2020-11-16T15:16:53-06:00 2019-12-31 410746749 CLIFTONLARSONALLEN LLP 10700 NORTHUP WAY SUITE 200 BELLEVUE WA 98004 990 2019-01-01 390807068 THEDACARE MEDICAL CENTER - SHAWANO INC THED 7155262111 PO BOX 8025 APPLETON WI 549128025 MARK THOMPSON CFO & COO 7155262111 2020-11-14 1 KURT BENNION CPA P01469618 4252506100 2020-11-14 2019 2022-09-23 18:48:47Z IMRAN ANDRABI MD PO BOX 8025 APPLETON WI 549128025 60285894 0 X WWW.THEDACARE.ORG X 1932 WI IMPROVING THE HEALTH OF OUR COMMUNITY. 10 6 0 61 0 0 6199 54170 55584357 60231724 -1742 0 41248 0 55630062 60285894 15916 0 0 0 24069000 22006371 0 0 0 22045785 24100470 46130701 46106841 9499361 14179053 67322855 103429745 4523342 26819783 62799513 76609962 X TO PROVIDE THE HIGHEST QUALITY HEALTH CARE, DELIVERED IN THE MOST EFFICIENT AND COST-EFFECTIVE WAYS, AND ACCESSIBLE TO ALL MEMBERS OF THE COMMUNITY. 0 0 44743358 0 60029359 THEDACARE IS A TAX-EXEMPT, NON-PROFIT CORPORATION, AS DESCRIBED IN SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE.THEDACARE MEDICAL CENTER-SHAWANO IS A 25-BED CRITICAL ACCESS HOSPITAL SERVING SHAWANO AND NEARBY COMMUNITIES. THERE ARE MORE THAN 300 TEAM MEMBERS LOCATED AT THE SHAWANO CAMPUS. THEDACARE MEDICAL CENTER-SHAWANO PROVIDES PATIENT CARE AND SUPPORT SERVICES INCLUDING DIAGNOSTIC SERVICES SUCH AS X-RAY, ULTRASOUND, MRI, CT SCAN, MAMMOGRAPHY AND MEDICAL LABORATORY TESTING AND SPECIALTY SERVICES SUCH AS CANCER CARE, CARDIOVASCULAR CARE, ORTHOPEDIC CARE, SPINE, NEUROLOGY, FAMILY BIRTH CARE, INTERNAL MEDICINE, EMERGENCY, OCCUPATIONAL HEALTH, PULMONOLOGY, UROLOGY, WOMEN'S CARE, OUTPATIENT SURGERY AND THERAPY SERVICES.IN ADDITON, WE OFFER AND CONVENIENT WALK-IN CARE, AND E-VISITS FOR ENHANCED COMMUNITY ACCESS TO HEALTHCARE.AS PART OF THE THEDACARE SYSTEM, WE OFFER PUBLIC AWARENESS CAMPAIGNS, CHARITY CARE, SUPPORT GROUPS, AND EDUCATION PROGRAMS TARGETED TO LOCAL COMMUNITY NEEDS. THEDACARE IS COMMITTED TO COMMUNITY FOCUSED EFFORTS IDENTIFIED IN THE COMMUNITY NEEDS HEALTH ASSESSMENT IN COUNTIES (SHAWANO AND MENOMINEE) WHERE SERVICES ARE PROVIDED. EFFORTS INCLUDE PARTNERSHIPS WITH SHAWANO COUNTRY VISION (ECONOMIC DEVELOPMENT), CHAMBER OF COMMERCE, MENOMINEE AND MUNSEE TRIBES AND RURAL HEALTH INITIATIVE (HEALTH AND SAFETY FOR AGRICULTURAL FAMILIES IN THE REGION). TOP PRIORITIES INCLUDE AODA (BINGE DRINKING AWARENESS CAMPAIGN) WORKSHOPS FOR LOCAL EMPLOYERS (IDENTIFICATION OF DRUG AND ALCOHOL ISSUES AND SUPPORT FACILITATION), AND IMPLEMENTATION OF DRUG COURT.THEDACARE PROVIDES SCHOLARSHIPS, CHARITY CARE, INTERPRETING AND EDUCATIONAL SERVICES AND VARIOUS OTHER COMMUNITY BENEFITS.THEDACARE OPERATES ON A NON-DISCRIMINATORY BASIS REGARDLESS OF RACE, COLOR, SEX, RELIGION, OR NATIONAL ORIGIN. THEDACARE PROVIDES A VARIETY OF FINANCIAL ASSISTANCE OPTIONS TO PATIENTS WHO MEET ESTABLISHED CRITERIA. SERVICES ARE ALSO PROVIDED TO BOTH MEDICARE AND MEDICAID PATIENTS AT SUBSTANTIAL DISCOUNTS FROM STANDARD FEES. 44743358 1 1 0 1 0 0 0 0 0 0 1 0 0 0 1 0 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 X 10 6 0 1 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X NATHANIEL CHERNE 9207355560 PO BOX 8025 APPLETON WI 549128025 IMRAN ANDRABI MD PRESIDENT & CEO - SYSTEM 4.00 36.00 X 0 1184478 65868 MARK THOMPSON BOARD MEMBER SENIOR VP, CFO & COO - SYSTEM 4.00 36.00 X X 0 681900 62765 MICHAEL WILLIAMS MD BOARD MEMBER / PHYSICIAN 1.00 39.00 X 0 462349 57980 JAMES ALBIN CIO 4.00 36.00 X 0 433321 47350 MAGGIE LUND CHRO 4.00 36.00 X 0 360217 51584 BRIAN STERNS FORMER KEY EMPLOYEE 4.00 36.00 X 0 189442 57247 MARK THIEL BOARD MEMBER / VICE PRESIDENT 1.00 39.00 X 0 196969 41350 KATHLEEN QUALHEIM MD BOARD MEMBER & SECRETARY / TREASURER / PHYSICIAN 40.00 0.00 X X 0 62480 12788 RICK KANE PRESIDENT (LEFT IN 2019) 1.00 0.00 X X 0 0 0 CHUCK DALLAS VICE PRESIDENT & PRESIDENT 1.00 0.00 X X 0 0 0 CHAD WAUKECHON SECRETARY/TREASURER (PASSED IN 2019) 1.00 0.00 X X 0 0 0 SHANNON DAUN MD BOARD MEMBER 1.00 0.00 X 0 0 0 YVETTE HARTMAN-WILBER BOARD MEMBER 1.00 0.00 X 0 0 0 CHARLIE HARVEY BOARD MEMBER 1.00 0.00 X 0 0 0 MATT HENDRICKS BOARD MEMBER 1.00 0.00 X 0 0 0 LORI SHERMAN BOARD MEMBER 1.00 0.00 X 0 0 0 0 3571156 396932 0 1 1 0 CHG MEDICAL STAFFINC INC PO BOX 972670 DALLAS TX 75397 MEDICAL STAFFING 341448 CHG COMPANIES INC PO BOX 972651 DALLAS TX 75397 MEDICAL STAFFING 294455 MEDICUS EMERGENCY ROOM SERVICES 22 ROULSTON RD WINDHAM NH 03087 MEDICAL STAFFING 222699 