PROVIDENCE LITTLE COMPANY OF MARY MEDICAL CENTER TORRANCE
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) | 65 and older | 8.3% | 18 to 34 | 2.4% | 3.50 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 8.7% | 18 to 34 | 2.9% | 3.00 |
|
3.
HCAI 30-Day readmission NOBH
|
Expected Payor | Medicare | 8.4% | Private | 3.1% | 2.70 |
|
4.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 9.0% | Private | 3.6% | 2.50 |
|
5.
HCAI 30-Day readmission NOBH
|
Expected Payor | Other | 7.5% | Private | 3.1% | 2.40 |
|
6.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 6.8% | 18 to 34 | 2.9% | 2.30 |
|
7.
HCAI 30-Day readmission MHD
|
Expected Payor | Medicare | 10.1% | Private | 4.4% | 2.30 |
|
8.
HCAI 30-Day readmission NOBH
|
Age (excluding maternal measures) | 50 to 64 | 5.3% | 18 to 34 | 2.4% | 2.20 |
|
9.
HCAI 30-Day readmission
|
Expected Payor | Other | 7.9% | Private | 3.6% | 2.20 |
|
10.
CMQCC NTSV cesarean rate
|
Age (for maternal measures only) | 18 to 29 | 0.2% | 2.00 |
2. Equity Plan
All-Cause Unplanned 30-Day Hospital Readmission Rate, by Behavioral Health Diagnosis (No Behavioral Health Disorders) All-Cause Unplanned 30-Day Hospital Readmission Rate (HCAI-SS-HWR) 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 rates (see above) include: - 65 years + - Medicare - Other Payors - 50-64 years 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 within 5 days of discharge for patients scored as high risk for readmission - 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 CMQCC Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean Birth Rate The disparity group for the patient population to reduce NTSV Cesarean Rates (see above) include: - Advanced maternal age, 40 years+ Goal: Monthly NTSV rates for the next 18 months will be < 23.6% for maternal aged patients > 40 years, achieved by the following actions: - Engage a multidisciplinary committee with peer review discussion of every NTSV case - Standardized labor protocols and practices - Transparently post Provider NTSV rates - Increase support services and Doulas - Participation in CMQCC and implement NTSV C/S Equity Learning Initiative - Improve communication and cultural competency - Provide access to in-person childbirth classes
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.