LOMPOC VALLEY MEDICAL 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	Expected Payor	Medicare	16.4%	Medicaid	5.7%	2.90
2. HCAI 30-Day readmission	Race and/or Ethnicity	Black or African American	14.5%	Hispanic or Latino	7.2%	2.00
3. HCAI 30-Day readmission	Race and/or Ethnicity	White	13.8%	Hispanic or Latino	7.2%	1.90
4. HCAI 30-Day readmission	Sex Assigned at Birth	Male	15.3%	Female	9.6%	1.60
5. HCAI 30-Day readmission	Expected Payor	Private	8.9%	Medicaid	5.7%	1.60
6. HCAI 30-Day readmission	Age (excluding maternal measures)	65 and older	15.1%	50 to 64	13.3%	1.10

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2. Equity Plan

Based LVMC has identified for targeted interventions. Each focus area includes measurable goals, strategies, and expected population impacts to advance equity in care and reduce preventable readmissions.

Disparity 1: Unplanned 30-Day Readmissions — Expected Payor: Medicare. Goal: Reduce all-cause 30-day readmissions for Medicare patients by 10% in the first year. Strategies: Conduct risk stratification for all Medicare patients. Use Transitional Care Teams or ECM partners to support discharge planning, teach-back education, medication reconciliation, and SDOH screening. Complete follow-up calls within 48 hours to confirm medications and address needs. Implement rapid referrals to community resources with closed-loop verification. Review readmissions daily and apply equity-focused interventions. Population Impact: Strengthens continuity of care, reduces preventable readmissions, and improves equity in outcomes.
Disparity 2: Unplanned 30-Day Readmissions — Black or African American Patients. Goal: Reduce all-cause 30-day readmissions for Black or African American patients by 10% in the first year. Strategies: Review readmissions by race, ethnicity, and diagnosis to identify high-disparity areas. Incorporate SDOH data such as housing, food security, transportation, utilities, and safety. Provide culturally responsive discharge planning and teach-back education. Engage family/support networks when appropriate. Conduct follow-up calls within 48–72 hours. Use Transitional Care Teams or ECM programs for community-based support with closed-loop referrals. Population Impact: Reduces inequities, improves access and support, and aligns care with patient needs.

Disparity 3: Unplanned 30-Day Readmissions — White vs. Hispanic/Latino. Goal: Reduce all-cause 30-day readmissions for White patients by 10% through targeted interventions addressing clinical and social barriers. Strategies: Review data by race, ethnicity, and diagnosis to identify departments with the largest disparities. Evaluate SDOH factors and tailor education to health literacy, access limitations, and geographic isolation. Use Transitional Care Teams for high-risk patients to ensure follow-up and adherence. Initiate follow-up calls within 48–72 hours. Population Impact: Improves outcomes across populations, reduces preventable hospitalizations, and promotes equitable, patient-centered care.

Disparity 4: Unplanned 30-Day Readmissions — Sex Assigned at Birth (Male vs. Female). Goal: Reduce all-cause 30-day readmissions for males by 10% in the first year. Strategies: Implement gender-responsive care transition programs for high-impact diagnoses (CHF, COPD, post-operative care). Use standardized discharge checklists including medication reconciliation and teach-back. Schedule follow-up appointments prior to discharge. Complete follow-up calls within 48 hours. Perform SDOH screening and rapid referral to community advocates with closed-loop confirmation. Population Impact: Enhances chronic disease management, supports behavioral health needs, and reduces gender-based disparities.

Disparity 5: Unplanned 30-Day Readmissions — Expected Payor: Private. Goal: Reduce all-cause 30-day readmissions for private payor patients by 10% in the first year. Strategies: Conduct risk stratification for all private payor patients. Use Transitional Care Teams to complete medication reconciliation, SDOH assessments, teach-back education, and rapid community referrals. Monitor readmissions daily and apply equity-focused interventions. Population Impact: Improves continuity of care, decreases avoidable hospital use, and increases patient satisfaction.
Disparity 6: Unplanned 30-Day Readmissions — Age 65 and Older. Goal: Reduce all-cause 30-day readmissions for adults 65+ by 10% in the first year. Strategies: Implement Age-Friendly Hospital measures emphasizing patient goals, medication safety, mobility, frailty prevention, and social support. Tailor chronic disease programs to address geriatric needs. Review readmissions daily to identify trends and provide timely interventions. Population Impact: Enhances safety and independence for older adults, reduces readmissions, and improves overall care quality.
Summary: LVMC's equity plan targets six priority disparities across payor type, age, sex assigned at birth, and race/ethnicity. Using evidence-based, equity-focused strategies—including risk stratification, transitional care, teach-back education, chronic disease management, and SDOH integration—LVMC aims to reduce preventable readmissions, improve equitable outcomes, and strengthen patient and community trust.

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

LOMPOC VALLEY MEDICAL CENTER