Expanding access to hepatitis C virus treatment--Extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care

Project ECHO®: a global cross-sectional examination of implementation success

BACKGROUND

Organizations implement innovations to disrupt the status quo and create value. Within sectors such as healthcare, innovations need to navigate large scale system and organizational factors to succeed. This research explores the implementation of a global innovation- Project ECHO®. Project ECHO® is a validated virtual communities of practice model organizational teams implement to build workforce capacity and capability. Project ECHO® has experienced broad global adoption, particularly within the healthcare sector, and is experiencing growth across other sectors. This study sought to examine the state of implementation success for Project ECHO® globally, to understand how these implementations compare across geographic and sectoral contexts, and understand what enablers/barriers exist for organizational teams implementing the innovation.

METHODS

An empirical study was conducted to collect data on 54 Project ECHO® implementation success indicators across an international sample. An online survey questionnaire was developed and distributed to all Project ECHO® hub organizations globally to collect data. Data was analyzed using descriptive statistics.

RESULTS

The 54 implementation success indicators measured in this survey revealed that the adoption of Project ECHO® across 13 organizations varied on a case-by-case basis, with a strong rate of adoption within the healthcare sector. Implementation teams from these organizations successfully implemented Project ECHO® within 12-18 months after completing Immersion partner launch training and operated 51 ECHO® Networks at the time of data collection. Implementation teams which liaised more regularly with ECHO® Superhub mentors often went on to launch a higher number of ECHO® Networks that were sustained over the longer term. This suggests that these implementation teams better aligned and consolidated their Project ECHO® pilots as new innovations within the local context and strategic organizational priorities. Access to research and evaluation capability, and a more automated digital client relationship management system were key limitations to showcasing implementation success outcomes experienced by the majority of implementation teams.

CONCLUSIONS

These findings make a valuable contribution to address a knowledge gap regarding how a global sample of organizations adopting Project ECHO® measured and reported their implementation successes. Key successes included pre-launch experimentation and expansion, Superhub mentorship, stakeholder engagement, and alignment to strategic priorities.

Healthcare social network research and the ECHO model™: Exploring a community of practice to support cultural brokers and transfer cultural knowledge

BACKGROUND

Project ECHO® networks at Children's Health Queensland Hospital and Health Service (CHQHHS) are communities of practice designed to mitigate services and systems fragmentation by building collaborative partnerships addressing priority child and youth health needs. Aboriginal and Torres Strait Islander people experience the negative impacts of fragmentation in addition to historical challenges of absent or culturally inappropriate health services. Access to culturally safe and responsive services can be improved by engaging Aboriginal and Torres Strait Islander Health Workers and similar roles in an online community of practice, supporting the integration of cultural and clinical knowledge and self-determination of Aboriginal and Torres Strait Islander consumers in decisions affecting their health. Analysing professional support networks and knowledge sharing patterns helps identify enablers and barriers to partnerships. Using social network research, the multilevel network inclusive of ECHO network members and their colleagues was studied to identify interdisciplinary and cross-sector advice exchange patterns, explore the position of cultural brokers and identify common relational tendencies.

METHODS

Social network theories and methods informed the collection of network data and analysis of advice-seeking relationships among ECHO network members and their nominees. Registered members from two ECHO networks were invited to complete the Qualtrics survey. Networks analysed comprised 398 professionals from mainstream health, Aboriginal and Torres Strait Islander Community Controlled Health Organisation, education, disability and child safety service settings.

RESULTS

Brokers were well represented, both those who hold knowledge brokerage positions as well as cultural brokers who incorporate clinical and cultural knowledge enabling holistic care for Aboriginal and Torres Strait Islander patients (38 individuals, 17% of network). Professionals who occupy brokerage positions outside the ECHO network tend to be more connected with co-members within the network.

CONCLUSIONS

This study is the first application of contemporary social network theories and methods to investigate an ECHO network. The findings highlight the connectivity afforded by brokers, enabling the coordination and collaboration necessary for effective care integration. Inclusion of cultural brokers in an ECHO network provides sustained peer group support while also cultivating relationships that facilitate the integration of cultural and clinical knowledge.

Examining the Outcomes of Project ECHO® as an Interprofessional Community of Practice for Pediatric Feeding Clinicians

Project ECHO® is a virtual, interprofessional, cased-based peer-learning model. To date, no studies have explored ECHO as a model for pediatric feeding education. This study examined the outcomes of establishing a pediatric feeding ECHO network. Using a prospective, mixed-methods design, two cohorts of allied health professionals were recruited. Each cohort participated in eight, 90-min videoconference sessions incorporating a didactic presentation and clinical case presentation. The case was presented by a participant, with questions and recommendations provided by the ECHO network. Participants completed: (1) a learning needs analysis before the ECHO series, (2) a self-reported confidence questionnaire pre, post, and 3-month post, (3) a satisfaction questionnaire after each session, and (4) an overall satisfaction questionnaire post-ECHO series. Time spent by hospital allied health clinicians providing impromptu phone/email feeding support to external clinicians was recorded for 8 weeks prior to and 8 weeks during the ECHO series. Forty-seven participants were included in the study, attending an average of 5.8 sessions. Significant improvements in self-reported confidence were observed across the three time points (p < 0.01) with less experienced participants demonstrating greater improvements. Participants reported high satisfaction with ECHO, with 93% (40/43) wanting continued access to ECHO in future. The multidisciplinary format, interactivity, structure, and case-based nature of ECHO were considered beneficial. A 75% reduction in requests for support from clinicians in the same catchment area was noted during the ECHO series. Results demonstrated that Project ECHO is a viable model for pediatric feeding education for clinicians working in the field. Further research is needed to investigate the long-term effects and impacts on clinical care.

Telehepatology Satisfaction Is Associated with Ethnicity: The Real-World Experience of a Vulnerable Population with Fatty Liver Disease

BACKGROUND

Since the coronavirus disease 2019 (COVID-19) pandemic began, telemedicine use has transformed healthcare delivery. Yet there is concern that telemedicine may widen care disparities for vulnerable populations, and patient experience data are limited.

AIMS

We aimed to assess patient satisfaction with hepatology-related telemedicine (telehepatology) for delivery of fatty liver disease (FLD) care in a safety-net healthcare system.

METHODS

Adult patients with FLD were surveyed regarding satisfaction with telehepatology. Clinical, demographic, resources, and social determinants of health (SDoH) data were collected to identify factors associated with satisfaction through multivariable modeling.

RESULTS

From June 2020 to March 2022, 220 participants were enrolled: the median age was 52 years, 37% were men, and 68% were Hispanic. One hundred nineteen (54%) had prior telehepatology experience. Overall, satisfaction was high; 70% reported being somewhat or very satisfied. On univariate analysis, Hispanic ethnicity (versus non-Hispanic, OR 0.34, 95% CI 0.1-0.9, p = 0.03) and limited access to personal cellphone/internet (OR 0.16, 95% CI 0.04-0.6, p = 0.01) were associated with lower satisfaction. On multivariable logistic regression modeling adjusted for pandemic duration, age, sex, severity of liver disease, and coexisting liver disease, Hispanic ethnicity and lack of personal cellphone/internet remained independently associated with lower telehepatology satisfaction (OR 0.24, 95% CI 0.07-0.9, p = 0.03 and OR 0.2, 95% CI 0.04-0.9, p = 0.04, respectively). The association remained statistically significant after inclusion of various SDoH in the multivariable model.

CONCLUSIONS

Satisfaction with telehepatology among FLD patients in a safety-net clinical setting was high overall. However, Hispanic ethnicity and lack of personal cellphone/internet were independently associated with lower telehepatology satisfaction. A better understanding of patients' experience with telehepatology is needed to identify reasons for dissatisfaction, and in-person visits should remain an option for patients to ensure equitable care.

Integrating methadone into primary care settings in Ukraine: effects on provider stigma and knowledge

INTRODUCTION

Stigma has undermined the scale-up of evidence-based HIV prevention and treatment. Negative beliefs influence clinicians' discriminatory behaviour and ultimately have wide-ranging effects across the HIV prevention and treatment continuum. Stigma among clinicians can be mitigated in several ways, including through interpersonal contact. In this study, we test whether interactions with people who inject drugs (PWID) influence attitudes of both direct and indirect providers of opioid agonist therapies (OATs) within the same primary care clinics (PCCs) where OAT is newly introduced.

METHODS

In a cluster randomized controlled trial integrating OAT and HIV care into PCCs in Ukraine, clinicians at 24 integrated care sites (two sites in 12 regions) from January 2018 to August 2022 completed a structured survey at baseline, 12 and 24 months. The survey included feeling thermometers and standardized scales related to clinician attitudes towards patients and evidence-based care. Nested linear mixed-effects models were used to examine changes in mean scores over three timepoints for both direct and indirect clinicians.

RESULTS

There were fewer significant changes in any of the scales for direct providers (n = 87) than for indirect providers (n = 155). Direct providers became less tough-minded about substance use disorders (p = 0.002), had less negative opinions about PWID (p = 0.006) and improved their beliefs regarding OAT maintenance (p<0.001) and medical information (p = 0.004). Indirect providers reported improvements in most stigma constructs, including a significant decrease in prejudice (p<0.001), discrimination (p = 0.001), shame (p = 0.007) and fear (p = 0.001) towards PWID.

