2014-05-14T17:03:03-05:00 2013-06-30 861065772 Deloitte Tax LLP 111 Monument Circle Suite 2000 Indianapolis IN 462045108 990 2012-07-01 352112529 StVincent Clay Hospital Inc STVI 8124422623 1206 East National Avenue Brazil IN 478342718 Jerry R Laue 8124422601 2014-05-14 1 Shawna M Jimenez P01222873 3174648600 2014-04-30 2012 2015-11-30 17:44:51Z Jerry R Laue 1206 East National Avenue Brazil IN 478342718 26817788 0 X www.stvincent.org X 2000 IN We are a nonprofit hospital dedicated to providing healthcare that leaves no one behind. 8 5 215 30 0 0 63074 68614 24517042 25160994 1358168 1356286 -101793 149267 25836491 26735161 32585 38338 0 0 9187011 8421609 0 0 0 13132319 14285026 22351915 22744973 3484576 3990188 42629989 47795015 13498723 13590129 29131266 34204886 X St.Vincent Clay Hospital is dedicated to providing spiritually-centered, holistic healthcare that sustains and improves the health of those served, with special attention to the poor and vulnerable. Both inpatient and outpatient health services are provided without regard to patient race, creed, national origin, economic status, insurance status or ability to pay. This mission extends well beyond the provision of core medical services to encompass medical and scientific research programs, the training and educating of health care professionals and active support of community-based partnerships and programs to improve health and quality of life. 0 0 16202938 38338 25160994 St.Vincent Clay Hospital (SVCH) is a 25-bed, critical access hospital serving rural Clay and contiguous counties and providing services without regard to patient race, creed, national origin, economic status, or ability to pay. During fiscal year 2013, SVCH treated 723 adults and children for a total of 2,884 inpatient days of service. The hospital also provided services for 31,338 outpatient visits, including 974 outpatient surgeries and 10,323 emergency room and minor care visits. See Schedule H for a non-exhaustive list of community benefit programs and descriptions. 3267976 St.Vincent Clay Hospital (SVCH) provides a substantial portion of its core health services to the poor, uninsured or underinsured and has proactively taken steps to address the accessibility, financing, and delivery of healthcare to the underserved. During the fiscal year ending June 30, 2013, the unreimbursed cost of free or discounted services provided to patients who were deemed indigent under state, county, or hospital guidelines was $3,267,976, which included $1,503,483 of traditional charity care and $1,764,493 in unpaid costs of care for those qualifying for Medicaid or other public programs for the poor. See Schedule H for a non-exhaustive list of community benefit programs and descriptions. 129599 In addition to core medical services, St.Vincent Clay Hospital (SVCH) partners with its community to assess community assets and needs and to work together to address issues impacting health and quality of life, with special emphasis on the poor and vulnerable. In fiscal year 2013, SVCH provided $129,599 in unbilled services to the poor and to the broader community. (When combined with the costs of free or discounted services for the poor listed in Line 4b, SVCH provided a total community benefit of $3,397,575 in fiscal year 2013.) SVCH serves and supports its community through such programs as Rural and Urban Access to Health, health careers classes and diabetes education. See Schedule H for a non-exhaustive list of community benefit programs and descriptions. 19600513 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 0 0 1 0 0 0 0 0 0 1 0 1 1 0 1 1 0 0 0 0 0 0 0 1 0 0 0 0 0 1 1 0 0 0 1 24 0 1 215 1 0 0 0 0 0 0 0 0 0 0 X 8 5 0 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 1 1 0 IN X Wayne R Knight 8124422623 1206 E National Avenue Brazil IN 478342718 Lynsey B Lunsford 0.20 0.00 X X 0 0 0 Craig A Johnson DO 40.00 0.00 X X 31361 0 21950 Kirk A Freeman PhD 0.20 0.00 X X 0 0 0 Jeffrey A Boyll 0.20 0.00 X 0 0 0 Joe A Milner 0.20 0.00 X 0 0 0 Katherine Humphreys Thru 122012 0.20 40.00 X 0 435559 20991 Megan Shidler 0.20 0.00 X 0 0 0 Jane E Sweeney 0.20 40.00 X 0 120515 48249 Jerry R Laue 40.00 0.20 X X 0 241755 63908 Wayne R Knight 20.00 20.00 X 188724 0 38543 Edward J Allison 40.00 0.00 X 181723 0 38427 Elaine J Kelley 40.00 0.00 X 167713 0 19816 Sandra L Haggart 40.00 0.00 X 110466 0 24279 679987 797829 276163 4 0 1 0 Indiana Physician Management 4420 N Pennsylvania Street Indianapolis IN 462051728 Physician services 487861 Comprehensive Pharmacy Services PO Box 116474 Atlanta GA 303686474 Pharmacy services 423967 Ameripath Indianapolis LLC 2560 N Shadeland Avenue Ste A Indianapolis IN 46219 Pathology services 172682 Bill Dunbar and Associates LLC 2601 Fortune Circle E 301A Indianapolis IN 46241 Revenue management consulting 153832 Mid America Clinical Labs 2560 N Shadeland Avenue Indianapolis IN 46219 Lab testing 135621 6 1038 22281 45295 68614 Net patient revenue 621990 13273168 13273168 Net Medicare/Medicaid 621990 11887826 11887826 25160994 1391223 1391223 111281 0 111281 111281 111281 14455 49392 -34937 -34937 -34937 34237 33235 1002 1002 Cafeteria revenue 722210 30693 30693 Pharmacy revenue 446110 6291 6291 36984 26735161 25160994 0 1505553 X 3253 3253 35085 35085 280578 280578 6234622 5294609 940013 23666 20098 3568 1476683 1254039 222644 406060 344837 61223 895703 760655 135048 24017 20396 3621 144879 123035 21844 56623 48086 8537 637025 540979 96046 44266 37592 6674 279787 237603 42184 580474 492954 87520 33819 33819 Community benefit 3397575 3397575 Purchased services 3045672 2586467 459205 Supplies 1748319 1484720 263599 Provider tax expense 1056492 897202 159290 2340375 1987509 352866 22744973 19600513 3144460 0 2516795 1136200 2782423 2794297 423970 425640 234560 186732 19055430 12312060 6859880 6743370 29812361 36508776 42629989 47795015 2083510 2207777 11415213 11382352 13498723 13590129 X 27732634 32627008 1398632 1577878 29131266 34204886 42629989 47795015 X 3990188 1034621 48811 X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 891 891 0 Explanation of Lobbying Activities: Part II-B, Line 1: Lobbying expenses represent the portion of dues paid to national and state hospital associations that is specifically allocable to lobbying. St.Vincent Clay Hospital, Inc. does not participate in or intervene in (including the publishing or distributing or statements) any political campaign on behalf of (or in opposition to) any candidate for public office. 