ST. ELIZABETH COMMUNITY 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
|
Expected Payor | Medicare | 11.8% | Private | 5.4% | 4.40 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Other | 10.4% | Private | 5.4% | 3.80 |
|
3.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 9.1% | Private | 5.4% | 3.40 |
|
4.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 13.0% | 18 to 34 | 4.3% | 3.10 |
|
5.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 10.4% | 18 to 34 | 4.3% | 2.40 |
|
6.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 10.3% | Hispanic or Latino | 7.1% | 1.40 |
|
7.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 12.1% | Female | 8.6% | 1.40 |
|
8.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 6.0% | 18 to 34 | 4.3% | 1.40 |
2. Equity Plan
The top disparities identified in the health equity report for the hospital are 30-day readmissions by expected payor, age, sex assigned at birth, and race/ethnicity. It's important to note how the unique demographics of our surrounding county influence this data. With a notably older and predominantly white adult population according to U.S. Census data, there is a potential overrepresentation in the data, skewing the stratification calculations. For instance, 14.2% of our community lives in poverty, and a significant portion — nearly half of Tehama County's residents, or 31,250 individuals — are Medi-Cal members, as reported by the Partnership Health Plan of California's 2024 Annual Data. Furthermore, about 6% of our community members lack any health insurance coverage underscoring . This demographic landscape is also evident in our payer mix, with 49% of our patients covered by Medicare and 24% by Medicaid, underscoring the correlation between age and poverty rates reflected in the identified disparities.
The hospital has developed a Health Equity Plan designed to address the disparities identified in our data. The plan details the actions we intend to take, outlining the anticipated impact on affected populations, setting clear, measurable objectives for improvement, and establishing specific timeframes for achieving these goals.
To drive continuous improvement, the hospital will conduct thorough reviews of all readmissions, seeking opportunities to enhance patient care. These reviews will analyze whether factors contributing to readmission stem from broader systemic issues or unique individual circumstances. Such distinctions will directly inform our targeted action plans, which may include essential staff training and education to refine our practices. Throughout this iterative process, our Senior Leadership will play an undeniably crucial role, actively supporting and guiding the resolution of every identified challenge, ensuring we consistently deliver the highest quality of care.
Furthermore, our commitment to continuity of care is demonstrated by ensuring all patients receive follow-up appointments with our South County clinic located in Corning, offering support for those without a primary care physician; conducting post-discharge follow-up calls within 48-72 hours to address medication and appointment needs; and appropriately utilizing home health services.
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.