2014-11-10T15:30:20-06:00 2013-12-31 390758449 WIPFLI LLP PO BOX 12237 GREEN BAY WI 543072237 990 2013-01-01 390830664 THEDA CLARK MEDICAL CENTER INC THED 9207355560 PO BOX 8025 APPLETON WI 549128025 TIM A OLSON CHIEF FINANCIAL OFFICER 9207355560 2014-10-15 1 TERRI REXRODE CPA MST P00096513 9206620016 2014-10-15 2013 2015-11-30 17:44:51Z TIM A OLSON PO BOX 8025 APPLETON WI 549128025 179443123 0 X WWW.THEDACARE.ORG X 1909 WI IMPROVING THE HEALTH OF OUR COMMUNITY. 15 11 0 425 661249 -78368 2641245 301929 180999029 179041924 25509 -10269 2478649 72307 186144432 179405891 0 50859 0 0 79140041 83603653 0 0 0 86632664 84748276 165772705 168402788 20371727 11003103 261738797 273804031 113517 379671 261625280 273424360 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 134436310 50859 177782784 250-BED ACUTE CARE HOSPITAL, LEVEL II TRAUMA CENTER, NEUROLOGY, AND OUTPATIENT SURGERY CENTER. WITH CORPORATE PARENT THEDACARE, INC., WE OFFER PUBLIC AWARENESS CAMPAIGNS, CHARITY CARE, SUPPORT GROUPS, AND EDUCATION PROGRAMS TARGETED TO LOCAL COMMUNITY NEEDS. 134436310 1 1 0 1 0 0 0 0 0 0 1 0 0 1 0 1 0 1 0 0 0 0 0 0 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 1 0 0 0 1 1 0 0 0 0 0 0 0 0 0 X 15 11 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 X KRISTEN COGSWELL 9207386471 122 EAST COLLEGE AVENUE APPLETON WI 54911 ANDERLA DAVID MD BOARD MEMBER 1.00 41.00 X 0 317508 28818 ATTASSI OMAR MD BOARD MEMBER 1.00 3.00 X 0 0 0 DALEY-ULLEM BETH BOARD MEMBER 1.00 2.00 X 0 0 0 DAVIS JOHN BOARD MEMBER 1.00 2.00 X 0 0 0 EDELMAN GARY MD BOARD MEMBER 1.00 42.00 X 0 432258 31028 JONES GINGER BOARD MEMBER 1.00 2.00 X 0 0 0 LARSON JIM BOARD MEMBER 1.00 3.00 X 0 0 0 MOARD DOUGLAS MD BOARD MEMBER 1.00 42.00 X 0 289271 27239 TIMBERLAKE KAREN BOARD MEMBER 1.00 2.00 X 0 0 0 WALSH CYRIL P BOARD MEMBER 1.00 2.00 X 0 0 0 STELLMACHER JON BOARD CHAIRMAN 1.00 2.00 X X 0 0 0 MALANOWSKI JOHN BOARD VICE-CHAIRMAN 1.00 2.00 X X 0 0 0 WELLER MIKE BOARD TREASURER 1.00 2.00 X X 0 0 0 WHITESIDE JEFFREY MD BOARD SECRETARY 1.00 2.00 X X 0 0 0 GRUNER DEAN BOARD MEMBER/CEO-SYSTEM 7.00 36.00 X X 155912 883497 175678 OLSON TIM VP, CFO-SYSTEM 6.00 35.00 X 72973 413510 104930 BURMEISTER BRIAN VP SR, PHYSICIAN & RURAL SERVICES 4.00 38.00 X 36249 326240 80071 BARNAS KIM VP SR AMC & THEDA CLARK HOSPITAL 10.00 30.00 X 103860 311582 99280 LIVINGSTON KEITH VP SR CIO 6.00 34.00 X 61562 348846 86106 PISTONE MAUREEN VP SR TALENT MANAGEMENT 6.00 34.00 X 52659 298403 80998 DEVINE GREGORY VP SR PROVIDER STRATEGIES AND SYSTEMS OF CARE 6.00 34.00 X 73066 414039 78875 HUNTER WILLIAM VP SR PLANNING & MARKETING 6.00 36.00 X 62952 356722 76222 LONG GREGORY MD CHIEF MEDICAL OFFICER 6.00 35.00 X 70252 398096 89753 POOLE JOHN VP SR THEDACARE IMPROVEMENT SYSTEM 6.00 34.00 X 58296 330348 83963 747781 5120320 1042961 35 0 1 0 SURGICAL ASSOCIATES NEENAH SC 100 THEDA CLARK MED PLAZA STE 400 NEENAH WI 54956 MEDICAL SERVICES 598267 NEUROSCIENCE GROUP OF NE WI 1305 W AMERICAN DRIVE NEENAH WI 54956 MEDICAL SERVICES 556653 AYLWARD PHYSICIANS LLC 130 SECOND STREET NEENAH WI 54956 MANAGEMENT SERVICES 300800 ORTHOPEDIC SPECIALISTS SC 1516 S COMMERCIAL STREET NEENAH WI 54956 MEDICAL SERVICES 247246 FOX VALLEY PATHOLOGISTS SC 325 N COMMERCIAL STREET NEENAH WI 54956 MEDICAL SERVICES 157463 9 300062 1867 301929 INPATIENT REVENUE NET 621990 87611519 87611519 OUTPATIENT REVENUE NET 621400 86801980 86801980 AFFILIATE RENTAL REVENUE 900099 1920346 1920346 OTHER REVENUE 621990 1444549 1444549 LAB REFERRAL REVENUE 621500 661249 661249 602281 602281 179041924 26963 26963 67917 0 67917 67917 67917 37232 -37232 -37232 -37232 EQUITY GAIN IN AFFILIATE 900099 4390 4390 4390 179405891 177782784 661249 659929 X 50859 50859 771469 771469 62811021 45627402 17183619 2756085 2756085 13067587 10255310 2812277 4197491 4197491 330800 330800 19649138 9034575 10614563 12419 12419 35993824 33743445 2250379 1394258 1390887 3371 35880 35880 115372 115372 3107283 3107283 13699883 13699883 444655 444655 BAD DEBT EXPENSE 7443160 7443160 EQUIPMENT MAINTENANCE 2491355 2491355 MEANINGFUL USE OVERPAYM 30249 30249 168402788 134436310 33966478 0 3410 3410 22621141 23544195 876338 1290255 213813453 120755696 93401331 93057757 144836577 155908414 261738797 273804031 113517 379671 113517 379671 X 260866771 272665851 758509 758509 261625280 273424360 261738797 273804031 X 11003103 795977 X X 0 1 X 1 0 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 13153 13153 0 PART II-B, LINE 1: WHA DUES OF $13,153. 