Page 10 – Bamboo Health

The Importance of ED Visit Follow-Ups for Patients with Multiple Chronic Conditions testing

Posted on June 2, 2022March 18, 2025 by Grace Keeling

Many adults living with more than one chronic condition experience gaps in their care as they receive treatment across multiple providers, including ED (emergency department) clinicians, primary care physicians, and other specialists.

According to the U.S. Department of Health and Human Services (HHS), 1 in 4 adults has multiple chronic conditions. Additionally, about 3 in 4 adults 65 and over have more than one chronic condition.

Medicare Beneficiaries with Multiple Chronic Conditions


Number of Chronic Conditions	Percentage of Beneficiaries
2-3	30.1%
4-5	20.9%
6 or more	14.5%

Note. Data from Centers for Medicare & Medicaid Services (CMS). 2014. “Multiple Chronic Conditions.” Retrieved June 1, 2022, from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Chronic-Conditions/MCC_Main.html

Many hospitals and ED providers fail to send medical records to outpatient providers after discharge. This gap in care coordination after an ED visit can result in adverse outcomes in patients with multiple chronic conditions.

According to the National Committee for Quality Assurance (NCQA), Medicare beneficiaries are at a higher risk after an ED visit due to overall body function, multiple medication use, and audio and/or visual impairments. In turn, this can increase the likelihood of readmission and death. A study from the Annals of Emergency Medicine found older adults showed an average mortality rate of 10% and ED readmission rate of 24% after an ED discharge.

NCQA also found many adults with multiple chronic conditions do not have a follow-up service from their healthcare providers within 7 days of an ED discharge. In 2020, about 57.2% of Medicare HMO beneficiaries and 59.6% of Medicare PPO beneficiaries had a follow-up after an ED visit.

To prevent readmission and other health complications after discharge, proper communication and coordination between providers is crucial. Bamboo Health’s Pings solution notifies a patient’s primary care physician of a care event, such as an ED visit, in real time. From there, physicians can communicate with their patient in a timely manner to schedule necessary follow-up visits to possibly prevent hospital readmission and other complications.

Pings patient notifications can help ED providers, primary care physicians, and chronic condition specialists stay informed about their patients’ health and in turn, improve overall patient outcomes. By connecting the entire care team, providers can better support whole person care for their patients managing multiple chronic conditions.

To learn more about Pings and how it can help your organization, click here.

Leveraging Care Coordination for Success Under the CMS Kidney Care Choices Model

Posted on June 2, 2022June 9, 2023 by Grace Keeling

Kidney Care Shifts Towards Value Based-Care

The face of kidney care in the United States is experiencing a seismic shift, rapidly moving away from a traditional fee-for-service model and toward a value based-care model centered around patient outcomes. While this sentiment is true for most other subsets of healthcare, it’s particularly pronounced in kidney care due to many significant efforts Centers for Medicare and Medicaid Services (CMS) has made in recent years to improve quality of care for Medicare beneficiaries with Chronic Kidney Disease (CKD) and End-stage Renal Disease (ESRD).

These efforts include the ESRD Treatment Choices (ETC) Model, as well as the value-based care Kidney Care Choices (KCC) model, which offers four payment options including the CMS Kidney Care First (KCF) Option, Comprehensive Kidney Care Contracting (CKCC) Graduated Option, CKCC Professional Option, and CKCC Global Option. Building upon the existing Comprehensive End Stage Renal Disease Care Model structure, KCC adds strong financial incentives for providers. In turn, KCC is encouraging nephrologists to increase their care coordination efforts in pursuit of later and more effective starts on dialysis, and an increased number of successful kidney transplants.

To achieve success under the KCC program, providers caring for CKD and ESRD patients should focus on:

Reducing Acute Hospitalization Utilization and the Total Cost of Care: This can be done by preventing avoidable readmissions and preventing unnecessary emergency department (ED) utilization. In the KCC program, doing so will result in greater savings versus the benchmark.
Ensuring Top Performance in Quality Measures: To maximize performance adjustments and earn back quality withholds, it’s important that participants in the KCC models provide high-quality care by engaging beneficiaries over time. For example, the time after an acute event when a patient may be seeking care or open to behavior changes, offers a meaningful opportunity to make strides in closing gaps.
Minimizing Leakage Rates: KCC participants can minimize outmigration (or “leakage”) rates through the identification of beneficiary utilization outside of their practice and engagement of the patient with appropriate care in their practice. To achieve high beneficiary retention rates, KCC participants should engage beneficiaries at key touch points during their care journey.

