4A (Expenses $ 1581716920 including grants of $ 11425400) (Revenue $ 1753721249)
"CLINICAL CARE: In 2022, we opened the Hale Family Building, our new clinical tower, strengthening our ability strengthening our commitment by enabling enhanced, more efficient care for the benefit of patients, families, and the teams who deliver and support that care. We continue to work to renovate our existing inpatient campus, aiming for completion by 2029.The services we offer from well child visits and treatment for typical child health issues (broken bones, tonsillitis, etc.) to chronic care (asthma, diabetes, obesity, etc.) and specialty services (oncology, cardiology, neurology) benefit from our clinicians' high level of specialization, our collaboration with research scientists (many of whom are also physicians) affiliated with the hospital, and our significant investments in equipment, facilities and clinical and support staff. We also offer the only pediatrics Department of Addiction Medicine in the U.S., as well as the only Orthopedic Sports Medicine program located at a children's hospital. We also offer the largest programs in Pediatric Anesthesiology, Pediatric Cardiology, and Pediatric Critical Care, in the nation. Boston Children's is the safety net institution for very sick children throughout the region, supporting the entire health care system for the most complex pediatric cases. We receive referrals from community hospitals as well as from other academic medical centers throughout New England. Approximately 25% of our inpatients are transferred from hospitals & medical centers across Massachusetts for care that no one else can provide. In FY22, Boston Children's saw approximately 1.2 million outpatient visits, 48,000 emergency department visits, 22,000 inpatient or observation stays, and 26,000 inpatient or day surgeries. Our inpatient case mix index was 1.72 (MA only) and the average length of stay was 5.91 days. Of the bedded cases, more than 19.1% (CMI > 2.00) can be qualified as clinically complex. Of these patients, approximately 35% (patients on Medicaid/Medicare) are considered low income.Our Medicaid ACO provides primary care to 20% of the children covered by Medicaid in the state. The ability to support the health-related social needs of patients and families via the ACO complements the work that we are doing in communities to address the more systemic social determinants of health. We are able to address ""downstream"" immediate needs of children and families, but also to work with communities and partners to affect the ""upstream"" factors that drive poorer health outcomes for so many. This includes a focus on policy that can impact the health. We remain committed to advancing health equity through our Sandra L. Fenwick Institute for Pediatric Health Equity and Inclusion. Through the Institute's works, we seek to transform pediatrics by addressing persistent disparities in the delivery of care to our nation's children. In 2022, with Tufts's decision to close their pediatric inpatient beds, and urgent unmet pediatric need in behavioral health, we agreed to partner with both Franciscans and Tufts Medicine to strengthen the care continuum in Boston and beyond. We also partnered with PM Pediatrics, a national provider of urgent care, to support ED alternatives. We continue to extend our virtual care offerings to our local providers, so that we can help to keep care with local pediatricians and community hospitals whenever possibleIncreasingly, we have been able to care for and improve life and health outcomes for medically complex children, many with conditions such as congenital heart conditions, childhood cancers & complex neurological and neurosurgical conditions. Our capabilities are accelerating rapidly as we develop new clinical & surgical approaches including gene therapies, stem cell transplant procedures, fetal surgical interventions, and the like.Boston Children's is at the absolute forefront nationally in these & many other areas. As a result, we have seen significant growth in the number of complex patients served patients who stay longer, require more resources (such as intensive care unit-level care), use a broader range of interdisciplinary specialists, and frequently require substantial support for their whole family. Some of them travel great distances, but equally many are from here in Massachusetts.Boston Children's MA/Regional network consists of our satellite/physician office locations, formal primary care relationships with groups such as the PPOC and Atrius, community health center relationships and a broad array of relationships with other hospitals in MA and NE including community hospitals, academic medical centers and specialty hospitals. We maintain relationships of varying structures, shapes and sizes with nearly all of the major academic medical centers and specialty hospitals in MA and New England, from a single service agreement such as providing remote EEG interpretations to Elliot Hospital to staffing community hospitals 24/7 365 per year to our multi-faceted Brigham relationship and joint cancer program with Dana Farber. Our satellite/physician office locations and our community hospital relationships in eastern MA have been central to our commitment to increasing access to high quality pediatric services. Over the past 20+ years we have gradually grown our network of satellites/physician office locations and community hospital relationships providing a mix of neonatal, ED and inpatient services. Today, nearly 40% of our outpatient specialty visits and surgical cases take place in a Boson Children's satellite or physician office location. Our affiliated community hospitals account for nearly half of our MA community hospital transfers and 30% of all intra-hospital transfers. These community hospital relationships also generate important downstream referrals to our specialists including important neonatal referrals from the obstetrical programs at these community hospitals. As fewer community hospitals provide inpatient pediatric care, these hospitals are increasingly serving as regional pediatric hubs to help stem the tide of patients who have to be referred to Boston for community level care."

