PROVIDENCE LITTLE COMPANY OF MARY MC – SAN PEDRO

1. Top 10 Disparities

2. Equity Plan

HCAHPS survey: Q. 17 Received information and education (H-COMP-6-Y-P) The disparity group for the patient population to improve the HCAHPS survey question on "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" include: - Asians - 65 years + - Medicare - White Goal: Improve the HCAHPS survey question 23, "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 3% in the next 18 months, achieved by the following actions: - Teach Back - Teach back is 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. Available in both English and Spanish. - AVS (After Visit Summary) - Patients are provided the AVS /discharge summary at discharge which is a written document explaining why they were hospitalized, medications prescribed, signs/symptoms to watch for, how to care for self, follow-up appointments - Medication Management Clinic - Patients with chronic or complex conditions are referred to the Medication Management Clinic after discharge for pharmacy services such as coordinating medication therapy, assess appropriateness of medications, adjust medications, review/educate about current medications, support access to medication refills - Bedside shift report - Off-going RN in-person hand off to the oncoming RN during shift report and at the bedside so patients/family members can ask questions - Hourly rounding - RNs and CNAs round hourly on patients to ensure their needs are being met and able to ask 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 while in the hospital. The patient's responses are written down for the entire care team to see when they visit the patient and can incorporate the patient's wishes into the care provided - Cyracom translator phone - Used when patients/families speak another language other than English and important information needs to be conveyed by the care team or vice versa All-Cause Unplanned 30-Day Hospital Readmission Rate (HCAI-SS-HWR) All-Cause Unplanned 30-Day Hospital Readmission Rate, by Behavioral Health Diagnosis (No Behavioral Health Disorders) All-Cause Unplanned 30-Day Hospital Readmission Rate, by Behavioral Health Diagnosis (MHD) The disparity group for the patient populations to improve all-cause unplanned 30-day hospital readmission rate (see above) include: - Asians - Other Payor - Black or African American - Male - Hispanic or Latino Goal: Reduce 30-day readmission rates by 10% within the next 18 months, achieved by the following actions: - Utilize evidence-based readmission risk assessment tool to flag high risk patients - Standardized work for Administrative Staff to schedule follow-up Primary Care appointments - Include follow-up appointment education into discharge education - Refer patients lacking a Primary Care Physician to Post Discharge Clinic and/or free or low-cost Vasek Polak clinic - Assess all patients for SDOH needs - Engage Social Work to provide local community resources from FindHelp - Partner with Community Health Investment to support connection to community resources - Implement a multidisciplinary readmission prevention discharge checklist - Implement Pharmacy led medication reconciliation on admission and discharge - Refer patients to hospital outpatient Medication Management Clinic - Order Home Health referrals, if applicable, for all Heart Failure patients - Educate patients of an automatic discharge follow-up call within 48 hours of discharge - Consideration of advanced care planning conversations with all high-risk patients diagnosed with Heart Failure, Renal and/or other complex conditions - For behavioral health patients: o Include behavioral health assessment early in the admission o Engage mental health resources into discharge planning, including substance use disorders

3. Structural Measures

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