The Care Coordination Gap in the CMS ACCESS Model

Posted on October 27, 2026October 14, 2026 by Jaime Conlan

Socially vulnerable Medicare beneficiaries in two-sided risk Medicare Advantage plans have up to 30% less high-risk medication use and up to 17% fewer hospitalizations than those in traditional fee-for-service Medicare, according to a study in The American Journal of Managed Care (AJMC). Now, CMS is testing whether a new kind of payment can bring more accountability for outcomes into traditional Medicare with the CMS ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) Model.

On January 1, 2027, a second cohort of health systems and physician groups will begin receiving payments from Medicare through the ACCESS model. ACCESS pays participating organizations Outcome-Aligned Payments for managing patients’ chronic conditions, rather than reimbursing them visit-by-visit. It’s an outcomes-first experiment, with full payment depending on patients reaching measurable health targets, such as lowering blood pressure. It remains to be seen how payment rates directly support this approach, and the first cohorts will be an early test.

So what does ACCESS cover, and what coordination gaps should care teams plan for?

How ACCESS Works With Primary Care

ACCESS is built around four initial tracks — early cardio-kidney-metabolic, cardio-kidney-metabolic, musculoskeletal, and behavioral health — and it’s intentionally designed to work alongside a beneficiary’s existing primary care relationship rather than replace it. Referring physicians can send patients to an ACCESS organization, receive regular electronic progress updates, and bill a new co-management payment for reviewing those updates and coordinating care.

On paper, ACCESS is a coordination model. In practice, it raises a more interesting question: When a patient’s ACCESS-covered care and the rest of their care happen in different places, who’s making sure both sides are working from the same picture?

This is the question every new payment model must work out in its early cohorts. It’s a real opportunity for CMS, participating organizations, and the primary care physicians (PCPs) in the middle of it to get it right. The model is still young, with a 10-year runway. There’s time to close this seam before it hardens into patterns.

Where the Coordination Gaps Are in the ACCESS Model

The referral workflow is still taking shape. Trade coverage of the model’s rollout has already noted that primary care coordination workflows between PCPs and ACCESS organizations remain undefined. CMS now provides a template for the updates that ACCESS organizations send to referring clinicians, but each practice still must determine how those updates fit into its day-to-day workflow. In the model’s first year, how and when information reaches a beneficiary’s regular physician may differ depending on which of the more than 160 participating organizations a patient enrolls with.
Substance use disorder support is coming, but it will be a separate track. CMS will add a substance use disorder (SUD) track in April 2027. That’s important because substance use rarely shows up on its own. It overlaps constantly with chronic pain, depression and anxiety, and cardiometabolic disease, which are conditions covered by the other tracks. Because SUD will be its own track, a patient’s SUD care and their pain or diabetes care may be managed by a different organization. An organization can be doing everything right within its track and still be working from an incomplete picture of a patient whose most urgent risk factor sits in another track.
It reaches less than half of the Medicare population. ACCESS is built specifically within traditional Medicare. It isn’t available to the 55% of eligible Medicare beneficiaries now enrolled in Medicare Advantage. Some major health plans have pledged to offer ACCESS-aligned payment options, but the level of support will vary from plan to plan. This can create its own coordination seam: a beneficiary who moves between traditional Medicare and Medicare Advantage, which beneficiaries can do every year during open enrollment, can gain or lose access to this kind of coordinated chronic care support depending on which side of that line they’re on at the time.
The economy is tight. The organizations best positioned to build real coordination infrastructure (such as real-time data sharing, care navigators, and closed-loop referral tracking) are also the ones facing the tightest margins to do so. Payment rates range from $90 to $420 per beneficiary per year, depending on the track, leaving participants little room to invest in care coordination and making it one of the first things new cohorts will need to address.

Why This Matters Most for the Patients With the Least Room for Gaps

ACCESS is too new to have its own outcomes data yet. But the AJMC cited earlier offers a useful analysis. Researchers analyzed data from more than 1.7 million socially vulnerable Medicare beneficiaries in two-sided risk Medicare Advantage plans, which had 13.5% to 16.6% fewer acute hospitalizations and 23.4% to 30% less high-risk medication use than those in traditional Medicare, with the largest gains among the most vulnerable groups.

