Depression, anxiety, and social isolation are common among older adults living with multiple chronic conditions. Yet behavioral health needs often go unrecognized and untreated. When that happens, the impact extends beyond mental health. Untreated depression and anxiety can make it harder for people to manage conditions such as diabetes, heart disease, and mobility challenges — often leading to higher use of emergency departments and hospitals.
A pilot program developed by VNS Health in collaboration with Vitalic, a geriatric-specialized behavioral health company, explored a different approach: proactively identifying Medicare Advantage members who may have unmet behavioral health needs and connecting them quickly to geriatric-specialized care through telehealth.
Early findings from the first six months of the program suggest that this proactive model may improve behavioral health outcomes and may also be associated with lower hospital use among medically complex older adults.
Download the full white paper to explore the program design, methodology, and detailed findings.
Key Findings
Analysis of the first six months of the program showed improvements in both behavioral health outcomes and health care utilization among participating members.
Key findings include:
- Depression scores (PHQ-9) declined by nearly 4 points
- Anxiety scores (GAD-7) declined by nearly 3 points
- Emergency department use decreased from 17.1% to 12.9%
- Hospital admissions decreased from 4.3% to 2.9%
Among a subgroup of participants whose depression improved from moderate or severe levels to mild levels, the combined rate of inpatient hospital stays or emergency department visits declined from 41% before enrollment to 18% after enrollment.
While reductions in hospital and emergency department use did not reach statistical significance, the observed patterns provide early signals that warrant further study
The program also revealed increased behavioral health needs among historically underserved populations, particularly non-English-speaking Medicare Advantage members.
Depression and Health Outcomes
Depression among older adults remains widely underdiagnosed, especially among people managing multiple chronic illnesses.
Research has shown that Medicare beneficiaries with comorbid depression incur more than 50% higher annual health care costs than those without depression. Much of that additional spending is driven by greater use of medical services rather than psychiatric care.
Despite these impacts:
- Fewer than half of older adults with depression are identified in primary care settings
- Only about 20% receive effective treatment
Clinical leaders involved in the program note that treating depression and anxiety earlier may improve a person’s ability to manage other chronic conditions, which can influence overall health outcomes and care utilization.
Identifying Needs Earlier
Traditional behavioral health care models often rely on referrals from primary care providers. Patients may face long wait times, transportation barriers, and other challenges accessing treatment.
The program evaluated in the white paper takes a different approach.
Using claims data and health assessments, health plan members who may have unmet behavioral health needs are identified proactively. Engagement specialists contact eligible members and offer an evaluation. Those who enroll receive telehealth care delivered by a multidisciplinary team with specialized geriatric expertise.
Treatment typically occurs during a roughly 12-week “acute phase” program that may include:
- Behavioral health coaching and case management
- Cognitive behavioral therapy
- Medication management
Care is delivered by a team that can include psychiatrists, psychiatric advanced practice nurses, social workers, and behavioral health coaches — all with specialized skills in geriatrics.
The program follows a phase-based care model, which prioritizes rapid engagement and focuses most clinical resources on patients with the greatest need. This approach aims to eliminate wait times and stabilize patients earlier in their care journey.
Expanding Access to Care
Early findings also suggest that proactive outreach may help address longstanding access barriers.
For example, 17% of enrolled patients were Spanish-speaking, compared with about 3% of the broader eligible population. This increase followed the addition of Spanish-speaking engagement specialists and clinicians, allowing the program to provide evaluation and treatment in Spanish.
The program also reached a large number of members living in the Bronx, an area with historically limited access to behavioral health services and high rates of psychological distress. Telehealth delivery helped remove common barriers such as transportation and provider shortages.
These findings suggest that proactive, telehealth-based models may help expand access to behavioral health services for populations that have traditionally faced challenges receiving care.
Why It Matters for Medicare Advantage Plans
In addition to improving clinical outcomes, the program helped identify previously undocumented behavioral health conditions among participating members.
When depression or bipolar disorder is diagnosed and documented, it can affect how Medicare Advantage plans calculate risk adjustment factors (RAF) — a system used by the Centers for Medicare & Medicaid Services (CMS) to adjust payments based on member complexity.
During the pilot, more participants qualified for relevant Hierarchical Condition Categories (HCCs) after their behavioral health evaluation, reflecting more complete identification of underlying psychiatric conditions.
Accurate diagnosis can help ensure health plans receive appropriate reimbursement for the complexity of care required by their members.
Early Program Results
The white paper describes the program as an early proof-of-concept study. While the initial sample size was relatively small and follow-up periods were limited, the findings provide encouraging early signals.
Participants experienced measurable improvements in depression and anxiety symptoms, along with trends toward reduced hospital and emergency department use.
As the program expands and longer follow-up periods become available, future research will examine its broader impact on patient outcomes and health care costs.
The findings suggest that proactively identifying and treating behavioral health needs may be an important step toward improving health outcomes while helping manage the cost of care for complex Medicare Advantage populations.