2026-05-13T11:06:26-05:00 2025-06-30 470617373 COMMONSPIRIT HEALTH 198 INVERNESS DRIVE WEST ENGLEWOOD CO 80112 990 2024-07-01 470757164 ALEGENT CREIGHTON HEALTH ALEG 4023434323 3033 N 3RD AVE PHOENIX AZ 85013 NICK O'TOOL MARKET CFO 4023434323 2026-05-13 1 1 HEATHER ADKINS P01725376 3032989100 2024 2025-03-06 01:10:19Z X TIM BRICKER 3033 N 3RD AVE PHOENIX AZ 85013 496126035 0 X WWW.CHIHEALTH.COM X 1992 NE THE MISSION OF THE CORPORATION IS TO NURTURE THE HEALING MINISTRY OF THE CHURCH, SUPPORTED BY EDUCATION AND RESEARCH. 14 9 2929 232 13130858 374335 6507737 3224708 367070555 393067618 10542350 9587774 96232694 81444079 480353336 487324179 1479673 1573326 0 0 153608378 167076092 0 0 0 315839231 326875052 470927282 495524470 9426054 -8200291 839014664 1082779488 279341800 512334847 559672864 570444641 X AS AN AFFILIATE OF COMMONSPIRIT HEALTH, WE MAKE THE HEALING PRESENCE OF GOD KNOWN IN OUR WORLD BY IMPROVING THE HEALTH OF THE PEOPLE WE SERVE, ESPECIALLY THOSE WHO ARE VULNERABLE, WHILE WE ADVANCE SOCIAL JUSTICE FOR ALL. 0 0 52152406 461237 111612272 ALEGENT CREIGHTON HEALTH STAFF ARE FOCUSED ON RESTORING PATIENTS' HEALTH BY USING PERSONALIZED CARE AND STATE-OF-THE-ART TECHNOLOGY. THE DIAGNOSTIC CENTER AT THE HOSPITALS ARE EQUIPPED WITH THE LATEST DIGITAL IMAGING TECHNOLOGY. HEALTHCARE PROVIDERS HAVE MEDICAL INFORMATION AT THEIR FINGER TIPS, SO DIAGNOSIS IS QUICKER AND TREATMENT CAN BE STARTED SOONER. EACH DIAGNOSTIC CENTER OFFERS A FULL RANGE OF DIAGNOSTIC IMAGING SERVICES INCLUDING BUT NOT LIMITED TO THE FOLLOWING: MRI, CT SCANNING, PET/CT SCAN, ULTRASOUND, MAMMOGRAMS, NUCLEAR MEDICINE, CLINICAL LABORATORY, X-RAY IMAGING, PULMONARY SERVICES, OUTPATIENT LABORATORY TESTING, ANGIOGRAPHY AND RADIOGRAPHY. 42014844 348207 84260727 AT ALEGENT CREIGHTON HEALTH, OUR TEAM OF BOARD-CERTIFIED SURGEONS PROVIDES A FULL RANGE OF SURGICAL SOLUTIONS. OUR SURGEONS ARE EXCEPTIONALLY SKILLED AND HAVE MANY YEARS OF EXPERIENCE, WHICH ENSURES EVERY PATIENT WILL RECEIVE THE EXPERTISE THEY NEED AND THE COMPASSIONATE CARE THEY DESERVE. WE TAKE PRIDE IN MAKING SURE YOUR EXPERIENCE IS AS CONVENIENT AND COMFORTABLE AS POSSIBLE. EACH PATIENT CAN COUNT ON US FOR AN UNPARALLELED LEVEL OF CARE AND QUALITY SURGICAL OUTCOMES. 15263641 131461 31811513 ALEGENT CREIGHTON HEALTH OFFERS A WIDE RANGE OF COMPREHENSIVE CARDIOVASCULAR SERVICES IN THE REGION, USING A TEAM APPROACH TO ADDRESS THE TOTAL NEEDS OF THE CARDIOVASCULAR PATIENT. CARDIAC SERVICES INCLUDE BUT ARE NOT LIMITED TO: HI-TECH DIAGNOSIS AND INTERVENTION, CARDIAC CATHETERIZATION LAB, ECHOCARDIOGRAPHY, VASCULAR ULTRASOUND, HEART SCANS AND HEART CHECKS, ANGIOPLASTY AND DRUG-ELUTING STENTS. 366354945 632420 153035932 ALEGENT CREIGHTON HEALTH GIVES BACK TO OUR COMMUNITY THROUGH A VARIETY OF MEDICAL SERVICES AND PARTNERSHIPS. ALEGENT HEALTH QUICK CARE PROVIDES URGENT MEDICAL TREATMENTS, SCREENINGS AND ADULT IMMUNIZATIONS FOR PATIENTS 18 MONTHS AND OLDER. THROUGH OUR COLLABORATION WITH OTHER LOCAL COMMUNITY ORGANIZATIONS SUCH AS BOYS TOWN, CREIGHTON UNIVERSITY, OUR HEALTHY COMMUNITY PARTNERSHIP AND ONE WORLD COMMUNITY HEALTH CENTER, ALEGENT CREIGHTON HEALTH IS HELPING TO IDENTIFY AND ADDRESS COMMUNITY HEALTH NEEDS. IN ADDITION, ALEGENT CREIGHTON HEALTH ALSO PROVIDES THE FOLLOWING SERVICES: MATERNITY CARE SERVICES, MENTAL AND BEHAVIORAL HEALTH CARE, ONCOLOGY, PROCEDURE CENTER AND INPATIENT FACILITIES INCLUDING INTENSIVE CARE. 366354945 632420 153035932 475785836 1 1 0 1 0 0 0 0 0 1 1 1 0 1 1 1 0 1 0 1 1 0 0 0 0 0 1 1 1 1 1 0 0 0 0 0 0 1 0 0 0 0 0 1 1 1 1 0 0 1 X 41 0 1 2929 1 1 1 0 0 0 0 0 0 0 0 0 1 0 X 14 9 1 0 0 0 1 1 1 1 1 0 0 1 1 1 1 1 1 0 0 1 0 X NICK O'TOOL 4023434323 7261 MERCY ROAD OMAHA NE 68124 JOHN PETERSDORF EX-OFFICIO BM/SYS SVP, OPERATIONAL FINANCE 1.00 45.00 X 0 3765894 2099029 TIM BRICKER EX-OFFICIO BM/ PRESIDENT & CEO CENTRAL REGION 5.00 45.00 X X 0 2600816 288935 JULIE GOEBEL INTERIM MARKET PRESIDENT NE/IA (BEG 05/01/25), DIV 10.00 40.00 X 1603848 0 53835 TROY HAMMETT REGION CFO 5.00 45.00 X 86198 1284957 58742 ANN SCHUMACHER PRESIDENT - IMMANUEL (TERMED 03/31/24) 0.00 0.00 X 1206821 0 21970 CARY WARD MD MARKET PRESIDENT (TERMED 5/1/25) 10.00 40.00 X 818432 0 108773 ANDREW SANTOS SVP MISSION (TERMED 9/6/24) 50.00 0.00 X 742989 0 48679 THOMAS FREDERICKSON FORMER HCE 0.00 50.00 X 0 720958 46894 JOSEPH THIRUMALAREDDY MD HOSPITALIST 1.00 49.00 X 2456 635784 59375 STEVE HOUSTON SVP STRATEGY AND BUSINESS DEVELOPMENT (TERMED 1/2/ 0.00 0.00 X 658165 0 10687 AARON AUSTIN REGION CHRO 10.00 40.00 X 599844 0 42905 ARMAN PAJNIGAR MD FORMER HCE 0.00 50.00 X 0 576442 53568 SEAN HANSEN MD HOSPITALIST 20.00 30.00 X 305551 271173 46258 MOHSIN MIRZA VP MEDICAL OPERATIONS 1.00 49.00 X 5160 557339 19047 KIRTIBALA GUPTA MD BOARD SECRETARY/PHYSICIAN 1.00 49.00 X X 0 362138 45016 HEATHER MORGAN MD BOARD MEMBER/PHYSICIAN 1.00 49.00 X 0 327320 62438 NICK OTOOL MARKET CFO 5.00 45.00 X 293806 0 52737 MARK LONGACRE PRESIDENT - 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PART X, LINE 2: ALEGENT CREIGHTON HEALTH'S FINANCIAL INFORMATION IS INCLUDED IN COMMONSPIRIT HEALTH'S CONSOLIDATED AUDITED FINANCIAL STATEMENTS, WHICH INCLUDES THE FOLLOWING DISCLOSURE: COMMONSPIRIT REVIEWS ITS TAX POSITIONS QUARTERLY AND HAS DETERMINED THAT THERE ARE NO MATERIAL UNCERTAIN TAX POSITIONS THAT REQUIRE RECOGNITION IN THE ACCOMPANYING CONSOLIDATED FINANCIAL STATEMENTS. SUB-SAHARAN AFRICA 1 1 PROGRAM SERVICES SCHOOL OF NURSING 195326 1 1 0 0 1 1 195326 0 195326 0 0 0 0 0 0 PART I, LINE 3: SUB-SAHARAN AFRICA: ACCRUAL ALEGENT CREIGHTON HEALTH HAS ONE DESIGNATED EMPLOYEE WHO IS THE LIAISON FOR THE HOSPITAL LOCATED IN TANZANIA. THE EMPLOYEE ASSISTS WITH THE PROGRAMS, SERVICES, AND ACTIVITIES FOR THE HOUSES FOR HEALTH AND SCHOOL OF NURSING DEPARTMENTS. 1 1 X 1 X 1 X 1 1 0 1 1 3059 2978314 0 2978314 0.00600 12900 33681389 31628480 2052909 0.00410 0 0 0 15959 36659703 31628480 5031223 0.01010 20 1271 346761 2171 344590 0.00070 2 618 556910 0 556910 0.00110 3 0 1588276 1226872 361404 0.00070 0 0 0 0 12 284 180889 0 180889 0.00040 37 2173 2672836 1229043 1443793 0.00290 37 18132 39332539 32857523 6475016 0.01300 2 0 8183 0 8183 0.00000 2 8183 8183 0.00000 1 21407599 0 42474823 55907611 -13432788 X 1 1 1 LAKESIDE AMBULATORY SURGICAL CENTER LLC AMBULATORY SURGICAL CENTER 0.63090 0.00000 0.36910 2 LAKESIDE ENDOSCOPY CENTER LLC AMBULATORY SURGICAL CENTER 0.51020 0.00000 0.48980 3 NEBRASKA SPINE LLC SPINE HOSPITAL 0.51000 0.00000 0.44000 4 BERGAN MERCY SURGICAL CENTER LLC AMBULATORY SURGICAL CENTER 0.63660 0.00000 0.36340 3 1 CHI HEALTH LAKESIDE 16901 LAKESIDE HILLS CT OMAHA NE 68130 WWW.CHIHEALTH.COM H000106 X X X A 2 CHI HEALTH MIDLANDS 11111 S 84TH ST PAPILLION NE 68046 WWW.CHIHEALTH.COM 680001 X X X A 3 CHI HEALTH PLAINVIEW 704 N 3RD ST PLAINVIEW NE 68769 WWW.CHIHEALTH.COM 620002 X X X B FACILITY REPORTING GROUP - A 0 0 1 X X X X X X X X X 24 1 1 1 1 X WWW.CHIHEALTH.COM/CHNA X X 1 25 1 WWW.CHIHEALTH.COM/CHNA 0 1 X 200.000000000000 400.000000000000 X X X X X X 1 1 X X X 1 X HTTPS://WWW.CHIHEALTH.COM/EN/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE.HTML X HTTPS://WWW.CHIHEALTH.COM/EN/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE.HTML X HTTPS://WWW.CHIHEALTH.COM/EN/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE.HTML X X X X X X 1 X 0 X X X X 1 X 0 0 FACILITY REPORTING GROUP - B 0 0 1 X X X X X X X X X 24 1 1 1 1 X WWW.CHIHEALTH.COM/CHNA X X 1 25 1 WWW.CHIHEALTH.COM/CHNA 0 1 X 200.000000000000 400.000000000000 X X X X X X 1 1 X X X 1 X HTTPS://WWW.CHIHEALTH.COM/EN/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE.HTML X HTTPS://WWW.CHIHEALTH.COM/EN/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE.HTML X HTTPS://WWW.CHIHEALTH.COM/EN/PATIENTS-VISITORS/FINANCIAL-ASSISTANCE.HTML X X X X X X 1 X 0 X X X X 1 X 0 0 FACILITY REPORTING GROUP A, PART V, SECTION B, LINE 3E: THE SIGNIFICANT HEALTH NEEDS ARE A PRIORITIZED DESCRIPTION OF THE SIGNIFICANT HEALTH NEEDS OF THE COMMUNITY AS IDENTIFIED THROUGH THE CHNA. FACILITY REPORTING GROUP B, PART V, SECTION B, LINE 3E: THE SIGNIFICANT HEALTH NEEDS ARE A PRIORITIZED DESCRIPTION OF THE SIGNIFICANT HEALTH NEEDS OF THE COMMUNITY AS IDENTIFIED THROUGH THE CHNA. PART V, SECTION B FACILITY REPORTING GROUP A FACILITY REPORTING GROUP A CONSISTS OF: - FACILITY 2: CHI HEALTH MIDLANDS, - FACILITY 1: CHI HEALTH LAKESIDE FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 5: IN CONDUCTING ITS MOST RECENT CHNA, CHI HEALTH LAKESIDE AND CHI HEALTH MIDLANDS TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITY SERVED BY THE HOSPITAL FACILITY, INCLUDING THOSE WITH SPECIAL KNOWLEDGE OF OR EXPERTISE IN PUBLIC HEALTH. ASSESSMENT PROCESS & METHODS:THE COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) INCORPORATED DATA FROM MULTIPLE SOURCES, INCLUDING PRIMARY RESEARCH (THROUGH THE PRC COMMUNITY HEALTH SURVEY AND PRC ONLINE KEY INFORMANT SURVEY), AS WELL AS SECONDARY RESEARCH (VITAL STATISTICS AND OTHER EXISTING HEALTH-RELATED DATA). IT ALSO ALLOWS FOR TRENDING AND COMPARISON TO BENCHMARK DATA AT THE STATE AND NATIONAL LEVELS. PRIMARY DATA COLLECTION:A PRECISE AND CAREFULLY EXECUTED METHODOLOGY IS CRITICAL IN ASSERTING THE VALIDITY OF THE RESULTS GATHERED IN THE PRC COMMUNITY HEALTH SURVEY. THUS, TO ENSURE THE BEST REPRESENTATION OF THE POPULATION SURVEYED, A MIXED-MODE METHODOLOGY WAS IMPLEMENTED. THIS INCLUDED TARGETED SURVEYS CONDUCTED BY PRC VIA TELEPHONE (LANDLINE AND CELL PHONE) OR THROUGH ONLINE QUESTIONNAIRES, AS WELL AS A COMMUNITY OUTREACH COMPONENT PROMOTED BY THE STUDY SPONSORS THROUGH SOCIAL MEDIA POSTING AND OTHER COMMUNICATIONS.RANDOM-SAMPLE SURVEYS (PRC) FOR THE TARGETED ADMINISTRATION, PRC ADMINISTERED 2,960 SURVEYS THROUGHOUT THE SERVICE AREA. COMMUNITY OUTREACH SURVEYS (SPONSORING AND SUPPORTING PARTNERS) PRC ALSO CREATED A LINK TO AN ONLINE VERSION OF THE SURVEY, AND THE SPONSORS AND SUPPORTING PARTNERS PROMOTED THIS LINK LOCALLY IN ORDER TO DRIVE ADDITIONAL PARTICIPATION AND BOLSTER OVERALL SAMPLES. THIS YIELDED AN ADDITIONAL 691 SURVEYS TO THE OVERALL SAMPLE. IN ALL, 3,651 SURVEYS WERE COMPLETED THROUGH THESE MECHANISMS, INCLUDING 1,997 IN DOUGLAS COUNTY, 844 IN SARPY COUNTY, 227 IN CASS COUNTY, AND 583 IN POTTAWATTAMIE COUNTY. ONCE THE INTERVIEWS WERE COMPLETED, THESE WERE WEIGHTED IN PROPORTION TO THE ACTUAL POPULATION DISTRIBUTION SO AS TO APPROPRIATELY REPRESENT THE METRO AREA AS A WHOLE. ALL ADMINISTRATION OF THE SURVEYS, DATA COLLECTION, AND DATA ANALYSIS WAS CONDUCTED BY PRC. ONLINE KEY INFORMANTS SURVEY PARTICIPATION INCLUDED PHYSICIANS, PUBLIC HEALTH REPRESENTATIVES, OTHER HEALTH PROVIDERS, SOCIAL SERVICES PROVIDERS, BUSINESS LEADERS, AND OTHER COMMUNITY LEADERS. FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 6A: CHI HEALTH IMMANUEL, CHI HEALTH MERCY COUNCIL BLUFFS, METHODIST HEALTH SYSTEM (METHODIST HOSPITAL, METHODIST JENNIE EDMUNDSON HOSPITAL, AND METHODIST WOMEN'S HOSPITAL), NEBRASKA MEDICINE (BELLEVUE MEDICAL CENTER AND NEBRASKA MEDICAL CENTER), AND NEBRASKA SPINE HOSPITAL (A JOINT VENTURE). FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 6B: CHARLES DREW HEALTH CENTER, INC., DOUGLAS COUNTY HEALTH DEPARTMENT, OMAHA COMMUNITY FOUNDATION, ONE WORLD COMMUNITY HEALTH CENTERS, INC., POTTAWATTAMIE COUNTY PUBLIC HEALTH, SARPY/CASS HEALTH DEPARTMENT, AND THE WELLBEING PARTNERS. FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 7D: THIS CHNA REPORT WAS ADOPTED BY THE CHI HEALTH BOARD OF DIRECTORS IN APRIL 2025. THE CHNA REPORT WAS ALSO SHARED WITH ORGANIZATIONS APPLYING FOR THE COMMUNITY HEALTH IMPROVEMENT GRANT PROGRAM. FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 11: THE MOST RECENT CHNA AND CORRESPONDING IMPLEMENTATION PLAN WAS COMPLETED IN THE TAX REPORTING YEAR 2024. THE FOLLOWING OUTLINES THE CURRENT IMPLEMENTATION PLAN PRIORITIES AND STRATEGIES. THE COMMUNITY IDENTIFIED THE FOLLOWING PRIORITIES AS TOP HEALTH NEEDS THROUGH PRIMARY AND SECONDARY DATA FROM KEY INFORMANT INTERVIEWS:TOP HEALTH NEEDS (FROM 2025 CHNA): - 1. MENTAL HEALTH- 2. SOCIAL DRIVERS OF HEALTH (SDOH)- 3. DIABETES- 4. HEART DISEASE AND STROKE- 5. INFANT HEALTH & FAMILY PLANNING- 6. INJURY & VIOLENCE- 7. SUBSTANCE USE- 8. NUTRITION, PHYSICAL ACTIVITY & WEIGHTFOR THIS PLAN THE HOSPITAL PRIORITIZED THE FOLLOWING HEALTH NEEDS:PRIORITY HEALTH NEED #1: BEHAVIORAL HEALTHTO ADDRESS THIS NEED THE HOSPITAL WILL IMPLEMENT THE FOLLOWING STRATEGIES IN FISCAL YEARS 2026- 2028:- INCREASE ACCESS TO BEHAVIORAL HEALTH SERVICES BY SUPPORTING THE BEHAVIORAL HEALTH WORKFORCE - INCREASE ACCESS TO BEHAVIORAL HEALTH SERVICES BY SUPPORTING COMMUNITY-BASED SERVICES AND RESOURCES - IMPROVE CAPACITY TO RESPOND TO VIOLENCE AND MENTAL HEALTH CRISES BY IMPLEMENTING HOSPITAL AND CLINIC-BASED INTERVENTIONS - SUPPORT SYSTEM-LEVEL CHANGES THAT SUPPORT BEHAVIORAL HEALTH AND SUBSTANCE ABUSE RECOVERYPRIORITY HEALTH NEED #2: CHRONIC DISEASETO ADDRESS THIS NEED THE HOSPITAL WILL IMPLEMENT THE FOLLOWING STRATEGIES IN FISCAL YEARS 2026- 2028:- IMPROVE MANAGEMENT OF CHRONIC DISEASES BY IMPROVING POST-HOSPITAL DISCHARGE CARE - IMPROVE PREVENTION AND MANAGEMENT OF CHRONIC DISEASES BY SUPPORTING COMMUNITY-BASED RESOURCESPRIORITY HEALTH NEED #3: MATERNAL AND CHILD HEALTHTO ADDRESS THIS NEED THE HOSPITAL WILL IMPLEMENT THE FOLLOWING STRATEGIES IN FISCAL YEARS 2026- 2028:- DECREASE MATERNAL AND CHILD HEALTH INEQUITIES BY SUPPORTING PRE AND POST NATAL SUPPORT PROGRAMS - DECREASE MATERNAL AND CHILD HEALTH INEQUITIES BY TRAINING CHI HEALTH STAFF - ADVOCATE FOR SYSTEM LEVEL MATERNAL AND CHILD HEALTH CHANGES BY PARTICIPATING IN LOCAL AND STATEWIDE GROUPS WORKING TO ADDRESS INEQUITIESPRIORITY HEALTH NEED #4: SOCIAL DRIVERS OF HEALTH (SDOH)TO ADDRESS THIS NEED THE HOSPITAL WILL IMPLEMENT THE FOLLOWING STRATEGIES IN FISCAL YEARS 2026- 2028:- IMPROVE FINANCIAL LITERACY BY SUPPORTING COMMUNITY ORGANIZATIONS WORKING TO EDUCATE COMMUNITY MEMBERS - INCREASE UNHOUSED COMMUNITY