Worklists / Patient Profile
Margaret Chen
74F · MBI: ••••1847 · Primary: CHF, NYHA Class III
READMIT RISK
94%
HCC SCORE
3.42
PMPM
$8,420
ATTRIBUTED PCP
Dr. R. Navarro
Clinical Timeline — Last 90 Days
Mar 28, 2026
Admission
CHF acute decompensated — Northeast General. LOS: 4 days.
Mar 12, 2026
Admission
CHF exacerbation — Northeast General. LOS: 5 days.
Feb 18, 2026
Admission
CHF acute on chronic systolic — Northeast General. LOS: 4 days.
Feb 2, 2026
ED Visit
Shortness of breath — Northeast General.
Jan 14, 2026
Office Visit
CHF follow-up — Cardiology Associates.
Omni WritebackHEDIS Care Gaps (3 Open)
HbA1c Testing
Overdue by 43 days
Diabetic Eye Exam
Due in 18 days
Nephrology Referral
Due in 17 days
Cortex NarrativeMargaret Chen is a 74-year-old female with NYHA Class III heart failure, Stage 3 CKD, and poorly controlled diabetes. She has been admitted three times in 90 days to Northeast General Hospital for acute decompensated CHF, each with 4+ day length of stay. Her PMPM of $8,420 is 2.8× the Northeast CHF cohort average of $3,020. Three HEDIS care gaps remain open. Cortex ML assigns a 94% probability of 30-day readmission under current care patterns.
Generated by Snowflake Cortex AI_AGG from Tuva encounters, medications, and quality_measures marts.
Omni WritebackDeploy Care Pathway
Pathway Template
Interventions
Projected Impact
-36% readmission probability · -$3,200 PMPM reduction
