FOOTHILL REGIONAL MEDICAL CENTER
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
|
Race and/or Ethnicity | Black or African American | 14.0% | White | 11.0% | 1.30 |
2. Equity Plan
The hospital will review recent readmissions among Black patients to identify factors that may be contributing to higher readmission rates, including gaps in discharge understanding, delayed follow-up, or unmet social needs. Strengthening the patient’s understanding of the care plan before discharge may help reduce these risks. Improving written discharge materials so that instructions are easier to understand at home, including the use of plain language and visuals for medication schedules, symptom warnings, and follow-up steps, may support greater clarity.
Medication access is an important component of a safe discharge. Pharmacy support can help verify that prescriptions are available, affordable, and free of insurance barriers. Resolving these issues before the patient leaves increases the likelihood that medications are started correctly and on time.
Staff will receive refreshed training on culturally responsive communication to support clearer interactions during the discharge process. Nursing can also contribute by confirming that patients understand who to contact after discharge and when follow-up should occur. This step does not require staff to schedule appointments; it simply ensures that patients leave with clear expectations and are less likely to become confused once home.
Case Management will monitor readmission trends by race on a quarterly basis to assess progress and identify remaining gaps. These reviews may highlight patterns such as missing medications, unclear instructions, or delays in outpatient care. The information gathered can help guide targeted improvements in education, communication practices, and handoff processes.
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 |
No |
Our hospital system strategic plan identifies healthcare equity goals and discrete action steps to achieve these goals |
No |
Our hospital system strategic plan outlines specific resources that have been dedicated to achieving our equity goals |
No |
Our hospital system strategic plan describes our approach for engaging key stakeholders, such as community-based organizations |
No |
Our hospital strategic plan identifies healthcare equity goals and discrete action steps to achieve these goals |
No |
Our hospital system has training for staff in culturally sensitive collection of demographics and/or social determinant of health information |
No |
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 |
No |
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 |
No |
Our hospital system participates in local, regional or national quality improvement activities focused on reducing health disparities |
No |
Our hospital system senior leadership, including chief executives and the entire hospital board of trustees, annually reviews our strategic plan for achieving health equity |
No |
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 |
No |
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.