MEMBERS' ACCESS TO HEALTHCARE BY SUPPORTING ORGANIZATIONS THAT PROVIDE HEALTH CARE AND SUPPORT SERVICES- REDUCE FOOD WASTE BY SUPPORTING ORGANIZATIONS WORKING TO ADDRESS IT - REDUCE FOOD INSECURITY AND INCREASE THE CONSUMPTION OF FRESH FRUITS AND VEGETABLES BY SUPPORTING NUTRITION ASSISTANCE AND INCENTIVE PROGRAMS - IMPROVE ACCESS TO TRANSPORTATION BY FURTHER EXPLORING THE BARRIERS AND PLANNING FOR FUTURE INTERVENTIONS - REDUCE HEALTH DISPARITIES BY CONNECTING PATIENTS WITH SOCIAL NEEDS TO COMMUNITY RESOURCES FACILITATED BY COMMUNITY HEALTH WORKERS - EXPAND DIVERSITY AND EQUITY IN THE HEALTHCARE WORKFORCE BY EXPANDING AND DEVELOPING HEALTHCARE CAREER PATHWAYS TO INCREASE WORKFORCE RECRUITMENT, RETENTION AND DIVERSITYTHE HOSPITALS WILL NOT ADDRESS THE FOLLOWING HEALTH NEEDS FOR THE FOLLOWING REASONS: IN ACKNOWLEDGING THE RANGE OF PRIORITY HEALTH NEEDS THAT EMERGED FROM THE CHNA PROCESS, CHI HEALTH LAKESIDE AND CHI HEALTH MIDLANDS HAVE PRIORITIZED THE HEALTH NEED AREAS ABOVE IN ORDER TO MOST EFFECTIVELY FOCUS RESOURCES AND PRODUCE A POSITIVE IMPACT. AS DESCRIBED IN THE PROCESS ABOVE, THE HOSPITALS TOOK INTO CONSIDERATION EXISTING PARTNERSHIPS, AVAILABLE RESOURCES, THE HOSPITAL'S LEVEL OF EXPERTISE, EXISTING INITIATIVES (OR LACK THEREOF), POTENTIAL FOR IMPACT, AND THE COMMUNITY'S INTEREST IN THE HOSPITAL ENGAGING IN THAT AREA IN ORDER TO SELECT THE PRIORITIES. THE FOLLOWING IDENTIFIED NEEDS WERE NOT EXPLICITLY PRIORITIZED IN THIS IMPLEMENTATION STRATEGY, BUT ARE BEING ADDRESSED THROUGH CROSS- CUTTING STRATEGIES WITHIN OTHER PRIORITIES AS DESCRIBED BELOW. INJURY & VIOLENCE: CHI HEALTH MAINTAINS AND CONTINUES TO EXPAND A STRONG FORENSIC NURSE EXAMINER PROGRAM AND A PARTNERSHIP WITH YOUTURN FOR IMMEDIATE TRAUMA RESPONSE, INCLUDING INPATIENT CASE MANAGEMENT AND COMMUNITY-BASED VIOLENCE INTERVENTION. CHI HEALTH IS DEDICATED TO IMPROVING INTERNAL CAPACITY FOR IDENTIFYING AND SUPPORTING VICTIMS OF HUMAN TRAFFICKING. ALL STAFF COMPLETE ANNUAL HUMAN TRAFFICKING TRAINING. CHI HEALTH OFFERS STOP THE BLEED TRAINING AND TOURNIQUET KITS TO LAW ENFORCEMENT, SCHOOL AND COMMUNITY MEMBERS TO PREPARE THEM TO STABILIZE A VICTIM(S) IN THE EVENT OF A MASS CASUALTY OR OTHER HEALTH EMERGENCY. HEALTH SYSTEM STAFF PARTICIPATE IN OMAHA 360, A COMMUNITY VIOLENCE PREVENTION AND INTERVENTION COALITION FOCUSED ON REDUCING GUN VIOLENCE IN NORTH OMAHA. CHI HEALTH PLANS TO LAUNCH AN OUTPATIENT CLINIC FOR SURVIVORS OF INTIMATE PARTNER VIOLENCE, SEXUAL ASSAULT AND HUMAN TRAFFICKING AT CHI HEALTH CREIGHTON UNIVERSITY CAMPUS CLINIC, CREIGHTON SCHOOL OF MEDICINE AND HEARTLAND FAMILY SERVICE. ADDITIONALLY, CHI HEALTH PROVIDES FINANCIAL AND IN-KIND CONTRIBUTIONS TO COMMUNITY ORGANIZATIONS AND SPONSORS RELEVANT EVENTS: (E.G. WOMEN'S CENTER FOR ADVANCEMENT, EMPOWERMENT NETWORK, YOUTURN).NUTRITION, PHYSICAL ACTIVITY, & WEIGHT: NUTRITION, PHYSICAL ACTIVITY, & WEIGHT WILL BE INDIRECTLY ADDRESSED THROUGH CHRONIC DISEASE STRATEGIES AS MANY OF THE PROGRAMS AND PARTNERS ADDRESSING CHRONIC DISEASE ALSO SUPPORT WORK AROUND NUTRITION, PHYSICAL ACTIVITY, & WEIGHT, RECOGNIZING THE RELATIONSHIP BETWEEN THE TWO. THIS NEED WILL ALSO BE ADDRESSED, IN PART, THROUGH THE FOOD ACCESS STRATEGIES UNDER THE SDOH PRIORITY, INCLUDING, BUT NOT LIMITED TO, LAUNCHING A MEDICALLY- TAILORED MEAL DEMONSTRATION PILOT, PROVIDING FINANCIAL SUPPORT AND IN-KIND CONTRIBUTIONS TO DOUBLE UP FOOD BUCKS, TO THE WOMEN, INFANT & CHILDREN (WIC)/SENIOR FARMER'S MARKET VOUCHER PROGRAM, AND TO ORGANIZATIONS COMMITTED TO THIS WORK, SUCH AS: CITY SPROUTS, BIG GARDEN/"GATHER" MOBILE KITCHEN CLASSROOM, SAVING GRACE AND WHISPERING ROOTS. THE FOLLOWING TOP HEALTH NEEDS WERE IDENTIFIED AND PRIORITIZED AS PART OF THE CHNA AND IMPLEMENTATION STRATEGY PLAN APPROVED IN 2022. ALTHOUGH A MORE RECENT CHNA WAS COMPLETED IN 2025, THE RELATED IMPLEMENTATION PLAN WAS NOT APPROVED UNTIL OCTOBER, 2025. THEREFORE THE WORK DESCRIBED BELOW IS TIED TO THE 2022 ASSESSMENT AND PLANS AND REPRESENTS WORK CARRIED OUT BY THE HOSPITAL DURING FISCAL YEAR 2025.THE COMMUNITY IDENTIFIED THE FOLLOWING PRIORITIES AS TOP HEALTH NEEDS THROUGH PRIMARY DATA OBTAINED THROUGH THE COMMUNITY HEALTH SURVEY AND KEY INFORMANT SURVEY, AS WELL AS A REVIEW OF SECONDARY DATA ON A VARIETY OF HEALTH INDICATORS.TOP HEALTH NEEDS (FROM 2022 CHNA): SOURCE FROM SIGNIFICANT HEALTH NEEDS OR FINDINGS SECTION OF THE CHNA- MENTAL HEALTH- NUTRITION, PHYSICAL ACTIVITY & WEIGHT- SUBSTANCE ABUSE- DIABETES- SEXUAL HEALTH- INJURY & VIOLENCE- HEART DISEASE & STROKE- TOBACCO USE- INFANT HEALTH & FAMILY PLANNING- POTENTIALLY DISABLING CONDITIONS- ORAL HEALTH- ACCESS TO HEALTH CARE SERVICES- RESPIRATORY DISEASE- CANCERSCH H, PART V, LINE 11 (CONTINUED) FACILITY REPORTING GROUP - A PART V, SECTION B, LINE 13H: THE PATIENT MUST HAVE A MINIMUM ACCOUNT BALANCE OF TEN DOLLARS ($10.00) WITH THE COMMONSPIRIT HOSPITAL ORGANIZATION. MULTIPLE ACCOUNT BALANCES MAY BE COMBINED TO REACH THIS AMOUNT. PATIENTS/GUARANTORS WITH BALANCES BELOW TEN DOLLARS ($10.00) MAY CONTACT A FINANCIAL COUNSELOR TO MAKE MONTHLY INSTALLMENT PAYMENT ARRANGEMENTS. THE PATIENT MUST SUBMIT A COMPLETED FINANCIAL ASSISTANCE APPLICATION. PATIENT COOPERATION STANDARDS - A PATIENT MUST COOPERATE WITH THE HOSPITAL FACILITY IN PROVIDING THE INFORMATION AND DOCUMENTATION NECESSARY TO DETERMINE ELIGIBILITY. SUCH COOPERATION INCLUDES COMPLETING ANY REQUIRED APPLICATIONS OR FORMS. THE PATIENT IS RESPONSIBLE FOR NOTIFYING THE HOSPITAL FACILITY OF ANY CHANGE IN FINANCIAL SITUATION THAT WOULD IMPACT THE ASSESSMENT OF ELIGIBILITY. A PATIENT MUST EXHAUST ALL OTHER PAYMENT OPTIONS, INCLUDING PRIVATE COVERAGE, FEDERAL, STATE AND LOCAL MEDICAL ASSISTANCE PROGRAMS, AND OTHER FORMS OF ASSISTANCE PROVIDED BY THIRD PARTIES PRIOR TO BEING APPROVED. AN APPLICANT FOR FINANCIAL ASSISTANCE IS RESPONSIBLE FOR APPLYING TO PUBLIC PROGRAMS FOR AVAILABLE COVERAGE. HE OR SHE IS ALSO EXPECTED TO PURSUE PUBLIC OR PRIVATE HEALTH INSURANCE PAYMENT OPTIONS FOR CARE PROVIDED BY A COMMONSPIRIT HOSPITAL ORGANIZATION WITHIN A HOSPITAL FACILITY. A PATIENT'S AND, IF APPLICABLE, ANY GUARANTOR'S COOPERATION IN APPLYING FOR APPLICABLE PROGRAMS AND IDENTIFIABLE FUNDING SOURCES, INCLUDING COBRA COVERAGE (A FEDERAL LAW ALLOWING FOR A TIME-LIMITED EXTENSION OF EMPLOYEE HEALTHCARE BENEFITS), SHALL BE REQUIRED. IF A HOSPITAL FACILITY DETERMINES THAT COBRA COVERAGE IS POTENTIALLY AVAILABLE, AND THAT A PATIENT IS NOT A MEDICARE OR MEDICAID BENEFICIARY, THE PATIENT OR GUARANTOR SHALL PROVIDE THE HOSPITAL FACILITY WITH INFORMATION NECESSARY TO DETERMINE THE MONTHLY COBRA PREMIUM FOR SUCH PATIENT, AND SHALL COOPERATE WITH HOSPITAL FACILITY STAFF TO DETERMINE WHETHER HE OR SHE QUALIFIES FOR HOSPITAL FACILITY COBRA PREMIUM ASSISTANCE, WHICH MAY BE OFFERED FOR A LIMITED TIME TO ASSIST IN SECURING INSURANCE COVERAGE. A HOSPITAL FACILITY SHALL MAKE AFFIRMATIVE EFFORTS TO HELP A PATIENT OR PATIENT'S GUARANTOR APPLY FOR PUBLIC AND PRIVATE PROGRAMS. PART V, SECTION B FACILITY REPORTING GROUP B FACILITY REPORTING GROUP B CONSISTS OF: - FACILITY 3: CHI HEALTH PLAINVIEW FACILITY REPORTING GROUP - B PART V, SECTION B, LINE 5: IN CONDUCTING ITS MOST RECENT CHNA, THE CHI HEALTH PLAINVIEW TOOK INTO ACCOUNT INPUT FROM PERSONS WHO REPRESENT THE BROAD INTERESTS OF THE COMMUNITY SERVED BY THE HOSPITAL FACILITY, INCLUDING THOSE WITH SPECIAL KNOWLEDGE OF OR EXPERTISE IN PUBLIC HEALTH. ASSESSMENT PROCESS AND METHODS:IN FISCAL YEAR 2025, CHI HEALTH PLAINVIEW CONDUCTED A COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) IN PARTNERSHIP WITH MULTIPLE AGENCIES ACROSS THE NORTH CENTRAL DISTRICT HEALTH DEPARTMENT (NCDHD) SERVICE AREA AND MOST OF THE HOSPITALS WITHIN THE NINE COUNTIES THAT MAKE UP THE NORTH CENTRAL DISTRICT (NCD). THE PROCESS WAS LED BY NCDHD AND THE EVALUATION SERVICES WERE CONTRACTED. THE CHNA UTILIZED DATA FROM NATIONAL, STATE AND LOCAL SOURCES SUCH AS: CENTERS FOR MEDICARE & MEDICAID SERVICES, US CENSUS, THE YOUTH RISK BEHAVIORAL SURVEILLANCE SURVEY OVERSAMPLE, ETC. QUALITATIVE DATA WAS GLEANED THROUGH A SURVEY SENT TO PARTNERS, A SURVEY TO THE COMMUNITY, KEY INFORMANT INTERVIEWS, AND FOCUS GROUPS. METHODS OF ANALYSIS FOR QUANTITATIVE DATA INCLUDED TIME SERIES, DESCRIPTIVE, INFERENTIAL, CAUSAL, AND PREDICTIVE ANALYSIS; WHILE QUALITATIVE DATA METHODS UTILIZED WERE CONTENT, QUALITATIVE, AND DIAGNOSTIC ANALYSIS. THE CHNA LED TO THE IDENTIFICATION OF PRIORITY HEALTH NEEDS FOR THE NCD, INCLUDING PIERCE COUNTY, FOR THE COMMUNITIES TO COLLECTIVELY ADDRESS OVER THE NEXT THREE YEARS. WITH THE COMMUNITY, THE HOSPITAL WILL FURTHER WORK TO IDENTIFY EACH PARTNER'S ROLE IN ADDRESSING THESE HEALTH NEEDS AND DEVELOP MEASURABLE, IMPACTFUL STRATEGIES.THE NCDHD CONVENED THE COMMUNITY IN A SERIES OF MEETINGS IN 2024 TO REVIEW PRIMARY AND SECONDARY DATA AND FURTHER PRIORITIZE NEEDS FOR THE NCD. ON MARCH 25, 2025, PARTNERS GATHERED FOR A FINAL REVIEW OF THE DATA AND TO DETERMINE THE SIGNIFICANT HEALTH NEEDS FOR THE NINE COUNTIES IN THE NCD. FACILITY REPORTING GROUP - B PART V, SECTION B, LINE 6A: ANTELOPE MEMORIAL HOSPITAL, AVERA CREIGHTON HOSPITAL, AVERA ST. ANTHONY'S HOSPITAL, BROWN COUNTY HOSPITAL, CHERRY COUNTY HOSPITAL, NIOBRARA VALLEY HOSPITAL, OSMOND GENERAL HOSPITAL, ROCK COUNTY HOSPITAL, AND WEST HOLT MEMORIAL HOSPITAL. FACILITY REPORTING GROUP - B PART V, SECTION B, LINE 6B: CHNA COLLABORATORS:- NORTH CENTRAL DISTRICT HEALTH DEPARTMENT (NCDHD) - TOMMY GEORGE, MPH, CPH (CONTRACTOR)- ANTELOPE MEMORIAL HOSPITAL- AVERA CREIGHTON - AVERA ST. ANTHONY'S O'NEILL - CHERRY COUNTY HOSPITAL - OSMOND GENERAL HOSPITAL - NIOBRARA VALLEY HOSPITAL - WEST HOLT MEMORIAL HOSPITAL - MIDTOWN HEALTH FACILITY REPORTING GROUP - B PART V, SECTION B, LINE 7D: THE CHNA REPORT WAS ALSO SHARED WITH ORGANIZATIONS APPLYING FOR THE COMMUNITY HEALTH IMPROVEMENT GRANT PROGRAM. FACILITY REPORTING GROUP - B PART V, SECTION B, LINE 11: THE MOST RECENT CHNA AND CORRESPONDING IMPLEMENTATION PLAN WAS COMPLETED IN THE TAX REPORTING YEAR 2024. THE FOLLOWING OUTLINES THE CURRENT IMPLEMENTATION PLAN PRIORITIES AND STRATEGIES. THE COMMUNITY IDENTIFIED THE FOLLOWING PRIORITIES AS TOP HEALTH NEEDS THROUGH PRIMARY AND SECONDARY DATA FROM KEY INFORMANT INTERVIEWS:TOP HEALTH NEEDS (FROM 2025 CHNA): - 1. ACCESS TO SERVICES- 2. BEHAVIORAL HEALTH- 3. CHRONIC CONDITIONS AND DISEASE PREVENTION- 4. SOCIOECONOMIC INSTABILITYFOR THIS PLAN THE HOSPITAL PRIORITIZED THE FOLLOWING HEALTH NEEDS:PRIORITY HEALTH NEED #1: BEHAVIORAL HEALTHTO ADDRESS THIS NEED THE HOSPITAL WILL IMPLEMENT THE FOLLOWING STRATEGIES IN FISCAL YEARS 2026- 2028:- INCREASE COMMUNITY AND HOSPITAL CAPACITY TO ADDRESS MENTAL HEALTH - OFFER TOBACCO CESSATION RESOURCES PRIORITY HEALTH NEED #2: SOCIAL DRIVERS OF HEALTH (SDOH)TO ADDRESS THIS NEED THE HOSPITAL WILL IMPLEMENT THE FOLLOWING STRATEGIES IN FISCAL YEARS 2026- 2028:- INCREASE ACCESS TO FOOD THROUGH SCREENING AND REFERRAL - PROVIDE ACCESS/ NAVIGATION TO COMMUNITY RESOURCES - INCREASE ACCESS TO COMMUNITY RESOURCES FOR SENIORSTHE HOSPITAL WILL NOT ADDRESS THE FOLLOWING HEALTH NEEDS FOR THE FOLLOWING REASONS: CHI HEALTH PLAINVIEW WILL ADDRESS SOCIOECONOMIC INSTABILITY THROUGH SOCIAL DETERMINANTS OF HEALTH (SDOH) ACTIVITIES AND, RECOGNIZING THAT ACCESS TO SERVICES IS A CROSS-CUTTING SIGNIFICANT HEALTH NEED, WILL ADDRESS IT THROUGH ACTIVITIES FOR THE TWO HOSPITAL PRIORITIES: BEHAVIORAL HEALTH AND SDOH. THE FOLLOWING IDENTIFIED NEEDS WERE NOT EXPLICITLY PRIORITIZED IN THIS ISP, BUT ARE BEING ADDRESSED THROUGH CROSS-CUTTING STRATEGIES WITHIN OTHER PRIORITIES AS DESCRIBED BELOW. CHRONIC CONDITIONS AND DISEASE PREVENTION. CHI HEALTH PLAINVIEW FACILITATES COMMUNITY AUTOMATED EXTERNAL DEFIBRILLATOR (AED) TRAININGS AND PARTNERS WITH NORTH CENTRAL DISTRICT HEALTH DEPARTMENT (NCDHD) TO PROVIDE COMMUNITY BLOOD PRESSURE SCREENINGS, IT HAS PARTNERED WITH NCDHD TO PLACE BLOOD PRESSURE MACHINES IN COMMUNITY SETTINGS SUCH AS THE SENIOR CENTER AND LIBRARY, AND TO PROVIDE COMMUNITY EDUCATION AROUND BLOOD PRESSURE. THE FOLLOWING TOP HEALTH NEEDS WERE IDENTIFIED AND PRIORITIZED AS PART OF THE CHNA AND IMPLEMENTATION STRATEGY PLAN APPROVED IN 2022. ALTHOUGH A MORE RECENT CHNA WAS COMPLETED IN 2025, THE RELATED IMPLEMENTATION PLAN WAS NOT APPROVED UNTIL OCTOBER, 2025. THEREFORE THE WORK DESCRIBED BELOW IS TIED TO THE 2022 ASSESSMENT AND PLANS AND REPRESENTS WORK CARRIED OUT BY THE HOSPITAL DURING FISCAL YEAR 2025.THE COMMUNITY IDENTIFIED THE FOLLOWING PRIORITIES AS TOP HEALTH NEEDS THROUGH PRIMARY DATA OBTAINED THROUGH THE COMMUNITY HEALTH SURVEY AND KEY INFORMANT SURVEY, AS WELL AS A REVIEW OF SECONDARY DATA ON A VARIETY OF HEALTH INDICATORS.TOP HEALTH NEEDS (FROM 2022 CHNA): - 1. BEHAVIORAL HEALTH: WE CONTINUE TO MEET TO ORGANIZE AWARENESS OF BEHAVIOR HEALTH BY OFFERING MENTAL HEALTH FIRST AID CLASSES. ALSO DEVELOPING A RELATIONSHIP WITH THE LOCAL SCHOOL TO GET A LIMHP TO SERVE IN BOTH LOCATIONS. - 2. CANCER: THROUGH OUR ANNUAL HEALTH FAIR, WE RAISE AWARENESS TO TESTING OFFERED HERE AT CHI HEALTH PLAINVIEW. ALSO DURING THE HEALTH FAIR WE OFFER FREE SKIN CHECKS TO ANYONE THAT WOULD LIKE ONE. - 3. CHRONIC DISEASE: THROUGH THE ANNUAL HEALTH FAIR A VARIETY OF LAB TESTS ARE OFFERED FREE OF CHARGE IN AN ATTEMPT TO CATCH ANY ABNORMAL RESULTS. - 4. SOCIAL DETERMINANTS OF HEALTH (INCLUDING ACCESS TO CARE)FOR THIS PLAN THE HOSPITAL PRIORITIZED THE FOLLOWING HEALTH NEEDS:PRIORITY HEALTH NEED #1: BEHAVIORAL HEALTH1.1 SUPPORT INTERNAL AND EXTERNAL EFFORTS TO PROMOTE MENTAL HEALTH SERVICES AND REDUCE SUBSTANCE ABUSE THROUGH EARLY INTERVENTION AND EDUCATION.1.1.1 CONVENE A BEHAVIORAL HEALTH COALITION THAT MEETS MONTHLY TO ADDRESS BEHAVIORAL HEALTH ISSUES, CONNECT SERVICE PROVIDERS AND MAINTAIN ACTIVE PARTICIPATION IN LOCAL AREA SUBSTANCE USE PREVENTION COALITIONS. COALITION MAY WORK ON THE FOLLOWING ACTIVITIES AND ADOPT OTHER STRATEGIES AS APPROPRIATE: - SUPPORT AND PROMOTE SCHOOL- BASED MENTAL HEALTH PROGRAMMING FOCUSED ON PREVENTION OF SUBSTANCE ABUSE AND SUICIDE - IDENTIFY EMERGING ISSUES THROUGH THE BEHAVIORAL HEALTH COALITION AND CREATE A TRAINING PLAN TO INCREASE COMMUNITY AWARENESS FY25 ACTIONS AND IMPACT:- OFFERED MENTAL HEALTH FIRST AID CLASSES - WORKING WITH THE LOCAL SCHOOL TO HIRE A LICENSED MENTAL HEALTH COUNSELOR (LMHC)FY25 MEASURES:- MENTAL HEALTH FIRST AID CLASSES CANCELLED DUE TO LOW ATTENDANCE. - AT THIS TIME WE HAVE NOT BEEN ABLE TO HIRE A LMHC1.1.2 EXPAND USE OF TELEHEALTH AND OTHER HEALTH CARE SYSTEM STRATEGIES FOR BEHAVIORAL HEALTH SERVICESFY25 ACTIONS AND IMPACT:- THERE HAS CONTINUED TO BE A SHORTAGE OF PROVIDERS TO PROVIDE THESE SERVICES. BEHAVIORAL HEALTH TELEHEALTH SERVICE WAS USED ONE TIME IN FY25 THROUGH OUR MED/SURG DEPARTMENT.FY25 MEASURES:- NO MEASURE TO REPORT1.1.3 SUPPORT AND PARTICIPATE IN THE NCDHD COMMUNITY HEALTH IMPROVEMENT PLAN (CHIP) EFFORTS TO: - INCREASE MENTAL HEALTH FIRST AID TRAINING (MHFA) PROVIDERS IN NCDHD DISTRICT - PROVIDE MHFA TRAININGS IN EACH COUNTY - BRING ONE BCBA (BOARD CERTIFIED BEHAVIOR ANALYST) TO THE DISTRICT - PROVIDE PEER TO PEER MENTAL HEALTH TRAINING TO LOCAL SCHOOLS (QPR, TEEN MHFA) - UTILIZE MEDIA OUTLETS TO INCREASE THE AWARENESS OF MENTAL HEALTH AND SUICIDE (RESOURCE LINE/ TEXT 741741/ PHONE 988) FY25 ACTIONS AND IMPACT:- STAFF PARTICIPATED IN A BIMONTHLY CHIP WORKGROUP, IN NORTH CENTRAL COMMUNITY CARE PARTNERS (NCCC), AND IN AREA SUBSTANCE ABUSE PREVENTION (ASAP) MEETINGS.