2500 2500 8986463 3888621 5097842 312487 305254 7233 9458981 8118185 1340796 294999 294999 6743370 Funds restricted by donor 1577878 Interest in investments held by Ascension Health Alliance 33425752 Receivables from third party programs 240028 Other 1150723 Pension plan 114395 36508776 Due to St.Vincent Hospital and Health Care 267935 Payables to third party programs 2471240 Intercompany debt with Ascension Health Alliance 8001143 Other liabilities 626177 Deferred compensation liability 15857 11382352 Festival of Trees 34237 34237 20281 6109 6845 34237 34237 20281 6109 6845 33235 1002 1 1 X 1 X 1 X 1 1 1 0 1 1 1503483 1503483 0.06610 4207707 2443214 1764493 0.07760 5711190 2443214 3267976 0.14370 2478 61302 61302 0.00270 47 65400 65400 0.00290 15 2897 2897 0.00010 2540 129599 129599 0.00570 2540 5840789 2443214 3397575 0.14940 1115 27600 27600 0.00120 1 9740 9740 0.00040 362 9900 9900 0.00040 1478 47240 47240 0.00200 0 407226 122168 7887121 7809030 78091 X 1 1 1 1 StVincent Clay Hospital Inc

1206 E National Avenue Brazil IN 47834

http://www.stvincent.org/St-Vincent-Cl X X X X StVincent Clay Hospital Inc 1 1 X X X X X X X X X 12 1 0 1 X X X X X X X X X 0 0 1 1 200.000000000000 1 400.000000000000 1 X X 1 1 X X X 1 0 1 X 0 0 Part I, Line 3c: The organization provides medically necessary care to all patients, regardless of race, color, creed, ethnic origin, gender, disability or economic status. The hospital uses a percentage of federal poverty level (FPL) to determine free and discounted care. At a minimum, patients with income less than or equal to 200% of the FPL, which may be adjusted for cost of living utilizing the local wage index compared to the national wage index, will be eligible for 100% charity care write off of charges for services that have been provided to them. Also, at a minimum, patients with incomes above 200% of the FPL but not exceeding 400% of the FPL, subject to adjustments for cost of living utilizing the local wage index compared to national wage index, will receive a discount on the services provided to them. Part I, Line 7: The cost of providing charity care, means tested government programs, and community benefit programs is estimated using internal cost data, and is calculated in compliance with Catholic Health Association ("CHA") guidelines. 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: St.Vincent Clay Hospital promotes the health of its communities by striving to improve the quality of life within the community. Research has established that factors such as economic status, employment, housing, education level, and built environment can all be powerful social determinants of health. Additionally, helping to create greater capacity within the community to address a broad range of quality of life issues also impacts health. St.Vincent Clay Hospital meets regularly with local organizations in the community to learn what resources are available and plan community health improvement efforts. In fiscal year 2013, these organizations included: Clay City Senior Citizen Center, Clay City Jr/Sr High School, 4H Extension, Northview High School, Step Ahead Community Roundtable, and YMCA. Schedule H, 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 Ascension Health. 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 in fiscal year 2013 was $1,278,573 at charges, ($407,226 at cost). Schedule H, Part III, Line 3: The provision for doubtful accounts is based upon management's assessment of expected net collections considering economic conditions, historical experience, trends in health care coverage, and other collection indicators. Periodically throughout the year, management assesses the adequacy of the allowance for doubtful accounts based upon historical write-off experience by payor category, including those amounts not covered by insurance. The results of this review are then used to make any modifications to the provision for doubtful accounts to establish an appropriate allowance for doubtful accounts. Part III, Line 4: The organization is part of the St.Vincent Health System's consolidated audit in which the footnote that discusses the bad debt expense is located on page 22. 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. Ascension Health and its related health ministries follow 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 has a written debt collection policy that also includes a provision on the collection practices to be followed for patients who are known to qualify for charity care or financial assistance. If a patient qualifies for charity or financial assistance certain collection practices do not apply. St.Vincent Clay Hospital, Inc. Part V, Section B, Line 3: In conducting its CHNA, the hospital facility took into account input from representatives of the community as well as those with special knowledge or expertise in public health. These included Wrap around Services; Clay County Tobacco Prevention and Cessation; Community Alliance and Services for Young Children; Family Preservation; Kids, Family, and Community; Cumberland Academy; Clay County Health Department; YMCA; Serving on the Streets; WIC; and many more. St.Vincent Clay Hospital, Inc. Part V, Section B, Line 7: Smoking - Even though this was not chosen as a top priority, St.Vincent Clay partners with the tobacco prevention and cessation coordinator for Clay County.Dental - Addressing this issue is not a direct priority of St.Vincent Clay; however, the hospital does partner with St. Anne's Clinic in Terre Haute. Teen Pregnancy - Addressing this issue is not a direct priority of St.Vincent Clay; however, the hospital does support abstinence education efforts. Unemployment - Addressing this issue is not a direct priority of St.Vincent Clay; however, the hospital does support efforts of organizations focused on economic development for Clay County. St.Vincent Clay Hospital, Inc. Part V, Section B, Line 20d: The discount was determined by reviewing the lowest discount provided to managed care payers that comprise at least 3% of our volume with an added prompt pay discount to the highest paid discount provided to our managed care payers. St.Vincent Clay Hospital, Inc. Part V, Section