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Karla  Thornton,  MD,  MPH  Professor  of  Medicine  (Infec8ous  Diseases)  Associate  Director,  Project  ECHO  University  of  New  Mexico  Health  Sciences  Center    

Project  ECHO  

Learning  Objec-ves  

• Describe  a  model  of  care  that  will  improve  access  to  best  prac8ce  care  for  chronic,  common,  complex  diseases  in  underserved  areas  

• Describe  the  4  components  of  the  ECHO  model  

• Iden8fy  how  to  par8cipate  as  a  partner  in  the  ECHO  project  

Moving  Knowledge  Instead  of  Pa3ents  

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The  mission  of  Project  ECHO®  (Extension  for  Community  Healthcare  Outcomes)  is  to  expand  the  capacity  to  provide  best  prac8ce  care  for  common  and  complex  diseases  in  rural  and  underserved  areas  and  to  monitor  outcomes.  

Project  ECHO:  Mission  

Supported  by  New  Mexico  Department  of  Health,  Agency  for  Health  Research  and  Quality,  New  Mexico  Legislature,  the  Robert  Wood  Johnson  Founda8on,  the  GE  Founda8on  and  Helmsley  Trust  

Hepa88s  C    

U.S.A.    4  M  

SOUTH  AMERICA  10  M  

AFRICA      32  M  

EAST    MEDITERRANEAN  

20  M    SOUTH  EAST  ASIA  

30  M  

AUSTRALIA  0.2  M  

Source:      WHO  1999  

WEST    EUROPE    9  M  

FAR  EAST  ASIA  60  M    

A  Global  Health  Problem  Over  170  Million  Carriers  Worldwide,  3-­‐4  Million  new  cases/year  

Hepa--s  C  in  New  Mexico  

• More  than  30,000  HCV  cases  •  In  2004  less  than  5%  had  been  treated  

•  40%  of  state  prisoners  with  HCV  –  none  treated    • Highest  rate  of  chronic  liver  disease/cirrhosis  deaths  in  the  na8on  

• Low  popula8on  density,  large  geographic  area  • 32  of  33  New  Mexico  coun8es  are  listed  as  Medically  Underserved  Areas  (MUAs)  

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Hepa--s  C  Treatment  

• Good  News  • Curable  in  45-­‐70%  of  cases  

• Bad  News  •  Severe  side  effects  • Anemia  100%,      • Neutropenia  >35%,    • Depression  >25%  

• No  primary  care  clinicians  trea8ng  HCV  

Goals  of  Project  ECHO  

• Develop  capacity  to  safely  and  effec8vely  treat  HCV  in  all  areas  of  New  Mexico  and  to  monitor  outcomes  

• Develop  a  model  to  treat  complex  diseases  in  rural  loca8ons  and  developing  countries  

Partners  

• University  of  New  Mexico  School  of  Medicine:  Departments  of  Internal  Medicine,  Telemedicine  and  CME  

• NM  Department  of  Correc8ons  • NM  Department  of  Health  • Indian  Health  Service  • FQHCs  and  Community  Clinics    • Primary  Care  Associa8on    

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Methods  

• Use  Technology  to  leverage  scarce  healthcare  resources  

• Sharing  “best  prac8ces”  • Case  based  learning  • Web-­‐based  database  to  monitor  outcomes      

Arora S, Geppert CM, Kalishman S, et al: Acad Med. 2007 Feb;82(2): 154-60.

What  is  Best  Prac-ce    in  Medicine  

• Algorithm  • Check  Lists  • Process  • Wisdom  Based  on  Experience  

Steps  

• Train  physicians,  nurse  prac88oners,  physician’s  assistants,  pharmacists  and  their  teams  in  HCV  

• Train  to  use  web-­‐based  soiware    • Conduct  teleECHO  clinics  –  “Knowledge  Network”  

• Ini8ate  case-­‐based  guided  prac8ce  –  “Learning  loops”  

• Collect  data  and  monitor  outcomes  centrally  

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Case Presentations

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Technology  

• Videoconferencing  Hardware  • Videoconferencing  Soiware  • Video  Recording  System  • You  Tube-­‐like  Website/Archive  • i  Health  –  Electronic  Clinical  Management  Tool  

• iECHO  –  Electronic  TeleECHO  Clinic  Management  Solu8on  

 

ECHO  vs.  Telemedicine  

ECHO  Telehealth  

ECHO  Supports  Community  Based  Primary  Care  Teams  

Pa8ents  reached  with  specialty  knowledge  &  exper8se  

Tradi8onal  Telemedicine  

Specialist  Manages  Pa8ent  Remotely  

How  well  has  the  model  worked  for  HCV?  