4B (Expenses $ 433338662 including grants of $ 0) (Revenue $ 0)
"RESEARCH: Our Research Mission is to be the leading source of research and discovery. We are the leader in discovery and innovation that is dramatically advancing not only pediatric care but adult care as well. We have the world's largest pediatric research program for many reasons. The most important reason is our focus on our patients. We are constantly evolving care, and caring for increasingly complex patients. Every child who walks through our doors teaches us something. In FY2022, Boston Children's was #1 in National Institutes of Health funding for all U.S. children's hospitals, and #4 in funding among all independent hospitals. More than 3,000 basic, clinical, and translational research employees work in our dedicated facilities, which total some 1 million square feet of space.Members of our research community include 12 members of the National Academy of Sciences, 21 members of the National Academy of Medicine, 25 Howard Hughes Medical Institute Investigators, and 8 Lasker Award recipients. In total, our research community publishes more peer-reviewed research in top scientific journals than the next 20 children's hospitals combined more than 3,000 annually since 2015.Our investigators are Harvard Medical School faculty basic scientists, clinical researchers and epidemiologistswho are accelerating the pace of medical discovery from brainstorm to bench to bedside. Our researchers were the first to develop 10 new disease-based stem cell lines by reprogramming adult stem cells that can be used to study treatments for diseases ranging from Parkinson's to Diabetes. Here are just a few research success stories from 2022- Our Gene Therapy Program, collaborating with the Leukodystrophy Clinic at Massachusetts General Hospital, infused first patient to receive gene therapy outside of a clinical trial for Cerebral adrenoleukodystrophy- Mapping symptoms of conditions like autism to hotspots in the brain could lead to treatment with noninvasive brain stimulation- Clinical trials started for first prosthetic pulmonary valve replacement specifically designed for pediatric patients that can expand over time (invented at Boston Children's)- Researchers identified proteins in urine that could help doctors diagnose and track a child's concussion- Genetic findings changed how we understand conditions ranging from sudden infant death syndrome to cerebral palsy to heart disease- Studies explored how to prevent ""chemo brain,"" an unfortunate side effect of chemotherapy on children's memory, attention, and learning- Surgical advances to make heart operations safer, like an improved system for controlling body temperature and tools to locate the vital tissues that control the beating of the heart so surgeons can operate safely around them"

