ALISO RIDGE BEHAVIORAL HEALTH, LLC
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.
No disparity data for this period.
2. Equity Plan
Aliso Ridge Behavioral Health is committed to equitable, person-centered psychiatric care. In response to disparities identified in demographic and access data, the following plan outlines targeted strategies to reduce inequities, improve outcomes, and ensure culturally responsive care across all patient populations.
1. Age-Based Disparities in Access and Outcomes
Action:
- Refine age-specific programming (e.g., adolescent vs. geriatric tracks) to ensure developmental relevance.
- Review admission and discharge trends by age group to identify barriers to timely care.
- Train staff on age-related psychiatric presentations and communication strategies.
2. Race and Ethnicity Disparities in Admission and Retention
Action:
- Conduct quarterly equity audits on admission, treatment engagement, and discharge by race/ethnicity.
- Expand cultural competency training and integrate culturally adapted therapeutic modalities.
- Partner with community organizations serving underrepresented racial/ethnic groups.
3. Payor Disparities in Access to Services
Action:
- Analyze service utilization by payor type (e.g., Medi-Cal, private insurance, uninsured).
- Strengthen financial navigation support and streamline authorization processes.
- Advocate for expanded coverage of psychiatric services through local and state channels.
4. Sexual Orientation Disparities in Safety and Engagement
Action:
- Ensure inclusive language and visibility of LGBTQ+ affirming resources throughout the facility.
- Incorporate sexual orientation considerations into safety planning and therapeutic goals.
- Facilitate staff education on minority stress and psychiatric risk factors in LGBTQ+ populations.
5. Gender Identity Disparities in Treatment Experience
Action:
- Implement gender-inclusive documentation and intake protocols.
- Offer staff training on affirming care for transgender and nonbinary patients.
- Monitor incidents and grievances for gender-related concerns and respond with corrective actions.
6. Language Access Disparities
Action:
- Expand translation of patient rights, safety protocols, and discharge materials into additional languages.
- Increase availability of bilingual staff and interpreter services.
- Track language preference and satisfaction in patient surveys.
7. Disparities in Psychiatric Crisis Response
Action:
- Review legal holds and crisis admissions by demographic group to identify patterns.
- Collaborate with local law enforcement and EMS to ensure equitable crisis response.
- Provide community education on psychiatric emergencies and rights.
8. Disparities in Discharge Planning and Continuity of Care
Action:
- Audit discharge plans for inclusion of culturally relevant and accessible resources.
- Strengthen coordination with outpatient providers serving marginalized populations.
- Track readmission rates by demographic group and adjust protocols accordingly.
9. Disparities in Patient Satisfaction and Grievance Trends
Action:
- Disaggregate patient satisfaction and grievance data by demographic variables.
- Use feedback to inform staff training, environmental adjustments, and programming.
- Elevate patient voice through advisory councils and structured feedback loops.
10. Staff Awareness and Responsiveness to Disparities
Action:
- Launch training on health equity, implicit bias, and trauma-informed care.
- Integrate disparity data into Safety Actions Updates and committee reviews.
- Recognize staff contributions to equity through spotlight programs and performance metrics.
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.