PALMDALE REGIONAL 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
|
Race and/or Ethnicity | Native Hawaiian or Pacific Islander | 29.5% | Hispanic or Latino | 14.0% | 2.10 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 18.0% | Private | 8.6% | 2.10 |
|
3.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 17.3% | Private | 8.6% | 2.00 |
|
4.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 17.6% | Hispanic or Latino | 14.0% | 1.30 |
|
5.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Male | 15.4% | Female | 13.3% | 1.20 |
|
6.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 17.4% | Female | 15.2% | 1.10 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 15.5% | Hispanic or Latino | 14.0% | 1.10 |
|
8.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 16.8% | 35 to 49 | 15.8% | 1.10 |
|
9.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 16.2% | 35 to 49 | 15.8% | 1.00 |
|
10.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 18 to 34 | 15.8% | 35 to 49 | 15.8% | 1.00 |
2. Equity Plan
A review of the facility's equity data identified unplanned readmissions as the primary disparity, particularly among patients without primary care access, those who missed follow-up appointments, and those who had difficulty understanding their medications. To address these gaps, the facility focused on improving care continuity and reducing preventable readmissions among the most affected populations.
Analysis showed that many readmitted patients did not see a Primary Care Provider (PCP) after discharge, leading to unmanaged conditions and avoidable hospital returns. In response, the facility established an Equity Action Plan with three targeted initiatives, each with measurable objectives and a quarterly performance goal of 90%. All initiatives exceeded their targets.
1. PCP appointment scheduled
To reduce disparities in primary care access, our facility partnered with a community clinic through its residency program. Uninsured and unaffiliated patients are now assigned a PCP before discharge, supporting ongoing care for those at the highest risk of readmission.
2. Follow-up appointment scheduled prior to Discharge
Discharge staff now schedule follow-up PCP appointments before patients leave the hospital, reducing barriers such as scheduling delays and transportation issues.
3. Discharge Med Rec: One-on-One Discharge Medication Education
To address medication-related readmissions, pharmacy staff provide individualized medication education for patients and families, including clear explanations of medication purpose, dosing, and safe use.
These initiatives directly addressed key drivers of readmission disparities by improving access to primary care, strengthening follow-up compliance, and enhancing understanding of medications. All efforts exceeded performance goals, demonstrating meaningful progress in reducing inequities and improving long-term patient outcomes.
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.