NORTHBAY 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
|
Expected Payor | Medicare | 18.5% | Private | 9.0% | 2.00 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 17.6% | Private | 9.0% | 2.00 |
|
3.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 23.0% | Hispanic or Latino | 13.6% | 1.70 |
|
4.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 19.0% | 18 to 34 | 11.5% | 1.70 |
|
5.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 18.1% | 18 to 34 | 11.5% | 1.60 |
|
6.
HCAI 30-Day readmission
|
Expected Payor | Self-Pay | 12.7% | Private | 9.0% | 1.40 |
|
7.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 15.1% | 18 to 34 | 11.5% | 1.30 |
|
8.
CMQCC breast milk feeding
|
Expected Payor | Medicaid | 59.6% | Private | 76.9% | 1.30 |
|
9.
CMQCC breast milk feeding
|
Race and/or Ethnicity | Hispanic or Latino | 61.2% | White | 75.7% | 1.20 |
|
10.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Female | 15.2% | Female | 15.2% | 1.20 |
2. Equity Plan
The top seven disparities are variations of disparities within the All-Cause Unplanned 30-day hospital readmissions rate: specifically, payor types (3), age (3), and race/ethnicity (1). NorthBay Medical Center serves as the centralized community-based hospital in Solano County and is a level 2 Trauma Center, as well as a STEMI and Stroke receiving center. Additionally, we have a dedicated Labor and Delivery, Mother Baby and NICU to serve our women's and children's population (WCS). Fairfield, the city in which NorthBay Medical Center is located, is set just off I-80 highway, in what is considered a commuting corridor between the San Francisco Bay and Sacramento city hubs. The populace treated relies mostly on Medicare and Medicaid to fund their healthcare. Many of these patients also participate in Partnership Health plans to support their medical care needs. NorthBay hospitals are the dedicated facilities of preference to provide emergency care to capitated patients enrolled with Western Health Advantage insurance plans. The socioeconomic makeup of the residents relying on care at NorthBay Medical Center aligns with the disparity groups in the readmission's metric. Many patients have lower incomes, and advanced age, relying on government assisted health plans. To ensure these populations are treated in a manner that meets their healthcare goals and avoids unplanned readmissions to the hospital, a new population health program has been established. These details will be elaborated upon in the responses below. This dedicated program is tasked with following high risk patient groups and providing supportive measures through routine phone call follow-ups along their healthcare journey. Two of the metrics in the top 10 disparities are specific to exclusive breastfeeding: specifically, Medicaid and Hispanic/Latina populations. The WCS program has a robust team of providers throughout the care continuum to assist new moms in navigating their breastfeeding journey. This includes inpatient and outpatient lactation specialists, a warm hotline for breastfeeding assistance during off hours, support groups and educational outreach programs. These include bilingual resources and education. As mentioned previously, by partnering with Partnership health plan, patients relying on Medicaid health insurance, have added resources through their programs to assist in receiving adequate care. NorthBay engages with a data driven partnership to ensure outcomes are aligned. The last identified disparity is specific to treatment for pneumonia patients based on sex (males more than females) resulting in death (mortality). Northbay Health established a dedicated workgroup to improve the mortality outcomes in patients with Pneumonia diagnosis and evolved the program into a more robust Mortality Reduction Committee. There were pneumonia and respiratory related interventions identified and implemented, review and modifications to Pneumonia order sets, care plans, and ensuring incorporation of the respiratory care team through referrals for pulmonary hygiene. Decompensation in respiratory status also triggers consults with the pulmonology/critical care team.
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.