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Project ECHO

Project ECHO. An Innovation in Healthcare Delivery Treatment of Hepatitis C January 26, 2012 Saverio Sava, MD First Choice Community Healthcare Associate Professor UNM Family & Community Medicine. Who We Are. A Federally Qualified Community Health Center System Founded in 1972

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Project ECHO

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  1. Project ECHO • An Innovation in Healthcare Delivery • Treatment of Hepatitis C • January 26, 2012 • Saverio Sava, MD • First Choice Community Healthcare • Associate Professor • UNM Family & Community Medicine

  2. Who We Are • A Federally Qualified Community Health Center System Founded in 1972 • Provider of Primary Medical, Dental, Behavioral Health and WIC Services2 • A major Safety Net Provider to the Uninsured and Underinsured in Bernalillo, Valencia, Sandoval, Torrance, Guadalupe, Santa Fe, and Socorro Counties in Central New Mexico • An Incubator for Innovation, Change & Community Development • 8 Locations in 3 Counties • Serving 50,000 Patients with over 200,000 Visits Annually

  3. Our Facility Locationsin Central New Mexico • Counties Serviced • Bernalillo • Guadalupe • Sandoval • Santa Fe • Socorro • Torrance • Valencia

  4. First Choice Locations

  5. Project ECHO • Celebrating Successes

  6. Innovations in Primary Care • Project ECHO • Utilizes the specialty expertise of an Academic Health Center in partnership with Primary Care and Public health practices in rural and undeserved communities.

  7. Project ECHO • What project ECHO represents is a bold experiment that implements a new approach to providing care.

  8. Project ECHO • Hepatitis C • A Growing Concern

  9. Hepatitis C: A Global Health Problem 170 Million Carriers Worldwide, 3-4 MM new cases/year EAST MEDITERRANEAN 20M WEST EUROPE 9 M FAR EAST ASIA 60 M U.S.A. 4 M SOUTH EAST ASIA 30 M AFRICA 32 M SOUTH AMERICA 10 M AUSTRALIA 0.2 M Source: WHO 1999

  10. HEPATITIS C IN NEW MEXICO HEPATITIS C IN NEW MEXICO • Estimated number is greater than 28,000 • In 2004 Less than 5% had been treated • Without treatment 8,000 patients will develop cirrhosis between 2010-2015 with several thousand deaths • 2300 prisoners diagnosed in corrections system (expected number is greater than 2400) - None treated • Highest rate of chronic liver disease/cirrhosis deaths in the nation

  11. GOALS GOALS • Develop capacity to safely and effectively treat Hepatitis C in all areas of New Mexico and to monitor outcomes • Develop a model to treat complex diseases in rural locations and developing countries

  12. METHOD METHOD • Use Technology (multipoint videoconferencing and internet) to leverage scarce healthcare resources • Disease Management Model focused on improving outcomes by reducing variation in processes of care and sharing “best practices” • Case based learning: Co-management of patients with UNMHSC specialists (Learning by Doing) • HIPAA compliant centralized database to monitor outcomes • Arora S, Geppert CM, Kalishman S, et al: Acad Med. 2007 Feb;82(2): 154-60.

  13. Rural New Mexico RURAL NEW MEXICO RURAL NEW MEXICO • Underserved Area for Healthcare Services • 32 of 33 New Mexico counties are listed as Medically Underserved Areas (MUAs) • 14 counties designated as Health Professional Shortage Areas (HPSAs) • 121,356 sq miles • 1.83 million people • 42.1% Hispanic • 9.5% Native American • 17.7% poverty rate compared to 11.7% nationally • >22% lack health insurance

  14. STEPS STEPS • Train physicians, nurses, pharmacists, educators in Hepatitis C • Train to use web based software - “ihealth” • Conduct telemedicine clinics – “Knowledge Network” • Initiate co-management – “Learning loops” • Collect data and monitor outcomes centrally • Assess cost and effectiveness of programs

  15. BENEFITS TO RURAL CLINICIANS COMMUNITY PARTNERS • No-cost CMEs and Nursing CEUs • Professional interaction with colleagues with similar interest – Less isolation with improved recruitment and retention • A mix of work and learning • Obtain HCV certification • Access to specialty consultation with GI, hepatology, psychiatry, infectious diseases, addiction specialist, pharmacist, patient educator

  16. How well has model worked for Hepatitis C ? • 500 HCV Telehealth Clinics have been conducted • >5000 patients entered HCV disease management program • CMEs/CEs issued: • 6100 CME/CE hours issued to ECHO Clinicians for Hep C. Total CME hours 27,000 at no cost