CONCLUSIONS

Integrating OAT services within primary settings was associated with significantly reduced stigma constructs and improved attitudes towards PWID, possibly through increased intergroup contact between PWID and general clinical staff. Unlike most stigma reduction interventions, re-engineering clinical processes so that PWID receive their care in PCCs emerges as a multilevel stigma reduction intervention through the integration of specialized services in PCCs. Integration influences different types of stigma, and has positive effects not only on health outcomes, but also improves clinician attitudes and efficiently reduces clinician stigma.

Transfer of Knowledge on Pneumoconiosis Care Among Rural-Based Members of a Digital Community of Practice: Cross-Sectional Study

BACKGROUND

Given the re-emergence of coal workers' pneumoconiosis in Appalachia and Mountain West United States, there is a tremendous need to train rural professionals in its multidisciplinary management. Since 2016, the Miners' Wellness TeleECHO (Extension for Community Health Outcomes) Program held by the University of New Mexico, Albuquerque, and Miners' Colfax Medical Center, Raton, New Mexico, provides structured longitudinal multidisciplinary telementoring to diverse professionals taking care of miners by creating a digital community of practice. Program sessions emphasize active learning through discussion, rather than didactic training. Professional stakeholder groups include respiratory therapists, home health professionals, benefits counselors, lawyers or attorneys, clinicians, and others. Rural-urban differences in knowledge transfer in such a community of practice, however, remain unknown.

OBJECTIVE

We aim to evaluate the role of the rurality of the patient or client base in the transfer of knowledge to professionals caring for miners using the digital community of practice approach.

METHODS

This is a cross-sectional study of 70 professionals participating in the Miners' Wellness TeleECHO Program between 2018 and 2019. Drawing insights from social network analysis, we examined the association between the rurality of participants' patient or client base and their self-reported receipt of knowledge. Our focal independent variable was the respondent's self-reported percentage of patients or clients who reside in rural areas. We measured knowledge transfer sources by asking participants if they received knowledge regarding the care of miners during and outside of TeleECHO sessions from each of the other participants. Our dependent variables included the number of knowledge sources, number of cross-stakeholder knowledge sources, number of same stakeholder knowledge sources, and range and heterogeneity of knowledge sources.

RESULTS

Respondents, on average, identified 4.46 (SD 3.16) unique knowledge sources within the community, with a greater number of cross-stakeholder knowledge sources (2.80) than same stakeholder knowledge sources (1.72). The mean knowledge source range was 2.50 (SD 1.29), indicating that, on average, respondents received knowledge sources from roughly half of the 5 stakeholder groups. Finally, the mean heterogeneity of knowledge sources, which can range between 0 and 0.80, was near the midpoint of the scale at 0.44 (SD 0.30). Multivariable analyses revealed that as the rurality of patient or client bases increased, participants reported more knowledge sources overall, more knowledge sources from outside of their stakeholder groups, a higher knowledge source range, and greater heterogeneity of knowledge sources (P<.05 for all comparisons).

CONCLUSIONS

Our findings suggest that participants who serve rural areas especially benefit from knowledge transfer within the TeleECHO community of practice. Additionally, the knowledge they receive comes from diverse information sources, emphasizing its multidisciplinary nature. Our results underscore the capacity of the TeleECHO model to leverage technology to promote rural health equity for miners.

Analysis of Telehealth Equity Within the Military Health System During the COVID-19 Pandemic

Background: Telehealth care expanded during the COVID-19 pandemic, although previous studies show racial, gender, and socioeconomic inequalities in its usage. Racial disparities are known to be mitigated in the Military Health System (MHS), whose 9.6 million beneficiaries are universally insured and nationally representative. This study investigated whether known disparities in telehealth usage were mitigated in the MHS. Methods: This study performed a retrospective cross-sectional study of TRICARE telehealth claims data from January 2020 to December 2021. Beneficiaries aged 0 to 64 years were identified with Common Procedural Terminology code modifiers 95, GT, and GQ, which indicated procedures that were delivered through either synchronous or asynchronous telecommunication services. Visits were defined as one encounter per patient per day. Analyses included descriptive statistics of patient demographics, number of telehealth visits, and differences between military-provided and private sector care (PSC). Military rank was used as a proxy for socioeconomic status (SES), generally combining income, education, and occupation type. Results: A total of 917,922 beneficiaries received telehealth visits during the study period: 25% in direct care, 80% in PSC, and 4% in both care settings. The majority of visits were received by females (57%) and associated with a Senior Enlisted rank (66%). The visits by racial category were proportional to the percentage of each category in the population. The lowest number of visits was for those older than 60 years, potentially receiving Medicare instead, and those associated with Junior Enlisted rank, a potential disparity that may also reflect access to leave or smaller family size. Conclusions and Relevance: Within the MHS, telehealth visits were equitable by race, in line with previous findings, but not by gender, SES, or age. Findings by gender are reflected in the greater U.S. population. Further research is needed to assess and address potential disparities associated with Junior Enlisted rank as proxy for low SES.

Addressing Emerging Needs Through the COVID-19 and Children With Medical Complexity ECHO

The COVID-19 and Children with Medical Complexity (CMC) Extension for Community Healthcare Outcomes (ECHO) was developed as a "just in time" learning format to respond to the vast number of challenges faced by health care clinicians, public health professionals, and families/caregivers of CMC during the coronavirus disease 2019 (COVID-19) pandemic. A unique aspect of the ECHO was the meaningful integration of family leaders who participated as faculty, learners, case study presenters, and guest lecturers. Another distinguishing feature of this ECHO was its inclusion within a Collaborative Improvement and Innovation Network. A mixed methods analysis found that the COVID-19 and CMC ECHO was associated with significant gains in knowledge and confidence in caring for CMC and their families during the COVID-19 pandemic. This article provides an overview of the results of the COVID-19 and CMC ECHO and provides recommendations related to utilizing the ECHO model as a rapid response mechanism for systems improvement, clinical practice improvement, and education during a public health emergency.

A scoping review of existing research between 1990 and 2023: Measuring virtual communities of practice across disciplines

Virtual communities of practice (VCoPs) can decrease social, structural, and professional isolation, provide opportunities for knowledge-sharing abilities, and may improve participants' self-reported sense of connectedness to one another and their profession. However, more research is needed to examine measurement of VCoPs effectiveness on participants. In this scoping review our research question was: What is the state of the science for VCoPs and how are these communities measured in current research specific to education and health/health education? Guided by Arksey and O'Malley's five stages for conducting a rigorous scoping review, we identified gaps in the evidence regarding the overall state of the science on measurement of VCoPs inclusive of quantitative and mixed-methods literature describing validated VCoP measurement in both English or Spanish from January 1990 to July 2023, and within the health, education, or health education disciplines. Initial searches yielded 2350 articles. Authors independently screened papers and extracted data. The results of this scoping review (N = 13 articles) highlight the measurement of VCoPs specific to education, healthcare, health education research. We found that measures had been tested in VCoPs within health, education, health education, and professional education information technologies disciplines, with the Community of Inquiry framework being the most common theoretical foundation. The findings provide an understanding of measurement tools and impacts and outcomes of VCoP participation and we make recommendations for future VCoP measurement tool development.

Extension for Community Healthcare Outcomes fetal alcohol spectrum disorder (ECHO FASD): Tele-mentoring program to increase healthcare capacity for FASD diagnosis

BACKGROUND

Children with fetal alcohol spectrum disorder (FASD) often experience delayed, missed, or incorrect diagnosis due to low FASD awareness and diagnostic capacity. Current strategies to expand awareness and diagnostic capacity are insufficient or impractical.

METHODS

This project examined the feasibility of Extension for Community Healthcare Outcomes (ECHO) tele-mentoring to train community clinicians about FASD. Participants attended ten 1-h weekly ECHO sessions that included presentations, vignettes, and discussions. Measurement utilized Bowen's feasibility domains.

RESULTS

Robust webpage traffic yielded 19 participants (demand). Fidelity scores, hub team field notes, and participant ratings indicated feasibility based on acceptability, implementation, practicality, and adaptation. Clinicians' knowledge and confidence improved and case-based diagnostic accuracy was high (limited efficacy).

CONCLUSIONS

ECHO FASD is a feasible training method that shows promise in increasing diagnostic capacity across many geographic regions.

Using the project ECHO™ model to teach mental health topics in rural Guatemala: An implementation science-guided evaluation

BACKGROUND

Mental health (MH) disorders are major causes of disability in Guatemala. Unfortunately, limited academic training and funding resources make MH care inaccessible to most people in rural Guatemala. These disparities leave many indigenous populations without care. Project ECHO™ is an educational model used globally to deliver virtual training for providers in rural/ underserved communities. The aim of this project was to implement and evaluate a Project ECHO™ program bridging MH training gaps for providers who serve rural communities in Guatemala.

METHODS

The Project ECHO™ curriculum was implemented through a partnership between educational and nonprofit institutions in Guatemala City and the United States. Participants were primary care physicians and nurses working in rural Guatemala as well as medical/nursing/psychology students. Evaluation of its implementation was guided by a RE-AIM framework. Reach, effectiveness, adoption, fidelity, sustainability, acceptability, feasibility, and appropriateness were evaluated using a mixed-methods approach, using a pre-post survey and semi-structured focus groups.

