CHospital Census & TCM Report
Data as of September 3, 2026 · TCM Patient Cases + Athena EHR

Level 3 · Center & provider

Center & Provider Census Detail

Every patient on census with case management, outreach, appointment status and the next action.

On census now
50

Inpatient, obs, ED, SNF, home health

Case managed
69.2%

Case opened while in facility

Needs action
201

Unresolved step in the loop

Contacted
67.7%

494 of 730 discharges

Visit ≤7 days
25.5%

Target outcome

Readmission flags
146

Admitted within 60 days of a prior discharge

Provider panel

Census and follow-up performance by PCP

ProviderCensusVolume 30dCase managedScheduledNo-showVisit ≤7dOpen
Dr. R. Nakamura4961.8%47.1%29.2%15.7%22
Dr. J. Persaud61184.1%54.4%19.4%19.3%14
Dr. S. Brennan2853.8%54%18.5%20%16
Dr. D. Moreau71367.7%56.9%12.1%20.7%22
Dr. L. Castellanos21062.7%46.6%2.9%21.9%23
Dr. T. Lindqvist51162.3%53.1%11.8%23.4%17
Dr. M. Okonkwo61268.8%56.8%11.9%24.3%17
Dr. K. Vasquez2875.4%62.7%8.1%25.4%15
Dr. A. Whitfield61069.7%63.3%7.9%26.7%15
Dr. P. Aiyer41066.2%60.7%10.8%34.4%15
Dr. H. Kaur41182.4%70%24.5%35.7%17
Dr. E. Boateng2472.7%64.2%14.7%35.8%8

