KEDREN COMMUNITY MENTAL 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 | 4.0% | Male | 2.3% | 1.70 |
2. Equity Plan
Asian (Non English)+ Asian (race/ethnicity) Plan: Asian American patients with a preferred non-English language are more likely to experience readmission compared to the reference group. The RR for Preferred Language – Asian is 44.5. For this measure, Spanish speaking as a preferred language has the lowest readmission.
Kedren began tracking readmission rates stratified by race and preferred language in 2025. Kedren will evaluate discharge instructions for this group to see if they are fully understood.
Also, when available upon discharge, patients to be referred to programs geared towards serving this population to address cultural barriers which may impact successful reintegration into the community.
To support discharge, interpreter services (Boostlingo) will be required for all Asian patients with limited English proficiency during discharge planning, discharge education, and completion of the patient satisfaction survey. This ensures patients fully understand their treatment plan, medications, follow-up appointments, and safety instructions, and reduces the risk of miscommunication that could contribute to readmission.
Measurable equity objectives: Reduce readmission rate for Asian patients, with preferred non-English language by 15% within 12 months.
White (Race/ethnicity) Plan: White patients are experiencing a higher readmission rate compared to the reference population. We plan to evaluate follow-up care, educational resources during discharge, co-occuring disorders, and social support post discharge. We plan to closely monitor readmission rates by race/ethnicity and create interventions with this data.
Measurable equity objectives: Reduce readmission rate for White patients, by 10% within 12 months.
Black (Race/ethnicity) Plan: Black patients are experiencing a higher readmission rate compared to the reference population. We plan to evaluate follow-up care, educational resources during discharge, co-occurring disorders, and social support post discharge. We plan to closely monitor readmission rates by race/ethnicity and create interventions with this data.
Measurable equity objectives: Reduce readmission rate for Black patients, by 10% within 12 months.
Female (Gender Identity) Plan: Female patients are experiencing a higher readmission rate compared to the reference population. We plan to evaluate follow-up care, update and enhance educational resources (handouts) during discharge, and social support post discharge. We also plan to better follow-up with patients understanding of discharge plans post discharge and how to access outside resources. We plan to closely monitor readmission rates for women to identify the factors for why women were readmitted and create interventions with this data to mitigate (if possible). We also plan to incorporate gender-focused Occupational Therapy (OT) groups to address unique issues. These groups will serve to support and create a space for women to share feedback about challenges they face in treatment and recovery, helping Kedren to identify and address gender-specific barriers to care.
Measurable equity objectives: Reduce readmission rate for Female patients, by 20% within 12 months.
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 |
No |
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.