4A (Expenses $ 123489374 including grants of $ 3146) (Revenue $ 139129326)
Avera Marshall's mission is to provide healthcare services to Marshall, Minnesota residents and residents of the surrounding area. Avera Marshall is a 501(c)(3) organization affiliated with Avera Health. Avera Marshall consists of a 25-bed critical access hospital and a 76-bed nursing home in Marshall, Minnesota, six physician clinics and four optometry clinics. The program services offered include primary care, general surgery, neurology (via telemed), dermatology, pediatrics, orthopedics, OB/GYN, urology, oncology, podiatry, nephrology, radiology, optometry, ophthalmology, level III trauma center, ICU, speech therapy, physical therapy and occupational therapy. Avera Marshall provides acute care and long-term healthcare services. Following is a breakdown of these statistics by facility:Avera Marshall Hospital1,494 Acute patient discharges401 Newborn patient discharges10 Swing bed patient discharges65,811 Outpatient visits68 Swing-bed patient days590 Newborn patient days128,881 Clinic visitsAvera Morningside Heights Care Center24,713 Long-term resident days118 Long Term Care patient dischargesAvera Marshall maintains records to identify and monitor the level of charity care it provides. These records include the amount of charges forgone for services and supplies furnished under its charity care policy and equivalent service statistics. The amount of charges foregone, based on established rates, were $250,967.Avera Marshall also provides community benefit health activities at less than or at no cost to support those in the area serviced, see Schedule H. As a member of the Avera Health Network, Avera Marshall upholds the vision of the Presentation and Benedictine Sisters to work through collaboration to provide quality, effective health ministry and to improve the healthcare of individuals and our communities through a regionally integrated network of persons and institutions. Avera Marshall engages in activities designed to improve the health of individuals and communities in response to a calling to heal the sick, the elderly, and the oppressed.

Avera Marshall
Part V, Section B, Line 5: The Avera Marshall Regional Medical Center Community Health Needs Assessment (CHNA) was conducted in collaboration and partnership with community members, community organizations, stakeholders from local public health and internal stakeholders. These partners assisted in the development and analysis of assessment information through a series of data collection processes. In addition, Avera Marshall partnered with Southwest Health and Human Services (SWHHS) to provide a more comprehensive look into the social determinants of health and wellness in the communities we serve. SWHHS shared their draft of their 2019 Quality of Life Survey with us, which allowed us to incorporate the perspectives of 488 individuals on what defines a healthy community. In addition, we talked to 82 community members of diverse backgrounds and used a five member CHNA advisory committee that represented various aspects of our service area: academic, governmental, non-profit, industry, and vulnerable populations. Care was taken to consider the perspectives of the underserved populations - Karen, Hispanic/Latino, African American, and Somali. We also consulted with Vondie Woodbury of The Woodbury Group.

Avera Marshall
Part V, Section B, Line 6a: The Avera Marshall region has three hospitals: Avera Marshall, Avera Tyler, and Avera Granite Falls. As it is that all three hospitals are in the Avera Health system, share equally the same demographic and geographic area, and have shared senior leadership, the conducted CHNA was a regional CHNA that was inclusive of all three hospitals. Additionally, the implementation plan established applies to all three facilities.

