4A (Expenses $ 95651842 including grants of $ 21374) (Revenue $ 105327697)
Winona Health Services (WHS), a 49-bed hospital, has provided care to its community and services from birth to death for 125 plus years. It is the sole community provider in the Winona, Minnesota area. In fiscal year 2022, WHS had 1,386 admissions, 172 births, 2,401 inpatient and outpatient surgeries, and 11,615 visits to the emergency room.To fulfill its mission of community service, the Corporation provides care to patients and residents who meet certain criteria under its charity care and community benefit policy without charge or at amounts less than its established rates. Because the Corporation does not (Continued on Schedule O) pursue collection of amounts determined to qualify as charity care, they are not reported as patient and resident service revenue.Charity Care: WHS provides medical care to the community regardless of an individual's ability to pay. The charity care cost based on charges foregone was approximately $585,590 for FY 2022. In furtherance of its charitable purpose, the Corporation provides a wide variety of benefits to the community. These services and donations account for a measurable portion of the Corporation's costs and serve to promote healthy life styles, community development, health education, and affordable access to care.The Corporation maintains records to identify and monitor the level of community benefit services it provides. Those records include management's estimate of the cost to provide charity care, the cost of services and supplies furnished for community benefit programs and costs in excess of program payments for treating Medical Assistance patients.In addition to community benefit costs, the Corporation provides additional community contributions such as services to Medicare and Medicaid patients below the costs for treatment, other uncompensated care, discounted pricing to the uninsured, and pays taxes and fees.During FY2022, many resources were dedicated to managing the covid 19 pandemic collaboratively within the community. Measures included expansion of virtual visit services, establishing separate covid testing and vaccine administration areas, working with local long-term care and congregate care communities to test residents and provide guidance on infection control practices. Numerous preparations and workflow changes were deployed to ensure patient access and safety. Physical facility modifications such as creating negative pressure rooms, monitoring entrances and traffic flows, repurposing of space, were made in response to the pandemic.

Winona Health Services
Part V, Section B, Line 5: In conducting the 2022 Winona County CHNA, a systematic process was used to get a comprehensive overview of Winona County residents, examining indicators of population health, identifying critical issues, gathering input from community members, and determining strategic priorities to improve the health of the community. The CHNA process involved collecting population data and community input. Additional indicators of community health status using existing local, state, and national secondary data sources were identified.It was essential that information was gathered about community members whose voices and health statuses may not be represented through local, regional and national secondary data sources, specifically the Hmong, Laotian and Hispanic populations. Project FINE (Focus on Integrating Newcomers through Education) was engaged to translate surveys and administer the CHNA to the immigrant and refugee populations in the community.After reviewing the survey results, a series of seven listening sessions were hosted at a variety of locations in May and June 2022 to gain feedback related to the findings. All Winona County residents were invited to participate in listening sessions which were held in person and virtually. All but three sessions were open to the general public. Population-specific sessions were held at the Winona Community Day Center for those experiencing housing insecurity and later sessions were held in St. Charles and Winona for populations needing translation assistance from Project FINE. A total of 78 people attended listening sessions. In addition to community members, representatives of the following organizations participated in listening sessions:- Engage Winona- Family & Children's Center- Hiawatha Valley Mental Health Center- Live Well Winona- Project FINE- SEMCAC- SEMCIL- Winona Area Public Schools- Winona County Alliance for Substance Abuse Prevention (ASAP)- Winona County Board- Winona County Health & Human Services- Winona Family YMCA- Winona Health- Winona Volunteer Services

Winona Health Services
Part V, Section B, Line 6b: The assessment was done collaboratively with Winona Health and Winona County Human Services.

