The New Roseland Hospital Transformation Proposal

THE NEW ROSELAND HOSPITAL TRANSFORMATION PROPOSAL

APPLICATION TO THE ILLINOIS DEPARTMENT OF HEALTHCARE AND FAMILY SERVICES FOR FUNDING UNDER HEALTHCARE TRANSFORMATION COLLABORATIVES

April 9, 2021 Table of Contents

INTRODUCTION ...... 1

PROPOSALS

1. THE RCH BEHAVIORAL HEALTH TRANSFORMATION AND ADOLESCENT SUSTAINABLE HEALING PROGRAM ...... 2

2. THE RCH OBSTETRIC IMPROVEMENT PLAN ...... 17

3. THE RCH CENTER FOR ARTHRITIS AND JOINT REPLACEMENT ...... 28

EXHIBITS

EXHIBIT A: APPLICATION FOR TRANSFORMATION FUNDING COVER SHEET

EXHIBIT B: ROSELAND HOSPITAL 2019 COMMUNITY HEALTH NEEDS ASSESSMENT EXHIBIT C: COMMUNITY LETTERS OF SUPPORT  SEN. EMIL JONES III  REP. KAM BUCKNER  REP. MARCUS C. EVANS JR.  REP. JUSTIN SLAUGHTER  REP. JAWAHARIAL OMAR WILLIAMS  SERVICE EMPLOYEES INTERNATIONAL UNION (“SEIU”)  ADVOCATE AURORA HEALTH  CHICAGO FAMILY HEALTH CENTER  INSTITUTE FOR WOMENS HEALTH  PHALANX FAMILY SERVICES  GATEWAY FOUNDATION  TCA HEALTH, INC EXHIBIT D: RACIAL EQUITY IMPACT ASSESSMENT

EXHIBIT F: RCH EMPLOYMENT DATA BY ZIP AND ETHNICITY

APRIL 9, 2021

To the Illinois Department of Healthcare and Family Services,

On behalf of The New Roseland Hospital (“RCH”) and the collaborators described herein, we are excited to present the following proposal for consideration and funding as part of the Illinois Healthcare Transformation Collaboratives Program (“HTCP”).

As a critical access hospital on Chicago’s south side, the RCH knows all too well the obstacles to ensuring equitable healthcare access and delivery. RCH’s service area spans six (6) zip codes1 and twelve (12) community areas2 within the city of Chicago.3 Of the 300,000 individuals that reside in RCH’s service area, 86% identify as non-Hispanic African American/Black, 8% identify as Non- Hispanic white, and 4% identify as Hispanic/Latinx.4 This is somewhat different than the racial distribution in greater South Chicago where 51.6% of the 1,026,829 persons identify as black, 30.9% identify as LatinX and 28.4% identify as white.5 The CDC has assigned South Chicago a social vulnerability index of 87.6, the highest social vulnerability index in the Chicagoland area.6

As soon as Illinois began its commitment to implementing this healthcare transformation, RCH committed to identifying those strategies and initiatives that will provide the most positive impact on its Community, in terms of health, wellness, access and equity. In fact, RCH has implemented its own transformation program7 independent of the HTCP which is a multi-phase, multi-tiered approach to providing more integrated and coordinated patient-driven healthcare services of the highest quality so as to empower patient-choice across the entire spectrum of acute recovery to generalized wellness.

Although there are so many opportunities for transformation, RCH is pleased to introduce and request funding for three (3) of its most exciting transformation programs during this initial offering for distribution under FY 2020/2021:

1. The New RCH Behavioral Health Transformation and Adolescent Sustainable Healing Program; 2. The New RCH Obstetric Improvement Plan; and 3. The New RCH Center for Arthritis and Joint Replacement.

1 60617, 60619, 60620, 60628, 60643 and 60827. 2 Auburn Gresham, Avalon Park, Beverly, Burnside, Chatham, Greater Grand Crossing, Morgan Park, Pullman, Riverdale, Roseland, Washington Heights and West Pullman 3 See Roseland Hospital 2019 Community Health Needs Assessment, at p. 3. (A copy of the Roseland Hospital 2019 Community Health Needs Assessment attached as Exhibit B.) 4 Id., 5 See University of Illinois at Chicago, Transformation Data & Community Needs Report: Chicago- South Side, February 2021, at 14. 6 Id., at 18. 7 https://www.roselandhospitaltalks.org/roseland-hospital-talks-transformat

1 | P a g e THE NEW ROSELAND HOSPITAL (“RCH”) ADULT BEHAVIORAL HEALTH TRANSFORMATION

EXECUTIVE SUMMARY

The RCH Adult Behavioral Health Transformation and Adolescent Sustainable Healing Program will be a robust collaboration to expand and improve the current behavioral health services that The New Roseland Hospital (“RCH”) provides to its patients and in service to the community.

The Adult Behavioral Health Transformation will expand RCH’s current adult behavioral health unit (“BHU”) by adding nineteen (19) beds to its existing twenty-four (24) bed adult BHU, for a total of forty-three (43) adult BHU beds. These additional nineteen (19) adult BHU beds will allow patients in crisis to be placed more quickly and avoid languishing in emergency departments. Transformation funds, if awarded, will be used to add these beds and ensure there is appropriate and adequate staff, equipment and resources to provide high-quality behavioral health care.

The Adolescent Sustainable Healing Program will be a new offering at RCH that will transform two stand-alone residential buildings on RCH’s campus into two gender-specific, 7-bed “healing centers” where adolescents can receive intensive inpatient behavioral, mental and substance abuse treatment. RCH recently discontinued its adolescent acute mental illness program because it did not have the resources and space necessary for a successful adolescent behavioral health program. With help from the Healthcare Transformation Program and in consultation with Maryville Academy, RCH will develop and implement a sustainable residential treatment program that will take adolescents1 from self-destruction to self-empowerment in a program that utilizes a Trauma-informed model of care and offers highly skilled professional services led by Dr. Jody Reed, the New RCH Behavioral Health Medical Director, and RCH’s other board-certified psychiatrists, psychologists, and therapists with advanced degrees and specializations in teen mental health, substance abuse, depression, anxiety, and eating disorders. RCH’s behavioral health team will utilize proven modalities and apply innovative treatment approaches to address the complexities of teen dual diagnosis disorders, including identifying and healing the core issues that underlie self-destructive behaviors.

Both the adult and adolescent programs will benefit from a transformational collaboration with outpatient and community service providers to provide earlier, and more comprehensive, cooperation to identify and address patient’s transition needs in advance of the “warm hand off”. By introducing and connecting the patient, their family and/or their support system(s) to the patient’s outpatient care plan as well as necessary community resources while still an inpatient, RCH can attack the social determinants of health that create obstacles to successful transitions, outpatient engagement and sustainable healing. RCH looks forward to facilitating more robust education and orientation to help patients, their families and their support

1 Adolescents will be defined as persons age 13-17 and adults will be persons age 18 and order.

2 | P a g e systems understand where to find help, how to find covered help and why outpatient follow-up is crucial for sustained healing.

Additionally, this collaboration can also address other post-discharge issues that may relate to safe housing, employment, available food and other barriers that cause patients to forego follow-up care and leave their treatment.2 By working together during the inpatient process and facilitating as many outpatient and community service connections as possible, RCH can help patients find sustainable healing in their community.

Ideally, by ensuring adequate placement and proper treatment for adults and adolescents in crisis, this collaboration can improve the utilization of outpatient treatment programs, reduce readmissions and ultimately reduce the costs borne by the Community for a system that does not currently support sustained healing.

South Chicago is in desperate need for more mental health professional services as the shortages that exist in that area are pervasive.3 Those that have studied this shortage recommend programming that incentivizes clinic-community linkages, promotes collaborative care models and builds capacity.4 RCH believes this proposal, if funded, will achieve the goals of this Illinois Healthcare Transformation Program and requests the Illinois Department of Healthcare and Family Services award this collaboration $5,000,000 to begin to operationalize the plan for its service area, an area with a community desperately in need.

PARTICIPATING ENTITIES

The RCH Adult Behavioral Health Transformation and Adolescent Sustainable Healing Program will involve the following entities:

 The New Roseland Hospital;  Maryville Academy;  Gateway Foundation;  Beloved Community Family Wellness Center;  Phalanx Family Services;  TCA Health; and  Chicago Family Health Center.5

Please refer to the Application for Transformation Funding Cover Sheet, attached here to as Exhibit A.

2 Id., at 40-43. 3 Id., at 51. 4 Id., at 54. 5 As this collaboration has been formed, there has been a great deal of interest in participation. RCH may request to include additional collaborators if the project is funded and operationalized.

3 | P a g e COMMUNITY INPUT

This collaborative endeavor will benefit a service area in south Chicago, which is part of Cook County that includes:

Zip Codes Community Areas 60617 Auburn Gresham Morgan Park 60619 Avalon Park Pullman 60620 Beverly Riverdale 60628 Burnside Roseland 60643 Chatham Washington Heights 60827 Greater Grand Crossing West Pullman

RCH identified and confirmed this service area needs more and improved behavioral health services through a commissioned Community Health Needs Assessment, which is attached as Exhibit B.

RCH and members of the Alliance for Health Equity (“AHE”), a collaborative of more than 30 hospitals, 7 health departments and 100 community partners, worked together between March 2018 through March 2019 to conduct a comprehensive Community Health Needs Assessment (“CHNA”) in Cook County.6 The primary data for the CHNA was collected by:

(i) Community input surveys; (ii) Community resident focus groups and learning map sessions; (iii) Health care and social service provider focus groups; and (iv) Two stakeholder assessments led by partner health departments (Forces for Change Assessment and Health Equity Capacity Assessment).7

Secondary data was compiled and analyzed in partnership with epidemiologists from the Chicago Department of Public Health and Cook County Department of Health, the Illinois Public Health Institute and member hospitals.

The CHNA confirmed that all of RCH’s service area has mental health/behavioral health professional shortages.8

6 See Roseland Hospital 2019 Community Health Needs Assessment, at 4. A copy of the Roseland Hospital 2019 Community Health Needs Assessment is attached as Exhibit B.). 7 Id., at 4. 8 Id., at 17, 18.

4 | P a g e The CHNA community participants identified access to mental health services as one of the most important factors for a health community.9

This study confirmed that RCH’s service area would benefit from additional and improved mental and behavioral health services to address community concerns related to chronic stress, pervasive trauma and fear related to a multitude of factors including child abuse, domestic

9 Id.

5 | P a g e violence, living in high-crime neighborhoods, ongoing and continuous racial discrimination and homelessness.10

Since then, RCH has also hosted a series of Town Hall Meetings (personally and virtually) for legislators, community members, and employees over the last two years in preparation of submitting this Transformation Plan. Additionally, RCH’s Chief Executive Officer has presented the Strategic Transformation Plan to the State of Illinois Legislative Medicaid Working Group. Legislators, community members, community services organizations, collaborators and employees have provided overwhelming support for these projects. Many have provided Community Letters of Support, which are attached to this Proposal as Exhibit C.

Given the need for adolescent and adult behavioral health services in the areas beyond RCH’s service area, it is all but certain this collaboration will benefit surrounding communities when area hospitals face capacity issues and patients needing placement may not have in-network insurance coverage at a particular area hospital.

DATA

Second only to childbirth, mental health and behavioral disorders are the “most frequent hospitalization blocks for South Chicago.”11 And in South Chicago, “the greatest percentage of readmissions and resource intensive hospitalizations [relate to] mental illness and substance abuse disorder.”12 Mood affective disorders, schizophrenia and psychoactive substance use disorders are among three of the top six disease blocks for hospital admission frequency and hospital readmissions.13 Moreover, these disease blocks are resource-intensive and outpatient treatable.”14 Unfortunately, “outpatient care prior to or subsequent to hospital-level care is proportionally low”.15

It well established there is a need for greater inpatient behavioral health services, especially in hospitals like RCH that accept all patients and cases regardless of payor source. This collaboration, however, will do more than simply add beds for inpatient care. The goal of this collaboration is to use the expanded inpatient service to facilitate and build stronger connections between patients, families, outpatient providers and community resources to incentivize ongoing recovery and improvement in a less acute and less resource-intensive setting.