Avera Marshall
Part V, Section B, Line 6b: Southwest Health and Human Services

Avera Marshall
"Part V, Section B, Line 11: The FY2019 community health needs assessment included priority areas around Mental Health, Obesity, and tobacco and e-cigarettes. Avera Marshall, like all healthcare facilities across the world, was impacted by the COVID-19 pandemic. Not only has the pandemic taken a toll on human life and well-being of communities, but it has also brought major upheavals in healthcare institutions, which continue to this day. During the two plus years of the pandemic, COVID-19 required hospitals and clinics to focus most of their time and resources on dealing with pandemic related illness, staffing shortages, and financial strain. As a result, hoped for implementation goals of our 2019 CHNAs were unable to be fully realized. Despite difficulties brought by COVID-19, Avera Marshall continued to provide and improve greater access to a full spectrum of mental health services, which was the first priority of the facility. The progress made with mental health services over the past three years, including continued work in 2022, included: Partnered with Western Mental Health Center (WMHC) and Southwest Health and Human Services (SWHHS) and law enforcement on crisis situations that occur within our region. This includes follow up with either post-hospitalization or post-ED visit with WMHC's Co-responder Program. Continued work with WMHC on improving relationships and referrals between programs and providing education to providers on programs/services that are offered at WMHC. This included discussions about opportunities to improve their Zero Suicide Program and/or create consistency across our region's programs. Our collaboration with WMHC included coordinating care and follow-up for patients with substance use issues. Worked with the VA in organizing both the Marshall Area Suicide Prevention Coalition and the Upper MN River Valley Suicide Prevention Coalition. Collaborated with the Avera Behavioral Health service line to add social service positions in the region to ensure psychosocial needs of patients are being met across care settings. These additional services have created resources for behavioral health services/resources that can be used by providers throughout the region which has helped increase admissions directly to our behavioral health unit in Marshall, which decreases the need for patients to be transferred elsewhere. Worked with the Avera Foundation and United Community Action to partner in offering transportation vouchers to patients who need care at the Avera Marshall Behavioral Health facility, but do not have means of transportation home. Avera Marshall region serves as a pilot site for the Avera Medical Group to track depression amongst our inpatient and outpatient Medicaid populations. This pilot program is a joint effort between Avera Marshall and WMHC. A new community health needs assessment was completed in FY2022. The following community health priority areas were identified: Cultural barriers that impact healthcare, including but not limited to interpretive services; Mental Health; and Transportation, as it relates to access for healthcare services. Avera Marshall developed an implementation plan for each of these three priorities. Mental Health:Avera Marshall's goal around mental health will be to lower depression rates and engage in issues around suicide prevention. Partners we are working with: Public Health, Clergy, Community Groups, Southwest Mental Health, AMG general practice providers, schools, and AMG Mental health providers. Steps we are taking: Avera Medical Group (AMG) tracks depression amongst our inpatient and outpatient Medicaid populations. AMG providers discuss depression with patients who show signs of depression and help connect them with our mental health services. Working with Southwest Mental Health by informing mental health patients of the resources provided by the agency, especially their mobile mental health crisis team. Utilizing Minnesota Department of Health (MDH) resources related to the 988 mental health hotline in our community education events. Conducting a community wide suicide prevention campaign called, ""Ask the Question"" to provide community members information about how to talk to friends and family about suicide in order to reduce the risk of suicide. This program is engaging public health, providing education to church leaders, and delivering public service messages. Cultural barriers that impact healthcare, including but not limited to interpretive services:Avera Marshall's goal around cultural barriers is to improve interpretive services, provide assistance in navigating the healthcare system, and educate our traditionally underserved populations in matters related to disease prevention and vaccinations. Partners we are working with: Public Health, Non-Avera Medical Providers, Churches, Community Groups, Local Employers, Medical Providers, ARCH Language Network, and Avera Staff. Steps we are taking: We are increasing access to in-person interpreters. One way is to develop a program where current staff who are bilingual in Karen, Somali, or Spanish have the opportunity to cross-train as certified medical interpreters. We have hired a Karen community health worker (CHW). Our goal over the next three years is to hire two additional CHWs for the Somali and Hispanic populations. Developing a relationship with a local medical provider who is part of the Somali community. Strengthening relationships with local employers who employ members of traditionally underserved populations in order to collaborate to provider health education opportunities and on-site vaccine clinics. Provided health related education for the Karen community by presenting information about health-related topics prior to their Sunday worship services. Partnering with Avera Foundation to develop spaces for interfaith reflection throughout our facilities (i.e., meditation rooms) to support spiritual well-being. Transportation, as it relates to access for healthcare services:Avera Marshall's goal is to improve transportation access for health care appointments for those who do not have transportation and develop stronger relationships with transportation services within our service area. Partners we are working with: Local and State Public Health, City of Marshall, United Community Action Partnership, Local Medical Transport Companies, and Avera Staff (CHW and Care Coordination). Steps we are taking: Working with the City of Marshall and public health to provide a bus stop at the Federally Qualified Health Center (FQHC). Added to the Karen CHW job responsibilities to arrange transportation for the Karen patients who do not have complex care coordination needs. This allows care coordination to focus on more complex cases and will allow the CHW to provide more targeted intervention on transportation for Karen community members. Meeting with public health and local medical transportation companies (including volunteer programs) to engage in dialogue about how we can best work together to provide short and long-distance transportation for medical services throughout the region. When emergency medical transportation is utilized, providing clear directions to family and friends of the patient to the destination facility. Additionally, when those family and friends do not have transportation have social work/care coordination find a local transport company to bring at least one family member to the destination facility.There are needs identified in the Community Health Needs Assessment which Avera Marshall has not included in its priority implementation plan. These needs were not included in the priority needs implementation plan in order to focus resources on the three most urgent health care needs. The needs not being directly addressed include: alcohol and drug abuse, cancer, and aging problems. We continue to address these needs throughout the Avera Marshall Region using the appropriate standards of care."

