CASA COLINA 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.
HCAHPS survey-received information
|
Preferred Language | Spanish Language | 80.0% | English Language | 94.3% | 1.20 |
|
2.
HCAHPS survey-recommend hospital
|
Race and/or Ethnicity | Asian | 83.3% | Hispanic or Latino | 93.8% | 1.10 |
|
3.
HCAHPS survey-received information
|
Race and/or Ethnicity | Multiracial and/or Multiethnic (two or more races) | 89.0% | Asian | 100.0% | 1.10 |
|
4.
HCAHPS survey-recommend hospital
|
Age (excluding maternal measures) | 50 to 64 | 91.3% | 65 and older | 100.0% | 1.10 |
|
5.
HCAHPS survey-recommend hospital
|
Expected Payor | Medicare | 89.9% | Private | 96.2% | 1.10 |
|
6.
HCAHPS survey-recommend hospital
|
Preferred Language | English Language | 90.4% | Spanish Language | 93.8% | 1.00 |
|
7.
HCAHPS survey-received information
|
Age (excluding maternal measures) | 35 to 49 | 92.3% | 65 and older | 93.3% | 1.00 |
|
8.
HCAHPS survey-received information
|
Sex Assigned at Birth | Male | 90.9% | Female | 95.2% | 1.00 |
|
9.
HCAHPS survey-received information
|
Gender Identity | Male | 90.9% | Female | 95.2% | 1.00 |
|
10.
HCAHPS survey-recommend hospital
|
Sex Assigned at Birth | Male | 88.9% | Female | 92.3% | 1.00 |
2. Equity Plan
The top two ranked disparities were in the measure related to readmission rate. Analysis of readmission rates by sex demonstrated that women were the best-performing group, with a readmission rate of suppressed, while men represented the lowest-performing group, with a suppressed readmission rate. The goal is to reduce the readmission rate among men to 2.45 within the next year by ensuring that at least 90 of male discharges are screened for social determinants of health (SDOH) and that appropriate support services are provided to address identified risk factors. Additional efforts will focus on strengthening discharge education for men through the teach-back method to verify comprehension and reinforce adherence to follow-up care. Implementation of these strategies aims to improve continuity of care and reduce preventable readmissions in this population. Four of the top ten identified disparities were associated with the measure evaluating the provision of written discharge education related to the medical diagnosis and symptoms to monitor after discharge. The analysis showed that Spanish-speaking patients had an 80 compliance rate with a rate ratio (RR) of 1.179 compared to the highest-performing group, English-speaking patients, at 94.3. Multi-Race patients had an 89 rate (RR = 1.124) compared to the highest-performing group, Black patients, at 100. Male patients had a 90.9 rate ratio (RR = 1.047) compared to the highest-performing group, female patients, at 95.2, with similar values identified for the gender identity and sex categories. The goal for each disparity is to reduce the gap between the identified group and the highest-performing group by 50 within the next year. Planned interventions include strengthening discharge education by ensuring materials are provided in the patients preferred language, integrating interpreter services, and confirming understanding through use of the teach-back method. In addition, staff training will be implemented to enhance culturally competent, patient-centered care. Training content will emphasize cultural humility, effective communication, implicit bias awareness, family and social dynamics, and an understanding of the healthcare beliefs of the diverse populations served. The remaining three disparities were associated with the patient experience measure evaluating the willingness to recommend the facility to family or friends. Analysis identified the following disparities: Asian patients had an 83.3 positive response rate with a relative risk of 1.126 compared to the highest-performing group, White patients, at 93.8; patients aged over 65 years had an 89.8 rate (RR = 1.114) compared to the highest-performing group, those aged 35–49 years, at 100; and Medicare patients had an 89.9 rate (RR = 1.070) compared to the highest-performing group, private pay patients, at 96.2. The goal for each disparity is to decrease the gap between the identified disparity group and the highest-performing group by 50 within the next year. Interventions to address these gaps will include staff education focused on enhanced communication and teaching strategies for patients aged 65 years and older, emphasizing the use of plain language, visual aids, and teach-back techniques while accounting for hearing, vision, or cognitive limitations. The Commit to Sit initiative will also be used to promote empathy, active listening, and effective communication during patient interactions. Additionally, a targeted survey will be conducted among Asian patients to identify key drivers of dissatisfaction and gather actionable insights to guide quality improvement efforts and improve the overall patient experience.
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.