In the South Chicago area, only 10% of patients who are hospitalized from the ED for mental disorders received outpatient care during the three (3) months before the hospitalization. Furthermore, only 14.5% of patients in South Chicago hospitalized for mental disorders received

10 Id. at 12. 11 See University of Illinois at Chicago, Transformation Data & Community Needs Report: Chicago- South Side, February 2021, at 22. 12 Id., at 25. 13 Id., at 27. 14 Id., at 26. 15 Id., at 28.

6 | P a g e outpatient care after the hospitalization; the lowest outpatient follow-up rate in the Chicagoland area.16 This remarkably low utilization of outpatient care leads RCH to believe that more must be done to connect patients and their families with outpatient resources, and build a foundation for that outpatient journey, during the hospitalization. By simply creating time and space to connect patients with the outpatient services and resources they need to forge a path for sustainable healing, RCH believes it can increase the percentage of discharged patients that continue with outpatient and follow-up care post-discharge. If successful, this program can make significant inroads to interrupt the viscous readmission cycle that plagues South Chicago hospitals and takes a toll on the surrounding communities.

Mental health, behavioral health and substance abuse admissions in the area typically arrive through the Emergency Department. By zip code, RCH’s service area has a significantly high percentage of emergency department visits that relate to mental health and substance abuse.

Emergency Department Rate due to Substance Abuse (age-adjusted rate per 10,000)

Emergency Department visits due to Mental Health among adults (age-adjusted rate pre 10,000)

Furthermore, the current pandemic has only exacerbated the mental health crisis that exists nationwide, and in RCH’s service area. According to a NHIS Early Release Program survey, only 11% of adults surveyed reported symptoms of anxiety disorder and/or depressive disorder between January and June of 2019; however, by January 2021, 41.1% of adults surveyed reported symptoms of anxiety disorder and/or depressive disorder a US Census Bureau Household Pulse survey, 41.1% of adults surveyed reported symptoms of anxiety disorder and/or depressive

16 See University of Illinois at Chicago, Transformation Data & Community Needs Report: Chicago- South Side, February 2021, at 28, 30.

7 | P a g e disorder.17 The US Census Bureau found younger adults were experiencing the most significant mental health impact related to the pandemic:

In addition to younger adults, minorities and persons of color are experiencing pandemic-related mental health symptoms at a disproportionate rate.18

The South Side of Chicago will only benefit from increased access to high-quality, sustainable mental health, behavioral health and substance abuse treatment if this collaboration receives the funding being requested.

17 https://www.kff.org/report-section/the-implications-of-covid-19-for-mental-health-and-substance-use-issue- brief/ 18 Id.

8 | P a g e HEALTH EQUITY AND OUTCOMES

As described above, the majority of individuals in RCH’s service area identify as African American and RCH’s service area has been described as having a mental health professional shortage.

MENTAL HEALTH PROFESSIONAL SHORTAGE AREA MAP

On the above map, the Health Professional Shortage Areas (“HPSA”) are scored on a scale of 0- 25 with the higher score indicating the highest need. All of RCH’s community service area, as well as other adjacent and surrounding areas, have been identified as having a mental health professional shortage.

Funding the RCH Adult Behavioral Health Transformation and Adolescent Sustainable Healing Program will increase capacity for inpatient mental health, behavioral health and substance abuse treatment in the underserved RCH service area, thereby increasing access to these necessary treatments in a community that is predominantly African American.

If funded, the program will also address the specific cultural and community barriers that have been identified in the RCH service area that prevent individuals from seeking outpatient care and services before or after an admission for mental health, behavioral health or substance abuse services. Addressing these community-specific and/or cultural barriers is something RCH believes to be transformational and critical to increasing access to treatment and sustainable healing.

QUALITY METRICS

The RCH Adult Behavioral Health Transformation will support HFS’ Pillars of Improvement focused on adult behavioral health by providing better care through:

9 | P a g e  Improved access to care by adding nineteen (19) adult BHU beds to facilitate appropriate placement out of Emergency Departments and other holding areas and timely treatment.  Community-specific strategies to facilitate improved outpatient utilization and reduced re-admissions  Improved quality treatment and coordinated care to decrease inpatient hospitalizations

RCH proposes the following metrics to be used by HFS following a Transformation funding award to monitor and track the projects progress in achieving the goals of the HFS’ Pillar of Improvement for adult and child behavioral health:

1. Percentage of outpatient follow-up after inpatient care (7-day and 30-day follow-up); 2. Number of visits to emergency departments for behavioral health services that result in hospitalization after inpatient treatment; 3. Mental health symptoms reduction from admission to discharge; 4. Productive engagement following admission (employment, job training, school enrollment, etc.)

Although the first two metrics can be tracked and monitored through Medicaid claims data, the Adult Behavioral Health Transformation and Adolescent Sustainable Healing Program will commit to gathering the data for the 3rd and 4th metrics through internal records, patient assessments and/or surveys.

CARE INTEGRATION AND COORDINATION

As described in the Executive Summary, above, the RCH Adult Behavioral Health Transformation and Adolescent Sustainable Healing Program will combine inpatient behavioral health treatment with outpatient providers and community resources to bridge the abrupt transition from inpatient to outpatient treatment to encourage and incentivize ongoing recovery. By introducing and connecting the patient, their family and/or their support system to the patient’s outpatient care plan as well as necessary community resources while an inpatient, RCH can break down the social determinants of health that create obstacles to sustainable healing.

As part of the physical transformation, RCH will create space for nineteen (19) adult BHU beds and fourteen (14) adolescent behavioral health beds in two separate gender specific residential healing centers. All behavioral health rooms and spaces will comply with all requirements for successful and safe behavioral health treatment. Additional communal, activity and group therapy space will be created for both the adult unit and the adolescent healing centers to allow RCH to facilitate the evidence-based treatment programs to bring about healing. Furthermore, the adolescent healing centers will be equipped with secure outdoor space where adolescents can participate in recreational activities - a critical component of adolescent treatment.

10 | P a g e RCH will develop a robust education and orientation program to help patients, their families and their support systems continue the journey towards sustained healing by providing the tools and resources to understand:

 The disease from which the patient is recovering and what to watch for during the patient’s healing journey;  What outpatient and community services will be most beneficial to the patient and where/how to access those services;  What covered services are available to the patient;  How to seek help in addressing coverage issues that may arise;  What community support systems and resources are available to address the patient’s specific social/cultural/economic needs post-discharge;  How to integrate healing strategies and recommendations in “the real world”; and  Specific strategies the patient, family and support system can employ to help the patient pursue their own healing journey without compromising and sacrificing their other responsibilities and priorities.19

Additionally, by involving outpatient and community resources, this collaboration will also help each patient address the other post-discharge issues that could impede their sustainable healing. The collaborators will work together to address potential issues with the patient’s ability to secure safe housing, employment, available food and other needs, that if not met could that cause patients to forego follow-up care and leave their treatment. By working together during the inpatient process and facilitating as many outpatient and community service connections as possible, RCH can help patients find sustainable healing in their community.

ACCESS TO CARE

By adding nineteen (19) adult BHU beds and fourteen (14) adolescent BHU beds (seven (7) in each gender-specific healing center), there will be more available behavioral healthcare, mental healthcare and substance abuse treatment for vulnerable persons within RCH’s service area and beyond. The additional beds will give RCH the ability and opportunity to admit and treat patients from RCH’s own ED as well as other area EDs and reduce the number of patients who need timely specialized services and would otherwise languish in an ED or elsewhere while awaiting appropriate placement.

Based on the Illinois Healthcare Facilities and Services Review Board Data, there are only 43 adolescent acute mental illness (“AMI”) beds within a 10-mile radius around RCH’s general service area. Given the adolescent population of 392,681 in RCH’s GSA, the bed-to-population ratio is one (1) bed to 9,132 adolescents.

19 See University of Illinois at Chicago, Transformation Data & Community Needs Report: Chicago- South Side, February 2021, at 36, 40.

11 | P a g e RCH’s GSA (10-Miles) Population Beds Beds to Population Adolescent AMI Beds 392,681 43 1 : 9,132 Adult AMI Beds 1,057,160 313 1 : 3,378

Compared to the city and state bed-to-population averages, RCH’s GSA has far less beds available to serve the adolescents in the community, who are primarily persons of color.

HSA 6 (Chicago) Population Beds Beds to Population Adolescent AMI Beds 633,416 304 1 : 2,084 Adult AMI Beds 2,076,118 1,117 1 : 1,859

Illinois Population Beds Beds to Population Adolescent AMI Beds 3,223,468 942 1 : 3,422 Adult AMI Beds 9,547,163 3,279 1 : 2,912

By developing a more comprehensive program involving outpatient services and community resources to provide “warmer” handoffs and more education to patients and their families, RCH will be able to increase access to the outpatient services and other resources that are being grossly underutilized.

SOCIAL DETERMINANTS OF HEALTH

The RCH Adult Behavioral Health Transformation and Adolescent Sustainable Healing Program is designed to specifically address the social determinants of health that are unique to the RCH service area, including racial and cultural factors that contribute to healthy communities. RCH has invested in the research and received substantial community input to identify the obstacles and barriers that confront behavioral health patients and their families/support systems generally, and specifically related to mental health.

Through its research and community needs assessments, RCH has learned that participants frequently link mental and behavioral health with the “traumas” that are inherent in the South Side Chicago community. Fears of violence, unsafe housing, poverty, domestic abuse, job security and lack of family support have been identified as an important contributor to mental and behavioral health issues. To confront these social factors, RCH will work with its collaborators to develop a Trauma Informed care model. Trauma Informed Care is based on the premise that all individuals experience trauma in their lives and clinicians must be cognizant of individual patient traumas to provide critical understanding and support while avoiding triggers that can exacerbate prior trauma. The Trauma Informed Model of Care is particularly important on the South Side where adolescents are often exposed to violence, domestic abuse, poverty and loss at a young age and persistently through childhood. The Adolescent Sustainable Healing

12 | P a g e program will create an atmosphere of trust and support to address prior traumas and guide the adolescent to develop sustainable, positive relationships that will equip them with the tools and confidence to achieve their highest form of well-being.

The RCH Adult Behavioral Health Transformation and Adolescent Sustainable Healing Programs are also designed to provide evidence-based clinical treatment, as well as social and community based resources and services to help patients transition out of the inpatient environment. By working together, outpatient providers, community service providers and the clinical team will be able to address the social factors that will contribute to a patient’s healing and the social barriers that must be overcome. During a patient’s journey through inpatient treatment towards discharge, this collaboration will provide patients and their families with a clear action plan to address those social determinants, establish a support and accountability structure and guide the patient on their healing journey. As part of the transition, the program will specifically address post-discharge issues that may relate to safe housing, employment, available food and other barriers that cause patients to forego follow-up care and leave their treatment. In terms of education, training and empowerment, the program will also facilitate more robust education and orientation to help patients, their families and their support systems post-discharge.20

MILESTONES

In the event of a funding award, the Adult Behavioral Health Transformation and Adolescent Sustainable Healing Program is prepared to proceed expeditiously to operationalize the programs as follows:

Adult Behavioral Health Unit Adolescent Sustainable Healing Month 1-3 A/E/C Documentation / Review A/E/C Documentation / Review

Month 4 Construction begins - Demolition and rough Construction begins - Demolition and rough Month 5 framing. framing. Month 6 Mechanical, electrical, plumbing, fire Month 7 protection rough out begins Month 8 Month 9 Month 10 Interior finish Month 11 Construction Complete Mechanical, electrical, plumbing, fire protection Month 12 Clinical operations start rough out begins Month 13 Month 14 Month 15 Month 16 Month 17

20 See, supra at 3.

13 | P a g e Month 18 Close-out construction

Month 19 Begin recruitment, training and orientation of staff (mental health aides, security, counselors, managers) Month 20 Clinical operations start

RCH intends to work with its collaborators throughout the construction process to develop programs, policies and protocols to improve care delivery and maximize patient healing, engagement and post-discharge success.

