Project ECHO’s Complex Care Initiative: Building Capacity to Help “Superutilizers”

Authors
Martha Hostetter
Sarah Klein
Douglas McCarthy
Case Study
August 2016

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.
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Population Addressed
People with Behavioral Health and Social Needs
Key Questions Answered
  • What are the key elements that make this complex care initiative effective for “superutilizers”?
  • What are the outcomes to date?
Level of Evidence
Promising
What does this mean?