SummaryAs part of Project Extension for Community Healthcare Outcomes (Project ECHO), specialists at the Albuquerque-based University of New Mexico Health Sciences Center train community- and prison-based primary care clinicians on appropriate care of chronic hepatitis C and also host weekly, 2-hour, case-based discussions via teleconference during which they provide guided feedback on how best to manage patients over the course of treatment. During these sessions, community-based providers also share advice and expertise and generally support each other, and specialists give short, didactic presentations on specific issues related to hepatitis C care. A separate part of Project ECHO trains prisoners to become peer educators, allowing them to teach fellow inmates about hepatitis C. The program significantly enhanced community-based providers’ knowledge, skills, and abilities related to hepatitis C, leading to enhanced access to care for patients. Based on this success, similar programs have been developed to assist community-based primary care physicians in treating many other chronic conditions.Moderate: The evidence consists of pre- and post-implementation comparisons of various measures of primary care clinician knowledge, skills, and satisfaction related to hepatitis C care, along with post-implementation statistics on program usage.
Developing OrganizationsUniversity of New Mexico Health Sciences Center
Upon the program launch, Project ECHO represented a collaboration between the University of New Mexico Health Sciences Center and 5 prison sites within the New Mexico Corrections Department, Indian Health Service facilities, 10 Federally Qualified Health Centers, and private practice physicians serving low-income communities, with a total of 21 participating treatment sites. At present, Project ECHO represents collaboration between specialists at the University of New Mexico Health Sciences Center and primary care clinicians throughout New Mexico, the United States, and the world.
Date First Implemented2003
The program began as a small-scale, volunteer pilot in 2003 focused on chronic hepatitis C. It has now expanded to include other complex diseases such as integrated addictions, chronic pain, palliative care, rheumatology, diabetes, dementia, HIV/AIDS, women’s health and complex care with partner sites at academic medical centers and other healthcare organization both nationally and globally.
Patient PopulationThe program serves community-based patients and prisoners with hepatitis C. Because so many hepatitis C patients have co-occurring substance abuse disorders, prisoners must complete a prison-based drug rehabilitation program before becoming eligible to participate in the hepatitis C virus program.Race and Ethnicity > American Indian or Alaska native; Vulnerable Populations > Impoverished; Prisoners; Rural populations; Substance abusers
Problem AddressedChronic hepatitis C is a common condition, especially in prisoners and other at-risk populations. Many with the illness, particularly those in rural areas, have limited access to high-quality medical evaluation, followup, and treatment. As a result, these individuals may spread the disease to others, and often end up suffering disease-related complications that can lead to death.
- A common condition, especially in prisoners and other at-risk populations: Between 3.2 and 4.0 million people in the United States have chronic hepatitis C (caused by the hepatitis C virus).1,2 The condition disproportionately affects injection drug users, prisoners, substance abusers, and others who engage in risky health behaviors.3,4 For example, newly released prisoners are 9 to 10 times more likely to have hepatitis C than the average individual.5 More than 28,000 New Mexicans have hepatitis C, including 42 percent of the state’s roughly 6,000 prisoners.
- Aggressive screening, but limited access to care: Due to the high-risk nature of the clients they serve, public health sites routinely test for hepatitis C virus antibodies. Those testing positive need specialized medical evaluation and treatment, including education on the condition (e.g., the need to avoid alcohol) and how to avoid spreading it to others.6,7,8 Treatment can frequently “cure” chronic hepatitis (bringing viral loads down to an undetectable level for a sustained period of time). However, many individuals diagnosed with hepatitis C cannot access education and treatment in a timely manner, leading some to question the appropriateness of widespread hepatitis C virus screening.9 For example, in New Mexico, almost all infectious disease specialists, gastroenterologists, and hepatologists trained in hepatitis C management work in Albuquerque or Santa Fe, leaving infected patients in prisons and other remote settings with limited access to specialty care before implementation of Project ECHO.10
- Leading to potential spread of disease, many complications and deaths: Without treatment, those with chronic hepatitis C may spread it to others by sharing needles or engaging in unprotected sex. Infected individuals frequently develop complications, including cirrhosis and liver disease, which can lead to death.
