10381492 0.38160 0 585123 66667 10839627 10800368 39259 X 1 1 1 1 WESTCHESTER-ELLENVILLE HOSPITAL INC 10 HEALTHY WAY ELLENVILLE NY 12428 HTTPS://ERHNY.ORG 5526700C X X X X X WESTCHESTER-ELLENVILLE HOSPITAL INC 1 0 0 1 X X X X X X X X X 22 1 0 1 1 X SEE PART V, PAGE 8 X 1 22 1 SEE PART V, PAGE 8 0 1 X 100.000000000000 300.000000000000 1 1 X X X 1 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X X X X X X 1 X 0 X X X X 1 X 0 0 WESTCHESTER-ELLENVILLE HOSPITAL, INC. PART V, SECTION B, LINE 5: AS REQUIRED BY THE NEW YORK STATE DEPARTMENT OF HEALTH AND IRS, ELLENVILLE REGIONAL HOSPITAL (ERH) MUST CONDUCT A THOROUGH COMMUNITY HEALTH ASSESSMENT (CHA) EVERY THREE YEARS. THE INFORMATION IS UTILIZED TO DEVELOP A COMMUNITY SERVICE PLAN (CSP) OUTLINING INTERVENTIONS DESIGNED TO IMPROVE HEALTH OUTCOMES IN THE SERVICE AREA. IN RECENT YEARS, THE NEW YORK STATE DEPARTMENT OF HEALTH HAS ENCOURAGED LOCAL HOSPITALS AND HEALTH DEPARTMENTS TO COLLABORATE IN CREATING JOINT COMMUNITY HEALTH IMPROVEMENT (CHIP)/CSP DOCUMENTS. ULSTER COUNTY DEPARTMENT OF HEALTH (UCDOH) HOSTED A SERIES OF MEETINGS WITH KEY STAKEHOLDER ORGANIZATIONS IN ULSTER COUNTY TO DISCUSS THE SELECTION OF HEALTH IMPROVEMENT PRIORITIES. ERH, WITH ITS PARTNERS UCDOH AND HEALTHALLIANCE HOSPITAL: MARY'S AVE CAMPUS (HA), JOINTLY SELECTED PREVENTING CHRONIC DISEASES AND PROMOTE WELL-BEING AND PREVENT MENTAL AND SUBSTANCE USE DISORDERS AS THE TWO PRIORITY AREAS FOR THE 2022-2024 CHIP/CSP. COMMUNITY-BASED ORGANIZATIONS, HEALTH CARE PROVIDERS, SEVERAL COUNTY OF ULSTER DEPARTMENTS, AND ULSTER COUNTY COALITIONS WERE ALSO INVOLVED IN THE DECISION-MAKING PROCESS AND WORKED TO SUPPORT THE SELECTED INITIATIVES. THIS COLLABORATION HAS CONTINUED TO INCLUDE MANY SERVICE AGENCIES IN ULSTER COUNTY.IN 2017, THE SEVEN LOCAL HEALTH DEPARTMENTS OF THE MID-HUDSON REGION, INCLUDING DUTCHESS, ORANGE, PUTNAM, ROCKLAND, SULLIVAN, ULSTER, AND WESTCHESTER COUNTIES, CREATED THE HUDSON VALLEY PUBLIC HEALTH COLLABORATIVE WITH THE ENDEAVOR OF CREATING THE FIRST REGIONAL CHA FOR THE MID-HUDSON REGION. THE COLLABORATIVE CONTRACTED THE SIENA COLLEGE RESEARCH INSTITUTE (SCRI) TO CONDUCT A RANDOM DIGIT DIAL REGIONAL COMMUNITY HEALTH SURVEY TO SUPPLEMENT THE REGIONAL CHA AND TO GAUGE THE PERCEPTION OF RESIDENTS SURROUNDING HEALTH AND RESOURCES IN THEIR COMMUNITIES. TO FURTHER INCREASE THE DATA COLLECTED FROM THE COMMUNITY, COLLABORATIVE MEMBERS HELD FOCUS GROUPS WITH SERVICE PROVIDERS TO FURTHER UNDERSTAND THE NEEDS OF SPECIFIC COMMUNITIES AND POPULATIONS AND THE BARRIERS THEY FACE TO ACHIEVING OPTIMAL HEALTH. IN 2022, ELLENVILLE REGIONAL RURAL HEALTH NETWORK (ERRHN), WHICH SERVES AS THE POPULATION HEALTH DEPARTMENT OF ELLENVILLE REGIONAL HOSPITAL (CREATED IN 2017), ASSISTED WITH THE REJOINING OF THIS GROUP TO MAKE ANOTHER REGIONAL CHA FOR 2022. SCRI WAS AGAIN CONTRACTED, AND 5,699 SURVEYS WERE COLLECTED FROM THE MID-HUDSON REGION'S POPULATION, WITH AN AVERAGE OF 814 SURVEYS COLLECTED FOR EACH OF THE SEVEN COUNTIES. ERRHN ALSO REQUESTED SCRI RESPONSES SPECIFIC TO THE ZIP CODES WITHIN ERH'S SERVICE AREA AND RECEIVED THE RESPONSES FROM 313 SURVEYS. AS A REGULAR PART OF THE MANY GRANT PROJECTS RUN BY ERRHN, GAP ANALYSES ARE PERFORMED ON POPULATION-LEVEL DATA TO UNDERSTAND BETTER THE COMMUNITY'S NEEDS THAT NEED TO BE ADDRESSED TO ENSURE A COMPREHENSIVE PUBLIC HEALTH PROGRAM.ADDITIONALLY, THE HEALTHY ULSTER COUNCIL, A BROAD-BASED COALITION FORMED BY REPRESENTATIVES FROM VARIOUS ORGANIZATIONS AND AGENCIES IN 2010, HAS BEEN ONGOING IN ITS FOCUS ON HEALTH PROBLEMS IN ULSTER COUNTY AND WAYS TO IMPROVE HEALTH OUTCOMES. REGULAR MEETINGS OF THE COALITION, ALONG WITH PRESENTATIONS AND DISCUSSIONS, HAVE KEPT THE LARGER COMMUNITY INVOLVED IN TRACKING HEALTH CONCERNS AND SOLUTIONS, INCLUDING ELLENVILLE AND THE TOWN OF WAWARSING. WESTCHESTER-ELLENVILLE HOSPITAL, INC. PART V, SECTION B, LINE 6B: 1) HEALTH ALLIANCE OF THE HUDSON VALLEY2) ULSTER COUNTY DEPARTMENT OF HEALTH AND MENTAL HEALTH3) THE INSTITUTE FOR FAMILY HEALTH4) DUTCHESS COUNTY DEPARTMENT OF HEALTH 5) ORANGE DEPARTMENT OF HEALTH6) PUTNAM DEPARTMENT OF HEALTH7) ROCKLAND DEPARTMENT OF HEALTH8) SULLIVAN DEPARTMENT OF HEALTH9) WESTCHESTER DEPARTMENT OF HEALTH WESTCHESTER-ELLENVILLE HOSPITAL, INC. PART V, SECTION B, LINE 11: FOR ERH SPECIFICALLY, THE FOCUS AREAS CHOSEN WITHIN THE TWO PREVENTION AGENDA PRIORITIES FOR THE YEARS 2022-2024 ARE:1) PREVENT CHRONIC DISEASES FOCUS AREA 4: PREVENTIVE CARE AND MANAGEMENT2) PROMOTE WELL-BEING AND PREVENT MENTAL AND SUBSTANCE USE DISORDERS. FOCUS AREA 2: PREVENT MENTAL AND SUBSTANCE USER DISORDERSPREVENT CHRONIC DISEASES FOCUS AREA 4, THE ELLENVILLE REGIONAL RURAL HEALTH NETWORK (ERRHN) WELLNESS PROGRAM, AND ITS EDUCATIONAL PROGRAMMING WILL BE CONTINUALLY DEVELOPED AND IMPLEMENTED. THE COLLABORATIVE WILL WORK TO INCREASE PARTICIPATION IN LIFESTYLE CHANGES, INCLUDING INCREASED PHYSICAL ACTIVITY, IMPROVED DIET, AND IMPROVED HEALTH AND WELL-BEING AWARENESS, UTILIZING THE EVIDENCE-BASED COMMUNITY HEALTH WORKER (CHW) MODEL.INTERVENTION 1 SUMMARY: ERH HAS IDENTIFIED OVER 40 FAMILIES WORKING WITH A COMMUNITY HEALTH WORKER TO PRACTICE HEALTHY GOAL SETTING, INCREASING PHYSICAL ACTIVITY, AND BUILDING MOTIVATION. THE FAMILIES MAY ALSO ACCESS THE ERRHN NUTRITIONIST AT NO COST TO THEM. ALL OF THIS IS DONE TO DECREASE THE RISK OF DEVELOPING CHRONIC DISEASE.INTERVENTION 2 SUMMARY: ERH UTILIZES COLLABORATIVE EFFORTS BETWEEN