Click any segment card or patient row for risk drivers and next best actions.
Care management enrollment
+9.2pp58.4%
Target: 75% of cohort78% to goal
Reached in last 90 days
+4.1pp71.6%
Target: 85%84% to goal
Avoidable cost in cohort
-$1.1M YoY$8.4M
Modeled from segment benchmarks
Patient finder segments
Click a segment to see who is in it and why
Identified vs engaged
High-risk members reached over time
Engagement is closing on identification, but the gap is still 542 members.
Patient worklist
10 members · sorted by risk score
| Patient | Segment | Risk | Open opps. | Last visit | Engagement | Annual cost | Action |
|---|---|---|---|---|---|---|---|
Leo Martinez 82y · Dr. Patel · Stroke, vascular dementia | Repeat utilizers | 4 | 2 months | Engaged | $74.1k | ||
Robert Wilson 63y · Dr. Thompson · CHF, CKD 3, T2DM | Repeat utilizers | 4 | 18 days | Engaged | $62.4k | ||
Harold Pike 80y · Dr. Novak · CHF, CKD 4, anemia | Polychronic, unengaged | 5 | 10 months | Unreachable | $66.8k | ||
James Anderson 75y · Dr. Brown · CKD 4, HTN, AFib | Polychronic, unengaged | 5 | 11 months | Unreachable | $58.2k | ||
Alice Nguyen 78y · Dr. Brown · COPD, osteoporosis | Rising risk | 3 | 4 months | Outreach in progress | $41.8k | ||
Priya Raman 68y · Dr. Thompson · T2DM, HTN, transport barrier | Social risk flagged | 3 | 6 months | Outreach in progress | $33.4k | ||
Elena Vargas 66y · Dr. Patel · T2DM w/ neuropathy, CAD | Multiple open opportunities | 7 | 8 months | Outreach in progress | $37.2k | ||
Denise Carter 71y · Dr. Kim · T2DM, obesity, depression | Multiple open opportunities | 6 | 7 months | Outreach in progress | $28.9k | ||
Marcus Bell 55y · Dr. Kim · COPD, tobacco use | Rising risk | 2 | 5 months | Declined | $21.6k | ||
Grace Oduya 59y · Dr. Osei · HTN, hyperlipidemia | Stable, managed | 0 | 1 month | Engaged | $9.2k |