2023-10-30T12:48:08-05:00 2022-12-31 390758449 WIPFLI LLP 1502 LONDON ROAD SUITE 200 DULUTH MN 55812 990 2022-01-01 410693877 SAINT ELIZABETH'S HOSPITAL OF WABASHA SAIN 6515654531 1200 GRANT BLVD WEST WABASHA MN 55981 JOHN WOLFE FINANCE ADMINISTRATOR 6515654531 2023-10-19 1 JOHN WOLFE 999009999 0 MICHAEL J PETERSON CPA P01833529 2187224705 2023-10-19 2 AAL1 IAL1 2022 2023-04-26 12:10:37Z GUNDERSEN ST ELIZABETH'S HOSPITAL AND CLINICS JIM ROOT 1200 GRANT BLVD WEST WABASHA MN 55981 43697880 0 X WWW.GUNDERSENHEALTH.ORG/ST-ELIZABETHS/HOSPITAL/ X 1955 MN WE WILL DISTINGUISH OURSELVES THROUGH EXCELLENCE IN PATIENT CARE, EDUCATION, RESEARCH, AND IMPROVED HEALTH IN THE COMMUNITIES WE SERVE. 9 4 440 67 354586 353586 2104764 846731 42592722 42712482 5596 16345 113786 122322 44816868 43697880 0 0 0 0 29094596 29993376 0 0 0 15108449 13737768 44203045 43731144 613823 -33264 25407052 24045078 8209551 6148367 17197501 17896711 WE WILL DISTINGUISH OURSELVES THROUGH EXCELLENCE IN PATIENT CARE, EDUCATION, RESEARCH, AND IMPROVED HEALTH IN THE COMMUNITIES WE SERVE. 0 0 37463607 0 42357896 SAINT ELIZABETH'S HOSPITAL OF WABASHA, INC. IS A 163-BED CAMPUS (25 HOSPITAL BEDS, 100 NURSING HOME BEDS, 38 ASSISTED LIVING APARTMENT BEDS) PROVIDING SERVICES WITHOUT REGARD TO PATIENT RACE, CREED, NATIONAL ORIGIN, ECONOMIC STATUS, OR ABILITY TO PAY. DURING 2022, SAINT ELIZABETH'S HOSPITAL OF WABASHA, INC. HAD A TOTAL OF 36,188 PATIENT DAYS (INCLUDES NH/APT DAYS) OF SERVICE. THE HOSPITAL ALSO PROVIDED SERVICES FOR 20,348 OUTPATIENT VISITS, WHICH INCLUDED 2,710 OF EMERGENCY ROOM VISITS AND 354 OUTPATIENT SURGERIES. SEE SCHEDULE H FOR A NON-EXHAUSTIVE LIST OF COMMUNITY BENEFIT PROGRAMS AND DESCRIPTIONS. 37463607 1 1 0 0 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 1 0 0 0 0 0 0 0 1 1 1 0 0 1 41 0 1 440 1 1 1 0 0 0 0 0 0 0 0 0 0 0 X 9 4 0 0 1 0 1 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 MN X JOHN WOLFE 6515655553 1200 GRANT BLVD WEST WABASHA MN 55981 ANDREA L HAUSER ADMINISTRATOR DIRECTOR 1.00 40.00 X 0 244113 51032 KIMBERLY A BESELER DIRECTOR 1.00 40.00 X 0 108881 33074 LLOYD HAAS DIRECTOR 1.00 40.00 X 0 112579 18635 DR MICHAEL EBERSOLD DIRECTOR 1.00 40.00 X 0 112200 0 PAUL FISCH DIRECTOR 1.00 40.00 X 0 46800 9973 RICHARD ZABEL CHAIR 1.00 X X 0 0 0 DARLENE THEISMANN VICE-CHAIR 1.00 X X 0 0 0 CINDY DENK SECRETARY 1.00 X X 0 0 0 LEIGHTON J WILKIE BOARD MEMBER 1.00 X 0 0 0 JOHN WOLFE FINANCE ADMINISTRATOR 40.00 X 0 180215 40070 JIM ROOT ADMINISTRATOR 40.00 X 0 187085 31195 KURT L HENN MANAGER, PHARM, & PROV LIASION 40.00 X 168936 0 9319 KIMBERLY D WOLTER DIRECTOR, NURSING 40.00 X 151434 0 9859 DENNIS SPANO PHYSICIAN 40.00 X 0 540333 58135 RUTH TIFFAULT PHYSICIAN 40.00 X 0 421280 64266 PHILLIP SCHWEND SURGEON 40.00 X 0 375886 59184 AMANDA J STERRY APRN 40.00 X 268082 0 10720 MARK SWENSON CRNA 40.00 X 219843 0 14552 808295 2329372 410014 34 0 1 0 GUNDERSEN HEALTHSYSTEM 1900 SOUTH AVE LA CROSSE WI 54601 CONTRACT LABOR/MEDICAL SERVICES 6341383 ADP 1 ADP BLVD ROSELAND NJ 07068 PAYROLL PROCESSING SERVICES 511386 SELECT REHABILITATION LLC PO BOX 71985 CHICAGO IL 60694 CONTRACTED REHAB SERVICES 447346 TRIMEDX PO BOX 636129 CINCINNATI OH 45263 BIOMEDICAL CONTRACTED SERVICES 270083 4 492565 354166 846731 NET PATIENT SERVICE REVENUE 621990 38111447 38111447 PHARMACY REVENUE 456110 4601035 4246449 354586 42712482 13345 13345 59503 0 59503 59503 59503 3000 0 3000 3000 3000 CAFETERIA REVENUE 722514 29541 29541 33278 33278 62819 43697880 42357896 354586 138667 778112 778112 22695112 21092377 1602735 464093 464093 4594002 4056037 537965 1462057 1337695 124362 1922928 1922928 35900 35900 2336315 1863163 473152 68058 5151 62907 698453 456569 241884 40257 35884 4373 924171 911331 12840 109088 106259 2829 24462 3494 20968 78764 78764 1574761 1507607 67154 95713 95713 MEDICAL SUPPLIES 4630604 4629596 1008 REPAIRS AND MAINTENANCE 469837 464194 5643 FOOD 423176 423176 DUES AND SUBSCRIPTIONS 51146 34243 16903 254135 72738 181397 43731144 37463607 6267537 0 1727380 801756 501219 2169557 9442488 8448513 12146 18110 773613 982242 914891 172721 14153826 4072981 11118720 10080845 916595 1371334 25407052 24045078 3499296 2999267 661684 39730 4048571 3109370 8209551 6148367 X 17197501 17896711 17197501 17896711 25407052 24045078 X -33264 732474 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 250000 250000 10748026 2395672 8352354 2740929 1617996 1122933 414871 59313 355558 10080845 OTHER RECEIVABLES 802773 RIGHT OF USE ASSETS 22351 THIRD PARTY PAYOR RECEIVABLES 193130 CAPITALIZED LEASES 353080 1371334 DUE TO/FROM GLAS 2659022 ASSET RETIREMENT OBLIGATION 59399 LEASE LIABILITY 390949 3109370 X PART X, LINE 2: GUNDERSEN HEALTH SYSTEM HAS REVIEWED TAX POSITIONS FOR ALL OPEN YEARS AND HAS CONCLUDED THAT NO LIABILITIES EXIST FOR UNCERTAIN TAX POSITIONS. THE SYSTEM'S INCOME TAX RETURNS ARE NO LONGER SUBJECT TO EXAMINATION FOR 2017 AND PRIOR YEARS. 