DIFFERENT HOSPITAL DEPARTMENTS AND OTHER COMMUNITY-BASED ORGANIZATIONS TO OFFER SERVICES TO THE COMMUNITY THAT AIMS TO HELP OVERCOME SOCIAL DETERMINANT-RELATED HEALTH BARRIERS. THE PROGRAMS INCLUDE PHYSICAL ACTIVITY CLASSES, COOKING CLASSES, GARDENING CLASSES, AND EVEN A FREE PRODUCE HANDOUT ALL OF THESE ACTIVITIES ARE PROVIDED TO THE COMMUNITY AT NO DIRECT COST.INDIVIDUALS AND FAMILIES IDENTIFIED AS AT RISK IN THE COMMUNITY, AT THE ERH ED, OR A LOCAL PCP ARE REFERRED TO THE RHN WELLNESS PROGRAM. INDIVIDUALS WHO ACCEPT THE REFERRAL ARE ENROLLED INTO THE COHORT AND COMPLETE AN INTAKE ASSESSMENT WITH A COMMUNITY HEALTH WORKER (CHW) THAT INCLUDES COLLECTING CLINICAL METRICS, AN SDOH SCREENING (PRAPARE), AND HEALTH KNOWLEDGE AND BEHAVIOR ASSESSMENTS. THE CHW WORKS WITH THE INDIVIDUAL TO DEVELOP AN ACTION PLAN TO BEGIN MAKING LIFESTYLE CHANGES THAT REDUCE THEIR RISK OF CHRONIC DISEASE. THE CHW SUPPORTS THE COHORT BY OFFERING MEETINGS AT THEIR HOUSE, COMMUNITY LOCATION, LOCAL STORES, OR HOSPITAL. PROGRAMS INCLUDE:1) ELIMINATING TRANSPORTATION BARRIERS.2) ARRANGING MEDICATION RECONCILIATION AND BLISTER PACKAGING WITH THE ERH PHARMACIST.3) GROCERY SHOPPING EDUCATION AT THE LOCAL GROCERY STORE. ADDITIONALLY, THE COHORT CAN MEET WITH A NUTRITIONIST ONSITE OR AT A SITE OF THEIR CHOOSING (TO OVERCOME TRANSPORTATION) TO MAKE MEAL PLANS AND HAVE NUTRITION COUNSELING. IN ADDITION, TO THE SUPPORT PROVIDED BY THE CHW AND NUTRITIONIST, THERE ARE MANY NO-COST HEALTH PROGRAMS COHORT MEMBERS CAN ATTEND THAT FOCUS ON HEALTH EDUCATION, NUTRITION (COOKING DEMONSTRATIONS, SUPPORT GROUP, ETC.), AND PHYSICAL ACTIVITY CLASSES.TO PROMOTE WELL-BEING AND PREVENT MENTAL AND SUBSTANCE USE DISORDERS FOCUS AREA 2, ERH WILL CONTINUE TO IMPLEMENT AND EXPAND PROJECT RESCUE (24/7 BUPRENORPHINE INDUCTION WITH A WARM HANDOFF TO A PEER AND TREATMENT PROVIDER). THE PROGRAM WILL CONTINUE TO SUPPLY HARM REDUCTION SUPPLIES AND EDUCATION ON HARM REDUCTION TO INDIVIDUALS SEEN IN THE ED AND THE COMMUNITY. ADDITIONALLY, ERH STAFF WILL CONTINUE TO SUPPORT THE ULSTER COUNTY SHERIFF'S ORACLE PROGRAM (OPIOID RESPONSE AS COUNTY LAW ENFORCEMENT), WHICH AIMS TO DIVERT INDIVIDUALS FROM POTENTIAL INCARCERATION TO DETOX AND TREATMENT SERVICES.INTERVENTION 1 SUMMARY: IMPLEMENT PROJECT RESCUE, A COLLABORATIVE PARTNERSHIP BETWEEN ERH AND CATHOLIC CHARITIES OF ORANGE, SULLIVAN, AND ULSTER. MEDICATION ASSISTED RECOVERY (MAR) (BUPRENORPHINE) WILL BE AVAILABLE IN THE ED FOR INDUCTION 24/7 (WITH ASSESSMENT FOR WITHDRAWAL SYMPTOMS) WITH A WARM HANDOFF TO A CERTIFIED RECOVERY PEER ADVOCATE (CRPA) AND A REFERRAL TO START TREATMENT. MAR IS AVAILABLE FOR UP TO THREE DAYS IN THE ED, WITH A GUARANTEE TO START TREATMENT WITH PARTNERING AGENCIES ON DAY FOUR. CONTINUE TO LINK INDUCTED PATIENTS TO THE MAT CARE MANAGER AS NECESSARY. INTERVENTION 2 SUMMARY: PROVIDE NECESSARY HARM REDUCTION SUPPLIES AND GUIDANCE TO PREVENT FATAL OVERDOSES AND THE OCCURRENCE AND TRANSMISSION OF INFECTIOUS COMPLICATIONS (I.E., HEPC, HIV, ENDOCARDITIS).INTERVENTION 3 SUMMARY: SUPPORT OF THE ULSTER COUNTY SHERIFF'S PROJECT ORACLE FACILITATE LAW ENFORCEMENT-ASSISTED DIVERSION FOR SUBSTANCE USE DISORDER BY PARTICIPATING IN THE COUNTYWIDE "HIGH-RISK MITIGATION TEAM," A CARE-COORDINATION MODEL THAT AIMS TO REDUCE RATES OF RELAPSE, OVERDOSE, AND DEATH. PART V, LINE 7, CHNA REPORT WEBSITE: HTTPS://ULSTERCOUNTYNY.GOV/HEALTH/RESEARCH-AND-REPORTS PLEASE NOTE LINKS ARE SUBJECT TO CHANGE DUE TO WEBSITE REDESIGN/CHANGES CAUSING DATA TO BE MOVED TO ALTERNATE LOCATIONS. PART V, LINE 10, IMPLEMENTATION STRATEGY WEBSITE: HTTPS://ERHNY.ORG/ABOUT-US/ PLEASE NOTE LINKS ARE SUBJECT TO CHANGE DUE TO WEBSITE REDESIGN/CHANGES CAUSING DATA TO BE MOVED TO ALTERNATE LOCATIONS. PART V, SECTION B, LINE 16A: HTTPS://ERHNY.ORG/WP-CONTENT/UPLOADS/2022/08/2022-ERH-FINANCIAL-ASSISTANCE-POLICY-PROCEDURE-ENGLISH.PDFHTTPS://ERHNY.ORG/WP-CONTENT/UPLOADS/2020/03/2020-ERH-FA-APP-ENGLISH-AND-SPANISH.PDFPLEASE NOTE THAT THERE'S A POSSIBILITY THAT THE LINK COULD CHANGE AFTER THE RETURN IS FILED. PART V, SECTION B, LINE 16B&C: HTTPS://ERHNY.ORG/WP-CONTENT/UPLOADS/2020/03/2020-ERH-FA-APP-DIRECTIONS-ENGLISH.PDFHTTPS://ERHNY.ORG/WP-CONTENT/UPLOADS/2020/03/2020-ERH-FA-APP-DIRECTIONS-SPANISH.PDFHTTPS://ERHNY.ORG/WP-CONTENT/UPLOADS/2022/08/2022-ERH-FA-SUMMARY-ENGLISH.PDFHTTPS://ERHNY.ORG/WP-CONTENT/UPLOADS/2022/08/2022-ERH-FA-SUMMARY-SPANISH.PDFPLEASE NOTE THAT THERE'S A POSSIBILITY THAT THE LINK COULD CHANGE AFTER THE RETURN IS FILED. PART I, LINE 5: ERH DID NOT BUDGET AMOUNTS FOR FREE OR DISCOUNTED CARE PROVIDED UNDER ITS FINANCIAL ASSISTANCE POLICY. THE HOSPITAL IS PREPARED TO PROVIDE FREE OR DISCOUNTED CARE FOR ALL ELIGIBLE PATIENTS. THE IMPACT OF FREE AND DISCOUNTED CARE IS NOT PREDICTABLE FOR THE HOSPITAL IN ORDER TO ESTIMATE THIS AMOUNT FOR BUDGETING PURPOSES. PART II, COMMUNITY BUILDING ACTIVITIES: THE BOARD OF TRUSTEES OF ERH IS COMPRISED OF ELEVEN MEMBERS; TEN OF THESE MEMBERS ARE VERY VISIBLE IN THE COMMUNITY AND ARE A DIRECT LINK FOR PATIENTS TO THE HOSPITAL ADMINISTRATION. ELLENVILLE REGIONAL HOSPITAL PARTNERS WITH CATSKILL HUDSON AREA HEALTH EDUCATION CENTER AND THE INSTITUTE FOR FAMILY HEALTH TO RECRUIT PRIMARY CARE PHYSICIANS. ELLENVILLE REGIONAL HOSPITAL APPLIES SURPLUS FUNDS TO IMPROVING THE QUALITY OF CARE FOR ALL PATIENTS AN EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED LICENSED MEDICAL PROVIDERS IN THE COMMUNITY. PART