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.