1 1 X 1 X 1 X 1 0 1 1 200557 200557 0.00460 7692461 7827196 0 0.00000 7893018 7827196 200557 0.00460 15734 15734 0.00040 50420 50420 0.00120 7378341 4573793 2804548 0.06410 2223 2223 0.00010 7446718 4573793 2872925 0.06580 15339736 12400989 3073482 0.07040 0 0 10000747 10045120 -44373 X 1 1 1 1 SAINT ELIZABETH'S HOSPITAL OF WABASHA INC 1200 GRANT BLVD WEST WABASHA MN 55981 WWW.GUNDERSENHEALTH.ORG/ST-ELIZABETHS 371485 X X X X SAINT ELIZABETH'S HOSPITAL OF WABASHA IN 0 0 1 X X X X X X X X 22 1 0 1 1 X SEE SUPPLEMENTAL SECTION X 1 22 1 HTTPS://WWW.GUNDERSENHEALTH.ORG/COMMUNITY-ASSESSMENT 0 1 X 200.000000000000 400.000000000000 X X X X 1 1 X X X X 1 X HTTPS://WWW.GUNDERSENHEALTH.ORG/PAY-MY-BILL/FINANCIAL-ASSISTANCE/ X HTTPS://WWW.GUNDERSENHEALTH.ORG/DOCUMENT/39791 X HTTPS://WWW.GUNDERSENHEALTH.ORG/DOCUMENT/39816 X X X X X X X 1 X 0 X X X X 1 X 0 0 SAINT ELIZABETH'S HOSPITAL OF WABASHA INC PART V, SECTION B, LINE 5: SEE ADDITIONAL DISCLOSURE BELOW. SAINT ELIZABETH'S HOSPITAL OF WABASHA INC PART V, SECTION B, LINE 6B: SAINT ELIZABETH'S CONDUCTED THE CHNA AND IMPROVEMENT PLAN DEVELOPMENT JOINTLY WITH WABASHA COUNTY PUBLIC HEALTH DEPARTMENT. IN ADDITION, OTHER AGENCIES, ORGANIZATIONS, AND CITIZENS ACTIVELY PARTICIPATE IN THE DEVELOPMENT OF IMPROVEMENT STRATEGIES FOR THE PRIORITIES SELECTED. SAINT ELIZABETH'S HOSPITAL OF WABASHA INC PART V, SECTION B, LINE 11: THE CURRENT CHNA/COMMUNITY HEALTH IMPROVEMENT PLAN CYCLE (2019-2022) WILL BE COMPLETED ON DECEMBER 31, 2022. THIS DATE WAS POSTPONED FROM JUNE 30, 2022 DUE TO A CHANGE IN THE FISCAL YEAR OF SAINT ELIZABETH'S HOSPITAL OF WABASHA, INC. BECAUSE OF A NEW SPONSORSHIP WITH GUNDERSEN HEALTH SYSTEM. THE CURRENT GOALS, STRATEGIES AND INDICTORS FOLLOW:MENTAL HEALTH (2019-2022)GOAL: IMPROVE THE MENTAL HEALTH OF INDIVIDUALS IN WABASHA COUNTYLONG-TERM PERFORMANCE INDICATOR: BY 2023, THE RESIDENTS OF WABASHA COUNTY WILL REDUCE THE AVERAGE NUMBER OF POOR MENTAL HEALTH DAYS IN THE LAST 30 DAYS FROM 2.8 (2016) TO 2.6. (SOURCE: COUNTY HEALTH RANKINGS)STRATEGY: SUICIDE PREVENTION TRAININGTHE WABASHA COUNTY MENTAL HEALTH ACTION TEAM WILL IMPLEMENT SUICIDE PREVENTION TRAINING IN THE COMMUNITY. ONE EXAMPLE OF A TRAINING IS QUESTION, PERSUADE, REFER (QPR). THE QPR TRAINING IS USED TO EDUCATE ANYONE IN THE COMMUNITY - TEACHERS, COACHES, PARENTS AND OTHERS - TO LEARN HOW TO ASK ABOUT SUICIDALITY, PERSUADE INDIVIDUALS THEY HAVE VALUE AND TO SEEK HELP AND HOW TO EFFECTIVELY ASSIST WITH REFERRING SOMEONE FOR HELP. AS PART OF THE WABASHA COUNTY MENTAL HEALTH ACTION TEAM, THE MEDICAL CENTER WILL: IDENTIFY AND RECRUIT INTENDED AUDIENCES (E.G., HEALTH AND SOCIAL SERVICES PROFESSIONALS, LAW ENFORCEMENT AND FIRST RESPONDERS, CLERGY AND FAITH COMMUNITIES, AND THE PUBLIC) CONDUCT SUICIDE PREVENTION TRAININGS ANNUALLY ACROSS AUDIENCESCOLLABORATIVE PARTNERS: WABASHA COUNTY MENTAL HEALTH ACTION TEAM ZUMBRO VALLEY MENTAL HEALTH WABASHA COUNTY SOCIAL SERVICES HIAWATHA VALLEY MENTAL HEALTH NAMI GUNDERSEN ST. ELIZABETH'S HOSPITAL AND CLINICS RESOURCES COMMITTED: STAFF TIMEMEDIUM-TERM INDICATOR: BY JUNE 30, 2022, 90 PERCENT OF TRAINING PARTICIPANTS WILL REPORT AN INCREASED UNDERSTANDING OF WHEN AND HOW TO UTILIZE GATEKEEPER SKILLS (E.G., ABILITY TO ENGAGE IN ACTIVE LISTENING, ASK CLARIFYING QUESTIONS AND MAKE AN APPROPRIATE REFERRAL).STRATEGY: PROMOTE AWARENESS OF MENTAL HEALTH CRISIS RESOURCESWABASHA COUNTY CURRENTLY HAS ACCESS TO REGIONAL RESOURCES THAT INCLUDE A TRAINED MOBILE CRISIS RESPONSE TEAM AND A 24-HOUR MENTAL HEALTH CRISIS HOTLINE. THE MENTAL HEALTH ACTION TEAM WILL WORK WITH ITS PARTNERS TO INCREASE THE UTILIZATION OF THESE RESOURCES. INITIATIVES INCLUDE: DEVELOP A COMMUNICATION PLAN TO BUILD GREATER AWARENESS OF MOBILE CRISIS RESOURCES AMONG INTENDED AUDIENCES (HEALTH AND SOCIAL SERVICES PROFESSIONALS, LAW ENFORCEMENT AND FIRST RESPONDERS, WORKPLACES, CLERGY AND FAITH COMMUNITIES AND THE PUBLIC) IMPLEMENT THE PLAN TRACK HOTLINE CALL VOLUMES AND NUMBER OF MOBILE CRISIS TEAM DISPATCHESCOLLABORATIVE PARTNERS: WABASHA COUNTY MENTAL HEALTH ACTION TEAM ZUMBRO VALLEY MENTAL HEALTH HIAWATHA VALLEY MENTAL HEALTH WABASHA COUNTY SOCIAL SERVICES NAMI GUNDERSEN ST. ELIZABETH'S HOSPITAL AND CLINICS RESOURCES COMMITTED: STAFF TIMEMEDIUM-TERM INDICATORS: BY JUNE 30, 2022, MOBILE CRISIS RESPONSE TEAMS WILL REPORT A 10 PERCENT INCREASE IN USE OF THE MOBILE CRISIS TEAM BY WABASHA COUNTY RESIDENTS. (BASELINE TBD.) BY JUNE 30, 2022, MOBILE CRISIS RESPONSE TEAMS WILL REPORT A 10 PERCENT INCREASE IN USE OF THE CRISIS HOTLINE BY WABASHA COUNTY RESIDENTS. (BASELINE TBD.) BY JUNE 30, 2022, VISITS TO GUNDERSEN ST. ELIZABETH'S EMERGENCY DEPARTMENT WITH A MENTAL HEALTH DIAGNOSIS WILL DECLINE BY FIVE PERCENT DUE TO AN INCREASE IN THE USE OF THE MOBILE UNIT AND CRISIS HOTLINE. (BASELINE TBD.)STRATEGY: PROMOTE MENTAL HEALTH PEER SUPPORT GROUPSTHE LOCAL NATIONAL ALLIANCE ON MENTAL ILLNESS (NAMI) CONNECTION RECOVERY SUPPORT GROUP IS A FREE, PEER-LED SUPPORT GROUP FOR ADULTS LIVING WITH MENTAL ILLNESS. PARTICIPANTS GAIN INSIGHT FROM HEARING THE CHALLENGES AND SUCCESSES OF OTHERS. GROUPS ARE LED BY NAMI-TRAINED FACILITATORS, WHO HAVE EXPERIENCED MENTAL ILLNESS. NAMI'S SUPPORT GROUPS ARE UNIQUE BECAUSE THEY FOLLOW A STRUCTURED MODEL TO ENSURE PARTICIPANTS HAVE AN OPPORTUNITY TO BE HEARD AND RECEIVE WHAT THEY NEED. THE GROUPS MEET ON A BI-WEEKLY, WEEKLY, OR MONTHLY BASIS. PEER SUPPORT IS CURRENTLY NOT AVAILABLE IN WABASHA COUNTY. THE MENTAL HEALTH ACTION TEAM WILL: INITIATE A PEER SUPPORT PROGRAM IN WABASHA COUNTY RECRUIT A TRAINED PEER SUPPORT FACILITATOR PROMOTE THE PEER SUPPORT PROGRAM IN THE WABASHA AREA MEASURE THE IMPACT OF THE PEER SUPPORT GROUPCOLLABORATIVE PARTNERS: WABASHA COUNTY MENTAL HEALTH ACTION TEAM ZUMBRO VALLEY MENTAL HEALTH HIAWATHA VALLEY MENTAL HEALTH WABASHA COUNTY SOCIAL SERVICES NAMI GUNDERSEN ST. ELIZABETH'S RESOURCES COMMITTED: STAFF TIMEMEDIUM-TERM INDICATOR: BY JUNE 30, 2022, 75 PERCENT OF PEER SUPPORT PARTICIPANTS WILL REPORT APPLYING NEWLY LEARNED COPING SKILLS THAT IMPROVE THEIR ABILITY TO BETTER MANAGE