2024-11-09T12:28:11-06:00 2023-12-31 873231666 PKF O'CONNOR DAVIES ADVISORY LLC 500 MAMARONECK AVENUE SUITE 301 HARRISON NY 105281633 990 2023-01-01 134111638 WESTCHESTER-ELLENVILLE HOSPITAL INC WEST 8456476400 10 HEALTHY WAY ELLENVILLE NY 12428 BOB RUE VICE PRESIDENT & CFO 8456476400 2024-11-09 1 1 GARRETT M HIGGINS P00543209 9143818900 2024-11-04 2023 2024-10-15 13:58:12Z ELLENVILLE REGIONAL HOSPITAL STEVEN KELLEY 10 HEALTHY WAY ELLENVILLE NY 12428 33425357 0 X WWW.ERHNY.ORG X 2000 NY TO PROVIDE EXCEPTIONAL HEALTH CARE SERVICES TO ALL PEOPLE WHO LIVE IN, WORK IN AND VISIT OUR SURROUNDING COMMUNITIES. 11 10 302 14 0 0 4720686 2794742 26459157 29970959 292875 584978 50020 45700 31522738 33396379 0 0 0 0 16000673 16606696 0 0 0 11204043 12247827 27204716 28854523 4318022 4541856 41883049 47754352 9003086 9429209 32879963 38325143 X ELLENVILLE REGIONAL HOSPITAL PROVIDES EXCEPTIONAL HEALTH CARE SERVICES TO ALL PEOPLE WHO LIVE IN, WORK IN AND VISIT OUR SURROUNDING COMMUNITIES. THIS HEALTH CARE IS DELIVERED WITH COMPASSION AND RESPECT BASED ON OUR COMMITMENT TO IMPROVING OUR COMMUNITY HEALTH THROUGH EXCELLENCE, INNOVATION AND STATE-OF-THE-ART TECHNOLOGIES. 0 0 21965019 29970959 IN-PATIENT DEPARTMENTS (MED/SURG AND SWING REHAB): IN 2023, THE HOSPITAL AND THE FOUNDATION SUPPORTED OUR STAFF WITH TUITION ASSISTANCE AND REIMBURSEMENT FOR EDUCATION RELATED TO HEALTH CARE SERVICES. THIS GENEROUS ASSISTANCE MADE IT POSSIBLE FOR NINE OF OUR STAFF MEMBERS TO PURSUE HIGHER DEGREES IN HEALTH CARE RELATED FIELDS. ERH TAKES PRIDE IN SERVING AS A TEACHING HOSPITAL AND HOSTING NURSING, PHARMACY AND PA STUDENTS FROM MANY SCHOOLS. IN 2023, ERH HOSTED STUDENTS FROM SUNY SULLIVAN, SUNY ULSTER, ORANGE, BOCES NEW VISIONS PROGRAM, LEMOYNE COLLEGE, CLARKSON UNIVERSITY, PACE UNIVERSITY, LONG ISLAND UNIVERSITY, AND MARIST COLLEGE. ERH COLLABORATED WITH THESE SCHOOLS TO PROVIDE ESSENTIAL AND MUCH NEEDED CLINICAL EXPERIENCE ROTATIONS. THE STUDENTS BENEFITED FROM WORKING SIDE BY SIDE WITH OUR SKILLED AND COMPASSIONATE CLINICAL TEAM. THEY OBSERVED FIRSTHAND THE DELIVERY OF EXCEPTIONAL CARE IN OUR INPATIENT, EMERGENCY DEPARTMENT, OPERATING ROOM, AND SPECIALTY SERVICES AS PART OF THEIR CLINICAL ROTATION. AS IN PAST YEARS, ERH PROVIDED THESE SERVICES WITHOUT REQUIRING ANY MONETARY COMPENSATION. PATIENT SATISFACTION AND POSITIVE OUTCOMES REMAIN SIGNIFICANT QUALITY INDICATORS WITH PATIENT SATISFACTION SCORES 90TH PERCENTILE FOR THE INPATIENT SERVICES AND FOR EMERGENCY DEPARTMENT. ERH'S LONG TERM CARE PLACEMENT RATE WAS NEAR 8% WHILE THE PATIENTS DISCHARGE TO HOME RATE WAS AT A STELLAR 80.%. THESE STELLAR RESULTS ARE THE PRODUCT OF A MULTIDISCIPLINARY COLLABORATIVE EFFORT AMONG NURSING, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH-LANGUAGE PATHOLOGY, RESPIRATORY THERAPY, PHARMACY, CASE MANAGEMENT AND REGISTERED DIETITIAN SERVICES. ERH CONTINUED TO HOLD STEADFAST COLLABORATING WITH COMMUNITY BASED AGENCIES AND PROVIDING QUALITY, COMPASSIONATE CARE AND GENERATING POSITIVE OUTCOMES. BY COMBINING EVIDENCE-BASED RESEARCH, EXCELLENT NURSING SKILLS, AND EXPANDING OUR CLINICAL EDUCATION PROGRAMS, THE INPATIENT UNIT AT ELLENVILLE REGIONAL HOSPITAL MADE IT THEIR GOAL TO IMPROVE PATIENT OUTCOMES ACROSS THE CARE SPECTRUM. SOME OF THE MITIGATION STRATEGIES IMPLEMENTED DURING THE ONSET OF THE PANDEMIC COMBINED WITH THE COVID-19 WAIVER ALLOWED OUR FACILITY TO OFFER A MUCH-NEEDED SERVICE. ERH WAS A GREAT RESOURCE FOR TERTIARY FACILITIES DESPERATELY SEEKING TO BALANCE THEIR PATIENT LOADS. WE SERVED PATIENTS WHO WERE READY TO LEAVE THE ACUTE CARE SETTING; HOWEVER, THEIR POSITIVE COVID-19 STATUS DID NOT ALLOW THEM TO RETURN TO LONG TERM CARE FACILITIES (LTC) FOR REHABILITATION. ERH PROVIDED THE CARE THEY NEEDED, HELPED THEM REGAIN THE STAMINA THEY HAD LOST AND ULTIMATELY, AFTER TESTING NEGATIVE FOR COVID-19, THESE PATIENTS MADE IT BACK TO LTC FACILITIES. PATIENT SAFETY CONTINUED TO BE PARAMOUNT IN OUR FACILITY. WE TRACKED AND REPORTED COMPLIANCE WITH MEDICATION SCANNING, A PRACTICE THAT ENHANCES SAFE MEDICATION ADMINISTRATION BY HELPING VERIFY PATIENT IDENTIFICATION AND CORRECT MEDICATION AND SUBSEQUENTLY ENSURING CORRECT MEDICATION ADMINISTRATION AND MITIGATING POTENTIAL ERRORS. OUR SCANNING AVERAGE OF 80.6% REMAINED WELL ABOVE NATIONAL AVERAGE. ERH'S SAFE PATIENT HANDLING COMMITTEE REVIEWED AND MAINTAINED SUCCESSFUL PRACTICES THAT MAXIMIZED A SAFE ENVIRONMENT FOR OUR PATIENTS AND STAFF. THE FOCUS OF THIS INITIATIVE IS TO ENSURE THAT OUR STAFF ARE INJURY FREE. THE COMMITTEE HAS MADE A TREMENDOUS EFFORT TO DELIVER GUIDANCE AND TRAINING STAFF ON TRANSFERS, BODY MECHANICS, AND USE OF ASSISTIVE DEVICES. THEY HAVE DONE THIS VERY EFFECTIVELY BY INCORPORATING EVIDENCE-BASED PRACTICES IN OUR EVERYDAY TASKS AND ROUTINES LIKE THE BMAT MODEL (BED SIDE MOBILITY ASSESSMENT TOOL). THE SAFE PATIENT HANDLING COMMITTEE CONTINUES TO MEET REGULARLY TO DISCUSS EDUCATIONAL NEEDS AND PROVIDE HANDS-ON TRAINING TO ALL CLINICAL STAFF. ADDITIONALLY, OUR BEDS ARE NOW EQUIPPED WITH ALARMS AND SPECIALTY MATTRESSES TO ASSURE SAFETY AND MAINTAIN SKIN INTEGRITY. WE ALSO CONTINUE TO USE THE VIDEO MONITORING SYSTEM TO HELP INCREASE SAFETY MEASURES FOR OUR PATIENTS ON ISOLATION. STAFF EDUCATION IS ALSO AN ESSENTIAL ELEMENT IN MAINTAINING AND PROMOTING CLINICAL COMPETENCY. ONE HUNDRED PERCENT OF OUR REGISTERED NURSES MAINTAINS CERTIFICATION IN BASIC AND ADVANCED LIFE SUPPORT THROUGH THE AMERICAN HEART ASSOCIATION AND TELEMETRY. OUR NURSE EDUCATOR PROVIDES EDUCATION OPPORTUNITIES VIA IN-SERVICES, WEBINARS, LECTURES, AND SCHOLARLY ARTICLES. THE HANDS ON TRAINING AND ACADEMIC OFFERINGS ENSURE OUR CLINICAL STAFF IS KNOWLEDGEABLE ON CURRENT TRENDS AND STANDARDS OF CARE. WE LINK ALL NEW HIRES WITH AN EXPERIENCED PRECEPTOR AND ADJUST THE ORIENTATION PROCESS TO MEET THE NEEDS OF EACH INDIVIDUAL. IN OUR FACILITY, EDUCATION DELIVERY INVOLVES EVERYONE. THE NURSE EDUCATOR COLLABORATES WITH THE NURSING TEAM, PHARMACY, REHABILITATION SERVICES, CLINICAL IT APPLICATIONS SPECIALIST, AND RESPIRATORY SERVICES TO OFFER COMPREHENSIVE ANNUAL EDUCATION FOR ALL NURSING STAFF. EMERGENCY DEPARTMENT:LIMITED ACCESS TO PUBLIC TRANSPORT AND SCANT EMERGENCY MEDICAL SERVICE COVERAGE ARE MONUMENTAL CHALLENGES IN ALL RURAL SETTINGS. IN 2023, THE NEWLY RENOVATED AND EXPANDED EMERGENCY DEPARTMENT PROVIDED HIGH-QUALITY EMERGENCY CARE TO OUR RURAL RESIDENTS AND SEASONAL VISITORS. BY COMBINING QUALITY CARE, EVIDENCE-BASED RESEARCH, EXCELLENT NURSING SKILLS, AND EXPANDING OUR CLINICAL EDUCATION PROGRAMS, THE EMERGENCY DEPARTMENT AT ERH FOCUSED ON IMPROVING PATIENT OUTCOMES ACROSS THE CARE SPECTRUM. WHILE MANAGING THE LASTING EFFECTS OF THE COVID PANDEMIC, ERH CONTINUED TO FOCUS ON THE RELENTLESS OPIOID CRISIS. OUR EMERGENCY DEPARTMENT'S RESCUE INITIATIVE REMAINS IN EFFECT AND CONTINUES TO GENERATE POSITIVE OUTCOMES. THE ED PROVIDERS ARE CERTIFIED TO PROVIDE MAT (MEDICATION ASSISTED TREATMENT). THIS HAS GREATLY FACILITATED TREATMENT OF PATIENTS PRESENTING TO THE ED AFTER AN OVERDOSE. WE HAVE CONTINUED OUR COLLABORATION EFFORTS