MARK TWAIN 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 | 13.5% | Medicaid | 11.8% | 1.10 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 13.5% | 50 to 64 | 12.8% | 1.10 |
|
3.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 12.6% | Female | 12.3% | 1.00 |
2. Equity Plan
Disparity 1: Payor-Related Readmission Disparities
Comparison: Medicare and Medicaid vs. Private Insurance
Impacted Population: Adults over 65, individuals with disabilities, and those of all ages with state/federally funded healthcare.
Action Plan:
• Enhance chronic disease management education during hospitalizations for high-risk patients and those with complex comorbidities.
• Increase the use of transitional care clinics, telemedicine, and home health services to facilitate a smoother recovery transition.
• Conduct follow-up phone calls within 48-72 hours post-hospital discharge.
Measurable Objective: Reduce 30-day all-cause readmissions by 8% within the next two years.
Disparity 2: Age-Related Readmission Disparities
Population Impact: Patients aged 65 and older experience higher unplanned readmission rates compared to younger patients (18-50).
Action Plan:Provide enhanced chronic disease management education to older patients during hospitalization.
• Increase the utilization of transitional care clinics for high-risk and older patients.
• Conduct follow-up phone calls within 48-72 hours post-discharge.
Measurable Objective: Reduce 30-day all-cause readmissions by 8% over the next two years.
Disparity 3 Readmission Rates Based on Sex Assigned at Birth (male)
Population Impact: Males exhibit higher readmission rates.
Action Plan:
• Implement male-centric health education emphasizing medication adherence, lifestyle management, and consistent follow-up care.
• Enhance discharge planning for high-risk male patients through clear, simplified instructions and expedited outpatient follow-up appointments.
Measurable Objective: Achieve an 8% reduction in 30-day all-cause readmissions over the next two years.
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
https://www.dignityhealth.org/central-california/locations/m
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.