III, LINE 2: THE AMOUNT REPORTED IN PART III, SECTION B, LINE 2 IS BASED ON THE AMOUNTS OF PATIENT ACCOUNTS WRITTEN OFF DUE TO BAD DEBT. PART III, LINE 3: THE AMOUNT REPORTED IN PART III, SECTION B, LINE 3 IS ESTIMATE OF ACCOUNTS MAY HAVE BEEN ELIGIBLE FOR FINANCIAL ASSISTANCE BASED ON THE KNOWLEDGE OF THE HOSPITAL PATIENTS AND THE COMMUNITY THAT THE HOSPITAL SERVES. SCHEDULE H, PART II: ELLENVILLE REGIONAL HOSPITAL'S POPULATION HEALTH PROGRAM IS BASED ON A BELIEF IN FOUR PILLARS FOR IMPROVED HEALTH:1. PROPER DIET2. MODERATE EXERCISE3. RISK REDUCTION4. STRESS MANAGEMENTA PROPER DIET IS BASED ON A BALANCED NUTRITIONAL PROGRAM AND EDUCATION TO COMMUNITY MEMBERS TO CONNECT THEM TO THE FOOD THEY EAT AND MAKE BETTER CHOICES.MODERATE EXERCISE IS ESSENTIAL FOR GOOD HEALTH AND FITNESS.RISK REDUCTION REFERS TO CONTROLLABLE RISKS, INCLUDING ALCOHOL, TOBACCO, SALT, SUGAR, EXCESS FAT, RISKY SEX, OPIATE AND OTHER DRUG USE, DANGEROUS DRIVING, AND OTHER ACTIVITIES THAT INCREASE RISKS TO HEALTH.STRESS MANAGEMENT REFERS TO OUR RESPONSE TO THE SOCIAL DETERMINANTS OF HEALTH; THESE INCLUDE INSECURITIES RELATED TO HOUSING, FOOD, RELATIONSHIP, JOB, FINANCES, AND RELATED FACTORS. WE REALIZE WE MAY NOT BE ABLE TO CHANGE THESE DYNAMICS; HOWEVER, WE MAKE EVERY EFFORT TO HELP OUR COMMUNITY MEMBERS COPE WITH THEIR CHALLENGES. OUR POPULATION HEALTH PROGRAMS ARE TAILORED TO ADDRESS ONE OR MORE OF THESE PILLARS.WE ALSO WORK IN CONCERT WITH THE INSTITUTE FOR FAMILY HEALTH (INSTITUTE), A FEDERALLY QUALIFIED HEALTH CENTER LOCATED ON THE HOSPITAL'S CAMPUS, ON SUCH WELLNESS INITIATIVES AS OUR ANNUAL HARVEST HEALTH FAIR. THE HARVEST HEALTH FAIR IS A FREE COMMUNITY HEALTH EVENT ON OUR CAMPUS THAT PROVIDES HEALTH SCREENINGS FOR ADULTS, SUCH AS BLOOD PRESSURE, GLUCOSE, AND MENTAL HEALTH SCREENINGS. CHILDREN'S RESOURCES INCLUDE ASTHMA AWARENESS ACTIVITIES. DIABETES EDUCATION AND PHARMACY CONSULTATIONS ARE ALSO AVAILABLE. IN ADDITION TO MEDICATION RECONCILIATION, STAFF FROM THE POPULATION HEALTH DEPARTMENT ALSO OFFER NARCAN TRAINING AND MEDICATION DISPOSAL TRAINING, WITH THE ONSITE PHARMACIST ABLE TO COLLECT OLD AND UNUSED MEDICATIONS. IN ADDITION, WE COLLABORATE WITH THE ELLENVILLE/ WAWARSING YOUTH COMMISSION, ELLENVILLE POLICE DEPARTMENT, ELLENVILLE, AND NAPANOCH FIRE DEPARTMENTS, ULSTER COUNTY SHERIFF'S DEPARTMENT, ELLENVILLE RESCUE SQUAD, AND ELLENVILLE SCHOOL DISTRICT PARENT TEACHER ORGANIZATION (PTO). THESE AGENCIES WORK TOGETHER TO PROVIDE FREE YOUTH ACTIVITIES, FREE CAR SAFETY SEAT CHECKS, AND FREE BIKE HELMETS AT THE FAIR. MEMBERS OF THE WAWARSING COUNCIL ARE ALSO INVITED TO PARTICIPATE AND SHARE THEIR RESOURCES WITH THE ATTENDEES. SINCE THE START OF THE COVID-19 PANDEMIC, THIS EVENT HAS BEEN ON HOLD. TO HELP TO REDUCE AND PREVENT CHRONIC DISEASES, INCLUDING DIABETES AND HYPERTENSION, THE POPULATION HEALTH DEPARTMENT COMPLETES OUTREACH EFFORTS, INCLUDING FREE BLOOD PRESSURE AND HEART AGE SCREENINGS AND FREE HEALTH EDUCATION AND EDUCATIONAL MATERIALS. WE ALSO PARTICIPATE IN OR HOST VARIOUS HEALTH FAIRS THROUGHOUT THE YEAR. THE POPULATION HEALTH DEPARTMENT NUTRITIONIST COORDINATES COOKING AND NUTRITION DEMONSTRATIONS AT VARIOUS EVENTS AND OFFERS FOLLOW-UP CONSULTATIONS WITH INDIVIDUALS.OUR EMERGENCY DEPARTMENT PROVIDERS REFER PATIENTS WHO NEED FOLLOW-UP CARE AND DO NOT HAVE A PRIMARY CARE PROVIDER TO THE INSTITUTE FOR CARE. PATIENTS SEEN IN THE EMERGENCY DEPARTMENT WITH MENTAL HEALTH SYMPTOMS ARE REFERRED TO THE BEHAVIORAL HEALTH STAFF AT THE INSTITUTE, WHO PROVIDE A WARM HANDOFF FOR PATIENTS WHO SCREENED POSITIVE FOR DEPRESSION OR SUICIDAL INDICATORS AND DO NOT REQUIRE IMMEDIATE INTERVENTION.ERH CONTINUES TO WORK COLLABORATIVELY WITH THE WAWARSING COUNCIL OF AGENCIES AND ULSTER COUNTY DEPARTMENT OF HEALTH TO ADDRESS TEEN PREGNANCY, SEXUAL ACTIVITY, AND SEX EDUCATION. OUR PARTNER, THE INSTITUTE, SITUATED ON OUR CAMPUS, OFFERS TEEN SERVICES. SINCE 2020, THE POPULATION HEALTH DEPARTMENT HAS PROVIDED COMPREHENSIVE SEXUAL EDUCATION TO TEENS IN THE ELLENVILLE CENTRAL SCHOOL DISTRICT THROUGH A PARTNERSHIP WITH PLANNED PARENTHOOD OF GREATER NEW YORK, UTILIZING FUNDING FROM THE HEALTH RESOURCES AND SERVICES ADMINISTRATION.WE ARE IMPROVING THE OUTCOMES FOR OUR INPATIENTS THROUGH OUR SWING BED OUTCOMES IMPROVEMENT PROJECT, WHICH HAS BEEN DEVELOPED TO QUANTIFY OUR SUB-ACUTE REHAB (SWING BED) PATIENTS' FUNCTIONAL OUTCOMES FROM ADMISSION TO DISCHARGE. THIS PROJECT INVOLVES MULTIPLE DISCIPLINES, INCLUDING NURSING AND REHAB. ONE OF THE MAIN GOALS OF THE PROJECT IS TO IMPROVE THE FUNCTIONAL INDEPENDENCE OF OUR SWING BED PATIENTS SO THAT THEY ARE DISCHARGED TO HOME, NOT A NURSING HOME. THIS PROJECT HAS BECOME A STATEWIDE MODEL FOR CAH FACILITIES. THE UNIVERSITY OF MINNESOTA IS CURRENTLY BUILDING ON THIS FOUNDATION, MEASURING QUALITY OUTCOMES IN A NATIONAL PROJECT SPONSORED BY HRSA. NYS OUTCOMES WERE SIGNIFICANTLY HIGHER THAN ANY OTHER STATE IN PRELIMINARY RESULTS. ERH PARTICIPATED IN THE WESTCHESTER DSRIP, AND OUR PROJECT FOCUSED ON REDUCING THE USE OF OPIOIDS BY CHRONIC PAIN PATIENTS SEEN IN OUR EMERGENCY DEPARTMENT. THE LEADERSHIP STAFF OF ELLENVILLE REGIONAL HOSPITAL AND THE INSTITUTE FOR FAMILY HEALTH DEVELOPED NEW AND INNOVATIVE PROTOCOLS TO ADDRESS CHRONIC PAIN PATIENTS, WHO OFTEN PRESENT IN THE EMERGENCY DEPARTMENT, SEEKING PAIN RELIEF. CHRONIC PAIN PATIENTS, IN MANY CASES, HAVE DEVELOPED AN ADDICTION TO OPIATE-BASED PAIN RELIEVERS. THE