5537505 5537505 145563825 70985979 74577846 1982268 1369773 612495 60729855 48399944 12329911 93057757 DUE FROM AFFILIATES 155908414 155908414 X PART X, LINE 2: IN ORDER TO ACCOUNT FOR ANY UNCERTAIN TAX POSITIONS, THEDACARE DETERMINES WHETHER IT IS MORE LIKELY THAN NOT THAT A TAX POSITION WILL BE SUSTAINED UPON EXAMINATION OF THE TECHNICAL MERITS OF THE POSITION, ASSUMING THE TAXING AUTHORITY HAS FULL KNOWLEDGE OF ALL INFORMATION. IF THE TAX POSITION DOES NOT MEET THE MORE-LIKELY-THAN-NOT RECOGNITION THRESHOLD, THE BENEFIT OF THAT POSITION IS NOT RECOGNIZED IN THE CONSOLIDATED FINANCIAL STATEMENTS. THEDACARE RECORDED NO ASSETS OR LIABILITIES RELATED TO UNCERTAIN TAX POSITIONS IN 2013 AND 2012. TAX RETURNS FOR THE YEARS ENDED 2010 AND BEYOND REMAIN SUBJECT TO EXAMINATION BY THE INTERNAL REVENUE SERVICE. 1 1 X 1 X 1 X 1 0 1 1 3064748 3064748 0.01900 20016553 17313934 2702619 0.01680 23081301 17313934 5767367 0.03580 23 1030658 1695797 1695797 0.01050 4 2676 544977 126350 418627 0.00260 4 6826121 6826121 0.04240 2 2778 230552 230552 0.00140 6 1064092 610831 610831 0.00380 39 2100204 9908278 126350 9781928 0.06070 39 2100204 32989579 17440284 15549295 0.09650 1 4 2065 2065 0.00000 1 266271 2345 2345 0.00000 1 320 7791 7791 0.00000 1 16 55 55 0.00000 1 10 724 724 0.00000 1 80746 1460 1460 0.00000 1 250 18295 3226 15069 0.00010 7 347617 32735 3226 29509 0.00010 0 3762935 3056019 22783073 26995676 -4212603 X 1 1 1 1 THEDA CLARK MEDICAL CENTER 120 SECOND STREET NEENAH WI 54956 X X X THEDA CLARK MEDICAL CENTER 1 1 X X X X X X X X X X 13 1 1 1 X WWW.THEDACARE.ORG/HOSPITALS-AND-CLINICS/T X X X X X X X X X X 0 0 1 1 200.000000000000 1 300.000000000000 1 X X X X X X X 1 1 X X X X X 1 0 1 X 0 0 THEDA CLARK MEDICAL CENTER PART V, SECTION B, LINE 1J: THEDA CLARK MEDICAL CENTER'S CHNA ALSO IDENTIFIED OWNER EXPECTATIONS, MISSION/VALUES, KEY COMPONENTS OF OUR COMMITMENT, ORGANIZATIONAL SUPPORT, ADVISORY TEAM GUIDANCE AND THE HEALTH IMPROVEMENT MODEL. THEDA CLARK MEDICAL CENTER PART V, SECTION B, LINE 3: PUBLIC HEALTHTHEDACARE WORKED CLOSELY WITH OUTAGAMIE, WINNEBAGO, WAUSHARA AND GREEN LAKE COUNTY PUBLIC HEALTH DEPARTMENTS THROUGHOUT THE ENTIRE NEEDS ASSESSMENT PROCESS. THEDACARE HAS REPRESENTATION ON THE FOX VALLEY COMMUNITY HEALTH IMPROVEMENT COALITION WHICH MEETS MONTHLY WITH LOCAL HEALTH SYSTEM REPRESENTATIVES AND PUBLIC HEALTH OFFICIALS FROM THE COUNTIES OF OUTAGAMIE, CALUMET AND WINNEBAGO AND CITIES OF APPLETON AND MENASHA. WAUSHARA AND GREEN LAKE PUBLIC HEALTH OFFICIALS ARE ALSO INVITED TO ATTEND. PUBLIC HEALTH IS REPRESENTED ON THEDACARE'S NEEDS ASSESSMENT ADVISORY COMMITTEE AND ALSO ON THE THEDACARE-LED COMMUNITY HEALTH ACTION TEAM. IN ADDITION TO THESE FORMAL MEETINGS, ONE-ON-ONE INTERVIEWS WITH PUBLIC HEALTH OFFICIALS WERE CONDUCTED EITHER OVER THE PHONE OR IN PERSON. SOURCES: DOUG GIERYN, WINNEBAGO COUNTY PUBLIC HEALTH DIRECTOR; KATHRYN MUNSEY, GREEN LAKE PUBLIC HEALTH OFFICER; PATTI WOHLFIEL, WAUSHARA COUNTY PUBLIC HEALTH OFFICERCOMMUNITY HEALTH ACTION TEAMS (CHAT) ARE THE PRIMARY RESOURCES THEDACARE USES TO ENGAGE THE COMMUNITY IN BETTER UNDERSTANDING THE LOCAL HEALTH NEEDS AND DEVELOPING PLANS FOR ACTION. THEDACARE'S COMMUNITY HEALTH SPECIALISTS HELP FACILITATE THE CHAT EFFORTS FOR FOUR CHAT TEAMS IN THE FOX CITIES, NEW LONDON, SHAWANO AND WAUPACA AREAS. EACH CHAT TEAM IS COMPRISED OF LOCAL COMMUNITY LEADERS FROM BUSINESS, EDUCATION, PUBLIC HEALTH, AREA HEALTH SYSTEMS, FAITH COMMUNITIES, NON-PROFIT ORGANIZATIONS AND GOVERNMENT. THESE LEADERS SELECT ISSUES TO STUDY, ORGANIZE "PLUNGE" EXPERIENCES (DAY-LONG FIELD TRIPS) TO GAIN IN-DEPTH UNDERSTANDING AND COLLABORATE IN PROBLEM-SOLVING INITIATIVES. THIS RESULTS IN SUSTAINABLE, EFFECTIVE COMMUNITY-BASED SOLUTIONS TO SYSTEMIC HEALTH ISSUES. THEDA CLARK MEDICAL CENTER PROVIDERS AND STAFF ARE INTEGRATED INTO A WIDE VARIETY OF THESE INITIATIVES. THE FOX CITIES CHAT INCLUDES LEADERS FROM PUBLIC HEALTH, UNITED WAY, COMMUNITY FOUNDATION, NON-PROFITS, EDUCATION, AND HEALTH ORGANIZATIONS WHICH COLLECTIVELY REPRESENT THE BROAD INTERESTS OF THE COMMUNITY. 