RESULTS

Forty unique participants attended the five sessions. Attitudes about mental health did not change quantitatively but self-efficacy improved in four of five modules. High quality fidelity scores were noted in two of five sessions. Sustainability scores across multiple domains were highly rated. Scores on instruments measuring acceptability, feasibility, and appropriateness were high. Focus groups showed two main themes: the curriculum filled a gap in education and further adaptation of the model might help improve the experience.

CONCLUSION

Implementation of the Project ECHO™ educational model appeared to have good reach/adoption, showed improvements in self-efficacy, illuminated facilitators and barriers to sustainability, and was felt to be acceptable, feasible, and appropriate. Qualitative analysis supported these conclusions. Future directions would include ongoing evaluation and monitoring of further Project ECHO™ curricular experiences through this partnership and adaptation of this project to other learners and settings in Latin America.

Exploring the Impact of ECHO Ontario Integrated Mental and Physical Health on Participants' Approach and Attitude Toward the Care of Patients With Complex Needs

OBJECTIVE

To examine how project Extension for Community Healthcare Outcomes-Integrated Mental and Physical Health (ECHO-IMPH) influences the attitudes and approaches of primary care providers and other participants towards patients.

METHODS

An exploratory qualitative approach was undertaken using semistructured interviews conducted between August 2020 and March 2021. One hundred and sixty-four individuals from two cycles of ECHO-IMPH were invited to participate, and 22 (n = 22) agreed to participate. Data were analyzed using the Braun and Clarke method for thematic analysis.

RESULTS

Three major themes were identified: 1) enhanced knowledge and skills; 2) changes in attitude and approach; 3) space for reflection and exploration. When participants were asked about areas for improvement, suggestions were focused on the structure of the sessions. Participants identified that ECHO-IMPH helped them to view patients more holistically, which led to greater patient-centered care in their practice. Additionally, skills gained in ECHO-IMPH gave participants the concrete tools needed to have more empathetic interactions with patients with complex needs.

CONCLUSIONS

ECHO-IMPH created a safe space for participants to reflect on their practice with patients with complex needs. Participants applied newly acquired knowledge and skills to provide more empathetic and patient-centered care for patients with complex needs. Based on the shift in perspectives described by participants, transformative learning theory was proposed as a model for how ECHO-IMPH created change in participants' practice.

The aims and effectiveness of communities of practice in healthcare: A systematic review

Communities of practice (CoPs) are defined as "groups of people who share a concern, a set of problems, or a passion about a topic, and who deepen their knowledge and expertise by interacting on an ongoing basis". They are an effective form of knowledge management that have been successfully used in the business sector and increasingly so in healthcare. In May 2023 the electronic databases MEDLINE and EMBASE were systematically searched for primary research studies on CoPs published between 1st January 1950 and 31st December 2022. PRISMA guidelines were followed. The following search terms were used: community/communities of practice AND (healthcare OR medicine OR patient/s). The database search picked up 2009 studies for screening. Of these, 50 papers met the inclusion criteria. The most common aim of CoPs was to directly improve a clinical outcome, with 19 studies aiming to achieve this. In terms of outcomes, qualitative outcomes were the most common measure used in 21 studies. Only 11 of the studies with a quantitative element had the appropriate statistical methodology to report significance. Of the 9 studies that showed a statistically significant effect, 5 showed improvements in hospital-based provision of services such as discharge planning or rehabilitation services. 2 of the studies showed improvements in primary-care, such as management of hepatitis C, and 2 studies showed improvements in direct clinical outcomes, such as central line infections. CoPs in healthcare are aimed at improving clinical outcomes and have been shown to be effective. There is still progress to be made and a need for further studies with more rigorous methodologies, such as RCTs, to provide further support of the causality of CoPs on outcomes.

Telemedicine in Patients Affected by Chronic Liver Disease: A Scoping Review of Clinical Outcomes and the Devices Evaluated

For patients with chronic liver disease (CLD), telemedicine is emerging as a useful tool to prevent liver decompensation or hospitalization, allowing access to and the decentralization of care, even for patients with limited resources. However, research and attendant evidence are still lacking; thus, this review aims to systematically explore the topic of telemonitoring for CLD to describe the currently used tools and clinical outcomes. The review was conducted by using key terms on PubMed/EMBASE and searching for observational studies or clinical trials (according to PRISMA recommendations) that were published between 6 April 2013 and 6 April 2023 to keep the technological framework limited to the last 10 years. The studies were described and grouped according to the aim of telemonitoring, the underlying disease, and the tools adopted to achieve remote monitoring. A total of 32 articles met the inclusion criteria. Of these, 11 articles report the successful use of a telehealth program to support and improve access to care in the management of HCV-related cirrhosis, eight articles examine the efficacy of telemedicine for remote monitoring interventions to prevent or decrease the risk of decompensation in high-risk patients, and five articles examine improvements in the physical performance and quality of life of cirrhotic patients through telehealth rehabilitation programs. Four studies were completed during the recent COVID-19 pandemic. Telehealth has the potential to provide and expand treatment access and reduce barriers to care for the most disadvantaged patients and might be able to reduce the need for hospital readmission for CLD, though most practice to test feasibility is still in the pilot stage.

Training the healthcare workforce: the global experience with telementorship for hepatitis B and hepatitis C

BACKGROUND

Telementorship has emerged as an innovative strategy to decentralise medical knowledge and increase healthcare capacity across a wide range of disease processes. We report the global experience with telementorship to support healthcare workers delivering hepatitis B virus (HBV) and hepatitis C virus (HCV) care and treatment.

METHODS

In early 2020, we conducted a survey of HBV and HCV telementorship programmes, followed by an in-depth interview with programme leads. Programmes were eligible to participate if they were located outside of the United States (U.S.), focused on support to healthcare workers in management of HBV and/or HCV, and were affiliated with or maintained adherence to the Project ECHO model, a telementorship programme pioneered at the University of New Mexico. One programme in the U.S., focused on HCV treatment in the Native American community, was purposively sampled and invited to participate. Surveys were administered online, and all qualitative interviews were performed remotely. Descriptive statistics were calculated for survey responses, and qualitative interviews were assessed for major themes.

RESULTS

Eleven of 18 eligible programmes completed the survey and follow up interview. Sixty-four percent of programmes were located at regional academic medical centers. The majority of programmes (64%) were led by hepatologists. Most programmes (82%) addressed both HBV and HCV, and the remainder focused on HCV only. The median number of participating clinical spoke sites per programme was 22, and most spoke site participants were primary care providers. Most ECHO sessions were held monthly (36%) or bimonthly (27%), with sessions ranging from 45 min to 2 h in length. Programme leaders identified collective learning, empowerment and collaboration to be key strengths of their telementorship programme, while insufficient funding and a lack of protected time for telementorship leaders and participants were identified as major barriers to success.

CONCLUSION

The Project ECHO model for telementorship can be successfully implemented across high and low-and-middle-income countries to improve provider knowledge and experience in management of viral hepatitis. There is a tremendous opportunity to further expand upon the existing experience with telementorship to support non-specialist healthcare workers and promote elimination of viral hepatitis.

Increasing the adoption of evidence-based communication practices for HPV vaccination in primary care clinics: The HPV ECHO study protocol for a cluster randomized controlled trial

BACKGROUND

The safe, highly-effective human papillomavirus (HPV) vaccine remains underused in the US. The Announcement Approach Training (AAT) has been shown to effectively increase HPV vaccine uptake by training providers to make strong vaccine recommendations and answer parents' common questions. Systems communications, like recall notices, can further improve HPV vaccination by reducing missed clinical opportunities for vaccination. Never tested in supporting HPV vaccination, the ECHO (Extension for Community Healthcare Outcomes) model is a proven implementation strategy to increase best practices among healthcare providers. This trial uses a hybrid effectiveness-implementation design (type II) to evaluate two ECHO-delivered interventions intended to increase HPV vaccination rates.

METHODS

This 3-arm cluster randomized controlled trial will be conducted in 36 primary care clinics in Pennsylvania. Aim 1 evaluates the impact of HPV ECHO (AAT to providers) and HPV ECHO+ (AAT to providers plus recall notices to vaccine-declining parents) versus control on HPV vaccination (≥1 dose) among adolescents, ages 11-14, between baseline and 12-month follow-up (primary outcome). Using a convergent mixed-methods approach, Aim 2 evaluates the implementation of the HPV ECHO and HPV ECHO+ interventions. Aim 3 explores exposure to and impact of vaccine information from providers and other sources (e.g., social media) on secondary acceptance among 200 HPV vaccine-declining parents within 12 months.

DISCUSSION

We expect to demonstrate the effectiveness and evaluate the implementation of two highly scalable interventions to increase HPV vaccination in primary care clinics. Our study seeks to address the communication needs of both providers and parents, increase HPV vaccination, and, eventually, prevent HPV-related cancers.

TRIAL REGISTRATION

ClinicalTrials.govNCT04587167. Registered on October 14, 2020.