MODEL INCLUDES A COMPLETE REDESIGN OF TREATMENT PROTOCOLS IN THE EMERGENCY DEPARTMENT UTILIZING NON-ADDICTIVE PAIN MEDICATIONS. THE RESULT HAS DRAMATICALLY REDUCED OPIATE PRESCRIBING IN THE EMERGENCY DEPARTMENT. THE PROTOCOL ALSO INCLUDES A "WARM" HANDOFF/REFERRAL TO A PATIENT CARE NAVIGATOR WHO HELPS THE PATIENT GET INTO PRIMARY CARE AT THE INSTITUTE OR OTHER COMMUNITY-BASED PROVIDERS. THE PRIMARY CARE TREATMENT PLAN INCLUDES FOUR PATHWAYS TO ADDRESS:1. MEDICAL ISSUES WITH A FOCUS ON TRANSITIONING AWAY FROM OPIATES2. A PSYCHIATRIC PATHWAY TO ADDRESS ADDICTION3. AN INTERVENTION PATHWAY TO ADDRESS PAIN AT ITS SOURCE4. A PSYCHO/SOCIAL PATHWAY TO ADDRESS THE NUMEROUS OTHER PROBLEMS OF CHRONIC PAIN PATIENTS.THE DSRIP OPIATE REDUCTION PROJECT RESULTS HAVE BEEN A 97% REDUCTION IN THE ADMINISTRATION OF OPIATES IN THE EMERGENCY DEPARTMENT AND AN 84% REDUCTION IN EMERGENCY DEPARTMENT VISITS FOR THIS POPULATION. IN ADDITION, THERE HAS BEEN A SUCCESS IN TRANSITIONING PATIENTS TO SAFER PAIN REGIMENS AND IMPROVED HEALTH. (SEE PART V, SECTION B, LINE 11 FOR ADDITIONAL INFORMATION).AS A RESULT OF THE SUCCESSES OF THE DSRIP PROJECT, ERH TOOK THE NEXT STEP AND LAUNCHED PROJECT RESCUE IN APRIL 2019. PROJECT RESCUE AIMED TO REDUCE MORBIDITY AND MORTALITY OF SUBSTANCE USE AND OVERDOSE THROUGH EXPANDED ACCESS TO MEDICATION-ASSISTED TREATMENT (MAT). THROUGH THIS PROJECT, INDIVIDUALS IN ACTIVE OPIOID WITHDRAWAL CAN PRESENT TO THE EMERGENCY DEPARTMENT FOR EVALUATION BY CLINICAL STAFF. IF THEIR SYMPTOMS REGISTER AS OPIOID WITHDRAWAL, THE INDIVIDUAL CAN RECEIVE MAT (BUPRENORPHINE) WITH A WARM HANDOFF TO A CERTIFIED PEER RECOVERY ADVOCATE (CRPA) FROM CATHOLIC CHARITIES. ED AT ERH WILL PROVIDE MAT FOR UP TO 72 HOURS, WHILE THE SUD COORDINATOR AND CRPA ARRANGE FOR THE CLIENT TO START TREATMENT WITH AN EXTERNAL PROVIDER NO LATER THAN DAY FOUR.SINCE THE IMPLEMENTATION OF PROJECT RESCUE, SERVICES HAVE EXPANDED TO INCLUDE LINKING PATIENTS TO A MAT CARE MANAGER THROUGH THE INSTITUTE FOR FAMILY HEALTH. THIS CARE MANAGER PROVIDES EXTRA INDIVIDUAL SUPPORT WHILE TRANSITIONING TO THE INSTITUTE'S MAT PROGRAM. THE INDIVIDUAL HAS DIRECT PHONE ACCESS TO THE MAT CARE MANAGER, WHO CAN HELP RESOLVE MEDICATION ISSUES AND SCHEDULE TRANSPORTATION IF NECESSARY. IN 2022, 38 PEOPLE WERE SUCCESSFULLY CONNECTED WITH SUBSTANCE USE TREATMENT OR SUPPORTS. THE TREATMENT SERVICES INCLUDED DETOXICATION, INPATIENT AND OUTPATIENT SERVICES, AND BRIDGE PRESCRIPTIONS FOR BUPRENORPHINE OR METHADONE. NOTICING THE HESITANCY AND AMBIVALENCE EXPERIENCED BY THOSE WHO USE SUBSTANCES, ERH IMPLEMENTED A HARM REDUCTION APPROACH TO SUBSTANCE USE DISORDER, AIMING TO RESPECT INDIVIDUAL AUTONOMY AND PROTECT THOSE WHO USE ALCOHOL AND ILLICIT SUBSTANCES FROM THE DANGERS OF USING. INDIVIDUALS CAN ACCESS LIFE-SAVING SUPPLIES THROUGH THE EMERGENCY DEPARTMENT AND A CONFIDENTIAL TEXT LINE (DISCUSSED LATER). SUPPLIES INCLUDE NALOXONE (NARCAN), FENTANYL TEST STRIPS, SAFE USE KITS, SAFE SNORTING KITS, SAFE SEX KITS, MEDICATION LOCK BAGS, AND MEDICATION DISPOSAL BAGS.ERH IS A LEAD AGENCY IN DISTRIBUTING NALOXONE (NARCAN), A LIFE-SAVING MEDICATION USED TO REVIVE INDIVIDUALS FROM OPIOID OVERDOSE, AND DISTRIBUTED 203 NARCAN KITS TO THE WAWARSING-ELLENVILLE AREA IN 2022. BEING THE FIRST ULSTER COUNTY ORGANIZATION TO LAUNCH VIRTUAL NARCAN TRAINING, ERH HAS IMPROVED AND EXPANDED ACCESS TO HARM REDUCTION SUPPLIES AMID A NATIONAL CRISIS. DURING THE COVID-19 PANDEMIC, ERH LAUNCHED A PROJECT RESCUE TEXT LINE WHICH ALLOWS FOR CONFIDENTIAL AND SECURE ACCESS TO HARM REDUCTION SUPPLIES. THROUGH AN ONLINE FORM, HARM REDUCTION SUPPLIES CAN BE REQUESTED, AS WELL AS A REQUEST FOR ASSISTANCE WITH LOCATING A SUBSTANCE USE TREATMENT PROGRAM AND INFORMATION REGARDING THE HOSPITAL'S BUPRENORPHINE PROGRAM. THIS SERVICE CONTINUES TO BE AVAILABLE TO THE COMMUNITY. SCHEDULE H, PART II, CONTINUATION: ELLENVILLE REGIONAL HOSPITAL ALSO CHAMPIONS EDUCATING THE PUBLIC ON PROPER MEDICATION DISPOSAL. IN 2022, ERH PROVIDED 1,561 MEDICATION DISPOSAL PACKETS TO COMMUNITY MEMBERS, ALLOWING FOR PROPER MEDICATION DISPOSAL IN THE PRIVACY OF ONE'S HOME.ERH CONTINUES TO OFFER INPATIENT AND OUTPATIENT MEDICATION RECONCILIATION SERVICES AND EDUCATION REGARDING THE SAFE USE OF MEDICATIONS. ERH HAS A ROBUST SYSTEM TO IDENTIFY AND REPORT MEDICATION ERRORS AND NEAR MISSES. SOURCES AND PROBABLE CAUSES OF THE ABOVE ARE IDENTIFIED THROUGH A FOCUSED REVIEW BY AN INTERDISCIPLINARY COMMITTEE. ERH HAS ESTABLISHED A SEAMLESS MEDICATION MANAGEMENT PROCESS FOR PATIENTS TRANSITIONING FROM THE HOSPITAL TO ANOTHER CARE SETTING WITHIN OR OUTSIDE THE HOSPITAL. PROVIDERS USE OUR MEDICATION RECONCILIATION FORMS AS A TRUSTED SOURCE OF DATE MEDICATIONS FOR THEIR PATIENTS.IN FEBRUARY 2017, WE IMPLEMENTED A NEW HOUSE-WIDE ELECTRONIC HEALTH RECORDS SYSTEM TO HELP US DELIVER HIGH-QUALITY CARE TO OUR PATIENTS. THIS SINGLE-PLATFORM ELECTRONIC HEALTH SYSTEM ALLOWS STAFF SEAMLESS ACCESS TO INFORMATION FROM ALL PATIENT VISITS AT ELLENVILLE REGIONAL HOSPITAL. THUS ALLOWING FOR MORE FORMATIVE EVALUATIONS AND STAFF TIME AS THEY NO LONGER NEED TO SIFT THROUGH CHARTS OR OTHER ELECTRONIC MEDICAL RECORD PROGRAMS TO OBTAIN PERTINENT PATIENT DATA. WE ALSO PARTNERED WITH HIXNY, A REGIONAL HEALTH INFORMATION EXCHANGE PLATFORM THAT ALLOWS HOSPITAL STAFF TO ACCESS RELEVANT MEDICAL DATA FROM OUTSIDE PROVIDERS TO PROVIDE OUR PATIENTS WITH THE MOST EFFECTIVE AND EFFICIENT