Cape Cod Healthcare Inc.

“Trustees and officers sit on the boards of the following: cape health insurance company: michael k lauf michael l connors michael g jones bruce johnston the members of cape cod healthcare, inc.'s board also sit on the board of cape cod medical office building, inc., a for-profit related organization.”

“The organization has members/incorporators who elect the organization's trustees.”

“The decisions of the governing body that need approval by its members/incorporators include approval of changes made to the corporation's bylaws and approval when there is a divesting of one of the major affiliates of the organization.”

“The organization's form 990 is reviewed at several levels. The organization engages a public accounting firm to assist in the preparation and review of its form 990 and who signs as paid preparer. Senior management of the organization is responsible for the timely preparation of form 990. The completed form 990 is provided to the finance committee and the entire board in advance of the filing deadline.”

“The organization maintains a conflict of interest policy and regularly and consistently monitors and enforces compliance with this policy. On an annual basis, each trustee, officer and employee at the senior management level completes a conflict of interest disclosure form. The forms are reviewed by cape cod healthcare, inc.'s ("cchc") director of clinical and research compliance who prepares a summary for cchc's compliance officer. Any material interests so disclosed are presented to the corporation's governance committee for review and resolution. All disclosure statements submitted by employees will be reviewed by human resources and/or cchc's director of clinical and research compliance. For any disclosure that is considered substantive the employee's area manager will be consulted to determine if the situation is generally acceptable, requires further examination and possible action or is generally not acceptable. Any action plan created to manage a conflict of interest will be monitored by the employee's area manager or supervisor.”

“The annual process for determining compensation of the organization's ceo, officers, executives and key employees include the following: ceo - compensation will be determined by the compensation committee of the board of trustees, and will include consideration of relevant market data furnished by a disinterested compensation consultant, and a review of job performance. Officers, executives and key employees - officer, executive and key employee compensation will be determined by the ceo and will include consideration of recent relevant market data furnished by a disinterested compensation consultant, and a review of job performance. The ceo's determination of such compensation will be subject to the approval of the compensation committee of the board of trustees. The process and conclusions are documented in the meeting minutes.”

“The organization makes its bylaws, financial statements and conflict of interest policy available to the public upon request. The organization's financial statements are also attached to the annually filed form pc, a publicly disclosed tax-exempt organization filing for the state of massachusetts.”

“The full title for bruce johnston is trustee/treasurer (until 5/20) and trustee/chair (as of 5/20) the full title for theresa ahern is senior vice president, strategy & government affairs (until 6/19) the full title for paul j. Niedzwiecki is vice president, strategy & government affairs (as of 5/19) the full title for sheryl decilio is vice president of patient financial services & revenue cycle (as of 1/19) the full title for michael g. Jones, esq is clerk (until 5/20) and sr vp & chief legal officer the full title for robert talerman is trustee (until 5/20), clerk (as of 5/20) the full title for ramani ayer is trustee (until 5/20), vice chair & treasurer (as of 5/20) form 990, part vii, section b with the exception of reporting for visiting nurse association of cape cod, inc., cape cod healthcare, inc. Pays independent contractors on behalf of its affiliates who file as part of a group form 990 as cape cod healthcare, inc. And affiliates.”

