PETALUMA VALLEY 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	Age (excluding maternal measures)	50 to 64	10.4%	65 and older	7.1%	1.50
2. HCAI 30-Day readmission	Sex Assigned at Birth	Female	8.4%	Male	6.1%	1.40
3. HCAHPS survey-received information	Preferred Language	English Language	84.3%	Spanish Language	92.9%	1.10
4. HCAHPS survey-recommend hospital	Expected Payor	Medicaid	85.7%	Medicare	93.9%	1.10
5. HCAHPS survey-recommend hospital	Preferred Language	English Language	92.0%	Spanish Language	100.0%	1.10
6. HCAHPS survey-recommend hospital	Sex Assigned at Birth	Male	90.2%	Female	95.1%	1.10
7. HCAHPS survey-received information	Expected Payor	Medicaid	81.0%	Medicare	85.4%	1.10
8. HCAHPS survey-received information	Expected Payor	Medicare	85.4%	Medicare	85.4%	1.00
9. HCAHPS survey-recommend hospital	Expected Payor	Medicare	93.9%	Medicare	93.9%	1.00
10. HCAI 30-Day readmission NOBH	Sex Assigned at Birth	Male	6.1%	Female	7.1%	1.00

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2. Equity Plan

Disparity Group #3,7,8 Goal: Improve the HCAHPS question, "During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital" by 1% in the next 18 months, achieved by the following actions: - Teach Back - Utilized to educate and validate patient understanding of their medication's purpose and side effects - Medication Information and Side Effects Sheet - Included in patient admission and discharge folder specific to new medications. - Provide verbal and written information and education in patients' preferred language. - AVS (After Visit Summary) - Provide patients with the AVS at discharge (explains why they were hospitalized, medications prescribed, signs/symptoms to watch for, how to care for self, follow-up appointments) - Care Network - Patients with chronic or complex conditions are referred to the Care Network after discharge for services and coordination of care (such as medication therapy) - Bedside shift report - Off-going RN in-person hand off to the oncoming RN during shift report and at the bedside with patients/family members - Hourly rounding - RNs and CNAs round on patients to meet their needs and answer questions - Leader rounding - Unit leaders round on patients asking scripted questions regarding the patient's perception of how care is being delivered and to allow the opportunity to provide information/education to the patient and family - Patient Care Boards posted in each patient's room provide information to the patient/family of who their care team is, activity level, diet status, next scheduled medication time, patient specific needs and a section for patients/families to write questions they may have - "What Matters Most" boards - During the patient's stay, the patient's RN asks the patient "what matters most" to them during hospitalization. The patient's responses are available so the entire care team can incorporate the patient's wishes into their care - Interpreter services utilization - Use when patients/families speak another language other than English and important information needs to be conveyed by the care team or vice versa Disparity Group 4,5,6,9 Goal: Improve the HCAHPS question, "Would you recommend this hospital to your friends and family?" by 1% in the next 18 months, achieved by the following actions: Enhance PERSON-CENTERED CARE - Ask patients "What Matters Most?" and post on patient board for care team to incorporate into the care plan. - Personalize and update information for the patient/family regarding who their care team is, activity level, diet status, patient specific needs, and a section for patients/families to write questions. - Screen all patients for preferred language, ensure qualified interpreters are available for non-English speaking patients. Provide educational materials in patient's preferred language to support understanding and engagement, enabling patients to comprehend their care plan and actively participate in decision-making. - Utilize interpreter services for patients with preferred language other than English. Incorporate Social Determinants of Health (SDoH) positive screening into care plan - FindHelp is used to generate a comprehensive list of local resources for housing, utilities, food, transportation to support health and well-being to support excellent health outcomes. Disparity Group #1,2,10 Goal: Reduce unplanned readmissions by 10% achieved by the following actions Actions: · Utilize evidence-based readmission risk assessment tool to flag high risk patients (LACE) · Standard work to schedule follow-up Primary Care appointments by CM staff · Refer patients without a Primary Care Physician to Petaluma community health center or equivalent · Screen all patients for SDOH needs · Engage CM/Social Work to provide local community resources from FindHelp · Partner with CareNetwork to support connection to community resources and outpatient case management/enhanced case management · Implement a multidisciplinary readmission prevention discharge checklist for all roles and incorporate into MDRs · Implement Pharmacy-led medication reconciliation on admission and discharge · Establish Pharmacy-Nursing medication patient education partnerships · Order timely Home Health referrals according to estimated discharge date · Educate patients of an automatic discharge follow-up call within 48 hours of discharge · Consider advanced care planning conversations with all patients with complex conditions · Behavioral health patients: o Include behavioral health assessment at admission o Engage mental health resources into discharge planning, including substance use disorders o Warm handoff to outpatient community resources

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

PETALUMA VALLEY HOSPITAL