ENLOE HEALTH
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 | 16.3% | 18 to 34 | 6.7% | 2.40 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 15.0% | 18 to 34 | 6.7% | 2.20 |
|
3.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 17.0% | Private | 10.1% | 1.70 |
|
4.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Asian | 17.1% | Hispanic or Latino | 10.2% | 1.70 |
|
5.
HCAI 30-Day readmission
|
Race and/or Ethnicity | American Indian or Alaska Native | 15.2% | Hispanic or Latino | 10.2% | 1.50 |
|
6.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 9.7% | 18 to 34 | 6.7% | 1.40 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 14.5% | Hispanic or Latino | 10.2% | 1.40 |
|
8.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 13.5% | Hispanic or Latino | 10.2% | 1.30 |
|
9.
CMQCC breast milk feeding
|
Race and/or Ethnicity | Hispanic or Latino | 65.9% | White | 83.1% | 1.30 |
|
10.
HCAI 30-Day readmission MHD
|
Sex Assigned at Birth | Male | 16.8% | Female | 14.3% | 1.20 |
2. Equity Plan
Enloe Health is working hard to reduce hospital readmissions and make healthcare fairer for everyone, especially for people from different backgrounds. Our team focuses on patient safety, personal care, social needs, quality treatment, and strong teamwork among care teams. In 2024, Enloe started a Health Equity Committee and is now building a new Readmission Multidisciplinary Committee to review all types of readmissions and find ways to improve care.
Enloe has been working for several years to find ways to reduce 30-day readmission rates. Since late 2023, the team has focused on studying patient backgrounds to better understand health equity issues that may lead to patients returning to the hospital too soon. These issues may be related to the quality of care or social factors such as age, race, income, or other personal characteristics.
Enloe has created many internal reports to help track and understand readmission trends. Since early 2024, the hospital has been collecting and analyzing data about health equity to meet the needs of different healthcare regulators. Enloe Health uses this data to develop a Health Equity Plan and develop strategies to address identified health equity disparities. Every year the data is reviewed, and a new plan is developed. The team assesses needs, sets clear goals, creates timelines, reaches out to the community, and puts systems in place to address the identified equity needs.
In maternal health, Enloe is part of the California Maternal Quality Care Collaborative (CMQCC) and supports breastfeeding. The hospital has updated its education materials to be more inclusive and now offers prenatal classes in Spanish. Enloe started the Birth Equity Learning Initiative in June 2023 and began online "Understanding Birth" classes in January 2024. These programs have clearly helped mothers and babies, especially in the Hispanic community.
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.