“We will be the health service provider of choice for cape cod residents by achieving and maintaining the highest standards in health care delivery and service quality. To do so, we will partner with other health and human service providers as well as invest in needed medical technologies, human resources and clinical services. Above all, we will help identify and respond to the needs of our community. Community benefits mission statement cape cod healthcare, inc., (cchc) through its community benefits initiatives, is committed to enhancing the quality of and access to comprehensive health care services for all residents of cape cod. Through continuous assessment of community needs, coordinated planning and the allocation of resources, this commitment includes a special focus on the unmet needs of the financially disadvantaged and underserved populations. We will take a leadership role in collaborative efforts joining our resources, talent, and commitment with that of other providers, organizations and community members. The community benefits mission statement was affirmed by the cchc community health committee and the board of trustees in 2000 and remains in effect. Target populations 1. Name of target population: residents across barnstable county with focus on specific regions of the cape most acutely impacted by geographic isolation, access to services, transportation barriers, and economic opportunity. Basis for selection: cchc's primary service area is barnstable county, which is a geographically isolated region located on the eastern seaboard of massachusetts and is made up of 15 towns. Nearly half the population of barnstable county reside in the three largest towns. Population size becomes increasingly smaller in towns of the lower and outer cape, and many of these towns are considered rural. Lack of access to healthcare and other supportive services is a major barrier to health for residents of these towns. 2. Name of target population: populations managing mental health and/or behavioral health disorders. Basis for selection: access to, and availability of, community-based behavioral health care in barnstable county is an area of concern. This is evidenced by high rates of patients presenting with mental health and substance use disorders in hospital emergency departments. Specific challenges reported by the community and included in the 2020-2022 cape cod hospital and falmouth hospital community health needs assessment report include access to services, lack of mental health services, substance use, lack of preventative services and stigma. 3. Name of target population: residents over the age of 65. Basis for selection: consistent with the previous chna, the population of barnstable county is older than for the state overall (27.8% vs. 15.1%). Barnstable county also has a higher proportion of residents who are within the "oldest" age categories compared to massachusetts overall, including those age 75-84 (8.8% vs. 4.4%) and those age 85 and older (3.9% vs. 2.3%). "aging health concerns" was the most frequently identified health concern for the community by survey respondents, with "health care services focused on seniors"support to older adults to maintain independent living" ranking among the most frequently selected health and social service priorities by survey respondents. 4. Name of target population: transitional-aged youth (18-24 years old). Basis for selection: the proportion of residents of barnstable county between 18 and 24 is lower than in the state (7.3% vs. 10.4%). Transitional-aged youth were identified in the 2020-2022 cape cod hospital and falmouth hospital community health needs assessment report as a specific at-risk population due to increasing rates of substance use treatment admissions and concerning health risk behaviors. The chna also identified the following needs that impact this population: workforce development, employment, education and economic opportunities. 5. Name of target populati”

“In fy21, cchc community benefits will follow the chna 2020-2022 goals and strategic implementation plan. This plan was put together with cchc leadership and other community stakeholders including barnstable county human services and behavioral health and infectious disease experts. It identifies the priorities, potential partners, and goals and objectives for the implementation plan, which will be followed for our next reporting year. The priority areas and goals for the implementation plan are: 1) physical health conditions - reduce and prevent the occurrence and severity of chronic and infectious disease in barnstable county through collaborative approaches. 2) behavioral health - be a leading partner in providing comprehensive regional health services and community resources for individuals with mental health conditions and substance use disorders. 3) social determinants of health: transportation - work with regional transportation systems to increase access to health care and other health related services in barnstable county. Housing - work with regional partners to ensure that vulnerable populations show improved health indicators through access to stable and quality housing. Healthcare workforce development - work with regional partners to ensure our community is served by a strong, adequate healthcare workforce. Food/nutrition - foster regional partners to develop of food security assessment process. Self-assessment form: hospital self-assessment update form - years 2 and 3 community benefits programs annual strategic grants program: chronic and infectious disease and prevention and wellness projects . Program type: community-clinical linkages. . Program is part of a grant or funding provided to an outside organization: yes . Program descriptions: the fy20 annual strategic grants program was a competitive grant initiative with the objective to support community-based chronic and infectious disease and prevention and wellness projects aligned with the health priorities identified in the 2020-2022 cape cod hospital and falmouth hospital community health needs assessment report and implementation plan. Grants were awarded to organizations with projects that reached vulnerable populations, maximized partnership collaboration and featured evidence-based programs or promising practices with the objective to improve the health of barnstable county residents. . Program hashtags: community education, health screening, prevention, support group . Eohhs focus issue(s) (optional): chronic disease with focus on cancer, heart disease, and diabetes, housing stability/homelessness, mental illness and mental health, substance use disorders, . Don health priorities (optional): built environment, education, housing, social environment. . Health issues: cancer-breast, cancer-cervical, cancer-colorectal, cancer-lung, cancer-multiple myeloma, cancer-other, cancer-ovarian, cancer-prostate, cancer-skin, chronic disease-alzheimer's disease, chronic disease-arthritis, chronic disease-cardiac disease, chronic disease-diabetes, chronic disease-hypertension, health behaviors/mental health-depression, health behaviors/mental health-mental health, health behaviors/mental health-responsible sexual behavior, infectious disease-hepatitis, infectious disease-lyme disease, injury-auto/passenger injuries, maternal/child health-child care, maternal/child health-reproductive and maternal health, other-senior health challenges/care coordination, social determinants of health-access to health care, social determinants of health-access to healthy food, social determinants of health-access to transportation, social determinants of health-affordable housing, social determinants of health-education/learning, social determinants of health-environmental quality, social determinants of health-homelessness, social determinants of health-income and poverty, social determinants of health-language/literacy, social determinants of health-nutrition, social determinants of”

