CEDARS-SINAI MARINA 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
|
Expected Payor | Medicaid | 11.0% | Private | 6.0% | 1.80 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 10.9% | Private | 6.0% | 1.80 |
|
3.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Hispanic or Latino | 11.9% | White | 8.1% | 1.50 |
|
4.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 11.7% | White | 8.1% | 1.50 |
|
5.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 10.5% | 50 to 64 | 8.2% | 1.30 |
|
6.
HCAHPS survey-received information
|
Expected Payor | Medicare | 81.5% | Other | 100.0% | 1.20 |
|
7.
HCAHPS survey-received information
|
Expected Payor | Medicaid | 86.5% | Other | 100.0% | 1.20 |
|
8.
HCAHPS survey-received information
|
Expected Payor | Private | 89.9% | Other | 100.0% | 1.10 |
|
9.
HCAHPS survey-received information
|
Race and/or Ethnicity | White | 82.7% | Hispanic or Latino | 89.3% | 1.10 |
|
10.
HCAHPS survey-recommend hospital
|
Race and/or Ethnicity | Asian | 85.4% | Black or African American | 92.2% | 1.10 |
2. Equity Plan
HCAI All-Cause Unplanned 30-Day Hospital Readmission Rate
Preventing unplanned 30-day readmissions continues to be a core focus at CSMH. By stratifying our data, we regularly assess key readmission patterns across race, ethnicity, age group, preferred language, and payor type to better understand the needs of specific populations and inform targeted improvement strategies. Findings from the HCAI Annual Health Equity Report revealed elevated readmission rates among (i)Medicare and (ii)Medicaid beneficiaries, (iii) adults aged 65 and older, and (iv) Hispanic or Latino and (v) Black or African American patients.
Our internal assessment suggests a set of interconnected drivers. Older adults experience increased readmission risk due to higher clinical complexity, prompting us to refine care models to better anticipate and support these needs. Within the Medicare population, outcomes are significantly shaped by dual-eligible patients (Medicare + Medicaid), who often have more complex medical conditions and face socioeconomic barriers that challenge their recovery. Among Medicaid only patients, socioeconomic influences, including limited resources, transportation barriers, housing instability, and variability in caregiver support are key contributors. The disparities noted among Black and Latino patients in the HCAI analysis align with the influence of these socioeconomic and structural factors rather than race itself. To address these realities, CSMH has strengthened care coordination and expanded supports that address medical and social needs. Key strategies include:
• A "Meds to Beds" program, delivering patient discharge prescriptions to the bedside prior to discharge
• Evaluation of high-ranking skilled nursing facilities and selective partnerships with only four and five star rated facilities
• Leveraging electronic medical record to create lists tracking high risk patients
• Social support via programs including Healthcare in Action (HIA) providing comprehensive medical, behavioral, and social support to people experiencing homelessness
In the coming year, CSMH will work to maintain this momentum along with institute additional interventions as next steps to reduce readmissions including:
• Dedicate resources to monitor patients post hip and knee surgeries
• Management of pneumonia and congestive heart failure (CHF) patients
• Select a dedicated clinician to serve as a patient navigator to track high-risk patients, ensuring continuity of care and timely follow-up
• Integrate a community health worker (CHW) to provide tailored, culturally responsive support that addresses nonclinical factors impacting recovery and ensures patients remain connected to needed resources after discharge
This initiative is a key goal for FY26, with the measurement period for readmission rates set from January 2026 through June 2026. Our objective is to achieve a 10% decrease in readmission rates within the identified populations, fostering equitable access to high-quality healthcare for all our patients.
HCAHPS Survey Responses: "Received Information and Education" and "Would Recommend Hospital"
Delivering clear, comprehensive patient education, both verbal and written, is a key priority at CSMH, ensuring patients feel informed, supported, and prepared to manage their recovery after discharge. At CSMH, the HCAHPS "Would Recommend Hospital" measure reflects how effectively we meet patient and family needs across communication, safety, responsiveness, coordination, and overall experience. Because this score captures patients' holistic impressions of their care, it serves as a critical indicator of the trust and confidence our community places in us. Several factors at the hospital affecting patient experience and overall environment were identified as challenges for the hospital:
• Patient environment given semi-private rooms and reduced privacy
• Increased noise and sleep disruptions with ongoing construction of the new hospital being built in close proximity
Following the identification of disparities in these two-patient perception and experience measures, several targeted strategies have been launched to ensure all patients feel respected, supported, and genuinely cared for, including the following:
• Establishing a structured monthly Patient Experience Committee in which patient experience data are systematically reviewed and disseminated, followed by unit-level reporting on initiatives and performance reinforcing shared accountability
• Formalizing a Hospital Quality Council goal specifically targeting patient experience, including education and information received
These efforts, supported by continuous staff involvement in the review and interpretation of patient experience data, are intended to advance the quality of the patient experience over time.
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.