Speakers: Dr. Jenny Chang, Tufts Medicine Integrated Network  |  Dr. Nishi Rawat, Bamboo Health  |  Moderator 

Moderator: Thank you all for joining us for today’s webinar, “Proven Behavioral Health Navigation at Scale, How Tufts Medicine Connects Behavioral Health Patients to Care.” Before we begin, I’ll walk us through a few quick housekeeping instructions. 

We’ll begin today’s webinar with a presentation. You can submit any questions you have throughout the webinar by typing them into the Q&A box you see on your screen. We’ll follow-up with you directly after the webinar. Today’s session is being recorded and will be available after the event. 

You can use the same link you used to log in to today’s webinar to access the recording. If at any time you have issues with audio or visuals, just try refreshing your browser. You can also submit any technical questions into the Q&A box. We are here to help. 

With that, I’m pleased to introduce today’s speakers, Dr. Jenny Chang, Senior Vice President of Community Engagement and Market Growth at Tufts Medicine Integrated Network. Dr. Chang oversees behavioral health strategy across the network alongside her broader portfolio and population health and community engagement. Board-certified in family medicine and geriatrics, she has spent her career building multidisciplinary care models within accountable care organizations and other risk-bearing contracts. She serves as the executive sponsor for the Bamboo Health Bridge program rollout at Tufts Medicine. 

We also have Dr. Nishi Rawat, Chief Clinical Officer and General Manager of Care Navigation at Bamboo Health. 

Dr. Rawat leads the development of technology solutions that bridge healthcare silos and advance whole person care with a focus on behavioral health. A former emergency medicine and critical care physician at Johns Hopkins, she founded OpenBeds® to expedite access to behavioral health and crisis care, which Bamboo Health acquired in 2018. Thank you both for being here today. I will now turn the floor over to Nishi to get us started. 

Dr. Nishi Rawat: Great. Thank you. Today we’re going to talk about care navigation, specifically for mental health and substance use disorders. Jenny is going to start by giving us an overview of Tufts Medicine. We’ll then discuss challenges that Tufts has faced with respect to behavioral health. And then I’ll talk about our Bamboo Bridge® care navigation solution and our performance at Tufts. We’ll finish up with what’s next for both organizations. 

So, with that, Jenny, I’ll hand it off to you to give us an overview of Tufts Medicine. 

Dr. Jenny Chang: Thanks, Nishi. It’s nice to be presenting with you again, although virtually this time. 

So I’d like to take some time just to talk a little bit about Tufts Medicine. 

For those of you who have not heard of Tufts Medicine, we are the principal teaching hospital that’s affiliated with Tufts University and the Tufts University School of Medicine. And for those of you who like history, Boston’s quite rich with it. And it was actually founded originally in 1796 by some Bostonians, including Paul Revere and Sam Adams. And it’s had multiple iterations. 

It’s been called the New England Medical Center for a number of decades. But really what I want to describe is this coming together that’s been more recent. So in 2014, we went through a series of changes. We were actually named Wellforce at the time when Tufts Medical Center merged with Lowell General. 

In 2017, Melrose Wakefield Hospital was added. And then 2018, we had Care Home, which is our home health foundation, and we have an inpatient hospice. And the clinically integrated network only formed in 2021 by merging two preexisting entities. And then in ’26, we’re really proud to announce that we actually just opened our own inpatient behavioral health hospital, which is a joint venture. 

But the takeaway is that as we’ve come together, each entity has had their own processes. And we’ve really tried to become a system. 

And the behavioral health resources that have existed across those systems have been different in different areas. And so this is really a story about the journey of how we came to our integrated behavioral health strategy and how we’ve learned to work together. 

So the next slide, I’m going to speak about the Tufts Medicine Integrated Network. Now, this is the contracting entity for Tufts Medicine. And we have actually we serve as the population health engine for the system, and we’ve been contracting in value-based care risk arrangements for several decades now, actually. The first, alternative quality payment, plan that came out of Blue Cross Blue Shield started in Massachusetts in 2009. 

