ADVENTIST HEALTH SIMI VALLEY
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 | 15.2% | 18 to 34 | 5.9% | 2.60 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 12.9% | 18 to 34 | 5.9% | 2.20 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 12.5% | 18 to 34 | 5.9% | 2.10 |
|
4.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 21.1% | Asian | 12.2% | 1.70 |
|
5.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 15.5% | Private | 9.2% | 1.70 |
|
6.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 13.3% | Private | 9.2% | 1.40 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Hispanic or Latino | 15.2% | Asian | 12.2% | 1.20 |
|
8.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Male | 13.8% | Female | 12.2% | 1.10 |
|
9.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 13.8% | Asian | 12.2% | 1.10 |
|
10.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 14.5% | Female | 13.4% | 1.10 |
2. Equity Plan
Disparities 1-3 Age related readmission disparities
Population impact Adults 35-65+ years of age have higher readmissions as to patients in the 18-34 group
Actions planned
Enhance heart failure management and discharge planning processes
Develop age friendly printed education
Assist with securing primary care providers
Implement age friendly medication counseling
Provide goals of care discussions for patients 65+
Involve other caregivers in discharge planning
Measurable objectives: Reduce 30-day readmission rate ratio for ages 35-49 from 2.0 to 1.5; for ages 50-64 from 2.0 to 1.5; and for ages 65+ from 2.4 to 1.9 within 24 months
Timeframe: Launch by Q1 2026; reassess Q4 2026 & Q2 2027
Disparity #4: Race/Ethnicity disparity
Population impact: Black patients are experiencing higher readmissions as compared to the reference group of Asians
Actions Planned
Strengthen culturally competent discharge planning & follow-up
Enhance community-based health coaching and home visits for patients with chronic diseases
Provide goals of care discussions for patients 65+
Involve other caregivers in discharge planning
Assist with securing primary care providers for patients
Perform deeper dive into social determinants of health and develop actions and resources
Measurable objectives: Reduce 30 days readmission rate ratio in Black or African American patients from 1.7 to 1.3 within 24 months
Timeframe: Launch by Q1 2026; reassess annually
Disparity #5: Medicare disparity
Population impact: Patients with the payor of Medicare are experiencing more readmissions when compared to the reference group of private payors
Actions planned
Enhance heart failure management and discharge planning processes including patient education
Develop age friendly printed education
Assist with securing primary care providers for patients
Implement age-friendly medication counseling
Perform deeper dive into social determinants of health and develop actions and resources
Provide goals of care discussions for patients 65+
Involve other caregivers in discharge planning
Measurable objectives: Reduce 30 days readmission rate ratio in Medicare payor patients from 1.7 to 1.3 within 24 months
Timeframe: Launch by Q1 2026; reassess annually
Disparity #6: Medicaid disparity
Population impact: Patients with payor of Medicaid are experiencing higher readmissions when compared to the reference group of private payors
Actions planned
Involve other caregivers in discharge planning
Assist with securing primary care providers for patients
Perform deeper dive into social determinants of health and develop actions and resources
Measurable objectives: Reduce 30 days readmission rate ratio in Medicaid payor patients from 1.5 to 1.2 within 24 months
Timeframe: Launch by Q2 2026; reassess annually
Disparity #7: Race/Ethnicity disparity
Population impact: Hispanic/Latino patients are experiencing higher readmissions when compared to the reference group of Asians
Actions Planned
Collection of preferred language in the EHR to highlight patients with need for interpretive services
Continued 24/7 availability of interpreter services
Strengthen culturally competent discharge planning
Enhance community-based health coaching and home visits for Hispanic/Latino patients with chronic diseases
Provide goals of care discussions for patients 65+
Involve other caregivers in discharge planning
Assist with securing primary care providers for patients
Measurable objectives: Reduce 30 days readmission rate ratio in Hispanic/Latino patients from 1.3 to 1.0 within 24 months
Timeframe: Launch end of Q1 2026; reassess annually
Disparity #8: Race/Ethnicity disparity
Population impact: White patients are experiencing more readmissions when compared to the reference group of Asians
Actions Planned
Involve other caregivers in discharge planning
Assist with securing primary care providers for patients
Perform deeper dive into social determinants of health and develop actions and resources
Measurable objectives: Reduce 30 days readmission rate ratio in Hispanic/Latino patients from 1.3 to 1.0 within 24 months
Timeframe: Launch by Q2 2026; reassess annually
Disparity #9-10: Sex disparity
Population impact: Males are experiencing more readmissions when compared to the female reference group
Actions Planned
Engage with community resources and support services
Structured and personalized education to promote self-efficacy in chronic disease management
Involve other caregivers in discharge planning
Assist with securing primary care providers for patients
Perform deeper dive into social determinants of health and develop actions and resources
Objectives: Reduce 30 days readmission rate ratio in male patients from 1.1 to 1.0 within 24 months
Timeframe: Launch by Q2 2026; reassess annually
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.