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I. Why create a Community Benefits report?
Memorial Hospital’s day-to-day operations as a tax-exempt organization include many system-wide initiatives such as wellness clinics, community health programs, and charitable giving. With these programs, Memorial Hospital fills existing local gaps, while making a positive impact in the communities we serve. This report will summarize Memorial Hospital’s community benefit efforts over the last year. The final section (VIII) will also provide a financial summary of charity care, bad debt, government-sponsored healthcare, and all subsidized community programs and other support.
II. Organizational Description and Information
Memorial Hospital is a Critical Access Hospital located in North Conway, New Hampshire, that is committed to meeting the health needs of the Mt. Washington Valley and surrounding communities by serving with its community partners to provide accessible, comprehensive, compassionate, and quality healthcare. The Hospital is also the sole member organization of Memorial Elder Health Services that operates the Merriman House, an on-site long-term care facility, and the Mount Washington Valley Adult Day Center, an adult day center facility that opened in 2019. In 2014, Memorial Hospital became part of the MaineHealth system, an integrated health system whose vision is to work together to make its communities the healthiest in America.
Through our internal strategic planning process, Memorial Hospital identified the following strategic priorities to help measure the effectiveness and appropriateness of our actions:
• Fostering a culture that provides an patient experience that exceeds expectations.
• Building strong relationships to improve community health status.
• Achieving long-term viability by meeting all financial requirements in a changing healthcare environment.
III. Community Needs Assessment
The Memorial Hospital Board of Trustees is made up of a diverse set of community members. Each MaineHealth Member Board requires a thorough Community Health Needs Assessment (CHNA) and directs its organization to respond to the needs identified. All hospitals within the MaineHealth system have conducted CHNAs to meet federal regulations that were created as part of the Affordable Care Act. MaineHealth and Memorial Hospital also participate in various initiatives to help support and provide updates to community needs assessment planning. Some of these initiatives include:
- Clinical Strategic Planning
- Financial Strategic Planning
- Facility Planning
- Workforce Planning
- Provider Recruitment Strategic Planning
- Emergency Preparedness Planning
Along with the internal assessments, member organizations also review and act on recommendations provided by local and state partners, such as the New Hampshire Bureau of Infectious Disease Control.
Supported by MaineHealth and working with our Community Health Collaborative and other New Hampshire organizations, Memorial Hospital conducted a Community Health Needs Assessment in 2016. County-level and agency data, public forums, as well as, smaller focus groups were the methodologies used to collect data, and obtain community input (including meeting with vulnerable populations). The process involved engagement and action by hospitals, state/local governments, and other partners. This written profile of the health needs of Carroll County, NH and Western Maine was shared widely in the region and used to develop implementation plans. The plans are evaluated and updated annually. Programs were then developed to address the specific needs. These detailed reports covered the time period of 2016-2018 and were formally adopted by each member organization’s Board for submission with their respective 990 filing.
Plans call for a CHNA to be replicated by all MaineHealth members every three years, therefore the process was repeated in FY2019. Each member and affiliate hospital held community forums in partnership with local and regional organizations to increase understanding and use of the Community Health Needs Assessment, and to inform action on local community-based health priorities. CHNA and Implementation Plan Reports were produced by each MaineHealth member hospital, in collaboration with MaineHealth.
IV. Subsidized Memorial Hospital Community Programs and Other Support
Community Health Improvement Services and Community Benefit Operations
Population Health. Memorial Hospital identified the need to extend services into the community and to broaden the definition of health to include social determinants. This involves reaching people where they live, work, and play. Consequently, Memorial supports a Population Health department which is designed to create community health improvement initiatives and programs. The three identified priority areas were Aging, Obesity Prevention/Healthy Lifestyles, and Substance Abuse Disorders.
Fall Prevention/Reduction. Carroll County has a higher rate of falls with injury (compared to state averages) among older citizens. As a result, several programs for community education and support have been put in place including A Matter of Balance (AMOB) and Tai Ji Quan. Both programs are offered on an ongoing basis in multiple sites throughout the community.