So, we’ve been in this space about really thinking about how we take care of patients as a whole, thinking about their total medical expenditure, thinking about their utilization. So, for our clinically integrated network, you can see here that we actually have close to 300,000 covered lives. And our physicians are actually half employed, less or more private than they are employed. And we only have about 100 BH clinicians our physicians in our network. 

So, when we think about bringing together a really heterogeneous group, we’ve actually got 523 separate independent businesses with separate tax IDs. We share governance. There’s a physician-led board, and we share risks together. So, it’s been a journey. 

One story I’m going to share is just that at one point, some of our employed psychiatrists felt like there might be competition with community providers. But the reality is we have way more behavioral health needs to go around than the resources that we have. And so this is why we actually designed an integrated behavioral health strategy. So, we actually hired Dr. Brent Forrester, who’s a world-renowned geriatric psychiatrist who really understands population health, to be our first service line leader. And in this journey of systemness, we’ve really needed to think about what do the patients need, where do they need them. If you look at the map, you can see our resources are dense in some areas and scattered in others. And so how do we think about what that landscape needs to look like in order to provide all of the patients that Tufts Medicine takes care of the behavioral health needs that they need? 

So, Nishi is going to dive next into sort of that landscape, and we’ll sort of pull it together how we got to where we are. 

Dr. Nishi Rawat: Great. Thanks, Jenny. Let’s first look at some of the national trends related to mental health. So now I’m sure many of these statistics are familiar with you, but let’s let’s go over them anyway just to set the stage. So right now in The US, about a third of the overall population has an underlying behavioral health need. When you look at that by payer type, that’s about quarter of commercial lives, a third of Medicare lives, and about 40% of Medicaid lives. 

Dr. Nishi Rawat: In addition, as many of you know, there’s a major shortage of behavioral health providers around the country with many people living in what we call designated mental health shortage areas. And patients with behavioral health conditions tend to be higher utilizers and cost more. For example, people who fail to receive aftercare following an emergency psychiatric visit have a six time higher chance of returning to the emergency department within two months. 

Jenny, is this consistent with what you’re seeing in Massachusetts and at Tufts in particular? 

Dr. Jenny Chang: Absolutely. On the next slide, I’ve sort of merged both the Massachusetts market and the Tufts Medicine market, but there are some really interesting numbers for those of you who like the numbers. 

When we think about prevalence in Massachusetts, you can see the numbers there. This data comes from CHIA, which is the Center for Health Information Analytics in Massachusetts. And it collects all of the health plans in the state. So, you can see the numbers actually aren’t that far off. 

I would say Medicare, Nishi, you had the numbers one and three about here. Medicare Advantage is a little bit lower. But in Massachusetts, what we’re seeing is that 11% of EDs are actually leading to emergency department (ED) boarding. They’re seeing patients coming in and there’s just not enough capacity in our hospitals to handle this. 

So boarding is something that we face Massachusetts. 

The other some interesting facts is that, in Massachusetts, it’s the second-longest ED wait time. So, it’s really not where patients should be getting care. And we’ll talk about this in the upcoming slides of really navigating patients to the right care at the right place at the right time. And also, six longest for BH visits in the country. 

So, we really do have a problem here. Some interesting things to note, though, the cost. If you look at the prevalence in Massachusetts and nationally, and the cost, and again, this is data from CHIA, we spend about 8.1% of the total medical expenditure on behavioral health needs. 

And so, Medicaid, it’s a little bit more aligned. 22.4% of the spend is on behavioral health, and Medicare Advantage only 2.3. And so, you might wonder, well, there’s this high prevalence, but we’re not actually spending that. 

Where is it going? And I’m going to get to that when we talk about the Tufts Medicine Integrated Network data dive that we did with our claims. I think the workforce component is another reason why we think about just behavioral health as a whole in our society. How do we think about the role that mental health and substance use plays, not just in the clinical setting, but also in our workforce? 

