SAN JOSE BEHAVIORAL HEALTH
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 | 3.4% | 50 to 64 | 0.2% | 16.30 |
|
2.
HCAI 30-Day readmission
|
Preferred Language | English Language | 4.6% | Spanish Language | 1.3% | 3.60 |
|
3.
HCAI 30-Day readmission
|
Disability Status | Does not have disability | 5.0% | Mobility disability | 0.1% | 40.70 |
|
4.
HCAI 30-Day readmission
|
Sexual Orientation | Straight or heterosexual | 3.1% | Bisexual | 0.6% | 5.20 |
|
5.
HCAI 30-Day readmission
|
Gender Identity | Female | 2.8% | Female-to-male (FTM)/transgender male/trans man | 0.4% | 7.90 |
|
6.
CMS IPFQR screening metabolic disorders
|
Age (excluding maternal measures) | 65 and older | 47.0% | 18 to 34 | 77.0% | 0.60 |
|
7.
CMS IPFQR screening metabolic disorders
|
Disability Status | Independent Living disability | 50.0% | Does not have disability | 76.0% | 0.70 |
|
8.
Joint Commission SUB-3
|
Preferred Language | Spanish Language | 38.0% | English Language | 39.0% | 0.90 |
|
9.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 18 to 34 | 2.1% | 50 to 64 | 0.2% | 9.90 |
|
10.
Joint Commission SUB-3
|
Disability Status | Independent Living disability | 0.0% | Does not have disability | 39.0% | 0.00 |
2. Equity Plan
Analysis of stratified performance data identified variation in outcomes across age groups, preferred language, disability status, sexual orientation, and gender identity for select quality measures, including unplanned 30-day readmissions, metabolic screening, and substance use disorder treatment at discharge. While overall performance remained stable, the hospital identified targeted opportunities to strengthen equity-focused care delivery.
To address these disparities, the hospital will implement the following actions:
Enhanced discharge planning and care transitions for higher-risk age groups, including reinforced follow-up appointment scheduling, medication reconciliation, and post-discharge outreach.
Continued strengthening of language access services, including timely interpreter use, culturally appropriate discharge education, and reinforcement of staff training on language access requirements.
Focused monitoring of preventive screening compliance, particularly for older adults and patients with disabilities, to ensure consistent metabolic screening and documentation.
Inclusive care practices and staff education, emphasizing culturally responsive, trauma-informed, and LGBTQ+-affirming care to support equitable treatment and engagement.
Ongoing data monitoring and validation, with attention to small subgroup sizes and data completeness, to refine interventions and assess progress over time.
The hospital will continue to review equity-stratified data annually and adjust improvement strategies as needed to promote equitable access, quality, and outcomes for all patient populations.
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.