SCHEDULE H
(Form 990)
Department of the Treasury
Internal Revenue Service
Hospitals
MediumBullet Complete if the organization answered "Yes" on Form 990, Part IV, question 20.
MediumBullet Attach to Form 990.
MediumBullet Information about Schedule H (Form 990) and its instructions is at www.irs.gov/form990.
OMB No. 1545-0047
2015
Open to Public Inspection
Name of the organization
KENNESTONE HOSPITAL INC
 
Employer identification number

58-2032904
Part I
Financial Assistance and Certain Other Community Benefits at Cost
Yes
No
1a
Did the organization have a financial assistance policy during the tax year? If "No," skip to question 6a . . . .
1a
Yes
 
b
If "Yes," was it a written policy? ......................
1b
Yes
 
2
If the organization had multiple hospital facilities, indicate which of the following best describes application of the financial assistance policy to its various hospital facilities during the tax year.
3
Answer the following based on the financial assistance eligibility criteria that applied to the largest number of the organization's patients during the tax year.
a
Did the organization use Federal Poverty Guidelines (FPG) as a factor in determining eligibility for providing free care?
If "Yes," indicate which of the following was the FPG family income limit for eligibility for free care:
3a
Yes
 
b
Did the organization use FPG as a factor in determining eligibility for providing discounted care? If "Yes," indicate
which of the following was the family income limit for eligibility for discounted care: . . . . . . . .
3b
Yes
 
%
c
If the organization used factors other than FPG in determining eligibility, describe in Part VI the criteria used for determining eligibility for free or discounted care. Include in the description whether the organization used an asset test or other threshold, regardless of income, as a factor in determining eligibility for free or discounted care.
4
Did the organization's financial assistance policy that applied to the largest number of its patients during the tax year provide for free or discounted care to the "medically indigent"? . . . . . . . . . . . . .

4

Yes

 
5a
Did the organization budget amounts for free or discounted care provided under its financial assistance policy during
the tax year? . . . . . . . . . . . . . . . . . . . . . . .

5a

Yes

 
b
If "Yes," did the organization's financial assistance expenses exceed the budgeted amount? . . . . . .
5b
Yes
 
c
If "Yes" to line 5b, as a result of budget considerations, was the organization unable to provide free or discountedcare to a patient who was eligibile for free or discounted care? . . . . . . . . . . . . .
5c
 
No
6a
Did the organization prepare a community benefit report during the tax year? . . . . . . . . .
6a
Yes
 
b
If "Yes," did the organization make it available to the public? . . . . . . . . . . . . .
6b
Yes
 
Complete the following table using the worksheets provided in the Schedule H instructions. Do not submit these worksheets with the Schedule H.
7
Financial Assistance and Certain Other Community Benefits at Cost
Financial Assistance and
Means-Tested
Government Programs
 (a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community benefit expense (d) Direct offsetting revenue (e) Net community benefit expense (f) Percent of total expense
a Financial Assistance at cost
(from Worksheet 1) . . . 		    62,573,185   62,573,185 7.490 %
b Medicaid (from Worksheet 3, column a) . . . . .     71,787,323 64,519,937 7,267,386 0.870 %
c Costs of other means-tested government programs (from Worksheet 3, column b) . .            
d Total Financial Assistance and Means-Tested Government Programs . . . . .     134,360,508 64,519,937 69,840,571 8.360 %
Other Benefits
e Community health improvement services and community benefit operations (from Worksheet 4).     540,879   540,879 0.060 %
f Health professions education (from Worksheet 5) . . .     229,914   229,914 0.030 %
g Subsidized health services (from Worksheet 6) . . . .            
h Research (from Worksheet 7) .            
i Cash and in-kind contributions for community benefit (from Worksheet 8) . . . .            
j Total. Other Benefits . .     770,793   770,793 0.090 %
k Total. Add lines 7d and 7j .     135,131,301 64,519,937 70,611,364 8.450 %
For Paperwork Reduction Act Notice, see the Instructions for Form 990. Cat. No. 50192T Schedule H (Form 990) 2015
Schedule H (Form 990) 2015
Page
Part II
Community Building Activities Complete this table if the organization conducted any community building activities during the tax year, and describe in Part VI how its community building activities promoted the health of the communities it serves.
(a) Number of activities or programs (optional) (b) Persons served (optional) (c) Total community building expense (d) Direct offsetting
revenue 		(e) Net community building expense (f) Percent of total expense
1 Physical improvements and housing            
2 Economic development            
3 Community support            
4 Environmental improvements            
5 Leadership development and
training for community members		            
6 Coalition building            
7 Community health improvement advocacy            
8 Workforce development            
9 Other            
10 Total            
Part III
Bad Debt, Medicare, & Collection Practices
Section A. Bad Debt Expense
Yes
No
1
Did the organization report bad debt expense in accordance with Heathcare Financial Management Association Statement No. 15? ..........................
1
Yes
 
2
Enter the amount of the organization's bad debt expense. Explain in Part VI the methodology used by the organization to estimate this amount. ......
2
35,944,468
3
Enter the estimated amount of the organization's bad debt expense attributable to patients eligible under the organization's financial assistance policy. Explain in Part VI the methodology used by the organization to estimate this amount and the rationale, if any, for including this portion of bad debt as community benefit. ......
3
1,503,863
4
Provide in Part VI the text of the footnote to the organization’s financial statements that describes bad debt expense or the page number on which this footnote is contained in the attached financial statements.
Section B. Medicare
5
Enter total revenue received from Medicare (including DSH and IME).....
5
289,697,383
6
Enter Medicare allowable costs of care relating to payments on line 5.....
6
340,837,244
7
Subtract line 6 from line 5. This is the surplus (or shortfall)........
7
-51,139,861
8
Describe in Part VI the extent to which any shortfall reported in line 7 should be treated as community benefit.Also describe in Part VI the costing methodology or source used to determine the amount reported on line 6.Check the box that describes the method used:
Section C. Collection Practices
9a
Did the organization have a written debt collection policy during the tax year? ..........
9a
Yes
 
b
If "Yes," did the organization’s collection policy that applied to the largest number of its patients during the tax year
contain provisions on the collection practices to be followed for patients who are known to qualify for financial assistance? Describe in Part VI .........................