4C (Expenses $ 41421355 including grants of $ 0) (Revenue $ 23734290)
"TEACHING: Boston Children's is committed to providing high quality continuing education for pediatric providers and specialists throughout the world. As the primary pediatric teaching affiliate of Harvard Medical School, our more than 2,000 attending physicians and researchers are on the clinical frontier of effectively understanding and treating many pediatric diseases and disorders.We are proud to be the primary teaching hospital of Harvard Medical School, and our Nursing Department partners with 27 schools of nursing throughout Massachusetts and New England. We are home to the largest and most competitive training program in pediatrics, seeding the word with the next generations of scientists, innovators and caregivers.We offer more than 70 Training Programs (44 are accredited - more than any other freestanding children's hospital). We host over 500 Boston Children's-based residents and clinical fellows annually, selected for their potential leadership in their respective fields and their commitment to advancing the frontiers of pediatric care. A 24-year analysis of residents who have graduated from our Department of Medicine found that roughly 40% go on to become leaders in academic medicine, filling positions such as deans, chairs and program heads across the country. More than one third of the chiefs of pediatric departments across the country trained at Boston Children's. Our simulation program, Immersive Design Systems, is the first hospital-based simulator program at a teaching hospital in New England. Our goal is to make ""practice prior to game time"" part of healthcare routine, offering a fully integrated quality assurance and improvement resource, preparation and testing environment for hospitals. Boston Children's offers the only training programs in New England for Adolescent Medicine, Congenital Cardiac Surgery, and Neurodevelopmental Disabilities; and the only training programs in Massachusetts for Adolescent Medicine, Congenital Cardiac Surgery, Neurodevelopmental Disabilities, Pediatric Cardiology, Pediatric Hematology/Oncology, Pediatric Nephrology, Pediatric Orthopedics, Pediatric Pathology, and Pediatric Surgery."

4D (Expenses $ 18990856 including grants of $ 0) (Revenue $ 0)
Community (Continued):Boston Children's is an effective advocate on legislative and regulatory matters, both at state and federal levels, that affect children's wellbeing such as increasing access to quality pediatric mental health programs, promoting better treatment and access to services for children with medical complexity and chronic conditions, improving the landscape for pediatric medical research and advancing innovative public health policies grounded in racial equity. Boston Children's advocacy history is rooted in the promotion of better insurance coverage for children, including major child health expansions in the 1990s, the passage of Massachusetts's 2006 health reform law, and significant national involvement in work to promote child health access through the Children's Health Insurance Program, Medicaid, and the Affordable Care Act. As a result, Massachusetts has achieved near universal health access for children, with only 1.5 percent of children uninsuredthe lowest rate in the country. Massachusetts has emphasized payment reform and cost containment policies within the health care system. Boston Children's played an active and vocal role in the development of the groundbreaking statewide payment reform legislation that was signed into law in August 2012. Nationally, Boston Children's engaged in efforts to preserve and improve Medicaid and the Children's Health Insurance Program, which serve as a safety net for children in all fifty states, ensuring their access to high-quality, effective coverage, and facilitates important quality measurement and improvement initiatives. We have also worked to ease the burdens on families in the Medicaid program who find it necessary to cross state lines for care.In 2006, Boston Children's (including its Boston Children's Hospital Neighborhood Partnerships Program for details see above) and a coalition of community organizations launched the Children's Mental Health Campaign (CMHC). The CMHC has converted its credibility and influence into several major policy accomplishments which have redefined the landscape of the children's mental health system in Massachusetts. In 2008, the CMHC was instrumental in securing passage of two landmark state laws. An Act Relative to Children's Mental Health (Chapter 321) creates a structure for enhancing early identification of behavioral health needs, treating children in the most appropriate settings, enhancing coordination among state health care agencies, and establishing mechanisms for oversight of and input into the state children's mental health system. Chapter 256 strengthened the state's mental health parity law by expanding the categories of disorders for which health insurance plans must provide mental health benefits. The CMHC is determined to hold key stakeholders accountable for implementing the new laws secured through its advocacy efforts. Current efforts at the state level address: access to behavioral health services, addressing the emergency room boarding crisis, improving mental health in schools, and creating a behavioral health urgent care system. At the federal level, Boston Children's is working with our peers to bolster the pediatric mental health workforce and ensure the availability of a full continuum of care for kids. Additionally, Boston Children's works in collaboration with a host of public health and prevention advocates to ensure public policies work to keep children safe and healthy. Boston Children's public health work includes social determinants of health and racial and social justice as an essential component. With this in mind, our priorities include closing the SNAP Gap, addressing issues in the housing market, and expanding the earned income tax credit. The hospital also lends expertise in efforts to reduce racial inequities in maternal and infant health, lead poisoning, and improve child passenger safety legislation. Boston Children's has established the over 4,000 member Children's Advocacy Network (CAN), a grassroots advocacy network that leverages the many voices of families, hospital staff, and community partners in support of child health. Since 2006, the hospital has trained hundreds of advocates through an in-depth training series that gives advocates a better understanding of the legislative process and the skills needed for effective advocacy. The CAN hosts monthly educational sessions, which offer hospital staff and community partners a monthly opportunity to learn about a current topic related to children's health policy and explore ways to advocate for children at the federal and state levels. Staff members from departments throughout the hospital regularly engage with the CAN to receive information about policy changes that may impact their patient population or schedule in-service presentations about current events in Washington and at the state level. During the COVID crisis, the CAN found creative solutions to keep advocates engaged including virtual advocacy briefings, webinars and trainings, as well as online event partnerships with the Offices of Health Equity and Community Health.