B, Line 21: The following steps were followed and considered reasonable efforts followed for purposes of identifying patients eligible for assistance under the facility's FAP:- Notified each individual of the Hospital's Financial Assistance Policy (FAP). This notification began on the date care was provided and ended on the 120th day after the first billing statement was provided to the individual. - Individuals were notified of the FAP as noted in Question 14. This includes, but is not limited to, the following:- Brief description of eligibility requirements and assistance provided- Direct individuals to our website and physical location of application forms- Provided instructions to obtain free copy of FAP and application by mail- Provided contact information for an individual/nonprofit organization to assist if the individual has questions- Provided statement of translations of FAP as well as plain language summaries- Provided statement that no FAP-eligible individual will be charged more for emergency/medically necessary care than AGB- For individuals who submitted an incomplete FAP, we provided that individual with information relevant to assist them with completion of the FAP. - For individuals who submitted a complete FAP, we made and documented a determination as to whether that person was eligible under the facility's FAP. - We determined eligibility based on other means such as establishing that the individual is eligible under one or more means tested programs (as noted in Question 12). St.Vincent Clay Hospital, Inc. Part V, Section B, Line 22: The following steps were followed and considered reasonable efforts followed for purposes of identifying patients eligible for assistance under the facility's FAP:- Notified each individual of the Hospital's Financial Assistance Policy (FAP) as noted in Question 14. This includes, but is not limited to, the following:- Brief description of eligibility requirements and assistance provided- Direct individuals to our website and physical location of application forms- Provided instructions to obtain free copy of FAP and application by mail- Provided contact information for an individual/nonprofit organization to assist if the individual has questions- Provided statement of translations of FAP as well as plain language summaries- Provided statement that no FAP-eligible individual will be charged more for emergency/medically necessary care than AGB- This notification began on the date care was provided and ended on the 120th day after the first billing statement was provided to the individual.- For individuals who submitted an incomplete FAP, we provided that individual with information relevant to assist them with completion of the FAP. - For individuals who submitted a complete FAP, we made and documented a determination as to whether that person was eligible under the facility's FAP. - We determined eligibility based on other means such as establishing that the individual is eligible under one or more means tested programs (as noted in Question 12). Part V, Section B, Line 5: St.Vincent Clay Hospital, Inc.: The Community Health Needs Assessment ("CHNA") of the hospital facility can be located at the following web address: http://www.stvincent.org/St-Vincent-Clay/. Part V, Section B, Line 16: St.Vincent Clay Hospital, Inc.: The following steps were followed and considered reasonable efforts for purposes of Question 16:- Notified each individual of the facility's Financial Assistance Policy (FAP). This notification began on the date care was provided and ended on the 120th day after the first billing statement was provided to the individual. - Individuals were notified of the FAP by methods as noted in Question 14. This includes, but is not limited to, providing the following:- A brief description of eligibility requirements and assistance provided- Directions on how to access the FAP and application on our website and physical location of application forms- Instructions to obtain free copy of FAP and application by mail- Contact information for an individual/nonprofit organization to assist if the individual has questions- Statement of translations of FAP as well as plain language summaries- Statement that no FAP-eligible individual will be charged more for emergency/medically necessary care than AGB- For individuals who submitted an incomplete FAP, we provided that individual with information relevant to assist them with completion of the FAP. - For individuals who submitted a complete FAP, we made and documented a determination as to whether that person was eligible under the facility's FAP. - We determined eligibility based on other means such as establishing that the individual is eligible under one or more means tested programs (as noted in Question 12). Part V, Section B, Line 17: St.Vincent Clay Hospital, Inc.: The following steps were followed and considered reasonable efforts for purposes of Question 17:- Notified each individual of the Hospital's Financial Assistance Policy (FAP). This notification began on the date care was provided and ended on the 120th day after the first billing statement was provided to the individual. - Individuals were notified of the FAP as noted in Question 14. This includes, but is not limited to, the following:- Brief description of eligibility requirements and assistance provided- Direct individuals to our website and physical location of application forms- Provided instructions to obtain free copy of FAP and application by mail- Provided contact information for an individual/nonprofit organization to assist if the individual has questions- Provided statement of translations of FAP as well as plain language summaries- Provided statement that no FAP-eligible individual will be charged more for emergency/medically necessary care than AGB- For individuals who submitted an incomplete FAP, we provided that individual with information relevant to assist them with completion of the FAP. - For individuals who submitted a complete FAP, we made and documented a determination as to whether that person was eligible under the facility's FAP. - We determined eligibility based on other means such as establishing that the individual is eligible under one or more means tested programs (as noted in Question 12). Part V, Section B, Line 18: St.Vincent Clay Hospital, Inc.: Question 