A Matter of Balance. The award-winning 8-week program emphasizes practical strategies to reduce fear of falling and increase activity levels. By learning to view falls and fear of falling as controllable, participants can set realistic goals to increase activity and change their environment to reduce fall risk factors. They learn new approaches to exercise that are designed to increase strength and balance.
Tai Ji Quan Moving for Better Balance. This evidence based program is designed to sustain positive life style changes adopted through AMOB.
Let’s Go! This is a nationally recognized childhood obesity prevention initiative. The goal is to increase physical activity and healthy eating habits for children from birth to 18 years through policy and environmental change. The Let’s Go! Program uses a multi-setting approach to reach youth and families where they live, learn, work, and play to reinforce the importance of healthy eating and active living. It is being offered in a variety of settings including schools, day care, pre-school and out-of-school settings. In the past year, we have expanded outreach to additional schools, childcare sites, out-of-school programs, and health care organizations. We have also worked within sites to expand their efforts to reach more students and families. The Let’s Go! Program was also adopted by the Conway School Board as a formal recommendation to implement in all schools in the district. We are now in over 22 sites in the community.
Advanced Care Planning Facilitation. Advanced Care Planning Facilitators are available to community members to assist in determining value-based decisions for end of life care. Education is offered in a variety of settings in the community. We have been part of a broader outreach effort for community education reaching multiple community organizations and residents. Memorial participated and/or helped sponsor several community events including a Caregiver event, and several community topic-specific presentations. We are also increasing capacity to provide facilitators for ACP discussions.
Healthy Aging Exercise Classes. Memorial is now offering classes directed by well-trained professionals promoting a variety of exercises to help people get started in a safe and friendly environment. Examples of classes include exercise, yoga and Pilates.
National Diabetes Prevention Program. We continue to offer evidence based programs facilitated by trained staff. This is a year-long program and the results have demonstrated successful outcomes.
Patient Financial Advocates. This program transitioned in 2019 to the MaineHealth Access to Care Program. Memorial Hospital assists patients in signing up for various health insurance options, including Affordable Care Act Marketplace Plans, NH Medicaid, and NH Medicaid expansion plans.
Medication Assistance. The Hospital assists patients in getting free prescription drugs based on income eligibility through various pharmaceutical companies through the Medication Bridge Program and the MedAccess Program.
Car Seat Program. When a newborn or any family in need requires a car seat, and no other resource is available, Memorial Hospital donates a new car seat.
Childbirth Education. Childbirth education is offered once per month for parents-to-be.
Breastfeeding Support Group. A weekly support group for mothers who are breastfeeding and facilitated by certified lactation specialists. All breastfeeding women, regardless of where they gave birth, are invited – this includes seasonal events.
Memory Loss/Dementia Caregivers Support Group. This program offers education, support and coping skills for caregivers, including pre-arranged care for family members while the caregiver attends the meeting.
Diabetes Support Group. This program is utilized by diabetics and their support people, and it provides an opportunity for education and discussion with other people who have diabetes or are dealing with it in the family.
Cancer Support Group. This group meets monthly to provide support along with information, education, speakers and encouragement for those with cancer and their support people. This group is facilitated by an oncology certified nurse and Social Services.
Alcoholics Anonymous. Space at Memorial hospital is donated free of charge for weekly AA meetings.
Community CPR Classes. Memorial partners with local fire departments to offer community CPR classes at a subsidized cost. This is an American Heart Association CPR and AED class being offered to members of the community in collaboration with some of the local Fire and EMS departments.
American Red Cross Blood Drives. Memorial staff organized five blood drives with employees donating their time and blood to participate. Our Volunteer Director organizes the event and signs up staff, coordinates with the Red Cross, and ensures a positive experience for participants.
Substance Use Disorder Community Forum: Memorial is involved in the planning committee as well as participates in the panel discussion at the forum - “Pathways from Silence to Solutions: Carroll County Responds to Substance Misuse & Addiction.”
Substance Use Disorder (SUD) Treatment and Prevention. Population Health, working with the Integrated Delivery Network (IDN) of Region 7, coordinates services to manage SUD treatment as well as working with schools to offer prevention strategies. Prevention strategies include offering self-regulation and promoting social and emotional well-being.
Substance Abuse Resource Guide. This was developed by Memorial and shared with community partners and community members.