RACIAL EQUITY

The RCH Adult Behavioral Health Transformation and its collaborators are committed to promoting racial equity as part of this program. The entire program is designed to bridge the systemic and structural gaps that exist between healthcare delivery in RCH’s service area and other areas of Chicagoland. Furthermore, RCH and its collaborators are actively working to increase staff and vendors to reflect the diversity of the community that surrounds RCH. RCH is committed to providing healthcare services and facilities that meet or exceed the expectations of its patients and community and are consistent with the services and facilities provided at other area hospitals in and around Chicagoland.

A copy of the completed Racial Equity Impact Assessment Guide by RACE FORWARD, is attached as Exhibit D.

MINORITY PARTICIPATION

The New RCH is committed to involving participants and vendors that are majority owned or managed by minorities or are certified participants in the Illinois Business Enterprise Program. RCH currently maintains a preferred vendor list to identify and facilitate contracting with minority business enterprises (“MBE”). To facilitate further minority participation, RCH is currently implementing a program to increase diversity in its vendor programs and contracting so that RCH’s relationships more closely mirror the diversity of its patients and surrounding community. The collaboration expects to be able to expand the list of minority participation once funded and able to engage additional participants.

JOBS

Currently, RCH’s workforce represents communities from all over Chicago and northern- Indiana. RCH is committed to a diverse workforce and proudly employs 490 hard-working individuals. Within the 490 employees, 80% are African American, 6% are Hispanic or Latino, 5% are white and 4% are Asian. See RCH Employment Data by Zip and Ethnicity attached as Exhibit F. RCH has been and continues to be committed to supporting and facilitating a diverse workforce that

14 | P a g e provides equal opportunities to qualified persons regardless of race, color, national origin, religion, sex, age, or disability.

RCH works closely with local organizations through special programs administered by the City of Chicago to hire candidates that reside within RCH’s community. RCH works in partnership with the Service Employees International Union to provide quality employment opportunities to local members.21 RCH also supports local students through affiliation agreements with area colleges so students can complete internships and rotations at RCH.

The addition of 19 adult BHU beds and 14 adolescent beds in its adolescent treatment centers will necessarily require RCH to hire at least 20 additional clinical and non-clinical staff. RCH will follow its current hiring policies and priorities to fill these positions.

SUSTAINABILITY

Funding the RCH Adult Behavioral Health Transformation is a sustainable investment. Once the beds have been added and the outpatient and community collaboration elements have been operationalized, RCH will be able to continue to provide treatment and services to individuals requiring mental health, behavioral health and substance abuse treatment for the foreseeable future. RCH and its collaborators are requesting funds to develop the space and build a program that can be replicated for years to come based on available payer and reimbursement structures and support area hospitals in need of places to send ED patients in crisis.

BUDGET

A brief summary of the proposed project budgets are as follows:

Adult BHU Adolescent BHU Project Description: Expand Adult Psych by 23 Renovation of 2 existing beds, provide behavioral residential buildings into safety upgrades to 2E wing Residential Behavioral Program Project SF: 8370 7372 Projected Budget/SF: $275 $200 Projected Project Budget: $2,300,000 $1,460,000 General Work $1,265,000 $803,000 Mechanical $345,000 $219,000

21 See SEIU Letter of Support, attached as Exhibit C.

15 | P a g e Electrical $230,000 $219,000 Plumbing $345,000 $146,000 Fire Protection $115,000 $73,000 Operations TBD TBD Salaries TBD TBD Equipment TBD TBD

GOVERNANCE STRUCTURE

The RCH Adult Behavioral Health Transformation and Adolescent Sustainable Healing Program will be developed and managed by The New Roseland Hospital Strategic Transformation Committee, a 16-person committee that will be led by Chairman Dr. Rupert Evans and includes the current RCH Board of Directors and representative individuals from the local community as well as each collaborating organization.

New Roseland Hospital Strategic Transformation Committee Dr. Rupert Evans New Roseland Hospital Board Chair Jai Dev Arya, M.D. New Roseland Hospital Board Finance Chair Bruce Liimatainen New Roseland Hospital Board Member Dr. Jeffrey Waddy New Roseland Hospital Board Vice Chair Tim Egan New Roseland Hospital Board Member Joyce Chapman Community Leader TBD Community Leader TBD Community Resident TBD Community Resident Dr. Angelette Evans Governor's State University Dr. James Munz Governor's State University Dr. Victoria Brander Operation Walk Nina C. Aliprandi Maryville Academy TBD Chicago Family Health FQHC TBD Beloved Community Family Wellness Center TBD TCA Health Inc.

The New Roseland Hospital Strategic Transformation Committee will develop all policies, monitor progress, analyze all performance data and ensure all required reporting. Additionally, Maryville Academy will provide consultation services in the development of the Adolescent Sustainable Healing Program.

16 | P a g e THE NEW ROSELAND HOSPITAL (“RCH”) OBSTETRIC IMPROVEMENT PLAN

EXECUTIVE SUMMARY

RCH has always been and continues to be a committed community partner providing high quality obstetric services to our neighborhood families. “Childbirth is the most frequent driver of hospital utilization in South Chicago.”1 Despite having excellent physicians on staff, patients prefer to travel outside of RCH’s service area to deliver their children in more modernized and updated labor and delivery departments. RCH’s labor and delivery department lacks the amenities that expecting and new mothers seek when choosing a hospital. By not having suite- style post-delivery recovery rooms and other amenities that patients seek, RCH is not able to serve the families in its service area, and therefore, cannot connect its community’s families to available local supports and resources they need to live and thrive after they leave the hospital.

The Healthcare Transformation Program now gives RCH the opportunity elevate its labor and delivery department to the standards its patients want and deserve, consistent with the facilities that are available in north Chicago and the Western suburbs, so that the community will utilize RCH’s new and improved labor and delivery department. The funds requested will be used to:

 Upgrade patient rooms so that every patient suite will have a private bathroom and shower and space to visit with family;  Invest in bilingual “navigators” to partner with community resources and connect expecting and new mothers with nearby, available services and supports to assist with prenatal care, groceries, car seats, transportation, housing, lactation assistance, pediatric health providers, insurance coverage and other services critical to supporting healthy, stable new families  Develop programs consistent with other sought-after labor and delivery departments including, midwifery programs to increase delivery options, lactation support, transportation assistance to help patients see their providers, celebratory catered meals to help new mothers recover from delivery, and other services that will treat expecting and new mothers in RCH’s service area as well as (or better than) the expecting and new mothers in other areas of Chicago.

To facilitate this transformation, the RCH Obstetric Improvement Program is requesting $3,000,000 to fund this collaboration as described in greater detail below.

PARTICIPATING ENTITIES

The RCH Obstetric Improvement Plan will involve the following entities:

1 University of Illinois at Chicago, Transformation Data & Community Needs Report: Chicago- South Side, February 2021, at 22.

17 | P a g e  The New Roseland Hospital (“RCH”);  Chicago Family Health Centers  TCA Health; and  Institute for Womens Health.

Please refer to the Application for Transformation Funding Cover Sheet, attached here to as Exhibit A.

COMMUNITY INPUT

This collaborative endeavor will benefit a service area in south Chicago, which is part of Cook County that includes:

RCH identified and confirmed this service area needs more and improved adolescent behavioral health services through a commissioned Community Health Needs Assessment.

2 See Roseland Hospital 2019 Community Health Needs Assessment, at 4. A copy of the Roseland Hospital 2019 Community Health Needs Assessment is attached as Exhibit B. 3 Id., at 4.

18 | P a g e Furthermore, RCH has also hosted a series of Town Hall Meetings (personally and virtually) for legislators, community members, and employees over the last two years in preparation of submitting this Transformation Plan. Additionally, RCH’s Chief Executive Officer has presented the Strategic Transformation Plan to the State of Illinois Legislative Medicaid Working Group. Legislators, community members, community services organizations, collaborators and employees have provided overwhelming support for these projects. Many have provided Community Letters of Support, which are attached to this Proposal as Exhibit C.

DATA

As discussed above, the vast majority of RCH’s obstetric patients are African American. According to RCH’s internal data the demographics of its obstetric patients shows a very high percentage of treating young, African American women:

African Hispanic White Total American # of patients FY 2018 165 2 3 170 # of patients FY 2019 159 6 3 168 # of patients FY 2020 280 14 9 303

Age: 0-17 18-29 30-44 45-54 55-59 60-54 65+ Total # of patients FY 2018 2 100 56 6 1 2 3 170 # of patients FY 2019 0 118 44 1 1 1 3 168

African American patients are overwhelmingly more likely to experience pregnancy-related complications and death. In 2018, prior to COVID-19, the Illinois Department of Public Health found that, compared to White women, African American women in Illinois were six times more likely to die from pregnancy-related conditions, which is twice the national average.4 The report also found that the vast majority of complications and deaths were preventable.5

This disparity is particularly concerning on the South Side of Chicago, which has become an obstetric and maternity care desert. In the last year, the number of hospitals offering maternity services on the South Side of Chicago has decreased significantly. Specifically, Jackson Park Hospital, Holy Cross Hospital, and St. Bernard Hospital, who are within RCH’s service area market, have all permanently closed their Labor and Delivery (“L&D”) Units. Metro South Hospital in Blue Island also closed, which resulted in the loss of another L&D Unit in the service area. The map below illustrates the available L&D Units in the South Chicago area.

4 Illinois Department of Public Health, Illinois Maternal Morbidity and Mortality Report, October 2018, p. 5 (available at: http://dph.illinois.gov/sites/default/files/publications/publicationsowhmaternalmorbiditymortalityreport112018.p df) 5 Id.

19 | P a g e A: University of Chicago Medicine B: Jackson Park Hosp. - L&D CLOSED C: South Shore Hospital D: Little Company of Mary Hospital E: Metro South Hospital -- CLOSED F: Ingalls Memorial Hospital G: Advocate Trinity Hospital H: Advocate Christ Hospital I: Holy Cross Hospital -- L&D CLOSED J: St. Bernard Hospital -- L&D CLOSED

Decreased access to obstetrical care in the South Side of Chicago adds disproportionate health risks to African American pregnant patients, including increased infant and maternal mortality in the African American community.

Accordingly, there is a significant need for L&D Unit improvement and expansion in the RCH service area. The remaining providers that are committed to providing obstetric care on the South Side must be salvaged for the sake of the risk-risk patients that reside in the service area. But currently, outdated facilities and low utilization is has resulted in major infrastructure needs and unsustainable operating losses.

Funding improved facilities that will increase efficiencies, outcomes and local utilization is critical – and the Healthcare Transformation Collaborative funds can address this issue head on.

Furthermore, funding a program that improves new and expecting mothers’ access to community-based birth organizations and family supports will facilitate the engagement and intervention needed to encourage greater utilization of prenatal care and other services. Services and supports that make prenatal care convenient and comfortable, including transportation, nutrition support, baby supplies, infant car seat campaigns and other such programs have been shown to increase and improve patient engagement. With greater patient engagement in their obstetric health, including during pregnancy, complications can be identified early and treated to avoid preventable adverse outcomes.

20 | P a g e HEALTH EQUITY AND OUTCOMES

RCH plans to partner with community organizations and area Federally-Qualified Health Centers (“FQHCs”) in the service area to develop more robust programs to deliver pre-natal care and pregnancy management services. With facility upgrades and improvements, RCH will be positioned to draw the community’s women to the hospital so they can receive the preventative care needed to avoid the pregnancy-related complications and other high risk obstetric issues are more frequent in the African American community of Chicago’s South Side.