WITH THE ULSTER COUNTY SHERIFF'S DEPARTMENT'S IN THE ORACLE PROGRAM AND UTILIZE THE SERVICES OF OUR IN-HOUSE SUBSTANCE USE DISORDER (SUD) PROGRAM. OUR COLLABORATIVE EFFORTS HAVE HELPED WITH INDUCTION OF MAT AND SECURING INPATIENT AND OUTPATIENT REHABILITATION SERVICES FOR THOSE WHO ARE IN NEED. OUR ED AND POPULATION HEALTH TEAMS CONTINUE COLLABORATING PROVIDING SAFE KITS UPON DISCHARGE TO PATIENTS WHO EXPERIENCED AN OVERDOSE EVENT AND EDUCATING PATIENTS AND FAMILY MEMBERS ON NALOXONE ADMINISTRATION. THE FOCUS REMAINED ON HARM-REDUCTION, EDUCATION, AND PREVENTION. WE ALSO CONTINUED TO WORK CLOSELY WITH OUR LOCAL EMS AGENCIES. RADIOLOGY:IN 2023, THE RADIOLOGY & CARDIOLOGY DEPARTMENTS AT ERH STARTED THE YEAR WITH OUTPATIENT MODALITIES HOVERING OR EXCEEDING VOLUME FOR ALL MODALITIES FROM THE PAST SEVERAL YEARS. EVEN WITH THE SPIKES IN COVID AND EXTREME FLUCTUATION, THE VOLUME REMAINED CONSISTENT. WITH MANY STAFF CONTRACTING COVID PERSONALLY MADE IT CHALLENGING TO OPERATE, HOWEVER ERH STAFF ARE RESILIENT AND HELD STRONG KEEPING UP WITH OUR PATIENT DEMAND AND CONTINUED TO PROVIDE SERVICES WITHOUT INTERRUPTION OR DELAY.MAMMOGRAPHY HAD ITS ANNUAL MQSA INSPECTION COMPLETED WITH NO CITATIONS. WE CONTINUED OUR REDUCED X-RAY REPEAT/REJECT RATE, WHICH AVERAGED ABOUT 3% OVER THE YEAR. THIS CONTINUED REDUCTION IN REPEATED EXAMS ALLOWED US TO PROVIDE THE HIGHEST LEVEL OF CARE TO OUR PATIENTS. ERH CONTINUED TO EXPAND ON THE SERVICES PROVIDED BY THE QUALITY IMPROVEMENT GRANT, WHICH WAS AWARDED 3 YEARS PRIOR. WITH THIS GRANT, ERH PERFORMED NUMEROUS EXAMS IN 2023. OFFERING THE EXAMS AT NO OUT OF POCKET COST TO THE PATIENTS PROVED TO BE SUCCESSFUL WITH MANY PATIENTS RECEIVING CRUCIAL SCREENING AND PREVENTATIVE CARE BASED ON THE TEST RESULTS. MANY OF THE CALCIUM SCORE PATIENTS HAD BEEN FIRST TIME PATIENTS AT ERH AND RETURNED FOR OTHER OUTPATIENT SERVICES AS A RESULT OF THE HIGH LEVEL OF CARE AND REMARKABLE EXPERIENCE.OVERALL, RADIOLOGY AND CARDIOLOGY POSITIONED THEMSELVES TO HAVE A STRONG 2024 AND DID SO WHILE KEEPING PATIENTS AND STAFF HEALTHY AND SAFE. ERH STRIVES TO OFFER THE HIGHEST LEVEL OF CARE AND OBTAIN THE NEWEST EQUIPMENT AVAILABLE TO PROVIDE THE BEST SERVICE TO OUR COMMUNITY.THE HOSPITAL ALSO PROVIDES AMBULATORY SURGERY, LAB SERVICES, IV THERAPY, PHYSICAL THERAPY, OCCUPATIONAL THERAPY, SPEECH LANGUAGE PATHOLOGY SERVICES, CARDIAC REHABILITATION, AND SPECIALTY CARE TO OUR PATIENTS. 21965019 1 1 0 1 0 0 0 0 0 0 1 0 0 1 1 1 0 1 0 0 0 0 0 0 0 0 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 1 49 0 302 1 0 0 0 0 0 0 0 0 0 0 0 0 X 11 10 0 0 0 0 0 0 0 1 1 0 0 1 1 1 1 1 1 1 1 0 NY X X BOB RUE CFO 8456476400 10 HEALTHY WAY ELLENVILLE NY 12428 STEVEN KELLEY PRESIDENT & CEO 36.00 5.00 X X 514683 0 22500 REVEREND JULIUS A COLLINS JR CHAIRPERSON 4.00 0.00 X X 0 0 0 MYRNA JARGOWSKY VICE CHAIRPERSON 2.00 6.00 X X 0 0 0 WILLIAM D BROWN TREASURER 3.00 8.00 X X 0 0 0 JOHN B GILLETTE SECRETARY 3.00 0.00 X X 0 0 0 RICHARD BRADFORD TRUSTEE 2.00 6.00 X 0 0 0 DR NEIL CALMAN MD TRUSTEE 2.00 0.00 X 0 0 0 PHILIP COOMBE III TRUSTEE 2.00 5.00 X 0 0 0 DAVID EIKSZTA TRUSTEE 2.00 5.00 X 0 0 0 JULIE C LONSTEIN TRUSTEE 2.00 0.00 X 0 0 0 CRAIG LOPEZ TRUSTEE, THRU 1/1/23 0.00 5.00 X 0 0 0 KRISTINA URSITTI DO TRUSTEE 2.00 0.00 X 0 0 0 BOB RUE CFO 36.00 5.00 X 238095 0 41336 ASHIMA BUTLER COO 36.00 0.00 X 249483 0 13930 MARIE BROWN REGISTERED NURSE 40.00 0.00 X 186916 0 40571 MARIA GONZALEZ CHIEF NURSING OFFICER 40.00 0.00 X 148376 0 38633 KERRY BYTHEWOOD-SAVERINO MANAGER PHARMACY 36.00 0.00 X 138904 0 0 THERESA AVERSANO DIRECTOR PHYSICAL MEDICINE & REHAB 40.00 0.00 X 140801 0 31473 CLARE FARRELL MANAGER OF LABORATORY SERVICES 37.50 0.00 X 141807 0 1495 1759065 0 189938 25 0 1 0 CCI CONSTRUCTION INC 70 CHESTNUT RIDGE ROAD MONTVALE NJ 07645 CONSTRUCTION SERVICES 913696 THE INSTITUTE FOR FAMILY HEALTH INC 2006 MADISON AVENUE 5TH FLOOR NEW YORK NY 10035 MEDICAL SERVICES 444250 WHITE GLOVE PLACEMENT INC 89 BARTLETT STREET BROOKLYN NY 11206 TRAVELING NURSES 424733 LAB CORP OF AMERICA HOLDINGS PO BOX 12140 BURLINGTON NC 272162140 LAB TESTING SERVICES 408720 CONSTABLE CUSTODIAL SERVICES INC PO BOX 1115 LIBERTY NY 12754 CLEANING SERVICES 384150 13 2708620 86122 2794742 PATIENT SERVICE REVENUE 621990 29970959 29970959 29970959 584978 584978 34098 28978 5120 5120 5120 CAFETERIA INCOME 900099 16894 16894 INCENTIVES 900099 10220 10220 PURCHASING REBATE 900099 4496 4496 8970 8970 40580 33396379 29970959 0 630678 1080027 377160 702867 12614291 9865788 2748503 17696 17696 1764133 1334144 429989 1130549 847912 282637 43192 32394 10798 146400 109800 36600 40330 40330 108162 108162 697699 523274 174425 139786 104839 34947 427496 350604 76892 342669 255328 87341 108091 81068 27023 1123283 840807 282476 573150 429862 143288 CONTRACT/PURCHASED SVCS 3561558 2668467 893091 BAD DEBT EXPENSE 1699277 1699277 MEDICAL SUPPLIES 1191563 893672 297891 PRESCRIPTION DRUGS 1090420 817815 272605 954751 715112 239639 28854523 21965019 6889504 0 2411329 4338331 7289841 5552750 245646 162312 3755747 3559376 225245 262443 623238 652234 23282525 10870841 12680343 12411684 12509158 18349904 2142502 2465318 41883049 47754352 2634006 2879416 1181870 1093601 5187210 5456192 9003086 9429209 X 31455424 36539993 1424539 1785150 32879963 38325143 41883049 47754352 X 4541856 1351545 -448221 X X 0 1 X 1 1 1 X RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED RESTRICTED 0 0 0 0 0 0 0 0 1 40330 40330 1 PART II-B, LINE 1: AMOUNT REPORTED ON LINE 1I REPRESENTS THE PORTION OF MEMBERSHIP DUES PAID BY THE ORGANIZATION TO PROFESSIONAL ASSOCIATIONS AND SIMILAR ORGANIZATIONS ATTRIBUTABLE TO LOBBYING ACTIVITIES. 12358596 4245220 8113376 9506741 6625621 2881120 1417188 1417188 12411684 INTEREST IN NET ASSETS OF ELLENVILLE REGIONAL HOSPITAL FOUNDATION 1760018 INSURANCE RECOVERY RECEIVABLE 603888 INVESTMENT IN ELLENVILLE REGIONAL FAMILY HEALTH PROPERTIES 96412 DUE FROM ELLENVILLE REGIONAL FAMILY HEALTH PROPERTIES CORPORATION 5000 2465318 ESTIMATED THIRD PARTY PAYOR SETTLEMENTS 4852304 INSURANCE CLAIM LIABILITY 603888 5456192 X 32607809 1351545 828213 2179758 30428051 108162 2860166 2968328 33396379 27171183 124099 124099 27047084 108162 1699277 1807439 28854523 PART X, LINE 2: THE HOSPITAL RECOGNIZES THE EFFECT OF INCOME TAX POSITIONS ONLY WHEN THEY ARE MORE LIKELY THAN NOT TO BE SUSTAINED. MANAGEMENT HAS DETERMINED THAT THE HOSPITAL HAD NO UNCERTAIN TAX POSITIONS THAT WOULD REQUIRE FINANCIAL STATEMENT RECOGNITION AND/OR DISCLOSURE. THE HOSPITAL IS NO LONGER SUBJECT TO EXAMINATION BY APPLICABLE TAXING JURISDICTIONS FOR YEARS PRIOR TO 2020. PART XI, LINE 2D - OTHER ADJUSTMENTS: REVENUE ATTRIBUTED TO CONSOLIDATED ENTITIES 438,624. CHANGE IN INTEREST IN NET ASSETS OF ELLENVILLE REGIONAL HOSPITAL FOUNDATION 360,611. RENTAL EXPENSES REPORTED ON PART VIII, LINE 6B 28,978. PART XI, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE NETTED AGAINST REVENUE 1,699,277. LOSS ON DISPOSAL OF FIXED ASSETS 800,278. ELIMINATIONS 352,057. CHANGE IN EQUITY INVESTMENT IN ELLENVILLE REGIONAL FAMILY HEALTH PROPERTIES 8,554. PART XII, LINE 2D - OTHER ADJUSTMENTS: EXPENSES ATTRIBUTED TO CONSOLIDATED ENTITIES 95,121. RENTAL EXPENSES REPORTED ON PART VIII, LINE 6B 28,978. PART XII, LINE 4B - OTHER ADJUSTMENTS: BAD DEBT EXPENSE NETTED AGAINST REVENUE 1,699,277. 