Actionable Insights Begin with Real-time ADT Data

Accomplishing these expanding measures of care starts with having the proper tools, resources, and data to identify in real time when beneficiaries are discharged from the hospital or admitted to a post-acute facility. From there, KCC program participants can reach out to the patient or facility to ensure the appropriate post-discharge care is delivered, educate the patient on resources and appropriate ED utilization, or work with the admitting facility to ensure the appropriate length of stay (LOS).

At Bamboo Health, our extensive infrastructure and network support the exchange of applications, information, and actionable insights in more than one billion patient encounters per year nationwide to provide kidney care providers with the ability to thrive under the KCC program. We enable provider success in KCC and other value-based kidney care models by optimizing encounter efficiency, reducing avoidable utilization, and ensuring patients are receiving critical care when they need it.

Our Pings solution for real-time admission, discharge, and transfer (ADT) data provides visibility into patient care events that can be used to help drive targeted interventions, facilitate reduction in acute hospital utilization and total per capita cost, as well as support quality performance improvement and beneficiary retention. These real-time insights into patients’ care journeys also allow providers and clinicians to collaborate on shared patient cases for the delivery of comprehensive value-based care in alignment with the KCC program model.

Contact Bamboo Health for More Information

For additional information, download Bamboo Health’s Pings for Kidney Care Overview or read about our partnership with Strive Health, the national leader in value-based kidney care, to optimize care coordination for improved kidney disease patient outcomes throughout Illinois, North Carolina, New Jersey, and Michigan.

Behavioral Health Care Coordination in Action

Posted on May 31, 2022 by Grace Keeling

The following blog post is an excerpt from Bamboo Health’s 2021 Annual Impact Report.

Amber, 32-years-old, has been in recovery from opioid use disorder for three years. She was able to quit heroin with the support of individual and group therapy in combination with buprenorphine. Last year, she started working full time again. When Amber’s father suddenly passes away; however, her grief is overwhelming. She turns back to heroin to cope, but with the increasing fentanyl in the supply, Amber overdoses. A bystander calls 911 and responding medics revive her. At the ED, the providers treat her acute needs, provide information about drug treatment facilities, and discharge her. A week later, following her father’s funeral, Amber uses again, this time alone, with no one to call for help when she overdoses. Her behavioral health treatment center finds out about the first overdose more than a month later through insurance claim data, but it’s too late.

While Amber is not a real person, unfortunately, scenarios like hers happen every day, fueling unprecedented fatal drug overdoses in the U.S. Complex problems like this require innovation from various angles, but in collaboration, not in silos.

Bamboo Health delivers products that support real-time care collaboration, promoting better outcomes for patients and making progress against the mental health and substance use crisis that has cut too many lives short and left family and friends grieving.

Our Behavioral Health Care Coordination (BHCC) solution facilitates provider-to-provider communication and coordination. Embedded in the clinical workflow at the point of care, the platform displays real-time data often disconnected from current EHRs, with decision support and patient analytics.

Here is how Amber’s situation could have been different through our BHCC solution. This time when she overdoses, her ED providers check the PDMP, integrated into their EHR, and see that she has been on a steady dose of buprenorphine. The BHCC platform also gives her treating providers visibility of her care team at the behavioral healthcare treatment center. At the same time, the treatment center receives a Ping, alerting them that Amber has been admitted to the ED. The treatment center connects with the ED providers to guide her care while admitted and talks to Amber once she is stabilized. The treatment center and ED providers discuss Amber’s transfer to outpatient treatment, which can be facilitated by the OpenBeds solution to find near real-time availability of beds. They determine that an appointment the next day is the best course of action. She’s discharged with her buprenorphine prescription continuing and an appointment set for the next morning. Her treatment center connects her with a peer counselor to help her navigate the next week until the funeral and continue regular appointments until the mental health crisis eases in the coming months.

The BHCC solution enables communication and collaboration missing from the first scenario to give Amber a better chance of success on her path to recovery.

To read our full 2021 Annual Impact Report, click here.

