COLLEGE 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	Race and/or Ethnicity	Hispanic or Latino	47.7%	White	26.6%	1.80
2. HCAI 30-Day readmission	Sex Assigned at Birth	Male	41.5%	Female	23.4%	1.80
3. HCAI 30-Day readmission	Race and/or Ethnicity	Middle Eastern or North African	37.2%	White	26.6%	1.40
4. HCAI 30-Day readmission	Expected Payor	Medicaid	39.0%	Private	29.0%	1.30
5. HCAI 30-Day readmission	Expected Payor	Medicare	32.0%	Private	29.0%	1.10
6. HCAI 30-Day readmission	Age (excluding maternal measures)	35 to 49	38.1%	18 to 34	36.2%	1.10

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2. Equity Plan

College Hospital Cerritos (CHC) is committed to advancing health equity and addressing the barriers to care for our patient population. Our multidisciplinary Utilization Review Committee led by our Chief of Staff, focuses on reducing unplanned readmissions for all disparity groups. The committee is comprised of Utilization Management Staff, Nursing, Social Services, Quality Improvement/Risk Management, Administration and Medical Staff.

One of the most effective methods to prevent readmissions, is for patients to follow up with appropriate aftercare appointments. While it is a patient's right to refuse aftercare, it is imperative that all patients are encouraged to continue treatment post discharge and proper appointments are made with the next provider of care. Education is provided to patients and their families/caregivers regarding the importance of aftercare.

It is the policy of CHC to begin the discharge planning process at the time of the patient's admission. CHC recognizes that a clinically responsible and appropriate discharge plan is one of the keys for the patient's successful transition back into the community and return to the activities of their daily life. Because of the nature of the patients that we serve, and their inherent risks at discharge, all patients are assessed for their discharge needs and potential barriers through their admission assessment and psychosocial evaluation. Patients may be identified as "high risk" through these assessments, if they have multiple or recent psychiatric admissions, or if they have medical comorbidities. Treatment plans are developed for those patients that are identified to be at risk for rapid readmission.

Social Service Staff will oversee and coordinate the discharge plan for each patient. The plan will begin at the intake interview. The Social Worker will intervene as necessary to assist patients and families in discharge planning. The Social Worker will coordinate with necessary community partners that are responsible for discharge placements.

Since discharge planning is often the result of a team decision, including the patient and their family, it is unlikely that a final plan will be formulated until the patient and their psycho-social situation are more clearly understood by the interdisciplinary staff. Therefore, it is the responsibility of the Social Worker to communicate with staff the needed information that is helpful in moving the discharge planning process along in a timely manner. The Social Service notes will reflect initial thoughts about discharge planning as well as a logical and sequential development and modification of the discharge plan as additional clarity is gained through a variety of sources.

When resistance to discharge is identified, the Social Worker will take the appropriate clinical steps to intervene and assist the patient and family in understanding the resistance and helping them to move toward the next level of treatment; all interventions will be discussed and coordinated with the treatment team. All reasonable efforts will be made to ensure discharge plans which maximize the patient's functioning. If a patient is ready for discharge and placement is unavailable, the patient (if willing) may remain inpatient until placement is secured. Should a non-conserved patient refuse appropriate placement despite social worker's encouragement, the worker will honor a patient's right to self-determination and work with the patient to form an alternate plan. Crisis referrals are provided to all patients regardless of their aftercare plan.

Population Impact:
Race/Ethnicity (specifically Black and Hispanic populations); males; Medicaid and Medicare beneficiaries; and patients aged 35 to 49 have been identified in the top disparities.

Measurable Objectives:
All readmissions are reviewed to identify opportunities for improvement. Data on readmission rates are collected monthly/quarterly and reported to the URC, Medical Executive Committee and Board of Directors. The data includes but is not limited to length of stay, physician, payor source, discharge location as well as patient demographics.

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	No
Our hospital system has training for staff in culturally sensitive collection of demographics and/or social determinant of health information	No
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	No
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	No
Our hospital system participates in local, regional or national quality improvement activities focused on reducing health disparities	No
Our hospital system senior leadership, including chief executives and the entire hospital board of trustees, annually reviews our strategic plan for achieving health equity	No
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	No

COLLEGE HOSPITAL