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Scaling up ECHO to address theOpioid EpidemicMiriam Komaromy, MDAssociate Director, ECHO InstituteFebruary, 2018

Arora S., Thornton K., Murata G., et al. N Eng J Med. 2011;364(23):2199-207.

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

ECHO model is not ‘traditional telemedicine’.Copyright 2017 Project ECHO

“Hub”“Spokes”

The ECHO ModelAmplification – Use Technologyto leverage scare resourcesShare Best Practicesto reduce disparityCase Based Learningto master complexityWeb-based Database toMonitor OutcomesCopyright 2017 Project ECHO

Benefits to Rural CliniciansNo-cost CMEs and Nursing CEUsProfessional interaction with colleagues with similar interestLess isolation with improved recruitment and retentionA mix of work and learningAccess to specialty consultationCopyright 2017 Project ECHO

Goals of Project ECHODevelop capacity to safely and effectively treatHepatitis C in all areas of New Mexico and tomonitor outcomes.Develop a model to treat complex diseases inrural locations and developing countries.Copyright 2017 Project ECHO

PartnersUniversity of New Mexico School of Medicine,Department of Medicine, Telemedicine and CMENM Department of CorrectionsNM Department of HealthIndian Health ServiceFQHCs and Community ClinicsPrimary Care AssociationCopyright 2017 Project ECHO

How well has model worked?600 HCV teleECHO Clinics have been conducted 6,000 patients entered HCV disease management programCME’s/CE’s issued:Total CME hours 79000 hours at no cost for HCV and 19 otherdisease areasCopyright 2017 Project ECHO

Project ECHO CliniciansHCV Knowledge Skills and Abilities (Self-Efficacy)TODAYMEAN (SD)PairedDifference(p-value)MEAN (SD)EffectSizefor thechange2.6 (1.2)5.1 (1.0)2.4 (1.3)( 0.0001)1.95. Serve as local consultant withinmy clinic and in my area for HCVquestions and issues.2.4 (1.2)5.6 (0.9)3.3 (1.2)( 0.0001)2.86. Ability to educate and motivateHCV patients.3.0 (1.1)5.7 (0.6)2.7 (1.1)( 0.0001)2.4BEFOREParticipationMEAN (SD)4. Ability to assess and managepsychiatric co- morbidities inpatients with hepatitis C.Community CliniciansN 25Copyright 2017 Project ECHO (continued)

Project ECHO CliniciansHCV Knowledge Skills and Abilities (Self-Efficacy)Community CliniciansN 25BEFOREParticipationMEAN (SD)Overall Competence(average of 9 items)2.8* (0.9)TODAYMEAN (SD)PairedDifference(p-value)MEAN (SD)Effect Sizefor thechange5.5* (0.6)2.7 (0.9)( 0.0001)2.9Cronbach’s alpha for the BEFORE ratings 0.92 and Cronbach’s alpha for the TODAY ratings 0.86 indicating a high degree of consistency inthe ratings on the 9 items.Arora S., Kalishman S., Thornton K., et al. Hepatol. 2010;52(3):1124-33.Copyright 2017 Project ECHO

Treatment OutcomesHepatitis C*SVR sustained viral responseNEJM : 364: 23, June 9-2011, Arora S, Thornton K, Murata G

Disease SelectionCommon diseasesManagement is complexEvolving treatments and medicinesHigh societal impact (health and economic)Serious outcomes of untreated diseaseImproved outcomes with disease managementCopyright 2017 Project ECHO

Bridge BuildingPareto’s PrincipleUNM HSCState HealthDeptCommunityPrivatePractice Health CentersChronic PainRheumatoid Arthritis Rheumatology ConsultationSubstance Use and Mental Health DisordersCopyright 2017 Project ECHO

Force MultiplierUse Existing Community CliniciansSpecialistsPrimary CareProvidersNursesCommunityhealth workersChronic PainRheumatoid Arthritis Rheumatology ConsultationSubstance Use and Mental Health DisordersCopyright 2017 Project ECHO

Successful Expansion into Multiple DiseasesMONTUEWEDTHURSFRIRheumatologyHBVCommunity HealthWorkersOpioid Addiction Bankhurst Gish CHW TeamCDC Good Healthand Wellness inIndian Country StrumingerTuberculosisBone HealthEndocrinology &DiabetesChronic Pain andOpioidManagementNurse Practitioner/Certified MidwifePrimary Care Burgos Lewiecki Bouchonville Comerci Van RoperCardiology Achrekar,Anderson &YatskowitzCrisis Interventionfor CommunityPolicing Agencies DuhiggMiners' WellnessPrison PeerEducation Program SoodReproductiveHealthSeizures and SpellsHepatitis C (HCV) ThorntonHIV/ HCVCorrectionsIntegratedAddictions andPsychiatry (IAP) KomaromyAntimicrobialStewardship Singh Imerman Arora Iandiorio &Thornton Brett, Irizarry &Mercier Komaromy