9b

Yes

 
Part IV
Management Companies and Joint Ventures(owned 10% or more by officers, directors, trustees, key employees, and physicians—see instructions)
(a) Name of entity (b) Description of primary
activity of entity 		(c) Organization's
profit % or stock
ownership % 		(d) Officers, directors,
trustees, or key
employees' profit %
or stock ownership % 		(e) Physicians'
profit % or stock
ownership %
1
2
3
4
5
6
7
8
9
10
11
12
13
Schedule H (Form 990) 2015
Schedule H (Form 990) 2015
Page
Part VFacility Information
Section A. Hospital Facilities
(list in order of size from largest to smallest—see instructions)
How many hospital facilities did the organization operate during the tax year?2
Name, address, primary website address, and state license number (and if a group return, the name and EIN of the subordinate hospital organization that operates the hospital facility) 		Licensed Hospital General-Medical-Surgical Children's Hospital Teaching Hospital Critical Hospital ResearchGrp Facility ER-24Hours ER-Other Other (Describe) Facility reporting group
1 KENNESTONE HOSPITAL
677 CHURCH STREET
MARIETTA,GA30060
www.wellstar.org
033-548 		X X         X   HEALTH PARK INPATIENT HOSPICE  
2 WINDY HILL HOSPITAL
2540 WINDY HILL ROAD
MARIETTA,GA30067
www.wellstar.org
033-545 		X X             LONG TERM ACUTE CARE  
Schedule H (Form 990) 2015
Page 4
Schedule H (Form 990) 2015
Page 4
Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
KENNESTONE HOSPITAL
Name of hospital facility or letter of facility reporting group  
Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A): 		1
Yes No
Community Health Needs Assessment
1 Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................ 1   No
2 Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C............... 2   No
3 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12...................... 3 Yes  
If "Yes," indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
4 Indicate the tax year the hospital facility last conducted a CHNA: 20 15
5 In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted ................. 5 Yes  
6 a Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C.................................. 6a Yes  
b Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................ 6b   No
7 Did the hospital facility make its CHNA report widely available to the public?.............. 7 Yes  
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
8 Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. .............. 		8 Yes  
9 Indicate the tax year the hospital facility last adopted an implementation strategy: 20 15
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10 Yes  
a If "Yes" (list url): SEE PART V, SECTION C
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b   No
11 Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.
12a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?............................... 12a   No
b If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........ 12b    
c If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $  

Schedule H (Form 990) 2015
Page 5
Schedule H (Form 990) 2015
Page 5
Part VFacility Information (continued)

Financial Assistance Policy (FAP)
KENNESTONE HOSPITAL
Name of hospital facility or letter of facility reporting group  
Yes No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 Yes  
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
b
c
d
e
f
g
h
14 Explained the basis for calculating amounts charged to patients?................. 14 Yes  
15 Explained the method for applying for financial assistance?................... 15 Yes  
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
b
c
d
e
16 Included measures to publicize the policy within the community served by the hospital facility?........ 16 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
SEE PART V, SECTION C
b
SEE PART V, SECTION C
c
d
e
f
g
h
i
Billing and Collections
17 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon non-payment?.................................. 17 Yes  
18 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a
b
c
d
e
Schedule H (Form 990) 2015
Page 6
Schedule H (Form 990) 2015
Page 6
Part VFacility Information (continued)

KENNESTONE HOSPITAL
Name of hospital facility or letter of facility reporting group  
Yes No
19 Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............ 19   No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
b
c
d
20 Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):
a
b
c
d
e
f
Policy Relating to Emergency Medical Care
21 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.................. 21 Yes  
If "No," indicate why:
a
b
c
d
Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
22 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
b
c
d
23 During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ............................... 23   No
If "Yes," explain in Section C.
24 During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ........................... 24   No
If "Yes," explain in Section C.
Schedule H (Form 990) 2015
Page 4
Schedule H (Form 990) 2015
Page 4
Part VFacility Information (continued)

