Ellis Hospital D/B/A Ellis Medicine

“Line 11a explanation - a copy of the ellis hospital's 990 was prepared and submitted for review to the chief financial officer. After cfo review was completed, the form 990 was sent to each member of the audit committee for review. After review by the audit committee, a copy of the form 990, including all required schedules, as ultimately filed with the irs, was given to each voting member of ellis' board of trustees, prior to its filing with the irs. After review by the board of trustees, and upon the recommendation of the audit committee, approval is given for filing the return with the irs.”

“Ellis hospital's conflict of interest policy applies to all hospital trustees, officers, employees, medical/dental staff members, directors, managers, appointees with administrative and/or decision-making responsibilities, volunteers or any of these parties' immediate families (collectively called hospital agents). The ellis hospital corporate bylaws require hospital agents and other selected individuals as identified by the vice president, human resources and the corporate compliance officer/director of internal audit (cco), to file a conflict of interest disclosure statement with the hospital on a annual basis. When the statements are completed they are returned to the cco. Upon receipt, the cco will review the disclosure and, if a potential conflict is disclosed, will meet with the hospital agent and/or his/her appropriate supervisor to discuss the disclosure and need for action if any. All statements for trustees are also reviewed by the cco, and if a potential conflict has been disclosed, he/she will meet with the board chairperson to discuss the disclosure and need for action, if any. All potential conflicts involving the board of trustees will be summarized by the cco and reported to the audit committee of the board. This committee will then share this information with the board chairperson. When a potential or actual conflict exists, an interested person may make a presentation to the board or at a committee meeting, but after such presentation, he/she shall leave the meeting during the discussion of, and the vote upon, the transaction or arrangement that could constitute the conflict of interest. The board or committee members shall determine by a majority vote whether the transaction or arrangement is in the hospital's best interest.”

“The current executive compensation plan is in full compliance with all existing rules and regulations applicable to a 501(c) corporation. The following is a summary of each plan: executive compensation plan-the president, and all other senior executivies are governed by our executive compensation program established by the board of trustees. The executive compensation plan is administered also by the executive compensation committee under the direction of the board of trustees. All payments from this program are based on audited results and reviewed by the board of trustees prior to any payments being made. The review of the compensation agreements and gathering of comparability data in determining the reasonableness of compensation follow the procedures described in treasury regulation section 53.4958-6.”

“Corporate compliance policies (including conflicts of interest policy) and audited financial statements are available to the general public via posting on the ellis hospital website: www.ellismedicine.org. In addition, these documents and governing documents are available to the public upon request.”

“Schenectady county city of schenectady new york state population 155,565 (2017) 65,625 (2017) 19,849,399 (2017) persons per square mile 756.6 (2010) 6,135.5 (2010) 411.2 (2010) persons under 18 years 21.7% (2015) 24.4% (2010) 21.3% (2015) persons 65 years and over 16.0% (2015) 11.4% (2010) 15.0% (2015) white alone 79.6% (2015) 61.4% (2010) 70.1% (2015) black or african american alone 11.4% (2015) 20.2% (2010) 17.6% (2015) bachelor's degree or higher (age 25+) 30.6% (2012-16) 21.1% (2012-16) 34.7% (2012-16) median value, owner-occupied housing $165,000 (2012-16) $112,900 (2012-16) $286,300 (2012-16) median household income $59,959 (2012-16) $41,243 (2012-16) $60,741 (2012-16) persons in poverty 11.4% (2016) 23.8% (2014) 14.8% (2016) figure 1: schenectady county, city, and state demographics source: us census bureau, state and county quickfacts ----------------------------------------------------------------------- schenectady county new york state adults 18-64 without any health insurance (2009-13) 8.4% 11.1% adults with regular health care provider (age-adjusted, 2013-14) 79.8% 84.6% (excl. Nyc) adults who visited doctor for routine check-up w/in 1 year (age-adjusted, 2013-14) 68.7% 72.3% adult dental visit w/in past year (2013-14) 70.0% 70.9% (excl. Nyc) figure 2: schenectady county and state health insurance and access measures source: hcdi, 2016 community health profile”

“In september 2017 ellis hospital opened a new business. The company is controlled by ellis hospital and is a for profit entity. It is called ellis nott street retail pharmacy. For purposes of the tax return it is labeled as disregarded entity. It's financial numbers have been conolidated with those of ellis hospital in the 2017 - 990 tax filing. The mission of the retail pharmacy is to serve the patients, employees, and community that ellis hospital provides health care to.”

