ST. MARY MEDICAL CENTER – LONG BEACH
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 | 15.7% | 18 to 34 | 5.2% | 3.00 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 14.6% | 18 to 34 | 5.2% | 2.80 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 14.5% | 18 to 34 | 5.2% | 2.80 |
|
4.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 15.7% | Private | 6.9% | 2.30 |
|
5.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 11.6% | Private | 6.9% | 1.70 |
|
6.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Male | 14.5% | Female | 8.7% | 1.70 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 17.0% | Hispanic or Latino | 10.8% | 1.60 |
|
8.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Multiracial and/or Multiethnic (two or more races) | 16.4% | Hispanic or Latino | 10.8% | 1.50 |
|
9.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 15.5% | Female | 10.8% | 1.40 |
|
10.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 12.9% | Hispanic or Latino | 10.8% | 1.20 |
2. Equity Plan
At St. Mary Medical Center, health equity means ensuring every patient receives optimal care regardless of race, ethnicity, language, disability status, sexual orientation, gender identity, and payer. Based on the HQI Disparities Report, St. Mary's top ten healthcare disparities are unplanned 30-day readmissions stratified by various demographic indicators. Reducing readmissions and working towards dismantling identified barriers to healthcare is therefore core to our mission and commitment to improving healthcare equity for our community. For Fiscal Year 2026 (FY26, July 2025 through June 2026) St. Mary's will be focusing on reducing readmission rates by age (36+ years old), payor (Medicare/Medi-cal), and gender assigned at birth (male). The goal is a 15% improvement in the Disparity Rate Ratio over the course of the fiscal year.
1. Equity Considerations.
Equity is integrated into our care model by:
• Proactive Social Drivers of Health (SDoH) Screening: Utilizing admission screening tools for housing, food, safety, and transportation needs. Positive screens will trigger Social Service (SS) consultations for community resource linkage.
• Patient-Centered Insights: Implementing a readmission interview tool for Care Coordination (CC) staff to capture patient perspectives regarding their readmission.
• Predictive Risk Stratification: Employing a risk assessment tool for early identification of at-risk patients, enabling tailored interventions.
• Holistic Care Planning: Multidisciplinary Rounds (MDR) comprehensively review clinical, psychosocial, and SDoH factors for equitable, proactive discharge planning.
• Culturally Competent Care: Delivering programs via our Community Health offerings in a culturally and linguistically appropriate manner.
2. Programs & Practices.
Targeting Readmission Disparities:
• Enhanced Discharge Planning: During the index visit, the High-risk CC Registered Nurse (RN) partners with outpatient nurse navigators for disease-specific education (i.e., congestive heart failure "CHF") and resources (e.g., scales, glucometers, film/video viewing, dietary consultation, holter monitors, oxygen, patients who needs dialysis gets dialyzed in ED).
• Transitional Care RNs (TCRNs): Ensure follow-up appointments and post-discharge support for high-risk patients.
• Interdisciplinary Collaboration: Team review to identify barriers impacting readmission risk. Includes physician peer review.
Addressing Access to Care:
• SocialWork/Care Coordination: Provides enrollment assistance for health insurance programs for uninsured/underinsured/low-income patients, ensuring medical home access and preventive care.
• Community Wellness Program: Offers on-site screenings, health/wellness education, and outpatient nurse navigation for management of preexisting conditions.
• Specific Patient Navigator Programs: e.g., CHF patient navigator, Substance Use Navigator for Substance Use Disorders (SUD)
• In-Hospital Support: Financial assistance and prescription purchases for patients in need.
• Community Health Improvement Grants Program: Funds local non-profits to address health needs, including access to care, aligned with our Community Health Needs Assessment (CHNA).
3. Improvements & Plans
1. Expand Health Equity Task Force membership
a. Current Members: Mission Integration, Community Health Outreach, Quality, Cardiac Care, HR
b. Expanded Members: CMO, Social Work/Care Coordination, Nursing, Medical Staff, Food & Nutrition
i. Consider expanding the CHF Program to include a CHF Coordinator to assist with community outreach, in addition to the Outpatient Nurse Navigator to help with early recognition and treatment prior to hospital-based intervention.
2. Focus resources on targeted diseases: CHF
3. Continue Interdisciplinary Team Review
a. Each disease process has their respective Interdisciplinary Committees to review program performance, including metrics on bundle compliance, readmission rates, opportunities for improvement, etc. Data is also reviewed at the Readmissions Committee.
b. Cases may also be forwarded for provider review and feedback via the Multidisciplinary Peer Review Committee.
4. Continue patient education:
a. Inpatient education on current conditions
b. Expansion of the CHF Program to include outreach coordinators can help assist with early recognition of patients with CHF and intervention efforts outside of the hospital.
5. Early Intervention and Recognition
a. Encouraging early recognition of patients needing CHF bundle elements, such as starting dialysis or administering antibiotics.
b. Staff education on the recognition of symptoms and the appropriate procedures in response.
c. Patient education on the recognition of symptoms and the appropriate procedures to maintain health/prevent complications while at home.
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.