Section B. Facility Policies and Practices

(Complete a separate Section B for each of the hospital facilities or facility reporting groups listed in Part V, Section A)
WINDY HILL HOSPITAL
Name of hospital facility or letter of facility reporting group  
Line number of hospital facility, or line numbers of hospital facilities in a facility
reporting group (from Part V, Section A): 		2
Yes No
Community Health Needs Assessment
1 Was the hospital facility first licensed, registered, or similarly recognized by a state as a hospital facility in the current tax year or the immediately preceding tax year?........................ 1   No
2 Was the hospital facility acquired or placed into service as a tax-exempt hospital in the current tax year or the immediately preceding tax year? If “Yes,” provide details of the acquisition in Section C............... 2   No
3 During the tax year or either of the two immediately preceding tax years, did the hospital facility conduct a community health needs assessment (CHNA)? If "No," skip to line 12...................... 3 Yes  
If "Yes," indicate what the CHNA report describes (check all that apply):
a
b
c
d
e
f
g
h
i
j
4 Indicate the tax year the hospital facility last conducted a CHNA: 20 15
5 In conducting its most recent CHNA, did the hospital facility take into account input from persons who represent the broad interests of the community served by the hospital facility, including those with special knowledge of or expertise in public health? If "Yes," describe in Section C how the hospital facility took into account input from persons who represent the community, and identify the persons the hospital facility consulted ................. 5 Yes  
6 a Was the hospital facility’s CHNA conducted with one or more other hospital facilities? If "Yes," list the other hospital facilities in Section C.................................. 6a Yes  
b Was the hospital facility’s CHNA conducted with one or more organizations other than hospital facilities?” If “Yes,” list the other organizations in Section C. ............................ 6b   No
7 Did the hospital facility make its CHNA report widely available to the public?.............. 7 Yes  
If "Yes," indicate how the CHNA report was made widely available (check all that apply):
a
b
c
d
8 Did the hospital facility adopt an implementation strategy to meet the significant community health needs
identified through its most recently conducted CHNA? If "No," skip to line 11. .............. 		8 Yes  
9 Indicate the tax year the hospital facility last adopted an implementation strategy: 20 15
10 Is the hospital facility's most recently adopted implementation strategy posted on a website?......... 10 Yes  
a If "Yes" (list url): SEE PART V, SECTION C
b If "No," is the hospital facility’s most recently adopted implementation strategy attached to this return? ...... 10b   No
11 Describe in Section C how the hospital facility is addressing the significant needs identified in its most recently conducted CHNA and any such needs that are not being addressed together with the reasons why such needs are not being addressed.
12a Did the organization incur an excise tax under section 4959 for the hospital facility's failure to conduct a CHNA as required by section 501(r)(3)?............................... 12a   No
b If "Yes" on line 12a, did the organization file Form 4720 to report the section 4959 excise tax?........ 12b    
c If "Yes" on line 12b, what is the total amount of section 4959 excise tax the organization reported on Form 4720 for all of its hospital facilities? $  

Schedule H (Form 990) 2015
Page 5
Schedule H (Form 990) 2015
Page 5
Part VFacility Information (continued)

Financial Assistance Policy (FAP)
WINDY HILL HOSPITAL
Name of hospital facility or letter of facility reporting group  
Yes No
Did the hospital facility have in place during the tax year a written financial assistance policy that:
13 Explained eligibility criteria for financial assistance, and whether such assistance included free or discounted care? 13 Yes  
If “Yes,” indicate the eligibility criteria explained in the FAP:
a
b
c
d
e
f
g
h
14 Explained the basis for calculating amounts charged to patients?................. 14 Yes  
15 Explained the method for applying for financial assistance?................... 15 Yes  
If “Yes,” indicate how the hospital facility’s FAP or FAP application form (including accompanying instructions) explained the method for applying for financial assistance (check all that apply):
a
b
c
d
e
16 Included measures to publicize the policy within the community served by the hospital facility?........ 16 Yes  
If "Yes," indicate how the hospital facility publicized the policy (check all that apply):
a
SEE PART V, SECTION C
b
SEE PART V, SECTION C
c
d
e
f
g
h
i
Billing and Collections
17 Did the hospital facility have in place during the tax year a separate billing and collections policy, or a written financial assistance policy (FAP) that explained all of the actions the hospital facility or other authorized party may take upon non-payment?.................................. 17 Yes  
18 Check all of the following actions against an individual that were permitted under the hospital facility's policies during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP:
a
b
c
d
e
Schedule H (Form 990) 2015
Page 6
Schedule H (Form 990) 2015
Page 6
Part VFacility Information (continued)

