How Care Coordination Technology Can Close Behavioral Health Gaps in Medicaid

Medicaid is the nation’s largest payer of behavioral health services. Of the estimated 52 million non-elderly adults living with mental illness, Medicaid covers nearly one in three, about 15 million adults. Yet despite its reach, barriers to accessing timely, coordinated behavioral health care remain entrenched.

Deep disparities in specialty availability and geographic access shape access to behavioral health care within Medicaid. Only 35.7% of psychiatrists accept new Medicaid patients, severely limiting access to essential mental health and substance use disorder services.

Rural communities face a dual burden due to the limited availability of providers overall and the longer travel distances required to access care. On average, rural residents travel twice as far to reach a hospital (10.5 miles) compared to urban residents (4.4 miles), and access to specialty care is even more limited. With only 131 specialists per 100,000 people in rural areas, compared to 312 in urban areas, many Medicaid members must choose between forgoing care or incurring significant logistical and financial burdens.

These gaps result in delayed treatment, higher rates of untreated illness, and increased emergency utilization. For health plans and service providers, improving behavioral health outcomes requires both care coordination and technology-enabled strategies that connect members to available specialists and community-based resources, regardless of their location.

What is Care Coordination Technology

According to the Department of Health and Human Services, care coordination is the deliberate organization of patient-care activities and the sharing of information among all participants involved in a patient’s care to ensure that the patient’s needs and preferences are known, communicated appropriately, and used to deliver care that is safe, effective, and responsive.

In Medicaid behavioral health, technology can support both:

1. Broad care coordination: Integrating systems like electronic health records with community resource directories, transportation scheduling, housing services, and benefits navigation.
2. Specific care coordination: Equipping care teams with tools to assess needs holistically, build actionable care plans, improve transparency and communication across providers, and maintain ongoing bi-directional communication between patients and service providers.

When configured well, technology becomes the hub that connects every aspect of a member’s care journey.

How Technology Can Provide Solutions To Behavioral Health Gaps

Medicaid enrollees with behavioral health needs represent the program's most medically complex and costly population. As of 2020, nearly 40% of the non-elderly adult Medicaid population had a mental health or substance use disorder. Many also live with chronic physical health conditions at twice the rate of other members. This comorbidity drives high utilization of emergency care, inpatient stays, and other expensive services.

Furthermore, individuals with behavioral health disorders experience disproportionately higher rates of certain health-related social needs (HRSNs). Compared to those without mental illness, they face 2–5 times greater odds of severe loneliness and elevated needs related to financial strain, food insecurity, housing instability, and transportation. This high prevalence underscores the need for ongoing screening and resource coordination.

Yet, the current system still siloes care. One provider may never see updates from another. Specialist referrals may go unfulfilled without alerts back to the referring team. Social needs, such as housing instability, transportation needs, or food insecurity, may be assessed but often left unaddressed due to a lack of real-time follow-up.

While EHRs, telemedicine, and mobile health tools remain important, the next generation of behavioral health care technology takes it a step further by integrating social care coordination, communication enhancements, referral tracking, and data insights directly into the clinical workflow. Enhanced behavioral health technology will allow for:

• Unified Member Profiles: Consolidates physical, behavioral, and social care data into a single record accessible by authorized care team members, reducing information gaps.
• Task Tracking: Assigning and tracking service tasks until they are completed.
• Closed-Loop Referral Tracking: Ensures that when a provider refers a patient to a therapist, food pantry, or housing agency, the system confirms receipt of the service and addresses any follow-up needs.
• Communication Portals: Creates secure messaging channels between members, care coordinators, and community-based organizations, enabling proactive outreach and reducing missed appointments.
• Population Health Views: Identifies high-risk segments that require targeted engagement, such as individuals discharged from inpatient behavioral health stays without a follow-up visit.
• Integrated Data Reporting: Integrated data reporting will enable the efficient measurement of impact on health, cost, and quality outcomes.

Moving Toward Integrated Behavioral Health and Social Care

Medicaid's behavioral health population faces some of the most formidable care access barriers in the U.S., and social determinants of health magnify these challenges. Without the proper support, even the best clinical recommendations can fail to translate into improved outcomes.

Technology-driven care coordination offers a practical and scalable path forward. By connecting providers, streamlining referrals, and incorporating social services into the same platform as medical and behavioral health, programs that support Medicaid beneficiaries can replace fragmented care with an integrated, person-centered model.

This approach not only improves individual outcomes but also helps health plans and providers meet quality benchmarks, avoid unnecessary costs, and ensure that no member falls through the cracks.