- STAFF SERVED ON NCDHD'S AND NCCC'S BOARD OF DIRECTORS.FY25 MEASURES:- CHIP MEETINGS: 2- NCCC/ASAP MEETINGS: 61.1.4 EXPLORE STRATEGIES AROUND VIOLENCE PREVENTION AND INCORPORATE HEALTH SYSTEM STRATEGIES TO PROVIDE TRAUMA INFORMED PATIENT CARE AND MITIGATE FURTHER VIOLENCEFY25 ACTIONS AND IMPACT:- THE UPPER MIDWEST CAH HUMAN TRAFFICKING TASK FORCE WAS STARTED IN JANUARY OF 2025. DURING FY25, THE TASK FORCE MET MONTHLY AND INCLUDED CHI EDUCATION MATERIAL AND POLICY REVIEW AS WELL AS GUEST SPEAKERS, INCLUDING CHI ETHICS AND LEGAL AND ACTIVE ND HUMAN TRAFFICKING TASK FORCE MEMBERS. TASK FORCE MEMBERS JOINED ON A VOLUNTARY BASIS AND HAD REPRESENTATION FROM NE, IA AND ND. - THE FORENSIC NURSE EXAMINER (FNE) PROGRAM MARKET MANAGER PROVIDED ONGOING EDUCATION ON INTIMATE PARTNER VIOLENCE (IPV), SEXUAL ASSAULT (SA), AND HUMAN TRAFFICKING (HT) IDENTIFICATION TO EMERGENCY DEPARTMENTS.- PROVIDED OPPORTUNITIES FOR EXISTING AND NEWLY RECRUITED FNE STAFF TO ATTEND THE INTERNATIONAL ASSOCIATION OF FORENSIC NURSES ANNUAL CONFERENCE, SUPPORTING ACCREDITED FNE TRAINING.- REPRESENTATION FROM CHI HEALTH STAFF ON NEBRASKA PATH AND SWICHT, TWO ANTI-TRAFFICKING WORK GROUPS IN NEBRASKA AND IOWA RESPECTIVELY.FY25 MEASURES:- HUMAN TRAFFICKING 101: 96.2% COMPLETION RATE105 ASSIGNED101 COMPLETED- PEARR* (FIVE STEPS TO VICTIM ASSISTANCE IN HEALTH CARE SETTINGS): 97.6% COMPLETION RATE41 ASSIGNED40 COMPLETED- TRAUMA INFORMED CARE*: 95.2% COMPLETION RATE42 ASSIGNED 40 COMPLETED- **PEARR/ TRAUMA INFORMED CARE TRAINING WAS ASSIGNED TO DEFINED CLINICAL STAFF ONLY.1.2 EXPAND COMMUNITY PARTNERSHIPS THAT ADDRESS PRIORITY COMMUNITY HEALTH NEEDS1.2.1 THROUGH THE COMMUNITY HEALTH IMPROVEMENT GRANT (CHIG) PROGRAM, AWARD ANNUAL GRANT FUNDING TO ONE OR MORE COMMUNITY ORGANIZATIONS WHO ARE ADDRESSING COMMUNITY HEALTH NEEDS.FY25 ACTIONS AND IMPACT:- CHI HEALTH PLAINVIEW DID NOT RECEIVE ANY 2025 CHIG APPLICANTS.FY25 MEASURES:- NO MEASURES TO REPORT.SCH H, PART V, LINE 11 (CONTINUED) FACILITY REPORTING GROUP - B PART V, SECTION B, LINE 13H: THE PATIENT MUST HAVE A MINIMUM ACCOUNT BALANCE OF TEN DOLLARS ($10.00) WITH THE COMMONSPIRIT HOSPITAL ORGANIZATION. MULTIPLE ACCOUNT BALANCES MAY BE COMBINED TO REACH THIS AMOUNT. PATIENTS/GUARANTORS WITH BALANCES BELOW TEN DOLLARS ($10.00) MAY CONTACT A FINANCIAL COUNSELOR TO MAKE MONTHLY INSTALLMENT PAYMENT ARRANGEMENTS. THE PATIENT MUST SUBMIT A COMPLETED FINANCIAL ASSISTANCE APPLICATION. PATIENT COOPERATION STANDARDS - A PATIENT MUST COOPERATE WITH THE HOSPITAL FACILITY IN PROVIDING THE INFORMATION AND DOCUMENTATION NECESSARY TO DETERMINE ELIGIBILITY. SUCH COOPERATION INCLUDES COMPLETING ANY REQUIRED APPLICATIONS OR FORMS. THE PATIENT IS RESPONSIBLE FOR NOTIFYING THE HOSPITAL FACILITY OF ANY CHANGE IN FINANCIAL SITUATION THAT WOULD IMPACT THE ASSESSMENT OF ELIGIBILITY. A PATIENT MUST EXHAUST ALL OTHER PAYMENT OPTIONS, INCLUDING PRIVATE COVERAGE, FEDERAL, STATE AND LOCAL MEDICAL ASSISTANCE PROGRAMS, AND OTHER FORMS OF ASSISTANCE PROVIDED BY THIRD PARTIES PRIOR TO BEING APPROVED. AN APPLICANT FOR FINANCIAL ASSISTANCE IS RESPONSIBLE FOR APPLYING TO PUBLIC PROGRAMS FOR AVAILABLE COVERAGE. HE OR SHE IS ALSO EXPECTED TO PURSUE PUBLIC OR PRIVATE HEALTH INSURANCE PAYMENT OPTIONS FOR CARE PROVIDED BY A COMMONSPIRIT HOSPITAL ORGANIZATION WITHIN A HOSPITAL FACILITY. A PATIENT'S AND, IF APPLICABLE, ANY GUARANTOR'S COOPERATION IN APPLYING FOR APPLICABLE PROGRAMS AND IDENTIFIABLE FUNDING SOURCES, INCLUDING COBRA COVERAGE (A FEDERAL LAW ALLOWING FOR A TIME-LIMITED EXTENSION OF EMPLOYEE HEALTHCARE BENEFITS), SHALL BE REQUIRED. IF A HOSPITAL FACILITY DETERMINES THAT COBRA COVERAGE IS POTENTIALLY AVAILABLE, AND THAT A PATIENT IS NOT A MEDICARE OR MEDICAID BENEFICIARY, THE PATIENT OR GUARANTOR SHALL PROVIDE THE HOSPITAL FACILITY WITH INFORMATION NECESSARY TO DETERMINE THE MONTHLY COBRA PREMIUM FOR SUCH PATIENT, AND SHALL COOPERATE WITH HOSPITAL FACILITY STAFF TO DETERMINE WHETHER HE OR SHE QUALIFIES FOR HOSPITAL FACILITY COBRA PREMIUM ASSISTANCE, WHICH MAY BE OFFERED FOR A LIMITED TIME TO ASSIST IN SECURING INSURANCE COVERAGE. A HOSPITAL FACILITY SHALL MAKE AFFIRMATIVE EFFORTS TO HELP A PATIENT OR PATIENT'S GUARANTOR APPLY FOR PUBLIC AND PRIVATE PROGRAMS. FACILITY REPORTING GROUP A, PART V, SECTION B, LINE 11 (CONTINUED 1): FOR THIS PLAN THE HOSPITAL PRIORITIZED THE FOLLOWING HEALTH NEEDS:PRIORITY HEALTH NEED #1: BEHAVIORAL HEALTH1.1 EXPAND ACCESS TO MENTAL HEALTH SERVICES FOR YOUTH1.1.1 OPERATE AN INTEGRATED SCHOOL-BASED MENTAL HEALTH PROGRAM (LED BY CHI HEALTH IMMANUEL)FY25 ACTIONS AND IMPACT:- MAINTAINED AN INTEGRATED SCHOOL-BASED MENTAL HEALTH PROGRAM IN THE DC WEST SCHOOL SYSTEM IN VALLEY, NE. THE PROGRAM SERVES STUDENTS AND THEIR FAMILIES IN GRADES K-12.FY25 MEASURES:- STUDENTS SERVED (NOT UNDUPLICATED): 31- AVERAGE NUMBER OF STUDENTS SERVED IN SCHOOL-BASED AND VIRTUAL PROGRAMS: 24- NEW STUDENT REFERRALS: 12- BILLABLE OFFICE VISITS: 4411.2 EXPAND ACCESS TO RESOURCES FOR INDIVIDUALS LIVING WITH ALZHEIMER'S AND DEMENTIA- RELATED DISEASES (ADRD)1.2.1 PROVIDE SUPPORT FOR INDIVIDUALS WITH ALZHEIMER'S/DEMENTIA AND THEIR CAREGIVERS (ALL HOSPITALS)FY25 ACTIONS AND IMPACT:- DESIGNATED A NEUROLOGIST AS OUR PROGRAM LEADER FOR ALZHEIMER'S - OPENED A BUSINESS CASE AND BEGAN RECRUITING FOR A COGNITIVE DISORDERS SPECIALIST NEUROLOGIST- ASSEMBLED A WORK GROUP TO BEGIN PLANNING FOR AN EARLY-ALZHEIMER'S INFUSION INTERVENTIONS THROUGH ANTI-AMYLOID THERAPIESFY25 MEASURES:- NO MEASURES TO REPORT1.3 EXPAND ACCESS TO BEHAVIORAL HEALTH SERVICES FOR ADULTS IN CRISIS1.3.1 CONTINUE TO PROVIDE ACCESS TO OUTPATIENT BEHAVIORAL HEALTH SERVICES AND REDUCE BEHAVIORAL HEALTH READMISSIONS THROUGH LASTING HOPE RECOVERY CENTER OUTPATIENT CLINIC (LED BY LASTING HOPE RECOVERY CENTER)FY25 ACTIONS AND IMPACT:- SUCCESSFUL OPENING OF AN ADULT INTENSIVE OUTPATIENT PROGRAM IN OCTOBER 2024- IMPLEMENTED MAT CLINIC AT LHRC IN APRIL 2025 TO SUPPORT PCP PATIENTS.FY25 MEASURES:- 784 INTENSIVE OUTPATIENT ( IOP) SESSIONS ATTENDED, SERVING 44 UNIQUE PATIENTS- 5,784 TRADITIONAL OUTPATIENT CLINIC VISITS1.3.2 DEVELOP AND PILOT AN INTEGRATED PEER SUPPORT SPECIALIST (PSS) PROGRAM ACROSS ALL AREAS OF BEHAVIORAL HEALTH SERVICES (LED BY CHI HEALTH IMMANUEL)FY25 ACTIONS AND IMPACT:- THIS STRATEGY IS SUPPORTED THROUGH A FY24-FY26 COMMONSPIRIT HEALTH MISSION AND MINISTRY FUND GRANT. THROUGHOUT FY25 THE BEHAVIORAL HEALTH SERVICE LINE: EXPANDED THE PEER SUPPORT SPECIALIST PROGRAM TO LASTING HOPE RECOVERY CENTER AND TO CHI HEALTH MERCY COUNCIL BLUFFS HOSPITALS. BY THE END OF FY25, THE PROGRAM EMPLOYED THREE 0.8 FTE AND ONE 0.5 FTE PEER SUPPORT SPECIALISTS.CONTINUED TO CONVENE A PEER SUPPORT SPECIALIST PROGRAM ADVISORY COUNCIL TO DESIGN THE PROGRAM MODEL AND TO PROVIDE TECHNICAL ASSISTANCE.TO SUSTAIN THE PROGRAM, BEGAN BILLING MEDICARE/MEDICAID FOR THEIR COVERED SERVICES.PRESENTED ABOUT THE PROGRAM TO COMMONSPIRIT HEALTH NATIONAL AND TO TWO LOCAL PEER SUPPORT AGENCIES. FY25 MEASURES:- NO MEASURES TO REPORT.1.4 ADVOCATE FOR POLICY CHANGE1.4.1 LEAD POLICY AND ADVOCACY EFFORTS THAT EXPAND ACCESS TO BEHAVIORAL HEALTH SERVICES (ALL HOSPITALS)FY25 ACTIONS AND IMPACT:- THROUGH THE NEBRASKA HOSPITAL ASSOCIATION AND INDEPENDENT EFFORTS, CHI HEALTH SUPPORTED LEGISLATIVE REFORMS TO ADDRESS HEALTH CARE FINANCE, WORKFORCE CHALLENGES AND WORKPLACE VIOLENCE.FY25 MEASURES:- # OF BEHAVIORAL HEALTH BILLS APPROVED (OF THOSE SUPPORTED BY NHA AND/OR CHI HEALTH): 41.4.2 SUPPORT SARPY/CASS TOBACCO COALITION (LED BY CHI HEALTH MIDLANDS)FY25 ACTIONS AND IMPACT:- TOBACCO EDUCATION & ADVOCACY OF THE MIDLANDS (TEAM) CONTINUED TO WORK WITH BUSINESSES, SCHOOL DISTRICTS, PUBLIC HOUSING PROGRAMS AND CITY PARKS TO IMPLEMENT SMOKE-FREE/ VAPE-FREE/ TOBACCO- FREE POLICIES. CONTINUED WORKING ON NEW INITIATIVES TO DECREASE THE NUMBER OF TOBACCO RETAILERS AND INCREASE THE NUMBER OF CESSATION ASSESSMENT AND REFERRAL SYSTEM POLICIES WITHIN HEALTH CARE, SOCIAL SERVICE, AND EDUCATION AGENCIES.FY25 MEASURES:- TEAM COALITIONMEMBERS: 125NEW MEMBERS: 18- MULTI-FAMILY BUILDINGS THAT ADOPTED 100% SMOKE-FREE/VAPE-FREE/TOBACCO-FREE POLICIES WITHIN SARPY/CASS COUNTY: 171- JURISDICTIONS THAT DESIGNATE OUTDOOR RECREATIONAL AREAS AS SMOKE-FREE/VAPE-FREE OR TOBACCO-FREE IN SARPY/CASS COUNTY: 12- CESSATION ASSESSMENT AND REFERRAL SYSTEM POLICIES WITHIN HEALTH CARE, SOCIAL SERVICE, AND EDUCATION AGENCIES IN SERVICE LINESARPY/CASS COUNTY: 101.5 DECREASE BEHAVIORAL HEALTH WORKFORCE SHORTAGE THROUGH EDUCATIONAL PARTNERSHIPS1.5.1 DEVELOP, IMPLEMENT AND EVALUATE BEHAVIORAL HEALTH WORKFORCE RECRUITMENT AND RETENTION STRATEGIES (ALL HOSPITALS)FY25 ACTIONS AND IMPACT:- CONTINUED FOCUS ON ONBOARDING AND CONTINUING EDUCATION FOR PROVIDERS TO SUPPORT RECRUITMENT AND RETENTION.FY25 MEASURES:- HIRED:ADDICTION PSYCHIATRISTS: 1PSYCHIATRIC NPS: 1CHEMICAL DEPENDENCY THERAPISTS: 11.6 REDUCE MENTAL HEALTH STIGMA1.6.1 SUPPORT INTERNAL/COMMUNITY MENTAL HEALTH STIGMA REDUCTION CAMPAIGNS (ALL HOSPITALS)FY25 ACTIONS AND IMPACT:- SENT A BEHAVIORAL HEALTH (BH) LEADER TO WASHINGTON D.C. FOR ANTI-STIGMA INSTRUCTOR CERTIFICATION TRAINING, FOCUSING ON SUBSTANCE USE DISORDERS, IN RESPONSE TO AN ASK FROM THE CSH BH EXECUTIVE COUNCIL, PARTNERING WITH THE ADDICTION POLICY FORUM.- THIS LEADER BECAME AN ANTI-STIGMA CERTIFIED INSTRUCTOR TO PROMOTE AN ANTI-STIGMA CULTURE, WITH THE GOAL OF FACILITATING AT LEAST ONE TRAINING SESSION FOR 20 ASSOCIATES IN FY25.- THE NEWLY TRAINED LEADER SUBSEQUENTLY TRAINED ALL BH LEADERS AND INCORPORATED A ONE-HOUR ANTI-STIGMA TRAINING INTO THE BEHAVIORAL HEALTH NEW EMPLOYEE INTRODUCTION TO BEHAVIORAL HEALTH SERVICELINE, EXPANDING THE INITIATIVE'S REACH.- THE TRAINING HAS BEEN INCORPORATED INTO THE NEW EMPLOYEE ONBOARDING FOR THE BEHAVIORAL HEALTH SERVICELINE (1-HOUR TRAINING).FY25 MEASURES:- THE LEADER'S CERTIFICATE IS VALID FOR 3 YEARS.- ACHIEVED 100% TRAINING COMPLETION FOR ALL 25+ DESIGNATED LEADERS AND BEGAN TRAINING NEW EMPLOYEES STARTING LAST MAY. WE HAVE TRAINED OVER 100 EMPLOYEES.- ADDITIONAL ASSOCIATES TRAINED AS TRAINERS.1.7 EARLY DETECTION OF DEPRESSION AND CONNECTION TO MENTAL HEALTH SERVICES AMONG PREGNANT PEOPLE1.7.1 CONDUCT PERINATAL DEPRESSION SCREENING DURING PRENATAL VISIT, WHILE INPATIENT FOR DELIVERY AND AT POSTPARTUM VISIT (LED BY CHI HEALTH CUMC-BERGAN MERCY, CHI HEALTH IMMANUEL, AND CHI HEALTH LAKESIDE) FY25 ACTIONS AND IMPACT:- CONTINUED TO IMPLEMENT INPATIENT DEPRESSION SCREENINGFY25 MEASURES:- CUMC - BERGAN MERCY: 30,000- IMMANUEL: 504- LAKESIDE: 9231.8 PREVENT SUICIDE1.8.1 EXPLORE LOCAL SCHOOL NEEDS REGARDING SUICIDE PREVENTION AND PROVIDE TRAINING AND FINANCIAL RESOURCES (E.G. QUESTION. PERSUADE. RESPOND (QPR), MENTAL HEALTH FIRST AID, ETC.) (ALL HOSPITALS)FY25 ACTIONS AND IMPACT:- NO ACTION TO REPORTFY25 MEASURES:- NO MEASURE TO REPORT FACILITY REPORTING GROUP A, PART V, SECTION B, LINE 11 (CONTINUED 2): PRIORITY HEALTH NEED #2: HEALTH-RELATED SOCIAL NEEDS2.1 HEALTHY FOOD ACCESS2.1.1 IMPLEMENT AND EVALUATE A FOOD PRESCRIPTION PROGRAM PILOT (LED BY CHI HEALTH CUMC-UNIVERSITY CAMPUS AND CHI HEALTH IMMANUEL)FY25 ACTIONS AND IMPACT:- CONTINUED TO SUPPORT THE CURA PROJECT BY RECRUITING PARTICIPANTS FROM SEVERAL CHI CLINICS. CURA IS AN 18-MONTH PROGRAM, LED BY CREIGHTON UNIVERSITY, THAT PROVIDES PATIENTS WHO HAVE DIABETES AND FINANCIAL STRESS OR FOOD INSECURITY WITH HEALTHY FOOD HOME DELIVERIES, FINANCIAL EDUCATION CLASSES AND COACHING, AND HEALTH COACHING TO SUPPORT SELF-MANAGEMENT OF THEIR CONDITION. PARTICIPANTS WERE ENROLLED ON A ROLLING BASIS (ABOUT 20 PARTICIPANTS EVERY THREE MONTHS). ENROLLMENT ENDED IN OCTOBER 2024.FY25 MEASURES:- # OF PARTICIPANTS (JULY 1, 2024-JUNE 30, 2025): 44 - # OF PARTICIPANTS SERVED THROUGHOUT THE LIFETIME OF THE PROGRAM (APRIL 2022-JUNE 2025): 215ENROLLED: 283AVERAGE AGE: 56.5GENDER: 75.6% FEMALERACE/ETHNICITY:AFRICAN AMERICAN: 50.5%WHITE: 42.1%LATINX: 6.4%OTHER: 1.0%AVERAGE BASELINE A1C: 8.1% BASELINE A1C <7%: 33.8%BASELINE A1C 7-8.9%: 38.0%BASELINE A1C>9%: 28.2%DROPPED: 89RETENTION RATE: 68.6%2.1.2 PROVIDE FINANCIAL SUPPORT AND PROMOTION OF DOUBLE UP FOOD BUCKS (DUFB), A SNAP INCENTIVE PROGRAM (ALL HOSPITALS)FY25 ACTIONS AND IMPACT:- CONTINUED TO FINANCIALLY SUPPORT THE DUFB PROGRAM STATEWIDE. DUFB PROVIDES THE FOLLOWING FOR PARTICIPATING SNAP ACCEPTING RETAIL SITES AND SNAP RECIPIENTS: FORMAL SUPPORT TO SITES TO STOCK FRESH FRUITS AND VEGETABLES AND HELP RECIPIENTS FIND FRESH FRUITS AND VEGETABLES AND BUY LOCAL PRODUCE WHEN POSSIBLE; DOLLAR-FOR-DOLLAR MATCHES ON FRESH FRUITS AND