• >500  HCV  Telehealth  ECHO  Clinics  have  been  conducted    

• >5000  pa8ents  entered  into  HCV  disease  management    program    

• >300  prisoners  treated  in  the  DOC  • >6,000  CME/CE  hours  issued  to  ECHO  HCV  clinicians  

 

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Benefits  to  Clinicians  

• No  cost  CMEs  and  Nursing  CEUs  • Professional  interac8on  with  colleagues  with  similar  interest  

•  Less  isola8on  with  improved  recruitment  and  reten8on  

• A  mix  of  work  and  learning    • Access  to  specialty  consulta8on  with  GI,  hepatology,  psychiatry,  infec8ous  diseases,  addic8on  specialist,  pharmacist,  pa8ent  educator    

Arora S, Thornton K, et al. Hepatology. 2010 Sept; 52(3):1124-33.

Project  ECHO  Clinicians  HCV  Knowledge,  Skills  and  Self-­‐Efficacy scale:    1  =  none  or  no  skill  at  all  7=  expert-­‐can  teach  others

Community  Clinicians  n=25  

Before  Par-cipa-on  

Mean      (SD)  

Today  Mean  (SD)  

Paired  Difference  Mean  (SD)  

(p-­‐value)  

Effect  Size  for  the  Change  

1.  Ability  to  iden8fy  suitable  candidates  for  the  treatment  of  HCV.  

 2.8  (1.2)  

 5.6  (0.8)  

 2.8  (1.2)  

(<0.0001)  

 2.4  

2.  Ability  to  assess  severity  of  liver  disease  in  pa8ents  with  Hepa88s  C.  

 3.2  (1.2)  

 5.5  (0.9)  

 2.3  (1.1)  

(<0.0001)  

 2.1  

3.  Ability  to  treat  HCV  pa8ents  and  manage  side  effects.  

 2.0  (1.1)  

 5.2  (0.8)  

 3.2  (1.2)  

(<0.0001)  

 2.6  

Arora  S,  Kalishman  S,  Thornton  K,  et  al.  Hepatology.  2010  Sept;  52(3):1124-­‐33.  

Project  ECHO  Clinicians  HCV  Knowledge,  Skills  and  Self-­‐Efficacy  scale:    1  =  none  or  no  skill  at  all  7=  expert-­‐can  teach  others  

   

Community  Clinicians  n=25  

Before  Par-cipa-on  Mean          (SD)  

Today  Mean    (SD)  

Paired  Difference  Mean  

(SD)      (p-­‐value)  

Effect  Size  for  the  Change  

4.  Ability  to  assess  and  manage  psychiatric  co-­‐morbidi8es  in  pa8ents  with  Hepa88s  C.  

 2.6  (1.2)  

 5.1  (1.0)    

 2.4  (1.3)  

(<0.0001)  

 1.9  

5.  Serve  as  local  consultant  within  my  clinic  and  in  my  area  for  HCV  ques-ons  and  issues.    

 2.4  (1.2)    

 5.6  (0.9)  

 3.3  (1.2)  

(<0.0001)  

 2.8  

6.  Ability  to  educate  and  mo8vate  HCV  pa8ents.    

 3.0  (1.1)  

 5.7  (0.6)  

 2.7  (1.1)  

(<0.0001)  

 2.4  

Arora  S,  Kalishman  S,  Thornton  K,  et  al.  Hepatology.  2010  Sept;  52(3):1124-­‐33.  

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N=17   Mean  Score  (Range  1-­‐5)  

Project  ECHO®  has  diminished  my  professional  isola8on.   4.3  My  par8cipa8on  in  Project  ECHO®  has  enhanced  my  professional  sa8sfac8on.   4.8  

Collabora8on  among  agencies  in  Project  ECHO®  is  a  benefit  to  my  clinic.   4.9  

Project  ECHO®  has  expanded  access  to  HCV  treatment  for  pa8ents  in  our  community.   4.9  

Access,  in  general,  to  specialist  exper8se  and  consulta8on  is  a  major  area  of  need  for  you  and  your  clinic.   4.9  

Access  to  HCV  specialist  exper8se  and  consulta8on  is  a  major  area  of  need  for  you  and  your  clinic.   4.9  

Project  ECHO®  

Annual  Mee-ng  Survey  

Outcomes  of  Treatment  for  Hepa88s  C  Virus  Infec8on  by  

Primary  Care  Providers  

Results  of  the  HCV  Outcomes  Study  

Arora  S,  Thornton  K,  et  al.  N  Engl  J  Med.  2011  Jun;  364:2199-­‐207.  

