ST. BERNARDINE 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
|
Race and/or Ethnicity | Multiracial and/or Multiethnic (two or more races) | 24.1% | Asian | 11.1% | 2.20 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 19.0% | 18 to 34 | 9.2% | 2.10 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 18.6% | 18 to 34 | 9.2% | 2.00 |
|
4.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 19.4% | Private | 9.6% | 2.00 |
|
5.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 15.8% | Private | 9.6% | 1.60 |
|
6.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 18.2% | Asian | 11.1% | 1.60 |
|
7.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 14.3% | 18 to 34 | 9.2% | 1.60 |
|
8.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 16.4% | Asian | 11.1% | 1.50 |
|
9.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Hispanic or Latino | 15.8% | Asian | 11.1% | 1.40 |
|
10.
AHRQ PSI surgical death rate
|
Sex Assigned at Birth | Female | 217.4% | Male | 156.6% | 1.40 |
2. Equity Plan
Disparity 1, 6, 8, 9: Unplanned 30-Day Readmitted Rate by Race
Analysis: In 2024, Blacks/ African Americans, Whites, Hispanics/ Latinos, and multiracial and/or multiethnic patient readmissions are higher than rates for Asians.
Actions Planned:
• Implement post-discharge phone calls within 2-3 days of discharge and refer eligible discharged patients to local primary care facilities for follow up (i.e. SBMC Transitional Care Clinic, FQHC)
• Develop culturally and linguistically educational materials for patients and support partners.
• Collaborate with community and providers to support patients post-discharge.
• Monitor readmission rates by disparity group, analyze root causes, and adjust interventions based on ongoing data (i.e. SBMC readmission taskforce, utilization management).
• Provide ongoing training to all staff (in person or electronically) on cultural competency, health literacy, effective communication, and patient-centered care.
Measurable Objectives: Reduce 30-day readmission rate ratio for Blacks/ African Americans, Whites, Hispanics/ Latinos, and multiracial and/or multiethnic patients by 1 %.
Timeframe: Launch by Q1 2026, reassess Q2 2026.
Disparity 2, 3, 7: Unplanned 30-Day Readmitted Rate by Age 35 and Older
Data Analysis:
Age 35 and older patient group readmissions are higher overall than the 18-34 age related disparity group.
Actions Planned:
• Implement structured post-discharge phone calls within 2-3 days of discharge and refer eligible discharged patients to local primary care facilities for follow up care (i.e. SBMC Transitional Care Clinic, FQHC)
• Develop culturally and linguistically educational materials for patients and support partners.
• Collaborate with community partners and providers (e.g., home health, social services) to support patients post-discharge.
• Monitor readmission rates by disparity group, analyze root causes, and adjust interventions based on ongoing data (i.e. SBMC readmission taskforce, utilization management).
• Provide ongoing training to all staff (in person or electronically) on cultural competency, health literacy, effective communication, and patient-centered care.
Measurable Objectives: Reduce 30-day readmission rate ratio for ages 35+ by 1%.
Timeframe: Launch by Q2 2025, reassess Q2 2026.
Disparity 4 and 5: Unplanned 30-Day Hospital Readmission Rate by Expected Payor
Data Analysis:
In 2024, Medicaid and Medicare recipients experienced a higher 30 day readmission rate than those with private insurance.
Actions Planned:
• Implement structured post-discharge phone calls within 2-3 days of discharge and refer eligible discharged patients to local primary care facilities for follow up care (i.e. SBMC Transitional Care Clinic, FQHC)
• Develop culturally and linguistically appropriate educational materials and engage patients/caregivers in shared decision-making.
• Collaborate with community partners and providers (e.g., home health, social services) to support patients post-discharge.
• Monitor readmission rates by disparity group, analyze root causes, and adjust interventions based on ongoing data (i.e. SBMC readmission taskforce, utilization management).
• Provide ongoing training to all staff (in person or electronically) on cultural competency, health literacy, effective communication, and patient-centered care.
Measurable Objectives: Reduce Medicare readmission rate by 1% within 24 months (07/2025-06/2027).
Timeframe: Implement by Q2 2026; evaluate biannually.
Disparity 10: Death Rate among Surgical Inpatients with Serious Treatable Complications
Data Analysis:
In 2024, the death rates among surgical inpatients with serious treatable complications was higher for females than males.
Actions Planned:
• Implement structured post-discharge phone calls within 2-3 days of discharge and refer eligible discharged patients to local primary care facilities for follow up care (i.e. SBMC Transitional Care Clinic, FQHC)
• Develop culturally and linguistically educational materials for patients and support partners.
• Collaborate with community organizations, primary care providers, and specialized services (e.g., home health, social services) to support patients post-discharge.
• Continuously monitor readmission rates by disparity group, analyze root causes, and adjust interventions based on ongoing data (i.e. SBMC readmission taskforce, utilization management).
• Provide ongoing training to all staff (in person or electronically) on cultural competency, health literacy, effective communication, and patient-centered care.
Measurable Objectives: Reduce the disparity rate by 1% within 24 months.
Timeframe: Implement in Q1 2026, review biannually.
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.