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

Patient Discharge Cockpit

Michael Johnson · CHF exacerbation (I50.9)
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MC
MJ
Michael Johnson
72 M · MRN-58231 · CHF exacerbation (I50.9)
PlanningUnit 5BCardiologyBlueShield MA Advantage HMOLOS 3d
ComorbiditiesHFpEFType 2 diabetes mellitusChronic kidney disease Stage 3bEssential hypertension
Estimated discharge
Tuesday 2:00 PM
HIGH delay risk
Six readiness dimensions

All six must align for discharge to actually happen

Open discharge map →
♡
Clinical readiness
92%Blocked
⚒
Functional & equipment readiness
42%Blocked
℞
Medication readiness
64%Blocked
$
Financial readiness
67%Blocked
▦
Care coordination readiness
94%Ready
✿
Patient agreement & support readiness
50%Blocked
Unified readiness model

Three axes → one “ready” verdict

Not ready · 5 blockers
Axis 1 · Feasibility
Can this disposition happen? (engine = authority)
2 blocker(s)
Target: HOME
Binding: Functional status · VIOLATED
Axis 2 · Progress
How far along is the work? (tasks, not a score)
0/2 required
10% of execution tasks complete
Clinical readiness0/1
Medication readiness0/2 ●
Care coordination readiness1/1
Patient agreement & support readiness0/6 ●
Axis 3 · Execution-staging
Is the bed actually secured? (acceptance pipeline)
Awaiting bed
Stage: Pending Acceptance
Facility-bound · not yet bed-confirmed (blocks completion).
  • ●2 engine constraint(s) violated: FUNCTIONAL, SOCIAL_SDOH.
  • ●Acceptance pipeline not at Bed Confirmed (currently PENDING_ACCEPTANCE).
  • ●T2 gate not cleared: Patient/family OOP acceptance documented (if residual cost).
  • ●2 required execution task(s) still open.
  • ●3 readiness gate(s) unmet: PT evaluation completed and documented; Prior auth approved for Sacubitril/valsartan (Entresto); Prior auth status for Sacubitril/valsartan (Entresto).
Scalars (display-only): clinical 81 · operational 46 — non-authoritative; feasibility + progress above are the truth.
30-d readmission risk
LACE+ + HOSPITAL · HRRP-tracked
HIGH

HRRP-tracked: Heart failure. Penalty applies if 30-d readmit exceeds risk-adjusted mean.

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

Active pathwayhigh risk

SNF skilled rehab

disposition=SNF · services=OUTPATIENT_PT_OT+OUTPATIENT_PHARMACY · rules=rule-medicare-snf-skilled

Open patient workflow →
4 / 16 steps
4 done0 in progress12 blocked0 pending

Intensity tier: LACE+ 11 (HIGH) + HOSPITAL 1 (LOW) → HIGH. · bumped by: HRRP-tracked condition

Engine-derived barriers

Top blockers · with one-click playbooks

1 barrier
  • WatchApproaching SLAOwner: Case Manager· Open 0d
    Bed / service availability

    Awaiting facility acceptance; tracking against 7d bed-hold.

    via acceptance tracking (AWAITING_PLACEMENT)

    No matching playbook · use Copilot chat to compose a custom action.
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

16 tasks
Hospitalist2
Assigned
Confirm clinical discharge criteria
Dr. Jordan Park
In progress
Hospitalist 'medically ready' attestation on file
Nursing1
Assigned
Complete discharge education (CHF self-care)
Sara Khan, RN
Pharmacy3
In progress
Complete medication reconciliation
Sam Reyes, PharmD
Waiting
Check medication coverage & pharmacy availability
Sam Reyes, PharmD
Assigned
Start prior authorization (Entresto)
Sam Reyes, PharmD
PT / OT2
Assigned
Complete PT mobility assessment
Aisha Patel, DPT
In progress
PT evaluation completed and documented
Case manager5
Suggested
Confirm caregiver availability
Maria Chen, RN
Assigned
Capture SNF preferences from patient/caregiver
Maria Chen, RN
Suggested
Schedule transportation
Maria Chen, RN
Assigned
Resolve: Bed / service availability
Assigned
Prior auth status for Sacubitril/valsartan (Entresto)
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.

Prior authorizations · M11

Each PA tracked Required → Submitted → Approved / Denied with the payer SLA clock. Runs concurrent with the referral, never serialized.

1 pending
Sacubitril/valsartan (Entresto)
49/51 mg · PO
Submitted
BlueShield MA Advantage HMO· SLA 7d· 25h elapsed
→ Awaiting payer (within SLA)
SLA windows: CMS-0057-F (Apr 2024) · MA PA streamlining. Synthetic demo data.
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 verified (X12 270/271) — the payer path is open.
    cite: X12 270/271 eligibility
  • Required capabilities met
    Match may be missing: DIALYSIS — confirm with the site.
    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