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Mental Health Month Spotlight on Care Navigation: A Compass for Behavioral Healthcare in a Fragmented System

Posted on by Jaime Conlan

Each May, Mental Health Awareness Month spotlights the challenges and opportunities in behavioral health. While there’s momentum to build a more coordinated crisis care system, many organizations still face barriers, especially when supporting high-need, high-cost populations. This year, we’ll look closer at the barriers preventing individuals from accessing care and how to overcome them for successful care navigation during workforce shortages.

The stakes are high. Without improved care navigation, here’s what we risk:

  • More than 28 million U.S. adults with mental illness go untreated each year (NAMI).
  • Healthcare workers reporting staffing shortages have nearly 2x the odds of experiencing anxiety and 3x the odds of burnout (CDC).
  • Individuals with three or more chronic conditions account for nearly 180 million physician visits per year, many of which involve overlapping behavioral health concerns (CDC).

Today, whole-person healthcare is complex, spanning multiple interconnected systems, from emergency departments and community clinics to justice settings and primary care. To unify these siloed systems with existing workflows, it’s essential to leverage the support of cost-effective and targeted technical and service assistance. There’s evidence that supporting this shift has financial value too – every $1 invested in behavioral healthcare is estimated to yield $5 in total savings (McKinsey).

Progress Is Achievable, But the Status Quo Isn’t Sustainable

Traditional care coordination can often break down due to staffing shortages, manual workflows and disconnected community resources, making it nearly impossible for care teams to keep up. What’s needed now are hybrid workforce models, blending clinical and non-clinical staff and technology-enabled navigation tools that allow care navigators to focus on what matters: relationships and improved health, not paperwork. When supported by real-time insights, automated follow-up tools and additional workforce support via care navigators, providers can act more quickly, compassionately and efficiently.

Care navigators do more than make referrals; they become an extension of care teams.. Equipped with real-time insights, they can quickly connect high-need, high-cost individuals to the proper care during pivotal moments, helping prevent crises and close gaps in care.

To support these healthcare shifts, states and providers need integrated tools that provide seamless physical and behavioral health insight beyond simple data points. True integration should act as a compass, supporting patients through complex journeys. One way to do this is using Intelligent Assist (IA)—technology that enhances decision-making rather than replacing it.

IA supports human decision-making, allowing care teams to spend less time searching for information and more time acting on it. In contrast to traditional AI, which tends to stop at prediction, IA promotes action and can help teams confidently take the next step.

Behavioral healthcare is whole-person health, and it demands a whole-system response that connects people to care, supports clinicians with context and guides every stakeholder through an often-confusing landscape.

As care teams and governments face increased costs, administrative burdens and workforce shortages, a consistent, coordinated approach to helping individuals navigate their care journey is needed. With the right processes, people and tools in place, no one should have to navigate care alone.

For more information on transforming behavioral healthcare coordination, download our strategy checklist or learn more about care navigation.

Rethinking the Next Site of Care: Leveraging AI for Smarter Patient Placement

Posted on by Jaime Conlan

Discharging a patient without the whole picture can lead to costly missteps. Too often, patients are discharged from emergency departments and other acute settings to high-cost, unnecessary post-acute care because providers lack full visibility to guide the best next step.

Home health services may provide a more cost-effective and outcome-driven solution for specific individuals than traditional discharges. By optimizing the site of service with AI-driven decision-support, providers can ensure that patients receive the right level of care, whether in a post-acute facility or at home with support, while avoiding unnecessary expenses and improving health outcomes.

Patients Have Distinct Care Needs, Requiring Streamlined Decisions During Pivotal Moments

When a provider determines where to refer an individual for follow-up care, individuals often fit into three categories:

  • Facility-based post-acute care means that an individual with high care needs would benefit from long-term facility stays.
  • Home care with support means an individual has low support needs and would be a good fit for home care.
  • “In between” means an individual has varying contributing factors that could make them a good fit for either facility care or home-based care. However, since the decision is not entirely straightforward, the individual could be at risk for potentially unnecessary and costly care.

Individuals who are in the “in between” category traditionally fall into this gap where greater decision support is needed. With emerging decision support technology, providers can easily analyze clinical, functional and social factors to guide decision-making on post-acute care, including information on:

  • Patient mobility tools, such as the use of a walker or wheelchair
  • History of memory issues or confusion
  • Medication management history and ability to manage at home

With such a wide variety of data points to manage for each patient, providers and value-based care organizations will need tools that maximize efficiency with zero data entry required.

These tools help providers assess the best discharge option, ensuring patients receive the most suitable care setting while alleviating financial strain on the healthcare system. Organizations need actionable, AI-driven insights proven to reduce unnecessary SNF and IRF utilization in real time.

