ADVENTIST HEALTH SIERRA VISTA

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	12.0%	Private	5.4%	4.40
2. HCAI 30-Day readmission	Expected Payor	Other	10.4%	Private	5.4%	3.80
3. HCAI 30-Day readmission	Expected Payor	Medicaid	8.7%	Private	5.4%	3.20
4. HCAI 30-Day readmission	Age (excluding maternal measures)	65 and older	11.9%	18 to 34	4.1%	2.90
5. HCAI 30-Day readmission	Age (excluding maternal measures)	50 to 64	10.8%	18 to 34	4.1%	2.60
6. HCAI 30-Day readmission	Sex Assigned at Birth	Male	12.5%	Female	7.2%	1.70
7. HCAI 30-Day readmission	Age (excluding maternal measures)	35 to 49	7.0%	18 to 34	4.1%	1.70
8. HCAI 30-Day readmission	Race and/or Ethnicity	Hispanic or Latino	10.9%	White	9.3%	1.20
9. CMQCC breast milk feeding	Expected Payor	Private	95.6%	Private	95.6%	1.00
10. CMQCC breast milk feeding	Race and/or Ethnicity	Hispanic or Latino	96.1%	Hispanic or Latino	96.1%	1.00

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2. Equity Plan

Our hospital is committed to closing gaps in care and improving outcomes for all patients. The data addressed in this equity plan shows the varying differences in readmission rates and breastfeeding practices across payor types, age groups, gender, and ethnicity. These disparities guide our equity plan, which includes measurable goals, structured timelines, and clear metrics for success.

Medicare patients face the highest disparity rate, with an 11.4% readmission rate compared to 5.0% for privately insured patients: a rate ratio of 4.5. Medicare patients are often older adults who have complex health needs along with limited support. Our goal is to reduce this rate to below 10% within 12 months. Early efforts will focus on staff education and discharge planning, followed by expanded care coordination mid-year. Success will be measured by a reduction in readmissions for this population of at least 1.5%, reaching that target by the end of 2026.

Patients with "Other" payor types, such as self-pay or military, experience a 10.0% readmission rate versus 5.0% for privately insured patients. We aim to cut this to 5% within 12 months by standardizing workflows, providing care coordination, and improving outpatient access. Progress will be tracked quarterly, with at least a 1% reduction each quarter.

Medicaid recipients, with an all-cause readmission rate of 8.7% compared to 5.0% for privately insured patients, often face barriers like transportation and limited resources. Our Care Management team received training on assessing social determinants for all adult patients this year, we will continue to monitor the success of these assessments by screening early and providing adequate resources to our patients to ensure successful discharges. Moving forward, in an effort to further reduce Medicaid readmissions, Adventist Health will expand community partnerships to reduce rates to 5% by the end of 2026. Quarterly reductions of 1% will indicate success.

Age disparities are also evident among readmission rates. Patients 65 and older have an 11.3% readmission rate compared to 3.9% for younger adults aged 18 to 34. Through chronic disease management, caregiver engagement, and coordination of care, we will bring this population's readmissions rate to below 10% within 12 months. Patients ages 50–64 experienced a readmission rate of 10.6% vs. 3.9% for younger adults. Education, preventive care and medication reconciliation will start early, aiming to decrease readmissions below 10% by the end of 2026. Adults 35–49 had a readmission rate of 6.8% vs. 3.9% for younger adults. This population will benefit from initiating flexible scheduling for follow-up care, along with telehealth services, reducing readmission rates to 5% within 12 months.

Gender and ethnicity differences were also observed among readmissions. Male patient all-cause readmissions were at 11.9% versus 7.0% for women. Outreach programs and education will launch early, targeting a reduction to below 10% within 12 months. Hispanic and Latino patients show a 10.9% readmission rate compared to 8.8% for White patients. We will expand bilingual care coordination and culturally tailored discharge education, aiming for readmission rates to fall below 10% by the end of 2026.

Maternal care disparities were smaller but equally important. Medicaid-covered births have a 94.2% exclusive breastfeeding rate compared to 95.6% for privately insured patients. We will aim to raise this rate to 96% within 12 months through enhanced lactation support and culturally sensitive education. White patients, at 94.9% compared to 96.1% for Hispanic mothers, will also reach 96% within 12 months, also focusing on enhanced lactation support and education. Quarterly increases of 0.5% will mark progress.

Quarterly reviews will ensure accountability and allow adjustments. By combining education, care coordination, and culturally responsive practices, we aim to create a healthcare environment where every patient receives equitable, high-quality care, regardless of age, race, gender, or socioeconomic status.

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

ADVENTIST HEALTH SIERRA VISTA