FREMONT 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) | 35 to 49 | 17.5% | 1.40 | ||
|
2.
HCAI 30-Day readmission
|
Expected Payor | Other | 24.6% | Medicare | 20.9% | 1.20 |
|
3.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Female | 19.7% | 1.10 |
2. Equity Plan
For the "age group" disparity - we continue to offer daily psychoeducation groups to support with building insight regarding their mental illness to reduce the risk of decompensation and recidivism. If appropriate, we round on these individuals daily to discuss levels of care after discharge including PHP and IOP to ensure treatment team is supporting with a safe discharge plan. Hospital will continue to offer family support to strengthen relationship to have a better outcome after discharge if they have an external support system.
For "expected" payor disparity - MediCal is the highest for readmission. We will continue with daily collaboration with counties to advocate for appropriate services for patients after discharge to decrease recidivism. We meet with 2 counties on a weekly basis to discuss mutual patients, treatment plans, and recommended discharge plan. Because PHP/IOP services are not available under medicaid plans, patients do not follow through with their assigned clinics or outpatient teams timely after discharge.
For "sex assigned at birth" - men measured higher for readmission. The hospital has implemented gender-based units and programming to support gender-based treatment. We offer daily groups targeted towards their identified gender to help them learn coping skills to match their treatment plan. In addition, the gender-based units, supports with building a community where are able to relate to each other and receive empathy from their peers.
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 |
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.