- Unrealized potential of primary care: Most underserved areas—including prisons—tend to have a relatively greater number of primary care doctors than specialists. These clinicians often have established, trusting relationships with patients who do not have the means or desire to travel long distances for specialty care. However, these clinicians generally lack the knowledge and expertise to manage chronic hepatitis C effectively on their own, including the serious side effects that often accompany drug treatment (e.g., anemia, depression, neutropenia).
Description of the Innovative ActivityThrough Project ECHO, the University of New Mexico Health Sciences Center trains community- and prison-based primary care clinicians on appropriate care of chronic hepatitis C and hosts weekly 2-hour clinics via teleconference in which primary care clinicians and specialists engage in case-based discussions and share best practices and guidance related to the care of individual patients. A separate part of Project ECHO trains prisoners to become peer educators who teach fellow inmates about chronic hepatitis C. Key program elements include the following:
- Initial training: Participating primary care clinicians attend a 2-day training workshop at the University of New Mexico led by the hepatitis C virus team, including a nurse with expertise in hepatitis C, a psychiatrist, and a liver specialist. During the first day, these community-based clinicians learn about the following: best-practice protocols in managing chronic hepatitis C (based on established guidelines); the case-based format to be used in the weekly sessions; and the Web-based software (known as iHealth) that helps clinicians manage patients over time. (See bullets below for more information on the case-based format and software.) Clinicians spend the second day shadowing team members as they care for patients.
- Weekly case consultations via videoconference: Each week, clinicians at participating organizations, including pharmacists, nurse practitioners, primary care physicians, and physician assistants, participate in a 2-hour teleconference with the hepatitis C virus team at the University of New Mexico, which includes a gastroenterologist, infectious disease specialist, psychiatrist with expertise in addiction medicine, and nurse educator. To date, more than 400 such sessions have been conducted. They help primary care providers develop greater expertise in hepatitis C virus, thus reducing their need for specialist support over time. Providers receive continuing medical education (CME) credit for participating. Each 2-hour call is primarily dedicated to discussion (mostly about specific cases), with 15 minutes reserved for didactic education, as outlined below:
- Longitudinal disease management through case-based discussion: Primary care clinicians take turns presenting approximately 25 pieces of information in a standardized format on individual patients to the hepatitis C virus team, with the typical session covering 15 patients. The specialists and primary care providers discuss each case, including potential psychiatric, medical, and substance use issues and treatment-related complications. Frequently the same patient will be discussed over multiple sessions, thus supporting clinicians' management over time. To date, more than 4,000 hepatitis C virus patient consultations have been performed during these sessions.
- Peer-based learning and support: As part of the case-based discussions, community-based physicians from other clinics in similar settings often provide advice, guidance, and lessons learned related to similar cases they have faced, including how they overcame barriers. In this way, the sessions also function as a peer-based learning network.
- Didactic education: For approximately 15 minutes each session, one of the hepatitis C virus team specialists gives a didactic presentation related to specific issues (often one that came up during the session), such as vaccination for hepatitis A and B.
- Access to care management software: Primary care clinicians have access to the Web-based software iHealth that supports longitudinal case management of patients according to established protocols.
- Peer-to-peer education for prisoners: As a separate part of the ECHO hepatitis C virus program, prisoners at participating sites are trained to be peer educators, teaching other prisoners about hepatitis C, including how to live with the condition and how to avoid spreading it to (or getting it from) others. To become a peer educator, prisoners complete a 40-hour training program (offered once every 3 or 4 months) at the prison led by the hepatitis C virus team from the University of New Mexico. Once trained, they participate in monthly interactive videoconferences during which they learn more about hepatitis C virus and can get questions answered by the team. To date, 136 prisoners have become peer educators; they get paid between 40 and 50 cents an hour to meet with their peers.