To encourage patient engagement, capital improvements are necessary. Patients in RCH’s service area frequently travel significant distances to deliver at other area hospitals that look and feel more updated. The two nearest other hospitals with labor and delivery departments are Advocate Trinity Hospital (with 23 beds 13.99 miles away) and OSF Little Company of Mary Medical Center (with 17 beds 18.53 miles away). These new and expecting mothers, who are typically young, single and unemployed, cannot travel these distances to other hospitals and providers regularly, which results in low utilization of pre-natal care and post-delivery follow- up. Patients often choose not to seek local and convenient maternity care at RCH because it feels old and outdated. For example, many patients are put-off by the shared shower room that currently exists on the L&D Unit. RCH plains to use Transformation Funds to install private showers in patient rooms.

The fact that a new or expecting mother lives on Chicago’s south side should not force her to have to choose between her community hospital that can provide high-quality services in an outdated space or a more well-appointed labor and delivery experience significantly far from her home and her support center. Putting aside the clinical benefits of improving local obstetric care at RCH, an improved and updated L&D unit at RCH will increase health equity by providing the women of color who reside in the South Side of Chicago an equivalent experience to what they receive when they travel to the north side or the suburbs.

Enticing local mothers to deliver close to home and in their community will also improve outcomes. More than just a capital improvement, the RCH Obstetric Improvement Plan implement bilingual “navigators” to connect obstetric patients to community resources and partners for pre-natal care and/or post-partum support. Because the RCH Obstetric Improvement Plan participants know and understand the community-based challenges its patients face, the collaborators will be able to connect more new mothers with the resources they need for their family to thrive. RCH and its community partners will work together to ensure every new mother has resources and information related to local, community based pediatric services, nutritional/grocery support, safe housing assistance, transportation home with a safe infant car seat and similar social and community supports.

With Transformation funds, the collaborative will also take the next step to improve health equity and outcomes by creating additional obstetric care choices that will empower patients, such as a midwifery program and a lactation clinic. The collaborative will also work to diversify

21 | P a g e the obstetrics department staff to ensure there are more bilingual staff to support and provide comfort to a growing number of non-English speaking patients at RCH.

QUALITY METRICS

The RCH Obstetric Improvement Plan will support HFS’ Pillar of Improvement focused on child and maternal health. Improving RCH’s L&D Unit will provide continued obstetric and maternity care that is quickly disappearing from the service area. By improving the L&D Unit, RCH will also be able to encourage new and expecting mothers to stay in the community to receive maternity care and deliver at RCH. By becoming the community’s choice for maternity and delivery care, RCH can work with prenatal care providers, other clinical providers and community resources to improve utilization of prenatal and postpartum care as well and provide access to other resources and assistance to help new families and babies thrive in the face of the social determinants of health that plague the South Side.

RCH proposes the following metrics to be reported to HFS following a Transformation funding award to monitor and track the projects progress in achieving the goals of the HFS’ Pillar of Improvement for child and maternal health:

1. Increase access and utilization of prenatal care visits; 2. Increase access and utilization of postpartum visits; 3. Increase in well-child visits within 30 days; 4. Increase in identified pregnancy-related complications receiving treatment without ED visit; 5. Improved utilization of RCH for labor and delivery; and 6. Improved patient satisfaction with services and amenities at RCH.

Although the first four metrics can be tracked and monitored through Medicaid claims data, the Obstetric Improvement Program will commit to gathering the data for the 5th and 6th metrics through internal records, patient assessments and/or surveys.

CARE INTEGRATION AND COORDINATION

As described above, the goal of the RCH Obstetric Improvement Plan is to create an all-inclusive local, convenient, community-based hub for the RCH service area’s obstetric needs. Through this collaboration, RCH will be able to participate in efforts to increase awareness among expecting mothers to receive early pre-natal care, follow-up post-partum care and well-child care. By connecting patients to these resources, RCH can intervene early, before emergency services are required, to address any complications or high-risk conditions. Furthermore, as described above, by increasing the community’s use of the RCH L&D unit, RCH and its collaborators will be able to connect its new mothers with the resources they need to heal post-pregnancy, receive pediatric care, and identify the community resources they need to thrive at home as a new family.

22 | P a g e ACCESS TO CARE

This RCH Obstetric Improvement Plan will increase access to a more comfortable, modern and supportive obstetric patient experience that is more readily available in other areas of Chicago and the suburbs. Although RCH currently has an L&D unit, it is under-utilized because patients from the RCH service area want a better experience and amenities. The RCH Obstetric Improvement Plan will not only improve access to certain quality of care, it will increase patient’s access to prenatal care, ongoing monitoring for high-risk and complicated pregnancies as well as post-partum supports and services.

SOCIAL DETERMINANTS OF HEALTH

Again, new and expecting mothers in RCH’s service area are typically young, single, sometimes unemployed, and sometimes without substantial education. Often times, RCH’s obstetric patients struggle with the complexities of their insurance benefits and coverage, and avoid prenatal care and post-partum supports because of a concern about costs, time away from work, or balancing childcare with a mother’s health needs.6

As the RCH services area has a growing Hispanic population, some patients forego care because of language barriers. By providing a comfortable, supportive hospital environment where local mothers are provided resources to help them navigate the healthcare system for themselves and their families, the RCH Obstetric Improvement Plan will have the opportunity to provide the outreach their patients need to overcome the specific challenges they will face while pregnant and/or with a new baby post discharge.

The collaborators in this project have the knowledge, experience and resources to guide new mothers that need assistance with housing, employment, groceries, transportation, childcare supplies and pediatric services. When RCH community members leave the service area to deliver their child, they may not have the opportunity to learn about and learn from these resources, but are instead discharged home without any assistance or help. The RCH Obstetric Improvement Plan wants to avoid new mothers being left without support and wants to be a focal point in the community for supporting local women and their obstetric needs.

MILESTONES

In the event of a funding award, the Adult Behavioral Health Transformation and Adolescent Sustainable Healing Program is prepared to proceed expeditiously to operationalize the programs as follows:

6 https://allhealthequity.org/wp-content/uploads/2019/06/FINAL_2019_CHNA-Report_Alliance-for-Health- Equity.pdf

23 | P a g e Month 1 - 3 A/E/C Documentation / Review Begin recruiting, training and orienting staff and support services including lactation consultant, social worker, patient educator and health navigator, midwives. Consideration to hiring maternal fetal medicine physician. Month 4-8 Phase 1 (Patient Rooms)

Month 9-12 Phase 2 (Nursing Station) Month 13-16 Phase 3 (Common Areas) Month 17-20 Phase 4 (Caesarian & Delivery) Month 21-24 Phase 5 (MEP/FP / Med Gas Upgrades) Month 25-26 Close out and commission Month 27 Clinical Operations Start

RACIAL EQUITY

The RCH Obstetric Improvement Plan and its collaborators are committed to promoting racial equity as part of this program. The entire program is designed to bridge the systemic and structural gaps that exist between healthcare delivery in RCH’s service area and other areas of Chicagoland. Furthermore, RCH and its collaborators are actively working to increase staff and vendors to reflect the diversity of the community that services RCH. RCH is committed to providing healthcare services and facilities that meet or exceed the expectations of its patients and community and are consistent with the services and facilities provided at other area hospitals in and around Chicagoland.

A copy of the completed Racial Equity Impact Assessment Guide by RACE FORWARD, is attached as Exhibit D.

MINORITY PARTICIPATION

The RCH Arthritis and Orthopedic Partnership is committed to involving participants and vendors that are majority owned or managed by minorities or are certified participants in the Illinois Business Enterprise Program. RCH currently maintains a preferred vendor list to identify and

Many of RCH’s preferred MBE vendors are already familiar with this project and are preparing bids for this project. To facilitate further minority participation, RCH is currently implementing a program to increase diversity in its vendor programs and contracting so that RCH’s relationships more closely mirror the diversity of its patients and surrounding community. The collaboration expects to be able to expand the list of minority participation once funded and able to engage additional participants.

24 | P a g e JOBS

RCH’s workforce represents communities from all over Chicago and northern- Indiana. RCH is committed to a diverse workforce and proudly employs 490 hard-working individuals. Among the 490 employees, 80% are African American, 6% are Hispanic or Latino, 5% are white and 4% are Asian. See RCH Employment Data by Zip and Ethnicity attached as Exhibit F. RCH has been and continues to be committed to supporting and facilitating a diverse workforce that provides equal opportunities to qualified persons regardless of race, color, national origin, religion, sex, age, or disability.

RCH works closely with local organizations through special programs administered by the City of Chicago to hire candidates that reside within RCH’s community. RCH works in partnership with the Service Employees International Union to provide quality employment opportunities to local members.7 RCH also supports local students through affiliation agreements with area colleges so students can complete internships and rotations at RCH.

As part of this collaboration, RCH anticipates hiring limited specialized staff (bilingual navigators, midwives, lactation consultants, etc.) to provide additional amenities to obstetrics patients. Needs for additional nursing, support or non-clinical staff will be closely monitored. If additional hires become necessary, RCH will follow its current hiring policies and priorities to fill these positions.

SUSTAINABILITY

Funding the RCH Obstetric Improvement Plan is a sustainable investment. Once the capital improvements are complete, RCH will be able to increase unit utilization and deliver high- quality obstetric care from its specialists currently on staff. The funds will also be used to establish new programming, including a midwifery program and lactation clinic that will also be sustainable once established. The collaborators are prepared to begin working with patients and supporting new families immediately and as utilization increases.

BUDGET

A brief summary of the proposed budget is as follows:

7 See SEIU Letter of Support, attached as Exhibit C.

25 | P a g e Obstetric Improvement Program Project Description: Patient Room, Nurse Station, Common Areas, Ceasarian & Delivery, MEPFP/Med Gas Upgrades Project SF: 9725 Projected Budget/SF: $325 Projected Project Budget: $3,160,000 General Work $1,580,000 Mechanical $632,000 Electrical $553,000 Plumbing $316,000 Fire Protection $79,000 Operations TBD Salaries TBD Equipment TBD

GOVERNANCE STRUCTURE

The RCH Obstetric Improvement Program will be developed and managed by The New Roseland Hospital Strategic Transformation Committee, a 16-person committee that will be led by Chairman Dr. Rupert Evans and includes the current RCH Board of Directors and representative individuals from the local community as well as each collaborating organization.

New Roseland Hospital Strategic Transformation Committee Dr. Rupert Evans New Roseland Hospital Board Chair Jai Dev Arya, M.D. New Roseland Hospital Board Finance Chair Bruce Liimatainnen New Roseland Hospital Board Member Dr. Jeffrey Waddy New Roseland Hospital Board Vice Chair Tim Egan New Roseland Hospital Board Member Joyce Chapman Community Leader TBD Community Leader TBD Community Resident TBD Community Resident Dr. Angelette Evans Governor's State University Dr. James Munz Governor's State University Dr. Victoria Brander Operation Walk Nina C. Aliprandi Maryville Academy TBD Chicago Family Health FQHC TBD Beloved Community Family Wellness Center

26 | P a g e TBD TCA Health Inc.

The New Roseland Hospital Strategic Transformation Committee will develop all policies, monitor progress, analyze all performance data and ensure all required reporting.

