COMMUNITY HOSPITAL OF SAN BERNARDINO
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) | 65 and older | 21.3% | 18 to 34 | 5.2% | 4.10 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 22.7% | Private | 5.7% | 4.00 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 18.4% | 18 to 34 | 5.2% | 3.50 |
|
4.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 15.0% | 18 to 34 | 5.2% | 2.90 |
|
5.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Multiracial and/or Multiethnic (two or more races) | 27.9% | Hispanic or Latino | 10.5% | 2.60 |
|
6.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 23.7% | Hispanic or Latino | 10.5% | 2.20 |
|
7.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 11.6% | Private | 5.7% | 2.00 |
|
8.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Asian | 20.4% | Hispanic or Latino | 10.5% | 1.90 |
|
9.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 19.5% | Female | 11.0% | 1.80 |
|
10.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Male | 16.6% | Female | 9.4% | 1.80 |
2. Equity Plan
Disparity 1,3,4 Plan: Age-Related Readmission Disparities (65 and older, 50–64, and 35–49 vs. 18–34) Population Impact: Adults 35-65 and older experiencing higher unplanned readmissions compared to younger patients.
Measurable Objectives: Reduce 30-day readmission rate ratio for ages 65 and older from 4.1 to 2.5, ages 50-64 from 3.5 to 2.5, and for ages 35-49 from 2.9 to 2.0 within 24 months. Timeframe: Pilot Q4 2025, reassess Q4 2026.
Disparity 2,7 Plan: Payor Related Readmission Disparities (Medicare/Medicaid vs. Private) Population Impact: Patients with Medicare/Medicaid show higher readmission rates compared to privately insured patients.
Measurable Objectives: Reduce Medicare readmission rate ratio from 4.0 to 2.0 and Medicaid from 2.0 to 1.0 within 24 months Timeframe: Pilot in Q4 2025, reassess Q4 2026.
Disparity 5,6,8 Plan: Race and/or Ethnicity Related Readmission Disparities (Multiracial/White/Asian vs. Hispanic or Latino) Population Impact: Multiracial, White, and Asian patients face higher readmission rates compared to the Hispanic or Latino population. Measurable Objectives: Reduce Race and/or Ethnicity readmission rate ratio from 4.0 to 2.0 and Medicaid from 2.0 to 1.0 within 24 months Timeframe: Pilot in Q4 2025, reassess Q4 2026.
Disparity 9,10 Plan: Sex Assigned at Birth- Male Related Readmission Disparities Population Impact: Male patients show higher readmission rates than females
Measurable Objectives: Reduce male readmission rate ratios from 1.8 for readmissions that include behavioral health diagnosis and 1.7 for those without a behavioral health diagnosis to a readmission rate ratio of 1.0 within 24 months.
Timeframe: Pilot in Q4 2025, reassess Q4 2026.
Actions Planned:
Strategies to reduce readmissions across all disparities include:
1. Enhanced Discharge Planning: Standardize and individualize discharge plans to include clear instructions, medication reconciliation, and follow-up appointments.
2. Post-Discharge Follow-up: Implement structured post-discharge phone calls within 2-3 days of discharge to address immediate concerns and confirm understanding of discharge instructions.
3. Patient Education and Engagement: Broad health education, community outreach, and vital screening programs available to all community members.
4. Chronic Diseases: Self-Management Education and outreach for asthma, cancer, diabetes, heart failure, plus tobacco cessation with distribution of educational materials and engagement of patients/caregivers in shared decision-making regarding their care.
5. Community Partnerships: Collaborate with community organizations, primary care providers, and specialized services (e.g., home health, social services) to support patients post-discharge.
6. Staff Training: Provide ongoing training to clinical and administrative staff on cultural competency, health literacy, effective communication, and patient-centered care.
By focusing on culturally tailored interventions, payer-based support, and age and gender-sensitive care strategies, Community Hospital of San Bernardino will reduce disparities in readmissions. These actions will advance equity, improve patient outcomes, and align with California Assembly Bill 1204.
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
https://www.dignityhealth.org/socal/locations/san-bernardino
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.