1 1 1 X 1 X 1 0 1 1 659952 659952 0.02290 6819007 3454916 3364091 0.11660 166131 166131 0.00580 7645090 3454916 4190174 0.14530 17314244 15953684 1360560 0.04720 17314244 15953684 1360560 0.04720 24959334 19408600 5550734 0.19250 1 746358 243370 9403056 9367210 35846 X 1 1 1 1 WESTCHESTER-ELLENVILLE HOSPITAL INC 10 HEALTHY WAY ELLENVILLE NY 12428 HTTPS://ERHNY.ORG 5526700C X X X X X WESTCHESTER-ELLENVILLE HOSPITAL INC 1 0 0 1 X X X X X X X X X 22 1 0 1 1 X SEE PART V, PAGE 8 X 1 22 1 SEE PART V, PAGE 8 0 1 X 100.000000000000 300.000000000000 1 1 X X X 1 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X SEE PART V, PAGE 8 X X X X X X 1 X 0 X X X X 1 X 0 0 WESTCHESTER-ELLENVILLE HOSPITAL, INC. PART V, SECTION B, LINE 5: AS REQUIRED BY THE NEW YORK STATE DEPARTMENT OF HEALTH AND IRS, ELLENVILLE REGIONAL HOSPITAL (ERH) MUST CONDUCT A THOROUGH COMMUNITY HEALTH ASSESSMENT (CHA) EVERY THREE YEARS. THE INFORMATION IS UTILIZED TO DEVELOP A COMMUNITY SERVICE PLAN (CSP) OUTLINING INTERVENTIONS DESIGNED TO IMPROVE HEALTH OUTCOMES IN THE SERVICE AREA. IN RECENT YEARS, THE NEW YORK STATE DEPARTMENT OF HEALTH HAS ENCOURAGED LOCAL HOSPITALS AND HEALTH DEPARTMENTS TO COLLABORATE IN CREATING JOINT COMMUNITY HEALTH IMPROVEMENT (CHIP)/CSP DOCUMENTS. ULSTER COUNTY DEPARTMENT OF HEALTH (UCDOH) HOSTED A SERIES OF MEETINGS WITH KEY STAKEHOLDER ORGANIZATIONS IN ULSTER COUNTY TO DISCUSS THE SELECTION OF HEALTH IMPROVEMENT PRIORITIES. ERH, WITH ITS PARTNERS UCDOH AND HEALTHALLIANCE HOSPITAL: MARY'S AVE CAMPUS (HA), JOINTLY SELECTED PREVENTING CHRONIC DISEASES AND PROMOTE WELL-BEING AND PREVENT MENTAL AND SUBSTANCE USE DISORDERS AS THE TWO PRIORITY AREAS FOR THE 2022-2024 CHIP/CSP. COMMUNITY-BASED ORGANIZATIONS, HEALTH CARE PROVIDERS, SEVERAL COUNTY OF ULSTER DEPARTMENTS, AND ULSTER COUNTY COALITIONS WERE ALSO INVOLVED IN THE DECISION-MAKING PROCESS AND WORKED TO SUPPORT THE SELECTED INITIATIVES. THIS COLLABORATION HAS CONTINUED TO INCLUDE MANY SERVICE AGENCIES IN ULSTER COUNTY.IN 2017, THE SEVEN LOCAL HEALTH DEPARTMENTS OF THE MID-HUDSON REGION, INCLUDING DUTCHESS, ORANGE, PUTNAM, ROCKLAND, SULLIVAN, ULSTER, AND WESTCHESTER COUNTIES, CREATED THE HUDSON VALLEY PUBLIC HEALTH COLLABORATIVE WITH THE ENDEAVOR OF CREATING THE FIRST REGIONAL CHA FOR THE MID-HUDSON REGION. THE COLLABORATIVE CONTRACTED THE SIENA COLLEGE RESEARCH INSTITUTE (SCRI) TO CONDUCT A RANDOM DIGIT DIAL REGIONAL COMMUNITY HEALTH SURVEY TO SUPPLEMENT THE REGIONAL CHA AND TO GAUGE THE PERCEPTION OF RESIDENTS SURROUNDING HEALTH AND RESOURCES IN THEIR COMMUNITIES. TO FURTHER INCREASE THE DATA COLLECTED FROM THE COMMUNITY, COLLABORATIVE MEMBERS HELD FOCUS GROUPS WITH SERVICE PROVIDERS TO FURTHER UNDERSTAND THE NEEDS OF SPECIFIC COMMUNITIES AND POPULATIONS AND THE BARRIERS THEY FACE TO ACHIEVING OPTIMAL HEALTH. IN 2023, ELLENVILLE REGIONAL RURAL HEALTH NETWORK (ERRHN), EXECUTED ON THE PLANNED ACTIVITIES AS NOTED IN THE CHA. THE HEALTHY ULSTER COUNCIL, A BROAD-BASED COALITION FORMED BY REPRESENTATIVES FROM VARIOUS ORGANIZATIONS AND AGENCIES IN 2010, CONTINUED THEIR FOCUSED WORK ON HEALTH PROBLEMS IN ULSTER COUNTY AND WAYS TO IMPROVE HEALTH OUTCOMES. REGULAR MEETINGS OF THE COALITION, ALONG WITH PRESENTATIONS AND DISCUSSIONS, HAVE KEPT THE LARGER COMMUNITY INVOLVED IN TRACKING HEALTH CONCERNS AND SOLUTIONS, INCLUDING ELLENVILLE AND THE TOWN OF WAWARSING. WESTCHESTER-ELLENVILLE HOSPITAL, INC. PART V, SECTION B, LINE 6B: 1) HEALTH ALLIANCE OF THE HUDSON VALLEY2) ULSTER COUNTY DEPARTMENT OF HEALTH AND MENTAL HEALTH3) THE INSTITUTE FOR FAMILY HEALTH4) DUTCHESS COUNTY DEPARTMENT OF HEALTH 5) ORANGE DEPARTMENT OF HEALTH6) PUTNAM DEPARTMENT OF HEALTH7) ROCKLAND DEPARTMENT OF HEALTH8) SULLIVAN DEPARTMENT OF HEALTH9) WESTCHESTER DEPARTMENT OF HEALTH WESTCHESTER-ELLENVILLE HOSPITAL, INC. PART V, SECTION B, LINE 11: FOR ERH SPECIFICALLY, THE FOCUS AREAS CHOSEN WITHIN THE TWO PREVENTION AGENDA PRIORITIES FOR THE YEARS 2022-2024 ARE:1) PREVENT CHRONIC DISEASES FOCUS AREA 4: PREVENTIVE CARE AND MANAGEMENT2) PROMOTE WELL-BEING AND PREVENT MENTAL AND SUBSTANCE USE DISORDERS. FOCUS AREA 2: PREVENT MENTAL AND SUBSTANCE USER DISORDERSPREVENT CHRONIC DISEASES FOCUS AREA 4, THE ELLENVILLE REGIONAL RURAL HEALTH NETWORK (ERRHN) WELLNESS PROGRAM, AND ITS EDUCATIONAL PROGRAMMING WILL BE CONTINUALLY DEVELOPED AND IMPLEMENTED. THE COLLABORATIVE WILL WORK TO INCREASE PARTICIPATION IN LIFESTYLE CHANGES, INCLUDING INCREASED PHYSICAL ACTIVITY, IMPROVED DIET, AND IMPROVED HEALTH AND WELL-BEING AWARENESS, UTILIZING THE EVIDENCE-BASED COMMUNITY HEALTH WORKER (CHW) MODEL.INTERVENTION 1 SUMMARY: ERH HAS IDENTIFIED OVER 95 FAMILIES WORKING WITH A COMMUNITY HEALTH WORKER TO PRACTICE HEALTHY GOAL SETTING, INCREASING PHYSICAL ACTIVITY, AND BUILDING MOTIVATION. THE FAMILIES MAY ALSO ACCESS THE ERRHN NUTRITIONIST AT NO COST TO THEM. ALL OF THIS IS DONE TO DECREASE THE RISK OF DEVELOPING CHRONIC DISEASE.INTERVENTION 2 SUMMARY: ERH UTILIZES COLLABORATIVE EFFORTS BETWEEN DIFFERENT HOSPITAL DEPARTMENTS AND OTHER COMMUNITY-BASED ORGANIZATIONS TO OFFER SERVICES TO THE COMMUNITY THAT AIMS TO HELP OVERCOME SOCIAL DETERMINANT-RELATED HEALTH BARRIERS. THE PROGRAMS INCLUDE PHYSICAL ACTIVITY CLASSES, COOKING CLASSES, GARDENING CLASSES, AND EVEN A FREE PRODUCE HANDOUT ALL OF THESE ACTIVITIES ARE PROVIDED TO THE COMMUNITY AT NO DIRECT COST.INDIVIDUALS AND FAMILIES IDENTIFIED AS AT RISK IN THE COMMUNITY, AT THE ERH ED, OR A LOCAL PCP ARE REFERRED TO THE RHN WELLNESS PROGRAM. INDIVIDUALS WHO ACCEPT THE REFERRAL ARE ENROLLED INTO THE COHORT AND COMPLETE AN INTAKE ASSESSMENT WITH A COMMUNITY HEALTH WORKER (CHW) THAT INCLUDES COLLECTING CLINICAL METRICS, AN SDOH SCREENING, AND HEALTH KNOWLEDGE AND BEHAVIOR ASSESSMENTS. THE CHW WORKS WITH THE INDIVIDUAL TO DEVELOP AN ACTION PLAN TO BEGIN MAKING LIFESTYLE CHANGES THAT REDUCE THEIR RISK OF CHRONIC DISEASE. THE CHW SUPPORTS THE COHORT BY OFFERING MEETINGS AT THEIR HOUSE, COMMUNITY LOCATION, LOCAL STORES, OR HOSPITAL. PROGRAMS INCLUDE: ELIMINATING TRANSPORTATION BARRIERS. ARRANGING MEDICATION RECONCILIATION AND BLISTER PACKAGING WITH THE ERH PHARMACIST. GROCERY SHOPPING EDUCATION AT THE LOCAL GROCERY STORE.ADDITIONALLY, THE COHORT CAN MEET WITH A NUTRITIONIST ONSITE OR AT A SITE OF THEIR CHOOSING (TO OVERCOME TRANSPORTATION) TO MAKE MEAL PLANS AND HAVE NUTRITION COUNSELING. IN ADDITION, TO THE SUPPORT PROVIDED BY THE CHW AND NUTRITIONIST, THERE ARE MANY NO-COST HEALTH PROGRAMS COHORT MEMBERS CAN ATTEND THAT FOCUS ON HEALTH EDUCATION, NUTRITION (COOKING DEMONSTRATIONS, SUPPORT GROUP, ETC.), AND PHYSICAL ACTIVITY CLASSES.TO PROMOTE WELL-BEING AND PREVENT MENTAL AND SUBSTANCE USE DISORDERS FOCUS AREA 2, ERH WILL CONTINUE TO IMPLEMENT AND EXPAND PROJECT RESCUE (24/7 BUPRENORPHINE INDUCTION WITH A WARM HANDOFF TO A PEER AND TREATMENT