Outcomes - Podcast

Host and produce Outcomes, a podcast focused on healthcare executive insights, social impact, and healthcare finance.

Share actionable tips, resources, and insights aimed at improving healthcare delivery and strategic investments in social determinants of health (SDOH).

Available on Spotify and YouTube.

Podcast Host and Producer

Valleywise Health

→  Reduced Emergency Department length of stay (LOS) and improved bed turnover by executing 40+ time-sensitive interventions weekly during night shift, including coordinating complex discharges, behavioral health placements, and social service referrals

→  Achieved estimated $1.2M+ annual cost avoidance by preventing approximately 520 extended ED stays annually through proactive behavioral health assessments and placement coordination

→ Improved clinical quality metrics by managing 150+ behavioral health assessments annually with coordinated placement into appropriate treatment settings, resulting in reduced readmission rates for high-risk patients

→ Enhanced community health outcomes by facilitating 150+ annual substance abuse treatment referrals and domestic violence interventions, with demonstrated successful placement rate

→ Strengthened hospital risk management and compliance through consistent reporting to protective services (APS/CPS) and law enforcement, while maintaining detailed documentation for regulatory requirements

→  Optimized resource utilization by coordinating 250+ annual shelter placements and transportation services, reducing inappropriate ED utilization and improving access to community-based care

→  Led cross-functional collaboration with ED staff, community partners, and healthcare providers to develop streamlined workflows for complex discharge planning and crisis intervention

Emergency Department Social Worker

UT Permian Basin

→  Led foundational courses in healthcare ethics and end-of-life care, developing future practitioners' capabilities in complex decision-making, family-centered care coordination, and crisis management

→ Designed innovative curriculum integrating real-world scenarios from healthcare settings to teach ethical frameworks, risk management, and patient advocacy in high-stakes medical situations

→ Advanced student understanding of healthcare delivery systems through practical examination of interdisciplinary collaboration, resource coordination, and ethical decision-making in complex care environments

→ Created and implemented evidence-based assessment methods measuring students' mastery of ethical frameworks, crisis intervention techniques, and complex stakeholder management

Adjunct Faculty

Abrazo Health

→  Orchestrated complex discharge planning for 500+ cases annually, managing interdisciplinary care teams and community partnerships to optimize length of stay metrics while ensuring quality outcomes

→ Designed comprehensive resource navigation program for new mothers, creating structured pathways to connect patients with community support services, mental health resources, and preventive care

→  Led cross-functional collaboration between Mother-Baby unit and community partners to establish seamless care transitions, reducing gaps in postpartum care delivery

→ Orchestrated complex discharge planning across multiple hospital units, managing interdisciplinary care teams to optimize length of stay while ensuring quality outcomes for diverse patient populations

Social Worker II

Watermark Retirement Communities

→ Spearheaded readmission reduction initiative for 32-bed skilled unit that achieved 15% decrease in 30-day readmissions through implementation of:

- 48-hour post-discharge follow-up protocol
- Risk stratification system identifying high-risk patients 
- Enhanced care transition documentation
- Partnerships with 10+ primary care providers, home health & hospice agencies, DME companies 

→  Managed care coordination for average monthly census of 30 skilled patients, achieving average length of stay of 18 days (below 20-day Medicare benchmark)

→ Led care transitions process across 64-bed facility, coordinating approximately 240 annual admissions and discharges while maintaining 95%+ compliance with documentation requirements

Director Of Social Services

SavaSeniorCare Administrative Services LLC

→  Led operational transformation of specialized memory care unit, implementing evidence-based dementia care protocols that enhanced resident safety while optimizing staffing efficiency and resource utilization

→ Designed and executed comprehensive staff training program focused on person-centered dementia care, achieving 100% staff certification in evidence-based interventions and reducing use of psychotropic medications

→  Developed innovative family education and engagement model, establishing structured support groups and communication protocols that improved family satisfaction and reduced acute care transfers

→ Pioneered quality metrics framework specific to memory care, creating dashboards tracking:

- Behavioral intervention success rates
- Falls reduction
- Family engagement levels
- Staff competency measures
- Emergency department transfer rates