2013 FOX CITY COMMUNITY HEALTH ACTION TEAM ROSTERROGER BERTSCHAUSEN, MINISTER FOX VALLEY UNITAVERSALIST FELLOWSHIPWILL BLOEDOW, RETIRED PASTORRAY DURKEE, APPLETON MEDICAL CENTER FOUNDATION, BOARD MEMBERKURT EGGEBRECHT, PUBLIC HEALTH OFFICER, APPLE HEALTH DEPARTMENTMICHAEL FROHNA, EXECUTIVE DIRECTOR, THEDACARE FOUNDATIONSJAY FULKERSON, CEO, HEALTH PAYMENT SYSTEMSSHANNON FULL, PRESIDENT, FOX CITIES CHAMBER OF COMMERCETIM GALLOWAY, PRESIDENT GALLOWAY COMPANYERNESTO GONZALES, PRESIDENT CASA HISPANADEAN GRUNER, CEO THEDACAREMARTI HENWALL, VP OF DONER ENGAGEMENT COMMUNITY FOUNDATION FOR THE FOX CITY REGIONPETER KELLY, PRESIDENT UNITED WAY OF THE FOX VALLEYSHANNON KENEVAN, DIVERSITY DIRECTOR HARMONY CAFE/GOODWILL INDUSTRIESGREG LEMKE ROCHON, CPO BOYS & GIRLS CLUB OF THE FOX VALLEYCHRIS METHENY, VP FOX VALLEY TECHNICAL COLLEGEJOHN MIELKE, MD, RETIRED CARDIOLOGIST THEDACAREPAULA MORGEN, COMMUNITY HEALTH THEDACARECATHY MUTSCHLER, DIRECTOR U.S. VENTUREAMY PULZER, DIRECTOR OSHKOSH AREA COMMUNITY FOUNDATIONCAROLYN SLAVIK, COORDINATOR MISSION SERVICES MINISTRY HEALTH SYSTEMROLLIE STEPHENSON, CEO FAITH TECHNOLOGIESDAVE VANDER ZANDEN, RETIRED EDUCATORBEN VOGEL, ASSISTANT SUPERINTENDENT APPLE AREA SCHOOL DISTRICTDEBORAH WETTER, GENERAL MANAGER VALLEY TRANSITKEY INFORMANT INTERVIEWS WERE CONDUCTED WITH EXPERTS REPRESENTING VULNERABLE OR MARGINALIZED POPULATIONS IN OUR COMMUNITY INCLUDING FARM FAMILIES, LATINO POPULATION, LESBIAN, GAY, BISEXUAL, TRANSGENDER (LGBT) POPULATION, LOW INCOME AND SENIORS. SOURCES: LEONA WHITTMAN, LIVING HEALTHY COMMUNITY CLINIC; TONY BEREGZAZZI, ADVOCAP; RHONDA STREBEL, RURAL HEALTH INITIATIVE; ERNESTO GONZALES, CASA HISPANA; DR. IRIS TORRES AND PATRICIA SARVALA, PARTNERSHIP COMMUNITY HEALTH CLINIC; TONY GONZALES, THOMPSON SENIOR CENTER; TRICIA NELSON, THEDACARE MEDICAL HOME; HISPANIC LATINO FOCUS GROUP PROJECT, 2011; CHAT PLUNGE ON HISPANIC POPULATION, 2010; CHAT PLUNGE ON GLBT POPULATION, 2011; CHAT INCLUDE BREAKFAST, 2013. THEDA CLARK MEDICAL CENTER PART V, SECTION B, LINE 4: AFFINITY HEALTH SYSTEM THEDA CLARK MEDICAL CENTER PART V, SECTION B, LINE 5D: THE CHNA WAS MADE AVAILABLE TO LOCAL CHAT, THEDACARE BOARDS AND LEADERSHIP TEAMS. THEDA CLARK MEDICAL CENTER PART V, SECTION B, LINE 6I: THEDACARE ADDRESSES COMMUNITY HEALTH IMPROVEMENT IN THE ANNUAL STRATEGIC PLANNING, AND REPORT PROCESS ANNUALLY AT THE BOARD OF TRUSTEES. THEDA CLARK MEDICAL CENTER PART V, SECTION B, LINE 7: ACCESS TO MENTAL HEALTH CARE - A VARIETY OF OTHER ORGANIZATIONS ARE WORKING ON THIS ISSUETOBACCO AND SMOKING - RECENT STATE LAWS AND SOCIAL NORMS HAVE HAD A SIGNIFICANT IMPACT ON SMOKING REDUCTION. A LOCAL COALITION EXISTS TO CHAMPION THIS ISSUEACCESS TO DENTAL CARE - SEVERAL RECENT INITIATIVES HAVE EXPANDED DENTAL CAPACITY INCLUDING THE START-UP OF A MOBILE DENTAL BUS SERVICEPREVENTIVE HEALTH SCREENINGS - PLAN TO ADD AS A PRIORITY IN NEXT PLAN CYCLEAFFORDABLE MEDICATIONS - BEYOND WHAT OUR LIMITED RESOURCES CAN SUPPORT AT THIS TIMEDIABETES - SIGNIFICANT EFFORTS ARE UNDERWAY WITHIN LOCAL HEALTHCARE ORGANIZATION PART V, LINE 13: 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. 2 AYLWARD SURGERY CENTER 120 SECOND STREET NEENAH WI 54956 OUTPATIENT SURGERY CENTER RENAISSANCE SURGERY CENTER 2400 WITZEL AVENUE OSHKOSH WI 54904 OUTPATIENT SURGERY CENTER 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, LN 7 COL(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 $7,443,160. PART II, COMMUNITY BUILDING ACTIVITIES: THE HEALTH OF THE COMMUNITY THEDA CLARK MEDICAL CENTER IS PROMOTED THROUGH SEVERAL COMMUNITY BUILDING ACTIVITIES AS DESCRIBED BELOW:SELF SUFFICIENCY PROJECT COALITION TO END POVERTY IN THE OSHKOSH AREA. POVERTY IS DIRECTLY RELATED TO HEALTH. POVERTY SIMULATION ACTIVITY TO HELP COMMUNITY LEADERS UNDERSTAND WHAT IT'S LIKE TO LIVE IN POVERTY AND ULTIMATELY ENCOURAGE POLICY AND PROGRAMS TO HELP LIFT PEOPLE OUT OF POVERTY. BACKYARD BUDDIES PROVIDES MENTORS TO HELP YOUTH FROM LOW-INCOME FAMILIES TO BE SUCCESSFUL ACADEMICALLY AND SOCIALLY. EDUCATION HAS DIRECT IMPACT ON HEALTH. WELL CITY INITIATIVE PROMOTES DEVELOPMENT OF A HEALTHY WORKPLACE THROUGHOUT THE FOX CITIES.NEW MENTAL HEALTH CONNECTION COALITION OF MENTAL HEALTH PROVIDERS MEETING TO IMPROVE ACCESS TO MENTAL HEALTH SERVICES THROUGHOUT THE FOX CITIES.CHAMBER OF COMMERCE SUPPORT ENCOURAGES ECONOMIC DEVELOPMENT WHICH IN TURN PROVIDES JOBS AND INCOME, BOTH CONTRIBUTORS TO HEALTH.VOICES OF MEN WORKS TO ADDRESS THE ROOT CAUSE OF VIOLENCE AGAINST WOMEN AND GIRLS WHICH INCLUDES DEVALUING AND OBJECTIFYING WOMEN AND TREATING WOMEN AS PROPERTY. NO WRONG DOOR EFFORT TO DEVELOP COMMUNITY WIDE MENTAL HEALTH SAFETY NET.DISASTER READINESS HELPS ENSURE THE ENTIRE COMMUNITY IS READY FOR POTENTIAL EMERGENCIES. PSYCHIATRIST RECRUITMENT IMPROVES