PROVIDER). THE PROGRAM WILL CONTINUE TO SUPPLY HARM REDUCTION SUPPLIES AND EDUCATION ON HARM REDUCTION TO INDIVIDUALS SEEN IN THE ED AND THE COMMUNITY. ADDITIONALLY, ERH STAFF WILL CONTINUE TO SUPPORT THE ULSTER COUNTY SHERIFF'S ORACLE PROGRAM (OPIOID RESPONSE AS COUNTY LAW ENFORCEMENT), WHICH AIMS TO DIVERT INDIVIDUALS FROM POTENTIAL INCARCERATION TO DETOX AND TREATMENT SERVICES.INTERVENTION 1 SUMMARY: IMPLEMENT PROJECT RESCUE, A COLLABORATIVE PARTNERSHIP BETWEEN ERH AND CATHOLIC CHARITIES OF ORANGE, SULLIVAN, AND ULSTER. MEDICATION ASSISTED RECOVERY (MAR) (BUPRENORPHINE) WILL BE AVAILABLE IN THE ED FOR INDUCTION 24/7 (WITH ASSESSMENT FOR WITHDRAWAL SYMPTOMS) WITH A WARM HANDOFF TO A CERTIFIED RECOVERY PEER ADVOCATE (CRPA) AND A REFERRAL TO START TREATMENT. MAR IS AVAILABLE FOR UP TO THREE DAYS IN THE ED, WITH A GUARANTEE TO START TREATMENT WITH PARTNERING AGENCIES ON DAY FOUR. CONTINUE TO LINK INDUCTED PATIENTS TO THE MAT CARE MANAGER AS NECESSARY. INTERVENTION 2 SUMMARY: PROVIDE NECESSARY HARM REDUCTION SUPPLIES AND GUIDANCE TO PREVENT FATAL OVERDOSES AND THE OCCURRENCE AND TRANSMISSION OF INFECTIOUS COMPLICATIONS (I.E., HEPC, HIV, ENDOCARDITIS).INTERVENTION 3 SUMMARY: SUPPORT OF THE ULSTER COUNTY SHERIFF'S PROJECT ORACLE FACILITATE LAW ENFORCEMENT-ASSISTED DIVERSION FOR SUBSTANCE USE DISORDER BY PARTICIPATING IN THE COUNTYWIDE "HIGH-RISK MITIGATION TEAM," A CARE-COORDINATION MODEL THAT AIMS TO REDUCE RATES OF RELAPSE, OVERDOSE, AND DEATH. PART V, LINE 7, CHNA REPORT WEBSITE: HTTPS://ERHNY.ORG/WP-CONTENT/UPLOADS/2023/11/ELLENVILLE-REGIONAL-HOSPITAL-COMMUNITY-HEALTH-NEEDS-ASSESSMENT-2022-2024-CHNA-1.PDFPLEASE NOTE LINKS ARE SUBJECT TO CHANGE DUE TO WEBSITE REDESIGN/CHANGES CAUSING DATA TO BE MOVED TO ALTERNATE LOCATIONS. PART V, LINE 10, IMPLEMENTATION STRATEGY WEBSITE: HTTPS://ERHNY.ORG/ABOUT-US/ PLEASE NOTE LINKS ARE SUBJECT TO CHANGE DUE TO WEBSITE REDESIGN/CHANGES CAUSING DATA TO BE MOVED TO ALTERNATE LOCATIONS. PART V, SECTION B, LINE 16A: HTTPS://ERHNY.ORG/WP-CONTENT/UPLOADS/2022/08/2022-ERH-FINANCIAL-ASSISTANCE-POLICY-PROCEDURE-ENGLISH.PDFHTTPS://ERHNY.ORG/WP-CONTENT/UPLOADS/2022/12/2020-ERH-FA-APP-ENGLISH-AND-SPANISH.PDFPLEASE NOTE THAT THERE'S A POSSIBILITY THAT THE LINK COULD CHANGE AFTER THE RETURN IS FILED. PART V, SECTION B, LINE 16B&C: HTTPS://ERHNY.ORG/WP-CONTENT/UPLOADS/2022/12/2020-ERH-FA-APP-DIRECTIONS-SPANISH.PDFHTTPS://ERHNY.ORG/WP-CONTENT/UPLOADS/2022/12/2020-ERH-FA-APP-ENGLISH-AND-SPANISH.PDFHTTPS://ERHNY.ORG/WP-CONTENT/UPLOADS/2024/01/2024-ERH-FA-SUMMARY-ENGLISH.PDFHTTPS://ERHNY.ORG/WP-CONTENT/UPLOADS/2024/01/2024-ERH-FA-SUMMARY-SPANISH.PDFPLEASE NOTE THAT THERE'S A POSSIBILITY THAT THE LINK COULD CHANGE AFTER THE RETURN IS FILED. PART I, LINE 5: ERH DID NOT BUDGET AMOUNTS FOR FREE OR DISCOUNTED CARE PROVIDED UNDER ITS FINANCIAL ASSISTANCE POLICY. THE HOSPITAL IS PREPARED TO PROVIDE FREE OR DISCOUNTED CARE FOR ALL ELIGIBLE PATIENTS. THE IMPACT OF FREE AND DISCOUNTED CARE IS NOT PREDICTABLE FOR THE HOSPITAL IN ORDER TO ESTIMATE THIS AMOUNT FOR BUDGETING PURPOSES. PART II, COMMUNITY BUILDING ACTIVITIES: THE BOARD OF TRUSTEES OF ERH IS COMPRISED OF ELEVEN MEMBERS; TEB IF THESE MEMBERS ARE VERY VISIBLE IN THE COMMUNITY AND ARE A DIRECT LINK FOR PATIENTS TO THE HOSPITAL ADMINISTRATION. ELLENVILLE REGIONAL HOSPITAL PARTNERS WITH CATSKILL HUDSON AREA HEALTH EDUCATION CENTER AND THE INSTITUTE FOR FAMILY HEALTH TO RECRUIT PRIMARY CARE PHYSICIANS. ELLENVILLE REGIONAL HOSPITAL APPLIES SURPLUS FUNDS TO IMPROVING THE QUALITY OF CARE FOR ALL PATIENTS AND EXTENDS MEDICAL STAFF PRIVILEGES TO ALL QUALIFIED LICENSED MEDICAL PROVIDERS IN THE COMMUNITY. PART III, LINE 2: THE AMOUNT REPORTED IN PART III, SECTION B, LINE 2 IS BASED ON THE AMOUNTS OF PATIENT ACCOUNTS WRITTEN OFF DUE TO BAD DEBT. PART III, LINE 3: THE AMOUNT REPORTED IN PART III, SECTION B, LINE 3 IS ESTIMATE OF ACCOUNTS MAY HAVE BEEN ELIGIBLE FOR FINANCIAL ASSISTANCE BASED ON THE KNOWLEDGE OF THE HOSPITAL PATIENTS AND THE COMMUNITY THAT THE HOSPITAL SERVES. SCHEDULE H, PART II: ELLENVILLE REGIONAL HOSPITAL'S POPULATION HEALTH PROGRAM IS BASED ON A BELIEF IN FOUR PILLARS FOR IMPROVED HEALTH:1. PROPER DIET2. MODERATE EXERCISE3. RISK REDUCTION4. SUPPORTS FOR SOCIAL DETERMINES OF HEALTH THE ELLENVILLE REGIONAL RURAL HEALTH NETWORK, LED BY ELLENVILLE REGIONAL HOSPITAL, HAS NO COST COMMUNITY WELLNESS PROGRAMS THAT ARE ESSENTIAL FOR PROMOTING HEALTHIER LIFESTYLES AND PREVENTING VARIOUS HEALTH ISSUES FOCUSING ON EXERCISE, NUTRITION, RISK REDUCTION, AND SUPPORT. OUR FREE EXERCISE PROGRAMS CAN ENCOURAGE PHYSICAL ACTIVITY, CRUCIAL FOR MAINTAINING A HEALTHY WEIGHT, STRENGTHENING MUSCLES AND BONES, AND REDUCING THE RISK OF CHRONIC DISEASES SUCH AS DIABETES AND HEART DISEASE. MEET WITH A NUTRITIONIST TO LEARN ABOUT MAKING HEALTHIER FOOD CHOICES, UNDERSTANDING PORTION SIZES, AND THE IMPORTANCE OF A BALANCED DIET RICH IN FRUITS, VEGETABLES, WHOLE GRAINS, AND LEAN PROTEINS. RISK REDUCTION PROGRAMS CAN PROVIDE INFORMATION AND RESOURCES FOR MANAGING FACTORS THAT CONTRIBUTE TO HEALTH RISKS, SUCH AS SMOKING CESSATION, DRUG AND ALCOHOL USE, AND REGULAR HEALTH SCREENINGS. SUPPORT FROM A COMMUNITY HEALTH WORKER CAN OFFER SOCIAL SUPPORTS FOR INDIVIDUALS FACING HEALTH CHALLENGES, PROVIDING A SENSE OF COMMUNITY AND ENCOURAGEMENT TO STAY MOTIVATED IN THEIR WELLNESS JOURNEY.THE ELLENVILLE REGIONAL RURAL HEALTH NETWORK IS A COLLABORATIVE TEAM OF LOCAL COMMUNITY STAKEHOLDERS WITH A MISSION TO CONTINUOUSLY PURSUE HEALTHIER LIVES FOR EVERYONE IN OUR COMMUNITY. THE TEAM IS LED BY ELLENVILLE REGIONAL HOSPITAL ALONG WITH THE INSTITUTE FOR FAMILY HEALTH, CORNELL COOPERATIVE EXTENSION OF ULSTER COUNTY, CATHOLIC CHARITIES OF ORANGE, SULLIVAN, & ULSTER, AND THE ULSTER COUNTY DEPARTMENT OF HEALTH AND MENTAL HEALTH. THE RURAL HEALTH NETWORK CONSTANTLY COLLABORATES WITH ADDITIONAL COMMUNITY PARTNERS SUCH AS LAW ENFORCEMENT, SCHOOLS, MUNICIPALITIES, COUNTY GOVERNMENT, PHARMACIES, FARMS, CORRECTIONAL FACILITIES, FAITH BASED INSTITUTIONS, SUBSTANCE USE DISORDER TREATMENT FACILITIES, PHARMACIES, AND MANY OTHER COMMUNITY BASED ORGANIZATIONS. TO PROMOTE COMMUNITY COLLABORATION, THE RURAL HEALTH NETWORK FACILITATES MULTIPLE COALITION MEETINGS AND ATTENDS SEVERAL OTHER MEETINGS LED BY OUR PARTNERS. THE RURAL HEALTH NETWORK FACILITATES MONTHLY RURAL HEALTH NETWORKING MEETINGS, MONTHLY MEETINGS FOR THE ULSTER PARTNERS FOR PREVENTION, AND QUARTERLY CONSORTIUM MEETINGS FOR THE RURAL COMMUNITIES OPIOIDS PROGRAM. THE RURAL HEALTH NETWORK IS A CHARTER MEMBER OF THE INTEGRATED ULSTER CONSORTIUM RUN BY THE ULSTER COUNTY DEPARTMENT OF MENTAL HEALTH AND A MEMBER OF THE HIGH-RISK MITIGATION TEAM LED BY THE ULSTER COUNTY SHERIFF'S OFFICE ORACLE PROGRAM. WE ALSO ATTEND AND PARTICIPATE WITH OTHER CONSORTIUM AND COALITION GROUPS SUCH AS THE ULSTER COUNTY DEPARTMENT OF MENTAL HEALTH'S OSAT MEETINGS & WORKGROUPS, THE ULSTER COUNTY DEPARTMENT OF HEALTH'S HEALTHY ULSTER COUNCIL AND HEART DISEASE TASK FORCE MEETINGS, THE TRI-COUNTY PREVENTION COALITION, THE ELLENVILLE CENTRAL SCHOOL DISTRICT WELLNESS