COTTAGE REHABILITATION 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
|
Age (excluding maternal measures) | 65 and older | 13.0% | 18 to 34 | 5.9% | 2.20 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 13.0% | 18 to 34 | 5.9% | 2.20 |
|
3.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 12.9% | Private | 6.8% | 1.90 |
|
4.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 12.5% | Private | 6.8% | 1.80 |
|
5.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 13.9% | Asian | 9.1% | 1.50 |
|
6.
HCAI 30-Day readmission
|
Preferred Language | Spanish Language | 14.9% | English Language | 11.0% | 1.40 |
|
7.
AHRQ pneumonia mortality rate
|
Sex Assigned at Birth | Male | 54.6% | Female | 42.6% | 1.30 |
|
8.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 11.5% | Asian | 9.1% | 1.30 |
|
9.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Hispanic or Latino | 11.1% | Asian | 9.1% | 1.20 |
|
10.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 6.6% | 18 to 34 | 5.9% | 1.10 |
2. Equity Plan
Overview & Population Impact
Our hospital recognizes that readmission disparities disproportionately impact specific populations, including older adults, individuals with chronic conditions, non-English speakers, and patients from low-income communities. Analysis of our top 10 disparities show higher readmission rates among patients in high Social Vulnerability Index (SVI) areas compared to the hospital average. These disparities lead to avoidable care utilization, higher costs, and increased patient burden.
The most impacted groups include:
• Medicaid-insured patients with limited outpatient follow-up access
• Patients with limited English proficiency (LEP) who face care coordination and health literacy barriers
• Patients with multiple chronic conditions requiring intensive follow-up
Goal
Reduce the 30-day readmission rate disparity between the highest-risk group and the hospital average by at least 5% within 24 months.
Measurable Objectives & Timeframes
1. Data Stratification & Monitoring — 0–6 months
o Implement enhanced tracking of readmissions by race, ethnicity, language, payer, ZIP code, and SVI.
o Review stratified data quarterly through the Quality and Equity Committee to identify disparities and refine interventions.
2. Enhanced Discharge Communication — 3–12 months
o Provide discharge instructions in preferred languages for 100% of LEP patients by month 12.
o Apply "teach-back" verification for 90% of all discharges by month 9 to confirm understanding.
3. Post-Discharge Follow-up Expansion — 6–18 months
o Launch a community health worker (CHW) and nurse navigator program for the top 15% highest-risk patients by month 6.
o Complete follow-up calls within 72 hours post-discharge for 90% of this cohort by month 12.
4. Improved Outpatient Access & Social Support — 6–24 months
o Partner with local FQHCs, home health, and transportation providers to secure follow-up appointments before discharge.
o Reduce no-show rates for target groups by 15% within 18 months.
5. Performance Measurement & Reporting — Ongoing; annual review
o Monitor readmission disparities quarterly and report progress to leadership and community partners annually.
o Evaluate success based on:
• Disparity reduction from 25% higher-than-average to ≤20% within 24 months
• Patient-reported understanding of discharge plans ≥90% by month 12
• Sustained improvement for two consecutive years
Evaluation
We will use rolling 12-month averages to monitor trends and adjust strategies. Stratified data will drive targeted interventions, ensuring cultural and linguistic appropriateness. Progress will be validated through quantitative readmission metrics and qualitative patient feedback.
Commitment
This plan integrates clinical quality improvement with social determinant interventions to reduce disparities and improve care continuity. Through data transparency, culturally responsive communication, and strengthened community partnerships, we are committed to ensuring all patients have equitable opportunities for recovery and reduced risk of avoidable readmission.
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.