HENRY MAYO NEWHALL 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) | 65 and older | 16.1% | 18 to 34 | 5.0% | 3.20 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 13.2% | 18 to 34 | 5.0% | 2.60 |
|
3.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 16.5% | Private | 6.3% | 2.60 |
|
4.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 14.3% | Private | 6.3% | 2.30 |
|
5.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 8.7% | 18 to 34 | 5.0% | 1.70 |
|
6.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Male | 12.9% | Female | 9.2% | 1.40 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Asian | 13.4% | Hispanic or Latino | 10.4% | 1.30 |
|
8.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 13.2% | Hispanic or Latino | 10.4% | 1.30 |
|
9.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 14.2% | Female | 11.5% | 1.20 |
|
10.
AHRQ pneumonia mortality rate
|
Sex Assigned at Birth | Male | 55.1% | Female | 48.0% | 1.10 |
2. Equity Plan
Health Equity Task Force Overview
Our hospital has launched a Health Equity Task Force, led by the VP of Clinical Support Services, to address health-related social needs and promote equity. This multidisciplinary team, comprising of leaders from Nursing, HR, IT, Quality & Safety, Clinical Informatics, Decision Support, Professional Development, and Case Management, developed a strategic Health Equity Action Plan.
Key Initiatives Include:
Updating anti-discrimination policies
Collecting preferred patient language, demographic SDOH data, Universal screening for five core social needs: housing, food, transportation, utilities, and safety
Identifying priority populations and equity goals
Allocating resources for equity initiatives
Training staff in culturally sensitive data collection
Documenting SDOH in the EHR
Engaging in disparity-focused quality improvement
Tracking KPIs by demographic factors
The Task Force meets regularly to monitor progress, address gaps, and drive continuous improvement, reflecting our commitment to equitable care for all patients.
Implementation Timeline:
Jan-Feb: Finalize screening tools, workflows, and dashboard updates
Mar: Train all staff; complete annual modules on SDOH and cultural sensitivity
Apr: Launch RN screening and LCSW intervention tools
May-Jul: Evaluate interventions, refine workflows, and validate dashboard data
Aug-Dec: Fully integrate into EHR, sustain reporting, and review data monthly
Metric to address each of the top 10 disparities: At least 90% of all patients will be screened for SDOH; 80% of patients with positive screens will receive documented intervention and follow up by LCSW prior to discharge.
1.HCAI All-Cause Unplanned 30-Day Readmission Rate Age 65 and older (15%) greater than reference group Age 18-34 (reference rate of 4.9) with a rate ratio of 3.1
Goal: Reduce patients aged 65 and older readmission rate by 1%
2.HCAI All-Cause Unplanned 30-Day Readmission Rate Age 50-64 (rate of 13) greater than reference group Age 18-34 (reference rate of 4.9) with a rate ratio of 2.7
Goal: Reduce patients aged 50-64 readmissions by 1%
3.HCAI All-Cause Unplanned 30-Day Readmission Rate Medicare Payor (rate of 15.5) greater than reference group Private Payor (reference rate of 6.0) with a rate ratio of 2.6
Goal: Reduce Medicaid readmissions by 1%
4.HCAI All-Cause Unplanned 30-Day Readmission Rate Medicaid Payor (rate of 13.9) greater than reference group Private Payor (reference rate of 6.0) with a rate ratio of 2.3
Goal: Reduce Medicaid readmissions by 1%
5.HCAI All-Cause Unplanned 30-Day Readmission Rate Age 35-49 (rate of 8.2) greater than reference group Age 18-34 (reference rate of 4.9) with a rate ratio of 1.7
Goal: Reduce patients aged 35-49 readmissions by 1%
6.HCAI All-Cause Unplanned 30-Day Readmission Rate (no behavioral health diagnosis) Male (rate of 12.2) greater than reference group Female (reference rate of 8.7) with a rate ratio of 1.4
Goal: Reduce Male readmissions by 1%
7.HCAI All-Cause Unplanned 30-Day Readmission Rate Male (rate of 13.4) greater than reference group Female (reference rate of 10.9) with a rate ratio of 1.2
Goal: Reduce Male readmissions by 1%
8.HCAI All-Cause Unplanned 30-Day Readmission Rate White (rate of 12.4) greater than reference group Hispanic or Latino (reference rate of 10.3) with a rate ratio of 1.2
Goal: Reduce White readmissions by 0.5%
9.HCAI All-Cause Unplanned 30-Day Readmission Rate Asian (rate of 12.0) greater than reference group Hispanic or Latino (reference rate of 10.3) with a rate ratio of 1.2
Goal: Reduce Asian readmissions by 0.5%
10.AHRQ Indicator Pneumonia Mortality Rate Male (rate of 52) greater than reference group Female (reference rate 48) with a rate ratio of 1.1
Goal: Reduce Male pneumonia mortality by 1% in the calendar year 2026.
Based on State benchmark of 12.99% for overall 30-day hospital-wide all-cause unplanned readmission, our hospital rate for 2024 is below that of California hospitals at 12.55%. Historically, based on state benchmark of 13.13% from January 2020 through December 2024, our 30-day hospital-wide all-cause unplanned readmission rate is 11.99%.
Based on a state benchmark of 59.9% for AHRQ Indicator Pneumonia Mortality Rate, our hospital rate for 2024 is below that of California Hospitals at 51.4%. Furthermore, based on a state benchmark of 64.3% for AHRQ Indicator Pneumonia Mortality Rate amongst males, our hospital rate for 2024 is below that of California Hospitals at 55.1%. We have kept these metrics in mind when establishing realistic goals for the organization.
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 |
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 |
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.