WINDY HILL HOSPITAL
Name of hospital facility or letter of facility reporting group  
Yes No
19 Did the hospital facility or other authorized party perform any of the following actions during the tax year before making reasonable efforts to determine the individual’s eligibility under the facility’s FAP?............ 19   No
If "Yes," check all actions in which the hospital facility or a third party engaged:
a
b
c
d
20 Indicate which efforts the hospital facility or other authorized party made before initiating any of the actions listed (whether or not checked) in line 19. (check all that apply):
a
b
c
d
e
f
Policy Relating to Emergency Medical Care
21 Did the hospital facility have in place during the tax year a written policy relating to emergency medical care that required the hospital facility to provide, without discrimination, care for emergency medical conditions to individuals regardless of their eligibility under the hospital facility’s financial assistance policy?.................. 21 Yes  
If "No," indicate why:
a
b
c
d
Charges to Individuals Eligible for Assistance Under the FAP (FAP-Eligible Individuals)
22 Indicate how the hospital facility determined, during the tax year, the maximum amounts that can be charged to FAP-eligible individuals for emergency or other medically necessary care.
a
b
c
d
23 During the tax year, did the hospital facility charge any FAP-eligible individual to whom the hospital facility provided emergency or other medically necessary services more than the amounts generally billed to individuals who had insurance covering such care? ............................... 23   No
If "Yes," explain in Section C.
24 During the tax year, did the hospital facility charge any FAP-eligible individual an amount equal to the gross charge for any service provided to that individual? ........................... 24   No
If "Yes," explain in Section C.
Schedule H (Form 990) 2015
Page 7
Schedule H (Form 990) 2015
Page 7
Part V
Facility Information (continued)
Section C. Supplemental Information for Part V, Section B. Provide descriptions required for Part V, Section B, lines 2, 3j, 5, 6a, 6b, 7d, 11, 13b, 13h, 15e, 16i, 18d, 19d, 20e, 21c, 21d, 22d, 23, and 24. If applicable, provide separate descriptions for each hospital facility in a facility reporting group, designated by facility reporting group letter and hospital facility line number from Part V, Section A (“A, 1,” “A, 4,” “B, 2,” “B, 3,” etc.) and name of hospital facility.
Form and Line Reference Explanation
SCHEDULE H, PART V, SECTION B, LINE 3J OTHER DESCRIPTIONS FROM THE COMMUNITY HEALTH NEEDS ASSSESSMENT (CHNA): The 2015 Joint Community Health Needs Assessment (www.wellstar.org/chna) of the WellStar Health System legacy hospital community - encompassing WellStar Cobb, Douglas, Kennestone, Paulding and Windy Hill hospitals - provides a list of multi-sector CHNA collaborators including individuals, organizations, and governmental agencies that were consulted and contributed special knowledge of medically underserved and low income populations and/or expertise in public health.
SCHEDULE H, PART V, SECTION B, LINE 5 INPUT FROM COMMUNITY REPRESENTATIVES & COMMUNITY SOURCES: The Kennestone and Windy Hill Hospitals integrated multiple sources of data from national and state web-based data platforms with multiple primary data gathering methods. To support the development of the 2015 CHNA and to foster broad collaboration among health systems and hospitals, WellStar engaged Georgia Health Policy Center (GHPC) in the Andrew Young School of Policy Studies at Georgia State University to work with its third-party CHNA consultant to leverage the quantitative and some of its qualitative (focus group) research it does for Kaiser Permanente. As a result, GPHCs data collection and analysis contributed to the CHNAs of four health systems (WellStar Health System, Grady Health System, Kaiser Permanente, and Piedmont Healthcare), a health plan and an urban county health department. WellStars third-party consultant solicited community input via photo testimonies, interviewing/surveying community stakeholders (representing a broad array of community-based organizations and other institutional asset engaged in socioeconomic determinants of health and health improvement), community members utilizing listening sessions at WellStars partnering community safety net clinics and Hispanic congregations/organizations and an online survey, and WellStar Medical Group providers. A comprehensive and expansive listing of CHNA collaborators can be found on page 39 of the joint legacy hospital CHNA report accessible to the public at www.wellstar.org/chna. Quantitative data sources include: 1. Community Commons (through Kaiser Permanente's web portal: www.chna.org/kp) 2. Georgia Department of Public Health's Online Analytical Statistical Information System (OASIS) 3. U.S. Census Bureau American Community Survey 5-Year Dataset 4. University of Wisconsin's County Health Rankings 5. Georgia Area Resource File 6. Staff from the Georgia Health Policy Center reviewed more than 60 data elements and developed county profiles and maps to understand the status of health and healthcare in the service region included in the Appendices of the 2015 Joint CHNA 7. WellStar Health Systems Enterprise Intelligence 8. Cobb Douglas Public Health 9. Behavioral Risk Factor Surveillance System (BRFSS) 10. Centers for Disease Control and Prevention for various indicators Qualitative data sources include: 1. Insights from 99 WellStar Medical Group (WMG) representatives regarding patient health status and community resources were gleaned from an online survey tool sent to WMG providers (MDs and nurse practitioners) and registered nurses. 2. A wide net was cast for community input with an online survey tool (available in English and Spanish) capturing demographics and overall personal health status and behaviors of 447 community members. Community clinics, health e-newsletters, workplace partners, a Public Health Department, a school system, a Hispanic non-profit, and faith-based organizations disseminated the online link via email and social media. Its approximated the survey link was distributed to 5,000 people. 3. 61 key informant surveys/interviews (all WellStar driven except eight by GHPC) were conducted with multi-sector leaders representing diverse organizations including Public Health Departments, governmental agencies, safety net clinics, business leaders, and regional health board representatives. Collecting information from a wide range of experts with first-hand knowledge about the community provided insight on health issues and care barriers along with recommended interventions. 4. To provide a broader base of input and use the CHNA process as a means to strengthen community partnerships, seven listening sessions (three in Spanish) were conducted with 58 medically underserved and uninsured community members. Sites for the sessions were partnering safety net clinic patients (Bethesda Community Clinic in Cherokee, Good Samaritan Health Center in Cobb, The CarePlace in Douglas), Latino community members (WellStar Congregational Health Network members Iglesia de Dios in South Cobb and McEachern UMC in Powder Springs), Ser Familia community members, and the Paulding County Health Department. In each listening session, a few community members provided: 5. photo testimonies from participants in listening sessions were taken to communicate the individuals greatest health-related need. 6. To fortify the seven listening sessions and gain a broader base of input, GPHC also conducted five focus groups with 41 participants in high need areas in each county in WellStars primary service area.
