Care Coordination_TEAM Bundles

Bamboo TEAM Bundles

Win at CMS TEAM From Day One

Bamboo TEAM Bundles is one of the most comprehensive and robust solutions designed to help hospitals excel under CMS’s mandatory Transforming Episode Accountability Model (TEAM). From ensuring accurate risk-adjusted benchmarks to effective discharge planning and post-acute care monitoring, this integrated solution drives results across the entire 30-day episode post-surgery.

Real-Time Decision Support Across Every Stage of the Surgical Episode

CMS TEAM regulations require hospitals to manage cost and quality across complex surgical episodes simultaneously. However, inconsistent specialist workflows, limited visibility into patient clinical risk and inadequate post-discharge care optimization and monitoring create operational blind spots at the most critical junctures of patient care. 

Bamboo TEAM Bundles changes the equation. With Real-Time Care Intelligence™ and industry-leading predictive analytics, we help hospitals act smarter before, during and after surgery.  

  • Prior to Day of Surgery: Capture complete patient complexity early and optimize site-of-care decisions to set the right benchmark from the start.   
  • During Surgery, In Facility: Deliver embedded real-time insights to guide smarter surgical and discharge decisions across all service lines.  
  • 30-Day Post-Anchor Window: Reduce SNF/IRF spending with AI-driven discharge recommendations, continuously monitor patients across care settings and prevent unnecessary readmissions and emergency department visits. 

Key Benefits

Smarter Surgical Site-of-Care Decisions

Leverage predictive analytics to optimize inpatient vs. outpatient placement, balancing quality and cost from the start in a site-neutral payment program.

Female doctor working with her laptop and tablet in medical office

Accurate Risk Adjustment Early

Surface suspect diagnosis code pre-surgery, even when claims data is unavailable, ensuring accurate risk adjustment and reimbursement.

AI-Powered PAC Optimization

Support higher quality, cost-effective outcomes with industry-leading AI-powered recommendations for discharge timing and post-acute placement informed by the patient’s risk profile and quality of available PAC facilities.

Maintain Episode Visibility Post-Discharge

Prospectively estimate readmission risk and track patients across care settings in real time, ensuring continuity, reducing readmissions and delivering on quality metrics throughout the 30-day window.

Closeup shot of a female doctor wearing glasses and a mask to represent CareFlow

Our Impact

Bamboo TEAM Bundles can deliver Real-Time Care Intelligence™ and AI-driven analytics to help hospitals act at pivotal care moments, improving quality, lowering costs and driving success under CMS TEAM.

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  • 25%

    reduction in 30-day readmissions

  • 19%

    decrease in SNF/IRF utilization

  • $1.2M

    saved in nine months by one regional health system

  • 20-30 min

    saved per patient via streamlined insights

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BH_Bamboo Intelligence Hub

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Bamboo Intelligence Hub™

One Powerful Hub. Every Critical Insight.

Connect physical and behavioral healthcare insights with the Bamboo Intelligence Hub™ — the only solution delivering truly integrated, longitudinal patient records in real-time, right within your existing workflows.

Improved Patient Visibility for Streamlined Workflows

1 in 4 adults with mental illness report not receiving the treatment they need. Overburdened providers and siloed data are costing lives and burning out the workforce. It’s time for a better way.

Break down the walls between behavioral and physical health data. Access real-time patient insights and histories from admission, discharge and transfer (ADT) data, behavioral health referrals, crisis resource availability and more — all in one place.

  • Integrated behavioral & physical health insights 
  • Faster, more informed clinical decisions 
  • Pivotal care moments, fully illuminated 

Key Benefits

Easily Integrate Systems to Break Barriers Between Behavioral and Physical Health

See the full picture of individuals’ care journeys with integrated physical and behavioral health data, leading to more informed decision-making and quicker access to life-saving care.

Reduce Workforce Burnout and Shortages

Give clinicians and care teams the tools they need to work at the top of their license. Simplify documentation, reduce redundant tasks and free up valuable time for patient care.

– Cut reporting and outreach time
– Strengthen clinical staffing models
– Empower care coordinators and reduce turnover

80% of patients in one state engaged in follow-up care when providers used Bamboo Health’s coordinated referral workflows.

Actionable Intelligence for Improved Outcomes

Surface high-value, actionable patient intelligence when it matters most — improving care coordination and patient outcomes.

– Real-time ADT event integration
– Full context for every patient interaction
– More confident, data-driven decision-making

Hear from Delaware

Learn how the State of Delaware is transforming crisis care and behavioral health coordination statewide.

Leaders in Real-Time Care Intelligence™

Our Impact

Bamboo Intelligence Hub unifies critical patient context to improve lives during pivotal care moments.

