SHASTA REGIONAL 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
|
Expected Payor | Medicare | 15.8% | Private | 8.8% | 1.80 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 15.6% | Private | 8.8% | 1.80 |
|
3.
HCAI 30-Day readmission
|
Race and/or Ethnicity | American Indian or Alaska Native | 25.0% | White | 14.4% | 1.70 |
|
4.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 20.6% | White | 14.4% | 1.40 |
|
5.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 16.0% | 18 to 34 | 11.5% | 1.40 |
|
6.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 13.9% | 18 to 34 | 11.5% | 1.20 |
|
7.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 12.2% | 18 to 34 | 11.5% | 1.10 |
|
8.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Female | 14.6% | Female | 14.6% | 1.00 |
|
9.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Female | 14.6% | Male | 14.2% | 1.00 |
|
10.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 20.6% | White | 14.4% | 1.00 |
2. Equity Plan
Shasta Regional Medical Center (SRMC) has identified the following top disparities in 30-day unplanned readmission rates: Medicare and Medicaid patients, American Indian/Alaska Native, Black/African American, Hispanic/Latino populations, males, and patients aged 35–49, 50–64, and 65+. These disparities reflect systemic challenges in care transitions, access, and social determinants of health (SDOH).
Planned Actions:
1. Targeted Discharge Education:
- Implement teach-back methodology for all high-risk discharges.
- Tailor discharge instructions to literacy and cultural needs.
- Prioritize medication reconciliation for Medicare patients with complex regimens.
2. Enhanced Care Coordination:
- Assign dedicated case managers for Medicare and Medicaid patients.
- Schedule post-discharge appointments prior to discharge.
- Provide transportation vouchers for patients with scheduled follow-ups.
3. Culturally Responsive Services:
- Maintain 24/7 interpreter services and translated discharge instructions.
- Capture preferred language in EHR and AVS (After Visit Summary).
- Employ bilingual navigators for Spanish-speaking patients.
4. SDOH Screening and Referral:
- Screen eligible inpatients using admit tools.
- Refer patients with positive screens to Social Work/CHW for food, housing, and transportation resources.
- Focus on Medicaid and working-age patients who frequently miss visits.
5. Data Monitoring and Stratification:
- Stratify readmission data by age, race/ethnicity, sex, and payor to identify trends and evaluate interventions.
- Use quarterly dashboards to monitor progress and adjust interventions as needed.
Measurable Objectives:
- Achieve ≥85% SDOH screening completion on eligible discharges.
- Complete ≥70% of resource referrals for patients with positive SDOH screens.
- Reduce Medicaid readmission rate to ≤13.5% by Q4 FY2026.
- Improve readmission rates for males and older adults by 10% over baseline by FY2026.
Timeframe:
- All initiatives are underway or launching in Q1 FY2026, with quarterly evaluations and full implementation by Q4 FY2026.
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.