The Power of Follow-Up: Ep. 7 of the ‘No Wrong Door’ Podcast
No Wrong Door is a podcast from Findhelp that explores how social care delivery is evolving to better support whole person care. Hosted by Findhelp VP of Marketing Amy Gordona, the series features conversations with social care experts, healthcare and government innovators, and Findhelp leaders who are shaping the future of access, coordination, and connected care.
Each episode offers an inside look at the systems, decisions, and ideas driving change—and what it takes to build a social safety net that works at scale.
Emergency departments are built for urgent care. But for many patients, an ED visit is just the visible tip of something deeper—unmet social needs, fragmented systems, and gaps in ongoing support.
In this episode of No Wrong Door, Vidya Lakshminarayanan, COO of Connxus (a health information exchange in Central Texas), shares how her team is transforming that moment after an ED visit into an opportunity: combining real-time data, community health workers, and coordinated referrals to connect patients to the care they actually need.
In this episode, we explore:
Emergency department utilization often reflects unmet social and systemic needs—not just acute medical issues
Health information exchanges (HIEs) can unify fragmented patient data into a single, actionable story
Community health workers play a critical role in building trust and ensuring referrals turn into real outcomes
Watch episode 7: “The Power of Follow-Up”
Key themes from the conversation
Emergency visits as signals, not endpoints
For many patients, an ED visit isn’t the beginning or the end of care—it’s a flare sent up from a system under strain.
Connxus treats these visits as indicators of deeper gaps, from lack of primary care access to unmet basic needs.
By identifying high utilizers and intervening after discharge, the team shifts from reactive care to proactive support.
“It’s not just about what’s happening in a person’s life on a day-to-day basis… it’s about how different things come together to shape a person’s life.”
Vidya Lakshminarayanan
COO at Connxus
Turning data into a patient story
Patients are often expected to retell their story over and over across providers. Connxus uses HIE data to eliminate that burden—aggregating clinical and social data into a unified, longitudinal view.
This isn’t just about efficiency. It’s about clarity and better care decisions at every touchpoint.
“We become your storytellers. You don’t have to remember the story… we link your data and deliver it to providers at the time of care.”
Vidya Lakshminarayanan
COO at Connxus
Community health workers: Closing the loop through human connection
Data can identify needs—but it can’t build trust. That’s where community health workers (CHWs) come in.
Connxus pairs its data infrastructure with a CHW program that reaches out to patients after ED visits, screens for social needs, and follows up over a six-month period.
This sustained engagement turns referrals into real outcomes.
“It’s not just a referral anymore. It becomes more impactful when you can show the outcome.”
Vidya Lakshminarayanan
COO at Connxus
Measuring what matters: Outcomes, not outputs
Connxus tracks success beyond outreach—focusing on engagement, navigation, and whether patients actually receive help.
The results are promising: most patients reduce preventable ED visits after participating in the program, demonstrating the real impact of coordinated social care interventions.
“Clearly there is a relationship between the social interventions that we are providing and the health care outcomes that we are seeing.”
Vidya Lakshminarayanan
COO at Connxus
The persistent fragmentation of social care
Even as innovation accelerates across healthcare, social care remains deeply fragmented—often disconnected from the clinical systems patients rely on most.
That gap isn’t just operational; it shapes outcomes, access, and patient experience.
No Wrong Door host Amy Gordona underscores a tension many in the field recognize: we’ve made progress, but not nearly enough. Bridging that divide isn’t just a technical challenge—it’s a systemic one.
“I’m always amazed that in 2026, this particular area of care… is still so fragmented from the rest of the services we all receive.”
Amy Gordona
VP of Marketing at Findhelp and host of ‘No Wrong Door’
This fragmentation is exactly what models like Connxus aim to solve—by aligning data, people, and partnerships into something that feels less like a maze and more like a pathway.
Learn more about Connxus’ work
Several of Vidya’s colleagues from Connxus will be presenting at the upcoming Connect Summit on May 13-14, discussing vital role of Community Health Workers in shifting patients from emergency care to sustainable primary and community-based support.
- Build Trusting Relationships: Learn how telephonic outreach and Findhelp program cards empower frontliners to engage vulnerable populations effectively.
- Close the Care Loop: Identify practical workflows for tracking patient follow-ups and graduation to ensure long-term transitions from the ED to community resources.
What’s next for No Wrong Door?
“The Power of Follow-Up” is available now—Episode 8 will be released on May 11 and features MiResource co-founder Mackenzie Drazan talking about how better data and smarter infrastructure can revolutionize behavioral health referrals.
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