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Data Supports Home Health as an Effective Alternative

A study of 1.6 million patients found that skilled nursing facility (SNF) and home health discharges resulted in equivalent readmission rates. This suggests that for many patients, home-based care can achieve the same quality as institutional settings when appropriate, at times at a lower cost and with greater patient comfort.

As hospitals and emergency departments seek to optimize discharge planning, weighing cost and clinical outcomes is essential. AI tools offer tailored, evidence-based site-of-care recommendations in real time by rapidly analyzing clinical, functional and social data.

When lower-acuity settings, such as home health, offer the same benefits as more intensive facilities, providers can improve efficiency while maintaining quality care. Accountable care organizations can also reduce excess SNF and inpatient rehabilitation facility stays with early and appropriate referrals to palliative care and hospice.

Moving Toward Smarter, Cost-Conscious Care

The healthcare industry is shifting toward site-of-care optimization, emphasizing lower-cost settings like home health, ambulatory infusion centers and physician offices. By leveraging innovative, AI-driven placement tools and prioritizing site-of-care optimization, healthcare organizations can improve patient outcomes, reduce unnecessary admissions and ease the financial burden on the system.

To learn more, check out an overview of solution options or contact us.

Insights on Solving Healthcare Fragmentation From Jeff Smith, as Featured in Forbes

Posted on by Jaime Conlan

Did you know the U.S. spends twice as much per person on healthcare as other wealthy nations, yet we still lag behind in terms of outcomes like life expectancy and infant mortality? Bamboo Health’s Chief Executive Officer, Jeff Smith, recently had the pleasure of sharing insights with the Forbes Technology Council on how to solve healthcare’s toughest fragmentation challenges.

(To see an enlarged version of this graphic, visit here)

Without affirmative answers, organizations may continue to invest heavily in care coordination and focus on common chronic conditions and comorbidities but fail to address underlying behavioral health challenges and leverage real-time insights when it’s needed most.

To read more, check out the full article or continue the conversation with us.

Update on Latest Healthcare Regulations in New Administration

Posted on by Jaime Conlan

The start of 2025 has brought several potential changes to the larger healthcare market.  Check out the latest to stay informed about potential regulatory shifts.

  • Senate confirmation of nominees to serve in key government posts will help advance the agenda of the Trump Administration. With trifecta control, the Republicans are well positioned, at least through 2026, to advance their policy agenda. This includes a strong focus on drug control and diversion activities, such as Make America Healthy Again, as well as the reduction of government fraud, waste and abuse. To date, Robert F. Kennedy Jr. has been confirmed as Secretary of Health and Human Services and Doug Collins has been confirmed as the Secretary of the Office of Veterans Affairs. At the sub-cabinet level, Dr. Marty Makary (FDA) and Dr. Mehmet Oz (CMS) have also been confirmed. Terrance Cole (DEA) is pending confirmation. Steve Davis and Amy Gleason (previously CPO of Main Street Health) have been tapped to lead the Department of Government Efficiency (“DOGE”).
  • Continued flurry of Executive Orders and Memorandums coming out of the Trump White House. Of note is the regulatory freeze and the deregulatory agenda of the new Administration – for each new regulation, 10 regulations must be eliminated. This is a high bar for any agency, and there has been a noticeable slowdown in rulemaking by the new administration and postings in the Federal Register.
  • Congress avoided a pending government shutdown and funded the federal government through Sept. 2025 with the passage of the Continuing Resolution. Now, Congress and the Administration have shifted their focus to the reconciliation process which could result in reductions to spending in a variety of categories, including programs such as Medicaid. Mandatory spending on priorities like defense, social security, Medicare and Medicaid currently accounts for 60% of all government spending. Efforts to reduce the size and scope of the federal government and pay for the continuation of the Trump tax cuts are not likely to be achieved without offsets that involve reductions in mandatory spending. To that end, the House-passed Budget Resolution has directed the Energy and Commerce Committee to find $880 billion in savings – a large portion of the budget under the jurisdiction of the Energy and Commerce Committee is for Medicaid. The details of what specific cuts would be made, or how the Senate will negotiate budget cuts to align with its own Budget Resolution, are being considered as part of the reconciliation process right now. This process could last several months. Because reconciliation requires a simple majority to advance, Republicans could move reconciliation through both the House and Senate without any Democrat votes, so that the negotiations will happen within and among Republican negotiators. A reduction in federal Medicaid cost sharing would lead to cost shifting of state budgets. As states must balance their budgets, reductions in federal funding for the Medicaid program at the state level will likely lead to further adjustments at the state level, although the extent and focus of those reductions will vary by state.