Winona Health Services
"Part V, Section B, Line 11: The 2019 CHNA process identified the following priorities that were addressed in Winona Health's 2019 Implementation Plan as well as the 2019 Community Health Improvement Plan developed by Winona County. Priority 1: Address and help reverse/prevent the unhealthy behaviors that contribute to obesity/overweight and subsequent chronic disease. Priority 2: Strive for health equity given the current inequitable distribution of social determinants of health. Priority 3: Improve mental health.The following health priorities were determined during the Winona County 2022 Community Health Needs Assessment. Each priority has specific goals and activities identified. The implementation plan is not a stagnant document, but a dynamic resource that adjusts based on feedback and need. As learnings, partnerships, and new ideas emerge, new solutions will be brought forth to impact these areas in collaboration with others in the community.Priority 1: Mental Health and Wellbeing - Support the mental health and wellbeing of Winona County Residents.This includes:- Expanding treatment and service options to individuals with diagnosed mental illness.- Creating awareness of mental health needs and treatment options.- Supporting the overall mental health of all residents resulting in an increased sense of purpose and wellbeing.Priority 2: Health Equity - Strive for equity to foster a healthy and thriving community for all.This includes:- Improving awareness and access to culturally appropriate services and education.- Improving communication between individuals who have different cultural backgrounds and beliefs.- Creating or supporting existing systems that positively impact determinants of health.- Recognizing and systematically measuring disparities in health so they can be eliminated.Priority 3: Healthy Behaviors - Support behaviors that promote health and result in the reduction of chronic disease.This includes:- Increase access to education on health behaviors related to weight management, substance use, and physical activity. Increase the percentage of community members living with a healthy weight.- Decrease incidence of chronic disease via increased physical activity and improved nutritional habits.- Reduce health risks by leveraging affordable strategies that reach all people for self-management of chronic disease.Additional Consideration: Social Connectedness - Encourage social connectedness across the community.Activities Underway in FY 2022:The following strategies and activities were deployed to impact the 2022 and 2019 CHNA priority areas: Gr8 Kids: Live Well Winona, Winona Area Public Schools, and Winona State University collaborated on the GR8 Kids program to increase and promote healthy behaviors in youth. GR8 Kids is an eight-week wellness program for 4th grade students led by Live Well Winona in partnership with Winona State University. Classes promote age-appropriate education in proper nutrition and active living. In the most recent iteration of the program, a sixth step of ""kindness"" was incorporated to begin impacting mental health (whether depression or anxiety in youth). Each class is 45 minutes and is held in the respective school's gymnasium. Past program data showed increases in exercise by students as well as increases in the number of students that ate the recommended servings of fruits and vegetables each day. Scheduling of GR8 Kids was impacted by the COVID-19 pandemic (albeit the program was reworked into an online offering in the midst of the pandemic) while in-person learning was put on hold. The Winona Community HUB:Winona Community HUB (HUB) connects vulnerable populations with the resources needed to live their best lives. This program addresses the root causes of factors that affect well-being and the role of drivers of health. The HUB impacts drivers of health in Winona County with a comprehensive strategy using the Pathways Community HUB Institute (PCHI) model, data-measuring software, and community connector (CC) positions at care coordination agencies (CCAs) across the community with a goal of changing local policy to reduce barriers to services. To be enrolled in the HUB, participants must be a Winona County resident, and someone in the household has screened positive for food insecurity, or someone in the household has been diagnosed with or has self-reported mental health concerns, or they are experiencing homelessness. The HUB launched in June 2019 and continues to expand into the community. The HUB currently operates in partnership with four CCAs - Winona Health, Hiawatha Valley Mental Health Center, Family & Children's Center, and Winona Volunteer Services that employ a total of five CCs serving HUB participants. Catholic Charities is currently in the process of onboarding as a CCA and plans to hire a CC in the near term. Winona Community HUB became the first certified Pathways Community HUB in the State of Minnesota in September 2022.Collaboration between Winona Health and the Winona Family YMCA: In December of 2020, the Winona Family YMCA opened a new facility on the Winona Health campus, which significantly improved efficiency of operations and expanded the Y's ability to serve a larger percentage of the community. As part of this new building development, Winona Health relocated rehabilitation and sports therapy services to the second floor of the new development. Like many similarly designed partnerships seen nationally, the aligned vision and values allow both agencies to have a greater impact and meet the growing needs of the community. Programming has been developed to support healthy transitions from acute need to a life of well-being. Workplace Well-being: As one of the area's largest employers, Winona Health recognizes that community well-being starts within their walls. Winona Health's HealthyU worksite well-being program was designed to support caregivers on their journey to wellbeing. HealthyU allows caregivers the opportunity to earn points by working on their health and well-being. When enough points are earned, caregivers may receive reduced health insurance premiums or a one-time payroll bonus. Program participation includes, but is not limited to: - Access to a web-based portal and mobile app that provides education, self-elected challenges and supports. - Access to screening services. - Membership subsidies to the Winona Family YMCA. - Resources to support weight management. In addition to group weight management challenges, eligible caregivers with a BMI of 25 or higher are able to participate in Intensive Therapy for Weight Management with Winona Health's registered dietitians. - Rotating group monthly challenges that address a variety of wellness aspects such as healthy food choices, meditation, physical activity, gratitude and social connection.Health Equity and Building Cultural Capacity: Winona Health has developed a clearly defined team responsible for building and implementing the necessary structures to embed Diversity, Equity and Inclusion (DEI) into all practices cross-organizationally. Winona Health partnered with Team Dynamics, a consulting group of organizational culture experts, who assisted with capacity building via training and coaching. A cohort was established that included individuals across the organization at all levels. Members completed the Intercultural Development Inventory (IDI) to assess personal intercultural competence and completed a debrief with a certified IDI administrator. Cohort members attended a series of seven trainings to help develop a shared language related to diversity, equity and inclusion, as well as build self-awareness of one's own identities and patterns within the context of cross-cultural communication. A smaller team of organizational champions, called the IDEA Team (Inclusion, Diversity, Equity and Allyship) was formed to continue to advance the culture and welcoming climate of Winona Health and to make system changes. IDEA Team members continue to receive coaching with Team Dynamics. Additional strategies to address cultural competency within Winona Health included: - Completing a Health Equity Organizational Assessment and developing an organizational workplan to address growth areas. - Team Dynamics provided intensive coaching to the IDEA team through Action Learning Projects related to the revision of key patient and employee facing policies within a lens of diversity, equity and inclusion. Revisions were suggested and submitted for approval. - An IDEA Team page was created on Winona Health's Intranet to serve as a hub of DEI resources. Policies and systems around communication barriers have been evaluated and next steps are proposed. Opportunities for improving care for patients who communicate in other ways besides spoken English were identified, and policy and system changes are underway.(Continued on Page 8)"

