HOLLYWOOD PRESBYTERIAN 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	16.8%	18 to 34	6.7%	2.50
2. HCAI 30-Day readmission	Age (excluding maternal measures)	65 and older	14.6%	18 to 34	6.7%	2.20
3. HCAI 30-Day readmission	Age (excluding maternal measures)	35 to 49	13.4%	18 to 34	6.7%	2.00
4. HCAI 30-Day readmission	Race and/or Ethnicity	Black or African American	20.3%	Hispanic or Latino	10.5%	1.90
5. HCAI 30-Day readmission	Expected Payor	Medicare	14.8%	Private	9.5%	1.60
6. HCAI 30-Day readmission NOBH	Sex Assigned at Birth	Male	14.7%	Female	10.1%	1.50
7. HCAI 30-Day readmission	Race and/or Ethnicity	White	15.2%	Hispanic or Latino	10.5%	1.40
8. CMQCC NTSV cesarean rate	Age (for maternal measures only)	30 to 39	0.3%	18 to 29	0.2%	1.40
9. HCAI 30-Day readmission	Expected Payor	Medicaid	12.6%	Private	9.5%	1.30
10. CMQCC breast milk feeding	Race and/or Ethnicity	Hispanic or Latino	31.4%	White	41.7%	1.30

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2. Equity Plan

We will prioritize three main focus areas over the next year:

1.Reducing age- and payer-related readmission disparities among adults 35+
2.Reducing racial/ethnic and sex-related readmission disparities
3.Improving maternal equity in NTSV cesarean rates and exclusive breast milk feeding

For each focus area, we will define populations, measurable objectives, and specific timelines.

Focus Area 1: Age & payer disparities in readmissions

Population impact: Adults 35 years and older with unplanned 30-day readmissions, especially those insured through Medicare and Medicaid, account for a large share of our total readmissions and resource utilization.

Objectives (by December 31, 2026)

•Reduce readmission rates among adults 50–64 from 16.8% to =15% and among adults 65+ from 14.6% to =13.0%, while maintaining or improving the rate for adults 18–34.
•Reduce the Medicare–Private readmission gap by at least 5%.
•Reduce the Medicaid–Private readmission gap by at least 5%.

Key strategies:
•Implement a standardized high-risk readmission bundle (pharmacy reconciliation, teach-back discharge education, and follow-up appointment scheduled before discharge) for all patients 35+ with priority on Medicare/Medicaid payers.
•Researching vendors to do post-discharge outreach: telephone or virtual follow-up within 72 hours for all high-readmission patients.
•Use risk-stratified care management (e.g., case management and transitional care nurses) to coordinate with primary care, specialists, home health, and SNFs for high-risk patients.
•Monitor readmission metrics monthly, stratified by age and payer, and review outliers in an interdisciplinary quality forum.

Focus Area 2: Racial/ethnic & sex disparities in readmissions

Population impact: Disparities in readmissions for Black/African American, White, and male patients suggest gaps in communication, trust, and care coordination that may reflect broader inequities in access to outpatient care and support.

Objectives (by December 31, 2026)

•Reduce the readmission rate for Black/African American patients from 20.3% to =17.0% and close the rate ratio with Hispanic/Latino patients.
•Reduce the readmission rate for White patients from 15.2% to =12.5%, narrowing the gap with Hispanic/Latino patients.
•Reduce the male–female readmission rate ratio from 1.5 toward =1.2.

Key strategies:
•Apply culturally and linguistically appropriate education in the discharge packet and, including interpreter services and translated discharge materials while patients are admitted.
•Expand community health worker (CHW) or navigator programs to support Black/African American and male patients with follow-up appointments, transportation, and linkages to primary care or specialty care.
•Embed equity-focused case review into readmission and adverse event reviews, explicitly examining race, language, and sex assigned at birth.
•Partner community health worker or navigator programs that serve Black/African American and working-age male populations to improve warm hand-offs and information sharing at discharge.

Focus Area 3: Maternal and newborn equity (NTSV C-section and exclusive breast milk feeding)

Population impact: The elevated NTSV cesarean rate among patients aged 30–39 and the lower exclusive breast milk feeding rate among Hispanic/Latino newborns affect birthing parents and infants at a critical life stage and have long-term health implications.

Objectives (by December 31, 2026)

•Reduce the NTSV cesarean rate for patients aged 30–39 by 10% (from 0.316 toward =0.27), while maintaining maternal and neonatal safety.
•Increase exclusive breast milk feeding among Hispanic/Latino newborns from 37% to =40%, narrowing the gap with White newborns.
Key strategies
•Standardize use of evidence-based labor management guidelines (e.g., ACOG/SMFM) to reduce non-medically indicated primary cesareans, with real-time physician feedback and peer review.
•Enhance prenatal and intrapartum education for birthing patients aged 30–39 on labor expectations, shared decision-making, and VBAC when clinically appropriate.
•Expand in-person lactation support, Spanish-language education materials, and early postpartum follow-up for Hispanic/Latino families.
•Track maternal measures quarterly by age and race/ethnicity, and review with the Obstetrics department, Nursing leadership, and the Quality Management Committee.

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

HOLLYWOOD PRESBYTERIAN MEDICAL CENTER