Geriatric Dementia Resource Support. The Adult Day Center started a geriatric dementia support program to provide resources for community members.
A New Life Prenatal Substance Abuse Program. Due to the continuing growing number of prenatal women presenting with Substance Use Disorder, Memorial continued to focus on the specific needs of this population. A structured, comprehensive program promotes a coordinated, centralized care approach. By linking the Midwifery/Obstetric care and more involved treatment for Substance Use Disorder, the goal is to improve the coordination of care, the patient experience, ongoing maternal success, and newborn health. Pregnancy often becomes a time when women struggling with addiction have new motivation to address their problems. Additionally, this population feels significant shame and lack of community. Our program is approaching these gaps by building connections--increased ongoing support from the medical care team as well as enhanced peer support. This program is offered to patients regardless of ability to pay.
Health Professions Education
Internships. The Hospital hosts and trains nursing student interns from several universities and health science students from the local high school.
LNA training. The Hospital provides Clinical Career Training for LNAs at the Merriman House nursing home.
EMS training. The Hospital provides training to various ambulance and emergency response services in the area.
“Healthcare Camps” for Middle School Students, School to Career Program. This includes planning, organizing, and implementing a unique healthcare camp for local middle school students.
Subsidized Health Services
White Mountain Community Health Center. Memorial Hospital donates provider services and an office building for this health clinic offering healthcare to low income residents in our community through the White Mountain Community Health Center.
Subsidized Community Physician Services. Carroll County has few private practice physicians. In order to ensure access to primary care and certain specialty care physicians, Memorial Hospital employs physicians and provides their services through its hospital-based practices. Services include Diabetes, Orthopedics, Primary Care, Women’s Health, Cardiology, Podiatry, and Surgery/Urology. Services are provided without regard to ability to pay. Given the demographics of Carroll County, these services – although critical – are not financially self-sufficient.
Cash and In-kind Contributions
Charitable Contributions. Memorial Hospital makes carefully selected contributions to other nonprofit organizations throughout the year, including the following:
• Mount Washington Valley Promotions
• Kennett High School
• Lifeflight Foundation
• Mount Washington Valley Supports Recovery
Career Exploration and Facility Tours. Staff members provide learning experience with tours of Memorial Hospital for local students who are exploring careers in healthcare or who want to learn more about healthcare.
Memorial Hospital provides assistance to local not-for-profit organizations around strategic and financial planning as well as governance assessments. Involvement also extends too many employees, executives and providers who serve on local boards or volunteer for local and regional organizations during working hours, including but not limited to the following:
• Mount Washington Valley Chamber of Commerce
• Foundation for Healthy Communities
• Mt. Washington Valley Economic Council
• Tech Village Board Meeting
• New Hampshire Hospital Association
• Osher Lifelong Learning Institute (OLLI) at Granite State College
• Visiting Nurse Home Care & Hospice
• Community Health Collaborative
• Carroll County Coalition for Public Health
• Granite United Way
• Substance Misuse Prevention Leadership Team
• Jen’s Friends
• MWV Citizens for Energy Efficient Communities
• Starting Point
• Roy Estes Network for Education on Water Safety (RENEWS)
• Childhood Health & Wellness Program in local schools
• UNH Cooperative Extension Advisory Council
• Medicaid 1115 Waiver Project (IDN 7)
• MWV Regional Collaborative
• Children Unlimited
• Transportation for patients (taxi service)
Memorial Hospital’s Aggregate “Net Community Benefit Investment” = $3,361,738
In addition to the aforementioned programs, Memorial Hospital provides its proportional share of support for the annual budget of the following programs through “member dues” as a hospital within the MaineHealth system.
Center for Health Improvement Services and Community Benefit Operations
Prevention and Wellness
Prevention. The Prevention Program works to deliver consistent, high-quality, preventive healthcare for adults by providing best-practice, evidence-based tools and support to primary care practice teams. The purpose is to provide a preventive health focus for patients and providers that helps to reduce the prevalence and severity of chronic disease. Focus areas include hypertension control, cancer screening, and diabetes prevention.