Patient worklist

201 records match the current filters

PatientTier / OwnerSetting & facilityCase mgmtAdmit / DischargeOutreachAppointmentWindowStatus / Next action
Callum Petrov
M468345 · 80y · Mesa Family Medicine
(247) 883-8954
60d readmitReturned
Critical
Nurse
Inpatient
Valley Baptist
Case open
Proj. DC Nov 8
Oct 30
Nov 8
Unable to reach
Nurse case manager · 4 attempts
Not scheduled
292d past
Readmit — no appointment
Rafael Tanaka
M400896 · 64y · Mesa Family Medicine
(489) 623-9377
60d readmit
Critical
Nurse
Inpatient
St. Aldon Regional
Case open
Proj. DC Dec 24
Dec 18
Dec 24
Contacted
Nurse case manager · 1 attempt
No-show
Jan 5 · 1 miss
246d past
No-show recovery
Delia Mbeki
M496123 · 59y · Saguaro Care
(341) 248-5979
Returned
Critical
Nurse
Inpatient
Mercy General
Case open
Proj. DC Aug 20
Aug 15
Aug 19
Contacted
Nurse case manager · 3 attempts
Not scheduled
8d past
Readmit — no appointment
Willie Chandler
M434782 · 65y · Mesa Family Medicine
(594) 225-3497
Returned
Critical
Nurse
Inpatient
Northside Medical Center
No case
No plan
Mar 5
Mar 8
Attempted
Nurse case manager · 1 attempt
Not scheduled
172d past
Readmit — no appointment
Dwight Abernathy
M410464 · 85y · Saguaro Care
(564) 508-7474
Returned
Critical
Nurse
Inpatient
Mercy General
Case open
Proj. DC Nov 3
Oct 29
Nov 3
Attempted
Nurse case manager · 2 attempts
Not scheduled
297d past
Readmit — no appointment
Amir Haddad
M473495 · 67y · Mesa Family Medicine
(545) 683-8266
Returned
Critical
Nurse
Inpatient
Northside Medical Center
No case
No plan
Aug 20
Aug 26
Not started
· 0 attempts
Not scheduled
1d past
Readmit — no appointment
Ingrid Nguyen
M436746 · 89y · Stonebridge Health
(357) 649-9397
60d readmitReturned
Serious
Nurse
ED
St. Aldon Regional ED
Case open
Proj. DC Apr 20
Apr 20
Apr 20
Contacted
Nurse case manager · 2 attempts
Not scheduled
129d past
Readmit — no appointment
Hattie Salazar
M490356 · 58y · Mesa Family Medicine
(288) 480-6357
60d readmitReturned
Serious
Nurse
ED
Northside Medical ED
No case
No plan
Jul 29
Jul 29
Contacted
Nurse case manager · 2 attempts
Not scheduled
29d past
Readmit — no appointment
Beatrice Mbeki
M418184 · 61y · Harbor Family Care
(654) 669-6458
Returned
Critical
Nurse
ED
Valley Baptist ED
No case
No plan
Aug 21
Aug 21
Attempted
Nurse case manager · 2 attempts
Not scheduled
6d past
Readmit — no appointment
Beatrice Abernathy
M442070 · 73y · Mesa Family Medicine
(579) 886-4418
60d readmit
Serious
Nurse
Inpatient
Mercy General
No case
No plan
May 1
May 11
Contacted
Nurse case manager · 2 attempts
No-show
May 20 · 1 miss
108d past
No-show recovery
Callum Guillory
M486687 · 67y · Lakeview Internal
(414) 245-4320
60d readmit
Serious
Nurse
Inpatient
Mercy General
Case open
Proj. DC Aug 9
Aug 2
Aug 9
Contacted
Care coordinator · 2 attempts
Cancelled
Aug 11 · 1 miss
18d past
No-show recovery
Jonas Haddad
M450014 · 76y · Saguaro Care
(674) 855-7072
Critical
Nurse
Inpatient
Mercy General
Case open
Proj. DC Jun 5
May 30
Jun 5
Contacted
Nurse case manager · 2 attempts
No-show
Jun 10 · 1 miss
83d past
No-show recovery
Dwight Baptiste
M471184 · 91y · Saguaro Care
(394) 735-2877
Critical
Nurse
Inpatient
Northside Medical Center
No case
No plan
Nov 12
Nov 16
Contacted
Care coordinator · 1 attempt
No-show
Nov 18 · 1 miss
284d past
No-show recovery
Terrance Ferreira
M465335 · 79y · Saguaro Care
(505) 755-1409
Critical
Nurse
Inpatient
St. Aldon Regional
No case
No plan
Nov 24
Nov 29
Contacted
Nurse case manager · 1 attempt
No-show
Dec 4 · 1 miss
271d past
No-show recovery
Rafael Rios
M480554 · 91y · Stonebridge Health
(495) 876-6441
Critical
Nurse
Inpatient
Northside Medical Center
Case open
Proj. DC Jan 18
Jan 8
Jan 18
Contacted
Care coordinator · 1 attempt
No-show
Jan 21 · 1 miss
221d past
No-show recovery
Willie Delgado
M439206 · 59y · Stonebridge Health
(488) 648-4220
Returned
Critical
Nurse
Inpatient
Mercy General
Case open
Proj. DC Aug 25
Aug 20
Aug 25
Contacted
Nurse case manager · 3 attempts
Cancelled
Aug 31 · 1 miss
2d past
No-show recovery
Priya Ferreira
M496179 · 66y · Millbrook Clinic
(399) 431-5019
60d readmitReturned
Critical
Nurse
Inpatient
Northside Medical Center
Case open
Proj. DC Apr 21
Apr 14
Apr 22
Contacted
Nurse case manager · 2 attempts
Completed
Apr 26 · 4d
Met
Readmit — visit completed
Imani Rios
M486109 · 72y · Lakeview Internal
(438) 596-6831
60d readmitReturned
Critical
Nurse
Inpatient
St. Aldon Regional
Case open
Proj. DC Jul 10
Jun 30
Jul 9
Contacted
Care coordinator · 1 attempt
Completed
Jul 14 · 5d
Met
Readmit — visit completed
Hattie Abernathy
M474845 · 68y · Harbor Family Care
(491) 431-6943
60d readmit
Good
Care coordinator
Inpatient
Mercy General
Case open
Proj. DC Aug 13
Aug 4
Aug 13
Not started
· 0 attempts
Not scheduled
14d past
No outreach yet
Harold Nguyen
M463119 · 62y · Saguaro Care
(373) 321-8618
60d readmit
Good
Care coordinator
Inpatient
Valley Baptist
Case open
Proj. DC Aug 6
Jul 29
Aug 6
Not started
· 0 attempts
Not scheduled
21d past
No outreach yet
Jonas Guillory
M460429 · 60y · Saguaro Care
(313) 574-1991
60d readmit
Good
Care coordinator
Inpatient
St. Aldon Regional
No case
No plan
Aug 26
Sep 2
Not started
· 0 attempts
Not scheduled
6d left
No outreach yet
Rosa Okafor
M454007 · 61y · Mesa Family Medicine
(478) 531-7053
Critical
Nurse
Inpatient
Valley Baptist
No case
No plan
Aug 24
Sep 3
Attempted
Nurse case manager · 2 attempts
Not scheduled
7d left
Contacted, no appointment
Dwight Chandler
M455735 · 63y · Harbor Family Care
(538) 741-2145
Critical
Nurse
SNF
Ridgeway LTAC
Case open
Proj. DC Jan 7
Dec 28
Jan 8
Contacted
Nurse case manager · 1 attempt
Cancelled
Jan 12 · 1 miss
231d past
No-show recovery
Priya Chandler
M401044 · 83y · Redwood Primary
(571) 285-8648
Critical
Nurse
SNF
Willowbrook SNF
Case open
Proj. DC May 3
Apr 18
May 3
Contacted
Nurse case manager · 1 attempt
Cancelled
May 8 · 1 miss
116d past
No-show recovery
Frank Abernathy
M477904 · 66y · Saguaro Care
(359) 554-2790
60d readmitReturned
Serious
Nurse
ED
Mercy General ED
Case open
Proj. DC Feb 6
Feb 6
Feb 6
Contacted
Nurse case manager · 3 attempts
No-show
Feb 12 · 1 miss
202d past
No-show recovery
Marcus Whitmore
M466959 · 63y · Foxfield Primary
(386) 380-6627
Critical
Nurse
SNF
Ridgeway LTAC
Case open
Proj. DC Jul 12
Jul 5
Jul 13
Contacted
Nurse case manager · 2 attempts
Cancelled
Jul 19 · 1 miss
45d past
No-show recovery
Imani Nguyen
M462420 · 89y · Stonebridge Health
(249) 663-4539
Returned
Serious
Nurse
Inpatient
Northside Medical Center
No case
No plan
Oct 1
Oct 9
Attempted
Nurse case manager · 1 attempt
Not scheduled
322d past
Readmit — no appointment
Otis Lindstrom
M400053 · 74y · Stonebridge Health
(681) 317-4386
Serious
Nurse
ED
Northside Medical ED
No case
No plan
