BAKERSFIELD MEMORIAL 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
|
Age (excluding maternal measures) | 50 to 64 | 15.8% | 18 to 34 | 4.0% | 4.00 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 15.1% | 18 to 34 | 4.0% | 3.80 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 12.4% | 18 to 34 | 4.0% | 3.10 |
|
4.
AHRQ pneumonia mortality rate
|
Race and/or Ethnicity | Hispanic or Latino | 117.1% | White | 95.5% | 2.50 |
|
5.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 16.1% | Private | 7.0% | 2.30 |
|
6.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 16.4% | Hispanic or Latino | 10.6% | 1.60 |
|
7.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Male | 13.6% | Female | 8.8% | 1.50 |
|
8.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 15.0% | Female | 10.1% | 1.50 |
|
9.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 10.1% | Private | 7.0% | 1.50 |
|
10.
AHRQ pneumonia mortality rate
|
Sex Assigned at Birth | Male | 103.7% | Female | 77.5% | 1.30 |
2. Equity Plan
At Bakersfield Memorial Hospital (BMH), equity means ensuring every patient receives optimal care regardless of age, race, ethnicity, payer status, or assigned sex. Our HCAI and AHRQ data reveal significant disparities, primarily in 30-day all-cause hospital readmission rates and pneumonia mortality rates. Addressing these inequities is central to our mission and commitment to patient-centered care.
1. Equity Considerations Equity is integrated into our care model by:
• Proactive Social Determinants of Health (SDoH) Screening: Utilizing Cerner (Feb 2024) to screen 68% of admissions for housing, food, safety, and transportation needs. Positive screens will trigger immediate Social Services (SS) consultations for community resource linkage.
• Patient-Centered Insights: Implementing a readmission interview tool (Feb 2025) for Care Coordination (CC) staff to capture patient perspectives regarding their readmission.
• Predictive Risk Stratification: Employing an AI risk assessment tool (April 2025) for early identification of at-risk patients, enabling tailored interventions.
• Holistic Care Planning: Multidisciplinary Rounds (MDR) comprehensively review clinical, psychosocial, and SDoH factors for equitable, proactive discharge planning.
• Culturally Competent Care: Delivering programs via our Community Health Initiative in a culturally-sensitive, linguistically appropriate manner.
2. Programs & Practices
Targeting Readmission Disparities:
• Enhanced Discharge Planning: High-risk CC Registered Nurse (RN) partner with outpatient nurse navigators for disease-specific education (e.g., CHF, diabetes, COPD, Pneumonia) and resources (e.g., scales, glucometers, incentive spirometry).
• Transitional Care RN (TCRN): Ensures follow-up appointments and post-discharge support for high-risk patients.
• Interdisciplinary Collaboration: SS and CC teams collaborate closely on SDoH barriers impacting readmission risk.
Addressing Access to Care:
• Dignity Health Community Health Initiative: Provides outreach and enrollment assistance for health insurance programs for uninsured/underinsured/low-income families, ensuring medical home access and preventive care.
• Community Wellness Program: Offers on-site screenings, health/wellness education, and outpatient nurse navigation for prevention (e.g., cardiovascular, asthma, diabetes, obesity).
• Specific Patient Navigator Programs: Substance Use Navigator for Substance Use Disorders (SUD) discharge planning, and an on-site Kern Health Systems Case Manager for complex Managed Medi-Cal patients (behavioral health/SUD).
• In-Hospital Support: Financial assistance and prescription purchases for patients in need.
• Community Health Improvement Grants Program: Funds local non-profits to address health needs, including access to care, aligned with our Community Health Needs Assessment (CHNA).
3. Improvements & Plans
Population Impact: Our interventions will improve outcomes for patients in age (35 to 64), payer (Medicare), and racial (Black/African American) groups for readmissions, and potentially Hispanic/Latino males for pneumonia mortality. Efforts will be aimed at reducing suffering, healthcare burden, and promoting health equity for thousands.
Measurable Objectives:
All-Cause Readmission Disparities:
• Goal 1: 20% reduction in all-cause 30-day readmission rates (CY24 12.7%; CY25 goal: 10.2%)
Pneumonia Mortality Disparities:
• Goal 2: 10% reduction in Pneumonia Mortality Rate for Hispanic or Latino patients (CY24 45.8%, CY25 goal: 41.22%)
Timeframes:
• Implementation: Initiatives began Feb 2024/Feb 2025 are ongoing.
• Data Monitoring: Quarterly monitoring for target disparities commences October 1, 2025.
• Target Achievement: All stated reductions (Goals 1 & 2) are targeted by September 30, 2026.
Actions:
• Sustained SDoH Screening (68%+) & SS Referrals (100% positive screens).
• Full AI Risk Tool Integration for early high-risk identification.
• Optimized CC & Discharge Planning: Consistent readmission interview tool use, diligent TCRN follow-up for high-risk patients, and proactive supply of self-management tools/education.
This comprehensive plan, with clear objectives, timelines, and integrated strategies, demonstrates BMH's commitment to addressing health disparities and advancing health equity.
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.