Discharge Command Center
Stanford Medicine · Units 5B / S4 / B6 · 40 patients · sorted by delay risk
Expected today
20next 36h
Across all units
At-risk discharges
21high risk
Operational readiness < 55%
Avoidable days
25census
Primary-attributed (no double-count)
Pending auths
10awaiting payer
SNF + meds + HH
Med access issues
0
PA + pharmacy stock
Placement blockers
3active
Auth + bed + guardianship
| Patient | Service · Payer | Disposition | EDD | Readiness · 8 parameters | Delay risk | Top blocker | Owner | Next best action |
|---|---|---|---|---|---|---|---|---|
Alma Singh | Medicine Medicaid pending | SNF | in 5d | clinical 70 · operational 22 | high | Guardianship + Medicaid pending | Tara Liu, MSW Social work | Escalate to legal partner — pro bono guardianship → |
Wanda Price | Medicine Medicaid pending | Memory care | in 8d | clinical 73 · operational 18 | high | Memory care funding path unresolved | Tara Liu, MSW Social work | Start HCBS waiver + charity bridge screen → |
David Chen | Behavioral Health Anthem Blue Cross CA (Medi-Cal MCO) | Home | in 2d | clinical 72 · operational 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 → |
Michael Johnson | Cardiology BlueShield MA Advantage HMO | SNF | in 1d | clinical 81 · operational 46 | high | SNF prefs + med PA | Maria Chen, RN Case manager | Send SNF preference form to caregiver → |
Celia Martin | Ortho BlueShield MA | SNF | in 2d | clinical 89 · operational 33 | high | SNF auth pending clinical upload | Maria Chen, RN Case manager | Attach PT note and resubmit auth packet → |
Samir Patel | Stroke Anthem PPO | LTACH | in 4d | clinical 61 · operational 29 | high | LTCH acceptance blocked by acuity review | Tara Liu, MSW Social work | Escalate complex placement huddle → |
Yasmin Hassan | Medicine Medi-Cal managed care | Respite | in 2d | clinical 87 · operational 26 | high | Medical respite bed unavailable | Tara Liu, MSW Social work | Escalate respite waitlist and backup shelter plan → |
Anthony Boyd | Medicine Self-pay (Medi-Cal application pending) | Respite | in 3d | clinical 74 · operational 22 | high | Medical respite + IV-abx-capable site needed; standard shelters can't manage PICC | Tara Liu, MSW Social work | Cherry Hill (Alameda) or ATAC (SF) medical respite — both accept PICC; secure Medi-Cal urgent-application → |
Priscilla Nguyen | Orthopedics Medicare FFS | SNF | in 5d | clinical 68 · operational 60 | high | Mid-stay: SNF acceptance pending; AM-PAC documents the referral packet | Maria Chen, RN Case manager | Send referral packet with AM-PAC; warm 2 backup SNFs → |
Linda Kowalski | Ortho Medicare FFS | SNF | in 1d | clinical 92 · operational 38 | high | SNF auth denied — peer-to-peer pending | Maria Chen, RN Case manager | Schedule MD peer-to-peer with BlueShield → |
Marisol Vega | Medicine Medicare FFS | Home + DME | in 1d | clinical 79 · operational 49 | high | Portable O2 CMN missing signature | Dr. Jordan Park Hospitalist | Sign CMN form 484 for home oxygen → |
Nathan Cooper | Medicine United MA | Home | in 2d | clinical 67 · operational 44 | high | Home health start-of-care unavailable | Maria Chen, RN Case manager | Book backup HH agency before noon → |
Marian Adler | Cardiology Humana MA | Home | in 2d | clinical 76 · operational 47 | high | Entresto denied; alternate plan needed | Sam Reyes, PharmD Pharmacy | Draft payer exception or ARB fallback → |
Joanne Keller | BMT BlueCross MA | Home | in 3d | clinical 64 · operational 42 | high | Home infusion nursing unavailable | Tara Liu, MSW Social work | Warm backup infusion vendor → |
Grace Nelson | BMT Kaiser MA | Home | in 3d | clinical 69 · operational 36 | high | Specialty pharmacy delivery not confirmed | Sam Reyes, PharmD Pharmacy | Confirm same-day specialty courier → |
Maria Hernandez | Cardiology Uninsured (charity-care pending) | Home + DME | in 1d | clinical 79 · operational 32 | high | 501(r) financial-assistance application pending; Entresto + Jardiena cash price ~$1.1k/mo | Tara Liu, MSW Social work | Complete Stanford FAP application + enroll in Novartis Entresto Central + BI Jardiance PAP → |
Rosa Mendez | Stroke Medicare FFS | IRF | in 1d | clinical 78 · operational 60 | med | Speech eval + caregiver coaching pending | Maria Chen, RN Case manager | Fri→Mon prep: dispatch weekend tasks → |
George Wilson | Medicine Medicare FFS | SNF | in 1d | clinical 88 · operational 71 | med | SNF bed for Mon AM | Maria Chen, RN Case manager | Confirm Bayview SNF intake slot → |
Owen Li | Ortho Medicare FFS | SNF | in 1d | clinical 94 · operational 62 | med | Family choosing between accepted SNFs | Maria Chen, RN Case manager | Send ranked SNF preference form → |
