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
108 of 167 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. M. Okonkwo | 1 | 3 | 69.2% | 50% | 16.7% | 0% | 2 |
| Dr. D. Moreau | 3 | 4 | 50% | 40% | 0% | 6.7% | 4 |
| Dr. J. Persaud | 1 | 2 | 87.5% | 46.7% | 42.9% | 13.3% | 5 |
| Dr. H. Kaur | 0 | 2 | 90% | 60% | 33.3% | 20% | 3 |
| Dr. P. Aiyer | 2 | 4 | 76.5% | 60% | 22.2% | 20% | 6 |
| Dr. L. Castellanos | 1 | 2 | 70% | 42.1% | 0% | 21.1% | 3 |
| Dr. A. Whitfield | 1 | 2 | 61.1% | 58.8% | 30% | 23.5% | 6 |
| Dr. R. Nakamura | 0 | 0 | 62.5% | 68.8% | 45.5% | 25% | 7 |
| Dr. S. Brennan | 0 | 1 | 50% | 25% | 0% | 25% | 1 |
| Dr. K. Vasquez | 0 | 3 | 81.3% | 68.8% | 0% | 31.3% | 4 |
| Dr. E. Boateng | 0 | 0 | 69.2% | 61.5% | 12.5% | 46.2% | 2 |
| Dr. T. Lindqvist | 0 | 2 | 72.7% | 72.7% | 0% | 54.5% | 3 |
46 records match the current filters
| Patient | Tier / Owner | Setting & facility | Case mgmt | Admit / Discharge | Outreach | Appointment | Window | Status / Next action |
|---|---|---|---|---|---|---|---|---|
Beatrice Mbeki M418184 · 61y · Harbor Family Care (654) 669-6458Returned | Critical Nurse | ED Valley Baptist ED | No case No plan | Aug 21 Aug 21 | Attempted Nurse case manager · 2 attempts | Not scheduled — | 6d past | Readmit — no appointment |
Hattie Abernathy M474845 · 68y · Harbor Family Care (491) 431-694360d readmit | Good Care coordinator | Inpatient Mercy General | Case open Proj. DC Aug 13 | Aug 4 Aug 13 | Not started — · 0 attempts | Not scheduled — | 14d past | No outreach yet |
Dwight Chandler M455735 · 63y · Harbor Family Care (538) 741-2145 | Critical Nurse | SNF Ridgeway LTAC | Case open Proj. DC Jan 7 | Dec 28 Jan 8 | Contacted Nurse case manager · 1 attempt | Cancelled Jan 12 · 1 miss | 231d past | No-show recovery |
Rafael Chandler M491987 · 60y · Harbor Family Care (643) 262-260760d readmitReturned | Good Care coordinator | Inpatient Valley Baptist | Case open Proj. DC May 26 | May 22 May 26 | Contacted Care coordinator · 3 attempts | Not scheduled — | 93d past | Readmit — no appointment |
Yuki Delgado M477234 · 67y · Bayside Medical (659) 484-191260d readmit | Good Care coordinator | ED Mercy General ED | No case No plan | Aug 17 Aug 17 | Not started — · 0 attempts | Not scheduled — | 10d past | No outreach yet |
Jonas Chandler M469648 · 58y · Harbor Family Care (667) 726-6808Returned | Serious Nurse | Home Health BrightPath Home Health | Case open Proj. DC Mar 14 | Feb 23 Mar 13 | Attempted Care coordinator · 1 attempt | Not scheduled — | 167d past | Readmit — no appointment |
Imani Ionescu M421864 · 84y · Bayside Medical (599) 492-7416Returned | Serious Nurse | Home Health BrightPath Home Health | Case open Proj. DC Apr 1 | Mar 6 Apr 2 | Attempted Nurse case manager · 1 attempt | Not scheduled — | 147d past | Readmit — no appointment |
Frank Ionescu M464107 · 80y · Harbor Family Care (214) 675-164560d readmitReturned | Good Care coordinator | SNF Golden Oaks Rehab | No case No plan | Oct 8 Nov 2 | Unable to reach Care coordinator · 5 attempts | Not scheduled — | 298d past | Readmit — no appointment |
