Exeter Health Resources 2020 Annual Report

ANNUAL REPORT

EXCEPTIONAL CARE DURING EXTRAORDINARY TIMES

The Operating Affiliates of Exeter Health Resources

Core Physicians is a community- based, multi-specialty group practice that provides comprehensive primary, specialty and pediatric dental care throughout the greater Seacoast Region. Over 160 providers in 15 locations pursue excellent patient satisfaction and quality outcomes through the provision of exceptional clinical care.

Exeter Hospital is a 100-bed, community-based hospital serving New Hampshire’s Seacoast Region. The hospital’s scope of care includes comprehensive medical and surgical healthcare services including, but not limited to: breast health, maternal/ child and reproductive medicine, cardiovascular, gastroenterology, sleep medicine, occupational and employee health, oncology, orthopedics, general surgery and emergency care services. Exeter Hospital is accredited by DNV Healthcare, Inc., and is a Magnet ® -recognized hospital. Magnet designation from the American Nurses Credentialing Center is the most prestigious distinction a health care organization can receive for nursing excellence and high quality patient care.

Rockingham Visiting Nurse Association & Hospice is a

community-based, home health and hospice agency providing individuals and families with the highest quality home care, hospice and community outreach programs within Rockingham and Strafford Counties.

Table of Contents

3 Letter from the President/CEO 4 Cl inical Affi l iations 5-7 Awards & Celebrations

8-12 Healthcare Heroes 13-16 Nursing Annual Report 17-22 United in Community 23-28 Financials

29-33 Our Community Gives Back 34-56 Donors 57 Trustees/Officers

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ANNUAL REPORT

Letter from the President/CEO

For many, if not all of us, the impact of the COVID-19 pandemic was life altering. The effects of COVID-19 stressed society to its core – globally, nationally and in our own communities. The saying “it’s always darkest just before the dawn” never held more truth in the vicious cycle of the COVID-19 pandemic; but perhaps, as this annual report of Exeter Health Resources is presented to you, we are arriving at the light of a new dawn in which the year to come will not solely be defined by the year that passed. For much of 2020, Exeter Health Resources and its affiliates Exeter Hospital, Core Physicians and Rockingham VNA & Hospice faced the challenge of caring for a community under assault by COVID-19, all the while managing the financial and operational disruptions wrought by the COVID-19 pandemic. Through it all our mission of providing medical care to the community was never threatened, rather it was uplifted by the nearly three thousand staff of Exeter Health Resources who put their lives on the line every day for someone else – a neighbor, a friend, a family member, a complete stranger. This annual report is really about those Healthcare Heroes and is meant to honor their courage and their compassion.

Sincerely,

Kevin J. Callahan, President, CEO

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Clinical Affiliations

Exeter Hospital and Core Physicians have formed clinical relationships with several leading medical organizations that enable us to provide advanced care close to home.

Dartmouth-Hitchcock Medical Center partners with Core Vascular Surgery to provide expanded vascular services to patients in our Exeter office.

Leading Massachusetts General Hospital Cancer Center radiation and medical oncologists and nurse practitioners provide care to patients at Exeter Hospital’s Center for Cancer Care , along with multidisciplinary clinics, genetic counseling, clinical trials and nurse navigators. Mass General also provides telemedicine stroke services to Exeter Hospital physicians to assist with the care of stroke patients at Exeter Hospital.

Exeter Hospital has two affiliations with Brigham and Women’s Hospital. The Center for Reproductive Care provides comprehensive infertility, reproductive endocrinology care and advanced reproductive surgery. Maternal Fetal Medicine provides expert care for women who have complications identified prior to or during pregnancy.

Exeter Hospital’s clinical collaboration with MassGeneral for Children brings pediatric hospitalists from MassGeneral for Children onsite 24/7 at Exeter Hospital to assess and treat pediatric patients in the Emergency Department, Family Center and inpatient pediatric unit.

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ANNUAL REPORT

Excellence. Every Patient. Every Time.

Centers for Medicare and Medicaid Services (CMS) have awarded Exeter Hospital the top 5 star rating for Quality and Patient Safety for eight consecutive quarters , all of calendar years 2019 and 2020. Additionally, Exeter Hospital received a grade of A for patient safety in the fall of 2019 and spring of 2020 from the Leapfrog Group, which reports twice annually.

Top Docs – Twenty-two physicians from Core Physicians’ primary and specialty care practices were recognized among the best physicians in the state in New Hampshire Magazine’s 2020 Top Doctors issue.

Magnet ® – Exeter Hospital has held Magnet recognition since 2013, conferred by the American Nurses Credentialing Center’s Magnet Recognition Program. This credential is the highest national honor for professional nursing practice and places Exeter Hospital in the top 8% of hospitals nationwide.

ASGE Recognition – The American Society for Gastrointestinal Endoscopy (ASGE) has once again recognized Exeter Hospital for its dedication to promoting quality and safety in endoscopy care. This recognition is conferred on only 10% of hospitals in the country.

Beacon Award for Excellence TM The American Association of Critical- Care Nurses (AACN) conferred a silver level Beacon Award for Excellence on the Progressive Care Unit (PCU) this year. Exeter Hospital was one of only two hospitals in the state holding any Beacon Awards at the time it was conferred. The award recognizes caregivers who successfully improve patient outcomes and align practices with AACN’s six Healthy Work Environment Standards. The hospital’s Family Center and Intensive Care Unit (ICU) have also received this prestigious award.