18 is more appropriately answered as not applicable as the Billing and Collections Policy of St.Vincent Clay Hospital, Inc. does not allow a hospital to engage in extraordinary collection actions before the organization made reasonable efforts to determine whether the individual is eligible for assistance under the financial assistance policy. Reasonable efforts taken include but are not limited to:- Notifying individuals of the financial assistance policy on admission- Notifying individuals of the financial assistance policy prior to discharge- Notifying individuals of the financial assistance policy in communications with the patients regarding the patients' bills- Documenting its determination of whether patients were eligible for financial assistance under the hospital facility's financial assistance policy Part VI, Line 2: Communities are dynamic systems in which multiple factors interact to impact quality of life and health status. In addition to the formal CHNA conducted every 3 years, St.Vincent Clay Hospital participates in a community roundtable called Step Ahead/Literacy Council whose purpose is to periodically assess assets and needs within the community, prioritize action and work in partnership to address identified challenges. The coalition works closely with its member organizations which come from multiple sectors of the community, including local government, business, education, faith communities, public health, health care providers and other social and human service organizations. In addition, the coalition works closely with other coalitions as well as the local and state health departments to stay abreast of changing needs within the community by identifying evidence-based and promising practices to address these needs. Part VI, Line 3: St.Vincent Clay Hospital communicates with patients in multiple ways to ensure that those who are billed for services are aware of the hospital's financial assistance program as well as their potential eligibility for local, state or federal programs. Signs are prominently posted in each service area, and bills contain a formal notice explaining the hospital's charity care program. In addition, the hospital employs financial counselors, health access workers, and enrollment specialists who consult with patients about their eligibility for financial assistance programs and help patients in applying for any public programs for which they may qualify. Part VI, Line 4: St.Vincent Clay Hospital is located in Brazil, Indiana which is the county seat and serves Clay and contiguous counties, in west Central Indiana. Clay County is a very rural county with an estimated population of 26,837. Clay County has had a slight decline in population growth since 2010. The population over age 45 is higher than state average. Per Capita Personal Income and Median Household Income are below state averages and the annual unemployment rate exceeds state average. Manufacturing provides a large percentage of employment in the county. The overall poverty rate and the poverty rate among children under age 18 is below state average. Part VI, Line 5: To provide the highest quality healthcare to all persons in the community, and in keeping with its not-for-profit status, St.Vincent Clay Hospital:- delivers patient services, including emergency department services, to all individuals requiring healthcare, without regard to patient race, ethnicity, economic status, insurance status or ability to pay- maintains an open medical staff that allows credentialed physicians to practice at its facilities- trains and educates health care professionals- participates in government-sponsored programs such as Medicaid and Medicare to provide healthcare to the poor and elderly- is governed by a board in which independent persons who are representative of the community comprise a majority Part VI, Line 6: As part of the St.Vincent Health System, St.Vincent Clay Hospital is dedicated to improving the health status and quality of life for the communities it serves. While designated associates at St.Vincent Clay Hospital devote all or a significant portion of their time to leading and administering local community-based programs and partnerships, associates throughout the organization are active participants in community outreach. They are assisted and supported by designated St.Vincent Health community development and service staff who work with each of its healthcare facilities to advocate for and provide technical assistance for community outreach, needs assessments and partnerships as well as to support regional and state-wide programs, community programs sponsored by St.Vincent Health in which St.Vincent Clay Hospital participates. Reports Filed With States Part VI, Line 7 IN Community Benefit Report Form 990, Part III, Line 4a, 4b and 4c: St.Vincent Clay Hospital provides the following hospital services: Bone Health (Orthopedics), Diabetes Care, Digestive Health (Gastroenterology), Emergency Medicine, Laboratory, Pastoral Care, Radiology, Rehabilitation Therapy, Respiratory Care, and Surgery. Some of these services operate at a loss in order to ensure that comprehensive services are available to the community.Such community-focused programs improve access to healthcare, advocate for the poor and vulnerable, promote health through free education and screenings and help to build better communities by improving quality of life. Community Benefit Overview St.Vincent Clay Hospital (SVCH) is part of St.Vincent Health, a non-profit healthcare system consisting of 22 locally-sponsored ministries serving over 47 counties throughout Central Indiana. Sponsored by Ascension Health, the nation's largest Catholic healthcare system, St.Vincent Health is one of the largest healthcare employers in the state. As part of St.Vincent Health, the St.Vincent Clay vision is to deliver a continuum of holistic, high-quality health services and improve the lives and health of Indiana individuals and communities, with special attention to the poor and vulnerable. This is accomplished through strong partnerships with businesses, community organizations, local, state and federal government, physicians, St.Vincent Clay associates and others. Working with its partners, and utilizing the CHNA completed every three years, St.Vincent Clay Hospital is committed to