Aug 19
Aug 19
Not started
· 0 attempts
Not scheduled
8d past
No outreach yet
Terrance Haddad
M442225 · 59y · Cedar Hills Family
(605) 328-7480
60d readmitReturned
Critical
Nurse
SNF
Willowbrook SNF
Case open
Proj. DC Jul 20
Jul 4
Jul 19
Contacted
Nurse case manager · 1 attempt
Completed
Jul 23 · 4d
Met
Readmit — visit completed
Ruth Mbeki
M417900 · 84y · Lakeview Internal
(590) 593-3751
60d readmitReturned
Good
Care coordinator
Inpatient
St. Aldon Regional
No case
No plan
May 8
May 16
Not started
· 0 attempts
Not scheduled
103d past
Readmit — no appointment
Rafael Chandler
M491987 · 60y · Harbor Family Care
(643) 262-2607
60d readmitReturned
Good
Care coordinator
Inpatient
Valley Baptist
Case open
Proj. DC May 26
May 22
May 26
Contacted
Care coordinator · 3 attempts
Not scheduled
93d past
Readmit — no appointment
Yuki Delgado
M477234 · 67y · Bayside Medical
(659) 484-1912
60d readmit
Good
Care coordinator
ED
Mercy General ED
No case
No plan
Aug 17
Aug 17
Not started
· 0 attempts
Not scheduled
10d past
No outreach yet
Otis Petrov
M463338 · 59y · Saguaro Care
(465) 269-1560
Returned
Serious
Nurse
Home Health
Anchor Home Services
Case open
Proj. DC Oct 15
Sep 15
Oct 15
Unable to reach
Nurse case manager · 3 attempts
Not scheduled
316d past
Readmit — no appointment
Callum Haddad
M425877 · 73y · Saguaro Care
(248) 456-3910
Returned
Serious
Nurse
SNF
Ridgeway LTAC
No case
No plan
Jun 1
Jun 9
Not started
· 0 attempts
Not scheduled
79d past
Readmit — no appointment
Jonas Chandler
M469648 · 58y · Harbor Family Care
(667) 726-6808
Returned
Serious
Nurse
Home Health
BrightPath Home Health
Case open
Proj. DC Mar 14
Feb 23
Mar 13
Attempted
Care coordinator · 1 attempt
Not scheduled
167d past
Readmit — no appointment
Imani Ionescu
M421864 · 84y · Bayside Medical
(599) 492-7416
Returned
Serious
Nurse
Home Health
BrightPath Home Health
Case open
Proj. DC Apr 1
Mar 6
Apr 2
Attempted
Nurse case manager · 1 attempt
Not scheduled
147d past
Readmit — no appointment
Rosa Kowalski
M494852 · 77y · Saguaro Care
(279) 268-7022
Returned
Serious
Nurse
Home Health
BrightPath Home Health
No case
No plan
Oct 15
Nov 4
Unable to reach
Nurse case manager · 4 attempts
Not scheduled
296d past
Readmit — no appointment
Terrance Okafor
M431153 · 70y · Mesa Family Medicine
(376) 552-5908
Serious
Nurse
Inpatient
Northside Medical Center
No case
No plan
Mar 10
Mar 20
Contacted
Care coordinator · 2 attempts
No-show
Mar 26 · 1 miss
160d past
No-show recovery
Terrance Delgado
M410664 · 62y · Saguaro Care
(262) 282-8296
Serious
Nurse
Inpatient
Valley Baptist
Case open
Proj. DC Jul 31
Jul 20
Jul 30
Contacted
Nurse case manager · 3 attempts
No-show
Aug 1 · 1 miss
28d past
No-show recovery
Gerald Ionescu
M468485 · 75y · Cedar Hills Family
(571) 889-3688
Serious
Nurse
Inpatient
Mercy General
Case open
Proj. DC Aug 22
Aug 14
Aug 23
Contacted
Nurse case manager · 2 attempts
Cancelled
Aug 29 · 1 miss
4d past
No-show recovery
Otis Guillory
M488451 · 61y · Saguaro Care
(679) 701-4525
60d readmitReturned
Good
Care coordinator
SNF
Ridgeway LTAC
Case open
Proj. DC Feb 26
Feb 7
Feb 26
Contacted
Care coordinator · 1 attempt
Not scheduled
182d past
Readmit — no appointment
Frank Ionescu
M464107 · 80y · Harbor Family Care
(214) 675-1645
60d readmitReturned
Good
Care coordinator
SNF
Golden Oaks Rehab
No case
No plan
Oct 8
Nov 2
Unable to reach
Care coordinator · 5 attempts
Not scheduled
298d past
Readmit — no appointment
Ruth Rios
M405675 · 83y · Bayside Medical
(555) 406-6405
60d readmit
Good
Care coordinator
Inpatient
Valley Baptist
Case open
Proj. DC Mar 2
Feb 28
Mar 3
Contacted
Care coordinator · 1 attempt
No-show
Mar 19 · 1 miss
177d past
No-show recovery
Nadia Rios
M406629 · 90y · Millbrook Clinic
(687) 422-7611
Returned
Critical
Nurse
Inpatient
Mercy General
Case open
Proj. DC Nov 6
Nov 3
Nov 7
Contacted
Nurse case manager · 2 attempts
Completed
Nov 12 · 5d
Met
Readmit — visit completed
Simone Abernathy
M494012 · 76y · Mesa Family Medicine
(480) 589-7701
Returned
Critical
Nurse
Inpatient
St. Aldon Regional
No case
No plan
Aug 9
Aug 16
Contacted
Nurse case manager · 3 attempts
Completed
Aug 20 · 4d
Met
Readmit — visit completed
Milton Salazar
M443698 · 77y · Saguaro Care
(463) 712-7743
Serious
Nurse
SNF
Golden Oaks Rehab
No case
No plan
Sep 2
LOS 1d
Not started
· 0 attempts
Not scheduled
In facility
No case management
Milton Sorensen
M432687 · 59y · Mesa Family Medicine
(216) 552-2766
Good
Care coordinator
Inpatient
St. Aldon Regional
No case
No plan
Aug 14
Aug 19
Not started
· 0 attempts
Not scheduled
8d past
No outreach yet
Lena Marsden
M426455 · 58y · Saguaro Care
(373) 425-3283
Good
Care coordinator
Inpatient
Northside Medical Center
No case
No plan
Aug 25
Aug 31
Not started
· 0 attempts
Not scheduled
4d left
No outreach yet
Otis Ferreira
M442154 · 89y · Bayside Medical
(268) 261-2258
Good
Care coordinator
Inpatient
St. Aldon Regional
No case
No plan
Aug 25
Aug 31
Not started
· 0 attempts
Not scheduled
4d left
No outreach yet
Dwight Lindstrom
M494692 · 67y · Saguaro Care
(613) 295-9180
Good
Care coordinator
Inpatient
St. Aldon Regional
No case
No plan
Aug 18
Aug 21
Not started
· 0 attempts
Not scheduled
6d past
No outreach yet
Marcus Salazar
M486929 · 91y · Harbor Family Care
(608) 469-2105
60d readmitReturned
Fair
Care coordinator
Inpatient
St. Aldon Regional
No case
No plan
Jul 25
Jul 28
Not started
· 0 attempts
Not scheduled
30d past
Readmit — no appointment
Gerald Abernathy
M467805 · 64y · Saguaro Care
(288) 386-4554
Serious
Nurse
Inpatient
St. Aldon Regional
Case open
Proj. DC Aug 31
Aug 26
Aug 31
Contacted
Nurse case manager · 3 attempts
Not scheduled
4d left
Contacted, no appointment
Imani Whitmore
M453496 · 65y · Mesa Family Medicine
(584) 323-6144
Serious
Nurse
Inpatient
Mercy General
Case open
Proj. DC Aug 31
Aug 25
Aug 31
Contacted
Nurse case manager · 3 attempts
Not scheduled
4d left
Contacted, no appointment
Jonas Lindstrom
M458699 · 87y · Stonebridge Health
(242) 401-7907
Serious
Nurse
SNF
Ridgeway LTAC
Case open
Proj. DC Sep 30
Sep 12
Sep 30
Contacted
Nurse case manager · 2 attempts
Cancelled
Oct 5 · 1 miss
331d past
No-show recovery
Gerald Abernathy
M449223 · 88y · Millbrook Clinic
(484) 623-3620
Serious
Nurse
Home Health
Anchor Home Services
Case open
Proj. DC Feb 16
Jan 31
Feb 16
Contacted
Nurse case manager · 3 attempts
Cancelled
Mar 4 · 1 miss
192d past
No-show recovery
Harold Salazar
M444693 · 75y · Mesa Family Medicine
(282) 344-6894
Serious
Nurse
ED
St. Aldon Regional ED
No case
No plan
Jul 13
Jul 13
Contacted
Nurse case manager · 2 attempts
Cancelled
Jul 17 · 1 miss
45d past
No-show recovery
Eleanor Whitmore
M403477 · 59y · Saguaro Care
(701) 441-5908
Serious
Nurse
SNF
Willowbrook SNF
No case
No plan
May 26
