MONTEREY PARK 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.

Measure	Stratification	Stratification Group	Stratification Group Rate	Reference Group	Reference Rate	Rate Ratio
1. HCAI 30-Day readmission	Race and/or Ethnicity	White	22.5%	Asian	12.3%	1.80
2. HCAI 30-Day readmission	Age (excluding maternal measures)	50 to 64	19.9%	65 and older	13.2%	1.50
3. HCAI 30-Day readmission	Expected Payor	Medicaid	17.1%	Medicare	12.9%	1.30
4. HCAI 30-Day readmission	Race and/or Ethnicity	Hispanic or Latino	14.1%	Asian	12.3%	1.10
5. HCAI 30-Day readmission	Sex Assigned at Birth	Male	15.3%	Female	14.0%	1.10

View Fullscreen

2. Equity Plan

Monterey Park Hospital (MPH) only had five (5) identified areas of disparity. All disparities were related to 30-day readmissions. Reducing Readmissions across all patients is a priority for MPH.

All actions to reduce health equity disparities related to reducing readmissions.

MPH's goal to address health equity disparities is to reduce 30-day readmission by 10% by Q1 FY 2028.

Disparity 1 White Race / Ethnicity All Cause 30-day Readmission Rate. Analysis of the data indicated that the disparate population is less likely to have family involvement in care both while hospitalized and after discharge, while the reference group is more likely to have involved family, including living with them, and be managed by a particular IPA.

Disparity 2 50-64 Age All Cause 30-day Readmission Rate: Analysis of the data indicates that the disparate population is more likely to not have health insurance, have poorly managed chronic disease conditions, unhoused, and substance use and / or mental health issues

Disparity 3 Medicaid Payor All Cause 30-day Readmission Rate. Analysis of the data indicates that the disparate population is more likely to be unhoused, have poorly managed chronic conditions including mental health and substance use disorders. Many of the population are unaware of the primary care provider to which they have been assigned.

Disparity 4 Hispanic Race / Ethnicity All Cause 30-day Readmission Rate: Analysis of the data indicates that the disparate population generally has more family support, but experience more variations in social determinants of care.

Disparity 5 Male Sex assigned at Birth All Cause 30-day Readmission Rate. Analysis of the data indicates that males experience variations in SDOH, including mental health issues and substance use issues, homelessness, and loneliness.

The following apply to all disparities;

Actions: Beginning with admission, all patients are evaluated for post discharge needs. Patients who have been recently discharged, are identified on the case manager census as having recently been discharged. Patients are screened for Social Determinants Of Health (SDOH) and interventions are provided to help reduce the impact of the concerns on their discharge. Patient care plans are developed to reflect individual needs. Daily multi-disciplinary rounds are conducted on all patients during the week. Patients are assigned a case manager to facilitate early identification of discharge needs. Case management is available on weekends. Discharged patients are provided with follow up appointments and with their primary care provider information. Patient relations make post discharge phone calls occur at approximately 3 days, 7 days and 14 days to ensure that they were able to obtain prescriptions and make follow up appointments. A pharmacist reviews discharge medications with the patient. Social services and case management connect patients with community resources for assistance after discharge. Patients are assessed for their level of understanding of patient education and discharge instructions by asking them to describe their understanding. If the patient allows, family (support persons) are included in the patient education and discharge instructions. Social services and case management connect patients with community resources for assistance after discharge, including housing, recuperative care, and mental health professional and substance use professional referrals. Patients are encouraged to ask questions about their care. We are currently evaluating programs to provide medications upon discharge. We assist with having patients apply for financial assistance including Medi-Cal.

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

MONTEREY PARK HOSPITAL