Glossary

Definitions and rules used across the Enterprise, Market and Center views.

Workflow stages

Admission: A patient enters a facility or setting included in the census.
In facility: The patient is currently admitted or under active care in the selected setting.
Case managed: A case-management or discharge-planning record was opened during the stay.
Projected discharge: Estimated discharge date used to plan outreach before the patient leaves.
Discharged: The patient has left the facility and is in the post-discharge follow-up window.
Outreach: Contact attempt(s) to schedule a PCP follow-up appointment.
Call scheduled: A PCP follow-up appointment has been scheduled in Athena.
Visit attended: The patient completed the scheduled PCP follow-up visit.
7-day visit: A PCP follow-up visit that occurred within 7 calendar days of discharge.

Inpatient: Acute-care hospital admission.
Observation: Hospital observation status, usually shorter than an inpatient stay.
ED: Emergency department visit that appears in the census feed.
SNF: Skilled nursing facility. Follows the same post-discharge workflow as hospital settings.
Home Health: Home health episode. Source data is currently partial; shown for visibility only.
Hospice: Not currently included in this report. Future expansion scope.

Critical: Highest risk. Routed to a nurse case manager for outreach.
Serious: High risk. Routed to a nurse case manager for outreach.
Good: Moderate risk. Routed to care coordinator / front-office team for outreach.
Fair: Lower risk. Routed to care coordinator / front-office team for outreach.

Risk is relatively stable and generally moves upward when it changes.

Nurse case manager: Outreach owner for Critical and Serious patients.
Care coordinator: Outreach owner for Good and Fair patients.
Front office: Clinic front-desk or referral team supporting scheduling.
Outreach attempts: Count of contact attempts made to reach the patient or schedule a visit.
Channel: Method used for outreach: phone call, text, portal message or mail.

Current census: Patients with status In facility today.
30-day admissions: Admissions in the last 30 days, including ED visits if present.
Case-managed rate: Percentage of in-facility patients with an opened case-management record.
Scheduled rate: Percentage of discharged patients with a PCP appointment scheduled.
7-day visit rate: Percentage of discharged patients with a PCP visit within 7 days of discharge.
No-show rate: Percentage of scheduled visits marked as no-show.
Average days to visit: Mean number of days from discharge to the attended PCP visit.
Readmission rate: Percentage of discharged patients readmitted within 60 days.

Readmission flag: An admission within 60 days of a prior discharge.
Window closing: Discharged patient with fewer than 3 days left in the 7-day follow-up window.
Needs action: Discharged patient with no scheduled PCP appointment, or a missed/no-show visit.
Not case managed: In-facility patient without an opened case-management record.
No-show: A scheduled PCP visit that the patient did not attend.
Cancelled: A scheduled PCP visit that was cancelled.
Rescheduled: A PCP visit that was moved to a later date.

Enterprise: All markets combined. Shows trends, funnel and cross-market scorecard.
Market: A geographic or business market. Shows centers/practices and market-level funnel.
Center / Practice: A clinic, practice or facility group. Shows provider panels and patient worklist.
Provider / PCP: Primary care provider assigned to the patient.
Patient: Individual census record. One row per admission or episode in the patient worklist.

Attributed members: Eligibility count of members attributed to a market or center. This is the denominator for every per-1,000 measure.
Per 1,000 attributed members: Events ÷ attributed members × 1,000. Used for current census, 30-day admissions and ED visits so markets and centers of different sizes can be compared.
Period filter (year / month): Selects a calendar month. It drives the funnel, outreach comparison, days-to-visit distribution and both scorecards. The three rolling boxes (current census, 30-day admissions, 30-day ED visits) and the trend chart always show the latest 30 days versus the prior 30 days and ignore this filter.
Open follow-up gaps: Raw count of patients with an unresolved next action. Deliberately not normalized — it is a worklist size, not a rate.
Version 1 scope: Inpatient and ED. Observation, SNF and Home Health remain selectable but are a later phase; Hospice is excluded.
Patient phone / click to call: Each patient row and detail panel shows the phone number as a dial link, so outreach staff can call directly from the report.

All numbers in this prototype are generated mock data for design validation.
Future production data will come from Athena EHR, TCM Patient Cases, SSRS/reference snapshots, payer reports and HIE feeds.
Deduplication across sources will be required before publishing live metrics.
Home Health data is currently incomplete; Hospice is not included.