ACCESS is, in part, CMS’s attempt to bring some of that same coordinated-care benefit into a part of Medicare that has historically lacked it.

The Opportunity Ahead

New cohorts will start every quarter through 2033. The organizations, physicians, states, and health plans leading the way are able to:

Figure out how to keep a beneficiary’s full picture connected across ACCESS and non-ACCESS care;
Maintain continuity across the conditions the model tracks and those it doesn’t;
And track individuals across traditional Medicare and Medicare Advantage

That’s the same problem real-time care navigation for high-need, high-cost patients is built around: making sure that when a patient’s care occurs in more than one place, someone — or something — still keeps the full picture in view.

Frequently Asked Questions: CMS ACCESS Model

What is the CMS ACCESS Model?
ACCESS (Advancing Chronic Care with Effective, Scalable Solutions) is a 10-year voluntary payment model from the CMS Innovation Center that pays participating organizations Outcome-Aligned Payments instead of billing Medicare per visit. These are recurring payments for managing a patient’s chronic conditions, with full payments depending on how many of an organization’s patients meet their health targets. It launched July 5, 2026, and runs within traditional Medicare. The goal is to test whether paying for results, rather than volume, can expand access to technology-supported care for chronic conditions at scale.

Which conditions does the ACCESS Model cover?
As of launch, ACCESS covers four tracks: early cardio-kidney-metabolic (eCKM), cardio-kidney-metabolic (CKM), musculoskeletal pain (MSK), and behavioral health (depression and anxiety). Starting April 1, 2027, CMS is adding four more: heart failure, chronic obstructive pulmonary disease (COPD), substance use disorder, and tobacco cessation, along with a follow-on track for chronic musculoskeletal pain. This doubles the number of tracks the model addresses within its first year.

How do primary care physicians work with ACCESS organizations?
PCPs and other referring clinicians can refer their Medicare patients directly to an ACCESS organization, and the organization sends regular electronic updates to keep the referring physician in the loop. CMS also created a new billing option for this: clinicians who review an update and take a related care-coordinating step can bill a co-management service, paid at approximately $30 per service (subject to geographic and standard Medicare adjustments), plus a one-time onboarding payment of about $10 the first time they bill for a given beneficiary on a given track. The service can be billed up to three times per 12-month care period for each patient and track, or about $100 total.

Can Medicare Advantage members participate in the ACCESS Model?
No. ACCESS is built specifically within traditional Medicare. However, Medicare Advantage plans can choose to offer similar outcomes-based payment arrangements on their own. Beneficiaries who switch between traditional Medicare and Medicare Advantage during annual open enrollment gain or lose ACCESS eligibility depending on which coverage they’re enrolled in at the time.

When can organizations join the ACCESS Model?
CMS is accepting applications on a rolling basis from January 2026 through April 2033, giving organizations multiple entry points over the model’s 10-year run rather than a single application window. The first cohort’s deadline was May 15 (extended from the original April 1, 2026, deadline), ahead of the July 5, 2026, launch. The second cohort begins January 1, 2027. New cohorts will start every quarter after that. Organizations considering ACCESS should check the CMS Participant Portal directly for the current application window.

Wondering how your organization can prepare for ACCESS? Connect with our team to talk through where care navigation fits into your value-based care strategy.

Medicaid Care Navigation: Reaching 90th-Percentile Follow-Up for Members

Posted on October 23, 2026October 26, 2026 by Jaime Conlan

Medicaid members with behavioral health needs often move between the emergency department (ED), inpatient units, and outpatient care without anyone connecting the dots. When those handoffs break down, members miss follow-up care and may return to the hospital, which affects outcomes and increases costs.

In a recent Becker’s Healthcare webinar, Bamboo Health shared how clients use Bamboo Bridge® to support members after an inpatient psychiatric stay. One independent analysis found 90th-percentile performance on 7-day and 30-day follow-up after hospitalization (FUH) for one large health plan, along with fewer readmissions among members who received care navigation.

