ALHAMBRA HOSPITAL MEDICAL CENTER
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 | Medicaid | 18.5% | Private | 7.9% | 2.30 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 14.3% | Private | 7.9% | 1.80 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 20.0% | 18 to 34 | 11.6% | 1.70 |
|
4.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Hispanic or Latino | 17.8% | Asian | 12.9% | 1.40 |
|
5.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 17.1% | Asian | 12.9% | 1.30 |
|
6.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 14.1% | 18 to 34 | 11.6% | 1.20 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 15.4% | Asian | 12.9% | 1.20 |
|
8.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 13.5% | 18 to 34 | 11.6% | 1.20 |
|
9.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 15.5% | Female | 14.7% | 1.10 |
|
10.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Female | 13.8% | Male | 13.8% | 1.00 |
2. Equity Plan
Alhambra Hospital Medical Center is committed to reducing readmission rates, especially for populations experiencing health disparities. The top ten disparities identified for our facility are all related to readmissions. The top two disparity groups are stratified under expected payor. Patients with state provided health insurance have higher readmission rate followed by patients with federal health insurance compared to the reference group of private pay patients. Three out of ten disparities are related to age group. Patients aged 50 to 64 readmit at the highest frequency followed by 65 or older and 35 to 49 age group compared to the reference group of patients 18 to 34 of age. Another stratification group identified with disparity is the race/ethnicity. Hispanic and Latino, Black/African American and White patients have a higher readmission rate than the Asian reference group. The last two disparities are related to sex assigned at birth. Males have the tendency to be readmitted within 30 days compared to the reference group females. However, females with no behavioral health diagnosis readmit at a higher rate than males.
As part of our effort to reduce readmission rates, Alhambra Hospital Medical Center has a multidisciplinary team that involves Physicians, Case Managers, Social Workers, Nurses and Leadership Team. The team meets regularly to review patients with identified disparities to make sure that appropriate resources, education and referrals are provided during hospitalization and after discharge. The focus is to reduce avoidable 30-day readmissions among this population which requires coordination of a multidisciplinary approach that emphasizes risk identification, transitional care, and engagement with community resources. Our facility has Quality Improvement, Utilization Resources and Risk Management Committee that oversees the readmission reduction program. The team uses readmission data of patients with disparities to identify any opportunities for improvement. The Quality Framework for process improvement, Plan Do Check Act (PDCA), is the method used to identify current and target states, complete a gap analysis and develop action plans that deliver results. Our program has been successful in reducing 30-day hospital readmission rates overall. The goal is to create a sustainable program that will reduce readmissions within 30 days for patients identified with 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.