Boston Children's Hospital
Part V, Section B, Line 5: Boston Children's 2022 assessment used a participatory, collaborative approach and examined health in its broadest context. The assessment draws on data collected for the larger Boston Community Health Needs Assessment (CHNA) that includes data from the Massachusetts Department of Public Health, vital records, and surveillance systems. In Greater Boston, key informant interviews were conducted with 62 leaders across sectors including 8 interviews conducted by Boston Children's. In addition, there were 29 focus groups facilitated with residents including 6 focus groups with families and parents, and 8 focus groups with youth. To understand experiences and needs of those served by Boston Children's satellite clinics outside Boston, 9 interviews were conducted with community representatives from public health, health care, housing and homelessness, government, and social services sectors in Brookline, Lexington, North Dartmouth/New Bedford, and Peabody. Boston Children's also conducted a Community Health Survey, completed by 157 respondents, to inform the prioritization of community health needs.

Boston Children's Hospital
Part V, Section B, Line 7d: The complete Boston Children's Community Health Needs Assessment report is available on the hospital's website at www.childrenshospital.org/community-health/needs. In addition to the report, there is also an executive summary, data and slides on the findings, and the hospital's Community Health Improvement Plan. A recorded session is also available with a Boston Children's staff member providing an overview of the process and sharing the key findings.Boston Children's distributed the report to internal staff and to a list of key external community contacts by email.

Boston Children's Hospital
Part V, Section B, Line 11: Boston Children's addresses the health and social needs identified in the community health assessment process through our clinical care, services and programs and in collaboration with community partners. The Boston Children's Community Health Improvement Plan can be viewed at: www.childrenshospital.org/sites/default/files/2022-12/community-health-needs-2022-improvement-plan.pdfBelow is a summary of the goals and objectives.Goal 1. Promote mental health and emotional wellness by nurturing resilient communities and building equitable, accessible, and supportive systems of care. Objectives:Increase the number of diverse, culturally/linguistically competent licensed clinical behavioral health workers and community-based behavioral health caregivers.Provide services and supports, and identify resources to increase mental health and trauma services where children live and learn.Goal 2. Support safe, stable, healthy, equitable, affordable housing for children and families.Objectives:Make direct investments in housing stabilization and affordable housing production and work toward policy and systems changes that would decrease the number of low/moderate-income families with children who are homeless or housing insecure. Increase pathways to mobility for low-income families through approaches that build assets and facilitate homeownership. Goal 3. Promote healthy youth development through youth-centered programming and career pathways.Objectives:Foster personal development of youth through leadership skill-building, mentorship, interest exploration, and identity formation.Expand career pathways for youth through college, trades/training, and direct employment.Strengthen capacity of youth workforce.Goal 4. Increase access to affordable and nutritious food.Objectives:Provide culturally relevant food and nutrition education to children and families.Strengthen community infrastructure for healthy food.Goal 5. Improve early childhood education, health, and developmental supports.Objectives:Expand training and quality improvement supports for early education and care (EEC) community-based providers.Enhance engagement and skill building for parents and families with children birth to 5-years old through community programing.Advocate and collaborate to sustain and increase the amount of flexible, affordable, high quality child care for children birth to 5-years old.Goal 6. Improve the health of children and families managing asthma and obesity.Objectives: Implement community health programs that reduce the racial disparities in care and health outcomes for children with asthma and obesity.