WEATHERBY LOCUMS INC PO BOX 972633 DALLAS TX 75397 MEDICAL STAFFING 195960 MICHAEL DAVID POLKA MD W4001 DEVINE LN APPLETON WI 54913 MEDICAL STAFFING 177425 8 54170 54170 OUTPATIENT REVENUE 621400 38646014 38646014 INPATIENT REVENUE 621400 21216766 21216766 CAFETERIA & VENDING REVENUE 900099 202365 202365 OTHER HOSPITAL SERVICES 621400 166579 166579 60231724 60285894 60029359 0 202365 990971 920443 70528 48998 48998 17320410 16516063 804347 3645992 3392870 253122 4239547 4032923 206624 11359 11359 520927 492065 28862 339153 339153 67699 67699 96764 96764 2676 2676 3786114 3786114 121925 121925 MEDICAL SUPPLIES 10209687 10209687 BAD DEBT EXPENSE 3417134 3417134 EQUIPMENT RENTAL 1287485 1287485 46106841 44743358 1363483 0 33638 15669828 6179916 42441106 1019352 1019352 80281468 35985447 47911048 44296021 83474 2288 12095427 1150 67322855 103429745 554319 3588588 3969023 3482408 61 0 19748726 4523342 26819783 X 62791113 76601562 8400 8400 62799513 76609962 67322855 103429745 14179053 -368604 0 X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 3244 3244 0 PART II-B, LINE 1: A PORTION OF THE WHA DUES REPRESENT LOBBYING PERFORMED IN REGARD TO HEALTHCARE ISSUES. TOTAL DUES PAID IN 2019 WERE $19,424. 16.7% OF THIS AMOUNT WAS SPENT ON LOBBYING. 1804508 1804508 52670152 14420968 38249184 25806808 21564479 4242329 44296021 DUE TO AFFILIATES 19748726 19748726 1 1 1 X 1 X 410.000000000000 1 0 1 1 466 218011 1 218010 0.00510 15409 10024789 9311505 713284 0.01670 15875 10242800 9311506 931294 0.02180 15 101478 142452 142452 0.00330 3 5401 61436 61436 0.00140 3 20753 1656810 1656810 0.03880 6 625067 520062 520062 0.01220 27 752699 2380760 2380760 0.05570 27 768574 12623560 9311506 3312054 0.07750 1 13328 3715 3715 0.00010 1 203 7797 7797 0.00020 1 4 8 8 0.00000 1 14 1210 1210 0.00000 4 13549 12730 12730 0.00030 0 1268793 0 11324549 10017250 1307299 X 1 1 1 1 THEDACARE MEDICAL CENTER - SHAWANO 309 N BARTLETTE STREET SHAWANO WI 54166 WWW.THEDACARE.ORG 1051 X X X X THEDACARE MEDICAL CENTER - SHAWANO IN 1 0 0 1 X X X X X X X X X 19 1 1 1 1 X SEE LINE 7D X X 1 19 1 SEE LINE 7D 0 1 X 200.000000000000 410.000000000000 X X X X X 1 1 X X X X X 1 X HTTPS://WWW.THEDACARE.ORG/POLICIES-AND-LEGAL-FORMS/PAYMENT-OPTIONS X HTTPS://WWW.THEDACARE.ORG/POLICIES-AND-LEGAL-FORMS/PAYMENT-OPTIONS X HTTPS://WWW.THEDACARE.ORG/POLICIES-AND-LEGAL-FORMS/PAYMENT-OPTIONS X X X X X X X 1 X 0 X X X 1 X 0 0 THEDACARE MEDICAL CENTER - SHAWANO, IN PART V, SECTION B, LINE 5: AS PART OF THE NEEDS ASSESSMENT ADVISORY TEAM, THEDACARE CONSULTED WITH THE PUBLIC HEALTH DEPARTMENTS OF OUTAGAMIE COUNTY, WINNEBAGO COUNTY, CALUMET COUNTY, SHAWANO, GREEN LAKE, MARQUETTE, WAUSHARA, WAUPACA AND THE CITY OF APPLETON.IN ADDITION, OVER THE COURSE OF A ONE YEAR PERIOD, SECONDARY DATA WAS COLLECTED, KEY INFORMANT INTERVIEWS WERE CONDUCTED, THEDACARE CHAT TEAMS (COMMUNITY HEALTH ACTION TEAM) PROVIDED INPUT AND PATIENT HEALTH DATA WAS STUDIED. VULNERABLE POPULATIONS INCLUDED LOW INCOME, RURAL FARM FAMILIES, OLDER ADULTS AND HISPANIC POPULATION, NATIVE AMERICAN TRIBES, AND RURAL FARMING FAMILIES. THEDACARE MEDICAL CENTER - SHAWANO, IN PART V, SECTION B, LINE 6A: THEDACARE REGIONAL MEDICAL CENTER-APPLETON IS A MEMBER OF THE FOX VALLEY COMMUNITY HEALTH IMPROVEMENT COALITION WHOSE MEMBERS INCLUDE THE PUBLIC HEALTH DEPARTMENTS OF CALUMET, OUTAGAMIE AND WINNEBAGO COUNTIES AND THE HEALTH DEPARTMENTS OF THE CITY OF APPLETON AND CITY OF MENASHA. MEMBERSHIP ALSO INCLUDES REPRESENTATIVES FROM CHILDREN'S HOSPITAL OF WISCONSIN, PARTNERSHIP COMMUNITY HEALTH CENTER (FQHC), AURORA HEALTH IN OSHKOSH AND AFFINITY HEALTH IN APPLETON. THIS COALITION WAS PART OF A JOINT CHNA PROCESS DURING 2019. THEDACARE MEDICAL CENTER - SHAWANO, IN PART V, SECTION B, LINE 7D: THE COMMUNITY HEALTH NEEDS ASSESSMENT REPORT AND IMPLEMENTATION STRATEGY ARE AVAILABLE ONLINE AT: HTTPS://WWW.THEDACARE.ORG/HOSPITALS-AND-CLINICS/THEDACARE-REGIONAL-MEDICAL-CENTER-SHAWANO.ASPX. THEDACARE MEDICAL CENTER - SHAWANO, IN PART V, SECTION B, LINE 11: THE THEDACARE COMMUNITY HEALTH IMPLEMENTATION STRATEGY WAS APPROVED BY THE THEDACARE MEDICAL CENTER-SHAWANO HOSPITAL BOARD AND THE THEDACARE BOARD OF TRUSTEES IN 2020.OBESITYOVERWEIGHT AND OBESITY ARE DRIVERS OF PREVENTABLE CHRONIC DISEASE AND REDUCED QUALITY AND LENGTH OF LIFE. IT WAS RANKED AMONG THE TOP 3 HEALTH PRIORITIES IN BOTH THE 2016 AND 2019 CHNAS.1. ALONG WITH