THEIR CHRONIC MENTAL ILLNESS.STRATEGY: STRENGTHEN HEALTHCARE'S ROLE IN IMPROVING MENTAL HEALTHGUNDERSEN ST. ELIZABETH'S IS EXPANDING ITS INTERNAL CAPACITY TO IMPROVE MENTAL HEALTH IN WABASHA COUNTY. GUNDERSEN ST. ELIZABETH'S WILL IMPROVE ITS INTERNAL TRAINING, PROTOCOLS, AND SYSTEMS TO BETTER SCREEN, REACH AND TREAT INDIVIDUALS WITH MENTAL HEALTH ISSUES.AS PART OF THAT EFFORT, GUNDERSEN ST. ELIZABETH'S WILL: ONBOARD A PSYCHIATRIST / PSYCHIATRIC NURSE TEAM; THE TEAM WILL PROVIDE MENTAL HEALTH ASSESSMENTS, MEDICATION MANAGEMENT AND COUNSELING TO PATIENTS WITHIN THE PRIMARY CARE SETTING DEVELOP AND IMPLEMENT A MENTAL HEALTH TRAINING AND EDUCATION PLAN FOCUSED ON PRIMARY CARE, EMERGENCY DEPARTMENT AND HOSPITAL PROVIDERS IMPLEMENT A MULTI-DISCIPLINARY COLLABORATIVE APPROACH TO MENTAL HEALTH CARE WITHIN THE CLINIC WORK WITH EXTERNAL AGENCIES (E.G., HIAWATHA VALLEY MENTAL HEALTH) TO ASSURE APPROPRIATE RESOURCES AND REFERRALSRESOURCES COMMITTED: STAFF TIMEMEDIUM-TERM INDICATORS: BY JUNE 2022, 100 PERCENT OF PRIMARY CARE, EMERGENCY DEPARTMENT, HOSPITAL PROVIDERS AND STAFF WILL HAVE RECEIVED TRAINING IN MENTAL HEALTH SCREENING, MANAGEMENT, AND REFERRAL. BY JUNE 2022, DEPRESSION SCREENING AND REMISSION SYSTEMS/PROTOCOLS USED IN PRIMARY CARE SETTING WILL BE TRACKED, MONITORED, AND REPORTED TO MINNESOTA COMMUNITY MEASURES. SENIOR HEALTH (2019-2022)GOAL: BUILD A DEMENTIA FRIENDLY WABASHA COUNTYLONG-TERM PERFORMANCE INDICATOR(S): BY JUNE 30, 2023, THE NUMBER OF WABASHA COUNTY AGENCIES/ORGANIZATIONS THAT HAVE BECOME 'DEMENTIA FRIENDLY OR OTHERWISE ADDRESSED DEMENTIA WILL INCREASE FROM 0 TO 10.STRATEGY: EQUIP WABASHA COUNTY COMMUNITIES TO BE "DEMENTIA FRIENDLY"DEMENTIA FRIENDS IS AN INTERNATIONAL MOVEMENT THAT IS STRIVING TO CREATE MORE DEMENTIA-FRIENDLY COMMUNITIES BY CHANGING THE WAY PEOPLE THINK, ACT, AND TALK ABOUT DEMENTIA. THE EFFORT FOCUSES ON RAISING AWARENESS, REDUCING STIGMA, AND SUPPORTING RESIDENTS WHO ARE TOUCHED BY DEMENTIA. BY HELPING EVERYONE IN A COMMUNITY UNDERSTAND WHAT DEMENTIA IS AND HOW IT AFFECTS PEOPLE, EACH PERSON CAN MAKE A DIFFERENCE FOR SOMEONE LIVING WITH DEMENTIA. THE SENIOR HEALTH ACTION TEAM WILL: LAUNCH DEMENTIA FRIENDS THROUGHOUT WABASHA COUNTY, INCLUDING THE FACILITATION OF DEMENTIA FRIENDS CHAMPION TRAINING COURSES AND INFORMATION SESSIONS HOST DEMENTIA FRIENDS TRAINING AND INFORMATION SESSIONS IN THE WABASHA AREA TO INCREASE THE COMMUNITY'S ABILITY TO ADDRESS DEMENTIA ESTABLISH "SPARK!" CULTURAL PROGRAM FOR PEOPLE WITH MEMORY LOSS IN PARTNERSHIP WITH INTERESTED ORGANIZATIONS. SPARK! PROGRAMS ARE DESIGNED TO KEEP PARTICIPANTS ACTIVELY ENGAGED IN THEIR COMMUNITIES BY PROVIDING EXPERIENCES THAT STIMULATE CONVERSATIONS, PROVIDE PEER SUPPORT, AND INSPIRE CREATIVITY THROUGH ENGAGEMENT IN MUSEUM EXPERIENCES, WORKSHOPS, AND PROGRAMSMEDIUM-TERM INDICATOR: BY JUNE 30, 2022, AT LEAST 10 AGENCIES REPRESENTING HEALTHCARE, SOCIAL SERVICES, LAW AND LEGAL, FAITH, BUSINESS AND COMMUNITY SECTORS WILL HAVE PARTICIPATED IN DEMENTIA FRIENDS TRAINING. STRATEGY: SUSTAIN CAREGIVERS BY OFFERING INFORMATION, RESOURCES AND SUPPORTINCREASING ACCESS TO RESOURCES AND SOCIAL CONNECTIONS CAN HELP IMPROVE CAREGIVERS' QUALITY OF LIFE. ONE WAY TO DO THIS IS THROUGH MEMORY CAFS. MEMORY CAFS ARE EVIDENCE-BASED SOCIAL GATHERINGS FOR PATIENTS WITH DEMENTIA AND THEIR CAREGIVERS THAT OFFER SOCIAL INTERACTION, RESOURCES, AND SUPPORT.THE SENIOR HEALTH ACTION TEAM WILL: ESTABLISH UP TO THREE MEMORY CAFS THROUGHOUT WABASHA COUNTY THAT PROVIDE ONGOING SOCIAL SUPPORT GATHERINGS FOR INDIVIDUALS LIVING WITH DEMENTIA AND THEIR CARE PARTNERS CONTINUE TO PROMOTE AND OFFER RESOURCES AND PROGRAMMING THAT BENEFIT CAREGIVERSMEDIUM-TERM INDICATORS: BY JUNE 30, 2022, THREE MEMORY CAFS WILL BE OPERATIONAL IN WABASHA COUNTY. BY JUNE 30, 2022, 90 PERCENT OF MEMORY CAF CAREGIVER PARTICIPANTS WILL REPORT BEING SUPPORTED SOCIALLY AND WITH RESOURCES AT THE MEMORY CAF. BY JUNE 30, 2022, 90 PERCENT OF MEMORY CAF CAREGIVER PARTICIPANTS WILL REPORT REDUCED STRESS BECAUSE OF THE MEMORY CAF.STRATEGY: INCREASE DETECTION OF DEMENT PART V, LINE 7A & LINE 10: HTTPS://WWW.GUNDERSENHEALTH.ORG/COMMUNITY-ASSESSMENT SCHEDULE H, PART V, SECTION B, LINE 5: GUNDERSEN ST. ELIZABETH'S HOSPITAL AND CLINICS IS COMMITTED TO ADDRESSING COMMUNITY HEALTH NEEDS COLLABORATIVELY WITH LOCAL PARTNERS. SAINT ELIZABETH'S AND WABASHA COUNTY PUBLIC HEALTH USED THE FOLLOWING METHODS TO GAIN KEY STAKEHOLDER AND COMMUNITY FEEDBACK ON THE STRENGTHS AND CHALLENGES OF BEING A HEALTHY COMMUNITY. THESE METHODS PROVIDED US WITH ADDITIONAL PERSPECTIVES ON HOW TO SELECT AND ADDRESS TOP HEALTH ISSUES FACING OUR COMMUNITIES.INPUT FROM COMMUNITY:A COMMUNITY HEALTH NEEDS ASSESSMENT WAS JOINTLY CONDUCTED BY GUNDERSEN ST. ELIZABETH'S AND WABASHA COUNTY PUBLIC HEALTH DEPARTMENT IN SUMMER 2022. COUNTY DATA AND HEALTH INDICATORS WERE COLLECTED AND REVIEWED BY A CHNA LEADERSHIP TEAM. IN ADDITION, A THOROUGH EVALUATION OF THE PROGRESS UNDERWAY TO ACCOMPLISH THE GOALS AND STRATEGIES OUTLINED IN THE CURRENT COMMUNITY HEALTH IMPROVEMENT PLAN (2019-2022) WAS COMPLETED.FOLLOWING AN EXTENSIVE ANALYSIS OF ALL DATA, TRENDS, AND OTHER ASSESSMENTS CONDUCTED BY AGENCIES AND ORGANIZATIONS SERVING WABASHA COUNTY RESIDENTS, THE LEADERSHIP TEAM SOUGHT ENGAGEMENT FROM KEY STAKEHOLDERS, HEALTH PROVIDERS, COMMUNITY LEADERS AND COUNTY RESIDENTS TO PRIORITIZE WABASHA COUNTY'S TOP TWO HEALTH NEEDS.GUNDERSEN ST. ELIZABETH'S AND WABASHA COUNTY PUBLIC HEALTH ARE COMMITTED TO