Memory Care Director

Creative Solutions In HealthCare

→  Led care coordination across multiple care settings (SNF, hospice, home health), developing expertise in complex care transitions and multi-provider collaboration that reduced care fragmentation

→  Managed diverse patient populations across care continuum, building deep understanding of:

Post-acute care operations
End-of-life care delivery
Care transition management
Value-based care models
Population health management

→  Orchestrated complex discharge planning for approximately 500+ patients annually across organizations, optimizing care transitions while ensuring quality outcomes and reducing readmission risk
Pioneered standardized assessment protocols that improved care coordination efficiency and resource utilization across multiple care settings

→ Developed expertise in navigating complex payment systems including Medicare, Medicaid, and private insurance, ensuring optimal reimbursement while maintaining high-quality care delivery

Social Services Director Interim

Envision Home Health and Hospice

→  Led complex care coordination across 200+ square mile rural service area, managing caseload of 50+ hospice patients while providing 24/7 crisis intervention support and end-of-life care coordination

→ Pioneered comprehensive financial navigation program, securing Medicaid coverage and additional services for high-need patients, directly improving access to care while optimizing organizational reimbursement

→ Orchestrated complex care transitions between home, skilled nursing facilities, and hospice settings, developing deep expertise in:

Rural healthcare delivery models
Multi-provider collaboration
Crisis intervention
Family-centered care planning
Medicare/Medicaid navigation

→ Spearheaded development of standardized protocols for:

After-hours crisis response
Family support during active dying process
Coordination with facility-based providers
Respite care arrangement
Financial resource navigation

→ Managed intensive care coordination in rural setting requiring:

- 400+ miles weekly travel for direct patient care
- 24/7 on-call crisis response
- Extended bedside support during end-of-life
- Complex family dynamics management
- Multi-facility coordination

Medical Social Worker


→ Helping digital health startups articulate their financial value story
→ Translating social determinants into business opportunities
→ Developing frameworks for measuring social program ROI
→ Creating compelling narratives for value-based care initiatives

My insights reach healthcare leaders and innovators through:

- The Business of Social Work (newsletter focusing on healthcare value creation with 1,000+ subscribers)
- Social Impact Revenue Strategy
- Frameworks for translating social impact into financial terms

Core Expertise:

Financial Storytelling for Healthcare Innovations
Social Impact Value Translation
Safety Net System Insights
Value-Based Care Narratives

I regularly share frameworks for quantifying healthcare's social impact through my newsletter and strategic advisory content. Connect for access to my latest financial modeling insights.


#HealthcareInnovation #ValueBasedCare #DigitalHealth #ImpactNarrative

Walk through a $27,000 discharge through a social worker's POV
Clock starts at 15:30 → $0.00. The discharge order is signed. 

A 90-minute clock starts ticking. On paper, the patient is “ready.” In reality, every KPI including LOS, throughput, readmissions, CAHPS, and Stars is on the line.

15:35 → +$3,000.00 (cumulative: $3,000)

The skilled nursing facility calls back: no bed tonight. One late refusal = ≈$3,000 for an extra inpatient day (KFF, 2023). LOS ticks up, the physician’s throughput stalls, and the unit holds a bed that should already be turning.

15:50 → +$1,856.00 (cumulative: $4,856)

While the bed is held, the ED begins to board new admits. Each boarded patient adds ≈$1,856 per day in incremental cost. The waiting room backs up, nurses scramble to cover hall beds, and metrics for “door-to-admit” start to slip.

16:10 → +$2,000.00 (cumulative: $6,856)

The team considers a discharge home instead. A referral is placed to home health, but capacity is thin. One agency estimates start-of-care pushed out by a week, but unsure. If it's delayed to Day 10, claims data show ≈$2,000 in added 90-day spend and higher odds of a 30-day bounce-back. The resident knows the inbox follow-up burden just multiplied.

16:25 → +$15,000–$27,000 (cumulative: $21,856–$33,856)

The family threatens an appeal. “We’re not ready.” At minimum, coverage extends another day. At worst, the patient boomerangs back—each readmission averaging ≈$16,300 nationally, with high-acuity cases hitting $27,000. The hospital edges closer to HRRP penalty exposure (up to 3% payment reduction).

