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
142 of 172 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. R. Nakamura | 2 | 3 | 75% | 60% | 16.7% | 20% | 1 |
| Dr. T. Lindqvist | 0 | 1 | 78.6% | 64.3% | 0% | 21.4% | 2 |
| Dr. K. Vasquez | 1 | 2 | 75% | 60% | 11.1% | 26.7% | 5 |
| Dr. J. Persaud | 1 | 3 | 93.8% | 73.3% | 0% | 33.3% | 2 |
| Dr. L. Castellanos | 1 | 2 | 83.3% | 94.1% | 6.3% | 35.3% | 5 |
| Dr. M. Okonkwo | 4 | 4 | 81.8% | 66.7% | 16.7% | 38.9% | 4 |
| Dr. D. Moreau | 1 | 1 | 93.8% | 73.3% | 9.1% | 40% | 5 |
| Dr. P. Aiyer | 2 | 3 | 92.9% | 75% | 0% | 41.7% | 1 |
| Dr. A. Whitfield | 2 | 4 | 88.9% | 87.5% | 0% | 50% | 4 |
| Dr. E. Boateng | 1 | 3 | 92.3% | 91.7% | 9.1% | 50% | 2 |
| Dr. S. Brennan | 2 | 2 | 83.3% | 100% | 25% | 50% | 1 |
| Dr. H. Kaur | 3 | 4 | 92.6% | 79.2% | 5.3% | 62.5% | 2 |
34 records match the current filters
| Patient | Tier / Owner | Setting & facility | Case mgmt | Admit / Discharge | Outreach | Appointment | Window | Status / Next action |
|---|---|---|---|---|---|---|---|---|
Callum Guillory M486687 · 67y · Lakeview Internal (414) 245-432060d readmit | Serious Nurse | Inpatient Mercy General | Case open Proj. DC Aug 9 | Aug 2 Aug 9 | Contacted Care coordinator · 2 attempts | Cancelled Aug 11 · 1 miss | 18d past | No-show recovery |
Imani Rios M486109 · 72y · Lakeview Internal (438) 596-683160d readmitReturned | Critical Nurse | Inpatient St. Aldon Regional | Case open Proj. DC Jul 10 | Jun 30 Jul 9 | Contacted Care coordinator · 1 attempt | Completed Jul 14 · 5d | Met | Readmit — visit completed |
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 |
Terrance Haddad M442225 · 59y · Cedar Hills Family (605) 328-748060d readmitReturned | Critical Nurse | SNF Willowbrook SNF | Case open Proj. DC Jul 20 | Jul 4 Jul 19 | Contacted Nurse case manager · 1 attempt | Completed Jul 23 · 4d | Met | Readmit — visit completed |
Ruth Mbeki M417900 · 84y · Lakeview Internal (590) 593-375160d readmitReturned | Good Care coordinator | Inpatient St. Aldon Regional | No case No plan | May 8 May 16 | Not started — · 0 attempts | Not scheduled — | 103d past | Readmit — no appointment |
Gerald Ionescu M468485 · 75y · Cedar Hills Family (571) 889-3688 | Serious Nurse | Inpatient Mercy General | Case open Proj. DC Aug 22 | Aug 14 Aug 23 | Contacted Nurse case manager · 2 attempts | Cancelled Aug 29 · 1 miss | 4d past | No-show recovery |
Yuki Lindstrom M455797 · 81y · Cedar Hills Family (400) 297-6753 | Serious Nurse | ED Northside Medical ED | Case open Proj. DC Aug 5 | Aug 5 Aug 5 | Contacted Nurse case manager · 2 attempts | Cancelled Aug 9 · 1 miss | 22d past | No-show recovery |
Amir Kowalski M446419 · 78y · Cedar Hills Family (339) 523-7456Returned | Serious Nurse | Home Health Anchor Home Services | Case open Proj. DC Apr 8 | Mar 14 Apr 8 | Contacted Nurse case manager · 3 attempts | Cancelled Apr 18 · 1 miss | 141d past | No-show recovery |
Xiomara Kowalski M497697 · 61y · Cedar Hills Family (659) 407-898460d readmit | Good Care coordinator | SNF Ridgeway LTAC | Case open Proj. DC Apr 8 | Mar 27 Apr 7 | Contacted Care coordinator · 2 attempts | Cancelled Apr 13 · 1 miss | 142d past | No-show recovery |
Nadia Baptiste M437611 · 89y · Cedar Hills Family (670) 351-995660d readmitReturned | Serious Nurse | SNF Riverstone Post-Acute | No case No plan | Feb 23 Mar 11 | Contacted Nurse case manager · 3 attempts | Completed Mar 15 · 4d | Met | Readmit — visit completed |
Hattie Salazar M451358 · 83y · Cedar Hills Family (694) 449-3390Returned | Critical Nurse | Home Health Comfort Care at Home | Case open Proj. DC Aug 26 | Jul 23 Aug 26 | Contacted Nurse case manager · 2 attempts | Completed Aug 31 · 5d | Met | Readmit — visit completed |
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 |
Delia Mbeki M413912 · 59y · Cedar Hills Family (319) 592-6489Returned | Good Care coordinator | Inpatient Mercy General | Case open Proj. DC Apr 24 | Apr 14 Apr 24 | Attempted Front desk · 2 attempts | Not scheduled — | 125d past | Readmit — no appointment |
