Care Delivery in the Future: The Role of the Health Care Workforce

Keynote #2 - Using ECHO for Workforce Expansion: Scaling Up to Address the Opioid Epidemic

(Note: This is an unedited transcript. For direct quotes, please refer to the video.)

SARAH DASH: Delighted to introduce Dr. Miriam Komaromy. She’s the associate director of Project ECHO, and she is going to tell us all about what Project ECHO is and how it is helping to address some of these issues. Thank you.

 

MIRIAM KOMAROMY: Hi everybody, I’m Miriam Komaromy, it’s nice to meet you all.

 

How many people here are familiar with the ECHO model? Wonderful. I’m going to take you on a rapid tour through what the ECHO model is, and then I’m going to talk about a specific application of the ECHO model, for expanding workforce in the area of addressing the opioid epidemic.

 

This picture is worth a thousand words when trying to describe what ECHO is. Let me tell you what’s happening in this picture, and then we can go into a few more details of the model. The people in the large picture there are specialists working at a university. They are all specialists in a particular disease area. In this case, this is an integrated addictions and psychiatry ECHO clinic, and this is a psychiatrist and addiction specialist, a public health nurse, a counselor, and a community health worker who all over expertise in addictions and mental health. The small pictures around the edges depict primary care teams from around the region. So, these are folks who are sitting in their own offices, often over a lunch hour, joining by video — we use zoom technology — to connect with the specialists and with other primary care teams around the area. And what happens in an ECHO session is, there is a brief lecture by one of the specialists on the topic of interest, and then the bulk of the time is spent on case based learning. So, these primary care teams are presenting actual patient cases from their own practices, in a de-identified way, and they are getting feedback and mentorship from the specialists, and also, support from the other primary care teams. So, this is in a sense, a virtual learning community. Everybody is gaining altogether in their understanding of how to manage mental health and addiction problems.

 

The sort of fundamental principles of ECHO are, to use technology to leverage scarce healthcare resources, in this case, the specialists. Case based learning is absolutely fundamental to the model. This is not webinars or lectures, it’s active, engaged learning. And the use of best practices is key. So, the specialist, their job, is to make sure that they are giving the most updated information to the primary care teams on how to manage these patients. They educate using guidelines and best practice strategies, and they educate about the newest evidence. Another principle of ECHO is All Teach, All Learn. So, when the model was started by my boss, [name], the idea was, well, these specialists will teach the primary care teams how to do this. We learned pretty quickly that actually, there is an awful lot for the specialists to learn from the primary care teams about how this actually plays out in clinical practice. In fact, the specialists learned not just from the physicians in the primary care setting, but from the counselors, the nurse, the community health workers, et cetera. So, it’s a fascinating interdisciplinary learning environment.

 

This illustrates this concept of forced multiplication. So, a few specialists up at the top, are teaching multiple primary care teams around a region, typically in underserved and rural areas, and they in turn are having an impact on hundreds and even thousands of patients who are their patients in the primary care setting. If you think about the difference between the ECHO model and traditional telemedicine, found at the bottom of this slide, you can see traditional telemedicine. Here, one specialist is connecting with a patient who is physically remote from that specialists and is providing consultation. Very, very important for expanding access in underserved areas. However, that specialist’s time is not being leveraged. They are still spending that half hour with that one patient, even though the patient is remote, and they can’t care for patients right in front of them in their community. With the ECHO model, illustrated above, you can see that a few specialists can provide expertise that has an impact on many, many patients over time.

 

Early on, when ECHO started 13 years ago, we gathered data showing that this participating in an ECHO series helps people to become more confident, they increase in knowledge, their attitudes changed toward providing care, and they start to actually get referrals within their community. So, if you have participated in a hepatitis C ECHO program, you may be the only provider in your community who is a primary care provider offering Hepatitis C treatment, and patients start to get referred to you. We knew we also needed to demonstrate that the model was safe and effective, and in 2011, we published a study in the New England Journal showing that primary care providers who are mentored through the ECHO model, are able to achieve equivalent outcomes to specialists working in an academic medical setting for treatment of Hepatitis C, with no greater rates of complications. In fact, the primary care providers see more underrepresented minority group members, compared with the specialists. So, it’s a way of reducing health disparities as well.

 

The ECHO movement has grown very rapidly over the past 13 years. A lot of what we do at the ECHO Institute in New Mexico, is train others to implement the ECHO model, and we do this, by the way, free of charge. We are funded by the state legislature and by foundations and federal grants, and we don’t charge anybody to implement the model. Our goal is really to spread access to the model to increase access for underserved populations.

 

Here is the State of New Mexico, with Albuquerque in the middle. Here are the sites around New Mexico that participated in our original Hepatitis C study. Here are providers over a span of several years who participated in various different ECHOs. So, each color dot on this map represents a different topic. We have ECHOs for childhood asthma, for rheumatology, for HIV, TB, autism, addictions, chronic pain, et cetera, et cetera. This is the New Mexico story. Here is a picture of all of the academic medical centers, and some public health entities around the United States who have implemented programs of their own. And many of these sites have implemented more than one ECHO program, so they start out usually focused on one topic, and then they spread. Much of ECHO is serving providers in rural areas, but it’s also being used in urban areas. For instance, University of Chicago has five ECHO programs that focus particularly on the south side of Chicago, and are working on things like, women’s health, hypertension, et cetera.

