PROVIDENCE ST. MARY 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
|
Age (excluding maternal measures) | 35 to 49 | 10.6% | 50 to 64 | 5.8% | 1.80 |
|
2.
HCAI 30-Day readmission NOBH
|
Expected Payor | Medicare | 6.9% | Private | 3.9% | 1.80 |
|
3.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 8.8% | Private | 5.2% | 1.70 |
|
4.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 7.2% | Private | 5.2% | 1.60 |
|
5.
CMQCC NTSV cesarean rate
|
Age (for maternal measures only) | 30 to 39 | 0.3% | 18 to 29 | 0.2% | 1.50 |
|
6.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 8.6% | 50 to 64 | 5.8% | 1.50 |
|
7.
CMQCC breast milk feeding
|
Expected Payor | Medicaid | 45.3% | Other | 66.7% | 1.50 |
|
8.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 8.3% | Hispanic or Latino | 5.9% | 1.40 |
|
9.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 7.2% | Private | 5.2% | 1.40 |
|
10.
HCAI 30-Day readmission MHD
|
Age (excluding maternal measures) | 65 and older | 10.6% | 50 to 64 | 7.7% | 1.40 |
2. Equity Plan
All-Cause Unplanned 30-Day Hospital Readmission Rate - By Age: o Ages 35-49 are a disparity group (rate ratio 1.8); best outcomes are in ages 50-64. o Ages 65+ are also a disparity group in some analyses (rate ratio 1.5-1.4), with 50-64 as the best-performing group. - By Expected Payor: o Medicare is a consistent disparity group (rate ratios 1.8, 1.7), with Private or Other payors performing best. o Medicaid is also identified as a disparity group in some analyses (rate ratio 1.4), with Private as the best-performing group. - By Race/Ethnicity: o White patients are a disparity group (rate ratio 1.4), with Hispanic or Latino patients as the best-performing group. Actions to Address Readmission Disparities - Weekly multidisciplinary team meetings (nursing, physicians, case management, quality) to identify causes of readmissions. - Partnerships with community programs for education on risk factors (blood pressure, nutrition, infection prevention, heart health), with a goal of attending at least two outreach events annually. - Outreach and education tailored to different age groups via fairs, colleges, and nursing homes. - Target: Decrease readmission rates for disparity groups by 5% by end of 2027. Behavioral Health Diagnosis - No Behavioral Health Disorders: o Medicare is the disparity group (rate ratio 1.8); Private payors perform best. - With Mental Health Disorders (MHD): o Ages 65+ are the disparity group (rate ratio 1.4); best outcomes in ages 50-64. o Focus on Substance Use Disorder programs: educate on follow-up and medication management, aiming for 60% of patients to attend at least one follow-up visit. Maternal Health: CMQCC NTSV PC-02 - By Age: o Ages 30-39 are the disparity group (rate ratio 1.5); best outcomes in ages 18-29. - Actions: o Encourage nursing staff to complete Bundle Birth Nurses training. o Partner with payor doula programs to promote labor support and advocacy, especially for first-time mothers. o Target: Reduce NTSV rate to less than 20% for ages 30-39 by end of 2027. Maternal Health: CMQCC Exclusive Breast Milk Feeding - By Expected Payor: o Medicaid is the disparity group (rate ratio 1.6); Other payors perform best. - Actions: o Partner with payor doula for prenatal breastfeeding education, focusing on outpatient education and follow-up. o Collaborate with high-risk labor & delivery groups to create community education programs. o Target: Achieve 75% exclusive breastfeeding rate for Medicaid population by end of 2027. Summary of Approach: The strategy centers on identifying disparity groups by age, payor, and race/ethnicity, then implementing targeted education, outreach, and care coordination. Goals are set for measurable improvement by 2027, with multidisciplinary collaboration and community partnerships as key drivers.
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.