Jun 16
Contacted
Nurse case manager · 2 attempts
No-show
Jun 18 · 1 miss
72d past
No-show recovery
Yuki Lindstrom
M455797 · 81y · Cedar Hills Family
(400) 297-6753
Serious
Nurse
ED
Northside Medical ED
Case open
Proj. DC Aug 5
Aug 5
Aug 5
Contacted
Nurse case manager · 2 attempts
Cancelled
Aug 9 · 1 miss
22d past
No-show recovery
Bernard Chandler
M401279 · 84y · Foxfield Primary
(437) 303-3608
Serious
Nurse
Home Health
Anchor Home Services
Case open
Proj. DC Dec 13
Nov 26
Dec 12
Contacted
Care coordinator · 3 attempts
Cancelled
Dec 17 · 1 miss
258d past
No-show recovery
Marcus Sorensen
M468118 · 77y · Harbor Family Care
(274) 471-6681
Serious
Nurse
SNF
Golden Oaks Rehab
Case open
Proj. DC Oct 9
Sep 16
Oct 9
Contacted
Nurse case manager · 3 attempts
Cancelled
Oct 12 · 1 miss
322d past
No-show recovery
Amir Kowalski
M446419 · 78y · Cedar Hills Family
(339) 523-7456
Returned
Serious
Nurse
Home Health
Anchor Home Services
Case open
Proj. DC Apr 8
Mar 14
Apr 8
Contacted
Nurse case manager · 3 attempts
Cancelled
Apr 18 · 1 miss
141d past
No-show recovery
Xiomara Kowalski
M497697 · 61y · Cedar Hills Family
(659) 407-8984
60d readmit
Good
Care coordinator
SNF
Ridgeway LTAC
Case open
Proj. DC Apr 8
Mar 27
Apr 7
Contacted
Care coordinator · 2 attempts
Cancelled
Apr 13 · 1 miss
142d past
No-show recovery
Nadia Baptiste
M437611 · 89y · Cedar Hills Family
(670) 351-9956
60d readmitReturned
Serious
Nurse
SNF
Riverstone Post-Acute
No case
No plan
Feb 23
Mar 11
Contacted
Nurse case manager · 3 attempts
Completed
Mar 15 · 4d
Met
Readmit — visit completed
Hattie Salazar
M451358 · 83y · Cedar Hills Family
(694) 449-3390
Returned
Critical
Nurse
Home Health
Comfort Care at Home
Case open
Proj. DC Aug 26
Jul 23
Aug 26
Contacted
Nurse case manager · 2 attempts
Completed
Aug 31 · 5d
Met
Readmit — visit completed
Imani Whitmore
M485117 · 74y · Foxfield Primary
(572) 399-1402
Returned
Critical
Nurse
SNF
Riverstone Post-Acute
Case open
Proj. DC Aug 22
Aug 10
Aug 23
Contacted
Nurse case manager · 1 attempt
Completed
Aug 26 · 3d
Met
Readmit — visit completed
Milton Okafor
M410778 · 71y · Harbor Family Care
(457) 812-5470
60d readmitReturned
Serious
Nurse
ED
Mercy General ED
Case open
Proj. DC Dec 5
Dec 5
Dec 5
Contacted
Nurse case manager · 2 attempts
Completed
Dec 7 · 2d
Met
Readmit — visit completed
Dwight Kowalski
M443432 · 65y · Mesa Family Medicine
(518) 773-7102
60d readmit
Good
Care coordinator
SNF
Riverstone Post-Acute
Case open
Proj. DC May 21
May 8
May 20
Contacted
Front desk · 1 attempt
No-show
May 24 · 1 miss
99d past
No-show recovery
Marcus Sorensen
M465961 · 83y · Foxfield Primary
(470) 320-6133
60d readmit
Fair
Care coordinator
ED
Northside Medical ED
No case
No plan
Aug 29
Aug 29
Unable to reach
PCP office · 4 attempts
Not scheduled
2d left
Window closing
Yuki Nguyen
M459122 · 80y · Saguaro Care
(309) 391-7162
60d readmit
Good
Care coordinator
ED
Mercy General ED
No case
No plan
Nov 25
Nov 25
Contacted
PCP office · 2 attempts
No-show
Nov 29 · 1 miss
275d past
No-show recovery
Amir Sorensen
M411686 · 78y · Bayside Medical
(277) 868-8849
60d readmit
Good
Care coordinator
SNF
Ridgeway LTAC
Case open
Proj. DC May 28
May 9
May 29
Contacted
Front desk · 2 attempts
No-show
Jun 1 · 1 miss
90d past
No-show recovery
Xiomara Petrov
M470800 · 86y · Redwood Primary
(257) 432-7572
Returned
Critical
Nurse
ED
Northside Medical ED
Case open
Proj. DC May 22
May 22
May 22
Contacted
Nurse case manager · 3 attempts
Completed
May 25 · 3d
Met
Readmit — visit completed
Ingrid Nguyen
M417709 · 77y · Harbor Family Care
(535) 477-3211
60d readmit
Good
Care coordinator
SNF
Ridgeway LTAC
Case open
Proj. DC Aug 12
Jul 27
Aug 12
Contacted
Care coordinator · 1 attempt
No-show
Aug 27 · 1 miss
15d past
No-show recovery
Jonas Mbeki
M442965 · 88y · Redwood Primary
(531) 525-7785
60d readmit
Good
Care coordinator
SNF
Golden Oaks Rehab
Case open
Proj. DC Jan 5
Dec 18
Jan 4
Contacted
Care coordinator · 1 attempt
No-show
Jan 20 · 1 miss
235d past
No-show recovery
Hattie Delgado
M452294 · 70y · Harbor Family Care
(251) 529-5851
Good
Care coordinator
ED
St. Aldon Regional ED
Case open
Proj. DC Aug 14
Aug 14
Aug 14
Not started
· 0 attempts
Not scheduled
13d past
No outreach yet
Dwight Haddad
M434710 · 82y · Foxfield Primary
(495) 382-8525
Good
Care coordinator
ED
Valley Baptist ED
No case
No plan
Sep 1
Sep 1
Not started
· 0 attempts
Not scheduled
5d left
No outreach yet
Simone Rios
M447565 · 74y · Mesa Family Medicine
(235) 485-4600
Serious
Nurse
Inpatient
Northside Medical Center
Case open
Proj. DC Aug 2
Jul 25
Aug 1
Contacted
Nurse case manager · 1 attempt
Not scheduled
26d past
Window missed
Delia Mbeki
M413912 · 59y · Cedar Hills Family
(319) 592-6489
Returned
Good
Care coordinator
Inpatient
Mercy General
Case open
Proj. DC Apr 24
Apr 14
Apr 24
Attempted
Front desk · 2 attempts
Not scheduled
125d past
Readmit — no appointment
Priya Mbeki
M455912 · 70y · Saguaro Care
(487) 368-9288
Good
Care coordinator
Home Health
Comfort Care at Home
Case open
Proj. DC Aug 15
Jul 18
Aug 15
Not started
· 0 attempts
Not scheduled
12d past
No outreach yet
Yuki Abernathy
M443863 · 62y · Stonebridge Health
(642) 210-7702
Serious
Nurse
Inpatient
Northside Medical Center
No case
No plan
Aug 18
Aug 26
Attempted
Nurse case manager · 1 attempt
Not scheduled
1d past
Window missed
Lena Chandler
M494542 · 88y · Bayside Medical
(259) 716-6280
Good
Care coordinator
SNF
Golden Oaks Rehab
Case open
Proj. DC Aug 23
Aug 3
Aug 22
Not started
· 0 attempts
Not scheduled
5d past
No outreach yet
Dwight Chandler
M439482 · 68y · Bayside Medical
(348) 600-1058
Returned
Good
Care coordinator
Inpatient
Northside Medical Center
No case
No plan
Apr 19
Apr 29
Not started
· 0 attempts
Not scheduled
120d past
Readmit — no appointment
Simone Mbeki
M498688 · 83y · Mesa Family Medicine
(259) 863-7381
Returned
Good
Care coordinator
Inpatient
St. Aldon Regional
No case
No plan
Jul 19
Jul 22
Not started
· 0 attempts
Not scheduled
36d past
Readmit — no appointment
Bernard Mbeki
M402511 · 67y · Mesa Family Medicine
(490) 893-3358
Good
Care coordinator
Home Health
Anchor Home Services
Case open
Proj. DC Aug 16
Jul 14
Aug 17
Not started
· 0 attempts
Not scheduled
10d past
No outreach yet
Xiomara Baptiste
M449252 · 90y · Harbor Family Care
(674) 640-4483
Serious
Nurse
Inpatient
Valley Baptist
Case open
Proj. DC Aug 2
Jul 25
Aug 2
Contacted
Nurse case manager · 2 attempts
Not scheduled
25d past
Window missed
Beatrice Abernathy
M460837 · 82y · Mesa Family Medicine
(232) 671-5129
Returned
Good
Care coordinator
Inpatient
Northside Medical Center
No case
No plan
Oct 3
Oct 7
Not started
· 0 attempts
Not scheduled
324d past
Readmit — no appointment
Ruth Ionescu
M493013 · 61y · Millbrook Clinic