27 | P a g e THE NEW ROSELAND HOSPITAL (“RCH”) CENTER FOR ARTHRITIS AND JOINT REPLACEMENT: WALKING TOGETHER TOWARDS A HEALTHY FUTURE

EXECUTIVE SUMMARY

The New Roseland Hospital (“RCH”) seeks to improve the quality of life of its community through Transformation Grant funding to develop RCH’s Center for Arthritis and Joint Replacement (The “Center”). Through leveraging Chicago’s academic and clinical strength in joint replacement surgery, partnering with industry, and taking guidance from its community, the Center hopes to enhance the health and socioeconomic well-being of the RCH community by improving access to and outcome from hip and knee replacement surgery. Directed by Operation Walk Chicago, an orthopedic healthcare nonprofit with extensive experience developing and running similar partnerships in underserved communities, and guided by its community led Advisory Board, the Center will partner Northwestern University academicians, NorthShore University Health System and Northwestern Medicine clinical specialists, the business community (implant and device manufacturers) and clinician-educators in order to provide quality joint replacement in a low-cost, community setting (RCH).

Despite the abundant need for healthcare, access is widely lacking, particularly in specialist care. The RCH community is an example of one of the most egregious healthcare disparities: Chicago is renowned for joint replacement surgery and yet there are almost no joint replacement surgeons caring for the RCH community.

Total hip and knee replacements (“TJR”) are among the most effective and cost-effective surgeries introduced in the last 60 years because they restore patients to active, pain-free lives. Unfortunately, these benefits are not shared equally. Disparities in TJR rates and outcomes represent the most glaring of the racial and ethnic disparities that exist in healthcare. For example, black Americans are one-third less likely to receive total knee replacement, and for those that do, their outcomes (e.g. walking distance, knee flexion) early after surgery are worse than their White peers. And although this disparity was first documented over 30 years ago, it persists today and appears to be worsening.2

1 Roseland Hospital Community Needs Assessment 2019, attached to this Proposal as Exhibit B. 2 Ibrahim Curr Orthop Pract. 2010 MAR–APR; 21(2): 126–131.

28 | P a g e Mobility is critical to health, chronic disease management and longevity. Improving cardiovascular fitness reduces death from heart disease.3 Adding even 15 minutes of physical activity a day improves mortality from all chronic diseases.4 Sedentary older people report that it is their joint pain from arthritis that prevents them from exercising. Overcoming this barrier to exercise is critical to getting older people active.5

Disenfranchised, disabled communities are poor communities. Inactivity not only makes chronic disease worse, it leads to more poverty. Disenfranchised, disabled communities are poor communities. The state of Michigan estimated the financial costs of adult inactivity resulted in $8.7 billion of direct medical costs (10 cents of every primary care dollar spent) and $2.5 million in lost productivity (~20 days of work per worker).6

Hip and knee replacement surgeries are remarkably successful at eliminating joint pain and disability and returning people to active, productive lives. For example, when compared with nonsurgical therapy, hip replacement improves average annual productivity by over $9500 a person, and the direct cost of surgery are more than offset by the net societal lifetime return estimated at over $30, 000 a patient.7 Hip and knee replacements, therefore, not only improve an individual’s health but the socioeconomic health of a community. Lack of access to this surgery is one of the systemic barriers that serve to restrict communities like RCH.

We propose establishing an interdisciplinary Center for Arthritis and Joint replacement focused on caring for the most vulnerable patients (elderly, disabled, frail and those without adequate resources), those patients who increasingly cannot access this life-changing surgery and the pre- and post-operative care necessary for success. Through partnering with industry, academicians, established clinical providers, and community organizations, the Center will offer experienced, high quality specialized care in a low-cost environment, using a variety of strategies to mitigate complications and reduce costly unanticipated care. The Center will report to its Advisory Council, where stakeholders will supervise quality and outcomes, guide program development and insure The Center meets the needs of RCH’s community.

Through this novel approach, customized to the needs and desires of each patient, we believe we have a model in which hyper-specialized orthopedic surgery (hip and knee replacement) provided in a lower-cost, local setting (The New RCH) will be cost effective and successful, bringing our community care that is currently unavailable locally and using a model we believe to be superior for at-risk populations. The Center would be, truly, transformational and could serve as a template for other conditions and communities.

3 Lee D J Psychopharmacol 2010. 4 Wien, CP. The Lancet 2011. 5 Lees FD, et al. J Aging Phys Acti. 2005. 6 Chenoweth, et al Economic costs of physical inactivity in the state of Michigan. Michigan Fitness Council. http://www.michiganfitness.org/indexpagedownloads/CostofInactivity.pdf 7 Ruiz D. 2013 J Bone Joint Surg Am.

29 | P a g e To facilitate this transformation, the RCH Center for Arthritis and Joint Replacement is requesting $2,000,000 to fund this collaboration as described in greater detail below.

PARTICIPATING ENTITIES

The Center for Arthritis and Joint Replacement will involve the following entities:

 The New Roseland Hospital;  Operation Walk Chicago, including its physicians, surgeons, physical therapists and educators from multiple health systems, including  the Northwestern University Feinberg School of Medicine Department of Physical Medicine & Rehabilitation and Orthopedic Surgery;  Lal Puri MD, Ravi Bashyal MD, and Scott Cordes MD from NorthShore University Health System and University of Chicago;  William Gilligan MD from Hinsdale Orthopedics;  Kiran Chekka MD, Medical Director of anesthesiology and ORs from Global Health Partners at Northwestern and the New Roseland Hospital;  Physical Therapists and administrators from Athletico and Achieve Orthopedic Physical Therapy;  Skilled Nursing Facilities (TBD);  Industry vendors, including Smith & Nephew, Stryker and others.

Please refer to the Application for Transformation Funding Cover Sheet, attached here to as Exhibit A.

COMMUNITY INPUT

This collaborative endeavor will benefit a service area in south Chicago, which is part of Cook County that includes:

RCH and members of the Alliance for Health Equity (“AHE”), a collaborative of more than 30 hospitals, 7 health departments and 100 community partners, worked together between March

30 | P a g e 2018 through March 2019 to conduct a comprehensive Community Health Needs Assessment (“CHNA”) in Cook County.8 The primary data for the CHNA was collected by:

The CHNA identified treatment of the diseases of aging, which would include arthritis and joint replacement, as among its top needs.10

DATA

Arthritis of the hip and knee is the leading cause of disability in the US. Rates of disabling arthritis are highest in African Americans, elderly and the poor. However, in Chicago, RCH’s service area has among the lowest rates of orthopedic surgery in the region.

Based on the data published and used by the Illinois Health Facilities and Services Review Board, the 10-mile service area around RCH includes eleven (11) other hospitals and nine (9) surgery centers that provide orthopedic surgery services. Although there is limited data on orthopedics, the available data demonstrates that the area within Chicago area Health Planning Area, HPA A-03, where RCH is located, had - by far - the fewest orthopedic cases.

Orthopedic Cases RCH 10-mile Service Area 15,013

8 See Roseland Hospital 2019 Community Health Needs Assessment, at 4. A copy of the Roseland Hospital 2019 Community Health Needs Assessment is attached as Exhibit B.). 9 Id., at 4. 10 Exhibit B.

31 | P a g e Chicago 34,265 HPA A-01 (Chicago - North and West of the Loop) 16,176 HPA A-02 (Chicago - West and Near Southside) 12,383 HPA A-03 (Chicago - Southside (including RCH) 5,706 HPA A-04 (Southwestern Suburban Cook County) 14,201 HPA A-05 (DuPage County) 15,083 HPA A-06 (Western Cook County) 7,844 HPA A-07 (Northern Cook County) 13,635 HPA A-08 (North Shore) 10,602 HPA A-09 (Lake County) 8,804

In 2019, there were only 5,706 orthopedic cases in HPA A-03 versus 16,176 cases for HPA A-01, which is the City of Chicago north and west of the Loop. HPA A-01 includes Northwestern Memorial Hospital (reporting 6,876 procedures), Lurie Children’s (1,445 reporting procedures) and Swedish Covenant (1,339 reporting procedures).

HEALTH EQUITY AND OUTCOME

Accordingly, this project will bring a new life changing healthcare service to a Chicago Safety Net Hospital that is readily accessible in other areas of Chicago, but underutilized by the poor, people of color and others disenfranchised, including the RCH community. In collaboration with experienced providers, using state of the art techniques and protocols of care patients in RCH’s service area will benefit from the opportunity to address their chronic pain and mobility issues and improve their quality of life. Through this project, with institutional clinical protocols, standards of care, education of providers, mentorship we will improve many areas of RCH’s care delivery for chronic conditions (specifically preoperative medical screening, surgery, anesthesia, postoperative management, therapy services and case management). In addition, the partnership with university hospitals and specialists will enhance RCH’s care of patients long- term, in a variety of ways.

Patients who have advanced hip or knee arthritis will be enrolled. Patients will undergo “shared decision making” decision-analysis process to help them understand their choices and preferences based on their specific needs and goals. This shared decision making model has been shown to overcome the surgical hesitancy seen in people of color. Using a model for comprehensive pre-operative assessment, patient-specific factors for poor outcome will be identified. Barriers to surgery will be identified and addressed. Interventions and treatments will be initiated long before surgery (which might include including medical treatments or social interventions) to reduce risk for adverse outcome. Examples include:

 Education about risks and benefits and strategies to improve outcome, in a group setting with individual counselling as needed.  Nutritional support when needed – weight loss counselling, education on healthy food practices and interventions for those whose parameters indicate deficiency;

32 | P a g e  Identifying and treating undiagnosed chronic diseases – for example, better diabetic control for three months before a surgery to reduce risk of postoperative complication  Cardiovascular optimization;  Pre-operative physical therapy to reduce disability and enhance self-efficacy;  Pre-operative nerve blocks to reduce opioid consumption in those at risk for abuse etc.  Caregiver identification and training  Coordination with social service agencies, including getting uninsured patients access to healthcare insurance

Specifically, the Center for Arthritis and Joint Replacement will:

 Employ experienced case management and outpatient nursing to coordinate care from the first pre- and postoperative care.  Utilize board-certified joint replacement surgeons and specialists from Northwestern University’s Departments of Orthopedic Surgery and Physical Medicine and Rehabilitation, NorthShore University Health System’s Department of Orthopedic Surgery and Operation Walk Chicago. Clinician -educators will perform patient care while educating the RCH clinical staff, ultimately transitioning to a RCH independent sustainable, high-quality clinical service.  Integrate and employ minimally invasive surgical techniques, anesthesia protocols and rehabilitation measures to facilitate rapid recovery  Involve streamlined anesthesia protocols (e.g. ultrasound guided local blocks, pre – and intraoperative);  Incorporate post-operative rehabilitation services in the context of a pandemic, which will include a novel wearable device (Trackpad) and regular remote education and supervision (Healant) for at home rehabilitation.  Develop and operationalize a new outpatient physical therapy and rehabilitation service at RCH, in collaboration with Athletico and Operation Walk Chicago.  Partner with subacute/ skilled nursing facilities that will provide extended inpatient care post-procedure for patients whose frailty and social needs requires further short-term rehabilitation stays.

QUALITY METRICS

The Center for Arthritis and Joint Replacement will support HFS’ Pillar of Improvement focused on equity and aligns with the Department’s goals to improve population health, improve access to care and implement evidence-based interventions to reduce health disparities. More directly, this Partnership will increase access to primary care, preventive medicine techniques and orthopedic specialty care that benefits patients’ mobility, which has a direct impact on their ability to move, work and live health lives.

33 | P a g e This collaboration proposes the following metrics to be reported to HFS following a Transformation funding award to monitor and track the projects progress in achieving the goals of the HFS’ Pillar of Improvement for equity and chronic condition management:

1. Improved pain and function, as measured by the HOOS (hip disability and osteoarthritis outcome score), KOOS (knee injury and osteoarthritis outcome score) and patient assessed healthcare quality of life; 2. Increased utilization and TJR procedures in service area; 3. Surgical complication lower than historical rates for comparable population; 4. Overall cost of care at or below historical rates for comparable population; 5. Return to work or community reentry; and 6. Patient satisfaction scores

Although some metrics can be tracked and monitored through Medicaid claims data, the Center will commit to gathering available the data all four metrics through internal records, patient assessments and/or surveys.