MENTAL HEALTH OF COMMUNITY. COMMUNITY ACTION FOR HEALTHY LIVING COALITION THAT ADVOCATES FOR HEALTHY LIFESTYLE CHANGE. THEDACARE NEIGHBORHOOD GARDEN/FARMER'S MARKETS PROVIDES FRESH PRODUCE TO AREA FOOD PANTRIES AND THE COMMUNITY.FOX VALLEY END OF LIFE COALITION - A GRASSROOTS CONSORTIUM WITH A MISSION TO IMPROVE END-OF-LIFE CARE AND CHOICES FOR ALL PEOPLE, THEIR FAMILIES, AND THEIR PHYSICIANS IN THE FOX CITIES.EMERGING LEADERS - MAKING AN IMPACT IN OUR COMMUNITY THROUGH DEDICATION TO SERVICE AND PHILANTHROPY.SUMMIT FOR HOPE - AIMS TO RAISE AWARENESS ABOUT SUBSTANCE ABUSE AND THE GROWING HEROIN ISSUE. PARTY AT THE PAC - PUTTING TEEN SAFETY IN FOCUS.ELECTRONIC RECYCLING EVENT WORKING TO TREAT THE EARTH WITH THE RESPECT THAT IT DESERVES.COMMUNITY SHARPS COLLECTION REDUCING THE RISKS OF INFECTIOUS WASTE.WISCONSIN SUSTAINABLE BUSINESS COUNCIL - TAKING AN ACTIVE POSITION ON THE ROLE OF CLIMATE CHANGE AND BUILDING HEALTHY COMMUNITIES BY REDUCING OR ELIMINATING OUR ENERGY WASTE AND WATER FOOTPRINT.ORGAN AND TISSUE ORGANIZATION ADVANCING ORGAN DONATION EDUCATION. RURAL HEALTH INITIATIVE - ADDRESSING GROWING CONCERNS REGARDING THE HEALTH AND SAFETY ISSUES FACING TODAY'S FARM FAMILIES. YMCA STRONG KIDS PROVIDING KIDS THE OPPORTUNITIES THEY NEED TO REACH THEIR FULL POTENTIAL, LIVE HEALTHIER, HAPPIER LIVES TODAY, AND GROW INTO PRODUCTIVE ADULTS IN THE FUTURE. FOX VALLEY FAMILY MEDICINE RESIDENCY PROGRAM TEACHING THE ART AND HEART OF CARE.BUILDING FOR KIDS BUILDING KIDS IMAGINATION, CREATIVITY AND CONFIDENCE.CHAT - COMMUNITY LEADERS WORKING TOGETHER TO EXPLORE LOCAL AND REGIONAL HEALTH ISSUES. THEDACARE CENTER FOR HEALTHCARE VALUE - OFFERS LEARNING EXPERIENCES THAT DEVELOP HEALTHCARE LEADERS WHO ARE CAPABLE OF CONFIDENTLY DRIVING THE LEAN TRANSFORMATION OF THEIR ORGANIZATIONS TO DELIVER MEASURABLY BETTER VALUE TO THE PATIENTS, FAMILIES AND COMMUNITIES THEY SERVE.TRAUMA SYMPOSIUM FOCUSING ON EMERGENCY PREPAREDNESS. SEXUAL ASSAULT NURSE EXAMINER WORKING TO END SEXUAL AND DOMESTIC VIOLENCE.UNITED WAY WORKING EVERY DAY TO IMPROVE THE COMMUNITY. PART III, LINE 2: 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 III, LINE 3: OVERDUE PATIENT ACCOUNTS ARE SENT THREE STATEMENTS BEGINNING THE MONTH AFTER THE ACCOUNT BECOMES OVERDUE. IF NO PAYMENT IS MADE DURING THIS PERIOD A FINAL LETTER IS SENT GIVING NOTICE OF THE OVERDUE ACCOUNT AND NOTIFYING THE INDIVIDUAL THAT THE AMOUNT WILL GO INTO COLLECTIONS. AT THIS POINT, THE AMOUNT IS MARKED AS BAD DEBT. PART III, LINE 4: A COST-TO-CHARGE RATIO WAS USED TO DETERMINE THE AMOUNTS REPORTED IN PART III LINES 2 AND 3. PATIENT PAYMENTS OR DISCOUNTS ARE APPLIED PRIOR TO DETERMINING BAD DEBT EXPENSE AND ARE NOT INCLUDED IN THE BAD DEBT WRITE-OFF REPORTED ON THE AUDITED FINANCIAL STATEMENTS. DEDUCTIBLES AND COINSURANCE AMOUNTS THAT ARE DEEMED UNCOLLECTIBLE ARE WRITTEN OFF EITHER TO BAD DEBT EXPENSE OR, IF APPLICABLE, TO CHARITY CARE IF THE PATIENT SO QUALIFIES FOR FINANCIAL ASSISTANCE. THE FINANCIAL STATEMENTS DO NOT CONTAIN A FOOTNOTE BUT THEY ACCOUNT FOR BAD DEBTS BASED ON GROSS CHARGES TO PATIENTS AFTER REFLECTING ANY PAYMENTS OR DISCOUNTS, OR AMOUNTS DETERMINED TO BE ELIGIBLE FOR CHARITY CARE/FINANCIAL ASSISTANCE. 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 SERVES AN 8-COUNTY PRIMARY SERVICE AREA. FIVE THEDACARE HOSPITALS PROVIDE SERVICE IN THIS AREA. THEDACARE CONDUCTS A COMMUNITY NEEDS ASSESSMENT EVERY THREE YEARS FOR THE ENTIRE SYSTEM GATHERING DATA PERTINENT TO EACH COMMUNITY. 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 25 COMMUNITY LEADERS IN BUSINESS, NON-PROFIT, CLERGY, HEALTHCARE, UNITED WAY, PUBLIC HEALTH AND THE LOCAL COMMUNITY FOUNDATION. 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: THEDA CLARK'S SERVICE AREA CONSISTS OF WINNEBAGO, WAUSHARA, AND GREEN LAKE COUNTIES LOCATED IN EAST-CENTRAL WISCONSIN. THE THREE COUNTY AREA HOSTS A COMBINED POPULATION OF 209,736. WINNEBAGO COUNTY: - SINCE 2000, WINNEBAGO COUNTY HAS EXPERIENCED A 6.1% POPULATION GROWTH, OR A TOTAL OF 9,500 RESIDENTS. - WINNEBAGO COUNTY HIGH SCHOOL GRADUATION RATE IS 90%,- HAS HAD A LOWER UNEMPLOYMENT RATE THAN THE STATE OR NATION PRIMARILY DUE TO A STRONG MANUFACTURING BASE. TRADE/TRANSPORTATION/UTILITIES, EDUCATION/HEALTH AND MANUFACTURING EMPLOY THE MOST PEOPLE IN THE COUNTY. - THE MEDIAN AGE OF WINNEBAGO COUNTY RESIDENTS IS 37 YEARS.- ELEVEN PERCENT OF WINNEBAGO COUNTY LIVE BELOW 100% OF THE FEDERAL POVERTY LEVEL.