TransECHO: A National Tele-Education Program for Expanding Transgender and Gender Diverse Health Care

Purpose: Few clinicians have received training to provide comprehensive primary care for transgender and gender diverse (TGD) people. This article describes the program design and evaluation outcomes of TransECHO, a national professional development program for training primary care teams on the provision of affirming integrated medical and behavioral health care for TGD people. TransECHO is based on Project ECHO (Extension for Community Healthcare Outcomes), a tele-education model that aims to reduce health disparities and increase access to specialty care in underserved areas. Methods: Between 2016 and 2020, TransECHO conducted 7 year-long cycles of monthly training sessions facilitated by expert faculty through videoconference technology. Primary care teams of medical and behavioral health providers from federally qualified health centers (HCs) and other community HCs across the United States engaged in didactic, case-based, and peer-to-peer learning. Participants completed monthly postsession satisfaction surveys and pre-post TransECHO surveys. Results: TransECHO trained 464 providers from 129 HCs in 35 U.S. states, Washington DC, and Puerto Rico. On satisfaction surveys, participants provided high scores for all items, including those related to enhanced knowledge, effectiveness of teaching methods, and intentions to apply knowledge and change practice. Compared with pre-ECHO survey responses, post-ECHO responses averaged higher self-efficacy and lower perceived barriers to providing TGD care. Conclusions: As the first Project ECHO on TGD care for U.S. HCs, TransECHO has helped to fill the gap in training on comprehensive primary care for TGD people.

Design, implementation and preliminary results of a type-2 hybrid cluster-randomized trial of integrating screening and treatment for major depressive disorder into specialty clinics providing opioid agonist therapies in Ukraine

INTRODUCTION

Ukraine has a high prevalence of co-occurring disorders (COD), defined as having both substance use (SUD) and psychiatric disorders. Major depressive disorder (MDD) is the most prevalent psychiatric disorder among people with SUD. People with COD experience poor health outcomes, and international agencies propose integrated COD care. In Ukraine, treatment for SUD is delivered in specialized substance use clinics, without providing any other medical services for comorbidities, including MDD. Here we present the protocol, along the with the preliminary results of the MEDIUM project, including observations over the first 6 months.

METHODS

A cluster-randomized type-2 hybrid trial was conducted to integrate MDD treatment into specialty clinics providing opioid agonist therapies (OAT) in Ukraine. Twelve clinics in four regions underwent randomization to control (N = 1) vs experimental arms (N = 2) in each region. Clinicians at experimental sites received tele-education through modified project ECHO using a facilitated screening, evaluation, and treatment algorithm of depression, with or without financial incentives. Service-, patient- and provider-level data were collected for the analysis every 6 months for 24 months.

PRELIMINARY RESULTS

For service delivery outcomes, 4421 patients enrolled on OAT across all sites were assessed for MDD for screening (76.7%), evaluation with diagnosis (43.5%) and treatment (30.7%) for MDD; 13.8% continued treatment at least for 6 months. For patient-level outcomes, 1345 patients and 54 providers participated in serial surveys every six months.

CONCLUSION

This study will be the first to explore integrated COD care in Ukraine and generate evidence on effective service integration and delivery strategies for people with COD receiving treatment at substance use clinics with broader implications for Eastern Europe and Central Asia region.

Telementoring With Project ECHO: A New Era in Diabetes-Related Continuing Education for Primary Care to Address Health Disparities

Project ECHO® is a telementoring workforce development model that targets under-resourced communities lacking access to specialty care. The model builds virtual communities of practice, including specialists and community primary care professionals (PCPs) to combat clinical inertia and health disparities. While the ECHO model has gained global recognition, implementation of the model related to diabetes is lagging compared to other specialty conditions. This review highlights diabetes-endocrine (ENDO)-focused ECHOs using data reported in the ECHO Institute's centralized data repository (iECHO) and the learning collaborative for diabetes ECHOs. It also describes the implementation of diabetes ECHOs and their evaluation. Learner and patient-centered outcomes related to diabetes ECHOs are reviewed. Program implementation and evaluations have demonstrated utility of the ECHO model for diabetes programs to (1) address unmet needs of diabetes care in the primary care setting, (2) improve knowledge and confidence in managing complex diabetes and change provider prescribing habits, (3) improve patient outcomes, and (4) address diabetes quality improvement practices in primary care. More studies with broader collaboration among sites are needed to evaluate the model related to diabetes, especially applied to addressing therapeutic inertia, adoption of diabetes technology, and reducing health disparities.

A randomized controlled trial for a peer-facilitated telemedicine hepatitis c treatment intervention for people who use drugs in rural communities: study protocol for the "peer tele-HCV" study

BACKGROUND

Hepatitis C virus (HCV) transmission is primarily driven by injection drug use, and acute HCV infection rates are increased in rural communities with substantial barriers to care. Treatment of HCV in persons who use drugs (PWUD) is cost effective, decreases high risk behaviors and HCV transmission, and achieves high rates of treatment completion and sustained viral response. Adapting HCV care delivery to utilize peer support specialists, telemedicine technology, and streamlined testing and treatment strategies can better reach rural populations living with HCV.

METHODS

This is an open label, two-arm, non-blinded, randomized controlled trial designed to test the superiority of peer-facilitated and streamlined telemedicine HCV care (peer tele-HCV) compared to enhanced usual care (EUC) among PWUD in rural Oregon. In the intervention arm, peers conduct HCV screening in the community, facilitate pretreatment evaluation and linkage to telemedicine hepatitis C treatment providers, and support participants in HCV medication adherence. For participants assigned to EUC, peers facilitate pretreatment evaluation and referral to community-based treatment providers. The primary outcome is sustained virologic response at 12 weeks post treatment (SVR12). Secondary outcomes include: (1) HCV treatment initiation, (2) HCV treatment completion, (3) engagement with harm reduction resources, (4) rates of substance use, and (5) engagement in addiction treatment resources. The primary and secondary outcomes are analyzed using intention-to-treat (ITT) comparisons between telemedicine and EUC. A qualitative analysis will assess patient, peer, and clinician experiences of peer-facilitated telemedicine hepatitis C treatment.

DISCUSSION

This study uses a novel peer-based telemedicine delivery model with streamlined testing protocols to improve access to HCV treatment in rural communities with high rates of injection drug use and ongoing disease transmission. We hypothesize that the peer tele-HCV model will increase treatment initiation, treatment completion, SVR12 rates, and engagement with harm reduction services compared to EUC. Trial registration This trial has been registered with ClinicalTrials.gov (clinicaltrials.gov NCT04798521).

Development, implementation, and feasibility of site-specific hepatitis C virus treatment workflows for treating vulnerable, high-risk populations: protocol of the Erase Hep C study - a prospective single-arm intervention trial

BACKGROUND

Hepatitis C virus (HCV) is the leading indication for liver transplantation and liver-related mortality. The development of direct-acting antivirals (DAA) and a simplified treatment algorithm with a > 97% cure rate should make global elimination of HCV an achievable goal. Yet, vulnerable populations with high rates of HCV still have limited access to treatment. By designing locally contextualized site-specific HCV treatment workflows, we aim to cure HCV in vulnerable, high-risk populations, including people experiencing homelessness (PEH) and people who inject drugs (PWID), in Austin, TX, USA.

METHODS

Our implementation science study will utilize a qualitative and design thinking approach to characterize patient and systemic barriers and facilitators to HCV treatment in vulnerable, high-risk populations seeking care across seven diverse primary care clinics serving PEHs and PWIDs. Qualitative interviews guided by the Practical, Robust Implementation and Sustainability Model (PRISM) framework will identify barriers and facilitators by leveraging knowledge and experience from both clinic staff and patients. Data synthesized using thematic analysis and design thinking will feed into workshops with clinic stakeholders for idea generation to design site-specific HCV treatment workflows. Providers will be trained on the use of a simplified HCV treatment algorithm with DAAs and clinic staff on the new site-specific HCV treatment workflows. These workflows will be implemented by the seven diverse primary care clinics serving vulnerable, high-risk populations. Implementation and clinical outcomes will be measured using data collected through interviews with staff as well as through medical chart review.

DISCUSSION

Our study provides a model of how to contextualize and implement site-specific HCV treatment workflows targeting vulnerable, high-risk populations in other geographic locations. This model can be adopted for future implementation research programs aiming to develop and implement site-specific treatment workflows for vulnerable, high-risk populations and in primary care clinical settings for other disease states beyond just HCV.

TRIAL REGISTRATION

Registered on ClinicalTrials.gov on July, 14, 2022. Identifier: NCT05460130 .

Machine learning can guide suitability of consultation and patient referral through telemedicine for hepatobiliary diseases

BACKGROUND AND AIM

Telemedicine is an evolving tool to provide health-care services. We evaluated the suitability of telemedicine to deliver effective consultation for hepatobiliary disorders.

METHODS

In this prospective study spanning over a year, we interviewed hepatologists delivering the teleconsultations through a pre-validated questionnaire. A consult was deemed suitable based on the physician's judgment in the absence of unplanned hospitalization. We evaluated factors determining the suitability through inferential statistics and machine learning models, namely, extreme gradient boosting (XGB) and decision tree (DT).