(294) 806-4802
Returned
Good
Care coordinator
Inpatient
Northside Medical Center
Case open
Proj. DC Aug 13
Aug 6
Aug 13
Attempted
Care coordinator · 2 attempts
Not scheduled
14d past
Readmit — no appointment
Eleanor Lindstrom
M403537 · 82y · Lakeview Internal
(649) 721-9331
Returned
Good
Care coordinator
Inpatient
Northside Medical Center
Case open
Proj. DC Oct 24
Oct 17
Oct 24
Attempted
Care coordinator · 2 attempts
Not scheduled
307d past
Readmit — no appointment
Marcus Ionescu
M412078 · 75y · Bayside Medical
(420) 541-3941
Returned
Good
Care coordinator
Inpatient
St. Aldon Regional
No case
No plan
Feb 1
Feb 9
Attempted
Care coordinator · 2 attempts
Not scheduled
199d past
Readmit — no appointment
Frank Tanaka
M407959 · 60y · Mesa Family Medicine
(587) 709-7935
Good
Care coordinator
SNF
Riverstone Post-Acute
No case
No plan
Aug 20
Aug 30
Not started
· 0 attempts
Not scheduled
3d left
No outreach yet
Hattie Chandler
M454226 · 63y · Mesa Family Medicine
(390) 753-6050
Returned
Good
Care coordinator
Inpatient
Mercy General
Case open
Proj. DC Jan 28
Jan 22
Jan 28
Not started
· 0 attempts
Not scheduled
211d past
Readmit — no appointment
Frank Petrov
M440076 · 69y · Redwood Primary
(302) 792-3527
60d readmitReturned
Fair
Care coordinator
SNF
Willowbrook SNF
Case open
Proj. DC Jul 8
Jun 22
Jul 8
Attempted
PCP office · 1 attempt
Not scheduled
50d past
Readmit — no appointment
Priya Haddad
M487648 · 82y · Mesa Family Medicine
(244) 778-8409
Serious
Nurse
Observation
St. Aldon Regional
Case open
Proj. DC Aug 31
Aug 27
Aug 31
Contacted
Nurse case manager · 1 attempt
Not scheduled
4d left
Contacted, no appointment
Yuki Lindstrom
M417291 · 76y · Harbor Family Care
(408) 356-4317
60d readmitReturned
Fair
Care coordinator
SNF
Willowbrook SNF
Case open
Proj. DC Oct 9
Sep 13
Oct 8
Not started
· 0 attempts
Not scheduled
323d past
Readmit — no appointment
Nadia Haddad
M404506 · 83y · Bayside Medical
(430) 498-2334
60d readmit
Good
Care coordinator
Inpatient
Valley Baptist
No case
No plan
Jul 30
Aug 6
Attempted
Care coordinator · 2 attempts
Not scheduled
21d past
Window missed
Ingrid Tanaka
M488266 · 87y · Harbor Family Care
(340) 766-3631
Fair
Care coordinator
Inpatient
Mercy General
No case
No plan
Aug 3
Aug 9
Not started
· 0 attempts
Not scheduled
18d past
No outreach yet
Yuki Abernathy
M489710 · 79y · Mesa Family Medicine
(506) 638-1430
Fair
Care coordinator
Inpatient
Valley Baptist
No case
No plan
Aug 9
Aug 14
Not started
· 0 attempts
Not scheduled
13d past
No outreach yet
Ingrid Whitmore
M423560 · 62y · Saguaro Care
(258) 328-2585
Fair
Care coordinator
Inpatient
Mercy General
Case open
Proj. DC Sep 3
Aug 28
Sep 3
Not started
· 0 attempts
Not scheduled
7d left
No outreach yet
Bernard Okafor
M454699 · 64y · Mesa Family Medicine
(223) 892-9564
Fair
Care coordinator
Inpatient
Mercy General
No case
No plan
Aug 10
Aug 19
Not started
· 0 attempts
Not scheduled
8d past
No outreach yet
Delia Lindstrom
M437026 · 83y · Bayside Medical
(520) 395-8620
Fair
Care coordinator
Inpatient
Northside Medical Center
No case
No plan
Aug 12
Aug 21
Not started
· 0 attempts
Not scheduled
6d past
No outreach yet
Ruth Tanaka
M499691 · 82y · Bayside Medical
(627) 214-2180
Good
Care coordinator
Inpatient
St. Aldon Regional
No case
No plan
Sep 2
LOS 1d
Not started
· 0 attempts
Not scheduled
In facility
No case management
Lena Marsden
M446959 · 76y · Cedar Hills Family
(421) 211-2680
Good
Care coordinator
Inpatient
Northside Medical Center
No case
No plan
Sep 3
LOS 0d
Not started
· 0 attempts
Not scheduled
In facility
No case management
Marcus Ferreira
M487351 · 77y · Saguaro Care
(519) 845-6666
Returned
Good
Care coordinator
SNF
Willowbrook SNF
Case open
Proj. DC Aug 24
Aug 9
Aug 25
Not started
· 0 attempts
Not scheduled
2d past
Readmit — no appointment
Alma Okafor
M423232 · 73y · Saguaro Care
(642) 716-4264
Returned
Good
Care coordinator
SNF
Riverstone Post-Acute
No case
No plan
Mar 27
Apr 17
Not started
· 0 attempts
Not scheduled
132d past
Readmit — no appointment
Callum Petrov
M485832 · 82y · Saguaro Care
(508) 753-5986
Returned
Good
Care coordinator
Home Health
Anchor Home Services
No case
No plan
May 27
Jun 10
Not started
· 0 attempts
Not scheduled
78d past
Readmit — no appointment
Alma Lindstrom
M425076 · 89y · Saguaro Care
(597) 322-5377
Returned
Good
Care coordinator
ED
St. Aldon Regional ED
No case
No plan
Feb 25
Feb 25
Not started
· 0 attempts
Not scheduled
183d past
Readmit — no appointment
Frank Kowalski
M477449 · 58y · Foxfield Primary
(622) 450-9370
Returned
Good
Care coordinator
ED
Valley Baptist ED
No case
No plan
Aug 12
Aug 12
Attempted
Front desk · 1 attempt
Not scheduled
15d past
Readmit — no appointment
Xiomara Marsden
M403117 · 71y · Harbor Family Care
(309) 479-2815
Returned
Good
Care coordinator
Observation
St. Aldon Regional
Case open
Proj. DC Mar 23
Mar 18
Mar 23
Attempted
Care coordinator · 1 attempt
Not scheduled
157d past
Readmit — no appointment
Nadia Okafor
M464109 · 89y · Mesa Family Medicine
(292) 863-4975
Returned
Good
Care coordinator
Home Health
Anchor Home Services
No case
No plan
Sep 12
Oct 12
Not started
· 0 attempts
Not scheduled
319d past
Readmit — no appointment
Otis Ionescu
M448633 · 84y · Saguaro Care
(292) 505-1401
Serious
Nurse
Home Health
BrightPath Home Health
Case open
Proj. DC Aug 12
Jul 18
Aug 11
Contacted
Nurse case manager · 1 attempt
Not scheduled
16d past
Window missed
Delia Delgado
M495766 · 75y · Lakeview Internal
(501) 850-3390
Returned
Good
Care coordinator
Home Health
BrightPath Home Health
Case open
Proj. DC Apr 20
Mar 19
Apr 20
Contacted
Front desk · 2 attempts
Not scheduled
129d past
Readmit — no appointment
Amir Petrov
M455939 · 60y · Stonebridge Health
(660) 714-5364
Returned
Good
Care coordinator
SNF
Golden Oaks Rehab
Case open
Proj. DC Jun 19
Jun 3
Jun 20
Contacted
Care coordinator · 3 attempts
Not scheduled
68d past
Readmit — no appointment
Imani Marsden
M448092 · 91y · Lakeview Internal
(543) 433-3348
Returned
Good
Care coordinator
Home Health
Comfort Care at Home
Case open
Proj. DC Mar 20
Feb 24
Mar 21
Attempted
Care coordinator · 2 attempts
Not scheduled
159d past
Readmit — no appointment
Rosa Whitmore
M435004 · 61y · Saguaro Care
(444) 712-8815
Returned
Good
Care coordinator
SNF
Golden Oaks Rehab
No case
No plan
Sep 27
Oct 21
Not started
· 0 attempts
Not scheduled
310d past
Readmit — no appointment
Milton Sorensen
M430743 · 64y · Saguaro Care
(215) 760-5274
Returned
Good
Care coordinator
Home Health
Anchor Home Services
No case
No plan
Apr 13
May 14
Not started
· 0 attempts
Not scheduled
105d past
Readmit — no appointment
Amir Tanaka
M421679 · 87y · Harbor Family Care
(654) 207-5499
Returned
Good
Care coordinator
ED
St. Aldon Regional ED
No case
No plan