- THE LARGEST MINORITY POPULATIONS ARE LATINO AND ASIAN. NATIVE AMERICANS ACCOUNT FOR APPROXIMATELY 1% OF THE POPULATION AND AFRICAN-AMERICANS REPRESENTS LESS THAN 1%. THE LATINO POPULATION HAS A SIGNIFICANT AND GROWING PRESENCE AT 4.6%. WAUSHARA COUNTY:- OVER THE COURSE OF THE PAST DECADE, WAUSHARA COUNTY HAS EXPERIENCED A POPULATION GROWTH OF 10.7%. - WAUSHARA COUNTY HIGH SCHOOL GRADUATION RATE IS 85%- HAS A MORE SEASONAL EMPLOYMENT BASE THAN THE STATE OR NATION. EDUCATION, HEALTH, TRADE, TRANSPORTATION AND UTILITIES AND PUBLIC ADMINISTRATION ARE THE LARGEST EMPLOYMENT SECTORS. WAUSHARA COUNTY'S AVERAGE ANNUAL WAGE ACROSS ALL INDUSTRY SECTORS IS BELOW THE STATE AVERAGE. - THE MEDIAN AGE OF WAUSHARA COUNTY'S POPULATION IS 46.2 YEARS.- THIRTEEN PERCENT OF WAUSHARA COUNTY LIVES BELOW 100% OF THE FEDERAL POVERTY LEVEL.- THE LARGEST MINORITY POPULATIONS ARE LATINO AND ASIAN. NATIVE AMERICANS ACCOUNT FOR APPROXIMATELY 1% OF THE POPULATION AND AFRICAN-AMERICANS REPRESENTS LESS THAN 1%. THE LATINO POPULATION HAS A SIGNIFICANT AND GROWING PRESENCE AT 4.6%. GREEN LAKE COUNTY:- HAS BEEN AMONG WISCONSIN'S SLOWER GROWING COUNTIES. - GREEN LAKE COUNTY GRADUATION RATE IS 90%.- GREEN LAKE'S UNEMPLOYMENT RATE IS SIGNIFICANTLY HIGHER THAN THE STATE. THE TOP EMPLOYERS IN GREEN LAKE COUNTY ARE IN HEALTH, EDUCATION AND MANUFACTURING. - THE MEDIAN AGE OF GREEN LAKE COUNTY RESIDENTS IS 41 YEARS.- ELEVEN PERCENT OF GREEN LAKE COUNTY LIVES BELOW 100% OF THE FEDERAL POVERTY LEVEL.- THE LARGEST MINORITY POPULATIONS ARE LATINO AND ASIAN. NATIVE AMERICANS ACCOUNT FOR APPROXIMATELY 1% OF THE POPULATION AND AFRICAN-AMERICANS REPRESENTS LESS THAN 1%. THE LATINO POPULATION HAS A SIGNIFICANT AND GROWING PRESENCE AT 4.6%. PART VI, LINE 5: EACH YEAR, THEDA CLARK MEDICAL CENTER'S PARENT ORGANIZATION THEDACARE SETS ASIDE A PERCENTAGE OF EXCESS BUDGETED MARGIN TO FUND AN EFFORT CALLED CHAT (COMMUNITY HEALTH ACTION TEAM). CHAT IS A GROUP OF 25 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. THROUGH CHAT, SUCH EFFORTS AS THE SHAWANO COUNTY RURAL HEALTH INITIATIVE HAVE BEEN DEVELOPED. THIS INITIATIVE TAKES BASIC HEALTH CARE AND SCREENING SERVICES TO THE FARM. EACH YEAR HUNDREDS OF FARM FAMILIES LIVING WITHOUT INSURANCE OR ONLY CATASTROPHIC COVERAGE RECEIVE CRITICAL ASSISTANCE. THIS INITIATIVE HAS NOW SPREAD TO OUTAGAMIE, WINNEBAGO AND WAUPACA COUNTIES. ANOTHER INITIATIVE IS THE NEW MENTAL HEALTH CONNECTION WHICH IS WORKING TO IMPROVE ACCESS TO MENTAL HEALTH SERVICES IN THE AREA. HIGH LATINO TEEN PREGNANCY RATES INSPIRED CHAT TO LAUNCH CUIDATE!, A CULTURALLY BASED TEEN PREGNANCY PREVENTION PROGRAM IN PARTNERSHIP WITH THE PARTNERSHIP COMMUNITY HEALTH CENTER. MAKING THE RIDE HAPPEN IS ANOTHER CHAT EFFORT THAT PROVIDES TRANSPORTATION TO OLDER ADULTS WHO OTHERWISE WOULD STAY COOPED UP IN APARTMENTS AND FIGHT DEPRESSION AND ISOLATION. PROJECT PROMISE IS A POVERTY INITIATIVE DEVELOPED THROUGH CHAT THAT BROUGHT TOGETHER MANY LOCAL AGENCIES AND BUSINESSES TO WORK TO ADDRESS POVERTY IN A COLLABORATIVE FASHION. VOICES OF MEN WAS LAUNCHED WITH SUPPORT FROM CHAT TO RAISE AWARENESS OF EVERYDAY BEHAVIORS OF MEN THAT CAN LEAD TO AN ACCEPTANCE OF VIOLENCE TOWARD WOMEN. ANOTHER RECENT INITIATIVE IS INCLUDE WHICH FOCUSES ON BUILDING INCLUSIVENESS AND TOLERANCE TO PREVENT SUICIDE AMONG THE GAY, LESBIAN, BISEXUAL, TRANSGENDER POPULATION. THEDACARE PROVIDES FUNDING AND STAFF SUPPORT TO MAKE CHAT COMMUNITY HEALTH EFFORTS POSSIBLE. - IN 2013, THEDACARE SHARED ITS CUTTING EDGE APPLICATION OF LEAN PRODUCTION IMPROVEMENTS WITH HUNDREDS OF HEALTHCARE AND NON-HEALTHCARE VISITORS FROM AROUND THE WORLD. MOST WERE VISITORS WERE FROM HOSPITALS AND HEALTH SYSTEMS IN THE UNITED STATES LOOKING TO IMPROVE QUALITY AND REDUCE COSTS.- THEDACARE HOSPITALS PROVIDED SUPPORT TO THE THEDACARE CENTER FOR HEALTHCARE VALUE WHICH IS COORDINATING EFFORTS ACROSS THE COUNTRY TO SHARE QUALITY IMPROVEMENT AND COST REDUCTION LEARNINGS. - THEDACARE PARTNERS WITH THE FOX CITIES/UW RESIDENCY CENTER TO PROVIDE HANDS ON EXPERIENCE FOR MEDICAL STUDENTS.- 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.- THEDACARE HOSPITALS PROVIDED FINANCIAL AS WELL AS DIAGNOSTIC AND LAB SUPPORT TO TWO AREA CLINICS PROVIDING MEDICAL AND DENTAL CARE TO THE UNDERSERVED IN OUR SERVICE AREA.