The Behavioral Health Challenge in Medicaid

Behavioral health needs are rising across every line of business, and Medicaid members face significant challenges.

One-third (33%) of non-elderly adults in the U.S. have a mental illness or substance use disorder (SUD). Rates are highest among Medicaid enrollees: 39% have a mental illness and/or SUD, compared with 31% of privately insured adults, according to KFF.
Nationally, the share of members with a mental health diagnosis rose 8% from 2019 to 2023.
Among non-elderly adults on Medicaid, 10% have a serious mental illness (SMI), according to KFF.
Medicaid members with a mental health condition or SUD cost 5 times as much per member per month as the general Medicaid population.
A federal access standard generally requires applicable Medicaid managed care plans to meet a 10-business-day maximum appointment wait-time standard for outpatient mental health and substance use disorder services, but a 2024 JAMA study found median waits for psychiatric care of 11 to 64 days in major cities.

These access gaps push members into more costly settings, often only after their condition has gotten worse. Members with mental health and SUD needs may also be managing chronic conditions, medication challenges and social needs, made harder by limited access to consistent outpatient care.

Untreated Behavioral Health Contributes to Physical Health Costs

One finding surprised many attendees: For many clients, physical healthcare accounts for most of total spend, even among members with SMI. For one member population, among Medicaid members with a mental health condition or SUD, about 70% of spend is medical. Untreated behavioral health conditions can contribute to higher physical healthcare costs.

Imagine a member with schizophrenia who experiences cognitive challenges and stops taking blood pressure medication. Without enhanced care team visibility into the member’s physical health needs, this member may go without necessary care.

The upside is real. Ensuring longitudinal care for this population can drive $1,377 in in-year cost reduction per newly diagnosed patient, according to an Evernorth analysis.

Where Members Fall Through the Cracks

Behavioral health conditions are so often under-assessed and under-treated, in part due to:

Primary care time limitations: Short visits leave little time for a full assessment, and providers who screen may face challenges arranging follow-up treatment.
Overburdened EDs and inpatient settings: These settings may not be equipped to provide ongoing behavioral healthcare. Without a clear handoff to longitudinal care, members often cycle back into the hospital.
Confusion across care settings: With distinct behavioral health service types, providers can struggle to know where to refer, and members and caregivers wait too long for care.

In Indiana, many counties face shortages of psychiatrists, especially those specializing in child and adolescent care or addiction. In rural areas, members may travel long distances for care. As a result, many don’t receive care until they’re in crisis.

Quality measures add another layer. Many Healthcare Effectiveness Data and Information Set (HEDIS) follow-up measures have tight timelines, so providers need real-time data to make a difference.

How Bamboo Bridge Connects Members to Care

Bamboo Bridge is a behavioral health activation and navigation solution. It uses real-time signals to identify members at pivotal moments, such as an ED visit, a hospital admission, a call to a crisis line or a flag for overdose risk. It draws on data from electronic medical records, utilization management, health information exchanges, admission, discharge and transfer (ADT) feeds, referrals, pharmacy data, and justice-involved data.

From there, Bamboo Health care navigators:

Engage the member and assess their needs and level of care
Match them with a curated, quality-vetted network of providers that builds on the plan’s own network
Handle referral and scheduling and connect members to social needs support
Follow up after the appointment with both the member and the treatment provider
Coordinate with the primary care provider or care manager to close the loop

“One of the most important aspects about Bamboo Bridge is that the program is built to supplement existing health plan and care infrastructure, not replace it,” Dr. Rawat said. Each step ties back to metrics that matter to health plans, and the program may support performance on several Medicaid Adult Core Set measures.

Bamboo Bridge uses an AI-powered, human-in-the-loop approach. AI supports tasks like summarizing data and scheduling with providers, while real people lead the work that depends on trust and clinical judgment.