Boston Children's Hospital
"Part V, Section B, Line 15e: The Financial Assistance Policy provides as follows:1. A Patient/Guarantor who is uninsured or who seeks financial assistance will be referred to a Hospital Financial Counselor for determination of availability of/eligibility for Private Health Plan coverage; for Public Health Care Assistance Programs; or for Hospital financial assistance programs. 2. Patients who do not qualify for Public Health Care Assistance Programs or Private Health Plan coverage, may apply for financial assistance by completing the Hospital's Financial Assistance Application and providing all information, documentation, and verification described in the Financial Assistance Application. The Financial Assistance Application is available for download on the Hospital's website and is also available by mail or in person. Details on how to access a copy of the Financial Assistance Application are found in the section of this Financial Assistance Policy entitled ""Publication/Availability of the Financial Assistance Policy, the Uninsured Patient Discount Policy, the Credit and Collection Policy, and Amounts Generally Billed Calculation."" The Financial Assistance Application includes accompanying instructions for completion.3. Under certain circumstances, the Hospital may deem a patient's enrollment in a means tested Public Health Care Assistance Program to presumptively confirm the patient's eligibility for financial assistance for any services for which financial assistance may be available under this Financial Assistance Policy.4. Information collected will be provided to a designated Director in Patient Financial Services for determination of availability of/eligibility for financial assistance under the terms of this Financial Assistance Policy.5. Patients/Guarantors who are approved to receive financial assistance will be notified in writing by Patient Financial Services staff.6. Eligibility determinations will remain in effect for a period of 12 months following the date of the determination, and will apply to all additional services for which financial assistance may be available under this Financial Assistance Policy, unless the Hospital determines that the patient has become enrolled in/qualified for Private Health Plan or coverage, or for a Public Health Care Assistance Program.7. Accounts will be adjusted with the financial assistance discount for both the applicable Foundation and Hospital. The discount will be applied against gross charges. 8. Patients/Guarantors can receive help with understanding the Financial Assistance Policy and completing the Financial Assistance Application by calling the Financial Counselors at (617) 355-7201 and/or by asking for help in person or by mail through the Financial Counseling Division of the Patient Financial Services Department at Boston Children's Hospital, 300 Longwood Avenue, Boston, MA, 02115, Farley Building rooms 160."

Boston Children's Hospital
Part V, Section B, Line 16j: Children's takes the following additional steps to make patients aware of the availability of financial assistance:- Posting of signage in all patient care admission areas of the availability of financial assistance,- All billing correspondence includes language regarding the availability of financial assistance,- The Hospital website provides contact information for Hospital Financial Counselors who can help assist patients with applying for programs to cover medical expenses.

Part V, Section B, Lines 16a-16c
The Hospital's FAP, FAP Application and plain language summary can be found at:https://www.childrenshospital.org/patient-resources/financial-and-billing-matters/credit-and-collection-policies

Part I, Line 3c:
Children's, based on its participation in the state of Massachusetts Health Safety Net, utilizes Federal Poverty Guidelines for determining eligibility for free care and discounted care to low income individuals. For purposes of discounted care, Children's offers discounts to individuals, regardless of income, who are uninsured and are ineligible for free care or other public programs.

