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
53 of 105 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 | 0 | 1 | 62.5% | 25% | 0% | 0% | 2 |
| Dr. D. Moreau | 0 | 3 | 75% | 37.5% | 33.3% | 0% | 5 |
| Dr. K. Vasquez | 1 | 1 | 50% | 42.9% | 0% | 0% | 1 |
| Dr. R. Nakamura | 0 | 0 | 33.3% | 16.7% | 100% | 0% | 4 |
| Dr. T. Lindqvist | 2 | 3 | 36.4% | 44.4% | 25% | 0% | 3 |
| Dr. L. Castellanos | 0 | 1 | 42.9% | 14.3% | 0% | 7.1% | 7 |
| Dr. J. Persaud | 2 | 4 | 60% | 30.8% | 75% | 7.7% | 5 |
| Dr. H. Kaur | 1 | 2 | 70% | 55.6% | 80% | 11.1% | 4 |
| Dr. S. Brennan | 0 | 0 | 16.7% | 50% | 33.3% | 16.7% | 2 |
| Dr. P. Aiyer | 0 | 1 | 66.7% | 41.7% | 20% | 25% | 4 |
| Dr. M. Okonkwo | 0 | 0 | 55.6% | 44.4% | 0% | 33.3% | 3 |
| Dr. E. Boateng | 0 | 0 | 75% | 50% | 0% | 50% | 1 |
41 records match the current filters
| Patient | Tier / Owner | Setting & facility | Case mgmt | Admit / Discharge | Outreach | Appointment | Window | Status / Next action |
|---|---|---|---|---|---|---|---|---|
Delia Mbeki M496123 · 59y · Saguaro Care (341) 248-5979Returned | Critical Nurse | Inpatient Mercy General | Case open Proj. DC Aug 20 | Aug 15 Aug 19 | Contacted Nurse case manager · 3 attempts | Not scheduled — | 8d past | Readmit — no appointment |
Dwight Abernathy M410464 · 85y · Saguaro Care (564) 508-7474Returned | Critical Nurse | Inpatient Mercy General | Case open Proj. DC Nov 3 | Oct 29 Nov 3 | Attempted Nurse case manager · 2 attempts | Not scheduled — | 297d past | Readmit — no appointment |
Jonas Haddad M450014 · 76y · Saguaro Care (674) 855-7072 | Critical Nurse | Inpatient Mercy General | Case open Proj. DC Jun 5 | May 30 Jun 5 | Contacted Nurse case manager · 2 attempts | No-show Jun 10 · 1 miss | 83d past | No-show recovery |
Dwight Baptiste M471184 · 91y · Saguaro Care (394) 735-2877 | Critical Nurse | Inpatient Northside Medical Center | No case No plan | Nov 12 Nov 16 | Contacted Care coordinator · 1 attempt | No-show Nov 18 · 1 miss | 284d past | No-show recovery |
Terrance Ferreira M465335 · 79y · Saguaro Care (505) 755-1409 | Critical Nurse | Inpatient St. Aldon Regional | No case No plan | Nov 24 Nov 29 | Contacted Nurse case manager · 1 attempt | No-show Dec 4 · 1 miss | 271d past | No-show recovery |
Harold Nguyen M463119 · 62y · Saguaro Care (373) 321-861860d readmit | Good Care coordinator | Inpatient Valley Baptist | Case open Proj. DC Aug 6 | Jul 29 Aug 6 | Not started — · 0 attempts | Not scheduled — | 21d past | No outreach yet |
Jonas Guillory M460429 · 60y · Saguaro Care (313) 574-199160d readmit | Good Care coordinator | Inpatient St. Aldon Regional | No case No plan | Aug 26 Sep 2 | Not started — · 0 attempts | Not scheduled — | 6d left | No outreach yet |
Frank Abernathy M477904 · 66y · Saguaro Care (359) 554-279060d readmitReturned | Serious Nurse | ED Mercy General ED | Case open Proj. DC Feb 6 | Feb 6 Feb 6 | Contacted Nurse case manager · 3 attempts | No-show Feb 12 · 1 miss | 202d past | No-show recovery |
Otis Petrov M463338 · 59y · Saguaro Care (465) 269-1560Returned | Serious Nurse | Home Health Anchor Home Services | Case open Proj. DC Oct 15 | Sep 15 Oct 15 | Unable to reach Nurse case manager · 3 attempts | Not scheduled — | 316d past | Readmit — no appointment |
Callum Haddad M425877 · 73y · Saguaro Care (248) 456-3910Returned | Serious Nurse | SNF Ridgeway LTAC | No case No plan | Jun 1 Jun 9 | Not started — · 0 attempts | Not scheduled — | 79d past | Readmit — no appointment |
Rosa Kowalski M494852 · 77y · Saguaro Care (279) 268-7022Returned | Serious Nurse | Home Health BrightPath Home Health | No case No plan | Oct 15 Nov 4 | Unable to reach Nurse case manager · 4 attempts | Not scheduled — | 296d past | Readmit — no appointment |
