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
134 of 182 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. S. Brennan | 0 | 3 | 60.9% | 69.6% | 12.5% | 17.4% | 8 |
| Dr. R. Nakamura | 2 | 3 | 75% | 60% | 0% | 20% | 5 |
| Dr. E. Boateng | 1 | 1 | 66.7% | 57.1% | 25% | 21.4% | 2 |
| Dr. A. Whitfield | 3 | 3 | 73.3% | 75% | 0% | 25% | 2 |
| Dr. L. Castellanos | 0 | 4 | 50% | 43.8% | 0% | 25% | 5 |
| Dr. M. Okonkwo | 1 | 4 | 75% | 66.7% | 11.1% | 25.9% | 3 |
| Dr. J. Persaud | 2 | 2 | 92.3% | 81.8% | 0% | 27.3% | 2 |
| Dr. D. Moreau | 2 | 3 | 68.8% | 57.1% | 12.5% | 28.6% | 5 |
| Dr. H. Kaur | 0 | 1 | 84.6% | 69.2% | 11.1% | 30.8% | 3 |
| Dr. K. Vasquez | 0 | 1 | 84.6% | 76.9% | 0% | 30.8% | 1 |
| Dr. T. Lindqvist | 3 | 5 | 66.7% | 53.3% | 12.5% | 33.3% | 4 |
| Dr. P. Aiyer | 0 | 1 | 57.1% | 71.4% | 10% | 50% | 2 |
42 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 |
Priya Ferreira M496179 · 66y · Millbrook Clinic (399) 431-501960d readmitReturned | Critical Nurse | Inpatient Northside Medical Center | Case open Proj. DC Apr 21 | Apr 14 Apr 22 | Contacted Nurse case manager · 2 attempts | Completed Apr 26 · 4d | Met | Readmit — visit completed |
Marcus Whitmore M466959 · 63y · Foxfield Primary (386) 380-6627 | Critical Nurse | SNF Ridgeway LTAC | Case open Proj. DC Jul 12 | Jul 5 Jul 13 | Contacted Nurse case manager · 2 attempts | Cancelled Jul 19 · 1 miss | 45d 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 |
Nadia Rios M406629 · 90y · Millbrook Clinic (687) 422-7611Returned | Critical Nurse | Inpatient Mercy General | Case open Proj. DC Nov 6 | Nov 3 Nov 7 | Contacted Nurse case manager · 2 attempts | Completed Nov 12 · 5d | Met | Readmit — visit completed |
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 |
Gerald Abernathy M449223 · 88y · Millbrook Clinic (484) 623-3620 | Serious Nurse | Home Health Anchor Home Services | Case open Proj. DC Feb 16 | Jan 31 Feb 16 | Contacted Nurse case manager · 3 attempts | Cancelled Mar 4 · 1 miss | 192d past | No-show recovery |
Bernard Chandler M401279 · 84y · Foxfield Primary (437) 303-3608 | Serious Nurse | Home Health Anchor Home Services | Case open Proj. DC Dec 13 | Nov 26 Dec 12 | Contacted Care coordinator · 3 attempts | Cancelled Dec 17 · 1 miss | 258d past | No-show recovery |
Imani Whitmore M485117 · 74y · Foxfield Primary (572) 399-1402Returned | Critical Nurse | SNF Riverstone Post-Acute | Case open Proj. DC Aug 22 | Aug 10 Aug 23 | Contacted Nurse case manager · 1 attempt | Completed Aug 26 · 3d | Met | Readmit — visit completed |
Marcus Sorensen M465961 · 83y · Foxfield Primary (470) 320-613360d readmit | Fair Care coordinator | ED Northside Medical ED | No case No plan | Aug 29 Aug 29 | Unable to reach PCP office · 4 attempts | Not scheduled — | 2d left | Window closing |
Dwight Haddad M434710 · 82y · Foxfield Primary (495) 382-8525 | Good Care coordinator | ED Valley Baptist ED | No case No plan | Sep 1 Sep 1 | Not started — · 0 attempts | Not scheduled — | 5d left | No outreach yet |
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 |
Ruth Ionescu M493013 · 61y · Millbrook Clinic (294) 806-4802Returned | Good Care coordinator | Inpatient Northside Medical Center | Case open Proj. DC Aug 13 | Aug 6 Aug 13 | Attempted Care coordinator · 2 attempts | Not scheduled — | 14d past | Readmit — no appointment |
Frank Kowalski M477449 · 58y · Foxfield Primary (622) 450-9370Returned | Good Care coordinator | ED Valley Baptist ED | No case No plan | Aug 12 Aug 12 | Attempted Front desk · 1 attempt | Not scheduled — | 15d past | Readmit — no appointment |
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 |
Ruth Tanaka M455483 · 85y · Foxfield Primary (258) 203-5944Returned | Good Care coordinator | SNF Willowbrook SNF | Case open Proj. DC Nov 11 | Nov 1 Nov 10 | Not started — · 0 attempts | Not scheduled — | 290d 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 |