CARE. IF PATIENTS CONSENT TO ALLOWING THE HOSPITAL ACCESS, OUR STAFF CAN LOOK AT HISTORIC MEDICAL HISTORY AND VISITS OUTSIDE ELLENVILLE REGIONAL HOSPITAL, MEDICATION HISTORY, AND LANDMARK LABORATORY AND RADIOLOGY RESULTS. UTILIZING SUCH A PROGRAM ENHANCES THE OVERALL QUALITY AND SAFETY OF CARE OUR PATIENTS CAN RECEIVE AT ELLENVILLE REGIONAL HOSPITAL. PART III, LINE 4: EFFECTIVE JANUARY 1, 2019, THE HOSPITAL ADOPTED NEW U.S. GAAP REVENUE RECOGNITION GUIDANCE ACCOUNTING STANDARD UPDATE. AS A RESULT, UPON THE HOSPITAL'S ADOPTION OF ASC 606, THE MAJORITY OF WHAT WAS PREVIOUSLY CLASSIFIED AS THE PROVISION FOR BAD DEBTS IN THE CONSOLIDATED STATEMENT OF OPERATIONS AND CHANGES IN NET ASSETS IS NOW REFLECTED AS IMPLICIT PRICE CONCESSIONS AND THEREFORE IS INCLUDED AS A REDUCTION TO PATIENT SERVICE REVENUE IN 2022. BAD DEBT EXPENSE IS $1,268,281. THE AMOUNT REPORTED IN PART III, SECTION B, LINE 2 IS BASED ON THE AMOUNTS OF PATIENT ACCOUNTS WRITTEN OFF DUE TO BAD DEBT. THE AMOUNT DOES NOT INCLUDE WRITE OFF DUE TO DISCOUNT OR ALLOWANCE. PART III, LINE 8: $19,629, WHICH IS 50% OF THE SURPLUS REPORTED ON PART III, SECTION B, LINE 7, PERTAINS TO PATIENTS THAT COULD HAVE QUALIFIED FOR FINANCIAL ASSISTANCE AND BE TREATED AS COMMUNITY BENEFIT.THE AMOUNT ON LINE 6 WAS DERIVED BY USING THE MEDICARE ALLOWABLE COSTS AS REPORTED ON THE HOSPITAL'S NYS INSTITUTIONAL COST REPORT AND OTHER APPLICABLE ADJUSTMENTS. PART III, LINE 9B: NO COLLECTION PROCESS IS UNDERTAKEN FOR KNOWN PATIENT WHO ARE ELIGIBLE FOR FINANCIAL ASSISTANCE. ONCE A PATIENT IS QUALIFIED OR DESIGNATED FOR FINANCIAL ASSISTANCE, STATEMENTS WILL STOP BEING SENT UNTIL A DETERMINATION IS MADE THAT THE PATIENT IS NOT ELIGIBLE FOR FINANCIAL ASSISTANCE. PART VI, LINE 2: ELLENVILLE REGIONAL HOSPITAL USES VARIOUS METHODS TO ASSESS THE COMMUNITY'S HEALTH NEEDS. ELLENVILLE REGIONAL HOSPITAL SEEKS THE VIEWS OF COMMUNITY MEMBERS TO GAIN THEIR THOUGHTS REGARDING THEIR COMMUNITY'S HEALTH CARE AND FEEDBACK REGARDING ERH SERVICES. THE BOARD OF TRUSTEES OF ERH IS COMPRISED OF TEN MEMBERS; NINE ARE VERY VISIBLE IN THE COMMUNITY AND ARE A DIRECT LINK FOR PATIENTS TO THE HOSPITAL ADMINISTRATION. THE 10TH MEMBER IS THE CEO OF THE INSTITUTE FOR FAMILY HEALTH, THE LARGEST FEDERALLY QUALIFIED COMMUNITY HEALTH CENTER IN NY STATE. COMMUNITY FEEDBACK IS A TOPIC OF DISCUSSION AT MOST BOARD MEETINGS. THE PRESIDENT AND CEO OF ERH, STEVEN L. KELLEY, IS A PROMINENT COMMUNITY MEMBER. MR. KELLEY AND OTHER ADMINISTRATIVE TEAM MEMBERS BELONG TO NUMEROUS ORGANIZATIONS, SERVE ON OTHER NOT-FOR-PROFIT BOARDS, AND ARE ACTIVE PARTICIPANTS. ALL CLINICAL DEPARTMENTS DO PATIENT SATISFACTION QUESTIONNAIRES. THESE QUESTIONNAIRES PROVIDE VALUABLE FEEDBACK FROM THE POPULATION THAT UTILIZES THE HOSPITAL SERVICES. IN ADDITION, STATISTICAL DATA FROM STATE AND COUNTY DATABASES ARE CONTINUALLY ANALYZED, LOOKING FOR TRENDS AND CHANGES IN THE DEMOGRAPHIC MAKEUP OF OUR PATIENTS. IN ADDITION, THE ERRHN OFTEN UTILIZES COMMUNITY SURVEYS AND HOSTS COMMUNITY FORUMS TO GATHER MORE INFORMATION ON THE HEALTH TOPICS THAT THE COMMUNITY FEELS ARE PERTINENT. THESE FORUMS HAVE BEEN THE BASIS FOR CHANGES TO THE POPULATION HEALTH PROGRAM.FOR EXAMPLE, FORUMS HELD IN EARLY 2019 POINTED OUT A NEED FOR EASIER ACCESS TO NUTRITION EDUCATION. FOLLOWING THIS, ERRHN HIRED A FULL-TIME NUTRITIONIST WHO COULD WORK WITH COMMUNITY MEMBERS AT NO COST. WE ALSO MONITOR THE TOP TEN INPATIENT DIAGNOSES ANNUALLY TO PLAN OUR SERVICES AROUND THE DISEASES MOST PREVALENT IN OUR LOCAL COMMUNITY. ERH WORKS CLOSELY WITH AN FQHC ON OUR CAMPUS. THE CEOS OF ERH AND FQHC PARTICIPATE ON THE BOARD OF DIRECTORS FOR BOTH ORGANIZATIONS. THIS COLLABORATIVE WORKING ARRANGEMENT HAS BEEN INVALUABLE IN ASSESSING THE NEEDS OF THE MEDICAL PROVIDERS AND THE PATIENTS IN THE COMMUNITY. PART VI, LINE 3: BY ITS EXEMPTION FROM FEDERAL AND STATE TAXES AND AS PART OF THE HOSPITAL'S MISSION TO SERVE THE COMMUNITY'S HEALTHCARE NEEDS, ERH PROVIDES CARE TO ALL PATIENTS IN NEED WITHOUT REGARD FOR THEIR ABILITY TO PAY. ELLENVILLE REGIONAL HOSPITAL (ERH) INFORMS ITS PATIENTS OF THE AVAILABILITY OF FINANCIAL ASSISTANCE IN SEVERAL WAYS. SIGNS ARE POSTED IN REGISTRATION, AND INFORMATION ON FINANCIAL AID IS LOCATED ON OUR WEBSITE. THESE SIGNS DIRECT THE PATIENTS TO SPEAK WITH DESIGNATED PATIENT FINANCIAL SERVICES REPRESENTATIVES. ALL PATIENTS WITHOUT INSURANCE ARE GIVEN A PACKET THAT INCLUDES A CHARITY CARE APPLICATION AND IS AVAILABLE UPON REQUEST BY THE PATIENT AND ON OUR WEBSITE. PATIENT STATEMENTS ALSO INCLUDE CONTACT INFORMATION REGARDING FINANCIAL ASSISTANCE. IN ADDITION, THE REGISTRATION STAFF DIRECTS PATIENTS TO A DESIGNATED PATIENT FINANCIAL SERVICES REPRESENTATIVE FOR MEDICAID APPLICATIONS.HTTPS://ERHNY.ORG/PATIENT-GUESTS/FINANCIAL-ASSISTANCE-PROGRAM/ PART VI, LINE 4: ELLENVILLE REGIONAL HOSPITAL (ERH), A 25-BED CRITICAL ACCESS HOSPITAL BUILT IN 1964(-1966), IS LOCATED IN THE TOWN OF WAWARSING, IN ULSTER COUNTY. ERH IS A NON-PROFIT SOLE PROVIDER HOSPITAL FOR ELLENVILLE AND ITS SURROUNDING COMMUNITIES LOCATED BETWEEN SHAWANGUNK RIDGE AND THE CATSKILL MOUNTAIN RANGE. THE ERH SERVICE AREA, DEFINED AS THE TOP TEN ZIP CODES OF PATIENT RESIDENCY TO WHICH ERH PROVIDES CLINICAL SERVICES EACH YEAR, HAS A POPULATION OF 28,000. THESE ZIP CODES COVER TOWNS AND VILLAGES IN ULSTER COUNTY AND INTO PARTS OF SULLIVAN AND ORANGE COUNTIES, INCLUDING ELLENVILLE, KERHONKSON, NAPANOCH, ACCORD, PINE