Objec-ves  

• To  train  primary  care  clinicians  in  rural  areas  and  prisons  to  deliver  HCV  treatment  to  rural  popula8ons  of  New  Mexico  

• To  show  that  such  care  is  as  safe  and  effec8ve  as  that  given  in  a  University  Clinic  

• To  show  that  Project  ECHO  improves  access  to  HCV  care  for  minori8es  

 Arora  S,  Thornton  K,  et  al..  N  Engl  J  Med.  2011  Jun;  364:2199-­‐207.  

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Par-cipants  

• Study  sites  •  Interven8on  (ECHO)  

•  Community-­‐based  clinics:16  •  New  Mexico  Department  of  Correc8ons:5  

• Control  •  University  of  New  Mexico  HCV  Clinic  

• Subjects  mee8ng  inclusion/exclusion  criteria  • Consecu8ve  treatment  naïve  pa8ents  seen  at  the  university  or  at  an  ECHO  site  

 Arora  S,  Thornton  K,  et  al..  N  Engl  J  Med.  2011  Jun;  364:2199-­‐207.  

Principal  Endpoint  

• Sustained  viral  response  (SVR):  no  detectable  virus  6  months  aier  comple8on  of  treatment  

 

Arora  S,  Thornton  K,  et  al..  N  Engl  J  Med.  2011  Jun;  364:2199-­‐207.  

 

Treatment  Outcomes  

Arora  S,  Thornton  K,  Murata  G,  Deming  P  et  al.  N  Engl  J  Med.  2011  Jun;  364:2199-­‐207.  

 

Outcome   ECHO  sites  (N=261)  

UNM  HCV  Clinic  (N=146)  

P  Value  

 Minority  

 65  %  

 41  %  

 <0.01  

 SVR  Genotype  1  

 50  %  

 46  %  

 0.57  

 SVR  Genotype  2  or  3  

 70  %  

 71  %  

 0.83  

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Conclusions  

• Rural  primary  care  clinicians  deliver  HCV  care  under  the  aegis  of  Project  ECHO  that  is  as  safe  and  effec8ve  as  that  given  in  a  university  clinic  

• Project  ECHO  improves  access  to  HCV  care  for  New  Mexico  minori8es.  

 

Arora  S,  Thornton  K,  et  al..  N  Engl  J  Med.  2011  Jun;  364:2199-­‐207.  

ECHO  Model  Cost-­‐effec-ve  for  HCV  

• In  60  %  of  pa8ents  treated  for  HCV  the  model  was  cost  savings  

• Overall  Cost  per  Discounted  Quality  of  Life  Year  Gained  was  less  than  $3500  

Wong,  et  al,  oral  presenta8on  AASLD,  Washington,  DC  2013  

Does ECHO Provide Good Value?

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Pignone M Ann Intern Med 2002;137:96; Freedberg KA N Engl J Med 2001;344:824; CDC Diabetes Cost Effectiveness Group JAMA 2002;287:2542 Winkelmayer WC Med Decis Making 2002;22:417; Heudebert GR Gastroenterology 1997;112:1078

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Disease  Selec-on  

• Common  diseases  • Management  is  complex  • Evolving  treatments  and  medicines  • High  societal  impact  (health  and  economic)  • Serious  outcomes  of  untreated  disease  • Improved  outcomes  with  disease  management  

 

Copyright  2013  Project  ECHO®  

Bridge  Building  UNM  HSC  

State  Health  Dept  

Private  Prac-ce  

Community  Health  Centers  

Pareto’s  Principle  

Chronic  Pain    

Rheumatoid  Arthri-s  +  Rheumatology  Consulta-on  

Substance  Use  and  Mental  Health  Disorders  

Force  Mul-plier  Use  Exis-ng  Community  Clinicians  

Specialists  Primary  Care  

Physician  Assistants  

Nurse  Prac--oners  

Chronic  Pain    

Rheumatoid  Arthri-s  +  Rheumatology  Consulta-on  

Substance  Use  and  Mental  Health  Disorders  

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Successful  Expansion  into    Mul-ple  Diseases  

Mon   Tue   Wed   Thurs   Fri    

8-­‐10  a.m.  

