PROVIDENCE SAINT JOSEPH MEDICAL CENTER

1. Top 10 Disparities

2. Equity Plan

All-Cause Unplanned 30-Day Hospital Readmission Rate, by Behavioral Health Diagnosis (Substance Use Disorder) The disparity groups for the patient populations to improve 30-day hospital readmission rate by Behavioral Health Diagnosis includes: - Sex Assigned at birth: Female - 50 - 64 years old All-Cause Unplanned 30-Day Hospital Readmission Rate (HCAI-SS-HWR) The disparity groups for the patient populations to improve all cause unplanned 30-day hospital readmission rate includes: - Race and/or ethnicity: Middle Eastern or North American - Race and/or ethnicity: White - 65 years and older - Payor: Medicare - 50 - 64 years Goal: reduce 30-day readmission rates by 10% within the next 16 months by the following action plan: - Utilize evidence-based readmission tactics including: o Comprehensive Discharge Planning o Early Case Management Assessment o Clear, patient-centered education on diagnosis, medications, and warning signs o Schedule follow-up appointments before discharge o SUD - additional resources as needed o Medication reconciliation and management o Medication reconciliation prior to discharge - ideally partnered with pharmacy on admission and discharge o Post Discharge Follow Up (Transitions in Care) o Warm hand off to next level of care (SNF, Home Health) o On Click Program starting 11/24/2025 o Continued collaboration with the SNF Collaborative o Palliative Care Team to support Goals of Care conversations o Patient Education o Provide in preferred language o Use teach-back methods to confirm understanding o Include family members and caregivers in education with an emphasis on those with chronic conditions i.e., Heart Failure and focused on pneumonia and sepsis o Use EHR based interventions to identify high-risk patients o Address Social Determinates of Health o Screen for barriers to transportation, food insecurity, and housing o Connect patients to community resources and services o Address Substance Use concerns that population (SUD) o Multi-professional Readmission Committee to establish goals, discuss process (PDSA), identify trends, sustain outcomes o Review cases for root causes and share with team o Engage Physician Advisor expertise CMQCC Exclusive Breast Milk Feeding (PC-05) The disparity groups for the patient population to increase exclusive breast milk feeding includes: - Preferred language: Spanish - Race and/or ethnicity: Hispanic and/or Latino Goal: increase exclusive breast milk feeding rates by 10% in the next 12 months with Spanish speaking and Hispanic or Latino race and/or ethnicity group by the following action plan: - Extended lactation coverage that includes night shifts and weekends o Of note, the entire lactation team is bilingual and fluent in Spanish to ensure information/education is provided in the preferred language - Provide educational resources and materials on breastfeeding in Spanish when it is the patient preferred language - Incorporate family members in the educational process - Continue to offer outpatient support groups and appointments in Spanish to assist mothers in preferred language - Launch of a Donor Breast Milk Program CMQCC Nulliparous, Term, Singleton, Vertex (NTSV) Cesarean Birth Rate (PC-02) The disparity group for the patient population to reduce NTSV Cesarean Rates include: - 40 and older Goal: reduce monthly NTSV rates to o 23.6% for patients > 40 years old by the following action plan: - Share provider level performance data by posting unblinded NTSV rates for transparency and review data regularly with providers for awareness and encourage accountability - Trend fall outs to understand cause and collaborate with Maternal Fetal Medicine, OB Department Chair, and Quality leader identify action plans and collaborate with coding as needed - Collaborate with divisional leaders for support of local program - Continue elective c-section patient education and consent process - Professional staff to send follow up letters to outlier physicians - Encourage high performing physicians to share best practices amongst the team - Continue the Labor in Motion Program developed by the Perinatal NPD - Enforcement of the Laborist 2nd Opinion form that has been developed to require collaboration between stakeholders prior to a potential NTSV - Share the daily and month-to-date NTSV numbers in L&D for constant awareness

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