MOUNTAINS COMMUNITY 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.
No disparity data for this period.
2. Equity Plan
Health Equity Plan: A Proactive Approach for Our Community
1. Our Commitment to Health Equity
As a Critical Access Hospital, Mountains Community Hospital's strength lies in our direct, personal connection to our community. Our mission is to be a trusted provider of exceptional care for every neighbor who depends on us. We recognize that while we may not have identified major disparities in our data, this is often due to the small size of our patient population, which makes it difficult to achieve statistical significance. This plan outlines a proactive and preventative strategy to identify and address potential inequities, making a firm commitment that every person in our community receives the highest quality of care, regardless of their background, beliefs, or circumstances. We will leverage our unique position as a community anchor to ensure our care is truly equitable.
2. Guiding Principles
This plan is built upon a foundation of core principles tailored for a small, community-focused environment.
• Relationship-Driven: We will rely on direct conversations and trust-based relationships with our patients and community members as our primary method for understanding and addressing their needs.
• Data-Informed: We will leverage simple, practical methods to collect and review data, using it as a guide to inform our decisions, not as a replacement for personal interaction.
• Integrated Effort: Health equity will be a shared responsibility. We will integrate this work into existing roles and daily workflows, rather than creating new, resource-intensive processes.
• Transparency and Trust: We will communicate our progress openly with our staff and community, building on the trust that already exists.
3. Strategic Focus Areas
This plan is structured around three key, practical pillars.
Pillar 1: Understanding Our Community Through Data
We will use our existing data and simple, direct methods to understand our patient population and identify potential barriers to care.
• Objective: Optimize our use of existing demographic and social determinants of health (SDOH) data to better understand our patient population.
o Initiative: We will conduct a comprehensive review of our current patient registration and nursing admission processes to ensure we are capturing and standardizing all necessary demographic and SDOH information. We currently screen all admitted patients for language preference, cultural and spiritual values, hearing and vision difficulties, social determinants of health, depression, and suicide risk. The goal is to make this data readily accessible for analysis.
• Objective: Use this data to create a clearer picture of our community's health.
o Initiative: We will create a simple, annual Health Equity Scorecard. This manual report will compare patient outcomes across different demographic groups to highlight areas for discussion and potential improvement, even with small data sets.
Pillar 2: Cultural Competency & Staff Education
A compassionate and culturally competent staff is our most valuable resource for providing equitable care.
• Objective: Ensure all staff are equipped to address language and communication barriers.
o Initiative: We will conduct an annual audit of our language services to identify any gaps. We will train all patient-facing staff on when and how to access interpreter services.
Pillar 3: Community Partnerships & Patient Voices
Our relationships are our greatest asset. This pillar focuses on leveraging those connections to drive change.
• Objective: Establish a formal mechanism for gathering patient and community feedback on health equity.
o Initiative: We will form a small Patient and Community Feedback Group composed of a diverse group of local residents. The group will meet semi-annually to discuss the care we provide and share insights on community needs.
4. Action Plan
• Quarter 1, 2026: Foundation & Task Force
• Form a small, cross-functional Health Equity Task Force to oversee the plan.
• Following comprehensive review of patient registration and nursing admission forms, finalize and implement updates, if indicated.
• Quarter 2, 2026: Data & Education
• Develop and present the first annual Health Equity Scorecard.
• Quarter 3, 2026: Community Engagement
• Launch the Patient and Community Feedback Group and hold the first semi-annual meeting.
• Complete the simple audit of language services and conduct staff training.
• Quarter 4, 2026: Resource & Review
• Complete the annual audit of language services and conduct staff training, if indicated.
• Review all first-year initiatives to plan for the following year.
By focusing on these deliberate, manageable steps, we will build a stronger, more equitable foundation for our hospital and the community we are privileged to serve.
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 |
No |
Our hospital system strategic plan identifies healthcare equity goals and discrete action steps to achieve these goals |
No |
Our hospital system strategic plan outlines specific resources that have been dedicated to achieving our equity goals |
No |
Our hospital system strategic plan describes our approach for engaging key stakeholders, such as community-based organizations |
No |
Our hospital strategic plan identifies healthcare equity goals and discrete action steps to achieve these goals |
No |
Our hospital system has training for staff in culturally sensitive collection of demographics and/or social determinant of health information |
No |
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 |
No |
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 |
No |
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 |
No |
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 |
No |
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.