The Power of the Patient’s Story to Transform Health Care

Lauran Hardin MSN, RN-BC, CNL

March 29, 2016

Interprofessional Value and the Patient Story….Where it all Began

24/18/2016

(c) 2014 Mercy Health Saint Mary's. All Rights Reserved. No Reproduction Without Prior Authorization

CPM: The Core Beliefs™

• Each person has the right to safe, individualized healthcare which promotes wholeness of body, mind and spirit.

• A healthy culture begins with each person and is enhanced by self-work, healthy relationships and system supports.

• Continuous learning, diverse thinking and evidence-based actions are essential to maintain and improve health.

• Partnerships are essential to plan, coordinate, integrate, deliver and evaluate healthcare across the continuum.

• Each person is accountable to communicate and integrate his/her contribution to healthcare.

• Quality exists where shared purpose, vision, values and healthy relationships are lived.

34/18/2016

Trinity Health

©2015 Trinity Health - Livonia, MI

• $13.6 billion in revenue• Almost $900 million

in community benefit ministry

• 89,000 full-time employees• 3,300 employed physicians• 22,890 affiliated physicians

• 86* Hospitals in 21 states

• 128 Long-term care, assisted, independent living and affordable housing communities

• • 44 Home Care Agencies

• • 14 PACE Centers

• • 70 Other Continuing Care Facilities

• Nearly 2.8 million home health/ hospice visits

Our diversified network extends across the full continuum of

care

Mercy Health Saint Mary’s Today

An integrated health care system in west Michigan: 2nd largest integrated health care system in Kent county

with $450M annual net revenueAchieved Magnet® designation on May 15, 2013Top Hospitals for Leapfrog 2013 - 2015Teaching hospital - 371 beds with ~ 4,500 colleagues - -

including 116 psychiatric, and 15 neonatal ICU beds 20 operating rooms between main campus and ASC

with 2 da Vinci surgical systemsProgressive leader in cancer care, neurosciences,

orthopedics, kidney transplant, diabetes and endocrine care, and behavioral health

Comprehensive clinical integration model aligning more than 500 employed and independent providers into Clinically Integrated System with at risk contracts Mercy Health Physician Partners – employed group of 250+

primary and specialty care physicians and APPs Affinia Health Partners – a membership organization unifying

employed and independent physicians in the communityc) 2015 Trinity Health Michigan dba Mercy Health Saint Mary’s. All Rights Reserved. No Reproduction Without Prior Authorization

6

Mercy Health Saint Mary’s –FY2015

• Serve residents in 15 counties• ~22,000 inpatient discharges• ~2200 births• ~20,000 surgeries• 80,000+ emergency department

visits• 23,500+ urgent care visits• 1.1+ million outpatient visits• Top quartile in national peer

group in H-CAHPS patient satisfaction for: – Rate Hospital– Would Recommend Hospital

• c) 2015 Trinity Health Michigan dba Mercy Health Saint Mary’s. All Rights Reserved. No Reproduction Without Prior Authorization

Source: Mercy Health Saint Mary’s financial reporting and Press Ganey

Core Service Area

The Situation

• Robert Wood Johnson Foundation reports 5% of the population uses nearly half of total healthcare spending (http://www.rwjf.org/en/topics/rwjf-topic-areas/health-policy/health-care-costs/HealthCareCostsFastFacts.html

• Recent analysis identifies “High frequency Patients” or “Super Utilizers” – who they are is poorly understood

• Successful Population Health strategies include management of these high risk patients

c) 2015 Trinity Health Michigan dba Mercy Health Saint Mary’s. All Rights Reserved. No Reproduction Without Prior Authorization

http://www.rwjf.org/en/topics/rwjf-topic-areas/health-policy/health-care-costs/HealthCareCostsFastFacts.html

(c) 2014 Mercy Health Saint Mary's. All Rights Reserved. No Reproduction Without Prior Authorization

High Frequency Patients – Population Approach

>10 ED Visits &/or > 4 Admitsin 12 months

Total Pts Total Visits

ED Visits

UC Visits

IP Admits

OBSAdmits

FY 2011 613 7,307 5,205 256 1,652 194FY 2012 735 8,501 5,590 397 2,073 441FY 2012 % Total Volume 10.5% 2% 10.1% 17.8%

8This is a confidential professional/peer/review and quality improvement document of the hospital and the Trinity Health system of providers. It is protected from disclosure pursuant to the provisions of state laws as well as the federal Patient Safety and Quality Improvement Act, 42 U.S.C. 299b-21¿b-26 and other federal laws. Unauthorized disclosure or duplication is absolutely prohibited. 2010

Chart1

Pain

Substance Use Disorder

Multiple Medical

Cancer

GI

ESRD

Cardiac

COPD

Psych

Neuro

OB

%

Subpopulations High Frequency Patients FY 2012

24

20

11

9

7

7

6

5

4

4

3

Provider ID Patients

Complex Patient Databaselast update 8/2/13multiple namesat >1 yrequals > 3 mosCCP, PCP, Boundaries(B), IPC

*used in trinequals >9 moequals >6 months out

Patient NameMRNDxReasonCategoryPCPCNLIPEDLOSCP DateIPEDLOSOutcomesRef SourceCerner CCPGroupCC Conf

Brian Merryman755026DM, GastroporesisPain/N/VRe-admitsHull/PostemaRebeccaPC5016*02/23/20125117shorter admits - happier patientPCDz

Katherine Beaty493358DM, GastroPain/ N/VRe-admitsApplegateRebeccaPC11147*03/12/20126017Paula1/8/13Dz

Michael Chambers1008307MD, GastroporesisPain/N/VRe-admitsMcBrideRebeccaPC10583*04/05/20123016Stopped hosp admit 3/5, 4/26, look back to 2009, hospicePtdied 7/25/13Dz

Jason Cardosa708152DM, GastroparesesPain/N/VRe-admitsAshmeadRebeccaPC88206/19/129630Durham 7/2/12Jillaine9/26/12Dz

Linda Williams1128081DM, GastroparesesPain/N/VRe-admitsGeissler/SicesRebeccaPC 5/2012143427/30/1271228Durham 9/2012, look at back to 20109/26/12Dz

Michael DuBoise1092813ESRD, GastroMultRe-admitsAlbrecht MetroRebeccaPC 201089658/17/124117Durham 9/24 145, died 12/201212/3/12Dz

Michael Boger1054202DM, GastroPainRe-admitsNone/SicesRebeccaPC1249/18/124114Durham 10/11PC11/15/12Dz

Dennis Kugel804595DM, GastroPain/NVRe-admitsSicesRebeccano PC401510/11/125218Durham7N3/11/13Dz

Fred Bogardus733036GastroparesisPain/N/VRe-admitsCarelRebeccano PC512410/3/122110Mary HDz

Billy Briscoe953837GastroparesisPain/N/VRe-admitsKitzsteinerRebeccano PC531212/12/12000Theresa HospDz

Roger Petree561296DM, GastroPain/NVRe-admitsPolizziRebeccaPC 201065131/2/13112JillaineDz

Tina Garza1148283DM, Gastro, ParaPain/NVRe-admitsBaldwinRebeccaPC77372/18/133314Rebecca#Dz

Jessie Korhonen333668DM, GastroPain/N/VRe-admitsAshmeadNoneno PC1124/8/13010did not intervene - improvedDr. AshmeadDz

Rebecca Centelli#271529Dz, GastroPain/NVRe-admitsWitherallNonePC25114/17/13115Jan Themm#Dz

Travis Worden844853Psych, GastroPain/NVRe-admitsHullNoneno PC31134/17/13000Carey J 8S6/4/13Dz

Joshua Flowers#728646DM, GastroPain/NVRe-admitsPowellNoneno PC69314/25/13000Mary H#Dz

Robert Planck181752DM ?GastroPain/NVRe-admitsUKRebeccano PC31135/21/13Rebecca

Emily Grunwell293106DM, GastroPain/NVRe-admitsnoneKristinno PC14+5/29/13Kristin

Sharon Ambrose151715DM, GastroPain/NVRe-admitsHullRebeccano PC418185/30/13Rebecca

Tonya Robinson1074433DM, GastroComplexComplexMerittnonePC47167/18/13PaulaDz

Gladys Pagan Garcia742039Pain/GastroComplexComplexDykstraRebeccaPC3136+7/23/13got Spanish Gastro toolPC/orderDz

Rosetta Lewis399617DM/GastroComplexComplexSepterNoneno PC11638/12/13Margie CMDz

Julie Kent905699DM/GastroComplexComplexHullNonePC in past6320+8/20/13Kristin H3Dz8/21/13

Theon Rembert258231DM/GastroComplexComplexSanaullahRebeccano PC415138/21/13ED Dr/CC Order8/30/13DZ

Darda Troyer446805CHFReadmitsRe-admitsQuiroznonePC75251/2/13000JillaineDz

Deneka Suggs865545CMReadmitsRe-admitsSteennoneno PC31393/18/133612Jillaine8/8/13Dz

Makaylah Winder804468CHFReadmitsRe-admitsNikolakeasRebeccaPC70533/19/13000died 6/2013RebeccaCNL onlyDz

Mitchell Lamb457311CHFReadmitsRe-admitsDurfeenoneno PC30104/10/13117?JillaineDZ

Joseph Metcalf549608HTNHeartsideHeartsideHeartsidenoneno PC0105/14/13na - resolvedJayna

Kim Sowell571304CHF/MMReadmitsRe-admitsHullnoneno PC54145/21/13?

Anthony Thomas587569CHFComplexComplexKitzsteinerRebeccano PC11+7/10/13Rebecca

Rosalind Campbell1125014Sickle CellPain/AddictionRe-admits AddictionSepter -MetroRebeccaPC71541*02/02/2012010PCDz

Valerie Chandler1033733Sickle CellReadmits/PregnantReadmitsScottRebeccaPC8650*04/25/20123222Created complex algorithmJillaineDz

Adrian Davis1042699Sickle CellPain/AddictionReadmitsWallerBethPC361212/14/1247202/12/13Dz

Shaun Long427586Sickle CellPain/AddictionMult EDBlairLaurieno PC1134/10/13000referred 5/14/12 resolved?Dz

Quinee Watson-Trotter608240Sickle CellED FFED FFnoneLaurieno PC0707/28/13Olgren/CC OrderDz

Noor Khalid Alfakhr1211206Sickle CellComplexComplexSalehnonePC21207/29/13PCDz

Nicole Lovelady1071910Sickle CellED FFED FFBrinkernonePC8/12/13ED PA/CC OrderDz

Rafael Benites227935Pain/AddictionPain/AddictionAddictionNoneRebeccaPC31138/21/12010Psych suicidalPCSUD

Michael Martin1049422Pain/AddictionPain/AddictionRe-admits AddictionSaierRebeccaPC66208/23/12010PCSUD

Brandon Thomas1191355Pain/AddictionComplexComplexHeartsidenoneno PC1039/27/12000Tanya

Thomas Spaulding408529Pain/AddictionMultRe-admits AddictionNoneRebeccaPC 2011225510/2/1218711/14/12SUD

Ricardo Torres618867Pain/AddictionReadmitsReadmitsNoneNonePC331911/21/12060PCSUD

Theresa White393790Pain/AddictionED FFED FFSein OhnNonePC441111/21/12384?PC8/2/13SUD

Lori Ann Troupe355051Pain/AddictionED FFED FFWiardaPC14112/5/12040needs SBAR#SUD

Jennifer Powell (Vaness)1129131Pain/AddictionED FFED FFDeckernoneno PC12321/3/1301406/7/13SUD

Richard Dalrymple48912Pain/AddictionED FFED FFWallernoneno PC413161/8/13020Died 6/27/13 - OD1/23/13SUD

Timothy Stowe239767Pain/AddictionPainRe-admitsNoneNAPC412271/24/13040Waller 2/5/132/12/13SUD

NASCHEKA EVANS703421Pain/AddictionPainEarly RefBeltranNAPC11101/21/132012Duram 7/20138/8/13SUD

Duane Allison Denning1177460Pain/? AddictionComplexComplexNoneNonePC86161/30/13010PCSUD

Monica Pace846282Pain/AddictionPain/AddictionPain/AddictionWallernoneno PC0401/29/13010MULTIPLE NAMESWallerSUD

Kenneth Regina1113172Pain/AddictionPain/AddictionRe-admitsNoneRebeccaPC2963/22/130304/10/13SUD

Derek Stark1116741Pain/AddictionPain/AddictionED FFNoneRebeccaPC11734/2/13143Cheryl PC4/26/13SUD

Antonio Mendez Sanchez503356Pain/AddictionPain/AddictionED FFWallernoneno PC0304/10/13000?ED

Jason Chatman650618Pain/AddictionPain/AddictionComplexComplexBethPC2054/16/13000Beth5/1/13SUD

Daniel Abraham1005603Pain/AddictionED FFED FFNoneNoneno PC01204/18/13020Kat4/30/13SUD

Kourtney Meeker697855Pain/AddictionED FFED FFNonenoneno0403/8/13Needs to be addedED referral3/8/13SUD

Treauna Jackson781166Pain/AddictionED FFED FFSepternoneno PC0205/30/13ED PA/Order6/4/13SUD

Jessica Hann1170767Pain/AddictionED FFED FFNoneNoneno PC22546/4/13ref Waller 7/23/13ED DR6/4/13SUD

Kathleen Jones678885Pain/AddictionED FFED FFBatesnonePC1636/5/13ref Waller 7/23/13Deanna PA ED/CC Order6/10/13SUD

Brent Hansen (Hanson)997397PainED FFED FFPowellNonePC01506/19/13needs SBARHeather EDSUD

Barbara Lowe566883Pain/AddictionED FFED FFNonenoneno PC0506/21/13Dr. Olgren6/25/13SUD

Shelly Lee1068414Pain/AddictionED FFED FFNonenoneno PC02707/2/13ED DR/OrderSUD

Sarah Cassleman1142608Pain/AddictionED FFED FFWolfenoneno PC01107/2/13ED DR/OrderSUD

Michelle Masalkowski574352Pain/AddictionED FFED FFKobielanoneno PC1927/8/13Jacob PA CC Order7/8/13SUD

Juan Reyes589158Pain/AddictionED FFED FFNonenoneno PC0907/8/13Dr. Figurski CC Order7/8/13SUD

Loren Wiman1168236Pain/AddictionED FFED FFSicesnonePC321337/9/13Garcia PA CC Order7/9/13SUD

William Taggert1033862Pain/AddictionComplexComplexFinkbeinerBethPC107/9/13Beth CNL7/22/13SUD

Dannette Coleman182228Pain/AddictionED FFED FFNonenonePC1627/19/13Laurie CNL9/5/13SUD

