UNIVERSITY OF CALIFORNIA DAVIS MEDICAL CENTER

1. Top 10 Disparities

2. Equity Plan

There are three main components of UCDH's action plan:
Unplanned Hospital Readmissions (Disparities 2, 3, 5, 6, 7, and 8)
UC Davis Health (UCDH) is implementing a multi-year, systemwide strategy to reduce hospital readmissions through risk-based, equitable care-transition support. Our approach centers on strengthening foundational care transitions for all patients while expanding targeted interventions for high-risk populations, particularly those with complex needs.
We will address the disparities in unplanned hospital readmissions through a focus on Multi-Visit Patient s(MVPs), defined as patients with 4+ unplanned hospital admissions within the past 12 months. Analysis shows significantly higher readmission rates among MVPs across six disparity domains:
2.53X more likely to have Medicare vs. private insurance
3.02X more likely to have Medicaid vs. private insurance
1.41X more likely to be age 50-64 vs. 18-34
2.20X more likely to be Multiracial vs. Asian
2.27X more likely to be Black/African American vs. Asian
UCDH has developed a 3-tiered risk-based care transition bundle framework to provide appropriate levels of transition services for MVPs. Key bundle components include: MVP-specific EMR tools; enhanced discharge education and post-discharge outreach; expanded transportation access; coordination with health navigators and behavioral and social service providers; partnerships with SNFs and community post-acute providers; and inpatient geriatric collaboration for older adults.
To reduce readmission disparities by September 30, 2026 we will: (1) begin implementation of the MVP program in Hospital Medicine, General Medicine, and Cardiology services (37% of hospital census); (2) track disparities via stratified readmission dashboards; (3) review dashboard readmission data quarterly in quality meetings; and (4) evaluate the effectiveness of the MVP program with the goal of reduced readmissions disparities in 4 of the 6 domains identified.
Patient Safety Indicator Death Rates (PSI 04) (Disparities 1, 4, and 10)

Disparities in PSI 04 rates arise from a complex mix of structural, institutional, and patient-level factors. Therefore, equity-oriented patient safety interventions and quality improvement initiatives are needed that focus on both complication prevention and timely recognition and treatment of complications across all patient populations.

Limited English Proficiency (LEP) may contribute to PSI 04 disparities experienced by Hispanic/Latino groups at UCDH, as communication barriers can impede recognition and timely treatment of post-surgical complications. To address this disparity by September 30, 2026 we will: (1) disaggregate PSI 04 data to identify the highest disparities by surgery and complication type; (2) starting with the highest disparity areas, review post-operative processes and written instructions to ensure they align with patient preferred language; and (3) review discharge education for post-surgical LEP patients to ensure information about our Medical Interpreting line is included.

Additionally, at UC Davis Health the PSI 04 rate for Medicare patients is higher than for Medicaid patients and the PSI 04 rate for male patients is higher than female patients. To address these disparities by September 30, 2026 we will: (1) disaggregate PSI 04 data to identify the highest disparities by surgery/complication type; (2) conduct a root cause analysis to identify the primary clinical and social drivers of these disparities; and (3) develop safety-improvement interventions and/or risk-based protocols to be implemented in the next reporting year.

Human Milk Feeding (Disparity 9)

In 2024, a disparity was identified in exclusive breastmilk feeding (EBF) during hospitalization between Medicaid patients (41.6%) and non-Medicaid patients (73.4%). The introduction of pasteurized donor human milk in February 2024 improved EBF rates in all groups, however this did not fully close the disparity gap (68.5% Medicaid patients versus 85.8% non-Medicaid patients in Q2 2025). An additional disparity was identified when disaggregating by race and ethnicity: between 2023 and 2024 there was a 5% decrease in EBF among Medicaid patients who self-identify as Black compared to all other racial groups which experienced a 36%-63% increase. This is theorized to be due to a lower acceptance of pasteurized donor human milk in this population.

To address this disparity we plan to: (1) engage with patients, subject matter experts, and community based organizations to gather data on barriers to breastfeeding and donor milk acceptance during hospitalization; (2) ensure that UCDH prenatal classes emphasize the benefits of breastfeeding/breastmilk and provide education on the donor milk program; (3) outreach to community clinics within the greater Sacramento area to increase awareness of UCDH prenatal classes, which are underutilized by Medicaid patients.

3. Structural Measures

5. Download Equity Measures Report

Click on the link below to download the equity measures report.

6. Looking for Related Reports?

• Hospital Supplier Diversity Plan
• Hospital Profile
• Hospital Fair Billing Policies