Avera Marshall
Part V, Section B, Line 13h: Presumptive charity care may be applied in situations where all other avenues of financial assistance have been exhausted. The facility has the discretion to weigh extenuating circumstances when determining eligibility for and the amount of charity care to provide.

Avera Marshall
Part V, Section B, Line 16j: A summary of the financial assistance policy is posted in the hospital facility's emergency room, waiting rooms, and admissions office and included in the billing statement. In addition, the financial assistance policy is discussed with the patient upon admission to the facility.

Avera Marshall
Part V, Section B, Line 20e: If a patient is self-pay and has a large balance, an Avera patient advocate will help them apply for other forms of assistance. If they are not eligible for any other coverage, the patient is given a financial assistance application to complete and return to the facility.

Avera Marshall
Part V, Section B, Line 24: The hospital financial assistance policy does not cover elective procedures. The hospital may have charged FAP eligible patients gross charges for services that are not covered under the financial assistance policy.

Part V, Section B, Lines 7a, 7b and 10a:
avera.org/about/community-health-needs-assessments/#marshall

Part V, section B, Line 16a-c
The FAP, FAP Application, and Plain Language Summary are available at:avera.org/patients-visitors/charity-patient-assistance-programs/financial-assistance-forms/

Part V, Section A website address:
avera.org/locations/marshall/

Part I, Line 3c:
The methodology used to determine eligibility for financial assistance takes into consideration income, net assets, family size and resources available to pay for care. In addition, presumptive charity care may be applied in situations where all other avenues have been exhausted.

Part I, Line 7:
Charity care was converted to cost using an overall cost-to-charge ratio addressing all patient segments. Unreimbursed Medicaid was calculated using the costing methods to prepare the cost report. Subsidized health services were calculated based on a combination of the Medicare cost report and actual expenses recorded to the general ledger. Community health improvement services, health professions education, and cash and in-kind contributions are reported based on actual expenses recorded to the general ledger.

Part I, Line 7g:
Provider based clinic costs are included in subsidized health services. Revenues of $1,187,682 and costs of $1,887,306 were included for a net community benefit of $699,624.

Part I, Line 7, Column (f):
The Bad Debt expense included on Form 990, Part IX, Line 25, Column (A), but subtracted for purposes of calculating the percentage in this column is $ 88,532.

Part II, Community Building Activities:
The organization provides education to community groups, has staff that serve on various committees/boards, pays the salaries of two police officers, provides leadership development and training for community members, and donates to various community organizations.