16:30 → $∞ (ledger reset to $0)

 The social worker steps in and re-maps SNF options, coordinates with the internal transport team, gives the family clear discharge info, and leaves them with a home health brochure to request later if needed. By 4:30, the patient leaves safely, and on time. 

 → Throughput recovers; the nurse reopens a bed.
 → ED flow resumes; the physician admits the next case.


The invisible math doesn’t show up in the chart, but it drives the whole system. 

→ Direct medical costs

→ Quality revenue: Stars/HCAHPS swings worth tens of millions in MA benchmark and rebate dollars (+5% benchmark at ≥4★).

→ Operational leakage

Care is measured in dollars, but value is created in seconds.

Social workers compress both.

Christina Y. Rodriguez

Social Care ROI Strategist | Founder, The Fundable 15

$15,000–$27,000. That’s the average cost of a single hospital readmission.
Every failed discharge, whether it’s a missed ride, a delayed home health visit, or a family appeal can trigger that loss.

And the only role inside the hospital that synchronizes all of those moving pieces:

Social work.

Only there’s no “buy button” for social work. No billing code for a social worker outside of behavioral health. 

Budgets code it as overhead. Strategy decks leave it out entirely.

Yet every day, social workers are the hidden margin defense:

Preventing a $15K readmission

Avoiding a $3K extra inpatient day

Cutting ED boarding costs up to $1.9K per day

Protecting Stars and HCAHPS revenue signals

That’s not courtesy. Not customer service. It's not even charity. 

That’s financial infrastructure.

In healthcare, you don’t exist unless you’re reimbursed.

It’s time to change that definition.

I'm breaking down the business case for medical social work this week. 

Because the truth is simple:

Without social work, the order-to-door clock bleeds money.

Years ago as a social worker I got a call on the baby floor. 
Computer was funky and I didn’t want to call IT right then. 

So in a minute or two I scribbled everything I needed, in the right order, to keep care moving.

Now I look back and laugh:

If I slapped a login screen on it today, someone would call it SaaS and raise $5M.

The best “products” don’t start in code. 

They start in the minds of people on the floor who see the gaps every single day.

Frontline workers are natural system designers.

We build frameworks under pressure, not because it’s sexy, but because someone’s care depends on it.

And when you take those lived frameworks and pair them with rigor, ROI logic, and strategy they stop being “notes” and start being contract-level impact.

And this week The Fundable 15 spotlighted maternal health vendors that do exactly that: take frontline wisdom and translate it into Stars lift on postpartum care timeliness and CAHPS,  the very measures that move billions.

1,000 social workers X  1 Question=  One undeniable trend
I just learned that my name came up at a national conference I didn't even attend. 

Nearly a thousand social workers were asked:

“Who do you think of as a social media influencer in social work or mental health?”

The answers filled a word cloud: NASW. Brené Brown. Dope Black Social Worker. 

And yes — my name was there too. But this isn’t about me.

It’s about what it means that social workers are finally being named as influencers of systems and not just support staff within them.

Because here’s the reality:

$3,000. The average cost of an avoidable ER visit.

37%. The percentage of social workers who say they only use social media personally, not professionally.

0.000.  That’s how much ROI is realized when our stories stay hidden.

The fact that a thousand social workers wrote down names from within our own ranks means the shift has started:

We’re building a presence strong enough that our value is spoken in rooms we haven’t entered yet.

💰 $55M. That’s the Series C raise one featured org announced the same week I published the first Fundable 15: Maternal Health Edition.

In just 10 days, this single edition has done what it was built to:

- Reached nearly 200 stakeholders with ~97% delivery and ~290 views

- Engagement spanning health systems, health plans, policy leaders, and maternal health innovators

- Readership from both the supply side and the demand side 

And alongside Diana Health's raise, other moves validated the fundability logic I surfaced: 

- Quilted Health advanced its MultiCare system integration

- Wildflower Health rolled out network and product expansions

This is exactly why I started this index from the ER breakroom on the night shift. 

Because markets are abstract. Outcomes are personal.

Read it here: https://lnkd.in/geT8eCgD

🚨 $27,000 on the line per patient.
I spoke at a virtual congressional briefing on H.R. 4185, 

This is legislation that would finally let clinical social workers bill Medicare for the full scope of hospital and clinic work we already do.