ADDRESSING COMMUNITY HEALTH NEEDS COLLABORATIVELY WITH LOCAL PARTNERS. GUNDERSEN ST. ELIZABETH'S AND THE WABASHA COUNTY PUBLIC HEALTH DEPARTMENT USED A MASS COMMUNICATION EFFORT TO GAIN AN UNDERSTANDING OF COMMUNITY MEMBERS' THOUGHTS ON THE STRENGTHS AND CHALLENGES OF BEING A HEALTHY COMMUNITY. THIS METHOD PROVIDED US WITH ADDITIONAL PERSPECTIVES ON HOW TO SELECT AND ADDRESS TOP HEALTH ISSUES FACING OUR COMMUNITIES.A CHNA PRIORITY SURVEY WAS PREPARED AND DISTRIBUTED THROUGH MULTIPLE EMAIL DISTRIBUTION LISTS, WEBSITES, AND SOCIAL MEDIA PLATFORMS. RESIDENTS WITHOUT ACCESS TO A COMPUTER OR INTERNET WERE INVITED TO UTILIZE RESOURCES AT THEIR LOCAL LIBRARY OR GUNDERSEN ST. ELIZABETH'S TO COMPLETE THE SURVEY. ORGANIZATIONS SERVING LOW-INCOME AND VULNERABLE POPULATIONS WERE PROVIDED WITH RESOURCES TO ENCOURAGE SURVEY PARTICIPATION AMONG THEIR CLIENTS. PRESS RELEASES, NEWSLETTERS, POSTERS, AND SOCIAL MEDIA POSTS WERE USED TO DRAW ATTENTION TO THE IMPORTANCE OF PUBLIC PARTICIPATION. FOLLOWING THE CLOSE OF THE SURVEY (A THREE-WEEK WINDOW PROVIDED AMPLE OPPORTUNITY FOR SURVEY RESPONSE), CHNA LEADERSHIP TEAM MEMBERS COLLATED AND EVALUATED SURVEY RESPONSE AND RESULTS.THE PRIORITIZATION PROCESS INCLUDED MULTIPLE STEPS: 1. THE CHNA LEADERSHIP TEAM IDENTIFIED THE TOP THREE HEALTH NEEDS IN WABASHA COUNTY BASED ON ITS EVALUATION OF COUNTY DATA, HEALTH INDICATORS, ASSESSMENTS COMPLETED BY OTHER ORGANIZATIONS/AGENCIES, AND CURRENT COMMUNITY HEALTH IMPROVEMENT PLAN PROGRESS.2. A CHNA PRIORITY SURVEY WAS WIDELY DISTRIBUTED TO SEEK COMMUNITY FEEDBACK ON THE IDENTIFICATION OF THE TOP TWO PRIORITIES TO BE ADDRESSED DURING THE NEXT CHNA THREE-YEAR CYCLE.3. THE CHNA LEADERSHIP TEAM REVIEWED THE SURVEY RESULTS AND OFFICIALLY SELECTED THE TOP TWO PRIORITIES FROM ITS FINDINGS4. THE CHNA LEADERSHIP TEAM SHARED THE TEAM'S RECOMMENDATIONS WITH GUNDERSEN ST. ELIZABETH'S AND WABASHA COUNTY PUBLIC HEALTH REPRESENTATIVES FOR APPROVAL AND AFFIRMATION. 5. THE CHNA LEADERSHIP TEAM DELEGATED THE EXISTING SENIOR HEALTH AND MENTAL HEALTH ACTION TEAMS WITH THE RESPONSIBILITY OF DEVELOPING A WABASHA COUNTY COMMUNITY HEALTH IMPROVEMENT PLAN (2023-2025) THAT OUTLINES SPECIFIC GOALS, STRATEGIES, PERFORMANCE INDICATORS, AND EVALUATION PROCESS FOR EACH NEED.THE FOLLOWING HEALTH ISSUES WERE SELECTED AS THE PRIORITIES:NUMBER 1: MENTAL HEALTH NUMBER 2: SENIOR HEALTHTHE CHNA LEADERSHIP TEAM IS FUELED BY A COMMITMENT TO HUMAN DIGNITY, THE COMMON GOOD, JUSTICE AND SOLIDARITY. WE BELIEVE THE CHNA PROCESS MUST BE INFORMED BY DIRECT INPUT FROM PERSONS WHO EXPERIENCE HEALTH DISPARITIES BASED ON INCOME AND/OR RACE AND ETHNICITY. WITH THAT IN MIND, THE CHNA PRIORITY SURVEY INCLUDED POINTED QUESTIONS ABOUT NEEDS AND SATISFACTION LEVELS OF THE LOW-INCOME POPULATION. AS PART OF 9 2019-2022 COMMUNITY HEALTH NEEDS ASSESSMENT 2023-2025 THE PROCESS TO SELECT THE HEALTH PRIORITIES, STRONG CONSIDERATION WAS GIVEN TO HOW INDIVIDUALS WHO ARE MORE VULNERABLE ARE IMPACTED BY THE HEALTH ISSUES.SCHEDULE H, PART V, SECTION B, LINE 6B:GUNDERSEN ST. ELIZABETH'S CONDUCTED THE CHNA AND IMPROVEMENT PLAN DEVELOPMENT JOINTLY WITH WABASHA COUNTY PUBLIC HEALTH DEPARTMENT. IN ADDITION, OTHER AGENCIES, ORGANIZATIONS, AND CITIZENS ACTIVELY PARTICIPATED IN THE DEVELOPMENT OF IMPROVEMENT STRATEGIES FOR THE PRIORITIES SELECTED.SCHEDULE H, PART V, SECTION B, LINE 11:THE CURRENT THREE -YEAR CHNA/COMMUNITY HEALTH IMPROVEMENT PLAN CYCLE (2023-2025) WILL BE COMPLETED ON DECEMBER 31, 2025.MENTAL HEALTH (2023-2025)GOAL: IMPROVE ACCESS TO SERVICES AND MANAGEMENT OF SUBSTANCE USE AND MENTAL HEALTH DISORDERS FOR RESIDENTS IN NEED WITHIN WABASHA COUNTY. IMPACT PERFORMANCE INDICATOR: THE 2026 WABASHA COUNTY HEALTH RANKINGS WILL REPORT A DECLINE (TO 10%) OF ADULTS IN WABASHA COUNTY THAT REPORT EXPERIENCING POOR MENTAL HEALTH FOR 14 OR MORE OF THE LAST 30 DAYS. BASELINE: COUNTY HEALTH RANKINGS 2022 - 13%STRATEGY 1: IDENTIFY SUBSTANCE USE AND MENTAL HEALTH SERVICE AND PROVIDER GAPS IN WABASHA COUNTY. ANALYZE PREVALENCE, UTILIZATION, OUT-REFERRAL, AND NEEDS ASSESSMENT DATA FROM ACROSS WABASHA COUNTY TO BETTER UNDERSTAND WHAT SUBSTANCE USE AND MENTAL HEALTH SERVICES AND PROVIDERS ARE NEEDED TO IMPROVE LOCAL ACCESS TO CARE.STRATEGY 2: IMPROVE THE INTEGRATION AND COORDINATION OF CARE AMONG PROVIDERS OF PATIENTS EXPERIENCING PHYSICAL AND MENTAL HEALTH DISORDERS. DEVELOP AN UNDERSTANDING OF LOCAL CARE PATHWAYS AND STRUCTURES THAT PROMOTE ENHANCED COMMUNICATION AND COLLABORATION AMONG ALL HEALTHCARE PROVIDERS IN WABASHA COUNTY. ESTABLISH A SINGLE POINT OF CONTACT FOR ALL MENTAL HEALTH/SUBSTANCE USE RESOURCES AND REFERRAL OPTIONS IN WABASHA COUNTY.STRATEGY 3: OFFER TRAINING TO PROVIDERS AND EDUCATION TO REFERRAL SOURCES AND COMMUNITY MEMBERS ABOUT CO-OCCURRING DISORDERS AND HOW THEY CAN BE IDENTIFIED, TREATED, AND MANAGED. ESTABLISH A PLAN AND TIMELINE FOR TRAINING COMMUNITIES ABOUT CO-OCCURRING DISORDERS, FOLLOWED BY THE DEVELOPMENT OF A COMMUNITY CAMPAIGN THAT RAISES AWARENESS AND ACCESS TO SERVICES.COLLABORATIVE PARTNERS: WABASHA COUNTY PUBLIC HEALTH, WABASHA COUNTY SOCIAL SERVICES HIAWATHA VALLEY MENTAL HEALTH, AND ZUMBRO VALLEY MENTAL HEALTH.SENIOR HEALTH (2023-2025)GOAL: PROVIDE AGE-FRIENDLY RESOURCES ACCESSIBLE TO OLDER WABASHA COUNTY RESIDENTS, ENABLING THEM TO HAVE REWARDING, PRODUCTIVE, AND SAFE LIVES.IMPACT PERFORMANCE INDICATOR(S): BY 2026, THE PROPORTION OF OLDER PEOPLE IN WABASHA COUNTY WHO SELF-RATE THEIR OVERALL QUALITY OF LIFE AS 'VERY GOOD (5) OR 'GOOD (4)' ON A SCALE RANGING FROM 'VERY POOR (1)' TO 'VERY GOOD (5)' INCREASES BY 10% FROM BASELINE THAT IS COLLECTED THROUGH AN AGE-FRIENDLY ASSESSMENT CONDUCTED IN 2023.STRATEGY 1: BECOME A MEMBER OF AARP'S NETWORK OF AGE-FRIENDLY STATES AND COMMUNITIES AND COMPLETE ALL REQUIREMENTS OF THE AGE-FRIENDLY MEMBERSHIP CYCLE. THE AARP NETWORK OFAGE-FRIENDLY STATES AND COMMUNITIES SERVES AS A CATALYST TO EDUCATE LOCAL LEADERS (ELECTED OFFICIALS, ENGAGED RESIDENTS, SENIOR SERVICE PROVIDERS) AND ENCOURAGE THEM TO IMPLEMENT THE TYPES OF CHANGES THAT MAKE COMMUNITIES MORE LIVABLE FOR PEOPLE OF ALL AGES, ESPECIALLY OLDER ADULTS. THE NETWORK PROVIDES INTERESTED ENTITIES WITH THE RESOURCES TO BECOME MORE AGE-FRIENDLY BY TAPPING INTO NATIONAL AND GLOBAL RESEARCH, PLANNING MODELS AND BEST PRACTICES. MEMBERSHIP MEANS THAT LEADERS HAVE MADE A COMMITMENT TO ACTIVELY WORK WITH RESIDENTS AND LOCAL ADVOCATES TO MAKE THEIR COMMUNITY AN AGE-FRIENDLY PLACE TO LIVE.STRATEGY 2: STRENGTHEN AND GROW WABASHA COUNTY REPRESENTATION ON THE SENIOR HEALTH ACTION TEAM TO INCLUDE ACTIVE PARTICIPATION FROM LAKE CITY, PLAINVIEW, AND OTHER SMALLER COMMUNITIES WITHIN WABASHA COUNTY. TO ENSURE ENGAGEMENT ACROSS WABASHA COUNTY, TEAM MEMBERS WILL OUTLINE A PLAN TO RECRUIT SENIOR HEALTH PROVIDERS, ADVOCATES AND OTHER KEY STAKEHOLDERS FROM COMMUNITIES CURRENTLY NOT REPRESENTED ON THE SENIOR HEALTH ACTION TEAM. OBJECTIVES WILL INCLUDE: GATHERING RECOMMENDATIONS OF POTENTIAL RECRUITS FROM CURRENT MEMBERS. DEVELOPING A METHOD FOR INFORMING AND EDUCATING RECRUITS OF THE MISSION AND WORK PLAN OF THE TEAM.SUCCESSFULLY ONBOARDING AT LEAST TWO NEW MEMBERS. SCHEDULE H, PART V, SECTION B, LINE 5 - CONTINUED: STRATEGY 3: CONTINUE TO GROW AND EXPAND ACCESS AND PARTICIPATION IN CONNECTIONS CAFE AND CAREGIVER SUPPORT ACROSS WABASHA COUNTY. THE FOLLOWING OBJECTIVES WILL BE IMPLEMENTED BY THE SENIOR ACTION TEAM: EXPAND MARKETING OF EXISTING WABASHA CONNECTIONS CAFE AND CAREGIVER SUPPORT TO SENIOR PROVIDERS AND OTHER TARGET AUDIENCES. DEVELOP A SCHEDULE OF MONTHLY ACTIVITIES/MEETINGS THAT CAN BE PROMOTED TO INCREASE ATTENDANCE. EXPLORE OPPORTUNITIES TO ESTABLISH A CONNECTIONS CAFE IN ANOTHER WABASHA COUNTY COMMUNITY.STRATEGY 4: CONTINUE TO EXPAND UTILIZATION OF MEMORY KITS AS A WAY OF EFFECTIVELY INTERACTING WITH PEOPLE IN ALL STAGES OF DEMENTIA. THE FOLLOWING OBJECTIVES WILL BE IMPLEMENTED BY THE SENIOR ACTION TEAM: DEVELOP VIDEO PROMOTIONS TO EDUCATE THE PUBLIC ON THE CONTENTS OF KITS AND HOW TO USE THEM. SET UP MEETINGS WITH WABASHA COUNTY CONGREGATE LIVING, SENIOR COMMUNITIES, AND ASSISTED LIVING FACILITIES TO INTRODUCE KITS TO STAFF. DEVELOP A "SHARE" PROGRAM WITH OTHER WABASHA COUNTY LIBRARIES TO BROADEN THE REACH OF KITS. SET UP EDUCATIONAL PRESENTATIONS WITH KEY COMMUNITY GROUPS.STRATEGY 5: EXPLORE AND EVALUATE STATE AND REGIONAL RESOURCES (DEMENTIA TOOL KITS, VIRTUAL EDUCATIONAL OPTIONS) THAT BETTER EQUIP WABASHA COUNTY COMMUNITIES TO BE DEMENTIA FRIENDLY. IF EVALUATION OF THESE RESOURCES SHOWS POTENTIAL FOR SUCCESS, IMPLEMENT IDENTIFIED RESOURCES TO IMPROVE ACCESS AND AWARENESS OF THESE RESOURCES TO COUNTY RESIDENTS. THE FOLLOWING OBJECTIVES WILL BE IMPLEMENTED BY THE SENIOR ACTION TEAM: ATTEND TRAINING AND EDUCATIONAL PROGRAMS TO LEARN MORE ABOUT AVAILABLE TOOL KITS AND RESOURCES FOR TARGETING WABASHA COUNTY SCHOOL DISTRICT STUDENTS AND STAFF. EXPLORE CREATIVE WAYS TO OFFER VIRTUAL PROGRAMMING (AVAILABLE THROUGH JUNIPER AND OTHER AGENCIES) IN A GROUP SETTING.COLLABORATIVE PARTNERS: WABASHA COUNTY PUBLIC HEALTH, WABASHA COUNTY SHIP, WABASHA PUBLIC LIBRARY, ELDER NETWORK, ACE BRAIN FITNESS, SOUTHEASTERN MINNESOTA AREA AGENCY ON AGING, CATHOLIC CHARITIES, THREE RIVERS COMMUNITY ACTION, CITY OF WABASHA, CITY OF KELLOGG, AARP, GREAT RIVER HOMES, GRANDPAD, AND SENIOR CITIZENS 2 1 - SAINT ELIZABETH NURSING HOME 1200 GRANT BLVD WEST WABASHA MN 55981 NURSING HOME 2 - SAINT ELIZABETH ASSISTED LIVING APTS 1200 GRANT BLVD WEST WABASHA MN 55981 RESIDENTAL HOUSING WITH SERVICES PART I, LINE 3C: PATIENTS WITH DEMONSTRATED FINANCIAL NEEDS WITH INCOME GREATER THAN 400% OF THE FPL MAY BE ELIGIBLE FOR CONSIDERATION UNDER A "MEANS TEST" FOR SOME DISCOUNT OF THEIR CHARGES FOR SERVICES FROM THE ORGANIZATION BASED ON A SUBSTANTIVE ASSESSMENT OF THEIR ABILITY TO PAY. THIS TEST CAPS TOTAL BALANCE DUE AT 25% OF TOTAL INCOME. A PATIENT ELIGIBLE FOR THE "MEANS TEST" DISCOUNT WILL NOT BE CHARGED MORE THAN THE CALCULATED AGB CHARGES. PART I, LINE 7: THE COST OF PROVIDING CHARITY CARE, MEANS-TESTED GOVERNMENT PROGRAMS, AND OTHER COMMUNITY BENEFIT PROGRAMS IS ESTIMATED USING INTERNAL COST DATA. THE ORGANIZATION USES A COST ACCOUNTING SYSTEM THAT ADDRESSES ALL PATIENT SEGMENTS (FOR EXAMPLE, INPATIENT, OUTPATIENT, EMERGENCY ROOM, PRIVATE INSURANCE, MEDICAID, MEDICARE, UNINSURED, OR SELF PAY). THE BEST AVAILABLE DATA WAS USED TO CALCULATE THE AMOUNTS REPORTED IN THE TABLE. FOR THE INFORMATION IN THE TABLE, A COST-TO-CHARGE RATIO WAS CALCULATED AND APPLIED. PART II, COMMUNITY BUILDING ACTIVITIES: SAINT ELIZABETH'S MEDICAL CENTER SUPPORTS A YOUTH READING PROGRAM. ACCORDING TO THE COUNTY HEALTH RANKINGS SITE, BETTER EDUCATED INDIVIDUALS LIVE LONGER, HEALTHIER LIVES THAN THOSE WITH LESS EDUCATION, AND THEIR CHILDREN ARE MORE LIKELY TO THRIVE. THIS IS TRUE EVEN WHEN FACTORS LIKE INCOME ARE TAKEN INTO ACCOUNT. SAINT ELIZABETH'S LEADERS PARTICIPATE IN MANY LOCAL ORGANIZATIONS AND COLLABORATIVE EFFORTS THAT HELP IMPROVE THE COMMUNITY. THESE INCLUDE THE