Integrated care in action: How forward-thinking providers are transforming behavioral health

Healthcare is evolving—not just in theory, but in practice. Across the country, forward-thinking providers are proving that integrating behavioral and primary care isn’t just possible—it’s transformational. These organizations are seeing fewer emergency visits, lower overall costs and better patient outcomes, demonstrating that high-need, high-cost populations can lead better lives with the right strategies.

One success story concerns an at-risk provider group recognized among the nation’s top performers. By fostering a collaborative partnership between primary care physicians and behavioral health specialists—particularly for individuals with serious mental illness and substance use disorders—this group has achieved remarkable outcomes. Through proactive engagement of these high-need patients, they have set a new standard of excellence, demonstrating the transformative power of integrated care.

In parallel, a forward-thinking Medicaid plan has strengthened care for its members by working with outpatient psychiatric hospitals to boost Follow-Up After Hospitalization (FUH) scores into the 90th percentile. This achievement unlocks significant Medicaid quality score payments and exemplifies how aligning best practices with measurable goals can spark sweeping improvements in patient care. Hospital readmissions for this cohort have remarkably improved.

Celebrating success

Too often, discussions about behavioral health focus on the hurdles rather than the triumphs. It is undeniable that 20% of Medicare beneficiaries—and an even higher proportion of dual-eligible individuals—struggle with behavioral health needs. We also know that preventable mental-health-related expenses cost the U.S. an estimated $477.5 billion each year, a figure poised to grow without targeted action.

However, across government-sponsored programs, forward-looking organizations are reducing avoidable costs by prioritizing integrated care. Patients with chronic comorbidities and serious mental illness are 2.8 to 6.2 times more expensive to treat and 25% more likely to experience preventable hospitalizations. By focusing on measures that reduce emergency department (ED) visits and readmissions, healthcare entities can enhance clinical outcomes while maintaining financial sustainability. Given the prevalence of behavioral health needs in the growing Medicare, Medicaid and dual-eligible populations, adopting these proven strategies is becoming an urgent priority for all stakeholders. Is this a strategic priority for you?

Considerations for developing integrated solutions

To weave behavioral health into the wider healthcare continuum, organizations should focus on four key areas—validated by the successes of leading provider groups and health plans.

1. Leverage technology for timely follow-up

a) Follow-up within 72 hours: Identify and engage high-risk individuals immediately following a pivotal care moment, such as an ED visit or hospital discharge. Advanced care coordination platforms, real-time data exchange and technology that supports human decision-making facilitate swift intervention, helping avert unnecessary admissions or readmissions.

b) Telehealth as a bridge to local behavioral health support: Telemedicine removes barriers like transportation, extending access to behavioral health specialists for individuals in underserved areas and maintaining patient engagement post-discharge. However, virtual care alone isn’t always enough. Individuals also need access to in-person behavioral health providers and crisis support when necessary. Ensuring a strong, high-performing behavioral health network helps sustain long-term engagement and continuity of care.

2. Align incentives between payers and providers—and share the impact

a) All-payer, all-population approach: Sustainable integration requires solutions that cover every population—commercial, Medicare, Medicaid and dual-eligible beneficiaries, ensuring consistent best practices for all. At the point of care, clinicians cannot be expected to discern and treat patients differently based on their payer type, making it essential to apply standardized, high-quality approaches across populations.

b) Measure and reward shared outcomes: Building HEDIS measures—such as FUH and Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse (FUA)—into contracts holds everyone accountable for ensuring that individuals get timely care. Timely follow-up directly reduces relapse risks and acute events, making these benchmarks vital for success.

c) Shared savings with specialists: Value-based reimbursement models reward high-quality outcomes and encourage deeper collaboration. By extending shared savings to behavioral health specialists, payers and providers alike commit fully to delivering holistic care. Ideally, this model also aligns primary care providers and behavioral health specialists within clinically integrated networks.

3. Cultivate robust practice engagement

a) Practice empowerment and comparative performance: Provider support with best practices, comparative performance and ongoing training help patients receive consistent, high-quality care. Who doesn’t want to help this population and be comparatively worse than their peers?

4. Prioritize equity and whole-person care

a) Address social determinants: Cultural competence, community partnerships and strategies that tackle housing, transportation and food insecurity make care accessible to those most need it. Recall that the majority of a patient’s life unfolds outside the physician’s office—strong support systems are crucial to long-term health.

b) Long-term recovery and resilience: Focusing on social determinants fosters trust and reduces stigma, ensuring behavioral health concerns are met with the same urgency as physical ailments.

Embracing a future of success

The evidence is clear: integrated behavioral health yields real, measurable results. Working alongside top-performing provider groups and progressive Medicaid plans, we have seen firsthand how these strategies succeed—even in the most complex environments. Organizations that embrace these approaches not only improve patient outcomes but also establish models that others are eager to follow.

In healthcare, the chance to reshape care delivery has never been greater. When success stories are shared, best practices become the rule rather than the exception. The benefits are far-reaching: patients receive timely, compassionate treatment; organizations can reduce costs while enhancing outcomes; and the entire system advances toward the reality of true whole-person care. By focusing on proven models that include robust technology and aligned incentives, we can finally address one of healthcare’s most persistent blind spots—treating underlying behavioral health challenges as an integral component of comprehensive care.

Jeff Smith is the CEO of Bamboo Health, which is focused on improving behavioral and physical health outcomes through the country's most powerful care collaboration network.