Healthy Eating and Active Living. This initiative reaches both children and adults in the community. The key parts of the initiative include clinical, community, and environmental/
policy interventions. Financial support for this initiative recognizes the importance of preventing obesity as a major driver of health care costs, a major risk factor for chronic diseases, and a well-documented community epidemic. We work to support our primary care teams in providing evidenced-based care related to the prevention, assessment, and treatment of pediatric and adult obesity. Additionally, MaineHealth supports Memorial Hospital in working with a variety of sectors to increase healthy eating and active living in places where children and their families live, work, learn, and play. MaineHealth works with the hospital food services directors to improve access to healthy foods in order to make the healthy choice the easy choice. Finally, we support clinical teams in addressing food insecurity in their setting by screening, connecting to resources, and emergency food bags.
Behavioral Health Integration. The Behavioral Health Integration Program works to improve patient care by bringing mental health clinicians into medical settings, and by improving the collaboration between medical and mental health providers. The goal of the program is to help people get effective and efficient care for mental and behavioral health problems.
Chronic Disease. The Chronic Disease Program seeks to improve care and outcomes for patients with pediatric and adult asthma, COPD, and diabetes. Chronic Disease team members develop and disseminate evidence-based decision support tools, assist with workflow redesign, data collection and reporting, community and policy strategies as well as promoting patient education and self-management.
Emergency Medicine. The Emergency Medicine Program improves the quality of care received by patients in Memorial’s Emergency Department. The program works to streamline processes and to effectively meet the acute medical needs of patients in the ED. Memorial Hospital also offers a Walk-in Clinic adjacent to the ED for those patients in need of primary care services.
Acute Care. Multiple initiatives that span the continuum of care with the goal of improving clinical quality outcomes include:
Clinical Informatics. The MaineHealth Informatics Committee, which includes Memorial Hospital, directs the integration of MaineHealth best practices into the electronic health record to advance the practice and delivery of care to patients across all care settings. This Committee’s work is informed by the evaluation of patient outcomes, quality measures, financial markers, and clinical satisfaction.
Antimicrobial Stewardship. The Antimicrobial Stewardship Program at MaineHealth and Memorial is a system-level initiative to promote the appropriate use of antimicrobial medications to include antibiotics, antifungals, and antivirals. The purpose is to improve patient outcomes and reduce microbial resistance, while decreasing the spread of infections caused by multidrug-resistant organisms.
Anticoagulation Management. The goal of the Anticoagulation Management Program at Memorial Hospital is to use a systematic and coordinated approach to establish policies and best practices in the use of anticoagulants throughout the system. This initiative aims to leverage expertise to create protocols such as in-transit anticoagulation therapy, dosing and administration, and use in patients who have specific disease states, such as atrial fibrillation or venous thromboembolism.
Palliative Care. The Palliative Care Program promotes palliative care across MaineHealth to include Memorial Hospital. The initiative includes clinician education about palliative care including identification of patients who may benefit from palliative care, provision of palliative services for complex medical conditions, addressing ethical issues, and engaging patients in discussing goals of care. The program promotes the use of Physician Orders for Life Sustaining Treatment (POLST) within Memorial as well as community-based advance directive/care planning.
Patient Centered Medical Home. This program supports our strategy for creating a strong primary care program through Patient Centered Medical Home transformation. Efforts include increasing capacity in quality improvement and practice redesign by offering learning collaboratives for staff, a coach development program, and providing educational opportunities including the dissemination of tools and resources. Our Advanced Primary Care strategy assists practices in achieving the Triple Aim: improving patient experience, population health, and reducing costs. Activities seek to ensure a high quality patient experience and improved provider and care team satisfaction.
Telehealth. The purpose of the Telehealth Program is to be the innovation hub for patient-centered healthcare delivery through the integration of advanced telemedicine technology. We aim to optimize the patient and provider experience by expanding access to high-quality, affordable healthcare. Through the leveraging of emerging technologies, we deliver virtual care solutions to providers across the care continuum that deliver efficiencies, convenience, and cost savings. The program is currently focused on virtual visits, e-consults, and virtual counseling.