References/Related ArticlesArora S, Kalishman S, Thornton K, et al. Expanding access to hepatitis C virus treatment—Extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care. Hepatology. 2010;52(3):1124-33. [PubMed]
Arora S, Thornton K, Jenkusky SM, et al. Project ECHO: linking university specialists with rural and prison-based clinicians to improve care for people with chronic hepatitis C in New Mexico. Public Health Rep. 2007;122(Suppl 2):74-7. [PubMed]
Arora S, Thornton K, Murata G, et al. Outcomes of Treatment for Hepatitis C Virus Infection by Primary Care Providers. N Engl J Med. 2011;364(23):2199-207. [PubMed]
Contact the InnovatorSanjeev Arora, MD
University of New Mexico
Albuquerque, NM 87131
Innovator DisclosuresDr. Arora has not indicated whether he has financial interests or business or professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
ResultsThe program significantly enhanced community-based providers’ knowledge, skills, and abilities related to hepatitis C, leading to high levels of provider satisfaction and enhanced access to care for patients.
Moderate: The evidence consists of pre- and post-implementation comparisons of various measures of primary care clinician knowledge, skills, and satisfaction related to hepatitis C care, along with post-implementation statistics on program usage.
- Enhanced provider knowledge and skills: The program has led to statistically significant increases in providers’ self-reported knowledge, skills, and abilities related to hepatitis C care.
- Overall competence: An aggregate measure of overall competence—measured on a scale of 1 to 7—increased from 2.8 before implementation to 5.5 a year later (1 indicates no skill and 7 indicates expert-level competence). In a separate survey, 97 percent of clinicians reported that the program had a moderate or major impact on their knowledge related to management and treatment of hepatitis C virus patients, while 98 percent reported it had a moderate or major impact on their ability to become competent in caring for such patients.
- Screening and assessment skills: Providers’ self-reported ability to identify patients who should be screened for hepatitis C virus rose from 4.2 before participation to 6.4 a year later (on the 7-point scale outlined above). Similar increases occurred in their self-reported ability to identify suitable candidates for hepatitis C virus treatment (2.8 to 5.6) and assess severity of liver disease in hepatitis C virus patients (3.2 to 5.5).
- Treatment skills: Providers’ self-reported ability to treat patients with and manage side effects rose from 2.0 to 5.2. Their ability to educate clinic staff about hepatitis C virus patients also rose (2.8 to 5.8), as did their ability to educate and motivate hepatitis C virus patients (3.0 to 5.7) and serve as a consultant within their clinic and to other local clinicians (2.4 to 5.6).
- Skills related to managing comorbidities: Providers’ self-reported ability to assess and manage comorbidities increased significantly, both for psychiatric (2.6 to 5.1) and substance abuse (2.6 to 4.7) problems.
- High levels of provider satisfaction: In annual surveys, participating clinicians report high levels of satisfaction with the program, including its ability to reduce professional isolation (which received a 4.3 rating on a scale of 1 to 5, with 1 meaning the program had no impact and 5 indicating a large impact), enhance professional satisfaction (4.8), and benefit the clinic through collaboration (4.9).
- Enhanced access to ongoing management, treatment, and education: Before implementation of this program, none of the participating primary care providers offered treatment for chronic hepatitis C. Fewer than 1,600 of the more than 30,000 New Mexicans with hepatitis C virus had received treatment, and no state prison inmates had been treated for hepatitis C virus or chronic liver disease. To date, ECHO clinicians have performed more than 4,000 consultations on hepatitis C virus patients, 68 percent of whom are ethnic minorities from underserved areas. As part of the survey highlighted above, participating clinicians uniformly report that the program has enhanced access to hepatitis C virus treatment in their community (scoring a 4.9 on the 5-point scale outlined above). To date, the peer educator program has reached one-fourth of all prisoners in New Mexico jails; program leaders expect all prisoners to have met with a trained peer educator within 2 years.
