SOUTHWEST HEALTHCARE RANCHO SPRINGS 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) | 65 and older | 15.1% | 18 to 34 | 4.3% | 3.50 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 14.2% | 18 to 34 | 4.3% | 3.30 |
|
3.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 15.5% | Private | 5.4% | 2.90 |
|
4.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 9.2% | 18 to 34 | 4.3% | 2.10 |
|
5.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 11.5% | Private | 5.4% | 2.10 |
|
6.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 16.4% | Hispanic or Latino | 8.8% | 1.90 |
|
7.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Male | 14.0% | Female | 8.3% | 1.70 |
|
8.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 15.1% | Female | 9.2% | 1.60 |
|
9.
AHRQ pneumonia mortality rate
|
Sex Assigned at Birth | Male | 68.3% | Female | 44.7% | 1.50 |
|
10.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 12.0% | Hispanic or Latino | 8.8% | 1.40 |
2. Equity Plan
SWH Rancho Springs Hospital partners with community organizations to help ensure healthcare equity — identifying the unique needs of our respective communities and developing programs, services and events that fully meet and fully address these needs. In addition, we continuously evaluate the health equity needs of the communities we serve to identify opportunities for continued improvement.
To reduce all-case unplanned 30-day hospital readmission rates for our identified disparity groups, SWH Rancho Springs Hospital prioritizes strategies focused on older adults, patients with chronic conditions, low health literacy, and those with significant social needs. Interventions are tailored for our Medicare and Medicaid population and include addressing differences in coverage and resource levels. Measurable objectives include reducing the 30-day readmission rate to less than 8.76%, well below the CMS national mean, by increasing the percentage of patients who receive timely follow-up appointments and enhancing coordination by tracking successful care transition between inpatient and outpatient settings. Immediate plans to prioritize vulnerable populations include patient-centered discharge instructions and resource materials, and post-discharge phone calls to reinforce care plans. Additional efforts to reduce all-caused 30-day unplanned hospital readmissions for our vulnerable populations include ensuring follow-up appointments with a primary care provider are scheduled and attended withing 7 days. To maintain long term success, SWH Rancho Springs Hospital is building sustainable partnerships with community-based organizations to address SDOH over several years.
To reduce the disparity for our male patients with regard to the AHRQ Pneumonia Mortality Rate, SWH Rancho Springs Hospital is focusing its efforts to increase vaccination rates, health literacy, and improving access to adequate healthcare for early detection and appropriate treatment. SWH Rancho Springs Hospital sets and tracks annual vaccination goals for high-risk populations aligning with seasonal vaccine schedules. Ongoing efforts include standardized protocols for diagnosis and treatment. Long-term endeavors include evaluation of the effect of targeted interventions on mortality rates, with reassessment based on CDC data trends.
SWH Rancho Springs Hospital prioritizes health equity by providing resources and education to decrease health equity disparities and provide the highest level of quality, compassionate healthcare to our patients.
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.