In Massachusetts, a report came out from the Massachusetts Health and Hospital Association that found that every 38 minutes, a healthcare worker is either physically assaulted, verbally abused or threatened, which is a really big problem. 

So in that with that background, thinking about, well, what does our data look like in our value-based care contracts? And so the nice thing about being a part of an integrated network is to be able to do this analysis on all of our claims. And what we found was maybe not startling, but I think for some of us it was. When you think about the percentage and the prevalence and the spend, you might wonder, well, where is that money going? 

And we’re actually seeing it in the metrics that we use to measure utilization. So, when you think about our patients that are being admitted for what used to be called preventable inpatient admissions is now called ambulatory care sensitive conditions. And those are the ones with heart failure, COPD, asthma, diabetes. And we’re seeing that of our preventable admissions in the inpatient setting for our risk patients, 80% of them actually have a co-occurring behavioral health condition. 

82% of those that are getting readmitted in the inpatient med-surg unit, we’re not talking about psychiatric hospital, 82% have a co-occurring BH condition. And 69% of our avoidable ED visits, those patients also have a co-occurring condition. And what we found is that if we can get people to care, to their behavioral health outpatient care, they do better. But we aren’t doing it very well. 

58% of those with a major BH condition, and 79% of those with what we consider a minor BH condition haven’t had an outpatient visit in 19 months. So that means someone goes to the emergency room three times a year or they get admitted, and then they go to urgent care, but they’re not actually billing for outpatient behavioral health or actually any outpatient visits in that time period. So like Nishi said, we know that patients, when they don’t have their behavioral health condition controlled, they spend more. The converse of that is if actually we get folks to their outpatient BH treatments, we know that they don’t spend as much. 

But we know that that’s not always easy. Right? And so how do we get people to that right place at the right time? And that’s sort of how we landed in this partnership. 

So, for the next slide, I do want to talk about this journey that we’ve had, again, this journey for systemness, but also the Tufts Medicine journey to provide integrated behavioral health. Part of, Dr. Forrester’s vision was to become the “it” system for behavioral health needs and this commitment that we have to patients to ensure that if they do have a behavioral health need or a substance use need, that we’re going to try to get them the care that they need. So, part of this mind shift, though, is it’s not just psychiatry alone. 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. So this is a simplified version of what we’re trying to build right now at Tufts Medicine. We have a comprehensive care model, and that’s inclusive of things like collaborative care. It’s really built on a primary care chassis. 

It requires care coordination to the resources that belong in that comprehensive care model, which could include a pharmacist. It could include a nurse. It could include a community health worker to address those social determinants of health. 

And then getting people to the right place. And at Tufts, it’s an academic institution. We have a lot of phenomenal clinicians and researchers, and we have a lot of specialty services, but we can’t be everything to everyone. And so what we were finding was that our services that we were providing weren’t always patients weren’t always getting aligned to those services. 

And so how do we build the infrastructure to be able to deliver really strong integrated behavioral health? And so, this is where Tufts Medicine Integrated Network as a population health entity, if you go to the next slide, will describe sort of that care navigation, that’s the center, component of how we’re actually trying to roll this out. So, the One Care team is the care team, the clinical care team that lives at the Tufts Medicine Integrated Network. And just to be clear, this is the model that’s built out primarily for our value-based care patients. 

For our PCPs who are referring, if the if they have a patient in their PCP practice who is in a value-based care contract, we still take care of them. But predominantly, this is built for our VBC patients, and it’s to support this care model. 

And these services are actually just of note non-billable services. So, when you think about collaborative care, which is based that’s more of a financial chassis to be able to provide integrated behavioral health in the primary care practice. But the One Care team is non-billable service services, and it serves as sort of the backbone for all of our value-based care patients and the care coordination that’s needed as part of the care model. So it’s sort of like a buffet. 

