TEMECULA VALLEY 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 | Medicaid | 17.5% | Private | 9.0% | 1.90 |
|
2.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 16.4% | Private | 9.0% | 1.80 |
|
3.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 16.8% | Asian | 12.5% | 1.30 |
|
4.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 15.4% | Asian | 12.5% | 1.20 |
|
5.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 15.8% | 35 to 49 | 13.8% | 1.10 |
|
6.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Hispanic or Latino | 14.5% | Asian | 12.5% | 1.20 |
|
7.
HCAI 30-Day readmission NOBH
|
Sex Assigned at Birth | Female | 13.8% | Female | 13.8% | 1.00 |
|
8.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 14.7% | Male | 14.7% | 1.00 |
|
9.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 50 to 64 | 14.0% | 35 to 49 | 13.8% | 1.00 |
|
10.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 18 to 34 | 13.9% | 35 to 49 | 13.8% | 1.00 |
2. Equity Plan
The top 10 disparities for our facility focus on all-cause unplanned 30-day hospital readmission rates for both genders, aged 35 and older with a focus on Black, White and Hispanic Medicaid or Medicare payors.
Thorough admission screening of social determinants of health allows for identification of patients determined to be high-risk for readmission. This allows the facility to immediately identify post-discharge needs and begin the intervention process.
Multidisciplinary planning that focuses on transitional care nursing, follow up discharge phone calls , and discharge education.
Enhanced screening for community-based services such as transportation, housing support, food insecurity, or medication access and affordability allows for appropriate referrals to available community resources.
Establishing relationships with these community resources allows for closed-loop referral processes.
Broadening community organization access to patients while still-inpatient promotes post-discharge utilization of resources.
Through enhanced discharge planning that focuses on cultural and linguistically tailored discharge instructions, we plan to increase patient knowledge and understanding of their disease processes. Involving caregivers and family members in planning and education will optimize post-discharge wellness.
Clothing and transportation needs are provided for patients in need upon discharge.
Disparities are tracked through the UHS Healthe Analytics Health Equity Dashboard. These measures identify at-risk populations to reduce all-cause 30-day readmission rates.
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.