UNITED WAY, CHAMPIONED TRANSFORMATION OF "WEIGHT OF THE FOX VALLEY" INTO MORE ROBUST "LIVEWELL FOX VALLEY" MODEL. RECEIVED COMMITMENT FROM 5 HEALTH SYSTEMS.2. ORGANIZATIONS OFFERING OBESITY-RELATED WORKSITE WELLNESS PROGRAMS INCREASED BY 233. EIGHT EARLY CARE & EDUCATION PROGRAMS ADDED STRATEGIES FOR SERVING WI GROWN FRUITS AND VEGETABLES4.. BREASTFEEDING FRIENDLY DESIGNATIONS REGARDING EARLY CARE & EDUCATION PROGRAMS AND WORKSITES INCREASED BY EIGHT5. MAJOR SPONSOR OF AMERICAN HEART ASSOCIATION RESULTING IN $203,500 IN FUNDRAISING FROM HEART BALL, GO RED FOR WOMEN AND HEART & STROKE WALK; MORE THAN 2.6 MILLION IMPRESSIONS ON SOCIAL MEDIA AND TRADITIONAL MEDIA; 450 PEOPLE TRAINED IN HANDS ONLY CPR INCLUDING 35 STUDENTS FROM LITTLE CHUTE HIGH SCHOOL WHO CONTINUE TO TRAIN FOX CITIES COMMUNITY MEMBERS AT LOCAL BUSINESSES/SCHOOLS/CHURCHES/COMMUNITY EVENTS6. ATTAINED PRELIMINARY STATUS AS DIABETES PREVENTION PROGRAM PROVIDER BY CDC7. THROUGHOUT THE APPLICATION PHASE OF 2017-2019 ENROLLED 159 PEOPLE8. ON AVERAGE PARTICIPANTS REDUCED RISK OF DEVELOPING DIABETES BY 58%9. LIFESTYLE INTERVENTION PROGRAM ENROLLED 172 PEOPLE SINCE 2017 WITH AVERAGE WEIGHT LOSS OF 22 POUNDS10. HAT SCORE IMPROVEMENT OF 15 POINTS, REDUCTION OF PREDIABETES AMONG 53%, AND 44% REDUCTION IN METABOLIC SYNDROME. ENHANCING PROCESS TO ALLOW PROVIDERS TO MORE READILY REFER PEOPLE TO THE PROGRAM.11. THE CORONARY HEALTH IMPROVEMENT PROGRAM ENROLLED 308 PEOPLE SINCE 2017 WITH AN AVERAGE DROP IN BMI OF 5% AND 20% DROP IN LIPIDSFARMERS MARKETS - SHAWANO AND MENOMINEE COUNTIES, HO-CHUNK NATION, MENOMINEE INDIAN TRIBE OF WISCONSIN, AND STOCKBRIDGE-MUNSEE BAND OF MOHICAN INDIANS HEALTH IN PLANNING COALITION IS WORKING WITH NATIVE AMERICA TRIBES AND JURISDICTIONS IN WISCONSIN TO IMPROVE ACCESS TO LOCAL, FRESH FOOD BY CONVENING A TEAM OF PLANNING AND PUBLIC HEALTH PROFESSIONALS TO IDENTIFY BARRIERS TO HEALTHY DIETS.MENTAL HEALTH/AODATHE STATE OF MENTAL HEALTH, ACCESS TO MENTAL HEALTH SERVICES AND DRUG ABUSE, IN PARTICULAR OPIOID ADDICTION, WERE NAMED AMONG TOP 3 HEALTH PROBLEMS ACROSS ALL MARKETS IN BOTH THE 2016 AND 2019 CHNAS.1. IN 2019, THEDACARE PROVIDED IN-KIND LEADERSHIP AND FINANCIAL SUPPORT TO CATALPA HEALTH - CHILDREN'S MENTAL HEALTH PROVIDER WHICH PROVIDES MENTAL HEALTH SERVICES TO CHILDREN THROUGHOUT NORTHEAST WISCONSIN2. NEW MH CONNECTION IS A COALITION OF 70+ MENTAL HEALTH AGENCIES TO ADDRESS ACCESS TO MENTAL HEALTH CARE - TC CHAIRS BOARD OF NEW MH CONNECTION AND PROVIDES IN-KIND OFFICE SPACE AT TCBH ETC. CONTRIBUTES $15,000 FUNDING ANNUALLY3. PROVIDED LEADERSHIP AND FUNDING FOR THE PARTNERSHIP COMMUNITY HEALTH CENTER WORKING TO IMPROVE THE HEALTH STATUS OF THE MEDICALLY UNDERSERVED BY PROVIDING COMPREHENSIVE PRIMARY CARE AND BEHAVIORAL HEALTH SERVICES4. PROVIDED $190,000 IN SUBSIDIZED MENTAL HEALTH SERVICES5. IN THE FALL OF 2019, THEDACARE SPONSORED PARTY AT THE PAC FOR THOUSANDS OF AREA YOUTH TO EDUCATE ON THE PERILS OF RISKY BEHAVIOR WHILE TEXTING/DRINKING AND DRIVING6. LAUNCHED OPIOID INITIATIVE - MAT EXPANSION - MAT USE OF VIVITROL PILOTED IN WAUPACA AND EXPANDED TO SHAWANO AND APPLETON NORTH - DRUG TAKE BACK BOXES WERE PLACED IN 6 HOSPITALS THROUGHOUT SYSTEM - PROVIDED PROMOTIONAL SUPPORT FOR SHAWANO DRUG TAKE BACK CAMPAIGNS IN WAUPACA AND SHAWANO7. TCBH WORKING WITH CATALPA AND SHAWANO SCHOOL DISTRICT TO EXPLORE PROVIDING MH COUNSELORS IN SHAWANO SCHOOLS. CATALPA HEALTH LAUNCHED IN WAUPACA IN 20198. SHAWANO AND WAUPACA CHAT TEAMS LED LAUNCH OF DRUG COURTS IN THEIR RESPECTIVE COUNTIES9. SEVENTEEN URBAN AND 6 RURAL SCHOOLS INITIATED SOURCES OF STRENGTH" HIGH SCHOOL PROGRAM, A SCHOOL-BASED RESILIENCY PROGRAM. THEDACARE COMMITTED $300,000 OVER 3 YEARS TO IMPLEMENT THE SCHOOL BASED PROGRAM.10. PROVIDED $5000 IN FINANCIAL SUPPORT OF STUDY REGARDING TEEN SUICIDE-RELATED BEHAVIORS IN PARTNERSHIP WITH MEDICAL COLLEGE OF WISCONSIN/NEW MENTAL HEALTH CONNECTION11. INITIATED PRIMARY CARE CONSULT. DR. PANZER AND DR. BELD DO INITIAL REVIEW OF ALL REFERRALS AND IF URGENT, GET THEM INTO EXPEDITED CARE (PSYCH, MH OR AODA). OTHERWISE, CONSULT WITH PC. HELPS PCP MANAGE PATIENTS IF ON WAIT LIST. WAIT LIST FOR PSYCHIATRIC NEEDS DROPPED FROM 600+ TO 0.12. INITIATED NPPP (NORTH PRIMARY CARE PSYCHIATRIC PARTNERSHIP) PROVIDER INTEGRATED IN PCP CLINIC. SEES PATIENTS ON WAIT LIST UP TO 4 TIMES. REFERS TO PSYCHIATRIST FOR INITIAL TRIAGE AND IF URGENT GETS