Part I, Line 7:
Children's used an internal cost accounting system for purposes of reporting certain amounts on Part I, line 7. The system is designed to address all segments of patient care (inpatient, outpatient and emergency) and assigns costs to patients from all payer sources (Medicaid, Medicare, managed care, commercial, uninsured and self-pay). The cost of charity care was determined based on the overall relationship of hospital costs as a percentage of hospital charges, applied to charges that qualified as charity care.Children's provides charity care to all children in need who meet the hospital's charity care standards, which are in alignment with all state mandated regulations. Nearly 30% of children who receive their care at Children's are insured through Medicaid programs in a number of states including Massachusetts. In aggregate, Medicaid programs do not reimburse the hospital for the total costs of providing care to these children. Children's has a strong commitment to improving the health status of the children in our local community. Based on a tri-annual community needs assessment, Children's supports a variety of programs and partners both internal and external that are addressing the needs of Boston children. Children's has also identified four major health focus areas in which it concentrates its efforts. For children in Boston, asthma, mental health, obesity and child development are major concerns. Children's has community based programs in each of these issue areas. The hospital also has an Office of Child Advocacy that provides support to these programs.Children's is a leader in education and training for healthcare professionals.Children's subsidizes services that are either limited or unavailable in the broader community. Examples include psychiatry, primary care, and dental care.Recognizing that Children's does not have the capacity to meet all the needs of the children of Boston, it supports through financial contributions and in kind services) a large number of community based organizations who are providing these important services. Beneficiaries range from full service community health centers to Head Start programs for pre-school children.For more information, visit www.childrenshospital.org/community.

Part I, Line 7g:
Children's does not subsidize physician services; thus there are none reported in the dollar amount for subsidized health services.

Part I, Ln 7 Col(f):
The total bad debt expense of $34,733,044 is included in Form 990, Part IX, line 25 column (A), but subtracted for purposes of calculating the percentage in this column.

Part I, Line 6a:
Children's files an annual community benefits report with the Attorney General's Office (AG) in Massachusetts. There are significant differences between the AG and IRS requirements for reporting community benefits expenditures. The IRS counts the following as community benefits while the AG does not: Medicaid shortfalls, indirect costs, health professions education, and research funded by tax-exempt and government sources. Children's AG Report is publicly available and can be accessed directly on the AG's web site, www.mass.gov/AG and Children's web site, www.childrenshospital.org.

Part II, Community Building Activities:
In FY22, Children's reported two types of community building activities: $2,067,950 for 22 community support programs and $525,858 for community health improvement advocacy. Children's community building activities are designed specifically to address health disparities and improve the health of children, families and communities. According to public health literature (see Ambulatory Pediatrics and Health Affairs), initiatives that address disparities for children across four different levels: the individual, systemic, community and society can lead to meaningful improvements in health.As described in Form 990, Part III Program Service Accomplishments, Children's takes a multi-pronged approach to tackle the most pressing health issues facing Boston children. At the same time, Children's addresses non-health or social determinants of health issues such as violence, workforce development and education, which also impact a child's health. Therefore, Children's directs its community building activities in the following areas:- Children's public policy advocacy efforts help to improve access to health care for all individuals and ensure high-quality pediatric services.- As a major employer in Massachusetts and civic leader in Boston, Children's supports efforts to ensure a diverse and culturally competent health care workforce as well as promotes economic health in thesurrounding communities. - To improve life in local neighborhoods, Children's has targeted support towards community based organizations that do not focus specifically on health, but rather on the vibrancy of the community. Contributions to groups such as the Fenway Community Development Corporation and Sociedad Latina are as important as partnerships with community health centers. For more information, visit https://www.childrenshospital.org/community-health

Part III, Line 2:
Bad debt expense reflects patient charges that have been deemed uncollectible, converted to cost based on the ratio of patient care cost to charges from Worksheet 2.

Part III, Line 3:
There is not any amount of bad debt reflected as charity care, because it can't be quantified accurately at this time. However, some bad debts would be charity care.

Part III, Line 4:
Children's Medical Center and Subsidiaries' Audited Financial Statements does not contain any footnotes describing bad debt.

Part III, Line 8:
Medicare allowable costs are obtained directly from the Medicare Cost Report and are determined in accordance with Medicare principles of reimbursement.

