WASHINGTON HOSPITAL – FREMONT

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	Age (excluding maternal measures)	65 and older	17.9%	18 to 34	3.8%	4.70
2. HCAI 30-Day readmission	Age (excluding maternal measures)	50 to 64	15.7%	18 to 34	3.8%	4.20
3. HCAI 30-Day readmission	Expected Payor	Medicare	17.8%	Private	5.1%	3.50
4. HCAI 30-Day readmission	Expected Payor	Medicaid	17.0%	Private	5.1%	3.30
5. HCAI 30-Day readmission	Age (excluding maternal measures)	35 to 49	7.0%	18 to 34	3.8%	1.90
6. HCAI 30-Day readmission	Preferred Language	Asian/ Pacific Islander Languages	19.8%	English Language	13.4%	1.50
7. HCAI 30-Day readmission	Race and/or Ethnicity	Native Hawaiian or Pacific Islander	19.3%	Asian	13.3%	1.50
8. HCAI 30-Day readmission	Sex Assigned at Birth	Male	16.3%	Female	13.2%	1.20
9. HCAI 30-Day readmission	Race and/or Ethnicity	Black or African American	16.3%	Asian	13.3%	1.20
10. HCAI 30-Day readmission NOBH	Sex Assigned at Birth	Male	14.8%	Female	12.1%	1.20

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2. Equity Plan

Washington Health's (WH) plan addresses the disparities through: Transitional care management (TCM), disease-specific protocols for high-risk diagnoses (DX) linked to readmissions, & disparity-specific interventions tailored to social, structural, and clinical needs.

Implementation between 10/25 & 9/26, with mid-year review, & final evaluation in 9/26.

All patients receive standardized discharge education & clinical staff utilize an evidence-based discharge checklist. Patients with Hospital Readmissions Reduction Program (HRRP)-targeted conditions, associated with high risk of readmissions, receive a 72-hour follow-up call post discharge & those with a medical group primary care physician (PCP) are referred for follow-up within 7 days. Transportation to appointments is arranged for those with access barriers. Virtual transitional care (est. 2025) provides 48-hr post-discharge follow-up, symptom (SYMP) checks, medication (med) review, & follow-up appointment coordination for Medicare patients.

Achievements to date:
• Reduced Emergency Department (ED) bounce-backs
• Scheduled PCP appointments pre-discharge for HRRP patients
• Review complex patients at weekly meetings
• Expanded the high quality network (HQN)
• Created & disseminated readmission prevention bundle education to HQN partners
• Social Determinants of Health (SDOH) screening for all discharges: housing, utilities, food, behavioral health, safety, transportation; with referrals
Upcoming plans:
• Expand TCM to include Medi-Cal patients
• Provide ongoing readmission prevention training to HQN partners & track compliance
• Additional interpreter use training for staff
• Dashboards to track disparity-specific metrics & intervention impact. Results will be used to adjust workflow, refine discharge planning, & ensure evidence-driven interventions
• Gather feedback from community partners/patient advisory groups
• Partner with County-sponsored managed health plan: on-site nurse 3–4 days/week
• Strengthen partnership with community health workers & Federally Qualified Health Center (FQHC) for on-site patient engagement 1-2 days/week
• Enable secure electronic health record (EHR) access for partner organizations
Disease-Specific Interventions - tailored to highest-volume readmission DX.
• Sepsis, Chronic Kidney Disease (CKD), Acute Kidney Failure: Early identification & management using sepsis protocol (est. 2008, periodically reviewed for clinical relevance & best practice, last revised in 2021); compliance monitoring for sepsis management; disease specific discharge education; timely PCP follow-up
o Re-measure lactate if initial lactate is elevated
o 3-hr & 6-hr bundle compliance of severe sepsis/septic shock
• Congestive Heart Failure (CHF) Medicare
o 7-day follow-up
o In-language education on fluids, diet, SYMP awareness, med review
o Daily inpatient risk screening to identify high-risk patients
o Collaboration with skilled nursing facility (SNF)/ home health (HH) to adhere to care plans
o Diet order initiative to reinforce heart-healthy diets during hospitalization
• Acute Myocardial Infarction: Cardiology follow-up, med adherence, cardiac rehab referral
• Pneumonia (PNA) & Chronic Obstructive Pulmonary Disease (COPD): In-language teaching, early SYMP monitoring, vaccination review
• Alcoholic Cirrhosis/Hepatitis: Inpatient alcohol withdrawal syndrome protocol for patient management, outpatient resources provided prior to discharge
By integrating disparity-focused care in clinical & post-discharge workflows, WH aims to reduce inequity in readmissions.
For interventions by disparity groups, please refer to our Equity Plan's supplemental document.
For each disparity group, the measurable objective will be to reduce readmissions. Reductions in readmissions are expected to be statistically significant for larger disparity groups such as Medicare patients or male patients. For smaller groups, the sample sizes make statistical significance harder to demonstrate, but reductions will be directionally important & clinically meaningful.
In implementing targeted actions to address disparities among specific patient groups, Washington Health remains committed to maintaining and enhancing the quality of care for all patients. The interventions and resources designed for disparity groups are integrated within broader clinical workflows and do not diminish the standard of care provided to other patient populations. All patients continue to receive evidence-based, person-centered care, and any improvements made for disparity groups are intended to elevate care standards system-wide. Our goal is to advance equity while upholding our commitment to safe, effective, and compassionate care for every patient.

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

WASHINGTON HOSPITAL – FREMONT