RESULTS

Of 1118 consultations, 917 (82.0%) were deemed suitable. On univariable analysis, patients with skilled occupation, higher education, out-of-pocket expenses, and diseases such as chronic hepatitis B, C, and non-alcoholic fatty liver disease (NAFLD) without cirrhosis were associated with suitability (P < 0.05). Patients with cirrhosis (compensated or decompensated), acute-on-chronic liver failure (ACLF), and biliary obstruction were likely unsuitable (P < 0.05). XGB and DT models predicted suitability with an area under the receiver operating curve of 0.808 and 0.780, respectively. DT demonstrated that compensated cirrhosis with higher education or skilled occupation with age < 55 years had 78% chance of suitability whereas hepatocellular carcinoma, decompensated cirrhosis, and ACLF patients were unsuitable with a 60-95% probability. In non-cirrhotic liver diseases, hepatitis B, C, and NAFLD were suitable, with a probability of 89.7%. Biliary obstruction and previous failure of teleconsultation were unsuitable, with a probability of 70%. Non-cirrhotic portal fibrosis, dyspepsia, and dysphagia not requiring intervention were suitable (probability: 88%).

CONCLUSION

A simple decision tree can guide the referral of unsuitable and the management of suitable patients with hepatobiliary diseases through telemedicine.

Accelerating guideline dissemination in nursing homes during the COVID-19 pandemic: A patient-centered randomized controlled trial

BACKGROUND

Nursing homes were ill-equipped for the pandemic; though facilities are required to have infection control staff, only 3% have taken a basic infection control course. Little is known about the implementation of effective practices outside of the acute care setting. We proposed an intervention utilizing Project ECHO, to connect Penn State University experts with nursing home staff and administrators to explore how infection control guidelines can be implemented effectively.

METHODS

A stratified cluster randomized design was used to assign nursing homes to either AHRQ-funded COVID-19 ECHO or AHRQ-funded COVID-19 ECHO+.

RESULTS

136 nursing homes participated. There were no significant differences in COVID-19 infection rate, hospitalization, deaths, or influenza, between ECHO or ECHO+.

DISCUSSION

The ECHO model has significant strengths when compared to traditional training, as it allows for remote learning delivered by a multidisciplinary team of experts and utilizes case discussions that match the context of nursing homes.

Palliative care teaching in the new internal medicine curriculum: Project ECHO-an innovative approach to postgraduate education

BACKGROUND

The Internal Medicine Training (IMT) Programme is an evolution of Core Medical Training introduced in 2019. The IMT curriculum places an increased emphasis on palliative care; however, access to palliative care training is variable. Project ECHO (Extension of Community Healthcare Outcomes) develops communities of practice and is a valuable tool for medical education. We report on an evaluation of Project ECHO to deliver palliative medicine training across a geographically large deanery in the North of England.

METHODS

The Project ECHO training programme involved multipoint video technology, telementoring, expert talks and case-based discussions over six sessions, and was fully mapped to the palliative care component of the IMT curriculum. We collected data particularly around attendance and self-reported confidence and knowledge.

RESULTS

By creating a community of practice, we provided virtual placements and over 9 hours of virtual direct contact with palliative medicine consultants; and in total, 921 individual attendances occurred, with 62% attending all six sessions. The course was associated with an increase in self-reported confidence and high satisfaction.

DISCUSSION

Project ECHO is an effective method of delivering teaching to trainees across a large geographical area. Course evaluation shows outstanding results in trainee satisfaction, confidence, knowledge, patient care, clinical skills and reduction in fear when managing death and dying.

Impact of an Urban Project ECHO: Safety-Net Clinician Self-Efficacy Across Conditions

INTRODUCTION

To mitigate the lack of specialty healthcare, Project ECHO (Extension for Community Health Outcomes) trains community-based primary care clinicians to better prevent the progression of, manage, and treat common health conditions. ECHO-Chicago launched in 2010 as the first urban-centered ECHO program, focusing on safety-net clinicians, and has trained over 5,175 community clinicians across 34 topic areas. This paper examines self-efficacy among ECHO-Chicago participants across 11 clinical series, including a novel use of qualitative themes from self-efficacy questions.

METHODS

Five years of baseline and postseries survey data were collected from 2014 to 2019, resulting in 951 participants. Paired t-tests assessed change from baseline survey to postsurvey, and Cohen's d determined effect size. Change was assessed by individual series, adult or pediatric focus, participants' prescription privilege status, and across series by qualitative question theme. Metrics included total change, any improvement, a 10% target, and a clinical competency threshold. Analysis occurred from July 2020 to January 2022.

RESULTS

All clinical series achieved statistically significant improvement in self-efficacy, and most had a large effect size. A total of 88% had any improvement, 65% met the 10% target of 0.7 points, and 52% met the competency threshold of 5.0 in the postsurvey. Prescribers had a significantly greater increase in their self-efficacy scores than nonprescribers. With a comparison across series, each theme achieved statistical significance, with most reaching large effect sizes.

CONCLUSIONS

ECHO-Chicago successfully increased participants' self-efficacy. This inquiry adds an urban focus, years of data, multiple series, and a novel qualitative theme component to enable comparisons across rather than solely within the ECHO series.

Turning Strategy into Action - Using the ECHO Model to Empower the Australian Workforce to Integrate Care

Introduction

Children's Health Queensland (CHQ) established a telementoring hub in Queensland, using the Project ECHO® model, to pilot and scale a range of virtual communities of practice (CoP) to empower the Australian workforce to integrate care.

Description

The establishment of the first Project ECHO hub in Queensland facilitated the implementation of a variety of child and youth health CoP that strategically aligned to the organisation's approach to integrate care through workforce development. Subsequently, other organisations nationally have also been trained to implement and replicate the ECHO model to effect more integrated care through CoPs in other priority areas.

Discussion

Findings from a database audit and desktop analysis of project documentation highlighted that using the ECHO model was effective in establishing co-designed and interprofessional CoP to support a cross-sector workforce to deliver more integrated care.

Conclusion

CHQ's use of Project ECHO highlights an intentional approach to establishing virtual CoP to build workforce capability to integrate care. The approach explored in this paper highlights the value of workforce collaboration amongst non-traditional partners to foster more integrated care.

Evaluation of treatment access and scope of a multistate hepatitis C virus Extension for Community Healthcare Outcomes telehealth service in the US Indian Health System, 2017-2021

PURPOSE

American Indians/Alaska Native (AI/AN) persons are disproportionately affected by hepatitis C virus (HCV). The Northwest Portland Area Indian Health Board Indian Country Extension for Community Healthcare Outcomes (ECHO) telehealth clinic supports primary care providers (PCPs) in treating HCV. We evaluated the extent to which Indian Country ECHO increases access to HCV treatment and holistically serves AI/AN patients.

METHODS

We conducted a retrospective descriptive analysis of Indian Country ECHO treatment recommendations from 2017 to 2021. Recommendations were classified into the following categories: HCV treatment with direct-acting antiviral medication, prevention, substance use disorder treatment, lab or imaging orders, pharmacological considerations, behavior changes, other, and referral. Subanalysis of treatment recommendations was completed for patients with cirrhosis.

FINDINGS

Of the 776 patients from 77 Indian Health System facilities who presented at Indian Country ECHO, 718 (93%) received treatment recommendations. Most patients (93%) received recommendations for HCV treatment by their PCP; only 3% received a recommendation for referral to a hepatologist or liver transplant center for additional care. Most patients received at least 1 recommendation beyond the scope of HCV treatment provision. Cirrhosis criteria were met by 8% of patients, of which 80% received recommendations for HCV treatment by their PCP and 25% received recommendations for referral to a specialist for additional care.

CONCLUSIONS

Most patients presented at the Indian Country ECHO received recommendations for HCV treatment by their PCP, along with recommendations beyond the scope of HCV. Indian Country ECHO telehealth clinic provides comprehensive recommendations to effectively integrate evidence-based HCV treatment with holistic care at the primary care level.

Project ECHO telementoring program in epilepsy for school nurses

OBJECTIVES

Many children with epilepsy experience seizures at school. School nurses must have the clinical expertise to deliver high-quality, safe care for students with epilepsy. However, in some regions of the U.S. access to interactive, epilepsy evidence-based education programs is limited. The objective of this project was to assess the feasibility of adapting the Epilepsy Foundation's (EFs) school nurse education program to the ECHO model and evaluate its impact on school nurse knowledge and self-efficacy in managing epilepsy in students with seizures and program satisfaction.

METHODS

The EFs educational program for school nurses was adapted to the ECHO model and delivered by a team of interdisciplinary epilepsy specialists via videoconferencing. Retrospective post-program surveys were administered at program completion. Data from 32 participants with complete post-program surveys were used for the analysis of knowledge and confidence. Descriptive statistics and the sign test were conducted.

RESULTS

Participants were 166 school nurses from 13 states. The majority had > 15 years of school nurse experience and served schools in suburban or rural areas. Improvements in knowledge and confidence were reported on most survey items. The highest improvements in self-reported knowledge and confidence were in psychosocial aspects of care, comorbidities, and recognition of nonepileptic events. Program satisfaction was rated as high by over 90% of participants.