Aug 2
Aug 2
Unable to reach
Care coordinator · 5 attempts
Not scheduled
25d past
Readmit — no appointment
Ruth Tanaka
M455483 · 85y · Foxfield Primary
(258) 203-5944
Returned
Good
Care coordinator
SNF
Willowbrook SNF
Case open
Proj. DC Nov 11
Nov 1
Nov 10
Not started
· 0 attempts
Not scheduled
290d past
Readmit — no appointment
Harold Ferreira
M481133 · 73y · Saguaro Care
(661) 528-1142
Returned
Good
Care coordinator
Home Health
Comfort Care at Home
Case open
Proj. DC Nov 18
Oct 28
Nov 18
Not started
· 0 attempts
Not scheduled
282d past
Readmit — no appointment
Hattie Abernathy
M498823 · 77y · Mesa Family Medicine
(416) 214-5239
Returned
Good
Care coordinator
Observation
Northside Medical Center
Case open
Proj. DC Jun 20
Jun 12
Jun 21
Contacted
Care coordinator · 3 attempts
Not scheduled
67d past
Readmit — no appointment
Jonas Sorensen
M427072 · 91y · Saguaro Care
(364) 875-4551
Returned
Good
Care coordinator
SNF
Ridgeway LTAC
No case
No plan
Mar 23
Apr 17
Not started
· 0 attempts
Not scheduled
132d past
Readmit — no appointment
Gerald Kowalski
M407679 · 90y · Saguaro Care
(455) 672-6408
Returned
Good
Care coordinator
ED
Mercy General ED
No case
No plan
Feb 8
Feb 8
Not started
· 0 attempts
Not scheduled
200d past
Readmit — no appointment
Willie Sorensen
M467014 · 63y · Harbor Family Care
(614) 369-3254
Returned
Good
Care coordinator
ED
Mercy General ED
No case
No plan
Oct 15
Oct 15
Not started
· 0 attempts
Not scheduled
316d past
Readmit — no appointment
Marcus Salazar
M489479 · 65y · Harbor Family Care
(450) 784-6615
Returned
Good
Care coordinator
ED
St. Aldon Regional ED
No case
No plan
Apr 14
Apr 14
Contacted
Care coordinator · 3 attempts
Not scheduled
135d past
Readmit — no appointment
Ruth Rios
M417655 · 59y · Harbor Family Care
(263) 776-2603
Good
Care coordinator
Inpatient
St. Aldon Regional
Case open
Proj. DC Nov 7
Oct 30
Nov 7
Contacted
PCP office · 2 attempts
No-show
Nov 10 · 1 miss
293d past
No-show recovery
Alma Ionescu
M416402 · 80y · Stonebridge Health
(703) 281-1138
Returned
Serious
Nurse
Inpatient
Valley Baptist
No case
No plan
Jul 2
Jul 8
Contacted
Nurse case manager · 2 attempts
Completed
Jul 14 · 6d
Met
Readmit — visit completed
Priya Whitmore
M434386 · 68y · Millbrook Clinic
(270) 591-7478
Good
Care coordinator
Inpatient
Northside Medical Center
Case open
Proj. DC Aug 23
Aug 20
Aug 24
Contacted
Care coordinator · 2 attempts
Cancelled
Aug 26 · 1 miss
3d past
No-show recovery
Marcus Salazar
M471092 · 90y · Mesa Family Medicine
(565) 460-4994
Good
Care coordinator
Inpatient
Northside Medical Center
No case
No plan
Apr 4
Apr 7
Contacted
Care coordinator · 1 attempt
No-show
Apr 9 · 1 miss
142d past
No-show recovery
Yuki Lindstrom
M432648 · 85y · Mesa Family Medicine
(555) 276-6006
Returned
Good
Care coordinator
Inpatient
Valley Baptist
Case open
Proj. DC Jan 19
Jan 11
Jan 19
Contacted
Care coordinator · 2 attempts
No-show
Jan 21 · 1 miss
220d past
No-show recovery
Terrance Whitmore
M486111 · 77y · Foxfield Primary
(594) 273-2513
Good
Care coordinator
Inpatient
Valley Baptist
Case open
Proj. DC Mar 27
Mar 16
Mar 26
Contacted
Front desk · 1 attempt
Cancelled
Apr 1 · 1 miss
154d past
No-show recovery
Xiomara Delgado
M461509 · 86y · Saguaro Care
(481) 588-2902
Good
Care coordinator
Inpatient
Mercy General
Case open
Proj. DC Dec 2
Nov 25
Dec 1
Contacted
Care coordinator · 1 attempt
No-show
Dec 6 · 1 miss
269d past
No-show recovery
Terrance Kowalski
M493861 · 63y · Redwood Primary
(491) 772-3577
Returned
Serious
Nurse
Inpatient
Mercy General
Case open
Proj. DC Dec 2
Nov 29
Dec 2
Contacted
Nurse case manager · 2 attempts
Completed
Dec 7 · 5d
Met
Readmit — visit completed
Amir Ionescu
M488059 · 59y · Saguaro Care
(686) 205-5493
Returned
Good
Care coordinator
Inpatient
Valley Baptist
No case
No plan
Jan 16
Jan 26
Contacted
PCP office · 3 attempts
No-show
Jan 31 · 1 miss
213d past
No-show recovery
Imani Chandler
M491878 · 74y · Millbrook Clinic
(676) 393-3864
Good
Care coordinator
Inpatient
Valley Baptist
Case open
Proj. DC Oct 25
Oct 18
Oct 25
Contacted
Care coordinator · 3 attempts
No-show
Nov 8 · 1 miss
306d past
No-show recovery
Simone Whitmore
M453485 · 72y · Lakeview Internal
(354) 846-5374
Returned
Serious
Nurse
Inpatient
Northside Medical Center
Case open
Proj. DC Jan 21
Jan 16
Jan 21
Contacted
Nurse case manager · 2 attempts
Completed
Jan 26 · 5d
Met
Readmit — visit completed
Yuki Kowalski
M448628 · 73y · Stonebridge Health
(670) 637-2793
60d readmitReturned
Fair
Care coordinator
SNF
Willowbrook SNF
Case open
Proj. DC Jun 1
May 8
Jun 1
Contacted
Care coordinator · 1 attempt
Cancelled
Jun 10 · 1 miss
87d past
No-show recovery
Harold Rios
M443407 · 78y · Saguaro Care
(544) 788-8396
60d readmit
Fair
Care coordinator
SNF
Riverstone Post-Acute
Case open
Proj. DC Nov 12
Oct 29
Nov 12
Contacted
Care coordinator · 2 attempts
No-show
Nov 24 · 1 miss
288d past
No-show recovery
Jonas Nguyen
M432064 · 78y · Foxfield Primary
(524) 379-1578
60d readmit
Good
Care coordinator
ED
Northside Medical ED
No case
No plan
Aug 24
Aug 24
Contacted
Care coordinator · 2 attempts
Not scheduled
3d past
Window missed
Delia Marsden
M444652 · 90y · Mesa Family Medicine
(223) 558-7933
Fair
Care coordinator
ED
St. Aldon Regional ED
No case
No plan
Aug 10
Aug 10
Not started
· 0 attempts
Not scheduled
17d past
No outreach yet
Otis Salazar
M491263 · 81y · Foxfield Primary
(698) 698-8245
Returned
Fair
Care coordinator
Inpatient
St. Aldon Regional
Case open
Proj. DC Dec 21
Dec 12
Dec 21
Not started
· 0 attempts
Not scheduled
249d past
Readmit — no appointment
Amir Delgado
M436446 · 84y · Mesa Family Medicine
(508) 623-7435
Returned
Fair
Care coordinator
Inpatient
Valley Baptist
No case
No plan
Jan 5
Jan 8
Contacted
Care coordinator · 2 attempts
Not scheduled
231d past
Readmit — no appointment
Gerald Rios
M459965 · 84y · Millbrook Clinic
(642) 631-7428
Returned
Fair
Care coordinator
Inpatient
Valley Baptist
Case open
Proj. DC Jun 3
May 29
Jun 4
Contacted
Front desk · 1 attempt
Not scheduled
84d past
Readmit — no appointment
Alma Kowalski
M419270 · 77y · Saguaro Care
(563) 400-3087
Fair
Care coordinator
ED
Northside Medical ED
Case open
Proj. DC Aug 13
Aug 13
Aug 13
Not started
· 0 attempts
Not scheduled
14d past
No outreach yet
Marcus Chandler
M480595 · 89y · Mesa Family Medicine
(411) 458-3296
Returned
Fair
Care coordinator
Inpatient
Northside Medical Center
Case open
Proj. DC Dec 7
Dec 5
Dec 8
Not started
· 0 attempts
Not scheduled
262d past
Readmit — no appointment
Willie Abernathy
M464415 · 80y · Redwood Primary
(258) 837-1205
Good
Care coordinator
Home Health
Comfort Care at Home
No case
No plan
Aug 20
LOS 14d
Not started
· 0 attempts
Not scheduled
In facility
No case management
Ruth Petrov