Get With The Guidelines ® Gold Plus – Exeter Hospital has received the Get With The Guidelines – Resuscitation Gold Plus Award for implementing specific quality improvement measures outlined by the American Heart Association ® for the treatment of patients who suffer cardiac arrests in the hospital, including patient safety, medical emergency team response, effective and timely resuscitation (CPR) and post-resuscitation care.

NCQA – Core Physicians and all of their local practices have received the NCQA Patient-Centered Medical Home (PCMH) recognition for using evidence-based, patient-centered processes that focus on highly coordinated care and long-term, participative relationships.

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Excellence. Every Patient. Every Time.

MassGeneral for Children SM This year, Exeter Hospital brought world-class care to our community’s children with the introduction of the MassGeneral for Children at Exeter Hospital Pediatric Hospitalist Program. Exeter Hospital now has a MassGeneral for Children pediatrician onsite 24/7 to assess and treat children in the Emergency Department (ED) , newborns in the Family Center and patients in the inpatient pediatric unit.

Center for Breast Health Achieves NAPBC ® Accreditation Exeter Hospital’s Center for Breast Health achieved accreditation from the National Accreditation Program for Breast Centers (NAPBC), a quality program of the American College of Surgeons (ACS). As the only hospital in the Seacoast with this accreditation , our Center for Breast Health has demonstrated excellence in the delivery of comprehensive, patient-centered, multidisciplinary, high-quality care for patients with breast disease.

New Plaistow Regional Health Center Opens

The new Plaistow Regional Health Center opened in summer 2020 at 127 Plaistow Road, providing expanded space in one convenient location for Core Physicians and Exeter Hospital services that were formerly located at two other Plaistow sites. Core Physicians primary care and lab services, along with Exeter Hospital Rehabilitation Services, Pediatric Rehabilitation and Mammography are now open. Additionally, Core Physicians offers rotating specialty services which include orthopedics, podiatry and cardiology, with additional specialties to follow. The Center also includes urgent care and X-ray services provided by ClearChoiceMD ® . Core Pediatric & Adolescent Medicine and additional Core Physicians specialty practices will move in over the next two years.

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ANNUAL REPORT

Center for Cancer Care Recognized for Excellence Exeter Hospital’s Center for Cancer Care has been recognized by the Commission on Cancer (CoC), a Quality Program of the American College of Surgeons (ACS), with the 2019 Outstanding Achievement Award (OAA). This award, which was created to recognize cancer programs that achieve excellence in providing quality care to cancer patients, was given to a select group of 49 accredited cancer programs throughout the United States. This represents just 7% of the programs that were surveyed.

New Affiliation with ClearChoiceMD ® Urgent Care Exeter Hospital, Core Physicians and ClearChoiceMD Urgent Care formed a clinical affiliation to improve quality and continuity of care for shared patients. The relationship includes ClearChoiceMD locations in Portsmouth and Epping, as well as Plaistow where they are co-located inside the new Plaistow Regional Health Center. With more people gravitating to an urgent care setting as a first stop when they need care, this new clinical affiliation will enhance the care coordination for patients if they are transferred to Exeter Hospital or Core Physicians and create a more integrated option for Core patients seeking access to urgent care services.

Partners for Women’s Health joins Core Physicians Partners for Women’s Health, a gynecology and obstetrics practice in Exeter with board certified physicians, certified nurse midwives and nurse practitioners, has joined Core Physicians. Partners for Women’s Health provides pre-conception counseling and both routine and high-risk obstetrical care. They also provide complete gynecological care for women in all stages of life. Partners for Women’s Health, which has provided care in the Seacoast area for 45 years, will now operate under the name Core Obstetrics & Gynecology with the same providers and staff.

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Thank you to all the Healthcare Heroes at Exeter Hospital, Core Physicians and Rockingham VNA & Hospice.

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ANNUAL REPORT

HEALTHCARE HEROES

Innovative Care in Unprecedented Times

Like healthcare organizations around the world, Exeter Hospital, Core Physicians and Rockingham VNA & Hospice had very little time to prepare for the COVID-19 pandemic. However, our healthcare organization has a history of providing innovative care so changes were rapidly put into place to meet the needs of both patients and staff.

To establish a safe and accessible testing area at the beginning of the pandemic, a COVID testing tent was set up in the Perry Circle of Exeter Hospital in late March. As new tests became available, the tent was removed and a new testing site was created at the Saltonstall Medical Building where Core Physicians and non-Core patients could call for COVID test appointments as it is a state testing site. As winter approached, the testing site was relocated to the Exeter Hospital parking garage. It also provided evaluation specific to COVID-19 symptoms, especially in the early days when tests were hard to come by. The clinic continues to care specifically for patients with symptoms of COVID-19 as the pandemic continues into fiscal year 2021. Core Physicians was one of the first healthcare organizations in New Hampshire to create a dedicated clinic for both adult and pediatric patients having symptoms consistent with COVID-19. This kept potential COVID patients separate from patients seeing their provider for other reasons, which minimized potential spread.

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ANNUAL REPORT

While Exeter Hospital, along with other hospitals nationwide, had to put a number of services on hold at the beginning of the pandemic, no staff members were furloughed and many staff members were redeployed to areas outside their normal scope of work. For example, Exeter Hospital Rehabilitation Services’ therapists staffed tables at all entrances, screening everyone who entered for COVID symptoms. While all services were reopened as the initial surge declined, many staff have filled in to help with the extensive cleaning and disinfecting that is being done throughout the health system. When personal protective equipment (PPE) was in short supply, the hospital’s Central Sterile Supply team used the same ultraviolet light technology to sterilize masks that Environmental Services (EVS) uses to disinfect patient rooms. This allowed PPE to be re-used the next day, completely sterilized. Putting this into place was a joint effort with infection prevention, EVS, facilities, materials management and more. Core Physicians primary care and specialty care services pivoted very quickly to providing telehealth visits whenever possible for their patients. With the new laws ensuring telehealth visits are covered by health insurance, patients have the option to “meet” with their provider on their computer, tablet or phone where they can see and talk to them from the comfort of their home. Currently, patients continue to have the option of telehealth or in person appointments.

