BARSTOW COMMUNITY 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 | 14.9% | 18 to 34 | 6.5% | 2.30 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 13.8% | Private | 6.3% | 2.20 |
|
3.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 12.2% | Hispanic or Latino | 11.3% | 2.20 |
|
4.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 11.7% | Hispanic or Latino | 11.3% | 2.10 |
|
5.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 12.9% | 18 to 34 | 6.5% | 2.00 |
|
6.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 12.2% | Private | 6.3% | 1.90 |
|
7.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 11.0% | 18 to 34 | 6.5% | 1.70 |
|
8.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 13.8% | Female | 10.4% | 1.30 |
2. Equity Plan
The attached form highlights disparities in 30-day unplanned hospital readmission rates at Barstow Community Hospital, we created SMART goals tailored to reducing these readmissions, especially among high-risk groups.
Here's a breakdown of the disparities identified:
• Age 50–64 has a readmission rate of 14.9% vs. 6.5% for ages 18–34.
• Medicare patients have a rate of 13.8% vs. 6.3% for private insurance.
• White patients have a rate of 12.2% vs. 11.3% for Hispanic/Latino.
• Black/African American patients have a rate of 11.7% vs. 11.3% for Hispanic/Latino.
• Age 65+ has a rate of 12.9%.
• Medicaid patients have a rate of 12.2%.
• Males have a rate of 13.8% vs. 10.4% for females.
________________________________________
SMART Goals to Decrease Readmissions
Goal 1: Reduce Readmissions Among Medicare Patients
• Specific: Implement a post-discharge follow-up program for Medicare patients.
• Measurable: Decrease readmission rate from 13.8% to 11% within 12 months.
• Achievable: Use care managers to call patients within 48 hours of discharge and schedule follow-up visits with Home Health Care
• Relevant: Medicare patients show the highest disparity in readmissions.
• Time-bound: Launch program by October 1, 2025, and evaluate quarterly.
Goal 2: Improve Transitional Care for Patients Aged 50–64
• Specific: Develop a targeted education and medication reconciliation program.
• Measurable: Reduce the readmission rate from 14.9% to 12% in one year.
• Achievable: Partner with pharmacy and nursing staff to provide discharge counseling.
• Relevant: This age group has the highest age-related disparity.
• Time-bound: Pilot program by November 2025, full rollout by January 2026.
Goal 3: Address Gender Disparities in Readmissions
• Specific: Investigate and address factors contributing to higher male readmissions.
• Measurable: Reduce male readmission rate from 13.8% to 11.5% in one year.
• Achievable: Conduct chart reviews and patient interviews to identify gaps.
• Relevant: Males have a significantly higher readmission rate.
• Time-bound: Complete analysis by December 2025, implement interventions by February 2026.
Goal 4: Enhance Support for Medicaid Patients
• Specific: Provide case management support and transportation assistance for Medicaid patients.
• Measurable: Reduce readmission rate from 12.2% to 10% in 12 months.
• Achievable: Use existing community resources and hospital case management.
• Relevant: Medicaid patients face socioeconomic barriers impacting readmissions.
• Time-bound: Begin support services by October 2025.
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.