SIERRA VIEW MEDICAL CENTER

1. Top 10 Disparities

2. Equity Plan

SVMC's only had 7 top disparities, all of which are centered around readmission rates. Below is the breakdown of each, including steps taken to address the noted disparity as well as goals for improvement.

• All-cause unplanned 30-day hospital readmission rates for ages 50-64
• All-cause unplanned 30-day hospital readmission rates for ages 65 and older
• All-cause unplanned 30-day hospital readmission rates for medicare patients
• All-cause unplanned 30-day hospital readmission rates for males
• All-cause unplanned 30-day hospital readmission rates for ages 35-49
• All-cause unplanned 30-day hospital readmission rates for Caucasians
• All-cause unplanned 30-day hospital readmission rates for Medicaid patients

Because SVMC believes every patient deserves the highest level of care, our approach does not focus on isolating specific groups, but rather addresses readmissions as a whole. Upon admission, each patient is evaluated by a member of our Social Services team—professionals trained to identify and mitigate barriers to a safe and successful discharge. They collaborate closely with physicians and bedside nurses through daily rounding, ensuring clear communication and updated information is shared with the care team, patients, and families. These interactions also provide opportunities for patients and families to ask questions, participate in care planning, and understand discharge needs.
Patients readmitted within 30 days are flagged in our system, automatically generating a high-priority referral to Social Services. A readmission assessment is then conducted to identify contributing factors. The most common reasons include:
• Medication non-compliance
• Declining recommendations for skilled nursing facility placement and opting to discharge home instead
• Delays in follow-up appointments with primary care providers
To address medication non-compliance, SVMC integrates a Clinical Pharmacist into the Social Services team. The pharmacist reviews medication regimens, provides detailed instructions, and ensures prescriptions are accessible and affordable through local pharmacies. Patients may also contact the pharmacist after discharge for additional support, a role we have found to be highly effective in preventing unplanned returns to the hospital or emergency department.
Timely follow-up care is another key factor. Through SVMC's Internal Medicine Residency program, we established a continuity clinic to provide post-discharge appointments for patients without a primary care provider or when their physician cannot accommodate a timely visit. This helps identify and mitigate issues early on that, if left unaddressed, could lead to a 30-day readmission.
When patients or families decline recommendations for skilled nursing or hospice care, our role is to provide education on safe discharge options and to ensure decisions align with their goals of care. Our responsibility is to support informed decision-making throughout the healthcare journey. We partner with several post-acute partners that offer virtual tours of their facilities as well as to have members of their team come meet with the patient and family to help increase comfort in making this decision. Additionally, if the patient returns to the emergency room indicating they might need a skilled facility, our social services team works to get them placed right away rather than requiring an additional hospital stay.
Although SVMC's readmission rates, as reported by CMS, are consistent with peer organizations, we have set a goal to reduce overall readmissions by 2%.

3. Structural Measures

5. Download Equity Measures Report

Click on the link below to download the equity measures report.

6. Looking for Related Reports?

• Hospital Supplier Diversity Plan
• Hospital Profile
• Hospital Fair Billing Policies