Terrance Delgado M410664 · 62y · Saguaro Care (262) 282-8296 | Serious Nurse | Inpatient Valley Baptist | Case open Proj. DC Jul 31 | Jul 20 Jul 30 | Contacted Nurse case manager · 3 attempts | No-show Aug 1 · 1 miss | 28d past | No-show recovery |
Otis Guillory M488451 · 61y · Saguaro Care (679) 701-452560d readmitReturned | Good Care coordinator | SNF Ridgeway LTAC | Case open Proj. DC Feb 26 | Feb 7 Feb 26 | Contacted Care coordinator · 1 attempt | Not scheduled — | 182d past | Readmit — no appointment |
Milton Salazar M443698 · 77y · Saguaro Care (463) 712-7743 | Serious Nurse | SNF Golden Oaks Rehab | No case No plan | Sep 2 LOS 1d | Not started — · 0 attempts | Not scheduled — | In facility | No case management |
Lena Marsden M426455 · 58y · Saguaro Care (373) 425-3283 | Good Care coordinator | Inpatient Northside Medical Center | No case No plan | Aug 25 Aug 31 | Not started — · 0 attempts | Not scheduled — | 4d left | No outreach yet |
Dwight Lindstrom M494692 · 67y · Saguaro Care (613) 295-9180 | Good Care coordinator | Inpatient St. Aldon Regional | No case No plan | Aug 18 Aug 21 | Not started — · 0 attempts | Not scheduled — | 6d past | No outreach yet |
Gerald Abernathy M467805 · 64y · Saguaro Care (288) 386-4554 | Serious Nurse | Inpatient St. Aldon Regional | Case open Proj. DC Aug 31 | Aug 26 Aug 31 | Contacted Nurse case manager · 3 attempts | Not scheduled — | 4d left | Contacted, no appointment |
Eleanor Whitmore M403477 · 59y · Saguaro Care (701) 441-5908 | Serious Nurse | SNF Willowbrook SNF | No case No plan | May 26 Jun 16 | Contacted Nurse case manager · 2 attempts | No-show Jun 18 · 1 miss | 72d past | No-show recovery |
Yuki Nguyen M459122 · 80y · Saguaro Care (309) 391-716260d readmit | Good Care coordinator | ED Mercy General ED | No case No plan | Nov 25 Nov 25 | Contacted PCP office · 2 attempts | No-show Nov 29 · 1 miss | 275d past | No-show recovery |
Priya Mbeki M455912 · 70y · Saguaro Care (487) 368-9288 | Good Care coordinator | Home Health Comfort Care at Home | Case open Proj. DC Aug 15 | Jul 18 Aug 15 | Not started — · 0 attempts | Not scheduled — | 12d past | No outreach yet |
Ingrid Whitmore M423560 · 62y · Saguaro Care (258) 328-2585 | Fair Care coordinator | Inpatient Mercy General | Case open Proj. DC Sep 3 | Aug 28 Sep 3 | Not started — · 0 attempts | Not scheduled — | 7d left | No outreach yet |
Marcus Ferreira M487351 · 77y · Saguaro Care (519) 845-6666Returned | Good Care coordinator | SNF Willowbrook SNF | Case open Proj. DC Aug 24 | Aug 9 Aug 25 | Not started — · 0 attempts | Not scheduled — | 2d past | Readmit — no appointment |
Alma Okafor M423232 · 73y · Saguaro Care (642) 716-4264Returned | Good Care coordinator | SNF Riverstone Post-Acute | No case No plan | Mar 27 Apr 17 | Not started — · 0 attempts | Not scheduled — | 132d past | Readmit — no appointment |
Callum Petrov M485832 · 82y · Saguaro Care (508) 753-5986Returned | Good Care coordinator | Home Health Anchor Home Services | No case No plan | May 27 Jun 10 | Not started — · 0 attempts | Not scheduled — | 78d past | Readmit — no appointment |
Alma Lindstrom M425076 · 89y · Saguaro Care (597) 322-5377Returned | Good Care coordinator | ED St. Aldon Regional ED | No case No plan | Feb 25 Feb 25 | Not started — · 0 attempts | Not scheduled — | 183d past | Readmit — no appointment |
Otis Ionescu M448633 · 84y · Saguaro Care (292) 505-1401 | Serious Nurse | Home Health BrightPath Home Health | Case open Proj. DC Aug 12 | Jul 18 Aug 11 | Contacted Nurse case manager · 1 attempt | Not scheduled — | 16d past | Window missed |