Part VI, Line 2:
Boston Children's assesses the community needs on an ongoing basis through continuous dialogue with the community, participation on committees, working groups, and task forces, as well as input from Community Advisory Board and partners.For more information, visit www.childrenshospital.org/community-health/needs

Part VI, Line 7, Reports Filed With States
MA

Part III, Line 9b:
Children's makes reasonable and diligent efforts to collect each patient's insurance and other information and to verify coverage for health care services. Children's applies collection actions to all patients in the same manner, irrespective of their insurance status. Children's does not (and does not permit its agents to) engage in collection action of any kind, including billing, with respect to patients/guarantors that are exempt from collection action under Children's Credit and Collection Policy and under Massachusetts regulations governing the Health Safety Net program. All patients/guarantors who are not exempt from collection action are advised in all billing-related communications of the availability of free care and financial assistance, including assistance in applying for public programs and the availability of charity care. Children's does not (and does not permit its agents to) engage in legal action against patients/guarantors, including liens, wage garnishments, or lawsuits, or report patients/guarantors to credit bureaus or credit agencies without specific, case-by-case authorization by Children's Board of Directors. No legal action occurred during the year. Children's Credit and Collection Policy is filed with the Massachusetts Division of Health Care Finance and Policy. That policy and related policies are also available to patients upon request and on the Hospital's website.

Part VI, Line 3:
Children's provides patients with information about financial assistance programs that are available through the Commonwealth of Massachusetts or through the hospital's own financial assistance program.For those patients that request financial assistance, Children's assists patients by screening them for eligibility in an available public program and assisting them in applying for the program. All patients/guarantors who are not exempt from collection action are advised in all billing-related communications of the availability of free care and financial assistance, including assistance in applying for public programs and the availability of charity care. The screening and application process for a financial assistance programs is done through either the Virtual Gateway (which is an internet portal designed by the Massachusetts Executive Office of Health and Human Services to provide an online application for the programs offered by the state) or through a standard paper application. All Virtual Gateway and paper applications are reviewed and processed by the Massachusetts Office of Medicaid. Hospitals have no role in the determination of program eligibility made by the state, but at the patient's request may take a direct role in appealing or seeking information related to the coverage decisions.

Part VI, Line 5:
As the only free-standing children's hospital in the state, Children's treats 90% of the sickest kids in Massachusetts and offers a range of services that are unavailable elsewhere in the region, including pediatric transplants, critical care transport services, a level 1 Pediatric Trauma Unit and a level 3 Neonatal Intensive Care Unit. Children's also qualifies for DSH payments as the state's largest provider of pediatric care to low-income families. Approximately 30% of its patients are covered by Medicaid, including patients insured by out-of-state Medicaid programs. In addition, Children's has an open medical staff model.Children's is also a leader in education and training for healthcare professionals. Boston Children's Hospital has 41 accredited programs and 35 non-accredited programs. We have 475 residents and fellows based at BCH, along with more than 900 residents and fellows rotating here each year from other institutions.Children's offers a variety of continuing education courses designed for health care professionals in pediatric practice. The courses are accredited by the Office of Continuing Education at Harvard Medical School and each hour of instruction is approved for Category 1 credits towards the AMA Physician's Recognition Award. Children's is home to the world's largest and most active research enterprise at a pediatric center. Children's research mission encompasses basic research, clinical research, community service programs and the postdoctoral training of new scientists.Children's has a twenty-five person voluntary Board of Directors. Eighteen of the Board members are not direct employees of the hospital. The Board oversees the Hospital's endowment and follows a 4.5% spending rule in keeping with the industry standard of the responsible management of assets. Reserves are invested back into patient care, teaching, research, patient safety and quality initiatives, equipment, facilities, community benefits and to subsidize vital services that run a deficit.

Part VI, Line 6:
Although Children's does not have true affiliates as defined by the IRS, it does have other affiliations.As the largest pediatric referral center in the region, Children's maintains a variety of relationships with community hospitals and other smaller pediatric programs throughout New England. These relationships include seven community hospitals in eastern Massachusetts where Children's physicians have formal arrangements to provide on-site emergency medicine, inpatient, neonatal and/or outpatient pediatric specialty services. Children's also owns and operates five outpatient facilities in Waltham, Lexington, Peabody, North Dartmouth and Jamaica Plain that offer access to pediatric specialty care in a wide array of subspecialties. Children's provides assistance to other pediatric facilities (Hasbro, RI, Dartmouth Hitchcock, NH, and Boston Medical Center) in the region through training, recruitment, consultations, on-site care and referrals for care that is not otherwise available.In addition, the Pediatric Physicians Organization at Children's brings together pediatricians, pediatric medical groups and pediatric specialists at Children's.

