MERCY SAN JUAN 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 | 17.4% | 18 to 34 | 6.4% | 2.70 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 16.5% | 18 to 34 | 6.4% | 2.60 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 13.9% | 18 to 34 | 6.4% | 2.20 |
|
4.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 17.1% | Private | 10.5% | 1.60 |
|
5.
HCAI 30-Day readmission
|
Expected Payor | Other | 15.7% | Private | 10.5% | 1.50 |
|
6.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 17.8% | Asian | 12.6% | 1.40 |
|
7.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Male | 15.7% | Female | 11.7% | 1.30 |
|
8.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 13.8% | Private | 10.5% | 1.30 |
|
9.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 15.4% | Asian | 12.6% | 1.20 |
|
10.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 16.5% | Female | 13.9% | 1.20 |
2. Equity Plan
1: Race/Ethnicity Disparities 6 & 9
Population Impact: Racial and ethnic minorities often face systemic barriers to healthcare access, language barriers, cultural insensitivity, and higher prevalence of chronic conditions, leading to health inequities and higher readmission rates.
Objective: Reduce the 30-day all-cause unplanned hospital readmission rate among Black/African American, and/or White patients by 2.5% within the next 12 months.
Actions:
• Utilize patient data to identify common medical conditions, social challenges and other factors to develop targeted interventions to address this disparity.
• Provide comprehensive cultural humility training for all staff interacting with patients, designed to enhance awareness of implicit bias and foster skills in culturally sensitive and respectful communication practices.
• Conduct patient screening for social determinants of health, then employ the Unite Us platform for referrals for identified needs and ensure their successful resolution.
• Evaluate and revise patient education materials for adherence to California/National Culturally and Linguistically Appropriate Services standards.
• Assess current availability and utilization of professional medical interpreters for all languages spoken by patient population, ensuring 24/7 access.
2: Age Disparities 1, 2 & 3
Population Impact: Older adults often have multiple comorbidities, polypharmacy, and reduced functional capacity, increasing readmission risk. The 50-64 and 35-49 age groups also show significant disparities, indicating challenges possibly related to chronic disease management and complex social situations.
Objective: Reduce the 30-day all-cause unplanned hospital readmission rate among patients aged 35-49 yrs., 50-64 yrs., and 65+ by 2.5% within the next 12 months.
Actions:
• Utilize patient data to assess age-specific risks for readmissions (e.g., cognitive impairment, frailty, social isolation for 65+; chronic disease progression, addiction for 35-64) to develop targeted interventions to address this disparity.
• Integrate mental health screening and referral pathways as behavioral health diagnosis often impacts readmissions.
• Strengthen coordination with skilled nursing facilities and rehabilitation centers for appropriate post-acute care for older adults.
3: Payor Disparities 4 & 5
Population Impact: Medi-Cal and Medicare patients often have complex medical needs, and potential barriers to accessing care. High readmission rates indicate substantial healthcare burden and potential for adverse patient outcomes.
Objective: Reduce the 30-day all-cause unplanned hospital readmission rate among patients with Medi-Cal and Medicare by 2.5% within the next 12 months.
Actions:
• Strengthen partnerships with Enhanced Care Management providers, Federally Qualified Health Centers and other primary care practices, and payors to improve transitions to effectively reduce readmission rates across our shared patient population.
• Employ the Unite Us platform to bridge gaps in social determinants of care by addressing identified needs and ensuring their successful resolution through a closed-loop referral process.
• Implement strategies to increase patient knowledge and utilization of Cal-AIM benefits, specifically prioritizing enrollment in Enhanced Care Management and arranging for medically-tailored meal delivery prior to discharge.
4: Sex Assigned at Birth Disparities 7 & 10
Population Impact: Consistent data indicates higher hospital readmission rates for males, an outcome that can often be attributed to several factors. These include differing health-seeking behaviors, reduced adherence to prescribed medical advice, or the unique prevalence and treatment considerations for specific health conditions more common among males.
Objective: Reduce the 30 day all-cause unplanned hospital readmission rate among male (sex assigned at birth) patients by 2.5% within the next 12 months.
Actions:
• Research and identify common underlying medical conditions, social factors, and health behaviors contributing to higher male readmission rates.
• Train staff on gender-sensitive communication and motivational interviewing, particularly for male patients.
• Develop male-targeted patient education materials, potentially focusing on active participation in health management and perceived benefits of adherence.
• Integrate male-specific health resources into discharge planning.
• Evaluate if the hospital environment or communication styles contribute to male disengagement and make adjustments.
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.