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Healthcare Heroes

Additionally, Core Physicians has introduced the ability for patients to check in and pre-register before coming to their appointment, saving time and allowing them to wait in their car until a room is ready for them.

The excitement and relief was apparent on the day the COVID-19 vaccine arrived at Exeter Hospital – many of the first frontline healthcare providers who received their shot were moved to tears. While the pandemic brought unprecedented circumstances to the entire world with little time to prepare, our community healthcare system responded quickly, pivoting in innovative ways to support our staff and care for our patients. Rockingham VNA & Hospice has continued to visit and care for homebound and hospice patients throughout the pandemic, ramping up PPE and screening to keep everyone safe. They also began using telehealth when appropriate, although many of their patients need hands-on care.

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ANNUAL REPORT

NURSING ANNUAL REPORT

Nursing Annual Report

Excellence in Practice

Exeter Hospital has been recognized by the American Nurses Credentialing Center (ANCC) as a Magnet ® organization since 2013. Magnet recognition is the gold standard for nursing excellence and is a factor when consumers assess health care organizations. In fact, in its annual showcase of America’s Best Hospitals, U.S. News & World Report includes Magnet recognition in its ranking criteria for quality of inpatient care. The Magnet model provides a framework for nursing practice, research and measurement of outcomes. Through this framework, the ANCC evaluates hospitals to determine if they meet specific criteria for nursing excellence. The assessment is based on a number of elements deemed essential to delivering superior patient care, including quality of nursing leadership, coordination and collaboration across specialties and processes for measuring and improving the quality and delivery of care.

Communication and Collaboration

Exeter Hospital Medical-Surgical Unit Improving Care for Patients at Risk for Delirium Over the last year, the inpatient care team from 4 West at Exeter Hospital has been working to improve care for patients who are at risk for delirium. Delirium is defined as an acute cognitive impairment which can be the result of an underlying medical condition, fever, side effects of medication, intoxication, sleep deprivation or emotional distress. It can lead to long-term functional decline and is characterized by restlessness, hallucinations and incoherent thoughts and speech. The improvement process includes using a delirium risk screening tool and implementing a specific plan of care for those patients identified as

being at-risk. Through the use of the screening tool and a specific plan of care, the team has seen significant and sustained cognitive improvement in many patients in as little as 24 hours. The care plan includes ensuring the patient gets out of bed and walks every day, employing various methods to encourage a normal sleep/wake cycle and daily cognitive stimulation. This may include music, encouraging the patient to reminisce or providing them with some sort of tactile stimulation. One tool is the fidget sleeve – a source of tactile, visual and sensory stimulation – that slips right onto a patient’s arm. The sleeves, which are hand knit by hospital volunteers, also provide comfort and warmth.

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ANNUAL REPORT

Professional Development

Many studies have shown improved patient safety, reduced length of stay and a decreased rate of readmissions in organizations at which nurses hold a bachelor’s degree or higher. In the journal Medical Care, one study noted that the risk of patient mortality decreases by nearly 4% when an additional 10% of hospital nurses hold a bachelor’s degree. At Exeter Hospital, 77% of nurses hold a bachelor’s degree or higher. With the addition of five nurses earning advanced degrees in 2020, Exeter Hospital is in the top 30% of health care organizations in the country with nurses holding a Bachelor of Science degree in nursing or higher. There are multiple studies identified by the American Association of Critical Care Nurses that demonstrate a linkage between nurses who are specialty-certified and increased confidence in knowledge, competency, job satisfaction and self-perceived status, resulting in better patient outcomes. In 2020, an additional eight Exeter Hospital nurses received specialty certification in their respective areas. This brings the total number of certified nurses to 155, which positions Exeter Hospital well above the national mean for number of nurses holding a specialty certification.

Innovation The hospital’s Vascular Access Nursing Team serves as a resource to anyone in the organization who needs assistance with difficult IVs, midlines and PICC (central catheter) line placements. They also offer consultations about best practices for challenging vascular access patients. Their combined experience and access to technology enables them to help out when and where needed. By using ultrasound technology to place peripheral intravenous devices, they

are able to quickly and safely administer IV antibiotics and lifesaving medications.

Building the program has increased the availability of staff who have this specific training and skill set, enabling IV placement with the use of ultrasound technology to be available 24 hours a day, seven days a week. This has resulted in increased patient satisfaction, as IVs are placed quickly and safely upon admission.

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Nursing Annual Report

Award Winning Units

Exeter Hospital’s HealthReach Diabetes team was honored with the Excellence in Diabetes Education

diabetes management. Additionally, every patient encounter included self-management education, such as ensuring patients had at least a 90 day supply of medications and other supplies on hand, and that they were set up for home delivery if needed. The team also provided patients with detailed guidelines about managing other illnesses along with diabetes, including when to call a provider. As a result of this work, the Department of Health and Human Services asked the Center staff if they would be interested in sharing their experience, with the goal of supporting similar telehealth services for those with diabetes in the future. This is a true example of excellence defined by current state and planning for future state.

