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 61 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. K. Vasquez | 0 | 1 | 66.7% | 33.3% | 0% | 0% | 0 |
| Dr. P. Aiyer | 0 | 1 | 80% | 80% | 0% | 20% | 0 |
| Dr. T. Lindqvist | 0 | 0 | 80% | 100% | 0% | 20% | 1 |
| Dr. J. Persaud | 0 | 2 | 100% | 50% | 0% | 25% | 0 |
| Dr. R. Nakamura | 1 | 1 | 80% | 75% | 0% | 25% | 1 |
| Dr. D. Moreau | 0 | 0 | 100% | 75% | 16.7% | 37.5% | 3 |
| Dr. L. Castellanos | 0 | 0 | 80% | 80% | 0% | 40% | 1 |
| Dr. E. Boateng | 0 | 1 | 100% | 85.7% | 16.7% | 42.9% | 2 |
| Dr. A. Whitfield | 1 | 2 | 100% | 75% | 0% | 50% | 0 |
| Dr. H. Kaur | 0 | 0 | 87.5% | 75% | 0% | 50% | 0 |
| Dr. M. Okonkwo | 2 | 2 | 70% | 75% | 16.7% | 50% | 0 |
8 records match the current filters
| Patient | Tier / Owner | Setting & facility | Case mgmt | Admit / Discharge | Outreach | Appointment | Window | Status / Next action |
|---|---|---|---|---|---|---|---|---|
Priya Chandler M401044 · 83y · Redwood Primary (571) 285-8648 | Critical Nurse | SNF Willowbrook SNF | Case open Proj. DC May 3 | Apr 18 May 3 | Contacted Nurse case manager · 1 attempt | Cancelled May 8 · 1 miss | 116d past | No-show recovery |
Xiomara Petrov M470800 · 86y · Redwood Primary (257) 432-7572Returned | Critical Nurse | ED Northside Medical ED | Case open Proj. DC May 22 | May 22 May 22 | Contacted Nurse case manager · 3 attempts | Completed May 25 · 3d | Met | Readmit — visit completed |
Jonas Mbeki M442965 · 88y · Redwood Primary (531) 525-778560d readmit | Good Care coordinator | SNF Golden Oaks Rehab | Case open Proj. DC Jan 5 | Dec 18 Jan 4 | Contacted Care coordinator · 1 attempt | No-show Jan 20 · 1 miss | 235d past | No-show recovery |
Frank Petrov M440076 · 69y · Redwood Primary (302) 792-352760d readmitReturned | Fair Care coordinator | SNF Willowbrook SNF | Case open Proj. DC Jul 8 | Jun 22 Jul 8 | Attempted PCP office · 1 attempt | Not scheduled — | 50d past | Readmit — no appointment |
Terrance Kowalski M493861 · 63y · Redwood Primary (491) 772-3577Returned | Serious Nurse | Inpatient Mercy General | Case open Proj. DC Dec 2 | Nov 29 Dec 2 | Contacted Nurse case manager · 2 attempts | Completed Dec 7 · 5d | Met | Readmit — visit completed |
Willie Abernathy M464415 · 80y · Redwood Primary (258) 837-1205 | Good Care coordinator | Home Health Comfort Care at Home | No case No plan | Aug 20 LOS 14d | Not started — · 0 attempts | Not scheduled — | In facility | No case management |
Simone Nguyen M414798 · 78y · Redwood Primary (663) 525-7326 | Good Care coordinator | ED St. Aldon Regional ED | Case open Proj. DC Jul 21 | Jul 21 Jul 21 | Contacted Front desk · 1 attempt | Cancelled Jul 25 · 1 miss | 37d past | No-show recovery |
Gerald Okafor M447411 · 63y · Redwood Primary (584) 248-7940 | Good Care coordinator | SNF Golden Oaks Rehab | Case open Proj. DC Feb 7 | Jan 16 Feb 6 | Contacted Care coordinator · 1 attempt | No-show Feb 18 · 1 miss | 202d past | No-show recovery |