COMMITTEE, THE ULSTER COUNTY FOOD SERVICES ACCESS NETWORK, THE ULSTER COUNTY BRINGING AGENCIES TOGETHER COALITION, AND THE FRUIT AND VEGETABLE PRESCRIPTION PROGRAM ROUNDTABLE LED BY CORNELL COOPERATIVE EXTENSION. OUR WELLNESS PROGRAM PROVIDES FREE SERVICES TO THE COMMUNITY BASED ON THE FOUR PILLARS. TO PROMOTE A HEALTHY DIET, COMMUNITY MEMBERS CAN MEET WITH OUR CERTIFIED NUTRITION COACH FOR NUTRITION EDUCATION ON FOOD GROUPS, PORTION SIZE, AND HOW TO READ NUTRITION LABELS. WE ALSO WILL COVER MEAL PLANNING AND SHOPPING FOR HEALTHY RECIPES WITH A WEEKLY RECIPE AND A SHOPPING GUIDE. THE NUTRITIONIST ALSO WORKS WITH INDIVIDUALS ONE ON ONE WHO HAVE OR ARE AT RISK FOR CHRONIC HEALTH CONDITIONS TO CREATE INDIVIDUAL NUTRITION GOALS AND PLANS TAILORED TO A PERSON'S HEALTH NEEDS USING THE COMMUNITY HEALTH WORKER MODEL. WE ALSO PROMOTE CONSUMPTION OF MORE FRUITS AND VEGETABLES THROUGH OUR FARM-ACY PROGRAM WHICH DISTRIBUTES FREE PRODUCE TWICE A MONTH. TO PROMOTE INCREASED PHYSICAL WELLNESS THROUGH MODERATE EXERCISE THE RURAL HEALTH NETWORK OFFERS FREE IN PERSON FITNESS CLASSES AND FREE ACCESS TO ONLINE FITNESS THROUGH OUR YOUTUBE CHANNEL. FITNESS CLASSES INCLUDE BUT ARE NOT LIMITED TO YOGA, TAI CHI, STRENGTH TRAINING, INTERVAL TRAINING, CARDIO DANCE, BRAIN & BALANCE, AND WALKING GROUPS. EACH MONTH WE OFFER ON AVERAGE APPROXIMATELY 55 FITNESS CLASS OFFERINGS. TO REDUCE OR LIMIT HEALTH RISKS FOR THE BETTER HEALTH OF THE POPULATION AS A WHOLE WE OFFER SERVICES TO PROMOTE REGULAR SCREENINGS FOR CANCER, SUBSTANCE USE DISORDER SUPPORTS, TOBACCO CESSATION SUPPORT, MEDICATION AND SHARPS DISPOSAL, AND SAFER SEX KITS. CANCER SCREENINGS SAVE LIVES WITH EARLY DETECTION. OUR COMMUNITY HEALTH WORKERS MAKE OUTREACH CALLS TO ELLENVILLE REGIONAL HOSPITAL PATIENTS TO SPREAD AWARENESS AND EDUCATION ABOUT CANCER SCREENING ELIGIBILITY AND LINK PATIENTS TO APPOINTMENTS TO GET SCREENINGS. OUR PARTNERS AT THE INSTITUTE FOR FAMILY HEALTH ALSO PARTICIPATE IN THIS GRANT INITIATIVE OUTREACHING TO THEIR PATIENTS. TO SUPPORT INDIVIDUALS AND THEIR FAMILIES WHO ARE STRUGGLING WITH SUBSTANCE USE WE HAVE A COMMUNITY HEALTH WORKER AVAILABLE TO SUPPORT THOSE INDIVIDUALS AND FAMILIES WITH ACCESS TO INFORMATION AND REFERRALS FOR TREATMENT, DISTRIBUTION OF HARM REDUCTION SUPPLIES, AND TRAINING AND DISTRIBUTION OF NARCAN. WE ALSO FACILITATE A NON-EMERGENCY HELP TEXT LINE AND A RESOURCE WEBSITE FOR SUD RELATED ASSISTANCE. TO HELP PREVENT SUBSTANCE USE AND MISUSE WE ACTIVELY WORK TO HELP THE POPULATION SAFELY SECURE AND DISPOSE OF ANY UNUSED MEDICATION WITH DISTRIBUTION OF MEDICATION LOCKING STORAGE DEVICES AND MEDICATION DECONSTRUCTION KITS. WE ALSO HOLD MONTHLY DRUG TAKE BACK EVENTS THROUGH OUT THE AREA. AT ELLENVILLE REGIONAL HOSPITAL WE ALSO HOST A MONTHLY TAKE BACK COLLECTION OF USED SHARPS AND DISTRIBUTE SHARPS CONTAINERS TO THE COMMUNITY TO LIMIT THE DANGER OF EXPOSURE TO USED NEEDLES IN THE COMMUNITY. SMOKING TOBACCO CAUSES STROKE AND CORONARY HEART DISEASE, WHICH ARE AMONG THE LEADING CAUSES OF DEATH IN THE US. OUR COMMUNITY HEALTH WORKERS OFFER TOBACCO CESSATION SUPPORT THROUGH OFFERING REFERRALS TO THE NYS QUIT LINE AND FACILITATING THE AMERICAN LUNG ASSOCIATION FREEDOM FROM SMOKING PROGRAM. LASTLY, ENGAGING IN RISKY SEXUAL BEHAVIOR CAN LEAD TO HIV INFECTION, SEXUALLY TRANSMITTED DISEASES, AND UNINTENDED PREGNANCY. TO HELP REDUCE THIS RISK WE DISTRIBUTION SAFER SEX KITS TO THE COMMUNITY. TO PROMOTE OVERALL WELLNESS THE COMMUNITY REQUIRES SUPPORT FOR ANY SOCIAL DETERMINATES OF HEALTH. SOCIAL DETERMINATES OF HEALTH INCLUDE THINGS LIKE FOOD INSECURITY, HOUSING INSECURITY, LOW OR NO INCOME, AND LACK OF TRANSPORTATION. OUR COMMUNITY HEALTH WORKERS CAN HELP IDENTIFY AND LINK COMMUNITY MEMBERS TO RESOURCES FOR THESE BARRIERS. USING THE EVIDENCE-BASED COMMUNITY HEALTH WORKER MODEL AND THE STAGES OF CHANGE, COMMUNITY HEALTH WORKERS HELP INDIVIDUALS SET GOALS AND SUPPORT THEM ON THEIR WELLNESS JOURNEY. OUR EMERGENCY DEPARTMENT PROVIDERS REFER PATIENTS WHO NEED FOLLOW-UP CARE AND DO NOT HAVE A PRIMARY CARE PROVIDER TO THE INSTITUTE FOR CARE. PATIENTS SEEN IN THE EMERGENCY DEPARTMENT WITH MENTAL HEALTH SYMPTOMS ARE REFERRED TO THE BEHAVIORAL HEALTH STAFF AT THE INSTITUTE, WHO PROVIDE A WARM HANDOFF FOR PATIENTS WHO SCREENED POSITIVE FOR DEPRESSION OR SUICIDAL INDICATORS AND DO NOT REQUIRE IMMEDIATE INTERVENTION.ERH PARTICIPATED IN THE WESTCHESTER DSRIP, AND OUR PROJECT FOCUSED ON REDUCING THE USE OF OPIOIDS BY CHRONIC PAIN PATIENTS SEEN IN OUR EMERGENCY DEPARTMENT. THE LEADERSHIP STAFF OF ELLENVILLE REGIONAL HOSPITAL AND THE INSTITUTE FOR FAMILY HEALTH DEVELOPED NEW AND INNOVATIVE PROTOCOLS TO ADDRESS CHRONIC PAIN PATIENTS, WHO OFTEN PRESENT IN THE EMERGENCY DEPARTMENT, SEEKING PAIN RELIEF. CHRONIC PAIN PATIENTS, IN MANY CASES, HAVE DEVELOPED AN ADDICTION TO OPIATE-BASED PAIN RELIEVERS. THE MODEL INCLUDES A COMPLETE REDESIGN OF TREATMENT PROTOCOLS IN THE EMERGENCY DEPARTMENT UTILIZING NON-ADDICTIVE PAIN MEDICATIONS. THE RESULT HAS DRAMATICALLY REDUCED OPIATE PRESCRIBING IN THE EMERGENCY DEPARTMENT. THE PROTOCOL ALSO INCLUDES A "WARM" HANDOFF/REFERRAL TO A PATIENT CARE NAVIGATOR WHO HELPS THE PATIENT GET INTO PRIMARY CARE AT THE INSTITUTE OR OTHER COMMUNITY-BASED PROVIDERS. SCHEDULE H, PART II, CONTINUATION: BECAUSE OF THE SUCCESSES OF THE DSRIP PROJECT, ERH TOOK THE NEXT STEP AND LAUNCHED PROJECT RESCUE IN APRIL 2019. PROJECT RESCUE AIMED TO REDUCE MORBIDITY AND MORTALITY OF SUBSTANCE USE AND OVERDOSE THROUGH EXPANDED ACCESS TO MEDICATION-ASSISTED TREATMENT (MAT). THROUGH THIS PROJECT, INDIVIDUALS IN ACTIVE OPIOID WITHDRAWAL CAN PRESENT TO THE EMERGENCY DEPARTMENT FOR EVALUATION BY CLINICAL STAFF. IF THEIR SYMPTOMS REGISTER AS OPIOID WITHDRAWAL, THE INDIVIDUAL CAN RECEIVE MAT (BUPRENORPHINE) WITH A WARM HANDOFF TO A CERTIFIED PEER RECOVERY ADVOCATE (CRPA) FROM CATHOLIC CHARITIES. ED AT ERH WILL PROVIDE MAT FOR UP TO 72 HOURS, WHILE THE SUD COORDINATOR AND CRPA ARRANGE FOR THE CLIENT TO START TREATMENT WITH AN EXTERNAL PROVIDER NO LATER THAN DAY FOUR.SINCE THE IMPLEMENTATION OF PROJECT RESCUE, SERVICES HAVE EXPANDED TO INCLUDE LINKING PATIENTS TO A MAT CARE MANAGER THROUGH THE INSTITUTE FOR FAMILY HEALTH. THIS CARE MANAGER PROVIDES EXTRA INDIVIDUAL SUPPORT WHILE TRANSITIONING TO THE INSTITUTE'S MAT PROGRAM. THE INDIVIDUAL HAS DIRECT PHONE ACCESS TO THE MAT CARE MANAGER, WHO CAN HELP RESOLVE MEDICATION ISSUES AND SCHEDULE TRANSPORTATION IF NECESSARY. IN 2023, 86 PEOPLE WERE SUCCESSFULLY CONNECTED WITH SUBSTANCE USE TREATMENT OR SUPPORTS. THE TREATMENT SERVICES INCLUDED DETOXICATION, INPATIENT AND OUTPATIENT SERVICES, AND BRIDGE PRESCRIPTIONS FOR BUPRENORPHINE OR METHADONE.ERH HAS ALSO IMPLEMENTED A HARM REDUCTION APPROACH TO SUBSTANCE USE DISORDER, AIMING TO RESPECT INDIVIDUAL AUTONOMY AND PROTECT THOSE WHO USE ALCOHOL AND ILLICIT SUBSTANCES FROM THE DANGERS OF USING. INDIVIDUALS CAN ACCESS LIFE-SAVING SUPPLIES THROUGH THE EMERGENCY DEPARTMENT AND A CONFIDENTIAL TEXT LINE (DISCUSSED LATER). SUPPLIES INCLUDE NALOXONE (NARCAN), FENTANYL TEST STRIPS, SAFER USE