- THEDACARE HOSPITAL EMPLOYEES TAKE PART IN HELPING HEARTS, AN EMPLOYEE VOLUNTEERISM PROGRAM ENCOURAGING STAFF TO GIVE OF THEIR TIME IN THE COMMUNITY. THEDACARE PROVIDES PAID STAFF TO COORDINATE THE PROGRAM AND IDENTIFY AND PROMOTE VOLUNTEERISM OPPORTUNITIES. THEDACARE EMPLOYEES DONATED MORE THAN $1,434,000 IN UNPAID VOLUNTEER HOURS TO LOCAL NON-PROFITS IN 2013. - THEDACARE SPONSORS PARTY AT THE PAC FOR THOUSANDS OF AREA YOUTH TO EDUCATE YOUTH ON THE PERILS OF RISKY BEHAVIOR AND DRIVING. HOSTED AT OUR PERFORMING ARTS CENTER, LIVE DRAMATIZATIONS ALONG WITH STORIES OF YOUTH DISABLED DUE TO DRIVING AND RISKY BEHAVIOR ENCOURAGE TEENS TO THINK TWICE BEFORE DRINKING OR TEXTING AND DRIVING. - THEDA CLARK MEDICAL CENTER PROVIDES HELPFUL COMMUNITY EDUCATION PROGRAMMING ON SUCH TOPICS AS ASTHMA, HEART DISEASE, PAIN MANAGEMENT, CPR, STROKE RISK AND DIABETES.- THEDA CLARK MEDICAL CENTER HOSTS HEALTH AND SAFETY FAIRS IN THE COMMUNITY.- THEDA CLARK MEDICAL CENTER HOSTS SUPPORT GROUPS FOR STOKE VICTIMS, GRIEF, DIABETES, AND INFANT LOSS. - THEDA CLARK MEDICAL CENTER WORKS WITH THE AREA CHAMBER OF COMMERCE AND LOCAL HIGH SCHOOLS AND COLLEGES TO INFORM YOUTH ABOUT MEDICAL CAREER OPPORTUNITIES AND TO HELP PREPARE OUR EDUCATIONAL FACILITIES TO MEET THE HEALTHCARE STAFFING NEEDS FOR THE COMMUNITIES WE SERVE.- THEDA CLARK MEDICAL CENTER OPERATES A RADIOLOGY SCHOOL TO PREPARE NEW TECHNOLOGISTS FOR CAREERS IN THE FIELD. - A PARTNERSHIP AMONG THEDA CLARK MEDICAL CENTER, CHILDREN'S HOSPITAL OF WISCONSIN AND ROOSEVELT ELEMENTARY SCHOOL PROVIDES ONE-ON-ONE MENTORING AND HEALTH EDUCATION TO UNDERSERVED CHILDREN IN THE NEENAH AREA. - THEDA CLARK MAKES FINANCIAL AND IN-KIND DONATIONS TO NON-PROFIT ORGANIZATIONS INCLUDING UNITED WAY, YMCA, KIWANIS, 4H, AND GIRL SCOUTS ETC TO SUPPORT COMMUNITY INITIATIVES THAT ADDRESS HEALTH RISK FACTORS SUCH AS POVERTY, EDUCATION, ENVIRONMENT AND MORE.- THEDA CLARK STAFF SUPPORT THE THEDACARE NEIGHBORHOOD GARDEN WHICH SUPPLIES PRODUCE TO THE LOCAL EMERGENCY SHELTER. - THEDA CLARK MEDICAL CENTER SUPPLIES ATHLETIC TRAINING SERVICES TO AREA HIGH SCHOOLS AT REDUCED COST.- THEDA CARE STAFF PARTICIPATES IN LEADERSHIP FOX CITIES TO GROOM MIDDLE MANAGERS IN THE WORKINGS OF THE ENTIRE COMMUNITY, FROM EDUCATION SYSTEMS AND RECYCLING PROGRAMS TO GOVERNMENT AND JUSTICE SYSTEMS. - THEDA CLARK MEDICAL CENTER STAFF IS INVOLVED IN STATEWIDE AND REGIONAL DISASTER READINESS PLANNING TO PREPARE OUR COMMUNITY FOR TIMES OF CRISIS.- THEDA CARE PRESIDENT AND CEO ARE ENGAGED IN STATEWIDE WISCONSIN COLLABORATIVE FOR HEALTHCARE QUALITY MAKING QUALITY HEALTHCARE DATA TRANSPARENT. PART VI, LINE 6: THEDACARE, THE PARENT ORGANIZATION, PROVIDES DIRECTION RELATED TO COMMUNITY NEEDS ASSESSMENT FOR ALL HOSPITALS AND MARKETS WITHIN ITS SERVICE AREA. EACH THEDACARE HOSPITAL, ALONG WITH COMMUNITY HEALTH IMPROVEMENT (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 1 THEDA CLARK MEDICAL CENTER FOUNDATION 130 SECOND ST NEENAH WI 54956 311550056 STATE OF WI 50859 GENERAL 1 PART I, LINE 2: IN ORDER FOR GRANT REQUESTS TO BE CONSIDERED THEY MUST MEET THE FOLLOWING GUIDELINES: 1) DIRECTED TOWARD PROJECTS THAT SUPPORT THEDACARE'S MISSION AND VALUES 2) BENEFIT THE COMMUNITES SERVED BY THEDACARE, INC. 3) BENEFIT A 501 (C)(3) NOT-FOR-PROFIT ORGANIZATION CONVERSELY, REQUESTS MUST NOT BE FOR: 1) THE SOLE BENEFIT OF AN INDIVIDUAL 2) POLITICAL ORGANIZATIONS OR CAMPAIGN COMMITTEES 3) RELIGIOUS ORGANIZATIONS (FOR STRICTLY RELIGIOUS PURPOSES) 4) ORGANIZATIONS IN CONFLICT WITH THEDACARE'S MISSION AND VALUES 5) STATE OR NATIONAL CAMPAIGNS ALL ORGANIZATIONS REQUESTING GRANT FUNDS MUST APPLY THROUGH THE THEDACARE WEBSITE. REQUESTS ARE SCREENED, REVIEWED, AND APPROVED BY COMMITTEE SIX TIMES THROUGHOUT THE FISCAL YEAR. A LETTER OF RESTRICTION IS ISSUED BY THEDACARE IN CONJUNCTION WITH ALL GRANT CHECKS. THIS LETTER OF RESTRICTION STATES THAT ALL GRANT FUNDS RECEIVED FROM THEDACARE MUST BE USED STRICTLY FOR THE PURPOSES FOR WHICH THEY WERE APPLIED. X X 1 1 X X X X 0 1 0 0 0 0 0 1 0 ANDERLA DAVID MD BOARD MEMBER 0 273016 0 43387 0 1105 0 9064 0 19754 0 346326 0 0 EDELMAN GARY MD BOARD MEMBER 0 55507 0 60349 0 316402 0 12000 0 19028 0 463286 0 0 MOARD DOUGLAS MD BOARD MEMBER 0 272885 0 15907 0 479 0 9350 0 17889 0 316510 0 0 GRUNER DEAN BOARD MEMBER/CEO-SYSTEM 112054 634967 42854 242840 1004 5690 23426 132745 2926 16581 182264 1032823 0 0 OLSON TIM VP, CFO-SYSTEM 58093 329193 11277 63901 3603 20416 13133 74418 2607 14772 88713 502700 0 0 BURMEISTER BRIAN VP SR, PHYSICIAN & RURAL SERVICES 28956 260598 5776 51985 1517 13657 6244 56197 1763 15867 44256 398304 0 0 BARNAS KIM VP SR