“Engage and consult with at least 250 patients with substance use disorders treated in the emergency departments at cape cod hospital and falmouth hospital. Goal status exceeded goal goal description motivate and assist 40% of patients who receive a consultation from the recovery specialist to accept a transfer to treatment or direct referral to treatment prior to discharge from the emergency department. Goal status exceeded goal goal description offer post - discharge follow-up and assistance to patients with substance use disorders who refused services while in the emergency departments. Goal status ongoing goal description raise awareness: sud is part of mental health and mental health issues in our behavioral health programs. Goal status ongoing goal description provide support for safe opportunities for youth in barnstable county to engage in meaningful activities including physical activities and mentorship. Goal status ongoing goal description provide support for recovery services in the community for patients with substance use disorders. Goal status ongoing partner name, description and web address gosnold, inc. - recovery specialists - www.gosnold.org barnstable county regional substance use council - www.bchumanservices.net/initiatives/regional-substance-use-council/ outer cape health services - office based addiction treatment - www.outercape.org duffy health center - recovery coach / navigator program - www.duffyhealthcenter.org big brothers big sisters - mentoring program for children at risk for substance use disorder - https://emassbigs.org/cape-cod/ pause a while - providing access to long term treatment for sud as a component of the treatment for and its related impact on physical wellness - https://pauseawhile.org/ program description - cape cod healthcare has identified a significant need for substance use disorder prevention and treatment in our community. Through a variety of programs and partnerships, cchc has made a commitment to direct resources towards this community health issue. Programs include: - cape cod hospital and falmouth hospital partnered with gosnold, inc. To provide peer-led recovery specialist services in the emergency departments at both hospitals. Recovery specialists have the lived experience of addiction and recovery and engage patients with substance use disorders prior to discharge from the emergency departments. Recovery specialists work as part of the hospital care team with the objective to motivate patients to accept treatment for substance use disorders through a transfer to an inpatient treatment program or direct referrals to outpatient treatment programs. - investments in prevention programs including mentoring for at risk youth - innovative treatments including office based addiction treatment - support services to meet community members where they are, including maternity department tours for mothers experiencing substance use disorder. Support to federally qualified health centers . Program type: access/coverage supports. . Program is part of a grant or funding provided to an outside organization: yes . Program hashtags: community health center partnership . Eohhs focus issue(s) (optional): mental illness and mental health. . Don health priorities (optional): built environment, social environment. . Health issues: health behaviors/mental health-mental health, infectious diseases, covid-19, other-dental health, other-senior health challenges/care coordination, social determinants of health-access to health care, social determinants of health-homelessness, social determinants of health-uninsured/underinsured, substance addiction-substance use. . Target population: regions served: barnstable - environments served: all gender: all age group: all race/ethnicity: all language: all - additional target population status: not specified goal description provide funding support to the federally qualified health centers per proposals and priorities set by each of the four entities on”