 Hepa88s  C    Arora  Thornton  

 Endocrinology    Bouchonville  

 Pallia8ve  Care      Neale  

10-­‐12  a.m.  

 Rheumatology    Bankhurst  

 Chronic  Pain    Katzman  

Integrated  Addic-ons  &  Psychiatry    Komaromy  

Complex  Care      Neale    Komaromy  

2-­‐4    p.m.  

 HIV    Iandiorio    Thornton  

Prison  Peer  Educator  Training    Thornton  

Women’s  Health  and  Genomics      Curet    

Learning  Capacity  

Time  

Increasing  Gap  

 

“Expanding  the    Defini8on  of  Underserved    Popula8on”  

Transforming  Primary  Care  with  Knowledge  Networks  

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Primary  Care  Nurse  

Medical  Assistant  

Community  Health    Worker  

Chronic  Disease  Management  is  a  Team  Sport  Force  Mul-plier  

Diabetes  and  Cardiac  Risk  Reduc-on    

Asthma  and  COPD  

Substance  Use  and  Mental  Health  Disorders  

ECHO  Specialty  CHW  Training  Mul-ple  Tracks  

• CREW  (Community  Resource  Educa8on  Worker)-­‐  Diabetes,  Obesity,  Diet,  Smoking  Cessa8on,  Exercise  

• CARS  (Community  Addic8on  Recovery  Specialist)  -­‐  Harm  reduc8on,  mo8va8onal  interviewing,  liaison  with  community  resources  

•  Let’s  Move  New  Mexico:  Obesity  Preven8on  Training  Program  

• NM  PEP  (New  Mexico  Prison  Peer  Educa8on  Program)  –  Focus  on  HCV,  other  infec8ous  diseases  and  addic8on  

CREW  (Diabetes  Community  Resource  Educa-on  Worker)    

• Narrow  focus  —  deep  knowledge  • Standardized  curriculum  • 3  Day  onsite  training  (Diabetes,  Obesity,  Diet,  Smoking  Cessa8on,  Exercise,  Mo8va8onal  Interviewing)  

• Weekly  video  based  teleECHO  Clinics  • Ongoing  support  via  knowledge  networks  

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Community  Health  Workers  in  Prison  The  New  Mexico  Peer  Educa-on  Project  Pilot  training  cohort,  CNMCF  Level  II,  July  27-­‐30,  2009  

Photo  consents  on  file  with  Project  ECHO®  and  CNMCF  

Poten-al  Benefits  of  ECHO  Model™  to  

Health  System      

•  De-­‐monopolize  knowledge  •  Improve  quality  and  safety  by  reducing  varia8on  in  care  •  Rapid  learning  and  best-­‐prac8ce  dissemina8on  •  Access  for  rural  and  underserved  pa8ents,  reduced  dispari8es  •  Workforce  training  and  force  mul8plica8on  •  Improving  Professional  Sa8sfac8on/Reten8on    •  Cost  effec8ve  care  -­‐  avoid  excessive  tes8ng  and  travel  •  Prevent  cost  of  untreated  disease  (e.g.  liver  transplant)  •  Suppor8ng  the  Medical  Home  Model  

Copyright  2013  Project  ECHO®  

ECHO  Replica-on  Sites  Worldwide:  •  Na-onal  AIDS  Control  Organiza-on  and  Maulana  Azad  (HIV)  –  New  Delhi,  India  

•  Ins-tute  of  Liver  and  Biliary  Sciences  (HCV)  –  New  Delhi,  India  •  Universidad  de  la  República  (Liver  Disease)  –  Montevideo,  Uruguay  

•  West/North  West  Hospitals  Group  (Diabetes)  –  Galway,  Ireland    •  ECHO  Ontario  (Chronic  Pain)  –  Queens  University  &  University  of  Toronto  Ontario,  Canada  

•  Northern  Ireland  Hospice  (Hospice  Care)  –  Belfast,  NI  •  Na-onal  Ins-tute  for  Mental  Health  Services  (NIMHANS)  (Mental  Health  and  Drug  Addic8on)  –  Bangalore,  India  

•  B.J.  Medical  College  (HIV)  –  Ahmedabad,  India    •  Vietnam  Na-onal  Lung  Hospital  (TB)  –  Hanoi,  Vietnam  •  Hospital  Italiano  (HCV)  –  Buenos  Aires,  Argen8na  

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Western  States  Consor-um  HCV  ECHO  Partner  Sites  

