The University of New Mexico team behind Project ECHO, a program that brings skills and niche expertise to medically underserved communities, is taking on perhaps its greatest challenge: improving care and lowering costs for “superutilizer” patients, many with serious mental illnesses or addictions in addition to their physical health problems.
Since 2003, the Project ECHO team (short for Extension for Community Health Outcomes), led by Sanjeev Arora, MD, has been training groups of primary care clinicians to handle conditions such as hepatitis C, diabetes, and epilepsy. Through videoconferencing sessions that combine didactic instruction with case-based learning, the primary care clinicians, who generally work in small or solo practices, present cases and learn from experts and each other. Over time, they gain the confidence and competencies needed to manage particular conditions.
Project ECHO’s approach began when Arora, a gastroenterologist, was troubled to find that New Mexico’s prison inmates and rural residents often went untreated for hepatitis C due to lack of specialists, distance to a specialized treatment center, or long waits for an appointment. His early efforts in hepatitis C worked better than Arora imagined. Within two years, the number of clinics treating the disease increased more than tenfold, and wait times for specialists fell from 18 months to two weeks. Enhancing the ability of primary care practices to treat more of these patients clears the way for the sicker patients to gain faster access to specialized centers. “The ECHO approach decongests the system in a sense,” Arora says, describing the approach that has become known as “moving knowledge, not people.”
Following the mantra of “Changing the World, Fast!”, Arora and his colleagues expanded Project ECHO from hepatitis C to other conditions (see graphic). And they have taught colleagues worldwide to use their approach, creating more than 70 ECHO-style training hubs in universities, health systems, and governments in 13 different countries. At the U.S. Department of Defense, for example, specialists are using virtual case conferences to support clinicians on aircraft carriers and overseas bases as they treat soldiers suffering from chronic pain. The model is also being used to train clinicians in community health centers in Chicago to address patients’ persistent hypertension and other needs.
Using ECHO to Manage Complex Patients
In their latest effort, the ECHO team is using a $8.4 million grant from the Center for Medicare and Medicaid Innovation to target the subset of New Mexico’s Medicaid beneficiaries who account for a disproportionate share of spending. As Project ECHO began working with these superutilizer patients, it became clear that a staggering number — some 90 percent — grapple with behavioral health conditions (in particular, substance abuse and personality disorders) that are often confounded by poverty and homelessness. “Behavioral health problems have turned out to be the elephant in the room for the complex care patient,” says Miriam Komaromy, MD, associate director of Project ECHO.
To meet this challenge, Project ECHO relies on University of New Mexico (UNM) psychiatrists, addiction medicine specialists, counselors, community health workers, and other experts to train primary care teams caring for complex patients in the state’s urban and rural areas. It’s the first time they’ve trained teams, rather than individual clinicians — a recognition suggesting that addressing patients’ medical, behavioral health, and social needs requires a full-court press. The teams, which are staffed and funded by Medicaid managed care plans, include a lead clinician (either a nurse practitioner or physician assistant), a nurse, a social worker (or counselor), and two community health workers. The latter play a crucial role in engaging patients by linking them to support services and coaching them on ways to stabilize their lives.
For example, if a primary care team is trying to address the needs of an oil field worker who developed an addiction to pain pills after a back injury, UNM experts might offer guidance on how to prescribe medications to treat the opioid addiction, how to assess suicide risk, and how to talk to someone who resists treatment. Such patients frequently turn up in clinics in New Mexico, which is among states most affected by a nationwide epidemic of drug overdoses.
Early results of Project ECHO’s complex care program are promising. Komaromy says that ProjectECHO, using their own survey, found that after 12 months, nearly 80 percent of patients said they always got the help they needed, when they needed it. Using pre-post data, they also found that the number of hospitalizations fell by 27 percent and emergency department visits dropped by 32 percent.
Resources Needed to Treat Complex Patients
As states expand their Medicaid programs, they are likely to uncover many such complex patients. “The number of people with Medicaid coverage who have comorbid behavioral health conditions is very high, higher than the general population,” says Benjamin Miller, PsyD, an assistant professor in the Department of Family Medicine at the University of Colorado and advocate for integrating behavioral health into primary care medicine.
But the ability to spread approaches such as the one ECHO uses for superutilizers will depend on finding sustainable financing to pay for the teams and other resources needed to convince more primary care providers to welcome complex patients into their practices. “Models like Project ECHO are very good at increasing the capabilities of practitioners in field,” notes Roger Kathol, MD, president of Cartesian Solutions Inc., a consulting firm that offers strategies for integrating behavioral and physical health services. But reimbursement to pay for the complex care they provide doesn’t always follow.
Arora agrees that to help patients with the most serious problems, providers need not only knowledge but support from care teams and payers. Right now, he says, “there is no financing system for getting the right knowledge to the right place at the right time. And you cannot solve this just by a simple thing.”