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
57 of 104 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. J. Persaud | 0 | 0 | 100% | 0% | 0% | 0% | 0 |
| Dr. R. Nakamura | 0 | 3 | 44.4% | 0% | 0% | 0% | 5 |
| Dr. T. Lindqvist | 0 | 0 | 53.3% | 33.3% | 40% | 6.7% | 5 |
| Dr. S. Brennan | 0 | 2 | 44.4% | 22.2% | 50% | 11.1% | 4 |
| Dr. M. Okonkwo | 0 | 1 | 25% | 25% | 0% | 12.5% | 5 |
| Dr. A. Whitfield | 0 | 0 | 42.9% | 42.9% | 0% | 14.3% | 1 |
| Dr. L. Castellanos | 0 | 1 | 57.1% | 14.3% | 0% | 14.3% | 3 |
| Dr. D. Moreau | 1 | 2 | 42.9% | 83.3% | 20% | 16.7% | 3 |
| Dr. E. Boateng | 0 | 0 | 60% | 50% | 20% | 20% | 1 |
| Dr. H. Kaur | 0 | 2 | 64.3% | 71.4% | 40% | 21.4% | 5 |
| Dr. K. Vasquez | 0 | 1 | 75% | 50% | 50% | 25% | 4 |
| Dr. P. Aiyer | 0 | 1 | 12.5% | 50% | 0% | 37.5% | 2 |
38 records match the current filters
| Patient | Tier / Owner | Setting & facility | Case mgmt | Admit / Discharge | Outreach | Appointment | Window | Status / Next action |
|---|---|---|---|---|---|---|---|---|
Callum Petrov M468345 · 80y · Mesa Family Medicine (247) 883-895460d readmitReturned | Critical Nurse | Inpatient Valley Baptist | Case open Proj. DC Nov 8 | Oct 30 Nov 8 | Unable to reach Nurse case manager · 4 attempts | Not scheduled — | 292d past | Readmit — no appointment |
Rafael Tanaka M400896 · 64y · Mesa Family Medicine (489) 623-937760d readmit | Critical Nurse | Inpatient St. Aldon Regional | Case open Proj. DC Dec 24 | Dec 18 Dec 24 | Contacted Nurse case manager · 1 attempt | No-show Jan 5 · 1 miss | 246d past | No-show recovery |
Willie Chandler M434782 · 65y · Mesa Family Medicine (594) 225-3497Returned | Critical Nurse | Inpatient Northside Medical Center | No case No plan | Mar 5 Mar 8 | Attempted Nurse case manager · 1 attempt | Not scheduled — | 172d past | Readmit — no appointment |
Amir Haddad M473495 · 67y · Mesa Family Medicine (545) 683-8266Returned | Critical Nurse | Inpatient Northside Medical Center | No case No plan | Aug 20 Aug 26 | Not started — · 0 attempts | Not scheduled — | 1d past | Readmit — no appointment |
Hattie Salazar M490356 · 58y · Mesa Family Medicine (288) 480-635760d readmitReturned | Serious Nurse | ED Northside Medical ED | No case No plan | Jul 29 Jul 29 | Contacted Nurse case manager · 2 attempts | Not scheduled — | 29d past | Readmit — no appointment |
Beatrice Abernathy M442070 · 73y · Mesa Family Medicine (579) 886-441860d readmit | Serious Nurse | Inpatient Mercy General | No case No plan | May 1 May 11 | Contacted Nurse case manager · 2 attempts | No-show May 20 · 1 miss | 108d past | No-show recovery |
Rosa Okafor M454007 · 61y · Mesa Family Medicine (478) 531-7053 | Critical Nurse | Inpatient Valley Baptist | No case No plan | Aug 24 Sep 3 | Attempted Nurse case manager · 2 attempts | Not scheduled — | 7d left | Contacted, no appointment |
Terrance Okafor M431153 · 70y · Mesa Family Medicine (376) 552-5908 | Serious Nurse | Inpatient Northside Medical Center | No case No plan | Mar 10 Mar 20 | Contacted Care coordinator · 2 attempts | No-show Mar 26 · 1 miss | 160d past | No-show recovery |
Simone Abernathy M494012 · 76y · Mesa Family Medicine (480) 589-7701Returned | Critical Nurse | Inpatient St. Aldon Regional | No case No plan | Aug 9 Aug 16 | Contacted Nurse case manager · 3 attempts | Completed Aug 20 · 4d | Met | Readmit — visit completed |
Milton Sorensen M432687 · 59y · Mesa Family Medicine (216) 552-2766 | Good Care coordinator | Inpatient St. Aldon Regional | No case No plan | Aug 14 Aug 19 | Not started — · 0 attempts | Not scheduled — | 8d past | No outreach yet |
