Level 1 · Enterprise
Admissions and ED visits, in-facility case management, post-discharge follow-up and 60-day readmissions. Drill down from a market row into its centers, providers and patients.
Setting: Inpatient — inpatient and ED are reported separately, never combined. Period filter (All months) drives the funnel, outreach, distribution and scorecards; the rolling boxes below always show the latest 30 days versus the prior 30 days, and the trend chart shows the trailing 12 months. Version 1 scope is inpatient and ED; observation, SNF and home health follow in a later phase.
13 patients in facility now · Inpatient
Last 30d · 45 events · prior 30d 60
Last 30d · 23 ED visits · prior 30d 34
Patients still waiting on a next action
Of discharges · All months
38 readmissions flagged
Events per 1,000 attributed members, trailing 12 months · dashed line is the prior-year baseline
Admission → case management → discharge → outreach → appointment · All months
TCM patient case opened, projected discharge date set
Nurse for Critical/Serious, coordinator or front desk for Good/Fair
The target outcome
All completed appointments
60-day readmission rate, discharges with vs. without a scheduled PCP appointment
Current census and 30-day volume by care setting
| Setting | In facility | Volume 30d | vs prior |
|---|---|---|---|
| Inpatient | 13 | 45 | ▲50.0% |
| Observation | 3 | 7 | ▼12.5% |
| ED | 0 | 23 | ▲35.3% |
| SNF | 16 | 21 | ▲31.3% |
| Home Health | 18 | 21 | ▲50.0% |
Home health census is partial in the source system; hospice is not yet included.
Click a market to drill into its centers and providers
| Market | Census | Volume 30d | Δ vs prior | Case managed | Contacted | Scheduled | Visit ≤7d | 60d readmit | Open actions |
|---|---|---|---|---|---|---|---|---|---|
| Desert Ridge | 1 | 16 | ▲128.6% | 55.8% | 56.5% | 37.6% | 9.4% | 15.3% | 38 |
| Gulf Coast | 3 | 11 | ▲22.2% | 69.7% | 60.3% | 49.2% | 23.8% | 7.9% | 17 |
| Piedmont | 3 | 9 | ▲12.5% | 78.4% | 74.6% | 66.2% | 33.8% | 16.9% | 17 |
| North Valley | 6 | 9 | ▲50.0% | 89% | 80.6% | 77.6% | 49.3% | 11.9% | 10 |
Every center ranked by 7-day PCP visit rate · All months · click a center for its providers and patients
| Center / practice | Census | Volume 30d | Per 1,000 | Case managed | Scheduled | No-show | Visit ≤7d | 60d readmit | Open actions |
|---|---|---|---|---|---|---|---|---|---|
| Mesa Family Medicine | 0 | 8 | 170 | 55.3% | 34% | 50% | 8.5% | 21.3% | 23 |
| Saguaro Care | 1 | 8 | 200 | 56.4% | 42.1% | 37.5% | 10.5% | 7.9% | 15 |
| Harbor Family Care | 1 | 3 | 57 | 77.1% | 50% | 23.5% | 20.6% | 5.9% | 8 |
| Bayside Medical | 2 | 8 | 178 | 61.3% | 48.3% | 14.3% | 27.6% | 10.3% | 9 |
| Stonebridge Health | 1 | 5 | 109 | 66.7% | 72.4% | 4.8% | 31% | 17.2% | 7 |
| Millbrook Clinic | 1 | 3 | 55 | 84% | 62.5% | 13.3% | 33.3% | 25% | 6 |
| Cedar Hills Family | 2 | 3 | 60 | 88.9% | 81.3% | 15.4% | 37.5% | 6.3% | 3 |
| Foxfield Primary | 1 | 1 | 16 | 89.5% | 61.1% | 9.1% | 38.9% | 5.6% | 4 |
| Redwood Primary | 2 | 3 | 71 | 91.7% | 77.3% | 0% | 45.5% | 4.5% | 1 |
| Lakeview Internal | 2 | 3 | 52 | 87.1% | 75.9% | 4.5% | 58.6% | 20.7% | 6 |