PROVIDENCE MISSION HOSPITAL – LAGUNA BEACH

1. Top 10 Disparities

2. Equity Plan

The disparities in RR suggest potential gaps in post-discharge support, care coordination, or health education specific to these groups. The higher RR among patients with "Other" insurance may reflect socio-economic factors, while gender differences might indicate varying health needs or conditions. Goal: Reduce 30-Day RR by 5-10% within the next 18 months. Initiatives: - Accurate capture of patient demographics and insurances upon registration - Utilize evidence-based readmission risk assessment tool to proactively identify and flag high-risk readmission patients to tailor interventions accordingly - Assess all admitted patients for Social Drivers of Health (SDoH) needs and address positive findings promptly - Sustain hospital SDoH screening rates above 95% - Patients receive information regarding Cipher automated post-discharge calls and Discharge Follow Up RN contact for post-discharge questions - Increase utilization of patients who answer and complete the transition of care post-discharge calls - Develop and implement comprehensive discharge protocols, including checklists to guarantee patient education and preparation for discharge. - Conduct systematic follow-up post-discharge calls to check on patient recovery and address any issues after discharge - Recommend that physicians refer patients to the Transitional Medical Clinic within 7 days post-discharge for continuity of care - Front-load Home Health visits within 7 days for high-risk patients. - Implement transition of care pharmacist-led discharge medication reconciliation for accurate medication capture and adherence - Provide tailored discharge materials AVS (After Visit Summary), specific to patient hospital diagnoses to enhance understanding and adherence - Increase utilization of "Find Help" platform within EMR, to search and directly add resources to patient's AVS - Implement "Co-Caring Model" with virtual RN to provide comprehensive discharge education throughout hospital stay - Conduct multi-disciplinary Care Coordination Rounds to address patient post-hospital discharge needs (DME, discharge disposition, etc.) - Increase utilization of the SDoH close-loop referral, for patients identified to have multiple drivers like housing, food insecurity, income, and transportation, to the hospital's Family Resource Centers (FRC) by 10% within 12 months. - Standardize SDoH closed-loop referral follow-up protocol from FRC team to facilitate service linkages to Camino Health Clinics, Community Base Organizations and/or internal FRC services: behavioral health, dental, case management, vision, physician outpatient community outreach. - Deploy Community Care Navigators to enhance continuity of care for the underserved population, focusing on securing recuperative and shelter placements and addressing holistic needs. - Utilize Community Nurse Navigators to educate on chronic conditions like DM and HTN. - Sepsis Nurse Navigator multi-disciplinary approach, focusing on care coordination, progression of care throughout hospitalization, patient education, medication education, and post-discharge needs addressed. - Increase utilization of ambulatory case management program to address post-discharge needs - Readmissions Committee weekly case reviews - Complex Case Conference weekly case reviews - Strengthen collaboration with local Home Health providers for smooth transitions and consistent care for patients post-discharge. - Develop stronger relationships with local SNFs to facilitate patient recuperation and continuity of care - Increase early referrals to the Palliative Care Team, providing timely support and specialized care for patients with complex needs. - Goals of Care are thoroughly discussed with patients and documented accurately to guide personalized treatment plans and informed decision-making. Goal: Improve HCAHPS "Received information and education" and "Would recommend hospital" by 5-10% within the next 18 months. Initiatives: - Rapid Improvement Events with nurse leaders to identify barriers and challenges, identify solutions specific to the problem, developed concrete action plans, role clarity with action plans for each role; implemented process measures to track the behaviors associated with the solution; provided in-operation leadership focused on building performance improvement strength and leading change (coaching, reinforcement, accolades, providing input and feedback on their tactics) - Implement structured protocols to boost communication and collaboration between Registered Nurses (RNs) and Patient Care Technicians (PCTs), improving responsiveness and overall patient care. - Implement Feedtrail while patients are in-hospital via text message where they complete short forms to indicate how hospital is meeting general patient experience with regard specifically to how their care is being provided by the clinical team, how well doctors are meeting patients' needs, or how to better meet their needs

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 Profile
• Hospital Fair Billing Policies