MARINHEALTH MEDICAL CENTER

1. Top 10 Disparities

2. Equity Plan

The National Institutes of Health define ‘disparity’ as “a difference between population groups in the way they access, experience, and receive healthcare.” (https://www.ncbi.nlm.nih.gov/books/NBK578532/ ) The MarinHealth Equity Plan looks to find healthcare disparities present in the Marin Health Medical Center (MHMC) patient population and through coordinated effort, uses best practices to address them.

Of the HCAI measures, Unplanned Hospital Readmissions, was identified as a disparity for MarinHealth Medical Center patient population. Hospital readmission is defined as an “unplanned return to the hospital within 30 days of discharge”.

Measure: Unplanned Readmissions, Stratification Group: Age
Patients aged 18-34 experienced the lowest unplanned readmission rate of 4.1% compared to all age groups (35-39, 50-64, 65+).
Analysis of this disparity revealed 24% of older age group had chronic illnesses and 37% had Mental Health or Substance Use diagnoses versus only 16% chronic illness, and 58% Mental Health/Substance Use of the reference group. So, the older patient groups are less healthy than the reference group and more at risk for readmissions. According to the 2025 Community Health Needs Assessment, Marin County has the oldest population in the Bay Area, with 38% of residents being 60 or older. The older adult population in Marin (over 60) is growing rapidly to a projected 42% in 2041. (2025 CHNA Report)

Measure: Unplanned Readmissions, Stratification Group: Expected Payor
Patients with Private Insurance experienced a lower unplanned readmission rate of 5.2% compared to patients with either Medicare (13.9%) or Medicaid (11.5%) insurance. Disparity in unplanned readmissions for patients with Medicare and Medicaid payor trends similar to the age group disparity. The private payor group was younger and healthier with fewer chronic diseases and lower percent of mental health substance use diagnosis.

Measure: Unplanned Readmissions- All Hospital Adults and Unplanned Readmissions (No behavioral Health Diagnosis), Stratification Group: Sex Assigned at Birth
Female Patients experienced lower readmission rates (8.4%, No Behavioral Health diagnosis, 9.7% All Female Patients) than Male patients (13.1%, No Behavioral Health diagnosis, 14.1% All Male Patients). Male patients had higher burden of chronic disease then women, although both groups had similar percent of mental health/substance use (45% female, 41% male) documented.

Measure: Unplanned Readmissions, Stratification Group: Race and/or Ethnicity
Hispanic or Latino patients had lower unplanned readmission rate (11.7%) than Black or African American (16.8%), Asian (12.7%), or White (11.9%) patients during 2024. All groups had similar percent of chronic diseases, 24%-25%. But Asians had much lower (23%) and Blacks much higher (69%) Mental Health/Substance Use disease documented than Whites (42%) and the Hispanic/Latino (54%) reference group.

Ongoing Actions to address Unplanned Readmissions Disparities:
1.Readmissions data is reported and checked regularly for performance improvement opportunities. Measurement is completed quarterly by diagnosis groups. Standing committees review readmission rates for trends and selected individual cases among disparity groups to ensure the readmission was not avoidable.
2.Readmission rates were analyzed to explore diagnosis groups and disease burden of each group. Workgroups to be formed during Q1 2026 to identify PI efforts and resources targeted to disease group characteristics; older, mental health/substance use diagnoses, more male.
3.Best practices to reduce readmissions are ongoing and applied for all groups including;
a.Assessing patient risk for readmission with standardized assessments
b.Predischarge multidisciplinary meetings to ensure a comprehensive post hospital plan in place for each patient.
c.Phone calls to recently discharged patients by RNs to address common transition of care factors leading to readmission such as access to medications, patient/family knowledge of emergency symptoms, and transportation to follow-up medical visits.
4.The aging population has unique health needs and at MHMC the Emergency Department has achieved Bronze Standard - Level 3 Geriatric Emergency Department Accreditation. The Emergency Department is focused on the highest standards of care for older adults.
5.MHMC also has national certifications in Stroke, Diabetes and Trauma services, all of which are highly utilized by elders.
6.MHMC participates in dedicated Quality Improvement Programs focused on the Medicaid patient population to help address social determinants of health that can lead to unplanned readmissions.
7.All inpatients are screened for Social Determinants of Health and receive a social services consultation for ‘Yes’ response and then linked to support services appropriate to individual needs.

3. Structural Measures

4. Web Address for Equity Report

https://mymarinhealth.org/about-us/quality

5. Download Equity Measures Report

Click on the link below to download the equity measures report.

6. Looking for Related Reports?

• Hospital Supplier Diversity Plan
• Hospital Profile
• Hospital Fair Billing Policies