CONCLUSIONS

Telementoring using the ECHO methodology is a feasible modality to educate and link epilepsy specialists and providers with school nurses nationwide. Findings suggest that attending the MSS ECHO provided an educational and meaningful learning experience. The gains in knowledge and confidence in psychosocial aspects of epilepsy care and comorbidities highlight the importance of the inclusion of this content in educational programs.

Clinician factors related to the delivery of psychotherapy for autistic youth and youth with attention-deficit hyperactivity disorder

LAY ABSTRACT

Autistic children and youth often experience mental health problems, such as anxiety, depression and behavioural challenges. Although there are therapy programmes that have been found helpful in reducing these issues, such as cognitive behaviour therapy, autistic children often struggle to receive adequate mental health care. Clinicians' knowledge, attitudes, confidence and beliefs about treating mental health problems in autistic people may be related to their choices in providing psychotherapy. Across Ontario, Canada, 611 mental health clinicians, working in publicly funded agencies, completed an online survey about their experiences and opinions on delivering therapy for autistic clients compared to those with attention-deficit hyperactivity disorder. Clinician knowledge was associated with their intention to treat autistic clients or clients with attention-deficit hyperactivity disorder, partly because of their attitudes and the social pressures or values they felt. Clinicians reported feeling less intent on providing therapy to autistic youth compared to youth with attention-deficit hyperactivity disorder because of differences in their attitudes, social pressures and knowledge. This research can inform the training and educational initiatives for mental health practitioners.

How the rural risk environment underpins hepatitis C risk: Qualitative findings from rural southern Illinois, United States

BACKGROUND

Hepatitis C virus (HCV) infection has increased among persons who inject drugs (PWID) in the United States with disproportionate burden in rural areas. We use the Risk Environment framework to explore potential economic, physical, social, and political determinants of hepatitis C in rural southern Illinois.

METHODS

Nineteen in-depth semi-structured interviews were conducted with PWID from August 2019 through February 2020 (i.e., pre-COVID-19 pandemic) and four with key informants who professionally worked with PWID. Interviews were recorded, professionally transcribed, and coded using qualitative software. We followed a grounded theory approach for coding and analyses.

RESULTS

We identify economic, physical, policy, and social factors that may influence HCV transmission risk and serve as barriers to HCV care. Economic instability and lack of economic opportunities, a lack of physically available HCV prevention and treatment services, structural stigma such as policies that criminalize drug use, and social stigma emerged in interviews as potential risks for transmission and barriers to care.

CONCLUSION

The rural risk environment framework acknowledges the importance of community and structural factors that influence HCV infection and other disease transmission and care. We find that larger structural factors produce vulnerabilities and reduce access to resources, which negatively impact hepatitis C disease outcomes.

Closing the treatment gap for alcohol use disorders in low- and middle-income countries

The alcohol-attributable disease burden is greater in low- and middle-income countries (LMICs) as compared to high-income countries. Despite the effectiveness of interventions such as health promotion and education, brief interventions, psychological treatments, family-focused interventions, and biomedical treatments, access to evidence-based care for alcohol use disorders (AUDs) in LMICs is limited. This can be explained by poor access to general health and mental health care, limited availability of relevant clinical skills among health care providers, lack of political will and/or financial resources, historical stigma and discrimination against people with AUDs, and poor planning and implementation of policies. Access to care for AUDs in LMICs could be improved through evidence-based strategies such as designing innovative, local and culturally acceptable solutions, health system strengthening by adopting a collaborative stepped care approach, horizontal integration of care into existing models of care (e.g., HIV care), task sharing to optimise limited human resources, working with families of individuals with AUD, and leveraging technology-enabled interventions. Moving ahead, research, policy and practice in LMICs need to focus on evidence-based decision-making, responsiveness to context and culture, working collaboratively with a range of stakeholders to design and implement interventions, identifying upstream social determinants of AUDs, developing and evaluating policy interventions such as increased taxation on alcohol, and developing services for special populations (e.g., adolescents) with AUDs.

Supporting School Mental Health Providers: Evidence from a Short-Term Telementoring Model

Background

To support student mental health, school staff must have knowledge of evidence-based practices and the capacity to implement them. One approach used to address this challenge is a group-based telementoring model called Extension for Community Healthcare Outcomes (ECHO). In other applications (e.g., healthcare settings), ECHO has been shown to increase healthcare professionals' self-efficacy and knowledge of evidence-based practices leading to improved patient outcomes.

Objectives

This study examined the potential for ECHO to be used as a method for increasing school staff engagement and knowledge of evidence-based school mental health practices.

Methods

Using a quasi-experimental design, this study compared outcomes across two professional development experiences aimed at promoting school staff ability to provide evidence-based mental health services. School staff from four school districts participated in a school mental health training initiative. All participants (N = 57) had access to asynchronous, online mental health modules. A sub-sample (n = 33) was also offered monthly ECHO sessions.

Results

Tests of group difference in outcomes revealed significant increases in engagement with online learning (d = 0.58) and satisfaction (d = 0.82) for those who participated in ECHO as compared to those who did not. Knowledge about evidence-based practices was not significantly different between groups.

Conclusions

Results suggest that group-based telementoring may be a promising approach for improving engagement and satisfaction with training initiatives aimed at promoting evidence-based school mental health practices. However, further study of ProjectECHO using experimental designs is needed to make causal inferences about its effect on provider outcomes.

Access to technology to support telehealth in areas without specialty care for liver disease

BACKGROUND AND AIMS

Telehealth may be a successful strategy to increase access to specialty care for liver disease, but whether the areas with low access to care and a high burden of liver-related mortality have the necessary technology access to support a video-based telehealth strategy to expand access to care is unknown.

APPROACH AND RESULTS

Access to liver disease specialty care was defined at the county level as <160.9 km (100 miles) from a liver transplant (LT) center or presence of local gastroenterology (GI). Liver-related mortality rates were compared by access to care, and access to technology was compared by degree of access to care and burden of liver-related mortality. Counties with low access to liver disease specialty care had higher rates of mortality from liver disease, and this was highest in areas both >160.9 km from an LT center and without local GI. These counties were more rural, had higher poverty, and had decreased access to devices and internet at broadband speeds. Technology access was lowest in areas with low access to care and the highest burden of liver-related mortality.

CONCLUSIONS

Areas with poor access to liver disease specialty care have a greater burden of liver-related mortality, and many of their residents lack access to technology. Therefore, a telehealth strategy based solely on patient device ownership and internet access will exclude a large proportion of individuals in the areas of highest need. Further work should be done at the local and state levels to design optimal strategies to reach their populations of need.

Building communities of practice through case-based e-learning to prevent and manage TB among people living with HIV-India

BACKGROUND

Co-management of HIV-TB coinfection remains a challenge globally. Addressing TB among people living with HIV (PLHIV) is a key priority for the Government of India (GoI). In 2016, GoI implemented single-window services to prevent and manage TB in PLHIV. To strengthen HIV-TB service delivery, case-based e-learning was introduced to health care providers at Antiretroviral Therapy centres (ARTc).

METHODS

We implemented a hub and spoke model to deliver biweekly, virtual, case-based e-learning at select ARTc (n = 115), from four states of India-Delhi, Uttar Pradesh, Andhra Pradesh and Tamil Nadu. We evaluated feasibility and acceptability of case-based e-learning and its impact on professional satisfaction, self-efficacy, knowledge retention using baseline and completion surveys, session feedback, pre-and post-session assessments. We reviewed routine programmatic data and patient outcomes to assess practices among participating ARTc.

RESULTS

Between May 2018 and September 2020, 59 sessions were conducted with mean participation of 55 spokes and 152 participants. For 95% and 88% of sessions ≥ 80% of respondents agreed that topics were clear and relevant to practice, and duration of session was appropriate, respectively. Session participants significantly improved in perceived knowledge, skills and competencies (+ 8.6%; p = 0.025), and technical knowledge (+ 18.3%; p = 0.04) from baseline. Participating ARTc increased TB screening (+ 4.2%, p < 0.0001), TB diagnosis (+ 2.7%, p < 0.0001), ART initiation (+ 4.3%, p < 0.0001) and TB preventive treatment completion (+ 5.2%, p < 0.0001).

CONCLUSION

Case-based e-learning is an acceptable and effective modus of capacity building and developing communities of practice to strengthen integrated care. E-learning could address demand for accessible and sustainable continuing professional education to manage complex diseases, and thereby enhance health equity. We recommend expansion of this initiative across the country for management of co-morbidities as well as other communicable and non-communicable diseases to augment the existing capacity building interventions by provide continued learning and routine mentorship through communities of practice.

Creating virtual communities of practice for ambulance paramedics: a qualitative evaluation of the use of Project ECHO in end-of-life care

Introduction

Ambulance services play a key role in the recognition and care of patients nearing their end of life, yet are expected to recognise and manage these complex presentations often with limited education. Paramedics operate across large geographical areas, meaning education delivery is challenging. Yorkshire Ambulance Service implemented Project Extension for Community Healthcare Outcomes (ECHO), which is the creation of virtual communities of practice to address this problem and increase access to specialist supervision, education and sharing of practice. We undertook a service evaluation of the programme and interviewed paramedics about their experiences with ECHO.

