GLENDALE MEMORIAL HOSPITAL AND HEALTH 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 | 15.9% | 18 to 34 | 6.2% | 2.60 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 15.6% | 18 to 34 | 6.2% | 2.50 |
|
3.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 16.5% | Private | 8.6% | 1.90 |
|
4.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 10.4% | 18 to 34 | 6.2% | 1.70 |
|
5.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Male | 14.8% | Female | 10.3% | 1.40 |
|
6.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 16.2% | Female | 11.6% | 1.40 |
|
7.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 12.0% | Private | 8.6% | 1.40 |
|
8.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 17.6% | Asian | 12.9% | 1.40 |
|
9.
HCAI 30-Day readmission
|
Preferred Language | Middle Eastern Languages | 15.9% | English Language | 13.0% | 1.20 |
|
10.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 14.2% | Asian | 12.9% | 1.10 |
2. Equity Plan
Glendale Memorial aims to reduce unplanned 30-day readmissions across its top 10 identified disparity groups to advance health equity. A multi-faceted strategy combines data, culturally sensitive care, patient education, community partnerships, and system-level improvements.
Core Strategies:
1. Expand Health Equity Task Force Membership - Oversee the plan, monitor progress, and champion initiatives.
2. Deep Dive Data Analysis - Analyze root causes for each group, focusing on primary diagnoses, post-discharge barriers (medication, follow-ups, transportation, SDOH), and discharge planning variations.
3. Staff Education and Training - Health equity, implicit bias, cultural sensitivity, communication, and qualified medical interpreter use for all staff.
Top 10 Disparity Action Plans:
Groups #1 (Age 50-64) & #2 (Age 65+):
• Possible Root Causes: Chronic disease, socioeconomic factors, polypharmacy, cognitive/functional decline, social isolation, complex medical needs, navigating healthcare.
• Actions:
• Tailored patient education (medication, follow-up)
• Resource navigation for chronic conditions
• Connect to community health programs, support groups, and SDOH services.
• Age-specific discharge planning, comprehensive medication reconciliation, functional/cognitive assessment, caregiver education.
• Strengthen post-acute care communication.
• Use large print, simple language, teach-back, involve family/caregivers in education.
• Impact & Objective: Reduce 30-day readmission rate by 10% by FY26 Q4 to enhance quality of life.
Groups #3 (Medicare) & #7 (Medicaid):
• Possible Root Causes: Medicare: older adults, chronic conditions. Medicaid: significant SDOH challenges.
• Actions:
• Universal SDOH screening (housing, food, transportation, utilities, social support).
• Referrals to community resources for positive SDOH screens.
• Strengthen partnerships with food banks, transportation, housing, free clinics.
• Impact & Objective: Reduce 30-day readmission rate by 10% for both groups by FY27 Q2 to address systemic barriers to care for economically vulnerable populations, improving health equity by supporting basic needs.
Group #4 (Age 35-49):
• Possible Root Causes: Work/family responsibilities, inconsistent primary care, undiagnosed/poorly managed chronic conditions, mental health comorbidities, substance use.
• Actions:
• Mental health & SUD screening, warm hand-offs to outpatient treatment.
• Financial counseling for insurance benefits and costs.
• Impact & Objective: Reduce 30-day readmission rate by 10% by FY26 Q4 in a usually productive age group, addressing underlying health issues before they become more severe.
Groups #5 (Male) & #6 (Male with Behavioral Health diagnosis):
• Possible Root Causes: Delays in seeking care (including preventive screenings), crisis presentation, stigma, especially with behavioral health.
• Actions:
• Clear, accessible (multilingual) information on rights, behavioral health care, support services.
• Prompt access to behavioral health specialists, proactive screening/referral.
• Clear protocols for warm hand-offs to community providers.
• Impact & Objective: Reduce 30-day readmission rate by 10% by FY26 Q4 to facilitate early detection and management of behavioral health needs, improving physical health outcomes and preventing escalation of symptoms.
Group #8 (Race/Ethnicity - Black or African American):
• Possible Root Causes: SDOH, lack of culturally sensitive providers, high chronic disease prevalence.
• Actions:
• Cultural sensitivity and implicit bias training (per core strategies).
• SDOH screening.
• Impact & Objective: Reduce 30-day readmission rate by 10% by FY26 Q4, with an additional objective of improving patient experience scores related to cultural sensitivity by 10% by FY26 Q4. Provides culturally appropriate support, leading to improved health outcomes and reduced disparities.
Groups #9 (Preferred Language - Middle Eastern Languages) & #10 (White - Armenian):
• Possible Root Causes: Language barriers, difficulty obtaining Armenian-speaking qualified medical interpreters.
• Actions:
• Ensure timely 24/7 qualified medical interpreters availability (in-person, video, phone); avoid family interpretation for medical info.
• Translate key discharge documents (instructions, medications, appointments) into Armenian.
• Educate staff on Armenian cultural norms (health, family involvement).
• Recruit Armenian-speaking staff/providers.
• Impact & Objective: Reduce 30-day readmission rate by 10% by FY26 Q4. Ensures safe and effective care by removing language barriers, fostering trust, and respecting cultural values.
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.