JOHN MUIR BEHAVIORAL 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
|
Sex Assigned at Birth | Female | 19.3% | Male | 14.5% | 1.30 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 23.3% | Other | 21.4% | 1.10 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 18 to 34 | 16.9% | 35 to 49 | 16.4% | 1.00 |
2. Equity Plan
In response to the requirements of California Assembly Bill 1204 (AB 1204), this report presents our analysis of health status and access to care disparities within our service area. Utilizing the Hospital Quality Institute (HQI) Platform with SpeedTrack we were provided with our comprehensive Data Analysis which identified our top three (3) disparities. Our plan for addressing these disparities is detailed herein.
Three (3) top disparities are apparent across patients captured as an All-Cause Unplanned 30-Day Readmission. Below we outline a plan to address contributing factors to unplanned readmissions.
Population impact: Female (sex assigned at birth) patients, patients with Medicare, and patients ages 18-34.
Analysis: Female patients and patients with Medicare show higher readmission rates compared to their reference groups. Patients ages 18-34, with a rate ratio of 1.0, do not show as significant a disparity in readmission rates and we will continue to monitor this while prioritizing action plans for the groups with rate ratios >1.0.
Actions:
Overall Readmission rates outperform the benchmark, remaining consistently under 5% (benchmark is under 10%); however, we continually work to improve readmissions with the following action plans:
Complex care meetings twice per week with leadership and front-line clinical teams
Improving access to medications after discharge by looking at discharge meds a day in advance, collaborating with providers and pharmacy
Our team schedules follow-up appointments for patients w/in 7 days of discharge
The target average length of stay is 6-7 days in Acute Psychiatric Treatment, to include coordination of care and access to treatment in order to prevent life threatening behaviors and reduce readmissions.
support continuous improvement of multidisciplinary teams for transitional care management Social Determinates of Health (SDOH) Screening of all patients for needs before discharge
link patients to mental health, housing, food, and transportation resources Continue support of and investment in community partners to prevent unplanned readmissions
Timeframe: Ongoing, monitored quarterly
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 |
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.