Methods

Semi-structured interviews were conducted with eight ambulance clinicians who took part in the end-of-life care (EoLC) ECHO programme. Thematic analysis and coding was undertaken to identify and develop the emerging themes.

Results

This study identified three key themes: programme structure, factors influencing engagement and professional impact. The provision of a virtual community of practice through Project ECHO was a unique and highly valued experience, which was accessible and allowed for networking, peer support and sharing of practice. The concept of a ripple effect was reported in disseminating learning across the wider team.

Conclusion

The development of virtual communities of practice as a novel educational intervention has the potential to transform clinical supervision and ongoing education for ambulance clinicians who are often isolated by the nature of ambulance services that cover large regions.

Integration intrapreneurship: implementing innovation in a public healthcare organization

AIM

As global events impact the way organizations operate and innovate in response to regional, workforce and consumer needs, the concept of intrapreneurism is attracting growing interest from policymakers and executives, particularly within the healthcare sector. The aim of this study was to capture the key learnings from the implementation of a telementoring pilot, to understand how intrapreneurship can embed innovation within an established organization to effect more integrated healthcare.

PURPOSE

A qualitative approach was used with a phenomenological lens to explore the key learnings of the Project ECHO^® (Extension for Community Healthcare Outcomes) pilot implementation to provide an understanding of what the project team's strategies and tactics were during the process of embedding a new business innovation. The implementation and piloting of Project ECHO^®, a telementoring model, in a large-scale public healthcare organization in Queensland, Australia, was investigated as an exemplar of integration intrapreneurship.

FINDINGS

Through an inductive approach, this qualitative study found the implementation of the Project ECHO^® pilot had specific dimensions and strategies/tactics which were exemplars of intrapreneurism. The organizational context and workforce characteristics described in this study presented new knowledge of how intrapreneurs implemented an innovation to address fragmentation of healthcare service delivery, professional isolation and instances of low-value care. This research contributes to a better understanding of the strategic and tactical approaches to implementing intrapreneurial innovations within a public healthcare organization, with learnings that can be adapted by intrapreneurs in other contexts.

Applying Project ECHO (Extension for Community Health Care Outcomes) to improve addiction care in rural emergency departments

Background

Advancements in research and legislation have improved emergency provider ability to treat opioid use disorder (OUD), but dissemination into rural emergency departments (EDs) is limited. Project Extension for Community Healthcare Outcomes (ECHO) allows community generalists to learn from specialists through telementoring. We aimed to use ECHO to facilitate knowledge translation, increase confidence, and change behavior of rural ED providers treating patients with OUD.

Methods

Stakeholder interviews were conducted with rural ED providers. A group of ED addiction experts created an ECHO curriculum with eight OUD topics. ED health professionals were recruited and completed pre/post surveys centered around knowledge and comfort with treating OUD in the ED, with focus on clinical practice and stigma. Following the ECHO model, sessions included a 20-min didactic followed by two cases presented by participants, with discussion facilitated by faculty.

Results

Twenty-seven participants registered; seven attended ≥75% of sessions and completed both surveys. Of the seven, three were physicians, two advanced practice providers, one nurse, and one clinical pharmacist. Eight 1-hour sessions were conducted in two cohorts between January and December 2021. On a 5-point Likert scale, respondents on average agreed with questions evaluating acceptability (mean ± SD 3.96 ± 0.64), appropriateness (mean ± SD 4.18 ± 1.18), and feasibility (mean ± SD 4.00 ± 1.17). Participants had a 1.09-point increase (paired t-test = 2.43, p = 0.05) on 7-point Likert-scale questions measuring self-efficacy and a 0.13-point change (paired t-test = 2.64, p = 0.04) on 4-point Likert scale questions measuring stigmatizing attitudes (reduction of attitudes). A total of 71% (5/7) reported changes in clinical practice and 57% (4/7) in departmental protocols after participation.

Conclusions

Our ED OUD ECHO course successfully created a model for rural ED providers to learn from ED addiction experts. It was well received and impacted self-reported provider stigmatizing attitudes, patient-facing behavior, and departmental initiatives. Recruitment was challenging and participation was limited. Future efforts will target maximizing recruitment.

Impact of Project ECHO on Patient and Community Health Outcomes: A Scoping Review

PURPOSE

Project Extension for Community Healthcare Outcomes (ECHO) is a hub-and-spoke tele-education model that aims to increase health care providers' access to evidence-based guidelines and enhance their capacity to care for complex patients in rural, remote, and underserved communities. The purpose of this scoping review was to examine evidence of the impact of Project ECHO programs on patient and community health outcomes.

METHOD

The authors used Arksey and O'Malley's framework and subsequent revisions proposed by Levac and colleagues to guide their review. They searched MEDLINE, EMBASE, CINAHL Plus, and Web of Science for English-language, peer-reviewed articles published between January 2003 and June 2020. Included studies focused on Project ECHO programs and reported either patient or community health outcomes. The authors used a standardized data extraction form to document bibliographical information and study characteristics, including health outcome level(s), as articulated by Moore's evaluation framework for continuing medical education.

RESULTS

Of the 597 search results, the authors identified 15 studies describing Project ECHO programs. These programs were implemented in the United States and Australia and facilitated education sessions with health care providers caring for adult patients living with 1 of 7 medical conditions. Included study findings suggest Project ECHO programs significantly changed patient-level outcomes (n = 15) and to a lesser extent changed community-level outcomes (n = 1). Changes in care were observed at the individual patient level, at the practice level, and in objective clinical measures, including sustained virologic response and HbA1c.

CONCLUSIONS

This review identified emerging evidence of the effectiveness of Project ECHO as a tele-education model that improves patient health outcomes and has the potential to positively impact community health. The small number of included studies suggests that additional evidence of patient- and community-level impact is required to support the continued adoption and implementation of this model.

Three-year progress report of Bone Health TeleECHO Moscow: a strategy to improve the care of patients with osteoporosis and other metabolic skeletal diseases in underserved communities of Russia

Bone Health TeleECHO Moscow is the first Russian-speaking Project ECHO (Extension for Community Healthcare Outcomes) program that is modeled after the original Bone Health TeleECHO created in the USA. Bone Health TeleECHO Moscow was effective (effect size of 0.87 p < 0.001) at improving clinicians' skills in the management of osteoporosis based on self-evaluation over 3 years.

INTRODUCTION

Bone Health TeleECHO (Extension for Community Healthcare Outcomes) Moscow is the first Russian-speaking ECHO program, modeled after Bone Health TeleECHO at the University of New Mexico, USA. The bone ECHO programs are designed to expand the capacity to deliver best practice skeletal healthcare worldwide through ongoing technology-enabled case-based collaborative learning. To evaluate the impact of the first 3 years of Bone Health TeleECHO Moscow on physicians' knowledge in the management of bone diseases.

METHODS

Demographic data were obtained, and outcomes were assessed through an electronic blinded self-efficacy questionnaire focusing on competence and skills in 20 domains of osteoporosis care before and after each year of participation in the Bone Health TeleECHO Moscow.

RESULTS

Over 3 years, a total of 296 participants completed the questionnaire. Average attendance for each monthly session increased from 64 in 2019 to 73 in 2020 and to 96 in 2021. Participants were from all regions of Russia and Russian-speaking countries. The mean age of respondents was 43 years with the youngest being 23 and the eldest 74. The most common participants' primary specialties were endocrinology (n = 263), gynecology (n = 20), orthopedics (n = 3), and other (n = 10). All of our participants were physicians, including 73 MD PhDs. This educational intervention was associated with a statistically significant improvement in each of the 20 domains of osteoporosis care, with an effect size of 0.87 (p < 0.001).

CONCLUSION

Bone Health TeleECHO is effective at improving clinicians' skills in the management of osteoporosis based on self-evaluation over 3 years.

John L, Thakur A, Steel L, Baskin A, Durbin A, Chacra MA, Lunsky Y. Mental health and COVID-19: The impact of a virtual course for family caregivers of adults with intellectual and developmental disabilities

BACKGROUND

The COVID-19 pandemic has significantly impacted family caregivers of adults with intellectual and developmental disabilities (IDD). This study evaluated a virtual course for family caregivers from across Canada, focused on supporting the mental health and well-being of adults with IDD and their families. The evaluation examined the feasibility and acceptability of the course, as well as the impact of the intervention on participants' overall health and well-being.

METHODS

The 6-week virtual course, informed by a parallel Extension for Community Healthcare Outcomes (ECHO) course for service providers, combined didactic instruction with applied activities. A total of 126 family caregiver course participants consented to be part of the research evaluation delivered over three cycles between October 2020 and April 2021. Attendance was measured at each weekly session. Satisfaction was assessed weekly and post-program. Learning, self-efficacy, and well-being were assessed pre- and post-course, and again at follow-up (8 weeks post-course). Mixed-effects models assessed changes between and within individuals across time.

RESULTS

Participants had consistent attendance, low-dropout rates, and reported high satisfaction, with 93% of participants reporting that their expectations for the course were met. Compared with pre-course, participants reported improved self-efficacy and well-being post-course, which were maintained at follow-up.

CONCLUSIONS

An interactive and applied virtual education course delivered to a large group of family caregivers of adults with IDD was both feasible and acceptable. It positively impacted participants' well-being by offering much needed mental health support and creating a peer-led community of practice.

