KAISER FOUNDATION HOSPITAL & REHAB CENTER – VALLEJO
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 | 14.9% | Private | 5.5% | 2.70 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 14.1% | 18 to 34 | 5.9% | 2.40 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 10.7% | 18 to 34 | 5.9% | 1.80 |
|
4.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 9.6% | Private | 5.5% | 1.70 |
|
5.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 12.0% | Hispanic or Latino | 8.7% | 1.40 |
|
6.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 11.7% | Hispanic or Latino | 8.7% | 1.30 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Asian | 10.4% | Hispanic or Latino | 8.7% | 1.20 |
|
8.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 6.9% | 18 to 34 | 5.9% | 1.20 |
|
9.
CMQCC breast milk feeding
|
Race and/or Ethnicity | Hispanic or Latino | 73.9% | White | 84.8% | 1.10 |
|
10.
CMQCC breast milk feeding
|
Age (for maternal measures only) | 18 to 29 | 76.1% | 30 to 39 | 79.2% | 1.00 |
2. Equity Plan
Using the Regional Kaiser Permanente health equity report, we will identify the populations impacted, including the Top 10 disparities. Through a variety of coordinated actions, we plan to reduce HCAI all-cause unplanned 30-day hospital readmissions by 10% within 2 years. We offer our patients culturally tailored patient education, we use interpreters as needed, we will continue to expand our community partnership and continue workforce training.
The Regional Age Friendly Hospital System (AFHS) Core Team will be leading and supporting all 21 KP NCAL facilities to achieve IHI AFHS Level 1 Recognition status by end of 2025 and then HI AFHS Level 2 Recognition status by end of 2026. The team will also ensure that all facilities have protocols in place to affirmatively attest to receive full credit for all 5 Domains of the CMA AFHS Measure by May 2025. This will position our hospitals to consistently and reliably provide high quality care to all hospitalized elderly patients.
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 |
4. Web Address for Equity Report
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.