“Ellis hospital (d/b/a ellis medicine), the sole remaining provider of acute hospital care in schenectady county, is a voluntary, not-for-profit, community and teaching hospital with 423 licensed beds between two inpatient campuses (ellis hospital and bellevue woman's center), including 52 inpatient mental health beds (see item 4b below). Ellis also operates several primary care and outpatient sites, including two comprehensive outpatient medical campuses (mcclellan street health center in the city of schenectady and medical center of clifton park in southern saratoga county) and an outpatient mental health facility (state street health center). All health care services are provided under a single corporate taxpayer identification number (tin) and a single operating certificate issued by the new york state department of health, the hospital's primary regulator. The hospital is overseen by a 25-member volunteer board of trustees drawn from the community, including six physician trustees. With the mission to "meet the health and wellness needs of our community with excellence," ellis balances state-of-the-art technology and advanced medical procedures with a 132-year tradition of community-based caring and a firm commitment to quality. Ellis has earned numerous recognitions for clinical excellence and community service. Ellis has been a new york state designated stroke center since 2005, and was the first hospital in new york state to receive the american stroke association's (asa) performance achievement award for stroke (in 2006). The ellis stroke center continues as a recipient of the gold/gold plus award (2007-2017), recognized for using the asa's "get with the guidelines" program for improving the quality of care and patient outcomes. The hospital is an accredited bariatric surgery center by the metabolic and bariatric surgery accreditation and quality improvement program (mbsaqip) of the american college of surgeons and the american society of metabolic and bariatric surgery. Additionally, the sleep disorders center is accredited by the american academy of sleep medicine; the belanger school of nursing is accredited by the national league for nursing accrediting commission; the family medicine residency is accredited by both the accreditation council for graduate medical education and the american osteopathic association; six ellis primary care practices in glenville, schenectady and clifton park have achieved national commission on quality assurance (ncqa) "patient-centered medical home" (pcmh) recognition; and five primary care practices participate in the federal cms "cpc+" quality program. Ellis has been recognized by the american heart association (aha) as a "fit-friendly worksite and received the aha's "innovation award" for presenting a unique program of health and wellness to employees. Ellis has been awarded blue distinction center designation by blue cross blue shield for cardiac care, bariatric care, knee and hip replacement, and maternity care. Ellis is also a partners in performance excellence gold baldrige award winner, recognized for its dedication and work to create a culture and systems where innovation and performance excellence become the accepted norm. Ellis has also been honored with the five rings award by intellicentrics, inc. For excellence in vendor credentialing and creating a culture of vigilance to make hospitals safer for employees and patients. During recent years, ellis has received community service awards from the chamber of schenectady county ("corporation of the year"), the city mission of schenectady ("partners award," specifically recognizing the hospital's free community shuttle, health service navigators, and other services for the underserved), the schenectady arc ("employer of the year," recognizing the hospital for providing employment, with opportunities for growth and meaningful experience, to individuals with developmental disabilities), the sight society of northeastern new york”