Because we have such a heterogeneous environment, we do have some practices that have embedded COCM. We have some practices that have hired therapists. And so, depending on what the need is of the patient, of the clinician, of the doctor who’s ordering who’s making referrals, we try to meet those needs. On the other side, on the right, you can see the services that we offer at Tufts. 

And we have what we’ve noticed is that in some areas, for example, at one point, our patients had a 6-8 week wait. But then our department of psychiatry said, our panels aren’t filling. Our doctors don’t have enough patients coming in. So there was this mismatch of the resources that we have the patients’ needs. 

And so this really was part of the problem we were trying to solve for. The other thing is the One Care team is not big enough to touch all of the 300,000 covered lives that we have, and so we were really thinking about how we could scale. So, this is how we landed with the Bamboo Bridge program, and I’m gonna pass over to Nishi to talk about all of the services that Bamboo Health had. And we actually already had an existing relationship with Bamboo Health. 

We’ve been leveraging the ADT feeds for quite some time, a number of years, and our staff was already leveraging that data to outreach to patients to begin with. 

Dr. Nishi Rawat: Great. Thanks, Jenny. So, before we dive into Bamboo Bridge, I’ll give a quick overview of Bamboo Health itself to help you understand how we’re partnering in the market. 

Alright. 

So here at Bamboo Health, we’ve been around for about fifteen years now providing data and tools to clinicians at the point of care to support the management of both mental health and substance use disorder conditions. So we’re not a Johnny come lately when it comes to behavioral health. Now with our prescription drug monitoring product, we serve about 50 states and territories and nearly every doctor and pharmacist in those areas. Our OpenBeds®, closed loop referral system, closed loop referral system is implemented across 14 states. 

And with our ADT product, we are working with 3,000 hospitals and 9,000 post-acute facilities, ADT, admission, discharge, transfer, aid product. Now with the increase in the prevalence of mental health and substance use disorder conditions since the pandemic, along with the overall recognition of their expense, our payer and provider customers have been asking us for more help with managing these populations. So, as a result, we stood up a care navigation service that leverages our data that’s emanating from those products I just spoke of. It leverages those data as triggers to identify those in need of urgent access to mental health and substance use disorder care and then drive action and desired outcomes at scale. 

Now, I’ll go more into detail as to how the solution works on the next slide. 

Dr. Nishi Rawat: So first, we use the products I just described to identify those in need, again, of urgent access to mental health and substance use disorder care. We call the, moments at which they need this care, we call them pivotal moments. For example, we know when someone’s in the emergency department having overdosed in need of urgent access to, let’s say, opioid use disorder care. We also know when someone’s being discharged from the inpatient psychiatric setting in need of follow-up care within a week. And we know from our prescription drug monitoring program data when someone is using controlled substances in a risky way. So, in addition to what we call these automated triggers, we put what we call an easy button in the physician or other clinician workflow so that clinicians can actively activate us to navigate their patients to the care that they need. 

So, after active or automated identification of those in need of care using our products or that easy button, we engage patients using a data-driven approach. We do a comprehensive intake, which includes disease-specific screeners for depression, anxiety. We then do clinical triage, and we get them to the most appropriate level of care as well as treatment provider. Now we, on the other side, manage networks of treatment providers. 

What we do is we measure the quality of these treatment providers using operational metrics, utilization data, as well as patient-level data. And then we use those data, those metrics, to curate networks based on the quality of the care that they’re providing, and we do that on behalf of our provider and payer customers. So, in short, for health system like Tufts Medicine or other provider, what we’re doing is providing air traffic control across any payer type for the patients and settings, primary care, ED, and inpatient, to standardize care and quality at scale. 

Now, Jenny will share some of the initial use cases designed to support system-wide efforts related to behavioral health at Tufts Medicine. Jenny? 

Dr. Jenny Chang: Thanks, Nishi. So the approach that we decided to take, actually, I would say is quite collaborative. Right, Nishi? We did sit down and we sort of talked about the use cases that we thought would be the best, to start with as we rolled this out. 

