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

Patient Discharge Cockpit

Celia Martin · Hip fracture s/p ORIF (S72.141A)
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MC
CM
Celia Martin
82 F · MRN-58553 · Hip fracture s/p ORIF (S72.141A)
Ready · pending logisticsUnit 5BOrthoBlueShield MALOS 5d
Estimated discharge
Wednesday 1:00 PM
HIGH delay risk
Six readiness dimensions

All six must align for discharge to actually happen

Open discharge map →
♡
Clinical readiness
100%Ready
⚒
Functional & equipment readiness
50%Blocked
℞
Medication readiness
75%Blocked
$
Financial readiness
50%Blocked
▦
Care coordination readiness
83%Ready
✿
Patient agreement & support readiness
50%Blocked
Unified readiness model

Three axes → one “ready” verdict

Not ready · 4 blockers
Axis 1 · Feasibility
Can this disposition happen? (engine = authority)
Clear
Target: HOME (provisional — unknown pending)
Binding: Functional status · UNKNOWN
Axis 2 · Progress
How far along is the work? (tasks, not a score)
0/2 required
11% of execution tasks complete
Clinical readiness1/1
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).
  • ●Acceptance pipeline not at Bed Confirmed (currently REFERRAL_DRAFTED).
  • ●T2 gate not cleared: Patient/family OOP acceptance documented (if residual cost).
  • ●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; Initial IMM delivered (Medicare patient appeal-rights notice).
Scalars (display-only): clinical 89 · operational 33 — 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

1 barrier
  • WatchApproaching SLAOwner: Financial counselor / CM· Open 0d
    Payer authorization

    Awaiting authorization; tracking against 7d bed-hold.

    via acceptance tracking (AWAITING_AUTH)

    → 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

5 tasks
Hospitalist0
No active tasks
Nursing0
No active tasks
Pharmacy1
In progress
Discharge medication reconciliation completed by pharmacist
PT / OT1
In progress
PT evaluation completed and documented
Case manager3
Assigned
Attach PT/OT notes to SNF auth packet
Maria Chen, RN
Assigned
Resolve: Payer authorization
Assigned
Post-acute service auth (SNF) initiated within payer SLA
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.

Stanford Health Care Skilled Nursing
SNF · Santa Clara CountyUNVERIFIED· 5★· 25 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
    Stanford Health Care Skilled Nursing 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