Stanford Med · Unit 5B Medicine·Day shift·Mon · 9:42 AM

Patient Discharge Cockpit

Alma Singh · Dementia + UTI (F03.91)
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MC
AS
Alma Singh
84 F · MRN-57810 · Dementia + UTI (F03.91)
BarrieredALC · complex-stayUnit 5BMedicineMedicaid pendingLOS 8d
Estimated discharge
Saturday 12:00 PM
HIGH delay risk
Six readiness dimensions

All six must align for discharge to actually happen

Open discharge map →
♡
Clinical readiness
75%Blocked
⚒
Functional & equipment readiness
50%Blocked
℞
Medication readiness
75%Blocked
$
Financial readiness
50%Blocked
▦
Care coordination readiness
83%Ready
✿
Patient agreement & support readiness
44%Blocked
Unified readiness model

Three axes → one “ready” verdict

Not ready · 8 blockers
Axis 1 · Feasibility
Can this disposition happen? (engine = authority)
3 blocker(s)
Target: ICF_CUSTODIAL
Binding: Decision-maker / legal · VIOLATED
Hard blockers: Legal decision-maker / guardianship, Patient agreement & support readiness
Axis 2 · Progress
How far along is the work? (tasks, not a score)
0/2 required
0% of execution tasks complete
Clinical readiness0/1
Medication readiness0/2 ●
Patient agreement & support readiness0/6 ●
Axis 3 · Execution-staging
Is the bed actually secured? (acceptance pipeline)
Awaiting bed
Stage: Referral Drafted
Facility-bound · not yet bed-confirmed (blocks completion).
  • ●1 engine constraint(s) violated: DECISION_LEGAL.
  • ●Hard category blocker(s): LEGAL_DECISION_MAKER, PATIENT_AGREEMENT.
  • ●Acceptance pipeline not at Bed Confirmed (currently REFERRAL_DRAFTED).
  • ●T2 gate not cleared: Hospitalist 'medically ready' attestation on file.
  • ●T2 gate not cleared: Patient/family OOP acceptance documented (if residual cost).
  • ●T2 gate not cleared: Guardianship/surrogate resolved or petition filed (if needed).
  • ●2 required execution task(s) still open.
  • ●4 readiness gate(s) unmet: PT evaluation completed and documented; Real-time payer eligibility + benefit detail verified at admit; Post-acute service auth (SNF) initiated within payer SLA; Admission social-work screen — decision-maker / capacity.
Scalars (display-only): clinical 70 · operational 22 — non-authoritative; feasibility + progress above are the truth.
30-d readmission risk
LACE+ + HOSPITAL · not HRRP-tracked
HIGH

Drives pathway intensity tier — HIGH score adds Coleman / Naylor touchpoints automatically.

Active pathway

No matching pathway. Patient needs a confirmed disposition + service stack to assign a workflow.

Engine-derived barriers

Top blockers · with one-click playbooks

2 barriers
  • Actively blockingApproaching SLAOwner: Social Worker· Open 8d
    Guardianship / legal

    ALC — Awaiting Guardianship; file/track petition (CA conservatorship ~4–6 wks).

    via extendedReadiness blocker (DECISION_LEGAL); acceptance tracking (AWAITING_GUARDIANSHIP)

    → drafts go to HITL queue, not sent until approved
  • Actively blockingOwner: Social Worker· Open 8d
    Housing / social

    No caregiver — home-with-support not viable without arranged care.

    via extendedReadiness blocker (SOCIAL_SDOH)

    → drafts go to HITL queue, not sent until approved
Execution layer · HITL queue

Pending actions · awaiting clinician approval

0 open

Drafted by playbooks / AI · NOT sent until you approve. Approve fires the integration mock + writes a Submission audit row.

No pending actions. Click Run playbook on a barrier to draft one.
From the family · patient portal

What the caregiver has told us

Not started
Recovery preferenceWants to talk it through
TransportNot sure — wants a call
Home supportNeeds extra help
Preferred pharmacy—
Preferred languageEnglish
Discharge teaching0/3 videos watched
Workflow swim lanes

Tasks by role · cross-functional discharge orchestration

6 tasks
Hospitalist1
In progress
Hospitalist 'medically ready' attestation on file
Nursing0
No active tasks
Pharmacy0
No active tasks
PT / OT0
No active tasks
Case manager1
Assigned
Post-acute service auth (SNF) initiated within payer SLA
Social work4
In progress
Engage pro bono guardianship clinic
Tara Liu, MSW
Assigned
Resolve: Guardianship / legal
Assigned
Resolve: Housing / social
Assigned
Admission social-work screen — decision-maker / capacity
Event simulator · demo only

Fire a realistic event to watch the engine recompute

src/lib/engine/dispatcher.ts
Event feed · dynamic engine

What moved the pillars

0 total
No events yet. Use the simulator below to fire a payer decision, FHIR observation, or vendor callback and watch the pillars move.

AI chart summary · live via Anthropic Claude

Runs through runAgent · writes an AgentInference audit row with cost, latency, prompt hash.

Click Run chart summary to call Claude Sonnet 4.6 on this patient's record. The audit row will be visible in Neon's AgentInference table within ~3s.

Prior auth drafter · Claude → HITL → CoverMyMeds

Draft → review → approve → submit

Live wire

Drafts via src/lib/ai/agents/prior-auth-drafter.ts → submits via src/lib/integrations/cmm.ts (mock-contract). Both write audit rows.

Resource referral · HITL gate

Registry-matched post-acute site. Sending writes the legally-load-bearing Submission (licensed reviewer) and opens the acceptance loop.

San Francisco Campus for Jewish Living
SNF · SF CountyUNVERIFIED· 4★· 24 candidates
Channel decision
Community Resource Registryrecommended
Structured referral with a tracked acceptance loop + audit row; closes back via the acceptance webhook.
Direct fax to facility
No acceptance tracking, no structured response — bed-days lost in the gap.
Phone to intake
Verbal only — no defensible artifact of what was sent.
Compliance evidence1 blocking issue · action gated
  • Accepting provider identifiedblocking
    San Francisco Campus for Jewish Living matched from the registry for this disposition + coverage.
    cite: 42 CFR §482.43(c) · accepting provider documented
  • Patient choice documentedblocking
    No recovery preference captured yet — send the preference form and wait for the family before referring.
    cite: 42 CFR §482.43(c) · patient freedom of choice
  • Coverage path confirmed
    Eligibility not yet verified — confirm coverage to avoid a denial on intake.
    cite: X12 270/271 eligibility
  • Required capabilities met
    No special capabilities required for this placement.
    cite: IMPACT Act 2014 · PAC capability match
  • Reviewer is licensed to submitblocking
    Submitting reviewer carries an active credential — the referral is on their license.
    cite: State board · HITL submission gate
A blocking rule failed — most often the family hasn't confirmed a recovery preference yet. The referral waits on the patient's choice (their portal).
Demo data · no PHI · mocked Epic + payer endpoints