LOCAL CHAMBER OF COMMERCE AND THE WABASHA AREA COMMUNITY RESOURCE CENTER. BY WORKING TOGETHER WITH OTHER ORGANIZATIONS IN THE COMMUNITY, WE EXPECT TO HAVE A GREATER IMPACT ON HEALTH. ACCORDING TO THE COUNTY HEALTH RANKINGS SITE, WITH A SHARED VISION AND COMMITMENT TO IMPROVED HEALTH, WORKING TOGETHER CAN YIELD BETTER RESULTS THAN WORKING ALONE. SAINT ELIZABETH MEDICAL CENTER PROVIDED JOB SHADOWING EXPERIENCES TO STUDENTS. ASSURING THAT RURAL COMMUNITIES HAVE A VIBRANT HEALTH CARE WORKFORCE IN THE FUTURE WILL HELP INCREASE ACCESS TO QUALITY OF CARE IN THE FUTURE.SAINT ELIZABETH MEDICAL CENTER ALSO CONDUCTS A COMMUNITY SHARPS PROGRAM. BY SAFELY REMOVING SHARPS FROM THE ENVIRONMENT, WE MAKE THE COMMUNITY SAFER IN TERMS OF INJURY AND INFECTION. PART III, LINE 2: AFTER SATISFACTION OF AMOUNTS DUE FROM INSURANCE AND REASONABLE EFFORTS TO COLLECT FROM THE PATIENT HAVE BEEN EXHAUSTED, THE CORPORATION FOLLOWS ESTABLISHED GUIDELINES FOR PLACING CERTAIN PAST-DUE PATIENT BALANCES WITHIN COLLECTION AGENCIES, SUBJECT TO THE TERMS OF CERTAIN RESTRICTIONS ON COLLECTION EFFORTS AS DETERMINED BY GUNDERSEN HEALTH SYSTEM. ACCOUNTS RECEIVABLE ARE WRITTEN OFF AFTER COLLECTION EFFORTS HAVE BEEN FOLLOWED IN ACCORDANCE WITH THE CORPORATION'S POLICIES. AFTER APPLYING THE COST-TO-CHARGE RATIO, THE SHARE OF THE BAD DEBT EXPENSE WAS $0 IN 2022. PART III, LINE 3: THE ORGANIZATION HAS A VERY ROBUST FINANCIAL ASSISTANCE PROGRAM; THEREFORE, NO ESTIMATE IS MADE FOR BAD DEBT ATTRIBUTED TO FINANCIAL ASSISTANCE ELIGIBLE PATIENTS. PART III, LINE 4: THE ORGANIZATION IS PART OF THE GUNDERSEN HEALTH SYSTEM'S CONSOLIDATED AUDIT IN WHICH THE FOOTNOTE THAT DISCUSSES THE BAD DEBT (IMPLICIT PRICE CONCESSIONS) EXPENSE IS LOCATED IN FOOTNOTE #2, PAGES 10, 11, 18 AND 19. PART III, LINE 8: A COST TO CHARGE RATIO IS APPLIED TO THE ORGANIZATION'S MEDICARE EXPENSE TO DETERMINE THE MEDICARE ALLOWABLE COSTS REPORTED IN THE ORGANIZATION'S MEDICARE COST REPORT. ST. ELIZABETH'S HOSPITAL OF WABASHA, INC. FOLLOWS THE CATHOLIC HEALTH ASSOCIATION (CHA) GUIDELINES FOR DETERMINING COMMUNITY BENEFIT. CHA COMMUNITY BENEFIT REPORTING GUIDELINES SUGGEST THAT MEDICARE SHORTFALL IS NOT TREATED AS COMMUNITY BENEFIT. PART III, LINE 9B: THE ORGANIZATION FOLLOWS GUNDERSEN HEALTH SYSTEM'S GUIDELINES FOR COLLECTION PRACTICES RELATED TO PATIENTS QUALIFYING FOR CHARITY OR FINANCIAL ASSISTANCE. A PATIENT CAN APPLY FOR CHARITY OR FINANCIAL ASSISTANCE AT ANY TIME DURING THE COLLECTION CYCLE. ONCE QUALIFYING DOCUMENTATION IS RECEIVED THE PATIENT'S ACCOUNT IS ADJUSTED. PATIENT ACCOUNTS FOR THE QUALIFYING PATIENT IN THE PREVIOUS SIX MONTHS MAY ALSO BE CONSIDERED FOR CHARITY OR FINANCIAL ASSISTANCE. ONCE A PATIENT QUALIFIES FOR CHARITY OR FINANCIAL ASSISTANCE, ALL COLLECTION ACTIVITY IS SUSPENDED. PART VI, LINE 2: IN ADDITION TO THE CHNA REPORTED IN PART V, SECTION B, SAINT ELIZABETH'S MEDICAL CENTER USES BOTH HOSPITAL DATA AND RELIABLE, THIRD PARTY REPORTS, INCLUDING DATA FROM GOVERNMENT SOURCES, TO ASSESS THE HEALTH NEEDS OF THE COMMUNITY IT SERVES. THESE REPORTS PROVIDE INFORMATION ABOUT KEY HEALTH, SOCIOECONOMIC, AND DEMOGRAPHIC INDICATORS THAT POINT TO AREAS OF NEED. SAINT ELIZABETH'S MEDICAL CENTER UTILIZES THIS INFORMATION TO DETERMINE DEVELOP PROGRAMS AND SERVICES TO BE PROVIDED FOR THE COMMUNITY. THESE NEEDS AND INITIATIVES ARE PRESENTED TO SENIOR LEADERSHIP AND BOARD MEMBERS TO ENSURE THE FINDINGS ARE CONSIDERED IN DEVELOPING THE ORGANIZATION'S STRATEGY, POLICY DEVELOPMENT, AND INTERNAL FINANCIAL AND OPERATIONAL DECISIONS. PART VI, LINE 3: THE ORGANIZATION GOES TO GREAT LENGTHS IN ORDER TO INFORM AND EDUCATE PATIENTS/PERSONS WHO MAY BE BILLED FOR PATIENT CARE ABOUT THEIR ELIGIBILITY FOR ASSISTANCE UNDER FEDERAL, STATE, OR LOCAL GOVERNMENT PROGRAMS AND UNDER THE ORGANIZATION'S CHARITY CARE POLICY. THE CHARITY CARE POLICY AND APPLICATION IS POSTED ON THE ORGANIZATION'S WEBSITE. ADMISSIONS, SOCIAL SERVICES, AND OTHER KEY AREAS CONTAIN SUMMARY INFORMATION OF THE CHARITY CARE POLICY. AS PART OF THE INTAKE/DISCHARGE PROCESS, PATIENTS ARE PROVIDED WITH A COPY OF THE POLICY AND OTHER IMPORTANT INFORMATION FOR FINANCIAL ASSISTANCE. IF DURING THE COURSE OF THE PATIENT REGISTRATION PROCESS, CARE ENCOUNTER, TREATMENT, OR UPON DISCHARGE IT BECOMES EVIDENT THAT A PATIENT MAY NEED FINANCIAL ASSISTANCE; THE PATIENT SHALL BE REFERRED TO THE ORGANIZATION'S COMMUNITY CARE PROGRAM. PATIENTS MAY BE IDENTIFIED AS NEEDING FINANCIAL ASSISTANCE AT ANY TIME DURING THE COURSE OF AN ENCOUNTER. A REFERRAL FOR CONSIDERATION OF COMMUNITY CARE FINANCIAL ASSISTANCE CAN BE INITIATED BY ANY MEMBER OF THE HOSPITAL'S WORKFORCE, INCLUDING MEDICAL STAFF MEMBERS, WHO BECOME AWARE OF THE PATIENT'S POTENTIAL NEED FOR COMMUNITY CARE FINANCIAL ASSISTANCE. THE COMMUNITY CARE POLICY WAS ALSO TRANSLATED INTO DIALECTS PREVALENT IN THE COMMUNITY IN ORDER TO REACH OUT TO THOSE THAT MAY SPEAK ANOTHER LANGUAGE (SPANISH). PATIENT REGISTRATION STAFF AND FINANCIAL COUNSELORS ARE PROVIDED WITH SCRIPTS TO FOLLOW WHEN INTERACTING WITH PATIENTS. AS PART OF THE CHARITY CARE PROCESS, PATIENTS MUST REGISTER WITH THE COUNTY PUBLIC ASSISTANCE TO SEE IF THEY MAY QUALIFY UNDER ANY OTHER FEDERAL OR STATE PROGRAMS. PART VI, LINE 4: SAINT ELIZABETH'S MEDICAL CENTER PRIMARILY SERVES THE RESIDENTS OF WABASHA COUNTY, MINNESOTA, AND THE SURROUNDING COUNTIES IN A RURAL AREA OF EASTERN MINNESOTA AND WESTERN WISCONSIN. THE POPULATION OF WABASHA COUNTY IS APPROXIMATELY 21,000, WITH 7% OF RESIDENTS LIVING AT OR BELOW THE FEDERAL POVERTY THRESHOLD. THE MEDIAN HOUSEHOLD INCOME IS APPROXIMATELY $62,000. APPROXIMATELY 5% OF THE INDIVIDUALS LIVING IN THE COUNTY ARE UNINSURED AND 12.7% RECEIVE MEDICAID. WABASHA COUNTY IS A DESIGNATED PRIMARY CARE SHORTAGE AREA. THERE IS ONE HOSPITAL (SAINT ELIZABETH'S MEDICAL CENTER) IN WABASHA COUNTY. PART VI, LINE 5: THE ORGANIZATION STRIVES TO FURTHER ITS EXEMPT PURPOSES BY THE FOLLOWING:-THE ORGANIZATION'S GOVERNING BOARD CONSISTS PRIMARILY OF PERSONS WHO RESIDE WITHIN THE PRIMARY SERVICE AREA WHO ARE NOT EMPLOYEES OF THE ORGANIZATION.