Schedule H, Part V, Line 7 and 10:
https://www.winonahealth.org/publications/community-health-needs-assessment/

Schedule H, Part V, Line 11 continued:
"Health Equity and Building Cultural Capacity (continued)- Winona Health caregivers involved in an environmental redesign initiative have collaborated with Team Dynamics coaches to consider how design choices can support an inclusive and equitable care experience. The Winona Health website now offers an accessibility menu, and language translation to maximize access. - The expansion of data collection regarding social needs and stratification of key quality measures by race has informed community collaborative efforts and other health initiatives aimed at eliminating disparity.Mental Health Strategies:Winona Health continued to work on behavioral health integration in primary care. Many organizations imbed primary care and behavioral health services to provide a seamless delivery of care. This model also connects providers and, in many cases, supports overall healthcare cost reduction. Winona Health put a standardized clinical process in place to ensure depression screening and referral resources, in addition to embedding social work resources within primary care. This strategy addressed health equity in addition to mental health.Unaddressed Needs from the FY22 CHNA and Looking Forward:Of the three priority areas identified in the CHNA, progress has been made across all areas to put programs and structures in place to shift towards improvement. Though Winona Health has targeted strategies, other community agencies and partners similarly use the CHNA as a resource for prioritizing community activities.The area of ""additional consideration"", social connectedness, was acknowledged in the narrative but unaddressed from the FY22 CHNA. No specific tactic was identified for improving social connectedness and those related measures. That being said, social connectedness is inherent in the work done across all priority areas and improvement made in most of these areas means deeper community collaboration and connectedness. It was highlighted in the narrative to bring to emphasize the need to rebuild community and connectedness following the pandemic.Similarly, across all questions in the survey, other opportunities and needs emerged but were not prioritized in the top three. Recognizing resource and capacity limitations, it was necessary to narrow strategies to ensure success and sustainability of those areas that showed the highest priority. However, even with areas that were not prioritized explicitly, there is overlap. For example, though the need of transportation to access medical appointments was not specifically articulated as a priority area, it is connected the focus area of health equity and would be addressed via those strategies. Social connectedness is an underlying tenet to any activity in this plan and in the future. With all areas, ""mental health and wellbeing"", ""health equity and ""healthy behaviors"", these are large and expansive topics that will need a breadth of strategies to make improvement. Programming will continue on the above identified areas and will be updated in partnership with our community to best collectively design ways to impact those greatest areas of need."