“. Program type: total population or community-wide interventions. . Program is part of a grant or funding provided to an outside organization: no . Program hashtags: community education, prevention. . Eohhs focus issue(s) (optional): chronic disease with focus on cancer, heart disease, and diabetes, mental illness and mental health. . Don health priorities (optional): education. . Health issues: cancer-breast, cancer-cervical, cancer-colorectal, cancer-lung, cancer-multiple myeloma, cancer-other, cancer-ovarian, cancer-prostate, cancer-skin, chronic disease-alzheimer's disease, chronic disease-cardiac disease, chronic disease-diabetes, chronic disease-hypertension, chronic disease-overweight and obesity, chronic disease-pulmonary disease, chronic disease-stroke, health behaviors/mental health-bereavement, health behaviors/mental health-depression, health behaviors/mental health-immunization, health behaviors/mental health-mental health, health behaviors/mental health-physical activity, health behaviors/mental health-stress management, infectious diseases, covid-19, injury-home injuries, maternal/child health-parenting skills, maternal/child health-reproductive and maternal health, other-senior health challenges/care coordination, social determinants of health-access to health care, social determinants of health-education/learning. . Target population: regions served: barnstable - environments served: all gender: all age group: all race/ethnicity: all language: all - additional target population status: not specified goal description at cape cod hospital and falmouth hospital, health education and outreach activities are offered to the community across a number of different health areas. From maternity department tours and new parenting classes, to community-based diabetes and stroke education, fall prevention classes, and advance care planning presentations, the hospitals dedicate clinical staff and resources to support the education and health literacy of barnstable county residents. Timeframe: year 1 of 3 goal status educational offerings are ongoing. Due to covid-related restrictions, many offerings pivoted to virtual events. Staff is ready to continue with in-person offerings when appropriate. Partner name, description and web address american cancer society - www.cancer.org visiting nurses association of cape cod - www.vnacapecod.org program description - at cape cod hospital and falmouth hospital, health education and outreach activities are offered to the community across a number of different health areas. From maternity department tours, breastfeeding and new parenting classes, to community-based diabetes, and stroke education, the hospitals dedicate clinical staff and resources to support the education and health literacy of barnstable county residents. This year we also engaged in awareness campaigns on issues related to women's health, heart health, and covid-19. Popular programs this year included an advanced care planning presentation, community education on genetic testing and cancer screenings and various behavioral health community education events. Community-based interpreter services . Program type: access/coverage supports. . Program is part of a grant or funding provided to an outside organization: yes . Program hashtags: health professional/staff training. . Eohhs focus issue(s) (optional): chronic disease with focus on cancer, heart disease, and diabetes, housing stability/homelessness, mental illness and mental health, substance use disorders,. . Don health priorities (optional): built environment, social environment. . Health issues: cancer-breast, cancer-cervical, cancer-colorectal, cancer-lung, cancer-multiple myeloma, cancer-other, cancer-ovarian, cancer-prostate, cancer-skin, chronic disease-alzheimer's disease, chronic disease-arthritis, chronic disease-asthma/allergies, chronic disease-cardiac disease, chronic disease-chronic pain, chronic disease-colitis/crohn's disease, chronic disease-diabetes”

