SAN DIMAS COMMUNITY HOSPITAL
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) | 50 to 64 | 17.0% | 18 to 34 | 8.9% | 1.90 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 14.4% | 18 to 34 | 8.9% | 1.60 |
|
3.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 15.7% | Private | 11.1% | 1.40 |
|
4.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 11.2% | 18 to 34 | 8.9% | 1.30 |
|
5.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 13.8% | Private | 11.1% | 1.20 |
|
6.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 15.3% | Hispanic or Latino | 12.9% | 1.20 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 15.1% | Hispanic or Latino | 12.9% | 1.20 |
|
8.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Male | 14.4% | Female | 12.7% | 1.10 |
|
9.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 15.1% | Female | 13.7% | 1.10 |
|
10.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Asian | 14.1% | Hispanic or Latino | 12.9% | 1.10 |
2. Equity Plan
San Dimas Community Hospital (SDCH) Top 10 Disparities:
Age: Patients 50-64 (16.6) had higher unplanned 30-day readmission rates compared to adults 18 to 34 (8.9).
Age: Patients 65 and older (14.2) had higher unplanned 30-day readmission rates compared to adults 18 to 34 (8.9).
Expected Payor: Medicare (15.3) patients had unplanned 30-day higher readmission rate compared to Medicaid (10.5)
Expected Payor: Medicaid (13.8) patients had unplanned 30-day higher readmission rate compared to Medicaid (10.5)
Race and/or Ethnicity: Black or African American (15.1) patients had higher unplanned 30-day readmissions rate compared to Hispanic or Latino (12.5).
Race and/or Ethnicity: Black or African American (15.1) patients had higher unplanned 30-day readmissions rate compared to Hispanic or Latino (12.5).
Age: Patients 35-49 (16.6) had higher unplanned 30-day readmission rates compared to adults 18 to 34 (8.9).
Sex Assigned at Birth: Males (14.1) had higher unplanned 30-day readmissions (no behavioral health diagnosis) than females (12.4).
Race and/or Ethnicity: Asian (14.1) patients had higher unplanned 30-day readmissions rate compared to Hispanic or Latino (12.5).
Sex Assigned at Birth: Males (14.8) had higher unplanned 30-day readmissions than females (13.3).
Action Plan:
Strengthen transitional care program for patients with chronic conditions prior to discharge by the Social Worker and/or designee conducting post-discharge calls within days of discharge.
Provide medication reconciliation and access support by reviewing discharge medications and providing vouchers for essential medications for uninsured patients.
Enhance patient education by simplifying discharge instructions using plain language and using teach-back method for discharges.
Integrate SDOH screening into discharge planning and connect patients with transportation, nutrition, or caregiver resources.
Review monthly readmission data with leadership and medical staff.
Measurable Objectives: >10% reduction in the identified disparities.
Specific Timeframe: All initiatives to be started or continued from Q4 2025 to Q4 2026 (2 years).
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 |
4. Web Address for Equity Report
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.