ST. AGNES 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
|
Age (excluding maternal measures) | 50 to 64 | 20.8% | 18 to 34 | 5.8% | 3.60 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 19.7% | Private | 6.3% | 3.10 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 18.1% | 18 to 34 | 5.8% | 3.10 |
|
4.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 16.2% | 18 to 34 | 5.8% | 2.80 |
|
5.
AHRQ pneumonia mortality rate
|
Race and/or Ethnicity | White | 89.3% | Hispanic or Latino | 33.2% | 2.70 |
|
6.
HCAI 30-Day readmission
|
Preferred Language | Spanish Language | 18.2% | English Language | 15.3% | 2.40 |
|
7.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 14.5% | Private | 6.3% | 2.30 |
|
8.
HCAI 30-Day readmission
|
Expected Payor | Other | 13.3% | Private | 6.3% | 2.10 |
|
9.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 26.0% | Asian | 13.1% | 2.00 |
|
10.
HCAI 30-Day readmission
|
Expected Payor | Self-Pay | 11.7% | Private | 6.3% | 1.90 |
2. Equity Plan
Saint Agnes Medical Center - Trinity Health, and its expert physicians, clinicians, and administrative team members are dedicated to serving the Common Good and addressing social influencers of health and patient trends that include identified disparities. We recognize the unique patient population that exists in Fresno and the Central Valley community. Our patient mix is 52 % Medicare, 31% Medicaid, 16% private pay, and 1% uninsured. Saint Agnes Medical Center (SAMC) was honored to receive the Quality & Sustainability Award for Timely Treatment for Severe Hypertension Rate and the MDC Superstar Award for Large Birth Volume Hospitals - with over 4,000 infants a year on average, and with 77% of maternal patients covered by Medicaid (Medi-Cal). Action begins with the organizations analysis of data collected within the EPIC (EHR) system, review of Health Equity dashboard, and analysis the Community Health and Well-being dashboard, and through Rapid Improvement Events (RIE). Saint Agnes Medical Center has dynamic teams in place that include Social Services, Community Health and Well-being, Health Equity and Human Impact, Quality and Risk Management, Health Equity Workgroup, Saint Agnes Medical Foundation - Outpatient Clinics, and a fast array of partnership with key community stakeholders, Community Based Organizations, and business leaders that collectively assist with continuous care with a lens towards reducing 30-day readmissions. The hospital executive leadership team has worked with management to increase utilization of Community Health Workers, addressing Social Influencers of Health (SIOH), educating patients regarding health resources and follow up care, lifting up and supporting telehealth and care transition programs, improving health literacy, providing rural mobile health care services, and meeting the unhoused population needs at the Holy Cross Health and Wellness Center. SAMC and the Saint Agnes Medical Foundation (SAMF) has established agreements with local FQHC's and Enhanced Care Management providers to more efficiently address the needs of Medi-Cal patients. By embedding care managers in its Emergency Department and in its GME Family Medicine clinic, and integrating care coordination with social supports, SAMC is redefining what it means to truly care for the whole person. SAMC also partners with county Public Health, Behavioral Health, and continues to advocate for essential health care services with local, state, and federal health care leaders to address health disparities, rural/urban patient care, and workforce needs all as a non-profit acute care hospital, established by the Sisters of the Holy Cross, and with 96 years of steadfast healthcare service. Of note, SAMC, hospital-wide all cause readmissions (CHF, COPD, AMI, PNA) is now beginning to turn around in the months of July and August 2025, as a result of Case Management rolling out a multidisciplinary readmissions task force work on discharge appointments 3-5 days post discharge, disease-specific discharge education and prompt start at Saint Agnes Home Health engagement as needed. These efforts will continue to become part of the standardized workplace practices.
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.