Problem Addressed

• 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 or HCV).^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 HCV 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 HCV 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 Activity

• Initial training: Participating primary care clinicians attend a 2-day training workshop at the University of New Mexico led by the HCV 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 HCV 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 HCV, 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 HCV 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 HCV 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 HCV 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 Web-based software (known as iHealth) that supports longitudinal case management of patients according to the established protocols.
• Peer-to-peer education for prisoners: As a separate part of the ECHO HCV 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 HCV team from the University of New Mexico. Once trained, they participate in monthly interactive videoconferences during which they learn more about HCV 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 Articles

Contact the Innovator

Innovator Disclosures

Results

• 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 HCV 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 HCV 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 HCV treatment (2.8 to 5.6) and assess severity of liver disease in HCV patients (3.2 to 5.5).
  • Treatment skills: Providers’ self-reported ability to treat patients with HCV and manage side effects rose from 2.0 to 5.2. Their ability to educate clinic staff about HCV patients also rose (2.8 to 5.8), as did their ability to educate and motivate HCV 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 co-morbidities: 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 HCV had received treatment, and no state prison inmates had been treated for HCV or chronic liver disease. To date, ECHO clinicians have performed more than 4,000 consultations on HCV 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 HCV 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.
  

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• 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 HCV 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 Disease. 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, human immunodeficiency virus/acquired immunodeficiency syndrome (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.

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 HCV team at the University of New Mexico (a psychiatrist, a nurse with expertise in HCV, 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 HCV program are not available, as program leaders cannot separate expenses for HCV 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 Sources

• In 2004, after a small-scale pilot test of the HCV program, the Agency for Healthcare Research and Quality (AHRQ) provided a $1.4 million 3-year grant to support expansion of the HCV program. To meet this grant’s requirement for matching funds, the New Mexico legislature provided a $900,000 three-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 HCV 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 AMC (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.

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 (FFS) 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 FFS payment system. Physicians in FQHCs 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 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 HCV 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 HCV care after gaining experience in managing patient care and side effects.

Use By Other Organizations