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  • 98%

    faster referral responses in psychiatric care*

  • 80%+

    patient engagement post-referral*

  • 1 Billion

    annual ADT events

*Data related to one psychiatric hospital

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Tell us all about your organization’s care coordination and care intelligence needs.

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See how our technologies deliver critical patient information in real-time and in clinical workflows.

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Read more about our customers’ successes and how we’re working to improve public health.

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Bamboo Bridge

Bamboo Bridge®

Transforming Behavioral Health Outcomes for High-Cost, High-Need Populations

Utilize care navigators and real-time intelligence to help individuals with physical and behavioral health needs at pivotal moments through the nation’s most trusted care collaboration network.

Navigate and Connect Physical & Behavioral Health in Real Time.

Individuals with behavioral health conditions drive significantly higher costs and worse outcomes—including 28% higher hospital utilization—placing a greater demand on providers.

Bamboo Bridge® goes beyond real-time insights. Our tech-enabled care navigators proactively identify, assess and engage individuals, connecting them to behavioral healthcare through emergency departments, inpatient and outpatient settings and primary care provider referrals within our curated network using:

  • In-Workflow Patient Navigation: Initiate care navigation directly from your electronic health record and admission, discharge and transfer (ADT) notifications—no disruption to clinical workflow.
  • Real-Time Transition Visibility: Receive instant updates on patient status and know exactly when care transitions are completed.
  • PDMP-Enabled Navigation for Individuals with Substance Use Disorder: Providers can initiate support with the Bamboo Easy Button in their existing workflow, or Bamboo Health can act as a delegate—leveraging PDMP data and alerts to identify risk and guide patients to appropriate care.
  • Preventive Roster Review: Care navigators manually assess rosters to identify high utilizers with unmet behavioral health needs, proactively engaging them to close care gaps.

Learn more here.

Key Benefits

Navigate Individuals to Behavioral Healthcare

Managing patients with high-cost behavioral health needs can be costly and challenging. You need the tools and care navigation support to deliver real-time, personalized care to patients during pivotal moments, whether they’re transitioning out of the hospital, seeking follow-up care or managing long-term conditions. Deliver holistic care that addresses both the physical and behavioral health your patients need without overburdening your staff.

Doctor speaking to and shaking hands with a healthcare executive

Drive Measurable Clinical & Financial Outcomes and Enhance Quality Scores

Enhance opportunities for more accurate reimbursement under value-based care arrangements with appropriate hierarchical condition category (HCC) documentation for behavioral health conditions. In doing so, streamline the documentation and coding process, particularly for complex cases involving behavioral health conditions.

Bamboo Impact Report 2023

Ease Workforce Burdens for Continuity of Care

Your team works hard to provide excellent care, but with workforce shortages and increasing demands, it can be tough to keep up. Bamboo Bridge integrates into your existing systems, offering care navigation support that lightens the load. Our solution helps ensure appropriate behavioral healthcare access for those with high needs by reducing emergency department reliance, supporting follow-up care and automating and centralizing key administrative processes, such as care documentation, transitions of care and HCC coding.

Without addressing mental health, we couldn’t manage chronic conditions effectively. That’s why our strategy had to evolve. With Bamboo Bridge®, we reduced 80-day referral delays to just weeks—and saw a 5x increase in patients keeping their first appointment.

Ryan Graham Privia Medical Group-Georgia

Our Impact

Bamboo Bridge helps providers deliver timely, coordinated care interventions during pivotal moments in a patient’s behavioral health journey. Compared to the traditional process with no follow-up intervention, these statistics represent large portions of populations that typically would go unnoticed and translate into better care for your patients and significant cost savings for your organization.

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  • 66%

    patient assessment rate

  • 60%

    appointment scheduling rate

  • 35%

    visit attendance rate

Get in Touch

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Speak with Us

Tell us all about your organization’s care coordination and care intelligence needs.

Speak with Us
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Schedule a Demo

See how our technologies deliver critical patient information in real-time and in clinical workflows.

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View Our Resources

Read more about our customers’ successes and how we’re working to improve public health.

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BH_Justice Involved

Justice Involved

Increasing Diversion by Connecting Individuals to Behavioral Health Treatment

Bamboo Health’s Justice Involved solution sends real-time alerts when an individual has an encounter with law enforcement or is incarcerated, helping coordinate care and treatment referrals.

Enhance Interoperability and Timely Care for Justice-Involved Individuals

Today, there are nearly two million justice-involved individuals in U.S, with these individuals facing three times the rate of mental illness on average. Over 65% of these individuals also meet medical criteria for experiencing substance use disorder, while only 11% receive treatment. 

