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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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
PromisingWhat does this mean?