Subsidized Health Services
MedAccess. This program provides free medications. MedAccess provides this community resource to uninsured and underinsured community members through the Patient Assistance Programs (PAPs). In addition to this service, MedAccess offers application assistance for other prescription access programs, local low-cost generic programs, and other state and federal programs either in-person or through a toll-free number (therefore, Memorial only counts the staff and program costs/support as a “net community benefit investment” here, and not the actual dollar figure of free medications provided through the program).
Other Access Assistance. Memorial’s Coverage Team helps uninsured or underinsured individuals explore their eligibility for various ACA/Marketplace coverage programs and benefits. Working closely with the MedAccess program, Coverage Team staff members help individuals complete application forms and submit necessary documents to secure coverage for their unique healthcare situation.
Community Health Needs Assessment
As described earlier in Section III of this report, MaineHealth member hospitals, including Memorial Hospital, conduct a Community Health Needs Assessment every three years. In 2019, MaineHealth helped each member hospital update their “CHNA and Implementation Plan Reports.” These reports were formally adopted by each member organization Board. This was the third CHNA conducted using the three-year cycle, which complies with federal regulations of the Affordable Care Act.
Memorial’s CHNA/Implementation Plan is posted online at www.mainehealth.org/chna.
Child Health Program
MaineHealth’s Child Health Programs work on a variety of prevention and public health activities to promote healthy childhood development. These include: understanding and addressing the effects of Adverse Childhood Experiences (ACEs); promoting the importance and increasing rates of childhood immunizations to protect children and communities from vaccine-preventable diseases; and improving the system of care for mothers with opioid use disorder and their children through access to treatment and community resources. We work with statewide partners from a variety of sectors to improve rates of developmental screening among young children and create or improve clinical pathways between medical homes and supporting service organizations. We also provide healthcare providers with tools to increase rates of well-child visits from birth through young adulthood within their primary care practices.
Working collaboratively with Maine Behavioral Healthcare and other healthcare organizations, the ACEs program brings together medical and community-based organizations to increase educational opportunities as well as screening for and referral to treatment for children and families experiencing the effects of ACEs. These educational programs, screening, and referral workflows are being expanded to MaineHealth’s other local health systems.
The childhood immunization program engages health professionals, provider organizations, community partners, family members, and local and state government in clinical, community, and policy interventions with the goals of:
• Increasing MaineHealth member-owned pediatric and family medicine practices’ combined up-to-date immunization rates by 2019:
o children by age 2 years for 10 vaccines to ≥ 62%
o adolescents by age 13 years for ≥ 2 HPV vaccines to ≥ 55% (or 10% increase at the practice level)
o adolescents by age 13 years for 1 Tdap/Td and 1 MCV vaccines to ≥ 85%
This year, MaineHealth continued to include the 2-year-old childhood immunization measure as one of its ten system-wide quality improvement priorities. This commitment to on-time immunization underscores the importance of vaccines as the most cost-effective health prevention activity for children, and one of society's greatest public health achievements.
Through these initiatives and more, we partner with community-based organizations and statewide partners to provide all children in Maine and Carroll County, NH the opportunity to have a healthy start.
Healthy Aging provides support to enable MaineHealth and Memorial to become a high-performing, age-friendly health system and hospital that meets the needs of older adults in a high quality, cost effective and efficient manner. The Healthy Aging team works collaboratively with healthcare professionals and community-based organizations to deliver programs focused on falls prevention, dementia care, safe mobility, post-acute care, and palliative care throughout the care continuum and community. They also engage local and statewide organizations in the dissemination of evidence-based programs that improve the health status of older adults and their caregivers. Healthy Aging has successfully developed and distributed the Matter of Balance Volunteer Lay Leader Model throughout Maine, New Hampshire and 44 other states.
V. Billing and Collection Practices
Memorial Hospital charges all patients the same price for the same services, regardless of payor source. Individuals are not required to pay or make arrangements to pay prior to the services being provided. On average, the first bill is sent to a patient 30 days after services are provided. After that initial billing date, the patient has 120 days to pay for those services before being sent to collection. Before collection action is taken by Memorial Hospital, the patient will have received 4 notices (the initial statement plus three additional notifications) that must be sent to patients informing them of their lack of proper payments and continued attempts to communicate with them about a solution. In the absence of either full payment or a patient’s attempts to communicate in order to resolve the situation, Memorial Hospital does use a responsible and professional collection agency if necessary. A bill will become classified as “bad debt” if a patient has not paid the full amount within 120 days. MaineHealth hospitals may pursue legal action for collecting an outstanding bill only with prior Board approval. Memorial Hospital’s Board has never pursued such legal action above and beyond credit reporting, with the exception of pursuing outstanding balances for the Merriman House (Memorial’s long-term care facility).
