PROVIDENCE HOLY CROSS 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 NOBH
|
Age (excluding maternal measures) | 50 to 64 | 9.2% | 18 to 34 | 3.3% | 2.80 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 9.9% | 18 to 34 | 3.7% | 2.70 |
|
3.
CMQCC NTSV cesarean rate
|
Race and/or Ethnicity | Asian | 0.5% | Hispanic or Latino | 0.2% | 2.50 |
|
4.
HCAI 30-Day readmission NOBH
|
Age (excluding maternal measures) | 65 and older | 7.9% | 18 to 34 | 3.3% | 2.40 |
|
5.
HCAI 30-Day readmission SUD
|
Expected Payor | Other | 15.6% | Medicare | 7.1% | 2.20 |
|
6.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 8.0% | 18 to 34 | 3.7% | 2.20 |
|
7.
HCAI 30-Day readmission NOBH
|
Expected Payor | Medicare | 8.9% | Private | 4.3% | 2.10 |
|
8.
CMQCC NTSV cesarean rate
|
Age (for maternal measures only) | 30 to 39 | 0.4% | 18 to 29 | 0.2% | 2.00 |
|
9.
CMQCC VBAC rate
|
Expected Payor | Medicaid | 150.4% | Other | 293.3% | 2.00 |
|
10.
CMQCC VBAC rate
|
Preferred Language | Spanish Language | 119.6% | English Language | 225.9% | 1.90 |
2. Equity Plan
Healthcare disparities in unplanned 30-day readmission rates remain an opportunity for multiple patient groups. We are committed to addressing these disparities for improvement of outcomes, cost-reduction, patient satisfaction and for promoting equitable care. This report outlines best-practice actions for multiple groups pertaining to readmission: - All-Cause Unplanned 30-Day Hospital Readmission Rate, by Behavioral Health Diagnosis (No Behavioral Health Disorders - Medicare, Ages 50-64 - HCAI All-Case Unplanned 30-Day Hospital Readmission Rate (HCAI-SS_HWR) ages 50 to 64) - All-Cause Unplanned 30-Day Hospital Readmission Rate, by Behavioral Health Diagnosis (No Behavioral Health Disorders) for 65 & Older - All-Cause Unplanned 30-Day Hospital Readmission Rate, by Behavioral Health Diagnosis (SUD) Other Payor - All-Cause Unplanned 30-Day Hospital Readmission Rate (HCAI-SS-HWR) - Ages 35-49 For each group, population impact, measurable objectives, and specific timeframes are detailed to guide effective intervention. Population impact: This group represents a large portion of the adult and senior population, with unique vulnerabilities to readmission due to chronic conditions, medication management challenges, as well as social determinant of health factors. Unplanned readmissions in this cohort contribute to increased healthcare costs and can signal gaps in post-discharge care. Measurable Objectives/Time Frame: - Reduce 30-Day readmission rates by 10% within 18 months - Monitor progress monthly, with full evaluation at 18 months Best Practice Actions: - Utilize evidence-based readmission risk assessment tool to flag high risk patients - Continue to monitor the LACE scores and ensure appropriate PIC referrals - Utilize caregivers on light duty as support via follow up calls to patients flagged as high risk - Schedule follow-up Primary Care appointments prior to discharge - Strengthen coordination with primary care providers, community resources, and palliative care partners - For behavioral health (patients: o Include behavioral health assessment/psych consult early in the admission o Engage mental health resources into discharge planning o Use people-first language to reduce stigma o Communicate in the patient's preferred language o Use culturally sensitive education and discharge materials Healthcare disparities in NTSV and VBAC remain an opportunity for multiple patient groups. We are committed to addressing these disparities for improvement of outcomes, cost-reduction, patient satisfaction and for promoting equitable care. This report outlines best-practice actions for multiple groups pertaining to obstetrical care: - CMQCC NTSV C-Section Birth Rate (PC-02) for Asian patients and mothers aged 30 - 39 - CMQCC Vaginal Birth After Cesarean (VBAC) Rate for Medicaid recipients and also for Spanish-speaking patients For each group, population impact, measurable objectives, and specific timeframes are detailed to guide effective intervention. Population impact: This group represents a smaller portion of the populations for PC-02 Asian patients. Also, given the greater the age with pregnant mothers, this sometimes present challenges, as well as social determinant of health factors. Measurable Objectives/Time Frame: - Reduce NTSV C-Section Rate for Asian patients and those aged 30-39 and VBACs for Spanish-speakers and Medicaid recipients by 5% within 18 months - Monitor progress monthly, with full evaluation at 18 months Best Practice Actions: - Develop culturally sensitive educational materials that address the benefits of vaginal birth, the risks associated with C-sections, and explain the process. This could include workshops or classes tailored to Asian patients and those aged 30-39. - Encourage the use of doulas or trained labor coaches who understand cultural nuances to support Asian patients. - Provide Spanish-speaking patients with access to bilingual healthcare providers and educational materials about VBAC options. - Offer thorough counseling on VBAC benefits and risks, especially tailored for Medicaid recipients, who may face financial constraints impacting decision-making.
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 |
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.