ADVENTIST HEALTH UKIAH 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) | 50 to 64 | 17.5% | 18 to 34 | 2.9% | 6.00 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 17.2% | 18 to 34 | 2.9% | 5.90 |
|
3.
HCAI 30-Day readmission
|
Race and/or Ethnicity | American Indian or Alaska Native | 15.0% | Hispanic or Latino | 6.2% | 4.90 |
|
4.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 13.7% | Hispanic or Latino | 6.2% | 4.50 |
|
5.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 17.3% | Medicaid | 5.2% | 3.30 |
|
6.
HCAI 30-Day readmission
|
Expected Payor | Private | 11.3% | Medicaid | 5.2% | 2.20 |
|
7.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 6.3% | 18 to 34 | 2.9% | 2.20 |
|
8.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 17.4% | Female | 9.5% | 1.80 |
|
9.
CMQCC breast milk feeding
|
Race and/or Ethnicity | Hispanic or Latino | 66.3% | White | 85.0% | 1.30 |
|
10.
CMQCC breast milk feeding
|
Expected Payor | Medicaid | 66.5% | Private | 75.9% | 1.10 |
2. Equity Plan
To address disparities in all-cause readmissions and exclusive breast milk feeding, Adventist Health Ukiah Valley focuses on strengthening care transitions, improving access to follow-up care, offering culturally responsive education, and tracking readmission and breastfeeding metrics. Priority populations include ages 50–64, 65+, males, American Indian/Alaska Native, Hispanic/Latino, White, Medicare, private payors, and Medicaid-insured patients. Our goals are to reduce readmissions by 10% and improve exclusive breastfeeding rates among Hispanic/Latino and Medicaid-covered births by 10% within 12 months.
Readmission Reduction Strategy
We use the readmission risk score to identify moderate- and high-risk patients before discharge. These patients are scheduled for a follow-up appointment within 10 days, and when no Primary Care Provider (PCP) exists, a hospital follow-up is arranged to prevent care gaps. Enhanced Care Management (ECM) referrals are made based on payer eligibility, with warm handoffs to community care management teams. Palliative care consults are requested for patients with complex needs, advanced illness, or high risk of return.
To improve access, Federally Qualified Health Clinic (FQHC) and Rural Health Clinic (RHC) partners hold dedicated discharge follow-up slots for high-risk patients and those with Social Drivers of Health (SDOH) concerns. Monthly readmission metrics are reviewed by a multidisciplinary committee, with stratification by age, race, sex, payer, and diagnosis to guide targeted interventions.
Exclusive Breastfeeding Equity
To reduce disparities among Hispanic/Latino and Medicaid patients, we have expanded culturally and linguistically responsive lactation support. Several nurses hold or are pursuing International Board Certified Lactation Consultant (IBCLC) certification, including Spanish-speaking staff trained to address cultural bias, breastfeeding barriers, and individualized support needs.
Interventions include bedside lactation support, postpartum follow-up calls within 72 hours, culturally appropriate education, Women Infant Children (WIC) referral, and access to peer counseling, virtual consults, and outpatient support groups. Breastfeeding rates, stratified by race/ethnicity and payer, are reviewed monthly through the maternal-child multidisciplinary committee to monitor improvement and adjust strategies.
Timeframe Overview
Currently in place: Risk score use, structured post-discharge follow-up scheduling, IBCLC-certified staff support, ECM referrals, and coordination with FQHC/RHC partners including designated discharge follow-up appointment slots.
• 0–6 months (Refinement and Monitoring): Strengthen referral workflows, expand lactation support access for Spanish-speaking and Medicaid-insured families, evaluate ECM engagement rates, and track breastfeeding and readmission metrics monthly with stratified equity dashboards.
• 6–12 months (Optimization and Expansion): Enhance warm handoff processes, improve appointment adherence through reminder systems and vendor coordination, streamline multidisciplinary review of SDOH outcomes, and increase IBCLC availability during peak postpartum volumes.
• 12+ months (Sustain and Hardwire): Embed successful strategies into standard workflows, maintain data-driven equity reviews, sustain IBCLC availability, formalize community clinic partnerships, and evaluate long-term impact on readmission reduction and breastfeeding disparities.
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.