Focusing on Follow-Up After Inpatient Hospitalization

Many health plans’ behavioral health strategy rests on four pillars: partnering with providers, sharing data across systems of care, running care coordination programs and promoting prevention and education.

The teams considered several areas, including follow-up after ED visits for SUD and mental illness. They chose follow-up after hospitalization (FUH) because members leaving an inpatient psychiatric stay are among the hardest to reach and engage.

Under the program, Bamboo Bridge supports Medicaid members ages 6 and older who are discharged from inpatient psychiatric units, from before discharge through 30 days after. Navigators route members to transitions of care and care management teams, as well as to outpatient behavioral healthcare, working alongside each team so members experience one connected path.

The Results

One independent analysis of Bamboo Health’s recent performance showed:

5% 30-day FUH rate (above the 90th percentile)
7% 7-day FUH rate (above the 90th percentile)
57% of members had appointments scheduled
82% of scheduled appointments were attended
16% decrease in readmissions for members who received care navigation compared with those who did not

Beyond the numbers, the partnership strengthened health plans’ relationships with providers in the market.

Lessons for Health Plans

Integrate, don’t add. Navigation should align with care management, provider workflows and shared outcome measures, so it works as part of the care strategy rather than another point solution.
Keep the cadence high. Daily huddles with the three participating facilities improved workflows, trust and camaraderie.
Fit into provider workflows. Find a partner who asks providers how to fit into their existing workflows and can pivot quickly, including by adding evening calls.
Act as one care team. Members should feel like support comes from a single team with a shared view of their needs.

Want the full story? Watch the on-demand webinar or contact us to walk through how this could work for your members.

How to Check Behavioral Health Capacity

Posted on October 19, 2026October 20, 2026 by Jaime Conlan

When a person reaches out for behavioral health treatment, they are often at their most vulnerable. What happens next can determine whether they ever try again. If they experience a fast, coordinated response, it could lead to a meaningful behavioral healthcare experience. If they are met with a delayed response — or worse, a dead end — it might be the last time they seek help. Too many behavioral health systems run on an open loop: a referral goes out, and there’s no reliable way to track what happens to it next.

The Real Cost of an Open Referral Loop

Research from the Annals of Family Medicine shows the strongest predictor of whether someone attends their first behavioral health appointment is how quickly they get in. That wait is exactly what OpenBeds® is built to shorten. OpenBeds has cut the average time to accept a referral from 7 days to 1.5 days. In Delaware, referrals are acknowledged in an average of 1 hour and 36 minutes.

When referrals go unanswered or take days to acknowledge, care outcomes are at risk. Every day a referral sits unacknowledged is a day someone in need can lose motivation to seek help.

What “Closed Loop” Means for a Behavioral Health Referral System

A closed-loop referral system tracks every referral from the moment it is created to the moment a person is placed in care, with no step depending on a phone call nobody remembers making or a fax nobody can confirm arrived. It means that the referring and receiving providers communicate within the same system, that status updates occur in near real time, and that even a referral sent to a facility without electronic capability still has a documented, trackable path to close-out rather than a dead end. States that have adopted this approach show what it looks like in practice: Delaware accepted more than 16,000 referrals in a single year, with an average acknowledgment time of under two hours, and Nevada cut its acknowledgment time from four days to under two hours.

The Behavioral Health Capacity Check That Should Run on Every Referral System

Closing the loop starts with an honest capacity check. Behavioral health leaders should be able to answer key questions, such as “How many referrals are open right now?” What is the average time from referral to acknowledgment? What is the average time to acceptance? Can staff see real-time availability, or are they calling around to find it? If volume rose 25% tomorrow, could the current process absorb it? For many organizations, the answer is that no one has ever measured these numbers, because the process was never built to produce them. The real risk isn’t that the process is slow. It is that the process is invisible.

From Referral Insight to Action

Closing the loop is not only about the referral pathway itself. It is also about what an organization does with the data generated by the pathway. The Bamboo Intelligence Hub® turns referral and care activity into a person-centric timeline and population-level dashboards, so leaders can see where referrals stall, where capacity is tightest and where a warm handoff becomes a kept appointment. It’s the same connected-transition model that Bamboo Health has outlined for populations across the care continuum. That visibility is what turns one closed referral into a system that keeps getting better.

