MEMORIALCARE SADDLEBACK 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
|
Age (excluding maternal measures) | 50 to 64 | 11.0% | 18 to 34 | 3.0% | 3.60 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 10.3% | 18 to 34 | 3.0% | 3.40 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 6.3% | 18 to 34 | 3.0% | 2.10 |
|
4.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 10.8% | Private | 5.5% | 2.00 |
|
5.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Male | 10.6% | Female | 6.0% | 1.80 |
|
6.
CMQCC breast milk feeding
|
Race and/or Ethnicity | Hispanic or Latino | 62.0% | White | 71.3% | 1.60 |
|
7.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 8.8% | Private | 5.5% | 1.60 |
|
8.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 10.8% | Female | 7.3% | 1.50 |
|
9.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 9.5% | Asian | 7.0% | 1.40 |
|
10.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 9.3% | Asian | 7.0% | 1.30 |
2. Equity Plan
MemorialCare Saddleback Medical Center is committed to continually analyzing, evaluating, and adapting strategies to identify disparities in care and improve processes that impact those populations. Through this work, 30-day unplanned readmissions among Black or African American, White, Medicaid, Medicare, Male, 50- to 64-year-old, 35- to 49-year-old, and 65 and older populations have been identified as an opportunity for improvement.
Readmissions disproportionately affect patients with chronic conditions, older adults, and individuals from underserved communities who face barriers such as limited access to follow-up care, transportation, and health literacy challenges. To address these issues, we conduct multidisciplinary discharge rounds, provide standardized discharge planning with clear instructions, medication reconciliation, and culturally appropriate education. Telephone advice nurses perform post-discharge follow-up phone calls on complex medical diagnoses (i.e., stroke, cardiac, post-surgery, etc.). The Social Services department collaborates with local organizations to address specific needs related to the social determinants of health and assists with transportation needs, access to medications, and follow-up appointments. Case managers collaborate with community services, high-performing home health care agencies and skilled nursing facilities upon discharge to ensure a smooth transition of care and maintain low hospital readmission rates. Our goals include reducing 30-day readmission rates by 2% within 12 months; improving patient understanding of discharge instructions; and helping connect patients to community resources. Readmission rates are monitored quarterly and stratified by population segmentation to identify disparities and trends. Annual reviews of disparity impact reports ensure ongoing equity.
Additionally, Saddleback identified an opportunity for exclusive breast milk feeding among Asian mothers. Our hospital has implemented a culturally tailored, evidence-based strategy to improve exclusive breastfeeding rates among Asian mothers by 5% by December 2026. Interventions include Lactation nurse-led education to dispel cultural myths and provide guidance on early breastfeeding and colostrum hand expression. Patients will receive educational handouts with QR codes linking to our Breastfeeding and Lactation Support page and individualized feeding plan cards. When medically necessary, human donor milk will be offered as a temporary bridge to maintain human milk feeding. Outpatient lactation support will be strengthened through scheduled clinic appointments and follow-up calls. Digital resources will include interpreter services, Mandarin-language education, culturally relevant "MythBusters" video clips, and a breastfeeding blog. Staff training will focus on cultural competence for labor and delivery nurses, with an emphasis on serving Asian populations. Goals include 90% of Asian mothers receiving lactation consults within 24 hours postpartum and 100% completion of cultural competence training by the end of 2026. This plan aims to identify disparities, implement equity-focused interventions, and report measurable outcomes to improve maternal and infant health outcomes while honoring cultural preferences and promoting equitable care.
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.