Ruth Rios M405675 · 83y · Bayside Medical (555) 406-640560d readmit | Good Care coordinator | Inpatient Valley Baptist | Case open Proj. DC Mar 2 | Feb 28 Mar 3 | Contacted Care coordinator · 1 attempt | No-show Mar 19 · 1 miss | 177d past | No-show recovery |
Otis Ferreira M442154 · 89y · Bayside Medical (268) 261-2258 | Good Care coordinator | Inpatient St. Aldon Regional | No case No plan | Aug 25 Aug 31 | Not started — · 0 attempts | Not scheduled — | 4d left | No outreach yet |
Marcus Salazar M486929 · 91y · Harbor Family Care (608) 469-210560d readmitReturned | Fair Care coordinator | Inpatient St. Aldon Regional | No case No plan | Jul 25 Jul 28 | Not started — · 0 attempts | Not scheduled — | 30d past | Readmit — no appointment |
Marcus Sorensen M468118 · 77y · Harbor Family Care (274) 471-6681 | Serious Nurse | SNF Golden Oaks Rehab | Case open Proj. DC Oct 9 | Sep 16 Oct 9 | Contacted Nurse case manager · 3 attempts | Cancelled Oct 12 · 1 miss | 322d past | No-show recovery |
Milton Okafor M410778 · 71y · Harbor Family Care (457) 812-547060d readmitReturned | Serious Nurse | ED Mercy General ED | Case open Proj. DC Dec 5 | Dec 5 Dec 5 | Contacted Nurse case manager · 2 attempts | Completed Dec 7 · 2d | Met | Readmit — visit completed |
Amir Sorensen M411686 · 78y · Bayside Medical (277) 868-884960d readmit | Good Care coordinator | SNF Ridgeway LTAC | Case open Proj. DC May 28 | May 9 May 29 | Contacted Front desk · 2 attempts | No-show Jun 1 · 1 miss | 90d past | No-show recovery |
Ingrid Nguyen M417709 · 77y · Harbor Family Care (535) 477-321160d readmit | Good Care coordinator | SNF Ridgeway LTAC | Case open Proj. DC Aug 12 | Jul 27 Aug 12 | Contacted Care coordinator · 1 attempt | No-show Aug 27 · 1 miss | 15d past | No-show recovery |
Hattie Delgado M452294 · 70y · Harbor Family Care (251) 529-5851 | Good Care coordinator | ED St. Aldon Regional ED | Case open Proj. DC Aug 14 | Aug 14 Aug 14 | Not started — · 0 attempts | Not scheduled — | 13d past | No outreach yet |
Lena Chandler M494542 · 88y · Bayside Medical (259) 716-6280 | Good Care coordinator | SNF Golden Oaks Rehab | Case open Proj. DC Aug 23 | Aug 3 Aug 22 | Not started — · 0 attempts | Not scheduled — | 5d past | No outreach yet |
Dwight Chandler M439482 · 68y · Bayside Medical (348) 600-1058Returned | Good Care coordinator | Inpatient Northside Medical Center | No case No plan | Apr 19 Apr 29 | Not started — · 0 attempts | Not scheduled — | 120d past | Readmit — no appointment |
Xiomara Baptiste M449252 · 90y · Harbor Family Care (674) 640-4483 | Serious Nurse | Inpatient Valley Baptist | Case open Proj. DC Aug 2 | Jul 25 Aug 2 | Contacted Nurse case manager · 2 attempts | Not scheduled — | 25d past | Window missed |
Marcus Ionescu M412078 · 75y · Bayside Medical (420) 541-3941Returned | Good Care coordinator | Inpatient St. Aldon Regional | No case No plan | Feb 1 Feb 9 | Attempted Care coordinator · 2 attempts | Not scheduled — | 199d past | Readmit — no appointment |
Yuki Lindstrom M417291 · 76y · Harbor Family Care (408) 356-431760d readmitReturned | Fair Care coordinator | SNF Willowbrook SNF | Case open Proj. DC Oct 9 | Sep 13 Oct 8 | Not started — · 0 attempts | Not scheduled — | 323d past | Readmit — no appointment |