Through collaboration with Northwestern University Department of Orthopedics and Operation Walk, patient specific outcomes, including quality of life measures, cost -efficacy analysis, and public health data regarding community rates of disability will be collected, analyzed and shared.

CARE INTEGRATION AND COORDINATION

This project will serve to bring a new service to a Chicago Safety Net Hospital, in collaboration with experienced providers, using state of the art techniques and protocols of care. Through this project, with institution of clinical protocols, standards of care, education of providers, mentorship we will improve many areas of RCH’s care (specifically preoperative medical screening, surgery, anesthesia, postoperative management, therapy services and case management). Care coordination will be directed by trained managers, who will use a novel risk mitigation technique designed for at risk populations, data from wearable devices and other methods to maximize patient outcome. The Center will develop and utilize experienced case managers and outpatient nursing staff to coordinate care along with the clinical team from the patient’s initial evaluation all the way through their postoperative care. By partnering with rehabilitation facilities and physical therapy providers, The Center will be able to ensure, efficient and effective coordinated care to maximize outcomes.

ACCESS TO CARE

Disparities in access to and outcome from hip and knee arthroplasty surgery are well-known and well-documented. (see figure 1, below) For example:

34 | P a g e  Black patients are reported to have a 40% lower probability of undergoing knee and hip arthroplasties.11

 Black patients have worse outcomes from surgery, with longer lengths of hospital; stay, more complications, more hospital readmissions.12

 Black and Hispanic patients wait longer (average 1.6 and 1.7 days, respectively) to have surgery after hip fracture than white patients (average 1.2 days).13

 Despite controlling for disease severity, surgeons are less likely to recommend TJR to their black patients.14

 Even when controlling for insurance status, black patients are less likely to be referred to an arthroplasty surgeon or high volume hospital.15

 In a cohort of 102,767 patients followed by the Women’s Health Initiative, black and Hispanic women were significantly less likely than white women to undergo total knee arthroscopy even after controlling for appropriateness for surgery and socioeconomic status.

 Since the onset of the Covid-19 global pandemic, in order to reduce use of acute hospital beds, hospitals considerably restricted elective surgeries – initially cancelling all elective surgeries, and more recently, giving preference to patients with resources and capacity to go home the same day or after a very brief hospital stay.

 Anecdotally, patients with disabilities, severe disease, multiple comorbidities, and those without the resources to pay for at home help describe increasing difficulty finding surgeons willing to care for them, inability to secure the postoperative care they need (such as home health care, extended outpatient physical therapy, or skilled nursing care) and discouragement to their pursuing this life changing surgery.

11 Singh, J. Ann Rheum Dis. 2014 Dec; 73(12): 2107–2115. 12 Id. 13 Dy C J Bone Joint Surg Am. 2016 May 18;98(10):858-65 14 Grooenweld Arthritis Rheum. 2008 May 15; 59(5): 730–737.2008 15 Losina E, Wright EA, Kessler CL, et al. Neighborhoods matter: use of hospitals with worse outcomes following total knee replacement by patients from vulnerable populations. Arch Intern Med 2007;167:182—7

35 | P a g e Figure 1 From: McBean AM, Gornick M. Differences by race in the rates of procedures performed in hospitals for Medicare beneficiaries. Health Care Financ Rev. 1994;15:77–90.

SOCIAL DETERMINANTS OF HEALTH

The RCH Center for Arthritis & Joint Replacement is designed to specifically address the social determinants of health that are unique to the RCH service area, including racial and cultural factors that contribute to healthy communities.

The reasons for TJR disparities are complex, involving patient-, physician-, and system-level factors. A number of potential explanations have been described: black patients express greater fear of TJR risks and are less familiar with benefits, black patients are less likely to be referred to orthopedic surgeons, and orthopedic surgeons (of whom only about 4% are African American) are less likely to recommend this surgery to their patients.

Compounding this problem is the historical, systemic disenfranchisement of communities of color. When Black or poor patients are concentrated in an area the disparity increases, suggesting that both individuals’ race and the racial composition of the neighborhoods in which they live drive differential use. Because Medicare covers the costs of total hip replacement and total knee replacement, the disparity cannot be entirely attributed to a lack of insurance or to a lack of financial access. Generations of barriers to quality healthcare and distrust among Black individuals of the health-care system are not easily erased.

Over the last several years, advancements in joint replacement technology, clinical care and reimbursement models have resulted in patients experiencing remarkably quick physical recoveries and dramatically declining hospital lengths of hospital stay. The shifts in healthcare reimbursement towards greater hospital risk, publication of hospital “scorecards,” and increasingly restricted payments to ancillary providers has disproportionately affected at-risk

36 | P a g e populations; over the last few years, the most disabled patients, those whose surgery is expected to be complicated and require more hospital resources, appear to be increasingly discouraged from seeking surgery.

The global COVID-19 pandemic worsened the disparity in our most vulnerable communities. In order to preserve hospital beds, Medicare & Medicaid Services (CMS) recommended halting all elective orthopedic surgeries on March 18, 2020. Although there was significant variation by state, hip and knee replacement surgeries declined 94% and 92%, respectively. More recently, most healthcare facilities have reopened to joint replacement surgery, but preference is given to those patients who have the resources and capacity to go home the same day or after a very brief hospital stay. Patients with disabilities, severe disease, multiple comorbidities, and those without the resources to pay for at home help have described increasing difficulty finding surgeons willing to care for them, inability to secure the postoperative care they need (such as home health care, extended outpatient physical therapy, or skilled nursing care) and discouragement from their pursuing this life changing surgery.

These trends are particularly unfortunate: studies of hip and knee replacement outcomes consistently show that patients who go into surgery more disabled, or wait longer to have surgery, have worse outcomes. Thus our most vulnerable patients, whose care the COVID-19 pandemic has interrupted, are at risk for worse outcome.

Our goal is to improve the physical functioning and quality of life of people suffering from advanced arthritis of the hip or knee who live in the greater RCH community, one of Chicago’s most vulnerable. We have reimagined the delivery of care from the typical surgeon- directed model (historically less successful in communities of color) to one in which shared decision making is the cornerstone of care. The biopsychosocial risk factors that predict poor outcome will be identified, and, where possible, mitigated in order to improve outcome and quality of life. Care coordination will be directed by trained managers, who will use a novel risk mitigation technique designed for at risk populations, data from wearable devices and other methods to maximize patient outcome.

MILESTONES

Construction Operational Month 1 - 3 A/E/C Documentation / Review Month 2 Month 3 Month 4 Construction start and Operation Walk to develop policies, mobilization protocols and schedules for establishing arthritis clinic and surgical center Month 5 Demolition and rough framing

37 | P a g e Month 6 Mechanical, Electrical and Fire Protection Rough Out Month 7 Month 8 Collaboration to begin marketing arthritis clinic to community Month 9 Begin recruiting and training staff to operate arthritis clinic Month 10 Month 11 Interior Finish, All Trades Open arthritis clinic 1 day/week Month 12 Month 13 Close Out Month 14 Clinical Operations Start Surgical cases begin under direction of Operation Walk with training provided to RCH clinicians and staff

RACIAL EQUITY

The Center for Arthritis and Joint Replacement and its collaborators are committed to promoting racial equity as part of this program. The entire program is designed to bridge the systemic and structural gaps that exist between healthcare delivery in RCH’s service area and other areas of Chicagoland. Furthermore, RCH and its collaborators are actively working to increase staff and vendors to reflect the diversity of the community that services RCH. RCH is committed to providing healthcare services and facilities that meet or exceed the expectations of its patients and community and are consistent with the services and facilities provided at other area hospitals in and around Chicagoland.

A copy of the completed Racial Equity Impact Assessment Guide by RACE FORWARD, is attached as Exhibit D.

MINORITY PARTICIPATION

The Center for Arthritis and Joint Replacement is committed to involving participants and vendors that are majority owned or managed by minorities or are certified participants in the Illinois Business Enterprise Program. RCH currently maintains a preferred vendor list to identify and

To facilitate further minority participation, RCH is currently implementing a program to further increase diversity in its vendor programs and contracting so that RCH’s relationships more closely mirror the diversity of its patients and surrounding community.

For this specific partnership, Operation Walk Chicago is managed and controlled by Dr. Victoria Brander, a female. Global Health Partners at Northwestern Medicine is owned and operated by

38 | P a g e a female person of color. The collaboration expects to be able to expand the list of minority participation once funded and able to engage additional participants.

JOBS

RCH’s workforce represents communities from all over Chicago and northern- Indiana. RCH is committed to a diverse workforce and proudly employs 490 hard-working individuals. Within the 490 employees, 80% are African American, 6% are Hispanic or Latino, 5% are white and 4% are Asian. See RCH Employment Data by Zip and Ethnicity attached as Exhibit F. RCH has been and continues to be committed to supporting and facilitating a diverse workforce that provides equal opportunities to qualified persons regardless of race, color, national origin, religion, sex, age, or disability.

RCH works closely with local organizations through special programs administered by the City of Chicago to hire candidates that reside within RCH’s community. RCH works in partnership with the Service Employees International Union to provide quality employment opportunities to local members.16 RCH also supports local students through affiliation agreements with area colleges so students can complete internships and rotations at RCH.

If additional hires become necessary, RCH will follow its current hiring policies and priorities to fill these positions.

SUSTAINABILITY

In this collaboration, Operation Walk will bring its expertise and experience to develop and operationalize arthritis treatment and orthopedic surgery at the New RCH. The initial investment in capital improvements, staffing and training will be significant. Once the program has been established and the New RCH is able to recruit and train its own clinical staff, the New RCH will be able to adopt and follow-through on the investment to continue to bring arthritis treatment and orthopedic joint replacement to the South Side.

Given the population and payor mix in RCH’s service area, the collaboration believes the majority of patients that will seek arthritis and joint replacement will have Medicare coverage, which will provide sufficient revenue to sustain the program after the Transformation investment has been completed. To address the gap in revenue that may exist for patients who are Medicaid beneficiaries or without coverage, the collaboration has budgeted for an “implant fund” to ensure there is adequate funding to initiate the program and monitor the financial impact of the program on RCH. Should the collaboration find additional funds will be needed to sustain the Center for Arthritis and Joint Replacement, the collaboration will consider additional grants and fundraising to support treatment for non-covered individuals.

16 See SEIU Letter of Support, attached as Exhibit C.

39 | P a g e Hip and knee replacement surgeries are remarkably successful, returning nearly all patients to more active lives. For example, when compared with nonsurgical therapy, hip replacement improves average annual productivity by over $9500 a person, and the direct cost of surgery are more than offset by the net societal lifetime return estimated at over $30, 000 a patient.17 Hip and knee replacements, therefore, not only improve an individual’s health but the socioeconomic health of a community.

BUDGET

A brief summary of the proposed budget is as follows:

Center for Arthritis and Joint Replacement Project Description: OR, MEP/FP Upgrades and New Equipment Purchase and Installation Project SF: 5610 Projected Budget/SF: $400 Projected Project Budget: $2,240,000 General Work $896,000 Mechanical $560,000 Electrical $448,000 Plumbing $224,000 Fire Protection $112,000 Operations Salaries $2,387,500 Equipment & Related $560,380 Upgrades Implant Fund $625,000

17 Ruiz D. 2013 J Bone Joint Surg Am.

40 | P a g e GOVERNANCE STRUCTURE

The Center for Arthritis and Joint Replacement, will be developed and managed by Dr. Victoria Brander and supervised by an interdisciplinary advisory board of stakeholders. The Center will report into The New Roseland Hospital Strategic Transformation Committee, a 16-person committee that will be led by Chairman Dr. Rupert Evans and includes the current RCH Board of Directors and representative individuals from the local community as well as each collaborating organization.

The New Roseland Hospital Strategic Transformation Committee will develop all policies, monitor progress, analyze all performance data and ensure all required reporting.