Priya Whitmore M434386 · 68y · Millbrook Clinic (270) 591-7478 | Good Care coordinator | Inpatient Northside Medical Center | Case open Proj. DC Aug 23 | Aug 20 Aug 24 | Contacted Care coordinator · 2 attempts | Cancelled Aug 26 · 1 miss | 3d past | No-show recovery |
Terrance Whitmore M486111 · 77y · Foxfield Primary (594) 273-2513 | Good Care coordinator | Inpatient Valley Baptist | Case open Proj. DC Mar 27 | Mar 16 Mar 26 | Contacted Front desk · 1 attempt | Cancelled Apr 1 · 1 miss | 154d past | No-show recovery |
Imani Chandler M491878 · 74y · Millbrook Clinic (676) 393-3864 | Good Care coordinator | Inpatient Valley Baptist | Case open Proj. DC Oct 25 | Oct 18 Oct 25 | Contacted Care coordinator · 3 attempts | No-show Nov 8 · 1 miss | 306d past | No-show recovery |
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 |
Jonas Nguyen M432064 · 78y · Foxfield Primary (524) 379-157860d readmit | Good Care coordinator | ED Northside Medical ED | No case No plan | Aug 24 Aug 24 | Contacted Care coordinator · 2 attempts | Not scheduled — | 3d past | Window missed |
Otis Salazar M491263 · 81y · Foxfield Primary (698) 698-8245Returned | Fair Care coordinator | Inpatient St. Aldon Regional | Case open Proj. DC Dec 21 | Dec 12 Dec 21 | Not started — · 0 attempts | Not scheduled — | 249d past | Readmit — no appointment |
Gerald Rios M459965 · 84y · Millbrook Clinic (642) 631-7428Returned | Fair Care coordinator | Inpatient Valley Baptist | Case open Proj. DC Jun 3 | May 29 Jun 4 | Contacted Front desk · 1 attempt | Not scheduled — | 84d past | Readmit — no appointment |
Terrance Abernathy M472131 · 87y · Millbrook Clinic (231) 427-8576 | Good Care coordinator | Observation St. Aldon Regional | No case No plan | Feb 16 Feb 21 | Contacted Front desk · 3 attempts | Cancelled Feb 24 · 1 miss | 187d past | No-show recovery |
Xiomara Nguyen M412182 · 69y · Millbrook Clinic (331) 422-4186 | Fair Care coordinator | SNF Golden Oaks Rehab | Case open Proj. DC Aug 29 | Aug 13 Aug 29 | Contacted PCP office · 3 attempts | Not scheduled — | 2d left | Window closing |
Callum Chandler M479131 · 75y · Millbrook Clinic (347) 633-5402 | Good Care coordinator | Home Health Comfort Care at Home | No case No plan | May 20 Jun 11 | Contacted Care coordinator · 3 attempts | Cancelled Jun 22 · 1 miss | 77d past | No-show recovery |
Callum Rios M414303 · 60y · Millbrook Clinic (692) 242-8191 | Good Care coordinator | SNF Willowbrook SNF | Case open Proj. DC Dec 22 | Dec 8 Dec 22 | Contacted Front desk · 1 attempt | No-show Jan 1 · 1 miss | 248d 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 |
Terrance Rios M403633 · 61y · Foxfield Primary (563) 376-2291 | Fair Care coordinator | Inpatient Valley Baptist | No case No plan | Aug 29 LOS 5d | Not started — · 0 attempts | Not scheduled — | In facility | No case management |
Hattie Lindstrom M424471 · 77y · Foxfield Primary (586) 398-9234Returned | Fair Care coordinator | ED St. Aldon Regional ED | Case open Proj. DC May 8 | May 8 May 8 | Attempted Front desk · 1 attempt | Not scheduled — | 111d past | Readmit — no appointment |
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 |
Hattie Lindstrom M493303 · 80y · Foxfield Primary (361) 883-5366 | Fair Care coordinator | Inpatient Mercy General | Case open Proj. DC Jun 30 | Jun 24 Jun 29 | Contacted Care coordinator · 3 attempts | No-show Jul 5 · 1 miss | 59d 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 |
Lena Salazar M480113 · 78y · Millbrook Clinic (616) 387-4527 | Fair Care coordinator | Home Health BrightPath Home Health | Case open Proj. DC Aug 22 | Aug 9 Aug 23 | Contacted Care coordinator · 3 attempts | Not scheduled — | 4d past | Window missed |
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 |