ECHO Care: a program to care for complex patients

1. ECHO Care: a program to care for complex patients Miriam Komaromy, MD Associate Director, Project ECHO

2. ECHO Care is a special health care program designed to support Medicaid patients who have complex health care needs

3. 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.

4. 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?

5. 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

6. 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

7. 5% of medicaid patients account for almost 60% of medicaid dollars Alittlereality.blogspot.com

8. Goals of ECHO Care Improve quality of care Decrease cost of care

9. The ECHO Care grant • Federal grant from the Center for Medicaid and Medicare Innovation “CMMI” • Part of the Affordable Care Act • 3 years, in two states: NM and WA • Focused on patients who have Managed Medicaid (and some whom also have Medicare) • 5000 patients, cared for by 20 teams

10. Who are the ECHO Care patients? • All NM Medicaid patients ranked by likelihood of hospitalization in next year • Mapped location of highest risk patients • Approximately 1/3 may be homeless • “Dual eligible” patients who also have Medicare tend to be older and have more chronic medical illnesses

11. 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 (5 if Medicare) • Hospitalization is frequent • Half of hospitalizations are thought to be avoidable • Reducing hospitalizations by half would save millions of dollars per year

12. High risk patients in NM

13. Where are the ECHO Care teams? • Greater Albuquerque metro area • First Choice Community Healthcare • UNM • Pres Medical Group • Farmington • Presbyterian Medical Services • Espanola Valley • El Centro Family Health • Southern NM?

14. How does ECHO Care address these problems? • 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)

15. Outpatient “Intensivist” Team (OIT) http://artastproductions.wordpress.com/2011/03/15/85/

16. Multidisciplinary, Integrated RN CHW NP Mr. L Counselor CHW ECHO Complex Care Specialists

17. Coordinated Greateribm.wordpress.com

18. ECHO Complex Care Clinic Improved access to coordinated specialty care

19. Why do we think this model will reduce hospitalizations? • 1 out of every 3 Medicare patients discharged from the hospital is re-hospitalized within 90 days • What reduces readmission? • Assigning a nurse care manager • Home visits • Hotline access to care • Medication reconciliation • All of these are part of ECHO Care Hansen, 2011 Naylor, 2011

20. Similar intensive, coordinated programs reduce hospitalization • ACT for severely mentally ill • PACE for frail elderly • Commonwealth Care Alliance • Camden Coalition • “Transitions” program

21. What’s different about ECHO Care? • Team is responsible for all primary care • Multidisciplinary—addresses social issues • Nurse-lead • “Real world” model: • “A Camry, nor a Rolls-Royce” • On-call access • Evidence-based care • ECHO specialty back-up

22. We are so excited to work with you to improve care for the most vulnerable patients in our society