 

I should say that the data supporting ECHO is not just that Hepatitis C paper, there is data around reductions and hospitalizations for complex care populations, for reductions in transfers from nursing homes, to hospitals, when the nursing homes participate in ECHOs reduction and use of physical and chemical restraints in nursing home settings for people who participate in a geriatric ECHO. And most recently from the VA and DOD, there is evidence of reduction in opiate prescribing among providers who participate in an opiate [unintelligible] ECHO.

 

Here is a picture of what’s happening around the world. This is a little bit outdated, but ECHO is spreading internationally very quickly, and we are now on almost every continent; spreading extremely rapidly in India and Africa.

 

So, how can we scale up ECHO to respond to an epidemic? When I showed you that picture initially of an ECHO session, you can imagine that you can’t have an unlimited number of folks joining that ECHO, or it stops being participatory, and it starts being a webinar that people check out — sit back and just listen. Somewhere around 25 or 30 people is kind of the maximum number of people connecting that you can actually handle and still have it be interactive. So, that does provide forced multiplication, but when you are thinking about trying to use this model to scale up and really address an epidemic, you want to be able to scale faster. About 13 months ago, we got money from HERSA to help to support federally qualified health centers, and expanding treatment of opioid use disorder. And we wanted to do this quickly, not training, starting one ECHO and serving the country with that. Not training a bunch of sites to stand up their own whole ECHO programs. Instead, we developed what we call a shared services model. So, what this is, is that at the ECHO Institute, we are supporting five ECHO hubs to offer an opioid ECHO program that is available to any federally qualified health center team or provider in the country. So, each of these entities around the edges — University of Washington, Billings Clinic in Montana, Boston Medical Center, et cetera, all they have to bring to the table is specialists. And what we offer is, we led the development of an integrated curriculum, so we are using the same curriculum across all the sites. We provide IT support, administrative support, evaluation support, and actually recruitment of providers for all five sites, from one sort of supporting hub. This has allowed us to get this up and running pretty quickly. So, we got funded 13 months ago; ten months ago, we launched all five of these ECHO clinics. And this is a picture of what’s been happening since then. We have these five hubs across the country, and we have 316 primary care folks who have participated in the program so far, from 144 HERSA funded health centers. Half of the participants are medical providers, and a third are behavioral health providers. The remainder are nurses, pharmacists, community health workers, et cetera. So, we are really training and interdisciplinary team, which is very key in being able to address this in the primary care setting.

 

We are just starting to evaluate the impact of the program, but one way that we’ve looked at it, is we’ve asked people who presented a case — when you presented that case today, what was the impact of that presentation? And 92% say it changed their plan of care for the patient they presented. If you are familiar with continuing medical education, sort of the holy grail is, how do you get people to actually change what they are doing based on the education they are receiving. And these kinds of numbers make us very happy. In addition, folks learn from hearing about cases presented by others. So, we ask today, in the session — you didn’t present a case, but you heard other cases presented. Did you learn something new today that will change your care of your own patients? And 81% said that they did. We are also seeing market increases in confidence, and changes in attitude, and we are hoping we will see a change in knowledge. We haven’t yet analyzed those data.

 

One more thing I want to say about the impact of the ECHO model on access to services:  For the last 12 years, I have operated an integrated addictions and psychiatry ECHO in New Mexico, and we’ve used that network of participating providers from every little corner of the state, to recruit provider’s physicians to participate in the Buprenorphine waiver training. The training to allow them to prescribe Buprenorphine for treatment of opioid use disorder in the office space setting. We wanted to look at — are we reaching providers who are working in traditionally underserved areas? We looked at zip codes that are poor, rural, and where are more than half of the residents identify as non-white. And what you can see in the darker line there, is what’s happened in New Mexico in terms of the increase per capita and the number of trained physicians in those underserved zip codes who have gotten the Buprenorphine training. And down below, in the gray, is what’s happened in this type of zip code and the rest of the country. So, our work has been associated at least with a fairly rapid increase in providers from traditionally underserved zip codes, taking up treatment of Buprenorphine, and getting that training.

 

The last thing I wanted to comment on, is that there has been a tremendous amount of federal funding for treatment of the opioid epidemic coming into states through a number of different sources. The black boxes are funding that came from ARC, that is focusing primarily on expanding treatment of opioid use disorder in rural settings, specifically asking partners to use the ECHO model. The green is the HERSA funded ECHO programs that I just told you about, that are using ECHO to address the opioid epidemic, and focused on federally quality health centers. Then the red boxes indicate states that have received funding through the CURES Act, the opioid state targeted response money — STR money, who said in their proposals that they are using opioid etho as one of the things that they are implementing with their CURES Act funding. So, you can see that many, many states have gotten that funding. A half a billion dollars was distributed to the states last year, through the CURES Act to address opioid use disorder. So, my thought would be that if all of these states, instead of implementing one opioid ECHO to address the problem, use the shared services model of using shared resources to maximize the number of different specialists who can actually be offering ECHO and reaching primary care providers all over the state, that we have a real potential to have an impact on workforce and scale up the trained workforce who can address these issues.

 

My contact information is on the last slide. I would be happy to talk with anybody about that. And our website, ECHO.umn.edu, has a lot more information about the ECHO model. So, to close, I would just say, I think states can really use this ECHO shared services model to scale up their workforce to meet the need for prevention and screening and treatment of opioid use disorder. Thank you all very much.

 

[Applause]