ST. ROSE 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
|
Race and/or Ethnicity | Multiracial and/or Multiethnic (two or more races) | 57.6% | Asian | 9.8% | 5.90 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 18.2% | 18 to 34 | 6.4% | 2.80 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 16.6% | 18 to 34 | 6.4% | 2.60 |
|
4.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 17.2% | Private | 6.7% | 2.60 |
|
5.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 15.1% | Private | 6.7% | 2.30 |
|
6.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 19.0% | Asian | 9.8% | 1.90 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 18.8% | Asian | 9.8% | 1.90 |
|
8.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 11.9% | 18 to 34 | 6.4% | 1.90 |
|
9.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 18.9% | Female | 11.7% | 1.60 |
|
10.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Male | 16.9% | Female | 10.6% | 1.60 |
2. Equity Plan
St Rose Hospital recognizes our unique patient population and the diverse community we serve. Since its founding, St Rose has served the Hayward community and launched initiatives to meet the social needs of our most vulnerable patients. In order to address All-Cause Unplanned 30-Day Hospital Readmission Rates, St. Rose Hospital has planned a multi-pronged approach spanning continuous data collection efforts, data reporting, staff redistribution, and enhanced care coordination. We have identified a need to track all patients readmitted within 30 days, regardless of reason for readmission. The infrastructure for this data collection exists at present and is being re-developed by the IT Department in collaboration with the Quality Department. These data will be analyzed by the Quality department and shared with leadership as well as the Case Management team in order to identify opportunities and strategies for prevention on a continuous basis. Furthermore, St Rose Hospital holds monthly Performance Improvement Patient Safety Committee Meetings which serve as a venue for discussing key safety measures from each department. In order to assess the root cause of readmissions within 30 days, the Case Management Department will add a measure related to 30-day readmissions for tracking and trending purposes. This will help us understand areas for improvement and evaluate progress on a quarterly basis.
Additionally, St Rose Hospital's Case Management team has identified an opportunity for increased engagement with patients by placing Case Management staff in the Emergency Department when staffing and patient volume allows, so that a Case Manager may be available in real time to consult with the Emergency Department team.
In order to address All-Cause Unplanned 30-Day Hospital Readmission Rates, St Rose Hospital has identified an opportunity to build relationships with the Skilled Nursing Facilities we share patients with. This allows us to bolster lines of communication with other facilities and ensure our patients receive the care they need outside our hospital, preventing readmission.
Finally, we have identified an opportunity for the expansion of our follow-up calls program. Our nursing team currently leads our follow-up call program for patients discharged to home. This process is being shared with the Case Management department and expanded to include patients discharged with home health. The goal of this expansion is for Case Management to work in tandem with the nursing teams to identify potential barriers to accessing follow-up care which may lead to an eventual readmission.
Based on the existing data, we are confident that the implementation of enhanced data collection, staffing redistributions, and expanded care coordination will address All-Cause Unplanned 30-Day Hospital Readmission Rates amongst the target disparity groups as well as all the patients we serve.
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 |
No |
Our hospital system strategic plan identifies healthcare equity goals and discrete action steps to achieve these goals |
No |
Our hospital system strategic plan outlines specific resources that have been dedicated to achieving our equity goals |
No |
Our hospital system strategic plan describes our approach for engaging key stakeholders, such as community-based organizations |
No |
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.