CommonSpirit Health (also known as Dignity Health in California)

1. Top 10 Disparities

2. Equity Plan

In CommonSpirit Health's California region, eight out of the top ten disparities were related to all-cause unplanned 30-day readmissions, stratified by payer type (specifically Medicare), age (i.e., adults over 50), and language. Common actions across hospitals to reduce these readmissions include enhanced chronic disease management education, structured post-discharge phone calls (within 48-72 hours), development of culturally and linguistically appropriate educational materials, collaboration with community partners (e.g., home health, social services, FQHCs), and continuous monitoring and root cause analysis of readmission data. Actions across hospitals to help reduce these readmissions include:
1. Enhanced Discharge Planning and Post-Discharge Support:
• Structured post-discharge phone calls within 24-72 hours post-discharge to address immediate concerns, verify understanding of instructions, confirm appointments, and identify barriers.
• Referral to primary care/transitional care: referring discharged patients to local primary care facilities, including clinics, FQHCs, and transitional care clinics, to bridge the gap between inpatient and outpatient care.
• Ensuring medication reconciliation and adherence by a clinical pharmacist for older adults with an emphasis on verifying complete understanding of discharge medications.
• Continuity of care coordination: strengthening coordination with skilled nursing facilities and rehabilitation centers for appropriate post-acute care.
2. Tailored Patient Education and Engagement:
• Prioritizing chronic disease management education during hospitalization, including tailored content on medication adherence and symptom recognition.
• Developing age-appropriate and culturally/linguistically sensitive materials
3. Addressing Social Determinants of Health (SDOH):
• Proactive SDOH screening and referrals: employing platforms like Unite Us for measuring social services linkage.
• Community Partnerships: Collaboration with community organizations, home health, and social services to support patients post-discharge
4. Staff Training and Data-Driven Improvement:
• Cultural competency and health literacy training
• Data analysis and root cause identification: continuously monitoring readmission rates by disparity group, analyzing root causes, and adjusting interventions based on ongoing data; leveraging readmission taskforces or multidisciplinary committees for this purpose.
• Risk stratification to identify at-risk patients early
Nulliparous, term, singleton, vertex (NTSV) C-section disparities emerged as a top regional disparity for persons 30-39 years old and those over 40 that was reflected in only one facility (Mercy Hospitals of Bakersfield). However, these disparities were identified as compared to birthing people under the age of 18, which is an unrealistic comparator; with advancing age comes additional comorbidities and risks to childbirth. Reducing the number of Cesarean sections performed in the United States has become a priority for healthcare organizations, patient safety advocates, consumers and maternity care providers. While the national Cesarean delivery rate has declined in recent years, most States and health care organizations remain above the Healthy People 2030 goal of 23.6 percent for the NTSV and above the national average for the Society of Maternal-Fetal Medicine's (SMFM) low-risk Cesarean measure.
CommonSpirit Health maintains a Women and Infants Clinical Institute that continuously monitors maternal and child health through various dashboards and devises solutions for improvement. In 2024, the region's NTSV rate was 25.6%; CommonSpirit aims to reduce this rate by 2% to meet the Healthy People 2030 goal. Several strategies are underway to improve birthing outcomes, including unnecessary C-section births, through the following tactics:
• Standardizing clinical treatment in acute settings through the Every Hospital, Every Patient, Every Time approach, which removes factors such as implicit bias, inaccurate diagnosis, and variation to standardize treatment
• Promoting language and literacy accessibility
• Addressing social determinants of health
• Data analysis by race/ethnicity and geographic location: the organization's large geographic footprint allows us to evaluate and address disparities and outcome variations for maternal health initiatives based on race/ethnicity and geographic locations
• Remote monitoring to address perinatal hypertension
• Embedding care extenders (e.g., community health workers) in obstetric settings

3. Web Address for Equity Report

https://www.dignityhealth.org/

4. Download Equity Measures Report

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