VI. Charity Care Policies
Memorial Hospital’s policy of charity care and financial assistance is easily understood, prominently posted, and publicly available. A process exists for offering charity care or financial assistance to patients who are unable to pay after they have already been billed. In addition to monitoring collection practices, copies of the charity care policy are made available to patients at all entry points (registration, ED, etc.) and with bill/collection notices. Memorial Hospital uses simple application procedures for charity care or financial assistance that do not intimidate or confuse applicants. Memorial Hospital’s employees who work in admissions, billing, accounts receivable, or patient services are fully informed and educated about all financial assistance policies. These staff members identify unpaid bills where persons are unable to pay, and separate these potential “charity care” bills from other bad debt accounts. Memorial Hospital provides assistance, on a sliding percentage basis, for those individuals that qualify with an income up to 200% of the Federal Poverty Guidelines. On a case-by-case basis, we have also granted assistance to individuals that may earn above the 175% of the Federal Poverty Guidelines but have met the catastrophic illness parameters.
VII. Good Governance and Executive Compensation Policies
Memorial Hospital has a Board of 8 community members, a majority of whom are not practicing physicians, officers, department heads, or other employees with a financial connection or otherwise affiliated with Memorial Hospital itself. The Board meets 12 times a year (on average), and has a written “conflict of interest” policy in place. The Board understands the specific mission of Memorial Hospital, and approves strategic planning initiatives aimed at carrying out this mission. Trustees understand their fiscal and other specific responsibilities while serving on the Board, and further education/information is provided to Board members if requested. Trustees and Executive Officers of Memorial Hospital do not receive loans on behalf of Memorial Hospital. Memorial Hospital ensures that a substantial part of its activities does not involve attempts to influence legislation, and that it will not take an official position or provide direct support for or against a political candidate. Moreover, in addition to the President, Chief Financial Officer, or both officially signing-off on Memorial Hospital’s yearly 990 and audited financial statements, the Board of Trustees also has final approval of the yearly audited financial statements. The Board has also adopted and maintains a corporate compliance program that includes a Code of Conduct for all staff education and training, monitoring for compliance, and a Helpline for staff to call, all intended to produce continual compliance with organizational policies and the law.
Memorial Hospital has a formal written compensation policy in place. In consultation with Sullivan Cotter and Associates, the MaineHealth Board Compensation Committee establishes appropriate compensation parameters for each member organization’s President and certain members of their Senior Management team. Working within those parameters, Memorial Hospital’s Board determines the level of compensation for its President. The findings of the Compensation Committee are made transparent to, and voted on by the full Governing Board. This “total executive compensation” is filed publicly by Memorial Hospital, and includes “total cash compensation” and “total value of all benefits and perquisites associated with position (such as housing allowances, social club memberships, signing bonuses, etc.).” The Board takes necessary action to prevent the President from voting or directly participating in the final Committee determination of his own compensation. Memorial Hospital’s executive compensation procedure relies upon appropriate data for comparability (e.g. compensation levels paid by both taxable and tax-exempt similarly situated organizations and independent compensation surveys by nationally recognized independent firms). Finally, Memorial Hospital refrains from allowing executive compensation to ever be based solely on Memorial Hospital’s revenues or other similar profit-sharing strategies.
VIII. Aggregate Financial Data
Memorial Hospital’s Community Benefit Summary ***
|1. Charity care (at cost)||$561,947|
|2. Bad debt (at cost)||$3,204,172|
|3. Government-sponsored health care (shortfall) - Unpaid cost of Medicare, Medicaid, and other
Hospital-specific indigent care programs
|4. Net Community Benefit Investment Programs (net expense)
|Total Value of Quantifiable Benefits Provided to the Community