Context of the InnovationEstablished in 1994 in Albuquerque, the University of New Mexico Health Sciences Center serves as the only academic medical center in New Mexico, providing education, research, patient care, and community outreach throughout the state. The center operates a liver clinic staffed by various specialists in the care of hepatitis C and other conditions that affect the liver. The impetus for this program came from a desire to address the multiple problems (outlined earlier) that New Mexico residents in rural areas and other remote settings face in accessing high-quality specialty care, particularly effective chronic disease management. Liver clinic leaders saw an opportunity to create a technology-enabled program that would allow academic medical center-based specialists to educate and support community-based clinicians based on established theories of learning. They decided to test the approach with hepatitis C virus care, with the hope that it could become a “disruptive innovation” that could be applied to many other chronic conditions once proven effective.
Planning and Development ProcessKey steps included the following:
- Recruiting partners: Program leaders recruited participating organizations over time through statewide conferences, presentations, and outreach. To participate, organizations must have access to the Internet and telephone and fax service (including a speaker phone), along with the capability to view word processing documents and presentations. Ideally, participants will also have videoconferencing capabilities (e.g., broadband Internet access and a video camera) to enhance the interaction between specialists and partner organizations.
- Developing standard protocol and training curriculum: The hepatitis C virus team at the Health Sciences Center developed a standardized protocol for managing chronic hepatitis C based on established guidelines developed by the American Association for the Study of Liver Diseases. The team also developed the curriculum and accompanying materials for the initial 2-day training session, including a standardized template to structure and guide case-based discussions.
- Pilot testing and expansion of hepatitis C program: The program began as a pilot test with a handful of sites in 2003 to evaluate the feasibility of the approach. Based on its success in the pilot, the program expanded over time to include the current network of organizations.
- Expansion to other conditions: The success with hepatitis C patients led to the creation of similar Project ECHO programs for many other chronic conditions, which have been rolled out over time. Project ECHO programs have now been developed for integrated addiction and psychiatry, rheumatology, mental health disorders, cardiac risk reduction/diabetes, asthma and pulmonary disease, chronic obstructive pulmonary disease, prevention of teenage suicide, child/adolescent/family psychiatry, chronic pain and headache, high-risk pregnancy, psychotherapy, occupational health, HIV/AIDS, childhood obesity, and psychotherapy. Programs have also been created to target specific issues and skills important to community-based physicians, including motivational interviewing and medical ethics.
- Expansion to other populations and TeleECHO clinics: Information provided in 2013 indicates that Project ECHO has evolved into a disruptive innovation that improves both capacity and access to specialty care for rural and underserved populations. This is accomplished by linking expert interdisciplinary specialist teams with primary care clinicians through TeleECHO clinics, in which the experts co-manage patient cases and share their expertise via mentoring, guidance, feedback, and didactic education. This enables primary care clinicians to develop the skills and knowledge to treat patients with common, complex diseases in their own communities, which reduces travel costs, wait times, and avoidable complications. The ECHO model is not telemedicine, where the specialist assumes the care of the patient, but instead a guided practice model where the primary care clinician retains responsibility for managing the patient, operating with increasing independence as their skills and self-efficacy grow.
Resources Used and Skills Needed
- Staffing: The program requires participating clinicians to attend 2 days of upfront training and to participate in the 2-hour weekly calls. The three-member hepatitis C virus team at the University of New Mexico (a psychiatrist, a nurse with expertise in hepatitis C virus, and a liver specialist) also participate in the weekly calls, and spend a modest amount of additional time preparing educational materials and presentations. Other staff spend a significant amount of time on program-related evaluation, although a would-be adopter may not need or wish to engage in the same level of effort.