Jonathan Umstead806036Pain/AddictionED FFED FFMeyernoneno PC01607/16/13ED PA/OrderSUD

Thomas Andrews859501Pain/AddictionED FFED FFNonenoneno PC11037/15/13ED PA/Order

Natia Mitchell265525Pain/AddictionED FFED FFWest Side ClinicnonePC22157/25/13Margie CM8/11/13SUD

Billijo Brenner757445Pain/AddictionED FFED FFWadwanoneno PC02007/26/13ED DR/Order8/8/13SUD

Holly Satterlee232391Pain/AddictionED FFED FFSepternoneno PC0408/8/13ED DR/Order8/8/13SUD

Jilliane Shane1162428Pain/AddictionIPIPHullnonePC20248/18/13PC Order9/1/13SUD

Janelle Shoen291272Pain/AddictionED FFED FFNonenoneno PC01308/21/13ED DR/Order9/10/13SUD

Ricardo Serrano Guadalupe Santiago1164377Pain/AddictionComplexComplexNoneRebeccaPC2358/21/13PC Order9/5/13SUDMult Names

Tracy Hill1163614Pain/AddictionED FFED FFPellnoneno PC0208/28/13ED DR/Order8/30/13SUD

Yolanda Smith922361Pain/AddictionED FFED FFWallernoneno PC0204/23/13

Corey Chapman788990Pain/AddictionED FFED FFNonenoneno PC01709/5/13Meridian CM9/5/13SUD

Jerry Hall529340PainEDFFED FFWhalennoneno PC19311/12/12040

Jacqueline Tyler442972PainPainPainBriggsNonePC11101/14/13000to DurhamPCNA

Valerie Canders1208183PainPainPain/EDKitzsteinerRebecca2354/1/13133Rebecca

Cindy Young495433PainED FFED FFCullennoneno PC0904/10/13000?KHP

Jeffrey Villarreal634555PainHeartsideHeartsideHeartsideNoneno PC0505/2/13000Jayna

Stacy David401946PainHeartsideHeartsideHeartsidenonePC311145/7/13Jayna

Pete Harper338396PainHeartsideHeartsideWirthnoneno PC0505/9/13NA - not recent visitsJayna

Rolando Perez Ibarra1148273PainHeartsideHeartsideHeartsidenoneno PC0105/9/13NA - not recent visitsJayna

Shannon Belcher498642PainPainED FFDudleynoneno PC0105/12/13Meridian CM/Natalie

Kimberly Alexander369357PainPainED FFWallernoneno PC02005/12/13??6/21/13

Felisa Martin1149291PainHeartsideHeartsideHeartsidenoneno PC0605/14/13Jayna

Quanisha Elliot1143140PainPainED FFNoneNoneno PC0705/25/13Kat

Eric Jones227847PainPainComplexComplexBethPC30465/25/13Beth

Dawn Valmassei421862PainHeartsideHeartsideHeartsideNoneno PC01305/2/13Jayna

Joel VanAsperen185779PainHeartsideHeartsideHeartsideNoneno PC01005/2/13DentalJayna

Theodore Cooks630549PainHeartsideHeartsideHeartsidenoneno PC01105/7/13Jayna

William Cooney355160PainHeartsideHeartsideHeartsidenoneno PC0305/7/13NA - not recent visitsJayna

Gerald Carter391196PainHeartsideHeartsideHeartsidenoneno PC0505/7/13Jayna

Pamela Kranz1046699PainHeartsideHeartsideHeartsidenoneno PC01005/9/13Jayna

Juan Mata646698PainHeartsideHeartsideHeartsidenoneno PC1335/14/13NA - not recent visitsJayna

Edwin Miller1068363PainHeartsideHeartsideHeartsidenoneno PC0105/14/13NA - not recent visitsJayna

Gary Mitchell1106845PainHeartsideHeartsideHeartsidenoneno PC0805/14/13NA - not recent visitsJayna

Maria Rodriguez672228PainHeartsideHeartsideHeartsidenoneno PC1135/21/13NA - not recent visitsJayna

Codie Kulczyski1076557PainED FFED FFHudsonnoneno PC12085/21/13Amy Mclaren CM

Belinda Jean Loveland852220PainHeartsideHeartsideHeartsidenoneno PC0305/21/13Jayna

Jason Michael Smith928124PainED FFED FFSalehnoneno PC0705/21/13?Jayna

Michael Evans258301PainED FFED FFHullnoneno PC1525/29/13Kat/CC Order

Gerald Schmidt387949PainED FFED FFGreennoneno PC2855/29/13Angela McJones/CC Order6/10/13

Amanda Krause1210564PainED FFED FF?nonenoneno PC3795/29/13set up Waller 6/25/13Angela McJones/CC Order6/26/13

Robin Bobo1003269PainED FFED FFHeartsidenoneno PC0405/30/13Jayna

Shirlie Wilson981843PainED FFED FFNonenoneno PC02006/5/13Corey PA ED/CC Order

Dorein Oneal1075539PainED FFED FFKennedynoneno PC01006/11/13Meridian CM/Natalie

Brittany Warner1118840PainED FFED FFKlinenonePC37146/11/13?PC & ED DR/CC Order8/30/13DZ Mgmnt

Mary Sannes396509PainED FFED FFWest Side Clinicnoneno PC0306/13/13Meridian CM/Natalie

Juanita Oakes221227PainED FFED FFSepternoneno PC11136/13/13KHP

Kristin Frost1045139PainED FFED FFnonenoneno PC01406/25/13Dr. Olgren/Kat/CC Order/second order Wolf PA6/27/13

Laura Peets629849PainED FFED FFMecanononeno PC006/27/13complex HADr Olgren/ED provider7/1/13

Nicole Miller1037182PainED FFED FFWiardanoneno PC6/27/13Figurski ED CC Order

Tanisha Brown602366PainED FFED FFCherry Stnoneno PC01207/2/13Olgren/CC Order

Cassandra Manning415342PainED FFED FFBucklerBethPC132+7/2/13Proactive ID - to DurhamBeth 7S

Kenneth Walls574886Pain/? AddictionED FFED FFnonenoneno PC01507/2/13Barnett PA CC Order7/2/13

Karla Parker560539Pain/MigrainesED FFED FFBlairnoneno PC03607/2/13Linked to PCP, refNatalie ED CM9/5/13DZ Mgmnt

Alicia Booth955101Pain/N/VED FFED FFWabekenoneno PC02307/5/13Wolf PA CC Order

Jonathan Deur651299PainED FFED FFHazlenoneno PC01407/10/13Dr. OlgrenDZ Mgmnt

Wanda Bivens751417Pain/MigrainesED FFED FFWege FMnoneno PC2877/16/13ED PA/CC Order9/5/13DZ Mgmnt

Cassandra VanderMyde942632PainED FFED FFChamberlainnoneno PC0607/14/13Waller 8/27/13Olgren, Figurski, Schaedig/CC Order8/14/13Dz or SUD

Alyse Croote665774Pain/dev addictionEDEDNguyennoneno PC0107/23/13Figurski ED CC Order7/23/13DZ Mgmnt

Cynthia Sanders1103744PainEDEDMeyernoneno PC0708/1/13Olgren/CC Order8/1/13DZ Mgmnt

Robert Reinhardt428300PainEDEDnonenoneno PC11708/8/13Barnett PA CC Order8/8/13DZ Mgmnt

Jacob Davis743523PainEDEDAshmeadnoneno PC0508/8/13prob. Addiction/psych tooEkkens/CC OrderSUD

Tammy Jo Claflin709410PainIPIPJarrellnonePC1368/12/13high dose methadonePCpredictive

Shana Regnerus1198193PainIPIPRitsemanonePC1008/12/13first visit = predictiveBeth 7S/PCpredictive

Emmanuel Broyles1068366Pain/suppliesComplexComplexnonenoneno PC14239/4/13Trauma/supplies/INS? ED/WoundDZ Mgmnt

Cari Johnson*1153868ETOH/PsychED FFED FFno PC

Patrick Simmons#1011301ETOH/COPD/PancreatitisReadmitsRe-admitsKitzsteinerLaurannever PC810347/10/1241119Needs planRebecca

Donald George17400ETOH/PancreatitisReadmitsReadmitsKitzsteinerLaurannever PC42207/9/125522Julie L

Laura Sevigny822584ESLD/ETOHReadmitsRe-admitsMechaelRebeccaPC62367/27/121214Died 11/2/12Rebecca

Tomas Fonseca1161880ETOH/PancreatitisReadmitsRe-admitsQuirozRebeccaPC 201274639/18/12113

Sandra Fasburg316279ETOHED FFED FFThomas JRebeccano PC428409/18/121212Rebecca8/14/13SUD

Kewpi Culbreath678459PancreatitisED FFRe-admitsEisengaBethno PC2379/17/12040Beth

Patrick Patterson1193738ETOH/PancreatitisReadmitsRe-admitsHeartsideBethnever PC45812/3/12119Died 1/1/13

Guillermo Garcia621089ETOH/ESLDED FFED FFDykstraRebeccaPC710341/3/13030

Alan Bohil257764ETOH/PancreatitisReadmitsRe-admitsHazleRebeccaPC715154/1/130130Needs planRebecca

Nathan Weimer947221ETOHReadmitsRe-admitsHullNonePC615384/1/13010PC6/4/13

Nanette Davis356696ETOH/PancreatitisED FFED FFSein-OhnNoneno PC21454/4/13010?unsure

Armando Lopez632256ETOHED FFED FFCherry StNoneno PC1424/10/13010?KHP

Malik Mohammed1159401ETOHED FFED FFRudynoneno PC02004/21/13000Heartside

Bradley Dunkel714189ETOHED FFED FFKitzsteinernoneno PC538304/21/13000MSW

Irvin Lee Merrill447801ETOHED FFED FF?noneno PC02304/23/130350Meridian CM

Stanley Dubis150014ETOH/PsychReadmitsReadmits?noneKevinno PC33104/25/13010Kevin H

Ronald Peterson781479ETOHED FFED FFnoneNoneno PC569105/1/13Nikki

Brent Dood936204ETOH/PancreatitisED FFED FFBrennernoneno PC3685/1/13Audrey

Isaac Rogers440396ETOHHeartsideHeartsideHeartsidenoneno PC0205/1/13NOT APP - no visitsJayna

Carlos Perez-Lopez1193738ETOH/COPD/AfibReadmitsReadmitsHeartsidenoneno PC71425/1/13Jayna7/2/13

Bruce VanVolkinburg1062909ETOHED FFED FFKitzsteinernoneno PC1495/1/13Jayna

Keith Anderson160190ETOH/PsychED FFED FFClinicanoneno PC415185/1/13d/c Faith hospice 5/24/13JaynaEOL

Roger James1058373ETOHHeartsideHeartsideHeartsidenoneno PC48145/2/13Jayna

Roland Tibbe361114ETOH/AnxietyHeartsideHeartsideHeartsideNoneno PC01005/2/13?SBARJayna

Steve Spadorcia801910ETOH/COPDHeartsideHeartsideHeartsidenoneno PC5/2/13Died 7/18/13 assaultJayna

Terry Johnson425772ETOH/COPDHeartsideHeartsideHeartsidenoneno PC0205/2/13now soberJayna

Larry Vandrunen450858ETOH/SuicidalHeartsideHeartsideHeartsidenoneno PC2575/2/13?how to count IP PsychJayna

Joey Rodriguez1038203ETOHHeartsideHeartsideHeartsidenoneno PC46345/2/13?how to count IP PsychJayna

Robert Rouse567199ETOHHeartsideHeartsideHeartsidenoneno PC01005/2/13Jayna

Thomas Adastik126504ETOHHeartsideHeartsideHeartsidenoneno PC0905/2/13Jayna

Roscella Eldridge1015219ETOHHeartsideHeartsideHeartsideNoneno PC0005/7/13no visits since 6/2012Jayna

James Combs133057ETOHED FFED FFHeartsidenoneno PC11155/7/13Jayna

Michael Garlick532371ETOHHeartsideHeartsideHeartsideNoneno PC02405/9/13Jayna

Sterlin Cole300029ETOHED FFED FFHeartsidenoneno PC11765/14/13KHP

William Califf729418ETOHED FFED FFHeartsidenoneno PC2875/14/13Meridian CM

Troy McLeod1092390ETOHHeartsideHeartsideHeartsideNoneno PC1645/14/13Jayna

Kevin Paluch9839969ETOHHeartsideHeartsideHeartsideNoneno PC1625/21/13Jayna

Eugene Williams1042907ETOH/PsychED FFED FFCherry StNoneno PC39175/23/13? Durham

Terry Bailey1082492ETOHED FFED FFHeartsidenoneno PC04105/30/13Jayna

Cornelius Berry988745ETOHED FFED FFHeartsidenoneno PC01205/30/13Jayna

Joseph Mullin1154135ETOHED FFED FFHeartsideNoneno PC769176/5/13Rebecca7/2/13

Domingo Castellon1204765ETOHED FFED FFnonenoneno PC1836/11/13Kat ED

Jodi Vanolst1041820ETOHReadmitsReadmitsQuirozNonePC8148+6/17/13Margie

Michael Armstrong1188883ETOHED FFED FFHeartsideNoneno PC02907/1/13ED Safety Plan7/1/13

Jeffrey Krupp616982ETOHED FFED FFMacholanNoneno PC31288/6/13conf 8/8/13Jennifer MiPct

Leann Cole1179937ETOH/PsychComplexComplexCherry Stnoneno PC318148/12/13Beth

Larry Law82836ETOH/SUDED FFED FFSubramaniannonePC8/12/13PC

Jesse Phillips1171434MMReadmitsRe-admitsDeckerNoneno PC42387/9/12didn't intervene?Theresa

Marjorie Griffin131490MMReadmitsRe-admitsSheulyBridgetno PC612911/20/12217Died inpatient 2/20/13

Cathryn Wilson951649MMReadmitsRe-admitsBucklerNonePC73433/27/13000Bridget

Agnes Schwartz101423MMReadmitsRe-admitsNguyenNonePC62604/1/132011Paula

Beatrice Sabrina Louis436518MMComplexRe-admitsStanfordNonePC82244/8/135210H3/ED CC Order x2 in 8/2013

Mary Smith376975MMReadmitsRe-admitsDudleyNoneno PC1064/10/13d/c w/hospice NA?