SCHEDULE H, PART V, SECTION B, LINE 6A ORGANIZATIONS INCLUDED IN COMMUNITY HEALTH NEEDS ASSESSMENT (CHNA): As an integrated health system, WellStar Health System submitted a joint 2015 CHNA for the five legacy hospitals (WellStar Cobb, Douglas, Kennestone, Paulding, and Windy Hill) located in its primary service area defined as one community. This varied approach from the individual 2013 CHNA reports and implementation strategies is attributed to WellStars System-wide delivery system of community benefit services and the ability to best leverage its economies of scale and services to address the prioritized health needs of the community, especially the most vulnerable. For the WellStar hospitals and its collaborative community partners, the joint approach to addressing priority health needs maximizes resources to enhance care access, strengthens partnerships for shared responsibility and helps improve overall community health. (Also, note there were no variances on the priority health needs of each individual hospital in the 2013 reports except for the data included. Due to hospital and community collaboration, the information and implementation strategy were basically the same for each hospital to be delivered and lead at the System-level.) (1) The joint WellStar legacy hospital CHNA report meets the requirements of paragraph (b)(6)(i) of this section. WellStars five legacy hospitals collaborated in conducting the 2015 CHNA, and, for specified quantitative and qualitative data, other hospital systems including Kaiser Permanente, Piedmont and Grady. Guided at the System level, WellStar hospitals solicited the help of state and local health departments and key informants to assess the health needs of the community and collaborated in conducting community surveys and hosting listening sessions and focus groups to solicit and receive input from residents, including its medically underserved, low-income, and minority populations. The 2015 CHNA report documents the joint CHNA process and contains all of the elements described in paragraph (b)(6)(i) of the IRSs 501(r) section in the Code of Regulations as it relates to community health needs assessments. The WellStar Health System Board of Trustees adopted the joint CHNA and its implementation strategy on June 2, 2016. (2) The joint CHNA report is clearly identified as applying to the hospital facility. All five WellStar legacy hospitals, WellStar Cobb, Douglas, Kennestone, Paulding, and Windy Hill hospitals, are noted on the cover of the joint CHNA and each hospitals president is listed as members of the WellStar Community Benefit Oversight Committee within the CHNA, along with a hospital-specific profiles and county-specific primary and secondary data and noted in the Tracking Progress section (2015 CHNA, page 62). (3) All of the collaborating hospital facilities and organizations included in the joint CHNA report define their community to be the same. Yes, based upon WellStars: 1. System-based model for delivering most all community benefit services and evaluating its impact (again, to leverage the economies of scale and services to deliver program that address the priority needs) 2. Overlapping hospital 90 percent catchment areas 3. Similar community health needs key findings and themes (access to care and healthy lifestyles prevalence of chronic disease) based upon intensive quantitative and qualitative data and the work of the WellStar Community Health Collaborative task force to identify the priority needs of the overall community (representatives from WellStar services lines, hospitals, departments and the community stakeholders) based on the severity of the need and assets of WellStar and its community stakeholders and partners to address the need.
SCHEDULE H, PART V, SECTION B, LINE 7A THE KENNESTONE HOSPITAL, INC. CHNA / Windy Hill hospital CHNA can be found online at the following web address: www.wellstar.org/chna and clicking on the 2015 Joint Community Health Needs Assessment (CHNA) link under the WellStar Legacy Hospitals header or directly: https://www.yumpu.com/en/document/view/55617879/wellstar-chna-report-2016. AND on the WELLSTAR HEALTH SYSTEM WEBSITE: WWW.WELLSTAR.ORG.
SCHEDULE H, PART V, SECTION B, LINE 10A KENNESTONE HOSPITAL'S MOST RECENTLY ADOPTED IMPLEMENTATION STRATEGY CAN BE found ON ITS WEBSITE AT: www.wellstar.org/chna and clicking on the Implementation Strategy link under the header WellStar Legacy Hospital header. or directly at: https://www.wellstar.org/about-us/documents/chna/ chna_implementation_strategy_2016.pdf WINDY HILL HOSPITAL'S MOST RECENTLY ADOPTED IMPLEMENTATION STRATEGY CAN BE found ON ITS WEBSITE AT: http://www.wellstar.org/aboutus/Documents/IMPLEMENTATION_STRATEGY/ WINDYHILL_IMPLEMENTATION_STRATEGY_11112013.PDF.
SCHEDULE H, PART V, SECTION B, LINE 11 PROGRAMS & STRATEGIES TO ADDRESS THE NEEDS OF THE COMMUNITY: WellStar IS implementing two new System-wide WCHC programs, WellStar 4-1 Care Network and Live Well, to address the priority health needs of the 2015 Joint CHNA. The programs are designed to: - Provide organization, framework and leadership to the delivery of community benefit services and enables us to more effectively evaluate and measure the impact on community health - Strengthen WellStars strategic community partnerships in public AND PRIVATE SECTORS THROUGH FORMALIZED ENGAGEMENT AS AS "PARTNERS IN HEALTH" LEVERAGING EXPERTISE, RESOURCES AND SERVICES TO COMPLEMENT AND/OR BRIDGE INTERVENTION GAPS AND ADDRESS HEALTH DISPARITIES - Boost WellStars ability to replicate and deliver community benefit services across an expanding health system footprint - Maximize the investment in WellStars safety net clinic/non-profit partners by better aligning our services and resources to address priority health needs - Improve overall community health, especially among the vulnerable. The WellStar 4-1 Care Network and Live Well programs provide organizational structure and accountability to WellStar and its legacy hospitals efforts to reach out to those in need, to improve the health of the communities we serve and to enhance access to care. These efforts flow from the WellStar mission and vision and to meet the requirements of federal government (Affordable Care Act Section 9007) of system-wide oversight and guidance regarding tracking community benefit activities, assessing community health needs and developing strategic plans that prioritize community benefit programming. 1. WellStar 4-1 Care Network: Clinical Care Intervention Program - Priority Need Addressed from the 2015 Joint CHNA: Underuse of Primary Care: includes ED utilization and increased care capacity at community safety net clinics Goals: - Expand the WellStar patient experience to partnering community safety net clinics to reduce health disparities through improved access to volunteer primary care physicians and other specialty medical services to vulnerable populations - Build a cost-efficient model of care - Develop and educate about available health resources and facilities to "prescribe" to the medically underserved and uninsured - Decrease ED utilization and readmissions for non-emergent needs to deliver the right care at the right place to the medically underserved and uninsured. THE NAME REFERS TO THE AIM OF THE LOW-COST HEALTHCARE DELIVERY SYSTEM IN THE COMMUNITY TO CARE "FOR ONE" ANOTHER BY ADDRESSING THE UNDERUSE OF PRIMARY CARE AND REDUCING ED UTILIZATION AND READMISSIONS FOR NON-EMERGENT ISSUES THAT POTENTIALLY COULD BE TREATED IN AN OUTPATIENT SETTING. It also reflects increasing safety net clinic capacity, education and resources via WellStar Medical Group (WMG) citizenship, with MDs and NPs volunteering four hours one time per month. 