VEGETABLES TO HELP RECIPIENTS AFFORD FRESH FRUITS AND VEGETABLES; SITE SUPPORT TO CREATE CULTURALLY APPROPRIATE ENVIRONMENTS HELPING RECIPIENTS CHOOSE FRESH FRUITS AND VEGETABLES; AND TRAINING, TOOLS AND RESOURCES FOR SITES TO OFFER IN-STORE NUTRITION EDUCATION, FOOD DEMONSTRATIONS, PROMOTION AND MARKETING, MEET REQUIRED REPORTING, AND ASSESSMENTS TO HELP RECIPIENTS USE FRESH FRUITS AND VEGETABLES.FY25 MEASURES:- SITES ACROSS NEBRASKA THAT COLLECT DUFB: 20NEW SITES ADDED BETWEEN 9/1/23 AND 8/31/24: 5 RURAL- DOLLAR AMOUNT SPENT BY SNAP CUSTOMERS AT DUFB SITES: $5,182,592DUFB EARNED FROM QUALIFYING PURCHASES: $439,489DUFB REDEEMED FOR MORE FRESH FRUITS AND VEGETABLES: $233,3092.1.3 PROVIDE FINANCIAL SUPPORT TO ORGANIZATIONS ADDRESSING FOOD SECURITY, SUCH AS SAVING GRACE (LED BY NEBRASKA SPINE)FY25 ACTIONS AND IMPACT:- DONATED FUNDS TO SAVING GRACE PERISHABLE FOOD RESCUE. SAVING GRACE PROVIDES FOOD TO FAMILIES IN THE OMAHA METRO- DONATED FUNDS TO THE ANNUAL THANKSGIVING TURKEY DRIVE SO THAT CHI COULD PROVIDE FOOD BASKETS TO NEEDY FAMILIES.FY25 MEASURES:- DONATED $5,750.00 TO SAVING GRACE AND DONATED $500.00 TO CHI HEALTH IMMANUEL FOR THANKSGIVING TURKEY DRIVE.2.1.4 SUPPORT A SENIOR AND WIC FARMERS MARKET VOUCHER REDEMPTION PROGRAM AND POP UP FARMSTANDS (ALL HOSPITALS)FY25 ACTIONS AND IMPACT:- CONTINUED TO PARTNER WITH BIG GARDENS AND WHISPERING ROOTS TO OFFER POP-UP FARMSTANDS AT SENIOR CENTERS AND WIC CLINICS. FY25 MEASURES:- SENIOR CENTER POP UPS:PARTICIPATING SITES: 7 UNIQUE SITES AND 15 FARMSTANDSVALUE OF VOUCHERS RECEIVED: $8,253 (2,751 VOUCHERS)VALUE OF THE 'DOUBLE UP' PRODUCE MATCH PROVIDED TO VOUCHER RECIPIENTS: $13,599- WIC CLINIC POP UPS:PARTICIPATING SITES: 3 UNIQUE SITES AND 8 FARMSTANDSFARMSTAND CUSTOMERS SERVED: 712- TOTAL FARMSTAND PURCHASES (INCLUDES ALL PAYMENT FORMS SUCH AS VOUCHERS, CASH, AND CREDIT): $80,7442.2 FINANCIAL LITERACY2.2.1 PROVIDE FINANCIAL SUPPORT AND PROMOTION OF THE BRIDGES OUT OF POVERTY FINANCIAL LITERACY PROGRAM (ALL HOSPITALS)FY25 ACTIONS AND IMPACT:- CONTINUED TO FINANCIALLY SUPPORT BRIDGES OUT OF POVERTY IN FACILITATING, "GETTING AHEAD IN THE WORKPLACE" COURSES TO CHI HEALTH STAFF AT OMAHA METRO HOSPITALS. THE 8-WEEK COURSE EDUCATES STAFF ABOUT BUILDING STABILITY/RESOURCES FOR A BETTER LIFE AT WORK AND AT HOME. - AWARDED A COMMUNITY HEALTH IMPROVEMENT GRANT (CHIG), ANNUAL GRANT FUNDING FOR COMMUNITY ORGANIZATIONS WHO ARE ADDRESSING COMMUNITY HEALTH NEEDS, TO BRIDGES OUT OF POVERTY. FY25 MEASURES:- FINANCIAL SUPPORT PROVIDED: $48,0002.3 SUPPORT EFFORTS TO ADDRESS HOUSING STABILITY2.3.1 IMPLEMENT AND SUSTAIN A MEDICAL RESPITE PROGRAM (ALL HOSPITALS)FY25 ACTIONS AND IMPACT:- THIS STRATEGY IS SUPPORTED THROUGH A FY25-FY27 COMMONSPIRIT HEALTH MISSION AND MINISTRY FUND GRANT. THROUGHOUT FY25:THE MEDICAL RESPITE PROGRAM AT SIENA FRANCIS HOUSE, IMPLEMENTED IN 2022, CONTINUED TO SERVE UNHOUSED COMMUNITY MEMBERS REQUIRING POST-ACUTE CARE. PROGRAM PARTICIPANTS RECEIVED CASE MANAGEMENT, ACCESS TO MEDICAL CARE, DAILY MEALS, AND CLOTHING. THE MEDICAL RESPIRE PROGRAM INCREASED ITS CAPACITY TO 25 BEDS. CHI HEALTH HEALTHY COMMUNITIES ADVISED THE PROGRAM THROUGH A MEDICAL RESPITE STEERING COMMITTEE. CHI HEALTH SUPPORTED SIENA FRANCIS HOUSE AS IT WORKED WITH THE NEBRASKA DEPARTMENT OF HEALTH AND HUMAN SERVICES TO APPLY FOR AN 1115 MEDICAID WAIVER THAT WOULD ALLOW THEM TO RECEIVE REIMBURSEMENT FOR MEDICAL RESPITE SERVICES. FY25 MEASURES:- MEDICAL RESPITE METRICS (AUGUST 2022-MARCH 2025):TOTAL REFERRALS TO THE PROGRAM: 338 (130 OR 38% FROM CHI HEALTH)TOP 5 PRIMARY CONDITIONS FOR REFERRAL:WOUND CARE AND RELATED CONDITIONS: 67 (23.5%)NEUROLOGICAL ISSUES: 39 (13.7%)NOT RECORDED: 33 (11.6%)SURGICAL AND RECOVERY ISSUES: 32 (11.2%)OTHER HEALTH ISSUES: 28 (9.8%)TOTAL REFERRALS ACCEPTED: 201 (59% ACCEPTANCE RATE)PARTICIPANTS ENROLLED: 154MALES: 127 (82%)FEMALES: 27 (18%)2.3.2 SUPPORT A HEALTH AND HOUSING COALITION (ALL HOSPITALS)FY25 ACTIONS AND IMPACT:- THIS STRATEGY IS SUPPORTED THROUGH A FY25-FY27 COMMONSPIRIT HEALTH MISSION AND MINISTRY FUND GRANT. THROUGHOUT FY25:THE HEALTH AND HOUSING COALITION (HHC), AN OMAHA METRO AREA GROUP OF STAKEHOLDERS REPRESENTING HEALTHCARE AND HOMELESS SUPPORT SERVICES, CONTINUED TO MEET QUARTERLY TO DISCUSS THE INTERSECTION OF CLINICAL CARE AND HOUSING NEEDS, SUSTAINABILITY OF THE CITY'S MEDICAL RESPITE PROGRAM, AND OTHER RELATED COMMUNITY PROJECTS AND NEWS.SEVERAL HHC SUBGROUPS ALSO CONTINUED TO MEET: THE MEDICAL RESPITE STEERING COMMITTEE MET BIWEEKLY TO ADVISE THE MEDICAL RESPITE PROGRAM.THE FREQUENTLY-USED SYSTEMS ENGAGEMENT (FUSE) DATA WORKGROUP MET MONTHLY TO ESTABLISH DATA-SHARING OPPORTUNITIES BETWEEN JUSTICE, HEALTHCARE, AND SOCIAL SERVICE SYSTEMS FOR AN EVENTUAL LAUNCH OF THE FUSE INITIATIVE IN OMAHA. FUSE IS A MODEL FOR STABILIZING INDIVIDUALS WHO ARE THE MOST FREQUENT USERS OF HOMELESS, HEALTH, AND JUSTICE SYSTEMS. FY25 MEASURES:- HHC ATTENDANCE: OCTOBER 29, 2025: 26 ATTENDEES REPRESENTING 16 ORGANIZATIONSAPRIL 30, 2025: 20 ATTENDEES REPRESENTING 12 ORGANIZATIONS2.3.3 EVALUATE AND SUSTAIN AN INPATIENT HOUSING CASE MANAGEMENT PROGRAM (ALL HOSPITALS)FY25 ACTIONS AND IMPACT:- EXPANDED THE ROLE OF THE HOUSING PROBLEM SOLVING AND CASE MANAGEMENT ROLE AT CUMC- BERGAN MERCY TO BE 1.0 FTE. MORE PATIENTS WERE ABLE TO BE ASSISTED DURING THIS TIME PERIOD.- THIS ROLE IS CONTINUING TO EXPAND TO 2.0 FTE WITH 1.0 FTE CONTINUING AT CUMC-BERGAN MERCY AND AN ADDITIONAL HOUSING PROBLEM SOLVING AND CASE MANAGEMENT WILL BE ADDED TO LASTING HOPE RECOVERY CENTER. FY25 MEASURES:- REFERRALS MADE TO TOGETHER FOR HOUSING CASE MANAGEMENT: 161PREVENTION: 41DIVERSION: 44UTILITIES: 30GENERAL INFORMATION: 49REFERRALS MADE NO CONTACT: 53- 16% OF THESE REFERRALS RECEIVED MONETARY ASSISTANCEFINANCIAL INTERVENTIONS TO PREVENT HOMELESSNESS OR ACHIEVE STABLE HOUSING: $34,532.792.4 ADDRESS TRANSPORTATION BARRIERS TO ACCESSING HEALTHCARE SERVICES2.4.1 CONVENE AN INTERNAL WORKING GROUP TO EXPLORE OPPORTUNITIES TO MEET PATIENT TRANSPORTATION NEEDS (ALL HOSPITALS)FY25 ACTIONS AND IMPACT:- WORKING TO SECURE FUNDING TO FACILITATE FOCUS GROUP DISCUSSIONS AROUND TRANSPORTATION WITHIN OMAHA- THESE FUNDS WILL ALSO BE UTILIZED TO CREATE A COMMUNITY COALITION AND TASKFORCE TO FOCUS ON TRANSPORTATION TO CREATE A BETTER TRANSPORTATION FORCE IN THE OMAHA AREAFY25 MEASURES:- NO MEASURES TO REPORT.- THE 2025 COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) IDENTIFIED ACCESS TO HEALTH CARE SERVICES AS A SIGNIFICANT COMMUNITY HEALTH NEED- 9.7% OF COMMUNITY MEMBERS REPORTED THAT TRANSPORTATION HINDERED THEIR ABILITY TO VISIT A DOCTOR IN THE PAST YEAR. FACILITY REPORTING GROUP A, PART V, SECTION B, LINE 11 (CONTINUED 3): 2.5 SOCIAL NEEDS INTEGRATION2.5.1 DEVELOP AND TEST REFERRAL PROCESSES FOR SOCIAL NEEDS THROUGH UNITE US (ALL HOSPITALS)FY25 ACTIONS AND IMPACT:- CONTINUED TO SEND REFERRALS THROUGH UNITE US.- EXPLORED OPPORTUNITIES FOR PROCESS IMPROVEMENT AND INCREASED UTILIZATION OF THE PLATFORM THROUGH QUARTERLY UNITE US UPPER CENTRAL REGION ADVISORY COUNCIL MEETINGS. FY25 MEASURES:- REFERRALSCHI HEALTH CUMC-BERGAN MERCY: 33 CHI HEALTH IMMANUEL: 141 CHI HEALTH LAKESIDE: 1 2.5.2 LEVERAGE COMMUNITY HEALTH WORKERS TO IMPROVE PATIENT OUTCOMES AND REDUCE HEALTH DISPARITIES (ALL HOSPITALS)FY25 ACTIONS AND IMPACT:- THIS STRATEGY IS SUPPORTED THROUGH A FY24-FY25 COMMONSPIRIT HEALTH MISSION AND MINISTRY FUND GRANT. THROUGHOUT FY25:CHI HEALTH IMPLEMENTED COMMUNITY LINK ADVOCATES (SYNONYMOUS WITH CHWS AND HERETOFORE REFERRED TO AS CLAS) TO WORK WITH PATIENTS WITHIN PRIMARY CARE CLINICS (IN-PERSON AND VIRTUALLY) TO ADDRESS IDENTIFIED HEALTH-RELATED SOCIAL NEEDS THAT ARE IMPACTING THEIR HEALTH STATUS. COMMUNITY LINK:EMPLOYED SIX FTE CLAS WHO RESIDE IN FIVE PRIMARY CARE CLINICS AND ONE FTE SUPERVISOR.ACCEPTED REFERRALS FROM OVER 28 OMAHA METRO AND LINCOLN AREA CLINICSCONTINUED TO LEND EXPERTISE TO COMMUNITY AND STATE ORGANIZATIONS WORKING TO STRENGTHEN THE CHW WORKFORCE THROUGH ENGAGEMENT IN ADVISORY GROUPS AND PRESENTATIONS. FY25 MEASURES:- REFERRALS RECEIVED: 3,986- BARRIERS IDENTIFIED: 5,508 (TOP FIVE INCLUDE: FINANCIAL, INSURANCE, TRANSPORTATION, FOOD, LEVEL OF CAREINTERVENTIONS PROVIDED: 10,213RESOURCES PROVIDED: 2,289COORDINATED CALLS: 865APPLICATION ASSISTANCE: 865INTERNAL REFERRALS: 731EDUCATION AND INFORMATION PROVIDED: 4,7162.5.3 SUPPORT THE IMPLEMENTATION OF PATHWAYS COMMUNITY HUB TO SUSTAIN A COMMUNITY HEALTH WORKER (CHW) WORKFORCE IN THE OMAHA METRO AND REDUCE DISPARATE MATERNAL AND INFANT HEALTH OUTCOMES (ALL HOSPITALS)FY25 ACTIONS AND IMPACT:- AWARDED A COMMUNITY HEALTH IMPROVEMENT GRANT (CHIG), ANNUAL GRANT FUNDING FOR COMMUNITY ORGANIZATIONS WHO ARE ADDRESSING COMMUNITY HEALTH NEEDS, TO OMAHA PATHWAYS COMMUNITY HUB. FOLLOWING THE PATHWAYS COMMUNITY HUB INSTITUTE MODEL, THE CERTIFIED OMAHA HUB IS DEVELOPING A SUSTAINABLE NETWORK OF COMMUNITY HEALTH WORKERS TRAINED FRONTLINE PUBLIC HEALTH WORKERS WHO HAVE A DEEP UNDERSTANDING OF AND CONNECTION TO THE COMMUNITY. THE HUB IS INITIALLY FOCUSED ON ADDRESSING UNFAIR DIFFERENCES IN OUTCOMES AMONG PREGNANT AND POSTPARTUM INDIVIDUALS. FY25 MEASURES:- PATHWAYS COMMUNITY HUB METRICS (APRIL 1, 2024-JUNE 30, 2025):FAMILIES SERVED (MEANING AT LEAST ONE HEALTH NEED SUCCESSFULLY ADDRESSED): 139BABIES BORN: 80BORN FULL-TERM: 88.1%HEALTHY BIRTH WEIGHT: 92.9%HEALTH NEEDS ADDRESSED: 880PATHWAYS CLOSED (PATHWAYS ARE TOOLS USED BY COMMUNITY HEALTH WORKERS TO IDENTIFY AND TRACK PARTICIPANTS NEEDS. A PATHWAY IS CLOSED WHEN A MEASURABLE OUTCOME IS ACHIEVED): 436SOCIAL SERVICE REFERRAL: 189NORMAL BIRTH WEIGHT: 74POSTPARTUM: 43FAMILY PLANNING: 33FOOD SECURITY: 21EMPLOYMENT: 13MEDICAL REFERRAL: 13MEDICAL HOME: 11ORAL HEALTH: 9TRANSPORTATION: 8HEALTHCARE COVERAGE: 8ADULT EDUCATION: 7HOUSING: 3MENTAL HEALTH: 3IMMUNIZATION: 1HEALTH EDUCATION MODULES DELIVERED: 445CHIG FUNDS AWARDED (3/1/25-2/28/26): $20,0002.6 INCREASE THE NUMBER AND DIVERSITY OF YOUTH INTERESTED IN HEALTH CARE CAREERS2.6.1 CREATE A HEALTH CARE CAREER PIPELINE FOR STUDENTS (LED BY CHI HEALTH CUMC-BERGAN MERCY, CHI HEALTH IMMANUEL, CHI HEALTH, LAKESIDE, AND CHI HEALTH MIDLANDS)FY25 ACTIONS AND IMPACT:- THIS STRATEGY IS SUPPORTED THROUGH A FY25-FY27 COMMONSPIRIT HEALTH MISSION AND MINISTRY FUND GRANT. THROUGHOUT FY25:HIRED AN FTE WORKFORCE DEVELOPMENT REGIONAL MANAGER TO ESTABLISH AND LEAD A CERTIFIED NURSING ASSISTANT (CNA) CAREER PATHWAY PROGRAM. THE MANAGER ESTABLISHED RECRUITING PATHWAYS AT ADDITIONAL LOCAL SCHOOLS AND COMMUNITY CENTERS.HIRED A CNA INSTRUCTOR. ESTABLISHED A CENTRAL REGION WORKFORCE PLANNING STEERING COMMITTEE TO TRAIN AND RECRUIT KEY CLINICAL ROLES: RESPIRATORY THERAPISTS, LAB/PHLEBOTOMISTS, CNA/PATIENT CARE TECHS, RADIOLOGY TECHS, CERTIFIED MEDICAL ASSISTANTS, SURGICAL TECHS, ELECTROCARDIOGRAM TECHS, AESTHESIA TECHS, AND SUB STERILE TECHS.FY25 MEASURES:- HEALTHCARE CAREER PRESENTATIONS: 6- CNA CAREER PATHWAY PROGRAM METRICS:STUDENTS WHO COMPLETED THE CHI HEALTH CAREER LADDER CNA TRAINING AND CERTIFICATION AT CHI IMMANUEL : 46STUDENTS WHO RECEIVED A SCHOLARSHIP FROM THE REGIONAL WORKFORCE DEVELOPMENT GRANT PROGRAM AND COMPLETED CNA TRAINING AND CERTIFICATION THROUGH ONE OF OUR EXTERNAL PARTNERS (METROPOLITAN COMMUNITY COLLEGE, FULTON HOMES): 22STUDENTS WHO RECEIVED THEIR CNA CERTIFICATION THROUGH THIS GRANT PROGRAM: 68STUDENTS WHO COMPLETED BASIC LIFE SUPPORT TRAINING: 22STUDENTS EMPLOYED IN THEIR RESPECTIVE FIELD WITHIN ONE YEAR (OF ALL WHO COMPLETED THE PROGRAM): 292.6.2 SUPPORT SIEMBRA SALUD, HEALTH CAREER LADDER PROGRAM (LED BY CHI HEALTH CUMC-BERGAN MERCY, CHI HEALTH IMMANUEL, CHI HEALTH, LAKESIDE, AND CHI HEALTH MIDLANDS)FY25 ACTIONS AND IMPACT:- NO UPDATES TO REPORT. THIS STRATEGY WAS SUPPORTED BY A FY22-FY24 COMMONSPIRIT HEALTH MISSION AND MINISTRY FUND GRANT. WHEN THE GRANT CONCLUDED, ITS ACTIVITIES WERE ASSUMED BY A NEW MISSION AND MINISTRY FUND GRANT DESCRIBED IN ACTIVITY 2.6.1.FY25 MEASURES:- NO MEASURES TO REPORT.2.6.3 THROUGH THE COMMUNITY HEALTH IMPROVEMENT GRANT (CHIG) PROGRAM, AWARD ANNUAL GRANT FUNDING TO ONE OR MORE COMMUNITY ORGANIZATIONS WHO ARE ADDRESSING COMMUNITY HEALTH NEEDS.FY25 ACTIONS AND IMPACT:- AWARDED A CHIG TO 25 COMMUNITY ORGANIZATIONS: CENTER FOR HOLISTIC DEVELOPMENT, COMUNIDAD MAYA PIXAM IXIM, EMPOWERMENT NETWORK, GIRLS INCORPORATED OF OMAHA, HABITAT FOR HUMANITY, HEAL OMAHA, HEARTLAND EQUINE THERAPEUTIC RIDING ACADEMY, HEARTLAND FAMILY SERVICE, I BE BLACK GIRL, INCOMMON, IMMIGRANT LEGAL CENTER, INTERCULTURAL SENIOR CENTER, LATINO CENTER OF THE MIDLANDS, NORTH 24TH ST BUSINESS IMPROVEMENT DISTRICT ASSOCIATION, MEN AGAINST DOMESTIC VIOLENCE, NEBRASKA AFGHAN COMMUNITY CENTER, NEIGHBORGOOD, NO MORE EMPTY POTS, OMAHA BRIDGES OUT OF POVERTY, OMAHA COMMUNITY FOUNDATION, RISE ACADEMY, RONALD MCDONALD HOUSE, SAVING GRACE, TOGETHER, WHISPERING ROOTSFY25 MEASURES:- CHIG FUNDS AWARDED (3/1/25-2/28/26): $500,0002.7 UTILIZE A HEALTH EQUITY TRANSFORMATION ASSESSMENT (HETA) TO ADDRESS PRIORITY COMMUNITY HEALTH NEEDS2.7.1 COMPLETE THE AMERICAN HOSPITAL ASSOCIATION'S HETA AND UTILIZE RESULTS TO DEVELOP AND IMPLEMENT AN ACTION PLAN THAT INCLUDES ACTIVITIES THAT WILL ADDRESS PRIORITY COMMUNITY HEALTH NEEDS.FY25 ACTIONS AND IMPACT:- HOSPITAL COMMITTEES CONTINUE TO MEET TO REVIEW AND IMPLEMENT THEIR HETA ACTION PLAN. FY25 MEASURES:- NO MEASURES TO REPORT. PRIORITY HEALTH NEED #3: VIOLENCE PREVENTION & INTERVENTION3.1 PROVIDE RESOURCES AND SUPPORT TO VICTIMS OF VIOLENCE3.1.1 SUPPORT AND EXPAND THE FORENSIC NURSE EXAMINER PROGRAM (ALL HOSPITALS)FY25 ACTIONS AND IMPACT:- THE FORENSIC NURSE EXAMINER (FNE) PROGRAM MARKET MANAGER PROVIDED ONGOING EDUCATION ON INTIMATE PARTNER VIOLENCE (IPV), SEXUAL ASSAULT (SA), AND HUMAN TRAFFICKING (HT) IDENTIFICATION TO EMERGENCY DEPARTMENTS.