This resource describes the Complex Care Initiative run by Project ECHO (Extension for Community Health Outcomes) at the University of New Mexico.

• In this initiative, interdisciplinary care teams provide therapy and medication to treat patients’ mental illnesses and addictions, provide hands-on support in managing their physical health problems, and connect them with housing and other social supports.
• The care teams receive regular coaching via videoconference from experts in addiction medicine, psychiatry, and other fields.
• The team’s key point of leverage is building trusting relationships with patients.
• For the first three years, the initiative was supported by an $8.4 million grant from the Center for Medicare and Medicaid Innovation and the four participating Medicaid managed care plans.
• In the first 12 months, the number of hospitalizations among participants fell by 27 percent and emergency department visits dropped by 32 percent.
• Reduced health care costs from this model may more than offset the salaries of the primary care teams.
• Challenges include staff turnover and burnout.