SummaryThrough an adaptation of Project ECHO (Project Extension for Community Healthcare Outcomes, which originated at the University of New Mexico), the University of Chicago Medical Center offers a series of 12 one-hour-long, interactive videoconference sessions to primary care clinicians in community-based clinics in urban, low-income areas. Each series focuses on a specific topic related to specialty care, with the goal of helping physicians feel more comfortable providing care in that area. Each session consists of a didactic presentation from an expert, followed by a case presentation and discussion in which participants share practical ideas on how to enhance specialty care in the primary care setting. The initial program, which focused on resistant hypertension, significantly increased primary care provider knowledge and confidence on this topic. Anecdotal reports suggest that it also increased intra-clinic consultations among providers, reduced the need for referrals to outside specialists, and enhanced patient access to specialty care. Subsequent series will focus on attention-deficit/hyperactivity disorder in children and other topics of importance to participating primary care clinicians.Moderate: The evidence consists of pre- and post-implementation comparisons of changes in primary care provider knowledge and confidence related to resistant hypertension, along with anecdotal reports on the program's impact on inter-clinic consultations, outside referrals, and access to specialty care.
Developing OrganizationsSouth Side Healthcare Collaborative; University of Chicago Medical Center
Use By Other OrganizationsAs noted, this program is based on Project ECHO at the University of New Mexico.
Date First Implemented2009
Vulnerable Populations > Impoverished; Urban populations
Problem AddressedResidents of urban areas, particularly low-income individuals covered by Medicaid or without insurance, often have difficulty accessing specialty care for chronic conditions. Lack of access is driven by several factors, including financial issues, logistical barriers, and language and communication issues. Local primary care clinicians could potentially fill the void, but most lack access to education and/or specialist consultations, and hence do not feel comfortable or confident providing specialty care.
- Lack of access to specialty care: Many residents of urban areas have difficulty accessing specialty care for chronic conditions. Medical directors of community health centers report that about 25 percent of primary care visits result in a referral to specialty care, and up to 50 percent of patients have difficulty accessing that care. Patients with Medicaid or with no insurance had considerably more problems than privately-insured or Medicare-insured patients.1
- Driven by multiple barriers: Multiple barriers limit access to specialty care for low-income, urban residents, as outlined below:
- Financial barriers: Many specialists do not accept patients covered by Medicaid and/or those without insurance. In addition, Medicaid does not cover certain types of specialty care, and some providers require upfront payments from patients. As a result, specialty care may be out of the financial reach of many patients.1
- Wait times: Wait times for appointments can be up to two times longer for patients with public insurance compared to patients with private insurance.2
- Logistical barriers: Relatively few specialists practice in low-income urban areas; rather, they tend locate in more affluent areas of cities and/or around hospitals. As a result, patients must travel farther to access needed care, something that many find difficult or impossible to do.3
- Communication and cultural barriers: Many patients must deal with language and/or other communication barriers when seeking care from specialists. Many also report feeling uncomfortable at the large medical centers where many specialists have their offices.3
- Unrealized potential of primary care to fill void: Primary care physicians in these areas often lack access to continuing medical education (CME) programs related to specialty care and/or have few opportunities to consult with specialists. Consequently, they tend to feel isolated and lack confidence in some areas of medicine, making them reluctant to provide specialty care.
Description of the Innovative ActivityThe University of Chicago Medical Center offers a recurring series of 12 one-hour, interactive videoconference sessions to primary care clinicians in community-based clinics in low-income areas. Each series focuses on a specific topic related to specialty care. The goal is to increase capacity at community health centers by enlarging physicians' knowledge base and making them feel more comfortable providing care for the conditions/diseases covered. Each session consists of a didactic presentation from an expert, followed by a case presentation and discussion in which participants share practical ideas on how to enhance specialty care in the primary care setting. Key program elements include the following:
- Interactive sessions covering specific topic: Each series of 12 one-hour-long sessions covers a specific topic area, with sessions held every other week. The first series (which is recurring) focused on resistant hypertension, while subsequent series will concentrate on attention-deficit/hyperactivity disorder (ADHD) in children. (See the Planning and Development Process section for more details on selection of these topics and others to be delivered in the future.) Use of high-quality video equipment lets clinicians and subject matter experts interact in real time, allowing them to become comfortable with each other and exchange information and resources freely. Each session consists of a didactic lesson, case presentations, and discussion, as outlined below:
- Didactic lesson by subject matter expert: A subject matter expert begins each session with a 20-minute presentation on some aspect of care. For example, for resistant hypertension, a leading specialist from the University of Chicago focused on what primary care providers need to know to provide more effective care to patients with the condition.