“Assist more than 800 individuals with free medical interpreters in community-based primary care and specialty care settings. Goal status we continued to assist individuals with free interpreter services, although numbers are down this year due to covid. Goal description analyze program utilization data to assess regional medical interpretation needs for program evaluation. Goal status completed. Goal description reach more areas throughout the cape by implementing a video interpreter program goal status completed: implemented 10 video remote units to ensure that limited speaking patients have better access for an interpreter partner name, description and web address community based medical offices on cape cod - various harbor community health center hyannis - www.hhsi.us/cape-cod/harbor-community-health-centerhyannis/ community based medical offices on cape cod - various office of multicultural affairs - dph - https://www.mass.gov/orei program description - cchc provides free medical language interpreters to community-based physician offices and hospitals to assist limited and non-english speaking patients and their families. The availability of proficient and professional interpreter services ensures the delivery of safe, quality health care and positive clinical outcomes. Children's cove partnership . Program type: direct clinical services. . Program is part of a grant or funding provided to an outside organization: no . Program hashtags: health professional/staff training. . Eohhs focus issue(s) (optional): violence. . Don health priorities (optional): health behaviors/mental health-depression, health behaviors/mental health-mental health, injury-home injuries, social determinants of health-violence and trauma,. . Target population: regions served: barnstable - environments served: all gender: all age group: children, infants, teenagers race/ethnicity: all, hyannis language: all - additional target population status: domestic violence history goal description the nurse practitioner will: provide an onsite visual medical exam in a child-friendly setting ensure the health and safety of child through a non-invasive exam "using a do no harm approach" identify, educate and provide referrals for instances of sexually transmitted infections and/or pregnancy photo-document and collect evidence if indicated. Support the child in their wellness. Goal status all medical exams are completed privately at children's cove and with parental permission. Children are always treated with dignity and respect, and the focus of the exam is to support the child in their wellness. During the exam, the nurse practitioner does not: use any invasive tools cause any pain interview the child speculate if anything did or did not happen. Partner name, description and web address children's cove - http://www.childrenscove.org program description - funding for a specialty trained nurse practitioner to provide a non-invasive physical exam to child victims of abuse and sexual assault. After a child has made the brave choice to disclose their abuse there is often the question "is my body ok?" we want to alleviate some of the stress from a child and caregivers mind. Because of that we have partnered with children's cove and the massachusetts pediatric sexual assault nurse examiner program (pedisane) to have a specially trained nurse practitioner on staff to ensure the best health and welfare of the child. Also included is the cost of lab testing services for these patients. Mental health services in the community . Program type: direct clinical services. . Program is part of a grant or funding provided to an outside organization: no . Program hashtags: community education, community health center partnership, health professional/staff training. . Eohhs focus issue(s) (optional): mental illness and mental health. . Don health priorities (optional): social environment. . Health issues: health behaviors/mental health-bereavement, health behaviors/mental health-de”

“. Program type: access/coverage supports. . Program is part of a grant or funding provided to an outside organization: yes . Program hashtags: health screening, prevention. . Eohhs focus issue(s) (optional): chronic disease with focus on cancer, heart disease, and diabetes, housing stability/homelessness, mental illness and mental health, . Don health priorities (optional): social determinants of health-access to health care, social determinants of health-access to transportation, social determinants of health-income and poverty. . Target population: regions served: barnstable - environments served: all gender: all age group: all race/ethnicity: all language: all - additional target population status: not specified. Goal description assist patients who are unable to afford or access transportation to ensure compliance with their discharge plan. Timeframe: year 1 of 3. Goal status acuity/lyft and vouchers for local taxi service used at both hospitals. Goal description assist residents who are unable to afford medications to ensure compliance with hospital discharge planning. Timeframe: year 1 of 3. Goal status ongoing assistance occurs through pharmacies at both hospitals goal description assist patients in need with their financial questions and needs. Timeframe: year 1 of 3. Goal status financial counselors are available at both hospitals. Counselors are trained in the specific needs of their departments (ex. Cancer treatment expenses) partner name, description and web address cape cod healthcare pharmacies at cape cod hospital and falmouth hospital - https://www.capecodhealth.org/medical-services/pharmacy/ acuity/lyft - scheduling & transportation - https://www.lyft.com/blog/posts/research-improving-access-to-care-medicaid american cancer society - http://www.cancer.org program description - in an effort to assist low-income and vulnerable populations, cape cod hospital and falmouth hospital provided various services to increase access to healthcare. This includes: - access to transportation upon discharge to those patients without resources for transportation. - the prescription assistance program: an initiative of cape cod hospital and falmouth hospital emergency, behavioral health and pharmacy departments as a community benefit assisting uninsured, under-insured and financially disadvantaged patients with no other viable means to pay for medications upon discharge from hospital facilities. The assistance program for vulnerable populations is highly utilized in the behavioral health center, the cancer centers, and the emergency departments. - financial counselors assist patients with complicated medical bills and connect those in need to community resources. Workforce and career development initiatives . Program type: total population or community-wide interventions. . Program is part of a grant or funding provided to an outside organization: no . Program hashtags: health professional/staff training, mentorship/career training/internship, physician/provider diversity, . Eohhs focus issue(s) (optional): n/a. . Don health priorities (optional): education, employment, social environment. . Health issues: social determinants of health-access to health care, social determinants of health-education/learning, social determinants of health-income and poverty. . Target population: regions served: barnstable - environments served: all gender: all age group: adults, teenagers, race/ethnicity: all language: all - additional target population status: disability status. Goal description cchc staff in various departments will provide clinical oversight and supervision to students engaged in allied health programs and various job training initiatives in the region. Timeframe: year 1 of 3. Goal status covid-19 restrictions limited student supervision opportunities this year. Goal description cchc will offer high quality and diverse training opportunities to clinical staff serving residents of barnstable county to ensure residents receive t”