BUSH, WAWARSING, GRAHAMSVILLE, SUNDOWN, DENNING, WOODBOURNE, WOODRIDGE, WURTSBORO, WURTSBORO HILLS, PHILLIPSPORT, SUMMITVILLE, HAVEN, AND YANKEE LAKE. ERH IS GEOGRAPHICALLY ISOLATED, WITH ITS POPULATION CENTER CONSISTING OF A 37% NON-WHITE POPULATION AND A 20% BELOW-POVERTY LEVEL, ACCORDING TO THE US CENSUS BUREAU. THE NEAREST HOSPITAL IS OVER 25 MILES AWAY ON PRIMARILY SECONDARY ROADS, AND DUE TO THE RURAL GEOGRAPHICAL ISOLATION, ERH SERVES A CRUCIAL NEED FOR THE COMMUNITY. IN 2022, THE EMERGENCY DEPARTMENT (ED) PATIENT VOLUME AT ELLENVILLE REGIONAL HOSPITAL (ERH) WAS 14,543. IN 2022, THE HOSPITAL SERVED 13,148 UNIQUE PATIENTS WHO MADE 31,456 VISITS. IT IS ALSO A TEACHING HOSPITAL WITH EDUCATIONAL PROGRAMS FOR RESIDENTS, MEDICAL STUDENTS, PHARMACISTS, PHYSICAL THERAPISTS, PHYSICAL THERAPIST ASSISTANTS, OCCUPATIONAL THERAPISTS, OCCUPATIONAL THERAPY ASSISTANTS, RADIOLOGY TECHNICIANS, NURSE PRACTITIONERS, REGISTERED NURSES, PHYSICIAN ASSISTANTS, PHLEBOTOMISTS, HIGH SCHOOL NEW VISION STUDENTS AND MORE.ERH WAS GRANTED CRITICAL ACCESS HOSPITAL (CAH) STATUS IN 2004 AND HAD 25 INPATIENT BEDS. THESE BEDS CAN BE USED FOR ACUTE CARE OR SWING BUT MAY NOT EXCEED 25. THE RULING IS SIGNIFICANT SINCE THE HOSPITAL IS LOCATED IN A FEDERALLY DESIGNATED HEALTH PROFESSIONAL SHORTAGE AREA (HPSA) AND MEDICALLY UNDERSERVED AREA (MUA). THERE WOULD BE A SUBSTANTIAL PROBLEM WITH UNINSURED AND UNDERINSURED HAVING ACCESS TO QUALITY HEALTHCARE WITHOUT ERH.THE TOWN OF WAWARSING IS LOCATED WITHIN ULSTER COUNTY IN THE MID-HUDSON VALLEY, APPROXIMATELY 90 MILES NORTHWEST OF NEW YORK CITY. THE TOWN OF WAWARSING, A RURAL TOWN DESIGNATED AS HAVING A MEDICALLY UNDER-SERVED POPULATION (MUP ID# 07223), HAS A POPULATION OF APPROXIMATELY 13,004, OF WHICH 4,097 RESIDE WITHIN THE VILLAGE OF ELLENVILLE, THE LARGEST POPULATION CENTER IN THE TOWN (ACS 2018). THE TOWN INCLUDES 11,091 HOUSEHOLDS AND 2,946 FAMILIES.CENSUS DATA INDICATES THAT OF THE WAWARSING POPULATION, 69.8% IDENTIFY AS WHITE, 9.9% IDENTIFY AS BLACK, 2.3% AS ASIAN, 0.5% AS NATIVE AMERICAN (OR ALASKAN NATIVE) AND 9.7% IDENTIFY AS TWO OR MORE RACES; WITH 22.6% OF RESIDENTS IDENTIFYING AS LATINX, AND 14% OF INDIVIDUALS SPEAKING SPANISH AT HOME. THE MEDIAN AGE IS 41.5 YEARS IN WAWARSING, WITH 37% OF ADULTS OVER 50. CHILDREN <18 ARE 18.8% OF THE POPULATION, 18-64 ARE 66%, AND FEMALES OF ALL AGES ACCOUNT FOR 44% OF THE POPULATION. IN THE TOWN OF WAWARSING, 17.9% OF INDIVIDUALS LIVE BELOW THE POVERTY LINE, INCLUDING 23% OF CHILDREN UNDER 18. ELLENVILLE CENTRAL SCHOOL DISTRICT HAD 1,516 STUDENTS ENROLLED FOR THE 2019-20 SCHOOL YEAR, 71% ECONOMICALLY DISADVANTAGED. ROUGHLY 16% OF RESIDENTS HAVE LESS THAN A HIGH SCHOOL EDUCATION.THE UNEMPLOYMENT RATE FOR THE CIVILIAN LABOR FORCE IN WAWARSING IS 9.6%, WITH A SIGNIFICANTLY HIGHER UNEMPLOYMENT RATE FOR INDIVIDUALS 20-24 (32%) AND A SUBSTANTIALLY LOWER RATE FOR INDIVIDUALS 25-29 YEARS OLD (1.9%). IN THE TOWN OF WAWARSING, 17.9% OF INDIVIDUALS LIVE BELOW THE POVERTY LINE, INCLUDING 23% OF CHILDREN UNDER 18 AND 18.8% OF SENIORS. 47.9% OF INDIVIDUALS BELOW THE POVERTY LEVEL DID NOT WORK IN THE PAST 12 MONTHS. 83.8% OF THE POPULATION HAS A HIGH SCHOOL DIPLOMA (OR EQUIVALENT). HOWEVER, RATES DIFFER SIGNIFICANTLY FOR MALES AND FEMALES, WITH ONLY 3% OF 25+ FEMALES HAVING LESS THAN A HIGH SCHOOL DIPLOMA BUT 18% OF 25+ MALES HAVING LESS THAN A HIGH SCHOOL DIPLOMA. 18.2% OF THE POPULATION HAS A BACHELOR'S DEGREE OR HIGHER.WAWARSING HAS A TOTAL OF 6,299 HOUSING UNITS, 65% OF WHICH ARE SINGLE UNITS, 71.9% OF WHICH ARE OCCUPIED, AND 28.1% VACANT. OF THE 4,530 OCCUPIED HOUSEHOLDS, 60% ARE DEFINED AS 'FAMILY HOUSEHOLDS' (2,719); 29.1% (1,319) HAVE RELATED CHILDREN UNDER 18 YEARS OLD, AND 9.3% (421) ARE SINGLE FEMALES WITH CHILD(REN) HOUSEHOLDS. ABOUT 44% OF THE POPULATION IS MARRIED. THE AVERAGE HOUSEHOLD SIZE WAS 2.4, AND THE AVERAGE FAMILY SIZE 2.96.IN THE VILLAGE OF ELLENVILLE, THE LARGEST POPULATION CENTER (4,000) IN THE TOWN OF WAWARSING, THE MEDIAN AGE IS 37 YEARS, WITH 41.5% OF THE POPULATION UNDER 25. THE POPULATION IS 52% MALE. ETHNIC AND RACIAL DEMOGRAPHICS INCLUDE 58.4% WHITE, 7.9% BLACK, AND 4% TWO OR MORE RACES, WITH 29.4% OF THE POPULATION IDENTIFYING AS LATINO. JUST OVER 16% OF THE POPULATION SPEAKS A LANGUAGE OTHER THAN ENGLISH AT HOME, PREDOMINANTLY SPANISH. ACCORDING TO THE 2010 CENSUS, THERE WERE 4,135 PEOPLE IN THE VILLAGE OF ELLENVILLE, INDICATING THE POPULATION HAS CONTINUED TO DECREASE.OVER 12% OF RESIDENTS IN THE VILLAGE ARE UNEMPLOYED, AND ROUGHLY 18% HAVE LESS THAN A HIGH SCHOOL EDUCATION. THE UNEMPLOYMENT RATE FOR INDIVIDUALS 30-34 IS HIGHER THAN THE VILLAGE RATE, AT 21.2%. THE RATE IS EVEN HIGHER FOR INDIVIDUALS WITHOUT A HIGH SCHOOL DEGREE, AT 25.5%. VETERANS REPRESENT 3.4% OF THE POPULATION. IN THE 12428 ZIP CODE AREA, INCLUDING THE VILLAGE OF ELLENVILLE, OVER 40% OF RESIDENTS ARE LOW-INCOME, MORE THAN 18.9% LIVE BELOW THE POVERTY LINE, 24% OF CHILDREN LIVE IN POVERTY, AND 37% OF SENIORS LIVE IN POVERTY.IN THE 2017 ACS 5-YEAR ESTIMATES, 1,841 HOUSEHOLDS IN THE VILLAGE, 53% OF WHICH ARE SINGLE UNITS, AND 85.1% (1,566) OF WHICH ARE OCCUPIED. 