Bamboo Health’s Justice Involved solution bridges this critical gap by seamlessly connecting health plans, state governments and providers to justice systems. With streamlined alert reporting and real-time booking and release data, individuals receive continuous care and timely assessment of treatment needs. States using Section 1115 waivers to provide expanded Medicaid eligibility for justice-involved individuals can leverage Justice Involved to divert more individuals from incarceration into appropriate care settings.  

Key Benefits

Maintain Consistent Care for Justice-Involved Individuals

Healthcare organizations can better connect with jail and prison systems using Justice Involved, which provides access to booking and release data. This information helps manage care events and offers more opportunities to assess an individual’s treatment needs.

Leverage Real-Time Alerts to Increase Treatment Referrals

Justice Involved connects to nearly all jails and prisons in the U.S. and can alert managed care organizations (MCOs), Medicaid, state administrators, providers and other stakeholders when individuals’ incarceration periods begin and end. By capturing essential incarceration event information, stakeholders can more quickly evaluate an individual’s need for mental health or substance use disorder treatment in near real-time. This ability to more quickly identify the highest-risk individuals fuels improved outcomes and cost savings for providers, reducing the impact of traditionally high rates of substance use disorder and comorbidities among this population.

Connect Individuals to Care and Increase Care Quality

Booking and incarceration alerts offer various coordinated care options, such as treatment referrals, and engage with individuals who may be at high risk for re-entering the justice system. Such alerts help by referring individuals in need of care to the appropriate treatment. Given that many of these individuals are eligible for Medicaid, state Medicaid programs can intervene during pivotal moments improving the quality of care.

Our Impact

With Justice Involved, organizations can leverage Bamboo Health’s real-time bed monitoring system to connect to nearly all jails and prisons in the U.S. and be alerted when an individual’s incarceration stay begins and ends for improved follow-up care.

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  • 2800

    Incarceration facilities on the Justice Involved network

  • 160M+

    Historical incarceration records

  • 1M+

    New incarceration records per month

  • 30%

    Reduction in recidivism in one state

Get in Touch

Contact Us

Speak with Us

Tell us all about your organization’s care coordination and care intelligence needs.

Speak with Us
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See how our technologies deliver critical patient information in real-time and in clinical workflows.

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View Our Resources

Read more about our customers’ successes and how we’re working to improve public health.

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Care Coordination_Discharge Summaries

A female doctor with tablet talking to patient in bed in hospital MOBILE discharge summaries

Discharge Summaries

Crucial Insights During Patient Transitions

Discharge Summaries from Bamboo Health provides seamless access to the most diverse interoperability framework, ensuring timely and appropriate care post-discharge.

Young female doctor smiling and showing tablet to senior female patient

Enhance Interoperability and Pursue Timely Follow-Up for Patients

Many providers and patients face communication challenges and gaps in care when a patient transitions from hospitals to other levels of care. This can lead to gaps in care that create care delays, treatment errors, unnecessary procedures and possible readmissions. Discharge Summaries alleviates this problem with reliable and timely patient context accessible in Bamboo Health’s existing nationwide Pings workflow.


Key Benefits

discharge summaries screen with doctor reading a tablet

Optimize Clinician Time with a Seamless, Unified Platform

Care coordinators receive notifications seamlessly in the Pings workflow, with clear flags upon availability to avoid the detective work and phone calls needed to manually track down missing patient discharge information. With an extracted view of actionable insights, clinicians are empowered with all the necessary information in a way that works best for them, while the full details are also available in a PDF or XML format.

discharge summaries screen

Reduce Readmissions with Complete Clinical Context

Empower care coordinators with complete clinical context, including discharge notifications, to improve transitional care management follow-ups. By facilitating the early capture of essential details, the solution minimizes avoidable emergency department visits and readmissions.

discharge summaries screen with doctor reading a tablet

Leverage Unmatched Network Scale

Discharge Summaries are available nationwide from the largest interoperability network, agnostic of discharging facilities’ Electronic Health Record. 

Leaders in Real-Time Care Intelligence™

Our Impact

Bamboo Health helps providers across the continuum of care make more informed decisions when they matter most, increasing access to care, enhancing patient safety and improving health equity.

Learn More
  • 250%

    increase in post-discharge visit completions at Landmark Health

  • $681,000

    received by reducing length of stay at Houston Methodist

  • 50%

    decrease in 30-day inpatient readmissions at The Mass League

Get in Touch

Contact Us

Speak with Us

Tell us all about your organization’s care coordination and care intelligence needs.

Speak with Us
Speak with Us

Schedule a Demo

See how our technologies deliver critical patient information in real-time and in clinical workflows.