While the Republicans are expected to maintain control of the Senate for the foreseeable future, the Trump Administration is viewing 2025 and 2026 as valuable windows to pursue their agenda. Expect more to come in the months and years ahead as the Trump Administration seeks to redefine and reshape the role of the federal government.

At Bamboo Health, we’re committed to helping organizations navigate any changes with actionable insights and strategies. Contact us today to learn how our solutions can empower life-improving actions for everyone experiencing physical and behavioral health disorders.

Unlocking the Full Potential of PDMPs Through Integration

Posted on by Jaime Conlan

Prescription drug monitoring programs (PDMPs) are one of the most powerful tools in addressing the opioid epidemic, yet many are still not utilized to their full potential. Gone are the days of relying only on traditional PDMPs that were isolated from the broader healthcare system – today’s advances in integration and interoperability have propelled PDMPs beyond their original scope, enabling healthcare providers to access real-time data that informs clinical decisions and improves public health outcomes.

Here are three ways PDMPs can work better for your organization:

  1. Optimize integration to turn data into actionable insights: Integration is critical to optimize access to timely insights without disrupting care. Organizations can turn data points into actionable insights by embedding PDMP data directly into electronic health records (EHRs) and other healthcare data systems. Seamless integration eliminates the need for manual lookups, reducing workflow disruptions and allowing providers to make informed decisions at the point of care. With insights on prescription histories and potential red flags such as high dosages or dangerous drug combinations readily available, clinicians can proactively address risks and tailor treatment plans to individual patient needs.
  2. Connect physical and behavioral health context to controlled substance monitoring: While PDMPs have traditionally focused on tracking controlled substance prescriptions, organizations must look beyond conventional data sources and incorporate additional insights that provide a more comprehensive view of a patient’s health. By surfacing broader physical and behavioral health insights within clinical workflows, healthcare organizations can enhance care coordination and implement more effective intervention strategies. Organizations can then maximize effectiveness by choosing a partner with an engaged network of interconnected data sources to surface additional data beyond what is traditionally collected, including: admission, discharge and transfer (ADT) data, behavioral health crisis referrals into PDMPs, nonfatal overdose monitoring and actionable insights on history of medication for opioid use disorder.
  3. Gain deeper controlled substance insight: PDMPs are now evolving to also help identify patients who have stopped taking buprenorphine or other medication-assisted therapy drugs, which could represent an increased risk of relapse or overdose. With this deeper level of proactive insight, providers can take prompt action and support intervention efforts.

The landscape of PDMPs continues to evolve, and integration remains a key driver in unlocking their full potential. By embracing advanced interoperability, expanding data sources and leveraging real-time insights, healthcare organizations can transform PDMPs from regulatory tools into life-saving resources.

To learn more, download our whitepaper or contact us.

How the Delaware Division of Substance Abuse and Mental Health Unifies Interstate Data for Improved Outcomes

Posted on by Jaime Conlan

Despite Delaware’s small population size of one million, nearly 15% of the state population (150,000 adults) have a mental health condition and 42,000 have a serious mental illness. We sat down with Michelle Singletary-Twyman, the Division Director of Operations at the Division of Substance Abuse and Mental Health in Delaware, to learn more about Delaware’s current care collaboration challenges and goals.

Q: How does Delaware currently approach care coordination?

A: “We use DTRN360, or the Bamboo Intelligence Hub™, as the care coordination platform that the Division of Substance Abuse and Mental Health Developed in collaboration with Bamboo. Our goal with the platform was to establish an opportunity for providers to have one central location to have data available to them about the clients so that they can help coordinate their care. Currently, people have to use fax and email to get information. The goal was to create a hub of information for providers to be able to have at their fingertips a client’s care journey and what medications they’re on, who their last provider was, and if they showed up to the appointment. All that information is easily accessible, so you’re helping the client to make the next plan for their level of care.”

Q: What criteria did you have for selecting a partner?

A: “We identified Bamboo as the front runner during the process, the entire group, based on the technical plan that they came up with for implementing a project like this. No one has this in place, so we had to create it. We had to find a provider that saw the clinical application, not just the IT application, which was really critical, and for someone to have a plan help us facilitate the consent process that we thought would work with our providers and be willing to work with other providers that might need to be needed, because the platform had to include social determinants of health as well, and we knew that someone may not have everything, but they would need to be able to collaborate with another provider to make sure we have every area covered in the platform.”

Q: Did you have a specific population in mind when improving care collaboration?

