NATIVIDAD MEDICAL CENTER

1. Top 10 Disparities

2. Equity Plan

7 of the 8 top disparity groups at Natividad Medical Center are linked to the HCAI All-Cause Unplanned 30-Day Hospital Readmission Rate, the focus of the Health Equity Plan. Disparities and Data
HCAI All-Cause Unplanned 30-Day Hospital Readmission Rate
-Disparities #1, #3, & #4 (Disparity Group: Age)
- 50 – 64: 9.0: Rate Ratio (RR) 2.3
- 35 – 49: 7.0 (RR 1.8)
- 65+: 6.8 (RR 1.8)
- Reference group: 18-34, with Reference Rate: 3.9.
-Disparities #2 & #5 (Disparity Group: Payor Source)
- Medicare: 7.8 (RR 2.2)
- Medicaid: 6.3 (RR 1.7)
- Reference group: Private Insurance with Reference Rate: 3.6.
-Disparity #6 (Disparity Group: Sex Assigned at Birth)
- Sex assigned at birth: Male: 8.4 (RR 1.7): Reference Group: Female, with Reference Rate 4.9
-Disparity #8 (Disparity Group: Race/Ethnicity)
- Race/Ethnicity: White: 6.3 (RR 1.0): Reference Group: Hispanic/Latino. with Reference Rate: 6.3, no disparity.
CMQCC Exclusive Breast Milk Feeding
-Disparity #7 (Disparity Group: Age)
- Age Group: 30-39: 29.3: (RR 1.0): Reference group 18-29, with Reference Rate: 29.9.


Core Measure: HCAI All-Cause Unplanned 30-Day Hospital Readmission Rate (Disparity Groups #1, #2, #3, #4, #5, #6, #8):
Population Impact:
Unplanned readmissions worsen outcomes for patient health and worsen patient experience and raise costs. Reducing disparities by age, payer, and sex improve patient health and cut spending, while continued monitoring ensures racial and ethnic equity.
Measurable Objective:
#1, #3, #4: Reduce 30-day readmission rates by 1% among disparity age groups 35-49, 50-
64, and 65+.
#2, and #5: Reduce 30-day readmission rates by 0.5% among disparity Expected Payor Groups Medicare & Medicaid.
# 6: Reduce 30-day readmission rates by 0.5% among disparity Sex Assigned at Birth-Male Groups.
#8: Maintain Equity between disparity groups Race/Ethnicity White: (Disparity Rate 6.3) and
Reference Group Hispanic/Latino (Reference Rate 6.3) with RR 1.0. Interventions:
1. Person-Centered Care: Provide instructions for discharge instructions in preferred language and literacy level of each patient.
2. Patient Safety: The Unit Coordinator on each hospital unit works with the patient to schedule a follow-up visit with their provider within 7 days of discharge from the hospital.
3. SDOH: Assess each patient for any of the following social determinants of health needs to prevent readmission: 1. Food insecurity, 2. Housing instability, 3. Transportation needs, 4. Utility difficulties, and/or 5. Interpersonal safety concerns before discharge. For any patient that a need is identified, include a list of resources in their discharge document.
4. Effective Treatment: Follow-up appointment with primary care provider within 1-week post discharge.
5. Care Coordination: Ensure discharge summary is faxed to primary care provider on the following business day.
6. Access to Care: Propose expansion of clinic hours to include early morning and late evening hours. Early clinic to start at 7am Monday through Friday and be open until 8pm Monday through Thursday.
Target Date: 4Q26
Core Measure: CMQCC Exclusive Breast Milk Feeding (Disparity Group #7):
CMQCC Exclusive Breast Milk Feeding for stratification Age group of 30-39 has a disparity rate of 29.3 (RR = 1.0) compared to the reference group age of 18-29 (RR = 29.9), ranking 7th among all disparity groups.
Population Impact:
Exclusive breastfeeding improves the health of infants and moms and reduces healthcare use. Providing equal breastfeeding support for all ages helps address work, recovery, and lactation challenges.
Measurable Objective: Increase the exclusive breast milk feeding rate by 1%.
Disparity Group: Age group: 30-39 Interventions:
1. Person-Centered Care: Offer personalized lactation support that considers donor milk, maternal age, birth plan, family structure, and return-to-work timeline.
2. Patient Safety: Provide consistent feeding education to reduce supplementation errors and feeding complications and offer donor milk.
3. SDOH: Assess each patient for any of the following social determinants of health needs to prevent readmission: 1. Food insecurity, 2. Housing instability, 3. Transportation needs, 4. Utility difficulties, and/or 5. Interpersonal safety concerns before discharge. For any patient that a need is identified include a link to WIC or other community lactation resources in their discharge document.
4. Effective Treatment: Ensure standardized clinical lactation protocols, offering of donor milk, and early intervention for challenges (e.g., latching issues, nipple pain, C-section recovery).
5. Care Coordination: Strengthen communication between prenatal, inpatient, and postpartum care teams. Integrate lactation plans into discharge summaries.
6. Access to Care: Propose expansion of lactation clinic hours and telehealth options to meet the scheduling needs of working mothers in this age group.
Target Date: 4Q26

3. Structural Measures

4. Web Address for Equity Report

https://www.natividad.com

5. Download Equity Measures Report

Click on the link below to download the equity measures report.

6. Looking for Related Reports?

• Hospital Supplier Diversity Plan
• Hospital Fair Billing Policies
• Hospital Profile