ECHO Hubsand Spokes:State of NewMexico

ECHO-AGEBeth Israel Deaconess Boston2:1 Matched Cohort Study11 nursing homes received ECHO intervention. Matched with22 controlsResidents in ECHO Age facilities were 75% less likely to bephysically restrainedResidents were 17% less likely to be prescribedantipsychoticsGordon S.E., Dufour A.B., Monti S.M., et al. J Am Med Dir Assoc. 2016;17(6):553-6.Copyright 2017 Project ECHO

Geriatric Mental Health ECHOUniversity of Rochester NYUniversity of Rochester experts in geriatric psychiatry helptrain and mentor primary care clinicians in NYSince 2014, 500 clinicians have participated in their ECHOproject funded by AHRQThere was a 20 % reduction in ED visits24 % reduction in overall costsFisher, E., Hasselberg, M., Conwell, Y., et al. Popul Health Manag. 2017;20(5):342-7.Copyright 2017 Project ECHO

123456789101112131415161718Admissions/1,000ECHO Care: ADMISSIONS/1,000/MONTH200First MonthOf ECHO18016014012010080604020Months Before/After ECHO EnrollmentCopyright 2017 Project ECHO

123456789101112131415161718ED Visits/1,000ECHO Care: ED VISITS/1,000/MONTH700First MonthOf ECHO600500400300200100Months Before/After ECHO EnrollmentCopyright 2017 Project ECHO

ECHO Care: -TOTAL EXPENDITURES/MONTHFirst MonthOf 9101112131415161718Expenditures/Month3,500Months Before/After ECHO EnrollmentCopyright 2017 Project ECHO

“Pain ECHO” changes knowledge, confidence,and prescribing patterns VA PCPs who attended a mean of 28 sessions hadincreased confidence and knowledge about painmanagement PCPs from FQHCs who attended a Pain ECHOprogram for a mean of 39 sessions decreasedprescribing of opioids 11. Ball, Pain Medicine, 20172. Anderson, Pain Medicine, 2017

ECHO CHW TrainingMultiple TracksCHW Specialist TrainingDiabetes and cardiovascular risk reduction: Diabetes,Obesity, Hypertension, Cholesterol, Smoking Cessation,Exercise PhysiologyOpioid Use DisorderECHO Care : Complex Multiple DiagnosesObesity Prevention: Diet, Exercise, Motivational InterviewingPrevention of Child Abuse and Neglect (PCAN)Copyright 2017 Project ECHO

Why is a CHW Intervention Effective?Live in CommunityUnderstand cultureAppreciate economic limitations of patient and knowcommunity resources available to patientOften know family and can engage other social resourcesfor patientSpend more time with patientCopyright 2017 Project ECHO

Community Based Care for Cardiac Risk Factor Reductionwas more Effective than Enhanced Primary CareBecker, D.M., Yanek, L.R., Johnson W.R., et al. Circulation. 2005;111:1298-1304.Copyright 2017 Project ECHO

Diabetes Specialty CHW ProgramNarrow Focus — Deep KnowledgeStandardized Curriculum3 Day OnsiteWeekly ECHO sessions for 16 weeksDietExerciseSmoking CessationMotivational InterviewingGentle NudgesFinger StickFoot ExamPart of Disease Management TeamCopyright 2017 Project ECHO

Community Health Workers in PrisonThe New Mexico Peer Education ProgramPilot training cohort, CNMCF Level II, July 27-30, 2009First day of peer educator trainingPhoto consents on file with Project ECHO and CNMCFCopyright 2017 Project ECHO

