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
36 of 53 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. E. Boateng | 0 | 0 | 60% | 60% | 33.3% | 0% | 1 |
| Dr. J. Persaud | 0 | 0 | 100% | 100% | 0% | 0% | 1 |
| Dr. K. Vasquez | 0 | 0 | 100% | 50% | 0% | 0% | 1 |
| Dr. S. Brennan | 0 | 2 | 57.1% | 57.1% | 25% | 14.3% | 4 |
| Dr. M. Okonkwo | 0 | 1 | 77.8% | 55.6% | 20% | 22.2% | 1 |
| Dr. A. Whitfield | 0 | 0 | 75% | 100% | 0% | 25% | 0 |
| Dr. L. Castellanos | 0 | 1 | 75% | 25% | 0% | 25% | 2 |
| Dr. T. Lindqvist | 1 | 2 | 60% | 25% | 0% | 25% | 1 |
| Dr. R. Nakamura | 2 | 1 | 80% | 66.7% | 0% | 33.3% | 1 |
| Dr. H. Kaur | 0 | 1 | 80% | 60% | 0% | 40% | 1 |
| Dr. D. Moreau | 2 | 2 | 100% | 50% | 0% | 50% | 0 |
| Dr. P. Aiyer | 0 | 0 | 50% | 83.3% | 20% | 83.3% | 0 |
13 records match the current filters
| Patient | Tier / Owner | Setting & facility | Case mgmt | Admit / Discharge | Outreach | Appointment | Window | Status / Next action |
|---|---|---|---|---|---|---|---|---|
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 |
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 |
Imani Whitmore M485117 · 74y · Foxfield Primary (572) 399-1402Returned | 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 |
Marcus Sorensen M465961 · 83y · Foxfield Primary (470) 320-613360d 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 |
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 |
Frank Kowalski M477449 · 58y · Foxfield Primary (622) 450-9370Returned | 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 |
Ruth Tanaka M455483 · 85y · Foxfield Primary (258) 203-5944Returned | 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 |
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 |
Jonas Nguyen M432064 · 78y · Foxfield Primary (524) 379-157860d 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 |
Otis Salazar M491263 · 81y · Foxfield Primary (698) 698-8245Returned | 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 |
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 |
Hattie Lindstrom M424471 · 77y · Foxfield Primary (586) 398-9234Returned | 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 |
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 |