(photo taken before COVID-19)

Award through the New Hampshire Division of Public Health Services – Department of Health and Human Services for actions during the national pandemic. The HealthReach Diabetes Center migrated their services to a telehealth format in mid-March. In an effort to keep as many patients as possible out of the hospital due to the pandemic, they increased their focus on patients at higher risk of being hospitalized by working with outpatient providers to improve

Exeter Hospital’s Progressive Care Unit (PCU) was recognized by the American Association of Critical Care Nurses (AACN) with a silver-level Beacon Award this year. This national, three-year award is given to units that demonstrate excellence in patient care. Exeter Hospital is one of only two hospitals in New Hampshire to currently hold this honor. In addition to the PCU, Exeter Hospital’s Intensive Care Unit and Family Center also hold silver-level Beacon Awards from the AACN. Exeter Hospital in-patient units were first honored with Beacon awards from the AACN in 2012 and have continued to be recognized. Exeter Hospital’s Surgical Services division received the Certified Nurse Operating Room ® (CNOR) Strong Award from the Competency and Credentialing Institute ® (CCI). This is the third consecutive year Exeter Hospital has received this award, which signifies dedication to practice and clinical confidence, resulting in improved patient outcomes. To be considered, at least 50% of perioperative nursing staff must be CNOR-certified.

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ANNUAL REPORT

UNITED IN COMMUNITY

Our Mission

The mission of Exeter Health Resources and its affiliates is to improve the health of the community. This mission will be principally accomplished without compromising Exeter Health Resources’ sustainability by supporting the provision of health services and information to the community by the affiliated companies of Exeter Health Resources.

Throughout the past year Exeter Hospital, Core Physicians and Rockingham VNA & Hospice have continued the pursuit of this mission. The COVID-19 pandemic brought enormous challenges in FY 2020, resulting in more than a $20 million dollar operating loss. Despite this, the affiliates provided $94,058,726 in charity care and other community benefit programs and services while avoiding staff layoffs and furloughs. This ensures the best access to healthcare services now and in the future.

This addendum includes an overview of community benefit services and programs provided by the affiliates that help to address needs identified in the 2019 Community Health Needs Assessment. Access to health care – Mental health services – Social drivers of health Substance use disorder – Support for the needs of seniors Transportation – Youth suicide prevention

For more information on how the affiliates of Exeter Health Resources work together with the community to improve the health of the New Hampshire Seacoast, or to view the 2019 Community Health Needs Assessment, please visit exeterhospital.com/about-us/community-benefits.

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ANNUAL REPORT

Giving Back to Our Community

Community Health Services

Charity Care

Health Professions Education

Research

Financial & In-Kind Contributions

Subsidized Health Services

Community Building Activities

Govt-Sponsored Healthcare (Medicaid Loss)

Govt-Sponsored Healthcare (Medicaid Loss)

$ 81,828,262 $ 7,768,180 $ 1,352,585 $ 1,023,161

. . . . . . . . . . . . . . . . . . . . . . . . . . . .

Subsidized Health Services

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Health Professions Education

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Community Health Services

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Charity Care

$ $ $ $

838,947 573,731 497,295 176,565

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Research

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Financial & In-Kind Contributions

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Community Building Activities

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Total

$ 94,058,726

. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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United in Community

To meet new and growing needs created by the COVID-19 pandemic, the affiliates of Exeter Health Resources initiated multiple new services and programs to support the community , often with limited external funding. Examples included drive through testing sites, specialized respiratory clinics, substantial investments in social distancing, and patient and employee screening . During this time, the healthcare system created new and innovative ways to connect with the communities it serves. In early spring 2020, the organization started a weekly community-based conference call with participants from various sectors, including administrators in education, town officials, community non-profits, the Region 6 IDN, area Chambers of Commerce, among many more. The call provided a platform for community leaders to communicate, discuss challenges due to the pandemic and to identify opportunities to collaborate.

Additional information can be found by visiting exeterhospital.com/patients-and-visitors/financial-assistance.

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ANNUAL REPORT

Community Impact Program

Exeter Hospital offers grants and sponsorships to non-profit organizations that support the areas of greatest need in our communities. The priorities were identified through the 2019 Community Health Needs Assessment, which can be viewed at exeterhospital.com/about-us/community-benefits. In total, $477,052 was distributed to local area non-profits during the first quarter of FY 2020. When the COVID-19 pandemic began, grants and sponsorships were put on hold while the organization responded to the crisis.

Access to Health Care

Mental Health Services

Youth Suicide Prevention

Priority Areas

Social Drivers of Health

Transportation

Substance Use Disorder

Support for the Needs of Seniors

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Grant and Sponsorship Recipents

Community Partners*

Alzheimer’s Association Annie’s Angels Memorial Fund Big Brothers Big Sisters of New Hampshire Birchtree Center Children’s Hospital at Dartmouth- Hitchcock (CHaD) Chase Home for Children Children’s Museum of New Hampshire Community Toolbox

Exeter Historical Society Exeter Parks and Recreation

New Hampshire Hospital Association Plaistow Community YMCA Raymond Coalition for Youth Seacoast Eat Local Seacoast Family Promise Seacoast Soul Models SoRock Strawbery Banke Museum United Way of the Greater Seacoast Waypoint Womenade of Greater Squamscott

Exeter Rotary Club Greater Seacoast

Community Health

HAVEN Home Care, Hospice & Palliative Care Alliance of New Hampshire

Hospice Help Foundation Jason R. Flood Memorial

Lamprey Health Care Leadership Seacoast My Breast Cancer Support New Generation New Hampshire Children’s Trust

End 68 Hours of Hunger Equality Health Center Exeter Area Chamber of Commerce Exeter Area YMCA

*contributions through April 2020

Big Brothers Big Sisters names Exeter Hospital the 2020-21 Business of the Year

Big Brothers Big Sisters of New Hampshire (BBBSNH) named Exeter Hospital the 2020-2021 Business of the Year in recognition of its deepening support of mentorship in Rockingham County. BBBSNH has been a grant recipient of Exeter Hospital’s youth suicide prevention grant program since 2016, and in 2019 Exeter Hospital launched a workplace mentoring site. Local middle school youth visited the hospital twice a month to meet with their mentors who work throughout the health system. After the pandemic arrived, mentoring matches remained in touch through letters, emails and phone calls.

