ADVENTIST HEALTH HOWARD MEMORIAL
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
|
Expected Payor | Medicare | 13.7% | Private | 7.7% | 1.80 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 12.5% | 50 to 64 | 10.2% | 1.20 |
2. Equity Plan
Adventist Health Howard Memorial Hospital reviewed the report and found only 2 disparities identified. Both disparity #1 & #2 are for readmission. Overall reduction in readmission has many components. Priority is given to Case Management when they round with Care Continuity every morning to review the patients who are at moderate and high risk for readmission. This risk for readmission is assessed on admission day #1 which includes use of an algorithm built into the electronic health record. Care Continuity then follows these patients post discharge to ensure timely follow up appointments are made that are customized to the patients' needs.
-Case Management is also handling referrals to outside support systems such as COMPASSS team for Partnership Health, Cal Aim, Substance Use Navigator, Social work needs, etc. There is a multi-modality team that conducts daily rounds to include the patient and their family, pharmacist, provider, nurse, and case management in goals of care and needs for successful discharge. Each month there is an ongoing Readmission Committee that meets to conduct a deep dive into 100% of all readmissions to include barriers, trends, and opportunities. All post-surgical patients receive several phone calls from the orthopedic navigator RN to follow up on their progress.
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.