ST. JOSEPH’S BEHAVIORAL HEALTH 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
|
Expected Payor | Medicare | 16.2% | Private | 11.1% | 1.50 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 15.5% | 18 to 34 | 11.3% | 1.40 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 14.7% | 18 to 34 | 11.3% | 1.30 |
|
4.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Hispanic or Latino | 15.0% | Black or African American | 12.1% | 1.20 |
|
5.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Asian | 14.7% | Black or African American | 12.1% | 1.20 |
|
6.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 14.6% | Black or African American | 12.1% | 1.20 |
|
7.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Female | 13.8% | Male | 12.4% | 1.10 |
|
8.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 11.5% | 18 to 34 | 11.3% | 1.00 |
2. Equity Plan
Action Plan for Top 10 Identified Disparities (8 identified for our hospital)
Measure: HCAI All-Cause Unplanned 30-Day Hospital Readmission Rate in an Inpatient Psychiatric Facility (IPF)
Disparity Group 1: Expected payor Medicare
Disparity Group 2: Age 50 to 64
Disparity Group 3: Age 35-49
Disparity Group 4: Race and/or Ethnicity Hispanic or Latino
Disparity Group 5: Race and/or Asian
Disparity Group 6: Race and/or Ethnicity White
Disparity Group 7: Female
Disparity Group 8: Age 65 and older
Equity Plan: Targeted Post-Discharge Follow-Up Program for Readmission Reduction
Goal: Reduce 30-day readmissions for female patients, patients aged 35 and older, Medicare payer, or a race/ethnicity of White, Asian, Hispanic or Latino, by implementing proactive case manager-led follow-up calls.
Target Population: Patients meeting the criteria of female OR aged 35 and older OR Medicare payer, OR a race/ethnicity of White, Asian, Hispanic or Latino AND who have had a prior readmission within the last 30 days.
Population Impact: Given that our eight identified disparity groups represent a significant portion of our patient population, we have chosen to focus our efforts on all newly admitted patients with a readmission in the past 30 days. This is a critical high-risk group, as research consistently shows that a previous readmission is a strong predictor of future readmission.
Intervention: Using clinical informatics we will identify newly admitted patients with a readmission in the past 30 days. These patients will then be placed in our post discharge follow up program. Patients identified will receive a case management follow up phone call within 3 days of patient discharge from the hospital (discharge date being day 0). Using a standardized script the case manager will include questions regarding the patient's mental well-being check-in, follow up appointments, medication adherence, and barrier identifications if any. The same phone call will be initiated 30 days post discharge.
Data collection and reporting
¦ Number of eligible patients identified per week/month.
¦ Number of Day 3 calls completed (and rate of completion).
¦ Number of Day 30 calls completed (and rate of completion).
¦ Types of barriers identified (e.g., transportation, medication cost, lack of understanding). Categorize for analysis.
¦ Types of interventions provided by CMs.
Measurable objectives: By 12 months the total number of 30 day readmissions to an Inpatient Psychiatric Facility will be reduced by 5% over the current 2024 readmissions. By 24 months the total number of 30 day readmissions to an Inpatient Psychiatric Facility will be reduced by 10% over the current 2024 readmissions.
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.