For further information or to view the hospital’s Community Benefits Report, visit exeterhospital.com/about-us/community-benefits.

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ANNUAL REPORT

FINANCIALS

Financial Summary

Exeter Health Resources’ financial performance was significantly impacted by the COVID-19 pandemic beginning in March 2020. All subsidiaries continued to provide exceptional care to their patients in the community while following State and CDC guidelines which included the postponement of elective procedures and limitations on normal operations during the period of March 17 –April 30, 2020 and the subsequent recovery period in the third and fourth quarter of fiscal year 2020. Gross patient service revenue generated by the three operating subsidiaries decreased nearly $4 million declining from $867.3 million in 2019 to $863.3 million in 2020 and $61.8 million as compared to the 2020 budget as operations were significantly impacted by the pandemic. The subsidiaries of Exeter Health Resources were the recipients of distributions from the Provider Relief Fund which totaled over $10 million and Exeter Hospital additionally received a grant of $1.65 million from the New Hampshire Department of Health and Human Services to help offset some of the lost revenue and increased costs the organization incurred particularly related to purchases of significant personal protective equipment to protect our patients, community and employees. While consolidated total revenues and other support declined $8.5 million or 2.3%, consolidated operating expenses compounded the decline as they increased by $15.4 million compared to 2019, resulting in a net operating loss of $20.6 million for fiscal 2020. The two leading contributors to additional operating expense were an increase of $8.8 million or 5% in salaries as Exeter Health Resources continued its commitment to keep the workforce fully employed in order to be redeployed as needed to respond to the impact of COVID-19 and the additional expenses required to meet new safety protocols, screening requirements and COVID-19 testing. The organization provided approximately $94.1 million of community benefits in fiscal 2020, which included $12.2 million to subsidize health services, other community service programs, charity care and the provision of direct cash contributions to other community agencies that support the mission of the organization. The other $81.9 million represents the costs of Medicare and Medicaid services provided to patients that exceeds reimbursement. Exeter Health Resources generated a $20.6 million loss from operations in fiscal 2020 which was $24 million lower than the operating gain of $3.4 million in 2019. The total non-operating gain was $12.5 million versus a $6.2 million gain in fiscal 2019 as investment returns accounted for $10.3 million of the increase. The organization continued its capital investment commitment by purchasing $23.4 million in property, plant and equipment in 2020 including the completion of an ambulatory center in Plaistow, new medical equipment, building renovations, infrastructure improvements and upgrades in information technology. Overall liquidity remained strong in fiscal 2020. The organization’s days cash on hand for 2020 was 220 days representing a 16 day decrease over 2019. Additionally, total cash, short term investments and investments increased approximately $28.5 million in 2020 in large part due to a $25.6 million increase in the investment portfolio as a result of stock market performance. Exeter Hospital maintained a Baa2 bond rating from Moody’s. The long term debt to equity ratio improved from 18.6% in 2019 to 18.1% in 2020 as no new debt was incurred in 2020.

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ANNUAL REPORT

Exeter Health Resources, Inc.

2020

2019

2018

2017

2016

Gross revenues and other support

$ 895,807,404

$ 884,233,554

$ 798,265,118 $ 730,327,367 $ 689,958,839

Deductions from revenue: Contractual allowances and discounts

518,750,153 11,373,261

497,083,376 12,933,872

436,297,117 9,392,322

394,040,880

365,323,160 10,394,101

Bad debt

8,240,171

Total deductions

530,123,414

510,017,248

445,689,439

402,281,051

375,717,261

Total revenues and other support

365,683,990

374,216,306

352,575,679

328,046,316

314,241,578

Consolidated operating expenses

386,260,374

370,839,501

352,333,580

327,870,755

304,182,585

Income (loss) from operations

(20,576,384)

3,376,805

242,099

175,561

10,058,993

Nonoperating gains (losses): Investment return

14,751,673

4,500,018 4,998,191 (1,263,838) (3,006,625) 1,011,509

9,326,460 120,891 (878,213) 1,073,897

17,182,663

8,214,729 158,678 (573,144) (2,376,330)

Unsolicited donations and gifts

122,266 (474,052)

85,568

Contributions to community programs

(792,524) 2,403,455

Impact of interest rate swaps

(2,257,679)

Other

314,384

238,130

(27,005)

(29,214)

Total nonoperating gains (losses), net

12,456,592

6,239,255

9,881,165

18,852,157

5,394,719

Excess (deficiency) of revenues and other support and nonoperating gains (losses) over expenses

$ (8,119,792)

$ 9,616,060

$ 10,123,264 $ 19,027,718

$ 15,453,712

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Exeter Health Resources, Inc. & Subsidiaries Consolidated Balance Sheets

