WOODLAND MEMORIAL 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
|
Age (excluding maternal measures) | 50 to 64 | 14.5% | 18 to 34 | 4.3% | 3.40 |
|
2.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 65 and older | 13.2% | 18 to 34 | 4.3% | 3.10 |
|
3.
HCAI 30-Day readmission
|
Age (excluding maternal measures) | 35 to 49 | 9.9% | 18 to 34 | 4.3% | 2.30 |
|
4.
HCAI 30-Day readmission
|
Expected Payor | Medicare | 14.1% | Private | 7.6% | 1.90 |
|
5.
HCAI 30-Day readmission
|
Expected Payor | Medicaid | 11.1% | Private | 7.6% | 1.50 |
|
6.
HCAI 30-Day readmission
|
Sex Assigned at Birth | Male | 14.1% | Female | 9.8% | 1.40 |
|
7.
CMQCC breast milk feeding
|
Age (for maternal measures only) | 18 to 29 | 62.4% | 30 to 39 | 74.6% | 1.20 |
|
8.
HCAI 30-Day readmission
|
Race and/or Ethnicity | White | 12.7% | Hispanic or Latino | 11.0% | 1.20 |
2. Equity Plan
Woodland Hospital analyzed the health status and access for the population we serve in Northern California. The analysis revealed that all-cause unplanned 30-day hospital readmission rates were higher than reference rates. The top 10 identified disparities are in these five categories.
• Age: Higher rates in age groups 35 to 65+ compared to the 18 to 34 year old reference group.
• Insurance: Higher rates in Medicare and Medicaid populations compared to the privately insured reference group
• Sex assigned at birth: Higher rates in the male population compared to the female reference population.
• Age(breast milk feeding): Higher rates in age groups 18-29 compared to the 30-39 year old reference group.
• Race and/or Ethnicity: Higher rates in White populations compared to the Hispanic or Latino reference group.
To address the identified disparities Woodland Memorial Hospital will continue its efforts to decrease the Adult All-Cause Readmission rates. Ongoing efforts are focused on initiatives conducted by Care Coordination and involved departments. A Readmission workgroup has been established.
Within 12 months, the program will enhance discharge planning through standardized, individualized care instructions and timely follow-up via phone or telehealth. Patient education will be improved with culturally appropriate materials and shared decision-making. Collaboration with community partners and primary care providers will ensure continued support post-discharge. Ongoing staff training in cultural competency and communication, along with continuous monitoring of readmission data, will guide adjustments to interventions for improved patient outcomes.
We have implemented several initiatives to support at-risk patients and reduce readmission rates. Our approach includes providing home healthcare orders, assisting patients with scheduling prompt primary care follow-up appointments, and ensuring at-risk patients are provided necessary medications at discharge.
To further support these efforts, we are in process to increase our staffing by hiring two Community Health Workers and Care Coordination Assistant.
Our goal is to reduce the readmission rate from our CY 2024 baseline by the end of CY 2025.
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.