TAHOE FOREST 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	10.0%	Private	5.7%	3.50
2. HCAI 30-Day readmission	Expected Payor	Medicaid	6.0%	Private	5.7%	2.10
3. HCAI 30-Day readmission	Sex Assigned at Birth	Male	9.2%	Female	6.3%	1.50
4. HCAI 30-Day readmission	Age (excluding maternal measures)	65 and older	10.8%	50 to 64	8.3%	1.30
5. CMQCC breast milk feeding	Expected Payor	Medicaid	87.4%	Private	92.4%	1.10

View Fullscreen

2. Equity Plan

Based on our risk stratification data, Tahoe Forest Hospital has only five key disparities, instead of ten, for targeted interventions.

Disparity 1: Exclusive Breastfeeding (EBF)-Medicaid, Goal: Increase EBF rates at discharge among Medicaid-insured patients by 5% in the first year, achieving parity across payer groups. Strategies: Equity-focused perinatal education: Increase Medicaid patient participation in Baby Friendly 101 virtual class. Early outreach: Prioritize prenatal Lactation and Perinatal Care Coordination for Medicaid patients. Population Impact: Supports infant immunity, maternal health, and reduced healthcare utilization.

Disparity 2: Hospital Readmissions-Medicaid, Goal: Reduce 30-day all-cause readmissions for Medicaid patients by 10% in the first year. Strategies: Risk stratification for all admissions/discharges. Dedicated Transitional Care Team: discharge planning, teach-back, medication reconciliation, Social Determinants of Health (SDOH) support. Early outpatient access within 7 days for high-risk patients. Post-discharge calls within 72 hours to confirm medications, symptoms, and social needs. SDOH screening and rapid referral via community health advocates. Warm handoffs with closed-loop referral verification. Daily review of readmissions for root cause analysis and equity-focused interventions. Population Impact: Enhances continuity of care, reduces disparities, strengthens community partnerships, and lowers preventable readmissions.

Disparity 3: Hospital Readmissions-Medicare, Goal: Reduce 30-day all-cause readmissions for Medicare patients by 10% in the first year. Strategies: Risk stratification for all Medicare admissions. Transitional Care Team support including medication reconciliation, teach-back, and SDOH interventions. Early outpatient access within 14 days for high-risk patients.72 hour post-discharge contact; home visits for highest-risk. Closed-loop referrals to ensure appointment attendance. Daily readmission review and trending. Population Impact: Improves patient safety, reduces hospital utilization, enhances satisfaction, and supports value-based care goals.

Disparity 4: Hospital Readmissions-Male Patients, Goal: Reduce 30-day all-cause readmissions for male patients by 10% in the first year. Strategies: Gender-specific discharge plans addressing cardiovascular, mental health, and substance use needs. Care Transitions Program for proper discharge and follow-up. Chronic Disease Management for conditions such as diabetes, heart disease, and hypertension. Behavioral health integration with hospital and post-discharge referrals. Daily readmission review for root cause analysis. Population Impact: Improves chronic disease management, mental health support, adherence to therapy, and reduces disparities in post-discharge outcomes.

Disparity 5: Hospital Readmissions-Patients ≥65 Years, Goal: Reduce 30-day all-cause readmissions for patients aged 65+ by 10% in the first year. Strategies: Age-Friendly Hospital measures across five domains: healthcare goals, medication management, frailty interventions, social vulnerability, and leadership. Transitional Care Management with follow-up and home support (Meals on Wheels, Friendly Visitor programs). Chronic Disease Management tailored to older adults. Daily review of readmissions for timely interventions.
Population Impact: Reduces avoidable readmissions, improves quality of life, supports vulnerable older adults, and achieves cost savings.

Summary:
Our hospital's five-disparity equity plan focuses on Medicaid and Medicare populations, male patients, and older adults, using evidence-based, equity-focused strategies. Interventions include early outreach, transitional care, chronic disease management, SDOH support, and ongoing data-driven review. This plan aims to improve health outcomes, reduce disparities, and enhance patient satisfaction and community trust.

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

TAHOE FOREST HOSPITAL