“Cchc staff will serve as leaders for community coalitions and initiatives that address needs identified in the 2020-2022 chna. Timeframe: year 1 of 3. Goal status although some coalitions paused operations during the covid-19 crisis, many continued to work virtually. Cchc staff continued in their roles on various boards and coalitions in the community. Partner name, description and web address zero suicide initiative - https://zerosuicide.edc.org/ jml care center - skilled nursing facility coordination - https://www.capecodhealth.org/locations/profile/jml-care-center/ program description - cchc staff are leaders in our region on issues related to community health and wellness. Staff serve in leadership positions on a variety of coalitions and initiatives including: the zero suicide initiative; various coalitions working on mental health, wellness and substance use; county-level board and committee positions; regional network on homelessness; postpartum depression task force; and coordination between skilled nursing facilities in our area. Cchc staff are instrumental in creating policy and programs to serve the health and wellness of our community. Support groups and community resources for wellness . Program type: direct clinical services. . Program is part of a grant or funding provided to an outside organization: no . Program hashtags: community education, support group. . Eohhs focus issue(s) (optional): chronic disease with focus on cancer, heart disease, and diabetes, mental illness and mental health. . Don health priorities (optional): built environment, education, social environment. . Health issues: cancer-breast, chronic disease-alzheimer's disease, chronic disease-cardiac disease, chronic disease-diabetes, health behaviors/mental health-bereavement, health behaviors/mental health-depression, health behaviors/mental health-mental health, health behaviors/mental health-stress management, maternal/child health-child care, maternal/child health-family planning, maternal/child health-parenting skills, maternal/child health-reproductive and maternal health, other-senior health challenges/care coordination,. . Target population: regions served: barnstable, environments served: all gender: all - age group: all - race/ethnicity: all language: all - additional target population status: not specified. Goal description work with community stakeholders and providers to determine needs for support groups and mental health wellness services and implement services in a way that makes them accessible to the entire community. Timeframe: year 1 of 3. Goal status support groups were implemented based on findings from the chna. Groups were able to pivot to continue to offer services despite the covid-19 crisis. Partner name, description and web address visiting nurse association of cape cod - vna -https://www.capecodhealth.org/about/vna/ program description - cape cod healthcare offers a variety of support groups and other resources for mental health and wellness in our community. These include helplines for behavioral health and breastfeeding help, various support groups for new parents, support groups for various diseases and physical conditions, and bereavement support groups. These services not only provide a social support system that encourages sharing similar experiences with the group, but also acts as a place to meet patients where they are and refer them to any community services they may need. Congestive heart failure clinic . Program type: direct clinical services. . Program is part of a grant or funding provided to an outside organization: no . Program hashtags: community education, prevention,. . Eohhs focus issue(s) (optional): chronic disease with focus on cancer, heart disease, and diabetes. . Don health priorities (optional): built environment, education. . Health issues: chronic disease-cardiac disease,. . Target population: regions served: barnstable, environments served: all gender: all - age group: adults, elderly,”

“Form 990 part i and part ix fundraising is conducted on behalf of cape cod healthcare, inc. By cape cod healthcare foundation, inc. Certain officers are compensated by cape cod heathcare, inc. Funds raised are reported at cape cod healthcare, inc. And affiliates.”

“Cape cod healthcare, inc.'s volunteers include its trustees.”

“Other changes in net assets or fund balances change in value split interest agreement $ 85,752 change in perpetual trusts $ 428,194 transfers to/from affiliates $(2,940,093) net assets released from restrictions $(1,086,958) 457b&f expenses $(1,081,890) other $(1,074,167) ------------- other changes in net assets $(5,669,162) =============”