2. Live Well: Healthy Behaviors Intervention Program - Priority Health Needs Addressed from the 2015 Joint CHNA: Cancer, Cardiovascular Disease, COPD/Asthma, Obesity, Type 2 Diabetes Goal: - Improve the health of medically underserved and uninsured residents through targeted preventive services, education and outreach. Live Wells targeted outreach to vulnerable populations to address healthy lifestyle-related priority health needs leverages the WellStar 4-1 Care Network partners by delivering health need-specific education, events and preventive screenings on-site and in other high-need site locations. Live Well works in tandem with 4-1 Care and other collaborative partnerships to help reduce the prevalence of chronic disease and its complications through prevention and wellness activities and the promotion of healthy lifestyles. Aligning the resources of the WellStar Community Education & Outreach team, Live Well also will partner with other community groups and organizations proximate to community safety net clinics for volunteerism, health navigation, transportation, and other supportive services. UNADDRESSED CHNA NEEDS - Health needs not identified as priority fall into one of three categories: 1) Beyond the scope of WellStar services, e.g. dental care which is addressed by safety nets clinics 2) Needs further intervention, but no plans for expanding current community benefit services at this time, e.g. maternal/infant health 3) Relying on community partners to lead efforts with expertise in these areas with WellStar in a supportive role, e.g. substance abuse, violence, suicide, STDs, transportation. To identify the six priority health needs WellStars legacy hospitals will address, leaders of Kennesaw State Universitys A.L. Burruss Institute of Public Service & Research were solicited to guide the WellStar Community Health Collaborative task force (made up of WellStar internal team members and community stakeholders) through the prioritization process. Health needs data summaries were advanced ahead of the Health Needs Summit on FebRUARY 25, 2016 for review. From the significant health needs identified by CHNA research conducted in the fall/winter of 2015, the priority health needs were determined via an online survey tool for the community WellStar legacy hospitals serve.
SCHEDULE H, PART V, SECTION B, LINE 13B FAP ELIGIBILITY CRITERIA - INCOME LEVEL OTHER THAN FPG: THE HOSPITAL ABIDES by the financial assistance requirements under IRC 501(R)(5). IRC 501(R)(5) requires health care facilities to limit the amounts charged for emergency and other medically necessary care that is provided to individuals eligible for assistance under the health care facilities financial assistance policy to not more than the amounts generally billed to individuals who have insurance. The hospital extends its sliding scale for Financial Assistance Policy (FAP) eligibility well beyond the minimum government levels to 300% of FPG. WellStar has chosen to use the average of the three best negotiated commercial rates as the trigger to not exceed in the application of the discounts/amounts charged to patients, on our sliding scale.
SCHEDULE H, PART V, SECTION B, LINE 13H FAP ELIGIBILITY CRITERIA - OTHER CRITERIA: Other special circumstances may qualify a patient for full indigent or sliding scale charity benefits. Special circumstances may include but not limited to: - Patient deceased, with verification that there is no estate. - Unable to contact patient but Propensity to Pay software returns a low ability/low propensity designation.
SCHEDULE H, PART V, SECTION B, LINE 15E METHOD FOR APPLYING FOR FINANCIAL ASSISTANCE: In order to qualify for Financial Assistance, cooperation with WellStar Health System hospital Financial Assistance staff is necessary in identifying and determining alternative sources of payment or coverage from public and private payment programs. In particular, all applicants filing a FAP Application for Financial Assistance must provide proof of Household Income and Household Assets by providing any or all of the following that are applicable: - Provide three (3) months of the most recent paycheck stubs or a statement from employer verifying gross wages - IRS W-2 issued during the past year - Most recent IRS Form 1040 - Most recent two (2) months of bank statements for each checking, savings, money market or other bank or investment account - Written statements for the most recent two (2) months for all other income (e.g., unemployment compensation, disability, retirement, student loans, award letter from Social Security Office, current Profit and Loss report for all self-employed applicants, alimony documentation, child support documentation, etc.) - Unemployment compensation denial letter - Documentation of asset values, including, without limitation, property tax statements, Certificates of Deposit, 401k, 403b, IRA and other investment statements - Contribution statements from individuals who contribute income or in-kind assistance to the patient. Financial Assistance Policy eligibility will be determined based on a thorough review of the submitted information.
SCHEDULE H, PART V, SECTION B, LINE 16A THE WELLSTAR HEALTH SYSTEM COMMUNITY FINANCIAL ASSISTANCE POLICY CAN BE FOUND ON ITS WEBSITE: https://www.wellstar.org/about-us/policies-procedures/pages/community-FINA NCIAL-ASSISTANCE-POLICY.ASPX. SCHEDULE H, PART V, SECTION B, LINE 16B THE WELLSTAR HEALTH SYSTEM FINANCIAL ASSISTANCE APPLICATION CAN BE FOUND ON ITS WEBSITE: https://www.wellstar.org/about-us/policies-Procedures/documents/financial- aid-program-application.pdf and clicking Application in the right navigation box titled Related Documents. A window will appear that allow you to scroll to the appropriate WellStar hospital and click for a PDF version of the application to print or download. SCHEDULE H, PART V, SECTION B, LINE 16C A PLAIN LANGUAGE SUMMARY OF THE WELLSTAR HEALTH SYSTEM FINANCIAL ASSISTANCE APPLICATION CAN BE FOUND ON ITS WEBSITE: https://www.wellstar.org/about-us/policies-procedures/documents/fap-plain- language-summary-wgh.pdf.
SCHEDULE H, PART V, SECTION B, LINE 16I PUBLICATION OF THE FINANCIAL ASSISTANCE POLICY (FAP): In addition to the other methods of posting the financial assistance policy, the hospital makes available for patients in admissions and outpatient registration areas a prominently displayed sign stating financial assistance is available and a brochure including frequently asked questions.
SCHEDULE H, PART V, SECTION B, LINE 20E ADDITIONAL EFFORTS MADE BEFORE COLLECTIONS ACTION INITIATED: The hospital facility also notified individuals of the financial assistance policy online at: http://www.wellstar.org/pages/online-bill-pay.aspx. Furthermore, the hospital facility utilizes a propensity to pay software. Individuals with a low ability/low propensity designation may qualify for full indigent or sliding scale charity benefits.
   
