AURORA BEHAVIORAL HEALTHCARE-SANTA ROSA, 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.
| Measure | Stratification | Stratification Group | Stratification Group Rate | Reference Group | Reference Rate | Rate Ratio |
|---|---|---|---|---|---|---|
|
1.
HCAI 30-Day readmission
|
Preferred Language | Other/Unknown | 92.2% | English Language | 4.1% | 22.40 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 7.6% | Private | 1.4% | 5.40 |
|
3.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 4.4% | Private | 1.4% | 3.10 |
|
4.
HCAI 30-Day readmission
|
Expected Payor | Other | 3.8% | Private | 1.4% | 2.70 |
|
5.
Joint Commission SUB-3
|
Race and/or Ethnicity | American Indian or Alaska Native | 54.5% | Asian | 25.2% | 2.20 |
|
6.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 6.2% | 18 to 34 | 2.9% | 2.10 |
|
7.
HCAI 30-Day readmission MHD
|
Sex Assigned at Birth | Male | 9.9% | Female | 5.2% | 1.90 |
|
8.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 9.8% | Female | 5.2% | 1.90 |
|
9.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 4.5% | 18 to 34 | 2.9% | 1.60 |
|
10.
Joint Commission SUB-3
|
Expected Payor | Medicare | 27.5% | Private | 19.8% | 1.40 |
2. Equity Plan
To effectively address disparities in screening rates, it is essential to continue disaggregating data by language, race, gender identity, and sexual orientation to clearly identify where gaps exist. Once these disparities are visible, the next step is to examine the barriers contributing to them, such as limited language access due to a lack of interpreters or translated materials, provider bias or insufficient cultural competency, and broader structural challenges like insurance coverage, stigma, or mistrust of the healthcare system. In addition to quantitative analysis, gathering qualitative input through focus groups with underrepresented patients will provide valuable insights into their lived experiences, helping to shape interventions that are both culturally responsive and patient centered.
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.