ARROWHEAD REGIONAL 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	Race and/or Ethnicity	Black or African American	19.5%	Hispanic or Latino	13.5%	2.90
2. AHRQ PSI surgical death rate	Expected Payor	Medicare	333.3%	Medicaid	230.8%	2.90
3. HCAI 30-Day readmission	Race and/or Ethnicity	White	18.0%	Hispanic or Latino	13.5%	2.70
4. HCAI 30-Day readmission	Age (excluding maternal measures)	50 to 64	19.1%	18 to 34	7.8%	2.50
5. HCAI 30-Day readmission	Age (excluding maternal measures)	65 and older	18.5%	18 to 34	7.8%	2.40
6. AHRQ PSI surgical death rate	Race and/or Ethnicity	White	457.1%	Hispanic or Latino	216.9%	2.10
7. HCAI 30-Day readmission	Race and/or Ethnicity	Asian	14.0%	Hispanic or Latino	13.5%	2.10
8. HCAI 30-Day readmission	Age (excluding maternal measures)	35 to 49	15.3%	18 to 34	7.8%	2.00
9. HCAI 30-Day readmission	Expected Payor	Medicare	20.0%	Private	11.1%	1.80
10. HCAI 30-Day readmission NOBH	Sex Assigned at Birth	Male	15.9%	Female	11.4%	1.40

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2. Equity Plan

Based on our risk stratification data, Arrowhead Regional Medical Center had the following ten key disparities.
Disparity 1: AHRQ Patient Safety Indicator Death Rate among Surgical Inpatients with Serious Treatable Complications expected payor. Goal: Enhance equity of care by decreasing the number of treatable complications in patients. Strategies: Risk stratification for all Medicare patients. Dedicated Transitional Care Team: Admission representatives, case management team. Concurrent review of serious treatable complications ensure clear, effective communication is occurring. Population Impact: Improves patient safety, reduces payor disparities by ensuring safety amongst all patients regardless of payor.

Disparities 2;3;7: Hospital Readmission Race and/or Ethnicity- Goal: Decrease disparity amongst race and or Ethnicity by 5%. Dedicated Transitional Care Team: Social Determinants of Health (SDOH) support. Access to outpatient services within 7 days for high-risk patients. Review daily readmission episodes to identify trends analyzing data focusing on equity interventions. Placement of post discharge phone calls to connect with patients and identify needs, build on continuity of care, reduce disparities, strengthen community partnership to lower the preventable readmissions. Population Impact: Reduces disparities ensuring quality safety care amongst all patients regardless of ethnicity.

Disparities 4;5;8: Hospital Readmission-Age Goal: Reduce 30-day all cause readmissions for patient's age. Transitional Care Team Support: Social Determinants of Health (SDOH) support. Provide patient education amongst the community regarding preventive care. Population Impact: Reduces disparities ensuring quality safety care amongst all patients regardless of age.

Disparity 6: AHRQ Patient Safety Indicator Death Rate among Surgical Inpatients with Serious Treatable Complications Race and/or Ethnicity: Goal: Focus on equitable access treatment. Transitional Care Team Support: Social Determinants of Health (SDOH) support. Provide patient
education amongst the community regarding preventive care. Population Impact: Reduces disparities ensuring quality safety care amongst all patients regardless of ethnicity.

Disparity 9: Hospital Readmission-Medicare, Goal: Reduce 30day all cause readmissions for Medicare patients by 5%. Transitional Care Team Support: Increase Patient education on preventive measures, provide medication reconciliation. Increase community outreach programs encouraging patient wellbeing, ensure patients have follow up visit scheduled prior to discharge; providing discharge follow up phone calls. Involvement of interdisciplinary team prior to discharge to identify any needs of patient prior to discharge. Population Impact: Reduces disparities ensuring quality safety care amongst all patients regardless of payor source.

Disparity 10: Hospital Readmissions-Male Patients, Goal: Reduction of 30-day-all-cause readmissions for male patients by 5% in the first year. Strategies: Gender specific discharge plans addressing substance use needs, mental health and cardiovascular. Ensuring chronic management for diabetes, hypertension, and heart diseases. Ensure patients have post-discharge referrals prior to discharge. Population Impact: Reduces disparities ensuring quality safety care amongst all patients regardless of sex assigned at birth.

Summary: Arrowhead Regional Medical Center equity plan focuses on interventions to reduce all cause readmissions by utilizing evidence-based strategies. Interventions include interdisciplinary discharge rounding, transitional care, chronic disease management, post discharge calls, and SDOH support. This plan aims to improve patient safety and decrease disparities by including the patient/or designated health designee from admission to discharge regarding their hospital treatment plan. Our hospital recognizes that many of the disparities reflected on our data are related to the demographics of our service area, including race, ethnicity, age, sex assigned at birth, and payor type. While we cannot change the underlying demographics of our service area, ARMC is committed to implementing focused strategies that lessen their impact and advance equity in care delivery.

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

ARROWHEAD REGIONAL MEDICAL CENTER