“Ellis serves the community by addressing identified health care priorities; including access to care, and prevention and treatment of chronic diseases; through a variety of programs. Identification of needs includes such mechanisms as the federally required community health needs assessment (see schedule h, part v) and the state-mandated three-year community service plan. These plans are built collaboratively through regional and community partnerships. On a regional basis, ellis is a member of the healthy capital district initiative (hcdi) a six-county health data collection and planning entity which brings together county public health departments, not-for-profit hospitals, fqhcs, and not-for-profit insurers. In both 2013 and 2016, hcdi conducted regional information-gathering exercises to provide the basis for the community health needs assessments of its member not-for-profit hospitals. These are available here http://www.ellismedicine.org/pages/community-report.aspx and are further described in schedule h. In addition to the federally-required chnas, during 2014 hcdi conducted a comprehensive 11-county greater capital region community health needs assessment (chna) on behalf of two regional health consortia, one of which was led by ellis. That chna, a requirement of the new york state medicaid delivery system reform incentive payment (dsrip) program, covered the specific healthcare needs of the medicaid population. A copy is available here: https://abhealth.us/about/community-needs-assessment/. On a community collaboration basis, ellis partners with schenectady county public health services (scphs), including joint grant applications and joint new york state department of health needs assessments. This includes the schenectady county strategic alliance for health (sah), a county-led, federally-designated and funded collaborative focused on preventing chronic disease and promoting community health. Ellis also provides co-leadership, meeting space, and resources for the schenectady coalition for a healthy community (schc), a community collaborative of about 60 healthcare providers, community-based organizations, and local government agencies. Schc met quarterly during 2017 to discuss community health needs and to monitor progress on ellis' 2016 implementation strategy. Ellis counted 19,841 inpatient discharges and 564,050 outpatient visits during 2017. In 2017, ellis provided $20,415,258 in financial assistance, consisting of $5,346,096 in charity care and $15,069,162 in uninsured discounts. Ellis has granted discounted rates to all uninsured patients since november 2009.”

“Ellis operates a 52-bed (certified and staffed) inpatient mental health unit, along with expanded outpatient services. This is the only inpatient mental health facility in schenectady county, and is one of only two inpatient units in a 16-county region providing services to adolescents. Ellis' mental health services include: inpatient care for adults and adolescents; outpatient child, adolescent, and adult mental health services; crisis intervention, including a 24-hour crisis information hotline; a peer advocacy program; and a support and education group for people with major disorders and their families. Ellis contracts with the schenectady county drug court to provide expedited mental health services to low-level offenders referred by the judicial system, and with the schenectady county correctional facility to provide post-incarceration support services, including peer services. In response to a nationally-studied "schenectady suicide cluster" of teenage african-american females, ellis moved the outpatient child and adolescent mental health clinic to substantially expanded facilities at the ellis mcclellan street health center, where it is co-located with the pediatric and family health centers. The ellis state street health center, which houses the outpatient mental health clinic and a personalized recovery oriented services (pros) service, was opened in 2017. This not only increased the size and improved the quality of facilities for adult outpatient mental health; it also has become part of an informal "medical village," with the mental health facility, a federally qualified health center (fqhc), another large community primary care clinic, and two pharmacies all located within one city block. In 2017, the ellis mental health programs had 1,908 inpatient discharges and 42,573 outpatient visits.”

“The ellis center, an 82-bed long-term skilled nursing facility (snf) and short-stay rehabilitation facility specializing in medically complex cases, operates from its renovated facility on the ellis mcclellan street health center campus. The facility provides residents with more private rooms and such amenities as a cyber-center, a larger hair salon, and a roof-top garden. Resident days for 2017 were 29,205.”

“Change in interest in foundation 315,184. Pension and postretirement related changes 7,050,684. Investment in affiliate -1,050,094. Yankee alliance tax income -716,743. Alliance for better health care -1,877. Urology associates -359,668.”

“The process has not changed from the prior year.”