THEM INTO PSYCH, MH OR AODA CARE RIGHT AWAY. EXPANDING TO NEENAH AND TRAINING ANOTHER PROVIDER. SHAWANO PSYCHIATRIST EMBEDDED IN PCP CLINIC.13. INPATIENT PSYCH WENT TO 7 DAYS ON/7 OFF FOR HOSPITALIST. FREES UP OUTPATIENT PSYCH TIME14. DEPRESSION SCREENING IS TAKING PLACE IN 100% OF TC PEDS AND FP CLINICS FOR PEOPLE AGE 12+15. CONDUCTING COLUMBIA SCREENING AT EVERY MENTAL HEALTH INITIAL APPOINTMENT16. CONDUCTING PHQ9 AT EVERY AODA INITIAL APPOINTMENTEARLY CHILDHOOD/FAMILY SUPPORTTHE WELL-BEING OF YOUNG CHILDREN WAS IDENTIFIED AS ONE OF TOP HEALTH CONCERNS IN 2016 AND 2019 CHNAS. IMPROVING EARLY CHILDHOOD ADDRESSES ROOT CAUSE OF MULTIPLE LONG-TERM PHYSICAL AND MENTAL HEALTH ISSUES.1. THEDACARE COMMITTED TO PROVIDING EVIDENCE-BASED REACH OUT AND READ EARLY CHILDHOOD READING PROGRAM IN ALL CLINICS BY 2019 - IN 2019, 23 OF 25 CLINICS WERE FULLY IMPLEMENTED AND TRAINED IN REACH OUT AND READ - 7,516 BOOKS WERE PROVIDED2. IMPROVED BIRTH CENTER ASSESSMENT AND REFERRAL PROCESS TO HOME VISITATION PROGRAMS - NUMBER OF HOSPITALS WITH HOME VISITATION REFERRAL INCREASED TO 4 FROM 2 - NUMBER OF ANNUAL HOME VISITATION ASSESSMENTS WERE 317 FROM 453. 2019 MAKE A DIFFERENCE DAY "MYSTERY BUSES" ENGAGED 300 TC AND PARTNER BUSINESS EMPLOYEES VOLUNTEERING AT 10 NON-PROFIT LOCATIONS ACROSS ALL HOSPITAL MARKETS FOCUSED ON EARLY CHILDHOOD AND YOUTH.HEALTH DISPARITIES/POVERTY: HEALTH DISPARITIES1. THEDACARE IS A PARTNER WITH THE POVERTY OUTCOMES & IMPROVEMENT TEAM (POINT), AN 18 MONTH INITIATIVE EQUIPPING THE ENTIRE FOX VALLEY REGION WITH CONTINUOUS IMPROVEMENT METHODOLOGIES FOCUSED ON POVERTY. POINT IS USING THESE PROCESSES TO STRENGTHEN EXISTING POVERTY REDUCTION EFFORTS, ADDRESS SERVICE GAPS, AND MEASURE PROGRESS ON REDUCING POVERTY IN NORTHEAST WISCONSIN. TC CONTRIBUTED $200,000 PLUS PRESENCE ON THE LEADERSHIP TEAM. POINT COLLABORATED WITH BOSTON-BASED INSTITUTE FOR HEALTHCARE IMPROVEMENT TO USE LEAN PROCESSES AND TOOLS TO HELP NON-PROFIT AGENCIES HELP PEOPLE BECOME SELF-SUFFICIENT. MORE THAN 40 NON-PROFIT AGENCIES ARE PARTICIPATING CONDUCTED WITH 106 UNMANAGED HEALTH CONDITIONS IDENTIFIED. 266 REFERRALS WERE MADE TO HEALTH CARE PROVIDERS.2. ACCESS TO HEALTHCARE FOR RURAL FARM FAMILIES. THEDACARE IS A MAJOR SUPPORTER OF THE RURAL HEALTH INITIATIVE WHICH TAKES HEALTHCARE SERVICES TO THE FARM REACHING A SIGNIFICANT VULNERABLE POPULATION OF LOW-INCOME FARMERS AND MIGRANT WORKERS, MANY OF WHOM ARE UNINSURED. AS OF 10/21/2019, RHI HAS SERVED 190 FAMILIES. 116 REFERRALS WERE MADE TO HEALTH CARE PROVIDERS. THESE NUMBERS ARE DECREASING AS FARMS DECREASE DUE TO THE ECONOMYGENERAL1. MEDICAL STUDENTS AND ACCESS TO PRIMARY CARE AND MENTAL HEALTH SERVICES2. THEDACARE ALSO PARTNERS WITH AREA NURSING SCHOOLS SUCH AS UW OSHKOSH AND FOX VALLEY TECHNICAL COLLEGE TO PROVIDE PROFESSIONAL MENTORS FOR THEIR NURSING PROGRAMS AND VENUES FOR NURSING STUDENTS TO PRACTICE THEIR SKILLS.3. THEDACARE HOSPITALS PROVIDE FINANCIAL AS WELL AS DIAGNOSTIC AND LAB SUPPORT TO A PARTNERSHIP COMMUNITY HEALTH CENTER (FQHC) PROVIDING MEDICAL, BEHAVIORAL AND DENTAL CARE TO THE UNDERSERVED IN OUR SERVICE AREA.4. 2019 SPONSORSHIP OF LOCAL NON-PROFIT INITIATIVES RELATED TO DISPARITIES: $85,0005. 2017-2019 THEDACARE EMPLOYEE VOLUNTEER HOURS RELATED TO DISPARITIES: 8,7096. THEDACARE PLAYED A CRITICAL ROLE IN THE DEVELOPMENT AND LAUNCH OF IMAGINE FOX CITIES VISIONING INITIATIVE WHICH ENGAGED THE ENTIRE FOX CITIES REGION IN A DISCOVERY AND DISCERNMENT PROCESS TO UNDERSTAND WHAT PEOPLE THINK ABOUT THEIR WELL-BEING TODAY, WHAT THEY EXPECT THEIR WELL-BEING TO BE IN THE FUTURE, AND ARTICULATE A VISION FOR GENERATIONS TO COME THAT WILL GUIDE LOCAL DECISION-MAKING. THIS VISION SETS THE LARGER CONTEXT FOR ADVANCING HEALTH AND WELL-BEING ACROSS THE REGION.7. THROUGH CONSULTANTS ENGAGED WITH IMAGINE FOX CITIES, BROUGHT LEADERS FROM RETHINK HEALTH TO FOX CITIES TO PARTICIPATE IN RWJF GRANT TO EXPLORE HOW LOCAL INSTITUTIONS CAN INVEST DIFFERENTLY TO PROPEL OUR COMMUNITY TOWARD THE NEW VISION. THEDACARE WILL PLAY A FUTURE LEAD ROLE. THEDACARE MEDICAL CENTER - SHAWANO, IN PART V, SECTION B, LINE 13H: PATIENTS ARE SENT AN OVERVIEW LETTER EXPLAINING THE PROCESS FOR APPLYING FOR OUR ASSISTANCE PROGRAM OR OUR STAFF WALKS THEM THROUGH THE PROCESS. THEY ARE ASKED TO COMPLETE AN APPLICATION THAT INCLUDES REQUESTS FOR INFORMATION. THIS INFORMATION IS NEEDED IN ORDER TO MAKE A DECISION AS