- PROVIDED OPPORTUNITIES FOR EXISTING AND NEWLY RECRUITED FNE STAFF TO ATTEND THE INTERNATIONAL ASSOCIATION OF FORENSIC NURSES ANNUAL CONFERENCE, SUPPORTING ACCREDITED FNE TRAINING.FY25 MEASURES:- FNES: 18- # OF FORENSIC NURSE EXAMINERS AVAILABLE TO PROVIDE 24/7 FNEP COVERAGE: 20- # OF HOSPITALS ENGAGED IN TELESANE PROGRAM: 8/ 8 HOSPITALS- IDENTIFIED IPV, SA, AND/OR HT CASES FOR WHICH FNES WERE CALLED TO PROVIDE SUPPORT (AS OF NOVEMBER 13, 2024): 434- # OF SURVIVORS OF DOMESTIC VIOLENCE, SEXUAL ASSAULT AND HUMAN TRAFFICKING SERVED THROUGH THE FORENSIC NURSE EXAMINER PROGRAM: 6593.1.2 SUPPORT TRAUMA RESPONSE, INCLUDING INPATIENT CASE MANAGEMENT AND COMMUNITY-BASED VIOLENCE INTERVENTION EFFORTS (LED BY CHI HEALTH CUMC-BERGAN MERCY AND CHI HEALTH CUMC-UNIVERSITY CAMPUS) FY25 ACTIONS AND IMPACT:- PARTNERED WITH HAVI TO PLAN A HOSPITAL VIOLENCE INTERVENTION PROGRAM (HVIP)- CONTINUED TO PARTNER WITH YOUTURNFY25 MEASURES:- YOUTURN REPORTED 1,700 POINTS OF CONNECTION IN STREET OUTREACH- COMMUNITY EVENTS ENGAGING 10,000 COMMUNITY MEMBERS- GUN VIOLENCE INPUT FROM MOTHERS EVENT HAD 10 MOTHERS ATTEND- CHI GUN VIOLENCE RESPONSE AND PREVENTION ADVISORY COUNCIL WITH 32 MULTIDISCIPLINARY MEMBERS REPRESENTING VARIOUS HOSPITAL AND CLINICAL DEPARTMENTS. THIS GROUP MET 7 TIMES- YOUTURN REPORTED 238 INDIVIDUALS ACTIVELY PARTICIPATING IN CASE MANAGEMENT- 11 PATIENTS IDENTIFIED AS ELIGIBLE FOR HVIP- THROUGHOUT FY25, YOUTURN ESTIMATES OVER 1,000 PUBLIC EDUCATION MATERIALS WERE DISTRIBUTED TO COMMUNITY MEMBERS. FACILITY REPORTING GROUP A, PART V, SECTION B, LINE 11 (CONTINUED 4): 3.2 PREVENT VIOLENCE AND INTERVENE WHEN IT IS SUSPECTED3.2.1 INCREASE HEALTH SYSTEM AND COMMUNITY CAPACITY TO IDENTIFY VICTIMS OF HUMAN TRAFFICKING AND RESPOND APPROPRIATELY (ALL HOSPITALS)FY25 ACTIONS AND IMPACT:- THE FORENSIC NURSE EXAMINER (FNE) PROGRAM MARKET MANAGER PROVIDED ONGOING EDUCATION ON INTIMATE PARTNER VIOLENCE (IPV), SEXUAL ASSAULT (SA), AND HUMAN TRAFFICKING (HT) IDENTIFICATION TO EMERGENCY DEPARTMENTS.- PROVIDED OPPORTUNITIES FOR EXISTING AND NEWLY RECRUITED FNE STAFF TO ATTEND THE INTERNATIONAL ASSOCIATION OF FORENSIC NURSES ANNUAL CONFERENCE, SUPPORTING ACCREDITED FNE TRAINING.- REPRESENTATION FROM CHI HEALTH STAFF ON NEBRASKA PATH AND SWICHT, TWO ANTI-TRAFFICKING WORK GROUPS IN NEBRASKA AND IOWA RESPECTIVELY.FY25 MEASURES:- FNES: 18- IDENTIFIED IPV, SA, AND/OR HT CASES FOR WHICH FNES WERE CALLED TO PROVIDE SUPPORT (AS OF DECEMBER 15, 2025): 659- FY25 STAFF PATHWAYS TRAININGS (OMAHA METRO AND IOWA COMPLETION RATES AS OF JANUARY 2026)HUMAN TRAFFICKING 101: 86.6% COMPLETION RATE8,641 ASSIGNED7,487 COMPLETEDPEARR* (FIVE STEPS TO VICTIM ASSISTANCE IN HEALTH CARE SETTINGS): 92.4% COMPLETION RATE5,022 ASSIGNED4,641 COMPLETEDTRAUMA INFORMED CARE*: 92.7% COMPLETION RATE5,016 ASSIGNED 4,650 COMPLETED**PEARR/ TRAUMA INFORMED CARE TRAINING WAS ASSIGNED TO DEFINED CLINICAL STAFF ONLY.3.3 PROVIDE TRAUMA- INFORMED CARE FOR PATIENTS3.3.1 EXPLORE ONGOING OPPORTUNITIES TO PROMOTE TRAUMA INFORMED CARE PRACTICES WITHIN THE BEHAVIORAL HEALTH SERVICE LINE (ALL HOSPITALS)FY25 ACTIONS AND IMPACT:- PARTNERED WITH REGION 6 TO OFFER MENTAL HEALTH FIRST AID AND COUNSELING ON ACCESS TO LETHAL MEANS FY25 MEASURES:- 2 MHFA TRAININGS: 7 ATTENDEES- 3 CALM TRAININGS: 30 ATTENDEES3.4 SUPPORT SCHOOL-BASED PROGRAMMING TO INCREASE PROTECTIVE FACTORS AND REDUCE RISK FACTORS FOR VIOLENCE3.4.1 PROVIDE FUNDING TO COMMUNITY-BASED ORGANIZATIONS DELIVERING EDUCATION AND TRAINING TO LOCAL SCHOOLS (ALL HOSPITALS)FY25 ACTIONS AND IMPACT:- THROUGH THE FY25-27 FIREARM SAFETY AND GUN VIOLENCE PREVENTION MMF GRANT, WE SUPPORT YOUTURN'S SCHOOL AND STREET OUTREACH EFFORTS IN THE NORTH OMAHA AREA. FY25 MEASURES:- NO MEASURES TO REPORT THE HOSPITAL IS NOT ADDRESSING, VIA THE IMPLEMENTATION PLAN, THE HEALTH NEEDS LISTED BELOW DUE TO THE FOLLOWING EXISTING WORK:ACCESS TO HEALTHCARE SERVICES: ACCESS TO CARE IS A FUNDAMENTAL COMPONENT OF CHI HEALTH'S MISSION AND STRATEGY. CHI HEALTH CONTINUES TO OFFER A WIDE ARRAY OF PRIMARY CARE ACCESS POINTS INCLUDING: EXTENDED CLINIC HOURS, PRIORITY CARE SERVICES (WALK-IN CARE), QUICK CARE AND VIRTUAL CARE. ADDITIONAL PROGRAMS LIKE MD SAVE, WHICH ALLOWS PATIENTS TO PRE-PURCHASE CERTAIN SERVICES AT A DISCOUNTED PRICE AND THE MEDICATION ACCESS PROGRAM (A PRESCRIPTION MEDICATION FINANCIAL ASSISTANCE PROGRAM) ARE WORKING TO LOWER THE COST OF CARE TO THE CONSUMER. IN ADDITION TO PROVIDING THE MAJORITY OF CARE TO THE UNINSURED AND UNDERINSURED IN THE OMAHA METRO AREA, CHI HEALTH WILL CONTINUE TO ADDRESS ACCESS TO HEALTHCARE SERVICES THROUGH FINANCIAL SUPPORT OF THE MAGIS CLINIC AND HOPE MEDICAL, AS WELL AS THROUGH FREE HEALTH SCREENINGS AND IMMUNIZATION CLINICS IN THE COMMUNITY.CANCER: CHI HEALTH CONTINUES TO PERFORM EXISTING CANCER OUTREACH THROUGHOUT THE COMMUNITY AND FINANCIALLY SUPPORT COMMUNITY PARTNERS SUCH AS THE AMERICAN CANCER SOCIETY, THE NEBRASKA CANCER COALITION AND PROJECT PINK'D. CHI HEALTH ALSO PARTICIPATES IN THE EVERY WOMAN MATTERS AND NEBRASKA COLON CANCER SCREENING PROGRAMS TO PROVIDE TESTING AND DIAGNOSTIC SERVICES FOR THE MEDICALLY UNDERSERVED IN NEBRASKA. CHI HEALTH CLINICS ARE WORKING TO INCREASE UTILIZATION OF HPV VACCINATION TO PREVENT CERVICAL CANCER.DIABETES: CHI HEALTH PERFORMS DIABETES OUTREACH AND EDUCATION ACROSS THE OMAHA METRO AREA, INCLUDING THROUGH THE INTEGRATION OF CERTIFIED DIABETES EDUCATORS IN PRIMARY CARE CLINICS. CHI HEALTH ALSO SUPPORTS THE CURA PROJECT, A PRODUCE PRESCRIPTION PROGRAM FOR LOW-INCOME, DIABETIC PATIENTS.HEART DISEASE AND STROKE: CHI HEALTH IS ADDRESSING SUBSTANCE ABUSE THROUGH BEHAVIORAL HEALTH STRATEGIES. SUBSTANCE ABUSE IS A BEHAVIORAL RISK FACTOR FOR HEART DISEASE AND STROKE. ADDITIONALLY, CHI HEALTH OFFERS PROGRAMMING DESIGNED TO MITIGATE RISK FACTORS FOR HEART DISEASE AND STROKE THROUGH CHI HEALTH HEART CARE CLASSES. CHI HEALTH IS A FINANCIAL SUPPORTER OF THE AMERICAN HEART ASSOCIATION.INFANT HEALTH & FAMILY PLANNING: CHI HEALTH PROVIDES FINANCIAL AND IN-KIND SUPPORT TO THE PATHWAYS COMMUNITY HUB PROGRAM AND OFFERS PERINATAL DEPRESSION SCREENING AND A BLACK, INDIGENOUS, PEOPLE OF COLOR (BIPOC) DOULA PROGRAM. REPRESENTATIVES FROM CHI HEALTH PARTICIPATE IN THE DOUGLAS COUNTY HEALTH DEPARTMENT-LED BABY BLOSSOMS COLLABORATIVE. ADDITIONALLY, CHI HEALTH SUPPORTS ORGANIZATIONS FOCUSED ON IMPROVING CHILD AND MATERNAL HEALTH OUTCOMES AND REDUCING RACIAL/ETHNIC DISPARITIES, SUCH AS I BE BLACK GIRL AND MARCH OF DIMES. NUTRITION, PHYSICAL ACTIVITY AND WEIGHT: CHI HEALTH IS PROVIDING FINANCIAL SUPPORT FOR DOUBLE UP FOOD BUCKS AND THE WOMEN, INFANT & CHILDREN (WIC)/SENIOR FARMER'S MARKET VOUCHER PROGRAM AS A STRATEGY TO ADDRESS HEALTH-RELATED SOCIAL NEEDS. ADDITIONALLY, CHI HEALTH PROVIDES FINANCIAL SUPPORT AND IN-KIND CONTRIBUTIONS TO ORGANIZATIONS COMMITTED TO ADDRESSING NUTRITION SUCH AS: BIG GARDEN/"GATHER" MOBILE KITCHEN CLASSROOM, CITY SPROUTS, SAVING GRACE, AND WHISPERING ROOTS.ORAL HEALTH: CHI HEALTH DID NOT PRIORITIZE ORAL HEALTH BASED ON THE CONSIDERATIONS ABOVE AND IN ORDER TO FOCUS AND MEANINGFULLY IMPACT OTHER AREAS OF NEED. OTHER COMMUNITY PARTNERS ARE ADDRESSING THIS NEED SUCH AS CHARLES DREW HEALTH CENTER DENTAL CLINIC, ONE WORLD COMMUNITY HEALTH CENTER AND FAMILY INC.POTENTIALLY DISABLING CONDITIONS: CHI HEALTH IS PROVIDING SUPPORT FOR INDIVIDUALS WITH ALZHEIMER'S/DEMENTIA AND THEIR CAREGIVERS AS A KEY STRATEGY TO ADDRESS BEHAVIORAL HEALTH. CHI HEALTH PROVIDES FINANCIAL SUPPORT TO THE NEBRASKA ALZHEIMER'S ASSOCIATION FOR FREE CARE CONSULTATION FOR FAMILIES WITH A LOVED ONE WHO HAS RECENTLY RECEIVED A DEMENTIA/ ALZHEIMER'S DIAGNOSIS. ADDITIONALLY, CHI HEALTH IMMANUEL OPERATES AN INPATIENT AND OUTPATIENT GERIATRIC PSYCHIATRY PROGRAM AND RECENTLY OPENED A NEUROLOGICAL INSTITUTE. RESPIRATORY DISEASES: CHI HEALTH PROVIDES FISCAL SPONSORSHIP AND IN-KIND SUPPORT OF TOBACCO EDUCATION AND ADVOCACY OF THE MIDLANDS (TEAM). SEXUAL HEALTH: OMAHA METRO AREA COMMUNITY PARTNERS, SUCH AS THE DOUGLAS COUNTY HEALTH DEPARTMENT, FEDERALLY QUALIFIED HEALTH CENTERS, AND THE WOMEN'S FUND ARE LEADING INITIATIVES TO ADDRESS SEXUALLY TRANSMITTED DISEASES. CHI HEALTH CLINICS ARE PROMOTING THE HPV VACCINATION FOR THE PREVENTION OF CERVICAL CANCER. FACILITY REPORTING GROUP B, PART V, SECTION B, LINE 11 (CONTINUED): PRIORITY HEALTH NEED #2: CARDIOVASCULAR HEALTH2.1 EXPAND ACCESS TO HEALTHY FOODS AND RECREATIONAL OPPORTUNITIES AND INCREASE AWARENESS OF RISK FACTORS FOR CHRONIC DISEASE BY ALIGNING HOSPITAL EFFORTS AND FINANCIAL SUPPORT WITH PIERCE COUNTY COMMUNITY PARTNERS.2.1.1 PARTICIPATE IN THE NCDHD COMMUNITY HEALTH IMPROVEMENT PLAN AND IDENTIFY OPPORTUNITIES TO SUPPORT COMMUNITY PARTNERS' CHRONIC DISEASE DETECTION AND MANAGEMENT EFFORTS SUCH AS:- INCREASE AMOUNT OF CPR CERTIFIED (INSTRUCTOR AND TRAINEES) - PROMOTE AND PROVIDE BLOOD PRESSURE SCREENINGS, WITH APPROPRIATE REFERRALS- PROMOTE AWARENESS OF THE RISKS OF ABNORMAL BLOOD PRESSURE VALUES- EXPLORE AVENUES FOR PHYSICAL ACTIVITY IN EACH COUNTY - INCREASE MEDICAID AWARENESS AND ENROLLMENTFY25 ACTIONS AND IMPACT:- WORK IN CONJUNCTION WITH THE LOCAL FIRE DEPARTMENT TO FACILITATE TRAINING FOR EMTFY25 MEASURES:- STAFF WHO COVERED FOR LOCAL EMTS AT LEAST ONCE: 9 2.1.2 EXPLORE OPPORTUNITIES TO SUPPORT HEALTHY FOOD CONSUMPTION AND BEHAVIORS SUCH AS: - SPONSORING A COOKING CLASS IN PLAINVIEW- INSTALL/ MAINTAIN COMMUNITY GARDEN AT CHI HEALTH PLAINVIEWFY25 ACTIONS AND IMPACT:- NO UPDATES TO REPORTFY25 MEASURES:- NO MEASURES TO REPORT2.1.3 HOST AN ANNUAL LAB FAIR OFFERING NO AND LOW COST SKIN CANCER SCREENING, BLOOD PRESSURE CHECKS AND GLUCOSE TESTING TO SUPPORT EARLY DETECTION OF RISK FACTORS FOR CHRONIC DISEASEFY25 ACTIONS AND IMPACT:- HOSTED A LAB FAIR IN APRIL 2025 AND OFFERED THE FOLLOWING SERVICES: COMPREHENSIVE METABOLIC PANELS, COMPLETE BLOOD COUNTS, LIPID PANELS, THYROID CHECKS, HBA1C, PROSTHETIC SPECIFIC ANTIGEN, BLOOD PRESSURE CHECKS, AND SKIN CHECKS.FY25 MEASURES:- APRIL LAB FAIR: ATTENDEES: 100- ATTENDEES THAT RECEIVED SERVICE: 942.1.4 WORK WITH CHI HEALTH CLINICS TO SUPPORT BLOOD PRESSURE SCREENING, DIABETES A1C TESTING AND MANAGEMENT, AND OTHER METRICS DETERMINED BY THE CLINICSFY25 ACTIONS AND IMPACT:- CONTINUED TO WORK WITH CLINICS TO MONITOR PROGRESS.FY25 MEASURES:- THIS METRIC CALCULATES THE PERCENTAGE OF PATIENTS 18 TO 75 YEARS OF AGE AND PART OF THE DIABETES REGISTRY, WHOSE MOST RECENT HEMOGLOBIN A1C (HBA1C) WAS GREATER THAN 9.0% OR HBA1C NOT COMPLETED IN THE LAST 12 MONTHS.- PLAINVIEWS PERFORMANCE FOR FY25 IS 5%- THIS METRIC CALCULATES THE PERCENTAGE OF HYPERTENSIVE PATIENTS 18 - 85 YEARS OF AGE WHOSE BLOOD PRESSURE WAS ADEQUATELY CONTROLLED (< 140/90 MMHG).- PLAINVIEW'S PERFORMANCE FOR FY25 IS 80%2.2 UTILIZE A HEALTH EQUITY TRANSFORMATION ASSESSMENT (HETA) TO ADDRESS PRIORITY COMMUNITY HEALTH NEEDS2.2.1 COMPLETE THE AMERICAN HOSPITAL ASSOCIATION'S HETA AND UTILIZE RESULTS TO DEVELOP AND IMPLEMENT AN ACTION PLAN THAT INCLUDES ACTIVITIES THAT WILL ADDRESS PRIORITY COMMUNITY HEALTH NEEDS.FY25 ACTIONS AND IMPACT:- ADDRESSING THE MENTAL HEALTH DESERT IN PIERCE COUNTY BY PROVIDING IN-PERSON LOCAL BEHAVIORAL HEALTH SERVICES.- PROMOTE BEHAVIORAL HEALTH EDUCATIONAL OPPORTUNITIES IN CONJUNCTION WITH HEALTHY CHOICES FOR PIERCE COUNTY COALITION. - CHI HEALTH PLAINVIEW IS RECRUITING TO ADD A LIMHP TO THE CLINIC. - CURRENT STATE ONE MENTAL HEALTH PROVIDER FOR 3,444 PEOPLE IN WESTERN PIERCE COUNTY. GOAL TO RECRUIT ONE PROVIDER TO DROP THE RATIO TO LESS THAN 2000 PEOPLE PER MENTAL HEALTH PROVIDER. FY25 MEASURES:- NO MEASURES TO REPORTTHE HOSPITAL IS NOT ADDRESSING, VIA THE IMPLEMENTATION PLAN, THE HEALTH NEEDS LISTED BELOW DUE TO THE FOLLOWING EXISTING WORK:CANCER AND CHRONIC DISEASE. CANCER AND CHRONIC DISEASE IS ADDRESSED THROUGH CARDIOVASCULAR HEALTH STRATEGIES AS MANY OF THE PROGRAMS AND PARTNERS ADDRESSING CARDIOVASCULAR HEALTH ALSO SUPPORT OTHER CHRONIC DISEASES. SOCIAL DETERMINANTS OF HEALTH. CHI HEALTH PLAINVIEW IS PARTNERING WITH NCDHD TO ADDRESS SOCIAL DETERMINANTS OF HEALTH THROUGH THE EFFORTS OUTLINED IN THE COMMUNITY HEALTH IMPROVEMENT PLAN. 11 1 - ACH-PLAINVIEW RURAL HEALTH CLINIC 704 N 3RD ST PLAINVIEW NE 68769 RURAL HEALTH CLINIC 2 - LAKESIDE ENDOSCOPY CENTER LLC 17001 LAKESIDE HILLS PLAZA OMAHA NE 68130 ENDOSCOPY CENTER 3 - LAKESIDE AMBULATORY SURGICAL CENTER LLC 17031 LAKESIDE HILLS DR OMAHA NE 68130 AMBULATORY SURGICAL CENTER 4 - BERGAN MERCY SURGERY CENTER LLC 7710 MERCY RD OMAHA NE 68124 AMBULATORY SURGICAL CENTER 5 - NEBRASKA SPINE HOSPITAL LLC 6901 N 72ND ST OMAHA NE 68122 SPINE HOSPITAL 6 - CHI HEALTH QUICK CARE LLC 7261 MERCY ROAD OMAHA NE 68124 QUICK CARE 7 - CHI HEALTH AMBULATORY SURGERY CTR - MDLS 11111 84TH ST PAPILLION NE 68046 AMBULATORY SURGICAL CENTER 8 - CHI HEALTH CLINIC PLAINVIEW 704 N 3RD ST PLAINVIEW NE 68769 RURAL HEALTH CLINIC 9 - CHI HEALTH LAKESIDE IMAGING CENTER 17201 LAKESIDE HILLS PL STE 107 OMAHA NE 68130 DIAGNOSTIC IMAGING CENTER 10 - CHI HEALTH NURSING HOME NETWORK 7261 MERCY ROAD OMAHA NE 68124 HOME CARE AND HOSPICE 11 - CHI HEALTH WEST OMAHA IMAGING CENTER 17201 WRIGHT ST STE 100 OMAHA NE 68130 DIAGNOSTIC IMAGING CENTER PART I, LINE 3C: UNLESS ELIGIBLE FOR PRESUMPTIVE FINANCIAL ASSISTANCE, THE FOLLOWING ELIGIBILITY CRITERIA MUST BE MET IN ORDER FOR A PATIENT TO QUALIFY FOR FINANCIAL ASSISTANCE: * THE PATIENT MUST HAVE A MINIMUM ACCOUNT BALANCE OF TEN DOLLARS ($10.00) WITH THE COMMONSPIRIT HOSPITAL ORGANIZATION. MULTIPLE ACCOUNT BALANCES MAY BE COMBINED TO REACH THIS AMOUNT. PATIENTS/GUARANTORS WITH BALANCES BELOW TEN DOLLARS ($10) MAY CONTACT A FINANCIAL COUNSELOR TO MAKE MONTHLY INSTALLMENT PAYMENT ARRANGEMENTS. * THE PATIENT MUST COMPLY WITH PATIENT COOPERATION STANDARDS AS DESCRIBED [IN THE FAP]. * THE PATIENT MUST SUBMIT A COMPLETED FINANCIAL ASSISTANCE APPLICATION. FOR PATIENTS AND GUARANTORS WHO ARE UNABLE TO PROVIDE REQUIRED DOCUMENTATION, A HOSPITAL FACILITY MAY GRANT PRESUMPTIVE FINANCIAL ASSISTANCE BASED ON INFORMATION OBTAINED FROM OTHER RESOURCES. IN PARTICULAR, PRESUMPTIVE ELIGIBILITY MAY BE DETERMINED ON THE BASIS OF INDIVIDUAL LIFE CIRCUMSTANCES THAT MAY INCLUDE: * RECIPIENT OF STATE-FUNDED