Level 3 · Center & provider
Every patient on census with case management, outreach, appointment status and the next action.
Inpatient, obs, ED, SNF, home health
Case opened while in facility
Unresolved step in the loop
44 of 72 discharges
Target outcome
Admitted within 60 days of a prior discharge
Census and follow-up performance by PCP
| Provider | Census | Volume 30d | Case managed | Scheduled | No-show | Visit ≤7d | Open |
|---|---|---|---|---|---|---|---|
| Dr. H. Kaur | 0 | 0 | 100% | 33.3% | 100% | 0% | 2 |
| Dr. J. Persaud | 0 | 1 | 85.7% | 28.6% | 50% | 0% | 3 |
| Dr. M. Okonkwo | 0 | 2 | 66.7% | 50% | 33.3% | 0% | 2 |
| Dr. S. Brennan | 0 | 0 | 0% | 0% | 0% | 0% | 0 |
| Dr. A. Whitfield | 0 | 0 | 62.5% | 50% | 25% | 12.5% | 1 |
| Dr. D. Moreau | 1 | 2 | 14.3% | 33.3% | 0% | 16.7% | 3 |
| Dr. P. Aiyer | 2 | 3 | 66.7% | 75% | 33.3% | 25% | 1 |
| Dr. R. Nakamura | 0 | 0 | 25% | 50% | 50% | 25% | 1 |
| Dr. L. Castellanos | 1 | 2 | 75% | 63.6% | 0% | 36.4% | 0 |
| Dr. E. Boateng | 0 | 0 | 60% | 60% | 33.3% | 40% | 1 |
| Dr. K. Vasquez | 0 | 3 | 90% | 60% | 0% | 40% | 2 |
| Dr. T. Lindqvist | 0 | 2 | 57.1% | 71.4% | 0% | 57.1% | 2 |
18 records match the current filters
| Patient | Tier / Owner | Setting & facility | Case mgmt | Admit / Discharge | Outreach | Appointment | Window | Status / Next action |
|---|---|---|---|---|---|---|---|---|
Yuki Delgado M477234 · 67y · Bayside Medical (659) 484-191260d 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 |
Imani Ionescu M421864 · 84y · Bayside Medical (599) 492-7416Returned | 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 |
Ruth Rios M405675 · 83y · Bayside Medical (555) 406-640560d 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 |
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 |
Amir Sorensen M411686 · 78y · Bayside Medical (277) 868-884960d 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 |
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) 600-1058Returned | 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 |
Marcus Ionescu M412078 · 75y · Bayside Medical (420) 541-3941Returned | 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 |
Nadia Haddad M404506 · 83y · Bayside Medical (430) 498-233460d 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 |
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 |
Callum Petrov M426193 · 70y · Bayside Medical (484) 680-7375Returned | 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 |
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 |
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 |
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 |
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 |
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 |