MAMMOTH HOSPITAL
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.
No disparity data for this period.
2. Equity Plan
After applying the CalHHS Data De-identification Guidelines (DDG), no disparities were identified among the stratified measures. Every calculation associated with all report fields has been evaluated for our hospital. While this AB 1204 Equity Report may appear sparsely populated and lacking values in some areas, this reflects the complexity of the reporting requirements—not a deficiency in the report itself.
The report incorporates the required calculations, stratifications, and the state's strict data privacy rules (including suppression under the California DDG), ensuring that it meets legal standards and equity reporting regulations. Many blank cells are the result of limited availability of certain stratification variables—particularly Disability Status, Sexual Orientation, and Gender Identity—which hospitals are not currently required by HCAI to collect. In addition, some results were masked or complementary masked under state privacy rules to protect patient confidentiality when subgroup sizes were too small to report. These safeguards explain why disparities were not identified in the current dataset.
Even when the final numbers are few, the work behind them is substantial—and necessary for accurate and compliant reporting. Our report fully complies with all equity reporting and privacy requirements. Importantly, zero disparities were identified among the stratified measures.
This AB 1204 Equity Report reflects CY 2024 hospital quality data, stratified and suppressed in accordance with HCAI's Data De-identification Guidelines. As no disparities were identified in these measures, Mammoth Hospital is leveraging findings from our 2025 Community Health Needs Assessment (CHNA) to guide proactive strategies and actions addressing community-identified equity priorities. The CHNA provides comprehensive information about the community's current health status, needs, and disparities and offers a targeted action plan to address these areas, including programmatic development and partnerships. Data was gathered from multiple well-respected secondary sources to help build an accurate picture of the current community and its health needs. A broad community survey was performed to in March of 2025 to review and provide feedback on the prior CHNA and to support the determination of the Significant Health Needs of the community moving forward. Mammoth Hospital identified three top community health priorities for 2025: Access to Primary Care, Access to Specialty Care, and Behavioral Health. These priorities were determined through a combination of community input, health data analysis, and facilitated conversations with hospital stakeholders. The CHNA is implemented on a 3-year cycle, which means that the goals and objectives listed below will be reviewed continuously over a three-year time period.
Access to Primary Care
Goal: Enhance primary care access points to improve overall health outcomes and reduce the need for costly emergency care.
Objectives:
Increase the availability of same-day appointments.
Improve public awareness of same-day appointment availability through community outreach and education to increase primary care utilization.
Access to Specialty Care
Goal: Ensure that community members have access to essential specialty services close to home.
Objectives:
Expand regular on-site coverage for high-demand specialties such as cardiology, rheumatology, and ENT to reduce patients' need to travel for care.
Invest in retaining and recruiting providers and the healthcare workforce to allow for the continued growth of local services.
Conduct a service line analysis for starting an eye care clinic.
Behavioral Health
Goal: Improve behavioral health outcomes through expanded services and community partnerships.
Objectives:
Continuously recruit additional behavioral health professionals with a focus on bilingual providers to expand access to services and develop an inclusive workforce.
Develop partnerships with local behavioral health organizations to enhance care coordination and ensure patients have appropriate access to community resources.
Foster relationships with local schools to provide education and outreach on mental health education and stigma reduction.
Conclusion
Mammoth Hospital is committed to advancing health equity even in the absence of disparities flagged by state data. By aligning our CHNA-informed priorities with equity best practices, we are addressing social determinants of health, expanding access, and building systems of care designed to support historically underserved populations.
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.