PRESCRIPTION PROGRAMS; * HOMELESS OR ONE WHO RECEIVED CARE FROM A HOMELESS CLINIC; * PARTICIPATION IN WOMEN, INFANTS AND CHILDREN PROGRAMS (WIC); * FOOD STAMP ELIGIBILITY; * ELIGIBILITY OR REFERRALS FOR OTHER STATE OR LOCAL ASSISTANCE PROGRAMS (E.G., MEDICAID); * LOW INCOME/SUBSIDIZED HOUSING IS PROVIDED AS A VALID ADDRESS; OR * PATIENT IS DECEASED WITH NO KNOWN ESTATE. PART I, LINE 6A: THE CHI HEALTH SYSTEM PRODUCES AN ANNUAL PUBLIC COMMUNITY BENEFIT REPORT THAT IS MAILED TO A CORE CONSTITUENCY, PLACED IN KEY PLACES THROUGHOUT THE ORGANIZATION AND DISTRIBUTED IN COMMUNITY MEETINGS. IT IS ALSO AVAILABLE ON THE COMPANY'S INTRANET SITE, AND ON ITS PUBLIC WEBSITE AT HTTPS://WWW.CHIHEALTH.COM/ABOUT-US/MISSION-VALUES/COMMUNITY-BENEFIT. PART I, LINE 7: COMMONSPIRIT HEALTH HOSPITALS USE A COST ACCOUNTING SYSTEM OR AN ADJUSTED COST TO CHARGE RATIO CALCULATED IN A MANNER CONSISTENT WITH WORKSHEET 2 FOR EACH REPORTING FACILITY, TO DERIVE THE REPORTED COSTS OF FINANCIAL ASSISTANCE, MEDICAID AND OTHER MEANS-TESTED PROGRAMS. WORKSHEET 3 OR THE EQUIVALENT IN THE COMMUNITY BENEFIT INVENTORY FOR SOCIAL ACCOUNTABILITY ("CBISA") SOFTWARE ARE USED TO CALCULATE EXPENSE AND REVENUE, INCLUDING WHERE APPLICABLE MEDICAID PROVIDER FEES AND PAYMENTS FROM UNCOMPENSATED CARE PROGRAMS. ACTUAL OR ESTIMATED COST AND ANY DIRECT OFFSETTING REVENUE IS REPORTED, AND SCHEDULE H WORKSHEETS OR THEIR EQUIVALENTS ARE USED, FOR OTHER COMMUNITY BENEFIT ACTIVITIES SUCH AS COMMUNITY HEALTH IMPROVEMENT SERVICES, COMMUNITY BENEFIT OPERATIONS, HEALTH PROFESSIONS EDUCATION, SUBSIDIZED HEALTH SERVICES, RESEARCH, AND CASH AND IN-KIND DONATIONS. PART II, COMMUNITY BUILDING ACTIVITIES: CHI HEALTH HAS A HISTORY OF CENTRALIZED COMMUNITY BENEFIT INVESTMENTS, AS WELL AS HOSPITAL SPECIFIC INVESTMENTS THAT ADDRESS COMMUNITY HEALTH NEEDS WHICH INCLUDE SUPPORT OF LOCAL HEALTH COALITIONS, INVESTMENTS IN PARTNERSHIPS AND PROGRAMS THAT ADDRESS TOP COMMUNITY HEALTH NEEDS, PARTICIPATION IN LOCAL COMMITTEES AND BOARDS TIED TO TOP HEALTH NEEDS, AND INVESTMENTS IN MANY OTHER WAYS AS DESCRIBED IN OTHER AREAS OF THE SCHEDULE H NARRATIVE.BELOW ARE SPECIFIC EXAMPLES OF WORK THAT FALLS WITHIN THE DEFINITION OF COMMUNITY BUILDING ACTIVITIES. THESE ACTIVITIES ARE CRITICAL IN HELPING BUILD SOCIAL, HEALTH, AND ECONOMIC OPPORTUNITIES IN OUR COMMUNITY THAT ULTIMATELY DRIVE HEALTH STATUS AND QUALITY OF LIFE FOR OUR RESIDENTS: - PARTICIPATE IN TOBACCO EDUCATION & ADVOCACY OF THE MIDLANDS TO REDUCE/STOP THE USE OF TOBACCO.- PARTICIPATE IN MEETINGS WITH COMMUNITY HEALTH DEPARTMENTS. PART III, LINE 2: THE AMOUNT OF THE ORGANIZATION'S BAD DEBT AT COST IS DETERMINED BY APPLYING THE COST TO CHARGE RATIO TO PATIENT CHARGES THAT ARE DEEMED TO BE UNCOLLECTIBLE. THIS AMOUNT REPRESENTS THE COST OF SERVICES PROVIDED TO PATIENTS WHO ARE UNABLE OR REFUSE TO PAY THEIR BILLS AND DO NOT QUALIFY FOR FREE OR ADDITIONAL DISCOUNTED CARE, GOVERNMENT SPONSORED PROGRAMS OR OTHER PAYMENT ASSISTANCE, AND ARE OTHERWISE UNINSURED.THE FILING ORGANIZATION PROVIDES FREE CARE TO ANY PATIENT WHOSE FAMILY INCOME IS AT OR BELOW 200% OF THE FEDERAL POVERTY LEVEL, OR DISCOUNTED CARE TO UNINSURED OR UNDER-INSURED INDIVIDUALS WHOSE FAMILY INCOME IS ABOVE 201% BUT LOWER THAN 400% OF THE FEDERAL POVERTY LEVEL. THE FILING ORGANIZATION ALSO PROVIDES OPTIONS FOR INTEREST-FREE EXTENDED PAYMENT PLANS FOR PATIENTS WHO HAVE DEMONSTRATED GOOD FAITH AND ARE COOPERATING IN RESOLVING THEIR HOSPITAL BILLS. ALL ACCOUNTS FOR ELIGIBLE UNINSURED PATIENTS AT ALL FACILITIES RECEIVE AN AUTOMATIC UNINSURED DISCOUNT. THE EXPECTED PATIENT PAYMENT AMOUNT ON THE PATIENT'S BILL REFLECTS THIS DISCOUNT. DISCOUNTS ARE ACCOUNTED FOR AS DEDUCTIONS FROM REVENUE, NOT AS BAD DEBT EXPENSE. PART III, LINE 3: ALEGENT CREIGHTON HEALTH MAKES EVERY EFFORT TO DETERMINE IF A PATIENT QUALIFIES FOR FINANCIAL ASSISTANCE UPON ADMISSION. ALEGENT CREIGHTON HEALTH'S FINANCIAL ASSISTANCE POLICY IS COMMUNICATED TO PATIENTS UPON ADMISSION AND IS AVAILABLE IN THE LANGUAGES PRIMARILY SPOKEN IN THE COMMUNITY. IT IS ALSO POSTED IN VARIOUS COMMON AREAS OF THE HOSPITAL, SUCH AS EMERGENCY ROOMS, URGENT CARE CENTERS, ADMITTING AND REGISTRATION DEPARTMENTS, HOSPITAL BUSINESS OFFICES LOCATED ON FACILITY CAMPUSES, AND OTHER PUBLIC PLACES, AND IS PROVIDED UPON BILLING IF ELIGIBILITY IS NOT PREVIOUSLY DETERMINED. ELIGIBILITY IS REEVALUATED AS NEEDED AND AMOUNTS ARE CLASSIFIED AS CHARITY AS SOON AS ELIGIBILITY IS KNOWN. ALEGENT CREIGHTON HEALTH ALSO UTILIZES A WAYSTAR SCORING SYSTEM TO ASSIST IN DETERMINING IF A PATIENT MAY QUALIFY FOR PAYMENT ASSISTANCE EVEN THOUGH THEY HAVE NOT APPLIED FOR IT. WAYSTAR USES A METHODOLOGY THAT APPLIES CONSISTENT SCREENING AND APPLICATION STANDARDS TO ALL PATIENTS UTILIZING HISTORICAL DATA TO DEVELOP A PREDICTIVE MODEL FOR HEALTHCARE PAYMENT ASSISTANCE. IN ITS DEVELOPMENT, SPECIAL ATTENTION WAS PAID TO THOSE SOCIOECONOMIC FACTORS THAT MIGHT ADVERSELY AFFECT THOSE PATIENTS DESERVING THE MOST ATTENTION. OTHER CRITERIA ARE ALSO UTILIZED TO ENSURE THAT SERVICES THAT HAVE QUALIFIED AS FINANCIAL ASSISTANCE ARE NOT REPORTED AS BAD DEBT. AS SUCH, ALEGENT CREIGHTON HEALTH DOES NOT BELIEVE THAT ANY AMOUNTS INCLUDED IN PART III, LINE 2, ARE ATTRIBUTABLE TO PATIENTS ELIGIBLE UNDER THE ORGANIZATION'S PAYMENT ASSISTANCE POLICY, AND THEREFORE, NO PORTION OF BAD DEBT EXPENSE IS INCLUDED AS COMMUNITY BENEFIT EXPENSE. PART III, LINE 4: ALEGENT CREIGHTON HEALTH DOES NOT ISSUE SEPARATE COMPANY AUDITED FINANCIAL STATEMENTS. HOWEVER, THE ORGANIZATION IS INCLUDED IN THE CONSOLIDATED FINANCIAL STATEMENTS OF COMMONSPIRIT HEALTH. THE FOLLOWING IS AN EXCERPT FROM COMMONSPIRIT'S CONSOLIDATED ANNUAL AUDITED FINANCIAL STATEMENTS FOR THE YEAR ENDED JUNE 30, 2025, RELATED TO PATIENT ACCOUNTS RECEIVABLE AND NET PATIENT REVENUE. THE ENTIRE FOOTNOTE CAN BE VIEWED IN THE ATTACHED COMMONSPIRIT CONSOLIDATED FINANCIAL STATEMENTS ON PAGES 11-12."PATIENT SERVICE REVENUE IS REPORTED AT THE AMOUNTS THAT REFLECT THE CONSIDERATION COMMONSPIRIT EXPECTS TO BE PAID IN EXCHANGE FOR PROVIDING PATIENT CARE. THESE AMOUNTS ARE DUE FROM PATIENTS, THIRD-PARTY PAYORS (INCLUDING HEALTH INSURERS AND GOVERNMENT PROGRAMS), AND OTHERS, AND INCLUDE CONSIDERATION FOR RETROACTIVE REVENUE ADJUSTMENTS DUE TO SETTLEMENT OF AUDITS AND REVIEWS. GENERALLY, PERFORMANCE OBLIGATIONS FOR PATIENTS RECEIVING INPATIENT ACUTE CARE SERVICES AND OUTPATIENT SERVICES ARE RECOGNIZED OVER TIME AS SERVICES ARE PROVIDED. NET PATIENT REVENUE IS PRIMARILY COMPRISED OF HOSPITAL AND PHYSICIAN SERVICES." PART III, LINE 8: COMMONSPIRIT HEALTH HOSPITALS PREPARE MEDICARE COST REPORTS IN A MANNER THAT COMPORTS WITH PROVIDER REIMBURSEMENT MANUAL (PRM) 15-1 AND PRM 15-2 CHAPTER 40 (TRANSMITTAL 18). AS SUCH, THE FOLLOWING LANGUAGE PER PRM 15-1 DESCRIBES THE COMPUTATION OF COSTS PER THE MEDICARE COST REPORT: TOTAL ALLOWABLE COSTS OF A PROVIDER ARE APPORTIONED BETWEEN PROGRAM BENEFICIARIES AND OTHER PATIENTS SO THAT THE SHARE BORNE BY THE PROGRAM IS BASED UPON ACTUAL SERVICES RECEIVED BY PROGRAM BENEFICIARIES. THE RATIO OF COVERED BENEFICIARY CHARGES TO TOTAL PATIENT CHARGES FOR THE SERVICES OF EACH ANCILLARY DEPARTMENT IS APPLIED TO THE COST OF THE DEPARTMENT. ADDED TO THIS AMOUNT IS THE COST OF ROUTINE SERVICES FOR PROGRAM BENEFICIARIES, DETERMINED ON THE BASIS OF A SEPARATE AVERAGE COST PER DIEM FOR ALL PATIENTS FOR GENERAL ROUTINE PATIENT CARE AREAS. ANOTHER FACTOR CONSIDERED IS A SEPARATE AVERAGE COST PER DIEM FOR EACH INTENSIVE CARE UNIT, CORONARY CARE UNIT, AND OTHER SPECIAL CARE INPATIENT HOSPITAL UNITS. COMMONSPIRIT HEALTH AND ITS SUBORDINATE CORPORATIONS BELIEVE THAT THE ENTIRE MEDICARE SHORTFALL FOR THE CONSOLIDATED ENTITIES CONSTITUTES COMMUNITY BENEFIT. THE IRS COMMUNITY BENEFIT STANDARD INCLUDES THE PROVISION OF CARE TO THE ELDERLY AND MEDICARE PATIENTS. MEDICARE SHORTFALLS MUST BE ABSORBED BY COMMONSPIRIT HEALTH HOSPITALS IN ORDER TO CONTINUE TREATING THE ELDERLY IN OUR COMMUNITIES. THE HOSPITALS PROVIDE CARE REGARDLESS OF THIS SHORTFALL AND THEREBY RELIEVE THE FEDERAL GOVERNMENT OF THE BURDEN OF PAYING THE FULL COST FOR MEDICARE BENEFICIARIES. ALEGENT CREIGHTON HEALTH'S SHORTFALL, AS REPORTED ON PART III, SECTION B, LINE 7, OF $13,432,788 REPRESENTS THE FILING ORGANIZATION'S MEDICARE COST REPORTS. PART III, LINE 9B: COMMONSPIRIT HEALTH ENSURES THAT PATIENT ACCOUNTS ARE PROCESSED FAIRLY AND CONSISTENTLY. COMMONSPIRIT HEALTH'S BILLING AND COLLECTION POLICY CONTAINS PROVISIONS THAT PROHIBIT THE COLLECTION OF AMOUNTS DUE FROM PATIENTS WHO THE ORGANIZATION KNOWS QUALIFY FOR FINANCIAL ASSISTANCE. ACCOUNTS WITH INCORRECT OR INCOMPLETE DEMOGRAPHIC INFORMATION ARE ASSIGNED TO A COLLECTION AGENCY IF THE COMMONSPIRIT HEALTH FACILITY, OR BILLING COMPANY RETAINED BY COMMONSPIRIT HEALTH, IS UNABLE TO OBTAIN AN UPDATED ADDRESS THROUGH SKIP TRACING OR OTHER MEANS. FOR PATIENTS WHO HAVE AN APPLICATION PENDING FOR EITHER GOVERNMENT-SPONSORED ASSISTANCE OR FOR ASSISTANCE UNDER COMMONSPIRIT HEALTH'S FINANCIAL ASSISTANCE POLICY, OR WHERE THE PATIENT IS ATTEMPTING IN GOOD FAITH TO SETTLE AN OUTSTANDING BILL WITH THE FACILITY VIA PAYMENT PLANS, COMMONSPIRIT HEALTH WILL NOT KNOWINGLY SEND THAT PATIENT'S BILL TO AN OUTSIDE COLLECTION AGENCY. ON SELF-PAY ACCOUNTS THAT DO NOT MEET THE CRITERIA NOTED ABOVE, THE INITIAL DETERMINATION OF ASSIGNMENT TO A COLLECTION AGENCY WILL VARY DEPENDING ON THE NATURE OF THE ACCOUNT WITH THE FINAL DECISION BEING AT THE DISCRETION OF THE BILLING COMPANY RETAINED BY COMMONSPIRIT HEALTH. UPON ASSIGNMENT OF SUCH A PATIENT ACCOUNT TO A COLLECTION AGENCY, COMMONSPIRIT HEALTH REQUIRES THE AGENCY TO COMPLY WITH THE FAIR DEBT COLLECTION PRACTICES ACT. PART VI, LINE 3: INFORMATION ABOUT COMMONSPIRIT HEALTH'S FINANCIAL ASSISTANCE PROGRAM AND A CONTACT NUMBER ARE MADE AVAILABLE TO PATIENTS AND THE PUBLIC. PATIENTS ARE INFORMED OF COMMONSPIRIT HEALTH'S FINANCIAL ASSISTANCE PROGRAM VIA SIGNAGE IN ALL ADMITTING AREAS AND IN VARIOUS COMMON AREAS OF THE HOSPITAL. FINANCIAL ASSISTANCE PROGRAM INFORMATION NOTICES ARE POSTED IN THE EMERGENCY AND ADMITTING DEPARTMENTS AND AT OTHER PUBLIC PLACES AS EACH FACILITY MAY ELECT. SUCH INFORMATION IS PROVIDED IN THE PRIMARY LANGUAGES SPOKEN IN THE COMMUNITIES COMMONSPIRIT HEALTH SERVES. THE SIGNAGE INCLUDES NOTIFICATION THAT FURTHER DISCOUNTS MAY BE PROVIDED UPON THE COMPLETION AND SUBMISSION OF A FINANCIAL ASSISTANCE APPLICATION AND HOW TO REACH STAFF THAT CAN ASSIST WITH ANSWERING QUESTIONS AND GUIDE PATIENTS THROUGH THE APPLICATION PROCESS. INFORMATION CAN ALSO BE FOUND ON THE FACILITY WEBSITES. HOSPITALS' PUBLICLY AVAILABLE COMMUNITY HEALTH IMPLEMENTATION STRATEGIES STATE THAT IT IS THE POLICY OF COMMONSPIRIT HEALTH TO PROVIDE, WITHOUT DISCRIMINATION, EMERGENCY MEDICAL CARE AND MEDICALLY NECESSARY CARE IN COMMONSPIRIT HOSPITAL FACILITIES TO ALL PATIENTS, WITHOUT REGARD TO A PATIENT'S FINANCIAL ABILITY TO PAY, AND THAT THE POLICY, PLAIN LANGUAGE SUMMARY AND RELATED MATERIALS ARE AVAILABLE IN MULTIPLE LANGUAGES ON THE HOSPITAL'S WEBSITE. IF FINANCIAL ASSISTANCE ELIGIBILITY IS NOT DETERMINED PRIOR TO BILLING, INITIAL BILLING STATEMENTS TO PATIENTS INCLUDE A REQUEST TO THE PATIENT TO PROVIDE ANY INSURANCE INFORMATION THAT WAS VALID FOR THE DATES OF SERVICE BILLED AND A STATEMENT INFORMING PATIENTS HOW TO CONTACT US REGARDING FINANCIAL ASSISTANCE. ADDITIONALLY, CONTRACT TERMS WITH COLLECTION VENDORS WORKING ON BEHALF OF COMMONSPIRIT HEALTH REQUIRE THEY FOLLOW COMMONSPIRIT HEALTH FINANCIAL ASSISTANCE POLICY. ALSO, REFERRAL OF PATIENTS FOR FINANCIAL ASSISTANCE MAY BE MADE BY ANY MEMBER OF THE COMMONSPIRIT HOSPITAL ORGANIZATION NON-MEDICAL OR MEDICAL STAFF, INCLUDING PHYSICIANS, NURSES, FINANCIAL COUNSELORS, SOCIAL WORKERS, CASE MANAGERS, CHAPLAINS, AND RELIGIOUS SPONSORS. A REQUEST FOR ASSISTANCE MAY BE MADE BY THE PATIENT OR A FAMILY MEMBER, CLOSE FRIEND OR ASSOCIATE OF THE PATIENT, SUBJECT TO APPLICABLE PRIVACY LAWS. PART VI, LINE 4: FOR THE PURPOSES OF THE CHI HEALTH LAKESIDE AND CHI HEALTH MIDLANDS COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) AND IMPLEMENTATION STRATEGY PLAN (ISP), THE PRIMARY SERVICE AREA WAS DEFINED AS THE FOUR COUNTIES THAT MAKE UP THE OMAHA METRO AREA: DOUGLAS, SARPY, AND CASS COUNTIES IN NEBRASKA, AND POTTAWATTAMIE COUNTY IN IOWA. HOME TO 924,653 PEOPLE IN 2025 (596,408 IN DODGE COUNTY, NEBRASKA, 206,804 IN SARPY COUNTY, NEBRASKA, 93,407 IN POTTAWATTAMIE COUNTY, IOWA, AND, 28,034 IN CASS COUNTY, NEBRASKA), THE OMAHA METRO IS NEBRASKA'S LARGEST METRO AREA. DOUGLAS AND SARPY ARE THE FIRST AND THIRD MOST POPULOUS COUNTIES IN NEBRASKA.THE OMAHA METRO AREA POPULATION IS LARGELY NON-HISPANIC WHITE WITH THE GREATEST RACE AND ETHNICITY DIVERSITY OBSERVED IN DOUGLAS COUNTY AND THE LEAST IN CASS COUNTY. IN DOUGLAS COUNTY, 14% IDENTIFY AS HISPANIC OR LATINO AND 11% IDENTIFY AS BLACK. THE PERCENTAGE OF OMAHA METRO RESIDENTS OVER 65 YEARS OF AGE IS LOWER COMPARED TO THE STATE (OMAHA METRO - 14%, NEBRASKA - 16%). CASS COUNTY HAS THE LARGEST PERCENTAGE OF RESIDENTS OVER AGE 65 (18%), WHILE SARPY HAS THE LOWEST (13%). EIGHT PERCENT OF OMAHA METRO RESIDENTS OVER THE AGE OF 25 DO NOT HAVE A HIGH SCHOOL DIPLOMA. THIS IS COMPARABLE TO THE STATE PERCENTAGE (8%). DOUGLAS AND POTTAWATTAMIE COUNTIES HAVE THE HIGHEST PERCENTAGE OF RESIDENTS WITHOUT HIGH SCHOOL DIPLOMAS AT 9%. SARPY COUNTY HAS A SIGNIFICANTLY HIGHER MEDIAN HOUSEHOLD INCOME COMPARED TO THE OTHER COUNTIES IN THE OMAHA METRO AREA (DOUGLAS: $77,457, SARPY $101,932, CASS: $88,255, POTTAWATTAMIE: $70,640). THE OMAHA METRO HAS 30 HEALTH PROFESSIONAL SHORTAGE AREAS ACROSS PRIMARY CARE, DENTAL HEALTH, AND MENTAL HEALTH DISCIPLINES.FOR THE PURPOSES OF THE CHI HEALTH PLAINVIEW COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA) AND IMPLEMENTATION STRATEGY PLAN (ISP), THE PRIMARY SERVICE AREA WAS DEFINED AS PIERCE COUNTY, NEBRASKA BASED ON HOSPITAL ADMISSIONS DATA AND OVERLAPPING SERVICE AREAS WITH CHNA COLLABORATORS.PLAINVIEW, NE