KITS, SAFER SNORTING KITS, SAFER SEX KITS, MEDICATION LOCK BAGS, AND MEDICATION DISPOSAL BAGS.ERH IS A LEAD AGENCY IN DISTRIBUTING NALOXONE (NARCAN), A LIFE-SAVING MEDICATION USED TO REVIVE INDIVIDUALS FROM OPIOID OVERDOSE AND DISTRIBUTED 357 NARCAN KITS TO THE WAWARSING-ELLENVILLE AREA IN 2023. BEING THE FIRST ULSTER COUNTY ORGANIZATION TO LAUNCH VIRTUAL NARCAN TRAINING, ERH HAS IMPROVED AND EXPANDED ACCESS TO HARM REDUCTION SUPPLIES AMID A NATIONAL CRISIS. ELLENVILLE REGIONAL HOSPITAL ALSO CHAMPIONS EDUCATING THE PUBLIC ON PROPER MEDICATION DISPOSAL. IN 2023, ERH PROVIDED 1,000 MEDICATION DISPOSAL PACKETS TO COMMUNITY MEMBERS, ALLOWING FOR PROPER MEDICATION DISPOSAL IN THE PRIVACY OF ONE'S HOME. PART III, LINE 4: EFFECTIVE JANUARY 1, 2019, THE HOSPITAL ADOPTED NEW U.S. GAAP REVENUE RECOGNITION GUIDANCE ACCOUNTING STANDARD UPDATE. AS A RESULT, UPON THE HOSPITAL'S ADOPTION OF ASC 606, THE MAJORITY OF WHAT WAS PREVIOUSLY CLASSIFIED AS THE PROVISION FOR BAD DEBTS IN THE CONSOLIDATED STATEMENT OF OPERATIONS AND CHANGES IN NET ASSETS IS NOW REFLECTED AS IMPLICIT PRICE CONCESSIONS AND THEREFORE IS INCLUDED AS A REDUCTION TO PATIENT SERVICE REVENUE IN 2023. BAD DEBT EXPENSE IS $1,699,277. THE AMOUNT REPORTED IN PART III, SECTION B, LINE 2 IS BASED ON THE AMOUNTS OF PATIENT ACCOUNTS WRITTEN OFF DUE TO BAD DEBT. THE AMOUNT DOES NOT INCLUDE WRITE OFF DUE TO DISCOUNT OR ALLOWANCE. PART III, LINE 8: $19,629, WHICH IS 50% OF THE SURPLUS REPORTED ON PART III, SECTION B, LINE 7, PERTAINS TO PATIENTS THAT COULD HAVE QUALIFIED FOR FINANCIAL ASSISTANCE AND BE TREATED AS COMMUNITY BENEFIT.THE AMOUNT ON LINE 6 WAS DERIVED BY USING THE MEDICARE ALLOWABLE COSTS AS REPORTED ON THE HOSPITAL'S NYS INSTITUTIONAL COST REPORT AND OTHER APPLICABLE ADJUSTMENTS. PART III, LINE 9B: NO COLLECTION PROCESS IS UNDERTAKEN FOR KNOWN PATIENT WHO ARE ELIGIBLE FOR FINANCIAL ASSISTANCE. ONCE A PATIENT IS QUALIFIED OR DESIGNATED FOR FINANCIAL ASSISTANCE, STATEMENTS WILL STOP BEING SENT UNTIL A DETERMINATION IS MADE THAT THE PATIENT IS NOT ELIGIBLE FOR FINANCIAL ASSISTANCE. PART VI, LINE 2: ELLENVILLE REGIONAL HOSPITAL USES VARIOUS METHODS TO ASSESS THE COMMUNITY'S HEALTH NEEDS. ELLENVILLE REGIONAL HOSPITAL SEEKS THE VIEWS OF COMMUNITY MEMBERS TO GAIN THEIR THOUGHTS REGARDING THEIR COMMUNITY'S HEALTH CARE AND FEEDBACK REGARDING ERH SERVICES. THE BOARD OF TRUSTEES OF ERH IS COMPRISED OF ELEVEN MEMBERS; TEN ARE VERY VISIBLE IN THE COMMUNITY AND ARE A DIRECT LINK FOR PATIENTS TO THE HOSPITAL ADMINISTRATION. THE 10TH MEMBER IS THE CEO OF THE INSTITUTE FOR FAMILY HEALTH, THE LARGEST FEDERALLY QUALIFIED COMMUNITY HEALTH CENTER IN NY STATE. COMMUNITY FEEDBACK IS A TOPIC OF DISCUSSION AT MOST BOARD MEETINGS. THE PRESIDENT AND CEO OF ERH, STEVEN L. KELLEY, IS A PROMINENT COMMUNITY MEMBER. MR. KELLEY AND OTHER ADMINISTRATIVE TEAM MEMBERS BELONG TO NUMEROUS ORGANIZATIONS, SERVE ON OTHER NOT-FOR-PROFIT BOARDS, AND ARE ACTIVE PARTICIPANTS. ALL CLINICAL DEPARTMENTS DO PATIENT SATISFACTION QUESTIONNAIRES. THESE QUESTIONNAIRES PROVIDE VALUABLE FEEDBACK FROM THE POPULATION THAT UTILIZES THE HOSPITAL SERVICES. IN ADDITION, STATISTICAL DATA FROM STATE AND COUNTY DATABASES ARE CONTINUALLY ANALYZED, LOOKING FOR TRENDS AND CHANGES IN THE DEMOGRAPHIC MAKEUP OF OUR PATIENTS. IN ADDITION, THE ERRHN OFTEN UTILIZES COMMUNITY SURVEYS AND HOSTS COMMUNITY FORUMS TO GATHER MORE INFORMATION ON THE HEALTH TOPICS THAT THE COMMUNITY FEELS ARE PERTINENT. THESE FORUMS HAVE BEEN THE BASIS FOR CHANGES TO THE POPULATION HEALTH PROGRAM.ERH CONTINUES TO SUPPORT THE FOUR PILLARS OF HEALTH PROVIDING SERVICES TO THE MEMBERS AT NO COST. WE ALSO MONITOR THE TOP TEN INPATIENT DIAGNOSES ANNUALLY TO PLAN OUR SERVICES AROUND THE DISEASES MOST PREVALENT IN OUR LOCAL COMMUNITY. ERH WORKS CLOSELY WITH AN FQHC ON OUR CAMPUS. THE CEOS OF ERH AND FQHC PARTICIPATE ON THE BOARD OF DIRECTORS FOR BOTH ORGANIZATIONS. THIS COLLABORATIVE WORKING ARRANGEMENT HAS BEEN INVALUABLE IN ASSESSING THE NEEDS OF THE MEDICAL PROVIDERS AND THE PATIENTS IN THE COMMUNITY. PART VI, LINE 3: BY ITS EXEMPTION FROM FEDERAL AND STATE TAXES AND AS PART OF THE HOSPITAL'S MISSION TO SERVE THE COMMUNITY'S HEALTHCARE NEEDS, ERH PROVIDES CARE TO ALL PATIENTS IN NEED WITHOUT REGARD FOR THEIR ABILITY TO PAY. ELLENVILLE REGIONAL HOSPITAL (ERH) INFORMS ITS PATIENTS OF THE AVAILABILITY OF FINANCIAL ASSISTANCE IN SEVERAL WAYS. SIGNS ARE POSTED IN REGISTRATION, AND INFORMATION ON FINANCIAL AID IS LOCATED ON OUR WEBSITE. THESE SIGNS DIRECT THE PATIENTS TO SPEAK WITH DESIGNATED PATIENT FINANCIAL SERVICES REPRESENTATIVES. ALL PATIENTS WITHOUT INSURANCE ARE GIVEN A PACKET THAT INCLUDES A CHARITY CARE APPLICATION AND IS AVAILABLE UPON REQUEST BY THE PATIENT AND ON OUR WEBSITE. PATIENT STATEMENTS ALSO INCLUDE CONTACT INFORMATION REGARDING FINANCIAL ASSISTANCE. IN ADDITION, THE REGISTRATION STAFF DIRECTS PATIENTS TO A DESIGNATED PATIENT FINANCIAL SERVICES REPRESENTATIVE FOR MEDICAID APPLICATIONS.HTTPS://ERHNY.ORG/PATIENT-GUESTS/FINANCIAL-ASSISTANCE-PROGRAM/ PART VI, LINE 4: ELLENVILLE REGIONAL HOSPITAL (ERH), A 25-BED CRITICAL ACCESS HOSPITAL BUILT IN 1964(-1966), IS LOCATED IN THE TOWN OF WAWARSING, IN ULSTER COUNTY. ERH IS A NON-PROFIT SOLE PROVIDER HOSPITAL FOR ELLENVILLE AND ITS SURROUNDING COMMUNITIES LOCATED BETWEEN SHAWANGUNK RIDGE AND THE CATSKILL MOUNTAIN RANGE. THE ERH SERVICE AREA, DEFINED AS THE TOP TEN ZIP CODES OF PATIENT RESIDENCY TO WHICH ERH PROVIDES CLINICAL SERVICES EACH YEAR, HAS A POPULATION OF 28,000. THESE ZIP CODES COVER TOWNS AND VILLAGES IN ULSTER COUNTY AND INTO PARTS OF SULLIVAN AND ORANGE COUNTIES, INCLUDING ELLENVILLE, KERHONKSON, NAPANOCH, ACCORD, PINE BUSH, WAWARSING, GRAHAMSVILLE, SUNDOWN, DENNING, WOODBOURNE, WOODRIDGE, WURTSBORO, WURTSBORO HILLS, PHILLIPSPORT, SUMMITVILLE, HAVEN, AND YANKEE LAKE. ERH IS GEOGRAPHICALLY ISOLATED, WITH ITS POPULATION CENTER CONSISTING OF A 37% NON-WHITE POPULATION AND A 20% BELOW-POVERTY LEVEL, ACCORDING TO THE US CENSUS BUREAU. THE NEAREST HOSPITAL IS OVER 25 MILES AWAY ON PRIMARILY SECONDARY ROADS, AND DUE TO THE RURAL GEOGRAPHICAL ISOLATION, ERH SERVES A CRUCIAL NEED FOR THE COMMUNITY. IN 2023, THE EMERGENCY DEPARTMENT (ED) PATIENT VOLUME AT ELLENVILLE REGIONAL HOSPITAL (ERH) WAS 14,543. IN 2023, THE HOSPITAL SERVED 12,096 UNIQUE PATIENTS WHO MADE 34,821 VISITS. IT IS ALSO A TEACHING HOSPITAL WITH EDUCATIONAL PROGRAMS FOR MEDICAL RESIDENTS, MEDICAL STUDENTS, PHARMACISTS, PHYSICAL THERAPISTS, PHYSICAL THERAPY ASSISTANTS, OCCUPATIONAL THERAPISTS, OCCUPATIONAL THERAPY ASSISTANTS, RADIOLOGICAL TECHNICIANS, NURSE PRACTITIONERS, REGISTERED NURSES, PHYSICIAN ASSISTANTS, PHLEBOTOMISTS, HIGH SCHOOL NEW VISION STUDENTS AND MORE.ERH WAS GRANTED CRITICAL ACCESS HOSPITAL (CAH) STATUS IN 2004 AND HAD 25 INPATIENT BEDS. THESE BEDS CAN BE USED FOR ACUTE CARE OR SWING BUT MAY NOT EXCEED 25. THE RULING IS SIGNIFICANT SINCE THE HOSPITAL IS LOCATED IN A FEDERALLY DESIGNATED HEALTH PROFESSIONAL SHORTAGE AREA (HPSA) AND MEDICALLY UNDERSERVED AREA (MUA). THERE WOULD BE A SUBSTANTIAL PROBLEM WITH UNINSURED