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
45 of 57 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 | 2 | 2 | 100% | 50% | 0% | 0% | 0 |
| Dr. P. Aiyer | 0 | 0 | 50% | 0% | 0% | 0% | 0 |
| Dr. R. Nakamura | 0 | 1 | 75% | 50% | 0% | 0% | 2 |
| Dr. S. Brennan | 0 | 0 | 55.6% | 66.7% | 0% | 11.1% | 0 |
| Dr. J. Persaud | 0 | 0 | 100% | 83.3% | 0% | 16.7% | 1 |
| Dr. K. Vasquez | 0 | 1 | 80% | 80% | 0% | 20% | 0 |
| Dr. T. Lindqvist | 0 | 1 | 85.7% | 57.1% | 25% | 28.6% | 2 |
| Dr. H. Kaur | 0 | 0 | 66.7% | 100% | 33.3% | 33.3% | 1 |
| Dr. L. Castellanos | 0 | 2 | 100% | 66.7% | 0% | 33.3% | 1 |
| Dr. D. Moreau | 0 | 1 | 80% | 80% | 0% | 40% | 3 |
| Dr. M. Okonkwo | 1 | 1 | 87.5% | 85.7% | 16.7% | 42.9% | 2 |
| Dr. E. Boateng | 0 | 0 | 75% | 75% | 0% | 50% | 0 |
12 records match the current filters
| Patient | Tier / Owner | Setting & facility | Case mgmt | Admit / Discharge | Outreach | Appointment | Window | Status / Next action |
|---|---|---|---|---|---|---|---|---|
Priya Ferreira M496179 · 66y · Millbrook Clinic (399) 431-501960d readmitReturned | Critical Nurse | Inpatient Northside Medical Center | Case open Proj. DC Apr 21 | Apr 14 Apr 22 | Contacted Nurse case manager · 2 attempts | Completed Apr 26 · 4d | Met | Readmit — visit completed |
Nadia Rios M406629 · 90y · Millbrook Clinic (687) 422-7611Returned | Critical Nurse | Inpatient Mercy General | Case open Proj. DC Nov 6 | Nov 3 Nov 7 | Contacted Nurse case manager · 2 attempts | Completed Nov 12 · 5d | Met | Readmit — visit completed |
Gerald Abernathy M449223 · 88y · Millbrook Clinic (484) 623-3620 | Serious Nurse | Home Health Anchor Home Services | Case open Proj. DC Feb 16 | Jan 31 Feb 16 | Contacted Nurse case manager · 3 attempts | Cancelled Mar 4 · 1 miss | 192d past | No-show recovery |
Ruth Ionescu M493013 · 61y · Millbrook Clinic (294) 806-4802Returned | Good Care coordinator | Inpatient Northside Medical Center | Case open Proj. DC Aug 13 | Aug 6 Aug 13 | Attempted Care coordinator · 2 attempts | Not scheduled — | 14d past | Readmit — no appointment |
Priya Whitmore M434386 · 68y · Millbrook Clinic (270) 591-7478 | Good Care coordinator | Inpatient Northside Medical Center | Case open Proj. DC Aug 23 | Aug 20 Aug 24 | Contacted Care coordinator · 2 attempts | Cancelled Aug 26 · 1 miss | 3d past | No-show recovery |
Imani Chandler M491878 · 74y · Millbrook Clinic (676) 393-3864 | Good Care coordinator | Inpatient Valley Baptist | Case open Proj. DC Oct 25 | Oct 18 Oct 25 | Contacted Care coordinator · 3 attempts | No-show Nov 8 · 1 miss | 306d past | No-show recovery |
Gerald Rios M459965 · 84y · Millbrook Clinic (642) 631-7428Returned | Fair Care coordinator | Inpatient Valley Baptist | Case open Proj. DC Jun 3 | May 29 Jun 4 | Contacted Front desk · 1 attempt | Not scheduled — | 84d past | Readmit — no appointment |
Terrance Abernathy M472131 · 87y · Millbrook Clinic (231) 427-8576 | Good Care coordinator | Observation St. Aldon Regional | No case No plan | Feb 16 Feb 21 | Contacted Front desk · 3 attempts | Cancelled Feb 24 · 1 miss | 187d past | No-show recovery |
Xiomara Nguyen M412182 · 69y · Millbrook Clinic (331) 422-4186 | Fair Care coordinator | SNF Golden Oaks Rehab | Case open Proj. DC Aug 29 | Aug 13 Aug 29 | Contacted PCP office · 3 attempts | Not scheduled — | 2d left | Window closing |
Callum Chandler M479131 · 75y · Millbrook Clinic (347) 633-5402 | Good Care coordinator | Home Health Comfort Care at Home | No case No plan | May 20 Jun 11 | Contacted Care coordinator · 3 attempts | Cancelled Jun 22 · 1 miss | 77d past | No-show recovery |
Callum Rios M414303 · 60y · Millbrook Clinic (692) 242-8191 | Good Care coordinator | SNF Willowbrook SNF | Case open Proj. DC Dec 22 | Dec 8 Dec 22 | Contacted Front desk · 1 attempt | No-show Jan 1 · 1 miss | 248d past | No-show recovery |
Lena Salazar M480113 · 78y · Millbrook Clinic (616) 387-4527 | Fair Care coordinator | Home Health BrightPath Home Health | Case open Proj. DC Aug 22 | Aug 9 Aug 23 | Contacted Care coordinator · 3 attempts | Not scheduled — | 4d past | Window missed |