Again, with the vision being that we were going to get to a place that was a payer agnostic, place agnostic type of solution where really no wrong front door, where patients could get the care that they needed. And so we’d leveraged the workflows that were already in place. So right now, like I had said, our care team was already segmenting the population, identifying high risk patients in our VBC contracts and outreaching using those ADT pivotal care moments to do complex care or transitions of care. And the thought was that we would actually expand because we were only really touching a small percentage of patients that really needed needs and they weren’t segmented out with whether or not they had behavioral health needs or not. 

And so, we thought perhaps we would use the current chassis we would roll out with the Bamboo Bridge program, identifying all discharges from hospital or emergency department and even SNF, depending on what data was coming through, of patients who had a listed ICD-ten behavioral health diagnosis on that discharge data point. So those patients and then actually, we decided that we would bucket the patients into different groups. 

Our most complex patients that were already enrolled in complex care were going to stay with those care managers. But anybody else who hadn’t was going to start funneling to the Bamboo Bridge program, which was going to I don’t have the exact numbers, but it really drastically increased the volume of patients that we were going be able to touch daily. 

And so, we decided we would start with the actioning the ADTs and start triaging those patients, navigating them to care. And part of that appeal, I think, as Nishi pointed out, was this idea that the network is curated. And so, we were able to say to Bamboo, these are the patients that we want to go to our specialists. If we have certain specialists in house, Bamboo was gonna help us get those patients to those providers. 

But also, they were gonna ensure that if there was a long wait list, that they were going to actually get the patient in as quickly as possible and would help find in their curated network a partner who was going to be able to provide either therapy or med management as needed, and then close the loop by sending a note back to the primary care doctor, given that our integrated behavioral health strategy is based out of primary care, the Bamboo Bridge program, their care navigators would be able to get a note back and start developing a level of trust that the patients were being seen in a timely fashion, they were followed up on, there was clear communication, which then transitioned us into this PCP easy button. 

And so, the PCP easy button actually, already was in existence as well. We actually white-labeled the Bamboo Bridge program. 

So, the care management team was actually closing the loop in this situation, and the PCPs were able to then start referring more volume than they already did to for behavioral health supports. So again, we started with the ADTs and then the PCP easy button. We’re actually were able to roll them out quite quickly. Some of the challenges we faced were really just the technical connections of Bamboo not living in our Epic environment. 

And because of our practices, some of the privates are not on Tufts Medicine’s Epic platform, lots of different EHRs are thinking about how we can get a standardized approach to that loop closure. Nishi, is there anything you wanted to add about that, those two phases? Okay. Great. 

Perfect. And so, there were other phases we talked about as well, and that sort of flows into the future state of where we’re headed next. But we were able to, from an operational implementation team, our teams came together. We worked very, very closely. 

We met weekly. We went live, and, we were able to roll out these programs. But before we actually went live, we actually did want to align around metrics and outcomes. Sometimes it’s we found that it’s better to think about what you wanna measure before you actually move out get the horses out of the barn. 

And so this was sort of what we were thinking about. For us, outreach was one component that we could be doing better. We knew we weren’t touching as many patients as we wanted. In fact, our own team was spending an exorbitant amount of time calling and leaving messages, playing phone tag, and our actual, completed outreach percentage was only about 14%. 

So, we had some licensed clinicians who are making phone calls when they really could be working at the top of their license providing clinical support. So, in that way, we wanted to measure the scale. 

We also wanted to measure our time to scheduled appointments and the number of completed assessments. 

And then the engagement, whether or not our docs were referring more. And then, of course, the North Star metrics are always utilization when we think about our value-based care contracts and what we’re trying to accomplish in that regard. These are the key metrics I think most of you are familiar with. 

What is the utilization in the emergency department? What does our inpatient utilization look like? Specifically around those preventable, what we now call ambulatory care sensitive conditions, and then readmission rates. 

