DAMERON 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 NOBH
|
Race and/or Ethnicity | Native Hawaiian or Pacific Islander | 3.6% | Native Hawaiian or Pacific Islander | 0.2% | 18.00 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 4.9% | 18 to 34 | 0.6% | 8.20 |
|
3.
HCAI 30-Day readmission SUD
|
Sex Assigned at Birth | Female | 8.0% | Male | 4.0% | 2.00 |
2. Equity Plan
Reduce disparities in readmission rates among:
• Patients with No Behavioral Health Diagnosis
• Age 65 and older
• Patients with Substance Use Disorders (SUD)
________________________________________
1. Data Analysis & Risk Stratification
• Segment patients by age, behavioral health status, and comorbidities.
• Use predictive analytics to identify high-risk individuals before discharge.
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2. Tailored Interventions
For No Behavioral Health Diagnosis
• Focus on medical complexity and social determinants (transportation, food security).
• Schedule follow-up care appointments prior to discharge.
• For uninsured and/or patients with no primary care provider work with Community Health Center to secure follow-up care
For Age 65+
• Implement comprehensive discharge planning with medication reconciliation.
• Create and implement individualized easy to follow discharge instruction packet
• Provide home health referrals, fall prevention education, and caregiver support.
• Schedule early post-discharge follow-up (within 7 days).
For Substance Use Disorders
• Integrate addiction specialists into care teams.
• Offer referral/linkage to community recovery resources.
• Ensure safe medication management and overdose prevention education.
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3. Care Coordination
• Assign case managers for high-risk patients.
• Use electronic health record alerts to flag patients needing extra support.
• Strengthen communication between inpatient, outpatient, and community providers.
________________________________________
4. Patient Education & Engagement
• Use teach-back methods to confirm understanding of discharge instructions.
• Provide multilingual resources and culturally sensitive education.
________________________________________
5. Community Partnerships
• Collaborate with local agencies, senior centers, and behavioral health organizations.
• Coordinate transportation assistance and home visit programs through available insurance programs.
________________________________________
6. Measurement & Continuous Improvement
• Track readmission rates by subgroup quarterly.
• Conduct root cause analysis for any persistent disparities.
• Share progress with staff and community stakeholders.
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://res.cloudinary.com/dpmykpsih/image/upload/dameron-ho
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.