Sofia: From Anxiety-Driven Utilization to Self-Management

Connecting members to the care and support they need, wherever they are.

Sofia, a 45-year-old experiencing chronic anxiety and panic attacks, frequently sought emergency care due to misinterpreting symptoms as medical emergencies.

01. Challanges

Undiagnosed and unmanaged anxiety led to high utilization and significant disruption in daily life.

  • Key Drivers

    • Repeated ER visits due to panic episodes
    • No formal behavioral health diagnosis
    • Lack of coping strategies
    • Avoidance of daily activities
    • Persistent stress and fear

02. Approach

Behavioral health integration focused on diagnosis, treatment, and patient education to support long-term self-management.

  • Interventions

    • Behavioral health assessment and diagnosis
    • Cognitive behavioral therapy (CBT)
    • Psychiatric evaluation and medication support
    • Education on symptom recognition
    • Regular follow-up and reinforcement

03. Outcome

With appropriate care and education, Sofia gained control over her symptoms and reduced unnecessary utilization.

  • Outcomes

    • Elimination of avoidable ER visits
    • Reduced frequency of panic attacks
    • Improved confidence in symptom management
    • Return to normal daily activities
    • Enhanced overall wellbeing

Key shift: Sofia moved from fear-driven utilization to informed, self-managed behavioral health stability.

~70%+

Enhanced Care Management (ECM) – Care Coordination Impact

of DHCS quality measures tied to care coordination (MCAS) show improvement in access, timeliness, and continuity of care

Signal: ECM-driven coordination is directly improving member engagement and reducing fragmentation.

52%

Community Supports (CS) – Preventive & Whole-Person Care

of plans improved preventive care engagement (e.g., well-care visits) tied to upstream interventions and social supports

Signal: CS services (housing, nutrition, transitions) are contributing to better preventive care uptake and long-term outcomes.

90%

Behavioral Health (BH) – Follow-Up & Engagement

of plans meet benchmarks for follow-up after emergency department visits for substance use disorders (FUA/FUM measures)

Signal: Strong follow-up rates are improving stabilization and reducing repeat crisis utilization.

About Atlas Healthcare Alliance

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Coordinated care improving community health and wellbeing

Advancing Healthier Communities

Our mission is to advance healthier communities by delivering coordinated care management, behavioral health services, and community-driven support systems that address the full spectrum of medical, behavioral, and social needs. Through collaboration with healthcare providers, community organizations, and trusted community health workers, we connect individuals to the resources, services, and support necessary to improve health outcomes, promote stability, and empower members to live healthier, more independent lives.

Aligning healthcare, services, and community partners together.

Removing Barriers to Care

Our purpose is to remove barriers to care by aligning healthcare providers, social service organizations, and trusted community partners to deliver coordinated, person-centered support. By integrating medical care, behavioral health services, and community-based resources, we address the social and environmental factors that influence health and well-being. Through collaboration, culturally responsive engagement, and community health worker outreach, we ensure individuals can access the services, guidance, and support they need to navigate complex systems, stabilize their lives, and achieve improved health outcomes.

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