- Case presentations by primary care providers: At each session, primary care providers present case reports of actual patients (de-identified to protect patient confidentiality). These reports allow clinicians to bring up questions and discuss real-life situations encountered by clinicians and patients, including effective strategies for overcoming barriers and challenges. For example, discussions might cover appropriate treatment regimens and follow up care, along with strategies for overcoming barriers to patient adherence to medication or dietary recommendations. Although program leaders originally asked clinicians to volunteer to present cases, they later changed this approach, having the subject matter expert assign a provider to present a case at the next session.
- Facilitated discussion: After the case presentation, the subject matter expert leads a discussion of different aspects of treatment and patient motivation and engagement highlighted by the case. This portion functions as a group problem-solving session, focusing on solutions to address common challenges facing physicians. For example, one clinician developed and shared a list of foods to avoid on an antihypertension diet. Patients found it easier to adhere to the recommended diet with a clear list of what they should not eat, rather than a list of approved foods.
- CME credit and monetary compensation: To encourage participation, the program offers compensation to clinics to make up for lost provider time spent preparing for and participating in the sessions. Clinicians also receive CME credit for participating.
Context of the InnovationThe University of Chicago Medical Center is a 532-bed academic medical center located on the campus of the University of Chicago. The center's Urban Health Initiative focuses on improving care on the city's south side by providing patient care and engaging in community-based research and medical education. The South Side Healthcare Collaborative, established by the Urban Health Initiative in 2005, consists of a network of more than 30 community-based health centers and 5 hospitals committed to improving access to quality care, preventing disease, and reducing unnecessary use of emergency care in this predominantly African-American area. The impetus for this program came from the subspecialty and patient care workgroups within the collaborative, which identified access to specialty care as a particular challenge for Medicaid and uninsured patients. Approximately 44 percent of the area's residents have incomes below 200 percent of the Federal poverty level and are either uninsured or dependent on public health insurance, such as Medicaid.4
ResultsThe initial program, which focused on resistant hypertension, significantly increased primary care provider knowledge and confidence in treating patients with this condition. Anecdotal reports suggest that it also increased intra-clinic consultations among providers, reduced the need for referrals to outside specialists, and enhanced patient access to specialty care.
Moderate: The evidence consists of pre- and post-implementation comparisons of changes in primary care provider knowledge and confidence related to resistant hypertension, along with anecdotal reports on the program's impact on inter-clinic consultations, outside referrals, and access to specialty care.
- More knowledgeable and confident providers: Pre- and post-implementation testing of physicians at 11 sites shows that those who participated in the program about resistant hypertension increased their knowledge of the subject by 33 percent, whereas those who did not participate declined 9 percent in knowledge. The same testing showed that participants experienced a 13.5 percent greater increase in self-efficacy and confidence in their knowledge of the topic compared to those not attending the sessions.
- More consultations within clinic, fewer outside referrals: Anecdotal reports suggest that participating clinicians consult more often with their colleagues about treatment of patients with resistant hypertension and make fewer referrals to outside specialists.
- Enhanced access to care for patients: Anecdotal reports suggest that patients now find it easier to access care for their resistant hypertension, encountering shorter wait and travel times for appointments (versus appointments in far-away specialty centers).
- To be determined impact on patient outcomes: Research staff are collecting and analyzing data on the program's impact on patient outcomes for resistant hypertension. Results are not yet available.
Planning and Development ProcessKey steps included the following:
- Considering a range of approaches to problem: The aforementioned workgroups looked at different potential strategies for addressing the problem, such as increasing the number of specialists willing to take referrals from community health centers, hiring specialists to practice at the community health centers, and training primary care providers to treat more severe or chronic disease. They chose the third alternative because it had the greatest chance of increasing capacity at community health centers, and because other programs already existed to recruit specialists willing to serve Medicaid beneficiaries and add specialists to community health centers.
- Adapting program developed for rural providers: While visiting a colleague in New Mexico, a committee member learned about Project ECHO, developed by Dr. Sanjeev Arora at the Albuquerque-based University of New Mexico. While Dr. Arora's program focused on bringing specialty knowledge to rural providers, the committee member felt that approach could be adapted to an urban setting.
- Training project staff: A technology expert, a leader of a local clinic, and a physician spent 3 days at the New Mexico program learning how it worked and visiting the Federally Qualified Health Centers that participate.
- Choosing topic areas: The partners and involved clinicians chose to begin with resistant hypertension because, at some sites, roughly half of patients have hypertension, and, overall, about one-fourth of referrals to specialists related to hypertension. Hypertension also caused many hospitalizations. The partners and clinicians have chosen a second topic (ADHD in children), with additional topics to be chosen based on clinician input.
- Curriculum development: The hypertension subject matter expert worked with others on the Project ECHO team to develop a structure and list of topics to cover in the sessions. Rather than a lecture format or a full hour of didactic presentation, they decided to follow a more traditional grand rounds structure in which actual cases are presented and discussed.
