JOHN MUIR MEDICAL CENTER-CONCORD CAMPUS
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
|
Expected Payor | Medicare | 16.0% | Private | 8.0% | 2.00 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 14.3% | Private | 8.0% | 1.80 |
|
3.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Multiracial and/or Multiethnic (two or more races) | 21.1% | Asian | 13.4% | 1.60 |
|
4.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 15.0% | 18 to 34 | 9.9% | 1.50 |
|
5.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 14.8% | 18 to 34 | 9.9% | 1.50 |
|
6.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Native Hawaiian or Pacific Islander | 18.3% | Asian | 13.4% | 1.40 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 17.8% | Asian | 13.4% | 1.30 |
|
8.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 12.5% | 18 to 34 | 9.9% | 1.30 |
|
9.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Hispanic or Latino | 14.8% | Asian | 13.4% | 1.10 |
|
10.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 13.8% | Asian | 13.4% | 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 disparities within our service area. Utilizing the Hospital Quality Institute (HQI) Platform with SpeedTrack we were provided our top ten (10) disparities. Our plan for addressing these disparities is detailed herein.
All ten (10) of our top disparities are apparent across patients captured as an All-Cause Unplanned 30-Day Hospital Readmission. Below we outline a Readmission Reduction Plan to address contributing factors to unplanned readmissions, including health disparities in our patient population.
Disparity 1 & 2: Medicare & Medicaid patients relative to private payers.
Population impact: Patients with Medicare/Medicaid show higher readmission rates compared to privately insured patients.
Actions planned:
Care Coordination: support continuous improvement of multidisciplinary teams (nurses, social workers, pharmacists) for transitional care management
Data Integration: a readmission risk calculator is in place in the electronic health record to identify high-risk patients and automate alerts for the care team
Social Determinates of Health (SDOH) Screening of Medicare/Medicaid patients for needs before discharge
Continue support of and investment in community partners to prevent unplanned readmissions for Medicaid patients
Disparity 3, 6, 7, 9: Racial and/or ethnic disparities experienced by the following groups:
Native Hawaiian or Pacific Islander
Multiracial and/or Multiethnic (two or more races)
Black or African American
Hispanic or Latino
Population impact: The above patients experience higher readmission rates compared to Asian patients. Asian patients experience the lowest readmission rates at our hospital.
Actions planned:
Care Coordination: support continuous improvement of multidisciplinary teams (nurses, social workers, pharmacists) for transitional care management
Data Integration: a readmission risk calculator is in place in the electronic health record to identify high-risk patients and automate alerts for the care team
Continuous improvement of interpreter services
Ensure adequate linguistic & communication support during discharge
Community Partnerships: link patients to housing, food, and transportation resources
SDOH Screening of all patients 18 years and older for needs before discharge
Disparity 4 and 8: Patients age 35-49 & 50-64
Population impact: Adults 35–64 experience higher unplanned readmissions compared to younger patients.
Actions planned:
Develop age-specific care transition programs (e.g., medication reconciliation, caregiver engagement, follow-up calls)
Data Integration: a readmission risk calculator is in place in the electronic health record to identify high-risk patients and automate alerts for the care team
Community Partnerships: link patients to housing, food, and transportation resources
SDOH Screening of all patients 18 years and older for needs before discharge
Disparity 5: Patients age 65 and older
Population impact: Adults 65+ experience higher unplanned readmissions compared to patients under age 35.
Actions planned:
Age-Friendly CMS structural requirement implementation (age-specific care transition program)
Data Integration: a readmission risk calculator is in place in the electronic health record to identify high-risk patients and automate alerts for the care team
Further develop ambulatory Senior Strategy to prevent unplanned readmissions
SDOH Screening of all patients 65 years and older for needs before discharge
Disparity 10: White patients compared to Asian patients
The rate ratio for this group is 1.0 which does not indicate a significant disparity. We will continue to monitor this while prioritizing action plans for the groups with rate ratios >1.0.
For all disparities above, the Readmission Reduction Plan measurable objectives are:
Reduce 30-Day All-Cause Readmission Rate by 10% in Native Hawaiian or Pacific Islander, Multiracial and/or Multiethnic (two or more races), Black or African American, Hispanic or Latino patients
Increase SDOH screening rates of patients admitted 18 years and older by 20% by year-end 2026
Timeframe for all of the above: All elements implemented by Q2 2026; evaluate biannually
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.