TO WHETHER THE PATIENT MEETS THE CRITERIA FOR ACCEPTANCE, AND IF ACCEPTED, WHAT LEVEL OF ASSISTANCE WILL BE PROVIDED. ONCE THE DECISION IS MADE, WE WILL NOTIFY THE PATIENT AND IF ACCEPTABLE, WRITE OFF THE BALANCE AS DETERMINED. THEDACARE MEDICAL CENTER - SHAWANO, IN PART V, SECTION B, LINE 15E: CONTRACTED WITH ELIGIBILITY VENDOR (CARDON) TO WORK DIRECTLY WITH UNINSURED PATIENTS TO ASSIST THEM WITH INSURANCE ENROLLMENT AND EDUCATION. THEDACARE MEDICAL CENTER - SHAWANO, IN PART V, SECTION B, LINE 16J: THE FAP AND APPLICATION WERE AVAILABLE AT HOSPITAL CASHIER OFFICES, ON OUR WEB SITE AND OFFERED TO ALL PATIENTS THAT EXPRESSED A FINANCIAL HARDSHIP WHEN CALLING THE BILLING OFFICE. THE PLS WAS PRINTED ON EVERY STATEMENT AND A FOOTER WAS ADDED TO THE FRONT OF THE STATEMENT ADVISING PATIENT TO SEE REVERSE SIDE OF STATEMENT FOR FINANCIAL ASSISTANCE AND PAYMENT OPTIONS. NOTIFICATION OF FINANCIAL ASSISTANCE AVAILABILITY WAS ADDED TO THE INITIAL LETTER SENT BY THE THIRD PARTY COLLECTION AGENCY. PART I, LINE 3C: IT IS THE ORGANIZATION'S POLICY THAT NO PATIENT SHOULD BE DENIED APPROPRIATE AND NECESSARY CARE ON THE BASIS OF INCOME. IN RESPONSE TO THIS POLICY, THE CARING HEARTS FINANCIAL ASSISTANCE PROGRAM WAS SET UP TO PROVIDE SHELTER TO THOSE PATIENTS WHO ARE UNABLE TO PAY FOR THEIR MEDICAL SERVICES. MEDICAL SERVICE FEES ARE WRITTEN OFF UNDER THE FINANCIAL ASSISTANCE PROGRAM THAT WOULD OTHERWISE HAVE BEEN SENT TO A COLLECTION AGENCY. PART I, LINE 7: THE COSTING METHODOLOGY USED TO CALCULATE THE AMOUNTS IN THE TABLE IS A COMBINATION OF AVERAGE COSTS AND ACTUAL COSTS PERTAINING TO SUPPLIES, WAGES, AND BENEFITS. FOR SUPPLIES, THE ACTUAL COST OF ITEMS USED FOR EACH EVENT IS APPLIED. IF NO ACTUAL COST IS AVAILABLE, WE THEN USE AN ESTIMATE. WAGES ARE CALCULATED BY MULTIPLYING THE AVERAGE WAGE RATE TIMES ACTUAL HOURS WORKED. THE BENEFIT RATE USED INCLUDES A FRINGE RATIO OF ALL BENEFITS RELATED TO THE ABOVE WAGE CALCULATION. THE COST ACCOUNTING SYSTEM DOES NOT DIFFERENTIATE BETWEEN DIFFERENT PAYER TYPES AND NO COST-TO-CHARGE RATIO IS USED. PART I, LINE 7G: NO PHYSICIAN CLINICS ARE INCLUDED IN SUBSIDIZED HEALTH SERVICES. PART I, LINE 7, COLUMN (F): THE BAD DEBT EXPENSE INCLUDED ON FORM 990, PART IX, LINE 25, COLUMN (A), BUT SUBTRACTED FOR PURPOSES OF CALCULATING THE PERCENTAGE IN THIS COLUMN IS $ 3,417,134. PART II, COMMUNITY BUILDING ACTIVITIES: ECONOMIC DEVELOPMENT - THE PRIMARY AIM OF THE CHAMBER IS TO PROTECT THE INTEREST OF THE BUSINESS COMMUNITY AS A WHOLE. STRONG EMPLOYMENT IS A SOCIAL DETERMINANT OF HEALTH, REDUCING POVERTY AND PROVIDING INDIVIDUAL AND FAMILY SUSTAINABILITY. THEDACARE WORKS TOGETHER WITH LOCAL CHAMBERS OF COMMERCE IS IN ALL OF THE COMMUNITIES IT SERVES. COMMUNITY SUPPORT - CARING HEARTS IS A FINANCIAL ASSISTANCE PROGRAM DESIGNED FOR PATIENTS WHO ARE UNABLE TO PAY FOR MEDICALLY NECESSARY SERVICES PROVIDED BY ALL DIVISIONS WITHIN THEDACARE. THE CARING HEARTS PROGRAM COVERS SERVICES WHICH ARE DEEMED TO BE MEDICALLY NECESSARY AS DETERMINED BY THEIR PHYSICIAN. THIS COST IS FOR TIME AND EXPENSE NEEDED TO SUPPORT CARING HEARTS.THE CARING HEARTS FINANCIAL ASSISTANCE PROGRAM IS IN EFFECT AT ALL THEDACARE FACILITIES - THEDACARE REGIONAL MEDICAL CENTERS IN APPLETON AND NEENAH, THEDACARE MEDICAL CENTER- BERLIN, THEDACARE MEDICAL CENTER-NEW LONDON, THEDACARE MEDICAL CENTER-SHAWANO, THEDACARE MEDICAL CENTER-WAUPACA AND THEDACARE MEDICAL CENTER-WILD ROSE.ENVIRONMENTAL IMPROVEMENTS - SHARPS COLLECTION. COMMUNITY SHARPS CAN BE TAKEN FOR COLLECTION AND DISPOSAL TO ANY OF THE 7 THEDACARE HOSPITALS.COMMUNITY SHARPS CAN BE DISPOSED OF AT THEDACARE REGIONAL MEDICAL CENTER-APPLETON AND NEENAH, THEDACARE MEDICAL CENTER-BERLIN, THEDACARE MEDICAL CENTER-NEW LONDON, THEDACARE MEDICAL CENTER-SHAWANO, THEDACARE MEDICAL CENTER-WAUPACA AND THEDACARE MEDICAL CENTER WILD ROSE.COMMUNITY OTHER: SART/SANE - THE SEXUAL ASSAULT RESPONSE TEAM WORKS WITH LOCAL LAW ENFORCEMENT, DOMESTIC ABUSE AGENCIES, SEXUAL ASSAULT AGENCIES, MENTAL HEALTH FACILITIES, LOCAL MEDICAL PROVIDERS TO IMPROVE IMMEDIATE RESPONSE TO VICTIMS OF SEXUAL ASSAULT. SART/SANE PROGRAMMING IS BASED AT THEDACARE REGIONAL MEDICAL CENTER-APPLETON AND SERVES THEDACARE REGIONAL MEDICAL CENTER-NEENAH, THEDACARE MEDICAL CENTER-BERLIN, THEDACARE MEDICAL CENTER-NEW LONDON, THEDACARE MEDICARE CENTER-SHAWANO, THEDACARE MEDICAL CENTER-WAUPACA AND THEDACARE MEDICAL CENTER-WILD