“September 29, 2016 meb (mental health and substance abuse) work group: specific participation in chip/csp projects, reports on projects and opportunities attendees: catholic charities housing office, new choices recovery center, conifer park, schenectady arc, schenectady county public health services, united way of the greater capital region, ellis medicine, community member with suicide prevention expertise september 29, 2016 topics: status of draft chip/csp document, reports from chip/csp work groups, obesity/diabetes, meb (mental health and substance abuse), reports from other work groups, asthma, falls prevention, teen pregnancy, tobacco, report on pich food forum, status of schenectady dsrip projects, next steps/schedule - work groups and full coalition, member updates and information sharing attendees: catholic charities housing office, united way of the greater capital region, new choices recovery center, schenectady arc, conifer park, schenectady county public health services, schenectady county public library, capital district physicians health plan, schenectady community action program, ellis medicine, capital district child care council, bethesda house, capital district tobacco-free community, price chopper, university at albany school of public health, st. Peter's health partners creating healthy schools program, ellis hospital diabetes education program, league of women voters of schenectady, sunnyview rehabilitation hospital, healthy capital district initiative january 10, 2017 topics (diabetes/obesity work group): pich grant updates, work group member updates, hcdi updates, data collection requirements for chip attendees: schenectady county public health services, bethesda house, united way, healthy capital district initiative, ellis hospital, schenectady community action program, price chopper, cornell cooperative extension january 19, 2017 topics (suicide/mental-emotional-behavioral work group): relationship to other community groups, data collection requirements for chip attendees: healthy capital district initiative, schenectady county public health services, catholic charities, conifer park, safe inc., ellis hospital january 19, 2017 topics: presentation on nuval healthy foods designation system, overview of healthy schenectady families home visiting program, presentation from capital district tobacco-free communities, work group updates, hcdi updates, update on chip/csp, dsrip update, reorganization of care central health home attendees: healthy capital district initiative, schenectady county public health services, schenectady county suicide prevention, ellis hospital, conifer park, catholic charities housing options, cancer peer education, price chopper, planned parenthood, schenectady county office of senior and long-term care services, capital district physicians health plan, schenectady arc, united way, capital district tobacco-free communities, visiting nurse service of schenectady, healthy schenectady families, schenectady county office of community services, schenectady community action program march 27, 2017 topics (suicide prevention task force): overview of suicide prevention efforts in new york state, data overview, swot analysis, logic model, building and maintaining a coalition attendees: safe inc., planned parenthood, ellis hospital, rehabilitation support services, schenectady county public health services, schenectady county office of community services, scotia-glenville schools, new choices recovery, columbia-greene community college, schenectady city school district, schenectady county community college, burnt hills-ballston lake high school, niskayuna high school, northeast career planning, healthy capital district initiative, schenectady county youth bureau, saratoga county office of community services, columbia-greene public health, solos suicide survivors group april 6, 2017 topics (diabetes/obesity work group): st. Peter's health partners exercise program in schenectady schools (lin”

“The data collection instrument was developed by hcdi in collaboration with the prevention agenda steering committee and siena college. The questions were asked in reference to a 12 month period to improve consistency in response. The questionnaire was pilot tested before adopted for use. Trained interviewers at siena college administered the questionnaires to ensure fidelity of the data. Participants who were ?18 years and eligible to take part in the study were interviewed on their cellphones or landlines. The questionnaire took approximately 15 minutes to complete and a response rate of 13.7% was obtained. Up to seven attempts were made before participants were classified as non-response. Forty-four percent of the respondents consented to be contacted in future surveys or other research studies. The participants were not compensated to take part in the survey. Descriptive statistics were used to summarize the data. 3. Written comments received on 2013 chna and implementation strategy: as required, ellis posted the 2013 chna and implementation strategy on its public website (http://www.ellismedicine.org/pages/community-report.aspx). In addition, the implementation strategy was included in the irs forms 990 schedule h also posted on the website. Ellis solicits public comments via the website itself (https://www.ellismedicine.org/pages/contact.aspx), facebook (https://www.facebook.com/ellismedicineny) and twitter (https://twitter.com/ellismedicine) with all accounts actively monitored by staff from the communications and marketing office. Ellis also solicited public comments through the regular meetings of the schenectady coalition for a healthy community (schc). No written comments were received between the website posting of the 2013 chna and implementation strategy in november 2013 and the preparation of the 2016 chna in september 2016. Comments were received, however, during meetings of schc and were used to modify and make mid-course corrections to the overall identification, evaluation, and prioritization of health needs. The most significant comments related to priority modifications so as to be able to take advantage of opportunities which occurred after adoption of the 2013 document. This particularly involved elevation of the priority of food insecurity (initially listed as tier b) as several funding opportunities became available. Greater knowledge of the impact of food insecurity on the overall well-being of individuals and families in schenectady then led to it inclusion as a component in the obesity/diabetes initiative for 2016. Given this experience, ellis expects to more aggressively encourage written comments on the 2016 chna and implementation strategy”