A: “The State of Delaware contracts with care teams to provide services for the uninsured. Although our contracts cover the services for anybody that can use insurance, it also we make sure we have the funds available for the uninsured. What we did was strategically track our clients that we already have, so we could identify where they were, and we utilized that client roster to establish the clients that we would get Pings™ on Thanksgiving weekend. Believe it or not, we found that we had clients that were all the way out in Nevada and our act teams are struggling to find people. Lo and behold, some of them were not even in the state. That was groundbreaking for us to go. We’ve got these clients, and we’re looking for them, and they might not even be here, and with Pings, we’d at least know where they are. We just had chills finding that information out, because we had no idea people were moving around like they were.”

Q: How did you envision this program reducing administrative burden?

A: “Remembering as a floor nurse and not having information to care for people who were in a psychotic state and they couldn’t tell you what was going on with them, whether they wanted to share the information or not, and we just had to figure out what they needed, because they weren’t able to tell us what they had had before for medications, or what treatment they’ve been involved with, or if this is the first time they’ve ever come for treatment. Just knowing this is going to help people to get what they need, I would encourage every state to try and adopt something like this. It will help people. It will save lives, and I think people be a lot more satisfied with their work because you can actually do the work you came to work to do.”

 

To learn more, watch the full video here on our resources page or contact us for more information.

What Is Real-Time Care Intelligence™?

Posted on by Jaime Conlan

In healthcare, every second counts, especially during pivotal moments in an individual’s care journey. At the pharmacy, hospital or crisis center, individuals count on providers to deliver life-saving care when it’s needed most. Yet outdated processes and manual systems can often hinder this process. Providers need more timely and accurate information to deliver on their most profound promise to individuals in their care.

To do so, Real-Time Care Intelligence™ empowers healthcare professionals with the information they need when they need them most, delivered seamlessly at the point of care. These actionable insights are accessible directly in daily workflows and illuminate an individual’s physical and behavioral health context, improving whole-person care outcomes.

The Core Components of Real-Time Care Intelligence

  1. Actionable Insights That Go Beyond Raw Data: Real-Time Care Intelligence leverages Knowledge for Good® to provide healthcare providers with distilled, holistic information directly relevant to clinical decision-making. This includes actionable insight on an individual’s medical history, current conditions, medication usage and social determinants of health.
  2. Real-Time Data Sharing: A critical aspect of Real-Time Care Intelligence is the ability to share and access actionable data across various healthcare settings instantaneously. This ensures that all care team members have the most up-to-date information, facilitating seamless transitions and coordinated care efforts.
  3. Engaged Care Collaboration Network: Real-Time Care Intelligence is bolstered by Bamboo Health’s extensive network of 52 states and territories, 100% of the top 10 best hospitals and more than half of the country’s largest health plans to improve more than 1 billion patient encounters annually. This network connects stakeholders across the healthcare continuum to facilitate sharing critical context on an individual’s care needs across hospitals, primary care providers, specialists, behavioral health professionals, social services and more. This interconnectedness allows for a more holistic approach to care.

The Benefits of Implementing Real-Time Care Intelligence

  • Enhanced Care Coordination: By providing real-time alerts and updates, Real-Time Care Intelligence ensures that all healthcare providers involved in an individual’s care are informed of significant events, such as hospital admissions or discharges. This promotes timely follow-ups and reduces the likelihood of redundant tests or procedures.
  • Improved Patient Outcomes: Access to comprehensive and timely patient data enables providers to make informed decisions, leading to better management of chronic conditions, reduced hospital readmissions and improved health outcomes.
  • Cost Reduction: Efficient care coordination and the prevention of unnecessary procedures contribute to a reduction in healthcare costs. For instance, organizations utilizing Real-Time Care Intelligence have reported significant savings through decreased readmission rates and optimized care transitions.

Real-Time Care Intelligence in Action

Consider a scenario where an individual with multiple chronic conditions visits the emergency department (ED). With Real-Time Care Intelligence, the individual’s primary care physician (PCP) receives an immediate notification that their patient is in the ED. Upon discharge, the PCP is alerted with a summary of the visit, enabling them to promptly schedule a follow-up appointment and adjust the patient’s care plan as necessary. This real-time communication ensures continuity of care and reduces the risk of complications.

Real-Time Care Intelligence represents a transformative approach in healthcare, emphasizing the importance of timely, actionable insights and comprehensive data sharing. Healthcare organizations can enhance care coordination, improve outcomes and achieve greater efficiency in service delivery. As the healthcare landscape evolves, embracing Real-Time Care Intelligence can be a crucial avenue for providers aiming to deliver high-quality, whole-person care.

Learn more about specific use cases for leveraging the power of real-time care intelligence on our case studies page.

 

 

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