ADVENTIST HEALTH SONORA – FAIRVIEW
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 | 13.3% | Private | 4.9% | 2.70 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 8.5% | Private | 4.9% | 1.70 |
|
3.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 12.5% | Female | 9.2% | 1.40 |
|
4.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 12.6% | 50 to 64 | 11.4% | 1.10 |
2. Equity Plan
Top ten disparities were identified in the data with attention to population impact, measurable outcomes, and specific timeframes. In accordance with AB 1204, HQI stratified the disparities as outlined by HCAI. All data were extracted, tracked, and trended for Calendar Year 2024. The review period included January 1, 2024 through December 31, 2024 using the HQI platform.
The primary disparities identified for Adventist Health Sonora were readmission differences associated with age, payer type, and sex assigned at birth. These included higher readmissions among adults sixty-five years and older when compared to adults fifty to sixty four years old, Medicare and Medicaid beneficiaries compared to private payer patients, and males compared to females.
Potential contributing factors include underlying chronic illnesses or co morbidities, challenges with medication adherence or access, insufficient transition of care processes, limited availability of nutrition resources, physical or cognitive limitations that are more common among older adults, and gaps in discharge instructions or post discharge follow up. Systemic disparities such as access to follow up care, transportation, and culturally informed communication may also influence readmission patterns.
AHSR will implement a systemwide improvement bundle with local tailoring to address these disparities. Key actions include targeted education for providers and nursing staff in partnership with the Case Management team to strengthen transitional care services. These services will include follow up instructions provided directly by the provider and the nurse at discharge, provision of discharge medications when possible, accurate medication reconciliation to avoid duplication, and education for patients and families using the teach back method to confirm understanding.
AHSR will attempt follow up phone calls to patients that are identified as high risk within seventy-two hours of discharge to support comprehension of aftercare plans and identify any immediate barriers. Social workers and case management will collaborate with skilled nursing facilities to strengthen continuity of care and ensure readiness at the next level of care to reduce the risk of readmission.
AHSR will continue its current practices of screening for social determinants of health and providing referrals, ensuring access to interpreter services, language concordant communication, and culturally informed patient engagement strategies.
Timeframes and objectives for reducing readmissions:
AHSR will determine how to reduce readmissions within disparity groups and develop actions for reductions. The organization will also aim to narrow the readmission rate ratio gap between disparity groups. Emergency Department implemented new collaborative process with Hospitalists to flag all potential readmissions for case management and hospitalist consult prior to admitting the patient.
Modified discharge process so that all AHSR patients (including those discharged on the weekends) have a follow-up appointment with their primary care provider made before they are discharged from the hospital. Case Management is following up on all weekend discharges to ensure patients have follow-up appointments.
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.