GARFIELD 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	Age (excluding maternal measures)	50 to 64	17.7%	18 to 34	3.1%	5.70
2. HCAI 30-Day readmission	Age (excluding maternal measures)	65 and older	16.7%	18 to 34	3.1%	5.30
3. HCAI 30-Day readmission	Age (excluding maternal measures)	35 to 49	9.7%	18 to 34	3.1%	3.10
4. HCAI 30-Day readmission	Expected Payor	Medicare	17.3%	Private	9.2%	1.90
5. HCAI 30-Day readmission	Race and/or Ethnicity	Black or African American	22.0%	Hispanic or Latino	13.1%	1.70
6. CMQCC breast milk feeding	Age (for maternal measures only)	30 to 39	14.3%	18 to 29	20.9%	1.50
7. HCAI 30-Day readmission	Preferred Language	English Language	14.8%	Asian/ Pacific Islander Languages	12.4%	1.20
8. AHRQ pneumonia mortality rate	Sex Assigned at Birth	Female	173.3%	Male	146.1%	1.20
9. AHRQ pneumonia mortality rate	Race and/or Ethnicity	Hispanic or Latino	171.4%	Asian	155.3%	1.10
10. HCAI 30-Day readmission	Race and/or Ethnicity	White	14.2%	Hispanic or Latino	13.1%	1.10

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2. Equity Plan

Disparity 1-3 Plan: Age Related Disparities (50-64, 65+, 35-49 vs. 18-34)
Population Impact: Adults 35-65+ experiencing higher unplanned readmissions compared to younger patients

Action Planned:
1. Develop age-specific care transition programs (e.g. medication reconciliation, caregiver engagement and continue on follow up discharge calls)
2. Focused on chronic disease self-management education
3. Use of friendly patient education handout
4. Employ risk assessment tool to identify patients likely to return
5. Improve patient/family education with teach-back and focus on Rx fill and use.

Measurable Objectives: Reduce 30-day readmission rate ratio for ages 50-64 from 5.5 to 4.5, and for 65+ from 4.9 to 3.5.

Timeframe: Launch interventions on 1Q2026 and monitor annually.
Disparity 4 Plan: Payer Status-Readmission (Medicare vs. Private)
Population Impact: Patients with Medicare show higher readmission rates compared to privately insured

Action Planned:
1. Expand care management and social work resources for Medicare patients
2.Connect patients to community-based support (transportation, medication assistance)
3. Prioritize high-risk Medicare patients and follow up care teams.

Measurable Objectives: Reduce Medicare readmission rate from 17.2 to 12.0 within 24 months.

Timeframe: Implement by 1Q2026 and evaluate annually.
Disparity 5 Plan: HCAI All-cause unplanned 30-day readmitted rate by race and/or Ethnicity (Black/African American vs. Hispanic/Latino)
Population Impact: Black/African American patients face higher readmission rates (22 vs 12.5)

Action Planned:
1. Strengthen culturally competent discharge planning and follow up
2. Provide community-based health references and home visits to Black patients with chronic disease.
3. Focused on chronic disease self-management education
4. Use of friendly patient education handout
5. Employ risk assessment tool to identify patients likely to return
6. Improve patient/family education with teach-back and focus on Rx fill and use.

Measurable Objectives: Narrow disparity rate from 1.8 to 1.4 within 2 years.

Timeframe: Initiate by 1Q 2026 and track annually.

Disparity 6 Plan: CMQCC Exclusive Breast Milk Feeding by Age 30-39

Population Impact: Age 30-39 shows lower compliance on exclusive breast milk feeding rate (14.3 vs 20.9)

Action Planned:
1. Establish a multidisciplinary breastfeeding support team and designated lactation nurse to educate and support patients.
2. Post-partum Director to continue to monitor progress and coordinate interventions
3. Educate all staff on the importance of early initiation of breastfeeding within 1 hour of birth

Measurable Objectives: Increase exclusive breastfeeding rate from 14.3 to 20 within the next two years

Timeframe: Initiate by 1Q2026 and evaluate annually

Disparity 7: HCAI All-Cause Unplanned 30-Day Hospital Readmission Rate by Preferred Language English
Population Impact: Patients with English as preferred language shows higher rate of readmission as compared to patients with Asian/Pacific Islander Languages

Action Planned:
1. Focused on chronic disease self-management education
2. Use of friendly patient education handout
3. Employ risk assessment tool to identify patients likely to return
4. Improve patient/family education with teach-back and focus on Rx fill and use.

Measurable Objectives: Narrow disparity rate from 1.2 to 1.0 within 2 years.
Timeframe: Start 1Q2026 and review annually

Disparity 8 Plan: Agency for Healthcare Research and Quality (AHRQ) Quality Indicator Pneumonia Mortality Rate Sex assigned at birth (Male vs Female)

Population Impact: Female patients have slightly higher pneumonia mortality compared to male patients in 2024 (184.9 vs 164.4)

Action Planned:
1. Early sepsis and pneumonia detection protocols has been implemented
2. Increase female targeted preventive care campaigns
3. Focused education on pneumonia patients

Measurable Objectives: Reduce mortality rate disparity ratio from 1.1 to 1.0 within a year

Timeframe: Start 1Q2026 and review annually
Disparity 9 and 10 Plan: HCAI All-Cause Unplanned 30-Day Hospital Readmission Rate by Race and/or Ethnicity (White and Asian vs Hispanic/Latino)
Population Impact: White and Asian patients face higher readmission rate

Action Planned:
1. Strengthen culturally competent discharge planning and follow up
2. Provide community-based health references and home visits to Black patients with chronic disease.
3. Focused on chronic disease self-management education
4. Use of friendly patient education handout
5. Employ risk assessment tool to identify patients likely to return
6. Improve patient/family education with teach-back and focus on Rx fill and use.

Measurable Objectives: Narrow disparity rate from 1.1 to 1.0 within 2 years.

Timeframe: Start 1Q2026 and review annually

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

GARFIELD MEDICAL CENTER