“-mental health and substance abuse - suicide and mental/emotional/behavioral infrastructure: the schenectady county office of community services (the local government's mental health unit) and ellis undertook a collaboration to form work groups evaluating mental health needs. In collaboration with researchers from the schenectady county public health services and students at union college, a project to focus on the chna-identified excess number of drug-addicted newborns in schenectady received ellis irb approval to conduct chart reviews of newborns with positive drug screen. The study evaluated the most commonly abused drugs and demographics of the newborns' mothers. Because of the small sample size, no final conclusions were reached. In 2015, ellis and scphs worked with hcdi which is compiling mental health and substance abuse data from such standardized survey tools as brfss and school climate survey to analyze among the capital region counties. The survey information continues to flag the newborn drug-related diagnosis rate in schenectady county as a critical issue compared with the region, although the single year rate did dip slightly (6.3%) between 2012 and 2013. Other indicators for which schenectady county exceeds the regional rate are post traumatic stress disorder (3.8% vs. 3.1%) and substance abuse-other (9.3% vs. 7.7%). Specific schenectady neighborhoods, however, greatly exceed regional rates on multiple indicators; for example the schenectady stockade rates exceed regional rates on 14 of 18 indicators, while the dementia rate in scotia/glenville is 83% above the regional rate. During 2016, the ellis outpatient mental health clinic applied for and received designation as a national health service corps (nhsc) practice site. The schenectady coalition for a healthy community (schc) initiated a mental/ emotional/behavioral (meb) workgroup in the fall of 2016 to discuss suicide prevention efforts in the community. This group met twice during late 2016 and early 2017. In march 2017, schc and schenectady county office of community services held a suicide prevention day of dialogue that brought together coalition partners, state leaders, community based organizations, members of the community to discuss the issue of suicide in the community and what can be done to prevent it. About 30 individuals attended the forum. The second half of the day was spent on training the group in the evidence-based suicide prevention training call "question, persuade, refer." it was important to give participants practical skills to take back to use in their organizations or lives as well as start the broader conversation about suicide prevention in the community. From this day of dialogue, schenectady county office of community services has decided to re-engage a previously formed suicide prevention coalition. This group will look at county level data and develop strategies to improve suicide prevention efforts including training in the community. This group will meet for the first time during january 2018. The coalition is still interested in offering mental health first aid trainings in the community as an additional evidence-based intervention; however the cost of doing so has become a barrier. In 2018, this will be explored again as well as ways to fund these trainings. Ellis medicine has assisted in planning workgroup meetings as well as providing input during these groups. Their access to primary care doctors as well as mental health professionals remains of key importance in moving this work forward. Sunnyview hospital and st. Peters health partners also participate in the workgroups of the coalition and support trainings by sending staff when relevant. The schenectady community recognizes suicide prevention as an important topic to investigate. A specific strength we have in this area is topic expertise. We have a coalition member who retired from the new york state suicide prevention center and thus has vast knowledge in this topi”