Physician Voices on ECHO Autism India-Evaluation of a Telementoring Model for Autism in a Low-Middle Income Country

OBJECTIVES

Training pediatricians in low- and middle-income countries (LMICs) in early diagnosis and comprehensive management of autism spectrum disorder (ASD) is crucial to ensure optimal developmental outcomes for a substantial number of children with ASD in this region. This study evaluates the relevance and effectiveness of an evidence-based telementoring model Extension for Community Healthcare Outcomes (ECHO) Autism in increasing pediatricians' access to best-practice care for children with ASD in LMIC contexts.

METHODS

ECHO Autism was launched by a ‟hub" team of multidisciplinary ASD experts at a child development center in Mumbai, India. The culturally modified model included 13 biweekly sessions conducted annually using video-conferencing technology. Sessions combined expert-delivered didactics and facilitated case-based discussions on best-practice methods in screening, diagnosing, and managing autism and its comorbidities. Sixty-two physicians, including 59 pediatricians across 2 cohorts (2019-2020), participated in the mixed-methods study to evaluate participants' reactions, knowledge, behaviors, and impact on children and families.

RESULTS

Participants represented a broad geographic reach across India (n = 47) and other LMICs (n = 15). Both quantitative and qualitative data revealed high levels of participant satisfaction and improved knowledge and self-efficacy in ASD diagnosis and management. Qualitative themes highlighted the adult-learning processes of ECHO Autism that participants considered novel and beneficial, such as reflective discussions, respectful mentoring, having a parent as ‟expert," and cultural relevance, alongside changes in practice behaviors.

CONCLUSION

ECHO Autism clinics facilitated by local experts in LMICs can improve access to early diagnosis and evidence-based, comprehensive management for children with ASD and their families by positively influencing pediatricians' knowledge, attitudes, and practice behaviors.

'More together than apart': The evaluation of a virtual course to improve mental health and well-being of adults with intellectual disabilities during the COVID-19 pandemic

BACKGROUND

To address the growing concerns over poor mental health experienced by adults with intellectual disabilities due to the COVID-19 pandemic, a national virtual mental health course was delivered and evaluated.

METHODS

This mixed methods study utilized both qualitative and quantitative assessments. Participants were 27 adults with intellectual disabilities who participated in the 6-week course. Participants completed measures of self-efficacy and well-being at three time points and qualitative satisfaction measures at post and follow-up.

RESULTS

Attendance was high and the course was feasible and acceptable to participants. Positive changes related to mental health self-efficacy were detected (p = .01), though mental well-being did not improve.

CONCLUSION

The study provided evidence for the feasibility and value of the course for this population. Future research should examine how virtual courses could support the population in terms of pandemic recovery and how courses may work for individuals who are less independent.

What role can education play in integrated care? Lessons from the ECHO (Extensions for Community Health Outcomes) Concussion program

Purpose

Design, implementation, and evaluation are all important for integrated care. However, they miss one critical factor: education. The authors define “integrated care education” as meaningful learning that purposefully supports collaboration and the development of adaptive expertise in integrated care. The ECHO (Extensions for Community Health Outcomes) model is a novel digital health solution that uses technology-enabled learning (TEL) to facilitate, support, and model integrated care education. Using ECHO Concussion as a case study, the authors describe the effects of technology-enabled integrated care education on the micro-, meso-, and macro-dimensions of integrated care.

Design/methodology/approach

This case study was constructed using data extracted from ECHO Concussion from video-archived sessions, participant observation, and internal program evaluation memos. The research team met regularly to discuss the development of relevant themes to the dimensions of integrated care.

Findings

On the micro-level, clinical integration occurs through case-based learning and the development of adaptive expertise. On the meso-level, professional integration is achieved through the development of the “specialist generalist,” professional networks and empathy. Finally, on the macro-level, ECHO Concussion and the ECHO model achieve vertical and horizontal system integration in the delivery of integrated care. Vertical integration is achieved through ECHO by educating and connecting providers across sectors from primary to quaternary levels of care. Horizontal integration is achieved through the establishment of lateral peer-based networks across sectors as a result of participation in ECHO sessions with a focus on population-level health.

Originality/value

This case study examines the role of education in the delivery of integrated care through one program, ECHO Concussion. Using the three dimensions of integrated care on the micro-, meso-, and macro-levels, this case study is the first explicit operationalization of ECHO as a means of delivering integrated care education and supporting integrated care delivery.

Experiences and perceptions of nurses participating in an interprofessional, videoconference-based educational programme on concurrent mental health and substance use disorders: a qualitative study

Background

Individuals with co-occurring mental health and substance use disorders (i.e., concurrent disorders) have complex healthcare needs, which can be challenging for nurses to manage. Providing optimal care for this subpopulation requires nurses to develop high-level competencies despite limited resources at their disposal and the isolated settings in which many of them work. The Extension for Healthcare Community Outcomes (ECHO®) is a promising collaborative learning and capacity building model that uses videoconference technology to support and train healthcare professionals in the management of complex and chronic health conditions. The aim of this study was to explore the experiences and perceptions of nurses participating in a Canadian ECHO programme on concurrent disorders about the competencies they developed and used in their clinical practice, and which factors have influenced this process.

Methods

The study was qualitative, guided by an interpretive description approach. Individual semi-structured interviews were held with ten nurses who had participated in the programme between 2018 and 2020. A thematic analysis was conducted iteratively using an inductive approach to progressive data coding and organization.

Results

Four themes and eighteen sub-themes were identified. During their participation in ECHO, the nurses perceived as having further developed eight clinical nursing competencies. Nurses viewed ECHO as a unique opportunity to open themselves to their peers’ experiences and reflect on their own knowledge. Learning from experts in the field of concurrent disorders helped them to build their confidence in managing complex clinical situations. The nurses’ sense of belonging to a community further enhanced their engagement in the programme, and learning was facilitated through the programme’s interprofessional environment. Nevertheless, the lack of contextualized educative content linked to local realities, the limited resources in concurrent disorders, and time constraints were experienced as factors limiting competency development.

Conclusions

ECHO is a promising alternative to conventional, in-person continuing education programmes to improve the development of advanced competencies among nurses providing care to individuals with chronic and complex health conditions. These findings can inform clinicians, educators, researchers, and decision makers who are developing, implementing, evaluating, and escalating future educational interventions in the field of CDs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12912-022-00943-w.

Supporting GPs in the Management of Children and Young People with ADHD Through Project ECHO®: Results from a Self-Efficacy Survey

Introduction:

Attention Deficit Hyperactivity Disorder (ADHD) accounts for a high proportion of paediatric outpatient visits in Australia. Shared care by general practitioners (GPs) would deliver more timely care, closer to home, however GPs indicated the need for interprofessional training support. This study describes the use of Project ECHO^®, a guided practice model, to support GPs with ADHD management, by connecting them virtually with an interprofessional team of paediatric specialists using a structured methodology.

Methods:

A retrospective pre/post-knowledge and self-efficacy survey across twenty-seven aspects of ADHD management was administered, using a seven-point Likert scale.

Results:

Significant improvement (p < 0.001) in provider self-efficacy was demonstrated across all tested domains.

Discussion:

Use of the ECHO model™ by an interprofessional team of paediatric specialists achieved an increase in GP knowledge and self-efficacy in the local management of children and young people with complex healthcare needs. Learnings indicate viability to expand the application of the ECHO model™ to address fragmentation for other priority populations across the Australian healthcare and human service sector landscape.

Conclusion:

Use of the ECHO model™ to support and train GPs was successful. Integration of care was achieved through strengthened partnerships between content and context experts, and the ECHO model™’s case-based learning methodology.

Advanced virtual mentoring of dentists in oral cancer screening and tobacco cessation - An interventional study

Context

Oral cancer is the third common cancer in India. Its mortality can be reduced through early detection and tobacco cessation ideally by dentists owing to their forte of work.

Aim

This study was conducted to discuss effectiveness of an advanced tele-mentoring programme in oral cancer screening and tobacco cessation for dentists across India.

Settings and Design

Online, interventional study.

Methods and Material

The 14-week long training programme with 52 participants/spokes from across India had weekly hour-long online sessions comprising of an expert-led didactic and case discussions by spokes. Online evaluation (pre- and post-training, post-session), weekly and post-one-year feedback were conducted. Successful spokes attended a hands-on workshop subsequently.

Statistical Analysis Used

One and independent sample t-tests determined the significance of the evaluation scores of the participants. Findings on attitudes and practice-related questions are presented as simple percentages.

Results

A notable increase in the overall and per-session mean knowledge score, and confidence in oral cancer screening was observed. Many participants started these services at their clinics, thereby reducing further referrals, and were also motivated to spread community awareness about the same.

Conclusion

This tele-mentoring programme, based on the novel Extension for Community Healthcare Outcomes model, is the first oral cancer screening training programme for dentists. This model-comprising of expert didacts, case discussions, and significant spoke-expert interaction-is a promising best-practices tool for reducing the disparity in knowledge and skills regarding oral cancer prevention among dentists across different locations. This would enable these most appropriate healthcare providers to contribute toward the overall goal of oral cancer prevention.