Schedule a Demo
Schedule a Demo

View Our Resources

Read more about our customers’ successes and how we’re working to improve public health.

View Our Resources
View Our Resources

Care Coordination_Care Gaps

Smiling young professional

Care Gaps

Real-Time Care Gap Identification Solution

Care Gaps delivers immediate notifications and detailed insight to help providers and payers quickly find and close open gaps in care, deliver better outcomes and improve quality measures.

Relaxed coworkers talking to their client online from the office

Close Costly Care Gaps

The information barriers and misaligned workflows between providers and payers make it difficult to identify and reconcile high-impact moments that matter for patients, such as transitions of care from an inpatient setting and prompt follow-up care after an emergency department visit for patients with chronic conditions.

Leveraging Bamboo Health’s robust national admission, discharge and transfer (ADT) network, Care Gaps actively surfaces those gaps in real time and within provider workflows, fostering better care coordination, patient care outcomes, increased cost savings and quality performance improvements with programs such as CMS Star Ratings and HEDIS.



Key Benefits

Doctors and professional reviewing content on a computer

Improve Patient Outcomes

Fluid and quick data transfer between plans and providers translates to fewer care gaps, which in turn results in better care delivery and experiences for patients and providers, and most importantly, better outcomes.

Open Care Gaps Filter

Optimize Care Collaboration

The Real-Time Care Intelligence™ provided by Care Gaps enables true care coordination by enabling payers and providers to more effectively be aware of open gaps, complete gap analysis, and quickly intervene and engage patients.

Meet & Exceed Quality Measures

Care Gaps helps payers and providers more effectively collaborate with healthcare organizations to improve performance on quality programs such as CMS Star Rating and HEDIS.

Leaders in Real-Time Care Intelligence™

Our Impact

Bamboo Health helps providers across the continuum of care make more informed decisions when they matter most, increasing access to care, enhancing patient safety and improving health equity.

Learn More
  • 250%

    increase in post-discharge visit completions at Landmark Health

  • $681,000

    received by reducing length of stay at Houston Methodist

  • 50%

    decrease in 30-day inpatient readmissions at The Mass League

Get in Touch

Contact Us

Speak with Us

Tell us all about your organization’s care coordination and care intelligence needs.

Speak with Us
Speak with Us

Schedule a Demo

See how our technologies deliver critical patient information in real-time and in clinical workflows.

Schedule a Demo
Schedule a Demo

View Our Resources

Read more about our customers’ successes and how we’re working to improve public health.

View Our Resources
View Our Resources

Care Coordination_Stories

Male doctor concentrating looking at a computer screen

Stories™

Patient Timeline Intelligence Solution

Stories™ provides real-time, relevant and clear patient history integrated at the point of care to optimize clinical decision making.

Mature male doctor using a tablet

Gain a Clear View of a Patient’s Care Delivery Timeline

Delivering whole-person care is impossible without an accurate view into a patient’s total history. High-value treatment information such as care plans, prior utilization history, care team attribution and available community resources are vital in making smooth transitions of care.

Stories solves the care disconnect by instantly displaying patient timelines into existing clinical workflows. Stories facilitates optimal decision making by flagging high-risk patients and showing in- and out-of-network activity, so care teams can provide the best patient outcomes.

Key Benefits

Drive Down Costs

Clear and timely data allows clinicians to avoid medically unnecessary admissions and readmissions. Better use of care resources leads to improvements in inpatient and emergency department throughput.

High Utilizer Tag in Stories

Optimize Clinical Encounters

Increase quality and patient satisfaction through improved discharge planning and enhanced collaboration with community partners.

Diverse group of doctors looking at digital tablet in medical office

Streamline Care Transitions

Insights on in- and out-of-network patient utilization and diagnosis history lead to improved communication among care team members and community resources, making overall care transitions smoother.

Leaders in Real-Time Care Intelligence™

Our Impact

Bamboo Health helps providers across the continuum of care make more informed decisions when they matter most, increasing access to care, enhancing patient safety and improving health equity.

Learn More
  • 250%

    increase in post-discharge visit completions at Landmark Health

  • $681,000

    received by reducing length of stay at Houston Methodist

  • 50%

    decrease in 30-day inpatient readmissions at The Mass League

Get in Touch

Contact Us

Speak with Us

Tell us all about your organization’s care coordination and care intelligence needs.

Speak with Us
Speak with Us

Schedule a Demo

See how our technologies deliver critical patient information in real-time and in clinical workflows.

Schedule a Demo
Schedule a Demo

View Our Resources

Read more about our customers’ successes and how we’re working to improve public health.

View Our Resources
View Our Resources