is an innovative program designed to improve access to primary and specialty care for patients with complex needs while also reducing the cost of care by utilizing a multidisciplinary team-based approach. In New Mexico, the ECHO Care program expanded the capacity of primary care clinicians through:
- The assembling, training and placement of “Outpatient Intensivist Teams” (OIT) which dramatically improve care and reduce costs for the Medicaid beneficiaries served in this program.
- Special teleECHO™ clinic designed to support the OITs as they care for patients with significant multi-morbidity, including mental health and substance abuse.
The OITs are comprised of: a Nurse Practitioner or Physician Assistant, Registered Nurse, Behavioral Health Counselor/Social Worker, two Community Health Workers, and part time Physician as well as administrative support. These OITs provide in-home and office-based primary care as well as care management and coordination for their patients. The ability to provide care “where the patients are” greatly enhances the ability of the patients to receive help “when they need it and where they need it”. This type of comprehensive model has also been shown to provide a more rewarding work environment for the health care team.
OIT members present patient cases to a team of specialists during bi-weekly Complex Care TeleECHO Clinics via video-conference and receive immediate, integrated recommendations for treatment. The core team of specialists come from a variety of disciplines including: Chronic Pain, Cardiology, Addiction, Endocrinology, Pharmacy, and Psychiatry. These clinics will also provide OITs with the opportunity to review cases from other teams around the state so that they can share what they have learned working with similar situations or problems. This work environment, which provides for continuous learning and sharing of information, helps decrease the sense of isolation many clinicians feel when working in underserved or rural areas.
Patients also receive intensive services during transitions of care after hospital discharge that includes coordination of all aspects of care, and tailored patient education. When a visit to a specialist office is needed, the OIT will coordinate and often accompany the patient to their appointment. In addition, patients will have 24 hour access to care, and will have rapid access to face-to-face visits with the team when needed.
- Use the ECHO™ model to improve quality of care and reduce total cost of care.
- Increase overall primary care capacity to diagnose and provide the best treatment for high-need and high-cost Medicaid beneficiaries.