addressing community health needs and developing and executing an implementation strategy to meet identified needs to improve health outcomes within the community. Community benefit is not the work of a single department or group within St.Vincent Clay, but is part of the St.Vincent mission and cultural fabric. The hospital leadership team provides direction and resources in developing and executing the Implementation Strategy in conjunction with the St.Vincent Health Community Development Department, but associates at all levels of the organization contribute to community benefit and health improvement. Charity Care and Certain Other Community Benefits at Cost Patient Services for Poor and Vulnerable Hospital and outpatient care is provided to patients that cannot pay for services, including hospitalizations, surgeries, prescription drugs, medical equipment and medical supplies. Patients with income less than 200% of the Federal Poverty level (FPL) are eligible for 100% charity care for services. Patients with incomes at or above 200% of the FPL, but not exceeding 400% of the FPL, receive discounted services based on an income-dependent sliding scale. Hospital financial counselors and health access workers assist patients in determining eligibility and in completing necessary documentation. St.Vincent Clay Hospital is committed to 100% access, and is proactive in providing healthcare that leaves no one behind. Public Program Participation St.Vincent Clay Hospital participates in government programs including Medicaid, SCHIP (Hoosier Healthwise), Healthy Indiana Plan (HIP) and Medicare and assists patients in enrolling for programs for which they are eligible. Per Catholic Health Association guidelines and St.Vincent Health's conservative approach, Medicare shortfall is not included as community benefit. Community Health Needs Assessment True community benefit responds to the particular needs and challenges of the community, building on its unique strengths and assets. The hospital leads a community health needs assessment every 3 years. Using a variety of tools, including surveys, key person interviews, focus groups, secondary data, and data analysis professionals, the team identifies community issues and concerns. These are shared with the community at large, and a consensus is reached about priorities and available resources.To provide community input and a basis for collaboration within the community to address health needs, St.Vincent leads or participates in a community roundtable or forum. This group brings together individuals and organizations from throughout the community who share a common interest in improving health status and quality of life and provide expertise in a variety of community areas including public health. Obesity, drug abuse, access to health care, and access to medication has all been identified as key community needs.Implementation Strategy Using the CHNA completed in 2013, the hospital developed a 2014-2016 Implementation Strategy to address priority community health needs. These strategies include:1. ObesityCreate ways for the Clay community to get physically fit - Develop a walking program for Clay County residents, which will be offered 8 months out of the year with one session per month. The goal is to get at least 5 people to consistently participate on a regular basis. 2. Drug AbuseInitiate educational opportunities on drug abuse - Host a panel discussion on the negative affects of drug abuse on the community.- Partner with the police to host a drop off drug day.- Create a presentation and educate the 2 high schools about drug use and abuse. 3. Access to HealthcareCoordinate access for vulnerable community members through a Health Access Worker (HAW)- Work with community based agencies, programs, services and providers to coordinate care for vulnerable community members.- Access referrals and assist clients based on Pathway indicators.- Document client intervention/assistance in eCAP.- Report completed Pathways on a quarterly basis and work on identified barriers to access with community stakeholders (goal of 300 completed Pathways a year).4. Access to MedicationCoordinate medication access for vulnerable community members through a Medication Access Coordinator (MAC)- Work with Pharmaceutical Assistance Programs (PAP); community based funding/assistance programs to access prescribed medications to vulnerable community members.- Coordinate and facilitate required documentation from Physician Providers and clients to assure application paperwork is accurate and complete.- Document work in electronic record and provide quarterly reports and outcomes.Rural and Urban Access to HealthAs part of its commitment to 100% access, St.Vincent Clay is one of eight St.Vincent Health ministries that participate in Rural and Urban Access to Health (RUAH), a community-based care coordination program. Effective care coordination provides a strategy for addressing certain social determinants of health by assuring barriers to care are addressed and individuals are connected to critical prevention and treatment services. Central to the program is a Health Access Worker whose role is to connect the hospital to the community by helping individuals address barriers to health care, and referring them to other local resources as needed. The Health Access Worker assists individuals with finding a medical home; applying for public programs such as Medicaid, food stamps, and the Healthy Indiana Plan; and in assessing needs so referrals can be made for other forms of community-based assistance. The Health Access Worker also advocates for clients with service providers and serves as a system navigator. RUAH outcomes are measured using the Pathways Model with 5 defined pathways/protocols (enrollment, medical home, pregnancy, medical referral and social services) as a means of tracking interventions and improving accountability towards positive, measurable changes in patients' lives. During fiscal year 2013, the Health Access Worker opened 884 pathways and completed 794 pathways.Medication AssistanceIn addition to care coordination, RUAH assists patients who meet income guidelines in obtaining free or reduced-cost prescription drugs. St.Vincent Clay Hospital provides a sophisticated and continually-updated database to track eligibility and