Robert Curtiss827504MMComplexComplexKitzsteinerNoneno PC2394/30/132223Jayna

George Kelly939390MMHeartsideHeartsideHeartsideNoneno PC0205/7/13NAJayna

Willie Griffin442956MMHeartsideHeartsideKitzsteinerNoneno PC1635/9/13Jayna

Richard Hoag569710MMHeartsideHeartsideHeartsideNoneno PC1835/9/13Jayna

Merta Davis238918MMReadmitsRe-admitsCampbellNonePC55515/16/13PC & ED6/21/13

Mary Dilworth932518MMComplexComplexSteenNonePC103615/16/13Jillaine

Rosalyn Knight64990MMComplexComplexJosephNoneno PC52215/16/13stabilized before interJillaine

Roxlynn Vincent745764MMComplexComplexHullNoneno PC1035/23/13NARebecca

Luis Pablo Lopez691071MM/?AddictionReadmitsRe-admitsnoneNonePC2465/29/13Sue N PC6/4/13SUD

David Brown112543MMComplexComplexNoneBethno PC1035/30/13Nikki

Kenneth Tatum1184637MM/?AddictionComplexComplexVANonePC147395/31/13PC

Moses Walker1125877MMComplexComplexMeyerNoneno PC2656/6/13ED PA/CC Order

Wallace Berry131116MMReadmitsRe-admitsAshmeadNonePC60546/13/13Pt died before interveneJillaine

Marian Foltice257019MMReadmitsRe-admitsFosterNoneno PC101396/13/13Jillaine

Timothy Hefferon1177353MMReadmitsRe-admitsSaierNoneno PC70546/13/13died 8/12/13JillaineDz Mgmnt

Scott Idsinga66149MMED FFED FFGiovanucciNonePC2857/2/13Natalie CM ED

Richard Krzykwa113345MMReadmitsRe-admitsSalehNoneno PC5126+7/12/13Paula TC

Bernadette Meyer533593MMReadmitsRe-admitsCesarioNoneno PC84327/10/13Paula TC

Kenneth Burchard468112MMED FFED FFResidentNoneno PC2457/12/13NP ED/CC Order

Kisha Cazier821496MMED FFED FFLangNoneno PC1447/15/13Mary HarnishDzMgmnt

Kimberley VanHaitsma723310MMComplexComplexBannisterNoneno PC83287/23/13Kristin H3DzMgmnt

Arthur Jabury253595MMReadmitsRe-admitsElsenNoneno PC30167/25/13Paula TCDzMgmnt

Margaret Ruth94192MMReadmitsRe-admitsRolinskiRebeccano PC40218/6/13Paula TCDzMgmnt

Edward DeRochey527239MMED FFED FFPelkeyNoneno PC2668/12/13Laviolette NP ED/ED CMDzMgmnt

Vera Little56256MMED FFED FFMcBrideNoneno PC1448/12/13? AnxietyNatalie CM ED

George Washington Clark603638MMReadmitsRe-admitsSalehNoneno PC60218/30/13Paula TCDzMgmnt

Tiffany Young582455MM/PsychPain/AddictionRe-admits AddictionWolfe - MetroRebeccaPC101934*02/17/201251813to Durham 12/20PC11/14/12

Lakeisa Foster959785MM/PsychPain/AddictionRe-admits AddictionRaffo now BlairBethPC6367*04/12/2012 & 6/18/12060would have stayed one month if did not pay utilitiesPC

Laura Hofferber1101759IR frequent visitsED FFED FFJosephnonePC 2009727279/20/1261421**update 4/19/13Megan

Roxie Ridgway472342MM/PsychComplexComplexSilvernalenone1 yr ago7302012/19/122167ref durham, ?SBARPaula

David Tyron1168915MM/PsychComplexComplexGrangerRebeccano PC62403/20/13040Rebecca/Kristindone only by CNL

Sharon Dewey180806MM/PsychComplexComplexMejuerLaurieno PC1025684/3/131103guardian and LTCED

Linda Welch487755MM/PsychComplexComplexKuiperBethPC93364/8/13020Beth

Timothy Wiggins1189375MM/PsychComplexComplexChamberlainLaurieno PC220134/5/130100ref DurhamKat7/22/13

Jennilee Orear742168MM/PsychComplexComplexSicesNoneno PC11034/1/13020Durham4/26/13

Shannon Corbett1143569MM/PsychComplexComplexnonenoneno PC25115/7/13NA - no visitsMeridian CM/ED CM

Brian Koppenol1184027MM/PsychHeartsideHeartsideHeartsidenoneno PC1255/9/13Jayna

Douglas Goff179424MM/PsychHeartsideHeartsideHeartsidenoneno PC0605/9/13Jayna

Jessica Hyde1197930MM/PsychComplexComplexBatesnoneno PC1185/16/13?

Carrie Colacchio932939MM/PsychComplexComplexPlattnonePC51017+5/29/13PC

Diane Jackson254628MM/PsychComplexComplexMejuernoneno PC42105/30/13ED PA/Order

Roger Artz1145116MM/PsychComplexComplexHeartsidenoneno PC11135/30/13Jayna

Misty Street1100076MM/PsychComplexComplexPA Grantnoneno PC52176/11/13ref durham, ?SBARTayna

John Teusink575127MM/PsychComplexComplexSteennonePC2166/29/13PC

Erin Gawne762864MM/PsychComplexComplexHalversonnoneno PC0506/29/13Nick PA ED

James Beeman443974MM/PsychComplexComplex?Kevinno PC2187/1/13Kevin

Geraldine McCarthy459753MM/PsychComplexComplexRuthBethPC13+7/9/13Beth

Tammy Bell329453MM/PsychComplexComplexVanWienenRebecca201240177/25/13conf 8/8/13Pauladied 8/17/13

Sunny Strouse1192454MM/PsychComplexComplexnonenonePC53178/12/13PC

Mary Gray106141MM/PsychComplexComplexWolfenone8/12/13Nikki MSW

Judith Ford110198MM/PsychReadmitsReadmitsDhirnoneno PC54149/17/13Jillaine

Roshawn Jackson1044705DM, ESRDMMRe-admitsHeart of the CityRebeccanever PC127755/5/122025needs SBARRebecca

Sharon Mitchell378237ESRD, ESCOPDReadmitsRe-admitsSaiernone2 yrs ago40457/9/123216Jillaine

Arrhonda Pittman162615ESRDPain in IRAMASpectrumMegannever PC1128/9/122227Durham 9/24, got sepsisDialysis

Glenn Lesure817788ESRDDepressionClyde ParkMeyerLaurannever PC2059/24/12010Durham 10/8, Psych and PC consults

Sue Clossen103728ESRD/COPDMMIR Freq accesssAlbrechtMeganno PC7272710/29/12318Megan IR

James Robinson691193ESRD/MMMM/addictionRe-admitsKuldanekBridget1x PC188711/2/134413needs SBARHospitalists

Jessie Rideout173163DM, MO, CVAED FFED FFKitzsteinerRebeccano PC310104/21/13000needs SBARKat

Jon Marvin283558DM, Amps, InfectionPain/InfectionRe-admitsKitzsteinerRebeccanever PC57144/21/134017Heartside7/2/13

James Otley1110163DM ESRDMMRe-admitsSalehnoneno PC50175/21/13Jillaine

Jerry Cone795527DM, CHF, ESRDMMRe-admitsBiliskononePC97377/23/13?Rebeccadied 7/27/13

Cimberly Reid428244PsychComplexComplexCaveceLaurannever PC2275/8/120006/14/12 tx stoppedKenda

Patti Dolan301746PsychComplexComplexNwankwoLaurannever PC40166/30/12206ref H3H34/10/13

Diane Kaulbeck Stadt916607PsychReadmitsReadmitsHiltsKrisinno PC616228/15/12256ConferenceH3

Elizabeth Lipinski1088010PsychED FFED FFSpectrum Resident ClinicLaurienever PC028010/2/120140Dick BrouwerKat11/14/12

Marcia McIntyre118703PsychED FFED FFWallerno PC017011/9/12010Connect w/WallerPH11/14/12

Donna Jean Williamson337458PsychED FFED FFOmegano PC4231311/12/12040Durham

Lizabeth DeGrote330625PsychReadmitsRe-admits AddictionDurhamRebeccaPC2201011/12/12326needs SBARDurham

Steven Nyenhuis155082PsychComplexComplexSpectrum Resident Clinic20111361/30/13112Natalie ED/Theresa TE

Charles Hesse611631PsychComplexComplexClouseRebeccano PC33193/27/13122Using dad's identity?Nikki6/12/13

Caron Rose479887PsychComplexComplexAppNoneno PC01304/1/13010M. Pena

Pamela Swanson681717PsychReadmitsReadmitsDarNone201055164/9/13101Nikki

Holly Underhill Huey512894PsychComplexComplexMatthews PANoneno PC31164/17/13122needs SBARMSW H2

David Anderson591616PsychViolenceViolenceSypniewskiNoneno PC0705/2/13000ED/PMU6/4/13

Lauri Watters739011Psych/COPDED FFED FFKitzsteinerNoneno PC03605/1/13050needs SBARJayna

Gary Thomas731142Psych/COPDED FFED FFKitzsteinerNoneno PC11135/2/13030Natalie/Jayna/ED RN5/25/13

Shane Williams904326PsychHeartsideHeartsideHeartsideNoneno PC0105/2/13? NA no visitsJayna

Martin Dombrowski377333PsychHeartsideHeartsideHeartsideNoneno PC11625/7/13020ref Durham 6/2013Jayna

Vanessa Lattimore1109620PsychHeartsideHeartsideHeartsideNoneno PC0205/9/13NAJayna

Todd Martin332123PsychHeartsideHeartsideHeartsideNoneno PC01105/14/13Jayna

Robert Homrich1086994Psych/COPDComplexComplexChandramouliNoneno PC3165/16/13Lorna

Jeffrey Thompson307057PsychComplexComplexDurhamNoneno PC32155/23/13Durham

Denise Kent192143PsychComplexComplexnonenoneno PC0605/30/13ED DR/order

Curley Braxton238177PsychComplexComplexHeartsidenoneno PC11625/30/13Jayna

Andrea Allerding1075178PsychComplexComplexAhrensNoneno PC12+6/5/13Beth CNL

Ruth Coulombe376001PsychComplexComplexBannisterNonePC62346/5/13Dr Bannister/Audrey

Vicky Curtis150688PsychComplexComplexSheulyNoneno PC11736/6/13needs SBAR? ED/MiPct Jennifer/TC

Melissa Sprik429947PsychED FFED FFnoneNoneno PC01406/13/13?ED CM

Joseph Schab114848PsychComplexComplex?nonenoneno PC01607/3/13SAGE team

Tara Manciu1036632AnxietyED FFED FFKlineNoneno PC02108/8/13connected to PCP/insDr. Ekkens/CC Order9/5/13

Rochelle Decker960778PsychIPIPDempseyNoneno PC1028/12/13predictiveDr. Kinsey-Callaway

Desiree Gibson977888PsychED FFED FFCherry StNoneno PC11018/12/13ED Dr/CC Order8/30/13Safety

Kaitlin Belrose722686PsychED FFED FFShullNoneno PC0108/14/13FF Muskegon PredictiveED PA/CC Order9/5/13Psych

Deanna Mays703766PsychComplexComplexBelsitoNoneno PC8/21/13Alpha Team8/20/13

Penifulle Johnson1173530PsychComplexComplexKennedyKevinno PC30107/30/13Ethics meetingSAGE team9/5/13Psych

Duane Looman752653Psych/PainReadmitsReadmitsSepternonePC3098/25/12050needs SBARPC

Martha Eck482483Psych/PainED FFED FFClarknoneno PC (2011)6201411/21/12080needs SBAR

Tammy Tiedemann437161Psych/PainED FFED FFStanfordnoneno PC23191/3/131122needs SBARNikki

Annette Harmon257236Psych/PainED FFED FFDurhamnonePC319181/3/13000Durham

Julie Saint292489Psych/PainPain/PsychReadmitsDillworthNonePC54351/21/13030from Bariatrics, held - Durham approved but stabl w/pine restCathy Wuis

Maurice Woods1142055Psych/PainComplexComplexBannisterRebeccaPC21111/31/13030PC4/10/13

Teone McGehee286923Psych/PainED FFED FFNoneLaurieno PC41471/22/130402/12/13

Jacob Datema189003Psych/PainReadmitsReadmitsCesariononeno PC21252/8/13040needs SBARCathy W

Naomi Brown760548Psych/PainED FFED FFNoneRebeccaPC0702/19/130150PC/Rebecca2/12/13

Esmeralda Romero597378Psych/PainComplexComplexNoneLaurieno PC11124/2/13010Kat/KHP4/26/13

Autumn DeHoff164713Psych/PainED FFED FFBarryNoneno PC1424/1/13030?Kat4/26/13

Leslie Pols626321Psych/PainComplexComplexWallerNoneno PC0104/2/13Not a current pt - wallerWaller

Samantha Dykstra1119319Psych/PainComplexComplexWallerNoneno PC01504/2/13010Waller4/10/13

Jessica Woodard969280Psych/PainED FFED FFLaGardeLaurieno PC01104/9/13000draft done SBAR?KHP/Kat

Tracy Bush451286Psych/PainComplexComplexSchneidernonePC2374/10/13010PC/Rebecca

Rebecca Perez489177Psych/PainED FFED FFCherry Stnoneno PC11134/10/13020?

Martin Dombrowski377333Psych/PainED FFED FFKitzsteinernoneno PC11625/7/13020to DurhamJayna

Sarah Hudson984209Psych/PainED FFED FFNonenoneno PC01505/9/13?ED or Jayna

Cindy Nelson622355Psych/PainHeartsideHeartsideHeartsidenoneno PC01905/14/13Jayna

Kirk Miles1145288Psych/PainHeartsideHeartsideHeartsidenoneno PC02705/23/13Jayna

Amber Augdahl1153104Psych/PainED FFED FFWolfeLaurieno PC01005/25/13KHP/referred again 7/31/13 Olgren CCOrderSUD

Brenda Barth496508Psych/PainED FFED FFRudynoneno PC01205/30/13Jayna

Stephanie VanderPloeg1216561Psych/PainComplexComplexHulstBethno PC1156/5/13Beth

Shirley Sandoval Gulley312061Psych/PainED FFED FFKennedynoneno PC510206/13/13Cathy Gastro

Emilee Zandbergen521415Psych/PainED FFED FFCharnleynoneno PC0406/19/13Schaedig PA CC Order

John Francis706943Psych/PainED FFED FFKhannoneno PC2656/27/13overtestingED Provider6/27/13

Sandra Hamilton766474Psych/PainED FFED FFBargwellnoneno PC4677/1/13Natalie CM ED7/1/13

Michelle Spoonts662172Psych/PainED FFED FFDeckernoneno PC0907/3/13SAGE Team

Rita Vanover232688Psych/PainED FFED FFShookNoneno PC1927/31/13Cherry St Omega Team9/5/13

Penny Desotell-Couch347722Psych/PainED FFED FFMiyamotononeno PC8/12/13ED PA/CC Order

Deborah Zomberg723810Psych/PainED FFED FFCavacecenoneno PC8/21/13Mark SAGE team

Kacinea Merrill (crittenden)464662Psych/PainED FFED FFBucklernoneno PC11338/21/13ED DR/CC Order9/5/13Psych/Pain

Essie Tims139753Psych/AddictionComplexComplexKennedyLauranno PC251011/9/121513Dr GJNA

Melissa Cross245411Psych/AddictionComplexComplexSicesRebeccaPC73271/29/13337ref durhamNikki4/26/13

Vanessa Vanderbilt (Veinbergs)967945Psych/AddictionComplexComplexNoneNoneno PC2974/2/13114Rebecca 7N4/26/13

William Murtha1176765Psych/AddictionComplexComplexNoneKevinPC0006/5/13Psych IP onlyKevin PMU6/26/13

Jodi Miller375668Psych/AddictionComplexComplexCherry StLaurieno PC01007/1/13Olgren/CC Order7/1/13

Donald Bryant436231Psych/AddictionComplexComplexAshmeadnoneno PC11537/1/13SAGE Team8/14/13

Carlton Fehsenfeld706270Psych/AddictionED FFED FFNonenoneno PC0807/23/13Dr. Olgren7/23/13

Rhoda VanderStarre343081Psych/AddictionED FFED FFNoneNoneno PC0207/30/13ED CC Order8/14/13

Courtney Reczek1295127complex ethicsComplexComplexNoneRebeccaPC12228/2/13gave opinion - worked with Nikki - guardian incapacitated, can't be placedNikki Lewis9/5/13PSYCH/SUD

Caroline Davis1019317CA/PsychComplexComplexNonenoneno PC0009/4/12in Jail 12/2012Jenna Hem/Oncnot app to count - complex but no intervention

Issac Miguel581744Cancer/MMComplexComplexMechaelnoneno PC1025410/31/12219?