-AS MENTIONED, THE ORGANIZATION PROVIDES SEVERAL SERVICES WHICH ARE NOT OTHERWISE AVAILABLE BEING IN A RURAL SETTING.-BASED ON THE ORGANIZATION'S MISSION, EMERGENCY ROOMS ARE MADE AVAILABLE TO ALL PATIENTS REGARDLESS OF THE ABILITY TO PAY.-THE ORGANIZATION ALSO PARTICIPATES IN THE EDUCATION AND TRAINING OF HEALTHCARE PROFESSIONALS THROUGH INTERNSHIP PROGRAMS.-THE HOSPITAL PARTICIPATES IN GOVERNMENT-SPONSORED HEALTH PROGRAMS (MEDICARE, MEDICAID, CHAMPUS, TRICARE).-THE HOSPITAL OFFERS VOLUNTEER OPPORTUNITIES TO THE COMMUNITY OR EVIDENCE OF THE ORGANIZATION'S RESPONSIVENESS TO THE COMMUNITY, INCLUDING OPPORTUNITIES FOR COMMUNITY INVOLVEMENT IN GOVERNANCE AND ADVISORY GROUPS. EXAMPLES OF PROGRAMS THAT WERE ESTABLISHED IN THE TAX YEAR THAT RESPONDED TO COMMUNITY NEEDS INCLUDE:-THE FACILITY STRIVES TO BE A LOW-COST/LOW-CHARGE FACILITY.-ADVOCATE COMMUNITY WIDE, STATE OR NATIONAL EFFORTS TO IMPROVE HEALTH OF THE POPULATION AND INCREASE ACCESS. - PARTNERSHIPS WITH OTHERS IN THE COMMUNITY (INCLUDING PUBLIC HEALTH DEPARTMENTS) TO IMPROVE COMMUNITY HEALTH AND WELL-BEING.- THE ROLE OF THE EMERGENCY DEPARTMENT AND URGENT CARE UNITS IN SERVING ALL PERSONS REGARDLESS OF ABILITY TO PAY.- AVAILABILITY OF FINANCIAL ASSISTANCE AND SLIDING SCALE DISCOUNTS AND CHANGES TO FINANCIAL ASSISTANCE OR COLLECTION POLICIES THAT WOULD BE VIEWED AS CONSTRUCTIVE.- THE ORGANIZATION IS A SOLE COMMUNITY HOSPITAL.- COMMUNITY MEMBERS UTILIZE THE HOSPITAL AS A VEHICLE TO CONNECT WITH AND CONTRIBUTE TO INDIVIDUALS AND THE OVERALL COMMUNITY THROUGH PHILANTHROPY AND VOLUNTEERING.- PROGRAMS ARE HAVING AN IMPACT ON COMMUNITY HEALTH ESPECIALLY PREVENTION ACTIVITIES, EFFORTS TO IMPROVE HEALTH AND INCREASE ACCESS TO HEALTH CARE SERVICES AND REDUCING HEALTH CARE COSTS. BEYOND INPATIENT HOSPITALIZATIONS, WE PROVIDE LOCAL ACCESS TO DIALYSIS, DIAGNOSTICS, EMERGENCY SERVICES AND URGENT CARE, SURGICAL SERVICES, EXTENDED CARE, LABORATORY AND RADIOLOGY SERVICES, REHAB SERVICE, PRIMARY CARE, SPECIALTY MEDICINE, SLEEP ASSESSMENT SERVICES, RETAIL PHARMACY AND RESPIRATORY THERAPY SERVICES. PART VI, LINE 6: SAINT ELIZABETH'S HOSPITAL OF WABASHA, INC IS AFFILIATED WITH GUNDERSEN LUTHERAN HEALTH SYSTEM. GUNDERSEN LUTHERAN HEALTH SYSTEM IS AN INTEGRATED HEALTH CARE SYSTEM THAT PROVIDES COMPREHENSIVE MEDICAL CARE TO PATIENTS PRIMARILY IN WISCONSIN, AS WELL AS IN IOWA AND MINNESOTA, BY OPERATING HOSPITALS, CLINICS, HEALTH PLANS, LONG-TERM CARE FACILITIES, AMBULANCE SERVICES, A FOUNDATION, AND AN ENERGY-PRODUCING COMPANY, IN ADDITION TO PROVIDING MEDICAL AND HEALTH/WELLNESS EDUCATION AND COMMUNITY OUTREACH, AND CONDUCTING MEDICAL EDUCATION AND CLINICALLY BASED RESEARCH. AS PART OF ITS OVERALL STRATEGY, THE SYSTEM HAS AFFILIATED WITH SEVERAL CRITICAL ACCESS HOSPITALS (CAHS) THAT ENABLE HIGHLY TRAINED PHYSICIANS TO PROVIDE COMPREHENSIVE INPATIENT, OUTPATIENT, AND CLINICAL CARE SERVICES TO PATIENTS IN THEIR COMMUNITIES. PART VI, LINE 7, REPORTS FILED WITH STATES MN X 1 1 X X X X 0 1 0 0 0 0 0 0 0 DENNIS SPANO PHYSICIAN 0 535199 0 0 0 5134 0 44225 0 13910 0 598468 0 0 RUTH TIFFAULT PHYSICIAN 0 417633 0 0 0 3647 0 42772 0 21494 0 485546 0 0 PHILLIP SCHWEND SURGEON 0 375801 0 0 0 85 0 43237 0 15947 0 435070 0 0 ANDREA L HAUSER ADMINISTRATOR DIRECTOR 0 240231 0 0 0 3882 0 33786 0 17246 0 295145 0 0 AMANDA J STERRY APRN 267991 0 0 0 91 0 10720 0 0 0 278802 0 0 0 MARK SWENSON CRNA 219649 0 0 0 194 0 9008 0 5544 0 234395 0 0 0 JOHN WOLFE FINANCE ADMINISTRATOR 0 169012 0 5200 0 6003 0 25109 0 14961 0 220285 0 0 JIM ROOT ADMINISTRATOR 0 184729 0 100 0 2256 0 27167 0 4028 0 218280 0 0 KURT L HENN MANAGER, PHARM, & PROV LIASION 168903 0 0 0 33 0 6855 0 2464 0 178255 0 0 0 KIMBERLY D WOLTER DIRECTOR, NURSING 151320 0 0 0 114 0 6199 0 3660 0 161293 0 0 0 PART I, LINE 1A GROSS-UP PAYMENTS RELATED TO EMPLOYEE RECOGNITION, FOR JIM ROOT, JOHN WOLFE, PHILLIP SCHWEND, RUTH TIFFAULT, DENNIS SPANO, AMANDA STERRY, MARK SWENSON, KURT HENN, KIMBERLY WOLTER, KRISTI PETERSON, ANDREA HAUSER, PAUL FISCH, KIMBERLY BESELER, LLOYD HAAS, INCLUDED IN TAXABLE COMPENSATION PART I, LINE 3 A RELATED ORGANIZATION OF THE FILING ORGANIZATION USES ONE OR MORE OF THE FOLLOWING TO ESTABLISH THE COMPENSATION OF THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL: -COMPENSATION COMMITTEE -INDEPENDENT COMPENSATION CONSULTANT -COMPENSATION SURVEY OR STUDY, AND -APPROVAL BY THE BOARD OR COMPENSATION COMMITTEE PLEASE REFER TO THE FORM 990, PART VI, LINE 15A DISCLOSURE IN SCHEDULE O FOR ADDITIONAL DETAILS ON HOW COMPENSATION OF THE ORGANIZATION'S TOP MANAGEMENT OFFICIAL IS ESTABLISHED. PART I, LINE 4B ELIGIBLE EXECUTIVES PARTICIPATE IN A PROGRAM THAT PROVIDES FOR SUPPLEMENTAL RETIREMENT BENEFITS. THE PAYMENT OF BENEFITS UNDER THE PROGRAM, IF ANY, IS ENTIRELY DEPENDENT UPON THE FACTS AND CIRCUMSTANCES UNDER WHICH THE EXECUTIVE TERMINATES EMPLOYMENT WITH THE ORGANIZATION. BENEFITS UNDER THE PROGRAM ARE UNFUNDED