Connecting Payers and Providers to Enhance the Delivery of Care

Posted on May 24, 2022June 9, 2023 by Grace Keeling

Payers and Provider Care Collaboration Drives Improved Outcomes

Today, payers, including private and public health insurance companies, government-run Medicare and Medicaid, and a variety of managed care plans, are finding ways to expand their role in healthcare. In addition to their traditional functions such as collecting their members’ premium payments, negotiating rates for services, and paying a percentage of provider claims, they are beginning to influence actual care delivery.

When you think about it—even patients who, at times, may have seen payers as barriers to care—it makes some sense. Payers often have the clearest visibility of longitudinal medical records, particularly for individuals who have been members of the same plans for years. This is because, for almost every care event, a claim is filed, and payers accumulate detailed member histories. Oftentimes, payers are more apprised of an individual’s health, lifestyle, and utilization patterns than primary care physicians and other care team members.

Their motivation for this shift is clear. Payers desire better health outcomes, which can lower their costs. When outcomes are improved and costs reduced, their members are healthier, increasingly satisfied, and more likely to be retained. Quite simply, their business depends largely on the administration of care, so why wouldn’t they be more involved, even if their involvement triggers skepticism in some minds?

Healthcare providers have a similar motivation. They also seek better outcomes and related benefits, including the positive impact on their reputation, greater patient satisfaction, the opportunity to execute more effective capitation contracts and valued-based contracts, and even financial incentives. Certain groups, like accountable care organizations participating in the CMS’s Medicare Advantage Plans, can be financially rewarded for their quality of care.

How Is Collaboration Improving Outcomes?

So how exactly are payers and providers coming together to administer care and improve outcomes? And where is this happening?

In a McKinsey & Company article titled “Innovation and value: What payer-led managed-care models may look like,” Emily Clark, Jennifer Rots, and Anna Stolyarova wrote the following:

“Payer-led activity in care delivery has continued over the past five years. M&A [mergers and acquisitions], strategic partnerships, and affiliations between payers, providers, and technology companies have continued as payers seek to expand their role in reimaging care models. As our prior research indicated, these models reorient traditional operations focused on financing healthcare around an integrated model that prioritizes health, efficiency, and customer experience.

In these models, payers take a substantially more active role in the health and healthcare of their members through one of three approaches: provider enablement via a management-services organization (MSO) or other services organization, a platform-based ecosystem convener, or direct ownership of care-delivery assets.”

How Bamboo Health Can Help

There is one key phrase in that explanation that stands out to us here at Bamboo Health: “… payers take a substantially more active role in the health and healthcare of their members…” It stands out because our company aims to improve whole person care for patients across the care continuum. If doing that means better connecting payers and providers—and fostering engagement between them—we’re all in. We’re working to accomplish this via our first-of-its-kind Behavioral Health Care Coordination solution.

Think of our solution as a vast network of payers and providers across the nation, working together in one platform that provides a holistic view of people’s health. Through this platform, they can do the following:

Communicate about members/patients.
Access near real-time patient data and analytics—including prescription drug monitoring data—directly in clinical workflows.
Be notified when patients experience care events.
Refer patients to behavioral health facilities.
Assess the efficiencies and outcomes of their care plans.

It is an ecosystem that helps both parties redefine how they work in concert to administer value-based care.

“In our eyes, payers have the opportunity to help providers better support their patients. Where this collaboration has occurred, quality of care and patient satisfaction has improved. Our role is to empower collaboration with the alerts, data, and insights providers need to offer their patients the personalized care they deserve,” said Christopher Skowronek, VP, Corporate Strategy and Partnerships at Bamboo Health.

Bamboo Health is committed to remaining at the forefront of payer-provider collaboration. Our Behavioral Health Care Coordination solution changes the dynamic for both parties—and patients. To learn more about it and what it can do for your state or organization, click here.

Shining a Light on Mental Health Awareness Month

Posted on May 20, 2022October 4, 2023 by Grace Keeling

During the month of May, we recognize Mental Health Awareness Month. Since 1949, this awareness initiative aims to provide support for individuals with mental illness and to educate the public on the importance of behavioral health.

According to the National Institute of Mental Health (NIMH), nearly 1 in 5 adults in the U.S. are living with mental illness. About half of the estimated 52.9 million individuals living with mental health conditions also suffer from substance use disorders of drugs and alcohol. This epidemic hit an all-time high last year as the number of drug overdose-related deaths was over 107,622, according to the Centers for Disease Control and Prevention (CDC).

