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

Patient Discharge Cockpit

Michael Johnson · CHF exacerbation (I50.9)
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MC
MJ
Michael Johnson
72 M · MRN-58231 · CHF exacerbation (I50.9)
Unit 5BCardiologyBlueShield MA Advantage HMOLOS 3d
Estimated discharge
Tuesday 2:00 PM
HIGH delay risk
Six readiness dimensions

All six must align for discharge to actually happen

Open discharge map →
♡
Medical readiness
Blocked
Readiness92%
⚒
Functional readiness
Blocked
Readiness44%
℞
Medication readiness
In progress
Readiness50%
✓
Payer / authorization readiness
Blocked
Readiness30%
▦
Resource availability
In progress
Readiness60%
✿
Patient + caregiver agreement
Blocked
Readiness20%
Discharge readiness
81%
Clinical
MD criteria, labs, vitals
46%
Operational
Auth, PT, transport, prefs
Operational readiness lifts as tasks complete. Goal: both ≥ 80% by 15:00 today to release tomorrow's discharge.
Predicted disposition
Skilled Nursing Facility
0.76 conf.
Alternate: Home + Home Health · 0.21 conf.
Rationale: prior CHF admission 2025-11, NYHA III, frailty score 0.43, caregiver POA available. Primary tilt → SNF for 7-day cardiac reconditioning; viable HH path if caregiver capacity confirmed.
Discharge timeline
  1. Fri 19:15Admission

    ED → 5B Medicine. CHF exacerbation, BNP 1820.

  2. Sat 08:40Disposition predicted

    AI predicts SNF (primary) vs. home + HH (alt). Confidence 0.76 — based on prior LOS, frailty, comorbidities.

  3. Sat 14:10PT eval requested

    Mobility + transfer assessment requested. Slot pending.

  4. Sun 09:00Prior auth initiated

    Entresto PA submitted to BlueShield MA. TAT 24h.

  5. Mon 09:42SNF match pending

    Bayview, Hillcrest, Marin Manor accept. Awaiting caregiver pick.

  6. Tue 14:00Discharge target

    Estimated discharge 14:00. At-risk: high.

Decision engine

Needs × Coverage × Resources

3 mismatches
Needs
Caregiver / PT gap
Coverage
PA pending
Resources
Vendor / SNF gap
3 edges red-dashed — fallback path warming
  • · Needs ↔ Coverage: medication / auth gap blocks the disposition match
  • · Needs ↔ Resources: caregiver / clinical need has no booked resource yet
  • · Coverage ↔ Resources: payer + vendor cannot be aligned in time — backup queued
PaCHE barriers

Top blockers

4 barriers
  • C — Care teamActively blockingOwner: pt
    Delayed PT/OT eval

    PT mobility evaluation requested but not completed. Needed for SNF acceptance + LOS decision.

  • P — PatientActively blockingOwner: case manager
    Caregiver / patient SNF prefs not captured

    Carla (daughter, POA) has not selected a SNF. Bayview, Hillcrest, Marin Manor accept BlueShield MA.

  • E — ExternalActively blockingOwner: pharmacy
    Medication prior authorization required

    Entresto (sacubitril/valsartan) PA required by BlueShield MA. Avg TAT 24h. DC may slip if not submitted today.

  • E — ExternalActively blockingOwner: case manager
    Transportation not scheduled

    NEMT not booked for transfer to SNF. Family pickup possible if home discharge chosen.

Next best actions

Recommended by OpenBed AI

4 ranked
  • Before 2:00 PM
    Request PT mobility evaluation

    Required before SNF accepts; slot before 2:00 PM.

    via Internal · Rehab Services

  • Today
    Send patient/caregiver SNF preference form

    Push portal form to Carla (daughter, POA).

    via Patient Portal · SMS + email

  • Now
    Check medication coverage & pharmacy availability

    Verify Entresto formulary tier + CVS Mission St stock + PA TAT.

    via BlueShield MA · CoverMyMeds · CVS

  • Submit by 10:30 AM
    Start SNF authorization packet

    Submit prior auth via BlueShield MA. Avg TAT 22h — submit today.

    via BlueShield MA · CoverMyMeds

Active tasks

For this patient

Open full task board →
  • AssignedConfirm clinical discharge criteriaDr. Jordan Park
  • In progressComplete medication reconciliationSam Reyes, PharmD
  • Waiting externalCheck medication coverage & pharmacy availabilitySam Reyes, PharmD
  • AssignedComplete PT mobility assessmentAisha Patel, DPT
  • AI suggestedConfirm caregiver availabilityMaria Chen, RN
  • AssignedCapture SNF preferences from patient/caregiverMaria Chen, RN
  • Needs approvalGenerate SNF referral packetPacket-Drafter Agent
  • CompleteCheck in-network SNF availabilityResource-Matcher Agent
Workflow swim lanes

Tasks by role · cross-functional discharge orchestration

12 tasks
Hospitalist1
Assigned
Confirm clinical discharge criteria
Dr. Jordan Park
Nursing1
Assigned
Complete discharge education (CHF self-care)
Sara Khan, RN
Pharmacy3
In progress
Complete medication reconciliation
Sam Reyes, PharmD
Waiting
Check medication coverage & pharmacy availability
Sam Reyes, PharmD
Assigned
Start prior authorization (Entresto)
Sam Reyes, PharmD
PT / OT1
Assigned
Complete PT mobility assessment
Aisha Patel, DPT
Case manager3
Suggested
Confirm caregiver availability
Maria Chen, RN
Assigned
Capture SNF preferences from patient/caregiver
Maria Chen, RN
Suggested
Schedule transportation
Maria Chen, RN

AI chart summary · live via Anthropic Claude

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

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

Medical readiness · deterministic rule engine

Reads cited criteria from src/lib/discharge/compliance.ts · scores deterministically · no AI involvement in severity.

92%
BLOCKED

Medical readiness 92% · 0 criteria failing (1 blocking). Patient not yet medically dischargeable.

⚙How this screen works
Cockpit is the single-pane view of one patient's six-pillar state
Inputs
What this screen reads
  • Epic FHIR encounter + clinical signals + medications
  • Cross-references to barriers, tasks, resource matches, portal state
  • Six-pillar engine snapshot for this patient
Engine
What it computes
  • Re-computes pillars whenever an event tied to this patient lands
  • Re-ranks Next-Best-Actions based on current barriers + readiness
  • Triggers chart-summarizer agent (Claude) on demand for the summary refresh
Outputs
What it writes / routes
  • Action buttons dispatch into the task orchestrator
  • 'Send preference form' pushes to portal via SSE
  • 'Start prior auth' fires CoverMyMeds submission + writes Submission row
  • Every approved action writes an AgentInference + Submission audit pair
Refresh trigger
When it updates
  • Any new FHIR observation on this patient
  • Any task completion that mentions this patientId
  • Any payer webhook for this patient's auths
  • Any portal event from caregiver
Partners involved:Anthropic Claude (via runAgent)CoverMyMeds (PA submission)Naviguide (SNF referral)ModivCare (NEMT booking)
Demo data · no PHI · mocked Epic + payer endpoints