requirements that vary by company and medication. In 2013, the medication assistant helped patients obtain a total of 254 medications for which the average wholesale price totaled $265,930. Health Fairs and ScreeningsSt.Vincent Clay Hospital participates in several health fairs and screenings throughout the year, including the YMCA Health Fair and Clay County 4H Fair. Participants can be tested for blood pressure, blood sugars, and more at low or no cost. Materials on health information and preventive services are a vital part of health fairs and screenings. During fiscal year 2013, St.Vincent Clay Hospital served approximately 2,000 people through its participation in these health fairs and screenings.Health Careers Vocational InstructionSt.Vincent Clay Hospital associates provide instruction for the Vocational Health Careers course offered through Clay Community Schools. This course introduces students to various aspects of the health care industry. Students have the opportunity to explore a number of health-related disciplines, learn associated entry level skills, and compare the educational requirements, credentialing and job opportunities of each with their personal abilities and interests as a means to making informed career choices. Varied instructional strategies and technologies are used to introduce medical terminology, anatomy and physiology, and health service legalities, with emphasis on a healthy lifestyle, wellness, health maintenance, and disease prevention. In the second semester, students serve an internship in an area of their interest. Community Benefit Cash and In-Kind Contributions In addition to the outreach programs operated by the hospital, the hospital makes cash and in-kind donations to a variety of community organizations focused on improving health status in the community. These take the form of cash donations to outside organizations, the donation of employee time/services to outside organizations and the representation of the hospital on community boards and committees working to improve health status and quality of life within the community. Community Building Activities Research shows that social determinants and quality of life play a major role in the health status of individuals and communities. Community building activities, which focus on improving the quality of life within a community, ultimately influence and improve health status. Athletic TrainingSt.Vincent Clay Hospital maintains a close relationship with Northview High School. As part of that partnership, the hospital pays for a full-time athletic trainer for the school. The athletic trainer assists athletes in achieving their optimum sports performance by recommending and monitoring proper training routines, preventing injuries, and providing immediate care, treatment, and rehabilitation after athletic trauma. The trainer serves as the liaison between players, coaches, physicians and family and is on-call at all of the sports events. This effort is just one way the hospital exhibits its dedication to making sure the children are safe while they play sports. YMCA PartnershipYMCA of Clay County and St.Vincent Clay Hospital believe that putting Christian principles into practice through programs that build healthy spirits, minds and bodies will result in a stronger community. Both believe it is important to touch kids' lives with a good foundation and teach important values for them to carry throughout their lives. With the financial support from St.Vincent Clay Hospital, and in conjunction with the "Strong Kids Campaign," the YMCA ensures all children, even those children unable to pay, can participate in its programs. 1 Tuition assistance 4 35085 Procedure for Monitoring Grants in the U.S.: Part I, Line 2: Schedule I, Part I, Line 2: The finance committee ensures that funds are distributed appropriately according to Acension Health's strategic business plan and consistent with corporate policies and procedures. X 1 1 X X X X 0 0 0 0 0 0 0 0 0 Katherine Humphreys Thru 122012 0 296189 0 95936 0 43434 0 6250 0 14741 0 456550 0 0 Jane E Sweeney 0 99999 0 18314 0 2202 0 29291 0 18958 0 168764 0 0 Jerry R Laue 0 169796 0 56429 0 15530 0 46610 0 17298 0 305663 0 0 Wayne R Knight 145201 0 29972 0 13551 0 22764 0 15779 0 227267 0 0 0 Edward J Allison 162199 0 4731 0 14793 0 18627 0 19800 0 220150 0 0 0 Elaine J Kelley 157615 0 4388 0 5710 0 13709 0 6107 0 187529 0 0 0 Part I, Line 1a St.Vincent Clay Hospital paid for cell phone usage for three of the listed officers/directors and highest compensated employees in Part VII. St.Vincent Clay Hospital will only reimburse a business expense when all three (3) of the following IRS requirements are met: 1. The expense must have a business connection (i.e., the expenses must be incurred while performing services on behalf of a SVH Entity); 2. The expense must be adequately substantiated by the Associate within a reasonable period of time; and 3. The Associate must return any excess reimbursement or allowance within a reasonable period of time. St.Vincent Clay Hospital "grossed up" the above applicable non-business expenses and included in the employees' W-2 as additional taxable compensation. Dr Craig Johnson See Part V 97134 See Part V 0 Schedule L, Part IV: Business Transaction Involving Interested Persons (a) Name of interested person: Dr. Craig Johnson(b) Relationship between interested person and organization: Dr. Craig Johnson (Vice-Chair) is a principal of Brazil Family Medicine. (c) Amount of transaction: $97,134(d) Description of transaction: St.Vincent Clay Hospital has a recruiting guarantee with Brazil Family Medicine for Dr. Craig Johnson's partner in the business.