AURORA LAS ENCINAS HOSPITAL

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 MHD	Expected Payor	Medicare	15.2%	Private	6.2%	2.50
2. HCAI 30-Day readmission MHD	Age (excluding maternal measures)	35 to 49	7.8%	18 to 34	3.8%	2.10
3. HCAI 30-Day readmission	Age (excluding maternal measures)	35 to 49	7.8%	18 to 34	3.8%	2.10
4. Joint Commission SUB-3	Sexual Orientation	Straight or heterosexual	10.3%	Choose not to disclose	5.5%	1.90
5. Joint Commission SUB-3	Race and/or Ethnicity	Black or African American	15.2%	White	8.7%	1.80
6. HCAI 30-Day readmission	Gender Identity	Male	7.5%	Female	4.4%	1.70
7. Joint Commission SUB-3	Expected Payor	Medicaid	11.6%	Private	8.5%	1.40
8. CMS IPFQR screening metabolic disorders	Age (excluding maternal measures)	65 and older	93.3%	50 to 64	86.3%	1.10
9. CMS IPFQR screening metabolic disorders	Race and/or Ethnicity	Black or African American	96.0%	White	87.8%	1.10
10. CMS IPFQR screening metabolic disorders	Sexual Orientation	Choose not to disclose	97.2%	Lesbian, gay or homosexual	87.6%	1.10

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2. Equity Plan

1. Measure: HCAI All-Cause Unplanned 30-day Hospital Readmission Rate in an Inpatient Psychiatric Facility (IPF)
Disparity Group 1: Medicare Expected Payor
Disparity Group 2: Age (excluding maternal measures) 50-64
Disparity Group 3: Male
Equity Plan:
Targeted assessment by outpatient services for Medicare patients age 50-64 and referrals to outpatient programing upon discharge to reduce hospital readmission rates.
Goal:
Reduce hospital readmission rate in IPF by 2% over the next 12 months to 7.5%. This would be 50% lower than the average rate in all of California hospitals surveyed.
Target Population:
A notable disparity within our data involves 30-day all-cause readmissions among patients covered by Medicare, particularly those requiring inpatient psychiatric care. Patients aged 50–64 demonstrate a higher rate of readmission compared to the reference group of patients under 35. According to www.data.chhs.ca.gov reporting for 2023 the 30-day readmission rate in California was 15.34%. Although our data shows this area of higher scoring in comparison to our internal data of 9.5%, 5.7% higher than 18 to 34 and 1.7% higher than 35 to 49 age groups, it remains 5.84% lower than the California average. Contributing factors may include multiple chronic medical conditions, limited social support, fragmented outpatient care coordination, and restricted access to community-based psychiatric resources that accept Medicare. Reynolds, C. et al (2022) paper in the World Psychiatry, determines that the SDOH’s that have significant effect on health inequities in this age population include “stigma against mental illness, mental health care disparity, flawed criminal justice system, and homelessness”, and “social isolation/loneliness”.
Intervention:
There are multitudes of studies and articles about mental health in older adults and the correlation of loneliness factors that continue to be explored in scientific literature. The question remains about how to implement a strategy to address this disparity on the front line of mental health care services being delivered to this population. One implementation to address this disparity by Las Encinas Hospital is to focus on connection to outpatient services including Intensive Outpatient Services and programs that specifically address challenges facing older adults within our population. The Outpatient director and her team will see patients who are able to attend our outpatient program and describe how their services will directly address their needs, while still under the services of the inpatient program. We will provide transportation to the program services, and a psychiatrist will follow them throughout the program.
Data collection and reporting:
Data will be collected on age specific groups of 50-64, 30 day readmission rate. This data will be reported during QAPI, MEC (Medical Executive Committee) and The Governing Body quarterly.

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

AURORA LAS ENCINAS HOSPITAL