A public proof surface for care coordination teams that need pathway risk, outreach friction, escalation pressure, and follow-up ownership in one operator-readable command layer.
Every lane keeps the patient story, owner, delay pressure, and next action together so operational review does not dissolve into status chasing.
Post-discharge medication reconciliation with missed specialty follow-up, low contactability, medication confusion, and transport gap.
Next move: Escalate same-day pharmacist review and arrange assisted transport for cardiology follow-up.
Therapy intake handoff is open while paperwork friction and caregiver uncertainty keep the transition exposed.
Next move: Route a navigator-assisted intake completion call with caregiver present.
A1C follow-up is partially aligned, but the lab is pending and the portal message is unread.
Next move: Trigger educator outreach and convert the next touch into a lab-confirmation call.
PT attendance is confirmed and the patient is on plan, so the lane stays monitored without unnecessary escalation.
Next move: Keep portal reminder cadence and verify PT attendance after first session.
Handoff risk is readable as a discrete operational event: source lane, target lane, cause, delay, regulatory pressure, and recommended response.
Transport barrier and missed callback have created a 28-hour delay with readmission exposure.
supervisor escalationIntake packet friction has created a 19-hour care continuity gap that needs a navigator callback.
navigator callbackLab confirmation is missing, creating a 12-hour care quality drift before educator outreach can complete.
lab outreachThe public demo avoids patient-identifying information and uses aliases, synthetic pathway records, and board-readable risk categories.
| Evidence lane | What leadership can see | Why it matters |
|---|---|---|
| Pathway pressure | Risk score, delay hours, contactability, and outcome window. | Shows where care quality is at risk before it becomes a late escalation. |
| Owner lane | RN coordination, navigator, population health, or rehab scheduling. | Prevents handoffs from becoming ownerless status updates. |
| Barrier signals | Transport, medication confusion, paperwork friction, unread portal, lab pending. | Separates solvable operational friction from generic patient-risk language. |
| Recommended response | Supervisor escalation, navigator callback, lab outreach, or monitoring cadence. | Turns review into an intervention packet instead of another report. |
This repo demonstrates the Kinetic Gain pattern for regulated service operations: compress complex signals into explainable, role-owned decisions.
Bring pathway stage, referral state, delay pressure, and contact plan into one record.
Separate clear, watch, high, and escalation lanes with readable thresholds.
Keep the handoff tied to a concrete role instead of a vague department queue.
Show what is exposed, what is recoverable, and where care capacity should move.