Eleanor Lindstrom M403537 · 82y · Lakeview Internal (649) 721-9331Returned | Good Care coordinator | Inpatient Northside Medical Center | Case open Proj. DC Oct 24 | Oct 17 Oct 24 | Attempted Care coordinator · 2 attempts | Not scheduled — | 307d past | Readmit — no appointment |
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 |
Lena Marsden M446959 · 76y · Cedar Hills Family (421) 211-2680 | Good Care coordinator | Inpatient Northside Medical Center | No case No plan | Sep 3 LOS 0d | Not started — · 0 attempts | Not scheduled — | In facility | No case management |
Delia Delgado M495766 · 75y · Lakeview Internal (501) 850-3390Returned | Good Care coordinator | Home Health BrightPath Home Health | Case open Proj. DC Apr 20 | Mar 19 Apr 20 | Contacted Front desk · 2 attempts | Not scheduled — | 129d past | Readmit — no appointment |
Imani Marsden M448092 · 91y · Lakeview Internal (543) 433-3348Returned | Good Care coordinator | Home Health Comfort Care at Home | Case open Proj. DC Mar 20 | Feb 24 Mar 21 | Attempted Care coordinator · 2 attempts | Not scheduled — | 159d 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 |
Simone Whitmore M453485 · 72y · Lakeview Internal (354) 846-5374Returned | Serious Nurse | Inpatient Northside Medical Center | Case open Proj. DC Jan 21 | Jan 16 Jan 21 | Contacted Nurse case manager · 2 attempts | Completed Jan 26 · 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 |
Ruth Petrov M424446 · 71y · Lakeview Internal (532) 528-5334 | Good Care coordinator | SNF Riverstone Post-Acute | No case No plan | Aug 17 LOS 17d | Not started — · 0 attempts | Not scheduled — | In facility | No case management |
Ruth Marsden M481938 · 78y · Lakeview Internal (206) 465-6385 | Good Care coordinator | Observation Northside Medical Center | Case open Proj. DC Aug 8 | Jul 30 Aug 8 | Contacted Care coordinator · 3 attempts | No-show Aug 16 · 1 miss | 19d past | No-show recovery |
Xiomara Chandler M471241 · 81y · Cedar Hills Family (377) 300-1117 | Good Care coordinator | Observation St. Aldon Regional | Case open Proj. DC May 8 | Apr 30 May 8 | Contacted Front desk · 1 attempt | No-show May 13 · 1 miss | 111d past | No-show recovery |
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 |
Ruth Whitmore M444995 · 80y · Lakeview Internal (372) 337-8115 | Good Care coordinator | ED Northside Medical ED | Case open Proj. DC Oct 16 | Oct 16 Oct 16 | Contacted Front desk · 2 attempts | Cancelled Oct 29 · 1 miss | 315d past | No-show recovery |
Harold Salazar M472125 · 83y · Lakeview Internal (598) 274-1501 | Fair Care coordinator | Inpatient Valley Baptist | No case No plan | Sep 2 LOS 1d | Not started — · 0 attempts | Not scheduled — | In facility | No case management |
Milton Ferreira M423514 · 84y · Cedar Hills Family (671) 736-9519Returned | Fair Care coordinator | SNF Golden Oaks Rehab | Case open Proj. DC Mar 24 | Mar 5 Mar 24 | Contacted Care coordinator · 1 attempt | Not scheduled — | 156d past | Readmit — no appointment |
Ingrid Delgado M484123 · 61y · Cedar Hills Family (278) 761-6013Returned | Fair Care coordinator | Observation Mercy General | No case No plan | Jun 13 Jun 21 | Not started — · 0 attempts | Not scheduled — | 67d past | Readmit — no appointment |
Rafael Guillory M448603 · 75y · Lakeview Internal (408) 472-2602Returned | Fair Care coordinator | Observation St. Aldon Regional | Case open Proj. DC Nov 10 | Nov 2 Nov 10 | Contacted Care coordinator · 1 attempt | Not scheduled — | 290d past | Readmit — no appointment |
Gerald Whitmore M436305 · 73y · Lakeview Internal (667) 729-8020 | Fair Care coordinator | Observation Mercy General | Case open Proj. DC Jun 24 | Jun 16 Jun 25 | Contacted Care coordinator · 3 attempts | No-show Jul 1 · 1 miss | 63d past | No-show recovery |
Beatrice Kowalski M462382 · 63y · Cedar Hills Family (606) 344-1113Returned | Good Care coordinator | Home Health Comfort Care at Home | Case open Proj. DC Apr 15 | Mar 12 Apr 15 | Contacted Front desk · 3 attempts | Completed Apr 17 · 2d | Met | Readmit — visit completed |