ROSE. PART III, LINE 2: PATIENT ACCOUNTS RECEIVABLE ARE UNCOLLATERALIZED PATIENT OBLIGATIONS THAT ARE STATED AT THE AMOUNT THAT REFLECTS THE CONSIDERATION TO WHICH THEDACARE EXPECTS TO BE ENTITLED IN EXCHANGE FOR PROVIDING PATIENT CARE. THESE OBLIGATIONS ARE PRIMARILY FROM LOCAL RESIDENTS, MOST OF WHOM ARE INSURED UNDER THIRD-PARTY PAYOR AGREEMENTS. THEDACARE BILLS THIRD-PARTY PAYORS ON THE PATIENTS' BEHALF, OR IF A PATIENT IS UNINSURED, THE PATIENT IS BILLED DIRECTLY. ONCE CLAIMS ARE SETTLED WITH THE PRIMARY PAYOR, ANY SECONDARY INSURANCE IS BILLED, AND PATIENTS ARE BILLED FOR COPAY AND DEDUCTIBLE AMOUNTS THAT ARE THE PATIENTS' RESPONSIBILITY. PAYMENTS ON ACCOUNTS RECEIVABLE ARE APPLIED TO THE SPECIFIC CLAIM IDENTIFIED ON THE REMITTANCE ADVICE OR STATEMENTS. THEDACARE DOES NOT HAVE A POLICY TO CHARGE INTEREST ON PAST DUE ACCOUNTS.PATIENT ACCOUNTS RECEIVABLE ARE RECORDED AT NET REALIZABLE VALUE BASED ON CERTAIN ASSUMPTIONS. FOR THIRD-PARTY PAYORS, INCLUDING MEDICARE, MEDICAID, MANAGED CARE AND COMMERCIAL PAYORS, THE NET REALIZABLE VALUE IS BASED ON THE ESTIMATED CONTRACTUAL REIMBURSEMENT PERCENTAGE, WHICH IS BASED ON CURRENT CONTRACT PRICES OR HISTORICAL PAID CLAIMS DATA BY PAYOR. FOR UNINSURED PATIENTS (WHICH INCLUDES BOTH PATIENTS WITHOUT INSURANCE AND PATIENTS WITH DEDUCTIBLE AND COPAYMENT BALANCES DUE FOR WHICH THIRD-PARTY COVERAGE EXISTS FOR A PORTION OF THE BILL), THE NET REALIZABLE VALUE IS DETERMINED USING ESTIMATES OF HISTORICAL COLLECTION EXPERIENCE. THESE ESTIMATES ARE ADJUSTED FOR EXPECTED RECOVERIES AND ANY ANTICIPATED CHANGES IN TRENDS, INCLUDING SIGNIFICANT CHANGES IN PAYOR MIX, ECONOMIC CONDITIONS OR TRENDS IN FEDERAL AND STATE GOVERNMENTAL HEALTH CARE COVERAGE. PART III, LINE 3: THE HOSPITAL IS REPORTING $0 BECAUSE IT DOES NOT HAVE A METHOD OF REASONABLY ESTIMATING THE PORTION OF ITS BAD DEBT EXPENSE ATTRIBUTABLE TO PATIENTS WHO WOULD QUALIFY FOR FINANCIAL ASSISTANCE BUT WHO DID NOT COMPLETE A FINANCIAL ASSISTANCE APPLICATION. PART III, LINE 4: SEE "PATIENT ACCOUNTS RECEIVABLE AND CREDIT POLICY" IN NOTE 1 ON PAGES10-11 OF THE ATTACHED FINANCIAL STATEMENTS. PART III, LINE 8: HOSPITALS MUST ACCEPT MEDICARE PATIENTS REGARDLESS OF WHETHER THEY MAKE A SURPLUS OR DEFICIT FROM PROVIDING SERVICES TO THOSE PATIENTS. WE DID NOT REPORT ANY SHORTFALL AS A COMMUNITY BENEFIT. THE COSTING METHODOLOGY USED TO DETERMINE THE MEDICARE ALLOWABLE COSTS REPORTED IN THE ORGANIZATIONS MEDICARE COST REPORT IS STEP DOWN. PART III, LINE 9B: OUR POLICY IS NOT TO PURSUE PATIENT ACCOUNTS TO THE EXTENT ANY CHARGES ARE ELIGIBLE AND WRITTEN OFF THROUGH OUR CHARITY CARE/FINANCIAL ASSISTANCE PROGRAM. IF ONLY A PORTION OF THE CHARGES ARE ELIGIBLE AND WRITTEN OFF THROUGH OUR CHARITY CARE/FINANCIAL ASSISTANCE PROGRAM, THE REMAINING BALANCE WILL BE BILLED TO THE PATIENT AND COLLECTED IN ACCORDANCE WITH OUR NORMAL COLLECTION POLICY. PART VI, LINE 2: THEDACARE COVERS A 9 COUNTY PRIMARY SERVICE AREA SERVED BY 7 HOSPITALS. THEDACARE CONDUCTS A COMMUNITY NEEDS ASSESSMENT EVERY THREE YEARS FOR EACH HOSPITAL GATHERING DATA PERTINENT TO THAT COMMUNITY AND THE SURROUNDING AREAS. INFORMATION COLLECTED INCLUDES DATA FROM THE WISCONSIN COUNTY HEALTH RANKINGS, FOX CITIES LIFE STUDY (LOCAL INDICATORS FOR EXCELLENCE), THE BEHAVIORAL RISK FACTOR SURVEILLANCE SURVEY, INSIGHTS FROM INTERVIEWS OF PUBLIC HEALTH OFFICIALS, INSIGHTS FROM INTERVIEWS WITH REPRESENTATIVES OF VULNERABLE POPULATIONS, EMERGENCY DEPARTMENT PATIENT DATA AND INSIGHTS GATHERED FROM MONTHLY MEETINGS OF THE THEDACARE-LED CHAT TEAM (COMMUNITY HEALTH ACTION TEAM) COMPRISED OF COMMUNITY LEADERS IN BUSINESS, NON-PROFIT, CLERGY, EDUCATION, DIVERSE POPULATION GROUPS, HEALTHCARE, UNITED WAY, PUBLIC HEALTH AND THE LOCAL COMMUNITY FOUNDATIONS. PART VI, LINE 3: PATIENT EDUCATION BEGINS WHEN A PATIENT IS ADMITTED TO A THEDACARE HOSPITAL. ADMISSION SPECIALISTS MEET WITH EACH PERSON INDIVIDUALLY TO ASSESS INSURANCE STATUS AND FINANCIAL NEED. IF NECESSARY, SPECIALISTS REFER PATIENTS TO CARE MANAGEMENT SPECIALISTS WHO ASSIST WITH THE ENROLLMENT OF PATIENTS IN AN APPLICABLE PROGRAM. THE HOSPITAL PATIENT HANDBOOK IS PROVIDED TO ALL IN-PATIENTS. INTERNAL POLICIES SUCH AS DISCOUNTED SERVICES POLICY, CARING HEARTS POLICY AND PAYMENT FOR SERVICE POLICY FOR SELF-PAY BALANCES PROVIDE GUIDANCE. THE THEDACARE WEBSITE, WWW.THEDACARE.ORG, PROVIDES EDUCATION REGARDING THE AFFORDABLE CARE ACT IN EASY TO UNDERSTAND LANGUAGE. IT DISCUSSES OPTIONS AND WHERE TO GO FOR ASSISTANCE. PART VI, LINE 4: THEDACARE MEDICAL CENTER-SHAWANO SERVICE AREA CONSISTS OF SHAWANO COUNTY AND MENOMINEE COUNTY LOCATED IN EAST-CENTRAL WISCONSIN. POPULATION OF SHAWANO COUNTY IS 41,560 AND THE POPULATION OF MENOMINEE COUNTY IS 4,346.SHAWANO COUNTY:- THE PERCENTAGE OF RESIDENTS LIVING BELOW THE FEDERAL POVERTY LEVEL IS 15%.