Engine-computed from the live census — deriveBarriers · readiness · EDD.
The gap concentrates in SNF preferences, prior authorizations, and DME delivery windows. Trigger caregiver intake + the PA queue for the bottom-quartile readiness patients.
Open task board →0 active prior-auth blocks · 0 medication-access blocks (engine-coded). Submitting today protects mid-week discharges.
Open coverage matcher →Pre-staging Friday-morning tasks (caregiver coach, meds-to-beds, Sat speech eval) typically protects against the weekend hold.
Pre-stage weekend prep →James Thompson — discharge order ready for a one-click sign.
Open patient cockpit →Sorted by delay risk · click any row to open the discharge cockpit
| Patient | Status | Unit | Service | Payer | Predicted disposition | EDD | Clinical | Operational | Delay risk | Top blocker | Owner | Next best action |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Michael Johnson 72 M · MRN-58231 | Planning | 5B | Cardiology | BlueShield MA Advantage HMO | SNFalt: Home | in 1d Tue 2:00 PM | 81% | 46% | HIGH | SNF prefs + med PA | Maria Chen, RN case manager | Send SNF preference form to caregiver→ |
| Linda Kowalski 68 F · MRN-58104 | Ready · pending logistics | 5B | Ortho | Medicare FFS | SNF | in 1d Tue 11:00 AM | 92% | 38% | HIGH | SNF auth denied — peer-to-peer pending | Maria Chen, RN case manager | Schedule MD peer-to-peer with BlueShield→ |
| James Thompson 64 M · MRN-58332 | ReadyAppeal-paused | 5B | Cardiology | Medicare FFS | Home | clock paused Mon 5:00 PM | 96% | 88% | LOW | QIO discharge appeal filed — clock paused (§405.1200) | Dr. Jordan Park hospitalist | Await QIO determination; appeal days excluded from avoidable days→ |
| Rosa Mendez 71 F · MRN-57990 | Planning | S4 | Stroke | Medicare FFS | IRF / ARU | in 1d Tue 3:00 PM | 78% | 60% | MED | Speech eval + caregiver coaching pending | Maria Chen, RN case manager | Fri→Mon prep: dispatch weekend tasks→ |
| Alma Singh 84 F · MRN-57810 | BarrieredALC · complex-stay | 5B | Medicine | Medicaid pending | SNF | in 5d Sat 12:00 PM | 70% | 22% | HIGH | Guardianship + Medicaid pending | Tara Liu, MSW social worker | Escalate to legal partner — pro bono guardianship→ |
| Carlos Rivera 58 M · MRN-58410 | Planning | 5B | Medicine | Aetna PPO | Home | in 1d Tue 1:00 PM | 74% | 52% | MED | Home O₂ vendor ETA Wed | Maria Chen, RN case manager | Confirm Lincare delivery window + backup→ |
| Patricia O'Brien 79 F · MRN-58025 | Planning | 5B | Cardiology | Humana MA | Home | in 1d Tue 4:00 PM | 84% | 64% | MED | Eliquis PA + HH agency capacity | Maria Chen, RN case manager | Submit Eliquis PA via CoverMyMeds→ |
| Raymond Park 67 M · MRN-58455 | Planning | 5B | Medicine | Medicare FFS | Home | in 2d Wed 12:00 PM | 58% | 70% | LOW | Awaiting IV → PO conversion | Dr. Jordan Park hospitalist | Pharmacy: convert ceftriaxone → cefpodoxime→ |
| Evelyn Baker 76 F · MRN-57890 | Planning | B6 | BMT | BlueCross MA | Home | in 2d Wed 11:00 AM | 68% | 54% | MED | Infusion pharmacy + caregiver education | Tara Liu, MSW social worker | Coordinate Coram home infusion intake→ |