Every person who reaches out for behavioral healthcare deserves a system that responds urgently. Closing the loop and knowing your organization’s true capacity is not just good operations. It is how a health system keeps its promise to the people it serves.

See it for yourself: To learn how OpenBeds® and the Bamboo Intelligence Hub® help organizations close that loop, connect with our team.

Behavioral Health Needs Action, Not More Data: Insights from CEO Jeff Smith

Posted on October 13, 2026October 8, 2026 by Jaime Conlan

Healthcare Teams Don’t Need More Data. They Need Someone Who Knows What to Do

This blog post is adapted from CEO Jeff Smith’s conversation with Monica Oss, founder and CEO of Open Minds; view the full conversation.

Ask anyone whose family member or friend has lived through a mental health or substance use disorder crisis what that person needed most. They won’t say “more data.” They’ll say they needed someone who was available and knew what to do.

That answer should shape how all of us, including providers, health plans, and state and county agencies, think about care coordination. We have more information about patients than ever. What’s missing is action when it matters.

What People in a Behavioral Health Crisis Need Most

When I talk with people who have lived this, three needs frequently arise:

Help during the crisis, not days or weeks later.
A support system that knows a person’s history and follows them from the emergency department (ED) to outpatient care to the community.
Dignity and empathy. Being understood without continuous explanation. Today, too many people have to retell their story at every new door they walk through, hoping someone finally understands what they need, while their story is documented and fragmented across disparate EHRs and clinical settings.

This is why whole-person care matters. Physical, behavioral, and social needs aren’t separate problems. They’re one person’s life, and they have to be addressed together.

What Happens When the Behavioral Health System Fails?

We tend to picture failure in behavioral health as something dramatic. More often it’s quiet: not knowing where to start, or a phone call that never gets returned.

These failures tend to occur at pivotal moments in care: the points when a person is most vulnerable and most likely to seek care. In this moment, the right response can change the direction of their life. These windows close quickly, but the wheels of the healthcare system move slowly, with responses coming in days or weeks. That gap is where people get lost.

The numbers show how wide the gap is. About two-thirds of primary care physicians report they can’t connect their patients to outpatient mental health services. If an airline lost that share of its connecting passengers, it would be grounded by Friday. In behavioral health, that’s an ordinary Friday.

The human cost comes with a financial one. People with underlying behavioral health conditions have total healthcare costs about 3x as much as those without them.

From Data to Action: Real-Time Care Coordination

We don’t need another dashboard. Data you can’t act on is just expensive wallpaper. What we need is infrastructure that notices a pivotal care moment when it happens and puts the right information in front of the right person so they can act.

Real-time care coordination changes what’s possible. A caseworker can get an alert when a client arrives at an ED. A referral can be tracked until it’s closed, instead of disappearing into a black box. Corrections, housing, and physical and behavioral health teams can share information and work from the same picture.

We’re seeing the results. In Delaware, the state’s Bamboo Intelligence Hub® deployment connects behavioral health, EDs, corrections, and social services into a single workflow. It has processed more than 250,000 behavioral health referrals since 2018 and closed the loop on 75% of them. With Bamboo Bridge®, one large Northeastern health system reduced ED visits by 44% for people with underlying behavioral health conditions.

Talk to us: If your teams are drowning in data but starving for action, see how Bamboo Bridge and the Bamboo Intelligence Hub turn pivotal care moments into timely, coordinated care. Contact our team to discuss what real-time care coordination could look like for the patients you serve.

Linking Treatment With Non-Fatal Overdose Tracking

Posted on October 6, 2026October 8, 2026 by Jaime Conlan

How PDMPs Are Turning Overdose Insights Into Outcomes

Every day, physicians across the country check a patient’s history in their state’s prescription drug monitoring program (PDMP) before writing a new controlled substance prescription. Beyond routine compliance, this lookup offers a valuable, real-time clinical signal. Quick insights, delivered directly within the workflow, could help a patient access treatment before it’s too late.