Schedule H, Part V, Line 16a-c:
https://www.winonahealth.org/wp-content/uploads/2021/02/WH-28-Financial-Assistance-and-Payment-Policy-Feb2021-signed.pdfhttps://www.winonahealth.org/wp-content/uploads/2018/10/2990a_financial_assistance_application__september_2018.pdfhttps://www.winonahealth.org/patient-information/billing/financial-assistance-care-program/https://www.winonahealth.org/wp-content/uploads/2018/10/2991a_winona_health_fap_brochure__september_2018.pdf

Part I, Line 6a:
The community benefit report is included in the annual report and community benefit information is listed in quarterly newsletters, both of which are posted on the Winona Health website: https://www.winonahealth.org/. Information is also included in the patient waiting rooms.

Part I, Line 7:
Charity care expense was converted to cost on line 7a based on an overall cost-to-charge ratio addressing all patient segments. Unreimbursed Medicaid on line 7b and subsidized health services line 7g was calculated using the costing methods to prepare the cost reports. Line 7e Community health improvement services, line 7f health professions education, and line 7i cash and in-kind donations were actual expenses compiled using the CBISA software.

Part II, Community Building Activities:
"Winona Health supports community building activities in a variety of ways. Whether via community boards, mental health coalitions, community support activities, or wellbeing collaboratives, Winona Health operates as a cornerstone of the community. Winona Health is one of the largest employers in the area, and operates as a trusted resource in the community. As a result, leadership and caregivers are often tapped to lead and participate in activities that advance the health of our community and create a place where all people can thrive. Winona Health supports and encourages these activities, and provides resources as able. This all aligns with Winona Health's mission of ""inspiring, recognizing, and empowering the caregiver in all of us."""

Part III, Line 2:
The corporation determines its estimate of implicit price concessions based on its historical collection experience with each class of patients and residents.

Part III, Line 3:
WHS estimates that 40% of implicit price concession accounts would likely qualify for the Organization's charity care guidelines if the patient would have been identified and followed through on the application process. This percentage is based on historical knowledge of those who were provided applications and those who completed and submitted application to qualify.

Part III, Line 4:
The footnote to the organization's financial statements that describes implicit price concessions is located on page 12-14 of the attached financial statements.

Part III, Line 8:
WHS provides services to patients under the Medicare program knowing they will not recover all the costs associated with providing these services. Providing these services is essential to these patients and the community and increases their access to healthcare services. Therefore, the entire Medicare shortfall is considered a community benefit. The Organization reported only those allowable costs and Medicare reimbursements reported in the Medicare cost report for the year.Total revenue received from Medicare is the gross reimbursement plus settlement. Both total revenue received from Medicare and the Medicare allowable costs are reported from the Medicare Cost Report. The Medicare Cost Report is completed based on the rules and regulations set forth by Centers for Medicare and Medicaid Services.

Part III, Line 9b:
In keeping with the mission, vision and values of Winona Health Services, our Organization is committed to giving a patient every opportunity to pay their medical debt in full or to make arrangements based on organizational policy. When a patient is in the process of applying for financial assistance, whether charity care or an interest free payment plan, there will be no collection efforts. Collection efforts include phone contacts, letters, patient interviews and filing a judgement against the patient and potential garnishment of wages. After a determination of financial assistance, any personal portion due follows the same collection procedures as other accounts. Accounts will be recalled from collection if an application is completed within 240 days of the date of the first invoice.

Part VI, Line 2:
Winona Health Services (WHS) uses a variety of methods to listen to its customers, and the methodologies vary by customer groups. The development of most major services includes the meeting of a community advisory group to assess operations and plans and provide recommendations to the leadership team. WHS also uses point of care feedback comment cards, focus groups, advisory committees comprised of community individuals, and web and consumer newsletter surveys to capture feedback from patients/residents and community. Immediate feedback is obtained from patients/residents and community through pre- and post-service calls, rounding, and informal surveys. WHS also works with local non-profit organizations gathering feedback from local agencies and their boards to ensure community needs are being met. The entire report is available on the Winona Health website.

Part VI, Line 7, Reports Filed With States
MN

Part VI, Line 3:
WHS places pamphlets that contain information about our charity care programs and policies throughout the Organization, including all patient access areas. In addition, information can be found on our statement, website or by calling the WHS business office either locally or toll-free. WHS also has a plain language brochure which explains options for financial assistance, charity care, government program assistance, and our uninsured discount program. In addition, the WHS social services department and/or a contracted patient advocate may meet with in-house or recently discharged patients to go over all the payment options which include charity care, governmental programs, or other alternative payment options. WHS works with the county to help initiate a screening process for applying for governmental programs by offering the patients an opportunity to lock in an effective date for those programs if subsequently found eligible. WHS also is contracted with MNSure and has Certified Application Counselors onsite to assist patients in applying for insurance coverage through the State run exchange.