M424446 · 71y · Lakeview Internal
(532) 528-5334
Good
Care coordinator
SNF
Riverstone Post-Acute
No case
No plan
Aug 17
LOS 17d
Not started
· 0 attempts
Not scheduled
In facility
No case management
Ruth Marsden
M481938 · 78y · Lakeview Internal
(206) 465-6385
Good
Care coordinator
Observation
Northside Medical Center
Case open
Proj. DC Aug 8
Jul 30
Aug 8
Contacted
Care coordinator · 3 attempts
No-show
Aug 16 · 1 miss
19d past
No-show recovery
Terrance Abernathy
M472131 · 87y · Millbrook Clinic
(231) 427-8576
Good
Care coordinator
Observation
St. Aldon Regional
No case
No plan
Feb 16
Feb 21
Contacted
Front desk · 3 attempts
Cancelled
Feb 24 · 1 miss
187d past
No-show recovery
Xiomara Nguyen
M412182 · 69y · Millbrook Clinic
(331) 422-4186
Fair
Care coordinator
SNF
Golden Oaks Rehab
Case open
Proj. DC Aug 29
Aug 13
Aug 29
Contacted
PCP office · 3 attempts
Not scheduled
2d left
Window closing
Marcus Baptiste
M463644 · 90y · Mesa Family Medicine
(408) 785-5278
Good
Care coordinator
SNF
Riverstone Post-Acute
Case open
Proj. DC Dec 24
Dec 13
Dec 23
Contacted
Front desk · 3 attempts
No-show
Dec 29 · 1 miss
247d past
No-show recovery
Dwight Lindstrom
M499457 · 64y · Mesa Family Medicine
(513) 312-6612
Good
Care coordinator
SNF
Golden Oaks Rehab
No case
No plan
Apr 23
May 9
Contacted
Care coordinator · 2 attempts
Cancelled
May 14 · 1 miss
110d past
No-show recovery
Bernard Haddad
M452113 · 89y · Saguaro Care
(322) 477-8089
Good
Care coordinator
Observation
Northside Medical Center
Case open
Proj. DC Dec 5
Nov 30
Dec 6
Contacted
PCP office · 3 attempts
Cancelled
Dec 12 · 1 miss
264d past
No-show recovery
Gerald Abernathy
M480702 · 74y · Harbor Family Care
(427) 789-2434
Good
Care coordinator
Home Health
BrightPath Home Health
No case
No plan
Jul 1
Jul 18
Contacted
PCP office · 3 attempts
No-show
Jul 26 · 1 miss
40d past
No-show recovery
Xiomara Chandler
M471241 · 81y · Cedar Hills Family
(377) 300-1117
Good
Care coordinator
Observation
St. Aldon Regional
Case open
Proj. DC May 8
Apr 30
May 8
Contacted
Front desk · 1 attempt
No-show
May 13 · 1 miss
111d past
No-show recovery
Callum Petrov
M426193 · 70y · Bayside Medical
(484) 680-7375
Returned
Serious
Nurse
ED
Northside Medical ED
Case open
Proj. DC Oct 28
Oct 28
Oct 28
Contacted
Nurse case manager · 3 attempts
Completed
Oct 31 · 3d · 1 miss
Met
Readmit — visit completed
Callum Chandler
M479131 · 75y · Millbrook Clinic
(347) 633-5402
Good
Care coordinator
Home Health
Comfort Care at Home
No case
No plan
May 20
Jun 11
Contacted
Care coordinator · 3 attempts
Cancelled
Jun 22 · 1 miss
77d past
No-show recovery
Terrance Lindstrom
M446107 · 60y · Saguaro Care
(326) 637-4690
Good
Care coordinator
Home Health
Comfort Care at Home
Case open
Proj. DC Jul 31
Jul 12
Jul 31
Contacted
Care coordinator · 1 attempt
No-show
Aug 6 · 1 miss
27d past
No-show recovery
Willie Rios
M407768 · 68y · Bayside Medical
(288) 707-3343
Good
Care coordinator
SNF
Ridgeway LTAC
Case open
Proj. DC May 27
May 16
May 27
Contacted
PCP office · 1 attempt
No-show
Jun 2 · 1 miss
92d past
No-show recovery
Callum Rios
M414303 · 60y · Millbrook Clinic
(692) 242-8191
Good
Care coordinator
SNF
Willowbrook SNF
Case open
Proj. DC Dec 22
Dec 8
Dec 22
Contacted
Front desk · 1 attempt
No-show
Jan 1 · 1 miss
248d past
No-show recovery
Simone Nguyen
M414798 · 78y · Redwood Primary
(663) 525-7326
Good
Care coordinator
ED
St. Aldon Regional ED
Case open
Proj. DC Jul 21
Jul 21
Jul 21
Contacted
Front desk · 1 attempt
Cancelled
Jul 25 · 1 miss
37d past
No-show recovery
Otis Whitmore
M401933 · 72y · Stonebridge Health
(395) 822-8831
Good
Care coordinator
Observation
St. Aldon Regional
No case
No plan
May 31
Jun 6
Contacted
Front desk · 1 attempt
No-show
Jun 16 · 1 miss
82d past
No-show recovery
Amir Abernathy
M449312 · 79y · Bayside Medical
(249) 224-1241
Good
Care coordinator
Observation
Mercy General
Case open
Proj. DC Nov 20
Nov 11
Nov 21
Contacted
Care coordinator · 2 attempts
No-show
Nov 24 · 1 miss
279d past
No-show recovery
Willie Kowalski
M437089 · 77y · Harbor Family Care
(311) 345-4972
Good
Care coordinator
SNF
Ridgeway LTAC
Case open
Proj. DC Mar 21
Mar 6
Mar 21
Contacted
Care coordinator · 1 attempt
Cancelled
Mar 27 · 1 miss
159d past
No-show recovery
Eleanor Abernathy
M480701 · 63y · Mesa Family Medicine
(601) 805-9411
Good
Care coordinator
Observation
Northside Medical Center
Case open
Proj. DC Nov 11
Nov 3
Nov 10
Contacted
PCP office · 1 attempt
Cancelled
Nov 14 · 1 miss
290d past
No-show recovery
Gerald Okafor
M447411 · 63y · Redwood Primary
(584) 248-7940
Good
Care coordinator
SNF
Golden Oaks Rehab
Case open
Proj. DC Feb 7
Jan 16
Feb 6
Contacted
Care coordinator · 1 attempt
No-show
Feb 18 · 1 miss
202d past
No-show recovery
Ruth Whitmore
M444995 · 80y · Lakeview Internal
(372) 337-8115
Good
Care coordinator
ED
Northside Medical ED
Case open
Proj. DC Oct 16
Oct 16
Oct 16
Contacted
Front desk · 2 attempts
Cancelled
Oct 29 · 1 miss
315d past
No-show recovery
Nadia Marsden
M492012 · 62y · Mesa Family Medicine
(649) 224-4526
Good
Care coordinator
ED
Northside Medical ED
No case
No plan
Aug 24
Aug 24
Contacted
Front desk · 2 attempts
Cancelled
Aug 26 · 1 miss
3d past
No-show recovery
Terrance Rios
M403633 · 61y · Foxfield Primary
(563) 376-2291
Fair
Care coordinator
Inpatient
Valley Baptist
No case
No plan
Aug 29
LOS 5d
Not started
· 0 attempts
Not scheduled
In facility
No case management
Harold Salazar
M472125 · 83y · Lakeview Internal
(598) 274-1501
Fair
Care coordinator
Inpatient
Valley Baptist
No case
No plan
Sep 2
LOS 1d
Not started
· 0 attempts
Not scheduled
In facility
No case management
Milton Ferreira
M423514 · 84y · Cedar Hills Family
(671) 736-9519
Returned
Fair
Care coordinator
SNF
Golden Oaks Rehab
Case open
Proj. DC Mar 24
Mar 5
Mar 24
Contacted
Care coordinator · 1 attempt
Not scheduled
156d past
Readmit — no appointment
Hattie Lindstrom
M424471 · 77y · Foxfield Primary
(586) 398-9234
Returned
Fair
Care coordinator
ED
St. Aldon Regional ED
Case open
Proj. DC May 8
May 8
May 8
Attempted
Front desk · 1 attempt
Not scheduled
111d past
Readmit — no appointment
Ingrid Delgado
M484123 · 61y · Cedar Hills Family
(278) 761-6013
Returned
Fair
Care coordinator
Observation
Mercy General
No case
No plan
Jun 13
Jun 21
Not started
· 0 attempts
Not scheduled
67d past
Readmit — no appointment
Rafael Guillory
M448603 · 75y · Lakeview Internal
(408) 472-2602
Returned
Fair
Care coordinator
Observation
St. Aldon Regional
Case open
Proj. DC Nov 10
Nov 2
Nov 10
Contacted
Care coordinator · 1 attempt
Not scheduled
290d past
Readmit — no appointment
Willie Nguyen
M417363 · 64y · Stonebridge Health
(211) 224-8765
Returned
Fair
Care coordinator
Home Health
Anchor Home Services
No case
No plan
Jan 16