Beyond Basic Prescription Lookup

For years, PDMPs have primarily supported oversight and compliance as efforts to curb the opioid epidemic. When an individual’s underlying substance use disorder (SUD) went unaddressed, there was an opportunity to do more to connect them with care.

That’s changing. State health agencies and PDMP partners are adding new layers to that same data. Now, a PDMP can alert a care navigator the moment it identifies risk. That navigator reaches out, connects the patient to treatment, and follows up to confirm they arrived. This provides an opportunity for PDMPs to take the next step – from tools primarily focused on risk identification to fully navigating patients to the care they need.

The Non-Fatal Overdose Signal

One of the most impactful layers is the integration of non-fatal overdose insights. Non-fatal overdose events, like an ED visit after an overdose, can be surfaced right inside the PDMP. The next time a physician looks up that patient, they can see the full picture, alongside other risk flags.

Some states now take it a step further. Instead of leaving that follow up to an already busy care team, the non-fatal overdose alert activates a dedicated care navigator. That navigator reaches out to the patient directly and helps connect them to care. Florida’s E-FORCSE® program is one example: after more than a year of surfacing overdose data inside the state PDMP, the program now routes those alerts straight to care navigators, so a person follows up with every patient who needs support.

Other PDMP Risk Signals to Watch

Overdose isn’t the only signal hiding in PDMP data. A few others matter just as much:

Missed medication. When a patient is prescribed medication for opioid use disorder (MOUD) but never picks up that prescription, it’s often an early warning sign that can be flagged so a navigator can check in before treatment lapses.
Physician referral. A physician who spots risky use or a possible SUD can request navigation support right inside their PDMP workflow, no extra forms needed.
Care transitions. Even if it wasn’t the main reason for the visit, a patient discharged with a behavioral health diagnosis is at real risk of falling through the cracks. Connecting PDMP data to admission, discharge and transfer (ADT) alerts extends this same idea to that moment, supporting whole-person care that treats physical and behavioral health together.

What PDMP Care Navigation Looks Like

Picture a patient in their early twenties with a history of SUD who isn’t in treatment. A physician reviewing their PDMP report can flag risky use and request navigation support with one click. Within 48 hours, a care navigator reaches out, assesses the patient’s needs and matches them to the right care. The navigator nudges them to attend that first visit, then confirms they showed up. The physician gets an update, and the navigator keeps watching for the next signal.

The physician keeps the same workflow. They still review a report before writing a prescription, now with additional support built directly into it. What’s different is what happens next.

A PDMP Care Navigation Model for Any State

States can follow a phased approach, building on the real-time data infrastructure they already have, to move closer to driving better outcomes:

Start with the real-time data that a state already has
Add overdose and other risk signals
Connect those signals to a navigator who can act on them.

States typically move through this in stages, starting with detection alone, then adding care navigation, then measuring results like ED visits and follow-up attendance.

Early results from other markets leveraging care navigation, including health systems and Medicaid plans, have demonstrated real declines in ED and inpatient utilization, along with follow-up rates well above baseline.

The case for treating the PDMP as a launchpad for care, beyond a basic compliance tool, keeps getting stronger.

Curious how this could work for your state or health system? Connect with us to learn more about how Bamboo Health’s integrated prescription monitoring and care navigation solutions can augment your teams.

Behavioral Health Navigation: Tufts Medicine Sees 44% Reduction in ED Visits

Posted on September 28, 2026October 6, 2026 by Jaime Conlan

Behavioral health needs continue to grow while most health systems lack sufficient capacity to meet them. Sometimes the problem is operational: patients are waiting for care, even while appointments remain unfilled.

In a recent webinar, Dr. Jenny Chiang, Senior Vice President of Community Engagement and Market Growth at Tufts Medicine Integrated Network, and Dr. Nishi Rawat, Chief Clinical Officer and General Manager of Care Navigation at Bamboo Health, explained how Tufts Medicine is fixing that mismatch with Bamboo Bridge®. The results after one year stand out: a 44% drop in emergency department (ED) visits, a 24% drop in inpatient admissions, and a 20% drop in hospital per-member-per-month (PMPM) costs for patients who attended their appointments.

