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 51 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. A. Whitfield | 1 | 2 | 60% | 75% | 0% | 0% | 2 |
| Dr. S. Brennan | 0 | 0 | 100% | 100% | 0% | 0% | 0 |
| Dr. T. Lindqvist | 0 | 1 | 83.3% | 50% | 0% | 16.7% | 1 |
| Dr. J. Persaud | 0 | 0 | 80% | 80% | 0% | 20% | 1 |
| Dr. K. Vasquez | 0 | 0 | 85.7% | 71.4% | 20% | 28.6% | 3 |
| Dr. D. Moreau | 0 | 0 | 83.3% | 66.7% | 0% | 33.3% | 2 |
| Dr. M. Okonkwo | 1 | 1 | 75% | 66.7% | 0% | 33.3% | 1 |
| Dr. R. Nakamura | 0 | 0 | 66.7% | 66.7% | 50% | 33.3% | 0 |
| Dr. L. Castellanos | 1 | 2 | 100% | 100% | 0% | 40% | 2 |
| Dr. P. Aiyer | 1 | 1 | 100% | 100% | 0% | 50% | 0 |
| Dr. E. Boateng | 1 | 1 | 100% | 100% | 0% | 75% | 0 |
| Dr. H. Kaur | 3 | 2 | 100% | 100% | 20% | 80% | 1 |
13 records match the current filters
| Patient | Tier / Owner | Setting & facility | Case mgmt | Admit / Discharge | Outreach | Appointment | Window | Status / Next action |
|---|---|---|---|---|---|---|---|---|
Terrance Haddad M442225 · 59y · Cedar Hills Family (605) 328-748060d 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 |
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 |
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 |
Amir Kowalski M446419 · 78y · Cedar Hills Family (339) 523-7456Returned | 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) 407-898460d 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) 351-995660d 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) 449-3390Returned | 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 |
Delia Mbeki M413912 · 59y · Cedar Hills Family (319) 592-6489Returned | 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 |
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 |
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 |
Milton Ferreira M423514 · 84y · Cedar Hills Family (671) 736-9519Returned | 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 |
Ingrid Delgado M484123 · 61y · Cedar Hills Family (278) 761-6013Returned | 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 |
Beatrice Kowalski M462382 · 63y · Cedar Hills Family (606) 344-1113Returned | 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 |