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 72 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. D. Moreau | 0 | 0 | 42.9% | 42.9% | 33.3% | 14.3% | 2 |
| Dr. M. Okonkwo | 0 | 2 | 63.6% | 63.6% | 0% | 18.2% | 0 |
| Dr. E. Boateng | 1 | 1 | 66.7% | 40% | 50% | 20% | 1 |
| Dr. H. Kaur | 0 | 0 | 100% | 60% | 0% | 20% | 1 |
| Dr. L. Castellanos | 0 | 1 | 22.2% | 44.4% | 0% | 22.2% | 2 |
| Dr. S. Brennan | 0 | 1 | 71.4% | 85.7% | 16.7% | 28.6% | 4 |
| Dr. A. Whitfield | 1 | 1 | 57.1% | 66.7% | 0% | 33.3% | 2 |
| Dr. P. Aiyer | 0 | 1 | 66.7% | 83.3% | 0% | 33.3% | 2 |
| Dr. R. Nakamura | 0 | 1 | 66.7% | 66.7% | 0% | 33.3% | 2 |
| Dr. K. Vasquez | 0 | 0 | 83.3% | 83.3% | 0% | 50% | 0 |
| Dr. T. Lindqvist | 2 | 2 | 50% | 75% | 0% | 50% | 1 |
| Dr. J. Persaud | 2 | 2 | 80% | 66.7% | 0% | 66.7% | 0 |
17 records match the current filters
| Patient | Tier / Owner | Setting & facility | Case mgmt | Admit / Discharge | Outreach | Appointment | Window | Status / Next action |
|---|---|---|---|---|---|---|---|---|
Ingrid Nguyen M436746 · 89y · Stonebridge Health (357) 649-939760d readmitReturned | Serious Nurse | ED St. Aldon Regional ED | Case open Proj. DC Apr 20 | Apr 20 Apr 20 | Contacted Nurse case manager · 2 attempts | Not scheduled — | 129d past | Readmit — no appointment |
Rafael Rios M480554 · 91y · Stonebridge Health (495) 876-6441 | Critical Nurse | Inpatient Northside Medical Center | Case open Proj. DC Jan 18 | Jan 8 Jan 18 | Contacted Care coordinator · 1 attempt | No-show Jan 21 · 1 miss | 221d past | No-show recovery |
Willie Delgado M439206 · 59y · Stonebridge Health (488) 648-4220Returned | Critical Nurse | Inpatient Mercy General | Case open Proj. DC Aug 25 | Aug 20 Aug 25 | Contacted Nurse case manager · 3 attempts | Cancelled Aug 31 · 1 miss | 2d past | No-show recovery |
Imani Nguyen M462420 · 89y · Stonebridge Health (249) 663-4539Returned | Serious Nurse | Inpatient Northside Medical Center | No case No plan | Oct 1 Oct 9 | Attempted Nurse case manager · 1 attempt | Not scheduled — | 322d past | Readmit — no appointment |
Otis Lindstrom M400053 · 74y · Stonebridge Health (681) 317-4386 | Serious Nurse | ED Northside Medical ED | No case No plan | Aug 19 Aug 19 | Not started — · 0 attempts | Not scheduled — | 8d past | No outreach yet |
Jonas Lindstrom M458699 · 87y · Stonebridge Health (242) 401-7907 | Serious Nurse | SNF Ridgeway LTAC | Case open Proj. DC Sep 30 | Sep 12 Sep 30 | Contacted Nurse case manager · 2 attempts | Cancelled Oct 5 · 1 miss | 331d past | No-show recovery |
Yuki Abernathy M443863 · 62y · Stonebridge Health (642) 210-7702 | Serious Nurse | Inpatient Northside Medical Center | No case No plan | Aug 18 Aug 26 | Attempted Nurse case manager · 1 attempt | Not scheduled — | 1d past | Window missed |
Amir Petrov M455939 · 60y · Stonebridge Health (660) 714-5364Returned | Good Care coordinator | SNF Golden Oaks Rehab | Case open Proj. DC Jun 19 | Jun 3 Jun 20 | Contacted Care coordinator · 3 attempts | Not scheduled — | 68d past | Readmit — no appointment |
Alma Ionescu M416402 · 80y · Stonebridge Health (703) 281-1138Returned | Serious Nurse | Inpatient Valley Baptist | No case No plan | Jul 2 Jul 8 | Contacted Nurse case manager · 2 attempts | Completed Jul 14 · 6d | Met | Readmit — visit completed |
Yuki Kowalski M448628 · 73y · Stonebridge Health (670) 637-279360d readmitReturned | Fair Care coordinator | SNF Willowbrook SNF | Case open Proj. DC Jun 1 | May 8 Jun 1 | Contacted Care coordinator · 1 attempt | Cancelled Jun 10 · 1 miss | 87d past | No-show recovery |
Otis Whitmore M401933 · 72y · Stonebridge Health (395) 822-8831 | Good Care coordinator | Observation St. Aldon Regional | No case No plan | May 31 Jun 6 | Contacted Front desk · 1 attempt | No-show Jun 16 · 1 miss | 82d past | No-show recovery |
Willie Nguyen M417363 · 64y · Stonebridge Health (211) 224-8765Returned | Fair Care coordinator | Home Health Anchor Home Services | No case No plan | Jan 16 Feb 22 | Not started — · 0 attempts | Not scheduled — | 186d past | Readmit — no appointment |
Callum Guillory M494130 · 68y · Stonebridge Health (615) 790-8084 | Fair Care coordinator | Inpatient Valley Baptist | Case open Proj. DC Apr 30 | Apr 21 Apr 30 | Contacted Care coordinator · 1 attempt | Cancelled May 6 · 1 miss | 119d past | No-show recovery |
Callum Petrov M484868 · 58y · Stonebridge Health (675) 342-8133 | Fair Care coordinator | Inpatient St. Aldon Regional | Case open Proj. DC Aug 3 | Jul 25 Aug 3 | Contacted Front desk · 3 attempts | Cancelled Aug 19 · 1 miss | 24d past | No-show recovery |
Cora Abernathy M497700 · 77y · Stonebridge Health (483) 351-3386 | Fair Care coordinator | Home Health Comfort Care at Home | No case No plan | Aug 21 LOS 13d | Not started — · 0 attempts | Not scheduled — | In facility | No case management |
Dwight Sorensen M438416 · 76y · Stonebridge Health (417) 344-8056 | Fair Care coordinator | ED Valley Baptist ED | No case No plan | Aug 17 Aug 17 | Attempted Care coordinator · 1 attempt | Not scheduled — | 10d past | Window missed |
Delia Nguyen M479226 · 77y · Stonebridge Health (563) 303-4545Returned | Fair Care coordinator | SNF Willowbrook SNF | Case open Proj. DC Jun 29 | Jun 12 Jun 29 | Contacted Care coordinator · 3 attempts | Completed Jul 4 · 5d · 1 miss | Met | Readmit — visit completed |