JOHN F. KENNEDY 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.

Measure	Stratification	Stratification Group	Stratification Group Rate	Reference Group	Reference Rate	Rate Ratio
1. HCAI 30-Day readmission	Race and/or Ethnicity	Black or African American	25.2%	Hispanic or Latino	10.6%	4.80
2. HCAI 30-Day readmission	Age (excluding maternal measures)	50 to 64	14.8%	18 to 34	5.9%	2.50
3. HCAI 30-Day readmission	Age (excluding maternal measures)	65 and older	14.2%	18 to 34	5.9%	2.40
4. HCAI 30-Day readmission	Race and/or Ethnicity	White	12.2%	Hispanic or Latino	10.6%	2.30
5. HCAI 30-Day readmission	Age (excluding maternal measures)	35 to 49	12.4%	18 to 34	5.9%	2.10
6. HCAI 30-Day readmission	Expected Payor	Medicare	15.5%	Private	7.7%	2.00
7. HCAI 30-Day readmission NOBH	Sex Assigned at Birth	Male	14.5%	Female	7.7%	1.90
8. HCAI 30-Day readmission	Sex Assigned at Birth	Male	15.7%	Female	8.8%	1.80
9. HCAI 30-Day readmission	Expected Payor	Medicaid	10.3%	Private	7.7%	1.30

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2. Equity Plan

Using findings from the HQI Disparities Report for our facility, JFK Memorial Hospital conducted a review of stratified quality data to identify the Top 10 disparities and its impact on 30-day unplanned readmissions. The analysis revealed key differences across race/ethnicity, age, payor type, and sex. Subsequently, the hospital is working on a comprehensive, equity-driven improvement plan that takes a multifaceted approach to address these disparities.

Planned Actions
These actions are intended to reduce readmission risk and close identified equity gaps for specific groups disproportionately affected: Black/African American patients, males (both overall and without behavioral health diagnoses), Medicare and Medicaid beneficiaries, and age cohorts 35–49, 50–64, and 65 and older. Cross-cutting interventions apply to all inpatients at elevated risk for readmission, ensuring hospital wide benefit while also addressing needs unique to each subgroup. In preparation for this, we have provided compulsory education modules, on addressing these disparities, to all staff.

The hospital will implement a cross-cutting Transitional Care Equity Bundle that standardizes best practices across all high-risk groups. Key components include culturally and linguistically appropriate discharge education; pharmacist-led medication reconciliation; universal social drivers of health (SDOH) screening with referral pathways to social work and community resources; 48–72-hour post-discharge follow-up calls for chest pain and stroke patients; and routine use of the teach-back method to confirm patient understanding.

Targeted actions will also be deployed including a culturally responsive CHW pilot for Hispanic patients and flexible follow-up options for adults aged 35–64; enhanced geriatric discharge bundles and post-acute coordination for older adults and Medicare beneficiaries; male-focused engagement strategies to address follow-up adherence; and transportation supports and rapid access to clinics for Medicaid beneficiaries

Measurable Objectives
The hospital established a standard improvement target across all disparity categories: achieving at least a 25% relative reduction in readmission disparities within the first 12 months and approximately 40% reduction within 24 months, consistent with evidence-based transitional-care models. Each group has specific numerical goals based on their baseline rates from the HQI report. Examples include reducing the Black/African American readmission rate from 25.2% toward 18.9% at 12 months and 15.1% at 24 months; reducing readmission rates for adults 50–64 and 65+ by similar relative margins; and narrowing gaps for Medicare and Medicaid beneficiaries through targeted post-acute planning, medication access, and SDOH supports.

Timeframes
Implementation will follow a structured timeline. In the first 0–3 months, the hospital will solidify workflows, train staff, enhance discharge processes, and establish referral pathways. Between 3–6 months, pilots will be launched for the highest-risk populations, including Black/African American patients and male inpatients. From 6–12 months, successful interventions will be scaled hospital wide, monitored through weekly dashboards, and refined through monthly equity huddles. By 12 months, the hospital will evaluate progress toward achieving the 25% reduction benchmark and make adjustments as needed. By 24 months, the hospital plans to achieve the 40% reduction targets, supported by monthly Medical Executive and Governing Board reviews that ensure accountability, oversight, and appropriate resource allocation.

Through these targeted and cross-cutting efforts, JFK Memorial Hospital reaffirms its commitment to advancing health equity, improving transitions of care, and reducing avoidable readmissions for the populations most impacted by disparities in our service area.

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

JOHN F. KENNEDY MEMORIAL HOSPITAL