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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.

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Presentation Transcript
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ECHO Care is a special health care program designed to support Medicaid patients who have complex health care needs
slide3

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
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
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
The most complex and costly patients
  • Multiple complex illnesses
  • Doubly or “triply” diagnosed—physical, mental, and addiction diagnoses
  • Severe social barriers to health
  • Limited social support
why is the care of these patients so expensive
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
Goals of ECHO Care

Improve quality of care

Decrease cost of care

the echo care grant
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
Outpatient “Intensivist” Team (OIT)

http://artastproductions.wordpress.com/2011/03/15/85/

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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
Multidisciplinary, Integrated

RN

CHW

NP

Mr. L

Counselor

CHW

ECHO Complex Care Specialists

echo complex care clinic
ECHO Complex Care Clinic

Improved access to coordinated specialty care

where are the echo care teams
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
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
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
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
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Referral forms available at:

http://echo.unm.edu/echocare/e-mag/

for more information

For more information:

Andrea Zurawski

(505) 272-6930

Azurawski@salud.unm.edu