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

Hostetter M, Klein S, McCarthy D
Publication Year: 2016
Patient Need Addressed: Behavioral health, Care Coordination/Management, Chronic Conditions, Substance Use
Population Focus: Medicaid beneficiaries
Demographic Group: Adult
Intervention Type: Service redesign, Staff design and care management
Type of Literature: Grey

How a New Mexico program leverages the primary care workforce in rural and other underserved areas

Insights Results

Overview of Model

  • Through Project ECHO, a New Mexico offered services through a complex care team as well as regular video conferences during which a team of multidisciplinary experts offer training and advise in providing complex cases. Model began targeting Hepatitis C patients and has since expanded to other condition areas
  • Targets Medicaid beneficiaries who incur high costs due to substance abuse problems and/or mental illnesses, often accompanied by significant physical health problems
  • Most of the 425 current participants in the program received Medicaid coverage under New Mexico’s 2014 expansion to cover poor, childless adults. The ECHO team works with all 4 of the state’s Medicaid managed care participants
  • Participants enrolled through referral by managed care plans, community health centers, emergency departments and social services if they 1) Have 2 or more chronic conditions (including physical conditions, mental health problems, or chemical dependencies); 2) Have been hospitalized in the past 6 months and in the preceding 12 months, or have had 3 or more emergency department visits in the last 6 months. When enrolling patients, the nurse practitioner visits their homes to assess their health and living situation and works with them to develop a care plan
  • Key program features: 1) Interdisciplinary teams that support patients and each other: 5 teams work in regions of the state with high numbers of patients. Care teams are mad up of a clinical lead (nurse practitioner or physician assistant), registered nurse, primary care physician, 2 community health workers, and a social worker or counselor. 4 Medicaid managed care plans pay team members’ salaries and the plans’ care manager liaise with the teams in the field; 2) Community health worker (CHW) engagement: CHW’s built trust through continued engagement and finding tangible ways to improve their lives (e.g., getting free cell phone). CHWs also help patients make connections with their communities to reduce social isolation
  • 5 primary care teams are supported by a large and varied group of experts at the University of New Mexico, include a psychiatrist, physicians specializing in addition medicine, cardiology, chronic pain, endocrinology, gastroenterology, infectious disease, internal medicine, nephrology, and palliative care; a pharmacist, a counselor specializing in addiction treatment; and a community health worker. Project ECHO reimburses them of 0.1 of an FTE (i.e., 1 half-day per week) which overs their attendance at 2-hour bi-weekly video conferences with primary care teams, as well as time spent responding to team members’ questions via phone or email
  • Funding: Funded through public-private collaboration. In 2012, University of New Mexico received $8.4 million grant from the Center for Medicare and Medicaid Innovation to support administration of project, development of training curricula, video conferences, involvement of medical specialist and evaluation for 4 years. New Mexico’s Medicaid agency required state’s 4 managed care plans to participate and pay salaries of primary care teams


    • In the first 12 months, the number of hospitalizations among participants fell by 27% and emergency department visits dropped by 32%
    • After 12 months, 76% of patients said it was always easy to get the care they needed, compared to 21% at baseline. 87% of patients reported being very satisfied with their care at 12 months compared to 27% at baseline
    • Since 2003, ECHO has expanded the number of conditions for their teleECHO clinics. They have also taught many others to use their approach; there are ECHO-style training hubs in more than 70 universities, health systems, and government agencies globally
      Key Takeaways
    • Use of predictive modeling to identify patients most likely to be hospitalized, as a marker for high cost, proved to be very difficult to reliably contact the transient population Project ECHO targeted
    • Building trust in patients is credited by ECHO researchers as being critical to the model’s success
    • 1 area of future research noted: narrowing enrollment criteria and establishing automatic referral to the patients so they can establish ha control group against which to measure effects of the approach
    • Key lessons learned: 1) A primary care model providing hands-on support from dedicated teams, with guidance from a multi-disciplinary group of experts can improve health care outcomes and reduce costs for patients with serious behavioral and physical health problems; 2) Staffing and supporting the primary care team is challenging because it is very time consuming and emotionally taxing; and 3) Sustaining this approach will require evidence that investment has improved outcomes for patients, and spreading it may require partnerships with other payers, including Medicare