UCSF MEDICAL CENTER AT MOUNT ZION
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.
AHRQ pneumonia mortality rate
|
Race and/or Ethnicity | Asian | 162.6% | White | 67.6% | 4.80 |
|
2.
AHRQ PSI surgical death rate
|
Age (excluding maternal measures) | 65 and older | 175.5% | 50 to 64 | 87.7% | 2.00 |
|
3.
AHRQ pneumonia mortality rate
|
Expected Payor | Private | 154.6% | Medicare | 83.9% | 1.80 |
|
4.
AHRQ PSI surgical death rate
|
Race and/or Ethnicity | Asian | 174.4% | White | 95.9% | 1.80 |
|
5.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 19.5% | Private | 12.9% | 1.50 |
|
6.
AHRQ PSI surgical death rate
|
Expected Payor | Private | 153.3% | Medicaid | 104.3% | 1.50 |
|
7.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Black or African American | 21.0% | White | 14.4% | 1.50 |
|
8.
HCAI 30-Day readmission
|
Race and/or Ethnicity | Native Hawaiian or Pacific Islander | 19.3% | White | 14.4% | 1.30 |
|
9.
AHRQ pneumonia mortality rate
|
Age (excluding maternal measures) | 50 to 64 | 119.0% | 65 and older | 89.5% | 1.30 |
|
10.
HCAI 30-Day readmission
|
Preferred Language | Spanish Language | 20.5% | English Language | 15.5% | 1.30 |
2. Equity Plan
1. UCSF Health will implement a coordinated set of interventions to reduce 30-day All-Cause readmission by combining enhanced care transition outreach programs and various ways to stratify patients. The Care Transition Outreach Program (CTOP) team will conduct timely post-discharge outreach which includes:
a. An automated call is sent to patients within 3 days of discharge home
b. Patients who identify a concern receive a call from a CTOP nurse to provide symptom triage, teaching, and care coordination
c. For certain "at-risk" patients who fail to answer the automated call, a nurse screens and manually calls those who have not already been contacted by another clinician.
d. A Social Worker addresses psychosocial needs and links patients with community resources, and pharmacists address medication access and questions
e. CTOP escalates patient concerns to Patient Relations to facilitate rapid service recovery
f. CTOP added text messaging for patients not reached by automated call and added health equity component to manual outreach
2. The AI projects
a. 30-day Readmission AI risk prediction model: piloting in 2 OPH programs, working with ESTAR fellow
b. AI-drafted discharge summaries: pilot
c. AI-drafted discharge instructions: pilot
3. Improve ambulatory access post-discharge
a. Standardized transitions workflows and improving post discharge access: collaborating with ambulatory leadership
b. Survey to all case managers and service line directors
c. Epic build of discharge order
d. Transition Care Management: piloted at our Lakeshore clinic, expanded to all primary care clinics
e. Onclick: 30-day longitudinal post-discharge support for Medicare FFS patients live-reduction in readmission rate
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.