Privia Health Partnership Recognized for Bridging Care Gaps for Medicare Advantage Patients


Lack of real-time data can present serious barriers to care coordination for patients after they leave the hospital. That challenge was the motivation for an innovative collaboration between Bamboo Health™, the leader in Real-Time Care Intelligence™, Humana and Privia Medical Group (PMG)–Georgia to bridge care gaps for patients enrolled in Medicare Advantage plans. The program was one of only 22 presentations selected for a Points of Light Award on May 14 at the 2024 K2 Collaborative Summit, a KLAS Research conference for health plans, providers and industry leaders.

“At Humana, we are dedicated to delivering personalized, high-quality care experiences for our members,” said John Cope, Director of Stars Technology at Humana. “Partnering with Bamboo Health and Privia in Georgia has enabled us to leverage cutting-edge technology to optimize care coordination and support our members’ healthcare journeys. This recognition reaffirms our commitment to driving innovation and fostering collaborative partnerships that positively impact patient outcomes and advance the future of healthcare.”

The collaboration, launched in Georgia, illustrates the value of health plans and provider organizations working together to achieve shared value-based care outcomes. Bamboo Health’s care coordination solutions, including Pings and Care Gaps, provided real-time notification flags for Transitions of Care (TRC) and post-ED follow-up for patients with high-risk multiple chronic conditions (FMC). This visibility allowed Humana’s health plan and Privia’s patient care teams to coordinate and monitor care from admission to discharge to post-acute and follow-up care. The proof-of-concept worked to avoid any gaps in care as patients pivoted from inpatient to follow-up settings within a 72-hour window.

By working together, the collaborative team was able to improve patient outcomes, reduce the risk of hospital readmissions, lower cost of care and better CMS Star Ratings. The results of the program included:

  • Increased visibility into patient whereabouts via Bamboo Health’s Pings platforms’ TRC & FMC flags over a 90-day period
  • 8.2 percent improvement in TRC measures by Privia
  • 3.2 percent ​​improvement in FMC measures by Privia
  • 84 percent of Pings alerts closed by Privia, resulting in timelier follow-up, better care coordination for patients/members, and improved provider satisfaction

“We are honored to be recognized alongside Bamboo Health and Humana for our collective efforts in driving innovation and improving patient care,” said Ryan Graham, Vice President of Practice Operations and Value-based Care at PMG–Georgia. “This collaboration exemplifies the power of technology-enabled solutions in bridging care gaps and enhancing care coordination. Through real-time insights and proactive interventions, we are improving health outcomes for our patients and strengthening the healthcare ecosystem as a whole.”

The project demonstrated that using technology to create strong governance structures and streamlined communication networks among all stakeholders is essential in improving alignment between health plans and care teams. Bamboo Health and Humana are currently assessing opportunities to add additional electronic health records (EHR) integrations and plan to expand the program to other provider organizations and markets across the country.