- THE PERCENTAGE OF CHILDREN ELIGIBLE FOR FREE AND REDUCED LUNCH IN SHAWANO IS 41%, ABOVE THE STATE AVERAGE OF 40%.- IN SHAWANO COUNTY 15% OF THE CHILDREN LIVE BELOW 100% OF THE FEDERAL POVERTY LEVEL.- SHAWANO COUNTY HAS 9% OF RESIDENTS WHO ARE UNINSURED.- SHAWANO COUNTY HIGH SCHOOL GRADUATION RATE IS 90%.- NINETY SEVEN PERCENT OF THE SERVICE AREA IS CAUCASIAN, HISPANIC POPULATION IS 2.6% AND NATIVE AMERICAN IS 8.2%. MENOMINEE COUNTY:- THE PERCENTAGE OF RESIDENTS LIVING BELOW THE FEDERAL POVERTY LEVEL IS 26.5%.- THE PERCENTAGE OF CHILDREN ELIGIBLE FOR FREE AND REDUCED LUNCH IN MENOMINEE COUNTY IS 89%, FAR ABOVE THE STATE AVERAGE OF 40%.- IN MENOMINEE COUNTY 43% OF THE CHILDREN LIVE BELOW 100% OF THE FEDERAL POVERTY LEVEL.- MENOMINEE COUNTY HAS 13% OF RESIDENTS WHO ARE UNINSURED.- MENOMINEE COUNTY HIGH SCHOOL GRADUATION RATE IS 78%.- THE MENOMINEE COUNTY SERVICE AREA IS CAUCASIAN 11.5, HISPANIC POPULATION OF 2.8% NATIVE AMERICAN POPULATION IS 82.9%. PART VI, LINE 5: EACH YEAR THEDACARE SETS ASIDE A PERCENTAGE OF ANY MARGIN AND DESIGNATES THESE FUNDS TO SUPPORT EFFORTS AND INITIATIVES COMING FROM CHAT (COMMUNITY HEALTH ACTION TEAM). CHAT IS A GROUP OF COMMUNITY LEADERS WHO STUDY SYSTEMIC HEALTH ISSUES OUTSIDE THE WALLS OF OUR HOSPITALS AND CLINICS AND WORK TO IDENTIFY INNOVATIVE, COLLABORATIVE SOLUTIONS THAT DRAW UPON THE WIDE ARRAY OF RESOURCES AND STRENGTHS OF OUR COMMUNITY. THERE ARE THEDACARE LED CHAT'S IN EACH HOSPITAL AREA WILD ROSE, WAUPACA, FOX CITIES, SHAWANO, BERLIN AND NEW LONDON. THEDACARE PROVIDES FUNDING AND DEDICATED STAFF TO MAKE CHAT COMMUNITY HEALTH EFFORTS POSSIBLE. PART VI, LINE 6: THEDACARE, THE PARENT ORGANIZATION, PROVIDES DIRECTION RELATED TO COMMUNITY HEALTH NEEDS ASSESSMENT FOR EACH HOSPITAL AND SURROUNDING COMMUNITIES WITHIN ITS SERVICE AREA. PLANS ARE APPROVED BY LOCAL HOSPITAL BOARDS. EACH THEDACARE HOSPITAL, ALONG WITH CHI STAFF AND COMMUNITY MEMBERS DETERMINE HOW BEST TO MEET LOCAL NEEDS. IMPLEMENTATION OF COMMUNITY PROGRAMMING OCCURS AT THE LOCAL LEVEL. PART VI, LINE 7, REPORTS FILED WITH STATES WI X 1 1 X X X X 0 1 0 0 0 0 0 1 0 IMRAN ANDRABI MD PRESIDENT & CEO - SYSTEM 0 881748 0 270005 0 32725 0 43518 0 22350 0 1250346 0 0 MARK THOMPSON BOARD MEMBER SENIOR VP, CFO & COO - SYSTEM 0 557906 0 100979 0 23015 0 43518 0 19247 0 744665 0 0 MICHAEL WILLIAMS MD BOARD MEMBER / PHYSICIAN 0 364501 0 60545 0 37303 0 35630 0 22350 0 520329 0 0 JAMES ALBIN CIO 0 358040 0 55950 0 19331 0 25000 0 22350 0 480671 0 0 MAGGIE LUND CHRO 0 301356 0 39841 0 19020 0 44000 0 7584 0 411801 0 0 BRIAN STERNS FORMER KEY EMPLOYEE 0 158264 0 8161 0 23017 0 38000 0 19247 0 246689 0 0 MARK THIEL BOARD MEMBER / VICE PRESIDENT 0 187656 0 9129 0 184 0 19000 0 22350 0 238319 0 0 PART I, LINE 1A ALL EXECUTIVES AT A LEVEL OF VICE PRESIDENT AND ABOVE ARE ELIGIBLE TO HAVE HEALTH OR FITNESS CLUB FEES REIMBURSED TO THEM, AND TAXED UPON REIMBURSEMENT. PART I, LINE 4B SENIOR LEVEL EXECUTIVES OF THE COMPANY ARE ENTITLED TO AN ANNUAL FLEXIBLE BENEFIT EQUAL TO 20% OF THE MIDPOINT OF THEIR SALARY RANGE. THIS 457(F) SUPPLEMENTAL BENEFIT PLAN COMPLIES WITH THE FINAL REGULATIONS UNDER SECTION 409A AND 457(F) OF THE INTERNAL REVENUE CODE. PARTICIPANTS MAY ELECT THE BENEFIT TO BE USED TO PURCHASE PARTICULAR INSURANCE BENEFITS, INVEST IN A CAPITAL ACCUMULATION ACCOUNT, OR A COMBINATION OF THE TWO. BENEFITS ARE ACCRUED ON A MONTHLY BASIS AND ARE SUBJECT TO THE SUBSTANTIAL RISK OF FORFEITURE AGREEMENT SIGNED BY THE PARTICIPANTS. PLAN CONTRIBUTIONS ARE MADE ON A QUARTERLY BASIS. PART I, LINE 7 EXECUTIVE AT RISK COMPENSATION PLAN: THE PLAN OBJECTIVES ARE TO ENHANCE THEDACARE INC'S ABILITY TO ACHIEVE ITS GOALS BY PROVIDING A TOOL FOR STIMULATING AND REWARDING SUPERIOR LEVELS OF PERFORMANCE AMONG LEADERS AND TO WORK TOGETHER AS A COHESIVE GROUP TOWARD COMMON GOALS. LEADERS FROM MANAGER LEVEL TO THE PRESIDENT AND CEO ARE ELIGIBLE TO PARTICIPATE IN THIS PLAN. THE PERCENTAGE FOR WHICH AN INDIVIDUAL IS ELIGIBLE IS DETERMINED