| George Wilson 82 M · MRN-58510 | Ready · pending logistics | 5B | Medicine | Medicare FFS | SNF | in 1d Tue 10:00 AM | 88% | 71% | MED | SNF bed for Mon AM | Maria Chen, RN case manager | Confirm Bayview SNF intake slot→ |
| Anita Gomez 54 F · MRN-58220 | Ready · pending logistics | 5B | Medicine | Anthem PPO | Home | T-24h · 6:00 PM Mon 6:00 PM | 91% | 76% | LOW | Insulin pen teach-back + glucometer | Sara Khan, RN nurse | Pharmacy meds-to-beds + 20-min teach→ |
| Frank DelaCruz 69 M · MRN-58118 | Planning | 5B | Cardiology | Medicare FFS | Home | in 1d Tue 12:00 PM | 80% | 80% | LOW | Cardiac rehab referral | Dr. Jordan Park hospitalist | Submit Phase II rehab referral→ |
| Diane Hsu 75 F · MRN-58388 | Ready · pending logistics | S4 | Stroke | BlueShield MA | Home | T-24h · 9:00 AM Tue 9:00 AM | 86% | 82% | LOW | Anticoag PA + neuro f/u | Maria Chen, RN case manager | Submit Eliquis PA + book neuro 7 days→ |
| Henry Ford 60 M · MRN-58002 | Planning | 5B | Medicine | Kaiser MA | Home | in 1d Tue 3:00 PM | 72% | 66% | MED | Outpatient nephrology slot | Maria Chen, RN case manager | Book nephrology 48h via Kaiser referral desk→ |
| Rita Johnson 88 F · MRN-58444 | Planning | 5B | Medicine | Medicare FFS | Home | in 1d Tue 11:00 AM | 76% | 58% | MED | Home safety eval + walker | Liam Park, OT ot | OT home safety + DME walker order→ |
| Marisol Vega 63 F · MRN-58531 | Planning | 5B | Medicine | Medicare FFS | Home | in 1d Tue 3:30 PM | 79% | 49% | HIGH | Portable O2 CMN missing signature | Dr. Jordan Park hospitalist | Sign CMN form 484 for home oxygen→ |
| Nathan Cooper 73 M · MRN-58542 | Planning | 5B | Medicine | United MA | Home | in 2d Wed 10:00 AM | 67% | 44% | HIGH | Home health start-of-care unavailable | Maria Chen, RN case manager | Book backup HH agency before noon→ |
| Celia Martin 82 F · MRN-58553 | Ready · pending logistics | 5B | Ortho | BlueShield MA | SNF | in 2d Wed 1:00 PM | 89% | 33% | HIGH | SNF auth pending clinical upload | Maria Chen, RN case manager | Attach PT note and resubmit auth packet→ |
| Owen Li 77 M · MRN-58564 | Ready · pending logistics | 5B | Ortho | Medicare FFS | SNF | in 1d Tue 12:30 PM | 94% | 62% | MED | Family choosing between accepted SNFs | Maria Chen, RN case manager | Send ranked SNF preference form→ |
| Beatrice Wong 80 F · MRN-58575 | Planning | 5B | Ortho | Aetna PPO | IRF / ARU | in 2d Wed 2:30 PM | 83% | 55% | MED | ARU medical director review pending | Aisha Patel, DPT pt | Upload stair trial and endurance note→ |
| Terrence Brooks 69 M · MRN-58586 | Ready · pending logistics | 5B | Cardiology | Medicare FFS | Home | in 1d Tue 5:00 PM | 91% | 73% | MED | Meds-to-beds delivery after 4 PM | Sam Reyes, PharmD pharmacy | Move pharmacy fill before 15:30 cutoff→ |
| Marian Adler 74 F · MRN-58597 | Planning | 5B | Cardiology | Humana MA | Home | in 2d Wed 9:30 AM | 76% | 47% | HIGH | Entresto denied; alternate plan needed | Sam Reyes, PharmD pharmacy | Draft payer exception or ARB fallback→ |
| Kevin Owens 59 M · MRN-58608 | Planning | S4 | Stroke | BlueCross MA | IRF / ARU | in 1d Tue 4:00 PM | 82% | 57% | MED | Speech eval delayed until afternoon | Aisha Patel, DPT pt | Escalate SLP slot into weekend prep batch→ |