Imani Whitmore M453496 · 65y · Mesa Family Medicine (584) 323-6144 | Serious Nurse | Inpatient Mercy General | Case open Proj. DC Aug 31 | Aug 25 Aug 31 | Contacted Nurse case manager · 3 attempts | Not scheduled — | 4d left | Contacted, no appointment |
Harold Salazar M444693 · 75y · Mesa Family Medicine (282) 344-6894 | Serious Nurse | ED St. Aldon Regional ED | No case No plan | Jul 13 Jul 13 | Contacted Nurse case manager · 2 attempts | Cancelled Jul 17 · 1 miss | 45d past | No-show recovery |
Dwight Kowalski M443432 · 65y · Mesa Family Medicine (518) 773-710260d readmit | Good Care coordinator | SNF Riverstone Post-Acute | Case open Proj. DC May 21 | May 8 May 20 | Contacted Front desk · 1 attempt | No-show May 24 · 1 miss | 99d past | No-show recovery |
Simone Rios M447565 · 74y · Mesa Family Medicine (235) 485-4600 | Serious Nurse | Inpatient Northside Medical Center | Case open Proj. DC Aug 2 | Jul 25 Aug 1 | Contacted Nurse case manager · 1 attempt | Not scheduled — | 26d past | Window missed |
Simone Mbeki M498688 · 83y · Mesa Family Medicine (259) 863-7381Returned | Good Care coordinator | Inpatient St. Aldon Regional | No case No plan | Jul 19 Jul 22 | Not started — · 0 attempts | Not scheduled — | 36d past | Readmit — no appointment |
Bernard Mbeki M402511 · 67y · Mesa Family Medicine (490) 893-3358 | Good Care coordinator | Home Health Anchor Home Services | Case open Proj. DC Aug 16 | Jul 14 Aug 17 | Not started — · 0 attempts | Not scheduled — | 10d past | No outreach yet |
Beatrice Abernathy M460837 · 82y · Mesa Family Medicine (232) 671-5129Returned | Good Care coordinator | Inpatient Northside Medical Center | No case No plan | Oct 3 Oct 7 | Not started — · 0 attempts | Not scheduled — | 324d past | Readmit — no appointment |
Frank Tanaka M407959 · 60y · Mesa Family Medicine (587) 709-7935 | Good Care coordinator | SNF Riverstone Post-Acute | No case No plan | Aug 20 Aug 30 | Not started — · 0 attempts | Not scheduled — | 3d left | No outreach yet |
Hattie Chandler M454226 · 63y · Mesa Family Medicine (390) 753-6050Returned | Good Care coordinator | Inpatient Mercy General | Case open Proj. DC Jan 28 | Jan 22 Jan 28 | Not started — · 0 attempts | Not scheduled — | 211d past | Readmit — no appointment |
Priya Haddad M487648 · 82y · Mesa Family Medicine (244) 778-8409 | Serious Nurse | Observation St. Aldon Regional | Case open Proj. DC Aug 31 | Aug 27 Aug 31 | Contacted Nurse case manager · 1 attempt | Not scheduled — | 4d left | Contacted, no appointment |
Yuki Abernathy M489710 · 79y · Mesa Family Medicine (506) 638-1430 | Fair Care coordinator | Inpatient Valley Baptist | No case No plan | Aug 9 Aug 14 | Not started — · 0 attempts | Not scheduled — | 13d past | No outreach yet |
Bernard Okafor M454699 · 64y · Mesa Family Medicine (223) 892-9564 | Fair Care coordinator | Inpatient Mercy General | No case No plan | Aug 10 Aug 19 | Not started — · 0 attempts | Not scheduled — | 8d past | No outreach yet |
Nadia Okafor M464109 · 89y · Mesa Family Medicine (292) 863-4975Returned | Good Care coordinator | Home Health Anchor Home Services | No case No plan | Sep 12 Oct 12 | Not started — · 0 attempts | Not scheduled — | 319d past | Readmit — no appointment |
Hattie Abernathy M498823 · 77y · Mesa Family Medicine (416) 214-5239Returned | Good Care coordinator | Observation Northside Medical Center | Case open Proj. DC Jun 20 | Jun 12 Jun 21 | Contacted Care coordinator · 3 attempts | Not scheduled — | 67d past | Readmit — no appointment |