Part III, Line 2:
The amount on line 2 represents implicit price concessions and bad debts. The Organization determines its estimate of implicit price concessions based on its historical collection experience with the respective class of patients and residents. Bad debt reflects amounts that will not be paid by patients based on an adverse change in the patient's ability to pay.

Part III, Line 4:
The footnote to the Organization's financial statements that describes implicit price concessions and bad debt is located in the audited financial statement report on pages 19 and 20.

Part III, Line 8:
Avera Marshall provides services to patients under the Medicare program knowing they may 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, in years the costs associated with services provided under the Medicare programs are not completely covered, the Medicare shortfall is considered a community benefit.Medicare allowable costs of care are based on 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:
If the patient qualifies for the organization's financial assistance policy for low-income, uninsured patients and is cooperating with the organization with regard to efforts to settle an outstanding bill within current self-pay collection policy guidelines and timeframes, the organization or its agent shall not send, nor intimate that it will send, the unpaid bill to any outside collection agency. Avera organizations will allow all individuals 120 days from the first post discharge statement to apply for financial assistance before sending the uncollected account to an outside collection agency. Avera will provide the patient with a statement or final notice that contains a listing of the specific collection action(s) it intends to initiate, and a deadline after which they may be initiated no earlier than 30 days before action is initiated. If the patient qualifies for 100% charity care, no further bills will be sent. A letter will be sent instead indicating that the patient's bill has been completely forgiven.

Part VI, Line 2:
Avera Marshall uses many sources to assess the needs of the community, including their medical staff's daily interactions with their patients and the community. Additional sources include federal, state, and county statistical information, public health data, internal data, and input from community members, businesses, city, and other local agencies. To gain community member input the following processes are used: interviews, focus groups, neighborhood canvassing, and surveys. Other sources have included a CHNA advisory committee that included representatives from multiple service areas in the community, including academic, governmental, non-profit, industry, and vulnerable populations. Care is taken with all information sourcing to make sure we gain the perspective of the underserved populations: Karen, Hispanic/Latino, African American, and Somali. Avera Marshall also partners with many area organizations, including Southwest Health and Human Services (SWHHS), where we share information, such as their Quality-of-Life survey.

Part VI, Line 4:
Avera Marshall is a 25-bed critical access hospital in Marshall, Minnesota. The primary service area is defined as Lyon County, Minnesota, including the communities of Marshall, Minneota, Ghent, Taunton, Lynd, Russell, Cottonwood, Tracy, Balaton and Garvin. Marshall is the county seat. According to the U.S. Census Bureau Quick Facts 2021 data, the estimated population of Lyon County as of July 1, 2021 is 25,231 and is predominately white at 88.8%. It is estimated that 17.0% of the population is 65 years and over. The median household income is $57,274 with an 8.8% poverty rate. Uninsured individuals under age 65 is estimated at 7.8%.

Part VI, Line 6:
Avera is a sponsored ministry of the Benedictine and Presentation Sisters. The communities in which Avera operates all have unique health and community benefit needs. In keeping with the Catholic Healthcare Association guidelines, each hospital strives to meet its community's identified needs. The corporate staff of Avera Health advocates for all members regarding community benefit related matters of state, regional and national importance.

Part VI, Line 3:
Uninsured patients who hold an inpatient status are counseled by a Patient Advocate to screen them for coverage eligibility and to assist in payer source enrollment. Those that are not eligible are provided a charity care application along with instructions on how to fill out the application. All patients receive statements that indicate who to contact should they need financial assistance. In addition, all patients receive a summary of financial assistance upon registration, as well as in their final statement. Should a patient contact Patient Financial Services and indicate inability to pay, they are transferred to a financial counselor to assist them with the financial assistance application process. Also, inpatient and same day surgery patients receive a brochure in their admissions packet. Pre-collection letters also include information regarding the financial assistance and uninsured programs.