- Costs: Data on the budget for the Project ECHO hepatitis C virus program are not available, as program leaders cannot separate expenses for hepatitis C virus from the many other Project ECHO programs now in operation. They estimate, however, that a would-be adopter could run the program (e.g., initial training, weekly calls, peer-based education) for roughly $200,000 a year. This figure does not include costs incurred by participating primary care clinicians, which include modest equipment expenses (e.g., $50 for a Web camera) and the “opportunity costs" of participating in the upfront training and weekly sessions.
Funding SourcesAgency for Healthcare Research and Quality; Robert Wood Johnson Foundation; New Mexico Department of Health; New Mexico State Legislature
Project ECHO has received various sources of funding over the years, some specifically earmarked for the hepatitis C virus program and others supporting Project ECHO programs targeted at other conditions. The evolution of funding sources appears below:
- In 2004, after a small-scale pilot test of the hepatitis C virus program, the Agency for Healthcare Research and Quality (AHRQ) provided a $1.4-million, 3-year grant to support expansion of the hepatitis C virus program. To meet this grant’s requirement for matching funds, the New Mexico legislature provided a $900,000 3-year grant, and the University of New Mexico committed $600,000 of in-kind services over the same time period.
- In March 2006, the New Mexico legislature approved roughly $1.5 million in annual funding to support the Project ECHO hepatitis C virus program, including treatment costs in prisons. Funding has subsequently dropped to $900,000 a year, with the New Mexico Department of Health contributing an additional $250,000 a year.
- In 2007, AHRQ provided an additional grant of $1.5 million under the Minority Research Infrastructure Support program (grant number R24 HS16510) to support pilot research for Project ECHO programs targeting four additional health conditions.
- In 2008, the Robert Wood Johnson Foundation awarded Project ECHO a 3-year, $5-million grant to replicate the model in six other disease areas and at a second academic medical center, the University of Washington.
- In 2009, AHRQ provided a $1.2 million grant (1 UC1 HS015135) to enhance Project ECHO’s Web-based disease management tool.
- Since Project ECHO’s inception, private companies (e.g., laboratories, pharmaceutical companies) have periodically supported the program by providing free medications, testing, and genotyping to program participants.
- In May 2012, Project ECHO was awarded nearly $8.5 million over 3 years from the U.S. Department of Health and Human Services (HHS) Health Care Innovation awards. The award is administered through HHS’s Center for Medicare and Medicaid Innovation. Under the grant, ECHO will identify 5,000 high-cost, high-utilization, high-severity patients in New Mexico and Washington State, and use a team of primary care “intensivists” trained to care for complex patients with multiple chronic diseases, working with area managed care organizations and care providers. Project ECHO will train as many as 300 workers to help increase primary care clinicians’ capacity to treat and manage complex patients.
Getting Started with This Innovation
- Focus on partner priorities: To be successful, this type of program requires close collaboration with multiple agencies interested in improving quality and reducing the costs of caring for chronic conditions. To get partners interested and committed, focus on those diseases/conditions of importance to them (as opposed to the sponsoring organization or society at large). For example, prison system leaders in New Mexico have indicated a willingness to help fund a Project ECHO program targeted at HIV/AIDS (because the prison health system lacks infectious disease physicians).
- Cast net wide for funding: The current fee-for-service payment system does not support the types of activities included in Project ECHO programs (e.g., peer-to-peer training and learning). Consequently, would-be developers will need financial support from outside the reimbursement system. Potential donors include state and local departments of health, universities, local and national foundations, other state agencies (e.g., the department of corrections), and private companies, including pharmaceutical companies, laboratories, and health plans/insurers. After 8 years of running the program, Project ECHO leaders recently approached health plans about supporting program services, with negotiations ongoing. Would-be adopters might consider approaching health plans and insurers at an earlier stage.
Sustaining This Innovation
- Understand and adapt to primary care clinician needs: Primary care clinicians in participating sites face significant financial pressures and realities in today’s fee-for-service payment system. Physicians in Federally Qualified Health Centers and rural primary care sites may find it difficult to give up billable time to participate in the weekly sessions. To get around this problem, work with the participating sites to hold the calls at times that minimize the potential financial impact, such as during lunch or after hours.