Unfortunately, many people may feel uncomfortable seeking help due to the stigma surrounding behavioral health issues. By coming together to destigmatize mental illness and showing support for those living with behavioral health issues, we can help millions of people get the treatment they deserve.

Helping Those With Mental Health Disorders

Some initiatives aiming to ease the behavioral health crisis include increased research for substance use prevention, better access to treatment, and improved crisis care. The National Institute on Drug Abuse (NIDA) supports research to find ways to prevent substance use. As awareness for mental health increases, the availability of treatment options expands. And the new National Suicide Prevention Lifeline phone number, 988, will roll out in July 2022 to connect individuals in emergency situations with life-saving mental health care.

These are only a handful of large initiatives to make mental health treatment more accessible. We, as providers and individuals, can make a great impact on this movement by helping our own loved ones get the behavioral health treatment they need.

Show Your Support

Some ways we can support and advocate for patients and even our loved ones struggling with their mental health include:

Express your concern in a gentle manner. Talking about mental health can be emotional. Being gentle can keep an individual comfortable during a sensitive conversation.
Be a good listener. Ask the individual questions and listen carefully when they tell their story.
Tell them there are people who care about them. Letting the individual know their loved ones care about them and their healing can go a long way.
Explain that you can get them help. Many people may feel uncomfortable in taking the first step to find treatment. Offering up resources to find treatment can be life-changing during this process.
Be aware of triggers. Individuals with behavioral health issues such as substance use disorders or anxiety may have certain triggers that impact their actions and emotions deeply. Being mindful of these triggers can support them during treatment.
Watch for behavioral changes. If an individual is exhibiting signs of anxiety, depression, anger, lethargy, or social isolation, check up on them to see if they need help.
Check in on them during recovery. Behavioral health treatment can take time, so it’s important to let the individual know they have your support throughout the entire journey.

You can also participate in Mental Health Awareness Month activities with the online community. Rallying together to tell our own stories and advocate for change can make a huge impact on society.

You can share your support for Mental Health Awareness Month by:

Sharing your support online with #Together4MH
Volunteering for advocacy events in your community
Attending virtual webinars through the National Alliance on Mental Health (NAMI)
Advocating for mental health policy change with #Vote4MentalHealth

Mental Health Awareness Month is a time for us to reflect on the behavioral health crisis. By working together, we can do our part in improving access to treatment and destigmatizing mental illness.

Executive Statement from Rob Cohen

Posted on May 19, 2022October 31, 2022 by Grace Keeling

Executive Statement from Rob Cohen, CEO of Bamboo Health

Recent news has highlighted the critical flaws in getting patients the urgent and necessary behavioral health help they need. In far too many instances across our nation, patients who need behavioral health treatment are discharged from an emergency department and left to rely on inadequate treatment directories to locate providers for follow-up care and guidance. For patients, this can be an inefficient manual process plagued by disconnected phone numbers, relocated or retired providers, or facilities unable to accept new patients. This leaves those – who are already facing critical situations – to feel hopeless and fall through the cracks.

This is all occurring at a time when we’ve reached yet another startling record in our nation’s growing opioid crisis, with an estimated 107,000 Americans dying of drug overdoses in 2021, according to provisional estimates just released by the Centers for Disease Control and Prevention.

We can and must do better. Bamboo Health is working to ensure that patients get access to the care they need when they need it most, by bridging gaps in behavioral healthcare and substance use disorder (SUD) treatment referral resources. We have partnered with more than a dozen states and counting to solve this problem, giving providers a way to easily and immediately refer individuals to treatment and coordinate care for the receiving facilities.

This is done through OpenBeds, our provider-facing behavioral health solution for health systems, health plans, state governments, behavioral health facilities, community organizations, and others. OpenBeds was developed to address the inefficient manual processes used to locate and refer patients to the appropriate level of care. The platform tracks bed and appointment availability and ensures quick patient referrals to the right behavioral health facilities through an up-to-date network maintained in partnership with our team and the states in which OpenBeds currently operates. With OpenBeds, providers in primary care, social work, the emergency department, and other stakeholders in the crisis management process can know exactly where treatment openings are available throughout the state and the type of treatment available, facilitated by a closed-loop referral system – helping to close care gaps and better support crisis management for patients and providers.