And now pass it to Nishi because she’s got the goods on and really how it rolled out. 

Dr. Nishi Rawat: So Yeah. 

Alright. Let’s look at the goods. Let’s look at our performance at Tufts Medicine. So, our performance has been relatively stable since we started working with Tufts over a year ago. 

But what you see here is a roll-up of the past six months of performance because that’s typically how we evaluate it. So over the past six months, we’ve seen about 3,000 cases or patients. This is across commercial, Medicaid, and Medicare lines of business, and, again, across multiple settings, ED, inpatient, and primary care. So, again, think air traffic control across Tufts Medicine. 

Approximately 65% of the time, we’re able to connect via call. We’re then able to complete an intake about half the time, as you see there, and then we’re able to schedule an appointment about half the time as well. 

Finally, are attending their appointments, that first appointment at a rate of 34%, which is quite high, benchmark to what you see out there with other hospitals as well as in the literature. Now note that all of these proportions that I just presented use the total number of cases as the denominator. You’ll also see that that scheduled appointment rate is slightly higher than the intake rate only because sometimes patients decline the intake, they waive that off, but they are willing to let us do the clinical triage component and schedule them with care. 

Now, in addition to these upstream metrics or process measures, we’ve seen nice decreases in ED and inpatient utilization, as well as a reduction in PMPM for those patients who attended their appointments. And I will dig into how we measured utilization on the following slide. 

Great. Thank you. 

All right. So in order to look at inpatient ED utilization, we used two main methods, and we used our own ADT, or admission discharge transfer fee data, that emanates from all the hospitals across Massachusetts. We have direct connections into the EHRs of these hospitals to get those data. Now we also received claims data from Tufts to validate our ED and inpatient utilization data and determine impact on total medical expenditure. 

So, we first evaluated ED and inpatient utilization using an interrupted time series, or ITS, approach. What we did was we followed the cohort who attended their first appointment over time and evaluated ED and inpatient episodes per patient. Now, of course, are limitations with this approach, namely related to, regression to the mean, as well as not being able to account for the effects of other value-based care programs on the cohort that we’re following. 

So, because of that, we also compared the impact on this cohort to other cohorts, specifically the set of value-based care patients who were referred to us but not engaged or didn’t have an intake performed. And we also looked at utilization for non-value-based care patients who attended their appointments. So that’s the methodology. Jenny, anything to add? I know it’s not perfect. It’s what we were able to do with the data that we had on hand as well as the resources. 

Dr. Jenny Chang: Yeah. I think the interrupted time series is really where we landed because that was there’s really no other way to do it. I think the caveat is just because it’s a larger integrated behavioral health strategy, we do have other programs that are happening in place. Some of these patients are engaging with other services. 

And I think it’s just a matter of time. I think regression to the mean is something that all clinical care management programs see and sort of worry about. But I think right now it’s too early to tell. We’re really just presenting data that we’re seeing. 

Not too early to tell, but whether we’ll sustained reduction is really what we’re hopeful for. 

Dr. Nishi Rawat: Yeah. That’s right. So, the pre time frame was four months or, sorry, a year, four quarters. And post right now, we’ve done a run out about four quarters as well. 

Dr. Jenny Chang: That’s right. 

Dr. Nishi Rawat: Great. 

So, what you see here is an overall summary of the analyses that we conducted along with results. And again, we believe that we’ve impacted ED as well as inpatient utilization, but we are unable to quantify any effect on readmissions at present because of the small number of events to date. 

Next slide, please. 

So, for ED utilization, we see an impact for the cohort that attended their behavioral health appointment, whether the trigger was the ADT for value-based care patients, primary care referral for value-based care patients, or primary care referral for non-value-based care patients. And that’s what you see there in the table. And that reduction at the top there is what we determine from the interrupted time series approach. Next slide. 