AND UNDERINSURED HAVING ACCESS TO QUALITY HEALTHCARE WITHOUT ERH.THE TOWN OF WAWARSING IS LOCATED WITHIN ULSTER COUNTY IN THE MID-HUDSON VALLEY, APPROXIMATELY 90 MILES NORTHWEST OF NEW YORK CITY. THE TOWN OF WAWARSING, A RURAL TOWN DESIGNATED AS HAVING A MEDICALLY UNDER-SERVED POPULATION (MUP ID# 07223), HAS A POPULATION OF APPROXIMATELY 13,004, OF WHICH 4,097 RESIDE WITHIN THE VILLAGE OF ELLENVILLE, THE LARGEST POPULATION CENTER IN THE TOWN (ACS 2018). THE TOWN INCLUDES 11,091 HOUSEHOLDS AND 2,946 FAMILIES.CENSUS DATA INDICATES THAT OF THE WAWARSING POPULATION, 69.8% IDENTIFY AS WHITE, 9.9% IDENTIFY AS BLACK, 2.3% AS ASIAN, 0.5% AS NATIVE AMERICAN (OR ALASKAN NATIVE) AND 9.7% IDENTIFY AS TWO OR MORE RACES; WITH 22.6% OF RESIDENTS IDENTIFYING AS LATINX, AND 14% OF INDIVIDUALS SPEAKING SPANISH AT HOME. THE MEDIAN AGE IS 41.5 YEARS IN WAWARSING, WITH 37% OF ADULTS OVER 50.CHILDREN <18 ARE 18.8% OF THE POPULATION, 18-64 ARE 66%, AND FEMALES OF ALL AGES ACCOUNT FOR 44% OF THE POPULATION. IN THE TOWN OF WAWARSING, 17.9% OF INDIVIDUALS LIVE BELOW THE POVERTY LINE, INCLUDING 23% OF CHILDREN UNDER 18. ELLENVILLE CENTRAL SCHOOL DISTRICT HAD 1,516 STUDENTS ENROLLED FOR THE 2019-20 SCHOOL YEAR, 71% ECONOMICALLY DISADVANTAGED. ROUGHLY 16% OF RESIDENTS HAVE LESS THAN A HIGH SCHOOL EDUCATION.THE UNEMPLOYMENT RATE FOR THE CIVILIAN LABOR FORCE IN WAWARSING IS 9.6%, WITH A SIGNIFICANTLY HIGHER UNEMPLOYMENT RATE FOR INDIVIDUALS 20-24 (32%) AND A SUBSTANTIALLY LOWER RATE FOR INDIVIDUALS 25-29 YEARS OLD (1.9%). IN THE TOWN OF WAWARSING, 17.9% OF INDIVIDUALS LIVE BELOW THE POVERTY LINE, INCLUDING 23% OF CHILDREN UNDER 18 AND 18.8% OF SENIORS. 47.9% OF INDIVIDUALS BELOW THE POVERTY LEVEL DID NOT WORK IN THE PAST 12 MONTHS. 83.8% OF THE POPULATION HAS A HIGH SCHOOL DIPLOMA (OR EQUIVALENT). HOWEVER, RATES DIFFER SIGNIFICANTLY FOR MALES AND FEMALES, WITH ONLY 3% OF 25+ FEMALES HAVING LESS THAN A HIGH SCHOOL DIPLOMA BUT 18% OF 25+ MALES HAVING LESS THAN A HIGH SCHOOL DIPLOMA. 18.2% OF THE POPULATION HAS A BACHELOR'S DEGREE OR HIGHER.WAWARSING HAS A TOTAL OF 6,299 HOUSING UNITS, 65% OF WHICH ARE SINGLE UNITS, 71.9% OF WHICH ARE OCCUPIED, AND 28.1% VACANT. OF THE 4,530 OCCUPIED HOUSEHOLDS, 60% ARE DEFINED AS 'FAMILY HOUSEHOLDS' (2,719); 29.1% (1,319) HAVE RELATED CHILDREN UNDER 18 YEARS OLD, AND 9.3% (421) ARE SINGLE FEMALES WITH CHILD(REN) HOUSEHOLDS. ABOUT 44% OF THE POPULATION IS MARRIED. THE AVERAGE HOUSEHOLD SIZE WAS 2.4, AND THE AVERAGE FAMILY SIZE 2.96.IN THE VILLAGE OF ELLENVILLE, THE LARGEST POPULATION CENTER (4,000) IN THE TOWN OF WAWARSING, THE MEDIAN AGE IS 37 YEARS, WITH 41.5% OF THE POPULATION UNDER 25. THE POPULATION IS 52% MALE. ETHNIC AND RACIAL DEMOGRAPHICS INCLUDE 58.4% WHITE, 7.9% BLACK, AND 4% TWO OR MORE RACES, WITH 29.4% OF THE POPULATION IDENTIFYING AS LATINO. JUST OVER 16% OF THE POPULATION SPEAKS A LANGUAGE OTHER THAN ENGLISH AT HOME, PREDOMINANTLY SPANISH. ACCORDING TO THE 2010 CENSUS, THERE WERE 4,135 PEOPLE IN THE VILLAGE OF ELLENVILLE, INDICATING THE POPULATION HAS CONTINUED TO DECREASE.OVER 12% OF RESIDENTS IN THE VILLAGE ARE UNEMPLOYED, AND ROUGHLY 18% HAVE LESS THAN A HIGH SCHOOL EDUCATION. THE UNEMPLOYMENT RATE FOR INDIVIDUALS 30-34 IS HIGHER THAN THE VILLAGE RATE, AT 21.2%. THE RATE IS EVEN HIGHER FOR INDIVIDUALS WITHOUT A HIGH SCHOOL DEGREE, AT 25.5%. VETERANS REPRESENT 3.4% OF THE POPULATION. IN THE 12428 ZIP CODE AREA, INCLUDING THE VILLAGE OF ELLENVILLE, OVER 40% OF RESIDENTS ARE LOW-INCOME, MORE THAN 18.9% LIVE BELOW THE POVERTY LINE, 24% OF CHILDREN LIVE IN POVERTY, AND 37% OF SENIORS LIVE IN POVERTY.IN THE 2017 ACS 5-YEAR ESTIMATES, 1,841 HOUSEHOLDS IN THE VILLAGE, 53% OF WHICH ARE SINGLE UNITS, AND 85.1% (1,566) OF WHICH ARE OCCUPIED. 39.9% OF HOMEOWNERS AND 54.3% OF RENTERS HAVE MONTHLY HOUSING COSTS THAT EXCEED 35% OF THE HOUSEHOLD INCOME. OF OCCUPIED UNITS, 63% ARE CONSIDERED 'FAMILY HOUSEHOLDS (50% OF WHICH ARE ESTIMATED TO BE SINGLE-PARENT HOUSEHOLDS), AND 21.9% OF OCCUPIED UNITS WERE DEFINED AS FEMALE HOUSEHOLDERS WITH NO MALE PRESENT. ABOUT 50% OF THE POPULATION IS MARRIED. OF OCCUPIED UNITS, 29.1 % HAD RELATED CHILDREN UNDER 18 LIVING WITH THEM, AND 24.8% OF HOUSEHOLDS HAD INDIVIDUALS AGED 65 OR OLDER: AVERAGE HOUSEHOLD SIZE 2.6 AND AVERAGE FAMILY SIZE 3.4.ERH'S CATCHMENT AREA INCLUDES A SUBSTANTIAL IMPOVERISHED POPULATION. FOR EXAMPLE, ELLENVILLE AND WAWARSING HAVE MEDIAN HOUSEHOLD INCOMES (TOWN $46,889 AND VILLAGE $45,531) THAT ARE SUBSTANTIALLY LOWER THAN (ABOUT THREE-QUARTERS) THE ULSTER COUNTY MEDIAN HOUSEHOLD INCOME OF $61,652 AND THE NYS MEDIAN HOUSEHOLD INCOME OF $62,765 (ACS 2017).IT IS ESSENTIAL TO NOTE THE ELLENVILLE FAMILY HEALTH CENTER (IFH), A PRIMARY CARE HEALTH CENTER OPERATED BY THE INSTITUTE FOR FAMILY HEALTH, IS ONE OF THE LARGEST FEDERALLY QUALIFIED HEALTH CENTERS (FQHC) IN NEW YORK STATE. THE FQHC IS ALSO LOCATED ON THE ERH CAMPUS. THE INSTITUTE IS COMMITTED TO PROVIDING HIGH-QUALITY, AFFORDABLE HEALTH CARE FOR ALL. IT STRIVES FOR EXCELLENCE AT ITS 26 PRACTICES WHILE ACCEPTING ALL PATIENTS REGARDLESS OF THEIR ABILITY TO PAY. THE ELLENVILLE IFH OFFERS PRIMARY CARE, MENTAL HEALTH CARE, DENTAL, AND SOCIAL WORK SERVICES, ALONG WITH MANY OTHER HEALTH SERVICES FOR PATIENTS OF ALL AGES. AS PART OF A FEDERALLY QUALIFIED COMMUNITY HEALTH CENTER NETWORK, IT MEETS NATIONAL STANDARDS FOR AFFORDABLE, ACCESSIBLE, AND COMPREHENSIVE HEALTH CARE SERVICES. THE CENTER IS ACCREDITED BY THE JOINT COMMISSION AND RECOGNIZED BY THE NATIONAL COMMITTEE FOR QUALITY ASSURANCE AS A LEVEL 3 PATIENT-CENTERED MEDICAL HOME; THE HIGHEST RECOGNITION AVAILABLE. THE IFH SEES APPROXIMATELY 3,600 PATIENTS PER YEAR AND OFFERS SAME-DAY APPOINTMENTS. ACCORDING TO THE INSTITUTE OF FAMILY HEALTH, A FEDERALLY QUALIFIED HEALTHCARE CENTER'S ELLENVILLE SITE DATA, NEARLY 59% OF HEALTH CENTER PATIENTS RESIDING IN THE 12428 ZIP CODE RECEIVE MEDICAID OR OTHER PUBLIC INSURANCE, AND 7.6% ARE UNINSURED. FURTHERMORE, ROUGHLY 10% OF ADULTS IN THE ZIP CODE HAVE NO USUAL SOURCE OF CARE. THE SAME PERCENTAGE OF ADULTS HAVE DELAYED OR NOT SOUGHT CARE DUE TO HIGH COSTS.WAWARSING AND THE VILLAGE OF ELLENVILLE WERE PREVIOUSLY HOME TO SEVERAL MANUFACTURING BUSINESSES, INCLUDING IMPERIAL SCHRADE AND HYDRO ALUMINUM, WHICH EMPLOYED MANY RESIDENTS. THE SURROUNDING AREA ALSO BOASTED SEVERAL LARGE RESORT HOTELS. DUE TO THESE BUSINESSES CLOSING THEIR DOORS AND A SIGNIFICANT DECLINE IN THE AREA'S TOURIST INDUSTRY, THE ELLENVILLE COMMUNITY HAS LOST OVER 2,000 JOBS SINCE THE 1990S. THE TOWN AND VILLAGE STRUGGLE WITH THE ISSUES THAT ACCOMPANY POVERTY AND UNEMPLOYMENT IN RURAL AREAS. OVER 12% OF RESIDENTS IN THE VILLAGE ARE UNEMPLOYED. MAJOR EMPLOYERS SUPPORTING THE REGION'S RESIDENTS ARE THE NYS DEPARTMENT OF CORRECTIONS, ELLENVILLE CENTRAL SCHOOL DISTRICT, AND ELLENVILLE REGIONAL HOSPITAL. PART VI, LINE 7, REPORTS FILED WITH STATES NY PART VI, LINE 4, CONTINUATION: AN AFFORDABLE SENIOR HOUSING PROJECT, A JOINT VENTURE BETWEEN THE HOSPITAL AND WARWICK PROPERTIES, INC., IS LOCATED ON THE ELLENVILLE REGIONAL HOSPITAL CAMPUS. ALL THREE