ECHO Care: a program to care for complex patients

ECHO Care is a special health care program designed to support Medicaid patients who have complex health care needs

Mr. L is a 54 year old man who has diabetes and high blood pressure. The diabetes has caused eye damage that has made him almost blind, and problems with his feet that lead to amputation of his right foot. He is on disability. He is depressed and isolated, and has trouble getting to medical appointments. He has been hospitalized three times this past year with pneumonia, a foot infection, and depression.

Our existing systems of care are not designed for patients like Mr L What kind of barriers would Mr. L face if he sought care in a traditional primary care setting?

Current system fails complex patients Fails to: Address social barriers Provide intensive outpatient care Provide coordinated care Integrate physical and mental health care Prevent hospitalization Contain costs

The most complex and costly patients Multiple complex illnesses Doubly or triply diagnosedphysical, mental, and addiction diagnoses Severe social barriers to health Limited social support

Alittlereality.blogspot.com 5% of medicaid patients account for almost 60% of medicaid dollars

Why is the care of these patients so expensive? Enormous burden of disease: physical and mental – 72% of patients have addiction diagnoses – 82% have mental illness diagnosis – Average of 3 chronic illness conditions Hospitalization is frequent Half of hospitalizations are thought to be avoidable Reducing hospitalizations by half would save millions of dollars per year

Goals of ECHO Care Improve quality of care Decrease cost of care

The ECHO Care grant Federal grant from the Center for Medicaid and Medicare Innovation CMMI Part of the Affordable Care Act 3 year grant Focused on patients who have Managed Medicaid 2500 patients, cared for by 10 teams across the state

Outpatient Intensivist Team (OIT)

How does ECHO Care support complex needs? Improves primary care - Team-based, multidisciplinary - Coordinated, high-intensity care - Integrated physical and mental health care - Addresses social barriers - Focus on transitions of care - Not billed as fee-for service care Improves access to coordinated specialty care – ECHO Complex Care Clinic (CCC)

Multidisciplinary, Integrated NP CHW RN Coun selor Mr. L ECHO Complex Care Specialists

ECHO Complex Care Clinic Improved access to coordinated specialty care

Where are the ECHO Care teams? Albuquerque metro area – UNM Southeast Heights Clinic – UNM Southwest Mesa Clinic Las Vegas, NM - El Centro Family Health Coming soon: – Memorial Medical Center (Las Cruces) – La Familia Medical Center (Santa Fe) – First Choice Community Healthcare (Albq S. Valley)

We are so excited to work with you to improve care for the most vulnerable patients in our society

Patients to refer to ECHO Care: Medicaid managed care Two or more poorly controlled medical/ behavioral comorbidities AND Two or more ED visits within the past 12 months OR One or more hospital admissions in the past 12 months that were related to poorly-controlled chronic conditions (excluding planned admissions)

Patients who are not eligible for ECHO Care: Younger than 18 years old Dual eligible, Medicare, or private insurance Residing in the long-term care facility Enrolled in hospice, ACT or PACE programs Moving out of ECHO Care area within 18 months

Referral forms available at: e-mag/

For more information: Andrea Zurawski (505)