   
   
   
   
   
   
   
   
   
   
   
   
   
   
Schedule H (Form 990) 2015
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Schedule H (Form 990) 2015
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Part VFacility Information (continued)

Section D. Other Health Care Facilities That Are Not Licensed, Registered, or Similarly Recognized as a Hospital Facility
(list in order of size, from largest to smallest)
How many non-hospital health care facilities did the organization operate during the tax year?  
Name and address Type of Facility (describe)
1
2
3
4
5
6
7
8
9
10
Schedule H (Form 990) 2015
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Schedule H (Form 990) 2015
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Part VI
Supplemental Information
Provide the following information.
1 Required descriptions. Provide the descriptions required for Part I, lines 3c, 6a, and 7; Part II and Part III, lines 2, 3, 4, 8 and 9b.
2 Needs assessment. Describe how the organization assesses the health care needs of the communities it serves, in addition to any CHNAs reported in Part V, Section B.
3 Patient education of eligibility for assistance. Describe how the organization informs and educates patients and persons who may be billed for patient care about their eligibility for assistance under federal, state, or local government programs or under the organization’s financial assistance policy.
4 Community information. Describe the community the organization serves, taking into account the geographic area and demographic constituents it serves.
5 Promotion of community health. Provide any other information important to describing how the organization’s hospital facilities or other health care facilities further its exempt purpose by promoting the health of the community (e.g., open medical staff, community board, use of surplus funds, etc.).
6 Affiliated health care system. If the organization is part of an affiliated health care system, describe the respective roles of the organization and its affiliates in promoting the health of the communities served.
7 State filing of community benefit report. If applicable, identify all states with which the organization, or a related organization, files a community benefit report.
Form and Line Reference Explanation
SCHEDULE H, PART I, LINE 6A PUBLICATION OF COMMUNITY BENEFIT REPORT: KENNESTONE HOSPITAL, INC. (CONSISTING OF KENNESTONE HOSPITAL AND WINDY HILL HOSPITAL) IS AN affiliate of Wellstar Health System, Inc. which on an annual basis issues a community benefit report. This report is subsequently distributed in and around the five-county primary service area of the health system. On an annual basis the hospital reportS ITS community health benefits report to the Georgia Hospital Association (GHA). GHA aggregates the hospital specific reports into a statewide community health benefit report. The State of Georgia also requires hospitals to file the Hospital Financial Survey and the Indigent Care Trust Fund Survey so that it can collect information on hospital financial class categories and also to determine the amount of uncompensated care by hospital. THE COMMUNITY BENEFIT REPORT CAN BE FOUND AT THE FOLLOWING LINK: https://www.wellstar.org/community/documents/wellstar- COMMUNITY-BENEFITS-REPORT.PDF.
SCHEDULE H, PART I, LINE 7 COST TO CHARGE RATIO: For purposes of the IRS Form 990, Schedule H, Wellstar Health System and Affiliates (including Kennestone and Windy Hill Hospitals) have estimated the current year cost to charge ratio for each hospital as it is reported in the annual community benefit report and as it will be reported in the state's Annual Hospital Financial Survey.
SCHEDULE H, PART III, SECTION A, LINE 2 METHODOLOGY USED TO ESTIMATE BAD DEBT: The reported bad debt charges is derived from the unpaid balances of patient accounts that are deemed uncollectible after 120 days of collection effort by the hospital's patient financial services staff. The unpaid patient accounts are then sent to collection agencies and any collected amount is deemed as bad debt recovery. The source of this data is the hospital's detailed financial trial balance. The net reported bad debt charges are then multiplied by the Hospital Financial Survey calculated cost to charge ratio to arrive at the estimated bad debt expense. SCHEDULE H, PART III, SECTION A, LINE 3 METHODOLOGY & RATIONALE USED TO DETERMINE BAD DEBT ATTRIBUTABLE TO PATIENT'S ELIGIBLE UNDER ORGANIZATION'S FAP: The bad debt attributable to patients eligible under the hospital's financial assistance program is determined using a weekly bad debt conversion report for a period of twelve months. The conversion rate for this period is used to determine this bad debt category. The total reported conversion charges is multiplied by a calculated cost to charge ratio to arrive at the cost of bad debt attributable to patient's eligible under the hospital's FAP.
SCHEDULE H, PART III, SECTION B, LINE 8 MEDICARE SHORTFALLS: Kennestone and Windy Hill Hospitals are providers of inpatient and outpatient services to Medicare program beneficiaries at determined rates. Without the participation in the Medicare program these patients may not have had convenient access to those services. The Medicare shortfall on SCHEDULE H, Part III, Section B, line 7 represents the uncompensated difference between the expected reimbursement and the Medicare charges for those services stated at cost. We determine a cost to charge ratio for Medicare patients as part of the annual filing of the Medicare cost report.
SCHEDULE H, PART III, SECTION C, LINE 9B COLLECTION PRACTICES: The policy written for collection practices that applies to all Wellstar Health System entities incorporates guidelines for personnel in the admissions and patient access areas to be trained in identifying patients that might qualify for financial assistance. It is also the policy of all Wellstar facilities to have at least one employee or contractor available at all times, especially in the hospitals with emergency rooms, who can provide assistance with the paperwork necessary to help patients who would qualify for governmental and other assistance programs.
