KINDRED HOSPITAL – SAN GABRIEL VALLEY
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.
AHRQ pneumonia mortality rate
|
Expected Payor | Private | 413.8% | Medicare | 190.5% | 2.20 |
|
2.
AHRQ pneumonia mortality rate
|
Race and/or Ethnicity | Asian | 342.9% | White | 215.2% | 1.60 |
|
3.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Female | 4.4% | Male | 2.8% | 1.60 |
|
4.
AHRQ pneumonia mortality rate
|
Sex Assigned at Birth | Female | 230.8% | Male | 216.4% | 1.10 |
2. Equity Plan
Upon full compliance with all equity reporting and privacy requirements, four disparities were identified among the stratified measures for Kindred Hospital San Gabriel Valley requiring targeted action: 1) elevated pneumonia mortality among privately insured patients, 2) higher pneumonia mortality among Asian patients, 3) increased all-cause 30-day readmissions among female patients, and 4) a smaller but meaningful pneumonia mortality gap between female patients (higher rate) and male patients (lower rate).
First, for context, the readmission numbers shown in this report do not represent all hospital readmissions. Due to statewide data limits in 2024, ScionHealth was able to track only patients who were transferred out then returned to a ScionHealth facility—not patients who were readmitted to other hospitals. As a result, these values represent return-from-transfer rates, which are much lower than the typical 30-day potentially preventable LTCH readmission rates reported by CMS.
Beginning in Q4 2025, the hospital will launch a comprehensive equity action plan to close these gaps, as follows:
1) Elevated pneumonia mortality among privately insured patients: To address the significantly higher pneumonia mortality rate among privately insured patients, the hospital will conduct detailed case reviews in Q4 2025 to evaluate diagnostic delays, authorization barriers, and escalation gaps. A multidisciplinary Pneumonia Equity Workgroup will map workflows and identify system vulnerabilities. In Q1 2026, standardized early-warning triggers, mandatory pneumonia huddles within four hours of admission, and strengthened case-management processes will be implemented to prevent care delays. Education and pathway reinforcement will occur in Q2 2026, followed by continuous monitoring in Q3-Q4 2026. The goal is a 10% reduction in pneumonia mortality among privately insured patients within 12 months and sustained pneumonia bundle compliance above 95%.
2) Higher pneumonia mortality among Asian patients: The hospital will also address the higher pneumonia mortality rate among Asian patients. Beginning in Q4 2025, race-stratified root-cause analyses will assess language barriers, cultural communication patterns, and interpreter use. Partnerships with community organizations will support culturally informed improvements. In Q1 2026, interpreter documentation checkpoints will be added, and pneumonia education materials will be translated into Chinese, Vietnamese, Korean, and Tagalog. Q2 2026 will introduce culturally informed Interdisciplinary Care Rounds for high-risk pneumonia patients, supported by linguistically tailored education. Monitoring and workflow refinement will continue through Q3-Q4 2026. Objectives include a 10% reduction in pneumonia mortality among Asian patients and a 25% increase in interpreter utilization by mid-2026.
3) Increased all-cause 30-day readmissions among female patients: To address higher 30-day readmissions among female patients, the hospital will begin in Q4 2025 with a review of top readmission drivers and social determinants that disproportionately affect women. In Q1 2026, improvements will include mandatory follow-up appointment scheduling before discharge, pharmacy-led medication reconciliation, and structured 48-hour follow-up calls. Q2 2026 will focus on tailored education and coordination with community resources for transportation, home health, and equipment needs, with ongoing monitoring in Q3-Q4 2026. The target is an 10% reduction in female readmissions within 12 months and a 95% completion rate for 48-hour follow-up calls.
4) Pneumonia mortality gap between female and male patients: Finally, to address the smaller pneumonia mortality gap between female and male patients, the hospital will review female pneumonia cases with ICU transfers or mortality in Q4 2025. In Q1 2026, staff education will emphasize atypical pneumonia presentations in women and reinforcement of sepsis and pneumonia alert workflows. Q2 2026 will include real-time adherence audits, followed by monitoring and stratification through Q3-Q4 2026. The goal is a 10% reduction in pneumonia mortality among female patients within 12 months.
Through these coordinated, data-driven strategies beginning in Q4 2025, the hospital reaffirms its commitment to advancing health equity, reducing preventable disparities, and ensuring all patients receive the highest standard of care. Quarterly dashboards, interdisciplinary reviews, and QAPI oversight will support measurable, sustainable improvement.
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.