Yolanda GUTIERREZ-CLEOTILDE1045708Complex CAED FFED FFNonenoneno PC21241/3/13000ED FF at Holland Hospital, referred hospice 1/3/13

Jacalyn Raap285225Complex CAComplexComplexHospicenonePC62264/16/13020PCEOL

Michael Fricke1024332Complex CAHeartsideHeartsideHeartsidenoneno PC0005/9/13no visits since 2012, ?diedJayna

Londall Houston262447HIVPain/AddictionRe-admits AddictionGalangnonePC0306/19/13stable but watch?PC - old referral

Sherry Dickerson428317Complex CAComplexComplexBuntingnonePC40307/25/13Kat ED7/30/13EOL

Marguerite Bouwman338812COPD/ESRDReadmitsRe-admitsElsenBridgetnever PC112375/17/122011

Ethel Major155776COPDReadmitsRe-admitsBeltranBridgetPC93508/23/124225

Evelyn Conrad846790COPDReadmitsRe-admitsFrunzaLaurienever PC1283510/1/12141851needs SBARPaula 10/2012/Kevin PA ED CC 6/2013

Marjorie VanderLaan55629COPDReadmitsRe-admitsVanWienenBridgetPC1117111/7/12119died 6/23/13NA

Glenda Adams539804COPDReadmitsRe-admitsGrohowskiBridgetPC863811/20/124120

Karen Kimber915387COPD/PsychReadmitsRe-admitsMecanoRebecca1x PC57221/3/13216Paula

Debra Grimes428983COPDReadmitsRe-admitsQuiroz/VPLaurannot PC70352/6/133056

Linda Westphal330587COPDReadmitsRe-admitsCesarioLaurannever PC61274/8/13000Biersack

Janet Zaagman136920COPD/MMReadmitsRe-admitsMacholannoneno PC40144/8/13000Paula

Calethia Robinson437426AsthmaReadmitsRe-admitsPowellnoneno PC412114/23/13040

Karrie Duram310498COPDReadmitsReadmitsHeartsidenoneno PC31145/7/13020Jayna

Billy Myers666093COPDHeartsideHeartsideHeartsidenoneno PC2235/14/13NA - no recent visitsJayna

Charlotte Beishuizen585791COPDReadmitsRe-admitsSalehnoneno PC2195/14/13Paula

Andre Kennedy1163974COPDReadmitsReadmitsHullnoneno PC92315/16/13?

Theodore McKissen398255COPD/MMReadmitsReadmitsApplegatenonePC310115/21/13Paula

Connie Jean Smith241291COPDReadmitsReadmitsRitsemanonePC65325/21/13Paula

Geraldine Smith710182COPDReadmitsRe-admitsSmith, LLaurannever PC2046/13/13?NAPaula

Steven Joseph628737AsthmaED FFED FFNonenoneno PC0606/25/13CC Order ED6/25/13

Danny White1123019COPDED FFED FFHeart of the Citynoneno PC88266/27/13Jacob B CC Order ED

Doris GibsonCOPDReadmitsRe-admitsBannisterLauranPCDied 1/20/13

Aggie White207149COPDReadmitsReadmitsBreton HCnonePC92357/2/13hospice 7/25/13Susan HuizenNA

Mary Ellen Smith376975COPDReadmitsRe-admitsHavemanLaurannever PC

Cynthia Phillips132066COPDReadmitsReadmitsShahnoneno PC50208/12/13Laurie Sayer

Hope Suttles393403AsthmaReadmitsReadmitsWolfenonePC8/12/13PC

NEURO

Matthew Eller1021582Seizures/NEUROClinic tx requestClinic tx requestnonenoneno PC1041/3/13NA - no visits - did w/Dr. OlgrenKat EDNA

Percy Shannon458690NeuroReadmitsReadmitsnonenoneno PC9265+5/31/13Margie - referred 2/13 - no time to do

Patrick Baskin781126Seizures/PsychED FFED FFHeartsidenoneno PC11026/7/13Delmer PA ED/CC Order6/7/13

HEARTSIDE PTS

Johnni Peck823002Psych/PainComplexComplexKitzsteinerNoneno PC4/3/13ref to Durham - no summaryHeartside

IR PATIENTS

Gordon Meredith988298IR frequent visitsIRFFIRFFBoutellnoneno PC1039/19/12never really did - all IRMegan

Rujka Mujic953067IR frequent visits

Rama Daylie1157316IR frequent visits

Kartina Archibald959840IR frequent visits

Benny McClerren1133932IR frequent visits

Rocky Smallacombe1150862IR frequent visits

Terry Henderson126394IR frequent visitsIRFFIRFFDillbecknonePC 201272727did not interveneMegan/Clyde Park Dialysis

Phyllis Miknavich672177IR frequent visits

Kathleen Dragica Jones6778885IR frequent visits

Deborah Diaz231717IR frequent visits

BROWING CLAYTOR PT

Cindy Koops448459Pain/Psych/AddictionED FFED FFPowellBCnever PC210420 office ( 7 no shows)18313 office visits (7 no shows)10/3/12NEEDSBC ProjectSUD8/8/13

Wanda Jackson474159PainED FFED FFBarryBCnever PC0808 office (0 no show)0406 office visits (1 no show)10/3/12BC ProjectPAIN

Sandra McGehee Edwards547655PainED FFED FFBarryBCnever PC0902 office (0 no show)0304 office visits (2 no show)9/13/12BC ProjectPAIN

Mislki Reizenstein11856Pain/Psych/DzED FFED FFBarryBCnever PC0607 office (2 no show)14213 office visits (4 no shows)10/3/12BC ProjectCOPD

Sandra Waters752465Pain/PsychED FFED FFKennedyBCJan-1221587 office (1 no show)0703 office visits ( 0 no shows)9/13/126/10/13BC ProjectPAIN

Cassandra Allen1454645PainED FFED FFPowellBCnever PC1945 office (1 no show)1248 office visits (4 no shows)11/6/12BC ProjectPain

Andre Frost1019770ETOH/PsychED FFED FFKennedyBCnever PC01106 office (2 no shows)12743 office visits (1 no show)11/6/126/10/13BC ProjectSUDprob in jail now 7/2013

Melinda Kucharski710887Pain/AddictionED FFED FFKennedyBCnever PC0700 office (1 no show)0600 office visits (2 no show)11/6/126/10/13BC ProjectSUD

Robin Anderson145584Multi MedicalED FFED FFKennedyBCAug-11314185 office (3 no show)0703 office visits (2 no shows)11/6/12BC ProjectMM

Sarah Rivera278391PainED FFED FFKennedyBCnever PC0902 office (0 no show)0200 office visits (2 no show)11/6/12BC ProjectPain

Latasha Long959337PainED FFED FFKennedyBCnever PC0503 office ( 0 no shows)0203 office ( 2 no shows)11/6/12BC ProjectPain

Brenda Heard445404Pain/AddictionED FFED FFKennedyBCnever PC1626 office (4 no shows)1147 office visits (0 no shows)11/6/12BC ProjectSUD

Mashriki Childrey709410MM/GastroED FFED FFPowellBCJan-1173496 office (5 no shows)2252 office visits (6 no shows)11/6/12BC ProjectGASTRO

WALLER

Tina Simmons974114Pain/AddictionComplexComplexWallernoneno PC0001/28/13created in case- no visitsWaller

WALLER - NO Complex care Summary - Cerner only

Delita Lee144705Pain/PsychWaller0204/23/13

Jason Potter708062Psych/AddictionWaller0104/10/13

James Wisner770168Pain/AddictionWaller0004/23/13

Jennifer Chavarria913851Pain/AddictionWaller0104/10/13

Justin White649381Pain/AddictionWaller020not in yet

Whitney Benson739229AnxietyWaller0303/26/13

Andrew Dykstra921174SUDWaller0003/26/13

Cassandra Heyboer571015AnxietyWaller0003/26/13

PRINCIPLES IP/OBS counted together, ED/UC counted together, Psych/Pine rest not counted

Other - NO Complex care Summary - Cerner only

Fatima Livoreka776575Pain/AddictionMiedemano01204/9/13

Thanh Huynh658504Pain/AddictionNoneno01004/9/13

Billy James Jackson800000185Psych/Safety0202/19/13

OLD REFERRALS DID NOT DO current model

Aziz Talundzic905066CHFReadmits/CultureRe-admitsSaleh3LPC?hospice 3/5

Aixa Nunez1131312VasculopathPainRe-admitsHullRebeccaPCHospice 3/16/12Intervened w/o process

Selmir Bajric1084014VasculopathPainRe-admitsQuinn - MetroRebeccaPCIntervened w/o process

Katherine Hesselschwerdt925892Pain/AddictionPain/AddictionRe-admits AddictionZookLauranPC4/2/12Conference declined by familySUD

Dawn Depres67577Pain pump, DM, GastroPain pump/N/VRe-admitsMankoff/ThornburgLauranPC3/15/12Resolved pain pumt 3/15,

Arnetta Clark462970MMComplex FamilyRe-admitsCalderon-TorresLauranPC2/20/12hospice 2/20, died 6/8/12PC

Brandon Thomas1191355Pain/AddictionPain/AddictionAddictionNoneNAPC1039/27/12only 1 visit - no planSUD

Danette Coleman*182228CBPPain/AddictionAddictionNoneRebeccaPC3/14/12coming to EDrereferred 7/2013

Gregory Sawyer1038649MMReadmitsRe-admitsWiardaLauranPCNADied inpatient 4/11/12

Ron Zinn849663DM, MO, BKAPain/InfectionRe-admitsRolinski?Bethnever PCDied in hospital 12/27/12

Sue Clossen10372810/29/12summary - not done

Jessie Phillips1171434ESRDLong stayLong stayDeckernever PC7/9/12summary - not done

Isidro Secundino-Solis915362ESRDReadmitsRe-admitsSchneiderRebeccanever PC2/21/12no summary

Karen KlawiterPsychColegrove

Patrick Thatcher1079042Psych/AddictionComplexEDAusielloNonenever PC0406/12/12summary - not app

Sarah Goodell1168271Psych/AddictionPCnot app

Betty Phillips392156CA/PsychReadmitsRe-admits Addictiondied 11/2012

Melvin Dickerson408756PainED FFED FFBarryBCnever PC0130?trial one with Sharon MiPct

Kelvin McCeree1213150MANY NAMESComplexComplexNoneNonePC6/13/13SBAR issue - new policyPC

Ronnie Daniels1099887comples EOL +homeless/cocaine8/4/13gave opinion - worked with Natalie

James Deising624767ETOHED FFED FFWallerNoneno PC>778/1/13Waller from beginning2/19/13SUD

John Porubsky

Megan VanZantDM

Darlene Dennis

Judy Smith?hospice

Cases Worked

MonthGASTROCARDIACSICKLE CELLPAIN/SUDPAINETOH/SUDMMMM/PSYCHESRDPSYCHPSYCH/PAINPSYCH/SUDCACOPDNEUROBCTOTAL

Jan-1200000000000000000

Feb-1210100001000000003

Mar-1210000000000000001

Apr-1210100001000000003

May-1200000000110001003

Jun-1210000000010000002

402000021200010012

Jul-12100003101000000066

Aug-12100200001110010077

Sep-12100103001000100077

Oct-12200100001100110077

Nov-12000210200311020132525

Dec-12101101010000000055

Jan-1311061100115111102121

Feb-13100000000020010044

Mar-13020100111110000088

Apr-1341142845237113004646

May-13320126221071116016109797

Jun-1300048332044113103434

Jul-1321088162113411003939

TOTAL177231464227181026308719313306

Aug-13

Sep-13

Nov-13

Dec-13

Cases Worked# of Cases

Jan-120

Feb-123

Mar-121

Apr-123

FY 2013Jan - June 2012May-123

NEURO30Jun-122

CARDIAC73Jul-126

CANCER93Aug-127

ESRD104Sep-127

GASTRO175Oct-127

COPD192Nov-1225

PSYCH265Dec-125

MULTIPLE MEDICAL456Jan-1321

PAIN768Feb-134

SUBSTANCE USE DISORDER8119Mar-138

TOTAL29355Apr-1346

May-1397

Jun-1334

OB00Jul-1339

Cases Worked

# of Cases

August 2013 Graphs

FY 2013

2013 Outcomes

OUTCOMES TABLEAug-13

% Decr% Decr% Decr% Decr% Decr

1 YR (18)9 MO (39)6 MO (29)3 MO (58)ALL (144)

IP60%51%75%83%68%

ED40%45%57%70%60%

LOS63%58%72%84%70%

1 YR (18)9 MO (39)6 MO (29)3 MO (58)

IP Before128138133166

IP After51683328

ED Before95383248503

ED After57211106155

LOS Before637666576781

LOS After234279162124

ALL (144)

