“In a number of chronic condition combinations, there were significant predictors of sustained per-member-per-month (PMPM) cost savings when a connection to behavioral health outpatient care was made.”
Visar Tasimi – SVP, Provider Success
For years, health care has been fragmented for high-risk members. Behavioral health and medical programs traditionally operate in silos, leaving patients to navigate gaps on their own — even with physical and social barriers to care. In our recent webinar, Lucet’s Visar Tasimi (SVP, Provider Success), and Jill Sharp (SVP, Care Delivery), explored the risks of fragmented care, the importance of whole-person approaches, and practical strategies for bridging behavioral and medical needs.
The risks of fragmented care
The care experience for high-risk members is fragmented due to complexities like comorbidities and the coordination of multiple primary and specialty care providers. Tasimi noted that “roughly four in five adults over 65 have multiple chronic conditions and need care, and about three in five of these members over 65 are not up to date with the preventive services they should be.”
That gap widens when behavioral health needs come into play. Nearly 40% of Medicare Advantage members have at least one unaddressed behavioral health or social need. When those needs are unmet, costs rise, outcomes decline, and patients face barriers to care.
Lucet’s analytics team studied the impact of connecting patients with behavioral health outpatient care. “We found that in a number of chronic condition combinations, there were significant predictors of sustained per-member-per-month (PMPM) cost savings when a connection to behavioral health outpatient care was made,” Tasimi said.
“It’s crucial that we’re connecting with patients to address outstanding concerns or confusion they may have around how to care for themselves.”
Jill Sharp – SVP, Care Delivery
The whole-person approach
Holistic, multidisciplinary care can make a difference. According to Sharp, “Many patients are not only dealing with complex treatment plans, but they also face challenges in managing their care. They have unmet social determinants of health (SDoH) or behavioral health needs. It’s crucial that we’re connecting with patients to address outstanding concerns or confusion they may have around how to care for themselves.”
Those connections require timely triage and the right care team members to step in. Sometimes the need is straightforward, such as a community health worker (CHW) arranging transportation. Other times, it’s as serious as supporting a patient through a new cancer diagnosis. Either way, the impact of coordinated care can be profound.
To illustrate this point, the speakers examined the case of Betty, a 79-year-old who lives alone in a rural area. She has multiple chronic conditions, including diabetes, heart disease, and depression, which are all compounded by social isolation.
Initially, her care team suspected medication inadherence. But, during a home visit, a CHW uncovered the true issue: Betty’s eyeglasses were broken, and she couldn’t read her insulin pen. “Ultimately, the CHW discovered that Betty had broken her eyeglasses a couple months ago and was not able to read any small print,” Sharp explained. With help from her son, Betty got replacement glasses, solving what turned out to be an entirely social issue.
Later, during an in-home assessment with her longitudinal care team, a provider identified symptoms of major depression. A referral was made to behavioral health, and Betty was able to be seen within five days. A licensed clinical social worker joined her care team and contributed to her shared, patient-centered plan.
Betty’s journey demonstrates how a coordinated team — providers, nurses, CHWs, care coordinators and behavioral health specialists — can address medical, social and behavioral needs together.
Scaling the model for health plans
These principles can work at scale. Tasimi shared how Lucet partnered with a regional health plan serving Medicare Advantage, Medicaid and Affordable Care Act (ACA) members. The plan faced a familiar challenge: heavy reliance on emergency departments for chronic care, compounded by provider shortages, long wait times and long travel distances for members in rural areas.
“We were seeing that the health plan members relied heavily on the emergency department for chronic condition visits. Unfortunately, this is a very expensive outlet to use and inefficient in terms of member care,” Tasimi said.
Lucet designed an in-home program for 5,000 members, starting with the top 8% of those who were high-cost. Each began with a one-hour in-home health evaluation, followed by monthly or semi-monthly visits as needed. This model allowed teams to uncover gaps, build action plans and engage members on their terms.
The program delivered measurable impact, driving $650 PMPM savings and a 27% reduction in total cost of care. Tasimi shared additional results: a 26% drop in admissions, as members gained the right resources instead of relying on inpatient care, along with a 6% reduction in emergency room use. Just as importantly, members accessed behavioral health care within an average of five days — critical when time is of the essence. By removing friction and making care easier to access, the program achieved an overwhelmingly positive member experience, with 91% reporting high satisfaction.
Rachel Jenkins is a marketing manager at Lucet.