September 30, 2020 and 2019

Assets

2020

2019

Current assets: Cash and cash equivalents

$ 46,405,715

$ 27,561,573

Short-term investments

4,403,891

4,397,140

Accounts receivable, less allowance for doubtful accounts of $15,506,878 in 2020 and $16,532,616 in 2019

35,181,607 6,042,608 6,386,319

36,342,342 4,482,425 6,385,022

Inventories

Prepaid expenses and other current assets

Current portion of funds held by trustee under revenue bond and other financing agreements

8,300,985

7,101,096

Total current assets

106,721,125

86,269,598

Investments, limited as to use

197,033,978

187,352,327

Funds held by trustee for professional liability claims

5,282,332

5,016,714

Property, plant and equipment, net

113,191,566

106,553,604

Other assets

20,152,463

18,601,718

Total assets

$ 442,381,464

$ 403,793,961

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ANNUAL REPORT

Exeter Health Resources, Inc. & Subsidiaries Consolidated Balance Sheets

September 30, 2020 and 2019

Liabilities and Net Assets

2020

2019

Current liabilities:

Accounts payable

$ 22,832,746 21,585,916 11,120,166 4,331,626

$ 19,533,741 18,480,353

Accrued salaries and payroll taxes

Due to third-party payors

5,602,312 4,161,045

Current portion of long-term debt

Total current liabilities

59,870,454

47,777,451

Accrued pension and other liabilities

78,752,594

35,495,835

Long-term debt, less current portion

38,336,431

42,637,622

Reserve for professional liability claims

4,898,560

4,898,560

Net assets:

Without donor restrictions With donor restrictions

235,388,832 25,134,593

251,796,200 21,188,293

260,523,425

272,984,493

Total liabilities and net assets

$ 442,381,464

$ 403,793,961

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Exeter Health Resources, Inc. &

Subsidiaries Consolidated Statements of Operations

September 30, 2020 and 2019

2020

2019

Net patient service revenues, net of contractual allowances and discounts

$ 344,569,474 (11,373,261)

$ 370,196,559 (12,933,872)

Less provision for bad debts

Net patient service revenues less provision for bad debts

333,196,213

357,262,687

Disproportionate share funding

6,591,068 25,477,768

5,193,628 11,606,815

Other revenues

Net assets released from restrictions used for operations

418,941

153,176

Total revenues and other support

365,683,990

374,216,306

Operating expenses:

Salaries and benefits Supplies and other

216,573,109 137,550,148 16,728,695 14,433,658

207,649,272 132,418,565 15,557,211 13,723,449

Depreciation

New Hampshire Medicaid enhancement tax

Interest

974,764

1,491,004

Total operating expenses

386,260,374

370,839,501

(Loss) income from operations

(20,576,384)

3,376,805

Nonoperating gains (losses): Unrestricted contributions

122,266

4,998,191 1,762,823

Investment income and dividends, net Realized gains on investments, net Unrealized gains (losses) on investments, net

1,079,030

739,845

15,374,202 (12,637,007) (3,006,625) (1,263,838)

12,932,798 (2,257,679)

Impact of interest rate swaps

Contributions to community programs

(474,052) 394,950 (80,566)

Other, net

831,542 179,967

Net periodic pension (cost) gain

Nonoperating gains, net

12,456,592

6,239,255

(Deficiency) excess of revenues and other support, and nonoperating gains over expenses

(8,119,792)

9,616,060

Net assets released from restriction used for capital

264,413 (23,998)

Transfer of balances between funds

(3,549,208) (4,738,368)

Adjustment to pension liability

(16,379,254)

Decrease in net assets without donor restrictions

$ (16,407,368)

$ (6,522,779)

28

ANNUAL REPORT

OUR COMMUNITY GIVES BACK

United in Wellness

Exeter Health Resources and its operating affiliates, Exeter Hospital, Core Physicians and

Rockingham VNA & Hospice, are United in Wellness . This simple, but important, phrase embodies our health system’s collective efforts to improve the health of the communities we serve. As a not-for-profit healthcare system, the operating affiliates of Exeter Health Resources are supported in part by community members, grateful patients and local business leaders, all of whom have been compelled to give back after their experience within our healthcare system. Whether it was because of the compassionate care provided to a loved one or, in some cases, inspired by their own personal experience, these individuals have helped to strengthen our collective efforts. With their support and our dedication to being United in Wellness, we are better able to purchase state-of-the-art equipment and technology, implement innovative treatment options and therapies, provide continuing education to clinical staff and assist with financial support for community members in need.

Exeter Health Resources’ Community Advancement Partners (CAPs)

We are stronger thanks to the support

of these devoted local businesses:

30

ANNUAL REPORT

Our Mission

The mission of the operating affiliates of Exeter Health Resources is to improve the health of the community. One of our greatest rewards is to hear from our patients expressing the quality of care and compassion they experienced while receiving care within our health system.

Through generous donations of time and funding, many local businesses as well as community members have made it their mission to help ensure future patients have the very best treatment available by supporting the advancement of Exeter Hospital, Core Physicians and Rockingham VNA & Hospice. Some of our grateful patient stories follow on these pages.

To learn how you can help, please visit unitedinwellness.org.