Part VI, Line 4:
Boston Children's conducted a community health needs assessment to ensure that it was addressing the most pressing health concerns across Boston - specifically the neighborhoods of Dorchester, Fenway, Jamaica Plain, Mattapan, Mission Hill, and Roxbury. The assessment also looked at those living in the communities served by Boston Children's locations outside of Boston, which includes Lexington, North Dartmouth, Peabody, Waltham, and Weymouth.FINDINGS:The residents of Boston Children's priority neighborhoods are ethnically and linguistically diverse, with wide variations in socioeconomic levels. Minority and low-income residents are disproportionately affected by the social and economic context in which they live. Population Overview: Boston's population is incredibly diverse in terms of race and ethnicity, country of birth, and language use. According to Census estimates, approximately 3 in 5 (60.0%) Boston residents identify as people of color. Key informants and focus group participants noted many languages spoken among residents, including Cantonese, Mandarin, Russian, Spanish, Haitian Creole, Cape Verdean Creole, and indigenous languages. About 1 in 5 Boston residents are 19 years old or younger. Charlestown (8.8%), Jamaica Plain (7.3%), and Mattapan (6.9%) have the highest proportion of children under 5 years old. The proportion of school-aged children (between the ages of 5 and 17) in Boston has declined over time. Education: Education is an important issue to Boston families and a critical factor affecting health. Assessment participants discussed how many children struggle in school, especially during the pandemic. In a survey during the pandemic, nearly 15% of Boston adults with children reported that they had unmet educational needs for children or teens during the COVID-19 pandemic. Early Childhood Services: In focus groups and interviews, early childhood and childcare services emerged as a growing need exacerbated by the pandemic. Between December 2017 and March 2021, there was an 11.3% decrease in the number of available childcare seats for children 0-5 years old across Boston. Between February 2020 and February 2021, the percent of eligible children referred to Early Intervention Services who actually received services decreased from 81% to 55%. Employment and Workforce: Jobs that pay well make it easier for families to afford childcare, high quality education, health care, and healthy food. However, interview and focus group participants described significant job loss linked with the pandemic and noted that finding and securing stable jobs is more difficult for residents of color, immigrants, people with disabilities, and residents with a criminal record. According to the Bureau of Labor Statistics, the Boston metro area's unemployment rate was 16.0% during the early stages of the pandemic in April 2020 and dropped to 3.7% nearly two years later in February 2022. Income and Financial Security: Community leaders and residents described financial stability as critical for health and shared that low-wage work and minimum wage is insufficient for many families to survive in Boston. Participants noted that the pandemic has worsened poverty for low-income residents across Boston. While 12.8% of families in Boston live below the poverty level, there are stark differences by race and ethnicity; for example, 3.2% of white families compared to 24.6% of Hispanic or Latino families are living below the poverty level. Housing and Homelessness: Interview and focus group participants cited housing affordability as a dominant concern that has been exacerbated by the pandemic and that directly impacts children. In the COVID-19 Health Equity Survey, 41.5% of adults overall and 54.7% of adults with at least one child in the home reported having trouble paying their rent or mortgage during the pandemic. Boston Children's Hospital Emergency Department Social Work records show a substantial increase in the annual number of families needing social work assistance with housing or homelessness from 51 families in 2014 to 411 families in 2021. Community leaders and residents described housing assistance as insufficient to meet the needs of low-income residents and families. Additionally, housing quality and in particular exposure to lead and asthma triggers were highlighted by a few interviewees as specific concerns for children and families. Transportation: Boston-based participants discussed transportation in the context of accessing services. Reports of transportation difficulties in the past year were highest among residents of Dorchester (02121 and 02125 zip codes; 20.4%), Mattapan (17.2%), and South Boston (16.2%). Many participants from satellite communities noted that public transportation options are often unreliable and cumbersome, and that transportation poses a challenge for coordinating school, childcare, and medical care for children.