COLLEGE MEDICAL CENTER
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 | 12.4% | 1.60 | ||
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 18.7% | 35 to 49 | 13.1% | 1.40 |
|
3.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 17.1% | Hispanic or Latino | 12.4% | 1.40 |
|
4.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Female | 13.6% | 1.30 | ||
|
5.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 13.1% | 1.30 | ||
|
6.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 18.0% | Medicaid | 14.7% | 1.20 |
|
7.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 13.1% | 1.10 | ||
|
8.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Asian | 13.3% | Hispanic or Latino | 12.4% | 1.10 |
2. Equity Plan
Current readmission patterns appear to be driven primarily by patient acuity rather than equity-related factors. To ensure this continues to hold true, the organization will regularly stratify readmission data by demographic and clinical variables, apply risk-adjusted acuity scoring to distinguish clinical complexity from care-process issues, and rely on a multidisciplinary review committee to validate trends and guide targeted improvements.
To strengthen safe and effective care transitions, especially for patients with higher clinical needs, the organization is standardizing key practices. We track and report on the timeliness of medication consent and initiations of Riese petitions to help prevent treatment delays. As well, appropriate use of long-acting injectables through enhanced education and coordinated post-discharge follow-up allows for greater stabilization for patients. Discharge materials are standardized to support health literacy, offered in multiple languages, aligned across digital and printed formats.
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 |
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.