PHASES OF THE PROJECT REMAIN FULLY OCCUPIED, WITH APPROXIMATELY 156 SENIOR CITIZENS LIVING INDEPENDENTLY IN ONE-BEDROOM APARTMENTS. THE PROJECT COLLABORATORS SECURED FUNDING FOR THE COMPLEX FROM THE NEW YORK STATE DIVISION OF HOUSING'S COMMUNITY RENEWAL HOUSING TRUST FUND. THE PARTNERSHIP SPONSORING THE HOUSING PROJECT IS DEVELOPING PLANS TO BUILD ADDITIONAL AFFORDABLE HOUSING CLOSE TO THE HOSPITAL, TARGETING SENIORS, SPECIAL NEEDS POPULATIONS, AND POSSIBLY RETURNING VETS. X X X X 0 0 0 0 0 0 0 1 0 STEVEN KELLEY PRESIDENT & CEO 366295 0 140000 0 8388 0 22500 0 0 0 537183 0 140000 0 BOB RUE CFO 180657 0 44000 0 13438 0 10198 0 31138 0 279431 0 0 0 ASHIMA BUTLER COO 189769 0 44000 0 15714 0 10022 0 3908 0 263413 0 0 0 MARIE BROWN REGISTERED NURSE 174941 0 11925 0 50 0 0 0 40571 0 227487 0 0 0 MARIA GONZALEZ CHIEF NURSING OFFICER 132728 0 15000 0 648 0 7176 0 31457 0 187009 0 0 0 THERESA AVERSANO DIRECTOR PHYSICAL MEDICINE & REHAB 131430 0 9200 0 171 0 0 0 31473 0 172274 0 0 0 PART I, LINE 7 EMPLOYEES OF THE ORGANIZATION RECEIVED A BOARD-APPROVED DISCRETIONARY BONUS, AWARDED BASED ON PERFORMANCE, AS REPORTED FOR THEM IN PART II, COLUMN B(II). PART II, COLUMN B(II) THE AMOUNT REPORTED FOR STEVEN L. KELLY IN PART II, COLUMN B(II), BONUS AND INCENTIVE COMPENSATION, WAS ALSO REPORTED ON THE 2022 FORM 990 IN PART II, COLUMN C, AS OTHER DEFERRED COMPENSATION. THE AMOUNT REPRESENTS BONUS EARNED IN 2022 AND PAID IN 2023. FORM 990, PART VI, SECTION B, LINE 11B WESTCHESTER-ELLENVILLE REGIONAL HOSPITAL, INC. HAS ITS FORM 990 PREPARED BY AN OUTSIDE ACCOUNTING FIRM. THE ACCOUNTING DEPARTMENT LEADERSHIP AND HOSPITAL ADMINISTRATORS CREATE AND/OR REVIEW REQUIRED FILING MATERIAL FOR YEARLY REPORTING. ACCOUNTING DEPARTMENT LEADERSHIP SUBMITS TO INDEPENDENT AUDITORS FILING MATERIAL TO CREATE A DRAFT 990 WHICH IS RETURNED FOR CORPORATE REVIEW. A SECOND REVIEW IS CONDUCTED BY ACCOUNTING DEPARTMENT LEADERSHIP AND HOSPITAL ADMINISTRATORS FOR ACCURACY. THEN ELECTRONIC OR HAND DELIVERED COPIES OF THE DRAFT 990 ARE PRESENTED TO THE BOARD MEMBERS OF THE ORGANIZATION FOR COMMENT. ANY COMMENTS ARE THEN GROUPED, SUMMARIZED, AND REPORTED TO THE INDEPENDENT AUDITORS FOR APPROPRIATE CHANGES. INDEPENDENT AUDITORS MAKE CHANGES SEND FINAL 990 FOR ONE LAST INTERNAL REVIEW AND APPROVAL FOR FILING. FORM 990, PART VI, SECTION B, LINE 12C THE CONFLICT OF INTEREST POLICY APPLIES TO THE FOLLOWING "PERSONNEL" OF THE HOSPITAL: MEMBERS OF THE BOARD OF TRUSTEES, OFFICERS, "SENIOR MANAGEMENT" (DEFINED TO BE THE PRESIDENT AND CHIEF EXECUTIVE OFFICER, SENIOR VICE PRESIDENTS AND VICE PRESIDENTS), ASSISTANT VICE PRESIDENTS, DEPARTMENT HEADS, AND OTHER EMPLOYEES (INCLUDING PHYSICIANS) WHO ARE IN A POSITION TO INFLUENCE ANY SUBSTANTIVE BUSINESS DECISION BETWEEN THE HOSPITAL AND A VENDOR. A DISCLOSURE STATEMENT MUST BE COMPLETED ANNUALLY BY THE APPLICABLE PERSONNEL STATING IF THEY ARE AWARE OF ANY ACTUAL OR POTENTIAL CONFLICTS. IF DURING THE YEAR, ANY MEMBER OF THE BOARD OF TRUSTEES, MEDICAL STAFF MEMBER OR EMPLOYEE BECOMES AWARE OF A CONFLICT, THEY PROMPTLY DISCLOSE IN WRITING TO THE ADMINISTRATOR OR PRESIDENT OF THE BOARD OF TRUSTEES ANY ACTUAL OR CONTEMPLATED TRANSACTION WHICH POSES A CONFLICT OF INTEREST. THE REPORT CONTAINS A STATEMENT OF ALL MATERIAL FACTS AS TO THE RELATIONSHIP OR INTEREST WHICH CREATES THE POSSIBLE CONFLICT OF INTEREST. THE DISCLOSURE OF ANY ACTUAL OR POTENTIAL CONFLICT OF INTEREST IS CONSIDERED BY THE BOARD OF TRUSTEES, WHICH DETERMINES WHETHER THE ACTUAL OR POTENTIAL CONFLICT OF INTEREST WILL HAVE AN ADVERSE EFFECT ON THE FACILITY. THE BOARD OF TRUSTEES CAUSES NOTICE TO BE GIVEN TO THE DISCLOSING PERSON, IN WRITING, OF THE DETERMINATION AND WHETHER THE SITUATION IS ALLOWED TO CONTINUE OR SHOULD BE TERMINATED, AND OF ANY OTHER ACTION THAT WILL BE TAKEN BY THE BOARD OF TRUSTEES OR SHOULD BE TAKEN BY THE BOARD MEMBER, MEDICAL STAFF MEMBER OR EMPLOYEE. FORM 990, PART VI, SECTION B, LINE 15 THE COMPENSATION COMMITTEE IS PROVIDED AN INDEPENDENT REPORT OF COMPARABLE HOSPITAL SALARY FOR THE CEO, INCLUDING FORM 990S OF SIMILAR SIZED ORGANIZATIONS. THE COMPENSATION COMMITTEE ALSO REVIEWS VARIOUS PERFORMANCE MEASURES AND OTHER INFORMATION AND ARRIVES AT A SALARY AND BENEFIT PACKAGE FOR THE CEO. THE COMPENSATION COMMITTEE APPROVES AND DECIDES THE COMPENSATION FOR CEO IN THE EXECUTIVE SESSION. THIS PROCESS WAS LAST UNDERTAKEN IN 2020 TO REVIEW CONTRACT'S COMPENSATION THROUGH 12/31/23. CONTEMPORANEOUS SUBSTANTIATION OF THESE DELIBERATIONS AND DECISIONS ARE ACCOMPLISHED THROUGH MINUTES OF THE COMMITTEE'S MEETINGS. THE DIRECTOR OF HUMAN RESOURCES OBTAINS SALARY INFORMATION FROM AN INDEPENDENT SOURCE OF LOCAL COMPARABLE HOSPITALS FOR EACH HIGHER-LEVEL POSITION AT THE HOSPITAL. THE INDEPENDENT INFORMATION CONTAINS SALARY LEVELS FOR EACH POSITION AT THE 25TH, 50TH, AND 75TH PERCENTILE. THE CEO THEN CONSIDERS THIS INFORMATION AND THE PERFORMANCE FOR EACH OF THESE EMPLOYEES AND DETERMINES THE APPROPRIATE SALARY LEVEL FOR OTHER OFFICERS AND KEY EMPLOYEE. THE SALARY INFORMATION IS THEN PRESENTED TO THE BOARD CHAIR FOR APPROVAL. THIS PROCESS WAS LAST UNDERTAKEN IN 2023. CONTEMPORANEOUS SUBSTANTIATION OF THESE DELIBERATIONS AND DECISIONS ARE DOCUMENTED IN THE FINANCE DEPARTMENT RECORDS. FORM 990, PART VI, SECTION C, LINE 19 THE ORGANIZATION MAKES ITS FORM 990 AND FORM 1023 AVAILABLE FOR PUBLIC INSPECTION AS REQUIRED UNDER SECTION 6104 OF THE INTERNAL REVENUE CODE. THE RETURN IS POSTED ON GUIDESTAR.ORG AND OTHER SIMILAR TYPES OF WEBSITES. IN ADDITION, THE FINANCIAL STATEMENTS, CONFLICT OF INTEREST POLICY, ARTICLES OF INCORPORATION, FORM 990, FORM 1023, AND BY-LAWS ARE ALSO AVAILABLE UPON WRITTEN REQUEST OR BY CALLING THE ORGANIZATION DIRECTLY. FORM 990, PART XI, LINE 9: CHANGE IN INTEREST IN NET ASSETS OF ELLENVILLE REGIONAL HOSPITAL FOUNDATION 360,611. CHANGE IN EQUITY INVESTMENT IN ELLENVILLE REGIONAL FAMILY HEALTH PROPERTIES -8,554. LOSS ON DISPOSAL OF FIXED ASSETS -800,278. FORM 990, PART XII, LINE 2C: THE ORGANIZATION HAS A COMMITTEE THAT ASSUMES RESPONSIBILITY FOR OVERSIGHT OF THE AUDIT OF ITS FINANCIAL STATEMENTS AND SELECTION OF AN INDEPENDENT ACCOUNTANT. THIS PROCESS DID NOT CHANGE FROM THE PRIOR YEAR. ELLENVILLE REGIONAL HOSPITAL FOUNDATION INC 10 HEALTHY WAY ELLENVILLE NY 124285612 371562427 FUNDRAISING FOR WESTCHESTER-ELLENVILLE HOSPITAL, INC. NY 501(C)(3) LINE 7 WESTCHESTER-ELLENVILLE HOSPITAL INC 1 ELLENVILLE REGIONAL SENIOR HOUSING DEVELOPMENT FUND COMPANY INC 10 HEALTHY WAY ELLENVILLE NY 124285612 261411484 LOW INCOME HOUSING (INACTIVE) NY WESTCHESTER-ELLENVILLE REGIONAL HOSPITAL INC C 1.00000 1 ELLENVILLE II REGIONAL SENIOR HOUSING DEVELOPMENT FUND COMPANY INC 10 HEALTHY WAY ELLENVILLE NY 124285612 270754224 LOW INCOME HOUSING (INACTIVE) NY WESTCHESTER-ELLENVILLE REGIONAL HOSPITAL INC C 1.00000 1 ELLENVILLE III REGIONAL SENIOR HOUSING DEVELOPMENT FUND COMPANY INC 10 HEALTHY WAY ELLENVILLE NY 124285612 300649484 LOW INCOME HOUSING (INACTIVE) NY WESTCHESTER-ELLENVILLE REGIONAL HOSPITAL INC C 1.00000 1 0 0 0 0 0 0 0 0 0 0 0 0 0 1 1 0 0 0 0