39.9% OF HOMEOWNERS AND 54.3% OF RENTERS HAVE MONTHLY HOUSING COSTS THAT EXCEED 35% OF THE HOUSEHOLD INCOME. OF OCCUPIED UNITS, 63% ARE CONSIDERED 'FAMILY HOUSEHOLDS (50% OF WHICH ARE ESTIMATED TO BE SINGLE-PARENT HOUSEHOLDS), AND 21.9% OF OCCUPIED UNITS WERE DEFINED AS FEMALE HOUSEHOLDERS WITH NO MALE PRESENT. ABOUT 50% OF THE POPULATION IS MARRIED. OF OCCUPIED UNITS, 29.1 % HAD RELATED CHILDREN UNDER 18 LIVING WITH THEM, AND 24.8% OF HOUSEHOLDS HAD INDIVIDUALS AGED 65 OR OLDER: AVERAGE HOUSEHOLD SIZE 2.6 AND AVERAGE FAMILY SIZE 3.4.ERH'S CATCHMENT AREA INCLUDES A SUBSTANTIAL IMPOVERISHED POPULATION. FOR EXAMPLE, ELLENVILLE AND WAWARSING HAVE MEDIAN HOUSEHOLD INCOMES (TOWN $46,889 AND VILLAGE $45,531) THAT ARE SUBSTANTIALLY LOWER THAN (ABOUT THREE-QUARTERS) THE ULSTER COUNTY MEDIAN HOUSEHOLD INCOME OF $61,652 AND THE NYS MEDIAN HOUSEHOLD INCOME OF $62,765 (ACS 2017).IT IS ESSENTIAL TO NOTE THE ELLENVILLE FAMILY HEALTH CENTER (IFH), A PRIMARY CARE HEALTH CENTER OPERATED BY THE INSTITUTE FOR FAMILY HEALTH, IS ONE OF THE LARGEST FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) IN NEW YORK STATE. THE FQHC IS ALSO LOCATED ON THE ERH CAMPUS. THE INSTITUTE IS COMMITTED TO PROVIDING HIGH-QUALITY, AFFORDABLE HEALTH CARE FOR ALL. IT STRIVES FOR EXCELLENCE AT ITS 26 PRACTICES WHILE ACCEPTING ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. THE ELLENVILLE IFH OFFERS PRIMARY CARE, MENTAL HEALTH CARE, DENTAL, AND SOCIAL WORK SERVICES, ALONG WITH MANY OTHER HEALTH SERVICES FOR PATIENTS OF ALL AGES. AS PART OF A FEDERALLY QUALIFIED COMMUNITY HEALTH CENTER NETWORK, IT MEETS NATIONAL STANDARDS FOR AFFORDABLE, ACCESSIBLE, AND COMPREHENSIVE HEALTH CARE SERVICES. THE CENTER IS ACCREDITED BY THE JOINT COMMISSION AND RECOGNIZED BY THE NATIONAL COMMITTEE FOR QUALITY ASSURANCE AS A LEVEL 3 PATIENT-CENTERED MEDICAL HOME; THE HIGHEST RECOGNITION AVAILABLE. THE IFH SEES APPROXIMATELY 3,600 PATIENTS PER YEAR AND OFFERS SAME-DAY APPOINTMENTS. ACCORDING TO THE INSTITUTE OF FAMILY HEALTH, A FEDERALLY QUALIFIED HEALTHCARE CENTER'S ELLENVILLE SITE DATA, NEARLY 59% OF HEALTH CENTER PATIENTS RESIDING IN THE 12428 ZIP CODE RECEIVE MEDICAID OR OTHER PUBLIC INSURANCE, AND 7.6% ARE UNINSURED. FURTHERMORE, ROUGHLY 10% OF ADULTS IN THE ZIP CODE HAVE NO USUAL SOURCE OF CARE. THE SAME PERCENTAGE OF ADULTS HAVE DELAYED OR NOT SOUGHT CARE DUE TO HIGH COSTS.WAWARSING AND THE VILLAGE OF ELLENVILLE WERE PREVIOUSLY HOME TO SEVERAL MANUFACTURING BUSINESSES, INCLUDING IMPERIAL SCHRADE AND HYDRO ALUMINUM, WHICH EMPLOYED MANY RESIDENTS. THE SURROUNDING AREA ALSO BOASTED SEVERAL LARGE RESORT HOTELS. DUE TO THESE BUSINESSES CLOSING THEIR DOORS AND A SIGNIFICANT DECLINE IN THE AREA'S TOURIST INDUSTRY, THE ELLENVILLE COMMUNITY HAS LOST OVER 2,000 JOBS SINCE THE 1990S. THE TOWN AND VILLAGE STRUGGLE WITH THE ISSUES THAT ACCOMPANY POVERTY AND UNEMPLOYMENT IN RURAL AREAS. OVER 12% OF RESIDENTS IN THE VILLAGE ARE UNEMPLOYED. MAJOR EMPLOYERS SUPPORTING THE REGION'S RESIDENTS ARE THE NYS DEPARTMENT OF CORRECTIONS, ELLENVILLE CENTRAL SCHOOL DISTRICT, AND ELLENVILLE REGIONAL HOSPITAL. PART VI, LINE 7, REPORTS FILED WITH STATES NY PART VI, LINE 4, CONTINUATION: AN AFFORDABLE SENIOR HOUSING PROJECT, A JOINT VENTURE BETWEEN THE HOSPITAL AND WARWICK PROPERTIES, INC., IS LOCATED ON THE ELLENVILLE REGIONAL HOSPITAL CAMPUS. ALL THREE PHASES OF THE PROJECT REMAIN FULLY OCCUPIED, WITH APPROXIMATELY 156 SENIOR CITIZENS LIVING INDEPENDENTLY IN ONE-BEDROOM APARTMENTS. THE PROJECT COLLABORATORS SECURED FUNDING FOR THE COMPLEX FROM THE NEW YORK STATE DIVISION OF HOUSING'S COMMUNITY RENEWAL HOUSING TRUST FUND. THE PARTNERSHIP SPONSORING THE HOUSING PROJECT IS DEVELOPING PLANS TO BUILD ADDITIONAL AFFORDABLE HOUSING CLOSE TO THE HOSPITAL, TARGETING SENIORS, SPECIAL NEEDS POPULATIONS, AND POSSIBLY RETURNING VETS. X X X X 0 0 0 0 0 0 0 1 0 STEVEN KELLEY PRESIDENT & CEO 368295 0 130000 0 8434 0 161750 0 0 0 668479 0 0 0 BOB RUE CFO 183891 0 40000 0 1180 0 9821 0 37587 0 272479 0 0 0 ASHIMA BUTLER COO 182293 0 40000 0 13898 0 9558 0 3908 0 249657 0 0 0 MARIE BROWN REGISTERED NURSE 158829 0 10875 0 4 0 0 0 36102 0 205810 0 0 0 MARIA GONZALEZ CHIEF NURSING OFFICER 128696 0 13000 0 594 0 6274 0 34936 0 183500 0 0 0 THERESA AVERSANO DIRECTOR PHYSICAL MEDICINE & REHAB 126244 0 8500 0 158 0 0 0 36573 0 171475 0 0 0 PART I, LINE 7 EMPLOYEES OF THE ORGANIZATION RECEIVED A BOARD-APPROVED DISCRETIONARY BONUS, AWARDED BASED ON PERFORMANCE, AS REPORTED FOR THEM IN PART II, COLUMN B(II). PART II, COLUMN B(II) THE AMOUNT REPORTED FOR STEVEN L. KELLY IN PART II, COLUMN B(II), BONUS AND INCENTIVE COMPENSATION, WAS ALSO REPORTED ON THE 2021 FORM 990 IN PART II, COLUMN C, AS OTHER DEFERRED COMPENSATION. THE AMOUNT REPRESENTS BONUS EARNED IN 2021 AND PAID IN 2022. THE AMOUNT REPORTED IN PART II, COLUMN C REPRESENTS BONUS EARNED IN 2022, PAYABLE IN 2023. FORM 990, PART III, LINE 4A ERH CONTINUED TO EXPAND ON THE SERVICES PROVIDED BY THE QUALITY IMPROVEMENT GRANT, WHICH WAS AWARDED 3 YEARS PRIOR. WITH THIS GRANT, ERH PERFORMED AN OUTSTANDING 890 EXAMS IN 2022. OFFERING THE EXAMS AT NO OUT OF POCKET COST TO THE PATIENTS PROVED TO BE SUCCESSFUL WITH MANY PATIENTS RECEIVING CRUCIAL SCREENING AND PREVENTATIVE CARE BASED ON THE TEST RESULTS. MANY OF THE CALCIUM SCORE PATIENTS HAD BEEN FIRST TIME PATIENTS AT ERH AND RETURNED FOR OTHER OUTPATIENT SERVICES AS A RESULT OF THE HIGH LEVEL OF CARE AND REMARKABLE EXPERIENCE. OVERALL, RADIOLOGY AND CARDIOLOGY POSITIONED THEMSELVES TO HAVE A STRONG 2023 AND DID SO WHILE KEEPING PATIENTS AND STAFF HEALTHY AND SAFE. ERH STRIVES TO OFFER THE HIGHEST LEVEL OF CARE AND OBTAIN THE NEWEST EQUIPMENT AVAILABLE TO PROVIDE THE BEST SERVICE TO OUR COMMUNITY. THE