Similarly, for inpatient utilization, we see an impact on utilization for the cohort that attended their behavioral health appointment, whether the trigger was, again, for ADT for the value-based care patients, primary care referral for the value-based care patients, or primary care referral for non-value-based care patients. 

Jenny, anything else to add? 

Dr. Jenny Chang: Yeah, I just think it’s a nice way to have the cohort analysis juxtaposed to the interrupted time series. When you cohort the patients and you think about, I mean, again, it introduces challenges like selection bias. But for the most part, I find these numbers really, really interesting because you can see for those that, that didn’t engage, their utilization is high. And then for those that actually made it to the appointment, their utilization has gone down. 

And so, it’s nice to actually see sort of that the cohorts broken down are follow the hypothesis that we have, which is if you get patients to that outpatient appointment, then their utilization will improve over time. So, and then the next question is probably if we could continue that outpatient therapy, how long and sustained could we see that, you know, held up, that utilization, and we’re excited to continue this relationship and continue measuring it. So, but we appreciate I would say I really appreciate having a partner like Bamboo doing this type of in-depth analysis and really setting aside the time to really look at the numbers and dive deep. 

Because sometimes you roll out a program and you want the quick easy answers, but in this case, we’re really trying to be very diligent. We’re pulling out claims data, not just on utilization, but the total cost of care. So, it’s been a really nice, partnership in that way. 

Dr. Nishi Rawat: We appreciate that. 

Alright. Well, we’re nearly at the end of our time here. So I’m gonna throw it back to Jenny to discuss what’s next for Tufts as well as the Bamboo Bridge initiative. Jenny? 

Dr. Jenny Chang: Perfect. So, we started with the actioning the ADTs and then also the PCP easy button, and we do wanna move into other spaces. The first two were really around our value-based care contracts, but we wanted to think about the larger system. And so that’s why we’re thinking about expanding into the inpatient and the EDs as well. 

But just to note, we are increasing our use case with our actioning our ADTs. We’re actually thinking about leveraging Bamboo’s data, historical data. So sometimes you have patients that are seen in the hospital that don’t have their diagnosis code added to their discharge list of diagnoses. So, you may have someone who goes in for heart failure and is being readmitted, but they’re not being coded for that BH condition. 

So, our ADT, actually the ADT is we’re actually thinking about merging some of our own pop health data, our own diagnoses data to identify pockets where that ADT, when that pivotal care moment happens, we’re capturing and we’re not missing the opportunity to get folks engaged in behavioral health in addition to all the chronic conditions. So, there’s this new what’s next, there’s an expansion of our ADT. And then the PCP easy button, we’re actually planning to expand into an easy specialty care referral button. And we’re thinking or we’re planning, not thinking. 

We are close to operationalizing having this specialty button go live. So, if you have an oncologist or you have an OBGYN who really wants their patient to get access and navigate to behavioral health and substance use supports, they will be able to use that button. And it won’t really matter that they’re not in our value-based care contracts. If they have a need and they’re screened and they’re triaged by the Bamboo Bridge program, we’re gonna get them to that care. 

On the inpatient side, what’s been interesting well, inpatient and emergency department, and I’m gonna be transparent. We actually thought of doing the emergency department first, and it we ran into some challenges where each of the emergency departments had their own workflows for their own supports. One of our EDs has a full-time social worker that’s able to do crisis management. Others only have them on for certain hours during the day. 

So, we’re still working through the, you know, the processes of how we have a workflow that doesn’t rely explicitly on the emergency room doctor to have to put a referral in. We’re really thinking about how we can automate this so that patients get the care. 

That being said, Tufts on our journey has worked really, really hard to reduce ED boarding. And in that, we had put a ton of resources in to the emergency departments. But actually, the trend that we have seen as the state and I didn’t mention earlier, but Massachusetts also wrote rolled out this behavioral health roadmap that was fantastic legislation that then the executive office of Health and Human Services, the state level, started implementing, designed these twenty four hour helpline as well as these community based behavioral health community health centers that could offer urgent care within twenty four hours. 