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Our Community Gives Back

First Virtual Cancer Walk a Success As with so many events this year due to COVID-19, the Exeter Hospital United in Wellness Cancer Walk & Trick or Treat Trot 5K went virtual. This new format

TROT 2020

435 VIRTUAL PARTICIPANTS

allowed for more flexibility, leading to some surprisingly happy results. Registrants had the option of choosing when to participate in the week-long event and this enabled people anywhere in the world to join. Of the 435 registrations, the Trot was represented in three additional countries (Cyprus, New Zealand and Germany), 11 states and Washington, DC. The virtual event raised a record breaking $75,000 +, all of which will go to The Beyond the Rainbow Fund to help Exeter Hospital’s cancer patients when they need it most. Every year, a personal story emerges that becomes the inspiration for the event. This year, Dan and Carolyn Smith of Hampton shared their appreciation for The Beyond the Rainbow Fund after a gift from this Fund helped save their home when Dan was going through cancer treatment and then recovering from a stroke. They shared their story in a video that reached many community members, and they walked their 5K route, a little at a time, as part of their determination to give back.

41 TEAMS

4 COUNTRIES $ 75,000 + RAISED

Falzone Family Inspires Community Support Jeanne and Michael Falzone offered a $10,000 matching gift challenge to Exeter Hospital’s United in Wellness Fund during the early days of the pandemic. The Fund was designated to support the hospital’s COVID-19 relief efforts. The Falzones wanted to encourage the community to help frontline healthcare heroes in the fight against COVID-19, and gave their $10,000 gift in honor of their

Core Physicians’ provider, Bruce Bartolini, MD. The community responded with donations totaling $30,000 to the United in Wellness Fund, supporting costs associated with the pandemic such as additional personal protective equipment (PPE), a specialized drive-up COVID-19 testing tent, free meals for staff during the first surge, and many other efforts to protect staff and patients.

$ 10 , 000 MATCHING GIFT CHALLENGE

JEANNE & MICHAEL FALZONE

$ 30 , 000 =

COMMUNITY RESPONSE

32

ANNUAL REPORT

Maureen Barrows – a Legacy of Giving Maureen Barrows was a friend and supporter of Exeter Hospital and a self-proclaimed “cancer thriver” who received years of treatment at the hospital’s Center for Cancer Care. In recognition of a generous donation to the Center for Orthopedics & Movement, the rock garden in the lobby was dedicated in memory of her son in 2016. Maureen, pictured here with her family, passed away in 2018 but her spirit of community involvement and giving are commemorated in the Maureen Barrows Community Champion Award. The first Barrows award was given to Elizabeth Bauma n, a longtime generous donor and volunteer

leader, who has also served as Chair of the United in Wellness Leadership Advisory Board and on the Cancer Campaign Cabinet. Elizabeth is a director of the Bauman Family Foundation, which recently donated $150,000 to the Together We Can Capital Campaign for the Center for Cancer Care. The second Barrows award was given to Tammy Symons . Tammy has served on the United in Wellness Leadership Advisory Board since 2017 and has volunteered for The Beyond the Rainbow Fund, especially with Kites Against Cancer, since 2010.

Resiliency in Motion Pearla Phillips has been supporting Exeter Hospital, Core Physicians and Rockingham VNA & Hospice in many ways over the past several years. Pearla is the current Chair of the United in Wellness Leadership Advisory Board. She is the founder and CEO of Resiliency in Motion, which is fitting as she has been so resilient in providing help in any way that’s needed. Resiliency in Motion (formerly FIT Body Transformation) became one of our Community Advancement Partners (CAPs) in 2020 and has organized many third-party fundraising events to

benefit The Beyond the Rainbow Fund and the Center for Cancer Care, including Candlepins for Cancer and a virtual magic show. Rockingham VNA & Hospice held their first ever online auction this year since they could not hold a fundraising event due to COVID-19. Pearla once again stepped up with three generously donated vacation trips for the auction. Community partners like Pearla and her team are an outstanding example of what it means to be United in Wellness.

33

COVID-19 Gift In Kind Donors

When the COVID-19 pandemic spread rapidly throughout the world, demand for personal protective equipment (PPE) far outstripped supply. While Exeter Hospital, Core Physicians and Rockingham VNA & Hospice had adequate supplies, there was concern that a COVID surge would result in a shortage. During this time, many businesses and individuals in the community generously donated supplies – PPE, meals, cards of encouragement and more – to support our Healthcare Heroes. We are incredibly grateful to our community for their outpouring of support – together, we truly are United in Wellness.

34

ANNUAL REPORT

Our Donors

The Operating Affiliates of Exeter Health Resources Major Gift Donors

F. Burton Dibble, Jr., MD Core Physicians Leadership Michael and Jeanne Falzone United in Wellness Fund Kathy Flygare

Glenn and Patricia McKenzie Center for Cancer Care Capital Campaign Neil S. Meehan, DO and Ebba Salvor Meehan Center for Cancer Care Capital Campaign Newburyport Bank Center for Cancer Care Capital Campaign Gary M. Proulx, MD and Sarah Proulx Exeter Hospital – Oncology General Fund and Thomas P. Wharton, Jr., MD Fund for Cardiology Seacoast United Sports Club, Inc. Exeter Hospital Nancy Sinclair Exeter Hospitall – Oncology General Fund and Thomas P. Wharton, Jr., MD Fund for Cardiology Mark and Tara Whitney Center for Cancer Care Capital Campaign

Major Gift Donors – $10,000 and Over (includes pledge gifts) Anonymous United in Wellness Fund Elizabeth H. Bauman and Luke Gullick Center for Cancer Care Capital Campaign, The Beyond the Rainbow Fund and Rockingham VNA & Hospice Robert E. Benoit Exeter Hospital – Oncology General Fund The Estate of Nikola A. Bujor Rockingham VNA & Hospice John and Geraldine Cerullo Exeter Hospital – Community Cares Fund Donahue, Tucker & Ciandella, PLLC Center for Cancer Care Capital Campaign