University  of  New  Mexico  21  Partner  Sites:  New  Mexico  Arizona  Montana    University  of  Washington  20  Partner  Sites:  Washington  Alaska  Idaho  Oregon  Montana    University  of  Utah  35  Partner  Sites:  Utah  California  Colorado  Idaho  Montana  Wyoming    St.  Joseph’s  Hospital,  AZ  18  Partner  Sites:  Arizona  

Number  of  Sites  in  one  loca8on  (city):                      1                    2                            3                                4  

*Fron3er  Coun3es  are  defined  as  those  coun3es  with  a  popula3on  density  of  less  than  7  persons  per  square  mile  

h#p://www.raconline.org/racmaps/mapfiles/fron5er.png  

ECHO  Replica-on  in  the  US  

   

•  University of Washington (HCV, Chronic Pain, HIV, Multiple Sclerosis) – Seattle, WA •  University of Chicago (Hypertension, Breast Cancer Survivorship/Women’s Health, Pediatric ADHD,

Childhood Obesity, HCV) – Chicago, IL •  University of Nevada Diabetes/General Endocrinology, Gastroenterology, Rheumatology, Sports Medicine,

Mental HealthMarriage & Family Therapy Intern Supervision Clinic (closed groups, by invitation only) – Reno, NV

•  University of Utah (HCV, Advanced Liver Care, Chronic Pain) – Salt Lake City, UT •  Florida/Caribbean AIDS Education and Training Center, University of South Florida (General HIV,

Adolescents/Pediatrics HIV, Co-Infection, Psychiatry & HIV, Spanish Language HIV) – Tampa, FL •  Harvard/Beth Israel Deaconess Medical Center (HCV, Gerontology – ECHO AGE) – Boston, MA •  St. Joseph’s Hospital & Medical Center (HCV) – Phoenix, AZ •  Community Health Center, Inc. (HIV, HCV, Chronic Pain, Opioid Addiction – Buprenorphine, Coaches

International—supporting Quality Improvement and Specialists) – Middletown, CT •  LA Net (AAPA Preventive Care, Nephrology, Adult Psychiatry) – Los Angeles, California •  CHI St. Luke’s Health (HCV, HBV, Infectious Disease) – Houston, TX •  University of California Davis (Pain Management) – Davis, CA •  University of Wyoming, Wyoming Institute for Disabilities (Assistive Technologies) – Laramie, Wyoming •  Ochsner Health System (Liver Care) – New Orleans, LA •  University of Texas MD Anderson Cancer Center (Cervical Cancer Prevention) – Houston, TX •  Oregon Health and Science University/Health Share of Oregon (Psychiatric Medication Management) –

Portland, OR •  University of Rochester Medical Center (Geriatric Mental Health) – Rochester, New York •  Visiting Nurses Association Health Group (Care Transition) – Red Bank, New Jersey •  Missouri Telehealth Network/University of Missouri (Autism) – Columbia, MS •  University of Colorado School of Public Health (Children and Youth with Epilepsy) – Denver, CO

ECHO  Replica-on  Sites  Worldwide  

   

•  Na8onal  AIDS  Control  Organiza8on  and  Maulana  Azad  (HIV)  –  New  Delhi,  India  

•  Ins8tute  of  Liver  and  Biliary  Sciences  (HCV)  –  New  Delhi,  India  •  Universidad  de  la  República  (Liver  Disease)  –  Montevideo,  Uruguay  •  West/North  West  Hospitals  Group  (Diabetes)  –  Galway,  Ireland    •  ECHO  Ontario  (Chronic  Pain)  –  Queens  University  &  University  of  

Toronto  Ontario,  Canada  •  Northern  Ireland  Hospice  (Hospice  Care)  –  Belfast,  NI  •  Na8onal  Ins8tute  for  Mental  Health  Services  (NIMHANS)  (Mental  

Health  and  Drug  Addic8on)  –  Bangalore,  India  •  B.J.  Medical  College  (HIV)  –  Ahmedabad,  India    •  Vietnam  Na8onal  Lung  Hospital  (TB)  –  Hanoi,  Vietnam  •  Hospital  Italiano  (HCV)  –  Buenos  Aires,  Argen8na  

4/24/15

17

Hepatitis C The ECHO Team

Use  of  mul8point  videoconferencing,  best  prac8ce  protocols,  co-­‐management  of  pa8ents  with  case  based  learning  (the  ECHO  model)  is  a  robust  method  to    safely  and  effec8vely  treat  common  and  complex  diseases  in  rural  and  underserved  areas  and  to  monitor  outcomes.