HOSPITAL ALSO PROVIDES AMBULATORY SURGERY, LAB SERVICES, IV THERAPY, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH LANGUAGE PATHOLOGY SERVICES, CARDIAC REHABILITATION, AND SPECIALTY CARE TO OUR PATIENTS. FORM 990, PART VI, SECTION B, LINE 11B WESTCHESTER-ELLENVILLE REGIONAL HOSPITAL INC. ACCOUNTING DEPARTMENT LEADERSHIP AND HOSPITAL ADMINISTRATORS CREATE AND/OR REVIEW REQUIRED FILING MATERIAL FOR YEAR REPORTING. ACCOUNTING DEPARTMENT LEADERSHIP SUBMITS TO INDEPENDENT AUDITORS FILING MATERIAL TO CREATE A DRAFT 990 WHICH IS RETURNED FOR CORPORATE REVIEW. A SECOND REVIEW IS CONDUCTED BY ACCOUNTING DEPARTMENT LEADERSHIP AND HOSPITAL ADMINISTRATORS FOR ACCURACY. THEN ELECTRONIC OR HAND DELIVERED COPIES OF THE FORM 990 ARE PRESENTED TO THE BOARD MEMBERS OF THE ORGANIZATION FOR COMMENT. ANY COMMENTS ARE THEN GROUPED, SUMMARIZED, AND REPORTED TO THE INDEPENDENT AUDITORS FOR APPROPRIATE CHANGES. INDEPENDENT AUDITORS MAKE CHANGES SEND FINAL 990 FOR ONE LAST INTERNAL REVIEW AND APPROVAL FOR FILING. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY APPLIES TO THE FOLLOWING "PERSONNEL" OF THE HOSPITAL: MEMBERS OF THE BOARD OF TRUSTEES, OFFICERS, "SENIOR MANAGEMENT" (DEFINED TO BE THE PRESIDENT AND CHIEF EXECUTIVE OFFICER, SENIOR VICE PRESIDENTS AND VICE PRESIDENTS), ASSISTANT VICE PRESIDENTS, DEPARTMENT HEADS, AND OTHER EMPLOYEES (INCLUDING PHYSICIANS) WHO ARE IN A POSITION TO INFLUENCE ANY SUBSTANTIVE BUSINESS DECISION BETWEEN THE HOSPITAL AND A VENDOR. A DISCLOSURE STATEMENT MUST BE COMPLETED ANNUALLY BY THE APPLICABLE PERSONNEL STATING IF THEY ARE AWARE OF ANY ACTUAL OR POTENTIAL CONFLICTS. IF DURING THE YEAR, ANY MEMBER OF THE BOARD OF TRUSTEES, MEDICAL STAFF MEMBER OR EMPLOYEE BECOMES AWARE OF A CONFLICT, THEY PROMPTLY DISCLOSE IN WRITING TO THE ADMINISTRATOR OR PRESIDENT OF THE BOARD OF TRUSTEES ANY ACTUAL OR CONTEMPLATED TRANSACTION WHICH POSES A CONFLICT OF INTEREST. THE REPORT CONTAINS A STATEMENT OF ALL MATERIAL FACTS AS TO THE RELATIONSHIP OR INTEREST WHICH CREATES THE POSSIBLE CONFLICT OF INTEREST. THE DISCLOSURE OF ANY ACTUAL OR POTENTIAL CONFLICT OF INTEREST IS CONSIDERED BY THE BOARD OF TRUSTEES, WHICH DETERMINES WHETHER THE ACTUAL OR POTENTIAL CONFLICT OF INTEREST WILL HAVE AN ADVERSE EFFECT ON THE FACILITY. THE BOARD OF TRUSTEES CAUSES NOTICE TO BE GIVEN TO THE DISCLOSING PERSON, IN WRITING, OF THE DETERMINATION AND WHETHER THE SITUATION IS ALLOWED TO CONTINUE OR SHOULD BE TERMINATED, AND OF ANY OTHER ACTION THAT WILL BE TAKEN BY THE BOARD OF TRUSTEES OR SHOULD BE TAKEN BY THE BOARD MEMBER, MEDICAL STAFF MEMBER OR EMPLOYEE. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION COMMITTEE IS PROVIDED AN INDEPENDENT REPORT OF COMPARABLE HOSPITAL SALARY FOR THE CEO, INCLUDING FORM 990S OF SIMILAR SIZED ORGANIZATIONS. THE COMPENSATION COMMITTEE ALSO REVIEWS VARIOUS PERFORMANCE MEASURES AND OTHER INFORMATION AND ARRIVES AT A SALARY AND BENEFIT PACKAGE FOR THE CEO. THE COMPENSATION COMMITTEE APPROVES AND DECIDES THE COMPENSATION FOR CEO IN THE EXECUTIVE SESSION. THIS PROCESS WAS LAST UNDERTAKEN IN 2020 TO REVIEW CONTRACT'S COMPENSATION THROUGH 12/31/23. CONTEMPORANEOUS SUBSTANTIATION OF THESE DELIBERATIONS AND DECISIONS ARE ACCOMPLISHED THROUGH MINUTES OF THE COMMITTEE'S MEETINGS. THE DIRECTOR OF HUMAN RESOURCES OBTAINS SALARY INFORMATION FROM AN INDEPENDENT SOURCE OF LOCAL COMPARABLE HOSPITALS FOR EACH HIGHER-LEVEL POSITION AT THE HOSPITAL. THE INDEPENDENT INFORMATION CONTAINS SALARY LEVELS FOR EACH POSITION AT THE 25TH, 50TH, AND 75TH PERCENTILE. THE CEO THEN CONSIDERS THIS INFORMATION AND THE PERFORMANCE FOR EACH OF THESE EMPLOYEES AND DETERMINES THE APPROPRIATE SALARY LEVEL FOR OTHER OFFICERS AND KEY EMPLOYEE. THE SALARY INFORMATION IS THEN PRESENTED TO THE BOARD CHAIR FOR APPROVAL. THIS PROCESS WAS LAST UNDERTAKEN IN 2022. CONTEMPORANEOUS SUBSTANTIATION OF THESE DELIBERATIONS AND DECISIONS ARE DOCUMENTED IN THE FINANCE DEPARTMENT RECORDS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS CONFLICT OF INTEREST POLICY, ARTICLES OF INCORPORATION, FINANCIAL STATEMENTS AND BYLAWS AVAILABLE UPON WRITTEN REQUEST. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN NET ASSETS OF ELLENVILLE REGIONAL HOSPITAL FOUNDATION 1,149. CHANGE IN EQUITY INVESTMENT IN ELLENVILLE REGIONAL FAMILY HEALTH PROPERTIES -9,152. HOSPITAL RESTRICTED NET ASSETS RELEASED TO RELATED FOUNDATION -20,000. FORM 990, PART XII, LINE 2C: THE ORGANIZATION HAS A COMMITTEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS DID NOT CHANGE FROM THE PRIOR YEAR. ELLENVILLE REGIONAL HOSPITAL FOUNDATION INC 10 HEALTHY WAY ELLENVILLE NY 124285612 371562427 FUNDRAISING FOR WESTCHESTER-ELLENVILLE HOSPITAL, INC. NY 501(C)(3) LINE 7 WESTCHESTER-ELLENVILLE HOSPITAL INC 1 ELLENVILLE REGIONAL SENIOR HOUSING DEVELOPMENT FUND COMPANY INC 10 HEALTHY WAY ELLENVILLE NY 124285612 261411484 LOW INCOME HOUSING (INACTIVE) NY WESTCHESTER-ELLENVILLE REGIONAL HOSPITAL INC C 1.00000 1 ELLENVILLE II REGIONAL SENIOR HOUSING DEVELOPMENT FUND COMPANY INC 10 HEALTHY WAY ELLENVILLE NY 124285612 270754224 LOW INCOME HOUSING (INACTIVE) NY WESTCHESTER-ELLENVILLE REGIONAL HOSPITAL INC C 1.00000 1 ELLENVILLE III REGIONAL SENIOR HOUSING DEVELOPMENT FUND COMPANY INC 10 HEALTHY WAY ELLENVILLE NY 124285612 300649484 LOW INCOME HOUSING (INACTIVE) NY WESTCHESTER-ELLENVILLE REGIONAL HOSPITAL INC C 1.00000 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0