SAN JOAQUIN GENERAL HOSPITAL

500 WEST HOSPITAL ROAD, FRENCH CAMP, CA 95231

HCAI ID: 106391010

Reporting Organization: SAN JOAQUIN GENERAL HOSPITAL
Report Period: 01/01/2024 – 12/31/2024
Hospital / Hospital System: Hospital
Report Type: General Acute Care Hospital
License No: 030000087
Licensee: SAN JOAQUIN, COUNTY OF
County: San Joaquin

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	Expected Payor	Medicare	17.3%	Private	5.0%	3.40
2. HCAI 30-Day readmission	Age (excluding maternal measures)	65 and older	16.9%	18 to 34	5.7%	2.90
3. HCAI 30-Day readmission	Age (excluding maternal measures)	50 to 64	15.1%	18 to 34	5.7%	2.60
4. HCAI 30-Day readmission	Age (excluding maternal measures)	35 to 49	11.3%	18 to 34	5.7%	2.00
5. HCAI 30-Day readmission	Expected Payor	Medicaid	9.6%	Private	5.0%	1.90
6. HCAI 30-Day readmission	Race and/or Ethnicity	Native Hawaiian or Pacific Islander	18.3%	Hispanic or Latino	10.1%	1.80
7. HCAI 30-Day readmission	Race and/or Ethnicity	Black or African American	15.9%	Hispanic or Latino	10.1%	1.60
8. HCAI 30-Day readmission	Sex Assigned at Birth	Male	14.7%	Female	9.9%	1.50
9. HCAI 30-Day readmission NOBH	Sex Assigned at Birth	Male	12.7%	Female	9.2%	1.40
10. HCAI 30-Day readmission	Race and/or Ethnicity	White	13.5%	Hispanic or Latino	10.1%	1.30

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2. Equity Plan

Initial analysis of the top 10 disparities identified using the stratification methodology described by the Health Equity Report submission guide was completed. This included presentation to our hospital Medical Executive Committee. The top 10 disparities are all in the All-Cause Unplanned 30-day Readmission category. In efforts to address All-Cause Unplanned 30-day Readmissions, SJGH has implemented the following actions: 1. Daily rounding with Case Management, Nursing, and Physician teams to identify patients at risk for discharge delay and difficulty with transitions to home. Case Management facilitates complex care placement and discharge phone calls to reeducate patients on post-hospital care and medication management - Status On-going; 2. Implementation of a Discharge Clinic led by Internal Medicine aimed at bridging hospital and ED patient to primary care providers. This clinic is multi-disciplinary and a partnership between the hospital and ambulatory care services. A multi-disciplinary care team assists with continuity of care including PCP examination, medication education and prescription authorizations, and patient education - Status On-going; 3. Partnership with community organizations for mental health and substance use disorder resources to establish care and reduce dependency on Emergency Department and hospital inpatient services - Status On-going; 4. Development of a Health Equity Workgroup (HEW) that will provide strategic oversight in the areas of workforce professional development and training, identification of health equity gaps, and monitoring of health equity related initiatives in the organization - Status In Progress with launch date of Q1 2026; 5. Request for Proposal process for consultancy support to enrich the equity components of the hospital strategic plan - Status In progress. San Joaquin General Hospital is committed to the developing measurable goals, defining timelines, and engaging community stakeholders to enhance our equity plan.

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

SAN JOAQUIN GENERAL HOSPITAL