While we continue to help solve our country’s behavioral health epidemic, one milestone we are particularly proud of is our work with Delaware’s Department of Health and Social Services’ Division of Substance Use and Mental Health. Through our work together, the state surpassed 100,000 referrals in December 2021 through its Delaware Treatment and Referral Network (DTRN), a system for Delawareans seeking substance use and mental health services. Delaware achieved this milestone with its referral system built on the OpenBeds platform, which launched in October 2018. The DTRN system identifies and tracks behavioral health and social determinants of health resources throughout the state, giving providers immediate visibility into resource availability across a shared network. This makes it easier to get people the help they need when they need it.

For individuals in need of immediate behavioral health services, our Treatment Connection solution, through OpenBeds, is also available to the community at large. It is an evidence-based assessment and referral site, which enables those seeking mental health and SUD treatment, or their loved ones, to find nearby, state-vetted treatment providers, evaluate the type of care they need, and submit anonymous or non-anonymous referral inquiries to providers. Unique to Treatment Connection is our ‘Learn About Treatment’ option. At-risk individuals can select the ‘Educational Material’ button to access substance use treatment resources or select ‘What Level of Treatment Do I Need’ to take a self-assessment, developed in partnership with the American Society of Addiction Medicine, to determine the appropriate type of treatment for themselves or a loved one. The Treatment Connection blog has additional articles and resources to learn more about mental health and substance use awareness, prevention, and treatment.

This Mental Health Awareness Month, let us make it a point to check in on our loved ones, colleagues, and neighbors to ensure that they are connected to the hands-on care they need. We can all do our part to make sure those in need receive access to life-changing behavioral health treatment. At Bamboo Health, we are proud to develop and leverage solutions that enable this access – connecting and informing providers and payers with unique data, insights, and clinical decision support tools to enhance their patients’ physical and behavioral health in real time when they need it most.

Delaware Documents 100,000 Referrals in Third Year of OpenBeds Referral Network

Posted on May 5, 2022June 9, 2023 by Grace Keeling

Combating Delaware’s Opioid Crisis

Drug overdoses play a major role in the nation’s behavioral health crisis. Per the Centers for Disease Control and Prevention (CDC), during a 12-month period ending in April 2021, there were 100,306 drug overdose deaths in the U.S., about a 28.5% increase from the previous year.

Like many other states, Delaware was not immune to the effects of the opioid crisis.

The following is an excerpt, with updated statistics, from our 2021 Annual Impact Report.

With the nation’s second-highest drug overdose mortality rate in 2019, Delaware’s Division of Substance Abuse and Mental Health needed a referral system that encompassed the entire continuum of behavioral health services. The Delaware Treatment and Referral Network (DTRN), powered by Bamboo Health’s cloud-based OpenBeds platform, now facilitates rapid digital referrals and fosters collaboration among mental health, SUD, and medical providers.

In its first year of the initiative, Delaware’s digital network for expedited patient referrals to inpatient and residential behavioral health programs sparked a 45% increase in treatment referral requests and improved the rapid acknowledgment of referrals by 25%. The DTRN also facilitated 20,924 treatment referrals in the first year, 75% of which were for inpatient services. More than half of these referrals specifically noted substance abuse.

With all communication now digital rather than manual, the DTRN has improved response rates to referral requests as well. A full 65% of receiving organizations now acknowledge a patient referral within 30 minutes, an increase of 25% since the program’s inception. The state uses the DTRN to identify service gaps, target funding, and evaluate behavioral health and substance abuse programs in its ongoing efforts to curb the opioid crisis and provide appropriate care for impacted patients.

How Bamboo Health Has Helped

Now after three years of partnership with Bamboo Health on the OpenBeds solution, the State of Delaware has realized remarkable results:

As 2021 ended, the DTRN hit an outstanding new milestone: 100,000 referrals. This represents 100,000 opportunities to improve the lives of citizens.
About 60% of referrals have been for inpatient services, with around half of referrals specially noting substance use disorder.
By assisting providers with the onboarding process to encourage adoption, Delaware expanded the number of active users on its referral network by 264% in the first year. The variety of distinct services offered by receiving organizations expanded in the first year as well, growing from 40 to 109—a 173% increase.

Bamboo Health is proud to play a critical role in helping Delaware’s Division of Substance Abuse and Mental Health and its service providers with this effort. For clinical staff, social workers, administrators, peers, and countless others who serve individuals with behavioral health conditions, the DTRN – powered by OpenBeds – has allowed for renewed focus on patients to transform the lives of patients and their families.