ADVENTIST HEALTH AND RIDEOUT
1. Top 10 Disparities
The following table lists the ten largest health equity disparities identified for this reporting period.
Disparities for each hospital equity measure are identified by comparing the rate ratios by stratification groups. Rate ratios are calculated differently for measures with preferred low rates and those with preferred high rates. Rate ratios are calculated after applying the California Health and Human Services Agency's "Data De-Identification Guidelines (DDG)," dated September 23, 2016.
The table below highlights the ten widest health equity disparities identified by hospitals and hospital systems during this reporting period. Measure names have been shortened for display purposes. To view each measure in full, please download the complete Hospital Equity Report using the link below.
| Measure | Stratification | Stratification Group | Stratification Group Rate | Reference Group | Reference Rate | Rate Ratio |
|---|---|---|---|---|---|---|
|
1.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 16.0% | 18 to 34 | 3.4% | 4.80 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 15.4% | 18 to 34 | 3.4% | 4.60 |
|
3.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 16.4% | Private | 5.9% | 2.80 |
|
4.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 9.1% | 18 to 34 | 3.4% | 2.70 |
|
5.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 17.8% | Asian | 10.0% | 1.80 |
|
6.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 10.3% | Private | 5.9% | 1.70 |
|
7.
AHRQ pneumonia mortality rate
|
Sex Assigned at Birth | Male | 78.4% | Female | 49.1% | 1.60 |
|
8.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 14.0% | Asian | 10.0% | 1.40 |
|
9.
CMQCC breast milk feeding
|
Race and/or Ethnicity | Asian | 57.3% | White | 79.4% | 1.40 |
|
10.
CMQCC breast milk feeding
|
Race and/or Ethnicity | Hispanic or Latino | 64.8% | White | 79.4% | 1.20 |
2. Equity Plan
The monitoring of readmission patterns helps us identify specific barriers faced by disparate populations so that we can refine discharge workflows, strengthen CHF-specific interventions, and target supportive services earlier in the stay.
Insights from SDoH screening and readmission interviews are used to adjust care plans before discharge, ensure resources like transportation or medication access are secured, and reduce preventable readmissions among vulnerable patients.
Adventist Health and Rideout (AHRO) has identified that 8 of the top 10 disparities involve all-cause 30-day readmissions, with chronic diseases and social inequities contributing significantly to these outcomes. To address these disparities, AHRO is implementing multidisciplinary workflow enhancements for patients with chronic conditions, specifically CHF, in disparate populations. Key actions include risk identification, screening for social drivers of health, ensuring follow-up appointments, optimizing medications, providing patient education, and monitoring compliance and outcomes across care teams. The measurable objective is to reduce all-cause 30-day readmissions among disparate populations by 5%. Specific timeframes for implementation and monitoring are defined within ongoing quality improvement initiatives.
- Identified Disparity
8 of the top 10 disparities at AHRO involve all-cause 30-day readmissions.
- Population Impact
Chronic diseases are a leading cause of hospital readmissions, and effective chronic disease management is critical in reducing them. Populations affected by social inequity and bias are at higher risk for readmissions. Understanding social drivers of readmissions for disparate populations with chronic disease supports improved outcomes and helps contain readmission-related costs.
- Measurable Objective
Decrease all-cause 30-day readmissions among disparate populations by 5%.
- Key Actions - Multidisciplinary Workflow Enhancements for CHF
Care Management
- Identify CHF diagnosis and disparate population status as high-risk for readmission at admission.
- Screen for social drivers of health on admission and refer to meet needs prior to discharge.
- Conduct and document a readmission interview for all 30-day readmissions, including social drivers of health.
- Ensure follow-up appointments are scheduled before discharge.
Pharmacy
- Conduct medication review and provide optimization recommendations for CHF within 24 hours of admission.
- Monitor ongoing effectiveness of CHF medications in collaboration with providers.
- Complete discharge medication review prior to discharge.
- Ensure medications are provided at discharge for CHF patients in disparate populations.
Nursing
- Utilize a transition-of-care checklist to ensure all discharge needs are addressed.
- Provide diagnosis-specific education and discharge instructions using teach-back to validate patient understanding.
Provider
- Develop and document individualized CHF-specific care plans.
Ambulatory Care
- Verify post-discharge appointments.
- Track and address no-show rates.
Quality Management
- Report social drivers of health for CHF patients in disparate populations.
- Monitor compliance with enhanced workflows.
3. Structural Measures
| Centers for Medicare & Medicaid Services (CMS) Hospital Commitment to Health Equity Structural (HCHE) Measure | Yes/No |
|---|---|
Our hospital system strategic plan identifies priority populations who currently experience health disparities |
Yes |
Our hospital system strategic plan identifies healthcare equity goals and discrete action steps to achieve these goals |
Yes |
Our hospital system strategic plan outlines specific resources that have been dedicated to achieving our equity goals |
Yes |
Our hospital system strategic plan describes our approach for engaging key stakeholders, such as community-based organizations |
Yes |
Our hospital strategic plan identifies healthcare equity goals and discrete action steps to achieve these goals |
Yes |
Our hospital system has training for staff in culturally sensitive collection of demographics and/or social determinant of health information |
Yes |
Our hospital system inputs demographic and/or social determinant of health information collected from patients into structured, interoperable data elements using a certified EHR technology |
Yes |
Our hospital system stratifies key performance indicators by demographic and/or social determinants of health variables to identify equity gaps and includes this information in hospital performance dashboards |
Yes |
Our hospital system participates in local, regional or national quality improvement activities focused on reducing health disparities |
Yes |
Our hospital system senior leadership, including chief executives and the entire hospital board of trustees, annually reviews our strategic plan for achieving health equity |
Yes |
Our hospital system senior leadership, including chief executives and the entire hospital board of trustees, annually reviews key performance indicators stratified by demographic and/or social factors |
Yes |
4. Web Address for Equity Report
5. Download Equity Measures Report
Click on the link below to download the equity measures report.
Click on the link below to download all equity measures reports.