IP Before565

IP After180

ED Before1229

ED After529

LOS Before2660

LOS After799

FY 2012 Subpopulations%

Pain24114

Substance Use Disorder2090

Multiple Medical1153

Cancer944

GI733

ESRD731

Cardiac630

COPD522

Psych420

Neuro417

OB315

2013 Outcomes

1 YR (18)

9 MO (39)

Need Diff Model

1 YR (18)

9 MO (39)

6 MO (29)

3 MO (58)

Encounters and LOS 12 Months Before & Intervals After Complex Care Intervention

Ins CMs

IP

ED

LOS

Multiple Names

IP

ED

LOS

Percent Reduction in Encounters After Intervention

2011 Readmission Data

Readmit charts

%

Subpopulations High Frequency Patients FY 2012

Dementia

%

Subpopulations of High Frequency Patients FY 2012

Dementia Graphs

IPEDLOSCP DateIPEDLOSOUTCOMES TABLEJun-13OUTCOMES TABLEAug-13

5016*02/23/201251171 YR (15)% Decr10 MO (12)% Decr6 MO (36)% Decr3 MO (21)% DecrALL (74)% Decr1 YR (18)% Decr9 MO (39)% Decr6 MO (29)% Decr3 MO (58)% DecrALL (74)% Decr

11147*03/12/20126017IP Before1006214895412IP Before128138133166565less than 3 IP or less than 5 ED

10583*04/05/20123016IP After376328554272188168%12969IP After5160%6851%330.752883%18068%

88206/19/129630ED Before7060400149690ED Before953832485031229

143427/30/1261024ED After3451442712170417255%24864ED After5740%21145%1060.5715570%52960%

89658/17/124117LOS Before5162746794501939LOS Before6376665767812660

1249/18/124114LOS After155701305316476977870%56571LOS After23463%27958%1620.7212484%79970%

401510/11/125118GRAPHS DONE JUNE 20138/1/139 mo8/1/136 mo8/1/133 mo

512410/3/121168/1/131 yrGASTRO7349225GASTRO89654117GASTRO112010

531212/12/12000GASTRO50165117GASTRO1244114GASTRO5312000GASTRO2511115

65131/2/13112GASTRO111476017GASTRO40155218GASTRO6513112GASTRO3113000

77372/18/133214GASTRO105833016GASTRO51242110GASTRO77373314GASTRO6931000

75251/2/13000GASTRO88209630SUD2104183CARDIAC7525000CARDIAC31393612

31393/18/13020GASTRO1434271228SUD01101274SICKLE36124720CARDIAC7053000

71541*02/02/2012010SICKLE71541010SUD070060SUD3319060CARDIAC3010117

8650*04/25/20123222SICKLE86503222SUD162114SUD4411384SICKLE113000

361212/14/123710SUD/Pain3113010SUD/Pain103000SUD141040SUD296030

31138/21/12010SUD/Pain6620010SUD/Pain2255187SUD12320140SUD1173143

66208/23/12010MM/Psych10193451813SUD/Psych25101513SUD41316020SUD030000

1039/27/12000MM/Psych6367060SUD/ETOH8103441119SUD41227040SUD205000

225510/2/12000ESRD127752025SUD/ETOH42205522SUD11102012SUD0120020

331911/21/12050ESRD40453216SUD/ETOH7463113SUD8616010SUD/ETOH62361214

441111/21/12283ESRD1122227SUD/ETOH428401212SUD040010SUD/ETOH715150130

14112/5/12040PSYCH227000SUD/ETOH237040SUD/ETOH71034030SUD/ETOH61538010

12321/3/13080PSYCH4016206MM/Psych7272761421SUD/PSYCH7327337SUD/ETOH2145010

413161/8/13020PSYCH61622256MM31418070PAIN1110000SUD/ETOH142010

412271/24/13030COPD112372011ESRD205010MM/PSYCH730202167SUD/ETOH0200000

11101/21/13000128956375157234ESRD72727318ESRD188714413SUD/ETOH53830000

86161/30/13000PSYCH02800140PSYCH136112SUD/ETOH02300350

19311/12/12030PSYCH0170010PSYCH/PAIN23191122SUD/ETOH3310010

11101/14/13000PSYCH42313040PSYCH/PAIN31918000SUD/PSYCH297114

810347/10/12411198/1/131 yrPSYCH22010326PSYCH/PAIN5435030ESRD31010000

42207/9/123314GASTRO50165117PSYCH/Pain309050PSYCH/PAIN2111030ESRD57144017

62367/27/121214GASTRO111476017PSYCH/Pain62014080PSYCH/PAIN4147040MM/Psych6240040

74639/18/12113GASTRO105833016CANCER10254219PSYCH/PAIN2125040MM/Psych1025681103

428409/18/12162GASTRO88209630PAIN080040COPD5722216MM/Psych9336020

2379/17/12030GASTRO1434271228PAIN090030COPD70353056MM/Psych220130100

45812/3/12119SICKLE71541010PAIN19304013324857633106162MM/Psych1103020

710341/3/13030SICKLE86503222PAIN2158070MM6129217

612911/20/12217PAIN194124MM7343000

331911/21/12050SUD/Pain6620010PAIN090020MM62602011

101934*02/17/201251813MM/Psych10193451813PAIN050020MM82245210

6367*04/12/2012 & 6/18/12060MM/Psych6367060COPD93504225MM2392223

7302012/19/12297ESRD127752025COPD12835141851PAIN235133

127755/5/122025ESRD40453216COPD11171119PAIN090000

40457/9/12215COPD86384120PAIN050000

1128/9/122227COPD060142PSYCH3319122

2059/24/12010PSYCH401620613838366668211279PSYCH0130010

188711/2/133311PSYCH61622256PSYCH5516101

2275/8/12000COPD112372011PSYCH3116122

40166/30/121021229161549542078/1/139 mo8/1/136 moPSYCH070000

616228/15/12264with low incidence out59%41%66%GASTRO7349225GASTRO89654117PSYCH0360050

028010/2/120140with low incidence in604063GASTRO5312000PSYCH1113030

017011/9/12000GASTRO40155218GASTRO6513112PSYCH1162020

4231311/12/12040GASTRO51242110GASTRO77373314PSYCH/PAIN0700150

2201011/12/12214SUD2104183CARDIAC7525000PSYCH/PAIN1112010

1361/30/13112SUD01101274SICKLE36124720PSYCH/PAIN142030

2275/8/12000SUD070060SUD3319060PSYCH/PAIN1162020

40166/30/12102SUD162114SUD4411384PSYCH/PAIN0150010

616228/15/12264PSYCH/PAIN0110000

028010/2/120140SUD/Pain2255187SUD12320140PSYCH/PAIN237010

017011/9/12000SUD/Psych25101513SUD41316020PSYCH/PAIN1113020

4231311/12/12040SUD/ETOH8103441119SUD41227040COPD6127000

2201011/12/12214SUD/ETOH42205522COPD4014000

1361/30/13112SUD/ETOH7463113SUD8616010COPD41211040

23191/3/13090SUD/ETOH428401212COPD3114020

319181/3/13000SUD/ETOH7103403016650378128155124

54351/21/13020MM/Psych7272761421SUD/PSYCH7327337

21111/31/13030MM31418070

3098/25/12020MM/PSYCH730202167

21252/8/13040ESRD72727318ESRD1887144138/1/133 mo

6201411/21/12000PSYCH02800140

41471/22/13040PSYCH0170010PSYCH/PAIN23191122GASTRO2511115

251011/9/121513PSYCH42313040PSYCH/PAIN31918000GASTRO3113000

73271/29/13236PSYCH22010326PSYCH/PAIN5435030GASTRO6931000

1025410/31/12219PSYCH/Pain309050CARDIAC31393612

21241/3/13000PSYCH/Pain62014080PSYCH/PAIN4147040CARDIAC7053000

112375/17/122011CANCER10254219PSYCH/PAIN2125040CARDIAC3010117

93508/23/123219PAIN080040COPD5722216

1283510/1/12131247PAIN090030COPD70353056SUD296030

1117111/7/12109PAIN1930401272345383097148SUD1173143

863811/20/124120PAIN2158070

57221/3/13216PAIN194124with low incidence out765972

70352/6/133035PAIN090020with low incidence in755772SUD0120020

4126901939129248565AGGREGATEPAIN050020SUD/ETOH62361214

COPD93504225SUD/ETOH715150130

Jun-13COPD12835141851SUD/ETOH61538010

IPEDLOSCP DateIPEDLOS1 YEAR N=15IPEDLOSCP DateIPEDLOS1 YEAR N=15COPD11171119SUD/ETOH2145010

5016*02/23/201251175016*02/23/20125117COPD86384120

11147*03/12/2012601711147*03/12/20126017COPD060142SUD/ETOH0200000

10583*04/05/2012301610583*04/05/2012301613237864764205265SUD/ETOH53830000

88206/19/12963088206/19/129630SUD/ETOH02300350

71541*02/02/201201071541*02/02/2012010with low incidence out52%46%59%SUD/ETOH3310010

8650*04/25/201232228650*04/25/20123222with low incidence in514558SUD/PSYCH297114

101934*02/17/201251813101934*02/17/201251813ESRD31010000

6367*04/12/2012 & 6/18/120606367*04/12/2012 & 6/18/12060ESRD57144017

127755/5/122025127755/5/122025MM/Psych6240040

2275/8/12000MM/Psych1025681103

40166/30/1210240166/30/12102MM/Psych9336020

2275/8/12000MM/Psych220130100

40166/30/1210240166/30/12102MM/Psych1103020

112375/17/122011112375/17/122011635170with low incidence inMM6129217

1007051637341559666502373415561%48%69%with low incidence outMM7343000

MM62602011

Less than 4 IP or less than 5 EDMM82245210

PAIN090000

IPEDLOSCP DateIPEDLOS>10 months N=12IPEDLOSCP DateIPEDLOS>10 months N=12PAIN050000

143427/30/1261024143427/30/1261024PSYCH3319122

1249/18/1241141249/18/124114PSYCH0130010

31138/21/1201031138/21/12010PSYCH5516101

66208/23/1201066208/23/12010PSYCH3116122

810347/10/1241119810347/10/1241119PSYCH070000

42207/9/12331442207/9/123314PSYCH0360050

40457/9/1221540457/9/12215PSYCH1113030

1128/9/122227PSYCH1162020

616228/15/12264616228/15/12264PSYCH/PAIN0700150

616228/15/12264616228/15/12264PSYCH/PAIN1112010

93508/23/12321993508/23/123219552753with low incidence in

626027428441306159272264210357%33%62%with low incidence outPSYCH/PAIN1162020

PSYCH/PAIN0150010

PSYCH/PAIN0110000

IPEDLOSCP DateIPEDLOS> 6 months n = 36

IPEDLOSCP DateIPEDLOS> 6 months n = 3689658/17/124117PSYCH/PAIN1113020

89658/17/124117401510/11/125118COPD6127000

401510/11/125118512410/3/12116COPD4014000

512410/3/12116531212/12/12000COPD41211040

531212/12/1200065131/2/13112COPD3114020

65131/2/1311275251/2/130001544817462514498

75251/2/13000

1039/27/12000225510/2/12000with low incidence out847087

225510/2/12000331911/21/12050with low incidence in837084

331911/21/12050441111/21/12283

441111/21/12283

14112/5/1204012321/3/13080ALL Aggregate Aug 2013

12321/3/13080413161/8/13020

413161/8/1302019311/12/12030122916154954207

19311/12/1203074639/18/1211313237864764205265

74639/18/12113428409/18/121621272345383097148

428409/18/121621544817462514487

2379/17/12030710341/3/13030TOTAL53511842546168500707

710341/3/13030331911/21/12050

331911/21/120507302012/19/12297with low incidence out695772

7302012/19/12297with low incidence in686070

2059/24/12010028010/2/120140

028010/2/120140017011/9/12000

017011/9/120004231311/12/12040

4231311/12/120402201011/12/12214

2201011/12/12214028010/2/120140

028010/2/120140017011/9/12000

017011/9/120004231311/12/12040

4231311/12/120402201011/12/12214

2201011/12/122143098/25/12020

3098/25/120206201411/21/12000

6201411/21/12000251011/9/121513

251011/9/1215131025410/31/12219

1025410/31/122191283510/1/12131247

1283510/1/121312471117111/7/12109

1117111/7/12109863811/20/12412072%70%76%with low incidence in

863811/20/1241201423936634211316470%71%75%with low incidence out

14840067942121164

IPEDLOSCP DateIPEDLOS>3 months N=21

IPEDLOSCP DateIPEDLOS>3 months N=2177372/18/133214

77372/18/13321431393/18/13020

31393/18/13020412271/24/13030

412271/24/13030

11101/21/1300086161/30/13000

86161/30/13000

11101/14/1300062367/27/121214

62367/27/121214612911/20/12217

612911/20/12217188711/2/133311

188711/2/133311

1361/30/13112

1361/30/1311223191/3/13090

23191/3/13090319181/3/13000

319181/3/1300054351/21/13020

54351/21/13020

21111/31/1303021252/8/13040

21252/8/1304041471/22/13040

41471/22/1304073271/29/13236

73271/29/13236

21241/3/1300057221/3/13216

57221/3/1321670352/6/133035817278with low incidence in

70352/6/13303587139383163693827476with low incidence out

95149450184197

Aggregate with Low Incidence Out

FY 2013

ALL CAUSE READMISSION RATESIP/OS 3 Visits = 544 patients = 1632 admits96665023734155

Excludes SMPRED/UC 5-9 Vistis  1364 patients = 6820 at least ED/UC visits61592722642103

MEDICAREALL PAYOR14239366342113164

Jul-1117%11%87139383163693696471with low incidence in

Sep-1116%9%3866571820121225515686672with low incidence out

Dec-1113.00%1.40%

Mar-1212.00%1.90%

Jul-122610

Sep-1214.69

Dec-1212.7510

Mar-1311.818

High Frequency Patient Primary Care

PCP ANALYSISFY 2011FY 2012FY 2013

Aggregate SummaryFY2011Aggregate SummaryFY2012FY 2012Aggregate SummaryFY2013TotalPhys Name - PHI(detail pull)NONE554842

Total complex patients611611FY 2011Total complex patients735Medical Record Nbr - PHI(detail pull)Phys Name - PHI(detail pull)Total complex patients768246PHYSICIAN, PCP UNKNOWNMEDICAL RESIDENTS101111

Age412NO NAME SENT BY HEALTHQUESTAge325NO NAME SENT BY HEALTHQUESTAge185PHYSICIAN, NO PCPCOMMUNITY BENEFIT CLINICS6811

Age 16-2557155PHYSICIAN, NO PCPAge 17-2561251PHYSICIAN, PCP UNKNOWNAge 18-2563171NO NAME SENT BY HEALTHQUESTPCMH182221

Age 26-4519014BROWNING CLAYTOR, HEALTHAge 26-4521322BROWNING CLAYTOR, HEALTHAge 26-45218118HEARTSIDE, CLINICPSYCH HOME435

Age 46-6016133HEARTSIDE, CLINICAge 46-6023151HEARTSIDE, CLINICAge 46-60229123HULL, BRYAN EOTHER7810

Age 61-7510179HULL, BRYAN E ResidentsAge 61-7513099HULL, BRYAN E ResidentsAge 61-7515020BROWNING CLAYTOR, HEALTH

Age >7510232CHERRY STREET, HEALTH SERAge >7510034CHERRY STREET, HEALTH SERAge >7510865CHERRY STREET, HEALTH SER

Gender13Clinica Santa MariaGender15Clinica Santa MariaGender12Clinica Santa Maria

Male26226METRO residentsMale34827METRO residentsMale35433METRO residents

Female34915VA GRAND RAPIDS, CLINICFemale3877VA GRAND RAPIDS, CLINICFemale4148VA GRAND RAPIDS, CLINIC

Race2SPARTA HCRace7SPARTA HCRace9SPARTA HC

ASIAN42Ferguson Health CenterASIAN33Ferguson Health CenterASIAN59SH Residents

BLACK14715CAMPBELL, JOHN N/Arbor Circle.BLACK1546CAMPBELL, JOHN N.BLACK1798CAMPBELL, JOHN N.