In a “virtual room” of 60+ staffers, providers, and advocates, the focus wasn’t therapy. It was the invisible labor that determines whether a patient makes it home or bounces back into the ER.

I remembered the ER nights where a 90-minute clock started ticking after discharge. 

In that window, the difference between a safe handoff and a $27K readmission was whether a social worker could secure meds, oxygen, food, transport, and caregiver readiness.

Under Medicare, social workers can only bill therapy codes. Everything else like  discharge planning, crisis stabilization, care coordination,  is treated as overhead.

That misalignment drains margins, burns out clinicians, and costs taxpayers billions.

The smarter way forward:

Pay the right professional for the right work. Align billing with what state law already authorizes.

Protect margins. Every avoided readmission = $15K–$27K saved. Every shortened bed-day = capacity preserved.

Free up physicians + nurses. One hour of MD time redirected to treatment is hundreds of dollars reclaimed.

The systems that survive rate cuts will be the ones that integrate medical + social care, measure ROI, and defend margins with math.

Social work IS  the infrastructure everyone needs. 

Or watch the compilation of my full responses during the Congressional briefing (5 mins) here: https://lnkd.in/g_j2N3Y6

You can’t put a price on the value social work brings.
But the cost of mismanaging it= $320B in avoidable spend every year for the healthcare industry

While building a social care market index, I’ve watched incredible organizations fail for the same reasons over and over.

So if you’ve got piles of money to burn and ops teams you want swamped and crispy, keep doing these 5 things:

1️⃣ Thinking good ideas prove themselves.
 
Reality: 8 in 10 pilots stall because they never tie to procurement math.

2️⃣ Assuming policy = progress.
 
Reality: Waiver language looks great, but dollars only move when workforce density is real.

3️⃣ Using the same playbook everywhere.

Reality: Some states align procurement + Stars. Others have limited traction, no matter how strong the model.

4️⃣ Believing a big MCO keeps you safe.

Reality: Even the largest plans carry compliance scars. Size without Stars cushion = risk.

5️⃣ Treating equity like charity.

Reality: Distressed plan crises prove ignoring social care isn’t neutral, in fact it’s financial malpractice.

Because social care is one of your strongest margin defenses.

As actuarial as risk adjustment.

As decisive as utilization management.

And that’s the lens The Fundable 15 gives you: a way to cut through myths and see which models are worth banking on now.

If you're tired of admiring the problems with SDOH and actually find who can help translate your social care needs into PMPM savings, Stars protection, and boardroom-ready ROI check it out here: https://lnkd.in/g5qswRRt

I saw this display. These dishes look different. But it’s just paint.
That’s exactly how equity turned into Stars, PMPM, and margin defense.

In the 70s, people called it equity, prevention, community health.

Then in the 80s,  the 1974 Health Planning Act was repealed. 

At the same time, managed care and capitation took off. 

Suddenly, insurers and provider organizations were responsible for the financial risk. 

The language shifted. What used to be equity became margin defense, Stars ratings, and network adequacy.

But the truth never changed: keep people well, build strong communities, protect resources.

If you feel like you’re speaking two languages at once....

The ideas didn’t change.

The container did.

If you’re leading a plan, system, or startup and feel caught between equity and margin defense, I build the translation maps that turn old wisdom into today’s ROI logic so you can win in both languages. I only take a handful of these per month so now's the time to reach out to lock in your Q4. 

P.S. I still might go back for those neon green bowls 💚

When I quit my job as an ER social worker, talks about HR1 were already in the headlines.
Everyone in healthcare could feel the ground shifting: Medicaid was being cut. Margins were evaporating.

I felt it too — but from a different angle.

At 2 a.m. in the ER, I saw how “unfunded” social risks were already reshaping outcomes and quietly destabilizing budgets.

Missed meds. Unsafe discharges. Preventable readmissions.

What looked like care gaps on the surface were really missed opportunities to lead with compassion and fiscal responsibility.

So I left. And I built The Fundable 15.

The first market index of SDOH-aligned models. A system to show, with rigor, which programs are contract-ready and which will define the next era of care.

HR1 didn’t just cut Medicaid.

It forced the market to transition from narratives to numbers.