The Growing Gap in Behavioral Health Access

20–30% of the U.S. population has an underlying behavioral health condition. Rates vary by coverage type: about 25% of commercial lives, 33% of Medicare lives and 39% of Medicaid lives.
Treating patients with behavioral health needs costs about three times as much as treating patients without them.
People who don’t get follow-up care after an emergency psychiatric visit have six times higher odds of returning to the ED within two months (based on aggregated client data)
The U.S. will be short 500,000 behavioral health providers by 2036, and about 40% of patients already live in a designated mental health shortage area.

So where do these costs show up? At Tufts Medicine, the claims data pointed to the ED and the hospital.

What Claims Data Revealed About Hospital Use

Tufts Medicine Integrated Network manages about 292,000 risk-based lives and includes 2,250 physicians and 897 advanced practice providers (APPs). About half of these clinicians are employed by the system. Only 102 behavioral health physicians and 92 behavioral health APPs serve that whole population.

When the team studied claims for its value-based care patients, it found that behavioral health conditions were closely tied to physical health costs:

80% of admissions for ambulatory care sensitive conditions involved a co-occurring behavioral health condition.
82% of readmissions involved one.
69% of avoidable ED visits involved one.

Among patients with a major behavioral health condition, 58% had no outpatient therapy visit in the past 19 months. The same was true for 79% of those with a minor one.

Building Integrated Behavioral Health Services in Primary Care

To address this challenge, Tufts Medicine built an integrated behavioral health strategy anchored in primary care. It includes collaborative care, care coordination and navigation to the right specialty services.

“It’s not just psychiatry alone,” Dr. Chiang said. “It’s not one program or one vendor. It’s really about the system capabilities of getting people access, treatment, managing those transitions and providing longitudinal care.”

How Bamboo Bridge Connects Patients to Care

Bamboo Bridge identifies patients with behavioral health needs and navigates them to the best next step in care.

The integrated service watches for pivotal moments, such as a hospital admission, an ED visit, a call to a crisis line, a flag for overdose risk or a provider’s referral to behavioral healthcare. To catch these moments, it pulls from Bamboo Health’s extensive networks.

With an AI-forward, human-in-the-loop approach, AI helps to flag when that patient most needs outreach and gives care navigators a more complete picture before they pick up the phone. It also helps with the back-office work of contacting behavioral health providers and moving referrals forward. People handle the parts of care that depend on trust and clinical judgment. Care navigators talk with each patient, assess their needs and choose the right level of care with them.

Bamboo Health care navigators reach out to each patient, complete an intake with condition-specific screeners, triage the patient clinically and schedule them with a provider in a quality-vetted network. They then send a note back to the referring primary care provider (PCP) to close the loop.

Tufts Medicine launched Bamboo Bridge in July 2025 with two use cases:

Acting on admission, discharge, and transfer (ADT) alerts: Bamboo Health monitors Tufts Medicine’s patient roster for hospital and ED events that include a behavioral health diagnosis. It then handles outreach, assessment and navigation. This takes non-clinical work off Tufts Medicine’s behavioral health staff so they can work at the top of their license.
A PCP easy button: Under a “no wrong door” approach, PCPs can refer patients from their existing workflow. Bamboo Bridge is white labeled, so patients experience it as part of Tufts Medicine’s own One Care team.

The Results: Fewer ED Visits and Hospital Stays

To measure impact, the teams compared ED and inpatient utilization among 931 value-based care patients in the four quarters before and after they started using Bamboo Bridge. They saw:

ED visits fell 44%, from 0.257 to 0.144 per patient.
Inpatient and observation admissions fell 24%, from 0.129 to 0.098 per patient.
Readmissions stayed about flat, but with only eight readmission events, the sample was too small to draw conclusions

A second analysis comparing these patients with other groups showed the same trend. Among patients who attended their appointments, ED use decreased by 37–51% and inpatient use by 19–63%, depending on the referral source and patient type. Patients who were referred but never engaged saw their hospital use rise. For example, patients referred through ADT alerts who never engaged had 59% more ED visits and 123% more inpatient stays than before referral.