Beatrice Wong | Ortho Aetna PPO | IRF | in 2d | clinical 83 · operational 55 | med | ARU medical director review pending | Aisha Patel, DPT PT / OT | Upload stair trial and endurance note → |
Kevin Owens | Stroke BlueCross MA | IRF | in 1d | clinical 82 · operational 57 | med | Speech eval delayed until afternoon | Aisha Patel, DPT PT / OT | Escalate SLP slot into weekend prep batch → |
Carlos Rivera | Medicine Aetna PPO | Home + DME | in 1d | clinical 74 · operational 52 | med | Home O₂ vendor ETA Wed | Maria Chen, RN Case manager | Confirm Lincare delivery window + backup → |
Patricia O'Brien | Cardiology Humana MA | Home | in 1d | clinical 84 · operational 64 | med | Eliquis PA + HH agency capacity | Maria Chen, RN Case manager | Submit Eliquis PA via CoverMyMeds → |
Evelyn Baker | BMT BlueCross MA | Home | in 2d | clinical 68 · operational 54 | med | Infusion pharmacy + caregiver education | Tara Liu, MSW Social work | Coordinate Coram home infusion intake → |
Henry Ford | Medicine Kaiser MA | Home | in 1d | clinical 72 · operational 66 | med | Outpatient nephrology slot | Maria Chen, RN Case manager | Book nephrology 48h via Kaiser referral desk → |
Rita Johnson | Medicine Medicare FFS | Home | in 1d | clinical 76 · operational 58 | med | Home safety eval + walker | Liam Park, OT PT / OT | OT home safety + DME walker order → |
Terrence Brooks | Cardiology Medicare FFS | Home | in 1d | clinical 91 · operational 73 | med | Meds-to-beds delivery after 4 PM | Sam Reyes, PharmD Pharmacy | Move pharmacy fill before 15:30 cutoff → |
Helen Yu | Stroke Medicare FFS | Home | in 1d | clinical 88 · operational 52 | med | Caregiver coaching not complete | Sara Khan, RN Bedside RN | Send stroke warning-sign education to daughter → |
Liam Murphy | BMT Medicare FFS | Home | in 2d | clinical 71 · operational 58 | med | Caregiver line-care teach-back pending | Sara Khan, RN Bedside RN | Schedule caregiver line-care session → |
Eleanor Park | Geriatrics Medicare FFS + supplement (Plan G) | Hospice | in 1d | clinical 88 · operational 54 | med | Family wants home not facility; private-pay caregiver needed for 24h coverage | Tara Liu, MSW Social work | Confirm Sutter Care at Home hospice intake; arrange 24h private-pay caregiver via Home Instead → |
Dorothy Vance | Medicine Medicare FFS | Home | in 5d | clinical 72 · operational 80 | med | Mid-stay: IV-to-PO antibiotics pending; home O₂ need under review | Maria Chen, RN Case manager | Confirm IV-to-PO switch criteria; order home O₂ eval → |
Victor Osei | Pulmonary Aetna Medicare Advantage | Home | in 6d | clinical 70 · operational 78 | med | Mid-stay: steroid taper + inhaler technique teach-back in progress | Dr. Jordan Park Hospitalist | Complete inhaler teach-back; confirm pulmonary follow-up ≤ 7d → |
Gloria Mendez | Neurology Medicare FFS | SNF | T-24h · 9:00 AM | clinical 88 · operational 82 | med | Day-of: transport + warm handoff to confirm for the morning | Maria Chen, RN Case manager | Confirm NEMT for 09:00; call report to receiving SNF → |
Nathan Cole | Medicine Medi-Cal Managed Care | Home | in 4d | clinical 58 · operational 50 | med | Admission: screens in progress — ESDP not yet completed | Tara Liu, MSW Social work | Complete admission ESDP + SDOH screen; set EDD → |
James Thompson | Cardiology Medicare FFS | Home | clock paused | clinical 96 · operational 88 | low | QIO discharge appeal filed — clock paused (§405.1200) | Dr. Jordan Park Hospitalist | Await QIO determination; appeal days excluded from avoidable days → |
Raymond Park | Medicine Medicare FFS | Home | in 2d | clinical 58 · operational 70 | low | Awaiting IV → PO conversion | Dr. Jordan Park Hospitalist | Pharmacy: convert ceftriaxone → cefpodoxime → |
Anita Gomez | Medicine Anthem PPO | Home | T-24h · 6:00 PM | clinical 91 · operational 76 | low | Insulin pen teach-back + glucometer | Sara Khan, RN Bedside RN | Pharmacy meds-to-beds + 20-min teach → |
Frank DelaCruz | Cardiology Medicare FFS | Home | in 1d | clinical 80 · operational 80 | low | Cardiac rehab referral | Dr. Jordan Park Hospitalist | Submit Phase II rehab referral → |
Diane Hsu | Stroke BlueShield MA | Home | T-24h · 9:00 AM | clinical 86 · operational 82 | low | Anticoag PA + neuro f/u | Maria Chen, RN Case manager | Submit Eliquis PA + book neuro 7 days → |
Harold Finch | Medicine Blue Shield PPO | Home | T-24h · 8:00 PM | clinical 94 · operational 90 | low | Day-of: ride home not yet confirmed | Maria Chen, RN Case manager | Confirm ride; meds-to-beds delivered; AVS reviewed → |
Demo data · no PHI · engine-computed readiness parameters = Medical · Functional · Medication · Decisional · Caregiver · Coverage · Legal · Continuity