DECLINED2423ASHMEAD LafayetteDECLINED3736LAFAYETTEDECLINED3047LAFAYETTE

HISPANIC123ELSEN, PAUL C NWHISPANIC018NWHISPANIC025ELSEN, PAUL C NW

MULTIRACIAL422APPLEGATE GRDVLMULTIRACIAL429GRDVLMULTIRACIAL724APPLEGATE GRDVL

NATIVE AM/ALASKAN AM1230QUIROZ DTWNNATIVE AM/ALASKAN AM1453DWTNNATIVE AM/ALASKAN AM1260QUIROZ DTWN

OTHER122AHRENS WLKEROTHER022WLKEROTHER019AHRENS WLKER

UNKNOWN114COLEGROVE SWUNKNOWN023SWUNKNOWN027COLEGROVE SW

WHITE41716SALEH EBLWHITE52324SALEH EBLWHITE53538SALEH EBL

Ethnicity12BISHOP KTWDEthnicity13BISHOP KTWDEthnicity18BISHOP KTWD

BLACK311ANDERSEN JENBLACK017ANDERSEN JENBLACK19ANDERSEN JEN

DECLINE32DURFEE ROCKDECLINE22DURFEE ROCKDECLINE11DURFEE ROCK

Blank34BATY PLNFDBlank017BATY PLNFDBlank16BATY PLNFD

EUROPEAN162FINKBEINER CALEEUROPEAN06FINKBEINER CALEEUROPEAN5FINKBEINER CALE

HISPANIC/LAT4011SANAULLAH, BABAR - LTCHISPANIC/LAT57HISPANIC/LAT49

NOT HISPAN/LAT5224ALI, SHAHNAZ - LTCNOT HISPAN/LAT674NOT HISPAN/LAT7183McCauley Clinic

OTHER13RUTHERFORD - LTCOTHER01CATHERINES HEALTH, CENTEROTHER

UNKNOWN104LAGARDE Belnap HCUNKNOWN11LTCUNKNOWN8PHYSICIAN, SEE REFERRING

VIETNAMESE14APP, PETER B Creston Med CenVIETNAMESE04BAUMGARTNER, DAVID DVIETNAMESE5LTC

Blank128PASSINAULT, JAMES PBlank13RUTHERFORD, DONALD E LTCBlank4RUTHERFORD, DONALD E

1SH Residents11SANAULLAH, BABAR LTC6SANAULLAH, BABAR LTC

8PHYSICIAN, SEE REFERRING11CATHERINES HEALTH, CENTER

6PHYSICIAN, SEE REFERRING5LAGARDE Belnap HC4APP, PETER B Creston Med Cen

3McCauley Clinic3APP, PETER B Creston Med Cen4LAGARDE, STACIA G Belnap HC.

2OASIS OF HOPE10KUTSCHE, DAVID O ? SH

10252BROUWER, ELIZABETH1GIOVANNUCCI, SAM J

3BRENNER, KRISTOPHER MH5BROUWER, ELIZABETH MH

4RAFFO, DAVID G VP.2SETCHFIELD, JAMES W MH3GREEN, RANDALL ?

1BORN, TAMMY L2SHAH, RIMA2WABEKE, JANICE KAYE MH

2BRENNER, KRISTOPHER MH3DUTHLER, RANDALL MH2DALM, STEPHEN C MH

1SELFE, ROBERT MH2RODDY, E. GAILE MH

3SHARMA, S. MH2RODDY, ELIZABETH MH

2BARNES, CHRISTOPHER R MH.5RAFFO, DAVID G VP.2KULDANEK, GREGORY A SH

1WOODWORTH, JOHN C MH1BODLEY, MICHAEL T SH

1BILISKO, THOMAS SH3BATTISTE, JENNIFER SH1BEVERSLUIS, MARCUS G SH

1KEMP, MARK W SH3BILISKO, THOMAS SH1VANLOWEPRINCE, SHEILA M SH

2DOSANJH, GURSHARN S.3HILTS, THOMAS E2FURNESS, CHADWICK A SH

1HESLIP, JOHN E SH1MASKILL, JOHN D SH3HOFFIUS, DAVID R2CLARK, RANDALL N SH

2BOESSENKOOL, ELIZABETH SH1VANDERKOLK, WAYNE E SH

1KOEPNICK, KURT SH2KUTSCHE, DAVID O SH

3DRUMM, DANIEL R SH1BEGROW, LEE P SH

3MOHR, DAVID JEFFREY SH3MASKILL, JOHN D SH

2GANS, JON SH2DOSANJH, GURSHARN S. SH

1HAZLE, GREGORY L GR Fam Drs4PASSINAULT, JAMES P2DRUMM, DANIEL R SH

1Oncology SMHC2Pulmonology SMHC1BATTISTE, JENNIFER SH

4Renal Spec SMHC6Oncology SMHC1BILISKO, THOMAS SH

1Pulmonology SMHC4Renal SMHC4GRANGER, WILLIAM ?

2FURNESS, CHADWICK A GR Fam DRs - Mercy??2GI SMHC3DUDLEY, KENNETH E GR Fam ??

4KUTSCHE, DAVID O ?3DUDLEY, KENNETH E GR Fam ??3HAZLE, GREGORY L GR Fam med

3EDWARDS, DENIS ?5RAFFO, DAVID G VP.

209612038PASSINAULT, JAMES P

2KARAYIL, DILJIT B3FREDRICKSON, MARK A.17Oncology SMHC

2KENNEDY, DANIEL2AGERSON, KIRK J5Renal SMHC

2GARZA-QUINTERO, RICARDO3HULST, LYNDA L2Pulmonology SMHC

2KROL, KARA3LEMKE, JOHN A3Ortho SMHC

2LOHANI, RAJANI3PELKEY, LESLIE MCANDREWS1EGWUATU, NNAEMEKA E

2LYONS, MONICA ANN3MOHR, DAVID JEFFREY1441

3MUELLER, TRICIA L.2BARGWELL, STEVEN T

2QADIR, SOHAIL3REYES, ANTHONY L.2BRADLEY, BARBARA

2RIEKSE, ROBERT G3RIEKSE, ROBERT G2BREITWEISER, KARL

2HANDY, SHARON L3THORNBURG, KAREN A2BREWER, LARRY

2SOLTYSIAK, ROBERT M2BARGWELL, STEVEN T2BRYANT, PAUL H

2BOONSTRA, LESLIE A.2BURNS, LAURENCE J

2STEVENS, TODD C2BREWER, LARRY2BYARS, MICHAEL A

2SUBRAMANIAN, JEEVARATHNA2BRUBAKER, JULIE J2CARLSON, R TROY

2TAVERA, CARLOS EDUARDO2FRIEND, CHAD ALAN2COE, CHAD M

2VANNOORD, JANINE K2GADBOIS, GREGORY P.2EISENGA, BERNARD

2HOLLEN, AMY CATHERINE2GARIBALDI, KAREN L.2FREDRICKSON, MARK A.

2HOLMAN, ROGER2GIBBONS, LINDSAY R.2FRIEND, CHAD ALAN

1ADNAN, MUHAMMAD K2GRANGER, WILLIAM2GARIBALDI, KAREN L.

2GRIEMSMAN, STACIE L2GRAESER, RONALD E

1ALI, KEVIN F2HANDY, SHARON L2HOFFIUS, DAVID R

1APP, MICHAEL J2HAVEMAN, JOANNA2HULL, REBECCA A.

1ARMSTRONG, MARK W2KENNEDY, DANIEL2KOBIELA, ROBERT D

1BARGWELL, STEVEN T2LEWIS, LEONARD A.2KROL, KARA

1BATES, MARIBEL2LIAO, THEODORE W.2LEWIS, LEONARD A.

1BEDELL, HEATHER L2MATHIS, ANDOLA C.2LIAO, THEODORE W.

2MIEDEMA, NIDIA ODALIS2LLOVET, MAGALIS

2OOSTEMA, ANGELA R2MCCORRY, DAVID F

1BOONSTRA, LESLIE A.2POSTMA, JOSEPH K2MEIER, JOHNATHAN GEOFFREY

2RICHARD, ROBERT CHARLES2MILLER, ROBERTO

1BORRERO, FLOR2SMENDIK, DOUGLAS JAMES2TENHAAF, WILLIAM M

1BOS, CINDY2STOUT, MICHAEL T2THOMAS, OLUWATOYIN

1BOSS, RICHARD S2TOBOLIC, TIMOTHY J2TRAVIS, MARC A

1BOUTELL, MATTHEW1ADNAN, MUHAMMAD K2VANDENBERG, W CHRISTIAN

1BRANDT, GWEN M.1AL GUBOORI, NADIA KADHIM1ABDEL-MAGEED, ALY S.

1BREITWEISER, KARL1APP, MICHAEL J1ACHTYES, ERIC D

1BREWER, LARRY1ARMSTRONG, ERICA L.1AGERSON, KIRK J

1ARMSTRONG, MARK W1AL GUBOORI, NADIA KADHIM

1BROUWER, ELIZABETH1AUSIELLO, DOMENICO S1ANDERSON, TRICIA M.

1BRYANT, PAUL H1BACH, ROBERT VINCENT1APP, MICHAEL J

1BULTJE, MICHAEL1BARANOWSKI BIRKMEIER, TER1ARLINSKY, DONALD

1BURNS, LAURENCE J1BARNES, CHRISTOPHER R.1ARMSTRONG, ERICA L.

1BURNS, THOMAS1BARNETT, CLARENCE R1ARMSTRONG, MARK W

1BUTELL MATTHEW1BARNETT, J RICHARD1BARANOWSKI BIRKMEIER, TER

1CALDERON-TORRES, PILAR1BATES, MARK1BECK, AMY

1CAMPBELL, LINDA M1BEEAI, MOHAMMED1BEEAI, MOHAMMED

1CARREL, DANIEL1BELSITO, FRANK1BORA, NIRALI S

1BHUNPAEN, JENNIFER A1BOS, CINDY

1CHEBES, ANDRZEJ1BODLEY, MICHAEL T1BRANDT, GWEN M.

1CHRISTENSEN, PETER1BOS, TAMALA1BRENNAN, GERARD PAUL

1CLARK, RANDALL N1BRAMAN, PAUL E.1BRUBAKER, RUSSEL V

1DAKKAK WAAD1BRANDT, GWEN M.1BUDREAU, KRISTEEN LEE

1DAKKA WAAD1BREITWEISER, ANN1BULTEMEIER, MARCI RAE

1DANS JOHN1BREITWEISER, KARL1BULTJE, MICHAEL

1DAVIES, SEENA1BRUBAKER, RUSSEL V1CAMPBELL, DOUGLAS G

1BURNS, LAURENCE J1CARLSON, SCOTT ALLEN

1BUSH, JENNY L1CARREL, DANIEL

1BYINGTON, DAVID1CHRISTENSON, WAYNE A

1DEW, JOHN S1CALDERON-TORRES, PILAR1CHRISTIAN, SHARON E

1CAMPBELL, DOUGLAS G1CLOUSE, ROBERT

1CARREL, DANIEL1CORY, JENNIFER A

1DUDLEY, KENNETH E1CHRISTENSEN, PETER1DAGEN, MARY MARGARET

1DYKSTRA, JOHN T1CHRISTENSON, WAYNE A1DAR, MADIHA

1ELSING, ERICA1CLARK, RANDALL N1DAVIDSON, DIANA E

1ERK MARK1CUNLIFFE, CHELSEA L.1DAVIS, MELISSA J

1FASBENDER, THOMAS A.1DALM, STEPHEN C1DAVIS, MICHELLE

1DAUM, TIMOTHY S1DELACRUZ, JUAN MIGUEL

1DAVID, LOURICE1DEMOCK, KRISTI L.

1FOE, LAWRENCE G1DAVIS, MELISSA J1DHIR, KARAN

1DENNIS, JONATHAN A1DIBBLE, PAUL

1FREDRICKSON, MARK A.1DIBBLE, PAUL1DICKINSON, MICHAEL

1FRICK, MARC1DRUMM, DANIEL R1DICKINSON, TIMOTHY K

1FRYE, JAMES H.1DUDLEY KENNETH1DIZON, MICHAEL B.

1GACA, PHILIP J1DYKSTRA, JOHN T1DOOD, JEFFREY J.

1GARIBALDI KAREN1ESTRELLA, EDNA1DUBLIS, STEPHANIE A

1GAUTHIER, PAUL1FEENSTRA, RICHARD D1DUBOIS, WILLIAM F

1GILLARD, PAUL J1FLOOD, JAMES E1DYKSTRA, JOHN T

1GIRI, SUKEPMA1FERRER, VLADIMIR1EISENMANN, DEBORAH L

1GOEBEL, PETER1GANGADHARAN, PALLIYATH1ELLOSO, MATTHEW L.

1GOLTZ, GRETCHEN C1GARIBALDI KAREN1FEENSTRA, RICHARD D

1GARZA-QUINTERO, RICARDO1FOLEY, WILLIAM J

1GAUTHIER, PAUL1FREESTONE, DAVID J

1GEISSLER, JAMES1GALE, MATTHEW J

1GUNNELL, ROBERT1GIANTURCO, MICHELLE1GANGADHARAN, PALLIYATH

1GURNELL ROBERT1GINGERICH, DONALD1GARRETT, GUY

1HAIGHT, PAUL1GOEBEL, PETER1GEISSLER, JAMES

1HAROLD, DONNA M1GOUSHAW, PHILIP J1GIBBONS, LINDSAY R.