IS LOCATED 141 MILES FROM OMAHA, NE AND 101 MILES FROM SIOUX CITY, IA. ACCORDING TO THE MOST RECENT CENSUS, PIERCE COUNTY IS 100% RURAL, ENCOMPASSES 573 SQUARE MILES, AND HAS 7,317 RESIDENTS. THE POPULATION DENSITY OF PIERCE COUNTY IS ESTIMATED AT 12.7 PERSONS PER SQUARE MILE, MAKING IT ABOUT HALF AS DENSELY POPULATED AS THE STATE OF NEBRASKA, WHICH IS 73% RURAL, AND HAS A POPULATION DENSITY OF 23.8 PERSONS PER SQUARE MILE. THE MAJORITY OF THE RESIDENTS IN PIERCE COUNTY (95.6%) ARE WHITE, NOT HISPANIC OR LATINO, 2.3% IDENTIFY AS HISPANIC OR LATINO, 0.6% ARE BLACK, AND 0.5% ARE AMERICAN INDIAN OR ALASKA NATIVE. COMPARED TO THE STATE OF NEBRASKA, PIERCE COUNTY HAS A SLIGHTLY HIGHER MEDIAN HOUSEHOLD INCOME, LOWER RATES OF PERSONS AND CHILDREN IN POVERTY, LOWER UNEMPLOYMENT RATE, HIGHER HIGH-SCHOOL GRADUATION RATE, AND A LOWER PERCENTAGE OF THE POPULATION THAT IS UNINSURED. WITHIN PIERCE COUNTY, THE PERCENTAGE OF UNINSURED POPULATION IS 8.4%, WHICH IS LESS THAN THE STATE AVERAGE (9.8%). POVERTY PRESENTS A BARRIER TO MANY FACTORS IMPACTING HEALTH, INCLUDING: ACCESS TO CARE, NUTRITION, EDUCATION AND SAFE HOUSING, ETC. IN PIERCE COUNTY 8.2% ARE LIVING BELOW THE POVERTY LINE. PIERCE COUNTY IS DESIGNATED AS A HEALTH PROFESSIONAL SHORTAGE AREA IN PRIMARY CARE (13), DENTAL CARE (9), AND MENTALHEALTH (17).7 THESE ARE UP OR THE SAME FROM THE 2021 CHNA RATINGS OF: PRIMARY CARE (7), DENTAL CARE (7), AND MENTAL HEALTH (17). THE SCORE RANGES FROM 0-26 WHERE THE HIGHER THE SCORE, THE GREATER THE PRIORITY. PIERCE COUNTY IS CONSIDERED A MEDICALLY UNDERSERVED AREA (MUA) IN PRIMARY CARE WITH AN INDEX OF MEDICAL UNSERVED SCORE OF 60.7 (TO QUALIFY FOR THIS DESIGNATION, THE SCORE MUST BE BELOW OR EQUAL TO N/A ON A SCALE OF 0 -100 WITH 100 BEING THE LOWEST NEED). CHI HEALTH PLAINVIEW AND OSMOND GENERAL ARE THE ONLY TWO HOSPITALS IN PIERCE COUNTY. PART VI, LINE 5: FINANCIAL ASSISTANCE: IT IS THE POLICY OF COMMONSPIRIT HEALTH TO PROVIDE, WITHOUT DISCRIMINATION, EMERGENCY MEDICAL CARE AND MEDICALLY NECESSARY CARE IN COMMONSPIRIT HOSPITAL FACILITIES TO ALL PATIENTS, WITHOUT REGARD TO A PATIENT'S FINANCIAL ABILITY TO PAY. THIS HOSPITAL HAS A FINANCIAL ASSISTANCE POLICY THAT DESCRIBES THE ASSISTANCE PROVIDED TO PATIENTS FOR WHOM IT WOULD BE A FINANCIAL HARDSHIP TO FULLY PAY THE EXPECTED OUT-OF-POCKET EXPENSES FOR SUCH CARE, AND WHO MEET THE ELIGIBILITY CRITERIA FOR SUCH ASSISTANCE. THE FINANCIAL ASSISTANCE POLICY, A PLAIN LANGUAGE SUMMARY AND RELATED MATERIALS ARE AVAILABLE IN MULTIPLE LANGUAGES ON THE HOSPITAL'S WEBSITE.USE OF SURPLUS FUNDS: AS A NOT-FOR-PROFIT HOSPITAL ORGANIZATION DEDICATED TO IMPROVING THE QUALITY OF LIFE, THE HOSPITAL REINVESTS ALL OF ITS SURPLUS FUNDS FROM OPERATING AND INVESTMENT ACTIVITIES TO IMPROVE THE QUALITY OF PATIENT CARE, EXPAND AND REPLACE EXISTING FACILITIES AND EQUIPMENT, INVEST IN TECHNOLOGICAL ADVANCEMENTS, SUPPORT COMMUNITY HEALTH PROGRAMS, AND ADVANCE MEDICAL TRAINING, EDUCATION, AND RESEARCH. THIS ACTIVE REINVESTMENT OF FUNDS MAKES IT POSSIBLE FOR THE HOSPITAL TO DELIVER ON ITS MISSION, INCLUDING HELPING TO ENSURE THAT EVERYONE IN THE COMMUNITIES SERVED HAS ACCESS TO HEALTH CARE.OPEN MEDICAL STAFF: MEDICAL STAFF PRIVILEGES ARE OPEN TO PHYSICIANS WHOSE EXPERIENCE AND TRAINING ARE VERIFIED THROUGH A CREDENTIALING PROCESS. THE PROCESS INCLUDES GATHERING AND VERIFYING CREDENTIALS, ALLOWING THE MEDICAL STAFF TO EVALUATE AN APPLICANT'S QUALIFICATIONS, PREVIOUS EXPERIENCE, AND COMPETENCE, AND ULTIMATELY MAKING A DECISION TO GRANT OR DENY MEDICAL STAFF MEMBERSHIP AND CLINICAL PRIVILEGES ON THE BASIS OF AUTHENTIC AND VALID CREDENTIALS.ROLE OF THE BOARD: THE COMMONSPIRIT HEALTH BOARD AND SPECIFIC COMMITTEES HAVE ORGANIZATIONAL, POLICY-BASED ROLES TO OVERSEE COMMUNITY BENEFIT AND COMMUNITY HEALTH PROGRAMS, AND THEY RECEIVE REGULAR REPORTS ON ACTIVITIES AND PERFORMANCE. HOSPITAL COMMUNITY BOARDS (OR THEIR DESIGNATED COMMUNITY HEALTH OR COMMUNITY BENEFIT COMMITTEES) ARE RESPONSIBLE FOR ENSURING THAT THE HOSPITALS CONDUCT AND ADOPT COMMUNITY HEALTH NEEDS ASSESSMENTS AND IMPLEMENTATION STRATEGIES, TAKE ACTIONS TO HELP ADDRESS IDENTIFIED SIGNIFICANT HEALTH NEEDS WITH AN EMPHASIS ON POOR AND VULNERABLE POPULATIONS AND HEALTH EQUITY, AND MONITORING ACTIONS AND PROGRESS TOWARD IDENTIFIED GOALS. PART VI, LINE 6: THE ORGANIZATION IS AFFILIATED WITH COMMONSPIRIT HEALTH. COMMONSPIRIT HEALTH WAS CREATED BY THE ALIGNMENT OF CATHOLIC HEALTH INITIATIVES AND DIGNITY HEALTH IN EARLY 2019. COMMONSPIRIT HEALTH, A NONPROFIT, FAITH-BASED HEALTH SYSTEM IS COMMITTED TO BUILDING HEALTHIER COMMUNITIES, ADVOCATING FOR THOSE WHO ARE POOR AND VULNERABLE, AND INNOVATING HOW AND WHERE HEALING CAN HAPPEN BOTH INSIDE ITS HOSPITALS AND OUT IN THE COMMUNITY. COMMONSPIRIT HEALTH OWNS AND OPERATES HEALTH CARE FACILITIES IN 24 STATES AND IS THE SOLE CORPORATE MEMBER (PARENT CORPORATION) OF OTHER PRIMARILY NONPROFIT CORPORATIONS. COMMONSPIRIT HEALTH AND SUBSTANTIALLY ALL OF ITS DIRECT AFFILIATES AND SUBSIDIARIES HAVE BEEN GRANTED EXEMPTIONS FROM FEDERAL INCOME TAX AS CHARITABLE ORGANIZATIONS UNDER SECTION 501(C)(3) OF THE INTERNAL REVENUE CODE. AS OF SEPTEMBER 24, 2025, COMMONSPIRIT HEALTH IS COMPRISED OF APPROXIMATELY 2,300 CARE SITES, CONSISTING OF 138 HOSPITALS, INCLUDING ACADEMIC HEALTH CENTERS, MAJOR TEACHING HOSPITALS, AND CRITICAL ACCESS FACILITIES, COMMUNITY HEALTH SERVICES ORGANIZATIONS, ACCREDITED NURSING COLLEGES, HOME HEALTH AGENCIES, LIVING COMMUNITIES, A MEDICAL FOUNDATION AND OTHER AFFILIATED MEDICAL GROUPS, AND OTHER FACILITIES AND SERVICES THAT SPAN THE INPATIENT AND OUTPATIENT CONTINUUM OF CARE. AN ADDITIONAL 20 HOSPITALS ARE OPERATED THROUGH UNCONSOLIDATED JOINT VENTURES. IN FISCAL YEAR 2025, COMMONSPIRIT HEALTH PROVIDED MORE THAN $3.071 BILLION IN FINANCIAL ASSISTANCE AND COMMUNITY BENEFIT FOR PROGRAMS AND SERVICES FOR THE POOR, FREE CLINICS, EDUCATION AND RESEARCH. FINANCIAL ASSISTANCE AND COMMUNITY BENEFIT TOTALED MORE THAN $5.156 BILLION WITH THE INCLUSION OF THE UNPAID COSTS OF MEDICARE. THE HEALTH SYSTEM, WHICH GENERATED OPERATING REVENUES OF $39.1 BILLION IN FISCAL YEAR 2025, HAS TOTAL ASSETS OF APPROXIMATELY $57.26 BILLION.COMMONSPIRIT HEALTH PROVIDES STRATEGIC PLANNING AND MANAGEMENT SERVICES AS WELL AS CENTRALIZED SERVICES FOR ITS DIVISIONS. THE PROVISION OF CENTRALIZED MANAGEMENT AND SHARED SERVICES INCLUDING AREAS SUCH AS ACCOUNTING, HUMAN RESOURCES, PAYROLL AND SUPPLY CHAIN PROVIDES ECONOMIES OF SCALE AND PURCHASING POWER TO THE DIVISIONS. THE COST SAVINGS ACHIEVED THROUGH COMMONSPIRIT HEALTH'S CENTRALIZATION ENABLE DIVISIONS TO DEDICATE ADDITIONAL RESOURCES TO HIGH-QUALITY HEALTH CARE AND COMMUNITY OUTREACH SERVICES TO THE MOST VULNERABLE MEMBERS OF OUR SOCIETY. 1 CHI HEALTH FOUNDATION 7261 MERCY RD OMAHA NE 68124 470648586 501(C)(3) 1320381 0 GENERAL SUPPORT OMAHA ARCHIOCESAN EDUCATION FOUNDATION INC 2222 N 111TH ST OMAHA NE 68164 470614394 501(C)(3) 50000 0 GENERAL SUPPORT UNITED WAY OF THE MIDLANDS 2201 FARNAM ST SUITE 200 OMAHA NE 68102 470376605 501(C)(3) 10000 0 GENERAL SUPPORT BUFFALO COUNTY COMMUNITY HEALTH PARTNERS INC PO BOX 1466 KEARNEY NE 68848 205852415 501(C)(3) 10000 0 GENERAL SUPPORT THE CREW CENTER 601 SNYDER ROAD WOODBINE IA 51579 352683912 501(C)(3) 12500 0 GENERAL SUPPORT RISE ACADEMY 3555 FARNAM STREET SUITE 501 OMAHA NE 68131 830583165 501(C)(3) 20000 0 GENERAL SUPPORT RONALD MCDONALD HOUSE CHARITIES IN OMAHA 620 S 38TH AVE OMAHA NE 68105 470755104 501(C)(3) 20000 0 GENERAL SUPPORT SAVING GRACE PERISHABLE FOOD RESCUE 4611 SOUTH 96TH STREET SUITE 154 OMAHA NE 68127 461852863 501(C)(3) 20000 0 GENERAL SUPPORT TOGETHER INC OF METROPOLITAN OMAHA 812 S 24TH STREET OMAHA NE 68108 470589290 501(C)(3) 20000 0 GENERAL SUPPORT WHISPERING ROOTS INC 4104 S 90TH STREET OMAHA NE 68127 461579222 501(C)(3) 20000 0 GENERAL SUPPORT 10 0 WOW/CARE SUPPORT 63 945 BOOK PROVIDING NECESSITIES FOR INPATIENTS SCHOLARSHIPS 6 14000 PART I, LINE 2: MOST DISBURSEMENTS IN FURTHERANCE OF THE ORGANIZATION'S EXEMPT PROGRAMS ARE MADE DIRECTLY IN THE ACTIVE CONDUCT OF THE ACTIVITIES CONSTITUTING THE EXEMPT PURPOSE OR FUNCTION OF THE ORGANIZATION. OTHERWISE, DISTRIBUTIONS IN FURTHERANCE OF THE INSTITUTION'S EXEMPT PROGRAMS ARE MADE IN ACCORDANCE WITH PROCEDURES OR SUBJECT TO CONDITIONS ESTABLISHED BY THE INSTITUTION'S GOVERNING BOARD OR MANAGEMENT DESIGNED TO ENSURE THAT RECIPIENTS OF SUCH DISBURSEMENTS FROM THE ORGANIZATION ARE ADEQUATELY INVESTIGATED AND GRANTED TO QUALIFIED RECIPIENTS. ALEGENT CREIGHTON HEALTH ONLY DISTRIBUTES FUNDS TO OTHER 501(C)(3) ORGANIZATIONS WITH THE SAME MISSION AND PURPOSE AS THE ALEGENT CREIGHTON HEALTH SYSTEM. THESE DISTRIBUTIONS ARE MONITORED TO ENSURE THEY ARE BEING USED AS SPECIFIED BY THE ORGANIZATION. PART III: LAKESIDE AND MIDLANDS PROVIDED 6 SCHOLARSHIPS DURING FISCAL YEAR 2025 TO STUDENTS INTERESTED IN THE HEALTHCARE INDUSTRY. 1 1 0 0 0 0 0 0 0 JOHN PETERSDORF EX-OFFICIO BM/SYS SVP, OPERATIONAL F 0 734757 0 1868174 0 1162963 0 2048138 0 50891 0 5864923 0 1148724 TIM BRICKER EX-OFFICIO BM/ PRESIDENT & CEO CENTR 0 1070057 0 1518117 0 12642 0 261781 0 27154 0 2889751 0 0 JULIE GOEBEL INTERIM MARKET PRESIDENT NE/IA (BEG 486463 0 328053 0 789332 0 19994 0 33841 0 1657683 0 0 0 TROY HAMMETT REGION CFO 18950 659271 0 555237 67248 70449 20325 0 27149 11268 133672 1296225 0 55500 ANN SCHUMACHER PRESIDENT - IMMANUEL (TERMED 03/31/2 255369 0 173447 0 778005 0 12959 0 9011 0 1228791 0 0 0 CARY WARD MD MARKET PRESIDENT (TERMED 5/1/25) 642888 0 163040 0 12504 0 76750 0 32023 0 927205 0 0 0 ANDREW SANTOS SVP MISSION (TERMED 9/6/24) 295373 0 0 0 447616 0 15499 0 33180 0 791668 0 0 0 THOMAS FREDERICKSON FORMER HCE 0 493935 0 219703 0 7320 0 20325 0 26569 0 767852 0 0 JOSEPH THIRUMALAREDDY MD HOSPITALIST 2456 634074 0 0 0 1710 0 19125 69 40181 2525 695090 0 0 STEVE HOUSTON SVP STRATEGY AND BUSINESS DEVELOPMEN 10784 0 0 0 647381 0 8643 0 2044 0 668852 0 0 0 AARON AUSTIN REGION CHRO 428410 0 164902 0 6532 0 18925 0 23980 0 642749 0 0 0 ARMAN PAJNIGAR MD FORMER HCE 0 574510 0 0 0 1932 0 18925 0 34643 0 630010 0 0 SEAN HANSEN MD HOSPITALIST 305551 269913 0 0 0 1260 0 16300 7425 22533 312976 310006 0 0 MOHSIN MIRZA VP MEDICAL OPERATIONS 5160 556583 0 0 0 756 17315 0 1732 0 24207 557339 0 0 KIRTIBALA GUPTA MD BOARD SECRETARY/PHYSICIAN 0 358662 0 0 0 3476 0 13587 0 31429 0 407154 0 0 HEATHER MORGAN MD BOARD MEMBER/PHYSICIAN 0 326295 0 0 0 1025 0 19763 0 42675 0 389758 0 0 NICK OTOOL MARKET CFO 293064 0 0 0 742 0 17277 0 35460 0 346543 0 0 0 MARK LONGACRE PRESIDENT - LKS & MDL HOSPITAL 189679 0 2500 0 88085 0 506 0 18780 0 299550 0 0 0 KEVIN MILLER PRESIDENT - LKS & MDL HOSPITAL (TERM 227722 0 0 0 15652 0 10806 0 18045 0 272225 0 0 0 CONNIE PETERS PRESIDENT - SCHUYLER & PLAINVIEW HOS 0 211622 0 0 0 14715 0 15417 0 11757 0 253511 0 0 PART I, LINE 3 DURING THE CALENDAR YEAR 2024, COMPENSATION FOR THE TOP MANAGEMENT OFFICIAL WAS ESTABLISHED BY COMMONSPIRIT HEALTH, A RELATED ORGANIZATION. COMMONSPIRIT HEALTH USED ONE OR MORE OF THE METHODS DESCRIBED IN SCHEDULE J, PART I, LINE 3 TO ESTABLISH THE TOP MANAGEMENT OFFICIAL'S COMPENSATION: (1) INDEPENDENT COMPENSATION CONSULTANT; (2) COMPENSATION SURVEY OR STUDY. SEE SCHEDULE O DISCLOSURE FOR FORM 990, PART VI, SECTION B, LINE 15 FOR ADDITIONAL INFORMATION. PART I, LINE 4A: CERTAIN REPORTABLE INDIVIDUALS ARE COVERED BY AN EXECUTIVE SEVERANCE POLICY THAT PROVIDES MARKET-STANDARD COMPENSATION, RANGING FROM PAYMENTS OF 9 MONTHS TO 2 YEARS OF BASE COMPENSATION, DEPENDING ON THE EXECUTIVE'S POSITION, IN THE EVENT OF A POSITION ELIMINATION OR OTHER INVOLUNTARY TERMINATION, IN ACCORDANCE WITH THE GUIDELINES OF THE POLICY. CERTAIN REPORTABLE INDIVIDUALS ARE COVERED BY A NON-EXECUTIVE SEVERANCE POLICY THAT PROVIDES MARKET-STANDARD COMPENSATION, RANGING FROM PAYMENTS OF 2 WEEKS TO 52 WEEKS OF BASE COMPENSATION, DEPENDING ON THE EMPLOYEE'S POSITION AND TENURE, IN THE EVENT OF A POSITION ELIMINATION OR OTHER INVOLUNTARY TERMINATION, IN ACCORDANCE WITH THE GUIDELINES OF THE POLICY. THE FOLLOWING REPORTABLE INDIVIDUAL RECEIVED SEVERANCE PAYMENTS DURING THE 2024 CALENDAR YEAR, AND THESE SEVERANCE PAYMENTS WERE INCLUDED IN THE INDIVIDUAL'S W-2 INCOME AND REPORTABLE COMPENSATION ON PART VII AND SCHEDULE J, PART II, COLUMN (B)(III): JULIE GOEBEL, $787,651; STEVEN HOUSTON, $647,078; ANDREW SANTOS, $446,331; ANN SCHUMACHER, $769,085. PART I, LINE 4B: CERTAIN LISTED PERSONS PARTICIPATE IN THE COMMONSPIRIT HEALTH SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN (SERP), A NONQUALIFIED RETIREMENT PLAN DESIGNED TO PROVIDE DEFERRED COMPENSATION TO KEY EXECUTIVES WHO HAVE CONTRIBUTED MATERIALLY TO THE SUCCESS OF OUR MINISTRY. THE SERP IS INTENDED TO PROVIDE HIGHLY COMPENSATED INDIVIDUALS WITH ADDITIONAL RETIREMENT INCOME TO HELP OFFSET REGULATORY LIMITS IN PLACE ON QUALIFIED RETIREMENT PLANS AND SOCIAL SECURITY. EACH ANNUAL CONTRIBUTION IS SUBJECT TO A FOUR-YEAR VESTING OR RETENTION PERIOD. UPON COMPLETION OF THE APPLICABLE FOUR-YEAR RETENTION PERIOD FOR EACH ANNUAL CONTRIBUTION, VESTING WILL OCCUR, AND ANY ACCUMULATED BENEFIT UNDER THE PLAN WILL BE RECEIVED. ON THE FIRST DAY OF THE CALENDAR MONTH AFTER THE FOURTH ANNIVERSARY OF THE SERP BENEFIT, THE ANNUAL CONTRIBUTION AND ITS ASSOCIATED INVESTMENT GAINS OR LOSSES BECOME 100% VESTED. IN ADDITION, THE PARTICIPANT'S SERP BENEFIT BECOMES 100% VESTED UPON ANY OF THE FOLLOWING EVENTS: 1) REACHING THE AGE OF 65 (THE PLAN'S NORMAL RETIREMENT AGE), OR 2) DEATH, OR BECOME DISABLED UNDER THE LONG-TERM DISABILITY PLAN OR SOCIAL SECURITY. SHOULD EMPLOYMENT END FOR ANY REASON OTHER THAN TERMINATION WITH SEVERANCE, RETIREMENT AT AGE 65 OR OLDER, DISABILITY, OR DEATH, UNVESTED SERP FUNDS ARE FORFEITED. IF EMPLOYMENT IS TERMINATED WITH SEVERANCE, THE TERMS AND CONDITIONS OUTLINED WITHIN THE SERP, AND NOT THOSE OF ANY SEVERANCE AGREEMENT, WILL CONTROL AND GOVERN PAYMENT ENTITLEMENT UNDER THE SERP. CERTAIN ELIGIBLE LISTED PERSONS