Early claims data from 296 patients showed a 20% reduction in hospital PMPM costs, consistent with the encounter results.

What Improved Care Navigation Means for Care Teams

The results suggest that referral alone isn’t enough. Getting patients to appointments is associated with better outcomes — a pattern Bamboo Health has written about before in “The Lie We’ve Been Telling Ourselves About Behavioral Health Engagement.”

Bamboo Bridge uses an AI-forward, human-in-the-loop model to support outreach, intake, and scheduling, including outside business hours, so care teams can do more with less.

Ready to learn more? Explore the Bamboo Bridge solution or connect with our team to talk through what a similar rollout could look like for your patient population.

Mail-Order PDMP FAQ

Posted on September 22, 2026September 25, 2026 by Jaime Conlan

Ongoing regulatory scrutiny and new priorities can change how regulators evaluate compliance. Multi-state operators who build PDMP checks into their daily workflow are in a strong position to show that work because they aren’t relying on staff to remember every step by hand.

A prescription drug monitoring program (PDMP) used to have one job. It showed a pharmacist what controlled substances a patient had already filled. That job is changing. In the recent webinar, “Dispensing Safely at Scale: A Multi-State PDMP Playbook,” hosted by the National Association of Boards of Pharmacy (NABP), state PDMP administrators described programs that are layering in new kinds of data.

Pharmacists who attended the webinar asked practical questions about running a PDMP check across state lines today. Here’s a look at where PDMP reports are headed and what multi-state dispensers are already asking.

Where PDMP Reports Are Headed Next

Several states are leading the way in innovative PDMP use cases, including integrating:

Opioid-antidote administration data from EMS crews, first responders, and health systems
Non-fatal overdose events, which carry an increased risk of continued overdose
Decedent data, meaning flagging patients who have died to help pharmacists catch this before filling a prescription for someone who has already passed away
Care navigation modules to turn insight into action with the support of automated care navigation follow-up
Opportunities to trigger additional care workflows to leverage real-time signals in new ways that drive faster action and improve compliance and quality outcomes

Taken together, these additions point to the same shift. A PDMP is becoming less like a static list of past fills and more like a live clinical signal.

Frequently Asked Questions from Multi-State Pharmacy Operators

Do we still need to file a zero report if we’re licensed in a state but rarely dispense there?

It depends entirely on the state. In a state like South Carolina and several other states, most dispensing software can auto-file a zero report on days you don’t dispense, and exemption forms don’t expire once submitted. Other states vary in how automatic or manual this process is. Check your state’s PDMP requirements.

Is there a way for a mail-order pharmacy to check multiple states without maintaining a separate login for each one?

Standard PDMP integration typically checks the pharmacy’s home state by default. Today, seeing data from other states usually means logging in to a state that shares data with your patient’s state, then searching it directly. Vendors are now building options designed specifically for how mail-order pharmacists are registered across states. It’s worth asking yours what’s available now versus what’s on the roadmap.

Will PDMPs ever track what wholesalers ship to pharmacies, not just what’s dispensed to patients?

Tracking of what wholesalers ship to pharmacies is not yet a common practice. A handful of states, including Ohio and Michigan, collect wholesaler-to-pharmacy distribution data. But most PDMP systems stop at the point of dispensing. It’s a more complex dataset, and closing that gap is more of a long-term direction than a near-term feature.

The Gaps Leading to Higher Costs and Risks

New data types and new operational questions are showing up on the same timeline. As PDMPs take on more clinical and care-coordination functions, the practical questions about how to use them well are only going to multiply. Staying current on both is part of staying ready.

For more information on multi-state PDMP check integration, read part one of this blog post or visit bamboohealth.com/nabpwebinar to connect with our team.