Marcus Salazar M471092 · 90y · Mesa Family Medicine (565) 460-4994 | Good Care coordinator | Inpatient Northside Medical Center | No case No plan | Apr 4 Apr 7 | Contacted Care coordinator · 1 attempt | No-show Apr 9 · 1 miss | 142d past | No-show recovery |
Yuki Lindstrom M432648 · 85y · Mesa Family Medicine (555) 276-6006Returned | Good Care coordinator | Inpatient Valley Baptist | Case open Proj. DC Jan 19 | Jan 11 Jan 19 | Contacted Care coordinator · 2 attempts | No-show Jan 21 · 1 miss | 220d past | No-show recovery |
Delia Marsden M444652 · 90y · Mesa Family Medicine (223) 558-7933 | Fair Care coordinator | ED St. Aldon Regional ED | No case No plan | Aug 10 Aug 10 | Not started — · 0 attempts | Not scheduled — | 17d past | No outreach yet |
Amir Delgado M436446 · 84y · Mesa Family Medicine (508) 623-7435Returned | Fair Care coordinator | Inpatient Valley Baptist | No case No plan | Jan 5 Jan 8 | Contacted Care coordinator · 2 attempts | Not scheduled — | 231d past | Readmit — no appointment |
Marcus Chandler M480595 · 89y · Mesa Family Medicine (411) 458-3296Returned | Fair Care coordinator | Inpatient Northside Medical Center | Case open Proj. DC Dec 7 | Dec 5 Dec 8 | Not started — · 0 attempts | Not scheduled — | 262d past | Readmit — no appointment |
Marcus Baptiste M463644 · 90y · Mesa Family Medicine (408) 785-5278 | Good Care coordinator | SNF Riverstone Post-Acute | Case open Proj. DC Dec 24 | Dec 13 Dec 23 | Contacted Front desk · 3 attempts | No-show Dec 29 · 1 miss | 247d past | No-show recovery |
Dwight Lindstrom M499457 · 64y · Mesa Family Medicine (513) 312-6612 | Good Care coordinator | SNF Golden Oaks Rehab | No case No plan | Apr 23 May 9 | Contacted Care coordinator · 2 attempts | Cancelled May 14 · 1 miss | 110d past | No-show recovery |
Eleanor Abernathy M480701 · 63y · Mesa Family Medicine (601) 805-9411 | Good Care coordinator | Observation Northside Medical Center | Case open Proj. DC Nov 11 | Nov 3 Nov 10 | Contacted PCP office · 1 attempt | Cancelled Nov 14 · 1 miss | 290d past | No-show recovery |
Nadia Marsden M492012 · 62y · Mesa Family Medicine (649) 224-4526 | Good Care coordinator | ED Northside Medical ED | No case No plan | Aug 24 Aug 24 | Contacted Front desk · 2 attempts | Cancelled Aug 26 · 1 miss | 3d past | No-show recovery |
Simone Chandler M450931 · 89y · Mesa Family Medicine (491) 551-5651 | Fair Care coordinator | Inpatient Northside Medical Center | Case open Proj. DC Aug 19 | Aug 15 Aug 19 | Contacted Care coordinator · 3 attempts | No-show Aug 21 · 1 miss | 8d past | No-show recovery |
Ingrid Lindstrom M495865 · 79y · Mesa Family Medicine (242) 715-8364 | Fair Care coordinator | Inpatient St. Aldon Regional | Case open Proj. DC Mar 27 | Mar 21 Mar 26 | Contacted Front desk · 2 attempts | No-show Apr 5 · 1 miss | 154d past | No-show recovery |
Callum Nguyen M426269 · 66y · Mesa Family Medicine (368) 360-4706 | Fair Care coordinator | Inpatient Northside Medical Center | Case open Proj. DC Feb 6 | Jan 27 Feb 5 | Contacted PCP office · 1 attempt | Cancelled Feb 11 · 1 miss | 203d past | No-show recovery |
Beatrice Lindstrom M479280 · 77y · Mesa Family Medicine (263) 300-7492 | Fair Care coordinator | SNF Willowbrook SNF | Case open Proj. DC Feb 14 | Feb 1 Feb 13 | Contacted Care coordinator · 2 attempts | Cancelled Feb 19 · 1 miss | 195d past | No-show recovery |
Alma Marsden M417085 · 67y · Mesa Family Medicine (629) 447-6161 | Fair Care coordinator | Home Health Anchor Home Services | Case open Proj. DC Jul 29 | Jul 8 Jul 29 | Attempted PCP office · 2 attempts | Not scheduled — | 29d past | Window missed |