Rosa Whitmore M435004 · 61y · Saguaro Care (444) 712-8815Returned | Good Care coordinator | SNF Golden Oaks Rehab | No case No plan | Sep 27 Oct 21 | Not started — · 0 attempts | Not scheduled — | 310d past | Readmit — no appointment |
Milton Sorensen M430743 · 64y · Saguaro Care (215) 760-5274Returned | Good Care coordinator | Home Health Anchor Home Services | No case No plan | Apr 13 May 14 | Not started — · 0 attempts | Not scheduled — | 105d past | Readmit — no appointment |
Harold Ferreira M481133 · 73y · Saguaro Care (661) 528-1142Returned | Good Care coordinator | Home Health Comfort Care at Home | Case open Proj. DC Nov 18 | Oct 28 Nov 18 | Not started — · 0 attempts | Not scheduled — | 282d past | Readmit — no appointment |
Jonas Sorensen M427072 · 91y · Saguaro Care (364) 875-4551Returned | Good Care coordinator | SNF Ridgeway LTAC | No case No plan | Mar 23 Apr 17 | Not started — · 0 attempts | Not scheduled — | 132d past | Readmit — no appointment |
Gerald Kowalski M407679 · 90y · Saguaro Care (455) 672-6408Returned | Good Care coordinator | ED Mercy General ED | No case No plan | Feb 8 Feb 8 | Not started — · 0 attempts | Not scheduled — | 200d past | Readmit — no appointment |
Xiomara Delgado M461509 · 86y · Saguaro Care (481) 588-2902 | Good Care coordinator | Inpatient Mercy General | Case open Proj. DC Dec 2 | Nov 25 Dec 1 | Contacted Care coordinator · 1 attempt | No-show Dec 6 · 1 miss | 269d past | No-show recovery |
Amir Ionescu M488059 · 59y · Saguaro Care (686) 205-5493Returned | Good Care coordinator | Inpatient Valley Baptist | No case No plan | Jan 16 Jan 26 | Contacted PCP office · 3 attempts | No-show Jan 31 · 1 miss | 213d past | No-show recovery |
Harold Rios M443407 · 78y · Saguaro Care (544) 788-839660d readmit | Fair Care coordinator | SNF Riverstone Post-Acute | Case open Proj. DC Nov 12 | Oct 29 Nov 12 | Contacted Care coordinator · 2 attempts | No-show Nov 24 · 1 miss | 288d past | No-show recovery |
Alma Kowalski M419270 · 77y · Saguaro Care (563) 400-3087 | Fair Care coordinator | ED Northside Medical ED | Case open Proj. DC Aug 13 | Aug 13 Aug 13 | Not started — · 0 attempts | Not scheduled — | 14d past | No outreach yet |
Bernard Haddad M452113 · 89y · Saguaro Care (322) 477-8089 | Good Care coordinator | Observation Northside Medical Center | Case open Proj. DC Dec 5 | Nov 30 Dec 6 | Contacted PCP office · 3 attempts | Cancelled Dec 12 · 1 miss | 264d past | No-show recovery |
Terrance Lindstrom M446107 · 60y · Saguaro Care (326) 637-4690 | Good Care coordinator | Home Health Comfort Care at Home | Case open Proj. DC Jul 31 | Jul 12 Jul 31 | Contacted Care coordinator · 1 attempt | No-show Aug 6 · 1 miss | 27d past | No-show recovery |
Milton Rios M469017 · 76y · Saguaro Care (641) 375-7949 | Good Care coordinator | Inpatient Northside Medical Center | No case No plan | Jul 26 Aug 3 | Unable to reach Care coordinator · 4 attempts | Not scheduled — | 24d past | Window missed |
Harold Rios M498101 · 69y · Saguaro Care (528) 782-2189 | Good Care coordinator | Home Health Anchor Home Services | Case open Proj. DC Sep 4 | Jul 30 Sep 3 | Contacted Care coordinator · 1 attempt | Not scheduled — | 7d left | Contacted, no appointment |
Harold Rios M486266 · 72y · Saguaro Care (582) 567-5209 | Good Care coordinator | SNF Golden Oaks Rehab | No case No plan | Jul 19 Aug 11 | Contacted Care coordinator · 1 attempt | Not scheduled — | 16d past | Window missed |
Ruth Mbeki M433503 · 65y · Saguaro Care (703) 607-6893 | Fair Care coordinator | Home Health Comfort Care at Home | Case open Proj. DC Aug 20 | Aug 5 Aug 19 | Attempted Front desk · 2 attempts | Not scheduled — | 8d past | Window missed |