AND NON-VESTED. DUE TO THE SUBSTANTIAL RISK OF FORFEITURE PROVISION, THERE IS NO GUARANTEE THAT THESE EXECUTIVES WILL EVER RECEIVE ANY BENEFIT UNDER THE PROGRAM. ANY AMOUNT ULTIMATELY PAID UNDER THE PROGRAM TO THE EXECUTIVE IS REPORTED AS COMPENSATION ON FORM 990. SCHEDULE J, PART II, COLUMN B. NO INDIVIDUALS RECEIVED CURRENT YEAR DISTRIBUTIONS. TRACY HENN FAMILY MEMBER TO KEY EMPLOYEE - KURT L. HENN 147153 EMPLOYEE OF HOSPITAL 0 FORM 990, PART VI, SECTION A, LINE 4 GUNDERSEN AND BELLIN HEALTH SYSTEMS, INC. (BELLIN), EACH A WISCONSIN NONPROFIT, NON-STOCK CORPORATION, ENTERED INTO A COMBINATION AGREEMENT DATED JULY 29, 2022 (THE AGREEMENT), TO ALIGN THEIR RESPECTIVE OPERATIONS AND TO FORM A SINGLE NONPROFIT HEALTH SYSTEM THROUGH THE CREATION OF BELLIN GUNDERSEN HEALTH SYSTEM, INC., A WISCONSIN NONPROFIT, NON-STOCK CORPORATION (BELLIN GUNDERSEN). ON DECEMBER 1, 2022, UPON CONSUMMATION OF THE ALIGNMENT OF THE TWO SYSTEMS (THE AFFILIATION), BELLIN GUNDERSEN BECAME THE SOLE CORPORATE MEMBER OF BOTH BELLIN AND GUNDERSEN. BELLIN AND GUNDERSEN AND THEIR RESPECTIVE AFFILIATES ARE EXPECTED TO MAINTAIN THEIR RESPECTIVE CORPORATE EXISTENCE. IN DECEMBER 2022, THE BYLAWS OF GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. WERE AMENDED AND RESTATED TO UPDATE THE SOLE CORPORATE MEMBER TO BELLIN GUNDERSEN HEALTH SYSTEM, INC. THE BYLAWS WERE ALSO UPDATED TO SPECIFY THE POWERS RETAINED BY GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. THE CHIEF EXECUTIVE OFFICER OF BELLIN GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. RETAINS AUTHORITY TO APPROVE ANY SIGNIFICANT CHANGES TO THE CORPORATION. SUBJECT TO THE RESERVED POWERS SPECIFIED IN THE BYLAWS, THE AFFAIRS OF THE CORPORATION SHALL BE MANAGED BY ITS BOARD OF TRUSTEES. FORM 990, PART VI, SECTION A, LINE 6 SAINT ELIZABETH'S HOSPITAL OF WABASHA, INC. HAS A SINGLE CORPORATE MEMBER, GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. FORM 990, PART VI, SECTION A, LINE 7A SAINT ELIZABETH'S HOSPITAL OF WABASHA, INC HAS A SINGLE CORPORATE MEMBER, GUNDERSEN LUTHERAN HEALTH SYSTEM, INC., WHO CAN ELECT MEMBERS TO THE GOVERNING BODY OF SAINT ELIZABETH'S HOSPITAL OF WABASHA, INC. FORM 990, PART VI, SECTION A, LINE 7B ALL DECISIONS THAT HAVE A MATERIAL IMPACT TO SAINT ELIZABETH'S HOSPITAL OF WABASHA, INC., FINANCIAL INFORMATION, OR CORPORATION ARE SUBJECT TO APPROVAL BY ITS SOLE CORPORATE MEMBER, GUNDERSEN LUTHERAN HEALTH SYSTEM, INC. FORM 990, PART VI, SECTION B, LINE 11B THE FORM 990 WILL BE AVAILABLE FOR ALL BOARD MEMBERS ONCE REVIEWED BY THE CFO AND 990 IS APPROVED AND FILED. FORM 990, PART VI, SECTION B, LINE 12C GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES MONITORS CONFLICTS ON BEHALF OF ST. ELIZABETH'S HOSPITAL OF WABASHA INC. ON AN ANNUAL BASIS BY REVIEWING DISCLOSURES ON COMPLETED CONFLICT OF INTEREST STATEMENTS. THE CONFLICT OF INTEREST REVIEW PANEL MEETS TO REVIEW ALL DISCLOSURES AND DETERMINE AN APPROPRIATE RESOLUTION TO BE ISSUED. IF A BOARD MEMBER WERE TO HAVE A RELATIONSHIP WITH ANOTHER COMPANY, THEY WOULD BE INSTRUCTED TO NOT MAKE DECISIONS WITH RESPECT TO PURCHASING PRODUCTS OR SERVICES FROM THAT COMPANY OR SUPPLIERS OR POTENTIAL SUPPLIERS OF THAT COMPANY WHILE SERVING ON THE BOARD. THEY MAY PARTICIPATE IN DISCUSSIONS RELATED TO SUCH PURCHASES, BUT THEY MUST DISCLOSE THEIR RELATIONSHIP DURING THESE DISCUSSIONS. FORM 990, PART VI, SECTION B, LINE 15 ALL PERSONNEL SERVICES FOR ST. ELIZABETH'S MEDICAL CENTER, INC. ARE PERFORMED BY EMPLOYEES OF GUNDERSEN LUTHERAN ADMINISTRATIVE SERVICES, INC. THE COMPENSATION OF THE CEO IS DETERMINED ANNUALLY BY A COMMITTEE MADE UP OF THE COMMUNITY MEMBERS OF THE BOARD OF TRUSTEES. THEIR DETERMINATION IS MADE AFTER A REVIEW OF MARKET DATA OBTAINED FROM SEVERAL ORGANIZATIONS AND CEO PERFORMANCE. MEETING MINUTES ARE TAKEN AND KEPT AT THE MEETINGS WHERE SUCH DISCUSSIONS TAKE PLACE. RECOMMENDATIONS FOR COMPENSATION FOR THE ORGANIZATIONS' KEY MANAGEMENT EMPLOYEES ARE DEVELOPED ANNUALLY BY THE CEO, AFTER A REVIEW OF PERFORMANCE AND COMPARABLE MARKET DATA. THE PROPOSED SALARIES ARE INDEPENDENTLY REVIEWED BY AN OUTSIDE AUDITING FIRM. THE COMPENSATION RECOMMENDATIONS, AUDIT REPORTS, ALONG WITH THE MARKET DATA, ARE PRESENTED TO A COMMITTEE MADE UP OF THE COMMUNITY MEMBERS OF THE BOARD OF TRUSTEES. THE COMPENSATION AMOUNTS ARE NOT EFFECTIVE UNTIL THE BOARD COMMITTEE APPROVES THEM. MEETING MINUTES ARE TAKEN AND KEPT AT THE MEETINGS WHERE THE BOARD REVIEWS AND APPROVES THE COMPENSATION OF THE KEY EMPLOYEES. FORM 990, PART VI, SECTION C, LINE 19 REQUESTS FOR ALL DOCUMENTS ARE MADE THROUGH THE LEGAL DEPARTMENT AND THE APPROPRIATE DOCUMENTS ARE MADE AVAILABLE FOR INSPECTION IN THE LEGAL DEPARTMENT. FORM 990, PART XI, LINE 9: ADJUSTMENT TO BASIS UPON AFFILIATION 732,474. FORM 990, PART IV, LINE 12B AND PART XII, LINE 2: THE ORGANIZATION WAS INCLUDED IN A SHORT YEAR CONSOLIDATED AUDIT FOR THE 11-MONTH PERIOD JANUARY 1, 2022 THROUGH NOVEMBER 30, 2022. THE ANSWERS FOR PART IV, LINE 12B AND PART XII, LINES 2A-2C HAVE BEEN ANSWERED YES EVEN THOUGH THE FORM 990 COVERS THE 12-MONTH PERIOD JANUARY 1, 2022 THROUGH DECEMBER 31, 2022. THE REASON FOR THIS CHANGE IS DUE TO A MERGER WITH THE BELLIN GUNDERSEN HEALTH SYSTEM. THE ACTIVITY OF DECEMBER 2022 WILL BE INCLUDED IN A CONSOLIDATED AUDIT FOR THE PERIODS OF DECEMBER 2022 - SEPTEMBER 2023 AS ALL THE RELATED PARTIES LISTED IN SCHEDULE R WILL BE TRANSITIONING TO THAT YEAR END. 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