GEORGE L. MEE MEMORIAL 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.
No disparity data for this period.
2. Equity Plan
Given our Critical Access Hospital's small size and the distribution of outcomes, the analysis did not identify any statistically significant disparities in the required areas. However, we have developed an equity plan based on equity and practice transformation goals as well as information from a community health needs assessment.
Goal 1: Data-driven equity assessment
Objective: Identify and monitor disparities in access, outcomes, and experience across demographic groups.
Activities: Standardize REAL, SOGI, and SDOH data collection; perform quarterly data reviews of chronic disease outcomes; and stratify quality measures to identify disparities.
Reporting: Include data in decision-making aimed at enhancing patient care.
Goal 2: Chronic Condition Management and Engagement
Objective: Improve disease management and self-care among adults with chronic conditions.
Activities: Develop targeted outreach for high-risk patients, integrate care management pathways in EHR, and conduct health education and peer-support groups.
Monitoring: Review the number of patients contacted and any barriers reported.
Goal 3: Implement a Community Health Worker (CHW) Program
Objective: Deploy CHWs to address social determinants, connect patients to care, and provide culturally competent non-clinical support to achieve health goals.
Activities: Hire bilingual CHWs, conduct social needs screening (SDOH) during office visits. Providers will refer patients with positive SDOH screenings to CHW assistance connecting local agencies. Individuals requiring a more comprehensive care management approach, including outreach and coordination of care, will be referred for Enhanced Care Management (ECM).
Criteria for CHW referral may include:
• Frequent ER visits or hospitalizations
• Chronic medical conditions
• Behavioral health concerns
• Homelessness or unstable housing
• Difficulty managing medications
• Food Insecurity
• Transportation barriers
• Older adults in need of Multipurpose Senior Services Program (MSSP)
• Caregiver strain
Monitor:
Track data on volume of patient referrals that connect successfully with CHW services, including individuals identified as qualifying for handoff to Enhanced Care Management services.
Reporting:
Report data on CHW and ECM referral volumes that successfully enroll in services.
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 |
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.