Embedding ECHO in Nurse Practitioner Curriculum

1. Embedding ECHO in Nurse Practitioner Curriculum Van Roper, PhD, FNP-C Associate Clinical Professor Medical Director, NP/CNM Primary Care tele-ECHO Clinic University of New Mexico, College of nursing svroper@salud.unm.edu THE UNIVERSITY OF NEW MEXICO

2. Disclosures I have nothing to disclose THE UNIVERSITY OF NEW MEXICO

3. Objective Describe and provide current evaluation of an effective virtual environment embedded in curricula benefiting both advance practice students and practicing clinicians. THE UNIVERSITY OF NEW MEXICO

4. What Is Telehealth? • Before we talk about ECHO, let’s review what telehealth is: • What it is… • The delivery of healthcare at a distance utilizing information & telecommunication technology • A collection of means/methods to enhance care delivery & education • Interdisciplinary • What it is not… • A specific clinical service • Telemedicine • Not faxes THE UNIVERSITY OF NEW MEXICO

5. Telehealth Domains Center for Connected Health Policy, National Telehealth Policy Resource Center Live Videoconferencing (synchronous) Store-and-Forward (asynchronous) Remote Patient Monitoring (RPM) Mobile Health (mHealth) THE UNIVERSITY OF NEW MEXICO

6. Telehealth Components • Telecomm • & • Link network • User • & • Provider • Technical • Equipment • Telehealth • System • Mode of • Delivery • Application • Process Med-e-Tel 2015 THE UNIVERSITY OF NEW MEXICO

7. Why Telehealth? Improves efficiency and quality Allows expertise to be available anywhere Telecommunication has improved quality & lowered cost of equipment Reimbursement & funding is changing (Office of Advancing Telehealth-OAT) Acceptance is spreading THE UNIVERSITY OF NEW MEXICO

8. ModelsofTelehealth • Provider to provider • Provider to healthcare facility to patient • Outpatient specialty consultation • Inpatient specialty consultation • EMS - ER consults while on scene & during transport • Family to patient remotely • Provider to patient THE UNIVERSITY OF NEW MEXICO

9. What is Project ECHO? • Lifelong learning & guided practice model • Increases workforce capacity to provide best-practice specialty care in underserved areas • Reduces health disparities • Hub & spoke knowledge-sharing networks • Virtual clinics with community providers (spokes) • Expert teams at an academic center (hub) • Multi-point videoconferencing • PCPs learn to provide specialty care within their own community • Creates an environment where All Teach, All Learn Focus: ProvidertoProvider THE UNIVERSITY OF NEW MEXICO

10. ChallengesinAdvanced Practice • Issues in primary care • Primary care has become more complicated • Advances in medical care evolve more rapidly • Difficult to keep up • Providers often feel professionally isolated • Issues in advanced practice education • Health care is increasingly more complicated • Can we really teach everything in ~2 years? • Residency vs fellowship vs virtual ongoing education THE UNIVERSITY OF NEW MEXICO

11. Linking Telehealthto Education • Establish use of telehealth in education • Utilize telehealth during education as a clinical tool • New graduate providers will have incorporated telehealth as part of their every day clinical practice • Provide continued education in ongoing advances in medical care • No cost to clinicians including complementary CMEs &/or CNEs • Increases capacity to provide higher level of care in local clinic • Improves provider confidence • Essentially develops an ongoing clinical support system that can be accessed as long as desired • Improves patient outcomes • May increase potential recruitment and retention THE UNIVERSITY OF NEW MEXICO

12. How We Are Doing It • Weekly NP/CNM Primary Care Clinic • Incorporated into 8 advance practice courses including family, pediatric, acute care/gerontology, and midwifery • 1½ hours every Friday noon till 1:30pm MST • Clinic format: didactic followed by case presentation(s) • Grading rubrics for participation, didactic presentation, and case presentation • Students, often paired, present didactic topics based on topics selected by faculty • Presentation criteria utilized in review by faculty and ECHO clinic hub • Assure robust information for practicing clinicians • Case presentations from clinical practice in collaboration with preceptor THE UNIVERSITY OF NEW MEXICO

13. NP-CNM Primary Care TeleECHO Clinic • A TeleECHO Clinic focused on: • Nurse Practitioners (family, pediatric, acute care) • Certified Nurse Midwives • Open to anyone interested in primary care • Physician’s Assistants (PAs) • Pharmacists • Physical Therapists (PTs) and Occupational Therapists (Ots) • Community Health Workers (CHWs) • Physicians • Overarching focus is on Primary Care in low-resource settings • Rural providers in particular face many challenges in delivering primary care THE UNIVERSITY OF NEW MEXICO