- Provide continuing medical education (CME), other support: The continued enthusiasm of primary care clinicians stems in part from a concerted effort by program leaders to provide CME credits (with more than 5,000 hours of credits awarded thus far in the hepatitis C virus program at no cost to participating doctors, and more than 20,000 hours awarded across all Project ECHO programs). They are also developing a program to allow nurses to become certified in hepatitis C virus care after gaining experience in managing patient care and side effects.
Use By Other OrganizationsSince its initial expansion project, the ECHO model has been successfully replicated across the United States and around the globe. Project ECHO’s National and Global Replication Initiatives include the following sites:
• University of Washington (hepatitis C virus, chronic pain, HIV, addiction)
• University of Chicago (hypertension, breast cancer, attention deficit hyperactivity disorder, childhood obesity)
• Department of Defense – Worldwide Initiative (chronic pain)
• Veteran’s Administration Health System - 11 Regions (chronic pain, diabetes, heart failure, hepatitis C virus, women’s health, nephrology)
• University of Nevada (diabetes/cardiovascular risk reduction, sports medicine, thyroid and diabetes, antibiotic stewardship, mental health)
• University of Utah (hepatitis C virus)
• University of South Florida, Evaluation and Technical Assistance Center, and Florida/Caribbean, AIDS Education and Training Center (general HIV, adolescents/pediatrics HIV, hepatitis C virus/HIV co-infection, psychiatry & HIV, Spanish language HIV)
• Harvard, Beth Israel Deaconess Medical Center (hepatitis C virus, gerontology – ECHO AGE)
• St Joseph Hospital - Arizona (hepatitis C virus)
• Community Health Center, Inc. – Connecticut (HIV, hepatitis C virus, chronic pain)
• LA Net (nephrology, adult psychiatry)
• Maulana Azad Medical College – New Delhi, India (HIV)
• Institute of Liver and Biliary Sciences – New Delhi, India (hepatitis C virus)
• ECHO India – Mumbai, Chandigargh, & Lucknow (autism)
• Uruguay (liver disease)
Armstrong GL, Wasley A, Simard EP, et al. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med. 2006;144(10):705-14. [PubMed]
2 Edlin BR. Five million Americans infected with the hepatitis C virus: a corrected estimate. 56th Annual Meeting of the American Association for the Study of Liver Diseases; 2005 Nov 11-15; Boston, Massachusetts. Hepatology 2005;42(4 Suppl 1):213A.
Centers for Disease Control and Prevention. Recommendations for prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR Recomm Rep. 1998;47(RR-19):1-39. [PubMed]
Centers for Disease Control and Prevention. Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. 2006;55(RR11):1-94. [PubMed]
Subiadur J, Harris JL, Rietmeijer CA. Integrating viral hepatitis prevention services into an urban STD clinic: Denver, Colorado. Public Health Rep. 2007;122(Suppl 2):12-7. [PubMed]
Heseltine G, McFarlane J. Texas statewide hepatitis C counseling and testing, 2000–2005. Public Health Rep. 2007;122(Suppl 2):6-11. [PubMed]
Zimmerman R, Finley C, Rabins C, et al. Integrating viral hepatitis prevention into STD clinics in Illinois (excluding Chicago), 1999–2005. Public Health Rep. 2007;122(Suppl 2):18-23. [PubMed]
Baldy LM, Urbas C, Harris JL, et al. Establishing a viral hepatitis prevention and control program: Florida’s experience. Public Health Rep. 2007;122(Suppl 2):24-30. [PubMed]
Arora S, Kalishman S, Thornton K, et al. Expanding access to hepatitis C virus treatment—Extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care. Hepatology. 2010;52(3):1124-33. [PubMed]
|Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.|
Service Delivery Innovation Profile
Original publication: June 22, 2011.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: July 03, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: May 24, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.