Resources Used and Skills Needed
- Staffing: A full-time program coordinator manages the various Project ECHO initiatives and oversees data collection. (In the absence of data collection, a part-time coordinator would be sufficient.) A part-time research assistant helps with data collection, while a part-time technical person assists with the setup for each session and stays during the sessions in case problems arise. In the beginning, setup took 30 minutes or longer, but now that participating sites have become more proficient, it takes only about 5 minutes.
- Costs: First-year program costs totaled roughly $100,000, including staff salaries, payments to clinicians to cover their time during the sessions, and equipment. The university already had the bridge technology—which allows several sites to participate in videoconferencing—so there was no need to purchase that equipment.
Funding SourcesAetna Foundation; American Cancer Society; University of Chicago Medical Center; Grant Healthcare Foundation
Tools and Other ResourcesFor more information on Project ECHO at the University of New Mexico, go to http://echo.unm.edu, and see the related Innovations Exchange profile describing this program, available at http://www.innovations.ahrq.gov/content.aspx?id=3144.
Getting Started with This Innovation
- Let community define problem: The community (rather than the academic medical center) identified the problem of inadequate access to specialty care and, hence, took ownership for addressing it. Once this occurred, the academic medical center offered its resources to help in addressing that problem. The end result was an effective collaboration with a joint commitment to work together.
- Involve partners and clinicians in choosing initial topics: As noted, the partners and involved clinicians chose the topics, which helped to generate enthusiasm and maximize participation. The second project focusing on ADHD has garnered an even larger response than the initial hypertension project.
- Allow time to create learning group: Clinicians may initially be shy and reticent, as it takes time to establish the confidence to present cases and exchange information and ideas freely. To encourage interaction, facilitators should remain positive and never criticize anyone's observations or ideas.
- Assign clinicians to present cases: Originally, program coordinators asked for volunteers to present cases. However, no one came forward. Once they assigned the case presentations, clinicians responded well.
- Make sure sites have adequate broadband: Bandwidth problems affected the Chicago area even more than in rural New Mexico, mostly due to high levels of activity on local internet connections in congested areas. Use of electronic health record systems also requires bandwidth, thus reducing the amount available for video streaming. In some cases, it became necessary to hook up a dedicated internet cable to ensure good reception. Program developers are investigating other technologies that may reduce costs and eliminate the need to use the University's existing technology.
Sustaining This Innovation
- Consider clinician motivation for participation: The planners originally budgeted $20,000 a year to compensate providers for time spent in the learning sessions, and offered CME credit for participating. However, many sites have not invoiced the program for that money, and some participating clinicians have not applied for CME credit. These actions suggest that opportunities to gain knowledge and interact with colleagues may motivate clinicians more than money or CME credit.
- Continue querying about topics of interest: After the initial program ended, participants filled out a course evaluation that included a question about potential topics for future programs. Participants indicated interest in diabetes, congestive heart failure, obesity, arthritis, and substance abuse.
- Archive sessions for future use: Participants have requested that sessions be recorded and made available for future use, including by those unable to attend the live session. This strategy can help to increase program reach.
- Approach organizations with special interests for possible funding: Researchers at the University of Chicago have determined that 20 to 30 percent of disparities in breast cancer outcomes in African-American women stem from issues related to primary care. Even though clinicians did not identify this topic as a high priority, program leaders have decided to develop a Project ECHO program on it, using funds from the American Cancer Society to create the curriculum and conduct the course.
Use By Other OrganizationsAs noted, this program is based on Project ECHO at the University of New Mexico.
Contact the InnovatorDaniel Johnson, MD
Senior Faculty Consultant, South Side Healthcare Collaborative
University of Chicago Medical Center
5841 S. Maryland Ave., MC 6082
Chicago, IL 60637
Innovator DisclosuresDr. Johnson has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
References/Related ArticlesCook NL, Hicks LS, O'Malley AJ, et al. Access to specialty care and medical services in community health centers. Health Aff (Millwood). 2007;26(5):1459-68. [PubMed] Available at: http://content.healthaffairs.org/content/26/5/1459.full.html
Getzenberg J, et al. The Chicago Health Care Access Puzzle: Fitting the Pieces Together. Chicago: Chicago Department of Public Health, Office of Policy & Planning, 2008. Available at: http://www.cityofchicago.org/content/dam/city/depts/cdph/policy_planning
/PP_ChgoHealthCareAccessRpt-1-.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat Reader® software .)
Patrick G, Hickner J. Four Models Bring Specialty Services to the Safety Net: Enhancing Scope of Practice and Referral Efficiency. California HealthCare Foundation, July 2009. Available at: http://www.chcf.org/publications/2009/07
2 Bisgaier J, Rhodes KV. Auditing access to specialty care for children with public insurance. N Engl J Med. 2011;364:2324-33.
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Original publication: March 14, 2012.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: March 26, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: February 19, 2014.
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.