1HARRIS, CLINTON1GREEN HENRY1GINGERICH, DONALD

1GREEN, HENRY L1GREEN, ERIC R

1HEINLEN, LENE A1GREEN, RANDALL1GRIEMSMAN, STACIE L

1HERRERA, MARISA A1GRIFFITHS, GLENN C1HALVORSON, MELISSA

1GUIKEMA, JAY S1HAMERSMA, JOHN

1HAIGHT, PAUL1HAROLD, DONNA M

1HEYBOER, DAVID1HAMERSMA, JOHN1HENDERSON, PHILLIP

1HAMPTON, AARON E1HINKIN, STEPHEN M

1HOOGMOED, RONALD P1HARDMAN, DONALD J1HOEKSTRA, LISA

1IRFAN MOHAMMAD1HARTMANN, JOHN G1HOLLEN, AMY CATHERINE

1HARTRUM, BETHANY ANNE1HOLMAN, HARLAND T

1JOHNSON, SCOTT1HAWKINS, LAWRENCE1HUDSON, CHRISTOPHER J

1HEMPHILL HARRIS, KARLA1IZOKAITIS, ANTHONY

1HERRERA, MARISA A1JARY, MARK L.

1KHAN, ADEEL1HESTRES RAYMOND1JENNINGS, MARTIN D

1KILKENNEY, ADAM L.1HEYBOER, DAVID1JHA, SACHCHIDANAND

1KLINE, MARY K1HIGHLAND DOC1JOHNSON, MICHAEL J

1KLIPHUIS, SALLY L1HINKIN, STEPHEN M1JOHNSON, SCOTT

1KOBIELA, ROBERT D1HOEKSTRA, LISA1JOHNSON, STEVEN

1HOFFMAN, AMANDA L1KARANEC, KRISTINA N.

1KULDANEK, GREGORY A1HOFFMAN, THOMAS1KEIRNAN, FLORENCE

1LAFLEUR, ROBERT S1HUDSON, JAMES D1KENNEDY, DANIEL

1LANDINO, COLLEEN1JHA, SACHCHIDANAND1KERN, KRISTI S

1JOHNSON, JEFFREY D1KIM, RODERICK S.

1LINDHOUT, KATHLEEN1JOHNSON, SCOTT1KIRCHINGER, DAVID

1LONGLEY, DEBORAH J1KERN, KRISTI S1KLINE, MARY K

1KLEINERT, SCOTT1KOEPNICK, KURT

1MALIK, MUBASHER1KLIPHUIS, SALLY L1KOSKEY, DAVID

1MANNINEN, CYNTHIA A.1KORTZ ANGELA1KRIEGER, JONATHAN J

1MARVIN, JOHN A1KOWACZ, JULIE MINER1KUIPER, MARK DONALD

1KOZAK, JENNIFER R.1KUIPERS, AUSTIN N.

1MATHIS, ANDOLA C.1KRISSOFF, MADELON1LARSEN, MATTHEW A

1MATTHEWS, ALISSA M1KVAL, TIMOTHY E1LARSON, MARCY S

1MAURER, JOHN R1LAFLEUR, GEORGES P1LEE, GERALD R

1LANGERAK, BRUCE ALAN1LENZ, MICHELLE LYNN

1MCCORRY, DAVID F1LANG, JAMES C1LIEUWEN, DAVID F

1MEIER, JOHNATHAN GEOFFREY1LEBER, STEVEN M1LONGLEY, DEBORAH J

1LERNER UNKNOWN1LOWERY, LISA M

1MUELLER, TRICIA L.1LIBRA, JEFFERY JOSEPH1LOWN, STEVEN

1MURPHY AARON1LIBRA JOE1MACFIELD, PETER S

1NEVIN, LYNN PODEHL1LLOVET, MAGALIS1MARVIN, JOHN A

1NGUYEN, HOANG1LOWERY, LISA M1MATHIS, ANDOLA C.

1NIAZ, FAIZA1MAHABEER, HOWARD A1MATTHEWS, ALISSA M

1NUGYEN HOANG1MCCARTHY, ANNE M.1MEHTA, SAMEER

1OBRIEN, MARK S1MCCORRY, DAVID F1MICHELAKIS, MICHAEL A

1MCGRATH, DAVID MICHAEL1MILLER, TRICIA R

1OETMAN, DUANE A1MCLEAN, JAMIE1MILLETT, JOHN

1OLIVER-ELIZABETH, TONY I1MEIER, JOHNATHAN GEOFFREY1MOHR, DAVID JEFFREY

1ORTIZ, JOSEPH DANIEL1MONTERO, ADAM FRANCIS1MORLEY-SMOLEK, KARA M

1OSBORNE, THERESA ANN1MUTCH, DAVID M1NIAZ, FAIZA

1OVERMYER, AMANDA J1NGUYEN HOANG1NOAH, CHRISTOPHER

1NWANKWO, UCHEBIKE N1OBRIEN, MARK S

1PELL, MARY1OASIS OF HOPE1OCONNOR, RICHARD

1OBRIEN, MARK S1OHARE, KATHLEEN

1POEHL, ROBERT1OHARE, KATHLEEN1ONONUJU, CHIDOZIE J

1POFF, DOUGLAS1OLSEN, MARIA-LUISA REYES1OOSTEMA, ANGELA R

1POKHREL, SASHANK1OLSON, PETER W L1OWENS, LANCE M

1OWENS, LANCE M1PAHWA, HARNEET S.

1PREFONTAINE, STEPHEN M.1PARKER, DAVID B1PARKER, DAVID B

1PUFF DOUGLAS1PEDTKE, DOROTHY ANNE1PATEL, TARULATA P.

1PUNDIR, KUSHAGRA1PELL, MARY1PERSENAIRE, PATRICIA F

1QUINN, ERYN C1PHILLIPS, BRIAN1PHILLIPS, JAMES E

1RANTA, JAMES P1PIERCE, ROBERT H1PHILLIPS, KRISTINE

1POEHL, ROBERT1PRESLEY, DAVID

1RICHARD, ROBERT CHARLES1POEL, LARRY A1QADIR, SOHAIL

1QADIR, SOHAIL1QUARSHIE, CHRISTOPHER T

1QUINN, DIARDRE H1QUINN, DIARDRE H

1SCHIPPER, BENJAMIN R.1RASIKAS, KYLE A1RAJLICH, JAN JOHN M

1SOLAREWICZ, MACIEJ1RICH, GARY L1RAMIREZ, ROSE MARIE

1STEVENS, JEFFREY MARK1RODRIGUEZ-IRIZARRY JAIME1RANTA, JAMES P

1STEWART, BRIAN JAMES1ROSLANIEC, PHILLIP L1RECHNER, STEPHEN

1STREET, MAUREEN R1RUTHRUFF, CHRISTOPHER M1RIEKSE, ROBERT G

1SYPNIEWSKI, REBECCA J1SANAULLAH, KHURRUM1RUTH, SHAWN R

1TALVERA CARLOS1SANKEY, BEVERLY J.1RUTKOSKI, TIMOTHY

1THORNBURG, KAREN A1SCHIPPER, BENJAMIN R.1SACKETT, GARY

1TORRES, GIUSEPPE BYRON1SCHMOKE, RAYMOND1SALLEVA, MAYSEE D

1SEALS, ROBERT H1SCHEERINGA, BRIAN W.

1TWESTON-OTOOLE JAMES1SEIN-OHN, KAREN ELIZABETH1SHATZ, EUGENE MARK

1VALEESWARAN, CHANDINI1SELFE, ROBERT1SHERMAN, STANLEY R

1VANDEBURG, ANITA D.1SHARMA, SOORYA KANT1SIEFERT, SHARON L

1VANDENBOSCH, SUSAN1SHATZ, EUGENE MARK1SIGELKO, DANIELLE M.

1VANDENBOSH CESAR1SIAPNO, CHARISSE N1SINGH, TULIKA

1VANDYKEN, RICHARD ALAN1SIEFERT, SHARON L1SLENDEBROEK, MATTHEW C.

1VEERAVALLI, SRIDIVYA1SILVERSTONE, WILLIAM R1SMITH, MERVYN W.

1VELDHOUSE, JOEL P.1STEVENS, JEFFREY MARK

1VELDHOUSE, LINNELLE1SOLTYSIAK, ROBERT M1STEWART, BRIAN JAMES

1VERKAIK, STEVEN J1STEURY, MONICA L1SUBRAMANIAN, JEEVARATHNA

1VOICES OF HOPE1STEVENS, TODD C1SUMNERS, MICHAEL J

1VORTIA, EUGENE K.1STUART, LEE OWEN1SYPNIEWSKI, REBECCA J

1WATSON, KELLY J1SUMNERS, MICHAEL J1TANNER, ADRIANA

1WEBER DR1SYPNIEWSKI, REBECCA J1THAPA, CHINIYA

1WIERSMA KELLY1TALMO, JANET L1TOAZ, LYNN ANN

1WILKINSON, PETER D1TANNER, ADRIANA1TONG, MARTIN T

1WILTRAKIS, MICHAEL R1UNZICKER, GWENDOLYN R

1WOO, JEFFERY ALLEN1TENHAAF, WILLIAM M1VANDERHILL, SCOTT D

1ZELASKO, PAMELA SUE1VANDERKAAY, CHRISTIAN B.

1ZIELINSKI, CHRISTOPHER F1TOAZ, LYNN ANN1VANDERMOLEN, LAURA ANN

1ZOOK, BRENDA SUE1TORRES, GIUSEPPE BYRON1VANHARE, JAMES J

1611TURKE, KIMBERLY G1VANRYN, CHRISTOPHER

1UNZICKER, GWENDOLYN R1VELDHOUSE, JOEL P.

1VALEESWARAN, CHANDINI1WAGNER, PAUL ANTHONY

1VANDEBURG, ANITA D.1WEBER, NORMAN A

1VANDERKAAY, CHRISTIAN B.1WEIRICH, ANGELA R

1VANDYKEN, RICHARD ALAN1WERLING, AMY LYNN

1VELDHOUSE, JOEL P.1WHITE, CRAIG

1VERKAIK, STEVEN J1WIELHOUWER, ERIC JAMES

1WILLIAMSON, JEFFREY R

1VORTIA, EUGENE K.1WRIGHT, TERRENCE P

1WALSH, THOMAS JOSEPH1YACOB, NASIM

1ZELASKO, PAMELA SUE

1WILLIAMS, GABRIEL B1ZIELINSKI, CHRISTOPHER F

1WILTRAKIS, MICHAEL R1708

1WRIGHT, TERRENCE P

1YACOB, NASIM

1ZIELINSKI, CHRISTOPHER F

208

Dementia Graphs

Inpatient and ED Visits

Aggregate Outcomes

COPD

LOS

Aggregate Outcomes

Gastroparesis

Inpatient and ED Visits

1 Year After Intervention

Daily Readmissions

LOS

1 Year After Intervention

Patients for Finance

FY 2011

FY 2012

FY 2013

Addiction

Linda Williams (Gastro)

Roshawn Jackson (MM)

Deborah Grimes (COPD)

Evelyn Conrad (COPD)

Jason Cardosa (Gastro)

Tiffany Young (Conv D/O)

The ETOHers

Beatrice Sabrina Louis (psych)

Jon Marvin (psych)

Marian Foltice (mm)

Timothy Hefferon (mm) died

Aggie White (COPD) hospice

Laura Hofferber (ESRD)

Thomas Spaulding (MM)

Tina Garza (MM/Gastro)

MERIDIAN PATIENTS

Irvin Merrill

Sandra Fasburg

Karla Parker

Shannon Corbett

Care Plan Outcomes

Maria Vata 888-437-0606 ext 1330Date

FasburgSandra316279MeridianJordan 888-3228844 ext 1394 Crystal 888-437-0606 ext 1304? 6/2013

ParkerKarla560539MeridianAyesha 313-324-3700?6/2013

BelcherShannon498642MeridianKaitlin 888-322-88435/14/13

CaliffWilliam729418Meridian?5/14/13

CorbettShannon1143569MeridianKaitlin 888-322-88434/23/13

SannesMary396509MeridianDebra 888-322-8843 ext 13582/25/13

MerrillIrvinMeridianAyesha 313-324-3700

ChapmanCoreyMeridianAyesha 313-324-37009/5/13

WhiteheadJustinMeridianAyesha 313-324-37009/5/13

9/9/13 Ayesha - Meridian - starts new frequent monitoring program in one month

meet daily with Drs. At Meridian to review high frequency patients

Can lock down pharmacy and Dr. to one prescriber/one source

Send letters to members w/frequent access

Can bill patient

Can deny insurance if continue to overuse

Provider Graphs

Last NameFirst NameMRN

DenningDuaneMultiple #s**1171460?multiple names??

HesseCharlesMultiple #s**611631Used Dad's Identification

HuynhThanhMultiple #s** 658504Same Person -per provider reportnot linked

HuynThan1211089

ThanhHuyn1222172? Same Person (8/2/13 order)

LipinskiElizabethMultiple #s** 1088010Lapinski, Lipinski, ArbanasAll linked in Cerner

MuhammadMalik1197187not linked

WashingtonDennis1017711

MccereeKelvin1213150

MuhammadKevin444206***Several names already linked under this one

MuhammadDennis1009243

MuhammadAmir1127425

MuhammadSaleem1177761

NyenhuisSteven155082Ins co report

OnealDoreinMultiple #s 1075539Dr. Findley reports patient has numerous alias' and Cerner looks like numerous records are linked together. What are the patient's other names?