AMC & THEDA CLARK HOSPITAL 82382 247148 16525 49575 4953 14859 19738 59213 5082 15247 128680 386042 0 0 LIVINGSTON KEITH VP SR CIO 48787 276459 9487 53757 3288 18630 10257 58122 2659 15068 74478 422036 0 0 PISTONE MAUREEN VP SR TALENT MANAGEMENT 41635 235936 7972 45174 3052 17293 9508 53881 2641 14968 64808 367252 0 0 DEVINE GREGORY VP SR PROVIDER STRATEGIES AND SYSTEM 58156 329552 13581 76957 1329 7530 9051 51288 2780 15756 84897 481083 0 0 HUNTER WILLIAM VP SR PLANNING & MARKETING 49629 281223 11593 65695 1730 9804 8762 49653 2671 15136 74385 421511 0 0 LONG GREGORY MD CHIEF MEDICAL OFFICER 57496 325811 11574 65588 1182 6697 10417 59030 3046 17260 83715 474386 0 0 POOLE JOHN VP SR THEDACARE IMPROVEMENT SYSTEM 47514 269250 9565 54203 1217 6895 9833 55718 2762 15650 70891 401716 0 0 PART I, LINE 1A EXECUTIVES RECEIVE REIMBURSEMENT FOR PERSONAL MEDICAL EXPENSES AT AN AMOUNT GROSSED-UP FOR TAXES. ALL EXECUTIVES IN THE SENIOR MANAGEMENT BENEFIT CATEGORY ARE ELIGIBLE TO HAVE HEALTH OR FITNESS CLUB FEES PAID DIRECTLY TO THE CLUB, OR REIMBURSED TO THEM ON EVIDENCE OF PAYMENT. SENIOR EXECUTIVES WHOSE DUTIES INCLUDE MEETING WITH PEOPLE OUTSIDE THE COMPANY FOR PURPOSES OF DEVELOPING BUSINESS RELATIONSHIPS HAVE COMPANY PAID MEMBERSHIPS AT A LOCAL COUNTRY CLUB. 3 EMPLOYEES RECEIVED TAXABLE MEDICAL EXPENSE REIMBURSEMENTS AND 1 EMPLOYEE RECEIVED CLUB DUES REIMBURSEMENTS. 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 KEY EXECUTIVES, IMPROVE THEDACARE INC'S ABILITY TO COMPETE WITH OTHER EMPLOYERS FOR HIGH TALENT EXECUTIVES AND TO ENCOURAGE TOP-LEVEL EXECUTIVES TO WORK TOGETHER AS A COHESIVE GROUP TOWARD COMMON GOALS. THE PRESIDENT OF THEDACARE INC. DEVELOPS A LIST OF SENIOR LEVEL EXECUTIVES WHO ARE ELIGIBLE TO PARTICIPATE IN THIS PLAN, AS WELL AS THE PERFORMANCE LEVELS THE SENIOR EXECUTIVES MUST ACHIEVE AND THE BONUS AMOUNTS THAT THE EXECUTIVES WILL RECEIVE. THE PRESIDENT THEN SUBMITS THIS LIST TO THE EXECUTIVE COMMITTEE OF THE BOARD OF TRUSTEES FOR FINAL APPROVAL. THESE EXECUTIVES MUST BE IN ACTIVE REGULAR SERVICE OF THEDACARE INC. FOR THE ENTIRE PLAN YEAR (JANUARY 1, 2012 TO DECEMBER 31, 2012) TO RECEIVE THEIR 2013 BONUSES. IF THE EMPLOYEE RETIRES, BECOMES DISABLED, MOVES TO A POSITION THAT IS ELIGIBLE UNDER THE BONUS PLAN OR MOVES TO A POSITION THAT IS NO LONGER ELIGIBLE FOR THE BONUS PLAN OR DIES, THE PLAN WILL BE PRORATED FOR THE AMOUNT OF TIME THEY SERVED THE COMPANY. IF AN ELIGIBLE EMPLOYEE IS FIRED OR LEAVES THE COMPANY FOR ANY OTHER REASON THE PLAN BONUS EARNED WILL BE FORFEITED. 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, AND ALL ELIGIBLE EMPLOYEES SHARE IN THE PAYOUT. THE PAYOUT AMOUNT IS DETERMINED BASED ON BOTH FINANCIAL AND EMPLOYEE HEALTH AND SAFETY THRESHOLDS. THE AMOUNT PER EMPLOYEE IS DETERMINED BY DIVIDING THE TOTAL GAIN REALIZED (THE EMPLOYEE SHARE) BY HOURS PAID TO ALL ELIGIBLE EMPLOYEES. THE RESULTING DOLLAR UNIT PAYOUT IS MULTIPLIED BY AN INDIVIDUAL EMPLOYEE'S NUMBER OF HOURS PAID. THIS PLAN IS OVERSEEN BY AN ADMINISTRATIVE COMMITTEE. THE THEDACARE BOARD OF TRUSTEES MUST APPROVE THE PLAN. FORM 990, PART 1, LINE 5 NUMBER OF EMPLOYEES: THEDACARE INC. CENTRALIZES PAYROLL AND TAX WITHHOLDING FUNCTIONS FOR A NUMBER OF AFFILIATED ENTITIES, WHILE ALL FILING UNDER THEDACARE'S FEDERAL IDENTIFICATION NUMBER. THEDA CLARK MEDICAL CENTER (TC) REPORTS "0" EMPLOYEES BECAUSE EMPLOYEES ARE PAID BY THEDACARE, INC., THEREFORE, TC DOES NOT FILE ANY W-2 FORMS. THEDACARE INC. IS REIMBURSED BY TC FOR SALARY EXPENSES FOR THE EMPLOYEES WHO ARE PERMANENTLY ASSIGNED TO TC. FORM 990, PART VI, SECTION A, LINE 6 THEDA CLARK MEDICAL CENTER, INC.'S SOLE MEMBER OF THE SINGLE CLASS OF VOTING MEMBERS IS THEDACARE, INC. FORM 990, PART VI, SECTION A, LINE 7A THEDACARE, INC. HAS SOLE AUTHORITY IN THE CORPORATION TO VOTE AND TAKE ANY ACTION WITH RESPECT TO THE ELECTION OF DIRECTORS AND OFFICERS. FORM 990, PART VI, SECTION A, LINE 7B THEDACARE, INC. HAS THE SOLE AUTHORITY WITH RESPECT TO THE FOLLOWING MATTERS: 1. AMENDMENT OF THE ARTICLES OF INCORPORATION 2. ADOPTION AND AMENDMENT OF BYLAWS OF THE CORPORATION 3. CONSOLIDATION, MERGER AND DISSOLUTION OF THE CORPORATION 4. MONITORING COMPLIANCE WITH LAWS AND REGULATIONS 5. SELECTION, APPOINTMENT, AND REMOVAL OF A CHIEF OPERATING OFFICER 6. PROVISION FOR LONG-RANGE FINANCIAL STABILITY OF THE HOSPITAL AND PROVISION FOR THE CONTROL AND USE OF THE PHYSICAL AND FINANCIAL RESOURCES OF THE HOSPITAL 7. ESTABLISHMENT OF A