14. Goals of NP-CNM Primary Care Clinic Enhance the competencies of NPs, CNMs, and graduates in rural and low-resource settings. Increase knowledge and self-efficacy through education and mentorship. Improve utilization and access to healthcare resources in the practitioner’s community. Provide support and enhance competencies of newly-graduated NPs and CNMs so that they have the ability to formulate a holistic primary care treatment plan. THE UNIVERSITY OF NEW MEXICO

15. Classes Currently Included Adult Health I (N536) Adult Health II (N535) Adult Health III (N537) Pediatrics II (N546) Family Fieldwork (N595) Primary Care (N555) Geriatric Care (N534) Antepartum (N544) Recently added to the Adult/Gerontology Acute Care Nurse Practitioner program curriculum (TraceBack pilot) New courses are being added over time THE UNIVERSITY OF NEW MEXICO

16. Student Participation • Students present initially paired then individually-presented case presentations • Pulled from student’s clinical training • Prepared in collaboration with clinical preceptor • Cases are reviewed and vetted by course faculty, NP-CNM PCE Medical Director, and Clinic Coordinator for accuracy and appropriateness • Grades are determined by a competency-based rubrics • Competencies provided by the National Organization of Nurse Practitioner Faculty (NONPF), America Association of Colleges of Nursing (AACN), Interprofessional Education Collaborative (IPEC), and the Association of Graduate Medical Education (AGME) • Effectively measure presentation skills and knowledge uptake THE UNIVERSITY OF NEW MEXICO

17. How Many Students Are There? • Approximately 20% of the 2016 graduating class participated in the NP-CNM Primary Care TeleECHO Clinic (n=28) • First cohort with ECHO embedded in their curriculum • 100% of the 2017 graduating class participated (n=42) • Average session audience is 25 during semesters • More data to come with future classes THE UNIVERSITY OF NEW MEXICO

18. What’s Happened So Far ~20% of graduating class return regularly as practicing clinicians for sessions Developed approaches to assist new graduates with negotiating for paid time with new employers to participate weekly High levels of satisfaction on anonymous student surveys in each class Ongoing research on knowledge uptake and satisfaction through surveys at 6 and 12 months post graduation Post clinic participant surveys inform future clinic topics for didactic presentations Incorporate topics for didactics from faculty survey often on subjects not covered in coursework due to time constraints THE UNIVERSITY OF NEW MEXICO

19. What’s Next • Transition to an interprofessional platform that includes all health sciences departments; however, it is not without its challenges… • Complex Chronic Disease IPE TeleECHO Rotation (CON, SOM, COP, PA) • Successful pilot but limited with integrating different schools’ schedules • Very small participant numbers but 1:1 faculty ratio • 4 week rotation: 2nd week formative case study; 4th week summative case study • Intensive experience with high satisfaction by both student and faculty • AGME award • Develop state wide model with affiliate institutions • Develop national model with other institutions THE UNIVERSITY OF NEW MEXICO

20. Questions? THE UNIVERSITY OF NEW MEXICO

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22. References&Resources American Telemedicine Association, Practice Guidelines for Live, On Demand Primary and Urgent Care, December 2014 Center for Connected Health Policy, National Telehealth Policy Resource Center. Accessed from: http://cchpca.org/ Center for Telehealth, University of New Mexico Health Sciences Center Office of Community Health. Accessed from http://hsc.unm.edu/community/telehealth/ Hiller J, Eliott J, Karnon J, & Elshaug A. (2010). How does Telehealth change health care delivery? PPT; University of Adelaide THE UNIVERSITY OF NEW MEXICO

23. References&Resources Lacktman, NM & Ferrante, TB; DC Proposes New Telemedicine Rules: What You Need to Know, Lexology, March 16, 2016. Accessed from: http://www.lexology.com/library/detail.aspx?g=53055553-ad08-440f-bede-3fda230329f4 New Mexico Telehealth Alliance. http://www.nmtelehealth.org/ Project ECHO. https://echo.unm.edu/ Robert J Waters Center for Telehealth & e-Health Law. http://ctel.org/ Southwest Telehealth Resource Center. http://southwesttrc.org/ Sutjiredjeki E, et al. (2015). Business Model as a Strategic Tool in Telehealth Development. PPT. Proceedings from Med-e-Tel 2015, Indonesia. THE UNIVERSITY OF NEW MEXICO