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
49 of 60 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 | 1 | 0% | 100% | 0% | 0% | 0 |
| Dr. R. Nakamura | 1 | 2 | 75% | 33.3% | 0% | 0% | 0 |
| Dr. L. Castellanos | 0 | 0 | 71.4% | 100% | 14.3% | 28.6% | 2 |
| Dr. M. Okonkwo | 1 | 1 | 100% | 57.1% | 25% | 28.6% | 3 |
| Dr. T. Lindqvist | 0 | 0 | 66.7% | 33.3% | 0% | 33.3% | 0 |
| Dr. K. Vasquez | 1 | 1 | 66.7% | 60% | 0% | 40% | 2 |
| Dr. J. Persaud | 1 | 1 | 100% | 83.3% | 0% | 50% | 1 |
| Dr. P. Aiyer | 1 | 1 | 100% | 60% | 0% | 60% | 1 |
| Dr. H. Kaur | 0 | 2 | 90.9% | 72.7% | 0% | 63.6% | 1 |
| Dr. S. Brennan | 2 | 2 | 80% | 100% | 33.3% | 66.7% | 1 |
| Dr. A. Whitfield | 0 | 0 | 100% | 100% | 0% | 75% | 2 |
| Dr. D. Moreau | 1 | 1 | 100% | 100% | 0% | 100% | 0 |
13 records match the current filters
| Patient | Tier / Owner | Setting & facility | Case mgmt | Admit / Discharge | Outreach | Appointment | Window | Status / Next action |
|---|---|---|---|---|---|---|---|---|
Callum Guillory M486687 · 67y · Lakeview Internal (414) 245-432060d 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 |
Imani Rios M486109 · 72y · Lakeview Internal (438) 596-683160d 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 |
Ruth Mbeki M417900 · 84y · Lakeview Internal (590) 593-375160d 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 |
Eleanor Lindstrom M403537 · 82y · Lakeview Internal (649) 721-9331Returned | 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 |
Delia Delgado M495766 · 75y · Lakeview Internal (501) 850-3390Returned | 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 |
Imani Marsden M448092 · 91y · Lakeview Internal (543) 433-3348Returned | 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 |
Simone Whitmore M453485 · 72y · Lakeview Internal (354) 846-5374Returned | 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 |
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 |
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 |
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 |
Rafael Guillory M448603 · 75y · Lakeview Internal (408) 472-2602Returned | 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 |
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 |