LONG-RANGE PLANNING MECHANISM 8. APPROVAL OF A HOSPITAL ORGANIZATION AND MAJOR AUTHORITY DELEGATION PATTERNS 9. APPROVAL OF FINANCIAL, CAPITAL, AND OTHER ITEMS 10. APPROVAL OF DEBT OR LEASES 11. CONSIDERATION AND ACTION UPON POLICIES CONCERNING RELATIONS WITH EXTERNAL GROUPS AND ORGANIZATIONS FORM 990, PART VI, SECTION B, LINE 11 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 PARTICIPATE 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. INTERNALLY, A COMPENSATION COMMITTEE REAFFIRMS THE COMPENSATION POLICY, REVIEWS DATA FROM CONSULTANTS, AND WITH INPUT FROM THE SENIOR VICE PRESIDENT OF HUMAN RESOURCES, ADVISES, VALIDATES, AND APPROVES A RANGE FOR CEO COMPENSATION. THE COMMITTEE ALSO RATIFIES THE AT-RISK COMPENSATION PLAN. FORM 990, PART VI, SECTION C, LINE 19 THEDA CLARK MEDICAL CENTER INC. DOES NOT MAKE ITS GOVERNING DOCUMENTS, CONFLICT OF INTEREST POLICY AND INTERNAL FINANCIAL STATEMENTS AVAILABLE TO THE PUBLIC. FORM 990, PART IX, LINE 11G CONTRACT SERVICES: PROGRAM SERVICE EXPENSES 1,070,490. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,070,490. PURCHASED SERVICES: PROGRAM SERVICE EXPENSES 4,238,422. MANAGEMENT AND GENERAL EXPENSES 9,481,127. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 13,719,549. PHYSICIAN FEES: PROGRAM SERVICE EXPENSES 1,103,864. MANAGEMENT AND GENERAL EXPENSES 317,547. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,421,411. TRAUMA CALL PAY: PROGRAM SERVICE EXPENSES 1,558,455. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 1,558,455. LAUNDRY: PROGRAM SERVICE EXPENSES 636,714. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 636,714. FACILITIES MANGEMENT SERVICES: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 614,817. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 614,817. NEUROSCIENCE GROUP FEES: PROGRAM SERVICE EXPENSES 283,203. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 283,203. DINING SERVICES: PROGRAM SERVICE EXPENSES 143,427. MANAGEMENT AND GENERAL EXPENSES 0. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 143,427. DOCUMENT STORAGE: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 103,322. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 103,322. DOCUMENT SHREDDING: PROGRAM SERVICE EXPENSES 0. MANAGEMENT AND GENERAL EXPENSES 97,750. FUNDRAISING EXPENSES 0. TOTAL EXPENSES 97,750. FORM 990, PART XI, LINE 9: NET ASSETS RELEASED TO OR FROM RESTRICTION 795,977. FORM 990, PART XII, LINE 2C: OVERSIGHT OF THE AUDIT: THE PROCESS HAS NOT CHANGED FROM THE PRIOR YEAR. THEDACARE INC 122 EAST COLLEGE AVENUE APPLETON WI 54911 391509362 HEALTHCARE WI 501(C)(3) LINE 11C, III-FI N/A 0 THEDACARE MEDICAL CENTER - NEW LONDON WI 1405 MILL STREET NEW LONDON WI 54961 390869788 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 0 RIVERSIDE MEDICAL CENTER INC 800 RIVERSIDE DRIVE WAUPACA WI 54981 390871113 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 0 APPLETON MEDICAL CENTER INC PO BOX 8025 APPLETON WI 54912 390824015 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 0 SHAWANO MEDICAL CENTER INC 309 N BARTLETTE STREET SHAWANO WI 54166 390807068 HOSPITAL WI 501(C)(3) LINE 3 THEDACARE INC 0 THEDA CLARK MEDICAL CENTER FOUNDATION INC 1818 NORTH MEADE STREET APPLETON WI 54911 311550056 FOUNDATION WI 501(C)(3) LINE 11A, I THEDACARE INC 0 APPLETON MEDICAL CENTER FOUNDATION INC 1818 NORTH MEADE STREET APPLETON WI 54911 391459276 FOUNDATION WI 501(C)(3) LINE 7 THEDACARE INC 0 WOLF RIVER AREA HEALTHCARE FOUNDATION INC 1405 MILL STREET NEW LONDON WI 54961 200049796 FOUNDATION WI 501(C)(3) LINE 11A, I NEW LONDON FAMILY MEDICAL CENTER INC 0 GEORGE F PEABODY FOUNDATION INC 2600 S HERITAGE WOODS DRIVE APPLETON WI 54915 391702534 FOUNDATION WI 501(C)(3) LINE 11A, I APPLETON MEDICAL CENTER INC 0 COMMUNITY HOSPICE FOUNDATION INC 1818 NORTH MEADE STREET APPLETON WI 54911 391511977 FOUNDATION WI 501(C)(3) LINE 7 THEDACARE INC 0 SHAWANO MEDICAL CENTER FOUNDATION INC 309 N BARTLETTE STREET SHAWANO WI 54166 391539117 FOUNDATION WI 501(C)(3) LINE 11A, I SHAWANO MEDICAL CENTER INC 0 THEDACARE FAMILY OF FOUNDATIONS INC 1818 NORTH MEADE STREET APPLETON WI 54911 464112255 FOUNDATION WI 501(C)(3) LINE 7 THEDACARE INC 0 NORTH APPLETON AMBULATORY CARE CENTER BUILDING COMPANY LLC 122 E COLLEGE AVENUE APPLETON WI 54911 262497187 RENTAL WI N/A 0 1 1 0 0 0 0 0 0 0 0 0 0 1 1 1 0 0 0 THEDA CLARK MEDICAL CENTER FOUNDATION B 50859 ACTUAL THEDA CLARK MEDICAL CENTER FOUNDATION C 300063 ACTUAL