SCHEDULE H, PART VI, LINE 2 NEEDS ASSESSMENT: To assess the current health and well-being of the community served, WellStar Health System, Inc. conducted a Joint Community Health Needs Assessment (CHNA) for its five legacy hospital community including KENNESTONE AND WINDY HILL HospitalS. The CHNA was a collaborative effort involving WellStar executive leadership, hospital leadership, public health agencies, and a multi-sector coalition of community stakeholders. Collaborators represented a broad knowledge base of the hospital's primary service area comprising Bartow, Cherokee, Cobb, Douglas, and Paulding counties and some outlying zip codes determined by utilization. To assess the current community health status and capture a broad base of input, WellStar used the following questions to guide the CHNA process and research: 1. What is the current health status of the community WellStar serves? 2. What are the major risk factors and causes of poor health in our community? 3. What actions by WellStar and its partners are needed to address the risk factors and causes? 4. What are the existing WellStar and community assets, programs and services that can help address the needs? 5. Who are the partners or potential partners with the expertise and resources to help expedite a connection to healthcare, education and resources?
SCHEDULE H, PART VI, LINE 3 PATIENT EDUCATION OF ELIGIBLITY FOR ASSISTANCE: THE HOSPITAL provideS notice of the availability of community financial assistance through the Financial Assistance Policy (FAP) via: - Signage - Patient Brochure - Billing Statement - Collection Action Letter - Online at: https://www.wellstar.org/about-us/policies-procedures/pages/community-FINA NCIAL-ASSISTANCE-POLICY.ASPX. Kennestone and Windy Hill Hospitals provide its patients with hospital personnel or contracted personnel who are trained in all aspects of governmental programs, payments plans, charity discounts, and other financial assistance offered to assist them in their hospital bills. If the patient is eligible for federal or state assistance programs, a staff member is knowledgeable in the steps necessary to qualify those individuals. If a patient is indigent or charity eligible they will be offered assistance through the hospital's charity and indigent care policy including the state's indigent care trust fund. If the patient has no other insurance and fails to qualify for indigent care assistance, the financial counselor can then offer the patient an opportunity to accept a payment plan with discounted payment options based on their ability to pay immediately or over time. All patients are afforded these opportunities.
SCHEDULE H, PART VI, LINE 4 COMMUNITY INFORMATION: As part of an integrated health system, WellStar Health system, inc. and Kennestone and Windy Hill hospitals' service area overlaps with the other WellStar legacy hospitals. This intersecting impact across WellStar's five-county primary service area of approximately 1.5 million residents in Bartow, Cherokee, Cobb, Douglas, and Paulding counties is not easily determined by a county by county analysis and as such is deemed as one community. The majority of patient volume comes from this service area although other health systems have a presence in the area as well. Demographically, the region is one of the fastest growing in the state as well as the country and the expansion of the services for the patient population reflects a desire to offer healthcare "closer to home" since WellStar is considered a part of a larger metropolitan Atlanta MARKET. ECONOMICALLY, the region is strong in per capita income but given recent trends a rise in the uninsured and indigent population has occurred. Kennestone and Windy Hill Hospitals are two of five hospitals that are affiliated with Wellstar Health System. The primary service area of the system is located in the Northwest Georgia area and receives the majority of its patients from one of five counties (Cherokee, Cobb, Douglas, Bartow and Paulding). Generally about 85% to 90% of the patient volume comes from this service area although other health systems have a presence in the area as well.
SCHEDULE H, PART VI, LINE 5 PROMOTION OF COMMUNITY HEALTH: As stated in the Wellstar Health System, Inc and Affiliates audited financial statements for the period ended 6/30/2016, Kennestone and Windy Hill Hospitals (affiliates of Wellstar Health System, Inc.) operate as charitable organizations consistent with the requirements of Internal Revenue Code SECTION 501(c)(3) and the "community benefit standard" of IRS Ruling 69-545. In this regard the governing body of the organization and/or its parent is composed of prominent citizens in the community, medical staff privileges in the hospital are available to all qualified physicians in the area consistent with the size and nature of the facility; Kennestone Hospital operates a full-time emergency room open to all regardless of ability to pay; and the hospitals (Kennestone and Windy Hill) provide care to the needy members of the community consistent with its charity care policy. The hospital's excess funds are generally applied to expansion and replacement of existing facilities and equipment, amortization of indebtedness, improvement of patient care, community benefit activities including health education, preventive screenings and health fairs, research, subsidized health services, and charity care. Kennestone Hospital committed $26,439,808 and Windy Hill Hospital committed $14,558,756 in capital expenditures for the year to meet those needs.
SCHEDULE H, PART VI, LINE 6 AFFILIATED HEALTH CARE SYSTEM: WellStar Health System, the largest health system in Georgia, is known nationally for its innovative care models, focused on improving quality and access to healthcare. WellStar consists of WellStar Medical Group, 240 medical office locations, outpatient centers, health parks, a pediatric center, nursing centers, hospice, homecare, as well as 11 inpatient hospitals: WellStar Atlanta Medical Center, WellStar Atlanta Medical Center South, WellStar Kennestone Regional Medical Center (anchored by WellStar Kennestone Hospital), WellStar West Georgia Medical Center, and WellStar Cobb, Douglas, North Fulton, Paulding, Spalding Regional, Sylvan Grove and Windy Hill hospitals. As a not-for-profit, WellStar continues to reinvest in the health of the communities it serves with new technologies and treatments. For more information, visit wellstar.org.
SCHEDULE H, PART VI, LINE 7 STATE FILING OF COMMUNITY HEALTH BENEFIT REPORT: On an annual basis the KENNESTONE AND WINDY HILL HOSPITALS report THEIR community health benefits report to the Georgia Hospital Association (GHA). GHA aggregates the hospital specific reports into a statewide community health benefit report. The State of Georgia also requires hospitals to file the Hospital Financial Survey and the Indigent Care Trust Fund Survey so that it can collect information on hospital financial class categories and also to determine the amount of uncompensated care by hospital.
Schedule H (Form 990) 2015
Additional Data


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