Feb 22
Not started
· 0 attempts
Not scheduled
186d past
Readmit — no appointment
Dwight Tanaka
M455574 · 70y · Bayside Medical
(570) 768-8109
Fair
Care coordinator
Inpatient
St. Aldon Regional
Case open
Proj. DC May 28
May 22
May 28
Contacted
Front desk · 3 attempts
No-show
May 30 · 1 miss
91d past
No-show recovery
Callum Guillory
M494130 · 68y · Stonebridge Health
(615) 790-8084
Fair
Care coordinator
Inpatient
Valley Baptist
Case open
Proj. DC Apr 30
Apr 21
Apr 30
Contacted
Care coordinator · 1 attempt
Cancelled
May 6 · 1 miss
119d past
No-show recovery
Hattie Lindstrom
M493303 · 80y · Foxfield Primary
(361) 883-5366
Fair
Care coordinator
Inpatient
Mercy General
Case open
Proj. DC Jun 30
Jun 24
Jun 29
Contacted
Care coordinator · 3 attempts
No-show
Jul 5 · 1 miss
59d past
No-show recovery
Milton Rios
M469017 · 76y · Saguaro Care
(641) 375-7949
Good
Care coordinator
Inpatient
Northside Medical Center
No case
No plan
Jul 26
Aug 3
Unable to reach
Care coordinator · 4 attempts
Not scheduled
24d past
Window missed
Hattie Ferreira
M462208 · 88y · Harbor Family Care
(312) 471-2481
Fair
Care coordinator
Inpatient
Mercy General
No case
No plan
Sep 5
Sep 11
Contacted
Care coordinator · 2 attempts
No-show
Sep 19 · 1 miss
350d past
No-show recovery
Callum Petrov
M484868 · 58y · Stonebridge Health
(675) 342-8133
Fair
Care coordinator
Inpatient
St. Aldon Regional
Case open
Proj. DC Aug 3
Jul 25
Aug 3
Contacted
Front desk · 3 attempts
Cancelled
Aug 19 · 1 miss
24d past
No-show recovery
Simone Chandler
M450931 · 89y · Mesa Family Medicine
(491) 551-5651
Fair
Care coordinator
Inpatient
Northside Medical Center
Case open
Proj. DC Aug 19
Aug 15
Aug 19
Contacted
Care coordinator · 3 attempts
No-show
Aug 21 · 1 miss
8d past
No-show recovery
Ingrid Lindstrom
M495865 · 79y · Mesa Family Medicine
(242) 715-8364
Fair
Care coordinator
Inpatient
St. Aldon Regional
Case open
Proj. DC Mar 27
Mar 21
Mar 26
Contacted
Front desk · 2 attempts
No-show
Apr 5 · 1 miss
154d past
No-show recovery
Callum Nguyen
M426269 · 66y · Mesa Family Medicine
(368) 360-4706
Fair
Care coordinator
Inpatient
Northside Medical Center
Case open
Proj. DC Feb 6
Jan 27
Feb 5
Contacted
PCP office · 1 attempt
Cancelled
Feb 11 · 1 miss
203d past
No-show recovery
Marcus Nguyen
M466398 · 58y · Harbor Family Care
(274) 438-3042
Fair
Care coordinator
Inpatient
Valley Baptist
Case open
Proj. DC Feb 28
Feb 22
Feb 28
Contacted
Front desk · 2 attempts
No-show
Mar 14 · 1 miss
180d past
No-show recovery
Harold Rios
M498101 · 69y · Saguaro Care
(528) 782-2189
Good
Care coordinator
Home Health
Anchor Home Services
Case open
Proj. DC Sep 4
Jul 30
Sep 3
Contacted
Care coordinator · 1 attempt
Not scheduled
7d left
Contacted, no appointment
Lena Mbeki
M437552 · 76y · Harbor Family Care
(308) 687-7539
Fair
Care coordinator
Home Health
Comfort Care at Home
No case
No plan
Aug 30
LOS 4d
Not started
· 0 attempts
Not scheduled
In facility
No case management
Cora Abernathy
M497700 · 77y · Stonebridge Health
(483) 351-3386
Fair
Care coordinator
Home Health
Comfort Care at Home
No case
No plan
Aug 21
LOS 13d
Not started
· 0 attempts
Not scheduled
In facility
No case management
Milton Abernathy
M487098 · 58y · Bayside Medical
(692) 443-6727
Fair
Care coordinator
Inpatient
St. Aldon Regional
Case open
Proj. DC Aug 31
Aug 24
Sep 1
Attempted
Care coordinator · 1 attempt
Not scheduled
5d left
Contacted, no appointment
Harold Abernathy
M442333 · 71y · Bayside Medical
(359) 791-8883
Good
Care coordinator
Home Health
Comfort Care at Home
Case open
Proj. DC Aug 26
Jul 25
Aug 26
Contacted
Care coordinator · 3 attempts
Not scheduled
1d past
Window missed
Yuki Nguyen
M419969 · 89y · Harbor Family Care
(506) 478-7799
Fair
Care coordinator
Home Health
Anchor Home Services
Case open
Proj. DC Mar 30
Feb 22
Mar 30
Contacted
Front desk · 1 attempt
Cancelled
Apr 2 · 1 miss
150d past
No-show recovery
Nadia Guillory
M414618 · 78y · Bayside Medical
(666) 206-3329
Fair
Care coordinator
SNF
Golden Oaks Rehab
Case open
Proj. DC Dec 1
Nov 11
Dec 2
Contacted
Care coordinator · 3 attempts
No-show
Dec 17 · 1 miss
268d past
No-show recovery
Nadia Ionescu
M415608 · 76y · Harbor Family Care
(461) 880-5701
Fair
Care coordinator
SNF
Ridgeway LTAC
Case open
Proj. DC Nov 29
Nov 11
Nov 30
Contacted
Care coordinator · 2 attempts
No-show
Dec 6 · 1 miss
270d past
No-show recovery
Harold Rios
M486266 · 72y · Saguaro Care
(582) 567-5209
Good
Care coordinator
SNF
Golden Oaks Rehab
No case
No plan
Jul 19
Aug 11
Contacted
Care coordinator · 1 attempt
Not scheduled
16d past
Window missed
Beatrice Lindstrom
M479280 · 77y · Mesa Family Medicine
(263) 300-7492
Fair
Care coordinator
SNF
Willowbrook SNF
Case open
Proj. DC Feb 14
Feb 1
Feb 13
Contacted
Care coordinator · 2 attempts
Cancelled
Feb 19 · 1 miss
195d past
No-show recovery
Ruth Baptiste
M417774 · 76y · Harbor Family Care
(547) 599-3554
Fair
Care coordinator
ED
Northside Medical ED
Case open
Proj. DC Jul 8
Jul 8
Jul 8
Contacted
PCP office · 3 attempts
No-show
Jul 12 · 1 miss
50d past
No-show recovery
Gerald Whitmore
M436305 · 73y · Lakeview Internal
(667) 729-8020
Fair
Care coordinator
Observation
Mercy General
Case open
Proj. DC Jun 24
Jun 16
Jun 25
Contacted
Care coordinator · 3 attempts
No-show
Jul 1 · 1 miss
63d past
No-show recovery
Gerald Delgado
M473675 · 73y · Harbor Family Care
(435) 604-8336
Fair
Care coordinator
ED
Northside Medical ED
Case open
Proj. DC Jun 9
Jun 9
Jun 9
Contacted
Front desk · 3 attempts
Cancelled
Jun 22 · 1 miss
79d past
No-show recovery
Beatrice Kowalski
M462382 · 63y · Cedar Hills Family
(606) 344-1113
Returned
Good
Care coordinator
Home Health
Comfort Care at Home
Case open
Proj. DC Apr 15
Mar 12
Apr 15
Contacted
Front desk · 3 attempts
Completed
Apr 17 · 2d
Met
Readmit — visit completed
Ruth Mbeki
M433503 · 65y · Saguaro Care
(703) 607-6893
Fair
Care coordinator
Home Health
Comfort Care at Home
Case open
Proj. DC Aug 20
Aug 5
Aug 19
Attempted
Front desk · 2 attempts
Not scheduled
8d past
Window missed
Alma Marsden
M417085 · 67y · Mesa Family Medicine
(629) 447-6161
Fair
Care coordinator
Home Health
Anchor Home Services
Case open
Proj. DC Jul 29
Jul 8
Jul 29
Attempted
PCP office · 2 attempts
Not scheduled
29d past
Window missed
Lena Salazar
M480113 · 78y · Millbrook Clinic
(616) 387-4527
Fair
Care coordinator
Home Health
BrightPath Home Health
Case open
Proj. DC Aug 22
Aug 9
Aug 23
Contacted
Care coordinator · 3 attempts
Not scheduled
4d past
Window missed
Dwight Sorensen
M438416 · 76y · Stonebridge Health
(417) 344-8056
Fair
Care coordinator
ED
Valley Baptist ED
No case
No plan
Aug 17
Aug 17
Attempted
Care coordinator · 1 attempt
Not scheduled
10d past
Window missed

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