Thomas P. Wharton, Jr., MD Fund for Cardiolog and The Kathleen Schusler Fund for Nursing Education and Professional Development Timothy and Jessie Foss Center for Cancer Care Capital Campaign The Lois G. Roy Dickerman Fund of the New Hampshire Charitable Foundation Rockingham VNA & Hospice Eileen McDonald Center for Cancer Care Capital Campaign

Exeter Hospital & Core Physicians Donors

Anthony and Allison Casassa Amy and Alexander Case Sandra S. Cassetta

Brian Keane S. Richard and Ellen Kilbourne Michael J. Lannon, MD and Georgina Lannon Claudette H. Lavigne Vasilios A. Lirofonis, DPM and Paola Lirofonis Francis P. MacMillan, Jr., MD and Laura B. MacMillan Donna and Michael McKinney Jeffrey Meisner Karen and Jack Michel

Champion Society of Giving – $1,000 and Over A. B. Spence Charitable Fund Anonymous Paul and Mary Bamford Ryan Bamford Bank of New Hampshire Baystate Financial Lynda Beck and Susan Ratnoff Bottomline Technologies, Inc. David and Robin Briden David and Jerilyn Brownell Christopher and Miriam Callahan Kevin and Deborah Callahan Brian and Kimberly Campbell The Carbon Crew, LLC Sheila and Robert Caruso

Chinburg Management, LLC ClearChoiceMD Urgent Care Jennifer Costain Debra and James Cresta Dunkin’ Exeter Engelberth Construction, Inc. First Seacoast Bank Foss Motors Margaret and Harry L. Hampton, Jr. Nathan and Helen Hazen Jane and Theodore Heidenreich Stephen G. Hermans, Esq. Jane E. Hislop Marybeth Jermyn

Michael and Catherine Moore Northern New England Clinical Oncology Society Kevin and Susan O’Leary Sean and Michelle O’Neil Oyster River High School Patricia A. Prue and David Wright

35

Our Donors

Exeter Hospital & Core Physicians Donors

Resiliency in Motion Seacoast Dermatology, PLLC Service Credit Union Karl L. Singer, MD and Paula J. Singer SmithGroup Spectrum Medical Group David and Donna Spielman Constance D. Sprauer, Esq. and Hans Rutishauser Elizabeth Strout Sun Life Financial Charles and Karen Thomas James Thompson III and Charisse Thompson Transformative Healthcare Phyllis and Ralph Wark Robin D. Willits Leader – $500 - $999 Airbrush Unlimited, Inc. Nancy W. Alcock-Hood Alexander Technology Group Julie and Timothy Bailey Nicole Bauer Martha and Dwights Bellows Benjamin and Elizabeth Bixby BMW of Stratham Catherine Callaghan Lori and Earl Chabot Tina and Dennis Cote Cindy Courtney Major Gen (Ret.) Susan Desjardins Sandra J. Egan Mary A. Ellis Sally S. Fay Brian Ferguson G&N Flooring by Design Robert Hamilton Peter S. Ihm, DO and Lisa Ihm Pauline A. Ikawa Kathleen and Paul Kerrigan

Las Olas Sarah Cutts Lode Kent A. Logan, MD and Kathleen Logan Kenneth and Nancy Lynch Deborah Mace and William J. Mace, Jr. Kirk Metcalf William Mountcastle Joseph and Jean Murdoch New England Dragway, Inc. Daniel and Sue Raposa William Rawson Alexandra and William Ritchie Philip Rowe William and Nancy Savini Michael B. Schaffer, MD and Hanna Schaffer Carrie and Stephen Shaw David and Donna Spielman Jeffrey and Rosanne Swanson James and Charisse Thompson Total Sports Repair, Inc. Richard and Ellen Vinikoff Dawn Walker Hetz Wochholz Elizabeth and Mark Zelepsky Supporter – $250 - $499 Alice Anderson Pamela R. and J. K. Appleton R. Scott Bacon Kelly Boston Nicole A. Bouchard-Crotty Jennifer Bourque John T. Burns Julie and Ronald Bushey Shelley and Bryan Chabot Denise and Mark Chasse Laura Chopelas James Clark, Jr. and Deborah Clark Compass Retirement Consulting Group, Inc. William Cummings Andrea M. Dec

Jane Del Dotto Sue DeMarco Paulette Dinulos Mark and Catherine Donlevie Dan Doran Edward Jones Investments John W. Edwards Elizabeth H. Fields Ruth Ford Staci Frazier Kellisue L. Friedman Valerie S. Greene Nancy Mikalonis Harris George B. Heckler, Jr. and Meredith Heckler Lori K. Hennelly Andrea Higgins-Iveson Lindsey Humes Mary Beth and David Kerrigan Nancy and Paul Kerrigan Lisa and David Keslar Samantha King

William D. LaCroix Kathleen Lawrence

Daniel R. Libby Paula D. Merritt Linda M. Mitchell Leroy and Christine Mix Barbara and Ryan Mountain Marie Nadeau Patrick H. Oddy Jennifer M. O’Dwyer Roger and Sally Paradis Maureen Pearson Brian Porter, MD Susan Ratnoff and Lynda Beck Rejuvenations Jeannine Ritchie, MD Sandra Rosenthal Dennis Sargent Claudia A. Sayer Carolyn and Samuel Shore Linda J. Spinella Frank and Jodie Sutherland

Deanna King Bob Koenig

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