Part VI, Line 4:
WHS defines its primary service area as the zip code of Winona and the immediate surrounding area with a population base of approximately 35,000 residents. Its secondary service area encompasses a 20-mile radius from Winona representing another 12,000 residents. WHS is located between two large, well-known tertiary health care centers, Mayo and Gundersen Lutheran. WHS has focused on fulfilling its community need: a full primary care facility. WHS defines itself as a primary care health system and provides its patients and residents connections to tertiary level services to meet their needs regionally or nationally, as the patient chooses. In 2020, Winona had a median household income of $60,020 and 11% of persons were below the poverty level. The majority of our patients live in Winona which has a population of over 26,772 people. Approximately 18.1% of our patients are uninsured and/or Medicaid recipients.

Part VI, Line 5:
As a sole community provider, WHS offers emergency and urgent care, primary care for all ages, surgical and specialty care, inpatient care, and senior services. Our Board is comprised of physicians and primarily community members. The Board and medical staff are involved in our strategic planning which focuses on the health of our community members. To meet the needs of our community, the Hospital extends privileges to medical staff that are qualified through licensure in the state of Minnesota. In a normal year, staff actively participate in several on-site and off-site health fairs offering free blood pressure checks, glucose screenings and expertise on health questions, as well as offering free community health talks for community members on certain health topics. Due to the COVID pandemic during 2020-2022, much of this activity was curtailed or transitioned to virtual delivery. Winona Health actively participated with other community resources to develop and carry out plans in response to the pandemic, including establishing a separate COVID testing and vaccination site on our campus, and working with area long-term care and congregate care communities to test residents and provide guidance on infection control practices. Excess funds are reinvested and used for patient care and facility upgrades.Additional programs that benefit the community include:Health Professional Training: Winona Health Services works closely with nurse and health professional education programs at Winona State University, St. Mary's University, Viterbo College, and Minnesota State College Southeast. Along with training LPNs and RNs on site, other students going into fields of athletic training, social work, nutrition, lab, radiology, physical therapy, respiratory therapy and health administration are also educated and mentored on site. Students work with staff in the following departments: medical/surgical/pediatric unit, family birth center, intensive care unit, emergency department, lab, radiology, social workers, cardiac rehab, physical and occupational therapy. Preventive Care: WHS encourages preventive care through a number of resources. An online patient portal, MyWinona Health, is a free web-tool that allows patients to have access to their Winona Health Services records anytime, anywhere with an internet connection. Patients can document their health history, access diabetes and asthma management programs, schedule appointments, receive lab test results, and track wellness activities. Winona Health Services offers a number of educational opportunities for the community, from CPR classes to free or low-cost screenings including prostate cancer, cholesterol, depression, skin cancer and mammograms. Community Health Talks provide individuals with educational information on a variety of health topics and are free throughout the year. The Winona Health Services Occupational Health department presents various preventive programs geared toward business leaders and HR professionals. The staff also participates in many community collaborative healthcare events.Employee Health: The Healthy U Program is a health management incentive initiative designed to support and encourage healthy activities for our employees and families. The program reinforces the emphasis on prevention, aiming to improve their health and well-being. Emergency Care: WHS provides 24-hour-a-day, 365-days-per-year emergency care to the community. It employs six full-time physicians and several mid-level providers as the service continues to grow. Winona Health Services has excellent relations with neighboring tertiary facilities and transports patients as needed to La Crosse and Rochester.Community Relations: WHS works with area nonprofit organizations to support health and youth-related activities. Presentations included topics such as stress management, career planning, men and women's health issues, joint pain and surgery, gastroesophageal reflux disease, nutrition, and weight management. Staff members are also involved in several non-profit committees, donating their time to support our community. Community Education: WHS's community education programming includes free or reduced-fee classes on childbirth and parenting, support groups for breastfeeding, cardio-pulmonary resuscitation, diabetes prevention, first aid, and smoking cessation. Staff conduct health screenings at free screenings events at Winona Health and other community health fairs. Winona Health Volunteers offer free healthcare directives educational sessions throughout the year.The Winona Health Community Care Network is a service available to community members who would like help with managing a chronic health condition. Its goal is to support and improve the overall health of individuals who are at high risk for frequent emergency department visits and hospital admissions.