Nadia Haddad M404506 · 83y · Bayside Medical (430) 498-233460d readmit | Good Care coordinator | Inpatient Valley Baptist | No case No plan | Jul 30 Aug 6 | Attempted Care coordinator · 2 attempts | Not scheduled — | 21d past | Window missed |
Ingrid Tanaka M488266 · 87y · Harbor Family Care (340) 766-3631 | Fair Care coordinator | Inpatient Mercy General | No case No plan | Aug 3 Aug 9 | Not started — · 0 attempts | Not scheduled — | 18d past | No outreach yet |
Delia Lindstrom M437026 · 83y · Bayside Medical (520) 395-8620 | Fair Care coordinator | Inpatient Northside Medical Center | No case No plan | Aug 12 Aug 21 | Not started — · 0 attempts | Not scheduled — | 6d past | No outreach yet |
Ruth Tanaka M499691 · 82y · Bayside Medical (627) 214-2180 | Good Care coordinator | Inpatient St. Aldon Regional | No case No plan | Sep 2 LOS 1d | Not started — · 0 attempts | Not scheduled — | In facility | No case management |
Xiomara Marsden M403117 · 71y · Harbor Family Care (309) 479-2815Returned | Good Care coordinator | Observation St. Aldon Regional | Case open Proj. DC Mar 23 | Mar 18 Mar 23 | Attempted Care coordinator · 1 attempt | Not scheduled — | 157d past | Readmit — no appointment |
Amir Tanaka M421679 · 87y · Harbor Family Care (654) 207-5499Returned | Good Care coordinator | ED St. Aldon Regional ED | No case No plan | Aug 2 Aug 2 | Unable to reach Care coordinator · 5 attempts | Not scheduled — | 25d past | Readmit — no appointment |
Willie Sorensen M467014 · 63y · Harbor Family Care (614) 369-3254Returned | Good Care coordinator | ED Mercy General ED | No case No plan | Oct 15 Oct 15 | Not started — · 0 attempts | Not scheduled — | 316d past | Readmit — no appointment |
Marcus Salazar M489479 · 65y · Harbor Family Care (450) 784-6615Returned | Good Care coordinator | ED St. Aldon Regional ED | No case No plan | Apr 14 Apr 14 | Contacted Care coordinator · 3 attempts | Not scheduled — | 135d past | Readmit — no appointment |
Ruth Rios M417655 · 59y · Harbor Family Care (263) 776-2603 | Good Care coordinator | Inpatient St. Aldon Regional | Case open Proj. DC Nov 7 | Oct 30 Nov 7 | Contacted PCP office · 2 attempts | No-show Nov 10 · 1 miss | 293d past | No-show recovery |
Gerald Abernathy M480702 · 74y · Harbor Family Care (427) 789-2434 | Good Care coordinator | Home Health BrightPath Home Health | No case No plan | Jul 1 Jul 18 | Contacted PCP office · 3 attempts | No-show Jul 26 · 1 miss | 40d past | No-show recovery |
Callum Petrov M426193 · 70y · Bayside Medical (484) 680-7375Returned | Serious Nurse | ED Northside Medical ED | Case open Proj. DC Oct 28 | Oct 28 Oct 28 | Contacted Nurse case manager · 3 attempts | Completed Oct 31 · 3d · 1 miss | Met | Readmit — visit completed |
Willie Rios M407768 · 68y · Bayside Medical (288) 707-3343 | Good Care coordinator | SNF Ridgeway LTAC | Case open Proj. DC May 27 | May 16 May 27 | Contacted PCP office · 1 attempt | No-show Jun 2 · 1 miss | 92d past | No-show recovery |
Amir Abernathy M449312 · 79y · Bayside Medical (249) 224-1241 | Good Care coordinator | Observation Mercy General | Case open Proj. DC Nov 20 | Nov 11 Nov 21 | Contacted Care coordinator · 2 attempts | No-show Nov 24 · 1 miss | 279d past | No-show recovery |
