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, Kristi Carney, MSW, LSW, CCM, Director of Behavioral Health at CareSource Indiana, and Dr. Nishi Rawat, Chief Clinical Officer and General Manager of Care Navigation at Bamboo Health, shared how CareSource Indiana used Bamboo Bridge® to support members after an inpatient psychiatric stay. The plan’s independent analysis found 90th-percentile performance on 7-day and 30-day follow-up after hospitalization (FUH), 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 CareSource, physical healthcare accounts for most of total spend, even among members with SMI. 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. For CareSource, the human element was key.
Focusing on Follow-Up After Inpatient Hospitalization
CareSource Indiana’s 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 CareSource Medicaid members ages 6 and older who are discharged from inpatient psychiatric units, from before discharge through 30 days after. Navigators route members to CareSource’s 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
CareSource Indiana’s 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 CareSource’s 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 CareSource Indiana story? Watch the on-demand webinar or contact us to walk through how this could work for your members.
