DESERT VALLEY 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	17.5%	18 to 34	9.8%	1.80
2. HCAI 30-Day readmission	Age (excluding maternal measures)	50 to 64	16.8%	18 to 34	9.8%	1.70
3. HCAI 30-Day readmission	Expected Payor	Medicare	18.4%	Private	11.0%	1.70
4. HCAI 30-Day readmission	Age (excluding maternal measures)	35 to 49	14.5%	18 to 34	9.8%	1.50
5. HCAI 30-Day readmission	Expected Payor	Medicaid	15.8%	Private	11.0%	1.40
6. HCAI 30-Day readmission NOBH	Sex Assigned at Birth	Male	17.4%	Female	12.7%	1.40
7. HCAI 30-Day readmission	Race and/or Ethnicity	Native Hawaiian or Pacific Islander	19.8%	Asian	15.2%	1.30
8. HCAI 30-Day readmission	Sex Assigned at Birth	Male	18.2%	Female	14.0%	1.30
9. HCAI 30-Day readmission	Race and/or Ethnicity	Black or African American	18.4%	Asian	15.2%	1.20
10. HCAI 30-Day readmission	Race and/or Ethnicity	White	17.4%	Asian	15.2%	1.10

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2. Equity Plan

Top 10 Disparities & Action Plans
1. Readmission Rate: Age 65+
Disparity Group: Age 65+
Reference Group: Age 18 to34
Rate Ratio: 1.8
Population Impact: Older adults are at higher risk for readmissions due to chronic conditions and complex care needs.
Measurable Objective: Reduce 30-day readmission rate for patients aged 65+ by 15% within 12 months.
Actions:
Implement geriatric care coordination protocols.
Expand post-discharge follow-up calls and home visits.
Partner with senior centers for medication and nutrition support.
Timeframe: Launch Q1 2026; evaluate quarterly.
2. Readmission Rate: Age 50 to 64
Rate Ratio: 1.7
Measurable Objective: Reduce readmissions by 10% in this age group.
Actions:
Enhance chronic disease management programs.
Provide health coaching for patients with diabetes, CHF, and COPD.
Timeframe: Begin Q1 2026; full implementation by Q3 2026.
3. Readmission Rate: Medicare Patients
Rate Ratio: 1.7
Measurable Objective: Improve care transitions for Medicare patients.
Actions:
Assign discharge navigators for Medicare patients.
Collaborate with primary care providers for timely follow-up.
Timeframe: Pilot in Q2 2026; scale by Q4 2026.
4. Readmission Rate: Age 35 to 49
Rate Ratio: 1.5
Measurable Objective: Reduce readmissions by 10% in this age group.
Actions:
Screen for behavioral health and social needs.
Offer virtual follow-up visits to improve access.
Timeframe: Integrate into discharge planning by Q2 2026.
5. Readmission Rate: Medicaid Patients
Rate Ratio: 1.4
Measurable Objective: Reduce readmissions by 10% for Medi-Cal patients.
Actions:
Expand SDOH screening and referrals.
Partner with community health workers for care navigation.
Timeframe: Start Q1 2026; review outcomes semi-annually.
6. Readmission Rate: Males (No Behavioral Health Diagnosis)
Rate Ratio: 1.4
Measurable Objective: Identify and address gender-specific barriers to post-discharge care.
Actions:
Conduct focus groups with male patients.
Develop targeted education materials and support services.
Timeframe: Research phase Q1 2026; interventions Q3 2026.
7. Readmission Rate: Multiracial Patients
Rate Ratio: 1.3
Measurable Objective: Improve culturally responsive care.
Actions:
Train staff on cultural humility and implicit bias.
Engage community representatives in care planning.
Timeframe: Training rollout Q2 2026; community engagement ongoing.
8. Readmission Rate: Males
Rate Ratio: 1.3
Measurable Objective: Improve male patient engagement and reduce readmissions.
Actions:
Launch male-focused health literacy campaigns.
Offer flexible appointment scheduling for working-age men.
Timeframe: Campaign launch Q2 2026.
9. Readmission Rate: Black or African American Patients
Rate Ratio: 1.2
Measurable Objective: Reduce disparities through targeted outreach.
Actions:
Partner with local organizations.
Monitor readmission data by race and adjust interventions.
Timeframe: Begin Q1 2026; evaluate biannually.
10. Readmission Rate: White Patients
Rate Ratio: 1.1
Measurable Objective: Ensure equitable care across all racial groups.
Actions:
Review discharge planning protocols for consistency.
Address gaps in access to post-acute care services.
Timeframe: Audit Q1 2026, improvements by Q3 2026.

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

DESERT VALLEY HOSPITAL