ECHO Hubsand Spokes:State of NewMexico

Army and Navy Pain Management ECHO Clinics Army ECHO Hubs: Regional Health Command-Europe (RHC-E) – Landstuhl, Germany Regional Health Command-Central (RHC-C)-JointBase San Antonio-Brook Army Medical Center – TX Regional Health Command-Pacific (RHC-P)-Tripler Army Medical Center – HI RegionalHealth Command-Atlantic (RHC-A) – Ft. Bragg, NCBelgium: Brussels Supreme HeadquartersAllied Powers Europe(SHAPE)Germany: Grafenwoehr Hohenfels Katterbach Landstuhl Regional MedicalCenter (LRMC)/FHC LRMC/IMC Stuttgart Wiesbaden VilseckItaly: Livorno VicenzaJapan: Camp ZamaSouth Korea: Camp Casey Camp Humphreys Camp Carroll Camp Walker Brian Allgood Army CommunityHospital/ 121st Combat SupportHospitalAlabama: Redstone ArsenalArizona: Fort HuachucaCalifornia: Fort IrwinColorado: Colorado SpringsGeorgia: Fort Gordon Fort Benning Ft. StewartHawaii: Schofield Barracks (FamilyMedicine and Troop MedicalClinic) Adult Medicine PatientCentered Medical Home(PCMH) Tripler Family Medicine PCMH Tripler Warrior Ohana PCMH VA Pain ClinicKansas: Fort Leavenworth Fort RileyKentucky: Fort Knox Fort CampbellLouisiana: Fort PolkMaryland: Fort MeadeMissouri: Fort Leonard WoodNew Mexico: White Sands Missile RangeNew York: Fort Drum West PointOklahoma: Fort SillSouth Carolina: Fort JacksonTexas: Fort Bliss Fort HoodVirginia: Joint Base Langley-Eustis Fort LeeWashington: Madigan Army Medical Center Navy ECHO Hubs: Navy Medicine East (NME)- Naval Medical Center (NMC)Portsmouth, VA Navy Medicine West (NMW)- Naval Medical Center SanDiego (NMCSD), CAArizona: NHYumaCalifornia: NMCSD Naval Training Center NHLemoore NH Twentynine Palms NH Camp Pendleton Naval Air Facility El Centro Naval Air Station North IslandFlorida: Naval Hospital (NH) Jacksonville Naval Air Station JacksonvilleMaryland: NHC Pax RiverMissouri: Behavioral Health Clinic (BHC) BooneNorthCarolina: NH Camp LeJeuneNew Hampshire: BHC Portsmouth NH Navy Safe HarborVirginia: NMC Portsmouth (CaseManagement, Pain Clinic,Physiatry, Internal Medicine) BHC Oceana TriCare Prime Clinic (TPC)Chesapeake TPC Virginia Beach 633rd Medical Group-Langley

ECHO Hubsand Superhubs:United States

ECHO Hubs andSuperhubs:Global

The “ECHO Act”(Expanding Capacity for Health Outcomes Act)Passed House/Senate by unanimous vote, November-December 2016Signed into law by President Barack Obama, December 2016Asks the Secretary of Health and Human Services to study the impact of Project ECHO on:ConditionsMental and substance use disorders, chronic diseases and conditions,prenatal and maternal health, pediatric care, pain management, andpalliative careWorkforceImplementation of public health programs, including those related todisease prevention, infectious disease outbreaks, and public healthsurveillancePublic HealthHealth care workforce issues, such as specialty care shortages andprimary care workforce recruitment, retention, and support for lifelonglearningRural andUnderservedPopulationsDelivery of health care services in rural areas, frontier areas, healthprofessional shortage areas, and medically underserved areas, and tomedically underserved populations and Native AmericansCopyright 2017 Project ECHO

Scaling ECHO to address the Opioid Epidemic

Komaromy M., Duhigg D., Metcalf A., et al. Subst Abus. 2016;37(1):20-4.

Opioid ECHOU. of NewMexicoECHOSharedServicesModelOpioid ECHOBillings ClinicOpioid ECHOU. ofWashingtonSupportingHub atECHOInstitute“Hub-lets” providespecialist teamsOpioid ECHOWestern NewYorkOpioid ECHOBostonMedicalCenterSupporting hub leads development of curriculum and provides IT,evaluation, and admin support, and participant recruitment for all hubs

HRSA-fundedNational Opioid ECHO ProgramPARTICIPATIONYear one355 participants from147 HRSA-funded healthcentersHalf are medical providers,and one third are behavioralhealth providersCopyright 2018 Project ECHO

HRSAOpioid Addiction Treatment ECHO Participants in ECHO for addiction/mental health report thatpresenting cases changes their management plan 1 For this national Opioid ECHO, early results show: Impact of case-based learning in each sessionFor those who presented a case: 92% say input changed management planLearning from cases presented by others: 81% learned something new from a case presented thatday which will change their care of their own patients Marked increase in confidence and significant increase in positive attitudeKomaromy, Psychiatric Services, 2017

Federal funding for Opioid Addiction Treatment ECHOFunding sourcefor HubSAMHSASTRHRSAAHRQIn 2017 0.5B was distributed to states through the CURES Act to address Opioid Use Disorder20 states are implementing Opioid ECHO using CURES funds