Part VI, Line 5:
Avera Marshall is one of the largest employers in the area and is committed to helping its community members get as much of their healthcare as close to home as possible. To this end, any surplus funds are reinvested in facilities to improve patient care, add/replace necessary equipment, and fund needed facility upgrades. To further ensure local care, medical staff privileges are extended to all qualified physicians in the community.In addition, Avera Marshall is the sole provider for hospital inpatient care, the only physician staffed 24/7 ER Level III Trauma offering coverage no matter the ability to pay, birthing center, and full-service surgery center. Avera Marshall provides numerous services which do not produce a profit. An example of this is psychiatric services provided by the facility. This is a subsidized health service. Some of the other services include dialysis, in-home palliative care, diabetic education, and eye injections at rural outreach facilities to decrease patient's travel time for patient's with limited vision. Avera Marshall is committed to taking care of all individuals, no matter their ability to pay. Charity care is always available for those with a diminished ability to pay. We staff patient advocates, who meet with patients with high deductible plans and high-cost medications to find drug programs to help cover a patient's out of pocket costs. We also work with patients to complete presumptive Medicaid, full Medicare applications, answer questions on the MNSure insurance programs, help patients coordinate their insurance benefits and complete charity care applications for Avera and Access Health services. In addition, on January 1st, Avera Marshall partnered with Rural Health Care Inc. to open Access Health-Marshall. This clinic offers a full range of primary healthcare services. Avera Marshall offers a number of services that are free or low cost, including: classes such as childbirth and various other support groups, participates in the Mother's Milk program by purchasing donated breast milk and providing it to babies free of charge during their hospital stay, Planet Heart community screenings with reduced imaging fees in addition to free vein screenings, rape and sexual assault services not fully funded by the county, Hospice medical provider not billed to patients, sharps and unused medical disposal services, offer a recycle eye wear program, transportation vouchers for patients without any options, physicals for sports are given to students who have no means to pay but wish to participate in athletic school activities, impact testing is provided to local schools to help support concussion testing and ensure student athletes do not return before they are ready, basic supply items are donated to school nurse providers for triage care, and in partnership with Big Stone Therapies, Avera Marshall provides athletic trainers to many high schools throughout the Marshall region with no cost to the school district. Avera Marshall also supports the local college, Southwest Minnesota State University with their medical needs for both students and athletes. For part of the year a drive-through COVID testing site was made available to the community. Community out-reach programs are done in partnership with local underserved communities and businesses. Avera also hired a community health worker to support the Karen community by helping to coordinate their health needs and provide in-person interpretation services. In addition, virtual and other in person interpretation services are offered in several different languages. Staff Care Coordinators are also employed to help high-need patients navigate their health care needs. Educational experiences for school-aged children, students needing work study experience, and med student internships are offered. On an annual basis Avera Marshall provides scholarships for medical students and high-school students. Avera Marshall also partners with the Transition-to-Work Program or Project SEARCH. This program allows local high-school students with significant intellectual disabilities to be employed in nontraditional, complex and rewarding jobs, allowing them to gain real-life work experience in order to achieve competitive employment upon graduation. The organization's governing body is comprised of volunteer members who reside in the community. Avera Marshall's leadership team, physicians, and general staff are encouraged to participate in civic and community organizations. Avera Marshall also offers many opportunities for community members to volunteer within the hospital, long term care, home care, hospice, and thrift store settings. Finally, to further safety for the community residents and patients, Avera funds two police officers for the City of Marshall. Avera Marshall's Thrift Store impacts the community in a variety of ways. The store donated approximately 80,000 pounds of fiber to Advanced Opportunities. Advanced Opportunities then sells the fiber to help support their programs, which at current fiber rates would be approximately $64,000. The Thrift Store supports our judicial system by being an option for court ordered community service. The Thrift Store works with Project Turnabout to provide opportunities for those dealing with addiction to re-enter the workforce.