“-inappropriate emergency department utilization: ellis led creation of two region-wide health innovations collaborations - a medicare mssp aco ("innovative health alliance of new york" (ihany)) and a medicaid dsrip pps ("alliance for better health" (afbh)) - both with goals of reducing inappropriate hospital utilization. Both collaborations were approved for inauguration in 2015 - the aco on january 1 and the pps on april 1. Ihany adopted the goal of reducing inappropriate hospital emergency department utilization as part of a comprehensive program intending to reduce costs and produce shared savings. Afbhc is required by the state to reduce inappropriate hospital utilization (both emergency department and inpatient) by 25% over a five year period. Ihany was successful in reducing emergency department use by its attributed patients during its first year of operations. -adolescent (teen) pregnancy: ellis, the schenectady city school district, planned parenthood mohawk hudson, the alliance for positive health (formerly the aids council), and the schenectady teen and adult coalition (stac) worked to consider causes and solutions to the consistently high rates of adolescent pregnancy in certain neighborhoods. The project engaged adolescents/teenagers in focus group and multiple meetings. A gap in health education at local schools was identified. After most health education teachers had been laid off due to budget cuts, students are receiving no health education classes between 6th grade and 10th grade. Planned parenthood arranged a 9th grade student assembly in november 2016, and is seeking to reintroduce middle school health classes. The schenectady foundation's "call to action for schenectady's youth" grant program is providing funding for the "cradle project," a multimedia project that is focusing a lens on schenectady's high rate of teenage pregnancy - the highest in the capital region - and its toll on the community. Dozens of local youth are involved in writing original music and dialog, performing and producing "cradle," a documentary film about teen pregnancy. The cradle project will also include music videos and forums about sexual health and professional development. -arthritis and disability: as this need was not categorized among the top priorities in the development of the chna, resources were devoted to other higher priority projects. -dental health: in 2015, ellis received the final payment of a $250,000 "member item" grant from state senator hugh t. Farley which was used to acquire equipment for the pediatric dental program. Ellis dental care now provides expanded services to low-income patients; including the new facilities for pediatric dental surgery and a program for parents and families of pediatric dental patients. During 2016, the ellis dental health center applied for and received designation as a national health service corps (nhsc) practice site. -falls: the chna identified particularly high falls mortality in the community, and a high number of falls in one neighborhood. Data analysis and "drilling down" identified a large senior housing facility in this neighborhood as the falls "hot spot." ellis staff met with administrators at the facility on several occasions. Union college students were engaged to assist the facility staff to track indicators and trends. Having identified the issue at one senior housing facility, ambulance call data were obtained from the local ambulance company in an effort to analyze the prevalence of falls at other senior facilities. Schenectady county public health services and schenectady county senior and long term care services partnered to offer tai chi for arthritis classes in the community to help prevent falls in older adults. As part of the work of the schenectady coalition for a healthy community, the schenectady county league of women voters (lwv) undertook lead activities for a "falls prevention work group." the work group met regularly and engaged experts from the st”

“-community and coalition building: ellis and scphs continue to lead and participate in numerous community coalitions. These include the schenectady coalition for a healthy community, the schenectady strategic alliance for health, and the healthy capital district initiative. In addition, during 2014 ellis undertook two major business initiatives promoting broad coalitions of healthcare providers. A medicare shared savings program accountable care organization (mssp aco) partnered three hospital systems, an fqhc, and several community medical practices. A new york state medicaid delivery system reform incentive payment program performing provider system (dsrip pps) partnered the same three hospital systems, two fqhcs, and two large community medical practices, along with more than 50 community agencies. Both were approved by their respective regulators to start operations in 2015. The mssp aco (innovative health alliance of new york, or ihany) was approved to start operations on january 1, 2015, and the dsrip pps (alliance for better health, or afbh) to begin on april 1, 2015. Each was established as a separate limited liability company (llc) and each undertook to adopt an operating agreement and seat a board of directors. The dsrip pps received scheduled funding from the new york state department of health under a five-year agreement. The mssp aco was funded by capital contributions from the two members of the llc (ellis hospital and st. Peter's health partners), and has not achieved "shared savings." in 2017, ellis withdrew as an equity partner of the mssp aco, but remains a clinical partner. In fall 2017, the federal centers for medicare and medicaid services (cms) approved renewal of ihany's mssp aco agreement for another three years. -community health improvement: ellis continued programs of community and patient education and support. -health professions education: ellis, the only hospital in the region to sponsor both physician education and nursing education, continued to provide a broad variety of health professions education programs including the belanger school of nursing, the family medicine residency, the general dental residency, grand rounds and other continuing professional education programs. Ellis also serves as a training and preceptorship site for numerous community-based health professions education programs. -subsidized and free health services: ellis continued to participate in government insurance programs including medicare and medicaid, while providing reduced rates and charity care for self-pay patients, as detailed in irs form 990, schedule h. Medicare, medicaid, and financial assistance (charity care) covered nearly two-thirds of inpatient discharges during 2017.”