  17. The Hepatitis C Trial

  18. Objectives To train primary care Clinicians in rural areas and prisons to deliver hepatitis C treatment to rural populations of New Mexico To show that such care is as safe and effective as that given in a University Clinic To show that Project ECHO improves access to hepatitis C care for minorities

  19. Participants Study sites Intervention (ECHO) Community-based clinics: 16 New Mexico Department of Corrections: 5 Control: University of New Mexico (UNM) Liver Clinic Subjects meeting inclusion / exclusion criteria Community cases seen by primary care physicians Consecutive University patients

  20. Principal Endpoint Sustained viral response (SVR): no detectable virus 6 months after completion of treatment

  21. Developing New Standards of Practice for Hepatitis C • 407 hepatitis C patients met inclusion and exclusion criteria • Age: 43.0 ± 10.0 years • Men: 63.3% • Minority: 65.2% • Genotype 1: 57.0% • Log10 viral load: 5.89 ± 0.95 • Treatment sites • UNMH: 146 • ECHO site: 261

  22. Treatment Outcomes SVR=sustained viral response NEJM : 364: 23, June 9-2011, Arora S, Thornton K, Murata G

  23. Conclusions Rural primary care Clinicians deliver hepatitis C care under the aegis of Project ECHO that is as safe and effective as that given in a University clinic Project ECHO improves access to hepatitis C care for New Mexico minorities

  24. KNOWLEDGE IMPORTANT - NOT TITLE FORCE MULTIPLIER HEALTHCARE IN NEW MEXICO Chronic Disease Management is a Team Sport Community Health Worker Medical Assistant Primary Care Nurse Hepatitis C Asthma and COPD Substance Use and Mental Health Disorders

  25. Project ECHO • Organizational Challenges & Barriers to • Implementation • In a Community Health Center

  26. Project ECHO • Ideological • Financial • Training & Staffing • Transforming our Healthcare System

  27. Project ECHO • Ideological Barriers • “It’s Not What We Do” • “Replacing the Lost Primary Care Effort”

  28. Project ECHO • Financial barriers • Effects on productivity • Buying Provider Time & Staff Support • Fixed Payment Systems for FQHC’s • Prevention May Save $$$ but….

  29. Project ECHO • Training & Staffing • Rapid Turnover of Support Staff • Increasing difficulty Recruiting PCP’s

  30. Project ECHO • Transforming our Healthcare System • How do we advocate so innovations that work are disseminated? • How do we institutionalize programs so they grow beyond individual champions?

  31. Project ECHO • Steps for Successful Implementation.

  32. Project ECHO • Steps for Successful Implementation. • 1. Start with a champion.

  33. Project ECHO • Steps for Successful Implementation. • 1. Start with a champion. • 2. Administration must buy in early.

  34. Project ECHO • Steps for Successful Implementation. • 1. Start with a champion. • 2. Administration must buy in early. • 3. Involve multiple key staff member.

  35. Project ECHO • Steps for Successful Implementation. • 1. Start with a champion. • 2. Administration must buy in early. • 3. Involve multiple key staff member. • 4. Key on staff satisfaction & retention.

  36. Project ECHO • Steps for Successful Implementation. • 1. Start with a champion. • 2. Administration must buy in early. • 3. Involve multiple key staff member. • 4. Key on staff satisfaction & retention. • 5. Highlight positive patient experiences.

  37. Project ECHO • Steps for Successful Implementation. • 1. Start with a champion. • 2. Administration must buy in early. • 3. Involve multiple key staff member. • 4. Key on staff satisfaction & retention. • 5. Highlight positive patient experiences. • 6. Highlight your program in organizational reports and newsletters.

  38. Project ECHO • Use the success of Project ECHO to explore other practice modifications that will likewise contribute to changing the face of how we deliver healthcare.

  39. Medicine & Public HealthInto the New Millennium Ten Great Public Health Achievements - United States 1900 - 1999 • Vaccinations • Sanitation • Healthier Mothers and Babies • Decline in Deaths from Coronary Heart Disease • Motor-Vehicle Safety • Family Planning • Fluoridation of Drinking Water • Safer and Healthier Foods • Safer Workplace • Recognition of Tobacco use as Health Hazard JAMA, April 28, 1999

  40. Project ECHO • The greatest impact on healthcare in this millennium will be through system innovations on how health care is delivered to improve the health of our communities.

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