41 | P a g e Application for Transformation Funding Cover Sheet

THE ROSELAND COMMUNTIY HOSPITAL (“RCH”) ADULT BEHAVIORAL HEALTH TRANSFORMATION AND ADOLESCENT SUSTAINABLE HEALING PROGRAM

Primary Contact for Collaboration

Entity: Roseland Community Hospital Name: Tim Egan Position: CEO Email: [email protected] Office Phone: 773-995-3015 Address: 45 W. 111th , Chicago, IL 60628

List of Participating Entities

Entity: Maryville Academy Name: Sister Catherine Ryan Position: President CEO Email: [email protected] Office Phone: 847-294-1999 Address: 1150 N. River Road, Des Plaines, IL 60016

Entity: Gateway Foundation Name: Teresa Garate Position: Vice President, Strategic Partnerships and Engagement Email: [email protected] Office Phone: 312-663-1130 Address: 55 E. Jackson Blvd. Suite 1500, Chicago, IL 60604

Entity: Beloved Community Family Wellness Center Name: Margie Johnson, MS Position: Chief Executive Officer Email: [email protected] Office Phone: (773) 651- 3828 Address: 6821 S. Halsted Street, Chicago, IL

Entity: Phalanx Family Services Name: Robbie “Tina” Sanders Position: CEO Email: [email protected] Office Phone: 773-291-1086 Address: 837 W. 119th St, Chicago, IL 60643

EXHIBIT A P a g e | 1 Entity: TCA Health Name: Veronica Clarke Position: President and CEO Email: [email protected] Office Phone: 773-995-6300 Address: 1029 E. 130th Street, Chicago, IL 60628

Entity: Chicago Family Health Center Name: Barrett Hatches Position: CEO Email: [email protected] Office Phone: 312-768-5000 Address: 120 W. 111th Street, Chicago, IL 60628

THE ROSELAND COMMUNITY HOSPITAL (“RCH”) OBSTETRIC IMPROVEMENT PLAN

Primary Contact for Collaboration

Entity: Roseland Community Hospital Name: Tim Egan Position: CEO Email: [email protected] Office Phone: 773-995-3015 Address: 45 W. 111th , Chicago, IL 60628

List of Participating Entities

Entity: Chicago Family Health Center Name: Barrett Hatches Position: CEO Email: [email protected] Office Phone: 312-768-5000 Address: 120 W. 111th Street, Chicago, IL 60628

Entity: TCA Health Name: Veronica Clarke Position: President and CEO Email: [email protected] Office Phone: 773-995-6300 Address: 1029 E. 130th Street, Chicago, IL 60628

EXHIBIT A P a g e | 2 Entity: Institute for Womens Health Name: Guillermo Font, MD Position: Director Office Phone: 708-366-4370 Address: 814 Park, River Forest, IL 60305

THE ROSELAND COMMUNITY HOSPITAL (“RCH”) ARTHRITIS AND ORTHOPEDIC PARTNERSHIP: INCREASING ACCESS TO ORTHOPEDIC HEALING

Primary Contact for Collaboration

Entity: Operation Walk Chicago & Northwestern University’s Department of Physical Medicine & Rehabilitation Name: Victoria Brander MD Position: Associate Professor, Physical Medicine & Rehabilitation Northwestern University Feinberg School of Medicine Email: Office Phone: 312-416-4363 Mobile Phone: Address: Global Health Partners at Northwestern 161 East Chicago Avenue, Suite 960 Chicago, IL 60611 USA Additional William Gilligan MD from Hinsdale Orthopedics entity S. David Stulberg MD from Northwestern University’s Department of members: Orthopedic Surgery Lal Puri MD, Ravi Bashyal MD and Scott Cordes MD from Northshore University Health System Kiran Chekka MD from Global Health Partners at Northwestern

List of Participating Entities

Entity: Roseland Community Hospital Name: Tim Egan Position: CEO Email: [email protected] Office Phone: 773-995-3015 Address: 45 W. 111th , Chicago, IL 60628

Entity: Operation Walk Chicago & Athletico Physical Therapy Name: Mark Kaufman Position: Chairman/Founder, Athletico Physical Therapy Ltd Operating Partner, Shore Capital Partners Email: [email protected] Office Phone: 1-877-ATHLETICO EXHIBIT A P a g e | 3 Mobile Phone: Address: 625 Enterprise Drive Oak Brook, IL 60523

Entity: Operation Walk Chicago & Achieve Physical Therapy Name: Robert Johnson PT Position: Physical Therapist Co-Founder and Co-Owner, Achieve Physical Therapy Email: [email protected] Office Phone: 1-312-642-3963 Address: Achieve Orthopedic Rehab Institute 900 North Michigan Avenue Chicago, IL 60611

EXHIBIT A P a g e | 4

Community Health Needs Assessment

2019

EXHIBIT B P a g e | 1 Roseland Hospital 2019 Community Health Needs Assessment (CHNA) Table of Contents

I. Intro to Roseland Hospital and Description of Roseland Hospital Service Area………………...... … 3

II. Overview of the Community Health Needs Assessment (CHNA) process……………………………… 4

III. Key Community Health Data and Community Input in Communities Served by RH...... 6

Community Input Survey...... 6

Community Focus Groups...... 8

Community Priorities...... 9

Secondary Data...... 12

IV. Summary of Roseland Hospital’s Previous CHNA Implementation Activities, 2013-2016………...... 27

2 EXHIBIT B P a g e | 2 Roseland Hospital 2019 Community Health Needs Assessment (CHNA) I. Intro to Roseland Hospital and Description of Roseland Hospital Service Area Roseland Hospital’s service area spans across six zip codes containing 12 community areas in the City of Chicago (Figure 1). Around 300,000 individuals reside in Roseland Hospital’s service area (2016 5-year estimates, American Community Survey) with 86% identifying as Non-Hispanic African American/black, 8% Non-Hispanic white, and 4% Hispanic/Latinx.

Figure 1. Roseland Hospital Service Area Map and List of Communities

Zip codes in Roseland Community Areas in Roseland’s Hospital’s service area Hospital’s service area:  Auburn Gresham  Morgan Park  60617  Avalon Park  Pullman  60619  Beverly  Riverdale  60620  60628  Burnside  Roseland  60643  Chatham  Washington Heights  60827  Greater Grand Crossing  West Pullman

3 EXHIBIT B P a g e | 3 Roseland Hospital 2019 Community Health Needs Assessment (CHNA) II. Overview of the Community Health Needs Assessment (CHNA) process Roseland Hospital (RH) and members of the Alliance for Health Equity (AHE), a collaborative of over 30 hospitals, 7 health departments, and 100 community partners, worked together between March 2018 through March 2019 to conduct a comprehensive Community Health Needs Assessment (CHNA) in Cook County.

The Affordable Care Act (ACA) includes a number of components designed to strengthen the healthcare system’s focus on prevention in addition to treating people who are ill. Under the ACA, hospitals are now required to conduct a CHNA every three years that has specific components including:  a description of the CHNA process, methods, collaborations, prioritized community health needs, and a description of existing facilities and resources in the community;  input from persons representing the broad needs of the community;  the CHNA must be posted and made available to the public; and  the Hospital must adopt and submit an implementation strategy to IRS within 5½ months of posting the CHNA.

Summary of our collaborative health equity approach to CHNA The AHE's collaborative CHNA combined robust public health data, community input, existing research, existing plans, and existing assessments to document the health status of communities within Chicago and Suburban Cook County and to highlight systemic inequities that are negatively impacting health. The CHNA also provided insight into community-based assets and resources that should be supported and leveraged during the implementation of health improvement strategies.

AHE completed this collaborative CHNA between March 2018 and March 2019. Primary and secondary data from a diverse range of sources were utilized for robust data analysis and to identify community health needs in Chicago and Suburban Cook County. The Illinois Public Health Institute (IPHI) worked with the CHNA committee and steering committee to design and facilitate a collaborative, community-engaged assessment. As with the 2015-2016 collaborative CHNA, this 2019 CHNA process is adapted from the Mobilizing for Action through Planning and Partnerships (MAPP) model, a community-engaged strategic planning framework that was developed by the National Association for County and City Health Officials (NACCHO) and the Centers for Disease Control and Prevention (CDC). Both the Chicago and Cook County Departments of Public Health use the MAPP framework for community health assessment and planning. The MAPP framework promotes a system focus, emphasizing the importance of community engagement, partnership development, and three types of data--secondary data, community input, and system analysis. AHE chose this inclusive, community- driven process to leverage and align with health department assessments and to actively engage stakeholders, including community members, in identifying and addressing strategic priorities to advance health equity.

Primary data for the CHNA was collected through four methods:  Community input surveys  Community resident focus groups and learning map sessions  Health care and social service provider focus groups  Two stakeholder assessments led by partner health departments-Forces of Change Assessment and Health Equity Capacity Assessment

Secondary data for the CHNA was compiled and analyzed in partnership with epidemiologists from the Chicago Department of Public Health (CDPH) and Cook County Department of Public Health (CCDPH), IPHI, and member hospitals. The partners worked with the AHE steering committee to select a common set of indicators based on an adapted version of the County Health Rankings and Roadmaps Model. Data was organized in the following categories: overview of health inequities; social and structural determinants of health; mental health and substance use disorders; access to quality health care and community resources; and chronic conditions. Secondary data used in the CHNA were compiled from a range of sources, including the American Community Survey from the U.S Census Bureau, the Behavioral Risk Factor Surveillance

4 EXHIBIT B P a g e | 4 Roseland Hospital 2019 Community Health Needs Assessment (CHNA)

System, and the Health Chicago Survey from the Chicago Department of Public Health. Additional information can be found in Figures 6 and 7 of the full Alliance for Health Equity CHNA report.

In alignment with the purpose, vision, and values, the Alliance for Health Equity prioritizes engagement of community members and community-based organizations as a critical component of assessing and addressing community health needs. Community partners have been involved in the assessment and ongoing implementation process in several ways both in providing community input and in decision-making processes (Figure 5 of Full CHNA Report). The community-based organizations engaged in the Alliance for Health Equity represent a broad range of sectors such as workforce development, housing services, food security, community safety, planning, community development, immigrant rights, primary and secondary education, faith communities, behavioral health services, advocacy, policy, transportation, older adult services, health care services, higher education, and many more. All community partners work with or represent communities that are disproportionately affected by health inequities such as communities of color, immigrants, youth, older adults and caregivers, LGBTQ+, individuals experiencing homelessness or housing instability, individuals living with mental illness or substance use disorders, individuals with disabilities, veterans, and unemployed youth and adults.

AHE has several focus areas that different partners are working together to address including the social and structural determinants of health, mental health and substance use disorders, chronic conditions, access to care and community resources, maternal and child health, and injury prevention.

Alliance for Health Equity - Overall Community Health Focus Areas

5 EXHIBIT B P a g e | 5 Roseland Hospital 2019 Community Health Needs Assessment (CHNA) III. Key Community Health Data and Community Input in Communities Served by Roseland Hospital The following section highlights primary and secondary data related specifically to the Roseland Hospital service area.

Primary Data Community Input Survey The community input survey was a qualitative tool designed to understand the community health needs and assets from the community residents. The community input surveys, along with focus group data, informed the priority areas and strategies for community health improvement in Chicago and suburban Cook County. There were 324 survey respondents from the Roseland Hospital service area.