(e) Sharing of organization revenues: No Form 990, Part VI, Section A, line 6 St.Vincent Clay Hospital, Inc. has a single corporate member, St.Vincent Health, Inc. Form 990, Part VI, Section A, line 7a St.Vincent Clay Hospital, Inc. has a single corporate member, St.Vincent Health, Inc. who has the ability to elect members to the governing body of St.Vincent Clay Hospital, Inc. Form 990, Part VI, Section A, line 7b All decisions that have a material impact to St.Vincent Clay Hospital, Inc.'s financial information or corporation as a whole are subject to approval by its sole corporate member, St.Vincent Health, Inc. Form 990, Part VI, Section B, line 11 Management, including certain officers, works diligently to complete the Form 990 and attached schedules in a thorough manner. Management presents the Form 990 to a designated committee of the Board to review and answer any questions. Prior to filing the returns, all Board members are provided the Form 990 and management team members are available to answer any Board member questions. Form 990, Part VI, Section B, line 12c The organization regularly and consistently monitors and enforces compliance with the conflict of interest policy in that any director, principal officer, or member of a committee with governing board delegated powers, who has a direct or indirect financial interest must disclose the existence of the financial interest and be given the opportunity to disclose all material facts to the directors and members of the committee with governing board delegated powers considering the proposed transaction or arrangement. The remaining individuals on the governing board or committee meeting will decide if conflicts of interest exist. Each director, principal officer and member of a committee with governing board delegated powers annually signs a statement which affirms such person has received a copy of the conflicts of interest policy, has read and understands the policy, has agreed to comply with the policy, and understands that the organization is charitable and in order to maintain its federal tax exemption it must engage primarily in activities which accomplish its tax exempt purpose. Form 990, Part VI, Section B, line 15 Compensation determinations of St.Vincent Clay Hospital's CEO, executive director, or top management officials are made by a compensation committee of St.Vincent Clay Hospital, Inc. and/or St.Vincent Health, Inc. In determining compensation of the organization's CEO, executive director, or top management officials, the process included a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision. The board, in executive session, reviewed and approved the compensation. In review of the compensation, the CEO, executive director, and top management were compared to other hospitals in the area that hold the same position. During the review and approval of the compensation, documentation of the decision was recorded in the board minutes. Individuals were not present when their compensation was decided. Compensation determinations of St.Vincent Clay Hospital's other officers or key employees are made by a compensation committee of St.Vincent Clay Hospital, Inc. and/or St.Vincent Health, Inc. In determining compensation of other officers or key employees of the organization, the process included a review and approval by independent persons, comparability data, and contemporaneous substantiation of the deliberation and decision. The board, in executive session, reviewed and approved the compensation. In the review of the compensation, the other officers or key employees of the organization were compared to other hospitals' employees in the area that hold the same position. During the review and approval of the compensation, documentation of the decision was recorded in the board minutes. Form 990, Part VI, Section C, line 19 The organization will provide any documents open to public inspection upon request. All Other Functional Expenses Form 990, Part IX, line 24e Corporate expense: Program service expenses 616,986. Management and general expenses 109,541. Fundraising expenses 0. Total expenses 726,527. Equipment rental/maintenance: Program service expenses 566,477. Management and general expenses 100,573. Fundraising expenses 0. Total expenses 667,050. Miscellaneous: Program service expenses 454,750. Management and general expenses 80,737. Fundraising expenses 0. Total expenses 535,487. Maintenance and repair: Program service expenses 341,441. Management and general expenses 60,620. Fundraising expenses 0. Total expenses 402,061. CHAN Fees: Program service expenses 4,571. Management and general expenses 812. Fundraising expenses 0. Total expenses 5,383. Contract labor: Program service expenses 3,284. Management and general expenses 583. Fundraising expenses 0. Total expenses 3,867. Changes in Net Assets or Fund Balances: Form 990, Part XI, line 9: FAS 158 pension liability 48,811. Tax Exempt Bond Issuance Part IV, Line 24A: St.Vincent Clay Hospital, Inc. is a health facility that is part of Ascension Health System. Ascension Health is the borrower for tax exempt hospital revenue bonds. St.Vincent Clay Hospital, Inc. holds an intercompany note payable with Ascension Health, and this information is reported on the balance sheet. Ascension Health PO Box 45998 St Louis MO 63145 311662309 National health system MO 501(C)(3) 11A, I Ascension Health Alliance 0 Central Indiana Health System Cardiac Services Inc 2001 W 86th Street Indianapolis IN 46260 351869951 Freestanding outpatient center IN 501(C)(3) 11C, III-FI StVincent Hospital & Health Care Center Inc 1 Jubilee Partnerships Inc 2301 N Park Avenue Indianapolis IN 46205 352060765 Outreach activities IN 501(C)(3) 1 StVincent Hospital & Health Care Center Inc 1 Rehabilitation Hospital of Indiana Inc 4141 Shore Drive Indianapolis IN 46254 351786005 Rehabilitation hospital IN 501(C)(3) 3 StVincent Health Inc 1 StVincent Anderson Regional Hospital Foundation Inc 2015 Jackson Street Anderson IN 46016 352053693 Supporting organization IN 501(C)(3) 11A, I StVincent Anderson Regional Hospital Inc 1 StJoseph Hospital & Health Center Inc 1907 W Sycamore Street Kokomo IN 46901 350992717 Hospital IN 501(C)(3) 3 StVincent Health Inc 1 StJoseph Foundation of Kokomo Indiana Inc 1907 W Sycamore Street Kokomo IN 46901 237313206 Supporting organization IN 501(C)(3) 11A, I StJoseph Hospital & Health Center Inc 1 StVincent Anderson Regional Hospital Inc 2015 Jackson Street Anderson IN 46016 460877261 Hospital IN 501(C)(3) 3 StVincent Health Inc 1 StVincent Carmel Hospital Inc 13500 N Meridian Street Carmel IN 46032 743107055 Hospital IN 501(C)(3) 3 StVincent Health Inc 1 StVincent Dunn Hospital Inc 1600 23rd Street Bedford IN 47421 272192831 Critical access hospital IN 501(C)(3) 3 StVincent Health Inc 1 StVincent Fishers Hospital Inc 13861 Olio Road Fishers IN 46037 454243702 Hospital IN 501(C)(3) 3 StVincent Health Inc 1 StVincent Frankfort Hospital Inc 1300 S Jackson Frankfort IN 