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
64 of 95 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. D. Moreau | 2 | 2 | 72.7% | 44.4% | 0% | 0% | 1 |
| Dr. L. Castellanos | 0 | 0 | 62.5% | 12.5% | 0% | 0% | 3 |
| Dr. M. Okonkwo | 1 | 1 | 71.4% | 50% | 0% | 0% | 0 |
| Dr. K. Vasquez | 0 | 0 | 66.7% | 83.3% | 0% | 16.7% | 2 |
| Dr. P. Aiyer | 0 | 1 | 81.8% | 54.5% | 16.7% | 18.2% | 5 |
| Dr. J. Persaud | 1 | 1 | 88.9% | 62.5% | 40% | 25% | 2 |
| Dr. R. Nakamura | 0 | 0 | 75% | 75% | 44.4% | 25% | 6 |
| Dr. H. Kaur | 0 | 2 | 85.7% | 71.4% | 20% | 28.6% | 1 |
| Dr. S. Brennan | 0 | 1 | 57.1% | 28.6% | 0% | 28.6% | 1 |
| Dr. A. Whitfield | 1 | 2 | 60% | 66.7% | 33.3% | 33.3% | 5 |
| Dr. E. Boateng | 0 | 0 | 75% | 62.5% | 0% | 50% | 1 |
| Dr. T. Lindqvist | 0 | 0 | 100% | 75% | 0% | 50% | 1 |
28 records match the current filters
| Patient | Tier / Owner | Setting & facility | Case mgmt | Admit / Discharge | Outreach | Appointment | Window | Status / Next action |
|---|---|---|---|---|---|---|---|---|
Beatrice Mbeki M418184 · 61y · Harbor Family Care (654) 669-6458Returned | 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 |
Hattie Abernathy M474845 · 68y · Harbor Family Care (491) 431-694360d 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 |
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 |
Rafael Chandler M491987 · 60y · Harbor Family Care (643) 262-260760d 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 |
Jonas Chandler M469648 · 58y · Harbor Family Care (667) 726-6808Returned | 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 |
Frank Ionescu M464107 · 80y · Harbor Family Care (214) 675-164560d 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 |
Marcus Salazar M486929 · 91y · Harbor Family Care (608) 469-210560d 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 |
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 |
Milton Okafor M410778 · 71y · Harbor Family Care (457) 812-547060d 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 |
Ingrid Nguyen M417709 · 77y · Harbor Family Care (535) 477-321160d 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 |
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 |
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 |
Yuki Lindstrom M417291 · 76y · Harbor Family Care (408) 356-431760d 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 |
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 |
Xiomara Marsden M403117 · 71y · Harbor Family Care (309) 479-2815Returned | 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 |
Amir Tanaka M421679 · 87y · Harbor Family Care (654) 207-5499Returned | 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 |
Willie Sorensen M467014 · 63y · Harbor Family Care (614) 369-3254Returned | 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) 784-6615Returned | 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 |
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 |
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 |
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 |
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 |
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 |
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 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 |
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 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 |