| Helen Yu 86 F · MRN-58619 | Ready · pending logistics | S4 | Stroke | Medicare FFS | Home | in 1d Tue 10:30 AM | 88% | 52% | MED | Caregiver coaching not complete | Sara Khan, RN nurse | Send stroke warning-sign education to daughter→ |
| Samir Patel 62 M · MRN-58630 | Planning | S4 | Stroke | Anthem PPO | LTCH / LTAC | in 4d Fri 11:00 AM | 61% | 29% | HIGH | LTCH acceptance blocked by acuity review | Tara Liu, MSW social worker | Escalate complex placement huddle→ |
| Joanne Keller 70 F · MRN-58641 | Planning | B6 | BMT | BlueCross MA | Home | in 3d Thu 12:00 PM | 64% | 42% | HIGH | Home infusion nursing unavailable | Tara Liu, MSW social worker | Warm backup infusion vendor→ |
| Liam Murphy 66 M · MRN-58652 | Planning | B6 | BMT | Medicare FFS | Home | in 2d Wed 3:00 PM | 71% | 58% | MED | Caregiver line-care teach-back pending | Sara Khan, RN nurse | Schedule caregiver line-care session→ |
| Grace Nelson 78 F · MRN-58663 | Planning | B6 | BMT | Kaiser MA | Home | in 3d Thu 9:00 AM | 69% | 36% | HIGH | Specialty pharmacy delivery not confirmed | Sam Reyes, PharmD pharmacy | Confirm same-day specialty courier→ |
| Wanda Price 89 F · MRN-58674 | BarrieredALC · complex-stay | 5B | Medicine | Medicaid pending | Memory care | in 8d Tue 12:00 PM | 73% | 18% | HIGH | Memory care funding path unresolved | Tara Liu, MSW social worker | Start HCBS waiver + charity bridge screen→ |
| Yasmin Hassan 57 F · MRN-58696 | Ready · pending logistics | 5B | Medicine | Medi-Cal managed care | Shelter / respite | in 2d Wed 4:30 PM | 87% | 26% | HIGH | Medical respite bed unavailable | Tara Liu, MSW social worker | Escalate respite waitlist and backup shelter plan→ |
| Maria Hernandez 67 F · MRN-58332 | Planning | 5B | Cardiology | Uninsured (charity-care pending) | Home | in 1d Tue 4:00 PM | 79% | 32% | HIGH | 501(r) financial-assistance application pending; Entresto + Jardiena cash price ~$1.1k/mo | Tara Liu, MSW social worker | Complete Stanford FAP application + enroll in Novartis Entresto Central + BI Jardiance PAP→ |
| Anthony Boyd 52 M · MRN-58401 | Planning | 5B | Medicine | Self-pay (Medi-Cal application pending) | Shelter / respite | in 3d Thu 11:00 AM | 74% | 22% | HIGH | Medical respite + IV-abx-capable site needed; standard shelters can't manage PICC | Tara Liu, MSW social worker | Cherry Hill (Alameda) or ATAC (SF) medical respite — both accept PICC; secure Medi-Cal urgent-application→ |
| David Chen 38 M · MRN-58518 | Barriered | 5B | Behavioral Health | Anthem Blue Cross CA (Medi-Cal MCO) | Home | in 2d Wed 3:00 PM | 72% | 18% | HIGH | No dialysis unit accepting behavioral comorbid; SNFs all declining; IOP scheduling collides with HD | Dr. Yuki Park hospitalist | Confirm Satellite Healthcare San Jose or UCSF dialysis as accepting; coordinate IOP at HealthRIGHT 360 around T/Th/Sat HD→ |
| Eleanor Park 84 F · MRN-58608 | Ready · pending logistics | 5B | Geriatrics | Medicare FFS + supplement (Plan G) | Hospice · home | in 1d Tue 1:00 PM | 88% | 54% | MED | Family wants home not facility; private-pay caregiver needed for 24h coverage | Tara Liu, MSW social worker | Confirm Sutter Care at Home hospice intake; arrange 24h private-pay caregiver via Home Instead→ |