So, as we started to see statewide programs expand, we found that actually our EDs were more decompressed. But where we were seeing a huge challenge was really, really complex sick patients with co-occurring behavioral health and substance use conditions. And so our departments of psychiatry actually moved to the staff and said, we actually don’t have the volume anymore in the emergency department. We’re seeing actually a rise in case of inpatient referrals. 

And these patients are coming back again and again and again and getting readmitted. And I think most folks here probably know that when you have a readmission within thirty days and the anchor diagnosis, you just don’t get paid. So, we’re providing unpaid care to patients who really might need more outpatient support. So, the thought is we’re going to start utilizing Bamboo Bridge to navigate our inpatients, whether or not they’re value-based care or not, into the community. 

The really nice thing about this program is that the silos that occur, team the discharges, but then doesn’t have jurisdiction to really follow or the infrastructure to follow that patient. And the ambulatory side of the house is just like sort of waiting to catch the patient and no one’s sort of following them in between. And the nice thing about the Bridge program is you might have the psychiatrist recommend a partial hospitalization program or an intensive outpatient program, but then no one’s calling to ensure that patient is attending the appointment. And what the Bridge program is providing is the ability to follow up with that patient, make sure that they go. 

If they don’t go, either reschedule them for that follow-up appointment or figure out a way to get them back to follow-up that care plan. So, we’re really excited about that because we think it’s gonna make a big impact on our readmissions once we start directly targeting those patients. And again, like I said, emergency department, we’re gonna have to figure out how we might automate it. The emergency room doctors are basically like, “Yes, please. 

Just take them all,” but we haven’t quite figured that out. The referral volume, we just worry won’t be high because the emergency doctors are so busy trying to just get all the services to the patients from their medical standpoint, that they would love some sort of automated pathway. So those are some of the, the things that we’re thinking about next and excited to think about really the scalability that, that can come and then some of the things that Nishith’s gonna talk about next, which we haven’t rolled out yet at Tufts, but we’re really eager to follow along to see where you’re headed in some of the more tech AI space. 

So thanks. 

Dr. Nishi Rawat: Yeah. So, you know, as you can see, we’ve had some nice results with Tufts, we’ve also seen similar results with our other payer provider partners, customers. And with the advent of generative AI, we see the opportunity to bottle what we’ve achieved, our processes, and really make an impact at scale. So right now, we’re using generative AI largely for non-patient-facing activities in terms of aggregating information across our different products to present to our care navigator. To do that, that outreach piece, to outreach to the behavioral health provider as well. 

And, that’s working well. The next step is really to have an, you know, agentic AI do that intake in a, you know, in a human way. We actually have already rolled out an end-to-end transitional care management solution for bread-and-butter cases, getting people coming out of the emergency department or inpatient setting and getting them into primary care, and we’re leveraging those capabilities now for our behavioral healthcare navigation service. So more to come. We are now testing our intake with a few partners, and then we’ll soon have this with AI end-to-end, like I said, shortly. So, more to come. 

In addition to, you know, achieving scale with AI, with the introduction of CMS’s access program, there are now opportunities to drive patient engagement and prevention of escalation of mental health and substance use disorder conditions in a lower-risk behavioral health population. 

And so that’s what we’re doing now as part of the CMS access program, with Bamboo Bridge being used to navigate higher-risk patients to the care that they need when that arises. 

Alright. Well, I think that brings us to a close. Jenny, any parting thoughts? 

Dr. Jenny Chang: I’m eager to see what’s going to come next in the next four quarters. 

Dr. Nishi Rawat: Alright. Fantastic. Thank you, everyone, for your time and attention. 

Moderator: That is all we have time for today. 

I want to thank you both for an excellent presentation, as well as Bamboo Health, for sponsoring today’s webinar. And to all of our attendees, thank you so much for joining us today. We hope you have a wonderful rest of your day.