46041 352099320 Critical access hospital IN 501(C)(3) 3 StVincent Health Inc 1 StVincent Frankfort Hospital Foundation Inc 1300 S Jackson Frankfort IN 46041 351531734 Supporting organization IN 501(C)(3) 11A, I StVincent Frankfort Hospital Inc 1 StVincent Health Inc 8425 Harcourt Road Indianapolis IN 46260 352052591 Parent company IN 501(C)(3) 11C, III-FI Ascension Health 0 StVincent Health Wellness and Preventive Care Institute Inc 8333 Naab Road Ste 301 Indianapolis IN 46260 461227327 Health and wellness services IN 501(C)(3) 9 StVincent Health Inc 1 StVincent Hospital and Health Care Center Inc 2001 W 86th Street Indianapolis IN 46260 350869066 Hospital IN 501(C)(3) 3 StVincent Health Inc 1 StVincent Hospital Foundation Inc 10330 N Meridian Street Ste 430N Indianapolis IN 46290 356088862 Supporting organization IN 501(C)(3) 11A, I StVincent Hospital & Health Care Center Inc 1 StVincent Jennings Hospital Inc 301 Henry Street North Vernon IN 47265 351841606 Critical access hospital IN 501(C)(3) 3 StVincent Health Inc 1 StVincent Madison County Health System Inc 1331 South A Street Elwood IN 46036 350876389 Hospital IN 501(C)(3) 3 StVincent Health Inc 1 StVincent Medical Group Inc 8425 Harcourt Road Indianapolis IN 46260 272039417 Physician professional services IN 501(C)(3) 9 StVincent Health Inc 1 StVincent Mercy Hospital Foundation Inc 1331 South A Street Elwood IN 46036 311066871 Supporting organization IN 501(C)(3) 11A, I StVincent Madison County Health System Inc 1 StVincent New Hope Inc 8450 N Payne Road Indianapolis IN 46260 351733591 Intermediate care facility IN 501(C)(3) 9 StVincent Health Inc 1 StVincent Pediatric Rehab Center Inc 1707 W 86th Street Indianapolis IN 46260 352048898 Specialty hospital IN 501(C)(3) 3 StVincent Hospital & Health Care Center Inc 1 StVincent Randolph Hospital Inc 473 Greenville Avenue Winchester IN 47394 352103153 Critical access hospital IN 501(C)(3) 3 StVincent Health Inc 1 StVincent Randolph Hospital Foundation Inc 473 Greenville Avenue Winchester IN 47394 352133006 Supporting organization IN 501(C)(3) 11A, I StVincent Randolph Hospital Inc 1 StVincent Salem Hospital Inc 911 N Shelby Street Salem IN 47167 270847538 Critical access hospital IN 501(C)(3) 3 StVincent Health Inc 1 StVincent Seton Specialty Hospital Inc 8050 Township Line Road Indianapolis IN 46260 351712001 Long term care hospital IN 501(C)(3) 3 StVincent Health Inc 1 StVincent Williamsport Hospital Inc 412 N Monroe Street Williamsport IN 47993 350784551 Critical access hospital IN 501(C)(3) 3 StVincent Health Inc 1 StVincent Williamsport Hospital Foundation Inc 412 N Monroe Street Williamsport IN 47993 743130159 Supporting organization IN 501(C)(3) 11A, I StVincent Williamsport Hospital Inc 1 SVSM Inc 2001 W 86th Street Indianapolis IN 46260 810607827 Holding company IN 501(C)(3) 11A, I StVincent Health Inc 1 St Mary's At Home Inc 3700 Washington Avenue Evansville IN 47750 351899560 DME/Home care IN 501(C)(3) 11A, I St Mary's Health Services Inc 1 St Mary's Building Corporation 3700 Washington Avenue Evansville IN 47750 237248362 Real estate holding company IN 501(C)(2) St Mary's Health Services Inc 1 St Mary's Warrick Emergency Medical Services Inc 3700 Washington Avenue Evansville IN 47750 205342518 Ambulance services IN 501(C)(4) St Mary's Health Services Inc 1 St Mary's Health Inc 3700 Washington Avenue Evansville IN 47750 352057801 Health ministry parent IN 501(C)(3) 11C, III-FI StVincent Health Inc 1 St Mary's Physician Network LLC 3700 Washington Avenue Evansville IN 47750 205023387 Physician professional services IN 501(C)(3) 9 St Mary's Medical Group LLC 1 St Mary's Health Services Inc 3700 Washington Avenue Evansville IN 47750 351679526 Investment services IN 501(C)(3) 11C, III-FI St Mary's Health Inc 1 St Mary's CARE Partners Inc 3700 Washington Avenue Evansville IN 47750 351899562 Tax-exempt affiliate reimbursements IN 501(C)(3) 11A, I St Mary's Health Inc 1 St Mary's Medical Center Foundation of Evansville Inc 3700 Washington Avenue Evansville IN 47750 237045370 Supporting organization IN 501(C)(3) 11A, I St Mary's Medical Center of Evansville Inc 1 St Mary's Medical Center of Evansville Inc 3700 Washington Avenue Evansville IN 47750 350869065 Hospital IN 501(C)(3) 3 St Mary's Health Services Inc 1 St Mary's Warrick Hospital Foundation Inc 1116 Millis Avenue Boonville IN 47601 351961890 Supporting organization IN 501(C)(3) 11A, I St Mary's Warrick Hospital Inc 1 St Mary's Warrick Hospital Inc 1116 Millis Avenue Boonville IN 47601 351343019 Hospital IN 501(C)(3) 3 St Mary's Health Services Inc 1 St Mary's Ohio Valley Heartcare LLC 901 St Marys Drive Evansville IN 47714 273474697 Cardiology services IN 501(C)(3) 11A, I St Mary's Medical Group LLC 1 St Mary's Physicians' Health Group LLC 3700 Washington Avenue Evansville IN 47750 261356310 Physician professional services IN 501(C)(3) 9 St Mary's Medical Group LLC 1 Primary Physician Network LLC 3700 Washington Avenue Evansville IN 47750 208775914 Physician professional services IN 501(C)(3) 9 St Mary's Medical Group LLC 1 Breast MRI Leasing Company LLC 10330 N Meridian St Ste 430N Indianapolis IN 46290 426662493 Sale and rental services IN StVincent Hospital and Health Care Center Inc Related 230642 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264020296 Real estate holding IN StVincent Carmel Hospital Inc Related 3029284 0 1 0.50000 Neuro Oncology Equipment LLC 10330 N Meridian St Ste 430N Indianapolis IN 46290 743103803 Sale and rental services IN StVincent Hospital and Health Care Center Inc Related 151678 1684704 0 1 0.50000 StVincent HealthUSP LLC 15305 Dallas Pkwy Ste 1600 Addison TX 75001 203749962 Ambulatory surgery center IN StVincent Health Inc Related 136436 387939 0 1 0.50000 StVincent Heart Center of Indiana LLC 10580 N Meridian Street Indianapolis IN 46290 364492612 Heart hospital IN Central Indiana Health System Cardiac Services Inc Related 20552234 78811464 0 0 0.74080 Women's Physician Surgery Center LLC 8081 Township Line Road Indianapolis IN 46260 352086841 Ambulatory surgery center IN StVincent Hospital and Health Care Center Inc Related -11530 252917 0 0 0.58900 Ambulatory Care Center LLC 1125 Professional Blvd Evansville IN 47714 352006018 OP Surgery IN St Mary's Health Services Inc Related 4879396 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