BY THE PARAMETERS LISTED FOR THE LEADERSHIP POSITION AND IN THE PLAN DOCUMENT ON FILE. LEADERS MAKE RECOMMENDATIONS FOR THEIR MANAGEMENT LEVEL DIRECT REPORTS TO THEIR EXECUTIVE LEADER BASED ON PERFORMANCE RESULTS. THE PRESIDENT AND CEO ALSO REVIEWS AND APPROVES. FOR SENIOR VICE PRESIDENTS, THE EXECUTIVE LEADERSHIP TEAM, AND THE PRESIDENT AND CEO, THE RECOMMENDATIONS ARE REVIEWED AND APPROVED BY THE HUMAN RESOURCES AND GOVERNANCE COMMITTEE OF THE BOARD AND THE EXECUTIVE COMMITTEE OF THE BOARD. THESE COMMITTEES ALSO REVIEW THE TOTAL SPEND FOR THE INCENTIVE PLANS. THESE LEADERS MUST BE IN ACTIVE REGULAR SERVICE OF THEDACARE INC. FOR THE ENTIRE PLAN YEAR (JANUARY 1, 2019 TO DECEMBER 31, 2019) TO RECEIVE A 2020 BONUS. CARING FOR SUCCESS: THE PLAN OBJECTIVES ARE TO PROVIDE INCENTIVE TO FOCUS THE ORGANIZATION'S RESOURCES, ENERGY AND ATTENTION ON THE FULFILLMENT OF THEDACARE'S MISSION. EMPLOYEE ELIGIBILITY IS BASED ON THE NUMBER OF HOURS WORKED. ALL ELIGIBLE EMPLOYEES SHARE IN THE PAYOUT. THE PAYOUT AMOUNT IS A FLAT DOLLAR AMOUNT, DETERMINED BASED ON BOTH FINANCIAL AND QUALITY THRESHOLDS. THE AMOUNT PER EMPLOYEE IS DETERMINED BY DIVIDING THE TOTAL GAIN REALIZED (THE EMPLOYEE SHARE) BY HOURS PAID TO ALL ELIGIBLE EMPLOYEES. THE THEDACARE BOARD OF TRUSTEES APPROVES THE SPEND FOR THE PLAN. A CITY OF SHAWANO WISCONSIN 396005594 2006-10-02 6000000 SEE PART VI 0 0 0 A 2517592 6000000 6000000 2007 0 0 1 1 A 0 0 0 0 0 0 1 A 0 0 1 0 1 0 0 0 1 A 0 PART I, COLUMN F: FINANCE THE EXPANSION, IMPROVEMENT AND EQUIPPING OF THE HOSPITAL FACILITY, SPECIFICALLY INCLUDING THE ADDITION OF AN ATTACHED CLINIC FACILITY FOR HOSPITAL-BASED PHYSICIANS AND RENOVATIONS OF OUTPATIENT SURGICAL FACILITIES. FORM 990, PART VI, SECTION A, LINE 3 ALL MANAGEMENT AND ADMINISTRATIVE FUNCTIONS ARE PROVIDED BY EMPLOYEES OF THEDACARE, INC., THE SOLE MEMBER AND PARENT COMPANY OF THEDACARE MEDICAL CENTER - SHAWANO, INC. FORM 990, PART VI, SECTION A, LINE 6 THEDACARE MEDICAL CENTER - SHAWANO, INC.'S SOLE MEMBER IS THEDACARE, INC. FORM 990, PART VI, SECTION A, LINE 7A THEDACARE, INC. HAS THE POWER TO ELECT AND REMOVE TRUSTEES. FORM 990, PART VI, SECTION A, LINE 7B ONLY THEDACARE, INC. MAY TAKE THE FOLLOWING ACTIONS: 1. MERGE OR CONSOLIDATE THE CORPORATION; 2. SELL, LEASE, OR TRANSFER ASSETS; 3. APPROVE JOINT VENTURES OR AFFILIATIONS; 4. AMEND THE ARTICLES OF INCORPORATION AND BYLAWS; 5. DEVELOP BUDGETS; 6. AUTHORIZE CAPITAL EXPENDITURES; 7. APPROVE STRATEGIC, SAFETY, AND QUALITY PLANS; AND 8. APPROVE THE DISSOLUTION OR LIQUIDATION OF THE CORPORATION. FORM 990, PART VI, SECTION B, LINE 11B A DRAFT OF THE FORM 990 IS PROVIDED TO THE ORGANIZATION'S DESIGNATED COMMITTEE OF THE BOARD OF DIRECTORS FOR REVIEW AND DISCUSSION AT A BOARD MEETING. THE FINAL VERSION OF THE FORM 990 IS EMAILED TO THE ENTIRE BOARD BEFORE THE RETURN IS FILED. FORM 990, PART VI, SECTION B, LINE 12C QUESTIONNAIRES ARE SENT TO ALL MANAGERS, TRUSTEES, AND OFFICERS ANNUALLY. COMPLETED FORMS ARE RETURNED TO THE COMPLIANCE OFFICER. THE COMPLIANCE OFFICER REVIEWS THE QUESTIONNAIRES AND FOLLOWS UP WITH ANY QUESTIONS ABOUT THE MANAGERS' ANSWERS ON THE CONFLICT OF INTEREST FORMS. ALL EMPLOYEES AND BOARD MEMBERS ARE COVERED UNDER THE CONFLICT OF INTEREST POLICY. THE CORPORATE COMPLIANCE COMMITTEE REVIEWS THE POTENTIAL CONFLICT AND THE CFO/BOARD OF TRUSTEES REVIEW ALL CONFLICTS. AFTER DISCLOSURE OF THE CONFLICT, THE EMPLOYEE SHALL NOT PARTCIPATE IN THE DECISION WHETHER TO ENGAGE IN THE TRANSACTION IN WHICH THE EMPLOYEE HAS AN INTEREST. FORM 990, PART VI, SECTION B, LINE 15 THEDACARE HIRES AN OUTSIDE CONSULTING FIRM TO CONDUCT A THOROUGH MARKET REVIEW OF EXECUTIVE COMPENSATION EVERY OTHER YEAR. THE HUMAN RESOURCES AND GOVERNANCE COMMITTEE OF THE BOARD WAS FORMED IN DECEMBER, 2018. THE OUTSIDE CONSULTANT PRESENTED HIS FINDINGS TO THE CHIEF HUMAN RESOURCES OFFICER, THE PRESIDENT AND CEO. THE INFORMATION WAS THEN PRESENTED TO THE HUMAN RESOURCES AND GOVERNANCE COMMITTEE OF THE BOARD AND THEN TO THE EXECUTIVE COMMITTEE OF THE BOARD. BOTH COMMITTEES WERE PROVIDED THE INFORMATION FOR REVIEW, EDUCATION AND ACCEPTANCE IN DECEMBER, 2019 AND JANUARY, 2020. FORM 990, PART VI, SECTION C, LINE 19 THEDACARE MEDICAL CENTER - SHAWANO, INC. DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND INTERNAL FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. 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