Table 1. Demographics of Community Input Survey Respondents in Roseland Hospital Service Area. The community survey asked residents about top health issues, top needs for a healthy community, greatest

6 EXHIBIT B P a g e | 6 Roseland Hospital 2019 Community Health Needs Assessment (CHNA) strengths in the community, and what needs to be improved. The top health issues identified by respondents in the communities served by Roseland Hospital were diabetes, mental health, age-related illness, substance-use, and cancers. All of these health issues were selected by 30% or more of survey respondents. Figure 3. Community Input Survey Data – Top Health Issues (Note: 313 respondents from the Roseland Hospital service area answered this question and multiple responses allowed per respondent)

Diabetes 44% Mental health 38% Age-related illness 33% Violence 33% Substance-use 32% Cancers 30% Heart disease and stroke 28% Obesity 14% Sexually Transmitted Infections 9% Lung disease 9% Dental problems 8% Infectious diseases 7% Motor vehicle crash injuries 4% Mother and Infant health 4% Child abuse 4% Other 4%

Survey respondents also identified the top needs for a healthy community. These top needs include access to healthcare and mental services, safety and low crime, access to community services, access to healthy foods, and quality job opportunities (Figure 4). These community needs were selected by 25% or more of the survey respondents.

7 EXHIBIT B P a g e | 7 Roseland Hospital 2019 Community Health Needs Assessment (CHNA)

Figure 4. Community Input Survey Data – Most Important Factors for a Healthy Community (Note: 313 respondents from the Roseland Hospital service area answered this question and multiple responses allowed per respondent)

Access to health care and mental health services 45% Safety and low crime 40% Access to community services 34% Access to healthy food 31% Quality job opportunities 26% Good schools 23% Clean environment 20% Affordable housing 19% Religion or spirituality 16% Strong community cohesion and social networks 15% Strong family life 15% Access to transportation 12% Parks and recreation 9% Diversity and inclusion 9% Affordable childcare 8% Arts and cultural events 8% Other 2%

Figure 5. Community Input Survey Data – Greatest strengths and areas for improvement

What are the greatest strengths in the community where you live? (open-ended, n=254) Responses most commonly related to the following categories:

 Community Cohesion  Transportation  Safety and Low Crime  Education  Parks and Recreation

What is one thing that you would like to see improved in your community? (open-ended, n=227)

Responses most commonly related to the following categories:

 Safety and Low Crime  Economic Development  Health Care  Food Accessibility  Infrastructure  Community Cohesion  Cleanliness

Community Focus Groups Between August 2018 and February 2019, Alliance for Health Equity partners collaborated to conduct a total of 57 focus groups with priority populations such as veterans, individuals living with mental illness, communities of color, older adults, caregivers, teens and young adults, LGBTQ+ community members, adults and teens

8 EXHIBIT B P a g e | 8 Roseland Hospital 2019 Community Health Needs Assessment (CHNA) experiencing homelessness, families with children, faith communities, adults with disabilities, and children and adults living with chronic conditions such as diabetes and asthma.

Thirty-six focus groups were conducted by IPHI and 21 Learning Map Sessions were led by West Side United, a regional collaboration of hospitals serving the West Side of Chicago and West Suburban Cook County, with notetaking by IPHI. IPHI developed the focus group questions using resources from existing CHNA toolkits and peer-reviewed studies, in consultation with the CHNA committee and colleagues at partner health departments. Each focus group was hosted by a hospital or community organization. The sessions were approximately 60-90 minutes long with an average of 8-12 participants. A total of 5 learning map sessions/focus groups were conducted with residents living within RH’s service area (Table 2).

Table 2. Focus group sessions conducted within Roseland Hospital’s service area Focus Group and Learning Map Sessions ABJ Community Services Affinity Community Services Gary Comer Youth Center NAMI Chicago Family Members NAMI Chicago Individuals Teen Living Program (Currently Ignite) Theace Goldsberry Community House (x2) Timothy Community Corporation

Community Priorities The major themes that emerged from focus groups on the South Side included social determinants of health, food systems, chronic diseases such as asthma and diabetes, access to care and community resources, behavioral health, and community safety and violence. Additional community input is highlighted in the secondary data section.

Social Determinants of Health Socioeconomic inequities were mentioned by several focus groups. Inequities in community economic investment and development, employment opportunities, quality affordable housing, education opportunities, community safety, and food access were highlighted.

Employment A lack of employment opportunities was one of the most frequently discussed issues among focus group participants. Participants living in the South regions of the county described having the least number of quality job opportunities and employment resources. However certain populations such as those living with mental illness, young adults, homeless individuals, and formerly incarcerated were highlighted as having significant barriers to employment regardless of their geographic location. In addition, multiple youth of color on the South Side described instances where they felt that their racial or ethnic background prevented them from obtaining employment. Within certain communities, jobs are available, but they are described as lacking benefits, part- time, temporary, and/or low paying.

“Access is one of the main things within our community - black community, people of color community. There are many stressors when we don’t have benefits, jobs, and access to healthcare.” - Community resident from Affinity Community Services focus group

9 EXHIBIT B P a g e | 9 Roseland Hospital 2019 Community Health Needs Assessment (CHNA)

Education Education was another widely discussed topic among focus group participants who mentioned the importance of quality education opportunities. The major education-related concerns expressed by focus group participants on the South Side of Chicago included school closures and diminishing education opportunities and poor-quality schools. Youth on the South Side of Chicago mentioned that school closures have led to more student dropouts. Multiple adult participants across Chicago mentioned serious concerns about the quality of Chicago schools, particularly schools that are majority students of color. Participants identified education as an underlying root cause of unemployment. Additionally, they linked education issues to many of the same problems caused by unemployment such as higher rates of community violence, increases in health issues such as substance use disorders and mental illness, and generational poverty.

Housing Homelessness and housing instability are associated with high rates of mortality and morbidity (Kushel, Gupta, Gee, & Haas, 2006). Housing instability does not have a standard definition and encompasses several issues including difficulty paying rent, overcrowding, frequent moves, living with relatives, and cost-burdened housing (Frederick, Chwalek, Hughes, Karabanow, & Kidd, 2014; Kushel et al., 2006).

“I think I have mold in my house. I have a lot of stress in me, I could be managing it better, but it is still there.” - Community resident from ABJ Community Services focus group

Focus group participants on the South Side of Chicago highlighted that segregation results in poor quality housing being concentrated in communities of color with high rates of violence and poverty. Some of the housing quality issues mentioned included dilapidated and crumbling structures, incomplete units, plumbing problems, and pest infestations. Renters described how these issues can be left unaddressed by landlords and property owners for extended periods of time or indefinitely. Some homeowners described these issues within their own homes but stated that they lacked the financial resources to address them. The health problems that were most often associated with these housing quality problems included exposure to mold, asthma, and stress. Children were identified as being at a higher risk for health problems associated with poor quality housing. A further complication is that several residents reported living in buildings where smoking is allowed within units and explained that this can further exacerbate health issues such as asthma.

Homelessness Adults and youth who are experiencing homelessness and housing instability reported several health problems that were a direct result including hypothermia, frost bite, severe weight fluctuations, gangrene, poor sleeping habits, and severe stress. Behavioral health conditions such as mental illness and substance use disorders were identified as both a cause of homelessness and the direct result of homelessness or housing instability.

“Not having the right shelter to go to. There are a lot of bad shelters where people do things you don’t want to be involved in.” - Community resident from Teen Living Program focus group

Homeless shelters and housing services were difficult to access for some community members. Homeless youth reported that shelters are particularly dangerous for teens and young adults and that they often resorted to staying on the streets or breaking into abandoned houses as an alternative. Multiple homeless teenage youth under age 18 reported being turned away from shelters in favor of families with children. They explained that they felt it was often due to them being young men of color. As a result, youth emphasized the need for more youth-specific services and homeless resources.

10 EXHIBIT B P a g e | 10 Roseland Hospital 2019 Community Health Needs Assessment (CHNA)

Food Systems Participants on the West and South Sides of the city county reported a high proportion of fast food restaurants and limited access to grocery stores selling healthier options. Community members living with chronic diseases such as diabetes explained that living in communities with less access to healthy food options and more access to fast food made it more difficult to manage their conditions.

Both youth and adults from multiple communities reported that having a healthy diet can be difficult for several other reasons as well including: • youth often find healthy foods unappealing particularly if they have had limited exposure to them; • the cost of healthy foods was frequently described as a barrier, but there was often disagreement among groups on this issue; • food pantries do not always provide healthy options; • fast foods are more convenient particularly for working parents with children; and • many lack the knowledge of how to prepare healthy meals.

“I work out a lot but I'm not always good with food. It is expensive to eat healthy food, but it is more expensive to be sick. It scares me because unhealthy food is there. You eat things just because you want to eat late at night.” - Community resident from Timothy Community Corporation focus group

Community Safety and Violence Community safety and violence was a cross-cutting theme that mentioned by multiple focus groups in a variety of contexts. The mostly commonly mentioned safety issues included gun violence, gang activity, drug-related activities, burglaries, and armed robberies. Participants related that the prevalence of violence in their communities has led to health issues such as chronic stress, decreased mental well-being, trauma among children and adults, and decreased physical activity due to a reluctance to exercise in unsafe neighborhoods.

Behavioral Health A major theme that emerged from the focus groups was chronic stress. Focus group participants linked chronic stress to several different health effects. Community members reported that stress impacted their ability to cope with chronic illnesses such as diabetes and could disrupt their ability to engage in behaviors such as healthy eating and exercise. Parents caring for children with asthma reported that the stress of caring for a family member had negative impacts on their mental and physical well-being. Youth living with asthma reported that stress was a trigger for their asthma attacks. Participants from one focus group directly linked chronic stress to the development of substance use disorders.

In addition to chronic stress, focus group participants described multiple situations that have led to trauma among community members living on the South Side including: • child abuse, • domestic violence, • living in high crime neighborhoods, • continual discrimination against marginalized racial and ethnic groups, and • homelessness.

“Everyone in the city is suffering from some level of trauma due to fear” - Community resident from Affinity Community Services focus group

Chronic Diseases In addition to behavioral health, chronic diseases such as asthma and diabetes were identified as major health priorities for South Side community members. The major themes that were mentioned by participants included:

11 EXHIBIT B P a g e | 11 Roseland Hospital 2019 Community Health Needs Assessment (CHNA)

• social determinants of health such as poverty, limited access to healthy foods, exposure to violence, and housing conditions are both underlying root causes of chronic disease and are barriers to the management of chronic disease; • education about preventing chronic disease, risk factors, and when to seek medical help is lacking in communities; • chronic illness such as asthma can be isolating for youth, parents, and adults; • taking care of a child with a life-threatening chronic illness can often cause severe chronic stress; and • community groups that share information about resources and support each other with adjusting to healthier lifestyles would be extremely helpful to communities.

Access to care and community resources Multiple participants on the South Side of Chicago mentioned barriers that impede their ability to access the healthcare system and community resources including: • the complexity of obtaining and keeping public benefit coverage; • the high cost of some private insurance plans; • an unequal distribution of healthcare services and facilities; and • poor quality healthcare options particularly for LGBTQ+ individuals and people of color.

Secondary Data This section highlights key data pertaining to social determinant of health indicators including, socioeconomic factors, housing, food insecurity, community belonging, and health outcomes. These quantitative data findings are supported by community members’ input during focus group sessions to showcase the importance of the findings from the community health needs assessment.

Poverty There is an extreme disparity in poverty rates among the communities of Roseland Hospital’s service area with Riverdale having a rate of 66% while Beverly has a poverty rate of 4%. Ten out of the 13 communities within Roseland Hospital’s service area have more than 20% of their population living in poverty, which is higher than the citywide rate of 19% (Figure 6). Of particular concern from a health perspective, child poverty is very high in the Roseland Hospital service area. Riverdale has a child poverty rate of 74%, more than twice as much as the citywide child poverty rate of 28% (Figure 7).

12 EXHIBIT B P a g e | 12 Roseland Hospital 2019 Community Health Needs Assessment (CHNA)

Figure 6. Percentage of persons in poverty (100% Federal Poverty Level-FPL), 2012-2016

Riverdale 66% Greater Grand Crossing 37% Burnside 33% Roseland 30% South Deering 30% West Pullman 29% Chatham 29% Auburn Gresham 29% Pullman 25% Avalon Park 21% Chicago 19% Washington Heights 19% Morgan Park 18% Beverly 4%