Willie Kowalski M437089 · 77y · Harbor Family Care (311) 345-4972 | Good Care coordinator | SNF Ridgeway LTAC | Case open Proj. DC Mar 21 | Mar 6 Mar 21 | Contacted Care coordinator · 1 attempt | Cancelled Mar 27 · 1 miss | 159d past | No-show recovery |
Dwight Tanaka M455574 · 70y · Bayside Medical (570) 768-8109 | Fair Care coordinator | Inpatient St. Aldon Regional | Case open Proj. DC May 28 | May 22 May 28 | Contacted Front desk · 3 attempts | No-show May 30 · 1 miss | 91d past | No-show recovery |
Hattie Ferreira M462208 · 88y · Harbor Family Care (312) 471-2481 | Fair Care coordinator | Inpatient Mercy General | No case No plan | Sep 5 Sep 11 | Contacted Care coordinator · 2 attempts | No-show Sep 19 · 1 miss | 350d past | No-show recovery |
Marcus Nguyen M466398 · 58y · Harbor Family Care (274) 438-3042 | Fair Care coordinator | Inpatient Valley Baptist | Case open Proj. DC Feb 28 | Feb 22 Feb 28 | Contacted Front desk · 2 attempts | No-show Mar 14 · 1 miss | 180d past | No-show recovery |
Lena Mbeki M437552 · 76y · Harbor Family Care (308) 687-7539 | Fair Care coordinator | Home Health Comfort Care at Home | No case No plan | Aug 30 LOS 4d | Not started — · 0 attempts | Not scheduled — | In facility | No case management |
Milton Abernathy M487098 · 58y · Bayside Medical (692) 443-6727 | Fair Care coordinator | Inpatient St. Aldon Regional | Case open Proj. DC Aug 31 | Aug 24 Sep 1 | Attempted Care coordinator · 1 attempt | Not scheduled — | 5d left | Contacted, no appointment |
Harold Abernathy M442333 · 71y · Bayside Medical (359) 791-8883 | Good Care coordinator | Home Health Comfort Care at Home | Case open Proj. DC Aug 26 | Jul 25 Aug 26 | Contacted Care coordinator · 3 attempts | Not scheduled — | 1d past | Window missed |
Yuki Nguyen M419969 · 89y · Harbor Family Care (506) 478-7799 | Fair Care coordinator | Home Health Anchor Home Services | Case open Proj. DC Mar 30 | Feb 22 Mar 30 | Contacted Front desk · 1 attempt | Cancelled Apr 2 · 1 miss | 150d past | No-show recovery |
Nadia Guillory M414618 · 78y · Bayside Medical (666) 206-3329 | Fair Care coordinator | SNF Golden Oaks Rehab | Case open Proj. DC Dec 1 | Nov 11 Dec 2 | Contacted Care coordinator · 3 attempts | No-show Dec 17 · 1 miss | 268d past | No-show recovery |
Nadia Ionescu M415608 · 76y · Harbor Family Care (461) 880-5701 | Fair Care coordinator | SNF Ridgeway LTAC | Case open Proj. DC Nov 29 | Nov 11 Nov 30 | Contacted Care coordinator · 2 attempts | No-show Dec 6 · 1 miss | 270d past | No-show recovery |
Ruth Baptiste M417774 · 76y · Harbor Family Care (547) 599-3554 | Fair Care coordinator | ED Northside Medical ED | Case open Proj. DC Jul 8 | Jul 8 Jul 8 | Contacted PCP office · 3 attempts | No-show Jul 12 · 1 miss | 50d past | No-show recovery |
Gerald Delgado M473675 · 73y · Harbor Family Care (435) 604-8336 | Fair Care coordinator | ED Northside Medical ED | Case open Proj. DC Jun 9 | Jun 9 Jun 9 | Contacted Front desk · 3 attempts | Cancelled Jun 22 · 1 miss | 79d past | No-show recovery |