PaceMonica846282Same Person - per provider report

MitchellMonica1214760not linked

BaldwinMichelle1186193not linked

MitchellMichelle?1178849not linked

TaylorAudrea1199957not linked

PowellJennifer1129131Vaness

TiedemannTammy437161Oaks, Sommerlinked in Cerner

VanderbiltVanessa967945Veinbergslinked in Cerner

WhiteTheresa393790also goes by Green, Brown - unverifiedreported - not sure in Cerner

HansenBrent997397also goes by Hansonlinked in Cerner

VanderBiltVanessa967945also goes by Veinbergslinked in Cerner

ColemanDanette182228using mom's name Sharmine Owensnot linked

156921

Guadalupe Ricardo Serrano Santiagosent to group 8/21/13

MRN 1164817 & 1164377

DOB: 12/13/78 & 11/23/80

Michael Andrew Hiess dob 07/05/1978 also some alias have been Michael Heiss, Michael Peter Heiss, Michael Weiss and Peter Druiter - from Ruth Eilers - not a high frequency pt yet

Group for Meghan July 2013

Primary DiagnosisReadmitTotal # of Pts >4 admitsTotal # of Pts >4 admits

Pain153

COPD408

CHF459

Multiple Dx5511

ESRD6012

Cancer7014

Total27054

TBD5511

4 or > admits340

3 admits620

2 admits1900

May 8, 2012

Palliative Care47%

No Palliative Care53%

September 19, 2012

4 or > admits388

3 admits550

2 admits1725

2663

Diagnoses >4 admits

Cancer58

ESRD50

CHF44

COPD37

ETOH23

Multiple Medical22

Pancreatitis13

Gastroparesis8

UK87

Group for Meghan July 2013

Number of Admissions

Number of Patients

Inpatient Readmissions 2011

Diagnosis

Number of Patients

Primary Diagnosis of Patients with 4 or > Admits 2011

4 or > admits

3 admits

2 admits

Number of Readmissions

Total Number of Patients (based on 20% sample)

Patients Readmitted in 2011

340

620

1900

Pain

COPD

CHF

Multiple Dx

ESRD

Cancer

Primary Diagnosis

Number of Patients

Diagnoses of Patients with 4 or > Admits in 2011

15

40

45

55

60

70

10-12-2011 thru 1/21/20123LPrior yr

Patient Name:MR #InsuranceAdmit StatusAdmit DateAdmitted From:LOS 3L:LOS:PCPsychTylenolATC?BowelSched?ADFASTDOCDischarged to:IP admits?Readmit?ED visits past yrADMIT DateDODADMIT Date

Bell, Elsie833145MedicareInpatient12/6/11Raybrook AL38NN1N1NY7CNot AddRaybrook AL43/12 CHF0Hospice d/c12/6/113/19/1210/7/11

Botwinski, Esther314925Priority MedicareInpatient11/30/11East Ridge Sr. Apt33NNNNNNN6CNot AddAllendale SAR001011/30/11N/A10/8/11

Bowler, Edward1154200Medicare, Pref. PPO Blue CrossObservation10/20/11Sunrise Dementia Unit55422Y2YY7DYTrilium Woods300Hospice d/c10/20/1112/13/1110/8/11

Bowler, Edward1154200Medicare, Pref. PPO Blue CrossObservation12/1/11Sunrise Dementia Unit77N11Y1YY7AYSunrise Dem unit200SAR12/1/1112/13/1110/18/11

Bowles, Helen1134424Medicare, UHC ParObservation10/7/11Pilgrim Manor55N1NNNNY6CNot AddPilgrim Manor000SAR10/7/115/10/1210/20/11

Brisco, Nathan46063MedicareObservation11/2/11Home with wife3030N22YNNN6CNot AddEmracing Life AFC20111/2/11?1/27/201210/21/11

Bush, Mae1164403Medicare, MedicaidObservation12/19/11home1OAP 62N115yNNy6cNot AddPine Rest01012/19/113/11/12Died in ICU After Cardiac arrest. ECT/Seroquel Dementia10/26/11

Cobb, Alice1163136Medicare, Conseco Non ParInpatient12/5/11Home with husband1PMU 14N11yNNy6bYPMU00012/5/11naVascular Dementia d/c home10/26/118

Conner, William257834Pine Rest HospitalObservation1/1/12home with wife5OAP 60N31NNNY6bYPine Rest1011/1/123/18/12Agitated Dementia. Geodon/Depakote died from stroke.11/1/11

Cushman, Edith1130659Medicare, Mich Blue CrossInpatient1/3/12fulton manor34NN2y2yn6bNot AddFulton Manor0011/3/12naDementia11/2/11

Dewitt, David581863MedicareInpatient10/8/11Rest Haven45N11yNNn6bNot AddRest haven00010/8/11naDementia Parkinsons/Paranoid schizophrenia11/4/11

Elliott, Arlene464019MedicareInpatient11/22/11advocare AFC3NN1N1yy7Not AddMetron of Cedar Springs01111/22/11naDementia11/5/11

Ferner, Donald367905Medicare, Pref. PPO Blue CrossInpatient1/16/12Hertiage LTC99N21NNNy6cNot AddRaybrook Dementia Unit1/16/12naDementia11/11/11

Goldberg, Dorothy1028662Self Pay Non PatientInpatient11/26/11Clark LTC3NN3y2yy7Not AddClark SAR00011/26/11naDementia11/14/11

Hall, Gerald383369Medicare, West Michigan PlumbersObservation12/23/11home with wife4OAP 16NN2NNNN6bNot AddPine Rest00112/23/11naDementia11/16/11

Hillman, Camille1044420Medicare, First Health-Fire KeepersObservation12/6/11home with son88N41NNNY7aNot AddFulton Manor001SAR12/6/11naDementiaWas in LTC before but they couldn't handle her - son took her home11/18/11

Horjus, Carolee500964Medicare, AARP, Medicaid MIInpatient11/16/11Home with HC551N1NNNY6DYRaybrook SAR100SAR11/16/11naDementia11/22/11

Horjus, Carolee500964Medicare, AARP, Medicaid MIInpatient10/26/11Home Alone22NN1NNNN6DNot AddHome with HC000home10/26/11naDementia11/23/11

Kruer, William851258MedicareInpatient10/8/11Clark Keller Lake55341Y1YY7aYSt. Joe's inpt pysch000IP Psych10/8/1111/13/11Dementia11/23/11

McBride, Danny1167302Medicare, Loyal American LifeObservation1/19/12laurels of sandy creek11NN1NNNY6cNot AddHackley Behavioral Health04/7/1201/19/12naDementia - ETOH11/26/11

Meulenberg, Shirley1114558Priority MedicareInpatient10/18/11Sunset AL88N41N1YN6cNot AddBrookcrest30110/18/11naParkinsons w/psychosis11/30/11

Miller, Kenneth1165060Medicare, Minnesota Blue CrossInpatient12/27/11heartland of crestview3PMU 14N11NNNY7aNot AddPMU101SAR p PMU12/27/11naDementia11/30/1114

Moore, Ollie346467MedicareInpatient11/4/11Home444N1N2YY7aYSpectrum Fuller20111/4/11naDementia12/1/11

Osterlund, Joyce1115136Humana Gold Choice, Comm. Mental Health Kent Co.Observation11/30/11home6PMU 18N21NNNN6cNot AddPMU000Home p PMU11/30/11naDementia12/5/11

Phelps, Marguerite231758Medicare Plus Blue PPOInpatient1/15/12home with daughter22NN1NNNY7cYHome with Hopsice000Faith Hospice1/15/121/24/12Dementia12/6/11

Rath, Dora785040Self Pay TraditionalObservation12/21/11maple creek77N31N3YY6DNot AddMaple Creek00012/21/11naDementia12/6/11

Rybicki, Bernice288197Medicare, Medicaid MichiganObservation11/5/11Pleasant Settings AFC66N11N1YY7aNot AddWhispering Woods00211/5/11naDementia12/9/11

Schmid, Mary Ann80669Commercial OtherObservation11/14/11metron of FH3PMU 33N31N3YN6eNot AddPMU01/13 demen111/14/112/4/12Dementia with Depression12/17/11

Schmid, Mary Ann80669Commercial OtherInpatient1/13/12Home441N1N2YN6eYHome with Hospice100Faith Hospice1/13/122/4/12Dementia with Depression12/19/11

Schmitt, Robert167122Hospice Faith Hospice ParInpatient10/21/11Oakcrest ASL33NN1N2YY6eNot AddOakcrest ASL12 ER, 1 PMU 1 IP110/21/111/25/12Dementia12/21/11

Schmitt, Robert167122Hospice Faith Hospice ParInpatient1/14/12Pine Rest Older Adult77225YNNY7cYOakcrest w/ Hospice103Faith Hospice1/14/121/25/12Dementia12/23/11

Seaward, James1093267MedicareInpatient10/26/11Vets55311NNNY6cYVets w hospice201HOM10/26/11naDementia12/27/11

Simpson, Ronald504571Medicare, MedicaidInpatient1/15/12home with wife3PMU 16N11NNNN6cNot AddMaple Creek0011/15/127/9/12Dementia12/27/11

Smith, Erta45844Medicare, MedicaidInpatient11/18/11Embracing Life AFC5PMU 13N31YNNN6dNot AddPMU - AFC53 PMU + 1 IP111/18/11naDementia plus Schizo12/28/1112

Stalker, Muriel383074Medicare Plus Blue PPO, Pref. PPO Blue CrossInpatient1/3/12Home Alone44NN2YNNY6dNot AddHeather Hills000SAR1/3/12naDementia1/1/12

Taylor, Vernon1093826Medicare Plus Blue PPO, Michigan Blue CrossInpatient11/11/11Home4PMU 34N51Y1YN7aYPMU Grace Douglas3 PMU00SAR11/11/11naDementia with Depression/Schizo1/3/12

Tein, Evalene758264Medicare Plus Blue PPOObservation11/23/11Pine Rest Older Adult55NN1NNNN6dNot AddPine Rest Oakcrest ASL000OAP11/23/11naDementia1/3/12

Terry, Marguerite448288Self Pay Non PatientInpatient12/17/11Lacey's AL33NN1NNNN7aNot AddPorter Hills SAR000SAR12/17/11naDementia1/5/12

Tuller, John1000159Medicare, Michigan Blue CrossInpatient1/5/12St. Ann44NN1YNNY7aNot AddSt. Ann's1001/5/12naDementia1/13/12

Vanderoer, John396816MedicareInpatient12/9/11Riddgeway AFC5PMU 6133N1YY7bYAFC w/Hospice001Faith Hospice12/9/1112/20/11Dementia w/Schizo1/14/12

Vandervelde, Bertha629298Medicare, AETNA PPO ParInpatient12/28/11whispering woods222N2N2YY7cYWhispering Woods/Faith Hospice102Faith Hospice12/28/11naDementia1/15/12

Velicky, Steven604338Medicare Plus Blue PPOInpatient11/1/11Railside AL22NNNN1YN7aNot AddRailside Assisted Living07/30 & 8/14011/1/11naDementia1/15/12

Wade, Jennie178664Medicare, Michigan Blue CrossInpatient11/23/11Home4747N51NNNN6dNot AddMetron of FH100SAR11/23/11naDementia1/16/12

Wilkerson, Helen104501Secure Horizon DirectInpatient12/27/11metron of belding1717991NNNN6dYTrillium Woods101Faith Hospice12/27/11naDementia1/19/1210

Timmerman, Harold 2/2012 - 8/20121170379Medicare, UHC ParInpatient2/18/12LTC42/16/12

Gravelyn, Arden992427Medicare, Mutual of Omaha Non ParInpatient2/16/12Home82/17/12

Marculis, Theresa1113563Secure Horizon DirectInpatient2/17/12Home52/17/12

Bailey, Jeanette1021270Auto State Farm Ins, Medicare, Pref. PPO Blue CrossInpatient2/17/12Home82/21/125

Douma, James1170647Secure Horizon DirectInpatient2/21/12Home153/27/12

Stanton, Barbara1044959Priority MedicareObservation3/27/12Home73/30/122

Lovelace, Donald1171127Medicare, Michigan Blue CrossInpatient3/30/12Home54/3/12

Timmerman, Maxine291802Priority MedicareObservation4/3/12Home34/3/12

Preston, Maxine105005Priority Medicare, Priority Health Caid HMOObservation4/3/12Home434/7/12

Odio-Lara, Jorge655821Public Aid TraditionalObservation4/7/12Home74/8/12

McBride, Danny1167302Medicare, Loyal American LifeInpatient4/8/12ASL94/15/12

Odio-Lara, Jorge655821Public Aid TraditionalObservation4/15/12Home234/23/12

Price, Robert1174617Medicare, Michigan Blue CrossInpatient4/23/12LTC44/23/12

Spring, Monroe1176347MedicareInpatient4/23/12LTC34/24/12

Vandeburg, Norman906062Priority MedicareObservation4/24/12LTC24/25/12

Gale, Violet785887MedicareInpatient4/25/12Home74/26/12

Posslenzny, Geraldine46460MedicareInpatient4/26/12LTC34/28/12

Hazen, Lyndon698401Self Pay Non PatientInpatient4/28/12LTC64/25/1212

Folkema, Genevieve797727Medicare, Pref. PPO Blue CrossInpatient4/25/12Home145/1/12

Pieratt, Frances1177295Medicare, Medicaid MichiganInpatient5/1/12LTC45/4/12

Lewis, Jean1176584Medicare, Pennsylvania Highmark BCObservation5/4/12ASL115/14/12

Jubert, Bernice50618Priority MedicareInpatient5/14/12Home85/15/12

Schlatter, Olen1176658Humana Choice PPOInpatient5/15/12LTC105/15/12

Weichman, Phyllis1174740Medicare, AARPInpatient5/15/12LTC65/25/12

Stone, Joan172396Medicare, Medicaid MichiganInpatient5/25/12AFC75/30/12

Porter, Beverly180138Medicare, Michigan Blue CrossInpatient5/30/12Home65/31/128

Peake, Robert1180304Humana Choice PPOObservation5/31/12LTC86/3/12

Stone, Joan172396Medicare, Medicaid MichiganInpatient6/3/12LTC36/12/12

Johnson, Donald71604BCN AdvantageObservation6/12/12Home46/10/12

Arins, Mary411586Medicare, Medicaid MichiganObservation6/10/12AFC96/30/124

Grabau, Patricia1183221MedicareInpatient6/30/12Home7(PMU 6)7/16/12

Dekker, Leon727753Priority MedicareInpatient7/16/12Home47/17/122

Kuzawa, Katherine299396Priority MedicareObservation7/17/12Home88/21/12

Voss, Gilbert658541Medicare, Pref. PPO Blue CrossInpatient8/21/12Home88/27/12

Anderson, Douglas427310Priority MedicareInpatient8/27/12Home28/26/12

Holloway, Derek1188915MedicareInpatient8/26/12Home48/23/124

Fuller, Laura365537Medicare, Pref. PPO Blue CrossInpatient8/23/12ASL6

557

6.8765432099

NOT Dementia w/Behaviors

Burns, Myrna49188Home2PMU 17NyPMUnaDepression

Donahue, Kevin965367Exodus House22N11y1ynnaNot AddPine RestnaBipolar Overdose

Buitenhuis, Willem214520Home33NN1NNNN6ANot AddHome with HC21naDelirium not Dementia

Carey, Myrtle288669home with son34ynyynnyYTrillium Woods001Hospice d/c1/6/121/21/12Pancreatic CA with hallucinations. No dementia1/6/12

Feenstra, Susanna917826Home5PMUNo Dementia

Harbach, Jean331457home with HC5Laurels of HudsonvilleNo Dementia

Knight, Rosalyn64990Home3Pine RestSchizo w/Parkinsons - not dementoa

Malcom Stella529119HomeDelerium - no dementia

Morrison, Sharon911754laurels of hudsonville4Laurels of HudsonvilleDepression - no dementia

Gregware, Carol231657home55NNNN1yNot AddPMU12/1/11Depression Overdose12/1/11