The leaders who thrive in this moment aren’t the ones with the loudest stories.

They’re the ones who pair empathy with math.

Who can see the signal before it hits the contract.

Because even in transition, signal never stops. 

Neither does the need for leaders who can hold both compassion and clarity.

If you’re leading through this transition:

- Anchor every social care investment to Stars or procurement math.

- Demand ROI proof, not just anecdotes.

And join me on The Fundable 15, to anticipate where the market is moving,  not after it’s already moved.

Subscribe here: https://lnkd.in/gcDRyJ29

A $4,800 per CHF admission is lost when social risks sit in PDFs. 
Datavant’s AI roll-up converts those notes into billable, risk-adjustable data.

I saw this often as an emergency room social worker at 2AM. 

Picture a 72-year-old man rolls in, short of breath.

The triage nurse asks about meds. He shrugs because he can’t remember.

Daughter thinks he’s been skipping his diuretics.

Primary’s chart is buried in scanned PDFs.

The hospitalist orders a broad panel “just to be safe,” knowing half this workup is probably redundant.

Later, social work documents that he lives alone, on food stamps, hasn’t filled prescriptions for weeks. Solid narrative… but in the billing record it becomes a free-text note. 

No ICD-10-Z code.

From the payer’s view he’s just another random CHF admission. No social risk. No context. Costs climb, interventions don’t connect, margins erode.

Now imagine the same 2 AM patient post-acquisition trajectory:

AI-generated chart summary sits on top.

Active problem list: CHF, CKD3, depression.

Med adherence flagged as a risk two weeks ago.

SDOH coded: food insecurity (Z59.4), transportation barrier (Z59.82).

That data flows into both the ER workflow and the payer’s risk file.

Hospitalist doesn’t just order labs but trigger a CHW referral, food box set for discharge.

 Payer doesn’t just see “CHF.” They see CHF + social risks.

Which means:

 ✅ Higher risk-adjustment revenue (aligned to true acuity).

 ✅ Documented SDOH intervention → Stars defense.

 ✅ Fewer readmits → cost offset.

This is why the Datavant × DigitalOwl move matters this week.

I surfaced $7.8B in contract-ready social care dollars that health plans and investors can act on. 
Here’s exactly how:

1. I audited every signal against public filings instead of recycling headlines.

2. I translated interventions into conservative PMPM math executives already use.

3. I tied each dollar directly to Stars bonuses, Medicaid retention, or quality withholds.

4. I cut through noise so you only see numbers that matter for contracts.

5. I used a format you can skim quickly, not a 60-page report.

6. I focused on procurement windows and dollars at risk and not just anecdotes.

7. I showed how signals evolve each quarter so they don’t go stale.

8. I proved accuracy in real time, something the big firms don’t publish.

When complexity rises, the clear voice wins.

Don’t tell people something matters, show them the exact unit of value it creates or protects, in the terms they already use to make decisions.

$25,000,000 = How much one state’s Stars bonus shifted in a single year,  tied almost entirely to ... postpartum care timeliness and CAHPS scores.

Not NICU days.
Not C-section rates.
Not the outcomes everyone loves to market.

Stars.

Maternal health models that can prove they lift PPC and patient experience protect margins. 

That’s why programs like certain ones are sticky. 

They deliver outcomes and map directly to double-weighted Stars measures.

Because when you strip away headlines and promises, the truth is simple:

Policy is progress.

Outcomes are proof.

Stars are survival.

If you’re a payer, innovator, or investor, this is the lever to pull. 

Align with Stars, and you don’t just win contracts you scale the care every mother deserves.

[P.S: Check out this week's edition of Fundable 15 to see exactly which maternal health models are contract-ready now : https://lnkd.in/g3Tf8EBt ]

Subscribing to Fundable 15 is like buying a Bloomberg Terminal… for the cost of Netflix.

Bloomberg: $24K/year.

McKinsey: $250K/project.

Fundable 15: $600/year.

And what do you get:

5-minute memos on social care models with ROI signals no one else spots.

Case-ready data that protects margins.

Confidence in the boardroom tomorrow morning.

That’s why it’s the easiest buy in healthcare strategy.

Check it out here: https://lnkd.in/g5qswRRt

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