RECEIVED AN ADDITIONAL PAYMENT DURING 2024 DUE TO A DELAY IN THE START DATE OF THE SERP. CERTAIN LISTED PERSONS ARE ELIGIBLE TO PARTICIPATE IN THE CATHOLIC HEALTH INITIATIVES SUPPLEMENTAL EXECUTIVE RETIREMENT PLAN, A SUPPLEMENTAL NON-QUALIFIED DEFERRED COMPENSATION PLAN FOR REGION CEOS/PRESIDENTS AND OTHER DESIGNATED COMMONSPIRIT EXECUTIVES AT THE LEVEL OF SENIOR VICE PRESIDENT AND ABOVE. DURING 2024 THE FOLLOWING DISTRIBUTIONS WERE MADE BY COMMONSPIRIT FROM THE DEFERRED COMPENSATION PLAN: TROY HAMMETT, $59,057; ANN SCHUMACHER, $115. DUE TO THE "SUPER" VESTING RULES UNDER THE CATHOLIC HEALTH INITIATIVES DEFERRED COMPENSATION PLAN, PARTICIPANTS WHO HAVE MET CERTAIN REQUIREMENTS SUCH AS INVOLUNTARY TERMINATION WITHOUT CAUSE, AGE, AGE AND YEARS OF SERVICE, OR MORE THAN 5 YEARS OF PLAN PARTICIPATION ARE ELIGIBLE TO RECEIVE THEIR 2024 CONTRIBUTIONS IN CASH. THESE CASH PAYOUTS ARE INCLUDED IN THE PARTICIPANT'S REPORTABLE COMPENSATION IN COLUMN (III) OTHER REPORTABLE COMPENSATION ON SCHEDULE J PART II. DURING 2024, THE FOLLOWING PAYMENTS WERE MADE PURSUANT TO THE SUPER VESTING RULES: TROY HAMMETT, $65,756; KEVIN MILLER, $11,238; CONNIE PETERS, $10,852; ANN SCHUMACHER, $6,247. CERTAIN LISTED PERSONS EMPLOYED BY DIGNITY HEALTH ARE ELIGIBLE TO PARTICIPATE IN NON-QUALIFIED 457(F) PLANS THAT ARE SUBJECT TO SUBSTANTIAL RISK OF FORFEITURE, AS REQUIRED BY THE IRS. THE 2007 EXECUTIVE DEFERRED COMPENSATION PLAN IS FOR EXECUTIVES HIRED PRIOR TO JUNE 30, 2006. THE BENEFIT IS INTENDED TO BRIDGE THE DIFFERENCE, IF ANY, BETWEEN THE BENEFIT PROVIDED UNDER THE DIGNITY HEALTH EXCESS BENEFIT PLAN HAD BENEFIT SERVICE NOT BEEN FROZEN AT JANUARY 1, 2008, AND THE BENEFITS PROVIDED FROM ALL OTHER QUALIFIED AND NON-QUALIFIED PLANS. BENEFITS VEST UNDER THIS 457(F) PLAN AT THE LATER OF THE DATE THE PARTICIPANT ATTAINS AGE 62 OR IS CREDITED WITH 15 YEARS OF SERVICE. THE 2010 EXECUTIVE DEFERRED COMPENSATION PLAN IS FOR CERTAIN OFFICERS AND KEY EMPLOYEES, PRIMARILY THOSE WHO ARE NOT ELIGIBLE TO PARTICIPATE IN THE DIGNITY HEALTH EXCESS BENEFIT PLAN OR THE 2007 EXECUTIVE DEFERRED COMPENSATION PLAN DESCRIBED ABOVE. THIS BENEFIT PROVIDES AN ANNUAL ACCRUAL OF 10% OF TOTAL COMPENSATION AND IS PAYABLE ANNUALLY ON JULY 1 ONCE VESTED, WHICH IS AGE 62 WITH 5 YEARS OF SERVICE. PAYMENTS PURSUANT TO THE PLAN ARRANGEMENTS OCCURRED DURING 2024 INCLUDE J. PETERSDORF, $1,148,724. PART II: ALEGENT CREIGHTON HEALTH FOLLOWS COMMONSPIRIT'S EXECUTIVE COMPENSATION PHILOSOPHY. COMMONSPIRIT'S EXECUTIVE COMPENSATION PHILOSOPHY IS DESIGNED TO ASSIST COMMONSPIRIT IN ATTRACTING AND RETAINING THE CALIBER OF EXECUTIVES REQUIRED TO ENABLE COMMONSPIRIT TO FULFILL ITS MISSION OF PROVIDING HIGH QUALITY HEALTHCARE FOR ALL PERSONS REGARDLESS OF THEIR ABILITY TO PAY FOR SERVICES, IMPROVING THE QUALITY OF LIFE IN THE COMMUNITIES COMMONSPIRIT SERVES, PROMOTING PATIENT AND EMPLOYEE SATISFACTION, AND ENSURING FINANCIAL STABILITY. A SUBSTANTIAL PORTION OF EXECUTIVE COMPENSATION IS PERFORMANCE BASED AND IS LINKED TO ORGANIZATIONAL GOALS APPROVED IN ADVANCE BY THE PEOPLE AND COMPENSATION COMMITTEE. THESE GOALS INCLUDE ATTAINMENT OF ANNUAL AND LONG-TERM FINANCIAL PERFORMANCE, CERTAIN HEALTHCARE QUALITY STANDARDS AND COMMONSPIRIT'S COMMITMENT TO SERVING THE POOR AND DISENFRANCHISED IN THE COMMUNITIES IT SERVES. TOTAL COMPENSATION, WHICH INCLUDES BASE SALARY, ANNUAL, AND LONG-TERM INCENTIVE COMPENSATION, IS ESTABLISHED TO APPROXIMATE THE PREVAILING MARKET CONDITIONS FOR EXECUTIVES OF COMPANIES OF SIMILAR SIZE, REVENUES AND COMPLEXITY. PAYMENTS PURSUANT TO A LONG-TERM FINANCIAL PERFORMANCE GOAL WERE PAID IN CALENDAR YEAR 2024. MICHAEL MILLER CHILD OF OFFICER 52040 EMPLOYMENT 0 FORM 990, PART V, LINE 1C: PAYMENTS TO VENDORS PAYMENTS TO VENDORS FOR ENTITIES THAT ARE PART OF COMMONSPIRIT HEALTH (CSH) ARE MADE BY CSH. CSH FILES THE FORM 1099S AND COMPLIES WITH THE BACKUP WITHHOLDING RULES FOR REPORTABLE PAYMENTS TO VENDORS AND GAMING WINNINGS. THE 1099S ISSUED BY CSH ON BEHALF OF ALEGENT CREIGHTON HEALTH ARE REPORTED TO THE IRS. FORM 990, PART VI, SECTION A, LINE 2 MARDELL WILSON AND KEVIN FITZGERALD: BUSINESS RELATIONSHIP FORM 990, PART VI, SECTION A, LINE 6 CHI NEBRASKA IS THE SOLE MEMBER OF ALEGENT CREIGHTON HEALTH. FORM 990, PART VI, SECTION A, LINE 7A ACCORDING TO THE ORGANIZATION'S BYLAWS, DIRECTORS SHALL BE APPOINTED OR REFUSED BY THE CORPORATE MEMBER. THE CORPORATE MEMBER MAY APPOINT ONE OR MORE INDIVIDUALS TO THE BOARD OF DIRECTORS, AND MAY AT ANY TIME REMOVE, WITH OR WITHOUT CAUSE, ANY MEMBER OF THE BOARD OF DIRECTORS. ACCORDING TO THE ORGANIZATION'S BYLAWS, DIRECTORS OF THE CORPORATION SHALL BE APPOINTED BY THE CORPORATE MEMBER NO LATER THAN JUNE 30 OF EACH YEAR. THE NAMES AND QUALIFICATIONS OF EACH INDIVIDUAL ACCEPTED BY THE BOARD OF DIRECTORS SHALL BE SUBMITTED TO THE CORPORATE MEMBER, WHO SHALL APPOINT OR REFUSE EACH NOMINEE IN ACCORDANCE WITH THE CORPORATE MEMBER'S BYLAWS AND WITH ENDORSEMENT OF THE SENIOR VICE PRESIDENT OF OPERATIONS. THE CORPORATE MEMBER MAY UNILATERALLY APPOINT ONE OR MORE INDIVIDUALS TO THE BOARD OF DIRECTORS SHOULD THE BOARD FAIL TO FURNISH THE CORPORATE MEMBER WITH A LIST OF INDIVIDUALS QUALIFIED TO SERVE ON THE BOARD OF DIRECTORS OF THE CORPORATION. FORM 990, PART VI, SECTION A, LINE 7B THE ORGANIZATION'S CORPORATE MEMBER IS CHI NEBRASKA. PURSUANT TO SECTION 5.4.1 OF THE ORGANIZATION'S BYLAWS, BOTH CHI NEBRASKA AND COMMONSPIRIT HEALTH HAVE RESERVED POWERS AS OUTLINED IN THE COMMONSPIRIT HEALTH GOVERNANCE MATRIX. PURSUANT TO THE GOVERNANCE MATRIX THE FOLLOWING RIGHTS ARE HELD BY THE CHI NEBRASKA'S BOARD: * APPROVE MEMBERS OF THE ALEGENT CREIGHTON HEALTH BOARD. * AMENDMENT OF THE CORPORATE DOCUMENTS OF ALEGENT CREIGHTON HEALTH. * APPROVE REMOVAL OF A MEMBER OF THE GOVERNING BODY OF ALEGENT CREIGHTON HEALTH. * ADOPTION OF LONG RANGE AND STRATEGIC PLANS FOR ALEGENT CREIGHTON HEALTH. THE FOLLOWING RIGHTS ARE RESERVED TO THE COMMONSPIRIT HEALTH BOARD DIRECTLY OR THROUGH POWERS DELEGATED TO THE COMMONSPIRIT HEALTH CHIEF EXECUTIVE OFFICER: * SUBSTANTIAL CHANGE IN THE MISSION OR PHILOSOPHY OF ALEGENT CREIGHTON HEALTH. * REMOVAL OF A MEMBER OF THE GOVERNING BODY OF ALEGENT CREIGHTON HEALTH. * APPROVAL OF ISSUANCE OF DEBT BY ALEGENT CREIGHTON HEALTH. * APPROVAL OF PARTICIPATION OF ALEGENT CREIGHTON HEALTH IN A JOINT VENTURE. * APPROVAL OF FORMATION OF A NEW CORPORATION BY ALEGENT CREIGHTON HEALTH. * APPROVAL OF A MERGER INVOLVING ALEGENT CREIGHTON HEALTH. * APPROVAL OF THE SALE OF ALL OR SUBSTANTIALLY ALL OF THE ASSETS OF ALEGENT CREIGHTON HEALTH. * TO REQUIRE THE TRANSFER OF ASSETS BY ALEGENT CREIGHTON HEALTH TO COMMONSPIRIT HEALTH TO ACCOMPLISH COMMONSPIRIT HEALTH'S GOALS AND OBJECTIVES, AND TO SATISFY COMMONSPIRIT HEALTH DEBTS. PURSUANT TO SECTION 5.5.2 OF THE ORGANIZATION'S BYLAWS, CHI NEBRASKA OR COMMONSPIRIT HEALTH MAY, IN EXERCISE OF THEIR APPROVAL POWERS, GRANT OR WITHHOLD APPROVAL IN WHOLE OR IN PART, OR MAY, IN ITS COMPLETE DISCRETION, AFTER CONSULTATION WITH THE BOARD AND ITS PRESIDENT AND THE CHIEF EXECUTIVE OFFICER OF THE ORGANIZATION, RECOMMEND SUCH OTHER OR DIFFERENT ACTIONS AS IT DEEMS APPROPRIATE. FORM 990, PART VI, SECTION B, LINE 11B FOLLOWING THE PREPARATION OF THE FORM 990 BY TAX ANALYSTS OF COMMONSPIRIT HEALTH (CSH), A RELATED ORGANIZATION, THE RETURN IS REVIEWED BY THE CSH TAX DIRECTOR AND THE LOCAL CHIEF FINANCIAL OFFICER. ADDITIONALLY, THE BOARD OF DIRECTORS ARE PROVIDED THE FINAL FORM 990 AND RELATED SCHEDULES TO REVIEW AND ARE ABLE TO ASK THE CHIEF FINANCIAL OFFICER AND TAX DIRECTOR QUESTIONS PRIOR TO FILING WITH THE IRS. UPON CHIEF FINANCIAL OFFICER APPROVAL AND SIGNATURE, THE TAX ANALYST FILES THE FINAL FORM 990 AS PRESENTED TO THE BOARD AND FINANCE COMMITTEE, MAKING ANY NON-SUBSTANTIVE CHANGES NECESSARY IN ORDER TO EFFECT E-FILING. ANY SUCH CHANGES ARE NOT RE-SUBMITTED TO THE BOARD. FORM 990, PART VI, SECTION B, LINE 12C THE ORGANIZATION HAS A CONFLICTS OF INTEREST ("COI") POLICY (THE "POLICY") IN PLACE TO PROTECT THE INTERESTS OF COMMONSPIRIT HEALTH ("COMMONSPIRIT") IN CIRCUMSTANCES THAT MAY RESULT IN A CONFLICT BETWEEN PERSONAL INTERESTS OF A PERSON AND THE INTERESTS OF THE ORGANIZATION AND THOSE IT SERVES. COMMONSPIRIT'S COI POLICY APPLIES TO COMMONSPIRIT, ITS DIRECT AFFILIATES AND SUBSIDIARIES AND ANY RELATED ENTITY THE GOVERNING DOCUMENTS OF WHICH REQUIRE THE ENTITY TO COMPLY WITH COMMONSPIRIT POLICY (COLLECTIVELY THE "SYSTEM ENTITIES"). THE FOLLOWING PERSONS ARE REQUIRED TO DISCLOSE ACTUAL OR POTENTIAL CONFLICTS OF INTEREST AS SOON AS THEY BECOME AWARE OF IT AND AT LEAST ANNUALLY THEREAFTER (VIA A FORMAL SYSTEM-ADMINISTERED SURVEY) IF THE PERSON'S AFFILIATION WITH COMMONSPIRIT CONTINUES: - MEMBERS OF CORPORATE AND COMMUNITY BOARDS OF SYSTEM ENTITIES - MEMBERS OF COMMITTEES OF CORPORATE AND COMMUNITY BOARDS OF SYSTEM ENTITIES - MEMBERS OF THE EXECUTIVE LEADERSHIP TEAM ("ELT") OF COMMONSPIRIT - CORPORATE OFFICERS OF SYSTEM ENTITIES - EMPLOYED PHYSICIANS AND ADVANCED PRACTICE PROVIDERS - KEY EMPLOYEES AND HIGHEST COMPENSATED EMPLOYEES AS SPECIFIED BY THE INTERNAL REVENUE SERVICE FOR FORM 990 PURPOSES WHO ARE NOT OTHERWISE INCLUDED IN THE CATEGORIES ABOVE - EMPLOYEES OF SYSTEM ENTITIES AT THE VICE PRESIDENT LEVEL AND ABOVE - ALL INDIVIDUALS ENGAGED IN RESEARCH AT INSTITUTIONS OWNED OR OPERATED BY A SYSTEM ENTITY - SELECT EMPLOYEES AS DETERMINED FROM TIME TO TIME BY LEADERSHIP A FAILURE TO DISCLOSE MAY RESULT IN DISCIPLINARY OR CORRECTIVE ACTIONS. REVIEW, AND MANAGEMENT OF PERCEIVED, POTENTIAL, OR ACTUAL CONFLICTS OF INTEREST ARE ACCOMPLISHED THROUGH A DEFINED COI DISCLOSURE REVIEW PROCESS AS FURTHER DESCRIBED BELOW. REPORTED POTENTIAL OR ACTUAL CONFLICTS OF INTEREST ARE INITIALLY REVIEWED BY LEGAL, CORPORATE RESPONSIBILITY OR RESEARCH INTEGRITY STAFF. STANDARD MANAGEMENT APPROACHES PER COI POLICY ARE APPLIED TO DISCLOSED CONFLICTS. DISCLOSURES THAT IDENTIFY PERCEIVED, POTENTIAL, OR ACTUAL COIS THAT REQUIRE IMMEDIATE MATERIAL ACTION TO RESOLVE, WILL BE IDENTIFIED, AND, A CONFLICT OF INTEREST MANAGEMENT PLAN DEVELOPED, WHICH PLAN SHALL BE SUBJECT TO ACCEPTANCE BY THE APPROPRIATE DIRECT MANAGER, SUPERVISOR, MEDICAL STAFF OFFICE, BOARD OR BOARD COMMITTEE (FOR BOARD, BOARD COMMITTEE, ELT OR CORPORATE OFFICER CONFLICTS), OR OTHER APPROPRIATE INDIVIDUAL OR BODY. ONCE ACCEPTED, THE CONFLICT OF INTEREST MANAGEMENT PLAN IS COMMUNICATED TO THE PERSON WITH THE ACTUAL OR POTENTIAL CONFLICT AND THE INDIVIDUAL MUST CONDUCT THEMSELVES IN CONFORMITY WITH THE PLAN. IN THE EVENT THAT A TRANSACTIONAL CONFLICT INTEREST ARISES IN CONNECTION WITH A SYSTEM ENTITY BOARD MEETING, THE CONFLICTED INDIVIDUAL MUST DISCLOSE THAT CONFLICT PRIOR TO OR AT THE BEGINNING OF THE MEETING IN WHICH THE MATTER IS TO BE CONSIDERED. THE CONFLICTED INDIVIDUAL IS EXCLUDED FROM VOTING ON THE TRANSACTION AND IS PROHIBITED FROM USING PERSONAL INFLUENCE WITH RESPECT TO THE MATTER, BUT IS NOT PROHIBITED FROM PROVIDING INPUT IF REQUESTED TO DO SO. FORM 990, PART VI, SECTION B, LINE 15 COMMONSPIRIT'S BOARD OF STEWARDSHIP TRUSTEES APPOINTS A PEOPLE AND COMPENSATION COMMITTEE, COMPRISED EXCLUSIVELY OF INDEPENDENT DIRECTORS, WHO ARE ACCOUNTABLE FOR ADOPTING A REASONABLE COMPENSATION PHILOSOPHY AND SETTING REASONABLE COMPENSATION PRACTICES FOR THE ORGANIZATION. COMMONSPIRIT'S COMPENSATION DEPARTMENT ENSURES THAT ITS PRACTICES ARE CONSISTENT WITH THE ORGANIZATION'S PHILOSOPHY, PRACTICES, AND PRINCIPLES, AS DETERMINED BY THE PEOPLE AND COMPENSATION COMMITTEE. WHEN NECESSARY, THE COMPENSATION DEPARTMENT ALSO ENGAGES AN INDEPENDENT CONSULTANT, AS WELL AS QUALIFIED INDEPENDENT COMPENSATION AND BENEFITS SPECIALISTS (INDEPENDENT EXPERTS) TO VALIDATE THE ORGANIZATION'S BENCHMARKING APPROACH FOR THE TOTAL COMPENSATION AND BENEFITS PACKAGES FOR CERTAIN EXECUTIVES. APPROPRIATE COMPARABILITY DATA IS ALSO OBTAINED BY THE COMMONSPIRIT HEALTH COMPENSATION DEPARTMENT FROM INDEPENDENT THIRD-PARTY SALARY SURVEYS, AS PART OF THE ORGANIZATION'S COMPENSATION PRACTICES (E.G., TOTAL ECONOMIC BENEFITS PAID BY SIMILARLY SITUATED ORGANIZATIONS, BOTH TAXABLE AND TAX-EXEMPT, FOR SIMILAR JOB RESPONSIBILITIES). THE DOCUMENTATION OF COMPENSATION DECISIONS INCLUDES THE COMPARABILITY DATA OBTAINED AND RELIED UPON BY THE COMPENSATION DEPARTMENT AND THE SOURCES FROM WHICH THE DATA WAS OBTAINED. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION'S GOVERNING DOCUMENTS AND CONFLICT OF INTEREST POLICY ARE AVAILABLE UPON REQUEST FROM THE ADMINISTRATION DEPARTMENT. IN ADDITION, THE ARTICLES OF INCORPORATION ARE AVAILABLE FROM THE NEBRASKA SECRETARY OF STATE WEBSITE AT WWW.SOS.NE.GOV/BUSINESS. THE ORGANIZATION'S FINANCIAL STATEMENTS ARE INCLUDED IN COMMONSPIRIT HEALTH'S CONSOLIDATED AUDITED FINANCIAL STATEMENTS THAT ARE AVAILABLE AT WWW.COMMONSPIRIT.ORG. FORM 990, PART VI, SECTION B, LINE 16B: ALEGENT CREIGHTON HEALTH HAS NOT FORMALLY ADOPTED A WRITTEN POLICY OR WRITTEN PROCEDURE REGARDING JOINT VENTURES. HOWEVER COMMONSPIRIT HEALTH'S SYSTEM-WIDE JOINT VENTURE MODEL OPERATING AGREEMENT INCORPORATES CONTROLS OVER THE VENTURE SUFFICIENT TO ENSURE THAT (1) THE EXEMPT ORGANIZATION AT ALL TIMES RETAINS CONTROL OVER THE VENTURE SUFFICIENT TO ENSURE THAT THE PARTNERSHIP FURTHERS THE EXEMPT PURPOSE OF THE ORGANIZATION; (2) IN ANY PARTNERSHIP IN WHICH THE EXEMPT ORGANIZATION IS A PARTNER, ACHIEVEMENT OF EXEMPT PURPOSES IS PRIORITIZED OVER MAXIMIZATION OF PROFITS FOR THE PARTNERS; (3) THE PARTNERSHIP DOES NOT ENGAGE IN ANY ACTIVITIES THAT WOULD JEOPARDIZE THE EXEMPT ORGANIZATION'S EXEMPTION; AND (4) RETURNS OF CAPITAL, ALLOCATIONS, AND DISTRIBUTIONS MUST BE MADE IN PROPORTION TO THE PARTNERS' RESPECTIVE OWNERSHIP INTERESTS. ANY JOINT VENTURE AGREEMENTS THAT DO NOT CONFORM TO THE MODEL AGREEMENT ARE GENERALLY REVIEWED BY COUNSEL. FORM 990, PART XI, LINE 9: BENEFIT PLAN ACCRUAL ADJUSTMENT -187,866. EQUITY CHANGES IN UNCONSOLIDATED ORGS. 17,311,936. OTHER CHANGES -999,479. 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